Hasil Pencarian  ::  Simpan CSV :: Kembali

Abstrak :

Kelainan kulit kering banyak ditemukan pada penyandang DMT2. Patogenesis kulit kering pada DMT2 dipicu oleh kondisi hiperglikemia kronik yang meningkatkan Advanced glycation end products (AGE) N(6)-carboxymethyl-lysine (CML), sitokin proinflamasi dan stres oksidatif.  Kombinasi Centella asiatica  oral  (CAo) dan topikal (CAt) diduga dapat meningkatkan efektivitas tatalaksana kulit kering DMT2. Penelitian bertujuan menganalisis efektivitas dan keamanan kombinasi CAo + CAt dalam memperbaiki kulit kering DMT2.

 

Penelitian merupakan uji klinis acak tersamar ganda di Poliklinik Metabolik Endokrin Departemen Penyakit Dalam RSCM dan 5 puskesmas di Jakarta pada bulan Juli 2018–Maret 2019. Subjek dibagi menjadi 3 kelompok, yaitu kelompok CAo + CAt, plasebo oral (Plo) + CAt, dan Plo + Plasebo topikal (Plt) masing-masing berjumlah 53 orang. Perbaikan kulit kering secara klinis diukur dengan Specified Symptom Sum Score (SRRC) dan Skin Capacitance (SCap). Perbaikan secara molekular diukur  CML, IL-1a, dan aktivitas superoksida dismutase (SOD). Keamanan kombinasi CAo + CAt dilakukan melalui penilaian efek simpang oral dan topikal.

 

Pada ketiga kelompok, median HbA1c > 7%. Glukosa darah sewaktu (GDS) kelompok CAo + CAt hari ke-15 dan 29 semakin menurun. Efektivitas kombinasi CAo + CAt dinilai melalui analisis subgrup berdasarkan nilai HbA1c dan GDS. Pada glukosa darah terkontrol baik, persentase penurunan SRRC lebih besar pada kelompok CAo + CAt vs Plo + Plt (p = 0,04). Peningkatan SCap kelompok CAo + CAt lebih besar dibandingkan Plo + Plt (p = 0,01). Pada glukosa darah terkontrol kurang baik peningkatan SOD kelompok CAo + CAt lebih besar dibandingkan Plo + Plt  (p = 0,01). Tidak terdapat korelasi antara CML, IL-1α dan SOD dengan SRRC atau SCap. Terdapat korelasi sedang sampai kuat dan arah korelasi sesuai antara CML dengan SOD (r = 0,58, p < 0,05)  dan  IL-1α dengan SOD (r = 0,70, p < 0,05) pada glukosa darah terkontrol baik. Tidak terdapat efek simpang oral dan topikal yang bermakna pada penggunaan CAo + CAt dibandingkan 2 kelompok.

 

Simpulan: Pada glukosa darah terkontrol baik, perbaikan SRRC dan SCap  kelompok CAo + CAt lebih besar dibandingkan Plo + Plt.  Pada glukosa darah terkontrol kurang baik peningkatan SOD kelompok CAo + CAt lebih besar daripada Plo + Plt. Terdapat korelasi sedang sampai kuat antara CML atau IL-1α dengan SOD pada glukosa darah terkontrol baik. Tidak terdapat efek simpang oral dan topikal yang bermakna pada kelompok CAo + CAt dibandingkan 2 kelompok.

 

Kata kunci: CML, DMT2, IL-1a, kulit kering, SCap, SOD, SRRC

 

---

Dry skin is a common findings in type 2 diabetes mellitus (T2DM). The pathogenesis of dry skin in T2DM rises from chronic hyperglycemic condition which causes an increase in levels of Advanced glycation end products (AGEs)  N(6)-carboxymethyl-lysine (CML), pro-inflammation cytokines and oxidative stress. Combination of oral and topical Centella asiatica (CA) is expected to ameliorate dry skin in T2DM patients more effectively.

 

This study was a double blinded randomized clinical trial in T2DM patients with dry skin in outpatients clinic of Metabolic Endocrine, Internal Medicine Department, dr. Cipto Mangunkusumo Hospital, and 5 primary health cares in Jakarta from July 2018 to March 2019. The subjects were divided into three groups, CA oral (CAo) + CA topical (CAt) group, oral placebo (Plo) + CAt group, and Plo + topical placebo (Plt) which included 53 subjects respectively. Dry skin improvement was evaluated clinically using Specified Symptom Sum Score (SRRC) and Skin Capacitance (SCap). The molecular improvement was evaluated using levels of CML, inflammation interleukin 1-α (IL-1α) concentration, and oxidative stress superoxide dismutase (SOD).

 

In the three groups, median of HbA1c > 7%. Random blood glucose (RBG) in CAo + CAt group in day-15 and 29 were further decreased. Effectivity of CAo + CAt combination were assessed via subgroup analysis based on HbA1c and RBG. In well controlled blood glucose, on day-29, percentage of SRRC decrement was greater in  CAo + CAt compared to control group without CA (p = 0,04). SCap value in CAo + CAt group was greater than control group (p = 0,01). In the partially controlled blood glucose, increment of SOD activity of CAo + CAt group was greater than control group (p = 0,01). There was no correlation found between CML, IL-1α and SOD with SRRC nor SCap. There were medium to strong correlation between CML with SOD (r = 0,58, p < 0,05)  and IL-1α with SOD (r = 0,70, p < 0,05)  in well controlled blood glucose. Systemic and topical adverse events were not found significantly in CAo or CAt usage compared to the other two groups.

 

Conclusion: In well controlled blood glucose, improvement of SSRC and SCap in CAo + CAt were greater than Plo + Plt.  In partially controlled blood glucose,  increment of SOD in CAo + CAt was greater than Plo + Plt.  There was moderate to strong correlation between CML or IL-1 and SOD in well controlled blood glucose. There were no significant adverse events found due to CAo + CAt compared to the other 2 group in the study.

 

Keywords: CML, diabetes mellitus, dry skin, IL-1a, SCap, SOD, SRRC

 

Abstrak :
Pengembangan humanisme sebagai inti profesionalisme diperlukan karena dokter profesional masa kini dituntut melakukan pelayanan berpusat pada pasien dan mengesampingkan kepentingan pribadi. Pengembangan humanisme dipengaruhi persepsi mahasiswa terhadap lingkungan pembelajaran terutama di klinik. Meskipun demikian, belum ada instrumen untuk menilai hal tersebut. Tujuan penelitian ini adalah menyusun instrumen penilaian iklim humanis lingkungan pembelajaran klinis. Penelitian ini menggunakan desain sequential exploratory mixed method dan dilakukan di Rumah Sakit dr. Cipto Mangunkusumo (RSCM) pada bulan Januari – Desember 2019. Penelitian dilakukan dalam empat tahap yaitu penyusunan instrumen, uji coba, penyusunan model iklim humanis lingkungan pembelajaran klinis dan implementasi. Tahapan penyusunan instrumen dimulai dengan sintesis konsep iklim humanis lingkungan pembelajaran klinis melalui telaah pustaka, focus group discussion dan wawancara mendalam. Dari penyusunan tersebut diperoleh konsep yang dijadikan rujukan draf instrumen Humanistic Climate Measure (H-CliM) yang terdiri atas 89 butir pertanyaan; 7 domain. Tahap kedua, dilakukan uji coba H-CliM bersama instrumen untuk menilai kompetensi humanisme Integrity Compassion Altruism Respect Empathy (ICARE). Kedua instrumen terbukti valid (r > 0,3) dan reliabel (α-cronbach > 0,7). Dilakukan analisis faktor untuk memvalidasi konstruk dan menghasilkan instrumen H-CliM final (46 butir pertanyaan; 4 domain) serta ICARE final (15 butir pertanyaan; 2 domain). Analisis receiver operating characteristic (ROC) menghasilkan titik potong ≥ 184,5 artinya, skor H-CliM ≥ 184,5 tergolong humanis. Analisis regresi logistik menghasilkan model iklim humanis yang 62% dapat menjelaskan variasi iklim humanis (R2 = 0,62). Model tersebut adalah: Logit P (iklim humanis) = 0,782 (rotasi klinis non-bedah) + 0,048 (kurikulum formal dan informal terkait humanisme) – 0,213 (hidden curriculum) + 0,036 (relasi dan fasilitas yang mendukung humanisme) + 0,044 (pengembangan kepribadian dan profesionalisme) + 0,409 (perempuan) + e. Penelitian ini berhasil mengembangkan instrumen penilaian iklim humanis yang valid dan reliabel yaitu instrumen H-CliM (α-Cronbach = 0,86). Lingkungan pembelajaran non-bedah 2 kali lebih humanis dibanding bedah (p = 0,0001). Persepsi terhadap iklim humanis lingkungan pembelajaran klinis berkorelasi lemah dengan capaian kompetensi humanisme. ......The development of humanism as the core of professionalism is crucial, seeing that professional doctors today are expected to carry through patient-centered services and put aside their personal interests. In clinical setting, cultivating humanism is highly influenced by students 'perceptions on clinical learning climate, therefore, it is necessary to assess that perception. However, to date there is no instrument to assess clinical learning climate. The purpose of this study is to develop an instrument to assess humanistic learning climate. This study utilizes a sequential exploratory mixed method design and is conducted at the Cipto Mangunkusumo hospital (RSCM) in January - December 2019. The research was conducted in four stages, which are the preparation of instruments, trials, development of humanistic climate models of clinical learning environments and implementation of the instrument. The stages of instrument preparation begin with the synthesis of concept of the humanistic clinical learning climate through literature review, focus group discussions and in-depth interviews. Afterward, the concept that was obtained utilized as a reference for drafting instrument of Humanistic Climate Measure (H-CliM) consisting of 89 questions; 7 domains. The second stage, an H-CliM trial was carried out along with instruments to assess the competence of the Integrity Compassion Altruism Respect Empathy (ICARE). Both instruments proved to be valid (r > 0.3) and reliable (α-Cronbach > 0.7). Factor analysis was carried out to validate the construct and produce the final H-CliM instrument (46 questions; 4 domains) and the final ICARE (15 questions; 2 domains). Receiver operating characteristic (ROC) analysis resulted in cut-off point of 184.5, which means that the H-CliM score ≥ 184.5 was classified as humanistic climate. Humanistic climate models obtained from the logistic regression analysis could explain 62% of variation of humanistic climate (R2= 0,62). The model is: Logit P (humanistic climate) = 0.782 (non-surgical clinical rotation) + 0.048 (formal and informal curriculum related to humanism) - 0.213 (hidden curriculum) + 0.036 (relationship and facilities that support humanism) + 0.044 (personality development and professionalism) + 0,409 (female) + e. This research succeeded in developing a valid and reliable humanistic climate assessment instrument, the H-CliM instrument (α-Cronbach = 0,86). Compare with surgical rotation, the non-surgical learning environment is twice more humanistic (p = 0.0001). Perceptions of the humanistic climate of the clinical learning environment are weakly correlated with the achievement of humanism competencies.

Abstrak :
Latar Belakang. Pembelajaran laparoskopik kolesistektomi umumnya hanya menekankan pada aspek keterampilan teknis dan belum memanfaatkan keterampilan nonteknis laparoskopik kolesistektomi dengan optimal, sehingga rentan terpajan risiko melakukan laparoskopik kolesistektomi yang mengalami cedera duktus biliaris. Penguasaan keterampilan nonteknis sangat penting bagi seorang dokter bedah, namun bukti-bukti studi yang menguatkan peran itu masih terbatas, terlebih di Indonesia. Studi ini bertujuan menganalisis peran pembelajaran keterampilan nonteknis kognitif dan merumuskan modul pembelajarannya. Metode. Dilakukan penelitian mixed method dengan pendekatan kualitatif dengan survei perilaku dokter bedah dalam melakukan laparoskopik kolesistektomi, dilanjutkan dengan analisis video operasi menggunakan sistem penilaian video Objective Structured Assessment of Technical Skills (vOSATS) dan Critical View of Safety (CVS) score. Hasil analisis kedua data tersebut menjadi bahan untuk wawancara mendalam yang menggali lebih lanjut fenomena yang mendasari perilaku dalam laparoskopik kolesistektomi. Selanjutnya data tersebut digunakan untuk menyusun modul pembelajaran melalui consensus Delphi, berdasarkan kebutuhan pembelajaran yang telah dieksplorasi. Pendekatan kuantitatif dirancang untuk mengevaluasi hasil pembelajaran dalam studi kuasi eksperimental yang membandingkan keterampilan nonteknis kognitif pada kelompok modul dan kelompok regular. Hasil dan Pembahasan. Hasil penelitian tahap kualitatif menemukan perilaku laparoskopik kolesistektomi responden penelitian yang belum baik, ditunjukkan oleh proporsi cedera duktus biliaris selama karir yang dilaporkan 62,79%, pencapaian CVS yang tidak sempurna, penggunaan alat bantu yang tidak optimal, dan kecenderungan untuk terlambat melakukan konversi. Pembelajaran keterampilan nonteknis kognitif dalam laparoskopik kolesistektomi juga belum terstruktur dan mendalam. Konsensus Delphi menyusun modul pembelajaran keterampilan nonteknis kognitif dalam bentuk kuliah didaktik dan diskusi berbasis kasus, dengan instrumen evaluasi keterampilan nonteknis kognitif laparoskopik kolesistektomi yang sahih dan andal, dalam bentuk pilihan ganda dan concordance test. Tahap kuantitatif menunjukkan rerata skor pilihan ganda, skor concordance test dan skor total yang lebih tinggi dibandingkan dengan kelompok regular (p < 0,001; Uji Mann-Whitney). Kesimpulan. Penelitian ini telah berhasil menyusun modul pembelajaran dan instrument evaluasi keterampilan nonteknis kognitif yang dapat mengajarkan dan menilai keterampilan nonteknis kognitif dengan baik. ......Background. The current focus of laparoscopic cholecystectomy training primarily emphasizes technical skills and does not fully utilize the non-technical laparoscopic cholecystectomy skills to their best potential. This leaves a vulnerability to the risk of bile duct injuries during laparoscopic cholecystectomy. Mastery of non-technical skills is crucial for a surgeon, yet there is limited evidence from studies supporting this role, especially in Indonesia. The purpose of this study is to analyze the role of cognitive non-technical skills learning and formulate its learning modules. Method. A mixed method research was conducted using a qualitative approach to survey the behavior of surgeons performing laparoscopic cholecystectomy, followed by an analysis of operation videos using the Objective Structured Assessment of Technical Skills (vOSATS) and Critical View of Safety (CVS) score. The analysis of both data sets serves as material for an in-depth interview that further explores the underlying phenomena of behavior in laparoscopic cholecystectomy. Subsequently, the data is utilized to construct a learning module through the Delphi consensus, based on the explored learning needs. The quantitative approach is designed to evaluate learning outcomes in quasi- experimental studies comparing cognitive non-technical skills between the module group and the normal group. Results and Discussion. The findings of the qualitative research phase revealed suboptimal laparoscopic cholecystectomy behavior among the study respondents, as indicated by a reported 62.79% proportion of bile duct injuries during their careers, imperfect achievement of CVS, suboptimal use of assistive tools, and a tendency to delay conversion. The teaching of non-technical cognitive skills in laparoscopic cholecystectomy is also lacking structure and depth. The Delphi consensus developed a module for teaching cognitive non-technical skills in the form of didactic lectures and case-based discussions. The module includes a valid and reliable evaluation instrument for cognitive non-technical skills in laparoscopic cholecystectomy, in the form of multiple-choice and concordance tests. The quantitative stage demonstrates that the mean scores of multiple-choice questions, concordance test scores, and overall scores are higher compared to the regular group (p < 0.001; Mann-Whitney test). Conclusion. This study has successfully developed a learning module and an evaluation instrument for cognitive non-technical skills that can effectively teach and assess cognitive non-technical skills.