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   Table of Contents - Current issue
October-December 2019
Volume 31 | Issue 4
Page Nos. 201-295

Online since Monday, September 16, 2019

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Effect of Vitamin D supplementation during pregnancy on maternal and perinatal outcomes p. 201
Tzu-Hui Lo, Ting-Yu Wu, Pei-Chen Li, Dah-Ching Ding
Vitamin D deficiency is common globally with a higher prevalence in women, especially during pregnancy. Among the pregnant women, Vitamin D deficiency was reported up to 80% in the Asian group. Vitamin D deficiency was related to a higher risk of maternal complications including preeclampsia, impaired glucose tolerance, and cesarean section rate, and neonatal complications including low birthweight, neonatal hypocalcemia seizure, and impaired skeletal, lung and immune development. There were no data supporting Vitamin D deficiency screening routinely in pregnancy regarding cost-effectiveness or health benefits. The measurement of Vitamin D in the high-risk group of women is necessary. Subsequent supplement with Vitamin D with and without calcium supplement during pregnancy had been statistically significantly reported to decrease the risk of preeclampsia, preterm birth, and low birth body weight. However, due to a lack of studies, the strategies of dietary and nutritional supplement for fetal growth restriction prevention are not statistically effective and are not yet recommended. The present review is to provide an overview of the clinical and the experimental evidence of Vitamin D deficiency-related complication and review of available options for the prevention and management of these complications.
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Diagnosis and interventional pain management options for sacroiliac joint pain p. 207
Ching-Wei Chuang, Sheng-Kai Hung, Po-Ting Pan, Ming-Chang Kao
The sacroiliac (SI) joint is among the most common sources of chronic low back pain, accounting for 15%–30% of patients presenting chronic low back pain. The complex anatomic structures, nerve innervation, and functional biomechanisms of the SI region make it challenging to diagnose and treat the SI joint as a pain source. In addition to physical therapy and medication for treating SI joint pain, multiple interventional measures including steroid injection, radiofrequency ablation, prolotherapy, and SI joint fusion have been proposed with various efficacies. This article describes the etiology, risk factors, and diagnostic methods as well as the different treatment modalities, focusing on interventional pain management options for patients suffering from SI joint pain.
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Fill the gap between traditional and new era: The medical educational reform in Taiwan p. 211
Wei-Chun Cheng, Tsung-Ying Chen, Ming-Shinn Lee
The 7-year medical education program in Taiwan has been established since 1949. More than 60 years later, many medical professionals have observed and voiced its deficiencies following the outbreak of severe acute respiratory syndrome. The deficiencies are three-fold: (1) specialties are excessively institutionalized, (2) students engage in passive learning and memorization, and (3) passing one written national examination serves as the means of granting permanent physician qualification. The situation has aroused concerns and discussions among medical professionals and educators for a new medical education program. Authorized by the Conference of Deans of Medical Schools in Taiwan, Prof. Chyi-Her Lin assembled a team for planning medical curricular reform. Subsequently, Prof. Shan-Chwen Chang organized a task force team which has been monitoring the new 6-year program since 2013. The aims of medical reform by Prof. Lin are (1) to eliminate the specialty training part, (2) to use innovative teaching methods to motivate students to learn proactively, and (3) to implement competency-based medical education. Now, the first class of physicians will enter the workplace in 2019, subject to various clinical challenges.
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In vivo assessment of endothelial function in small animals using an infrared pulse detector p. 217
Cyuan-Cin Liu, Wei-Min Liu, Hsien-Tsai Wu, Chien-Hsing Wang, An-Bang Liu
Objective: Endothelial dysfunction is the earliest change in atherosclerosis. Flow-mediated dilatation (FMD) is used to assess endothelial function in humans. However, this assessment is not easy in small animals. This study demonstrated the reliability and reproducibility of a proposed instrument for in vivo assessment of FMD in a rodent model using infrared pulse sensors. Materials and Methods: We used 24 adult male Wistar Kyoto rats randomly divided into three groups. FMD was measured under continuous infusion of normal saline followed by intra-arterial infusion of acetylcholine (Ach; n = 8), sodium nitroprusside (SNP; n = 8), or N-nitro-L-arginine methyl ester (L-NAME; n = 8). Results: The dilatation indices (DIs) of all three groups were similar before application of the vasoactive agents (1.82 ± 0.46, 1.81 ± 0.44, and 1.93 ± 0.40, P = 0.877, by one-way analysis of variance). The DI was significantly increased during infusion of Ach (2.97 ± 1.03 vs. 1.82 ± 0.46, P = 0.015), unchanged during infusion of SNP (1.81 ± 0.44 vs. 1.98 ± 0.40, P = 0.574), and attenuated during infusion of L-NAME (1.91 ± 0.40 vs. 1.42 ± 0.35; P = 0.028). Conclusion: The results of this study correlated well with those of human studies, suggesting that this method can be used for in vivo evaluation of endothelial function in small animals.
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Acinetobacter baumannii and methicillin-resistant Staphylococcus aureus in long-term care facilities in eastern Taiwan p. 222
Hsin-Chi Tsai, Tung-Yi Huang, Jung-Sheng Chen, Wen-Jen Chen, Chong-Yen Lin, Bing-Mu Hsu
Objective: The prevention of infections is crucial in long-term care programs. Investigations of the occurrence and sources of pathogens in long-term care facilities (LTCFs) are still lacking, especially in eastern Taiwan. In this study, we conducted a surveillance of two common pathogens, Acinetobacter baumannii (AB) and methicillin-resistant Staphylococcus aureus (MRSA), in LTCFs in Hualien. Materials and Methods: Pathogenic assays including isolation, identification, and antimicrobial susceptibility tests were conducted for AB and MRSA at LTCFs in Eastern Taiwan. Staphylococcal cassette chromosome mec typing assays were done to understand the relatedness of clonal strains of MRSA. Results: All AB-positive samples in the LTCFs were mainly from water-rich samples and were drug susceptible. Our data indicated that the AB strains from LTCFs were similar to those from Puzi River watersheds in Taiwan, which were not drug resistant to commonly used antibiotics. On the other hand, the drug resistance analysis of MRSA indicated that the genotypes from the LTCFs were similar to those from nearby hospitals. Eight strains of MRSA were isolated from four LTCFs, of which five were identified as hospital-acquired strains according to SSCmed typing assays. Conclusion: These findings suggest that MRSA in LTCFs might propagate from hospitals and could be transmitted between hospitals and LTCFs. Health authorities should be aware of this risk. The long-term follow-up of MRSA is recommended in local medical institutions as well as in LTCFs for correlative analysis.
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Special care dentistry in a charity clinic: Demographic analysis and barriers to care in Singapore p. 232
Guang Xu David Lim
Objective: Geriatric and special care dentistry (GSD) aims to improve oral health of seniors or adults disabilities facing barriers to care. This is coherent with the philosophy of “compassion relief.” Tzu Chi Singapore's Free Clinic exemplifies this through promoting health via various avenues to reach out. This article aims to provide a demographic analysis of patients with special care needs (PSCN), including age, gender, race, medical diagnoses, and treatment rendered. The patients were appraised on their complexity with the British Dental Association case mix model. Materials and Methods: PSCN seen by a dentist in Tzu Chi Singapore from November 2016 to December 2017 were recorded. The profiling of patients was done retrospectively. Results: Fifty-five dental PSCN were treated over 82 visits. 58.2% were seen in the free clinic, 27.3% in nursing homes, and 14.5% in oral health day programs for adults with intellectual disability. Their average age was 61.2 years, and the clinic was attended by patients of different races. Their medical profiles were grouped into seven categories, and the average case mix total banded score was 21.6, indicating that the average patient had “severe complexity”. A few themes relevant to Singapore were discussed, such as specialist GSD clinics, accessing dental services, socioeconomic status, state versus charity healthcare, and provision of future GSD services. Conclusions: Charity dental services such as free clinic can capture a niche of complex patients who may become marginalized in an established public healthcare.
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Knowledge, attitude, and practice regarding the screening of cervical cancer among women in New Delhi, India Highly accessed article p. 240
Neha Dahiya, Kavita Aggarwal, Megha Chandra Singh, Suneela Garg, Rajesh Kumar
Objective: Cervical cancer is one of the major concerns of public health importance in today's world. It is a leading cause of mortality in women of reproductive age group worldwide, mainly in developing countries. Reduction in mortality and morbidity due to cervical cancer is possible through early detection and treatment. The major factors influencing the early detection of cervical cancer are knowledge regarding risk factors, screening, Pap smear, and symptoms among women. Materials and Methods: The present cross-sectional study was carried out to assess the knowledge, attitude, and practice of women about the risk factors, symptoms, and prevention of cervical cancer. Data were obtained from 220 women who visited international trade fair using a pretested self-administered questionnaire. Results: Only 75 study women (50.0%) had ever heard of cervical cancer. The knowledge regarding cervical cancer and its various domains was significantly higher in students and unmarried women. The foul-smelling vaginal discharge was the most common early symptom of cervical cancer according to most of the study women (26, 17.3%). Most of the study women (19, 12.7%) reported tobacco and smoking as the most common risk factor associated with cervical cancer. Only 39 women (26%) had ever heard of cervical cancer screening. Only 27 women (18.0%) ever had Pap smear done in the past and 87 women (58.0%) were willing to undergo cervical cancer screening is offered free of cost. Conclusion: The study demonstrates the lack of awareness in women regarding cervical cancer and its screening modalities. This necessitates spreading awareness regarding early symptoms and risk factors associated with cervical cancer for early detection and treatment initiation.
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Comparison of short- to mid-term efficacy of nonfixation and permanent tack fixation in laparoscopic total extraperitoneal hernia repair: A systematic review and meta-analysis p. 244
Chi-Wen Lo, Yao-Chou Tsai, Stephen Shei-Dei Yang, Cheng-Hsing Hsieh, Shang-Jen Chang
Objective: We systematically reviewed the literature and pooled data for a meta-analysis to compare the efficacy and safety of mesh fixation and nonfixation in laparoscopic total extraperitoneal (TEP) hernia repair. Materials and Methods: We performed a systematic search of PubMed® and a Cochrane review for all randomized controlled trials that compared the efficacy and complications of mesh fixation versus nonfixation in TEP hernia repair. The evaluated outcomes included perioperative (operative time and conversion rate) and postoperative parameters (pain scores, duration of hospital stay, surgical complications including seroma, delayed return of bladder function, chronic pain, and recurrence). Cochrane Collaboration Review Manager Software (RevMan®, version 5.2.6) was used for statistical analysis. Results: Ten trials met the inclusion criteria and were included in a pooled analysis. In total, 1099 patients (1467 hernias) had received TEP hernia repair (748 and 719 hernia defects in the nonfixation and fixation groups, respectively). The nonfixation group required shorter operative time (weighted mean difference [WMD] = −2.36 min, P= 0.0006) and had less pain on postoperative day 1 (WMD = −0.44, P= 0.04) than the fixation group. No significant differences were observed between groups with regard to conversion rate, hospital stay, recurrence rate, or complication rate. However, the incidence of postoperative urine retention was higher in the fixation group (odds ratio = 0.26, P= 0.03). Conclusion: For patients with a nonrecurrent uncomplicated hernia defect with the size <3 cm, nonfixation yielded comparable efficacy with mesh fixation, but less short-term postoperative pain, and a lower risk of urine retention. In addition, the nonfixation method involved a shorter operative time and lower costs. However, no difference in the incidence of chronic pain was observed.
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Perioperative complications and Intensive Care Unit utilization in super-superobese patients undergoing laparoscopic bariatric surgery p. 254
Chia-Li Kao, Cheuk-Kwan Sun, Hsiu-Jung Lin, Kuo-Chuan Hung
Objective: Anesthetic management for super-superobese (SSO) patients (body mass index [BMI] ≥60 kg/m2) presents a challenge for anesthesiologists. This study aimed at characterizing the early complications and Intensive Care Unit (ICU) utilization in SSO patients receiving laparoscopic bariatric surgery. Materials and Methods: Totally, 25 SSO patients receiving laparoscopic bariatric surgery between June 2006 and December 2011 were reviewed. The data collected included patient demographics, preoperative comorbidities, anesthetic techniques, airway management, perioperative adverse events, ICU utilization, and early complications occurring within 30 days of index surgery. Early complications were defined as the adverse events that led to permanent detrimental effects or required significant additional intervention. Results: A retrospective analysis was performed on data from 25 consecutive SSO patients (age: 31.2 ± 11.1 years; BMI: 64.9 ± 4.7 kg/m2). Tracheal intubation was attempted successfully in all patients but was difficult in two cases when using laryngoscopy. Bronchospasm was observed in five cases (20%) after tracheal intubation. Postoperative ICU utilization was required in five cases (20%). Early complications occurred in two cases during their stay in postanesthesia care unit (including one case of respiratory failure and one case of hyperkalemia) and in two cases during their stay in ICU (both with respiratory failure). The incidence of early complications was 16%. All patients were discharged from the hospital without sequelae. Conclusions: It is imperative to anticipate the potential for developing perioperative adverse events and postoperative complications in SSO patients after bariatric surgery. Appropriate utilization of ICU resources may enhance patient safety.
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Postacute care model of stroke in one hospital p. 260
You-Chien Hsu, Guei-Chiuan Chen, Pei-Ya Chen, Shinn-Kuang Lin
Objectives: The National Health Insurance Bureau of Taiwan has established a postacute care model of stroke (PAC-stroke). Patients with acute stroke occurring within the preceding 30 days and with modified Rankin scale (mRS) scores of 2–4 can be transferred to PAC hospitals for 6–12 weeks of rehabilitation. We conducted a retrospective review to explore the results of PAC-stroke. Materials and Methods: From April 2015 to December 2017, patients who transferred from our hospital to four PAC hospitals were reviewed. We evaluated their functional status using the mRS, Barthel index (BI), functional oral intake scale, EuroQoL-5D, Lawton–Brody instrumental activities of daily living scale, Berg balance test, usual gait speed, 6-min walk test, Fugl–Meyer sensory and motor assessments, mini-mental state examination, motor activity log quantity and quality tests, and concise Chinese aphasia test, before and after the PAC program. Results: A total of 53 patients with initial mRS score of 3 (6 patients) or 4 (47 patients) were enrolled, including 39 with cerebral infarction and 14 with cerebral hemorrhage, with a median age of 67 (mean: 68.3 ± 13.3) years. Seven patients had serious complications, including six cases of pneumonia and one fracture. The readmission rates within 14 days after transfer to the PAC hospital and in the overall PAC program were 3.8% and 13.2%, respectively. After exclusion of eight patients who dropped out early, 45 patients completed the PAC program. The median lengths of stay at the upstream hospital and PAC hospitals were 26 and 63 days, respectively. Improved mRS and BI scores were observed in 42% and 78% of the patients, respectively. The results of all 14 functional assessments improved significantly after the PAC program. Conclusion: Significant improvements in mRS and BI scores and all functional assessments within an average of 63 days of PAC hospital stay helped 73% of the patients to return home.
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Intra-auricular modification of facelift incision decreased the risk of Frey syndrome p. 266
Chih-Ying Chen, Peir-Rong Chen, Yu-Fu Chou
Objective: Frey syndrome is a complication followed by parotidectomy which caused gustatory sweating and facial flush. There were several methods for the prevention of Frey syndrome, but most of them had no obvious effects. In this study, we compare the intra-auricular modification of facelift incision with the traditional lazy-S incision to see if it can decrease the risk of Frey syndrome. Materials and Methods: This is a retrospective study. From 2003 to 2009, a total of 61 patients with benign parotid tumor who received parotidectomy at Hualien Tzu Chi Hospital and were followed at outpatient department for at least 5 years were enrolled. Patients were divided into two groups according to the type of incisions during operation: (1) Group M: intra-auricular modification of facelift incision or (2) Group S: traditional lazy-S incision. All patients received the partial thickness sternocleidomastoid muscle flap. Clinical data including age, gender, pathologic result, presentation of Frey syndrome, size of tumor, length of operation, blood loss from surgery, length of placement of drain, total amount of drainage, and length of stay were collected and analyzed. Results: Sixty-one patients were enrolled. Eighteen patients were in Group M and forty-three were in Group S. There was no significant difference of age, gender, and size of tumor between the two groups. The pathologic results included parotitis, pleomorphic adenoma, Warthin's tumor, and others. No significant difference of pathologic results, blood loss from surgery, length of placement of drain, total amount of drainage, and length of stay between two groups was obtained. The length of operation was longer in Group M (P = 0.001) and the incidence of Frey syndrome was lower in Group M than Group S (P < 0.05). Conclusions: The use of intra-auricular modification of facelift incision can decrease the incidence of Frey syndrome.
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Evaluation of the Chinese version of the swallowing screen in stroke patients with dysphagia p. 270
Jiin-Ling Jiang, Jia-Lun Yu, Jen-Hung Wang, Yao-Yi Wang, Wan-Hsiang Wang
Objective: The purpose of this study was to validate a Chinese version of the modified Standardized Swallowing Assessment (SSA) instrument used by nurses in stroke patients with dysphagia and explore the feasibility of the simplified instrument. Materials and Methods: This study involved a cross-sectional design. Nurses independently applied the modified SSA to 127 patients with stroke before a complete dysphagia evaluation conducted by a speech–language pathologist. Factor analysis of eight dysphagia variables in the modified SSA was performed to evaluate construct validity. The accuracy of the screening instrument was assessed through receiver operating characteristic (ROC) analysis. Results: The comprehensive swallowing assessment revealed that 49.6% of the stroke patients had dysphagia. The modified SSA had an acceptable internal consistency coefficient. The inter-rater agreement between nurses using the modified SSA showed a Kappa coefficient of 0.509. All items had a communality loading of >0.5, and two factors accounted for 73.89% of the response variance. The area under the ROC curve was 0.79 (95% confidence interval: 0.71–0.87). The sensitivity and specificity derived for dysphagia detection were satisfactory according to the results obtained from the original 8-item and simplified 6-item scales (sensitivities = 82.50% and 81.00% and specificities = 59.40% and 64.10%, respectively; accuracy = 70.87% and 72.44%, respectively). Conclusion: This preliminary study suggests that the modified SSA is a potentially reliable and valid nurse-administered screening instrument for dysphagia detection in patients with stroke.
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Allopurinol use associated with increased risk of acute myocardial infarction in older people in a case–control study p. 276
Kuan-Fu Liao, Cheng-Li Lin, Shih-Wei Lai
Objective: There is controversy about the association between the allopurinol use and the risk of acute myocardial infarction. The aim of the study was to examine the association between allopurinol use and acute myocardial infarction in older people in Taiwan. Materials and Methods: We used the 2000–2013 database of the Taiwan National Health Insurance Program to conduct a case–control study. Cases were assigned as subjects aged 65 years and older with the first incident acute myocardial infarction. Matched controls were assigned as subjects aged 65 years and older without any type of coronary artery disease. Ever use of allopurinol was defined as subjects who had at least a prescription of allopurinol before the diagnosis date of first incident acute myocardial infarction. The odds ratio (OR) and the 95% confidence interval (CI) for acute myocardial infarction associated with allopurinol use were estimated by the multivariable logistic regression model. Results: There were 4701 cases with the first incident acute myocardial infarction and 9369 matched controls. The adjusted OR of acute myocardial infarction was 2.2 (95% CI 1.7– 2.7) for subjects with ever use of allopurinol, compared with never use. The adjusted ORs of acute myocardial infarction were 2.0 (95% CI 1.5–2.6) for subjects with average daily dosage of allopurinol <200 mg and 2.5 (95% CI 1.6–4.0) for subjects with average daily dosage of allopurinol ≥200 mg. Conclusion: Allopurinol use is associated with increased odds of acute myocardial infarction in older people, which is dosage dependent.
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Duodenal perforation after gastrostomy tube replacement: Case report and literature review p. 280
Hsiao-Hui Yang, Chia-Jung Ke, Ting-Han Shih
Gastrostomy is commonly used to provide long-term enteral access for patients with feeding impairment. Routine replacement is a safe procedure, but it has various complications. We present a case of nasopharyngeal cancer, who visited the emergency department for gastrostomy tube dislodgement. Diffuse abdominal pain developed 3 days after replacement of the gastrostomy tube with a temporary silicone Foley tube. Emergency diagnostic laparoscopy was performed and found tip migration and causing duodenal perforation. Tip migration and compression necrosis of mucosa were the possible mechanisms. The condition was successfully treated by emergency laparoscopic duodenorrhaphy.
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Presence of adult Loa loa in the anterior chamber of the eye along with microfilaremia from nonendemic region: A rare presentation from India p. 283
Varsha Kumari, Sofia Ahmad, Aradhana Singh, Tuhina Banerjee
We report an unusual case of adult Loa loa infection in the anterior chamber of the eye of a 65-year-old female from rural area of Jharkhand, India, with no history of travel to endemic places but the presence of microfilaria of Loa loa in blood. Loiasis is endemic to African countries, with few sporadic cases affecting the Indian population. However, in none of the reports, microfilaremia was detected. This atypical feature in this case adds to the epidemiological variations in parasitic presentations in nonendemic regions.
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A primary paraganglioma of the liver mimicking hepatocellular carcinoma p. 286
Chia-Shuen Lin, Yung-Hsiang Hsu
Paragangliomas occurring primarily in the liver parenchyma are extremely rare. The radiological features mimic hepatocellular carcinoma. Herein, we describe a case with a presurgical diagnosis of hepatocellular carcinoma, which was pathologically confirmed as hepatic paraganglioma after surgery. A 41-year-old woman visited our hospital for evaluation of a hepatic mass detected incidentally in a health examination 7 years previously. Triple-phase computed tomography of the liver showed a homogeneous and strongly arterial enhancing mass, followed by portovenous washout at the posterior segment of the right lobe. In view of the enhancement pattern and highly vascular nature, the hepatocellular carcinoma was included in the differential diagnosis. Anatomical resection of segment VII was carried out. Grossly, the mass was encapsulated and soft. Microscopically, it had a typical “Zellballen pattern.” Immunohistochemical staining for CD56 was positive, and sustentacular cells at the periphery of the tumor cell nests were also demonstrated by S-100 protein. Therefore, the diagnosis of primary paraganglioma of the liver was confirmed. In conclusion, hepatic paraganglioma should be considered in the differential diagnosis in cases of hepatic masses displaying “early enhancement, early washout.”
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Huge ovarian mature cystic teratoma with gliomatosis peritonei and massive ascites in a postmenopausal woman p. 289
Chia-Shuen Lin, Ci Huang, Pei-Chen Li, Yung-Hsiang Hsu, Dah-Ching Ding
Teratoma of the ovary is the most frequently encountered germ cell tumor. It usually occurs in young women. Gliomatosis peritonei (GP) is mature neural glial tissue implanted onto the peritoneal surface. We present a case of a mature teratoma accompanied by GP and massive ascites in postmenopausal women. A 54-year-old, G0P0, woman presented in the gynecology outpatient department with abdominal distension for 6 months. Computed tomography scan of the abdomen and pelvis displayed an ovarian mass about 20 cm × 18 cm with peritoneal seeding, ascites, and enlarged paraaortic lymph nodes. A total hysterectomy and bilateral adnexectomy were performed. The pathology showed the left ovary contained a dermoid cyst. The biopsy of the peritoneal nodule displayed glial tissue confirming the diagnosis of GP. The patient remained in good condition 6 months postoperatively. We suggest GP be considered in patients presenting with teratomas and massive ascites. The radiological diagnosis is challenging due to the rarity of GP. Continued follow-up of patients with teratomas and GP is mandatory due to the potential of malignant transformation.
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Incomplete anterior choroidal artery syndrome in a pregnant female p. 292
Liyana Najwa Inche Mat, Wan Aliaa Wan Sulaiman, Fan Kee Hoo, Laila Mastura Ahmad Apandi, Hamidon Basri
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Serum leptin levels and peripheral arterial stiffness in patients with type 2 diabetes p. 294
Sora Yasri, Viroj Wiwanitkit
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Reply from authors for Serum leptin levels and peripheral arterial stiffness in patients with type 2 diabetes p. 295
Chia-Wen Lu, Chung-Jen Lee, Jia-Sian Hou, Du-An Wu, Bang-Gee Hsu
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