Few previous studies have investigated the pathomechanism and managements of rotator cuff lesions with shoulder stiffness. Based on observations by Codman in 1934, frozen shoulder presumably relates to rotator cuff tendenitis. In the past six decades, tended to discriminate primary frozen shoulder from secondary shoulder stiffness due to shoulder disorders such as rotator cuff lesions or trauma. Intrinsic degeneration and outlet acromial spur impingement are reported as pathogenic causes of rotator cuff lesion. Although patients with rotator cuff lesions with shoulder stiffness or adhesive capsulitis (frozen shoulder) may have similar complaints about pain and motion limitation, the pathological reactions in these disorders remain unclear. In our investigation of clinical vignettes of shoulder stiffness, inflammation-mediated adhesions in the subacromial bursa in rotator cuff lesions, and changes in inflammatory cytokine levels have been linked to myofibroblast recruitment in the subacromial bursa. Our study provides the first indication that increased interleukin -1β expression and myofibroblast recruitment in the subacromial bursa are correlated with rotator cuff lesions with shoulder stiffness. Increased inflammatory cytokine concentrations in the lesions also provide new molecular insight into the pathological role of the subacromial bursa in the development of shoulder stiffness in rotator cuff lesions. Although rotator cuff repair is a shoulder-tightening procedure and is not recommended until resolution of the shoulder stiffness in rotator cuff lesions with stiff shoulder, our clinical evidence-based survey suggests that a combined procedure of manipulation, lysis of adhesions, acromioplasty, and rotator cuff repair is a useful procedure if the symptoms do not improve 3 months of aggressive rehabilitation.

Facial asymmetry is common in humans. Significant facial asymmetry causes both functional as well as esthetic problems. When patients complain of facial asymmetry, the underlying cause should be investigated. The etiology includes congenital disorders, acquired diseases, and traumatic and developmental deformities. The causes of many cases of developmental facial asymmetry are indistinct. Assessment of facial asymmetry consists of a patient history, physical examination, and medical imaging. Medical imaging is helpful for objective diagnosis and measurement of the asymmetry, as well as for treatment planning. Components of soft tissue, dental and skeletal differences contributing to facial asymmetry are evaluated. Frequently dental malocclusion, canting of the occlusal level and midline shift are found. Management of facial asymmetry first aims at correcting the underlying disorder. Orthognathic surgery is performed for the treatment of facial asymmetry combined with dental occlusal problems. A symmetrical facial midline, harmonious facial profile and dental occlusion are obtained from treatment. Additional surgical procedures may be required to increase or reduce the volume of skeletal and soft tissue components on both sides to achieve better symmetry.

Vertebral compression fracture is the most common complication of osteoporosis. It may result in persistent severe pain and limited mobility, and significantly impact the quality of life. Conservative therapy using external bracing, bed rest and analgesics is necessary for pain control in these patients. However, some patients may experience protracted or ongoing pain even with these measures. Surgical treatment is indicated when conservative treatment fails, or in patients with spinal instability or neurologic deficit. Elderly patients often have comorbilities, and because of osteoporosis, high risk of postoperative complications such as implant loosening, and further adjacent fractures. Vertebroplasty involves a percutaneous injection of bone cement into the collapsed vertebrae under fluroscopic imaging guidance. It was first reported in 1987 for the management of a painful, aggressive hemangioma of a vertebral body. Since then, vertebroplasty has been widely accepted for the treatment of vertebral osteoporotic compression fractures without neurological damage. This article summarizes the advances in vertebroplasty, and discusses the indications, technique, alternative methods, results and complications. The contents include a review of the supporting evidence to provide a comparison of the safety and efficacy of vertebroplasty and kyphoplasty.

Background: Cardiac myxoma, the most common primary tumor of the heart, has variable clinical presentations and an immunohistochemical profile. Survivin, an antiapoptosis protein, may play an important role in the causes of cardiac myxoma. This investigation will report the expression pattern of survivin in cardiac myxomas. Methods: This study included 40 patients with cardiac myxoma, who were treated with surgical excision of the lesion. Detailed clinical parameters were reported and the expression of survivin was studied by immunohistochemical staining. Results: The patient population was comprised of 24 (60%) women and 16 (40%) men. The mean age of the patients was 42 years, with an age range of 30 to 63 years. All study cases were sporadic myxomas rather than familial myxoma. Patients were asymptomatic (20%), or had dyspnea (40%), stroke (15%), chest pain (12%), and fever (12%) on presentation. All lesions were located in the left atrium. The location of the myxoma and clinical events did not differ in terms of pathological changes, such as vascular proliferation, inflammation, cellularity, hyaline, calcification and thrombosis. Cardiac myxoma was characterized by a survivin dependent pathway with 100% immunohistochemical staining in the cytoplasm and the distribution in scoring system of survivin expression were 1 case (2.5%) in score 1; 12 cases (30%) in score 2; 12 cases (30%) in score 3 and 15 (37.5%) in score 4. Conclusion: Cardiac myxomas demonstrate strong expression of survivin in the cytoplasm. This implies survivin may play an important role in the apoptosis pathway in cardiac myxomas.

Background: This in vitro study investigated the angiogenesis and osteogenesis effects of shockwaves on bone marrow stromal cells (BMSCs) from hips with osteonecrosis. Methods: BMSCs were harvested from the bone marrow cavity of the proximal femur in six patients with osteonecrosis of the femoral head. The specimens were divided into four groups, the control, shockwave, shockwave plus nω-nitro- L-arginine methyl ester (L-NAME) and a nitric oxide (NO) donor (NOC18) groups. The control group received no shockwaves and was used as the baseline. The shockwave group received 250 shockwave impulses at 14 Kv (equivalent to 0.18 mJ/mm2 energy flux density). The shockwave plus LNAME group was pre-treated with L-NAME before receiving shockwaves. The NOC18 group received NOC18 after cell culture for 48 hours. The evaluations included cell proliferation (MTT) assay, alkaline phosphatase, real time reverse transcriptase-polymerase chain reaction analysis of vessel endothelial growth factor (VEGF), bone morphogenic protein (BMP)-2, RUNX2 and osteocalcin mRNA expression and von Kossa stain for mineralized nodules. Results: The shockwave group showed significant increases in MTT, VEGF, alkaline phosphatase, BMP2, RUNX2 and osteocalcin mRNA expression and more mature mineralized nodules compared with the control. Pre-treatment with L-NAME significantly reduced the angiogenic and osteogenic effects of extracorporeal shockwave therapy (ESWT) and the results were comparable with the control. Administration of NOC18 significantly enhanced the angiogenesis and osteogenesis effects compared with the control and the results were comparable with the shockwave group. Conclusion: ESWT significantly enhanced the angiogenic and osteogenic effects of BMSCs mediated through the NO pathway in hips with osteonecrosis. These innovative findings, at least in part, explain some of the mechanism of shockwaves in osteonecrosis of the hip.

Background: Schizophrenia is accompanied by an activation of the immune/inflammatory system. In the present study, the relationships between serum interleukin (IL)-6, tumor necrosis factor (TNF)-α, and transforming growth factor (TGF)-β1 levels and schizophrenia were explored in a group of Taiwanese inpatients. Furthermore, the serum IL-6, TNF-α, and TGF-β1 levels of patients with schizophrenia were compared before and after 1 month of antipsychotic treatment. Methods: The serum IL-6, TNF-α, and TGF-β1 levels of 34 acute stage schizophrenic patients and 30 healthy control subjects were collected. These levels were again collected in the 34 patients after 1 month of antipsychotic treatment. An analysis of covariance (ANCOVA) adjusted for gender was performed to examine the differences in cytokine levels between the schizophrenic patients and the control group. Repeated measures ANCOVA adjusted for gender was performed to examine the differences in cytokine levels of the schizophrenic patients before and after 1 month of treatment. Results: Using ANCOVA adjusted for gender, significantly increased IL-6 levels were found in schizophrenic patients compared with the control group (p = 0.02), but there were no significant differences in TNF-α and TGF-β1 levels (p = 0.06 and 0.91, respectively). After 1 month of medical treatment, there were no significant differences in IL-6 (p = 0.64), TNF-α (p = 0.48), and TGF-β1 (p = 0.23) levels in the schizophrenic patients, although IL-6 appeared to be normalizing. Conclusion: An increase in the IL-6 level may play a role in the pathophysiology of schizophrenia. A larger sample size and a longer period of follow-up are needed to confirm this finding.

Background: A combination of salmeterol and fluticasone propionate (SAL/FP) has been shown to be effective in the treatment of asthma. We compared the efficacy and tolerability of SAL/FP (50/250 μg) with fluticasone propionate (FP) 250 μg administrated twice daily for 2 weeks in treating patients with mild to moderate asthma. Methods: This was a randomized, double-blind study in adult patients with symptomatic asthma that was not controlled by 1000 μg/d inhaled corticosteroids (ICS) alone. 48 asthmatics were randomized to receive 2 inhalations of SAL/FP 50/250 μg bis in die (BID) or 2 inhalations of FP 250 μg BID, both delivered via Accuhaler device, for 2 weeks. The primary objective was the mean change from baseline in the mean morning peak expiratory flow (PEF) over the two week period. Other parameters included lung function, daily asthma symptom scores, evening PEF, percentage of days free of rescue medication use and daily rescue medication use. Tolerability was assessed by adverse events spontaneously elicited at clinic visits. Results: 46 patients provided evaluable efficacy for analysis. The morning PEF improved significantly throughout the two weeks of treatment compared with baseline in the SAL/FP group. Mean morning PEF was 23.0 L/min higher in SAL/FP group than in FP group (p = 0.013). The change of forced expiratory volume in one second (FEV1) from baseline was greater in SAL/FP group compared to FP group (p = 0.048). There were similar effects on day-time and night-time symptom scores, percentage symptom free days and nights and usage of salbutamol. 70.8% of the patients receiving SAL/FP were satisfied with the treatment, while only 26.1% of patients receiving FP alone were (p = 0.020). No death or acute exacerbation occurred. Conclusion: SAL/FP 50/250 μg was safe and effective, and had a high level of patient satisfaction resulting in significantly greater increases in morning PEF and FEV1 compared to the use of FP 250 μg alone.

Background: Lactoferrin has been shown to exhibit anti-enterovirus 71 (EV71) and antirotavirus properties. This trial was conducted to determine whether a formula containing bovine lactoferrin (bLF) exerts a protective effect against EV71 or rotavirus infection among children from 2 to 6 years old. Methods: A prospective, randomized, single blind clinical trial of an oral supplement containing bLF (daily dose approximately 70 to 85 mg) was carried out with healthy children in a day care center from March 2002 to June 2003. The incidence of enterovirus or rotavirus infection and the serum level of interferon- gamma (IFN-γ) and interleukin-10 (IL-10) were compared between children receiving and not receiving bLF. Results: A total of 172 children, 96 in group A, which received bLF, and 76 in group B which did not receive bLF, completed the trial. During the study period, no EV71 was isolated and seroconversion of EV71 antibodies was noted in only one child. Fourteen episodes of presumptive enterovirus infection and 12 episodes of presumptive viral enteritis were detected. No significant differences were observed between groups in the incidence of presumptive enterovirus infection or viral enteritis or the number of laboratory confirmed enterovirus or rotavirus infections. No significant differences were observed in the serum levels of IFN-γ and IL-10 between groups either prior to or following the trial. In both groups, IFN-γ levels increased, but IL-10 was unchanged following the trial. Conclusion: An oral supplement of bLF at a dose of 70 mg/day did not show any benefits in the prevention of EV71 or rotavirus infection, or any impact on IFN-γ or IL-10 serum levels in healthy children in this trial.

Background: Sprengel deformity is a congenital failure of descent of the scapula. Limited shoulder abduction and cosmetic appearance are the major concerns. Although the Woodward procedure reportedly affords satisfactory correction, the long-term functional outcome postoperatively has not been addressed. Methods: Eight patients (9 shoulders) who underwent the Woodward procedure for Sprengel deformity were evaluated. The cosmetic appearance and functional results of the shoulders were evaluated using the Cavendish grading system and functional Constant scoring. Grading of the cosmetic appearance, range of motion of the shoulder, and radiographs were obtained for interpretation. Results: After a mean follow-up of 113 ± 29 months, the cosmetic appearance had improved. The Cavendish cosmetic grade improved significantly (p = 0.000). The superior displacement ratio decreased from 0.5 ± 0.1 to 0.2 ± 0.1 (p = 0.004). The height-to-width ratio of the affected scapula increased from 1.3 ± 0.2 (range 1.1 to 1.7) to 1.6 ± 0.2 (range 1.4 to 2.0) (p = 0.001). The abduction of the shoulder improved from 122 ± 14 (range 100 to 140) degrees to 157 ± 20 (range 125 to 180) degrees (p = 0.008). The average abduction power of the involved shoulders was 21.8 ± 3.2 lbs, which was not significantly different from the uninvolved shoulders 23.1 ± 2.5 lb (p = 0.525). The average Constant score for the operated shoulders was 91.7 ± 4.2 (range 82 to 96) points. Conclusion: The Woodward procedure offers substantial improvement of shoulder function and cosmetic appearance for patients.

Background: Current evidence suggests that obstructive sleep apnea-hypopnea syndrome (OSAHS) is an independent risk factor for systemic hypertension. The mechanisms linking OSAHS to hypertension remain unclear. However, recent studies have indicated that abnormal autonomic control may be an important factor. Our study aims to evaulate differences in autonomic activity between hypertensive and normotensive OSAHS patients before and during continuous positive airway pressure (CPAP) therapy. Methods: Fifty-three OSAHS patients were analyzed in this study. Patients were divided into 2 groups, one group comprising patients with hypertension and the other of patients without hypertension. Heart rate variability (HRV) was assessed by polysomnography, before patients received CPAP titration and during CPAP titration. Then, HRV was compared between the hypertensive and normotensive groups. Multivarate analyses were used to evaluate the influence of clinical variables on autonomic activity. Results: Although HRV before CPAP titration was not statistically different between the 2 groups, low frequency variability was significantly lower in hypertensive subjects who received CPAP titration compared with normotensive subjects. Multivariate analysis revealed that hypertension is a determinant factor of autonomic change during CPAP use. Conclusions: Our findings demonstrate that CPAP therapy results in a greater and immediate change in autonomic activity in hypertensive OSAHS patients compared with normotensive OSAHS patients. This suggests that CPAP lowers blood pressure by decreasing the patient's autonomic activity.

Background: The serum potassium (K+) level is kept in a narrow range to sustain normal physiology within the human body by the kidneys. The serum K+ level in different stages of chronic kidney disease (CKD) remains undefined. Methods: We conducted a cross-sectional study to observe the serum K+ level in patients without clinical manifestations of hyperkalemia in the late stages of CKD (stages 3-5). A total of 531 patients with late stage CKD were included and followed up for at least 1 year, from March 2006 to May 2007. The patients were sub-grouped by stages of CKD, which were determined by a Modification of Diet in Renal Disease equation estimating the glomerular filtration rate (eGFR). The serum creatinine, eGFR and K + levels were recorded at least twice during the study. We analyzed the average K + level in these late-stage CKD patients. Results: The average K + level increased along with renal function deterioration in the late stages of CKD (stage 3: 4.36 ± 0.49; stage 4: 4.50 ± 0.55; stage 5: 4.69 ± 0.73 mEq/L, p < 0.05). Men and patients with diabetes mellitus, a low eGFR, and a low hemoglobin might have higher levels of serum K+. We also noticed that there was a linear increase in the standard deviation of the serum K + level as renal function deteriorated. The use of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers was not associated with hyperkalemia in our patients. Conclusion: Our results reflected that the serum K + level increased in correlation with the decline in the eGFR in the late stages of CKD. Also, male gender, diabetes mellitus, and anemia might be risk factors for higher K + levels in CKD patients. The variation in the serum K + level became wider as renal failure progressed.

Background: Liver transplantation (LT) in patients with portal vein thrombosis (PVT) remains a challenge for transplant surgeons. In this study, we included a group of patients with PVT who underwent LT, and analyzed patient outcomes. Methods: A total of 356 patients who underwent LT consisting of 167 cases of deceased donor LT and 189 cases of live donor LT at Chang Gung Memorial Hospital Linkou Medical Center between September 1996 and June 2009 were retrospectively reviewed; 24 (6.7%) of these patients had PVT at transplantation. Their clinical features, surgical management, and outcomes were analyzed. Results: Surgical management of patients with PVT included a thrombectomy followed by direct anastomosis between the recipient's and the liver graft portal vein (PV) (n = 13), interposition vein graft between the recipient's coronary vein (CV) and the liver graft PV (n = 3), direct anastomosis of the recipient's CV and the liver graft PV (n = 1), interposition jump graft from the recipient's superior mesenteric vein to the liver graft PV (n = 4), and transection of the thrombotic PV followed by interposition of a venous graft between the recipient's PV and the liver graft PV (n = 3). There were 7 hospital mortalities. The mean follow-up for the 17 surviving patients was 36.3 months (range, 3.4– 105.1 months), and 14 patients were still alive at the end of the study. Four patients (16.7%) had rethrombosis of portal inflow after LT. Patients with PVT undergoing LT had a significantly higher mortality rate (p = 0.033) than patients without PVT undergoing LT. However, there was no significant difference in the cumulative survival rates (p = 0.0696). Further analysis of patient survival according to PVT grade, venous graft application, and reconstructed portal flow routes also exhibited no significant differences. Conclusions: LT for patients with PVT is clinically feasible and should not be considered a contraindication. However, a favorable outcome is achievable only with ideal surgical management to overcome PVT during LT.

The most prominent sites of Castleman's disease (CD) are the thorax (mediastinum or lung hilum) and abdomen. It rarely occurs in the cervical area and only one case has been reported in the posterior triangle of the neck. We report a new case of cervical posterior triangle CD in a child. A 9-year-old boy presented with an indolent mass in the posterior triangle (level V) on the left side of his neck for more than six months. Complete excision was undertaken and the histopathological diagnosis was CD of the hyaline-vascular type. At the 3-year follow up, there were no signs of recurrence. The etiologies of persistent cervical lymphadenopathy in children vary. Though it is very rare, we should keep in mind that CD is possible. In addition, CD can be either localized (unicentric) or diffuse (multicentric). The treatment and prognosis of these two are quite different. Therefore, for any case of CD, systemic evaluation is recommended for a precise diagnosis and proper management.

Fetishism is characterized by recurrent, intense sexual fantasy or behavior involving the use of nonliving objects, such as women's undergarments, over a period of at least six months. This disorder occurs mostly in males and usually begins in adolescence. The neurobiological etiologies of fetishism remain unclear, and studies on treatment were limited. We present a 14- year-old boy with attention deficit hyperactivity disorder with fetishistic behavior who was treated successfully with 36 mg extended-release methylphenidate daily and 4 months of cognitive– rational emotive psychotherapy.