BAB II TINJAUAN PUSTAKA
5.2 Saran
a. Masih diperlukan penelitian lebih lanjut dengan skala yang lebih besar sehingga nilai Fib-4 Index dapat lebih divalidasi.
b. Fib-4 Index sebagai penanda (marker) dalam penentuan ukuran kecil varises esofagus pada pasien sirosis hati memiliki akurasi yang tinggi. Namun, perlu pula penelitian lanjutan pada pasien sirosis hati tanpa varises esofagus untuk mendapatkan nilai cut-offFib-4 Index yang dapat memprediksi varises esofagus besar.
c. Perlu dilakukan penelitian lanjutan Fib-4 Index yang dikombinasikan dengan metode non – invasif prediktor fibrosis hati lainnya yang diharapkan dapat disusun suatu algoritma diagnostik dalam memprediksi ada tidaknya varises esofagus beserta ukurannya pada pasien sirosis hati. d. Disarankan untuk dilakukan penelitian lebih lanjut yang menilai Fib-4
Index terhadap besar varises esofagus pada pasien sirosis hati yang mengalami perdarahan saluran cerna
40
DAFTAR KEPUSTAKAAN
1. Eyal Ashkenazi MD , Yulia Kovalev MD and Eli Zuckerman MD.
Evaluation and Treatment of Esophageal Varices in the Cirrhotic Patient IMAJ 2013; 15 : 109-115.
2. Jensen DM. Endoscopic screening for varices in cirrhosis: findings, implications, and outcomes. Gastroenterology 2002; 122:1620-1630
3. D’Amico G, Criscuoli V, Fili D, Mocciaro F, Pagliaro L. Metaanalysis of trials for variceal bleeding. Hepatology 2002; 36:1023-1024
4. Carbonell N, Pauwels A, Serfaty L, Fourdan O, Lévy VG, Poupon R. Improved survival after variceal bleeding in patients with cirrhosis over the past two decades. Hepatology 2004; 40:652–659
5. Chalasani, N., C. Kahi. 2003. Improved patient survival after acute variceal bleeding : a multicenter, cohort study. Am J Gastroenterol 98(3):653–659 6. Stokkeland K, Brandt L, Ekbom A, Hultcrantz R. Improved prognosis for
patients hospitalized with esophageal varices in Sweden 1969–2002. Hepatology 2006; 43:500-505
7. de Franchis R. Evolving consensus in portal hypertension. Report of the Baveno IV consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2005; 43:167-176
8. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W and the Practice Guidelines Committee of the American Association for the Study of Liver Diseases, the Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46:922-938
9. de Franchis R. Revising consensus in portal hypertension: report of the Baveno V consensus workshop on methodology of diagnosis and therapy in portal hypertension. J Hepatol 2010; 53:762-768
41
10. de Franchis R. Non-invasive (and minimally invasive) diagnosis of oesophageal varices. J Hepatol 2008; 49:520-527
11. Castera L, Le Bail B, Roudot-Thoraval F, et al. Early detection in routine clinical practice of cirrhosis and oesophageal varices in chronic hepatitis C: Comparison of transient elastography (FibroScan) with standard laboratory tests and non-invasive scores. J Hepatol 2009; 50:59-68
12. Sebastiani G, Tempesta D, Fattovich G, et al. Prediction of oesophageal varices in hepatic cirrhosis by simple serum noninvasive markers: Results of a multicenter, large-scale study. J Hepatol 2010; 53:630-638
13. Cheney CP, Goldberg EM, Chopra S. Cirrhosis and portal hypertension : an overview. In : Friedman LS and Keeffe EB, eds.Handbook of Liver Disease. 2nd ed. China, Pa : Churchill Livingstone; 2004: 125-138
14. Wolf DC. Cirrhosis of the Liver. eMedicine Specialities. 29 Nov 2012.
15. Suk TK. Revision and update on clinical practice guideline for liver cirrhosis. The Korean Journal of Hepatology 2012; 18:1-21
16. Bissell D, Maher JJ. Hepatic Fibrosis and Cirrhosis. In : Zakim D and Boyer TD, eds. Hepatolog. A Textbook of Liver Disease, vol 1, 3rd ed, Tokyo, 1996: 506
17. World Health Organization. Hepatitis C - global prevalence (update). Weekly Epidemiological Record, 1999, 74:425-427
18. Hernomo K. Pengelolaan perdarahan masif varises esofagus pada sirosis hati. Thesis. Airlangga University Press, Surabaya. 1983
19. Benvegnu L, Gios M, Bocato S et.al. Natural history of compensated viral cirrhosis a prospective study on the incidence and hierarchy of major complications. Gut 2004; 53:744-749
20. Garcia-Tsao D, Wongcharatrawee S. (VA Hepatitis C Resource Center Program). Treatment of patients with cirrhosis and portal hypertension literature review and summary of recommended interventions. Version 1 (October 2003)
42
21. Friedman SL: Hepatic Fibrosis. In : Schiff ER, Sorrell MF, Maddrey WC, eds. Schiff’s Diseases of the Liver. 9th ed. Philadelphia, Pa: Lippincott-Raven; 2003:409-28
22. Kuntz, Erwin., Kuntz, Han-Dieter. 2008. Hepatology : Textbook And Atlas. Germany : springer medizin verlag heilderberg
23. Lee D. Cirrhosis of the Liver. MedicineNet.com, Jan 2005.
24. Erlingen S, Benhamou JP. Cirrhosis : clinical aspect. In : Oxford Textbook of Clinical Hepatology, Vol 1, 2nd ed.Hong Kong, Pa: Oxford Medical Publications; 1999:629-44
25. Sharara AI, Rockey DC. Gastroesophageal Variceal Hemoorhage.
26. Sanyal A, Bosch J, Blei A, Arroyo V, 2008 Portal Hypertension and its complication. GASTROENTEROLOGY ;134:1715–1728.
N Engl J Med 2001; 345:669-681
27. R. de Franchis, “Stellate cells and the “reversible component” of portal hypertension,” Digestive and Liver Disease, vol. 32, no. 2, pp. 104–107, 2000.
28. Y. Iwakiri and R. J. Groszmann, “Vascular endothelial dysfunction in cirrhosis,” Journal of Hepatology, vol. 46, no. 5, pp. 927–934, 2007.
29. D. C. Rockey, “Hepatic blood flow regulation by stellate cells in normal and injured liver,” Seminars in Liver Disease, vol. 21, no. 3, pp. 337–349, 2001 30. Wheatley AM , Zhang X - Y 1998 . Intrahepatic modulation of portal
pressure and its role in portal hypertension .Digestion ;59 : 424 – 428 .
31. M. Fernandez, M. Mejias, E. Garcia-Pras, R. Mendez, J. C. Garcia-Pagan, and J. Bosch, “Reversal of portal hypertension and hyperdynamic splanchnic circulation by combined vascular endothelial growth factor and platelet-derived growth factor blockade in rats,” Hepatology, vol. 46, no. 4, pp. 1208– 1217, 2007
32. Bari K, Garcia-Tsao G. Treatment of portal hypertension. World J Gastroenterol 2012 March 21; 18(11): 1166-1175
43
33. Berzigotti A, Seijo S, Reverter E, Bosch J. 2013 Assessing Portal Hypertension in liver diseases. Expert Rev. Gastroenterol. Hepatol. 7(2), 141–155
34. Groszmann RJ, Garcia-Tsao G, Bosch J, Grace ND, Burroughs AK, Planas R, Escorsell A, Garcia-Pagan JC, Patch D, Matloff DS, Gao H, Makuch R. B-blockers to prevent gastroesophageal varices in patients with cirrhosis. N Engl J Med 2005; 353: 2254-2261
35. Ripoll C, Groszmann R, Garcia-Tsao G, Grace N, Burroughs A, Planas R, Escorsell A, Garcia-Pagan JC, Makuch R, Patch D, Matloff DS, Bosch J. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology 2007; 133: 481-488
36. D’Amico G, Garcia-Pagan JC, Luca A, Bosch J. HVPG reduction and prevention of variceal bleeding in cirrhosis. A systematic review. Gastroenterology 2006;131:1624
37. D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis. A systematic review of 118 studies. J Hepatol 2006;44:217-231
38. Laleman W, Van Landeghem L, Wilmer A, Fevery J, Nevens F. 2005. Portal hypertension: from pathophysiology to clinical practice. Liver International : 25: 1079–1090.
39. Merkel C, Marin R, Angeli P, et al. A placebo-controlled clinical trial of nadolol in the prophylaxis of growth of small esophageal varices in cirrhosis. Gastroenterology 2004;127:476–484
40. Merli M, Nicolini G, Angeloni S, et al. Incidence and natural history of small esophageal varices in cirrhotic patients. J Hepatol 2003;38:266–272
41. Bosch J et al. Portal Hypertension and Gastrointestinal Bleeding .Seminars in liver disease/volume 28, number 1, 2008
42. de Franchis R. Evaluation and follow-up of patients with cirrhosis and oesophageal varices. J Hepatol 2003;38:361–363
43. Dite P et al. Esophageal varices. World Gastroenterology Organisation practice guideline: June 2008
44
44. D’Amico G, de Franchis R. Upper digestive bleeding in cirrhosis: post-therapeutic outcome and prognostic indicators. Hepatology 2003;38:599–612
45. Idezuki Y: General rules for recording endoscopic findings of esophagogastric varices. (1991). Japanese Society for Portal Hypertension. World J Surg 19:420-422, 1995
46. Sebastiani, G., D. Tempesta, G. Fattovich, L. Castera, P. Halfon. 2010. Prediction of oesophageal varices in hepatic cirrhosis by simple serum noninvasive markers: Results of a multicenter, large-scale study. J Hepatol 53(4):630-638
47. Stefanescu, H., M. Grigorescu, M. Lupsor, A. Maniu, A. Crisan, B. Procopet, D. Feier, R. Badea. 2011. A New and Simple Algorithm for the Noninvasive Assessment of Esophageal Varices in Cirrhotic Patients Using Serum Fibrosis
Markers and Transient Elastography
48. Torriani FJ, Rodriguez-Torres M, Rockstroh JK, et al. Peginterferon Alfa-2a plus ribavirin for chronic hepatitis C virus infection in HIV-infected patients. N Engl J Med 2004; 351:438-50
49. Mallet V, Vernier VD, Roussins C et al (2009). The accuracy of the FIB-4 index for the diagnosis of mild fibrosis in chronic hepatitis B. Alimentary Pharmacology & Therapeutics;29:409-15
50. Hui AY, Chan HLY, Wong VWS, et al (2005). Identification of chronic hepatitis B patients without significant liver fibrosis by a simple noninvasive predictive models. Am J Gastroenterol; 616-23
51. Emam, E, Ramadan A, Badway M, Atia H, Warda MHA, Gawish HH. Prediction of oesophageal varices in patients with compensated cirrhosis:A novel scoring system.Arab J Gastroenterol.2009;10:129-34.
52. Cherian JV, Deepak N, Ponnusamy PR, Somasundaram A, Jayanthi V. Non-invasive Predictors of Esophageal Varices. Saudi J Gastroenterol.2011;17(1):64-8.
53. Poynard, T., P. Bedossa, P. Opolon. 1997. For the OBSVIRC, METAVIR, CLINIVIR, and DOSVIRC groups. Natural history of liver fibrosis progression in patients with chronic hepatitis C. Lancet 349:825-32
45
54. Costa, L.B., M.L.G. Ferraz, R.M. Perez, A.S. Ferreira, C.A.L. Matos. 2002. Effect of host-related factors on the intensity of liver fibrosis in patients with chronic hepatitis C virus infection. Braz J Infect Dis 6(5):219-224
55. Kujovich, J.L. 2005. Hemostatic defects in end stage liver disease. Crit Care Clin 21:563-587 Lee, D. 2005. Cirrhosis of the Liver.
56. Caldwell, S.H., M. Hoffman, T. Lisman, B.G. Macik. 2006. Coagulation disorders and hemostasis in liver disease : Pathophysiology and critical assessment of current management. Hepatology 44(4):1039-46
57. Tafarel R J, et al. Prediction of esophageal varices in hepatic cirrhosis by noninvasive markers. Eur J Gastroenterol Hepatol.2011;23:754-58.
58. Sarwar, S., A.A. Khan, A.K. Butt, F. Shafqat, K. Malik, I. Ahmad. 2005. Non-endoscopic prediction of esophageal varices in cirrhosis. J Coll Physicians Surg Pak 15
59. Schepis, F., C. Camma, D. Niceforo. 2001. Which patients with cirrhosis should undergo endoscopic screening for esophageal varices detection?
:528–31
Hepatology33
60. Khuram, M., N.Y. Khan, M. Arif, M.M. Irshad, K. Hammatul Bushra, Z. Hassan. 2006. Association of platelet count to splenic index ratio with presence of esophageal varices in patients with hepatitis C virus related compensated cirrhosis.
:333–8
Pak J Gastrenterol 20
61. Okuda, M., K. Li, M.R. Beard. 2002. Mitochondrial injury, oxidative stress, and antioxidant are induced by hepatitis C virus core protein. Gastroenterology 122:366-75
:37–42
62. Budiyasa, D.G.A., A. Yuna, I.K. Mariadi., I.D.N. Wibawa, N. Purwadi, I.G.A. Suryadarma. 2011. Correlation between Serum Albumin Level and Degree of Esophageal Varices in Patients with Liver Cirrhosis. The Indonesian Journal of Gastroenterology, Hepatology, and Digestive Endoscopy 12(1);23-27
63.Khan, H., N. Iman. 2009. Hypoalbuminemia: a marker of esophageal varices in chronic liver disease due to hepatitis B and C. Rawal Med J 34:98-101
46
47
Lampiran 2
LEMBAR PENJELASAN KEPADA CALON SUBJEK PENELITIAN
Assalamualaikum w.w
Selamat Pagi dan Salam Sejahtera Bapak / Ibu / Saudara / i sekalian
Terima kasih atas kesediaan Bapak / Ibu, Saudara / i meluangkan waktu untuk membaca dan mengisi surat persetujuan ini. Sebelumnya perkenankan saya memperkenalkan diri, nama saya dr.Leo Widia Saputra. peserta Program Pendidikan Dokter Spesialis Ilmu Penyakit Dalam di Fakultas Kedokteran Universitas Sumatera Utara (FK – USU). Saya sedang melakukan pengumpulan data penelitian tugas akhir sebagai salah satu syarat menyelesaikan pendidikan di FK – USU. Adapun judul penelitian saya adalah “Hubungan Ukuran Besar Varises Esofagus secara Endoskopi dengan Fib-4 Index pada penderita Sirosis Hati”.
Penelitian ini bertujuan untuk mengetahui hubungan antara ukuran varises esofagus (pelebaran pembuluh darah kerongkongan) secara endoskopi dibandingkan dengan “Fib-4 Index” pada penderita sirosis hati (gagal hati) sehingga “Fib-4 Index” dapat menjadi alat alternatif non – invasif dalam mendeteksi ada tidaknya serta ukuran varises esofagus dan pertimbangan terapinya terutama pada daerah geografis yang fasilitas endoskopinya belum memadai.
Pada Bapak/Ibu yang bersedia mengikuti penelitian ini nantinya akan dilakukan pemeriksaan laboratorium awal berupa pemeriksaan darah sebanyak 10 cc yang akan diambil dari lengan oleh ahlinya untuk menilai parameter darah lengkap, fungsi hati, fungsi faktor pembekuan darah, dan deteksi virus hepatitis penyebab gagal hati. Kemudian akan dilakukan pemeriksaan USG dan selanjutnya tindakan endoskopi. Tindakan pemeriksaan ini tidak berbahaya dan tidak menimbulkan rasa sakit. Akhirnya dari pemeriksaan itu semua akan dianalisis hubungan antara “Fib-4 Index” menggunakan rumus perhitungan antara beberapa parameter hasil pemeriksaan darah dibandingkan dengan gambaran endoskopi sebagai standar baku deteksi varises esofagus.
Keikutsertaan Bapak / Ibu / Saudara / i adalah sukarela.Segala biaya pemeriksaan sepenuhnya tanggung jawab peneliti. Bila keterangan yang saya berikan masih belum jelas, maka Bapak/Ibu dapat menghubungi saya pada: Nama : dr. Leo Widia Saputra
Alamat : Jl. Majapahit No.69 Medan
Telepon : 085270185851
Peneliti,
48
Lampiran 3
LEMBAR PERSETUJUAN SETELAH PENJELASAN (INFORMED CONSENT)
---
Saya yang bertanda tangan dibawah ini :
Nama :...
Umur :... Tahun
Jenis Kelamin : Laki-laki/ Perempuan.
Alamat :...
No Telp/HP : ...
Setelah mendapat penjelasan dari peneliti tentang kebaikan dan keburukan prosedur penelitian ini , dengan penuh kesadaran dan tanpa paksaan menyatakan bersedia
Demikianlah surat persetujuan bersedia ikut dalam penelitian ini saya buat, untuk dapat digunakan seperlunya.
ikut serta dalam penelitian tentang “Hubungan Ukuran Varises Esofagus secara Endoskopi dengan Fib-4 Index pada penderita Sirosis Hati”.
Medan, ...2013
Saksi Yang Memberi Pernyataan
49
Lampiran 4
KERTAS KERJA PROFIL PESERTA PENELITIAN
Tanggal : ……… MR : ……… I. Nama :……….. Anamnese Pribadi Umur : ……….. Jenis Kelamin : ...……….. Alamat : ..……… No telp :..……… II. Asites : (-)/min./sedang/berat Pemeriksaan Klinis
Hepatik Ensefalopati : (-)/grd.I/grd.II/grd.III/grd.IV
III. a. Laboratorium Pemeriksaan Penunjang -Trombosit : ………..………….. - AST - ALT : ……… - Viral marker : .……….. - Albumin : ... - Bil.total : ... - PT : ... - INR : ... b. Endoskopi :ø VE F1 / F2 / F3 c. Fib-4 Index : ……….... IV.
Child – Pugh score/grade : .../... Lain – lain
50
Lampiran 5
LEMBAR KUESIONER KEPATUHAN PENGOBATAN MORISKY-8
No Pertanyaan Ya/
Tidak
Nilai (Ya=0, Tidak=1)
1 Apakah anda terkadang lupa mengkonsumsi obat ?
2
Pasien terkadang tidak mengkonsumsi obat selain alasan lupa. Dalam 2 minggu terakhir, apakah ada hari dimana anda tidak mengkonsumsi obat ?
3
Pernahkah anda mengurangi atau menghentikan obat tanpa sepengetahuan dokter karena anda merasa tidak nyaman saat mengkonsumsinya ?
4 Saat anda bepergian atau keluar rumah, apakah anda kadang lupa mengkonsumsi obat ?
5 Apakah anda mengkonsumsi obat anda semalam ?*
6 Saat anda merasa gejala anda sudah berkurang, apakah anda berhenti mengkonsumsi obat ?
7
Mengkonsumsi obat setiap hari merupakan ketidaknyamanan bagi beberapa orang. Apakah anda merasa jenuh dengan pengobatan anda ?
8
Seberapa sering anda kesulitan untuk mengingat mengkonsumsi obat anda ?
A. Tidak pernah/ Jarang
B. Sekali-sekali C. Kadang-kadang D. Sering E. Setiap saat A= 1; B-E= 0 TOTAL NILAI
51
Lampiran 6
DAFTAR RIWAYAT HIDUP
I. Identitas Pribadi
Nama : dr. Leo Widia Saputra
Tempat/Tgl Lahir : Medan / 28 Juli 1978 Suku/Bangsa : Sumatera Barat / Indonesia
Agama : Islam
Alamat : Jl. Majapahit No 69, Medan
II. Pendidikan
SDKemala Bhayangkari Medan Tamat Tahun 1988
SLTPHarapan 1 Medan Tamat Tahun 1994
SMAPembangunan IKIPPadang Tamat Tahun 1997
FK Universitas Islam Sumatera Utara Tamat Tahun 2009
III. Riwayat Pekerjaan
Dokter jaga Klinik Spesialis Zain Medan 2008 sampai sekarang Dokter jaga RSU Permata Bunda Medan 2009
Dokter Konsultan Daerah RSU dr.F.L. Tobing Sibolga, Oktober 2011 – Januari 2012
IV. Perkumpulan Profesi IDI Medan
PDUI Medan
PAPDI Sumatera Utara
V. Journal Reading
1. Miyatake N, Shikata K, Makino H, Numata T. Decreasing abdominal circumference is associated with improving estimated glomerular filtration rate (eGFR) with lifestyle modification in Japanese men: A pilot study. Acta Med Okayama 2011;65(6):363-367.
2. Naini AE, Moradi M, Mortazavi M, Harandi AA, Hadizadeh M, Shirani F, et al. Effects of oral L-carnitine supplementation on lipid profile, anemia, and quality of life in chronic renal disease patients under hemodialysis: A randomized, double-blinded, placebo-controlled trial. Journal of Nutrition and Metabolism 2012. doi:10.1155/2012/510843.
3. Coles AH, Fisher KA, Darling C, McManus D, Maitas O, Yarzebski J, et al. Recent trends in post-discharge mortality among patients with an initial acute myocardial infarction. Am J Cardiol 2012;110:1073-1077.
52
4. Badenhorst D, Norton GR, Sliwa K, Brooksbank R, Essop R,
Sareli P, et al. Impact of β2-adrenoreceptor gene variants on cardiac cavity size and systolic function in idiopathic dilated cardiomyopathy. The Pharmacogenomics Journal 2007;7:339-345.
5. Zhu XF, Lu LX, Wang Y, Xu KW, Li DJ, Zhu X, et al. Effect and predictive elements for 52 weeks telbivudine treatment on naïve HbeAg positive chronic hepatitis B. Hepat Mon 2011;11(12):980-985.
6. Kamada T, Fujimura Y, Gotoh K, Imamura H, Manabe N, Kusunoki H, et al. A study on the efficacy of proton pump inhibitors in Helicobacter pylori negative primary care patients with dyspepsia in Japan. Gut and Liver 2013;7(1):16-22.
7. Oboni JB, Vidal PM, Pralong F, Waeber G. Predictive factors of adrenal insufficiency in patients admitted to acute medical wards: A case control study. BMC Endocrine Disorders 2013;13(3).
8. Khunti K, Weston C, Gholap N, Molokhia M, Paul S, Millett C, Curcin V, et al. All cause mortality in relation to glycated haemoglobin in individuals with newly diagnosed type 2 diabetes: A retrospective cohort study. The British Journal of Diabetes and Vascular Disease 2012;13(1):22-30.
9. Layios N, Lambermont B, Canivet JL, Morimont P, Preiser JC, Garweg C, et al. Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients. Crit Care Med 2012;40:2304-2309.
10.Jager CPC, van Wijk PTL, Mathoera RB, Leuvenink JDJ, Poll TVD, Wever PC. Lymphocytopenia and neutrophil-lymphocyte count ratio predict bacteremia better than conventional infection markers in an emergency care unit. Critical Care 2010;14:R192.
VI. Tulisan Ilmiah di Departemen Ilmu Penyakit Dalam 1. Aspek Psikosomatik Pada Asma Bronkial 2. HD VS CAPD
3. Multiple Myeloma
VII. Publikasi Ilmiah
1. Saputra Leo Widia, Kembaren Tambar, Ginting Franciscus, Ginting Josia. Baseline Characteristic of Oral Candidiasi In Adam Malik Hospital: Laporan kasus. PETRI XIV, Semarang , 2012. 2. Saputra Leo Widia, Zain Lukman Hakim, Baseline Characteristic
of NAFLD in Adam Malik Hospital : Laporan kasus. PEGI, Solo , 2012
53
VIII. Partisipasi Dalam Kegiatan Ilmiah
1. Peserta Kursus “Advanced Cardiac Life Support”. PERKI. Medan, 8-10 Mei 2009.
2. Peserta Kursus “Fundamental Critical Care Support (FCCS)”. PERDICI. Medan, 17-18 Mei 2009.
3. Peserta Kursus “Advanced Cardiac Life Support”. PERKI. Jakarta, 17-19 Juli 2009.
4. Peserta Simposium “The Natural Astaxanthin Sumposium 2009: An Update on Clinical Research”. Medan, 2 November 2009.
5. Peserta Simposium “Respiratory Evidenced and Respiratory Competence Synergy on Clinical Practice”. MERCY 2010. Medan, 19-21 Maret 2010. 6. Peserta Simposium “Current Management in Internal Medicine”. 11th
7. Peserta Simposium “Update on Diabetes Management and Medical Nutrition Therapy”. PAPDI. Medan, 17 April 2010.
Annual Scientific Meeting Internal Medicine. Medan, 1-3 April 2010.
8. Peserta Simposium “Pemenuhan Gizi Seimbang dengan Susu UHT”. IDI. Medan, 31 Juli 2010.
9. Peserta Simposium “Recent Advances on Management of Secondary Ischemic Stroke Prevention”. PERDOSSI. Medan, 27 November 2010. 10.Peserta Kursus “Advanced Electrocardiography (ECG)”. PERKI. Medan
10-11 Desember 2010.
11.Peserta Simposium “Multi Lamellar Emulsion (MEL) Moisturizer, The
New Platform Technology for Skin Barrier Function”. PERDOSKI.
Medan, 23 Februari 2011.
12.Peserta Workshop “Medical Skill Upgrade Cardio-Metabolic”. PAPDI. Medan 2 April 2011.
13.Peserta Simposium “Clinical Rheumatology in Daily Practice”. Rheumatology Update 2011. Medan, 9-10 Juli 2011.
14.Peserta Simposium “Patophysiology and Recent Management of Chronic
Constipation and Acute Diarrhea”. The Indonesian Society of
Gastroenterology. Medan, 13 November 2011.
15.Peserta Simposium “The New Option of Insulin Resistance Treatment in Type 2 Diabetes”. PERKENI. Medan, 20 November 2011.
16.Peserta Free Paper Poster Presentation “Kongres Nasional XV Perhimpunan Dokter Spesialis Penyakit Dalam Indonesia (KOPAPDI XV)”, Medan, 12-15 Desember 2012.
17.Peserta Workshop “Diabetes Update for Excellent”. PERKENI. Medan, 17 Maret 2012.
18.Peserta Simposium “A New Novel DPP-4 Inhibitor for T2DM Treatment”. PERKENI. Medan, 1 April 2012.
19.Peserta Simposium “Diabetic Neuropathy”. PERKENI. Medan, 8 September 2012.
20.Peserta Workshop “Terapi Insulin”. Dies Natalis 60 FK-USU. Medan, 11 September 2012.
21.Peserta Simposium “Right from The Start: An Urgent Concern”. FEDS-5. Medan, 23 Februari 2013.
22.Peserta Workshop “Managing Diabetes Mellitus: From A to Z”. Jeanne Latu Conference, 2 Maret 2013.
54
23.Peserta Simposium “Recent Management in Helicobacter pylori Infection, Irritable Bowel Syndrome and Hepatic Encephalopathy”. PPHI. Medan, 20 April 2013.
24.Peserta Pelatihan Program Pengembangan Pendidikan Keprofesian Berkelanjutan Ultrasonografi Tahap Satu bagi Spesialis dan PPDS Penyakit Dalam. Departemen Penyakit Dalam FK USU dan PUSKI. Medan, 15-18 April 2013.
25.Peserta Simposium “Current and Future Treatment in Diabetes Management”. PERKENI. Medan, 11 Mei 2013.
26.Peserta Kursus “Diabetes Camp 2013”. PERSADIA. Berastagi, 18-19 Mei 2013.
27.Peserta Kursus “Partnership for Diabetes Control in Indonesia”. PERKENI. Medan, 7-9 Juni 2013.
28.Peserta Simposium “Linagliptin: A Novel Unique DPP IV Inhibitor”. PAPDI. Medan, 11 Juni 2013.
55
Lampiran 7
HASIL STATISTIK
Karakteristik Klinis Subjek Penelitian
Jenis Kelamin
Frequency Percent Valid Percent
Cumulative Percent Valid Laki-laki 57 75,0 75,0 75,0
Perempuan 19 25,0 25,0 100,0
Total 76 100,0 100,0
One-Sample Kolmogorov-Smirnov Test
Umur Platelet AST Albumin Bil.Total PT INR ALT Fib.4
N 76 76 76 76 76 76 76 76 76
Normal Parametersa,b Mean 49,76 147,17 139,46 2,489 5,5199 5,2582 1,4111 58,83 7,9930 Std. Deviation 11,631 115,581 182,518 ,7194 7,43221 5,37422 ,43186 71,128 10,64238 Most Extreme Differences Absolute ,089 ,212 ,242 ,126 ,248 ,170 ,137 ,237 ,235 Positive ,089 ,212 ,230 ,126 ,248 ,170 ,137 ,225 ,227 Negative -,056 -,148 -,242 -,077 -,239 -,169 -,110 -,237 -,235 Kolmogorov-Smirnov Z ,780 1,852 2,114 1,100 2,159 1,483 1,192 2,070 2,046 Asymp. Sig. (2-tailed) ,578 ,002 ,000 ,177 ,000 ,025 ,117 ,000 ,000
a. Test distribution is Normal. b. Calculated from data.
NPar Tests (kecil)
NPar Tests (besar)
One-Sample Kolmogorov-Smirnov Test
25 50.40 11.871 .109 .109 -.100 .546 .927 25 199.04 145.588 .176 .176 -.139 .882 .418 25 3.9732 6.37777 .298 .298 -.280 1.489 .024 25 79.92 81.361 .244 .244 -.202 1.221 .102 25 2.808 .7071 .208 .208 -.087 1.041 .228 25 3.3040 4.68352 .271 .271 -.247 1.357 .050 25 1.2145 .37872 .244 .244 -.186 1.218 .103 25 41.24 36.449 .295 .295 -.181 1.477 .025 25 3.9158 2.67219 .144 .144 -.088 .721 .677 Umur Platelet Bil.Total AST ALbumin PT INR ALT Fib.4 N Mean Std. Deviation Normal Parametersa,b
Absolute Positive Negative Most Extreme Differences
Kolmogorov-Smirnov Z As ymp. Sig. (2-tailed)
Test distribution is Normal. a.
Calculated from data. b.
56
T-Test
One-Sample Kolmogorov-Smirnov Test
51 49.45 11.618 .093 .093 -.071 .663 .772 51 121.75 88.655 .207 .207 -.139 1.479 .025 51 6.2780 7.84536 .229 .229 -.226 1.638 .009 51 168.65 210.120 .265 .265 -.237 1.890 .002 51 2.333 .6787 .164 .164 -.090 1.171 .129 51 6.2161 5.47257 .144 .144 -.132 1.029 .241 51 1.5075 .42675 .129 .129 -.093 .920 .366 51 67.45 81.979 .252 .252 -.238 1.801 .003 51 9.9916 12.41276 .239 .239 -.229 1.707 .006 Umur Platelet Bil.Total AST ALbumin PT INR ALT Fib.4 N Mean Std. Deviation Normal Parametersa,b
Absolute Positive Negative Most Extreme Differences
Kolmogorov-Smirnov Z As ymp. Sig. (2-tailed)
Test distribution is Normal. a.
Calculated from data. b. Group Statistics 25 50.40 11.871 2.374 51 49.45 11.618 1.627 25 199.04 145.588 29.118 51 121.75 88.655 12.414 25 3.9732 6.37777 1.27555 51 6.2780 7.84536 1.09857 25 79.92 81.361 16.272 51 168.65 210.120 29.423 25 2.808 .7071 .1414 51 2.333 .6787 .0950 Besar kecil besar kecil besar kecil besar kecil besar kecil besar Umur Platelet Bil.Total AST ALbumin N Mean Std. Deviation Std. Error Mean
Independent Samples Test
.021 .885 .332 74 .741 .949 2.857 -4.743 6.641 .330 46.868 .743 .949 2.878 -4.841 6.739 5.915 .017 2.868 74 .005 77.295 26.950 23.595 130.995 2.442 32.995 .020 77.295 31.654 12.895 141.695 1.095 .299 -1.275 74 .206 -2.30484 1.80702 -5.90540 1.29572 -1.369 57.598 .176 -2.30484 1.68342 -5.67507 1.06539 6.693 .012 -2.032 74 .046 -88.727 43.660 -175.721 -1.734 -2.639 71.356 .010 -88.727 33.623 -155.763 -21.691 .173 .679 2.826 74 .006 .4747 .1680 .1400 .8094 2.786 46.067 .008 .4747 .1704 .1317 .8176 Equal variances as sumed Equal variances not ass umed Equal variances as sumed Equal variances not ass umed Equal variances as sumed Equal variances not ass umed Equal variances as sumed Equal variances not ass umed Equal variances as sumed Equal variances not ass umed Umur Platelet Bil.Total AST ALbumin F Sig. Levene's Test for Equality of Variances
t df Sig. (2-tailed)
Mean Difference
Std. Error
Difference Lower Upper 95% Confidence
Interval of the Difference t-test for Equality of Means
57
NPar Tests
Mann-Whitney Test
T-Test
Ra nks 25 48.72 1218.00 51 33.49 1708.00 76 25 29.68 742.00 51 42.82 2184.00 76 25 30.52 763.00 51 42.41 2163.00 76 Besar kecil besar Total kecil besar Total kecil besar Total Platelet Bil.Tot al AS TN Mean Rank Sum of Ranks
Test Statisticsa 382.000 417.000 438.000 1708.000 742.000 763.000 -2.825 -2.438 -2.206 .005 .015 .027 Mann-Whitney U Wilcoxon W Z
As ymp. Sig. (2-tailed)
Platelet Bil.Total AST
Grouping Variable: Besar a.
Group Sta tisti cs
25 3.3040 4.68352 .93670 51 6.2161 5.47257 .76631 25 1.2145 .37872 .07574 51 1.5075 .42675 .05976 25 41.24 36.449 7.290 51 67.45 81.979 11.479 25 3.9158 2.67219 .53444 51 9.9916 12.41276 1.73813 Besar kecil besar kecil besar kecil besar kecil besar PT INR ALT Fib.4
N Mean St d. Deviat ion
St d. E rror Mean
58