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Introduction: In medical education, the clerkship phase is a demanding period during which medical students learn to navigate the responsibilities of medical school and clinical medicine. Grit, a personal quality regarded as a non-cognitive trait, refers to perseverance and passion; specifically, it represents the ability to endure hardship and work industriously toward a goal. Most studies analysed grit as a single concept and few studies have investigated the effect of grit on the well-being of medical students through the whole-specialty training (i.e. surgical and non-surgical specialty rotations) required in clinical clerkships. Therefore, this study investigated whether associations exist between medical students' grit, measured by the two subconstructs of perseverance and passion, and their well-being during clerkships in surgical and non-surgical specialty units., Methods: This one-year prospective web-based questionnaire study enrolled fifth-year medical students at a tertiary medical centre in central Taiwan between September 2017 and July 2018 in their first-year clerkship. The students' sex, age, and grit were measured at the start of their clerkship. Routine surveys were conducted over one year to assess burnout and compassion satisfaction for students' well-being, and the training specialty characteristics of the surgical and non-surgical specialty departments were recorded. This study included 92 medical students and 1,055 survey responses from individual specialty rotations. Descriptive, univariate and multivariate analyses were performed., Results: Our results revealed that medical students' perseverance, as part of grit, was related to lower burnout and higher compassion satisfaction during clerkships, but not the subconstruct of passion. Moreover, the positive trait of perseverance measured in our study had greater explanatory power for compassion satisfaction than for burnout. Furthermore, the results revealed that older medical students suffered from less burnout than their younger counterparts, and that male medical students expressed higher compassion satisfaction than their female counterparts., Discussion: Perseverance, as a subconstruct of grit, is a positive personal quality for medical students' clerkships, and methods driving the cultivation of perseverance in medical education should be considered. In addition, even though positive traits such as perseverance equipped medical students for compassion satisfaction, additional factors attributed to medical students' burnout must be identified., Competing Interests: The authors declare that this study was conducted in the absence of any commercial or financial relationships that could be construed as potential conflicts of interest., (Copyright © 2024 Lin, Lin, Chen and Lin.)

Background: Air pollution is speculated to affect the reproductive health of women. However, a longitudinal association between exposure to air pollution and dysmenorrhea has not been identified, which this study aimed to examine this point. Methods: Two nationwide databases, namely the Taiwan Air Quality Monitoring database and the Taiwan National Health Research Institutes database were linked. Women with a history of dysmenorrhea (International Classification of Disease, Ninth Revision, Clinical Modification code 625.3) before 2000 were excluded. All participants were followed from January 1, 2000 until the diagnosis of dysmenorrhea, withdrawal from National Health Insurance, or December 31, 2013. Furthermore, air pollutants were categorized into quartiles with three cut-off points (25th, 50th, and 75th percentiles). The Cox regression model was used to calculate the hazard ratios of dysmenorrhea. Results: This study enrolled 296,078 women. The mean concentrations of yearly air pollutants were 28.2 (±12.6) ppb for nitric oxides (NO x ), 8.91 (±7.93) ppb for nitric oxide (NO), 19.3 (±5.49) ppb for nitrogen dioxide (NO 2 ), 0.54 (±0.18) ppm for carbon monoxide (CO), and 31.8 (±6.80) μg/m 3 for PM 2.5 . In total, 12,514 individuals developed dysmenorrhea during the 12-year follow-up. Relative to women exposed to Q1 concentrations of NO x , women exposed to Q4 concentrations exhibited a significantly higher dysmenorrhea risk [adjusted hazard ratio (aHR)= 27.9, 95% confidence interval (CI) = 21.6-31.3]; similarly higher risk was found for exposure to NO (aHR = 16.7, 95% CI = 15.4-18.4) and NO 2 (aHR = 33.1, 95% CI = 30.9-37.4). For CO, the relative dysmenorrhea risk in women with Q4 level exposure was 28.7 (95% CI = 25.4-33.6). For PM 2.5 , women at the Q4 exposure level were 27.6 times (95% CI = 23.1-29.1) more likely to develop dysmenorrhea than those at the Q1 exposure level. Conclusion: Our results showed that women would have higher dysmenorrhea incidences while exposure to high concentrations of NO, NO 2 , NO x , CO, and PM 2.5 ., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Lin, Yang, Lin, Chang, Hsu, Wang, Lin, Hsu and Kao.)

High levels of albuminuria have been demonstrated to associate with hearing loss in non-diabetic people, while the clinical impact of low-grade albuminuria has attracted less attention. This cross-sectional population-based study aimed to examine whether hearing loss in non-diabetic United States (US) adults is independently associated with low-grade albuminuria or reduced estimated glomeruli filtration rate (eGFR).A total of 2518 participants aged 20 to 69 years were selected from the US National Health and Nutritional Examination Survey database. Participants with diabetes or high-grade albuminuria were excluded. Hearing loss was assessed using low-frequency pure-tone average (LFPTA) thresholds (0.5, 1.0, 2.0 kHz) and high-frequency pure-tone average (HFPTA) thresholds (3.0, 4.0, 6.0, 8.0 kHz). Logistic and linear regression analyses were used to evaluate associations between renal function indicators and hearing loss.The median age of included participants was 37.4 years, and 55% of them were female. Multivariate analysis revealed that participants with urinary albumin-to-creatinine ratio (UACR) in the highest tertile had a significantly higher risk of hearing loss (OR, 1.79; 95% CI, 1.01-3.19) and higher HFPTA thresholds (β: 2.23; SE: 0.77). Participants with eGFR <60 mL/min/1.73 m had higher LFPTA thresholds (β: 4.31; SE: 1.79). After stratification by sex, a significant risk remained only for males in the highest UACR tertile, with 2.18 times the risk of hearing loss (95% CI, 1.06-4.48).Non-diabetic US males with low-grade albuminuria are at increased risk of hearing loss, independent of eGFR.

Background: Resilience refers to the ability to be flexible and adaptive in response to challenges. Medical students in clerkship who are transitioning from medical studies to clinical practice face a variety of workplace demands that can lead to negative learning experiences and poor quality of life. This study explored whether medical students' resilience plays a protective role against the stresses incurred during workplace training and on their professional quality of life during clerkships., Methods: This was a 1-year prospective web-based questionnaire study comprising one cohort of medical students in their fifth year who were working as clerks as part of their 6-year medical education programme at one medical school in Taiwan between September 2017 and July 2018. Web-based, validated, structured, self-administered questionnaires were used to measure the students' resilience at the beginning of the clerkship and their perceived training stress (i.e. physical and psychological demands) and professional quality of life (i.e. burnout and compassion satisfaction) at each specialty rotation. Ninety-three medical students who responded to our specialty rotation surveys at least three times in the clerkship were included and hierarchical regressions were performed., Results: This study verified the negative effects of medical students' perceived training stress on burnout and compassion satisfaction. However, although the buffering (protective) effects of resilience were observed for physical demands (one key risk factor related to medical students' professional quality of life), this was not the case for psychological demands (another key risk factor). In addition, through the changes in R square (∆R 2 ) values of the hierarchical regression building, our study found that medical students' perceived training stresses played a critical role on explaining their burnout but their resilience on their compassion satisfaction., Conclusions: Medical students' resilience demonstrated a buffering effect on the negative relationship between physical demands and professional quality of life during clerkships. Moreover, different mechanisms (predictive paths) leading to medical students' professional quality of life such as burnout and compassion satisfaction warrant additional studies.

Objective: To confirm the efficacy and safety of AM-111 (brimapitide), a cell-penetrating c-Jun N-terminal Kinase (JNK) inhibitor, in patients suffering from severe to profound acute unilateral idiopathic sudden sensorineural hearing loss (ISSNHL)., Study Design: Prospective, double-blind, randomized, placebo-controlled phase 3 study with follow-up visits on Days 3, 7, 28, and 91., Setting: Fifty-one European and Asian sites (tertiary referral centers, private ENT practices)., Patients: Two hundred fifty-six patients aged 18 to 65 years presenting within 72 hours following ISSNHL onset with mean hearing loss ≥ 40 dB and mean threshold ≥ 60 dB at the 3 worst affected contiguous test frequencies., Interventions: Single-dose intratympanic injection of AM-111 (0.4 or 0.8 mg/ml) or placebo; oral prednisolone as reserve therapy if hearing improvement < 10 dB at Day 7., Main Outcome Measures: Hearing improvement to Day 28 was the primary efficacy endpoint; complete hearing recovery, frequency of reserve therapy used, complete tinnitus remission, improvement in word recognition were secondary endpoints. Safety was evaluated by the frequency of clinically relevant hearing deterioration and adverse events., Results: While the primary efficacy endpoint was not met in the overall study population, post-hoc analysis showed a clinically relevant and nominally significant treatment effect for AM-111 0.4 mg/ml in patients with profound ISSNHL. The study drug and the administration procedure were well tolerated., Conclusions: AM-111 provides effective otoprotection in case of profound ISSNHL. Activation of the JNK stress kinase, AM-111's pharmacologic target, seems to set in only following pronounced acute cochlear injury associated with large hearing threshold shifts.

Objectives: To compare the efficacy of pentoxifylline with that of conventional steroid therapy in diabetic patients with idiopathic sudden sensorineural hearing loss (ISSNHL) and to compare blood sugar levels during hospitalization., Materials and Methods: Medical charts were retrospectively reviewed for all diabetic patients admitted to one institution for ISSNHL between 2000 and 2015. We analyzed 298 cases; 50 patients received pulse steroid treatment (steroid group) and 248 received intravenous administration of pentoxifylline only (pentoxifylline group). Hearing change was evaluated by comparing the initial hearing tests with follow-up hearing tests for up to 3 months. Blood sugar levels were also compared between the 2 groups., Results: At 3 months post-treatment, the degree of hearing recovery was similar between the 2 groups. The pure-tone average was improved from baseline by 17.9±21.2 dB in the steroid group and 18.9±20.7 dB in the pentoxifylline group (p=0.776); hearing recovery rates were also similar (40% vs 39.1%; p=0.826). During hospitalization, average fasting blood sugar levels were higher (203.9±92.0 vs 174.4±54.8 mg/dL; p=0.033) and acute hyperglycemia was more common (48.0% vs 33.1%; p=0.044) with steroid versus pentoxifylline treatment., Conclusion: Hearing recovery rates did not significantly differ between steroid and pentoxifylline treatment in diabetic patients with ISSNHL, but pentoxifylline appeared to be associated with better blood sugar control.

Objectives: Hearing deterioration is a major concern for hearing-preserved patients with vestibular schwannomas who are treated with stereotactic radiosurgery (SRS). Thus, determining which patients are more likely to have worse hearing outcomes following SRS may facilitate clinicians in deciding whether conservative policy should be applied in the interest of hearing preservation. This study aimed to define the predictors of hearing outcomes following SRS., Patients and Methods: This retrospective study included 100 patients who underwent low-dose SRS (12- to 13-Gy marginal dose) for vestibular schwannomas between January 2004 and January 2014. Clinical factors and hearing outcomes following radiosurgery were reviewed., Results: All patients had serviceable hearing at diagnosis and prior to SRS. The median follow-up period was 6.5years (range, 3-10years). The hearing preservation rate in the first, third, and fifth year after radiosurgery was 89%, 68%, and 63%, respectively. A mean cochlear dose lower than 4Gy was a favorable predictor of hearing outcome. Maximal cochlear dose, patient age, pre-treatment pure-tone average, and imaging characteristics were not associated with post-treatment hearing preservation. Our study showed an accelerated rate of deterioration of serial pure-tone average in the first 3years, followed by a more gradual decline after radiosurgery., Conclusion: Our results suggest that cochlear dose constraint is the most crucial factor for hearing preservation. This study provides insight into the rate of hearing preservation and the pattern of hearing deterioration following radiosurgery and can help clinicians advise patients of hearing outcomes following SRS., (Copyright © 2017 Elsevier B.V. All rights reserved.)

Objectives: Otitis media with effusion (OME) has a higher incidence in adult intensive care unit (ICU) patients. This observational study sought to examine the effect of tracheostomy on OME in critically ill patients and explore the predisposing factors., Materials and Methods: Twenty-seven ICU patients who had undergone prolonged intubation (more than 14 days) received traditional tracheostomies. Otoscopic examination, tympanometry, and spectral gradient acoustic reflectometry were performed both at the time of the tracheostomy and 7 days later. We collected data on the patients' demographics (age and gender), underlying diseases, duration of intubation prior to the tracheostomy, history of gastroesophageal reflux disease, length of antibiotic use, level of consciousness, and presence of nasogastric tubes., Results: At the time of the tracheostomy, 25 (46%) ears from 14 (52%) patients were classified as cases of OME, 17 (31%) ears and 7 (26%) patients as normal cases, and 12 (11%) ears from 6 (11%) patients as cases of negative pressure in the tympanic cavity. Seven days after the tracheostomy, OME was resolved in 17 (68%) ears and persisted in 6 (24%) ears, whereas negative pressure developed in 2 (8%) ears. Our data showed that the incidence of OME reduced from 46% to 22% after tracheostomy was performed on the patients., Conclusion: The incidence of OME in adult ICU patients who were intubated for more than 14 days was found to reduce after tracheostomy. Notably, the rate of improvement in the conscious patients was significantly higher than that in the unconscious patients.

Objectives: Deep neck infection is a potentially life-threatening disease and rarely seen in children. Because of the obscure complaints and symptoms, the diagnosis of deep neck infection may be delayed, which may result in inappropriate treatment. This retrospective study was aimed at analyzing the occurrence of complications, diagnostic methods and proper managements of deep neck infection in children., Methods: A retrospective study was performed on 30 children with deep neck infection treated from October 1999 through October 2003. The etiology, clinical symptoms, laboratory examination, radiological examination, bacteriology, and treatments were retrospectively analyzed., Results: The most common predisposing factors were tonsillitis and upper respiratory tract infection. The most common symptoms were fever (93.3%) and painful swelling of the neck (70.0%). Both peritonsillar (24.3%) and parapharyngeal space infections (24.3%) were the most common, followed by submandibular space infections (18.9%). The most common pathogens isolated were Staphylococcus aureus (27.3%) and viridans streptococci (22.7%). The mean duration of hospitalization was 7.9 days, with a range from 2 to 18 days. Complications occurred in 2 patients, including recurrence and pulmonary edema., Conclusions: Deep neck infection should be suspected in a child who presents with fever and painful swelling of the neck. Staphylococcus aureus and viridans streptococci were the most common pathogens. Computed tomography scan should be performed in time and infections in peritonsillar and ,parapharyngeal spaces were the most common.

Although laryngomalacia is the leading cause of stridor in infancy, vocal cord paralysis, despite its low incidence, is still the second most common cause. However, the etiology of infant vocal cord paralysis is different from that of adults, and the management protocol is controversial. Therefore, we conducted this study to better characterize the cause and outcome of vocal cord paralysis in infants. From January 1997 to December 2003, we treated thirteen infants younger than one year for vocal cord paralysis. Seven infants were idiopathic (idiopathic group), two might be caused by prior surgery (iatrogenic group), two might be caused by central neuropathy (neurological group), and two were born after difficult delivery (obstetrical group). In the idiopathic group, six infants spontaneously recovered and one infant had right-side recovery, but the left side was still paralytic. All infants in the iatrogenic and obstetrical groups spontaneously recovered. However, no infant in the neurological group recovered. Spontaneous recovery occurred in 76.9% of affected infants. More than half (70%) of these spontaneous recoveries occurred within 6 months. In our experience, direct flexible laryngoscopy is mandatory for all infants younger than one year of age presenting with stridor. Except for extreme infants (e. g. bilateral vocal cord paralysis with severe respiratory distress and central neuropathy) who require a temporary tracheotomy to relieve the airway obstruction, we recommend waiting for at least 6 months before proceeding to invasive surgical interventions.

Background: Most lymphomas that involve the tonsil are large B cell lymphomas. Large B-cell lymphoma is a high grade malignancy which progresses rapidly. Tonsillar lymphoma usually presents as either a unilaterally enlarged palatine tonsil or as an ulcerative and fungating lesion over the tonsillar area. Small lymphocytic lymphomas (SLL) of the Waldeyer's ring are uncommon., Case Presentation: We report a 41-year-old male who presented with a ten-year history of snoring. Physical examination revealed smooth bilateral symmetrically enlarged tonsils without abnormal surface change or cervical lymphadenopathy. Palatal redundancy and a narrowed oropharyngeal airway were also noted. The respiratory disturbance index (RDI) was 66 per hour, and severe obstruction sleep apnea (OSA) was suspected. No B symptoms, sore throat, odynophagia or dysphagia was found. We performed uvulopalatopharyngoplasty (UPPP) and pathological examination revealed incidental small B-cell lymphocytic lymphoma (SLL)., Conclusion: It is uncommon for lymphoma to initially present as OSA. SLL is an indolent malignancy and is not easy to detect in the early stage. We conclude that SLL may be a contributing factor of OSA in the present case.

Subglottic leiomyoma is a rare disease. We encountered such a tumor in a 7-year-old boy who was transferred to our hospital with respiratory distress and hoarseness of 2 week's duration. Stridor was noted and flexible fiberoscopy revealed a huge mass over the subglottis. The tumor was removed endoscopically. Pathologic examination disclosed a leiomyoma. The patient recovered well and no recurrence was noted during 17 months of follow-up. Although subglottic leiomyoma is rare, it should be included in the differential diagnosis of a subglottic tumor.

Metastatic hepatocellular carcinoma (HCC) in the sinonasal region is rare. We report the case of a 45-year-old male hepatitis B carrier who had metastatic HCC 2 years after resection of the primary tumor. The patient died of terminal hepatic failure 6 weeks after the discovery of nasal septal metastasis. The clinical and histopathologic characteristics of the primary and metastatic hepatocellular tumors are described. This is the first reported case of nasal septal metastasis from HCC.

Endotracheal intubation is an important airway procedure in the management of neonates and infants. Prolonged intubation may result in severe laryngeal injury which may lead to chronic laryngeal disability. The nature and causes of post-extubation airway obstruction were evaluated with videoendoscopy. From June 1998 to September 2000, detailed videoendoscopic examination of pediatric airway was performed in 30 children who had persistent stridor after endotracheal extubation or failure of elective extubation. Common locations of post-extubation lesion are the posterior glottis and subglottis. Retrospective analysis of the causes of stridor included: (1) isolated intubation laryngotracheitis (n = 19); (2) intubation laryngotracheitis with neuromuscular dysfunction which resulted in tongue drop, laryngotracheal incoordination, saliva pooling over the larynx or poor cough reflex(n = 5); and (3) specific airway problems such as laryngomalacia, subglottic stenosis or vocal paralysis(n = 6). We favored the term of "intubation laryngotracheitis" instead of "intubation injury" or 'intubation trauma". Although most cases of intubation laryngotracheitis heal, leaving a normal or near-normal larynx, some of them still suffer from airway obstruction after endotracheal extubation. Specific airway problems such as severe laryngomalacia or vocal cords paralysis and neurogenic defects should also be taken into consideration.