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All Journal Jurnal Ners Indonesia Sains Olahraga : Jurnal Ilmiah Ilmu Keolahragaan Jurnal Kedokteran Brawijaya Media Ilmu Keolahragaan Indonesia Jurnal Kedokteran dan Kesehatan : Publikasi Ilmiah Fakultas Kedokteran Universitas Sriwijaya Jurnal Kedokteran Anatomica (Anatomica Medical Journal) Jurnal Respirologi Indonesia Jurnal Keperawatan dan Fisioterapi (JKF) Jurnal Respirasi (JR) JURNAL ONLINE KEPERAWATAN INDONESIA Medika Kartika : Jurnal Kedokteran dan Kesehatan Jurnal Ilmiah PANNMED (Pharmacist, Analyst, Nurse, Nutrition, Midwivery, Environment, Dentist) Journal of Telenursing (JOTING) SCRIPTA SCORE Scientific Medical Journal Caring : Indonesian Journal of Nursing Science Respiratory Science Jurnal Impresi Indonesia Journal of Endocrinology, Tropical Medicine, and Infectious Disease (JETROMI) International Journal of Health and Pharmaceutical (IJHP) The Journal of Society Medicine (JSOCMED) Jurnal Keperawatan Medicina Biomedica Journal Jurnal Kesehatan
Tarigan, Amira Permatasari
Department Of Pulmonology And Respiratory Medicine, Faculty Of Medicine, Universitas Sumatera Utara/Universitas Sumatera Utara Hospital, Medan
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Relationship Between Asthma Therapy Types, Pulmonary Function, and Asthma Control in Primary Healthcare Facilities in Medan Darmawan, Nengah; Tarigan, Amira Permatasari; Pradana, Andika
Journal of Society Medicine Vol. 4 No. 2 (2025): February
Publisher : CoinReads Media Prima

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.71197/jsocmed.v4i2.194

Abstract

Introduction: Asthma is a chronic respiratory disease that affects millions globally. Effective asthma therapy is essential for improving pulmonary function and achieving asthma control. However, many patients remain uncontrolled despite treatment. This study aims to evaluate the relationship between asthma therapy types, pulmonary function, and asthma control in primary healthcare facilities in Medan. Method: This retrospective descriptive study utilized medical records of asthma patients from May 2022 to May 2023 at several primary healthcare centers in Medan. Data collected included demographic characteristics, asthma therapy types (inhaler vs. inhaler + oral), pulmonary function (APE prediction), and asthma control levels. Chi-Square tests were performed to assess statistical associations. Results: The study found that most asthma patients were female (83.3%) and over 50 years old (62.5%). Regarding pulmonary function, 73.0% of patients had an APE prediction of ≥60%, indicating relatively good lung function. However, asthma control remained poor, with 68.8% of patients classified as uncontrolled. The majority of patients (68.8%) used inhalers as their primary therapy, while 31.2% received a combination of inhaler and oral medication. Statistical analysis showed no significant relationship between the type of asthma therapy and pulmonary function (p = 1.000), nor between the type of therapy and asthma control level (p = 0.067). Conclusion: The study found no significant relationship between asthma therapy type, pulmonary function, and asthma control level. These findings suggest that other factors, such as therapy adherence, proper inhaler technique, and medication adjustments, may contribute to asthma control.
Profil Tatalaksana ICS/LABA pada Pasien Asma Persisten Sedang di Poliklinik Paru RS Prof. Chairuddin Panusunan Lubis Universitas Sumatera Utara Resti, Riska; Tarigan, Amira Permatasari; Pradana, Andika; Wahyuni, Arlinda Sari
ANATOMICA MEDICAL JOURNAL | AMJ Vol 8, No 2 (2025)
Publisher : Universitas Muhammadiyah Sumatera Utara

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.30596/amj.v8i2.23821

Abstract

Asma adalah penyakit heterogen kronis yang paling umum pada saluran pernapasan di wilayah Asia-Pasifik dengan tingkat kontrol asma tertinggi adalah asma yang terkontrol sebagian yaitu 63%, diikuti oleh asma yang tidak terkontrol sebesar 30% dan asma yang terkontrol penuh sebesar 7%. Tujuan penelitian adalah untuk mengetahui profil penggunaan ICS/LABA berdasarkan tingkat kontrol asma. Penelitian dilakukan dengan metode retrospektif kohort analitik menggunakan 61 rekam medis dari 1 Januari 2017 hingga 31 Desember 2019. Subjek penelitian adalah pasien dengan asma persisten sedang yang menerima terapi ICS/LABA selama minimal 3 bulan. Analisis statistik deskriptif digunakan untuk menilai profil pengobatan ICS/LABA pada hasil klinis. Jenis kelamin didominasi oleh perempuan sebanyak 48 orang (78,7%), rentang usia 41-50 tahun sebanyak 20 orang (32,8%). Pada karakteristik pengobatan didominasi oleh ICS/LABA jenis Diskus Salmeterol/Fluticason propionat dosis 50/250 mcg sebanyak 33 orang (54,1%) dan ICS/LABA jenis Turbuhaler Formoterol Fumarat/Budesonide dosis 4,5/160 mcg sebanyak 28 orang (45,9%). Proporsi tingkat kontrol asma tertinggi adalah asma terkontrol sebagian sebanyak 44 orang (70,5%). Profil penatalaksanaan yang bervariasi didapatkan dengan mayoritas penggunaan ICS/LABA adalah jenis Diskus Salmeterol/Fluticason propionat dengan dosis 50/250 mcg.Kata Kunci : asma persisten sedang, ics/laba, profil tatalaksana
The Effect of Providing Digital Education Through Smartphone Applications on Control Level of Asthma Patients at Outpatient Clinic University of North Sumatra Hospital Medan Pohan, Indah Triana Sari; Tarigan, Amira Permatasari; Pandiaman, Pandia; Erna, Mutiara
Journal of Society Medicine Vol. 4 No. 4 (2025): April
Publisher : CoinReads Media Prima

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.71197/jsocmed.v4i4.199

Abstract

Introduction: Asthma is a chronic airway disease where achieving and maintaining asthma control is the main goal of management. Effective asthma control requires good patient self-management, including the ability to recognize symptoms and take appropriate action. This study aimed to assess the effect of digital education through the Paru Sehat smartphone application on asthma control levels in patients at the Outpatient Clinic of the University of North Sumatra Hospital, Medan. Method:This study used a quasi-experimental within-subject (pre-post) design. Asthma control levels were measured using the Asthma Control Test (ACT) before and after the use of the Paru Sehat application. Data analysis was conducted using a paired t-test for normally distributed data and the Wilcoxon test for non-normal data. A p-value <0.05 was considered statistically significant. Results: Before the intervention, 56% of patients had partially controlled asthma, 40% were uncontrolled, and only 4% were fully controlled. After using the Paru Sehat application, the proportion of fully controlled patients increased to 20%, partially controlled decreased to 48%, and uncontrolled cases reduced to 32%. However, this improvement was not statistically significant (p = 0.058). Conclusion: The use of the Paru Sehat application showed a trend toward improved asthma control, but the change was not statistically significant. Further research with a larger sample size and longer intervention duration may be needed to determine its effectiveness.
Correlation Between Fagerstrom Score and Brinkman Index With Spirometry Results in Lung Cancer Patients at Haji Adam Malik General Hospital and Prof. Dr. Chairuddin Panusunan Lubis Hospital University of North Sumatera Medan Pinem, Agung Haganta; Tarigan, Setia Putra; Tarigan, Amira P.; Ashar, Taufik
Jurnal Impresi Indonesia Vol. 4 No. 8 (2025): Indonesian Impression Journal (JII)
Publisher : Riviera Publishing

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.58344/jii.v4i8.6944

Abstract

Lung cancer is one of the leading causes of cancer-related deaths globally. Cigarette smoking remains the primary risk factor. The Fagerstrom Test for Nicotine Dependence (FTND) and the Brinkman Index are used to assess nicotine addiction and smoking intensity, respectively. These indices are associated with pulmonary function, typically assessed through spirometry. Objective: To determine the relationship between Fagerstrom scores and Brinkman Index with spirometry results in lung cancer patients. Methods: This quantitative observational study applied a cross-sectional design involving 68 smoking lung cancer patients at RSUP Haji Adam Malik and RS Prof. CPL Universitas Sumatera Utara. Data were collected via FTND and Brinkman Index questionnaires and spirometry testing. Data were analyzed using the Kruskal-Wallis test with a significance level of p<0.05. Results: Most patients exhibited moderate nicotine dependence (44.1%) and moderate smoking history per Brinkman Index (52.9%). Spirometry results indicated a high prevalence of obstructive and restrictive impairments. There was a significant correlation between FTND/Brinkman Index and lung function (p<0.001). Conclusion: Both Fagerstrom scores and Brinkman Index show a strong relationship with spirometry outcomes, indicating impaired pulmonary function among lung cancer patients.
COMPARISON OF UPPER EXTREMITY MUSCLE STRENGTH BETWEEN PATIENTS WITH STABLE AND EXACERBATED CHRONIC OBSTRUCTIVE PULMONARY DISEASE AT A HOSPITAL IN MEDAN Rocky Malindo Sidabutar; Amira Permatasari Tarigan; Pandiaman Pandia; Taufik Ashar
Jurnal Kedokteran dan Kesehatan : Publikasi Ilmiah Fakultas Kedokteran Universitas Sriwijaya Vol. 12 No. 3 (2025): Jurnal Kedokteran dan Kesehatan : Publikasi Ilmiah Fakultas Kedokteran Univers
Publisher : Fakultas Kedokteran Universitas Sriwijaya

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32539/jkk.v12i3.688

Abstract

One of the main complications in patients with COPD is muscle weakness or atrophy, which becomes more pronounced during exacerbations, leading to a decline in quality of life, prognosis, and an increased risk of future exacerbations. This study compared upper limb muscle strength between stable COPD patients and those experiencing exacerbations. A cross-sectional study design was used, with an independent sample t-test to compare the mean values of two unpaired groups. Sampling was conducted using a non-probability consecutive sampling technique. Researchers assessed upper limb muscle strength using a Hand-grip Dynamometer on a predetermined sample size that met the inclusion and exclusion criteria. The results showed a significant correlation between the history of exacerbations within the past year and COPD in both groups (p < 0.05). Upper limb muscle strength in the exacerbation group was lower than in the stable COPD group. The independent t-test yielded a p-value of 0.001, indicating a significant difference in upper limb muscle strength between the stable and exacerbation COPD groups.
Effectiveness of the 4-7-8 Breathing Technique in Enhancing Sleep Quality for COPD Patients Satria, Orita; Nasution, Nurromsyah; Apriani, Fitri; Andriani, Rizki; Damayanti, Siti; Permatasari Tarigan, Amira
Jurnal Respirologi Indonesia Vol 45 No 4 (2025)
Publisher : Perhimpunan Dokter Paru Indonesia (PDPI)/The Indonesian Society of Respirology (ISR)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36497/jri.v45i4.948

Abstract

Background: Chronic obstructive pulmonary disease (COPD) is a disease that is a health problem throughout the world. COPD sufferers can experience problems with decreased oxygen levels. This incidence can cause COPD sufferers to experience decreased sleep quality. Poor sleep quality will have an impact on the sufferer's physiology. Therefore, COPD sufferers can do breathing exercises, such as the 4-7-8 breathing exercises, which play a role in maximizing oxygen in the respiratory system. This study was conducted to determine the effect of 4-7-8 breathing exercises on improving sleep quality in patients with COPD Method: This study used a quasi-experimental design with a pretest-posttest without a control. This research was conducted on 45 samples, which were recruited in Cut Nyak Dhien Regional Hospital's pulmonary polyclinic, from February 29 to March 18, 2024. The main interventions carried out are the 4-7-8 breathing technique, and the study tool is the Pittsburgh Sleep Quality Index (PSQI) questionnaire. The data analysis method used was the Wilcoxon statistical test. Results: There is a decrease from 13.33 (pre-intervention) to 4.93 (post-intervention) for the mean score of the breathing exercise 4-7-8. There is a significant influence between influence of the 4-7-8 breathing exercise on improving sleep quality in COPD patients (P=0.001). Conclusion: There is a significant effect of breathing exercise 4-7-8 on improving sleep quality in COPD patients.
Intervention Effect Between Smartphone and the Knowledge in Chronic Obstructive Pulmonary Disease Patients at Prof Chairuddin Panusunan Lubis General Hospital Tarigan, Amira Permatasari; Pradana, Andika; Rhinsilva, Ella; Ramadhani, Adini Arifah; Sihombing, Benny; Monica, Nanda Soraya; Vera, Yeni
SCRIPTA SCORE Scientific Medical Journal Vol. 5 No. 2 (2024): SCRIPTA SCORE Scientific Medical Journal
Publisher : Talenta Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.32734/scripta.v5i2.14694

Abstract

Background: Health applications can assist in managing chronic patients such as Chronic Obstructive Pulmonary Disease (COPD). A smartphone application “Paru Sehat” is expected to help COPD patients increase their knowledge about the disease and its treatment. Objective: This study aims to examine the benefits of smartphone applications “Paru Sehat” on the level of knowledge of patients with the COPD about the disease and its treatment. Methods: A quasi-experimental studies were conducted in outpatient of stable COPD patients at Pulmonology and Respiratory Medicine Universitas Sumatera Utara Hospital. This research was conducted from March to June 2022. A questionnaire which elaborated question about COPD and its treatment were used to evaluate the level of knowledge of participants before and after 3 months of using smartphone application “Paru Sehat”. Results: From a sample of 38 COPD patients, the average knowledge level of COPD patients before using the “Paru Sehat” application as 5.125; after using the smartphone application, it was 8.5625. The hypothesis test shows that the value of p = 0.000, indicating an increase in the level of knowledge about COPD and its treatment. Out of 38 patients, all research subjects were male with the most age being 60 to 70 years old, having a history of heavy smoking and the highest level of severity of COPD 2. Conclusion: “Paru Sehat” application can influence the knowledge of COPD patients about their illness and treatment as well as the patient's independence in dealing with their illness. Keyword: COPD, level of patient knowledge, smarthphone application Latar Belakang: Aplikasi kesehatan dapat membantu dalam menangani pasien kronis seperti Penyakit Paru Obstruktif Kronik (PPOK). Aplikasi smartphone “Paru Sehat” diharapkan dapat membantu pasien PPOK meningkatkan pengetahuannya tentang penyakit dan pengobatannya. Tujuan: Penelitian ini bertujuan untuk menilai manfaat dari aplikasi smartphone “Paru Sehat” untuk tingkat pengetahuan pasien PPOK mengenai penyakit dan pengobatannya.  Metode: Penelitian quasi eksperimental dilakukan pada pasien PPOK stabil rawat jalan di Pulmonologi dan Kedokteran Respirasi Rumah Sakit Universitas Sumatera Utara. Penelitian ini dilakukan antara bulan Maret 2022 hingga Juni 2022. Kuesioner yang berisi pertanyaan tentang PPOK dan pengobatannya digunakan untuk mengevaluasi tingkat pengetahuan peserta sebelum dan sesudah 3 bulan menggunakan aplikasi smartphone “Paru Sehat”. Hasil: Dari sampel 38 pasien PPOK, rata-rata tingkat pengetahuan pasien PPOK sebelum menggunakan aplikasi smartphone “Paru Sehat” adalah 5,125; setelah menggunakan aplikasi smartphone menjadi 8.5625. Uji hipotesis menunjukkan nilai p = 0,000 yang menunjukkan adanya peningkatan tingkat pengetahuan tentang PPOK dan pengobatannya. Dari 38 pasien, seluruh subjek penelitian berjenis kelamin laki-laki dengan usia terbanyak yaitu 60 hingga 70 tahun, memiliki riwayat perokok berat dan tingkat keparahan PPOK 2 tertinggi (GOLD 2). Kesimpulan: Aplikasi “Paru Sehat” dapat mempengaruhi pengetahuan pasien PPOK tentang penyakitnya dan pengobatannya serta kemandirian pasien dalam menghadapi penyakitnya. Kata Kunci: Aplikasi smartphone, PPOK, tingkat pengetahuan pasien
Effects of Upper Arm and Breathing Exercise on Interleukin-6 in COVID-19 Patients Tarigan, Amira Permatasari; Listyoko, Aditya Sri; Pandia, Pandiaman; Pradana, Andika; Eyanoer, Putri Chairani; Sinaga, Sudirman Parningotan; Vera, Yeni; Firdaus, Ruby; Ramadhani, Adini Arifah
Jurnal Respirasi Vol. 10 No. 1 (2024): January 2024
Publisher : Faculty of Medicine Universitas Airlangga

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.20473/jr.v10-I.1.2024.36-41

Abstract

Introduction: COVID-19 disease has become a comprehensive world issue and has been declared a significant threat to global health. Interleukin-6 (IL-6) is an important inflammatory marker and one of the triggers of the cytokine storm in COVID-19, where increased levels can be an independent predictor of COVID-19 mortality. This study aimed to observe the effect of upper arm and breathing exercises on IL-6 levels in severe COVID-19 patients. Methods: The study design was quasi-experimental, with blood tests conducted before and after the examination. A total of 20 patients with confirmed COVID-19 were involved, divided into intervention and control groups. Results: Blood tests to determine baseline IL-6 levels were performed in all patients. Patients from the intervention group were given upper arm and breathing exercises for ten days, twice a day, via video tutorials on mobile phones, while patients from the control group did not receive any exercises. Patients from the intervention group obtained mean pre- and post-exercise IL-6 levels of 42.38 ± 48.48 and 16.78 ± 18.29, respectively (p = 0.005). Conclusion: Upper arm and breathing exercises showed significant changes in IL-6 levels in severe COVID-19 patients.
Deterioration of Respiratory Symptoms in Uncontrolled CPFE: A Case Report Raffael, Frans; Tarigan, Amira Permatasari
Jurnal Respirasi Vol. 11 No. 1 (2025): January 2025
Publisher : Faculty of Medicine Universitas Airlangga

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.20473/jr.v11-I.1.2025.54-61

Abstract

Introduction: Chronic obstructive pulmonary disease (COPD) has a global impact on health and increases healthcare costs. Combined pulmonary fibrosis and emphysema (CPFE) combines interstitial lung disease (ILD) and emphysema. Excessive short-acting β2-agonist (SABA) usage escalates exacerbation risk, affecting prognosis. Case: A 44-year-old former smoker presented with worsening shortness of breath, cough, and weight loss. Examination showed respiratory distress, including wheezing. Initially, he was diagnosed with tuberculosis (TB) and COPD exacerbation. He regularly used jet nebulizers without medical supervision, and during the initial treatment, he developed acute respiratory failure, leading to acidosis. Treatment involved SABA and short-acting muscarinic-antagonist (SAMA), steroids, and oxygen therapy. In November 2023, his condition worsened, requiring emergency treatment. Radiological findings indicated CPFE. Management included nebulized medications, intravenous steroids, and antibiotics. Despite challenges, he rarely attended follow-up appointments after showing improvement, missing scheduled rehabilitation therapy, inhaler monitoring, comorbid therapy, and home oxygen monitoring. Conclusion: Combined pulmonary fibrosis and emphysema combines ILD and emphysema, causing severe respiratory impairment. Management mirrors that of COPD, involving inhalers, corticosteroids, and oxygen therapy.
A Rare Case of Completely Healed Pneumomediastinum Due to Asthma Exacerbation in A Young Male Patient Tarigan, Amira Permatasari; Pandia, Pandiaman; Pradana, Andika; Hutabarat, Eva Susanti Debora; Ramadhani, Adini Arifah
Respiratory Science Vol. 4 No. 2 (2024): Respiratory Science
Publisher : Indonesian Society of Respirology (ISR)

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.36497/respirsci.v4i2.95

Abstract

Background: The term pneumomediastinum (PNM) refers to the presence of air within the mediastinal cavity. This illness is uncommon but can arise in adolescents with severe asthma attacks. In children aged 5 to 34, the incidence of pneumomediastinum after an acute asthma attack is 1 in 25,000. Men made up the majority of patients (76 percent of all cases). Pneumomediastinum can be diagnosed with the assistance of a chest CT scan. Case: A young man was diagnosed with pneumomediastinum due to an acute asthma attack in this case report. Symptoms of uncontrolled asthma include shortness of breath that worsens with wheezing, chest tightness, and a nonproductive cough. Since the age of 12, the patient in this instance has been receiving salbutamol inhalers. The physical examination revealed polyphonic lung respiration and subcutaneous crepitus in the neck, shoulders, and anterior chest. With adequate management of an asthma episode, pneumomediastinum recovers spontaneously, followed by recurrent symptomatic status, physical examination, and radiography examination. Discussion: Acute asthma exacerbations are one of the factors that can lead to spontaneous pneumomediastinum, in which mediastinal air can permeate the tissue and generate a pneumothorax, and if there is air in the subcutaneous area, it can lead to subcutaneous emphysema. Conclusion: Pneumomediastinum was a rare incidence, pulmonologists examining young adults with acute asthma exacerbations should evaluate for pneumomediastinum. In usual asthma therapy, a chest CT-scan is essential to screen for pneumomediastinum.
Co-Authors Afiatika Ahsani Afniwati Agus Dwi Susanto Andika Pradana Andika Pradana Andika Pradana Andika Pradana Andriani, Rizki Apriani, Fitri Ardinata, Dedi - Armi Mawaddah Aznan Lelo Bayani, Sri Caecilia Marliana Chandra F Zendrato Christine, Tamara Dalimunthe, Muhammad Bayhaqi Damayanti, Siti Darmawan, Nengah Deneuve, Olivia Monica Dewi Elizadiani Suza ELMAN BOY Elmeida Effendy Endang Susilawati Endang Susilawati Endy Todo Sirait Erna Mutiara Erna, Mutiara Evi Karota Fajrinur Syarani Febrina Susanti Firdaus, Ruby Fotarisman Zaluchu, Fotarisman Ghamal Arif Hanafiah Girsang, Isah Masdiana Harahap, Juliandi Helyanna Helyanna Hisham Farouk Hutabarat, Eva Susanti Debora Jefri, Budi Jubilette Windy Hutabarat Juliandi Juliandi Kawati, Salma Merda Listyoko, Aditya Sri Lucia Aktalina M. Sinaga, Bintang Yinke Marini Puspita Sari Martina Evelyn R.H Maryaningsih, Maryaningsih Miranda, Melly Monica, Nanda Soraya Muhammad Amin Nahrisyah, Putri Nainggolan, Nuryunita Nani Andriani Nasution, Nurromsyah Nasution, Syafiah Amalina Noni Novisari Soeroso Nurul Citta Banu Putri Nuryunita Nainggolan Orita Satria Ozar Sanuddin Pandia, Pandiaman Pandiaman Pandia Pandiaman Pandia Pandiaman, Pandia Pendiaman Pandia Pinem, Agung Haganta Pohan, Indah Triana Sari Putra, M Yusuf Adira Putri C Eyanoer Putri Chairani Eyanoer, Putri Chairani Putri Eyanoer Raffael, Frans Rahmah, Lestari Ramadhani, Adini Arifah Ratna Akbari Ganie, Ratna Akbari Resti, Riska Rhinsilva, Ella Rianti Tarigan Rifda Hayati Rika Endah Nurhidayah Rina Amelia Rocky Malindo Sidabutar S*, Erfiyani Salma Merda Kawati Samoedro, Erlang Santi Syafril, Santi Saragih, M. Khairul Aswin Sembiring, Rosita Juwita Septiani Waruwu Shilvanna Litania Sihombing, Benny Simanjuntak, Donal Anjar Sinaga, Sudirman Parningotan Sri Sumartiningsih Susanthy Djajalaksana Syahrani, Fajrinur Syarani, Fajrinur Tambunan, Adrian Nurrachman Tari Mediyanti Tarigan, Setia Putra Taufik Ashar Tri Setia Negara Sinulingga Ulfa hasanah Vera, Yeni Wahyuni, Arlinda Sari Wilson Arthur Zein Wina Elizabeth Octaria Saragih Wiwien Heru Wiyono Yahwardiah Siregar Yessi Andriani Zainal Yetty Machrina Yusni Yusni Zulkarnain Zulkarnain Zulkarnain Zulkarnain