tag:blogger.com,1999:blog-33990542985855899822024-02-19T10:42:11.141+09:00Theo's BLOGILMU BEDAH dan AUDIO VIDEOTheo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.comBlogger25125tag:blogger.com,1999:blog-3399054298585589982.post-32726723421221209742017-04-10T13:51:00.001+09:002017-04-10T13:51:48.653+09:00<div><br></div><div><br></div><div>Sent from my BlackBerry 10 smartphone on the Telkomsel network.</div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-76215794651547887852016-05-01T17:47:00.001+09:002016-05-01T17:47:14.777+09:00MyLinkedingAlerts<P>This is test mail to varify your blog</P> <P>WPDeals</P> <P>#54321fatafata$101#2016*$linkeding80</P>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-8526725377460079912014-09-01T18:45:00.001+09:002014-09-01T18:45:32.317+09:00Theo Rompas's invitation is awaiting your response<span style="display: none !important;font-size: 1px;visibility: hidden;opacity: 0;color: transparent;height: 0;width: 0;mso-hide: all;"></span> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; border-collapse:collapse; width:100% !important; font-family:Helvetica,Arial,sans-serif; margin:0; padding:0;" width="100%" bgcolor="#DFDFDF"> <tbody> <tr> <td colspan="3"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="1"> <tbody> <tr> <td> <div style="height:5px;font-size:5px;line-height:5px;"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td> <table cellspacing="0" cellpadding="0" border="0" align="center" width="100%" style="table-layout: fixed;"> <tbody> <tr> <td align="center"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; min-width:290px;" width="600" class="responsive"> <tbody> <tr> <td style="font-family:Helvetica,Arial,sans-serif;"> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:8px;font-size:8px;line-height:8px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#DDDDDD"> <tbody> <tr> <td align="left" valign="middle" width="95" height="21" id="base-header-logo"><a style="text-decoration:none;cursor:pointer;border:none;display:block;height:21px;width:100%;" href="http://www.linkedin.com/blink?simpleRedirect=3ANnT1UplZSrCAZqSkCcP4McChKqmRBsyRBrmZEnSZDrSMJoyRJtCVFnSRJrScJr6RBfmtKqmJzon9Q9D1JrzRQ9z0Qbj9zu6pJqDFEbntMemBNryQZpjYOtyZBbSRLoOVKqmhBqSVFr2VTtTsLbPFMt7hE&msgID=I7713860372_1&markAsRead="><img src="http://s.c.lnkd.licdn.com/scds/common/u/images/email/logos/logo_linkedin_tm_email_95x21_v1.png" width="95" height="21" alt="LinkedIn" style="border:none;text-decoration:none;" /></a></td> </tr> </tbody> </table> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:8px;font-size:8px;line-height:8px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#333333"> <tbody> <tr> <td width="20" class="responsive-spacer"> <table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td width="100%"> <table width="560" cellspacing="0" cellpadding="1" border="0" class="header-spacer" style="table-layout: fixed;"> <tbody> <tr> <td width="560"> <div style="height:12px;font-size:12px;line-height:12px;width:560px;"> </div></td> </tr> </tbody> </table></td> <td width="20" class="responsive-spacer"> <table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#FFFFFF"> <tbody> <tr> <td width="20" class="res-width10"> <table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td style="color: #333333; font-family: Helvetica,Arial,sans-serif; font-size: 15px; line-height: 18px;" align="left"> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-height10"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"> <tbody> <tr> <td style="font-family:Helvetica,Arial,sans-serif;color:#333333;"><b>Theo Rompas</b> would like to connect on LinkedIn. How would you like to respond?</td> </tr> <tr> <td style="border-bottom-color: #E5E5E5;border-bottom-width: 1px; border-bottom-style: solid;"> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"> <tbody> <tr> <td width="150" valign="top" style="vertical-align: top;" class="res-img100"><a href="http://www.linkedin.com/blink?simpleRedirect=30OcjAUcjsPcz0UejwRdP4Ue3kZh4BKrSBQonhFtCVF9BtNiA5Ih6B9fnBBiShBsC5EsOoVclZMu6lvtCVFfmJB9D9Bp6VFrmlObnhMpmdzoiRLt6ZEs2RybmtSrCBvrmRLoORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4Cc3gJcCdUpCRGuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="text-decoration:none;cursor:pointer;"><img alt="Theo Rompas" src="http://m.c.lnkd.licdn.com/mpr/mpr/shrink_150_150/p/4/005/068/1ef/280cdbb.jpg" width="150" height="150" border="0" class="res-img100" style="border:none;text-decoration:none;outline:hidden;display:block;" /></a></td> <td width="20"> <table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td style="vertical-align: top; font-family: Helvetica,Arial,sans-serif;" width="100%"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"> <tbody> <tr> <td valign="top"><a href="http://www.linkedin.com/blink?simpleRedirect=0Mcz4Ve34TcP8Me3AUdjsNe3wRfkh9rCZFt65QqnpKqipnskF1r4hFijRVpkJApn9xq7cCej5vs7xBnTpKqjRHpipOpmhKqmRBsyRQs6lzoS4JpmRxryRybmtSrCBvrmRLoORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4Cc3gJcCdUpCRGuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="font-size: 20px; font-weight: bold; color:#000000;text-decoration:none;">Theo Rompas</a></td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:3px;font-size:3px;line-height:3px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td style="color: #666666; font-size: 15px;" class="res-font16">Consultant of Head and Neck Surgery at Dian Harapan General Hospital</td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:10px;font-size:10px;line-height:10px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td> <table border="0" cellpadding="0" cellspacing="0" align="left"> <tbody> <tr> <td align="center" height="30" valign="middle" bgcolor="#287BBC" background="http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png" style="background:url(http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png) repeat-x scroll bottom #287BBC;background-color:#287BBC;border:1px solid #1B5480;-moz-border-radius:3px;-webkit-border-radius:3px;border-radius:3px; cursor: pointer;"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="transparent"> <tbody> <tr> <td width="13"> <table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td><a href="http://www.linkedin.com/blink?simpleRedirect=c38NejwNdPcOc3wVe3kTcjwUdjR4imVLqnhxt6BSrCAClT5agmN4qkAZumlbp6lOomxP9zANnT1UplZSrCAZqSkCsClArCBJpn8Jt71BoSdxbmVLt7hRoyRybmtSrCBvrmRLoORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4Cc3gJcCdUpCRGuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="text-decoration:none; font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;" target="_blank"><span style="font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;">Confirm you know Theo</span></a></td> <td width="13"> <table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table></td> <td width="20" class="res-width10"> <table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="600" class="responsive"> <tbody> <tr> <td align="left"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"> <tbody> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:10px;font-size:10px;line-height:10px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td align="left"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; font-size:11px; font-family:Helvetica,Arial,sans-serif; color:#999999;" width="100%" class="responsive res-font10"> <tbody> <tr> <td>You are receiving Reminder emails for pending invitations. <a style="text-decoration:none;color:#0077B5;" href="http://www.linkedin.com/blink?simpleRedirect=1JrSd5cylOpmtDrSNyc3gBomRxrjASon1xs4kO9jAMq7hIomlEomlPfmNFomRB9z0Sc30OfmhF9z5vczsPc3oUcP4TdQAZp6BD9zANnT1UplZSrCAZqSkCoDlPrDkJpyRDtCVFnSRJrScJr6RBfmtKqmJzon9Q9CZLpPRQ9z0Qbj9zu6pJqDFEbntMemBNryQZpjYOtyZBbSRLoOVKqmhBqSVFr2VTtTsLbPFMt7hE&msgID=I7713860372_1&markAsRead=">Unsubscribe</a></td> </tr> <tr> <td></td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:10px;font-size:10px;line-height:10px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td>© 2014, LinkedIn Corporation. 2029 Stierlin Ct. Mountain View, CA 94043, USA</td> </tr> </tbody> </table></td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <img src="http://www.linkedin.com/emimp/-nqi9pw-hzjmfxc2-40.gif" style="width:1px; height:1px;" /> Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com1tag:blogger.com,1999:blog-3399054298585589982.post-25989109498268801862014-08-25T21:45:00.001+09:002014-08-25T21:45:45.759+09:00Theo Rompas's invitation is awaiting your response<span style="display: none !important;font-size: 1px;visibility: hidden;opacity: 0;color: transparent;height: 0;width: 0;mso-hide: all;"></span> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; border-collapse:collapse; width:100% !important; font-family:Helvetica,Arial,sans-serif; margin:0; padding:0;" width="100%" bgcolor="#DFDFDF"> <tbody> <tr> <td colspan="3"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="1"> <tbody> <tr> <td> <div style="height:5px;font-size:5px;line-height:5px;"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td> <table cellspacing="0" cellpadding="0" border="0" align="center" width="100%" style="table-layout: fixed;"> <tbody> <tr> <td align="center"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; min-width:290px;" width="600" class="responsive"> <tbody> <tr> <td style="font-family:Helvetica,Arial,sans-serif;"> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:8px;font-size:8px;line-height:8px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#DDDDDD"> <tbody> <tr> <td align="left" valign="middle" width="95" height="21" id="base-header-logo"><a style="text-decoration:none;cursor:pointer;border:none;display:block;height:21px;width:100%;" href="http://www.linkedin.com/blink?simpleRedirect=3ANnT1UplZSrCAZqSkCcP4McChKqmRBsyRBrmZEnSZDrSMJoyRJtCVFnSRJrScJr6RBfmtKqmJzon9Q9D1JrzRQ9CkSbmBLr7dPenFEbntMemBNryQZpjYOtyZBbSRLoOVKqmhBqSVFr2VTtTsLbPFMt7hE&msgID=I7713860372_1&markAsRead="><img src="http://s.c.lnkd.licdn.com/scds/common/u/images/email/logos/logo_linkedin_tm_email_95x21_v1.png" width="95" height="21" alt="LinkedIn" style="border:none;text-decoration:none;" /></a></td> </tr> </tbody> </table> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:8px;font-size:8px;line-height:8px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#333333"> <tbody> <tr> <td width="20" class="responsive-spacer"> <table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td width="100%"> <table width="560" cellspacing="0" cellpadding="1" border="0" class="header-spacer" style="table-layout: fixed;"> <tbody> <tr> <td width="560"> <div style="height:12px;font-size:12px;line-height:12px;width:560px;"> </div></td> </tr> </tbody> </table></td> <td width="20" class="responsive-spacer"> <table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#FFFFFF"> <tbody> <tr> <td width="20" class="res-width10"> <table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td style="color: #333333; font-family: Helvetica,Arial,sans-serif; font-size: 15px; line-height: 18px;" align="left"> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-height10"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"> <tbody> <tr> <td style="font-family:Helvetica,Arial,sans-serif;color:#333333;"><b>Theo Rompas</b> would like to connect on LinkedIn. How would you like to respond?</td> </tr> <tr> <td style="border-bottom-color: #E5E5E5;border-bottom-width: 1px; border-bottom-style: solid;"> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"> <tbody> <tr> <td width="150" valign="top" style="vertical-align: top;" class="res-img100"><a href="http://www.linkedin.com/blink?simpleRedirect=30OcjAUcjsPcz0UejwRdP4Ue3kZh4BKrSBQonhFtCVF9BtNiA5Ih6B9fnBBiShBsC5EsOoVclZMu6lvtCVFfmJB9D9Bp6VFrmlObnhMpmdzoiRLt6ZEs2RybmtSrCBvrmRLoORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4CpjoJqmZIsTcVuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="text-decoration:none;cursor:pointer;"><img alt="Theo Rompas" src="http://m.c.lnkd.licdn.com/mpr/mpr/shrink_150_150/p/4/005/068/1ef/280cdbb.jpg" width="150" height="150" border="0" class="res-img100" style="border:none;text-decoration:none;outline:hidden;display:block;" /></a></td> <td width="20"> <table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td style="vertical-align: top; font-family: Helvetica,Arial,sans-serif;" width="100%"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"> <tbody> <tr> <td valign="top"><a href="http://www.linkedin.com/blink?simpleRedirect=0Mcz4Ve34TcP8Me3AUdjsNe3wRfkh9rCZFt65QqnpKqipnskF1r4hFijRVpkJApn9xq7cCej5vs7xBnTpKqjRHpipOpmhKqmRBsyRQs6lzoS4JpmRxryRybmtSrCBvrmRLoORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4CpjoJqmZIsTcVuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="font-size: 20px; font-weight: bold; color:#000000;text-decoration:none;">Theo Rompas</a></td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:3px;font-size:3px;line-height:3px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td style="color: #666666; font-size: 15px;" class="res-font16">Consultant of Head and Neck Surgery at Dian Harapan General Hospital</td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:10px;font-size:10px;line-height:10px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td> <table border="0" cellpadding="0" cellspacing="0" align="left"> <tbody> <tr> <td align="center" height="30" valign="middle" bgcolor="#287BBC" background="http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png" style="background:url(http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png) repeat-x scroll bottom #287BBC;background-color:#287BBC;border:1px solid #1B5480;-moz-border-radius:3px;-webkit-border-radius:3px;border-radius:3px; cursor: pointer;"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="transparent"> <tbody> <tr> <td width="13"> <table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> <td><a href="http://www.linkedin.com/blink?simpleRedirect=c38NejwNdPcOc3wVe3kTcjwUdjR4imVLqnhxt6BSrCAClT5agmN4qkAZumlbp6lOomxP9zANnT1UplZSrCAZqSkCsClArCBJpn8Jt71BoSdxbmVLt7hRoyRybmtSrCBvrmRLoORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4CpjoJqmZIsTcVuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="text-decoration:none; font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;" target="_blank"><span style="font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;">Confirm you know Theo</span></a></td> <td width="13"> <table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table></td> <td width="20" class="res-width10"> <table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"> <tbody> <tr> <td> <div style="height:0px;font-size:0px;line-height:0px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="600" class="responsive"> <tbody> <tr> <td align="left"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"> <tbody> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:10px;font-size:10px;line-height:10px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td align="left"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; font-size:11px; font-family:Helvetica,Arial,sans-serif; color:#999999;" width="100%" class="responsive res-font10"> <tbody> <tr> <td>You are receiving Reminder emails for pending invitations. <a style="text-decoration:none;color:#0077B5;" href="http://www.linkedin.com/blink?simpleRedirect=1JrSd5cylOpmtDrSNyc3gBomRxrjASon1xs4kO9jAMq7hIomlEomlPfmNFomRB9z0Sc30OfmhF9z5vczsPc3oUcP4TdQAZp6BD9zANnT1UplZSrCAZqSkCoDlPrDkJpyRDtCVFnSRJrScJr6RBfmtKqmJzon9Q9CZLpPRQ9CkSbmBLr7dPenFEbntMemBNryQZpjYOtyZBbSRLoOVKqmhBqSVFr2VTtTsLbPFMt7hE&msgID=I7713860372_1&markAsRead=">Unsubscribe</a></td> </tr> <tr> <td></td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:10px;font-size:10px;line-height:10px"> </div></td> </tr> </tbody> </table></td> </tr> <tr> <td>© 2014, LinkedIn Corporation. 2029 Stierlin Ct. Mountain View, CA 94043, USA</td> </tr> </tbody> </table></td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"> <tbody> <tr> <td> <div style="height:20px;font-size:20px;line-height:20px"> </div></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table></td> </tr> </tbody> </table> <img src="http://www.linkedin.com/emimp/-nqi9pw-hz9ssloi-6e.gif" style="width:1px; height:1px;" /> Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-38921738787430612242014-08-21T06:04:00.001+09:002014-08-21T06:04:32.181+09:00I'd like to add you to my professional network on LinkedIn<span class="preheader" style="display: none !important; font-size: 1px;"></span><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#DFDFDF"><tbody><tr><td colspan="3"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="1"><tbody><tr><td><div style="height:5px;font-size:5px;line-height:5px;"> </div></td></tr></tbody></table></td></tr><tr><td align="center" width="100%"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; min-width:290px;" width="550" class="responsive"><tbody><tr><td style="font-family:Helvetica,Arial,sans-serif;"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:8px;font-size:8px;line-height:8px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#DDDDDD"><tbody><tr><td align="left" valign="middle" width="95" height="21" id="base-header-logo"><a style="text-decoration:none;cursor:pointer;border:none;display:block;height:21px;width:100%;" href='http://www.linkedin.com/blink?simpleRedirect=1QsSlRpRZBt6BSrCAZqSkCrStLr2RBt6BSrCAJt7dBtmsJr6RBfmtKqmJzon9Q9D1JrzRQ9DcPbnlIcCkRcTFEbntMemBNryQZpjYOtyZBbSRLoOVKqmhBqSVFr2VTtTsLbPFMt7hE&msgID=I7713860372_1&markAsRead='><img src='http://s.c.lnkd.licdn.com/scds/common/u/images/email/logos/logo_linkedin_tm_email_95x21_v1.png' width="95" height="21" alt="LinkedIn" style="border:none;text-decoration:none;"/></a></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:8px;font-size:8px;line-height:8px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#333333"><tbody><tr><td width="20" class="responsive-spacer"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td width="100%"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:12px;font-size:12px;line-height:12px"> </div></td></tr></tbody></table></td><td width="20"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#FFFFFF"><tbody><tr><td width="20" class="res-width10"><table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td style="color: #333333; font-family: Helvetica,Arial,sans-serif; font-size: 15px; line-height: 18px;" align="left"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-height10"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td width="120" valign="top" style="vertical-align: top;"><img alt="Theo Rompas" src="http://m.c.lnkd.licdn.com/mpr/mpr/shrink_60_60/p/4/005/068/1ef/280cdbb.jpg" width="60" height="60" border="0" class="res-img120" style="border:none;outline:hidden;"/></td><td width="20"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td style="vertical-align: top; font-family: Helvetica,Arial,sans-serif;" width="100%"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td style="font-size: 20px; font-weight: bold; color:#333333;" valign="top">Theo Rompas</td></tr><tr><td style="color:#333333;font-size:15px;" class="res-font16">Consultant of Head and Neck Surgery at Dian Harapan General Hospital</td></tr><tr><td style="color:#B3B3B3;font-size:13px;" class="res-font16">Jayapura Area, Papua, Indonesia</td></tr></tbody></table></td></tr></tbody></table></td></tr><tr><td><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td style="border-bottom:1px solid #e5e5e5;"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr><tr><td><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td style="font-family:Helvetica,Arial,sans-serif;color:#333333;font-size:15px;">Hi Theo,</td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:15px;font-size:15px;line-height:15px"> </div></td></tr></tbody></table></td></tr><tr><td style="font-family:Helvetica,Arial,sans-serif;color:#333333;font-size:15px;">I'd like to add you to my professional network on LinkedIn.</td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:15px;font-size:15px;line-height:15px"> </div></td></tr></tbody></table></td></tr><tr><td>- Theo</td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr><tr><td><table border="0" cellpadding="0" cellspacing="0" align="left"><tbody><tr><td align="center" height="30" valign="middle" bgcolor="#287BBC" background="http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png" style="background:url(http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png) repeat-x scroll bottom #287BBC;background-color:#287BBC;border:1px solid #1B5480;-moz-border-radius:3px;-webkit-border-radius:3px;border-radius:3px; cursor: pointer;"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="transparent"><tbody><tr><td width="13"><table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td><a href="http://www.linkedin.com/blink?simpleRedirect=30OcjAUcjsPcz0UejwRdP4Ue3kZh4BKrSBQonhFtCVF9BtNiA5Ih6B9fnBBiShBsC5EsOpQsSlRpRZBt6BSrCAZqSkConhzbmlQqnpKqiRQsSlRpORIrmkZpSVFqSdxsDgCpnhFtCV9pSlipn9Mfm4CsPcJtmMOpjkPuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=" style="text-decoration:none; font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;" target="_blank"><span style="font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;">Confirm that you know Theo</span></a></td><td width="13"><table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table></td><td width="20" class="res-width10"><table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="550" class="responsive"><tbody><tr><td align="left"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"><tbody><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td align="left"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; font-size:11px; font-family:Helvetica,Arial,sans-serif; color:#999999;" width="100%" class="responsive res-font10"><tbody><tr><td>You are receiving Invitation to Connect emails. <a style="text-decoration:none;color:#0077B5;" href="http://www.linkedin.com/blink?simpleRedirect=6RLoQkO9n9BpStLr68Md2lxrm5Jejpxs65Mhj8Bej1Et6NxpmxxpncZr6BxrmkCt6JGoP5DrzdGoDkMoShCfmhFoioNdz0MczRAqioNbjRAqmQCsPcJtmMOpjkPuCwJtT0Vqn5KbjRAqmkCt7dBtmtvpnhFtCVFfmJB9Clyqn9zsS9RsSVRbmlQqnpKqiRQsSlRpORIrmkZpSVFqSdxsDgCkjoPp4l7q5p6sCR6kk4ZrClHrRhAqmQCsSVRfngCsPcJtmMOpjkPuCwJtT0Vqn5KbjRBfP9SbSkLrmZzbCVFp6lHrCBIbDtTtOYLeDdMt7hE&msgID=I7713860372_1&markAsRead=">Unsubscribe</a></td></tr><tr><td>This email was intended for Theo Blogger. <a style="text-decoration:none;color:#0077B5;" href="http://www.linkedin.com/blink?simpleRedirect=e3wTd3RAimlIoSBQsC4Ct7dBtmtvpnhFtCVFfmJB9CNOlmlzqnpOpldOpmRLt7dRoPRx9DcPbnlIcCkRcTFEbntMemBNryQZpjYOtyZBbSRLoOVKqmhBqSVFr2VTtTsLbPFMt7hE&msgID=I7713860372_1&markAsRead=">Learn why we included this.</a></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td>© 2014, LinkedIn Corporation. 2029 Stierlin Ct. Mountain View, CA 94043, USA</td></tr></tbody></table></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><img src="http://www.linkedin.com/emimp/-nqi9pw-hz35e2lu-3s.gif" style="width:1px; height:1px;"/>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-32647238585382546392014-08-14T21:19:00.001+09:002014-08-14T21:19:42.953+09:00<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="letter-spacing: 0.0px;"><b>KORELASI ANTARA EKSPRESI GALECTIN-3 SITOPLASMA DENGAN GRADE DAN METASTASE KARSINOMA SEL SKUAMOSA RONGGA MULUT</b></span></div>
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<span style="letter-spacing: 0.0px;"><i>Oleh :</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>Dr. Theo A. Rompas, SpB</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>Pembimbing :</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>Prof. Dr. Sunarto Reksoprawiro, SpB(K)Onk(K)KL</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>dr. Tulus Panuwun MS, SpPA (K)</i></span></div>
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<span style="letter-spacing: 0.0px;"><b>Training Bedah Kepala Leher</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Divisi Bedah Kepala Leher Departemen Ilmu Bedah</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>FK UNAIR / RSU Dr. Soetomo - Surabaya</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>KATA PENGANTAR</b></span></div>
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<span style="letter-spacing: 0.0px;">Sebagai kalimat awal pada kata pengantar ini penulis ingin mengutip sebuah kalimat indah yang patut kita renungkan bersama yang berasal dari seorang ahli bedah berkebangsaan Prancis yang hidup pada tahun 1510-1590, yaitu Ambroise Pare, yang berbunyi sebagai berikut: <i>“Je le pansay, Dieu le guarit”</i>, saya membalut, Tuhan yang menyembuhkan.</span></div>
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<span style="letter-spacing: 0.0px;">Penulis memanjatkan puji dan syukur ke hadirat Tuhan Yang Mahakuasa, atas berkat dan rahmatnya sehingga penulis dapat menyelesaikan tulisan ilmiah ini. Karya ilmiah ini disusun dalam rangka memenuhi persyaratan dalam mengikuti Program Training Bedah Kepala Leher di Divisi Kepala Leher Departemen/ SMF Ilmu Bedah Fakultas Kedokteran Universitas Airlangga/ RSU Dr. Soetomo di Surabaya. Tulisan ilmiah ini dengan judul <b><i>KORELASI ANTARA EKSPRESI GALECTIN-3 SITOPLASMA DENGAN GRADE DAN METASTASE KARSINOMA RONGGA MULUT</i></b>, diharapkan menjadi sumbangan dalam dunia kedokteran, baik dari segi ilmiah maupun dalam meningkatkan pelayanan kesehatan pada masyarakat.</span></div>
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<span style="letter-spacing: 0.0px;">Karya ilmiah ini terwujud berkat bantuan berbagai pihak, maka perkenankanlah penulis secara khusus dan tulus menyampaikan terima kasih kepada:</span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dekan Fakultas Kedokteran Universitas Airlangga Surabaya atas kesempatan yang diberikan kepada saya mengikuti program Training Bedah Kepala Leher.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Direktur Rumah Sakit Umum Daerah Dr. Soetomo Surabaya atas kesempatan dan fasilitas yang diberikan kepada saya mengikuti program Training Bedah Kepala Leher.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Prof. Dr. Sunarto Reksoprawiro, SpB(K)Onk(K)KL, selaku Ketua PEBKLI dan guru besar di Sub Divisi Kepala Leher yang telah memberi kesempatan kepada saya mengikuti Program Training Bedah Kepala Leher, serta membimbing dan mengarahkan selama masa training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dr. Agung Prasmono, SpB, BTKV (K), MARS, selaku Kepala Bagian Ilmu Bedah Fakultas Kedokteran Universitas Airlangga atas kesempatan dan fasilitas yang diberikan kepada saya sehingga dapat menimba ilmu di Bagian Ilmu Bedah.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dr. Sahudi, SpB (K) KL selaku Kepala Divisi Bedah Kepala Leher telah memberi kesempatan kepada kami mengikuti Program Training Bedah Kepala Leher, serta membimbing dan mengarahkan selama masa training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tulus Panuwun, dr, MS, Sp PA (K), selaku pembimbing di bidang Patologi Anatomi yang telah meluangkan waktunya memberikan masukan serta perbaikan dalam penelitian ini.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Atika Ssi, MKes selaku pembimbing statistik yang telah meluangkan waktu dan pikirannya dalam membimbing dalam bidang statistik dan metodologi penelitian.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Prof. Dr. Martatko Marmowinoto SpB(K)Onk(KL) yang membimbing dan memberi nasehat, mengarahkan selama training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dr. Urip Murtedjo SpB(K)KL yang membimbing, memberikan motivasi dan nasehat selama training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dr. Yoga Wijayahadi SpB(K)Tauma (K)KL yang penuh kesabaran membimbing dan memberikan motivasi selama training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dr. Dwi Hari Susilo SpB(K)Onk (K)KL yang membimbing dan memberikan motivasi selama training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dr. Maryono Dwi Wibowo SpB(K)KL yang membimbing dan memberikan motivasi selama training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Seluruh Senior, teman-teman trainee, staf administrasi dan peserta PPDS Ilmu Bedah di lingkungan Laboratorium/SMF Ilmu Bedah dan Patologi Anatomi Fakultas Kedokteran Universitas Airlangga/ RSU dr. Soetomo Surabaya yang telah banyak membantu dan bekerja sama dengan baik selama masa training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Seluruh staf paramedik, staf administrasi di GBPT RSUD Dr. Soetomo yang senantiasa membantu penulis selama masa training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Semua pihak yang telah membantu dalam kelancaran penelitian ini. </span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Terima kasih dan rasa hormat saya yang tak terhingga kepada kedua orang tua serta saudara-saudara saya, ibu mertua saya dan seluruh keluarga atas iringan doa dan kasih sayang selama masa training.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Istriku tercinta, Hellen Rumambi dan anak-anakku tersayang Quincy Romano dan Noah Aaron, terima kasih untuk seluruh cinta, kasih sayang, pengorbanan dan doa yang diberikan selama training.</span></li>
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<span style="letter-spacing: 0.0px;">Akhirnya penulis menyadari bahwa karya tulis ini masih banyak kekurangan dan kelemahan, sehingga kritik dan saran untuk penyempurnaanya sangat penulis harapkan. Besar harapan penulis, karya akhir ini dapat membantu para tenaga medis dalam merawat penderita. Penulis tak lupa menyampaikan mohon maaf sedalam-dalamnya atas kesalahan dan kekurangan selama masa pendidikan. Kiranya Kasih Tuhan menyertai kita semua.</span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Surabaya, Desember 2012</span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Penulis</span></div>
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<span style="letter-spacing: 0.0px;"><b>DAFTAR LAMPIRAN</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>KORELASI ANTARA EKSPRESI GALECTIN-3 SITOPLASMA DENGAN GRADE DAN METASTASE KARSINOMA SEL SKUAMOSA RONGGA MULUT</b></span></div>
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<span style="letter-spacing: 0.0px;">Theo Adolf Rompas* , Sunarto Reksoprawiro*, Tulus Panuwun**</span></div>
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<span style="letter-spacing: 0.0px;"><b>ABSTRAK</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Tujuan:</b> <i>Galectin-3</i> adalah suatu gugus protein yang berikatan dengan <i>β-galactoside </i>yang berperan dalam banyak fungsi biologis baik normal maupun patologis seperti regulasi proliferasi sel, angiogenesis, hambatan apoptosis dan adhesi sel. Penelitian ini bertujuan mengetahui nilai prognostik ekspresi <i>galectin-3 </i>pada karsinoma sel skuamosa rongga mulut.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Bahan dan Cara</b>: Penderita yang masuk dalam penelitian ini adalah penderita karsinoma sel skuamosa rongga mulut yang menjalani pembedahan di Divisi Bedah Kepala Leher Bagian Ilmu Bedah Fakultas Kedokteran Universitas Airlangga/ RSU Dr. Soetomo Surabaya tahun 2010-2012. Ekspresi <i>galectin-3 </i>diperiksa dengan cara imunohistokimia dengan menggunakan antibodi monoklonal <i>galectin-3 Ab-1 (Clone9C4),</i> dalam satu seri pemeriksaan pada 30 spesimen karsinoma sel skuamosa rongga mulut di Bagian Patologi Anatomi Fakultas Kedokteran Airlangga/ RSU Dr Soetomo Surabaya.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Hasil: </b>Dua puluh delapan (93,3%) dari 30 spesimen menunjukkan ekspresi <i>galectin-3. </i>Dengan uji statistik, peningkatan ekspresi <i>galectin-3 </i>ini tidak berhubungan dengan derajat histopatologi, besar tumor maupun status KGB.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Kesimpulan:</b> Ekspresi <i>galectin-3 </i>pada tidak berkorelasi dengan grade dan metastase karsinoma sel skuamosa rongga mulut.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Kata kunci</b>: Ekspresi <i>galectin-3</i>, karsinoma sel skuamosa rongga mulut, derajat histopatologi, besar tumor, status KGB.</span></div>
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<span style="letter-spacing: 0.0px;">*<span class="Apple-tab-span" style="white-space: pre;"> </span>Divisi Bedah Kepala Leher Bagian Ilmu Bedah Fakultas Kedokteran Universitas Airlangga / RSU. Dr. Soetomo Surabaya</span></div>
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<span style="letter-spacing: 0.0px;">**<span class="Apple-tab-span" style="white-space: pre;"> </span>Bagian Patologi Anatomi</span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Fakultas Kedokteran Universitas Airlangga / RSU. Dr. Soetomo Surabaya</span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB I</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>PENDAHULUAN</b></span></div>
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<span style="letter-spacing: 0.0px;">Karsinoma rongga mulut saat ini menempati urutan ke enam dari keseluruhan jenis keganasan yang ada (Jerjes et al., 2012). Karsinoma rongga mulut adalah kelompok keganasan yang masuk dalam kategori keganasan kepala leher (Wein et al., 2010). Topik diskusi karsinoma rongga mulut identik dengan pembicaraan tentang karsinoma sel skuamous pada rongga mulut <i>(oral squamous cell carcinoma)</i> oleh karena karsinoma tersebut mencakup 90%-95% dari keseluruhan jenis keganasan (Cohen et al, 2006; Abeloff, 2008; Wein et al, 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Rata-rata diseluruh dunia setiap hari ditemukan kurang lebih 640.000 kasus baru karsinoma rongga mulut, tetapi secara geografis terdapat perbedaan pada setiap daerah atau negara (Oral Cancer Foundation, 2012). Di Amerika Serikat, ACS (American Cancer Society) dan OCF (Oral Cancer Foudation) menyatakan selama tahun 2012 setiap hari ditemukan 100 kasus baru karsinoma rongga mulut dan faring, dan dalam setahun total akan berjumlah 40.250 kasus baru (OCF, 2012; ACS, 2012; SEER, 2012). Disamping itu diperkirakan total jumlah kematian sebanyak 7.850 kejadian dengan asumsi, dalam setiap jam akan ada satu pasien yang meninggal akibat keganasan rongga mulut (ACS, 2012). Jumlah ini menunjukan peningkatan dibanding tahun tahun sebelumnya, dimana selama tahun 2011 kasus baru berjumlah 37.000 (OCF, 2012) dan pada tahun 2002 berjumlah 20.300 (Shah dan Patel, 2003). Di negara barat dan Amerika Serikat, dari tahun 2005-2009 rata-rata kasus baru 10,8 per 100.000 populasi (ACS, 2012; SEER, 2012). </span></div>
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<span style="letter-spacing: 0.0px;"><i>Center for Disease Control and Prevention</i> (CDC) menyampaikan sejak tahun 2004-2008 insiden berkurang 1.0% pada wanita, akan tetapi pada laki-laki dan kelompok tertentu seperti etnis kulit hitam dan kelompok sosial ekonomi rendah, angka kejadiannya cenderung meningkat (CDC, 2005; Abeloff, 2008; ACS, 2012).</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span></div>
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<span style="letter-spacing: 0.0px;">Secara epidemiologis jumlah insiden dan prevalen tiap negara berbeda, tapi faktor predisposisi utama tetap sama yaitu rokok/tembakau dan alkohol. Di Amerika Serikat terjadi hal sebaliknya, dimana peningkatan insiden karsinoma, kecuali di Amerika Serikat, dimana peningkatan insiden infeksi HPV-16 dihubungkan dengan peningkatan angka kejadian karsinoma rongga mulut. Di Asia bagian selatan dan India, mengunyah tembakau, <i>betel quid</i> dan <i>areca-nut</i> dianggap sebagai pencetus utama disamping merokok (Farah, 2012; SERR, 2012; ACS, 2012). Selain alkohol dan tembakau, paparan sinar matahari yang tinggi, terutama ultraviolet-B, menjadi penyebab utama karsinoma pada bibir, seperti yang banyak terjadi di Australia (Bittar et al., 2010; Manuaba, 2010). Faktor-faktor predisposisi diatas dan faktor predisposisi lain seperti infeksi virus EBV dan HPV-type16, faktor lingkungan dan iritasi kronis, pada umumnya bisa dicegah <i>(preventable risk factor), </i>kecuali kerentanan genetik (<i>genetic susceptibility) </i>(Wein et al., 2010; Saman, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Terapi utama karsinoma rongga mulut mencakup pembedahan, sedangkan terapi lain merupakan terapi tambahan seperti radioterapi, kemoterapi, <i>photodynamic therapy</i>, imunoterapi dan <i>targeted therapy </i>(Jerjes et al., 2012; Szeimies et al., 2012; ACS, 2012). Karsinoma rongga mulut jika di terapi pada stadium dini, <i>survival rate</i> mencapai 80-90%, tapi pada umumnya pasien datang sudah pada stadium lanjut, kurang lebih 53,16% dari keseluruhan kasus (Bittar et al., 2010). Angka kematian pada stadium lanjut sangat tinggi, jumlah yang meninggal dalam 5 tahun pertama setelah didiagnosa sebesar 50%-61% atau <i>relative 5-year survival rate </i>36,3% pada stadium III dan 23,3% pada stadium IV (Wein, 2010; Bittar et al.,2010; ACS, 2012). Keadaan ini terjadi di negara berkembang maupun di negara-negara maju (OCF, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Sampai saat ini kemajuan teknologi dianggap belum dapat memperbaiki prognosis karsinoma rongga mulut. Hal ini karenak adanya keterlambatan diagnosis baik karena keterlambatan pasien maupun dokter, juga akibat lemahnya faktor prognostik yang ada sekarang seperti sistem TNM dan <i>grading</i> histopatologi (Ganly et al., 2009; Mahdey et al., 2011; ACS, 2012). Faktor prognostik yang tepat tidak saja untuk memperkirakan <i>survival rate</i>, tapi lebih dari itu dapat merubah rencana terapi, seperti tindakan lebih agresif walaupun masih dalam stadium dini. </span></div>
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<span style="letter-spacing: 0.0px;">Faktor prognostik selain sistem TNM dan <i>grading</i> histopatologi telah banyak dilaporkan antara lain faktor etnis, umur, jenis kelamin, gaya hidup, ada tidaknya <i>protective factor</i>, lokasi tumor, besar tumor, ketebalan tumor, batas reseksi bebas tumor baik secara histopatologis maupun secara imunohistokimia <i>(molecular margin/gene signature)</i>, derajat diferensiasi, adanya invasi perineural atau pembuluh darah dan pemeriksaan biomarker baik jaringan ataupun serum (Bittar et al., 2010; Wein et al., 2010; Balan et al., 2010; Srivastava et al., 2011; Mahdey et al., 2011; Reis et al, 2011; Moraes et al., 2012). Salah satu<i> biomarkers</i> <i>(molecular markes)</i> yang mulai diteliti sekarang adalah <i>galectin-3 </i>atau disingkat <i>Gal-3</i> yang dapat diperiksa secara lokal pada jaringan tumor maupun secara sistemik pada serum (Cooper dan Baronds, 1999; Mazurek et al., 2000; Tadbir et al., 2010; Balan et al., 2010; Cay, 2012; Lepur, 2012).</span></div>
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<span style="letter-spacing: 0.0px;"><i>Galectin-3</i> adalah suatu gugus protein yang berikatan dengan <i>glycan</i>, dalam hal ini berupa <i>β-galactoside</i> (<i>β-galactoside-binding protein</i>) (Mazurek et al., 2000; Lepur, 2012).</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span><span style="letter-spacing: 0.0px;">Secara spesifik <i>galectin-3 </i>terdiri dari 3 <i>domains</i> yaitu: terminal pendek NH2 tempat terjadinya fosforilasi serine; rangkaian protein berulang menyerupai kolagen alfa dan satu terminal COOH yang merupakan gugus protein yang memiliki affinitas dengan karbohidrat yang disebut dengan <i>carbohydrate-binding domains</i> atau <i>carbohydrate-recognition domain (CRD)</i>. Substans yang berikatan dengan <i>galectin-3</i> umumnya berupa <i>ligand</i> (Lepur, 2012). Ikatan ini mencetuskan banyak fungsi, antara lain membantu transformasi neoplastik, proses angiogenesis, perkembangan neoplasma melalui regulasi proliferasi sel, hambatan apoptosis dan meningkatkan adhesi sel (Cooper dan Barondes, 1999; Mazurek et al., 2000; Balan et al., 2010; Lepur, 2012). Secara umum ekspresi <i>galectin-3 </i>dihubungkan dengan invasi dan metastase tumor (Piantelli et al., 2002; Takenaka et al., 2005).</span></div>
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<span style="letter-spacing: 0.0px;">Berbagai laporan tentang <i>galectin-3</i> sebagai <i>biomarkers</i> telah banyak dilaporkan, termasuk hubungannya dengan berbagai penyakit keganasan seperti keganasan pada ovarium, payudara, gaster, kolon, tiroid, esofagus, kandung kemih, prostat, paru-paru, pankreas, maupun pada jenis keganasan tertentu seperti pada glioma, meningioma, limfoma, melanoma dan karsinoma sel skuamous (Honjo et al., 2000; Abe dan Suzuki, 2007; Tsuboi et al., 2007; Balan et al., 2010). Pada umumnya penelitian-penelitian ini menyokong bahwa <i>galectin-3 </i>berperan dalam progresifitas dan agresifitas kanker melalui temuan tingginya konsentrasi <i>galectin-3 </i>dalam serum maupun jaringan tumor (Inohara et al.,1999; Choufani et al., 1999; Iurisci et al., 2000; Shibata et al.,2005; Davidson et al., 2006; Pietro et al., 2006; Vereecken et al., 2007; Miranda et al., 2009; Zhao et al., 2009; Zhao et al., 2010; Choi et al., 2010; Tadbir et al., 2010; Zhao et al., 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Dipihak lain, beberapa penelitian yang menemukan korelasi terbalik, dimana penurunan ekspresi <i>galectin-3 </i>diasosiasikan dengan potensi metastase, seperti pada karsinoma payudara, ovarium, uterus dan prostat (Honjo et al., 2000; Piantelli et al., 2002; Takenaka et al., 2004). Hasil penelitian <i>galectin-3 </i>pada karsinoma kolon bahkan mendapatkan dua hasil yang berbeda, sebagian menemukan peningkatan ekspresi, sebagian lagi menemukan terjadi penurunan ekspresi (Honjo et al., 2000). Eude-Le Parco dkk melalui percobaan pada tikus yang diinduksi mengalami kanker usus menyerupai karsinoma kolorektal pada manusia, menemukan bahwa, ada atau tidak ekspresi <i>galectin-3 </i>tidak mempengaruhi progresifitas maupun agresifitas pada proses keganasan yang diteliti (Eude-Le Parco et al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Hasil penelitian yang bervariasi ini, dapat dimungkinkan karena ekspresi <i>galectin-</i>3 tergantung jenis organ atau jaringan dan sifat tumor (Takenaka et al., 2004). Selain itu adanya perbedaan pada cara pemeriksaan, alat dan teknik, maupun perbedaan lokasi <i>galectin-3, </i>yang terdeteksi, apakah dalam serum, inti sel maupun sitoplasma (Choufani et al., 1999; Iurisci et al., 2000; Shibata et al.,2005; Davidson et al., 2006; Zhao et al., 2009; Tadbir et al., 2010; Zhao et al., 2010; Balan et al., 2010; Cay, 2012). Dengan demikian, dalam melakukan penelitian tentang hubungan <i>galectin-3 </i>dengan suatu proses keganasan harus dilakukan dengan hati-hati, dimana perlu dipertimbangkan hal-hal yang dapat mempengaruhi ekspresi <i>galectin-3.</i> (Vereecken et al., 2007). </span></div>
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<span style="letter-spacing: 0.0px;">Dalam penelitian ini akan dicari korelasi antara tingkat ekspresi <i>galectin-3</i> dalam sitoplasma jaringan tumor dengan agresifitas karsinoma rongga mulut, dalam hal ini hubungannya dengan derajat histopatologi, besar tumor (<i>T stage), nodal status</i> dan metastase jauh, untuk menentukan apakah ekspresi <i>galectin-3 </i>sel tumor mempunyai nilai prognostik.</span></div>
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<span style="letter-spacing: 0.0px;">Apakah ekspresi <i>galectin-3</i> sitoplasma sel tumor berkorelasi dengan derajat histopatologis dan metastase karsinoma sel skuamosa rongga mulut.</span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Tujuan penelitian</b></span></li>
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<span style="letter-spacing: 0.0px;">Mengetahui korelasi antara ekspressi <i>galectin-3</i> sitoplasma sel tumor dengan derajat histopatologis dan metastase karsinoma sel skuamosa rongga mulut.</span></div>
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<span style="letter-spacing: 0.0px;">Dengan mengetahui hubungan ekspressi <i>galectin-3</i> sitoplasma sel tumor dengan derajat histopatologis dan metastase karsinoma sel skuamosa rongga mulut, maka dapat ditentukan apakah <i>galectin-3</i> mempunyai nilai prognostik. Hal tersebut dapat menjadi acuan bagi klinisi dalam perencanaan terapi, terutama pada stadium dini atau pada kondisi belum tampaknya metastase baik regional maupun sistemik.</span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB II</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>TINJAUAN KEPUSTAKAAN</b></span></div>
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<span style="letter-spacing: 0.0px;">Kanker adalah salah satu penyakit dengan tingkat mortalitas dan morbiditas yang tinggi, dimana diseluruh dunia ditemukan lebih dari 10 juta kasus baru setiap tahunnya, terdapat 20 juta pasien yang saat ini hidup dengan kanker dan 6 juta kematian setiap tahunnya adalah akibat kanker (Petersen, 2008). Diperkirakan 43% dari seluruh kematian akibat kanker, adalah kanker yang berhubungan dengan tembakau, alkohol, <i>unhealthy diets</i>, kurang aktifitas dan infeksi (Petersen, 2008). Tembakau dan alkohol secara sinergi menjadi penyebab utama kanker pada daerah kepala dan leher seperti pada rongga mulut, faring, laring dan esofagus (Petersen, 2008; Bolesina et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Proses keganasan pada daerah kepala leher mencakup karsinoma rongga mulut, faring, sinus paranasal, kelenjar liur, kelenjar tiroid, melanoma, sarkoma dan <i>small cell neuroendocrine</i>. Variasi karsinoma pada daerah kepala dan leher, selain berbeda lokasi, juga berbeda jenis histopatologi dan berbeda sifat biologinya (Cohen et al., 2006; Wein et al., 2010). Jenis histopatologi yang paling sering adalah karsinoma sel skuamosa, dengan lokasi anatomi utama pada rongga mulut <i>(Oral Squamous Cell Carcinoma</i>), dimana menempati lebih dari 90% dari seluruh jenis keganasan pada kepala leher (Cohen et al., 2006). </span></div>
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<span style="letter-spacing: 0.0px;">Karsinoma rongga mulut saat ini menempati urutan ke enam dari keseluruhan jenis kanker yang ada (Jerjes et al., 2012; Ogbureke dan Bingham, 2012). Rata-rata di seluruh dunia setiap tahun ditemukan kurang lebih 640.000 kasus baru dimana 2/3 dari jumlah tersebut terjadi di negara-negara berkembang (Ganly et al., 2009; Oral Cancer Foundation, 2012). Di Uni Eropa ditemukan 66.650 kasus baru tiap tahun (Ganly et al., 2009). Insiden di negara barat dan di Amerika Serikat dari tahun 2005-2009 berjumlah 10,8 per 100.000 populasi (ACS, 2012; SEER, 2012). Laporan dari <i>Oral Cancer Foundation </i>US yang di update tanggal 27 September 2012 menyatakan di Amerika Serikat setiap hari ditemukan 100 kasus baru keganasan rongga mulut dan faring dan diperkirakan akan berjumlah 40.250 kasus baru selama tahun 2012, dimana satu pasien akan meninggal tiap jamnya (Oral Cancer Foundation, 2012; ACS, 2012; SEER, 2012). Jumlah ini menunjukkan peningkatan dibanding tahun sebelumnya, dimana pada tahun 2011 kasus baru berjumlah 37.000, sedangkan pada tahun 2002 berjumlah 20.300 (Shah dan Patel, 2003; Oral Cancer Foundation, 2012; Abeloff, 2008; Wein et al, 2010). <i>American Cancer Society</i> dan <i>Center for Disease Control and Prevention</i> menyampaikan adanya penurunan insiden pada tahun 2004-2008 sebesar 1.0% pada kelompok wanita akan tetapi pada laki-laki dibawah 45 tahun, penduduk golongan kulit hitam dan pada golongan dengan sosial ekonomi lebih rendah cenderung terjadi peningkatan insiden (CDC, 2005; Abeloff, 2008; ACS, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Negara yang melaporkan terjadi peningkatan insiden karsinoma rongga mulut antara lain Denmark, Prancis, German, Skotlandia, Eropa Timur dan Eropa bagian tengah, Australia, Jepang, New Zealand dan USA (Petersen, 2008). Peningkatan insiden kira-kira 4,4%, terutama pada kelompok umur lebih muda dan termasuk dalam golongan bukan pengguna tembakau maupun alkohol <i>(non-smokers dan non-drinkers)</i> dan diduga berhubungan dengan HPV-16 (D’souza et al., 2005; Cohen et al, 2006; ACS, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Adanya perbedaan prevalensi karsinoma rongga mulut pada tiap negara atau daerah berhubungan dengan perbedaan geografis dan etnis, perbedaan budaya dan kebiasaan setempat, misalnya dalam hal konsumsi alkohol, tembakau. Demikan juga, perbedaan ini dipengaruhi adanya perbedaan kondisi lingkungan kerja seperti daerah industrial, jumlah polutan dan jumlah paparan sinar matahari. Perbedaan prevalensi ini juga dipengaruhi adanya kerentanan pada etnis tertentu. Dengan adanya perbedaan-perbedaan ini, terbentuk daerah dengan kategori daerah berprevalensi tinggi karsinoma rongga mulut <i>(high risk areas/endemic areas)</i> ataupun daerah dengan prevalensi rendah <i>(low risk areas) </i>(Cohen et al., 2006; Ganly et al., 2009; Feller dan Lemmer, 2012; Ogbureke dan Bingham, 2012;).</span></div>
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<span style="letter-spacing: 0.0px;">Prevalensi karsinoma rongga mulut di Bangladesh, India, Pakistan dan Srilangka merupakan daerah dengan prevalensi paling tinggi di dunia, 30% dari jumlah total diseluruh dunia, sedangkan di Inggris hanya 3% dan di Prancis sebesar 6% (Ganly et al., 2009). Pada daerah tertentu di Taiwan, juga ditemukan tingginya angka kejadian dan kematian karsinoma rongga mulut, yang dihubungkan dengan adanya polusi logam berat dalam tanah, seperti Cr, Ni, Cu dan Zn (Chiang et al., 2012). Di Israel adanya kerentanan etnis terhadap kejadian karsinoma rongga mulut, dapat dilihat tingginya kejadian pada kelompok <i>Ashkenazi-Jews</i> dari pada <i>Sephardic-Jews</i>, dimana pada kedua kelompok ini selain terdapat perbedaan geografisnya juga terdapat perbedaan secara genetik <i>(genetic susceptibility)</i> (Sidransky, 2008; Feller dan Lemmer, 2012). Daerah dengan sosioekonomi rendah, kebiasaan konsumsi alkohol maupun tembakau yang tinggi, gizi kurang, kebersihan dan layanan kesehatan yang rendah, juga merupakan tempat-tempat dengan prevalensi tinggi karsinoma rongga mulut (Cohen et al., 2006; Ganly et al., 2009; Ogbureke dan Bingham, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Faktor resiko atau faktor predisposisi utama karsinoma rongga mulut adalah rokok/tembakau dan alkohol.</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span><span style="letter-spacing: 0.0px;">(Manuaba, 2010; Bittar et al., 2010; SEER, 2012; ACS, 2012). Di Australia lebih banyak ditemukan kanker pada bibir karena tingginya paparan sinar matahari (ultraviolet) (Manuaba, 2010; Bittar et al., 2010). Faktor faktor lain yang berhubungan dengan kejadian karsinoma rongga mulut, mencakup infeksi virus EBV dan HPV-type16, <i>genetic susceptibility</i> seperti pada Plummer-Vinson <i>syndrome</i>, gangguan nutrisi atau kurangnya faktor protektif. (Newkirk dan Holsinger, 2006; Radhakrishnan et al., 2012; Saman, 2012; Bittar et al., 2012; Feller dan Lemmer, 2012; Farah et al., 2012). Paparan bahan kimia/logam berat, iritasi mekanis yang lama seperti pada penggunaan gigi palsu yang tidak tepat atau gigi yang tajam dan pada beberapa penyakit kronis, seperti sifilis dan HIV dapat mencetuskan karsinoma rongga mulut (Wein et al.,2010; Manuaba, 2010; ACS, 2012; Chiang et al., 2012; Saman, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Dari seluruh faktor resiko yang ada, tembakau <i>(smoke/smokeless)</i> dan alkohol diperkirakan berperan 75%-80% sebagai penyebab karsinoma rongga mulut (Uittamo, 2012). Data yang ada, menunjukkan bahwa lebih dari 90% pasien dengan kanker rongga mulut mempunyai hubungan dengan penggunaan tembakau (Ganly et al., 2009). Dibandingkan antara perokok <i>(smoker)</i> dan para pengguna tembakau tanpa merokok <i>(smokeless tobacco users)</i> ternyata kejadian karsinoma rongga mulut lebih tinggi pada perokok (Balfour et al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Bahan karsinogen yang terdapat pada rokok sangat banyak, seperti <i>acetaldehyde, nitrosamines</i> dan berbagai radikal bebas. <i>Nitrosamines</i> terbukti ditemukan tinggi kandungannya pada saliva pengguna tembakau tanpa merokok <i>(smokeless tobacco users).</i> <i>Nitrosamines</i> merusak enzim-enzim yang bersifat antioksidan seperti katalase dan <i>glutathione reductase</i> (Ogbureke dan Bingham, 2012). Beberapa peneliti menyampaikan bahwa karsinogen utama yang terkandung dalam tembakau yaitu <i>acetaldehyde,</i> kadarnya sangat tinggi, dengan jumlah kurang lebih 1000 kali lebih banyak dari bahan karsinogen lain (Balfour et al., 2009; Uittamo, 2012). Walaupun demikian rokok bukan faktor etiologi tunggal, oleh karena dari seluruh perokok di seluruh dunia hanya sebagian kecil yang mengidap karsinoma rongga mulut (Ganly et al., 2009). </span></div>
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<span style="letter-spacing: 0.0px;">Selain dalam tembakau, <i>acetaldehyde</i> juga berperan sebagai karsinogen utama dalam minuman beralkohol (Wang dan Inoue-Fruehauf, 2006; </span><span style="color: #323333; letter-spacing: 0.0px;">McCullough et al., 2012)</span><span style="letter-spacing: 0.0px;">. Dengan demikian tembakau dan alkohol secara bersamaan meningkatkan kandungan <i>acetaldehyde </i>dalam saliva <i>(</i>sinergisme<i>). </i>Keadaan ini yang menyokong sinergisme tembakau dan alkohol sebagai pencetus karsinoma ronggga mulut. Konsumsi alkohol ringan sampai sedang beresiko 3-9 kali mendapatkan karsinoma rongga mulut, sedangkan peminum alkohol berat <i>(heavy drinkers)</i>, faktor resikonya meningkat sampai 30 kali. Jika seseorang peminum berat (<i>heavy drinkers) </i>juga termasuk perokok berat <i>(heavy smokers)</i>, maka faktor resiko ini akan meningkat menjadi 100 kali dibanding bukan perokok dan bukan peminum <i>(non-smokers and non-drinkers) </i>(Ogbureke dan Bingham, 2012; Uittamo, 2012). Penelitian terakhir juga menunjukan bahwa penggunaan <i>mouthwashes</i> yang mengandung alkohol ternyata meningkatkan resiko karsinoma rongga mulut, dan lebih meningkat lagi resikonya jika disertai dengan merokok atau konsumsi alkohol (</span><span style="color: #323333; letter-spacing: 0.0px;">McCullough et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Beberapa minuman beralkohol dengan kandungan <i>acetaldehyde</i> tinggi, antara lain minuman <i>Calvados</i> di Prancis, <i>port wines</i> dan beberapa minuman keras lain yang terbuat dari buah-buahan tertentu di Eropa Timur. Minuman keras dengan kadar<i> acetaldehyde </i>rendah terdapat pada <i>vodka</i> dan <i>beer</i> (Uittamo, 2012). </span></div>
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<span style="letter-spacing: 0.0px;"><i>Acetaldehyde</i> selain terdapat dalam tembakau dan alkohol, ternyata juga terbentuk dari hasil metabolisme etanol oleh enzim <i>alcohol dehydrogenase (ADH)</i>. Secara normal a<i>cetaldehyde</i> yang terbentuk oleh ADH<i> </i>akan di metabolisme lebih lanjut oleh enzim <i>aldehyde dehydrogenase </i>(ALDH) menjadi acetat yang tidak bersifat karsinogen. Aktifitas ADH dan ALDH ini terdapat pada seluruh sel, termasuk dalam mukosa rongga mulut. Defisiensi aktifitas ALDH pada etnis tertentu atau adanya <i>polymorphisms </i>pada gen ALDH, menunjukkan adanya peningkatkan konsentrasi <i>acetaldehyde</i> dalam darah maupun dalam saliva (Sidransky, 2008).</span></div>
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<span style="letter-spacing: 0.0px;">Metabolisme etanol selain terjadi dalam sel mukosa normal juga dimetabolisme oleh mikroba normal rongga mulut dengan aktifitas ALDH yang rendah, sehingga dengan metabolisme yang tidak lengkap, lebih banyak terbentuk <i>acetaldehyde</i>, dan menumpuk dalam rongga mulut dan saliva (McCullough et al., 2012; Uittamo, 2012). Selain itu beberapa penelitian menunjukan bahwa ternyata <i>acetaldehyde </i>juga diproduksi mikroba normal rongga mulut melalui metabolisme karbohidrat secara anaerob (McCullough et al., 2012). Jenis mikroba rongga mulut yang telah diidentifikasi berjumlah lebih dari 750 macam spesies, dimana 50% adalah jenis streptokokus yang berupa kuman gram positif. Jenis mikroba lain antaranya, kuman gram negatif, jamur dan virus. Dalam keadaan normal, mikroba rongga mulut akan melekat pada lapisan tipis glikoprotein yang terdapat pada permukaan gigi yang disebut <i>pellicle</i> dan membentuk <i>biofilm</i>. <i>Pellicle</i> diproduksi oleh kelenjar liur dan berfungsi melindungi gigi dari keasaman. Jika kebersihan rongga mulut jelek, <i>biofilm</i> akan menebal, membentuk <i>plaque. </i>Sumber energi mikroba rongga mulut adalah karbohidrat, dan hasil metabolisme akhir karbohidrat adalah <i>acetyl coA,</i> tapi dalam keadaan anaerob metabolisme akhir adalah <i>acetyldehyde </i>yang bersifat karsinogen (Uittamo, 2012). Dengan demikian, kebersihan rongga mulut yang buruk, penggunaan alkohol, penggunaan tembakau dan adanya <i>polymorphisms (kerentanan genetik),</i> secara bersamaan meningkatkan resiko karsinoma rongga mulut.</span></div>
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<span style="letter-spacing: 0.0px;">Konsentrasi <i>acetyldehyde</i> dalam rongga mulut dapat berkurang bermakna dengan penggunaan cairan kumur <i>chlorhexidine</i>, permen karet yang mengandung <i>xylitol</i> dan bahan makanan/ tablet suplemen yang mengandung asam amino semi-essential seperti <i>L-Cysteine, </i>yang banyak terdapat pada daging, yogurt, telur, susu dan brokoli yang bersifat mencegah pertumbuhan tumor <i>(protective effects)</i> (Uittamo, 2012; Radhakrishnan et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Saat ini di Amerika Serikat terdapat paradigma baru penyebab karsinoma rongga mulut dan faring, yaitu infeksi HPV16, khususnya pada kelompok <i>non-smoker non drinkers</i> (D’souza et al., 2005; ACS, 2012). Dari keseluruhan penderita karsinoma rongga mulut ditemukan kurang lebih 90% terinfeksi HPV-16 (Bittar et al., 2010; Oral Cancer Foundation, 2012; Farah et al., 2012). HPV dideteksi melalui pemeriksaan jaringan tumor apakah ada atau tidak HPV-DNA (Cohen et al. 2006). HPV16 adalah virus yang sama, yang ditemukan pada 99,7% penderita karsinoma serviks (Ogbureke dan Bingham, 2012). Jika <i>Epstein Barr virus</i> (EBV) berhubungan dengan karsinoma nasofaring, HPV lebih banyak ditemukan pada karsinoma rongga mulut maupun faring, yaitu 87% pada karsinoma orofaring, 68% pada rongga mulut dan 24% pada laring (Newkirk dan Holsinger, 2006; Balfour et al., 2009). Diduga HPV menginduksi <i>tumorigenesis </i>melalui integrasi dengan gen secara acak dan meningkatkan fungsi proliferasi sel <i>(upregulates),</i> seperti onkogen HPV E6 dan E7 (Balfour et al., 2009). Selain itu integrasi HPV E6 juga menginaktifasi p53 yang berfungsi sebagai <i>tumor supressor gen,</i> menyebabkan gagalnya apoptosis (Cohen et al., 2006; Ogbureke dan Bingham, 2012).</span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Faktor Proteksi</b></span></li>
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<span style="letter-spacing: 0.0px;">Dalam berkembangnya setiap keganasan termasuk keganasan rongga mulut, perlu dipertimbangkan ada tidaknya faktor proteksi/pelindung <i>(protective effects/factors)</i> (Bittar et al., 2010). Faktor protektif saat ini menjadi penting karena memberikan kontribusi besar dalam pencegahan terjadinya karsinoma rongga mulut (Feller dan Lemmer, 2012; Farah et al., 2012). Pada percobaan menggunakan tikus yang dilakukan implantasi sel kanker yang diberikan <i>pectin</i> yang dimodifikasi dari jeruk <i>(modified citrus pectin</i>), menunjukkan terjadi hambatan pertumbuhan tumor, hambatan angiogenesis dan hambatan metastase melalui hambatan pada fungsi <i>galectin-3</i> (Nangia-Makker et.al., 2002). Kebiasaan etnis tertentu dengan diet ikan, nasi, sayur dan buah yang segar, terutama yang mengandung karotene dan vitamin C dan E mempunyai efek proteksi pada keganasan rongga mulut (Bittar et al., 2010; Nepomuceno, 2011; Najaran dan Emami, 2011). Kebiasaan secara etnis ini sama sekali tidak berhubungan dengan faktor genetik (Petersen, 2008; Bittar et al., 2010). Faktor diet lain yang dilaporkan sebagai faktor protektif karsinoma rongga mulut adalah minuman kopi, makanan tinggi asam folat dan makanan yang mengandung <i>L-Cysteine</i> (Saman, 2012; Uittamo, 2012). Di negara barat kurangnya faktor protektif ini memberi kontribusi 30%, nomor dua setelah tembakau, sebagai faktor resiko timbulnya keganasan rongga mulut, sedangkan di negara-negara berkembang kontribusinya kira-kira 20% (Petersen, 2008). </span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Biologi Molekular</b></span></li>
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<span style="letter-spacing: 0.0px;">Dengan berbagai faktor resiko dan penyebab yang ada pada penderita karsinoma rongga mulut, proses awal yang terjadi adalah kerusakan gen yang terdapat pada rantai DNA (Manuaba, 2007). Empat kelompok gen utama yang bisa mengalami kerusakan adalah: <i>proto-oncogens, tumor suppressor genes, </i>gen yang mengatur apoptosis dan gen yang mengatur perbaikan DNA (<i>DNA repair) </i>(Kumar et al., 2005). Kerusakan gen ini, apakah mutasi, delesi atau amplifikasi, akan menyebabkan gen tersebut mengkoding pembentukan protein abnormal yang merubah sifat atau bentuk sel tersebut (<i>genetic level and</i> <i>phenotypic levels</i>) menjadi sel neoplasma. Sifat neoplasma ditandai adanya pertumbuhan sel yang cepat, bersifat invasif dan bermetastase atau disebut <i>tumor progression </i>(Kumar et al., 2005; Manuaba, 2007). </span></div>
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<span style="letter-spacing: 0.0px;">Perubahan genetik seperti mutasi, delesi atau amplifikasi yang terjadi sangat kompleks, bertahap dan tidak berdiri sendiri (Kumar et al., 2005). Secara umum tahapan yang terjadi sebagai berikut: <i>non-lethal injury </i>menyebabkan gagalnya<i> repair DNA, </i>gagalnya<i> repair </i>DNA<i> </i>mengakibatkan aktivasi proto-onkogen, inaktivasi <i>tumor suppressor gene </i>dan hambatan apoptosis. Keadaan ini termanifestasi sebagai <i>genetic instability, polymorphisme </i>dan <i>loss of heterozygosity (LOH)</i>, yang merupakan tahap paling dini pertumbuhan neoplasia yang merupakan perubahan tingkat gen <i>(genetic level)</i>. <i>Polymorphisme </i>(banyak bentuk)<i> </i>adalah suatu kondisi dimana hanya satu gen tapi dapat mengkoding lebih dari satu macam produk genetik yang berbeda fungsi dan bentuk, dimana fungsi produk tersebut bisa berkurang atau berlebihan dibanding fungsi normal. Pada tahap ini belum ada manifestasi neoplasma, terjadi pada proses inisiasi dan menyebabkan timbulnya kerentanan genetik (<i>genetic susceptibility).</i> Jika terjadi perubahan genetik lanjutan misalnya <i>point mutation </i>maka gen tersebut akan menampilkan sifat, fungsi dan bentuk sel yang berbeda dari sel induk (<i>phenotypic</i> levels) (Kumar et al., 2005; Sidransky, 2008; Ganly et al., 2009). <i>Point mutation</i> adalah digantinya satu basa nukleotida pada <i>codon</i> pada pasangan alele yang tersisa dengan jenis basa nukleotida yang lain. </span></div>
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<span style="letter-spacing: 0.0px;">Keadaan ini merupakan hasil dari proses adaptasi sel yang lama, kurang lebih diatas 10-20 tahun dan membutuhkan paling tidak 6-10 kejadian perubahan genetik <i>(genetic event) </i>(Wein et al., 2010). Pola ini merupakan model dasar perkembangan dan progresifitas berbagai macam <i>solid tumor</i> (Sidransky, 2008; Ganly et al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Diperkirakan 10% dari keseluruhan keganasan mempunyai komponen herediter, baik yang diketahui seperti pada etnis <i>Ashkenazi-Jews</i> di Israel, <i>Li-Fraumeni syndrome </i>dan anemia <i>Fanconi’s, </i>maupun yang tidak diketahui. Salah satu kerentanan genetik <i>(genetic susceptibility)</i> yang umum terjadi pada karsinoma rongga mulut adalah adanya <i>polymorphisme, </i>misalnya <i>polymorphisme </i>dalam sintesa</span><span style="font-size: 11px; letter-spacing: 0px;"> </span><span style="letter-spacing: 0.0px;">enzim ADH, enzim ALDH, sitokrom P450 (CYP), <i>Glutathione S-Transferase</i> (GST) dan <i>N-acetyltransferase</i> dalam metabolisme alkohol dan <i>acetaldehyde</i>, serta adanya ekspresi enzim <i>telomerase </i>(Sidransky, 2008). </span></div>
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<span style="letter-spacing: 0.0px;">Beberapa hasil penelitian tentang <i>genetic susceptibility </i>tetap konsisten menunjukan bahwa <i>polymorphisme </i>menyebabkan individu tertentu memiliki <i>genetic instability</i> dengan akibat berkurangnya kemampuan memperbaiki kerusakkan DNA <i>(DNA repair)</i>, berkurangnya kontrol siklus sel, berkurangnya fungsi apoptosis dan adanya pemeliharaan telomer <i>(telomere maintenace)</i> <i>(</i>Sidransky, 2008). Telomer adalah urutan basa nukleotida pada bagian paling ujung dari <a href="http://id.wikipedia.org/wiki/DNA"><span style="letter-spacing: 0px;">DNA</span></a> jadi termasuk dalam untai DNA akan tetapi telomer tidak mengkode <a href="http://id.wikipedia.org/wiki/Protein"><span style="letter-spacing: 0px;">protein</span></a> apa pun, sehingga bukan merupakan <a href="http://id.wikipedia.org/wiki/Gen"><span style="letter-spacing: 0px;">gen</span></a>. Telomer akan memendek setiap kali adanya pembelahan sel. Jika telomer sudah terlalu pendek kestabilan genom terganggu dan sel akan mati. Ini adalah kematian sel terprogram atau apoptosis. Pada keadaan tertentu dengan adanya enzim telomerase, telomer akan tetap panjang dan kematian sel tidak terjadi (<i>telomere maintenace)</i>. Pada kondisi normal sel matur tidak memilki enzim telomerase.</span></div>
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<span style="letter-spacing: 0.0px;">Proto-onkogen adalah gen yang secara normal mengontrol pertumbuhan sel. Proto-onkogen yang teraktivasi (amplifikasi) akan menjadi onkogen, dimana onkogen akan menyebabkan pertumbuhan sel yang berlebihan (Chang et al., 2010). Proto-onkogen yang jelas mengalami amplifikasi pada karsinoma sel skuamosa kepala dan leher adalah proto-onkogen <i>cyclin D1 (PRAD1; CCND1)</i> (Sidransky, 2008). Amplifikasi ini ditemukan lebih banyak pada karsinoma pada lidah dan berhubungan dengan prognosa yang jelek (Mahdey et al., 2011). Onkogen lain yang terbentuk adalah onkogen yang mengekspresikan <i>epidermal growth factor reseptor (EGFR)</i> yang meningkatkan pertumbuhan sel epidermis dan <i>matriks metalloproteinase (MMPs), </i>dan sering dihubungkan dengan migrasi dan adhesi sel neoplasma (Sidransky, 2008; Chang et al., 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Tumor suppressor gene (TSG) adalah gen yang fungsinya kebalikan dari proto-onkogen (Chang et al., 2010). Secara normal TSG berperan dalam menghambat pertumbuhan sel (apotosis), regulasi siklus sel, perbaikan DNA dan adhesi sel (Chang et al., 2010). TSG yang paling sering bermutasi adalah p53 melalui <i>point mutation. </i>Mutasi ini bukan saja pada sel kanker tapi ditemukan pada lesi prakanker daerah kepala dan leher. <i>Point mutation</i> ini merupakan <i>genetic event </i>yang melengkapi LOH yang sudah ada pada gen p53 dan merupakan kejadian awal proses keganasan pada daerah kepala leher (Chang et al., 2010).</span></div>
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<span style="letter-spacing: 0.0px;">Konsep <i>field cancerization</i> menunjukan bahwa pada keganasan traktus aerodigestivus bisa disertai dengan <i>second primary tumors </i>berupa<i> metachronous tumor</i> dan <i>synchronous tumor</i>. <i>Second primary tumors </i>pada karsinoma kepala leher, terutama dihubungkan dengan merokok, alkohol maupun paparan sinar matahari (Cohen et al., 2006; Sidransky, 2008; Ganly et al., 2009; Wein et al., 2010; Chang et al., 2010; Szeimies et al., 2012; Jerjes et al., 2012). Tumor primer sekunder <i>(second primary tumors)</i> yang terjadi atau dideteksi bersamaan atau kurang dari 6 bulan sejak tumor primer awal <i>(initial primary tumor), </i>disebut <i>synchronous tumors/lesion</i> sedangkan jika lebih dari 6 bulan disebut <i>metachronous tumors/lesion </i>(Kraus dan Joe, 2003; Wein et al., 2010). <i>Second primary tumor</i> kemungkinan terjadi pada tahun pertama sebesar 4% dan menjadi 25% pada 10 tahun berikutnya (Kraus dan Joe, 2003).</span></div>
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<span style="letter-spacing: 0.0px;"><i>Field cancerization</i> adalah adanya perubahan genetik pada area tertentu akibat adanya paparan karsinogen yang lama dan terus-menerus, misalnya alkohol dan tembakau. Permukaan mukosa aerodigestivus merupakan temoat yang sering mengalami <i>field cancerization. </i>Perubahan genetik utama adalah LOH <i>(loss of heterozygosity) </i>(Ganly et al.,2009). <i>LOH</i> adalah hilangnya fungsi gen pada satu <i>alele </i>berpasangan<i>, </i>misalnya <i>tumor suppressor gene</i> akibat mutasi. Dalam kondisi ini tidak terjadi gangguan fungsi oleh karena <i>tumor suppressor gene </i>pada pasangan <i>alele</i> berfungsi normal. <i>Field cancerization</i> tidak menyatakan telah terjadi proses keganasan, tapi secara molekuler sangat berpotensi berkembang kearah keganasan (Chang et al., 2010; Szeimies et al., 2012; Jerjes et al., 2012). Beberapa penulis menyampaikan bahwa, LOH dapat dideteksi dengan pemeriksaan sederhana <i>toluidine blue</i> atau lampu fluoresensi (</span><span style="color: #323333; letter-spacing: 0.0px;">Ujaoney et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Konsep <i>field cancerization</i> pertama kali di kemukakan oleh Slaughter dkk. pada tahun 1953 dengan dasar bahwa karsinoma sel skuamosa rongga mulut lebih cenderung mengadakan ekstensi kearah samping dari pada kearah dalam, dan menyebutnya sebagai <i>lateral cancerization</i>, yaitu adanya transformasi sel-sel normal disekitar tumor (perkembangan karsinoma multifokal) (Slaughter et al., 1953). Kesimpulan Slaughter ini didasarkan pada pemeriksaan patologi, dimana tampak adanya hiperplasia, hiperkeratinisasi, fibrosis dan atrofi pada tepi reseksi tumor yang secara makroskopis tampak normal, dan dalam folow-up lanjutan dari 783 pasien dengan karsinoma rongga mulut, Slaughter menemukan 11,2% pasien mengalami pertumbuhan tumor primer kedua (Slaughter et al., 1953; Braakhuis et al., 2003). Konsep lain yang berbeda dengan konsep ini dikemukakan oleh Sidransky dkk. Sidransky dkk berpendapat bahwa <i>field cancerization</i> terjadi akibat adanya migrasi sel-sel yang berpotensi ganas ke dalam kumpulan sel-sel normal, jadi tetap satu induk sel <i>(monoclonal),</i> yang selanjutnya mengalami transformasi anaplastik (Dakubo et al., 2007; Sidransky, 2008). </span></div>
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<span style="letter-spacing: 0.0px;">Walaupun tidak menyingkirkan hipotesa Sidransky, banyak peneliti menunjukkan bahwa pada pemeriksaan sel mukosa normal pada penderita karsinoma rongga mulut, hampir seluruhnya ditemukan adanya LOH atau <i>deletion</i> terutama pada kromosom 9p21 (Lydiatt et al., 1998). Data ini menunjukkan bahwa perkembangan keganasan rongga mulut adalah bersifat multifokal, artinya beberapa lesi premaligna yang berdiri sendiri dapat terjadi pada beberapa tempat yang berbeda pada rongga mulut <i>(multiple clonal)</i> (Braakhuis et al., 2003; Feller dan Lemmer, 2011). </span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Lesi Premaligna dan Patologi</b></span></li>
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<span style="letter-spacing: 0.0px;">Beberapa lesi premaligna, yaitu lesi rongga mulut jinak, dapat berkembang kearah keganasan seperti leukoplakia, eritroplakia, <i>submucosal fibrosis, Lichen planus, verrucous hyperplasia, necrotizing sialometaplasia</i> dan <i>dysplasia</i> (Kraus dan Joe, 2003; Wein et al., 2012; Farah et al., 2012). Eritroplakia adalah lesi yang berwarna merah cerah. Secara histopatologi menunjukan gambaran displasia dengan derajat yang bervariasi, dan lebih sering menunjukan gambaran karsinoma <i>in situ</i>. Semua eritroplakia harus diterapi lebih agresif (Ganly et al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Yang paling sering ditemukan adalah leukoplakia, berupa lesi keputihan yang susah dibersihkan. Kemungkinan leukoplakia bertransformasi kearah malignan hanya 6%, sedangkan eritroplakia kemungkinannya 91% menjadi ganas (Wein et al., 2012).</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span><span style="letter-spacing: 0.0px;">Leukoplakia ada dua bentuk yakni <i>homogeneous type</i> dan <i>nonhomogeneous type</i>. <i>Homogeneous</i> leukoplakia berbentuk keputihan, rata dan tipis. Tipe ini banyak ditemukan tapi jarang berubah ke gambaran displasia. <i>Nonhomogeneous leukoplakia</i> berbentuk nodular, berbintik atau <i>verrucous</i> dan sering dihubungkan dengan perubahan displasia. Secara stastistik, beberapa faktor yang berhubungan dengan transformasi leukoplakia kearah malignan adalah sebagai berikut: wanita, leukoplakia yang lama, leukoplakia pada lidah atau dasar mulut, lesi lebih besar dari 2cm, <i>nonhomogeneous type </i>dan adanya displasia (Ganly et.al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Setiap lesi premaligna yang di curigai perlu pemeriksaan histopatologi untuk melihat apakah ada gambaran displasia. Derajat displasia yang dianut adalah klasifikasi WHO 2005 yaitu: hyperplasia, displasia ringan, displasia sedang, displasia berat dan karsinoma <i>in situ</i> (Ganly et al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Pada kondisi ragu-ragu apakah suatu lesi premaligna non displasia akan bersifat agresif atau tidak, dapat dilakukan pemeriksaan <i>toluidine blue, chemiluminescent illumination system, salivary tumor markers</i> <i>(Cyfra 21-1,</i> <i>tissue polypeptide antigen</i> dan <i>CA125)</i> atau pemeriksaan <i>molecular marker </i>berupa <i>salivary microRNA</i>. (Nagler et al., 2006; Poh et al., 2006; Park et al., 2009; Ujaoney et al., 2012; Centelas et al., 2012). Beberapa laporan menyatakan bahwa pemeriksaan dengan <i>toluidine blue</i> dapat membantu mendeteksi adanya LOH pada lesi premaligna, walaupun secara sitologi belum ditemukan adanya gambaran displasia (Ganly et al., 2009). <i>Molecular marker</i> lain yang banyak dilaporkan, antara lain <i>podoplanin, p53, HPV gen, cyclin D1, p27, p63</i> dan <i>galectin-3</i> atau disingkat <i>Gal-3</i> (Cooper dan Baronds, 1999; Mazurek et al., 2000; Ganly et al., 2009; Tadbir et al., 2010; Balan et al., 2010; Cay, 2012; Lepur, 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Terapi lesi premaligna paling baik dilakukan dengan terapi fotodinamik <i>(Photodynamic therapy, PDT),</i> terutama untuk lesi multifokal, dan dapat dikombinasi dengan modalitas terapi yang lain (Jerjes et al., 2012; Szeimies et al., 2012). Fotosensitisasi dapat menggunakan <i>photosensitisers</i> generasi pertama <i>(Photofrin, 5-ALA dan Verteporfin)</i> atau generasi kedua yang sangat <i>potent</i> seperti <i>Foscan</i> (Jerjes et al., 2012). Perkembangan PDT saat ini sudah sangat maju, bahkan sekarang mulai digunakan pada lesi maligna, dengan cara mengkombinasikan dengan <i>antiangiogenic agent</i>, terutama pada kasus dengan resisten kemoradiasi (Bhuvaneswari et al., 2011). PDT saat ini dikenal sebagai modalitas terapi ke empat <i>(the fourth modality)</i> sesudah bedah, radioterapi dan kemoterapi (Jerjes et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Mendeteksi lesi premaligna atau karsinoma rongga mulut sedini mungkin sangat penting oleh karena terapi pada stadium dini <i>survival rate</i> bisa mencapai 80-90%, tapi jika sudah stadium lanjut, angka kematian menjadi sangat tinggi, dimana <i>relative 5-year survival rate</i> 36,3% pada stadium III dan 23,3% pada stadium IV (Wein et al., 2010; Bittar et al., 2010). Rata-rata dari semua stadium, <i>five-year survival rate</i> 50% dan menjadi 15% pada stadium lanjut (Farah et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Secara histopatologi, karsinoma rongga mulut adalah identik dengan karsinoma sel skuamous <i>(oral squamous cell carcinoma</i>) oleh karena mencakup 90%-95% dari keseluruhan jenis keganasan (Abeloff, 2008; Wein et al., 2010; Feller dan Lemmer, 2012; Ogbureke dan Bingham, 2012). Ada beberapa varian dari karsinoma sel skuamous seperti <i>sarcomatoid squamous cell carcinoma, basaliod carcinoma </i>dan<i> verrucous carcinoma. Basaliod carcinoma</i> bersifat sangat agresif, sedangkan <i>verrucous carcinoma</i> adalah varian yang bersifat <i>low grade. Verrucous carcinoma</i> jarang metastase tapi sering mengadakan invasi lokal <i>(locally agressive)</i>. Sifat lain <i>verrucous carcinoma </i>yaitu lebih sering pada umur lanjut, lebih radioresisten, sering rekuren dan dikatakan, berhubungan dengan infeksi HPV (Kraus dan Joe, 2003; Ganly et al., 2009). Jenis histopatologi lain yaitu adenokarsinoma (banyak pada wanita terutama pada palatum durum), sarkoma, limfoma dan melanoma (Ganly et al., 2009; Wein et al., 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Selain jenis histopatologi, derajat histopatologi juga perlu diketahui untuk perencanaan terapi (Wein et al., 2010). Derajat histopatologis adalah suatu penilaian secara kualitatif diferensiasi sel tumor dari sel normal dan jumlah mitosis dalam tumor (Kumar et al., 2005). Derajat histopatologis apakah <i>low grade malignancy</i> atau <i>high garde malignancy</i> sangat berhubungan dengan agresifitas tumor dan prognosa penyakit (Kumar et al., 2005). G1 (<i>grade 1</i>) menunjukkan diferensiasi sel yang baik dimana secara jelas dapat diketahui jenis asal sel (</span><span style="color: #231e20; letter-spacing: 0.0px;"><i>well differentiated)</i></span><span style="letter-spacing: 0.0px;">, sedangkan G4 (<i>grade 4</i>) adalah gambaran sel yang tidak bisa dikenal lagi asalnya (</span><span style="color: #231e20; letter-spacing: 0.0px;"><i>undifferentiated)</i></span><span style="letter-spacing: 0.0px;"> (Greene et al., 2006). Klasifikasi derajat diferensiasi seperti di kutip dari </span><span style="color: #231e20; letter-spacing: 0.0px;"><i>AJCC Cancer Staging Atlas 2006</i> adalah sebagai berikut:</span></div>
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<span style="letter-spacing: 0.0px;"><i>GX<span class="Apple-tab-span" style="white-space: pre;"> </span> Grade cannot be assessed</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G1<span class="Apple-tab-span" style="white-space: pre;"> </span> Well differentiated</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G2<span class="Apple-tab-span" style="white-space: pre;"> </span> Moderately differentiated</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G3<span class="Apple-tab-span" style="white-space: pre;"> </span> Poorly differentiated</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G4<span class="Apple-tab-span" style="white-space: pre;"> </span> Undifferentiated</i></span></div>
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<span style="letter-spacing: 0.0px;">G1 dan G2 termasuk <i>low grade malignancy, </i>sedangkan G3 dan G4 termasuk <i>high grade malignancy </i>(Wein et al., 2010).</span></div>
<ol>
<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Gejala Klinis</b></span></li>
</ol>
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<span style="letter-spacing: 0.0px;">Walaupun rongga mulut mudah diperiksa baik oleh pasien maupun dokter, tapi pada umumnya pasien datang pada stadium lanjut (Ganly et al., 2009). Keterlambatan dalam diagnosa atau mengenal lesi premaligna merupakan salah satu faktor yang menyebabkan buruknya prognosis penyakit ini (Bittar et al., 2010; Feller dan Lemmer 2012; Farah et al., 2012). Jumlah kasus yang di diagnosis sudah pada stadium III berjumlah kurang lebih 53,16% (Bittar et al., 2010).</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span><span style="letter-spacing: 0.0px;">Keadaan ini tidak saja terjadi di negara berkembang tapi juga di negara negara maju (Bittar et al., 2010; Oral Cancer Foundation, 2012). Angka kemungkinan hidup dalam 5 tahun setelah didiagnosis akan turun menjadi 15% jika didiagnosa pada stadium lanjut atau telah ada penyebaran limfatik (Oral Cancer Foundation, 2012; ACS, 2012). Keterlambatan ini mencakup <i>patient delayed</i> dan <i>professional delayed</i> (Farah et al., 2012). <i>Patient delayed </i>maksudnya waktu antara gejala awal dirasakan sampai konsultasi pertama ke dokter, <i>professional delayed</i> adalah waktu antara konsultasi pertama sampai ditetapkannya diagnosa definitif (Centelas et al., 2012; Farah et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Gejala karsinoma rongga mulut bervariasi sesuai letak anatominya (Ganly et al., 2009). Karsinoma rongga mulut dibatasi mulai dari perbatasan kulit dan bagian merah bibir (<i>vermillion</i>), kearah posterior sampai di palatum durum dibagian di bagian superior dan mencakup 2/3 anterior lidah pada bagian inferior dengan batas pada linea terminalis lidah (<i>papila circumvallate</i>) dan pilar anterior tonsil pada sisi lateral (Shah dan Patel, 2003; Wein et al., 2010).</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span><span style="letter-spacing: 0.0px;">Rongga ini terbagi dalam tujuh tempat spesifik <i>(specifik subsite),</i> yaitu: bibir, <i>dentoalveolar ridge</i>, lidah, trigonum retromolar, dasar mulut, mukosa bukal dan palatum durum (Shah dan Patel, 2003; Wein et al., 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Angka kejadian keganasan pada lidah dan dasar mulut cukup tinggi, terutama di negara barat, yaitu 20%-40% pada lidah dan 12%-20% pada dasar mulut. Di Asia dimana banyak kebiasaan mengunyah tembakau dan <i>betel nuts</i>, ditemukan lebih banyak pada daerah trigonum retromolar dan mukosa bukal (Shah dan Patel, 2003). Jika digabungkan seluruh kasus umumnya lidah dan dasar mulut mencakup 50% dari keseluruhan <i>anatomic subsite</i> keganasan rongga mulut (Fellar dan Lemmer, 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Pasien umumnya datang dengan keluhan adanya tumor, perdarahan, nyeri, pembesaran kelenjar getah bening leher atau adanya gangguan bicara, bernapas atau makan (Kraus dan Joe, 2003). Pada banyak kasus, umumnya tidak bergejala. Nyeri timbul karena adanya infiltrasi pada otot atau serabut saraf (Bolesina et al., 2012). Keluhan-keluhan ini harus diperiksa dengan teliti, yang mencakup keseluruhan pemeriksaan rongga mulut dan faring, pemeriksaan leher untuk melihat apakah ada pembesaran kelenjar dan keadaan umum pasien (Newkirk dan Holsinger, 2006). Pertumbuhan tumor yang bersifat <i>endophytic</i>, kadang-kadang sulit dikenal dan sulit ditentukan batas ekstensinya, pada keadaan ini perlu dilakukan pemeriksaan dengan pembiusan umum. Dalam pemeriksaan rongga mulut dan faring perlu diperhatikan untuk melihat apakah ada lesi lain (<i>synchronous tumors/lesion</i>) disamping lesi utama <i>(initial primary tumor)</i>, sesuai konsep <i>field cancerization</i> (Kraus dan Joe, 2003; Ganly et al., 2009). Setiap ulkus rongga mulut yang bersifat nyeri dan tidak sembuh atau tidak ada respons pada pengobatan lokal dalam satu sampai dua minggu atau bertambahnya konsistensi pada observasi, harus dicurigai suatu malignansi dan harus dilakukan biopsi. Lesi jinak jika berkembang ke arah maligna umumnya berbentuk lesi <i>exophytic</i> atau <i>ulcerative</i> (Bolesina et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Gejala yang ditemukan pada bibir sering berupa ulkus dan terutama terjadi pada bibir bagian bawah kira-kira 88%-95% (Wein et al., 2010). Pada lesi bentuk nodular atau sklerotik harus di palpasi untuk menentukan ukuran sebenarnya. Adanya rasa kebas pada salah satu sisi bibir menunjukan adanya infiltrasi pada nervus mentalis (Kraus dan Joe, 2003). Metastase pada kelenjar getah bening leher jarang ditemukan, kira-kira 10% dari kasus. Tapi jika ditemukan sering bersifat bilateral oleh karena adanya komunikasi pada aliran limatiknya (Kraus dan Joe, 2003; Wein et al., 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Keluhan utama tumor pada <i>alveolar ridge</i> biasanya nyeri saat mengunyah (Kraus dan Joe, 2003). Keluhan lain yang lebih jarang adalah adanya perdarahan <i>intermittent</i> dan lepasnya gigi. <i>Mandibular alveolar ridge</i> <i>(lower alveolus)</i> lebih sering timbul lesi dari maksila dan sisi korpus mandibula lebih sering dari daerah simpisis. Adanya anastesia pada gigi dan bibir bawah menunjukan adanya infiltrasi pada kanal mandibula dan nervus alveolaris inferior (Ganly et al., 2009). Metastase ke kelenjar getah bening leher jarang ditemukan (Kraus dan Joe, 2003).</span></div>
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<span style="letter-spacing: 0.0px;">Struktur lidah adalah berupa kumpulan otot yang dibungkus oleh <i>non-keratinizing squamous epithelium</i>. Lidah dalam rongga mulut (2/3 anterior) terbagi atas sisi lateral, sisi ventral, ujung lidah dan sisi dorsal. Sisi ventral lidah berhadapan dengan dasar mulut bagian anterior. Sisi posterolateral adalah bagian yang paling sering mengalami pertumbuhan tumor, kira-kira 75% dibanding sisi yang lain. Keluhan utama tumor ganas lidah adalah ulkus yang nyeri atau benjolan yang bertumbuh eksofitik (Wein et al., 2010). Kadang-kadang ada penjalaran nyeri ke telinga akibat adanya infiltrasi ke cabang mandibularis nervus trigeminus (V3) (Kraus dan Joe, 2003). Kemungkinan adanya <i>second primary tumor </i>pada karsinoma lidah cukup tinggi, sekitar 24% (Kraus dan Joe, 2003). Demikian juga kejadian <i>occult metastase</i> ke kelenjar getah bening leher cukup tinggi, kira-kira 40%. Oleh karena itu dianjurkan dilakukan <i>elective neck dissection </i>sekalipun <i>T-stage</i> pada T1 atau T2 karena secara umum terbukti meningkatkan <i>survival rate (</i>Kraus dan Joe, 2003). </span></div>
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<span style="letter-spacing: 0.0px;">Karsinoma dasar mulut biasanya pada laki-laki dekade ke-6 dan jarang terdeteksi pada stadium dini karena lokasinya tersembunyi (Kraus dan Joe, 2003). Kurang lebih 35% ditemukan dengan besar tumor (<i>T-stage</i>) lanjut, T3-T4 (Wein et al., 2010). Gejala lesi pada dasar mulut umumnya nyeri lokal mapun nyeri pada telinga ipsilateral karena infiltrasi pada nervus lingualis yang merupakan cabang dari nervus mandibularis (V3) (Kraus dan Joe, 2003). Keluhan lain yang cukup sering adalah <i>seperti ada makanan yang terjebak pada dasar mulut</i> (Ganly et al., 2009). Otot dasar mulut, genioglossus, milohioid dan hioglossus berfungsi sebagai <i>barrier</i> penyebaran tumor. Jika ada invasi pada otot-otot ini terjadi hambatan gerakan lidah dan timbul <i>dysarthria</i>. Tumor pada anterior dasar mulut sering berkembang kearah posterior ke dasar lidah (lidah 1/3 posterior). Tumor yang teraba <i>fix</i>, menandakan adanya infiltasi ke periosteum atau ke mandibula (Ganly et al., 2009). Kejadian <i>second primary tumor</i> dan metastase ke kelenjar leher ipsilateral maupun kontralateral cukup sering, sama dengan karsinoma pada lidah, oleh karena itu dianjurkan dilakukan <i>elective neck dissection</i> sekalipun <i>T-stage</i> pada T1 (Kraus dan Joe, 2003; Wein et al., 2010).</span></div>
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<span style="letter-spacing: 0.0px;">Karsinoma pada mukosa bukal sering sekali berbentuk <i>exophytic</i> dengan mukosa sekelilingnya tampak gambaran leukoplakia (Ganly et al., 2009). Jenis patologis yang sering adalah <i>verrucous carcinoma</i> yang bersifat <i>low-grade malignancy</i>, tapi <i>locally aggressive </i>(Kraus dan Joe, 2003; Wein et al., 2010). Karsinoma ini sering diasosiasikan dengan mengunyah tembakau atau <i>betel nut</i> (Wein et al., 2010). Nyeri jarang menjadi keluhan utama sehingga jarang pasien datang dengan tumor T1 (Ganly et al., 2009). Terapi utama adalah reseksi bedah dan jarang diperlukan <i>elective neck dissection </i>(Wein et al., 2010). </span></div>
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<span style="letter-spacing: 0.0px;">Pasien dengan tumor pada trigonum retromolar umumnya terdiagnosa sudah pada stadium lanjut dimana 50% pasien sudah disertai metastase regional (Wein et al., 2010). Adanya trismus menunjukan adanya infiltrasi tumor pada otot pterigoid medialis (Kraus dan Joe, 2003). Ekstensi tumor sering ke dasar lidah, <i>arcus faucial</i> dan tonsil (Wein et al., 2010).</span></div>
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<span style="letter-spacing: 0.0px;">Gejala pada karsinoma palatum durum umumnya nyeri, adanya perdarahan dan gangguan bicara (Kraus dan Joe, 2003). Adanya lesi yang dicurigai keganasan harus dikonfirmasi secara patologis untuk membedakan dengan lesi yang lain. Pada pertumbuhan tumor yang lanjut, terjadi ekstensi ke kavum nasi lewat foramen insisivus atau ke dasar otak melalui foramen palatinus mayor (Kraus dan Joe, 2003). Aliran limfatik dari palatum durum sedikit, sehingga jarang ada metastase regional ke leher (Kraus dan Joe, 2003).</span></div>
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<span style="letter-spacing: 0.0px;">Setiap lesi pada rongga mulut yang dicurigai suatu proses keganasan harus dipastikan dengan pemeriksaan histopatologi. Pemeriksaan jaringan bisa dengan biopsi insisi, <i>punch biopsy</i> atau biopsi jarum halus, tergantung letak lesi. (Newkirk dan Holsinger, 2006; Ganly et al., 2009). Demikian juga temuan adanya pembesaran kelenjar getah bening leher, sebaiknya dikonfirmasi dengan pemeriksaan sitologi. Pemeriksaan dengan CT, MRI maupun PET mempunyai akurasi yang tinggi dalam menetapkan adanya proses neoplastik pada kelenjar leher, seperti adanya gambaran seperti cincin dan nekrosis sentral (Kraus dan Joe, 2003).</span></div>
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<span style="letter-spacing: 0.0px;">Persentasi metastase ke kelenjar getah bening leher kira-kira 2%-9% dari keseluruhan karsinoma sel skuamosa daerah kepala leher dan paling sering yang berasal dari lesi dasar mulut dan lidah (Chang et al., 2006). Secara umum dikatakan, lesi pada daerah posterior rongga mulut lebih mungkin metastase ke kelenjar getah bening leher daripada lesi pada sisi anterior (Kraus dan Joe, 2003). Pemeriksaan histopatologi pembesaran kelenjar getah bening leher dianjurkan pemeriksaan biopsi jarum halus (FNA). Biopsi terbuka pada kelenjar leher tidak dianjurkan (Kraus dan Joe, 2003). </span></div>
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<span style="letter-spacing: 0.0px;">American Joint Committee on Cancer (AJCC) merekomendasikan klasifikasi lokasi kelenjar getah bening leher sebagai berikut: </span></div>
<ul>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level I: <span class="Apple-tab-span" style="white-space: pre;"> </span>Submental, </i></span></li>
</ul>
<div style="color: #231e20; font-family: Arial; font-size: 12px; margin-left: 72px; text-indent: 36px;">
<span style="letter-spacing: 0.0px;"><i>Submandibular</i></span></div>
<ul>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level II: <span class="Apple-tab-span" style="white-space: pre;"> </span>Upper jugular</i></span></li>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level III: <span class="Apple-tab-span" style="white-space: pre;"> </span>Mid-jugular</i></span></li>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level IV:<span class="Apple-tab-span" style="white-space: pre;"> </span>Lower jugular</i></span></li>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level V: <span class="Apple-tab-span" style="white-space: pre;"> </span>Posterior triangle </i></span></li>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level VI: <span class="Apple-tab-span" style="white-space: pre;"> </span>Prelaryngeal (Delphian), Pretracheal, Paratracheal</i></span></li>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Level VII: <span class="Apple-tab-span" style="white-space: pre;"> </span>Upper mediastinal</i></span></li>
<li style="color: #231e20; font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="color: black; font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><i>Other groups: <span class="Apple-tab-span" style="white-space: pre;"> </span>Sub-occipital</i></span></li>
</ul>
<div style="color: #231e20; font-family: Arial; font-size: 12px; margin-left: 108px; text-indent: 36px;">
<span style="letter-spacing: 0.0px;"><i>Retropharyngeal</i></span></div>
<div style="color: #231e20; font-family: Arial; font-size: 12px; margin-left: 108px; text-indent: 36px;">
<span style="letter-spacing: 0.0px;"><i>Parapharyngeal</i></span></div>
<div style="color: #231e20; font-family: Arial; font-size: 12px; margin-left: 108px; text-indent: 36px;">
<span style="letter-spacing: 0.0px;"><i>Buccinator (facial)</i></span></div>
<div style="color: #231e20; font-family: Arial; font-size: 12px; margin-left: 108px; text-indent: 36px;">
<span style="letter-spacing: 0.0px;"><i>Preauricular</i></span></div>
<div style="color: #231e20; font-family: Arial; font-size: 12px; margin-left: 126px; text-indent: 18px;">
<span style="letter-spacing: 0.0px;"><i>Periparotid and intraparotid (AJCC, 2006).</i></span></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
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<span style="letter-spacing: 0.0px;">Metastase jauh pada karsinoma rongga mulut umumnya terjadi pada stadium lanjut, jarang terjadi pada stadium dini. Metastase terutama terjadi di paru-paru atau tulang (Kraus dan Joe, 2003). Penentuan ada tidaknya metastase jauh, dilakukan berdasarkan pemeriksaan klinis dan pemeriksaan penunjang tambahan, seperti radiologi toraks dan USG abdomen (Chang et al., 2006). Karsinoma rongga mulut yang lanjut atau yang ada riwayat perokok berat sebaiknya dilakukan pemeriksaan CT toraks, oleh karena pemeriksaan foto rontgen saja tidak bisa mendeteksi adanya metastase paru pada perokok (Bolesina et al., 2012). </span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Sebelum terapi dilakukan, perlu dilakukan penentuan stadium klinis (<i>clinical staging</i>). Stadium klinis yang dipakai berdasarkan <i>TNM system</i> dari <i>Union for International Cancer Control (UICC)</i> dan <i>American Joint Committee on Cancer </i>(AJCC) yang selalu diperbaharui secara berkala dan dipakai sebagai keseragaman dalam menggambarkan penyakit neoplastik. Penentuan stadium klinik harus ditentukan sebelum terapi direncanakan, terutama untuk memperkirakan prognosa, membantu merencanakan terapi, menilai <i>outcome</i> setelah terapi dan dapat digunakan untuk membandingkan dengan kasus yang sama dari berbagai institusi di seluruh dunia (Kraus dan Joe, 2003; Bolesina et al., 2012). Jika stadium klinis telah ditetapkan dan terapi telah dimulai, maka setiap temuan lain dapat ditambahkan tetapi tidak boleh merubah stadium klinis awal (Bolesina et al., 2012). </span></div>
<div style="font-family: Arial; font-size: 12px;">
<span style="letter-spacing: 0.0px;"><b>Tabel. 2.1: Klasifikasi sistem TNM Karsinoma Rongga Mulut dan Faring</b></span></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px;">
<img alt="pastedGraphic_6.png" src="webkit-fake-url://F7A755F8-7B7F-4708-8B62-0297A4F35BE2/pastedGraphic_6.png" /></div>
<div style="font-family: Arial; font-size: 10px; margin-bottom: 10px; text-align: justify;">
<span style="letter-spacing: 0.0px;">Dikutip dari Bolesina et al., 2012</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; min-height: 14px; text-align: justify;">
<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify;">
<span style="letter-spacing: 0.0px;"><b>Tabel. 2.2: Stadium Klinis Karsinoma Rongga Mulut dan Faring</b></span></div>
<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px;">
<img alt="pastedGraphic_7.png" src="webkit-fake-url://F7A755F8-7B7F-4708-8B62-0297A4F35BE2/pastedGraphic_7.png" /></div>
<div style="font-family: Arial; font-size: 10px;">
<span style="letter-spacing: 0.0px;"><i>* Extracapsular spread (ECS) of disease is added as ECS + or ECS—as a descriptor.</i></span></div>
<div style="font-family: Arial; font-size: 10px;">
<span style="letter-spacing: 0.0px;"><i>These descriptors will not influence nodal staging.</i> Dikutip dari Bolesina et al., 2012</span></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<ol>
<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Terapi dan Penanganan KGB Leher</b></span></li>
</ol>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Terapi karsinoma rongga mulut mencakup beberapa modalitas seperti pembedahan, radioterapi, kemoterapi, imunoterapi, <i>targeted therapy,</i> terapi fotodinamik dan beberapa jenis terapi lain yang umumnya bersifat tambahan (Ichwan et al. 2012; Arun et al., 2012; ACS,2012). Secara umum terapi pilihan adalah pembedahan atau radioterapi atau kombinasi keduanya (Trang dan Lavertu, 2005; Mendenhall et al., 2008; Ganly et al.,2009). Modalitas terapi tunggal apakah pembedahan atau radioterapi saja ditujukan hanya pada lesi kecil (T1-T2). Perkembangan alat-alat maupun teknologi baru seperti sinar gamma, <i>electrons, protons, atomic nuclei, tridimensional (3DR), sterotactic, Modulated Intensity Radiotherapy (MIR)</i> dan <i>Image-Guided Radiation Therapy (IGRT)</i> membantu dokter memperbaiki ketepatan radiasi, tapi disisi lain hal ini menyebabkan keterlambatan terapi standar dan cenderung meningkatkan rekurensi dan metastase (Bolesina et al.,2012). </span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Eksisi bedah dianjurkan oleh karena memungkinkan untuk menilai tepi reseksi secara mikroskopik termasuk invasi ataupun infiltrasi sel-sel tumor pada jaringan sekitarnya <i>(pathologic staging)</i> dan menghindari akibat radiasi seperti <i>xerostomia</i> dan <i>osteoradionecrosis</i> (Kraus dan Joe, 2003; Sunarto, 2007; Ganly et al., 2009; Wein et al., 2010). Kelemahan utama pembedahan dibanding radiasi adalah adanya gangguan fungsi, terutama jika dilakukan reseksi mandibula atau lidah (Kraus dan Joe, 2003). Saat ini umumnya berpendapat eksisi bedah adalah terapi lokoregional utama yang paling efektif untuk tumor solid termasuk karsinoma rongga mulut dan memberikan kesembuhan sebagian besar penderita kanker (Sunarto, 2007; Wein et al., 2009). </span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Pilihan terapi bersifat individual dan harus disesuikan dengan faktor tumor (stadium, letak, <i>grading</i> histologi), faktor pasien (umur, pekerjaan, sosio-ekonomi, gaya hidup, kondisi fisik, psikologis pasien) dan faktor dokter (pembedahan, radioterapi, kemoterapi, perawatan dan layanan penunjang lain) (Mendenhall et al., 2008; Ganly et.al.,2009; Wein et al., 2010). Komunikasi antara dokter dan pasien maupun keluarganya sangat diperlukan untuk menyampaikan rencana terapi, termasuk kemungkinan kegagalan, komplikasi, maupun tahapan terapi lanjutan (Ganly et al.,2009; Wein et al., 2010).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Konsep utama dalam reseksi tumor primer adalah kecukupan reseksi dari tepi tumor <i>(surgical margins)</i>. Rekurensi pada <i>surgical margins </i>yang positif, dua kali lebih tinggi dari tepi reseksi yang negatif (Kraus dan Joe, 2003). Demikian juga <i>5-year survival rates </i>dan kejadian rekurensi tidak berbeda antara <i>close surgical margins </i>(kurang dari 5mm) dan <i>microscopically positive margins </i>(Kraus dan Joe, 2003). Oleh karena itu untuk mendapatkan tepi reseksi bebas tumor sebesar 5mm atau lebih, minimal harus dilakukan reseksi 8-10 mm dari batas tumor (Chang et al., 2006). Divisi Bedah KL RSUD Dr. Soetomo menganjurkan batas reseksi 1 cm sampai 2 cm dari tepi tumor dan dilakukan konfirmasi histopatologi untuk menyatakan bahwa batas reseksi bebas tumor (Divisi Bedah KL RSUD Dr. Soetomo, 2009). Poh dkk. berdasarkan uji eksperimental mengusulkan penentuan batas reseksi menggunakan bantuan lampu fluoresensi durante operasi, dimana hasilnya lebih baik dari cara konvensional (Poh et al., 2006).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Prosedur operasi yang dilakukan disesuaikan dengan besar tumor, lokasi dan struktur anatomi yang terinfiltrasi tumor (Wein et al., 2010). Tumor kecil (T1-T2) dan terletak anterior dapat di reseksi transoral (Ganly et al., 2009). Tumor besar, infiltratif dan lokasi lebih ke posterior memerlukan pemaparan yang lebih luas, seperti <i>upper cheek flaps</i>, <i>lower cheek flaps</i> atau <i>mandibulotomy</i> (Ganly et al., 2009; Wein et al., 2010). Jika terbukti jelas infiltrasi ke mandibula, perlu dilakukan reseksi, apakah mendibulektomi marginal atau mandibulektomi segmental. Pada pasien dengan mandibula yang <i>edentulous</i> dan pada pasien yang telah menjalani radioterapi, sebaiknya jangan melakukan mandibulektomi marginal, tapi mandibulektomi segmental, oleh karena pada mandibulektomi marginal banyak terbuka saluran-saluran dalam tulang yang memudahkan terjadi metastase (Ganly et al.,2009). Periosteum mandibula berfungsi sebagai penghambat penyebaran tumor ke dalam tulang (Ganly et al., 2009). Adanya infiltrasi ke mandibula meningkatkan resiko penyebaran tumor ke basis kranii melalui nervus alveolaris inferior (Ganly et al., 2009). </span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Penilaian apakah ada <i>early invasion</i> ke korteks mandibula secara radiologis cukup sulit (Ganly et al., 2009). Gambaran radiologi konvensional yang menyatakan adanya invasi ke tulang, memerlukan kehilangan mineral tulang sebesar paling sedikit 30%-50% (Ganly et al., 2009). Pemeriksaan lain yang lebih canggih seperti CT scan, MRI dan PET dan <i>bone scan</i> radioaktif menghasilkan banyak positif palsu (Ganly et al., 2009). Penilaian yang dianggap paling realitis adalah penilaian klinis dengan bantuan radiologi sederhana, dan sudah cukup untuk pengambilan keputusan (Ganly et al., 2009).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Dalam terapi lokoregional karsinoma rongga mulut, selain reseksi tumor primer yang adekuat, perlu dipertimbangkan untuk diseksi kelenjar getah bening leher (Lucioni, 2007). Penelitian pada pasien-pasien yang dilakukan diseksi leher profilaktik atau <i>elective neck dissection</i> (END) ternyata ditemukan adanya metastase pada level I sebesar 53.3%, level II sebesar 40% dan level III sebesar 6,7% (Wein et al., 2010). Pada kasus karsinoma rongga mulut yang disertai metastase regional ke kelenjar getah bening leher (N-positif) jelas perlu dilakukan diseksi kelenjar leher secara menyeluruh level I-V <i>(comprehensive neck dissection)</i>, apakah secara radikal atau modifikasi (MRND) (Gavilan et al., 2002; Lucioni, 2007; Robbins et al., 2010; Wein et al., 2010). Pada kasus karsinoma rongga mulut dengan N0 <i>(clinically negative neck)</i>, perlu dipertimbangkan dengan baik apakah perlu dilakukan diseksi leher <i>(elective neck dissection)</i> atau tidak, oleh karena diseksi leher yang tidak berguna hanya menyebabkan morbiditas, sedangkan jika pada <i>follow-up</i> ditemukan adanya metastase pada kelenjar leher maka dua permasalahan yang bisa terjadi: pertama efektifitas tindakan terapeutik <i>(chance of cure)</i> berkurang 50% (Kraus dan Joe, 2003; Ganly et al., 2009); kedua terjadi penurunan <i>5-year survival rates,</i> 59% sampai 35% (Wein et al., 2010).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Tumor primer yang besar (T3-T4) atau adanya invasi ke mandibula (teraba <i>fix)</i> adalah faktor resiko atau tanda klinis yang sangat berkorelasi terjadinya metastase ke kelenjar getah bening leher, sehingga dianjurkan dilakukan diseksi leher profilaktik (Wein et al.,2010). Faktor resiko lain yang perlu dipertimbangkan, apakah perlu diseksi leher profilaktik adalah letak tumor primer, <i>histological grade</i>, morfologi tumor, gambaran patologi dan kedalaman invasi (Ganly et al., 2009; Robbins et al., 2010; Wein et al., 2010). </span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Diseksi leher profilaktik atau <i>elective neck dissection </i>(END) atau <i>supraomohyoid neck dissection (SOHND)</i>, adalah diseksi sebagian saja dari KGB leher (<i>selective neck dissection)</i> yaitu KGB<i> </i>pada level I,II dan III, oleh karena pada N0 (<i>clinically negative neck)</i> kemungkinan metastase ke level IV dan V sangat kecil. Pada tumor primer lidah perlu diseksi level I sampai IV <i>(extended</i> SOHND) oleh karena metastase dari tumor primer pada lidah bisa langsung metastase pada level IV <i>(skip metastase) </i>(Ganly et al., 2009; Wein et al., 2010). Jika pada pemeriksaan <i>frozen section</i> didapatkan adanya metastase pada KGB leher, maka harus dikerjakan <i>comprehensive neck dissection</i> apakah klasik RND atau <i>radical neck dissection</i> yang dimodifikasi (MRND). Dikatakan bahwa, untuk melakukan <i>selective neck dissection</i> sebaiknya tersedia konfirmasi patologis (Ganly et al., 2009). </span></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify;">
<span style="letter-spacing: 0.0px;"><b>Tabel. 2.3. Faktor Resiko Karsinoma Rongga Mulut Bermetastase ke Kelenjar Getah Bening Leher</b></span></div>
<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px;">
<img alt="pastedGraphic_8.png" src="webkit-fake-url://F7A755F8-7B7F-4708-8B62-0297A4F35BE2/pastedGraphic_8.png" /></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify;">
<span style="letter-spacing: 0.0px;">( Ganly et al., 2009)</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">RND klasik merupakan <i>gold standard, </i>dan hasil <i>control disease</i> nya paling baik, sebanding dengan MRND ditambah radioterapi,<i> </i>tapi oleh karena sangat tinggi juga komplikasi post operasinya, tindakan ini kurang dianjurkan dan hanya dikerjakan ditempat dengan fasilitas terbatas atau jika selama operasi jelas tampak ada infiltrasi pada struktur yang bersangkutan (Ganly et al., 2009). Dibagian Bedah Kepala Leher RS Dr Soetomo Surabaya tetap menganjurkan RND klasik pada N+ dan pada <i>T-stage</i> T3-T4 dengan N0 (Divisi Bedah KL RSUD Dr. Soetomo, 2009).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Kemoterapi maupun modalitas terapi lain lebih ditujukan pada kasus <i>incurable</i> atau gagal dengan pengobatan konvensional (Ganly et al., 2009; Manuaba, 2010). Untuk stadium lebih lanjut (Stadium III dan IV), eksisi luas tumor primer di sertai radiasi post-operasi adalah menjadi pilihan (Ganly et al.,2009). Kemoradiasi sebagai <i>neo-adjuvant</i> mungkin meningkatkan <i>survival</i> tapi juga meningkatkan morbiditas pasien (Bolesina et al.,2012). Terapi lain mencakup terapi fotodinamik, imunoterapi, <i>targeted therapy </i>dan berbagai jenis terapi lain (Jerjes et al., 2012).</span></div>
<ol>
<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Prognosa</b></span></li>
</ol>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Hingga saat ini dianggap kemajuan teknologi belum dapat memperbaiki prognosis karsinoma rongga mulut, disamping keterlambatan diagnosis, juga akibat lemahnya faktor prognostik yang ada sekarang seperti sistim TNM dan <i>grading</i> histopatologi (Mahdey et al., 2011; Farah et al., 2012). <i>Survival rate </i>pada stadium dini bisa mencapai 80-90%. Pada stadium lanjut, angka kematian meningkat bermakna, dimana pada stadium III sebesar 36,3% dan pada stadium IV sebesar 23,3% (Wein et al., 2010; Bittar et al., 2010). Secara umum <i>five-year survival rate</i> karsinoma rongga mulut hanya sebesar 50% (Farah et al., 2012).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Walaupun sistem TNM ini dipakai secara umum tapi banyak yang menganggap sebagai faktor prognostik adalah jauh dari sempurna, misalnya <i>nodal metastase</i> jauh lebih bermanfaat dari pada <i>T stage</i> (Ganly et al., 2009). Faktor prognostik yang tepat diperlukan untuk memperkirakan <i>survival rate</i>, tapi lebih dari itu dapat merobah rencana terapi, seperti tindakan lebih agresif walaupun masih dalam stadium dini (Ganly et al., 2009).</span></div>
<div style="font-family: Arial; font-size: 12px; margin-bottom: 10px; text-align: justify; text-indent: 36px;">
<span style="letter-spacing: 0.0px;">Faktor prognostik selain sistem TNM dan derajat histopatologi telah banyak dilaporkan, antara lain, etnis, umur, jenis kelamin, gaya hidup, ada tidaknya <i>protective factor</i>, lokasi tumor, besar tumor, batas eksisi bebas tumor baik secara histopatologis maupun secara imunohistokimia <i>(molecular margin/gene signature)</i> dan pemeriksaan biomarker serum (Zhu et al., 2010; Wein et al., 2010; Bittar et al., 2010; Mahdey et al., 2011; Reis et al., 2011).</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> </sup></span><span style="letter-spacing: 0.0px;">Salah satu <i>molecular markes</i> yang banyak diteliti adalah ekspresi <i>galectin-3</i> atau disingkat <i>Gal-3</i> oleh sel-sel tumor (Cooper dan Barondes, 1999; Balan et al. 2010; Lepur, 2012).</span></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<ol>
<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b><i>Galectin-3</i></b></span></li>
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<span style="letter-spacing: 0.0px;">Hubungan antara <i>galectin-3</i> dengan kanker telah banyak dilaporkan, seperti korelasi antara ekspressi <i>galectin-3</i> dengan <i>tumorigenesis, neoplastic transformation, neoplastic progression</i> baik melalui regulasi proliferasi sel, inhibisi apoptosis, <i>cell adhesion, invasion, angiogenesis </i>dan metastase (Cooper dan Barondes, 1999; Honjo et al., 2000; Prietro et al., 2006; Balan et al., 2010; Lepur, 2012). <i>Galectin </i>adalah protein pengikat karbohidrat yang merupakan gugus protein yang secara spesifik berkonyugasi melalui ikatan kovalen dengan <i>β-galactose</i>. </span></div>
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<span style="letter-spacing: 0.0px;"><i>Galectin </i>pertama kali diisolasi pada belut pada tahun 1974, dan dikenal saat itu dengan <i>electrolectin.</i> <i>Galectin </i>ditemukan pada vertebrata pada tahun 1976, dengan berat molekul 15kD, yang saat ini struktur tersebut dikenal sebagai <i>galectin-1</i> (Cummings dan Liu, 2009). <i>Galectin-3</i> pertama kali diperkenalkan pada tahun 1982 sebagai makrofag marker dengan nama <i>Mac-2</i>, yang diisolasi dari fibroblast tikus dengan berat molekul 35kD (Cummings dan Liu, 2009; Balan et al., 2010). Suatu protein yang sama, yang juga dipelajari oleh peneliti-peneliti lain dengan nama <i>Ig-E binding protein, L-29 dan L-31, </i>sejak nomenklatur tahun 1994 diganti menjadi <i>galectin-3</i> (Cummings dan Liu, 2009).</span></div>
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<span style="letter-spacing: 0.0px;"><i>Galectin</i> terdiri dari tiga<i> subgroup</i>, <i>proto-type, tandem-repeat type </i>dan <i>chimera type</i>. <i>Proto-type</i> <i>galectin</i> disebut juga <i>dimeric</i> mengandung satu CRD (Galectin-1,2,5,7,10,11,13,14,15), <i>tandem-repeat type</i> <i>galectin </i>yang disebut juga biCRD memiliki dua CRD (Galectin-4,6,8,9,12) dan <i>chimera type</i>, dimana galectin ini memiliki satu CRD dengan N-terminal <i>(Galectin-3)</i> (Balan et al., 2010; Lepur, 2012). Secara spesifik <i>galectin-3 </i>terdiri dari 3 struktur yaitu: terminal pendek NH2 tempat terjadinya fosforilasi serine; terdapat rangkaian protein berulang menyerupai kolagen alfa; dan satu terminal COOH yang memiliki affinitas dengan karbohidrat yang disebut juga <i>carbohydrate-binding domains</i> atau <i>carbohydrate-recognition domain (CRD)</i> (Cay et al., 2012). </span></div>
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<span style="letter-spacing: 0.0px;"><i>Galectin</i> adalah protein yang berikatan dengan <i>glycan </i>(Mazurek et al., 2000; Cummings dan Liu, 2009; Lepur, 2012). <i>Glycan</i> adalah sebutan untuk bagian karbohidrat yang terikat pada struktur biomolekul kompleks seperti protein, lipid atau molekul <i>organic</i> lain. Reaksi atau proses terjadinya ikatan antara <i>glycan</i> dan struktur lain misalnya <i>galectin-3 </i>disebut <i>glycosylation</i>. <i>Glycosylation </i>bisa pada sisi <i>amide nitrogen </i>atau disebut juga <i>N-glycosylation</i> atau pada sisi <a href="http://en.wikipedia.org/wiki/Hydroxyl"><span style="letter-spacing: 0px;"><i>hydroxyl</i></span></a><i> </i><a href="http://en.wikipedia.org/wiki/Oxygen"><span style="letter-spacing: 0px;"><i>oxygen</i></span></a> atau disebut juga <i>O-glycosylation</i>.</span><span style="font-size: 11px; letter-spacing: 0px;"> </span><span style="letter-spacing: 0.0px;">Proses ini menjadi penting karena menghasilkan berbagai fungsi biologi (Abe dan Suzuki, 2007; Lepur, 2012). <i>Glycan</i> yang berikatan dengan protein disebut <i>lectin</i>. Jika jenis karbohidrat <i>(glycan)</i> pada <i>lectin</i> adalah karbohidrat <i>β-galactoside/β-galactose, </i>maka disebut <i>galectin.</i> Dengan demikian <i>galectin</i> adalah <i>lectin</i> yaitu struktur ikatan antara protein dan karbohidrat <i>(glycan)</i> dimana struktur <i>glycan </i>yang berikatan dengan protein adalah karbohidrat <i>β-galactoside.</i> Struktur ini disebut <i>sugar binding proteins, carbohydrate binding proteins, galatoside binding proteins</i> ataupun dengan penyebutan <i>glycan binding proteins (GBPs)</i>, yaitu struktur molekul yang termasuk dalam <i>sugar functional group</i> yang mempunyai fungsi cukup luas dalam organisme hidup. Dengan demikian <i>galectin </i>adalah sebuah<i> lectin, </i>dimana<i> glycan </i>yang berikatan dengan protein adalah<i> galactoside </i>dengan spesifikasi fungsi tertentu yang spesifik (Lepur, 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Ciri khas <i>galectin</i> antara lain mempertahankan keutuhan urutan asam amino <i>(amino acid sequence)</i> dengan cara mempertahankan struktur tempat ikatan dengan karbohidrat atau disebut juga <i>carbohydrate-binding domains/carbohydrate-recognition domain (CRD</i>). Satu CRD mempunyai susunan kurang lebih 135 asam amino (Lepur, 2012). Walaupun begitu hanya sebagian kecil residu yang berikatan dengan <i>glycan </i>(Cummings dan Liu, 2009). <i>Glycan</i> atau substans yang mengandung karbohidrat yang berikatan dengan CRD, umumnya adalah <i>glycoprotein</i> disebut juga <i>ligand (high affinity ligand binding), </i>misalnya. <i>subtrates, inhibitors, activators, neurotransmitters</i> dan berbagai struktur lain (Balan et al., 2010; Mahdey et al., 2011; Reis et al., 2011). Affinitas ini sangat tinggi terhadap <i>natural glycoconjugate ligands</i> <i>(glycan ligands</i>) yang terdapat pada permukaan sel atau pada matriks ekstrasel, misalnya protein pada membrana basalis (<i>laminin dan fibronectin</i>), reseptor pada membran sel (<i>CD7, CD43, CD45, integrins α7β1 dan integrins α1β1</i>) dan <i>lysosome-associated membrane proteins</i> (LAMP-1 dan LAMP-2) (Cummings dan Liu, 2009). Affinitas ini berkurang jika terjadi <i>phosphorylation</i> pada N-terminal <i>galectin-3 </i>(Mazurek et al., 2000). </span></div>
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<span style="letter-spacing: 0.0px;"><i>Galectin</i> dapat ditemukan pada banyak organisme, disintesis dalam <i>ribosome cytoplasmic, </i>dan menumpuk dibawah membran sel (Lepur, 2012). Jika disekresi dapat ditemukan pada permukaan luar sel atau pada matriks ekstraselular (</span><span style="color: #323333; letter-spacing: 0.0px;">Vereecken et al., 2007)</span><span style="letter-spacing: 0.0px;">. Galectin dapat di ekspresi (<i>gene expression) </i>oleh sel-sel yang teraktivasi misalnya sel T, sel B, <i>regulatory T-cell, </i>sel dendrit, sel mast, eosinofil, monosit/makrofag dan netrofil (Cummings dan Liu, 2009). Gen yang bertanggung jawab mengkoding sintesa <i>galectin-3 </i>adalah gen <i>LGALS3</i> pada kromosom 14 (Lepur, 2012). G<i>alectin-3 </i>di ekspor keluar sel tidak melalui jalur klasik dan mekanisme yang jelas belum diketahui, diduga bersamaan dengan sekresi <i>growth factor</i> atau<i> cytokines</i> (Cummings dan Liu, 2009). Sampai saat ini regulasi <i>(gene regulation ) </i>maupun sekresi <i>galectin-3 </i>belum diketahui dengan jelas (Cummings dan Liu, 2009). </span></div>
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<span style="letter-spacing: 0.0px;"><i>Gene regulation</i> adalah pengaturan <i>gene expression</i> dalam hal <i>timing, location</i> dan jumlah, sehingga produk yang ada sesuai yang dibutuhkan misalnya pengaturan kadar <i>cyclin </i>yang berfungsi sebagai kontrol siklus sel<i>. Gene regulation</i> antara lain <i>transcriptional regulation</i> yaitu baik secara <i>genetic, modulation dan epigenetic</i>. Cara <i>genetic, </i>adalah<i> direct interaction,</i> dimana protein berikatan dengan tempat tertentu pada DNA <i>(regulatory DNA binding site), enhancer, insulator</i> dan <i>silancer</i>, misalnya pada ikatan tertentu pada DNA menghambat <i>RNA polymerase</i>. Cara <i>Modulation</i>, adalah pengaturan transkripsi oleh karena adanya signal intrasel melalui beberapa reaksi kimia seperti <i>phosphorylation, acetylation </i>dan<i> glycosylation. </i>Cara <i>epigenetic</i> adalah pengaturan ekspresi gen (<i>gene expression)</i> tanpa merobah susunan basa nukleotida, misalnya <i>DNA methylation. </i></span></div>
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<span style="letter-spacing: 0.0px;"><i>Gene expression</i> adalah proses dimana informasi genetika<i>(genetic code)</i> pada DNA dipakai untuk sintesa protein. Tahap <i>gene expression</i> yaitu <i>transcription, RNA splicing, translation, post translation modification. Transcription </i>adalah pembentukkan RNA yang merupakan <i>copies</i> dari DNA oleh enzim <i>RNA polymerase</i>. DNA terdiri dari 2 untaian, <i>templete strand</i> dan <i>coding strand</i>. RNA yang terbentuk identik dengan<i> coding strand </i>kecuali T diganti U. <i>RNA Splicing ( RNA processing, post-transcriptional modification</i>). RNA primer yang terbentuk (pre-mRNA) memerlukan beberapa seri modifikasi untuk menjadi mRNA matang, <i>5’capping, 3’cleavage </i>dan<i> polyadenylation. RNA splicing</i> adalah reaksi yang melepaskan intron dan menggabungkan exon yang bertetangga. Pada proses <i>translation, </i>pada beberapa <i>non-coding RNA, mature RNA </i>adalah menjadi produk akhir, tapi mRNA membawa satu untaian <i>(single sequence</i>) kode untuk sintesa protein. Setiap <i>codon</i> pada mRNA akan berikatan dengan <i>anticodon</i> pada tRNA yang membawa satu asam amino. Ribosom akan membantu tRNA berikatan dengan mRNA dan mengambil setiap asam amino dan merangkai menjadi protein sesuai urutan yang ada pada mRNA. <i>Folding </i>adalah suatu proses dimana rantai polipeptida selanjutnya melipat dan membentuk sebuah struktur tiga dimensi yang benar. Tidak melipat atau salah melipat <i>(unfolded/misfolded</i>) menyebabkan protein tersebut tidak aktif atau bersifat toksik. </span></div>
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<span style="letter-spacing: 0.0px;">Fungsi <i>galectin-3 </i>terutama berhubungan dengan lokasi dimana struktur ini berada, proses glikosilasi yang terjadi dan jenis <i>glycan ligands</i> yang terikat (Lepur, 2012; Cummings dan Liu, 2009). G<i>alectin-3</i>, jika berada dalam sitoplasma akan berfungsi melindungi sel dari apoptosis <i>(exhibits antiapoptotic activity)</i>, sedangkan jika berada pada ekstrasel akan menginduksi apoptosis (Davidson et al., 2006; Stillman et al., 2006; Suzuki dan Abe M, 2008).</span></div>
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<span style="letter-spacing: 0.0px;">Efek antiapoptosis ini terjadi melalui reaksi fosforilasi pada <i>N-terminal</i> atau ikatan dengan <i>glycan ligands Bcl-2 </i>(Lepur, 2012). Davidson dkk melaporkan, adanya penumpukan <i>galectin-3</i> dalam sitoplasma, akibat gagalnya mekanisme import <i>galectin-3</i> ke intisel berhubungan dengan efek antiapoptosis <i>galectin-</i>3, seperti jelas terlihat pada perkembangan mukosa mulai dari normal menjadi adenoma selanjutnya berkembang menjadi karsinoma (Davidson et al., 2006). Sebaliknya jika <i>galectin-3</i> berada diluar sel akan meng-induksi terjadinya apoptosis melalui reaksi glikosilasi <i>galectin-3</i> dengan permukaan sel (Cooper dan Barondes, 1999; Stillman et al., 2006; Suzuki dan Abe, 2008; Lepur, 2012). </span></div>
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<span style="letter-spacing: 0.0px;">Glikosilasi yang menginduksi apoptosis ini, melibatkan CD71 dan CD45 (Cummings dan Liu, 2009) atau CD95 sebagai <i>glycan ligands </i>(Fukumori et al.,2004). Proses glikosilasi dapat diaktifkan maupun dihambat oleh <i>sialic acid</i>. Proses ikatan <i>sialic acid</i> dengan <i>galectin-3</i> disebut <i>sialylation</i>. <i>Sialylation</i> berfungsi sebagai <i>on-off switch</i> affinitas <i>galectin-3</i> terhadap <i>glycan ligands</i>. Selain <i>sialylation</i>, <i>on-off switch</i> pada gelectin-3 terjadi akibat adanya fosforilasi pada <i>N-terminal Ser</i> (Mazurek et al., 2000; Lepur, 2012). Pada kondisi <i>switch off</i>, terjadi hambatan <i>galectin-3 </i>untuk menginduksi apoptosis seperti yang terjadi pada kondisi keganasan (Lepur, 2012).</span></div>
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<span style="letter-spacing: 0.0px;"><i>Glycan ligands</i> yang terikat pada<i> galectin-3</i> dengan cara glikosilasi, selain berperan pada apoptosis, juga berperan pada adhesi sel, <i>receptor turnover,</i> interaksi dengan patogen dan <i>intracellular trafficking</i> (Lepur, 2012). Fungsi lainnya adalah menyokong respons imun dan radang seperti inhibisi produksi IL-5 <i>(antiinflamatory cytokines)</i>, aktivasi sel mast, netrofil dan monosit dan membantu sintesis dan sekresi radikal bebas seperti <i>reactive oxygen species</i> (Cummings dan Liu, 2009). Beberapa <i>glycan ligands</i> <i>galectin-3 </i>dalam sel adalah <i>Bcl-2, Fas Reseptor (CD95), synexin</i> dan <i>Alg-2</i> (Cummings dan Liu, 2009). Selain itu <i>ligands galectin-3</i> lain, <i>laminin dan fibronectin,</i> jika teraktivasi oleh <i>galectin-3 </i>menginduksi proses krusial dalam proses <i>epithelial to mesenchymal transition (EMT</i></span><span style="font-size: 11px; letter-spacing: 0px;"><i>)</i></span><span style="letter-spacing: 0.0px;"> dimana sel tumor mandapatkan sifat <i>invasive</i> dan potensi metastase (Nangia-Makker et al., 2002; Takenaka et al., 2004).</span></div>
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<span style="letter-spacing: 0.0px;">Penelitian Honjo dkk pada karsinoma lidah mendukung hal diatas, dimana ditemukan peningkatan ekspresi <i>galectin-3</i> pada sitoplasma dan adanya hambatan apoptosis (Honjo et al., 2000). Hambatan apoptosis juga terjadi akibat adanya substans tumor yang menghambat proses glikosilasi <i>galectin-3</i> ekstrasel (Abe dan Suzuki, 2007). Fukumori dkk menunjukkan dalam penelitiannya melalui kultur sel, bahwa <i>galectin-3 </i>yang berikatan dengan CD95<i> </i>menghambat terjadinya apoptosis melalui hambatan pada jalur signal <i>caspase-8. </i>CD95 adalah salah satu reseptor yang menginduksi terjadinya apoptosis melalui dua jalur signal tergantung tipe sel, yaitu tipe sel dengan jalur <i>caspase-8</i> dan tipe sel dengan jalur mitokondria. Fukumori mengusulkan bahwa dalam strategi terapi melalui CD95 perlu melibatkan <i>galectin-3</i> (Fukumori et al., 2004).</span></div>
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<span style="letter-spacing: 0.0px;">Peran <i>galectin-3</i> pada proses metastase juga banyak dilaporkan<i> </i>(Piantelli et al., 2002; John et al., 2003; Takenaka et al., 2004). John dkk dalam penelitiannya, memberikan injeksi <i>recombinant galectin-3 (galectin-3C)</i> yang dipotong terminal NH2 pada tikus yang diimplantasi sel-sel kanker payudara, menunjukkan adanya penurunan kejadian metastase, disamping itu tumor mengecil sampai terjadinya regresi (John et al., 2003). Zhao dkk. menyatakan bahwa ikatan <i>galectin-3</i> serum dengan sel tumor menyebabkan terbukanya <i>protective shield</i> pada sel tumor dan memudahkan terjadinya adhesi sel tumor dengan sel endotel pembuluh darah <i>(tumor-endothelial cell interaction)</i> (Zhao et al., 2009). Selain itu adhesi ini terjadi akibat adanya ikatan antara antigen T <i>(Thomsen-Friedenreich antigen)</i> pada permukaan sel tumor dengan <i>galectin-3</i> pada permukaan sel endotel (Glinsky VV et al., 2001). </span></div>
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<span style="letter-spacing: 0.0px;"><i>Tumor-endothelial cell interaction </i>ini menunjang teori Al Mehdi dkk. tentang metastase. Dari sejumlah sel tumor yang masuk sirkulasi hanya sebesar 0,01% yang selamat dan berkembang menjadi foki metastase. Umumnya sel tumor dalam sirkulasi rusak oleh sistem imun dan gerakan hemodinamik (Luzzi KJ et al., 1998). Al Mehdi dkk. menjelaskan bahwa sel tumor yang selamat didalam sirkulasi, akan melekat pada sel endotel, berproliferasi <i>intravascular </i>dan membentuk <i>string</i> dalam kapiler. Dengan berjalannya waktu tumor akan membesar, merusak dinding pembuluh darah dan bertumbuh dalam <i>target organ. </i>Dalam hal ini tidak ditemukan adanya<i> trapping</i> maupun ekstravasasi tumor. Pendapat ini dikemukakan setelah mengamati proses metastase menggunakan mikroskop <i>epifluorescence. </i>Dikatakan bahwa sel tumor yang mengalami ekstravasasi, sangat cepat dibersihkan oleh sel-sel parenkim tidak lebih dari 48 jam. Hal-hal yang diamati adalah, tidak ditemukan adanya trapping sel tumor oleh karena lumen kapiler jauh lebih besar dari sel tumor dan dalam proses adhesi ini juga tidak ditemukan keterlibatan platelet atau element darah lainnya (Al Mehdi et al., 2000). Kunci dari proses ini adalah interaksi antara sel tumor dan sel endotel <i>(tumor-endothelial cell interaction) </i>(Al Mehdi et al., 2000). Interaksi <i>T antigen-galectin-3</i> dapat menjadi target terapi dalam menemukan terapi <i>anti adhesive cancer</i> (Glinsky VV et al., 2001; John CM et al., 2003).</span></div>
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<span style="letter-spacing: 0.0px;">Peran lain <i>galectin-3 </i>pada proses keganasan adalah menginduksi terjadinya angiogenesis (Nangia-Makker et al., 2000; Pietro et al., 2006; Tsuboi et al., 2007; Miranda et al. 2009). Angiogenesis dan pertumbuhan kapiler baru dalam tumor merupakan faktor utama yang menunjang kelangsungan hidup sel tumor dan merupakan pintu gerbang metastase. Tiga kelompok signal ekstrasel yang menstimulasi terjadinya angiogenesis adalah: <i>soluble growth molecules</i> seperti <i>acid fibroblast growth factors (aFGF), basic fibroblast growth factors (bFGF) </i>dan <i>vascular endothelial growth factors VEGF), </i>mempengaruhi pertumbuhan dan diferensiasi sel-sel endotel. <i>Transforming growth factor β (TGFβ) </i>dan<i> angiogenin </i>menghambat proliferasi endotel. Berbagai sitokin yang dilepas melalui proteolisis, yang terikat pada matriks ekstrasel meningkatkan proliferasi. Sebagai tambahan faktor diatas diketahui juga bahwa ada suatu bahan larut, berupa protein pengikat karbohidrat seperti <i>E-selectin, vascular cell adhesion molecule-1 (VCAM-1) </i>dan <i>P-selectin </i>menstimulasi migrasi dan morfogenesis endotel jika terjadi ikatan dengan ligand <i>glycoconjugate.</i></span></div>
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<span style="letter-spacing: 0.0px;">Nangia-Makker dkk dalam penelitiannya menunjukan bahwa fungsi <i>E-selectin </i>dapat diganti oleh <i>galectin-3 </i>sehingga migrasi, morfogenesis dan angiogenesis tetap berlangsung. Proses ini dapat dihambat dengan pemberian <i>anti-galectin-3 polyclonal antibody </i>atau MCP (<i>modified Citrus Pectin)</i> yang secara kompetitif berikatan dengan <i>galectin-3. Penelitian </i>fungsi <i>galectin-3 </i>ini dibuktikan secara <i>in-vitro</i> maupun <i>in-vivo. Galectin-3 </i>disekresi dalam matriks ekstrasel (ECM) oleh sel tumor dan makrofag, terutama saat monosit berdiferensiasi menjadi makrofag. MCP yang diberikan secara injeksi atau per oral berfungsi sebagai <i>ligand</i> terhadap <i>galectin-3, </i>dan secara bermakna menghambat angiogenesis, pertumbuhan dan metastase tumor (Nangia-Makker et al., 2002).</span></div>
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<span style="letter-spacing: 0.0px;">Laporan hubungan <i>galectin-3</i> dengan berbagai proses keganasan telah banyak dilaporkan. Saussez dkk. meneliti 137 kasus karsinoma kepala leher dengan membandingkannya dengan epitel normal, displasia ringan dan displasia tinggi. Saussez menemukan adanya progresifitas ekspresi <i>galectin-3</i> mulai dari sel epitel normal, displasia ringan, displasia berat dan kemudian sel kanker (Saussez et al., 2008). Pietro dkk juga melaporkan adanya </span><span style="color: #323333; letter-spacing: 0.0px;">hubungan erat antara tingkat ekspresi <i>galectin-</i>3 dengan stadium klinis melanoma maligna (Prieto et al., 2006; Vereecken et al., 2007). Sedangkan </span><span style="letter-spacing: 0.0px;">Choi dkk. melaporkan, tingkat ekspresi <i>galectin-3</i> berhubungan dengan stadium tumor <i>(T-stage)</i> dan <i>nodal status</i>, sehingga <i>galectin-3 </i>dapat menjadi faktor prognostik untuk karsinoma sel skuamous di laring (Choi et al., 2010; Cay, 2012). Hasil penelitian Shibata dkk. pada karsinoma sel skuamous esophagus menunjukan adanya peningkatan ekspresi <i>galectin-3</i> dalam inti sel, dimana peningkatan ini berhubungan dengan kejadian invasi pembuluh darah dan derajat diferensiasi sel tumor. Dikatakan bahwa peningkatan ekspresi <i>galectin-</i>3 dalam sitoplasma tidak berkorelasi dengan kedua hal tersebut (Shibata et al., 2005). </span></div>
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<span style="letter-spacing: 0.0px;">Tidak semua studi tentang <i>galectin-3</i> menunjukan adanya peningkatan ekspresi, beberapa peneliti menemukan kebalikannya, yaitu adanya penurunan ekspresi <i>galectin-3 </i>pada karsinoma ovarium, uterus dan payudara (Takenaka et al., 2004). Pada karsinoma kolon bahkan terdapat perbedaan hasil penelitian, beberapa peneliti mendapatkan adanya peningkatan ekspresi sedangkan peneliti lain menemukan terjadi penurunan ekspresi <i>galectin-3</i> (Honjo et al., 2000). Penelitian yang berbeda dilakukan Eude-Le Parco dkk. dimana dilakukan manipulasi genetik pada tikus, sehingga terdapat tikus yang bisa memproduksi <i>galectin-3 (galectin-3+/+)</i> dan tikus yang tidak bisa memproduksi <i>galectin-3 (Galectin-3-/-)</i>. Kedua kelompok ini kemudian diinduksi kanker, menyerupai karsinoma kolon dan rektum. Hasil penelitian ini menunjukkan bahwa, baik pada inisiasi proses keganasan, derajat histologi maupun metastase tidak ditemukan adanya peran <i>galectin-3.</i> Eude-Le Parco dkk. menyimpulkan, kemungkinan <i>galectin-3</i> tidak berperan pada kanker seperti pada kanker pada penelitian ini (Eude-Le Parco et al., 2009). </span></div>
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<span style="letter-spacing: 0.0px;">Vereecken dkk. menekankan bahwa dalam mengamati ekspresi <i>galectin-3 </i>yang dihubungkan dengan proses keganasan harus dilakukan dengan hati-hati oleh karena adanya variasi ekspresi <i>galectin-3 </i>tergantung lokasi pemeriksaan, apakah inti sel, sitoplasma atau ekstrasel (Vereecken et al., 2007). </span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB III</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>KERANGKA KONSEPTUAL DAN HIPOTESA PENELITIAN</b></span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Kerangka Konseptual</b></span></li>
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<span style="letter-spacing: 0.0px;"><b> </b></span><span style="font-family: Helvetica;"><img alt="pastedGraphic_9.png" src="webkit-fake-url://F7A755F8-7B7F-4708-8B62-0297A4F35BE2/pastedGraphic_9.png" /></span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;"><b>Hipotesis</b></span></li>
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<span style="letter-spacing: 0.0px;">Ekspresi <i>Galectin-3</i> berhubungan dengan agresifitas karsinoma rongga mulut yang ditandai dengan derajat histopatologis yang tinggi (G3 dan G4) atau besar tumor primer melebihi 4cm atau adanya metastase ke KGB regional atau metastase jauh.</span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB IV</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>METODE PENELITIAN</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>4.1. Rancangan Penelitian</b>.<span class="Apple-tab-span" style="white-space: pre;"> </span></span></div>
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<span style="letter-spacing: 0.0px;">Penelitian ini bertujuan untuk mengetahui apakah tingkat ekspresi <i>galectin-3 </i>berkorelasi dengan tingkat agresifitas karsinoma sel skuamosa rongga mulut. Rancangan penelitian yang digunakan adalah observasional analitik dengan pendekatan <i>cross sectional.</i></span></div>
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<span style="letter-spacing: 0.0px;"><b>4.2. Populasi dan Sampel</b></span></div>
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<span style="letter-spacing: 0.0px;"><b><span class="Apple-tab-span" style="white-space: pre;"> </span>4.2.1. Populasi</b></span></div>
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<span style="letter-spacing: 0.0px;">Populasi penelitian adalah semua blok parafin pasien karsinoma sel skuamosa rongga mulut yang tersimpan di Laboratorium Patologi Anatomi RS Dr. Soetomo Surabaya dari tahun 2010 s/d tahun 2012.</span></div>
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<span style="letter-spacing: 0.0px;"><b>4.2.2. Sampel</b></span></div>
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<span style="letter-spacing: 0.0px;">Sampel penelitian adalah semua blok parafin pasien karsinoma rongga mulut di Laboratorium Patologi Anatomi RSU Dr. Soetomo Surabaya dari tahun 2010 s/d tahun 2012 yang bisa dilakukan pemeriksaan <i>galectin-3. </i></span></div>
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<span style="letter-spacing: 0.0px;"><b>4.2.3. Besar Sampel</b></span></div>
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<span style="letter-spacing: 0.0px;">Karena kasus karsinoma sel skuamosa rongga jarang dan tidak semua blok parafin memenuhi syarat pemeriksaan <i>galectin-3, </i>maka diambil secara keseluruhan<i>(total sampling)</i>. Besar sampel yang diteliti sebesar 30 spesimen.</span></div>
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<span style="letter-spacing: 0.0px;"><b>4.3. Lokasi dan Waktu Penelitian</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>4.3.1. Lokasi</b></span></div>
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<span style="letter-spacing: 0.0px;">Penelitian dilakukan di Bagian/SMF Ilmu Bedah dan Bagian/SMF Patologi Anatomi Fakultas Kedokteran Universitas Airlangga/RSU Dr. Soetomo Surabaya.</span></div>
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<span style="letter-spacing: 0.0px;"><b>4.3.2. Waktu Penelitian</b></span></div>
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<span style="letter-spacing: 0.0px;">Waktu pelaksanaan penelitian selama 4 bulan sejak bulan September 2012 sampai bulan Desember 2012.</span></div>
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<span style="letter-spacing: 0.0px;"><b>4.4. Variabel Penelitian</b></span></div>
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<span style="letter-spacing: 0.0px;">Pada penelitian ini variabel yang diteliti adalah:</span></div>
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<span style="letter-spacing: 0.0px;"><b>4.4.1. Variabel <i>Independent</i></b></span></div>
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<span style="letter-spacing: 0.0px;">Ekspresi <i>Galectin 3</i> pada karsinoma sel skuamosa rongga mulut.</span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span><b>4.4.2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Variabel <i>Dependent</i></b></span></div>
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<span style="letter-spacing: 0.0px;">Agresifitas karsinoma rongga mulut. </span></div>
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<span style="letter-spacing: 0.0px;"><b>4.5. Definisi Operasional</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>4.5.1. <i>Galectin-3</i></b></span></div>
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<span style="letter-spacing: 0.0px;">Merupakan biomarker yang dapat berikatan dengan <i>ß Peroksidase</i> yang merupakan glikoprotein sel dan dapat diidentifikasi pada inti dan sitoplasma sel dan diperiksa dengan cara imunohistokimia (IHC). Ekspresi dari <i>galectin-3</i> ditunjukkan dengan skor sebagai berikut: negatif (-) bila ekspresi tidak meningkat, positif (+) bila ekspresi <i>galectin-3 </i>meningkat sedang dan positif 2 (++) bila ekspresi <i>galectin-3</i> sangat meningkat atau ekspresi kuat.</span></div>
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<span style="letter-spacing: 0.0px;"><b>4.5.2. Agresifitas Karsinoma Rongga Mulut</b></span></div>
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<span style="letter-spacing: 0.0px;"><b> 4.5.2.1. Derajat Histopatologi:</b></span></div>
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<span style="letter-spacing: 0.0px;"><i>G1<span class="Apple-tab-span" style="white-space: pre;"> </span> Well differentiated</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G2<span class="Apple-tab-span" style="white-space: pre;"> </span> Moderately differentiated</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G3<span class="Apple-tab-span" style="white-space: pre;"> </span> Poorly differentiated</i></span></div>
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<span style="letter-spacing: 0.0px;"><i>G4<span class="Apple-tab-span" style="white-space: pre;"> </span> Undifferentiated</i></span></div>
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<span style="letter-spacing: 0.0px;">Derajat Rendah<span class="Apple-tab-span" style="white-space: pre;"> </span>: G1 dan G2</span></div>
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<span style="letter-spacing: 0.0px;">Derajat Tinggi<span class="Apple-tab-span" style="white-space: pre;"> </span>: G3 dan G4</span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span><b>4.5.2.2. Sistem TNM </b></span></div>
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<span style="letter-spacing: 0.0px;">T: besar tumor </span></div>
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<span style="letter-spacing: 0.0px;">N: adanya metastase ke KGB leher</span></div>
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<span style="letter-spacing: 0.0px;">M: adanya metastase ke paru<span class="Apple-tab-span" style="white-space: pre;"> </span></span></div>
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<span style="letter-spacing: 0.0px;"><b>4.6. Cara Kerja</b></span></div>
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<span style="letter-spacing: 0.0px;">Prosedur pemeriksaan immunohistokimia galectin 3 mengikuti prosedur tetap cara pemeriksaan immunohistokmia 3 step dengan <i>microwave mediated antigen retrieval</i> untuk parafin. Ada beberapa tahapan :</span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Deparafinisasi :</span></li>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Xylol<span class="Apple-tab-span" style="white-space: pre;"> </span>: 3 kali 5 menit</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Alkohol absolut<span class="Apple-tab-span" style="white-space: pre;"> </span>: 1 kali 5 menit</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Alkohol 96%<span class="Apple-tab-span" style="white-space: pre;"> </span>: 1 kali 5 menit</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Alkohol 70%<span class="Apple-tab-span" style="white-space: pre;"> </span>: 1 kali 5 menit</span></li>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dicuci dengan tris ( hydroxymethyl aminomethan ) 2 kali masing-masing 3 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dilakukan tahap <i>microwave</i> selama 10 menit dengan 10 mM sitrat buffer pH6.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dicuci dengan tris 2 kali masing-masing 3 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dilakukan <i>blocking </i>dengan <i>dual endogenous enzyme block</i> (kit) pada suhu kamar.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dicuci dengan tris 2 kali masing-masing 3 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Ditetesi antibodi primer <i>galectin-3Ab1</i> (Clone 9C4) <i>human monoclonal antibody </i>(scintific, USA) selama satu malam pada suhu 2-8</span><span style="font-size: 8px; letter-spacing: 0px;"><sup>o</sup></span><span style="letter-spacing: 0.0px;">C</span><span style="font-size: 8px; letter-spacing: 0px;"><sup> .</sup></span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dicuci dengan tris 2 kali masing-masing 3 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Ditetesi antibodi sekunder ( Labelled polymer HRP) selama 30 menit pada suhu kamar.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dicuci dengan tris 2 kali masing-masing 3 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Ditetesi larutan peroksidase DAB ( 3,3 diaminobenzidine tetrahydrochloride ) selama 5-10 menit pada suhu kamar.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dicuci dengan aquades 2 kali masing-masing 3 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dilakukan <i>counterstain </i>dengan <i>mayer haematoxylin</i> selama 5 menit.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Dilakukan dehidrasi kemudian <i>mounting</i> dengan enttelan (Xylene).</span></li>
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<span style="letter-spacing: 0.0px;"><b>4.8. Analisis Data</b></span></div>
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<span style="letter-spacing: 0.0px;">Pada tahap awal akan dilakukan analisa deskriptif. Tahap selanjutnya dilakukan uji dengan <i>chi square</i> untuk mengetahui apakah ada hubungan antara ekspresi <i>galectin 3</i> dengan agresifitas karsinoma sel skuamosa rongga mulut. Apabila syarat <i>chi square</i> tidak terpenuhi, yaitu jumlah sel yang mempunyai nilai harapan kurang dari 5 tidak boleh lebih dari 20% jumlah sel, maka analisis data dilakukan menggunakan uji <i>Fisher’s Exact.</i> </span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB V</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>HASIL PENELITIAN DAN PEMBAHASAN</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.1. Hasil Penelitian</b></span></div>
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<span style="letter-spacing: 0.0px;">Penelitian dimulai dengan penelusuran catatan medik penderita karsinoma rongga mulut di Divisi Bedah Kepala Leher/ SMF Ilmu Bedah Fakultas Kedokteran Airlangga/ RSU Dr. Soetomo Surabaya selama kurun waktu tiga tahun sejak tahun 2010 sampai tahun 2012. Data ini kemudian disesuaikan dengan data dibagian Patologi Anatomi Fakultas Kedokteran Universitas Airlangga/ RSU Dr. Soetomo Surabaya. Didapatkan 30 spesimen karsinoma sel skuamosa rongga mulut. </span></div>
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<span style="letter-spacing: 0.0px;"><b>5.1.1. Distribusi Karsinoma Rongga Mulut Menurut Umur dan Jenis Kelamin</b></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Dari total 30 spesimen karsinoma rongga mulut pada penelitian ini didapatkan paling banyak terdapat pada jenis kelamin laki-laki sebanyak 76,7% dengan ratio laki dibanding perempuan 3:1. Rentang umur mulai dari 32 tahun sampai 72 tahun dan kelompok umur paling banyak diatas 50 tahun (66,6%).</span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.1. Distribusi Umur dan Jenis Kelamin Karsinoma Sel Skuamosa Rongga Mulut</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.1.2. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Stadium Klinis dan Derajat Histopatologis</b></span></div>
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<span style="letter-spacing: 0.0px;"><b><span class="Apple-tab-span" style="white-space: pre;"> </span></b>Secara histopatologis ditemukan w<i>ell differentiated </i>pada 29 spesimen (96,7%). Jumlah spesimen berdasarkan besar tumor sebanding antara T1,T2 dan T3,T4, masing-masing sebesar 50%. Jumlah spesimen berdasarkan adanya metastase pada KGB leher, ditemukan N negatif sebanyak 20 kasus (66,7%). Jumlah spesimen berdasarkan derajat histopatologi, besar tumor dan adanya metastase pada KGB leher, ditemukan agresifitas tinggi sebesar 57,7%. Hasil terperinci dapat dilihat pada tabel 5.2 sampai dengan tabel 5.5.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.2. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan <span class="Apple-tab-span" style="white-space: pre;"> </span>Derajat Histopatologis</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.3. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Besar Tumor</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.4. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Status KGB</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.5. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Derajat Histopatologi, Besar Tumor dan Status KGB</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.2. Ekspresi <i>Galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut<span class="Apple-tab-span" style="white-space: pre;"> </span></b>Ekspresi<i> galectin-3 </i>ditunjukkan dengan skor sebagai berikut: negatif (-) bila ekspresi tidak meningkat, positif (+) bila ekspresi <i>galectin-3 </i>meningkat sedang dan positif 2 (++) bila ekspresi <i>galectin-3</i> sangat meningkat atau ekspresi sangat kuat. Dari keseluruhan spesimen, terdapat 2 spesimen (6,7%) spesimen dengan hasil negatif atau tidak meningkat, 28 spesimen (93,3%) menunjukan adanya peningkatan ekspresi <i>galectin-3</i>.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.6. Ekspresi Imunohistokimia <i>galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.2.1<span class="Apple-tab-span" style="white-space: pre;"> </span>Ekspresi <i>Galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut Berdasarkan Derajat Histopatologi</b></span></div>
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<span style="letter-spacing: 0.0px;"><b><span class="Apple-tab-span" style="white-space: pre;"> </span></b>Dari keseluruhan 29 spesimen dengan agresifitas rendah (G1), didapatkan 2 spesimen (6,9%) dengan ekspresi <i>galectin-3 </i>tidak meningkat atau negatif dan 27 spesimen (93,1%) menunjukkan adanya peningkatan ekspresi <i>galectin-3</i>. Spesimen dengan agresifitas tinggi (G3) terdapat pada 1 spesimen menunjukan ekspresi <i>galectin-3</i> kuat (100%). </span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.7. Ekspresi Imunohistokimia <i>galectin-3 </i>Karsinoma Rongga Mulut Berdasarkan Derajat Histopatologis</b></span></div>
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<span style="letter-spacing: 0.0px;">Hasil uji <i>Fisher’s Exact</i> didapatkan nilai signifikansi sebesar 1,000 (p>0,05) berarti tidak ada hubungan antara agresifitas berdasar derajat histopatologi dengan ekspresi <i>galectin 3</i>.</span></div>
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<span style="letter-spacing: 0.0px;"><b>5.2.2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ekspresi <i>Galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut Berdasarkan Besar Tumor</b></span></div>
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<span style="letter-spacing: 0.0px;"><b><span class="Apple-tab-span" style="white-space: pre;"> </span></b>Pada besar tumor T1 ditemukan 7 spesimen (87,5%) terjadi peningkatan ekspresi <i>galectin-3</i>, dimana 25% meningkat sedang dan 62,% sangat meningkat. Pada tumor T2 ditemukan 6 spesimen (85,7,5%) terjadi peningkatan, dimana 57,1% meningkat sedang dan 28,6,% meningkat kuat. Pada tumor T3 ditemukan seluruh spesimen terjadi peningkatan ekspresi <i>galectin-3</i>, dimana 3 spesimen (33,3%) meningkat sedang dan 6 spesimen (66,7%) sangat meningkat atau ekspresi kuat. Pada tumor T4 ditemukan seluruhnya terjadi peningkatan ekspresi <i>galectin-3</i>, dimana 4 spesimen (66,7%) meningkat sedang dan 2 spesimen (33,3%) meningkat kuat. Pada T1+T2 ditemukan 2 spesimen (13,3%) tidak meningkat, 6 spesimen (40%) meningkat sedang dan 7 spesimen (46,7%) sangat meningkat. Pada T3+T4 ditemukan seluruh spesimen meningkat dimana 7 spesimen (46,7%) meningkat sedang, dan 8 spesimen (53,3%) meningkat kuat. </span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.8. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Besar Tumor</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.9. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Besar Tumor T1+T2 dan T3+T4</b></span></div>
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<span style="letter-spacing: 0.0px;">Hasil uji Fisher’s Exact didapatkan nilai signifikansi sebesar 0,462 (p>0,05) berarti tidak ada hubungan antara agresifitas berdasar berat tumor (stadium T) dengan ekspresi <i>galectin 3</i>.</span></div>
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<span style="letter-spacing: 0.0px;"><b>5.2.3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ekspresi <i>Galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut Berdasarkan Metastase KGB leher</b></span></div>
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<span style="letter-spacing: 0.0px;"><b><span class="Apple-tab-span" style="white-space: pre;"> </span></b>Berdasarkan status KGB leher, pada N0 ditemukan 1 spesimen (5,2%) tidak terjadi peningkatan ekspresi <i>galectin-3</i>, 42,1% meningkat dengan ekspresi sedang dan 52,7% menunjukkan ekspresi kuat. Pada N1 semuanya meningkat dimana 25% meningkat sedang, sedangkan 75% ekspresi meningkat kuat. Pada N2, 16,6% tidak tampak peningkatan ekspresi <i>galectin-3</i>, 50% meningkat sedang dan 33,3% ekspresi meningkat kuat. Pada N3 semua spesimen menunjukkan peningkatan ekspresi <i>galectin-3, </i>dimana seluruhnya 100% meningkat sedang. Pada status KGB leher berdasarkan N0 dan N+, didapatkan ekspresi <i>galectin-3 </i>sebagai berikut; pada N0 5,2% tidak terdapat peningkatan ekspresi <i>galectin-3, </i>42,1% tampak meningkat dengan ekspresi sedang dan 52,7% meningkat dengan ekspresi kuat. Pada N+ 9,1% tidak tampak peningkatan ekspresi <i>galectin-3.</i> Ekspresi sedang tampak pada 45,45% spesimen dan ekspresi kuat juga pada 45,45% spesimen.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.10. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Status KGB</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.11. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Status KGB N(-) dan N(+)</b></span></div>
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<span style="letter-spacing: 0.0px;">Hasil uji Fisher’s Exact didapatkan nilai signifikansi sebesar 0,666 (p>0,05) berarti tidak ada hubungan antara agresifitas berdasar status KGB (<i>nodal status) </i>dengan ekspresi <i>galectin 3.</i></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.2.4.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ekspresi <i>Galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut Berdasarkan Derajat Histopatologi, Besar tumor dan Metastase KGB leher</b></span></div>
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<span style="letter-spacing: 0.0px;"><b><span class="Apple-tab-span" style="white-space: pre;"> </span></b>Berdasarkan derajat histopatologi, besar tumor (stadium T) dan metastase KGB leher (<i>nodal status)</i>, ditemukan ekspresi <i>galectin-3 </i>sebagai berikut: pada karsinoma sel skuamosa rongga mulut dengan agresifitas rendah, 7,7% tidak ada peningkatan ekspresi <i>galectin-3,</i>ekspresi sedang pada 38,5% spesimen dan peningkatan dengan ekspresi kuat pada 53,8% spesimen Pada karsinoma sel skuamosa rongga mulut dengan agresifitas tinggi ditemukan 5,9% tidak ada peningkatan ekspresi <i>galectin-3, </i>peningkatan dengan ekspresi sedang pada 47,05% spesimen dan peningkatan dengan ekspresi kuat pada 47,05% spesimen.</span></div>
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<span style="letter-spacing: 0.0px;"><b>Tabel 5.12. Distribusi Agresifitas Karsinoma Rongga Mulut Berdasarkan Derajat Histopatologi, Besar Tumor dan Status KGB</b></span></div>
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<span style="letter-spacing: 0.0px;">Hasil uji Fisher’s Exact didapatkan nilai signifikansi sebesar 0,857 (p>0,05) berarti tidak ada hubungan antara agresifitas berdasar derajat histopatologi, besar tumor dan status KGB dengan ekspresi <i>galectin 3.</i></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 1. Pembesaran 40x pada jaringan normal, ekspresi <i>galectin-3(-)</i></b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 2. Pembesaran 20x pada karsinoma sel skuamosa ekspresi <i>galectin-3(-)</i></b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 3. Pembesaran 40x pada jaringan tumor dengan ekspresi <i>galectin-3(+) </i></b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 4. Pembesaran 12,5x pada jaringan tumor dengan ekspresi <i>galectin-3(++)</i></b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 5. Pembesaran 200x pada jaringan tumor dengan ekspresi <i>galectin-3 </i>(-)</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 6. Pembesaran 200x pada jaringan tumor dengan ekspresi <i>galectin-3 (+)</i></b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 7. Pembesaran 200x pada jaringan tumor dengan ekspresi <i>galectin-3(++)</i></b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 8. Pembesaran 400x pada jaringan tumor dengan ekspresi <i>galectin-3</i> (-)</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 9. Pembesaran 400x jaringan tumor dengan ekspresi <i>galectin-3</i> (+)</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Gambar 10. Pembesaran 400x jaringan tumor dengan ekspresi <i>galectin-3</i> (++)</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.3. Pembahasan</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>5.3.1.<span class="Apple-tab-span" style="white-space: pre;"> </span>Gambaran Umum Hasil Penelitian</b></span></div>
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<span style="letter-spacing: 0.0px;">Pada penelitian ini kami dapatkan 30 spesimen karsinoma sel skuamosa rongga mulut yang dikumpulkan sejak tahun 2010 sampai tahun 2012. Jumlah ini tidak mencerminkan total jumlah kasus yang dirawat dibagian Bedah Kepala Leher RSU Dr. Soetomo, oleh karena tidak semua kasus memiliki blok parafin. Sebagian kasus data patologis terbatas pada sediaan sitologi dan sebagian kasus yang memilki blok paraffin tapi tidak memenuhi syarat pemeriksaan imunohistokimia. </span></div>
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<span style="letter-spacing: 0.0px;">Secara umum dari 30 spesimen ini adalah spesimen dari penderita karsinoma sel skuamosa rongga mulut dengan rata-rata umur 53 tahun, dengan ratio antara laki-laki dan perempuan sebesar 3:1. Data ini sesuai banyak kepustakaan bahwa karsinoma sel skuamosa rongga mulut memang lebih banyak pada laki-laki diatas 40 tahun (Farah et al., 2012). Keadaan ini banyak dihubungkan dengan faktor resiko seperti konsumsi alkohol, tembakau (<i>smoke/smokeless)</i>, dan <i>betel quid </i>(Balfour et al., 2009). Pada kasus-kasus dengan umur yang lebih muda dibawah 40-45 tahun lebih sering dihubungkan dengan infeksi <i>human papillomavirus </i>(Farah et al., 2012).</span></div>
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<span style="letter-spacing: 0.0px;">Lebih dari 50% sampel yang ada menunjukan sudah stadium III dan dan IV, adanya pembesaran KGB leher terdapat pada 33,3% kasus, dan besar tumor pada T3 dan T4 terdapat pada 50% kasus. Seperti yang dilaporkan Bittar dkk, bahwa 53,16 % kasus karsinoma rongga mulut sering didiagnosa sudah diatas stadium III (Bittar et al., 2010).</span></div>
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<span style="letter-spacing: 0.0px;"><b>5.3.2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ekspresi <i>Galectin-3 </i>pada Karsinoma Sel Skuamosa Rongga Mulut </b></span></div>
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<span style="letter-spacing: 0.0px;">Ekspresi <i>galectin-3 </i>pada penelitian ini ditentukan secara kualitatif oleh seorang ahli patologi dengan nilai negatif (-), positif 1 (+) dan positif 2 (++). Lokasi ekspresi <i>galectin-3 </i> yang dinilai adalah dalam sitoplasma. Hasil penelitian ini menunjukkan 28 spesimen dari 30 (93,3%) terjadi peningkatan ekspresi <i>galectin-3</i>, apakah sedang atau tinggi (+ dan ++). Hasil ini umumnya sama dengan banyak penelitian lain. Pada penelitian Honjo dkk dalam penelitian pada 54 spesimen karsinoma sel skuamosa lidah mendapatkan 84,9% terjadi peningkatan ekspresi <i>galectin-3</i> (Honjo et al., 2000). Miranda dkk dalam penelitian pada 65 pasien dengan karsinoma laring menemukan 55 (84,6%) terjadi peningkatan ekspresi <i>galectn-3</i> yang bermakna (Miranda et al., 2009).<i> </i>Shibata dkk menemukan 46,5% dari 154 pasien terjadi peningkatan ekspresi <i>galecton-3</i> (Shibata et al., 2005). Tadbir dkk menunjukkan bahwa konsentrasi <i>galectin-3 </i>serum meningkat pada sebagian besar kasus karsinoma sel skuamosa rongga mulut (Tadbir et al., 2010).</span></div>
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<span style="letter-spacing: 0.0px;"><b>5.3.3.<span class="Apple-tab-span" style="white-space: pre;"> </span>Ekspresi <i>Galectin-3 </i>pada Agresifitas Karsinoma Sel Skuamosa Rongga Mulut </b></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Agresifitas karsinoma rongga mulut yang masuk pada penelitian adalah derajat histopatologi, besar tumor dan status KGB. Uji statistik yang dilakukan pada penelitian ini, tidak menemukan adanya korelasi antara tingkat ekspresi <i>galectin-3 </i>dengan agresifitas karsinoma sel skuamosa rongga mulut. Hasil uji Fisher’s Exact berdasarkan derajat histopatologi didapatkan nilai signifikansi sebesar 1,000 (p>0,05), berdasarkan besar tumor (stadium T) didapatkan nilai signifikansi sebesar 0,462 (p>0,05), berdasarkan status KGB (<i>nodal status) </i>didapatkan nilai signifikansi sebesar 0,666 (p>0,05) dan berdasarkan derajat histopatologi, besar tumor dan status KGB didapatkan nilai signifikansi sebesar 0,857 (p>0,05). Semua uji ini menunjukan tidak ada hubungan agresifitas karsinoma rongga mulut dengan tingkat ekspresi <i>galectin 3.</i></span></div>
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<span style="letter-spacing: 0.0px;">Hasil penelitian ini sama dengan hasil penelitian Honjo dkk, dimana peningkatan ekspresi <i>galectin-3 </i>tidak berhubungan dengan derajat histopatologi, besar tumor maupun status KGB regional. Akan tetapi dalam follow-up selama 10 tahun setelah terapi awal, Honjo dkk menemukan bahwa <i>survival rate </i>maupun <i>disease-free survival rate </i>jauh lebih baik pada pasien dengan ekspresi <i>galectin-3 </i>yang rendah (Honjo et al., 2000). Demikian juga penelitian Shibata dkk, menunjukkan bahwa ekspresi galectin-3 dalam sitoplasma tidak berhubungan dengan faktor klinikopatologi, tapi ekspresi dalam intisel berhubungan dengan derajat diferensiasi histologis (Shibata et al., 2005). Tadbir dkk dalam penelitiannya menunjukkan peningkatan konsentrasi <i>galectin-</i>3 serum tidak berhubungan dengan gambaran klinikopatologi karsinoma sel skuamosa rongga mulut (Tadbir et al.,2010). </span></div>
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<span style="letter-spacing: 0.0px;">Walaupun demikian, beberapa penelitian lain menunjukkan adanya hubungan antara ekspresi <i>galectin-3 </i>dengan agresifitas proses keganasan. Miranda dkk dalam penelitiannya pada 65 pasien dengan karsinoma laring, menunjukkan peningkatan ekspresi galectin-3 berhubungan dengan karsinoma laring yang bersifat invasif (Miranda et al., 2009). Hasil yang sama juga ditemukan oleh Choi dkk (Choi et al., 2010). Penelitian Saussez pada 137 kasus karsinoma kepala leher menemukan bahwa, peningkatan ekspresi <i>galectin-3</i> secara bertahap terutama dalam inti sel berhubungan dengan progresifitas tumor, mulai dari epitel normal, displasia ringan, displasia berat dan paling tinggi pada jaringan tumor (Saussez et al., 2008). Choufani dkk dalam penelitiannya bahkan mendapat hasil yang terbalik dimana pada kasus-kasus keganasan kepala leher yang agresif cenderung terjadi penurunan ekspresi <i>galectin-3</i> dan ligandnya, dibanding jaringan normal (Choufani et al., 1999). Penelitian Choufani dkk. diikuti oleh Piantelli dkk, dengan hasil yang sama (Piantelli et al., 2002).</span></div>
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<span style="letter-spacing: 0.0px;">Adanya perbedaan ini terjadi dengan berbagai sebab, antara lain adanya perbedaan penggunaan antibodi <i>galectin-3, </i>apakah monoklonal atau poliklonal. Monoklonal antibodi hanya bisa mengenal molekul <i>galectin-3 </i>yang utuh, sedangkan poliklonal antibodi dapat mengenal <i>galectin-3 </i>utuh maupun yang terbelah (balan et al., 2010). Pembelahan ini tergantung pada ada tidaknya polimorfisme nukleotida tunggal <i>(SNP: single nucleotide polymorphism) </i>pada gen <i>galectin-3 </i>(rs4644). <i>SNP</i> ini ditemukan pada 5% sampai 12% populasi Asia maupun Kaukasia (Balan et al., 2010). Pada penelitian ini menggunakan <i>mouse monoclonal antibody (Clone 9C4). </i>Perbedaan lain mencakup cara penilaian apakah kualitatif atau kuantitatif, lokasi <i>galectin-3 </i>apakah serum, ekstrasel, sitoplasma ataupun intrasel (Cay, 2012). Demikian juga peralatan yang digunakan bisa manual atau komputerisasi (Media-Cybernetics), misalnya penggunaan mikroskop cahaya, <i>fluorescence microscopy, </i>kamera digital resolusi tinggi, <i>software </i>khusus<i> </i>(Stillman et al., 2006; Miranda et al., 2009).</span></div>
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<span style="letter-spacing: 0.0px;">Sampai saat ini penelitian tentang <i>galectin-3</i> tetap berlanjut, bukan saja hubungan secara diagnostik atau nilai prognostik tapi juga nilai terapeutik seperti pemberian <i>anti-galectin-3 polyclonal antibody </i>atau MCP (<i>modified Citrus Pectin)</i> yang terbukti bisa menghambat progresifitas tumor melalui hambatan migrasi dan morfogenesis endotel (Nangia-Makker et al., 2000). Demikian juga pemberian <i>recombinant galectin-3 </i>yang dimodifikasi ternyata dapat menghambat ikatan antigen T <i>(Thomsen-Friedenreich antigen)</i> dari sel tumor dengan galectin-3 pada permukaan sel endotel. Demikian juga, <i>recombinant galectin-3C </i>dapat berfungsi anti <i>galectin-3</i> dan dapat menjadi target terapi dalam menemukan terapi <i>antiadhesive cancer</i> (Glinsky VV et al., 2001; John CM et al., 2003).</span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB VI</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>RINGKASAN</b></span></div>
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<span style="letter-spacing: 0.0px;">Telah dilakukan penelitian korelasi antara ekspresi <i>galectin-3 </i>sitoplasma dengan <i>grade </i>dan metastase karsinoma rongga mulut. Hipotesa yang diuji adalah apakah ekspresi <i>galectin-3 </i>sitoplasma mempunyai korelasi dengan agresifitas karsinoma rongga mulut. Penelitian ini dilakukan dari bulan September 2012 sampai Desember 2012 di Bagian/SMF Ilmu Bedah dan Bagian/SMF Patologi Anatomi Fakultas Kedokteran Universitas Airlangga/RSU Dr. Soetomo Surabaya.</span></div>
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<span style="letter-spacing: 0.0px;">Rancangan penelitian yang digunakan adalah observasional analitik dengan pendekatan <i>cross sectional. </i>Jumlah sampel yang ditemukan sebanyak 30 sampel berupa blok parafin jaringan karsinoma sel skuamosa rongga mulut. Keseluruhan sampel dilakukan pengecatan imunohistokimia dengan menggunakan monoklonal antibodi <i>galectin-3</i> untuk melihat ekspresi <i>galectin-3 sitoplasma. </i>Data yang diperoleh dianalisis menggunakan uji <i>Fisher’s Exact.</i></span></div>
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<span style="letter-spacing: 0.0px;">Dari hasil penelitian ini didapatkan peningkatan ekspresi <i>galectin-3 </i>pada 93,3% spesimen, tidak menunjukkan adanya korelasi dengan agresifitas karsinoma sel skuamosa rongga mulut, baik terhadap derajat histopatologis, stadium tumor maupun status KGB regional. Melalui uji Fisher’s Exact didapatkan nilai signifikansi sebesar 0,857 (p>0,05), berarti tidak ada hubungan antara agresifitas dengan ekspresi <i>galectin-3.</i></span></div>
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<span style="letter-spacing: 0.0px;"><b>BAB VII</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>KESIMPULAN DAN SARAN</b></span></div>
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<span style="letter-spacing: 0.0px;">Kesimpulan<span class="Apple-tab-span" style="white-space: pre;"> </span>:</span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Ekspresi galectin-3 dapat menjadi biomarker dalam menentukan karsinoma rongga mulut.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tingkat ekspresi galectin-3 tidak berhubungan dengan derajat diferensiasi sel tumor, besar tumor maupun status KGB regional.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tingkat ekspresi galectin-3 yang rendah pada stadium dini mungkin berhubungan dengan <i>survival rates</i> yang tinggi.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tingkat ekspresi galectin-3 yang tinggi pada stadium dini mungkin berhubungan dengan <i>survival rates </i>yang rendah.</span></li>
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<span style="letter-spacing: 0.0px;">Saran<span class="Apple-tab-span" style="white-space: pre;"> </span>: </span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Perlu penelitian lanjutan dan jangka panjang untuk melihat survival rates pada pasien-pasien dengan ekspresi galectin-3 rendah maupun tinggi.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Penelitian lanjutan perlu metodologi penelitian dengan cara kualitatif dan kuantitatif.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px 0px 10px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Diharapkan adanya penelitian mengenai <i>anti-galectin-3</i> dimasa depan.</span></li>
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<span style="letter-spacing: 0.0px;"><b>DAFTAR KEPUSTAKAAN</b></span></div>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Cooper DNW, Barondes SH. <b><i>God must love galectins; He made so many of them. </i></b>Glycobiology;9;979-984; 1999.</span></li>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Davidson PJ, Li S, Lohse AG, Vandergaast RV, Verde E, Pearson A, Patterson RJ, Wang JL, Arnoys EJ. <b><i>Transport of galectin-3 between the nucleus and cytoplasm. I. Conditions and signals for nuclear import. </i></b>Glycobiology;16;7;602-611; 2006.</span></li>
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<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Suzuki O, Abe M. <b><i>Cell surface N-glycosylation and sialylation regulate galectin-3 induced opoptosis in human diffuse large B cell lymphoma. </i></b>Oncology Reports;19;743-748; 2008.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Szeimies Rm, Torezan L, Niwa A, Valente N, Unger P, Kohl E, Schreml S, Babilas P, Karrer S, Festa-Neto C. <b><i>Clinical, histopatological and immunohistochemical assessment of human skin field cancerization before and after photodynamic therapy. </i></b>British Journal of Dermatology;67;150-159; 2012.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tadbir AA, Fattahi MJ, Khademi B, Pourshahidi S, Ebrahimi H, Sardari Y, Fattah Z. <b><i> Serum level of Galectin-3 in Patiens with Oral Squamous Cell Carcinoma. </i></b>Middle East Journal of Cancer;1(2);77-81; 2010.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Takenaka Y, Fukumori T, Raz A.<b><i>Galectin-3 and metastasis. </i></b>Glycoconjugate Journal 19, 543–549, 2004. </span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Trang TT, Lavertu P. <b><i>The Evolving Role of Neck Dissection in the Era of Organ Preservation Therapy for Head and Neck Squamous Cell Carcinoma</i></b> in: Squamous Cell Head and Neck Cancer: <i>Recent Clinical Progress and Prospects for the Future.</i>;4;59-65; Humana Press 2005.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tsuboi K, Shimura T, Masuda N, Ide M, Tsutsumi S, Yamaguchi S, Asao T, Kuwano H. <b><i>Galectin-3 Expression in Colorectal Cancer: Relation to Invasion and Metastasis. </i></b>Anticancer Research;<i>27</i>;2289-2296; 2007.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Tsuda M, Ohba Y. <b><i>Functional Biomarkers of Oral Cancer</i></b> in: Oral Cancer ed. Ogbureke KUE. 15;277-290; InTech 2012.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Uittamo J. <b><i>Production of Carcinogenic Acetaldehyde by Oral Microbiome. </i></b>Doctoral Dissertation; Depart of Oral and Maxillofacial Diseases Helsinki University Central Hospital; 2012.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Ujaoney S, Motwani MB, Degwekar S, Wadhwan V, Zade P, Chaudhary M, Hazarey V, Thakre TP, Mamtani M. <b><i>Evaluation of chemiluminescence, toluidine blue and histopathology for detection of high risk oral precancerous lesions: A cross-sectional study. </i></b>BMC Clinical Pathology;12;6; 2012.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Vereecken P, Ghanem G, Morandini R, Suciu S, Baren NV, Heenen M. <b><i>Defining the Prognostic Value for Galectin-3 in Cutaneus Melanoma.</i></b> The Journal of International Medical Research;35;731-732; 2007.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Waes CV. <b><i>Molecular Biology of Squamous Cell Carcinoma </i></b>in Ballenger’s Otorhinolaryngology Head and Neck Surgery 16th ed;1309-1320; BC Decker Inc.; 2003.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Wang XD, Inoue-Fruehauf H. <b><i>Alcohol and Cancer: Cellular Mechanisms of Action</i></b> in: Dietary Cancer Risk Factors in: Nutrition and cancer Prevention. Press;IX;28;579-590; CRC 2006.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Wein RO, Malone JP, Weber RS. <b><i>Malignant Neoplasms of the Oral Cavity</i></b> in: Cummings Otolaryngology Head & Neck Surgery 5th.;96;1293-1317; Mosby-Elsevier 2010.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Zhao Q, Barclay M, Hilkens J, Guo X, Barrow H, Rhodes JM, Yu L. <b><i>Interaction between circulating galectin-3 and cancer-associated MUC1 enhances tumour cell homotypic aggregation and prevents anoikis. </i></b>Molecular Cancer;9;154; 2010.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Zhao Q, Guo X, Nash GB, Stone PC, Hilkens J, Rhodes JM, Yu L. <b><i>Circulating galectin-3 promotes metastasis by modifying MUC1 localization on cancer cell surface.</i></b> Cancer Res;69;17;6799-6806; 2009.</span></li>
<li style="font-family: Arial; font-size: 12px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica;"></span><span style="letter-spacing: 0.0px;">Zhu X, Ding M, Yu M, Feng M, Tan L, Zhao F. Identification of galecin-7 as a potential biomarker for esophageal squamous cell carcinoma by proteomic analysis. BMC Cancer; 10;290;2010.</span></li>
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<span style="letter-spacing: 0.0px;"><b>LAMPIRAN. 1</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>PROSEDUR PEMERIKSAAN IMUNOHISTOKIMIA</b></span></div>
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<span style="letter-spacing: 0.0px;"><span class="Apple-tab-span" style="white-space: pre;"> </span>Prosedur pemeriksaan imunohistokimia galectin-3 mengikuti prosedur tetap cara pemeriksaan imunohistokimia 3 step dengan <i>microwave mediated antigen retrieval</i> untuk parafin. Ada beberapa tahapan :</span></div>
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<li style="font-family: Arial; font-size: 11px; margin: 0px; text-align: justify;"><span style="font-family: Helvetica; font-size: 12px;"></span><span style="letter-spacing: 0.0px;">Deparafinisasi :</span></li>
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<span style="letter-spacing: 0.0px;">- Xylol<span class="Apple-tab-span" style="white-space: pre;"> </span>: 3 kali 5 menit</span></div>
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<span style="letter-spacing: 0.0px;">- Alkohol absolut<span class="Apple-tab-span" style="white-space: pre;"> </span>: 1 kali 5 menit</span></div>
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<span style="letter-spacing: 0.0px;">- Alkohol 96%<span class="Apple-tab-span" style="white-space: pre;"> </span>: 1 kali 5 menit</span></div>
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<span style="letter-spacing: 0.0px;">- Alkohol 70%<span class="Apple-tab-span" style="white-space: pre;"> </span>: 1 kali 5 menit</span></div>
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<span style="letter-spacing: 0.0px;"> 2.<span class="Apple-tab-span" style="white-space: pre;"> </span>Dicuci dengan <i>tris</i> (<i>hydroxymethyl aminomethan</i>) 2 kali masing-masing 3 menit</span></div>
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<span style="letter-spacing: 0.0px;"> 3. Dilakukan tahap <i>microwave</i> selama 10 menit dengan 10 mM sitrat buffer pH 6</span></div>
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<span style="letter-spacing: 0.0px;"> 4. Dicuci dengan <i>tris </i>2 kali masing-masing 3 menit.</span></div>
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<span style="letter-spacing: 0.0px;"> 5. Dilakukan <i>blocking</i> dengan <i>dual endogenous enzyme block</i> (kit) pada suhu kamar</span></div>
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<span style="letter-spacing: 0.0px;"> 6. Dicuci dengan <i>tris</i> 2 kali masing-masing 3 menit.</span></div>
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<span style="letter-spacing: 0.0px;"> 7. Ditetesi antibodi primer <i>Galectin-3 Ab-1 (Clone 9C4) mouse monoclonal </i></span></div>
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<span style="letter-spacing: 0.0px;"><i> antibody</i> (<i>Thermo scientific, USA</i>) selama satu malam pada suhu 2 – 8 </span><span style="font-size: 7.3px; letter-spacing: 0px;"><sup>0</sup></span><span style="letter-spacing: 0.0px;">C. </span></div>
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<span style="letter-spacing: 0.0px;"> 8. Dicuci dengan <i>tris </i>2 kali masing-masing 3 menit</span></div>
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<span style="letter-spacing: 0.0px;"> 9. Ditetesi antibodi sekunder (<i>Labelled Polymer-HRP</i>) selama 30 menit pada suhu </span></div>
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<span style="letter-spacing: 0.0px;">kamar.</span></div>
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<span style="letter-spacing: 0.0px;"> 10. Dicuci dengan <i>tris</i> 2 kali masing-masing 3 menit.</span></div>
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<span style="letter-spacing: 0.0px;"> 11. Ditetesi larutan peroksidase <i>DAB</i> (3,3’-diaminobenzidine tetrahydrochloride) </span></div>
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<span style="letter-spacing: 0.0px;">selama 5-10 menit pada suhu kamar.</span></div>
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<span style="letter-spacing: 0.0px;"> 12. Dicuci dengan aquades 2 kali masing-masing 3 menit</span></div>
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<span style="letter-spacing: 0.0px;"> 13. Dilakukan <i>counterstain</i> dengan <i>mayer haematoxylin</i> selama 5 menit.</span></div>
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<span style="letter-spacing: 0.0px;"> 14. Dilakukan dehidrasi kemudian mounting dengan <i>enttelan</i> (<i>Xylene</i>). </span></div>
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<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Descriptives</b></span></div>
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<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Crosstabs</b></span></div>
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<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<div style="font-family: Arial; font-size: 12px; min-height: 14px;">
<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 12px;">
<span style="letter-spacing: 0.0px;"><b>Analisis Hubungan Derajat histopatologi dengan ekspresi galectin-3</b></span></div>
<div style="font-family: Arial; font-size: 13px; min-height: 15px;">
<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Crosstabs</b></span></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Derajat Histopatologi * Ekspresi Galectin-3</b></span></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Agresifitas berdasar Derajat Histopatologi * Ekspresi Galectin-3</b></span></div>
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<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Crosstabs</b></span></div>
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<img alt="pastedGraphic_54.png" src="webkit-fake-url://F7A755F8-7B7F-4708-8B62-0297A4F35BE2/pastedGraphic_54.png" /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Derajat Histopatologi * Ekspresi Galectin-3</b></span></div>
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<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<span style="letter-spacing: 0.0px;"><b>Agresifitas berdasar Derajat Histopatologi * Ekspresi Galectin-3</b></span></div>
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<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<span style="letter-spacing: 0.0px;"></span><br /></div>
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<span style="letter-spacing: 0.0px;"></span><br /></div>
<div style="font-family: 'Times New Roman'; font-size: 12px; min-height: 15px;">
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<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Analisis hubungan besar tumor dengan ekspresi galectin-3</b></span></div>
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<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Crosstabs</b></span></div>
<div style="font-family: 'Times New Roman'; font-size: 12px; min-height: 15px;">
<span style="letter-spacing: 0.0px;"></span><br /></div>
<div style="font-family: Helvetica; font-size: 12px; margin-bottom: 10px; text-align: center;">
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<span style="letter-spacing: 0.0px;"><b></b></span><br /></div>
<div style="font-family: Arial; font-size: 13px;">
<span style="letter-spacing: 0.0px;"><b>Besar Tumor * Ekspresi Galectin-3</b></span></div>
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<span style="letter-spacing: 0.0px;"><b>Agresifitas berdasar Status Besar Tumor * Ekspresi Galectin-3</b></span></div>
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Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-15565189805381397402014-06-23T17:58:00.001+09:002014-06-23T17:58:16.947+09:00Theo Rompas's invitation is awaiting your response<span class="preheader" style="display: none !important; font-size: 1px;"></span><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#DFDFDF"><tbody><tr><td colspan="3"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="1"><tbody><tr><td><div style="height:5px;font-size:5px;line-height:5px;"> </div></td></tr></tbody></table></td></tr><tr><td align="center" width="100%"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; min-width:290px;" width="550" class="responsive"><tbody><tr><td style="font-family:Helvetica,Arial,sans-serif;"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:8px;font-size:8px;line-height:8px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#DDDDDD"><tbody><tr><td align="left" valign="middle" width="95" height="21" id="base-header-logo"><a style="text-decoration:none;cursor:pointer;border:none;display:block;height:21px;width:100%;" href='http://www.linkedin.com/e/v2?e=-nqi9pw-hwrjxk11-l&t=nmp&tracking=eml-comm_invm-b-logo_home-remind2013&ek=inv_exp_19'><img src='http://s.c.lnkd.licdn.com/scds/common/u/images/email/logos/logo_linkedin_tm_email_95x21_v1.png' width="95" height="21" alt="LinkedIn" style="border:none;text-decoration:none;"/></a></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:8px;font-size:8px;line-height:8px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#333333"><tbody><tr><td width="20" class="responsive-spacer"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td width="100%"><table width="100%" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:12px;font-size:12px;line-height:12px"> </div></td></tr></tbody></table></td><td width="20"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#FFFFFF"><tbody><tr><td width="20" class="res-width10"><table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td style="color: #333333; font-family: Helvetica,Arial,sans-serif; font-size: 15px; line-height: 18px;" align="left"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-height10"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td style="font-family:Helvetica,Arial,sans-serif;color:#333333;"><b>Theo Rompas</b> would like to connect on LinkedIn. How would you like to respond?</td></tr><tr><td style="border-bottom-color: #E5E5E5;border-bottom-width: 1px; border-bottom-style: solid;"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td width="150" valign="top" style="vertical-align: top;" class="res-img100"><a href="https://www.linkedin.com/e/v2?e=-nqi9pw-hwrjxk11-l&a=preRegInvite&tracking=eml-comm_invg-b-photo-accept-reminder&ek=inv_exp_19&invitationID=5881758980237189120&sharedKey=IiDlAJqW" style="text-decoration:none;cursor:pointer;"><img alt="Theo Rompas" src='http://m.c.lnkd.licdn.com/mpr/mpr/shrink_150_150/p/4/005/068/1ef/280cdbb.jpg' width="150" height="150" border="0" class="res-img100" style="border:none;text-decoration:none;outline:hidden;display:block;"/></a></td><td width="20"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td style="vertical-align: top; font-family: Helvetica,Arial,sans-serif;" width="100%"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td valign="top"><a href="https://www.linkedin.com/e/v2?e=-nqi9pw-hwrjxk11-l&a=preRegInvite&tracking=eml-comm_invg-b-name-accept-reminder&ek=inv_exp_19&invitationID=5881758980237189120&sharedKey=IiDlAJqW" style="font-size: 20px; font-weight: bold; color:#000000;text-decoration:none;">Theo Rompas</a></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:3px;font-size:3px;line-height:3px"> </div></td></tr></tbody></table></td></tr><tr><td style="color: #666666; font-size: 15px;" class="res-font16">Consultant of Head and Neck Surgery at Dian Harapan General Hospital</td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td><table border="0" cellpadding="0" cellspacing="0" align="left"><tbody><tr><td align="center" height="30" valign="middle" bgcolor="#287BBC" background="http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png" style="background:url(http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png) repeat-x scroll bottom #287BBC;background-color:#287BBC;border:1px solid #1B5480;-moz-border-radius:3px;-webkit-border-radius:3px;border-radius:3px; cursor: pointer;"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="transparent"><tbody><tr><td width="13"><table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td><a href="https://www.linkedin.com/e/v2?e=-nqi9pw-hwrjxk11-l&a=preRegInvite&tracking=eml-comm_invg-b-button-accept-reminder&ek=inv_exp_19&invitationID=5881758980237189120&sharedKey=IiDlAJqW" style="text-decoration:none; font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;" target="_blank"><span style="font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;">Confirm you know Theo</span></a></td><td width="13"><table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table> </td><td width="20" class="res-width10"><table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="550" class="responsive"><tbody><tr><td align="left"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"><tbody><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td align="left"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; font-size:11px; font-family:Helvetica,Arial,sans-serif; color:#999999;" width="100%" class="responsive res-font10"><tbody><tr><td>You are receiving Reminder emails for pending invitations. <a style="text-decoration:none;color:#0077B5;" href="http://www.linkedin.com/e/v2?e=-nqi9pw-hwrjxk11-l&t=goo&tracking=eml-comm_invg-f-unsub&ek=inv_exp_19&gid=I7228826534_1&id=20060&email=seahealth09%2Epapa69mama%40blogger%2Ecom">Unsubscribe</a></td></tr><tr><td></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td>© 2014, LinkedIn Corporation. 2029 Stierlin Ct. Mountain View, CA 94043, USA</td></tr></tbody></table></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><img src="http://www.linkedin.com/emimp/-nqi9pw-hwrjxk11-l.gif" style="width:1px; height:1px;"/>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-9790138073718206962014-06-16T18:18:00.001+09:002014-06-16T18:18:41.341+09:00Theo Rompas's invitation is awaiting your response<span class="preheader" style="display: none !important; font-size: 1px;"></span><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#DFDFDF"><tbody><tr><td colspan="3"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="1"><tbody><tr><td><div style="height:5px;font-size:5px;line-height:5px;"> </div></td></tr></tbody></table></td></tr><tr><td align="center" width="100%"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; min-width:290px;" width="550" class="responsive"><tbody><tr><td style="font-family:Helvetica,Arial,sans-serif;"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:8px;font-size:8px;line-height:8px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#DDDDDD"><tbody><tr><td align="left" valign="middle" width="95" height="21" id="base-header-logo"><a style="text-decoration:none;cursor:pointer;border:none;display:block;height:21px;width:100%;" href='http://www.linkedin.com/e/v2?e=-nqi9pw-hwhkkt1w-4g&t=nmp&tracking=eml-comm_invm-b-logo_home-remind2013&ek=inv_exp_19'><img src='http://s.c.lnkd.licdn.com/scds/common/u/images/email/logos/logo_linkedin_tm_email_95x21_v1.png' width="95" height="21" alt="LinkedIn" style="border:none;text-decoration:none;"/></a></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:8px;font-size:8px;line-height:8px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif;" width="100%" bgcolor="#333333"><tbody><tr><td width="20" class="responsive-spacer"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td width="100%"><table width="100%" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:12px;font-size:12px;line-height:12px"> </div></td></tr></tbody></table></td><td width="20"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="#FFFFFF"><tbody><tr><td width="20" class="res-width10"><table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td style="color: #333333; font-family: Helvetica,Arial,sans-serif; font-size: 15px; line-height: 18px;" align="left"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-height10"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td style="font-family:Helvetica,Arial,sans-serif;color:#333333;"><b>Theo Rompas</b> would like to connect on LinkedIn. How would you like to respond?</td></tr><tr><td style="border-bottom-color: #E5E5E5;border-bottom-width: 1px; border-bottom-style: solid;"><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td width="150" valign="top" style="vertical-align: top;" class="res-img100"><a href="https://www.linkedin.com/e/v2?e=-nqi9pw-hwhkkt1w-4g&a=preRegInvite&tracking=eml-comm_invg-b-photo-accept-reminder&ek=inv_exp_19&invitationID=5881758980237189120&sharedKey=IiDlAJqW" style="text-decoration:none;cursor:pointer;"><img alt="Theo Rompas" src='http://m.c.lnkd.licdn.com/mpr/mpr/shrink_150_150/p/4/005/068/1ef/280cdbb.jpg' width="150" height="150" border="0" class="res-img100" style="border:none;text-decoration:none;outline:hidden;display:block;"/></a></td><td width="20"><table width="20" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td style="vertical-align: top; font-family: Helvetica,Arial,sans-serif;" width="100%"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%"><tbody><tr><td valign="top"><a href="https://www.linkedin.com/e/v2?e=-nqi9pw-hwhkkt1w-4g&a=preRegInvite&tracking=eml-comm_invg-b-name-accept-reminder&ek=inv_exp_19&invitationID=5881758980237189120&sharedKey=IiDlAJqW" style="font-size: 20px; font-weight: bold; color:#000000;text-decoration:none;">Theo Rompas</a></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:3px;font-size:3px;line-height:3px"> </div></td></tr></tbody></table></td></tr><tr><td style="color: #666666; font-size: 15px;" class="res-font16">Consultant of Head and Neck Surgery at Dian Harapan General Hospital</td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td><table border="0" cellpadding="0" cellspacing="0" align="left"><tbody><tr><td align="center" height="30" valign="middle" bgcolor="#287BBC" background="http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png" style="background:url(http://s.c.lnkd.licdn.com/scds/common/u/img/email/bg_btn_katy_blue_medium.png) repeat-x scroll bottom #287BBC;background-color:#287BBC;border:1px solid #1B5480;-moz-border-radius:3px;-webkit-border-radius:3px;border-radius:3px; cursor: pointer;"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" bgcolor="transparent"><tbody><tr><td width="13"><table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td><td><a href="https://www.linkedin.com/e/v2?e=-nqi9pw-hwhkkt1w-4g&a=preRegInvite&tracking=eml-comm_invg-b-button-accept-reminder&ek=inv_exp_19&invitationID=5881758980237189120&sharedKey=IiDlAJqW" style="text-decoration:none; font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;" target="_blank"><span style="font-size: 13px;font-family: Helvetica,Arial,sans-serif;font-weight: bold;color: white;white-space: nowrap;display: block;">Confirm you know Theo</span></a></td><td width="13"><table width="13px" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table> </td><td width="20" class="res-width10"><table width="20px" border="0" cellspacing="0" cellpadding="1" class="email-spacer res-width10"><tbody><tr><td><div style="height:0px;font-size:0px;line-height:0px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="550" class="responsive"><tbody><tr><td align="left"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; " width="100%" class="responsive"><tbody><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td align="left"><table border="0" cellspacing="0" cellpadding="0" style="font-family:Helvetica,Arial,sans-serif; font-size:11px; font-family:Helvetica,Arial,sans-serif; color:#999999;" width="100%" class="responsive res-font10"><tbody><tr><td>You are receiving Reminder emails for pending invitations. <a style="text-decoration:none;color:#0077B5;" href="http://www.linkedin.com/e/v2?e=-nqi9pw-hwhkkt1w-4g&t=goo&tracking=eml-comm_invg-f-unsub&ek=inv_exp_19&gid=I7228826534_1&id=20060&email=seahealth09%2Epapa69mama%40blogger%2Ecom">Unsubscribe</a></td></tr><tr><td></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:10px;font-size:10px;line-height:10px"> </div></td></tr></tbody></table></td></tr><tr><td>© 2014, LinkedIn Corporation. 2029 Stierlin Ct. Mountain View, CA 94043, USA</td></tr></tbody></table></td></tr><tr><td><table width="1" border="0" cellspacing="0" cellpadding="1" class="email-spacer"><tbody><tr><td><div style="height:20px;font-size:20px;line-height:20px"> </div></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table></td></tr></tbody></table><img src="http://www.linkedin.com/emimp/-nqi9pw-hwhkkt1w-4g.gif" style="width:1px; height:1px;"/>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-53563570711831208042014-06-09T22:30:00.001+09:002014-06-09T22:30:59.350+09:00Invitation to connect on LinkedIn<table border="0" cellspacing="0" cellpadding="0" style="font-family:Arial;" width="100%" bgcolor="#F4F4F4"><tr><td align="center"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Arial;border:solid 1px none;-moz-border-radius:0px;-webkit-border-radius:0px;border-radius:0px;" bgcolor="#f4f4f4" width="100%" class=""><tr><td width="98%" valign="top" align="center"> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Arial;border:solid 1px none;-moz-border-radius:0px;-webkit-border-radius:0px;border-radius:0px;" bgcolor="#FFFFFF" width="590" class="responsive"><tr><td width="98%" valign="top" align=""> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Arial;" width="100%" bgcolor="#f4f4f4"> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:10px;font-size:10px;line-height:10px;"> </div></td></tr></table> </td> </tr> <tr> <td align="right"> <img src="http://s.c.lnkd.licdn.com/scds/common/u/img/logos/logo_emails_trans_98x24.png" alt="LinkedIn" border="0" height="24" width="98"> </td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:10px;font-size:10px;line-height:10px;"> </div></td></tr></table> </td> </tr> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Arial;" width="100%" class="responsive"> <tr> <td bgcolor="#ffffff" style="border: 1px solid rgb(221, 221, 221); 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font-size: 12px;"> <p style="margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0;"> I'd like to add you to my professional network on LinkedIn.<br/> <br/> - Theo </p> </td> <td> <table width="5" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:0px;font-size:0px;line-height:0px;"> </div></td></tr></table> </td> </tr> <tr> <td colspan="3"> <table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:5px;font-size:5px;line-height:5px;"> </div></td></tr></table> </td> </tr> <tr> <td colspan="3"> <table width="5" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:0px;font-size:0px;line-height:0px;"> </div></td></tr></table> </td> </tr> </table> </td> </tr> <tr> <td> <table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:12px;font-size:12px;line-height:12px;"> </div></td></tr></table> <table border="0" cellspacing="1" cellpadding="6" style="font-family:Arial;" > <tr> <td> <table border="0" cellpadding="6" cellspacing="1" align=""><tr><td align="center" valign="middle" bgcolor="#FFE86C" background="http://s.c.lnkd.licdn.com/scds/common/u/img/bg/yellow_button_back.png" style="background:url(http://s.c.lnkd.licdn.com/scds/common/u/img/bg/yellow_button_back.png) repeat-x scroll 100% 0 #FFE86C;background-color:#FFE86C;border:1px solid #E8B463;-moz-border-radius:4px;-webkit-border-radius:4px;border-radius:4px;"><div style="padding-right:10px;padding-left:10px;"><a href="https://www.linkedin.com/e/-nqi9pw-hw7tih15-5z/isd/5881758980237189120/IiDlAJqW/?hs=false&tok=3YCEitZVXGE6g1" style="text-decoration:none;"><span style="font-size:12px;font-family:Arial;font-weight:bold;color:#333333;white-space:nowrap;display:block;"> Confirm that you know Theo </span></a></div></td></tr></table> </td> </tr> </table> </td> </tr> </table> </td> <td width="15"><table width="15" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:0px;font-size:0px;line-height:0px;"> </div></td></tr></table></td> </tr> </table> <table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:15px;font-size:15px;line-height:15px;"> </div></td></tr></table> </td> </tr> </table> <table border="0" cellspacing="0" cellpadding="0" style="font-family:Arial;" width="100%" bgcolor="#f4f4f4"> <tr><td><table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:5px;font-size:5px;line-height:5px;"> </div></td></tr></table></td></tr> <tr> <td align="left" style="color:#999;font-family:Arial,sans-serif;font-size:11px;line-height:15px"> <div style="text-align: left;">You are receiving Invitation to Connect emails. <a href="http://www.linkedin.com/e/-nqi9pw-hw7tih15-5z/I6sm9NapOeXo8XhZlYgmIY82lNFm4Rzzg0fHOWhpOdz84JDyRQQ/goo/seahealth09%2Epapa69mama%40blogger%2Ecom/20061/I7228826534_1/?hs=false&tok=2eBjOyAirGE6g1">Unsubscribe</a></div> <div>© 2014, LinkedIn Corporation. 2029 Stierlin Ct. Mountain View, CA 94043, USA<table width="1" border="0" cellspacing="0" cellpadding="0" class=""><tr><td><div style="height:1px;font-size:1px;line-height:1px;"> </div></td></tr></table></div> </td> </tr> </table> </td></tr></table> </td></tr></table> </td></tr></table> <img src="http://www.linkedin.com/emimp/-nqi9pw-hw7tih15-5z.gif" style="width:1px; height:1px;"/>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-4791468557985303982011-11-25T16:52:00.000+09:002011-11-25T16:52:52.672+09:00Penile measurements in normal adult Jordanians<div dir="ltr" style="text-align: left;" trbidi="on"> <br />
<div style="background: white; border-color: currentColor currentColor rgb(234, 234, 234); border-style: none none solid; border-width: medium medium 1pt; mso-border-bottom-alt: solid #EAEAEA .5pt; mso-element: para-border-div; padding: 0cm 0cm 2pt;"> <div class="MsoNormal" style="background: white; border: currentColor; line-height: normal; margin: 0cm 0cm 6pt; mso-border-bottom-alt: solid #EAEAEA .5pt; mso-outline-level: 1; mso-padding-alt: 0cm 0cm 2.0pt 0cm; padding: 0cm;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 13pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-font-kerning: 18.0pt;">Original Research<o:p></o:p></span></b></div></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">International Journal of Impotence Research</span></i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> (2005) <b>17</b>, 191–195. doi:10.1038/sj.ijir.3901272 Published online 28 October 2004<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 2;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 14.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penile measurements in normal adult Jordanians and in patients with erectile dysfunction<o:p></o:p></span></div><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGNLgVZpzxeG7L14q7daMCmHKmKl8qzfojyJTIvKwX9UtIr65zbLMqv1zreWwtiJ82SMKaKfViW24o7jyTj9c06mjINnHnNGGog4iNR_PPyPrREuTGT9XBYwZK8xTlEDUxsaijqxfar-w/s1600/statue-69.4.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgGNLgVZpzxeG7L14q7daMCmHKmKl8qzfojyJTIvKwX9UtIr65zbLMqv1zreWwtiJ82SMKaKfViW24o7jyTj9c06mjINnHnNGGog4iNR_PPyPrREuTGT9XBYwZK8xTlEDUxsaijqxfar-w/s320/statue-69.4.jpg" width="213" /></a></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Z Awwad<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#aff1" title="affiliated with 1"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">1</span></a></sup>, M Abu-Hijleh<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#aff2" title="affiliated with 2"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">2</span></a></sup>, S Basri<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#aff2" title="affiliated with 2"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">2</span></a></sup>, N Shegam<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#aff3" title="affiliated with 3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup>, M Murshidi<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#aff1" title="affiliated with 1"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">1</span></a></sup> and K Ajlouni<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#aff3" title="affiliated with 3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt 0.05pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">1.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><sup><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1</span></sup><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Department of Urology, Jordan University Hospital, Amman, Jordan<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt 0.05pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">2.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><sup><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2</span></sup><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jordan Center for the Treatment of Erectile Dysfunction, Amman, Jordan<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt 0.05pt; mso-list: l0 level1 lfo1; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">3.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><sup><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3</span></sup><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">National Center for Diabetes, Endocrinology and Genetics, Amman, Jordan<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Correspondence: Z Awwad, Urology, Jordan University Hospital, Queen Rania Street, PO Box 13046, Amman, Jordan. E-mail: <a href="mailto:zawwad@yahoo.com"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">zawwad@yahoo.com</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Received 2 April 2004; Revised 21 September 2004; Accepted 21 September 2004; Published online 28 October 2004. <o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Abstract<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">The purpose of this work was to determine penile size in adult normal (group one, 271) and impotent (group two, 109) Jordanian patients. Heights of the patients, the flaccid and fully stretched penile lengths were measured in centimeters in both groups. Midshaft circumference in the flaccid state was recorded in group one. Penile length in the fully erect penis was measured in group two. In group one mean midshaft circumference was 8.98</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shapetype coordsize="21600,21600" filled="f" id="_x0000_t75" o:preferrelative="t" o:spt="75" path="m@4@5l@4@11@9@11@9@5xe" stroked="f"> <v:stroke joinstyle="miter"> <v:formulas> <v:f eqn="if lineDrawn pixelLineWidth 0"> <v:f eqn="sum @0 1 0"> <v:f eqn="sum 0 0 @1"> <v:f eqn="prod @2 1 2"> <v:f eqn="prod @3 21600 pixelWidth"> <v:f eqn="prod @3 21600 pixelHeight"> <v:f eqn="sum @0 0 1"> <v:f eqn="prod @6 1 2"> <v:f eqn="prod @7 21600 pixelWidth"> <v:f eqn="sum @8 21600 0"> <v:f eqn="prod @7 21600 pixelHeight"> <v:f eqn="sum @10 21600 0"> </v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:f></v:formulas> <v:path gradientshapeok="t" o:connecttype="rect" o:extrusionok="f"> <o:lock aspectratio="t" v:ext="edit"> </o:lock></v:path></v:stroke></v:shapetype><v:shape alt="plusminus" id="Picture_x0020_1" o:spid="_x0000_i1059" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></b><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1.4, mean flaccid length was mean 9.3</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_2" o:spid="_x0000_i1058" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></b><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1.9, and mean stretched length was 13.5</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_3" o:spid="_x0000_i1057" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></b><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2.3. In group two, mean flaccid length was 7.7</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_4" o:spid="_x0000_i1056" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></b><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1.3, and mean stretched length was 11.6</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_5" o:spid="_x0000_i1055" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></b><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1.4. The mean of fully erect penile length after trimex injection was 11.8</span></b><b style="mso-bidi-font-weight: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_6" o:spid="_x0000_i1054" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></b><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1.5. In group 1 there was no correlation between height and flaccid length or stretched length, but there was a significant correlation between height and midpoint circumference, flaccid and stretched lengths, and between stretched lengths and midpoint circumference. In group 2 there was no correlation between height and flaccid, stretched, or fully erect lengths. On the other hand, there was a significant correlation between the flaccid, stretched and fully erect lengths. Comparing group 1 and group 2, the patients in group 1 were slightly older than in group 2 (<i>P</i>=0.035), but there was no significant difference in their height. However, there was a significant difference regarding the mean flaccid length 9.3 <i>vs</i> 7.7 (<i>P</i>=0.001), and the mean stretched length 13.5 <i>vs</i> 11.6 (<i>P</i>=0.000). We divided both groups into those who are less than 40 y of age, and over 40 y old. There was no statistical difference in the stretched and flaccid lengths between the younger and older individuals in each group. However, when we compared the stretched and flaccid lengths in those of less than 40 y old in group 1 and 2, a significant difference was noticed. Similarly, a significant difference in the stretched and flaccid lengths in those patients over 40 y of age was also present.<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto; mso-outline-level: 4;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Keywords: <o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 7.5pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">penis, measurement, Jordan<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Introduction<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penile size is often associated with much interest in different cultures including the Arab culture. Larger size is perceived to validate sexual function and fertility potential, although a recent study showed that only one-third of women attach substantial importance to the size of the male sexual organ.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib1"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">1</span></a></sup> Clinicians especially urologists are confronted by questions regarding the normal penile dimensions as well as the relation to different parts of the body such as foot size.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib2"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">2</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">The knowledge of what normal penile size is has become more important in the presence of demand for penile lengthening procedures.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup> Moreover, penile size might be important in the manufacturing of condoms.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib4"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">4</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Several studies regarding phallic size have been published.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib5"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">5</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib6"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">6</span></a></sup> The aim of this study is to report penile measurements in two groups of adult Jordanian populations. The first group is of normal individuals, while the second group is of patients with erectile dysfunction as well as to compare our results with previously published data.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Patients and methods<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Individuals included in group one were patients aged 17 y and older attending urology clinic for reasons other than erectile dysfunction.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Individuals of the second group were patients attending Jordan specialized center for the treatment of erectile dysfunction. Patients in both groups were further subdivided into those who are below 40 y of age and those over 40 y.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Patients with hormonal or chromosomal abnormality as well as patients with previous history of congenital penile problems, surgery or Peronyie's disease were excluded from the study.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Verbal consent was obtained from all patients. Height of the patients in both groups was recorded. Penile measurements were taken immediately after the patient undressed to minimize the effect of temperature and touch on penile size. The measurements were taken while the patients were lying down and the legs slightly abducted. The flaccid and fully stretched penile lengths were measured in both groups. In addition, midshaft circumference in the flaccid state was measured in group one, and in the second group, penile length in the fully erect penis was measured. Full erection state was achieved using intracavernosal injection of trimex (each 1 ml of trimex is composed of papaverine 30 mg, phentolamine 1 mg, and prostaglandin 10 </span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="mu" id="Picture_x0020_7" o:spid="_x0000_i1053" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 6pt;" type="#_x0000_t75"> <v:imagedata o:title="mu" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image002.gif"> </v:imagedata></v:shape></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">g). The dose of trimex ranging from 0.1 to 0.4 ml. Patients who did not achieve full nonbendable erection were excluded from the study.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">A measuring tape was used to measure the length, and the midshaft circumference of the penis. The starting point was on the dorsal aspect of the penis at its base at the pubic–penile skin junction, pushing the prepubic fat pad against the pubic bone as described by Wessels <i>et al</i>,<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup> while the tip of the penis was the other reference point.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Measurements were taken by the two urologists, and endocrinologist involved in the investigation for group one and two, and each one was instructed on the same and exact method of measurement. In addition, several measurements were repeated by two investigators on different visits and found to be similar. All measurements were approximated to the nearest 0.5 cm.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Statistical analysis<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Data management and statistical analysis<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Data were entered and analyzed using EPI info version 6. Initially, range and logical checks were performed on the data. Defected errors were corrected by returning to original data forms.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">The stretched and flaccid penile length was compared between the group with and without erectile dysfunction. Statistical significance of obscene difference was assessed using the two-sample independent <i>t</i>-test.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Statistical analysis by age was also performed to remove the possible effect of age on these companions correlation between height, penile length, and midpoint circumference.</span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Results<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">A total of 271 patients were included in group one (mean age 44.6</span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_8" o:spid="_x0000_i1052" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">16.3) y, range (17–83). <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl1"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 1</span></a> shows the clinical characteristics and measurements of group one.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 1. Clinical characteristics and measurements of Group1 (271 patients)<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border: 1pt solid rgb(153, 153, 153); mso-border-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Variable</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mean</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">+<i>s.d.</i><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Range</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 1;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Age (y)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">44.6<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_38" o:spid="_x0000_i1051" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>16.3<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">17−83<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height (cm)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">171.6<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_39" o:spid="_x0000_i1050" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>6.6<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">150−195<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Length stretch (cm)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">13.5<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_40" o:spid="_x0000_i1049" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>2.3<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7.5−20<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Length flaccid (cm)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.3<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_41" o:spid="_x0000_i1048" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.9<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4.0−15<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Circumference mid (cm)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.9<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_42" o:spid="_x0000_i1047" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.5<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2.0−12<o:p></o:p></span></div></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html"><b><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">BACK TO ARTICLE</span></b></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In group two, 109 patients were included (mean age 41</span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_10" o:spid="_x0000_i1046" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.7) y (range 22–68). <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl2"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 2</span></a> shows the clinical characteristics and measurements of this group.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 2. Clinical characteristics and measurements of Group 2 (109 patients)<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border: 1pt solid rgb(153, 153, 153); mso-border-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Variable</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mean</span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_133" o:spid="_x0000_i1045" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></i></b><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">s.d.</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Range</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 1;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Age (y)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">41.0<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_134" o:spid="_x0000_i1044" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>11.7<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">22−68<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height (cm)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">171.5<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_135" o:spid="_x0000_i1043" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>6.7<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">153−190<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Length stretch (cm)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.6<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_136" o:spid="_x0000_i1042" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.4<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.0−15<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Length flaccid (cm)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7.7<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_137" o:spid="_x0000_i1041" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.3<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">4.0−10<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 5;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Fully erected (cm)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.8<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_138" o:spid="_x0000_i1040" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.5<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8−16<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 6; mso-yfti-lastrow: yes;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Duration ED (weeks)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">154.6<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_139" o:spid="_x0000_i1039" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>161.9<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1−1300<o:p></o:p></span></div></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: rgb(234, 234, 234); line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ED: erectile dysfunction.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><br />
</div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In group 1, there was no correlation between height and flaccid length (<i>r</i>=0.03, <i>P</i>>0.05) or stretched length (<i>r</i>=0.05, <i>P</i>>0.05). On the other hand, there was a significant correlation between height and midpoint circumference (<i>r</i>=0.14, <i>P</i><0.05). There was also a significant correlation between flaccid and stretched lengths (<i>r</i>=0.60, <i>P</i><0.05), and between stretched lengths and midpoint circumference (<i>r</i>=0.30. <i>P</i><0.05) as shown in <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 3</span></a>.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 3. Correlation between variables in Group I<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border: 1pt solid rgb(153, 153, 153); mso-border-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Variable</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">r<o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">P<i>-value</i><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">95</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">% <i>CL</i><o:p></o:p></span></b></div></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 1;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height+flaccid length<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.03<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-0.15<r<0.09<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height+stretch length<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.05<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-0.07<r<0.17<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height+midpoint circumference<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.14<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><0.05<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.01<r<0.25<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stretch+midpoint circumference<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.30<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><0.05<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.18<r<0.04<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stretch length+flaccid length<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.60<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><0.05<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.53<r<0.68<o:p></o:p></span></div></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: rgb(234, 234, 234); line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS: not significant.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br clear="all" style="mso-special-character: line-break;" /> <o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In group 2, there was no correlation between height and flaccid length (<i>r</i>=0.04, <i>P</i>>0.05), stretched length (<i>r</i>=0.04, <i>P</i>>0.05), or fully erect length (<i>r</i>=0.17, <i>P</i>>0.05). On the other hand, there was a significant correlation between the flaccid and stretched lengths (<i>r</i>=0.65, <i>P</i><0.05), the flaccid and fully erect length after trimex injection (<i>r</i>=0.44, <i>P</i><0.05), and the stretched and fully erect length (<i>r</i>=0.51, <i>P</i><0.05) (<a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl4"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 4</span></a>).<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 4. Correlation between variables in Group 2<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border: 1pt solid rgb(153, 153, 153); mso-border-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Variable</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">r<o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">P<i>-value</i><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">95</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">% <i>CL</i><o:p></o:p></span></b></div></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 1;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height+flaccid length<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.04<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-0.23<<i>r</i><0.15<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height+stretch length<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.04<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-0.22<<i>r</i><0.15<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height+fully erect<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.14<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">-0.32<<i>r</i><0.05<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid+fully erected<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.44<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><0.05<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.27<<i>r</i><0.58<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 5;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stretch+fully erected<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.51<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><0.05<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.36<<i>r</i><0.64<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 6; mso-yfti-lastrow: yes;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid+stretch length<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.65<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><0.05<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.52<<i>r</i><0.74<o:p></o:p></span></div></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: rgb(234, 234, 234); line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NS: not significant.</span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(234, 234, 234); line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Comparing group 1 and group 2, the patients in the first group were slightly older than in group 2 (<i>P</i>=0.035), but there was no significant difference in their height. There was a significant difference regarding the mean flaccid length 9.3 <i>vs</i> 7.7 (<i>P</i>=0.001), and the mean stretched length 13.5 <i>vs</i> 11.6 (<i>P</i>=0.000) (<a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl5"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 5</span></a>).<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 5. Differences between the two groups<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid none; border-width: 1pt 1pt 0px; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid solid none none; border-width: 1pt 1pt 0px 0px; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Group 1</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid solid none none; border-width: 1pt 1pt 0px 0px; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Group 2</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: solid solid none none; border-width: 1pt 1pt 0px 0px; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">P<i>-value</i><o:p></o:p></span></b></div></td> </tr>
<tr style="mso-yfti-irow: 1;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mean</span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_147" o:spid="_x0000_i1038" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></i></b><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">s.d.</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mean</span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_148" o:spid="_x0000_i1037" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></i></b><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">s.d.</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 2;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Age<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">44.6<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_149" o:spid="_x0000_i1036" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>16.3<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">40.0<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_150" o:spid="_x0000_i1035" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>11.6<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.035<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid length<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.3<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_151" o:spid="_x0000_i1034" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.9<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7.7<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_152" o:spid="_x0000_i1033" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.3<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.001<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stretch length<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">13.5<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_153" o:spid="_x0000_i1032" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>2.3<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.6<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_154" o:spid="_x0000_i1031" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>1.4<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.000<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 5; mso-yfti-lastrow: yes;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Height<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">171.7<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_155" o:spid="_x0000_i1030" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>6.6<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">171.5<span style="mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_156" o:spid="_x0000_i1029" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span>6.7<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.8<o:p></o:p></span></div></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><br />
</div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">The two groups were further divided into those less than 40 and more than 40 y old. No statistical difference was reported in the stretched and flaccid lengths between the younger and older individuals in each group. However, when we compared the stretched and flaccid lengths in those less than 40 y old in group 1 and 2, there was a significant difference. Similarly, there was a significant difference in the stretched and flaccid lengths in those patients more than 40 y old (<a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl6"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 6</span></a>).<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 6. Stretched and flaccid penile lengths of both groups by age<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid none; border-width: 1pt 1pt 0px; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Age group</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td colspan="2" style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .25pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stretch length</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td colspan="2" style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-top-alt: solid #999999 .25pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid length</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> </tr>
<tr style="mso-yfti-irow: 1;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mean</span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_167" o:spid="_x0000_i1028" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></i></b><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">s.d.</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">P<i>-value</i><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Mean</span></i></b><b style="mso-bidi-font-weight: normal;"><i style="mso-bidi-font-style: normal;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_168" o:spid="_x0000_i1027" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span></i></b><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">s.d.</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">P<i>-value</i><o:p></o:p></span></b></div></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 2;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><<i>40</i><o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ED-<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">13.5 (2.1)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.001<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.2 (1.7)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.000<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ED+<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.8 (1.5)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7.8 (1.2)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> </tr>
<tr style="mso-yfti-irow: 5;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">><i>40</i><o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> </tr>
<tr style="mso-yfti-irow: 6;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ED-<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">13.6 (2.5)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.000<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.5 (2.1)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">0.000<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 7; mso-yfti-lastrow: yes;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ED+<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.5 (1.3)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7.6 (1.4)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: rgb(234, 234, 234); line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">ED-: without erectile dysfunction; ED+: with erectile dysfunction.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br clear="all" style="mso-special-character: line-break;" /> <o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Discussion<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">The definition of normal penile size is of a considerable interest in the diagnosis and treatment of sexual dysfunction. Furthermore, some patients who are otherwise physically normal seek to validate their sexual function and fertility potential through objective confirmation of normal size of their phallus. Most men who seek penile lengthening surgery overestimate normal penile length, and in one series none of 67 patients complaining of short penis were found to have severely short penis.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib7"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">7</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid and erect length is important, because patient perception of inadequate penile size in either state could be an important factor in asking for penile length or girth enhancement.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Several studies have been published regarding measurements of penile length, but no studies are reported from Arab countries, and in this study we aim to establish normal values for penile lengths in normal Jordanian individuals as well as in patients with erectile dysfunction and to compare it with published data from different ethnic origins.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Penile length is most commonly measured, and is usually estimated from the tip of the penis to the pubic–penile skin junction. Wessells <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup> introduced the term functional penile length by adding the measured fat pad depth to the erect length.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In comparing our results with other investigators (<a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#tbl7"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Table 7</span></a>), Bondil<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib5"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">5</span></a></sup> reported the longest penile length in the flaccid and stretched states, and though this might be a normal variation, measurements were obtained only after three manual stretches of the penis. The longest erect penile length was reported by Kinsey,<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib8"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">8</span></a></sup> data analyzed by Jamison and Gebhard,<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib9"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">9</span></a></sup> although the data might have been biased as the measurements were recorded by the patients. Other studies<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib4"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">4</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib10"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">10</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib11"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">11</span></a></sup> reported mean flaccid length range (8.16–9.22 cm), and stretched length (12.45–12.5 cm). In this study the mean penile lengths were slightly longer at 9.3 and 13.5, respectively.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 12pt; mso-outline-level: 2;"><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Table 7. Comparing penile measurements in centimeters by various investigators<o:p></o:p></span></b></div><br />
<table border="1" cellpadding="0" cellspacing="0" class="MsoNormalTable" style="border-collapse: collapse; border: currentColor; mso-border-alt: solid #999999 .5pt; mso-padding-alt: 0cm 0cm 0cm 0cm; mso-yfti-tbllook: 1184;"><thead>
<tr style="mso-yfti-firstrow: yes; mso-yfti-irow: 0;"> <td style="background: rgb(246, 246, 246); border: 1pt solid rgb(153, 153, 153); mso-border-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Authors</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Date of study</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Number of subjects</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Age in years (range)</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid length (cm)</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Stretched (S), or erect (E) length (cm)</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Flaccid midshaft circumference (cm)</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(153, 153, 153) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: solid solid solid none; border-width: 1pt 1pt 1pt 0px; mso-border-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; padding: 0cm 6pt 6pt;"> <div align="center" class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt; text-align: center;"><b><i><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Country</span></i></b><b><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><o:p></o:p></span></b></div></td> </tr>
</thead> <tbody>
<tr style="mso-yfti-irow: 1;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Kinsey<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1948<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2770<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">20−59<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.7<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">15.5 (E)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">USA<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 2;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bondil<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1992<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">905<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">17−91<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">10.7<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">16.74 (S)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">France<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 3;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">da Ros<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1994<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">150<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">14.5 (E)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Brazil<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 4;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Wessells<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1996<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">80<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">21−82<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.85<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">12.45 (S), 12.89 (E)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">USA<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 5;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ponchietti<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2001<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">3300<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">17−19<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">12.5 (S)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">10.0<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Italy<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 6;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ajmani<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1985<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">320<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">17−23<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.16<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.83<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Nigeria<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 7;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Schneider<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2001<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">111<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">18−19<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.6<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">14.48 (E)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Germany<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 8;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">32<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">40−68<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.22<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">14.18 (E)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> </tr>
<tr style="mso-yfti-irow: 9;"> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153); border-style: none solid; border-width: 0px 1pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Present study<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2003<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">271 (N)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">17−83<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">9.3<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">13.5 (S)<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">8.98<o:p></o:p></span></div></td> <td style="background: white; border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(0, 0, 0) rgb(0, 0, 0); border-style: none solid none none; border-width: 0px 1pt 0px 0px; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Jordan<o:p></o:p></span></div></td> </tr>
<tr style="mso-yfti-irow: 10; mso-yfti-lastrow: yes;"> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153); border-style: none solid solid; border-width: 0px 1pt 1pt; mso-border-bottom-alt: solid #999999 .5pt; mso-border-left-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">109 (ED)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">22−68<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">7.7<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">11.6 (S)<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"> <div class="MsoNormal" style="line-height: normal; margin: 0cm 0cm 0pt;"><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA<o:p></o:p></span></div></td> <td style="background: rgb(246, 246, 246); border-color: rgb(0, 0, 0) rgb(153, 153, 153) rgb(153, 153, 153) rgb(0, 0, 0); border-style: none solid solid none; border-width: 0px 1pt 1pt 0px; mso-border-bottom-alt: solid #999999 .5pt; mso-border-right-alt: solid #999999 .5pt; padding: 1.8pt 6pt;"></td> </tr>
</tbody></table><br />
<div class="MsoNormal" style="background: rgb(234, 234, 234); line-height: normal; margin: 0cm 0cm 10pt; mso-margin-bottom-alt: auto; mso-margin-top-alt: auto;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">NA: not available; N: normal; ED: erectile dysfunction.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><br clear="all" style="mso-special-character: line-break;" /> <o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Not many studies reported on midpoint measurements; however in this study, the main midpoint circumference (8.98 cm) was less than that reported by Ponchietti <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib10"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">10</span></a></sup> at (10 cm), but similar to what was reported by Ajmani <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib11"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">11</span></a></sup> (8.83 cm).<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Although some studies reported penile length in young adult males only,<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib10"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">10</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib11"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">11</span></a></sup> we included all age groups. Aging is associated with penile tissue stiffness and abnormal corporal compliance.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib12"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">12</span></a></sup> Also described in aging men, a decrease in penile extensibility because of the loss of elasticity of the tunica albuginea.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib5"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">5</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib13"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">13</span></a></sup> Despite this, Schneider <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib4"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">4</span></a></sup> found that the erect penile length did not differ significantly in the erect state between young and older men, although younger men had significantly wider penises. In this study, in group one, the stretched length was longer and the width narrower than that reported by Ponchietti <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib10"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">10</span></a></sup> of young Italian males. In addition, we found no significant difference in penile measurements between younger, less than 40 y and older individuals in each group, which is similar to what was reported by Wessells <i>et al</i>.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Ajmani <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib11"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">11</span></a></sup> reported on penile size in men of African origin and contrary to popular believe flaccid length is shorter, and midpoint circumference is narrower than what is reported by other investigators. When comparing different races, it was found that East Asians penile measurements were statistically lower in comparison to Caucasians.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib14"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">14</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In both groups there was no correlation between height and either flaccid or stretched lengths. On the other hand, there was a significant correlation with midpoint circumference in potent men. Ponchietti <i>et al</i>,<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib10"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">10</span></a></sup> in a subgroup of 325 males, found similar correlation between height and midpoint circumference. In addition, he found that flaccid and stretched penile lengths correlate positively with height, and inversely with weight. Other investigators found no association between somatometric measurements such as height, weight, waist/hip ratio, and BMI, with penile size, and the only positive correlation was with the length of the index finger.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib15"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">15</span></a></sup> Shah and Christopher<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib2"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">2</span></a></sup> looked at relation of penile length to shoe size and found no correlation.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In both groups there were significant correlations between stretched and flaccid lengths. Also, in group two there was a significant correlation between stretched and erect lengths, which is similar to other reports which found that only stretched length predicted the erect length.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a>, <a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib4"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">4</span></a></sup> However, we also found significant correlation in impotent men between flaccid and erect lengths.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">In this study we compared penile measurements between potent and impotent men. When we compared group two with group one, the penile length in impotent men was significantly shorter in both the flaccid and the stretched states. The mean flaccid length was 7.7 <i>vs</i> 9.3 (<i>P</i>=0.001), and the mean stretched length was 11.6 <i>vs</i> 13.5 (<i>P</i>=0.000). Penile tissue is composed of smooth muscle cells resting on collagen and elastic fibers limited by the tunica albuginea. The integrity of these structures and adequate blood flow (incoming and outgoing) associated with appropriate neurological control are required for normal penile erection. Tumescence results from arterial dilatation and relaxation of smooth muscle cells, which increase blood flow into the dilated lacunar spaces and causes engorgement of the penis.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib16"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">16</span></a></sup> The tunica albuginea is nearly entirely composed of collagenous fibers, but also a few elastic fibers can be found. When the tissue is unstretched, the collagen fibers are situated in an undulating arrangement. The elastic fibers are oriented longitudinally and they connect the undulating bundles of collagen fibers. They have the function of bringing the bundles of collagen fibers back to the nondistended position after being stretched.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib13"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">13</span></a></sup> Moreira <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib17"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">17</span></a></sup> defined penile extensibility as the difference between the length of the flaccid penis and the penis submitted to a maximal constant stretch. They measured penile extensibility before and after removing the skin and cavernous tissue in 17 cadavers and four patients undergoing penile implantation. They found that the penile extensibility did not correspond to a decrease in the cavernous smooth muscle fibers or to the increase in the amount of fibrous tissue of the corpora cavernosa, which they observed mainly in patients with arterial disease. They concluded that the tunica albugenia is the main determining factor for penile extensibility. The cause of impotence in our patients was mainly psychogenic, neurology, medication, and anxiety. Iacono <i>et al</i> reported the presence of structural disorders in the tunica albuginea of patients suffering from psychogenic, arteriogenic, and venogenic impotence with significant decrease in the elastic fibers in the tunica albuginea of impotent men compared to a control group. The decrease in length in impotent men in this study could be explained by the loss of elastic fibers, and the lack of intermittent stretching in the tunica albuginea, confirming the common saying (if you do not use it you lose it).<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Organic impotence in aging men could be due to a venous leakage factor through veins that are situated normally on the distal third of the ventral penile surface.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib18"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">18</span></a></sup> The impaired veno-occlusive function of the tunica albuginea is contributed to by the decrease in elastic fibers concentration found in impotent men.<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib19"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">19</span></a></sup><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Wessells <i>et al</i><sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib3"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">3</span></a></sup> reported on 80 physically normal men evaluated for sexual dysfunction, and recorded erect length at 12.89, which is longer than our patients at 11.8, while schnider <i>et al</i>,<sup><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#bib4"><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">4</span></a></sup> who compared erect length in young potent and old impotent men, found potent men had longer erect penises though the difference was insignificant. On the other hand, the flaccid penis in impotent men was longer than in potent men. In this study we found that both younger and older impotent men have significantly shorter stretched penile length than potent men.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Conclusion<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 12pt 0cm;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">The average flaccid penile length in adult potent Jordanians is 9.3</span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_17" o:spid="_x0000_i1026" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">1.4 cm, while the stretched length is 13.5</span><span style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN; mso-no-proof: yes;"><v:shape alt="plusminus" id="Picture_x0020_18" o:spid="_x0000_i1025" style="height: 5.4pt; mso-wrap-style: square; visibility: visible; width: 5.4pt;" type="#_x0000_t75"> <v:imagedata o:title="plusminus" src="file:///C:\Users\Theo\AppData\Local\Temp\msohtmlclip1\01\clip_image001.gif"> </v:imagedata></v:shape></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">2.3 cm. Patients with erectile dysfunction tend to have significantly shorter penises. There was a significant correlation between height and midpoint circumference, and between flaccid, and stretched lengths in group 1, and between flaccid, stretched, and erect lengths in group 2.<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 0pt;"><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"><a href="http://www.nature.com/ijir/journal/v17/n2/full/3901272a.html#top"><span style="color: white; font-size: 7.5pt; mso-bidi-font-size: 11.0pt;">Top of page</span></a><o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: rgb(0, 174, 239); line-height: normal; margin: 0cm 0cm 0pt; mso-outline-level: 4;"><b><span lang="EN" style="color: white; font-family: "Verdana","sans-serif"; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">References<o:p></o:p></span></b></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 6pt 36.05pt; mso-list: l1 level1 lfo2; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><a href="" name="bib1"></a><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">1.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Francken AB, van de Wiel HB, van Dreiel MF, Weijmar Schultz WC. What importance do women attribute to the size of the penis? </span><i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Eur Urol</span></i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> 2002; </span><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">42</span></b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">: 426–431. | <a href="http://dx.doi.org/10.1016/S0302-2838(02)00396-2" title=""><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Article</span></a> | <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=12429149&dopt=Abstract" title="Article on PubMed - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">PubMed</span></a> | <a href="http://links.isiglobalnet2.com/gateway/Gateway.cgi?&GWVersion=2&SrcAuth=Nature&SrcApp=Nature&DestLinkType=FullRecord&KeyUT=000180007100002&DestApp=WOS_CPL" title="Article on ISI - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">ISI</span></a> | <a href="http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD38nmvFShuw%3D%3D&pissn=0955-9930&pyear=2005&md5=1f30c30ff93acbe10e285fc03da7cd6d" title="Article on ChemPort - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">ChemPort</span></a> |<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 6pt 36.05pt; mso-list: l1 level1 lfo2; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><a href="" name="bib2"></a><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">2.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Shah J, Christopher N. Can shoe size predict penile length? </span><i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">BJU Int</span></i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> 2002; </span><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">90</span></b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">: 586–587. | <a href="http://dx.doi.org/10.1046/j.1464-410X.2002.02974.x" title=""><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Article</span></a> | <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=12230622&dopt=Abstract" title="Article on PubMed - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">PubMed</span></a> | <a href="http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:DC%2BD38vntVCksw%3D%3D&pissn=0955-9930&pyear=2005&md5=9b22f7d0db6b8c931a17761d2ff42afe" title="Article on ChemPort - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">ChemPort</span></a> |<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 6pt 36.05pt; mso-list: l1 level1 lfo2; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><a href="" name="bib3"></a><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">3.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Wessells H, Lue TF, McAninch JW. Penile length in the flaccid and erect states; guidelines for penile augmentation. </span><i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">J Urol</span></i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> 1996; </span><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">156</span></b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">: 995–997. | <a href="http://dx.doi.org/10.1097/00005392-199609000-00041" title=""><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">Article</span></a> | <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=8709382&dopt=Abstract" title="Article on PubMed - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">PubMed</span></a> | <a href="http://links.isiglobalnet2.com/gateway/Gateway.cgi?&GWVersion=2&SrcAuth=Nature&SrcApp=Nature&DestLinkType=FullRecord&KeyUT=A1996VB45300040&DestApp=WOS_CPL" title="Article on ISI - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">ISI</span></a> | <a href="http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:BymA38%2FpsFc%3D&pissn=0955-9930&pyear=2005&md5=28aafa7c8217bc4cb8f750a17cb93b0e" title="Article on ChemPort - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">ChemPort</span></a> |<o:p></o:p></span></div><br />
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<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 6pt 36.05pt; mso-list: l1 level1 lfo2; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><a href="" name="bib5"></a><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">5.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Bondil P <i>et al</i>. Clinical study of the longitudinal deformation of the flaccid penis and of its variations with aging. </span><i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Eur Urol</span></i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> 1992; </span><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">21</span></b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">: 284–286. | <a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?holding=npg&cmd=Retrieve&db=PubMed&list_uids=1459150&dopt=Abstract" title="Article on PubMed - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">PubMed</span></a> | <a href="http://chemport.cas.org/cgi-bin/sdcgi?APP=ftslink&action=reflink&origin=npg&version=1.0&coi=1:STN:280:ByyD1MzgtV0%3D&pissn=0955-9930&pyear=2005&md5=b3ab0e770ef1dbbe1b2abf8f15cf5af7" title="Article on ChemPort - "><span style="color: #3366cc; mso-bidi-font-size: 11.0pt;">ChemPort</span></a> |<o:p></o:p></span></div><br />
<div class="MsoNormal" style="background: white; line-height: normal; margin: 0cm 0cm 6pt 36.05pt; mso-list: l1 level1 lfo2; mso-margin-top-alt: auto; tab-stops: list 36.0pt; text-indent: -18pt;"><a href="" name="bib6"></a><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: Verdana; mso-fareast-font-family: Verdana; mso-fareast-language: IN;"><span style="mso-list: Ignore;">6.<span style="font-size-adjust: none; font-stretch: normal; font: 7pt/normal "Times New Roman";"> </span></span></span><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">Da Ros C <i>et al</i>. Caucasian penis: what is the normal size? </span><i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">J Urol</span></i><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;"> 1994; </span><b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-bidi-font-size: 11.0pt; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">151</span></b><span lang="EN" style="color: black; font-family: "Verdana","sans-serif"; font-size: 10pt; mso-ansi-language: EN; mso-bidi-font-family: "Times New Roman"; mso-fareast-font-family: "Times New Roman"; mso-fareast-language: IN;">: 323A, abstract 381.<o:p></o:p></span></div><br />
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</div></div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-66106012519543363362011-11-23T18:04:00.004+09:002011-11-23T18:19:58.572+09:00Burung Manguni di Minahasa<div dir="ltr" style="text-align: left;" trbidi="on"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaiiH4ga9B9ef_NlPk2ke0EnzX20w77V7fB9UEMWq85qEftZwXnHELsjxV-CqvF20xe3Kav5uQadynEZkqtT-2H3N-EchWYlc0GVRmNZReBzNeN0kqxwPX6uXrFaksO_bOlEUSRCq6Z5c/s1600/GreatHornedOwl.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="213" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjaiiH4ga9B9ef_NlPk2ke0EnzX20w77V7fB9UEMWq85qEftZwXnHELsjxV-CqvF20xe3Kav5uQadynEZkqtT-2H3N-EchWYlc0GVRmNZReBzNeN0kqxwPX6uXrFaksO_bOlEUSRCq6Z5c/s320/GreatHornedOwl.jpg" width="320" /></a></div> Burung Manguni yang dinamakan ‘Hoot’ (bahasa Jawa: burung hantu), bentuknya sebesar burung Kakatua, berbuluh hitam keabu-abuan, matanya bulat membelalak menghadap kedepan, ada pula jenis burung hantu kecil ‘Tootosik’ dinamakan sesuai bunyi siulannya. Pada saat “bertugas” mereka bertengger membelakangi arah datangnya berita, apa bila pertanda baik siulannya syahdu dan apabila ada bahaya suaranya tergesa-gesa lemah seakan berbisik. Pertanda akan ada kemenangan mutlak bila ‘hoot’nya nyaring mengalun dan dilakukan berturut 3 kali 9 (‘telu makasiou’). Atas dasar pemikiran ini maka Jan Timbuleng (sekampung dengan Penulis, Walian) menamakan pasukan Permestanya ‘Brigade 999’ atau Triple Nine.<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsFEGfcbuJd1Sh39Wk4S_lLd_PHFm0YROcx_qPNbSQ2IEV_IJaZ4xtN4lzwZ2TI9i452t0NvUE4Fqa4gU3rKUTXmNLSGQ4eo8JRXN0Dbb2qqH_v8TlZDt1m6nlx365notJkc08Fu-wE4k/s1600/ajh-barredowl-mouse.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="271" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgsFEGfcbuJd1Sh39Wk4S_lLd_PHFm0YROcx_qPNbSQ2IEV_IJaZ4xtN4lzwZ2TI9i452t0NvUE4Fqa4gU3rKUTXmNLSGQ4eo8JRXN0Dbb2qqH_v8TlZDt1m6nlx365notJkc08Fu-wE4k/s320/ajh-barredowl-mouse.jpg" width="320" /></a></div> Masih ada jenis burung malam “Ki’ek”yang sambil terbang menyambar rendah dengan suara melengking (satu kali saja) selalu membawa berita ‘awas bahaya sudah dekat’. Ada lagi jenis burung Kookokuk yang belum pernah dilihat karena tempatnya jauh dalam hutan, apabila siulan si “kookokuk” nya mendekat menandakan bahaya semakin dekat dan bila suara jauh melemah artinya lawan telah menjauh. Pada siang hari ada burung “Menge’ngekek”, sebesar terkukur, buluh coklat, sayap kuning, ekor hitam panjang apabila tetap bertengger dibelukar dengan suara tawa mengejek tanda ‘awas waspada’ dan bila dia terbang rendah memintas didepan dengan suara panjang “nge’ek” berarti sebaiknya berhenti sebentar atau batalkan perjalanan. Kicauan burung ‘Kuoo’ dan ‘Kowkow’ bersahut-sahutan pada pagi hari menandakan suasana gembira dan tenteram, dan yang sekali-sekali diselingi suara mengantuk berat dari burung ‘Mu’kurz’ yang dijuluki roh penjaga hutan yang kesiangan.<br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnT6kamKh_vSOjNV8wwCCYOepenXdNKKiVpEMxXdvIb_H9NGyAIz0Qnrw8i7hcaC3lGrVkWRfK3P62WZk0PRn_v7kEsY4pH1onfAPxKIIb6Ut91DjmbCEPyo-0Gz5TrKoW0rk_DUuZZfk/s1600/Barn-owl-in-flight-small.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="254" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnT6kamKh_vSOjNV8wwCCYOepenXdNKKiVpEMxXdvIb_H9NGyAIz0Qnrw8i7hcaC3lGrVkWRfK3P62WZk0PRn_v7kEsY4pH1onfAPxKIIb6Ut91DjmbCEPyo-0Gz5TrKoW0rk_DUuZZfk/s320/Barn-owl-in-flight-small.jpg" width="320" /></a></div>Untuk menyelami akan asal usul logo Pemerintah Kabupaten Minahasa yang menempatkan burung Manguni sebagai figur pokok dan pencantuman motto “I Yayat U Santi” perlulah kita tahu latar belakang pembuatannya dan penciptanya.<br />
Pada tahun 1967, Pemerintah Kabupaten Minahasa menyelenggarakan sayembara untuk penciptaan simbol Minahasa,yang diikuti oleh 4 seniman dan oleh Panitia diputuskan bahwa gambar lambang terbaik adalah hasil karya dari Adolf Kainde, kemudian dalam sidang DPRD Minahasa ditetapkan sebagai logo Pemerintah Kabupaten Minahasa.<br />
Adolf Kainde, kelahiran Flores 1937, bersekolah di Tomohon. Setelah Permesta sebagai tenaga harian kemudian disamping mengajar di SMA Aquino sebagai staf redaksi <br />
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<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgi-cLIhQcez8cRdGoXaMDIyB08r3F3bXyIbxuIRVODqle9F_f4HoMCmyD1Aj31azF8JP0MREpjTUWQUBd7_6By6f8QW84nQj3YvRRcrGrji2OBeHnDkXVnKQl97-OxsmVBbXWFnDUmzAk/s1600/220px-Northern_Spotted_Owl_USFWS-thumb.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgi-cLIhQcez8cRdGoXaMDIyB08r3F3bXyIbxuIRVODqle9F_f4HoMCmyD1Aj31azF8JP0MREpjTUWQUBd7_6By6f8QW84nQj3YvRRcrGrji2OBeHnDkXVnKQl97-OxsmVBbXWFnDUmzAk/s320/220px-Northern_Spotted_Owl_USFWS-thumb.jpg" width="210" /></a></div><br />
Harian Kompas edisi Sulut dan saat meninggal di Malalayang thn 2000 sebagai Agent Manager Bier Bintang. Adolf Kainde dikaruniai bakat menggambar dan koreografi, dan untuk konsultasi perencanaan gambar lambang Minahasa, beliau didampingi oleh pamannya Johanis Ngangi, waktu itu sebagai anggota BPH (Badan Pemerintahan Harian) era Bupati Letkol. Sumampouw. Bpk. Johanis Ngangi, kelahiran Tonsea Lama 1912, meninggal 1984 di Tomohon adalah bekas guru Sekolah Rakyat di Tomohon dan pernah sebagai Anggota DPRD Kabupaten Minahasa, beliau juga memiliki bakat melukis dan mengarang lagu-lagu Tombulu antara.lain ‘Opo Wana Natase’ (th.1939).<br />
Adapun dasar pemikiran kedua beliau tersebut bahwa kata-kata “I Yayat U Santi” dari bahasa Tombulu tua yang arti harafia ‘acungkan pedang perang’. Dan ini dapat dibuktikan dan disajikan pada tari-tari perang seperti; seruan dalam tari perang cakalele “KAWASARAN’ (Kabasaran) adat Minahasa. Inilah konteks pengertiannya untuk logo Minahasa adalah “Siap berjuang untuk pembangunan Minahasa”.<br />
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Dipilihnya burung Manguni dari antara jenis burung lain didasarkan pada mithos leluhur Minahasa bahwa burung Manguni adalah salah satu ciptaan oleh Roh atau Opo paling atas yang menguasai langit dan bumi. Oleh ‘Opo Empung Wananatas’ tersebut menugaskan kepada burung Manguni (mauni = mengamati) untuk menjaga keselamatan anak-cucu Toar-Lumimuut, berjaga-jaga pada malam hari, tidak boleh tidur dan diberi kemampuan bunyi siul berbeda untuk signal aman atau bahaya. Penulis banyak tahu mengenai hal ini dari Srikandi Permesta, Len Karamoy (asal Tomohon), sebelum Permesta beliau memimpin sekelompok gerilya pecahan dari PPK (Pasukan Pembela Keadilan) pimpinan Jan Timbuleng.<br />
"Wikipedia"</div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com2tag:blogger.com,1999:blog-3399054298585589982.post-32071715867055610292011-11-23T09:14:00.000+09:002011-11-23T09:14:19.906+09:00Cara upgrade iOS iPhone, iPad dll paling amanKe google ketik: download stock firmware felix. Pilih yg bagian iPhone, misalnya iPhone 3gs, iOS 5.01, save pada folder tersendiri di mana saja, misalnya di Dokument. <br />
Selanjutnya buka itunes, Cek iTunes berfungsi baik atau tidak, caranya bula iTunes Store, jika Store terbuka normal, berarti iTunes berfungsi baik. <br />
Colok iPhone 3Gs, trus pilih icon iPhone, ke summary, teken shift + klik restore, lalu pilih firmware yg td di download pada folder yang anda simpan, biarkan berlansung terus. Ini adalah cara paling aman, oleh karena upgrade dgn cara OFFLINE.<br />
Jadi deh.<br />
Selamat mencoba.Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-55404502662309128942011-11-21T17:26:00.001+09:002011-11-22T08:17:25.465+09:00MEMBUAT RINGTONES iPhone kualitas tinggi<div dir="ltr" style="text-align: left;" trbidi="on"><div><h2 class="uiHeaderTitle">MEMBUAT RINGTONES iPhone kualitas tinggi (lihat di notes saya)</h2></div><div class="clearfix"><div class="mbs uiHeaderSubTitle lfloat fsm fwn fcg">by <a href="http://www.facebook.com/profile.php?id=1279367123"><span style="color: #3b5998;">Theo Adolf Rompas</span></a> on Monday, December 14, 2009 at 12:40am</div><div class="uiHeaderSubActions rfloat"></div></div><div class="mbl notesBlogText clearfix"><div>Ringtones iPhone<br />
Ini adalah cara paling legal tanpa software lain (Software Khusus) dengan kualitas bisa sebagus CD. Bitrate bisa mencapai 320kbps. Asik kan. <br />
BEGINI CARANYA:<br />
Isi lagu dalam iTunes. Pilih lagu dengan kualitas bagus, misalnya lagu yang di RIP dari cd dengan pilihan Apple Lossless (di iTunes klik Edit, Prefernces, General, klik Import Setting dan Robah menjadi LOSSLESS), bitrate bisa 900 keatas. Jangan yang 128 kbps, JELEK, lagu begitu sama dengan MP3 yang di jual dikaki lima he...he.....Ini kualitas lagu HiFi loh. Setelah itu di iTunes klik Edit, Prefernces, General, klik Import Setting dan Robah menjadi AAC, atur ke bitrate 320kbps.<br />
Langkah selanjutnya:<br />
Klik music, add file atau folder tempat lagu yang di RIP dan klik oke.<br />
Setelah lagunya atau banyak lagu masuk ke library, PILIH SALAH SATU, klik dan play. Catat potongan lagu yang akan dibuat ringtones, mis detik ke 50(0:50) sampai 1 menit 30 detik(1:30), cukup 40 detik kan?He....he.....SUKA SUKA KITALAH.<br />
Klik kanan lagu tersebut dan klik get info. Pada option tentukan start time=0:50 dan stop time=1:30 seperti contoh diatas.<br />
Klik oke.<br />
Klik kanan kembali dan klik convert to AAC. <br />
Akan terbentuk file yang sama, jadi FILENYA tampak double tapi yang akan kita bikin ringtones durasi pendek sesuai yang kita tentukan mis. 40 detik.<br />
Klik kanan file itu dan copy.<br />
Paste ke folder yang ditentukan. Misalnya buat folder baru terserah dimana saja mis. di my music dengan nama folder RINGTONES FOR iPhone. Buat beberapa lagu yg diinginkan jadi ringtone.<br />
Sekarang masuk ke folder tersebut dan masing masing di klik kanan dan rename. Judul lagu dirapikan dan semua extension dari m4a di robah menjadi m4r.<br />
Kembali ke iTunes. Pada Library klik ringtones yang masih kosong.<br />
Klik menu dan add folder, cari folder diatas (mis. RINGTONES FOR iPhone) yang ditentukan tadi.<br />
Klik oke.<br />
Nah semua lagu itu akan masuk ke ringtones.<br />
Lagu (files durasi pendek) double tadi yang ada di Library iTunes, dimana kita copy tadi sebaiknya di delete semua supaya jangan bikin kotor library, iya kan? Tapi saat Remove pilih Keep File.<br />
Hubungkan iPhone, klik iphone pada iTunes dan pada pilihan sync ringtones di check. Klik apply.<br />
Jadi deh.........semua lagi itu sudah ada dalam ringtones iphone. Selamat ya.<br />
From Theo.....</div></div></div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-71555098531738768952011-11-20T15:04:00.001+09:002011-11-20T15:18:08.291+09:00Noah Birthday November 2011<div dir="ltr" style="text-align: left;" trbidi="on"><div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdU7LeFw3FhlXB1kboEeZwj2RAIH6gEIl3gljUNJwNkBXrH1VYWFoUWfN3h35Sr3t5CC51mGIQJvCDpwmPbpXL1MhcBW6_Hk0nb3UY_-Byc_qw3PSzId4i1pg18qzFWEpOS6iE_woWqXY/s1600/SBY+Nov+2011++%252839%2529.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjdU7LeFw3FhlXB1kboEeZwj2RAIH6gEIl3gljUNJwNkBXrH1VYWFoUWfN3h35Sr3t5CC51mGIQJvCDpwmPbpXL1MhcBW6_Hk0nb3UY_-Byc_qw3PSzId4i1pg18qzFWEpOS6iE_woWqXY/s320/SBY+Nov+2011++%252839%2529.JPG" width="240" /></a></div><br />
<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj722fgPCxzHnYAKol3LOlwJmaQEMe0HhHB6ObA6DDoBSHB-ZhtL6ax1NdGjY0UWkG0kpccmf_l0lKCo2XNuPM-eijT4Xcp63eg9V63wnAy2QuWNFL-GxoOfLTTw7tEzGoQZsSRZHRIIq4/s1600/SBY+Nov+2011++%252832%2529.JPG" imageanchor="1" style="clear: left; float: left; margin-bottom: 1em; margin-right: 1em;"><img border="0" height="320" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEj722fgPCxzHnYAKol3LOlwJmaQEMe0HhHB6ObA6DDoBSHB-ZhtL6ax1NdGjY0UWkG0kpccmf_l0lKCo2XNuPM-eijT4Xcp63eg9V63wnAy2QuWNFL-GxoOfLTTw7tEzGoQZsSRZHRIIq4/s320/SBY+Nov+2011++%252832%2529.JPG" width="240" /></a></div></div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-7455584770590287312011-11-16T22:43:00.001+09:002011-11-17T12:26:16.794+09:00Solusi Jika iTunes Store Nggak Bisa Dibuka<b>Solusi Jika iTunes Store Nggak Bisa Dibuka</b><br />
<br />
Suddenly and without warning I was unable to connect to the iTunes Store from my Vista home computer. It just hung there in the “Loading…” phase. I could access the iTunes Store from each of the other computers in my house but that didn’t help me any. How utterly annoying to lose access to the iTunes Store, podcasts, album artwork, etc. from the only computer in my house on which I keep my iTunes library…and for no apparent reason.<br />
For DAYS I tried every conceivable internet suggestion to resolve the problem including: modifying router settings, anti-virus settings, firewall settings, iTunes settings, browser settings, uninstalling, re-installing, rebooting, doing a system restore…to no avail. And Apple’s website was pathetically useless.<br />
Then some tech-head, aka “My Hero”, offered this 60-second solution from an online forum: delete the iTunes preferences file in two places. Here’s how:<br />
Cara I: (terbaik/teruji)<br />
I got it, so for future reference, here is what i did:<br />
Start --> Programs --> Accessories (Right Click on Command Prompt) --> Run as Administrator<br />
then type in:<br />
netsh winsock reset<br />
whabam! it worked<br />
Cara II:<br />
1. Close iTunes.<br />
2. Delete the iTunesPrefs.xml file from C:Users+user name+AppDataRoamingApple ComputeriTunes.<br />
3. Delete the iTunesPrefs.xml file from C:Users+user name+AppDataLocalApple ComputeriTunes.<br />
4. Launch iTunes & follow the setup prompts.<br />
Voilà! I be iTunes happy again!<br />
By the way, for those who have trouble finding the files, note that AppData is a hidden folder. You can “unhide” hidden folders, files, etc., as follows (for Windows 7 — earlier versions have different ways to do this):<br />
1. In Windows Explorer, click on Organize<br />
2. Choose Folder and search options<br />
3. Click of the View tab<br />
4. Navigate to Files and Folders | Hidden Files and Folders<br />
— this should already be visible<br />
5. Enable Show hidden files, folders, and drives<br />
Cara III:<br />
Hi,<br />
There is simple solution for that case (forWindows 7, 64):<br />
1. C:\ProgramData\Apple\Installer Cache\AppleApplicationSupport 2.0.1<br />
2. Right click<br />
3. Uninstall<br />
4. C:\ProgramData\Apple\Installer Cache\AppleApplicationSupport 1.5.2<br />
5. Right click<br />
6. Install<br />
7. Restart Windows<br />
It's allTheo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com1tag:blogger.com,1999:blog-3399054298585589982.post-47738137220345703862011-11-16T08:04:00.002+09:002011-11-16T08:04:26.730+09:00PENANGGULANGAN KANKER PAYUDARAPENANGGULANGAN KANKER PAYUDARA<br />
Bagian Bedah RSUD ABEPURA JAYAPURA<br />
Dr. Theo Rompas<br />
<br />
I.PENDAHULUAN<br />
Payudara merupakan mahkota bagi seorang wanita, sehingga bila ada kerusakan sedikit saja dapat menimbulkan dampak psikologis dan sosial yang besar baik pada penderita maupun keluarganya. Oleh karena itu pengertian yang baik dan kesadaran akan pentingnya kesehatan payudara harus lebih ditingkatkan. Dilihat dari kasus kanker payudara yang datang memeriksakan diri ke dokter umumnya sudah pada stadium lanjut dimana pengobatan bersifat paliatif, artinya pengobatan bertujuan meringankan penderitaan keluhan penderita seperti luka bernanah, sakit pada payudara dan semua keluhan berhubungan dengan keluhan itu. Dengan demikian tujuan pengobatan berupa “sembuh” yang mempunyai makna penderita bebas kanker dan semua keluhan yang menyertainya, minimal 15-20 tahun tidak tercapai. Selain itu tujuan terapi yang berkembang saat ini yaitu pembedahan dengan mempertahankan payudara (‘conservative surgery’) sehingga gangguan kosmetika diperkecil, juga tidak tercapai. Oleh karena itu penemuan dan pengobatan kanker payudara pada stadium dini sangat-sangatlah penting. Perlu diingat bahwa penanganan kanker payudara faktor kosmetik setara pentingnya dengan penyakit dasarnya.<br />
Keterlambatan ini pada umumnya bersumber dari penderita sendiri, antara lain pengertian yang mendasar tentang kanker payudara yang kurang sehingga menimbulkan rasa takut. Rasa takut ini bisa mengenai keberhasilan hasil pengobatan, cara pengobatannya ataupun akan kehilangan payudaranya. Dengan demikian dapat dipahami bahwa penyuluhan mendapatkan tempat yang sangat penting dalam mengatasi keterlambatan ini. Tentu saja untuk mencapai tujuan ini petugas kesehatan harus dapat memberikan keterangan yang benar dan jelas dengan modal pengetahuan yang cukup. Jika petugas kesehatan yang bersangkutan tidak memahami apa yang perlu disampaikan kepada penderita maupun masyarakat adalah tidak ada salahnya untuk meminta bantuan petugas kesehatan yang lebih tahu atau merujuk ke tempat (Puskesmas/RS) daripada memberikan keterangan yang salah yang dapat merugikan penderita. <br />
Jika seorang wanita mendapati pada payudaranya terdapat sebuah benjolan, akan timbul beberapa pertanyaan besar dalam dirinya, apakah ini kanker?, tumor?. Tentu untuk menjawab pertanyaan yang sederhana ini perlu pamahaman yang cukup mengenai istilah yang terkait dengan hal tersebut. Pada umumnya dimasyarakat berkembang beberapa istilah yang penggunaanya sering dicampuradukan, yaitu tumor, kanker dan neoplasma.Pengertian yang benar mengenai istilah-istilah tersebut adalah sebagai berikut :<br />
Tumor:Tumor adalah istilah yang ditujukan pada setiap penyakit yang berupa benjolan abnormal pada tubuh, artinya benjolan itu secara normal harus tidak ada. Jadi payudara sendiri yang berupa benjolan pada tubuh tentu saja bukan tumor karena secara normal memang harus ada pada setiap wanita dan malahan harus dipertahankan keindahannya dan dicegah dari berbagai macam penyakit yang bisa saja timbul. Tumor bisa dibedakan dalam tumor jinak, tumor ganas (kanker) dan tumor yang mempunyai kecenderungan menjadi ganas(lesi praganas atau pra-kanker). Contoh tumor jinak antara lain: kutil, kista atau benjolan yang berisi cairan seperti atheroma, penyakit bawaan seperti meningokel dsb.<br />
<br />
Kanker: Kanker adalah suatu penyakit yang umumnya berbentuk tumor, bersifat ganas yang timbul akibat adanya pertumbuhan sel-sel tubuh yang berkembang biak secara tidak normal, tidak terkontrol, merusak bentuk dan fungsi organ yang ditumbuhinya. Disebut ganas karena sel ini bertumbuh tidak terbatas pada tempat asalnya tapi bertumbuh menyusup ke jaringan sekitarnya (infiltrasi) bahkan membentuk anak sebar dan berkembang ke organ lain yang disebut juga metastase. Metastase dapat bersifat langsung, lewat saluran limfe (limfogen) atau melalui pembuluh/aliran darah (hematogen). Jika dibiarkan tumbuh terus akan mengakibatkan penderitaan yang berat serta kematian. Sel ini disebut juga sel tumor ganas yang pada dasarnya berasal dari sel yang normal tapi oleh karena suatu sebab yang bermacam-macam terjadi kerusakan pada penentu sifat dan fungsi sel tersebut. Pembawa sifat dan fungsi sel tersebut disebut gen. Gen ini adalah suatu susunan protein yang sangat kompleks, yang berbeda untuk setiap jenis sel. Oleh karena itu ada kanker yang berasal dari kelenjar, dari kulit, dari selaput lendir (mukosa) dari tulang, sel saraf dan struktur-struktur lain. Pada kanker payudara jenis selnya dapat bermacam-macam tergantung sumber sel normal yang terganggu, apakah berasal dari bagian kelenjarnya, dari saluran air susunya, dari jaringan penunjangnya atau dari struktur lain pada payudara.<br />
<br />
Neoplasma:Istilah ini digunakan secara umum untuk penyakit dimana selnya bertumbuh secara abnormal karena gangguan pada gen sel tersebut. Neoplasma disebut ganas jika pertumbuhannya seperti kanker. Jadi kanker adalah sama dengan neoplasma ganas atau tumor ganas. Jika selnya tumbuh terbatas pada tempat asalnya, tidak menginfiltrasi dan tidak bermetastase disebut neoplasma jinak atau tumor jinak misalnya fibroadenoma mamma.<br />
Dengan pengertian istilah ini kita dapat menjawab bahwa benjolan itu jelas adalah tumor, tapi untuk menjawab apakah bukan kanker atau bukan neoplasma harus kita lihat keadaan sel yang menyusunnya melalui mikroskop. Jadi apakah kita akan menganjurkan kepada penderita untuk memeriksakan dirinya ke laboratorium untuk melihat jenis sel?, jawabnya belum tentu. Untuk dapat memahami jawaban pendek tersebut kita perlu mengetahui hal-hal umum yang sangat penting yang berkaitan dengan kanker payudara, yang dapat membantu petugas kesehatan yang bekerja sebagai ujung tombak dan berhubungan langsung dengan masyarakat. Dengan demikian diharapkan kanker payudara bisa tertanggulangi dengan baik dengan pengertian bahwa, kita mengobati kanker payudara pada stadium dini dan meningkatkan kualitas hidup penderita dengan kanker payudara stadium lanjut.<br />
II.ANATOMI FISIOLOGI PAYUDARA<br />
Payudara atau kelenjar susu yang bentunya bulat ini merupakan kelenjar kulit atau apendiks kulit yang terletak diatas fascia dari otot dada (muskulus pectoralis). Pada sisi luar atas kelenjar ini keluar dari bulatannya ke arah ketiak (aksila), disebut ekor payudara (‘tail of Spence’). Setiap payudara terdiri dari 12-20 lobulus kelenjar yang masing-masing mempunyai saluran kepapila mamma, yang disebut duktus laktiferus. Diantara kelenjar susu dan fascia pektoralis dan diantara kulit dan kelenjar tersebut ada jaringan ikat yang disebut ligamentum Cooper yang memberi rangka pada payudara sehingga bentuknya tegak dan sedikit menggantung. Pendarahan terutama dari cabang-cabang dari arteri aksilaris dan arteri interkostalis. Penyaliran limfe 75% kearah aksila, sebagian lagi ke kelenjar parasternal, terutama dari bagaian sentral dan medial dan ada pula penyaliran ke kelenjar interpektoralis. Di aksila terdapat rata-rata 50 buah kelenjar getah bening yang berada disepanjang disepanjang arteri dan vena brakialis (lengan atas). Saluran limfe dari seluruh payudara menyalir kekelompok anterior aksila, kelompok sentral aksila, kelenjar aksila bagian dalam, yang lewat sepanjang vena aksilaris dan yang berlanjut langsung ke kelenjar servikal bagian kaudal dalam di supraklavikuler. Jalur yang lain dapat ke pembuluh mammaria interna, ke rektus abdominis, ke pleura dan ke payudara sebelahnya (kontralateral).<br />
Volume payudara sangat bervariasi tergantung umur, siklus menstruasi, gravida atau laktasi. Kesemuanya itu terkait pada hormonal, terutama estrogen dan progesteron. Penting dipahami perubahan payudara selama daur mentruasi. Sekitar hari kedelapan menstruasi payudara jadi lebih besar dan pada beberapa hari sebelum menstruasi terjadi pembesaran maksimal. Kadang-kadang timbul benjolan yang nyeri dan tidak rata. Selama beberapa hari menjelang menstruasi payudara menjadi tegang dan nyeri sehingga pemeriksaan fisik terutama palpasi tidak mungkin dilakukan. Pada saat itu pemeriksaan mammografi juga tidak ada manfaatnya karena kontras kelenjar terlalu besar. Begitu menstruasi mulai semuanya berkurang. Pada wanita dewasa volume antara 150-250 cc dianggap kecil, 250-350 cc dianggap sedang, sedangkan yang besar kira-kira 350-500 cc. Volume yang kurang dari 150 cc dianggap suatu hipoplasi mamma sdangkan yang lebih dari 500 adalah suatu hiperplasia mamma. Pada wanita yang menyusui payudara dapat sangat membesar dengan volume dapat mencapai 1000 cc atau lebih. Umumnya payudara simetris, tapi perbedaan yang tidak mencolok dianggap normal. <br />
III.PENYAKIT-PENYAKIT PAYUDARA<br />
<br />
Penyakit pada payudara pada dasarnya sangat banyak, tidak semuanya adalah kanker, seperti :<br />
1). Neoplasma :<br />
-Neoplasma ganas : kanker payudara, sarkoma payudara<br />
-Neoplasma jinak : fibroadenoma mamma, kistosarkoma filoides, adenoma, lipoma<br />
-Neoplasma in situ : karsinoma in situ duktus, karsinoma in situ lobulus<br />
-Neoplasma yang sifatnya tidak atau kurang jelas : kistosarkoma filoides<br />
2) Displasia :<br />
-Kista payudara<br />
-Fibroadenosis<br />
-Adenofibrosis<br />
-Fibrokistik<br />
3).Kelainan Bawaan:<br />
-Mamma aberans<br />
-Polithelia<br />
-Polimasti<br />
-Inversi putting susu<br />
4).Aplasia, hiperplasia,hipertrofi<br />
5).Keradangan atau mastitis<br />
6).Gynekomastia<br />
Kanker payudara ialah kanker yang berasal dari jaringan penunjang payudara, termasuk puting susu dan gelang susu (areola mamma). Tidak termasuk ialah kanker yang berasal dari kulit payudara.<br />
IV. INSIDENS DAN FREKWENSI<br />
Kanker payudara banyak kita jumpai. Pada wanita menduduki tempat nomor dua setelah karsinoma serviks uteri. Di Amerika serikat karsinoma payudara merupakan 28 % kanker pada wanita kulit putih dan 25% pada wanita kulit hitam.<br />
Kurva insidens usia bergerak naik terus sejak 30 tahun terakhir. Kanker ini jarang sekali ditemukan pada wanita usia di bawah 20 tahun. Angka tertinggi pada usiia 45-66 tahun. Insidens karsinoma mamma pada laki-laki hanya 1% dari kejadian pada perempuan.<br />
<br />
V.ETIOLOGI DAN FAKTOR RESIKO<br />
<br />
Penyebab kanker payudara adalah multifaktorial dan belum seluruhnya diketahui. Yang jelas adalah terjadinya kerusakan pada gen seperti telah dijelaskan sebelumnya.<br />
1).Karsinogen:<br />
Karsinogen ialah zat yang dapat menimbulkan kanker. Di alam dikatahui ada lebih dari 2000 jenis bahan karsinogen, sehingga praktis tidak ada orang yang bebas dari kontaminasi bahan ini. Karsinogen dapat berupa bahan kimia, radiasi pengion, hormon, virus, rangsangan kronis dsb. Untungnya tidak semua kerusakan yang terjadi manifest sebagai kanker.<br />
2).Genetik:<br />
Faktor genetik, yang merupakan faktor bawaan sejak lahir, menentukan mudah tidaknya seseorang mendapat kanker dan mudah tidaknya memperbaiki kerusakan tubuh yang terjadi<br />
3).Faktor lingkungan:<br />
Faktor ini menyangkut tempat tinggal, pekerjaan, makanan, kebiasaan hidup, polusi dsb. dimana hal ini mempengaruhi kekuatan, dosis/kadar serta lamanya paparan (exposure) terhadap bahan-bahan yang bersifat karsinogen.<br />
Walaupun faktor resiko tidak terkait langsung sebagai penyebab, kedua istilah ini sering disebut tumpang tindih. Mengetahui faktor resiko sangat penting dalam prevensi dan deteksi dini kanker payudara. Hal ini sangat penting disampaikan pada masyarakat saat melakukan penyuluhan tentang kanker payudara. Faktor resiko tersebut yaitu (dikutip dari:Breast, Bland K.I et.al. in Principles Of Surgery, 7 th.1999):<br />
1. Umur diatas 35 tahun<br />
2. Menstruasi pertama pada umur dibawah 13 tahun<br />
3. Henti haid pada umur diatas 50 tahun<br />
4. Melahirkan anak pertama pada umur diatas 30 tahun<br />
5. Tidak mempunyai anak<br />
6. Tidak menyusui anak<br />
7. Mempunyai riwayat pernah mengidap tumor jinak payudara<br />
8. Mempunyai riwayat pernah mengidap kanker payudara pada payudara sebelahnya<br />
9. Ibu atau saudara perempuannya pernah atau mengidap kanker payudara<br />
10. Kegemukan<br />
11. Riwayat radiasi dosis tinggi pada daerah dada<br />
12. Gambaran mammografi adanya displasia dari parenkim <br />
13. Riwayat kanker endometrium atau ovarium (indung telur)<br />
14. Status sosial ekonomi yang lebih tinggi cendrung resiko lebih besar<br />
15. Tempat tinggal daerah urban <br />
VI. CARA MENEGAKKAN DIAGNOSA <br />
Dalam menegakkan diagnosa kanker payudara, pemeriksaan yang sistimatis dan teliti yang mencakup anamnesa dan pemeriksaan fisik, sangat besar manfaatnya apalagi ditambah dengan pemeriksaan penunjang yang lain. Dalam menegakkan diagnosa harus disertai dengan penentuan stadium penyakit untuk menentukan rencana terapi.<br />
Keluhan :<br />
Bisa bersumber dari payudara atau diluar payudara. Keluhan yang berhubungan dengan payudara yaitu :<br />
1. benjolan pada payudara yang tidak nyeri<br />
2. borok (ulkus)<br />
3. nyeri pada payudara (jarang dijumpai)<br />
4. keluar cairan dari puting susu<br />
5. eksema atau erosi pada puting susu<br />
6. payudara mengecil atau membesar (payudara asimetris)<br />
7. puting susu masuk kedalam (retraksi niple)<br />
Untuk keluhan yang bersumber diluar payudara umumnya diakibatkan adanya metastase (penyebaran). Keluhannya tergantung pada organ yang bersangkutan seperti batuk- batuk, batuk darah, sesak nafas, jika besumber dari paru-paru. Perut kembung dan kuning pada kulit (ikterus) jika berasal dari hati. Linu-linu, sakit pada tulang, patah tulang, bahkan kelumpuhan jika terjadi penyebaran ke sistim skletal. Keluhan lain sesuai organ yaitu sakit kepala, buta, gangguan saraf, gangguan ingatan, timbul tumor pada kulit atau jaringan di bawah kulit, pembesaran pada kelenjar misalnya pada ketiak dan leher dan hilangnya suara akibat infiltrasi pada saraf pita suara. <br />
Gejala :<br />
Gejala-gejala kanker payudara dapat bermacam-macam. Seperti hal diatas bisa bersumber dari payudara dan diluar payudara. Gejala yang bisa ditemukan pada payudara yaitu : <br />
1. tumor<br />
2. borok<br />
3. erosi atau eksema pada puting susu<br />
4. keluar cairan dari puting susu<br />
5. payudara mengkerut atau membesar<br />
6. nyeri.<br />
Penemuan-penemuan diatas perlu disertai dengan pemeriksaan untuk menentukan apakah ada penyebaran ke kelenjar getah bening terutama ke aksiler atau organ lain. Pemeriksaan ini memerlukan pemeriksaan laboratorium termasuk radiologi dan test fungsi organ. Diagnosa ditegakkan dengan pemeriksaan sel-sel tumor secara mikroskopis. Pemeriksaan ini diambil dengan cara biopsi jarum halus (FNAB) untuk pemeriksaan sitologi dan lebih akurat lagi (tergantung stadium) dilakukan pemeriksaan jaringan secara histopatologis, dengan cara insisi (sebagian jaringan) ataupun eksisi keseluruhan tumor. Pemeriksaan histopatologi yang dilakukan di meja operasi untuk menentukan tindakan operatif selanjutnya pada keadaan diagnosa yang ragu-ragu disebut ‘frozen section’.<br />
VII. PENANGANAN <br />
Terapi kanker ialah multimodal , dengan cara kombinasi operasi, radioterapi, chemoterapi,dan hormon terapi. Kombinasi mana yang terbaik dokter akan menentukan setelah mengadakan pemeriksaan yang teliti dan penentuan stadium kanker. Penentuan stadium sangat penting oleh karena menjadi dasar terapi yang dipilih dan menentukan prognosa penyakit. Dengan demikian tentu saja sangat diharapkan penderita diterapi pada stadium yang sedini-dininya. Penentuan stadium dikerjakan di Rumah sakit. Secara umum penentuan stadium berdasarkan keadaan tumor (T), keadaan kelenjar getah bening=node(N) dan apakah ada metastase (M), disebut juga TNM system.<br />
Sampai saat ini operasi adalah cara terapi yang paling berhasil untuk menyembuhkan kanker payudara. Seluruh paket pengobatan kanker payudara yang masih belum kelihatan menyebar memerlukan waktu 9 bulan sampai 5 tahun. Untuk kanker yang telah menyebar umumnya akan timbul residif (kambuh) atau penyebaran.<br />
Tujuan pengobatan kanker payudara dapat :<br />
A. Kuratif<br />
Pengobatan kuratif adalah pengobatan untuk mneyembuhkan penderita dari serangan kanker.makin lanjut stadiumnya makin kecil kemungkinan dapat disembuhkan. Kanker stadium 0 hampir 100% dapat disembuhkan. Kanker stadium IV hampir tidak dapat disembuhkan. Kemungkinan sembuh pada kanker stadium dini yaitu stadium 0, I, II cukup besar. Sebagian dari stadium III masih dapat disembuhkan walaupun prosentasinya tidak besar.<br />
Pengertian sembuh pada kanker payudara berbeda dengan penyakit lain, walupun penderita kelihatan sehat, belum tentu bebas dari kanker, karena sewaktu-waktu bisa timbul lagi ( residif) atau timbul penyebaran. Penderita dinyatakan sembuh bila dia bebas kanker sedikitnya selama 15-20 tahun.<br />
2. Paliatif<br />
Pengobatan paliatif adalah pengobatan untuk meringankan penderitaan yang ditujukan pada kasus-kasus yang tidak dapat disembuhkan lagi. Tujuannya adalah untuk meningkatkan kwalitas hidup. Keluhan yang membutuhkan terapi paliatif yaitu nyeri, borok, infeksi , sesak nafas, kelumpuhan, patah tulang, dsb. <br />
3. Pengobatan terminal<br />
Pengobatan terminal atau perawatan terminal adalah suatu tindakan pada saat menjelang kematian sehingga penderita dapat meninggal dengan tenang dan damai. <br />
Ketiga jenis terapi ini tidak terpilah-pilah secara tegas, tapi seringkali saling tumpang tindih. Cara-cara pengobatannya mencakup operasi, radiasi, kemoterapi, hormonal dan terapi bilogis. Tindakan operasi adalah tindakan /cara pengobatan yang tertua, yang paling berhasl membebaskan penderita dari serangan kanker. Pada stadium dini tindakan operasi telah dimodifikasi sehingga tindakan tidak seraddikal dahulu, dimana keseluruhan payudara diangkat. Saat ini berkembang terapi operatif dengan mempertahankan keutuhan payudara sehingga gangguan kosmetik dikurangi yang disebut Breast conserving treatment (BCT). Jenis terapi ini berbentuk suatu paket yang terdiri dari reseksi segmental, diseksi kelenjar aksiler, dan radioterapi. Prosedur ini disebut juga QU.A.RT (Quadrantectomy,Axillary dissection, dan Radiation Therapy). Jika tumornya sudah besar harus dilakukan pengangkatan seluruh payudara beserta keseluruhan otot atau sebagiannya yang disebut radikal mastektomi atau radikal mastektomi yang dimodifikasi. Kehilangan payudara dapat ditanggulangi dengan melakukan rekonstruksi atau pemakaian protese payudara.<br />
Terapi radiasi digunakan untuk mengecilkan tumor ataupun menghilangkan sisa-sisa sel ganas pada daerah getah bening regional. <br />
Kemoterapi dipakai untuk membersihkan / membunuh sel-sel tumor yang bermetastase ataupun dapat dipergunakan untuk mempermudah tindakan operasi. Misalnya pada tumor yang inoperable ( tidak memungkinkan untuk dioperasi) dapat dikecilkan dengan mempergunakan obat-obatan yang dapat mematikkan sel ganas biarpun tidak secara keseluruhannya sehingga operasi dapat dikerjakan. Oleh karena itu ada istilah induced chemotherapy (ICT) dan adjuvant chemotherapy (ACT). Terapi hormonal dipakai bukan bertujuan menyembuhkan kanker, tapi memperlambat atau menghentikan sementara pertumbuhan sel-sel ganas. Jenis terapi ini dapat bersifat operatif, misalnya pengangkatan indung telur (ovarium) atau pemebrian obat-obatan, misalnya tamoxifen sebagai antiestrogen. Jenis terapi lain yang masih dalam penelitian yaitu immunoterapi dimana sistim kekebalan tubuh ditingkatkan dan terapi biologis yang berupa rekayasa genetik.<br />
VIII. HASIL PENGOBATAN<br />
Hasil pengobatan kanker sampai saat ini belum memuaskan. Diperkirakan baru sepertiga penderita yang dapat disembuhkan dan itupun terbatas pada stadium yang dini. Pada kanker stadium lanjut hasil pengobatan sesuai dengan tujuan yaitu bersifat paliatif, yaitu meningkatkan kualitas hidup, tapi tidak menyembuhkan penyakitnya. Umumnya hanya 5% yang dapat bertahan hidup selama 10 tahun, 20 % dalam 5 tahun dan 50 % bertahan hidup dalam 2½ tahun. Kanker payudara tidak ada yang dapat sembuh spontan tanpa pengobatan. Jika tidak diobati kanker payudara makin lama makin besar, melekat dengan kulit dan dinding dada, timbul borok yang berbau dan mudah berdarah, timbul keluhan dan gejala akibat penyebaran jauh dan akhirnya meninggal dalam kesengsaraan. Dengan demikian deteksi dini dan terapi pada stadium dini sangat diutamakan.<br />
IX.DETEKSI DINI KANKER PAYUDARA<br />
Deteksi dini adalah usaha menemukan kanker sedini mungkin. Hal ini dapat dilakukan dengan penyuluhan tentang kanker , mengajarkan para wanita dewasa untuk melakukan pemeriksaan payudara sendiri (SARARI) dan skrining kanker payudara terutama pada golongan masyarakat resiko tinggi. <br />
X. PEMERIKSAAN PAYUDARA SENDIRI (SARARI)<br />
Sebagian besar (+ 90%) kanker payudara itu pertama kali diketahui adanya oleh penderita karena ia meraba adanya tumor atau kelainan pada payudaranya. Karena itu setiap wanita dewasa dianjurkan melakukan pemeriksaan payudara sendiri (SARARI) secara teratur. Pada wanita pramenopause SARARI itu dianjurkan dikerjakan sebulan sekali, seminggu setelah selesai menstruasi. Pada yang telah menopause dilakukan sebulan sekali pada tanggal tertentu, misalnya tiap tanggal 1 pada permulaan bulan. Dengan latihan secara teratur setiap wanita akan bisa melakukan SARARI dengan baik. Batas minimal besar tumot yang dapat diraba ialah 1 cm. Tumor yang lebih kecil dari 1 cm tidak dapat diraba. Sampai sebesar 2 mm masih mungkin dapat dilihat dengan pemeriksaan mammografi.<br />
Tujuannya ialah supaya setiap wanita :<br />
1. Mengetahui dengan baik payudaranya sendiri.<br />
2. Dapat segera mengetahui bila ada kelainan pada payudaranya.<br />
Pemeriksaan SARARI dilakukan dengan cara : inspeksi, palpasi, dan memijat putting susu dan pemeriksaan.<br />
Cara melakukan SARARI<br />
1. Inspeksi (cara melihat payudara)<br />
Pemeriksaan ini dilakukan dengan membuka baju dan behanya sampai setinggi pusat. Pelaku berdiri atau duduk di muka kaca, supaya dapat melihat payudaranya sendiri. Inspeksi payudara dilakukan dalam keadaan kedua lengan :<br />
1) Menggantung lemas disamping tubuh<br />
2) Diangkat tinggi-tinggi disamping kepala, yang akan ikut mengangkat kedua payudaranya keatas sehingga dapat melihat pergerakan payudara. Perhatikan :<br />
(1) Bentuk kedua payudara : normal/tidak, simetris/tidak<br />
(2) Besarnya payudara : kecil, besar, sedang atau apakah simetris/tidak<br />
(3) Apakah ada kelainan :kulit areola atau putting susu seperti : perubahan warna, erosi, borok, oedema (seperti kulit jeruk), tarikan kulit (retraksi), dsb. <br />
(4) Apakah ada benjolan pada payudara : ya/tidak<br />
(5) Bagaimana pergerakan payudara : normal/tidak atau berbarengan/tidak<br />
2. Palpasi (cara meraba payudara) <br />
Palpasi payudara sebaiknya dikerjakan dalam keadaan berbaring di tempat tidur. Punggung pada sisi payudara yang akan diraba diganjal dengan bantal tipis sehingga payudara tersebar merata di atas dinding dada. Meraba payudara menggunakan telapak ujung-ujung jari ke-2 sampai ke-5. Jaringan payudara ditekankan ke dinding dada.<br />
Ada 2 cara meraba payudara :<br />
1) Cara radiar :<br />
Perabaan mulai dari tepi payudara radiar menuju putting susu. Dalam hal ini payudara dianggap sebagai suatu jam, dengan pusatnya pada puting susu. Misalnya mulai meraba pada jam 12, lalu jam 1, jam 2, jam 3 dst. Sampai seluruh payudara teraba.<br />
2) Cara sirkuler<br />
Perabaan mulai dari puting susu secara sirkuler seperti spiral ke arah luar sampai seluruh payudara teraba. <br />
Pada palpasi perhatian terutama pada payudara bagian ketiak dan puting susu karena di daerah ini paling sering ditemukan kanker. Kalau ada tumor akan teraba ada sesuatu yang lebih padat dari jaringan sekitarnya. Kalau ada tumor buat catatan dan tentukan :<br />
1) Tanggal berapa ditemukan<br />
2) Dimana letaknya : misalnya pada payudara kiri, jam 2, 3 jari dari putting<br />
3) Berapa besarnya : misalnya 1 cm<br />
4) Bagaimana bentuknya : bulat/oval/tidak teratur<br />
5) Bagaimana konsistensinya : lunak/padat/keras<br />
6) Bagaimana batas-batasnya : tegas/tidak tegas<br />
7) Bagaimana mobilitasnya : mudah/sukar digerakkan<br />
8) Berapa banyaknya : 1,2,3<br />
9) Apakah nyeri : ya/tidak <br />
3. Memijat puting susu<br />
Untuk melihat apakah ada darah atau cairan abnormal yang keluar dari puting susu itu.<br />
Kalau ada perhatikan :<br />
1) Kapan ditemukan : tanggal berapa<br />
2) Bagaimana warnanya : jernih, kuning, merah, hitam atau darah<br />
3) Seperti apa cairan yang keluar : air,darah, nanah, air susu<br />
Cara Pemeriksaan Beha Sendiri<br />
Pagi-pagi sebelum beha itu dicuci perhatikan bagian dalam kapnya apakah ada plek yang masih basah atau telah mengering karena ada darah atau cairan abnormal keluar dari putting susu yang melekat pada bagian dalam kap beha itu.<br />
Melakukan skrining kanker payudara <br />
Skrining kanker ialah pemeriksaan payudara secara masal pada segolongan penduduk pada suatu daerah dan waktu tertentu. Skrining ini umumnya dikerjakan dengan pada segolongan masyarakat yang “kelihatan sehat” , yang belum menunjukkan keluhan. Deteksi dini itu dikerjakan terutama pada golongan wanita yang mempunyai risiko tinggi mendapat kanker.<br />
1. Pemeriksaan payudara secara fisik oleh skriner yang telah terlatih<br />
2. Pemeriksaan mammografi yaitu pemotretan payudara<br />
Dengan mammografi sampai tumor sebesar 2 mm mungkin dapat dilihat.<br />
Hanya perlu diketahui tidak semua tumor dapat dilihat. Ada tumor yang dapat diraba secara fisik tetapi tidak dilihat dengan mammografi atau sebaliknya ada tumor yang tidak dapat diraba tetapi dapat dilihat dengan mammografi. <br />
Bila pada skrining ditemukan adanya kelainan, kelainan itu perlu diperiksa lebih lanjut apakah suatu kanker atau bukan. Syukur sekali bukan kanker dan kalau kanker umumnya masih merupakan kanker dini, sehingga payudara masih dapat diselamatkan dan masih dapat disembuhkan. Kanker yang ditemukan dengan skrining umumnya jauh lebih dini daripada yang ditemukan dengan pemeriksaan biasa setelah ada keluhan.<br />
<br />
<br />
DAFTAR PUSTAKA:<br />
1. Charles M. Haskell and Dennis A. Casciato : Breast Cancer. In: Manual of Clinical Oncology. Ed: Dennis A. Casciato and Barr B Lowitz. 4th Lippincott Williams & Wilkins. Philadelphia 2000.p.:218-236.<br />
2. Sukardja IDG : Penanggulangan Kanker Payudara. Bagian Bedah FK UNAIR / RSUD.DR.Sutomo. Surabaya.<br />
3. Robert B Dickinson and Marc E. Lippman : Molecular Biology of Breast Cancer. In: Cancer of The Breast. In: Cancer - Principles & Practice of Oncology 5th Ed. By. Editor: Vincent T. DeVita, Samuel Hellman and Steven A. Rosenberg. Lippincot – Raven. Philadelphia.1997.p: 1541-1552.<br />
4. Jay Harris, Monica Morrow and Larry Norton : Malignant Tumor Of The Breast. In : Cancer Of The Breast.In : Cancer - Principles & Practice of Oncology 5th Ed. By. Editor: Vincent T. DeVita, Samuel Hellman and Steven A. Rosenberg. Lippincot – Raven. Philadelphia.1997.p: 1557-1606.<br />
5. Walter C. Willet : Fat. In.: Cancer Prevention : Diet and Risk Reduction. In: Cancer - Principles & Practice of Oncology 5th Ed. By. Editor: Vincent T. DeVita, Samuel Hellman and Steven A. Rosenberg. Lippincot – Raven. Philadelphia.1997.p: 560.<br />
6. Peter Greenwald : Dietary Fiber. In.: Cancer Prevention : Diet and Risk Reduction. In: Cancer - Principles & Practice of Oncology 5th Ed. By. Editor: Vincent T. DeVita, Samuel Hellman and Steven A. Rosenberg. Lippincot – Raven. Philadelphia.1997.p:570-571.<br />
7. Leslie Bernstein, Ronald Ross and Brian E. Henderson.: Cancer Prevention: Hormones. In: Cancer - Principles & Practice of Oncology 5th Ed. By. Editor: Vincent T. DeVita, Samuel Hellman and Steven A. Rosenberg. Lippincot – Raven. Philadelphia.1997.p: 609-615.<br />
8. Barbara K. Rimer and Joellen Schildkraut : Cancer Screening. In: Cancer - Principles & Practice of Oncology 5th Ed. By. Editor: Vincent T. DeVita, Samuel Hellman and Steven A. Rosenberg. Lippincot – Raven. Philadelphia.1997.p:621-624.<br />
9. Kirby I.Bland, Michael P. Vezeridis and Edward M. Copeland III.: Breast in.: Principles of Surgery. 7th Ed.Editor : Seymour I. Schwartz. McGraw-Hill co. New York 1999.P.:533-592.<br />
10. Philip Thorek : Anatomy in Surgery. 2nd. J.B.Lippincott Company. Philadelphia 1962.p.:254-265.<br />
11. Sjamsuhidajat R dan Wim de Jong : Buku Ajar Bedah. Penerbit Buku Kedokteran EGC. 1997. hal :540-555.<br />
12. Juan A. del Regato, Harlan J.Spjut and James D.Cox.: Cancer.6th ed. The C.V.Mosby Co.USA.1985.p.:853-897.Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-60636901603590279102011-03-26T23:31:00.000+09:002011-03-26T23:31:28.828+09:00Lyric Pada iPhoneHalo friends.<br />
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</div><div class="MsoNormal"><b><span lang="EN-GB" style="font-size: 18.0pt; mso-bidi-font-size: 12.0pt;">Dasar Panduan Nutrisi Parenteral Partial<o:p></o:p></span></b></div><h1><b><span lang="EN-GB" style="font-size: 18.0pt; mso-bidi-font-size: 12.0pt;"><o:p> </o:p></span></b></h1><div class="MsoNormal"><b><i><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Divisi Bedah Digestif<o:p></o:p></span></i></b></div><h2><span lang="EN-GB">Bagian Bedah F.K UNSRAT/RSUP Manado</span></h2><h2><span lang="EN-US" style="mso-ansi-language: EN-US;">Dr.Theo Rompas<o:p></o:p></span></h2><div class="MsoBodyText"><span class="Apple-style-span" style="font-size: large;"><span class="Apple-style-span" style="font-size: 17px;"><br />
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</tbody></table></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">enderita dengan trauma yang besar, sakit berat atau sepsis mengalami peningkatan kebutuhan energi, peningkatan katabolisme disertai kehilangan massa tubuh yang cepat. Meskipun pemberian nutrisi konvensional mampu dengan baik mengatasi malnutrisi biasa, bahkan hiperalimentasi ternyata gagal mengatasi perubahan metabolik terhadap pasien-pasien seperti diatas. Penurunan berat badan, kehilangan otot yang mengakibatkan keseimbangan nitrogen yang negatif tetap saja terjadi, berapapun jumlah nutrisi yang diberikan. Hal ini karena respons metabolik pada pasien sakit kritis, trauma hebat dan atau disertai tindakan operasi dan sepsis sangat berbeda dengan dengan penderita <i>malnutrisi/starvasi</i> (kekurangan gizi akibat intake yang kurang). Selama beberapa dekade terakhir ini jumlah energi yang diberikan pada pasien sepsis atau sakit berat termasuk penderita trauma dengan SIRS justru menurun, karena telah dibuktikan bahwa kebutuhan energi pasien tidaklah jauh berbeda dengan pasien normal. Hipermetabolisme yang timbul pada kenyataannya diimbangi dengan aktifitas fisik yang menurun. Oleh karena itu strategi untuk mengatasi kehilangan otot dan keseimbangan nitrogen yang negatif adalah mengatasi penyebab hipermetabolisme dan memberi tunjangan nutrisi yang adekwat dalam kualitas bukan kwantitas. Pemahaman penyebab terjadinya hipermetabolisme ini berarti adalah pemahaman yang jelas dari <i>respons metabolik</i>. Respons ini terkait dengan berbagai reaksi akibat adanya trauma, seperti neuroendokrin, imunologis dan mencakup berbagai macam mediator inflamasi.<o:p></o:p></span></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><b><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Respons Neuroendokrin<o:p></o:p></span></b></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Suatu trauma akan menyebabkan kerusakan jaringan dan perdarahan, sedangkan tubuh akan memberikan reaksi sebagai respons akibat trauma yang terjadi. Proses yang termasuk dalam respons ini meliputi serangkaian stimulus dan transmisi dari sistem saraf yang diatur oleh susunan saraf pusat, aktifitas kelenjar endokrin dan reaksi imunologis yang mencakup mediator tertentu yang bekerja antar sel. Keseluruhan reaksi ini memberikan respons fisiologis-reaksi adaptif sebagai suatu jawaban untuk keadan abnormal akibat faktor pemicu tersebut. Hasil akhir berupa “Stress Respons Syndrome”. Bila gangguan tersebut berlangsung singkat maka respons ini bermanfaat. Namun jika ada gangguan sekunder seperti infeksi maka respons yang terjadi bersifat merusak dan terjadi gangguan fungsi organ.<o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Luka, kerusakan jaringan dan perdarahan merupakan rangsangan(stimulus) yang akan menimbulkan signal dari perifer kesentral. Input sensoris dari luka atau jejas akan ditransmisikan ke thalamus melalui tractus spinothalamicus dan menimbulkan sensasi nyeri yang umumnya bersamaan dengan respons emosional, sehingga sistem simpatis teraktivasi. Hal ini terjadi bersamaan dengan penurunan volume sirkulasi akibat perdarahan<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Perdarahan akan terdeteksi melalui baroreseptor (aortic body dan carotid body) sebagai penurunan tekanan arterial. Hal ini menyebabkan vasokonstriksi akibat adanya refleks simpatis dari kelenjar adrenal dan terjadi sekresi adrenalin dan noradrenalin. Selain itu aortic bady dan carotid body terdapat kemoreseptor yang dapat mendeteksi adanya penurunan tekanan O<sub>2</sub> (PaO<sub>2</sub>) atau peningkatan ion H<sup>+ </sup>atau tekanan CO<sub>2</sub> (PCO<sub>2</sub>) didalam darah yang menyebabkan respons neuroendokrin di hipothalamus. Hasil dari respons ini menyebabkan darah “diperas” kembali kejantung dan otak sehingga perfusi dan oksigenasi keduanya tercukupi (kedua organ ini tidak peka terhadap respons ini, sehingga disebut juga organ klas satu) dan organ lain dimana resistensi perifernya meningkat menjadi korban yaitu: ginjal, otot, kulit, usus(viscera) dan hati. Kejadian ini disebut ‘protective redistribution’ oleh karena organ lain diselamatkan dan organ lain menjadi korban. Secara klinis ditandai dengan akral dingin, berkeringat (rangsangan simpatis pada kelenjar keringat) takikardi (naiknya cardiac output), frekwensi napas menjadi cepat dan vena kolaps dengan tensi yang mungkin masih tetap normal. Vena kolaps oleh karena 75% jumlah total darah berada pada sirkulasi vena.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Jika tidak ada pertolongan dalam 24-48 jam tekanan hidrostatik menurun dan tekanan onkotik meningkat sehingga terjadi sekresi ADH yang menyebabkan retensi air oleh ginjal. Dan akibat perfusi ginjal yang menurun sistem RAA teraktivasi menyebabkan retensi Na oleh hormon aldosteron. Proses ini disebut juga tahap hemodilusi yang dipercepat dengan pemberian resusitasi cairan untuk mencukupi perfusi dan oksigenasi jaringan. Penjelasan singkat mengenai hal ini adalah sebagai berikut: secara normal darah arterial mengandung 20 Vol.% O<sub>2</sub>, artinya dalam 100 cc darah arterial mengandung 20 cc O<sub>2</sub>. Dalam darah vena kandungan oksigen 15Vol.%O<sub>2</sub>. Hal ini berarti dalam tiap 100 cc darah diambil 5 cc O<sub>2</sub>. Kebutuhan oksigen permenit secara normal adalah 250 cc O<sub>2</sub>. Dengan demikian cardiac output dapat dihitung sebagai berikut, 250/5 O<sub>2</sub> x 100 cc darah = 5 liter darah. Berdasarkan hal ini dapat dimengerti mengapa terjadi peningkatan heart rate dan/atau respiratory rate. Misalnya terjadi hemodilusi sehingga kandungan oksigen darah arterial menjadi 17,5 vol% O<sub>2</sub> dan kandungan darah vena tetap 15 vol%, maka oksigen yang diambil tiap 100 cc darah hanya 2,5 vol%O<sub>2</sub>. Jadi untuk memenuhi kebutuhan normal oksigen cardiac output harus meningkat menjadi 250/2,5 O<sub>2</sub> x100 cc darah = 10 liter melalui peningkatan heart rate. Jika ada kompensasi respiratory dimana respiratory rate meningkat sehingga pengambilan oksigen permenit tetap 5 vol% O<sub>2</sub> , misalnya kandungan darah arterial 17,5 vol% O<sub>2</sub> dan darah vena menjadi 12,5 vol% maka cardiac output tidak meningkat. Umumnya kedua mekanisme ini saling tumpang tindih.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Respons lain yang perlu dipahami secara mendalam yaitu pelepasan mediator-mediator sistemik dari luka atau jaringan yang mengalami jejas dan atau kerusakan jaringan akibat iskemik yang timbul sekunder akibat hipoperfusi yang berkepanjangan atau tidak/tak teratasi. Keadaan ini merupakan cascade dari SIRS.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Salah satu organ yang perlu mendapat perhatian khusus adalah usus. Pada fase shock terjadi ileus paralitik disertai distensi usus. Distensi usus ini disertai hipoperfusi jaringan menyebabkan disrupsi mukosa usus. Bakteri usus yang bersifat komensal mengalami perubahan sifat menjadi oportunistik (perubahan keseimbangan kehidupan flora usus) dan mengadakan invasi yang sekarang dikenal dengan sebutan translokasi bakteri. Translokasi bakteri ini juga ternyata dipengaruhi oleh obat-obatan yang sering secara rutin digunakan seperti pemberantasan bakteri anaerob. Selain itu juga pemberian H<sub>2</sub> inhibitor seperti cimetidine dimana terjadi perobahan suasana keasaman lumen usus. Dengan demikian kerusakkan menjadi begitu luas.<o:p></o:p></span></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><b><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Respons Inflamasi<o:p></o:p></span></b></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Awalnya reaksi inflamasi hanya bersifat lokal yang merupakan respons dari infeksi atau trauma atau keduanya beserta dengan kerusakan jaringan/organ lain yang bersifat sekunder. Reaksi lokal ini merupakan pencetus SIRS dimana mediator-mediator inflamasi saling berinteraksi secara sistemik. Secara garis besar terdiri dari dua respons yaitu: <b><i>Inflammatory cascade dan Coagulation cascade</i></b>. Keduanya saling terkait dan tidak bisa dipisahkan dengan respons neuroendokrin dan respons metabolisme. Berbagai mediator tersebut antara lain:<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Komplemen sistem yang merupakan gugusan <i>protein plasma</i> yang berfungsi menghancurkan/lisis mikroorganisme. Komplemen teraktivasi oleh antigen, mediator radang, bahan kimia tertentu atau endotoksin. Jika reaksi ini berlebihan menjadi suatu proses yang merusak jaringan tubuh sendiri, misalnya pada ARDS. Aktivasi sistem komplemen tampak sebagai peningkatan leukosit.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Leukosit (PMN) yang teraktivasi dan rusak dan jaringan yang iskemik melalui enzim xantin oksidase akan memproduksi radikal oksigen. Radikal oksigen ini sangat merusak jaringan dengan terbentuknya oksigen <i>peroksidase H<sub>2</sub>O<sub>2</sub></i>. Beberapa tulisan menyatakan bahwa radikal oksigen terkait dalam lingkaran setan suatu reaksi inflamasi, <i>trauma-kerusakan endotel-deposisi platelet dan fibrin-ischemia-kerusakan jaringan-aktivasi komplemen-terbentuk radikal oksgen-dan kerusakan endotel</i>.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Sitokin (cytokines) merupakan bahan biologik peptida yang berfungsi sebagai mediator yang diproduksi oleh monosit (monokin) dan limfosit/makrofag (limfokin). Kurang lebih ada seratus bahan yang diproduksi oleh makrofag, tapi yang penting ialah IL1, IL2 dan IL6 dimana interaksi diantaranya menyebabkan proliferasi B sel dan produksi antibodi dan berperan terjadinya proteolisis. Sitokin yang diproduksi oleh monosit ialah TNF dan IF yang mempunyai kemampuan seperti IL1. Platelet Activating Factor (PAF) yang diproduksi oleh berbagai sel seperti PMN, makrofag dan endotelial sel fungsi pentingnnya adalah untuk menginduksi PMN sendiri.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Suatu mediator yang berbahan dasar bukan protein adalah eicosanoid. Bahan ini dibentuk dari phospholipid plasma membran yang meliputi prostaglandin, tromboxan dan leukotrien yang semuanya merupakan metabolit asam arachidonat. Eicosanoid mempunyai peran yang besar terhadap respons biologis dan berperan banyak pada keradangan akut. Asam lemak yang merupakan precursor eicosanoid adalah asam lemak esensial rantai panjang tak jenuh T-3 dan T-6. asam lemak ini selain disintesa oleh tubuh sendiri juga didapat dari luar (diet). Eicosanoid yang berasal dari asam lemak T-3 potensinya lebih kecil (1/10 sampai 1/100) dibandingkan dengan eicosanoid yang berasal dari T-6, dengan demikian efek keradangan yang ditimbulkannya lebih kecil. Pengaruhnya terhadap proses keradangan terutama terhadap sitokin, T-3 lebih menguntungkan oleh karena mampu menurunkan produksi sitokin dibandingkan dengan asam lemak yang lain. Dapat dikatakan asam lemak T-3 menurunkan respons keradangan karena efeknya pada produksi eicosanoid dan sitokin. Suatu studi yang dilakukan pada tikus yang mengalami ‘endotoksin-induced lung injury’ yang diberikan diet asam lemak T-3 yang tinggi memperlihatkan adanya pengurangan permeabilitas pulmoner dan perbaikkan hipotensi. Interaksi yang rumit ini diduga menentukan manifestasi klinis dan prognosanya.<o:p></o:p></span></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><b><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Respons Metabolik<o:p></o:p></span></b></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Respons metabolik sangat berhubungan dan saling tumpang tindih dengan keadaan shock, reaksi neuroendokrin dan respons inflamasi seperti telah dijelaskan diatas. Dahulu respons ini dibagi dalam dua fase yaitu: fase awal (ebb fase) dan fase lanjut (flow fase). Pada ebb fase terjadi usaha memperbaiki sirkulasi dan perfusi jaringan. Pada fase lanjut terjadi hiperglikemia, mobilisasi lemak/lipolisis dan pemecahan asam amino otot, retensi air dan natrium, penurunan konsumsi oksigen dan peningkatan glukoneogenesis. Sekarang respons metabolik digolongkan dalam 4 fase yaitu fase: shock, resusitasi, hipermetabolik dan sindrome disfungsi organ multiple (MODS). Tergantung pada keparahan trauma/infeksi dan penanganan yang diberikan, tidak semua kasus berkembang menjadi fase hipermetabolik dan MODS.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><br />
</div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Fase Shock, dimana terjadi hipoperfusi dan disfungsi organ akibat perdarahan ataupun trauma lainnya.<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Fase Resusitasi yang menyangkut resusitasi aktif, termasuk pembedahan maupun respons neuroendokrin untuk mempertahankan perfusi dan oksigenasi jaringan seperti telah dijelaskan diatas. Selama fase ini sebagian besar mediator inflamasi teraktivasi.<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Fase Hipermetabolik. Fase ini merupakan fase katabolik yang dapat berakhir dalam beberapa hari hingga beberapa minggu. Disini terjadi balance nitrogen negatif, lipolisis dan peningkatan sekresi insulin, katekolamin dan kortisol. Pada fase awal keadaan ini mempunyai keuntungan karena berhubungan dengan pertahanan tubuh melalui proses inflamasi seperti dijelaskan sebelumnya. Namun jika aktifasi ini berlanjut terus, reaksi inflamasi ini merusak dan berakibat timbunya SIRS (Systemic Inflamatory Respons Syndrome).<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l1 level1 lfo3; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">MODS (Multi Organ Dysfunction Syndrome). Keadaan ini merupakan kelanjutan dari SIRS.<o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Secara esensial semua proses yang terjadi ini membutuhkan energi yang luar biasa besarnya sesuai tingkatan besarnya trauma. Sumber utama energi yang sebenarnya digunakan pada orang normal adalah glukosa. Glukosa disimpan dalam bentuk glikogen dalam otot dan hanya digunakan dalam otot dan tidak dikeluarkan secara sistemik, sehingga glukosa dibentuk melalui glukoneogenesis dari protein terutama dari otot dengan penghematan protein viscera, gliserol, laktat atau piruvat melalui TCA (Tricarboxylic Acid Cycle) atau siklus Krebb. Selain itu energi diambil dari lemak untuk jaringan yang bukan glucose dependent dan terbentuk keton bodies dan CO<sub>2</sub> dan energi diambil dari gliserol dan asam lemak. <o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Secara umum dapat disimpulkan terjadi peningkatan:<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l3 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Aktifitas kardiovaskuler seperti:<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 72.0pt; mso-list: l3 level2 lfo1; tab-stops: list 72.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: "Courier New"; font-size: 13.0pt; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Takikardi<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 72.0pt; mso-list: l3 level2 lfo1; tab-stops: list 72.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: "Courier New"; font-size: 13.0pt; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">“pulse Pressure” yang melebar<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 72.0pt; mso-list: l3 level2 lfo1; tab-stops: list 72.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: "Courier New"; font-size: 13.0pt; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: "Courier New";"><span style="mso-list: Ignore;">o<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">“cardiac output” yang meningkat<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l3 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">“Metabolic Rate”<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l3 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">“Oxygen Consumption”<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l3 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Katabolisme Protein<o:p></o:p></span></div><div class="MsoBodyText" style="margin-left: 36.0pt; mso-list: l3 level1 lfo1; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Hiperglikemia.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Pada pasien dengan responsnya <i>baik</i> “cardiac index” dapat melampaui 4,5 liter/menit/m<sup>2</sup>. Jika respons tidak baik sehingga “cardiac index” kurang dari 2,5 liter/menit/m<sup>2</sup>, konsumsi oksigen turun sampai dibawah 100 ml/menit/m<sup>2</sup> (normal:120-160 ml/menit/m<sup>2</sup>. selain adanya endotoksin maka anoksia ini menyebabkan kerusakan sel dan menghambat utilisasi/pemanfaatan oksigen untuk “Oxidative Phosphorylation”. ATP yang disintesa sangat besar jumlahnya. Tapi tidak ada reserve ATP ataupun kreatinin fosfat, dengan demikian terjadi glikolisis anaerobik dan hanya terbentuk 2 ATP dari satu mol glukosa (pada metabolisme aerobik 34 ATP) dengan hasil akhir berupa laktat yang dibentuk dari piruvat. Pada keadaan dimana responsnya baik piruvat piruvat dikonversi menjadi “Acetyl Co-Enzym A” untuk masuk dalam “Krebs Cycle” untuk diubah kembali menjadi glukosa. Pada keadaan shock hal ini terhambat. Laktat yang menumpuk menyebabkan acidosis laktat. Perlu diingat acidosis yang berkelanjutan dalam tiga hari pertama berkorelasi dengan ISS (“Injury Severity Score”) dan memprediksi terjadinya ARDS (“Adult Respiratory Distress Syndrome”).<o:p></o:p></span></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><b><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Dampak<span style="mso-spacerun: yes;"> </span>pada “Substrate Metabolisme”<o:p></o:p></span></b></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Pada pasien sakit berat terjadi suatu kondisi yang mirip dengan kehamilan dan pasien diabetes, dimana terjadi intoleransi glukosa dan hiperglikemia. Hal ini terjadi karena “turn over”/mobilisasi glukosa meningkat sedangkan pemanfaataan oleh jaringan menurun, dimana pada fase dini shock dengan adanya pengaruh katekolamin terjadi hambatan pada sel </span><span lang="EN-GB" style="font-family: "Courier New"; font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">ß</span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"> pankreas dan kadar insulin dapat turun sampai dibawah 8 unit/ml. Pada tahap selanjutnya dimana glukoneogenesis terutama akibat glukokortikoid dan glukagon, terjadi peningkatan insulin sebagai respons terhadap hiperglikemia yang terjadi, tapi karena adanya “Growth Hormon” terjadi hambatan fungsi insulin terhadap metabolisme glukosa. Jadi pada keadaan ini terjadi hiperglikemia, hiperinsulinema dan katabolisme sebagai sumber kalori menjadi karakteristik. Kadar glukosa sebaiknya dipantau dan dapat dilakukan titrasi dengan insulin IV, tapi perlu diingat adanya resistensi insulin oleh jaringan. Hal ini penting karena hiperglikemia dapat meningkatkan insufisiensi ventilasi dan diuresis osmotik. Pemberian nutrisi parenteral (glukosa) pada keadaan ini dapat memperburuk keadaan, harus ada kombinasi dengan pemakaian emulsi lemak.<o:p></o:p></span></div><div class="MsoBodyText" style="text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Lemak dapat sebagai sumber energi, juga komponen yang esensial untuk setiap sel terutama penting untuk menjamin integritas dinding sel. Dalam keadan sepsis terjadi kekurangan delta-6 desaturase yang diperlukan untuk konversi asam lemak esensial, sehingga terjadi kekurangan asam lemak esensial yang sangat diperlukan oleh sistem kekebalan tubuh. Hal ini memicu pembentukan TNF dan leukotrien yang akan merangsang<span style="mso-spacerun: yes;"> </span>spasme bronkus lebih kuat dari efek histamin, meningkatkan permeabilitas kapiler. Hal ini menunjukkan pentingnya tunjangan asam lemak. <o:p></o:p></span></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><b><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Pengelolaan<o:p></o:p></span></b></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Pengelolan pertama adalah menjamin oksigenasi jaringan secepatnya dengan memperbaiki volume intravaskuler dengan cairan elektrolit, koloid atau darah. Jika perlu dengan obat-obatan vasoaktif. Tanpa sirkulasi yang adekuat dan perfusi jaringan yang baik, usaha pengobatan yang lain akan sia-sia dimana penderita akan jatuh pada suatu kondisi yang bersifat irreversibel. Pembedahan untuk mengatasi sumber infeksi atau pembedahan yang bersifat resusitatif merupakan langkah berikutnya. Tindakan ini dapat dilakukan secara simultan dengan tindakan awal dengan syarat tindakan awal tetap dijalankan.<o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Selama fase akut diatas tidak dianjurkan memaksakan pemberian nutrisi. Pemberian glukosa dalam jumlah banyak berbahaya oleh karena menyebabkan hiperglikemia. Tahap ini seperti dijelaskan sebelumnya adalah ebb fase. Setelah fase krisis dilalui, biasanya dalam 24-48 jam, pemberian nutrisi sangat penting. Asam amino sangat penting untuk mengatasi kehilangan protein yang banyak bersamaan dengan pemberian glukosa dalam jumlah yang cukup sebagai sumber kalori.<o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Berbagai macam sumber kalori yang lain telah dicoba sebagai pengganti glukosa, tapi glukosa masih merupakan karbohidrat yang terbaik. Kebanyakan pasien cukup diberikan 25-30 Kcal/kgBB/hari, dimana glukosa sebagai non-protein kalori sebanyak 70%-80% dan sisanya dalam bentuk lemak. Penulis lain ada yang berpendapat perbandingan ini maksimal 50:50. Pemberian kalori ini mengurangi katabolisme protein dan penumpukan keton bodies akibat metabolisme lemak. Perhitungan kebutuhan kalori ini harus disesuikan dengan kebutuhan cairan, elektrolit, protein dan lemak. Kebutuhan elektrolit harian yang harus diikutsertakan dalam perhitungan ialah Na<sup>+</sup>: 3 mEq/kgBB/hari dan K<sup>+</sup>: 1-2 mEq/kgBB/hari.<o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Kebutuhan protein dalam proses katabolik adalah sekitar 1,2-2,0 g/kgBB/hari, bila fungsi ginjal baik. Memberikan lebih dari itu tidak akan meningkatkan sintesis protein malahan akan menyebabkan uremia. Rasio non-protein kalori dan nitrogen harus diantara 100:1 dan 150:1 untuk menjamin sintesis protein. Suplemen dengan glutamin, arginin, nukleotida, vit E dan C, zinc dan asam lemak rantai panjang T-3 sangat penting oleh karena dapat mengurangi respons imun yang berlebihan. Bahan suplemen ini disebut juga imunonutrien.<o:p></o:p></span></div><div class="MsoBodyText"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Pilihan utama pemberian nutrisi adalah secara enteral, kecuali: tidak dapat, tidak boleh dan tidak makan atau lewat sonde lambung dapat diberikan secara perenteral. Perlu diingat pemberian secara parenteral yang lama dapat menyebabkan atrofi mukosa usus, translokasi bakteri dan sepsis. Jika secara enteral hanya mampu menampung sebagian dapat diberikan sebagian secara parenteral. Walaupun ada penulis yang menyatakan bahwa puasa kurang dari satu minggu tidak menyebabkan atrofi mukosa usus dan translokasi bakteri, tapi pada umumnya dianjurkan nutrisi enteral dini.<o:p></o:p></span></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText"><b><u><span lang="EN-GB" style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt;">Panduan Umum Nutrisi Parenteral</span></u></b><u><span lang="EN-GB" style="font-size: 14.0pt; mso-bidi-font-size: 12.0pt;"> <o:p></o:p></span></u></div><div class="MsoBodyText"><br />
</div><div class="MsoBodyText" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 14.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Oleh karena adanya kendala tertentu dalam pemberian nutrisi parenteral total, maka dibawah ini dijelaskan secara umum cara pemberian <i>nutrisi parenteral partial</i> yang diberikan melalui <i>vena perifer</i>. Panduan dibawah ini merupakan panduan dasar yang dapat dimodifikasi dan disertai sedikit pengulangan bahasan yang telah dijelaskan diatas.<o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 150%;"><br />
</div><div class="MsoBodyText" style="line-height: 150%;"><b><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Kebutuhan Biologik Normal:<o:p></o:p></span></i></b></div><div class="MsoBodyText2" style="line-height: 150%;"><span lang="EN-GB">Kalori: 25-30 kcal/BB/hari (mis.BB 70 kg = 1750-2100). Sumber kalori ini terbagi berdasarkan sumbernya sebagai berkut:</span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>50% = karbohidrat<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>30% = protein<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>20% = lemak<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><b><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Kebutuhan Karbohidrat</span></i></b><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">: </span></i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">100-200 gram/ hari. Beberapa hal yang perlu diingat tentang manfaat karbohidrat yaitu:<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><br />
</div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Mengurangi katabolisme protein<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Mengurangi penumpukan keton bodies akibat metabolisme fat.<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>1 gram karbohidrat<span style="mso-tab-count: 1;"> </span>= 4,1 kcal<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>1 gram fat<span style="mso-tab-count: 2;"> </span>= 9,3 kcal<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Jika karbohidrat hanya berasal dari cairan dektrose 5% atau 10% maka dalam :<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>1000 cc D5<span style="mso-tab-count: 1;"> </span>= 50 gram<span style="mso-tab-count: 1;"> </span>= 205 kcal<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>1000 cc D10<span style="mso-tab-count: 1;"> </span>= 100 gram<span style="mso-tab-count: 1;"> </span>= 410 kcal<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Dapat dilihat bahwa pemenuhan kalori hanya dari larutan dextrose dengan isoosmolaritas saja tidak cukup, dengan demikian perlu tambahan kalori dari sumber lain misalnya emulsi lemak atau dengan karbohidrat jenis lain atau dengan konsentrasi yang lebih tinggi. Kebutuhan kalori ini perlu juga disesuaikan dengan:<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; margin-left: 36.0pt; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Jumlah kebutuhan cairan harian (maintenance)<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; margin-left: 36.0pt; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Kebutuhan elektrolit terutama Na<sup>+</sup> dan K<sup>+</sup><o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; margin-left: 36.0pt; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Protein dan lemak<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; margin-left: 36.0pt; mso-list: l4 level1 lfo5; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Osmolaritas yang dapat ditoleransi vena perifer yaitu < 800 mOsm.<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Suatu hal yang sangat penting dalam pemberian dekstrose/glukose adalah karbohidrat jenis ini bersifat insulin dependent. Dengen demikian pemberiannya harus dimulai dengan konsentrasi yang rendah dan ditingkatkan secara perlahan dan harus merata dalam 24 jam. Penghentian pemberian dextrose secara mendadak atau tidak teratur dapat menyebabkan kadar gula darah yang turun tiba-tiba. Penjelasan hal ini adalah sebagai berikut; saat pemberian dekstrose konsentrasi tinggi kadar insulin juga tinggi dan saat konsentrasi pemberian diturunkan, insulin yang tinggi <i>(overshoot insulin) </i>dapat menyebabkan hipoglikemia akut. Bila ada ketidakmampuan insulin daat terjadi hiperglikema. R/ Triofusin yang mengandung dextrose, fruktose dan xylitol, jarang menyebabkan hiperglikemia ataupun tambahan insulin.<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><br />
</div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><br />
</div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><br />
</div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><b><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Protein<o:p></o:p></span></i></b></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Pemberian protein untuk menjaga balance nitrogen positif, dimana protein berfungsi untuk regenerasi sel, enzim, dan berbagai reaksi biologis dalam tubuh. Untuk itu diperlukan 1 gram /BB/ hari. Yang paling diperlukan L-asam amino, oleh karena proses pembentukan protein lebih cepat. <i>Perlu diingat larutan asam amino juga mengandung karbohidrat dan elektrolit.</i> Pemberian asam amino/protein saja tanpa diberikan kebutuhan kalori, menyebabkan asam amino dirobah menjadi energi melalui jalur glukoneogenesis. Dengan demikian pada pemberian asam amino yang bertujuan menjaga balance nitrogen positif, perlu ada <i>”perlindungan”<span style="mso-spacerun: yes;"> </span></i>kalori 25 kcal tiap 1 gram asam amino. Misalnya pada pemberian asam amino/protein 50 gram, dibutuhkan 1200 kcal atau 300 gram karbohidrat. Jika asam amino bertujuan sebagai “<i>nitrogen sparing effect”</i> dimana menjaga agar protein viscera atau otot tidak dirobah menjadi kalori, jadi balance nitrogen sama dengan nol, maka tidak perlu diberikan kalori.<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Larutan asam amino pada umumnya bersifat hiperosmotik, oleh karena itu pada pemberian melalui vena perifer perlu dilakukan pengenceran misalnya dengan dekstrose, atau dipilih asam amino dengan konsentrasi rendah. Contoh yang ada dipasaran <i>R/ Aminofusin L-600</i> dimana kandungan tiap 1000 cc sebagai berikut:<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Asam amino<span style="mso-tab-count: 1;"> </span>= 50 gram<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Karbohidrat<span style="mso-tab-count: 1;"> </span>= 100 gram<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Na<sup>+</sup><span style="mso-tab-count: 2;"> </span>= 40 mmol<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>K<sup>+</sup><span style="mso-tab-count: 2;"> </span>= 30 mmol<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Osmolaritas<span style="mso-tab-count: 1;"> </span>= 1.100 mOsm<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">R/<span style="mso-spacerun: yes;"> </span>Pan Amin G</span></i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">:<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Asam amino<span style="mso-tab-count: 1;"> </span>= 27,2 gram<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Karbohidrat<span style="mso-tab-count: 1;"> </span>= 50 gram<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Na<sup>+ </sup>dan K<sup>+</sup><span style="mso-tab-count: 1;"> </span>= tidak ada<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Osmolaritas<span style="mso-tab-count: 1;"> </span>= 507 mOsm<o:p></o:p></span></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><br />
</div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><b><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Fat<o:p></o:p></span></i></b></div><div class="MsoHeader" style="line-height: 150%; tab-stops: 36.0pt; text-align: justify;"><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Misalnya R/Ivelip.</span></i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"> Larutan ini tersedia dalam beberapa kemasan dengan konsentrasi 10% dan 20%. Satu liter larutan 20% mengandung 2000 kcal dengan osmolaritas yang rendah yaitu 270 mOsm. <i>Pada botol 250 cc yang mengandung 50 gram lemak mengandung 500 kcal dengan osmolaritas yang sama</i>. Larutan 20% dengan kemasan 250 cc atau 100 cc lebih disukai oleh karena mudah dalam pengaturannya.<o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 150%;"><b><i><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Cairan Harian<o:p></o:p></span></i></b></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Neonatus:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>= 60-80 cc/BB pada hari I<o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 2;"> </span>= 80-100 cc/BB pada hari II<o:p></o:p></span></div><div class="MsoBodyText" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 2;"> </span>= 100-120 cc/BB pada hari III dst.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Bayi dan anak:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 2;"> </span>=<span style="mso-spacerun: yes;"> </span>< 10 kg<span style="mso-tab-count: 1;"> </span>= 100 cc/BB<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 2;"> </span>=<span style="mso-spacerun: yes;"> </span>10-20 kg<span style="mso-tab-count: 1;"> </span>= 1000 cc + 50 cc/BB-10<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 2;"> </span>=<span style="mso-spacerun: yes;"> </span>> 20 kg<span style="mso-tab-count: 1;"> </span>= 1500 cc + 20 cc/BB-20<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Pada orang dewasa = 2000-3000 cc/hari, atau disesuaikan dengan status penderita.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span><b><i>Elektrolit<o:p></o:p></i></b></span></div><div class="MsoBodyText2" style="line-height: 150%; text-indent: 36.0pt;"><span lang="EN-GB">Jumlah kebutuhan harian elektrolit bervariasi sesuai kepustakaan yang ada.</span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 2;"> </span>= Na<sup>+</sup><span style="mso-tab-count: 1;"> </span>=1-3 mEq/BB/ hari<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 108.0pt; text-align: justify; text-indent: -36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">= K<sup>+</sup><span style="mso-tab-count: 1;"> </span>=1-2 mEq/BB/hari.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify; text-indent: 36.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Ada yang menganjurkan pemberian kalium 30-40 mEq/hari sudah cukup atau 20 mEq tiap 1000 cairan. Kalium tidak diberikan pada 3-5 hari I atau jika produksi urine < 1000/ 24 jam pada penderita BB=70 kg, (atau kurang dari 1 cc/bb/jam untuk ). Dosis maksimum 100 mEq / hari dan diberikan secara drips yang dicampur dengan larutan lain, tidak boleh diberikan secara bolus. Kalium tersedia dalam kemasan 25 cc berisi 25 mEq.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Natrium terdapat pada banyak jenis cairan, dan harus diperhatikan pada tiap kombinasi pemberian nutrisi. Misalnya Ringer Asetat ataupun Ringer Laktat mengandung 130 mEq.<o:p></o:p></span></div><h4 style="line-height: 150%;"><span lang="EN-GB">Saat Pemberian</span></h4><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>Pemberian nutrisi parenteral umumnya dimulai pada hari ke III pasca-bedah/trauma. Jika keadaan membutuhkan koreksi nutrisi cepat, maka pemberian paling cepat 24 jam pasca-trauma/bedah. Jika keadaan ragu-ragu dapat dilakukan pemeriksaan kadar gula. Jika kadar gula darah < 200 mg/dl. pada penderita non diabetik, nutrisi parenteral dapat dimulai.<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Nutrisi parenteral tidak diberikan pada keadaan sebagai berikut:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">24 jam pasca-bedah/trauma<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">gagal napas<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">shock<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">demam tinggi<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 36.0pt; mso-list: l2 level1 lfo4; tab-stops: list 36.0pt; text-align: justify; text-indent: -18.0pt;"><span lang="EN-GB" style="font-family: Symbol; font-size: 13.0pt; line-height: 150%; mso-bidi-font-family: Symbol; mso-bidi-font-size: 12.0pt; mso-fareast-font-family: Symbol;"><span style="mso-list: Ignore;">·<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">brain death (alasan cost-benefit)<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Vena perifer yang dipilih sebaiknya pada lengan, oleh karena pemberian melalui vena tungkai bawah resiko flebitis dan trombosis vena dalam lebih besar. Seperti telah dijelaskan diatas bahwa karbohidrat diperlukan sebagai sumber kalori. Dalam pemenuhan kalori adalah suatu keharusan dan multak ada dekstrose, sehingga mengurangi proses glukoneogenesis. Sebagai sumber kalori lain adalah emulsi lemak. Jika akan diberikan emulsi lemak sebaiknya terbagi sama banyak dalam hal jumlah kalori. Misalnya dibutuhkan jumlah kalori 1200 maka perhitungannya sebagai berikut:<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>600 kcal<span style="mso-tab-count: 1;"> </span>= glukosa 150 gram<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;"><span style="mso-tab-count: 1;"> </span>600 kcal<span style="mso-tab-count: 1;"> </span>= fat 70 gram<o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%; text-align: justify;"><span lang="EN-GB" style="font-size: 13.0pt; line-height: 150%; mso-bidi-font-size: 12.0pt;">Kombinasi ini menghindari keadaan hiperosmolar dan hiperglikemia. Pemberian emulsi lemak harus hati-hati dan sebaiknya diberikan seminggu sekali. Lebih baik jika dilakukan pemeriksaan fungsi hepar secara teratur.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div><div class="MsoNormal" style="line-height: 150%;"><span lang="EN-GB"><br />
<b>Contoh:<o:p></o:p></b></span></div><div class="MsoNormal" style="line-height: 150%; margin-left: 108.0pt; text-indent: -72.0pt;"><b><span lang="EN-GB">Hari I<span style="mso-tab-count: 1;"> </span>: (masa stabilisasi) cukup diberikan kristaloid (RL atau Ringer Asetat)<o:p></o:p></span></b></div><div class="MsoBodyText3" style="line-height: 150%;"><span lang="EN-GB"><span style="mso-tab-count: 1;"> </span>Hari II<span style="mso-tab-count: 1;"> </span>: Triofusin 500 sebanyak 1500 cc + intrafusin 3,5% 500 cc maka:</span></div><div class="MsoNormal" style="line-height: 150%;"><b><span lang="EN-GB"><span style="mso-tab-count: 2;"> </span>Cairan<span style="mso-tab-count: 1;"> </span>: 2000 cc<o:p></o:p></span></b></div><h5 style="line-height: 150%;"><span lang="EN-GB"><span style="mso-tab-count: 2;"> </span>Asam amino<span style="mso-tab-count: 1;"> </span>: 17,5 gram</span></h5><div class="MsoNormal" style="line-height: 150%;"><b><span lang="EN-GB"><span style="mso-tab-count: 2;"> </span>Energi<span style="mso-tab-count: 2;"> </span>: 870 kcal<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 150%;"><b><span lang="EN-GB"><span style="mso-tab-count: 2;"> </span>Na<sup>+</sup><span style="mso-tab-count: 2;"> </span>: 30,8 mEq<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 150%;"><b><span lang="EN-GB"><span style="mso-tab-count: 2;"> </span>K<sup>+</sup><span style="mso-tab-count: 2;"> </span>: 15 mEq<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 150%;"><b><span lang="EN-GB"><span style="mso-tab-count: 2;"> </span>Osmolaritas<span style="mso-tab-count: 1;"> </span>: 745 mOsm<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 150%; margin-left: 108.0pt; text-align: justify;"><b><span lang="EN-GB">Data ini menunjukan kekurangan natrium dan kalium. Untuk itu dapat ditambahkan Kcl 15-20 cc (15-20 mEq) atau sesuai data laboratorium, sedangkan natrium dapat ditambahkan NaCl 3% 200 cc yang mengandung 105 mEq Na<sup>+</sup>. NaCl 3%=513 mEq Na<sup>+</sup>/L<o:p></o:p></span></b></div><div class="MsoNormal" style="line-height: 150%; margin-left: 108.0pt; text-indent: -72.0pt;"><b><span lang="EN-GB">Hari III<span style="mso-tab-count: 1;"> </span>: Triofusin 500 sebanyak 1500 cc + intrafusin 3,5% 1000 cc + Ivelip<span style="mso-spacerun: yes;"> </span>10% 100 cc.<o:p></o:p></span></b></div><div class="MsoBodyText3" style="line-height: 150%;"><span lang="EN-GB">Contoh ini dapat dimodifikasi dengan mudah sesuai kebutuhan. Perlu diingat larutan yang mengandung dektrose harus diberikan terus-menerus. Dengan demikian dapat dipergunakan stop-cock sehingga cairan lain yang daat diberikan selang seling. Ketrampilan kita dalam pemberian nutrisi ini perlu disertai dengan komposisi berbagai jenis cairan yang ada dipasaran termasuk osmolaritasnya.</span></div><div class="MsoBodyText3" style="line-height: 150%;"><span lang="EN-GB"><!--[if gte vml 1]><v:shapetype
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</div><h3><span lang="EN-GB">Kepustakaan</span></h3><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">1.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Daldiyono, Thana A.R., Kapita Selekta Nutrisi Klinik, Perhimpunan Nutrisi Enteral dan Parenteral Indonesia, 1998, hal:.1-20.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">2.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Atmadjaya I.N.K. Endocrine and Metabolic Respons to Trauma, Proyek Trigonum Plus IX, Malang, 6-8 Oktober 2000.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">3.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Wahjuprajitno B, Peran Lemak Pada Sepsis, dalam Simposium “Lipid Emulsion in Ctritically Patient”, Jakarta 19 Pebruari 2000.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">4.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Hill G.L, Disorders of Nutrition and Metabolism in Clinical Surgery, Churchill Livingstone, 1992.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">5.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Konferensi Konsensus, Penggunaan Rasional Emulsi Lipid Di Rumah Sakit, Vivendi Universal Publishing. Medimedia Singapore. 2001. <o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">6.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Simposium: Lipid Emulsion in Critically ill patient, Perhimpunan Dokter Intensive Care Indonesia, Jakarta, 2002.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">7.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Moenadjat, Y, SIRS dan Burn Sepsis, Luka Bakar-Pengtahuan Klinis Praktis. Farmedia.2000.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">8.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Moenadjat,Y , Perubahan Metabolik dan Nutrisi pada Luka Bakar, Luka bakar-Pengetahuan Klinis Praktis, Farmedia.2002.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">9.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Tjokroprawiro H., et al., Nutrisi Perenteral-Simposium Terapi Cairan III RSUD Dr.Sutomo, Surabaya, 1992.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">10.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Evans T.W. and Smithies M., Organ Dysfunction, BMJ 1999;318: 1606-1609 (12 june)<o:p></o:p></span></div><h2 style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-style: normal; font-weight: normal;"><span style="mso-list: Ignore;">11.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-style: normal; font-weight: normal;">Kanji S., Devlin J.W., Pieko K.A., et al., Recombinant Human Activated Protein C, Drotrecogin Alfa (Activated): A Novel Therapy for Severe Sepsis[Pharmacotherapy 21(11):1389-1402, 2001. © 2001 Pharmacotherapy Publications, Inc.]<o:p></o:p></span></h2><h2 style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-style: normal; font-weight: normal;"><span style="mso-list: Ignore;">12.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-style: normal; font-weight: normal;">Edwards J. D, Shoemaker W C, Vincent<span style="mso-spacerun: yes;"> </span>J-L., Oxygen Transport: Principles and Practice- Views and reviews,</span><span lang="EN-GB" style="font-style: normal; font-weight: normal; mso-bidi-font-size: 10.0pt;"> BMJ 1994;308:68 (1 January),</span><span lang="EN-GB" style="font-style: normal; font-weight: normal;"> W B Saunders.<o:p></o:p></span></h2><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">13.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Carr C.S., et al., Randomised trial of safety and efficacy of immediate postoperative enteral feeding in patients undergoing gastrointestinal resection, </span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 10.0pt;">BMJ 1996;312:869-871 (6 April)</span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">14.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Silk D.B.A. and Gow N.M., Postoperative Starvation After Gastrointestinal Surgery. BMJ 2001;323:761-762.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">15.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Holgersen R.B., and Boesby S., Influence Of Postoperative Eneteral Nutrition On Postsurgical Infection, Gut, Vol 39, 833-835, 1996, BMJ Publishing Group.<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">16.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">Windsor A.C.J., et al., Compared with Parenteral Nutrition, Enteral Feeding attenuates The Acute Phase Respons and Improves Disease in acute Pancreatitis, GUT 1998;42:431-435<o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 36.0pt; mso-list: l0 level1 lfo2; tab-stops: list 36.0pt; text-indent: -18.0pt;"><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-list: Ignore;">17.<span style="font: 7.0pt "Times New Roman";"> </span></span></span><strong><span lang="EN-GB" style="font-weight: normal;">Lewis S.J.</span></strong><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">, </span><strong><span lang="EN-GB" style="font-weight: normal;"> Egger M.</span></strong><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">,</span><strong><span lang="EN-GB" style="font-weight: normal;">Sylvester P.A</span></strong><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">, </span><strong><span lang="EN-GB" style="font-weight: normal;">Thomas S.</span></strong><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;">, Early enteral feeding versus "nil by mouth" after gastrointestinal surgery: systematic review and meta-analysis of controlled trials, BMJ </span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 10.0pt;">2001;323:773 ( 6 October )</span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"> </span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 10.0pt;"> </span><span lang="EN-GB" style="font-size: 13.0pt; mso-bidi-font-size: 12.0pt;"><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div><div class="MsoNormal" style="margin-left: 18.0pt;"><br />
</div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com1tag:blogger.com,1999:blog-3399054298585589982.post-21934007925730074492010-08-27T19:06:00.000+09:002010-08-27T19:06:37.281+09:00Si Kinsi lulus FK UNSRAT.....<div class="separator" style="clear: both; text-align: center;"><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnAPUdz-jU7gxLQ-wYJVASIFHNJNGCY9FBfaXzQ2pL2LliKguknt4DeKDG2VyUWH1ajRpctWSu22J4SsLS_6Mdorp54c2j2jX7CASKDff08Dr9PKLzvCwuD5_LIRVs-WBhAXBZ_u5Q2xA/s1600/3.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEhnAPUdz-jU7gxLQ-wYJVASIFHNJNGCY9FBfaXzQ2pL2LliKguknt4DeKDG2VyUWH1ajRpctWSu22J4SsLS_6Mdorp54c2j2jX7CASKDff08Dr9PKLzvCwuD5_LIRVs-WBhAXBZ_u5Q2xA/s320/3.jpg" /></a></div>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-44547252232555005582010-08-27T18:23:00.000+09:002010-08-27T18:23:15.853+09:00Tumor Maksilofascial at Abepura General Hospital<a href="http://goo.gl/photos/zBt2" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: 1em;"><img src="http://lh3.ggpht.com/_FW6K1790qHE/THdLphHG1IE/AAAAAAAAAHo/EMW7BgI_coY/s160-c/DropBox.jpg" border="0" /></a>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-65909984941962799632010-08-27T16:42:00.002+09:002010-08-27T17:51:53.751+09:00Tumor Maksilofascial at Abepura General Hospital<a href="http://goo.gl/photos/BmuG" imageanchor="1" style="clear: right; margin-bottom: 1em; margin-left: 1em;"><img border="0" src="http://lh5.ggpht.com/_FW6K1790qHE/THdL-sHPDgI/AAAAAAAAAFI/0CYZMuKTsrk/s512/Picture%20051.jpg" /></a>Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-590033720355749992010-08-26T15:49:00.000+09:002010-08-26T15:49:36.307+09:00Honey-Based Dressings and Wound Care: An Option for Care in the United StatesHoney-Based Dressings and Wound Care: An Option for Care in the United States <br />
Barbara Pieper Journal of Wound, Ostomy and Continence Nursing<br />
January/February 2009 <br />
Volume 36 Number 1 <br />
Pages 60 - 66 <br />
<br />
<br />
<br />
<br />
<br />
Abstract<br />
Honey-based wound dressings have been used worldwide since ancient times. A honey product received US Federal Drug Administration approval in 2007, making this dressing an option for wound care. Honey has been found to exert anti-inflammatory and antibacterial effects without antibiotic resistance, promote moist wound healing, and facilitate debridement. However, it may cause a stinging pain. As is true of any wound dressing, its use must be carefully selected and monitored. Continued research is needed to add to its evidence base. This article provides a summary of the current evidence base for the use of honey and a review of its therapeutic effects and discusses implications for WOC nursing practice.<br />
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Introduction<br />
Referenced in ancient medical writings of Egypt, Greece, and parts of India, honey is considered to be the oldest wound dressing.1,2 In 2007, the US Food and Drug Administration gave clearance to market a honey-based wound dressing product (Medihoney, Derma Sciences, Toronto, Ontario, Canada).3 The product uses active Manuka honey (Leptospermum scoparium), derived from tea plants, and Leptospermum polygalifolium, known as the jelly bush.4 Manuka is the name of the floral source of the honey L scoparium.1 This article summarizes the current evidence base for the use of honey, its therapeutic effects, and implications for WOC nursing practice.<br />
Composition of Honey<br />
Honey consists of multiple components derived from plants and bees during the maturation processes. It is a product obtained from bees of the genera Apis and Meliponinae.5 Bees collect nectar from flowers; nectar has a sugar content ranging from 5% to 60%. The resulting compound is composed of sucrose, glucose, and fructose.6 Nectar is processed by bees and deposited in the wax cells of the hive. The water content of honey is reduced to 17% by evaporation from the warmth of the hive and fanning of bees. The bees also add enzymes to the honey including invertase (which converts sucrose into glucose and fructose) and glucose oxidase (which oxidizes glucose and produces gluconic acid). Production of gluconic acid lowers honey's pH and contributes to hydrogen peroxide production.6 The resulting compound is converted to glucose and fructose, and the glucose is converted to gluconic acid and hydrogen peroxide by glucose oxidase. Culinary honeys undergo heat treatment, which destroys the enzyme responsible for producing hydrogen peroxide. In contrast, honey used for wound care does not undergo heat treatment. Instead, it is sterilized by [gamma]-radiation, thus retaining its biologic activity.1 The resulting honey is a supersaturated solution whose pH ranges from 3.2 to 4.2.1,6<br />
Therapeutic Effects of Honey Dressings<br />
WOC nurses should be knowledgeable of the therapeutic effects of a dressing when selecting it for wound care. This section reviews the anti-inflammatory and antimicrobial effects of honey, its ability to support moist wound healing, debride the wound bed, and control odor, and its effects on scar formation.<br />
Anti-inflammatory Effects<br />
Excessive inflammation can prevent healing or cause further tissue damage by increasing reactive oxygen species or free radicals.2 Honey has been shown to reduce both acute and chronic inflammation.7 Although the mechanism for the anti-inflammatory action of honey is not entirely understood,1 multiple effects have been reported. For example, histological studies of biopsy specimens show a reduced number of inflammatory cells when exposed to honey.2,8 Honey has also been shown to modulate the activity of immunocompetent cells such as monocytes in the wound.1 In addition, honey may stimulate peripheral blood B and T lymphocytes in cell culture and activate phagocytes from the blood.2,8 Honey has been reported to stimulate monocytes in cell culture to release cytokines tumor necrosis factor-1, interleukin (IL)-1, and IL-6, which act as intermediates in the immune response.2 Honey also supplies glucose that is critical for the “respiratory burst” in macrophages needed to generate hydrogen peroxide, and it provides substrates for glycolysis for energy production in macrophages.2<br />
The potential benefits of honey's anti-inflammatory effect include alleviation of the pain associated with inflammation. A reduction in edema provides other positive effects. The pressure from edema restricts the blood flow of oxygen and nutrients, which leukocytes need to fight infection and fibroblasts need for connective tissue synthesis.2,8 Thus, reducing edema not only alleviates associated pain but also improves microcirculation and increases the availability of dissolved oxygen and nutrients needed for tissue repair and regeneration.<br />
The anti-inflammatory effects of honey reduce hypertrophic scarring during the maturation phase of wound healing.2 The free radicals formed when excessive or prolonged inflammation is present stimulate the fibroblasts that produce the collagen fibers of a scar. The anti-inflammatory effects of honey reduce formation of reactive oxygen species, thus decreasing the fibroblast and collagen production needed to create a hypertrophic scar.<br />
Antibacterial Effects<br />
Honey has a broad spectrum of bactericidal and bacteriostatic activities.1,2 Although the antibacterial effects of honey have long been known,2 there is currently increased interest in these properties, partly due to the emergence of antibiotic-resistant strains of microorganisms. Medical honey has not been observed to foster bacterial resistance.9,10 Instead, honey is hypothesized to inhibit bacterial growth primarily due to its high osmolarity.2,10,11 However, some researchers contend that this effect is lost once the wound drainage dilutes the honey. Other factors thought to contribute to the antibacterial effects of honey are the phytochemicals in the nectar collected by the bees. This has been demonstrated for honey from the Leptospermum species from Australia and New Zealand. The antibacterial activity of honey may vary as many as 100-fold based on the type of honey and how it was processed.2,10 Producers have a registered trademark (UMF—Unique Manuka Factor) to measure the antibacterial potency of honey.12 The higher the number, the more potent the honey's antibacterial activity. The highest rating is 18.12<br />
Other antibacterial effects of honey are associated with its acidic pH (range, 3.2–4.5), which may prevent biofilm formation and cross-contamination.4 Honey's ability to prevent cross-contamination is linked to its high osmolarity; it draws fluids into the wound, resulting in a viscous solution that provides a protective barrier against cross-infection.1<br />
Hydrogen peroxide, produced in honey by the enzyme glucose oxidase, is an important source of honey's antibacterial activity.13 The amount of hydrogen peroxide in a wound varies over time, based on rates of production, destruction, and dilution by exudate. The hydrogen peroxide produced by honey is not cytotoxic. The amount produced is 1,000 times lower than a hydrogen peroxide 3% solution rinse.1,2,7 This low concentration of hydrogen peroxide may act as a “messenger” in promoting healing, and it may stimulate both fibroblasts and epithelial cells.1<br />
Research has shown that honey exerts antibacterial activity against clinical isolates of Staphylococcus aureus, methicillin-resistant S aureus, vancomycin-resistant enterococci, [beta]-hemolytic streptococci, and vancomycin-sensitive enterococci.2,9–11,14,15 Examples of microorganisms that honey may inhibit are given in Table 1. Lusby and colleagues 16 reported that only Serratia marcescens and Candida albicans were not inhibited by honey. However, as noted earlier, the precise mechanisms that account for these antimicrobial effects are not entirely understood. It is known that honey's antibacterial activity acts much more slowly than traditional antiseptics that decrease bacterial counts within minutes.9 Honey also differs from other antiseptics because it retains its bactericidal activity in vitro even after dilution.11,14,15 Researchers are seeking to more clearly understand honey's antimicrobial activity because it persists irrespective of bacterial resistance to antibiotics. The clinical relevance of this is apparent as clinicians continue to grapple with the growing problem of antimicrobial resistance.<br />
<br />
________________________________________<br />
TABLE 1. Examples of Microorganisms Against Which Honey Is Effectivea <br />
________________________________________<br />
Gethin 17 examined bacteriologic findings associated with the use of Manuka honey. She noted (1) a small number of clinical trials but a multitude of case reports and observational reports, (2) a lack of research rigor, and (3) a paucity of trials on the use of topical honey in wound management of people with diabetes. Based on this review, Gethin concluded that honey may help reduce bacterial burden, but its floral source should be specified in all studies because it profoundly influences honey's effectiveness as an antibacterial agent.<br />
Debridement Properties<br />
Honey may facilitate wound debridement through several mechanisms. It enables the autolytic action of tissue proteases.2 Because of its strong osmotic action, honey pulls lymph fluid from the wound tissues to add moisture needed for autolytic debridement. The osmotic action washes the wound base from beneath, removing debris and painlessly lifting off slough and necrotic tissue.2,8 The production of hydrogen peroxide may also contribute to debridement.1 Matrix metalloproteases of connective tissue and neutrophil serine proteases may be activated by hydrogen peroxide.2 Although high protease activity is strongly associated with impaired wound healing, this has not been shown to be the case with honey, possibly because the anti-inflammatory effect of honey tempers this situation.2 Honey may provide a more comfortable and cost-effective method of debridement than mechanical or surgical excision.2<br />
Odor Control Properties<br />
Decreased wound odor has been reported when honey dressings were used to treat abscesses, diabetic foot ulcers, leg ulcers, and fungating wounds.1 Honey reduces wound odor via 2 mechanisms. First, malodor is attributed to the presence of anaerobic bacteria such as Bacteroides spp, Peptostreptococcus spp, and Prevotella spp. Honey exerts antibacterial action in vivo and in vitro against these anaerobes, reducing their presence in the wound bed and subsequent ability to produce odor. Second, honey provides glucose as an alternative to the amino acids created when serum and dead cells are metabolized by bacteria.18 As a result, lactic acid is produced as compared to the malodorous ammonia, amines, and sulfur compounds typically formed by the metabolism of amino acids from decomposed serum and tissue proteins when honey is not present.1,2,8,18<br />
Wound Healing Effects<br />
Honey has been reported to promote wound healing through several mechanisms. It promotes a moist wound environment by drawing lymph into the wound through osmosis and preventing the dressing from adhering to the wound bed.18 In addition, the levulose and fructose contained in honey may improve local nutrition and promote epithelialization.1,2 The acidic nature of honey provides an optimal environment for fibroblast activity.1 Molan 2 noted that honey (1) stimulates angiogenesis, thus increasing oxygen and nutrients to the wound and promoting healthy granulation tissue; (2) hastens epithelialization, possibly decreasing the need of skin grafting; and (3) stimulates collagen synthesis and improves tensile strength.<br />
Honey's effect on wound healing has been examined with various wound types (Table 2). Gunes and Eser 18 completed a randomized clinical trial comparing honey dressing (n = 15) versus an ethoxy-diaminoacridine plus nitrofurazone dressing (n = 11) on pressure ulcer healing. The investigators were not blinded to treatment group. Wounds were traced and evaluated with the Pressure Ulcer Scale for Healing tool. Both groups had decreased scores over the course of the study, but the honey group had 4 times the rate of healing of the control group.<br />
<br />
________________________________________<br />
TABLE 2. Types of Wounds for Which Honey Dressings Have Been Useda <br />
________________________________________<br />
Gethin and Cowman 19 examined healing of leg ulcers with Manuka honey in an 8-patient case series. Mean reduction in wound area across all wounds was 54.8% over the 4-week period. This improvement, in part, might have been attributable to renewed interest and compliance in wound care. Dunford and Hanano 20 examined the effects of honey for the treatment of venous leg ulcers that had not healed after 12 weeks of compression therapy. This prospective, nonrandomized study reported on 40 patients from 4 centers. Thirteen patients (32.5%) dropped from the study primarily because of an increased stinging ulcer pain (n = 6, 15%), deterioration in health (n = 3), and deterioration in the ulcer condition (n = 2). Overall, pain levels decreased in 50% of participants, wound odor decreased in 24 patients, wound area decreased significantly, and 7 ulcers healed.<br />
Ahmed and colleagues 21 examined the use of honey dressings with 21 patients with chronic wounds, 23 with complicated surgical wounds, and 16 with acute traumatic wounds. Treatment lasted for 1 to 28 weeks; all wounds had failed previous treatments. All but one patient (who dropped due to pain) completed the study, and 57 of 59 patients (96.6%) achieved healing of their wounds. During treatment, they noted decreased edema and wound exudate, enhanced debridement, decreased odor, and advanced epithelialization. No allergic reactions occurred. Stephen-Haynes 22 evaluated a Manuka-impregnated dressing on 20 patients with nonhealing wounds. She reported that the honey dressing was easy to apply (65%), was easy to remove (75%), stayed in place (85%), improved the wound bed (80%), and was comfortable (65%).<br />
Honey has been used on damaged skin associated with radiation therapy for cancer. Moolenaar and colleagues 23 initiated a prospective randomized controlled study in Caucasian women who received radiotherapy to the breast or the thoracic wall and developed grade 3 radiation-induced dermatitis. In 21 women, 24 skin reactions were evaluated: 12 were treated with a honey dressing and 12 with paraffin dressings. No statistically significant difference in time to healing and closure was found when treatments were compared. However, subjects managed with the honey dressing had a trend toward less pain, itching, and irritation. Neither treatment resulted in relevant side effects.<br />
Topical honey has also been examined in the management of radiation-induced mucositis for head and neck cancers.24 Twenty patients received the radiation therapy alone and 20 received 20 mL of pure honey applied to the mucosa 15 minutes pretreatment, 15 minutes posttreatment, and 6 hours postradiation therapy. The honey-treated patients had a significant reduction in symptomatic grade 3/4 mucositis and had either no change or a positive change in body weight.<br />
Subrahmanyam 25 randomly assigned 50 burn patients to early tangential excision and skin grafting (n = 25) versus honey treatment (n = 25). The honey-treated group had less blood volume replaced. After 3 months, the graft group had significantly better functional and cosmetic results than the honey-treated group. In fact, 3 of the honey-treated patients had significant contractures. The authors concluded that early tangential excision and skin grafting was superior to topical honey treatment.25<br />
Misirlioglu and colleagues 26 compared honey- impregnated gauze with 3 other dressings (hydrocolloid, paraffin gauze, and saline-soaked gauze) on split-thickness, skin-graft donor sites. Eighty-eight patients' grafts were treated half with the honey-based dressing and half with 1 of the other 3 dressings. The honey-treated sites showed a faster epithelialization time and lower pain compared to the paraffin and saline-soaked dressings. However, these differences did not persist when the honey dressing was compared to the hydrocolloid dressing. They concluded that the honey dressing was safe and could be an alternative dressing for split-thickness, skin-graft donor sites.26<br />
Systematic Reviews of Wound Healing<br />
The results of 3 systematic reviews illustrate existing evidence pertaining to the effectiveness of honey dressings in chronic wound healing. Fox 27 searched 5 databases, literature from companies, and the Internet. She identified 6 studies that examined the use of honey in wound management for adults with chronic wounds. None were randomized controlled trials or comparative studies of honey treatment versus usual treatment. All were found to have major design flaws. Despite this paucity of research-based evidence, 5 of the 6 articles described honey as a superior treatment option, thus creating a dilemma for clinicians who are questioned by patients about the use of a honey dressing. Fox 27 concluded that there is a paucity of high-quality literature related to the use of topical honey in adults with chronic wounds and recommended caution in the use of honey-based dressings. Moore and colleagues 28 reported a systematic review of 7 nonblinded, randomized controlled trials that used honey as a wound dressing for superficial burns (n = 6) and infected postoperative wounds (n = 1). All of the studies compared honey to other active therapies, but the alternative interventions included atypical treatments such as potato peelings and amniotic membrane. The main outcomes of the studies were healing time and infection rate. In all of the studies, honey was associated with a shorter healing time, eradication of infection, decreased use of antibiotics, and decreased hospitalization. Nevertheless, since 6 of the studies were done by the same researcher, Moore and colleagues 28 suggest caution when interpreting these findings. In contrast, Molan 29 analyzed research from 17 randomized controlled trials with 1,965 participants, 5 clinical trials involving 95 participants, and 16 trials on 533 wounds on experimental animals. He concluded that honey could promote wound healing when other dressings have failed.29 He also noted that trials examining the efficacy of honey dressings were rarely blinded because the odor of honey is easily recognizable to both investigators and subjects.<br />
Scar Formation<br />
Topham 30 reported scarless healing when honey was used in some cavity wounds. He suggested 3 potential mechanisms resulting in this outcome: (1) saccharides at the wound surface may encourage the production of hyaluronic acid from glucose, which simultaneously suppresses the formation of fiber-forming collagens; (2) glucose at the wound bed creates an environment that enables wound-healing proteoglycans to exert their effects without producing excessive quantities of collagens; and (3) the mechanism by which sugar attaches to collagen may change its structure.<br />
Use of Honey in Children<br />
Honey dressings have also been used in children. Simon and colleagues 31 described 16 wound care situations in 14 patients with impaired wound healing due to the toxicity of chemotherapy and radiation therapy, persistent or intermittent immunosuppression, malnutrition from nausea, vomiting, or mucositis, or infection. Honey was found to be a nonadherent dressing. One child experienced local pain, resulting in discontinuation of the honey dressings. Although measurement methods were not presented, the authors reported a high acceptance by patients and their families that positively impacted patient satisfaction. Vardi and coworkers 32 described 9 neonates who had undergone major operations and presented with chronic open wounds that failed to heal with conventional treatment after 14 days. The conventional treatment included systemic antibiotics, cleaning the wound twice daily, and applying an ointment. Swab cultures were taken daily. Conventional treatment failure was defined as after 14 days of systemic antibiotics and local treatment, the wound was still open, oozing pus, and swab cultures were positive. The honey-based dressing resulted in improved wound healing in all neonates after 5 days of treatment, and all of the wounds closed within 21 days. Systemic adverse events (ie, hyperglycemia, electrolyte imbalance, or significant irritation of surrounding tissue) did not occur. Okeniyi and colleagues 33 examined healing of 43 incised pyomyositis abscess wounds with honey in 32 Nigerian children. The most common cause of this infection was S aureus, which was attributed to the hot and humid tropical climate, poor hygiene, and malnutrition. All children received antibiotics, but the hospital length of stay was shorter and wounds healed faster in the honey-treated group. No wound required secondary wound closure and no side effects were seen in either group.<br />
Bell 6 reviewed the literature from 1996 to 2006 and 2 studies using honey for treating wounds or skin damage in children. One study evaluated the use of honey for treatment of wound infections in neonates 32 and the other reported honey for treatment of diaper dermatitis. The second study that Bell summarized combined honey with beeswax and olive oil in the treatment of 12 infants with incontinence-associated dermatitis. A swab culture for C albicans was taken before therapy and at the end of treatment. Rash severity was rated on a 5-point scale. The honey mixture was applied to the affected areas 4 times per day for a maximum of 7 days. By day 7, 10 of the 12 infants had mild or no incontinence-associated dermatitis. Based on these studies, Bell 6 concluded that the evidence of using honey was interesting, but evidence supporting its use in infants and neonates is weak and recommended that randomized controlled clinical trials with sufficient power should be completed to provide more definitive data. Weaknesses in the available evidence included variability in honey preparations, small sample sizes in the 2 studies identified, and absence of cultures for subjects in the dermatitis study.<br />
Although microbes cannot grow in honey, Clostridium botulinum spores are a theoretical concern in raw products meant for infants. Specifically, the gastric environment in infants is less acidic, and it may provide less effective protection against Clostridium spores than the gastric lumen of an adult. Nevertheless, C botulinum has not been reported yet with honey dressings.6<br />
Clinical Considerations<br />
WOC nurses should make decisions about the use of honey dressings based on current best evidence and research-based knowledge of principles of topical wound care (Table 3). This process begins with an assessment of wound type. White 8 identified the use of honey for (1) chronic wounds such as leg ulcers and pressure ulcers, (2) wounds with delayed healing and local infection, (3) acute wounds such as burns and locally infected wounds without cellulitis, and (4) wound bed preparation for grafting. Honey also may be used as a compassionate treatment option for patients whose care has failed other treatments.9<br />
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TABLE 3. Considerations for Honey-Based Dressingsa <br />
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The type of honey dressing product should match the wound type. Honey gel/ointment may be applied directly to the wound or an appropriate dressing placed on the wound. The gel/ointment is covered with an occlusive dressing so as to maintain a moist environment to keep the preparation from drying out on the wound bed.8 A practical challenge associated with the use of a liquid/gel honey application is ensuring that it remains in place on vertical wounds such as leg ulcers or abdominal wounds.9,34 If the honey-based product is not available in this format, soaking an alginate dressing with honey and covering with a gauze layer followed by a transparent dressing may help maintain contact with the wound. The alginate honey dressing is especially attractive because it has been found to be malleable, easy to apply, nonadherent to the wound base, and less painful on removal.12<br />
The frequency of dressing change needs to be based on the amount of drainage. If the outer dressing becomes moist with exudate, it must be removed to prevent contamination and maceration of periwound skin. As the drainage decreases, the dressing can be left on for longer periods (4–7 days), thus decreasing the frequency of dressing changes.12 Strike-through of the honey dressing should be avoided because it leaves a sticky residue on affected surfaces.34 A heavy flow of drainage that washes honey to the outer surface may also allow the dressing to stick to the wound, necessitating more frequent dressing changes.35 If a nonadherent dressing is used on the wound base, it should be sufficiently porous to allow components of the honey to diffuse to the wound.35<br />
Relative and absolute contraindications for using a honey dressing also must be considered. These include the following: (1) using a honey product that is not indicated for wound care; (2) sensitivity to bee venom/stings or honey; (3) dry, necrotic wounds; (4) dressings that cannot be changed within a specific time; (5) wounds requiring surgical debridement; and (6) following incision and drainage of an abscess.31,36 Although Stephen-Haynes 22 noted that dressings made from animal products have the potential to provoke an immune reaction, Simon and colleagues 31 observed that no reports of anaphylaxis have ever been associated with the use of honey products for wound care. In addition, since honey is a potential source of glucose absorption, patients with diabetes may be at a slightly greater risk of hyperglycemia.22<br />
Although honey has antibacterial properties, systemic antibiotics may still be needed. For example, this is true of oncology patients with profound neutropenia 31 and any situation in which there is invasive infection, including those with cellulitis.<br />
Some patients experience pain associated with the use of honey dressings. Transient stinging reported as pain may occur for around an hour after its application.8 Blaser and associates 9 reported that 1 of 7 patients stopped treatment due to severe pain, but the pain in this case was later found to be related to opioid resistance. The cause of the transient pain often seen with the use of honey dressings is not fully understood, but it may be related to its osmotic effect (ie, drawing fluid from the wound) or its acidic pH.9 Honey-associated wound pain can be treated with an analgesic or a more dilute honey preparation.8 In some patients, the use of a gel preparation that contains wax ester and ethoxylated oil has been found effective.9<br />
As with any topical therapy, the WOC nurse must assess the effectiveness of a honey-based dressing. Anderson 36 identified key questions to be used when assessing outcomes of a honey dressing:<br />
1. Is there a reduction in redness and swelling in terms of inflammation indicating positive changes in the wound? Has the infection resolved?<br />
2. What is the person's pain description? Has it increased or decreased with the honey dressing? Is it pain the person is willing to tolerate with the dressing?<br />
3. What is the condition of the surrounding skin and is it improving?<br />
4. Is the number of dressing changes decreasing over time? (If dressing frequency is not decreasing, the honey may not be effective due to the amount of drainage and the amount of honey may need to be increased.)<br />
5. Is there a reduction in necrotic tissue?<br />
6. What are the patient's and the clinician's rating of wound odor and is it decreasing?<br />
7. Considering the wound and other dressings, is it cost-effective?<br />
Summary<br />
Honey dressing products have been used worldwide for many years, and a honey-based dressing is not available in the United States. A review of existing research reveals increasing evidence regarding the efficacy of honey-based products for healing selected chronic wounds. Honey has been used with adults and children and on acute and chronic wounds. It exerts an antibacterial effect without the risk of antibiotic resistance. Some patients report pain reduction, but stinging or increased pain has also been reported. As with any wound care treatment, prospective randomized controlled studies are needed to provide a more robust and informative evidence base concerning its use in wound care.<br />
ACKNOWLEDGMENT<br />
The authors have no significant interest, financial or otherwise, in any company that might have an interest in the publication of this educational activity.<br />
KEY POINTS<br />
[check mark] Honey wound care products have a long historical use worldwide and have been recently approved by the Food and Drug Administration in the United States.<br />
[check mark] Honey-based dressings should be considered with other wound dressings in patient care decisions. WOC nurses should be aware of recommendations for not using these products such as an allergy to honey or bee products.<br />
[check mark] Honey dressings have anti-inflammatory and antibacterial effects. They promote moist wound healing and facilitate debridement. They may cause a stinging pain in some patients.<br />
[check mark] Only honey products approved for wound care should be used.<br />
[check mark] Clinician/patient/family teaching on the proper use of this product is critical.<br />
[check mark] Evaluation of the outcomes of a honey-based dressing should be done as it is done for other dressings.Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com3tag:blogger.com,1999:blog-3399054298585589982.post-79250349949310191962010-08-26T13:54:00.001+09:002010-08-26T13:54:56.090+09:00Manajemen Luka<u><b>Manajemen Luka</b></u><br />
Dr. Theo Rompas<br />
Bagian Bedah Rumah Sakit Dian Harapan <br />
Abepura-Jayapura<br />
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Pendahuluan<br />
Kehidupan manusia normal dibatasi pada rentang fungsi yang terbatas. Tubuh akan beradaptasi (menyesuaikan diri) secara fisiologis maupun morfologis apabila terjadi beban fisiologis maupun stimulus (rangsangan) patologis. Jika batas adaptasi ini terlampaui maka dapat terjadi perlukaan (cedera). Pada tingkat tertentu dapat terjadi pemulihan sampai normal atau mendekati normal. Namun , bila stimulusnya berat akan terjadi kerusakan irreversible. Misalnya pada rangsangan panas, mulai dari sengatan matahari, siraman air panas (luka bakar ketebalan sebagian), ataupun luka bakar berat sampai terjadi karbonisasi (seluruh kulit, bahkan lemak dan otot ikut terbakar).<br />
Definisi luka adalah hilangnya atau rusaknya sebagian jaringan tubuh. Keadaan ini dapat dapat diakibatkan trauma benda tajam atau tumpul, perubahan suhu, listrik maupun kimiawi. Berdasarkan penyebab tersebut beserta mekanismenya dapat terjadi luka tertutup maupun luka terbuka seperti luka lecet, memar, luka robek, luka iris, luka tusuk, luka bakar maupun luka kombinasi.<br />
Proses penyembuhan luka ini telah dijelaskan pada berbagai catatan sejarah. Pada saat itu telah dipahami benar bahwa setiap benda asing dan jaringan mati harus dikeluarkan dari luka, pembersihan luka dapat mencegah infeksi dan pus terlokulisasi (menumpuk) harus dialirkan (drainage). Larutan-larutan khusus seperti madu telah dikenal dapat mengurangi proses pernanahan pada luka. Sedangkan pada luka-luka primer dijahit dengan mempergunakan rambut ataupun rahang dari serangga. Pada abad XVI Pare (ahli bedah Prancis) memperhatikan bagaimana kerusakan jaringan sebagai akibat tindakan para dokter pada jaman itu, misalnya aplikasi minyak ternyata menghambat proses penyembuhan luka, bahkan dapat menyebabkan sepsis. Pernyataannya yang sangat terkenal dan tetap dingat setiap dokter saat ini adalah, “do not put anything in a wound you would not put in your own eyes”. Pada perkembangan selanjutnya, seperti pemahaman tentang bakteri dan tindakan-tindakan atraumatik pada luka dapat mengurangi kejadian sepsis maupun kematian. Saat ini tindakan asepsis, penggunaan antiseptik dan antimikroba merupakan era baru dalam perawatan luka<br />
Pada awal abad XX, kontrol nyeri, pengertian tentang pemberian cairan infus dan cairan pengganti darah lainnya dan penggunaan antibiotika merupakan kontributor utama dalam perawatan luka, saat itu proses penyembuhan yang abnormal belum mendapat perhatian. Kini dengan makin dipahami mekanisme biologi perbaikan jaringan (tissue repair) sampai tingkat biokimia dan molekular, kembali terjadi perobahan dalam konsep perawatan luka. Bahkan dengan adanya observasi pada beberapa mamalia bahwa proses penyembuhan luka bukan sekedar penyembuhan/perbaikan (repair) tapi suatu “regeneration”, suatu penyembuhan luka tanpa bekas scar atau fibrosis. Saat ini sementara berkembang penelitian-penelitian dan usaha bagaimana proses penyembuhan luka pada manusia bersifat regenerasi (“Fetal Wound Repair”)<br />
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Klasifikasi Luka<br />
Luka dapat diklasifikasi dalam dua kategori utama: akut dan kronis. Luka akut adalah luka dimana proses reparasi (repair) tahapan “normal” dengan hasil penyembuhan tetap mempertahankan fungsi maupun anatomis. Biasanya luka jenis ini terjadi pada orang yang kondisi kesehatan baik, dimana luka dapat ditutup primer atau ditutup primer tertunda. Luka kronis adalah luka yang gagal sembuh sesuai waktunya, dimana hasil penyembuhannya disertai kehilangan fungsi maupun gangguan anatomis. Biasanya pada pasien-pasien dengan penyakit kronis seperti diabetik ulcer, venous statis ulcer dan pressure ulcer.<br />
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Fase Penyembuhan Luka<br />
Sejak adanya perlukaan/trauma, proses penyembuhan luka telah dimulai berupa proses peradangan (inflamasi), pertumbuhan (proliferasi) dan pembentukan kembali (remodelling). Pemahaman tahapan mekanisme proses penyembuhan ini sangat erat dengan tindakan terapi yang dibuat maupun berbagai variasi penutupan luka.<br />
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Fase inflamasi<br />
Fase inflamasi berlangsung sejak terjadinya luka sampai kira-kira hari kelima. Pembuluh darah yang terputus pada luka akan menyebabkan pendarahan dan tubuh akan berusaha menghentikannya dengan vasokon-striksi, pengerutan ujung pembuluh yang putus (retraksi), dan reaksi hemostasis. Hemostasis terjadi karena trombosit yang keluar dari pembuluh darah saling melengket, dan bersama jala fibrin yang terbentuk, membekukan darah yang keluar dari pembuluh darah. Sementara itu, terjadi reaksi inflamasi.<br />
Sel mast dalam jaringan ikat menghasilkan serotonin dan histamine yang meningkatkan permeabilitas kapiler sehingga terjadi eksudasi, penyebukan sel radang, disertai vasodilatasi setempat yang menyebabkan udem dan pembengkakan. Tanda dan gejala klinis reaksi radang menjadi jelas yang berupa warna kemerahan karena kapiler melebar (rubor), rasa hangat (kalor), nyeri (dolor), dan pembengkakan (tumor).<br />
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Aktivitas seluler yang terjadi adalah pergerakan leukosit menembus dinding pembuluh darah (diapedesis) menuju luka karena daya kemotaksis. Leukosit mengeluarkan enzim hidrolitik yang membantu mencerna bakteri dan kotoran luka. Limfosit yang monosit yang kemudian muncul ikut menghancurkan dan memakan kotoran luka dan bakteri. Fase ini disebut juga fase lamban karena reaksi pembentukan kolagen baru sedikit dan luka hanya dipertautkan oleh fibrin yang amat lemah.<br />
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Fase Proliferasi<br />
Fase proliferasi disebut juga fase fibroplasia karena yang menonjol adalah proses proliferasi fibroblast. Fase ini berlangsung dari akhir fase inflamasi sampai kira-kira akhir minggu ketiga. Fibroblast berasal dari sel mesenkim yang belum berdiferensiasi, menghasilkan mukopolisakarida, asam aminogisin, dan prolin yang merupakan bahan dasar kolagen serat yang akan mempertautkan tepi luka.<br />
Pada fase ini, serat-serat dibentuk dan dihancurkan kembali untuk penyesuaian diri dari tegangan pada luka yang cenderung mengerut. Sifat ini, bersama dengan sifat kontraktil miofibroblast, menyebabkan tarikan pada tepi luka. Pada akhir fase ini, kekuatan regangan luka mencapai 25% jaringan normal. Nantinya, dalam proses penyudahan, kekuatan serat kolagen bertambah karena ikatan intramolekul dan antarmolekul.<br />
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Pada fase fiboplasia ini, luka dipenuhi sel radang, fibroblast, dan kolagen, membentuk jaringan berwarna kemerahan dengan permukaan yang berbenjol halus yang disebut jaringan granulasi. Epitel tepi luka yang terdiri atas sel basal terlepas dari dasarnya dan berpindah mengisi permukaan luka. Tempatnya kemudian diisi oleh sel baru yang terbentuk dari proses mitosis. Proses migrasi hanya terjadi ke arah yang lebih rendah atau datar. Proses ini baru berhenti setelah epitel saling menyentuh dan menutup seluruh permukaan luka. Dengan tertutupnya permukaan luka, proses fibroplasia dengan pembentukan jaringan graanulasi juga akan berhenti dan mulailah proses pematangan dalam fase penyudahan (remodeling).<br />
Fase penyudahan (remodeling)<br />
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Pada fase ini terjadi proses pematangan yang terdiri atas penyerapan kembali jaringan yang berlebih, pengerutan sesuai dangan gaya gravitasi, dan akhirnya perupaan kembali jaringan yang baru terbentuk. Fase ini dapat berlangsung berbulan-bulan dan dinyatakan berakhir kalau semua tanda radang sudah lenyap. Tubuh berusaha menormalkan kembali semua yang menjadi abnormal karena proses penyembuhan. Udem dan sel radang diserap, sel muda menjadi matang, kapiler baru menutup dan diserap kembali, kolagen yang berlebih diserap dan sisanya mengerut sesuai dengan regangan yang ada.<br />
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Selama proses ini dihasilkan jaringan parut yang pucat, tipis, dan lemas, serta mudah digerakkan dari dasar. Terlihat pengerutan maksimal pada luka. Pada akhir fase ini, perupaaan luka kulit mampu menahan regangan kira-kira 80% kemampuan kulit normal. Hal ini tercapai kira-kira 3/6 bulan setelah penyembuhan. Perupaan luka tulang (patah tulang) memerlukan waktu satu tahun atau lebih untuk membentuk jaringan yang normal secara histology atau secara bentuk.<br />
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Tipe Penutupan Luka<br />
Penyembuhan luka kulit tanpa pertolongan dari luar seperti yang telah diterangkan tadi, berjalan secara alami.luka akan terisi jaringan granulasi dan kemudian ditutup jaringan epitel. Penyembuhan ini disebut penyembuhan sekunder atau sanatio per secundam intentionem. Cara ini biasanya makan waktu cukup lama dan meninggalkan parut yang kurang baik, terutama kalau lukanya menganga lebar.<br />
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Jenis penyembuhan yang lain adalah penyembuhan primer atau sanatio per primam intentionem, yang terjadi bila luka segera diusahakan bertaut, biasanya dengan bantuan jahitan. Parut yang terjadi biasanya lebih halus dan kecil.<br />
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Namun, penjahitan luka tidak dapat langsung dilakukan pada luka yang terkontaminasi berat dan /atau tidak berbatas tegas. Luka yang compang-camping seperti luka tembak, sering meninggalkan jaringan yang tidak dapat hidup yang pada pemeriksaan pertama sukar dikenal. Keadaan ini diperkirakan akan menyebabkan infeksi bila luka langsung dijahit. Luka yang demikian sebaiknya dibersihkan dan dieksisi (debrideman) dahulu dan kemudian dibiarkan selama 4-7 hari. Baru selanjutnya dijahit dan akan sembuh secara primer. Cara ini umumnya disebut penyembuhan primer tertunda. Terjadinya infeksi pada luka pascaeksisi umumnya terjadi karena eksisi luka tidak cukup luas dan teliti.<br />
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Jika, setelah dilakukan debrideman,luka langsung dijahit, dapat diharapkan terjadi penyembuhan primer. <br />
Pada manusia, penyembuhan luka dengan cara reorganisasi dan regenerasi jaringan hanya terjadi pada epidermis, hati, dan tulang yang dapat menyembuh alami tanpa meniggalkan bekas. Organ lain, termasuk kulit, mengalami penyembuhan secara epimorfosis, artinya jaringan yang rusak diganti oleh jaringan ikat yang tidak sama dengan jaringan semula.<br />
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Gangguan Proses Penyembuhan Luka<br />
Penyembuhan luka dapat terganggu oleh penyebab dari dalam tubuh sendiri (endogen) atau oleh penyebab dari luar tubuh(eksogen).<br />
Penyebab endogen terpenting adalah gangguan koagulasi yang disebut koagulopati dan gangguan system imun. Semua gangguan pembekuan darah akan menghambat penyembuhan luka sebab hemostasis merupakan titik tolak dan dasar fase inflamasi gangguan system imum akan menghambat dan mengubah reaksi tubuh terhadapluka, kematin jaringan, dan kontaminasi. Bila system daya tahan tubuh, baik seluler maupun humoral terganggu, pembersihan kontaminan dan jaringan mati serta penahanan infeksi tidak berjalan baik.<br />
Gangguan system imun dapat terjadi pada infeksi virus, terutama HIV, keganasan tahap lanjut, penyakit menahun berat seperti tuberkulosis, hipoksia setempat, seperti ditemukan pada arterioskleoisis, diabetes melitus, morbus Raynaud, morbus Burger, kelainan pendarahan (hemangioma, fistel arteriovena), atau fibrosis. System imun juga dipengaruhi oleh gizi kurang akibat kelaparan, malabsorbsi, juga oleh kekurangan asam amino esensial, mineral, maupun vitamin, serta oleh gangguan dalam metabolisme makanan, misalnya pada penyakit hati. Selain itu, fungsi system imun ditekan oleh keadaan umum yang kurang baik,seperti pada usia lanjut dan penyakit kronis.<br />
Penyebab eksogen meliputi penyinaran sinar ionisasi yang akan mengganggu mitosis dan merusak sel dengan akibat dini maupun lanjut. Pemberian sitostatik, obat penekan reaksi imun, misalnya setelah transplantasi organ, dan koatekosteroid juga akan mempengaruhi penyembuhan luka. Pengaruh setempat, seperti infeksi, hematom, benda asing, serta jaringan mati seperti sekuester dan nekrosis, termasuk penggunaan bahan-bahan topikal apakah larutan kompres, kream, salep antibiotika dan desinfektan yang sangat sitotoksik (mematikan sel) adalah sangat menghambat penyembuhan luka.<br />
Bila luka atau ulkus (borok) tidak kunjung sembuh,harus dilakukan pemeriksaan kembali dengan memperhatikan fase penyembuhan luka untuk menentukan sebab gangguan. Lakukan anamnese lengkap dilanjutkan dengan pemeriksaan fisik,radiologi, biakan, dan kalau perlu lakukan biopsi histologik/patologik serta pemeriksaan serologik.<br />
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Tindakan Perawatan luka<br />
Pertama-tama dilakukan pemeriksaan secara teliti untuk memastikan apakah ada perdarahan yang harus dihentikan. Kemudian, tentukan jenis trauma, tajam atau tumpul, luasnya kematian jaringan, banyaknya kontaminasi, dan berat ringannya luka. Luka trauma berat memerlukan penanganan segera, dengan memperhatikan kondisi yang mengancam jiwa maupun mengancam terjadinya amputasi.<br />
Prinsip utama perawatan luka adalah mengoptimalkan proses penyembuhan secara normal, bukan mempercepat. Sampai saat ini belum ada bahan/obat yang terbukti secara klinis dapat mempercepat proses penyembuhan. Proses penyembuhan adalah “nature of law”. Dengan demikian setiap tindakan, pemberian obat-obatan maupun bahan aplikasi lokal (wound dressings) pada luka harus dipastikan tidak bersifat sitotoksik<br />
Tindakan dilakukan dengan anastesia setempat atau umum, tergantung berat dan letak luka, serta keadaan penderita. Luka dan sekitarnya dicuci dengan air dan didesinfeksi dengan antiseptik/desinfektan. Bahan yang dapat dipakai ialah larutan yodium povidon 1% dan larutan klorheksidin ½%. Larutan yodium 3% atau alcohol 70% hanya digunakan untuk membersihkan kulit di sekitar luka. Kemudian, daerah sekitar lapangan kerja ditutup dengan kain steril dan secara steril dilakukan kembali pembersihan luka dari kontaminasi secara mekanis, misalnya pembangunan jaringan mati dengan gunting atau pisau (debrideman) dan dibersihkan dengan bilasan, guyuran, atau semprotan cairan isotonis misalnya NaCL. Irigasi ini sangat berguna melarutkan dan mengurangi jumlah kuman Eksisi luka dan irigasi yang baik dapat mencegah infeksi. Akhirnya, dilakukan penjahitan dengan rapi. Bila diperkirakan akan terbentuk atau dikeluarkan cairan yang berlebihan, perlu dibuat pengaliran (drain bukan untuk darah). Luka ditutup dengan bahan yang dapat mencegah lengketnya kasa, misalnya kasa yang mengandung vaselin, atau suatu bahan yang netral dan tidak bersifat sitotoksik, ditambah dengan kasa penyerap dan dibalut (jika perlu pergunakan pembalut elastis).<br />
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“wound Dressings”<br />
Sampai saat ini sangat beragam bahan-bahan yang dipergunakan dalam penutupan luka. Mulai dari jenis plesternya sampai jenis kasa maupun kandungan bahan aktif dalam kasa yang kontak dengan luka. Bahan yang paling murah dan benar adalah kasa steril saja. Syarat suatu bahan penutup luka adalah:<br />
Tidak sitotoksik<br />
Tidak nyeri saat pergantian kasa<br />
Bersifat protektif<br />
Tidak berbau<br />
Membantu proses penyembuhan (menjaga kelembaban kulit)<br />
Murah dan mudah didapat.<br />
Suatu prinsip penting dalam merawat luka adalah jangan menambah kerusakan dengan aplikasi bahan-bahan yang bersifat sitotoksik.<br />
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Penyulit<br />
Pada tahap awal dapat terjadi hematom pada luka. Keadaan ini harus dicegah dengan mengerjakan hemostasis secara teliti. Hematom yang mengganggu atau terlalu besar sebaiknya dibuka dan dikelurkan. Seroma adalah penumpukan cairan luka lapangan bedah. Jika seroma mengganggu atau terlalu besar, dapat dilakukan pungsi. Jika seroma kambuh, sebaiknya dibuka dan dipasang penyalir. Infeksi luka terjadi jika luka yang terkontaminasi dijahit tanpa pembilasan dan eksisi yang memadai. Pada keadaan demikian, luka harus dibuka kembali, dibiarkan terbuka dan penderita diberi antibiotik sesuai dengan hasil biakan dari cairan luka atau nanah.<br />
Penyulit lanjut dapat berupa keloid dan jaringan parut hipertrofik yang timbul karena reaksi serat kolagen yang berlebihan dalam proses penyembuhan luka. Serat kolagen di sini teranyam teratur. Keloid yang tumbuh berlebihan melampaui batas luka, sering disertai gatal dan cenderung kambuh bila dilakukan intervensi bedah.<br />
Parut hipertrofik hanya berupa parut luka yang menonjol, nodular, dan kemerahan, yang menimbulkan rasa gatal dan kadang-kadang nyeri. Parut hipertrofik akan menyusut pada fase akhir penyembuhan luka setelah sekitar satu tahun, sedangkan keloid justru tumbuh.<br />
Keloid dapat ditemukan di seluruh permukaan tubuh. Tempat yang sering biasanya, kulit dada, di wajah, sternum, pinggang, daerah rahang bawah, leher, telinga, dan dahi. Keloid agak jarang dilihat di bagian tengah wajah, pada mata, cuping hidung, atau mulut.<br />
Pengobatan keloid pada umumnya tidak memuaskan, biasanya dilakukan penyuntikan kortikosteroid intrakeloid, bebat tekan, radiasi ringan dan salep steroid atau beberapa jenis salep yang terbukti secara klinis mis ®madecassol (2 kali sehari selama 3-6 bulan) atau ®mederma jelly. Untuk mencegah terjadinya keloid, sebaiknya pembedahan dilakukan secara halus, diberikan bebat tekan dan dihindari kemungkinan timbulnya komplikasi pada proses penyembuhan luka.<br />
Kontraktur jaringan parut di bekas luka atau bekas operasi kadang sangat mencolok, terutama di wajah, leher, dan tangan. Kontraktur dapat mengakibatkan cacat berat dan gangguan gerak pada sendi, misalnya pada luka bakar.<br />
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Perawatan Masa Depan<br />
Saat ini dalam penelitian suatu usaha proses penyembuhan merupakan suatu proses regenerasi seperti diamati pada fetus hewan, dimana luka intrauterin yang sembuh sama sekali tidak disertai adanya scar (fibrosis). Saat ini yang mulai dipakai sebagai bahan penutup luka adalah golongan enzim seperti hyaluronic acid, kolagenase sampai growth faktor untuk luka-luka kronis.<br />
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Kepustakaan<br />
Schwatz, Principles of Surgery<br />
Norton, Surgery-Basic Science and Clinical Evidence<br />
Hamilton Bailey, Emergency SurgeryTheo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com0tag:blogger.com,1999:blog-3399054298585589982.post-80806533616722933172010-08-26T13:45:00.000+09:002010-08-26T13:45:31.423+09:00Cara Perawatan Luka ModernSelamat Datang.<br />
Dahulu dan mungkin sampai sekarang ini perawatan luka masih banyak yang menerapkan cara yang kurang tepat. Penggunaan Povidon Iodine, Salep luka, Rivanol masih banyak digunakan, baik dari kalangan medis sendiri seperti dokter dan perawat maupun masyarakat umum. Anda ingin tahu? Bagus!!!Theo Rompas,MD,FICShttp://www.blogger.com/profile/12647123216887141932noreply@blogger.com2