Lower urinary tract symptoms (LUTS) are highly prevalent in men and increase with age. Because LUTS are common among elderly men, they are usually considered synonymous with benign prostatic hyperplasia (BPH). Drugs should be the first-line treatment for BPH and surgical intervention should be performed only when there are complications or LUTS refractory to medical treatment. In addition to medical treatment, several minimally invasive therapies, such as thermal therapy, prostatic lift, laser evaporation, or laser enucleation techniques have been developed. Recent investigations have also revealed that bladder dysfunction such as detrusor overactivity and detrusor underactivity may also contribute to male LUTS. In the treatment of LUTS suggestive of BPH (LUTS/BPH), the following questions should be considered: Is there an obstruction? Are we treating BPH or LUTS? Can management targeting BPH reduce LUTS? Should patients with LUTS be treated before bladder outlet obstruction is confirmed? What is the role of transurethral resection of the prostate (TURP) nowadays? Will new techniques provide better outcomes than TURP? This article discusses the current consensus and controversies in the treatment of LUTS/BPH.

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Traditionally, male lower urinary tract symptoms (LUTS) have been considered a synonym for benign prostate hyperplasia (BPH) because most male LUTS develops in aging men. Medical treatment should be the first-line treatment for BPH and surgical intervention should be performed when there are complications or LUTS refractory to medical treatment. Recent investigations have revealed that bladder dysfunction and bladder outlet dysfunction contribute equally to male LUTS. In the diagnosis of LUTS suggestive of BPH (LUTS/BPH), the following questions should be considered: Is there an obstruction? Are the LUTS caused by an enlarged prostate? What are the appropriate tools to diagnose an obstructive BPH? Should patients with LUTS be treated before bladder outlet obstruction is confirmed? This article discusses the current consensus and controversies in the diagnosis of LUTS/BPH.

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Objective: The mode of delivery in breech presentation (BP) is controversial. Several studies have reported the advantages and disadvantages of delivery mode in BP. The aim of this study was to compare the Apgar scores in BPs between vaginal and cesarean delivery. Materials and Methods: A retrospective study was conducted at Dr. Zainoel Abidin General Hospital from January 2010 to December 2012. Data on the mode of delivery and Apgar scores at 1 and 5 min for infants with a BP were extracted from the medical records. Logistic regression was employed to assess the correlation between mode of delivery and Apgar scores. In addition, a meta-analysis was conducted to summarize findings from other regions. Results: A total of 205 (3.9%) BPs among 5252 deliveries between January 2010 and December 2012 were analyzed for this study. There were 26% (52 cases) vaginal and 74% (153 cases) cesarean deliveries. The mode of delivery for BP had a significant association with Apgar score at 1 min (odds ratio [OR] 95% confidence interval [CI] = 6.462 [2.476–16.870], P = 0.0001) and 5 min (OR 95% CI =7.727 [1.416–42.175], P = 0.018). Our meta-analysis showed that the delivery mode had a significant association with Apgar score in BP (OR: 3.69; 95% CI: 2.18–6.26, P = 0.0001). Conclusions: There was a significant association between Apgar scores in BPs and mode of delivery. Our results suggest better outcomes for cesarean than vaginal delivery in BPs.

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Fixation of comminuted or osteoporotic fractures in the proximal humerus is a challenge for orthopedic surgeons. In the past two decades, locking plates have been used for proximal humeral fracture fixation. However, complications such as loss of reduction have been reported, and the implants are not always available in some regions. Therefore, we describe an alternative procedure involving fixation with a nonlocking cloverleaf plate augmented with tension wiring to provide adequate stability and prevent loss of reduction.

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Objective: We evaluated the effectiveness and safety of gamma knife radiosurgery (GKRS) for the treatment of intracranial dural arteriovenous fistulas (dural AVFs) over the past 10 years. Materials and Methods: The records of 21 patients diagnosed with dural AVFs between 2004 and 2014 and treated with GKRS were reviewed retrospectively. Complete obliteration (CO) was defined as total symptom relief plus confirmation through magnetic resonance imaging or conventional angiography. Results: The median follow-up was 70.5 months (range 3–136 months). Five patients underwent embolization (2 after GKRS). One patient underwent GKRS twice. The CO rate was 47%, and partial to CO rate was 88%. The complete symptom resolution rate was 77%, and all patients achieved partial to complete symptom resolution. The CO rates for Borden Type I and Type II/III dural AVFs were 66.7% and 25% (P = 0.153), respectively, and complete symptom-free rates were 76.9% and 75.0% (P = 1.000%), respectively. The median duration between initial GKRS and complete symptom resolution was 14.3 months. The median treatment to image-free durations for Borden Type I and Type II/III dural AVFs were 25.9 and 60.4 months (P = 0.028), respectively, and treatment to symptom-free durations were 10.6 and 36.7 months (P = 0.103), respectively. One patient had a recurrent hemorrhage. Two patients experienced brain edema after stereotactic radiosurgery and one patient experienced cystic formation after GKRS. The morbidity rate was 19% (four patients) and there was no mortality. Conclusion: Treatment with GKRS for dural AVFs offers a favorable rate of obliteration. Patients with dural AVFs that are refractory or not amenable to endovascular or surgical therapy may be safely and effectively treated using GKRS.

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Immune reconstitution inflammatory syndrome is a collection of inflammatory disorders associated with paradoxical worsening of preexisting infectious processes following the initiation of highly active antiretroviral therapy (HAART) in individuals infected with human immunodeficiency virus (HIV). It involves a wide range of pathogens, neoplasms such as Kaposi's sarcoma (KS) and some autoimmune diseases. We describe an autopsy report of a 40-year-old man infected with HIV. He experienced a rapid dissemination of KS resulting in death within 6 months after starting HAART. His serum viral load had significantly decreased 4 log10 within 32 days and his CD4+ T-cell count increased 4-fold. He presented with multiple skin lesions over the chin and anterior neck, which rapidly spread over the trunk, 4 extremities, perianal region, and penis. Finally, he developed acute dyspnea and a plain chest radiograph showed bilateral pulmonary infiltrations. Despite treatment, he died of acute respiratory failure. At autopsy, multiple KS lesions were noted in the bilateral lungs, liver, kidneys, and gastrointestinal tract. Increased inflammatory cytokines during immune reconstruction from HAART-reactive human herpes virus type-8 infection, linked to the tumorigenesis of KS, finally led to rapid dissemination and death.

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We report a case of acute pulmonary embolism with hemodynamic instability diagnosed by a computed tomography pulmonary angiogram. The patient developed pulseless electrical activity during systemic thrombolytic therapy with recombinant tissue plasminogen activator. Successful return of spontaneous circulation was achieved after immediate cardiopulmonary resuscitation with chest compressions for 6 min. His electrocardiogram (ECG) on arrival in the emergency department displayed sinus tachycardia, an S wave in lead I, a Q wave in lead III, incomplete right bundle branch block (RBBB), T-wave inversion (TWI) in leads V1–V3, ST elevation in leads aVR and V1, and ST depression in leads I, II, III, aVF, and V4–V6. These characteristic ECG changes might have prognostic value for clinical deterioration. He recovered after treatment. After discharge, the ECG showed resolution of TWI in leads V1–V3 and incomplete RBBB, suggesting recovery from right ventricular dysfunction, which was confirmed by an echocardiogram on follow in the outpatient department.

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Scar endometriosis is uncommon and defined as the presence of ectopic endometrial glands in abdominal soft tissues after a gynecological operation. Malignant transformation has been reported but remains rare. Carcinogenesis occurs in ectopic endometrial tissue with repeated hormone stimulation during the menstrual cycle. We present a case of clear cell carcinoma directly arising from scar endometriosis after a cesarean section and review all 16 cases reported.

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Objectives: The objective of this study is to investigate the feelings (well-being) of emergency physicians in Taiwan regarding their job and the relationship between these feelings and the work environment. Materials and Methods: A questionnaire was used to survey emergency physicians across Taiwan from January to June 2014. The questionnaire contents were categorized into five specific factors that could affect well-being, including “emergency quality, emergency safety, support environment, workload, and salary and benefits.” Well-being was rated directly on a scale of 1–10, with 10 indicating the highest level of happiness. Physician retention was also surveyed. The correlations among the five factors, well-being, and physician retention were analyzed. The five factors were quantified as a “happiness index” and compared between religious and nonreligious hospitals and medical centers and regional hospitals. Results: A total of 398 questionnaires were received, and the response rate was 39%. Of these, 42.7% of responders reported high ratings for well-being (scores of 7–10, 1 is the worse, and 10 is the best) and 40.3% felt neutral (scores of 5–6). Only 12.3% doctors did not think they would stay at the same position for the next 3 years. All five factors had moderately significant correlations with each other (γ = 0.195–0.534, γ< 0.01). All five factors also significantly correlated with well-being. Emergency safety (γ = 0.121, γ< 0.05), salary and benefits (γ = 0.143, γ< 0.05), and well-being (γ = 0.189, γ< 0.01) were correlated with physician retention. The happiness indices of emergency quality, support environment, and workload were significantly higher in regional hospitals than medical centers. Conclusions: All five indicators had impacts on well-being. The respondents reported heavy workloads, including high stress and even poorly met physiological needs. In addition, the threat of violence, salaries, and well-being correlated with physician retention. Hospital administrators can make efforts to improve the well-being of doctors and physician retention by adjusting environmental factors.

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Bladder pheochromocytoma is a rare tumor. The typical manifestations are hematuria, hypertension, headache, sweating, and tachycardia provoked by micturition or overdistention of the bladder. We herein report a case of bladder pheochromocytoma in a 52-year-old woman who presented without micturition attacks. Her clinical course had a latent period of 10 years. A urinary bladder tumor was found incidentally on magnetic resonance imaging.Cystoscopy revealed a large submucosal tumor covered by congested urothelium with a broad base over the left lateral wall of the bladder. Transurethral resection was performed, and the final diagnosis was confirmed by pathological analysis. The patient remained recurrence free after 7-year follow-up.

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Objective: Human leukocyte antigen (HLA) DRB1*04:36 is a low-frequency HLA-DRB1 allele. The aim here is to report the ethnicity of DRB1*04:36 and its associated HLA haplotypes among Taiwanese individuals. Materials and Methods: A sequence-based typing method was employed to confirm this low incidence allele. Polymerase chain reaction was performed to amplify exons 2 and 3 of the HLA-A and HLA-B loci and exon 2 of the HLA-DRB1 locus using group-specific primer sets. The amplicons were sequenced in both directions using BigDye Terminator Cycle Sequencing Ready Reaction kits and the manufacturer's protocols. One group of unrelated blood donors used in this study consists of randomized individuals with Taiwanese ethnicity who participate in the Tzu Chi Bone Marrow Donor Registry and the other group are randomized unrelated individuals from mainland China. The family members in the family part of the study are volunteer blood donors. Results: In exon 2, the DNA sequence of DRB1*04:36 is identical to DRB1*04:03:01 except for a nucleotide segment from residue 286 to residue 308. The nucleotide segment from residue 286 to residue 308, incidentally, is identical to that of DRB1*11:01:01:01. These observations suggest that DRB1*04:36 may have been derived through a gene recombination event involving DRB1*04:03:01 and DRB1*11:01:01:01. Our family study indicated that the HLA haplotype in association with DRB1*04:36 can be deduced to be A*24:02-B*39:01-DRB1*04:36. A randomized population study using Taiwanese suggests that additional DRB1*04:36 associated HLA haplotypes seem to exist. Conclusion: The information on the ethnicity of the DRB1**04:36 allele, and the deduced probable HLA haplotypes associated with the low incidence DRB1*04:36 allele that we report here, is of value to HLA testing laboratories for reference purposes. In addition, they can be used by stem cell transplantation donor search coordinators to aid the creation of strategy for finding compatible donors who are part of unrelated bone marrow donor registries when a patient carries this uncommon HLA allele.

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Tracheobronchomegaly (also called Mounier–Kuhn syndrome) is a rare disease characterized by flaccid and markedly dilated trachea and main bronchi on inspiration with narrowing or collapse on expiration or cough. It is associated with recurrent lower respiratory tract infection. A 75-year-old man with unexpected giant tracheomegaly had a significant peritubal air leak which impeded an operation. Lumbar epidural anesthesia was performed for a subsequent operation without any sequela. Careful evaluation with chest radiography is basic to exclude a large airway. Chest computed tomography and fiber-optic bronchoscopy provided the diagnosis of a large airway. If a large airway is suspected, these examinations help to evaluate and manage the airway.

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