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I Dewa Gede Ugrasena
Department Of Child Health, Faculty Of Medicine, Airlangga University/Dr. Soetomo Hospital, Surabaya, East Java, Indonesia
Biochemistry, Genetics & Molecular Biology Dentistry Earth & Planetary Sciences Health Professions Immunology & microbiology Medicine & Pharmacology Neuroscience Nursing Public Health Other

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CORRELATION PERCENTAGE OF S AND G2/M WITH PERCENTAGE OF LYMPHOBLASTS IN PEDIATRIC ACUTE LYMPHOBLASTIC LEUKEMIA Erawati Armayani; Yetti Hernaningsih; Endang Retnowati; Suprapto Ma'at Ma'at; I Dewa Gede Ugrasena
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol 24, No 1 (2017)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v24i1.1155

Abstract

Leukemia Limfoblastik Akut (ALL) merupakan keganasan klonal di sumsum tulang/Bone Marrow (BM). Angka bertahan hidup5 tahun saat ini >85%, tetapi 15-20% relaps sehingga perjalanan penyakit jelek. Perjalan penyakit jelek jika setelah tahap induksilimfoblas menetap di Darah Tepi (DT) dan BM >5% serta tahap S BM >6%. Tahap G2/M merupakan petunjuk prognosis ALL anak,selain itu sebagai target pengobatan. Tujuan penelitian menganalisis kenasaban persentase tahap S dan G2/M dengan persentaselimfoblas DT pasien ALL anak sebelum dan sesudah kemoterapi induksi. Jenis penelitian analitik observasional longitudinal (kohor)di ALL anak kasus baru diperiksa sebelum dan sesudah induksi. Persentase limfoblas secara mikroskopis. Persentase fase S dan G2/MflowcytometryBD Facs Callibur. Kenasaban bermakna hanya persentase tahap S dan limfoblas sebelum induksi (r=0,449; p=0,007).Kelainan gen ALL pada ekspresi cyclins dan CDK sehingga hilang kendali checkpoint siklus sel, merangsang transisi tahap G1 menjaditahap S. Persentase tahap S tidak berbeda pada remisi dan meninggal (p=0,138). Persentase tahap G2/M berbeda antara remisi danmeninggal (p=0,006) dan bernasab dengan luaran kemoterapi induksi (koefisien Eta= 0,744), G2/M ≥1,26% meramalkan remisi.Terdapat kenasaban antara persentase siklus sel tahap S dengan persentase limfobas sebelum kemoterapi induksi. Persentase siklus seltahap S memberikan gambaran siklus sel pada sel limfoblas. Terdapat kenasaban antara persentase siklus sel tahap G2/M dengan luarankemoterapi induksi tahap G2/M menjadi faktor peramal luaran kemoterapi induksi ALL. Perlu penelitian lanjutan dengan sampel BM,subtipe dan pengamatan semua tahap kemoterapi.
ACQUIRED β−THALASSEMIA IN CHILDREN WITH ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) Maria Christina Shanty Larasati; Mangihut Rumiris; Mia Ratwita Andarsini; I Dewa Gede Ugrasena; Bambang Permono
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol 20, No 1 (2013)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v20i1.444

Abstract

Thalassemias are heterogeneous group of genetic disorders. β-thalassemia is existed due to impaired production of beta globins chains, which leads to a relative excess of alpha globin chains. The abnormalities of haemoglobin synthesis are usually inherited but may also arise as a secondary manifestation of another disease, most commonly haematological neoplasia. This article presenting two cases of acquired β-thalassemia in children with ALL focusing on the diagnosis and the possible relationship between the two haematological diseases. The first case is a four (4) year old boy with ALL-L1 type at maintenance phase of chemotherapy, he suffered from anaemia with Hb 8.0 g/dL, WBC 22,600/mm3 and platelets count of 200,000/mm3, peripheral blood smear revealed anisocytosis, polychromes, hypochromia, basophilic stippling, and normoblastocytes. The result of Hb electrophoresis of Hb A of 54.9%, Hb F of 29.4%, Hb E of 13.4% and Hb A2 of 2.3%. The patient was diagnosed as ALL-L1 type and β-thalassemia. The second case, is a 13 year old girl with remission ALL-L1 type after chemotherapy, she suffered from anaemia with Hb 6.7 g/dL, WBC 12,400/mm3, platelet count was 200,000/mm3, and peripheral blood smear obtained anisocytosis, hypochromia, normoblastocytes, myelocytes and basophilic stippling. The result of Hb electrophoresis are: Hb F 0.41%, Hb A1c 0.78%, Hb A2 2.95% with the conclusion of a β-thalassemia trait, this patient was diagnosed with ALL-L1 type remission + β-thalassemia trait. The case reviewers assume that acquired β-thalassemia which happened in those patients were the altered expression of globin chain which mechanism for this syndrome might be the acquisition of a mutation that affects RNA or proteins involved in β-globin gene regulation and resulting the reduction of the (α/β)-globin biosynthetic ratios, or/and associated with chemotherapy-inducement.
COMPARISON OF PERIPHERAL BLOOD ACTIVATED NK CELL PERCENTAGE BEFORE AND AFTER INDUCTION PHASE CHEMOTHERAPY IN PEDIATRIC ACUTE LYMPHOBLASTIC LEUKEMIA Syntia TJ; Endang Retnowati; Yetti Hernaningsih; I Dewa Gede Ugrasena; Soeprapto Ma’at
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol 23, No 3 (2017)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v23i3.1208

Abstract

Leukemia Limfoblastik Akut (LLA) adalah keganasan sel progenitor limfoid yang berasal dari sumsum tulang dan ditandai proliferasileukosit. Kejadian LLA masih tinggi, sehingga perlu diteliti peran sel NK dalam melawan leukemia. Tujuan penelitian adalah untukmengetahui perbedaan persentase sel NK teraktivasi sebelum dan sesudah pengobatan induksi dan hubungan persentase sel NK teraktivasisebelum pengobatan induksi dengan keluaran kemoterapi pasien LLA anak. Penelitian analitik observasional dengan rancang banguncohort prospektif. Subjek penelitian 27 pasien di Ruang Rawat Inap Hemato-Onkologi Anak RSUD Dr. Soetomo Surabaya, antara bulanMaret–Juli 2016. Metode memeriksa flowcytometry menggunakan alat BD FACS CaliburTM reagen Fast Immune CD56FITC/CD69PE/CD45 Per CP No.katalog.5055879. Analisis statistik dengan uji Wilcoxon Signed Rank dan regresi logistik. Terdapat perbedaan bermaknarerata persentase sel NK teraktivasi sebelum pengobatan induksi 0,57% (SB 0,53%) dan sesudahnya 2,01% (SB 1,86%) p=0,000.Menunjukkan peningkatan bermakna sel NK teraktivasi sesudah pengobatan induksi. Kenasaban sel NK teraktivasi sebelum pengobataninduksi dengan keluaran kemoterapi berkurangnya gejala penyakit (remisi) dan meninggal R=0.723 berarti kenasabannya kuat.Peningkatan persentase sel NK teraktivasi sesudah pengobatan induksi disebabkan kerja kemoterapi meningkatkan hasil MICA/B dankerja activating receptors sel NK (NKG2D) yang bersifat sitotoksik yang kuat. Persentase sel NK teraktivasi sebelum pengobatan induksiyang rendah disebabkan mekanisme menghilangnya tumor di LLA. Terdapat perbedaan bermakna persentase sel NK teraktivasi sebelumdan sesudah pengobatan induksi. Hasilnya dapat menjadi peramal keberhasilan pemberian kemoterapi LLA anak. Persentase sel NKteraktivasi sebelum kemoterapi tahap induksi yang tinggi berpengaruh kuat terhadap keluaran kemoterapi berkurangnya gejala penyakitdan sebaliknya bila rendah berpengaruh terhadap kemungkinan yang bersangkutan meninggal. Diperlukan hasil jangka panjang sampaiselesai dalam pengelolaan pemberian pengobatan terkait.
Correlation between Procalcitonin, Erythrocyte Sedimentation Rate and Red-Cell Distribution Width with Outcomes in ALL Nathalya Dwi Kartikasari; I. G.A.A Putri Sri Rejeki; I Dewa Gede Ugrasena
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol 27, No 3 (2021)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v27i3.1580

Abstract

Acute Lymphoblastic Leukemia (ALL) increases annually and the incidence is mostly found in children. Its high failure rate is due to infection in the induction phase of chemotherapy. One of the strategies is laboratory testing to determine prognostic factors or predictors that can help clinicians determine therapy and outcomes in ALL. Research related to Procalcitonin (PCT), Erythrocyte Sedimentation Rate (ESR), and Red-cell Distribution Width (RDW) test in ALL children with poor outcomes has never been performed at Dr. Soetomo Hospital, Surabaya. This study aimed to determine the correlation of some infection parameters (PCT, ESR, and RDW) with outcomes in ALL. This was a cross-sectional study in the Pediatric Ward of the Dr. Soetomo Hospital in the period of June-August 2019. A total of 34 ALL patients after the induction phase of chemotherapy according to ALL-2018 protocol were included in this research. Procalcitonin, ESR, and RDW were determined using an ELFA method, photometrical capillary stopped-flow kinetic method, and flow cytometry method. The age of the study subjects ranged from 3 months to 16 years old, 32 patients (94.1%) were categorized as ALL-L1, 23 patients (67.6%) used protocol of high-risk group stratification. The study subjects were divided into 10 patients with poor outcomes and 24 patients with a good outcome. Procalcitonin was (2.66±13.15), ESR was (22.65±19.18), and RDW was (14.97±2.727). There was a significant correlation between PCT and outcomes.
Correlation between Serum Ferritin and Heart Function in Children with Major Thalassemia at Dr. Soetomo Hospital Evisina Hanafiati Frans; Mahrus A Rahman; Teddy Ontoseno; I Dewa Gede Ugrasena; R Fatchul Wahabe
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol 26, No 1 (2019)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v26i1.1401

Abstract

 Background: Cardiac hemosiderosis in major thalassemia has a high mortality rate. Serum ferritin levels are routinely performed to measure body iron deposit Early detection of cardiac dysfunction by routine echocardiography is very important to prevent complications due to hemosiderosis. Objective: To analyze correlation between serum ferritin levels and heart function in thalassemia major children. Methods: A cross-sectional study involving children of thalassemia major less than 18 years in the pediatric hematology oncology outpatient clinic at Dr. Soetomo Hospital. The subjects were children diagnosed with thalassemia major who had received more than 10 transfusions and had ferritin levels above 500 µg / L. All subjects were taken through consecutive sampling and performed echocardiography to measure right ventricular systolic function, left ventricular systolic function, and diastolic function. The factors analyzed included serum ferritin levels, TAPSE index, ejection fraction, and E / A ratio. Statistical analysis using chi square. Results: A total of 82 children were taken as the study sample that met the inclusion and exclusion criteria, 1 sample was dropped out due to pneumonia. Serum ferritin was not correlated to right ventricular systolic function (Cramer's phi constant 0.14, p = 0.209). Serum ferritin was not correlated with left heart systolic function (Cramer's phi constant 0.187, p = 0.09). Serum ferritin was not related to diastolic function (Cramer's phi constant 0.124, p = 0.264). Conclusion: Serum ferritin level in major thalassemia was not correlated with cardiac function
Correlation of Epidermal Fibroblast Growth Factor and Clinical Improvement of Asthma in Children after Zinc Supplementation Retno Asih Setyoningrum; Anang Endaryanto; I Dewa Gede Ugrasena
Jurnal Respirasi Vol. 6 No. 3 (2020): September 2020
Publisher : Faculty of Medicine Universitas Airlangga

Show Abstract | Download Original | Original Source | Check in Google Scholar | Full PDF (178.86 KB) | DOI: 10.20473/jr.v6-I.3.2020.61-66

Abstract

Background: Background The presence of remodeling process on the pathogenesis of asthma that involves some growth factors such as epidermal growth factor (EGF) and fibroblast growth factor (FGF) causes the chronicity of the disease. The role of zinc on the pathogenesis of asthma is being widely investigated. This study aimed to analyze the correlation between EGF and FGF2 and clinical improvement of asthma after  zinc supplementation.Methods: A quasi-experimental study was conducted in Outpatient Clinic Dr. Soetomo Hospital. The samples were persistent asthma patients from 6-15 years old who received controller therapy. The samples were divided into 2 groups, those who received zinc supplementation as the intervention group, and who received pacebo as the control. EGF and FGF2 plasma level of both groups were measured, and clinical improvement was evaluated with Childhood Asthma Control Test (C-ACT).Results: There were 11 patients who received zinc supplementation and 12 patients in the control group. There was a significant difference (p = 0.000) on the increase of EGF level in the intervention group (55.59 ± 6.48) than the control (5.35 ± 5.55). There was a significant difference (p = 0.000) on the increase of the FGF2 level in the intervention group (6.37 ± 1.41) than the control (0.72 ± 0.48). The increase of EGF (r = 0.592; p = 0.003) and FGF2 (r = 0.607; p = 0.002) would be followed by the increase of C-ACT scores.Conclusion: Zinc supplementation increase EGF and FGF2 levels. This improvement is correlated with clinical improvement of patients.
Profile of Tumor Necrosis Factor Alpha Levels in Childhood Malignancy with Febrile Neutropenia Tigor Pandapotan Sianturi; Puspa Wardhani; I Dewa Gede Ugrasena
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol 28, No 3 (2022)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v28i3.1886

Abstract

Infection is a significant cause of morbidity and mortality in childhood malignancy with Febrile Neutropenia (FN). Tumor Necrosis Factor-Alpha (TNF-α) is involved in host defense against bacterial invasion. However, changes in TNF-α levels with the possibility of bacterial infection confirmed by blood culture are still unclear. The study aimed to evaluate TNF-α levels in childhood malignancy with FN who had blood cultures with a control group. Observational cross-sectional analysis during January-October 2020 at Dr. Soetomo General Academic Hospital, Surabaya. Childhood malignancy with FN episodes as the case group and nonfebrile neutropenia as the control. TNF-α levels examination used plasma with the Enzyme-Linked Immunosorbent Assay (ELISA) sandwich method. Blood culture results were obtained from the patient's medical record. The differences in TNF-α levels in the case groups and control were analyzed by the T-square test for two independent samples or Mann-Whitney U according to the data distribution. There were 18 cases group with 30 FN episodes and 15 controls. There were 8(26.66%) positive and 22(73.33%) negative blood cultures from 30 FN episodes. The mean TNF-α levels in the positive blood culture cases group and control: 14.72±5.77 and 9.78±2.74 pg/mL, and the median (min-max) negative blood cultures: 12.19 (7.01-25.70) pg/mL. There was no significant difference in TNF-α levels in the positive and negative blood culture cases group (p=0.527), but there was a significant difference in the control (p=0.049 and p=0.027). Therefore, TNF-α levels cannot be used as a marker of bacterial infection in the case groups.
Region Variation of Hematological Malignancies and Solid Tumors in Children in East Java Andi Cahyadi; Esthy Poespitaningtyas; Diah Kusuma Arumsari; Maria Christina Shanty Larasati; Mia Ratwita Andarsini; I Dewa Gede Ugrasena
Asian Journal of Health Research Vol. 2 No. 1 (2023): Volume 2 No 1 (April) 2023
Publisher : Ikatan Dokter Indonesia Wilayah Jawa Timur

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.55561/ajhr.v2i1.71

Abstract

Introduction: The prevalence of childhood cancer in East Java is unevenly associated with differences in exposure to carcinogens in urban-industrial areas, agricultural chemicals, industrial waste along the river, and socio-culture. However, there are no data on regional variations in childhood cancer in East Java. We describe the regional variation of hematological malignancies and solid tumors in East Java. Material and Methods: The study was conducted by cross-sectional on children with cancer aged <18 years in dr. Soetomo General Academic Hospital in 2014-2015. The data evaluated were gender, age, and cancer type (hematological malignancy and solid tumor). They came from Mataraman, Madura Island, industrial-urban areas (Surabaya-Sidoarjo-Gresik), and Tapal Kuda. We used the Chi-square test and Logistic Regression for data analysis (p<0.05 for two-tailed test). Results: During the study period, there were 353 children with cancer, consisting of 56.9% hematological malignancies and 43.1% solid tumors: 60.9% boys, and 82.4% aged <10 years. Hematological malignancies in industries-urban areas are more numerous than in Mataraman, Madura Island, and Tapal Kuda; 67.8%, 52.8%, 47.2%, and 50.9%, respectively (p=0.031). Hematologic malignancies were also more common in aged <10 years (60.5% vs 40.3%; p=0.004 OR=2.265; 95% CI=1.295-3.362) and Javanese race (p=0.025; OR=3.257; 95% CI=1.121-5.263). Children in industrial-urban areas had more hematological malignancies than Mataraman (p=0.027; OR=2.353; 95% CI=1.101-5.030) also Tapal Kuda (p=0.015; OR=1.881; 95% CI=1.132-3.124) and Madura Island (p=0.032; OR=2.033; 95% CI=1.064-3.882). Conclusion: Hematological malignancies in industry and urban areas are more numerous than Mataraman, Madura Island, and Tapal Kuda area. Solid tumors were mostly found on Madura Island.
Non-Genetic Risk Factors for The Formation of Factor VIII Inhibitors in Hemophilia A Patients in RSUD Dr. Soetomo Intani Dewi Syahti Fauzi; Maria C Shanty Larasati; I Dewa Gede Ugrasena
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol. 26 No. 1 (2019)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v26i1.1400

Abstract

Neutralizing alloantibodies (inhibitors) is one of the complications that affect the morbidity and quality of life of hemophilia patient and can be caused by multifactorials. Genetic and inhibitors examination are not routine and expensive. Therefore, identification of non-genetic factors is important to predict the formation of inhibitors. To analyze non-genetic risk factors for the formation of factor VIII inhibitors in children with Hemophilia A.  A cross-sectional study of hemophilia children aged 1-18 years at the pediatric hematology oncology outpatient clinic of Dr. Soetomo hospital in March-April 2018. Factors analyzed included the severity of hemophilia, early age of diagnosis, initial age of therapy, type of replacement therapy, frequency of factor VIII administration, and severity of bleeding by bleeding score. Statistical analysis using Chi square, Fisher, ANOVA and logistic regression analysis. A total of 29 children were evaluated, 7/29 mild, 15/29  moderate, and 7/29  severe hemophilia. Inhibitors were found in 11/29 subjects, 7/11 low (1-5 BU) and 4/11 high titer (> 5 BU). The initial age of diagnosis ≤ 1 year is associated with the formation of factor VIII inhibitors (OR 8.75; 95% CI = 1.5-50.2; p = 0.015). Severity of hemophilia, early age of therapy, type of replacement therapy, frequency of therapy, and bleeding score was not significantly associated with the formation of factor VIII inhibitors. The initial age of diagnosis less than 1 year is a significant risk factor for the formation of factor VIII inhibitors.
Correlation between Serum Ferritin and Heart Function in Children with Major Thalassemia at Dr. Soetomo Hospital Evisina Hanafiati Frans; Mahrus A Rahman; Teddy Ontoseno; I Dewa Gede Ugrasena; R Fatchul Wahabe
INDONESIAN JOURNAL OF CLINICAL PATHOLOGY AND MEDICAL LABORATORY Vol. 26 No. 1 (2019)
Publisher : Indonesian Association of Clinical Pathologist and Medical laboratory

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.24293/ijcpml.v26i1.1401

Abstract

Cardiac hemosiderosis in major thalassemia has a high mortality rate. Serum ferritin levels are routinely performed to measure body iron deposit Early detection of cardiac dysfunction by routine echocardiography is very important to prevent complications due to hemosiderosis. To analyze correlation between serum ferritin levels and heart function in thalassemia major children. A cross-sectional study involving children of thalassemia major less than 18 years in the pediatric hematology oncology outpatient clinic at Dr. Soetomo Hospital. The subjects were children diagnosed with thalassemia major who had received more than 10 transfusions and had ferritin levels above 500 µg / L. All subjects were taken through consecutive sampling and performed echocardiography to measure right ventricular systolic function, left ventricular systolic function, and diastolic function. The factors analyzed included serum ferritin levels, TAPSE index, ejection fraction, and E / A ratio. Statistical analysis using Chi-Square. A total of 82 children were taken as the study sample that met the inclusion and exclusion criteria, 1 sample was dropped out due to pneumonia. Serum ferritin was not correlated to right ventricular systolic function (Cramer's phi constant 0.14, p = 0.209). Serum ferritin was not correlated with left heart systolic function (Cramer's phi constant 0.187, p = 0.09). Serum ferritin was not related to diastolic function (Cramer's phi constant 0.124, p = 0.264). Serum ferritin level in major thalassemia was not correlated with cardiac function.
Co-Authors Ahmad Suryawan Anang Endaryanto Andi Cahyadi Andi Cahyadi Andi Cahyadi Aras, Jusli Arief, Yuni Sufyanti Aryati Aryati Bambang Permono Budi Utomo Diah Kusuma Arumsari Dimarzsiana Dara Sjahruddin Djajadiman Gatot Djajadiman Gatot Dominicus Husada Dominicus Husada Eileen Savage Endang Retnowati Endang Retnowati Erawati Armayani Erfina Lim Esthy Poespitaningtyas Evisina Hanafiati Frans Fauzi, Intani Dewi Syahti Hapsari Widya Ningtiar Harianto Notopuro I Gusti Ayu Putu Eka Pratiwi I Wayan Bikin Suryawan I. G.A.A Putri Sri Rejeki IGAA Putri Sri Rejeki IM Widiaskara Intani Dewi Syahti Fauzi Irene Ratridewi Irwanto, Irwanto Ismoedijanto Kaoru Nishiyama Kardani, Astrid Kristina Kezia Warokka Putri Larasati, Maria C Shanty Mahrus A Rahman, Mahrus A Mangihut Rumiris Maria C Shanty Larasati Maria Christina Shanty Larasati Maria Christina Shanty Larasati Maria Christina Shanty Larasati Masafumi Matsuo Maulidia, Rahmawati Mia Ratwita Mia Ratwita Andarsini Mohammad Sjaifullah Noer Muchtaruddin Mansyur Muhammad Faizi Murti Andriastuti, Murti Mutiani, Faradillah Nathalya Dwi Kartikasari Ninik Asmaningsih Soemyarso Noer Saudah Noer Saudah, Noer Nunki, Nastasya Nursalam Nursalam Nursalam, Nursalam Parwati Setiono Basuki Ponpon Idjradinata Priscilla Putri Harmany PT Pramitha Puspa Wardhani R Fatchul Wahabe Retno Asih Retno Asih Setyoningrum Riadi Wirawan Rianto Setiabudy Risky Vitria Prasetyo Roedi Irawan S.Pd. M Kes I Ketut Sudiana . Savitri Laksmi Winaputri Shanty, Maria Christina Sherly Yuniarchan, Sherly Shrimarti Rukmini Devy Soedewo, Fery Hudowo Soeprapto Ma’at Sudarmo, Subijanto Marto Suprapto Ma&#039;at Ma&#039;at Susanto Nugroho Syntia TJ Taku Shirakawa Tanzilia, May Fanny Teddy Ontoseno Tigor Pandapotan Sianturi Widiaskara IM Yetti Hermaningsih Yetti Hernaningsih