Bethesda Hospital

Hypertension is the most common chronic non-infectious disease, with an estimated 1.56 billion people suffering from hypertension by 2025. Data from Ngesti Waluyo General Hospital also shows that hypertension is the highest case for outpatient care in the first quarter of 2025. Patients with hypertension often experience headaches that can cause sleep disturbances, anxiety, and emotional instability that can affect the patient's quality of life, so therapy is needed to reduce headaches and lower blood pressure. Nonpharmacological therapy performed by nurses independently is Swedish foot massage which can increase endorphin production to reduce headache pain and lower blood pressure. The study describes the implementation of Swedish Foot Massage to reduce headache and blood pressure in hypertensive patients using a case report approach. The results showed that the patient experienced a decrease in pain scale after therapy from a scale of 5 to 1, and a decrease in mean systolic blood pressure from 140.66 mmHg to 127mmHg, and mean diastolic from 90 mmHg to 87 mmHg. Swedish foot massage therapy is effective in reducing headache pain scale and blood pressure in hypertensive patients.

Abstract IntroductionAmyotrophic lateral sclerosis (ALS) is a rare, progressive neurodegenerative disease involving upper and lower motor neurons. However, the scarcity of However, the scarcity of pharmacotherapy choices pose significant challenges in managing ALS. This study aims to highlight the realities of ALS management in Indonesia.Case ReportA 39-year-old woman presented with dyspnoea and limb weakness in January 2024, which progressed to tetraparesis by July 2025. Her vital signs included a blood pressure of 102/74 mmHg, heart rate of 75 bpm, respiratory rate of 27x/min, temperature of 36°C, and oxygen saturation of 93% (room air). Neurological examination revealed tetraparesis (333/333; 111/111), with bilateral thenar-hypothenar atrophy. Physiological reflexes were diminished, and pathological reflexes were positive. The patient was admitted in early July with similar symptoms. Special examinations via lumbar puncture, magnetic resonance imaging (MRI), and spine CT scans revealed normal results. TTR-amyloidosis antibody, ANA, and anti-TPO test results were negative. Sural nerve biopsy indicated neuropathy. Electromyography revealed denervation from the cervical to lumbosacral regions, leading to a diagnosis of definite ALS (El Escorial criteria, King's grade 3). The ASLFRS-R score was 20. The patient received Riluzole 2x50 mg (from Germany) along with psychological support, physiotherapy, home care, and palliative treatment.Discussion and ConclusionThis case highlights the limited access to diagnostic tests and management for ALS in Indonesia. Edaravone and riluzole are the only available symptomatic treatments in Indonesia; unfortunately, their distribution are limited. Palliative and supportive care are currently the only options available for ALS patients in Indonesia. Uncertainty regarding the outcome affects the patient's quality of life.

Abstract Three Interlinked Electronic Register (TIER.Net) is South Africa’s national electronic HIV patient database, used to monitor antiretroviral therapy (ART) delivery and laboratory results. However, few published evaluations have quantified TIER.Net data quality relative to national sources. We aimed to evaluate how well decentralised ART referral and laboratory result data are captured in TIER.Net. We conducted a retrospective analysis comparing TIER.Net to national electronic health systems. For decentralised ART, we used de-identified data from 56 clinics in eThekwini (2020-2023) and compared the annual number of TIER.Net decentralised ART referrals to ART prescriptions in the Synchronised National Communication in Health (SyNCH) database. For laboratory data, we used de-identified records from 103 clinics in KwaZulu-Natal (2015-2022) and compared the annual number of TIER.Net viral load (VL) and CD4 tests with the number in National Health Laboratory Service (NHLS). The proportion of SyNCH decentralised ART prescriptions and NHLS VL and CD4 counts captured in TIER.Net were calculated by clinic, and trends were assessed using linear mixed-effects models (LMMs). The median proportion of SyNCH decentralised ART prescriptions captured in TIER.Net was 104.4% (IQR: 99.85-115.1 % ) in 2020 and 102.44% (IQR: 100.5-104.5%) in 2023. The LMM estimated an annual decrease of 2.8% (95% CI: -4.8; -0.9%). The median proportion of NHLS VLs captured in TIER.Net was 85.7% (IQR: 70.0-97.9%) in 2015 and 99.1% (IQR: 94.5-102.5%) in 2022. The LMM estimated an annual increase of 1.8% (95% CI: 1.4-2.1%). The median proportion of NHLS CD4s captured in TIER.Net was 74.3% (IQR: 63.9-85.4%) in 2015 and 80.1% (IQR: 68.4-89.1%) in 2022. The LMM estimated no statistically significant trend over time (-0.08%, 95% CI: -0.6; 0.4%). Reassuringly, capture of TIER.Net for decentralised ART and VL data has improved to near 100%, but CD4 count capture remains sub-optimal, highlighting strengths and limitations of conducting analyses with this critical HIV programme database.

Abstract Advanced HIV disease (AHD), treatment interruption and viraemia remain key challenges to effectiveness of HIV programmes in South Africa. Understanding the trends of these measures and their variation across geographic regions can inform more targeted and responsive interventions. We conducted a retrospective cohort study using routine, de-identified data from TIER.Net, a national HIV electronic register. We curated data from 116 primary care clinics in eThekwini, uMgungudlovu, and uMkhanyakude Districts in KwaZulu-Natal province. We included people living with HIV aged ≥16 years, who initiated or collected ART between 1 July 2018 and 30 June 2023. We examined trends in annual proportion of AHD, treatment interruption and viraemia, and mapped the clinic-level proportions of these outcomes using inverse distance weighted interpolation maps. Among 123,473 clients initiating ART with CD4 count measurements, the overall prevalence of AHD remained stable over the period (20.0%-22.2%). There was an overall decline in treatment interruptions from 13.2% to 11.3% among the 544,066 clients who had scheduled visits. Of the 446,899 clients who had viral load results, overall viraemia ≥50 copies/mL increased from 12.9% to 20.2%, whereas viraemia ≥1000 copies/mL remained stable at approximately 6%. Spatial analyses highlighted geographic disparities in AHD, treatment interruption, and viraemia across and within the districts. While declines in treatment interruptions are promising, the persistence of AHD and viraemia (≥50 copies/mL) require further investigation and highlight ongoing challenges for HIV control. The observed spatial variation across districts underscores the need of geographically tailored interventions to strengthen programmatic effectiveness, particularly in hyper-endemic settings like KwaZulu-Natal.

We present the case of an 81-year-old patient, who was transferred to our department for diagnostic work-up and treatment of hemoptysis of the right lung. Two-phase contrast-enhanced chest CT revealed filling defects in right upper lobe and middle lobe pulmonary artery during the pulmonary-artery phase who vanished in the subsequent aortographic phase, consistent with systemic-artery-to-pulmonary-artery fistulas (SA-PAFs) of right bronchial artery mimicking pulmonary embolism. Selective bronchial catheter-arteriography confirmed bronchial SA-PAFs and bronchial artery embolization was performed effectively and without complication. For the best of our knowledge, this is the first case of a bronchial systemic-artery-to-pulmonary-artery-fistula mimicking PE directly correlated and proved with bronchial artery angiography.

Rectovesical fistula (RVF) is defined as an extra-anatomic communication between the rectum and bladder. A multitude of approaches and techniques have been described; however, there is a lack of consensus regarding which of these procedures is the optimal cost-effective, appropriate treatment to perform. We describe the repair of a persistent RVF via a transperineal approach, utilizing the dartos fascia flap, a technique with minimal description in the literature.

This study evaluated the safety and efficacy of an enzymatic bromelain-based debridement (BBD) agent (NexoBrid®) in children with deep thermal burns. We conducted a multicenter, open-label, parallel design, randomized controlled trial at 36 burn centers in Europe, US, Israel and India. Main eligibility criteria included children 0-18 years old, suffering from deep thermal burns covering 1-30 % of their total body surface area. Patients were randomized to either BBD or standard of care (SOC) eschar removal methods. Primary endpoints included time to complete eschar removal (superiority), percentage of wound area surgically excised (superiority) and blinded 12 months follow-up assessment of cosmesis and function using the Modified Vancouver Scar Scale (MVSS, non-inferiority). One hundred and forty-five children were enrolled between 2015 and 2020 (last patient completed 12-month follow-up on April 2021); 72 were randomized to BBD and 73 to SOC. All three primary endpoints of the study were met. The median time to complete eschar removal was significantly lower in the BBD arm (1 vs. 6 days, P < 0.001). The mean [SD] percentage of wound area surgically excised was also significantly lower in the BBD arm (1.5 % [12.1 %] vs. 48.1 % [46.6 %], P < 0.001). Mean [SD] 12-month MVSS scores were 3.8 [2.9] and 4.9 [3.3] in the BBD and SOC arms, respectively (non-inferiority demonstrated at P < 0.001). The incidence of adverse events was similar between the groups, and there were no significant safety issues or deaths during the trial. BBD was demonstrated to be safe and effective in children. Its use lead to a shorter time to complete eschar removal, a reduction in excisional surgery and non-inferior cosmesis and function results as compared to SOC eschar removal methods.

Abstract Background Gamification has been discussed in various settings of medical education, highlighting its potential to increase engagement and boost motivation. Tools like "points," "badges," or "leaderboards" are known to work well in any area of learning. Purpose In a mid-sized hospital, creating a structured echocardiography training curriculum for internal medicine residents can be challenging due to rotating teachers and students and a general lack of resources. A self-guided training curriculum using concepts from computer gaming seemed appropriate to engage and motivate trainees. Methods We set up a self-organized training program where residents without prior echocardiography skills could progress through a step-by-step curriculum to gain basic echocardiography expertise. After a brief introductory session and distribution of a paper curriculum, trainees were included in the daily echocardiography schedule. They could advance to higher "levels," each allowing them to use more advanced tools, such as spectral Doppler or the Simpson method ("weapons"). To complete each level, trainees had to answer theoretical questions, analyze echo loops stored on a network drive, and perform a short hands-on exam under the supervision of a senior cardiologist ("final boss"). We also published "highscores" regularly, highlighting residents with the most exams during a given interval. To enhance the skills of our senior cardiologists, we developed "challenges" introduced several times per year, covering techniques like lung ultrasound or pulmonary vein Doppler. Results The process was evaluated through an anonymous online questionnaire completed by about half of the residents. The training concept received positive feedback, but the results were overshadowed by the lack of time residents were able to allocate to perform echocardiographies at all. Additionally, the amount of in-depth personal supervision was criticized. Conclusions Although our echocardiography education concept did not fulfill all our expectations, developing a self-organized echocardiography training curriculum using gamification elements seems promising. Future refinements should include more supervision and regular training and briefing of all individuals involved in the process. Even more important seems to be a general allocation of resources to echocardiography training. Since medical education is vital for ensuring treatment quality and staff satisfaction, more research is necessary to test and compare different teaching approaches scientifically. In the future, an online or mobile-app based training platform could serve as a hub for echocardiography teaching, where institutions and learners register, access teaching resources, and track their progress, using gamification tools to motivate and engage trainees. Training scheme Challenge.jpg

Stevens-Johnson syndrome (SJS) is a life-threatening condition resulting from a severe reaction to the use of certain drugs, with the highest incidence found in children. It manifests as a triad of skin, orifice, and ocular mucosa lesions. Ocular manifestations most commonly involve the conjunctiva and eyelids. This case report further discusses symblepharon as an ocular manifestation of SJS. A case report. A 10-year-old boy came with decreased vision and an inability to produce tears. On examination, pseudomembranous conjunctivitis was found in both eyes, granulation tissue in the right eye, and erosion of the corneal epithelium in the left eye. The posterior segment could not be assessed due to symblepharon. It was known that the patient previously experienced SJS in early 2023. Symblepharectomy was carried out with the indication of separate adhesions caused by symblepharon. Symblepharon is a rare, severe ocular manifestation of SJS (Stevens-Johnson syndrome). Previous studies found that severe ocular occurred in around 4% and 11.1% of cases. This happened because of ongoing chronic inflammation due to SJS. Symblepharon is an adhesion of eyelids and bulbar conjunctiva, which can harm the eye because it can cause cicatricial then disruption of the tear film meniscus, limit eye mobility, and cause visual disturbances. Symblepharon occurs due to prolonged inflammation, which can structurally and functionally disrupt the eye. Early discovery of symblepharon, especially in severe manifestations of SJS, can help prevent further damage to the eye.