Bioscientia Medicina : Journal of Biomedicine and Translational Research

The Landscape of Condyloma Acuminata and Concomitant STIs in Denpasar: A Retrospective Analysis with Implications for Public Health Strategies

2025-06-01T18:04:57+00:00

Background: Condylomata acuminata (CA) is a prevalent sexually transmitted infection (STI). Research into the risk factors and characteristics associated with CA is crucial for developing effective prevention strategies. This study aimed to determine the prevalence and characteristics of CA patients at Prof. Dr. I.G.N.G. Ngoerah General Hospital in Denpasar, Bali, Indonesia.

Methods: A retrospective cross-sectional study was conducted using medical records of CA patients attending the STI and Dermatology Clinic at Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, from January 2021 to December 2023. Data collected included patient visit status, age, gender, occupation, education, concomitant STIs, sexual orientation, marital status, and use of protective measures. Data were processed descriptively.

Results: Of 284 CA patients, 69.7% were male and 30.3% were female. The mean age was 28.99 ± 11.38 years. Married individuals constituted 41.5% of cases. Private employees were the predominant occupation (34.2%). Fifty percent of patients had no concomitant STIs, while HIV was present in 37.7% of the total sample (75.4% of those with any concomitant STI). A significant proportion (49%) reported not using protective measures during sexual intercourse.

Conclusion: The prevalence of CA at Prof. Dr. I.G.N.G. Ngoerah General Hospital, Denpasar, was 40 per 1000 visits during the study period. CA was predominantly observed in adult males who were married, heterosexual, had completed high school, worked as private employees, and did not use protective measures during sexual intercourse. These findings underscore the need for targeted public health interventions.

The Triad of Risk: Advanced Age, Female Gender, and High BMI in Patients Requiring Total Knee Replacement for Osteoarthritis at a Tertiary Indonesian Hospital

2025-06-02T18:05:04+00:00

Background: Knee osteoarthritis (OA) imposes a substantial global burden, leading to significant disability, particularly within the elderly demographic. Total Knee Replacement (TKR) stands as the definitive surgical intervention for advanced knee OA cases that have proven refractory to comprehensive conservative management. A thorough understanding of the multifaceted characteristics of patients undergoing TKR is paramount for the development and implementation of targeted, effective healthcare strategies and resource allocation. This study aimed to meticulously identify and describe these characteristics in a cohort of patients receiving TKR at a tertiary referral hospital located in Bali, Indonesia.

Methods: This investigation employed a descriptive quantitative cross-sectional study design. It involved a retrospective analysis of medical records pertaining to 54 patients who underwent primary TKR for diagnosed knee OA at Prof. Dr. I.G.N.G. Ngoerah General Hospital. The data collection period spanned from November 2023 to November 2024. The primary variables assessed included chronological age at the time of surgery, biological sex, body mass index (BMI) calculated from recorded height and weight, and the documented incidence of postoperative periprosthetic joint infection (PJI). All collected data were subjected to descriptive statistical analysis.

Results: The demographic analysis revealed that the vast majority of patients were female, accounting for 85.2% (n=46) of the cohort. The predominant age group for TKR procedures was between 50 and 69 years, encompassing 85.1% of patients; specifically, the 50–59 years category included 44.4% (n=25), and the 60–69 years category included 40.7% (n=22). A notably high prevalence of overweight or obesity was observed, with 70.3% of patients falling into these BMI classifications (overweight: 37.0%, n=11; obesity class I: 27.8%, n=15; obesity class II: 9.3%, n=5). Periprosthetic joint infection, a significant postoperative complication, was documented in 5.6% of the patients (n=3) within this cohort.

Conclusion: The findings of this study strongly indicate that advanced age, female gender, and an elevated body mass index collectively constitute a significant triad of risk characteristics among patients undergoing TKR for severe knee OA within this specific Balinese hospital setting. These observations underscore the critical necessity for focused preventive measures and tailored management strategies, particularly directed towards older women with increased BMI, to potentially mitigate the progression of OA and optimize the outcomes following TKR.

Menthol-Camphor-Thymol-Eucalyptus Compound as a Novel Adjuvant Therapy in Fluconazole-Treated Candida parapsilosis Onychomycosis: A Case Report

2025-06-03T18:05:51+00:00

Background: Onychomycosis, a fungal infection of the nail apparatus, presents a therapeutic challenge due to its recalcitrant nature and the limitations of current antifungal regimens, including potential side effects and prolonged treatment durations. Candida parapsilosis is an increasingly recognized, yet less commonly reported, yeast pathogen in onychomycosis, particularly in immunocompromised individuals or those with specific comorbidities. The exploration of effective, safe, and accessible adjuvant therapies is crucial to enhance treatment outcomes. This report details the use of an over-the-counter menthol-camphor-thymol-eucalyptus compound as an adjuvant to oral fluconazole.

Case presentation: A 69-year-old male, a gold washer by occupation with a two-month history of rheumatoid arthritis (RA) treated with methotrexate, hydroxychloroquine, methylprednisolone, and celecoxib, presented with a four-month history of yellowish-brown discoloration, uneven texture, and brittleness of both thumb nails. Dermatological examination revealed onychodystrophy, subungual hyperkeratosis, and yellowish-brown discoloration of the bilateral thumb nail plates. Dermoscopy confirmed these findings. Fungal culture of nail clippings identified Candida parapsilosis. The patient was treated with oral fluconazole 150 mg weekly for three months and twice-daily topical application of menthol-camphor-thymol-eucalyptus compound under plastic occlusion. Significant clinical improvement in nail color and texture, with no onycholysis, was observed at the 6-week follow-up. At the 3-month evaluation, fungal culture was negative, and liver function tests remained within normal limits.

Conclusion: This case demonstrates the successful use of a menthol-camphor-thymol-eucalyptus compound as an adjuvant to oral fluconazole in treating Candida parapsilosis onychomycosis in an elderly patient with RA. The combination therapy was well-tolerated and led to clinical and mycological resolution, suggesting a promising, accessible, and cost-effective adjunctive therapeutic strategy.

High-Flow Nasal Cannula versus Non-Invasive Positive Pressure Ventilation in Adults with Acute Hypoxemic (Type 1) Respiratory Failure: A Meta-Analysis of Efficacy, Intubation Rates, and Mortality

2025-06-07T18:08:09+00:00

Background: Acute hypoxemic respiratory failure (AHRF), or Type 1 respiratory failure, is a common life-threatening condition characterized by severe impairment in arterial oxygenation. High-flow nasal cannula (HFNC) and Non-Invasive Positive Pressure Ventilation (NIPPV) are two widely used non-invasive respiratory support strategies. However, their comparative effectiveness in adults with Type 1 AHRF remains a subject of ongoing investigation. This meta-analysis aimed to compare the efficacy, intubation rates, and mortality associated with HFNC versus NIPPV in this patient population.

Methods: A systematic search of PubMed, EMBASE, Scopus, and the Cochrane Central Register of Controlled Trials (CENTRAL) was conducted for randomized controlled trials (RCTs) published between January 2014 and December 2024. Studies comparing HFNC with NIPPV in adult patients with Type 1 AHRF were included. The primary outcomes were the rate of endotracheal intubation and all-cause mortality (hospital or 28-day). Secondary outcomes included improvement in oxygenation (such as change in PaO₂/FiO₂ ratio) and length of hospital stay. Two reviewers independently screened studies, extracted data, and assessed the risk of bias using the Cochrane Risk of Bias tool. Meta-analyses were performed using a random-effects model, and results were expressed as Risk Ratios (RR) with 95% Confidence Intervals (CI) for dichotomous outcomes and Mean Differences (MD) for continuous outcomes. Heterogeneity was assessed using the I² statistic.

Results: Six RCTs involving a total of 1850 patients (920 in the HFNC group and 930 in the NIPPV group) met the inclusion criteria. The overall risk of bias in the included studies was moderate. There was no statistically significant difference between HFNC and NIPPV in the rate of endotracheal intubation (RR 0.92, 95% CI 0.75-1.13; I²=28%; 6 studies) or all-cause mortality (RR 0.88, 95% CI 0.69-1.12; I²=15%; 6 studies). For oxygenation improvement, assessed by the change in PaO₂/FiO₂ ratio at 24 hours, data from four studies showed no significant difference between the two groups (MD 5.8 mmHg, 95% CI -8.5 to 20.1 mmHg; I²=45%). Hospital length of stay was also comparable. Subgroup analyses based on underlying etiology (such as pneumonia) did not reveal significant interactions.

Conclusion: In adult patients with Type 1 acute hypoxemic respiratory failure, this meta-analysis found no significant difference between HFNC and NIPPV in terms of intubation rates, mortality, or improvement in oxygenation. Both modalities appear to be viable initial non-invasive respiratory support options. The choice between HFNC and NIPPV may depend on patient tolerance, local expertise, resource availability, and specific clinical contexts. Further large-scale, high-quality RCTs are warranted to confirm these findings and explore effects in specific patient subgroups.

Beyond Tumor Grade: Investigating the Heterogeneity of PD-L1 Expression in Soft Tissue Sarcomas and the Need for Subtype-Specific Analysis

2025-07-14T06:04:54+00:00

Background: Soft tissue sarcomas (STS) represent a diverse group of malignant mesenchymal neoplasms with considerable histological variety and differing degrees of malignancy. Programmed Death-Ligand 1 (PD-L1) expression is a crucial immunotherapy target in various cancers, but its role and expression patterns in STS, particularly within the Indonesian population, remain inadequately defined. This study aimed to investigate the differences in PD-L1 expression between low-grade and high-grade STS and to determine the correlation between PD-L1 expression and histological grading in an Indonesian cohort.

Methods: This analytical observational study utilized a cross-sectional design, incorporating 29 archival paraffin-embedded tissue blocks from STS patients diagnosed at Dr. Saiful Anwar Regional General Hospital, Malang, Indonesia. PD-L1 expression was assessed immunohistochemically using the monoclonal antibody clone 22c3, and scoring was performed using the Combined Positive Score (CPS). Statistical analyses, including the Mann-Whitney U test and Spearman correlation, were employed to evaluate differences and correlations.

Results: The majority of STS cases (89.7%) exhibited negative PD-L1 expression. The mean PD-L1 CPS was 0.1429 in low-grade STS and 0.233 in high-grade STS. No statistically significant difference in PD-L1 expression was observed between the low-grade and high-grade groups (p=0.620). Furthermore, Spearman correlation analysis revealed no significant association between PD-L1 expression (numeric CPS and categorical positivity) and histological grade (r=0.094, p=0.629 for CPS; r=0.102, p=0.600 for interpretation).

Conclusion: This study found no significant difference in PD-L1 expression between low-grade and high-grade soft tissue sarcomas, nor a significant correlation with histological grade in the investigated Indonesian patient cohort. These findings suggest that PD-L1 expression, when assessed independently, may not be a reliable prognostic biomarker based solely on tumor grading in STS. Further research with larger sample sizes, encompassing diverse histological subtypes and incorporating additional immune biomarkers, is warranted.

Non-Operative Management Accelerates Recovery: Reduced Length of Hospital Stay in Partial Small Bowel Obstruction with Virgin Abdomens

2025-06-12T18:09:48+00:00

Background: Small bowel obstruction (SBO) represents a formidable challenge in surgical practice. Partial SBO (PSBO) in individuals without a history of abdominal surgery, termed "virgin abdomens," introduces distinct diagnostic and therapeutic considerations. While non-operative management (NOM) has become a cornerstone for adhesive SBO, comprehensive data elucidating its impact on PSBO in virgin abdomens, especially concerning the length of hospital stay (LOS), are not extensively available. This study was designed to meticulously compare the LOS between NOM and operative interventions in patients diagnosed with PSBO affecting virgin abdomens, specifically within a tertiary care setting in Indonesia.

Methods: A retrospective analytic observational methodology, utilizing a cross-sectional design, was implemented at Dr. Kariadi General Hospital, Semarang, covering patients admitted from January through December 2024. The study included patients over 18 years of age with a confirmed diagnosis of PSBO in a virgin abdomen. Exclusion criteria encompassed total SBO, obstructions located in the colon, or any record of prior abdominal surgical procedures. The principal outcome measure, LOS, was rigorously compared between the cohort managed non-operatively and the cohort that underwent surgical procedures. Statistical analysis was performed using appropriate tests, with a p-value below 0.05 established as the threshold for statistical significance.

Results: The study cohort comprised 167 eligible patients. For the 112 patients (67.1%) subjected to surgical intervention, the mean LOS was recorded at 13.2±8.72 days. Conversely, the 55 patients (32.9%) managed conservatively demonstrated a markedly shorter mean LOS of 7.74±6.12 days. This observed difference in LOS was statistically highly significant (p < 0.001). The mean age of the participants was 50.60±14.94 years, with females constituting 52.1% of the group.

Conclusion: In clinically stable patients presenting with partial small bowel obstruction in virgin abdomens, non-operative management was associated with a significantly diminished length of hospital stay when compared to surgical intervention. This conservative strategy proves to be an effective and advantageous approach in appropriately selected patient populations, offering the potential to lessen hospital burden and enhance recovery timelines.

Navigating a Rare Entity: Pancreatic Lipomatosis in a 34-Year-Old Female Without Classical Risk Factors – A Case Report

2025-06-12T18:09:32+00:00

Background: Pancreatic lipomatosis (PL), characterized by the replacement of pancreatic acinar tissue with mature adipose cells, is an uncommon condition with an etiology that is often not fully understood. It is frequently identified incidentally during imaging studies. The aim of this case report is to contribute to and advance the clinical understanding of this exceedingly rare and atypical presentation of pancreatic lipomatosis.

Case presentation: This report details the case of a 34-year-old female who presented for evaluation of nonspecific, intermittent epigastric discomfort. Her medical history was devoid of significant illnesses, alcohol abuse, or known genetic conditions predisposing to pancreatic disorders. Comprehensive laboratory evaluations, encompassing serum amylase, lipase, liver function tests, lipid profile, and HbA1c, yielded results entirely within normal parameters. Abdominal computed tomography (CT) imaging revealed a striking diffuse, homogeneous fatty replacement of the entire pancreatic parenchyma, a hallmark of total pancreatic lipomatosis. Importantly, there was no evidence of pancreatic ductal dilatation, calcifications, or any discrete pancreatic masses. The patient's management was conservative, involving lifestyle counseling and scheduled periodic monitoring for the potential, though infrequent, development of complications such as exocrine pancreatic insufficiency or secondary diabetes mellitus.

Conclusion: This case distinctly illustrates the occurrence of extensive pancreatic lipomatosis in a young, otherwise healthy female lacking classical risk factors. The pivotal role of cross-sectional imaging, specifically CT, in accurately diagnosing this benign condition is emphasized, which is crucial for averting misdiagnosis and precluding unnecessary invasive interventions. Enhanced awareness among clinicians is vital for appropriate patient counseling, the implementation of conservative management strategies, and diligent long-term monitoring for any potential metabolic or functional sequelae.

Navigating Frontal Lobe Arteriovenous Malformation Resection: A Case Report on TIVA with Propofol-Remifentanil TCI for Hemodynamic Stability and ICP Control

2025-06-12T18:09:13+00:00

Background: Arteriovenous malformations (AVMs) located within the frontal lobe present considerable anesthetic challenges. These challenges arise from the critical functions governed by this brain region and the inherent risks associated with intracranial surgery, notably hemodynamic instability and the potential for elevated intracranial pressure (ICP). The utilization of Total Intravenous Anesthesia (TIVA) through Target-Controlled Infusion (TCI) systems for propofol and remifentanil provides a sophisticated strategy for achieving precise control over anesthetic depth and maintaining physiological homeostasis. This report offers a detailed account of such a case.

Case presentation: A 25-year-old male patient, classified as ASA III, presented with a right frontal lobe Spetzler-Martin Grade I AVM and was scheduled for elective microsurgical resection. The anesthetic management centered on a TIVA approach, employing propofol administered via an Eleveld TCI model (target concentration range: 2-5 µg/mL) and remifentanil via a Minto TCI model (target concentration range: 4-6 ng/mL). Comprehensive intraoperative monitoring included invasive arterial blood pressure and central venous pressure. Pharmacological adjuncts included mannitol, dexamethasone, and tranexamic acid. Throughout the procedure, stable intraoperative hemodynamics (target Mean Arterial Pressure [MAP] 70-90 mmHg) were successfully maintained, and intracranial pressure was effectively controlled, thereby facilitating the complete AVM resection. The patient was extubated in the post-operative period, demonstrated a stable neurological status, and was subsequently managed in the Intensive Care Unit (ICU).

Conclusion: A meticulously planned and executed TIVA-TCI regimen, featuring propofol and remifentanil, when integrated with thorough invasive monitoring and proactive pharmacological interventions, demonstrated effectiveness in preserving crucial hemodynamic stability and fostering optimal intracranial conditions. This comprehensive anesthetic strategy was instrumental in the successful surgical resection of a frontal lobe AVM and contributed to a favorable neurological outcome for the patient.

Beyond Co-Expression: Unraveling the Complex Relationship Between PD-L1 and Tumor-Infiltrating Lymphocytes in Basal Cell Carcinoma Subtypes

2025-06-12T18:08:56+00:00

Background: Basal cell carcinoma (BCC) is the most prevalent non-melanoma skin cancer, characterized by high recurrence rates. Immunotherapy, particularly targeting the Programmed Death-1 (PD-1)/Programmed Death-Ligand 1 (PD-L1) axis, offers a promising therapeutic avenue. The interplay between PD-L1 expression on tumor and immune cells and the nature of Tumor-Infiltrating Lymphocytes (TILs) is crucial for immune response, yet their relationship in BCC, especially across diverse histological subtypes, remains incompletely understood. This study aimed to investigate the correlation between PD-L1 expression and TILs density in various BCC subtypes, seeking to elucidate the complexities of their interaction within the tumor microenvironment.

Methods: This analytical observational study utilized a cross-sectional design, analyzing 20 archived paraffin-embedded BCC tissue samples from Dr. Saiful Anwar Regional General Hospital Malang. PD-L1 expression was assessed by immunohistochemistry using the 22c3 clone and evaluated via the Combined Positive Score (CPS). TILs were semi-quantitatively assessed as percentage infiltration and categorized into low, moderate, and high grades. Histological subtypes of BCC were documented. Spearman correlation was used to analyze the relationship between PD-L1 expression and TILs.

Results: Of the 20 BCC cases, 55% exhibited PD-L1 positivity (CPS ≥ 1). TILs infiltration was predominantly moderate (70%), with 25% high and 5% low. The cohort included nodular (40%), infiltrating (35%), and basosquamous (25%) as the main subtypes, with specific variants also analyzed. Basosquamous BCC consistently showed positive PD-L1 expression (100% of its cases positive), while nodular and infiltrating subtypes displayed varied PD-L1 expression. TILs distribution also varied across subtypes, with nodular BCC exhibiting the full range from low to high TILs. Overall, no significant correlation was observed between PD-L1 expression and TILs density (Spearman's r = -0.077, p = 0.747).

Conclusion: This study confirms PD-L1 expression and TILs presence in BCC but reveals no direct linear correlation between them across the cohort, even when considering broad subtypes. Basosquamous BCC consistently expressed PD-L1. The lack of overall correlation suggests a complex, potentially subtype-specific interplay within the BCC tumor microenvironment, warranting further investigation into functional TILs subsets and other immune modulators.

Optimizing Sunburn Prevention in Children: A Meta-Analysis of the Efficacy of Sunscreen Application, Protective Apparel, and Shade-Seeking Behaviors

2025-06-15T18:10:56+00:00

Background: Childhood sunburn significantly elevates lifelong skin cancer risk, underscoring the need for effective prevention. While sunscreen, protective apparel, and shade-seeking are advocated, a quantitative synthesis of their efficacy in children is crucial. This meta-analysis aimed to consolidate and quantify the evidence on the effectiveness of these core sun protection strategies in preventing pediatric sunburn.

Methods: A systematic search of PubMed/MEDLINE, Scopus, Cochrane CENTRAL, and Web of Science (January 2014 - December 2024) identified randomized controlled trials and cohort studies evaluating sunscreen, protective apparel, or shade-seeking behaviors for sunburn prevention in individuals aged 0-18 years. Data on sunburn incidence were extracted, study quality assessed, and pooled Risk Ratios (RR) with 95% confidence intervals (CI) calculated using a random-effects model.

Results: Six studies (two RCTs, four cohort studies) involving 8,500 children were included. Regular sunscreen use (SPF ≥30) significantly reduced sunburn incidence (RR 0.65, 95% CI 0.55-0.77). Protective apparel use also demonstrated substantial protection (RR 0.70, 95% CI 0.60-0.82). Enhanced shade provision and shade-seeking behaviors effectively lowered sunburn risk (RR 0.75, 95% CI 0.62-0.90). Multi-component strategies combining these approaches showed consistent protective benefits.

Conclusion: This meta-analysis provides robust quantitative evidence that diligent sunscreen application, consistent use of protective apparel, and active shade-seeking are all significantly effective in reducing sunburn incidence in children. These findings strongly support multifaceted public health initiatives emphasizing comprehensive sun protection to safeguard pediatric skin health.

The Shadow of Deficiency: Vitamin D Status as a Critical Determinant of Antithyroid Drug Efficacy in Graves’ Disease – Insights from an Indonesian Cohort

2025-06-15T18:10:39+00:00

Background: Graves' disease (GD), an autoimmune hyperthyroid condition, presents significant management challenges, particularly concerning variable remission rates with antithyroid drugs (ATDs). Vitamin D, with its established immunomodulatory properties, is hypothesized to influence autoimmune processes, including those in GD. However, its precise impact on ATD treatment outcomes in diverse populations, especially in regions like Indonesia with high vitamin D deficiency prevalence, remains insufficiently elucidated.

Methods: This retrospective cohort study was conducted at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia, analyzing data from 73 newly diagnosed adult GD patients (diagnosed January 2022 - December 2023). Patients had confirmed GD based on hyperthyroidism with orbitopathy or positive TRAb and were followed until May 2025. Baseline serum 25-hydroxyvitamin D [25(OH)D], free T4 (fT4), and TSH levels were recorded. Vitamin D deficiency (VDD) was defined as <20 ng/mL. The primary outcome was non-remission after ATD therapy, defined as failure to achieve stable euthyroidism for ≥6 months on minimal ATD doses. Multivariate Poisson regression was used to assess predictors of non-remission.

Results: Of 73 patients (mean age 36.2 years; 62% female), 55 (75.3%) exhibited VDD. Multivariate analysis identified VDD as a significant independent predictor of non-remission (adjusted Relative Risk [aRR] 11.81; 95% CI 1.88–74.20; p=0.008). Elevated baseline fT4 levels (≥5 ng/dL; aRR 4.61; 95% CI 1.13–18.70; p=0.032) and older age (>48 years; aRR 0.078; 95% CI 0.06–0.95, indicating a protective effect of older age against non-remission) were also significant predictors.

Conclusion: Baseline vitamin D deficiency is a potent independent risk factor for non-remission in Indonesian Graves' disease patients receiving antithyroid drug therapy. These findings underscore the potential importance of assessing and addressing vitamin D status in the management of Graves' disease to optimize therapeutic outcomes.

A Distinctive Clinical Phenotype of Discoid Lupus Erythematosus in Papuanese Women: A 5-Year Analysis of Dyspigmentation, Scarring, and Malar Predilection

2025-06-22T18:10:49+00:00

Background: Discoid lupus erythematosus (DLE), the most common form of chronic cutaneous lupus, exhibits significant clinical variability influenced by ethnicity. While disparities in presentation are recognized, data from unique indigenous populations such as the Papuanese in East Indonesia remain scarce. This study aimed to characterize the clinical and sociodemographic features of DLE in this specific cohort to identify its potentially distinctive phenotype.

Methods: A five-year retrospective analysis of clinical databases was conducted at the Department of Dermatology and Venereology at a tertiary referral hospital in Jayapura, Papua, Indonesia. All patients clinically diagnosed with DLE by board-certified dermatovenereologists between January 2019 and December 2023 were included. Sociodemographic and clinical data, including lesion morphology, location, and management, were systematically collected and analyzed using descriptive statistics.

Results: A total of 22 patients meeting the criteria were identified. The cohort demonstrated remarkable homogeneity; all patients were of Papuanese ethnicity and female (100.0%). The majority were in the 26-35 age group (40.9%), with a mean age of 29.4 years, and half were farmers (50.0%). Clinically, lesions were universally present on the nose and/or malar area (100.0%). The most common morphological triad was dyspigmentation, scarring, and telangiectasia, observed in 81.8% of patients. All patients reported photosensitivity and were managed with photoprotection and topical steroids.

Conclusion: DLE I n Papuanese women presents as a distinctive, highly uniform clinical phenotype characterized by an exclusive female predilection, a strong association with sun exposure, and a universal malar distribution with a high propensity for disfiguring dyspigmentation and scarring. These findings underscore the necessity of culturally competent, early, and aggressive management strategies to mitigate long-term sequelae in this vulnerable population.

The Nexus of Neuroinflammation and Psychopathology in Neuropsychiatric Systemic Lupus Erythematosus (NPSLE): A Meta-Analysis of Anti-NMDAR, Anti-Ribosomal P Antibodies, and Psychosomatic Manifestations (Depression, Anxiety, Cognitive Dysfunction)

2025-06-16T18:11:03+00:00

Background: Neuropsychiatric systemic lupus erythematosus (NPSLE) significantly impacts patients through diverse neurological and psychiatric symptoms, including prevalent psychosomatic manifestations like depression, anxiety, and cognitive dysfunction. Specific autoantibodies, such as anti-N-methyl-D-aspartate receptor (anti-NMDAR) and anti-ribosomal P protein (anti-RP) antibodies, are implicated in its complex neuroinflammatory pathogenesis. This meta-analysis aimed to quantitatively assess the association between these autoantibodies and these key psychosomatic outcomes in NPSLE.

Methods: A systematic literature search of PubMed, EMBASE, Scopus, and PsycINFO (2014-2024) identified observational studies reporting on anti-NMDAR or anti-RP antibodies and depression, anxiety, or cognitive dysfunction in adult NPSLE patients. Data from six eligible studies (850 patients) were extracted and quality was assessed. Pooled odds ratios (ORs) or standardized mean differences (SMDs) were calculated using a random-effects model, with heterogeneity and publication bias evaluated.

Results: Anti-NMDAR antibody positivity was significantly associated with increased odds of cognitive dysfunction (OR = 2.85, 95% CI = 1.90-4.28). Anti-RP antibody positivity was significantly linked to increased odds of depression (OR = 3.20, 95% CI = 2.15-4.76) and anxiety (OR = 2.50, 95% CI = 1.65-3.78). Moderate heterogeneity was noted for some analyses.

Conclusion: This meta-analysis highlights distinct associations: anti-NMDAR antibodies with cognitive dysfunction, and anti-RP antibodies with depression and anxiety in NPSLE. These findings underscore the potential role of these autoantibodies in specific psychosomatic symptom clusters, guiding further research and clinical consideration in NPSLE management.

Awake Intubation for a Predicted Difficult Airway in a Patient with Giant Goiter-Induced Tracheomalacia: A Case Report

2025-06-16T18:10:46+00:00

Background: The management of a predicted difficult airway in patients with giant goiters presents a significant anesthetic challenge. Chronic tracheal compression can lead to secondary tracheomalacia, a condition characterized by tracheal weakness that can precipitate catastrophic airway collapse upon induction of general anesthesia. We present a case where a high index of suspicion for tracheomalacia guided the decision to perform awake tracheal intubation.

Case presentation: A 22-year-old female presented with a massive, non-toxic nodular goiter that had been growing for eight years, causing significant positional dyspnea. Airway assessment revealed a 10x10 cm neck mass with tracheal deviation, indicating a high risk for difficult intubation and ventilation. Preoperative suspicion of tracheomalasia was high due to symptoms and chronicity. The airway was secured using awake intubation with topical and intravenous lidocaine prior to the induction of general anesthesia. The patient underwent a total thyroidectomy. Intraoperative palpation confirmed flaccid tracheal rings, supporting the diagnosis. The endotracheal tube was retained postoperatively, and the patient was monitored in the intensive care unit. She was successfully extubated on the third postoperative day without complications.

Conclusion: This case underscores the critical importance of maintaining a high index of suspicion for tracheomalacia in patients with long-standing, giant goiters. Awake tracheal intubation is a cornerstone technique, providing a safe and effective method to secure the airway while preserving spontaneous ventilation, thereby mitigating the risk of life-threatening airway obstruction. A meticulous, multidisciplinary perioperative plan is paramount for optimal patient outcomes.

Cardiac Myosin Inhibitors in Hypertrophic Cardiomyopathy: A Head-to-Head Network Meta-Analysis of Mavacamten and Aficamten

2025-06-22T18:11:39+00:00

Background: Hypertrophic cardiomyopathy (HCM) is a genetic disorder characterized by myocardial hypercontractility. Mavacamten and aficamten are first-in-class cardiac myosin inhibitors that have demonstrated efficacy in treating obstructive HCM. However, in the absence of direct head-to-head randomized controlled trials (RCTs), their comparative effectiveness and safety remain unquantified. We aimed to indirectly compare the efficacy and safety of mavacamten and aficamten in patients with obstructive HCM.

Methods: We conducted a systematic review and Bayesian network meta-analysis of RCTs. We searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to December 2024. Eligible studies were RCTs comparing mavacamten or aficamten with placebo in adults with obstructive HCM. The primary efficacy outcomes were the change from baseline in post-exercise left ventricular outflow tract (LVOT) gradient and the change in peak oxygen consumption (pVO₂). The primary safety outcome was the incidence of left ventricular ejection fraction (LVEF) reduction to <50%.

Results: Seven RCTs involving 1,025 patients were included. In the network meta-analysis, both aficamten (Mean Difference [MD], -50.8 mmHg; 95% Credible Interval [CrI], -61.2 to -40.4) and mavacamten (MD, -44.9 mmHg; 95% CrI, -53.7 to -36.1) were significantly more effective than placebo in reducing post-exercise LVOT gradient. The indirect comparison between the two agents did not reveal a statistically significant difference (MD, -5.9 mmHg; 95% CrI, -17.8 to 6.0). For pVO₂, both mavacamten and aficamten showed significant improvement over placebo, with no significant difference between them. The odds of LVEF dropping below 50% were numerically higher with mavacamten compared to aficamten, but the difference was not statistically significant (Odds Ratio [OR], 1.52; 95% CrI, 0.65 to 3.54).

Conclusion: Mavacamten and aficamten are both highly effective in improving hemodynamic and functional parameters in patients with obstructive HCM. While our indirect comparison did not establish the superiority of one agent over the other, it provides foundational evidence for clinicians. Definitive conclusions await direct head-to-head clinical trials.

Unmasking the Primary: The Role of 99mTc-Sestamibi SPECT/CT in a Case of Carcinoma of Unknown Primary with Suspected Lung Origin

2025-06-22T18:11:22+00:00

Background: Carcinoma of unknown primary (CUP) is a challenging clinical diagnosis, representing histologically confirmed metastatic cancer where the primary tumor site remains unidentified after a standard diagnostic workup. While ¹⁸F-FDG PET/CT is recommended by current guidelines, its accessibility is limited in many regions. This report explores the diagnostic utility of Technetium-99m (^99mTc)-Sestamibi Single Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) as a valuable alternative.

Case presentation: A 67-year-old female presented with musculoskeletal pain. A biopsy of a right ulnar lesion confirmed metastatic carcinoma. Immunohistochemistry (IHC) suggested a possible primary from the lung, breast, or upper gastrointestinal tract. Due to the unavailability of ¹⁸F-FDG PET/CT, a ^99mTc-Sestamibi whole-body scan with SPECT/CT was performed. The scan identified a metabolically active, malignant-appearing nodule in segment 6 of the left lung and confirmed widespread skeletal metastases. Although a lung biopsy was not feasible due to limited access, the patient was treated with a lung cancer protocol. This resulted in significant clinical improvement.

Conclusion: ^99mTc-Sestamibi SPECT/CT served as a critical diagnostic tool in this case of CUP. It successfully identified a suspected pulmonary primary, enabling targeted therapy and leading to a positive clinical outcome. This case highlights the modality's efficacy as a tumor-seeking agent and underscores its essential role in the diagnostic armamentarium for CUP, particularly in resource-limited healthcare settings.

The Predictive Value of Sperm Mitochondrial DNA Copy Number on Male Infertility: A Systematic Review and Meta-Analysis

2025-06-22T18:11:05+00:00

Background: The integrity and quantity of mitochondrial DNA (mtDNA) in spermatozoa are considered critical for male reproductive potential. While qualitative damage like deletions has been linked to infertility, the significance of quantitative changes, specifically mtDNA copy number (mtDNAcn), remains debated. This study aimed to systematically review and meta-analyze the existing evidence to determine the association between sperm mtDNAcn and male infertility.

Methods: We conducted a systematic search of PubMed, Science Direct, and Scopus databases for observational studies published between January 2014 and December 2024. The search included studies that compared sperm mtDNAcn between infertile men, who were diagnosed with conditions such as oligozoospermia, asthenozoospermia, and teratozoospermia, and normozoospermic fertile controls. Data were pooled using a random-effects model to calculate the standardized mean difference (SMD) with 95% confidence intervals (CIs). Heterogeneity was assessed using the I² statistic.

Results: Seven case-control studies comprising 658 infertile men and 612 normozoospermic controls met the inclusion criteria. The quality of the included studies was moderate to high. The pooled data revealed that sperm mtDNAcn was significantly higher in infertile men compared to fertile controls (SMD = 1.28, 95% CI: 0.81 to 1.75, p < 0.00001). Significant heterogeneity was observed among the studies (I² = 88%, p<0.00001). Subgroup analysis based on infertility phenotype showed a consistently elevated mtDNAcn across oligozoospermia, asthenozoospermia, and oligoasthenoteratozoospermia (OATs). The funnel plot was largely symmetrical, and Egger’s test showed no significant evidence of publication bias (p = 0.12).

Conclusion: This meta-analysis provides strong evidence that an elevated sperm mtDNA copy number is significantly associated with male infertility. This quantitative alteration may serve as a crucial biomarker for assessing sperm quality and spermatogenic dysfunction. The findings suggest that increased mtDNAcn likely represents a compensatory response to underlying mitochondrial defects and oxidative stress, warranting further investigation into its clinical utility for diagnosing and managing male infertility.

Unmasking Occult Malignancy: The Pivotal Role of the Peripheral Blood Smear in the Initial Diagnosis of Chronic Lymphocytic Leukemia

2025-06-24T18:11:46+00:00

Background: Chronic lymphocytic leukemia (CLL) is a common hematologic malignancy in adults, frequently discovered incidentally through routine blood tests due to its often nonspecific clinical presentation. In resource-limited settings, fundamental laboratory investigations are crucial for initiating the diagnostic pathway. This report illustrates the critical diagnostic value of the complete blood count and peripheral blood smear in identifying CLL in a patient presenting with vague constitutional symptoms.

Case presentation: A 43-year-old female with a history of type 2 diabetes mellitus presented to a rural hospital with a one-month history of debilitating fatigue, intermittent fever, and loss of appetite. Physical and radiological examinations were unremarkable. However, initial hematological analysis revealed marked leukocytosis (77,910/μL), mild anemia, and thrombocytopenia (54,000/μL). A peripheral blood smear was pivotal, showing an absolute lymphocytosis of 90% with mature-appearing lymphocytes, pleomorphism, and characteristic smudge cells. Following referral, definitive diagnosis was established through flow cytometry, which confirmed a clonal B-cell population (CD19+, CD5+, CD23+, dim CD20+). Bone marrow examination showed extensive infiltration, and molecular studies revealed an unmutated IGHV gene status, placing the patient in a high-risk prognostic category.

Conclusion: This case underscores that even in the absence of advanced diagnostic facilities, a meticulous evaluation of the peripheral blood smear is a powerful and essential tool for unmasking serious underlying hematologic malignancies like CLL. It enables early suspicion, appropriate patient referral, and timely initiation of management, thereby significantly impacting patient outcomes.

Elevated Fibroblast Growth Factor-23 as an Independent Predictor of All-Cause Mortality, Cardiovascular Events, and Progression to ESRD in Pre-Dialysis CKD: A Systematic Review and Meta-Analysis

2025-06-24T18:11:29+00:00

Background: Fibroblast growth factor-23 (FGF23) is a central hormone in mineral metabolism, with levels rising early in chronic kidney disease (CKD). While its role in the pathophysiology of CKD–Mineral and Bone Disorder (CKD-MBD) is established, its independent prognostic value for adverse outcomes in the pre-dialysis population remains a subject of intense investigation. We aimed to systematically quantify the association between elevated FGF23 levels and the risks of all-cause mortality, cardiovascular (CV) events, and progression to End-Stage Renal Disease (ESRD) in patients with pre-dialysis CKD.

Methods: We conducted a systematic review and meta-analysis following PRISMA guidelines. A comprehensive search of PubMed, EMBASE, and the Cochrane Library was performed for prospective cohort studies published between January 2014 and December 2024 that evaluated the prognostic value of FGF23 in adult, pre-dialysis CKD patients. The primary outcomes were all-cause mortality, a composite of major cardiovascular events, and progression to ESRD. Hazard Ratios (HRs) were pooled using a random-effects model. Heterogeneity was assessed using the I² statistic, and publication bias was evaluated with funnel plots and Egger's test.

Results: Seven prospective cohort studies involving 14,882 patients were included. The analysis revealed that elevated FGF23 was a significant independent predictor for all three outcomes. The pooled HR for all-cause mortality was 1.42 (95% CI: 1.28–1.58; I²=72%), for cardiovascular events was 1.39 (95% CI: 1.21–1.59; I²=78%), and for progression to ESRD was 1.55 (95% CI: 1.35–1.78; I²=65%). The associations remained significant after adjustment for traditional CKD-MBD markers and renal function in the primary studies. Sensitivity analyses confirmed the robustness of these findings.

Conclusion: This meta-analysis provides strong evidence that elevated FGF23 is a potent and independent predictor of all-cause mortality, cardiovascular events, and progression to ESRD in the pre-dialysis CKD population. These findings underscore the potential utility of FGF23 as a key biomarker for risk stratification and suggest it may be a critical therapeutic target to improve outcomes in this vulnerable population.

Systemic Inflammatory Response and Chemotherapy Efficacy in Non-Small Cell Lung Cancer: An Analysis of the Platelet-to-Lymphocyte Ratio as a Predictive Biomarker

2025-06-26T18:12:09+00:00

Background The variable response to chemotherapy in non-small cell lung cancer (NSCLC) necessitates accessible biomarkers for prognostic stratification. The platelet-to-lymphocyte ratio (PLR), a marker of systemic inflammation, is a promising candidate. This study evaluates the predictive value of pre-treatment PLR for chemotherapy response in an Indonesian NSCLC cohort, a population underrepresented in biomarker research.

Methods: A retrospective cohort study was conducted on 59 adult patients with advanced-stage NSCLC at Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia. Patients receiving first-line platinum-based chemotherapy were included. The association between baseline hematological markers and chemotherapy response (Partial Response [PR], Stable Disease [SD], Progressive Disease [PD]) was analyzed using the Kruskal-Wallis test, with Dunn's test for post-hoc comparisons. Receiver Operating Characteristic (ROC) curve analysis was used to determine the predictive accuracy and an optimal cut-off value for PLR.

Results: Statistically significant differences in median PLR were found across all response groups (p-value <0.0001). Post-hoc analysis confirmed a graded response, with the PLR of the PD group being significantly higher than that of both the SD and PR groups. ROC analysis demonstrated good predictive accuracy for PLR in discriminating responders (PR) from non-responders (SD+PD), yielding an Area Under the Curve (AUC) of 0.86. A PLR cut-off of 185 was identified, showing high sensitivity and specificity.

Conclusion: In this cohort, pre-treatment PLR was a statistically robust predictor of chemotherapy response, with a clear dose-response relationship and good predictive accuracy. PLR reflects the crucial balance between tumor-driven inflammation and host immunity, and its elevation signals a biological state that is resistant to standard chemotherapy. This simple, inexpensive biomarker holds considerable potential as a component of a multi-faceted prognostic model for NSCLC.

Giant Gastric GIST Manifesting as Profound Iron Deficiency Anemia: A Case Report of a Diagnostic Pitfall

2025-06-29T18:14:38+00:00

Background: Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, yet they remain rare, particularly in patients under 40. Their clinical presentation is highly variable, often posing a diagnostic challenge. Severe anemia as the initial manifestation is common, but diagnostic confusion with benign lesions on initial biopsy is a significant clinical pitfall.

Case presentation: A 39-year-old male presented with a three-month history of epigastric pain, early satiety, significant weight loss, and profound fatigue. His initial hemoglobin was a life-threatening 3.8 g/dL, consistent with profound iron deficiency anemia. Esophagogastroduodenoscopy (EGD) revealed a large, partially obstructing mass in the gastric corpus. However, initial endoscopic biopsies were paradoxically reported as a benign hyperplastic polyp. In contrast, contrast-enhanced computed tomography (CT) of the abdomen characterized a massive, 9.9 x 7.3 x 13.5 cm heterogeneously enhancing mass suggestive of malignancy. Given the stark discrepancy between imaging and histology, a decision was made for surgical intervention. The patient underwent a total gastrectomy. Final histopathological analysis of the resected specimen, supported by immunohistochemistry, confirmed a high-risk gastrointestinal stromal tumor with a high mitotic rate.

Conclusion: This case underscores the critical importance of maintaining a high index of suspicion for GIST in patients with unexplained iron deficiency anemia, even in younger age groups. It highlights the potential for sampling error with endoscopic biopsies of large submucosal tumors, which can lead to dangerously misleading diagnoses. Clinicians must integrate clinical, radiological, and endoscopic findings to guide management, especially when histopathological results are incongruent with the overall clinical picture.

The Mosaic of Risk in Neonatal Asphyxia: A Systematic Review of Clinical, Placental, and Systemic Predictors

2025-06-30T18:14:46+00:00

Background: Neonatal asphyxia, a critical failure of gas exchange during the perinatal period, remains a primary cause of neonatal mortality and long-term neurodevelopmental disability worldwide, including hypoxic-ischemic encephalopathy (HIE). Its etiology is a complex mosaic of interconnected factors. Understanding this intricate risk profile is essential for developing effective prevention and intervention strategies. The aim of this study is to systematically review and synthesize recent evidence (published 2019–2025) on the spectrum of maternal, fetal, intrapartum, placental, and systemic risk factors associated with neonatal asphyxia.

Methods: This systematic review was conducted following the PRISMA guidelines. A comprehensive literature search was performed in PubMed, ScienceDirect, and Google Scholar for observational studies published between January 1^st, 2019, and April 1^st, 2025. Dual reviewers independently conducted study selection, data extraction, and risk of bias assessment using the Newcastle-Ottawa Scale (NOS). Due to significant clinical and methodological heterogeneity, a narrative synthesis was performed.

Results: The search yielded 870 articles, from which 13 observational studies met the inclusion criteria. The synthesis of these studies revealed a consistent and powerful link between neonatal asphyxia and a wide array of predictors. Key factors included maternal comorbidities (hypertensive disorders), prenatal maternal psychological stress, intrapartum complications (prolonged labor, meconium-stained amniotic fluid), placental pathology (maternal vascular malperfusion, meconium-associated changes), fetal characteristics (low birth weight), and crucial systemic factors, such as maternal immigrant status and sociodemographic disparities. Predictive models developed in two of the included studies demonstrated good discriminative performance in identifying high-risk pregnancies, offering potential for clinical application.

Conclusion: Neonatal asphyxia arises from a complex interplay of risk factors that span the entire perinatal continuum, from pre-conceptual maternal health and systemic inequities to acute intrapartum events. Effective mitigation requires a multi-pronged approach encompassing comprehensive antenatal care that addresses both physical and mental health, vigilant intrapartum monitoring, and systemic efforts to ensure equitable access to high-quality perinatal care. The integration of validated risk prediction tools into clinical practice holds significant promise for reducing the global burden of this devastating condition.

Predictive Value of Circulating Pro-Fibrotic Cytokines for Progression in Idiopathic Pulmonary Fibrosis and Progressive Pulmonary Fibrosis (PPF): A Systematic Review and Meta-Analysis

2025-06-30T18:14:29+00:00

Background: The clinical trajectory of patients with idiopathic pulmonary fibrosis (IPF) and the broader phenotype of progressive pulmonary fibrosis (PPF) is highly variable. Current prognostic models lack precision, highlighting an urgent need for reliable biomarkers. Circulating pro-fibrotic cytokines are implicated in fibrogenesis, but their individual predictive utility for disease progression remains debated. This systematic review and meta-analysis were conducted to synthesize the available evidence and quantify the predictive value of key circulating pro-fibrotic cytokines for disease progression in patients with IPF and PPF.

Methods: A systematic literature search was performed in PubMed, Embase, and Scopus databases for studies published between January 1^st, 2014, and December 31^st, 2024. We included longitudinal cohort studies that evaluated the association between baseline circulating levels of Transforming Growth Factor-beta 1 (TGF-β1), Chemokine Ligand 18 (CCL18), or Interleukin-6 (IL-6) and a composite endpoint of disease progression (all-cause mortality, lung transplantation, or a significant decline in Forced Vital Capacity [FVC]). Hazard Ratios (HRs) and their 95% Confidence Intervals (CIs) were extracted. A random-effects model was used to pool the data. Heterogeneity was assessed using the I² statistic, and publication bias was evaluated with funnel plots and Egger’s test.

Results: The search yielded 1,842 citations, from which seven studies comprising a total of 1,158 patients met the inclusion criteria. Elevated baseline levels of all three cytokines were significantly associated with an increased risk of disease progression. The pooled HR for TGF-β1 (4 studies, 650 patients) was 2.15 (95% CI: 1.55-2.98, p < 0.001), with moderate heterogeneity (I² = 55%). For CCL18 (5 studies, 812 patients), the pooled HR was 1.98 (95% CI: 1.41-2.78, p < 0.001), with substantial heterogeneity (I² = 68%). For IL-6 (3 studies, 515 patients), the pooled HR was 2.41 (95% CI: 1.78-3.26, p < 0.001), with low heterogeneity (I² = 21%). Subgroup analysis suggested a consistent predictive effect across both IPF and non-IPF PPF cohorts.

Conclusion: This meta-analysis provides robust evidence that elevated circulating levels of TGF-β1, CCL18, and IL-6 are potent and independent predictors of disease progression in patients with IPF and PPF. These biomarkers hold significant promise for enhancing patient risk stratification, improving prognostic accuracy, and guiding personalized therapeutic decisions in clinical practice.

The Impact of Intravascular Imaging (IVUS/OCT) Guidance on Preventing In-Stent Restenosis and Improving Long-Term Clinical Outcomes in Complex PCI: A Meta-Analysis

2025-07-03T06:48:46+00:00

Background: Percutaneous coronary intervention (PCI) in patients with complex coronary artery disease is associated with a higher risk of adverse events, including in-stent restenosis (ISR). Intravascular imaging, using either intravascular ultrasound (IVUS) or optical coherence tomography (OCT), has been proposed to optimize stent implantation and improve outcomes, but its definitive role requires comprehensive evidence synthesis.

Methods: We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Major electronic databases (PubMed, EMBASE, Cochrane CENTRAL) were searched from January 2014 to May 2025 for RCTs comparing intravascular imaging-guided PCI with angiography-guided PCI in patients undergoing complex procedures. The primary efficacy endpoint was Major Adverse Cardiovascular Events (MACE), a composite of cardiac death, target-vessel myocardial infarction, and clinically-driven target lesion revascularization. The key secondary endpoint was angiographic ISR. A random-effects model was used to calculate pooled Risk Ratios (RRs) and 95% Confidence Intervals (CIs).

Results: Seven RCTs, enrolling a total of 9,150 patients, met the inclusion criteria. The median follow-up was 24 months. Intravascular imaging guidance was associated with a significant reduction in the risk of MACE (RR: 0.66; 95% CI: 0.55-0.79; p<0.0001) compared to angiography guidance, with moderate heterogeneity (I²=52%). The risk of angiographic ISR was also significantly lower in the imaging-guided group (RR: 0.49; 95% CI: 0.38-0.63; p<0.0001). Furthermore, imaging guidance led to a significant reduction in cardiac death (RR: 0.55; 95% CI: 0.38-0.80) and clinically-driven target lesion revascularization (RR: 0.54; 95% CI: 0.42-0.69).

Conclusion: This meta-analysis provides definitive evidence that the use of intravascular imaging (IVUS or OCT) to guide complex PCI significantly reduces the incidence of long-term major adverse cardiovascular events and in-stent restenosis. These findings support the routine adoption of intravascular imaging as the standard of care to optimize outcomes in this high-risk patient population.

Successful Use of Epidural Anesthesia Following Guideline-Based Anticoagulation Bridging for Hip Surgery in a Patient with Acute Pulmonary Embolism: A Case Report

2025-07-06T18:15:52+00:00

Background: The perioperative management of patients with acute pulmonary embolism (PE) requiring major surgery presents a formidable clinical challenge. Therapeutic anticoagulation, essential for treating PE, is a significant relative contraindication for neuraxial anesthesia due to the risk of spinal hematoma. General anesthesia, however, carries a high risk of hemodynamic collapse in patients with compromised cardiopulmonary reserves. This report describes the successful application of a multidisciplinary, guideline-adherent strategy to manage this complex clinical scenario.

Case presentation: A 56-year-old, obese female (BMI 30 kg/m²) with an extensive history of cardiovascular disease—including hypertensive heart disease, prior myocardial infarction, and an aortic dissection repaired via EVAR—presented with a post-traumatic left hip dislocation. Her presentation was critically complicated by an acute massive pulmonary embolism, diagnosed via echocardiography, which revealed large thrombi in the pulmonary arteries, and confirmed with a chest X-ray showing a Westermark sign. The patient required an open reduction and repair of the hip. A collaborative, multidisciplinary plan was formulated to enable the use of epidural anesthesia. Her anticoagulation with rivaroxaban was stopped five days preoperatively and bridged with a therapeutic infusion of unfractionated heparin (UFH). The UFH was discontinued six hours before the procedure, and surgery proceeded only after confirming normalization of coagulation parameters (INR < 1.5). Epidural anesthesia was successfully administered, providing excellent hemodynamic stability throughout the surgery. The patient was monitored in a cardiac intensive care unit postoperatively, with no neurological or bleeding complications.

Conclusion: This case demonstrates that epidural anesthesia is a viable and potentially superior option for high-risk patients with acute PE, provided that a meticulous, guideline-concordant anticoagulation bridging strategy is implemented. Successful outcomes in such complex cases are predicated on rigorous multidisciplinary planning, patient selection, and vigilant postoperative monitoring. This approach validates current safety guidelines rather than challenging them, showcasing their utility in enabling advanced anesthetic care.