Tzu Chi Medical Journal

Heart rate reduction and autonomic response in young adults following different vagal maneuvers

Yuan-Chia Cheng, Huai-Min Chen, Wei-Che Lee, Chao-Wen Chen, Hsing-Lin Lin — 2012-01-16

Abstract: Objective: Vagal maneuvers can cause a bradycardiac response with a reciprocal increase in parasympathetic outflow and reduction of sympathetic tone. Heart rate variability (HRV) analysis is useful in the evaluation of the autonomic nervous system. The present study investigated the magnitude of heart rate (HR) reduction and autonomic response in healthy young adults following three vagal maneuvers: carotid sinus massage (CSM), the cold face test (CFT), and the Valsalva maneuver (VM).Materials and Methods: A prospective study was conducted in 50 healthy volunteers between 21 and 35 years old who completed CSM, the CFT, and the VM in random order. Before and after each test, the RR intervals were recorded by electrocardiography for 5min to analyze variability in the time and frequency domains, and to monitor changes in the HR, blood pressure (BP), and body temperature (BT).Results: After each test, HR, BP, and BT significantly decreased compared with values at rest (all p values < 0.05). The mean HR during CSM, the CFT, and the VM significantly decreased by 4.0%, 3.2%, and 2.3%, respectively, revealing that CSM most potently induced HR reduction. Significantly increased variance of the RR (VAR) indicated that CSM, the CFT, and the VM induced cardiac autonomic function (p=0.001, p=0.009, and p=0.009, respectively). Although not all of these changes were statistically significant, increased power of the normalized low-frequency component (LF%), decreased power of the normalized high-frequency component (HF%), and an increased LF/HF ratio suggested relative sympathetic enhancement. Only the VM had significant effects on sympathovagal balance in the LF%, HF%, and LF/HF (p=0.006, p=0.004, and p=0.006, respectively).Conclusion: Of the three maneuvers, CSM had the greatest effects on HR reduction, while only the VM had significant effects on sympathovagal modulation. Although accurate assessment of vagal activity was not available from spectral analysis of HRV, the increases in VAR, LF%, and LF/HF, and decrease in HF% observed in this study suggest that increases in cardiac autonomic activities and sympathetic dominance occur as compensatory responses to HR reduction in a 5-min window following vagal maneuvers. More research is required to determine whether CSM is a superior initial nonpharmacologic treatment for supraventricular tachyarrhythmia in a young population if there are no contraindications.

The formation and performance of medical humanities by interns in a clinical setting

2011-12-29

Abstract: Objectives: There were two aims of this study: first, we attempted to identify the medical humanities performed by interns in the clinical ward; second, we wanted to explore the ways that interns learn medical humanities.Materials and Methods: This research was carried out in a general internal medicine model unit of a medical center in southern Taiwan. Researchers conducted field work by participant observation in the ward for 9 months from December 2008 to May 2009, and from November 2009 to January 2010. Eight interns were enrolled in this study. Humanistic behaviors performed by the interns who were investigated during the course of their medical activities were recorded in field records. After participant observation, five interns were interviewed to collect information on their learning processes related to medical humanities. The field records and interview transcriptions were coded according to categories of medical professionalism defined in this study.Results: Four major characteristics of medical humanities were observed from the field work: primacy of patient welfare, patient autonomy, social justice, and sincerity. The most common humanistic practices performed by the interns included converting medical knowledge into lay language when communicating with the patient’s family, closing the bedside curtain for privacy and arranging social worker consultations to help patients. Three learning models were also identified that were associated with the performance of humanistic practices observed in the field. Interns may learn medical humanities through learning by doing, a teaching-learning model, informal peer learning, or a combination of these.Conclusion: This study confirmed that sincerity is a characteristic of medical professionalism and medical humanities. Participant observation can be used as an ideal tool for identifying humanistic medical practices in daily clinical settings, and an interview can become a supplemental method to validate what has been observed.

Application of signs of dying identified in traditional Chinese, Tibetan, and modern Western medicine in terminal care

Jyh-Gang Hsieh, Ying-Wei Wang — 2012-03-05

Abstract: Objectives: The purpose of this study was to promote culturally sensitive hospice care by understanding the concepts of approaching death in traditional Chinese and Tibetan medicine.Materials and Methods: We searched for information on signs of dying in Western medicine using MEDLINE and the Cochrane Library Database. We conducted in-depth interviews using a semi-structured questionnaire with six traditional Chinese medical doctors qualified to practice both Western and Chinese medicine. A literature review of Chinese and Tibetan medicine included an analysis of the classical textbooks of these traditional medicine systems. The literature was analyzed using qualitative analysis software.Results: Western medicine uses physiologic phenomena to describe signs of dying, while traditional Chinese medicine believes that signs of dying can be summarized as different symptom complexes and can be used to predict disease prognosis. Tibetan medicine views dying as a complex and interdependent process in which the patient’s body and mind simultaneously disintegrate. Traditional Chinese and Tibetan medicine pay more attention to the observable signs of disease.Conclusions: In Taiwan, Western medicine is the main treatment option delivered during hospice care, but many patients and families are still influenced by traditional medicine concepts. The understanding of traditional medicine can provide culturally sensitive care for terminally ill patients of different cultures.

Granular cell tumor of the left maxillary paranasal sinus in a 24-year-old man

Chia-Fen Yang, Szu-Ying Chin — 2011-11-28

Abstract: Granular cell tumors (GCTs) are uncommon benign lesions which usually occur in the head and neck region. However, paranasal sinus presentation is extremely rare. We report a case of a 24-year-old man with clinical symptoms of chronic sinusitis, which is believed to be the first reported case arising from the paranasal sinuses in the English literature. His symptoms included bilateral nasal obstruction, discharge, postnasal drip, and hyposmia. He received a multiple sinusectomy and there was no evidence of recurrence in the 6-month follow-up. We also summarize the clinical information, clinical presentation, microscopic picture, treatment, and patient status after treatment of three previously reported cases involving naso-paranasal areas along with our case. The diagnostic criteria for malignant transformation and the role of bone invasion are also reviewed.

Nasopharyngeal papillary adenocarcinoma: A case report and clinicopathologic review

Yuan-Tung Chu, Chung-Tai Yue — 2011-12-21

Abstract: Nasopharyngeal papillary adenocarcinoma (NPAC) is an extremely rare malignant tumor derived from the nasopharyngeal surface epithelium, with only a limited number of cases reported in the literature. NPAC presents as a slow-growing exophytic mass, with an excellent prognosis and rare recurrence following appropriate surgical management. In contrast, ordinary nasopharyngeal carcinoma is typically accompanied by metastatic neck masses, and radiotherapy is the mainstay of treatment. The immunohistochemical profile supports the derivation of NPAC from the surface epithelium rather than from the subjacent minor salivary glands. This tumor most commonly involves the roof, lateral wall, and posterior wall of the nasopharynx. Nasal obstruction is the main presenting symptom. The diagnosis can be confirmed readily by endoscopic biopsy. This report describes NPAC in a 50-year-old man with symptoms of blood-tinged rhinorrhea and morning headache. The patient is currently well without tumor recurrence after surgical treatment.

Severe hyponatremia and syndrome of inappropriate secretion of antidiuretic hormone (SIADH) induced by duloxetine

Shu-Ju Yang, Po-Lun Wu — 2011-11-07

Abstract: Hyponatremia is a significant complication of treatment with selective serotonin reuptake inhibitors. There are a limited number of case reports of hyponatremia following treatment with duloxetine. We describe a case of a 57-year-old woman who had begun taking duloxetine for depression. Three weeks later, she reported fatigue, weakness, lethargy and drowsiness. During an emergency room evaluation, laboratory examination revealed hyponatremia and serum hypo-osmolarity. She had duloxetine-induced syndrome of inappropriate secretion of antidiuretic hormone (SIADH) and duloxetine was discontinued. Hyponatremia correction was started and, in one week, the mental status of the patient gradually improved, paralleling the resolution of her hyponatremia. She was started on trazodone 25mg/day for depression without recurrence of hyponatremia.

Complete metastasectomy to treat simultaneous metastases of the duodenum and pancreas caused by renal cell carcinoma

Yen-Cheng Chen, Ying-Chin Yang, Ming-Hsun Li, Hann-Chorng Kuo, Ming-Che Lee — 2011-12-02

Abstract: Renal cell carcinoma (RCC) metastatic to the pancreas is relatively uncommon, and RCC metastatic to the duodenum is extremely rare, with only a small number of case reports in the literature. We describe a 76-year-old woman with a history of RCC who had been treated by radical left nephrectomy 6 years earlier. The patient presented with anemia, hematochezia, and a bulging mass in the pancreaticoduodenal area, and was treated by pancreaticoduodenectomy. Histopathology confirmed metastatic RCC of the duodenum, the pancreas, and one of the dissected regional lymph nodes. The patient remains healthy to date without recurrence more than 24 months after pancreaticoduodenectomy. Our case report and review of the literature supports the curative surgical treatment in this rare group of patients.

Williams-Beuren syndrome

2011-09-05

Williams-Beuren syndrome, Mendelian inheritance in Man number 194050, is a genetic disorder caused by microdeletion of the Williams-Beuren syndrome chromosomal region on chromosome 7, spanning 1.5 million to 1.8 million base pairs and containing around 26–28 genes. The genotypic and phenotypic correlation is still not fully understood. Clinically, patients present with multiple systemic disorders include distinctive facial features (). Infant hyperglycemia, feeding difficulties, colic, and growing problems may be encountered. The adult height is usually below the third percentile. Gross developmental delays, poor physical co-ordination, and connective tissue abnormalities such as overly loose joints are obvious. Moderate intellectual disability but with specific strengths in verbal short-term memory and language, overfriendliness, and an empathetic personality are commonly observed. Elastin arteriopathy occurs in 75% of patients with this syndrome. Any artery may be narrowed, and peripheral pulmonic stenosis is common in early infancy. Supravalvular aortic stenosis is the most common arteriopathy requiring surgical correction. Genetic diagnosis using fluorescence in situ hybridization to demonstrate deletion of the Williams-Beuren syndrome chromosomal region, which encompasses the elastin gene, is the mainstay of laboratory diagnosis ().

Adenomatoid tumor of the uterus

Yung-Hsiang Hsu — 2011-09-07

A 43-year-old woman had dysmenorrhea for more than 6 months. The patient had a total hysterectomy with diagnosis of adenomyosis. Grossly, one grayish-white well-defined tumor nodule 1.5 cm in diameter was seen in the corpus. Histopathology showed the tumor was composed of numerous cystic spaces mimicking lymphangioma (A). Immunohistochemistry showed strongly positive staining for cytokeratin in the cystic lining diagnostic of adenomatoid tumor (B). Adenomatoid tumors are commonly seen in the fallopian tubes. These tumors are sometimes found in the uterine wall, usually beneath the serosa and close to the cornua.

A huge retropharyngeal air pocket in a 7-month-old infant

Jiann-Jy Chen, Hin-Cheung Shum, Chi-Jen Chen, Dem-Lion Chen, Yao-Mao Tang — 2012-01-03

A 7-month-old girl presented with poor dietary intake, a productive cough, rhinorrhea, and fever for over 2 weeks. She was admitted to a local hospital where she was examined for sepsis and received intravenous antibiotics. Over the following 3 days, her condition was stable and the fever subsided; however, on her 4th day in hospital, she developed dyspnea and acute supraglottitis was suspected. Anteroposterior chest radiography (A) and lateral neck radiography (B) did not demonstrate the thumb sign of epiglottitis; instead, a huge, 6.9 × 3.1-cm, retropharyngeal air pocket that threatened the upper airway was discovered. Emergency endotracheal intubation and echo-guided needle aspiration and drainage were performed and a corticosteroid was intravenously administrated. Follow-up lateral neck radiography (C) and contrast-enhanced computed tomography (D) demonstrated that the air pocket had been relieved, but a huge, 4.0 × 4.0 × 2.5-cm, retropharyngeal, gas-forming abscess was discovered, which contained an air-fluid mixture. The patient was transferred to a medical center for further evaluation and management. Three days later, a pus culture of the retropharyngeal gas-forming abscess was diagnosed as Pseudomonas aeruginosa, which is sensitive to gentamicin, amikacin, ceftazidime, ciprofloxacin, levofloxacin, meropenem, piperacillin/tazobactam, cefpirome, and cefoperazone-sulbactam without any antibiotic resistance.