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Introduction Bundle Regular of AMSA-Indonesia National Competitions (BRAINs) is a full compilation of all works submitted in every national competitions held by Asian Medical Students’ Association (AMSA) Indonesia. The previous bundle is named AMSA Indonesia National Competition Bundle (AINCB). Each year, AMSA Indonesia held three national competition events entitled Pre-conference competition for East Asian Medical Students’ Conference (PCC for EAMSC), National Paper Poster Training, and also Pre-conference competition for Asian Medical Students’ Conference (PCC for AMSC). This third bundle, compile all works participated in PCC for EAMSC 2014, which aimed to choose Indonesia representative in EAMSC 2014 in Seoul — South Korea, on January 12-16th. The theme for this competition is “Walking side by side: acompanying the patientson their lifelong strugle with chronic disease” In this competition, Indonesia will send 1 Scientific Paper, 1 Scientific Poster, and Health Campaign consist of 1 Film and1 Public Poster.

EAMSC 2014 will be held in Seoul – South Korea, on January 12-16th

Once compiled, Bundle of AMSA will be both distributed to all local AMSA and published via the AMSA-Indonesia web so that all members could easily access and obtain useful information gather in this bundle. Enjoy and keep involved in academics!

Judges • • •

dr. Dimas Bayu, SpPD dr. Forman Erwin Siagian, MBiomed dr. Dhanasari Vidiawati, MSc, CM-FM

Total Team of PCC for EAMSC Contributors

2014

Regional Chairperson Garda Widhi Nurraga Universitas Diponegoro Secretary of Academics Fabianto Santoso Universitas Indonesia A-Team Creative Project Ayudhea Tannika Universitas Kristen Krida Wacana

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Scientific Paper

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Scientific Poster

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Health Campaign

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Table of Content Introduction .………………………...……………………………………………..................................…….2 Table of Content …………………………………………...………………………..............…………………..3

Scientific Paper Combination Of Heterogeneous Nuclear Ribonucleoprotein K (Hnrnp K), Afp (Α-Fetoprotein) And Il-22 As Biomarkers To Predict The Survival Rate In Liver Cirrhosis Patients: Acute And Long Term Prediction - Ilham Akbar R, Fadhilah Putri Wulandari, Siti Nurul Magfirah...........................................................5 PLACE PHOTO HERE, OTHERWISE DELETE BOX Lec A Specific Protein Utilization In Staphyococcus Aureus Biofilm Bacteria As A Vaccine Candidate For The Prevention Of Chronic Amoebic Dysentery Caused By The Protozoan Entamoeba Histolytica - Ivan Bintang Pratama, Dwi Fitria Rahayuningwati, Dewangga Primananda Susanto, Januardi Indra................................……………………............…………….................................................…………….....15 The Potential Effect Of Music Therapy For Improving The Quality Of Live Of Stroke Patients - Januardi Indra, Furqan Hidayatullah, Veronica Verina Setyabudhi……….................................................……..................23 Abc (Assessments, Building Execution, Core Evaluation And Monitoring) : An Integrated Approach And Revolutionary Health System To Reduce Coronary Heart Disease Mortality In Indonesia - Ayu Pramitha Wulandari, Khrisna Rangga Permana, Shanti Andri Sakarisa, Depy Irmayanti ...........................................................................……….............................................................................31 Comparison Of Knowledge, Perception, And Attitude Toward Leprosy Patients Between Society Near And Distant From Rehabilitation Center - Leonard Andreas Wiyadharma, Matthew Billy, Mochamad Iskandarsyah Agung Ramadhan.......................................................................................................................................41 Correlation Between History Of Depression Status And Incidence Of Ischemic Stroke In Surakarta Liswindio Apendicaesar , Kevin Wahyudy Prasetyo, Eka Satya Nugraha..................................................47 A Cross Sectional Study Of Pengawas Minum Obat (Pmo) In Going Hand In Hand With Tuberculosis Patients In Jakarta Respiratory Center (Jrc) – The Indonesian Association Against Tuberculosis Nathania S. Sutisna, Fabianto Santoso, Eka Satya Nugraha, Yenna Tasia..........…………………………...........................................................................................................52 Post For Post-Stroke Patient (P4p): A Scientific Review - Nurul Cholifah Lutfiana, Athaya Febriantyo Purnomo, Dewa Ayu Megayanti…………………........................................................................................59

Scientific Poster Comparison of Knowledge, Perception, and Attitude toward Leprosy Patients between Society Near and Distant from Rehabilitation Center - Leonard Andreas Wiyadharma, Matthew Billy, Mochamad Iskandarsyah Agung Ramadhan..………………………………………………..................................................................65 Burden And Quality Of Life In Caregiver Of Cancer Patient In Cancer Community Jakarta Afria Beny Safitri, Rifa Roazah, Ridho Ahmad Jabbar.................................................................………...66 Combination of Heterogeneous nuclear ribonucleoprotein K (hnRNP K), AFP (α-fetoprotein) and IL-22 as biomarkers to predict the survival rate in liver cirrhosis patients: acute and long term prediction - Ilham Akbar R, Fadhilah Putri Wulandari, Siti Nurul Magfirah……..............................................................…...67

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Table of Content The Development of Early Detection Method for Autoimmune Disease, Lupus Nephritis and Silent Lupus Nephritis In Indonesia with HMGB-1 as an Antibody Marker - Intan Kautsarani, Dewangga Primananda S., M. Vardian Mahardika, Afiyf Kaysa Waafi, Fania Dora Aslamy....................................................................68

Health Campaign Die Hard Vs Live Happily – Chelsea Vanessa, Ayudhea Tannika, Eifraimdio Paisthalozie.......….............69 Bad and Good Habits Related to Heart Disease - Elisabeth Pauline Tifany, Theresia Indriani Prima Chesar .............................................................................……..................................................................………...70

Fight Cancer with Psychosocial Therapy - Monica….......................….......................…….........………...71 Engaged the Caregiver for A Better Coordinated Care - Widya Oktaviana Tarigan, Dymiargani Nandaputra Milono......………………………………………………………………………………………...72 Love Yourself, Love Others - Jeslyn Tengkawan, Joanna Febrila.......... ....................................... .................73

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Combination of Heterogeneous nuclear ribonucleoprotein K (hnRNP K), AFP (αfetoprotein) and IL-22 as biomarkers to predict the survival rate in liver cirrhosis patients: acute and long term prediction Ilham Akbar R, Fadhilah Putri Wulandari, Siti Nurul Magfirah Hasanuddin University, Makassar, Indonesia ABSTRACT Background: According to the World Health Organization (WHO), in 2006 approximately 170 million infected human liver cirrhosis. This figure includes about 3% of the the entire human population in the world and each year new infections cirrhosis hepatic increased 3-4 million people. The prevalence of disease in the liver cirrhosis Indonesia, is not known. The prevalence of liver cirrhosis in 2007 in Indonesia ranges from 1 to 2.4%. Of the average prevalence (1.7%), estimated at more than 7 million people in Indonesia suffer from cirrhosis hepatic. Material and methods: This study uses internet article and approved journal from many website. After journal and article have been collected, literature review was conducted to create a novel and newest idea for fast diagnostic effectively and efficiently as the most needed research in liver cirrhosis disease as the chronic hepatological disease. Results: Systemic IL-22 was detectable in 74% of patients but only in 10% of healthy donors (P < 0.001). Elevated levels of IL-22 were associated with ascites (P = 0.006), hepatorenal syndrome (P < 0.0001), and spontaneous bacterial peritonitis (P = 0.001). Patients with elevated IL-22 (>18 pg/ml, n = 57) showed significantly reduced survival compared to patients with regular (≤18 pg/ml) levels ofIL-22 (321 days versus 526 days, P = 0.003). Other factors associated with reduced overall survival were high CRP (≥2.9 mg/dl, P = 0.005, 0.141 to 0.702), elevated serum creatinine (P = 0.05), presence of liver-related complications (P = 0.028) model of end stage liver disease (MELD) score ≥20 (P = 0.017) and age (P =0.011, HR). Particularly in early HCC, and identified as heterogeneous nuclear ribonucleoprotein K (hnRNP K) by tandem mass spectrometry (MALDI TOF/TOF). The overexpression in HCC was subsequently validated by western blot and immunohistochemistry. ROC curve analysis showed that hnRNP K intensity could detect early HCC at 66.67 % sensitivity and 84 % specificity, which was superior to serum α-fetoprotein (AFP) in detection of early HCC. Furthermore, the diagnosis test demonstrated, when combined with hnRNP K and serum AFP as biomarker panel to detect early HCC at different cut-off value, the sensitivity and specificity could be enhanced to 93.33 % and 96 %, respectively. Conclusion: The combination between IL-22 with cut off value > 18 pg/ml, Heterogeneous Nuclear Ribonucleoprotein K (hRNP K) with cut off value ≥ 7.160 ppm, and AFP (α-fetoprotein) with cut off value ≥ 100 ng/mL will bring a better prognosis and prediction, in long term and acute prediction, respectively. Background The word cirrhosis comes from the Greek word kirrhos, which means orange yellow (1). Laennec gave cirrhosis its name kirrhos in 1819 in a brief footnote to his treatise De l’auscultation mediate (2). The definition of cirrhosis remains morphological, described by a working party for the World Health Organization (WHO) in 1978 as: “a diffuse process characterized by fibrosis and the conversion of normal

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liver architectures into structurally abnormal nodules” (3). According to the World Health Organization (WHO), in 2006 approximately 170 million infected human liver cirrhosis. This figure includes about 3% of the the entire human population in the world and each year new infections cirrhosis hepatic increased 3-4 million people. The prevalence of disease in the liver cirrhosis Indonesia, is not known. The prevalence of liver cirrhosis in 2007 in Indonesia ranges

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from 1 to 2.4%. Of the average prevalence (1.7%), estimated at more than 7 million people in Indonesia suffer from cirrhosis hepatic. Certain reversible components of cirrhosis have been indicated where significant histological improvement have occurred with regression of cirrhosis but complete resolution with a return to normal architecture seems unlikely (5). The underlying immunological response has usually been acting for months or years where inflammation and tissue repairing are in progress simultaneously which leads in the end to fibrosis and cirrhosis (6). Interleukin (IL)-22 is among newly identified parameters of hepatocyte biology that recently became the major focus of basic and translational research on liver injury and inflammation [7]. This member of the IL-10 cytokine family is primarily produced by activated CD4+ or CD8+ T cells, gδ-T cells, macrophages/dendritic cells and a diverse array of natural killer (NK)-like cells recently coined innate lymphoid cells [7-9]. IL-22 is biochemically and functionally akin to IL-6 and able to efficiently initiate the hepatic acute phase response [10,11]. However, in contrast to IL-6, IL-22 almost exclusively acts on nonleukocytic cells. As a result, cells of epithelial origin, including hepatocytes, but not leukocytes, are major targets of IL-22 [7-9]. The potential of IL-22 as a parameter of liver diseases is further highlighted by detection of its increased expression in patients’ liver biopsy specimens using immunohistochemistry method [10,1213]. Enhanced levels of systemic IL-22 have recently been observed in patients with chronic hepatitis [11] and acute hepatitis B infection by using hematology and biochemically analysis in laboratorium [11]. The best currently evaluated prognosis score for patients with liver cirrhosis is the MELD score. Systemic IL-22 levels in patients with liver cirrhosis significantly correlated with the MELD score, substantiating that IL-22 is associated with deterioration of liver function and subsequent mortality of cirrhotic patients.

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The MELD score is a short-term (three- to six-month) predictor of survival in patients with end-stage liver disease, but is a weak predictor of survival in patients with compensated liver cirrhosis in the long term. In multivariate analysis, systemic IL-22 was (independently from age, presence of liverrelated complications, elevated creatinine, high CRP and high MELD score) associated with long-term mortality. Taking into account that IL-22 serum levels were stably increased in the majority of patients in the course of liver cirrhosis Hepatocellular carcinoma is one of the most common malignant tumors worldwide and is particularly prevalent in China and Asia. Persisting viral infections such as Hepatitis B (HBV) and Hepatitis C (HCV), which are the major common risk factors of HCC, is responsible for about 80% of all HCC [14]. Chronic infection with HBV in the setting of cirrhosis increases the risk of HCC 70-fold [15]. The proteome of tumor tissue is a rich source of cancer biomarkers, and protein released from tumor tissues may be more cancer specific than those from nontumor tissue. Investigation of the tumor tissue proteome can identify proteomic signatures corresponding to clinicopathological features, and individual protein in such signatures may be good biomarker candidate [16]. In spite of many recent technological advances in methods for the separation and analysis of protein, twodimensional gel electrophoresis (2-DE) coupled with tandem mass spectrometry MS is still the “gold standard” technique [17]. In the present study, proteomic 2-DE approach was used to analyze HCC patients. hnRNP K was successfully identified as a candidate biomarker for early HCC, when compared to cirrhosis controls. The sensitivity and specificity of hnRNP K alone or in combination with AFP in relevant clinical populations make this a suitable tool for the detection of early HCC. In this research, we investigate how the combination of Heterogeneous nuclear ribonucleoprotein K (hnRNP K) with AFP (Alfa feto protein) and IL-22 is the best

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diagnostic method to do short and long term prediction in liver cirrhosis patients which hnRNP K-AFP will be used to detect early HCC and IL-22 will be used to prognose the long term condition where other complications that might happen. Material and Metods Literature searching This study uses internet article and approved journal from many website. Literature review After journal and article have been collected, literature review was conducted to create a novel and newest idea for fast diagnostic effectively and efficiently as the most needed research in liver cirrhosis disease as the chronic hepatological disease. Results IL-22 serum levels are increased in patients with liver cirrhosis To investigate whether liver cirrhosis is associated with increased serum IL-22, the cytokine was determined in sera of healthy donors and liver cirrhosis patients, respectively. IL-22 was detectable (>2.6 pg/ml) in 89 of 120 patients with liver cirrhosis, but only in 4 of 40 healthy controls (74.1% vs. 10.0%, P < 0.001) (Figure 1).. Age and gender were not associated with the systemic IL-22 level in patients with liver cirrhosis (P > 0.2 for both). Furthermore, the mean value of systemic IL-22 in healthy controls obtained in this study was similar to the mean systemic level of IL-22 in the literature reported for older patients (3.3 Âą 1.4 pg/ml, 51.6 Âą 7.6 years) [27]. In order to determine a reference range, we used the 95% interval of lL-22 serum concentrations that were observed in healthy donors. Based on that strategy, we defined the upper limit of normal (ULN) serum IL-22 concentration to be 18 pg/ml. According to this ULN, 57 out of 120 (47.5%) patients with liver cirrhosis but only 2 out of 40 (5.0%) healthy donors displayed elevated IL-22 serum levels.

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IL-22 serum levels increase in the course of liver disease. Next, we were interested whether IL-22 serum levels are stably increased in the course of liver disease. Follow-up sera were available in 29 patients with liver cirrhosis. Thirteen patients (44.8%) had elevated IL22 serum levels at baseline. (P = 0.0192, Figure 2). Only 3 of 13 patients (23.1%) with elevated IL-22 serum levels at baseline showed a decline of IL-22 below the ULN at followup while 9 of 16 patients (56.3%) with IL-22 serum levels below the ULN at baseline showed an increase of IL-22 above ULN at follow-up. IL-22 is detectable in livers from patients with liver cirrhosis A recent report demonstrates that IL-22 is produced locally in livers of patients with chronic viral hepatitis [26]. In order to provide evidence that enhanced systemic IL22 as observed herein likely derived from diseased liver tissue, IL-22 expression was determined in liver biopsies by immunohistochemical staining (available from only 10 patients, as liver biopsies are not routinely performed in patients with advanced liver cirrhosis). IL-22 positive cells were observed in 7 of 10 liver biopsies from patients with different etiologies of liver cirrhosis. In agreement with Park et al. [26], IL-22 expression was detectable mainly in non-parenchymal cells (Figure 3). Serum IL-22 and etiologies of liver disease We next investigated whether distinct etiologies of liver diseases in the patient cohort under investigation affected IL-22 serum levels. Notably, no significant differences became apparent between levels of IL-22 in sera from patients with liver cirrhosis due to chronic hepatitis B (HBV), chronic hepatitis C (HCV) and alcoholic cirrhosis (AC) (P > 0.2). For hereditary, cholestatic, autoimmune liver diseases as well as toxic liver injury and nonalcoholic steatohepatitis, the number of patients was too low to draw a valid conclusion. Patients with chronic HBV, chronic HCV and alcoholic cirrhosis had significantly higher IL-22 serum levels than healthy controls (P

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= 0.009, P < 0.001 and P < 0.001, respectively). These data do not support an association between the etiology of the underlying liver disease and elevated serum IL-22. Elevated IL-22 serum levels are associated with reduced survival of patients with liver cirrhosis To investigate whether IL-22 serum levels are associated with survival of patients with liver cirrhosis, we compared survival of patients with liver cirrhosis and normal IL-22 levels (below the ULN of 18 pg/ml) with survival of patients having elevated IL-22 serum levels (above the ULN of 18 pg/ml). As illustrated in Figure 4, survival of patients with elevated IL-22 serum levels was significantly reduced compared to patients with normal IL-22 serum levels (P = 0.003). The estimated mean survival time was 526.4 days for patients with normal systemic IL-22 and 321.3 days for patients with elevated IL 22 (Figure 4). IL-22 serum levels are associated with complications of liver cirrhosis To investigate whether systemic IL-22 levels are associated with complications of liver cirrhosis, we compared liver cirrhosisrelated complications between patients with IL-22 serum levels above or below the ULN of 18 pg/ml. Elevated IL-22 levels were more frequent in patients with liver cirrhosis-related complications than in patients with compensated liver cirrhosis (60.0% vs. 17.1%, P < 0.001). Moreover,elevated IL-22 serum levels were more frequent in patients with ascites, hepatorenal syndrome (HRS) and spontaneous bacterial peritonitis as compared to patients without these complications (Figure 5). IL-22 serum levels correlate with MELD score The currently best-evaluated prognostic score for patients with liver cirrhosis is the MELD score. In the present study, there was a significant association between high MELD score (â&#x2030;Ľ20) and reduced survival (P = 0.017, hazard ratio (HR) 0.364, confidence interval (CI) (0.159 to 0.835)).

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As IL-22 serum levels were associated with mortality of patients with liver cirrhosis, we investigated the relation between the MELD score and IL-22 serum levels. As shown in Figure 6, IL-22 serum levels significantly correlated with the MELD score. The MELD score includes the laboratory parameters for creatinine, bilirubin and international normalized ratio for prothrombin time (INR). Therefore, we also investigated if the individual parameters of the MELD score correlate with serum IL-22 levels in our patients. As illustrated in Table 1, creatinine and INR but not bilirubin correlated with IL-22 serum levels. IL-22 serum levels correlate with surrogate parameters for inflammation To investigate whether IL-22 serum levels are associated with determinants of liver synthetic capacity, inflammation or damage, potential correlations of the cytokine with serum albumin (surrogate marker of liver synthetic capacity), Creactive protein (CRP, surrogate marker of ongoing inflammation), and alanine aminotransferase (ALT) as well as aspartate aminotransferase (AST), both surrogate markers of liver damage, were analyzed (Table 1). A strong positive correlation was found between serum IL-22 and CRP levels (Table 1). Furthermore, weak but significant inverse correlations between serum levels of IL-22 and albumin, as well as ALT, were observed (Table 1). Overexpression of hnRNP K in early HCC tissue Protein spots that showed at least twofold changes and a significant difference in intensity (p<0.05) between HCC and cirrhotic liver samples were included for further analysis. Among the proteins identified as upregulated using mass spectrometry, the protein labeled SSP2215 was found to be consistently overexpressed in HCC tissues compared with cirrhotic liver tissues (p<0.01) (Figure 7A). This protein was expressed more strongly than other candidate biomarkers in all HCC tumors of different stages (p<0.01) (Figure 7B). Because detection of early HCC in high risk subjects (e.g., those with cirrhosis and/or

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hepatitis B) could guide further treatment and improve patients’ clinical outcomes, we were motivated to distinguish any potential biomarker with expression related to early HCCs. Intriguingly, a stronger expression of SSP2215 was found to be significant in early HCCs compared to other protein spots. Moreover, significant overexpression of this protein was maintained in late HCC tumors, suggesting that expression of SSP2215 may be related to HCC development (Figure 7C). Finally, the SSP2215 spot was identified as heterogeneous nuclear ribonucleoprotein K (hnRNP K) by mass spectrometry . HnRNP K is a potential biomarker for early HCC To assess the individual performance of hnRNP K as a potential biomarker to discern early HCC from cirrhosis, and to detect early HCC from late HCC in tissue, we selected optimal fixed cutoff thresholds for hnRNP K and then calculated test sensitivity and specificity by receiver operating characteristic (ROC) curves (Figure 8). At a cutoff threshold of ≥6.396 ppm, hnRNP K showed a high accuracy to discern early HCC tissue from cirrhosis tissue with a sensitivity of 93.33% and a specificity of 75% (AUC = 0.89, p<0.01) (Figure 8A). Likewise, hnRNP K separated early HCC from late HCC at a cutoff threshold of 7.16 ppm with a sensitivity of 66.67% and a specificity of 84% (AUC = 0.75, p<0.01) (Figure 8B). Serum AFP had a lower diagnostic capability (AUC = 0.60, p>0.05) of detecting early HCC from late HCC either at a cutoff value of 100 ng/mL (Sen = 64.29%, Spe = 56%) or 400 ng/mL (Sen = 64.29%, Spe = 40%) (Figure 8C), which is in accordance with the acknowledged reports that AFP is insensitive for early HCC detection. It is well known that the combination of multiple biomarkers will improves capability for disease diagnosis. We used fixed cutoff thresholds of 7.16 ppm hnRNP K and 100 ng/mL AFP to discern early HCC from late HCC with a sensitivity of 93.33%, specificity of 44% and accuracy of 62.5%. In contrast, the serial test, with fixed cutoff thresholds of 7.16 ppm hnRNP K and 100 ng/mL AFP, requires that both

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hnRNP K and AFP are abnormal, and it increased specificity and accuracy to 96% and 72.5%, respectively, at the expense of sensitivity (33.33%) when early HCC were compared to late HCC. If a higher threshold of AFP (400 ng/mL) was combined with hnRNP K, the overall accuracy decrease either in the parallel test (62.5% vs 55%) or in the serial test (72.5% vs 70%), suggested that the combination of fixed hnRNP K with relative lower AFP (100 ng/mL) as a cutoff threshold was more powerful to diagnose early HCC. Discussion The pathogenesis of liver cirrhosis consists of 4 stage: 1. Redox alterations, 2. Oxidant stresses, 3. Inflammatory cell infiltration and activation, and 4.Centrilobular hypoxia. First, ADH mediated Etholoxidation leads to reduction of oxidized (NAD+) to NADH. Increased NADH shifts redoxstate of hepatocytes which affects other NAD+ dependent processes including Lipid & CHO metabolism leading to hepatic steatosis whichNADH provoke steatosis by stimulating fatty acid synthesis & inhibiting mitochondrial beta oxidation. Fatty acids accumulate in hepatocytes& are stored as TG’s. Second, Etholoxidatnleads to formation of free radical species – hydroxyethyl, super oxide, & hydroxyl radical which inflicts oxidative damage to intracellular compounds which consists 4 process: 1. attack unsaturated lipids causes lipid peroxidation and lead to tissue damage & fibrosis, 2. attack DNA causing deletion & mutations and lead to mitochondrial dysfunction, 3. decrease antioxidant defenses by decreasing amounts of Vitamin A and E which increase hepatic lipid peroxidation and cause lysosomal damage, and 4. decrease glutathione. Third, induce 2 process, 1.Kuppfer cell activation & cytokine production example TNF, IL 1, IL 6, IL 8 causing oxidative injury, 2. Immune response to altered hepatocellularproteins (caused by oxidative injury) leading to formation of Abs. And the last, fourth, due to increase O2 demand for ethanol

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metabolism, a zone of hypoxia around central veins, which is the farthest from oxygenated blood, develops. (Figure 10) Lymphoid cells are supposed to be the major source of IL-22 [18], though cells of the macrophage/dendritic cell type have been likewise reported to be capable of producing the cytokine [19,20]. In contrast, major liver targets of IL-22 are certainly hepatocytes which express functional IL-22 receptors to a large extent [21]. In the present study, we performed immunohistochemistry to confirm IL-22 expression in cirrhotic livers. Indeed, IL-22 was detectable in non-parenchymal cells in the hepatic lobe and in areas of necroinflammation. These observations are in agreement with previous data from patients and murine models, suggesting that the liver is an important source of serum IL22 under conditions of hepatic inflammation/injury [22,23]. The potential role of IL-22 in liver diseases has been intensively studied in murine models for T cell-mediated hepatitis [24], fulminant hepatic failure [30], alcoholic liver injury [22] and regeneration after hepatectomy [25]. In those models, IL22 attenuated liver injury [20,22], prevented hepatic failure [24] and improved hepatic steatosis [24]. On the other hand, blockage of IL-22 bioactivity increased liver injury [20] and was associated with decreased hepatocyte proliferation following hepatectomy [31]. On the whole, with the exception of experimental hepatitis B virus infection [32], murine models largely suggest a tissue protective function of IL-22 in hepatic disorders. The limited data available suggest increased serum IL-22 in patients with acute HBV infection [33] and in patients with chronic hepatitis [34], respectively. This latter study also links hepatocarcinogenesis to IL-22 function. IL-22 may be particularly important for outcome of liver cirrhosis. To relate systemic IL-22 to the prognosis of clinical liver cirrhosis, prospective cohort study in which patients with advanced liver cirrhosis were consecutively enrolled and longitudinally followed. Our data show that,

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compared to healthy donors, IL-22 serum levels were significantly elevated in patients with liver cirrhosis. Furthermore, elevated IL-22 levels were associated with liverrelated complications, such as ascites, hepatorenal syndrome and spontaneous bacterial peritonitis. These observations altogether indicate that high IL-22 serum levels may reflect the severity of liver disease. IL-22 sera contents in healthy donors were, for the most part, barely detectable and set the basis for calculation of a reference range. This reference range defined levels below 18 pg/ml as being normal (ULN), which agrees with previous reports on IL-22 in sera of healthy donors obtained in the US and Europe [35, 36, 37]. According to this threshold, 47.5% of patients with liver cirrhosis showed elevated IL-22 serum concentrations. Follow-up analyses of serum IL-22 levels in patients with liver cirrhosis suggest that mean IL-22 levels increase during the course of liver disease. The majority of patients with elevated IL-22 baseline levels maintain elevated levels during follow-up, while more than half of patients with normal IL-22 serum levels at baseline develop increased levels during follow-up. These results indicate that IL-22 elevation is not a transient phenomenon in patients with liver cirrhosis. The mechanisms mediating this IL-22 increase in the patients are not yet clear. However, it can be assumed that increasing IL-22 levels are connected with increased cytokine production as well as reduced hepatic or renal elimination. No difference between IL-22 produced in cirrhosis liver by different etiologies. The MELD score includes three blood surrogate parameters addressing different aspects of liver deterioration. INR and bilirubin reflect liver synthetic capacity and excretory function, while creatinine indicates renal decompensation due to hepatic failure. IL-22 serum levels correlated with two parameters of the MELD score, that is, creatinine and INR. Furthermore, weak inverse correlations were observed between systemic IL-22 and serum

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albumin and ALT. IL-22 also correlated with CRP, a well-established surrogate marker of hepatic inflammation and prognosis of liver cirrhosis. CRP and creatinine were both associated with serum IL-22, further suggesting that enhanced systemic IL-22 is driven by hepatic inflammation along with renal deterioration. Whether IL-22 bioactivity likewise contributes to renal deterioration is unknown. Development of HCC is a complex process involving multiple changes in gene and protein expression. It usually occurs in the presence of liver cirrhosis. Detection of early HCC in patients with chronic liver cirrhosis is crucial, since the most effective treatments for early HCC are curative. Patients diagnosed at an early HCC stage are optimal candidates for resection, liver transplantation, or percutaneous ablation with the possibility of long term cure. We identify disease-related proteins present in the early HCC tumor tissues by tissue proteomics, which would lead to a better understanding of the mechanisms driving tumor development could provide useful biomarkers for early detection and prognostic prediction. HnRNP K was selected to be identified and further validated both because of its high expression level in HCC tissue compared to the cirrhosis control, and its capability of distinguishing early HCC from late HCC. Validation of aberrant expression of hnRNP K in additional independent HCC tissues further reinforced the use of hnRNP K as a potential tumor marker. Correlation analysis showed that hnRNP K was not only a potential biomarker for the detection of early HCC, but also the expression level of this protein was positively correlated with the increased tumor size and the presence of microsatellites. This demonstrated that hnRNP K overexpression may be related to active tumor growth and intrahepatic micrometastasis. In the present study, we found that hnRNP K is overexpressed in individuals with HCC of all sizes and that it could distinguish early HCC from late HCC. This

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makes it a candidate biomarker for HCC screening in patients with high risk HBV infection. We compared the capability of tissue hnRNP K with serum AFP (cut off thresholds: 100 ng/mL) in diagnosing early HCC, and as expected, hnRNP K showed a better performance than AFP in detecting early HCC (sensitivity: 66.7% vs. 64.29%, specificity: 84% vs. 56%). Because a single biomarker will not provide information regarding both tissue type and malignant transformation throughout the various stages of tumor development and progression, we further combined tissue hnRNP K intensity and serum AFP concentration to form a biomarker panel. This enhanced both the sensitivity and specificity by parallel and serial tests.The results showed that parallel test with tissue hnRNP K intensity and serum AFP cutoff thresholds optimized sensitivity (93.33%), whereas serial test optimized test specificity (96%). The combined use of hnRNP K and serum AFP has improved utility for screening and diagnosing early HCC in cirrhotic tissue. Our study describes for the first time the usefulness of hnRNP K as a tumor biomarker for detecting early HCC, especially the detection of early HCC from liver cirrhosis. The 2-DE and immunohistochemistry data showed that hnRNP K is a specific biomarker for tumor tissue. Detecting hnRNP K expression in tissue may facilitate the accuracy of HCC diagnosis. Both the general histodiagnosis of small nodules and the distinction of highgrade dysplastic nodules form early HCC are extremely challenging, a positivity of hnRNP K staining in tissue could be taken as indicator of HCC. (Figure 9) Conclusion Elevation of IL-22 levels are predictive for reduced survival in patients with liver cirrhosis independent of age, presence of liverrelated complications, CRP, creatinine and the MELD score. Our data indicate that processes in the liver that lead to deterioration of liver cirrhosis and its sequelae are associated with an increase of

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IL-22. In here, we demonstrate cut-off threshold for IL-22 is > 18 pg/ml. To diagnose fastly present of tumor tissue type and malignant we because a single biomarker will not provide information regarding both tissue type and malignant transformation throughout the various stages of tumor development and progression, we further combined tissue hnRNP K intensity and serum AFP concentration to form a biomarker panel. This enhanced both the sensitivity and specificity by parallel and serial tests. The results showed that parallel test with tissue hnRNP K intensity and serum AFP with cut-off threshold hnRNP K ≥7.160 ppm and AFP ≥ 100 ng/mL optimized sensitivity (93.33%), whereas serial test optimized test specificity (96%). The combined use of hnRNP K and serum AFP has improved utility for screening and diagnosing early HCC in cirrhotic tissue. The combination between IL-22 > 18 pg/ml and heterogeneous ribonucleoprotein K (hRNP K)-AFP ≥7.160 ppm and ≥ 100 ng/mL will bring a better prognosis and prediction, in long term and acute prediction, respectively. (Table 2) References 1. Arey LB, Burrows W, Greenhill JP, Hewitt RM, editors board. Dorland’sillustrated medical dictionary 23rd edition. Philadlphia: Press of W.B SaundersCompanty;1962:286. 2. Duffin JM. Why does cirrhosis belong to Laennec? CMAJ 1987;137:393-396 3. Anthony PP, Ishak KG, Nayak NC, Poulsen HE, Scheuer PJ, Sobin LH. Themorphology of cirrhosis. Recommendations on definition, nomenclature, and classification by a working group sponsored by the World HealthOrganization. J Clin Pathol 1978;31:395-414 4. European Association for the Study of the Liver: EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol 2010, 53:397-417.

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5. Iredale JP, Guha IN. The evolution of cirrhosis. In: Textbook of hepatology from basic science to clinical practice. 3rd edition. Edited by Rodés J, Benhamou J-P, Blei A, Reichen J, Rizzetto M. Oxford, Blackwell Publishing 2007:583-589.. 6 Wynn T. Cellular and molecular mechanisms of fibrosis. J Pathol2008;214:199-210. 7. Wolk K, Witte E, Witte K, Warszawska K, Sabat R: Biology of interleukin-22. Semin Immunopathol 2010, 32:17-31. 8. Sonnenberg GF, Fouser LA, Artis D: Border patrol: regulation of immunity, inflammation and tissue homeostasis at barrier surfaces by IL-22. Nat Immunol 2011, 12:383-390. 9. Lafdil F, Miller AM, Ki SH, Gao B: Th17 cells and their associated cytokinesin liver diseases. Cell Mol Immunol 2010, 7:250-254. 10. Jiang R, Tan Z, Deng L, Chen Y, Xia Y, Gao Y, Wang X, Sun B: Interleukin-22 promotes human hepatocellular carcinoma by activation of STAT3. Hepatology 2011, 54:900-909. 11. Zhang Y, Cobleigh MA, Lian J, Huang C, Booth CJ, Bai X, Robek MD: A proinflammatory role for interleukin-22 in the immune response to hepatitis B virus. Gastroenterology 2011, 141:18971906. 12. Dambacher J, Beigel F, Zitzmann K, Heeg MHJ, Göke B, Diepolder HM, Auernhammer CJ, Brand S: The role of interleukin-22 in hepatitis C virus infection. Cytokine 2008, 41:209-216. 13. Park O, Wang H, Weng H, Feigenbaum L, Li H, Yin S, Ki SH, Yoo SH, Dooley S, Wang F, Young HA, Gao B: In vivo consequences of liverspecific interleukin22 expression in mice: Implications for human liver disease progression. Hepatology 2011, 54:252-261. 14. Bosch FX, Ribes J, Cleries R, Diaz M: Epidemiology of hepatocellular carcinoma. Clin Liver Dis 2005, 9:191– 211. v. 15. Rabe C, Pilz T, Klostermann C, Berna M, Schild HH, Sauerbruch T, Caselmann

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WH: Clinical characteristics and outcome of a cohort of 101 patients with hepatocellular carcinoma. World J Gastroenterol 2001, 7:208–215. 16. Kondo T: Tissue proteomics for cancer biomarker development: laser microdissection and 2D-DIGE. BMB Rep 2008, 41:626–634. 17. Elrick MM, Walgren JL, Mitchell MD, Thompson DC: Proteomics: recent applications and new technologies. Basic Clin Pharmacol Toxicol 2006, 98:432– 441. 18. Wolk K, Witte E, Witte K, Warszawska K, Sabat R: Biology of interleukin-22. Semin Immunopathol 2010, 32:17-31. 19. Wolk K, Witte E, Wallace E, Döcke W, Kunz S, Asadullah K, Volk H, Sterry W, Sabat R: IL-22 regulates the expression of genes responsible for antimicrobial defense, cellular differentiation, and mobility in keratinocytes: a potential role in psoriasis. Eur J Immunol 2006, 36:1309-1323. 20. Bingold TM, Ziesché E, Scheller B, Sadik CD, Franck K, Just L, Sartorius S, Wahrmann M, Wissing H, Zwissler B, Pfeilschifter J, Mühl H: Interleukin-22 detected in patients with abdominal sepsis. Shock 2010, 34:337-340. 21. Zheng Y, Valdez PA, Danilenko DM, Hu Y, Sa SM, Gong Q, Abbas AR, Modrusan Z, Ghilardi N, de Sauvage FJ, Ouyang W: Interleukin-22 mediates early host defense against attaching and effacing bacterial pathogens. Nat Med 2008, 14:282-289. 22. Sugimoto K, Ogawa A, Mizoguchi E, Shimomura Y, Andoh A, Bhan AK, Blumberg RS, Xavier RJ, Mizoguchi A: IL-22 ameliorates intestinal inflammation in a mouse model of ulcerative colitis. J Clin Invest 2008, 118:534-544. 23. Ziesché E, Bachmann M, Kleinert H, Pfeilschifter J, Mühl H: The interleukin22/STAT3 pathway potentiates expression of inducible nitric-oxide synthase in human colon carcinoma cells. J Biol Chem 2007, 282:16006-16015.

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24. Radaeva S, Sun R, Pan H, Hong F, Gao B: Interleukin 22 (IL-22) plays a protective role in T cell-mediated murine hepatitis: IL-22 is a survival factor for hepatocytes via STAT3 activation. Hepatology 2004, 39:1332-1342. 25. Ki SH, Park O, Zheng M, MoralesIbanez O, Kolls JK, Bataller R, Gao B: Interleukin-22 treatment ameliorates alcoholic liver injury in a murine model of chronic-binge ethanol feeding: role of signal transducer and activator of transcription 3. Hepatology 2010, 52:1291-1300. 26. Jiang R, Tan Z, Deng L, Chen Y, Xia Y, Gao Y, Wang X, Sun B: Interleukin-22 promotes human hepatocellular carcinoma by activation of STAT3. Hepatology 2011, 54:900-909. 27. Zhang Y, Cobleigh MA, Lian J, Huang C, Booth CJ, Bai X, Robek MD: A proinflammatory role for interleukin-22 in the immune response to hepatitis B virus. Gastroenterology 2011, 141:18971906. 28. Park O, Wang H, Weng H, Feigenbaum L, Li H, Yin S, Ki SH, Yoo SH, Dooley S, Wang F, Young HA, Gao B: In vivo consequences of liverspecific interleukin22 expression in mice: Implications for human liver disease progression. Hepatology 2011, 54:252-261. 29. Leipe J, Schramm MA, Grunke M, Baeuerle M, Dechant C, Nigg AP, Witt MN, Vielhauer V, Reindl CS, SchulzeKoops H, Skapenko A: Interleukin 22 serum levels are associated with radiographic progression in rheumatoid arthritis. Ann Rheum Dis 2011, 70:14531457. 30. Córdoba J: New assessment of hepatic encephalopathy. J Hepatol 2011, 54:1030-1040. 31. Pickert G, Neufert C, Leppkes M, Zheng Y, Wittkopf N, Warntjen M, Lehr H, Hirth S, Weigmann B, Wirtz S, Ouyang W, Neurath MF, Becker C: STAT3 links IL-22 signaling in intestinal epithelial cells to mucosal wound healing. J Exp Med 2009, 206:1465-1472

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32. Xing W, Zou M, Liu S, Xu T, Gao J, Wang J, Xu D: Hepatoprotective effects of IL-22 on fulminant hepatic failure induced by d-galactosamine and lipopolysaccharide in mice. Cytokine 2011, 56:174-179. 33. Ren X, Hu B, Colletti LM: IL-22 is involved in liver regeneration after hepatectomy. Am J Physiol Gastrointest Liver Physiol 2010, 298:74-80. 34. Lavoie TN, Stewart CM, Berg KM, Li Y, Nguyen CQ: Expression of interleukin-22 in Sjögren’s syndrome: significant correlation with disease parameters. Scand J Immunol 2011, 74:377-382

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35. Feng JT, Liu YK, Song HY, Dai Z, Qin LX, Almofti MR, Fang CY, Lu HJ, Yang PY, Tang ZY: Heat-shock protein 27: a potential biomarker for hepatocellular carcinoma identified by serum proteome analysis. Proteomics 2005, 5:4581–4588. 36. Yi X, Luk JM, Lee NP, Peng J, Leng X, Guan XY, Lau GK, Beretta L, Fan ST: Association of mortalin (HSPA9) with liver cancer metastasis and prediction for early tumor recurrence. Mol Cell Proteomics 2008, 7:315–325. 37. Ostrowski J, Bomsztyk K: Nuclear shift of hnRNP K protein in neoplasms and other states of enhanced cell proliferation. Br J Cancer 2003, 89:1493–1501.

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Lec A Specific Protein Utilization In Staphyococcus aureus Biofilm Bacteria As A Vaccine Candidate For The Prevention Of Chronic Amoebic Dysentery Caused By The Protozoan Entamoeba histolytica Ivan Bintang Pratama, Dwi Fitria Rahayuningwati, Dewangga Primananda Susanto, Januardi Indra. Medical Student, University of Brawijaya, Indonesia ABSTRACT Background: Indonesia is at the first position in Southeastern Asia and India is in the first position for the case of amoebic in Asia. Unfortunately, it is difficult to detect patients with amoebic early. However, it is known that high numbers of patient are tested and positive for amoebic and has severe clinical manifestations such as colon ulcers that cause injury to the colon membrane. In the acute stage, patients with amobiasis are characterized by the presence of blood and mucus in the stool. While on chronic stage, characterized by the clinical manifestation that much more severe like abscess in organs including liver, lungs, and the brain. Material and Methods: True experimental design in vivo using draft Post Test Only Randomized Controlled Group Design. Wistar rats as experimental animals were divided into 5 groups with different doses of Lec A protein each treatment. Result: The results showed that the vaccine is able to increase rat IgG immune response was significantly (p < 0,05). Pearson test of the effect with increasing doses of IgG showed significant results (R = 0.889). The results of the experimental animals that have been vaccinated and induced Entamoeba histolytica is also able to increase rat IgG immune response was significantly (p < 0,05). Pearson test of the effect with increasing doses of IgG showed significant results (R = 0.970). Macroscopic observation of the data found a positive control colon ulcer formation and liver abscess, while the P1, P2 and P3 are not found ulcer formation colon and liver abscess. Microscopic observation of the negative control was found picture of cysts in the stool, while the P1, P2 and P3 are not found picture of cysts in the stool. Conclusion: Lec A protein able to increase rat IgG levels and prevents the formation of ulcers colon and liver abscess as a clinical manifestation of amoebic. Keywords: Amoebic, Entamoeba histolytica, Staphylococcus aureus, Lec A Protein, IgG, vaccines. INTRODUCTION Amoebic is a state of the presence of Entamoeba histolytica with or without clinical manifestations and called food borne disease. Entamoeba histolytica also cause dysentery amoeba, cosmopolitan distribution is often found in the tropics and subtropics, especially in areas with weak socioeconomic, poor sanitation, and hygiene. Amoebic according to the WHO classification is divided into asymptomatic and symptomatic, which included being the amoebic symptomatic is intestinal amoebic and for examples are dysentery, non dysentery colitis, as well as containing amoebic cysts Entamoeba

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histolyticaappendicitis who has clinical symptoms (symptomatic) or not (asymptomatic) (Rasmaliah 2003). Based on Riset Kesehatan Dasar Health (Riskesdas) a research about prevelance of amoebic in Indonesia on 2007 showed a national prevalence of diarrhea in Indonesia (based diagnosis and medical personnel complaint respondents) are as much as 9%. In Indonesia, there are 14 provinces that have high levels of etiology about amoebic. The province of Nanggroe Aceh Darussalam (NAD) has an incidence rate as much as 18.9% and lowest is the Yogyakarta which reached up to 4.2%. The prevalence of diarrhea is 13% more rural in urban areas.

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When stratified by group of infectious diseases, the proportion of deaths due to diarrhea was 13.2%, which was ranked 4 out of 10 as the causes of death in Indonesia. Highest cause of deaths due to diarrhea in the age group of 29 days until 11 months are 31.4% and aged 1 until 4 years are 25.2%. During the year 2008, Indonesia was reported to have occurred the outbreak of diarrhea in 15 provinces with the number of patients as much as 8,443 people and 209 people died (Case Fatality Rate / CFR = 2.48%) and most of it are caused by Entamoeba histolytica that lead to amoebic. Based on US Census Bureau International Database (2004), Indonesia is at the first position in Southeastern Asia about prevalence of amoebic. And from the same International Database, India is in the first position for the case of amoebic in Asia. Unfortunately, it is difficult to detect patients with amoebic early. This is because the early symptoms of amoebic are often overlooked and not being considered as life threatening symptoms. Society considers amoebic is just a kind of ordinary diarrhea. However, it is known that high numbers of patient are tested and positive for amoebic and have severe clinical manifestations such as colon ulcers that cause injury to the colon membrane. The stool of patients with amoebic is in form of mucus and blood. Patients were also impaired in the Gastro Intestinal Tract (GIT) due to ulcers in the colon. In the acute stage, patients with amobiasis are characterized by the presence of blood and mucus in the stool. While on chronic stage, amoebic patients are characterized by the clinical manifestation that much more severe like abscess in organs including liver, lungs, and the brain. Chronic stage is the most severe stage of amoebic. Patients who had entered the chronic stage should receive intensive care in hospital (Craig, 2005). Until now, treatment that is used in the form of drugs has a high level of toxicity and a lot of side effects such as nausea, diarrhea, and a metallic taste. Moreover, it could cause hypersensitive and in the high doses or prolonged use can cause side

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effects such as leucopenia, neutropenia, and peripheral neuropathy (Russell, 1996). Staphylococcus aureus is a gram-positive group of bacteria commonly found in the nose and skin colonize approximately 2530% in healthy adults (Shiel, 2012). Culturing Staphylococcus aureus is much easier to do compared to culturing Entamoeba histolytica. Staphylococcus aureus has the same protein structure similarity with Entamoeba histolytica is Gal / GalNAc lectin that is specific recombinant protein on Gal / GalNAc lectin in the Lec A part ( Houpt, 2004). Lec A is one component of a defense that artifacts in Entamoeba histolytica protozoan that helps in adhesion on certain surfaces such as the intestinal wall engraving small pores and helps trophozoite spread to other organs. In addition, Gal / GalNAc lectin Lec A is also resistant to the lysis by complement and assist in the process of encystment (Mann, 2002). Humans have a defense system against foreign substances that enter the body called the body's immune system. There are two types of the immune system, innate immune system and adaptive immune system. Amoebic vaccine is an innovation that affecting the function of human adaptive immune system (Abbas, 2004). Research goals are including the general objective and special ojective. The general objective is to obtain the evidence that the Lec A protein from the Staphylococcus aureus bacterium can giving response in improving the specific antibody response Immunoglobulin G (IgG) against Entamoeba histolytica that can be used as a vaccine for Amoebic. The specific objective is to determine the increase in specific IgG antibody responses in mice models ( Rattus norvegicus ) that were conditioned amoebic by infecting Entamoeba histolytica into the mice models after the administration of Lec A protein from Staphylococcus aureus, and determine the ability of Lec A protein from Staphylococcus aureus bacteria as potential candidates of vaccine for the main prevention of amoebic that mainly occurred in Asia.

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MATERIAL AND METHODS Research Design This study uses a true experimental design in the laboratory by in vivo method using the Randomized Post Test Only Controlled Group Design. The Sample Studies Sample studies using rat models (Rattus norvegicus) female Wistar strain were then given some treatment. The calculation of repetition in the sample is ( t - 1 ) ( r - 1 ) ≥ 15 , t : number of treatments , r : number of repetitions . In this study, t = 5 so: (5-1) (r-1) ≥ 15  r-1 ≥ 15:4  r = 3.75 + 1 = 4.75  rounding into 5 Research Variables Independent variable in this study is the amoebic vaccine administration and the induction of Entameba histolytica in trophozoite phase that divided into several groups : negative control ( no treatment ) , Positive Control ( induction of Entamoeba histolytica trophozoite for amoebic infection) , P1 (Lec A protein 0.1 cc / KgBW + induction of Entamoeba histolytica trophozoite ), P2 (Lec A protein 0.15 cc / KgBW + induction of Entamoeba histolytica trophozoite ) ; P3 (Lec A protein 0.2 / KgBW + induction of Entamoeba histolytica trophozoite ) . Dependent variable consisted of ( a) the levels of IgG , (b ) the number of Entamoba histolytica cyst Research Methods a. Culture of Staphylococcus aureus Small number of Staphylococcus aureus were taken from the colonies in the BAP (Blood Agar Plate) medium and replanted in two mediums, the MSA (Mannitol Salt Agar) medium , incubated at 37 °C for 24 hours, and the Brain Heart infusion (BHI) enriched media, incubated at 37 ° C for 1218 hours . b . Isolation of Lec A protein from Staphylococcus aureus Modification performed in the sample part that was pellet deposition at the last rotate. Pellets were suspended with PBS pH 7.4 until its volume reaches 5 times than before, then added n - octyl - β -

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Diglucopyranosyde ( NOG ) so the concentration reaches 0.05 % . Then performed homogenization using vortex with full speed for 1 minute. After completing the homogenization process, then preformed centrifugation with a speed of 12000 rpm at 4 °C for 15 minutes. Biofilm layer was taken from the platelet sedimentation and isolated with the same way as the steps above. This treatment was repeated up to six times until the amount of biofilm needed is adequate for further process. Molecular weight monitoring was done using SDS – PAGE 42 kDa. 500 ml of the samples that has been diluted with PBS was taken and heated 100°C for 5 minutes in 500 ml of buffer solution containing 5 mM Tris HCl pH 6.8, 2 - mercapto ethanol 5 % , w / v sodium dodecyl sulfate 2.5 % , v / v glyserol 10 % with Bromophenol blue as the color tracer. Mini slab gel 12.5 % with tracking gel of 4% were chooses. Voltage used was 125 mV. Dye that used was coomassie brilliant blue. Sigma range marker standard molecules are used to determine the molecular weight of the antigen to be used. c. Extraction of Lec A Electrophoresis performed at protein of Staphylococcus aureus to obtain Lec A that would be used as the active matter of amoebic vaccine. Gel was cut straight to the desired molecular weight and the ribbon pieces were collected and put in a dialysis membrane tube using electrophoresis running buffer. Electroelution then performed using a horizontal electrophoresis apparatus with 125 mV voltages for 25 min. Electrophoresis results was dialyzed with PBS buffer pH 7.4 for 2 X 24 hours @ 2 liter and replaced 3 times. d. Addition of Adjuvant Complete Freund’s adjuvant (CFA) and Incomplete Freund's Adjuvant (IFA) was ready for use in a liquid suspension state without the need for prior preparation process. The reason for choosing CFA and IFA in the manufacture of this vaccine was to increase the amount of IgG so that antibody formation can be accelerated. Mix

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adjuvant with Lec A from Staphylococcus aureus at a ratio of 1:1 by vortexing. e. Booster The vaccine was injected intraperitoneal (i.p ). Treatment group 1 received Lec A 0.1 cc / KgBW ; Treatment Group 2 received Lec A of 0.15 cc / KgBW ; Treatment Group 3 received a 0.2 cc Lec A/ KgBW . f. Decision Blood Blood of mice from each group were taken as much as + 1 cc via lateral vein from tail. g. Checking IgG The first process was the antigen coating by adding antigen into the test container. Close the plate and incubated for 24 hours in a temperature of 24o C. Antigen that has been incubated removed from the test container (wells) and then washed twice with PBST buffer solution and being shaken for 5 minutes for each washing. Then the buffer solution in the wells was removed. Add blocking buffer to block the empty wells. Subsequently performed incubation for 1 hour in temperatures of 24 oC. Then read using ELISA reader to determine the levels of IgG from each group. h. Amoebic Conditioning Rats (Rattus norvegicus ) wistar strain which had been vaccinated was set to be infected by inducing the rats with Entamoeba histolytica for amoebic status. RESULT Five groups consisting of Negative control (no treatment), Positive Control (induction of Entamoeba histolytica trophozoite), P1 (Lec A protein 0.1 cc/KgBW + induction of Entamoeba histolytica trophozoite), P2 (Lec A protein)

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i. Entamoeba histolytica Cyst Observation and State of Animal Models Intestines Observations performed with light microscopes. Observations aim to detect the presence of cysts in the feces. At observation, samples were dyed with eosin to facilitate observations of Entamoeba histolytica cyst. The purpose of observations on gut of animal models was to see if there is the formation of ulcers caused by Entamoeba histolytica trophozoit attachment. j. Data Collection and Analysis Procedures The data taken were in the form of the measurement of rat IgG, the state of rat intestinal macroscopic, and microscopic observation of cysts in rat feces. Analysis which conducted were normality test and variant test. If the distribution of normal and variant data were the same (p > 0.05) then one way ANOVA test hypotheses would be performed . However, if not equal (p < 0.05) Kruskal Wallis test would be used. Furthermore, post hoc Tukey test is performed as a follow-up of one way ANOVA, and Mann Whitney test was performed as a follow-up Kruskal Wallis to determine significant differences within each group. The differences in each group were valued meaningful or significant if p <0.05. Statistical test were checked with SPSS 16.

0.15 cc/KgBW + induction of Entamoeba histolytica trophozoite); P3 (Lec A protein 0.2/KgBW + induction of Entamoeba histolytica trophozoite) obtained the following data:

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a)

b)

Different notation indicates a significant difference (p <0.05) a) The results of measurements of IgG after vaccination. ANOVA test data obtained from the value of p = 0.042. b) The results of the correlation between increased IgG test with different doses of each treatment after vaccination. Pearson test score is R = 0.889 and p = 0.003

a)

b)

Different notation indicates a significant difference (p <0.05) a) The results of measurements of IgG after induction E.histolytica. ANOVA test data obtained from the value of p = 0.004. b) The results of the correlation between increased IgG test with different doses of each treatment after induction E.histolytica. Pearson test score is R = 0.970 and p = 0.000 Macroscopic observations circumstances bowel (colon ulcers) and liver abscess in each group of data obtained as follows: Kelompok Negative Control Positive Control P1 P2 P3

Ulcer Colon Negative (-) Positive (+) Negative (-) Negative (-) Negative (-)

Liver Abscess Negative (-) Positive (+) Negative (-) Negative (-) Negative (-)

Cyst Negative (-) Positive (+) Negative (-) Negative (-) Negative (-)

Based on the figure, we can conclude that which is a positive control group given the vaccine without colon ulcers are formed and liver abscess. While in the P1, P2, and P3 was not

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found colon ulcer formation and liver abscess after being given the vaccine. This suggests giving protein Lec A can prevent the formation of ulcers in the colon and liver abscess.

Pictue 1. Microscopic observation of Entamoba histolytica cysts on positive control group

Picture 4. Macroscopic observation of the colon for each treatment group

Pictue 2. Microscopic observation of feces each treatment group

Picture 5. Macroscopic observation of healthy liver (negative control) and liver abscess (positive control)

Picture 3. Macroscopic observation of the colon without ulcer colon formation DISCUSSION One of the proteins that are present in Entamoeba histolytica Gal/GalNAc lectin, and the specific recombinant is Lec A. Lec A is one component of defense in Entamoeba histolytica protozoan that helps

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Picture 6. Macroscopic observation of liver each treatment group adhesion on certain surfaces such as the intestinal mucosa beyond will bring small pores which can lead to the inclusion of trophozoite to other sites. To kill the host cells required trophozoite Entamoeba histolytica contact with Gal/GalNAc lectin.

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Inhibition by Gal/GalNAc lectin will prevent damage to the host cell. Activation of Gal/GalNAc lectin can reduce about 90% abscess ( Petri , 2000) . Inducing Gal/GalNAc lectin is able to increase the specific antibody response (IgG) of the host cell. In addition, Gal/GalNAc lectins are also resistant to lysis by complement and assist in the process of encystment (Mann, 2002). One of the innovations for the prevention of amoebic by using Gal/GalNAc lectin found on Stapylococcus areus. The principle of vaccination is to produce an increase in IgG antibody immune response that acts as a receptor that will recognize specific antigens contained in the Gal/GalNAc lectin in Entamoeba histolytica and continues to destroy the parasite. IgG antibodies has advantages over other antibodies. Serum IgG levels more easily stimulated and is the highest number of antibodies in the body (Houpt , 2004) . Amoebic vaccine candidate consists of Lec A from Staphyoccocus aureus protein and adjuvant injected into the body through blood vessels by using a syringe. Lec A Protein will be identified by the immune system that is useful macrophages to destroy foreign proteins in the body. After Lec A Protein is destroyed , part of the antigen protein called LecA protein complex taken toward MHC antigen protein that serves to forward the Lec A protein complex leading to B cells so that B cells differentiate into memory cells to recognize the protein complex in Lec A protein long periods of time and to activate effector cells specific antibodies against Entamoeba hystolitica into our bodies will be recognized by the immune system and antibodies such as IgG and destroy so Amoebic can be prevented. CONCLUSION The conclusion of this research was the Lec A protein can increase IgG as quantitative immune response in wistar strain rat model (p <0.05), after administration of Lec A protein and Entamoeba histolytica induced into experimental animals, IgG immune response

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were increased significantly (p <0,05). Cyst formation was not found in the feces of wistar rat model that has been given Lec A protein. Giving Lec A protein can prevent the formation of colon ulcers and liver abscess as the clinical manifestation of amoebic. Based on the research, it can be concluded that Lec A protein can be used as a potential vaccine candidate against amoebic. REFERENCES Abbas, Abul K., Andrew H. Lichtman. 2004. “Basic Immunology” Philadelphia. Elsevier : 3;5 Barroso L, Houpt E, Lockhart L, et al. 2010.“Prevention of intestinal amebiasis by vaccination with the Entamoeba histolytica Gal/GalNac lectin”. Vaccine;22(5–6):611–617. Craig,W. A. W. M. Scheld, J. M. Hughes. 2005. “Amebiasis, an emerging disease”. Emerging infections 5.ASM Press, Washington, D.C.p. 197-212. Houpt, Eric, Lisa Barroso, Lauren Lockhart, et al. 2004. “Prevention of intestinal amebiasis by vaccination with the Entamoeba histolytica Gal/GalNac lectin”, vol 22. Issues 5–6, 26: 612–618. Mann BJ. 2002. ”Structure and function of Entamoeba histolytica Gal/GalNac lectin”. Retrieved October, 8 2012 from http://www.ncbi.nlm.nih.gov/pubmed/12 049210 Plotkin S. 2008. ”Vaccines: correlates of vaccine-induced immunity”. Retrieved October, 8 2012 from http://www.ncbi.nlm.nih.gov/sites/entrez ?db=pubmed&cmd=Search&term=Clin %20Infect%20Dis[Jour]+AND+47[Volu me]+AND+401[page]plotkin%20s Rasmaliah. 2003. “Epidominologi Amoebiasis Dan Upaya Pencegahannya”. Retrieved October, 5 2012 from http://repository.usu.ac.id/bitstream/1234 56789/3770/1/fkm.rasmaliah.pdf . Russell,S. J.; R. A.; Conradi, S. E.. 1996. "Sudden death due to metronidazole/ethanol interaction". The American Journal of Forensic Medicine and Pathology 17 (4): 343–346

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Seigneur, Marie, Joelle Mounier, et al. 2005. “Entamoeba histolytica binds to human enterocytes”. Journal Cellular Microbiology;(2005) (4), 569–579

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World Health Organization.1968.“Initiative For Vaccine Research”. Retrieved October, 5 2012 from http://www.who.int/vaccine_research/dis eases/soa_parasitic/en/index1.html.

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THE POTENTIAL EFFECT OF MUSIC THERAPY FOR IMPROVING THE QUALITY OF LIVE OF STROKE PATIENTS Januardi Indra, Furqan Hidayatullah, Veronica Verina Setyabudhi Medical Faculty of Brawijaya University, Malang, Indonesia ABSTRACT Background - Stroke is a leading cause of death in the United States. Over 800,000 people die in the U.S. each year from cardiovascular disease and strokes. There are approximately 1.1 million stroke survivors living in United Kingdom. Stroke has a very high prevalence in Indonesia, it is estimated that more than 17,000,000 people is suffer from stroke. It is known that one in five strokes developed into fatal. It means that, every year in Indonesia more than 3000,000 people die because of strokes, yet the stroke treatment and therapy is found to be not adequate Methods - This is a systematical review study by analyzing the two kinds of experiments such as bio-chemical based experiment that analyzing the effect of music in our brain and body using MRI and any other kind of instrumentals to identify the chemical change that happening inside our brain and body after given some session of music therapy and the clinical symptom experiments whose subjects are people in a post-stroke rehabilitation which stimulated with music in their training session compared with the group that wasn’t stimulated and then analyzed the change that happened to both of the subject which then conclude as a systematic writing. Results - Table 3 showed the effect of music in decreasing the Beck Depression Inventory (BDI) and Beck Anxiety inventory (BAI) which indicate a positive result of the treatment with music in changing the mood. Music therapy can also influence the cognitive performance, reduce pain, and work as a functional therapy for the psychomotor. Conclusion - Music therapy can reduce the symptoms of post- stroke symptoms such as impaired psychomotor, cognitive, aphasia, body stress respond and mood significantly. Thus make it a potential treatment since it also cheap and non-invasive INTRODUCTION Stroke is a leading cause of death in the United States. Over 800,000 people die in the U.S. each year from cardiovascular disease and strokes(CDC 2013). There are approximately 1.1 million stroke survivors living in United Kingdom (Adamson, J et al., 2004). In 2010, stroke was the fourth largest cause of death in united Kingdom after cancer, heart disease and respiratory disease, causing almost 50.000 deaths (Townsend N et al., 2012).P on behalf of the IST-3 investigators (2012) IST-3 main results I Primary and secondary outcomes among 3,035 patients randomized in European Stroke Conference Abstracts, Lisbon, Portugal May 2012). Indonesia is one of the country which has the most stroke cases in the world, it is estimated that more than 17,000,000 people in Indonesia are suffering from stroke. It is known that one in five stroke developed into fatal. It means

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that, every year in Indonesia more than 3000,000 people die because of stroke. Stroke, which usually called as brain’s attack is a disease happened cause of the blockage of vascular through the brain system. The blockage of its vascular system suddenly stops the oxygen and nutritional support to the brain system. As the Brain system is highly dependable to its vascularization, the disturbance of its vascularization may lead to brain cells death. Once the brain cells are death, it can’t be turned back to a previous state. In many cases, stroke used to leave a permanent disability. Moreover as the time goes, the possibility of a stroke patient experiencing complications with other diseases grows higher and higher. There are two types of stroke in human body based on its mechanism. First tipe is ischemic stroke, this stroke is the most common stroke, it has been proved that

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ischemic stroke causes more than 85% of all stroke cases. The major causes of ischemic stroke are the blockage of brain vascularization by blood clots or fatty deposits. As human brain always needs nutrients and oxygen to fulfill its functions, the blockage of its vascularization will reduce the oxygen and nutrients flow to the brain. For every single minute the brain lost its demand of nutrients and oxygen, every single brain cell continues to develop apoptotic cycle. The other type of stroke is hemorrhagic stroke, hypertension is known as the major causes of this type of stroke. Hemorrhagic stroke occurs when a blood vessel bursts in the brain. Blood accumulates and compresses the surrounding brain tissue. Based on its location, this stroke is divided in to intracerebral hemorrhage and subarachnoid hemorrhage. Intracerebral hemorrhage is the most common type of hemorrhagic stroke. It occurs when an artery in the brain bursts, flooding the surrounding tissue with blood. Subarachnoid hemorrhage is bleeding in the area between the brain and the thin tissues that cover it. (Adam, R et al., 2009). As the main integration system in human, Brain provides some complex coordination for almost every part of human body such as cognitive, psychomotor; release several important hormones, memory, and some other. When the ischemic or hemorrhagic stroke attacked brain’s cell, the brain functions becomes weaker and ends as the death brain. Once strokes attacked human brains, its function can never be turned back into normal state. Damage of human’s brain is irreversible, and the damage on human’s brain is also leads to some disability of its function. Dysfunction of human brain can caused some effect arise, from mild disability, and even it can leads to death (Adamson, J et al., 2004). More than half of all stroke survivors are left dependent on others for everyday activities (Royal College of Physicians National Sentinel Stroke Clinical Audit 2010 Round 7 Public report for England,Wales and Northern Ireland. Prepared on behalf of theIntercollegiate Stroke Working Party May 2011 P43).

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Patient condition After stroke attack are 42% will be independent, 22% have mild disability, 14% have moderate disability, 10% have severe disability, 12% have very severe disability, these data shows that more than 50% stroke patients is independent people. Furthermore, treatment after the stroke attack is not satisfying enough. One of the most appropriate drugs after strokes attack is trombolysin, but in England Wales and Northern Ireland only 5% of patients received thrombolysis treatment in 2010, though it could have benefited 14% of patients (Sandercock, P on behalf of the IST-3 investigators (2012) IST-3 main results I Primary and secondary outcomes among 3,035 patients randomised” in European Stroke Conference Abstracts, Lisbon, Portugal May 2012.) For every 1,000 patients who receive thrombolysis, a clot busting treatment, only 80 patients will live more independently. (Royal College of Physicians (2011) National sentinel stroke clinical audit 2010 round 7. Public report for England, Wales and Northern Ireland. P34). The impact is the recurrence rates of stroke attack is still high, and as the recurrent stroke attack increase, the risk of death in it is patient is higher than before. Stroke is a chronic disease that excessively reduces a person's quality of life. Yet to achieve welfare based on WHO, one of the parameters that can be measured is the quality of life of the patients. Various complications which lead to disability in stroke patients and the low of the cure rate are one of the factors which degrade the quality of life in stroke patients. In addition, to improve its quality of live since they can’t do anything by their own when they have some severe disability, stroke patient need assistance from someone else to perform their daily living activity. However, it often requires a high number of money to taking care and assisting the ideal daily function of stroke patients in a holistic manner. If that ideal situation can’t be experience by the stroke patient, it usually make the quality of life of stroke patient is decreasing and it result to a more severe state of stroke. The current state of stroke patient management is

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still not capable to restore the post-stroke patient completely. Music is used to regulated mood and arousal in the daily life and to promote physical and psychological health and wellbeing in clinical setting (Chanda, M.L et al., 2013). The following are some of effects of music, which help to explain the effectiveness of music therapy: Research has shown that music with a strong beat can stimulate brainwaves to resonate in sync with the beat, with faster beats bringing sharper concentration and more alert thinking, and a slower tempo promoting a calm, meditative state. Also, research has found that the change in brainwave activity levels that music can bring can also enable the brain to shift speeds more easily on its own as needed, which means that music can bring lasting benefits to your state of mind, even after youâ&#x20AC;&#x2122;ve stopped listening. Music has also been found to bring many other benefits, such as lowering blood pressure (which can also reduce the risk of stroke and other health problems over time), boost immunity, ease muscle tension, and more. With so many benefits and such profound physical effects, itâ&#x20AC;&#x2122;s no surprise that so many are seeing music as an important tool to help the body in staying (or becoming) healthy. Some positive effect from music is that music can affect the secretion of some substances that regulate our body. Besides that, the released endorphin as the result of music stimulation is so essential to decrease the stress level of stroke patient so it is clinically can activate a various mechanism that can reduce the disability effect such as cognitive and psychomotor. Music is a cheap and easy thing to be applied and is one of the instruments that can be used to reduce the disability that happened to a stroke patient. METHODS A systematic review was conducted by reviewing the information from some journals as the basis of this paper. The journals are about but not limited to music therapy, stroke rehabilitation, trials of music

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therapy in some kinds of rehabilitations, music therapy effect in mood and anxiety, and other journals that related to stroke. The review process conducted by analyzing the two kinds of experiments: a bio-chemical based experiment that analyzing the effect of music in our brain and body using MRI and any other kind of instrumentals to identify the chemical change that happening inside our brain and body after given some session of music therapy and the clinical symptom experiments whose subjects are people in a post-stroke rehabilitation which stimulated with music in their training session compared with the group that wasnâ&#x20AC;&#x2122;t stimulated and then analyzed the change that happened to both of the subject either with an indirect observation with the questioner, or direct observation by observing the subjects performance or the result of the rehabilitation or using both methods. All the data from the experiments then processed and concluded in order to get the best possible method for the rehabilitation of stroke patient RESULTS Psychomotor Formation Induced by Music Therapy Music has also been found to bring many other benefits, such as lowering blood pressure (which can also reduce the risk of stroke and other health problems over time), boost immunity, ease muscle tension, and more.Based on the journal of neurology, the up-regulation of dopaminergic function may enhanced psikomotoric formation, and the results show that the primary motor cortex within the affected hemisphere of patients with chronic predominantly subcortical stroke retains the ability to encode a motor memory with training and a single oral dose of levodopa significantly enhanced this effect relative to placebo. One potential problem limiting the use of amphetamines in elder individuals with brain lesions has been the range of potentially undesirable effects. For this reason, the finding that dopaminergic agents could enhance training effects in the subacute period following stroke triggered enthusiasm. In healthy

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humans intake of levodopa increases motor memory formation,whereas dopamine receptor antagonists impair motor learning. (Floel, A et al., 2005) Based on the journal of brain, music listening leads to increased dopamine synthesis in the brain. Increased dopamine directly enhances alertness, speed of information processing, attention, and memory in healthy humans and also global cognitive functioning in patients with cognitive impairment. It is, thus, possible that the music-related enhanced cognitive recovery seen in our study was mediated by positive mood induced by music, and hence the dopaminergic mesocorticolimbic system, especially since the music the patients listened to was their own favourite music and concurrent effects on mood were also observed. (Sarkamo, T et al., 2008) The Effect of Transcranial Direct Current Stimulation (TDCS) Combine with Melodic Intonation Therapy (MIT) as Cognitive and Behavefioral Performance Based on the journal of Transmitters and Modulators in Health and Disease, the goal of Melodic Intonation Therapy (MIT) as a speech therapy that emphasizes musical aspects of language. The positive effects of MIT on speech recovery may be mediated by a frontotemporal brain network in the right hemisphere.Combine with the noninvasive brain stimulatin technique, Transcranial direct current stimulation (TDCS)to augment the benefits of MIT for patients with severe non-fluent aphasias.The TDCS was applied to the posterior inferior frontal gyrus (IFG) of the right hemisphere, under the assumption that the posterior IFG is a key region in the process of recovering from aphasia.Participants' language fluency improved significantly more with real tDCS + MIT, compared totDCS + MIT. These results provide evidence that combining tDCS with MIT may enhance activity in a sensorimotor network for articulation in the right hemisphere, to compensate for damaged left-hemisphere language centers.An intonation-based speech therapy, Melodic Intonation Therapy, may be

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particularly suited for patients who suffer from severe non-fluent aphasia. Another line of research has recently emerged which shows that combining behavioral therapies with non-invasive brain-stimulation might enhance the potential for recovery. Indeed, the future of stroke-recovery therapy may lie in combining behavioral therapy with complimentary non-invasive brain stimulation to maximally engage brain areas that are important for recovery. We explored this promising frontier of rehabilitation by investigating the effects of combining noninvasive brain stimulation with a behavioral intonation-based speech therapy.tDCS can improve cognitive and behavioral performance on tasks involving the stimulated brain area. Transcranialdirect current stimulation is an ideal non-invasive brain stimulation technique for use in treatment therapies because it is portable, relatively inexpensive, and safe. Though tDCS does not have the temporal or spatial acuity of Transcranial Magnetic Stimulation (TMS), it is possible to stimulate a larger area of cortex using the technique, and to easily combine tDCS with simultaneous behavioral therapy; this is ideal for modulating cortical activity in a network of related brain areas that is relevant to stroke recovery. The results of studies investigating whether tDCS can be used to improve stroke victims' motor skill have been encouraging .(see table 1)

The positive effects of tDCSwere due to the particular placement of the anodal electrode over the right IFG (Inferior Frontal Gyrus), or if anodal stimulation over other brain areas, such as the right anterior temporal cortex could also improve the

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beneficial effects of MIT. Additionally, it remains unknown whether tDCS, as applied in this study, exerts a positive influence on language recovery only in combination with a behavioral speech therapy, or if tDCS can be used on its own to improve verbal fluency for stroke patients. Because neural plasticity that facilitates language recovery after stroke may involve the development of neural connections that are latent in the undamaged brain, it is possible that modulating cortical excitability with noninvasive brain stimulation will have its greatest impact when a behavioral therapy is used to induce neuroplastic changes.(Vines, B.W et al., 2009) Music Enhances Brain Plasticity Stroke can cause brain cell to death and disturb cognitive function of human which lead to speech and language problems, slow and cautious behavior, and memory problems. Music exposure can increase neurogenesis in the hippotalamus, modify the expression of glutamate receptor GluR2 in the auditory cortex and in the anterior cingulated, increasing brain derived neurothropic factor (BDNF) levels in the hippocampus and in the hypothalamus, and also increasing the levels of tyrosine kinase receptor B, a BDNF receptor, in the cortex which all of it can enhances the brain plasticity. Brain plasticity has a big role in regenerating the brain cell, restoring brain cognitive function. (sarkamo,2008). The research performed prove that music can enhances brain plasticity, is the study to determine whether everyday music listening can facilitate the recovery of cognitive functions after stroke. 60 stroke patients with a left or right hemisphere middle cerebral artery stroke to a music group, a language group, or a control group. Post hoc tests of the change scores showed that at the three month stage, verbal memory recovery was significantly better in the music group than in the control group or in the language group. Focused attention recovery was significantly better in the music group than in the control group and marginally better in the music group than in the language group. These gains continued and were seen in tests

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at the six-month stage. This study shown to you the effect of music listening to a progressive cognitive change experience by the patient. (see table 2). (sarkamo, 2008)

Effect of music therapy on mood: Post-stroke depression is reported to present in 32.9 â&#x20AC;&#x201C; 35.9% of stroke patients, which is significantly higher than the prevalence of depression in general population (10%). Post stroke depression can lead to cognitive dysfunction, and have negative influence on the recovery process of stroke since it can higher the blood pressure which can worsen the stroke prognosis and any other chemical change in the body that lead to complication of some disease and may lead to death. In the experiment performed by Dong Soo Kim, The Beck Depression Inventory (BDI) and Beck Anxiety inventory (BAI) tests were performed for the music and control groups before and after treatment to determine the effect of music therapy on psychological status of stroke patients. The BDI test is the test that is performed to measure the level of depression of someone using questioner while the BAI test is the test performed to measure the level of anxiety of a person. The BDI score after music therapy session was performed decreased by average 2.3 points in the music group and increased by average 0.2 points in the control group. The change in BDI score was statistically significant in the music group (p=0.048), but not in the control group. The BAI score after music therapy decreased by average 0.2 points in the music group, but did not change in the control group. (See table 3)

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The decreasing number of BDI score in music group represents the decreasing of depression for subject in the group, and the decreasing number of BAI score in music group represents the decreasing of anxiety for subject in the group. An extra questioner was also used in this experiment for patients who received music therapy and their caregivers, the percentages of patients and caregivers who answered that there was a positive psychological change after music therapy were 77.8% and 66.7%, respectively. (Kim, D. S et al., 2011) Effect of Music Therapy in Pain Management Pain can have a debilitating effect in the process of rehabilitation. Someone in pain may lack the motivation to make the extra physical effort required to get out of a wheelchair or bed. For example, unrelieved pain may interfere with the use of a limb or cause resistance to the exercise program that is intended to improve mobility. Immobility can cause joints to stiff, and subsequent attempts to move will be even more painful. (Ahmad, E. L. H.,( Brashear, A et al., 2010). Hope: The Stroke Recovery Guide). A pilot study has been prove that music can reduce pain by enhancing relaxation. Music can also reduce pain by shifting the patient attention and focus from paint, creating a less pain perception and in overall reduce pain that the patient experience. It have also been proven in Annual Review of Nursing Research which provides 98 references that shown the music therapy and pain that patient experience.(Pratt, R. R. (2004). Art, Dance, and Music Therapy).

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DISCUSSION Research shows that music can influence the increase of dopamine in the brains of patients with stroke. Dopamine is a neurotransmitter which is essential in some parts of the brain ( Guyton et al., 2010) . At the time of stroke affecting the brain, the reduction in levels of dopamine are released in the blood occurred. The deficiency of dopamine which has a very important function as transmitter signals between brain cells and another is the one that responsible for disability in stroke patients. Dopamine is frequently used in the VTA (ventral segmented area) brain section, further dopamine affects primarily the ventral region and other parts of the area ( b BjĂśrklund A et al., 2007). Favorite music used stroke patients can increase ability the ability of immune response to add the number of dopamine that they want. Released dopamine from brain will then initiate VTA which would increase the frontal part of the brain cell response to produce more dopamine, which means adding the neurotransmitter supply. The addition of neurotransmitters often followed by the clinical restoration in psychomotor and cognitive function which gradually improved. In addition to dopamine, music theurapy can also increase a person's ability in language. Frontotemporal part of the brain is the part that controls the language center in an organism, which stroke attack on this place will result in aphasia. Itâ&#x20AC;&#x2122;s found that music through MIT (Melody Intonation therapy) can increased the activity of frontotemporal section of the brain to minimize the damage which occurs on the frontotemporal section. MIT given with the Transcranial Direct Current Stimulation (TDCS) in patients has been shown capable of reducing aphasia in patients. Because aphasia is one of the most common disabilities that greatly reduces patient quality of life, restoring the ability to speech can increasing mood and willingness of someone to join the therapy for more serious .

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One of the problems that occur when someone is in stroke is the lack of a person's ability to return to its normal state before the stroke exposure. One of the reasons is because brain cells are extremely difficult to divide. The main function in the body is often disturbed due to brain damage. Itâ&#x20AC;&#x2122;s known that music therapy on the hipopocampus section of the brain can directly increase Glur2 expression that will stimulate the production of BDNF (brain derived neurogenic factor), an increase in BDNF stimulates nerve cells in the hypothalamus and hipopocampus to produce hormones and factors that influence the hypothalamus rehabilitation after stroke. One of the additional disease occurred in someone that had a stroke is the less stable psychological condition. Stroke patients often experience stress which over time will lead to anxiety. The decreasing of the ability of the brain and the social factor which occur in people with stroke is the contributing factor of that condition occurred in people with stroke. The BAI (Beck Anxiety Inventory) core and the BDI (Beck Depression Inventory) score represent the high rate of stress and anxiety in patients with stroke. Music therapy performed in patients found to have positive effects resulting in lower BDI and BAI in these patients. BAI and BDI decline in these patients resulted in increase of ability of someone to face the social and self pressures. Excessive stress and anxiety often increase the blood pressure and can be a predisposing factor of hypertension which lead to the formation of aneurisma which can lead to another stroke attack. One of the main problems why patient did not discipline or even didnâ&#x20AC;&#x2122;t want to continue the rehabilitative therapy is because the patient did not feel comfortable when performing the rehabilitative therapy. Every time they are rehabilitated especially the movement rehabilitation, they often fell the pain because of the method used in therapy. It makes the patients mood change into a depressed one even before the therapy conducted. The patient mood influences the patient to not continuing their therapy. This

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phenomenon of course decrease the number of stroke patient that can back to normal state. Music has been proved to lower the pain sensation and also promote relaxation that can increase the mood of the patient which led to a well running rehabilitation since their mood is up. Conclusion Music therapy can reduce the symptoms of post- stroke symptoms such as impaired psychomotor, cognitive, aphasia, body stress respond and mood significantly. Moreover, because music is a method that is not invasive, inexpensive, and easy to carry anywhere, music can be applied as a new method of intervention in the treatment of post-stroke patient. REFERENCES Adamson, J., Beswick, A., & Ebrahim, S. (2004). Stroke and Disability. Journal of Stroke and Cerebrovascular Diseases vol 13, No. 4 2004 P171-177. Townsend, N., Wickramasinghe, K., Bhatnagar, P., Smolina, K., Nichols, M., Leal ,J., Luengo, F. R., Rayner, M. (2012). Coronary heart disease statistics 2012 edition. Lloyd, J. D., Jones, D., Adams, R., (Carnetho, M et al., 2009). Heart disease and stroke statistics. A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation 2009;119:e21-e181. Chanda, M.L., Levitin, D.J. (2013). The neurochemistry of music. Floel, A., Hummel, F., Breitenstein, C., Knecht, S., & Cohen, L.G. (2005). Dopaminergic effects on encoding of motor memory in chronic stroke. Neurology. Sarkamo, T., Tervaniemi, M., Laitinen, S., Forsblom, A., Soinila, S., Mikonnen, M., Autti, T., Silvennoinen, H. M., Erkkila, J., Laine, M., Perets, I., Hietanen, M. (2008). Music listening enhances cognitive recovery and mood after middle cerebral artery stroke. Brain.

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Vines, B.W., Norton, A. C., Schlaug, G. (2009). Stimulating Music: Combining Melodic Intonation Therapy with Transcranial DC Stimulation to Facilitate Speech Recovery after Stroke. Kim, D. S., Park, Y. G., Choi, J. H., Im, S. H., Jung, K. J., Cha, Y.A., Jung, C.O., Yeon, Y.H. (2011). Effect of Music Therapy on Mood in Stroke Patients.

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Ahmad, E. L. H.,( Brashear, A et al., 2010). Hope: The Stroke Recovery Guide. Pratt, R. R. (2004). Art, Dance, and Music Therapy . b Björklund, A., Dunnett, S.B. ( 2007 ) . “Dopamine neuron systems in the brain : an update " . Trends Neurosci . 30 ( 5 ) : 194-202 . doi : 10.1016/j.tins.2007.03.006.PMID 17,408,759 .

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ABC (ASSESSMENTS, BUILDING EXECUTION, CORE EVALUATION AND MONITORING) : AN INTEGRATED APPROACH AND REVOLUTIONARY HEALTH SYSTEM TO REDUCE CORONARY HEART DISEASE MORTALITY IN INDONESIA 1

KhrisnaRanggaPermana , AyuPramithaWulandari1, Shanti Andri Sakarisa1, Depy Irmayanti2 1 th 7 Semester Medical Student, Faculty of Medicine, University of Brawijaya, Indonesia 2 rd 3 Semester Medical Student, Faculty of Medicine, University of Brawijaya, Indonesia ABSTRACT Background : Coronary heart disease (CHD) is main chronic cardiovascular diseases which its prevalences are increasing over year proven by death numbers exceed 13 millions in the mid of year 2013 in the world. This is related to human lifestyle and health system response which is shifting over. Many attempts have been tried to reduce the deaths. Nationwide epidemiological data on it are still lacking in Indonesia. This study aims to provide epidemiological data, to identify factors that significantly influencing CHD impacts and to propose an applicable health program to minimize death rates at its finest potential so it won't be burden for medical world, society and government. Material and Methods : Variables included in this cross-sectional study are age, gender, education level, home place residence, economy level, diabetes mellitus, hypertension, alcohol history, smoking history and obesity. Original samples were 661.165 respondents above 15 years olds who answered the heart disease questions. Data were collected by direct interview and physical measurement by trained surveyors. Bivariate and multivariate test both performed in this study to find out the coefficient significance of variables among valid available data. Result : Significant correlations are found between CHD and age (p=0,001), gender (p=0,001), education level (p=0,001), home place residence (p=0,001), economy level (p=0,001), diabetes mellitus (p=0,001), hypertension (p=0,001), smoking history (p=0,001), alcohol history(p=0,001)and obesity (p=0,001). Prevalence of CHD in population above 15 years olds is 9,2% with the highest is in Sulawesi Tengah (16,9%) based on province-based data analysis. The dominant determinant factor was diabetes mellitus (OR=4,06). And there were many undiagnosed CHD case compared to the real number CHD case. Discussion : After knowing trends of CHD in Indonesia, what factors significantly contributing and CHD distribution area, modifying factors and system contributing to the high deaths due to CHD offers a solution to reduce it across the nation. The sinergy intercooperation between medical students, medical professionals, society and governments are objects to the proposed health program: assessments, building execution, core evalution and monitoring (ABC)-oriented methods. Conclusions: The ABC program is capable of minimizing unwatched critical points in health system field to reach the state of low death rate because of CHD and to strengthen sinergy intercooperation betweenmedical students, medical professionals, society and government. Requirements needed for establishing this program are compatible with many developing countries sharing the common problems. Keywords: Coronary heart disease, health system, intercooperation, CHD deaths rate INTRODUCTION Coronary heart disease (CHD) is main chronic cardiovascular diseases which its prevalences are increasing over year proven by death numbers exceed 13 millions in the

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mid of year 2013 in the world (WHO, 2013). In Indonesia, CHD is the leading cause of death and its number also increases over year. 40% people were dead due to heart attack and they didn't know that they

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actually had CHD. Disease develops when a combination of fatty material, calcium, and scar tissue (plaque) builds up in the arteries that supply the heart with blood. Through these arteries, called the coronary arteries, the heart muscle (myocardium) gets the oxygen and other nutrients it needs to pump blood. The plaque often narrows the artery so that the heart does not get enough blood. This slowing of blood flow causes chest pain, or angina.If plaque completely blocks blood flow, it may cause a heart attack (myocardial infarction) or a fatal rhythm disturbance (sudden cardiac arrest).Because of those facts, CHD absolutely has high influence as a chronic disease and major burden in health communities and it can be problematic in several ways such as it can decrease patient's quality of live, physically debilitate the patient, and lead to impairment in social capability (Longley, 2005). Accordingly, there were many accessible health procedures to lower the burden, such as lifestyle intervention and health system management. There is lot of health campaign to strive this number but those campaigns weren't in sinergy. Huge cost already spent for electing all those healthcampaigns and the secondary and tertiary therapy for CHD. So, we need to discover what factors and what health intervention system which good and suitable are for Indonesia. One of the most promising alternatives is to intensify all people to participate through a program held by government and supported by medical personnels and society itsself to help reaching the target of reducing CHD mortality in order to make CHD not a burden in the futureand it won't be a hindrance to proper medical care of chronic disease patients. But until this time, the epidemiological data about CHD in Indonesia is so limited and the current health system in fact doesn't decrease the CHD mortality number in real based on data. These conditions make an effort to fight CHD getting harder while its prevalences are increasing over year due to its iceberg phenomenon.

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Factors assessed in this study seem to be relevant with optimal result for our goal, includes age, gender, education level, home place residence, economy level, diabetes mellitus, hypertension, smoking history, alcohol history and obesity. Factors are of the ten most frequently reported in correspondence associated with CHD mortality, based on available data obtained from governmental health institutes, hospitals and any other local health providers (Fresser, 2005). Therefore, this study is eventually designed to measure the significance of any statistical correlation between CHD and the related determinant factors. Any intervention towards those factors willbe proposed later as a part of the preferred solution best applied by the local government to reach the expected target of reducing CHD mortality (RISKESDAS, 2010). MATERIAL AND METHOD This study was conducted at Faculty of Medicine Universitas Brawijaya from August â&#x20AC;&#x201C; September 2013. Data were obtained from database of several health institutes which directly under Departemen Kesehatan Republik Indonesia(DEPKES RI) authority, such as Pendaftaran Pemilih dan Pendataan Penduduk BerkelanjutanPEMILU(P4B), Badan Pusat Statistik (BPS), Badan Pendidikan dan Pelatihan Sumber Daya Manusia (PPSDM), Survei Sosial Ekonomi Nasional (Susenas) and the Basic Health Research (Riset Kesehatan Dasar or RISKESDAS), and also from annual report from local WHO representative in Indonesia for 440 districts in 33 provinces in Indonesia. Cross-sectional descriptive study design was chosen to look for association among available data taken from online-published database. Variables involved for the subsequent statistical analysis are age, gender, education level, home place residence, economy level, diabetes mellitus, hypertension, smoking history and obesity (AHA, 2013).To make data valid and complete in every variables, the analysis of data was chosen until year 2007. Yet, not all data are completely

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available since there are few recentlycompared to the real number of CHD case. founded provinces. Incomplete data will be The asked symptoms in question were a excluded first before the statistical tests were history of bluish lips when crying or doing executed. activities, chest pain, severe depression, Original data were collected through shortness of breath when walking in the structured interviews directly to the street ordinary, palpitations, shortness of respondents as well as measurements of breath, leg swelling. Determinant factors weight, height, waist circumference and studied were age, gender, education level, blood pressure by health personnel-trained home place residence, economy level, collectors. Original samples were 661.165 diabetes mellitus, hypertension, smoking respondents above 15 years olds who history, alcohol history and obesity. Obesity answered the heart disease questions. status used criteria of DEPKES RI, Economic status of the data obtained from hypertension measured according to the JNC the data Susenas 2007. Heart disease was VII criteria and interviews, and diabetes determined according to the interview in the mellitus (DM) from the results of the form of answers, never been diagnosed with interview. Data were analyzed with bivariate the disease or have experienced symptoms and multivariate test using SPSS statistical of heart disease. The diagnosed and the software version 15 to take account of symptomatic undiagnoses cases were complex sampling design. RESULTS AND DISCUSSION Data Results and Explanatory Review Table 1. The Prevalence of Heart Disease According to the Characteristics of the Respondents in the Population Age Above 15 years and its Bivariatte Analysis Factors Age 15-24 years 25-34 years 35-44 years 45-54 years 55-64 years 65-74 years 75 + years

SE

95 %

CI

N Weighted

OR

95 %

CI

P 0.0001

Gender Female Male Education level Uneducated Ungraduated Primary School Graduated Primary School Graduated Junior High School Graduated Senior High School Graduated from University Home Place Residence Village

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% 5.0 6.6 8.7 11.7 14.5 17.3 18.6

0.1 0.1 0.1 0.2 0.2 0.3 0.4

4.8 6.4 8.4 11.3 14.1 16.7 17.8

5.2 6.8 8.9 12.0 15.0 17.8 19.4

7.465 9.894 12.484 12.761 9.205 6.794 3.402

1 1.34 1.81 2.52 3.24 3.99 4.36

1.29 1.74 2.41 3.09 3.78 4.09

1.40 1.89 2.63 3.40 4.20 4.64

10.3 8.0

0.1 0.1

10.1 7.8

10.5 8.2

36.256 25.749

1.32 1

1.30

1.35

14.5 13.1

0.2 0.2

14.1 12.8

15.0 13.5

9.396 14.556

2.42 2.15

2.25 2.00

2.60 2.30

9.8

0.1

9.5

10.0

18.462

1.54

1.44

1.65

6.6

0.1

6.4

6.8

8.653

1.01

0.94

1.08

6.0

0.1

5.8

6.2

8.417

0.91

0.85

0.97

5,4

0.2

6.2

7.0

2.368

1

-

-

0.0001 0.0001

0.0001 10.0

0.1

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37.485

1.24

1.19

1.30

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City/ Town Economy Level Low Upper Middle Diabetic Mellitus Yes No Hypertension Yes No Obesity Obese Over Weight Normal Thin Smoking History Yes No Alcohol History at least 1 year Yes No

8.2

0.1

8.5

8.5

24.520

1

-

-

9.5 8.9

0.1 0.1

9.3 8.7

9.8 9.1

27.615 34.274

1.08 1

1.04 -

1.11

33.9 8.8

0.7 0.1

32.6 8.6

35.2 8.9

3.740 58.178

5.33 -

5.02 -

5.66 -

13.1 7.3

0.1 0.1

12.8 7.1

13.3 7.4

28.481 29.774

1,92 -

1,87 -

1.97 -

11.4 9.7 8.3 11.1

0.2 0.2 0.1 0.2

11.1 9.3 8.2 10.8

11.8 10.0 8.5 11.4

7.761 5.641 36.751 10.888

1.42 1.18 1 1.37

1.37 1.13 1.33

1.48 1.23 1.42

9.7 8.9

0.1 0.1

9.5 8.7

9.9 9.1

24.748 37.217

1.10 -

1.08 -

1.13 -

0.0001 0.0001 0.0001 0.0001

0.0001 0.0001 12.4 9.1

0.3 0.1

11.9 8.9

13.0 9.2

3.350 58.435

1.42 -

1.35 -

1.50 -

Table 2. Multivariate Analysisof FactorsDetermining of HeartDisease Factors

Category 25-34 years vs 15-24 years 35-44 years vs 15-24 years 45-54 years vs 15-24 years 55-64 years vs 15-24 years 65-74 years vs 15-24 years 75+ years vs 15-24 years

OR adj. 1.23 1.52 1.89 2.21 2.48 2.49

95 % 1.17 1.44 1.79 2.07 2.31 2.29

CI 1.30 1.60 2.00 2.35 2.65 2.71

P 0.0001

Gender

Female vs Male

1.57

1.50

1.63

0.0001

Education Level

Uneducated vs Graduated from University Ungraduated Primary School vs Graduated from University Graduated Primary School vs Graduated from University Graduated Junior High School vs Graduated from University Graduated Senior High School vs Graduated from University

1.30

1.19

1.43

0.0001

1.46

1.34

1.59

1.26

1.16

1.36

1.05

0.96

1.13

0.94

0.87

1.02

Home Place Residence

Village vs City/Town

1.12

1.07

1.18

0.0001

Economy Level

Low vs Upper Middle

1.04

1.00

1.07

0.0347

Diabetic Mellitus

Yes vs No

4.06

3.79

4.35

0.0001

Hypertension

Yes vs No

1.32

1.29

1.36

0.0001

Age

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Obesity Smoking History Alcohol History least 1 year

at

Obese vs Normal Overweight vs Normal Thin vs Normal Yes vs No

1.14 1.02 1.30 1.44

1.09 0.97 1.25 1.38

1.20 1.07 1.35 1.50

0.0001

Yes vs No

1.77

1.67

1.88

0.0001

The first table (Table 1) shows the bivariate analysis result of factors, age, gender, education level, home place residence, economy level, diabetic mellitus, hypertension, smoking history and alcohol history at least 1 year. All those factors are significantly related to CHD (p<0.05). The 10 variables in the bivariate analysis on population age 15 years and above, all eligible (p <0.25) to proceed to the multivariate analysis (Table 2). Multivariate analysis shows comparation to each variable with other and how much it affects the occur of CHD (OR adjective = OR adj). It shows the prevalence of heart disease and the risk of heart disease increases with ageon Table 1. Susenas (National Economic Census) also showed the same picture. AHA (American Heart Association) reported that more than 83% of people who die from coronary heart disease aged 65 years atas. Life expectancy in Indonesia is estimated to decrease. In 2015, the estimated life expectancy is 69.09 years. (BPS 2010). Thus, the prevalence of heart disease will certainly increase if not prevented (Kemenkes Indonesia, 2010). The prevalence of heart disease in Indonesia women shows higher than in men (Department of Health, 2012). Some literature says men have a higher risk of heart attack than women and usually develop at a younger age. However, according to the results of the prevalence of heart disease symptoms in the population aged above 15 years (Table 1) was also higher in women (10.3% vs. 8%). Even the results of several studies in the literature suggests that rural communities in different picture of the hospital at that time, was the prevalence of ischemic heart disease in women is higher than men (Grzywna Z, 2005). This fact will bring us to give more

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0.0001

attention and intervention to women risk factors in Indonesia. Highest prevalence of heart disease in those who are uneducated (14.1%) and decreased with increasing levels of education to graduated at university level. This phenomenon was expected to occur because of the low knowledge of people about CHD and how to live with healthy lifestyle. Intervention must be more focus on uneducated society (Profil Kesehatan Indonesia, 2007). The prevalence of heart disease is higher in rural areas compared to cities and higher in lower economic status. Current reality, cardiovascular disease as a cause of death is increasing throughout the world, irrespective of rich or poor (Isom, 2001). In fact, about 80% of deaths from cardiovascular disease in the world occur in low-income countries and developing countries such as Indonesia. In this study, Table 1, also showed that the prevalence of heart disease is higher in rural than urban areas (10% vs. 8,2%). National Economic Census in 2004 results also showed that the prevalence of heart disease according to symptoms is also higher in rural areas. This fact shows that people than come from lower economic status which far from glamour lifestyle, also could get CHD as well as, even higher, than society that live in big city (Nielsen, 2004). The results of this analysis also confirms that the risk factors that have been known to have a significant association with heart disease. Hypertension, diabetes mellitus, and obesity tend to increase the risk of heart disease(11,1% on Table 1). Even thin people also tend to increase the risk compared to normal people (11% on Table 1). This fact depicts that thin, normal people, and obese people have almost same tendension and chance to get CHD

35


(OR adj 1.14;1.02;1.30 on Table 2). are likely to increase the risk of heart disease Nowadays most all intervention sand health over 2 times (OR adj> 2 on Table 2).The campaigns are focus on obese people, just most dominant determinant factor is merely how to decrease bodyweight. We diabetes mellitus with an adjusted OR forgot to do the same attention to the normal 4.06(Table 2). It means patient with diabetes and thin ones because they get the same mellitus has higher chance likely to get chance. After knowing this fact from this CHD, 4.06 times, than the one who is not. study, we will be suggested to think to By treating well diabetes mellitus make a hollistical move for CHD prevalence number, we can reduce the CHD intervention and prevention to strive CHD case reciprocal proportionally (Diss, 2004). mortality.Behavioral factors of smoking, It shows that medical field is not merely drinking alcohol also showed a tendency composed of some factors standing alone. It to increased risk of coronary heart disease is composed many factors that related one (Table 1). Economic transition, each other, by interventing one factor, we urbanization, industrialization, and can affect another factor. globalization bring lifestyle changes that Prevention efforts need to be increase the incidence of heart disease pursued because the case fatality rate (CFR) include smoking, drinking alcohol, and the of blood circulatory system diseases pattern of consumption of unhealthy foods. (including CHD in it) is quite high. Report These habits can actually be changed and its directorate general medical services, the control is necessary as early as possible. Department of Health shows that in 2010 the These risk factors are believed to increase CFR circulatory system disease in the risk of death from CHD. Smoking is hospitalized patients in hospitals in known to increase the risk of death from Indonesia head the top list (10.8%). If no coronary heart disease 1.44 times(OR adj appropriate action is taken, by 2015, 1.44) and drinking alcohol at least 1 year globally, an estimated 20 million people will 1.77 times (OR adj 1.77). die from this disease. Good health approach But from the 10 factors analyzed do with and system are promising solution for this heart disease factors only age 55 years or phenomenon (Press, 2010). older and suffering from diabetes mellitus Review in Health System Field Table. 3 The Prevalence of Heart Disease According to the Health Workerâ&#x20AC;&#x2122;s Diagnosis (D) and The Symptoms That Have Been Experienced (S) in The Population Above 15 years old.

Heart disease (D/S)

Prevalence % 9.2

SE (%)

95%

CI

N weighted

0.09

9.0

9.4

62.005

Heart according to the diagnosis (D)

1.2

0.02

1.13

1.21

7.890

Heart according to the symptoms (S)

8.1

0.08

8.0

8.3

54.115

Anginaâ&#x20AC;&#x2122;s symptoms

4.8

0.02

0.43

0.49

3.060

Table 4. Prevalence of CHD Case, Diagnosed CHD and Symptomatic CHD in the Population Age Above 15 yearsold Province

CHD Case 95% CI

DIAGNOSED CHD SYMPTOMATIC CHD % SE 95 CI N % % weighted 2.8 0.18 2.4 3.1 333 14.2

%

SE

DI Aceh

16.6

0.52

15.6

17.6

N weighted 2.008

Sumatra Utara

4.2

0.20

3.8

4.6

1.512

1.1

0.08

1.0

1.3

408

Sumatra Barat

15.4

0.49

14.5

16.4

2.132

1.7

0.11

1.5

1.9

239

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SE

95%

CI

0.47

13.3

15.2

N weighted 1.675

3.1

0.17

2.8

3.5

1.104

13.9

0.47

13.0

14.9

1.894

36


Riau

10.0

0.59

8.9

11.2

1.479

1.0

0.16

0.7

1.4

148

9.1

0.55

8.1

10.2

1.331

Jambi

6.5

0.45

5.6

7.4

533

0.9

0.10

0.8

1.1

77

5.6

0.45

4.8

6.5

456

Sumatra Selatan

6.3

0.41

5.6

7.2

1.097

1.0

0.09

0.8

1.2

167

5.4

0.40

4.7

6.3

930

Bengkulu

7.2

0.52

6.2

8.2

340

0.7

0.08

0.5

0.8

32

6.5

0.52

5.6

7.6

308

Lampung

3.5

0.26

3.0

4.0

757

0.6

0.07

0.5

0.8

137

2.8

0.24

2.4

3.4

620

Bangka Belitung

9.6

0.52

8.6

10.6

325

1.2

0.15

1.0

1.5

41

8.5

0.49

7.5

9.5

283

Kep. Riau

9.2

0.80

7.8

10.9

389

1.4

0.21

1.0

1.8

58

8.0

0.73

6.7

9.5

331

DKI Jakarta

9.8

0.49

8.8

10.8

2.850

1.6

0.14

1.4

1.9

477

8.3

0.47

7.4

9.2

2.373

Jawa Barat

10.8

0.30

10.2

11.4

12.562

1.4

0.06

1.3

1.5

1.659

9.5

0.29

9.0

10.1

10.903

Jawa Tengah

10.7

0.24

10.3

11.2

10.862

1.1

0.05

1.0

1.2

1.136

9.7

0.24

9.2

10.2

9.725

DI Yogyakarta

8.8

0.60

7.7

10.1

1.028

1.3

0.16

1.1

1.7

157

7.6

0.57

6.5

8.8

871

Jawa Timur

7.1

0.19

6.7

7.5

8.527

1.0

0.05

0.9

1.1

1.178

6.2

0.18

5.8

6.5

7.350

Banten

7.9

0.57

6.8

9.0

2.217

0.9

0.13

0.7

1.2

252

7.0

0.57

6.0

8.2

1.966

Bali

6.9

0.50

6.0

8.0

780

1.0

0.10

0.8

1.2

109

6.0

0.48

5.2

7.0

670

NTB

9.2

0.59

8.1

10.5

1.179

0.8

0.10

0.6

1.0

103

8.5

0.58

7.4

9.7

1.076

NTT

13.0

0.57

11.9

14.1

1.410

1.0

0.09

0.8

1.2

105

12.1

0.55

11.1

13.3

1.305

Kalimantan Barat

6.2

0.45

5.4

7.2

745

0.9

0.11

0.7

1.1

103

5.4

0.41

4.7

6.3

642

Kalimantan Tengah

9.0

0.51

8.1

10.1

538

0.7

0.08

0.6

0.9

43

8.4

0.51

7.4

9.4

496

Kalimantan Selatan

10.8

0.44

10.0

11.7

1.117

1.0

0.16

0.8

1.4

108

9.9

0.40

9.1

10.7

1.009

Kalimantan Timur

6.0

0.32

5.4

6.7

542

1.1

0.09

0.9

1.3

99

5.0

0.31

4.4

5.6

443

Sulawesi Utara

10.8

0.57

9.7

11.9

623

1.7

0.15

1.4

2.0

99

9.2

0.54

8.2

10.3

524

Sulawesi Tengah

16.9

.86

15.3

18.6

1.138

1.9

0.15

1.6

2.2

128

15.3

0.83

13.7

17.0

1.010

Sulawesi Selatan

12.6

0.39

11.8

13.4

2.891

1.1

0.08

1.0

1.3

262

11.6

0.39

10.8

12.4

2.629

Sulawesi Tenggara

12.6

0.61

11.5

13.9

670

1.0

0.11

0.8

1.3

54

11.7

0.59

10.6

12.9

616

Gorontalo

16.0

0.94

14.2

17.9

388

1.2

0.16

0.9

1.6

30

14.9

0.93

13.2

16.8

357

Sulawesi Barat

11.7

0.83

10.2

13.4

325

0.5

0.12

0.3

0.8

15

11.2

0.83

9.7

13.0

310

Maluku

8.5

0.57

7.5

9.7

305

0.9

0.15

0.6

1.2

32

7.7

0.54

6.7

8.9

274

Maluku Utara

8.9

0.54

7.9

10.0

226

1.0

0.12

0.8

1.3

26

8.0

0.53

7.0

9.1

200

Papua Barat

10.3

0.92

8.6

12.2

187

1.4

0.22

1.0

1.9

25

9.0

0.92

7.4

11.0

162

Papua

6.0

0.52

5.0

7.1

322

0.9

0.14

0.7

1.2

51

5.1

0.48

4.2

6.1

271

Total

9.2

0.09

9.0

9.4

62.005

1.2

0.02

1.1

1.2

7.890

8.1

0.08

8.0

8.3

54.115

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CHD prevalence in the population aged 15 years and above was 9.2 % (Table 3 and 4). The prevalence of heart disease according to a history of ever experiencing symptoms that lead to heart disease in the population aged 15 years and and above was 8.1% (Table 3 and 4). Among the five questions symptoms of heart disease that lead to four types of heart disease, the highest prevalence of heart disease was angina (Table 3). CHD diagnosed by health workers was only 1.2 % of all cases of CHD (Table 3 and 4). This shows that there are still many people who experience symptoms of CHD but remain undiagnosed(Kim, 2011).Sulawesi Tengah was the province with the highest prevalence of CHD as a whole, but the highest percentage of heart disease that has been diagnosed by a health worker (1.9% on Table 4) compared to overall heart disease in the province of North Sumatra (27.0 % on Table 4), followed by Kalimantan Timur, Lampung, Jakarta and DI Aceh. The province with the lowest percentage of diagnosed CHD was Sulawesi Barat (0.5% on Table 4). After knowing all CHD trends in all provinces in Indonesia, we can do more focus intervention and make priority Figure 1. The ABC concept

scale to reduce CHD mortality (Van de Water W, 2012). Local government and health providers should increase quality of health personnels to minimize the number of undiagnosed CHD cases (Pedoman Riset Kesehatan Dasar, 2007). Solution : The Assessments, Building Execution, Core Evalution and Monitoring (ABC) Concept Actually, there were alot of attempts and efforts undergone by local governments, health providers or health workers intervention, such as health campaign or any other forms. However, none of them seems to give a satisfying result in purpose to decrease the number of CHD mortality based on data we discussed before. This paper proposes a new integrative approach and revolutionary health system by enhancing the performance of medical personnels and local government, or local people who capable of continuously dealing with the CHD cases in a certain area where they belong to (Gordienko, 2009). The technical details largely take place on the authority of governmental approach into this issue. This study was only equipped with a prototipe model and are next to be described in a figure concept below.

BUILDING ASSESSMENTS EXECUTION

Step 1 : Assessments Basically, the program model consists of several components, namely medical students, medical profesionals and government are focussing and the last come from cardiology health institute/departments. First of all, the role of medical students and medical professionals

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CORE EVALUATION & MONITORING

G O A L

who have already acquired an appropriate amount of information and skills is of primary attention. This capable skill is to diagnose the CHD so the undiagnosed case will be reduced. A governmental-derived organization and non governmental organizations have function to support the need of facilities and administration

38


properties of the ABC concept (Chou, 2008). Primary healthcare, Puskesmas, is at the very frontline towards fulfilling the healthrelated needs for local people. In fact, in remote areas, they may practically be the only healthcare provider accessible to the local population. If Indonesia wants to reduce the CHD mortality number, all basic and front line health services must be in good balance, all things must be considered from the very roots of problem. The current state, in which almost Puskesmas have no doctors at all compared to big city which has many hospitals, will affect the result of healthcare service and overall health outcomes for CHD intervention. Step 2 : Building Execution The interventions on providing the quality of life is not only take care after the hospitality but also how to inform, to explain, to teach and to make understand society whatâ&#x20AC;&#x2122;s the main cause of CHD. People mostly misunderstanding about the factors causes CHD like obesity which is not only obese can get CHD but also thin people does. In fact there are lots factors that also causes CHD that even harmer like age, gender, education level, home place residence, economy level, diabetes mellitus, hypertension, smoking history (Choby, 2000). The priority of giving information is not only for individual, but also family, groups and society. The main focus of those interventions are to the poor family and for family that has an high risk of getting CHD. So thatâ&#x20AC;&#x2122;s why the economy level and home place residence is belonging to the factors related, cause most of them are not really understand and knows about factors related CHD and CHD itself. And then, besides inform and prevention, the health workers also can educate the patients of CHD how to survive and live with their disease by reducing the anxiety, seek to understand the patientâ&#x20AC;&#x2122;s perspective of a stressful situation, provide factual information concerning diagnosis, treatment, and prognosis, control stimuli as appropriate for patient needs, and encourage family to stay with patient as

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appropriate. Make patients feel comfort and calm is the best way to survive. Step 3 : Core Evaluation and Monitoring Being healthy and get lost from CHD need more effort, preventing and interventions is not only ways to be healthy. After doing the prevention and interventions the health workers and government especially have to monitor and evaluate what are the result from their works to know how much the process are received and doing well by the people. From those evaluations and monitoring will known which are the hardest factors related CHD to be eliminated and then try to find another ways to make those hardest factors controlled (Ruder, 2008). Actually, evaluation and monitoring is the main way to see, to know, and to learn how does all actions are going well. CONCLUSION Coronary heart disease (CHD) is main chronic cardiovascular diseases which its prevalences are increasing over year in Indonesia. To make a better life and to providing the quality of life have to know the factors according CHD. After knowing those factors, the CHD can be controlled. The aim of this review is not only to find what is the cause, but also how to give the ways in decreasing CHD. The ABC ( assessment, building execution and core evaluation and monitoring) concept is a problem based management that focused how to overcome CHD from the beginning till the end focused on the roles of government and health worker as informer. Hopely, the steps can be easily applied in other places that have the same problem. ACKNOWLEDGMENT We thank to Prof. Dr. dr. M. RasjadIndra for his guidance to finish this paper into a great cross sectional research. We hope this scientific paper will becomethe basis for the future CHD intervention.

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REFERENCES American Heart Association. Risk factors and coronary heart disease. (cited 20013 Sept 26). Available from: http://www.americanheart.org/presenter.j html identifier=4726 Blagosklonny MV: Molecular theory of cancer. Cancer Biol Ther 2005, 4:621-7. Choby C, Mangoni M, Boccara G, Nargeot J, Richard S. Evidence for CHD drugs sodium currents in primary cultured myocytes from human, pig and rabbit arteries. Pfl端gers Arch 2000; 440:149-52. Chou CC, Lunn CA, and Murgolo NJ. (KCa3.1: target and marker for cancer, autoimmune disorder and vascular inflammation? Expert Rev Mol Diagn 2008; 8:179-187. Diss J, Fraser S, Djamgoz M. Voltage-gated Na+ channels: multiplicity of expression, plasticity, functional implications and pathophysiological aspects. Eur Biophys J 2004; 33: 180-93. Fraser SP, Diss JK, Chioni AM, Mycielska ME, Pan H, Yamaci RF, Pani F, Siwy Z, Krasowska M, Grzywna Z, Brackenbury WJ, Theodorou D, Koyuturk M, Kaya H, Battaloglu E, De Bella M. T, Slade MJ, Tolhurst R, Palmieri C, Jiang J,Latchman DS, Coombes RC, and Djamgoz, M.B. Voltage-gated sodium channel expression and potentiation of human CHD. Clin HeartRes 2005; 11: 5381- 5389. Gordienko D, Tsukahara H. Tetrodotoxinblockable depolarization-activated Na+ currents in a cultured endothelial cell line derived from rat interlobar artery and human umbilical vein. Pfl端gers Arch 2009; 428:91-3. Isom LL. Sodium channel beta subunits: anything but auxillary; 2001:742-54. Kemenkes Indonesia. Seri 3. Morbiditas/mortalitas. Edisi tahun 2010. Jakarta: Departemen Kesehatan Republik Indonesia; 2010. Kim IK, Park S, Hwang H, et al. Clinical significance of age at the time of

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diagnosis among young CHD. 2011;14(4):314-321. Le Guennec JY, Ouadid-Ahidouch H, Soriani O, Besson P, Ahidouch A, and Vandier C. Voltage- gated ion channels, new targets in anti-coronary research. Recent Pat Anticoronary Drug Discov 2007;2:189-202. Longley DB, Johnston PG: Molecular mechanisms of drug resistance. J Pathol 2005, 205:275-92. Nielsen DL. Mechanisms and functional aspects of multidrug resistance in Ehrlich ascites tumour cells, Dan. Med. Bull 2004. 51(4): 393-414. Pedoman Riset Kesehatan Dasar 2007. Jakarta: Badan Penelitian dan Pengembangan Kesehatan; 2007 Press D.J., Pharoah P. Risk Factors for Breast Cancer; A Reanalysis of Two Case-control Studies From 1926 and 1931. Epidemiology 2010;21:566-572. Profil Kesehatan Indonesia 2007. Jakarta: Departemen Kesehatan Republik Indonesia; 2008. RISKESDAS 2010. (2010). Retrieved April 15, 2012, from Badan Penelitian dan Pengembangan Kesehatan Kementerian Kesehatan RI: http://www.riskesdas.litbang.depkes.go.i d/2010/ index.php? Ruder E.H., Dorgan J.F., Kranz S., KrisEtherton P.M., Hartman T.J. Examining CAD 2008;8(4):334- 342. Van de Water W, Markopoulus C, van de Velde CJ, et al. Association between age at diagnosis and disease- specific mortality among CHD patiens. JAMA. 2012 ;307(6):590-597. WHO. Cardiovascular diseases. (cited 2013 Jun IS). A vailable from: http:l/www.who.int/cardiovascular~ diseases/en/.

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Comparison of Knowledge, Perception, and Attitude toward Leprosy Patients between Society Near and Distant from Rehabilitation Center Leonard Andreas Wiyadharma, Matthew Billy, Mochamad Iskandarsyah Agung Ramadhan Medical student, Faculty of Medicine, Universitas Indonesia, Indonesia ABSTRACT Background: Leprosy is still a major health problem in the world. Other than having physical impairments, negative stigma also arises from the community. This social stigma is because of the lack of knowledge and information of leprosy. Such negative point of view can lead to the decreased quality of life to the leprosy patient. However, society nearby the rehabilitation center tends to tolerate them and have less negative stigma. Therefore, this study is conducted to compare the differences of knowledge, perception, and attitude toward leprosy patient between society near and distant from rehabilitation center. Materials and Methods: Cross-sectional method was used for this research. Two groups that are compared for this study; people from society nearby rehabilitation center (N-58) and people from society distant from rehabilitation center (N-63). For distant society, the authors chose Jakarta because of the availability of the authors. Both groups received same validated questionnaires. Results: The distribution of data is not normal. The results of knowledge, perception, and attitude toward leprosy patients of the society nearby rehabilitation center respectively are 7, 10, and 8.5. On the other hand, the results of the society distant from rehabilitation center are 8,8, and 7. Conclusion: The perception and attitude of the society nearby the rehabilitation center are higher compared to society distant from the rehabilitation center, while the knowledge is not significantly different. This shows that the negative stigma is less in the society nearby the rehabilitation center than in society distant from rehabilitation center. The data obtained from the research can be used for situational analysis and reducing negative stigma. For further research, factors that contribute to the development of better stigma can be conducted.

INTRODUCTION Leprosy (Morbus Hansen or kusta in Indonesian) is an infectious chronic disease that damages skin and nerve system and caused by bacteria species Mycobacterium lepraeor Mycobacterium lepromatosis. (WHO, 2012) It has symptoms such as mutilating pale skin lumps, sores, or bumps that will not disappear after several weeks or months. The symptoms can be developed into hair loss and nerve damage, the last one can drive to eye disruption, muscle atrophy and loss of sensation in limbs or trunks. These symptoms arise 5 until 20 years after infection because of the long incubation period. The disease can be infected through direct and indirect touch from untreated cases and droplets from nose and mouth as well. Although infectious, the communicability of this disease is not that high. (Melinda, 2013) Because of the

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genetic factor, only 5% of populations have susceptibility to leprosy cases. Leprosy is still a major health problems in the world even though there have been an effort to eradicate leprosy since 1991. This disease caused burden, especially in developing and poor countries due to risk factors, mainly bad sanitation. Based on WHO (2013) data, there are 192.246 leprosy cases in the world per 2011, which then increases to 232.857 per 2012. It also becomes burden in tropic countries, for instance Indonesia, since it belongs to neglected tropical disease. In Indonesia, the cases number of leprosy is high. Even though it is claimed by Ministry of Health (2011) that Indonesia was successful in decreasing leprosy prevalence up to 81% as 2011 since elimination program in 1991, Indonesia is in the third rank of the most leprosy cases in the world behind India and

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Brazil with 18.894 cases of leprosy. The prevalence itself is 0.93 per 10.000. Talking about leprosy is not being apart with talking about social stigma surrounding the leprosy patients. The fear of leprosy that it is an incurable, mutilating, and contagious disease has been arisen since ancient China, Egypt, and India era. Throughout the history, the sufferings have been not accepted by their communities. Albeit the development of this disease has been improving, such as multidrug therapy as the treatment for leprosy, the fear of people with leprosy is still present. The fear is related to transmission and effect it caused, such as fingers discontinuity or poor appearance of face. Such a fear causes negative stigma which can lead into discrimination and even inhumane attitudes toward them. This thing

can happen due to lack of understanding and information about leprosy that leads into misapprehension about the way this disease is being transmitted and being treated. ( Edward, 2012) Negative stigma may worsen leprosy patientsâ&#x20AC;&#x2122; quality of life. People around the focus of leprosy patients tend to be more tolerating them. In other words, they have less negative stigma compared with people in the region which does not have focus of leprosy patients. But the proofing itself has not been strong yet. Therefore, the authors are interested to conduct a research about comparative analysis between stigma social from those who had been habituated with leprosy patients in their environment and those who had not been habituated with leprosy patients in their environment.

Table 1. Trends in new cases reported annually since 2005 in 16 countries reporting â&#x2030;Ľ1000 new cases during 2012 ( WHO, 2013 )

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MATERIAL AND METHODS Cross-Sectional Study We had picked two groups that would be subjects for this study. Those were populaces who had been habituated with leprosy patients in their environment (represented by population of Sitanala Village, Tangerang, Banten and populaces who had not been habituated with leprosy patients in their environment (represented by population of DKI Jakarta). We used random sampling as sampling technique, specifically cluster random sampling for respondents both region. All of the respondents were health populaces with no leprosy exposure throughout their lives. They also had identity attributes for their residency of each. 58 respondents were chosen from each region to fill the questionnaire regarding knowledge, perception, and attitude towards leprosy patients.

The questions in the questionnaire spread were made by the author team, referencing to some studies. The questionnaire had been validated by pre-sampling test. There were three main components in this questionnaire. There were knowledge, perception, and attitude towards leprosy patients. The knowledge section asked about how well they knew about leprosy. The perception section asked about how they thought about leprosy patients. And the attitude section asked about how they behave regarding to leprosy patients. For knowledge section, the answer choices were yes or no, with exception for questions about infection way, cause, management, and symptoms, which were given some choices. Meanwhile, the answer choices for perception and attitude section were agree or not agree. The answers then coded into score to be analyzed through SPSS for Windows 11.5 version. The analysis technique used was analytic, definitely independent categorical comparative.

RESULTS First, these tables show the difference of knowledge, perception, and attitude towards leprosy patient between near and distant from rehabilitation center. The distribution of data based on normality test is not normal. Table 2 shows the difference of knowledge with descriptive and inferential statistical test. The significance level of difference is 0.125. Table 2. Difference of total of knowledge near and distant from rehabilitation center

Location

Knowledge Near Distant

N 58 63

Median 7.00 8.00

Min-max 5.00 – 12.00 4.00 – 12.00

P value Std. Error Mean ( Mann_Whitney Test ) 0.23 0.125 0.21

Table 3 shows the difference of perceptiontowards leprosy patient between near and distantfrom rehabilitation center. The significance level of the difference after using inferential statistical test is below 0.001. Table 3. Difference of total of perception near and distantfrom rehabilitation center

Location

Perception Near Distant

N 58 63

Median 10.00 8.00

Min-max 4.00 - 12.00 4.00 – 12.00

P value Std. Error Mean ( Mann_Whitney Test ) 0.19 <0.001 0.28

And, table 4 shows the difference of attitude towards leprosy patient between near and distantfrom rehabilitation center. The median of total perception toward leprosy patient in near

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one is 8.50. Meanwhile, the median of total perception in distant from leprosy rehabilitation center is 7.00. Then, the significance level of difference is below 0.001. Table 4.Difference of total of attitudenear and distantfrom rehabilitation center.

Location

Attitude Near Distant

N 58 63

Median 8.50 7.00

Min-max 6.00 – 9.00 2.00 – 9.00

P value Std. Error Mean ( Mann_Whitney Test ) 0..13 <0.001 0.23

For perception and attitude, we categorize it into four different components : mobility; domestic life; interpersonal interactions and relationship; community, social, and civic life. This difference in these components is illustrated in Figure 1 and the satistical difference is shown at table 5 8   7  

M ed 6   ia 5   n 4   Near  

3  

distant  

2   1   0   mobility  

domes5c  life  

interpersonal   community,  social,   interac5ons  and   and  civic  life   rela5onship  

Figure 1. Median of four aspects in perception and attitude toward leprosy patient between near and distant from rehabilitation center Aspect Table 5. Significance level of different of four aspects in perception and attitude toward leprosy patient between near and distant from rehabilitation center

Mobility Domestic life Interpersonal interactions and relationship Community, social, civic life

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Nilai p ( Mann_Whitney Test ) <0.001 <0.001 <0.001 0.006

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DISCUSSION According to Tsutsumi et al (2005), quality of life and depression status of a leprosy patients is directly affected by the stigma perceived by leprosy patients. Another study (National Leprosy Relief Nepal, 2007/2008) was conducted and yield a result that leprosy patients that have visible impairments face difficulities in participating daily social activities. These statement are enforced by two former studies in Bangladesh and India that leprosy patients have significantly lower quality of life compared to people in general population. Moreover, if there are lack of morale and support of the society, significant contraints could be inflicted to the leprosy patient. It can be seen that how the society stigmatized leprosy patients lowers the quality of life. Because the leprosy patients got stigmatized and denied by the society, they usually limit themselves from the society and even the rehabilitation center. From the lack of medication and rehabilitation, they will continue to develop the disease and stay in the society that rejected them. From this, a key strategy is needed to overcome the stigma and help the rehabilitation of the leprosy patients. A rehabilitation process is affected by many things, and one of them is the support from the society nearby the leprosy patients. Therefore, this research is conducted with the purpose of seeing whether there are differences about knowledge, perception, and attitude toward leprosy patients between people who lived near the rehabilitation center and those who are not. We hypothesized that there are differences about knowledge, perception, and attitude of the people who lived near and distant from the leprosy rehabilitation center. Based on inferential statistical test (Mann Whitney Test) which is done to the collected questionnaires, there is no significant difference about the total knowledge about leprosy between people who lived nearby and distant from the leprosy rehabilitation center. On the other hand, there are significant difference about the perception

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and attitude of the people who lived nearby and distant from the leprosy rehabilitation center. Thus, our hypothesis is partially accepted based on the result of significant differences of perception and attitude. However, knowledge about leprosy was not affected by the location of where the respondents live. The questions in our questionnaires can be classified into four groups, which are mobility; domestic life; interpersonal interactions and relationship; and community, social, and civic life. From the statistical test conducted to the results, the results for each of them are significantly different. The society nearby rehabilitation center have better results than society distant from the rehabilitation center. It means that the quality of life of the leprosy patients can be better in the society nearby rehabilitation center. The result of this study is not consistent with a literature review published by Van Brakel (2003), where the leprosy stigma was a global phenomenon and not affected by the condition of the country, whether it was an endemic or non-endemic country. This is probably due to review of multiple researches with different kind of samples and types of questionnaires. In our study, we specifically divide the samples to two groups, which are the samples from people nearby rehabilitation center, and those who are distant from the rehabilitation center. By this division of group, it is more likely to give clearer result of difference between both groups. The result of this study could be very useful for number purposes, (i) To understand more about the situation of the people around leprosy rehabilitation area. The result can be used to describe and analyze the situation surrounding a rehabilitation area so that it can help the preparation of making a leprosy rehabilitation area. (ii) To help reducing leprosy stigma in a community. Data about stigma could be used to reason people that have already develop leprosy stigma. Other than that,

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it can be used prevent people to develop leprosy stigma. (iii) For further research. By this research, we are able to see the differences of perception and attitude of people toward the leprosy patient based on the nearness to the rehabilitation center. Hopefully, another research can be conducted to find out factors that contributes to the development of better attitude and perception towards leprosy patient and to reduce the level of stigmatization. Apparently, during the collection of the data nearby the rehabilitation center, we could not directly observe the respondents due to the low compliance of the head of area which we visited. The head of area distributed the questionnaires by himself to the area nearby rehabilitation center, but not under our supervision. If a similar study could be done, we advice that the collection of data should be done by the researchers themselves. CONCLUSION There are differences in perception and attitude of the society nearby and distant from rehabilitation center, with both of them are higher in the sociery nearby the rehabilitation center. However, the knowledge yield no difference between those areas. This result can be a good lead, because better perception and attitude of the society can help leprosy patients undergo the rehabilitation as well as increasing their quality of life. A further study can be conducted in order to find out the factors that can affect the development of leprosy stigma. If such research can be conducted, hopefully we can decrease the stigma specifically in area distant from the rehabilitation center, which can result in the increasing quality of life of leprosy patients. REFERENCES Edward, EL (2010). Understanding the stigma of leprosy. South Sudan Medical

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Journal,3(3), 45-48. Retrieved from http://www.southsudanmedicaljournal.co m/assets/files/Journals/SSMJ%20Vol%2 03%20No%203%2003%2008%2010.pdf . KementerianKesehatan (2011). Prevalensikustaberhasilditurunkan 81 persen. Retrieved October 2 2013 from http://www.depkes.go.id/index.php?vw= 2&id=1421. Melinda, R. (2013). Leprosy overview. Retrieved October 2 2013 from http://www.webmd.com/skin-problemsand-treatments/guide/leprosy-symptomstreatments-history. Netherlands Leprosy Relief Nepal. (2008). Annual Progress Repost 2065/2065 (2007/2008). A report contributing to the better understanding of NLR supported Leprosy control program in Nepal. The Leprosy Mission Canada (2011). What is leprosy?. Retrieved October 2 2013 from http://www.leprosy.ca/Page.aspx?pid=24 5. Tsutsumi, A., Izutsu, T., Islam, A., Jalal, UA., Nakahara, S., &Takagi, F. Depressive Status of leprosy patients in Bangladesh: association with selfperception of stigma, Leprosy Review 2004, 75: 57-66. Pmid: 15072127 Van Brakel, WH. (2003). Measuring leprosy stigma â&#x20AC;&#x201C; a prelimenary review of leprosy literature. International Journal of Leprosy and Other Microbial Diseases, 71(3) , 190-197 World Health Organization (2012). Leprosy: Fact sheet N°101. Retrieved October 2 2013 from http://www.who.int/mediacentre/factshee ts/fs101/en/. World Health Organization (2013). Global leprosy: update on the 2012 situation. Weekly Epidemiological Record, 25(88), 365-380. Retrieved from http://www.who.int/wer/2013/wer8835.p df

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Correlation between History of Depression Status and Incidence of Ischemic Stroke in Surakarta Liswindio Apendicaesar (UNS), Kevin Wahyudy Prasetyo (UNS), Eka Satya Nugraha (UI) ABSTRACT Background: Ischemic stroke happens about 80% of all Stroke incidences in the world. It is associated with some risk factors, such as depression, smoking, and physical activity. Material and Methods: This study uses retrospective cohort approach to collect data needed. . The authors used a set of questionnaires to interview the total samples of 45 people consist of 23 ischemic stroke patients and 22 non-ischemic stroke patients in Surakarta. The questions include the history of depression status, starting age of smoking, and also physical activity. Results: The data analysis using logistic regression test shows that there is statistically significant correlation between depression status and ischemic stroke incidence (p<0.05). This significance also applies to starting age of smoking and physical activity status variables. Odds Ratio (OR) for depression status variable is 1.20. It means that people who have depression status got 1.2 times bigger risk having ischemic stroke. The OR value for starting age of smoking factor is 2.4 and for physical activity status factor is 1.67. Conclusion: Depression can increase the risk of ischemic stroke. Keywords: ischemic stroke, depression status Introduction Stroke or cerebrovascular accident is a rapid loss of brain function due to the disturbance of blood supply to the brain. This happens either because of ischemia or hemorrhage. The ischemia is caused by the blockage of either thrombosis or arterial embolism. Globally, stroke was the second most frequent cause of death in 2008, accounting for 6.2 million deaths (~11% of the total) (WHO, The Top 10 Causes of Death, 2013)[1]. Approximately 9 million people had a stroke in 2008 and 30 million people have previously had a stroke and are still alive (WHO, Global Health Risk, 2009)[2]. According to Indonesian Minister of Health, there are 8 patients of stroke out of 1000 people. It is the main cause of death in Indonesia attacking all range of age with proportion 15.4%. One out of 7 deaths in Indonesia is caused by stroke (Indonesian Department of Health, 2011) [3]. Stroke is divided into two kinds: non-hemorrhagic and hemorrhagic. Nonhemorrhagic stroke is the most common stroke found to happen, about 80% of all stroke incidents. It happens mainly due to the occlusion of brain blood vessel. Hemorrhagic stroke is caused by the rupture of micro-aneurism from Charcot or etat crible in brain (Sims NR, 2009)[4]. Stroke is associated with some modifiable risk factors such as high blood pressure,

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cholesterol levels, diabetes, cigarette smoking, alcohol consumption and drug use, lack of physical inactivity, processed red meat consumption and unhealthy diet (Larsson, Virtamo, & Wolk, 2011)[5]. Lately there also have been researches indicating that depression can also be strong risk factor for stroke particularly in middle-aged women (Jackson & Mirsha, 2013)[6]. Depression is a psychological disorder characterized feeling upset, feeling useless, lost, hopeless, helpless, pathologically guilty, accompanied by other somatic component such as anorexia, constipation, decrease of pulsation or blood tension. Typically to diagnose depression is when the patient suffers from sleep-disorder, appetite-disorder, and loss of sexual desire (Maramis & Maramis, 2009)[7]. Globally, more than 350 million people of all ages suffer from depression. It is the leading cause of disability worldwide, and is a major contributor to the global burden of disease. More women are affected by depression than men. Depression results from a complex interaction of social, psychological and biological factors. It can, in turn, lead to more stress and dysfunction and worsen the affected personâ&#x20AC;&#x2122;s life situation and depression itself. There are interrelationships between depression and physical health. For example, cardiovascular disease can lead to depression and vice versa (WHO, Fact Sheet on Depression, 2012)[8].

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According to Indonesian Basic Health Research (Riskesdas), the number of mental-disorder (for anxiety and depression) in Indonesia 2007 is about 11.6% or 19 million of the citizens for age above 15 (Indonesian Ministry of Health, 2011)[9]. In this study, the authors try to find out the relationship between the incidence of ischemic stroke and its history of depression status, because there is still few studies indicating that depression can lead to ischemic stroke incidence. Materials and Methods This study uses retrospective cohort approach to collect data needed, because the authors determined the samples based on illness status of ischemic stroke that it was traced back to identify its correlation with the risk factors as exposure. Before collecting samples, the authors looked for several references as basis of thinking and hypothesis. The samples taken were ischemic stroke and non ischemic stroke people in Surakarta city, which were chosen by fixed exposure sampling method. The total sample used is 45 people consist of 23 ischemic stroke patients and 22 non-ischemic stroke patients (Murti, 2006)[10]. The dependent variable in this study is ischemic stroke status. Depression status acts as the independent variable. This

study uses history of physical inactivity status and starting age of smoking as confounding factors to decrease the bias result of this study. The authors conducted this study by having home-visit to samples in Surakarta city. Before getting the data, an informed consent has to be given by the samples of research. The interview was done by giving a set of questionnaires to the samples that included questions about the history of depression status, starting age of smoking, and also physical activity. We used validated questionnaires for the history of smoking and physical activity status. For the History of Depression Status, we used Beckâ&#x20AC;&#x2122;s Depression Inventory (Beck, Steer, & Brown, 1996)[11]. In asking the respondents to fill the questionnaires, we told them to answer the questions based on their condition before having ischemic stroke for the exposed samples. After the data was collected, it was then analyzed by using SPSS program to find the correlation between the risk factors and ischemic stroke. The power of correlation can be measured quantitatively by logistic regression method. This test can show the Odds Ratio (OR) as the power of correlation that describes how much the risk factor can contribute to the incidence of disease. Chi square test is used to find out whether the data obtained is statistically significant.

RESULTS The research has been conducted from August to September 2013. Here is the result of this research: A. Distribution of sample This research uses a total of 45 people consist of 23 ischemic stroke patients and 22 non ischemic stroke patients (Table 1). Table 1. Sample distribution based on patientsâ&#x20AC;&#x2122; status Patientsâ&#x20AC;&#x2122; status Frequency ischemic stroke 23 non ischemic stroke 22 Total 45 Table 2. Sample distribution based on starting age of smoking Starting age of smoking Frequency <18 years old 28 >=18 years old 17 Total 45

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The number of the sample that started smoking at age of less than 18 years old is 28 and it’s showed that 17 people started smoking at age of 18 years old or more (Table 2). Table 3. Sample distribution based on depression status Depression status Frequency Positive 18 Negative 27 Total 45 Table 4. Sample distribution based on physical activity status Physical activity status Frequency Positive 26 Negative 19 Total 45 Table 3 shows that based on the depression status, more people have no depression status (27 people) than those who have that status (18 people). Whereas table 4 shows us that a number of 26 people have positive physical activity status compared with 19 people who don’t. B. Result of Data Analysis This research uses logistic regression model test to analyze the collected data. The test is used to identify the correlation between variables used in research whether it’s statistically significant or not. Table 5. Logistic regression test’s result Variables OR CI 95% p Lower Upper Depression status 1.20 0.212 6.801 0.04 Starting age of 2.40 0.124 46.391 0.024 smoking Physical activity 1.67 0.074 37.728 0.026 status The result of data analysis shows that there is correlation between history of depression status statistically significant correlation between and ischemic stroke incidence is significant with depression status and ischemic stroke incidence p=0.04. Odds Ratio (OR) for history of (p<0.05). This significance also applies to depression status variable is 1.20, which shows starting age of smoking and physical activity that people with history of depression status got status variables. Odds Ratio (OR) for depression 1.2 times bigger risk of having ischemic stroke. status variable is 1.20. It means that people who The value of Confidence Interval (CI) 95% for have depression status got 1.2 times bigger risk depression status is 0.212 to 6.801, which it having ischemic stroke. Starting age of smoking implies that history of depression status can be a and physical activity status are risks for having risk for a person 0.212 to 6.801 times to get ischemic stroke too due to OR>1. The value of ischemic stroke. Moreover, the correlation Confidence Interval (CI) 95% for depression between the confounding factors the authors use status is 0.212 to 6.801. It describes that in this study and the incidence of ischemic depression status can be a risk 0.212 to 6.801 stroke is also significant. Smoking that starts times for a person to get ischemic stroke (Table before 18 is bigger risk of stroke than smoking 5). starts after 18 with p=0.024. Physical inactivity is a risk of stroke with p=0.026. Starting age of Discussion smoking and physical activity status can be risks Our results are consistent to the theory we for having ischemic stroke due to OR>1. obtained, that depression, early starting age of Our result is in line with cohort study smoking and physical inactivity can increase the conducted by Pan An et al 2011, that mentions risk of stroke. It is shown that statistically, depression can increase the risk of stroke 1.49

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times. There are possible mechanisms of how depression may increase the risk factor of stroke. Depression has known neuroendocrine (sympathetic nervous system activation, dysregulation of the hypothalamic-pituitaryadrenocortical axis, platelet aggregation dysfunction, etc.) and immunological/inflammatory effects, which could influence stroke risk. Late-life depression may represent a manifestation of sub-clinincal vascular disease. Depression may be associated with poor health behaviors (i.e. smoking, physical inactivity, poor diet, lack of medication compliance), obesity and other major comorbidities, which might increase stroke risk. Moreover, there is a study suggests that the consumption of antidepressant may reduce the risk of stroke mortality (Pan, et al., 2011)[12]. The starting age of smoking may be related to the years of smoking; which the earlier it starts, the worse it will impact the smokers. After all, there is a study shows the hazard rate of stroke is increased when the starting age of smoke is below 18 (Wu, et al., 2011)[13]. The other confounding factor we observe is physical activity. Plausible biologic pathways support an inverse association between physical activity and risk of stroke. Physical activity modifies risk factors for stroke such as hypertension, cardiovascular disease, type 2 diabetes, and obesity by reducing blood pressure, improving lipid profile, decelerating atherosclerosis, ameliorating endothelial dysfunction, reducing systemic inflammation, and improving insulin sensitivity. Potential effects on ischemic stroke risk may be mediated through mechanisms common to coronary heart disease (e.g. factors that modify atherosclerosis progression, especially risk of acute clot rupture) (Sattelmair, Kurth, Buring, & Lee, 2010)[14]. This study may be bias due to the retrospective method that the correspondents might mistake recalling their memory regarding to their history of depression status and their history of physical activity status when they fill the questionnaires. However, it was obvious from the correspondentsâ&#x20AC;&#x2122; testimonials that they had had big personal problem that had depressed them before stroke or they had not paid attention to their physical activity before stroke. This study is also weak as cohort study because of its

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small number of samples due to the short time given to conduct this study. Hence, this study is not representative enough to be applied for big population. In addition, the authors also did not control other confounding factors and thus may cause more bias to the result. Conclusion Depression may increase the risk of ischemic stroke incidence with p=0.04, which it shows significant correlation (p<0.05). Odds Ratio (OR) for history of depression status variable is 1.20, which shows that people with history of depression status got 1.2 times bigger risk of having ischemic stroke. According to this study, the confounding factors we observe also show significant correlation (p<0.05). Smoking, when it starts before 18, can increase the risk of ischemic stroke bigger than when it starts after 18 with p=0.024. Nevertheless, physical inactivity can also increase the risk of ischemic stroke incidence with p=0.026. References 1. WHO (2013). The Top 10 Causes of Death. url: http://who.int/mediacentre/factsheets/fs310/e n. retrieved: 28 September 2013 2. WHO (2009) Report: Global Health Risk. url: http://who.inte/mental_health. retrieved: 28 September 2013 3. Indonesian Department of Health (2011). 8 dari 1000 Orang di Indonesia Terkena Stroke. Indonesian Ministry of Health (url): http://www.depkes.go.id/index.php?vw=2&i d=1703. retrieved: 28 September 2013 4. Sims, NR., Muderma, H. (September 2009). Mitochondria, Oxidative Metabolism and Cell Death in Stroke. Biochimica et Biophysica Acta 1802(1): 80-91 5. Larsson, SC., Virtomo, J., Wolk, A. (2011). Red Meat Consumption and Risk of Stroke in Swedish Men. American Journal of Clinical Nutrition 94(2): 417-421 6. Jacskon, CA., Mishra, GD (2013). Depression and Risk of Stroke in Midaged Women: A Prospective Longitudinal Study. Centre for Longitudinal and Life Course Research 44(6): 1555-1560 doi: 10.1161/STROKEAHA.113.001147

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7. Maramis, WF., Maramis, AA. (2009). Ilmu Kedokteran Jiwa. Surabaya, Indonesia: Airlangga University Press 8. WHO (2012). Article: Fact Sheet on Depression. url: http://www.who.int/mediacentre/factsheets/fs 369/en/index.html. retrieved: 28 September 2013 9. Indonesian Department of Health (2011). Article: The Great Push: Investing Mental Health. Indonesian Ministry of Health (url): http://www.depkes.go.id/downloads/Buku%2 0Panduan%20HKJS__.pdf. retrieved: 28 September 2013 10. Murti, B. (2006). Desain dan Ukuran Sampel untuk Penelitian Kuantitatif dan Kualitatif di Bidang Kesehatan. Yogyakarta, Indonesia: Gadjah Mada University Press

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11. Beck, AT., Steer, RA., Brown, GK. (1996). Beck Depression Inventory-2nd Edition. Philadelphia, USA: The Psychological Corporation. 12. Pan, A., Okereke, OI., Sun, Q., Logroscino, G., Manson, JE., Willet, WC., et al. (2011). Depression and Incident Stroke in Women. 42(10): 2770-2775. doi: 10.1161/STROKEAHA.111.617043 13. Wu, F., Chen, Y., Pervez, F., Segers, S., Argos, M., Islam, T., et al. (2013). A Prospective Study of Tobacco Smoking and Mortality in Bangladesh. PLoSONE 8(3): e58516. doi: 10.1371/journal.pone.0058516 14. Sattelmair, JR., Kurth, T., Buring, JE., Lee, IM. (2010). Physical Activity and Risk of Stroke in Women. 41(6): 1243-1250. doi: 10.116/STROKEAHA.110.584300

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A cross sectional study of Pengawas Minum Obat (PMO) in going hand in hand with tuberculosis patients in Jakarta Respiratory Center (JRC) – The Indonesian Association Against Tuberculosis Nathania S. Sutisna1, Fabianto Santoso2, Eka Satya Nugraha2, Yenna Tasia3 Asian Medical Students’ Association (AMSA) – Universitas Pelita Harapan 2 Asian Medical Students’ Association (AMSA) – Universitas Indonesia 3 Asian Medical Students’ Association (AMSA) – Atma Jaya Catholic University Asian Medical Students’ Association (AMSA)-Indonesia 1

ABSTRACT Background: Tuberculosis (TB) is an infectious disease that is the second most deadly disease in the world.Indonesia has the third largest population affected by TB, which accounts for 10% of TB cases worldwide and is considered the third most deadly disease in Indonesia. TB treatment regimen is a 6 months long process with an intensive phase, followed by a continuous phase. Compliance to this treatment regimen and regular consumption of medication is crucial to the treatment.Adherence in consuming anti-TB drugs regularly is considered the most important success factor in treating TB. World Health Organization (WHO) designed Directly Observed Therapy, Short-course (DOTS) as a strategy to eradicate TB by increasing the effectiveness of TB treatment through preventing irregular consumption of TB drugs. Pengawas Minum Obat (PMO) is one of the DOTS strategy applied in Indonesia that involves appointing someone to support to TB patients, motivating, educating and reminding them to take their medication regularly. In most cases in Indonesia, family members assume the role of PMO due to the lack of health care workers. This research aims to study the factors which influence the role of PMO in the treatment of TB patients. Methods: This is a cross sectional study involving 22 cured TB patients from Jakarta Respiratory Center. Data were collected through medical records and interview. Data analysis is done by Chisquare analysis. Results:The result showed that there is no relationship between the education level of PMO (p=0.318), occupation of PMO (p=0.631) and duration of treatment (p=0.597) with the role of PMO in supervising the TB patients. Ideally, TB patients prefer family members as PMO for practical reasons and the psychological support they can give. The results of this study is revealing of the PMO system in Indonesia. Delayed or failed TB treatment is a BACKGROUND significant problem in Indonesia. The four Tuberculosis (TB) is an infectious disease biggest factors that contribute to this that is the second most deadly disease, after phenomenon are patients’ lack of motivation, HIV/AIDS. The incidence and mortality rate of the drugs’ side effects, lack of transportation or TB is higher in low and middle-income access to medical facilities and lack of countries. In 2011, 1.4 million people died from communication between patient and healthcare TB, with 95% of TB deaths occurring in low workers. Factors that affect the success of TB and middle-income countries.1 treatment are gender, age, co-morbidity, Indonesia is a middle-income country that pregnancy, malnutrition, cigarette smoking, names TB as one of its national health corticosteroid treatment, genetic factor, terminal problems. After India and China, Indonesia is kidney disease, environment and compliance to the largest population affected by TB. The the treatment regimen. Compliance in prevalence of TB in Indonesia in 2011 was 281 consuming anti-tuberculosis drugs regularly is per 100,000 people; the incidence was 189 per considered as the most important success factor 100,000 people and mortality rate reached 27 that can be modified by community medicine.3 per 100,000 people.2 The most severe effects of irregular

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consumption of TB drugs are multiple drug resistant tuberculosis (MDR-TB) or extensively multiple drug resistant tuberculosis (XDR-TB).4 Both MDR and XDR TB lead to a higher mortality rate1, leading to increased difficulty in the eradication of TB. WHO designed DOTS (Directly Observed Therapy, Short-course) to increase the effectiveness of TB treatment by preventing irregular consumption of TB drugs. The study conducted by Masniari (2007) stated that lack of communication between healthcare workers and TB patients caused irregular consumption of TB drugs3. Hence, one of the DOTS strategies that is widely known in Indonesia is Pengawas Minum Obat (PMO)5 or literally translated as drug-taking observer. PMO is a person appointed to give support to TB patients, motivating, educating and reminding them to take their medication regularly. A study conducted in Indonesia showed that family members as PMO is a significant factor in the regular consumption of TB drugs (correlation coefficient 0.210).6 On the other hand, some research has shown that there are disadvantages to the PMO systemand who should have the role of PMO is still highly debated.7,8 However it should be noted that the five elements of DOTS strategy resulted in more than 80% recovery rate from TB.5 This research will study the characteristic of the ideal PMO in helping patients adhere to their treatment regimen. METHODS This research is a cross sectional study conducted from August to September 2013. Using the simple random sampling method, we obtained 22 respondents who agreed to be interviewed for the research. They were patients at Jakarta Respiratory Center (JRC) that are declared cured from TB. Two methods were used to collect data: medical records and interview with the respondents. Medical record reveals the demographic data of the patients while phone interview reveals the patients and PMOâ&#x20AC;&#x2122;s data: occupation, education and relationship between patient and his PMO. SPSS 17.0 for Windows was used as the analyzing program for this study. Data were analyzed using Chi-square analysis. As per

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protocol convention, all missing data were excluded. RESULTS From 22 respondents that have agreed to be interviewed, 3 respondents felt that PMO did not help in their adherence to the TB treatment regimen. Instead it was their self motivation to get better, not help from others, is what made them comply to the treatment regimen. Table 1. Demographic of the Patients n Age (median) 40.5 Gender Male 17 Female 5 Occupation Entrepreneur 3 Employee 13 Housewife 4 Student 1 Education Elementary school graduate 4 Jr. High school graduate 1 High school graduate 13 Undergraduate 4 Duration of Medication 168.5 (median) Table 2. Demographic of the PMO n Gender Male 6 Female 16 Occupation Entrepreneur 2 Employee 4 Housewife 13 Student 1 Education Elementary school graduate 3 Jr. High school graduate 6 High school graduate 11 Undergraduate 0 Unknown 2 Relationship with patient Spouse 12 Family (parent or sibling) 10 Ideally the role of PMO is a supportive

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one, motivating TB patients during their treatment regimen and regularly reminding TB patients to consume their TB drugs. Fisher's Test was used to analyze the relation between the occupation and education of PMO with their role. Relationship between education of PMO and their role Based on education, respondents were classified into higher education (undergraduate and senior high school graduate) and lower education (junior high graduate and elementary school graduate). Analysis of data showed that there is no relationship between the education level of PMO with their role (p=0.318). Relationship between occupation of PMO and their role Respondents were grouped into 2 main classification of occupation, working - which includes entrepreneur and employee, and not working - which includes student and housewife. This classification is based on the free time the respondents have, in which

Fig 1. Normal Q-Q Plot of Duration of Treatment (Helped = Yes)

workers will have less free time than those not working. Analysis of data showed that there are no relationship between occupation of PMO with their role (p=0.631). Table 3. Relationship between occupation and education of PMO and their role Variable Demographic of PMO p value Helped by PMO Occupation 0.631 Helped by PMO Education 0.318 Relationship between duration of treatment and the role of PMO Duration of treatment is the duration from when patients are first diagnosed with TB according to international standards until patients are declared cured at the end of their treatment regime based on a negative acid fast bacilli (AFB) test. In our study, it was found that there was no relationship between the duration of treatment and the role of PMO (p=0.597)

Fig. 2 Normal Q-Q Plot of Duration of Treatment (Helped = No)

Fig. 3 Boxplot of Duration of Treatment, with Independent Variable = helped by PMO

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DISCUSSION DOTS in Indonesia DOTS as WHO’s strategy to eradicate TB has 5 components: (i) political commitment with increased and sustained financing, (ii) case detection through quality-assured bacteriology, (iii) standardized treatment, with supervision and patient support, (iv) an effective drug supply and management system, and (v) monitoring and evaluation system, and impact measurement. The third point of DOTS is the focus of this study, which in itself have three components: (i) treatment services that ensure standardized therapy and use most effective regimen, (ii) supervision and patient support to make sure TB patients consume TB drug, and (iii) improving access to treatment.9 Based on the component “supervision and patient support”, the Indonesian government adopted the PMO strategy which involves appointing someone to support TB patients and reminding them to take their medication regularly. This strategy corresponds to the International Standard for Tuberculosis Care (ISTC), which that states every practitioner who treats tuberculosis patients must give appropriate information regarding to the disease and ensure and evaluate the adherence of TB patients to their medication (7th standard).10 In Singapore, trained healthcare professionals are appointed to supervise TB patients.11 The same system is applied in India, where trained healthcare professionals or other trained personnel who are not family members of the TB patients are appointed to be the supervisor.12 In Indonesia, the ratio of national healthcare workers to the population is 2 per 10.000 people for doctors and 13.8 per 100.000 people for nurses and midwives. This is significantly less than the ratio of Singapore, which is 19.2 dan 6.5 per 100.000 people respectively for doctors and 63.9 dan 10.0 per 100.000 population respectively for nurses and midwives.13 Moreover, Senewe (2002) has shown that accessibility to healthcare facilities were significant (p=0.015) to adherence of TB treatment.14 Moreover, healthcare facilities in Indonesia are unevenly distributed. This shows that it is

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not feasible for Indonesia to mobilize its healthcare workers as PMO. Hence, Indonesia used another system of supervision. An appointed person to supervise the TB patients is called Pengawas Minum Obat (PMO). Requirements to be PMO are: (i) a person who is known, trusted and approved by both the healthcare professional and patient, (ii) a person who lives near the patient, (iii) a person who is willing to help the patient, and (iv) a person who is willing to be trained and educated. Based on these requirements a lot of people play the role of PMO, such as local healthcare professionals, healthcare cadre (a group of people who are trained and committed to help TB patients) and family members.15 Relationship between education of PMO and their role From our study, it has been concluded that there is no relationship between the education level of PMO and their role in supporting TB patients. This result is consistent with the study conducted by Purwanta (2005), which states that PMO’s education level is irrelevant to TB patients’ adherence to their treatment regimen. Patients feel that most importantly PMO are attentive towards the patient and are committed to the program for the whole treatment duration. The study found that patients feel PMO’s knowledge about TB drugs was more important than their education level.16 Widjanarko (2006) in his study in Semarang, statistically proved that there is a significant positive relation (p < 0.05) between PMO’s knowledge of TB and their role.17 All of the PMO involved in our study were volunteers who helped the TB patients without receiving any pay, they served based on their motivation and commitment. This means that PMO, regardless of their education level, can carry out their tasks well as long as they are committed. Hence we concluded that there is no relationship between PMO education level and their role. Relationship between occupation of PMO and their role Based on the results of our study, there is

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no relationship between the PMO’s occupation and their role in supporting TB patients. Similar results were obtained from studies done previously, one of which is by Purwanta (2005), with patients stating that the PMO’s occupation was insignificant, as long as they had free time to spare for the patients.16 From this, we can conclude that as long as the PMO have spare time, their occupation will not interfere with their commitment in helping the TB patients. Part of the PMO’s task is to ensure that TB patients take their medicine regularly. The medication schedule therefore can be regulated in accordance with the PMO’s work schedule. Relationship between duration of treatment and the role of PMO In this research, the relationship between the duration of TB patients’ treatment and the role of PMO was studied. Garrido MDS et al explained in his study that the successful treatment of TB patient was influenced by various factors, one of which was the DOTS program. It was found that 89% of TB patients were declared cured due to the DOTS program, of which one of its components is the PMO strategy.18 As seen in the results above, statistically there is no relationship between the duration of treatment and the role of PMO. Descriptively speaking however, a shorter duration of treatment (median= 167 days) was found in patients that felt that PMO played a role in their successful treatment regimen, as compared to the group who felt otherwise (median= 196 days). Even though the difference in this duration of treatment is insignificant statistically, this study proved that the role of PMO does have a positive impact in the duration of treatment, resulting in a shorter duration of treatment. This difference found between the 2 groups of TB patients can also be influenced by other bias factors, such as comorbid diseases. This can also be seen from several pieces of data with its range far from the mean. Hence, even though the role of PMO does have a positive impact on the duration of treatment, there are other contributing factors.

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Ideal PMO Research conducted in urban and rural areas in Yogyakarta (Purwanta, 2005) studied the criteria for an ideal PMO based on interviews with TB patients. Overall, maturity was the most important to the patients rather than the PMO’s age. However it is noted that for patients living in rural areas, which may be considered as being highly traditional, they prefer PMO who are older so that they may reprimand the patients. This is due to traditional beliefs in which the elders are respected and it is improper for young people to reprimand their elders. This study revealed that most TB patients hope that their family members will be their PMO, whether it be their parents or spouse, as they felt that it was more practical and that it is better psychologically.16 Standard TB treatments consists of 2 months (intensive phase) of daily dose of Rifampicin, Isoniazid, Pyrazinamide, and Ethambutol, followed by 4 months (continuous phase) of thrice weekly doses of Rifampicin and Isoniazid. There are numerous side effects from TB drugs, such as nausea, confusion and loss of appetite. Patients must endure the side effects for the whole 6 months, which is taxing both physically and psychologically for the patients. Forgetting to take the drugs usually happens during the non-daily dose phase (continuous phase).4 In addition to a patient’s own motivation to be cured, it has been proven by numerous studies that the presence of close relatives helps TB patients. Family members can motivate and remind patients to take their medication regularly18. We interviewed the respondents and asked who would be an ideal PMO to help them through their TB treatment. Most of the respondents felt that a close family member is the ideal PMO because of the motivation they could provide and their psychological bond. In conclusion, after considering all the aspects in relation to Indonesia including the characteristics of the Indonesian population, the DOTS strategy of using a family member as PMO is effective in supporting TB patients. This is due to practical reasons, as

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family members are physically near the patient and due to psychological reasons, as family members have a strong bond with the patient. CONCLUSION Considering many aspects of public health in Indonesia, such as unevenly distributed primary healthcare and low ratio of healthcare workers to population, Indonesia had set a feasible and applicable supervision and patient support system, which called Pengawas Minum Obat (PMO). This study concluded statistically there are no relation between the role of PMO with their education, occupation and patientsâ&#x20AC;&#x2122; duration of medication. Most of the PMO are coming from family members who have strong psychological bond with the patients, hence they had motivation to help the patients and going hand in hand to fight the disease. REFERENCES 1. World Health Organization. Global Tuberculosis Report 2012. Geneva; 2012. 2. World Health Organization. Tuberculosis fact sheet. Geneva; 2013. 3. Linda M, Priyanti ZS, Tjandra YA. Factors that affect the recovery of lung tuberculosis patients. J Respir Indo. 2007; 27(3):176-185. 4. Perhimpunan Dokter Paru Indonesia. Tuberkulosis : pedoman diagnosis & penatalaksanaan di Indonesia. Jakarta; 2006. 5. World Health Organization. Global tuberculosis control : surveillance, planning, financing: WHO report 2006. Geneva; 2006. (WHO/HTM/TB/2006.362) 6. Hutapea TP. Pengaruh dukungan keluarga terhadap kepatuhan minum obat anti tuberkulosis [internet]. 2006 [updated 2006; cited 2013 September 29]. Available from: http://jurnalrespirologi.org/jurnal/April09/ Dukungan%20Keluarga.pdf 7. Zwarenstein M, Schoeman JH, Vundule C. Lombard CJ, Tatley M. Randomised controlled trial of self-supervised and directly observed treatment of

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tuberculosis.The Lancet. 2008; 352(9137): 1340-3. 8. Volmink J, Garner P. Directly observed therapy for treating tuberculosis. Cochrane Database Syst Rev. 2007; 17(4): CD003343. 9. Ministry of Health of Indonesia. Fakta seputar tuberkulosis: pengendalian tuberkulosis di Indonesia. Indonesia: 2013. 10. The Tuberculosis Coalition for Technical Assistance. International standards for tuberculosis care (ISTC). United States; 2006. 11. Ministry of Health of Singapore. TB Statistics [internet]. Singapore. 11 November 2012 [updated 2013 January 31; cited 2013 September 29. Available from: http://www.moh.gov.sg/content/moh_web /home/statistics/infectiousDiseasesStatisti cs/Tuberculosis_TB_Stats.html 12. Ministry of Health and Family Welfare of India. TBC India [internet]. India. 2007 [updated 2007; cited 2013 September 29]. Available from: http://www.tbcindia.nic.in/rntcp.html#DO TS%20in%20India 13. World Health Organization. WHO Indonesia: Health profile [internet]. 2013. [updated: 2013 October 7; cited: 2013 October 28]. Available from: http://www.ino.searo.who.int/EN/Section 3_24.htm#Human_Resources 14. Senewe FP. Faktor-faktor yang mempengaruhi kepatuhan berobat penderita tuberkulosis paru di puskesmas Depok.Bul. Panel. Kesehatan. 2002; 30(1): 31-38. 15. Priyanti ZS. Pelatihan DOTS [course]. Jakarta: Pulmonology Department and Respiratory Medicine, Faculty of Medicine, University of Indonesia. 2008. 16. Purwanta. Ciri-ciri pengawas minum obat yang diharapkan oleh penderita tuberkulosis paru di daerah urban dan rural di Yogyakarta. JMPK. 2005; 8(3): 141-7. 17. Widjanarko B, Prabamurti PN, Widyaningsih N. Analisis faktor-faktor yang mempengaruhi praktik pengawas

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minum obat (PMO) dalam pengawasan penderita tuberkulosis paru di kota Semarang. J Prom Kes Indo. 2006; 1(1): 15-24. 18. Garrido MDS., Penna ML, Perez-Porcuna TM, Souza ABd, Marreiro LdS, Albuquerque BC, et al. Factor associated with tuberculosis treatment default in an

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endemic area of the Brazilian Amazon: a case control-study. Plos One. 2012; 7:1-7. 19. Sukoco NEW. Studi kualitatif deskripsi interaksi antara peran pengawas minum obat dengan pasien TB paru di kabupaten Majalengka. Buletin Penelitian Sistem Kesehatan. 2012; 15(4):339-344.

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POST FOR POST-STROKE PATIENT (P4P): A Scientific Review Nurul Cholifah Lutfiana, Athaya Febriantyo Purnomo, Dewa Ayu Megayanti 5th Semester Medical Student, Faculty of Medicine, University of Brawijaya, Indonesia ABSTRACT Background : In Indonesia, every 1000 people, 8 of them got attacked by stroke. Every 7 people death in Indonesia, 1 of them caused by stroke.Some people that got attacked by stroke suddenly loss their ability to do their activity daily living.This may cause post stroke patient developed depression after stroke period.Mood depression is considered as the strongest predictor of quality of life in stroke survivors.Through this study, we aim to formulate suggestions in improving quality of life of post stroke patient. Material and Methods : To fulfill our aim, we conducted a review of policies from Stroke Foundation of Indonesia (Yastroki ) about stroke management in Indonesia, we also reviewed international standards made by National Heart Disease and Stroke. We compared the views reflected in those policies on mental health, including definitions used, and the implementation of policies in real situations.The review was conducted in September 2013. Result : POST 4 POST-STROKE PATIENTS (P4P) policy, can give advantages for post-stroke patient, their family, their society, and the government. And it can prove the function of government in health division, especially for stroke patient. If we can give a good service for this patient, economic side and productivity of Indonesia’s human source can increase. Conclusions: Stroke is a cerebrovascular disease, which is one kind of chronic disease that can cause death or disability. Some people that got attacked by stroke suddenly loss their ability to do their activity daily living, may developed depression after stroke periodand depression can makes post-stroke patient progress of the disease worsen. From this scientific review we can conclude that Indonesia’s government is still paying less attention to degenerative diseases such as stroke. Whereas the impact of stroke on the declining influence productivity and economic capabilities. Thus, we suggest POST 4 POST-STROKE PATIENTS (P4P) policy, we can give patient with have home-based rehabilitation and relieving stress community. For the family members can get training about “How to Face Stroke Attack”, and for government can do its function as a provider of society demands. It leads to lower morbidities prevalence of post-stroke morbidities and it means there will be higher health status of the country. And not to forget also there will be a higher productivity of the nations which is important to improve the nations well in the economical subject. Keywords: Post-stroke, depression, government Introduction In 2008, mortality from stroke was the fourth leading cause of death in the United States, and stroke was a leading cause of long-term severe disability (Minino, Murphy, Xu, & Kochanek, 2008). Nearly half of older stroke survivors experience moderate to severe disability (Kelly-Hayes, Beiser, Kase, Scaramucci, D'Agostino, & Wolf, 2003). In Indonesia, every 1000 people, 8 of them got attacked by stroke. Stroke is leading cause of death in all age with 15,4% proporsion. Every 7 people death in Indonesia, 1 of them caused by stroke. (Riskesdas, 2011)

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Some people that got attacked by stroke suddenly loss their ability to do their activity daily living. They can’t do activities as well as before they got stroke. This may cause post stroke patient developed depression after stroke periode. As we know that psychological affect progression of the disease, post stroke depression makes incidence of recurrence stroke increase and interfere quality of life of post stroke patient that makes progress of the disease worsen. Mood depression is considered as the strongest predictor of quality of life in stroke survivors. Moreover, post stroke depression is associated with an increased disability,

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increased cognitive impairment, increased mortality, both on short and long term, increase risk of falls and, finally, with worse rehabilitation outcome. Conversely, the absence of post-stroke depression in young adults is a significant predictor of the ability to return to work. Moreover, an improvement of depressive symptoms has been associated with a better functional recovery. (Suzanne & Barker-Collo, 2007) Correlation between post stroke depression and functional recovery make depression as urgent thing to manage and control to improve quality of life of post stroke patient. While, stroke management nowadays still not aware about post stroke depression that alter progress of stroke it self. Thus, we conducted a review of post stroke depression with a focus on preventing and managing post stroke depression. We explored management of stroke nowadays and assessed whether those management are appropriate enough to improve quality of life of post stroke patient. Through this study, we aim to formulate suggestions in improving quality of life of post stroke patient. Material and Methods To fulfill our aim, we conducted a review of policies from Stroke Foundation of Indonesia (Yastroki ) about stroke management in Indonesia. To put those policies in a global perspective, we also reviewed international standards made by National Heart Disease and Stroke. We compared the views reflected in those policies on mental health, including definitions used, and the implementation of policies in real situations. The review was conducted in September 2013. Results In Indonesia there are some rules about healthy, for example pasal 28 H (1) UUD 1945: “setiap orang berhak hidup sejahtera lahir dan batin, bertempat tinggal, dan mendapatkan lingkungan hidup yang baik dan sehat serta berhak memperoleh pelayanan kesehatan” and UU no 23 tahun 1992 about health. If there is something unfit

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in the health problem, the government can make a new policy. But it seems that Indonesia’s government is still paying less attention to degenerative diseases such as incidence of stroke in Indonesia tends to increase quite high, but it seems the government's attention to a disease associated with degenerative - beyond infectious disease - is still lacking. Therefore community participation is needed to overcome or suppress the high incidence of stroke in Indonesia. Unlike the Americans, the U.S. government provides funding of about U.S. $ 51 trillion, either directly or indirectly to be used for the prevention and management of stroke. Therefore it is time that the government and the public has the discretion to determine the agreement on strategic efforts to reduce the incidence of stroke, which in principle consists of effective prevention before the stroke and an increase in stroke management effectively and optimally. Stroke not only attack old age , but also for the young and productive . In Indonesia , it is estimated that each year 500,000 people suffered a stroke, about 2.5 % or 125,000 people died , and the rest is mild or severe disability . The impact of stroke on the declining influence productivity and economic capabilities , ranging from families to the economic impact on the community and the nation's economic burden. Public awareness of general health needs to be improved , especially about the stroke , as well as how to prevent it is relatively very low . Still limited facilities and service units available stroke became an obstacle , treatment and rehabilitation of post- stroke are still very limited both treatments performed in the hospital, the family and society . Similarly, care and attention and public appreciation of the human post- stroke is still lacking, including the implementation of policies for accessibility infrastructure and public facilities for the disabled ( insability ) post- stroke beings. Problems faced by human beings really a concern Stroke Foundation of Indonesia ( Yastroki ) as well as a basis in preparing the work program in

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order to assist and participate in efforts to tackle and deal with the problem of stroke in Indonesia. Thus, we suggest POST 4 POSTSTROKE PATIENTS (P4P) policy, we can gather all the patients with same condition to have home-based rehabilitation which is applicative for them and to relieve stress together with their community of stroke attack history. Also this could be a channel for the family members to get the training about “How to Face Stroke Attack”. And there will be sharing knowledge and testimony of the stroke survivors to motivate the post-stroke patients to survive with low disability, and it can be charity event also in terms of management of stroke for example the giving process of survivor’s wheelchair to the post-stroke patients who can’t walk normally. When we conduct P4P policy, it will be advantage for not only the post stroke patients, but also the society as a whole, especially family members. The family of post-stroke patients will be helped because they will be more prepared and equipped with knowledge about stroke, moreover for low economic people, which is identically with low education level. Even bigger range in government, because the government has already done its function as a provider of society demands, it will convey good message toward the society that even the minority of society like post-stroke patients still handled by government, it shows that government still care toward the existence of stroke patients. It leads to lower morbidities prevalence of post-stroke morbidities and it means there will be higher health status of the country. And not to forget also there will be a higher productivity of the nations which is important to improve the nations well in the economical subject. Table below shows to readers that patients after stroke are tend to get psychological problem like depression in the middle of their survival. On how the patients have anxiety and depression have p value (significance value) is less than 0.0001 which is really significant in their life to having problem like this. (Raju, 2010)

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Discussion Stroke is one of the leading causes of morbidity in the UK, with over 100,000 people experiencing a stroke each year. It is characteristically considered to be a condition causing weakness and paralysis. In fact up to 20% of people have no weakness, and a further unknown number of people have clinically silent stroke. More importantly, all patients with cerebrovascular disease are at risk of cognitive loss and some cognitive loss is probably present in almost all patients. In addition, serious psychological problems and strain are common in carers of people with stroke. Mood disturbance is common on stroke patients in the forms of depression or anxiety. (The Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke (2008) Royal College of Physicians) Psychological mood disturbance is associated with higher rates of mortality, long term disability; hospital readmission; suicide and higher utilization of outpatient services if untreated. In order to overcome the problems, the depression that really significance as told in the result session(Raju 2010), actually depression supposed to be pressed by the policy come from the government. What the

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patients want to press psychological problem in their mind is there is someone who accompany them in their life. The people who accompany their life after stoke attack is everybody surround the. Therefore everybody oblige to know how to accompany and help post-stroke patient in order to make health status become better than before. These are the steps for psychological intervention this proposal needed to do in order to maximize the effects.

What the post-stroke patients need in the psychological perspectives are 1. the person-centred involvement of patients and their families/carers in goal setting and treatment planning; 2. the importance of providing ongoing support to patients and their families/carers; 3. partnership working between carers, Local Health Boards (LHBs) and the Welsh Government for future service planning Post-stroke patient is the risky target to get the complexity of complication, which is going to downwards their quality of life. Nowadays, stroke doesn’t only attack on the elder, but even younger one have the same risk factor to having stroke. In the Rolfs A et al’s study done in February 2013, the youngest age to get stroke is 18 years old, which is in that age, everybody could still do many things for their life, family, society and even bigger nation. Accordingly, we have to struggle for poststroke patient’s quality of life because for even young patient, their life path is still long way ahead. They are the seeds of the nation. They are also still productive and having many ideas as a young generation which is

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deserve to survive to bring the nation into the better condition. Also for the old one, even if they are old and not as productive as the young people, goal of treatment for old people is at least they can do their daily activity by their own, for example take bath, having their lunch, defecation and urination by their own. At least they can fulfill their necessity in daily, therefore they don’t have to depend and become burden on the other people who take care of them. Actually, post-stroke people can continue their life with minimum morbidities as long as after they got stroke, they get rehabilitation continuously. The complexity of stroke management does exist. Not only giving the medication and rehabilitation for the patient, but also we need to compromise their feelings to make a distance with depression or spiritless. If the rehabilitation is done with no obstacles such as suppressor factor like depression, they could do something better in the rehabilitation and improve well. Thus, post-stroke patient will have their daily life activities normally or with minimum morbidities. Fortunately, the research of pharmacological and rehabilitation management for post-stroke patients is always improving day by day. But lately, we have another problem which sounds cliché but have really tangible implication for patients, which is psychological condition of the patient. Because the science of psychological is really abstract, what we can do to overcome this problem is just avoid the psychological problem afflict the patient. Unfortunately, the post-stroke patient is really vulnerable to have those problems, because they have different human function after stroke attack, like aphasia, paralyzed, and many others. Not to mention there a lot of unconscious discrimination happens in society of Indonesia. Most of society let their family member whose have stroke attack to just get rest on the bed and hoping that actions will implicate to the patient’s recovery, while the reality says no. Stroke can cause depression in a number of ways. A stroke causes physical damage to the brain. When brain cells are damaged, the

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parts of the body and mental functions controlled by these cells may not work properly (Adams, Zoppo, & Kummer, 2002; Feigin, 2004; Rudd, Irwin, & Penhale, 2005) This physical damage can cause a number of psychological effects such as emotionalism (having difficulty controlling your emotions) and personality changes, as well as depression (NHS Choices website, 2011; Stein, 2009; Godefroy & Bogousslavsky, 2007). Having a stroke can be a frightening experience. Stroke happens very suddenly and it can take some time to come to terms with the shock of what has happened. Many people feel frightened, anxious, frustrated or angry about what has happened to them, the impact of the disabilities they may be left with and the changes this may bring to their life. This is normal, but sometimes these feelings can develop into depression (Hinds, 2000). There are a number of treatments and selfhelp techniques available for depression. treatment will depend on how severe your depression is and may involve a combination of: talking therapies, such as counselling; antidepressant medication; self help. The most effective treatment is psychological intervention or counselling, combined, if appropriate, with anti-depressant medication (MIND, 2011; RCP National Clinical Guidelines for Stroke). There are many things you can do yourself to cope with depression, and improve your well-being. Social contact: Meeting people regularly, every day if possible, is an important source of wellbeing. Talking to others can be a big help. If you are able to, keep talking to family and friends, and try not to push people away or assume you are a burden.Join a support group: Many people find support groups useful. They provide a chance to meet people who have been through a similar experience, and many arrange social activities. Stroke clubs are support groups for people affected by stroke and there are also groups for people with depression. Contact us for details of stroke clubs near you and see the Useful organisations section for other organisations

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that can help. (Depression Alliance, 2011; Royal College of Psychiatrists, 2011) Returning to hobbies and interests also an important part of the rehabilitation process after stroke. You could even look at trying new things. Try not to be put off by thoughts that you are unable to do things as well as you could before the stroke. Many activities can be adapted to enable you to carry on enjoying them. Exercise: Recent research shows that exercise is very beneficial in treating and preventing depression. Doing any physical activity regularly, however gentle, can help (NHS Choices UK; NICE, 2009) Conclusion Stroke is a cerebrovascular disease, which is one kind of chronic disease that can cause death or dissability. Some people that got attacked by stroke suddenly loss their ability to do their activity daily living. This may cause post stroke patient developed depression after stroke periode and depression can makes post-stroke patient progress of the disease worsen. So we have to manage and control to improve quality of life of post stroke patient. From this scientific review we can conclude that Indonesia’s government is still paying less attention to degenerative diseases such as stroke. Whereas the impact of stroke on the declining influence productivity and economic capabilities , ranging from families to the economic impact on the community and the nation's economic burden. Thus, we suggest POST 4 POST-STROKE PATIENTS (P4P) policy, we can gather all the patients with same condition to have home-based rehabilitation and relieve stress together with their community of stroke attack history. Also this could be a channel for the family members to get the training about “How to Face Stroke Attack”. When we conduct P4P policy, it will be advantage for not only the post stroke patients, but also the society as a whole, especially family members. Even bigger range in government, because the government has already done its function as a provider of society demands, it will convey good message toward the society that even

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the minority of society like post-stroke patients still handled by government, it shows that government still care toward the existence of stroke patients. It leads to lower morbidities prevalence of post-stroke morbidities and it means there will be higher health status of the country. And not to forget also there will be a higher productivity of the nations which is important to improve the nations well in the economical subject. References Kelly-Hayes M, Beiser A, Kase CS, Scaramucci A, D'Agostino RB, Wolf PA. (2003). The influence of gender and age on disability following ischemic stroke: the Framingham Study. J Stroke Cerebrovasc Dis, 12, 119–26. Miniño AM, Murphy SL, Xu J, Kochanek KD. (2011). Deaths: final data for 2008. Natl Vital Stat Rep, 59, 10. Riskesdas: http://www.depkes.go.id/index.php?vw=2 &id=1703 Suzanne L, Barker-Collo. (2007). Depression and anxiety 3 months post stroke: Prevalence and correlates. Archives of Clinical Neuropsychology, 22, 519-531. Adams, H P , Zoppo, G, Kummer, R (2002) Management of stroke: A practice guide for the prevention, evaluation and treatment of acute stroke. Professionals Communications, Inc, p 139-140. Feigin, V ( 2004) When lightening strikes, Harper Collins Publishers, caring for stroke patient, p.139- 140. Rudd,A, Irwin, P, Penhale, B ( 2005) Stroke at your fingertips. Class Publishing ( London) Ltd. P.112 NHS Choices website. Stroke recovery. http://www.nhs.uk/Conditions/Stroke/Pag es/recovery.aspx (updated 15th Oct 2010, accessed 28th Sept 2013). Stein,J et al. (2009). Stroke recovery and rehabilitation. Demos Medical Publishing, United States of America. P463. Godefroy, O and Bogousslavsky, J. (2007). The behavioural and cognitive neurology of stroke. Cambridge university press, Cambridge. P529.

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Hinds, D M. ( 2000) After a stroke, Martins the printers Ltd Berwick Upon Tweed P,142,143. MIND, Depression,http://www.mind.org.uk/help/ diagnosis_and_conditions/depression(Upd ated Jan 2011, accessed 27 Sept 2013) RCP National Clinical Guidelines for Stroke, Third Editionhttp://bookshop.rcplondon.ac.uk/c ontents/6ad05aab-8400-494c-8cf49772d1d5301b.pdf (accessed 27 Sept 2013) Depression Alliance, Depression, Self help/coping, http://www.depressionalliance.org/helpand-information/self-helpcoping.php(accessed 27 Sept 2013). Royal College of Psychiatrists, Depression, http://www.rcpsych.ac.uk/mentalhealthinf ormation/mentalhealthproblems/depressio n(Updated Jan 2011, accessed 27 Sept 2013). NHS Choices UK, Living with depression, http://www.nhs.uk/Conditions/Depression /Pages/living-with.aspx(accessed 21 Jan 2011). The National Institute for Health and Clinical Excellence(NICE),Depression. Treatment and management of depression in adults, including adults with a chronic physical health problem. October 2009 Guidelines. P.4 (accessed 27 Sept 2013) NHS Choices UK, Living with depression, http://www.nhs.uk/Conditions/Depression /Pages/living-with.aspx(accessed 27 Sept 2013). The National Institute for Health and Clinical Excellence(NICE),Depression. Treatment and management of depression in adults, including adults with a chronic physical health problem. October 2009 Guidelines. P.4 (accessed 27 Sept 2013) American Heart Association. Psychosocial Problems, Quality of Life, and Functional Independence Among Indian Stroke Survival. Rinu Susan Raju, Prabhakaran S. Sarma and Jeyaraj D. Pandian. Stroke. 2010;41:2932-2937; originally published online October 21, 2010 (accessed 27 September 2013)

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Die Hard Vs Live Happily Chronic Obstructive Pulmonary Disease (COPD) is 1 of 10 main death causes in Indonesia, which makes it very important for people to start to care about it. Most cases are presented with a long smoking history and/or long exposure to air pollution. Although this disease takes time to fully emerge, the difficulty of breathing caused by COPD, once the disease has developed, will cause the patients to suffocate so much that their quality of life will eventually be reduced. Moreover, COPD treatment is a life-long treatment, which makes COPD harder to fight against off because the patients usually come from the lower economic class and it’s usually impossible for them to keep on having medications for their whole life. This poster aims to raise awareness in public about how COPD will disturb and reduce the patients’ quality of life and also show the way to prevent COPD.

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Bad and Good Habits Related to Heart Disease Nowadays, the causes of disease are no longer from genetics factors but something we often call it as habits. One of those diseases is heart disease. Heart disease has been increasing and becomes the number one killer in the world including Indonesia. Smoking is no longer an odd thing for us. Even now smoking has become a habit in human societies. They also consider smoking is an alternative way to help them release their stress. All this time, most of us think that smoking will only cause pulmonary related diseases. Nevertheless through smoking, there are many other complications that can occur including heart disease. Aside from smoking, consumption of alcohol can also lead to heart disease. Unfortunately, some of us think that their life which is free from smoking and alcohol probably would not cause them to suffer the heart disease. It is partially true but nonetheless, there are some other habits which could make you earn the title as a heart disease patient. It is due to the activities and routines that we do daily. Generally most of us will say that we do not have much time for some exercises. However, if we do not exercise regularly, this condition will eventually lead to fat being buried in our tissues. The accumulation of fat will clog the blood flow specifically the blood flow in the heart and most likely the occurrence of heart disease will be higher. Furthermore, we never realized that most of the food we eat everyday usually contain substances that can lead to heart disease. Therefore, we must throw away all the bad habits and start having a healthy lifestyle. BRAINs|

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Fight Cancer with Psychosocial Therapy Cancer is a chronic disease that causes 7.6 million people in the world died in 2008, in which 70% of the total deaths from in low-and middle-income countries, such as Indonesia. World Health Organization (WHO) estimates that the number of cancer deaths will increase to 13.1 million by 2030. While in Indonesia, the Health Ministry said that the prevalence of cancer in 2012 increased to 4.3 from 1 to 1,000 people to 1,000 people. Prevalence continues to increase every year, not only in adults but also in children.Children with cancer who ought to play happily with her friends, must fight the pain of cancer. They tend to refuse medical treatment thereby reducing the chances of healing’s success. One of the efforts that have been done by the cancer foundation (Yayasan Pita KuningAnak Indonesia) to help children in Indonesia by helping aiding children to fight cancer with psyhosocial therapy. In this therapy, not only provide comfort to children with cancer through play and sing together, but also to provide counseling to their parents. By this psychosocial therapy, it is expected that children with cancer can be entertained, more vibrant in medical treatment. So, the chance of healing’s success becomes high.

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Engaged the Caregiver for A Better Coordinated Care

Chronic diseases are worldwide public health problem with an increasing incidence and prevalence,poor outcomes, and it takes a lot of money for the treatment cost. Data from the World Health Organization show that out of the 36 million people who died from chronic disease in 2008, 9 million were under 60 and 90% of these premature deaths occurred in second and third world countries.Generally, the patients of chronic disease was having financial problem to pay their treatment cost so they are counting on government health insurance.Their insurance claim will give their countries a lot of financial burden. Chronic disease management aims to help people controls the effects of their chronic illness. What we need to fight chronic disease is a coordinated care between patients and the caregiver. Patients, family, caregiver, doctor, and medical experts needs to be committed to raise an awareness of the number one cause of death, disability, and the treatment cost that getting more expensive each year. This problem has taken a lot of mother, father, daughter, son, and all of people that were loved. Hopefully, with the disease management and high chronic disease awareness, patients with chronic disease can live their life longer than they were expected to be.

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Love Yourself, Love Others Acquired Immunodeficiency Syndrome (AIDS) is a disease of the human immune system caused by HIV (Human Immunodeficiency Virus), which manifests as failure of the immune system and allows life-threatening opportunistic infection. HIV/AIDS is commonly transmitted through sexual contact and intravenous drug use. Highest incidence of HIV/AIDS occurs in adolescents and young adults where they are in their most sexually active years. HIV prevalence amongst people who use IV drugs in Indonesia is 36%. Now, HIV/AIDS epidemic in Indonesia is the fastest growing in Asia and it makes HIV/AIDS one of many big problems in Indonesia. Lately, people do not seem to be aware of how big this problem is. More than 1 million people were diagnosed with AIDS since 1981 and social stigma from other people makes the problem bigger. Social stigma makes people afraid to seek treatment and receive inadequate amount of information about prevention, which make it hard to stop the disease and aggravate patients' situation. People infected with HIV should be treated with care, and things that should be avoided are changing sexual partners and sharing needles with infected person. So, let's love yourself by avoiding AIDS and love others by caring about the people who are struggling with AIDS.

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