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Acute pericarditis is caused by various factors, but purulent pericarditis is rare. Primary purulent pericarditis in immunocompetent hosts is very rare in the modern antibiotics era. We report a successfully treated case of primary purulent pericarditis complicated with cardiac tamponade and pneumopericardium in an immunocompetent host. A 69-year-old female was referred from another hospital because of pleuritic chest pain with a large amount of pericardial effusion. She was diagnosed with acute pericarditis accompanied by cardiac tamponade. We performed emergency pericardiocentesis, with drainage of 360 ml of bloody pericardial fluid. The culture grew Streptococcus anginosus, confirming the diagnosis of acute purulent pericarditis. We performed pericardiostomy because cardiomegaly and pneumopericardium were aggravated after removal of the pericardial drainage catheter. The patient received antibiotics for a total of 23 days intravenously and was discharged with oral antibiotic therapy. Purulent pericarditis is one of the rare forms of pericarditis and is life-threatening. A multimodality approach is required for proper diagnosis and treatment of this disease.

Background Sepsis-induced cardiomyopathy (SIC) occurs frequently in critically ill patients, but the clinical features and prognostic impact of SIC on sepsis outcome remain controversial. Here, we investigated the predictors and outcomes of SIC. Methods Patients admitted to a single medical intensive care unit from June 2016 to September 2017 were retrospectively reviewed. SIC was diagnosed by ejection fraction (EF)

Background: Hyperbilirubinemia and hypoalbuminemia are frequently appeared and associated with poor prognosis in critically ill patients. We aim to evaluate the association between the bilirubin to albumin ratio and prognosis in intensive care unit (ICU) patients. Methods: This was a retrospective study of 731 patients who were admitted to the medical intensive care unit (MICU) at a tertiary-care center from July 2015 to September 2017. We analyzed the bilirubin to albumin ratio on admission to the MICU, including clinical characteristics and other examinations. Results: The overall 28-day survival of MICU patients was 69.1%. On univariate analysis, Acute Physiology and Chronic Health Evaluation (APACHE) II score (P

Previous studies that have examined the impact of the 2008 financial crisis on syndicated loans have ignored potential differences between lending banks by explicitly or implicitly aggregating all lenders together and focusing on borrower characteristics. One must jointly consider both borrower and lender to fully understand the complex role of the syndicate during this period. We consider the identity of the lender, with a focus on five major US banks that failed and their five corresponding acquirers. Our results highlight the distinct roles of investment and commercial banks and facilitate an understanding of relationship and transactional‐based lending.

Background The longevity of polydioxanone (PDO)-barbed lifting threads remains controversial. Objectives The authors sought to assess the longevity extension effect of a crisscross implantation pattern in PDO-barbed thread lifting. Methods To acquire the desired outcome in PDO-barbed thread lifting, the authors suggested a paradigm shift to incorporate biochemical factors in enforcing the physico-mechanical lift. A nude mouse model was employed to evaluate their theory to compare the conventional fan-shaped protocols in barbed thread lifting with an architectural construction of intersections of fibrous capsule in a crisscross pattern. Three fragments of monofilament PDO-barbed–lifting threads were implanted in the dorsal skin of 12 nude mice. The pattern of implantation was fan-shaped in the control group and crisscross in the experimental group. Tissue specimens containing tangential areas of threads were harvested, fixed, and paraffin-embedded. Samples were horizontally cut and histologically analyzed employing hematoxylin and eosin, Massons’ Trichrome, and Sirius red staining. Fibrotic areas and the width of fibrosis from the thread were also analyzed. Results Fibrous capsulations around the barbed area of the PDO-barbed lifting threads were threefold greater than those around the barb-free areas of the threads. In the crisscross implantation pattern, width and density of the fibrotic areas were fivefold greater than those of the fan-shaped areas. Induction of fibrous capsules around the PDO-barbed thread was markedly condensed in the crisscross areas. Conclusions This study provides the basis for a more logical implantation pattern in PDO-barbed lifting threads for facial rejuvenation. By generating controlled multiple crisscross patterns, we can create more intense fibrogenesis, reduce tension applied on each barbed thread, and, therefore, extend the longevity of the result. Level of Evidence: 4

The purpose of this study is to clarify the relationship among guesthouse service quality, trust, satisfaction and loyalty to suggest ways to solve these guesthouse problems. Based on data analysis results, it was revealed that responsiveness is most influential among service quality factors of the guesthouse. through trust, the service quality of guesthouse influences satisfaction and loyalty more strongly. In addition, trust has a significant effect on loyalty through satisfaction. The managerial implications of these findings are as follows: First, a guesthouse service system should be established; and it is also critical to have guesthouse staffs improving communication skill to provide prompt service. Second, the systematic service training for guesthouse staffs is needed through service manuals or other compatible ways. Finally, it is necessary to make practical efforts to build trust with customers and, eventually, to increase satisfaction.

Herein, a Bi2WO6/Bi4V2O11 heterostructured photocatalyst was fabricated through a facile one-pot solvothermal method. In this heterojunction system, highly homogeneous-dispersed Bi4V2O11 nanocrystals were anchored onto Bi2WO6 nanoflakes, endowing the heterojunction with nanosized interfacial contact. Because of the favorable interfacial contact and band alignment, photoinduced charge carrier transfer is facilitated in the Bi2WO6/Bi4V2O11 heterojunction, which can be verified by photocurrent and photoluminescence measurements. In contrast with pristine Bi2WO6 and Bi4V2O11 samples, the Bi2WO6/Bi4V2O11 heterostructured photocatalyst displays drastically improved photocatalytic Cr(VI) reduction activity under visible-light irradiation. More significantly, the as-fabricated heterojunction possesses superior activity for Cr(VI) relative to the counterpart obtained by mechanical mixing, indicating that the interfacial contact plays a determinant role in promoting charge carrier transfer. Moreover, Bi2WO6/Bi4V2O11 heterojunctions exhibited good cycling stability even after 5 cycles. A plausible photocatalytic Cr(VI) reduction reaction mechanism over the Bi2WO6/Bi4V2O11 heterojunction is proposed on the basis of band alignment. This work reports a high-efficiency photocatalyst for Cr(VI) and might shed light on the decisive factor for optimizing the heterostructure.

The recent financial crisis presents an opportunity to examine stock market reactions to syndicated loan decisions reached by borrowers and lenders regarding loan type and loan purpose. We find that during the crisis, the renegotiation flexibility provided by revolving credit is positively valued, whereas during the low†interest†rate period following the crisis, both revolving and term loans are viewed favorably. We also examine information asymmetry effects and find that after the crisis, low†creditworthy borrowers generate a positive market response, but during the crisis, high†creditworthy borrowers are viewed positively and low†creditworthy borrowers are punished by the market.

Since the time of its inception within facial anatomy, wide variability in the terminology as well as the location and extent of retaining ligaments has resulted in confusion over nomenclature. Confusion over nomenclature also arises with regard to the subcutaneous ligamentous attachments, and in the anatomic location and extent described, particularly for zygomatic and masseteric ligaments. Certain historical terms—McGregor’s patch, the platysma auricular ligament, parotid cutaneous ligament, platysma auricular fascia, temporoparotid fasica (Lore’s fascia), anterior platysma-cutaneous ligament, and platysma cutaneous ligament—delineate retaining ligaments of related anatomic structures that have been conceptualized in various ways. Confusion around the masseteric cutaneous ligaments arises from inconsistencies in their reported locations in the literature because the size and location of the parotid gland varies so much, and this affects the relationship between the parotid gland and the fascia of the masseter muscle. For the zygomatic ligaments, there is disagreement over how far they extend, with descriptions varying over whether they extend medially beyond the zygomaticus minor muscle. Even the ‘main’ zygomatic ligament’s denotation may vary depending on which subcutaneous plane is used as a reference for naming it. Recent popularity in procedures using threads or injectables has required not only an accurate understanding of the nomenclature of retaining ligaments, but also of their location and extent. The authors have here summarized each retaining ligament with a survey of the different nomenclature that has been introduced by different authors within the most commonly cited published papers.

Femoral fractures can be common in nonambulatory patients with myopathies because they present with notable osteoporosis. From the orthopaedic perspective, this can be complicated by a pre-existing knee flexion contracture and small femoral shaft size. The goals of treatment are to reduce external immobilization, maximize comfort for transfers, prevent functional loss, and preclude refracture. The purpose of our work is to describe the anesthetic and orthopaedic considerations in treating a bed-bound adult patient with nemaline dystrophy and a midshaft femur fracture. The authors have obtained the patient's informed written consent for print and electronic publication of the case report.

We evaluate and compare market reaction to syndicated loan announcements for two sets of high-profile banks, consisting of five banks that failed in 2008 during the financial crisis and the five banks that ultimately acquired them. Results show that loan announcements are viewed differently for the two sets of banks when partitioned on loan type, loan purpose and information asymmetry. In addition to event study analysis we analyze differences in loan attributes and borrower risk characteristics for the two groups. Additional evidence on the impact of the financial crisis is shown by comparing loan announcements for the acquiring banks during pre- versus post-crisis periods. Our findings highlight the importance of the role of the syndicate in supporting the borrowers of failed banks and the timeliness with which the government encouraged the mergers or sale.

This exploratory study investigates the adoption and use of information and communication technologies in Myanmar by examining the nature and structure of the information technology profession. The investigation is based on a theoretical framework consisting of three components: domains of information technology professional expertise; the scope of the information technology professional’s knowledge, skills and experience; and specific knowledge and skills associated with the domains of professional expertise. The findings show that specialist skills in systems development, database, network and communications are important. This paper also provides insights that are not found in current literature which investigates information technology skills in Myanmar.

International audience; Introduced more than 20 years ago, laparoscopic pancreatic surgery (LAPS) has not reached a uniform acceptance among HPB surgeons. As a result, there is no consensus regarding its use in patients with pancreatic neoplasms. This study, organized by the European Association for Endoscopic Surgery (EAES), aimed to develop consensus statements and clinical recommendations on the application of LAPS in these patients.METHODS:An international panel of experts was selected based on their clinical and scientific expertise in laparoscopic and open pancreatic surgery. Each panelist performed a critical appraisal of the literature and prepared evidence-based statements assessed by other panelists during Delphi process. The statements were further discussed during a one-day face-to-face meeting followed by the second round of Delphi. Modified statements were presented at the plenary session of the 24th International Congress of the EAES in Amsterdam and in a web-based survey.RESULTS:LAPS included laparoscopic distal pancreatectomy (LDP), pancreatoduodenectomy (LPD), enucleation, central pancreatectomy, and ultrasound. In general, LAPS was found to be safe, especially in experienced hands, and also advantageous over an open approach in terms of intraoperative blood loss, postoperative recovery, and quality of life. Eighty-five percent or higher proportion of responders agreed with the majority (69.5%) of statements. However, the evidence is predominantly based on retrospective case-control studies and systematic reviews of these studies, clearly affected by selection bias. Furthermore, no randomized controlled trials (RCTs) have been published to date, although four RCTs are currently underway in Europe.CONCLUSIONS:LAPS is currently in its development and exploration stages, as defined by the international IDEAL framework for surgical innovation. LDP is feasible and safe, performed in many centers, while LPD is limited to few centers. RCTs and registry studies are essential to proceed with the assessment of LAPS.

Background Electrical burns are one of the most devastating types of injuries, and can be characterized by the conduction of electric current through the deeper soft tissue such as vessels, nerves, muscles, and bones. For that reason, the extent of an electric burn is very frequently underestimated on initial impression. Methods From July 1999 to June 2006, we performed 15 cases of toe tissue transfer for the reconstruction of finger defects caused by electrical burns. We performed preoperative range of motion exercise, early excision, and coverage of the digital defect with toe tissue transfer. Results We obtained satisfactory results in both functional and aesthetic aspects in all 15 cases without specific complications. Static two-point discrimination results in the transferred toe cases ranged from 8 to 11 mm, with an average of 9.5 mm. The mean range of motion of the transferred toe was 20° to 36° in the distal interphalangeal joint, 16° to 45° in the proximal interphalangeal joint, and 15° to 35° in the metacarpophalangeal joint. All of the patients were relatively satisfied with the function and appearance of their new digits. Conclusions The strategic management of electrical injury to the hands can be both challenging and complex. Because the optimal surgical method is free tissue transfer, maintenance of vascular integrity among various physiological changes works as a determining factor for the postoperative outcome following the reconstruction.

Without intending to do so, China has in recent years played a major role in East Asia’s economic integration. It has done so mainly through the production and supply chain networks it has spun across the region. This paper argues that given the developmental trends in the Chinese economy, the Chinese government should pursue a more active strategy towards a broader and more balanced economic integration with the region. The emergence of a multi-track production structure, increased importance of domestic consumption and the services sector, together with faster integration of the domestic economy, will fundamentally change China’s trade and investment relationships with the rest of East Asia and necessitate a review of China’s economic integration strategy. The paper also argues that ASEAN can play a useful role in facilitating the region-wide integration process.

Superficial acral fibromyxoma (SAF) was first reported by Fetsch et al. [1] in 2001; they described the distinctive soft tissue tumor, which had common clinical, histopathologic, and immunohistochemical features, in 37 patients [1-5]. To date, however, few cases of SAF have been described in the literature. A 54-year-old man presented with a 1-year history of a slowly growing lesion on the volar surface of the left second toe and complained of tenderness when walking. On physical examination, the patient had a skin-colored quadrangular mass, measured as approximately 4 cm×4 cm×2 cm in size (Fig. 1A). It was a nodular lesion with a well-defined margin, but had no erosion, eschar, or bleeding. In addition, it did not invade the periungual or subungual region. Furthermore, it had a soft surface with soft tissue adhesion. There were no notable findings on radiography nor a family history. However, the patient did have a several-year history of tinea pedis. The patient scratched the itching area, resulting in alternating wound healing and scarring. The patient was tentatively diagnosed with hypertrophic scar or keloid, for which we performed a complete resection of the mass (Fig. 1B). On histopathology, the mass was located underneath the hyperkeratinized epidermis, and it extended into the dermal and subcutaneous layer. Its cross-section showed a yellowish-white, jelly-like substance. Its histopathologic findings included a fascicular or storiform arrangement of spindle-shaped or stellate-shaped tumor cells in the myxocollagenous matrix (Fig. 2A). These findings were suggestive of proliferative fibroblasts. Accentuated microvasculature was present in the matrix, accompanied by the overall presence of mast cells throughout the lesion. However, there was no marked presence of other inflammatory cells. Moreover, there was no dysplasia or hyperplasia of the tumor cells. On immunohistochemistry, the tumor cells were positive for CD34 and negative for desmin, S100, and epithelial membrane antigen (EMA) (Fig. 2B). The patient was eventually diagnosed with SAF. At a 12-month follow-up, there were no notable complications or recurrence (Fig. 3). Fig. 1 Preoperative and intraoperative clinical photos. (A) Preoperative clinical photo showing a 4 cm×4 cm×2 cm solitary skin-colored mass on the volar side of the left second toe. (B) Resected specimen. Fig. 2 Findings of histopathologic and immunohistochemical stains. (A) Collection of spindle-shaped fibroblasts in a myxocollagenous matrix that blend into primarily myxoid areas of fibrous stroma (H&E, ×200). (B) Immunohistochemical stains (×200) ... Fig. 3 Postoperative view. Good cosmetic results were achieved without recurrence (12 months later). SAF is a solitary, nodular, slowly-growing, asymptomatic soft-tissue tumor with a well-defined margin. It is a rare tumor entity that mainly affects the soft tissue of the extremities and commonly occurs as a small nodule in the periungual or subungual regions of the fingers or toes. It has a predilection for middle-aged adults, showing a male predilection with a male-to-female ratio of 2:1. In addition, the mean age of onset is estimated at 43 years. It can take 3 months to 30 years until a diagnosis of SAF is confirmed. SAF is known to invade the nail, but causes no bone destruction on radiography. Grossly, the tumor has a semispherical polypoid or a verrucous shape. It also contains a grayish-white or yellowish-white jelly-like substance on cross-sections [1-5]. Histopathologically, SAF is a non-encapsulated, well-circumscribed tumor. It commonly occurs in the dermis and sometimes extends into the subcutaneous layer. In the myxoid or myxocollagenous matrix, spindle-shaped or stellate-shaped fibroblast-like cells undergo a proliferation of moderate degree. There is an irregular, loose, fascicular or storiform arrangement of the tumor cells accompanied by the overall presence of mast cells. It has no other inflammatory cells [1-5]. The myxoid matrix of the lesion is highlighted by alcian blue (pH 2.5) stain. On immunohistochemistry, it is positive for CD34, CD99, and vimentin but negative for S-100 protein, α-smooth muscle actin, glial fibrillary acidic protein, keratin, and human melanoma black-45. There is variability in the immunoreactivity for CD10 and EMA [1-5]. Differential diagnoses of SAF include tumors with myxoid lesions (myxoid fibrous histiocytoma, superficial angiomyxoma, myxoid dermatofibrosarcoma protuberans, low-grade myxofibrosarcoma, and myxoid neurofibroma) and those mainly affecting the fingers and nails (sclerosing perineurioma, acquired digital fibrokeratoma, and periungual fibroma) [1-5]. Immunohistochemistry plays a particularly important role in the differential diagnosis of myxoid lesions with similar histopathologic features. Myxoid fibrous histiocytoma is negative for CD34 and positive for factor XIIIa. Superficial angiomyxoma is positive for CD34 and is negative for S100, which is similar to the immunohistochemical findings of SAF, but it is negative for both SMA and muscle specific actin. Myxoid dermatofibrosarcoma protuberans is positive for CD34 and vimentin, and is negative for EMA, desmin, and XIIIa. Low-grade myxofibrosarcoma is positive for vimentin, but it is negative for CD34 and desmin. Myxoid neurofibroma is a tumor of neural origin, showing positive immunohistochemistry for S100, which is of help in making a differential diagnosis of SAF [1-5]. It is known that SAF has a benign natural course, for which the standard treatment modality is complete surgical removal. Incomplete surgical removal might cause a recurrence. Patients with SAF should be under regular follow-up. Prescott et al. reported that SAF had nuclear pleomorphism or mitotic activity showing malignant potential, but its malignant transformation or metastasis has not been described [1-5].

Basal cell carcinoma (BCC) is one of the most common skin malignancies. Its well-known etiologic factors include ultraviolet (UV) exposure, ionizing radiation, arsenal exposure, and genetic predisposition. Moreover, its etiological association with trauma or scar tissue has also been documented [1-3]. A 39-year-old woman visited us with the chief complaint of a hypertrophic scar occurring in the right supratip region (Fig. 1A). The patient had no past history of having abnormal symptoms or diseases in the right supratip region, but presented with a 10-month history of acne-like pustules. The patient also stated that the inflammation waxed and waned as the scars were frequently irritated during wound healing. Thereafter, residual scars gradually protruded and were suggestive of hypertrophic scarring, for which the patient visited us to undergo a scar revision. On physical examination, the patient had a round, protruding, solid, hard nodular lesion, measuring approximately 0.7 cm×0.7 cm in size. Grossly, the nodule showed a well-defined margin and a smooth surface, which was accompanied by depigmentation as well as mild capillary dilatation. There were no such findings as erosion, eschar, or bleeding. The patient also had no subjective symptoms such as pruritus or pain. Clinically, the patient was tentatively diagnosed with hypertrophic scarring occurring after recurrent episodes of trauma. First, considering that the patient was a young unmarried woman, we wished to minimize the postoperative nasal deformity and scar formation. We therefore decided to induce epithelialization following the tangential resection of the nodule. Following a resection of the nodule, however, we could not completely rule out the possibility of a tumor because it is well established that skin tumors commonly occur on the nose. We therefore performed a histopathologic examination, and the patient was diagnosed with nodular BCC (Fig. 2). The patient then underwent a complete resection of the tumor at a subcutaneous depth involving a 2-mm safe margin. The site of the defect was reconstructed using a bilobed flap (Fig. 1B). Currently, at 18 months postoperatively, the patient has been undergoing regular follow-up. The patient had no recurrence, and cosmetic outcomes were satisfactory (Fig. 1C). Fig. 1 Clinical photos. (A) Preoperative view. A well-defined, 0.7 cm×0.7 cm round, skin-colored nodule on the nasal dorsum. (B) Intraoperative view. Surgical design using a bilobed flap. (C) Postoperative view. Good cosmetic results 12 months after ... Fig. 2 Histologic findings. (A) Histologic image showing a tumor mass composed of nests of basaloid cells (H&E, ×4). (B) Tumor nests showing peripheral palisading nuclei and peritumoral fibrosis (H&E, ×200). BCC occurs frequently in the head-and-neck regions including the face; common sites of occurrence include the nose and eyelid. In addition, most cases occur in adults aged 40 years or older, and they also show a predilection toward body areas that are vulnerable to long-term sunlight exposure. Presumably, this might be because the long-term, excessive exposure to physicochemical irritants might induce the occurrence of skin malignancies [2]. In 1828, Jean-Nicholas Marjolin et al. first described the possible role of trauma in the pathogenesis of skin malignancies. Since then, several authors have reported the malignant transformation of a wound or scar tissue. "Marjorlin's ulcer" was originally coined to describe the cancer originating from a burn injury scar. However, its usage has since been extended to describe all malignancies arising from scar tissue [3]. In 1986, Noodleman and Pollack [3] reported that there was a relationship with trauma in 7.3% of 1,774 cases of BCC. More recently, Ozyazgan and Kontas [1] reported that trauma and scar tissue play a role in the pathogenesis of BCC. In Korea, two cases of BCC have been reported to have arisen from trauma [4]. To date, however, few reports have addressed this subject compared with about the number of reports on squamous cell carcinoma arising from scar tissue. The length of time that elapses from the onset of trauma until a tumor occurs can vary, ranging from several weeks to several decades. Many types of trauma have been documented as causes of BCC, such as burn injury scars, vaccination sites, chicken pox scars, tattoo sites, sharp or blunt physical injury, skin exposed to polycyclic aromatic hydrocarbons, lupus vulgaris, chronic stasis ulcers, sites of cold injury, site of hair transplantation, lesions of epidermolysis bullosa, colostomy sites, dog bites, electrical burns, and gunshot wounds [1-5]. Little is known about the pathophysiology of the malignant transformation of scar tissue [1,3]. However, reports suggesting various types of involvement of trauma in the pathophysiology of BCC have included the following: 1) The BCC incidentally occurs with no etiological association with the trauma. BCC is a very common disease entity. Therefore, based on the recognition of major skin trauma or wounds, patients spontaneously consider the BCC to have occurred in association with the trauma. However, there is no actual correlation between the two phenomena [3]. 2) The skin becomes more vulnerable to UV exposure because of the atrophy and decreased perfusion in the trauma-induced scar tissue. Thus, the nutritional supply is compromised, which eventually leads to a lack of ability to repair DNA damage [3]. 3) With chronic irritation to the damaged skin tissue, malignant transformation occurs. The damaged skin tissue releases toxins that may cause cellular mutation. Chronic wounds exposed over the long-term to these toxins become more vulnerable to malignant transformation [5]. 4) In cases of tumors arising from dense scar tissue, immunological privilege prevents lymphocyte infiltration. This interferes with the immune surveillance system. Thus, the tumor can protect itself from human defense mechanisms until its growth reaches a significant level [3]. 5) In the presence of trauma, the epidermal cells are implanted into the dermis. This triggers the occurrence of foreign body reactions in the dermis, alters the normal wound healing activity of the tissue, and renders the tissue more vulnerable to damage [5]. In cases of BCC arising from trauma or scar tissue, the degree of malignancy is not relatively higher than that due to other causes [1,3]. Therefore, standard treatment modalities are performed for the management of BCC. Our case highlights that BCC may also occur even after the trauma. Therefore, clinicians must rule out the possibility of malignant transformation when they examine patients with traumatic scars located on body surfaces that are vulnerable to sunlight exposure.

Announcements of syndication loans increase borrowers' shareholder wealth if they are revolving credit agreements but not if they are term loans. Share price responses to revolving credit announcements are positive and significant, whereas the wealth effect for term loans is negative and significant. The results show that announcements from both the financial press and commercial information providers can affect borrower share price reaction. Overall, single syndication announcements appear to be more newsworthy than multiple announcements reported in the financial press, and we find evidence of information leakage, post-announcement drift, or both.

A keloid is one of the most frustrating clinical problems in wound healing. Keloids form following dermal injury and exhibit exuberant and indefinite growth of collagen. Many theories have been propounded in trying to explain some of the vagaries of keloids. From one of the theories, keloid scars may develop at any age; patients between 10 and 30 years of age (reproductive age) are the most affected population, and there may be a hormonal influence because keloid scars tend to grow during puberty and pregnancy, and resolve during menopause [1]. In our experience, pregnancy-related recurrent keloids have arisen from the ear, despite the patient's successful completion of our treatment. The case presented here illustrates the possible connection between keloid formation and hormonal changes during pregnancy. A 27-year-old pregnant female visited our clinic due to progressive growth of her left auricular keloid. Three years prior to the visit, she had developed a scar on her left auricle after treatment for acute inflammation caused by an ear piercing procedure at a non-medical institute. She showed no other particular medical history. She also reported that the lesions appeared and became larger after the first trimester of pregnancy (Fig. 1). On physical examination, the left auricle showed a keloid of nearly circular appearance, approximately 2.2 cm in diameter, with a mean thickness of about 1.5 cm, extending from the superior pole of the auricle down to the middle ear. The skin surface of the keloid was irregular and showed dispersed minute superficial ulcer with itching sensation. Fig. 1 Preoperative photo showing a keloid after the first pregnancy. Because of pregnancy, we waited to perform a core extirpation of the keloid until 6 months after delivery. Compression on the auricle was performed postoperatively in combination with the application of scar care ointment. Even after 1 month, the clinical result remained obviously acceptable where the core extirpation had been performed. Two years later, the patient returned with a huge enlargement of the left auricular keloid. Similar to the previous keloid, it appeared and became bigger (2.2×1.7 cm) simultaneously with child bearing. She remembered that the keloid started to enlarge rapidly in her first trimester of her second pregnancy, with mild itching and redness. She was asked to return after her delivery (Fig. 2). Fig. 2 Preoperative photo showing a keloid after the second pregnancy. Accordingly, she underwent core extirpation 6 months after her second delivery, and compression treatment was performed postoperatively in combination with the application of scar care ointment. The patient was satisfied with the results at postoperative 4 months. The scar tissues, sized at 2.0×1.5 cm and 2.0×1.0 cm, were excised over repeated core extirpations. In both histopathologic reports, no flattening of the overlying epidermis, presence of keloidal collagen, or a prominent fascia-like fibrous band occurred, which confirms the diagnosis of keloid (Fig. 3). Fig. 3 (A) First pregnancy. Histopathologic photograph showing thepresence of keloidal collagen and a prominent fascia-like fibrous band, which confirms the diagnosis of keloid (H&E, ×100). (B) Second pregnancy. Histopathologic photograph showing ... Up to the present, the clinical outcome has shown a clean and satisfactory auricle. The patient has not undergone another pregnancy nor presented any additional keloid growth; specifically, she has reported that her lobular keloid remains inactive. In most known series of keloids, there is a higher incidence in women, with an apparent peak in the immediate post-pubertal years. Lane et al. [2] reported in his study that those who had ear piercings at 11 years of age or above were more likely to develop keloids (80%) than were those who had ear piercings under 11 years of age (23.5%). Because of this observation, the possibility of a female hormonal influence on keloid formation has been advanced. In a study of connective tissue tumors, Geschichter and Lewis [3], bioassayed a single keloid of an ear that had been preserved in formalin; they reported that this keloid tissue contained large amounts of estrogen and gonadotropic substances. However, no confirmation of their work has appeared in the literature. Jacobsson [4] reported a case of a woman whose 4-year-old scar became hypertrophic during pregnancy. Reviewing the different actions of pregnancy hormones, it appears that estrogens are the hormones most likely involved in the keloidal tendency that may accompany pregnancy [5]. The ovaries and adrenal cortex of mature women produce estrogens. In pregnancy, the major site of production is the placenta. Our patient noted rapid enlargement and irritation of her keloid, which began in the first trimester of pregnancy. This supports our view on the effect of hormonal influence in scar or keloidal tissue during pregnancy, and agrees with the concept that regression of symptoms occurs after delivery. It is known that auricular and lobular keloids appear on account of inflammation caused by an unhygienic ear piercing procedure. However, we report our treatment experience in a case with recurrent keloids during pregnancy after showing no particular change at the time of treating the inflammation. We conclude that pregnancy is the strongest risk factor for keloid recurrence in addition to the three clinical risk factors identified through a review of the literature: treatment history, timing of keloid growth, and timing of regression.

Brachymetatarsia is a rare clinical entity that presents a challenging problem for surgeons. One-stage lengthening with an autologous bone graft has been preferred for metatarsals that require a limited lengthening. With a gradual lengthening of metatarsals, callus distraction (callotasis) can achieve a greater length gain and a concomitant lengthening of the soft tissue. This article presents results of callotasis for adults with first brachymetatarsia.The outcomes of nine cases of first brachymetatarsia in five adult patients who underwent metatarsal lengthening by callotasis between March 1999 and February 2005 were retrospectively reviewed and analyzed.The average length gain was 16.4 mm and the average lengthening percentage was 43.7%. In addition, the average healing index was calculated as 3.8 months/cm, which was higher than that reported previously in the fourth brachymetatarsia.It was concluded that the period of bony consolidation following callotasis is longer in the first brachymetatarsia than in the fourth brachymetatarsia. Presumably, this might be because of the anatomically larger osteotomized cut surface and its weight-bearing function.

症例は69歳の男性で慢性腎不全のため1986年, CAPDに導入した. 腹膜透析液はBaxter社製ダイアニールを1日4回の交換としていたが, 血清Mg濃度が高値となったためMg濃度が低いダイアニールPD2に変更した. 特記すべき合併症もなく良好に経過したが, 1988年6月に初めて大動脈弁無冠尖の石灰化を指摘された. 定期的心エコー検査で経過観察していたが, 弁石灰化は急速に進行し, 1991年7月の心エコーでは左冠尖・無冠尖の石灰化が著しく, 弁口面積は0.68cm2と狭小化し重症大動脈弁狭窄症 (AS) と診断された. 待機手術を予定していたが突然死した. 剖検で大動脈弁の3尖全体にわたる石灰化を認め, aortic calclfic stenosis (ACS) と診断された. 経過中PTH値, Ca×P積, 血清脂質濃度, 血清Mg値と石灰化の進行時期は一致しなかった. しかし腹膜透析液を乳酸濃度の高いPD2に変更後, 血漿重炭酸濃度は23-27mEq/lと高値が持続した. アルカローシスが組織への石灰沈着を促進するという報告があり, 大動脈弁石灰化が急速に進行した原因となっている可能性が示唆された.