Background: Taiwan is located in a subtropical area where there are approximately 50 kinds of land snakes and six principal kinds of venous snakes. Snakebite envenomation is not an uncommon issue in Taiwan. We design a study to obtain an understanding of the characteristics of snakebites and snakebite patients in a medical center in northern Taiwan. Materials and Methods: This was a retrospective medical records study of an 8-year period. We used the key word “snake” to search the emergency department (ED) diagnosis of all patients and then used antivenom management codes to select patients for inclusion. The species of snake involved, time and site of the bite, geographic data of the patients and patient outcomes were recorded. Results: In total, there were 125 snakebite patients (male 70%, female 30%). The snakes involved were Protobothrops mucrosquamatus (50%), followed by Trimeresurus stejnegeri (7%). The feet and ankles were the most frequently bitten areas (42.4%). The peak months were July and October. The average ED stasis time was 2 hours and 45 minutes, and 65.6% of snakebite patients received antivenom. In patients bitten by P. mucrosquamatus, there was a high surgical rate, 23.8% higher than those reported in other studies. No mortalities or side effects of antivenom were reported in these patients. Conclusion: We propose a clinical flow chart for physicians who are treating patients bitten by P. mucrosquamatus. Snakebites, especially those inflicted by P. mucrosquamatus, induce severe soft tissue swelling, which can mimic compartment syndrome. Antivenom for P. mucrosquamatus is the first and only choice of treatment. The amount of antivenom needs to match the clinical symptoms. Patients bitten by P. mucrosquamatus may need longer observation times than patients bitten by other species of snakes, in addition to toxicologist consultations, sonographic examinations, and measurement of the objective compartment pressure before surgery.

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Background: Reducing anesthesia-controlled time (ACT) such as extubation time may improve operating room (OR) efficiency result from different anesthetic techniques. However, the information about the difference in ACT between desflurane (DES) anesthesia and propofol-based total intravenous anesthesia (TIVA) techniques for laparoscopic cholecystectomy (LC) under general anesthesia (GA) is not available in the literature. Methods: This retrospective study uses our hospital database to analyze the ACT of elective LC after either DES anesthesia or TIVA via target-controlled infusion (TCI) with propofol from January 2010 to December 2011. The various time intervals including waiting for anesthesia time, anesthesia time, surgical time, extubation time, exit from OR after extubation, total OR time, postanesthetic care unit (PACU) stay time, and percentage of prolonged extubation (≥15 min) were compared between the two anesthetic techniques. Results: We included data from 622 patients undergoing LC, with 286 patients receiving TIVA and 336 patients receiving DES anesthesia. The extubation time was faster (7.8 ± 0.4 vs. 10.9 ± 0.4 min; P < 0.001) and the exit from OR after extubation was faster (6.8 ± 0.5 vs. 9.3 ± 0.5 min, P < 0.001) in the TIVA group than that in the DES group. Besides, the incidence of prolonged extubation was lower (4.5% vs. 10.1%, P = 0.014) in the TIVA group than that in the DES group. The prolonged extubation was associated with age, sex, anesthetic technique, and anesthesia time. Conclusions: In our hospital, propofol-based TIVA by TCI provided faster extubation time, faster exit from OR after extubation, and lower prolonged extubation rate compared with DES anesthesia in LC. Besides, older age, female, DES anesthesia, and lengthy anesthesia time were factors affecting prolonged extubation.

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Stress is an inevitable phenomenon in life. Stress plays a pivotal role in regulating the body's physiology. Stress also improves the survival skills of an individual. However, when stress becomes unmanageable, it starts affecting the individual adversely. The adverse effects of the stress alter the normal physiology and the mental well-being of the individual. People attempt to cope with their stressor using various coping strategies. Adapting coping strategies may help in successful handling of stress. Maladaptive coping strategies, on the other hand, though control stress, are often transient and may result in the impairment of mental health. Evidences suggest that stress significantly affects the immune system of the body. The effect of stress on the immune system may depend on the nature and severity of the stressor. Ineffective regulation of stress results in immune dysregulation. Effective coping strategies for handling stress might be useful to correct the immune dysregulation.

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Normal descending aorta is in the left thorax. Thus, ruptured type B aortic dissection more commonly presents with left hemothorax. However, there is a case of type B dissection complicated with right hemothorax.

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Post-stroke depression (PSD) is the most common neuropsychiatric complication of stroke, such that it can occur in one-third of stroke survivors. It has been tried to be explained by the disruption in the neural circuits involved in the mood regulation in the setting of some additional clinical risk factors. However, there is no consensus in this regard. Herein, we present a 58-year-old male patient presenting with isolated psychotic depression which was finally found to be associated with acute ischemic stroke of bilateral centrum semiovale. This report constitutes an extremely rare illustration of acute onset organic psychotic depression which was clearly demonstrated to be associated with ischemic stroke. Through the presentation of this patient and limited literature, we propose some discussions regarding the pathophysiology of PSD. We also remark the need for future reports of neuroimaging methods to clarify the unknown neural correlates in these manifestations.

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Background: Shoulder pain is a common complaint across the population. It is associated with co-morbidities such as depression, diabetes mellitus, musculoskeletal disorders or cancer. However, there has been no study on the association of shoulder symptoms with future development of diseases. This nationwide population-based study aimed to investigate and clarify this association. Materials and Methods: A total of 76,304 patients with shoulder symptoms during 2000 and 2013 were selected from the National Health Insurance Research Database in Taiwan. Clinical endpoints such as hypertension (HTN) and cardiovascular disease (CVD) were evaluated by hazard ratio (HR) with 95% confidence interval (CI) after adjusting any confounding factors in Cox regression analysis. Results: Among the registered subjects, 16,570 (21.72%) and 8,453 (11.08%) patients developed HTN and CVD, respectively. After adjusting gender, age, household income, catastrophic illness, season, urbanization level and level of care, patients with shoulder symptoms aged ≥65 years had the highest risk of HTN (adjusted HR = 5.806, 95% CI = 5.464-6.169, P < 0.001), and CVD (adjusted HR = 4.371, 95% CI = 4.047-4.721, P < 0.001), with reference to younger age group of 22-44. The association of older age persisted in other cardiovascular problems (P < 0.001). Conclusions: Shoulder symptoms were associated with HTN and CVD. Future studies are required to elucidate the clinicopathogenesis.

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Despite its many benefits, there are several potentially significant complications inherent to chest tube insertion (CTI), a commonly used invasive procedure to evacuate air or fluid from the pleural space. The average rate of complications following CTI ranges from 5% to 10%, whereas insertion-related complications are rare. Here, we present the case of a 45-year-old female suffering from a motor vehicle accident who developed Grade IV liver laceration complicated with intra-abdominal hemorrhage and right-sided fractures from the fourth to the ninth rib. Misplacement of the preventive CTI for potential hemopneumothorax during the first attempt was observed by computed tomography and simultaneously led to diaphragmatic penetration. Subsequently, massive bloody pleural effusion from the abdominal cavity through the defect in the right hemidiaphragm was noted through a newly inserted chest tube when the patient coughed due to endotracheal suctioning. This case illustrates the significance of identification of patients at high risk for complications related to CTI and the utility of ultrasound guidance during CTI.

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Basal cell carcinoma (BCC) is the most common type of skin cancer. Polypoid BCC is very rare and distinguishes from other types of BCC by being female predominant, locating on nonsun-exposed areas, prevailing in dark-skinned races, and having large average size, but considered nonaggressive. We report a case of BCC presenting as an inconspicuous polyp. A 40-year-old female sustained a slowly growing mass at the left groin for many years. Physical examination revealed a polypoid mass over the right groin without specific symptoms. Surgical removal with simple polypectomy was performed, whereas the pathological features revealed BCC with polyp feature. There has been no recurrence after the surgery. This case highlights the importance of remaining clinically alert to differentiate a benign-looking polyp.

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Objective: The aim of this study is to use stroke volume variation (SVV) as an indicator to predict fluid responsiveness in patients undergoing protective one-lung ventilation (OLV) in pressure-controlled ventilation mode. Design and Setting: A prospective clinical study in an operating room in a medical center. Patients: Fourteen patients receiving video-assisted thoracic surgery while undergoing OLV in pressure-controlled ventilation mode. Methods: After starting OLV in pressure-controlled ventilation mode, all patients were administered 6 ml/kg 6% hydroxyethyl starch for 20 min. Vigileo-FloTrac system was used to record hemodynamic variables before and after volume loading. The ability of SVV to predict fluid responsiveness was tested by calculating the area under the receiver operating characteristic (ROC) curve for an increase in stroke volume index of ≥10% after volume loading, and the optimal threshold value of SVV was calculated. Results: The area under the ROC curve for SVV to discriminate between responders and nonresponders was 0.89 (95% confidence interval, 0.700–1; P = 0.03). The optimal threshold value of SVV was 8.5% (sensitivity 88.89%; specificity 75%). Conclusions: SVV may be suitable for predicting fluid responsiveness in patients undergoing protective OLV in pressure-controlled ventilation mode.

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