Saturday, December 31, 2016

How To Make Stir-Fried Water Spinach (Tumis Kangkung)

Tumis Kangkung is one of my favorite Indonesian food. Here, I would like to share how to make it.

First of all, you have to prepare the ingredient.


Ingredient:
1) One small tomato











2) Three green chilies










3) Three shallots











4) Galangal










5) One piece of garlic








6) Salt












7) One glass of water
8) Shrimp paste
9) Coconut oil

10) Of course, don't forget the water spinach itself as the main ingredient!



















Procedure:
1) Slice the tomato, green chilies, shallots, galangal, and garlic.























2) Prepare the frying pan, heat the coconut oil.

3) Add the sliced tomato, green chilies, shallots, galangal, garlic, and also the shrimp paste and salt sufficiently. Then, cook them well.

4) After it is cooked, you can add the water spinach and one glass of water. Stir it well. In this step, you may add a little of flavoring.
























5) Cover the frying pan with its cover. Wait for about 15 minutes or until it is cooked.






















6) Finally, the stir-fried water spinach is ready to be served!


That's all. Happy cooking!
Thanks for visiting my blog :)

Saturday, December 24, 2016

LPDP Scholarship Journey #2

[Picture Source: Toga MBA Consulting]

In this post, I would like to explain about the substantial selection which is the next selection after you successfully pass the administrative selection. All the things about the administrative selection, you can visit here. The substantial selection is the crucial factor in deciding whether you are qualified or not to be the awardee, so you have to prepare a lot for this last selection. There are 3 kinds of substantial selection, they are on the spot essay writing, leaderless group discussion, and interview session. All of the types of the selections are using English. 

Either on the spot essay writing or leaderless group discussion, you have to be aware of the hot topic at that time. If you don't know the topic you won't be able to write the essay and you won't be able to speak during the leaderless group discussion. The topic will be given directly on the spot and you will not have time to do research about it. LPDP considers you that you have known about the topic, if you are not knowing about it, it will be a disaster for you, you may not get any high score and it can impact whether you will be considered to get the scholarship awardee or not. In other words, you have to be literate, you have to know every hot topic every day.

To be literate, I always read every news in Kompas.com and watch the news on the television every day. Besides that, the writing skill also has to be sharpened. You have to practice writing the essay. After you read or watch a news, try to write your opinion either in your blog or your other social media. If you practice it for several times, you will be adapted to write the essay spontaneously as you have learned the pattern in delivering your idea into a collection of the words. In the end, you will not feel difficult when writing the essay on the spot as you have practiced it a lot. 

The leaderless group discussion is the selection to know how well you involve in a group discussion. Since, it's a leaderless group discussion, the psychologist who assesses your performance just let the group flow by the group member's own will without any direction. There may be around 8-10 people in the group, try not to dominate, try also not to be passive. Be active but in the better way by knowing the ethics when you involve in the group like respecting a member who is delivering his/her idea by not cutting him/her or not arguing him/her aggressively. Try to deliver your idea in well structured, audibly, and easy to be understood. It's okay to agree or not agree, at the time when you disagree with someone opinion, please never hurting him/her by not looking down his/her ideas, try to give your appreciation toward his/her opinion and explain why you disagree so what your thinking is. 

Having no direction doesn't mean that the discussion run carelessly. Your group has to decide how the discussion will run. For example, at my time, we decided one person to be the moderator to control the discussion. We also decided that every member is obligated to speak, to deliver his/her ideas/opinion toward the topics in the same quantity of the time so there will be no dominant member who will talk so much than the others and also there will be no passive member who may speak lesser than the others. Hence, the discussion ran like this, the moderator introduced the topic and delivered his/her idea, then let the members one by one to deliver their own idea. After every member had their own time to speak, the moderator started to let every member give the response toward each member's idea. In the end, the moderator gave the conclusion and everybody had approved the conclusion. If I wasn't wrong, the time for the leaderless group discussion provided is only about 30 minutes, so if there are 10 people, it means that one person may only have the opportunity to speak 3 minutes in total. 

If you are a person who is quite clumsy every time you have to speak in promptly, why don't you practice? Since practice makes perfect. Try to find your friends who are also striving to apply for the LPDP scholarship. Create a group and practice the leaderless group discussion at a certain day when all of you are able to attend. By practicing together, all of you can know which part of each other has to be improved. In the next-next meeting, all of you can master the discussion. 

The last, the interview session. This is the part that is the most decisive whether you are eligible or not to be the awardee. Interview session is the time when you can explain about your study plan and convince them that you are qualified to be the awardee and potential to give a big contribution in the future for the society and the nation. Of course, you have to be your own self and be honest. There will be 3 interviewers, 1 of them is a psychologist, while 2 of them are well understood about your study interest. Since it's about yourself, you must know really well for the answer, but sometimes you may not give the best answer, so I suggest you also to practice. By practicing, you will be more prepared and give your best answer during the real interview. The interview will spend for about 30 minutes. 

I practiced with not only 1 friend, but also my other friends, since every person may have their opinion. They can help you to assess whether you have given the best answer or not. They also can assess your performance. Being nervous has to be avoided, by practicing you can get rid of your nervousness. During the practice, I have prepared around 50 questions and the answers that may be asked during the interview. If you would like to see the list of the questions and how I try to answer it, you can contact me by giving your email address in the comment column below. 

Actually, there is like a passing grade, every applicant is being assessed and given a score. For example, if the passing grade is 700 and your total score is not reaching the passing grade you are not considered to be accepted. If you can reach the passing grade, you have the opportunity to be considered as the awardee, there will be other factors whether you are able to be accepted or not, one of the factors is whether you are recommended by the interviewers or not. If not, even though you are reaching the passing grade, you may not be able to be accepted. So, after you have tried your best during the substantial selection, it's time for you to keep praying, may God touches the LPDP committee's heart to let you become the awardee. 

Just for your information, the comparison of the score for the on the spot essay writing, leaderless group discussion, and interview session respectively are about 1:1:5. So, the interview session truly takes the big part in your total score. So, pay attention more to it, but it doesn't mean you pay less attention to other parts, you have to pay attention to them also. 

That's all about the explanation of substantial selection in order to get the LPDP scholarship. If you are in the state of undergoing this selection, give your best efforts, never give up, and keep praying. Thanks for visiting my blog. I felt sorry if there are any mistakes. See you in LPDP awardee big-family.

LPDP Scholarship Journey #1

[Picture Source: lpdp.kemenkeu.go.id]

A good news for every student in Indonesia who is eager to continue the study either to a master degree or doctoral degree, based on the mandate of UUD 1945, at least 20% from The Indonesian Budget (APBN) is used for education function. Some of the fund from the allocation of education function is managed by an institution which is Indonesian Endowment Fund for Education (LPDP). Ministry of Finance of The Republic of Indonesia through LPDP gives a full scholarship to the students. The students can choose to study either domestic or overseas. In my post, I may focus more on how to prepare for applying the LPDP scholarship for the student who would like to continue the study overseas. 

I am still standing to the selection system applied at my time, because, of course, they may create some modifications to the system in the following years ahead to make the system better and better. At my time, there are 2 kinds of selection, administrative selection, and substantial selection. You have to pass the administrative selection first, then you can continue to the substantial selection. 

In this post #1, I only talk about administrative selection, while the substantial selection will be talked in the post #2.

Firstly, the administrative selection. You are not allowed to underrate the administrative selection. Even though they only ask you to submit some documents, but if you fail to meet all of the documents required, you will totally fail. It's no joke if you fail from a very first selection, isn't it? Every information about what kind of documents required to be submitted can be accessed directly from LPDP website (http:/*www.lpdp.kemenkeu.go.id), replace * with /. From my point of view, here are the most crucial and usually difficult to be obtained by the deadliner student (a student who usually do all the task in the very last minutes):
  1. Health certificate that certifies you that you are healthy, free from tuberculosis disease, and free from narcotics and psychotropics substance.
  2. Recommendation letter. 
  3. Three essays about your study plan, your biggest achievement, and your contribution.
  4. Certificate of Police Record aka SKCK.
  5. English proficiency: minimum TOEFL ITP 550/TOEFL iBT 79/IELTS 6.5/TOEIC 750.
Obtaining health certificate for those three conditions is not a one day service. At least you have to spare for about 5 days to get the examination result. Let me explain this through my experience. I went to a government hospital around Pasar Minggu on the weekday at 09:00. I did the registration and went to a doctor. She asked me to fill a form to know about my health history. She asked me some questions to confirm about what I had filled in the form. After listening to what I have said during the interview, she was able to consider whether I am healthy or not. To examine whether I am free from tuberculosis disease and free from narcotics and psychotropics substance, the doctor asked me to go to the laboratory to give the sample. In the laboratory, the analyst took my blood and sputum, I also was asked to give the urine sample. Then, the analyst asked me to go to the radiology department to have a roentgen examination, she also asked me to come back again to the laboratory in the next day to give a sputum sample taken directly after waking up. The result was able to be obtained after 3 days of analysis, so that's why it requires at least 5 days to obtain the health certificate, from registration, examination, until the release of the examination result.

If you are a full-time student or a person who is really busy every weekday from the morning until the afternoon by your own business, you have to plan to go to the hospital long before it. You have to set the date when you can have a free time to go to the hospital that from what I have experienced, you have to be free for 3 days. The first day to do the registration and do some examinations, the second day to give another sample required, and the last day to take the examination result. One more thing you have to pay attention is that you have to register yourself before the hospital closes the registration. Some hospital closes the registration at 12:00. It means that if you come around 13:00, you will be asked to go home and come again next day. 

About how much you have to pay for the examination, I spent around 500k to obtain the certificate for those three conditions. My friends spent around 1 million, my another friend spent around 300k, so it depends on what hospital you visit. What I have explained before was what I have just experienced to make you able to get the overview of the process, of course, it may be different from a different hospital and different time. Therefore, it's better for you to ask all of the information, for example about the fee, the schedule, the duration, or other things you would like to ask by calling the hospital customer service number. Hence, you can set a plan about how, where, and when you visit the hospital.

Getting recommendation letter depends on who is the person whom you would like to ask. A busy person must be approached far-far away before the deadline. So many unexpected things may happen to constrain you getting the recommendation letter quickly. For example, the person is taking a leave during her pregnancy until labor, the person is having a business trip for 1 month, the person is taking a research activity abroad for 2 months, or other things that may happen unexpectedly. Therefore, at least you have contacted the person 2 months before the deadline to know whether it is possible or not having the recommendation letter from him/her.

LPDP obligates you to have a recommendation letter from a person who is the leader in your institution or your companies. For a fresh graduate or a student, generally, you have to ask your research supervisor or your Faculty Dean. At my time, LPDP didn't tell how many recommendation letters the applicant should get. At first, I only thought to ask my research supervisor to give me the recommendation letter. Then, I asked to my senior who was the LPDP awardee, she said that she got more than 1 recommendation letter. Being confused about how many recommendation letter really required by LPDP, I asked other LPDP awardees, they answered the same, they got 2 recommendation letters, so I quickly asked my Faculty Dean to give me the recommendation letter. My Faculty Dean didn't know me really well, different with my research supervisor who knew me better, you may experience the same thing, as long as you can make sure your Faculty Dean that you are good enough to apply for the scholarship, your Faculty Dean may give you the recommendation letter. So, finally, you will have 2 recommendation letter. 

Writing essays have to be perfect. You shouldn't write your essays carelessly to point out that you are better than other applicants. An essay about your study plan is the most important essay you have to give attention more. Through this essay, the reviewer can see how big is your intention to continue your study. The more detail you write in your essay, the better. It means that you have explored all of the things about your future study including how many credits you will take, what your research plan is, who your research supervisor will be, until what student organization you will join. 

To know how many credits that you will take, you can know it directly in your prospective university website if it's available. If it's not, you can send an e-mail to the e-mail contact provided. To know about your research plan, you can ask your own self, what is your passion? what is the impact of your research to the society? how big is the impact? Is it feasible to be done or not? While, to know who your supervisor will be, you can search some research journal fit to your research interest, then you can see who the author is, after that you can contact the author and ask him/her to be your research supervisor. There is another way to find your research supervisor like what I have done. 

I went to an event named ACBI (Asian Chemical Biology Initiative). The missions of Asian Chemical Biology Initiative are (1) to speed up Asian chemical biology research by fostering international collaborations and by sharing research resource among Japan, Korea, China (the mainland and Hong Kong), Singapore, UAE, New Zealand, and India, and (2) to promote chemical biology in emerging Asian countries (e.g. Vietnam, The Phillippines, Thailand, Malaysia, and Indonesia) by recruiting and training brightest graduate students from those countries). Specifically, this newly established initiative organizes annual meetings over five years in Hanoi, Manila, Bangkok, Jakarta, and other major cities in Southeast Asia where Asian chemical biology will get together to foster mutually beneficial collaborations and to interview local student candidates (ACBI, 2016).

I came to the ACBI in Jakarta, in January 2015. There are more than 30 professors who came from a various university, various country, and various research field. The committee had set up every student to be interviewed by some professors who is fit to the student's research interest. I was interviewed by 8 professors. All of them were very nice and warm. From those professors, I can determine some professors who were really fit to my research interest. So, if you would like to find your prospective research supervisor, you can come to ACBI. Since it's an annual event, you have to check the schedule, when and where it will be conducted, and don't miss it. 

The essay about your biggest achievement and your contribution is your own self that understand well what you should write. The essay about your biggest achievement is all about your past, while your contribution is not only about your past, what contribution that you have given to the society, but also about your future, what contribution that you will give to the society. Therefore, if you are still a freshman in a college and dreaming of continuing your study after finishing your bachelor degree, you can set a plan, what kind of achievements that you would like to achieve and what kind of contribution you would like to give to the society during your 4 years in the college. So, you can have the materials to be told in your essay.

My suggestion to make your essay perfect is being reviewed by your friends or seniors for several times, revise it for so many times until all of the reviewers said that it is flawless. Every person may have their own opinion, from my point of view and my reviewers, all of three my essays was close to perfect, at least it was not written carelessly. I spared for about 1 month to finish it. I'm not saying that my essays were extremely perfect, I was just trying to make it perfect. If you would like to see my essays, you can ask me through the comment column below and give me your e-mail address. I said sorry in front if the essay doesn't meet your expectation. I believe you can do better than me. Absolutely, you have to write it better than me. 

Certificate of Police Record aka SKCK must be obtained in your origin area. If you are a student who studies far away from your home, you have to come back home to take care your certificate of police record. That's why it is difficult to be taken care for a deadliner student since you have to set a plan when you can have a free time to go back to your home. The police station usually open only in the weekday so you may have to take a permission from your institution to have a leave one day or if you are lucky, you indeed have a free time in the weekday. Other than that, you have to pay attention to what documents that you have to prepare before visiting the police station so they will accept all of your documents not asking you to go back again due to lack of any documents. You can search through the internet to know what kind of documents needed. 

English proficiency must be taking you to spend for several months according to your capability to prepare it. If you are good enough in English and have already had the certificate of English proficiency, congratulation! you don't need to take a long preparation to apply for the scholarship because from what I have experienced, getting the English proficiency certificate was the longest time to prepare among all of the document required. I spent about 3 months to be ready facing the English proficiency test in order to get the certificate. I was taking TOEFL. Before I start to prepare, I took the TOEFL prediction, and it was about 477, so below the target (550). I had to learn more to win the TOEFL, so I decided to learn TOEFL by buying Barron TOEFL books, downloading TOEFL practices and exercises application, watching movies or drama using English subtitle. I learned all of them by my own self without joining any courses. I believe I can prepare it by my own self since I acknowledged some of my friends who were successfully done it also by their own self. I truly prepared for the English proficiency in a full day every day, without being active in the institution or working in a company. I couldn't imagine if I was a full-time worker whether I would be able to prepare for TOEFL or not. In other words, I was truly unemployed, at that time when most of my friends had already sat in a company or institution. You do have to sacrifice something in order to get something more precious. 

If you study for TOEFL carefully and diligently, you may find the formula how to answer each question in TOEFL test. After I thought that I was ready to face the TOEFL test, I tried my first attempt to win it. As I felt not confident enough during the test, I couldn't adapt well to the test situation, I was only able to get the TOEFL score for about 546 which means I was lacking 4 points to reach the target. I didn't give up, I evaluated myself what I have to do better in order to reach the target so I started again to learn. My second attempt, I felt better, I felt more confident. The result never betrays the effort. I was able to reach the target because my TOEFL score was 567. I felt so relieved and grateful. 

There are so many forms to verify your English proficiency, not only TOEFL ITP, but also iBT, IELTS, or TOEIC. To apply for LPDP, LPDP allows you to choose which one is more suit with you. Nevertheless, I suggest you, choose the form that is also asked by the university you would like to enter. Most of the universities in Europe don't accept TOEFL ITP, while some universities in Asia still accept TOEFL ITP, so you have to be aware with this. 

In conclusion, if you can prepare well those 5 crucial things which are the health certificate, recommendation letter, essays, certificate of police record, and English proficiency certificate, you may feel relieved. There are other documents needed to be submitted but they are not too difficult to be collected from my point of view. So, you can take a breath for a while after finishing all these five crucial documents. 

I hope what I told about the administrative selection to apply for LPDP scholarship can be useful for you, visit my second post about the substantial selection. I'm sorry if there are any mistakes. If you would like to discuss more about the scholarship, don't hesitate to contact me by leaving your comments. Thank you very much for your visiting. Hope you succeed in obtaining the scholarship. Keep striving and praying!

Tuesday, November 29, 2016

Active

[Picture Source: Gettyimages.co.uk]

The dew on the leaves.
Turquoise and polka dot,
ready to jump,
to mix with other colors.
But then,
blocked by a military.

Forced to obey.
So many hard rocks to choose.
The one should be seen,
failed to appear.
Just go,
just hand over it to the military.

A soft marshmallow in the market,
seemed to have same texture with tofu.
Both had so many cracks.
Laughed.
Interesting.
Mashed.
But,
weren't wrecked.

Learned.
Not to believe,
what is seen.

Found the colors.
Told the reason.
Told what happened.
Asked to also find.
To feel the strive,
crawling inside the labyrinth.

Wondering,
what is the real path?

Still hidden in the darkness.

Just keep active.
Just be acceptant.

Friday, November 11, 2016

Water

[Picture Source: Nature Wallpapers and Backgrounds - Desktop Nexus]

Mixed,
water above the surface.
Between the waterfall and a missing path.

 Asked to forecast,
what is next to the bright side,
5, 10, and 50 footsteps ahead.

Tended to stop,
because didn't want to feel the water. 
Still wanted to be with the roots.
Forever.

Empty.
No knocking. 
One root told about the missing path,
so the water was unstoppable.

Not so popular, 
more often to be avoided.
Eliminated. 

A lonely weird penguin,
at the edge of the waterfall.
Decided to dive into the deep water,
during the entire night.

Dreaming a faith.
To make sure.
To make stronger.
A sound to remind:
there is always a scene in each footstep. 

Saturday, November 5, 2016

Opinion: The Defamation of Religion

[Picture Source: Humanrightshouse.org]

A liberal lecturer talked in front of the students in the class. He said, "Why do Moslems get angry when an army trampled down and peed on an Al-Qur'an? Isn't it only a collection of papers? While what have been stated was still in Lauhul Mahfuzh so why do Moslems get angry?" Then, a creative student approached the lecturer while bringing a book created by the lecturer. He said, "Your book is really cool and you analyze it perfectly". Suddenly, he dropped the book and spit on it. The lecturer got angry and tried to hit him. Fortunately, the creative student can tackle it and said, "Why do you get angry? Isn't it only a collection of papers? While the idea is still in your head since you are the one who created it. The lecturer got ashamed and directly got out from the class. 

A belief is also the part of an identity. This is our instinct when somebody insults our belief or our identity. Of course, we will get angry and so do you when somebody insults your belief or identity. You do get angry, don't you? So, it's not impossible not to get angry unless you don't have the sense of belongings of the belief or the identity. If you don't get angry, your identity is needed to be questioned. 

The defamation of religion done by the Governor of Jakarta toward Islam in 2016, I do get angry as a Moslem. However, the government seemed to keep quite whereas I live in a country that enforces the law. It has been stated in the law that the defamation of religion is wrong, so the offender has to be punished, like what has happened in Bali, a Christian woman insulted Hindu offerings, so she was jailed in Bali for 14 months in 2013 [1]. 

Then, a number of Moslems from around of Indonesia did a demonstration toward the government in Jakarta to enforce the law and to process the offender which the peak of the demonstration occurred on Friday, November, 4th 2016. They intended to meet the President, to deliver their aspiration. Unfortunately, the President was not in the place [2]. 

I don't know why it looked like the President refused to meet them. Whatever the reason was, only the president his own self that knew the reason. Just like other Moslems felt, I did want the President to greet and listen to the Moslems' aspiration since some of them had come from really far away to be able to unite with other Moslems in Jakarta. I hope the representative from the government could accept the aspiration well and arranged another step to process it. 

Everybody knew there is still something wrong in law enforcement in Indonesia. Sometimes they do it well toward an offender that doesn't have the power like an old woman (63 yo) proven to steal woods and was jailed for about 1 year and 3 months [3]. However, it seems difficult to sentence a corruptor who has stolen so much money from the government since the corruptor still has a power or the corruptor is successfully punished but the punishment may seem easy, not as heavy as his criminal act. So many factors that I don't know so the law enforcement in Indonesia still looked injustice in my opinion. 

If the government can't process the defamation of religion done by the offender while so many demonstrators have already delivered their aspiration toward the government to enforce the law, I just can accept it for what it is since I don't have the power. It is the decision from the government, they may have already had the reasons why it should not be processed by the law. If that so, just make it transparent and explain to the people especially to the Moslems all of the reasons why the government has made the decision like that. Make the people understand so the people can accept it with a big heart.

But if the reasons will seem like nonsense which the government tries everything to protect the offender in order to make the offender be called off about the punishments, even though de jure the offender may be proven guilty, I can not accept it. But by seeing the situation what just happened until these days, we can not look forward more to the law enforcement in Indonesia. At least, the Moslems have gathered to deliver the aspiration. Once again, Indonesia still needs to learn more how to enforce the law. 

For this time, as a Moslem, I need to accept for what it is and have a big hearted. Just understand the situation and try to forgive the offender. Every Moslem has already known that it's not good to get angry, if you get angry, it's okay but Islam asked the Moslems not to get angry over 3 days. Just learn to forgive. Forget about the law enforcement since Indonesia still need to learn about it to make all the people feel justice. For me, until now, it's okay to feel injustice since I can do nothing besides trying to forgive.

I hope in the future, the government of Indonesia can be more mature and be able to enforce the law better. Absolutely, I hope in the future, nobody else insults someone's belief or identity. Please, be mature and respect each other. If you want to be respected, you need to respect others.  


References:
[1] Jakarta Informer. (2013). Christian Woman Jailed in Bali for Insulting Hindu Offerings. [Website].
[2] Kompas. (2016). Demo 4 November. [Website].
[3] Liputan 6. (2015). Nenek Asyani Terdakwa Pencuri Kayu Divonis 1 Tahun Penjara. [Website].

Wednesday, November 2, 2016

Opinion: The Loss of TPF Documents

[Picture Source: Alchetron (Website)]

Flying to Utrecht, Netherlands, to study law in master course program and to do research about enforced disappearances on September, 6th 2004, Munir lost his life. Before his departure, a friend, Pollycarpus, whom he didn't know him really well, asked his wife, Suciwati, about his flight schedule. Pollycarpus set a criminal act toward Munir during the flight. 

Munir ate up fried noodle with beef and a glass of orange juices. Then, he sent a message to his wife about his uncomfortable feeling on his stomach. He went back and forth to the toilet for six times, then he was given a treatment from a doctor. He was extremely weak but he couldn't be helped by the doctor. "If the disease is mild, he must be able to survive for about 3 days", the doctor said. At the same time, Pollycarpus called Budi Santoso and said, "Big Fish Operation has been finished". 

In the court, Pollycarpus was found guilty. He poisoned Munir with Arsen (a toxic chemical compound) through his food that Munir ate up. Nevertheless, the mastermind behind him has never been revealed [1].

The incident happened around SBY governance so SBY built a team to focus investigating about Munir case, named TPF (Tim Pencari Fakta/Team of Fact Finder). After finishing its duty period, TPF handed over a document which comprised of some recommendations for the advanced investigation. One of the recommendations is to investigate more Hendropriyono who was assured as a responsible party for Munir case [2]. 

Munir case hasn't finished yet until Jokowi governance. The people insisted Jokowi to continue the investigation. Jokowi agreed but he needed the original document to be studied. What Mensesneg (a division at SBY governance that was responsible to hand over the document to the next governance) gave to Jokowi governance was not the original document but it was only the copied version. Jokowi refused the copied version since it might have been less accuracy and potentially to be manipulated. The original documents was mentioned missing [2].

Ex the Head of TPF, Sudi Silalahi, said, "Based on SBY recall, there are 6 documents and has been spread to the government. However, he hadn't told about the position of the original document yet [3]. One of the ex of TPF members, Hendardi assesed, "The problem of the lost of original TPF documents please do not make it difficult. There are 7 documents in total, I' m wondering if all of the 7 documents went missing, it doesn't make sense" [4]. The head of MPR (judicial institution), Zulkifli Hasan added, "Do not politicize it. Please, search it well" [5].

In my opinion, Instead of searching the original document when it seems that there are some parties that try to cover and hide it by giving so many excuses to make the original document unrevealed, it's better to build again another TPF and do the investigation again from the beginning. If the member of the new TPF involve the ex members, I believe, the investigation can be done faster, more effective, and more efficient since they must be still remember what they have done during their work period. Moreover, by doing investigation through the new TPF, who knows if they will coincidently find the original document. 

I know, it will spend more times to build a new TPF but I think, it's better than do nothing. Or another solution, keep searching the original document but in the other side, also keep building the new TPF so it will be like undergoing two ways to reach one purpose in the same time. It's better to do something while waiting the result of finding, again, it's better than do nothing, I think. 

Essentially, finishing the investigation of Munir case is a must since it correlated to the human rights. Munir is a human rights activist so the loss of his life intentionally by a party who didn't like him is absolutely a violation toward human rights. If the government doesn't continue or start again the investigation, it seems like the government doesn't respect to the human rights or in other words, the government doesn't respect to the people whereas the existance of the government is because of the people. They have to do what people want it to do which is to respect human rights, to respect justice.

There are so many rights insisted by the human rights activists to be preserved and respected by the government and the people, like the rights to study, the rights to have a job, the rights to get married, etc. Nevertheless, personally, I only more concern about the right to live as the essential of human rights since this crucial thing also hasn't been respected well until this time. From my opinion, it's okay to see other components of rights in human rights, but please do it after the rights to live has been respected really well. It doesn't need to be concerned, just focus on the rights to live first. Without living, human never can have the rights to study, to have a job, or even to get married.

In conclusion, it's really really substantial to do the investigation whether to continue the last investigation or to start again the new investigation because the most important thing is the government do something to show its goodwill to respect the human rights. I hope in the future, the people of Indonesia can live comfortably.


References:
[1] Tempo. (2014). Kronologi Kematian Munir. [Website].
[2] Tempo. (2016). Jubir Istana: Presiden Jokowi Akan Selesaikan Kasus Munir. [Website].
[3] Kompas. (2016). Cerita SBY telusuri Dokumen TPF Pembunuhan Munir. [Website].
[4] Kompas. (2016). Polemik Keberadaan Dokumen TPF Munir, Perkara Mudah yang Dibuat Susah?. [Website].
[5] Kompas. (2016). Ketua MPR: Soal Data TPF Munir Tidak Usah Dipolitisasi. [Website].

Saturday, October 29, 2016

Opinion: The Meaning of Youth Vow Day

Every October, 28th, my brother in law celebrates his birthday. In the same time, all of the Indonesian people celebrate Youth Vow Day. It was exactly in October, 28th 1928, the Youth Vow Day bore. As Indonesian youth, sometimes I ask myself what I have done for Indonesia and what kind of contribution I have done.

The youths in the past strived to make Indonesia be free from the imperialist. They understood really well that they could not make it if they do it alone. Regardless of the diversity of the tribes, cultures, and languages, they kept unite them self because they knew by the unity, they would gain more power and more chance to fight back and get rid the imperialist from the homeland. Therefore, on October 28th, 1928, they vowed that they, Indonesian youths, were from one country, country of Indonesia; one nation, nation of Indonesia; and one language, language of Indonesia. The bahasa version of Youth Vow is shown below.

[Picture Source: kochiefrog.com]

By the unity, Indonesian youths became stronger to fight back the imperialist. Therefore, the meaning of Youth Vow Day in the past was the struggle to fight back the imperialist by a unity of Indonesian youth. How about the meaning of Youth Vow Day today? 

The meaning of Youth Vow Day according to Jusuf Kalla, The Vice President of Indonesia, is to move forward. He underlined that the world today has so many alterations so if Indonesia only depends on the unity, it will not enough to make Indonesia bigger. "We need to keep the meaning of the unity from Youth Vow, but the youths today should not only think about it but also think to move forward with the unity" [1]. 

While in my opinion, the meaning of Youth Vow Day is similar to the meaning of it in the past which is to strive and fight back the imperialist by the unity. The imperialist that I mean is in the form of new imperialism. As we gradually face the globalization, we may be colonized for the second time by the new type of imperialism. For example, since the beginning of 2016, countries in ASEAN has started the AEC (ASEAN Economic Community) program.  

The purpose of the establishment of AEC is to form a huge market and to be one of the largest economies in the world [2]. By the AEC, the trading between ASEAN countries will be easier. AEC also let the people from different countries work in other countries in ASEAN easily. From this point, we can see a disadvantage which may be encountered by Indonesia, if Indonesia is not ready to face the AEC. For example, if so many better workers from other ASEAN countries decide to work in Indonesia, the recent local workers may be replaced by them and Indonesia will have an increase in the number of unemployment people since they are unable to circumvent them. If this thing happens for a long period, Indonesia may undergo the new form of imperialism which the local people will be cornered and unable to overpower the immigrants, then the immigrants begin to control the governance. It may happen if Indonesia is not ready for the human resources.

Therefore as a youth, we can implement the Youth Vow by keeping strive to fight back a new form of potential imperialism by the unity. The Indonesian youths today need to unite by contributing something to Indonesia, to make Indonesia distinguished from other countries in ASEAN or even in the world. We can contribute to the nation by achieving something in an international competition or by doing nonstop learning in the whole life so we will not be left behind from other countries. 

Today are so many examples of Indonesian youths who have lifted the nation dignity in the international arena. Tontowi Ahmad and Liliyana Natsir successfully brought gold medal from badminton competition in Rio Olympiad 2016; Joey Alexander Sila, a 10-years-old pianist obtained Grand Prix 1st International Festival-Contest of Jazz Improvisation Skill and successfully made Bruno Mars do standing ovation at Grammy Awards; and Irene Kharisman Sukandar was the first Indonesian woman awarded as the Grandmaster (the highest level of chess athlete and was ranked 59th between other woman chess athletes in the world [3].

Totowi/Liliyana, Joey, and Irene are just a few example of excellent Indonesian youths. There are so many youths actively participated in the international competition that I can not mention their names one by one. If they can make it, it means that you do can make it. You just need to see what is the excellence of yourself and then you work hard to hone the skill. I believe you also can be one of them. 

Nonstop learning means that your education doesn't stop until you reach bachelor, master, or Ph.D. degree, but you stay foolish and hungry--just like Steve Jobs said--which by staying foolish and hungry, you will keep learning a new knowledge from whatever and wherever every time. You need to always be still curious about something new because the world changes so fast. If we slowly follow the changes, we may be left behind and controlled by other big countries. If it happens, in the end, our independence will be threatened. 

So, the meaning of Youth Vow Day, in my opinion, is by keeping strive to fight back the new form of potential imperialism by the unity to contribute to Indonesia which can be implemented by achieving something in the international arena or nonstop learning. If we unite to lift our nation dignity by those contributions, I believe we can maintain our independence and will never be colonized for the second times.

References:
[1] Republika. (2016). JK: Makna Sumpah Pemuda Harus Dijaga. [Website].
[2] ASEAN. (n.d.). ASEAN Economic Community. [Website].
[3] Juliawanti, L. (n.d.). 5 Pemuda-Pemudi yang Sukses Bangkitkan Indonesia di Mata Internasional. [Website].

Opinion: Avoid Black Campaign

[Picture Source: qureta.com (has been modified)]

My eyes felt really hurt every time scrolling the page of facebook, twitter, and other social media I have. I felt annoyed, disturbed, and fed up toward the black campaign thrown each other by the supporters of each candidate. Even though black campaigns and negative campaigns are purposed to strike down their opposing candidate by telling their bad things, both campaigns are different. Muhammad Qodari, Executive Director of Indo Barometer, said that a black campaign is a campaign that should be avoided since the information is not based on a fact, while a negative campaign is a campaign that we should preserve since the information is based on a fact and important for the electors as a consideration which candidate should be chosen [1]. 

As an elector, I felt disgusted by the black campaign shared by the supporters who can not give responsibility to its validity. They shared hatred and invited the other electors to feel also their hatred toward the candidate whom they hate whereas what they told about the candidate is probably incorrect. As an elector who has a conscience and education, I knew which one is correct and which one is incorrect, I knew whether it is a black campaign or a negative campaign.

If most of the electors in the nation couldn't differentiate whether it is a black campaign or a negative campaign. They can be easily influenced by the black campaign and wrongly getting the information, then wrongly elect a candidate.  In the end, the nation may wrongly obtain the elected candidate while the future of the nation is on the hand of the elected candidate.  Therefore, the best election system in my opinion is when there is no black campaign so the electors only obtain the information which is based on a fact. They can elect properly and finally obtain the appropriate elected candidate.

Unfortunately it seems difficult to eradicate black campaign, our government still in the formulation of the regulation. Black campaigns may be appear until now in every type of election. For example, during governor of Jakarta election which the campaign period starts from October 2016 until February 2017. So, brace yourself to face the black campaigns.

Most of the black campaigns appear in social media. Usually I use social media to see my friends' recent news about their lives. But when there are so many black campaigns shared by friends, it is like not fulfilling my intention to see the social media. Regardless of whether it is incorrect or not, the information from black campaigns is still not based on a fact. In my opinion, every information that is not based on a fact is a lie. I hate a lie so I hate every time seeing my social media full of black campaigns or full of lies shared by friends. Yes, every time during the election period. Don't you feel fed up, disgusted, and annoyed by lies every day in social media? I do! Since my purpose to see my social media is to see their recent news but I ended up by finding so many black campaigns shared by them which is not what I want.

Here, I come to a solution. Some of social media like facebook has a feature to hide a posting that we would not like to see. But, if he/she shares black campaigns frequently, I suggest you to click "unfollow" button from his/her timeline. Don't worry to click unfollow, since facebook doesn't allow him/her to be notified if someone has already unfollowed him/her. By unfollowing, you can't see his/her post which is full of black campaigns and it also means you are free from hatred spread. In this post, I'm not telling you how to hide/unfollow someone in social media because you can easily find the information in other sources in the internet. I just would like to make you aware that you can be free from black campaigns shared in social media by avoiding someone who frequently shares the black campaigns. Just like Muhammad Qodari said, black campaign is a campaign that should be avoided. For some times after the election period, you may want to follow someone that you have already unfollowed during the election period again, so just follow again in his/her social media, hope he/she has stopped sharing the black campaigns.

If you would like to know a whole information including the vision, mision, and programs offered by all candidates, just go to their official social media account. These official social media account of all candidates should not let a post which tends to be a black campaign appear in their official social media. By comparing the information obtained from the official source, I hope you can consider the proper candidate to be chosen so it's better to follow all candidates' official social media rather than only following one. By following all of them, you can compare.

As a Jakarta citizen who will participate in the Governor of Jakarta election in 2017, I would like to share the official social media of all candidates which is written below [2]:
  1. Agus Harimurti Yudhoyono and Sylviana Murni: AgusSylviForDKI1 (facebook), @AgusSylviDKI (twitter), @AgusSylvyForDKI1 (instagram), and AgusSylviDKI.com (website).
  2. Basuki Tjahaja Purnama and Djarot Saiful Hidayat: AhokDjarot (facebook), @AhokDjarot (twitter), ahokdjarot (instagram), and ahokdjarot.id (website).
  3. Anies Rasyid Baswedan and Sandiaga Salahudin Uno: Anies Sandi, #jakartamajubersama, Anies Baswedan, Suara Anies, Relawan Anies, Sandiaga Salahudin Uno  (facebook); @jktmajubersama, @Aniesbaswedan, @Suaraanis, @Relawananies, @sandiuno (twitter), @jakartamajubersama, @aniesbaswedan, @relawananies, @sandiuno (instagram), and jakartamajubersama.com (website).
In conclusion, black campaign is bad and should be avoided. The solutions I offer are by avoiding someone in social media who frequently shares black campaign and just following the official social media of all candidates.

My last word, learn and explore more the information provided from their official social media and avoid illegal account which tends to spread black campaigns. Say no to black campaign. Be educated and wise to choose. Hope, by avoiding black campaigns, one step closer to have the truly best elected candidate. It's not only for Governor of Jakarta election, but for other upcoming type of elections. And hope Indonesia will be a bigger and bigger nation in the world.

Reference:
[1] Hukum Online. (2007). Perlu Pembedaan Tegas antara Black dan Negative Campaign. [Website]
[2] Warta Kota Tribunnews. (2016). Ini Akun Medsos Resmi yang Terdaftar di KPU DKI. [Website]

Wednesday, July 27, 2016

Catatan Obat Gangguan Kardiovaskuler #7

 

Gagal jantung adalah pembahasan materi gangguan kardiovaskular kali ini, setelah pada catatan-catatan sebelumnya dibahas mengenai hipertensi, aritmia, iskemia, dan infakrd miokardial. Gagal jantung atau kegagalan fungsi pompa jantung merupakan keadaan patofisiologi yang dikaitkan dengan disfungsi jantung dan merupakan titik akhir berbagai penyakit sistem kardiovaskular. Gejala muncul bervariasi tergantung seberapa cepat terjadinya gagal jantung. Gagal jantung meliputi gagal jantung ventrikel kiri, ventrikel kanan, atau ventrikel kiri dan kanan. Faktor risiko gagal jantung antara lain hipertensi, diabetes, hiperlipidemia, inaktivasitas, obesitas, alkohol, merokok, dan diet garam. 

Gagal ventrikel kiri gejalanya berupa:
  1. Sesak napas (dyspnea) terutama pada posisi berbaring.
  2. Nyeri dada, sputum diwarnai darah, lelah dan bigung.
  3. Peningkatan ventilasi dan denyut jantung.
  4. Palpasi menghasilkan denyut kuat lemah.
  5. Auskultasi paru menghasilkan bunyi abnormal (pada pemeriksaan fisik).  
Penyebab gagal jantung antara lain pada kondisi kerja jantung tidak seimbang, seperti volume overload (hipertiroid) atau tekanan overload (hipertensi sistemik), pengisian jantung terbatas (mitral stenosis, penyakit perikardial), reduksi miosit (infark miokardial, lupus), atau penurunan kontraktilitas miosit (akibat infeksi virus dan bakteri, keracunan alkohol, kobalt, dan doxorubicin). 

Pada gagal ventrikel kiri terdapat perubahan hemodinamik yaitu penurunan output (akibat disfungsi sistolik) dan penurunan pengisian (disfungsi diastolik). Selain itu, terdapat pula perubahan neurohormonal berupa aktivasi sistem simpatis, aktivasi sistem RAA, pelepasan vasopresin, dan pelepasan sitokin. Terdapat pula perubahan seluler seperti inefisiensi kalsium intrasel, desensitisasi adrenergik, hipertropi miosit, apoptosis, dan fibrosis. 

[Sumber Gambar: biology-forums.com]

Gagal ventrikel kanan gejalanya berupa napas pendek, edema, nyeri abdominal, pemeriksaan fisik sama dengan gagal jantung kiri. Gagal ventrikel kanan disebabkan oleh peningkatan afterload pada ventrikel kanan (abnormalitas arteri atau kapiler paru) dan iskemia ventrikel kanan. Pada kelanjutannya akan terjadi disfungsi sistolik dan diastolik, penurunan kontraktilitas miosit, dan perubahan seperti pada gagal ventrikel kiri. Gagal ventrikel kanan juga dapat berasal sebagai kelanjutan dari gagal ventrikel kiri. Manifestasi klinik gagal ventrikel kanan antara lain napas pendek, peningkatan tekanan vena jugular, ascites, edema pada kaki, refluks hepatojugular, dan nyeri abdominal kuadran kanan.

[Sumber Gambar: airphysio.com]

Terapi untuk gagal jantung bertujuan untuk mencegah gagal jantung melalui identifikasi faktor risiko (mencegah berkembangnya disfungsi ventrikel dan gagal jantung). Perawatan/penanganan terhadap faktor risiko ini adalah terapi nonfarmakologinya. Terapi farmakologi untuk disfungsi sistolik antara lain ACEI, diuretik, beta bloker, dan digoksin. Sementara untuk disfungsi diastolik antara lain ACEI, beta bloker, CCB, dan nitrat.

Penanganan terhadap faktor risiko, artinya pasien yang memiliki faktor risiko harus mencapai target pengobatannya agar tidak berlanjut menjadi lebih parah kondisinya yang dalam hal ini diharapkan jangan sampai terkena gagal jantung.
  1. Pasien hipertensi diupayakan tercapai target tekanan darahnya yaitu kurang dari 130/80 mmHg.
  2. Pasien diabetes, target terapi HbA1c <= 6,5-7,0%, kadar gula darah puasa < 110-130 mg/dl, dan kadar gula darah 2 jam setelah makan < 140-180 mg/dl.
  3. Orang yang kurang aktivitas fisik, setidaknya melakukan aerobik 20-30 menit 3-5 kali dalam seminggu. 
  4. Pasien obesitas, melakukan penurunan berat badan dan diupayakan mencapai BMI < 30.
  5. Perokok, diupayakan untuk berhenti merokok.
  6. Diet garam, maksimum 2-3 gram per hari.
 Apabila pasien hipertensi melakukan kontrol tekanan darahnya dengan agresif, maka penurunan risiko terkena gagal jantungnya berkurang menjadi 50%. 

ACEI direkomendasikan untuk mencegah gagal jantung pada pasien dengan risiko tinggi, yaitu pasien dengan peyakit arteri koroner, penyakit vaskular perifer, strok, diabetes dan dengan faktor risiko lainnya. ACEI dan beta bloker direkomendasikan utnuk semua pasien dengan riwayat infark miokard. Terapi ACEI menurunkan risiko kematian sel jantung, infark miokard, strok, atau gagal jantung. 

Untuk pasien yang tidak dapat mentoleransi batuk sebagai efek samping dari ACEI, direkomendasikan menggunakan ARB. Kombinasi hydralazine dan nitral oral dapat dipertimbangkan untuk pasien yang tidak dapat mentolerir ARB, yaitu pasien yang mengalami insufisiensi renal.

Antagonis aldosteron direkomendasikan bagi pasien dengan terapi standar, termasuk diuretik. Dapat dipertimbangkan penggunaanya pada pasien post infark dengan gagal jantung secara klinik atau diabetes. Namun, antagonis aldosteron tidak direkomendasikan bagi pasien dengan:
  • kreatinin > 2,5 mg/dL (atau klirens < 30 mL/menit).
  • serum potasium > 5,0 mmo/L
  • terapi meliputi diuretik hemat kalium.
 Pada penggunaannya suplemen kalium tidak direkomendasikan kecuali jika kadar kalium kurang dari 4,0 mmol/L. 

Terapi diuretik direkomendasikan untuk mengembalikan dan menjaga volume normal pada pasien dengan riwayat overload cairan berupa gejala kongestif dan peningkatan tekanan pada saat pengisian. Dalam hal ini, diuretik kuat lebih banyak digunakan daripada tiazid pada pasien gagal jantung. 

Sekian terkait dengan gagal jantung. Terkait dengan penjelasan lebih lengkap seperti apa mekanisme kerja tiap obatnya dan contoh obatnya dapat dibaca pada catatan saya sebelum-sebelumnya. Semua materi saya peroleh dari handout kuliah. Mohon maaf apabila terdapat kesalahan. Semoga bermanfaat dan terima kasih sudah berkunjung.

Tuesday, July 26, 2016

Catatan Obat Gangguan Kardiovaskuler #6

[Sumber Gambar: blog.biowebspin.com]

Kali ini yang dibahas adalah ischaemic heart disease dan infark miokardial

Ischaemic heart disease terjadi ketika kebutuhan aliran darah melebihi suplai darah oleh arteri koroner. Pada kondisi normal, suplai oksigen dan nutrisi melalui arteri koroner sesuai dengan kebutuhan metabolik miokardial. Ketika kebutuhan metabolik di jantung meningkat, aliran darah koroner juga meningkat. Oleh karena itu, keseimbangan oksigen miokardial dipengaruhi oleh meningkatnya kebutuhan oksigen dan nutrisi miokardium, seperti latihan fisik, stres, dan cuaca dingin. Selain itu, dipengaruhi pula oleh adanya metabolik kardial dan nitrogen oksida yang meningkatkan aliran darah koroner. Penyebab iskemia miokardial adalah aterosklerosis dan trombus. Faktor risiko dari penyakit ini antara lain merokok, diabetes, hipertensi, hiperlipidemia, kurang aktivitas fisik, obesitas, dan genetik. 

Telah dijelaskan bahwa salah satu penyebab iskemia adalah aterosklerosis dan trombus. Adanya kondisi tersebut menyebabkan adanya penyumbatan pada pembuluh darah. Penyumbatan yang ada secara progresif pada arteri koroner, menghambat darah yang mengandung oksigen dan nutrisi untuk dapat memasuki sel yang membutuhkan oksigen dan nutrisi tersebut sehingga akibatnya suplai oksigen dalam sel tidak memadai. Ketika kebutuhan oksigen dan nutrisi tidak memadai, maka sel akan mengalami apoptosis dan selanjutnya nekrosis. Apoptosis terjadi ketika adanya aktivasi TNF alfa, interleukin-1-converting enzym (ICE related protease) inaktivasi poli-ADP-ribose-polymerase (PARP) dan fragmentasi DNA. Selanjutnya nekrosis terjadi akibat penurunan ATP dan penurunan pompa ion, aktivasi protease, serta kerusakan membran. Akibatnya, jantung tidak dapat bekerja sesuai dengan fungsinya. Nekrosis adalah kematian sel pada jaringan tubuh dan bersifat ireversibel terjadi ketika sel cedera berat dalam waktu lama dan sel tidak mampu beradaptasi lagi tau memperbaiki dirinya sendiri (hemostasis).

Manifestasi klinis iskemia miokardial adalah angina pektoris. Angina merupakan gejala utama iskemia miokardial. Gejalanya berupa nyeri dengan karakteristik menyebar dari dada ke lengan hingga leher, rasa tertekan dan terbakar pada wilayah sternum. Faktor kimia yang dilepaskan oleh sel miokardial yang mengalami iskemia antara lain K+, H+, dan adenosin. Faktor kimia ini kemudian menstimulasi nosiseptor. Nosiseptor adalah saraf aferen primer untuk menerima dan menyalurkan rangsangan nyeri. Secara klinis angina pektoris terdiri dari 3 tipe, yaitu:
  1. Stable angina, berupa nyeri dada yang muncul akibat peningkatan beban jantung akibat latihan, emosi, stres, dingin. Nyeri dada pada tipe angina ini dapat diprediksi dan terjadi akibat penyempitan arteri koroner. 
  2. Unstable angina, berupa nyeri dada yang muncul meskipun tidak ada peningkatan kebutuhan oksigen dan nutrisi, contohnya pada saat istirahat. Hal ini terjadi akibat adanya blok arteri koroner. 
  3. Variant angina disebabkan oleh vasospasme arteri koroner. Vasospasme adalah kejang pembuluh darah, menyebabkan vasokonstriksi dan berpotensi iskemia jaringan dan nekrosis. Biasanya dikaitkan dengan penyakit arteri koroner tetapi lebih ke peningkatan aktivitas saraf simpatis. Serangan dapat terjadi lebih sering pad amalam hari, pada saat istirahat atau gerakan fisik minimal. Faktor risiko dikaitkan dengan stres, paparan dingin, dan merokok.
Terapi iskemia miokardial bertujuan untuk mencegah terjadinya infark dan kematian (memperpanjang hidup) dan mereduksi gejala (meningkatkan kualitas hidup). Terapi dapat berupa terapi nonfarmakologi dan terapi farmakologi. Terapi nonfarmakologi dengan mengontrol aktivitas fisik, menghindari stres (emosional, fisiologis), menghindari faktor risiko lain seperti hiperlipidemia, obesitas, hipertensi, diabetes, merokok dan lain-lain. Target terapi farmakologi adalah peningkatan aliran darah koroner  melalui dilatasi arteri koroner, penurunan beban kerja jantung melalui reduksi denyut jantung dan kontraksi. Terapi farmakologi terdiri dari:
  1. Vasodilator nitrat organik, contohnya amil nitrit, nitrogliserin, isosorbid dinitrit. 
  2. Aktivator kanal kalium (mekanisme aksi berupa dilatasi), contohnya nicorandil, pinacidil.
  3. Antagonis Beta adrenoceptor (mekanisme aksi berupa blok reseptor beta sehingga terjadi reduksi denyut jantung dan CO, akibatnya terjadi penurunan beban kerja miokardial dan kebutuhan oksigen), contohnya atenolol, propanolol/
  4. Bloker kanal kalsium, contohnya nifedipin, amlodipin.
  5. ACEI, contohnya captopril, enalapril, lisinopril.
  6. Antiplatelet (tujuannya mencegah agregasi platelet, sehingga menghambat terjadinya trombosis, digunakan sebagai profilaksis terutama pada unstable angina). Berdasarkan mekanisme kerjanya dibagi menjadi 3, yaitu (1) penghambat COX-1, yaitu aspirin, mekanisme kerja dengan menghambat COX-1 dalam mensintesis prostaglandin, prostasiklin, dan tromboksan, sehingga dapat mencegah agregasi platelet sehingga menghambat terjadinya trombosis. Trombosis adalah proses koagulasi/penggumpalan darah di dalam pembuluh darah; (2) antagonis ADP, mekanisme aksi sebagai antagonis kompetitif reseptor ADP, contohnya ticlopidine dan clopidogrel (prodrug). ADP dilepaskan oleh trombosit yang aktif ke membran trombosit lain yang kemudian akan mengaktifkan enzim fosfolipase yang pada akhirnya terbentuklah tromboksan yang berperan dalam agregasi trombosit; (3) Antagonis GPIIb/IIIa, mekanisme kerja sebagai antagonis kompetitif reseptor GPIIb/IIIa. Reseptor ini juga berperan dalam pembentukkan tromboksan. Contoh obat golongan ini adalah antibodi monoklonal (abciximab), peptida sintetik eptifibatide, dan molekul sintetik (tirofiban). 


Infark miokardial, lebih sering didengar sebagai serangan jantung, adalah kerusakan atau kematian jaringan miokardial akibat iskemia. Terjadi akibat adanya blok arteri koroner oleh trombus dan vasospasme kronis. Perlu diketahui bahwa terdapat dua arteri koroner yang menyuplai miokardium, yaitu arteri koroner kiri dan arteri koroner kanan. Sebanyak kurang lebih 50% infark terjadi pada arteri koroner kiri. Ada 2 tipe infark miokardium yaitu transmural (meliputi keseluruhan dinding ventrikel) dan subendokardial (meliputi sepertiga atau separuh dinding ventrikel bagian dalam). 



Terdapat 2 fase pada transmural, fase pertama adalah saat kejadian infark miokard yang dimulai dari iskemia dan berlanjut tanpa penanganan selama 0-2 jam. Sementara fase 2 adalah kelanjutan fase 1, yaitu saat tanpa penanganan selama 2-24 jam, seperti pada gambar di bawah ini.



Pada fase 1 tahap 1, dimulai saat terjadinya iskemia dan belum ada tanda kerusakan maupun nekrosis. Tahap 2 terjadi saat menit kurang dari 20 dan 40 belum juga mendapatkan penanganan, pada tahap ini telah terjadi kerusakan/cedera namun belum sampai ke nekrosis. Tahap 3 terjadi pada menit ke 30, tahap ini telah terjadi nekrosis sebanyak 10%, berlanjut pada menit ke-60 atau pada saat jam ke-1, terjadi nekrosis sebanyak 30%. Pada tahap ke 5, nekrosis telah mencapai separuhnya atau 50% pada jam ke-2.

Fase 2 berlanjut ketika sampai 2 jam dimulai saat terjadinya iskemia pada fase 1 belum juga mendapat penanganan. Pada fase 2 tahap 1 ini, terjadi pada jam ke-3 kelanjutan dari fase 1, telah terjadi nekrosis sebanyak 60%. Berlanjut pada tahap 2, 90% nekrosis terjadi pada 3 jam berikutnya, yaitu di jam ke-6, dan nekrosis mencapai puncaknya, 100%, pada jam ke 24 atau selama 1 hari sejak iskemia dimulai dan tidak juga memperoleh penanganan.

Dalam patogenesis infark miokard, terjadi kompensasi. Kompensasi terjadi akibat hipotensi dan perubahan hemodinamik. Kompensasi berupa:
  • pelepasan katekolamin, menyebabkan peningkatan denyut jantung, kekuatan kontraksi, dan resistensi perifer.
  • retensi natrium dan air.
  • aktivasi sistem RAA.
  • Hipertropi ventrikel.
Perlu diketahui bahwa kompensasi tersebut justru dapat memperparah fungsi jantung yang mengalami infark. Manifetasi klinisnya berupa nyeri dada parah, kerusakan ireversibel, pelepasan enzim miokard, perubahan EKG, respon inflamasi, dan nekrosis. 
  1. Nyeri dada berupa nyeri dada yang parah dan rasa tidak nyaman, sensasi tertekan dan rasa remuk pada dada diikuti mual, muntah, berkeringat, dan lemah. 
  2. Terkait pelepasan enzim, enzim dilepaskan oleh sel yang rusak yang akan lisis, enzim tersbut berupa CPK (creatinine phosphokinase), lactate dehydrogenase (LDH) ke dalam darah. 
  3. Perubahan EKG terjadi pada gelombang T, ST, dan Q. 
  4. Respon inflamasi muncul akibat sel miokardium cedera, akibatnya terjadi infiltrasi leukosit, peningkatan jumlah leukosit dan demam.
  5. Nekrosis, berupa kematian sel yang terjadi di area miokardium yang mengalami infark.
  6. Jaringan parut terjadi akibat perbaikan jaringan yang mengalami nekrosis. 
Komplikasi infark miokard terjadi tergantung dari area infark. Komplikasi dapat berupa lepasnya sel miokard yang mati yang menyebabkan perdarahan dalam ventrikel, terbentuknya tromboemboli, perikarditis (umumnya terjadi 1-2 hari setelah infark), aritmia, penurunan fungsi jantung, gagal jantung, dan syok kardiogenik. Terapi infark miokard bertujuan untuk meminimalisir area yang mengalami infark, mencegah kerusakan iskemik yang lebih parah, mencegah terjadinya trombosis koroner. Terapi farmakologi berupa:
  1. Antiplatelet, untuk meningkatkan aliran darah dan mencegah kerusakan otot jantung.
  2. Trombolitik, menormalkan aliran darah dengan melarutkan bekuan darah dalam arteri koroner.
  3. Vasodilator, meningkatkan aliran darah ke miokardium dan mereduksi beban jantung.
  4. Beta bloker, mengurangi beban kerja jantung melalui penurunan denyut jantung dan kontraksi.
  5. ACEI, meningkatkan aliran darah.
  6. Antiaritmia, mengontrol ritme jantung yang terjadi akibat infark miokard.
  7. Terapi pendukung berupa oksigen (menjaga suplai oksigen ke jaringan dan level  oksigen otot jantung) dan analgesik (mengurangi rasa nyeri), bila perlu diberi morfin. 
Contoh trombolitik antara lain streptokinase, anistreplase, alteplase, urokinase. Streptokinase diperloeh dari beta-hemolitik streptococcus. Anistreplase merupakan prodrug, kompleks dari plasminogen dan streptokinase. Alteplase merupakan rekombinan tissue plasminogen activator. Sementara urokinase merupakan enzim endogen manusia yang mengkonversi plasminogen menjadi plasmin.

Sekian yang dapat disampaikan. Semua materi diperoleh dari handout kuliah dan hasil mencari dari sumber lain di internet. Digunakan untuk meningkatkan pemahaman, mohon jangan dijadikan sebagai acuan, carilah dari sumber yang lebih valid. Mohon maaf apabila terdapat kesalahan. Semoga bermanfaat. Terima kasih sudah berkunjung :D

Catatan Obat Gangguan Kardiovaskuler #5

Pada catatan kali ini, akan dijelaskan mengenai gangguan kardiovaskuler selain hipertensi, yaitu aritmia. Aritmia merupakan gangguan pada detak jantung atau irama jantung, ketika organ tersebut berdetak terlalu cepat, terlalu lambat, atau tidak teratur. Sebelum membahas lebih lanjut terkait dengan patofisiologinya, perlu diketahui terlebih dahulu fisiologinya, hal-hal seperti apa yang terjadi seharusnya pada keadaan normal.

Pada normalnya, laju dan ritme jantung terjadi ketika miokardium tereksitasi melalui aktivitas listrik. Pada keadaan istrirahat intraseluler, miokardium bertegangan sekitar -90 mV, sementara di nodus SA sekitar -40 mV. Pada keadaan istirahat pula terjadi influks K+ dan efluks Na+ melalui pompa Na+/K+. Potensial aksi terjadi ketika ion Na+ masuk ke intrasel, hal ini menyebabkan stimulasi pada serat otot tunggal, lalu menyebabkan aktivitas listrik menyebar ke seluruh miokardium. Potensial aksi di miokardium terdiri dari 4 fase:
  1. Fase 0: depolarisasi (Na+ influks)
  2. Fase 1: repolarisasi parsial (Na+ inaktif, K+ efluks)
  3. Fase 2: plateu (Ca2+ influks lambat)
  4. Fase 3: repolarisasi (Ca2+ inaktif, K+ influks)
  5. Fase 4: potensial pacemaker (Na+ influks lambat, K+ efluks lambat
  6. Fase 1-3: periode refraktori.  



Terkait dengan penjelasan mengenai apa yang dimaksud dengan depolarisasi dan repolarisasi otot jantung, dapat dibaca di sini

Ritme jantung yang teratur adalah dimulai dari nodus SA sebagai pacemaker (pencetus/pemacu detak jantung). Depolarisasi yang terjadi oleh nodus SA mencetuskan depolarisasi pada atrial. Kemudian menyebar hingga terjadi konduksi di nodus AV secara lambat. Selanjutnya dilanjutkan konduksi melalui berkas/bundel his dan serat purkinje yang lebih cepat. Nodus SA ini dikendalikan oleh sistem saraf otonom. Terkait dengan aktivitas parasimpatis dapat dicetuskan melalui reseptor M2 muskarinik. Sementara aktivitas simpatis melalui reseptor beta 1. Aktivasi pada saraf simpatis ini akan mengakibatkan peningkatan denyut jantung (efek kronotropik positif), peningkatan automatisiti, dan fasilitasi konduksi nodus AV. Ritme jantung/denyut jantung yang normal adalah 60-100 bpm (detak per menit).

Sekilas terkait inotropik dan kronotropik. Inotropik ada dua macam, yaitu inotropik positif dan negatif. Inotropik positif adalah kondisi ketika terjadi peningkatan kontraktilitas miokard, sebaliknya kondisi ketika terjadi penurunan kontraktilitas miokard adalah inotropik negatif biasanya obat yang berperan seperti ini digunakan untuk mengurangi beban kerja jantung. Kronotropik juga terbagi menjadi dua macam, yaitu kronotropik positif dan negatif. Kronotropik positif adalah kondisi ketika terjadi peningkatan denyut jantung melalui pengaruhnya pada saraf dan mengubah irama yang dihasilkan oleh nodus SA. Sebaliknya, kronotropik negatif adalah yang berperan dalam menurunkan denyut jantung juga dengan cara mengubah irama yang dihasilkan oleh nodus SA. 

Alat yang digunakan untuk merekam aktivitas listrik jantung adalah EKG. Pada rekamannya, dapat dilihat pola yang menunjukkan depolarisasi dan repolarisasi dari miokardium. Pola yang tampak adalah P-QRS-T. P adalah saat ketika terjadi depolarisasi atrial. QRS adalah saat terjadi depolarisasi ventrikel. Sementara T adalah saat terjadi repolarisasi ventrikel.

[Sumber Gambar: elearning.code3cme.com]

Aritmia jantung dihasilkan akibat gangguan pembentukkan impuls, konduksi impuls, atau kombinasi keduanya. Gangguan pembentukkan impuls dapat berupa:
  1. Sinus bradikardi (< 60 bpm) disebabkan oleh lambatnya spontanitas SA.
  2. Sinus takikardi (> 100 bpm) disebabkan oleh cepatnya cetusan nodus SA.
Gangguan konduksi impuls dapat berupa (1) blok jantung yang menyebabkan blok/memperlambat konduksi, dan (2) proses reentry akibat blok searah dalam pathway konduksi (iskemia/IM). Gangguan aritmia dapat pula terjadi akibat kecacatan dari kanal ion tervoltasi (voltage-gated ion channel) secara genetik. Reentry adalah reaktivasi jaringan refraktori akibat blok konduksi. Manifestasi klinik pada pasien aritmia jantung antara lain memiliki denyut jantung yang mengalami peningkatan atau penurunan, ritme jantungnya dapat teratur atau tidak teratur, dan kompleks pada EKG-nya dapat sempit atau luas. Aritmia terjadi karena ada reentry, sirkuit menjadi abnormal. Contohnya pada WPW (Wolf Parkinson White) sindrom. 


WPW sindrom adalah gangguan beberapa sistem konduksi dari jantung yang sering disebut  sindrom pra eksitasi. Pada jantung normal, sinyal listrik hanya menggunakan satu jalur pada saat memasuki jantung. Saat sinyal listrik bergerak dari atrium menuju ventrikel diperlukan jeda agar jantung berdetak dengan tepat. Jika ada jalur konduksi ekstra, sinyal listrik bisa mencapai ventrikel terlalu cepat sehingga gejala yang dialami penderita WPW sindrom berupa takikardi, pusing, dada berdebar, dan serangan jantung (jarang terjadi).

Cardiac channelopathies merupakan salah satu bentuk aritmia akibat genetik. Jadi terjadi gangguan fungsi pada subunit kanal ionnya. Subunit kanal ion dapat mengalami gangguan fungsi akibat terjadi mutasi pada gen yang meregulasinya yaitu Ankyrin B dan LQT4. Akibatnya, potensial aksi dapat terjdadi lebih cepat, atau lebih lambat. 


Manajemen untuk antiaritmia berupa terapi nonfarmakologi dan farmakologi. Terapi nonfarmakologi untuk aritmia akut adalah carotid sinus massage. Terapi profilaksis (untuk mencegah penyebaran penyakit) dapat digunakan implamantable defibrillator (stimulator detak jantung). Terapi nonfarmakologinya dapat juga digunakan pacing yang bersifat sementara maupun yang permanen. 

Terapi farmakologi memiliki taget untuk automatisiti dan konduksi agar dapat mengembalikan ritme jantung ke normal, mencegah kekambuhan, memperbaiki konsekuensi hemodinamik aritmia, dan mereduksi risiko keparahan aritmia. Obat-obatan antiaritmia berdasarkan Vaughan-Williams Classification, terdiri dari beberapa kelas, yaitu:
  1. Kelas I, bloker kanal natrium (aksi membran secara langsung).
  2. Kelas II, yaitu antagonis beta adrenoseptor.
  3. Kelas III, yang dapat memperlama repolarisasi atau durasi potensial aksi.
  4. Kelas IV, yaitu bloker kanal kalsium.
  5. Selain itu antiaritmia dapat pula berupa agonis purinergik dan glikosida digitalis.  
Antiaritmia kelas I memblok kanal natrium, pada subunit alfa. Mempengaruhi aksi membran secara lansgung, efek ke fase 0 (potensial aksi) di mana terjadi reduksi laju maksimum depolarisasi.  Kelas I ini terbagi lagi menjadi 3, yaitu: (1) Kelas Ia yang memblok kanal natrium dan juga kanal kalium, sehingga terjadi prolong periode refraktrori. Contoh obat yang termasuk golongan Ia adalah quinidine, disopyramide, dan procainamide. Obat ini biasa digunakan untuk mencegah kekambuhan fibrilasi atrial; (2) Kelas Ib yang memblok kanal natrium, yang bekerja lebih efektif pada laju yang tinggi, contoh obatnya adalah lidocaine dan mexiletine. Obat ini biasa digunakan untuk pengobatan dan pencegahan takikardi ventrikular dan fibrilasi ventrikular; serta (3) Kelas Ic yang memblok kanal natrium, tanpa dipengaruhi laju, contoh obatnya adalah flecainide dan encainide. Obat ini biasa digunakan untuk mencegah fibrilasi atrial dan sindrom WPW.

Antiaritmia kelas II berperan sebagai antagonis beta adrenoseptor. Perlu diketahui bahwa adrenalin dapat menyebabkan aritmia melalui efeknya terhadap potensial pacemaker dan influks kalsium secara lambat. Aritmia terjadi pula akibat peningkatan aktivitas simpatis. Aktivitas simpatis ini mempengaruhi konduksi AV secara kritikal. Oleh karena itulah obat golongan ini berperan dalam meningkatkan periode refraktori dari nodus AV. Contoh obatnya adalah propanolol. Kegunaannya adalah untuk mencegah kekambuhan takiaritmia (fibrilasi atrial akibat aktivitas simpatis).

Antiaritmia kelas III, berperan dalam memperlama atau prolong potensi aksi miokardium melalui prolong interval QT dan periode refraktori. Mekanismenya masih belum jelas sepenuhnya. Namun, mungkin terlibat dalam penghambatan kanal kalium pada saat repolarisasi, meningkatkan influks kalsium selama prolong potensi aksi sehingga menyebabkan peningkatan fase after-depolarisation, interupsi reentrant takikardi, atau menekan aktivitas ektopik. Contoh obatnya adalah amiodarone dan satolol. Kegunaannya adalah untuk takikardi terkait sindrom WPW, efektif untuk takiaritmia supraventrikular dan ventrikular. Sotalol digunakan pada SVT dan menekan denyut ektopik ventrikular.

Antiaritmia kelas IV, berperan dalam memblok kanal kalsium. Konduksi pada nodus SA dan AV diperlambat, direduksi pula fase after depolarisation-nya sehingga menekan timbulnya denyut ektopik prematur. Contoh obatnya adalah verapamil dan diltiazem. Digunakan untuk menegah kekambuhan paroximal supraventricular tachycardia (SVT) dan mereduksi laju ventrikel pada pasien dengan fibrilasi atrial.

Selain antiaritmia di atas, terdapat adenosine yang tidak termasuk kelas antiaritmia, merupakan nukleotida purin yang dapat mengaktivasi reseptor A1 dan mempunyai efek terhadap nodus AV. Reseptor A1 ini berhubungan dengan kanal kalsium miokardium yang diaktivasi oleh asetilkolin. Konduksi nodus AV diperlambat, terhadi hiperpolarisasi dan memperlambat peningkatan potensial pacemaker, mengagntikan posisi verapamil karena lebih aman dengan waktu paruhnya yang pendek. Digunakan untuk terminasi SVT. 

Antiaritmia digoksin juga tidak termasuk ke dalam kelas antiaritmia, mekanismenya adalah memblok Na/K-ATPase pada membran sel sehingga meningkatkan natrium intrasel dan kalsium. Meningkatkan kontraksi miokardium, memperlambat konduksi AV melalui peningkatan periode refraktori nodus AV. Digunakan untuk fibrilasi atrial. 

Demikian yang bisa dituliskan. Semua materi saya peroleh dari handout kuliah dan hasil mencari dari sumber lain yang saya temukan di internet. Mohon maaf apabila terdapat kesalahan. Jangan dijadikan sebagai referensi, gunakan untuk meningkatkan pemahaman saja. Semoga bermanfaat. Terima kasih sudah berkunjung :)