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Introduction Table of Content Bundle Regular of AMSA-Indonesia National Competitions (BRAINs) is a full compilation of all works submitted in every Introduction .………………………...……………………………………………........................................…….2 national competitions held by Asian Medical Students’ Association (AMSA) Indonesia. The previous bundle is named Table of Content …………………………………………...………………………..............………...…………..3 AMSA Indonesia National Competition Bundle (AINCB).

Scientific Paper

Each year, AMSA Indonesia held three national competition

Pre-conference competitioncerevisiae for East -Asian REGENTS: Renal Regeneration through Hematopoieticevents Stem entitled Cells Induced

by Saccharomyces Medical Students’ Conference (PCC for EAMSC), National Ayu PramithaWulandari, Putu Nina Belinda Saka, Made PradnyawatiChania, Nurdian..........................................5 Paper Poster Training, and PHOTO also Pre-conference PLACE HERE, competition for Asian Medical Students’ Conference (PCC for AMSC).

The Importance of Geriatric Medicine in Indonesia - Rio Alexsandro, OTHERWISE Monica.......................…………….....13 DELETE BOX third bundle, compile all works participated in PCC for Organized Efforts in Management for Coronary Heart This Disease Patients ─ Increasing the Quality of Life EAMSC 2014, which aimed to choose Indonesia representative Steven Philip and Anselma Halim..................................................................................................……..................21

in EAMSC 2014 in Seoul — South Korea, on January 12-16th.

The theme for this competition is “Walking side by side: Expression of CD68 in patients with multibacillary type of leprosytheaspatientson a markertheir of intracellular acompanying lifelong struglelocation with chronic from Micobacterium leprae - Utomo Andi Pangnguriseng, disease” Mukhraeni.................................................................32

Profile of Nasopharyngeal Carcinoma in Dr. Cipto Mangunkusumo Hospital in 2010: Towards a Better In this competition, Indonesia will send 1 Scientific Paper, 1 Scientific Poster, Health CampaignLiu, consist of 1 Sigit Film and1 Healthcare System - Vito Filbert Jayalie, Maria Satya Paramitha, Jessica,and Cindy Anastasia Adhitya Public Poster.

Ramadianto, Marlinda Adham.................................................................................................................................37 Once compiled, Bundle of AMSA will be both distributed to all local AMSA and published via the AMSA-Indonesia web so that Scientific Poster EAMSC 2014 will be held in Seoul – South Korea, on January all members could easily access and obtain useful information Osteoarthritis Vs Osteoarthrosis - Ilva W. Savitri, Arcita gather Hanjani Pramudita....................................................44 12-16th in this bundle.

Profile of Nasopharyngeal Carcinoma in Dr. Cipto Mangunkusumo Hospital in 2010: Towards a Better Enjoy and keep involved in academics!

Healthcare System - Vito Filbert Jayalie, Maria Satya Paramitha, Jessica, Cindy Anastasia Liu, Adhitya Sigit Ramadianto, Marlinda Adham..................................................................................................................………...45

Judges

Lec A Specific Protein Utilization In Staphyococcus aureus Biofilm Bacteria As A Vaccine Candidate For • dr. Dimas Bayu, SpPD The Prevention Of Chronic Amoebic Dysentery Caused By The Protozoan Entamoeba histolytica - Ivan • dr. Forman Erwin Siagian, MBiomed Bintang Pratama, Dwi Fitria Rahayuningwati, Dewangga Primananda Susanto, Januardi Indra....................…...46

•

dr. Dhanasari Vidiawati, MSc, CM-FM

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 Contributors Nathania S. Sutisna, Fabianto Santoso, Eka Satya Nugraha, Total Yenna Tasia..........………........................................47 Team of PCC for EAMSC Regional Chairperson 2014 Garda Widhi Nurraga Health Campaign Universitas 7 JumpsDiponegoro To Care Diabetic - Hardy W. S., K. Risang, Erwin Y.......….................................................................48 Scientific Paper 23 Secretary Academics- Camoya Gersom, Chrisandi Yusuf,Scientific Poster 12 Hands ofofCompanion Intan Kautsarani......................................................49 Fabianto Santoso Health Campaign 19 Universitas Indonesia Save The Golden Generation - Ivan Bintang Pratama, Akbar Fitrahadi, Yeni Purnamasari.................………...50 A-Team Creative Give Your HeartProject Supply - Dewa Ayu Megayanti, Aditya Dimas, Ayu Pramitha Wulandari, Putu Nina Belinda Ayudhea Tannika Saka...........................................................................................................................……………………………...51 Universitas Kristen Krida Wacana

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REGENTS: Renal Regeneration through Hematopoietic Stem Cells Induced by Saccharomyces cerevisiae Ayu PramithaWulandari1,a, Putu Nina Belinda Saka2,b, Made PradnyawatiChania3,c, Nurdiana4,c 1,2 Medical Student,University of Brawijaya, Malang.

3 Department of Pharmacology, University of Brawijaya, Malang.c ABSTRACT Background: Chronic kidney disease (CKD) has become a serious problem that leads to disability or even death. Patient will suffer multiple organ dysfunctions signed byhighcreatinine level, anemia, hypertension, overload syndrome, and uremia. In 2012, there are 300.000 people suffering CKD in Indonesia, with approximately 50.000 people need to take hemodialysis every year.

Apparently, it is estimated that in 2025, there will be 1,5 million people who suffer CKD and need either hemodialysis or kidney transplantation.

Objective: To evaluateSaccharomyces cerevisiaeeffectin chronic mice with CKD based on creatinine level, hematopoietic stem cell (CD34+)from bone marrow and kidney, anatomy and histopathology of kidney.

Materials and Method:Chronic kidney disease (CKD)in male balb/c mice were induced by a single carbon tetrachloride (CCL4) intraperitoneally (i.p)injectionin dose (0,5 ml/kg).

Saccharomyces cerevisiaein doses 50 mg/kg, 100 mg/kg, and 200 mg/kg of body weight were administered to CKD mice per orally for 6 weeks. At the end of the treatment, blood, kidney, and bone marrow were analyzed for CD34+ expression. The kidney of each mice also studied to check any morphological changes.

Result:Saccharomycescerevisiaehas significantly increase the percentage of CD34+ of bone marrow (p=0,000) and kidney (p=0,000). Significantlydecreasedcreatininelevel(p=0,005).

Correlation betweenSaccharomyces cerevisiaedose and CD34+ kidney, showed significant and strong correlation (r=-0,665). It has significant and strong correlation with CD34+ bone marrow (r= 0,808). It also has significant and strong correlation with creatinine level (r= 0,635).

Conclusion: Saccharomyces cerevisiaehas significant effect to cure CKD. It may be due to increased release of hematopoietic stem cell that probably regenerate kidney.

Keyword:Chronic kidney disease,Saccharomyces cerevisiae, beta glucan, Hematopoietic Stem Cells, CD34+.

Introduction Chronic kidney disease (CKD) has became a major publichealth problem in the world. This disease can lead to disability or even death for the patient.The sign of chronic kidney disease are decreasing of renal function, high creatinine levels, anemia, hypertension, overload syndrome, uremia (Prodjosudjadi, 2012). WHO data shown that kidney disease has high mortality rate in the world, it is about 775.103 peopleand has killed about 30.013 people in Indonesia (Tsai et al., 2009; Sugiura, 2009).

CKD can lead to multiple organ failure such as calcium metabolic disorder, impaired glucose metabolism, metabolic acidosis, urea poisoning, even can lead to coma till death if

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it does not get appropriate treatment. It due to kidney has a systemic affect to other survival organs in human body (Fauci et al, 2008).

Hemodialysis becomes therapeutic use for CKD so far. Despite, this method only prolong patient’s lifetimebut, not cure their diseases. Primary way to treat this disease is using kidney transplant. However, it has many disadvantages, such the high cost, possibility of rejection occurs during transplant process, and limited hospital that could run transplantation (Rakyat Merdeka, 2011).

Because it is still difficult to treat CKD, new innovation for its alternative treatment in medicine is required. For over

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the past decade, stem cell has known and significant advances has been madein medicine through it. Stem cell discovery has potential clinical application of organ regeneration (Yokoo et al., 2011).This discovery has also opened an opportunity for degenerative disease such CKD to be healed by kidney regeneration process.Stem cell is multipotent cell which cell can differentiate into many types of cells. These include hematopoietic stem cell (HSC). It has proven that HSC could differentiate into many types of cells include nephron cells of kidney. The latest method to develop regenerative medicine isto mobilize HSC from bone marrow. Thus, it can regenerate kidney injury in CKD. This method has advantage, in addition to repair kidney injury, this method is also safe because it can minimize the risk of patient’s injury during treatment process (Sell, 2004; Ito et al.,2009).

For all this time, Indonesian people have been known yeast Saccharomyces cerevisiae which is used to make tempe, beer, bread. However, most of them did not know thet yeast Saccharomyces cerevisiae has other benefits. Recent studies shown that 60% of pure beta glucan contained in yeast saccharomyces cerevisiae. It also contained in mushroom and wheat, but, the highest beta glucan contained in yeast (Mason, 2004). Lin et al.,(2009) research shown that beta glucan help atherosclerosis healing process. Another research shown that it help to mobilize HSC that affect regeneration of islet beta pancreas in diabetes mellitus mice (Al-Farabi et al., 2011). Lin et al.,(2009) research has shown that administration ofbeta glucan on mice able to increase granulocyte colony stimulating factor (G-CSF). These factors play role in the HSC mobilization process into circulation and induce repair mechanism of tissue injury,particularly, kidney cells in CKD. Due to Saccharomyces cerevisiae role which could enhance G-CSF to mobilize HSC that can repair injured kidney in CKD, it needed a research to prove Saccharomyces cerevisiaerole in repairing either anatomical or functional of kidney damage whose induced CKD.Thus, it can be obtained new

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alternative therapy based on regenerative medicine using stem cells to treat CKD in the future.

Material and Method Animal Maintenance Balb/c mice 6-7 weeks were chosen as chronic kidney disease (CKD) model as described previously (Adams and Scadden, 2006). Balb/c obtained from Center of Laboratory Animal Breeding in Brawijaya University.

Mice adapted in the Pharmacology laboratory for seven days and divided by five groups.

Induction of Chronic Kidney Disease Induction of chronic kidney disease (CKD) in mice used carbon tetrachloride (CCl4). Balb/c mice was injected 0.5 ml/g BW CCl4 intraperitoneally (i.p) three times a week for 6 weeks to make CKD (Juarez et al, 2008).

Administration of Saccharomyces cerevisiae Saccharomyces cerevisiae obtained from Microbiology Laboratory, Faculty of Medicine, Brawijaya University. Dose of administration divided into 50 mg/g BW, 100 mg/g BW, and 200 mg/g BW [11].

Saccharomyces cerevisiae was given per orally in mice. Before given per orally, yeast Saccharomyces cerevisiae was homogenized with distilled water, and it was given for6 weeks by using sonde. After 6 weeks, the blood was collected from mice heartwith 1 ml syringe, from kidney, and femur bone which has fixed using formalin 10%.

Measurement of CD34+ expression using Flowcytometri Centrifugation preparation of whole blood in 40C temperatures, with a speed of 6000 rpm for 15 minutes. Cell sediment was mixed with cytoperm / cytofix number of 2 times the number of cells obtained. The mixture of cells and cytoperm / cytofix soup and centrifuged to obtain pellets. Then wash the pellet BD added a number of 4 times the number of cells obtained in the first sentifugasi.Mixture centrifuged and add lysis buffer number 2 times the number of cells obtained early. After that add the antibody labeled for each sample, five tubes were prepared and processed in parallel. Single

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stained with CD34+PE added to the wash tube. The entire sample is then stored in 4˚C in dark conditions and analyzed using flowcytometry (FACScan) for 1 hour (Adams and Scadden, 2006).

Creatinine Measurement Creatinine collected from mice serum. It kept in the vacoutainer and given creatinine serum reagent.

Evaluation of Kidney Histology Kidney were calsificated at 5% (w / v) EDTA and embedding with paraffin wax. Next cut with a microtome with a thickness of 4 µm and subsequently stained with standard procedures Hematoxyleneosinstaining (HE). Kidney viewed by using Olympus CX31 light microscope and photographed with a Nikon Coolpix 9090 camera to assess the percentage of nephrone cells destruction in the kidney.

Data Analysis Results of creatinine measurement in mice, the number of hematopoietic stem cellssigned by increasing CD34+ level, and kidney cell morphology of control and treatmentwere statistically analyzed using SPSS 17.0 for Windows.

P1

P2

P3

Picture 3. Treatment Control, P1 (50 mg/ grBW), P2 (100 mg/ grBW), P3 (200 mg/ gr BW) Percentage of Hematopoietic Stem Cell (CD34+) on Kidney

P< 0.05 R= -0.665

Result Histology of Glomerulus in Kidney stained with Hematoxylen-Eosin (HE)

14,676 ± 2,859

8,280 ± 1,142 7,825 ± 1,281

Picture 1. Negative Control (normal mice) 1,865 ± 0,054

a

b

b

a

Picture 4. CD34+ Percentage on Kidney Picture 2. Positive Control (CKD mice)

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Percentage of Hematopoietic Stem Cell (CD34+) on Bone Marrow

P<0.05 R= -0.635

P < 0.05 R= -0.808

0,643 ± 0,083

0,458 ± 0,030 0,385 ± 0,046

2,723 ± 0,375 0,379 ± 0,049

0,320 ± 0,028 1,725 ± 0,273 0,893 ± 0,109 1,095 ± 0,147

a

a

a

a

b

Picture 5. CD34+ Percentage on Bone Marrow Creatinine Serum Analysis

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ab

a

a

Picture 6. Creatinine Serum Discussion

Histology of Glomerulus in Kidney stained with Hematoxylen-Eosin (HE) Histologyof glomerulus in kidney result on Negative Control Group (KN) which did nott induceby CCl4, showednormal kidney, there is no cast protein, and glomerulus size still normal.

Histologyof glomerulus in kidney result on Positive Control Group (K+) which is induced by CCl4showed an infiltration of inflammatory cell, glomerulus atrophy and cast protein. Cast protein is a marker of epithelial damage on kidney.

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Histology of glomerulus in kidney result on P1, P2, P3 groups : • In treatment 1 which injected by CCl4 and given by 50 mg/kg body weight ofSaccharomyces cerevisiae,we found infiltration of inflammed cell, but the number is decreased.

• In treatment 2 which injected by CCl4 and given by Saccharomyces cerevisiae with dose100 mg/kgBB, we found glomerulus size slightly increased like normal size and there is no infiltration of inflammed cell or protein cast.

• In treatment 3 which injected by CCL4 and given by Saccharomyces cerevisiae with dose200 mg/kgBB, we found glomerulus size returning to the normal size and there is no infiltration of inflammed cell.

Percentage of Hematopoietic Stem Cell (CD34+) on Bone Marrow The result of ANOVA statistic test (right graphic) of CD34+ number which expressed in bone marrow is obtained p value=0,000 (p<0,05). It shows that there are minimal two treatment groups which have significant difference. After post hoc tukey test, we found significant difference between positive control group with treatment 3, treatment 1 with treatment 3, treatment 2 with treatment 3.

The result of regression correlation test (left graphic) between increase of doseand increase of CD34+ number which expressed in bone marrow is obtained p value<0,05. It means there is a relation between the increase of dose with increase of CD34 number which expressed in bone marrow with strength of relation is very strong (R=-0,808). It proves there is relation betweenincrease of yeast dose with increase of stem cell CD34+ in bone marrow.

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The result of ANOVA statistic test (right graphic) of CD34+ number which expressed in bone marrow is obtained p value=0,000 (p<0,05). It meansthere are minimal two treatment groups which have significant difference. After post hoc tukey test, we found significant difference between positive control group with treatment 1, treatment 2 and treatment 3. In addition, significant CD34+ increase is found in treatment 1 with treatment 3.

The result of regression correlation test (right graphic) between increase of dose with increase of CD34+number which expressed in kidney is obtained p value<0,05. It means there is relationship between increase of dose and increase of CD34+number which expressed in kidney with relationship strength is strong (R=0,665). It proves there is relationship between increase of yeast dose with increase of stem cell CD34+ in bone marrow.It proves there is relationship between increase of yeast dose and increase of CD34+number which expressed in kidney.

In normal condition,HematopeiticStemCells(HSC) isabundant inthe bonemarrowbutit can not bereleased into thecirculationandnotgo toanotherorgancirculation.This is causedby thestrong bond thatbindthebonemarrowtoCXCR-4 andSDF-1.

Administration ofSaccharomyces cerevisiae containingbeta glucan caninducemacrophagestosecreteG-CSF whichG-CSF canbindto its receptorandactivatesosteclast.Osteoclast activation can untie the bond between CXCR-4 and SDF-1 so that the HSC can be released into the circulation.When HSC is detached from the bone marrow, HSC can lead to damaged kidney tissue

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due to kidney will release a signal to mark the HSC to go to damaged area so HSC that come from circulation can reach damaged kidney tissue which measuredby the percentage of CD34+in the kidney.

Result of Data Analysis and Discussion of Creatinine Level The result of ANOVA statistic test (left graphic) to serum creatinine level is p value<0,05. It means there are minimal two treatment groups that have significant difference. After post hoc tukey test, we found significant difference between negative control group and positive control. In addition, there is significant decrease of serum creatinine level in group P2 and P3 compared with positive control. Even, P2 and P3 can return serum creatinine level like normal condition exactly (negative control).

The result of regression correlation test between increase of dose and decrease of creatinine level is p value<0,05. It means there is relation between the increase of dose and decrease of creatinine level which is strong. It proves that increasing thedose ofSaccharomyces cerevisiae can turn lowerserumcreatinine level.

Relationship Among Variables In thePearson correlation testbetween variables, itdoes notremainclosecorrelationbetweenCD34+ bone marrowwithCD34+ kidney and blood creatininelevel(r =0.808; r=0.665; r=0.635). Thisprovesthat theinduction ofrelease ofhematopoieticstem cellhas an influenceon the expression ofCD34+ inkidneyandbone marrowwhich in turnlowerblood creatinine levelsandrelease ofhaematopoieticstem cell(HSC) in the bloodwhichthenhelp damaged kidneyto regenerate.

Conclusion:

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1. Saccharomyces cerevisiae is able toimprove thehistologicalstructure of thekidneyin micemodel ofchronic renal failure.

2. Administration of Saccharomyces cerevisiae canreduce level ofcreatininein micemodel ofchronic renal failure.

3. Administration ofSaccharomyces cerevisiae canincrease the percentage ofHSCwhichcharacterized byCD34+marker,bothin the bone marrowandkidneys, which means it can increasethe releaseand mobilization fromtheHSC. Suggestion: Further research need to be taken in order to find the optimal result of proper dose and side effects ofSaccharomyces cerevisiae administration, thus can be developed as a regenerative treatment of CKD. ACKNOWLEDGEMENT Thank to Dr.dr.Nurdiana, M.kes, Mr. Muhaimin Rifa’i,PhD, Mr.Memet,Mr. Yudha for their guidance to finish this experimental study into a successful research.

REFERENCES 1. Al-Farabi, Makhyan Jibril, Zukhri, Dicky Stevano et al.

(2011).STEMPOWERING (Stem Cell Empowering):Inovasi Pengembangan Terapi Auto-Regenerasi Berbasis Mobilisasi Hematopoietic Stem Cell Pada Tikus Model DM Menggunakan Ekstrak Jamur Tiram (PleurotusOstreatus) 2. Anshory, M. (2008). Tugas Akhir (Skripsi): EfekPemberianCornmeal dan Cornmeal-soy terhadapKetebalan Aorta TikusRattusnorvegicus yang DiberiDietAterogenik.

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FakultasKedokteranUniversitasBrawij aya 3. Guyton,Arthur C. (2006).Text book of medical physiology eleventh edition.

31:401-415 4. Heldal, Kristian, Hartmann, Anders, et al.2010.

Benefit of Kidney Transplantation beyond 70 years age.

Nephrol dial transplant 25:1680-1687 5. Ito, Koichi, Masuda, Yuki, Yamasaki, Yoshihiko, et al. (2009). Maitake Beta-glucan Enhances Granulopoiesis and Mobilozation of Granulocytes by Increasing G- CSF Production and Modulating CXCR4/SDF-1 Expression.

International Immunopharmacology 9: 1189-1196 6. JeanMichel.

(2005).Saccharomycescerevisiae.Http: //www.inra.fr/Internet/Directions/DIC/ PRESSE/COMMUNIQUES/ images/sia2004/ saccharomyes cerevisiae l.jpg accessed October,1st 2011 at 15.34 7. Juarez, Fernando, Vazquez, Maria Luisa, et al.(2008). Acute Renal Failure Induces by Carbon Tetrachloride in Rats With Hepatic Cirrhosis. Annals of Hepatology7(4): 331-338 8. Lin, Fangming, Cordes, Kimberly, Li, Linheng, et al. (2003). Hematopoietic Stem Cells Contribute to the Regeneration of Renal Tubules after Renal Ischemia Reperfusion Injury in Mice. J Am Soc Nephrol14: 11881199 9. Mason, Roger. (2004). What is Beta Glucan A Concise Guide to the Benefits and Uses of the Most Powerful Natural Immune Enhancer Known to Science. USA : 561 Shunpike 10. Matovinovic, Mirjana Sabljar. (2009).

Pathophysiology and Classification of

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Kidney Disease. Pathophysiology and Classification of Kidney Disease Journal 11. Robak, Waszkiewicz, Bartnikowska, E. (2009). Effects of Spent Brewer’s yeast and Biological β-glucans on Selected Parameters of Lipid.Journal of Animal and Feed Sciences 18: 699-708 12. Adams GB and Scadden DT. (2006).

The hematopoietic stem cell in its place. Nat Immunol.2006;7:333-7 13. Rahmawati,Devie.2009.http://www.ui .ac.id/download/siaranpers/Penelitian Biologi_ver2-1.pdf. Accessed on October 5th 2011 at 20.30 14. SANGER. (2004). Peptidase of Saccharomyces cerevisae.Http //merops.Sanger.ac.Uk/speccards/pept idase/spOO0895.htm. Accessed on October, 1st 2011 at 16.04 15. Sell, S. 2004. Stem Cell Handbook ed (2004): 1-18 16. Siregar,Mulia.2011.http://ekbis.rakyat merdekaonline.com/news.php?id=221 05 accessed on September 27th 2011 on 22.45 17. Sjafriani,Ririn.(2010).http://www.rep ublika.co.id/berita/gayahidup/infoseh at/10/03/23/107551-cegah-gagalginjal-dengan-deteksi-dini.html.

Accessed September 27th on 22.31 18. Sugiura, Toshihiro, Wada, Akira.

(2009). Resistive Index Predicts Renal Prognosis in Chronic kidney disease. Nephrol Dial Transplant 24: 2780-2785 19. Tsai, Yi-Chun, Hung, Chi Chih.

(2009). Quality of life predicts risks of end-stage renal disease and mortality in patients with chronic kidney disease. Nephrol dial transplant 25; 1621-1626 20. WHO.(2010).http://www.worldlifeex pectancy.com/contactUs.php.

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Accessed on September 27th2011 at 22.30 21. Yang Jong In, Jung-HwanYoon, dan Yung-Jue Bang. (2010). Synergistic Antifibrotic Efficacy of Statin and Proteinkinase C Inhibitor in Hepatic Fibrosis. J Physiol Gastrointest Liver Physiol 298:45-6 22. Yokoo, Takashi, Matsumoto Kei, Yokote, Shinya. (2011). Potential Use of Stem Cells for Kidney Regeneration. International Journal of Nephrology 105-8461.

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The Importance of Geriatric Medicine in Indonesia Rio Alexsandro, Monica AMSA-Universitas Tarumanegara ABSTRACT Old age is the age of a person who has reached 60 years of age or above. In the next few years, an estimated population of elderly will continue to increase, both in the world as well as in Indonesia. A surge in elderly population that will occur will be giving effect to the state, such as health and economic problems.

Geriatric services that are holistic is one effort that can be done to tackle health problems in the future. One goal of this ministry is to improve geriatric quality of life of the elderly. See the importance of the existence of geriatric services in the future, the role of physicians as well as much-needed supporting facilities in Indonesia.

Keywords: Elderly, Health Workforce, Facilities Introduction Population data from the United Nations (UN) said that in 10 years, the number of elderly in the world to reach the 1 billion. An increasing number of people in the world each year, the population is dominated by the elderly over the age of 60 years or more. Total elderly population in 2000 amounted to 605 million, and is expected in 2025 will reach 1.2 billion people.1, 2 One of the developing countries in the world are experiencing an increase in the elderly population is Indonesia based charts. In 2011 in Indonesia, the number of elderly reached 8.2% of the total population of Indonesia, with an estimated number of 19.5 million people. This figure is expected to increase to 13.2% and 25.5% in 2025 and in 2050. 1,3,4,5 Figure 1 Percentage of People 60 years old and over in selected Developing Countries5

One of the factors caused the increasing of elderly every year in Indonesia is the increasing of life expectancy figure. BPS (central statistic

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biro) says that life expectancy figure in 2010 is 67.4 year with the number of 23,992,552 million of people. And, it is predicted by 2020, life expectancy figure will increase to 71.1 year with the number of 28,882,879 million people. 3,4 The increase of elderly from years to years will cause a lot of problems in medical and economy sectors. Minister of health of Indonesia, Nafsiah Mboi, told that impact of the increasing of elderly is the appearance of a lot of chronic diseases. More over, the explosion of elderly can cause the increasing of non communicable disease. In 1990, in developing countries, non communicable diseases is in second rank with 27%, neuropsychiatric disorder with 9%, and injuries with 15%. While in 2020 it is predicted that all of them will be increase, non communicable diseases will be the first rank with 43%, neuropsychiatric disorders with 14%, and injuries with 21%. 4, 6 Figure 2 Global Burden of Disease 1990-2020 by Disease Group in Developing Countries6

The increasing of elderly will be a challenge to the world and to every country in improving the needs to accommodate and to maintain the

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status of health to elderly. Survey that has been done to 26 countries, give a result that health program system in developing countries not ready yet to guarantee the elderly health status. 6 In Indonesia, medical care to elderly by institution of social service in medication will be started in 2014. Not only medical care to elderly which a priority to the nation, empowering human resources is also a priority of the nation in 2014. So far medical care workers are also needed in implementing the medical cares to elderly. 4 In addition to the health workforce, health care is one of supporting the country's health status. Countries with an increasing number of elderly would have to start thinking about the availability of medical support facilities lansia.

7 From the data mentioned above, it can be concluded that the number of elderly people in Indonesia will continue to increase each year, while the health workforce to perform geriatric care are lacking. Writing this paper has the purpose to inform the reader about the importance of elderly care in Indonesia in order to identify and improve the quality of the health system, both in terms of the health workforce and support facilities in the future.

Methods The method used in writing of this paper is the study of literature. In this method, a team of writers write a review of the aspects that will be reviewed by way of rewriting theories or opinions of a particular party. Theories or opinions of certain parties is obtained from textbooks or journals that are considered new by the team of writers, so that the information submitted is update.

8 Results Geriatric Definition Definition of geriatrics base of Encylopedia of Public Health is the branch of clinical medicine focusing on health promotion among older people and the prevention and treatment of disease and disability in late life.9 Definition of geriatric according to the book Know Your Elderly and Care is a branch of medical science that studies gerontology and

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health in the elderly in many aspects, promotive, preventive, curative, and rehabilitative.10 So, geriatric is a study that is a branch of the science of gerontology who specializes in health issues elderly patients, both in the business promotive, preventive, curative, and rehabilitative.

Elderly Definition and Classification According to Shaban M I, the elderly are older people is a biological process experienced by all creatures. It starts early in age and lasts for the rest of life and accompanied by changes in vital body organs and tissues. 11 Elderly according to the WHO classification divides into middle age (middle age) and elderly (Elderly), elderly parents (old) and the elderly are very old (very old). A middle-aged man with an age range 45-59 years, 60-74 years elderly, elderly 75-89 years old, and very old elderly above 90 years. 12 According to the Law of the Republic of Indonesia Number 13 Year 1998 on Elderly Welfare, advanced age is a person who has reached the age of 60 years. 13 From some of the definitions and classifications in the elderly, it can be concluded that when the elderly person is 60 years old.

Elderly Statistics in the World Health information that can accurately describe the actual state, as well as having an influence on planning in dealing with health problems in the world and in those countries.

Based on population data conducted by the UN, the data obtained that the number of elderly in the world in the next 10 years, to reach the 1 billion mark. 1,14 In 2010, the population of the world is 6.9 billion people. Where 11% of the total population is resident over the age of 60 years and 80 years and over. The number of elderly people aged over 60 years in the year 2010 was 759 million, whereas the elderly over the age of 80 years amounted to 105 million people. 15 From these data, the United Nations estimates that by 2050 the number of elderly in the world population will reach 2 billion people.

Estimated number of people in the world will rise to 9.1 billion people, and 22% of the total

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population is the population over the age of 60 years and 80 years. If in the year 2010, the elderly population aged over 60 years is 759 million people, in 2050 is expected to reach 2 billion people. While the elderly population aged 80 years and over 400 million people. 1,15 Elderly Statistics in Indonesia According to the Ministry of Social Affairs of the Republic of Indonesia, the number of elderly people in Indonesia from year to year continues to increase. This is evidenced by data from the Central Bureau of Statistics reported that in 1980, the number of elderly is 7.9 million or 5.45% of the total population of Indonesia. In 1990 increased to 6:29% of the total population of Indonesia is 12.7 million people, in 2000 to 14.4 million people, in 2003 to 16.1 million in 2004 to 17.7 million people, in 2006 to 19 million, and in 2010 there were 23.9 million elderly or 9.77% of the total population of Indonesia. The increase continues to occur each year is expected to continue rising to reach 30 million by 2020. 12,16 Table 1 Total of Elderly in Indonesia 12,16 Year

Total

Percentage

1980

7.998.543

5,45 %

1990

12.778.121

6,29 %

2000

14.439.967

7,18 %

2006

19.000.000

8.90%

2010

23.992.552

9,77 %

2020

28.822.879

11,34 %

The increasing number of the elderly population, the rate of life expectancy also increased from year to year. In 1980 the average life expectancy is 52.2 years older, was 59.8 years in 1990, the year 2000 was 64.5 years in 2006 was 66.2 years, and in 2010 was 67.4 years. Estimated that in 2020 life expectancy elderly will increase to 71.1 years. Life expectancy increasingly higher every year this will be a problem for the world or a country. The higher the life expectancy, the burden borne by the state even more severe. In addition, high life expectancy can also increase the rate of chronic diseases in the country. 12,16

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Table 2 Angka Usia Harapan Hidup 12,16 Year

USIA HARAPAN HIDUP (UHH)

1980

52,2 years

1990

59,8 years

2000

64,5 years

2006

66,2 years

2010

67,4 years

2020

71,1 years

Health Problems In Elderly WHO estimates of infectious diseases in the country in 1990 around 50% and it will turn into a non-disease comunicable disease about 40%.

According to Kane & Ouslander, health problems that often occur in the elderly is often referred to as the 14 I Immobility (less mobile), instability (standing and walking is unstable or easily fall), Incontinence (beser pissing urinate and or defecate), Intellectual impairment (intellectual impairment / dementia), Infection (infection), impairment of vision and hearing, taste, smell, communication, convalescence, skin integrity (impaired sensory perception, communication, healing, and skin), Impaction (difficult bowel movements), Isolation (depression), Inanition (malnutrition), Impecunity (no money), Iatrogenesis (disease caused by drugs), insomnia (trouble sleeping), Immune deficiency (decreased endurance), and Impotence (impotence). 17 Naturally elderly will decline, physical, biological, and mental development. Decreased function of the various organs of the body will make the elderly are susceptible to the disease is acute or chronic. In addition it is also common in the elderly physical dependence, it can no longer perform daily activities because of the disease itself. There is an increasing number of elderly will also create health problems facing the more complex problems especially relating to degenerative.18

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According to Mc. Kenzie, many people believe that the health status of the elderly has improved over the past few years because many elderly people are living longer, but on the other hand according Darmojo elderly population particularly vulnerable to infection, susceptible to disease. The most consistent risk factors of illness and death for the entire population is age, and in general, the health status of the elderly is not as good as when they were younger. As already stated above by Nugroho2 that the elderly will be many setbacks organs. 19, 20 So which is expected in the elderly despite advanced age, should keep health with respect to lifestyle such as diet, physical activity, break habits, not smoking and other others.21 Health Workforce Kinds of Health Workforce Estimated in the 21st century health workforce will be needed to handle the high volume of elderly patients. No matter what the specialization will be taken for treatment of elderly patients is not too different from the handling of basic medical sciences. However, doctors in the future requires a debriefing in handling geriatric patients.

There are approximately 30 'geriatric syndrome' including physical, mental, and social. 22 This includes nurses,doctors, social workers, caregivers and policy makers acting at all levels starting from primary health care to the specialized unit at a tertiary hospital, rehabilitation and long-term care facilities, as well as in the office of the local or national health care authorities.23 In the geriatric clinic, there are some doctors who were involved in it, such as general practitioners such as specialist doctors geriatric medicine, eye doctor, dermatologist, dentist, psychiatry, etc. 24 Specialist science of medicine is a branch of medical science that plays a role in addressing health problems and disease, both in children and in the elderly. The development of science specialists in internal medicine toward a more in-depth on a particular organ made in this pathology has another subspecialty. Though divided into several subspecialty, but actually they are all inter-related and connected.

Subspecialist the field of allergy immunology clinic is, gastroentero-hepatology, geriatrics,

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kidney-hypertension, hematology-oncologymedical, cardiology, metabolic, psychosomatic, pulmonology, rheumatology, tropical infections, and medical emergencies.25,26 Subspesialis geriatrics is the study of a variety of health problems and diseases in the elderly. Treatment of the elderly can be given to elderly patients who are treated or ongoing treatment, such as the treatment of cognitive disorders such as dementia and delirium, malnutri, infection, dehydration, electrolyte disorders, psychological disorders such as depression, urinary incontinence or Alvi, impaired balance, falls, immobility or limitation of motion, decubitus ulcers, and sensory disorders such as hearing and vision. 25,26 Apart from giving treatment to the elderly, geriatric medicine specialists also need the skills to care for patients. Required skills such as how to install the stomach sonde (flocare), put a urinary catheter, decubitus ulcer patient care, and the skills to assess cognitive function, mental status, and functional status in patients.

25 Health Labor Statistics in Indonesia Ration of medical care workers per 100,000 residents in 2008 is categories below the target.

In 2008, ratio of specialist doctors is 7.73, general practitioners are 26.3, and nurses are 1567.75. Meanwhile, target of specialist doctors is 9, general practitioners are 30, and nurse is 158.27 Medical specialist in internal medicine or called an internist is one of the specialists who are needed in Indonesia. According PAPDI current number of medical specialists in internal medicine in Indonesia is 2556 people. This figure is still less than many of the targets set by the Papdi 20,000 specialists in internal medicine.

Still the shortage of specialists and specialists in internal medicine distribution uneven contributed to a new problem in Indonesia. If you see the current spread of the disease in most specialists in the capital Jakarta. While in other areas such as in Maluku, West Nusa Tenggara of specialists in internal medicine is so few. 25 Figure 3 Distribution of internist in Indonesia

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Source: Halo internist25 Not only is still lacks a specialist in internal medicine, Indonesia is still shortage of doctors subspecialist. The ratio of specialists in internal medicine and subpesialis was 75% and 25%.

According to a survey conducted by Papdi, current interest subspesialis doctors against doctors is much higher than for specialists in internal medicine. However Papdi also mentioned that despite high interest subspesialis doctors and the numbers are still lacking, the addition should be regulated because Indonesia still needs a specialist for internal medicine in the area. 25 Elderly Medical Facilities Medical treatment to elderly has three kinds of applied treatment, medical treatment to elderly in society, medical treatment to old people in society based on hospital, and medical treatment to elderly based on hospital Elderly medical facilities The medical treatment to elderly in society is a medical treatment by puskesmas and practitioner as a leader. In this medical treatment, puskesmas has a role in collecting, building a group of elderly.28 Practitioner responsible for medical treatment or curative action to elderly. Medical treatment to elderly in society based on hospital is a geriatric service as a leader. Hospital has a direct and indirect role to elderly. Indirect action is by giving a guidance to elderly to puskesmas (medical treatment to people) in his or her territory. 28 Besides, elderly based of hospital is a medical treatment that done by hospital which has a special treatment for elderly. The treatment given by hospital to elderly based on hospital are: 28 Geriatric Polyclinic

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In this polyclinic, elderly has a curative treatment, also consultation regard to their diseases.

Doctor whom has a role in geriatric polyclinic is a subspecialist. So that, elderly whom has treatment in this clinic is a patient whose already has recommendation from other polyclinic.

Acute Geriatric Ward Is a ward or special room to elderly whom suffer chronic disease, such as stroke, pneumonia, diabetic, etc. To this treatment, geriatric team has a role in doing assessment, curative, and rehabilitation to elderlys.

The team consists of general practitioner, nurse, social worker of medic, fisioterapis, speechterapis, internis, okupasi terapis, ortotis prostetis, rehabilitation of medic specialist (dokter spesialis rehabilitasi medik), psikolog, also geriatris.

Day-hospital day-hospital is a treatment of geriatric that implemented to on going patient, such as curative, assessment, ambulation, rehabilitation, and recreation. Geriatric/internist, nurse, physiology, etc., take part in day hospital.

Chronic geriatric ward Chronic geriatric ward id a ward or a special room for elderly whom suffer of chronic disease, of which has to stay and has to have long term medication.

Nursing home Nursing home is an institution or bureau acts in handling elderly in medic or chronic disease which no longer needs of hospital medication.

Geriatric rehabilitation Geriatric rehabilitation is rehabilitation can apply to patient whom has acute and chronic disease.

Geriatric consultation The consultation is a consultation service to elderly. The aim of the consultation to give medication to patient, to recommend the patient to go to geriatric polyclinic.

The Important of Elderly Health Care Geriatric services are services performed specifically for elderly patients. In Indonesia, geriatric services have existed since the 20th century, and is still in the development stage to date. According to the MOH, geriatric care has a goal to pursue a happy future for the elderly, so

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that the elderly can live independently and are not a burden on the family. Another goal of geriatric care is to maintain the health of the elderly from sickness or health problems, the elderly make early diagnosis, to treatment of the elderly who suffer from an illness, guiding the elderly to live independently, as well as providing assistance in the form of moral and attention. 29 Besides that, The American Geriatric Society also identified five goals to increase and optimalizing the health of elderly, such as to give the older person good health care, to increase the number of health worker to caring the older people, to increase and recruit health care professional and phsyciatrics in geriatric medicine, and to influence the public policy about geriatric medicine. 30 While the principles of geriatric care alone there are 4, namely holistic approach or biopsikososialspiritual, coordination, involving family members in the implementation of services, providing integrated diagnosis, and oriented to the needs of elderly tersebut. 10 The main principle of health care is a holistic ministry that involves various aspects. Various aspects that should be present by doctor in holistic ministry are: 10,28 Promotive Promotion is an attempt by the medical team to improve the health of the elderly in order to prevent the elderly from sickness. Promotive can be done in several ways, one of which is to create an appropriate environment for the elderly, such as the floor is not slippery to minimize the incidence of falls.

Preventive Preventive is an effort made in three ways: primary prevention, secondary, and tertiary.

Primary prevention is the prevention conducted in healthy elderly by way of immunization, counseling, etc.. Secondary prevention is a way in which to detect the presence of disease in the elderly before clinical symptoms appear.

Examples of secondary prevention is early detection of cancer, cervical cancer screening in elderly women. As for the tertiary prevention is usually performed on elderly who have experienced illness or disability. The goal of secondary prevention is to improve and maintain the function of the body.

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Early diagnosis and prompt treatment In doing early diagnosis, not just medical personnel are able to do, but seniors can do it yourself. An elderly can perform self-diagnosis to yourself by filling out a self-test, or by looking at the Card Towards Healthy (KMS).

While the diagnosis made by the medical officer is physical status examination, physical examination diagnostic, psychiatric examination, screening for a disease, etc.. After making a diagnosis, the medical officer that the doctor will provide treatment according to the symptoms of the elderly.

Disability limitation Handicap experienced by elderly may caused from several aspects, such as difficulties or limitation in activating skeletal, muscle, nerve.

Rehabilitative Is an effort done by medic officer to help elderly whom suffering dysfunctional or handicap so that they could do their activities.

E.g. elderly whom has hearing problem and be given a hearing aid.

Discussion Ever-increasing numbers of age life expectancy in Indonesia caused the elderly population keeps increasing every year. This is certainly going to be a new challenge for the government of Indonesia in dealing with various problems in the elderly. The elderly who are in a state of healthy and active, of course will be slightly reduce the burden of the government in particular against the efforts of health workforce health management. While the elderly who suffered health problems and requires long-term treatment will certainly be an issue for the country.

Thus, the existence of services ranging from implementation of geriatric health of elderly in society, elderly health services in communitybased hospitals, and elderly health services hospital based is indispensable in addressing this issue. While the elderly who suffered health problems and requires long-term treatment will certainly be an issue for the country. 31 However, there are some obstacles that occur in this geriatric services run as the lack of health workforce. Geriatric services will be made new by 2014, would have needed a special medical team, as a doctor specialist geriatric. Data from a

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number of PAPDI mentions that needed specialists is as much as 20,000 doctors, whereas there is at present only 2556 doctors. Lack of health workforce as a specialist in the disease course, have influence in treatment efforts against health problems faced by geriatric medicine. In fact, as we know that treatment efforts is one of the efforts that need to be done by the medical team of elderly patients suffering from certain diseases.

In addition promotif and preventive efforts also became a special concern for the doctor.

This is because the purpose of the Ministry is making the elderly geriatric Indonesia can live actively and independently. physically, mentally, and socially. Promotif and preventive efforts are usually given on the elderly who are still active and independent, with the intention of distancing or avoiding the elderly from attack a disease that often strikes the elderly. The existence of preventive efforts is expected to improve the quality of life of the elderly.

Conclusion From the above discussion, can be known that geriatric services are essential services in the future. Various aspects to enhance, maintain, and troubleshoot the health of geriatric service coverage for the sake of the survival of the elderly to remain active and independent. To achieve success, it is also a geriatric service roles as well as physicians and ancillary facilities.

References bbc.co.uk[internet]. Jumlah manula satu miliar dalam 10 tahun[updated 2013 Jan 13;cited 2012 Oct 1].

Available from: http://www.bbc.co.uk/indonesia/majalah/201 2/10/121001_unaging.shtml.

World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 5 S Permanasari I[internet]. Saatnya negara-negara antisipasi ledakan[updated 2013 Jan 13;cited 2012 Sept 5].

Available from: http://nasional.kompas.com/read/2012/09/05/ 17472153/Saatnya.Negara.Negara.Antisipasi.

Ledakan.Lansia.

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Anna LK[internet]. Fokus pada jumlah lansia[updated 2013 Jan 13;cited 2012 Sept 5].

Available from: http://health.kompas.com/read/2012/09/05/06 533520/Fokus.pada.Jumlah.Lansia World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 5.

World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 8 World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 13 Sastroasmoro S, Ismael S. Dasar - dasar metodologi penelitian klinis. Jakarta:CV Sagung Seto;2011.

Kirch W. Encyclopedia of Public Health. Tucker B, editor. Germany:Springer; 2008.

Maryam RS, Ekasari MF, Rosidawati, Jubaedi A, Batubara I. Mengenal usia lanjut dan perawatannya.

Jakarta: Salemba Medika;2008.

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Tahun 2003:vol 2: hal 27 Saragih RW, Supiana R[internet]. Hari senja yang indah di binjai [updated 2013 Jan 13;cited 2012].

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Data/Informasi Kesehatan Provinsi Jawa Barat. Bandung: Bakti Husada;2011. menkoskera.go.id[internet]. Tahun 2050 akan ada dua miliar penduduk lanjut usia [updated 2013 Jan 13;cited Oct 17 2012]. Available from: http://www.menkokesra.go.id/content/tahun2050-akan-ada-2-miliar-penduduk-lanjutusia.

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Hamid A[internet]. Penduduk lanjut usia di Indonesia dan masalah kesejahteraannya. [updated 2013 Jan 13;cited Oct 23 2007].

Available from: http://www.kemsos.go.id/modules.php?name =News&file=article&sid=522.

Kane R L, Ouslander J G, Abrass I B, Resnick B. Essentials of Clinical Geriatrics. McGrawHill Professional; 2008.

Nugroho, Wahyudi. Perawatan Lanjut Usia, Jakarta: EGC; 1995.

Mc. Kenzi F. Kesehatan Masyarakat, Jakarta: EGC; 2003.

Darmojo, Budhi. Dkk. Buku Ajar Geriatri.

Jakarta: FKUI; 1999.

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World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 50-53 World Health Organization. Teaching Geriatrics in Medical Education II. Department of Ageing and Life Course and IFMSA. 2007; 2: halaman 53-56 rscm.co.id[internet]. Poliklinik geriatri terpadu [updated 2013 Jan 13;cited 2011]. Available from: http://www.rscm.co.id/index.php?bhs=in&id =OUR1000014.

Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia[internet]. Halo internis. Available from:http://www.pbpapdi.org.

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Pranarka K. Penerapan geriatrik kedokteran menuju usia lanjut yang sehat. Universa Medicina. 2006;25(4):187-97

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Organized Efforts in Management for Coronary Heart Disease Patients ─ Increasing the Quality of Life Steven Philip and Anselma Halim Atma Jaya Chatolic University and Universitas Pelita Harapan, Indonesia ABSTRACT Introduction In 1990, noncommunicable and degenerative disease are only 27% from the total cases in developing countries. The number of NCDs and degenarative disease will rise as much as 16% (became 43%) of the total cases in 2020. According to WHO research in 2013,cardiovascular disease (CVD) is the main cause of NCDs death in West Pacific region. Cardiovascular disease (especially coronary heart disease) in Indonesia has also became the main cause of death. It had caused burden and many disadvantages for the country, society, and physicians. In the end, patients will continue to suffer and eventually die; resulting in an increase of cardiovascular disease mortality and a statically low healthcare quality in the country.

Methods The methods used to complete this paper were using study literatures adapted from literature studies to demonstrate cardiovascular disease (one type of NCDs) as the most common chronic disease in Indonesia, examples of international treatments available in countries resembling Indonesia, and the difficulties faced by government, physicians, and the patients. In the end of the paper, we summarize the available interventions into one big idea.

Result Cardiac rehabilitation (the patients who attend a cardiac rehabilitation shows great improvement for the number of HDL, LDL, LDL/HDL ratio, BMI, body fat, and exercise capacity), a new software for medical recording to help the GPs (there is a positive correlation between educational (technology) intervention to physicians and result from the patient’s treatment.), and a data collection of different types of group in the country from the government (they have their own needs) are the three different types of interventions for each patient, GPs, and government.

Discussion From the results, we create an intergrated solution (a CVD institution which include cardiac rehabilitation, a software training centre, and a research team with an open chances for medical students to contribute and learn in any subdivision of the institution) which organized in any level of aspect including individual, social and govermental and has a promising result in the treatment of CVDs especially coronary artery disease.

Conclusion The increasing prevalence of non communicable diseases in Indonesia, especially coronary artery disease (one type of cardiovascular diseases) has become the biggest disadvantage for government, society (including their family), and the patient itself. Thus, organized intervention in micro, meso and macro aspect might effectively help the patient with CAD who need long life treatment, not only by biological improvement but also an increase in the quality of life.

Introduction In 1990, noncommunicable and degenerative disease are only 27% from the total cases in developing countries. Unfortunately, the number of NCDs and degenarative disease will rise as much as 16% (became 43%) of the total cases in 2020(“1990, around 49% of disease group in developing countries is communicable diseases Google Search,” n.d.). In addition,based on WHO data, NCDs (mainly cardiovascular diseases, cancer, diabetes mellitus, and chronic

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respiratory diseases) also contribute approximately 50% of annual deaths especially in developing countries such as Asia Pacific region and it kills more than 36 million people each year around the world.(“CDC Global Health - Noncommunicable Diseases - The Problem of Noncommunicable Diseases and CDC’s Role in Combating Them,” n.d.)(“WHO | Noncommunicable diseases,” n.d.) By 2013, according to WHO’s data, nearly 80% of NCD deaths (around 29 million people) occur in low

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and middle income countries (with a GDP of $1,036 to $4,085) before the age of 60. Most of them are in the same risk factors: tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets. (“WHO | Noncommunicable diseases,” n.d.) NCDs are highly prevantable through effective interventions of modifiable risk factor, but in reality, NCDs still have a big number of incidence, and thus, becoming a challenge, especially for a developing country like Indonesia. NCDs have become a major problem in Indonesia’s healthcare area.(“WHO | 10 facts on noncommunicable diseases,” n.d.) This is supported by WHO data, that in 2008, Indonesia (one of the Asia Pacific countries) itself, has 582,777 males and 481,666 females who died because of NCDs (“Mortality: Total NCD Deaths by country,” n.d.) and 0,7% of the total deaths are caused by coronary heart disease and diabetes (400 males and 300 females per 100,000 people).(“Mortality: Cardiovascular diseases and diabetes, deaths per 100,000 by country,” n.d.) According to WHO research in 2013,cardiovascular disease (CVD) is the main cause of NCDs death in West Pacific region.

The number has reached 17.3 million of death (80% of it are from the low-middle income people) and it will keep rising to 23.3 million in 2030. Cardiovascular disease in Indonesia has also became the main cause of death.(“Skrt depkes - free eBooks download,” n.d.)

Along with the increasing prevalence of NCDs in Indonesia, especially CVD which contribute a big number in NCD’s prevalence, had caused burden and many disadvantages for country and society. In World Economic Forum, NCDs have been established not only as a threat to human health, but also to the development and economic growth of a country. Half of those who died because of chronic NCDs such as CVD, were in their highly productive years, and thus, the disability imposed and the live losses are endangering industrial competitive level against other nations.

Cardiovascular disease is caused by disorders of the heart and blood vessels, and includes coronary heart disease (heart attacks), cerebrovascular disease (stroke), raised blood pressure (hypertension), peripheral artery disease, rheumatic heart disease, congenital

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heart disease and heart failure. The major causes of cardiovascular disease are tobacco use, physical inactivity, unhealthy diet and harmful use of alcohol. (“WHO | Cardiovascular diseases,” n.d.) Based on European WHO, cardiovascular diseases are a group of disorders of the heart and blood vessels, including coronary heart disease (disease of the blood vessels supplying the heart muscle), cerebrovascular disease (diesease of the blood vessels supplying the brain), peripheral arterial disease (disease of blood vessels suppling the arms and legs), rheumatic heart disease (damage to the heart muscle and heart valves from rheumatic fever, caused by streptococcal bacteria), congenital heart disease (malformations of heart structure existing at birth), and deep vein thrombosis and pulmonary embolism (blood clots in the leg veins, which can dislodge and move to the heart and lungs). (“Definition,” n.d.)

Amongst all the cardiovascular diseases, the most common disease is Coronary artery disease (CAD). Coronary artery disease is a serious medical problem that affects about 7 million people annually.(“principle of anatomy and physiology 13th edition - Google Scholar,” n.d.)

It remains as the major cause of death and premature disability in developed societies.

Current predictions estimate that by the year 2020 CVD, notably atherosclerosis (the beginning of CAD), will become the leading global cause of total disease burden.(Longo et al., 2011) CAD results from the effects of the accumulation of atherosclerotic plaques in coronary arteries, which leads to a reduction in blood flow to the myocardium. Some individuals have no signs or symptoms, while others experience angina pectoris (chest pain), and still others suffer heart attacks.CAD begins with the thickening of the walls of coronary arteries (the process can also occur in arteries outside the heart) and loss of elasticity. These are the main characteristics of a group of diseases called arteriosclerosis. One form of arteriosclerosis is atherosclerosis, a progressive disease characterized by the formation in the walls of large and medium-sized arteries of lesions called atherosclerotic plaques. Atherosclerotic plaques are developed from molecules produced by the liver and small intestine called lipoproteins.

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These spherical particles consist of an inner core of triglycerides and other lipids and an outer shell of proteins, phospholipids, and cholesterol.

Like most lipids, cholesterol does not dissolve in water and must be made water-soluble in order to be transported in the blood. This is accomplished by combining it with lipoproteins.

Excessive amount of LDL (one of the major types of lipoprotein-low density lipoprotein) in the inner layer of an artery wall promotes atherosclerosis, especially when it undergoes oxidation and the proteins bind to sugars. In response to this process, endothelial and smooth muscle cells of the artery secrete substances that attract monocytes from the blood and convert them into macrophages. The macrophages then ingest and become so filled with oxidized LDL particles that they have a foamy appearance when viewed microscopically (foam cells). T cells follow monocytes into the inner lining of an artery, where they release chemicals that intensify the inflammatory response. Together, the foam cells, macrophages, and T cells form a fatty streak, the beginning of an atherosclerotic plaque. When the cap over the plaque breaks open in response to chemicals produced by foam cells or if T cells induce foam cells to produce tissue factor (TF) that result in blood clot formation, heart attacks occur. Treatment of CAD include drugs (antihypertensives, nitroglycerin, beta-blockers, cholesterollowering drugs, and clot-dissolving agents) and various surgical procedures such as coronary artery bypass grafting (CABG) and nonsurgical procedures such as percutaneous transluminal coronary angioplasty (PTCA). (“principle of anatomy and physiology 13th edition - Google Scholar,” n.d.)

Those treatments above require a relatively high budget and a long time. Most of the times, patients are unable to afford them (for people with low to middle low income) or their conditions become worse since they slowly lose their hope in living and do not want to continue to take medications. Meanwhile, in rural area, medical care is hard to reach for patient because health center like hospital very limited in rural area, even if the patient want to recieve the treatment they can’t. Facing these conditions, doctors will encounter difficulties in treating the patients because they no longer want to

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cooperate. Ironically, many middle-high patients in Indonesia do not believe their local physicians anymore, and it became a huge obstacle for Indonesian doctors because they do not even have the chance to treat and medically advice the patients, no matter how good they are. Middlehigh income patients are brand-minded and feel more prestigious if they can go abroad for medication. Moreover, Indonesian goverment are lack of awareness about NCDs and more concentrated in communicable diseases like infection, (“Kantor Utusan Khusus Presiden RI untuk MDGs | Jakarta,” n.d.) and thus, it has become a major difficulty for the physicians because our goverment facilities are not for NCDs rehabilitation. The situation has also become worse when the government themselves are unable to provide the budget in healthcare through national insurance, especially for those expensive treatments. In the end, patients will continue to suffer and eventually die; resulting in an increase of cardiovascular disease mortality and a statically low healthcare quality in the country.

Material and methods The methods used to complete this paper were using study literatures adapted from literature studies to demonstrate cardiovascular disease (one type of NCDs) as the most common chronic disease in Indonesia, examples of international treatments available in countries resembling Indonesia, and the difficulties faced by government, physicians, and the patients.

First of all, we browsed the internet to search aproblem which became a national issue recently using the keywords “chronic disease epidemiology” in search engine. Approximately more than 2 million websites shown had relations with the keywords. Therefore,we filtered the websites that are used as the sources by only selecting websites from trusted sourcesofinternational groups such as WHO, scientific journal, and official website from government.

Next step, we integrated all the sources to reorder chronic diseases, starting from the most common to the least common. Then, we summarize examples of long term treatments which are available and proven internationally and the difficulties faced by government,

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physicians, and patients. We conducted simple literature review to understand better about the treatments and difficulties of the chosen disease.

After we got general knowledge about all the topic, we decided our concern in cardiovascular disease because it has the highest prevalence of chronic disease in our country, Indonesia and hasbecame the most dangerous disease after some common communicable diseases.

Lastly, we sort all the treatments that will be applicable for our country and thus, think about the best solution for the problems faced by the patients, physicians, and goverment towards cardiovascular disease.

Results There are several suitable interventions to accompany the patients through their lifelong struggle with chronic diseases in Indonesia for cardiovascular disease other than drugs or surgical therapy. Below are three interventions that could be done by each subjects; patients, physicians, and goverment.

A. Method of Management for the Patient One of the most successful intervention for the patients is cardiac rehabilitation. It is offered to people after cardiac events to aid recovery and prevent further cardiac illness.

Cardiac rehabilitation programmes typically achieve this through exercise, education, behaviour change, counselling, support, and strategies aimed at targeting traditional risk factors for cardiovascular disease. Cardiac rehabilitation is an essential part of the contemporary care of patients with heart disease and is considered a priority in countries with a high prevalence of coronary heart disease and heart failure. (Dalal, Zawada, Jolly, Moxham, & Taylor, 2010) Table 1 are the tables of the condition of the CVD patient before and after cardiac rehabilitation.

Table 1 – Effect of Cardiac Rehabilitation and Exercise Training on Lipids, Obesity Indexes, and Exercise Capacity in a Large Cihirt With Cirinary Artery Disease As we can see in the Table 1, the total cholesterol and triglycerides in elderly group

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show no significant changes after rehabilitation. However, other aspects such as HDL, LDL, LDL/HDL ratio, BMI, body fat, and exercise capacity show a significant changes after the rehabilitation. The similar result can also be seen in the younger group.

Total cholesterol and LDL shows no significant changes, while other aspects show significant changes after rehabilitation.

Table 2 Effect of Cardiac Rehabilitation and Exercise Training on Behavioral Characteristic and Quality of Life Parameters In Patient With Coronary Artery Disease The Table 2 shows that in elderly group, the overall behavioral characteristics show a significant changes after rehabilitation except hostility. However, the quality all of life parameters show significant changes after rehabilitation. There is also a similar result in younger group. The overall behavioral characteristics show a significant changes except depression and hostility. The overall quality-of-life parameters also show significant changes except for mental health and general health after rehabilitation.

B. Method of Management for the Physicians Involved Computerized medical records can help in improving data quality for each patient and may affect in a better health result since the physicians are able to give more specific treatment for each of their patient according to the health progression of each patient. Doctors may learn to use a more modern equipment to improve their quality of treatment. (Lusignan, Hague, Brown, & Majeed, 2004) The Table 3 shows an example of an increase in recording entries.

Table 3 Change in IHD data Recording During Phase 1 of the Primary Care Data Quality (PCDQ) Programme (number, with precentages given in parentheses) The Table 3 shows that with a software of computerized data recording, there is an increase in the second data collection, which means there will be more patients who will be treated more specifically.

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Data recording using software data recording allows physicians to be able to keep track of the history of the patient specifically. Spesific history of patient demonstrates the whole pattern of the disease regulary and thus, making it easier for doctors to see possibilities of new effective treatment and maybe new diagnosis.

(Lusignan et al., 2004) Table 4 – Types of Intervention Including Spesific Components To support the computerized medical record as educational intervention for the physicians,there is another study of a metaanalysis study regarding this which shows that intervention to physicians that have been done, shows great improvement for the patient, especially for chronic disease patients who need long care treatment. The result can be seen in above and below table.

Those meta-analysis journal prove a perfect positive correlation between educational intervention to physicians and result from patient’s treatment. The correlation shows in the Table 5 Table 5 – Number of Different Intervention Used in Disease Management Programmes for Chronic Disease From the Table 5, twenty four programmes that included provider education assessed measures of provider adherence to guidelines, of which 12 (50%) significantly improved theses measures. Meanwhile, sixteen programmes with provider feedback evaluated improved provider adherence to guidelines. Nine of these (56%) significantly improved provider adherence.

C. Method of Management from the Government As we can see in the data below (taken in Argentina, a developing country resembling Indonesia). The management among different group of people should not be generalized since each group has their own needs. More specific health care may result in a higher increase of life quality of the patients. (Fleischer, Diez Roux, Alazraqui, Spinelli, & De Maio, 2011) Figure 1 - Predicted Mean BMI and Probability of Hypertension, Diabetes, Low Physical Activity and Eating Fruit anb

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Vegetables Among Men, By Education According to Different Level of Urbanicity The trend of the mean in the Figure 1, show that more educated men tend to have higher BMI, lower probability of hypertension, higher probability of low physical activity, and higher probability of eating fruits and vegetables.

Figure 2 - Predicted Mean BMI and Probability of Hypertension, Diabetes, Low Physical Activity and Eating Fruit anb Vegetables Among Women, By Education According to Different Level of Urbanicity The trend of the mean in the Figure 2, show that more educated women tend to have lower BMI, lower probability of hypertension, and higher probability of eating fruits and vegetables.

Discussion There are many types of managements or methods that can be applied to patients who suffer coronary heart disease. Oftenly, physicians use drugs or surgical interventions to treat and to relieve the pain of the patients.

However, Indonesian physicians forgot to try treatments other than drugs or surgery. They see the patients as if they are objects of their practice rather than subjects who have feelings and other components of quality of life as a human being.

Improvement of a patient’s quality of life may result in a better clinical or health conditions and also prevent further illness. After conducting a research and intergrating the information that was collected, there are some organized effort in managing patients with coronary heart disease including methods to increase their quality of life. The interventions require integrity from all aspect which interact with the patient with chronic disease, the patient as a subject, GP who directly related with the patient and also in macro – level , government, which provide facilities and infrastructure to support micro and meso – level. By intergrating from all level , the quality of life from the patient could be restored and in the same time, chronic disease could be suppressed or at least do not express worse clinical manifestation. (Lubkin & Larsen, 2006) One type of intervention which can improve the patient’s quality of life is a rehabilitation (in this case caridac rehabilitation). As we can see

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from the result above, patients (both elder and younger group) who attend a cardiac rehabilitation which includes exercise, education, behaviour change, counselling, support, and strategies, shows great improvement for the number of HDL, LDL, LDL/HDL ratio, BMI, body fat, and exercise capacity.(Dalal et al., 2010) When a person heals from their psychology aspects in addition for their body systems healing, he recovers faster and shows a more significant improvement. In a rehabilitation, patients have someone to always remind him or her to continue to exercise and thus, improve their heart functions. Exercise and regular daily activities are essential for increasing a patient’s peak oxygen uptake, also improved physical fitness associated with reductions in submaximal heart rate, systolic blood pressure, and rate pressure product (RPP), and decreasing myocardial oxygen requirments.

Regular training in rehabilitation also improve fitness which allows patient with advanced coronary artery disease who ordinarily experience myocardial ischemia during physical exertion to perform such task at a higher intensity level berfore reaching their ischemic ECG. In addition, improvement in cardiorespiratory endurance on exercise testing is associated with a significant reduction in subsequent cardiovascular fatal and nonfatal events independent of other risk factors. (Leon et al., 2005)They also get various types of education which improves their awareness about the diseases itself and also the importance of the treatments and preventions of further illness.

Education which affect the improvement quality of life of the patient could be from formal education, seminar and also self – management education. Self – management education facilitate acquisition by the patient of preventive or therapeutic health care activities collaboration with care providers. This programs emphasize the role of the patient education in preventive and therapeutic health care activities. Self – management education itself effectively has moderate benefit on important intermediate end point especially for hypertension for patient with CAD. (Warsi A, Wang PS, LaValley MP, Avorn J, & Solomon DH, 2004) Counselling and support from a professional counselor may result in an effect of greater hope to live, a relieve

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from stress due to the disease, and a higher motivation to continue the treatments given.

Usually patients with a long life treatment have unstable emotions such as anger, anxiety and social isolation. By psycholosocial intervention, patient will be in their comfort zone and ready to receive treatments. Human beings were born to be social beings, not an individual. They cannot live on their own. Having others to support them especially in encountering the disease they suffer, may result in a better health improvements since they have motivations to continue to live. (Leon et al., 2005) As the world continues to develop in technology and information aspect, other fields of study should also connect and integrated with technology including medicine. Physicians should be familiar of using computer and softwares regarding medical records. Data of a patient are important for further treatment decisions. A more specific treatments can be obtained from a sufficient provided data because doctors can see the trend of the patient’s health improvement which differ from one another. An example of a study which used a program named PCDQ shows a positive change in data recording within primary care. This can be seen in the result above,in table 1.3 which shows that the program leads to more data entries in the second collection. This shows that patients are also aware of technology and that it might help them in a better medication. They know that technology can be a great help especially in recording their health improvements. A key factor in the success of the programme appeared to be the leadership and involvement of local clinicians. The programme is also a highly costeffective investment because it only employs less than one full-time clerical member of staff.(Lusignan et al., 2004) Another result from meta-analysis study (table 1.4 and 1.5) shows a positive correlation between educational (technology) intervention to physicians and result from the patient’s treatment. In table 1.5, 12 (50%) shows significantly improved theses measures of adherence to guidelines and nine of those (56%) significantly improved provider adherence. This shows the importance of using a software in data recording to provide a better medications for the patients. (“Interventions

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used in disease management programmes for ...

[BMJ. 2002] - PubMed - NCBI,” n.d.)

Government also plays an important role in the cardiovascular disease management. They might be of a great help because they can provide health data of their own citizens which then can be used to obtain more specific health care to different subpopulation group in the country. The data from the result above shows that different subpopulation group have different needed. The data from subpopulation’s charactheristic will help government to build infrastructure or policy based on the characteristic of the population in spesific area.

Every specific group of people need different types of intervention because they have different needs. For example, area with many population of higly educated man with high prevalence of CAD which has tendency to higher probability of eating fruit and vegetables, goverment should support them by building more freshmarkets and also create a new local goverment policy to push their population to have frequent physical activity. High schools in Singapore, for example, had done the same policy of which they insist their overweight students to have daily excercise, supervised by school tearchers.(Fleischer et al., 2011) Regarding to the discussions above of three different results of the interventions for three different subjects, government can create a whole new different institution of cardiovascular disease which provide interventions for three subjects who play major roles in the disease management. The institution might include a cardiac rehabilitation, a software and technology training center for physicians, research teams for cardiovascular diseases and the epidemiology, and last, the institution may also provide a place for medical students to learn and to contribute for the improvement of management of cardiovascular disease. Medical students may help in the rehabilitation as assisstants of counselors or exercise instructors or in a research team. Medical students might also join courses of how to use softwares in recording patients’ health data. Figure 3 Conclusion

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As a conclusion, global epidemic diseases has changed. In 1990s, communicable diseases were the prime concern of global health issue and non communicable disease only 27%, but within 2 decades noncommunicable diseases become 46% and has become the largest prevalence around the world especially in Asia Pasific region including Indonesia.

With increasing prevalence of NCDs in Indonesia, especially CVD which has become our biggest disadvantage for goverment, society (including their family), and the patient itself.

Half of those who died because chronic NCD, were in their productive years which affect economic structure nationally.

Indonesian patients, GPs and even goverment are trying to deal with these problem and they face many problems in dealing with the problems. Intergrated solution which orgenaized in any level of aspect including individual, social and govermental should be developed because it has a promising result in intervention of chronic disease, especially coronary artery disease (biggest prevalence in CVD) which needs a long life treatment.

With the increasing prevalence of NCDs in Indonesia, especially CVD which has become our biggest disadvantage for goverment, society (including their family), and the patient itself.

Organized intervention in micro, meso and macro aspect effectively help the patients with CAD who need long life treatment, not only by biological improvement but also an increase in the quality of life.

References 1990, around 49% of disease group in developing countries is communicable diseases - Google Search. (n.d.). Retrieved March 18, 2013, from https://www.google.com/search?q=1990%2C +around+49%25+of+disease+group+in+deve loping+countries+is+communicable+diseases &ie=utf-8&oe=utf8&aq=t&rls=org.mozilla:enUS:official&client=firefox-a CDC Global Health - Noncommunicable Diseases The Problem of Noncommunicable Diseases and CDC’s Role in Combating Them. (n.d.). Retrieved March 18, 2013, from

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http://www.cdc.gov/globalhealth/ncd/overvie w.htm Dalal, H. M., Zawada, A., Jolly, K., Moxham, T., & Taylor, R. S. (2010). Home based versus centre based cardiac rehabilitation: Cochrane systematic review and metaanalysis. BMJ : British Medical Journal, 340. doi:10.1136/bmj.b5631 Definition. (n.d.). Retrieved September 8, 2013, from http://www.euro.who.int/en/what-wedo/health-topics/noncommunicablediseases/cardiovascular-diseases/definition Fleischer, N. L., Diez Roux, A. V., Alazraqui, M., Spinelli, H., & De Maio, F. (2011).

Socioeconomic Gradients in Chronic Disease Risk Factors in Middle-Income Countries: Evidence of Effect Modification by Urbanicity in Argentina. American Journal of Public Health, 101(2), 294–301. doi:10.2105/AJPH.2009.190165 Interventions used in disease management programmes for ... [BMJ. 2002] - PubMed NCBI. (n.d.). Retrieved September 29, 2013, from http://www.ncbi.nlm.nih.gov/pubmed/12399 340 Kantor Utusan Khusus Presiden RI untuk MDGs | Jakarta. (n.d.). Retrieved September 27, 2013, from http://webcache.googleusercontent.com/searc h?q=cache:Imoj_hmbm0J:mdgsindonesia.org/official/in dex.php/component/content/article/19tulisan/materi-MDGs/88ncd1+&cd=6&hl=en&ct=clnk&client=firefo x-a Leon, A. S., Franklin, B. A., Costa, F., Balady, G. J., Berra, K. A., Stewart, K. J., … Lauer, M. S. (2005). Cardiac Rehabilitation and Secondary Prevention of Coronary Heart Disease An American Heart Association Scientific Statement From the Council on Clinical Cardiology (Subcommittee on Exercise, Cardiac Rehabilitation, and Prevention) and the Council on Nutrition, Physical Activity, and Metabolism (Subcommittee on Physical Activity), in Collaboration With the American Association of Cardiovascular and Pulmonary Rehabilitation.

Circulation,

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111(3), 369–376. doi:10.1161/01.CIR.0000151788.08740.5C Longo, D., Fauci, A., Kasper, D., Hauser, S., Jameson, J., & Loscalzo, J. (2011).

Harrison’s Principles of Internal Medicine, 18th Edition. McGraw Hill Professional.

Lubkin, I. M., & Larsen, P. D. (2006). Chronic Illness: Impact and Interventions. Jones & Bartlett Learning.

Lusignan, S. de, Hague, N., Brown, A., & Majeed, A. (2004). An educational intervention to improve data recording in the management of ischaemic heart disease in primary care. Journal of Public Health, 26(1), 34–37. doi:10.1093/pubmed/fdh104 Mortality: Cardiovascular diseases and diabetes, deaths per 100,000 by country. (n.d.).

Retrieved September 8, 2013, from http://apps.who.int/gho/data/node.main.A865 ?lang=en Mortality: Total NCD Deaths by country. (n.d.).

Retrieved September 8, 2013, from http://apps.who.int/gho/data/node.main.A860 ?lang=en principle of anatomy and physiology 13th edition - Google Scholar. (n.d.). Retrieved September 25, 2013, from http://scholar.google.com/scholar?hl=en&as_ sdt=0,5&q=principle+of+anatomy+and+phys iology+13th+edition Skrt depkes - free eBooks download. (n.d.).

Retrieved September 8, 2013, from http://www.gobookee.net/skrt-depkes/ Warsi A, Wang PS, LaValley MP, Avorn J, & Solomon DH. (2004). Self-management education programs in chronic disease: A systematic review and methodological critique of the literature. Archives of Internal Medicine, 164(15), 1641–1649. doi:10.1001/archinte.164.15.1641 WHO | 10 facts on noncommunicable diseases. (n.d.). Retrieved September 8, 2013, from http://www.who.int/features/factfiles/noncom municable_diseases/facts/en/index5.html WHO | Cardiovascular diseases. (n.d.). WHO. Retrieved September 8, 2013, from http://www.who.int/topics/cardiovascular_dis eases/en/ WHO | Noncommunicable diseases. (n.d.).

WHO. Retrieved September 8, 2013, from

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http://www.who.int/mediacentre/factsheets/fs 355/en/

Table and Figure Table 1

Table 2

Table 3

Table 4

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Table 5

Figure 1

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Figure 3

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Expression of CD68 in patients with multibacillary type of leprosy as a marker of intracellular location from Micobacterium leprae Utomo Andi Pangnguriseng, Mukhraeni AMSA-UMI, Faculty of Medicine, Muslim University of Indonesia ABSTRACT Introduction : Leprae is infection chronic disease caused by Mycobacterium leprae that attack perifer neuron where they produce themself intracellularly in phagocytic cells of the host. CD68 is one of the receptor that expressed by the macrophage, dendiritic, and langerhans cell.Therefore, weoutlinesome ofthe researchtoprovethatCD68 could expressed in leprosy patient as a local intracelluler marker from M. Leprae.

Methode : This research using sistemic review with collecting data technique and searching the literature related with the topic. Literature management would be using descriptive qualitative technique.

Result : From the studies showed that expressionofCD68cellsin the lesionsaccording to thepositiveexpression ofPGL-1 butnot with theamountofacid-fast bacilliwere founded. Fite-Faraco stainingcanconfirmthatfoundmanyMicobacteriumlepraeinskintissuesof patients.

Discussion :The histopathological features in skin lesion of leprosy patients with Fite-Faraco’s stain, immunohistochemical PGL-1 and CD68 showed that M. leprae had inside location of the cells with phagocytes function which gaves same location of all expressed for that staining.

Conclusion :showed the CD68 have very important role to expression leprosy within macrophages cells for to sent signal to host resistance system. Expressin of CD68 in patients with multibacillary type of leprosy can be used as an identifier intracellular location of Micobacterium leprae.

Keyword : CD68, Leprosy, Micobacterium leprae, Multibacillary type of leprosy Introduction Leprae is infection chronic disease caused by Mycobacterium leprae that attack perifer neuron where they produce themself intracellularly in phagocytic cells of the host.1 Based on WHO Since 2002-2006 there is new developing number of leprae in many country such as Democratic Republic of Kongo, Indonesia, and Philipphine. Still based on WHO, in 2011 there are 219.075 new cases of leprae in the wordl with the prevalency 4,06 per 10000 citizens while based on the health data of Indonesia itself i 2011 there are 19371 new cases of leprae with prevalency 8,03 per 100000 citizens. 2 Leprae classifie into Pausibasiler type (PB) and Multibasiler type (MB) based on the leprae basil that attacked the host. The first and the most important defense of an infection especially related with the structure of the bactery and how he host imunology mechanism gives the respond onto it. M. Leprae very well known with the special sand unique structural.

The speciality is leprae bacils contain various lipid and lipopolisacharide in the cell wall than

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any other organism that will make every macrophage that phagosite M. Leprae will change to foamy cell. Phenolic glycolipid-1 (PGL-1) is one of the lid capsul and wall cell that contain group of phenol glycosylate that show unique trisacharide characteristic to M. Leprae. PGL-1 can also be found in infected skin on leprae bacils. In the other part, CD68(4) is one of the receptor that expressed by the macrophage, dendiritic, and langerhans cell. The band mate from CD 68 known chemically as a protein modification like acetylated low density lipoprotein (AcLDL), oxyde LdL, and metcylated bovine serum albumin. DC68 also can figure out and endocytosis the bactery lipopolyscharide.

So we make research to prove that CD68 could expressed in leprae patient as a local intracelluler marker from M. Leprae.

Methode This research using sistemic review with collecting data technique and searching the literature related with the topic. Literature management would be using descriptive qualitative technique.

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Result In study by Sri V muchtar,Pham D Bang, Takao F, Naoya S, Asnadah, Rasyidin , Muh, Dali A and Yasuko Y, intracellular location of Mycobacterium leprae by expression of CD68 receptors on tissue leprosy. Patients no 1,7, 8, dan 10 gave results with Fite-faraco’s staining which that can make confirmation the number of acid-fast bacilli was so much that founded and concomitant to the distribution of PGL-1 and expression of cells 68 that phagocyted the bacilli. In the patients no.3 and 4 Fite-faraco’s staining gave information the small number of bacilli M. leprae with fragmented in skin biopsy but expression in staining of the PGL-1 antigenic we founded more most than bacilli and thus, also with expression of cells CD68 that have same location with PGL-1 and cells that Table 1.

Pasien no.

Fite Faraco PGL-1 1 +++ +++ 2 3 + +++ 4 + +++ 5 6 + ++ 7 +++ +++ 8 ++ +++ 9 + ++ 10 +++ +++

phagocyted the bacilli. In the other hand, patient no.2 and 5 the Fite-faraco’s stainings showed negative result M.leprae in skin tissue that examined and expression of PGL-1 staining, also gave negative results. But, for stain the macrophages we founded results and the expression of cells CD68 in lesion was minimal and then, interestingly the expression of cells CD8 was more mostly than cells CD68 that located by surrounding of CD68 area. In the patients no.6 dan 9 , with Fite-faraco’s staining gave confirmation and result M.Leprae was minimal with expression of staining of PGL-1 that more much then number of bacilli that founded and also the result of expression of cells CD68 that gave same result and location with PGL-1 and same area with cells that phagocyted bacilli. 5

In a previous study conducted by Juarez Antonio SQ, Luiz W, Hellen T, Rosana M, Carla P, Maria Irma about immunohistochemical evaluation of magrophage activity and its relationship with apoptotic cell death ini the polar form of leprosy , the patient, 16 with the tuberculoid form and 13 patient with the lepromatous form were from the Amazon region, State of Para,Brazil. The classification of the clinical presentation of the disease was made in accordance with the Riddley-Joplin. The histopatology from TT form lesion showing granulomatosus inflammatory infiltrate with giants cells langhans-like. In the LL form, the lesion showing disperse granulomatosus

inflammatory infiltrate, with multiples hitiocytes in derma and sometimes Virchow cell. The immunohistochemistry showed to a more intense macrophage activity in TT forms of the infection and multiples apoptotic cells associated in LL forms.

Overall comparison of the immunostaining pattern between groups,despite variations in intensity of immunistaining. Mean macrophage activity as demonstrated by the immunoexpression of iNOS was 118.4 ± 69.cell/mm² in the TT group and 118.62 ± 49.56 cells/mm² in the LL group (p= 0.949). mean CD68 postivity was 61.90 ± 28.83 cells/mm² in the TT group and 78.07 ± 69.99 cells/mm² in the LL group (p = 0.949). 6

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CD68 +++ + +++ +++ + ++ +++ +++ ++ +++

CD8 + ++ + + ++ ++ + + ++ +

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On the research an in vitro model of Mycobacterium Leprae induced granuloma formation by Hongsheng Wang , Yumi Maeda, Yasuo Fukutomi and Masahiko Makino, To characterize mac- rophages, ECs and MGCs in the granuloma-like aggre- gates, we performed immunofluorescence staining for macrophage markers CD68, CD1a and CD163 (data not shown). Both the macrophages and the MGCs could ex- press the CD68 and CD1a marker, but the expression level of CD68 on the macrophages was higher than that on the MGCs. With the increasing number of nuclei in MGCs, lower levels of CD68 was observed (not shown), although there was no significant difference in the ex- pression levels of CD1a between macrophages and MGCs. These data indicate that MGCs belong to the monocyte/macrophage lineage. 7 They investigated the expression levels of cell surface anti-gens on macrophages from different groups at two differ- ent time points, day 1 and day 9 On day 1, there was no significant difference in the expression of cell surface anti- gens on macrophages between groups. Compared with day 1 macrophages, day 9 macrophages, which were infected with M. leprae and co-cultured with PBMCs to form granuloma-like aggregates, showed higher expression of CD14 (pattern recognition receptor), CD68 (macro- phage marker related to phagocytic activities), CD163 (scavengerreceptor)andCD206 (mannosereceptor),al- though the expression ofmajor histocompatibilitycomplex(MHC)class-II,CD86,andtoll-likereceptor (TLR)-4 didnot change (Figure 1).Interestingly, inour long-term culture (9days)ofmacrophagesinfected withM.leprae,

theexpression ofCD14,CD68,CD163,TLR4,CD86and CD206wassignificantly lowerthan that inmacrophages infected with M. leprae and cocultured with PBMCs.

Discussion Phagocytosis or endocytosis can be occurs in several cells such as keratinocytes , smooth muscle cells, Schwann cell and mononuclear “professional” macrophage. The mechanism that occourred within the mononuclear “professional” macrophage that involes the processing and degradation with lysis of proteinglycolipid complexes by golgi apparatus and

granular endoplasmic reticulum-derived lysosomal enzyme. Macrophage lysosomes fuse with phagosomes to form phagolysosomes, the specific organelies of this cells. 4,8,9,10 When M. leprae (with specified antigen, PGL-1) reaches its main target in peripheral nerves does not release toxins or induce immediate responses and it is phagocytosed within Schwann cell phagosome devoid of

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CD206expressionwasthelowestinmacrophages cocultured withPBMCs, althoughCD163expressionwas significantly high (Figure 1). CD163 and CD206 are markers ofM2macrophages,whereasCD86expression is associated withM1macrophages.Therefore, theM1and M2macrophagesappeared tocoexistingranulomas.7 Figure3

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lysosomal enzymes, where the bacilli has a apace may multiply.(4, 11, 12, 13) In lepromatous leprosy patients, phagocytose bacilli intraphagosomal within the macrophage atill present, golgo apparatus and granular endoplasmic reticulum activation also generates enzyme-rich lysosomes that partially the bacteria break up into granular necrobiotic structures and the phospholipids unprocessed may remain to deposited as cytoplasmic foamy droplets and when with residual bacilli forming granuloma vacuolated lepra cells (virchowcytes); these ones suggest a functional deficiency of lysosomal phospholipases with excessive release of free radicals and inhibition of lysosomal phospholipases. Secondarily, however, humoral immune responses with forming antibody towards to antigenic PGL-1 may follow. (8, 9, 16) Macrophages that active function in phagocytose process can be showed with the expression of cells CD68+ in the skin tissue of leprosy patients, which the spread and expressed that had variation between the multibacillary patients. And thenm the expression of cells CD68+ that founded in the skin tissue given positive confirmation about M. leprae that inside location in macrophage and showed the expressed concomanint the bacilli area and spreading the antigenic PGL-1. (10, 18, 19) The expression gives the meaning that the skin lesion of MB patients contains many granuloma that predominantly the accumulation of macrophages cells and active within phagocytes act but not maximally in function.(20,21,22) Expression of cells CD68+ that observed on same areas of the antigenic PGL-1.

These point given the explain that the function macrophages was active and still good act allowed the phagocytosis to destroyed leprosy bacilli becomes small form, so the expression of PGL-1 appear more mostly because the number of bacilli that few had possibility for active phagolysosome due to the free radical by bacilli not excessive and then nothing inhibition of lysosomal phospholipase.(16,17) The histopathological features in skin lesion of leprosy patients with Fite-Faraco’s stain, immunohistochemical PGL-1 and CD68 showed that M. leprae had inside location of the cells with phagocytes function which

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gaves same location of all expressed for that staining.(16,21) Conclusion From the studies showed the CD68 have very important role to expression leprosy within macrophages cells for to sent signal to host resistance system. An expressin of CD68 in patients with multibacillary type of leprosy can be used as an identifier intracellular location of Micobacterium leprae.

Reference 1. Pannikar VK. Defining a case of leprosy.

Lepr. Rev.1992 : 61S-65S 2. Steger JW,Barret TL. Leprosy. In : Military dermatology 2nd,ed California.2000 3. Rees RJW, Young DB. The microbiology of leprosy. In : Hasting RC, ed. Leprosy.

2nd,E dinburgh : Churchill Livingstone. 1994 : 49-86 4. Kaufman SHE. Cell-mediated immunity. In : hasting RC,ed. Leprosy. 2nd ed Edinburgh : Churchill Livingstine.1994 :157-168.

5. Sri V Muchtar, Pham D. bamg, Takao Fujimura, Naoya Satoh, Asnadah, Rasyidin Abdullah, Muh, Dali Amiruddin dan Yasuko Yogi. Intracellular locatiob of Mycobacterium leprae by expression of CD68 receptor of tissue carrier leprosy.

6. Juarez Antonio Simoes Quaresma, Luiz Wagner de Oliveira Lima, Hellen Thaiz Fuzii, Rosana Maria Feio Libonati,Carka Pagliari, Maria Irma Seixas Duarte.

Immunohistochemical evaluation of magrophage activity and its relationship with apoptotic cell death in the polar forms of leprosy. Microbial pathogenesis 49 (2010) 135-140 7. Hongsheng Wang, Yumi Maeda, Yasuo Fukutomi and Masahiko.An in vitro model of Mycobacterium leprae induced granuloma formation. Wang et al.BMC Infections Diseases 2013,13:279.

8. Abulafia J, Vignale RA. Leprosy : accessory immune system as efector of infectious, metabolic and immunologic reactions. Inter. J Dermatol. 2001;40 (11) ; 673-687 9. Birdi TJ, Anita NH. The macrophage in leprosy : a review on the current status. Int. J.lepr.1989;57(2) ; 511-525.

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10. Rowden G. macrophages and dendritic cells in the skin. In : Boa JD,ed. Skin immune system. Boca Rotan, Fl; CRC Press.1997 : 109-146 11. Abulafia J, vignale. RA. Leprosy : pathogenesis updated. Inter. J Dermatol.

199;38 :321-334 12. Krahenbuhl JL. Role of the macrophage in resistance to leprosy. In : Hasting RC, ed leprosy. 2nd ed Edinburgh : Churchill Livingstine.1994 :137-158 13. Godal T, Rees RJW. Fate of Mycobacterium leprae in macrophage of patients with lepromatous of tuberculoid leprosy. Int. J Lep. 1970; 38 : 439 – 442 14. Moshella SL, Hurley HJ. Diseases of the mononuclear phagocytic system. In : Dermatology. 3th ed. Philadelphia : W.B. sauranders Co. 1999 : 1100 – 1112.

15. Rea TH, Modlin RL. Leprosy. In : Fitzpatrick TB et al, eds, Fitzpatrick’s dermatology in general medicine. 5 th ed.

New York 16. Bos JD, eds. Skin immune system (SIS).

Cutaneus immunology and clinical immunodermatology. New York : CRC Press. 1997

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17. Moschella SL, Cropley TG. Mononuclear phagotyc and dendritic cell systems. J Am Acad Dermatol. 1990; 22 : 1091-1097 18. Kahn HJ, Thorner P, Baumal R, et al. immunohistochemical staining of macrophages in skin lesions of leprosy : the role of antibody to microbacteria in human serum and various polyclonal immune rabbit antisera. Histochem J. 1985; 17 : 1009-1020 19. Petzelbauer P, Fodinger D, rappersberger K,et al. CD68 positive epidermal dendritic cells. J Invest. Dermatol. 1993; 101 : 256261 20. Rea TH, Modlin RL. Immunopathology of leprosy skin lesions. Semin. Dermatol.

1991; 10 : 188-193 21. Fokkens WJ, Trenite GJN, Virmond M, Jan AK, Andrade VLG, Baar NG, Naafs B. The nose in leprosy : immunohistology of the nasal mucosa. Int. J Lepr. 1998; 66(3) : 328-339 22. Modlin RL, Rea TH. Immunopathology of leprosy. In : Hasting RC ; ed. Leprosy. 2nd ed. Edinburgh : Churchill Livingsone. 1994 : 225-234

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Profile of Nasopharyngeal Carcinoma in Dr. Cipto Mangunkusumo Hospital in 2010: Towards a Better Healthcare System Vito Filbert Jayalie*, Maria Satya Paramitha*, Jessica*, Cindy Anastasia Liu*, Adhitya Sigit Ramadianto*, Marlinda Adham** *Medical student in Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia **Department of Otorhinolaryngology, Faculty of Medicine Universitas Indonesia, Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia ABSTRACT Background: Cancer has been one of the causes of all mortality in Indonesia, and nasopharyngeal carcinoma (NPC) has become the most common head and neck malignancy in Indonesia with 12,000 new cases per year. Non-specific signs and symptoms, lack of awareness from General Practitioners (GP) that leads to late or missed diagnosis, and poor cancer registry and lack of access to basic medical care makes NPC difficult to deal with. Realizing these challenges, this study on is conducted to show the epidemiological, clinical, and histopathological characteristics of NPC in the country.

Material and methods: A cross-sectional study is conducted by collecting the medical records of NPC patients in 2010 in Otorhinolaryngology Department of Faculty of Medicine Universitas Indonesia-Dr. Cipto Mangunkusumo Hospital (CMH), Jakarta, Indonesia.

Results: Out of 167 patients, two-third is male, 80.2% are older than 30 years old, most of them are Sundanese (22.2%), and three-quarters is classified as WHO type III. Palpable lump in the neck is the most common symptom (58.1). Salt fish consumption makes up the most prevalent risk factor (29.9%).

Conclusion: Nasopharyngeal carcinoma is one of an iceberg phenomenon of chronic diseases in Indonesia, which needs to be solved. By knowing the risk factors and understanding how certain factors affect chronic diseases, these diseases can be prevented and managed well and finally reduced in number.

Therefore, a multi-dimentional and multidisciplinary approach among government, doctors, and other health providers are necessary to build a better healthcare system in Indonesia.

INTRODUCTION Indonesia is an archipelagic country with more than 13000 islands and 240 million ethnically-diverse inhabitants. The country as a whole is considered lower-middle income by the World Health Organization. In 2010, cancers comprised 13% of all mortality in the country.

The death rate from cancer in males and females are 135.9 and 108.9 per 100000 population, respectively (WHO, 2011). NPC is the most common malignancy in the head and neck, placing it as the fourth most common among all malignancies in Indonesians. Estimates put the Incidence of NPC at 6.2 per 100000 population, or 12000 new cases per year, with all the cases associated with EBV (Adham et al., 2012).

Nasopharyngeal carcinoma (NPC) is one type of malignancy with a distinct geographical distribution (Chang, 2006). While considered rare in most parts of the world, NPC cases are frequently found in southern China and southeast Asia. Additionally, a smaller number

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of cases is also found in North Africa and the Arctic. Males are three times more likely to be affected by NPC compared to females (Anghel et al., 2012), and incidence peaks around the age of 45-60 years (Adham et al., 2012), which is still considered productive age range.

Environmental risk factors of NPC include Epstein-Barr virus (EBV) infection, consumption of salted fish, and family history of NPC; consumption of preserved food and tobacco smoking may also increase risk of NPC (Chang, 2006; Adham et al., 2012).

As with other chronic diseases, NPC presents numerous challenges that go beyond simply treating the disease. The malignancy causes various non-specific signs and symptoms, and despite its high incidence, general practitioners’ awareness of NPC is inadequate, potentially leading to many late or missed diagnosis (Fles, 2011; Adham et al., 2012). Indeed, many cases are referred to hospitals in advanced stages.

Early detection techniques such as

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nasopharyngeal brushing, blood tests, and adjuvant laboratory examinations are available and affordable, but still need to be socialized to practitioners (Adham et al., 2012). Simply reaching a hospital is not an easy thing either: Indonesians in rural areas may lack access to adequate basic medical care, let alone to molecular diagnostics such as EBV serology and DNA load. Nationally, the country does not yet have a proper cancer registry (Anghel et al., 2012; Adham et al., 2012).

Once diagnosed, treatment may cause heavy socioeconomic burden to the patient and his/her family, especially considering that NPC affects individuals in productive age. NPC also puts a significant burden on healthcare resources of the country. Additionally, a diagnosis of cancer may impact the patient’s psychological well-being, which, in turn, plays a role in deciding whether the patient will get an optimal treatment or not (Frick et al., 2006).

Realizing the enormous challenge presented

by NPC, we conducted a study on NPC patients in CMH, Jakarta, Indonesia so as to shed some light on the epidemiological, clinical, and histopathological characteristics of NPC in the country. Through careful analysis, we aim to build upon our findings and recommend ways to improve the quality of care for NPC patients.

MATERIAL AND METHODS To gather data on nasopharyngeal carcinoma patients, this cross-sectional study collected the medical records of NPC patients in the Otorhinolaryngology Department of Faculty of Medicine Universitas Indonesia-Dr. Cipto Mangunkusumo Hospital, Jakarta. Dr. Cipto Mangunkusumo Hospital (CMH) is the national referral hospital in Indonesia, so it receives patients from all parts of the country. This study used total sampling method; the necessary data from all NPC patients in year 2010 were extracted and then analyzed to put the problem of NPC in Indonesia into perspective. The use of medical record in the study is compliant to the university and hospital regulations.

RESULTS In 2010, there were 167 medical records of NPC patients in CMH. During data extraction, it was found that many records were filled

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incompletely. These records are still included in analysis, so each variable may have different number of samples.

Around two-thirds (68,3%) of the NPC patients are male and most of them (80.2%) are older than 30 years old. The patients come from various ethnicities in Indonesia; the most common are Sundanese (22,2%) and Javanese (18,6%).

Palpable lump in the neck is the most common complaint in presentation, found in 58,1% of patients, followed by nasal congestion (49,1%) and unilateral hearing defect (39,5%).

The majority of patients have felt these complaints for 6 months or less. However, there are patients who tolerated the complaints for more than a year before going to a physician.

Among the known environmental risk factors, the most prevalent is salted fish consumption, identified in 29,9% of patients. Smoking and passive smoking are also quite prevalent.

From the identified risk factors, the most prevalent was salted fish consumption (29.9%).

While others showed not really high percentage, with betel and alcohol consumption as the two lowest (1.2% and 3.6% respectively).

Based on the histopathological findings, three-quarters of cases (75,4%) were classified as WHO-3. WHO classification is not available in 3% of cases, which is then classified into ‘others’. Clinically, around half of the patients (51%) were already in stage IV upon diagnosis in CMH. DISCUSSION Characteristics of the Patients Male patients make up 68,3% of NPC cases found in 2010. This distribution is consistent with previous findings by Chang and Adami (2006) that shows NPC having a male predisposition in the regions of North America, Middle East/North Africa, Arctic, Southeast Asia, and China and East Asia. The predisposition can be found in developing and developed countries alike (Jemal, 2011).

More than 80% of NPC patients in our study are older than 30 years old. This finding follows the general age trend of NPC that starts to rise after age 30. Incidence peaks in the age 31-60 years group, with 69,4% of patients in this age group. Again, this peak concurs with many

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previous findings. Adham et al (2012) found the peak in age 31-50 years old; in North Africa, the peak is around 50 years of age; in China, the majority of patients come in the fifth and sixth decades of life. Report by Loh et al (2006), NPC in Singapore peaks in age 41-50 years old.

The majority of patients in this study are of either Sundanese, Javanese, Sumatrans, or Betawi descent. Compared to other ethnicities, these four have the largest number of population in Indonesia; hence, this distribution may simply reflect the general population and not genetic risk factor. Research by Adham et al (2012) found that people of Javanese descent are most prevalent in NPC cases. Nevertheless, other ethnicities are also affected by NPC and thus, the malignancy is considered a multi-ethnic problem.

Sign and Symptoms Based on our study, most patients developed symptoms such as neck lump, nasal congestion, bloody discharge, epistaxis, hearing defect, tinnitus and unilateral headache. The common early signs and symptoms of NPC is unilateral hearing loss from effusion in a middle ear or a mass on the neck caused by regional spread.

Nasal obstruction can be a result of large or exophytic lesions. Adjacent cranial nerves paralysis can be caused by tumor growth and manifests into various symptoms such as facial pain due to involvement of trigeminal nerve, diplopia accompanying injury on abducens nerve; ophthalmoplegia due to the involvement of cranial nerves III, IV, and VI; and xerophthalmia due to the involvement of greater superficial petrosal nerve (Weber, 2007).

From a study conducted by Chih-Ying Su and Chun-Chung Lui, extension of NPC towards paranasopharyngeal space is considered frequent, signaled by neck masses, auditory symptoms (unilateral or bilateral), bloody nasal discharge, and cranial nerve palsy. The most common cranial nerve palsy to be found is trigeminal neuropathy caused by perineural invasion to trigeminal nerve of the intracranial segment. Facial pain or paresthesia is also found a lot at the time of diagnosis, especially when the tumor has invaded the intracranial paracavernous region. In the early stage of the diseases, these symptoms are still tolerable for the patients. However, the worst possible

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outcomes for the patients are nerve dysfunction and sensory impairment of ophthalmic division.

About the duration of the symptoms, most of the patients come to seek a medical advisor within 6 months after the occurrence of neck lump, nasal congestion and unilateral hearing defect. But unfortunately, there were still a lot of patients who came to seek medical advice after more than 6 months, even years. By coming to the doctor or health provider earlier, the patients should probably have a better prognosis. So, doctors role in this case to be an educator about an early detection system and seeking health behaviour for the patients.

Risk Factors Increased risk of NPC has been associated with numerous factors. While an overwhelming majority of NPC is positive for EBV, other factors still play a role in oncogenesis. Certain ethnic groups may be healthy carriers of EBV. Genetic risk factors include p53 mutations and polymorphism in genes encoding metabolic enzymes (Weber, 2007). Environmental factors such as carcinogens and nutrition may affect NPC in epigenetic level. Thus, NPC is considered to have multifactorial etiology (Adham et al., 2012).

• Smoking will establish risk factor of head & neck malignancy. Result in this experiment is the same as the previous study led by Polesel et al (2011); in which Tobacco smoking is not related to undifferentiated nasopharyngeal carcinoma (WHO-3) since most of the patients did not smoke.

• Salted fish, which is a common food with nitrosamine as its component. This component has been proven to cause NPC in many studies. Study done by Zheng et al stated that there were a strong association between salted fish consumption and EBV with NPC (1994). Another study lead by Armstrong RW, found that salted marine fish was shown to be a strong and significant risk factor for NPC incidence in Chinese populations (Armstrong et al, 1998). Lau et al (2013) also showed that there was a strong correlation between salted fish consumption and NPC in Hongkong (p < 0.05). The involvement of salted fish and the development of NPC is

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believed to be related to its component, which is nitrosamine (Ward et al, 2000).

• Betel consumption; although betel consumption associated with 70% increased risk of NPC in Taiwan, but apparently Indonesia show a different pattern with that country. Although betel consumption is associated with oral cancer, but its involvement in NPC is remained unproven (Chang & Adami, 2006).

Histologic Findings Histopathologically, there are many types of malignancy in nasopharynx: squamous cell carcinoma as the most common type, lymphoma, salivary gland malignancy, and sarcoma (Weber, 2007). Squamous cell carcinoma is further divided by WHO classification into WHO type 1 (keratinizing form with poor prognosis within 10% survival rate after 5 years); WHO type II (non-keratining and poorly differentiated); and WHO type III (non-keratinizing and undifferentiated). The highest prevalence in Southeast Asia, including Indonesia, which is also shown in our research, is patients with WHO Type III (Adham et al., 2012).

A serologic examination by Neel HB in 1985 showed that in small and submucosal tumors, which are difficult to be identified, more specific signs and symptoms were found in each of the WHO classifications. In WHO type 1 tumors, “common garden variety” of squamous cell carcinomas can be located within head and neck regions. This type of tumors appeared to be more persistent and had higher recurrence rate.

On the other hand, even though WHO type 2 and 3 tumors usually happened earlier and survival rate after treatment was higher, early and advanced neck metastasis commonly happened.

The tumors in these types were found to be small, submucosal, and not easily detectable.

These type of tumors also appeared to be more sensitive towards radiation compared with WHO type 1 tumors.

The classification of others (3%) was due to the difference between hospitals in Indonesia; in which pathologist in CMH classified NPC based on WHO classification, but others may not.

Usually, patients who came to CMH with pathologic findings are directly treated based on the findings. The reason for not doing another biopsy or histopathological diagnosis is to

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decrease the funding needed to be spent by patients as Indonesia is still considered as one of the developing countries.

Staging of NPC Since most of the patients were diagnosed in the late stage, this may indicate that the early detection system in Indonesia is not yet established. Doctors and other health providers should give more illumination, seminar, and others to increase awareness among both patients and medical staff, especially doctors as a primary health care provider.

NPC as a Chronic Disease Dealing with NPC in Indonesia cannot be considered as an easy matter since there are still some major problems; such as: low medical awareness towards this chronic disease and its effect; lack of hospital and medical facilities especially in rural areas; and nationwide cancer diagnostic and registration system (Anghel et al., 2012). Lack of health facilities and low awareness towards this disease in a country can be a big obstacle for performing early detection on NPC. Moreover, most of the early signs and symptoms are not specific; often may lead to situations where NPC is considered as the most confusing and commonly misdiagnosed disease (Adham et al., 2012).

Since NPC mostly affects individuals in productive ages (begins in 20 years old until 4050 years old); NPC has created a socioeconomic problem for the country; especially in the occupation sectors and health system.

Simple, regular, and affordable techniques for early detection of NPC; such as nasopharyngeal brushing, blood tests, and adjuvant laboratory examinations; are still necessary to be socialized. As a developing country, Indonesia only has a few facilities for molecular testing, especially in rural areas. This is an unfortunate reality since molecular examinations; such as EBV-IgA serology and EBV-DNA load testing; are very promising for early diagnosis and down-staging of NPC. Health workers in rural areas must be educated further in sample-taking technique and how to transport the samples.

(Adham et al., 2012) In addition, as one of the chronic diseases, NPC needs to be treated as early as possible and followed-up periodically. Most of the challenges usually come from the patients. Anxiety and

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depression has become the most prominent psychopathological comorbidities; especially when the patients undergo uncomfortable therapies (Frick et al., 2006). Some patients may become reluctant to follow the treatment or even to consult with medical professionals about their conditions. Lack of awareness about the outcome of this disease can also be the reason on why some people do not want to do further confirmation when they are diagnosed with NPC. It is undeniable, though, that by confirming the diagnosis with radiological examinations; such as CT-Scan; contributes to the improvement of this disease since by knowing the staging and the extent of the metastasis (if there is one) can help the medical professionals to determine the appropriate treatment for the patients. Moreover, insufficient knowledge from GP, especially in primary medical health care, also causes problems to deal with. Researches show that the knowledge of GPs were declining after two-weeks period of NPC awareness education to them. Therefore, education of the GPs in endemic areas should be done regularly to reduce mortality rate of NPC patients and to increase the quality of life of the patients (Eles et al., 2010; Wilderman et al., 2012).

Multidimentional and multidisciplinary approach from the government, medical doctors and other health providers are also needed to be done. Until now, medical doctors have done numerous approaches towards better treatment and prevention of NPC; such as: educating the medical doctors in primary medical health care (Wilderman et al., 2012). But the participation of governments towards prevention of NPC; especially regarding the health policies; must be shown more.

Strength and Limitations The data of this research is obtained from the medical records of all NPC patients in Dr. Cipto Mangunkusumo Hospital in 2010. As the national referral hospital in Indonesia, Dr. Cipto Mangunkusumo Hospital has patients from all over Indonesia. Therefore, the data that is being used in this research may represent the characteristics of all NPC patients in Indonesia.

However, the fact that not all NPC patients comes to CMH may cause a bias in our sample.

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A major obstacle in this study is the lack of data with adequate quality. Several medical records are incompletely filled, hindering data extraction. This obstacle may be caused by several factors, including human error or not having the records computerized. Therefore, to aid NPC patients further and to nurture a healthy research environment, medical records should be filled as completely as possible and perhaps computerized.

CONCLUSION The characteristic of 167 patients who came to Dr. Cipto Mangunkusumo Hospital in 2010 showed the same sex and age distribution compared with other studies. However, the Sundanese is more prone to the disease than other ethnicity, which differed from the previous study.

In this study, most people who came to seek the ENT regarding to NPC present with neck lump, nasal congestion, bloody discharge, epistaxis, hearing defect, tinnitus and unilateral headache. But, medical seeking behaviour of the patients in Indonesia based on this study is still low as a lot of them came after 6 months of symptoms. In addition, the most prominent risk factors related to NPC is salted fish consumption.

Regarding to the diagnosis of this disease, WHO-3 was found in almost all cases, and half of the patients came at stage 4 upon diagnosis.

As the result, a lot of work must be done to fix the problem regarding to NPC in Indonesia. A multidimentional approach and collaboration should be shown among government with his policies, medical providers by giving a seminar and education about NPC, particularly early detection, and patients especially associated with health seeking behaviour. Moreover, a better cancer registration such as computerized system will ease the research and study regarding to NPC in Indonesia. Finally, by knowing the risk factors of the development of NPC and understanding on what and how certain contributing factors affect the journey of this chronic disease, ultimately we can contribute to create a better healthcare system in Indonesia especially for chronic diseases, and of course a better Indonesia.

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REFERENCES Adham, M., et al.

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Nasopharyngeal carcinoma in Indonesia: Epidemiology, incidence, signs, and symptoms at presentation.

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Al-Sarraf M., LeBlanc M., Giri P.G., et al.

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Chemoradiotherapy versus radiotherapy in patients with advanced nasopharyngeal cancer: phase III randomized Intergroup study 0099. J Clin Oncol. 16, 13101317.

Anghel I., et al. (2012). Nasopharyngeal carcinoma: Analysis of risk factors and immunological markers.

Chirurgia,107, 640-645.

Armstrong R.W., et al. (1998). Nasopharyngeal carcinoma in Malaysian Chinese: Salted fish and other dietary exposures. Int J Cancer,77, 228-235.

Chan A.T., Teo P.M., Leung T.W., Johnson P.J. (1998). The role of chemotherapy in the management of nasopharyngeal carcinoma. Cancer.

82(6): 1003-1012.

Chang E.T., Adami H.O. (2006). The enigmatic epidemiology of nasopharyngeal carcinoma. Cancer Epidemiology Biomarkers Prev, 15, 1765-1777.

Cu, C.Y. & Lui C. C. (1996). Perineural invasion of the trigeminal nerve in patients with nasopharyngeal carcinoma.

American Cancer Society, 78, 2063-2069.

Fles R., Wildeman M.A., Sulistiono B., Haryana S.M., Tan I.B. (2010).

Knowledge of general practitioners about nasopharyngeal cancer at the Puskesmas in Yogyakarta, Indonesia.

BMC Medical Education, 10, 81.

Frick, E., Tyroller, M. & Panzer, M. (2006). Anxiety, depression and quality of life of cancer patients undergoing radiation therapy: a cross-sectional study in a community hospital outpatient centre. European

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Journal of Cancer Care, 16, 130136.

Gu M.F., Liu L.Z., He L.J., Yuan W.X., Zhang R., Luo G.Y., et al. (2012).

Sequential chemoradiotherapy with gemcitabine and cisplatin for locoregionally advanced nasopharyngeal carcinoma. Int J Cancer.

Jemal, A., et al. (2011). Global cancer statistics. CA: A Cancer Journal for Clinicians, 61, 69-90.

Lau H.Y., et al. (2013). Seculat trends of salted fish consumption and nasopharyngeal carcinoma: A multi jurisdiction ecological study in 8 region from 3 continents. BMC Cancer, 13, 298.

Lawrence T.S., Ten Haken R.K., Giaccia A. (2008). Principles of Radiation Oncology. In: DeVita VT Jr., Lawrence TS, Rosenberg SA, editors. Cancer: Principles and Practice of Oncology. 8th ed.

Philadelphia: Lippincott Williams and Wilkins.

Loh, K. S., et al. (2006). Familial nasopharyngeal carcinoma in a cohort of 200 patients. Arch Otolaryngology Head Neck Surgery, 132, 82-85.

Neel, H.B. (1985). Nasopharyngeal carcinoma: Clinical presentation, diagnosis, treatment, and prognosis.

Otolaryngol Clin North Am, 18, 479-490.

Polesel, J., et al. (2011). Tobacco smoking, alcohol drinking, and the risk of different histological types of nasopharyngeal cancer in a low risk population. Oral Oncology, 47, 541545.

Rodriguez-Galindo C, Wofford M, Castleberry RP, et al. (2005).

Preradiation chemotherapy with methotrexate, cisplatin, 5fluorouracil, and leucovorin for pediatric nasopharyngeal carcinoma.

Cancer. 103, 850-857.

Ward M.H., et al. (2000). Dietary exposure to nitrite and nitrosamines and risk of

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nasopharyngeal carcinoma in Taiwan. Int J Cancer, 86, 603-609.

Weber, G. F. (2010). Molecular mechanisms of cancer. New York: Springer.

Wildeman M.A., et al (2012). Shortterm effect of different teaching methods on Nasopharyngeal Carcinoma for general practitioners September 2013)

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in Jakarta Indonesia. PLos One, 7, e32756.

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Noncommunicable diseases country profiles 2011. WHO, 2011.

Zheng X, et al. (1994). Epstein-Barr virus infection, salted fish and nasopharyngeal carcinoma. Acta Oncologica, 33, 867-872.

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7 Jumps To Care Diabetic Diabetes Mellitus is a metabolic disease which is marked with the increased level of blood sugar, which is caused by the lack of insulin excretion or the insulin itself defected, causing in its ineffectiveness. Every human in the world has the risk of suffering diabetes, from within themselves(genetic)or from outside factor, e.gtype of consumed food. This disease doesn’t recognize age, whether you’re young or elderly.

Through health campaign, such as these videos and poster, we try to tell the story of person who is suffering diabetes, where the risk of contracting the disease may come from genetical factor and his lifestyle. From consumpting sweetened beverages, lack of physical activity, sleeping too much, immobile while consumpting snack, and just resting around the clock not be up on the room.This campaign is created to give us an impression of how diabetes impedes people and steps to manage it.

One day, he was reminded of his father, whom passed away from diabetes. He began to realize that he too, begins to exert the same symptoms as his father had, such as, itchy feeling on the skin surface, thirsty, often wakes at night, due to the feeling of want to pee. These symptoms, prompting him to make a decisive change of his life, starting from changing the diet schedule, variety of the beverages (restricting junk food) and also the amount of itself.Not only that, diabetes patient can also adjust several changes to manage the diabetes, such as, visit physician regularly to control the disease, consume the prescribed drug on schedule, remain cautious in activity, you may also share the stories with other patient.

In every change, there’s always a barrier of challenges, either from inside the patient itself or outside factor. But, Act NowAndHealthy Tomorrow.

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Hands of Companion

Leukemia is a second ranked cause of death in the world and it is one of the leading cause of death related to circulation system in our body especially in blood. The exact cause of leukemia is still unknown.

If this abnormal cell growth attacked someone with weak physical can lead to complication in organ major or even death.

This video tells the story of a leukemia patient who was late treated by her nearest person. However,she has been succeed to inspire that person to do a noble things in his life. He dedicated himself as a physician who will always try to understand and take care his patients to improve their quality of life. And this poster portray about leukemia which can attack all ages, from children,adolescent or even ederly. We may be unable to fully control the disease, but we are able to show more compassion to patient. Love is what they need to feel, love is what they need to have. By support and accompany them, we want them to think that there is still a hope and be stronger to fight for their life.

Leukemia is not a disease that can not be cured, but it requires patience, perseverance and cooperation between patients, parents and physicians. From this video and poster health campaign , we want to raise the awareness of people about walking side by side with the patient, not just cure or delay the death,but also improve their quality of life by our support and companion.

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Save The Golden Generation Globally 15 million people have an acute stroke every year and one third of them die secondary to stroke events. Most research on stroke prevention and treatment is done in developed countries, yet more than 85% of strokes occur in developing countries. In particular, stroke remains an unrecognized cause of death and disability in South East Asia (Kulshreshtha, 2010).

There are many causes of stroke and one of them caused by trauma in the head. Stroke is the most avoidable chronic disease. From time to time, child abuse cases keep raising and getting worst each day. Nowadays, there are 5 children died every day because of child abuse and mostly caused trauma in the head and causing internal cranial hemorrhage then leading to stroke.

4 from 6 of the child abuse victim died because of mistake in the emergency management. We conclude that is an issue which is need more attention to be considered about. If it done correctly, the brain damage could be minimalized. The next step is rehabilitation, to make the stroke patients can do daily activities assisted by professional medical health care. It is important for them and they need support from their environment especially family. By this opportunity, we made a poster and a video about the first thing to do if there would be a brain trauma injury and the rehabilitation for stroke children to do their daily activities also accompanying them for their future to save the golden generation.

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Give Your Heart Supply About 17,3 million people died from Cardiovascular Disease (CVD). By 2030, more than 23 million people estimated will die annually from CVD. In Indonesia, cardiovascular disease has become the first rank as major cause of death in Indonesia. Even though people know the fatal impact of having cardiovascular disease, however, most of them still have not changed their life style or making lifestyle modification. Besides, life style modification has a beneficial impact on patients toCVD. Previous studies shown that life style modification can stabilize or promote regression of patients with CVD. In fact, there are many drugs take role in curing CVD. It is easy to get. However, it makes people who have CVD feel safe by only taking medicine, and they neglected lifestyle modification. Whereas, medication are nonsense without lifestyle modification. Medication has to be accompanied by lifestyle modification. Overall, preventing CVD is the best solution. Such as eat fish, no junk food, normal blood pressure and cholesterol control, eat more vegetables and fruits, cycling, drink water, jogging or walking. Overall lifestyle modification can not be separated in every single of life. So, Give your Heart Supply! EAT WELL, DRINK WELL, AND LIVE WELL!

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