Accreditation
SINTA 2Nationally Accredited Journal
Vol. 9 No. 12 (2025): Bioscientia Medicina: Journal of Biomedicine & Translational Research
Articles
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Presumed Polymyositis in Chronic Hepatitis C: Navigating Diagnostic Uncertainty and Therapeutic Imperatives in Recurrent Myopathy
Views: 425Downloads: 311Background: Polymyositis (PM) is a cell-mediated inflammatory myopathy for which viral triggers, particularly the Hepatitis C virus (HCV), are increasingly recognized. The convergence of these conditions creates a formidable clinical scenario, often compelling urgent therapeutic intervention despite incomplete diagnostic data. This report explores the management of such a case, highlighting the pragmatic decision-making required when definitive investigations are deferred.
Case presentation: A 48-year-old male with untreated chronic HCV infection (Genotype 1b, viral load 2.8 x 10⁶ IU/mL) presented with a debilitating relapse of severe, symmetric proximal muscle weakness, three years after a similar episode. He exhibited profound weakness (Medical Research Council grade 2/5 in hip flexors) and marked myonecrosis (Creatine Kinase 8,572 U/L). Although comprehensive myositis-specific autoantibodies were negative, a strong clinical and biochemical profile led to a presumptive diagnosis of an acute PM exacerbation. Definitive diagnostics, including muscle biopsy, were deferred by the patient. Empirical treatment with high-dose corticosteroids and azathioprine was initiated, predicated on a careful risk-benefit analysis concerning immunosuppression in active viral infection. This strategy resulted in rapid and significant clinical and biochemical improvement. The patient was subsequently scheduled for direct-acting antiviral therapy to address the underlying viral trigger.
Conclusion: This case underscores the critical challenge of managing severe, presumed autoimmune disease in the face of diagnostic ambiguity. It demonstrates that a therapeutic strategy guided by strong clinical evidence can be effective for controlling acute, disabling flares. Furthermore, it champions a necessary dual-paradigm approach: acute immunomodulation to preserve function, followed by targeted antiviral therapy to eradicate the probable etiological trigger, thereby aiming to prevent future recurrence and achieve durable remission.
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Autologous Parietal Peritoneum as a Biliary Interposition Conduit for Complex Post-Cholecystectomy Bile Duct Injuries: A Feasibility Study and Report of Two Cases
Views: 327Downloads: 263Background: Complex iatrogenic bile duct injuries (BDIs) are formidable surgical challenges, with Roux-en-Y hepaticojejunostomy (RYHJ) being the standard reconstruction. However, RYHJ permanently alters gastrointestinal physiology and is associated with significant long-term morbidity. This has prompted a search for physiology-preserving alternatives. We describe a novel technique using a tubularized autologous parietal peritoneal graft for biliary reconstruction.
Case presentation: This report details the successful management of two patients with high-grade, post-cholecystectomy BDIs (Strasberg-Bismuth Type E1 and E3). Both patients presented with obstructive jaundice and controlled biliary fistulae. Definitive single-stage reconstruction was performed. A segment of parietal peritoneum was harvested, tubularized over a T-tube to create an interposition conduit, and anastomosed to bridge the biliary defect. The repair was reinforced with a pedicled omental flap. Both patients demonstrated complete resolution of jaundice and normalization of liver function tests, with radiological evidence of graft patency and no stricture at 12-month follow-up.
Conclusion: This preliminary experience in two patients suggests that the use of a tubularized autologous parietal peritoneal graft is a surgically feasible technique for the reconstruction of complex BDIs. This approach offers a potential physiology-preserving alternative to traditional bilioenteric anastomosis. Its safety, efficacy, and long-term durability remain unknown and require rigorous evaluation in larger prospective studies.
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The Synergistic Impact of Astrocyte Reactivity and Vitamin D Deficiency on Post-Stroke Cognitive Impairment: A Systematic Review and Meta-Analysis
Views: 397Downloads: 236Background: Post-stroke cognitive impairment (PSCI) is a common, debilitating outcome of ischemic stroke. Glial Fibrillary Acidic Protein (GFAP), marking astrocyte reactivity, and Vitamin D, a neuro-immunomodulatory steroid, are independently linked to PSCI. This study aimed to quantify the synergistic impact of elevated serum GFAP and concurrent Vitamin D deficiency on PSCI risk.
Methods: Following PRISMA guidelines, a systematic search of PubMed, Scopus, and Web of Science was conducted for prospective cohort studies (2015-2025) assessing acute serum GFAP, 25-hydroxyvitamin D (25(OH)D), and subsequent cognitive outcomes in ischemic stroke patients. Quality was assessed using the Newcastle-Ottawa Scale. A meta-analysis of seven studies (n=3,850) was performed using a random-effects model to calculate pooled odds ratios (ORs) for PSCI across four biomarker-defined groups. A formal test for synergistic interaction was conducted by assessing the departure from additivity of effects on the log-odds scale.
Results: Seven high-quality studies were included. Compared to the reference group (Normal GFAP/Sufficient Vitamin D), the pooled OR for PSCI was 2.18 (95% CI: 1.85-2.57) for high GFAP alone and 1.95 (95% CI: 1.65-2.30) for Vitamin D deficiency alone. For the dual-biomarker group (High GFAP/Deficient Vitamin D), the pooled OR was 4.75 (95% CI: 3.98-5.67). This observed risk was significantly greater than the 3.13 OR expected from a purely additive model (p for interaction < 0.001), confirming a significant synergistic effect. Sensitivity analysis showed the effect was most pronounced in patients with moderate-to-severe strokes (NIHSS > 5).
Conclusion: Elevated serum GFAP and Vitamin D deficiency synergistically increase the risk of PSCI, particularly in patients with more severe strokes. The interplay between acute astroglial injury and compromised systemic neuroprotection appears to be a critical determinant of cognitive outcomes. While confounding by patient frailty requires further study, this dual-biomarker profile identifies a high-risk subgroup and highlights a key pathophysiological interaction.
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Beyond the Floor: Traumatic Medial Rectus Entrapment in a Medial Orbital Wall Fracture Presenting with Diplopia and Retinal Hemorrhage
Views: 569Downloads: 431Background: Medial orbital wall fractures with extraocular muscle entrapment represent a significant but less common variant of orbital trauma compared to floor fractures. These injuries pose a diagnostic and management challenge, with the potential for severe, long-term functional deficits and life-threatening systemic complications if not addressed promptly. This report details a case of medial rectus muscle entrapment complicated by a concurrent posterior segment injury.
Case presentation: A 21-year-old male presented to the emergency department following a motorcycle accident, sustaining blunt trauma to his left eye. He reported an acute onset of blurred vision and binocular diplopia. Ophthalmic examination revealed a visual acuity of 20/80 in the left eye. There was a manifest esotropia and a profound abduction deficit, with marked restriction of movement on attempted lateral, superolateral, and inferolateral gaze. The forced duction test was positive, confirming mechanical restriction. Funduscopy identified significant retinal hemorrhages. A maxillofacial computed tomography scan confirmed a comminuted fracture of the left medial orbital wall (lamina papyracea) with clear evidence of medial rectus muscle entrapment within the fracture fragments. The patient underwent urgent surgical intervention involving exploration of the medial orbit, careful release of the incarcerated medial rectus muscle, and anatomical reconstruction of the wall with a titanium mini-plate. Intraoperative forced duction testing confirmed complete resolution of the mechanical restriction. Postoperatively, the patient showed free passive ocular motility, although active movement was recovering, and the retinal injuries required continued observation.
Conclusion: This case underscores the critical importance of maintaining a high index of suspicion for medial rectus entrapment in patients presenting with post-traumatic diplopia and an abduction deficit. A thorough clinical examination, particularly the forced duction test, is paramount and often more definitive than imaging alone. Urgent surgical decompression and reconstruction are imperative to prevent permanent strabismus from muscle ischemia and to mitigate the risk of the oculocardiac reflex. Furthermore, the presence of concomitant intraocular injuries, such as traumatic retinopathy, must be diligently assessed as they significantly impact the final visual prognosis.
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Vitamin D Supplementation is Associated with Attenuated Ocular Surface Oxidative Stress in Mild Thyroid Eye Disease: A Preliminary Interventional Study
Views: 469Downloads: 283Background: Thyroid eye disease (TED) is an autoimmune orbitopathy where inflammation drives significant oxidative stress, contributing to patient morbidity. Malondialdehyde (MDA), a lipid peroxidation product, is a key biomarker of this oxidative damage. While vitamin D has known systemic immunomodulatory effects, its capacity to mitigate local oxidative stress on the ocular surface in TED is poorly understood. This study aimed to investigate the association between oral vitamin D supplementation and tear film MDA levels in patients with mild TED.
Methods: A prospective, single-center, quasi-experimental pre-post study without a control group was conducted on 15 patients diagnosed with mild, active TED (Clinical Activity Score ≤3). Participants received 1000 IU of oral cholecalciferol (Vitamin D3) daily for 21 consecutive days. The primary outcome was the change in tear film MDA concentration, measured by ELISA. Secondary outcomes included serum 25-hydroxyvitamin D [25(OH)D] levels and clinical ocular surface parameters (Ocular Surface Disease Index [OSDI], Tear Break-Up Time [TBUT], Schirmer's I test).
Results: A statistically significant reduction in mean tear film MDA levels was observed, decreasing from a baseline of 8.69 ± 4.15 ng/L to 5.70 ± 1.56 ng/L post-intervention (p<0.001). This was accompanied by a significant increase in mean serum 25(OH)D levels from 18.2 ± 5.9 ng/mL to 29.8 ± 6.4 ng/mL (p<0.001). Significant improvements were also noted in OSDI scores (p=0.002) and TBUT (p=0.005). The reduction in tear film MDA showed a significant negative correlation with the increase in serum 25(OH)D (r = -0.68, p=0.005).
Conclusion: In this preliminary, uncontrolled study, short-term oral vitamin D supplementation was associated with a significant attenuation of ocular surface oxidative stress in patients with mild TED. These findings provide initial biochemical evidence for the potential localized benefits of vitamin D and support the need for larger, placebo-controlled randomized trials to validate its role as a safe adjunctive therapy for managing the ocular surface component of this disease.
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The Paradoxical Role of Interleukin-10 in Systemic Lupus Erythematosus: A Correlational Study of Serum Levels and Disease Activity
Views: 457Downloads: 284Background: Systemic lupus erythematosus (SLE) is a multifaceted autoimmune disease where the cytokine Interleukin-10 (IL-10) exhibits a paradoxical role, functioning as both a potent anti-inflammatory mediator and a robust B-cell stimulator. The clinical significance of serum IL-10 as a biomarker of disease activity is a subject of intense debate, with conflicting reports in the literature. This study was designed to investigate this relationship within a specific Southeast Asian cohort.
Methods: An observational, cross-sectional study was conducted at a tertiary referral hospital in Palembang, Indonesia, enrolling 48 adult patients with a confirmed diagnosis of SLE. Disease activity was quantitatively scored using the Mexican Systemic Lupus Erythematosus Disease Activity Index (MEX-SLEDAI). Serum IL-10 concentrations were precisely measured using a quantitative sandwich enzyme-linked immunosorbent assay (ELISA). The primary statistical analysis involved the Spearman rank correlation test. A post-hoc power analysis was performed to contextualize the statistical findings.
Results: The study population was predominantly female (95.8%), with the largest subgroup (54.2%) presenting with mild disease activity. The mean serum IL-10 concentration was 9.91±1.36 pg/mL in the mild activity group, rose to a peak of 12.22±1.95 pg/mL in the moderate activity group, and was 10.65±2.34 pg/mL in the severe activity group. The Spearman correlation test identified a weak, positive association that did not achieve statistical significance (r=0.274, p=0.059). The post-hoc power analysis confirmed the study was underpowered to definitively detect a correlation of this magnitude.
Conclusion: In this cohort of Indonesian SLE patients, a statistically significant correlation between serum IL-10 levels and disease activity was not established. Given the study's methodological context, including its cross-sectional design and limited statistical power, the findings are inconclusive but hypothesis-generating. The results reinforce the profound complexity of IL-10 biology in SLE and underscore the challenges in validating it as a standalone biomarker, highlighting the need for larger, longitudinal investigations.
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Serum Nerve Growth Factor Levels in Painful Diabetic Neuropathy: A Systematic Review and Meta-Analysis
Views: 459Downloads: 308Background: Painful diabetic neuropathy (PDN) is a severe complication of type 2 diabetes mellitus (T2DM). Nerve Growth Factor (NGF) is vital for neuronal health, but its status as a systemic biomarker in PDN is contested due to conflicting reports on serum levels. This study aimed to quantitatively synthesize the literature on the association between serum NGF concentrations and the presence of PDN in patients with T2DM.
Methods: PubMed, Scopus, Web of Science, and Embase were searched for observational studies from January 2015 to August 2025 that measured serum NGF in T2DM patients with PDN versus control groups (T2DM without PDN or healthy individuals). Data were independently extracted by two reviewers. A random-effects model was used to calculate the pooled Standardized Mean Difference (SMD) and 95% confidence intervals (CIs) to account for assay variability. Heterogeneity was explored using the I² statistic and meta-regression.
Results: From 1,482 records, seven cross-sectional studies (485 PDN patients, 511 controls) were included. The meta-analysis revealed that patients with PDN had significantly lower serum NGF concentrations compared to controls, with a pooled SMD of -1.28 (95% CI: -1.79 to -0.77, p < 0.00001). Substantial heterogeneity was present (I² = 84%). Meta-regression showed that a longer duration of diabetes was significantly associated with a greater reduction in NGF levels (p = 0.02). No significant publication bias was detected.
Conclusion: This meta-analysis provides consolidated evidence that lower systemic NGF levels are a strong feature of established PDN. The findings support the neurotrophic deficit hypothesis in PDN pathophysiology and identify NGF as a candidate biomarker requiring rigorous validation in longitudinal studies that carefully differentiate painful from painless neuropathy phenotypes.
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Lower Body Negative Pressure for Spaceflight Associated Neuro-ocular Syndrome: A Systematic Review and Meta-Analysis
Views: 525Downloads: 372Background: Spaceflight associated neuro-ocular syndrome (SANS) is a critical health risk for astronauts on long-duration missions, characterized by potentially vision-altering ocular changes. Lower body negative pressure (LBNP) is a primary countermeasure designed to reverse the foundational cephalad fluid shifts. This study provides the first rigorous, quantitative synthesis of LBNP's efficacy on key SANS-related ocular parameters.
Methods: Following PRISMA guidelines, a systematic search of PubMed, ScienceDirect, and the Cochrane Library (2015–2025) was conducted. Studies quantifying the effect of LBNP on intraocular pressure (IOP), optic nerve sheath diameter (ONSD), or choroidal thickness (CT) in microgravity or its ground-based analogs were included. A random-effects meta-analysis calculated the pooled mean difference (MD). Leave-one-out sensitivity analysis and assessment of publication bias were performed to ensure robustness.
Results: Seven studies (N=89 subjects) met the criteria. The meta-analysis demonstrated that LBNP application resulted in statistically significant reductions in IOP (MD = -2.15 mmHg; 95% CI [-3.01, -1.29]; p < 0.001), ONSD (MD = -0.31 mm; 95% CI [-0.45, -0.17]; p < 0.001), and subfoveal Choroidal Thickness (MD = -18.50 µm; 95% CI [-25.65, -11.35]; p < 0.001). Subgroup analysis revealed a more pronounced effect in ground-based studies. The results were robust in sensitivity analyses, and funnel plots suggested a low risk of publication bias.
Conclusion: This meta-analysis provides robust, quantitative evidence supporting LBNP's efficacy in acutely mitigating the cardinal structural signs of SANS. By directly counteracting the underlying pathophysiology, LBNP is affirmed as a cornerstone countermeasure technology essential for preserving astronaut ocular health during the upcoming era of deep space exploration.
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Optimizing the Surgical Field via Multimodal Controlled Hypotension during Posterior Spinal Fixation for a T11 Burst Fracture: An Anesthetic Case Study
Views: 415Downloads: 282Background: Significant intraoperative blood loss is a major challenge in complex spinal surgeries, impairing surgical field visibility and increasing patient morbidity. Controlled hypotension is an established anesthetic technique to mitigate this challenge, yet the optimal combination of agents to ensure efficacy and safety remains an area of active investigation. This case study details the successful application of a multimodal anesthetic regimen, centered on the synergistic effects of dexmedetomidine and isoflurane, to achieve deliberate hypotension during posterior stabilization of a thoracic burst fracture.
Case presentation: A 39-year-old male, classified as American Society of Anesthesiologists (ASA) physical status II, presented with a traumatic, unstable burst fracture of the eleventh thoracic vertebra (T11) following a high-energy fall. He was scheduled for a posterior decompressive laminectomy and T10-T12 pedicle screw fixation. Anesthetic management was initiated with a multimodal approach utilizing intravenous infusions of dexmedetomidine and morphine, supplemented by maintenance with isoflurane. This strategy was employed to maintain a target mean arterial pressure (MAP) of 60-65 mmHg. Throughout the 135-minute procedure, the patient’s hemodynamics remained exceptionally stable within the target range. The estimated blood loss was minimal (approximately 350 mL), providing the surgical team with an excellent, clear operative field. The patient emerged smoothly from anesthesia with no neurological deficits and experienced a favorable postoperative recovery.
Conclusion: This case demonstrates that a multimodal anesthetic strategy incorporating dexmedetomidine, a volatile agent, and opioid infusions is a highly effective and safe method for inducing and maintaining controlled hypotension in major spinal surgery. This approach successfully optimized the surgical conditions by minimizing blood loss and enhancing visibility, without compromising hemodynamic stability or vital organ perfusion, thereby contributing to a positive patient outcome.
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Clinicopathological Spectrum and Management of Lacrimal Gland Tumors: A Five-Year Retrospective Analysis from an Indonesian Tertiary Center
Views: 351Downloads: 531Background: Lacrimal gland tumors are a rare and heterogeneous group of neoplasms, representing a significant diagnostic and therapeutic challenge. Regional data, particularly from Southeast Asia, is sparse. This study aims to define the clinicopathological spectrum, radiological features, and management strategies for lacrimal gland tumors at a major tertiary referral center in Indonesia.
Methods: A retrospective, cross-sectional analysis was conducted on all patients with histopathologically confirmed lacrimal gland tumors treated between January 2019 and June 2024. Data extracted from medical records included demographics, detailed clinical presentations (visual acuity, proptosis, pain scores), radiological findings from computed tomography (CT) and magnetic resonance imaging (MRI), definitive histopathological diagnoses with immunohistochemical profiles, and treatment modalities with short-term outcomes. Descriptive statistics and comparative analyses were performed.
Results: A total of 35 patients (19 male, 16 female; mean age 48.2 ± 16.5 years) were included. Non-epithelial lesions (88.6%) were more common than epithelial tumors (11.4%). The most prevalent diagnosis was idiopathic orbital inflammation (IOI) (n=12, 34.3%), followed by lymphoproliferative disorders (n=11, 31.4%). Adenoid cystic carcinoma (ACC) was the most frequent malignant epithelial tumor (n=3, 8.6%). Superior eyelid edema was the hallmark of non-epithelial lesions (83.9%), whereas proptosis (mean 6.2mm) and severe pain (mean VAS 7.3/10) were characteristic of ACC. Radiological findings were highly correlative, with IOI showing diffuse gland enhancement and ACC demonstrating bone erosion and perineural invasion. Management was tailored to histology, with corticosteroids for IOI, radiotherapy for lymphomas, and radical surgery for ACC.
Conclusion: In this Indonesian cohort, lacrimal gland tumors are predominantly non-epithelial, with inflammatory and lymphoproliferative conditions being most common. A high index of suspicion for malignancy, particularly ACC, is warranted in patients presenting with pain and proptosis. Integrating clinical, radiological, and pathological data is paramount for accurate diagnosis and effective management.
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Therapeutic Keratoplasty for Severe, Travel-Associated Fungal Keratitis: A Meta-Analysis of Globe Salvage and Visual Acuity Outcomes
Views: 386Downloads: 268Background: Severe, travel-associated fungal keratitis represents a formidable diagnostic and therapeutic challenge, often progressing to corneal perforation despite aggressive medical therapy. Therapeutic keratoplasty (TK) is frequently required to preserve globe integrity. However, its efficacy in this specific, epidemiologically distinct cohort of patients remains poorly quantified. This meta-analysis aimed to synthesize the available evidence on globe salvage and visual acuity outcomes following TK for severe fungal keratitis acquired during international travel.
Methods: A systematic search was conducted in PubMed, Scopus, and Web of Science for studies published between January 2015 and December 2024, reporting outcomes of TK for travel-associated fungal keratitis. The primary outcome was the proportion of cases achieving globe salvage, defined as the avoidance of enucleation or evisceration. The secondary outcome was the mean improvement in Best-Corrected Visual Acuity (BCVA) measured in LogMAR units. Data were pooled using a random-effects model. Heterogeneity was assessed using the I² statistic.
Results: Seven retrospective case series met the inclusion criteria, comprising a total of 102 eyes. The included studies were geographically diverse, with patient travel histories predominantly linked to tropical and subtropical regions in Southeast Asia and South America. The pooled proportion for globe salvage was 89.2% (95% Confidence Interval [CI]: 82.5% to 94.1%). There was low to moderate heterogeneity among the studies for this outcome (I² = 31%, p=0.19). The pooled mean improvement in BCVA from pre-operative assessment to final follow-up was 1.21 LogMAR (95% CI: 0.98 to 1.44). Substantial heterogeneity was observed for the visual acuity outcome (I² = 78%, p<0.001). The most commonly identified fungal genera were Fusarium and Aspergillus.
Conclusion: Therapeutic keratoplasty demonstrates a high rate of anatomical success, effectively salvaging the globe in the vast majority of patients with severe, travel-associated fungal keratitis. While visual acuity is significantly improved, the final outcomes remain guarded and are highly variable. These findings underscore the critical role of TK in the management of this sight-threatening condition and highlight the need for strategies to improve post-operative visual prognosis.
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Functional Limb Salvage Following a 24-Hour-Delayed Fasciotomy for Pediatric Hand Compartment Syndrome: A Case Report
Views: 526Downloads: 379Background: Acute compartment syndrome (ACS) in the pediatric hand is a formidable surgical emergency where delayed diagnosis can lead to devastating neuromuscular deficits and limb loss. The narrow therapeutic window, often termed the "golden hours," is considered critical for preventing irreversible ischemic necrosis. Presentations delayed beyond this period, especially in pre-verbal children, pose a significant clinical and ethical dilemma regarding the utility and risks of surgical intervention.
Case presentation: A 2-year-old female presented to our emergency department 24 hours after a severe crush injury to her right hand from a noodle-making machine. The hand was massively swollen, cyanotic, and insensate, with no detectable capillary refill or digital oximetry readings. A clinical diagnosis of advanced, multi-compartmental ACS was made. Emergency surgical decompression was performed via seven incisions, releasing all ten osteofascial compartments. Intraoperative assessment revealed dusky, non-contractile but bleeding muscle. Following staged debridements, the patient demonstrated remarkable recovery. At six months, she achieved full range of motion in all digits except the middle finger and demonstrated age-appropriate grip and pincer grasp, with the primary sequela being a fixed flexion contracture of the middle finger's proximal interphalangeal joint.
Conclusion: This report highlights a case of unexpected functional recovery following a significantly delayed fasciotomy. The outcome supports a nuanced approach to delayed pediatric ACS, suggesting that in select cases, aggressive surgical decompression should be considered as the potential for a positive outcome may exist. This case serves as a powerful, hypothesis-generating observation that raises critical questions about the absolute temporal limits for surgical intervention and underscores the importance of individualized surgical judgment.
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Destructive Thyroiditis: A Rare and Perplexing Complication of Lithium Therapy in Bipolar Disorder
Views: 358Downloads: 257Background: Lithium is a cornerstone therapy for Bipolar I Disorder, yet its use necessitates vigilant monitoring for adverse drug reactions (ADRs). While lithium-induced hypothyroidism is a well-documented complication, the emergence of thyrotoxicosis secondary to destructive thyroiditis is a rare and diagnostically challenging event. This report presents a systematic analysis of a case of suspected lithium-induced thyroiditis notable for its paradoxical clinical presentation as a severe depressive episode.
Case presentation: A 33-year-old female with a 10-year history of Bipolar I Disorder, stable on lithium for two years, was admitted with a severe depressive episode and active suicidal ideation. The onset of her psychiatric decompensation was temporally correlated with a diagnosis of thyrotoxicosis (suppressed TSH <0.005 uIU/mL; elevated FT4 >7.77 ng/dL). A formal causality assessment using the Naranjo Adverse Drug Reaction Probability Scale yielded a score of 6, indicating a "probable" relationship between lithium and the thyroiditis. Critically, the thyrotoxic state, which conventionally mimics mania, presented atypically as severe depression.
Conclusion: This case of probable lithium-induced destructive thyroiditis, presenting paradoxically with severe depression, underscores the critical need for a high index of suspicion for iatrogenic endocrinopathies in patients on lithium who exhibit any mood destabilization. A systematic approach to ADR assessment is essential to guide appropriate clinical management in such complex presentations.
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A Methodical Approach to a 15-Year Diagnostic Enigma: Unmasking Acrodermatitis Continua of Hallopeau Through Dermoscopy, Histopathology, and Structured Therapeutic Sequencing
Views: 385Downloads: 293Background: Acrodermatitis continua of Hallopeau (ACH) is a rare, debilitating variant of pustular psoriasis. Its profound clinical mimicry of common infections, particularly onychomycosis, often leads to extensive diagnostic delays and ineffective treatments, causing significant patient morbidity. This report details a case with a 15-year history of misdiagnosis, illustrating a structured methodological approach to diagnosis and management.
Case presentation: A 40-year-old Indonesian woman presented with a 15-year history of painful pustular lesions and severe onychodystrophy affecting seven digits, refractory to numerous antimicrobial therapies. The diagnostic process was systematically re-evaluated; dermoscopy revealed features inconsistent with onychomycosis (dotted vessels, hemorrhagic spots), prompting a definitive skin and nail matrix biopsy. Histopathology confirmed pustular psoriasis with pathognomonic Kogoj's spongiform pustules and Munro's microabscesses. Treatment was initiated with cyclosporine (3.3 mg/kg/day), leading to rapid remission. However, the development of gingival hyperplasia and hypertension necessitated a transition to weekly methotrexate (15 mg). The patient achieved and maintained clinical remission on this regimen.
Conclusion: This case underscores the necessity of a high index of suspicion for ACH in chronic, treatment-resistant nail dystrophy. It demonstrates that a methodical application of dermoscopy and histopathology is indispensable for overcoming clinical mimicry. The main lesson is that structured diagnostic evaluation and sequenced therapy, responsive to adverse events, are crucial for achieving long-term remission and restoring quality of life.
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From Antenatal Clue to Postnatal Cure: Surgical Management of a Symptomatic Jejunal Duplication Cyst in an Infant
Views: 369Downloads: 219Background: Alimentary tract duplication cysts represent a rare and challenging subset of congenital anomalies. Their non-specific symptomatology often leads to their misidentification as more common pediatric conditions, making a clear diagnostic pathway essential. With jejunal localization being particularly uncommon, these lesions can range from being asymptomatic to causing life-threatening abdominal emergencies. The evolution of high-resolution prenatal imaging, however, has fundamentally altered their management, enabling proactive postnatal intervention.
Case presentation: A three-month-old female infant, with a history of a non-specific cystic intra-abdominal mass identified on a second-trimester antenatal ultrasound, was referred for progressive abdominal distension and non-bilious vomiting. Postnatal examination revealed a palpable right upper quadrant mass. A contrast-enhanced computed tomography (CT) scan confirmed a 3.9 x 3.9 x 3.3 cm thick-walled jejunal duplication cyst causing partial obstruction. The patient underwent a successful exploratory laparotomy with segmental jejunal resection and primary end-to-end anastomosis. The postoperative course was uneventful, with complete resolution of symptoms. Histopathology confirmed a benign jejunal duplication cyst without heterotopic mucosa.
Conclusion: Jejunal duplication cysts are a critical, albeit rare, consideration in the differential diagnosis of an infant with an abdominal mass or intestinal obstruction. This case serves as a paradigm of modern perinatal care, where an antenatal clue facilitates a planned, definitive postnatal cure. Complete surgical resection remains the gold standard, preventing severe complications and ensuring an excellent long-term prognosis.
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A Hierarchy of Harm: A Meta-analysis of Infection, Thrombosis, and Mortality Risks Across Central Catheters, Arteriovenous Grafts, and Fistulas
Views: 451Downloads: 274Background: Vascular access is a critical lifeline for patients with end-stage kidney disease requiring hemodialysis. The optimal choice among central venous catheters (CVCs), arteriovenous grafts (AVGs), and arteriovenous fistulas (AVFs) is a subject of intense debate, as each modality carries a distinct profile of risks. This meta-analysis was performed to establish a definitive, quantitative hierarchy of these risks to better inform clinical and policy decisions.
Methods: A systematic search of PubMed, Scopus, and the Cochrane Library was conducted for studies published between January 2015 and September 2025 that compared complication rates among CVCs, AVGs, and AVFs in adult hemodialysis patients. Seven high-quality cohort studies met the inclusion criteria, encompassing 18,542 patients. Data on access-related bloodstream infections (ARBSI), access circuit thrombosis/dysfunction, and all-cause mortality were extracted. Pairwise meta-analyses using a random-effects model calculated pooled risk ratios (RR) and 95% confidence intervals (CI).
Results: Central venous catheters were associated with a profoundly higher risk of ARBSI compared to both AVFs (RR 8.12, 95% CI 6.98–9.45, p < 0.001) and AVGs (RR 4.55, 95% CI 3.89–5.33, p < 0.001). Arteriovenous grafts demonstrated a markedly higher risk of access circuit thrombosis compared to AVFs (RR 2.78, 95% CI 2.41–3.21, p < 0.001). All-cause mortality was highest in patients with CVCs, showing a significantly increased risk compared to AVF users (RR 1.92, 95% CI 1.68–2.19, p < 0.001).
Conclusion: This meta-analysis provides robust, contemporary quantitative evidence for a clear hierarchy of harm in hemodialysis access. CVCs pose the greatest risk for infection and mortality, AVGs present the highest risk for thrombosis, and AVFs represent the safest option. These data provide a powerful rationale for reinforcing systemic healthcare initiatives aimed at minimizing CVC exposure and promoting timely AVF placement.
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The Differential Risk of Intraoperative Floppy Iris Syndrome (IFIS) with Tamsulosin versus Other α1-Adrenergic Antagonists: A Systematic Review and Comparative Meta-Analysis
Views: 557Downloads: 279Background: α1-adrenergic antagonists are a cornerstone therapy for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH). Their association with intraoperative floppy iris syndrome (IFIS) during cataract surgery is well-established, yet the comparative risk between the highly α1A-selective agent tamsulosin and other α1-blockers has not been adequately quantified in a meta-analysis. This study aimed to synthesize the evidence to determine the magnitude of this differential risk.
Methods: Following PRISMA guidelines, a systematic search was conducted across PubMed, Embase, Scopus, and the Cochrane Library through September 2025. We included comparative studies reporting IFIS incidence in adults on α1-blockers undergoing cataract surgery. Data were independently extracted by two reviewers. The primary outcome was the pooled Odds Ratio (OR) for IFIS, calculated using a random-effects model. Heterogeneity was assessed with the I² statistic.
Results: The search yielded 1,218 records, with six studies comprising 10,878 patients meeting the inclusion criteria. The incidence of IFIS was 18.7% in the tamsulosin group versus 2.9% in the comparator group (other α1-blockers or control). Tamsulosin was associated with a significantly greater risk of IFIS (Pooled OR = 4.28, 95% CI: 2.91–6.31, p < 0.00001). This corresponds to an absolute risk increase of 15.8% and a Number Needed to Harm (NNH) of 7, suggesting one additional case of IFIS occurs for every seven patients treated with tamsulosin instead of a different agent. Moderate heterogeneity was noted (I² = 62%).
Conclusion: This meta-analysis provides robust evidence that tamsulosin carries a more than four-fold increased odds of IFIS compared to other α1-blockers. This substantial and clinically meaningful risk, highlighted by an NNH of 7, mandates a risk-stratified approach to BPH management. A patient's present or future ophthalmological needs must be a central factor in the shared decision-making process when selecting an α1-blocker.
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Baseline Visual Acuity as an Independent Predictor of Therapeutic Outcomes in HIV-Associated Cytomegalovirus Retinitis: A Three-Year Cohort Study in Indonesia
Views: 320Downloads: 186Background: Cytomegalovirus (CMV) retinitis is a severe opportunistic infection causing irreversible blindness in patients with advanced human immunodeficiency virus (HIV). In the modern era of highly active antiretroviral therapy (HAART), understanding the key determinants of visual prognosis is critical for effective patient management, particularly in resource-limited settings. This study aimed to evaluate the clinical spectrum of CMVR and identify independent predictors of short-term visual outcomes in a cohort of HIV-positive patients in Indonesia.
Methods: A retrospective cohort study was conducted on HIV-positive patients diagnosed with CMV retinitis between January 2021 and December 2023 at a tertiary referral hospital in Bali, Indonesia. Data on demographics, clinical features, CD4+ T-cell counts, HAART status, and visual acuity (VA) at baseline and three months were collected. Visual acuity was converted to the Logarithm of the Minimum Angle of Resolution (LogMAR) for analysis. A multivariable linear regression model was employed to identify independent predictors of three-month visual outcomes.
Results: The study included 26 patients (38 eyes). The cohort was predominantly male (61.5%) with a mean age of 36.73 years. Severe immunosuppression was common, with 65.4% of patients having a CD4+ count below 50 cells/mm³. Posterior uveitis was the most frequent presentation (68.4%). In the multivariable linear regression analysis, baseline LogMAR VA was the only significant independent predictor of three-month LogMAR VA (β = 0.71, p < 0.001) after adjusting for age, CD4+ count, and HAART status. The baseline CD4+ T-cell count was not a significant independent predictor of visual outcome (p = 0.841).
Conclusion: Baseline visual acuity, a direct functional measure of existing retinal damage, is the most powerful independent predictor of short-term visual prognosis in patients with HIV-associated CMV retinitis. This finding highlights the irreversible nature of retinal necrosis and underscores that the opportunity to save sight lies in preemptive action. We advocate for the urgent integration of routine ophthalmological screening into the care protocols for high-risk HIV populations to detect and treat CMVR before significant vision loss occurs.
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The Pointed Challenge: Endoscopic Management of an Ingested Sharp Foreign Body and a Synthesis of Modern Techniques
Views: 1,667Downloads: 295Background: The ingestion of sharp-pointed foreign bodies constitutes a high-acuity medical emergency, distinguished from other ingested objects by its significant potential for severe complications, including visceral perforation and hemorrhage. While flexible endoscopy has emerged as the cornerstone of management, its successful application hinges on a systematic, protocol-driven approach. This manuscript presents a case of an ingested straight pin and uses it as the framework for a critical synthesis of modern diagnostic and therapeutic strategies.
Case presentation: A 40-year-old female presented to the emergency department, hemodynamically stable and completely asymptomatic, two hours after accidentally swallowing a straight pin. A benign abdominal examination belied the potential danger. Plain radiography confirmed a single, sharp metallic object in the gastric antrum. An urgent esophagogastroduodenoscopy under general anesthesia was performed. The pin was securely grasped with rat-tooth forceps and extracted without incident. The patient's recovery was uneventful, and she was discharged on the first postoperative day.
Conclusion: This case provides a high-fidelity validation of current international guidelines, demonstrating that a protocol-driven approach—encompassing rapid triage, definitive imaging, and urgent therapeutic endoscopy—is both safe and maximally effective for upper gastrointestinal sharp foreign bodies. The successful outcome underscores the critical importance of this management algorithm in preventing progression to life-threatening complications. This case-driven synthesis reinforces that adherence to a rigorous, evidence-based protocol is the most effective strategy to navigate this pointed clinical challenge and consistently achieve optimal patient outcomes.
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Balancing Efficacy and Tolerability: A Prospective Cohort Study of Oral and Intravenous Methylprednisolone for Active Graves' Ophthalmopathy in an Indonesian Tertiary Care Center
Views: 447Downloads: 289Background: In managing active, moderate-to-severe Graves' Ophthalmopathy (GO), a notable gap often exists between treatment efficacy in controlled trials and effectiveness in real-world practice. High-dose corticosteroids are standard, but the choice between intravenous (IV) and oral routes involves a complex trade-off between efficacy, tolerability, and practicality, particularly in diverse populations.
Methods: This single-center, pragmatic, prospective cohort study was conducted at a tertiary hospital in Indonesia from March 2023 to March 2024. Thirty-six GO patients were treated with either IV pulse or daily oral methylprednisolone based on a shared clinical decision-making process. The primary outcome was the change in proptosis. To address the non-randomized design and control for selection bias, a propensity score-adjusted Analysis of Covariance (ANCOVA) was used to compare treatment effectiveness.
Results: Baseline analysis revealed that patients selected for IV therapy had significantly more severe proptosis. Both unadjusted and adjusted analyses showed that each regimen resulted in a significant reduction in proptosis from baseline (p < 0.01). In the primary, propensity score-adjusted analysis, no statistically significant difference was detected in the degree of proptosis reduction between the IV and oral groups. However, the tolerability profiles were profoundly different; patients in the oral group experienced a significantly higher incidence of adverse events, including dyspepsia (66.7%) and Cushingoid features (55.6%), compared to a single case of transient hypokalemia in the IV group.
Conclusion: In this real-world setting, after statistically controlling for baseline severity, both IV and oral methylprednisolone demonstrated comparable effectiveness in reducing proptosis. However, the intravenous route was associated with a vastly superior safety profile. These findings underscore the critical importance of tolerability in clinical decision-making and support the continued recommendation of IV pulse therapy as the first-line treatment.
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The Diagnostic Accuracy of IgG Avidity Testing for Differentiating Acute from Chronic Toxoplasmosis in Pregnant Women: A Meta-Analysis
Views: 738Downloads: 550Background: Differentiating acute from chronic Toxoplasma gondii infection during pregnancy is a critical diagnostic challenge. Persistent Immunoglobulin M (IgM) antibodies create ambiguity, complicating clinical management. The IgG avidity test serves as a key tool to estimate infection timing. This meta-analysis aimed to systematically evaluate and quantify the diagnostic accuracy of the IgG avidity test for identifying acute toxoplasmosis in pregnant women.
Methods: A systematic literature search was conducted across PubMed, Scopus, Web of Science, EMBASE, and LILACS for studies published between January 2015 and December 2025 evaluating the IgG avidity test's diagnostic accuracy in pregnant women. Included studies required data for a 2x2 contingency table. The QUADAS-2 tool was used for bias assessment. A bivariate random-effects model was used to pool sensitivity, specificity, likelihood ratios (PLR, NLR), and the diagnostic odds ratio (DOR).
Results: Seven studies, comprising 1,250 pregnant women, were included. The pooled sensitivity was 0.96 (95% Confidence Interval [CI]: 0.92–0.98), and the pooled specificity was 0.97 (95% CI: 0.94–0.99). The pooled PLR was 32.5 (95% CI: 15.1–69.8), the NLR was 0.04 (95% CI: 0.02–0.08), and the DOR was 785 (95% CI: 289–2134). The area under the SROC curve was 0.99 (95% CI: 0.97–1.00). Substantial heterogeneity was observed across studies. A sensitivity analysis excluding one study with a high risk of bias did not significantly alter the results, and Deeks' test showed no evidence of publication bias (p=0.21).
Conclusion: The IgG avidity test demonstrated excellent pooled diagnostic accuracy for differentiating acute from chronic toxoplasmosis in pregnancy. However, significant heterogeneity across studies underscores that a single performance estimate is not universally applicable. The test is a powerful tool for resolving diagnostic uncertainty, but results must be interpreted based on assay-specific performance and in the context of the complete clinical picture.
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Erythema Nodosum Leprosum as a Harbinger of Relapse in Multibacillary Leprosy: A Clinico-Histopathological Case Study
Views: 383Downloads: 248Background: Leprosy, a chronic granulomatous disease caused by Mycobacterium leprae, presents formidable long-term management challenges. In the post-elimination era, differentiating a true bacteriological relapse from a late-onset Erythema Nodosum Leprosum (ENL) reaction in patients who have completed multidrug therapy (MDT) is a critical diagnostic dilemma. Misdiagnosis can lead to inappropriate treatment, risking disease progression and irreversible nerve damage.
Case presentation: A 30-year-old male presented with a severe, systemic inflammatory illness two years after completing MDT for lepromatous leprosy. His symptoms included crops of painful, erythematous nodules, fever, and arthralgia. While clinically suggestive of a severe ENL reaction, a slit-skin smear revealed a paradoxically high bacterial index (BI) of +5 with a morphological index (MI) of 0%. A skin biopsy was performed for definitive diagnosis. Histopathology revealed a dual pathology: a diffuse infiltrate of foamy macrophages typical of lepromatous leprosy, alongside a dense neutrophilic panniculitis characteristic of ENL. Crucially, Fite-Faraco staining demonstrated vast numbers of intact, solid-staining acid-fast bacilli, providing unequivocal evidence of active bacterial proliferation.
Conclusion: This case demonstrates that a diagnostic algorithm integrating a high index of clinical suspicion with comprehensive bacteriological and histopathological methods is essential for accurately identifying relapse masked by ENL. The presence of viable bacilli confirms that ENL can be a direct clinical harbinger of relapse, mandating a dual therapeutic strategy that combines aggressive anti-inflammatory treatment with the immediate re-initiation of MDT.
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Laparoscopic Cholecystectomy is Associated with Superior Clinical Outcomes in Pediatric Cholelithiasis: A 6-Year Comprehensive Surgical Outcome Analysis from Semarang, Indonesia
Views: 343Downloads: 284Background: The incidence of pediatric cholelithiasis is increasing globally, driven primarily by the childhood obesity epidemic. In a nation of over 270 million people like Indonesia, with rising obesity rates, understanding the optimal surgical management is a national health priority. This study provides the first detailed, comparative surgical outcome analysis for pediatric cholecystectomy from a major Indonesian referral center.
Methods: A retrospective cohort study of all pediatric patients (≤18 years) undergoing cholecystectomy from January 2019 to December 2024 was conducted. Data on preoperative demographics, clinical presentation, intraoperative variables (operative time, blood loss, conversion rate), and postoperative outcomes (length of stay, 30-day complications graded by Clavien-Dindo) were extracted. Laparoscopic (LC) and open cholecystectomy (OC) groups were compared using Mann-Whitney U and Fisher’s exact tests.
Results: The cohort of 30 patients (70% female, mean age 12.0 years) had a 60% prevalence of overweight or obesity. Laparoscopy was the initial approach in 25 cases (83.3%), with one conversion to open surgery (4%). Compared to the OC group (n=6), the definitive LC group (n=24) demonstrated significantly superior outcomes: median operative time was shorter (72 vs. 115 minutes, p=0.004), median estimated blood loss was lower (15 vs. 80 mL, p<0.001), and median postoperative length of stay was significantly reduced (3 vs. 5 days, p=0.002). The postoperative complication rate was lower in the LC group (8.3% vs. 33.3%, p=0.14), with all complications being minor (Clavien-Dindo Grade I-II).
Conclusion: Laparoscopic cholecystectomy is a safe, effective, and efficient procedure that provides superior clinical outcomes compared to the open approach in the Indonesian pediatric population. These findings provide robust local evidence to establish LC as the unequivocal standard of care and justify investment in minimally invasive surgical training and infrastructure to meet the rising burden of this disease.
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The Clinical and Pathological Landscape of Pediatric Appendicitis in Central Java, Indonesia: A Retrospective Cohort Study Highlighting a High Burden of Delayed Diagnosis
Views: 333Downloads: 429Background: The timely diagnosis of pediatric appendicitis is a global challenge, particularly in low- and middle-income countries where health system barriers can lead to significant delays and increased morbidity. This study aimed to characterize the clinical and pathological presentation patterns of pediatric appendicitis at a major Indonesian referral center to identify evidence of diagnostic delay and to analyze associated surgical management trends.
Methods: A retrospective cohort study was conducted at Dr. Kariadi General Hospital on all pediatric patients (n=52) who underwent appendectomy between January 2022 and December 2024. Data on demographics, definitive histopathological diagnoses, and surgical approaches were collected and analyzed. The manuscript was prepared in accordance with the STROBE guidelines for observational studies.
Results: The cohort was predominantly male (63.4%), with a peak incidence in the 6–10 year age group (42.3%). The most striking finding was the histopathological diagnosis: a remarkable 48.0% of patients were diagnosed with chronic appendicitis with acute exacerbation, a strong indicator of delayed presentation. Minimally invasive surgery was performed in 48.0% of cases. While a significant association was observed between laparoscopic surgery and a shorter postoperative length of stay (p < 0.001), this finding was subject to significant confounding by indication.
Conclusion: The exceptionally high prevalence of chronic exacerbated appendicitis is the principal finding of this study, serving as a powerful public health signal for systemic delays in the pediatric acute care pathway in this region. While minimally invasive surgery is associated with faster recovery, the more pressing priority is addressing the upstream factors—including public awareness and primary care referral systems—that lead to late surgical presentation and increased cumulative morbidity.
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The Nexus of Comorbid Thyroid Dysfunction, Developmental Trauma, and Marital Distress in Severe Depression: A Case Study of an Integrative Bio-Psycho-Social-Spiritual Approach
Views: 320Downloads: 290Background: The management of major depressive disorder (MDD) is frequently complicated by the presence of medical comorbidities and profound psychosocial stressors. This complexity creates a significant risk for "diagnostic overshadowing," where one clinical issue may mask others, leading to incomplete treatment. This case report illustrates a systematic diagnostic and therapeutic pathway for a patient whose severe depression represents a confluence of biological, psychological, and social determinants.
Case presentation: We present the case of a 50-year-old female with Severe Major Depressive Disorder, Recurrent Episode (F32.2), whose functional impairment was profound (GAF=40). A systematic diagnostic inquiry revealed a nexus of pathology: previously misidentified hypothyroidism (TSH > 100 µIU/mL), comorbid metabolic syndrome (BMI 31.2 kg/m², HbA1c 7.8%); a significant history of developmental trauma (Adverse Childhood Experiences Score ≥ 4); and acute, severe marital distress involving recurrent spousal infidelity. Informed consent was obtained after assessing her capacity, with family collaboration.
Conclusion: The patient was managed using an integrative bio-psycho-social-spiritual framework. This multidimensional approach involved concurrent medical stabilization, psychopharmacological treatment (Sertraline), and a phase-oriented, trauma-informed psychotherapy. The integration of culturally congruent mind-body practices was essential for building the therapeutic alliance. This holistic strategy resulted in significant, quantifiable improvement in depressive symptoms (BDI-II score decreased from 32 to 18) and functional outcomes. This case underscores the necessity of a systematic, multi-domain assessment to avert clinical error and demonstrates a replicable methodology for treating complex presentations of severe depression.
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Personalized Periodontal Regeneration: Integrating 3D Bioprinting with Autologous Activated Growth Factor (AGF) for Enhanced Alveolar Bone Defect Healing
Views: 162Downloads: 114Background: The complete structural restoration of alveolar bone defects remains a critical challenge in reconstructive periodontology. Conventional grafting methods often fail to replicate the complex microarchitecture of periodontal tissues. This study integrated three-dimensional bioprinting technology with Autologous Activated Growth Factor to construct personalized scaffolds for treating severe infrabony periodontal defects.
Methods: A randomized controlled clinical study was conducted at a private hospital in Palembang, South Sumatera, involving patients with Stage III periodontitis exhibiting vertical alveolar bone defects. Cone-beam computed tomography data guided the precise three-dimensional bioprinting of polycaprolactone and beta-tricalcium phosphate scaffolds. These constructs were functionalized operatively with Autologous Activated Growth Factor prepared from peripheral blood. The control group received conventional deproteinized bovine bone mineral with a collagen membrane. Clinical attachment level, probing depth, and radiographic bone fill were evaluated over six months.
Results: The three-dimensional bioprinted scaffolds functionalized with Autologous Activated Growth Factor demonstrated superior clinical outcomes. At six months, the experimental group showed a mean probing depth reduction of 4.82 mm and a clinical attachment level gain of 4.15 mm. Radiographic analysis revealed a mean bone fill of 82.4% in the experimental group compared to 64.1% in the control. Inflammatory biomarkers were significantly modulated, indicating a highly favorable regenerative microenvironment.
Conclusion: The synergistic integration of personalized three-dimensional bioprinted scaffolds with the potent osteoinductive and angiogenic properties of Autologous Activated Growth Factor significantly enhanced alveolar bone defect healing, providing a highly predictable alternative for complex periodontal regeneration.
