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   Table of Contents - Current issue
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October-December 2018
Volume 30 | Issue 4
Page Nos. 195-257

Online since Monday, September 24, 2018

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REVIEW ARTICLES - CLINICAL  

Individualizing medical treatment of overactive bladder p. 195
Hann-Chorng Kuo
DOI:10.4103/tcmj.tcmj_83_18  PMID:30305780
Overactive bladder (OAB) syndrome is highly prevalent in both men and women and might have negative impact on quality of life. Clinical trials of OAB usually highly select participants that may not reflect the real-world practice of OAB patients. The spectrum of OAB includes patients with idiopathic, neuropathic, with bladder outlet obstruction, and patients in elderly and medical comorbidities. Patients might have poor response to OAB medication or have adverse events after treatment. Therefore, treatment of OAB should be individualized to obtain therapeutic efficacy and avoid unacceptable adverse events. This article reviews the recently published literature and provides a guide for physicians to choose the appropriate treatment for different OAB patients.
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Impact of vegan diets on gut microbiota: An update on the clinical implications Highly accessed article p. 200
Ming-Wun Wong, Chih-Hsun Yi, Tso-Tsai Liu, Wei-Yi Lei, Jui-Sheng Hung, Chin-Lon Lin, Shinn-Zong Lin, Chien-Lin Chen
DOI:10.4103/tcmj.tcmj_21_18  PMID:30305781
Numerous studies indicate that microbiota plays an important role in human health. Diet is a factor related to microbiota which also influences human health. The relationships between diet, microbiota, and human health are complex. This review focuses on the current literature on vegan diets and their unique impact on gut microbiota. We also report on the health benefits of a vegan diet for metabolic syndrome, cardiovascular disease, and rheumatoid arthritis concerning relevant impacts from gut microbiota. Despite evidence supporting the clinical relevance of vegan gut microbiota to human health, the whole mechanism awaits further investigation.
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Treatment strategies for neuromyelitis optica p. 204
Tzu-Lun Huang, Kung-Hung Lin, Jia-Kang Wang, Rong-Kung Tsai
DOI:10.4103/tcmj.tcmj_102_18  PMID:30305782
Neuromyelitis optica (NMO) is an autoimmune demyelinating disease with pathogenic autoantibodies that act against the astrocyte water channel protein, i.e. aquaporin-4: the disease is associated with recurrent episodes of optic neuritis (ON) and transverse myelitis, often resulting in severe disability. The main goals in treatment of NMO include acute symptomatic therapy and long-term stabilization of symptoms by preventing relapse. In recent years, ongoing randomized controlled trials in NMO patients have studied evidence for treatment. Briefly, acute-stage management (with pulse therapy using corticosteroids and/or plasmapheresis) and maintenance therapy (including rituximab, mycophenolate mofetil, and azathioprine) have been recommended in some case series and retrospective studies. Because of the high prevalence of liver disease, all NMO patients in Taiwan should be screened for hepatitis B and C before treatment is initiated. Although immunosuppression and plasma exchange are the mainstays of therapy for NMO ON, several selective and potentially therapeutic strategies targeting specific steps in NMO pathogenesis including blockers of NMO-IgG binding and inhibitors of granulocyte function have been evaluated in recent years.
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Clinical manifestations and basic mechanisms of myocardial ischemia/reperfusion injury p. 209
Chiu-Fen Yang
DOI:10.4103/tcmj.tcmj_33_18  PMID:30305783
Acute myocardial ischemia/reperfusion (I/R) injury is a significant, unsolved clinical puzzle. In the disease context of acute myocardial infarction, reperfusion remains the only effective strategy to salvage ischemic myocardium, but it also causes additional damage. Myocardial I/R injury is composed of four types of damage, and these events attenuate the benefits of reperfusion therapy. Thus, inventing new strategies to conquer I/R injury is an unmet clinical need. A variety of pathological processes and mediators, including changes in the pH, generation of reactive oxygen radicals, and intracellular calcium overload, are proposed to be crucial in I/R-related cell injury. Among the intracellular events that occur during I/R, we stress the importance of protein phosphorylation signaling and elaborate its regulation. A variety of protein kinase pathways could be activated in I/R, including reperfusion injury salvage kinase and survivor-activating factor enhancement pathways, which are critical to cardiomyocyte survival. In addition to serine/threonine phosphorylation signaling, protein tyrosine phosphorylation is also critical in multiple cell functions and survival. However, the roles of protein kinases and phosphatases in I/R have not been extensively studied yet. By better understanding the mechanisms of I/R injury, we may have a better chance to develop new strategies for I/R injury and apply them in the clinical patient care.
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ORIGINAL ARTICLES - CLINICAL RESEARCH Top

Sensorineural hearing loss in patients with chronic renal failure on hemodialysis in Basrah, Iraq p. 216
Haider K Saeed, Ahmed M Al-Abbasi, Shukryia K Al-Maliki, Jasim N Al-Asadi
DOI:10.4103/tcmj.tcmj_149_17  PMID:30305784
Objectives: The objective of this study is to determine the effect of hemodialysis on the hearing threshold in patients with chronic renal failure (CRF). Materials and Methods: Fifty-nine patients with CRF on regular hemodialysis were followed up for 1 year with a pure-tone audiometric examination every 6 months. Results: The mean age of the patients was 41.8 ± 9.2 years (range: 17–50 years). At the beginning of the study, 39 patients (66.1%) had sensorineural hearing loss (SNHL). During the 12-month follow-up, 6 more patients developed SNHL giving a point prevalence rate of 76.3% at the end of the study. The hearing loss was more evident in the higher frequencies. Of the studied patients, 64.4% showed deterioration of the hearing threshold. The mean hearing threshold at the beginning of the study was 29.2 ± 21.1 dB versus 36.9 ± 17.3 dB at the end of the study (P < 0.001). No significant relation was found between age, sex, serum electrolytes, blood urea, and duration of CRF and hearing loss. Multivariate analysis showed that the duration of hemodialysis was the only significant independent predictor of SNHL. Conclusion: SNHL is common in patients with CRF on hemodialysis. It was mild to moderate in the majority of patients. Hearing impairment was most obvious at the high frequencies. Most of the patients showed further deterioration in the hearing threshold with the duration of dialysis.
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Assessment of perceived stress and association with sleep quality and attributed stressors among 1st-year medical students: A cross-sectional study from Karwar, Karnataka, India p. 221
Clevin Rashmi Rebello, Prasad Budri Kallingappa, Preethi G Hegde
DOI:10.4103/tcmj.tcmj_85_17  PMID:30305785
Objectives: The objective is to study the extent of perceived stress among 1st-year medical students using the Perceived Stress Scale-14 (PSS-14) and its association with sleep quality as assessed by the Pittsburgh Sleep Quality Index (PSQI) and attributed stressors. Materials and Methods: A cross-sectional study was conducted of 121 1st-year medical students at Karwar Institute of Medical Sciences, Karwar, Karnataka, India. The extent of their stress was assessed using the PSS-14 and their sleep quality was assessed using the PSQI. Graded stress exerted by the attributed stressors was also assessed. Results: A total of 33.8% of participants had perceived stress scores of >28. Among academic stressors, performance in examinations (34.7%), lack of time for recreation (30.6%), curriculum (24.8%), and frequency of examinations (24.8%) were the highest rated stressors. Quality of food in the mess (50.4%) and lack of entertainment in the institution (39.7%) were the highest rated psychosocial stressors. There was a positive correlation between the PSS-14 scores and various academic stressors and the global PSQI score. Conclusion: First-year medical students reported a high level of stress, including academic and psychosocial stressors. Effective changes in the curriculum and living conditions can reduce the level of stress among these students.
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High serum leptin levels are associated with central arterial stiffness in geriatric patients on hemodialysis p. 227
Chiu-Huang Kuo, Yu-Li Lin, Chih-Hsien Wang, Yu-Hsien Lai, Ru-Jiang Syu, Bang-Gee Hsu
DOI:10.4103/tcmj.tcmj_10_18  PMID:30305786
Objective: Central arterial stiffness predicts cardiovascular (CV) mortality in hemodialysis (HD) patients. The aging process transforms lipid distribution and thus alters adipokine secretion. The harmful effects of leptin on CV events may change in the elderly. The purpose of this study was to investigate the relationship between leptin and central arterial stiffness markers through carotid–femoral pulse wave velocity (cfPWV) in geriatric HD patients. Materials and Methods: Patients over 65 years old on chronic HD were recruited. Blood samples were collected, and the cfPWV was measured with the SphygmoCor system. The patients with cfPWV values >10 m/s were defined as the high arterial stiffness group. Results: In total, 30 (51.7%) of the 58 geriatric patients on chronic HD in this study were in the high arterial stiffness group. The high arterial stiffness group had higher rates of diabetes mellitus (P = 0.019), hypertension (P = 0.019), and higher systolic blood pressure (P = 0.018), pulse pressure (P = 0.019), body mass index (P = 0.018), serum leptin levels (P = 0.008), and hemoglobin levels (P = 0.040) than those in the low arterial stiffness group. Multivariable forward stepwise linear regression analysis showed logarithmically transformed leptin (log-leptin, β =0.408, adjusted R2 change = 0.164; P = 0.001) and diabetes (β =0.312, adjusted R2 change = 0.085; P = 0.009) were associated with cfPWV values in geriatric HD patients. Moreover, an increased serum leptin level (odds ratio: 1.053; 95% confidence interval: 1.007–1.100; P = 0.023) was an independent factor for central arterial stiffness among geriatric HD patients after multivariate logistic regression analysis. Conclusion: In this study, a higher serum leptin level was correlated with central arterial stiffness in geriatric HD patients.
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Increased prevalence of obstructive sleep apnea in patients with pectus excavatum: A pilot study p. 233
Yeung-Leung Cheng, I-Shiang Tzeng, Mei-Chen Yang
DOI:10.4103/tcmj.tcmj_115_17  PMID:30305787
Objective: Laryngomalacia is the most common congenital laryngeal anomaly and is associated with pectus excavatum (PE). Patients with laryngomalacia and patients with obstructive sleep apnea (OSA) both experience upper airway obstruction, and patients with laryngomalacia had been found to have a higher prevalence of PE. However, no studies have established the prevalence of OSA in patients with PE. We conducted this pilot study to evaluate the prevalence of OSA in patients with PE. Materials and Methods: A total of 42 patients ≥20 years old with PE who were admitted for Nuss surgery to correct PE in Taipei Tzu Chi Hospital between October 2015 and September 2016 were invited to participate in the study; 31 of the 42 patients agreed. All 31 patients completed an Epworth sleepiness scale questionnaire to evaluate excessive daytime sleepiness (EDS) and underwent overnight polysomnography to evaluate OSA before Nuss surgery. Results: The prevalence of snoring in the study participants was 100%. Ten of 31 patients (32.3%) reported EDS. The overall prevalence of OSA with an apnea/hypopnea index ≥5/h was 25.8%, and all patients with OSA were men. Conclusions: The prevalence of OSA in patients with PE seemed to be higher than that previously reported in the general population, implying that OSA might be a potential etiology or, at least, an aggravating factor for the development or progression of PE or might be responsible for the postoperative recurrence of PE in some patients. Further studies are needed to clarify this relationship.
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Passive limb movement test facilitates subthalamic deep brain stimulation under general anesthesia without influencing awareness p. 238
Sheng-Tzung Tsai, Shee-Ping Chen, Sheng-Huang Lin, Shinn-Zong Lin, Shin-Yuan Chen
DOI:10.4103/tcmj.tcmj_17_18  PMID:30305788
Objectives: We have shown that neuronal activity in the subthalamic nucleus (STN) in patients with Parkinson's disease can be accurately recorded during deep brain stimulation (DBS) with general anesthesia (GA). However, a vigorous passive range of motion (PROM) test might exert awakening effects on patients who are lightly anesthetized. We will explore the effects of PROM on the heart rate (HR) and mean arterial pressure (MAP) during microelectrode recording (MER) and confirm whether it facilitates identifying the sensory motor portion of the STN under GA. Materials and Methods: 3T magnetic resonance image targeting of the STN was done to guide MER during frame-based stereotactic procedures for DBS. Regular induction and endotracheal intubation for GA were performed and then maintained with a volatile anesthetic agent and muscle relaxant only. The depth of anesthesia was monitored by the bispectral index (BIS). Results: A total of ten patients were enrolled in this study. Their mean age was 48.5 ± 10.8 years old with a disease duration 8.6 ± 2.4 years at the time of surgery. During MER, PROM significantly decreased recording tract numbers and still reached the STN at a recorded length at 5.5 ± 0.8 mm. Compared with baseline, PROM increased HR by a mean 0.5 beats/min and MAP by a mean 1.4 mmHg (P = 0.1178 and 0.0525). The change in BIS was −0.7 (P = 0.4941), and the mean alveolar concentration of the anesthetic agent changed little throughout surgery. Conclusions: PROM was effective in triggering and magnifying neuronal firing signal without influencing patient awareness during MER for STN-DBS under GA.
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Open reduction and internal fixation with plating is beneficial in the early recovery stage for displaced midshaft clavicular fractures in patients aged 30–65 years old p. 242
Jian-Yuan Chu, 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_25_18  PMID:30305789
Objectives: Midshaft clavicular fractures are increasingly treated operatively rather than nonoperatively. Studies have shown mixed results for both types of treatment. The aim of this study was to compare the early-stage functional status associated with open reduction and internal fixation (ORIF) with plating and that associated with conservative treatment for displaced midshaft clavicular fractures. Materials and Methods: A single-center retrospective review of the results of 120 cases of displaced midshaft clavicular fractures in patients aged 30–65 years old was conducted. The primary outcome was fracture union status at 6 months. Other outcomes were subjective shoulder value (SSV) scores, visual analog scale (VAS) scores, and radiographic shortening at 6 weeks, 3 months, and 6 months. The complication rates in the operative and nonoperative groups were recorded. Results: The delayed union rate at 6-month postoperatively and VAS scores at 6 weeks, 3 months, and 6 months postinjury were significantly higher in the conservative treatment group than in the ORIF group. SSV scores were significantly improved at 6-month postinjury in the ORIF group. Conclusions: This is the first study to discuss the importance of early-stage functional restoration after ORIF with plating for displaced midshaft clavicular fractures. This surgery leads to lower pain complications in the earlier stages of bone healing and lower delayed union rates compared with conservative treatment, in patients aged 30–65 years old.
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CASE REPORTS Top

Spontaneous colonic rupture related to the segmental absence of muscularis propria in an adult p. 247
Chih-En Tseng, Shih-Pin Lin, Hou-Chi Huang, Mei-Chung Chin
DOI:10.4103/tcmj.tcmj_143_17  PMID:30305790
Colonic perforation is a medical emergency that may be fatal if surgery cannot be performed in a timely manner. Colonic rupture in adults is caused by primary (idiopathic) and secondary factors. Although the segmental absence of muscularis propria (SAMP) is a recognized cause of secondary colonic rupture in neonates and infants, few cases have been reported in adults. Here, we present the case of a large colonic rupture caused by SAMP in a 60-year-old woman and a review of the literature. We suggest that SAMP should be included in the differential diagnosis of large perforation and/or periperforation membranous thinning of the colonic wall in adults.
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Early renal arterial rupture and arterial pseudoaneurysm in graft kidneys from the same deceased donor p. 250
Yu-Hua Lin, Chun-Hou Liao, Bing-Jun Jiang, Tzu-Hung Chen
DOI:10.4103/tcmj.tcmj_180_17  PMID:30305791
Vascular complications are serious problems after kidney transplantation. An aneurysm or rupture in a graft artery is a rare but potentially devastating complication, which may lead to renal function impairment, graft loss, or even death. In this paper, we present two rare vascular complications in the early postoperative course after renal transplantation from the same deceased donor. In the first case, a 49-year-old woman who had spontaneous graft arterial rupture 13 days after kidney transplantation presented with sudden distension in the right lower abdomen. In the second case, a 56-year-old woman recipient with a graft renal arterial pseudoaneurysm presented with decreased urine output and deteriorating renal function 32 days after transplantation. Immediate surgical repair was performed, and fibrin sealant was applied to strengthen the fragile renal arterial wall. Although the function of both graft kidneys recovered well after surgery, the first graft kidney was removed 2 months later because of repeated fungal and bacterial infections. Aggressive surgical reconstruction may preserve graft kidneys in patients with vascular complications after kidney transplantation, but recovery of the graft condition remains a demanding challenge in renal transplantation.
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IMAGES IN CLINICAL MEDICINE Top

Multiple preretinal yellowish dots in a patient with syphilis p. 255
Chi-Ting Horng, Ping-Feng Tsai, Ming-Ling Tsai
DOI:10.4103/tcmj.tcmj_79_18  PMID:30305792
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CORRIGENDUM Top

Corrigendum: Open reduction and internal fixation with plating is beneficial in the early recovery stage for displaced midshaft clavicular fractures in patients aged 30–65 years old p. 257

DOI:10.4103/1016-3190.234515  PMID:30305793
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