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   Table of Contents - Current issue
Coverpage
April-June 2022
Volume 34 | Issue 2
Page Nos. 113-253

Online since Monday, April 11, 2022

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REVIEW ARTICLES - BASIC  

The potential of using itaconate as treatment for inflammation-related heart diseases p. 113
Hui-Chen Ku, Ta-Chung Shen, Ching-Feng Cheng
DOI:10.4103/tcmj.tcmj_83_21  
Intracellular metabolites can cause critical changes in biological functions. Itaconate is perhaps the most fascinating substance in macrophages. Lipopolysaccharide can activate aconitate decarboxylase 1 and induces the generation of itaconate from the tricarboxylic acid cycle by decarboxylation of cis-aconitate. It has been reported that itaconate has beneficial effects on inflammation and oxidation. The mechanisms involved in these effects include the suppression of succinate dehydrogenase, the activation of nuclear factor E2-related factor 2 by alkylation of Kelch-like ECH-associated protein 1, suppression of aerobic glycolysis through regulation of glyceraldehyde-3-phosphate dehydrogenase and fructose-bisphosphate aldolase A, and suppression of IκBζ translation through activating transcription factor 3 activation. All of these findings elucidated the possible therapeutic implications of itaconate in inflammation-related diseases. In this review, we highlight that itaconate is a crucial molecule of the immunomodulatory response in macrophages and can regulate between immune response and cardiovascular metabolism. Furthermore, these discoveries suggest that itaconate is a very novel therapeutic molecule for the treatment of inflammation-related heart diseases.
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The roles of sodium-potassium-chloride cotransporter isoform-1 in acute lung injury p. 119
Po-Chun Hsieh, Yao-Kuang Wu, Chan-Yen Kuo, Yen-Hsien Lee, Mei-Chen Yang, Chou-Chin Lan
DOI:10.4103/tcmj.tcmj_50_21  
Acute lung injury (ALI) is often characterized by severe lung inflammation and pulmonary edema with poor gas exchange and hypoxemia. Alveolar inflammation and water flooding are, in fact, notable features of ALI pathogenesis. The sodium-potassium-chloride co-transporter isoform 1 (NKCC1), localized at the basolateral surface of the lung epithelium, drives water transport via back transport of Na+ and Cl to the alveolar air space. NKCC1, therefore, is crucial in regulating alveolar fluid. Increased expression of NKCC1 results in increased alveolar fluid secretion and impaired alveolar fluid clearance. During ALI, the with no lysine kinase (WNK), oxidative stress responsive kinase 1 (OSR1), and STE20/SPS1-related proline/alanine-rich kinase (SPAK) pathways are activated, which upregulates NKCC1 expression. Proinflammatory cytokines also enhance the expression of NKCC1 via c-Jun N-terminal kinase-and p38-dependent pathways. NKCC1 activation also increases the expression of proinflammatory cytokines via cell rupture and activation of macrophages. Increased proinflammatory cytokines, in turn, recruit inflammatory cells to the site of injury and cause further lung damage. Animals with high expression of NKCC1 show more severe lung injury with presentations of more severe pulmonary edema and microvascular permeability, higher expression of proinflammatory cytokines, and greater neutrophilic infiltration. In contrast, animals with low expression of NKCC1 or those treated with NKCC1 inhibitors show less severe lung injury with milder levels of presentations of ALI. These reports collectively highlight a novel role of NKCC1 in ALI pathogenesis. Manipulation of NKCC1 expression levels could, therefore, represent novel modalities for effective ALI treatment.
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Erythrocyte degradation, metabolism, secretion, and communication with immune cells in the blood during sepsis: A review p. 125
Chih-Yu Chan, Ching-Feng Cheng, Hao-Ai Shui, Hui-Chen Ku, Wen-Lin Su
DOI:10.4103/tcmj.tcmj_58_21  
Sepsis is a health issue that affects millions of people worldwide. It was assumed that erythrocytes were affected by sepsis. However, in recent years, a number of studies have shown that erythrocytes affect sepsis as well. When a pathogen invades the human body, it infects the blood and organs, causing infection and sepsis-related symptoms. Pathogens change the internal environment, increasing the levels of reactive oxygen species, influencing erythrocyte morphology, and causing erythrocyte death, i.e., eryptosis. Characteristics of eryptosis include cell shrinkage, membrane blebbing, and surface exposure of phosphatidylserine (PS). Eryptotic erythrocytes increase immune cell proliferation, and through PS, attract macrophages that remove the infected erythrocytes. Erythrocyte-degraded hemoglobin derivatives and heme deteriorate infection; however, they could also be metabolized to a series of derivatives. The result that erythrocytes play an anti-infection role during sepsis provides new perspectives for treatment. This review focuses on erythrocytes during pathogenic infection and sepsis.
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Emerging role of the itaconate-mediated rescue of cellular metabolic stress p. 134
Der-Shan Sun, Hsin-Hou Chang
DOI:10.4103/tcmj.tcmj_79_21  
Metabolic regulations play vital roles on maintaining the homeostasis of our body. Evidence have suggested that ATF3 and nuclear factor erythroid 2–related factor 2 (NRF2) are critical for maintaining cell function, metabolism, and inflammation/anti-inflammation regulations when cells are under stress, while the upstream regulators in the stressed cells remain elusive. Recent findings have shown that tricarboxylic acid cycle metabolites such as itaconate and succinate are not just mitochondrial metabolites, but rather important signaling mediators, involving in the regulations of metabolism, immune modulation. Itaconate exerts anti-inflammatory role through regulating ATF3 and NRF2 pathways under stressed conditions. In addition, itaconate inhibits succinate dehydrogenase, succinate oxidation and thus blocking succinate-mediated inflammatory processes. These findings suggest itaconate-ATF3 and itaconate-NRF2 axes are well-coordinated machineries that facilitate the rescue against cellular stress. Here, we review these fascinating discoveries, a research field may help the development of more effective therapeutic approach to manage stress-induced inflammation, tissue damage, and metabolic disorder.
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Hepatitis C virus core protein: Not just a nucleocapsid building block, but an immunity and inflammation modulator p. 139
Hemalatha Mani, Jui-Hung Yen, Hao-Jen Hsu, Chun-Chun Chang, Je-Wen Liou
DOI:10.4103/tcmj.tcmj_97_21  
Coevolution occurs between viruses and their hosts. The hosts need to evolve means to eliminate pathogenic virus infections, and the viruses, for their own survival and multiplication, have to develop mechanisms to escape clearance by hosts. Hepatitis C virus (HCV) of Flaviviridae is a pathogen which infects human liver and causes hepatitis, a condition of liver inflammation. Unlike most of the other flaviviruses, HCV has an excellent ability to evade host immunity to establish chronic infection. The persistent liver infection leads to chronic hepatitis, liver cirrhosis, hepatocellular carcinoma (HCC), as well as extrahepatic HCV-related diseases. HCV genomic RNA only expresses 10 proteins, many of which bear functions, in addition to those involved in HCV life cycle, for assisting the virus to develop its persistency. HCV core protein is a structural protein which encapsulates HCV genomic RNA and assembles into nucleocapsids. The core protein is also found to exert functions to affect host inflammation and immune responses by altering a variety of host pathways. This paper reviews the studies regarding the HCV core protein-induced alterations of host immunity and inflammatory responses, as well as the involvements of the HCV core protein in pro- and anti-inflammatory cytokine stimulations, host cellular transcription, lipid metabolism, cell apoptosis, cell proliferations, immune cell differentiations, oxidative stress, and hepatocyte steatosis, which leads to liver fibrosis, cirrhosis, and HCC. Implications of roles played by the HCV core protein in therapeutic resistance are also discussed.
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The prospects of employing probiotics in combating COVID-19 p. 148
Moutoshi Chakraborty, Saurab Kishore Munshi
DOI:10.4103/tcmj.tcmj_104_21  
Unanticipated pathogenic risk and emerging transmittable diseases can result from interspecies exchanges of viruses among animals and humans. The emergence of the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) causing coronavirus disease-19 (COVID-19) pandemic has recently exemplified this mechanism. Cough, fever, fatigue, headache, sputum production, hemoptysis, dyspnea, diarrhea, and gastrointestinal disorders are the characteristic features of the disease. The most prevalent and serious manifestation of the infection tends to be pneumonia. The new strains of SARS-CoV-2 with more infectivity have been emerging at regular intervals. There is currently no World Health Organization-approved particular drug for COVID-19. Besides, developing novel antivirals would take much time. Thus, repurposing the application of natural products can provide alternatives and can facilitate medication against COVID-19 as well as can slow down the aggressive progression of the disease before the arrival of approved drugs. Probiotics have long been known for their positive effects on the gut microbiome and impact on immune responses. Particularly, their involvement against viral diseases, especially those of the upper and lower respiratory tract, is of current interest for their prospective application against COVID-19. In this review, we comprehensively address the mode of action of probiotics and their possible intervention against coronavirus diseases correlating with their efficacy against viral diseases. In this regard, we explored recently published relevant research and review articles in MEDLINE/PubMed related to COVID-19 and the effects of probiotics on viral infections.
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The role of calmodulin and calmodulin-dependent protein kinases in the pathogenesis of atherosclerosis p. 160
Mei-Fang Chen
DOI:10.4103/tcmj.tcmj_119_21  
Atherosclerosis is a chronic inflammatory disease that triggers severe thrombotic cardiovascular events, such as stroke and myocardial infarction. In atherosclerotic processes, both macrophages and vascular smooth muscle cells (VSMCs) are essential cell components in atheromata formation through proinflammatory cytokine secretion, defective efferocytosis, cell migration, and proliferation, primarily controlled by Ca2+-dependent signaling. Calmodulin (CaM), as a versatile Ca2+ sensor in diverse cell types, regulates a broad spectrum of Ca2+-dependent cell functions through the actions of downstream protein kinases. Thus, this review focuses on discussing how CaM and CaM-dependent kinases (CaMKs) regulate the functions of macrophages and VSMCs in atherosclerotic plaque development based on literature from open databases. A central theme in this review is a summary of the mechanisms and consequences underlying CaMK-mediated macrophage inflammation and apoptosis, which are the key processes in necrotic core formation in atherosclerosis. Another central theme is addressing the role of CaM and CaMK-dependent pathways in phenotypic modulation, migration, and proliferation of VSMCs in atherosclerotic progression. A complete understanding of CaM and CaMK-controlled individual processes involving macrophages and VSMCs in atherogenesis might provide helpful information for developing potential therapeutic targets and strategies.
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REVIEW ARTICLES - CLINICAL Top

Epidemiology of atypical parkinsonian syndromes p. 169
Raymond Y Lo
DOI:10.4103/tcmj.tcmj_218_20  
Atypical parkinsonism or atypical parkinsonian syndromes (APS) refer to a group of neurodegenerative disorders which mimic typical Parkinson's disease but poorly respond to levodopa treatment and deteriorate faster. APS are very rare and among them, progressive supranuclear palsy (PSP), multiple system atrophy (MSA), and corticobasal degeneration (CBD) are the three relatively better characterized entities. The prevalence estimates of PSP, MSA, or CBD are mostly <10/105, and the incidence estimates are around 1/105 person-year; both estimates remain stable over the past few decades. The age at onset is relatively young for MSA at late 50s, followed by CBD at early 60s, and then PSP at late 60s. The gender difference is not significant in APS, although slight female predominance in CBD has been reported in literature. Little is known about genetic and environmental risk factors for PSP, MSA, and CBD; although the COQ2 mutation has been identified as a genetic risk for MSA, familial cases are extremely rare. Survival after symptom onset is generally within 10 years, but cases with longer disease duration do exist. Respiratory infection remains the major cause of death for APS, but cardiac arrest should be particularly considered in MSA. In addition to disease rarity, the phenotype–pathology discrepancy in APS makes the epidemiological studies even more challenging. Including biomarkers in future diagnostic criteria and establishing disease registry for collecting sufficient number of APS cases may increase the likelihood of finding modifiable risk factors for prevention and intervention.
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Assessment of uremic sarcopenia in dialysis patients: An update p. 182
Yu-Li Lin, Bang-Gee Hsu
DOI:10.4103/tcmj.tcmj_254_20  
Uremic sarcopenia, which is highly prevalent in dialysis patients, leads to an increased risk of adverse outcomes, such as poor quality of life, falls, fracture, hospitalization, and even mortality. Therefore, early detection of uremic sarcopenia is crucial for administering quick and adequate multidisciplinary therapy to improve clinical outcomes. This review updates the current information about uremic sarcopenia assessment in chronic dialysis patients. We discuss the methods of assessing skeletal muscle mass, strength, and physical performance. We also discuss surrogate markers derived from serum and dialysate creatinine, in addition to emerging screening tools. The prevalence, clinical relevance, and impact of uremic sarcopenia on survival are reviewed and we discuss the limitations and challenges in applying the current working definition of sarcopenia based on the senior population to dialysis patients. The review shows that dialysis patients with skeletal muscle weakness or poor physical performance, either with or without low skeletal muscle mass, should undergo multidisciplinary therapy, included nutritional counseling, lifestyle modification, and exercise intervention, to mitigate the detrimental effects of uremic sarcopenia.
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ORIGINAL ARTICLE - BASIC Top

Melatonin combined with sorafenib synergistically inhibit the invasive ability through targeting metastasis-associated protein 2 expression in human renal cancer cells p. 192
Chu-Che Lee, Po-Yu Huang, Yi-Hsien Hsieh, Yong-Syuan Chen, Jen-Pi Tsai
DOI:10.4103/tcmj.tcmj_204_21  
Objectives: Renal cell carcinoma (RCC) was the most common and lethal urological malignancy with the dismal outcome when distant metastasis. Melatonin was known as a potential oncostatic agent against several types of malignancy and sorafenib had been considered as an agent to treat RCC, but the synergistic effects of melatonin and sorafenib on human RCC have not been elucidated. Materials and Methods: Human renal cancer cell lines (Caki-1 and ACHN) were treated with melatonin combined with sorafenib were detected the cell growth and cell cycle by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-tetrazolium bromide assay and flow cytometry. The ability of cell migration/invasion was performed with in vitro migration and invasion assay. The proteins and mRNA expression of metastasis-associated protein 2 (MTA2) from the RCC cells were measured by quantitative reverse transcription-polymerase chain reaction and western blotting. Clinical significance of MTA2 in RCC tissues was analyzed from The Cancer Genome Atlas database by using TISIDB software. Results: Our results showed that melatonin combined with sorafenib, sorafenib or melatonin-treated alone did not induce the cytotoxic effects or cell cycle arrest in human RCC cells and HK2 cells. Additionally, cotreatment with melatonin and sorafenib synergistically reduced migration and invasion in human Caki-1 and ACHN cells through synergistically suppression of MTA2 expression. Bioinformatics analysis showed that MTA2 expression significantly correlated with overall survival (P < 0.002), tumor grade (P < 0.001) and tumor stage (P < 0.001) in human RCC. Conclusion: Our results demonstrated that concomitantly used melatonin and sorafenib could significantly reduce the abilities of migration and invasion of RCC cells through inhibiting MTA2. We considered that this novel promising combination strategy towards the treatment of RCC, but further studies are warranted.
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ORIGINAL ARTICLES - CLINICAL RESEARCH Top

Association of serum osteopontin with first hospitalization and all-cause mortality after kidney transplantation p. 200
Hsiao-Hui Yang, Bang-Gee Hsu, Ching-Chun Ho, Ming-Che Lee
DOI:10.4103/tcmj.tcmj_269_20  
Objective: Osteopontin (OPN) is involved in vascular calcification and atherosclerosis. We evaluated the association between serum OPN levels and the first postoperative hospitalization and all-cause mortality in patients who received kidney transplantation (KT). Materials and Methods: Seventy KT recipients were enrolled in this study from January to April 2012. The primary end point was first postoperative hospitalization or death. All patients were monitored in the outpatient clinics until June 30, 2017. Serum OPN level was measured by enzyme-linked immunosorbent assay. Results: During follow-up (median length, 65 months), 47 first postoperative hospitalizations and 8 deaths occurred. In comparison with serum median OPN levels, serum OPN level was positively associated with KT duration (P = 0.048), serum blood urea nitrogen (BUN; P = 0.043), and serum creatinine levels (P = 0.045) but negatively associated with estimated glomerular filtration rate (eGFR; P = 0.049). Hospitalized KT recipients had a higher prevalence of diabetes mellitus (DM) (P = 0.032), BUN (P = 0.002), and serum OPN level (P = 0.001) but lower eGFR (P = 0.030) than did patients not hospitalized. KT recipients who died had higher serum level of creatinine (P = 0.009) and OPN (P = 0.001) but lower eGFR (P = 0.036) than did surviving patients. Multivariate Cox analysis adjusted for age, gender, DM, hypertension, eGFR, KT duration, and steroid used showed that serum OPN level was associated with both first postoperative hospitalization (P = 0.049) and all-cause mortality (P = 0.017). Conclusions: Serum OPN level is a potential biomarker for first postoperative hospitalization and all-cause mortality in KT recipients.
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A randomized controlled trial to compare antibiotic prophylaxis in elective gynecological surgeries: Single dose of cefazolin versus single dose of cefazolin and tinidazole p. 207
Shivani Garg, Seema Chopra, Shalini Gainder, Rashmi Bagga, Nusrat Shafiq, Neelam Aggarwal
DOI:10.4103/tcmj.tcmj_176_21  
Objectives: To evaluate if addition of an anti-anaerobic agent to standard drug-cefazolin for antimicrobial prophylaxis would further decrease postoperative infectious morbidity or not. This is relevant as most of the infections in gynecological surgeries are anaerobic but cefazolin does not protect against anaerobes. Materials and Methods: The study design was a parallel randomized controlled trial. Two hundred patients undergoing benign gynecological surgeries were divided into two groups of 100 each. Group A received 2 g cefazolin 30–60 min before incision and Group B received 2 g cefazolin 30–60 min and 1.6 g tinidazole 60–120 min before incision. The patients were followed for any infectious morbidity for 1 month postoperatively. The analysis was done separately for abdominal, laparoscopic, and vaginal surgeries. The analysis was also done for surgeries according to the wound category, i.e. clean and clean-contaminated. Results: The two groups were comparable for age and body mass index (BMI). The two groups were comparable for the factors affecting infectious morbidity such as duration of surgery, blood loss, blood transfusions, duration of hospital stay, and need for additional antibiotics. The postoperative infectious morbidity was analyzed in terms of fever, surgical site infection (SSI), and urinary tract infection (UTI). No patient in vaginal and laparoscopic groups suffered from infectious morbidity. In abdominal surgeries group, postoperative fever occurred in 6/74 (8.1%) and 11/74 patients (14.8%) in Groups A and B, respectively (P = 0.38). SSI occurred in 1/74 (1.3%) and 2/74 (2.7%) patients in Groups A and B, respectively (P = 1.0). UTI occurred in 5/74 patients (6.7%) and 2/74 patients (2.7%) in Groups A and B, respectively (P = 0.44). The data were also analyzed for infectious morbidity for clean and clean-contaminated wound categories, and the results were nonsignificant between both groups for each type of wound category (P > 0.05). Conclusion: Cefazolin alone is a sufficient antibiotic prophylaxis for benign gynecological procedures.
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Aging is associated with slower renal progression in patients with chronic kidney disease p. 214
Chia-Tse Yeh, Chun-Yu Lin, Ting-Yun Lin, Ching-Hsiu Peng, Yi-Chun Wang, Szu-Chun Hung
DOI:10.4103/tcmj.tcmj_102_21  
Objectives: Chronic kidney disease (CKD) is prevalent among the elderly. However, little is known about how the clinical course of CKD vary with age. The purpose of this study was to examine the impact of aging on the risk of end-stage kidney disease (ESKD) in patients with moderate to advanced CKD. Materials and Methods: A total of 454 patients with stages 3–5 CKD were prospectively followed for a median of 5.1 years. The primary outcome was ESKD needing chronic dialysis therapy or preemptive kidney transplantation. The secondary outcome was a composite of ESKD or all-cause mortality. Results: The mean age of the patients was 65 ± 13 years. 65.4% were men, 44.9% had diabetes mellitus, and 22.7% had cardiovascular disease. Overall, 142 participants progressed to ESKD and 63 participants died. Compared with young patients (age <65 years, n = 205), elderly patients (age ≥65 years, n = 249) were associated with a significantly decreased risk of ESKD in Cox proportional hazards models adjusted for sex, smoking history, diabetes mellitus, cardiovascular disease, systolic blood pressure, estimated glomerular filtration rate, urine protein: Creatinine ratio, use of renin-angiotensin-aldosterone blocker, hemoglobin, phosphate, interleukin-6, body mass index, and N-terminal pro-brain natriuretic peptide (hazard ratio [HR]: 0.66; 95% confidence interval [CI]: 0.45, 0.96; P = 0.028). The results remained statistically significant when death as a competing risk was taken into account (subdistribution HR: 0.65; 95% CI: 0.45, 0.95, P = 0.026). Notably, elderly did not predict a higher risk for the composite outcome (HR: 0.94; 95% CI: 0.67, 1.32; P = 0.723). Conclusion: Elderly confers a decreased risk of ESKD in Taiwanese patients with moderate to advanced CKD. Our findings suggest that age is an important effect modifier for CKD progression.
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Transarterial chemoembolization with or without sorafenib for hepatocellular carcinoma: A real-world propensity score-matched study p. 219
Tzu-Rong Peng, Ta-Wei Wu, Chao-Chuan Wu, Sou-Yi Chang, Cheng-Yi Chan, Ching-Sheng Hsu
DOI:10.4103/tcmj.tcmj_84_21  
Objectives: Transarterial chemoembolization (TACE) or sorafenib may prolong survival in patients with unresectable hepatocellular carcinoma (HCC); however, whether their combination prolongs survival than TACE alone remains controversial. We aimed to compare the overall survival (OS) of patients with unresectable HCC treated with TACE plus sorafenib (TACE-S) versus TACE alone. Materials and Methods: All patients with unresectable HCC who received TACE as the initial therapy between January 2006 and January 2017 at Taipei Tzu Chi Hospital were enrolled. We matched patients treated with TACE-S and those treated with TACE alone (TACE) by performing propensity score matching at a 1:2 ratio. Our primary outcome was OS during a 10-year follow-up period, and represented as a hazard ratio calculated using Cox proportional hazard regression models. Results: Among 515 patients with unresectable HCC were treated initially with TACE, 56 receiving TACE-S group and 112 receiving TACE alone (TACE group) were included in the primary outcome analysis. The TACE-S group had significantly longer median OS than did the TACE group (1.55 vs. 0.32, years; P < 0.001), and the 5-year OS rates was 10.7% in the TACE-S group and 0.9% in the TACE group (P < 0.001). In multivariate analyses, patients with a lower Child–Pugh score, tumor size ≤5 cm, and no extrahepatic metastasis before treatment and those receiving antiviral agents and receiving TACE-S had longer OS (all P < 0.001). Conclusion: Antiviral agents and the combination of TACE with sorafenib may improve the OS of patients with unresectable HCC.
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Psychiatric comorbidity and quality of life in patients with epilepsy on anti-epileptic monotherapy and polytherapy p. 226
Jagriti Yadav, Priti Singh, Surekha Dabla, Rajiv Gupta
DOI:10.4103/tcmj.tcmj_34_21  
Objective: The bio-psycho-social factors affecting the quality of life in patients with epilepsy can be numerous but are often overlooked. The behavioral side effects of anti-seizure medications can be one such potential factor. The aim of the study is to address the effect of the number of anti-seizure medications on the development of psychiatric comorbidity and quality of life in patients with adequate seizure control. Materials and Methods: The study recruited 100 participants with generalized tonic-clonic seizures from a tertiary care center in North India, who were seizure-free from the last 1 month. The study participants were divided into two groups based on whether they were on monotherapy or polytherapy. The two groups were matched for their socio-demographic and clinical profile. We assessed for psychiatric comorbidity in each group using Mini International Neuropsychiatric Interview. All the study participants were given Hindi translated version of quality of life in the epilepsy-31 questionnaire for objective assessment of the quality of life. Results: The patients receiving anti-epileptic polytherapy had significantly higher prevalence of psychiatric comorbidity than patients on monotherapy. Furthermore, the patients on polytherapy scored significantly less on the cognitive domain of quality of life as well as the overall quality of life domain in the epilepsy-31 questionnaire. Conclusion: The patients with epilepsy must be evaluated for psychiatric comorbidity and side effect profile of anti-seizure medications to improve the quality of life. This is particularly more important for patients who are on anti-epileptic polytherapy even if the seizure control is adequate.
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Utilization of hospice and nonhospice care in patients with end-stage renal disease on dialysis p. 232
Shu-Chen Wang, Kai-Chieh Hu, Wei-Chuan Chang, Chung-Y Hsu
DOI:10.4103/tcmj.tcmj_207_21  
Objectives: The prevalence of end-stage renal disease (ESRD) and the number of patients undergoing dialysis in Taiwan are high. Since September 2009, the National Health Insurance has started to provide hospice care to patients with renal failure in Taiwan. Therefore, it is necessary to understand the use of hospice and nonhospice care in patients with ESRD on dialysis. We aim to understand trends in patients with ESRD receiving hospice and nonhospice care as well as medical care efforts during the last month of their lives (2009–2013). Materials and Methods: The cohort study was conducted using 1 million randomly selected samples from the Taiwan Health Insurance Research Database for millions of people in Taiwan in 2009–2013. Descriptive statistics were presented to summarize the characteristics of data. To compare differences between cohorts, Chi-square tests and Student's t-tests were used. Mann–Whitney U-tests were performed for nonnormally distributed data. Mantel–Haenszel test was test for trend. Results: We recruited 770 ESRD patients who underwent hemodialysis; among them, 154 patients received hospice care. Patients who received hospice care had a significantly longer survival time after removal of mechanical ventilator (20 vs. 0 days) and after discontinuation of dialysis (2 vs. 0 days) compared with those who did not receive hospice care. Patients who received hospice care had more pain control (61.04% vs. 17.37%, P < 0.0001) and other symptomatic control (55.84% vs. 43.18% with diuretics, P < 0.05; 64.29% and 48.21% with laxatives, P = 0.0004) medications than those who did not. Nevertheless, the overall medical cost in the hospice group was significantly lower (90 USD and 280 USD, P < 0.0001). Conclusion: Our results suggest that the addition of hospice care may permit patients a longer life-support-free survival time. In addition, despite a more frequent symptomatic controlling agent use, hospice care significantly reduced the overall medical expenditure.
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Oral health assessment in children aging 8–15 years with bronchial asthma using inhalation medication p. 239
Vaibhav Bansal, Kolli V. G. Reddy, Sugandh Shrivastava, Sunil Dhaded, Syed Mohammed Noorani, Mohd Ikram Shaikh
DOI:10.4103/tcmj.tcmj_74_21  
Objectives: The aim of the present study was to evaluate and compare oral health status of bronchial asthma patients between the age group of 8–15 years with healthy individuals and examines the relationship between the severity of asthma, dose duration, method of taking medication, and use of AeroChamber on the dental health of children diagnosed with asthma. Materials and Methods: The present cross-sectional study assessed the oral status of asthmatic patients and compared with a control group of 200 nonasthmatic patients. Both groups were matched in relation to age and gender. The oral health was assessed by measuring oral hygiene, caries status, periodontal health, and candidiasis of participants. Oral hygiene was measured by plaque index, caries assessment was done with the decayed missing filled teeth index/decayed extracted filled (DMFT/def index) and the periodontal status was measured with community periodontal index (CPI) adapted from the WHO (1997). Results: Plaque index score among asthmatics group was 1.49 ± 0.65 was significantly higher than healthy group 1.08 ± 0.57. The significant difference was noted in the mean caries (DMFT/def) score for asthmatic patients (2.31 ± 1.65/1.02 ± 0.39) and the controls (1.98 ± 1.54/0.74 ± 0.39). The CPI score was also significantly high in asthmatics (3.19 ± 1.68) in comparison to healthy individuals (2.32 ± 2.07). The candidiasis was absent in healthy individuals while it was present among 28 patients in the asthmatic group. The patients who were taking medication from longer period of time (9–12 months) had significantly worse oral health. The study result did not show any significant difference with the type of inhalation. However it showed significantly improved oral health for patients using AeroChamber in comparison to the patients not using it. Conclusion: Oral health was significantly poor in asthmatic patients in comparison with the healthy individuals. Increased frequency of asthma medication use was associated with increased likelihood of poor oral health. Use of AeroChamber improves the oral health of patients.
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Acceptability of coronavirus disease 2019 vaccination among Indian health-care professionals: A cross-sectional survey p. 245
Manpreet Arora, Charu Khurana, Pulin Saluja, Aparna Dave
DOI:10.4103/tcmj.tcmj_45_21  
Objective: The epidemic of novel coronavirus disease 2019 (COVID-19) has led to the development of several vaccine candidates which has been progressing at an unprecedented rate. Health-care professionals are somewhere standing between their professional commitments and personal well-being, amid concerns about the safety and efficacy of the vaccine. The present survey was conducted to analyze their approach toward vaccination. Materials and Methods: An online questionnaire-based cross-sectional survey was conducted among 250 health-care professionals comprised of Medical, Dental, Ayurveda, Physiotherapy doctors, and nursing staff working at a tertiary care hospital in Gurugram city. A self-administered 10-item questionnaire in the Google document format was developed to assess their perception and attitude toward vaccination. The present survey was carried out for 2 months from November to December 2020. The responses recorded were subjected to the statistical analysis using the Chi-square test and the level of statistical significance was set at P ≤ 0.05. Results: Among all participants, 72 (28.8%) were male and 178 (72.2%) were female. Of all, 60.4% of the health-care professionals somewhat or completely agreed to accept a vaccine as soon as it is available. Nursing staff reported more likely to accept COVID-19 vaccination than the other health-care professionals. Majority of the HPs (44%) were found to be concerned about the rapidity in the development of vaccine. Conclusion: The overall attitude toward vaccination was positive but specific concerns regarding COVID-19 vaccine are prevalent. Thus, to maintain the benefits of vaccination programs and for its successful implementation, understanding and addressing their vaccine hesitancy will be crucial.
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LETTERS TO THE EDITOR Top

Letter to the editor concerning: Stroke and diets: A review p. 251
Maximilian Andreas Storz
DOI:10.4103/tcmj.tcmj_184_21  
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Reply from author for letter to the editor concerning: Stroke and diets: A review p. 253
Chin-Lon Lin
DOI:10.4103/tcmj.tcmj_194_21  
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