Kamis, 09 Desember 2010


 Task-shifting concept has been applied for many aspects in our life. It is not a new concept to be introduced in medical field but has been used for hundreds years. For the introduction, I would like to use one simple example in explaining about task-shifting. Basically, family consists of father, mother and children. Previously, the role of father is working to earn money or at least to get some food such as fish, chicken or rice, depending on the occupation. The role of mother is take care and looks after children for their needs as well as for her husband. These jobs include cooking and washing. Nowadays, women have dual functions. They do not only act as wife but do they have their own occupation outside their lovely home. The increase in workload has forced a lot of family to hire servant. This servant helps this family in term of cooking, washing, and look after children while parents working. The example mentioned above explained about task shifting.
     In relation to medical field, task-shifting is very important nowadays. Why it is important? This is because of the lack of human resource as a doctor. The world population is growing fast. The growing of population has expanded world population because the advance health care and technologies, we are able to increase life expectancy. This does not mean that the quality of life has been increased at maximum level. The increased in life expectancy has become other burden to health care facilities because of the increase in number of people with chronic diseases such as hypertension and cancer. At the same time, there is a serious shortage of medical doctor in many parts of the world. In Malawi for example, there is around one doctor for every 100 000 population.
      The phenomenon above has forced us to find other solution in providing adequate medical care to the patients as well as increase in accessibility of the patient to health care facilities and services. In Malawi for example, Government officials had determined a problem related to antiretroviral drugs prescription. This had led to change in the Nurses and Midwives Practice Act and Pharmacy, Medicines and Poisons Act that allow nurse to prescribe drugs for antiretroviral therapy. Other examples include the training of cadre. This task-shifting is not only occurs in low or middle income countries, but it also happen in developed countries. Sweden, United Kingdom and Canada have given authorities to nurse to prescribe medication.  Cadre is important because they can be accessed by population easily. Task-shifting from doctor to cadre could give some benefits if training is sufficient. If sufficient training of cadre is given, we can probably control factors that can lead to in-effectives and in-efficient care by cadres such as irrational drug use. The presence of cadres can be formal or informal. Ethiopia has established a new system related to new cadres creation known as Health extension Worker. The aim of this new system is to establish appropriate legal basis for new cadres so that it can be integrated into civil service system and the existing delivery and regulatory system.  

    In conclusion, task-shifting phenomenon must be evaluated carefully because it can either give a lot of benefits or simply reduce the effectiveness and efficiency of care delivery.

References:1. World Health Organization, 2008. Task Shifting, Global Recommendation and Guidelines.

Selasa, 07 Desember 2010


For this post, I would like to share with readers about SARS and coronavirus infections. Coronavirus is the virus that can cause Severe Acute Respiratory Syndrome. Basically, coronavirus can cause common cold (10 – 35%), with high prevalence of the disease in late fall, winter and early spring. SARS is an outbreak that occurred in 2002-2003. This new emerging disease is originated from Southern China that may be caused of human contact with infected animals such as palm civet, racoon dog or ferret badger. However, these animals are not the natural hosts for this virus. Horseshoe bat is thought to be the natural host.
Basically, the disease transmission can occur by several methods such as large and small aerosols as well as through fecal-oral pathway. Sneezing, coughing, and contact with secretes containing virus can lead to infection.
Pathogenesis of this virus begins with the attachment of virus to respiratory epithelial cells via angiotensin converting enzyme 2 receptor. The virus can disseminate systemically and can be found in blood, urine and stool (up to 2 months). It does not only cause serious lung infection but spread to other organs as well including liver.  In respiratory tracts, viral replication can lead to the damage of epithelial cells. Other than that, chemokines and interleukins are released as well in response to the damage. Other changes include hyaline membrane formation, desquamation of pneumocytes in alveolar spaces and infiltration of monocytes and lymphocytes. Virus usually persists in respiratory tract for about 2 – 3 weeks.

The incubation period of SARS is between 2 – 7 days in average. The clinical manifestation of SARS include high fever, followed by malaise, myalgia, and headache and followed by non productive cough after 1 – 2 days (first week). Some people develop diarrhea. In X-ray examination, we can see patchy consolidations that are frequently seen in lower lobes and peripheral lung regions or interstitial infiltrates. These can progress toward diffuse involvements. In second week, usually the conditions get worst with multi-organs involvement. Adult Respiratory Distress Syndrome may develop. Age more than 50, hepatitis, diabetes, and cardiovascular disease are the risk factors of developing severe form of disease.

The diagnosis of SARS can be confirmed by real time RT-PCR from respiratory tracts specimen and plasma early in the disease and from other specimen such as urine and stool after a week of the disease, tissue culture by using Vero E6 cells as well as serology test. In serology test, antibodies toward virus can be detected within 28 days after disease after the onset of illness. Other lab test that can be performed is blood test. In SARS, we can find lymphopenia with CD4 + T cells are the largest cells affected rather than CD8 + T cells and NK cells.  Thrombocytopenia can also be observed in as the disease progress.

The treatment include supportive treatment such as mechanical ventilator, IV infusion, immunomodulatory such as use of corticosteroid to prevent pulmonary fibrosis and other measures.

In conclusion, prevention of this emerging disease is simple. Hand washing and increased awareness of both infected person and community is needed to reduce the impact of epidemic or pandemic.

References:1. Fauci. Et al. Common Viral Respiratory Infections and Severe Acute Respiratory Syndrome (SARS). Harrison’s Principles of Internal Medicine. 2008.
 2. dr. Titik Nuryastuti Lecture Notes on The Emerging Disease Avian Influenza and Coronavirus/SARS. 2010.

Minggu, 05 Desember 2010

Working together.


     In this post, I would like to give some information about working in a way that is effective and efficient. When we are talking about work, there are a lot of considerations need to be thought. Leadership and teamwork are two out of many aspects that are needed to produce excellent work. I will begin my explanation with leaderships. What is the meaning of leaderships actually? Basically, there are many definition related to this word. Leadership can be defined as a process of establishing direction for a group, gaining members’ commitments and motivating them to achieve goals. Other than that, Hemphills and Coons (1957), stated the meaning of leadership as the behaviour of an individual directing the activities of a group, towards a shared goals. Rauch and Behling (1984), gave other meaning but related; The process of influencing the activities of organized group towards goal achievements. The last but not least is the definition given by Jacobs and Jaques (1990), a process of giving purpose to collective effort and causing a willing effort to be expected to achieve purpose. Leader is a very important person in all organizations. Without leader, the goals or aim of a team or group cannot be formed and developed and the activities cannot be synchronized effectively. There are many characteristics of successful leader, and I would like to mention 9 traits of effective leader that are motivation, flexibility, intelligent, sensitivity to others, stability, self-confident, dominance, high energy and locus of control.
    In the first paragraph, I have mentioned some definition of leadership that consistently mentioned about group. What is group? Is there any different between group and team? A team is something more complex than group according to Weaver, 2008. Group is any collection of people that interacts each other because perceived themselves as having similar purposes or similar interests (Martin and Henderson, 2001). The names mentioned in previous sentence had added other elaboration about team; team is a group of with a sense of common goal or task, the pursuit of which requires collaboration and coordination of its members’ activities, who have regular and frequent interactions with one another. In order to clarify the difference between those terms, I will use one example. Let’s take Facebook as an example. There are thousands or perhaps millions of groups in this social networking program. If we join any group, we do not have any responsibility for that group. We can be either active participants or passive in which we do not do anything for contributing to that group but we join because we are interested in something and shared common interests with them. Team is different than this condition because as a part of team, you need to make decisions, take actions and agree with resolution which that would not have had to do as individuals. In a team, different organizations and professionals shared a common endeavour and act in different ways but expected to work efficiently together towards cooperation, collaboration and good coordination. One of the examples that can be mentioned here is rehabilitative team for disaster management. This team basically consists of 6 domains that have different educational and professional backgrounds but have the responsibility to work together, so that the goals can be achieved. This team consists of medical and paramedical staffs, local authorities, orthotists and prosthetists, NGOs, relatives and neighbours as well as the patients themselves.
    In conclusion, teamwork is a very important concept to be understood. So, everyone in the team knows about their specific roles and responsibilities. Together with the leadership concept, it would produce more efficient and more effective coordination and collaboration.


1.Rai, F. 2009. Leadership and Motivation among Health Care Staff.  (online accessed on December 4th   2010)
URL: http://www.gfmer.ch/GFMER_members/pdf/Leadership_motivation_Fuad_Rai_2009.pdf
2. Tzenalis, A. Sotiriadou, C. 2010. Health Promotion as Multi-professional and Multi-disciplinary Work. (online accessed on December 4th   2010)
URL: http://www.caringsciences.org/volume003/issue2/Vol3_Issue2_01_Tzenalis.pdf

Jumat, 03 Desember 2010

Driving Force


   What is the meaning of motivation? When we see other people are very dedicated of doing something, can we say that they are motivated? Or in case of someone need to do something because he or she is forced to do it, can it be considered as motivation? In this post, I will focus more on the motivation and share some theories and perhaps an example regarding this topic. According to Higgin, 1994, Motivation is related the internal force that drive person to satisfy the unsatisfied goal. In this context, a person is forced to be dedicated or diligent to her or his work. Moreover, motivation is important of the good outcome because person with higher motivation level will do work optimally in order to achieved the desired goal. Other definition of motivation was formulated is a ration of how well an organization converts input in the form of resources, labour, materials, machinery into goods and services (Sink, 1984).
    Motivation is very important in all aspects of life. Because of our future career is medical doctors, I would like to focus more on the health care setting. Basically, motivation of health care workers are related to many aspects such as good incentives, supportive environment, good communication, well-structured organization and many other factors. Lack of motivation can decrease the performance of the work. Commitment toward something is also related to motivation. Lack of motivation can lead to lack of commitment as well. As a result, it can lead to high turnover rates and poor morale. High turnover rates can threaten health care organization in term of profitability, quality of care as well as the fiscal viability of the organization. Why this consequence can occur? Basically, replacement costs more than retention of the worker. According to Joint Commission of Accreditation of Healthcare Organization (JCAHO), in order to replace a nurse, 100% of nurse salary needs to be spent. Example of the turnover case that can increase the hospital cost in replacement is:
       Let say the turnover rates of 30%, the current average turnover rate among health workers and hospital employing 1000 nurses at $ 50 000 per nurse per year will spend $ 15,000,000 a year in replacement cost.
      The cost of when nurses are retained is more cost effective because we can allocate organization fund to give more incentives in term of bonus to the health workers who perform their job well. Other external motivation measures that can be used to sustain healthcare worker are free parking area for worker and contests. Free parking area for worker may lessen our financial burden especially for worker that has low salary. Seminar and program such as short course training can also be done to improve the quality of care by health care workers. Even though incentive and other measures mentioned above are related to increase in commitment and retention, the effect is short. Other measures such as providing the corporate culture that remove the barriers or increases the employee’s potential to find meaning of work should be implemented for long term effect results.
   In conclusion, motivation is an important aspect to drive individual and organization to be dedicated to achieve their aims or goals optimally.


1. A.O. Okaro. Et al. 2010. Impact of Motivation on Productivity of Radiographers in TwoTertiary Healthcare Institutions in Enugu Metropolis Southeastern Nigeria. (online accessed on December 2nd 2010)
URL: http://www.eurojournals.com/ajsr_8_04.pdf
2. Morrison, Eileen E.; Burke, George C. III; and Greene, Lloyd, "Meaning in Motivation: Does Your Organization Need an Inner Life?"(2007). Faculty Publications-School of Health Administration. Paper 1. (online accessed on December 2nd 2010)
URL: http://ecommons.txstate.edu/cgi/viewcontent.cgi?article=1000&context=sohafacp

Kamis, 02 Desember 2010

First step to come.....


 Travel Medicine is one of the fields in medicine that concerns about many aspects of diseases related to travel. It involves interdisciplinary health specialties such as epidemiology, preventive medicine, emergency medicine, infectious diseases, tropical diseases, gastroenterology, dermatology and others in its application.  As we know, different parts of the world have different disease distribution. There are many risks that should be evaluated before we can go to other countries such as destination itself.
    Basically, there are many preparation need to be done before we travel to the other countries. One of the preparations is pre travel medical recommendations:
1. Consult your physician, local Public Health Department, or travel clinics before you are travelling ideally 4-6 weeks before you travel. This allows us to be immunized or taken chemoprophylaxis for malaria as needed.
2. Prepare a traveller’s health history and traveller medical kit. Traveller’s health history consists of several information such as recent medical condition, recent drugs use (generic and brand name as well as the dose), history of drugs allergy, ABO blood type and rhesus factor type, up to date immunizations, name and telephone numbers of your physician as well as the closest relatives.
3.   Make sure you bring your hand phone that in which you can make international call in emergency case.
4. Make sure you have your physician numbers –office, mobile phone as well as fax.
5. Check your insurance coverage for accidents and illness occurring outside your home country.
6. Specifically inquire if your regular insurance policy or health policy will cover medical evacuation by air ambulance.
7. Arrange additional medical plan if you do not have it in case of emergency situation.

   Immunization and chemoprophylaxis plan should be consulted with your physician and we can also check the other websites that provide up to date information regarding disease outbreak, endemic, epidemic and pandemic such as World Health Organization (WHO), Centre of Disease Control and Prevention (CDC), as well as other public and private organizations. In malaria endemic area such as Africa, chemoprophylaxis should be taken against P.falciparum that is resistance chloroquine should be prescribed with doxycycline and atovaquone/ proguanil. Other areas in which hepatitis A is common vaccine should be given. This vaccine should be given and can confer immunity for a year. Second vaccination with hepatitis A after 6-12 months will confer immunity for about 20 years. Typhoid vaccination will confer immunity up to 3 years. Hepatitis B vaccination should be given to people who are planning to work as healthcare workers overseas in which hepatitis B is common there. Other groups include tourist who would like to stay for long periods (more than 3 months). Cholera vaccination should be given to those backpackers travelling to remote area with limited access to medical care as well as people who are working as volunteer in refugees camps and in disaster relief.
   In conclusion, prevention should be taken early because this can prevent transmission of the disease from the other countries as well as bringing infection to our own countries. Travel medical triad that consists of the traveller, the trip and the proposed health intervention.

1. Jong, E.C.Approach to Travel Medicine and a Personal Travel Medicine Kit. (online accessed on December 2nd  2010)
URL: http://www.thelancetglobalhealthnetwork.com/wp-content/uploads/2008/03/jong_ch01-x2613.pdf

2. NHS, 2009. Travel Medicine Guidelines. (online accessed on December 2nd 2010)

Rabu, 01 Desember 2010



  Rabies is one of the viral diseases that infect Central nervous system. For this topic, I would explain more about medical aspect of rabies. Rabies virus belongs to rhabdoviridae family. This virus has become one of diseases that need serious attention because of its clinical manifestation that at worst can lead to death. Early prevention is necessary to prevent complications. Rabies was previously thought to have dogs as its primary hosts and vector. Surveillance and vaccination programs carried out in North America and Europe have revealed wild animals such as bats, racoon and foxes as major hosts for rabies. Basically, different animals have different specific variant or variants. Different variants in different hosts are distributed in different areas geographically. Bats have unrestricted distribution and seemed to be the major contributor for rabies infections in human. This mammalian has one specific variant known as Ln/Ps that has the ability to bind to certain cell receptors or have the greater efficiency in initial replication in non neuronal tissues. Other than rabid animal bites, other means of transmission of rabies are infected corneal transplantation, infected solid organ transplantation, exposure of mucosa or un-intact skin to saliva of rabid animal and etc.

     The pathogenesis of this virus is related to its ability to bind to nicotinic receptors. Before I explain further about the pathogenesis, I would like to give some information about the incubation period. The incubation period for rabies infection is between one month and three months. In rare cases, as short as 2 weeks or as long as more than a year incubation period can occur. Before the virus bind to nerve cells, the replication occurs in other cells, predominantly in muscle cells near the inoculation sites. The presents of specific receptors allow the invasion of both sensory and motor neurons. The transportation methods used are fast axonal transport of virus heading towards spinal cord and brainstem. Virus spread to gray matter in CNS via neuroanatomic connections and leads to inflammatory changes mostly and neuronal death in few neurons. This condition leads to neuronal dysfunction that produce rabies symptoms such as encephalitis, flaccid paralysis and other serious manifestations such coma and death.

       There are three phases of rabies disease: prodrome phase, acute neurologic phase and coma/death phase. The duration of each phase varies.  The duration of prodrome phase is between 1 -7 days. The symptoms include fever, malaise, nausea, vomiting, anxiety, agitation, pruiritus, pain and paraesthesia at the site of inoculation and headache. In acute neurologic phases, there are two kinds of manifestations: encephalitic (in 80%) and Paralytic (in 20%). The duration for the former is 1- 7 days and the latter is 2-10 days. The symptoms of the former one are fever, confusions, hallucinations, hyperactivity and pharyngeal spasm that can lead to hydrophobia as well as seizures. In paralytic rabies the symptom is ascending flaccid paralysis. The third phase duration is 1-14 days.

   In conclusion, rabies can be prevented from complication development if early intervention by rabies PEP is carried out. The awareness of the population in which the prevalence of rabies are high should be raised through education and campaign measures for examples. The information above is simplified and further information can be obtained from Harrison book. 

1.Fauci. et al. Rabies. Harrison's Principles of Internal Medicine. 2008.

Senin, 29 November 2010

What's bothering them?


    In this post, I would like to explain more about post-traumatic trauma disorder (PTSD). If stress is present in acute state and is not recurrent, it may have low probability of developing PTSD. PTSD is common in many unresolved case. The incidence of PTSD is higher when mass disaster happened such as Jogjakarta Earthquake in 2006. There are many clinical manifestation of PTSD including associated symptoms of detachment and loss of emotional responsivity, avoidance behaviours toward stimuli, recurrence thought, dreams and flashback of the events as well as feeling of depersonalized and unable to recall the specific aspect of trauma.

Moreover, there are three stages of disaster’s victim psychological reaction: Shocked stage, Honeymoon stage, Disillusionized  stage. The first stage usually occurs just after the event hit until several days of disaster. There are many criteria of victim who are still living in this stage such acquiring basic needs to survive, finding a place that is secure – that can provide adequate food, and place for sleep, having unclear recognition of reality such as still go to the office to work despite of having serious disaster, concern about their family members excessively and many other symptoms. In the second stage, the duration may vary from each individual. It can take several weeks or several months to proceed to the third stage. People reactions in this honeymoon stage may react differently. Some people tried to escape from the disaster area and migrate to the other area that is more secure. For some people who have skills or other abilities to survive in the new place, this action may allow them to recover faster than other people in term of economy. Other than that, some response by staying at their home instead of dangerous condition that threats them. The action taken may be due to their concern about home or attachment to their home. In this stage, many people are expected to have sleepiness. The third stage is the disillusionized stage. In this stage, people stage to feel hopelessness when mass media stop the reporting the disaster and people that are not affected by disaster (who are living outside the area) start to forget about them. This stage may occur after several months of honeymoon stage and may last for more than a year. 

  The etiology and pathophysiology of PTSD are related to the excessive norepinephrine discharge in locus coeruleus as well as increase in noradrenergic discharge at projection sites in hippocampus and amygdala. This theory correlate PTSD and fear-based memories.

  The treatments of choice for PTSD are SSRIs, TCAs such as imipramine and amitriptyline, MAOI phenelzine, trazadone (for insomnia treatment), propranolol (used in acute phase for PTSD prevention), and many other medications. The first three groups of drugs mentioned above help in reducing anxiety, symptoms of intrusions and avoidance behaviour. Psychotherapeutic therapy can help in the treatment of avoidance therapy and demoralization. 

References:1. Fauci. Et al. Stress Disorder. Harrison’s Principles of Internal Medicine. 2008.
2. Sakurai, S. Miyata, S. Nakagawa, I. PTSD and Natural Disaster.
. [online accessed on November 29th 2010]
URL: http://www.soi.asia/seminar/tsunami/material/PTSD_miyata.pdf