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   Table of Contents - Current issue
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January-March 2020
Volume 32 | Issue 1
Page Nos. 1-99

Online since Thursday, January 2, 2020

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REVIEW ARTICLE - BASIC  

The role of hydrogen peroxide-inducible clone-5 in tumor progression p. 1
Wen-Sheng Wu
DOI:10.4103/tcmj.tcmj_120_19  
The poor prognosis of cancers such as hepatocellular carcinoma is due to high recurrence rate mainly caused by metastasis. Target therapy aiming at critical signal molecules within these pathways is one of the promising strategies for the prevention of metastasis. Hydrogen peroxide-inducible clone-5 (Hic-5), which belongs to the paxillin superfamily, is emerging as a potential target along the metastatic signaling pathway. Hic-5 and paxillin share similar structural features; however, there are a lot of different biochemical properties between them, including tissue-specific distribution, regulation of gene expression, critical signal cascade, and the impacts on cellular phenotypes. This review focus on the recent studies of Hic-5 related to its impacts on signal transduction and transcription responsible for tumor progression. Hic-5 may regulate mitogen-activated protein kinase cascade for cell migration and invasion in various systems. Hic-5 can mediate transforming growth factor-β1-induced epithelial–mesenchymal transition (EMT) via RhoA- and Src-dependent signaling. Moreover, Hic-5 plays a central role in a positive feedback Hic-5-NADPH oxidase-ROS-JNK signal cascade. This sustained signaling is required for regulating EMT-related genes including E-cadherin, Snail, MMP9, and Zeb-1. In addition, Hic-5 can be a transcription coregulatory factor for a lot of nuclear receptors. Owing to the critical role of Hic-5 in signal transduction and transcription responsible for tumor progression, it can be a potential therapeutic target for the prevention of tumor metastasis.
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REVIEW ARTICLES - CLINICAL Top

Precision medicine in the diagnosis and treatment of male lower urinary tract symptoms suggestive of benign prostatic hyperplasia p. 5
Jing-Liang Chen, Yuan-Hong Jiang, Cheng-Ling Lee, Hann-Chorng Kuo
DOI:10.4103/tcmj.tcmj_107_19  
Male lower urinary tract symptoms (LUTSs) are highly prevalent in men and the incidence increases with aging. The pathophysiology of male LUTSs might be bladder outlet dysfunctions such as bladder neck (BN) dysfunction, benign prostatic obstruction, and poor relaxation of external sphincter and bladder dysfunctions such as detrusor overactivity (DO), detrusor underactivity, DO, and inadequate contractility. Male LUTSs include voiding and storage symptoms, and precision diagnosis should not be done based on the symptoms alone. Videourodynamic study provides a thorough look at the bladder and bladder outlet and can clearly demonstrate the underlying pathophysiology when the initial medication fails to relieve LUTS. Medical treatment should be given based on the underlying pathophysiology of LUTS, and surgical intervention to remove prostate should only be performed when a definite bladder outlet obstruction due to prostatic obstruction has been confirmed by invasive urodynamic study.
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Uncertainty and health literacy in dementia care p. 14
Raymond Y Lo
DOI:10.4103/tcmj.tcmj_116_19  
The number of dementia cases increases with age, and the prevalence of dementia at the age above 80 is approaching 20% in Taiwan. Dementia is not simply a neurological disorder, but also a long-term care issue in public health and a matter of social adaptation. Scientific discoveries about dementia diagnostics, therapeutics, and preventive strategy have become the focus of media attention, but always updated and overwhelmed, which appears to increase rather than decrease the uncertainty and complexity of health communication in dementia care. Health literacy is essential for patients to understand medical information, utilize medical resources, and make shared decisions; however, the capacity to handle health information is often compromised in older adults with cognitive decline. Both ends of the increased uncertainty in dementia science and the reduced capacity in older adults are major challenges in dementia care. Dementia literacy, defined as knowledge and beliefs regarding dementia that aid recognition, management, or prevention, plays a vital role in effective care risk assessment and communication. However, little is known about the current state of dementia literacy among older adults, people with dementia, and their caregivers, and how well the dementia care practice can be implemented at the individual level is questionable. Empowering caregivers with adequate dementia literacy and developing a risk communication model in practice will translate the power of knowledge to effective care strategies, thus ameliorating the caregiver burden and enhancing the life quality of people with dementia in the long run.
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REVIEW ARTICLE - MEDICAL EDUCATION Top

Teaching communication skills: Using Gagne's model as an illustration p. 19
Wen-Lin Lo, Ming-Chen Hsieh
DOI:10.4103/tcmj.tcmj_59_19  
Communication skills is an essential competence for physicians. Good communication skills correlate with higher patient satisfaction and overall patient outcome. Therefore, such training should start as early as in the undergraduate curriculum with experiential methods and more advanced skills to be integrated at different levels. Design of the training program should prepare for the transfer of communication skills into the clinical setting. Supervision from clinician educators could enhance the transfer of communication skills. Faculty development programs could help clinician educators to develop teaching skills needed in teaching communication. Continuous feedback from teachers and reflective practice of the learners are essential for effective learning of communication skills. The design of the teaching should be based on theory such as adult learning theory or experiential learning. Gagne's model provides a template for the systemic design of instructional events, and this article will illustrate an example of teaching communication skills based on the model.
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ORIGINAL ARTICLE - BASIC RESEARCH Top

The aging effects on phenylephrine-induced relaxation of bladder in mice p. 26
Chun-Kai Hsu, Hsi-Hsien Chang, Stephen Shei-Dei Yang
DOI:10.4103/tcmj.tcmj_178_18  
Objective: We have demonstrated that phenylephrine (PE) activates the capsaicin-sensitive nerves, and then activates capsaicin-sensitive nerves to release an unknown substance that facilitates the release of norepinephrine (NE) from adrenergic nerves. Subsequently, NE stimulates β-ARs in the detrusor muscle in mice, leading to neurogenic relaxation of the urinary bladder (UB). Materials and Methods: We examined if there existed sensory-motor dysfunction in UB of aging mice. To investigate the change of PE-induced detrusor relaxation in aging male-C57BL/6 mice (12- vs. 24-month-old mice), UB strips from mice were isolated, cut into strips, and mounted in the organ bath. Results: The UB strip contractility responding to various agents was estimated using tissue bath wire myography. Acetylcholine (ACh) and KCl-induced UB strips contraction was not significantly different between 24- and 12-month mice. NE-induced UB strips relaxation was significantly lower in 24-month than 12-month mice. Denuded bladder strips showed similar decreased relaxation response to NE. This NE-induced relaxation was inhibited by silodosin and lidocaine. PE did not induce contraction in UB strips of aging mice. In contrast, PE-induced relaxation was weaker in 24-month than 12-month mice. Conclusion: Our results suggested that the PE-induced relaxation was age related. Aging seemed to lead the sensory-motor dysfunction. More animal and human studies are required to prove this concept and its clinical usefulness in the future.
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ORIGINAL ARTICLES - CLINICAL RESEARCH Top

Therapeutic efficacy of mirabegron 25 mg monotherapy in patients with nocturia-predominant hypersensitive bladder p. 30
Cheng-Ling Lee, Hueih-Ling Ong, Hann-Chorng Kuo
DOI:10.4103/tcmj.tcmj_226_18  
Objective: The objective of this study was to evaluate the efficacy of mirabegron 25 mg daily in patients with nocturia-predominant hypersensitive bladder (HSB). Materials and Methods: This study prospectively investigated 219 consecutive patients with nocturia-predominant HSB and treated with mirabegron 25 mg daily from July 2015 to 2016. Patient with nocturia episode decreased by ≥1/night after treatment was considered successful. The subjective symptom score, such as International Prostate Symptom Score (IPSS), Quality of life index, Overactive Bladder Symptom Score (OABSS), Urgency Severity Scale, patient perception of bladder condition (PPBC), and nocturia episodes per night, was assessed before and 1 month after mirabegron treatment and between successful and failed groups. Results: A total of 219 patients, including 51 women and 168 men, were enrolled. The mean age of the population was 72.3 ± 11.0 years. Totally, 58 (26.5%) of the patients had improvement in nocturia at 1 month after treatment. Among them, 14 (27.5%) women and 44 (26.2%) men had improvement in nocturia episodes after treatment (P = 0.858). Compared the clinical data between successful and failed group, the baseline symptom scores were more severe in successful group, including IPSS-storage subscore (4.84 ± 2.09 vs. 4.11 ± 2.19, P = 0.031), OABSS (3.21 ± 0.67 vs. 2.91 ± 1.00, P = 0.037), and nocturia episodes (3.81 ± 0.95 vs. 3.095 ± 1.32, P = 0.000). Multivariate analysis revealed only a higher nocturia episodes (P = 0.046) predict a successful treatment result. Mirabegron 25 mg daily significantly improved PPBC score along the 3 months' follow-up (P < 0.05), and postvoid residual volume did not increase after mirabegron treatment in overall patients. Conclusions: Mirabegron 25 mg daily treatment showed a limited therapeutic effect on nocturia-predominant HSB patients. The patients with higher OAB symptoms predict a successful result.
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Dengue infection in North India: An experience of a tertiary care center from 2012 to 2017 p. 36
Anju Dinkar, Jitendra Singh
DOI:10.4103/tcmj.tcmj_161_18  
Objective: Recently, an alarming rise of dengue has been seen in India which remains a major public health concern. This study has been designed for a comprehensive overview of the epidemiology, gender, age, area distribution, symptomology, and seasonal variability. Materials and Methods: Retrospective analysis of 900 suspected dengue cases of all age groups of either sex from 2012 to 2017 at a North Indian tertiary care hospital revealed 461 (51.22%) cases seropositive for dengue. Results: The age group of 20–30 years was the most affected group with male predominance. The urban population was more affected as 75.05%, and maximum cases were detected in October month followed by November. Common abnormal laboratory parameters were thrombocytopenia (99.1%), hepatic dysfunction (59%), and leukopenia (26.68%). Two uncommon findings, pancytopenia and pancreatic dysfunction were reported in 7 and 3 cases respectively. Conclusion: Dengue infection in India has evolved rapidly, and regular outbreaks have been observed with a changing epidemiology, as the disease is rapidly spreading from urban to rural areas with increasing atypical manifestations.
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Compatibility of pulse–pulse intervals with R–R intervals in assessing cardiac autonomic function and its relation to risks of atherosclerosis p. 41
Cheuk-Kwan Sun, Cyuan-Cin Liu, Wei-Min Liu, Hsien-Tsai Wu, Ruay-Ming Huang, An-Bang Liu
DOI:10.4103/tcmj.tcmj_68_18  
Objective: Heart rate variability (HRV) analysis using electrocardiographic R–R intervals (RRIs) in either a time or a frequency domain is a useful tool for assessing cardiac autonomic dysfunction in clinical research. For convenience, pulse–pulse intervals (PPIs) acquired by photoplethysmography have been used to assess HRV. However, the compatibility of PPI with RRI is controversial. Materials and Methods: In this study, we investigated the compatibility of PPI with RRI in five groups of participants, including nonoverweight young individuals with a body mass index (BMI) <24 kg/m2 (Group 1, n = 20, aged 18–40 years), overweight young individuals with a BMI ≥24 kg/m2 (Group 2, n = 13, aged 21–38 years), nonoverweight upper middle-aged individuals with a BMI <24 kg/m2 (Group 3, n = 21, aged 45–89 years), overweight upper middle-aged individuals with a BMI ≥24 kg/m2 (Group 4, n = 14, aged 43–74 years), and diabetic patients with a BMI ≥24 kg/m2 (Group 5, n = 19, aged 35–74 years). We then used cross-approximate entropy (CAE) to assess the compatibility between RRI and PPI and analyzed HRV in the time and frequency domains derived from PPR and RRI with traditional methods. Results: The CAE values in Group 1 were significantly lower than those in Group 2 (1.68 ± 0.16 vs. 1.78 ± 0.15, P = 0.041), Group 3 (1.68 ± 0.16 vs. 2.05 ± 0.27, P < 0.001), Group 4 (1.68 ± 0.16 vs. 1.87 ± 0.23, P = 0.023), and Group 5 (1.68 ± 0.16 vs. 2.09 ± 0.23, P < 0.001). There were no significant differences in HRV acquired by PPI and RRI, except for proportion of pairs of adjacent NN intervals differing by more than 50 ms in the entire recording in Group 1. All HRVs derived from PPI were different from those acquired from RRI in the other groups. Conclusion: PPI may be an alternative parameter for effectively assessing cardiac autonomic function in nonoverweight healthy individuals. It should be used carefully in overweight, elderly, or diabetic individuals.
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Effects of poor hepatic reserve in cirrhotic patients with bacterial infections: A population-based study p. 47
Tsung-Hsing Hung, Chih-Chun Tsai, Hsing-Feng Lee
DOI:10.4103/tcmj.tcmj_142_18  
Objective: Ascites, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis, and esophageal variceal bleeding are major complications associated with cirrhosis. The presence of these complications indicates poor hepatic reserve. This study aimed to identify the effects of poor hepatic reserve on mortality in cirrhotic patients with bacterial infections. Patients and Methods: The Taiwan National Health Insurance Database was used to identify 43,042 cirrhotic patients with bacterial infections hospitalized between January 1, 2010, and December 31, 2013, after propensity score matching analysis. Of these, 21,521 cirrhotic patients had major cirrhotic-related complications and were considered to have poor hepatic reserve. Results: Mortality rates at 30 and 90 days were 24.2% and 39.5% in the poor hepatic reserve group and 12.8% and 21.7% in the good hepatic reserve group, respectively (P < 0.001 for each group). The cirrhotic patients with poor hepatic reserve (hazard ratio [HR], 2.10; 95% confidence interval [CI] = 2.03–2.18; P < 0.001) had significantly increased mortality at 90 days. The mortality HRs in patients with one, two, and three or more complications compared to patients without complications were 1.92 (95% CI = 1.85–1.99, P < 0.001), 2.61 (95% CI = 2.47–2.77, P < 0.001), and 3.81 (95% CI = 3.18–4.57, P < 0.001), respectively. Conclusion: In cirrhotic patients with bacterial infections, poor hepatic reserve is associated with a poor prognosis. The presence of three or more cirrhotic-related complications increases mortality almost four folds.
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Characteristics and outcomes of patients requiring airway rescue by the difficult airway response team in the emergency department and wards: A retrospective study p. 53
Ting-Sian Yu, Cheuk-Kwan Sun, Ying-Jen Chang, I-Wen Chen, Chien-Ming Lin, Kuo-Chuan Hung
DOI:10.4103/tcmj.tcmj_184_18  
Objective: In this retrospective cohort study, we aimed to determine the characteristics and outcomes of patients in the emergency department (ED) and wards who required emergency tracheal intubation by the difficult airway response team (DART). Materials and Methods: All patients between 18 and 80 years old receiving emergency tracheal intubation by the DART at a single tertiary referral hospital from January 2014 to December 2016 were reviewed and divided into ward and ED groups. Patient characteristics, comorbidities, indications for intubation, airway maintenance technique, and survival-to-discharge rates were analyzed and compared. Results: Totally, 192 patients (ward, n = 135; ED, n = 57) were eligible for the current study. Compared with the ward group, patients in the ED group were younger (58.9 ± 13 vs. 51.5 ± 15.6 years, P = 0.001), male-predominant (71.1% vs. 87.7%, P = 0.014), and had a higher incidence of trauma (6.7% vs. 22.8%, P = 0.001). The most common indications for tracheal intubation were respiratory distress (52.6%) and cardiac arrest (17.8%) in the ward group, and respiratory distress (31.6%) and airway protection (28.1%) in the ED group. Patients in the ED group received more fiberoptic intubations (42.1% vs. 17.8%, P = 0.039) and had a higher survival-to-discharge rate (87.7% vs. 44.4%, P < 0.001) than those in the ward group. Conclusions: Better recognition of differences in patient characteristics and indications for intubation in different units of the hospital may enable the DART to customize specialized equipment to improve efficiency and implement appropriate strategies for airway rescue to improve patient outcomes.
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Rapid effect of a single-dose buprenorphine on reduction of opioid craving and suicidal ideation: A randomized, double blind, placebo-controlled study p. 58
Jamshid Ahmadi, Ebrahim Moghimi Sarani, Mina Sefidfard Jahromi
DOI:10.4103/tcmj.tcmj_220_18  
Objective: Opioid use disorder is a prevalent addiction problem that can be treated with buprenorphine, but dependence, diversion, and abuse of buprenorphine occur. Although including naloxone reduces these problems, the combination formulation is not available worldwide. The administration of the medication under supervision may also be useful in decreasing unintended uses of the medication. The objective is to assess the influence of a single, physician-administered dose of buprenorphine on withdrawal craving and suicidal ideation in opioid-dependent patients over a period of 4 days of abstinence from opioids. Materials and Methods: Sixty-one men who used heroin, opium, or prescription opioids and met Diagnostic and Statistical Manual of Mental Disorders Five Edition criteria for opioid use disorder were randomized to receive a single, sublingual dose of buprenorphine (16 mg, 32 mg, or placebo; n's = 20, 20, and 21 per group). The study was carried out in an inpatient psychiatric ward, with appropriate precautions and monitoring of cardiovascular and respiratory measures. Buprenorphine was administered when the patients were in moderate opioid withdrawal, exhibiting four to five symptoms. Self-reports of craving (The Opioid Craving Scale) and suicidal ideation (Beck Scale for Suicidal Ideation) were taken at baseline and on each of the 4 days after treatment. Results: The group did not differ significantly on demographic features, and all of the patients completed the 4-day study. Craving was reduced from baseline during the observation period in each of the three groups, demonstrating a significant effect of treatment (P < 0.0005), and the dose-by-time interaction (P < 0.0005). Both 32 mg and 16 mg groups differed significantly from the placebo group. No significant differences were observed between the 32 and 16 mg groups, suggesting that the maximal effect on craving reduction was achieved with the 16-mg dose. Suicidal ideation was decreased from baseline during the observation period in each of the three groups, demonstrating a significant effect of treatment (P < 0.0005), and the dose-by-time interaction (P < 0.017).The 32 mg group differed significantly from the placebo group. No significant differences were observed between the 16 and placebo groups, suggesting that the maximal effect on suicidal ideation reduction was achieved with the 32 mg dose. Conclusions: A single high dose of 16 mg or 32 mg buprenorphine reduces opioid craving, but a single high dose of only 32 mg buprenorphine reduces suicidal ideation.
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Association of nonalcoholic fatty liver and chronic kidney disease: An analysis of 37,825 cases from health checkup center in Taiwan p. 65
Hao-Wen Liu, Jia-Sin Liu, Ko-Lin Kuo
DOI:10.4103/tcmj.tcmj_233_18  
Objective: Nonalcoholic fatty liver (NAFLD) and chronic kidney disease (CKD) share common pathogenic mechanisms and risk factors. The relationship between in NAFLD and CKD remains controversial. We aim to assess the association between NAFLD and CKD. Materials and Methods: A cross-sectional study was based on individuals who received physical checkups at the Taipei Tzu Chi Hospital from September 5, 2005, to December 31, 2016. Demographic and clinical characteristics of the study population were collected. NAFLD was defined by abdominal ultrasonography and excluded other liver disease. CKD was defined as estimated glomerular filtration rate ≤60 mL/min/1.73 m[2] or the presence of proteinuria. The association between NAFLD and CKD was then analyzed using SAS software by using the multivariable logistic model. A higher prevalence of CKD was shown in individuals with NAFLD compared to those without NAFLD. Results: In univariate analysis, individuals with mild NAFLD and moderate-to-severe NAFLD were both significantly associated with CKD (odds ratio [OR], 1.23; 95% confidence interval [CI], 1.13–1.33; OR, 1.66; CI, 1.49–1.85) when compared to individuals without NAFLD. After multivariate adjustment, individuals with moderate-to-severe NAFLD were still significantly more likely to have CKD (OR, 1.17, 95% CI, 1.03–1.33). Conclusions: Our finding showed that the presence and severity of NAFLD was positively associated with CKD in unadjusted and adjusted analysis. Further follow-up studies may be needed to validate these associations.
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Negative correlation of serum adiponectin level with peripheral artery occlusive disease in hemodialysis patients p. 70
Yu-Hsien Lai, Yu-Li Lin, Chih-Hsien Wang, Chiu-Huang Kuo, Bang-Gee Hsu
DOI:10.4103/tcmj.tcmj_19_19  
Objective: Adiponectin is a fat-derived hormone that secretes exclusively by adipocytes and has antiatherosclerotic effects. Peripheral arterial occlusive disease (PAOD) is associated with an increased risk of death in hemodialysis (HD) patients. The aim of this study was to evaluate the relationship between serum adiponectin levels and PAOD by ankle–brachial index (ABI) in HD patients. Materials and Methods: Blood samples were obtained from 100 HD patients. Serum adiponectin levels were measured using a commercial enzyme-linked immunosorbent assay kit. ABI values were measured using the automated oscillometric method (VaSera VS-1000). ABI values that <0.9 were included in the low ABI group. Results: Among the 100 HD patients, 18 of them (18.0%) were in the low ABI group. Compared with patients in the normal ABI group, the patients in the low ABI group had a higher prevalence of diabetes (P = 0.043), older age (P = 0.027), and lower serum adiponectin level (P = 0.003). In addition, the multivariable logistic regression analysis showed that adiponectin (Odds ratio [OR]: 0.927, 95% confidence interval [CI]: 0.867–0.990, P = 0.025) and age (OR: 1.054, 95% CI: 1.002–1.109, P = 0.043) were the independently associated with PAOD in HD patients. Conclusion: In this study, serum adiponectin level was found to be associated with PAOD in HD patients.
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Dose escalation (81 Gy) with image-guided radiation therapy and volumetric-modulated arc therapy for localized prostate cancer: A retrospective preliminary result p. 75
Sheng-Yao Huang, Chen-Ta Wu, Dai-Wei Liu, Tzu-Hwei Wang, Yen-Hsiang Liao, Yi-Wei Chen, Wen-Lin Hsu
DOI:10.4103/tcmj.tcmj_2_19  
Objectives: The objective of the study is to report the acute and late toxicity and preliminary results of localized prostate cancer treated with high-dose radiation therapy (RT). Materials and Methods: Between March 2010 and October 2018, a total of 53 patients with clinically localized prostate cancer were treated with definitive RT at our institution. All patients were planned to receive a total dose of 81 Gy with the volumetric-modulated arc therapy technique. Patients were stratified by prognostic risk groups based on the National Comprehensive Cancer Network risk classification criteria. Acute and late toxicities were scored by the Radiation Therapy Oncology Group morbidity grading scales. The definition of biochemical failure was using the 2005 ASTRO Phoenix consensus definition. Median follow-up time was 46.5 months (range: 4.7–81.0 months). Results: The 3-year biochemical failure-free survival rates for low-, intermediate-, and high-risk group patients were 100%, 87.5%, and 84%, respectively. The 3- and 5-year overall survival rates were 83% and 62%, respectively. Three (5.6%) patients developed Grade II acute gastrointestinal (GI) toxicity. Four (7.5%) patients developed Grade II acute genitourinary (GU) toxicity, and none experienced Grade III or higher acute GI or GU symptoms. One (1.8%) patient developed Grade II or higher late GI toxicity. Six (11.3%) patients experienced Grade II late GU toxicity. No Grade III or higher late GI and GU complications have been observed. Conclusions: Data from the current study demonstrated the feasibility of dose escalation with image-guided and volumetric-modulated arc therapy techniques for the treatment of localized prostate cancer. Minimal acute and late toxicities were observed from patients in this study. Long-term prostate-specific antigen controls are comparable to previously published results of high-dose intensity-modulated RT for localized prostate cancer. Based on this favorable outcome, dose escalation (81 Gy) has become the standard treatment for localized prostate cancer at our institution.
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Analysis of emergency air medical services over 9 years in the Penghu archipelago of Taiwan p. 82
Meng-Yu Wu, Chia-Jung Li, Yueh-Tseng Hou, Yu-Long Chen, Fung-Wei Chang, Giou-Teng Yiang
DOI:10.4103/tcmj.tcmj_216_18  
Objective: Emergency air medical services (EAMS) share a common helicopter system for prehospital care and transfer in several countries. In Penghu, two systems are involved in EAMS: the helicopter and C130 systems. Given their features and limitations, patients using the two systems have significantly different characteristics. Materials and Methods: To clearly understand the disease patterns and dynamic changes in transferred patients, we studied 1228 patients transported from Penghu to Taiwan between January 2009 and December 2017. Results: Our findings show that the helicopter group had more acute diseases, while the C130 system group had more chronic diseases. Cardiovascular disease was the most common diagnosis (328 patients, 26.71%), followed by cerebrovascular disease (263 patients, 21.41%) and gastrointestinal disease (221 patients, 17.99%). Following interventions to support local medicine by Tri-Service General Hospital and the establishment of a cardiac catheterization laboratory, the annual number of transported patients decreased, especially those with cardiovascular diseases. The disease pattern also shifted from acute to chronic disease. Conclusion: Current data indicate that the local medical system is developing the ability to manage chronic diseases and care problems. This article analyzes dynamic changes in the disease patterns of transferred patients in both EAMS groups, providing a strong foundation for developing local medical systems.
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CASE REPORTS Top

A rare complication of ipsilateral femoral neck fracture after removal of the long Gamma nail in a healed intertrochanteric fracture p. 88
Chin-Kai Huang, Chih-Kai Hong, Wei-Ren Su, Yi-Hung Huang, Lin-Yu Chao
DOI:10.4103/tcmj.tcmj_188_18  
Ipsilateral femoral neck fracture after hardware removal in healed trochanteric fracture is a rare complication. We reported a case of a 79-year-old woman who had undergone open reduction and internal fixation for her left intertrochanteric fracture with a long Gamma nail about 1 year ago. She asked for implants removal due to local irritation. However, 5 days after implants removal, left subcapital femoral neck fracture occurred. Removal of implants under elective indications could lead to high complication rate. Orthopedic surgeons should perform the removal of hardware in healed intertrochanteric fracture for very selected cases.
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Case of internal jugular vein thrombosis and fever: Lemierre's syndrome or Trousseau's syndrome? p. 91
Meng-Yu Wu, Yueh-Tseng Hou, Jian-Yu Ke, Giou-Teng Yiang
DOI:10.4103/tcmj.tcmj_34_19  
Internal jugular vein thrombosis is a rare critical cardiovascular emergency, which has potential catastrophic clinical outcomes by resulting in stroke and pulmonary embolism. Several etiologies have been reported; however, there are limited data on Lemierre's and Trousseau's syndromes, which are both rare conditions with advanced disease progression and poor clinical outcomes. Lemierre's syndrome may present with typical progressively infectious symptoms and signs, including sore throat, neck mass, and fever, whereas Trousseau's syndrome may present with thrombophlebitis and painful edema. Without antibiotic agents controlling the infection, the condition of patients with Lemierre's syndrome may progress to sepsis or septic shock. The infection pattern plays an important role for differential diagnosis. Herein, we describe the case of a 46-year-old woman presenting with atypical symptoms of Trousseau's syndrome mimicking Lemierre's syndrome. Laboratory analysis including protein C, protein S, rheumatoid factor, and antinuclear antibody ruled out hypercoagulopathy and autoimmune vasculitis. Abdominal computed tomography and panendoscopy revealed ulcerative tumor at the antrum. Pathological examination confirmed the presence of signet-ring cell adenocarcinoma. We highlight the clinical features and etiologies of internal jugular vein thrombosis, especially in Lemierre's syndrome and Trousseau's syndrome, to aid physicians in making an early diagnosis and providing timely management.
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IMAGES IN CLINICAL MEDICINE Top

Granulomatous invasive fungal sinusitis p. 96
Satvinder Singh Bakshi, Roopa Urs
DOI:10.4103/tcmj.tcmj_173_19  
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MEDICAL EDUCATION Top

The story of antipsychotics: A metaphorical overview Highly accessed article p. 97
Nishtha Khatri
DOI:10.4103/tcmj.tcmj_195_18  
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