Open Access Indonesian Journal of Medical Reviews
Open Access Indonesian Journal of Medical Reviews (OAIJMR) is an international, peer-reviewed, fully open-access medical journal published six times per year by HM Publisher in collaboration with CMHC Research Center. It publishes original research articles, case reports, narrative reviews, systematic reviews, and meta-analyses in medicine, health sciences, biomedical sciences, and evidence synthesis.
HM Publisher in collaboration with CMHC Research Center
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Unequal Per-Grade Loss of Macular Ganglion Cell–Inner Plexiform Layer Thickness in Non-Proliferative Diabetic Retinopathy: An Indonesian Cross-Sectional Study
Background: Diabetic retinopathy is a neurovascular disease in which neurodegeneration accompanies microvascular injury. How ganglion cell–inner plexiform layer (GCL–IPL) loss is distributed across non-proliferative diabetic retinopathy (NPDR) severity is unsettled; Indonesian data are scarce. Objective: To quantify mean macular GCL–IPL thickness across mild, moderate and severe NPDR; test whether successive per-grade decrements are equal and scale-dependent; characterise discrimination between grades; and bound the influence of aggregate-data uncertainty and confounding. Methods: Cross-sectional analysis of 32 eyes of 29 consecutive adults with mild, moderate or severe NPDR without macular oedema at Dr. M. Djamil General Hospital, Padang (2023–2025). Mean macular GCL–IPL thickness was measured by spectral-domain optical coherence tomography. Only aggregate data existed, so sharp bounds came from exhaustively enumerating every eye-level dataset compatible with the published summaries and the reported normality test. Result: GCL–IPL thickness fell from 86.0 ± 3.63 μm (mild) to 71.0 ± 4.71 μm (moderate) and 63.8 ± 3.39 μm (severe); F(2, 29) = 86.288, p < 0.001, η² = 0.856 (95% CI 0.724–0.900). All pairwise contrasts were significant (Bonferroni p ≤ 0.0008). The per-grade steps were unequal: mild→moderate lost 15.0 μm against 7.2 μm for moderate→severe, a difference of 7.8 μm (95% CI 1.75–13.85, p = 0.013). That asymmetry is a property of the equal-interval grade score and disappears under ETDRS-level scoring (p = 0.759). Mild and severe eyes separated completely in every admissible dataset (area under the curve 1.000); moderate versus severe, 0.827–0.964. Conclusion: GCL–IPL thickness tracks NPDR severity steeply, but the apparent front-loading of loss is scale-dependent and must not be read as biology. The mild-grade mean lay within the published normative band — an interval built for individual eyes, not for group means — so these data show a gradient, not pre-clinical thinning.
Copyright (c) 2026 Sarah Yasmin Ramadhanti, Weni Helvinda, Khalilul Rahman https://creativecommons.org/licenses/by-nc-sa/4.0
Baseline Optical Coherence Tomography Biomarkers Predict Failure to Dry the Macula on Anti-VEGF Therapy in Diabetic Macular Oedema — but Only When Response Is Defined Anatomically: A Systematic Review and Meta-Analysis
Background: Baseline optical coherence tomography (OCT) biomarkers are used to counsel patients before anti-vascular endothelial growth factor (anti-VEGF) therapy for diabetic macular oedema, but the two published syntheses covered visual acuity only. Objective: To estimate the association between adverse baseline OCT biomarkers and poor anatomical response, and to test whether it depends on the response definition. Methods: Europe PMC and MEDLINE were searched for cohort studies relating a baseline OCT biomarker to an anatomical outcome after anti-VEGF therapy. Odds ratios were pooled by correlated hierarchical effects with robust variance estimation, the unit of analysis being the biomarker-outcome estimate. Endpoints were pre-specified into clinically anchored and percentage-reduction strata; risk of bias used ROBINS-E. Result: Seventeen studies (1,758 eyes) gave 54 estimates. In the primary stratum (10 studies, 26 estimates, 1,058 eyes) an adverse biomarker carried an odds ratio of 3.75 (95% CI 2.27 to 6.19; p = 0.0004) for failing to dry the macula: against a background rate near 35 in 100, about 67 in 100 (55 to 77). Ellipsoid zone disruption was best supported (3.55, 1.43 to 8.84). The direction reversed against percentage-reduction endpoints (0.84, 0.31 to 2.30; interaction p = 0.006); subretinal fluid from 3.33 to 0.18 (0.06 to 0.53). It held across 20 sensitivity analyses (3.29 to 4.90). Certainty was low. Conclusion: About two-thirds of eyes with adverse baseline morphology remain wet after loading, against one-third without it — but only where response means the retina became dry. Percentage-reduction endpoints are coupled to baseline thickness and invert it.
Copyright (c) 2026 Angel Lim, I Gusti Ayu Stiti Sadvika https://creativecommons.org/licenses/by-nc-sa/4.0
Acute Kidney Injury and Rapidly Progressive Glomerulonephritis in Acute Post-Streptococcal and Post-Infectious Glomerulonephritis: Pooled Prevalence, Age-Related Risk and Prognostic Determinants — A Systematic Review and Meta-Analysis
Background: Acute post-streptococcal glomerulonephritis (APSGN) commonly causes acute nephritic syndrome in children, yet how often it causes acute kidney injury (AKI) or a rapidly progressive course is unquantified. Objective: To pool the prevalence of AKI, kidney replacement therapy (KRT) and rapidly progressive or crescentic glomerulonephritis (RPGN), and to explain the variation between cohorts. Methods: PubMed and Europe PMC were searched. Observational studies reporting AKI, KRT or RPGN in post-streptococcal or post-infectious glomerulonephritis were eligible. Prevalence was pooled by random-intercept logistic regression, determinants as odds ratios. Risk of bias used ROBINS-E, certainty GRADE. Result: Thirty studies were included, 26 pooled. How a study defined AKI dominated its reported risk: 62.3% (95% CI 44.7-77.2) under a bare creatinine or eGFR threshold, 35.0% (21.3-51.7) under consensus criteria and 16.0% (8.6-27.8) where none was stated (p = 0.0001). Definition class and income setting explained 66.7% of variance. Across 21 cohorts AKI complicated 34.7% (23.1-48.5) of presentations (n = 2,454; I2 = 95.2%; prediction interval 3.2-89.4%), rising to 49.6% (35.5-63.7) in the 13 cohorts stating a definition. KRT was required in 3.3% (1.4-7.8) and RPGN in 6.8% (3.4-13.2). Among children each year of age raised the odds of an adverse outcome by 17% (OR 1.17, 1.09-1.24); heavy proteinuria gave OR 2.66 (1.50-4.73). Certainty was very low. Conclusion: Reported AKI risk depends more on how a centre defines AKI than on the population served. Between a third and a half of children develop AKI; severe outcomes are uncommon. A minimum reporting standard is proposed.
Copyright (c) 2026 Garri Prima Decroli, Harnavi Harun https://creativecommons.org/licenses/by-nc-sa/4.0
One-Month Anatomical and Functional Response to Intravitreal Bevacizumab in Diabetic Macular Edema: A Retrospective Single-Arm Study in Padang, Indonesia
Background: Intravitreal bevacizumab is the anti-vascular endothelial growth factor agent available for diabetic macular edema (DME) in most Indonesian public hospitals, but West Sumatran data are scarce. Objective: We quantified the one-month response and bounded what these data support. Methods: This was a re-analysis (STROBE) of the aggregate tabulations of a retrospective single-arm pre-post series of all eyes given bevacizumab 1.25 mg/0.05 mL for DME at Dr. M. Djamil General Hospital, Padang (January 2022 to December 2024). Central macular thickness (CMT) and Snellen acuity before and one month after injection were compared by exact McNemar test with Wilson 95% confidence intervals (CI); unidentified quantities were bounded by exhaustive enumeration rather than assumed. Result: Fourteen eyes of 11 patients were analysed, and mean CMT fell from 527 to 318 μm (−40%; Glass's Δ 1.37). The anatomical paired table is identified: CMT reached 300 μm or less in 9 of 14 eyes (64.3%, 95% CI 38.8–83.7; exact McNemar P = 0.004), holding under complete clustering (worst case P = 0.031). The acuity transition table is not identified; across its four admissible forms the exact P spans 0.008 to 0.057, widening to 0.227 once clustering is added. Effect modification by glycaemic control was not identified (risk difference bounded only between −0.833 and +1.000 across 24 reconstructions), and no between-stratum difference is detectable at 80% power. Conclusion: The anatomical benefit at one month is therefore large and robust, whereas the functional benefit is suggestive but not established, and the roles of diabetes duration and glycaemic control remain undetermined.
Copyright (c) 2026 Yolanda Wulandari Erwen, Weni Helvinda, Khalilul Rahman https://creativecommons.org/licenses/by-nc-sa/4.0
Preoperative Sarcopenia and Major Postoperative Complications After Gastrectomy for Gastric Cancer: Does Adding Muscle Function to Muscle Mass Improve Risk Prediction? A Systematic Review and Meta-Analysis
Background: Consensus bodies define sarcopenia by low muscle mass plus impaired function, yet most gastrectomy studies use computed-tomography muscle mass alone. Whether adding function improves prediction of major postoperative complications remains uncertain. Objective: To quantify the association between preoperative sarcopenia and major complications after gastrectomy for gastric cancer and compare function-inclusive with imaging-mass-only definitions. Case presentation: This systematic review and meta-analysis searched PubMed and Europe PMC through 17 June 2026 for adult gastrectomy cohorts reporting Clavien-Dindo grade IIIa or higher complications. Ten cohorts (4,883 patients) entered the primary pool. Sarcopenia increased the odds of major complications (OR 1.71, 95% CI 1.24–2.35; I² = 48.0%; prediction interval 0.73–3.99). Function-inclusive and imaging-mass-only definitions produced nearly identical estimates (OR 1.72, 95% CI 0.91–3.23, four cohorts, versus OR 1.71, 95% CI 1.12–2.62, six cohorts; interaction p = 0.997). The estimate remained stable in leave-one-out, cluster-selection, and exact-binomial sensitivity analyses, and no funnel asymmetry was detected. Conclusion: Preoperative sarcopenia identifies higher-risk patients after gastrectomy. Adding muscle function did not increase the pooled association, but the function-inclusive subgroup was small and incomplete; the absence of a detected difference should not be interpreted as equivalence. Within-cohort evidence favored multidimensional assessment over a single muscle measure.
Copyright (c) 2026 I Putu Oktayana, Gregorius Iwan Budiman Bomba, Nugroho Sofian Aji https://creativecommons.org/licenses/by-nc-sa/4.0
Perceived Service Quality, Not Accessibility, Drives Patient Satisfaction with Traditional Medicine: A Cross-Sectional Study at Bhutan's National Traditional Medicine Hospital
Background: Sowa Rigpa, Bhutan's traditional medicine system, is free at the point of use, yet the determinants of patient satisfaction remain poorly quantified. Objective: To determine which dimensions of the service experience predict overall satisfaction among repeat attenders at the National Traditional Medicine Hospital in Thimphu. Methods: This analytical cross-sectional study interviewed 209 patients aged 15–80 years with at least two previous attendances between 1 and 29 July 2025. A bilingual structured questionnaire assessed perceived service quality, accessibility and satisfaction (Cronbach's alpha 0.877). Associations were tested using Fisher's exact test with Benjamini–Hochberg correction. Result: Overall satisfaction was high in 88.3% of evaluable respondents (95% CI 83.1–92.1), including 98.1% for outpatient therapy and 93.9% for day-therapy massage, whereas perceived accessibility was high in 72.0%. Overall perceived quality was associated with satisfaction (p = 0.0014), as were perceptions of common services (p = 0.0001) and day-therapy massage (p = 0.0007); all survived correction. Accessibility was not associated with satisfaction (p = 0.3237). Poor accessibility was reported more often by men (OR 2.89, 95% CI 1.52–5.48), patients aged 35 years or under (OR 2.19, 95% CI 1.10–4.34) and better-educated patients (OR 2.81, 95% CI 1.27–6.20). Conclusion: Patient satisfaction at this national referral centre was driven by perceived care quality rather than accessibility. Privacy, waiting-area space and service hours are the main actionable priorities.
Copyright (c) 2026 Karma Gaylek, Lobzang Dawa, Hendsun Hendsun https://creativecommons.org/licenses/by-nc-sa/4.0
Takayasu Arteritis Presenting as Orbital Apex Syndrome With Irreversible Monocular Blindness and Long-Segment Right Carotid Stenosis: A Case Report With 58 Months of Follow-Up
Background: Takayasu arteritis is a granulomatous large-vessel vasculitis that usually becomes apparent only after stenotic damage has occurred and can be difficult to recognise when classical peripheral vascular signs are absent. Objective: To describe the clinical course, diagnostic challenges and long-term outcome of Takayasu arteritis presenting as orbital apex syndrome with irreversible monocular blindness and long-segment right carotid stenosis. Case Presentation: A 36-year-old man presented in August 2020 with a chronic progressive right hemicranial headache that acutely worsened and was followed by complete loss of vision in the right eye. Examination showed right optic nerve dysfunction, ptosis, proptosis, absent pupillary reflexes and complete ophthalmoplegia involving the third, fourth and sixth cranial nerves, a constellation corresponding to orbital apex syndrome. There were no constitutional symptoms, no limb claudication and no significant inter-arm blood pressure difference. Contrast-enhanced computed tomography of the brain and orbits was unrevealing. Computed tomography angiography seven days later showed long-segment luminal irregularity and stenosis of the right common carotid artery extending continuously into the cervical, petrous, cavernous and supraclinoid internal carotid segments, with a preserved contralateral carotid and posterior circulation; the erythrocyte sedimentation rate was elevated. Takayasu arteritis was diagnosed and treated with high-dose glucocorticoid followed by azathioprine and antiplatelet therapy. The headache resolved but the visual loss did not. Applied retrospectively, the 2022 American College of Rheumatology/EULAR criteria yielded one point against a threshold of five, because three examination items were never recorded and aortic imaging was never done. At 58 months the patient was clinically stable but had grade 3 lymphopenia and grade 1 thrombocytopenia. Conclusion: Takayasu arteritis should be considered in young adults with progressive headache and focal neuro-ophthalmic deficits even when pulses and blood pressures are symmetrical.
Copyright (c) 2026 Erwin Dharmawan, Pande Ketut Kurniari, Gede Kambayana https://creativecommons.org/licenses/by-nc-sa/4.0
Diagnostic Accuracy of the Simplified Carbapenem Inactivation Method versus the Modified Hodge Test in Carbapenem-Resistant Pseudomonas aeruginosa: A Cross-Sectional Study
Background: Carbapenem-resistant Pseudomonas aeruginosa (CRPA) is among the pathogens contributing most to the global burden of antimicrobial resistance, and its pooled prevalence in Indonesia reaches 43%. Carbapenem resistance and carbapenemase production are not equivalent, and only the enzymatic route is transmissible and therapeutically decisive. Molecular confirmation is unavailable in most Indonesian laboratories, so an accurate low-cost phenotypic assay is needed. Objective: To compare the simplified carbapenem inactivation method (sCIM) with the Modified Hodge Test (MHT) for detecting carbapenemase production in carbapenem-resistant P. aeruginosa. Methods: This cross-sectional diagnostic-accuracy study evaluated 30 meropenem- and imipenem-resistant clinical isolates archived at Dr. Soetomo General Academic Hospital, Surabaya, using PCR for blaIMP, blaGES, blaOXA, blaNDM, blaKPC and blaVIM as the reference standard. Result: A carbapenemase gene was detected in 13/30 isolates (43.3%): blaIMP in 9, blaGES in 3 and blaOXA in 1. sCIM achieved 92.31% sensitivity (95% confidence interval 64.0-99.8), 100.00% specificity (80.5-100.0), 96.7% accuracy and near-perfect agreement with PCR (kappa 0.932). MHT achieved 46.15% sensitivity (19.2-74.9), 88.24% specificity (63.6-98.5) and fair agreement (kappa 0.360). The paired exact McNemar test confirmed the sensitivity advantage of sCIM (p = 0.031), and bootstrapping showed a 26.6-percentage-point difference in overall accuracy (95% confidence interval 10.0-43.3). MHT detected no blaGES-positive isolate and only 6/9 blaIMP-positive isolates; sCIM detected all of both, while neither assay detected the single poorly expressed blaOXA isolate. Conclusion: sCIM is an accurate, rapid and inexpensive assay that should replace MHT in Indonesian laboratories and feed directly into stewardship and infection-control decisions.
Copyright (c) 2026 Fara Nayo Faramarisa, Kristiawan Basuki Rahmat, Berliana Nisfa Laily, Eddy Bagus Wasito, Kuntaman https://creativecommons.org/licenses/by-nc-sa/4.0
Dermoscopic Characteristics of Nail Involvement in Patients with Psoriasis Vulgaris: A Descriptive Cross-Sectional Study at a Tertiary Hospital in Surakarta, Indonesia
Psoriasis vulgaris is a chronic immune-mediated inflammatory disease that frequently involves the nails, yet nail changes are often overlooked despite their diagnostic and prognostic importance. Dermoscopy (onychoscopy) is a non-invasive tool that may improve detection of nail involvement, but data from Indonesian populations are scarce. This study aimed to describe the dermoscopic characteristics of nail changes in patients with psoriasis vulgaris. A descriptive cross-sectional study was conducted on 30 adults with clinically diagnosed psoriasis vulgaris (ICD-10 L40.0) attending the Dermatology and Venereology Polyclinic of Dr. Moewardi General Hospital, Surakarta, between November and December 2024, selected by purposive sampling. Each patient underwent full clinical and dermoscopic (DermLite) nail examination with digital photography. Proportions were summarised with 95% Wilson confidence intervals (CI). Subjects were predominantly male (17; 56.7%), and the largest age group was 45–64 years (13; 43.3%). Nail changes were detected dermoscopically in 24 patients (80.0%; 95% CI 62.7–90.5). Among affected patients (n=24), the most frequent features were nail pitting (75.0%), onycholysis (62.5%), crumbling (54.2%), splinter haemorrhage (50.0%) and subungual hyperkeratosis (41.7%); less frequent were leukonychia (33.3%), Beau's lines (16.7%), oil-spot/salmon patch (12.5%) and red lunula (4.2%). Nail involvement exceeded a pooled literature reference (p=0.006); matrix and nail-bed features occurred in comparable proportions (p=0.744); and feature frequencies departed from a uniform distribution (chi-square=28.7, p<0.001). In conclusion, dermoscopic nail changes were common in psoriasis vulgaris, most often nail pitting and onycholysis. Dermoscopy is an efficient, non-invasive method that can support the diagnosis of nail psoriasis in Indonesian clinical practice.
Laparoscopic Valve-Preserving Cecectomy for Fibrous Obliteration of the Appendix Mimicking an Appendiceal Mucocele: A Case Report
Fibrous obliteration of the appendix is an under-recognized, benign process in which the normal appendiceal mucosa, lymphoid follicles, and submucosa are progressively replaced by fibroblastic and neurogenic tissue. When the obliterated lumen dilates and accumulates low-attenuation material, it can closely imitate an appendiceal mucocele or a low-grade appendiceal mucinous neoplasm on computed tomography (CT), creating a therapeutic dilemma: the surgeon must avoid both under-treatment, which risks a neoplastic margin or pseudomyxoma peritonei, and over-treatment with an unnecessary colectomy. We report a 59-year-old woman with six months of recurrent epigastric and right-lower-quadrant pain and a soft, non-peritonitic abdomen, in whom contrast-enhanced CT showed a well-defined, tubular, fluid-density appendiceal lesion measuring 4.5 × 2.4 × 6 cm extending toward the cecum, with a basal calcific focus and no post-contrast enhancement, interpreted as a probable mucocele. Given its size, basal location, and indeterminate nature, a laparoscopic cecectomy was performed: the mesoappendix and ligament of Treves were sealed and divided, the right colon was mobilized, and the cecum was transected with a linear stapler oriented to preserve the ileocecal valve, with intact en-bloc retrieval in an endobag. Histopathology revealed fibrous obliteration—luminal replacement by spindle cells in a loose fibromyxoid stroma with chronic inflammation and absent normal mucosa—rather than a mucinous neoplasm. Recovery was uneventful, with a one-day stay and resolution of the right-sided pain. Valve-preserving laparoscopic cecectomy is a safe, function-sparing alternative to segmental colectomy for selected benign appendiceal and cecal disease when the base is involved or the diagnosis is indeterminate.
Probiotics and Synbiotics for Glycaemic Control and Beta-Cell Function in Children with Type 1 Diabetes Mellitus: A Meta-Analysis of Randomised Controlled Trials
Gut dysbiosis has been implicated in the pathogenesis and progression of type 1 diabetes mellitus (T1DM), and microbiota-based interventions have been proposed as adjuncts to insulin. The paediatric evidence remains fragmented and the effect on residual beta-cell function has not been a focus. This meta-analysis quantified the effect of probiotic and synbiotic supplementation on glycated haemoglobin (HbA1c) and synthesised beta-cell and immune outcomes in children with T1DM. PubMed/MEDLINE was searched for randomised controlled trials (RCTs) of oral probiotics, prebiotics, or synbiotics added to insulin in T1DM, with HbA1c as the primary outcome. Standardised mean differences (SMD, Hedges’ g) were pooled with a random-effects model (DerSimonian–Laird). Subgroup, leave-one-out, an a-priori paediatric-only sensitivity, and exploratory small-study analyses were performed. Risk of bias used Cochrane RoB 2.0. Beta-cell and immune outcomes were synthesised narratively. Seven RCTs (453 participants) were included. Supplementation produced a significant, small-to-moderate reduction in HbA1c (pooled g = −0.50, 95% CI −0.71 to −0.30; z = −4.94, p < 0.0001), with low heterogeneity (I² = 11.0%, τ² = 0.008, Q = 6.74, df = 6, p = 0.345) and a prediction interval of −0.84 to −0.17, corresponding to about 0.3 to 0.5 HbA1c percentage points. The effect was consistent across disease stage (between-group p = 0.957), was preserved in the strictly paediatric analysis (g = −0.54), and was robust to leave-one-out removal. Beta-cell outcomes were inconsistent. Supplementation was safe. In conclusion, in children with T1DM, probiotics and synbiotics conferred a modest but consistent improvement in HbA1c, without convincing evidence of beta-cell preservation. The intervention appears safe but the clinical magnitude is small and does not currently justify a change to routine practice.
Medial Condyle Fracture of the Humerus Following an Arm-Wrestling Injury in an Adolescent: A Rare Kilfoyle Type II Injury with Transient Ulnar Neuropathy Managed by Open Reduction and Pinning
Fractures of the medial condyle of the humerus are uncommon injuries in the pediatric and adolescent population, accounting for fewer than two percent of elbow fractures, yet they are clinically important because the fracture line crosses both the articular surface and the distal humeral physis. Delayed or inadequate treatment may lead to nonunion, growth arrest, cubitus varus or valgus deformity, and elbow instability. We report a 15-year-old male who presented with one month of persistent left elbow pain after an arm-wrestling contest during which the elbow shifted and he fell onto the affected arm. He described intermittent paresthesia of the ring and little fingers and morning stiffness. Examination revealed medial elbow swelling, tenderness over the medial condyle, painfully limited motion, and paresthesia in the ulnar nerve distribution. Plain radiographs confirmed a left medial condyle fracture classified as Kilfoyle type II. Because of the intra-articular nature of the injury and the risk of displacement, open reduction and internal fixation with Kirschner-wire pinning was performed, followed by intravenous fluid support, ceftriaxone for prophylaxis, and intravenous paracetamol for analgesia. One week postoperatively the patient showed marked improvement, with resolution of stiffness, reduced pain, recovered range of motion, and improvement of the ulnar nerve symptoms, and no complications were observed. This report highlights arm wrestling as a rare mechanism of adolescent medial condyle fracture, its association with transient ulnar neuropathy, and the favorable early outcome achievable with prompt anatomical fixation and structured postoperative care.
Transient Unilateral Recurrent Laryngeal Nerve Palsy Presenting as Post-extubation Stridor after Total Thyroidectomy for Non-toxic Multinodular Goiter: Anesthetic Implications and Airway Rescue
Total thyroidectomy is among the most frequently performed endocrine procedures worldwide, yet it carries a defined risk of recurrent laryngeal nerve (RLN) injury that can precipitate post-extubation stridor and emergent airway compromise. Transient unilateral RLN palsy is estimated to occur in 2 to 10 percent of cases for benign disease and remains an important anesthetic consideration even in carefully planned surgery. We report the case of a 53-year-old woman with controlled hypertension and a longstanding bilateral non-toxic multinodular goiter of 8.5 by 10 centimeters who underwent intraoperative conversion from subtotal to total thyroidectomy under general anesthesia with endotracheal intubation. Intraoperative course was stable on a balanced regimen of midazolam, fentanyl, propofol, atracurium, and isoflurane. Ten minutes after a smooth extubation, she developed inspiratory stridor, suprasternal retractions, and desaturation. Awake reintubation with preserved spontaneous ventilation was performed using low-dose sedation, intravenous lidocaine, and direct laryngoscopy, which simultaneously secured the airway and demonstrated paresis of the left vocal cord while the right cord was mobile. The patient was transferred to the intensive care unit, received systemic methylprednisolone, and was extubated successfully within 24 hours with complete recovery of bilateral vocal cord mobility on follow-up laryngoscopy. In conclusion, awake reintubation with maintained spontaneous breathing is a powerful maneuver that secures the airway and confirms the laryngeal diagnosis at a single procedure. Early systemic corticosteroid, vigilant monitoring, and otolaryngology liaison support rapid neurapraxia recovery, with multidisciplinary cooperation as the cornerstone of a favorable outcome.
Copyright (c) 2026 Muhammad Rezha Mansyur, Isngadi, Jeffri Prasetyo Utomo
Ultrasound-Guided Combined Femoral and Popliteal-Sciatic Nerve Block for Foot Debridement in a Patient with Peripheral Arterial Disease, Heart Failure with Reduced Ejection Fraction, and Pulmonary Oedema: A High-Risk Case Report
Peripheral arterial disease (PAD) in its advanced stage leads to critical limb ischaemia requiring operative debridement, and coexisting heart failure with reduced ejection fraction (HFrEF) and pulmonary oedema make general and neuraxial anaesthesia hazardous. We describe a 59-year-old man with three-vessel coronary artery disease previously treated by multiple percutaneous coronary interventions, HFrEF (ejection fraction 36%), hypertension, diabetes mellitus and bilateral PAD who presented with acute decompensated heart failure, pulmonary oedema and bilateral pleural effusion together with an extensive left foot ulcer requiring urgent debridement and necrotomy. An ultrasound-guided combined femoral and popliteal-sciatic nerve block was performed using 20 mL of 1.5% lidocaine and 20 mL of 0.25% bupivacaine. The patient remained conscious and haemodynamically stable with systolic blood pressure 90–110 mmHg, heart rate ~85 beats/min and SpO₂ 100%. The 60-minute procedure was uneventful with no local anaesthetic toxicity, new neurological deficit or respiratory compromise, and the patient was transferred to the high-care unit. Ultrasound-guided peripheral nerve blockade represents a cardiopulmonary-sparing anaesthetic strategy that can deliver adequate operating conditions for lower-extremity surgery in patients with PAD and severe cardiac and respiratory comorbidity. Keywords: Peripheral nerve block, Peripheral arterial disease, Heart failure with reduced ejection fraction, regional anesthesia, ultrasound guidance.
Semaglutide and the Risk of Non-Arteritic Anterior Ischaemic Optic Neuropathy: A Systematic Review and Meta-Analysis
Semaglutide, a glucagon-like peptide-1 receptor agonist (GLP-1 RA), has emerged as an effective treatment for type 2 diabetes mellitus and obesity management. However, recent pharmacovigilance and observational studies have raised concerns regarding a potential association between semaglutide use and non-arteritic anterior ischaemic optic neuropathy (NAION), a serious form of optic neuropathy causing sudden vision loss. We conducted a systematic review and meta-analysis of observational studies examining the association between semaglutide exposure and NAION risk. We searched PubMed, Embase, and Google Scholar without date restrictions, with the final search completed on 31 March 2026. Study selection was based on predefined inclusion criteria, and quality was assessed using the Newcastle-Ottawa Scale (NOS). A random-effects model was used to estimate pooled hazard ratios (HR) with 95% confidence intervals (CI). Heterogeneity was quantified using the I² statistic. Publication bias was examined using funnel plots and Egger’s regression test. Six observational studies comprising 699,141 participants were included in the meta-analysis. Overall, semaglutide was associated with a significantly increased risk of NAION (pooled HR 1.802; 95% CI 1.221–2.658; p = 0.003). Substantial heterogeneity was observed (I² = 72.8%, Q = 18.37, p = 0.003). Subgroup analyses revealed that the positive association was driven by four prospective cohort studies reporting elevated NAION risk (HR = 2.402; 95% CI 1.662–3.468), whereas two retrospective studies reported null associations (HR = 0.98; 95% CI 0.60–1.60). Sensitivity analyses demonstrated robustness of the primary finding. In conclusion, this meta-analysis provides evidence of a potential increased risk of NAION associated with semaglutide use in observational studies, particularly among individuals with type 2 diabetes and obesity. Clinical awareness of this signal is warranted, and further prospective investigation is recommended.
Efficacy and Safety of Psilocybin-Assisted Therapy for Depression: A Meta-Analysis of Randomised Controlled Trials
Psilocybin-assisted therapy shows promise for depression, though current evidence relies on Phase 2 trials with notable methodological limitations. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) evaluating psilocybin-assisted therapy for major or treatment-resistant depression up to February 2024. We evaluated depressive symptom severity using random-effects meta-analysis, moderator analyses, Cochrane Risk of Bias 2, and GRADE methodology. Nine RCTs (N=514) were included. Psilocybin therapy demonstrated a large pooled effect size for symptom reduction (SMD = 1.270, 95% CI: 0.865–1.676, p<0.001). However, substantial heterogeneity was observed (I² = 79.1%). Comparator type significantly moderated outcomes, with waitlist controls showing substantially larger effects than active/placebo controls. Overall GRADE certainty of evidence was rated LOW due to risk of bias, heterogeneity, short-term outcomes, and publication bias concerns. In conclusion, while psilocybin-assisted therapy yields a large pooled effect estimate for depression, current findings are preliminary. Results are heavily qualified by methodological constraints, including waitlist-inflated efficacy, compromised blinding from subjective psychedelic effects, and the confounding influence of integrated psychological support. Confirmation through robust Phase 3 trials is required before supporting routine clinical implementation.
Delayed Presentation of Lumbosacral Myelomeningocele with Tethered Cord Syndrome: Endogenous Tissue Expansion Enabling Primary Closure Without Flap Reconstruction
Myelomeningocele (MMC) represents the most common open neural tube defect, typically presenting at birth or within the neonatal period. Delayed presentation beyond infancy in resource-limited settings remains exceptionally rare and poses unique surgical challenges, particularly regarding soft-tissue reconstruction and prevention of cerebrospinal fluid (CSF) leakage. This case highlights an unusual 4-year delayed presentation with progressive neurological deterioration including tethered cord syndrome and severe functional impairment requiring comprehensive multidisciplinary intervention. A 4-year-old male from rural Banda Aceh presented with a massive lumbosacral myelomeningocele, significant developmental delay, progressive lower extremity paresis (strength 2/5 bilaterally), and documented tethered spinal cord at L4. The patient demonstrated profound motor and sensory deficits with absent deep tendon reflexes and saddle distribution hypoesthesia. Neurosurgical intervention involved careful meningeal sac dissection, separation of functional from nonfunctional neural tissue, adhesiolysis, filum terminale sectioning, neural placode tubularization, and watertight dural closure. Remarkably, the chronic CSF accumulation had functioned as an endogenous tissue expander, providing sufficient skin laxity to enable primary midline closure without requiring flap reconstruction. Early postoperative assessment demonstrated neurological stabilization with subtle functional improvement and complete wound healing without complications. In conclusion, this case demonstrates the importance of multidisciplinary management in delayed neural tube defect presentation and introduces the concept of endogenous tissue expansion via chronic CSF accumulation as a novel biomechanical phenomenon enabling simplified soft-tissue reconstruction. Primary closure without flap reconstruction successfully prevented CSF leakage while preserving neurological stability in the postoperative period. Recognition of such mechanisms may inform surgical strategy in resource-limited settings where complex reconstructive options remain unavailable. The case highlights that even delayed presentations warrant aggressive surgical intervention when specialized expertise becomes available.
Comparative Evaluation of Target-Controlled Infusion versus Syringe Pump Bolus for Remifentanil Administration on the Incidence of Apnoea and Bradycardia during General Anaesthesia Induction: A Double-Blind Pilot Randomised Controlled Trial
Remifentanil is widely utilized during general anaesthesia induction to attenuate adverse haemodynamic responses to tracheal intubation. However, its profound analgesic efficacy is inherently linked to dose-dependent adverse effects, primarily opioid-induced respiratory depression (apnoea) and bradycardia. This pilot study evaluates the safety profile of pharmacokinetically guided target-controlled infusion (TCI) compared to conventional syringe pump (SP) bolus administration. A double-blind, pilot randomised controlled trial was conducted involving 36 ASA I–II patients undergoing elective maxillofacial surgery. Patients received a standardized co-induction of propofol (2.0 mg/kg), followed by remifentanil via SP (1 µg/kg over 60 seconds) or TCI (initial effect-site concentration [Ce] of 6 ng/mL for 5 minutes, reduced to 4 ng/mL). Primary outcomes were the incidence of apnoea (>15 seconds) and bradycardia (<50 bpm). Apnoea occurred in 33.3% of the SP group versus 16.7% in the TCI group (RR 2.00; p=0.222). Mean onset of apnoea was 41.0±11.0 seconds (SP) and 31.0±3.6 seconds (TCI) (p=0.085). Bradycardia was observed in 72.2% of the SP cohort and 50.0% in the TCI cohort (RR 1.44; p=0.153). All bradycardic events were transiently managed with 0.5 mg of atropine. In conclusion, in this pilot cohort, remifentanil delivered via TCI did not achieve statistical superiority over SP bolus administration in reducing the incidence of apnoea or bradycardia. Fully powered clinical trials are required to definitively establish any pharmacokinetic safety advantages.
Management of Refractory Mechanical Ventilation Weaning in a Geriatric Neurocritical Patient with ARDS and COPD Using the ISCCM 2023 Guidelines: A Case Report
Mechanical ventilator weaning failure occurs in 20–30% of critically ill patients, with the risk significantly amplified by chronic obstructive pulmonary disease (COPD), acute neurological impairment, and severe hypoxemia. A 72-year-old female with COPD developed acute respiratory distress syndrome (ARDS) secondary to hospital-acquired pneumonia (HAP) following a re-craniotomy for an epidural hematoma. Following an initial extubation failure marked by hypercapnia (PaCO₂ 50.7 mmHg), the patient required reintubation. Her initial PaO₂/FiO₂ ratio of 127 mmHg indicated severe gas exchange impairment. Management utilized the 2023 Indian Society of Critical Care Medicine (ISCCM) guidelines. To facilitate weaning, the sedation strategy was transitioned from an initial thiopental infusion to dexmedetomidine, while continuous electrocardiographic monitoring was employed during the rapid correction of severe hypokalemia. The integration of early percutaneous dilatational tracheostomy (PDT), targeted diuresis, and resolution of ventilator-induced diaphragmatic dysfunction (VIDD) improved her PaO₂/FiO₂ ratio to 295 mmHg. In conclusion, successful ventilator liberation in complex neurocritical cases requires a rigorous, multidisciplinary approach. Integrating the ISCCM ABCDEFGHI bundle ensures the systematic correction of pathophysiological barriers, metabolic derangements, and sedation accumulation, leading to favorable clinical outcomes.
Efficacy of Multimodal Prehabilitation vs. Standard Care on Postoperative Morbidity and Quality of Life in Major Gastrointestinal Oncology Surgery: A Systematic Review and Meta-Analysis
Major gastrointestinal oncology surgery induces profound physiological stress, precipitating a severe reduction in functional capacity and high rates of postoperative complications. Traditional perioperative pathways optimize intraoperative and postoperative care but systematically overlook preoperative functional reserves. A systematic review and meta-analysis were conducted in strict adherence to PRISMA guidelines. Systematic searches were executed across PubMed, Embase, Cochrane CENTRAL, and Scopus from database inception to March 2026. High-quality clinical trials evaluating multimodal prehabilitation against standard care in gastrointestinal cancer surgery were analyzed. Pooled odds ratios (OR) and standardized mean differences (SMD) with 95% Confidence Intervals (CI) were calculated using a random-effects model, with heterogeneity assessed via the $I^2$ statistic. Multimodal prehabilitation significantly reduced overall 30-day postoperative complications compared to standard care (OR 0.35, 95% CI: 0.18–0.69, p=0.010, $I^2$=42%). This was driven primarily by a striking decrease in Grade II pulmonary infections. Functional capacity was remarkably preserved; prehabilitated patients demonstrated statistically superior walking distances postoperatively (SMD 1.25, 95% CI: 0.95–1.55, p<0.001). Sarcopenic patients receiving targeted nutritional supplementation with beta-hydroxy beta-methylbutyrate exhibited sustained improvements in chair rise repetitions (Mean Difference 4.0, 95% CI: 2.5–5.5) and significant physiological remodeling of intramuscular adipose tissue. In conclusion, multimodal prehabilitation fundamentally alters the physiological trajectory of patients undergoing major gastrointestinal oncology surgery. By proactively mitigating surgical stress and attenuating catabolic decline, this intervention ensures superior functional restitution and minimizes short-term morbidity.
Low-Dose Prophylaxis versus On-Demand Therapy in Hemophilia Management: A Systematic Review and Meta-Analysis of Clinical Outcomes and Cost-Effectiveness in Resource-Limited Settings
Hemophilia A and B impose a catastrophic burden in resource-limited settings (RLS), where the standard of care—high-dose primary prophylaxis—remains economically inaccessible. Consequently, patients rely on episodic (on-demand) therapy, which fails to prevent the debilitating cascade of hemophilic arthropathy. This study aims to validate Low-Dose Prophylaxis (LDP) as a superior standard of care by synthesizing real-world clinical data. We conducted a systematic review and meta-analysis of pivotal studies published between 2011 and 2025, encompassing cohorts from India, Indonesia, China, Pakistan, and Ivory Coast in accordance with PRISMA guidelines. Interventions included low-dose Factor VIII/IX (10–25 IU/kg), Extended Half-Life (EHL) factors, and Emicizumab. Primary outcomes were Annualized Bleeding Rate (ABR) and Hemophilia Joint Health Score (HJHS). The clinical meta-analysis included 127 pediatric and adolescent subjects. LDP demonstrated a statistically significant reduction in ABR compared to on-demand therapy (Pooled Mean Difference: -8.14; 95% CI: -10.5 to -5.7; p<0.001). EHL prophylaxis reduced mean ABR from 6.0 to 0.07. Joint health improved significantly, with HJHS scores decreasing from 5.42 to 2.28 (p=0.0013) post-intervention. Quality of life metrics, including school absenteeism, showed profound improvements. In conclusion, low-dose prophylaxis is a clinically superior and viable strategy in RLS, effectively arresting the progression of arthropathy and improving functional independence. Healthcare policy in developing nations must prioritize prophylactic models over episodic care to prevent irreversible musculoskeletal disability.
Hemodynamic Stability via Ultrasound-Guided Axillary Brachial Plexus Block with Levobupivacaine-Dexamethasone in a Patient with Impending Thyroid Storm and Hand Fracture
The perioperative management of patients with uncontrolled hyperthyroidism requiring emergency surgery presents an acute clinical challenge, as surgical trauma and anesthesia can precipitate a life-threatening thyroid storm. This case report examines the strategic role of regional anesthesia in mitigating such risks through complete afferent blockade and sympathetic stabilization. A 28-year-old male presented with multiple right-hand fractures following a motorcycle accident. The patient had a history of untreated hyperthyroidism for one year and exhibited classic clinical thyrotoxicosis, including tachycardia of 104 bpm, hypertension of 164/90 mmHg, bilateral exophthalmos, and hyperkinesis. Laboratory investigations confirmed primary hyperthyroidism with a markedly elevated free T4 of 86.6 pmol/L and suppressed TSH. His Burch-Wartofsky Point Scale (BWPS) score was calculated at 30, indicating an impending thyroid storm. Following rapid medical optimization with propylthiouracil, propranolol, hydrocortisone, and amlodipine, surgical intervention was successfully performed under ultrasound-guided axillary brachial plexus block. The anesthetic mixture comprised 20 mL of 0.5 percent levobupivacaine and 8 mg of perineural dexamethasone. The patient demonstrated remarkable hemodynamic stability throughout the two-hour procedure, maintaining a systolic blood pressure between 115 and 135 mmHg and a heart rate between 82 and 94 bpm, without progressing to a thyroid crisis. In conclusion, ultrasound-guided regional anesthesia, specifically the axillary approach, offers a superior safety profile for thyrotoxic patients by avoiding airway instrumentation and preventing the sympathetic surges associated with general anesthesia. The synergistic use of levobupivacaine and dexamethasone provides a dual benefit of enhanced cardiac safety and peripheral endocrine stabilization.
Adiposity-Induced Voiding Dysfunction: Unraveling the Association Between Overweight Status and Symptom Severity in Non-Retentive Benign Prostatic Hyperplasia
Benign prostatic hyperplasia (BPH) has historically been viewed through a prostato-centric lens, attributing lower urinary tract symptoms (LUTS) primarily to prostatic volume and mechanical obstruction. However, this model fails to account for the substantial symptom burden observed in patients without significant retention or massive enlargement. Emerging evidence suggests that systemic metabolic dysregulation, particularly adiposity, plays a crucial role in the pathophysiology of LUTS. This study aims to evaluate the association between Overweight status and the subjective severity of LUTS in a specific cohort of non-retentive BPH patients, thereby isolating metabolic contributors from acute mechanical failure. We conducted an observational analytic cross-sectional study at the Urology Polyclinic of RSUD Dr. Moewardi, Surakarta, Indonesia, from June 2024 to January 2025. The study enrolled 110 men diagnosed with BPH who met strict criteria for non-retentive status (post-void residual <150 mL, no indwelling catheter). Participants were stratified into normal BMI (<25 kg/m²) and Overweight (≥25 kg/m²) groups. Symptom severity was quantified using the International Prostate Symptom Score (IPSS). Data were analyzed using the Mann-Whitney U test and Chi-square analysis. The cohort comprised 72 (65.5%) normal-weight and 38 (34.5%) overweight patients. A statistically significant disparity in symptom severity was observed. The overweight group exhibited a significantly higher mean IPSS (17.87 ± 5.18) compared to the normal group (11.54 ± 4.71) (p<0.001). Notably, 44.7% of overweight patients presented with severe LUTS, compared to only 5.6% of normal-weight patients. Conversely, 90.9% of patients with mild symptoms belonged to the normal-weight group. In conclusion, overweight status is significantly associated with increased LUTS severity in non-retentive BPH patients. The findings suggest that adiposity exacerbates voiding dysfunction through systemic inflammatory, hormonal, and autonomic pathways independent of urinary retention. These results advocate for the integration of weight management as a core therapeutic strategy in BPH care.
Penile Preservation in a Young Adult with Aggressive Spindle Cell Carcinoma: A Case of Wide Local Excision and Glanular Reconstruction in a Resource-Limited Setting
Penile sarcomatoid squamous cell carcinoma, also known as spindle cell carcinoma, is a rare and aggressive malignancy characterized by biphasic histology. Its management in young adults under 40 years of age is challenging, particularly in resource-limited settings where advanced diagnostic adjuncts like immunohistochemistry are often unavailable, necessitating reliance on morphological diagnosis and clinical acumen. We report the case of a 36-year-old uncircumcised male presenting with a rapidly growing, 2.5 cm exophytic glanular mass (cT2N0M0). Diagnostic workup relied on clinical assessment and morphological evaluation to rule out differentials, as immunohistochemical markers were unavailable. The patient underwent penile-sparing wide local excision (WLE) with intraoperative frozen section control (5 mm margins) and primary glanular reconstruction. Due to the high-grade histology and resource constraints preventing dynamic sentinel node biopsy, the patient was managed with a strict active surveillance protocol for the inguinal basin. Histopathology using Hematoxylin and Eosin (H&E) staining confirmed a high-grade malignancy with a predominant population of atypical spindle cells arranged in fascicles, consistent with Spindle Cell Carcinoma. Deep and lateral margins were negative. At 12-month follow-up, the patient remains disease-free with no evidence of local recurrence or inguinal lymphadenopathy. The International Index of Erectile Function (IIEF-5) score remained stable (23/25), indicating excellent functional preservation. In conclusion, penile preservation via WLE is a viable option for selected cases of Spindle Cell Carcinoma. In resource-limited settings where immunohistochemistry is inaccessible, accurate diagnosis relies on identifying characteristic morphological features on H&E staining combined with clinical history. Strict surveillance is mandatory to monitor for nodal progression in the absence of invasive staging.
Evaluation of Morphine-Sparing Efficacy with Low-Dose Ketamine in Pediatric Postoperative Pain: A Pilot Randomized Controlled Trial
Postoperative pain management in the pediatric population requires a delicate balance between effective analgesia and the minimization of opioid-related adverse events, particularly respiratory depression. While multimodal analgesia is the standard of care, the optimal dose-reduction potential of opioids when combined with N-methyl-D-aspartate (NMDA) antagonists remains undefined. We conducted a prospective, single-center, pilot randomized controlled trial using a double-blind observer protocol. Twenty pediatric patients aged 2 months to 7 years undergoing elective surgery were randomized into four groups. The control group (Group M) received standard continuous morphine at 0.33 µg/kg/min. Three intervention groups received fixed low-dose ketamine at 0.33 µg/kg/min combined with tapered morphine doses: Group KM-1 at 0.23 µg/kg/min, Group KM-2 at 0.16 µg/kg/min, and Group KM-3 at 0.06 µg/kg/min. The primary outcome was analgesic efficacy assessed by FLACC scores at 24 hours. Secondary outcomes included hemodynamic stability and rescue analgesia requirements. Baseline characteristics were comparable across groups. At 24 hours, the median FLACC scores were comparable between the high-dose control (Median 2.0; Interquartile Range 1.5–2.0) and the lowest morphine group (Group KM-3: Median 2.0; Interquartile Range 1.5–2.0; p = 0.438). Group KM-3 achieved an 81% reduction in morphine consumption with a 0% rescue analgesia rate, identical to the control group. In conclusion, preliminary data from this pilot study suggest that low-dose ketamine may permit a substantial reduction in morphine dosage of up to 81% without compromising analgesic efficacy. These findings warrant confirmation in larger, fully powered multicenter trials.
Severe Hyponatremia with Normokalemia in Pembrolizumab-Lenvatinib Combination Therapy for Metastatic Renal Cell Carcinoma: A Case of Suspected Secondary Adrenal Insufficiency and Clinical Differentials
The combination of Pembrolizumab and Lenvatinib has become the standard first-line treatment for advanced renal cell carcinoma (RCC). However, the overlapping toxicity profiles of immune checkpoint inhibitors (ICIs) and tyrosine kinase inhibitors (TKIs) create significant diagnostic challenges, particularly regarding electrolyte disturbances. Differentiating ICI-induced secondary adrenal insufficiency from TKI-induced toxicity or syndrome of inappropriate antidiuretic hormone (SIADH) is critical, especially in resource-limited settings where rapid hormonal assays are unavailable. A 67-year-old male with metastatic clear cell RCC presented with confusion, fatigue, and nausea 14 days after initiating palliative Pembrolizumab and Lenvatinib. He had a history of partial nephrectomy and was on Candesartan. Evaluation revealed severe hypotonic hyponatremia (113 mmol/L), acute kidney injury (Creatinine 2.2 mg/dL), and a hypertensive crisis (BP 229/138 mmHg). Notably, despite renal impairment and angiotensin receptor blocker therapy, potassium levels were normal (4.2 mmol/L). The hyponatremia was refractory to 3% hypertonic saline. Suspecting secondary adrenal insufficiency, empiric high-dose corticosteroids were administered, resulting in rapid normalization of serum sodium and resolution of symptoms. In conclusion, in patients receiving ICI-TKI therapy, the specific profile of severe hyponatremia with normokalemia—particularly in the context of renal insufficiency and RAAS blockade—serves as a high-value clinical indicator of preserved mineralocorticoid function. This points toward secondary adrenal insufficiency rather than primary adrenal injury or TKI-induced renal tubular acidosis. This case underscores the utility of deductive physiology in oncology practice.
Severe Erythema Nodosum Leprosum Complicated by Warm Autoimmune Hemolytic Anemia: Navigating the Immunosuppressive Paradox
Erythema nodosum leprosum (ENL) is a severe, systemic immune-complex mediated complication of multibacillary Hansen’s disease. While anemia of chronic disease is frequently observed in leprosy, the concurrent development of Warm Autoimmune Hemolytic Anemia (wAIHA) is an exceptionally rare and precarious clinical entity. This comorbidity creates a therapeutic paradox wherein the high-dose corticosteroids required to halt hemolysis may exacerbate the risk of sepsis in patients with necrotic skin lesions and compromised barrier function. We report the case of a 42-year-old male with multibacillary Hansen’s disease on multidrug therapy who presented with high-grade fever, progressive fatigue, and necrotic cutaneous lesions. Laboratory evaluation revealed life-threatening normocytic normochromic anemia (Hemoglobin 3.5 g/dL) and a leukemoid reaction (WBC 42,540/µL). Hemolysis was confirmed by elevated lactate dehydrogenase (564 U/L), indirect hyperbilirubinemia, and a strongly positive direct Coombs test (IgG). A diagnosis of wAIHA secondary to severe necrotic ENL was established. Standard high-dose pulse steroid therapy was deemed high-risk due to the patient’s extreme neutrophilia (NLR 80.25) and open necrotic ulcers. Consequently, a tailored regimen of intermediate-dose intravenous methylprednisolone (62.5 mg twice daily) combined with broad-spectrum antibiotics was initiated. This strategy successfully suppressed hemolysis and resolved the ENL reaction without precipitating secondary opportunistic infections. In conclusion, the coexistence of wAIHA and ENL suggests a shared mechanism of dysregulated T-cell immunity and molecular mimicry. This case demonstrates that in scenarios involving high infectious risk, an individualized, intermediate-dose corticosteroid protocol can achieve remission while mitigating the dangers of profound immunosuppression.
Beyond Viral Load: The Clinical and Endocrine Profile of ART-Naive HIV-Infected Men with Hypogonadism, Opportunistic Infections, and Malnutrition
In patients with advanced human immunodeficiency virus (HIV), the clinical presentation often extends beyond immunodeficiency to a syndemic of interacting comorbidities. Male hypogonadism is a critical but often under-recognized endocrine dimension of this syndrome. This study aimed to characterize the clinical, metabolic, and endocrine profile of antiretroviral therapy (ART)-naive men to provide a comprehensive baseline understanding of this syndemic state before therapeutic intervention. An analytical cross-sectional study was conducted from April to October 2024, enrolling 64 consecutively presenting ART-naive men with HIV at a tertiary hospital in Palembang, Indonesia. We performed a comprehensive assessment including WHO clinical staging, nutritional evaluation (BMI), and screening for comorbidities. Endocrine status was assessed by measuring total testosterone, Luteinizing Hormone (LH), and serum albumin, from which bioavailable testosterone was calculated using the Vermeulen formula. Bivariate correlations and comparative analyses were conducted to explore relationships between variables. The cohort presented with profound immunodeficiency (median CD4 count: 23.5 cells/µL) and advanced disease (92.2% in WHO Stage 3 or 4). A high burden of opportunistic infections (40.6% pulmonary tuberculosis) and malnutrition (48.4% underweight; median serum albumin: 3.25 g/dL) was observed. Based on total testosterone (<300 ng/dL), the prevalence of hypogonadism was 32.8%. However, analysis using the more physiologically relevant calculated bioavailable testosterone (<70 ng/dL) revealed a higher prevalence of 42.2%. Secondary (hypogonadotropic) hypogonadism was the overwhelmingly dominant etiology (28.1%). Bioavailable testosterone was significantly and positively correlated with both CD4 count (ρ=0.35, p=0.005) and BMI (ρ=0.41, p=0.001). In conclusion, ART-naive men presenting with advanced HIV in this setting are caught in a syndemic of immunodeficiency, infectious disease, malnutrition, and profound endocrine dysfunction. The high prevalence of secondary hypogonadism, strongly associated with the severity of immune collapse and poor nutritional status, highlights the HPG axis as a key casualty of systemic illness. These findings provide a compelling rationale for integrating routine hormonal and metabolic screening into the initial assessment of all men newly diagnosed with HIV.
Preoperative Fasting Duration as a Potential Predictor of Glycemic Instability in Non-Diabetic Emergency Surgery Patients: A Prospective Observational Pilot Study
Preoperative fasting is a cornerstone of anesthetic safety, yet in emergency surgery, fasting periods are frequently prolonged and unregulated. The metabolic consequences of such extended fasting in non-diabetic patients, who are often assumed to be metabolically resilient, are poorly understood. This pilot study aimed to investigate the association between prolonged fasting and pre-induction glycemic instability. We conducted a prospective, observational pilot study at a tertiary referral hospital, enrolling 30 non-diabetic adult patients (ASA I-E/II-E) undergoing emergency surgery. The primary exposure was preoperative fasting duration, analyzed as both a continuous variable and a dichotomized category (≤8 vs. >8 hours). The primary outcomes were pre-induction blood glucose levels, analyzed continuously and with two categorical thresholds: glycemic instability (<85 mg/dL) and clinically significant hypoglycemia (<70 mg/dL). Associations were assessed using Chi-Square tests and Spearman's rank correlation. A majority of patients (60%) fasted for >8 hours. A strong negative correlation was found between the duration of fasting and pre-induction blood glucose levels (Spearman's ρ = -0.78, p<0.001). Using the <85 mg/dL threshold, 83.3% of patients fasting >8 hours exhibited glycemic instability, compared to 25% of those fasting ≤8 hours (p=0.002). Using the standard <70 mg/dL threshold, 55.6% of patients fasting >8 hours developed clinically significant hypoglycemia, compared to 8.3% of those fasting ≤8 hours (p=0.011). In conclusion, this pilot study provides a strong preliminary signal that prolonged preoperative fasting is significantly associated with a decline in blood glucose and an increased incidence of both glycemic instability and clinically significant hypoglycemia in non-diabetic emergency surgical patients. These findings challenge the assumption of metabolic security in this population and underscore the urgent need for larger, definitive studies. Routine pre-induction glucose monitoring should be strongly considered as a potential safety standard in this vulnerable group.
Acinar Gland Hyperplasia Masquerading as Pancreatic Head Carcinoma: A Case Report on a Diagnostic and Surgical Dilemma
The preoperative differentiation of benign from malignant pancreatic head masses presents a significant clinical challenge. While pancreatic ductal adenocarcinoma (PDAC) is the primary concern, rare benign pathologies can be radiologically and clinically indistinguishable from cancer, leading to diagnostic uncertainty and complex surgical decisions. A 61-year-old male presented with a classic triad of obstructive jaundice, significant weight loss, and right upper abdominal pain. A contrast-enhanced computed tomography (CT) scan of the abdomen revealed a solid mass in the head of the pancreas, causing concomitant dilation of the common bile and pancreatic ducts—the "double duct sign." These findings were highly suggestive of pancreatic head carcinoma, prompting a decision for surgical intervention. The patient underwent a standard pancreaticoduodenectomy (Whipple procedure). Surprisingly, the final histopathological examination of the resected specimen revealed no evidence of malignancy. The diagnosis was benign acinar gland hyperplasia. The postoperative course was complicated by a delayed post-pancreatectomy hemorrhage from a gastroduodenal artery pseudoaneurysm, which was successfully managed with minimally invasive transarterial embolization (TAE). In conclusion, acinar gland hyperplasia is an exceedingly rare benign condition that can precisely mimic the clinical and radiological features of pancreatic cancer. This case underscores the current limitations of preoperative diagnostics and affirms that aggressive surgical management is justified in patients with a high suspicion of malignancy, as the risk of withholding surgery for a potentially curable cancer outweighs the risk of resecting a benign lesion. Furthermore, it highlights that the Whipple procedure carries a significant risk of life-threatening complications, such as delayed hemorrhage, irrespective of the underlying pathology, necessitating vigilant postoperative care.