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   Table of Contents - Current issue
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November-December 2018
Volume 38 | Issue 6
Page Nos. 247-292

Online since Monday, October 22, 2018

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ORIGINAL ARTICLES  

The clinical outcome of brain metastases in nonsmall cell lung cancer patients with epidermal growth factor receptor mutation- A retrospective single-institution analysis Highly accessed article p. 247
Cho-Hao Lee, Tzu-Chuan Huang, Yung-Chih Wang, Yi-Ying Wu, Ching-Liang Ho, Jia-Hong Chen
DOI:10.4103/jmedsci.jmedsci_41_18  
Introduction: Nonsmall cell lung cancer (NSCLC) is the leading cause of cancer-related deaths in many countries. Brain metastases (BM) from NSCLC are poor prognosis, with a median survival of 6 months following whole-brain radiotherapy. NSCLC patients harboring activating epidermal growth factor receptor (EGFR) mutations have generally responded to afatinib with good objective response rate, progression-free survival (PFS), and overall survival (OS), and platinum-double chemotherapy. These findings demonstrate the potential effectiveness of afatinib for the treatment of EGFR-positive with BM. The aim of this retrospective study is to present data on the prognostic effect of afatinib versus gefitinib in an unselected population with newly diagnosed NSCLC with BM collected. Patients and Methods: Data were obtained from our electronic database from 48 patients with newly diagnosed EGFR mutative NSCLC with BM and treated from January 2007 to December 2017, in which data on EGFR mutation was all available at the time of diagnosis. Results: Thirteen of forty-eight were treated with afatinib, and the other was treated with gefitinib. There were seven Exon 19 deletion and six were Exon 21 mutation ([p.Leu858Arg, (c.2573T>G)]:4; [p.Leu861Gln, (c.2582T>A)]:2). There was 18 Exon 19 deletion, and 16 were Exon 21 mutation ([p.Leu858Arg, (c.2573T>G)]:16) and the other one was Exon 18 mutation [p.Gly719Ser (c.2155G>A)]. There was no significant difference between two groups included PFS (afatinib: 12.0 months vs. gefitinib: 10.1 months, P = 0.766) and OS (afatinib: 20.6 months vs. gefitinib: 14.5 months, P = 0.362). Conclusion: From the K–M survival curve evaluation, neither the PFS nor OS have the statistical significance between gefitinib and afatinib. We provided a real-world data to compare the efficacy of EGFR-TKI in NSCLC. Due to relative small sample size, we urged large clinical trial to provide more precise results.
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New combination for patients with latent tuberculosis infection: A pilot study p. 252
Te-Yu Lin, Feng-Cheng Liu
DOI:10.4103/jmedsci.jmedsci_46_18  
Background: Latent tuberculosis infection (LTBI) is characterized by the presence of immune responses to Mycobacterium tuberculosis without clinical evidence of active TB. LTBI treatment among persons at risk for progression to active disease is an important strategy for TB control and elimination. This prospective observational study aimed to compare the incidences of hepatitis and side effects between a new 2-month combination regimen of isoniazid, rifampin and pyrazinamid (2HRZ) plus excipient and the standard 3-month regimen of isoniazid and rifapentine (3HP) for LTBI treatment in Taiwan. Materials and Methods: Between January 1, 2017, and December 31, 2017, all patients aged ≥20 years diagnosed LTBI were included in the study. Demographic and baseline laboratory assessment of the patients at diagnosis was collected. Eligible individuals were allocated to the 2-month regimen comprising HUEXC030, isoniazid, rifampin, and pyrazinamide (2HRZ) or 3-month regimen with isoniazid and rifapentine (HP). All symptoms and side effects during treatment were recorded. Results: Nineteen patients received the 2-month regimen with HRZ plus HUEXC030, while 23 received the 3-month regimen with HP. The treatment completion rates were 73.7% and 82.6% in the 2- and 3-month regimen groups, respectively. The most common side effects during treatment were fatigue/myalgia/weakness, loss of appetite, and rash. The aspartate aminotransferase, alanine aminotransferase, and total bilirubin levels were similar in both groups after 4 weeks of treatment. Conclusions: This study demonstrates that LTBI patients receiving the 2-month regimen with HRZ plus HUEXC030 experienced similar side effects including hepatitis as patients on the 3-month regimen with HP. This new combination treatment regimen may be an alternative for the treatment of LTBI.
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Estimated daily intake and cumulative risk assessment of phthalates in Taiwan military personnel p. 258
Nai-Yueh Ko, Yuan-Ting C Lo, Zu-Yi Sia, Ya-Chi Lu, Jhih-Yuan Wei, Ming-Jhou Cai, Hsiu-Ying Ku, Senyeong Kao, Hsien-Liang Su, Junn-Liang Chang, Han-Bin Huang
DOI:10.4103/jmedsci.jmedsci_52_18  
Background: Phthalate esters (PAEs), which may have potential adverse health effects, are widely used in industrial and consumer products. The public raised concerns of exposure to PAEs after di-2-ethylhexyl PAE (DEHP) had been illegally used in food products in Taiwan in 2011. However, there is little information regarding the exposure levels of PAEs among Taiwanese military personnel. Objective: Health risk assessment indicators, including daily intake (DI), hazard quotient (HQ), and hazard index (HI), were used to assess the distribution and trends of PAEs and cumulative risk in Taiwanese military personnel. Materials and Methods: We recruited 503 participants who participated in northern voluntary military service from June to August 2017. We calculated the DI of five PAEs, namely dimethyl PAE, diethyl PAE, dibutyl PAE (DBP), benzyl butyl phthalate, and DEHP, and selected the reference dose (RfD) described by the US Environmental Protection Agency (EPA) as an acceptable exposure reference value to compute the HQ and HI. We used statistical analysis to examine the differences and trends of PAE metabolites in urine and investigated the possible primary sources of PAEs with principal component analysis. Results: The detection rates of 7 PAE metabolite concentrations were ≥72.2%. All DIs, HQRfDs, and HIRfDs were not over the standard EPA RfD. For all participants, two principal components (PC) were extracted. Three DEHP metabolites and MBP were correlated with PC1, and MiBP and MnBP were correlated with PC2. Conclusions: The main potential sources of PAE exposure for Taiwanese military personnel are DEHP and DBP. Efforts to reduce exposure to environmental PAEs are necessary to maintain health within the military.
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Pattern and outcome of unintentional pediatric trauma in the emergency department of a tertiary care hospital in South India p. 269
Kundavaram Paul Prabhakar Abhilash, David Vincent, Anjali Sarah George, Kimmin Kalyaniwala, Anand Prajapathi, Sheba Meriam Thomas
DOI:10.4103/jmedsci.jmedsci_82_18  
Background: Pediatric trauma is a significant cause of morbidity, and few studies on profile and outcome have been done in the emergency departments (EDs) of India. Methodology: This prospective observational study was conducted between October 2014 and December 2014 in the adult and pediatric ED's of Christian Medical College, Vellore. All patients younger than 18 years, who presented with unintentional injury, were enrolled in this study. Results: The adult and pediatric ED's attended to a combined 24,482 patients (16,169 adults and 8313 children and adolescents) during the 3-month study with 8.2% (2022/24,482) being trauma incidents. Pediatric and adolescent (<18 years) trauma patients comprised 20% (397) of trauma cases, and adult (>18 years) trauma patients made up the remainder 80% (1624). Falls are the most common mechanism of injury among infants and toddlers with decreasing frequency with age. With increasing age, the place of injury changes from the surroundings of home to playgrounds, schools, and the roads. About 80% of injuries among infants occur at home while only 12% of adolescent injuries occur at home. Road traffic injuries account for 46% of injuries sustained by adolescents. Most of the children and adolescents (63%) were managed conservatively. Minor surgical intervention was required in 20% whereas 11% required major surgical intervention. Majority (77%) was discharged stable from the ED, and 21% were admitted. The in-hospital mortality of pediatric trauma was 1.2% (5/397). Conclusions: Pediatric and adolescent trauma is a significant cause of morbidity and mortality in India, accounting for almost one-fifth of injured patients. There exists a need for injury prevention programs focusing on peridomestic safety among children <12 years and school and road safety among children >12 years and adolescents.
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A retrospective study to estimate serum vancomycin trough concentrations in pediatric patients with current recommended dosing regimen p. 275
Chia-Ning Chang, Wen-Tsung Lo, Ming-Chin Chan, Chih-Chien Wang
DOI:10.4103/jmedsci.jmedsci_103_18  
Background: Vancomycin is widely prescribed to treat infections caused by methicillin-resistant Staphylococcus aureus (MRSA). According to the Infectious Disease Society of America 2011 MRSA guidelines for adults, trough concentrations of 15–20 μg/ml were recommended with vancomycin 15–20 mg/kg/dose every 8–12 h not to exceed 2 g per dose in patients with normal renal function. As the data for dosage and monitoring of vancomycin in children are still controversial, physicians often follow the guidelines established for adults. To evaluate serum vancomycin trough concentrations in pediatric patients with currently recommended dosing regimen, we evaluated clinical data. Methods: This retrospective observational study collected pediatric patients aged <18 years for whom vancomycin was administered at a single medical center between 2009 and 2015. Results: Fifty pediatric patients were analyzed. Two groups were identified according to the vancomycin dosage. Fourteen (28%) patients underwent vancomycin at 60 mg/kg/day (high dose) and 36 (72%) patients at 40 mg/kg/day (low dose). The average serum vancomycin trough concentrations of the two groups were 13.12 μg/ml (high-dose group) and 9.02 μg/ml (low dose group), respectively. In addition, 71% (high-dose group) and 91% (low-dose group) of patients could not reach the target trough concentrations 15–20 μg/ml, set by the Infectious Disease Society of America. Conclusion: This investigation revealed that the current recommended vancomycin dosing regimens in children (40–60 mg/kg/day) mostly brought out trough concentrations <10 μg/ml in this research population.
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CASE REPORTS Top

A case of coats' disease of adult onset: Rare association with prognostic consequences of refractoriness p. 280
Dibyendu Dhali, Sukhendu Maiti, Ranjita Santra (Dhali), Radha Krishna Mandal
DOI:10.4103/jmedsci.jmedsci_93_17  
Coats' disease is a nonhereditary ocular disease, with no systemic manifestation, first described by George Coats in 1908. It occurs more commonly in children and has a male predominance. Most patients present clinically with unilateral decrease in vision, strabismus, or leukocoria. The most important differential diagnosis is unilateral retinoblastoma, which occurs in the same age group and has some overlapping clinical manifestations. We present a rare case of Coats' disease in an adult with leukocoria. A 37-year-old male presented with dimness of vision with constricted visual field in his left eye for the past 3 months. Ocular examination revealed visual acuity as 6/6 in the right eye and 6/60 in the left eye, which was also same on pinhole correction with leukocoria in the left eye. A fundus examination of the left eye revealed multiple telangiectatic and irregular, dilated aneurysmal retinal vessels, exudative retinal detachment with deep, and extensive subretinal lipid exudates with a well-defined macular edema. Direct fluorescein angiography (DFA) showed early and persistent leakage in the abnormal vessels and hypofluorescence corresponding to the subretinal exudates in the left eye that lead to the confirmation of the diagnosis of Coats' disease. The ocular examination and DFA findings were unremarkable for the right eye. Our report aims to document and illustrate the features of Coats' disease in an adult male, highlights the importance of establishing the correct differential diagnosis, and changes to existing treatment modalities.
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Metastatic renal cell carcinoma of pancreas without a detectable primary tumor mimicking pancreatic cancer: A case report and review of the literature p. 283
Wei-Nung Liu, Yi-Jen Peng, Wei-Chou Chang, Ping-Ying Chang
DOI:10.4103/jmedsci.jmedsci_11_18  
Distant metastases are common in patients with renal cell carcinoma (RCC). Metastatic neoplasms affecting the pancreas account for <2% of all malignancies in the pancreas and RCC is the most common malignancy among them. Metastatic RCC with the nonidentifiable primary renal tumor is extremely rare. In the present study, we reported the case of a 62-year-old male with metastatic RCC to the pancreas without a primary renal tumor mimicking pancreatic cancer. Accurate pathologic diagnosis with immunohistochemistry staining and proper multidisciplinary treatment with targeted therapy may improve the clinical outcomes of these patients.
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Botryomycosis of orofacial region: A rare case report p. 287
Devika S Pillai, Subhas Babu, Shruthi Hegde, Vidya Ajila, G Sachin Ram
DOI:10.4103/jmedsci.jmedsci_20_18  
Botryomycosis is a rare chronic granulomatous infection that usually involves the skin and rarely viscera. The main causative organism is Staphylococcus aureus, and rarely, Pseudomonas and Escherichia coli. Both cutaneous and visceral forms of the disease are recognized. Botryomycosis may develop in apparently healthy individuals as well as the immunologically compromised. The involvement of orofacial region is rare in the literature. Diagnosing botryomycosis is very challenging. Dental specialists require thorough knowledge regarding the features and management of this infrequent entity in their practice. Isolation of the causative agent and antibiotic susceptibility tests are essential to provide appropriate treatment. We hereby report a rare case of a 37-year-old healthy male with recurrent episodes of botryomycosis involving the orofacial region. The present report highlights the clinical and histopathologic features of botryomycosis with literature review.
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LETTER TO EDITOR Top

Primary uterine primitive neuroectodermal tumor p. 292
Mahmood Dhahir Al-Mendalawi
DOI:10.4103/jmedsci.jmedsci_47_18  
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