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   Table of Contents - Current issue
Coverpage
April-June 2021
Volume 33 | Issue 2
Page Nos. 101-201

Online since Monday, March 29, 2021

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REVIEW ARTICLES - CLINICAL  

Will repeated botulinum toxin A improve detrusor overactivity and bladder compliance in patients with chronic spinal cord injury? p. 101
Sheng-Fu Chen, Hann-Chorng Kuo
DOI:10.4103/tcmj.tcmj_77_20  
Chronic spinal cord injury (SCI) can induce neurogenic detrusor overactivity (NDO), leading to urinary incontinence and renal damage due to low bladder compliance and high detrusor pressure during the storage and voiding of urine. In 2011, Botox® (onabotulinumtoxinA, botulinum neurotoxin serotype A [BoNT-A]) was approved by the Food and Drug Administration for the treatment of NDO. Intradetrusor injection of BoNT-A has been shown to have clinical utility for the treatment of urinary incontinence, with consequent improvements in quality of life for patients. In the past 20 years, this treatment has been shown to be an effective treatment for patients with SCI refractory to antimuscarinic medication. The present review focused on publications in MEDLINE/PubMed relating to botulinum toxin to evaluate the treatment outcomes of repeated injection of BoNT-A, the mechanisms of action, results of clinical and urodynamic studies, and adverse effects.
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A review of water exchange and artificial intelligence in improving adenoma detection p. 108
Chia-Pei Tang, Paul P Shao, Yu-Hsi Hsieh, Felix W Leung
DOI:10.4103/tcmj.tcmj_88_20  
Water exchange (WE) and artificial intelligence (AI) have made critical advances during the past decade. WE significantly increases adenoma detection and AI holds the potential to help endoscopists detect more polyps and adenomas. We performed an electronic literature search on PubMed using the following keywords: water-assisted and water exchange colonoscopy, adenoma and polyp detection, artificial intelligence, deep learning, neural networks, and computer-aided colonoscopy. We reviewed relevant articles published in English from 2010 to May 2020. Additional articles were searched manually from the reference lists of the publications reviewed. We discussed recent advances in both WE and AI, including their advantages and limitations. AI may mitigate operator-dependent factors that limit the potential of WE. By increasing bowel cleanliness and improving visualization, WE may provide the platform to optimize the performance of AI for colonoscopies. The strengths of WE and AI may complement each other in spite of their weaknesses to maximize adenoma detection.
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Arterial stiffness: A brief review p. 115
Jen-Pi Tsai, Bang-Gee Hsu
DOI:10.4103/tcmj.tcmj_44_20  
Apart from the result of multiple diseases as well as aging, arterial stiffness (AS) predicts cardiovascular disease (CVD), especially in patients with chronic kidney disease (CKD). Patients with CKD have high CVD prevalence, and an extraordinarily high risk for CVD might be related to nontraditional risk factors, including AS. The mechanism of AS development could be attributed to oxidative stress, inflammation, uremic milieu (e.g., uremic toxins), vascular calcification, and cumulative effects of traditional cardiovascular risk factors on arteries such as diabetes mellitus or hypertension. There were a variety of non-invasive techniques to measure AS. One of these techniques is carotid–femoral pulse wave velocity, which is the reference measurement of AS and is related to long-term CVD outcomes. AS progression has corresponding medical treatments with modest beneficial results. This review briefly discusses the risk factors, measurements, and treatments associated with AS.
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Chinese herbs and acupuncture to improve cognitive function in Alzheimer's disease p. 122
Wei WuLi, Horng-Jyh Harn, Tzyy-Wen Chiou, Shinn-Zong Lin
DOI:10.4103/tcmj.tcmj_51_20  
Alzheimer's disease (AD) is a neurodegenerative disease with a variety of causes. Traditional Chinese medicine (TCM), which includes the two main approaches of acupuncture and herbal medication, views the human body as a self-controlled system network. Fundamental theories, including “qi,” the five elements, and the theory of viscera, form the basis for classification. Diseases in humans are considered to be caused by an imbalance of “yang qi” and “yin qi” that lead to the nonhomeostasis of organs. Acupuncture is derived from 12 main meridians and 365 acupuncture points characterized by “blood and qi.” Needling of different positions corresponds to specific disease treatments to increase qi. Treatment with Chinese herbal medicines is based on syndrome differentiation characterized as “Zheng” which differs from the cause orientation approach of Western medicine. In this article, we review basic and clinical research studies that describe TCM herbs and acupuncture for the treatment of AD. Moreover, we propose that these two approaches be integrated to improve the outcomes for AD patients.
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Effects of vegetarian diet on bone mineral density Highly accessed article p. 128
Tzyy-Ling Chuang, Chun-Hung Lin, Yuh-Feng Wang
DOI:10.4103/tcmj.tcmj_84_20  
Factors, such as hormonal changes in postmenopausal women, natural aging degeneration, race, gender, body size, lifestyle, physical activity, sunlight, dietary intake, medications, or other environmental issues, can affect the rate of bone formation or reabsorption, cause changes in bone mineral content, and influence the development of osteoporosis. Do vegetarian diets adversely affect bone mineral density (BMD)? Among postmenopausal Buddhists, long-term practitioners of vegan vegetarian were found to have a higher risk exceeding the lumbar fracture threshold and a lower level of hip BMD after controlling for other variables. However, results of several prospective longitudinal studies failed to show a harmful effect of vegetarianism on bone health. In the Taiwanese adult population, researchers also did not find that a vegetarian diet significantly affects age-related BMD decline. Due to the various levels of nutrients in the diet (such as protein, alkali, calcium, Vitamin K, and phytoestrogens) and major lifestyle factors (such as smoking and physical exercise), determining the impact of a vegetarian diet on bone health is very complex. Good-quality vegetarian food can provide a healthy foundation for building and maintaining healthy bones and preventing fractures.
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Role of diet and lifestyle modification in the management of nonalcoholic fatty liver disease and type 2 diabetes p. 135
Orsu Prabhakar, Mylipilli Bhuvaneswari
DOI:10.4103/tcmj.tcmj_86_20  
Nonalcoholic fatty liver disease (NAFLD) is considered as the hepatic evidence of insulin resistance which is the hallmark of type 2 diabetes. NAFLD is considered as the risk factor for developing type 2 diabetes and has a high frequency of occurrence in those with existing type 2 diabetes. Compared with patients with only NAFLD or type 2 diabetes, these patients show a poor metabolic profile and increase mortality. Hence, effective treatment strategies are necessary. Here, we review the role of diet and lifestyle modification in the management of NAFLD and type 2 diabetes. Based on the available studies, it has been shown that the addition of any kind of physical activity or exercise is beneficial for patients with both NAFLD and type 2 diabetes. Proper dietary management leads to weight loss are also effective in improving metabolic parameters in patients with both NAFLD and type 2 diabetes. In conclusion, it is clear that increasing physical activity or exercise is effective in improving metabolic parameters in patients who are suffering with both NAFLD and type 2 diabetes.
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ORIGINAL ARTICLE - BASIC RESEARCH Top

Reactivity of human antisera to codon optimized SARS-CoV2 viral proteins expressed in Escherichia coli p. 146
Yee-Huan Toh, Yu-Weng Huang, Yo-Chen Chang, Yi-Ting Chen, Ya-Ting Hsu, Guang-Huey Lin
DOI:10.4103/tcmj.tcmj_189_20  
Objective: The coronavirus disease 2019 (COVID-19) pandemic caused by the SARS-CoV2 virus continues to pose a serious threat to public health worldwide. The development of rapid diagnostic kits can assist the Tzu Chi Foundation in supporting global volunteers working to provide relief during the current pandemic. Materials and Methods: In this study, nucleotide sequences derived from publicly available viral genome data for several domains of the SARS-CoV2 spike and nucleocapsid (N) proteins were chemically synthesized, with codon optimization for Escherichia coli protein expression. No actual viral particles were involved in these experiments. The synthesized sequences were cloned into an E. coli expression system based on pQE80L, and expressed viral proteins were subsequently purified using Ni-affinity chromatography. Western blotting was conducted using human antiviral sera to assess the response of codon-modified viral proteins to COVID-19 patient sera. Results: N protein was expressed in amounts large enough to support large-scale production. The N-terminal domain, receptor-binding domain (RBD), Region 3, and the S2 domain were expressed in small but sufficient amounts for experiments. Immunoblotting results showed that anti-N IgG and anti-N IgM antibodies were detected in most patient sera, but only 60% of samples reacted with the recombinant RBD and S2 domain expressed by E. coli. Conclusion: The results indicated that codon-optimized SARS-CoV2 viral proteins can be expressed in E. coli and purified for rapid antibody detection kit preparation, with the codon-optimized N protein, RBD, and S2 protein demonstrating the most potential.
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ORIGINAL ARTICLES - CLINICAL RESEARCH Top

Diagnostic value of fibroblast growth factor 23 for abdominal aortic calcification in Indonesian hemodialysis patients p. 154
Riri Andri Muzasti, Netty Delvrita Lubis
DOI:10.4103/tcmj.tcmj_2_20  
Objective: Homeostasis of serum phosphorus and calcitriol level is regulated mainly by fibroblast growth factor 23 (FGF23). Studies show that elevated serum FGF23 level was significantly associated with aortic calcification severity, peripheral blood vessels, and a higher score of coronary artery calcification in patients undergoing hemodialysis. We did this cross-sectional study to determine the FGF23 diagnostic value for abdominal aortic calcification in Indonesian hemodialysis patients. Materials and Methods: This study included seventy-five, chronic hemodialysis patients. An enzyme-linked immunosorbent assay method was used to measure serum intact FGF23 level, and abdominal aortic calcification was detected by lateral lumbar X-ray. The diagnostic value of FGF23 was analyzed using receiver operating characteristic (ROC) curves. Results: fifty-one (68.0%) patients had abdominal aortic calcification (AAC). Serum intact FGF23 level ranged from 217 to 950 pg/mL with a median level of 328 pg/mL. The FGF23 levels in the serum of patients with AAC were significantly higher than those without AAC (P < 0.001). The best cutoff point was 277 pg/mL. The calculated area under the ROC curves was 0.959 (95% confidence interval, 0.912–1.00); sensitivity was 94.0% and specificity was 84.0% (P < 0.001). Conclusion: serum intact FGF23 level may be proposed as a proper tool for abdominal aortic calcification in Indonesian hemodialysis patients.
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The diagnostic and prognostic utility of insulin growth factor of squamous cell carcinoma in oral cavity p. 160
Sumit Kumar Tiwari, Shakuntala Saini, Pawan Singhal, Ashwin Mathur, Maheep Sinha
DOI:10.4103/tcmj.tcmj_50_20  
Objective: The present study was conducted to find the utility of insulin growth factors (IGFs) as diagnostic and prognostic biochemical parameters in patients suffering from squamous cell carcinoma of oral cavity. Materials and Methods: A total of 360 male and female patients diagnosed with precancerous conditions (PCC) and oral squamous cell carcinoma (OSCC) of Stage I to IV were selected for the present study. Patients were interviewed using a structured questionnaire to ascertain their demographic and medical history. After completing the history and physical examination, patients were subjected to routine blood investigations along with determining insulin growth factor (IGF-1, IGFBP-3) levels. The data obtained were then subjected to statistical analysis using SPSS 20.0 version. Results: The mean values of IGF-1, insulin-like growth factor-binding protein-3 (IGFBP-3), and ratio of IGF-1 and IGFBP-3 were obtained. The intergroup comparison was done between PCC and all the stages of OSCC for all the IGFs. The result obtained was found to be statistically significant (P < 0.05). Conclusion: The present study concluded that a positive correlation was observed for various insulin growth factors (IGF-1, IGFBP-3; and ratio of IGF-1 and IGFBP-3) between OSCC and PCC such as erythroplakia and oral submucous fibrosis. Thus, the study highlighted the use of IGFs as diagnostic and prognostic parameters in patients suffering from cancerous conditions.
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Allergen detection and analysis in Eastern Taiwan area p. 165
Chia-Jung Chen, Yu-Hsien Liu, Teng-Yi Lin, Rong-Hwa Jan
DOI:10.4103/tcmj.tcmj_72_20  
Objective: Environmental factors, eating habits, and different ages might affect the profiles of allergy sensitization. The purpose of this study was to survey the different profiles of allergen sensitization in different ages in eastern Taiwan. Materials and Methods: We analyzed the allergic patients who had allergen sensitization examinations by the Phadiatop (atopy screen; IBT Laboratories, Lenexa, KS, USA) and the Pharmacia CAP System method at Haulien Tzu Chi Hospital from January 2010 to December 2015. Results were compared in different ages. Results: A total of 15,455 patients were analyzed. The food and aeroallergen screen sensitization rate of children was significantly higher than that of adults (44.0% vs. 9.9% and 61.9% vs. 52.2% P < 0.05). Children had statistically significantly higher cow milk allergen-specific sensitization rate than that of adults (32.9% vs. 5.8% P < 0.05). The higher sensitization of shrimp occurred in adults than children. (33.6% vs. 24.8% P < 0.05). Conclusion: Our data demonstrate that children have higher cow milk allergy sensitization and adults have higher sensitization of shrimp.
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Risk factors of admission in 72-h return visits to emergency department p. 169
Sung-Wei Liu
DOI:10.4103/tcmj.tcmj_155_20  
Objective: Return visit to emergency department (ED) is a common phenomenon and has been a clinical indicator of quality of care in ED. Most of previous articles focused on the characteristics of the patients returning within 72 h after ED discharge, while those on subsequent admission are numbered. This study's purpose is to identify risk factors for admission among 72-h return visit in the ED adult population. Materials and Methods: This retrospective cohort study was conducted at a medical center in Eastern Taiwan. The study period was from January 1, 2013, to December 31, 2013. We excluded patients who left against medical advice or without being seen, who was admitted or transferred at the index ED visit, whose medical records were incomplete, and whose age was below 18 years old. Significant variables were selected based on univariate analysis and later entered into multivariate logistic regression analysis to identify risk factors for 72-h return admission. Results: We identified 1575 eligible visits, and there were 1,119 visits entering into the final analysis. Male gender (odds ratio [OR] = 1.44), ambulance-transport at return visit (OR = 3.68), senior staff (OR = 1.52), work-up (OR = 3.03), and longer length of stay (LOS) were associated with higher risks of admission among ED 72-h return visits. Age, comorbidity, mode of transport at index visit, consultation, triage, type of illness, outpatient department visit between ED visits, and interval between index and return visits were not significantly associated with return admission.Conclusion: Gender, mode of transportation, staff experience, check-up, and LOS are associated with ED return admission.
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Embryological considerations and evaluation of congenital anomalies of craniovertebral junction: A single-center experience p. 175
Reddy Ravikanth, Pooja Majumdar
DOI:10.4103/tcmj.tcmj_62_20  
Objectives: Craniovertebral junction (CVJ) abnormalities constitute a group of treatable neurological disorders, especially in the Indian subcontinent. Thus, it is essential that clinicians should be able to make a precise diagnosis of abnormalities and rule out important mimickers on multidetector computed tomography (MDCT) as this information ultimately helps determine the management, prognosis, and quality of life of patients. CVJ is the most complex part of the cervical region. Congenital malformations of this region can cause serious neurological deficit and require a surgical intervention. The present study was undertaken to know the embryological basis of the CVJ and to identify commonly observed congenital CVJ abnormalities, their frequency, and mode of presentation. Materials and Methods: Diagnosed cases of CVJ anomalies on dynamic MDCT head were reviewed at a tertiary care center between January 2014 to December 2019. Type of anomaly, clinical presentation, and associated malformations were recorded. Different types of variations were expressed in terms of percentage. Results: Congenital anomalies were seen in 42 cases. Fifteen types of anomalies were detected. Anomalies were either singly or in combination. The CVJ anomalies were more common in young adults (28%), almost equal in both sexes. The most common anomaly was basilar invagination (52.3%), followed by atlanto-occipital assimilation (33.3%), and Arnold–Chiari malformation is the most common soft tissue anomaly. In fourteen cases, additional anomalies of other vertebrae were present. The most common symptoms were weakness of extremities, neck pain, paresthesia, torticollis, and gait disturbances. About 28 patients got improved, 8 patients had residual deficit as that of preoperative status, and 4 patients got deteriorated after surgery, at 1-month follow-up. About 34 patients had improved, 5 remained static, and 3 patients got worsened at the end of 3-month follow-up. About 37 patients had improved, 4 patients remained static, and 2 patients got deteriorated at 6 months of follow-up. The patients with increased atlantodens interval 3–5 mm showed 77% improvement after surgery. Conclusion: Congenital CVJ anomalies, though rare, are fatal. CVJ abnormalities constitute an important group of treatable neurological disorders with diagnostic dilemma. The atlantodental interval is the most important preoperative prognostic marker. Dynamic CT imaging can provide additional useful information to the diagnosis of CVJ instability. To prevent long-term neurological problems, early diagnosis and treatment of congenital bony CVJ anomalies is important.
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Selection of the optimal dosage of tranexamic acid to reduce blood loss during pediatric cleft palate surgery p. 181
Amir Shafa, Hamidreza Shetabi, Lili Adineh-Mehr, Keivan Bahrami
DOI:10.4103/tcmj.tcmj_111_20  
Objective: The aim of the present study was to evaluate and select the optimal dosage of tranexamic acid (TXA) to reduce blood loss during cleft palate surgery in children. Materials and Methods: This randomized double-blind clinical trial was performed on 80 children under 3 years of age that were candidates for cleft palate surgery. These children were divided into four groups as follows: the first, second, and third groups received 5, 7.5, and 10 mg/kg of TXA, respectively. Moreover, the fourth group was considered as the control group. Before induction of anesthesia and then every 15 min during the surgery, some parameters such as mean arterial pressure, heart rate, SpO2, and ETCO2were recorded. Moreover, the amount of blood loss during the surgery, the level of surgeon's satisfaction, and incidence rate of complications were assessed and recorded. Results: The amount of blood loss during the surgery in TXA groups receiving dosages of 5, 7.5, and 10 mg/kg with the means of 63.75 ± 10.62, 61.25 ± 15.03, and 61.00 ± 14.29, respectively, was significantly lower than that of the control group with the mean of 92.25 ± 19.83 (P < 0.001). Moreover, no significant difference was found between the three groups receiving TXA dosages in terms of the amount of blood loss, the level of surgeon's satisfaction (P > 0.05). Conclusion: According to the results of the present study, all three dosages of TXA had a significant role in reducing blood loss in cleft palate surgery. Given the potential for increased risk of side effects from the drug, it seems safe to use the minimal dosage of this drug to control and reduce blood loss during cleft palate surgery in children <3 years of age.
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Gender differences in the association between social support and caregiver alcohol use in posttraumatic stress disorder of east Taiwan adolescents p. 188
Ching-Yi Kao, Tyler Bradshaw, Theodoris Mazarakis
DOI:10.4103/tcmj.tcmj_123_20  
Objectives: This study investigates traumatic experiences in a sample of high-risk Taiwanese adolescents in rural areas of Taiwan; correlation with psychosocial factors is assessed with focus on social support and caregiver alcohol use. Materials and Methods: This was a cross-sectional study using stratified cluster sampling. Structured questionnaires were used to collect demographic characteristics, social support (Taiwan Relationship Inventory for Children and Adolescents), and posttraumatic stress disorder (PTSD) symptoms (Chinese version of UCLA-PTSD Reaction Index) from a sample of 751 adolescents (54.6% females) with 61.2% response rate in high schools in Hualien County, Taiwan. Results: Girls with trauma experiences manifested significantly higher PTSD scores, concurrent with higher number of traumatic events (TE), while the likelihood of reporting trauma and subsequent PTSD symptoms was similar in both genders. Increased risk of reported trauma and PTSD in adolescent Taiwanese is strongly associated with caregiver alcohol use and lack of social support, particularly in girls. Conclusion: We found that girls reported higher numbers of TE which was concurrent with significantly higher PTSD scores. Early detection of alcohol use disorders among caregivers as well as assessment of quality of family interaction would benefit at risk adolescents through specifically tailored interventions to address these factors.
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CASE REPORT Top

Mucoid impaction mimicking multiple metastatic lung cancer p. 195
Yi-Chih Huang, Hsu-Chao Chang, Yi-Hsin Lee, Mei-Chen Yang
DOI:10.4103/tcmj.tcmj_74_20  
The most common etiology of multiple pulmonary nodules is metastatic lung cancer. Although benign etiologies have been reported, mucoid impaction less commonly presents as multiple pulmonary nodules. Herein, we report the case of an 81-year-old demented man who presented with multiple pulmonary nodules due to mucoid impaction. Chest radiographs revealed rapid resolution after tracheostomy and adequate mucus clearance. We suggest that mucoid impaction may present as multiple pulmonary nodules mimicking multiple metastatic lung cancer.
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PATHOLOGY PAGE Top

Hyalinizing trabecular tumor, a rare histologically unique tumor of the thyroid, coexisting with papillary thyroid carcinoma p. 198
Chiu-Hsuan Cheng
DOI:10.4103/tcmj.tcmj_279_20  
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IMAGES IN CLINICAL MEDICINE Top

Acute syphilitic posterior placoid chorioretinopathy with typical placoid edge in a Taiwanese male p. 200
Ping-Feng Tsai, Chi-Ting Horng, Ming-Ling Tsai
DOI:10.4103/tcmj.tcmj_135_20  
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