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Background Two hypothetical mechanisms have been proposed for fat embolism syndrome: mechanical obstruction and biochemical reactions. However, it has not been proven whether these mechanisms are correlated. This study aimed to demonstrate the relationship between these two hypothetical mechanisms by observing biochemical and histological changes in animals. Methods After a preliminary study, 700 mg/kg of triolein was injected via the ear vein into 25 rabbits and hemodynamic changes in triglycerides, lipases, free fatty acids, and albumin over time were observed. Necropsies were immediately conducted on all experimental animals, and the lungs were examined histologically. Results Eight rabbits died within 1 hour after the injection due to mechanical obstruction. Six rabbits died 7–60 hours after the injection due to diffuse hemorrhage of the lung induced by the toxic biochemical reactions of free fatty acids. Histological examinations of the lungs of the surviving rabbits showed petechiae on the surfaces and evidence of recovery from hemorrhage. Blood levels of free fatty acids increased immediately after the injection of triolein. Conclusions This study revealed that fat emboli primarily injure the lung via mechanical obstruction. The fat is hydrolyzed into fatty acids and causes secondary damage via biochemical reactions. The present study sheds light on the pathophysiology of fat embolism syndrome, with possible implications for its management and prevention.

Background The placement of a closed suction drain is indispensable for preventing serious infections; however, closed suction drains are inevitably accompanied by increases in local infections, pain, and length of hospital stay, and delays in breast cancer treatment including postoperative chemotherapy and radiotherapy. We analyzed predictive factors of total drainage volume and duration. Methods Among patients who were diagnosed with primary breast cancer between January 2016 and December 2017, we retrospectively analyzed those who underwent immediate implant-based breast reconstruction. Factors that could affect the total volume and duration of drainage, including lipo-prostaglandin E1 use, preoperative chemotherapy, resected breast issue weight, age, body mass index (BMI), serum white blood cell count, erythrocyte sedimentation rate, and C-reactive protein (CRP) level, were analyzed. Results The mean volume and duration of drainage were 1,213.6 mL and 14.8 days respectively. BMI and CRP on postoperative day (POD) 1 were correlated with the total drainage volume. Age, BMI, and resected breast tissue weight were correlated with the drainage duration. Multiple regression analysis showed that CRP level on POD 1, age, and resected breast tissue weight significantly affected the drainage duration. Multiple regression analysis also showed that the total drainage volume was significantly affected by BMI and CRP level on POD 1. Conclusions The factors found to affect the duration of drainage in patients undergoing implant-based breast reconstruction were CRP on POD 1, age, resected breast tissue weight, and BMI. The CRP level on POD 1 and BMI influenced the total volume of drainage.

Background Several oncoplastic approaches have been implemented in recent years to enhance cosmetic results and to reduce complications. The round block technique is a volume displacement technique for breast reconstruction after breast-conserving surgery (BCS). However, its indications are currently limited according to tumor location, and its cosmetic results and complications have not been clearly established. We hypothesized that the round block technique could produce favorable cosmetic results without major complications regardless of tumor location or nipple-tumor distance, below a certain resected tumor volume and tumor-breast volume ratio. Methods All breast reconstructions using the round block technique after BCS were included in this analysis. Patients’ data were reviewed retrospectively to investigate complications during follow-up, and clinical photos were used to evaluate cosmetic results. The relationships of tumor location, nipple-tumor distance, tumor volume, and the tumor-breast volume ratio with cosmetic results were investigated. Results In total, 108 breasts were reconstructed. The mean resected tumor volume was 30.2±15.0 mL. The cosmetic score was 4.5±0.6 out of 5. Tumor location, nipple-tumor distance, tumor volume, tumor-breast volume ratio, radiotherapy, and chemotherapy had no significant effects on cosmetic results or complications. There were no major complications requiring reoperation. Conclusions Breast reconstruction using the round block technique after BCS can lead to good cosmetic results without major complications regardless of the tumor location, nipple-tumor distance, radiotherapy, or chemotherapy. Below the maximum tumor volume (79.2 mL) and the maximum tumor-breast volume ratio (14%), favorable results were consistently obtained.

After a partial mastectomy, large or ptotic breasts can be reconstructed using breast reduction techniques. Wise-pattern reduction is typically used to remove masses in any quadrant of the breast, but this technique leaves a large inverted T-shaped scar. Instead, the short scar periareolar inferior pedicle reduction (SPAIR) technique involves a periareolar line and does not result in a scar along the inframammary fold (IMF). A 49-year-old patient with macromastia and severely ptotic breasts was diagnosed with invasive cancer of the left breast. Her large breasts caused pain in her back, shoulders, and neck. She also expressed concern about postsurgical scarring along the IMF. In light of this concern, we chose the SPAIR technique, and we designed and performed the procedure as described by Hammond. During surgery, we removed 36 g of breast tumor and 380 g of breast parenchyma from the left breast. To establish symmetry, we also removed 410 g of tissue from the right breast. Postoperatively, the patient reported satisfaction regarding the reduction mammaplasty and, in particular, noted decreased back, shoulder, and neck pain. In summary, we used the SPAIR technique to achieve oncologic and aesthetic success in a patient with macromastia and a tumor located lateral to the nipple-areolar complex.

Background Direct-to-implant breast reconstruction following nipple-sparing mastectomy is becoming increasingly common. The weight of the breast specimen informs implant selection. However, specimens of the same weight may have different volume. Therefore, identifying the factors affecting the density of breast specimens may facilitate the selection of implants with an appropriate volume. Methods From December 2015 to May 2018, 108 patients underwent direct-to-implant reconstruction following nipple-sparing mastectomy. The weight of the breast specimens was measured using an electronic scale in the operating room. Furthermore, the volume of specimens was measured using the water displacement technique. Multiple regression analysis was performed on factors that can affect breast density, such as menopause, neoadjuvant chemotherapy (CTx), age, body mass index, and diabetes mellitus. Results The average density of breast specimens in patients older than 50 years (n=36) was 0.96±0.04 g/mL, which was significantly lower than the 1.01±0.08 g/mL observed in patients younger than 50 years (n=72) (P=0.007). The mean density of breast specimens in patients who underwent neoadjuvant CTx (n=25) was 0.96±0.06 g/mL, which was significantly lower than the value of 1.00±0.08 g/mL in those who did not (n=83). Conclusions It is advisable to select an implant slightly larger than the mastectomy specimen weight in patients older than 50 years or in those who have undergone neoadjuvant CTx.

Summary:. Costochondritis after breast reconstruction and radiation therapy is rarely reported. Moreover, it is difficult to diagnose using computed tomography and magnetic resonance imaging; as such, wound debridement and reconstruction must be performed in several stages. A 51-year-old woman was diagnosed with invasive cancer of the right breast, and she underwent nipple sparing mastectomy and direct-to-implant breast reconstruction in November 2007. Thirteen years later, in September 2020, she experienced pain and swelling on her right breast. Incisional drainage and implant removal were performed in another clinic; however, the infection was not controlled. An implant-induced infection was suspected, and debridement was performed to a level where fresh tissue appeared in the upper layer of the intercostal muscle. Antibiotics and open dressing were used for 10 days; however, yellowish debris was noted, and third to fifth ribs and costal cartilages turned dark brown. Radiation-induced costochondritis was diagnosed based on clinical findings from the intraoperative field, wound course, and cartilage biopsy. Radical chest wall resection and reconstruction was performed using Teflon (Dupont/Chemours, Wilmington, Del.) and latissimus dorsi musculocutaneous flap. The patient was discharged 2 weeks after surgery without any complications. Costochondritis should be clinically diagnosed while performing the first debridement in staged operation. Radical chest wall resection is essential with chest wall reconstruction using Teflon and a latissimus dorsi musculocutaneous flap.

Background:. Upper blepharoplasty in elderly patients has characteristics that differ from those of younger patients. Blepharoptosis in elderly patients causes not only aesthetic problems but also functional problems such as entropion, visual disturbance, and sore eyes. We hypothesized that factors influencing patient satisfaction with upper blepharoplasty in elderly patients include aesthetic outcomes, functional outcomes, and personal factors. Methods:. This study included 57 patients aged >65 years who underwent upper blepharoplasty between April 2018 and March 2019. All surgeries were performed through the “Upper Blepharoplasty Service Project” of the public health center in Geoje City. To evaluate the individual characteristics of the patients, a preoperative questionnaire (including sociodemographic characteristics, main symptoms of discomfort in the upper eyelid, and degree of expectation of surgical results) was administered to the patients. After 6 months, a satisfaction survey was conducted accordingly. Results:. The main symptoms of discomfort were sagging of the skin of the upper eyelid. The mean score for patient satisfaction was 3.84 ± 0.40, and satisfaction with the results of surgery relative to the cost was 4.53 ± 0.63, which was the highest score. Significant verification of the regression coefficients showed that functional improvement and cognitive degree of postsurgery precautions had a significant effect on patient satisfaction, whereas aesthetic outcomes and expectations of surgical results were not correlated with patient satisfaction. Conclusion:. The findings indicated that elderly patients tended to be satisfied with functional improvement that resolved their symptoms of discomfort and personal factors such as cost and cognitive degree of precautions after upper blepharoplasty.

BackgroundThe intraoperative parathyroid hormone (IOPTH) assay is widely used in patients with primary hyperparathyroidism (PHPT). We investigated the usefulness of the IOPTH assay in Korean patients with PHPT.MethodsWe retrospectively reviewed the data of 33 patients with PHPT who underwent parathyroidectomy. Neck ultrasonography (US) and 99mTc-sestamibi scintigraphy (MIBI scan) were performed preoperatively and IOPTH assays were conducted.ResultsThe sensitivity of neck US and MIBI scans were 91% and 94%, respectively. A 50% decrease in parathyroid hormone (PTH) levels 10 minutes after excision of the parathyroid gland was obtained in 91% (30/33) of patients and operative success was achieved in 97% (32/33) of patients. The IOPTH assay was 91% true-positive, 3% true-negative, 0% false-positive, and 6% false-negative. The overall accuracy of the IOPTH assay was 94%. In five cases with discordant neck US and MIBI scan results, a sufficient decrease in IOPTH levels helped the surgeon confirm the complete excision of the parathyroid gland with no additional neck exploration.ConclusionThe IOPTH assay is an accurate tool for localizing hyperfunctioning parathyroid glands and is helpful for evaluating cases with discordant neck US and MIBI scan results.

Ectopic adrenocorticotropic hormone (ACTH) syndrome is caused most frequently by a bronchial carcinoid tumor or by small cell lung cancer. Medullary thyroid carcinoma (MTC) is a rare etiology of ectopic ACTH syndrome. We describe a case of Cushing syndrome due to ectopic ACTH production from MTC in a 48-year-old male. He was diagnosed with MTC 14 years ago and underwent total thyroidectomy, cervical lymph node dissection and a series of metastasectomies. MTC was confirmed by the pathological examination of the thyroid and metastatic mediastinal lymph node tissues. Two years after his last surgery, he developed Cushingoid features, such as moon face and central obesity, accompanied by uncontrolled hypertension and new-onset diabetes. The laboratory results were compatible with ectopic ACTH syndrome. A bilateral adrenalectomy improved the clinical and laboratory findings that were associated with Cushing syndrome. This is the first confirmed case of ectopic ACTH syndrome caused by MTC in Korea.

BackgroundAdvanced information technology can be used when developing diagnostic and treatment strategies to provide better care for diabetic patients. However, the levels of need and demand for the use of technological advances have not been investigated in diabetic patients. We proposed and developed an individualized, ubiquitous (U)-healthcare service using advanced information technology for more effective glucose control. Prior to our service initiation, we surveyed patient needs and other pertinent information.MethodsDuring August 2009, we conducted a 34-item questionnaire survey among patients with diabetes who were older than 40 years in two certain hospitals in Korea.ResultsThe mean age of the 228 participants was 61.2±9 years, and males made up 49.1% of the sample. Seventy-one percent replied that they wanted individualized healthcare service, and they also wanted their health information to be delivered through mobile devices such as a cellular phone or a personal digital assistant (40.4%). Most patients had never heard of U-healthcare services (81.1%); however, after explaining the concept, 71.1% of participants responded that they would use the service if it was provided. Despite their willingness, participants were concerned about technical difficulty in using the service (26.3%) as well as the cost of the service (29.8%).ConclusionThe current study suggests that more than 70% of diabetic patients are interested in using U-healthcare services. To encourage widespread use, the application program or device of U-healthcare services should be simple, easy to use and affordable while also including a policy for the protection of private information.

ABSTRACT Scrub typhus is a mite-borne disease caused by the obligately intracellular bacterium Orientia tsutsugamushi. We previously demonstrated that ScaA, an autotransporter membrane protein of O. tsutsugamushi, is commonly shared in various genotypes and involved in adherence to host cells. Here, we identified a mixed-lineage leukemia 5 (MLL5) mammalian trithorax group protein as a host receptor that interacts with ScaA. MLL5, identified by yeast two-hybrid screening, is an alternative splicing variant of MLL5 (vMLL5) which contains 13 exons with additional intron sequences encoding a tentative transmembrane domain. Indeed, vMLL5 is expressed on the plasma membrane as well as in intracellular compartments in eukaryotic cells and colocalized with adherent O. tsutsugamushi. In addition, ScaA-expressing Escherichia coli showed significantly increased adherence to vMLL5-overexpressing cells compared with vector control cells. We mapped the C-terminal region of the passenger domain of ScaA as a ligand for vMLL5 and determined that the Su(var)3-9, Enhancer of zeste, Trithorax (SET) domain of MLL5 is an essential and sufficient motif for ScaA binding. We observed significant and specific inhibition of bacterial adhesion to host cells in competitive inhibition assays using the C-terminal fragment of ScaA or the SET domain of vMLL5. Moreover, immunization with the C-terminal fragment of ScaA provided neutralizing activity and protective immunity against lethal challenge with O. tsutsugamushi as efficiently as vaccination with the whole passenger domain of ScaA. These results indicate that vMLL5 is a novel cellular receptor for ScaA-mediated adhesion of O. tsutsugamushi and facilitates bacterial adhesion to host cells, thereby enhancing bacterial infection. IMPORTANCE O. tsutsugamushi is a mite-borne pathogen that causes scrub typhus. As an obligately intracellular pathogen, its adhesion to and invasion of host cells are critical steps for bacterial growth. However, the molecular basis of the bacterial ligand and host receptor interaction is poorly defined. Here, we identified a splicing variant of MLL5 (vMLL5) as a cellular adhesion receptor of ScaA, an outer membrane autotransporter protein of O. tsutsugamushi. We mapped the interacting domains in the bacterial ligand and host receptor and confirmed their functional interaction. In addition, immunization with the C-terminal region of ScaA, which involves an interaction with the SET domain of vMLL5, not only induces enhanced neutralizing antibodies but also provides protective immunity against lethal challenge with O. tsutsugamushi.

The aim of this study was to investigate the relationship between the collagen type I/III ratio and scarring in patients who underwent immediate reconstruction with the round block technique (RBT) after breast conservation surgery. Seventy-eight patients were included, and demographic and clinical characteristics were recorded. The collagen type I/III ratio was measured using immunofluorescence staining and digital imaging, and scarring was assessed using the Vancouver Scar Scale (VSS). The mean VSS scores were 1.92 ± 2.01 and 1.79 ± 1.89, as assessed by two independent plastic surgeons, with good reliability of the scores. A significant positive correlation was found between VSS and the collagen type I/III ratio (r = 0.552, p < 0.01), and a significant negative correlation was found between VSS and the collagen type III content (r = −0.326, p < 0.05). Multiple linear regression analysis showed that the collagen type I/III ratio had a significant positive effect on VSS (β = 0.415, p = 0.028), whereas the collagen type I and collagen type III content had no significant effect on VSS. These findings suggest that the collagen type I/III ratio is associated with scar development in patients undergoing RBT after breast conservation surgery. Further research is needed to develop a patient-specific scar prediction model based on genetic factors affecting the collagen type I/III ratio.

Background and Objectives: Infections and capsular contractures remain unresolved issues in implant-based breast reconstruction. Capsular contractures are thought to be caused by the endogenous flora of the nipple duct. However, little is known about the antibiotic susceptibility of the microorganisms involved. This study aimed to evaluate the composition of endogenous breast flora and its antimicrobial susceptibility in patients with breast cancer. This study will aid in selecting a prophylactic antibiotic regimen for breast reconstruction surgery. Materials and Methods: We obtained bacteriologic swabs from the nipple intraoperatively in patients who underwent implant-based breast reconstruction following nipple-sparing mastectomy between January 2019 and August 2021. Antibiotic susceptibility tests were performed according to the isolated bacteriology. Statistical analysis was performed based on several patient variables to identify which factors influence the antibiotic resistance rate of endogenous flora. Results: A total of 125 of 220 patients had positive results, of which 106 had positive culture results for coagulase-negative Staphylococcus species (CoNS). Among these 106 patients, 50 (47%) were found to have methicillin-resistant staphylococci, and 56 (53%) were found to have methicillin-susceptible staphylococci. The methicillin resistance rate in the neoadjuvant chemotherapy group (56.3%) was significantly higher (OR, 2.3; p = 0.039) than that in the non-neoadjuvant chemotherapy group (35.5%). Conclusions: Based on the results, demonstrating high and rising incidence of methicillin-resistant staphylococci of nipple endogenous flora in patients with breast cancer compared to the past, it is necessary to consider the selection of prophylactic antibiotics to reduce infections and capsular contracture after implant-based breast reconstruction.

ABSTRACTScrub typhus is an acute febrile disease caused by Orientia tsutsugamushi infection. Despite the wide range of approaches explored during the last seventy years, an effective prophylactic vaccine is not yet available. Here, we developed a novel recombinant antigen derived from conserved regions of 56 kDa type-specific antigen (TSA56), a major outer membrane protein responsible for genetic heterogeneity and antigenicity, and evaluated it as a protective vaccine antigen. Our findings demonstrate that immunization with conserved blocks of TSA56 (cTSA56) not only provides protective immunity against lethal challenges with the homologous genotype, but also confers significantly better protection against heterologous genotypes than TSA56. Adoptive transfer of CD4+ or CD8+ T cells from immunized mice provided significantly enhanced protection against lethal challenge, whereas immune B cells failed to do so, indicating that cellular immunity against the conserved epitopes plays a protective role. Moreover, immunization with a 10-mer peptide mixture, screened from CD8+ T cell epitopes within the conserved region of TSA56, provided enhanced protection against lethal challenge with O. tsutsugamushi. Therefore, this novel recombinant antigen is a promising candidate for scrub typhus vaccine against a wide range of O. tsutsugamushi genotypes.