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   2018| April-June  | Volume 30 | Issue 2  
    Online since May 11, 2018

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Medical leadership: An important and required competency for medical students
Tsung-Ying Chen
April-June 2018, 30(2):66-70
DOI:10.4103/tcmj.tcmj_26_18  PMID:29875585
Good medical leadership is the key to building high-quality healthcare. However, in the development of medical careers, the teaching of leadership has traditionally not equaled that of technical and academic competencies. As a result of changes in personal standards, the quality of medical leadership has led to variations between different organizations, as well as occasional catastrophic failure in the standard of care provided for patients. Leaders in the medical profession have called for reform in healthcare in response to challenges in the system and improvements in public health. Furthermore, there has been an increased drive to see leadership education for doctors starting earlier, and continuing throughout their careers so that they can take on more important leadership roles throughout the healthcare system. Being a physician requires not only management and leadership but also the need to transfer competencies to communication and critical thinking. These attributes can be obtained through experience in teamwork under the supervision of teaching staff. Therefore, medical students are expected to develop skills to deal with and resolve conflicts, learn to share leadership, prepare others to help and replace them, take mutual responsibility and discuss their performance.
  4,348 408 6
Vegetarian diet, food substitution, and nonalcoholic fatty liver
Tina H Chiu, Ming-Nan Lin, Wen-Harn Pan, Yen-Ching Chen, Chin-Lon Lin
April-June 2018, 30(2):102-109
DOI:10.4103/tcmj.tcmj_109_17  PMID:29875591
Objectives: Vegetarian diets have been shown to improve insulin resistance and reduce body weight, but the effects on nonalcoholic fatty liver require further confirmation. We aim to investigate the association between vegetarian diets, major food groups, and nonalcoholic fatty liver, and to compare the degree of liver fibrosis between vegetarians and nonvegetarians in those with fatty liver. Materials and Methods: We analyzed cross-sectional data from the Tzu Chi Health Study which included 2127 nonvegetarians and 1273 vegetarians who did not smoke or habitually drink alcohol and had no hepatitis B or hepatitis C. Fatty liver and liver fibrosis were determined using ultrasonography and the nonalcoholic fatty liver disease fibrosis score, respectively. Diet was assessed through a validated food frequency questionnaire. Results: Vegetarian diets were associated with lower odds of fatty liver (odds ratio = 0.79, 95% confidence interval: 0.68–0.91) after adjusting for age, gender, education, history of smoking and alcohol drinking. Adjustment for body mass index (BMI) attenuated the protective association. Vegetarians had less severe fibrosis than nonvegetarians. Replacing a serving of soy with a serving of meat or fish was associated with 12%–13% increased risk, and replacing a serving of whole grains with a serving of refined grains, fruits, and fruit juice was associated with 3%–12% increased the risk of fatty liver. Conclusion: Vegetarian diets, replacing meat and fish with soy, and replacing refined carbohydrates with whole grains, may be inversely associated with nonalcoholic fatty liver related to BMI.
  3,726 320 4
Salivary micro RNA as a potential biomarker in oral potentially malignant disorders: A systematic review
T N Uma Maheswari, Archana Venugopal, Nivedhita Malli Sureshbabu, Prathiba Ramani
April-June 2018, 30(2):55-60
DOI:10.4103/tcmj.tcmj_114_17  PMID:29875583
Oral potentially malignant disorders (OPMD) are oral mucosal disorders which have a high potential to turn into malignancy. A recent report suggests that 16%–62% of epithelial dysplasia cases of OPMD undergo malignant transformation, showing the need for early detection of malignancy in these disorders. Micro RNA (miRNA) plays an important role in cellular growth, differentiation, apoptosis, and immune response, and hence, deregulation of miRNA is considered a signature of oral carcinogenesis. A search was done using MeSH terms in the PubMed, ScienceDirect databases, hand search, and finally, six studies were included in this systematic review. A total of 167 patients with oral cancer, 78 with OPMDs, 147 healthy controls, and 20 disease controls were analyzed for the expression of salivary miRNAs. Quality assessment based on the Quality Assessment of Diagnostic Accuracy Studies 2 tool was used to obtain a risk of bias chart using Revman 5.3 software and it was proved that the study done by Zahran et al. in 2015 had a low risk of bias. The results of this study revealed upregulated miRNA 184 with an area under the curve (AUC) of 0.86 and miRNA 21 with an AUC of 0.73 and downregulated miRNA 145 with an AUC of 0.68, which proved that these miRNAs are significant in detecting early malignancy in OPMD and should be further analyzed in various populations. This systematic review explored the potential of expression of salivary miRNA in OPMD for future studies. This could pave the way to utilize saliva as a surrogate marker in diagnosing early malignant changes in OPMD.
  3,464 483 3
Human umbilical cord-derived mesenchymal stem cells reduce monosodium iodoacetate-induced apoptosis in cartilage
Yu-Hsun Chang, Kun-Chi Wu, Hwan-Wun Liu, Tang-Yuan Chu, Dah-Ching Ding
April-June 2018, 30(2):71-80
DOI:10.4103/tcmj.tcmj_23_18  PMID:29875586
Objective: The present study investigated the therapeutic potential and underlying mechanisms of human umbilical cord mesenchymal stem cells (HUCMSCs) on joint cartilage destruction induced by monosodium iodoacetate (MIA) in mice. Materials and Methods: HUCMSCs were tested for mesenchymal stem cell (MSC) characteristics including surface markers by flow cytometry and mesoderm differentiation (adipogenesis, osteogenesis, and chondrogenesis). Terminal deoxynucleotidyl transferase dUTP nick end labeling assay and Western blot assay were used to evaluate MIA-induced chondrocyte apoptosis. In the in vivo study, 18 mice were divided into three groups (n = 6 each); normal saline (control), MIA-treated, and MIA-treated/HUCMSC-transplantation. Rota-Rods tests were used to evaluate MIA-induced cartilage destruction behaviors in mice. Histological changes in the mice cartilage were examined by immunohistochemistry. Results: HUCMSCs had an immunophenotype similar to bone marrow-derived MSCs and were able to differentiate into adipocytes, osteocytes, and chondrocytes. Conditioned medium of the HUCMSCs exhibited an anti-apoptotic effect and inhibited expression of caspase 3 in MIA-treated chondrocytes. HUCMSC transplantation assisted in recovery from movement impairment (from 30% on day 7 to 115% on day 14) and in regeneration and repair of cartilage damaged by MIA. (International Cartilage Repair Society score: 3.8 in the MIA group vs. 10.2 in the HUCMSC-treated group); HUCMSC transplantation ameliorated cartilage apoptosis through the caspase 3 pathway in MIA-induced cartilage destruction in mice. Conclusion: Taken together, these observations suggest that HUCMSC transplantation appears to be effective in protecting cartilage from MIA damage.
  2,885 266 2
Activating transcription factor 3, an early cellular adaptive responder in ischemia/reperfusion-induced injury
Heng Lin, Ching-Feng Cheng
April-June 2018, 30(2):61-65
DOI:10.4103/tcmj.tcmj_37_18  PMID:29875584
Recent studies have reported that ischemia/reperfusion (I/R) may act in the immune system where an exaggerated inflammatory response is initiated. With the activation of the immune system, damage-associated molecular patterns migrate and adhere to the I/R region, consequently inducing multiorgan injury. Emerging data indicate that upon I/R, stress-inducible proteins, including activating transcription factor 3 (ATF3), play essential roles in signaling during antiapoptotic, antimigration, and anti-inflammatory processes. Accumulating data suggest that ATF3 may be a potential target in I/R- or inflammation-induced organ dysfunction. This minireview focuses on the emerging evidence of the roles of ATF3 in multiple organs including the kidney, myocardium, and brain following I/R injury. In addition, this review addresses the role of ATF3 in chronic inflammation-induced pathophysiologies such as diabetes and atherosclerosis.
  2,795 267 2
Metallo-β-lactamase-mediated resistance among clinical carbapenem-resistant Pseudomonas aeruginosa isolates in northern Iran: A potential threat to clinical therapeutics
Abdol Ahad Dogonchi, Ezzat Allah Ghaemi, Abdollah Ardebili, Sajjad Yazdansetad, Abazar Pournajaf
April-June 2018, 30(2):90-96
DOI:10.4103/tcmj.tcmj_101_17  PMID:29875589
Objective: Carbapenems are effective agents to treat multidrug-resistant (MDR) strains of bacteria, including Pseudomonas aeruginosa. However, there is a potential threat of emergence of carbapenem-resistant P. aeruginosa (CRPA). The aim of this study was to determine antibiotic susceptibility patterns and metallo-beta-lactamase (MBL)-mediated resistance in clinical P. aeruginosa isolates. Materials and Methods: Different clinical specimens were subjected to conventional culture-based identification of P. aeruginosa. Antimicrobial susceptibility patterns and MBL production were evaluated using the Kirby-Bauer and combined double-disk synergy test methods, respectively. Multiplex polymerase chain reaction was performed to investigate the presence of the blaIMP, blaVIM, blaNDM, blaSPM, and blaSIMgenes. Results: A total of 71 clinical P. aeruginosa isolates were recovered, of which 28.17% were identified as CRPA. The most active antibiotics were colistin and polymyxin B (92.96% susceptibility to each). A total of 35% and 50% of CRPA isolates were MDR and extensively drug-resistant (XDR), respectively. MBL activity was shown in 20% of CRPA. A total of 90%, 40%, and 5% of CRPA isolates harbored the blaIMP, blaVIM, and blaNDMgenes, respectively. No correlation was found between the MBL-encoding genes of P. aeruginosa and patient characteristics. Conclusion: Although the prevalence of CRPA in our therapeutic centers was relatively low, this rate of carbapenem resistance reflects a threat limiting treatment choices. A high prevalence of MDR/XDR phenotypes among the MBL-producer isolates suggests the need for continuous assessment of antimicrobial susceptibility and surveillance of antibiotic prescription. In addition, infection control measures are needed to prevent further dissemination of these organisms.
  2,694 275 8
Superficial temporal artery-middle cerebral artery bypass for the treatment of complex middle cerebral artery aneurysms
Chien-Hui Lee, Sheng-Tzung Tsai, Tsung-Lang Chiu
April-June 2018, 30(2):110-115
DOI:10.4103/tcmj.tcmj_193_17  PMID:29875592
Objectives: Direct microsurgical clipping for complex middle cerebral artery (MCA) aneurysms may require a long ischemic time. Sacrifice of the parent artery with trapping or endovascular coiling also may lead to ischemic stroke. We described our institutional experience with the treatment of complex MCA aneurysms using extracranial-intracranial (EC-IC) (superficial temporal artery [STA]-MCA) bypass. Materials and Methods: We retrospectively reviewed patients who had treatment of IC aneurysms with the assistance of STA-MCA bypass from July 2002 to December 2016. Six patients with complex MCA aneurysms were identified, and we reviewed their clinical characteristics. Results: There were three men and three women with age ranging from 27 to 59 (mean 49) years old. Image studies showed subarachnoid hemorrhage in three cases. All patients underwent STA-MCA anastomosis, and the follow-up period ranged from 2 to 116 months (mean 51.5 months). Two of the six MCA aneurysms were fusiform, two aneurysms had bizarre configurations, one was a dissecting saccular aneurysm, and one had a blister configuration. Three patients received direct vessel trapping, two patients received aneurysm clipping, and one received aneurysm coiling. The postoperative bypass patency rate was 100%. The modified Rankin scale showed good outcomes in the six patients. Conclusions: EC-IC bypass plays an important role as a salvage procedure in the treatment of complex MCA aneurysms which have a fusiform, bizarre, or blister configuration.
  2,170 189 1
High serum leptin level is associated with peripheral artery disease in adult peritoneal dialysis patients
Yu-Hsien Lai, Chih-Hsien Wang, Jen-Pi Tsai, Jia-Sian Hou, Chung-Jen Lee, Bang-Gee Hsu
April-June 2018, 30(2):85-89
DOI:10.4103/tcmj.tcmj_8_18  PMID:29875588
Objective: Peripheral artery disease (PAD) is associated with systemic atherosclerosis and indicates an increased risk of mortality in peritoneal dialysis (PD) patients. A high leptin level accelerates atherosclerosis in apoE-deficient mice. The purpose of this study was to examine the association of serum leptin level and PAD in adult PD patients. Materials and Methods: The clinical characteristics of sixty PD patients recruited from June 2015 to October 2016 were obtained. Serum leptin concentrations were determined. Ankle–brachial index (ABI) values were measured and those with a left or right ABI <0.9 were defined as the low ABI group. Results: Twenty of these 60 PD patients (33.3%) had diabetes mellitus and 32 patients (53.3%) had hypertension. Thirteen PD patients (21.7%) were in the low ABI group. Higher serum leptin (P = 0.002) and C-reactive protein (CRP, P < 0.001) levels were found in the low ABI group compared with those in the normal ABI group. More number of patients with diabetes (P = 0.015) and current smokers (P = 0.037) were noted in the low ABI group than in the normal ABI group. After adjustment for factors that were significantly associated with PAD in multivariate logistic regression analysis, each increase of 1 ng/mL in the serum leptin level (odds ratio [OR], 1.062; 95% confidence interval [CI], 1.014–1.114; P = 0.012) and each increase of 0.1 mg/dL in the serum CRP level (OR, 1.107; 95% CI, 1.011–1.211; P = 0.028) were found to be independent predictors of PAD in PD patients. Conclusion: Higher serum leptin and CRP levels correlated positively with the diagnosis of PAD in PD patients.
  2,151 159 2
Human leukocyte antigen-A*24:02-B*40:247-C*03:04-DRB1*16:02, a deduced probable human leukocyte antigen haplotype associated with a low-incidence human leukocyte antigen allele B*40:247 in Taiwanese individuals: A case analysis
Kuo-Liang Yang, Zheng-Zhong Zheng, Li-Yun Lin
April-June 2018, 30(2):81-84
DOI:10.4103/tcmj.tcmj_19_18  PMID:29875587
Objective: HLA-B*40:247 is a low incidence allele in the HLA-B locus. The aim of this study is to confirm the ethnicity of B*40:247 and its deduced probable HLA- associated haplotype in Taiwanese individuals. Materials and Methods: A total of 2,329 unrelated Taiwanese individuals and 66,212 unrelated mainland Chinese individuals were tested for HLA using a sequence-based typing method. We confirmed the low incidence allele B*40:247 in Taiwanese. Polymerase chain reaction was performed to amplify exons 2, 3 and 4 of the HLA-A and HLA-B loci and exon 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 B*40:247 is identical to B*40:01:01 in exons 2, 3 and 4 except for residue 853, where G of B*40:01:01 is changed to A in B*40:247 (codon 261, GTA->ATA). The nucleotide replacement causes a one amino acid change at codon 261 where V (valine) of B*40:01:01 is replaced by I (isoleucine) in B*40:247. We deduced the probable HLA haplotype associated with B*40:247 in Taiwanese to be HLA-A*24:02-B*40:247-C*03:04-DRB1*16:02. Conclusion: Information on the ethnicity and distribution of B*40:247 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.
  2,120 165 -
Navigation-assisted endoscopic endonasal surgery of a glomangiopericytoma with intraorbital extension: A case report and literature review
Chan-Jung Chang, Chuan-Hung Sun, Tzu-Sheng Chen, Hung-Pin Wu
April-June 2018, 30(2):119-121
DOI:10.4103/tcmj.tcmj_161_17  PMID:29875594
A glomangiopericytoma, or sinonasal type hemangiopericytoma, is a rare lesion which accounts for <0.5% of all sinonasal tumors. The mainstay treatment is wide excision. Instead of traditional open surgical approaches, such as midfacial degloving or lateral rhinotomy, we offer a case of 21-year-old male with diagnosis of glomangiopericytoma with skull base and intraorbital invasion and received navigation-assisted endoscopic excision of a glomangiopericytoma.
  2,068 160 1
Bedside pleuroscopy in the Intensive Care Unit
Hean Ooi
April-June 2018, 30(2):97-101
DOI:10.4103/tcmj.tcmj_11_18  PMID:29875590
Objectives: It is not always possible to move critically ill patients to the operating or endoscopy room for a pleuroscopy. Bedside pleuroscopy is indicated for these patients. The aim of this study was to investigate the safety and complications of bedside pleuroscopy in an Intensive Care Unit (ICU). Materials and Methods: The patients who had undergone routine examinations for pleural effusion, with no established diagnosis at the previous admission were included in this analysis. Patients received local analgesia with bedside pleuroscopy performed by a chest physician in the ICU with continuous monitoring. Results: Twenty-five patients (17 males and 8 females) with a mean age of 74 ± 3 years were enrolled. Their mean APACHE II score was 23 ± 1. The duration of drainage from the pigtail catheter was a mean 3.9 ± 0.2 days, and mean ventilator usage was 6 ± 0.7 days. The length of stay in the ICU was 11 ± 1 days. Most pleural effusions occurred on the right side (17/25, 68%). Fifteen patients (60%) had malignant effusions, four (16%) had parapneumonic effusions, three (12%) had empyema, and two (8%) had tuberculosis. Complications occurred in 11 (44%) patients. There were no major complications such as bleeding or procedure-related death. The most common complication was transient chest pain (n = 6, 24%). Conclusions: Pleuroscopy performed at the bedside in the ICU is a simple and safe procedure. It has the potential for use in critical patients as serious complications are rare.
  2,054 145 -
Management of acquired bronchopleural fistula due to chemical pneumonia
Reddy Ravikanth, Sunil Mathew, Denver Steven Pinto
April-June 2018, 30(2):116-118
DOI:10.4103/tcmj.tcmj_98_17  PMID:29875593
Bronchopleural fistula (BPF) is a sinus tract between the bronchus and the pleural space that may result from a necrotizing pneumonia/empyema (anaerobic, pyogenic, tuberculous, or fungal), lung neoplasms, and blunt and penetrating lung injuries or may occur as a complication of procedures such as lung biopsy, chest tube drainage, thoracocentesis, or radiation therapy. The diagnosis and management of BPF remain a major therapeutic challenge for clinicians, and the lesion is associated with significant morbidity and mortality. Here, we present a 70-year-old male with acquired BPF due to chemical pneumonitis caused by aspiration of kerosene who presented with the symptoms of fever, cough with expectoration, breathlessness and signs of tachycardia, tachypnea, diminished breath sounds, and crepitations. After a 3-week course of culture-sensitive antibiotics with β-lactam and β-lactamase inhibitors, open drainage of the empyema was done following which the patient showed symptomatic improvement and was discharged.
  1,904 200 -
Sclerosing mesenteritis
Chien-Chin Chen, Kai-Sheng Liao, Chih-Jen Huang
April-June 2018, 30(2):122-123
DOI:10.4103/tcmj.tcmj_62_18  PMID:29875595
  1,823 155 1
Ileal knotting secondary to a mesodiverticular band associated with axial torsion of a Meckel's diverticulum and small bowel volvulus
Vipul D Yagnik
April-June 2018, 30(2):124-125
DOI:10.4103/tcmj.tcmj_117_17  PMID:29875596
  1,755 145 1