CRITICAL THINKING IN EPIDEMIOLOGY Diabetes Mellitus is Strongl Asso!iate" #it$ Tuber!

ulosis in In"onesia%

Anggota & '( Ellis Se)ianessi .( Ri/0a Isti 1o2ar a 3( Kurnia Putri A( 4( Mareta Ra2a"$ona 5( Della Agustina 6( St$e7ani E0a Purna2a 8( Kaltriani Lestari *'+'+'++'+',*'+'+'++'+.3*'+'+'++'+33*'+'+'++'+3,*'+'+'++'+4,*'+'+'++'+56*'+'+'++'+66-

Dosen Pengasu$ & Najmah S.KM, M.PH

9AK:LTAS KESEHATAN MASYARAKAT :NI;ERSITAS SRI<I=AYA TAH:N .+'3

STROBE Statement > Checklist ang se$arusn a "ila)or0an "ala2 )enelitian "engan "esain 0asus 0ontrol (case-control studies)( Ite2 Re!o22en"ation Re)orte" No on )age =u"ul "an Abstra0 1 a. Studi desain yang digunakan dicantumkan di abstrak atau judul. !"! Abstrak : Dicantumkan di design studynya yaitu, Casecontrol study comparing the prevalence of diabetes mellitus (fasting blood glucose level >126 mg/dl) among newly diagnosed pulmonary ! patients and matched neighbourhood controls"

b. #agian abstrak terdiri dari ringkasan in$%rmati$ terhada& a&a yang sudah dilakukan dan ditemukan '(erda&at latar belakang, tujuan, design studi, hasil, kesim&ulan) Pen"a$uluan *atar #elakang+,asi%nalisasi *atar belakang dari studi terda&at di &aragra$ &ertama yaitu &ada kalimat : # he $revalence of diabetes mellitus is increasing worldwide% especially in &sia% where tuberculosis ( !) is highly endemic" 'ost te(tboo)s state that diabetes is a ris) factor for !% but little is )nown about the nature and strength of this relationship" *riginal studies on this sub+ect were mostly conducted more than ,- years ago%""". (ujuan dari studi ini dicantumkan &ada akhir kalimat &aragra$ &ertama, yaitu : #/e therefore e(amined to what

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(ujuan

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e(tent diabetes is associated with an increased ris) of ! in 0ndonesia". Meto"e Desain Penelitian

Setting

Desain studi yang dicantumkan &ada bagian design terda&at &ada kalimat: 0Case-control study comparing the prevalence of diabetes mellitus (fasting blood glucose level >126 mg/dl) among newly diagnosed pulmonary ! patients and matched neighbourhood controls." 2ambaran dari : *%kasi : 3ntuk !ase )enelitian dilakukan 4akarta (engah dan ,umah Sakit Hasan Sadikin #andung, yang tercantum &ada kalimat &ertama di bagian 'ethods 1.""" an out-patient ! clinic in central 2a)arta% and 3asan 4adi)in 5eneral 3ospital% !andung""". Sedangkan untuk !ontrol )enelitian meru&akan masyarakt 5nd%nesia yang berada di lingku& ,(, se&erti yang tercantum &ada kalimat : #"""selected a control sub+ect of the same se( and age (61-7) living within the same ru)un tetangga% the smallest residential unit in 0ndonesia% which consists of 189:- households""". Peri%de rekruitmen, e7&%sure, $%ll%89u&, dan &engum&ulan data terda&at &ada bagian ;esults &ada kalimat, 0!etween 'arch 2--1 and 'arch 2--8% ,<1 new $ ! patients were recruited""": '&aragra$ 1, kalimat &ertama). Kemudian hasil &enelitian da&at

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diketahui &ada bagian yang sama di kalimat, 0$atients presented after a median of : months (range 1 wee) to over 1 year) with cough (=<"=7)""". '&aragra$ 1 kalimat kelima)" Partisi&an+,es&%nden ! a. Kriteria res&%nden yang memenuhi kriteria sebagai : ;ase : #"""an out-patient ! clinic in central 2a)arta% and 3asan 4adi)in 5eneral 3ospital% !andung% consecutive new $ ! patients aged over 18 years of age were included in the study. 'kalimat &ertama bagian 'ethods)" ;%ntr%l : #"""randomly selected a control sub+ect of the same se( and age (61-7) living within the same ru)un tetangga% the smallest residential unit in 0ndonesia% which consists of 189:households" >irst-degree relatives of patients were e(cluded" Control sub+ects with signs and symptoms suggesting active ! or a history of prior antituberculosis treatment were also e(cluded. 'kalimat &ertama &aragra$ &ertama)" b. (idak ditemukan &ada jurnal &enelitian ini. <ariabel &ada &enelitian ini adalah : Diabetes Mellitus: =#2 >1-! mg+dl dan diantara >11? dan @1-! mg+dl 'AHB ;riteria). 2lyc%suria, menggunakan indikat%r ukur ';%mbur (est, ,%che, 4akarta, 5nd%nesia).

!"!

!"6

<ariables

!"6

!"6

 3rine 2luc%se ;%ncentrati%n : abn%rmal jika >.? mg+dl Plasma ;reatinine : abn%rmal jika n%rmal Calue @"? mm%l+l '8anita) dan @11? mm%l+l '&ria). H5< : menggunakan indikat%r test H5< ''Determine, Abb%tt Diagn%stics, H%%$dd%r&, (he Netherlands).D 3mur : diklasi$ikasikan menjadi / kel%m&%k umur yaitu E1" tahun, -?9-" tahun, .?9." tahun, dan F/? tahun. Penda&atan : diklasi$ikasikan menjadi . kel%m&%k yaitu @1, 19-, dan >- 3S G+ca&ita+day. Ke&adatan hunian rumah : dikateg%rikan &adat jika terda&at >- indiCidu di setia& kamar. ,i8ayat k%ntak (#

!"6 !"6

!"6

!"6 '(able 1)

!"6 '(able 1) !"6 '(able 1) !"6 '(able 1) !"6 '(able 1)

Sumber Data+ Pengukuran

HI

#%dy Mass 5nde7 : &enentuan batas indikat%r berdasarkan median untuk setia& case dan c%ntr%l. a. Sumber Data ;ase : 0"""an out-patient ! clinic in central 2a)arta% and 3asan 4adi)in 5eneral 3ospital% !andung% consecutive new $ ! patients aged over 18 years of age were included in the study" ?iagnosis was based on clinical presentation and chest @-ray e(amination% confirmed by microscopic detection of acid-fast bacilli" reatment consisted of a standard regimen% 23;AB/,3:;:"""'kalimat &ertama

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bagian 'ethods): ;%ntr%l : #"""randomly selected a control sub+ect of the same se( and age (61-7) living within the same ru)un tetangga% the smallest residential unit in 0ndonesia% which consists of 189:households" >irst-degree relatives of patients were e(cluded" Control sub+ects with signs and symptoms suggesting active ! or a history of prior antituberculosis treatment were also e(cluded. 'kalimat &ertama &aragra$ &ertama)" b. Pengukuran, baik untuk case dan c%ntr%l menggunakan cara yang sama Diabetes Mellitus: teknik kuantitati$ dengan sebelumnya &asien ber&uasa /H jam terlebih dahulu , standar yang digunakan adalah standar AHB. K%nsentrasi =#2 diukur sebelum dan sesudah &eng%batan anti (#. Da&at dilihat &ada kalimat berikut : 0Co antidiabetic agents were ta)en within ,< h before blood sampling for measurement of fasting blood glucose (>!5) concentrations""" 0n all patients% >!5 concentrations were measured before and after one month of anti-tuberculosis treatment"". 2lyc%suria, teknik semi kuantitai$, da&at dilihat &ada kalimat : 04emi-Duantitative measurement of glycosuria was done using urine dipstic)s".: 3rine 2luc%se ;%ncentrati%n :

!"6

!"6

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#ias

"

3kuran Studi

1?

<ariabel Kuantitati$

11

teknik kuantitati$ dengan mengukur k%nsentrasi urine gluc%se. Plasma ;reatinine : teknik kuantitati$, dengan mengukur &lasma creatine. H5< : 0.""(30E) testing was conducted using the dipstic) test"". Adanya recall bias ketika me8a8ancarai in$%rman, hal ini da&at terlihat dari &ernyataan : 0&d+ustment for the higher freDuency of ! contacts among the cases did not lower the ris) estimates" his difference may have been due to recall bias. 'bagian ?iscussion &aragra$ ketiga)" 3ntuk !ase )enelitian dilakukan 4akarta (engah dan ,umah Sakit Hasan Sadikin #andung, yang tercantum &ada kalimat &ertama di bagian 'ethods 1.""" an out-patient ! clinic in central 2a)arta% and 3asan 4adi)in 5eneral 3ospital% !andung""". Sedangkan untuk !ontrol )enelitian meru&akan masyarakt 5nd%nesia yang berada di lingku& ,(, se&erti yang tercantum &ada kalimat : #"""selected a control sub+ect of the same se( and age (61-7) living within the same ru)un tetangga% the smallest residential unit in 0ndonesia% which consists of 189:households""". Diabetes Mellitus: teknik kuantitati$ dengan sebelumnya &asien ber&uasa /H jam terlebih dahulu , standar yang digunakan adalah standar AHB. K%nsentrasi

!"6

!"6

!"6

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!"! dan !"6

!"6

=#2 diukur sebelum dan sesudah &eng%batan anti (#. Da&at dilihat &ada kalimat berikut : 0Co antidiabetic agents were ta)en within ,< h before blood sampling for measurement of fasting blood glucose (>!5) concentrations""" 0n all patients% >!5 concentrations were measured before and after one month of anti-tuberculosis treatment"". 3rine 2luc%se ;%ncentrati%n : teknik kuantitati$ dengan mengukur k%nsentrasi urine gluc%se. Plasma ;reatinine : teknik kuantitati$, dengan mengukur &lasma creatine. 3mur : diklasi$ikasikan menjadi / kel%m&%k umur yaitu E1" tahun, -?9-" tahun, .?9." tahun, dan F/? tahun. Penda&atan : diklasi$ikasikan menjadi . kel%m&%k yaitu @1, 19-, dan >- 3S G+ca&ita+day. Ke&adatan hunian rumah : dikateg%rikan &adat jika terda&at >- indiCidu di setia& kamar. ,i8ayat k%ntak (# 'Ja dan (idak)

!"6

!"6

!"6 '(able 1)

!"6 '(able 1) !"6 '(able 1) !"6 '(able 1)

#%dy Mass 5nde7 : &enentuan batas indikat%r berdasarkan median untuk setia& case dan c%ntr%l. Met%de Statistik 1a. Ditemukan &ada kalimat, 0Crude and ad+usted odds ratios (*;s) were calculated as estimates of

!"6 '(able 1)

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the relative ris)s with corresponding =87 confidence intervals (C0) and a logistic regression model" &d+usted *;s reflect the ris) of ! for people with diabetes mellitus compared to normal individuals after ad+ustment for variables including1 se(% age% body mass inde( (!'0% calculated as )g/m2)% presence of ! contact in the family or household% income and number of individuals per household" b. Ditemukan &ada kalimat, #$ossible confounding of the relationship between diabetes and ! was e(amined using logistic regression" 4e(% income and overcrowding did not alter the *; significantly" 3istory of ! contact was significantly more common among cases than controls ( able 1)F however% ad+ustment to this variable didnot reduce the ris) estimates" ! patients had a lower !'0 than controls% but ad+ustment. c. (idak ditemukan dalam bagian met%de dalam jurnal d. (idak ditemukan dalam bagian met%de dalam jurnal e. (idak ditemukan dalam bagian met%de dalam jurnal Hasil Partisi&an 1.I a. 3ntuk !ase da&at dilihat &ada kalimat berikut, 0""",<1 new $ ! patients were recruited% of whom ,8, were included for further

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analysis" wenty-seven were e(cluded because of a past history of ! (nG 6) and incomplete data (n G21)" le ( able 1)": 'bagian ;esults &aragra$ &ertama). Sedangkan untuk !ontrol da&at dilihat dari, 04i( hundred and twenty-two sub+ects were recruited as matched controls" 4i(ty-si( were e(cluded for further analysis because of suspected ! (n G 22)% history of ! treatment (n GH) or incomplete data (n G:H): 'bagian ;esults &aragra$ kedua). b. Penyebab &artisi&an dikeluarkan dari &enelitian ;ase ditemukan &ada kalimat, 0 wenty-seven were e(cluded because of a past history of ! (nG 6) and incomplete data (n G21) 'bagian ;esults &aragra$ &ertama). ;%ntr%l ditemukan &ada kalimat, 04i(ty-si( were e(cluded for further analysis because of suspected ! (n G 22)% history of ! treatment (n GH) or incomplete data (n G:H). 'bagian ;esults &aragra$ kedua). c. (idak terda&at diagram alur di jurnal a. Karakteristik studi &artisi&an Case% da&at dilihat &ada kalimat% #$atients had a median age of :-"- years (range 189H8)% and 2:< (82",7) were male" Cases had a median !'0 of 1H"H )g/m2 !"6

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Data Deskri&ti$

1/I

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(range 11"29:1",). 'bagian ;esults &aragra$ &ertama). ;%ntr%l, da&at dilihat &ada kalimat, 0 he remaining 886 controls had a similar se( distribution% age (median :-"yearsF range 189H6) and socioeconomic bac)ground as the patients ( able 1)" Control sub+ects had a higher body weight than patients% while history of ! contact was less common ( able 1). 'bagian ;esults &aragra$ kedua). b. (idak ditemukan data yang hilang 'missing data) baik untuk case mau&un c%ntr%l &ada jurnal. ;ase, da&at dilihat &ada kalimat, 0&ll were newly diagnosed with $ ! confirmed by sputum microscopy" 'ycobacterium tuberculosis culture results were available in :H: patients% and were positive in :2< (<H"=7)" $atients presented after a median of : months (range 1 wee) to over 1 year) with cough (=<"=7)% haemoptysis (,2"87)% shortness of breath (66"17)% fever (HH":7) and weight loss (<,"17)" Cases had a median !'0 of 1H"H )g/m2 (range 11"29:1",)" &ntibodies against 30E were present in 6 of ,-2 ! patients e(amined (1"87) and none of the ,- controls tested" 'ild elevation of plasma creatinine was found in one of 2:, cases e(amined. 'bagian ;esults &aragra$ &ertama). ;%ntr%l, da&at dilihat &ada kalimat, 0Control sub+ects had a

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9 !"6

Data Hasil

11I

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Hasil 3tama

1!

higher body weight than patients% while history of ! contact was less common.'bagian ;esults &aragra$ kedua). a. Da&at ditemukan &ada kalimat : ?iabetes mellitus was more common in patients with ! than in control sub+ects (>igure)" 4i(ty ! patients (1:"27) had diabetes compared with 1< (:"27) controls (*; ,"H% =87C0 2"H9<"1) ( able 2)" 0mpaired >!5 was present in 18 ! patients (:":7) and five controls (-"=7% *; ,"2% =87C0 1"8911"H)" 5lycosuria was present in ,: of ,18 ! cases (1-",7) and 16 of ,1: controls (:"67)% corresponding to an *; of :"1 (=87C0 1"H98"6) ( able 2)" he median age of ! patients with diabetes% impaired >!5 and no diabetes was ,8"-% ,8"- and 2H"1 years% respectively ($ I -"--1)" he median !'0 was 21"2% 16"= and 1H"< )g/m2% respectively (>igure% &)" ?iabetes was newly diagnosed in :6/6- patients (6-"-7) and 12/1< controls (66"H7) with diabetes" &mong 2, patients with a history of diabetes% only 1= (H="27) were being treated% all with oral hypoglycaemic agents" ;epeated measurement during ! treatment showed normalisation of >!5 in 2/8: (:"H7) patients who initially had >!5 >126 mg/dl% and conversion to diabetes in 6/2=8 (2"-7) patients with normal >!5 before ! treatment.

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!"H K =igure A

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Analisis *ainnya Dis0usi Hasil+5n$%rmasi Penting

16

b. Ditemulan &ada kalimat, #$ossible confounding of the relationship between diabetes and ! was e(amined using logistic regression" 4e(% income and overcrowding did not alter the *; significantly" 3istory of ! contact was significantly more common among cases than controls ( able 1)F however% ad+ustment to this variable didnot reduce the ris) estimates" ! patients had a lower !'0 than controls% but ad+ustment. c. (idak ditemukan dalam jurnal &enelitian ini. (idak ditemukan dalam jurnal &enelitian ini. Ditemukan &ada kalimat, 0/e have found a strong association of ! and diabetes in two urban clinics in 0ndonesia" /e believe this is the first study to e(amine this association in 0ndonesia% where more than 1-7 of the worldJs ! patients live%2 and one of the first in 4outh-Bast &sia. 'bagian ?iscussion% &aragra$ &ertama dan kalimat &ertama)" Ditemukan &ada kalimat, 0&s the study sub+ects were very poor% with limited access to regular health care% the proportion with undiagnosed diabetes may in fact have been higher. '&aragra$ &ertama)" Ditemukan &ada kalimat : 0mmunological studies support the hypothesis that diabetes is a ris) factor for !" $roduction of interferon-gamma% which is crucial for host defence agains !% has been found to be low in diabetic mice infected with '"

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1H

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Keterbatasan

1"

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5nter&retasi

-?

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tuberculosis% and it has been shown that alveolar macrophage in ! patients with diabetes show less activation" Cohort studies performed in Burope and th Knited 4tates in the 1=:-s also support this hypothesis1 diabetics showed a three- to four-fold increased ris) of developing !" & recent case-control study of ! patients in 'e(ico reported a higher ris) estimate than ours1 the prevalence of diabetes was 2="67% which was 6"<- fold higher than the bac)ground prevalence of diabetes in the study area" $revious studies from Lorea% Burope and the K4 in which diabetes patients were prospectively followed% reported ris) estimates similar to ours" 0f diabetes% as our study suggests% is such a strong ris) factor for !% this may have significant clinical and epidemiological implications" 0n 2-28% H87 of diabetics will live in developing countries where more than =-7 of ! cases reside"

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2eneralisasi

-1

Ditemukan &ada kalimat, 0!ased on our study% we would recommend screening all ! patients above :8 years of age at least once% and loo)ing for symptoms of diabetes in younger patients" 4creening and earlier management of diabetes may

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reduce the ris) of developing active !". In?or2asi Lainnn a =unding -Ditemukan &ada kalimat, 0 his study is an indirect result of the pro+ect M0mmunogenetic basis of susceptibility to and disease manifestations of mycobacterial infectionsJ% conducted within the M4cientific $rogramme 0ndonesia CetherlandsJ (4$0C) and supported by the ;oyal &cademy of &rts and 4ciences (LC&/)""": 'bagian &c)nowledgements).

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I2iCe in$%rmati%n se&arately $%r cases and c%ntr%ls