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"ABSTRAKLatar Belakang: Sekitar 9-33% pasien penyakit trofoblas maligna (PTM) yang diobati dengan kemoterapi agen tunggal akan membutuhkan terapi multi agen karena adanya resistensi terhadap obat lini pertama, termasuk metotreksat (MTX), atau efek samping toksisitas. Hingga saat ini, resistensi terapi lini pertama masih menjadi masalah akibat tingkat identifikasi yang masih rendah. Sebelumnya, belum pernah dilakukan penelitian mengenai kadar Beta-HCG sebagai prediktor resistensi pada pasien PTM risiko rendah.Tujuan: Mengetahui nilai prediktif kadar Beta-HCG untuk risiko resistensi metotreksat pada PTM risiko rendah.Metode: Penelitian ini adalah studi analitik potong lintang menggunakan data rekam medis dari 58 subjek. Subjek adalah semua pasien yang terdiagnosis dengan PTM risiko rendah dan diberikan terapi MTX pada bulan Januari 2011 hingga Desember 2016 di RSUPN Dr. Cipto Mangunkusumo. Pengambilan subjek dilakukan secara konsekutif. Subjek dengan data yang tidak lengkap atau adanya riwayat PTM sebelumnya dieksklusi dari penelitian ini.Hasil: Prevalensi resistensi MTX yaitu 32,8%. Tidak ditemukan asosiasi bermakna antara karakteristik demografik (usia, paritas, pekerjaan, dan pendidikan) ataupun karakteristik klinis (riwayat kehamilan, interval antara kehamilan terakhir dan awal kemoterapi, ukuran tumor, riwayat gagal kemoterapi, lokasi dan jumlah metastasis) dengan resistensi MTX. Ditemukan perbedaan bermakna pada kadar Beta-HCG antara kelompok resistensi dan tidak resistensi pada siklus 4 (p<0,001), 6 (p<0,001), dan 8 (p<0,001). Perbedaan bermakna juga ditemukan pada perubahan kadar Beta-HCG dari awal hingga minggu kedua (p<0,001, AUC 0,8). Cut-off penurunan Beta-HCG sebesar 23% memiliki sensitivitas sebesar 78,9% dan spesifisitas sebesar 74,4% untuk memprediksi resistensi MTX.

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ABSTRACT

Background: Approximately 9-33% patients with gestational trophoblastic neoplasia (GTN) treated with single agent chemotherapy would need multi agent chemotherapy, whtether due to resistance to first-line therapy, including methotrexate (MTX), or toxic side effect. Currently, resistance to first-line therapy is still a problem due to low identification rate. To this date, there are no studies regarding Beta-HCG level as a MTX resistance predictor for low risk GTN.

Purpose: Identify the predictive value of Beta-HCG level for the risk of MTX resistance in low risk GTN.

Methods: This was an analytical cross-sectional study using medical records of 58 subjects. Subjects were all patients diagnosed with low risk GTN and given MTX therapy during the period of January 2011 to December 2016 at Cipto Mangunkusumo Hospital. Consecutive sampling was done. Subjects with incomplete data or history of previous GTN were excluded from this study.

Results: The prevalence of MTX resistance was 32,8%. No significant association was found between demographic characteristics (age, parity, job, and education) or clinical characteristics (gestational history, interval between last pregnancy and the start of chemotherapy, tumor size, history of chemotherapy failure, location and number of metastasis) and MTX resistance. A significant difference in the level of Beta-HCG between resistance and non-resistance groups were found on cycle 4 (p<0,001), 6 (p<0,001), and 8 (p<0,001). A significant difference was also found in the change of Beta-HCG from the start to the second week of therapy (p<0,001, AUC 0,8). Beta-HCG decrease cut-off of 23% had the sensitivity of 78,9% and specificity of 74,4% to predict MTX resistance.

Conclusions: The prevalence of MTX resistance was 32,8% in this study. The decrease in Beta-hCG level from the start to the second week of therapy could be used as a MTX resistance predictor in low risk GTN patients."

"Latar belakangPenyakit trofoblas gestasional (PTG) merupakan keganasan di bidang ginekologi yang sangat sensitif terhadap kemoterapi. Untuk PTG metastasis risiko tinggi, rejimen kemoterapi standar saat ini dari WHO meliputi kombinasi etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO). Kemoterapi EMA-CO telah terbukti memberikan respon terapi yang baik di beberapa negara di dunia, namun kemoterapi EMACO memerlukan biaya yang besar dan fasilitas yang memadai dalam menangani komplikasi efek samping yang mungkin terjadi. Di beberapa senter, termasuk RSUPNCM, dikembangkan kombinasi kemoterapi lain yakni methotrexate dan etoposide (ME) dan methotrexate, actinomycin, cyclophosphamide atau chlorambucil (MAC).TujuanMengevaluasi penggunaan kemoterapi ME dan MAC pada tatalaksana PTG metastasis risiko tinggi selama 10 tahun pada periode 2000-2010 di RSUPNCM.MetodePasien PTG metastasis risko tinggi menurut kriteria Hammond di Rumah Sakit Cipto Mangunkusumo periode Januari 2000 hingga Desember 2010 masuk sebagai subjek penelitian. Kelompok terbagi menjadi kelompok dengan terapi ME dan terapi MAC. Pencatatan angka remisi, resisten, efek samping berupa leukopeni, trombositopeni, dan keluhan gastrointestinal berupa mual dan muntah menjadi keluaran penelitian. Analisis statistik menggunakan uji Fisher.HasilTerdapat 70 pasien PTG dari tahun 2000-2010 yang masuk ke dalam kriteria inklusi tercatat pada rekam medis RSUPNCM, namun hanya 53 pasien yang menjalani kemoterapi, di mana 43 pasien mendapatkan kemoterapi ME dan 10 pasien mendapatkan kemoterapi MAC. Tidak ada perbedaan bermakna antara angka remisi penggunaan ME dan MAC ( 81.4% vs 90%, p = 1.0). Tidak ada perbedaan bermakna pula dalam kejadian leucopenia (7& vs 10%, p = 1.0), dan kejadian gastrointestinal seperti mual dan muntah (7% vs 10%, p = 1.0). Namun, terdapat perbedaan bermakna antara kejadian trombositopenia, di mana kejadian lebih tinggi pada penggunaan MAC (7% vs 20%, p =0.32).Kesimpulan: Tidak terdapat perbedaan bermakna angka remisi dan efek samping leukopeni dan keluhan mual, muntah pada penggunaan kemoterapi ME dibandingkan MAC pada tatalaksana PTG metastasis risiko tinggi, di mana kejadian trombositopeni lebih tinggi pada penggunaan MAC dibandingkan ME. Kadar beta hCG serum sebelum kemoterapi tidak memberikan perbedaan dalam respon terhadap kemoterapi. Namun, hasil penelitian ini harus dianalisa dengan hati-hati, mengingat jumlah sampel yang sedikit.

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Background

Gestational trophoblastic neoplasia (GTN) is a highly chemotherapy sensitive malignancy in gynecology. A combined chemotherapy currently recommended by WHO is the combination of etoposide, methotrexate, actinomycin D, cyclophosphamide, and vincristine (EMA-CO). This combined chemotherapy has been shown to give a good outcome in several cancer centres across the world. However, EMACO is costly and required adequate facilities to anticipate the side effects of the chemotherapy. Several oncology centres, including Cipto Mangunkusumo hospital have been trying other chemotherapy combinations, which are methotrexate and etoposide (ME) and methotrexate, actinomycin, cyclophosphamide atau chlorambucil (MAC).

Aim

To evaluate the outcome of ME and MAC in 10 years treatment of high risk GTN in Cipto Mangunkusumo hospital in a periode of 2000-2010.

Methods

Metastatic high risk GTN patients according to Hammond criteria in Cipto Mangunkusumo hospital from January 2000 to December 2010 are included in research subjects. The patients were divided into two groups, the patients who received ME and those who received MAC. The remission rate, side effects of leucopenia, thrombocytopenia, and gastrointestinal disorders, such as nausea and vomiting were recorded as the outcome of the treatment. The analytical statistic was using Fisher.

Result

From the periode of 2000-2010, there were 70 GTN patients in Cipto Mangunkusumo hospital who were included in the inclusion criterias, recorded in the medical records. There was only 53 patients who received chemotherapy, 43 patients received ME, and 10 patients received MAC. There was no difference on the remission rate between ME and MAC ( 81.4% vs 90%, p = 1.0). There was no difference in the incident of leucopenia (7& vs 10%, p = 1.0), and gastrointestinal complaints, such as nausea and vomiting (7% vs 10%, p = 1.0). However, patients treated with ME had lower incidence of thrombocytopenia in comparison to those treated with ME (7% vs 20%, p =0.32).

Conclusion: No difference in remission rate and side effects of leucopenia, nausea, and vomiting between ME and MAC group. However, the incidence of thrombocytopenia is higher in MAC group. Serum beta hCG level prior to therapy has not affecting the response towards chemotherapy."

"Penelitian longitudinal prospektif analitik untuk menilai ketepatan prediksi timbulnya penyakit trofoblas ganas melalui sistem penilaian prognosis mola hidatidosa yang dikembangkan oleh NETDC (New England Trophoblast Disease Center) telah dilakukan. Di antara parameter faktor risiko yang dinilai; usia penderita, jenis mola hidatidosa, pembesaran uterus, kadar hCG serum, kista lutein, serta ada-tidaknya komplikasi merupakan factor risiko yang bermakna untuk timbulnya keganasan setelah mola hidatidosa dievakuasi (p=0,032). Penelitian dilakukan pada 50 penderita mola hidatidosa dengan pengamatan lanjutan selama 1 tahun (Januari 2001-Desember 2002) di Bagian Obstetri dan Ginekologi RS Mohammad Hoesin, Palembang. Hasilnya menunjukan prediksi keganasan skor NETDC 50% pada risiko tinggi dan 10% risiko rendah untuk berkembang menjadi ganas (p<0,05). Hasil ini lebih besar dibandingkan dengan nilai yang diajukan WHO yaitu 19-30%. Risiko untuk terjadinya keganasan pasca mola hidatidosa pada kelompok risiko tinggi ialah 9,0 kali lebih tinggi disbanding pada kelompok risiko rendah (CI: 1,769-45,786). (Med J Indones 2004; 13: 40-6)

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A prospective longitudinal analytic study assessing the efficacy of NETDC (New England Trophoblastic Disease Center) prognostic index score in predicting malignancy after hydatidiform mole had been performed. Of the parameter evaluated; age of patients, type of hydatidiform mole, uterine enlargement, serum hCG level, lutein cyst, and presence of complicating factors were significant risk factors for malignancy after hydatidiform mole were evacuated (p<0.032). The study were done on 50 women diagnosed with hydatidiform mole with 1 year observation (January 2001-December 2002) at the Department of Obstetrics and Gynecology, Mohammad Hoesin Hospital, Palembang. The results showed that the NETDC prognostic index score predicted malignancy in 50% of high risk group and 10% in low risk group (p<0.05). This showed a higher number than that found by the WHO (19%-30%). The risk for incidence of malignancy after hydatidiform mole in the high risk group is 9.0 times higher compared to that of the low risk group (CI: 1.769-45.786). (Med J Indones 2004; 13: 40-6)"

"In this volume Dr Hui has brought together a comprehensive overview of gestational trophoblastic disease that includes all the currently recognized entities: complete and partial hydatidiform moles, placental site trophoblastic tumor, epithelioid trophoblastic tumor, gestational choriocarcinoma, persistent gestational trophoblastic neoplasia, placental site nodule and exaggerated placental site reaction. Each entity is reviewed in detail, with emphasis on genetic background, clinical presentation, pathologic findings and ancillary studies, differential diagnosis and clinicopathological correlations.Descriptions of the pathology are supported by numerous excellent photomicrographs. Recent advances in our understanding of the genetics of gestational trophoblastic diseases are stressed. Introductory chapters cover the developmental biology of the placenta and the genetic basis of gestational trophoblastic disease, and one chapter is devoted to the molecular diagnosis of gestational trophoblastic disease. This chapter includes a review of the use of short tandem repeat (STR) genotyping which is of particular value in the diagnosis of hydatidiform moles. The final chapter covers clinical aspects of gestational trophoblastic disease, including treatment. The text throughout is current and thoroughly referenced. "

"Perawat sebagai bagian dari tenaga kesehatan memiliki peran untuk memberikan asuhan keperawatan yang komprehensif untuk memantau dan memonitor kondisi ibu. Salah satu peran perawat maternitas adalah memberikan asuhan keperawatan pada pasien dengan penyakit trofoblas dengan menerapkan teori keperawatan. Dari lima kasus kelolaan, dua kasus berumur 40 tahun. Semua kasus mengalami peradarahan. Dua kasus mengalami penyakit trofoblas ganas low risk. Dua kasus dikuretase, satu kasus histerektomi dan dua kasus kemoterapi. Semua kasus mengalami anemia baik anemia ringan sampai berat. Pasien mengalami masalah kekurangan volume cairan, kecemasan, defisit perawatan diri dan kesiapan peningkatan pengetahuan. Teori ini sesuai diterapkan pada pasien dengan penyakit trofoblas untuk memperoleh rasa nyaman selama proses tindakan dan dapat melewati proses kuretase dan kemoterapi dengan risiko minimal. Penanganan sedini mungkin akan meningkatkan peluang hidup ibu cukup besar dan peluang memiliki anak kembali cukup besar.

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Nurse as a part from health worker has role for giving comprhensive nursing care to see and observe the mother condition. One of the maternity nurse role is to give a nursing care to the patient with mola hidatidosa and applied the nursing concept. Five case management, the age of two cases are under 20 years old, one case is 27 years old, and two cases over the 40 years old. All of the cases have the bleeding. Two cases is low risk trofoblast gestational disease. Curettage is done for the two cases, hysterectomy is done for one case, and chemotherapy is done for the two cases. All of the cases get anemia, start from high until low anemia. Patients experience problems of fluid volume deficit, anxiety, self care deficit, and readness to increase knowledge. Both theory are able to be applied for the patient with Mola Hidatidosa to get the comfort feeling along the surgical prosess and can pass the curettage and chemotherapy process with the minimal risk. By early managing will increase the probability of the life and have the next child again."

"ABSTRAKDiet Rendah Gula dan Tinggi Serat sebagai Intervensi Menurunkan glukosa Darah pada   Keluarga dengan Masalah Ketidakstabilan Kadar Glukosa Darah Peningkatan jumlah penduduk dewasa di perkotaan sebagai populasi berisiko berdampak pada munculnya berbagai penyakit, diantaranya Diabetes Mellitus. Diet tidak seimbang dapat menjadi faktor risiko terjadinya Diabetes Mellitus. Tujuan karya ilmiah ini adalah untuk menggambarkan keefektifan intervensi keperawatan diet rendah dan gula tinggi serat dengan pendekatan keluarga selama lima minggu dalam menurunkan kadar glukosa darah. Hasil asuhan keperawatan diperoleh penurunan kadar glukosa darah pada Ibu R dari 258 mg/dL menjadi 146 mg/dL.Kesimpulan hasil karya ilmiah ini adalah intervensi diet rendah gula dan tinggi serat dengan pendekatan keluarga efektif dalam menurunkan kadar glukosa darah. Hasil penelitian merekomendasikan diterapkannya intervensi diet rendah gula dan tinggi serat dengan melibatkan keluarga oleh perawat komunitas pada keluarga dengan masalah risiko ketidastabilan kadar glukosa darah.

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ABSTRACT

Glucose Level in Family with Risk for Unstable Blood Glucose Level. The increase of adult population in urban areas as at-risk population have an impact on the emergence of various diseases, including Diabetes Mellitus. An unbalanced diet can be a risk-factor for Diabetes Mellitus. The purpose of this scientific paper is to describe the effectiveness of low sugar and high fiber diet intervention with family approach for five weeks in reducing blood glucose levels. The result obtained from nursing care show a decrease in blood glucose levels in Mrs. R from 258 mg/dL to 146 mg/dL. The conclusion is a low sugar and high fiber diet intervention with family approach was effective in reducing blood glucose levels. This results recommends the implementation of low sugar and high fiber diet intervention with family involvement by community nurses in families with a risk for unstable blood glucose levels. Diabetes Mellitus, diet, blood glucose."

"FAKTOR RISIKO PENYAKIT KARDIOVASKULER TERHADAP PERUBAHAN TINGKAT KEBUGARAN KARDIORESPIRASI PADA PROGRAM GERMAS Fida Dewi Ambarsari1, Ambar W. Roestam2, Imran Agus Nurali3 1 Magister Kedokteran Kerja, Fakultas Kedokteran Universitas Indonesia, Jakarta2 Departemen Kedokteran Komunitas, Fakultas Kedokteran Universitas Indonesia, Jakarta3Direktorat Kesehatan Lingkungan, Kementerian Kesehatan RI, Jakarta Email : fidadewi@gmail.com Abstrak Latar belakang: Tingkat kebugaran kardiorespirasi yang rendah berhubungan dengan faktor risiko kardiovaskuler seperti obesitas, hiperkolesterolemia, DM tipe 2 dan hipertensi. Secara umum pekerja perkantoran memiliki beban kerja ringan dengan aktifitas fisik kurang aktif atau sedenter sebagai faktor meningkatnya risiko penyakit kardiovaskuler. Tujuan penelitian untuk melihat hubungan perubahan faktor risiko penyakit kardiovaskuler terhadap perubahan kebugaran kardiorespirasi pada pelaksanaan program Germas selama 12-15 minggu. Metode: Desain potong lintang pendekatan komparatif dua kali pengukuran dengan interval 12-15 minggu pada tahun 2017-2018. Subyek ASN pemerintah pusat n= 102 , faktor risiko penyakit kardiovskuler yang diukur: IMT, tekanan darah, kolesterol, gula darah dan aktifitas fisik. Kebugaran kardiorespirasi dengan metode rockport. Hasil: Implementasi Germas dalam interval 12-15 minggu, rerata VO2 maks meningkat 0.75 2.65 ml/kg/menit dan prevalensi pekerja yang bugar meningkat 6.9 menjadi 86.3 . Umur 40 ndash;59 tahun 3,44 kali berisiko tidak meningkat kebugaran kardiorespirasinya dibandingkan usia 20 ndash; 39 tahun p 0.04, IK 95 1.00 ndash; 11.84 , lama kerja memiliki hubungan bermakna terhadap peningkatan kebugaran p 0.05 . Indeks massa tubuh memiliki korelasi bermakna terhadap perubahan VO2 maks p=0.02, r -0.21 . Regresi linear diperoleh umur dan indeks massa tubuh sebagai faktor prediksi VO2 maks. Kesimpulan: Observasi selama 12-15 minggu implementasi Program Germas belum efektif meningkatkan kebugaran kardiorespirasi. Diperlukan kesadaran diri, edukasi dan pemantauan individu serta waktu observasi yang lebih lama untuk menilai efektifitas.

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Cardiovascular Disease Risk Factors to Cardiorespiratory Fitness Changes in Community Healthy Movement Programme GERMAS Abstract Background Low cardiorespiratory fitness CRF level associated to cardiovascular CVD risk factors such as obesity, hypercholesterolemia, diabetes mellitus type 2 and hypertension. Generally, office workers have light physical effort to work and tend to be a sedentary physical activity behavior that is also risk factors of cardiovascular disease. This study aims to identify correlation of CVD risk factors changes CRF level in 12 15 weeks among community healthy movement programme GERMAS . Methods Comparative cross sectional study of double examination on year 2017 2018, baseline and second data have 12 15 weeks intervals. Subject are government office workers n 102 , CVD risk factors determined BMI, blood pressure, cholesterol level, blood glucose and physical activity. CRF examined by Rockport methods. Results average of VO2 max was increased 0.75 2.65 ml kg minute and CRF level prevalence was increased 6.9 after 12 ndash 15 weeks. Age 40 59 years has 3.44 times to not improved on increasing CRF than age 20 39 years p 0.04, CI95 1.00 11.84 , Duration of work has significant association to CRF changes p 0.05 . BMI have significant correlation to VO2 max p 0.02, r 0.21 . Linear regression shown age and body mass index as a predictors for VO2 max. Conclusion Based on 12 15 weeks observation, community healthy movement programme GERMAS implementation was not optimal to increased cardiorespiratory fitness. It is need self awareness, individual education and monitoring also has to be a longer observation. "

"ABSTRAKSkizofrenia merupakan penyakit neurobiologis berat dan terus menerus yang mengakibatkan terganggunya respon seseorang dan berdampak pada kehidupan individu, keluarga dan masyarakat. Tanda gejala yang muncul diantaranya berupa harga diri rendah HDR dan risiko perilaku kekerasan RPK . Hasil penanganan kasus ini bertujuan untuk menganalisis perbandingan perubahan tanda gejala dan kemampuan pasien HDR dan RPK antar yang diberikan tindakan keperawatan terapi kognitif perilaku dengan yang diberikan latihan asertif menggunakan teori Stuart dan adaptasi Roy. Penanganan kasus ini menggunakan pendekatan multiple case study, yaitu kasus HDR dan RPK dengan jumlah partisipan 16 orang, Hasil penanganan kasus menunjukan bahwa pasien dengan jenis kelamin laki-laki yang berusia rata-rata 34.4 tahun, terjadi penurunan tanda gejala HDR dan RPK terutama pada aspek perilaku, kognitif dan afektif setelah diberikan tindakan keperawatan ners dan ners spesialis berupa terapi kognitif perilaku dan latihan asertif. Rekomendasi dari penanganan kasus ini adalah latihan asertif bisa diprioritaskan karena menurunkan tanda gejala lebih banyak pada diagnosis HDR dan RPK

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ABSTRACTSchizophrenia is a severe and continuous neurobiological disease that results in disruption of one 39 s response and impacts on the lives of individuals, families and communities. Symptoms that appear include low self esteem HDR and the risk of violent behavior RPK . The results of this case handling aims to analyze the comparison of symptom change and ability of HDR and RPK patients among those given behavioral cognitive therapy nursing behaviors with those given assertive exercise using Stuart 39 s theory and Roy 39 s adaptation. The handling of this case using a multiple case study approach, namely cases of HDR and RPK with the number of participants 16 people, The results of case handling showed that patients with male gender aged average 34.4 years, decreased signs of HDR and RPK symptoms, especially on aspects behavioral, cognitive and affective after being given nursing actions ners and specialist ners in the form of cognitive behaviour therapy and assertiveness tarining. The recommendation of this case is that assertiveness training can be prioritized because it decreases more symptoms symptoms in HDR and RPK diagnoses."

"ABSTRAKSkizofrenia merupakan penyakit neurobiologis berat dan terus menerus yang mengakibatkan terganggunya kehidupan individu. Tanda gejala yang terjadi klien berupa berupa gejala positif dan gejala negatif dengan diagnosis keperawatan harga diri rendah kronik dan risiko perilaku kekerasan. Tujuan karya ilmiah akhir spesialis ini adalah untuk mengetahui perubahan tanda gejala dan kemampuan klien harga diri rendah kronik dan risiko perilaku kekerasan setelah mendapatkan tindakan keperawatan ners generalis dan ners spesialis : terapi kognitif perilaku dan latihan asertif. Asuhan medik adalah pemberian antipsikotik dan asuhan keperawatan adalah tindakan ners dan ners spesialis. Metode karya ilmiah akhir yang digunakan adalah riset operational dengan jumlah sampel 30 klien. Hasil penelitian ini didapatkan bahwa tanda dan gejala harga diri rendah kronik dan risiko perilaku kekerasan menurun secara bermakna (p-value ≤ 0.05) dan kemampuan klien meningkat secara bermakna (p-value ≤ 0.05) setelah pemberian tindakan keperawatan ners generalis dan ners spesialis terapi kognitif perilaku dan latihan asertif. Pemberian kombinasi tindakan ners, ners spesialis terapi kognitif perilaku dan latihan asertif sangat direkomendasikan untuk penatalaksanaan diagnosis keperawatan harga diri rendah kronik dan risiko perilaku kekerasan.

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ABSTRACTSchizophrenia is a severe and continuous neurobiological disease that results in disruption of individual life. Signs and symptoms that occur on clients are in the form of positive symptoms and negative symptoms with a nursing diagnosis chronic low self-esteem and the risk of violent behavior. The purpose of this specialist s final scientific work is to determine changes in signs and symptoms and the client's ability who have chronic low self-esteem and the risk of violent behavior after obtaining nursing actions by generalist nurses and specialist nurses : cognitive behaviour therapy and assertiveness training. Medical care is the provision of antipsychotics and nursing care is the action of nurses and specialist nurses. The final scientific method used is operational research with a sample of 30 clients. The results of this study showed that the signs and symptoms of chronic low self-esteem and the risk of violent behavior decreased significantly (p-value ≤ 0.05) and the ability of clients increased significantly (p-value ≤ 0.05) after giving generalist nursing actions and specialist nursing actions cognitive behaviour therapy and assertiveness training. Giving a combination of actions by nurses, specialist nurses cognitive behaviour therapy and assertiveness training is highly recommended for the management of nursing diagnoses of chronic low self-esteem and the risk of violent behavior."

"Tuberkulosis dan diabetes melitus telah menjadi double bourden of disease, sehingga diperlukan prediktor sebagai dasar deteksi dini tuberkulosis pada pasien diabetes. Tujuan penelitian ini untuk mengetahui apakah faktor risiko penyakit imunodefisiensi, penggunaan steroid jangka panjang dan riwayat vaksinasi BCG dapat digunakan sebagai prediktor DM-TB. Penelitian ini merupakan survey cross-sectional yang dilakukan di enam Puskesmas dan Diabetes Centre di Ternate. Sebanyak 92 pasien DM diskrining untuk pemeriksaan TB dan 31 pasien didiagnosis DM-TB. Dalam uji statistik, risiko penyakit imunodefisiensi dan vaksinasi BCG tidak signifikan berhubungan dengan kejadian DM-TB (p=0,981 dan p=0,524). Penggunaan steroid jangka panjang memberikan hasil yang signifikan(p=0,01).

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Tuberculosis (TB) and diabetes melitus (DM) have become the double burden of diseases. Therefore, there is a need for predictor for early detection of tuberculosis in diabetic patients. The purpose of this study was to determine whether immunodeficiency disease risk factors, long-term steroid use and BCG vaccination can be used as a predictor in combination of DM-TB. This cross-sectional study was conducted in six public health centers and Diabetes Center in Ternate. Ninety two diabetic patients were screened for TB examination and 31 patients diagnosed with DM-TB. The risk of immunodeficiency diseases and BCG vaccination was not significantly associated with the incidence of DM-TB (p=0.981 and p=0.524). However, long-term use of steroids was significantly related (p=0.01)."