Cermin Dunia Kedokteran

Differences in Pain Visual Analog Scale and High-sensitivity C-reactive Protein Levels After Perioperative Fentanyl and Ketamine Administration in Post-laparotomy Patients: A Double-blind Randomized Controlled Trial

2026-01-23T16:06:50+07:00

Introduction: Postoperative pain remains a significant challenge in perioperative management. This study aims to analyze the differences in pain scores using the visual analog scale (VAS) and high-sensitivity C-reactive protein (hsCRP) levels between perioperative ketamine administration and perioperative fentanyl administration in post-laparotomy patients. Methods: A double-blind randomized controlled trial was conducted on 24 laparotomy patients divided into ketamine (n = 12) and fentanyl (n = 12) groups. The ketamine group received a 0.2 mg/kg bolus followed by a 0.1 mg/kg/hour infusion, while the fentanyl group received a 0.5 mcg/kg/hour infusion during surgery; drug administration was stopped immediately after extubation. VAS scores were assessed at 4 and 8 hours postoperatively, and hsCRP levels were measured preoperatively and 6 hours postoperatively. Statistical analysis used independent t-tests, Mann-Whitney U tests, and Pearson correlation. Results: The ketamine group showed significantly lower VAS scores at 4 hours postoperatively (2.92 vs 5.25; p = 0.017), but no significant difference at 8 hours (6.00 vs 5.75; p = 0.514). Postoperative hsCRP levels were lower in the ketamine group compared to fentanyl (4.58 vs 7.77; p = 0.006). A positive correlation was found between increased VAS scores and elevated hsCRP (r = 0.566; p = 0.004). Conclusion: Ketamine provides significantly superior early postoperative analgesia and more effectively suppresses the acute inflammatory response than fentanyl. However, its analgesic advantage diminishes by 8 hours, indicating the need for a multimodal strategy for sustained postoperative pain management.

The Relationship Between the Quality of Health Services and Total Costs in Patients with Open Appendectomy in a Type C Hospital with Indonesia Health Insurance (BPJS Kesehatan) Coverage

2025-10-15T14:03:15+07:00

Introduction: Under BPJS Health, both open and laparoscopic appendectomies, are reimbursed at the same rate despite differences in consumable use. This study aimed to investigate whether open appendectomy provides favorable clinical outcomes at a lower cost and to analyze healthcare costs and service quality in class C private hospitals. Methods: This quantitative study was conducted at a type C hospital in South Jakarta from January 2022 to August 2023. The sample size was calculated using G*Power, the minimum required sample was 70 patients, based on linear multiple regression analysis. Patients included were those with appendicitis undergoing appendectomy under BPJS Kesehatan coverage, selected through purposive sampling. Patients with upgraded insurance or laparoscopic surgery were excluded. Data from medical records were analyzed using logistic regression with a significance level of p < 0.05. Results: Postoperative infection after appendectomy does not significantly influence cost and quality of care, possibly due to other factors. However, length of stay does, as longer
patients require more resources. Cost significantly influences quality of care (p < 0.05). Conclusion: Postoperative infections do not significantly
impact care costs, suggesting case-mix and illness severity are more influential. Longer stays result in higher costs, especially in advanced services. Hospital management should prioritize controlling complications and infections to improve service and meet accreditation standards.

The Relationship between Fluid Intake Levels and Anxiety Levels among Medical Students at Tanjungpura University

2025-10-16T18:35:19+07:00

Introduction: Insufficient fluid intake is associated with an increase in one's negative emotions, whereas prevalence of increased anxiety is high among medical students, and could affect their academic performance. This study aims to determine the correlation between the level of daily fluid requirement fulfillment and anxiety level of medical students in Tanjungpura University class 2019. Methods: A cross-sectional analytical research design with research subjects of 78 people recruited via total sampling method. The questionnaires used in this research are the BEVQ-15, translated and modified by the authors and the Indonesian Zung's SAS, both with established validity and reliability. Analysis of the relationship between the 2 variables used the Spearman rank-order correlation coefficient test (non-parametric). Results: Most students (74.4%) had insufficient fluid intake levels; while the average student met 87.3% of their daily fluid requirements. Meanwhile, students’ anxiety level was found to be at a mild (88.5%) and moderate (11.5%) level. The Spearman correlation test showed that the correlation between the level of daily fluid requirement fulfillment and anxiety level of medical students in Tanjungpura University class 2019 had a significance value of 0.580 (p > 0.05). Conclusion: No significant correlation between the level of daily fluid requirement fulfillment and anxiety level of medical students in Tanjungpura University class 2019.

Higher Body Mass Index is Associated with Improved Overall Survival in Kidney Cancer Patients: A Systematic Review and Meta-Analysis

2026-06-30T16:23:01+07:00

Introduction: Obesity is linked to better oncological outcomes for renal cell carcinoma (RCC), despite being a well-known risk factor for many diseases. This article assesses the relationship between kidney cancer outcomes (overall survival/OS) and body mass index (BMI). Methods: PubMed, Medline, Embase, CINAHL, and Central were used to retrieve studies. Research published up to December 2024 is included in this review. The review was carried out using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020. The quality of the study was assessed with the Newcastle-Ottawa Scale (NOS). RevMan version 5.4.1 was used to analyze and evaluate data. Results: Seven retrospective studies (HR 0.80, 95% CI 0.70–0.93, p = 0.03) showed that the group with normal BMI had a significantly lower overall survival rate than the group with obese or overweight BMI. Obesity may improve kidney cancer treatment outcomes, but the pathophysiology is not yet clear. Some studies suggest that overweight or obese individuals often have higher cancer biology, as they have lower levels of metabolic genes and fatty acids, which are important factors in tumor development. Healthy nutrition can also protect against treatment-related stress or make treatment work better. Conclusion: Obese or overweight individuals with kidney cancer had better results. Conversely, underweight group had more negative consequences.

Non-Surgical Treatment of a Lateral Malleolar Fracture in an Adolescent Athlete Prior to Return to Play – A Case Report

2025-04-02T23:31:02+07:00

Introduction: An ankle fracture is a discontinuity of the distal tibia or fibula involving the tibiotalar joint and is the most common fracture site in football. Most football-related fractures can be managed non-operatively; however, return-to-play (RTP) decisions should not be based on time alone. Case: A 17-year-old male football player sustained an incomplete right lateral malleolus fracture with preserved alignment after two inversion injuries. He was immobilized in a cast for two weeks, followed by non-weight bearing with crutches, and was referred to a sports medicine clinic for ankle stiffness and right calf atrophy. Reconditioning consisted of twice-daily non-weight bearing ankle mobility and strengthening exercises, followed by balance training and functional testing. After one week, active range of motion and calf size were clinically comparable between sides, although right single-leg balance remained inferior despite exceeding 45 seconds. At the subsequent evaluation, single-leg balance exceeded 60 seconds bilaterally and was symmetrical; squats and lunges were pain-free with good movement quality; and single-leg hop distance was symmetrical, although right-sided landing stability remained mildly impaired. Discussion: This article aims to review the principles and protocols of therapy, especially non-surgical therapy, for lateral malleolus fracture before the patient was finally allowed to RTP, and to compare their application in this case. Conclusion: Non-operative management followed by progressive reconditioning enabled this athlete to begin graded non-contact training. Full RTP should be deferred until full training is tolerated without pain or swelling and landing stability has recovered.

Osteochondroma of the Proximal Tibia in a 12-Year-Old Male: A Case Report

2026-06-12T13:50:38+07:00

Introduction: Osteochondroma is the most common benign bone tumor, commonly occurring in the metaphyseal region of long bones during the second and third decades of life. Although frequently asymptomatic, osteochondroma arising from the proximal tibia in a skeletally immature patient is uncommon and may present challenges due to its proximity to the growth plate. This case highlights the diagnostic and surgical considerations in pediatric patient required to preserve skeletal growth while achieving complete tumor removal. Case: A 12-yearold boy presented with a painless swelling over the proximal region of the right tibia that had progressively developed over two months. Physical examination revealed a firm, immobile bony mass measuring approximately 2 × 2.5 cm, no tenderness and without neurovascular impairment. Radiographic evaluation demonstrated a pedunculated osteochondroma with continuity of the cortex and medulla with the host bone, showing growth away from the epiphysis and a positive neck sign. Surgical excision was performed with careful preservation of surrounding neurovascular structures. Histopathological examination confirmed the diagnosis of conventional osteochondroma without malignant features. Conclusion: This case represents an uncommon presentation of proximal tibial osteochondroma in a skeletally immature patient. Early recognition, appropriate imaging assessment, and meticulous surgical planning are essential to prevent complications and maintain normal limb function. At follow-up, the patient showed no recurrence and returned to normal activities.

Persistent Hypoglycemia in Critically Ill Non-Diabetic Patients: Uncovering Non-Insulin-Related Causes — A Case Report

2026-05-19T13:40:03+07:00

Introduction: Hypoglycemia is uncommon in patients without diabetes mellitus, yet critical illness can precipitate it through impaired gluconeogenesis and depletion of hepatic glycogen stores. When this occurs in the absence of insulin therapy or a diabetic history, identifying the underlying cause becomes a diagnostic challenge. Case: A 56-year-old male presented with decreased consciousness secondary to severe hypoglycemia (glucose 42 mg/dL). He had a history of suspected metastatic stage IV prostate cancer with a markedly elevated prostatespecific antigen (PSA) of 930.8 ng/mL, severe anemia (Hb 4.9 g/dL), transaminitis (aspartate aminotransferase/AST 108 U/L), and a normal HbA1c of 4.7% with no prior history of diabetes mellitus. During hospitalization, he was additionally diagnosed with complicated urinary tract infection and hospital-acquired pneumonia. By day three, persistent recurrent hypoglycemia developed despite glucose supplementation. On day five, the patient deteriorated into type 2 respiratory failure requiring ICU admission, and subsequently died. Discussion: Persistent hypoglycemia in this patient was likely multifactorial, involving tumor-related mechanisms, critical illness with concurrent infections, hepatic dysfunction, and prolonged malnutrition, whereas normal HbA1c and the absence of glycosuria excluded underlying diabetes mellitus and renal glucose wasting. Conclusion: This case underscores that persistent hypoglycemia in critically ill non-diabetic patients is a clinically important and often diagnostically elusive condition. A multifactorial approach encompassing malignancy-related mechanisms, hepatic dysfunction, sepsis, and nutritional depletion is essential for timely recognition and management.

Management of Preseptal Cellulitis in Rural Practice: Challenges and Therapeutic Success – A Case Report

2026-06-12T14:03:55+07:00

Introduction: Preseptal cellulitis is an infection localized to the anterior portion of the orbital septum. The most common causes are Staphylococcus aureus and Streptococcus species. Beta-lactam antibiotics are considered the first-line treatment. However, rural settings pose challenges due to limited diagnostic resources and widespread antibiotic use without medical supervision. Case: A 29-year-old woman presenting to a rural health center with eyelid swelling and localized pain. The patient had a history of irrational amoxicillin use. Limited access to culture testing and guidelines led to empiric ciprofloxacin therapy. The patient demonstrated significant clinical improvement after five days of treatment. There was no disease progression or complications. Discussion: Amoxicillin-clavulanate and cephalosporin remain the preferred treatments for preseptal cellulitis because they provide appropriate coverage against common gram-positive pathogens. Ciprofloxacin is not routinely recommended as monotherapy because of its variable activity against streptococci, potential adverse effects, and risk of promoting antimicrobial resistance. Nevertheless, previous reports have included ciprofloxacin in alternative regimens for patients with severe beta-lactam allergy or limited therapeutic options. In this case, its use represented a context-specific clinical decision based on prior incomplete antibiotic exposure, medication availability, and the absence of microbiological testing. Careful clinical assessment and close monitoring were essential to ensure treatment safety. Conclusion: This case illustrates the potential use of ciprofloxacin as a pragmatic alternative in resource-limited environments where first-line agents are unavailable.

Retropupillary Iris Claw Intraocular Lens Implantation in Patient with Late Intraocular Lens Dislocation – A Case Report

2025-08-27T18:24:52+07:00

Introduction: Late intraocular lens dislocation is an uncommon complication of cataract surgery but still a serious condition. Surgical approaches to improve better vision is by repositioning the existing intraocular lens (IOL) or replacing with a new IOL by fixing it either to anterior chamber (ACIOL), to the scleral wall, or to the iris (iris claw). Case: A 53-year-old woman with blurry vision in the past 2 years with history of phacoemulsification cataract surgery on both eyes in 2008. The examination showed the patient's left eye had 20/400 vision with a posterior dislocated IOL in the anterior vitreous cavity within the pupillary area. Considering the possibility of subclinical damage from previous cataract surgery, the low Endothelial Cell Density and approximately 15% ruptured ciliary zonule, retropupillary iris claw was chosen as the surgical approach. The visual acuity improved to 20/40 at follow up one week later, and improved to 20/30 after one month, iris claw intraocular lens (ICIOL) was intact with no complications. Discussion: Late IOL dislocation is a rare but increasingly recognized late complication of cataract surgery, primarily resulting from progressive zonular weakness, with aging likely contributing in this patient. Successful management was achieved by exchanging the dislocated IOL with a retropupillary iris claw IOL, providing good visual recovery without major early postoperative complications. Conclusion: Replacing new IOL using retropupillary iris claw procedure as a less invasive and safe procedure can improve visual acuity with minimal complication.

Propofol-Related Infusion Syndrome:Diagnosis and Management

2024-12-06T13:26:48+07:00

Propofol-related infusion syndrome (PRIS), first described in 1990, is a rare and dangerous condition caused by high-dose (> 4 mg/kg/hour) and prolonged (> 48 hours) administration of propofol in mechanically ventilated patients. This condition is characterized by a progressive constellation of multi-organ failure. The main clinical presentations include severe metabolic and lactic acidosis, rhabdomyolysis, acute liver failure, lipemic blood, hyperkalemia, and cardiovascular impairment or marked bradycardia, which can lead to cardiac arrest. The mechanism of PRIS remains unclear and is likely controversial. The most effective way to prevent PRIS is to remain vigilant and maintain a high level of suspicion during prolonged propofol administration. Early recognition of clinical manifestations, prompt discontinuation of propofol infusion, and timely initiation of supportive management are essential to reduce morbidity and mortality associated with PRIS. Understanding the underlying pathophysiology and identifying patients at high risk may improve preventive strategies and optimize outcomes in critically ill patients receiving prolonged propofol infusion.

AREDS2 as a Retinal Geroprotective Strategy: A Literature Review Through a Geroscience Lens

2025-09-02T14:25:22+07:00

Introduction: Age-related macular degeneration (AMD) is a leading cause of irreversible vision loss among the elderly population. The Age-Related Eye Disease Study 2 (AREDS2) supplementation was developed as an evidence-based nutraceutical strategy to slow the progression of AMD. This review aims to evaluate the clinical evidence and potential application of AREDS2 as a geroprotective retinal intervention within the framework of precision geromedicine. Methods: A narrative review of recent AREDS and AREDS2 studies was conducted, integrating concepts from geroscience related to retinal aging. Results: The AREDS2 formulation, which replaced beta-carotene with lutein and zeaxanthin, demonstrated an 18% reduction in AMD progression risk without increasing lung cancer risk among smokers. AREDS2 components target key aging pathways, including oxidative stress, mitochondrial dysfunction, chronic inflammation, and dysregulated autophagy. In addition, potential modulation of mTOR and AMPK signaling suggests a role in extending retinal healthspan. Conclusion: AREDS2 represents a promising nutraceutical approach as a retinal gerotherapy within the paradigm of precision geromedicine. Its clinical implications include preventing AMD progression, optimizing visual function in older adults, and enabling integration into precision-based ophthalmologic practice. Further research is warranted to validate the molecular mechanisms and assess the cross-population effectiveness, thereby strengthening its role in broader age-related ocular health interventions.

Bullous Pemphigoid: Risk Factors, Clinical Manifestations, Diagnosis, and Management

2024-10-31T09:58:57+07:00

Bullous pemphigoid is an autoimmune disease characterized by subepidermal bullae, primarily affecting the elderly population. This disease involves autoantibodies targeting hemidesmosomal proteins, particularly BP180 and BP230, which play a crucial role in dermal-epidermal adhesion. Although bullous pemphigoid may resolve spontaneously, some cases exhibit a chronic course with significant complications. Diagnosis is based on history-taking, physical examination, and supportive investigations, including direct immunofluorescence (DIF) and enzyme-linked immunosorbent assay (ELISA) testing. Management involves topical corticosteroids for localized cases and systemic corticosteroids for more extensive involvement. Immunosuppressive agents such as methotrexate or azathioprine are used as adjunctive therapy. Several factors, including advanced age, neurological comorbidities, and exposure to certain medications, may increase the risk of developing bullous pemphigoid and influence its prognosis. Early recognition of characteristic clinical findings, confirmation through immunopathological examination, and selection of treatment according to disease severity and patient comorbidities are essential to improve clinical outcomes. Long-term monitoring is also required to detect relapse, treatment-related adverse effects, and complications associated with this disease. Although the mortality rate remains high, effective management can help alleviate symptoms and minimize long-term complications.