Background: CyberKnife radiation therapy has a widely used system in the treatment of extracranial lesions. Implanting gold fiducial markers around a tumor is an important procedure for the planning and aiming of CyberKnife radiation therapy. Thus, the purpose of this study was to evaluate the feasibility, safety, and efficacy of percutaneous fiducial marker implantation of hepatic malignancies under sonographic guidance for CyberKnife radiation therapy. Materials and Methods: From April 2009 to November 2011, we retrospectively reviewed 30 percutaneous fiducial marker implantations in 30 patients with hepatic tumors. All patients underwent percutaneous fiducial marker implantation under sonographic guidance. The feasibility, safety, and efficacy of this technique were analyzed on immediate follow-up unenhanced computed tomography (CT) and 1-week follow-up contrast-enhanced CT. The efficacy of this technique was defined as implantation enabling adequate treatment planning and CT simulation. Results: All 30 patients (100%) had successful fiducial marker implantation under sonographic guidance. The mean number of fiducial markers implanted per patient was 4.30 (range: 4-6 seeds). There was one minor complication (3.33%, 1/30). All 30 patients successfully underwent CyberKnife radiation therapy after fiducial marker implantation. Conclusion: Sonographic-guided percutaneous fiducial marker implantation of hepatic malignancies is a feasible, safe, and effective technique for preparing patients before CyberKnife radiation therapy.

Background: The median nerve innervates the forearm and the hand muscles. Variations in its number of branches to pronator teres are frequently seen. The knowledge of its innervation to pronator teres is of utmost importance in understanding the several presentation of pronator teres syndrome, in investigating the median nerve lesions, to design satisfactory treatment, and to avoid iatrogenic injuries during operations. Hence, the aim of this study was to study the innervation of pronator teres muscle and its variations. Materials and Methods: The study was carried out on 24 cadaveric upper limbs. Dissection of the cubital fossa was done and branches of the median nerve to the pronator teres were identified and measured. The elbow articular line (interepicondylar line) was used as a reference point to measure the distance of various branches. Results: We found there were 1, 2, 3 and 4 branches in 5 (20.8%), 12 (50%), 5 (20.8%) and 2 (8.3%) specimens out of 24 upper limbs. In one specimen, we also found that musculocutaneous nerve was supplying the pronator teres muscle and that was arising 10.9 cm above the intercondylar line. Conclusion: This study will increase the knowledge of the anatomical distribution of nerves to pronator teres and therefore help in the treatment of pronator teres syndrome and in various surgical procedures.

Objective: This study was to clarify the prevalence of do-not-resuscitate (DNR) and identify the factors related to critically ill patients who have DNR directives or not in a medical Intensive Care Unit (ICU) in Taiwan. Materials and Methods: A retrospective chart review of 100 critically ill patients expired between January and December 2012 were included. The outcome was DNR or not when patient expired. Other variables regarding patient's demographics, disease-and DNR-related information were recorded. Logistic regression model was used to assess the related factor about DNR. A P < 0.05 was considered statistically significant. Results: DNR rates were 87%, and the mean interval from DNR signature to death was 3.9 days. Compared with the patients without DNR signature, the patients with DNR signature had no statistical significance of cancer diagnosis (odds ratio [OR] = 3.41, 95% confidence interval [CI] = 0.88-13.25, P = 0.076), and frequency of ICU admission (OR = 4.17, 95% CI = 0.92-18.86, P = 0.063). In addition, there were 4.22-fold (95% CI = 0.90-19.89) but no statistical significance (P = 0.068) of the frequency of ICU admission by patients with DNR directives compared to those without DNR directives after adjusting the variables of age, gender, economic status, primary diagnosis, and level of consciousness. Conclusion: Although this study indicated no statistical significance, we found that a patient with a cancer diagnosis and more frequency of ICU admissions tended to influence on family members concerning DNR directives in clinical setting. Early initiation of palliative care and DNR discussion may enhance the quality of care for dying patients.

Purpose: Intentional carbon monoxide (CO) poisoning has become the commonly used method of suicide in some Asian countries. The objective of this study was to identify the predictors that impact the outcome of intentional CO-poisoned patients with acute respiratory failure. Materials and Methods: This is a retrospective observational study of 796 consecutive patients diagnosed with acute CO poisoning that presented to the emergency department (ED). Patients who were CO poisoned with intentional exposure and acute respiratory failure were enrolled and divided into two groups. The poor outcome group consisted of in-hospital death, the presence of persistent neurological sequelae, and the presence of delayed neurologic sequelae. The good outcome group consisted of other enrolled patients. Demographic and clinical data of the two groups were extracted for analysis. Results: A total of 148 patients were enrolled in this study. Of the eligible subjects, 67.6% (100) were identified with positive toxicology screening results. On arriving ED, parameters associated with patients with a poor outcome included hypotension, myocardial injury, prolonged lag times from the first ED arrival to initiation of hyperbaric oxygen therapy, higher white blood cell count, and higher serum levels of blood urea nitrogen, creatine kinase, and troponin-I (P < 0.05). Positive toxicology screening result did not relate to the outcome. Multivariate analysis showed that the myocardial injury was an independent factor for poor outcome (odds ratio, 2.750; 95% confidence interval, 1.168-6.474; P = 0.021). Conclusions: Myocardial injury is an independent predictor of in-hospital death and neurologic sequelae in patients with intentional CO poisoning and acute respiratory failure.

Background: Phosphodiesterase 4 (PDE4) inhibitors negatively modulate many inflammatory responses, and some of these pharmacological effects are mediated by inhibition of PDE4B in inflammatory cells. While inactivation of PDE4B, but not other PDE4 isotypes, is known to inhibit lipopolysaccharide (LPS)-induced tumor necrosis factor-α (TNF-α) production in macrophages, a cell type critical in mediating innate immunity, the impact of PDE4B on many other inflammatory responses in these cells remains largely unknown. Materials and Methods: To investigate whether PDE4B regulates additional inflammatory mediators other than TNF-α, in this study we initially used two-dimensional gel electrophoresis approach to screen the secreted proteins that are modulated by the PDE4 inhibitor rolipram in LPS-stimulated Raw 264.7 macrophages. Results: Three proteins were identified, of which the proinflammatory chemokine CC chemokine ligand 3 (CCL3) and cytokine TNF-α were downregulated and the antiinflammatory cytokine interleukin-1 receptor antagonist was upregulated. Further analysis on CCL3 production in mouse peritoneal macrophages revealed that the reduced CCL3 secretion was associated with a substantial decrease in CCL3 mRNA accumulation. The inhibitory effect of rolipram on CCL3 production was mimicked by the protein kinase A activator 6-Bnz-cAMP, but not the exchange protein directly activated by cAMP activator 8-pCPT-2'-O-Me-cAMP. Analysis of PDE4-deficient macrophages showed that ablation of only PDE4B reproduced the rolipram effect on CCL3 production. Moreover, PDE4 inhibitor potentially attenuates T-cell migration to CCL3 in inflammatory sites. Conclusions: These findings suggest that PDE4B may regulate the production of diverse inflammatory mediators in LPS-stimulated macrophages, and an inhibitor with PDE4B selectivity should retain the anti-inflammatory effects of nonselective PDE4 inhibitors in endotoxin-induced inflammatory conditions.

A 25-year-old farmer from rural Bengal presented in the emergency with acute retention of urine and severe radicular pain along the lower back and back of thighs. He had a history suggestive of bladder outflow obstruction for past 1-year, but no history of retention of urine. Radicular pain and marked constipation were of recent onset. There was no history suggestive of urinary tract infection or significant weight loss. There was no past history of surgery, trauma or other major illness. On examination, the bladder was distended and digital rectal examination revealed an anteriorly placed immobile, nontender, extra luminal soft, cystic pelvic mass. Ultrasonography revealed a cystic mass within pelvis with back pressure changes of the kidneys and ureters, while contrast enhanced computed tomography of abdomen revealed a 10.5 cm × 10 cm thick-walled, nonenhancing, unilocular lesion occupying the pouch of Douglas pressing on the bladder neck anteriorly. An ELISA test for echinococcus antigen was negative. Laparotomy revealed an immobile, retroperitoneal, tense, cystic swelling occupying the entire pelvic cavity containing crystal clear fluid suggesting possibility of hydatid cyst. Exploration of the cyst with scrupulous precautions to avoid spillage showed an endocyst. Endocystectomy with partial pericystectomy was done. Patient had an uneventful recovery. This case report depicts an atypical presentation of isolated primary extra-peritoneal pelvic hydatid cyst in a young male hailing from a nonendemic areas.

The Meigs' syndrome is a rare syndrome defined as the triad of benign solid ovarian tumors, ascites, and pleural effusion, which resolve spontaneously and permanently after tumor resection. Lung collapse due to a large amount of pleural effusion is a common mechanism of death. It always requires surgical treatment. We report an 84-year-old woman with a large ovarian fibroma associated with Meigs' syndrome and short of breath. It is difficult to diagnose preoperatively and is usually misdiagnosed as an ovarian malignancy. Considering the patient's serious clinical condition and assuming that she had Meigs' syndrome with a large ovarian mass and possible lung collapse due to large amount of pleural effusion, we chose the most appropriate surgical treatment after pathologic examination, then enabled definitive diagnosis of the benign tumor and removed the huge ovarian fibroma. This resulted in a timely symptoms resolution, short hospitalization, and relatively low morbidity in elderly.

Pyogenic liver abscess (PLA) is a global emerging infectious disease. The common presentations of PLA include fever, abdominal pain, anorexia, weight loss, and malaise. In Taiwan, Klebsiella pneumoniae is the most frequently isolated pathogen from PLA. Most cases of K. pneumoniae liver abscess (KLA) develop metastatic infections at other sites that cause severe complications, such as endophthalmitis, meningitis, or brain abscess. Herein, we describe a case of KLA that unusually presented as lower back pain. The patient received antibiotic therapy and underwent drainage procedure. He was eventually discharged in a stable condition, without any complications caused by the metastatic infections.

Osler-Weber-Rendu syndrome is a hereditary disease which is diagnosed by criterions of clinical symptoms and examinations. Here, we report a definite case of Osler-Weber-Rendu syndrome who had epistaxis, skin telangiectasia, and pulmonary arteriovenous malformation (PAVM). His initial clinical presentations were growing pulmonary nodule with cough and occasional chest pain. PAVM with rupture of aneurysm was diagnosed histologically after wedge resection of the nodule in his right lower lung.