Soft tissue defects exposing the Achilles tendon are common in patients who have undergone trauma or in those with pressure ulcers associated with vascular diseases. Here, we present our recent experience of using a bipedicled fasciocutaneous flap to resurface the complex soft tissue defect and provide a gliding surface for the exposed Achilles tendon. The donor-sites were covered with split-thickness skin grafts and healed well without complications. The bipedicled fasciocutaneous flap survived completely, and the wound healed satisfactorily at 2 months follow-up. The bipedicled fasciocutaneous flap is a reliable flap for coverage of defects overlying the Achilles tendon, especially in patients with vascular problems and/or advanced age. The ease of handling, short operative time, and early recovery of mobilization function are of great benefit to patients. This method can be a valuable alternative for defect reconstructions overlying the Achilles tendon, with satisfactory results both functionally and cosmetically.

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Background: The epidemiologic studies of basal cell carcinoma (BCC) in Taiwan are lacking. Aim: This study aimed to provide the epidemiologic and pathologic information of BCC among the northern Taiwanese population and try to identify the association of patient demographic characteristics with histopathological findings. Materials and Methods: We retrospectively analyzed 103 BCC cases diagnosed between December 1985 and December 2011 at the Tri-Service General Hospital, Taipei, Taiwan. The patients' age and sex, and anatomic distribution, subtype, depth, and pigmentation of the lesions were analyzed. Results: Of the patients, 59 were men and 44 were women (male-to-female ratio, 1.34). The overall mean age was 69.5 ± 12.91 years; with the mean age of the women lower than that of the men (66.9 vs. 71.4 years). The frequency of microscopic pigmentation in BCC was 52.4%. Nodular BCC was more inclined to develop microscopic pigmentation. The BCCs with depths greater than 3.3 mm tended to have no microscopic pigmentation. Superficial BCCs tended to involve the trunk and to occur in people younger than 60 years of age. Conclusions: This updated analysis study of BCC showed the mean age of BCC had a trend to increase in northern Taiwan. The male-to-female ratio in our study was slightly higher than those of other Asian countries. We suggest that excision of BCC without pigmentation could be deeper than pigmented BCC.

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Background: Purple urine bag syndrome (PUBS), an uncommon phenomenon that turns urine tubes or bags purple or blue, can be encountered in long-term-care facilities. A thorough literature review shows that East Asia has a high incidence of PUBS. It is important to recognize the clinical features and risk factors of this phenomenon. The aim of this study is to explore the characteristics of patients with PUBS and correlate the onset of PUBS symptoms with risk factors. Materials and Methods: We reported nine cases of clinically confirmed PUBS between January 2009 and June 2013. Pertinent clinical information was collected, including age, feeding type, renal function, type of Foley catheter, urine analysis, and bacteriological data. Results: All of patients with PUBS presented with stable vital signs without evidence of clinical infection, such as fever or chills. The mean age of the patients was 86.6 ± 10.1 years, with a preponderance of females (77%). Five PUBS patients (55%) had a history of chronic renal insufficiency. Six patients (66%) had constipation. A logistic regression univariate analysis demonstrated a statistically significant urine pH in patients with PUBS [odds ratio (OR), 3.078; P = 0.036]. Risk factors, such as gender, were found to be significant using logistic regression multivariate analysis (OR, 0.031; P = 0.021). During the follow-up, all of the patients had Foley catheters re-inserted, and all of the patients received health education. Conclusion: The incidence of PUBS in the elderly population is associated with asymptomatic bacteriuria, urine pH, and gender but not renal function, type of feeding, or type of Foley catheter used. To understand PUBS and maintain urological hygiene, it is important to educate families and health care workers about PUBS and to recognize that PUBS is not regarded as a symptom of severe disease.

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Background: Intracranial arteriovenous malformation (ICAVM) is a rare and life-threatening disease. Clinical presentations of pediatric ICAVMs are variable and unpredictable. The Spetzler-Martin grading scale (SMGS) is a commonly used system for predicting prognoses and guiding therapeutic protocols. However, the application of this system to children is controversial. Objective: The purposes of this study were to retrospectively analyze clinical presentations of children with ICAVM and to investigate the relationship between the SMGS and the prognoses of children with ICAVM. Materials and Methods: Based on the International Classification of Diseases, 9 ^th revision, Clinical Modification (ICD-9-CM) code 747.81, we retrospectively reviewed eight children with ICAVMs admitted to a medical center from 1991 to 2012. The primary selection criterion was the diagnosis of the ICAVM, which was not irrelevant to traumatic injury or known coagulopathy. Patients' outcomes were determined based on evaluation records of admission, discharge, and clinic visit 6-month after the ICAVM episode. For purposes of data analysis, outcomes were divided into "1 = death," "2 = persistent vegetative state," "3 = severe disability," "4 = moderate disability," and "5 = low disability." The relationship between the Glasgow outcome scale (GOS) and SMGS was analyzed using a scatter plot and Spearman's correlation coefficient. Results: A total of eight patients with at least follow-up 6-month consisted of four males (50.0%) and four females (50.0%). Their ages ranged from 7 to 15 years, and the mean age was 12.63 years. Common sites of ICAVM nidus included basal ganglia (n = 3, 37.5%), and frontal-temporal region (25.0%). 62.5% of patients experienced bleeding on the right side of the brain. About 62.5% of patients complained of headache. 62.5% of patients showed loss of consciousness. About 37.5% of patients showed generalized seizures. The SMGS were Grade I in one patient (12.5%), Grade II in two patients (25.0%), Grade III in two patients (25.0%), and Grade IV in three patients (37.5%). The clinical outcomes for the overall series were 87.5% excellent or good (GOS score equal or above 4) and only one case dead. The correlation between SMGS and GOS, analyzed by Spearman's correlation coefficient, was insignificant. Treatment, either by stereotactic radiosurgery (SRS) or surgery, was irrelevant to the prognosis of patient with ICAVM. Conclusion: Intracranial arteriovenous malformation is a life-threatening disease in children. Headache is a warning. Clinical presentations, including altered level of consciousness and generalized seizures in patient with ICAVM may suggest bleeding. The use of this system in children with ICAVM should be considered patients' age for their better potential neuroplasticity and good healing capacities in higher grade of patients. Treatment, either by surgery or SRS, may be irrelevant to patients' prognoses in this study.

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Type II enteropathy-associated T-cell lymphoma (Type II EATL) is only rarely reported in Asia, especially in Taiwan and is known to be associated with a high bowel perforation rate. We described a case of Type II EATL with fatal perforation of the small intestine during his first cycle of chemotherapy. Conventional treatment for enteropathy-associated T-cell lymphoma consists of combination chemotherapy used for aggressive T-cell lymphoma (e.g., cyclophosphamide, adriamycin, vincristine, prednisone). Perforation of intestine often occurs at the time of diagnosis or in the early days of the first cycle of chemotherapy in these patients. To rescue and treat patient promptly, intestinal perforation should always be kept in mind as a differential diagnosis of acute abdominal pain in these patients. This case report highlights the potential pitfall in managing patients with gastrointestinal lymphoma and the need for maintaining a low threshold for prechemotherapy surgical intervention in patients diagnosed with type II EATL.

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Background: Coronary artery disease occurs frequently and is a major cause of morbidity and mortality in patients with chronic renal failure. Because the number of patients requiring dialysis for end-stage renal disease (ESRD) has increased, the number of patients in this population who require coronary artery bypass grafting (CABG) has increased. The aim of this study was to examine the effect of early hemodialysis (HD) on the early surgical outcomes of ESRD patients undergoing CABG. Materials and Methods: Fifty-nine dialysis-dependent patients who underwent isolated CABG with cardiopulmonary bypass (CPB) were enrolled in this study. These patients were divided into two groups based on the timing of the first postoperation HD session. In the early HD group, HD was performed within 6 h postoperation; in the scheduled HD group, HD was performed >6 h postoperation. The preoperative characteristics, operative variables, and postoperative outcomes were retrospectively analyzed. Results: The time to first HD after CABG was 2.43 ± 1.58 h in the early HD group and 20.68 ± 6.98 h in the scheduled HD group (P < 0.001). There were no significant differences in the operative variables, namely duration of operation, CPB time, and aortic cross-clamp time, between the two groups. The incidence of postoperative pneumonia was higher in the scheduled HD group (31.8%) than in the early HD group (2.7%). There was a trend of decreased incidence of postoperative pneumonia in the early HD group with marginal significance from the univariate analysis. The intensive care unit and hospital stay duration of both groups were similar. Nine patients died in the hospital, yielding an overall 30-day mortality of 8.47%. Conclusion: In dialysis-dependent patients who underwent CABG, the short-term outcomes and surgical mortality were acceptable. Dialysis-dependent renal failure should not be considered a contraindication for CABG. Early HD in the postoperative period demonstrated the trend to reduce the incidence of postoperative pneumonia; however, other parameters of surgical outcomes were insignificant.

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Acute appendicitis and acute cholecystitis are commonly seen in acute abdominal disease. However, it is rarely described that synchronous acute cholecystitis and acute appendicitis presented. Here, we present a case of 78-year-old male suffered from cholelithiasis with acute cholecystitis synchronized with acute appendicitis treated with nonsurgical management successfully.

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Sorafenib was approved in 2005 for the treatment of metastatic renal cell carcinoma and advanced hepatocellular carcinoma (HCC). Acute pancreatitis is a side-effect of sorafenib usage. We present a patient with advanced HCC who presented with acute Grade D pancreatitis caused by sorafenib administration. Following the discontinuation of sorafenib, fasting, and fluid replacement, the patient's clinical manifestation of Grade D pancreatitis subsided in a short time. One month after discharge, she resumed sorafenib treatment (200 mg/day) due to disease progression. Based on this experience, resumption of sorafenib treatment appears to be safe.

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Aortic dissection (AoD) is one of the most common catastrophes involving the aorta. Nevertheless, early diagnosis remains to be a challenge in the emergency department (ED), particularly in young individuals. The diagnosis of acute AoD is often delayed secondarily to its propensity to masquerade as other illnesses (i.e., renal colic, spinal-cord injury, and acute cauda equina syndrome) that result in acute lower-back pain (LBP). Here, we report a 38-year-old man who presented to our ED because of acute LBP with one leg numbness and weakness. It was subsequently found to have acute Type A AoD. This young man was diagnosed early in the ED and treated promptly without major adverse sequelae. We highlight that ED physicians should always keep high alertness in vascular emergencies (i.e., acute AoD), whilst engaging a patient with an acute-onset severe LBP with one leg numbness and weakness.

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Pyogenic liver abscess (PLA) is a common intra-abdominal infection in immunocompromised patients. The disease is associated with a high mortality rate if not be diagnosed promptly. Fever may be the only sign of PLA and the disease is sometimes misdiagnosed because it is often asymptomatic. We report a 26-year-old male who presented with Klebsiella pneumoniae PLA 3 weeks after being treated for K. pneumoniae peritonsillar abscess. The K. pneumoniae PLA was diagnosed by abdominal ultrasound and treated with percutaneous drainage and an adequate period of antibiotic therapy. This case demonstrates the importance of considering K. pneumoniae PLA in immunocompetent patients who present with fever of unknown cause and recent K. pneumoniae infection.

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We report a case of an 81-year-old woman who had a history of type 2 diabetes mellitus with the presentation of a recurrent community-acquired liver abscess caused by capsular serotype K1 Klebsiella pneumoniae after a previous liver abscess had been cured. With regards to the serotype K1 K. pneumoniae strains, the molecular genome of the recurrent strain differed completely from the strain that had caused the primary community-acquired liver abscess even though the antibiogram was the same. This case attempts to highlight that capsular serotype K1 could be an important factor influencing liver abscess formation and its subsequent recurrence.

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