The Efficacy of Intraosseous Access for Initial Resuscitation in Patients with Severe Trauma: A Retrospective Multicenter Study in South Korea.

Background/Objective: In patients with severe trauma, intraosseous (IO) access is an alternative when intravenous (IV) access proves challenging. However, detailed insights into its utilization patterns and effectiveness are lacking. This study aims to evaluate the use and efficacy of IO access in hemodynamically unstable patients with trauma at level-1 trauma centers in South Korea. Methods: Data from six centers over 12 months were analyzed, focusing on patients with traumatic cardiac arrest or shock. Overall, 206 patients were included in the study: 94 in the IO group and 112 in the IV group. Results: The first-attempt success rate was higher in the IO group than in the IV group (90.4% vs. 75.5%). The procedure time in the IO group was also shorter than that in the IV group. The fluid infusion rate was lower in the IO group than in the IV group; however, the use of a pressure bag with IO access significantly increased the rate, making it comparable to the IV infusion rate. Further, regarding IO access, a humeral site provided a higher infusion rate than a tibial site. Conclusions: IO access offers a viable alternative to IV access for the initial resuscitation in patients with trauma, providing advantages in terms of procedure time and first-attempt success rate. The use of a pressure bag and a humeral site for IO access afforded infusion rates comparable to those associated with IV access.

CT anthropometric analysis of the prognosis of traumatic brain injury: A retrospective study to compare between psoas muscle and abdominal skeletal muscle.

BACKGROUND: Recent studies have suggested that skeletal muscle area (SMA) and psoas muscle area (PMA), markers for sarcopenia, are associated with the prognosis of many diseases. However, it remains unclear which of the two is a superior prognostic marker. Thus, the objective of this study was to analyse these markers in patients with traumatic brain injury (TBI). METHODS: Patients with TBI [abbreviated injury scale (AIS) score of 4 or 5] were selected. Those with an AIS score of 4 or 5 for chest, abdomen, or extremity lesion were excluded. Clinical data, including Glasgow Outcome Scale (GOS), mortality, and anthropometric data, were collected. SMA and PMA were measured. Skeletal muscle index (SMI) and psoas muscle index (PMI) were calculated for each muscle area divided by height squared. The good prognosis group was defined as patients with a GOS score of 4 to 5. The poor prognosis group was defined as those with a GOS score of 1-3. Data of both groups were analysed for the overall prognosis. After excluding patients with a hospital stay of 1 or 2 days, the modified prognosis and mortality of patients were analysed. RESULTS: A total of 212 patients were enrolled in the statistical analysis. Patients with good prognosis showed a larger PMA (17.4 cm2 vs. 15.0 cm2, P = 0.002) and PMI (6.1 cm2/ m2 vs. 5.3 cm2/ m2, P = 0.001). After modification, patients with good prognosis showed a larger PMA (17.4 cm2 vs. 14.9 cm2, P = 0.002) and PMI (6.1 cm2/ m2 vs. 5.3 cm2/ m2, P = 0.01). On binary logistic regression analysis, PMI was found to be a significant risk factor for the modified prognosis (Odds ratio (OR) (95% confidence interval (CI)): 0.763 (0.633 - 0.921), P = 0.005) and modified mortality (OR (95% CI): 0.740 (0.573 - 0.957), P = 0.022). CONCLUSION: Less amount of psoas muscle (PM) was found to be a significant risk factor for the prognosis of patients with TBI. PM was a better prognostic marker than skeletal muscle (SM) in patients with TBI. Further studies are needed to increase our understanding of sarcopenia and TBI.

A Comprehensive Analysis of the Association of Psoas and Masseter Muscles with Traumatic Brain Injury Using Computed Tomography Anthropometry.

OBJECTIVE: Psoas and masseter muscles are known markers of sarcopenia. However, the relative superiority of either muscle as a marker is unclear. Therefore, this study analyzed the two muscles in patients with a prognosis of traumatic brain injury (TBI). METHODS: Patients with TBI visiting a regional trauma center between January 2017 and December 2018 were selected, and their medical records were reviewed. TBI patients with an abbreviated injury score (AIS) of 4 or 5 were selected. Patients with an AIS of 4 or 5 at the chest, abdomen, and extremity were excluded. Patients with a hospital stay of 1 to 2 days were excluded. Both muscle areas were measured based on the initial computed tomography. The psoas muscle index (PMI) and the masseter muscle index (MMI) were calculated by dividing both muscle areas by height in meters squared (cm2/m2). These muscle parameters along with other medical information were used to analyze mortality and the Glasgow outcome scale (GOS). RESULTS: A total of 179 patients, including 147 males (82.1%), were analyzed statistically. The mean patient age was 58.0 years. The mortality rate was 16.8% (30 patients). The mean GOS score was 3.7. Analysis was performed to identify the parameters associated with mortality, which was a qualitative study outcome. The psoas muscle area (16.9 vs. 14.4 cm2, p=0.028) and PMI (5.9 vs. 5.1 cm2/m2, p=0.004) showed statistical differences between the groups. The PMI was also statistically significant as a risk factor for mortality in logistic regression analysis (p=0.023; odds ratio, 0.715; 95% confidence interval, 0.535-0.954). Quantitative analyses were performed with the GOS scores. Bivariate correlation analysis showed a statistically significant correlation between PMI and GOS scores (correlation coefficient, 0.168; p=0.003). PMI (p=0.004, variation inflation factor 1.001) was significant in multiple regression analysis. The masseter muscle area and MMI did not show significance in the study. CONCLUSION: Larger PMI was associated with statistically significant improved survival and GOS scores, indicating its performance as a superior prognostic marker. Further analyses involving a larger number of patients, additional parameters, and more precise settings would yield a better understanding of sarcopenia and TBI.

Systematic Preventable Trauma Death Rate Survey to Establish the Region-based Inclusive Trauma System in a Representative Province of Korea.

BACKGROUND: Trauma mortality review is the first step in assessing the quality of the trauma treatment system and provides an important basis for establishing a regional inclusive trauma system. This study aimed to obtain a reliable measure of the preventable trauma death rate in a single province in Korea. METHODS: From January to December 2017, a total of 500 sample cases of trauma-related deaths from 64 hospitals in Gyeonggi Province were included. All cases were evaluated for preventability and opportunities for improvement using a multidisciplinary panel review approach. RESULTS: Overall, 337 cases were included in the calculation for the preventable trauma death rate. The preventable trauma death rate was estimated at 17.0%. The odds ratio was 3.97 folds higher for those who arrived within "1-3 hours" than those who arrived within "1 hour." When the final treatment institution was not a regional trauma center, the odds ratio was 2.39 folds higher than that of a regional trauma center. The most significant stage of preventable trauma death was the hospital stage, during which 86.7% of the cases occurred, of which only 10.3% occurred in the regional trauma center, whereas preventable trauma death was more of a problem at emergency medical institutions. CONCLUSION: The preventable trauma death rate was slightly lower in this study than in previous studies, although several problems were noted during inter-hospital transfer; in the hospital stage, more problems were noted at emergency medical care facilities than at regional trauma centers. Further, several opportunities for improvements were discovered regarding bleeding control.

Applicability of the masseter muscle as a nutritional biomarker.

Nutritional assessment is feasible with computed tomography anthropometry. The abdominal muscle at the L3 vertebra is a well-known nutritional biomarker for predicting the prognosis of various diseases, especially sarcopenia. However, studies on nutritional assessment of the brain using computed tomography are still scarce. This study aimed to investigate the applicability of the masseter muscle as a nutritional biomarker.Patients who underwent simultaneous brain and abdominopelvic computed tomography in the emergency department was retrospectively analyzed. We assessed their masseter muscle 2 cm below the zygomatic arch and abdominal muscle at L3 via computed tomography anthropometry. The skeletal muscle index, prognostic nutritional index, and other nutritional biomarkers were assessed for sarcopenia using the receiver operating characteristic curve analysis.A total of 314 patients (240 men and 72 women) were analyzed (mean age, 50.24 years; mean areas of the masseter and abdominal muscles, 1039.6 and 13478.3 mm, respectively). Masseter muscle areas significantly differed in sarcopenic, obese, and geriatric patients (P < .001). The areas under the curve of the masseter muscle in sarcopenic, geriatric, and obese patients were 0.663, 0.686, and 0.602, respectively. Multivariable linear regression analysis showed a correlation with the abdominal muscle area, weight, and age.The masseter muscle, analyzed via computed tomography anthropometry, showed a statistically significant association with systemic nutritional biomarkers, and its use as a nutritional biomarker would be feasible.

Hypofractionated Radiation Therapy for Progressive Heterotopic Ossification: The Relationship between Dose and Efficacy.

PURPOSE: We sought to evaluate treatment outcomes after hypofractionated short-course radiation therapy (RT) for progressive heterotopic ossification (HO). METHODS AND MATERIALS: Nine consecutive patients were treated between January 2016 and December 2018. None had received previous preventive RT. RT was performed to prevent further HO progression with one of the following dose-fractionation regimens: 7 Gy × 2 fractions, 9 Gy × 1 fraction, 6 Gy × 2 fractions, 6 Gy × 3 fractions, 8 Gy × 2 fractions, or 7 Gy × 3 fractions. RESULTS: All patients were male, with a median age of 30 years (range, 16-55). Eight patients presented with grade III Brooker classification. The most commonly involved site was the hip, followed by femur and knee. With a median assessment time of 7.1 (range, 5.1-23.1) months, eight patients achieved decreased HO, with five showing a dramatic (≥50%) reduction. Among the five excellent responders, a 21 Gy with 7 Gy per fraction schedule was used in four patients. HO status was maintained at the final median follow-up of 11.6 months (range, 6.2-36.1), and Brooker's grade was improved in three patients. No significant RT-related toxicity was noted. CONCLUSIONS: The current RT scheme was effective for the management of progressive HO. It is speculated that higher RT doses could result in the superior efficacy of progressive HO.

Validity of bone scans to detect missed injury in patients with major trauma.

BACKGROUND: It is easy to miss injuries in patients with major trauma (MT). The authors hypothesized that bone scans (BSs) would reduce the number of missed injuries. However, there was not enough evidence on BS in patients with MT. The purpose of the present study was to identify the basic results of BS in patients with MT. METHODS: The medical records of patients with MT between January 2013 and December 2013 were reviewed. Patients who underwent a BS were enrolled in the study. Hot-uptake lesions without previous evaluation were checked by X-ray. Hot-uptake lesions on BSs that differed from previous evaluations were checked by computed tomography (CT) scans. The results of BSs were analyzed along with the results of X-ray and CT scans. The sensitivity, specificity, positive predictive value, and negative predictive value (NPV) were calculated. RESULTS: There were 115 patients with MT who received BS during the study period. The sensitivities were high on average (98.48-86.54). In addition, the NPVs were high (96.30-82.93). There were 16 cases of hidden fracture diagnosed after a BS. CONCLUSION: BS showed high sensitivity and high NPV. Further large-scale studies might add more validity to the use of BS in patients with MT.

Physical and nutrition statuses of geriatric patients after trauma-related hospitalization: Data from the Korean National Health and Nutrition Examination Survey 2013-2015.

Population aging is associated with increasing numbers of geriatric trauma patients, and various studies have evaluated their short-term outcomes, assessment, and treatment. However, there is insufficient information regarding their long-term outcomes. This study evaluated the physical and nutritional statuses of geriatric patients after trauma-related hospitalization.Data regarding physical and nutritional status were obtained from the Korean National Health and Nutrition Examination Survey VI (2013-2015).A total of 21,069 individuals participated in the survey, including 5650 geriatric individuals. After excluding individuals with missing data, 3731 cases were included in the analyses. The average age was 68 years, and most individuals were women (n = 2055, 55.08%). There were 94 patients had been hospitalized because of trauma. Trauma-related hospitalization among geriatric patients was significantly associated with reduced strength exercise (23.56% vs 12.99%, P = .043), activity limitations caused by joint pain (0.65% vs 3.31%, P = .028), self-care problems (8.00% vs 16.77%, P = .008), pain or discomfort (29.48% vs 40.51%, P = .024), hypercholesterolemia (27.37% vs 39.36%, P = .037), and mastication discomfort (39.98% vs 57.85% P = .005). The adjusted analyses revealed that trauma-related hospitalization was independently associated with activity limitations caused by joint pain (odds ratio [OR]: 5.04, 95% confidence interval [CI]: 1.29-19.67, P = .020), self-care problems (OR: 2.24, 95% CI: 1.11-4.53, P = .025), pain or discomfort (OR: 1.77, 95% CI: 1.08-2.89, P = .023), and mastication discomfort (OR: 2.06, 95% CI: 1.22-3.46, P = .007).Medical staff should be aware that geriatric patients have relatively poor physical and nutritional statuses after trauma-related hospitalization, and manage these patients accordingly.

Effect of surgical timing and outcomes for appendicitis severity.

PURPOSE: This study was aimed to evaluate the effect of time of surgery for acute appendicitis on surgical outcomes to optimize the timing of appendectomies. METHODS: Medical records of patients who underwent an appendectomy were reviewed to obtain data on time of symptom onset, time of hospital presentation, and start times of surgery. Surgical findings were used to define appendicitis as either uncomplicated or complicated. The uncomplicated group included patients with simple, focal, or suppurative appendicitis, and the complicated group included patients with gangrenous, perforated appendicitis or periappendiceal abscess formation. The 2 groups were analyzed by age, sex, and time. RESULTS: A total of 192 patients were analyzed. The mean time from symptom onset to start of operation showed a significant difference between both groups (1,652.9 minutes vs. 3,383.8 minutes, P < 0.001). The mean time from hospital visit to start of operation showed no difference between both groups (398.7 minutes vs. 402.0 minutes, P = 0.895). Operating within 24 hours of symptom onset had a relative risk of 1.738 (95% confidence interval, 1.319-2.425) for complications. Operating more than 36 hours after symptom onset was associated with an increased risk of postoperative ileus and a longer hospital stay. CONCLUSION: Complicated appendicitis is associated with a delay in surgery from symptom onset rather than a delay at hospital arrival. Surgeons should take into account the time from symptom onset when deciding on the timing of appendectomy. We recommend that appendectomy be performed within 36 hours from symptom onset.

International normalized ratio and serum C-reactive protein are feasible markers to predict complicated appendicitis.

BACKGROUND: Diagnostic approach for complicated appendicitis is still controversial. We planned this study to analyze preoperative laboratory markers that may predict complications of appendicitis. METHODS: Patients who underwent appendectomy were retrospectively recruited. They were divided into complicated appendicitis and non-complicated appendicitis groups and their preoperative laboratory results were reviewed. RESULTS: A total of 234 patients were included. Elevated international normalized ratio (INR) and serum C-reactive protein (CRP) were associated with complicated appendicitis (p = 0.001). On ROC curve analysis, area under the curve (AUC) of CRP and INR were 0.796 and 0.723, respectively. CONCLUSIONS: INR and CRP increased significantly in patients with complicated appendicitis. Further studies evaluating INR and CRP in patients undergoing conservative management for appendicitis are required.

Combination treatment with 17ß-estradiol and therapeutic hypothermia for transient global cerebral ischemia in rats.

OBJECTIVE: Therapeutic hypothermia is now regarded as the only effective treatment of global ischemic injury after cardiac arrest. Numerous studies of the neuroprotective effects of 17ß-estradiol have yielded conflicting results depending on administration route and dose. Herein, we investigated the neuroprotective effect of postischemic 17ß-estradiol administration combined with therapeutic hypothermia. METHODS: Twenty-one rats were randomly divided into 4 groups: control (group I), therapeutic hypothermia (group II), 17ß-estradiol treatment (group III), and therapeutic hypothermia combined with 17ß-estradiol treatment (group IV). One rat was assigned to a sham operation group. With the exception of the sham-operated rat, all animals underwent transient global cerebral ischemia for 20 minutes by the 4-vessel occlusion method. Hypothermia was maintained at 33°C for 2 hours in groups II and IV, and 17ß-estradiol (10 µg/kg) was intraperitoneally administered to rats in groups III and IV. Neurologic deficit scores and hippocampal cornu ammonis 1 neuronal injury were assessed 72 hours postischemia. RESULTS: The neurologic deficit score was not significantly different among the groups. The percentage of normal neurons in the hippocampal cornu ammonis 1 was 7.32% ± 0.88% in group I, 53.65% ± 2.52% in group II, 51.6% ± 3.44% in group III, and 79.79% ± 1.6% in group IV. The neuroprotective effect in the combined treatment group was markedly greater than in the single treatment groups, which suggests that hypothermia and 17ß-estradiol work synergistically to exert neuroprotection. CONCLUSION: Postischemic administration of low-dose 17ß-estradiol appears to be neuroprotective after transient global ischemia, and its effect is potentiated by therapeutic hypothermia.

Therapeutic hypothermia complicated by spontaneous brain stem hemorrhage.

Hypothermia increases clotting time, which is known as hypothermic coagulopathy. However, prothrombin time and activated partial thromboplastin time prolongation associated with therapeutic hypothermia is usually mild and thus, hypothermic coagulopathy is not considered to cause clinically significant bleeding. On the other hand, PT and aPTT do not seem to reflect the severity of hypothermic coagulopathy. Serious bleeding complications of therapeutic hypothermia has not been reported previously. Herein, we introduce a case of spontaneous brain stem hemorrhage as a complication of therapeutic hypothermia-induced coagulopathy.

Left-sided appendicitis in a patient with situs inversus totalis.

Situs inversus totalis is a rare inherent disease in which the thoracic and abdominal organs are transposed. Symptoms of appendicitis in situs inversus (SI) may appear in the left lower quadrant, and the diagnosis of appendicitis is very difficult. We report a case of left-sided appendicitis diagnosed preoperatively after dextrocardia that was detected by chest X-ray, although the chief complaint of the patient was left lower-quadrant pain. The patient underwent an emergent laparoscopic appendectomy under the diagnosis of appendicitis after abdominal computed tomography (CT). In patients with left lower quadrant pain, if the chest X-ray shows dextrocardia, one should suspect left-sided appendicitis. A strong suspicion of appendicitis and an emergency laparoscopic operation after confirmation of the diagnosis by imaging modalities including abdominal CT or sonography can reduce the likelihood of misdiagnosis and complications including perforation and abscess. Laparoscopic appendectomy in SI was technically more challenging because of the mirror nature of the anatomy.

Correlation between breast arterial calcification detected on mammography and cerebral artery disease.

PURPOSE: This study was carried out to determine the relationship between breast arterial calcification (BAC) and cerebral artery disease. MATERIALS AND METHODS: We investigated the relationship between BAC on mammography and cerebral artery-origin T2-hyperintensity on brain MRI and which is associated with an increased risk for stroke. A total of 168 women, ages 40-78 years, who underwent both mammography and brain MRI, were enrolled in this study. BAC was counted as positive if it was found on more than one view a breast. The T2-hyperintensity was systemically defined and graded as follows: punctuate; patchy; and confluent white-matter hyperintensity (WMH); caps; bands; and irregular periventricular hyperintensity (PVH). Patchy and confluent WMH and irregular PVH were considered as positive findings for cerebral artery disease. We also obtained data regarding cardiovascular risk factors that might function as confounding factors. Statistical analysis was performed for association of the BAC and positive MRI findings. RESULT: The presence of BAC showed a strong correlation with the positive MRI findings (Odds ratios, adjusted with statically significant cardiovascular factors of 6.86 for positive WMH and 9.04 for positive PVH, p < 0.05). CONCLUSION: The mammographic finding of BAC, which may be a useful marker of women at higher risk for stroke, should receive more of clinicians' attention and its presence should never be omitted from the report.

[Double strand break of DNA in gastric adenoma and adenocarcinoma].

BACKGROUND/AIMS: DNA double strand break (DSB) is one of the critical types of DNA damage. When unrepaired DSB is accumulated in the nucleus of the cells having mutations in such genes as p53, it will lead to chromosomal instability and further more to mutation of tumor-activating genes resulting in tumorogenesis. Some of malignant cancers and its premalignant lesions were proven to have DSB in their nuclei. The aim of this study was to define the differences in expression of 53BP1 and gamma-H2AX, the markers of DSB, among normal, gastric adenoma, and gastric adenocarcinoma tissues. METHODS: Tissue microarray was made with the tissues taken from 121 patients who underwent gastrectomy for gastric adenocarcinoma, and 51 patients who underwent endoscopic mucosal resection for gastric adenoma. Immunochemical stain was performed for the marker of DSB, 53BP1 and gamma-H2AX in the tissue microarray. The normal tissues were collected from histologically confirmed tissues with no cellular atypia obtained from the patients with gastric adenocarcinoma. RESULTS: In gastric carcinoma cells, 53BP1 and gamma-H2AX were highly expressed as compared to normal epithelial cells and gastric adenoma (p<0.01). There were no differences in the expression of 53BP1 and gamma-H2AX between normal epithelium and gastric adenoma. The expression of 53BP1 in the adenoma with grade II and III atypism was more elevated than in those with grade I atypism. The expression of 53BP1 and gamma-H2AX were not significantly different according to the clinicopathologic parameters in the patients with gastric adenocarcinoma. CONCLUSIONS: The DSB in DNA seems to be associated with the development of gastric adenocarcinoma, but does not affect the premalignant adenoma cells.

The combination effect of sodium butyrate and 5-Aza-2'-deoxycytidine on radiosensitivity in RKO colorectal cancer and MCF-7 breast cancer cell lines.

BACKGROUND: The overall level of chromatin compaction is an important mechanism of radiosensitivity, and modification of DNA methylation and histone deacetylation may increase radiosensitivity by altering chromatin compaction. In this study, we investigated the effect of a demethylating agent, a histone deacetylase(HDAC) inhibitor, and the two agents combined on radiosensitivity in human colon and breast cancer cell lines. METHODS: In this study, we used RKO colorectal cancer cell line and MCF-7 breast cancer cell lines and normal colon cell lines. On each of the cell lines, we used three different agents: the HDAC inhibitor sodium butyrate(SB), the demethylating agent 5-Aza-2'-deoxycytidine(5-aza-DC), and radiation. We then estimated the percentage of the cell survival using the XTT method and experimented to determine if there was an augmentation in the therapeutic effect by using different combinations of the two or three of the treatment methods. RESULTS: After treatment of each cell lines with 5-aza-DC, SB and 6 grays of radiation, we observed that the survival fraction was lower after the treatment with 5-aza-DC or SB than with radiation alone in RKO and MCF-7 cell lines(p < 0.001). The survival fraction was lowest when the two agents, 5-aza-DC and SB were combined with radiation in both RKO and MCF-cell lines. CONCLUSION: In conclusion, 5-aza-DC and SB can enhance radiosensitivity in both MCF-7 and RKO cell lines. The combination effect of a demethylating agent and an HDAC inhibitor is more effective than that of single agent treatment in both breast and colon cancer cell lines.

Laparoscopy-assisted completion total gastrectomy for gastric cancer in remnant stomach: report of 2 cases.

The completion total gastrectomy is often performed in gastric cancer patients who have previously undergone distal gastrectomy owing to benign or malignant disease. This procedure includes not only removal of the remnant stomach, but also a lymphadenectomy in accordance with upper third gastric cancer. Although laparoscopy-assisted gastrectomy has been approved as one of the treatments of choice for early gastric cancer and its application has also been extend to advanced gastric cancer, only a few studies have reported on laparoscopy-assisted completion total gastrectomy. This is probably because the procedure is technically complicated procedure due to the intra-abdominal adhesion and anatomical changes. Recently, we successfully carried out laparoscopy-assisted completion total gastrectomy in 2 patients diagnosed with advanced gastric cancers in the remnant stomach. Distal gastrectomy was initially performed using laparoscopy-assisted and open procedures, respectively. Furthermore, we conducted the curative operations through a sufficiently extended lymphadenectomy or even through the resection of surrounding organs.

Epidermoid cyst appearing as a malignancy-mimicking subcutaneous lesion on ultrasonography.

PURPOSE: It is challenging to diagnose epidermoid cysts on ultrasonography; except in typical, benign-appearing cases. The purpose of this study was to include epidermoid cysts in the differential diagnosis of diverse subcutaneous lesions, especially malignancy-mimicking lesions, as seen on ultrasonography. METHODS: We reviewed 19 cases of pathologically confirmed epidermoid cysts in 19 patients (male, 8; female, 11). Three radiologists, who were blinded to the pathology data, classified (by consensus) these epidermoid cysts as benign or malignancy-mimicking lesions, according to generally accepted ultrasonographic criteria, including the margin, shape, echotexture, and transitional zone with surrounding tissue, and also including the growth pattern and adjacent tissue change. The ultrasonographic data were then correlated with the pathology results regarding the ruptured or unruptured status of the cysts. RESULTS: Epidermoid cysts have been noted as showing a wide-spectrum of findings on ultrasonography. Twelve of our cases showed benign ultrasonographic features: six cases had typical, benign ultrasonographic features with unruptured status; two cases with ruptured status did not have clear ultrasonographic features, although we decided by consensus that there were benign ultrasonographic features; and four cases with unruptured status had peculiar internal echogenicities, described as "internal rod-like contents", that could be considered to be a variation of the typical ultrasonographic finding of epidermoid cysts. Seven cases showed malignancy-mimicking ultrasonographic features; all seven of these had ruptured status. CONCLUSION: The diagnosis of ruptured epidermoid cysts should be included in the differential diagnosis of malignancy-mimicking subcutaneous lesions. The internal rod-like contents can be regarded as another typical ultrasonographic finding of epidermoid cysts.