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   Table of Contents - Current issue
Coverpage
January-March 2019
Volume 31 | Issue 1
Page Nos. 1-66

Online since Wednesday, January 2, 2019

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REVIEW ARTICLES - CLINICAL  

Female genital mutilation; culture, religion, and medicalization, where do we direct our searchlights for it eradication: Nigeria as a case study p. 1
Olalekan Olugbenga Awolola, NA Ilupeju
DOI:10.4103/tcmj.tcmj_127_18  PMID:30692824
Female genital mutilation (FGM) is a form of violence against the girls and the women and also an infringement into the rights of the women in the society. It is practiced mostly in Africa, but migration has revolutionized its spread to almost all parts of the world. The government and the constituted authorities, our traditional rulers, the legislative, the judiciary, and the law enforcement agents have the machineries to stop this inhuman behavior, but they lack the will and the necessary information about the incidence and consequences of FGM. The review involved Internet and literature search mostly those written on the African continent and some that were specific to Nigeria from 1999 to 2018. This article reviewed the spread, the obstetrics and the gynecological complications, the roles of the traditional circumcisers, and the negative and the positive roles of the caregivers, especially its medicalization in the abandonment of FGM in Nigeria. The article also looked critically at the best ways to achieve zero tolerance to FGM. To achieve the targeted zero tolerance to FGM, the identified factors have to be tackled holistically.
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The roles of anti-citrullinated protein antibodies in the immunopathogenesis of rheumatoid arthritis p. 5
Hui-Chun Yu, Ming-Chi Lu
DOI:10.4103/tcmj.tcmj_116_18  PMID:30692825
Rheumatoid arthritis (RA) is a common systemic autoimmune disease. Its major manifestation is persistent joint inflammation, which can lead to bone destruction and severe disability. The immunopathogenesis of RA is very complex, involving both innate and adaptive immune systems. Recently, the discovery of anti-citrullinated protein antibodies (ACPAs) has revolutionized the diagnosis and our understanding of the immunopathogenesis of RA. The presence of ACPAs is also closely linked to the disease activity of RA. Therefore, it is reasonable to believe that ACPAs and protein citrullination are key issues for the development of RA. We have summarized the recent study results in this review. The first theory concerning the pathogenesis of RA proposed that ACPAs link the well-known genetic and environmental risk factors for developing RA. However, due to the close association between joint inflammation and ACPAs, a more direct role of ACPAs in the immunopathogenesis of RA is anticipated. Within the past 10 years, many studies, including some of our own, have shown that ACPAs can promote an inflammatory response through complement activation, formation of neutrophil extracellular traps, and direct binding to key players, including monocytes, osteoclasts, and osteoblasts, in the mediation of bone destruction in the joints of RA patients. We also present some new perspectives and issues that need to be further investigated.
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ORIGINAL ARTICLES - BASIC Top

Transplanting human umbilical cord mesenchymal stem cells and hyaluronate hydrogel repairs cartilage of osteoarthritis in the minipig model p. 11
Kun-Chi Wu, Yu-Hsun Chang, Hwan-Wun Liu, Dah-Ching Ding
DOI:10.4103/tcmj.tcmj_87_18  PMID:30692826
Objectives: Osteoarthritis (OA) is a chronic disease of degenerative joints. Mesenchymal stem cells (MSCs) have been used for cartilage regeneration in OA. We investigated the therapeutic potential of human umbilical cord-derived MSCs (HUCMSCs) with hyaluronic acid (HA) hydrogel transplanted into a porcine OA preclinical model. Materials and Methods: The HUCMSCs were characterized with respect to morphology, surface markers, and differentiation capabilities. Quantitative reverse-transcriptase polymerase chain reaction (qRT-PCR) was used to examine gene expressions in a HUCMSC–HA coculture. Two healthy female minipigs weighing 30–40 kg and aged approximately 4 months were used in this large animal study. A full-thickness chondral injury was created in the trochlear groove of each of the pig's rear knees. After 3 weeks, a second osteochondral defect was created. Then, 1.5 mL of a HUCMSC (5 × 106 cells) and HA composite (4%) was transplanted into the chondral-injured area in the right knee of each pig. Using the same surgical process, an osteochondral defect (untreated) was created in the left knee as a control. The pigs were sacrificed 12 weeks after transplantation. Macroscopic and microscopic histologies, qRT-PCR, and immunostaining evaluated the degree of chondral degradation. Results: The HUCMSCs exhibited typical MSC characteristics, including spindle morphology, expression of surface markers (positive for CD29, CD4, CD73, CD90, and human leukocyte antigen [HLA]-ABC; negative for CD34, CD45, and HLA-DR), and multipotent differentiation (adipogenesis, osteogenesis, and chondrogenesis). More extensive proliferation of HUCMSCs was noted with 4% and 25% of HA than without HA. Expression of COL2A1 and aggrecan in the HUCMSC-derived chondrocytes was increased when HA was included. The treated knees showed significant gross and histological improvements in hyaline cartilage regeneration when compared to the control knees. The International Cartilage Repair Society histological score was higher for the treated knees than the control knees. Conclusion: Our findings suggest that cartilage regeneration using a mixture of HUCMSCs and HA in a large animal model may be an effective treatment for OA, and this study is a stepping stone toward the future clinical trials.
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Human leukocyte antigen-A*33:03-B*58:01-DRB1*15:140, a deduced probable human leukocyte antigen haplotype in association with a human leukocyte antigen low-incidence allele DRB1*15:140 in Taiwanese individuals: A case analysis p. 20
Kuo-Liang Yang, Zheng-Zhong Zheng
DOI:10.4103/tcmj.tcmj_72_18  PMID:30692827
Objective: Human leukocyte antigen (HLA)-DRB1*15:140 is a low-frequency allele in the HLA-DRB1 locus. The aim of this study is to confirm the ethnicity of DRB1*15:140 and to deduce a probable HLA-DRB1*15:140-associated HLA haplotype in Taiwanese individuals. Materials and Methods: A total of 1815 healthy unrelated Taiwanese individuals and 14,562 unrelated mainland Chinese individuals were tested for HLA using a sequence-based typing method. Polymerase chain reaction was performed to amplify exons 2 and 3 of the HLA-A and HLA-B loci and exons 1 and 2 of the HLA-DRB1 locus using group-specific primer sets. The amplicons were sequenced in both directions with the BigDye Terminator Cycle Sequencing Ready Reaction Kit according to the manufacturer's protocols. Results: The DNA sequence of HLA-DRB1*15:140 is identical to DRB1*15:02:01:01 in exons 1 and 2, except at residue 91 of DRB1*15:02:01:01 where a G in DRB1*15:02:01:01 is replaced by an A in DRB1*15:140 (codon 2; GAC->AAC). The nucleotide substitution in exon 1 introduces a one amino acid substitution at residue 2 where an aspartic acid (D) in DRB1*15:02:01:01 is replaced by an asparagine (N) in DRB1*15:140. We deduced the probable HLA haplotype associated with DRB1*15:140 in Taiwanese to be HLA-A*33:03-B*58:01-DRB1*15:140. Conclusion: Information on the ethnicity and distribution of DRB1*15:140 and its deduced probable HLA haplotype in association with the low-incidence allele is of value for HLA-testing laboratories for reference purposes and can help bone marrow donor registries find compatible donors for patients with this uncommon HLA allele.
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ORIGINAL ARTICLES - CLINICAL RESEARCH Top

Osteocalcin and carotid–femoral pulse wave velocity in patients on peritoneal dialysis p. 23
Po-Jui Chi, Yu-Li Lin, Jen-Pi Tasi, Chih-Hsien Wang, Jia-Sian Hou, Chung-Jen Lee, Bang-Gee Hsu
DOI:10.4103/tcmj.tcmj_12_18  PMID:30692828
Objective: Vascular calcification is a cardiovascular risk factor in dialysis patients. Vascular calcification involves a complex process of biomineralization resembling osteogenesis, which leads to arterial stiffness. Osteocalcin is the most abundant noncollagenous protein in the bone matrix. It is synthesized in the bone by osteoblasts and reflects the rate of bone formation. The aim of this study was to evaluate the relationship between serum osteocalcin levels and the carotid–femoral pulse wave velocity (cfPWV) in peritoneal dialysis (PD) patients. Materials and Methods: Serum intact osteocalcin and cfPWV were measured in 62 PD patients. Those with CfPWV values >10 m/s were defined as the high central arterial stiffness group, while those with values ≤10 m/s were regarded as the low central arterial stiffness group, according to the European Society of Hypertension and of the European Society of Cardiology guidelines. Results: Seventeen of the 62 PD patients (27.4%) were in the high central arterial stiffness group. The high central arterial stiffness group were older (P = 0.002), had a longer PD vintage (P = 0.018), and had higher serum osteocalcin levels (P = 0.001) than those in the low group. Multivariate logistic regression analysis showed that the osteocalcin level (odds ratio: 1.069, 95% confidence interval (CI): 1.005–1.137, P = 0.035), PD vintage (odds ratio: 1.028, 95% CI: 1.010–1.048, P = 0.003), and age (odds ratio: 1.081, 95% CI: 1.005–1.162, P = 0.035) were independently associated with central arterial stiffness in PD patients. Among these patients, cfPWV (ρ: 0.216, P = 0.001) values and log-transformed intact parathyroid hormone (ρ: −'0.447, P < 0.001) levels were independently associated with the osteocalcin level in PD patients after multivariate forward stepwise linear regression analysis. Conclusion: Older PD patients with a longer PD vintage and higher serum osteocalcin levels had higher central arterial stiffness as measured by cfPWV. The serum osteocalcin level is an independent marker of central arterial stiffness in PD patients.
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Ovo-lactovegetarian diet as a possible protective factor against gallbladder polyps in Taiwan: A cross-sectional study p. 29
Hao-Wen Liu, Cheng-Yu Chen
DOI:10.4103/tcmj.tcmj_16_18  PMID:30692829
Objective: Gallbladder polyps (GBPs) are an increasingly common incidental finding and 3% to 8% of GBPs become malignant. A poor prognosis is expected in patients with gallbladder cancer. No studies have considered the relationship between diet and the development of GBPs in the Taiwanese population. The objective of this study was to investigate whether a vegetarian diet protects against GBP development. Materials and Methods: This cross-sectional study included 11,717 individuals who received a health checkup at Taipei Tzu Chi Hospital (New Taipei City, Taiwan) between October 2011 and October 2016. All individuals completed questionnaires that collected data about their characteristics, dietary patterns, and lifestyle. Physical examinations were conducted, and blood chemistry tests were performed. The presence of GBPs was determined using ultrasonography. We subsequently evaluated the association between diet and GBP prevalence using multivariate analysis. Results: The prevalence of GBPs for the entire group was 8.3%. GBPs were significantly less common in the vegetarian groups (vegans 9.0%, ovo-lacto vegetarians 7.5%, and semi-vegetarians 7.2%) compared with the omnivore group (9.6%) (P = 0.002). Step-wise logistic regression revealed that an ovo-lacto vegetarian diet was a possible protective factor (odds ratio = 0.83, P = 0.015). Conclusions: The study findings showed a strong negative association between an ovo-lacto vegetarian diet and GBP occurrence.
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Treatment outcomes for multidrug-resistant tuberculosis in Eastern Taiwan p. 35
Chih-Bin Lin, Hung-Chieh Sun, Chen-Yuan Chiang, Che-Wei Wu, Hsu-Wen Chou, Tao-Qian Tang, Jen-Jyh Lee
DOI:10.4103/tcmj.tcmj_18_18  PMID:30692830
Objectives: The objective of this study is to evaluate the treatment outcomes of patients with multidrug-resistant tuberculosis (MDR-TB) under special programmatic management in Eastern Taiwan over the past 10 years. Materials and Methods: All newly diagnosed MDR-TB patients and MDR-TB patients enrolled previously with persistent positive cultures were included in this study, from May 2007 to April 2017, in Eastern Taiwan. A panel of pulmonologists designed the initial MDR-TB regimens. Subsequently, regimens were adjusted according to drug susceptibility test results for second-line drugs. Mobile teams were organized for treatment support, and several measures were adapted to safeguard effective treatment support. Results: A total of 178 patients with bacteriological confirmed pulmonary MDR-TB were identified, of whom 167 had treatment outcomes when the study was conducted. Of these 167 patients, 120 (71.9%) were cured, 11 (6.5%) completed therapy (78.4% had successful treatment), 25 (15.0%) died, 9 (5.4%) had treatment failure, none were transferred out, and 2 (1.2%) were lost to follow-up. Surgery was performed on 8 (4.8%). Conclusions: This is an analysis of the treatment outcomes after adopting the Directly Observed Treatment, Short-course Plus program to treat MDR-TB patients in Eastern Taiwan. We had a low proportion of loss-to-follow-up, resulting in a high treatment success rate. This program serves as an effective model in providing quality care to patients with MDR-TB.
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Prognosticators of hepatocellular carcinoma with intrahepatic vascular invasion p. 40
Yuan-Chen Lo, Feng-Chun Hsu, Shih-Kai Hung, Kuo-Chih Tseng, Yu-His Hsieh, Moon-Sing Lee, Chih-Wei Tseng, Hon-Yi Lin, Liang-Cheng Chen, Wen-Yen Chiou
DOI:10.4103/tcmj.tcmj_14_18  PMID:30692831
Objective: The prognosis of intrahepatic vascular invasion, including unilateral or main portal vein tumor thrombosis (PVTT) and hepatic vein thrombosis, is still poor. Many patients with intrahepatic vascular invasions never receive radiotherapy (RT). In recent years, more conformal RT techniques such as intensity-modulated RT (IMRT) have been developed and applied to treat other cancers and have significantly improved treatment results and decreased side effects. The purpose of this study is to evaluate the treatment results in patients with intrahepatic vascular invasion and explore the role of IMRT in these treatments. Materials and Methods: There were a total of 73 patients with newly diagnosed AJCC stage IIIB hepatocellular carcinoma (HCC), with either PVTT or hepatic vein tumor thrombosis between 2007 and 2015 in our hospital. IMRT was used for all patients who received RT. Prognostic factors, including treatment modalities, liver function, and comorbidities, were analyzed using univariate and multivariate analysis with the Cox model. Survival time was analyzed using the Kaplan–Meier method. Results: The longest follow-up time was 45.3 months. The median age was 67 years. Univariate analyses indicated that IMRT, transarterial chemoembolization (TACE), target therapy (sorafenib), tumor size, Child-Pugh class, and ascites were significantly associated with overall survival (OS). In multivariate analysis, IMRT (hazard ratio [HR], 0.495; P = 0.019), sorafenib (HR, 0.340; P = 0.013), tumor size (HR, 2.085; P = 0.020), and Child-Pugh class (P = 0.004), were independent prognostic predictors for patients with intrahepatic vessel invasion, but TACE and ascites were not. The outcomes of patients who had different treatment modalities were significantly different (P < 0.001). Patients who received IMRT with TACE had the best outcomes. Patients who received an RT dose above 5400 cGy had better outcomes than those who with a dose below 5400 cGy, although the results were not significantly different (P = 0.248). Conclusion: IMRT is an important treatment component for patients with intrahepatic vascular invasion. Combined treatment modalities, such as IMRT with TACE, could improve the outcomes of HCC patients with intrahepatic vessel invasion.
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Medium-term clinical outcomes of laminoplasty with adjunct short anterior fusion in multilevel cervical myelopathy p. 47
Tsung-Chiao Wu, Kuang-Ting Yeh, Ru-Ping Lee, Tzai-Chiu Yu, Ing-Ho Chen, Cheng-Huan Peng, Kuan-Lin Liu, Jen-Hung Wang, Wen-Tien Wu
DOI:10.4103/tcmj.tcmj_22_18  PMID:30692832
Objectives: Expansive open-door laminoplasty (EOLP) is effective for multilevel cervical spondylotic myelopathy (MCSM). When MCSM is combined with one- or two-level segmental kyphosis, instability, or major anterior foci, EOLP with short-segment anterior cervical fusion (ACF) results in good short-term neurological recovery and can preserve postoperative range of motion (ROM). The objective of this study was to evaluate the medium-term clinical outcomes of this procedure and to analyze the risk factors affecting the neurological function at the last follow-up. Materials and Methods: A total of 87 patients were enrolled in this retrospective study conducted from January 2007 to May 2011. These patients exhibited MCSM with combined short segmental kyphosis, instability, or major anterior pathology, and received EOLP and short-segment anterior fusion. The follow-up period lasted at least 60 months. The radiographic outcomes were collected from plain radiographs with dynamic views checked preoperatively and at the last follow-up. Neurological status and visual analog scale scores for neck pain were evaluated. Logistic regression analysis was then applied to determine the correlation between radiographic parameters and rates of neurological recovery. Results: The mean Japanese Orthopedics Association recovery rate at the last follow-up was 77.8%. The improvement in functional scores and reduction in neck pain were statistically significant. The most influential risk factor affecting neurologic recovery was preoperative functional status. Conclusions: EOLP followed by short-segment ACF is a favorable treatment for patients with MCSM with concomitant short-segment kyphosis, instability, or major anterior pathology.
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Magnetic resonance angiography determined variations in the circle of Willis: Analysis of a large series from a single center p. 52
Reddy Ravikanth, Babu Philip
DOI:10.4103/tcmj.tcmj_167_17  PMID:30692833
Objective: The purpose of this study is to evaluate and describe the prevalence and patterns of arterial variants in the circle of Willis (CW) seen in noncontrast three-dimensional time-of-flight magnetic resonance angiography in a series of patients with cerebral vascular accidents (CVAs). Materials and Methods: A descriptive study was undertaken in 200 patients who presented for screening for CVA in the Department of Radiodiagnosis and Imaging, St. John's Medical College Hospital, Bengaluru, from September 2014 to September 2016. Results: The most common types of CW in a single subject were anterior variant Type A and posterior variant Type E. Type A in the anterior circulation is the normal adult pattern. There is a single anterior communicating artery. The internal carotid artery bifurcates into the precommunicating segment of the anterior cerebral artery and middle cerebral artery. Type E in the posterior circulation is hypoplasia or absence of both posterior communicating arteries and isolation of the anterior and posterior parts of the circle at this level. Overall, CW variants were slightly more common in women than in men. Conclusion: Our findings show that the configuration of the CW may vary greatly in the general population. The wide range in the morphology of CW warrants further research on various races and larger populations to confirm the influence of genetic, regional, environmental, and hemodynamic factors or their combination.
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CASE REPORTS Top

Janus kinase 2 V617F mutation in an unrelated peripheral blood stem cell donor p. 60
Shang-Hsien Yang, Hsiang-Lin Wan, Ming-Hui Gu, Tso-Fu Wang
DOI:10.4103/tcmj.tcmj_189_17  PMID:30692834
Polycythemia vera (PV) is relatively uncommon in early adulthood, and evidence about the prevalence of the Janus kinase 2 (JAK2) V617F mutation in the general population is limited. Here, we report a previously healthy volunteer peripheral blood stem cell (PBSC) donor who developed symptomatic PV with the JAK2 V617F mutation 2 years after PBSC mobilization and harvest. The characteristic mutation was identified retrospectively in the blood sample of the donor at the confirmation typing stage, which was before granulocyte colony-stimulating factor injection. This report presents a safety issue for both donor and recipient of hematopoietic stem cell transplantation. Clinicians should be aware of this during health workup and postdonation follow-up of unrelated PBSC donors. Any abnormal and/or equivocal laboratory data, especially during the donor workup stage, should not be overlooked.
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A rare case of septic cavernous sinus thrombosis as a complication of sphenoid sinusitis p. 63
Ming-Chun Chen, Yu-Huai Ho, Pau-Nyen Chong, Jui-Hsia Chen
DOI:10.4103/tcmj.tcmj_1_18  PMID:30692835
Isolated sphenoid sinusitis is a rare disorder and may present with severe complications due to its proximity to the orbital and intracranial areas. We report a 13-year-old boy hospitalized for septic shock with fever of unknown origin. Facial palsy was later noted. Brain magnetic resonance imaging showed a sphenoid mass and right cavernous sinus and internal jugular vein thrombosis. Biopsy revealed chronic rhinosinusitis. Complete recovery followed by an incision/drainage procedure and antibiotic treatment. Acute sphenoid sinusitis should be included in the differential diagnosis of septic manifestations mimicking central nervous system infection or cranial nerve palsy.
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LETTER TO THE EDITOR Top

Dengue fever with chikungunya concurrent infection p. 66
Pathum Sookaromdee, Viroj Wiwanitkit
DOI:10.4103/tcmj.tcmj_121_18  PMID:30692836
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