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Objectives: Recent metabolomic studies of sepsis showed that increased circulatory acylcarnitines were associated with worse survival. However, it is unknown whether plasma carnitine and acylcarnitines can reflect the severity of sepsis, and the role of specific acylcarnitines in prognostic assessment need further confirmation. This study aimed to clarify these questions., Design: Prospective multicenter cohort studies with derivation and validation cohort design., Setting: ICUs at two medical centers and three regional hospitals in Taiwan., Patients: Patients with sepsis and acute organ dysfunction were enrolled. Recruitment of the derivation (n = 90) and validation cohorts (n = 120) occurred from October 2010 through March 2012 and January 2013 through November 2014, respectively., Interventions: Plasma samples were collected immediately after admission, and the levels of carnitine and acylcarnitines were measured by ultra-high performance liquid chromatography-mass spectrometry., Measurements and Main Results: In the derivation cohort, increased plasma levels of short- and medium-chain acylcarnitines were significantly associated with hepatobiliary dysfunction, renal dysfunction, thrombocytopenia, and hyperlactatemia. However, acetylcarnitine is the only acylcarnitine significantly correlating with various plasma cytokine concentrations and also associated with blood culture positivity and 28-day mortality risk. The association between plasma acetylcarnitine and multiple organ dysfunction severity, blood culture positivity, and 28-day mortality, was confirmed in the validation cohort. Patients with high plasma acetylcarnitine (≥ 6,000 ng/mL) had significantly increased 28-day mortality compared with those with plasma acetylcarnitine less than 6,000 ng/mL (52.6% vs 13.9%; hazard ratio, 5.293; 95% CI, 2.340-11.975; p < 0.001 by Cox proportional hazard model)., Conclusions: We confirm that plasma acetylcarnitine can reflect the severity of organ dysfunction, inflammation, and infection in sepsis and can serve as a prognostic biomarker for mortality prediction.

Purpose: It has been the observation of the senior author that there is a bony fullness or "double medial malleolus" over the middle facet as a consistent finding with most talocalcaneal coalitions (TCC). To document this observation, we reviewed records and radiographs in 3 patient groups., Methods: Part 1: retrospective chart review was completed for 111 feet to determine the clinical presence of a palpable "double medial malleolus." Part 2: computed tomography (CT) scans for evaluation of tarsal coalition or symptomatic flatfoot between January 2006 and December 2014 were retrospectively reviewed for the same cohort. Soft tissue thickness was measured as the shortest distance between bone and skin surface at both the medial malleolus and the middle facet/coalition. The volume of the middle facet or coalition was measured at their midpoint. These findings were compared among feet with TCC (n=53), calcaneonavicular coalition (CNC) (n=20), and flatfoot (n=38)., Results: Part 1-clinical: from medical records, 38 feet (34%) had documented record of a palpable medial prominence. Of the feet reviewed with a "double medial malleolus," all had TCC (no false positives or false negatives). Clinical and CT prominence demonstrated significant correlation (rs=0.519, P=0.001). Part 2-radiographic: CT observation of "double medial malleolus" is significantly associated with TCC (P<0.001). CT observation of double medial malleolus is 81% sensitive and 79% specific as a predictive test for TCC. The middle facet-to-skin distance was significantly closer in those with TCC versus controls (P<0.001). The ratio was larger in patients with TCC versus CNC (P=0.006) or flatfeet (P<0.001). Volume was nearly twice the size in patients with TCC versus the controls (P<0.001)., Conclusions: TCCs have a bony prominence below the medial malleolus on clinical exam and CT scan not present in flatfeet or CNCs. This abnormal middle facet is almost twice the size of the normal middle facet. Obesity or severe valgus may mask this finding. If a palpable bony prominence is noted just below the medial malleolus during examination of a painful foot with a decrease in subtalar motion, the likely diagnosis is TCC. With this added clinical finding, appropriate images can be ordered to confirm the diagnosis of the latter. We advise CT scans with 3D images for surgical planning. The primary finding for tarsal coalitions in textbooks is decreased subtalar motion. This new finding of a palpable enlarged medial prominence just below the medial malleolus is highly associated with TCCs., Level of Evidence: Level III.

The aim of this study was to investigate the risk of fracture and the difference between sexes from a nationwide database of fracture risk among children aged 4-17 years with or without attention deficit hyperactivity disorder (ADHD, ICD-9-CD codes 314). The Longitudinal Health Insurance Database (LHID 2000) was used to analyze fracture characteristics of children from the National Health Insurance that covered 96.1% of the Taiwanese population (N=21.4 million). A total of 7200 ADHD children aged between 4 and 17 years whose diagnosis had been confirmed in at least three outpatient clinics between 1 January 2000 and 31 December 2009 were included, and a cohort of 36 000 children without ADHD matched for age, sex, and urbanization was recruited for analysis. The incidence rate of fractures in ADHD children was 21.0 (95% confidence interval=19.4-22.7) per 1000 person-years, significantly (P<0.001) higher than 15.0 (95% confidence interval=14.4-15.6) in non-ADHDs. After adjusting by age, sex, urbanization level, and geographic region, the statistically significant (P<0.001) hazard ratios (HR) of fracture for ADHD children compared with non-ADHD children included 1.62 in girls and 1.38 in boys, 1.53 in the skull, neck, and trunk (ICD-9-CM 800-809), 1.28 in the upper extremity (ICD-9-CM 810-819), and 1.84 in the lower extremity (ICD-9-CM 820-829). The HR also (P<0.001) increased significantly in all age groups, including 1.35 in 4-6, 1.37 in 7-9, and 1.54 in 10-17 years. ADHD should be listed among risk factors of children's fractures in each sex, all age groups, and all body areas that the parents, teachers, caregivers of ADHD children, and pediatric orthopedists should be aware of. Besides, ADHD girls were more affected than ADHD boys, especially after 10 years of age, whereas the adjusted HR was the highest in the lower extremities. Nationwide analysis matched for age and sex showed that ADHD should be considered the risk factor of children's fracture, especially for girls older than 10 years of age.

The objective of this study is to evaluate the efficacy and safety profiles of the targeted medications, bevacizumab and cetuximab, in combination with cytostatic drugs in patients with locally advanced or metastatic pancreatic cancer. In this retrospective phase 2 study, a total of 59 patients with pancreatic cancer were recruited and received conventional (gemcitabine, cisplatin, and fluorouracil) or targeted regimen (conventional plus bevacizumab and cetuximab for the first cycle) in 2-week intervals for four cycles. The primary end-point for this study was the overall response rate. Secondary end-points were progression-free survival and the safety profiles of the combined therapy. The median time-to-progression and overall survival were 3 and 7 months, respectively, in the conventional treatment group as well as 11 and 13 months, respectively, in the targeted medications treatment group. The most common adverse events in both treatment groups were nausea and vomiting. Moderate (Grade 2) nausea and vomiting were more common in the conventional group than the targeted group but severe (Grade 3) nausea and vomiting were more common in the targeted group. Bevacizumab and cetuximab in combination with gemcitabine, cisplatin, and fluorouracil may help lengthen overall survival up to six months for patients with pancreatic cancer.

Sepsis-related mortality has been found increased in RAG-1 knockout mice. However, in patients admitted to medical intensive care units, it is unknown whether severe lymphocyte depletion at admission is associated with increased interleukin (IL)-7 and IL-15 levels in circulation, and increased mortality. We prospectively enrolled 92 patients who were admitted to medical intensive care units for severe sepsis or septic shock. At admission, 24 patients (26.1%) had severe lymphopenia, defined as lymphocyte counts of less than 0.5 × 10(3)/μL. Severe lymphopenia was associated with significantly higher plasma levels of tumor necrosis factor α, IL-6, IL-8, and IL-10 and was also independently associated with 28-day mortality (adjusted hazard ratio, 3.532; 95% confidence interval, 1.482-8.416; P = 0.004). The levels of plasma IL-15, but not IL-7, were increased modestly in patients with severe lymphopenia compared with those without (median, 12.2 vs. 6.4 pg/mL; P = 0.005). The elevated plasma IL-15 levels were contrarily associated with significantly decreased B-cell lymphoma 2 mRNA expression in peripheral blood mononuclear cells. In conclusion, severe lymphopenia was associated with increased mortality in patients with severe sepsis. We found that patients with sepsis with severe lymphopenia had down-regulated B-cell lymphoma 2 mRNA expression in peripheral blood mononuclear cells, despite increased plasma IL-15 concentrations. Whether IL-7 and IL-15 are insufficient in patients with severe lymphopenia during severe sepsis warrants further investigations.

Nodular fasciitis is a benign, proliferative lesion of myofibroblasts developed from the fascia. It arises commonly in the upper extremities of adults and in the head and neck region of infants and children. Involvement of the knee is exceedingly rare. We report a case of a 4-year-old girl with a knee mass, causing limitation of knee flexion and pain. Arthroscopic examination was performed followed by arthrotomy and tumor excision. Pathologic findings revealed clusters of spindle cells with arrangement of storiform pattern in a loosely textured mucoid matrix. To the best of our knowledge, this is the youngest patient associated with articular nodular fasciitis in the knee joint.

Equinus of the ankle is a common deformity in spastic cerebral palsy. Many methods have been developed to lengthen the Achilles tendon to correct the deformity. A new mesh Achilles tendon lengthening (ATL) procedure that might decrease immobilization and promote recovery was performed in 36 tendons with equinus deformity (22 patients, average age=6.2). The results were compared with those of two other methods: the Vulpius group and the Z-lengthening group. The corrected dorsiflexion angle of the ankle at a subsequent 2-year follow-up of the mesh ATL and Vulpius groups matched (25.5±3.0 and 27.1±3.5°, respectively), whereas that of the Z-lengthening group was higher (33.9±3.8°). Nevertheless, statistics of the timing of each patient's readiness to begin rehabilitation and walking as well as gaining better stability for running and one-legged hopping indicated that the mesh ATL group recovered significantly quicker than the Vulpius and Z-lengthening groups. The mesh ATL procedure achieves a successful correction of the equinus deformity in spastic cerebral palsy comparable with that of the Vulpius procedure, with the advantage of preserving the gastrocnemius without a complete section. This confers greater antigravity stability and quicker recovery in patients.

Large gastric submucosal tumors should be excised to prevent ischemic mucosal ulceration of the overlying surface and central necrosis of the neoplasm, which may in turn lead to massive hemorrhage. Large tumors near the esophagocardiac junction or on the posterior wall are usually resected by an open procedure. We describe 2 cases of upper gastrointestinal tract bleeding owing to huge submucosal tumors in the posterior gastric high body treated by laparoscopic resection of the gastric tumors. These 2 patients recovered smoothly without major or minor complications. We emphasize that design of specific strategies for individual tumors is essential for the successful laparoscopic resection of tumors adjacent to the esophagocardiac junction and large tumors on the posterior wall.

Objectives: This prospective, randomized trial compared the safety and effectiveness of laparoscopic Roux-en-Y gastric bypass (LRYGBP) and laparoscopic mini-gastric bypass (LMGBP) in the treatment of morbid obesity., Summary Background Data: LRYGBP has been the gold standard for the treatment of morbid obesity. While LMGBP has been reported to be a simple and effective treatment, data from a randomized trial are lacking., Methods: Eighty patients who met the NIH criteria were recruited and randomized to receive either LRYGBP (n = 40) or LMGBP (n = 40). The minimum postoperative follow-up was 2 years (mean, 31.3 months). Perioperative data were assessed. Late complication, excess weight loss, BMI, quality of life, and comorbidities were determined. Changes in quality of life were assessed using the Gastro-Intestinal Quality of Life Index (GIQLI)., Results: There was one conversion (2.5%) in the LRYGBP group. Operation time was shorter in LMGBP group (205 versus 148, P < 0.05). There was no mortality in each group. The operative morbidity rate was higher in the LRYGBP group (20% versus 7.5%, P < 0.05). The late complications rate was the same in the 2 groups (7.5%) with no reoperation. The percentage of excess weight loss was 58.7% and 60.0% at 1 and 2 years, respectively, in the LPYGBP group, and 64.9% and 64.4% in the LMGBP group. The residual excess weight <50% at 2 years postoperatively was achieved in 75% of patients in the LRYGBP group and 95% in the LMGBP group (P < 0.05). A significant improvement of obesity-related clinical parameters and complete resolution of metabolic syndrome in both groups were noted. Both gastrointestinal quality of life increased significantly without any significant difference between the groups., Conclusion: Both LRYGBP and LMGBP are effective for morbid obesity with similar results for resolution of metabolic syndrome and improvement of quality of life. LMGBP is a simpler and safer procedure that has no disadvantage compared with LRYGBP at 2 years of follow-up.

Intussusception seldom occurs naturally in adults, but is frequently found due to an underlying disease. We present the case of a 46-year-old man with the chief complaint of repeated abdominal cramping pain, especially in the right lower quadrant, and diarrhea of 1 year's duration. Abdominal sonography and computed tomography showed ileocecal intussusception, and colonoscopy found one protruding tumor at the cecum. Biopsy of the tumor revealed malignant lymphoma cells. Due to persistent symptoms, fear of intestine obstruction caused by further intussusception, and the possibility of mesenteric vascular compression, the patient underwent laparoscopic right hemicolectomy before systemic chemotherapy. The symptoms were relieved successfully after surgery. We emphasize that the majority of adults with intussusception may have an underlying malignancy. The most important rule in treatment is avoidance of tumor emboli spread during manipulation. Therefore, a trial of reduction of the intussuscepted intestine should be prohibited.

Mini-laparoscopic appendectomy (mini-LA) can be performed safely and efficiently. It is the first treatment choice for patients with acute, uncomplicated appendicitis in our hospital. To evaluate the feasibility of mini-LA for simple and ruptured appendicitis in children, we retrospectively compared the outcomes between mini-LA and open appendectomy for appendicitis in children. From October 1998 to August 2000, the medical records of 585 patients with appendicitis were retrospectively reviewed. Children were defined as patients younger than 15 years of age. The percentage of mini-LA, operation time, time to first flatus passage, duration of hospital stay, and demand for intra-muscular pethidine injection were compared between the mini-LA and open appendectomy. The complications among simple and ruptured appendicitis and the cost of mini-LA and open appendectomy were also analyzed. The operation was performed with one infra-umbilical 10-mm incision, and pneumoperitoneum was established at 12 to 15 mm Hg. A 2-mm laparoscope was inserted via the supra-pubic port, and another 2-mm working port was set-up between the other two ports. Statistical testing using the Whitney-Mann U test and Fisher exact test was performed as appropriate. Of the 585 patients, there were 100 children. The youngest patient was 4 years of age and only 7 patients were younger than 5 years. Among children, 18% had a perforated appendix. Mini-LA accounted for 83% of appendectomies in the pediatric group, but it increased yearly (from 41.7% in 1998 to 92.5% in 2000). The operation time of mini-LA and open appendectomy were 57.32 minutes and 49.12 minutes. There was significant improvement in mini-LA from 1998 to 1999. Flatus passage, hospital stay, and pethidine use all favored the mini-LA. For pediatric appendicitis involving a ruptured appendix, postoperative ileus and length of hospital stay were significantly shortened in the mini-LA group. The postoperative complication was not significantly different between mini-LA and open appendicitis. Mini-LA can be safely performed in pediatric patients and it provides early postoperative recovery and short hospital stay. Even for a ruptured appendix, the mini-LA can be the treatment of choice in a well-equipped hospital with well-trained surgeons.

Objective: To prove the feasibility of hand-assisted laparoscopic liver resection for tumors located in the posterior portion of the right hepatic lobe., Summary Background Data: Use of laparoscopic liver resection remains limited due to problems with technique, especially when the tumor is located near the diaphragm, or in the posterior portion of the right lobe., Methods: Between October 2001 and June 2002, a total of 7 patients with solid hepatic tumors involving the posterior portion of the right lobe of liver underwent hand-assisted laparoscopic hepatectomy with the HandPort system at our hospital. Surgical techniques used included CO2 pneumoperitoneum and the creation of a wound on the right upper quadrant of the abdomen for HandPort placement. The location of tumor and its transection margin were decided by laparoscopic ultrasound. The liver resection was performed using the Ultrashear without portal triad control, with the specimens obtained then placed in a bag and removed directly via the HandPort access., Results: The 5 male and 2 female patients ranged in age from 41 to 76 years (mean 62.3 +/- 14.4). Surgical procedures included partial hepatectomy for 6 patients and segmentectomy for one, all successfully completed using a variant of the minimally invasive laparoscopic procedure without conversion to open surgery. The mean duration of the operation was 140.7 +/- 42.2 minutes (90-180). The blood loss during surgery was 257.1 +/- 159 mL (250-500), without any requirement for intraoperative or postoperative transfusion. Pathology revealed hemagioma (n = 2), colon cancer metastasis (n = 2), and hepatocellular carcinoma (n = 3). There were no deaths postoperatively, with 1 patient suffering bile leakage. Mean hospital stay was 5.3 +/- 1.3 days postsurgery., Conclusion: The results of this study suggest that laparoscopic liver resection using the HandPort system is feasible for selected patients with lesions in the posterior portion of the right hepatic lobe requiring limited resection. Individuals with small tumors may benefit; because a large abdominal incision is not required, the wound-related complication rate might be reduced.

Oral administration of green tea or caffeine to hairless SKH-1 mice for 2 weeks stimulated UV-induced increases in apoptotic sunburn cells in the epidermis, and a similar effect was observed when caffeine was applied topically immediately after UV. In mice pretreated with UV for 22 weeks (high-risk mice without tumors), topical applications of caffeine 5 days a week for 18 weeks with no further UV treatment inhibited carcinogenesis and stimulated apoptosis in the tumors. Oral administration of green or black tea to UV-pretreated high-risk mice for 23 weeks inhibited skin tumorigenesis, decreased the size of the parametrial fat pads and decreased the thickness of the dermal fat layer away from tumors and directly under tumors. Administration of the decaffeinated teas had little or no effect on these parameters and adding caffeine to the decaffeinated teas restored their inhibitory effects. Administration of caffeine alone also inhibited carcinogenesis and decreased the size of the parametrial fat pads and the thickness of the dermal fat layer. Using data from individual mice and linear regression analysis, we found a highly significant positive correlation between the thickness of the dermal fat layer away from tumors and the number of tumors per mouse.

Summary: The benefits of laparoscopic appendectomy appear to be controversial. Since 1994, several abdominal procedures have been completed by using the needlescopic technique, but there appear to be no prospective studies to demonstrate the perceived benefits of needlescopic appendectomy. The authors compared open, laparoscopic, and needlescopic appendectomy in a randomized fashion with regard to duration of surgery, length of hospitalization, analgesic dosage, and surgery-associated complications. From March to July 1998, 75 patients admitted at the emergency station of the authors' hospital with a final diagnosis of acute appendicitis without tumor formation were randomized to receive one of the three treatment categories: open (OA), laparoscopic (LA), and needlescopic (nLA) appendectomy. Laparoscopic and needlescopic appendectomy were performed by using a three-port technique, although the size of the trocar used varied. There were 26 patients in the OA group, 23 in the LA group, and 26 in the nLA group. The mean operation durations for the OA, LA, and nLA groups were 55.4 +/- 28.0 minutes, 69.1 +/- 48.8 minutes, and 62.3 +/- 26.3 minutes, respectively, and these were not significantly different from one another. The mean number of the analgesic doses (Pethidine 1 mg/kg) required was 1.3 +/- 1.2 mg/kg, 0.5 +/- 0.8 mg/kg, and 0.2 +/- 0.6 mg/kg, respectively. Significant differences were noted when comparing the OA with the LA or nLA groups (OA vs. LA, P = 0.02; OA vs. nLA, P = 0.0002; LA vs. nLA, P = 0.06). The mean oral intake durations were 32.2 +/- 16.9 hours, 21.0 +/- 14.6 hours, and 20.8 +/- 16.4 hours, respectively, after surgery for the OA, LA, and nLA groups, and the between-group differences were statistically significant for the OA versus LA group ( P = 0.004) and for the OA versus nLA group ( P = 0.003). The mean durations of hospitalization for the OA, LA, and nLA groups were 3.6 +/-1.8 days, 2.8 +/- 1.4 days, and 2.4 +/- 0.9 days, and difference was detected between the OA and the nLA groups ( P = 0.02). The OA group rendered a greater wound-complication rate and ileus than did the other two groups, but the differences were not detected between the three categories ( P = 0.065, 0.6935). The result of the current study confirmed that the nLA procedure is a feasible and safe one. The nLA procedure provided substantial advantages over the OA procedure in the contexts of diminished postoperative pain and shorter hospital stay without significant increases in postoperative complication rate or surgical time.

Vertical banded gastroplasty (VBG) is an effective treatment for morbid obesity. Recent advancement in laparoscopic surgery has made laparoscopic VBG possible. The authors compared retrospectively the outcomes of laparoscopic VBG versus open VBG in patients with morbid obesity. From June 1998 to April 1999, 100 patients (18 men, 82 women; average age, 32.6 years) underwent laparoscopic VBG, and 40 patients (7 men, 33 women; average age, 28.8 years) underwent conventional open VBG. The two groups were similar regarding sex, age, and body mass index distribution. Mean surgical time, blood loss estimate, duration of postoperative recovery, analgesic usage, complications, and weight reduction were compared among the two groups. Laparoscopic VBG was successful in 99 (99%) of the 100 patients. Mean surgical time was longer in duration for the laparoscopic VBG group than it was for the open VBG group (173 vs. 101 minutes, P < 0.01). The laparoscopic VBG group had earlier flatus passage (1.9 vs. 2.6 days; P < 0.01), less usage of analgesics (meperidine 50 mg/unit; 0.9 vs. 2.3 units; P < 0.01), and a shorter postoperative hospital stay (3.7 vs. 6.0 days; P < 0.01). Estimated blood loss, surgical complication rate, and weight reduction were similar among the two groups. Although laparoscopic VBG required a longer surgical time and was technically more demanding, it resulted in shorter recovery time, less analgesic use, and less severe physical discomfort. The authors' findings show that the two methods were approached safely equally.

Objective: A growing body of research has shown that there are important links between certain psychiatric disorders and health symptom reporting. Two disorders in particular (posttraumatic stress disorder (PTSD) and major depression) have been the most widely implicated to date, and this association has sometimes been used to explain the occurrence of ill-defined medical problems and increased somatic symptoms in certain groups, most recently Gulf War veterans., Methods: Structured psychiatric diagnostic interviews were used to examine the presence of major psychiatric (axis I) disorders and their relation to health symptom reporting in a well-characterized, stratified subset of Gulf War veterans and a non-Gulf-deployed veteran comparison group., Results: Rates of most psychiatric disorders were substantially lower than national comorbidity estimates, consistent with prior studies showing heightened physical and emotional well-being among active-duty military personnel. Rates of PTSD and major depression, however, were significantly elevated relative to the veteran comparison group. The diagnosis of PTSD showed a small but significant association with increased health symptom reports. However, nearly two-thirds of Gulf participants reporting moderate to high health symptoms had no axis I psychiatric diagnosis., Conclusions: Results suggest that rates of psychiatric illness were generally low with the exception of PTSD and major depression. Although PTSD was associated with higher rates of reported health problems, this disorder did not entirely account for symptoms reported by participants. Factors other than psychiatric status may play a role in Gulf War health problems.