Proceedings Book of International Conference and Exhibition on The Indonesian Medical Education Research Institute

The Economic Burden on Private Hospitals in Treating ICU Vs Non-ICU Patients: Investigating The Financial Gap Between Indonesian Case Base Groups (INA-CBG) Rates and Hospital Billing

Ida Juita Halim — 2025-01-17

Objectives: Indonesia’s healthcare financing relies on a bundled payment system, the Indonesian Case Base Groups (INA-CBG) rates, whereas private hospitals calculate costs using Activity-Based Costing (ABC). This difference can lead to significant financial gaps, especially in ICU and non-ICU care. Methods: A random sample of 93 ICU and non-ICU patients from a private hospital in Bekasi, West Java, was analyzed. We compared the INA-CBG rates and hospital billing for ICU and non-ICU care by considering comorbidities, hospital length of stay (LOS), and mortality rates. Results: The average LOS was longer for ICU patients (6.78 days) than non-ICU (4.98 days). The ICU mortality rate was 20%, while non-ICU was 2.33%. Globally, ICU LOS averages 5-7 days, with a 30% mortality rate. INA-CBG covered only 41.89% of costs for non-ICU patients and 57.14% for ICU patients. Conclusion: This study demonstrates the significant financial strain created by the discrepancy between the INA-CBG claims and the actual costs particularly for private hospitals handling patients with high severity.

Characteristics of Neurophobia Among Medical Students: A Single-Centre Study In Indonesia

Ramdinal Aviesena Zairinal — 2025-01-17

Backgrounds: Neurophobia is a fear of neurology among medical students. Early detection is necessary for prevention and further treatment because neurophobia will have a negative impact on patient care. The objective of this study is to investigate the occurrence of neurophobia among medical students. Methods and Materials: A cross-sectional study using the validated NeuroQ questionnaire was distributed to Faculty of Medicine, University of Indonesia (FMUI) students. Inclusion criteria are age ≥18 years, pre-clinical and clerkship students, able to read, understand, speak Indonesian and answer questions independently, and willing to participate in research. Exclusion criteria are questionnaire data that is not filled in completely. Descriptive and comparative tests were carried out to analyze variables. Results: A total of 89 FMUI students completed the questionnaire with an average NeuroQ score of 17.22 (SD 1.999). Most of the students (73 students; 82%) had a NeuroQ score ≥16 points, 32 students (36%) had neurophobia, and 41 students (46%) had marked neurophobia. Gender was not related to the total NeuroQ score (p=0.815). There was no significant difference between pre-clinical and clerkship students with the total NeuroQ score (p=0.246). Conclusions: Most students experience neurophobia. New strategies are needed to change students' perceptions of neurology.

Effect of Laser Therapy on Inflammation in Pneumonia or Pneumonia Sepsis through the Nf-Kb Regulatory Pathway: A Literature Review Study

Rahmad Rahmad — 2025-01-17

Pneumonia is the most frequent cause of death from infectious diseases is the eighth leading cause of death in the United States. Meanwhile, sepsis and septic shock remain the leading causes of death among critical patients despite decades of significant advances in supportive therapy. A major factor leading to high morbidity and mortality from septic shock is the lack of effective treatment. Many different options have been proposed, among which the prospect of low-level laser therapy is being discussed quite actively. Laser therapy is a viable way to treat pneumonia or sepsis pneumonia. It is known for its benefits as an anti-inflammatory effect that can reduce the levels of pro-inflammatory cytokines, namely IL-6, as well as increase TNFα levels and enhance the balance of inflammatory processes. Additional research is required to confirm the effect of laser therapy on inflammation, especially the NF-kB pathway in cases of pneumonia or sepsis pneumonia in vitro, in vivo and in clinical studies.

Comprehensive Histopathological Properties of Dartos Tissue Associated with Hypospadias Severity and Chordee: A Prospective Study

Putu Angga Risky Raharja — 2025-01-17

Background: The cause of chordee in hypospadias is not fully understood. Dartos fascia resection has been shown to correct penile curvature, suggesting its potential involvement. This study aimed to evaluate the histopathological properties of dartos tissue and their association with hypospadias severity and chordee.Methods and Materials: Dartos tissue samples were collected from 37 children with hypospadias and ten controls undergoing circumcision between March and October 2024. Histopathological analysis using hematoxylin-eosin and Masson’s trichrome staining assessed for collagen, smooth muscle, and vascular density. Assessment and quantification of all histopathological components were blinded. Results: The hypospadias group showed lower collagen density (60.85±6.75% vs. 67.31±4.61%; p=0.003) and higher smooth muscle density (7.34±4.92% vs. 2.51±2.24%; p<0.001) compared to controls, with no significant difference in vessel density. Sub-analysis showed severe chordee was linked to lower collagen density compared to mild (Mean Difference [MD] -6.24±2.41%; p=0.014) and moderate chordee (MD -5.73±2.54%; p=0.031). Conclusions: The dartos tissue in hypospadias patients exhibited lower collagen density and higher smooth muscle density, with chordee severity specifically linked to decreased collagen density.

Case Report: Resuscitation in Intraoperative Third Space Loss in Pediatric Patient with Paracentesis for Massive Ascites

Astrid — 2025-01-17

The accuracy of intraoperative fluid resuscitation is one of the important factors influencing the outcome of surgery. In action conditions with the occurrence of fluid loss from massive "third space loss" in a fast period of time can affect fluid regulation causing ascites re-accumulation hyponatremia, hepato-renal function disorders, to shock. This case report evaluated the success of fluid replacement during massive paracentesis and post-procedure monitoring in the recovery unit. Case description: 5-year-old girl, with massive ascites suspicious of malignancy planned to undergo a paracentesis procedure. The patient had clinical abdominal distention, mild-moderate dehydration, vomiting, and decreased skin turgor. Another abnormality found was a hydrocephalus post-VP Shunt in 2023. The patient was assessed as ASA 3 based on his physical status. Maintenance fluids are calculated to meet basal metabolic needs during surgery based on the Holliday-Segar formula using the 4-2-1 rule. Fluid resuscitation during procedure can be performed with crystalloid, typically 40-60 mL/kg, with a bolus of 10-20 mL/kg to assess fluid responsiveness. In conclusion, fluid administration was carried out using goal-directed fluid therapy, where fluid resuscitation is adjusted based on various hemodynamic parameters.

Nimotuzumab in Combination with Chemoradiation for Locally Advanced Head and Neck Squamous Cell Carcinoma Cancer Patients: A Single-Arm Observational Study

Sakinah Rahma Sari — 2025-01-17

Background: Head and neck squamous cell carcinoma (HNSCC) incidence is predicted to increase in 2030. Most patients with HNSCC are diagnosed as locally advanced (LA), with a worse prognosis even with combination therapy. Nimotuzumab, a humanized-antibody monoclonal against epidermal growth factor receptor (EGFR), was hypothesized to improve LA-HNSCC patients’ survival. This study evaluated the real-world efficacy of adding nimotuzumab to chemoradiation (CRT) in patients with LA-HNSCC survival. Methods:This single-arm retrospective study was conducted in Dr. Cipto Mangunkusumo General Hospital. Patients diagnosed with LA-HNSCC from October 21, 2009, to May 21, 2024 were included. The outcomes assessed were patients’ two-year overall survival (OS), two-year progression-free survival (PFS), and treatment toxicities. Results: From the total of 30 patients included in the analysis, 93.3% were alive, and 86.7% of patients survived disease progression at the end of the two-year observation. The most common side effects were toxicities against the salivary gland (32.7%), mucous lining (21.2%), and skin (30.8%). Conclusions:This single-arm real-world study demonstrated the exceptional efficacy and safety of nimotuzumab in combination with CRT.

Potential Application of Circulating Tumor Cell Markers to Evaluate Response to Chemotherapy in Breast Cancer Patients: A Narrative Review

I Gusti Ngurah Gunawan Wibisana — 2025-01-17

Breast cancer treatment has shifted from conventional therapy to personalized medicine based on heterogeneous and dynamic cancer biology characteristics. Cancer cells can actively spread from the primary tumor into the peripheral circulation as circulating tumor cells (CTC) to initiate cancer progression. The liquid biopsy technique, which includes repeated assessment of the number and molecular profile of CTCs, can be used to detect changes in CTC biological behavior, determine chemotherapy resistance, and predict recurrence at the molecular level. Only 3% of the CTC population, in the form of proliferating CTCs, survive and continue the metastatic process as a result of the immune system, biophysical factors, and chemotherapy. These viable CTCs can be identified through 7-Amino Actinomycin D labels, which bind to DNA in the nucleus. These CTCs have the property of cancer stemness and plasticity through the presentation of epithelial and mesenchymal markers due to the epithelial-mesenchymal transition (EMT) process, which enables CTCs to escape the immune system by expressing PD-L1 as immune checkpoint surface signals. When CTCs are still in circulation, they express MUC1, which binds to endothelium and initiates the metastatic adhesion cascade process. Using a flow cytometry method based on surface and intracellular protein markers, these proliferating CTCs can be identified using a label-dependent approach. The response to chemotherapy can be assessed by analyzing information on the changes in the number and characteristics of breast cancer CTCs based on a combination of EMT, immunological checkpoints, cancer stem cells, cell viability, and endothelial adhesion marker protein.

The Role of Acupuncture and Stem Cell Therapy in Enhancing Stroke Recovery

Imelda Dimara — 2025-01-17

Stroke is an acute neurological disorder caused by disrupted blood flow to the brain, depriving cells of oxygen. From 1990 to 2019, it was the world’s second-leading cause of death and the third-leading cause of combined death and disability. Acupuncture plays a role in stem cell treatment by activating the body's natural recovery processes through physical stimulation, aiding the recovery and rehabilitation of stroke patients. Several studies have explored combining stem cell therapy with acupuncture, yielding promising results in improving patient outcomes. This review assesses the effectiveness of combining acupuncture with stem cell therapy for stroke recovery. Analysis of seven randomized controlled trials shows that both stem cell transplantation and acupuncture contribute to the rehabilitation of stroke patients. When applied together, this combined therapy improves the survival, retention, and functional differentiation of implanted stem cells, creating a synergistic effect that amplifies the benefits of each treatment and compensates for their individual limitations. Key acupuncture points for this combination therapy include GV20, GV14, LI11, ST36, and GV26, with treatment durations ranging from 10 to 22 days.

The Autonomic-Cognition Clinical Correlation in Indonesian Parkinson’s Disease Subjects

Abraham Al Jody — 2025-01-17

Background: Dysautonomia and cognitive impairment are common in PD, affecting quality of life and disease progression. Understanding their connection enables earlier identification of at-risk patients. This study investigates the correlation between dysautonomia and cognitive impairment in Indonesian PD patients. Methods and Materials: This cross-sectional study collected demographic and clinical data, including SCOPA-COG INA and SCOPA-AUT INA. Independent t-tests, Mann-Whitney U tests, Pearson’s, and Spearman’s correlation tests analyzed associations. Results: We recruited 33 PD subjects, primarily male (72.7%) and elderly (63.6%). The median age was 61 years, with 60.6% having a disease duration of at least 5 years and 66.7% at a mild stage. Median levodopa equivalent daily dose (LEDD) was 325 mg. Median SCOPA-COG INA and SCOPA-AUT INA were 24 and 17. Cognitive impairment was present in 45.4%, and dysautonomia in 15.2%. Elderly subjects had lower SCOPA-COG INA (20.19±7.18 vs 27.58±5.98). Cognitively impaired subjects had worse SCOPA-AUT INA (20.6±7.81 vs. 13.89±6.43) and higher LEDD (408.33±140.25 vs. 275.28±134.51). Cognitively impaired subjects had worse SCOPA-AUT INA urinary symptoms (p<0.05). No differences were found between subjects with and without dysautonomia or when divided by median SCOPA-AUT INA. SCOPA-COG INA and SCOPA-AUT INA were significantly correlated (ρ = -0.368, p < 0.05), as were the SCOPA-COG INA memory domain and SCOPA-AUT INA cardiovascular domain (ρ = 0.399, p < 0.05). Conclusion: In Indonesian PD patients, cognitive impairment is significantly correlated with dysautonomia. Age, age at onset, and LEDD were significantly associated with cognitive impairment but not with dysautonomia. Further exploration could enhance understanding of this correlation.

Plasmapheresis and Multidisciplinary Intensive Care Management for Guillain-Barré Syndrome with Prolonged Mechanical Ventilation: A Case Report

Khadafi Indrawan — 2025-01-17

Guillain-Barré syndrome (GBS) is a rare, acute autoimmune peripheral neuropathy often triggered by infections. It leads to rapid-onset muscle weakness and, in severe cases, respiratory failure requiring mechanical ventilation. Plasmapheresis is recommended to reduce circulating autoantibodies that damage peripheral nerves. Guidelines suggest that early initiation of plasmapheresis may improve clinical outcomes, especially in patients with significant motor weakness. A 41-year-old female was referred to the emergency room with progressive ascending bilateral limb weakness, sensory deficits, and urinary incontinence. Symptoms emerged 26 days prior and treatments from previous hospitals were ineffective. Physical examination revealed cranial nerve involvement, proprioceptive disturbance, and reduced deep tendon reflexes. Laboratory tests showed leukocytosis, thrombocytosis, hypoalbuminemia, electrolyte imbalance, and elevated D-dimer. Cerebrospinal fluid analysis was normal. The patient was diagnosed with GBS, intubated by day six post-admission due to respiratory failure and tracheotomized by day eight. The patient was admitted to the intensive care unit. Plasmapheresis, initiated on day 17, improved motor strength after three sessions spaced over 10 days. However, delayed intervals between sessions and limited access potentially impeded the recovery process. Despite improvements, the patient remained ventilator-dependent and require multidisciplinary interventions. Inhalation therapy, enteral feeding, physical rehabilitation, and psychiatric interventions were administered. The family was informed of potential long-term ventilator dependency and home care preparation. This case underscores the importance of timely plasmapheresis and coordinated, multidisciplinary ICU management in severe GBS, encompassing neurological treatment, respiratory care, nutrition management, physical rehabilitation, and psychological support for the patient and their caregivers.

Exploring the Relationship Between Comprehensive Respiratory Assessment and Intra-Extracardiac Biomarkers in Heart Failure Rehabilitation

Kevin Triangto — 2025-01-17

Introduction: Heart failure with reduced ejection fraction (HFrEF) is well-known as a systemic disease that involves cardiac and extracardiac issues, with respiratory function playing on of the key role in rehabilitation prognosis. Biomarkers such as soluble suppression of tumorigenicity 2 (sST2), myostatin, miRNA-133, and NT-proBNP indicate disease progression. Notably, sST2, which is also produced by the lungs, predicts heart failure outcomes. This study examines the relationship between comprehensive respiratory assessments (e.g., diaphragmatic ultrasonography, spirometry) and intra-extracardiac biomarkers to improve rehabilitation strategies. Methods: Sixty-nine HFrEF patients underwent respiratory evaluations, including diaphragmatic ultrasonography, spirometry, chest expansion measurements, and a six-minute walking test (6MWT). Biomarkers assessed were sST2, myostatin, miRNA-133, and NT-proBNP. Associations between respiratory parameters and biomarkers were analyzed using t-tests and correlation analyses. Results: The median age was 56 years, and 33 (47.82%) of the subjects had diaphragmatic dysfunction, resulting in poorer 6MWT performance (378.03±58.15 m vs 409.75±63.65 m, p=0.017) and other parameters. Superior chest expansion negatively correlated with sST2 (r=−0.387, p=0.001) and positively with miRNA-133 (r=0.442, p<0.001). Similar results were found for inferior chest expansion. No significant correlations were observed for other biomarkers. Conclusion: This study highlights strong associations between chest expansion and sST2/miRNA-133, suggesting that incorporating respiratory assessments and training into HFrEF rehabilitation could enhance outcomes by addressing cardiorespiratory insufficiencies. Given sST2's predictive value for heart failure prognosis, these findings support a multi-component rehabilitation strategy incorporating respiratory training, such as aerobic and inspiratory muscle exercises, to enhance cardiopulmonary outcomes. This integrated approach offers promise for future HFrEF rehabilitation protocols.

Anesthetic Management in Atrial Septal Defect with Small Left Ventricle and Pulmonary Hypertension

Angela Christina — 2025-01-17

Atrial septal defect (ASD) can remain undiagnosed throughout adulthood and frequently develop complications. We report major challenges caused by late onset ASD including small left ventricle and pulmonary hypertension. We report the successful management of ASD closure in a 24-year-old man presented with a large secundum ASD with a diameter of 57 mm and bidirectional shunt, and a small left ventricle (LV). Moderate mitral regurgitation (MR) and tricuspid regurgitation (TR) were also found. Right heart catheterization showed high flow, low resistance pulmonary hypertension (PH). Despite surgery went well with short period of cardiopulmonary bypass (CPB) time. We found decreased function in both ventricles when weaning from cardiopulmonary bypass machine, which required epinephrine 0.2-0.4 mcg/kg/min, milrinone 0.375 mcg/kg/min, norepinephrine 0.05 mcg/kg/min, and dobutamine 5 mcg/kg/min to stabilize the hemodynamics. Post-operative transesophageal echocardiography (TEE) showed a left to right shunt small ASD with a diameter of 2 mm, trivial TR, moderate MR, no LV D-Shape, and small LV. The ejection fraction was 59%, with a high level of hemodynamic support, cardiac output of 3.6 l/m, and stroke volume of 41 mL. The patient was able to be weaned off hemodynamics supports and ventilator within five days. The patient was discharged 12 days after surgery. The management of ASD can be challenging in the presence of small LV, pulmonary hypertension, and arrhythmia.

Case Report: Excision of Left Maxillary Osteosarcoma in a 16-Year-Old Boy Under General Anesthesia with Difficult Airway Procedure

Listyo Lindawati Julia — 2025-01-17

Osteosarcoma is a rare, malignant bone tumor commonly found in adolescents, affecting the long bones. Maxillary involvement, though less frequent, can present significant challenges in surgical resection and anesthetic management. This case describes a 16-year-old male with a maxillary osteosarcoma sinistra undergoing excision under general anesthesia, performed with difficult airway intubation devices. Endotracheal tube (ETT) insertion via nasal intubation is performed with awake intubation. At the end of surgery, the patient was extubated uneventfully and referred to ICU.

Multidisciplinary Approach of Neonatal Intensive Care in Bam Syndrome: A Rare Case Report

Tabina Putri Humaira — 2025-01-17

Bosma Arhinia Microphthalmia Syndrome (BAMS) is a very rare condition characterized by eye defects, a complete absence of nose, and hypogonadotropic hypogonadism, which is caused by a genetic mutation in the gene SMCHD1 located in chromosome 18p11. Fewer than 100 cases were reported globally over the previous century, and only a few clinical studies have discussed its occurrence and management in Indonesia. Therefore, there are no clear guidelines about the management of neonates with BAMS due to its rarity. This study reported a BAMS neonatal patient with atresia choana, microphthalmia, pectus excavatum, facial dysmorphic, unspecified hearing loss, and hydronephrosis. An MSCT scan of the patient revealed an absence of cavum nasi, undeveloped paranasal sinus, microcephaly, abnormal size of bulbus oculi sinistra, and the presence of cleft palate. This condition prompted the patient to require intensive medical support early in life due to breathing and feeding difficulties, as well as the need for several examinations on many aspects to determine the extent of the syndrome which has different characteristics for each individual. Therefore, a multidisciplinary approach is necessary to provide the most suitable management for each neonate with BAMS. This case report described the patient’s neonatal intensive care and management with a multidisciplinary team which includes a neonatologist, an ophthalmologist, an otorhinolaryngologist, a radiologist, an endocrinologist, and an oral and maxillofacial surgeon. This study aims to improve the knowledge of BAMS patient management in the future since there are no standardized guidelines or treatment protocols, and the case is rarely studied.

Postoperative Esophagectomy Management in Intensive Care Unit: Cooperation and Comorbidities

Anasthasia D. Sutedja — 2025-01-17

Esophagectomy remained a high-risk and high-mortality surgery for patients with esophageal carcinoma, with a rate of morbidity of up to 65% and a 30-day mortality of up to 4%. Although many have described intraoperative management of such patients, long-term and comprehensive analysis of postoperative anesthesia management was limited due to chronic and arduous follow-up throughout intensive care. We present a case of a 64-year-old male in the intensive care unit (ICU) after undergoing esophagectomy and gastric pull-up performed by digestive and thorax surgeons. The patient was found with sputum retention, inadequate cough, and desaturation after stepping down to the ward. Reintubation was done, and the patient was readmitted to ICU. During the second admission, relaparotomy successfully repaired the leakage, but trial extubation was unsuccessful. The patient developed sepsis due to ventilator-associated pneumonia. Tracheostomy was considered and dismissed as there was a high risk of descending pulmonary infection. The patient was signed up for palliative care, and during his last days, the family decided not to resuscitate him. After one month of intensive care, the patient succumbed to his illness. Optimizing patient care in the ICU should include fluid, nutrition, pain, and respiratory management. Multispecialty team approach was essential, with an anaesthesiologist acting as a moderator in managing pain, stress, hemodynamics, ventilation, enhanced recovery, early detection, and management of complications.