Recurrent urinary tract infection (UTI) might be one of the most common problems in urological clinics. Recent research has revealed novel evidence about recurrent UTI and it should be considered a different disease from the first infection. The pathogenesis of recurrent UTI might include two mechanisms, bacterial factors and deficiencies in host defense. Bacterial survival in the urinary bladder after antibiotic treatment and progression to form intracellular bacterial communities might be the most important bacterial factors. In host defense deficiency, a defect in pathogen recognition and urothelial barrier function impairment play the most important roles. Immunodeficiency and urogenital tract anatomical abnormalities have been considered the essential risk factors for recurrent UTI. In healthy women, voiding dysfunction and behavioral factors also increase the risk of recurrent UTI. Sexual intercourse and estrogen deficiency in postmenopausal women might have the strongest association with recurrent UTI. Traditional lifestyle factors such as fluid intake and diet are not considered independent risk factors now. Serum and urine biomarkers to predict recurrent UTI from the first infection have also attracted a wide attention recently. Current clinical evidence suggests that serum macrophage colony-stimulating factor and urinary nerve growth factor have potential predictive value for recurrent UTI. Clinical trials have proven the efficacy of the oral immunoactive agent OM-89 for the prevention of UTI. Vaccines for recurrent UTI are recommended by the latest guidelines and are available on the market.

Alzheimer's disease (AD) and osteoporosis are both common degenerative diseases in the elderly population. The incidence of both diseases increases with age and will be posing enormous societal burden worldwide. It may appear that AD and osteoporosis are two distinct diseases although many risk factors are shared. Previous observational studies have shown that patients with osteoporosis have higher risks of developing AD than those who do not have osteoporosis. Although osteoporosis, falls, and fractures are more often seen in patients with AD than other older adults, the association between these two diseases may be due to a pathophysiological link rather than one condition causing the other. Several in vitro and in vivo studies lend support to this notion. Patients with AD have excessive amyloid plaques in the brain, and the pathology may extend to peripheral organs and cause skeletal amyloid deposition, which would enhance receptor activator nuclear factor-kappa B ligand signaling and lead to greater osteoclast activities. Patients with osteoporosis may have Vitamin D deficiency or lower levels of Vitamin D binding protein, which protects against amyloid aggregation, thus linking Vitamin D deficiency and AD or osteoporosis and AD. Osteoporosis coexisting with AD provides a window to examine the amyloid hypothesis from peripheral tissues. Future studies are warranted to clarify the role of genetic background regarding Vitamin D levels, exposure to sunlight, estrogen replacement therapy, and physical activity in patients with both chronic diseases.

Ovarian torsion is a rare but emergency condition in women. Early diagnosis is necessary to preserve the function of the ovaries and tubes and prevent severe morbidity. Ovarian torsion refers to complete or partial rotation of the adnexal supporting organ with ischemia. It can affect females of all ages. Ovarian torsion occurs in around 2%–15% of patients who have surgical treatment of adnexal masses. The main risk in ovarian torsion is an ovarian mass. The most common symptom of ovarian torsion is acute onset of pelvic pain, followed by nausea and vomiting. Pelvic ultrasonography can provide information on ovarian cysts. Once ovarian torsion is suspected, surgery or detorsion is the mainstay of diagnosis and treatment.

Objective: Hypertension is a risk factor for peripheral artery disease (PAD). Serum leptin plays an important role in promoting endothelial dysfunction. The aim of this study is to investigate whether the leptin level is associated with PAD in hypertensive patients. Materials and Methods: Ninety-eight hypertensive patients were enrolled in this study. Ankle-brachial index (ABI) values were measured using an automated oscillometric device. Patients with an ABI value <0.9 were considered the low ABI group. C-reactive protein (CRP) was measured using standard enzymatic automated methods. Serum levels of human leptin were determined using a commercially available enzyme immunoassay. Results: Eighteen (18.4%) hypertensive patients were included in the low ABI group. Hypertensive patients in the low ABI group had higher serum creatinine (P < 0.001), CRP (P = 0.003), and leptin (P < 0.001) levels, higher prevalence of diabetes (P = 0.036), and current smoking (P = 0.034) than patients in the normal ABI group. Univariate linear regression analyses revealed that body weight (P = 0.014), waist circumference (P = 0.010), body mass index (P = 0.002), and logarithmically transformed CRP (log-CRP,P= 0.001) were positively correlated with serum log-leptin levels in hypertensive patients. Multivariate stepwise linear regression analysis showed that log-leptin (β = 0.439, adjusted R² change = 0.224,P< 0.001) was also an associated factor of PAD in hypertensive patients. Conclusion: A higher log-leptin value is an independent predictor of PAD in hypertensive patients.

Objective: Cardiovascular events are the most frequent cause of death or disability among people with systemic lupus erythematosus (SLE). However, the causes of this increased the risk of major adverse cardiovascular events (MACEs) are not completely understood. The Age-adjusted Charlson Comorbidity Index (ACCI) is a prognostic classification that was initially developed for patients who have a number of comorbid conditions and the ACCI has been validated in many clinical settings. Materials and Methods: In this study, 5998 patients were enrolled from the National Health Research Institute Database of Taiwan. All the patients' sequential clinical data related to their diagnosis of SLE were reviewed from 2004 to 2007 to determine their risk of MACE occurrence and of all-cause mortality using their ACCI scores. Results: The predictive accuracy of the ACCI scores in relation to MACE occurrence among SLE patients was estimated and the C-statistic for this curve was found to be 0.687 (95% confidence interval [CI]: 0.664–0.709). The distribution of ACCI scores for MACE patients was 4.7%, 10.3%, 11.4%, and 21.5% for those with ACCI scores in the ranges of 0–1, 2–3, 4–5, and >6, respectively. A plot of the cumulative risk also showed a much higher risk among SLE patients with an ACCI score of >6. When patients were divided into different groups based on their ACCI scores, those with ACCI scores of >6 had an adjusted hazards ratio of 4.88 (95% CI: 3.84–6.19;P< 0.001) as compared to those with ACCI scores of 0–1. Conclusion: SLE patients with higher ACCI scores have a significantly higher risk of a MACE and of all-cause mortality. Our results suggested that ACCI scores may be useful as an index for estimating global cardiovascular risk among patients with SLE.

Objective: Leptin is an adipocyte-derived hormone and has shown positive correlation with obesity and metabolic syndrome (MetS) in many studies. However, there are few studies investigating this relation in elderly people. Therefore, we aimed to investigate the correlation between the fasting serum leptin level and MetS among older Taiwanese. Materials and Methods: The fasting serum leptin level was obtained from 62 Taiwanese participants over 65 years old and was measured using a commercially available enzyme immunoassay kit. MetS and its components were defined using diagnostic criteria from the International Diabetes Federation. Results: Thirty elderly participants (48.4%) had MetS. The serum leptin level was positively correlated with MetS (P < 0.001). Multivariate logistic regression analysis of the factors significantly associated with MetS showed that logarithmically transformed leptin (log-leptin, each increase 0.1 ng/mL log-leptin, odds ratio: 1.276, 95% confidence interval: 1.015–1.603,P= 0.037) was still an independent predictor of MetS in elderly persons. Univariable linear analysis showed that body weight (r = 0280,P= 0.028), body mass index (r = 0.417,P= 0.001), waist circumference (r = 0.419,P= 0.001), blood urea nitrogen (r = 0255,P= 0.046), log-insulin (r = 0436,P< 0.001), and logarithmically transformed homeostasis model assessment of insulin resistance (r = 0359,P= 0.004) positively correlated with fasting serum log-leptin levels. Multivariate forward stepwise linear regression analysis of the factors significantly associated with fasting serum log-leptin levels revealed that waist circumference (adjusted R² = 0.083,P= 0.002), statin use (adjusted R² = 0.058,P= 0.016), and female gender (adjusted R² = 0.041,P= 0.034) were independent predictors of fasting serum log-leptin levels among elderly participants. Conclusion: In elderly Taiwanese, the serum leptin level was positively correlated with MetS. Waist circumference, statin use, and female gender were independent predictors of the fasting serum leptin level in elderly participants.

Objective: To report our initial experience with and the short-term outcomes of two-phase laparoendoscopic single-site cervical ligament-sparing hysterectomy (LESS-CLSH). Materials and Methods: A retrospective case study included 40 women who underwent LESS-CLSH from January 2014 to December 2016 at Buddhist Tzu Chi General Hospital. Uterine specimens were extracted through contained manual morcellation with a tissue pouch. The first phase was LESS supracervical hysterectomy and conization of the internal orifice of the cervix. The second phase was transvaginal cervical conization and cylinderization. Women with a uterus diameter of >12 cm, a broad ligament myoma, or severe pelvic adhesion were categorized into a difficult group, and others were categorized into a nondifficult group. Results: The difficult group required more time and had more blood loss than the nondifficult group. The mean surgical time was 187.2 ± 33.9 and 139.1 ± 20.7 min, and the mean blood loss was 533.3 ± 333.3 and 225.3 ± 168.2 mL in the difficult and nondifficult groups, respectively. The overall visual analog scale (VAS) pain scores at 0–4, 24, and 48 h after surgery were 7.1 ± 1.9, 4.2 ± 1.6, and 2.3 ± 1.5, respectively; no difference in the VAS pain scores, pain relief score, and hospitalization duration was observed between the two groups. Minor surgical complications or adverse events on follow-up were noted. Three months after surgery, the diameter and thickness of the cervix were decreased by approximately 0.5 and 1.0 cm, respectively. Conclusion: LESS-CLSH is a minimally invasive, safe, and feasible approach, even for difficult laparoscopic hysterectomy. Contained manual morcellation enables more controlled specimen removal than morcellation only.

Objective: To evaluate the association between rheumatoid arthritis (RA) and cardiovascular comorbidities, including hyperlipidemia, hypertension, and diabetes, in Taiwanese patients based on the data from medical records. Materials and Methods: A retrospective study was performed using the computerized medical records from a regional hospital located in southern Taiwan. A total of 2293 patients (age range 30–79 years) with a diagnosis of RA (International Classification of Diseases, Ninth Revision, Clinical Modification code 714.0) treated since the opening of the study hospital in July 2000 until February 2013 were included. The RA cases were frequency matched for age and sex with 9172 patients without RA. The associations of RA with hyperlipidemia, hypertension, and diabetes were evaluated using multiple logistic regression analysis. Results: Significant associations between RA and hyperlipidemia (adjusted odds ratio [OR] = 2.05, 95% confidence interval [CI] = 1.77–2.38,P< 0.001) and hypertension (adjusted OR = 2.76, 95% CI = 2.43–3.14,P< 0.001) were observed. However, diabetes was not significantly associated with RA in either male or female patients. Conclusion: Findings from this retrospective medical record study indicated that hyperlipidemia and hypertension were significant cardiovascular comorbidities of RA.

A retropharyngeal mass may distort the airway anatomy and reduce the space available for manipulation of intubation devices. We encountered a patient with a cervical chordoma occupying the retropharyngeal space. Fiber-optic orotracheal intubation was attempted to secure the airway. Although the fiber-optic bronchoscope (FOB) was successfully placed into the trachea, the tracheal tube could not be passed through the glottis. An airway was then successfully established with the Trachway device, a video-assisted system with a rigid but malleable intubating stylet. In conclusion, although a FOB is commonly used to secure a difficult airway, the present case report demonstrates that fiber-optic intubation is not always successful. Video intubation devices with a rigid stylet (such as Trachway) may be helpful in patients with a cervical chordoma. We suggest this device be available as backup for patients with distorted airway anatomy.

Breast lesions are rare prepubescents. The majority of breast lesions in this age group are benign. The most common of these rare lesions is juvenile fibroadenoma, which accounts for only 0.5% of all fibroadenomas. It is uncommon to have a palpable lesion in juveniles as very small lesions show obvious asymmetry. Fibroadenomas can grow to a large size, and surgical intervention is cosmetically challenging, especially in achieving symmetry in a developing breast. A 12-year-old girl presented with right breast swelling associated with tenderness. The mass had initially been small on self-discovery 1 year previously and grew with time. There was no overlying skin changes or any significant risk factors for breast malignancy. Triple assessment showed features of fibroadenoma, but we were unable to rule out a phyllodes tumor. She subsequently underwent excision biopsy of the right breast lesion for symptomatic control and histopathology examination (HPE) of the lesion. The HPE report confirmed the diagnosis of fibroadenoma. The patient recovered well postoperatively with no complications. Juvenile breast lesions are rare, and it is a challenge to provide an adolescent with the best treatment in terms of clinical and psychological care. A surgical approach requires meticulous planning to ensure a fine balance between adequate resection and the best cosmetic outcome for a developing breast.

Upper extremity deep vein thrombosis is an extremely important clinical entity with potential for considerable morbidity and mortality. A 64-year-old woman was brought to the emergency department with complaints of left upper limb and neck swelling for 4 days. Ultrasonography of the neck showed thrombosis of the left internal jugular and other surrounding veins associated with local lymphadenopathy. Computed tomography (CT) of the neck also showed a hypodense 0.6 cm × 0.8 cm × 1.2 cm lesion in the right middle lobe bronchus, causing complete occlusion and collapse of the right middle lobe of the lung. Fine-needle aspiration cytology and a lymph node biopsy showed nongranulomatous lymphadenitis. The patient was started on fondaparinux 10 mg subcutaneously once daily. She was discharged on oral anticoagulants for 6 months. Repeat CT scan after 6 months showed dissolution of the lesion and reexpansion of the right lung.