Archives of The Medicine and Case Reports
Archives of The Medicine and Case Reports (AMCR) is a quarterly, peer-reviewed, open-access medical journal published by HM Publisher in collaboration with CMHC Research Center. AMCR publishes original research, rigorous evidence syntheses, and ethically reported case studies across medicine and related health sciences. Every manuscript that passes editorial screening undergoes double-anonymous review by at least three independent reviewers. Authors retain copyright, and articles are published under CC BY-NC-SA 4.0.
HM Publisher in collaboration with CMHC Research Center
Authors retain copyright and grant Archives of The Medicine and Case Reports (AMCR) the right of first publication. Published articles are licensed under the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License (CC BY-NC-SA 4.0). This license permits users to copy, redistribute, and adapt the work for non-commercial purposes, provided that appropriate credit is given, a link to the license is supplied, changes are indicated, and adaptations are distributed under the same license. Copyright in the journal website, logo, layout, and other publisher-owned materials does not transfer copyright in individual articles.
Green-Laser-Flanged Intrascleral Fixation of a Secondary Intraocular Lens in Aphakia with Reduced Endothelial Reserve: Rapid Visual Rehabilitation, a +1.00 Dioptre Prediction Error, and a Minimum Reporting Data Set
Background: Aphakia without capsular support is decided largely by the state of the corneal endothelium. Objective: To present the result with a structured audit of the record and a numbered minimum data set for reporting laser-flanged intrascleral fixation. Methods: A 60-year-old man was referred twelve months after left phacoemulsification complicated by posterior capsule rupture, with no lens implanted. Best-corrected acuity with a +10.00 D aphakic spectacle was 20/200 (1.00 logMAR), uncorrected acuity was counting fingers at one metre, intraocular pressure was 15 mmHg, vitreous was present in the anterior chamber, and endothelial cell density was about 1200 cells/mm². Pars plana vitrectomy was combined with double-needle intrascleral fixation of a three-piece polyvinylidene-fluoride-haptic lens through 27-gauge tunnels 2.0 mm behind the limbus; the haptics were flanged with a 532 nm green laser, and surgery took 30 minutes. Results: Uncorrected acuity was 20/60 on day one, 20/40 at one week and 20/30 at one month, when best-corrected acuity reached 20/20 with +0.75 -0.50 and anterior segment tomography showed an optic tilt of about 2°; the result was stable at three months. Conclusion: A full logarithmic unit of best-corrected acuity was recovered, yet the achieved spherical equivalent of +0.50 D against a -0.50 D target represents a +1.00 D hyperopic prediction error, and no post-operative endothelial measurement, biometric input or laser parameter was recorded.
Copyright (c) 2026 Ade John Nursalim, Yovita https://creativecommons.org/licenses/by-nc-sa/4.0
Chronic Hyperglycemia Assessed by HbA1c and Hematocrit Values in Patients with Type 2 Diabetes Mellitus: A Cross-Sectional Study at a Tertiary Laboratory in Makassar, Indonesia
Type 2 Diabetes Mellitus (T2DM) is characterized by persistent hyperglycemia that may impair erythrocyte function, elevate oxidative stress, and provoke osmotic diuresis, all of which could theoretically alter the hematocrit; because glycated hemoglobin (HbA1c) and hematocrit are among the most frequently requested tests in diabetes care, clarifying their relationship has direct laboratory-medicine relevance, yet reported associations remain inconsistent. This analytical cross-sectional study aimed to determine the relationship between chronic hyperglycemia, quantified by HbA1c, and hematocrit in patients with T2DM at the Clinical Laboratory of Stella Maris Hospital, Makassar, Indonesia. Forty-four outpatients with T2DM meeting predefined criteria were enrolled consecutively by purposive sampling from 27 February to 4 March 2025, and same-day HbA1c and hematocrit were analyzed. The association was assessed by Spearman rank correlation with a bootstrap 95% confidence interval (CI), at p<0.05. The mean age was 62.98 ± 11.14 years and 23 participants (52.3%) were female; mean diabetes duration was 8.80 ± 2.99 years, mean HbA1c 7.77 ± 2.52% (61.4 mmol/mol), and mean hematocrit 38.47 ± 5.45%, with only 20 patients (45.5%) reaching the HbA1c target of <7%. Spearman analysis showed no significant correlation between HbA1c and hematocrit (ρ = −0.001; 95% CI −0.30 to 0.30; p = 0.996), a negligible effect size. In conclusion, among Indonesian patients with T2DM, HbA1c was not significantly correlated with hematocrit; the hematocrit should not be used as a surrogate for long-term glycemic control, while HbA1c remains the reference standard and the hematocrit retains independent value within the complete blood count.
Copyright (c) 2026 Amirah, Hana Yurlin, Arlitha Deka Yana Akbar, Desyani Ariza, Kasmuddin https://creativecommons.org/licenses/by-sa/4.0
Maintenance Immunosuppressive Prescribing Patterns in Kidney Transplant Recipients at an Indonesian Tertiary Referral Hospital: A Retrospective Cross-Sectional Study
Kidney transplantation is the optimal kidney replacement therapy for end-stage kidney disease, but graft survival depends on lifelong maintenance immunosuppression. Indonesian data on how these medicines are actually prescribed remain scarce. Retrospective cross-sectional drug-utilisation study of 53 maintenance immunosuppressant prescriptions dispensed to kidney transplant recipients at a tertiary referral hospital in Yogyakarta, Indonesia, between 2017 and 2024. Proportions were estimated with Wilson 95% confidence intervals (CI); within-class preference with exact binomial tests; associations with Fisher exact tests; prescribing concentration with diversity indices and bootstrap CIs; and frequencies were benchmarked against published French, Korean and Indonesian reference proportions using Holm-adjusted exact binomial tests, reported as absolute differences and prevalence ratios. Reporting followed STROBE. Recipients were mostly aged 18–49 years (73.6%) and male (64.2%). Tacrolimus was the only calcineurin inhibitor prescribed (100.0%; 95% CI 93.2–100.0), and mycophenolic acid the only antiproliferative agent. Methylprednisolone was the preferred corticosteroid (69.8%; 56.5–80.5; p = 0.002) and enteric-coated mycophenolate sodium the preferred formulation (77.4%; 64.5–86.5; p < 0.001). The modal regimen was tacrolimus plus methylprednisolone plus mycophenolate sodium (56.6%; 43.3–69.0). Tacrolimus and mycophenolic acid use exceeded a French national cohort (+8.7 and +9.5 percentage points; Holm-adjusted p = 0.040 and 0.034), whereas corticosteroid maintenance did not differ significantly (96.2% versus 88.1%; p = 0.086). Prescribing was highly concentrated (Herfindahl–Hirschman Index 3,799). In conclusion, maintenance prescribing was exceptionlessly tacrolimus- and mycophenolate-based, exceeding even high-volume European practice, and reproduced an independent Indonesian series almost exactly. Corticosteroid maintenance was near-universal, identifying corticosteroid minimisation and therapeutic drug monitoring capacity as priority targets.
Copyright (c) 2026 Dimo Pratama, Aqmarina Tamimi, Yulia Wardhani https://creativecommons.org/licenses/by-sa/4.0
Reversible Movement Disorder Unmasking Secondary Fahr Syndrome after Total Thyroidectomy: A Case of Bilateral Basal Ganglia and Cerebellar Calcification from Chronic Hypoparathyroidism
Fahr syndrome denotes bilateral, symmetrical calcification of the basal ganglia and other deep brain structures occurring secondary to an identifiable disorder, most often hypoparathyroidism, and must be distinguished from idiopathic Fahr disease. Clinical data from Indonesia remain limited, and the movement disorder that heralds the condition is frequently mistaken for primary neurological disease. We report a 35-year-old woman who presented with a one-hour history of involuntary movements of the face and all four limbs and dysarthria from excessive facial muscle contraction, superimposed on a seven-year history of intermittent right-hand paraesthesia. Her background included a total thyroidectomy seven years earlier with subsequent levothyroxine-treated hypothyroidism, chronic hypocalcaemia presumed to reflect post-surgical hypoparathyroidism (calcium carbonate 500 mg every 12 hours), and a six-year diagnosis of “idiopathic” generalised epilepsy made without neuroimaging. Examination showed full consciousness, a positive Chvostek sign, mild four-limb ataxia and minor memory impairment. Non-contrast cranial computed tomography demonstrated multiple calcifications in both parietal lobes, the basal ganglia and both cerebellar hemispheres, without haemorrhage or infection. Serum calcium was 4.5 mg/dL and parathyroid hormone was below 6 pg/mL, confirming secondary Fahr syndrome from post-thyroidectomy hypoparathyroidism. Treatment with calcium carbonate, phenytoin, levothyroxine and vitamin B complex produced complete resolution of the involuntary movements and seizures and marked improvement of ataxia within six weeks, sustained at two months. This case underscores the need to screen phosphocalcic metabolism and obtain neuroimaging before labelling epilepsy idiopathic in any thyroidectomised patient, and the value of sustained metabolic control as both treatment and secondary prevention.
Copyright (c) 2026 Made Ngurah Jiyesta Wibawa, I Putu Ananta Wijaya Sabudi https://creativecommons.org/licenses/by-sa/4.0
Perioperative Shift in Respiratory Bacterial Colonization and Post-operative Pneumonia in Spine Surgery Patients Requiring Intensive Care: A Prospective Cohort Study
Spine surgery frequently requires post-operative intensive care and endotracheal intubation, both of which predispose to nosocomial respiratory infection, yet the perioperative dynamics of airway bacterial colonization in spine surgery patients and their relationship to pneumonia are poorly characterised, particularly in Indonesian practice. We conducted a prospective cohort study of 34 patients undergoing elective spine surgery with post-operative care in the ICU/PICU of Dr. Moewardi Regional General Hospital, Surakarta. Paired pharyngeal swab cultures were obtained at induction and during intubated intensive care, with disk-diffusion susceptibility testing. Post-operative pneumonia was defined by chest-radiographic infiltrate plus leukocytosis or leukopenia. Associations were assessed using Fisher exact tests, Haldane-Anscombe corrected odds ratios, rank correlation, and Cohen's h, with 95% confidence intervals. Most patients underwent decompressive laminectomy with posterior spinal fusion (76.5%). Pre-operative pathogenic colonization was present in 21/34 patients (61.8%; 95% CI 45.0-76.1). The flora shifted toward pathogens post-operatively, with Staphylococcus aureus rising from 6 to 9 isolates (+50%), Acinetobacter baumannii from 2 to 4, and new Serratia marcescens and Proteus mirabilis; ciprofloxacin resistance predominated and increased. Post-operative pneumonia occurred in 1/34 patients (2.94%; 95% CI 0.52-14.92). Pre-operative colonization was not associated with pneumonia (Fisher p=1.000; OR 1.98, 95% CI 0.07-52.17). ICU stay >48 h and endotracheal-tube duration >24 h were each strongly rank-correlated with pneumonia (rho=0.696), although, given a single event, the exact test was not significant (p=0.059). Intensive-care exposure rather than pre-operative colonization characterised pneumonia risk, while resistant Gram-negative organisms emerged perioperatively. Duration-focused prevention and antimicrobial stewardship are warranted in orthopedic critical care.
Severity-Level Stratification and Robson Ten-Group Classification of Caesarean Sections at a Tertiary Referral Hospital in West Sumatra, Indonesia: A Cross-Sectional Study
Caesarean section rates have risen worldwide, and the World Health Organization endorses the Robson Ten-Group Classification System as the global standard for facility-level audit. Severity-stratified Robson data remain scarce in Indonesia, and none exist for central Sumatra. This cross-sectional census characterised the clinical-severity distribution and Robson classification of caesarean sections at RSUP Dr. M. Djamil, the sole tertiary (type A) referral hospital for central Sumatra, during 2021. All 679 deliveries were reviewed by total sampling; 560 (82.47%, 95% CI 79.43–85.15) were caesareans, a fraction reflecting the apex-referral casemix rather than population practice. Proportions were estimated with Wilson confidence intervals, distributions tested by goodness-of-fit chi-square with Cohen's w, and indicators benchmarked against national and WHO standards. Severity level II predominated (48.93%, 95% CI 44.81–53.06), with level I (47.86%) and level III (3.21%) (chi-square=228.700, p<0.001, w=0.639). Robson Group 10 was largest (30.19%, 95% CI 26.86–33.75), followed by Group 5 (21.80%) and Group 2 (15.02%); Groups 5 and 10 together contributed 51.99%. Group 10 exceeded the Indonesian mean of 14.20% (prevalence ratio 2.13, 95% CI 1.90–2.38, p<0.001). Preterm single-cephalic pregnancies dominate this casemix and represent the priority target for severity-stratified caesarean audit and preterm-referral optimisation in Indonesian tertiary obstetric practice.
Clinical Outcomes of Rapid Versus Gradual Blood Pressure Normalisation in Asymptomatic Hypertensive Urgency: A Systematic Review and Meta-Analysis
Hypertensive urgency presents a clinical dilemma regarding optimal blood pressure management. Whilst guidelines advocate gradual reduction to prevent organ damage through vascular autoregulation disruption, rapid normalisation remains common in clinical practice. This systematic review and meta-analysis synthesised evidence comparing rapid and gradual blood pressure normalisation strategies in asymptomatic hypertensive urgency. Systematic searches of Scopus, PubMed/MEDLINE, and Embase were conducted. Nine randomised or quasi-randomised controlled trials were included involving 4,195 adult participants with asymptomatic hypertensive urgency. Studies compared rapid blood pressure normalisation with gradual reduction over various timeframes. Primary outcomes included acute kidney injury (AKI), symptomatic hypotension, and major adverse cardiovascular events (MACE). Random-effects meta-analysis using standardised mean difference (Hedges' g) was performed. Rapid blood pressure normalisation was associated with significantly higher adverse events compared with gradual reduction (pooled SMD = 0.8854, 95% confidence interval [0.6235–1.1472], p < 0.000001; I² = 61.11%). Subgroup analysis revealed substantial effects for AKI (SMD = 0.9199, p = 0.000012) and symptomatic hypotension (SMD = 1.0103, p < 0.001), whilst MACE showed no significant difference (SMD = 0.3777, p = 0.435). Heterogeneity was moderate to substantial (I² = 61.11%, Tau² = 0.0881). Sensitivity analyses demonstrated robust findings. In conclusion, gradual blood pressure reduction in asymptomatic hypertensive urgency was superior to rapid normalisation, particularly for preventing acute kidney injury and symptomatic hypotension. These findings support current guideline recommendations for cautious, titrated antihypertensive strategies in this population.
Transfusion-Refractory Warm Autoimmune Hemolytic Anemia with Dual Direct Antiglobulin Test Positivity and Marked Monocytosis in an Elderly Patient: A Case Report
Warm autoimmune hemolytic anemia represents a significant clinical challenge in adult hematology, with corticosteroid refractoriness occurring in approximately thirty to forty percent of cases. Management becomes substantially more complex in elderly patients with multiple comorbidities, where standard immunosuppressive therapy frequently fails and alternative therapeutic strategies become necessary. A sixty-three-year-old male with three months of documented warm autoimmune hemolytic anemia presented with acute hemolytic crisis manifested by severe anemia (hemoglobin declining from five point three to four point four grams per deciliter over four days) and accelerated hemolysis. Direct antiglobulin testing demonstrated dual positivity with immunoglobulin G one plus and complement component three-d two plus, indicating complement-mediated hemolysis. Notably, marked monocytosis ranged from seventy to seventy-four percent across serial complete blood counts. The patient demonstrated rapid immunosuppressive treatment failure with escalated triple therapy (methylprednisolone, mycophenolate mofetil, azathioprine) failing within four days of initiation. Transfusion refractoriness was evident despite premedication protocols. Concurrent medical conditions included hypertensive heart disease with documented coronary artery disease, newly diagnosed type two diabetes mellitus with suboptimal glycemic control, benign prostatic hyperplasia requiring catheterization, and clinical immunosuppression complications. The patient was referred to a tertiary academic medical center for advanced therapeutic decision-making. In conclusion, this case illustrates the diagnostic and therapeutic complexity of warm autoimmune hemolytic anemia with complement activation in an elderly population, highlighting the necessity for rapid escalation to advanced therapeutic modalities beyond conventional immunosuppression when clinical deterioration occurs despite maximal standard therapy.
Inverse Association between Platelet-to-Lymphocyte Ratio and Clinical Severity in Pediatric Dengue Infection: A Retrospective Cross-Sectional Analysis at Wangaya Hospital, Indonesia
Dengue heavily burdens endemic regions. Early prediction of disease progression in pediatric populations is critical for optimizing outcomes. This study evaluates the Platelet-to-Lymphocyte Ratio (PLR), an emerging inflammatory marker, as a correlative biomarker of clinical severity in pediatric dengue. A retrospective cross-sectional analysis included 139 pediatric patients with confirmed dengue at Wangaya Regional General Hospital, Denpasar, Indonesia. Patients were classified using 2009 World Health Organization criteria into Dengue Fever (DF), Dengue with Warning Signs (DWS), and Severe Dengue (SD). Hematological parameters were obtained strictly during the critical transition phase. Statistical analyses included Kruskal-Wallis tests, Spearman correlation, Receiver Operating Characteristic (ROC) curve analysis, and Ordinal Logistic Regression. The cohort, primarily school-aged children (92.1%), presented with 11.5% DF, 73.4% DWS, and 15.1% SD. A statistically significant, weak-to-moderate inverse correlation existed between the admission PLR and clinical severity (r = -0.293, p < 0.001). The median admission PLR declined progressively from 78.1 in DF, to 59.8 in DWS and further to 24.3 in SD. ROC analysis discriminating Severe Dengue yielded an Area Under the Curve of 0.685. Regression confirmed the PLR as an independent, modest correlative factor when adjusting for age, sex, and fever onset day. In conclusion, a statistically significant, weak-to-moderate inverse association exists between admission PLR and pediatric dengue severity. While offering accessible pathophysiological insights, its moderate diagnostic accuracy limits its use as an isolated triage tool. The PLR may assist early risk stratification in resource-limited settings when utilized alongside standard clinical assessments.
Long-Term Renal Outcomes and Safety Profile of Non-Steroidal Mineralocorticoid Receptor Antagonists in Non-Diabetic Chronic Kidney Disease: A Retrospective Cohort Study
Non-steroidal mineralocorticoid receptor antagonists, specifically finerenone, have demonstrated profound cardiorenal protective effects in diabetic kidney disease. However, their efficacy and safety in non-diabetic chronic kidney disease remain inadequately characterized, particularly within Southeast Asian populations experiencing high rates of hypertensive nephrosclerosis. A retrospective cohort study was conducted at a tertiary hospital in Makassar, Indonesia, evaluating 148 adult patients with non-diabetic chronic kidney disease (stages 3-4) who received finerenone between January 2022 and December 2024. Clinical data, including urinary albumin-to-creatinine ratio (UACR), estimated glomerular filtration rate (eGFR), and serum potassium, were analyzed using generalized and piecewise linear mixed-effects models over 24 months. The cohort (N=148) demonstrated a significant reduction in median UACR from a baseline of 845 mg/g to 460 mg/g at 24 months (p < 0.001). Following an initial hemodynamic eGFR dip in the first six months, the chronic annualized slope of decline stabilized at -2.2 mL/min/1.73 m² per year (95% CI: -2.8 to -1.6). Mild hyperkalemia occurred in 16.2% of patients, and moderate-to-severe hyperkalemia in 4.1%. Concomitant sodium-glucose cotransporter-2 inhibitor (SGLT2i) use was associated with a lower risk of incident hyperkalemia (OR 0.45, 95% CI 0.22-0.89). In conclusion, in this real-world observational cohort, adding finerenone to standard care in non-diabetic CKD patients was associated with significant reductions in UACR and an attenuation of eGFR decline over 24 months, alongside a manageable safety profile. These findings warrant further investigation in large, randomized trials.
Re-evaluating Immediate, Adjuvant, and Salvage Intravesical Chemotherapy in Non-Muscle-Invasive Bladder Cancer: A Systematic Review and Meta-Analysis of Gemcitabine Non-Inferiority to Mitomycin C
Non-muscle-invasive bladder cancer demonstrates a uniquely high propensity for recurrence following initial transurethral resection of bladder tumor. A single, immediate post-operative instillation of chemotherapy became the established standard to mitigate this risk. Mitomycin C historically functioned as the agent of choice; however, frequent drug shortages and significant local toxicity profiles necessitated the rigorous evaluation of viable alternatives. Gemcitabine, a pyrimidine nucleoside analogue, emerged as a promising candidate. This study aimed to evaluate the comparative efficacy and safety of gemcitabine versus mitomycin C across immediate post-operative, adjuvant, and salvage clinical settings. A systematic review and meta-analysis were conducted in accordance with PRISMA guidelines. The analysis utilized data from seven key comparative trials evaluating gemcitabine versus mitomycin C. A highly specific search strategy isolated direct head-to-head comparative studies. Data extraction focused exclusively on recurrence rates, time to recurrence, and adverse events. Pooled Odds Ratios and Standardized Mean Differences were calculated using a DerSimonian-Laird random-effects model. Sensitivity analyses isolating randomized controlled trials and excluding upper tract urothelial carcinoma data were explicitly performed. Five primary studies provided head-to-head comparative data for recurrence, comprising 405 patients. Two additional studies evaluated sequential salvage therapy. Adjuvant gemcitabine regimens demonstrated a significant reduction in recurrence compared to mitomycin C (Odds Ratio 0.38, 95 percent Confidence Interval 0.19 to 0.75). In strictly immediate single-dose settings, mitomycin C demonstrated a trend toward superior recurrence prevention over gemcitabine (Odds Ratio 1.65). Toxicity analysis heavily favored gemcitabine, showing a significantly lower incidence of chemical cystitis (Odds Ratio 0.22). Sequential salvage therapy yielded a 30 percent to 37 percent long-term recurrence-free survival. In conclusion, gemcitabine demonstrated non-inferiority to Mitomycin C regarding overall oncological safety and exhibited a markedly superior tolerability profile. Mitomycin C retained a marginal advantage in the strict immediate post-operative window due to its potent cell-cycle-independent action. However, Gemcitabine's efficacy in adjuvant settings and favorable side-effect profile established it as a highly rational alternative.
The Prognostic Superiority of Early ΔNLR Variations in Predicting In-Hospital Mortality among Emergency and Ward Patients with COVID-19: A Systematic Review and Meta-Analysis
The neutrophil-to-lymphocyte ratio is an established biomarker reflecting systemic inflammation and immune dysregulation. However, single baseline measurements upon hospital admission often fail to capture the highly dynamic immunological trajectory of patients infected with the severe acute respiratory syndrome coronavirus 2. This study aimed to evaluate the prognostic superiority of early variations in the neutrophil-to-lymphocyte ratio, defined as ΔNLR, compared to static baseline measurements for predicting in-hospital mortality among patients admitted to the emergency department and general medical wards. A systematic review and meta-analysis were strictly conducted according to PRISMA guidelines. Data were meticulously extracted from ten selected observational cohort studies. The primary outcome assessed was in-hospital mortality. Standardized mean differences and 95 percent confidence intervals were calculated utilizing a DerSimonian-Laird random-effects model to appropriately account for anticipated clinical heterogeneity. The comprehensive meta-analysis integrated data from 4582 patients across ten independent studies. Both the baseline neutrophil-to-lymphocyte ratio and the early ΔNLR were significantly elevated in non-survivors compared to survivors. However, the early variation in the ratio, measured precisely at 24 to 48 hours post-admission, demonstrated a significantly higher predictive value for in-hospital mortality. The pooled standardized mean difference for baseline measurements between non-survivors and survivors was 0.82 (95 percent confidence interval: 0.61 to 1.03, p less than 0.001). In stark contrast, the pooled standardized mean difference for the early ΔNLR was 1.34 (95 percent confidence interval: 1.05 to 1.63, p less than 0.001), indicating a substantially stronger effect size and superior prognostic discrimination. In conclusion, early dynamic variations in the neutrophil-to-lymphocyte ratio offer superior prognostic value compared to static baseline measurements for predicting fatal outcomes in COVID-19 patients. Integrating kinetic monitoring into emergency and ward triage protocols can significantly optimize early risk stratification.
Incremental Prognostic Value of Systemic Immune-Inflammation Index Over GRACE and TIMI Scores in Acute Coronary Syndrome: A Meta-Analytical Approach
Current risk stratification in acute coronary syndrome relies heavily on the Global Registry of Acute Coronary Events (GRACE) and Thrombolysis in Myocardial Infarction (TIMI) scores. These models insufficiently account for systemic inflammatory burden. The Systemic Immune-Inflammation Index has emerged as a promising hematological biomarker to address this gap. A systematic literature search and quantitative meta-analysis were conducted following PRISMA guidelines. Six clinical studies focusing on the Systemic Immune-Inflammation Index and GRACE/TIMI scores in acute atherosclerotic conditions were included. Data were pooled utilizing a random-effects model to calculate the Standardized Mean Difference of index levels between high-risk and low-risk patient cohorts. The pooled meta-analysis demonstrated significantly elevated Systemic Immune-Inflammation Index levels in patients who subsequently experienced Major Adverse Cardiovascular Events compared to those who did not, yielding an overall Standardized Mean Difference of 1.12 (95 percent confidence interval: 0.99 to 1.25, p less than 0.001). Qualitative synthesis revealed that integrating this index into the GRACE and TIMI models yielded significant improvements in the Area Under the Curve, Net Reclassification Improvement, and Integrated Discrimination Improvement metrics. In conclusion, the addition of the Systemic Immune-Inflammation Index to conventional scoring systems significantly improves prognostic accuracy and risk reclassification for patients presenting with acute coronary syndrome. It serves as an accessible biomarker capturing residual inflammatory risk undetected by standard clinical models.
Synergistic Impact of Dual Hereditary Protein C and S Deficiency Exacerbated by Acute Pan-Sinusitis in Recurrent Cerebral Venous Sinus Thrombosis: A Case Report
Cerebral venous sinus thrombosis is a rare neurovascular emergency characterized by thrombotic occlusion of the dural venous sinuses. While various prothrombotic states predispose individuals to this condition, the concurrent presentation of dual hereditary Protein C and Protein S deficiency is exceptionally uncommon. This dual coagulopathy severely impairs natural anticoagulant mechanisms. We report the case of a 49-year-old male presenting with severe postural dizziness, vertigo, and bilateral lower extremity paresthesia. The patient had a history of a previous cerebral venous sinus thrombosis diagnosed in September 2023, for which he was receiving warfarin. Due to historically variable international normalized ratio levels and new symptoms, a comprehensive re-evaluation was initiated. Neuroimaging confirmed acute extension of the thrombosis involving the superior sagittal, left transverse, and left sigmoid sinuses, alongside an incidental finding of acute pan-sinusitis. To eliminate the confounding effect of warfarin on thrombophilia screening, the patient was bridged to low-molecular-weight heparin for fourteen days prior to testing. Subsequent functional assays confirmed profound deficiencies in Protein C (26 IU/dL) and Protein S (13 IU/dL). Management involved treating the regional pan-sinusitis and a strategic pharmacological transition to rivaroxaban (20 mg daily), resulting in complete clinical stabilization. In conclusion, this case underscores the necessity of rigorous methodological timing in thrombophilia testing and highlights regional inflammation as a potent acute trigger in genetically susceptible individuals. It further demonstrates the long-term viability of direct oral anticoagulants in complex dual inherited coagulopathies.
Perioperative Safety and Outcomes of SGLT2 Inhibitors in Diabetic Kidney Disease Patients Undergoing Non-Cardiac Surgery: A Meta-Analysis of Euglycemic Ketoacidosis and Acute Kidney Injury Risks
Sodium-glucose cotransporter-2 inhibitors (SGLT2i) have revolutionized the management of diabetic kidney disease (DKD), offering profound renoprotection through the restoration of tubuloglomerular feedback and reduction of intraglomerular pressure. However, their perioperative safety profile remains a subject of intense debate. While the pharmacological mechanisms of SGLT2 inhibitors may theoretically ameliorate ischemia-reperfusion injury and prevent acute kidney injury (AKI), the metabolic shift towards ketogenesis raises concerns regarding perioperative Euglycemic Diabetic Ketoacidosis (euDKA). This meta-analysis aimed to quantify the risks of AKI and euDKA in DKD patients continuing or withholding SGLT2i prior to non-cardiac surgery. A systematic review and meta-analysis were conducted following PRISMA 2020 guidelines. We analyzed data from seven high-quality studies, including large-scale propensity-matched cohorts and randomized controlled trials published through 2026, involving patients with type 2 diabetes mellitus (T2DM) and DKD undergoing non-cardiac surgery. The primary outcomes were the incidence of postoperative AKI (KDIGO criteria) and euDKA. Secondary outcomes included 30-day mortality and urinary tract infections. Pooled Odds Ratios (OR) with 95% Confidence Intervals (CI) were calculated using a random-effects model (DerSimonian-Laird). The pooled analysis included a total of 142,530 patients. The use of SGLT2 inhibitors was associated with a robust and statistically significant reduction in postoperative AKI compared to non-users (Pooled OR 0.69; 95% CI 0.62–0.78; p < 0.001). This renoprotective signal was consistent across various surgical subtypes. Conversely, SGLT2i use was associated with an increased risk of euDKA (Pooled OR 2.34; 95% CI 1.45–3.78; p = 0.001), although the absolute event rate remained low (<1%). Subgroup analysis revealed that preoperative withdrawal of <24 hours significantly exacerbated DKA risk compared to a withdrawal period of 3–4 days, without providing additional protection against AKI. In conclusion, in patients with DKD undergoing non-cardiac surgery, preoperative SGLT2 inhibitor use presents a distinct renoprotective paradox: it significantly reduces the risk of AKI, likely through attenuation of oxidative stress and preservation of renal oxygenation, but increases the risk of euDKA. The benefits of AKI prevention outweigh the rare risk of DKA, provided a structured preoperative withdrawal protocol of 3 days is strictly implemented.
Ruptured Congenital Cholesteatoma Presenting as Atticoantral Chronic Suppurative Otitis Media in a 4-Year-Old: A Diagnostic Challenge
Chronic suppurative otitis media (CSOM) of the atticoantral type is a distinct otologic pathology driven by cholesteatoma, characterized by enzymatic bone erosion and a high risk of intracranial complications. While typically acquired through retraction pockets, a subset of these cases represents congenital cholesteatomas (CC) that have silently expanded and ruptured the tympanic membrane. This presentation mimics acquired disease, creating a diagnostic blind spot. We report the case of a 4-year-old male presenting with a one-year history of persistent, foul-smelling otorrhea and otalgia in the right ear. Despite a history of recurrent cold, there was no prior trauma or otologic surgery. Physical examination revealed an attic perforation with purulent discharge. Computed tomography scan (CT-scan) identified a soft tissue mass filling the epitympanum and mesotympanum with significant erosion of the scutum and ossicles. The patient underwent a modified radical mastoidectomy with type II tympanoplasty. Intraoperative findings revealed an extensive cholesteatoma sac consistent with a congenital origin that had secondarily ruptured. In conclusion, congenital cholesteatoma must be considered in the differential diagnosis of pediatric CSOM, even in the presence of a perforation. This ruptured presentation highlights the necessity of early HRCT imaging over conventional radiography. The canal wall down approach remains a critical strategy for eradicating extensive pediatric disease to prevent recidivism.
Ocular Salvage in Serratia marcescens-Associated Odontogenic Orbital Abscess: Unmasking Latent Diabetes Mellitus and the Role of Immunoparesis
Odontogenic sinusitis accounts for up to 40 percent of chronic maxillary sinusitis cases. While typically polymicrobial, the isolation of Serratia marcescens, an opportunistic Enterobacteriaceae, is an aberration in community settings and often signals profound underlying immunodeficiency. This report documents a rare case of Serratia-induced subperiosteal orbital abscess that unmasked latent type 2 diabetes mellitus. A 64-year-old male farmer presented with unilateral proptosis, ophthalmoplegia (frozen globe), and severe orbital pain following chronic odontogenic symptoms. Initial assessment revealed a random blood glucose of 500 mg/dL and glycated hemoglobin of 11.5 percent, confirming undiagnosed type 2 diabetes mellitus. Computed Tomography demonstrated a right maxillary abscess with osteolytic destruction of the lamina papyracea and an extraconal collection. Microbiological analysis of deep tissue biopsy via Vitek 2 confirmed Serratia marcescens while histopathology ruled out invasive fungal sinusitis. Management involved a dual-front strategy: rapid glycemic stabilization and broad-spectrum antibiotics, followed by functional endoscopic sinus surgery and dental extraction on Day 3. Post-operative follow-up showed resolution of proptosis from 24 mm to 16 mm, restoration of intraocular pressure from 32 mmHg to 14 mmHg, and improvement in visual acuity from light perception to 6/18. In conclusion, the isolation of Serratia marcescens in odontogenic sinusitis serves as a sentinel marker for metabolic dysregulation. This case highlights the synergistic lethality of neglected dental pathology and diabetic immunoparesis. Early recognition, exclusion of fungal mimics, and aggressive multidisciplinary intervention are paramount for ocular salvage.
The Silent Sequelae: Irreversible Profound Sensorineural Hearing Loss Following Mumps Parotitis in a Pediatric Patient
Mumps-associated Sudden Sensorineural Hearing Loss (SSNHL) is a rare but catastrophic complication of epidemic parotitis, historically estimated to occur in 1 per 20,000 cases. Despite global vaccination efforts, the re-emergence of mumps in adolescent populations due to waning immunity poses significant otologic risks. This report documents a case of unilateral, profound SSNHL in a vaccinated pediatric patient, highlighting the diagnostic challenges when auditory symptoms manifest after the resolution of systemic parotitis. An 11-year-old Balinese male presented with acute-onset tinnitus and hearing loss in the left ear, occurring one week after the clinical resolution of bilateral parotid swelling. The patient had a history of basic immunization. Audiometric evaluation revealed profound sensorineural hearing loss in the left ear with a Pure Tone Average of 110 dB, while the right ear remained normal. Serological analysis confirmed acute mumps infection with a highly positive IgM titer (Index 11.0). Hematological profiling demonstrated leukopenia with a neutrophil shift. Despite a prompt and aggressive multimodal treatment protocol including high-dose intravenous methylprednisolone, oxygen therapy, and neurotrophic support, follow-up audiometry at 14 days revealed no functional improvement (Pure Tone Average 91.25 dB). In conclusion, mumps-induced SSNHL is characterized by rapid, irreversible cochlear destruction that frequently exhibits resistance to corticosteroid therapy. The dissociation between the resolution of systemic parotitis and the onset of otologic sequelae requires high clinical vigilance. This case emphasizes the critical need for serological confirmation in pediatric SSNHL and underscores the poor prognosis associated with this specific viral etiology.
Palatal Abscess of Odontogenic Origin Causing Dyspnea in an Elderly Patient: A Case Report and Critical Review of Management Strategies
Odontogenic infections are prevalent clinical entities, typically presenting as localized pathologies within the alveolar process. However, a palatal abscess—a specific manifestation arising from the spread of infection through the palatal cortical plate of maxillary teeth—rarely escalates to cause life-threatening airway compromise. This report details an exceptional case of a palatal abscess causing significant dyspnea in an elderly patient, challenging the conventional understanding of the hard palate as a robust anatomical barrier preventing deep space extension. A 68-year-old female presented to the emergency department on October 1st, 2022, with a five-day history of progressively enlarging palatal swelling, dysphagia, and dyspnea. Clinical examination revealed a massive, fluctuant mass extending from the hard to the soft palate, obstructing the oropharyngeal inlet. Despite a leukocyte count at the upper limit of normal and an afebrile status—indicative of geriatric immunosenescence—the patient exhibited objective tachypnea (24 breaths/min). Diagnosis was confirmed via needle aspiration. Management involved immediate airway stabilization, broad-spectrum antibiotics (Ceftriaxone and Metronidazole), and corticosteroids. On October 3rd, 2022, the patient underwent incision and drainage under general anesthesia, yielding 15cc of purulent material. The source was identified as carious residual roots of the maxillary right second molar (FDI #17). Post-operative recovery was rapid, with discharge on October 6th, 2022. In conclusion, this case underscores that palatal abscesses can evolve into critical airway emergencies, particularly in geriatric patients with diminished physiological reserves and blunted immune responses. Prompt recognition, aggressive multidisciplinary management, and definitive dental treatment are paramount to preventing mortality.
Divergent Carcinogenic Risks of Domestic versus Ritual Combustion on Nasopharyngeal Carcinoma in Bali: A Matched Case-Control Study
Nasopharyngeal carcinoma (NPC) is endemic in Indonesia, particularly among the ethnically distinct Balinese population. The interplay between Epstein-Barr virus (EBV) and environmental co-factors remains critical to its pathogenesis. A unique cultural duality exists in Bali regarding inhalant exposure: the utilitarian combustion of firewood and tobacco versus the ritual combustion of incense. This study aims to distinguish the carcinogenic risks of these disparate smoke sources using robust statistical methods to account for sparse data bias. A matched case-control study was conducted at a tertiary referral center in Denpasar, Bali. Forty-two patients with histopathologically confirmed WHO Type III Undifferentiated NPC were matched by age and sex with 42 non-cancer controls screened via Digby score. Exposures to firewood, passive and active smoking, and ritual incense were assessed. To address quasi-complete separation due to high exposure prevalence, Firth’s Penalized Likelihood Logistic Regression was employed to determine Adjusted Odds Ratios (AOR). Firewood smoke exposure emerged as the predominant risk factor (AOR 14.21; 95% CI 4.82–42.15; p < 0.001), significantly higher than previously estimated by standard models. Passive smoking was confirmed as a substantial independent risk factor (AOR 11.54; 95% CI 3.91–33.82; p < 0.001). Conversely, despite universal usage, ritual incense exposure showed no association with NPC (AOR 0.92; 95% CI 0.35–2.41; p = 0.865), likely due to the open-air ventilation of Balinese shrines. Salted fish consumption remained a significant co-factor (AOR 6.80; p = 0.002). In conclusion, the study establishes a clear etiological hierarchy: chronic domestic pollutants such as biomass and tobacco smoke are potent drivers of NPC in Bali, likely acting as tumor promoters via EBV reactivation. Ritual incense, in the context of Balinese architecture, is not a significant risk. Public health interventions must prioritize healthy kitchen ventilation and tobacco control.
Bronchoscopic Resolution of Refractory Atelectasis in a Toddler with Polymicrobial MDR Pneumonia: A Case Report
Pediatric acute respiratory distress syndrome (PARDS) complicated by ventilator-associated pneumonia (VAP) poses significant management challenges, particularly when caused by multidrug-resistant organisms such as Stenotrophomonas maltophilia and Pseudomonas aeruginosa. A frequent and deleterious complication is plate-like atelectasis, which may prove refractory to conservative management due to anatomical constraints in the pediatric airway and biofilm formation. A 23-month-old male presented with severe PARDS and polymicrobial VAP. Despite extubation to High-Flow Nasal Cannula (HFNC), the patient developed persistent right upper lobe plate-like atelectasis refractory to aggressive physiotherapy and targeted antibiotic therapy with Levofloxacin and Ceftazidime for 21 days. On Day 75 of illness, a flexible bronchoscopy was performed. Intraoperative findings revealed hyperemic mucosa without macroscopic mucus plugging. However, the procedure, involving saline lavage and suctioning, resulted in immediate recruitment. Within 24 hours, the respiratory rate decreased from 45 to 24 breaths per minute, and the SpO2/FiO2 ratio improved significantly from 185 to 310, allowing weaning from respiratory support. In conclusion, in toddlers with multidrug-resistant VAP, atelectasis may persist due to biofilm-mediated micro-obstruction rather than macroscopic plugging. Flexible bronchoscopy is a safe and effective therapeutic adjunct in these cases, facilitating distal airway recruitment and breaking the cycle of chronic infection.
The Diagnostic Utility of Low Neutrophil-to-Lymphocyte Ratio (NLR) as an Indicator of Severity in Adult Dengue Hemorrhagic Fever: A Retrospective Study from Bali
Dengue hemorrhagic fever (DHF) remains a critical public health challenge in tropical regions. Unlike bacterial sepsis, where a high neutrophil-to-lymphocyte ratio (NLR) typically indicates severity, viral kinetics in dengue often present differently due to bone marrow suppression. This study evaluates the association between low NLR and disease severity in an adult cohort in Indonesia, aiming to identify a cost-effective marker for risk stratification. A retrospective cross-sectional study was conducted at Wangaya Regional General Hospital, Denpasar, Indonesia, from January to August 2025. We analyzed 92 confirmed adult DHF patients aged 18 years and older. Severity was graded using standard World Health Organization criteria (Grades 1–4). For the purpose of diagnostic performance analysis, severe DHF was defined as Grade 2 (spontaneous bleeding) and Grade 3 (circulatory failure) combined. The correlation between NLR and severity was analyzed using the Spearman rank test. Receiver Operating Characteristic (ROC) analysis determined the optimal cut-off for identifying severe cases. The cohort was predominantly young adults (18–25 years; 47.8%) with a male preponderance (68.5%). The severity distribution included Grade 1 (n=68; 73.9%), Grade 2 (n=21; 22.8%), and Grade 3 (n=3; 3.3%). A significant, moderate inverse correlation was observed between NLR and severity grade (r = -0.347; p < 0.001). Mean NLR decreased progressively from Grade 1 (2.90) to Grade 2 (1.20) and Grade 3 (0.65). ROC analysis for detecting Grade 2 or higher DHF showed an Area Under the Curve (AUC) of 0.82 (95% CI: 0.75–0.89). An NLR cut-off of less than 0.85 yielded a sensitivity of 87.5% and specificity of 72.0%. In conclusion, a low NLR is significantly associated with higher clinical severity in adult DHF. Unlike bacterial infections, a declining NLR below 0.85 serves as a potential marker for identifying patients at risk of bleeding and circulatory compromise in resource-limited settings.
The Healthy Weight Paradox: Unmasking High Dyslipidemia Prevalence in Normoweight Adults with Normal Waist Circumference
The reliance on body mass index (BMI) as the sole anthropometric indicator for cardiovascular risk is increasingly debated. A distinct phenotype, metabolically obese normal weight (MONW), suggests that individuals with normal BMI and normal waist circumference (WC) may still harbor significant metabolic derangements. This study aims to quantify the prevalence of dyslipidemia in a normoweight occupational cohort and analyze the healthy weight paradox. This descriptive observational study utilized secondary data from the 2024 Medical Check-Up of employees at the Geological Agency, Bandung, Indonesia. A total of 142 subjects met the strict inclusion criteria: BMI 18.5–22.9 kg/m² and normal waist circumference (<90 cm for men, <80 cm for women). Lipid profiles—Total cholesterol (TC), low-density lipoprotein (LDL), high-density lipoprotein (HDL), and Triglycerides (TG)—were analyzed. Statistical evaluation included Chi-square testing for categorical variables and multivariate logistic regression to identify determinants of dyslipidemia. Despite normal anthropometry, 54.93% (n=78) of subjects exhibited dyslipidemia. The most prevalent abnormalities were borderline high TC (24.65%) and mixed dyslipidemia (20.42%). A significant gender disparity was observed, with 62.0% of males exhibiting dyslipidemia compared to 38.1% of females (p < 0.05). Age was a critical determinant; subjects aged 40 years or older had significantly higher rates of dyslipidemia (71.62%) compared to those younger than 40 years (p < 0.01). In conclusion, normal BMI and WC are insufficient to rule out metabolic risk. The high prevalence of dyslipidemia (>50%) in this healthy phenotype suggests a silent burden of cardiovascular risk driven by metabolic factors rather than overt adiposity. Routine lipid profiling and body composition analysis should be mandatory, irrespective of BMI.
Efficacy and Safety of CD19-Targeted Chimeric Antigen Receptor (CAR) T-Cell Therapy in Refractory Systemic Lupus Erythematosus: A Systematic Review of Clinical Outcomes and B-Cell Depletion Kinetics
Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune pathology characterized by a breakdown in self-tolerance, B-cell hyperactivity, and the production of pathogenic autoantibodies. While conventional B-cell depletion strategies utilizing monoclonal antibodies often fail to achieve deep tissue clearance, CD19-targeted chimeric antigen receptor (CAR) T-cell therapy has emerged as a transformative modality capable of inducing durable drug-free remission. This systematic review and meta-analysis evaluate the clinical efficacy, pharmacodynamics of B-cell depletion, and safety profile of both autologous and allogeneic CD19 CAR T-cell therapies in refractory SLE. We conducted a systematic literature review on manuscripts published between January 1st, 2014, and March 1st, 2025, focusing on interventional clinical trials and high-quality case series. Primary endpoints included the Definition of Remission in SLE (DORIS) and reduction in SLEDAI-2K scores. Secondary endpoints analyzed B-cell aplasia kinetics, seroconversion of anti-dsDNA, and adverse events, including cytokine release syndrome (CRS), immune effector cell-associated neurotoxicity syndrome (ICANS), and novel autoimmune-specific toxicities. Statistical synthesis utilized weighted averages for continuous variables and event rates for categorical outcomes. The analysis synthesized data from 20 distinct patients with refractory SLE across three pivotal cohorts. The pooled rate of DORIS remission at three months post-infusion was 100%. The mean SLEDAI-2K score decreased from a baseline of 12.5 to 0.8 at three months. Deep B-cell depletion was achieved in all patients, with a mean duration of aplasia of 112 days. Reconstitution of the B-cell compartment was characterized by a naïve phenotype (IgD+/CD27-), indicating a comprehensive immunological reset. Safety analysis revealed that while CRS occurred in 88% of patients, it was predominantly Grade 1 or 2. No high-grade ICANS occurred. Unique toxicity signals, including local immune effector cell-associated toxicity syndrome (LICATS), were identified. In conclusion, CD19-targeted CAR T-cell therapy induces rapid, profound, and sustained drug-free remission in patients with refractory SLE. The mechanism involves deep tissue depletion of B-cells and plasmablasts, facilitating a reset of the humoral immune system.
Cerebral Toxoplasmosis with Preserved CD4 Count (>300 cells/µL) in the HAART Era: Unmasking Immune Reconstitution Inflammatory Syndrome and the Diagnostic Utility of Cotrimoxazole
Cerebral toxoplasmosis (TE) typically presents in HIV-positive patients with severe immunosuppression (CD4 <100 cells/µL). However, in the era of Highly Active Antiretroviral Therapy (HAART), presentations have become atypical. We report a rare case of TE in a patient with a preserved CD4 count (>300 cells/µL), highlighting the phenomenon of unmasking immune reconstitution inflammatory syndrome (IRIS). A 22-year-old female, HIV-positive on a Tenofovir-Lamivudine-Efavirenz (TLE) regimen for one month, presented with subacute hemicrania, focal motor seizures, and complex visual hallucinations (zoopsia). Despite a CD4 count of 307 cells/µL and a suppressed viral load (<40 copies/mL), Contrast-Enhanced Computerized Tomography (CE-CT) revealed multiple ring-enhancing lesions with significant perilesional edema. The patient was diagnosed with TE-associated Unmasking IRIS. Due to the unavailability of Pyrimethamine, she was treated with high-dose Cotrimoxazole (960 mg q6h). Significant clinical improvement was observed by day 4, characterized by the cessation of seizures and hallucinations. Follow-up at two weeks confirmed sustained neurological recovery. In conclusion, a preserved CD4 count does not exclude opportunistic infections in the early post-HAART period. This case underscores the diagnostic pitfall of immune discordance and validates the efficacy of Cotrimoxazole as a primary therapeutic intervention in resource-limited settings.
Navigating the Perfect Storm: Ultrasound-Guided Peripheral Nerve Block for Emergency Amputation in a Patient with Acute STEMI and Failed PCI
Acute limb ischemia presenting concurrently with acute coronary syndrome creates a precarious clinical dilemma, often termed the "cardiac cripple" scenario. The mortality risk is compounded when patients have a history of failed percutaneous coronary intervention, severe left ventricular dysfunction, and require emergency major amputation while on active dual antiplatelet therapy. In these patients, general anesthesia poses a risk of hemodynamic collapse, while neuraxial anesthesia is contraindicated due to bleeding risks. A 75-year-old male presented with a Rutherford Grade III-IV "dead limb" of the right lower extremity and concurrent Acute Anterior STEMI (Killip II, TIMI 7/14, GRACE 137). His history included a failed percutaneous coronary intervention two months prior and three-vessel disease, resulting in a left ventricular ejection fraction of 32%. General anesthesia posed an unacceptable risk of exacerbating myocardial pump failure, while spinal anesthesia was contraindicated due to recent clopidogrel ingestion. A decision was made to perform a below-knee amputation using an ultrasound-guided femoral nerve block and a popliteal sciatic nerve block via the crosswise approach. The procedure utilized 0.5% ropivacaine with 2 mg dexamethasone. The patient remained hemodynamically stable without vasopressor support, reported a Visual Analogue Scale score of 0 intraoperatively, and avoided adverse cardiac events. In conclusion, peripheral nerve blockade, specifically the combined femoral and crosswise popliteal sciatic approach, serves as a superior anesthetic alternative in high-risk cardiac patients. It bypasses the sympatholytic risks of general anesthesia and the coagulation constraints of neuraxial techniques, offering a safe corridor for life-saving surgery.
Liquid Nitrogen-Recycled Autograft Augmented with a Non-Vascularized Fibular Strut for Refractory Pediatric Osteosarcoma: A Case Report of the Cryo-Immunological Reconstruction
Reconstruction of large segmental bone defects following limb salvage surgery for osteosarcoma presents a significant challenge in pediatric populations, particularly in resource-limited settings where expandable endoprostheses are inaccessible. This study evaluates the efficacy of a biological reconstruction technique using Liquid Nitrogen-treated recycled autograft augmented with a fibular strut, known as the Modified Capanna Technique. We present the case of an 8-year-old female with Enneking Stage IIB high-grade osteoblastic osteosarcoma of the distal femur. The patient exhibited a refractory response (Huvos Grade II) to a neoadjuvant non-methotrexate chemotherapy regimen. Wide resection was performed, followed by a specific cryo-protocol: the tumor-bearing bone was frozen in Liquid Nitrogen (−196°C) for 20 minutes, thawed physiologically, augmented with an intramedullary non-vascularized fibular strut, and stabilized with a locking compression plate. At 12 months postoperative, the patient achieved solid radiographic union with a Radiographic Union Scale for Tibial fractures score of 11/12. No local recurrence or distant metastasis was detected. The Musculoskeletal Tumor Society score improved from 10% pre-operatively to 80% post-operatively, reflecting independent ambulation. A comparative analysis revealed that the procedure cost was approximately 12% of a standard imported megaprosthesis. In conclusion, the liquid nitrogen-recycled autograft, when mechanically augmented, offers a theoretically sound and cost-effective limb salvage solution. It provides immediate anatomical restoration and potential cryo-immunological benefits, making it a viable alternative for refractory cases in developing healthcare systems.
A Comparative Analysis of Ipsilateral, Contralateral, and Bilateral Average ONSD in Correlating with Cerebral Midline Shift: Re-framing a Non-Invasive Tool from a Quantitative Predictor to a Clinical Classifier
In traumatic brain injury (TBI), non-invasive proxies for mass effect are crucial. The optic nerve sheath diameter (ONSD) is used to estimate intracranial pressure (ICP), but its correlation with structural outcomes like midline shift (MLS) is poorly defined, particularly regarding the optimal measurement method (unilateral vs. bilateral). We prospectively enrolled 38 adult TBI patients who received both a CT scan and a bedside ONSD ultrasound within 24 hours. Data was re-analyzed to classify ONSD relative to lesion location (Ipsilateral, Contralateral) and to correlate these, plus the Bilateral Average (ONSD-Avg), with CT-measured MLS using Spearman's correlation. We used linear regression to assess quantitative prediction (R-square) and binary logistic regression (ROC curve) to assess clinical classification (AUC) for predicting MLS >5mm. A significant, positive correlation was found between MLS and Ipsilateral-ONSD (rs = 0.450, p = 0.005) and ONSD-Avg (rs = 0.383, p = 0.018). The Contralateral-ONSD correlation was not significant (rs = 0.210, p = 0.206). A Wilcoxon test confirmed Ipsilateral-ONSD was significantly wider than Contralateral-ONSD (p < 0.01). The linear regression model for MLS quantification was statistically significant (p = 0.015) but had a very low predictive power (R-square = 0.153). In contrast, the logistic regression model found ONSD-Avg to be an excellent classifier for detecting surgical MLS (> 5mm), with an Area Under the Curve (AUC) of 0.88 (95% CI 0.75-0.96). In conclusion, ONSD measurement is significantly affected by asymmetric, unilateral TBI pathology. The bilateral average (ONSD-Avg) is the most reliable screening method, as it compensates for unilateral pressure gradients. The low R-square (15.3%) confirms ONSD is a poor quantitative predictor of MLS, reflecting the non-linear pressure-volume relationship. However, the high AUC (0.88) proves ONSD is an excellent clinical classifier for identifying patients with surgical-threshold mass effect. ONSD should not be used to "quantify" MLS, but rather to "classify" patient risk.
Squamous Papilloma of the External Auditory Canal as a High-Fidelity Mimic of Malignant Otitis Externa: A Case Report
Malignant otitis externa (MOE) is a life-threatening osteomyelitis of the skull base, typically affecting geriatric patients with diabetes mellitus. Its initial presentation of otalgia, otorrhea, and an external auditory canal (EAC) mass demands an immediate, high index of suspicion. Squamous papilloma, a benign human papillomavirus (HPV)-related neoplasm, is exceedingly rare in the EAC. This report details a case where this rare benign entity presented as a high-fidelity clinical and laboratory mimic of MOE. We present the case of a 71-year-old female with poorly controlled Type 2 Diabetes Mellitus who presented with a three-week history of severe, refractory otalgia. A systematic diagnostic evaluation was performed, including clinical examination, full audiological assessment, serum inflammatory markers, and high-resolution computed tomography (HRCT) of the temporal bones. The patient's presentation was a textbook surrogate for MOE, including severe otalgia, purulent otorrhea, a friable EAC mass, and markedly elevated erythrocyte sedimentation rate (ESR) (78 mm/hr) and C-Reactive Protein (CRP) (45.2 mg/L). However, HRCT demonstrated an occluding soft-tissue mass without the hallmark finding of temporal bone erosion. The patient underwent transcanal excisional biopsy. Histopathological (H&E) analysis provided the definitive diagnosis of a benign squamous papilloma, with pathognomonic koilocytosis consistent with HPV infection. The patient's severe symptoms resolved completely upon excision. In conclusion, this case highlights a critical diagnostic pitfall. A secondarily infected EAC squamous papilloma can create a clinical and laboratory picture indistinguishable from early-stage MOE. The absence of bony erosion on HRCT is the single most critical finding to pivot the diagnosis away from invasive osteomyelitis. This report underscores the mandatory role of a systematic diagnostic pathway combining imaging and histopathology to prevent misdiagnosis and avoid unnecessary, prolonged, and toxic systemic antimicrobial therapy.
When the Lungs Suffer for the Ovary: A Case of Meigs Syndrome Presenting as Severe Dyspnea and Massive Unilateral Pleural Effusion
Meigs syndrome is a rare clinical entity defined by the triad of a benign ovarian tumor, ascites, and pleural effusion. It characteristically resolves completely after the surgical removal of the primary tumor. Despite its benign nature, the clinical presentation often mimics advanced-stage ovarian malignancy, posing a significant diagnostic challenge. A 47-year-old nulligravid woman presented with a two-week history of severe dyspnea, orthopnea, and pleuritic chest pain, set against a four-month backdrop of progressive abdominal distension and a 10-kg weight loss. Physical examination revealed findings consistent with a massive right-sided pleural effusion, significant ascites, and a large, firm pelvic-abdominal mass. Imaging confirmed a massive right pleural effusion and a complex ovarian mass exceeding 16 cm. A diagnosis of Meigs syndrome was established after pleural fluid analysis revealed a cytologically negative, exudative fluid. The patient's acute respiratory distress was managed with serial therapeutic thoracentesis, with 5,000 mL of fluid removed over five days, leading to dramatic symptomatic improvement. She was subsequently stabilized for definitive surgical intervention. In conclusion, this case powerfully illustrates the critical importance of including Meigs syndrome in the differential diagnosis for women with an ovarian mass and concurrent pleuro-peritoneal effusions. Timely recognition and a staged, multidisciplinary management approach are paramount for alleviating life-threatening symptoms and achieving an excellent prognosis, reaffirming the clinician's highest duty: to diligently seek out the curable, even when faced with the seemingly incurable.