Background: Previous studies have demonstrated the feasibility of a remifentanil–propofol (RP) mixture use in sedation for medical examinations. However, delivery of an RP mixture by target-controlled infusion (TCI) for colonoscopy has not been described. Here, we investigate the appropriate proportion of RP mixed regimens, prepared in two different ratios for colonoscopy. Methods: A retrospective study including patients who received a colonoscopy between May 2018 and January 2019 was conducted. Group 1 and Group 2 were, respectively, administered a mixture of RP at concentrations of 2.5 μg/mL-10 mg/mL and 5.0 μg/mL-10 mg/mL by adjusting a TCI pump with Schneider model to keep the Observer's Assessment of Alertness/Sedation scale between 1 and 2. The primary outcome was to determine the appropriate proportion of RP for the procedure in terms of hemodynamic conditions and adverse events. The secondary endpoints included the total dosage of anesthetics and total times of TCI pump adjustments. Results: A total of 120 patients in Group 1 and 116 patients in Group 2 were eligible for analysis. Several parameters were significantly different between Group 1 and Group 2, with Group 1 having a higher respiratory rate, a lower end-tidal carbon dioxide pressure, fewer patients with hypotension (mean arterial pressure <60 mmHg; 1 vs. 7, P = 0.033) or apnea with desaturation (peripheral oxygen saturation < 90%; 1 vs. 12, P = 0.001), more propofol consumption (162.4 ± 49.6 mg vs. 130.3 ± 48.8 mg, P < 0.001), less remifentanil consumption (40.6 ± 12.3 μg vs. 65.1 ± 24.4 μg, P < 0.001), and fewer total times of TCI pump adjustment (1 [0–1] vs. 1 [1–2], P < 0.001), as compared to Group 2. Conclusions: In colonoscopy, TCI with an RP mixed regimen prepared in the proportion of 2.5 μg/mL-10 mg/mL with propofol Schneider model target 2.5–3.0 μg/mL provided appropriate hemodynamic conditions, sufficient sedation and analgesia, and less adverse events.

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Multimodal analgesia (MMA) strategy is widely used for anesthesia and perioperative pain management. MMA provides continuous and satisfactory postoperative pain management, subsequently prevents patients from the development of chronic postsurgical pain (CPSP). We report a 55-year-old female patient with impingement syndrome and provide an MMA protocol for rotator cuff surgery with satisfactory pain management, which combines oral nonopioid analgesics, long-acting dinalbuphine sebacate (Naldebain ER Injection) and ultrasound-guided peripheral nerve blocks. This protocol modifies the timing of long-acting dinalbuphine sebacate injection, thus decreases dinalbuphine sebacate associated side effects. The ultrasound-guided nerve block provides enough time for long-acting dinalbuphine sebacate to reach the therapeutic level. Moreover, multiple oral analgesics act as preventive analgesia, which further enhances postoperative long-acting dinalbuphine sebacate analgesia. We suggest that this MMA protocol can be performed successfully in patients receiving shoulder surgery to provide good pain management and inhibits the consequent CPSP. We believe this MMA protocol may also be used in other types of surgery.

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Primary squamous cell carcinoma of the thyroid gland (PSCCT) is a rare malignancy seen in <1% of all primary malignancies of the thyroid gland, and it carries a poor prognosis. The patient usually presents with metastasis at the time of the presentation. Here, we report two cases of PSCCT. On clinical assessment, both the cases were considered as suspicious for malignancy. Radiological investigations showed a nodular lesion measuring 5 cm × 3.5 cm × 2 cm with internal vascularity in the first case while large multilobulated mass measuring 8.4 cm × 8.3 cm × 5.6 cm compressing the surrounding structures in the second case. Both of the patients underwent surgical interventions. The final diagnosis of PSCCT was made after thorough investigations excluding the possibility of primary focus elsewhere in the body. Both patients succumbed to death within 8 months. We report these two cases of PSCCT due to the rarity of this entity in literature.

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Mitochondrial disease, which was previously considered as a rare clinical entity, is presently identified as a significant cause of a broad range of muscle, cardiac, neurologic, as well as endocrine disorders. One of the rare mitochondrial diseases is Kearns–Sayre syndrome (KSS). Here, we present a case of a 22-year old male with progressive bilateral blepharoptosis of 5-year duration, which was painless and not associated with diplopia or vision loss. There were no similar abnormalities in his family. On neurologic examination, prominent bilateral blepharoptosis was evident with restriction of ocular movements. There was a salt-and-pepper pigmentary retinopathy with normal optic disks and vessels. Cerebrospinal fluid protein concentrations were increased, and a diagnosis of KSS was made.

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Unilateral patellar tendon ruptures are a common complication that can occur frequently among athletic patients below the age of 40; however, bilateral spontaneous patellar tendon ruptures are rare and still not fully understood. We present a case of bilateral patellar tendon rupture in a 37-year-old patient with a history of systemic lupus erythematosus (SLE) who had concomitant chronic renal failure. Primary repair utilizing the Krackow interlocking stitch technique provided excellent outcomes in both knees. This case highlights the rare occurrence of spontaneous bilateral patellar tendon rupture in patients with SLE and chronic renal failure.

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Background: The grade of dysplasia on cervical pap smears may be indicated by micronucleus (MN) scoring, much like cancers of the oral cavity, urinary bladder, and esophagus. Methods: Cross-sectional study. MN scores of 106 subjects comprising all major diagnostic categories included in “The Bethesda system, 2014 for reporting cervical pap smears” were taken. High grade squamous intraepithelial lesion (HSIL) and Invasive carcinoma (IC) were further grouped as “high-risk” and the rest, “low-risk” to construct receiver operating characteristic (ROC) curve to seek a cutoff delineating the two classes. Analysis of variance was used to determine the significance of differences in MN scoring between the various groups. Results: The difference of mean MN scores of HSIL (9.4) and IC (10.7) was significant from the low-risk group but not within themselves. A huge difference in MN scores between low-grade squamous intraepithelial lesions and HSIL is notable. The difference of mean age was significant between high and low-risk groups. ROC curve delivered a cutoff of 5.15 to distinguish between the two categories with 85.7% sensitivity, 97.2% specificity, and 93.3% accuracy. Conclusions: Sequential and significant increase of MN score from low- to high-grade dysplasia is established by the current study. A cutoff of 5.15 MN scores adequately detects HSIL and IC. Despite its performance, MN scoring is time-consuming, labor-intensive, and strenuous process, which might make it difficult to impose on laboratories and pathologists.

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Background: Analysis of O⁶-methylguanine DNA methyltransferase (MGMT) methylation considers as a predictive marker for chemotherapy sensitivity. Mutation in BRAF and Kirsten RAt sarcoma viral oncogene homolog (KRAS) gene is also crucial in colorectal tumorigenesis which is associated with primary resistance to epidermal growth factor receptor therapy. This study was aimed to identify the methylation of MGMT gene and to detect BRAF and KRAS mutations in colorectal cancer (CRC). Methods: The methylation level of MGMT gene was measured by pyrosequencing from bisulfite-treated DNA. Direct sequencing was performed to identify BRAF and KRAS mutations. The expression of MGMT was evaluated by immunohistochemistry. Results: Analysis of MGMT methylation showed that 15 (30%) samples were classified as Group 1 (mean range ≥27%, methylated), 27 (54%) samples were Group 2 (mean range: 10%–26%, intermediate), and 8 (16%) samples were Group 3 (mean range <10%, unmethylated). Direct sequencing showed no mutation (V600E) of BRAF gene and 11 (22.5%) samples with mutated KRAS which was 9 (18.4%) and 2 (4.1%) samples mutated at codons 12 and 13, respectively. Immunohistochemistry results showed that from 29 methylated MGMT, 19 (65.5%) samples had low expression and 10 (34.5%) samples had high expression of MGMT. Conclusions: Altogether, our result showed that most of the samples showed MGMT methylation and it tended to decrease the expression of MGMT. In addition, BRAF and KRAS mutations were exclusively occurred. These data give a contribution to the situation of MGMT methylation and BRAF and KRAS mutations in CRC patients in Denpasar whose data are limited. Further studies are needed to identify the key molecular pathway of CRC that will be potential for CRC management.

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Background: Determine factors influencing the continuance intention of the Quit & Win smartphone app based on the technology acceptance model (TAM). Methods: This cross-sectional study was conducted on volunteer military personnel who smoke. Participants were asked to download a smoking cessation app and use it for 15-20 minutes before completing a questionnaire. Items in the questionnaire included those on demographic information, perceived usefulness, perceived ease of use, and continuance intention. The structural equation modeling (SEM) was applied to evaluate the TAM. Results: A total of 90 participants were included in this study. The model accounted for 0.81 of the variance in participants' intention to continue using the app. The results revealed that perceived usefulness affected continuance intention, self-efficacy affected perceived ease of use, and perceived ease of use affected perceived usefulness. Conclusions: This study applied the TAM to determine the factors influencing the continuance intention to use a smoking cessation app and revealed that perceived usefulness is the most crucial factor affecting continuance intention. Therefore, future designers of smoking cessation apps shall improve perceived usefulness to increase the continuance intention of users.

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