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   2020| March-April  | Volume 40 | Issue 2  
    Online since March 19, 2020

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Cumulative effective dose caused by diagnostic imaging and its associated risk for cancer development in trauma patients referred to the emergency department
Akbar Aliasgharzadeh, Mehran Mohseni, Morteza Salimian, Bagher Farhood, Masoud Najafi, Hossein Safari, Habiballah Moradi
March-April 2020, 40(2):51-58
Background: The current study aimed to determine the cumulative effective dose caused by diagnostic imaging and its associated risk for cancer development in trauma patients referred to an emergency department. Methods: This study was carried out retrospectively in an emergency department (Kashan, Iran) from April 2015 to October 2015. Then, the types of diagnostic radiologic studies performed on adult trauma patients in their first 24 h upon presentation were recorded. Finally, the cumulative effective dose of trauma patients and its associated risk for cancer development were obtained. Results: In total, the patients received 3323 radiologic examinations including 2169 radiographs and 1154 computed tomography (CT)-scans. The most common type of plain radiographic and CT-scan examinations included anterior posterior and posterior anterior chest as well as head, respectively. The mean cumulative effective dose received by trauma patients referred to the emergency department was 2.47 ± 4.29 mSv. Most of the effective dose was from CT-scan examinations (90.65% of total cumulative effective dose; 2181.91 mSv). The majority of patients (83.40%) received between 0.00 and 5.00 mSv cumulative effective dose. Moreover, the cancer risk per average cumulative effective dose received by trauma patients was 1.01 × 10−4. Conclusions: In current study, the mean cumulative effective dose per each trauma patient (2.47 mSv) was relatively less than that of the other evaluated studies. It was also found that although the number of CT-scans was relatively few compared to plain radiographs, most of the cumulative effective dose of patients resulted from CT-scans; hence, using unnecessary CT-scan examinations should be avoided.
  683 232 -
Optimized procedures for simultaneous quantitation of low concentration levels of morphine and codeine in urine using gas chromatography–mass spectrometry
Sheng-Hui Tang, Chien-Huei Chuang, Shu-Fen Chen, Wei-Chen Chuang, Hung-Sheng Shang
March-April 2020, 40(2):68-75
Background: Detection techniques with high specificity, precision and accuracy are required for evidence of illicit drug intake. The study aim was to develop a low-concentration drug testing method for morphine and codeine in urine samples using gas chromatography-mass spectrometry (GC-MS) to establish a precise quantitative analytical method that improves upon limit of detection (LOD), limit of quantitation (LOQ), precision, and accuracy of currently available detection methods. Methods: Using a 300 ng/mL urine sample, solid phase extraction was performed using an automated solid phase method. All analyses were performed using a Hewlett-Packard (Palo Alto, CA) HP 6890 gas chromatograph interfaced to a HP 5973 mass selective detector (MSD) equipped with a DB-5MS column to acquire full-scan and SIM mass spectrometric data. Solid phase extraction was optimal at pH 9.0 in a 2 ml sample volume. An internal standard concentration of 100 ng/mL yielded optimal results. Results: Standard solution ranges (40-450 and 40-1500 ng/mL) significantly influenced LOQ. Calibration methods were not associated with LOD and LOQ for either MOR or COD. The intra- and inter-day precision values did not exceed 2% and were not different within groups. The accuracy of the examined method ranged from 97.8% to 103.3%. All parameters were validated in 33 clinical urine specimens. Conclusions: This developed method was successfully used for the determination of morphine and codeine in human urine for forensic identification. The examined protocol can be applied to simultaneous quantification of morphine and codeine at low concentration levels in urine.
  711 130 -
Risk factors of tumor relapse in patients with clinical stages 1–3 esophageal squamous cell carcinoma after curative surgery
Yen-Shou Kuo, Chao-Lin Lee, Po-Jen Yun, Yu-Chi Sung, Ti-Hui Wu, Hsu-Kai Huang, Shih-Chun Lee, Tsai-Wang Huang, Ying-Yi Chen
March-April 2020, 40(2):59-67
Background: The aim of this study was to determine the risk factors for disease progression in patients with clinical stages 1–3 squamous cell carcinoma (SCC) of the esophagus after curative surgery. Methods: This is a retrospective study of postoperative risk factors for patients with SCC after esophagectomy. The factors related to disease progression, including stage, clinical tumor response, operation types, number of resected lymph node number, standard uptake value (SUV), tumor differentiation, lymphovascular space invasion, perineural invasion, extracapsular invasion, and tumor regression grade, were analyzed. Results: A total of 73 patients treated between 2011 and 2015 were included in the study. Twenty-six patients developed disease recurrence, including 10 locoregional and 16 distant metastases. Clinical tumor response, procedure types, tumor differentiation, extracapsular invasion, and average standard uptake value (SUVmax) were significantly associated with overall survival. On multivariate analysis, clinical tumor response (P = 0.044), minimally invasive esophagectomy (MIE) (P = 0.006), and tumor differentiation (P = 0.042) remained independent predictors for the disease progression. Conclusions: Clinical tumor response, MIE, tumor differentiation, extracapsular invasion, and average SUVmax of tumor (postconcurrent chemoradiotherapy) were independent predictors for the disease progression. Our findings put forward the postoperative predictors of disease progression in esophageal SCC to identify high-risk patients and deliver proper treatment.
  642 166 -
The effect of adenosine A2A receptor antagonist istradefylline on multiple organ dysfunction in heatstroke rats
Chih-Chin Shih, Jye-Hann Chen, Mei-Hui Liao, Cheng-Ming Tsao, Hsieh-Chou Huang, Chin-Chen Wu
March-April 2020, 40(2):76-82
Background: Global warming increases the incidence of heatstroke, which is the most severe heat illness. The mortality in patients with heatstroke is due to neurological disability and multiple organ failure caused by systemic inflammatory response. Adenosine A2A receptor antagonist has both neuroprotective and anti-inflammatory effects. Thus, we examined whether a new A2A receptor antagonist istradefylline has beneficial effects in heatstroke rats. Methods: Wistar rats were divided into four groups: (1) control group, with vehicle only (intravenous [iv] for 10 min); (2) control + istradefylline group, with 0.3 mg/kg istradefylline (iv for 10 min); (3) heatstroke group, rectal temperature reached 44.1°C, and then returned to room temperature with vehicle (iv for 10 min); and (4) heatstroke + istradefylline group, rectal temperature reached 44.1°C, and then returned to room temperature with 0.3 mg/kg istradefylline (iv for 10 min). During the experimental period, rectal temperature, heart rate, blood pressure, and pressor responses to norepinephrine (NE) were monitored. Before and after the rats were put into heating chamber, and after the rats returned to room temperature for 6 h, their blood was taken to analyze creatine kinase, lactate dehydrogenase, blood urea nitrogen, creatinine, alanine transaminase, albumin, total protein, and platelet count. In addition, the blood flow of tongue, left limb, and right limb was also monitored. Finally, we examined their survival rate. Results: In the present study, heatstroke rats showed high core body temperature accompanied with cardiac abnormalities and multiple organ dysfunction, mimicking the clinical manifestations of heatstroke patients. Treatment of heatstroke rats with istradefylline only partially improved platelet loss and vascular hyporeactivity to NE. However, istradefylline had no significant effects on cardiac abnormalities and multiple organ dysfunction in rats with heatstroke. Conclusions: These results suggest that although istradefylline has a mild impact on abnormal platelet count and pressor response to NE in heatstroke, both effects are unlikely to counteract multiple organ dysfunction and the mortality.
  492 128 -
Propofol-based total intravenous anesthesia reduces prolonged extubation as compared to desflurane-based anesthesia: A few more facts are required
Habib Md Reazaul Karim
March-April 2020, 40(2):99-100
  490 104 -
Double extremes of brain tumors – Dilemma of decision-making and pitfalls of image: A case report and literature review
Kun-Ting Hong, Yi Wan, Chi-Tun Tang
March-April 2020, 40(2):83-87
Coexistence of multiple primary intracranial tumors has been reported previously. However, most of simultaneous tumors occurred after intracranial radiotherapy or in high association with heredity. Both primary intracranial tumors arising simultaneously at synchronous discrete sites were introduced without prior radiation or genetic disorders. These tumors showed the same characteristic according to preoperative images. Two distinct tumors, meningioma and anaplastic oligoastrocytoma were revealed by postoperative histopathological findings. We present this unusual case to exhibit the rare possibility that two distinct primary brain tumors can occur in the same patient. Although magnetic resonance image were used to define the tumor patterns in almost cases, some diagnostic pitfalls may occur with coexistent primary brain tumors. Hence, a discrepancy between clinical impressions and radiological findings should raise a further survey for potential different natures. Reviewing the literature, we should remove the symptomatic tumors based on mass effect and presenting symptoms first, whether it is a benign-looking meningioma or a malignant astrocytoma. Surgical priority for two distinct synchronous tumors from each other needs individual evaluation carefully.
  478 97 -
Nalbuphine sebacate interferes with the analgesic effect of fentanyl
Tsai-Shan Wu, Hsuan-Cheng Wu, Zhi-Fu Wu, Yi-Hsuan Huang
March-April 2020, 40(2):101-102
  443 91 1
Catheter-directed thrombolysis for acute renal infarction
Hao-Cho Ou, Yi-Chang Lin, Shih-Hung Tsai, Chih-Yuan Lin
March-April 2020, 40(2):96-98
Acute renal infarction is an uncommon disease, which is frequently misdiagnosed or diagnosed late because of its nonspecific clinical presentation, and may result in irreversible damage to the renal parenchyma. Here, we present a case of acute renal infarction in a 51-year-old male, presenting with left flank pain and being diagnosed through computed tomography. We successfully performed catheter-directed thrombolysis to rescue the ischemic renal tissue and preserve the renal function.
  382 87 -
Multiple interferences of serologic studies in an Epstein–Barr virus-related infectious mononucleosis
Ruei-Yu Su, Li-Ju Ho, Cherng-Lih Perng
March-April 2020, 40(2):92-95
Epstein–Barr virus (EBV) infection is a common infectious disease in young adults and children. A 4-year-old boy was presented with enlarged tonsils and purulent discharge. Sudden airway collapse and desaturation were noted, and endotracheal tube intubation was performed. The laboratory data demonstrated positive results for EBV immunoglobulin M (IgM). Polyclonal B-cell activation that led to positive results for cytomegalovirus (CMV) IgM and herpes simplex virus (HSV) IgM was also detected by the interference of heterophilic antibodies. A low-dose intravenous immunoglobulin (IVIG) infusion was performed, and an IVIG-related false-positive result for CMV immunoglobulin G (IgG) was observed. After the aggressive medical care, the boy was discharged under a stable condition. Herein, we report the important features of EBV-related infectious mononucleosis that harvested multiple interferences. First, the heterophilic antibodies caused due to polyclonal B-cell activation resulted in the false-positive result for CMV IgM and HSV IgM. Second, the IVIG interpreted the CMV IgG. We must be aware of the multiple interferences that could misinterpret our laboratory data.
  370 95 -
Sleeve fracture of the patella
Hsieh Guan-Hsiang, Ru-Yu Pan, Lin Liu-Chih, Wang Chih-Chien
March-April 2020, 40(2):88-91
We present an 11-year-old male child without any underlying disease. He was admitted to the emergency room after having felt severe pain in his right knee on kicking the ground while falling down earlier that day. Radiography showed an avulsion fracture of the lower pole of the patella and a high-riding patella. At the next day after the injury, we performed open reduction and internal fixation surgery. After surgery, the recovery of the patient was good.
  386 78 -