Objective: Arthropod-borne viral diseases are a major burden on the health-care system worldwide. Only a few studies have reported on coinfection of dengue fever (DF) with the chikungunya virus in North India. We investigated the seroprevalence and significance of the clinicobiochemical profile of dengue and chikungunya coinfection. Besides this, the authors try to emphasize rationalize platelets transfusion. Material and Methods: The present study was conducted at the Heritage Institute of Medical Science, Varanasi, India, from July to December 2016. A total of 1800 suspected cases with acute viral febrile illness (age >18 years) were investigated to exclude other causes of acute febrile illnesses. Of these, 121 patients (6.72%) were diagnosed as seropositive for dengue and chikungunya mono or coinfection using IgM ELISA and were included in the study. Results: The male gender was predominant. The majority were in the 20–30-year age group with cases peaking in November. There were 102 (84.29%) cases of dengue, 6 (4.95%) cases of chikungunya, and 13 (10.74%) cases positive for coinfection. Fever was present in all cases. Headache followed by nausea/vomiting and generalized weakness were the most common symptoms in patients with DF while body aches and joint pain were most common in those with chikungunya fever. Deranged liver function and leukopenia were the most common complications in dengue. Conclusion: Joint-related symptoms (pain and restricted movements) were statistically significant in chikungunya monoinfection. Two patients with DF were died. There was no significant added severity of clinical features and blood investigations in patients with coinfection with dengue and chikungunya compared to those with monoinfections.

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Staphylococcus aureus is a versatile pathogen which can cause various mild to life-threatening infectious diseases. The evolution of S. aureus resistance is notorious, from penicillin and oxacillin to vancomycin. Vancomycin, introduced in 1956, was once considered a most reliable antibiotic for methicillin-resistant S. aureus (MRSA); unfortunately, the first strain of S. aureus with decreased susceptibility to vancomycin emerged in 1996. Vancomycin has been approved in Taiwan since 1983, and the prevalence rates of heteroresistant vancomycin-intermediate S. aureus (hVISA) and vancomycin-intermediate S. aureus (VISA) in 2003 were 0.7% and 0.2%, respectively. However, a ten-fold increase of hVISA and VISA to 10% and 2.7%, respectively, in 2012–2013 could indicate a challenging clinical situation in Taiwan. The most commonly reported staphylococcal cassette chromosome mec (SCCmec) types of hVISA and VISA are usually SCCmec type III or II, typical nosocomial MRSA strains. Preventing the spread of resistant pathogens through infection control interventions and judicious antibiotic stewardship is a serious medical issue.

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Though the American society of hematology Guidelines and British guidelines do not recommend screening of thyroid diseases in cases of immune thrombocytopenia (ITP), more than 160 cases of hyperthyroidism associated with ITP have been reported. Numerous case reports would suggest that patients with ITP and concurrent hyperthyroidism would respond to control of thyroid disease rather than the standard ITP treatment. Although this issue is still debatable, we report a case of a young female with a previous diagnosis of hyperthyroidism which was not well controlled, had presented with severe thrombocytopenia. Initially, all work-up had been done to find out the cause of thrombocytopenia. After all normal reports except deranged thyroid function tests, the patient was labeled as ITP and started on steroids. Even after a few months of steroid treatment, platelet counts had not improved. However, after starting antithyroid drugs, platelet counts had become normalized.

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Objective: In addition to high-quality chest compression, parameters of resuscitation efficiency such as early chest compression, early defibrillation, and decreased hands-off time are also vital in the Advanced Cardiac Life Support (ACLS) protocol. However, because of limited time and equipment in ACLS courses, efficiency of performance is difficult to evaluate. Materials and Methods: A free, easy-to-use iOS and Android app (CodeTracer^®) was developed for real-time recording of cardiopulmonary resuscitation (CPR) performance. Interventions performed during resuscitation were set up as buttons. When the simulated scenario in the ACLS course began, instructors recorded every intervention and the team performed by pushing the appropriate buttons. When the scenario ended, the CodeTracer^® automatically computed parameters, including the percentage of no-flow time, time to initiating CPR, and time to initiating defibrillation and also generated a graphic log for later discussion. Results: A total of 76 resuscitation episodes were recorded, 27 in the practice scenarios and 49 in the final Megacode simulations. After the course, the average percentage of no-flow time decreased 5.79%, time to initiating CPR decreased 3.05 s, and time to initiating defibrillation decreased up to 20.27 s. Of note, physicians as leaders seem to have better performance after the ACLS course than before, but the results were insignificant except for the percentage of no-flow time. Conclusions: CodeTracer^® can record and calculate objective parameters for resuscitation performance in ACLS courses and can assist instructors in disseminating important concepts to participants. It can be a useful tool in ACLS courses.

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Objective: Previous studies have reported that a vegetarian diet may lower blood pressure (BP), but the effect of diet on BP in asymptomatic participants with proteinuria is unknown. We examined the association of diet and BP in individuals with or without proteinuria. Materials and Methods: This cross-sectional study analyzed data from participants who were more than 40 years old and received physical checkups at Taipei Tzu Chi Hospital from September 5, 2005, to December 31, 2016. Diets were assessed at baseline by a self-reported questionnaire and categorized as vegan, lacto-ovo vegetarian, or omnivore. There were 2818 (7.7%) vegans, 5616 (15.3%) lacto-ovo vegetarians, and 28,183 (77.0%) omnivores. The effect of different parameters on BP was determined using a multivariate multiple linear regression model with no intercept, with control for important characteristics and lifestyle confounders. Results: The vegan group had a lower mean systolic BP (−3.87 mmHg, P < 0.001) and diastolic BP (−2.48 mmHg, P < 0.001) than the omnivore group. Participants with proteinuria had a higher systolic BP (4.26 mmHg, P < 0.001) and diastolic BP (2.15 mmHg, P < 0.001) than those without proteinuria. Interaction analysis indicated that vegan participants with proteinuria had a lower systolic BP (−2.73 mmHg, P = 0.046) and diastolic BP (−2.54 mmHg, P = 0.013) than other participants with proteinuria. However, individuals in the lacto-ovo group with proteinuria had a BP similar to other participants with proteinuria. Conclusions: A vegan diet was associated with lower BP in asymptomatic participants with proteinuria. This diet could be a nonpharmacologic method to reduce BP.

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Objective: Waldeyer's lymphatic ring consists of group of tonsils located over the posterior oropharyngeal wall. The palatine tonsils are largest tonsil. The present study was aimed to evaluate the significance of lymphoid hyperplasia, lymphocyte infiltration with and without defect in the surface epithelium in chronic tonsillitis (CT) and chronic adenotonsillar hypertrophy (CAH) in resected tonsillectomy and adenotonsillectomy specimens. Materials and Methods: A total of 85 patients were included in the study. Fifty-one cases underwent bilateral tonsillectomy and 34 cases underwent adenotonsillectomy. Results: The lymphoid hyperplasia was higher in CAH (30/34; 88.24%) as compared to CT (26/50; 52%). Lymphocyte infiltration with or without defect in the surface epithelium was common in CT. The histopathologic criteria of lymphoid hyperplasia and lymphocyte infiltration with or without defect in the surface epithelium showed a statistically significant difference between CT and CAH. Conclusion: CT and CAH may be differentiated on the basis of reliable histopathological criteria. Punch biopsy can be performed to avoid CT complication if the clinical diagnosis is true. Choristomas can be clinically confused with true neoplasms, if large in size.

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Depression is the predominant pole of disability in bipolar disorder and compared with mania/hypomania, has less systematic research guiding the development of treatment especially in its acute phase (acute bipolar depression). The deficiency in the management of the acute bipolar depression largely reflects the natural divergence of opinion resulting from significant knowledge gaps. At present, there are only 3 approved drug treatments for acute bipolar depression: olanzapine/fluoxetine combination, quetiapine (immediate or extended release), and lurasidone (monotherapy or adjunctive to lithium or valproate). Nonapproved agents and nonpharmacologic treatment such as lamotrigine, antidepressants, modafinil, pramipexole, ketamine, and electroconvulsive therapy are often prescribed to treat acute bipolar depression. This article discusses the challenges of diagnosing bipolar depression, and reviews above treatment options for acute bipolar depression.

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Fibrous dysplasia (FD) is a rare bony disorder in which normal bone is replaced by abnormal fibro-osseous tissue. It often involves the long bones, craniofacial bones, ribs, and pelvis. Approximately 30% of monostotic FD (MFD) lesions are found in the cranial or facial bones. In general, FD is found in teenagers, and it usually becomes static after adulthood. FD involves the maxilla almost two times more often than the mandible. It frequently appears in the posterior region of the jaw bone and is usually unilateral. Here, we present an unusual case of symptomatic MFD affecting the anterior region of the mandible in a 43-year-old female with the clinical, radiographical, and histopathological features. The clinical examination showed both the labial and lingual bone expansion in the anterior mandible. The radiographic examination revealed a lesion with both radiopaque and radiolucent features showing a “ground-glass” appearance. The diagnosis was obtained after confirmatory intrabony biopsy with the histopathological examination, and it was diagnosed with benign FD. The patient preferred regular follow-up of MFD after discussion. During the regular follow-up, MFD lesion showed no obvious signs of progression or malignancy features.

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Objectives: Adrenocortical scintigraphy for patients with primary aldosteronism (PA) without discontinuation or modification of antihypertensive medications is of concern because of drug interference with the renin–angiotensin–aldosterone system. We report the surgical outcomes of patients with PA lateralized with adrenocortical scintigraphy without drug discontinuation or modification. Materials and Methods: We retrospectively reviewed 34 patients with PA with computed tomography (CT)-documented adrenal tumors who had undergoing subsequent I-131-6 β-iodomethyl-norcholesterol (NP-59) single photon emission CT (SPECT)/CT followed by unilateral adrenalectomy according to the results of NP-59 uptake between May 2005 and December 2014. All enrolled patients underwent standard confirmatory tests and lateralization with NP-59 SPECT/CT without discontinuation of existing antihypertensive medications, including spironolactone. The pathological findings, hypertension outcomes, and biochemical changes were reported. The accuracy of NP-59 SPECT/CT without drug discontinuation or modification was also evaluated. Results: None of the 34 enrolled patients (M:F = 16:18) had complications such as a hypertensive crisis, life-threatening hypokalemic event, or cardiac arrhythmia. Pathology disclosed 31 (91%) adenomas and three cases of hyperplasia. Hypertension cure and improvement were observed in 12 (35%) and 18 (53%) patients, respectively. All of the 30 patients (100%) without postoperative use of beta-blockers and with an available postoperative aldosterone/renin ratio achieved a biochemical cure. The positive predictive values of NP-59 SPECT/CT were 91%, 88%, and 100% for the pathological findings, hypertension outcomes, and biochemical changes, respectively. Conclusion: Noninvasive NP-59 SPECT/CT without discontinuation or modification of antihypertensive medications not only provided accurate lateralization and safety but also resulted in a high improvement rate for PA-associated hypertension.

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Objective: Increased circulating leptin, a marker of leptin resistance, is common in patients with obesity and is also an independent factor in prediction of cardiovascular disease. The aim of this study was to evaluate the relationship between fasting serum leptin levels and the aortic augmentation index (AIx) in kidney transplant recipients. Materials and Methods: Fasting blood samples were obtained from 70 kidney transplant recipients. The aortic AIx was measured using a validated tonometry system (SphygmoCor). Plasma leptin levels were measured using a commercial enzyme-linked immunosorbent assay kit. Results: Simple linear analysis of the aortic AIx in kidney transplant recipients showed that body fat mass (P = 0.002), diastolic blood pressure (DBP) (P = 0.020), logarithmically transformed triglycerides (P = 0.035), and leptin (P < 0.001) were positively correlated, while height (P = 0.004) and the glomerular filtration rate (P = 0.022) were negatively correlated with the aortic AIx in kidney transplant recipients. Forward stepwise linear regression analysis of the factors significantly associated with the aortic AIx showed that leptin (P < 0.001), DBP (P = 0.014), and body height (P = 0.036) were independent predictors of the aortic AIx in kidney transplant recipients. Conclusion: These results suggest that the serum fasting leptin level is associated with the aortic AIx in kidney transplant recipients.

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The correlation between a low adenoma detection rate (ADR) and interval cancers (ICs) has made ADR one of the most important quality indicators for colonoscopy. Data from nation-wide colorectal cancer (CRC) screening programs showed that there is room for improvement in ADR in order to reduce ICs in Taiwan. Measures with and without adjunct tools have been shown to have the potential to increase ADR, with the latter being more convenient to apply without additional cost. Optimal withdrawal techniques coupled with sufficient withdrawal time, training endoscopists with emphasis on recognition of subtle characteristics of flat lesions, dynamic position changes during the withdrawal phase, removing small polyps found during insertion, and retroflexion in the right colon have all been associated with increased ADR. In particular, water exchange (WE), which is characterized using water in lieu of air and suction removal of infused water during insertion, appears to meet the needs of colonoscopy patients in Taiwan. Analyses of both primary and secondary outcome variables of recently published studies have consistently shown that WE yields higher ADR than traditional air insufflation, even in propofol-sedated patients. Colonoscopists participating in the nationwide CRC screening program in Taiwan should consider applying one or more of the above measures to improve ADR and hopefully reduce ICs.

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The medical education environment is rapidly changing. Competency-based medical education (CBME) is a great advance, but operationalizing competencies for teaching and assessment is problematic. Entrustable professional activities (EPAs) can revitalize CBME by connecting competencies to practice, creating flexibility in programs. CBME requires and deepens the nature of workplace-based assessments. It is important to use EPAs to verify residents' ability to care for critically ill patients unsupervised in simulation education.

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