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Bioscientia Medicina : Journal of Biomedicine and Translational Research

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Published by Universitas Sriwijaya

ISSN : - EISSN : 25980580 DOI : -

Core Subject : Health, Science,

Biochemistry, Genetics & Molecular Biology Immunology & microbiology Medicine & Pharmacology Neuroscience

BioScientia Medicina is an open access international scholarly journal in the field of biomedicine and translational research aimed to publish a high-quality scientific paper including original research papers, reviews, short communication, and technical notes. This journal welcomes the submission of articles that offering a sensible transfer of basic research to applied clinical medicine. BioScientia Medicina covers the latest developments in various fields of biomedicine with special attention to medical sciences, Traditional Herb, genetics, immunology, environmental health, toxicology, bioinformatics and biotechnology as well as multidisciplinary studies. The views of experts on current advances in nanotechnology and molecular/cell biology will be also considered for publication as long as they have a direct clinical impact on human health.

Arjuna Subject : Kedokteran - Anatomi

Articles 1,209 Documents

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The Steel-Blue Peppering and Systemic Eosinophilia: Dermoscopic-Histopathological Correspondence of the Tyndall Effect in Generalized Fixed Drug Eruption William Yudistha Anggawirya; Shienty Gaspersz; Ferra Olivia Mawu; Thigita Aga Pandaleke; Anggi Anastasia Ursula Dien
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1538

Background: Generalized fixed drug eruption (GFDE) represents a severe and distinctive variant of delayed-type hypersensitivity, characterized by widespread, recurrent pigmentary lesions involving at least three anatomical sites. Its clinical presentation often mimics extensive lichenoid dermatoses or infectious conditions such as Hansen’s disease, leading to significant diagnostic delays, particularly in geriatric populations with polypharmacy. While dermoscopy offers a non-invasive bridge to histopathology, specific correlative studies in generalized cases remain scarce. Case presentation: We report the case of a 69-year-old male presenting with diffuse, well-demarcated, violaceous plaques affecting the face, trunk, extremities, and genitalia. The eruption demonstrated a pathognomonic acute latency, recurring at identical anatomical sites within six hours of re-exposure to an unprescribed analgesic cocktail. High-definition non-contact polarized dermoscopy identified two distinct morphological patterns: a brown starburst pattern with central clearing on the extremities and diffuse steel-blue peppering on femoral lesions. Notably, the patient exhibited a mixed immunophenotype characterized by marked eosinophilia (2,080 cells per microliter) and elevated total immunoglobulin E (2,295 IU per milliliter). Parasitic infection was rigorously excluded via negative stool examination and serology, and a Naranjo probability score of 10 confirmed a definite adverse drug reaction. Histopathological examination confirmed interface dermatitis with necrotic keratinocytes and marked pigment incontinence. Conclusion: This study illustrates that steel-blue peppering is a reliable dermoscopic surrogate for deep dermal pigment incontinence via the Tyndall effect. The discrepancy between high systemic eosinophilia and low tissue eosinophilia suggests a complex, potentially mixed-hypersensitivity phenotype in generalized cases, distinct from classic localized fixed drug eruption.

Pediatric Steroid High-Responder: Irreversible Visual Loss and Secondary Glaucoma Following Chronic Cutaneous-Ocular Dexamethasone Misuse I Ketut Anom Widyantara Eka Dana Weka Mona; Ni Made Ayu Surasmiati; I Gusti Ayu Ratna Suryaningrum
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1539

Background: Chronic misuse of potent topical corticosteroids can lead to irreversible visual loss, particularly in the pediatric population which exhibits a more aggressive trabecular meshwork remodeling response than adults. This case aims to delineate the silent progression of steroid-induced ocular hypertension in the absence of red-eye symptoms and emphasizes the critical pharmacokinetic risks of cutaneous-ocular absorption in children. Case presentation: We report a catastrophic case of a 7-year-old male presenting with irreversible vision loss following six years of unsupervised, intermittent use of a combined Neomycin-Polymyxin B-Dexamethasone ointment for recurrent hordeolum. The cumulative exposure exceeded 125 mg of Dexamethasone. Examination revealed bilateral dense posterior subcapsular cataracts (PSC) and advanced glaucomatous optic neuropathy in left eye. Following sequential phacoaspiration, the left eye showed persistently elevated IOP (IOP elevated up to 59 mmHg) attributed to decompensated outflow facility. Management required Trabeculectomy with intraoperative 5-Fluorouracil (5 mg/0.1 mL). The high- responder phenotype in children involves rapid formation of Cross-Linked Actin Networks (CLANs) and MYOC gene upregulation. We discuss the double-hit mechanism where cataract extraction washes out hyposecretory factors, unmasking total trabecular blockage. The choice of 5-Fluorouracil over Mitomycin C is defended based on the safety profile regarding hypotony maculopathy in pediatric myopic eyes. Conclusion: Dexamethasone carries a high risk of transcutaneous-ocular absorption in pediatric eye and eyelids. Regulatory reform reclassifying antibiotic-steroid combinations as non-repeatable prescriptions is imperative to prevent such preventable blindness.

Outcomes of Surgical Resection versus Medical Management in Chronic Pulmonary Aspergillosis: A Systematic Review and Meta-Analysis of Comparative Cohorts Avino Mulana Fikri; Fauzar; Roza Kurniati
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1540

Background: Chronic pulmonary aspergillosis (CPA) is a progressive and debilitating fungal infection that complicates structural lung diseases, particularly in patients with a history of treated tuberculosis. The therapeutic strategy remains a subject of intense debate, polarized between surgical resection, which offers a potential definitive cure but carries significant operative risks, and long-term azole therapy, which is suppressive but prone to drug resistance and high relapse rates. This study aimed to systematically evaluate survival outcomes and recurrence risks between these two modalities, specifically addressing the clinical heterogeneity between simple aspergilloma (SA) and chronic cavitary pulmonary aspergillosis (CCPA). Methods: We conducted a systematic review and meta-analysis of six pivotal retrospective cohort studies published between 2013 and 2022, representing the modern era of thoracic surgery. Databases including PubMed, Scopus, and Embase were searched for comparative studies reporting overall survival (OS) and recurrence rates. Data were pooled using a random-effects model to account for clinical heterogeneity. The risk of bias was assessed using the Newcastle-Ottawa Scale (NOS), with specific adjustments for allocation bias and confounding factors. Results: The meta-analysis integrated data from 268 patients. Surgical resection was associated with a significant reduction in all-cause mortality compared to medical therapy (Pooled Hazard Ratio [HR] 0.12; 95% CI 0.04–0.35). In stratified analysis, recurrence rates were 2.7% for simple aspergilloma versus 10.3% for CCPA in surgical arms, contrasting sharply with relapse rates of 36–50% in medical arms upon drug cessation. An analysis of adjuvant antifungal therapy in a subset of patients showed no statistical benefit in completely resected simple aspergilloma. Postoperative complications occurred in 24.5% of surgical cases, primarily consisting of prolonged air leaks. Conclusion: Surgical resection offers superior recurrence-free survival in selected candidates with localized disease compared to medical therapy. While effectively curative for simple aspergilloma, surgery in CCPA acts as a cytoreductive measure with a persisting recurrence risk, necessitating a multimodal approach. Medical therapy remains the mainstay for patients with bilateral disease or poor pulmonary reserve, but requires indefinite duration to prevent relapse.

Functional Restoration of the Superior Auriculocephalic Sulcus in Cryptotia: A Case Report Validating the Twin Compression Theory via an Extended Sub-Galeal Advancement Flap Stevani Irwan; Al Hafiz
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1541

Background: Cryptotia, characterized by the invagination of the superior helix beneath the temporal skin, presents significant functional challenges regarding the retention of eyewear and protective masks. While prevalent in East Asian populations, data from the Indonesian archipelago is scarce. This study aims to document the functional and aesthetic outcomes of a modified surgical technique in a monozygotic twin, addressing the twin compression etiological hypothesis. Case presentation: A 7-year-old male monozygotic twin presented with Type I Cryptotia of the right ear, with a superior helix-to-mastoid distance of 0 mm. The co-twin exhibited normal auricular morphology. The patient underwent a partial otoplasty combined with a modified posterior auricular advancement flap. The specific modification involved extended sub-galeal undermining to recruit maximum tissue elasticity. Cartilage reshaping was performed using non-absorbable horizontal mattress sutures. Postoperative evaluation at 3 months revealed a superior helix-mastoid distance increase to 12 mm and an auriculocephalic angle restoration to 30 degrees. Patient-Reported Outcome Measures via a validated Visual Analog Scale showed an improvement from 2 to 9 out of 10. No immediate recurrence or hypertrophic scarring was observed. Conclusion: The extended sub-galeal advancement flap offers a promising solution for sulcus restoration, prioritizing vascularity and tissue recruitment over skin grafting. This case supports the intrauterine mechanical compression theory as a viable etiology for sporadic cryptotia. Short-term results are robust, though long-term surveillance is required to monitor cartilage memory.

Intracrine Dynamics of Luminal Breast Cancer: Correlating Intratumoral Estradiol with Estrogen Receptor Alpha Overexpression in an Advanced-Stage Cohort Erdiansyah Reza Lesmana; Widyanti Soewoto; Brian Wasita
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1542

Background: In postmenopausal breast cancer, systemic serum estradiol levels often fail to reflect the biologically active concentrations within the tumor microenvironment, a phenomenon known as intracrineology. While the roles of estrogen receptor alpha (ERα) and beta (ERβ) are well-characterized, the specific relationship between local ligand concentration and receptor expression in advanced-stage malignancies remains under-investigated. This study investigates the correlation between intratumoral estradiol (E2) concentration and the expression of ER isoforms in Luminal A and Luminal B subtypes. Methods: A retrospective cross-sectional study was conducted on 56 tissue samples (38 Luminal A, 18 Luminal B) from patients at Dr. Moewardi Regional General Hospital, Indonesia. Pre-analytical variables were strictly controlled, ensuring cold ischemia time was less than one hour. Expressions of E2, ERα, and ERβ were quantified using immunohistochemistry and assessed via H-Scores. Due to non-normal data distribution, associations were analyzed using Spearman’s Rho and Generalized Linear Models (GLM) with a Gamma distribution and log-link function, coupled with bootstrapping to generate robust confidence intervals. Results: The cohort was characterized by advanced disease, with 85.7% of patients presenting with Stage III or IV breast cancer. Luminal A tumors exhibited significantly higher mean intratumoral E2 (91.58 versus 56.67; p = 0.038) and ERα expression (122.23 versus 109.72; p = 0.045) compared to Luminal B. A significant positive correlation was observed between tissue E2 and ERα (Rho = 0.347; p = 0.009). GLM analysis confirmed E2 as a significant predictor of ERα expression (p = 0.015), independent of age and stage. No significant correlation was found between E2 and ERβ (p = 0.113). Conclusion: Intratumoral estradiol is a significant positive correlate of ERα expression in luminal breast cancer, supporting the existence of a ligand-driven autocrine maintenance loop even in advanced stages. The lack of correlation with ERβ suggests divergent regulatory mechanisms. These findings reinforce the rationale for therapies targeting local aromatase activity.

Maternal Hyperthyroidism and Delayed Diagnosis of Bilateral Choanal Atresia in a 4-Month-Old Infant: A Case Report on Stentless Endoscopic Reconstruction Meilia Ghinasari; Bestari Jaka Budiman; Dolly Irfandy
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1543

Background: Bilateral choanal atresia (BCA) is a life-threatening congenital anomaly typically presenting as a neonatal respiratory emergency. Survival beyond the neonatal period without surgical intervention is exceptionally rare. While the etiology is multifactorial, emerging evidence implicates maternal thyroid dysregulation in craniofacial malformations. This study reports a rare case of BCA diagnosed in a 4-month-old infant and evaluates the efficacy of stentless endoscopic repair using laterally-based mucoperiosteal flaps. Case presentation: A 4-month-old female infant presented with failure to thrive (weight 5.2 kg, less than the 3rd percentile) and cyclical respiratory distress. Perinatal history revealed the mother had Graves' disease and discontinued methimazole at 6 weeks gestation. Retrospective analysis of maternal serum indicated uncontrolled thyrotoxicosis during the critical organogenesis window (TSH less than 0.01 mIU/L; fT4 2.8 ng/dL at 7 weeks). Diagnostic imaging confirmed mixed bony-membranous atresia. The patient underwent transnasal endoscopic choanoplasty using a laterally-based mucosal preservation technique. A 10-Fr silicone feeding tube was placed transnasally but did not function as a structural stent. Conclusion: The intervention resulted in immediate airway patency. Quantitative outcomes showed an increase in oxygen saturation from 96% to 99% on room air and significant weight gain from 5.2 kg to 6.7 kg over two months. Follow-up at six months showed no restenosis. This case suggests a potential dual-hit teratogenic mechanism involving early methimazole exposure and subsequent uncontrolled maternal hyperthyroidism. Furthermore, it supports the efficacy of stentless repair in minimizing granulation tissue formation.

Comparative Efficacy, Safety, and Patient Preference of One-Month (1HP) versus Three-Month (3HP) Rifapentine-Based Regimens for Latent Tuberculosis: A Network Meta-Analysis of HIV, Silicosis, and General Risk Populations Muhammad Ridwan; Roza Kurniati; Fauzar
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1544

Background: The programmatic management of latent tuberculosis infection (LTBI) is undergoing a paradigm shift from long-course isoniazid monotherapy to short-course rifamycin-based regimens. While the 3-month weekly rifapentine/isoniazid (3HP) regimen is well-established, the ultra-short 1-month daily rifapentine/isoniazid (1HP) regimen offers a potential advancement in adherence. However, concerns regarding systemic hypersensitivity reactions, hepatotoxicity mechanisms, and efficacy in non-HIV populations like silicosis remain. Methods: We conducted a systematic review and network meta-analysis (NMA) utilizing a random-effects frequentist model. We executed a comprehensive search of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials to identify randomized controlled trials comparing rifapentine-based regimens. We analyzed data comprising over 10,000 participants to evaluate the efficacy (prevention of active TB), safety (hepatotoxicity and hypersensitivity), and completion rates of 1HP, 3HP, 4-month rifampin (4R), and 9-month isoniazid (9H). We specifically integrated novel data on silicosis patients and patient preference metrics. Results: The network analysis demonstrated that 1HP was non-inferior to 9H in preventing active tuberculosis (Incidence Rate Difference: -0.02 per 100 person-years). 1HP achieved the highest treatment completion rate (97%), significantly superior to 3HP (82%) and 9H (69%). Safety analysis revealed a distinct divergence: 3HP was associated with a higher incidence of systemic flu-like drug reactions (3.5%) compared to 9H (0.4%), whereas 1HP demonstrated a safety profile that minimized both the hepatotoxicity of isoniazid and the hypersensitivity of intermittent rifapentine. In silicosis patients, modified 1-month regimens proved safe. However, preference analysis indicated that 81% of patients preferred the weekly dosing of 3HP over the daily burden of 1HP. Conclusion: 1HP represents the most effective strategy for maximizing treatment completion without compromising bactericidal activity. The daily dosing of 1HP appears to induce immune tolerance, mitigating the hypersensitivity reactions observed in weekly 3HP dosing. While 3HP remains a viable option for those preferring less frequent dosing, 1HP is the superior clinical recommendation for rapid sterilization of latent reservoirs.

Vitamin D Supplementation Efficacy in Severe Vitamin D-Deficient versus Insufficient COPD Patients: A Stratified Meta-Analysis of Exacerbation Risk Ikhsan Tri Kurnia; Dewi Wijaya
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1545

Background: Chronic obstructive pulmonary disease (COPD) is characterized by persistent airway inflammation and recurrent exacerbations that accelerate disease progression. Vitamin D deficiency is highly prevalent in this population and correlates with impaired macrophage function. However, randomized controlled trials regarding supplementation have yielded conflicting results. We hypothesized that efficacy is limited by a ceiling effect, where benefits are strictly restricted to patients with profound baseline deficiency. Methods: We conducted a systematic review and stratified meta-analysis of randomized controlled trials comparing Vitamin D supplementation to placebo in COPD. To ensure methodological homogeneity and avoid data duplication, we strictly included only primary RCTs and excluded aggregate IPD meta-analyses. Studies investigating acute treatment of active exacerbations were also excluded. Data were stratified by baseline serum 25-hydroxyvitamin D [25(OH)D] levels into Severe Deficiency (<10 ng/mL) versus Insufficiency/Sufficiency (≥10 ng/mL). The primary outcome was the risk of moderate-to-severe exacerbations, analyzed using pooled Odds Ratios (OR) with a random-effects model. Results: Five pivotal prevention trials (Lehouck, PRECOVID, ViDA, Hornikx, and Rafiq Pilot) comprising approximately 1,212 participants were included in the quantitative synthesis. In the unstratified analysis, Vitamin D showed no significant benefit (OR 0.78; 95% CI 0.55–1.10). However, stratification revealed a distinct therapeutic window. Patients with severe deficiency (<10 ng/mL) experienced a statistically significant reduction in exacerbation risk (Pooled OR 0.51; 95% CI 0.32–0.87; p=0.012). This effect was driven primarily by trials utilizing high-dose bolus supplementation. Conversely, patients with baseline levels ≥10 ng/mL showed no benefit (OR 0.98; p=0.72), confirming the biological ceiling effect. Conclusion: Vitamin D supplementation confers a significant protective benefit against COPD exacerbations exclusively in patients with severe baseline deficiency (<10 ng/mL). The results support a precision medicine approach—screen, stratify, and target—while cautioning that efficacy appears dependent on correcting profound deficiency, potentially utilizing high-dose intermittent regimens.

Thresholds of Cytoprotection: Ethanolic Propolis Extract Mitigates Ischemia-Reperfusion Injury via the MDA/IL-6 Axis in a Graded Rat Skin Flap Model Dinar Kukuh Prasetyo; Amru Sungkar; Brian Wasita
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 3 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i3.1546

Background: Distal necrosis in reconstructive skin flaps results from ischemia-reperfusion (I/R) injury, driven by reactive oxygen species (ROS) and pro-inflammatory cytokines. While Propolis exhibits antioxidant properties, its efficacy limit relative to the severity of ischemic challenge remains undefined. Methods: A randomized, controlled experimental study was conducted using 36 male Wistar rats. A graded ischemia model was engineered using modified McFarlane flaps with increasing length-to-width ratios: Mild (2:1), moderate (3:1), and severe (4:1). Subjects were stratified into vehicle (Control) and treatment (Propolis 800 mg/kg/day, oral) groups across all dimensions. The primary endpoint was the percentage of viable flap area on Day 7. Secondary endpoints included serum Malondialdehyde (MDA), Interleukin-6 (IL-6), and histological scoring of inflammation. Results: All animals survived the procedure. Propolis significantly increased viable tissue area in the moderate ischemia group (76.4 ± 4.2%) compared to Vehicle (52.1 ± 5.8%; p < 0.001). In Mild ischemia, survival was near-maximal in both groups (>92%). However, in Severe ischemia, Propolis failed to prevent significant necrosis (34.2 ± 6.1% survival vs. 28.5 ± 5.4% in Vehicle; p = 0.092), indicating a therapeutic ceiling. Biochemically, Propolis suppressed MDA (11.92 ± 0.45 nmol/mL) and IL-6 (121.0 ± 4.71 pg/mL) significantly in moderate challenges but was overwhelmed by the oxidative surge in severe ischemia (MDA > 12.0 nmol/mL). Conclusion: Propolis confers significant protection against I/R injury by dampening lipid peroxidation and systemic inflammation, but this effect exhibits a distinct threshold. It is highly effective in moderate ischemic challenges but insufficient for severe vascular compromise.

Levator Ani Avulsion as the Key Mediator Between Vaginal Delivery and Pelvic Organ Prolapse: A Systematic Review and Meta-Analysis of Imaging Studies Heristanto; Rahajeng
Bioscientia Medicina : Journal of Biomedicine and Translational Research Vol. 10 No. 4 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Publisher : HM Publisher

Show Abstract | Download Original | Original Source | Check in Google Scholar | DOI: 10.37275/bsm.v10i4.1547

Background: Vaginal childbirth is universally recognized as the primary etiological factor for pelvic organ prolapse (POP), yet the precise biomechanical cascade remains a subject of intense investigation. While connective tissue attenuation contributes to support failure, recent advanced imaging evidence suggests that levator ani avulsion (LAA)—a macroscopic traumatic detachment of the puborectalis muscle from the pubic ramus—acts as the fundamental structural mediator. This study aimed to systematically review and meta-analyze imaging-based literature to quantify the mediating role of LAA in the pathogenesis of POP. Methods: We conducted a systematic review and meta-analysis of observational studies utilizing magnetic resonance imaging (MRI) and 3D/4D Transperineal Ultrasound. The search strategy targeted longitudinal and cross-sectional studies comparing women with confirmed LAA to those with intact pelvic floors following vaginal delivery. Data were extracted regarding the prevalence of avulsion, pelvic organ prolapse quantification (POP-Q) stages, and levator hiatus dimensions. The primary outcome was the Odds Ratio (OR) of significant POP (Stage ³2). Secondary outcomes included quantitative analysis of hiatal ballooning. Data were synthesized using a random-effects model. Results: The analysis included 3,218 women across 9 high-quality imaging studies. The pooled analysis revealed a profound and statistically significant association between LAA and POP, with a pooled Odds Ratio of 3.84 (95% CI: 2.65–5.56; p < 0.0001). Women with LAA demonstrated a significantly larger levator hiatal area on Valsalva compared to those with intact muscles (Mean Difference: +6.03 cm²), confirming that avulsion leads to intractable hiatal ballooning. Long-term follow-up data (up to 23 years) indicated that this muscular defect does not heal and is associated with a progressive deterioration in pelvic organ support over time. Conclusion: Levator ani avulsion is the critical biomechanical mediator converting the event of vaginal delivery into the chronic pathology of prolapse. The injury compromises the dynamic closure of the levator hiatus, resulting in hiatal ballooning and subsequent apical and anterior compartment descent. These findings necessitate a paradigm shift in obstetric counseling and emphasize the need for preventative strategies to minimize traumatic muscle injury during the second stage of labor.

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Rachmat Hidayat

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Kab. ogan ilir,

Sumatera selatan

INDONESIA