Age Group-Specific Improvement of Vertebral Scoliosis after the Surgical Release of Congenital Muscular Torticollis

Background  Congenital muscular torticollis (CMT) is a common musculoskeletal disorder in children. Secondary scoliosis can occur in patients with CMT; however, the extent of inclination and improvement of scoliosis after surgical correction of CMT have not been adequately studied. In this study, we aimed to evaluate and measure the improvement in vertebral tilting after surgical correction according to age at the time of surgery. Methods  Between June 2007 and January 2020, 831 patients with CMT underwent sternocleidomastoid release. Among them, 426 patients were enrolled, and their medical records were retrospectively reviewed. Ultimately, 210 patients available for radiological evaluation and analysis were enrolled in this study. The patients were divided into four groups according to age at the time of surgery to determine the relationship between age and changes in scoliosis. Results  Our findings showed an improvement in scoliosis in all age groups after surgery. The results for follow-up after 1 year confirmed long-term improvement in vertebral tilting. The degree of improvement in scoliosis was significantly higher in the younger age group than in patients aged 18 years or older. Conclusion  The effect of surgical release on scoliosis was significant in all age groups. The findings of this study suggest that CMT should be corrected before the age of 3 years to ensure an optimal surgical mitigation of scoliosis. Furthermore, in cases of neglected CMT, surgical release should be actively attempted because there is significant improvement.

Intramuscular hemangioma in the zygomaticus minor muscle: a case report and literature review

Intramuscular hemangioma is a rare vascular benign proliferation that can occur within any muscle, particularly in the trunk and extremities. In the head and neck region, the masseter muscle is most commonly involved, followed by the periorbital and sternocleidomastoid muscles. Diagnosing intramuscular hemangioma is challenging because there are no characteristic symptoms; instead, magnetic resonance imaging is the best imaging modality to diagnose these lesions. Complete surgical resection is the treatment of choice, although the local recurrence rate is high. Herein, we report a rare case of intramuscular hemangioma located in the zygomaticus minor muscle, which is related to smiling and usually runs along the orbicularis oculi muscle. Distinguishing or separating these two muscles is challenging. However, based on the muscle vector of the midface and radiological findings, the two muscles were successfully separated. The zygomaticus minor was cut very slightly to approach to the lesion and the muscle fibers were split to excise it. A follow-up examination revealed no nerve damage or muscle dysfunction at 4 weeks postoperatively. This rare case may serve as a reference for managing intramuscular hemangioma in the head and neck region.

Basal cell carcinoma misdiagnosed as trichoepithelioma

Trichoepithelioma is a benign hair follicle tumor that can undergo malignant transformation into basal cell carcinoma in rare cases. Due to the similar clinical and histological features of trichoepithelioma and basal cell carcinoma, distinguishing between these types of tumors can be a diagnostic challenge. Punch biopsy obtains only a small sample of the entire lesion, and thus inherently involves a risk of misdiagnosis between histologically similar diseases. Therefore, if the possibility of misdiagnosis can reasonably be suspected, clinicians should conduct an excisional biopsy or immunohistochemical staining (e.g., CD10 and Bcl-2) to ensure an exact diagnosis. Although trichoepithelioma is benign, the surgical excision of solitary trichoepithelioma should be considered in order to avoid the possibility of malignant transformation, which has occasionally been documented for multiple familial trichoepitheliomas. Herein, we report a case that was initially misdiagnosed as trichoepithelioma before ultimately being diagnosed as basal cell carcinoma through excision and immunohistochemical staining.

An Ultrasonically Powered Implantable Microprobe for Electrolytic Ablation

Electrolytic ablation (EA) is a promising nonthermal tumor ablation technique that destroys malignant cells through induction of a locoregional pH change. EA is typically performed by inserting needle electrodes inside the tumor followed by application of direct current (DC), thus inducing electrolysis and creating localized pH changes around the electrodes. In this paper, we report an ultrasonically powered implantable EA microprobe that may increase the clinical relevance of EA by allowing wireless control over device operation (capability to remotely turn the device on and off) and providing flexibility in treatment options (easier to administer fractionated doses over a longer period). The wireless EA microprobe consists of a millimeter-sized piezoelectric ultrasonic receiver, a rectifier circuit, and a pair of platinum electrodes (overall size is 9 × 3 × 2 mm³). Once implanted through a minimally invasive procedure, the microprobe can stay within a solid tumor and be repeatedly used as needed. Ultrasonic power allows for efficient power delivery to mm-scale devices implanted deep within soft tissues of the body. The microprobe is capable of producing a direct current of 90 µA at a voltage of 5 V across the electrodes under low-intensity ultrasound (~200 mW/cm²). The DC power creates acidic (pH < 2) and alkaline (pH > 12.9) regions around the anode and the cathode, respectively. The pH change, measured using tissue-mimicking agarose gel, extends to 0.8 cm³ in volume within an hour at an expansion rate of 0.5 mm³/min. The microprobe-mediated EA ablative capability is demonstrated in vitro in cancer cells and ex vivo in mouse liver.

Analysis of prognostic factors affecting poor outcomes in 41 cases of Fournier gangrene

Purpose

We present our experience involving the management of this disease, identifying prognostic factors affecting treatment outcomes.

Methods

The patients treated for Fournier gangrene at our institution were retrospectively reviewed. Data collected included demographics, extent of soft tissue necrosis, predisposing factors, etiological factors, laboratory values, and treatment outcomes. The severity index and score were calculated. Multivariate regression analysis was used to determine the association between potential predictors and clinical outcomes.

Results

A total of 41 patients (male:female = 33:8) were studied. The mean age was 54.4 years (range, 24-79 years). The most common predisposing factor was diabetes mellitus (n = 19, 46.3%). Sixteen patients (39.0%) were current smokers. Seven patients had chronic kidney disease. The most frequent etiology was urogenital lesion (41.5%). The mortality rate was 22.0% (n = 9). Multivariate regression analyses showed that extension of necrosis beyond perineal/inguinal area and pre-existing chronic kidney disease were significant and independent predictors of mortality. Extension of necrosis beyond perineal/inguinal area was a significant predictor of increased duration in the intensive care unit and hospital stay. In addition, pre-existing chronic kidney disease was a significant predictor of flap reconstruction in the wound.

Conclusion

Fournier gangrene with extensive soft tissue necrosis and pre-existing chronic kidney disease was associated with poor prognosis and complexity of patient management. Early recognition of dissemination and premorbid renal function is essential to reduce mortality and establish a management plan for this disease.

Solitary mastocytoma presenting at birth

Mastocytosis is a rare disease which occurs in both children and adults, and it can manifest as a solitary or multiple skin lesions. Both can cause cutaneous or systemic symptoms. Because of the heterogeneity of clinical presentation of mastocytosis and its rare prevalence, it can be hard to suspect the mastocytosis at the first time. Most solitary mastocytomas are about 1-5 cm in diameter and have features of brownish-yellow, minimally elevated plaques with a smooth shiny surface. This article presents a case of solitary mastocytoma which occurred in neonate and that we treated through surgical excision. In histopathological examination, it consisted of c-kit-positive mast cells. Although pediatric cutaneous mastocytosis might regress spontaneously, clinicians should keep in mind that it could be associated with systemic mastocytosis which involves hematopoietic system.

Reduction of Closed Frontal Sinus Fractures through Suprabrow Approach

Background

The traditional approach for reduction of frontal sinus fractures is coronal incision. Inherent complications of the coronal approach include long scar, hair loss, and long operation time. We describe a simple approach for the reduction of frontal sinus anterior wall fractures using a suprabrow incision that is commonly used for brow lift.

Methods

From March 2007 to October 2016, the authors identified patients with anterior wall frontal sinus fractures treated by open reduction through a suprabrow incision. Only cases with photographic/radiographic documentation and a minimum follow-up of 6 months were included. The incision line was designed to be at the upper margin of the eyebrow. Medical records and radiographic data were retrospectively reviewed. Surgical outcomes, cosmetic results, and complication were assessed. The patient scale of the patient and observer scar assessment scale was used to assess patient satisfaction for incisional scar at the 6-month follow-up.

Results

Thirty-one patients underwent fracture reduction through a suprabrow approach during the study period, with a mean follow-up of 41 months. No patients showed any recurrent displacement, eyebrow asymmetry, or infection during follow-up. Thirteen patients reported their forehead paresthesia postoperatively, and 12 of them had preoperative symptom. One patient complained of incisional scar and underwent scar revision. All patients were satisfied with their eyebrow and forehead contour.

Conclusion

The suprabrow approach allowed for an accurate reduction of the fractures in the anterior wall frontal sinus by providing direct visualization of the fracture. This transcutaneous approach can effectively restore forehead contour with acceptable postoperative complications and patient satisfaction.

Effectiveness of Acellular Dermal Matrix on Autologous Split-Thickness Skin Graft in Treatment of Deep Tissue Defect: Esthetic Subjective and Objective Evaluation

BACKGROUND

A split-thickness skin graft (STSG) is performed to cover a large full-thickness skin defect. Esthetic and functional deficits can result, and many studies have sought to overcome them. This study compared the effectiveness of the acellular dermal matrix (ADM) graft and STSG concerning esthetic and functional effectiveness of ADM on scar quality.

METHODS

Of the patients who underwent anterolateral thigh free flap from 2011 to 2015, patients who received skin graft only (n = 10) or skin graft with ADM (n = 20) for coverage of the donor site were enrolled. In all cases, autologous STSG was performed with 1:1.5 meshed 0.008-0.010-inch-thick skin. In the skin graft with ADM group, 0.008-0.013-inch-thick meshed ADM (CGderm^®; CGBio, Inc., Seungnam, Korea) was co-grafted. Negative-pressure wound therapy (CuraVAC^®; CGBio, Inc., Seungnam, Korea) was applied to both groups in continuous mode at -120 mmHg. We investigate early outcomes (skin loss rate, duration of negative-pressure wound therapy, days to removal of stitches, days to achieve complete healing, and complications) and late outcomes in terms of scar quality (vascularity, pigmentation, pliability and height) and graft-related symptoms (itching sensation and pain). Assessments used the Vancouver Scar Scale and the Patient and Observer Scar Assessment Scale. Skin fold was measured to evaluate the elasticity of scar tissue.

RESULTS

In the Vancouver Scar Scale, vascularity subscore (p = 0.003) and total score (p = 0.016) were significantly lower in the skin graft with ADM group. In Patient and Observer Scar Assessment Scale, the pain (p = 0.037) and stiffness subscores (p = 0.002), and total score (p = 0.017) were significantly lower in the skin graft with ADM group.

CONCLUSIONS

Skin graft with ADM results in better scar quality in objective and subjective aspects.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Free-Flap Transfer for Coverage of Transmetatarsal Amputation Stump to Preserve Residual Foot Length

Surgical management of soft-tissue defects of the forefoot and midfoot caused by trauma or diabetic complications can be challenging because locoregional tissue is insufficient to provide adequate flap. This deficiency necessitates higher-level amputations, such as Chopart or even transtibial amputation, resulting in far more debilitating functional outcomes than are seen with partial foot amputation. The purpose of this study was to examine the surgical outcomes after transmetatarsal amputation and a free-flap transfer to preserve foot length. This prospective case series was conducted from January 2011 to December 2015 at the Department of Plastic and Reconstructive Surgery at our institute. A total of 16 patients (11 men and 5 women) were enrolled in this study, all of whom were candidates for higher-level amputation because of inadequate soft-tissue coverage after debridement. Each patient underwent transmetatarsal amputation and reconstruction of the amputation stump using free-flap transfers to preserve foot length. Preoperative and postoperative data were collected to evaluate the postoperative outcomes. All 16 free-flap transfers were successful, with no major complications. In 2 cases, partial flap necrosis required additional skin grafting. The mean follow-up period was 24.3 months (range = 7-55 months). Flap coverage was stable, and all the patients were comfortable with their prostheses at long-term follow-up. Use of a free flap to reconstruct a transmetatarsal amputation stump provided stable coverage, preserved maximal foot length, and resulted in good functional outcomes.

Change of Facial Asymmetry in Patients With Congenital Muscular Torticollis After Surgical Release

BACKGROUND

A number of studies have shown that facial asymmetry improves in congenital muscular torticollis (CMT) patients after surgical release. This study confirmed the improvement in facial asymmetry, and analyzed factors that affect the change of facial asymmetry in CMT patients after surgical release by using objective and quantitative methods.

METHODS

Facial asymmetry was analyzed in 60 CMT patients who underwent surgical release before 10 years of age. Horizontal and lower facial asymmetry angles (HFAA and LFAA) in the clinical photograph were used to measure facial asymmetry. Postoperative improvements in HFAA and LFAA were evaluated in each age group, after grouping the patients by age. Patients were divided into 2 groups according to the postoperative head tilt and functional deficit. Postoperative improvements in HFAA and LFAA were compared between 2 groups. The relationships between postoperative improvements in HFAA and LFAA and independent variables (age, follow-up period, preoperative HFAA or LFAA, postoperative head tilt, and postoperative functional deficit) were analyzed.

RESULTS

Mean age at operation was 34.8 months (range, 6-120 mo). Horizontal facial asymmetry angle was improved significantly postoperatively in groups <5 years of age. Lower facial asymmetry angle was improved significantly postoperatively in all age groups. No significant difference was found in the postoperative improvements in HFAA and LFAA between 2 groups according to the postoperative head tilt and functional deficit. In the correlation analysis, postoperative improvements in HFAA and LFAA were proportional to the follow-up period (r = 0.256, P = 0.048) and preoperative HFAA or LFAA (r = 0.600, P < 0.001).

CONCLUSIONS

Facial asymmetry in CMT patients can be improved in part if surgical release is performed before 10 years of age and the possibility of improvement may be different according to the area of the face. After surgical release, facial asymmetry will improve over a long period of time, and patients with more severe facial asymmetry have a better remodeling potential to achieve facial symmetry.

Computed tomography contrast media extravasation: treatment algorithm and immediate treatment by squeezing with multiple slit incisions

In our hospital, an adverse event reporting system was initiated that alerts the plastic surgery department immediately after suspecting contrast media extravasation injury. This system is particularly important for a large volume of extravasation during power injector use. Between March 2011 and May 2015, a retrospective chart review was performed on all patients experiencing contrast media extravasation while being treated at our hospital. Immediate treatment by squeezing with multiple slit incisions was conducted for a portion of these patients. Eighty cases of extravasation were reported from approximately 218 000 computed tomography scans. The expected extravasation volume was larger than 50 ml, or severe pressure was felt on the affected limb in 23 patients. They were treated with multiple slit incisions followed by squeezing. Oedema of the affected limb disappeared after 1-2 hours after treatment, and the skin incisions healed within a week. We propose a set of guidelines for the initial management of contrast media extravasation injuries for a timely intervention. For large-volume extravasation cases, immediate management with multiple slit incisions is safe and effective in reducing the swelling quickly, preventing patient discomfort and decreasing skin and soft tissue problems.

Vascularized Free Lymph Node Flap Transfer in Advanced Lymphedema Patient after Axillary Lymph Node Dissection

Lymphedema is a condition characterized by tissue swelling caused by localized fluid retention. Advanced lymphedema is characterized by irreversible skin fibrosis (stage IIIb) and nonpitting edema, with leather-like skin, skin crypts, and ulcers with or without involvement of the toes (stage IVa and IVb, respectively). Recently, surgical treatment of advanced lymphedema has been a challenging reconstructive modality. Microvascular techniques such as lymphaticovenous anastomosis and vascularized lymph node flap transfer are effective for early stage lymphedema. In this study, we performed a two-stage operation in an advanced lymphedema patient. First, a debulking procedure was performed using liposuction. A vascularized free lymph node flap transfer was then conducted 10 weeks after the first operation. In this case, good results were obtained, with reduced circumferences in various parts of the upper extremity noted immediately postoperation.

A Surgical Technique for Congenital Preauricular Sinus

BACKGROUND

Preauricular sinuses represent a common congenital abnormality in children. Classically, a preauricular sinus manifests as a small opening, usually near the anterior limb of ascending helix. The difficulty in the surgical treatment of preauricular sinus is the high recurrence rate. The aim of this article is to review the outcomes of preauricular sinus and to introduce our surgical technique and its prognosis.

METHODS

A single-institutional retrospective review was performed for all patients who had undergone excision of congenital periauricular sinus between October 2007 and April 2014. Medical records were reviewed for demographic information, wound complication, and recurrence rate. The sinus tract was visualized with the aid of preoperative dye instillation and intraoperative probe insertion. The skin next to the sinus opening was incised elliptically, and the tract itself was dissected medially to the end of the sinus tract and posteriorly to the cartilage of the ascending helix.

RESULTS

The review identified 44 patients for a total of 57 preauricular sinus tracts. The mean age at time of operation was 16.3 years with a range from 9 months to 65 years. Unilateral preauricular sinus tract was present in 31 patients (11 right and 20 left preauricular tract), and 13 patients had bilateral sinus tract. None of the patients had experienced wound issues postoperative, and there were no recurrent sinus tract formation or infection.

CONCLUSION

Using a combination of dye instillation, probe insertion, and modified dissection, we were able to achieve a recurrence free series of preauricular sinus tract excision among a heterogenous group of patients. A large patient series is necessary to replicate the results of this study.

Improvement of Congenital Muscular Torticollis with Mild Symptoms in Non-Treated Adult after Simple Surgical Myotomy of Sternocleidomastoid Muscle under Local Anesthesia

In adult congenital muscular torticollis (CMT) patients, physical therapy is not as effective because the development of sternocleidomastoid muscle (SCM) muscle is complete. While surgical release can address CMT in adult patients, the risk of general anesthesia and visible postoperative scar is a concern, expecially in patients with mild symptoms. In this paper, we report our experience in treating such patients with minimal-incision myotomy under local anesthesia. A review was performed for all adult patients who had undergone the simple myotomy procedure. Surgical indication was reserved for patients with mild fibrotic band in the SCM muscle with minimal lengthdiscrepancybetween the muscles. All patients had recognizable head tiltand palpation of fibrotic band on affected side of the neck. Surgical details are described in the main body of text. Three female patients had undergone the procedure. Torticollis was resolve in all patients with complete restoration of ranage of motion. There were no postoperative complications, and patient satisfaction was high. We have reported three cases of mild CMT in adult female patients, who had undergone minimal-incision myotomy under local anesthesia. Outcomes were satisafactory with no morbidity to report. With careful patient selection, this method offers an alternate treatment option for adult CMT patients with mild symptoms.

Application of Hand Towel Drape over Dingman Mouth Gag

In cleft palate surgery, the environment is especially critical when suturing. Encum-bered, obstructive space in the environment can hinder a suture while using the Dingman mouth gag. We introduced a novel but simple draping technique. A simple hand towel is placed over the gag. A hole is cut out in the middle according to each patient's mouth. After making the hole, the hand towel is soaked in water and gently squeezed. Then the towel is properly placed over the Dingman mouth gag. Dripping water on the hand towel during the suture helps keep it in place. Using this draping technique, we cut 14 minutes of operation time compared to the average operation time of the past 2 years. There were several disadvantages in previous draping method. First, long suture material may easily get caught. Second, the operation field can easily be contaminated. Third, focusing on the operation becomes difficult due to the obstruction. This draping technique can compensate for the disadvantages of the previous Dingman mouth gag.

Molecular classification of basal cell carcinoma of skin by gene expression profiling

Non-melanoma skin cancers (NMSC) including basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) are more common kinds of skin cancer. Although these tumors share common pathological and clinical features, their similarity and heterogeneity at molecular levels are not fully elaborated yet. Here, by performing comparative analysis of gene expression profiling of BCC, SCC, and normal skin tissues, we could classify the BCC into three subtypes of classical, SCC-like, and normal-like BCCs. Functional enrichment and pathway analyses revealed the molecular characteristics of each subtype. The classical BCC showed the enriched expression and transcription signature with the activation of Wnt and Hedgehog signaling pathways, which were well known key features of BCC. By contrast, the SCC-like BCC was enriched with immune-response genes and oxidative stress-related genes. Network analysis revealed the PLAU/PLAUR as a key regulator of SCC-like BCC. The normal-like BCC showed prominent activation of metabolic processes particularly the fatty acid metabolism. The existence of these molecular subtypes could be validated in an independent dataset, which demonstrated the three subgroups of BCC with distinct functional enrichment. In conclusion, we suggest a novel molecular classification of BCC providing insights on the heterogeneous progression of BCC.

Magnetic resonance imaging as a determinant for surgical release of congenital muscular torticollis: correlation with the histopathologic findings

OBJECTIVE

(1) To present the magnetic resonance imaging (MRI) findings of congenital muscular torticollis (CMT) of subjects who underwent surgical release and subjects who showed a good prognosis with stretching exercises and (2) to correlate the MRI findings with the histopathologic findings of CMT for subjects who underwent surgical release in order to examine the hypothesis that the MRI findings of CMT can be used as a determinant to perform surgical release of CMT.

METHOD

The neck MRI findings of 33 subjects who underwent surgical release for CMT were compared with those of 18 subjects who were successfully managed only with conservative management. The MRI findings were correlated with the histopathologic sections of the CMT mass.

RESULTS

All 33 subjects (100%) who underwent surgical release showed one or more low signal intensities within the involved sternocleidomastoid muscle (SCM) on the T1- and T2-weighted images of neck MRI. The eighteen non-surgical candidates showed only enlargement of the SCM without low signal intensity within the SCM. The histopathologic findings showed interstitial fibrosis and/or the presence of aberrant tendon-like excessive dense connective tissue that was either well-arranged or disorganized.

CONCLUSION

The histopathologic findings and MRI findings showed good correlation in terms of the amount of fibrosis and aberrant dense connective tissue within the SCM. If multiple or large low signal intensities within the SCM are noted, we think that surgical release should be considered.

Comparison of clinical severity of congenital muscular torticollis based on the method of child birth

OBJECTIVE

To compare the clinical severity of congenital muscular torticollis (CMT) based on the method of child birth.

METHOD

Children diagnosed with CMT and who were < 6-years-of-age at the time of their first visit at the Center for Torticollis, Ajou Medical Center, were included in this study. The medical records were retrospectively reviewed with reference to the method of child birth and the clinical severity of CMT. The clinical severity of CMT was determined either by whether stretching exercises were needed for the children <6-month-of-age or whether surgical release was required for the children ≥6-months-of-age at the time of the first visit.

RESULTS

One hundred seventy eight subjects with CMT were enrolled. There was no significant difference in the rate of surgical release according to the method of child birth. For 132 patients <6-month-of-age there was also no significant difference in the rate of stretching exercises.

CONCLUSION

There was no significant difference in the clinical severity of CMT based on the method of child birth. This finding suggests that prenatal factors alone could be a cause of CMT and that the clinical severity of CMT in children delivered by Cesarean section is not different when compared with the severity of CMT in children born through vaginal delivery.

Role of JAK3 in myogenic differentiation

Skeletal muscle differentiation is regulated by transcription factors, including members of the myogenic regulatory factor (MRF) family and many signaling pathways. The JAK1 and JAK2 pathways are known to each have different effects on myoblast proliferation and differentiation; however, the role of JAK3 in myoblast differentiation remains unclear. In this study, we investigated the effect of JAK3 inhibition on myogenic differentiation in the C2C12 mouse myoblast cell line. During myogenic differentiation, treatment with the JAK3 inhibitor WHIp154 significantly increased the number of MHC-positive multinucleated myotubes and the expressions of myosin heavy chain (MHC), myogenin (MGN), MyoD, and myogenic enhancer factor 2 (MEF2). Knockdown of the JAK3 gene using siJAK3 also significantly increased MHC, MGN and MyoD mRNA expressions as well as insulin-like growth factor-II (IGF-II) gene expression. During differentiation, JAK3 was initially activated and later decreased. Differentiation decreased STAT1, which was further decreased by WHIp154. In contrast, STAT3 gradually was elevated during differentiation, and was increased by JAK3 inhibition. Moreover, we found that up-regulation of AKT activity and down-regulation of ERK activity cooperated to accelerate myogenic differentiation. Taken together, these data indicate that JAK3 inhibition potently facilitates myoblast differentiation through antagonistic STAT1/STAT3 activities. Additionally, JAK3 inhibition induced precocious differentiation and played important roles for terminal differentiation, including fusion, which is involved with regulation of AKT and ERK pathways.

Sepsis with multiple abscesses after massive autologous fat grafting for augmentation mammoplasty: a case report

BACKGROUND

Autologous fat grafting to the breast for breast reconstruction and cosmetic breast augmentation has gained much attention recently. However, its efficacy and the severities of its associated complications are of concern. The authors experienced one case of multiple breast abscesses after augmentation mammoplasty by autologous fat grafting.

METHODS

A 42-year-old woman presented to the authors' emergency department reporting tenderness, swelling, and a sensation of heat in both breasts. The patient had undergone augmentation mammoplasty by autologous fat grafting 7 days previously. Abscess formation was suspected based on the patient's history, physical examination, laboratory findings, and image study.

RESULTS

Incision and drainage were performed immediately with the patient under general anesthesia, and 500 ml of a foul, brown, turbid, purulent fluid containing necrotic fat debris was drained from each breast. Empiric antibiotics were started on the first hospital day, and betadine and saline-irrigation were administered daily for 2 weeks. Incisions were closed on hospital day 19 when laboratory data and local infection signs had improved. At the patient's 9-month follow-up assessment, breast contours were found to be well preserved, and scarring was minimal.

CONCLUSION

Immediate complications such as edema, hematoma, and infection require serious consideration after autologous fat grafting in the breast. In particular, infection probably is the most serious complication because the volume of the fat injected is large and can induce systemic infections such as sepsis and distort the contours of the breast. To avoid such infections, systemic and multicenter studies are required to determine how fat grafting should be performed to minimize the risks of fat necrosis and infection.

The thickness of the sternocleidomastoid muscle as a prognostic factor for congenital muscular torticollis

Objective

To examine whether the thickness of the sternocleidomastoid muscle (SCM) could be used as a prognostic factor for congenital muscular torticollis (CMT).

Method

This was a retrospective study conducted in a pediatric rehabilitation service at a tertiary medical center. Fifty-two children who met the following inclusion criteria were included: 1) children who were 3 month-old or younger, 2) children diagnosed with CMT, 3) passive rotation of the face toward the shoulder of the tilted side ≤60°, 4) children who had been managed according to the clinical pathway for CMT, 5) children who had been followed up for 6 months or more after the end of treatment. The duration and total number of stretching exercise sessions were reviewed with reference to the thickness of the SCM.

Results

Among the 52 children with CMT, 46 children were successfully managed with only stretching exercise of the SCM for 1-6 weeks (group 1: 88.5%) and 6 children were managed with botulinum toxin A injection, surgical release or both in addition to stretching exercise (group 2: 11.5%). The difference in the SCM thickness between the affected and normal sides was significantly greater in group 2 than that in group 1 (p=0.026). A strong correlation was found between the total duration of stretching exercise and the difference in the SCM thickness in group 1 (Pearson' γ=0.429; p=0.003).

Conclusion

Children with a thicker SCM seem to require a longer duration of stretching exercise and other therapeutic interventions in addition to stretching exercise for CMT. Therefore, the thickness of the SCM may be one prognostic factor for CMT treatment.

Subungual glomus tumours of the hand: diagnosis and outcome of the transungual approach

We report 17 patients with a subungual glomus tumour. All complained of pain and tenderness when touched, and nine patients experienced severe pain in the cold. A transungual approach with nail plate avulsion on one side was used in all cases. A surgical microscope was used to localise and dissect the tumour and to repair the nail bed and matrix. This method has produced good results, without local recurrence or postoperative nail plate deformity.

A case of non-involuting congenital haemangioma with multiple epidermal cysts

While infantile haemangiomas are the most common tumours of childhood, rare congenital haemangiomas grow to maximum size at birth and then spontaneously and rapidly regress (rapidly involuting congenital haemangiomas). However, certain congenital haemangiomas, described recently as 'non-involuting congenital haemangiomas', evolve differently and do not regress. There are several options regarding the treatment of infantile haemangiomas, but few reports have addressed the treatments of non-involuting congenital haemangiomas, though a small number have recommended surgical excision. However, the treatments of non-involuting congenital haemangiomas with multiple epidermal cysts have not been investigated. Epidermal cysts can cause recurrent infection, and we suspect that recurrent ulceration might cause the implantation of epidermal cells into the dermis, and result in the development of multiple epidermal cysts. Currently, epidermal cysts are treated by surgical excision, which should reduce complication rates. Herein, we report our experience of treating repeatedly infected non-involuting congenital haemangioma with multiple epidermal cysts.

Intradural extracerebral choristoma. Case report and review of the literature

BACKGROUND

Intracranial extracerebral neuroglial choristoma is a very rare entity. A cleft palate or a nasopharyngeal teratoma has been described as accompanying choristoma, but there are no observations of both anomalies being simultaneously present and combined.

METHODS

An 8-month-old girl presented with seizures, without evidence of any other neurological abnormalities. Brain magnetic resonance imaging demonstrated a 2.0-cm-sized, round-shaped mass in the frontal midline. The T(1)- and T(2)-weighted images showed a well-circumscribed iso-signal intensity lesion with no gadolinium enhancement.

RESULTS

Surgical exploration revealed a yellowish tumor mass with whitish soft tissue material within the tumor, adherence to the surrounding blood vessels, and therefore subtotal removal was performed. Pathologic examination was neuroglial choristoma with 1.5% of MIB-1 labeling index. The patient also had a cleft palate with a pinkish palatal mass and underwent repair of the cleft palate, and excision of mass that was a mature cystic teratoma on pathologic examination. Follow-up at 18 months later showed that there was no evidence of tumor regrowth or neurological deficit, and the neurological development was normal.

CONCLUSION

The authors described a rare case of intracranial extracerebral neuroglial choristoma accompanied by both nasopharyngeal teratoma and cleft palate and suggested its benign nature from the low MIB-1 labeling index.

Vagus nerve stimulation for depression: rationale, anatomical and physiological basis of efficacy and future prospects

Treatment-resistant depression (TRD) is a major public health concern due to its high costs to society. One of the novel approaches for the treatment of depression is the vagus nerve stimulation (VNS). Therapeutic brain stimulation through delivery of pulsed electrical impulses to the left cervical vagus nerve now has established safety and efficacy as an adjunct treatment for medication-resistant epilepsy and has recently been approved as an adjunct long-term treatment for chronic or recurrent depression. There is considerable evidence from both animal and human neurochemical and neuroimaging studies, that the vagus nerve and its stimulation influence limbic and higher cortical brain regions implicated in mood disorders, providing a rationale for its possible role in the treatment of psychiatric disorders. Clinical studies (open-label and comparator with treatment in naturalistic setting) in patients with TRD have produced promising results, especially when the response rates at longer-term (one- and two-year) follow-up time points are considered. Ongoing research efforts will help determine the place of VNS in the armament of therapeutic modalities available for major depression.

Serum cytokine profiles and their correlations with disease activity in Takayasu's arteritis

OBJECTIVE

To investigate serum profiles of inflammatory cytokines in patients with Takayasu's arteritis (TA) and to determine their correlations with disease activity of TA.

METHODS

Forty-nine patients with TA and 12 age- and sex-matched controls were studied. Blood samples were obtained and were divided into active and stable disease groups. Paired blood samples were available in 19 patients at the active stage before treatment and at the remitted stage after treatment. Serum tumour necrosis factor (TNF)-alpha, interferon (IFN)-gamma, interleukin (IL)-6, IL-12 and IL-18 levels were determined by enzyme-linked immunosorbent assay.

RESULTS

Serum TNF-alpha, IL-6 and IL-18 levels of patients with TA were significantly higher than those of controls (P<0.05), but IFN-gamma and IL-12 levels were not. Serum IL-6 and IL-18 levels were significantly higher in the active disease group than in the stable disease group (P<0.05), but the levels of TNF-alpha were not different between the groups. In the 19 patients with paired samples, serum IL-18 levels at the remitted stage after treatment were significantly decreased compared with the active stage before treatment (P<0.001). The changes in IL-18 levels between active and remitted stages correlated well with changes in erythrocyte sedimentation rate (P<0.001).

CONCLUSION

Serum IL-18 and IL-6 levels were elevated in patients with TA, especially in those with active disease. Serum IL-18 levels correlated well with disease activity of TA. These results suggest that IL-6 and IL-18 might contribute to the pathogenesis of TA and that IL-18 could be a useful marker for monitoring disease activity of TA.

Post-interventional immunosuppressive treatment and vascular restenosis in Takayasu's arteritis

OBJECTIVE

To investigate the outcome of vascular interventions and the effect of post-interventional immunosuppressive treatment on the occurrence of vascular restenosis in patients with Takayasu's arteritis (TA).

METHODS

Forty-two patients with TA who had undergone vascular intervention and had serial angiographies before and after intervention were enrolled. The demographic and clinical data were collected at the time when the interventions were performed, and the intervention modalities and post-interventional medical treatments were evaluated.

RESULTS

Sixty-three interventions were performed in 42 patients. Twenty (31.7%) interventions restenosed 24.0 +/- 21.9 months after intervention; the likelihood decreasing as time passed. Estimates of arterial patency after intervention were 90.1% at 1 yr, 75.5% at 2 yr, 68.4% at 3 yr, 61.6% at 5 yr and 49.3% at 10 yr. According to the log rank test, interventions that were performed during the stable stage of the disease (P = 0.039) and those that were followed by treatment with glucocorticoids and immunosuppressive agents (P = 0.044) were independent variables for the maintenance of arterial patency. Their hazard ratios were 0.30 and 0.41, respectively.

CONCLUSION

Restenosis occurred in 31.7% of TA patients after intervention. A lower restenosis rate was observed when the vascular interventions were performed at the stable stage and when post-interventional immunosuppressive treatment was implemented.

Use of internal mammary vessel perforator as a recipient vessel for free TRAM breast reconstruction

Breast reconstruction is a cosmetically critical procedure for women and it must be undertaken to balance the shape, size, and position of the breast with the other breast. Since the first introduction of the free abdominoplasty flap in 1979, the transverse rectus abdominis musculocutaneous (TRAM) flap technique has been a widely accepted method of breast reconstruction after mastectomy. In breast reconstruction with a free flap, the selection of suitable recipient vessels is the critical decision to be made by the surgeon. The most common recipient vessel for free flap breast reconstruction is the axillary system. However, when used as a recipient, the axillary system may limit flap movement and flexibility in breast shaping. The use of the internal mammary vessels as a recipient site attains ideal breast symmetry. However, the technique requires partial rib resection and eliminates the opportunity for a potential coronary artery bypass graft, which requires the internal mammary artery. Based on these considerations, the selection of suitable recipient vessels constitutes an important requirement for successful free tissue transfer. The authors have performed breast reconstruction with the TRAM flap anastomosed to the internal mammary perforator vessel and conclude that these perforators could be useful as recipient vessels, especially in the case of immediate breast reconstruction with the free TRAM flap.

Consistent features in the forelimb representation of primary motor cortex in rhesus macaques

The purpose of this study was to systematically map the forelimb area of primary motor cortex (M1) in rhesus macaques in an effort to investigate further the organization of motor output to distal and proximal muscles. We used stimulus-triggered averaging (StTAing) of electromyographic activity to map the cortical representation of 24 simultaneously recorded forelimb muscles. StTAs were obtained by applying 15 microA stimuli to M1 sites while the monkey performed a reach and prehension task. Motor output to body regions other than the forelimb (e.g., face, trunk, and hindlimb) was identified using repetitive intracortical microstimulation to evoke movements. Detailed, muscle-based maps of M1 revealed a central core of distal (wrist, digit, and intrinsic hand) muscle representation surrounded by a "horseshoe"-shaped zone of proximal (shoulder and elbow) muscle representation. The core distal and proximal zones were separated by a relatively large region representing combinations of both distal and proximal muscles. On the basis of its size and characteristics, we argue that this zone is not simply the result of stimulus-current spread, but rather a distinct zone within the forelimb representation containing cells that specify functional synergies of distal and proximal muscles. Electrode tracks extending medially from the medial arm of the proximal muscle representation evoked trunk and hindlimb responses. No distal or proximal muscle poststimulus effects were found in this region. These results argue against the existence of a second, major noncontiguous distal or proximal forelimb representation located medially within the macaque M1 representation.

Compensation of phase change on reflection in white-light interferometry for step height measurement

We present a method for compensating for the phase change on reflection in scanning white-light inteferometry that practically permits precise three-dimensional profile mapping of composite target surfaces that comprise multiple, dissimilar materials. The compensation method estimates the variation of phase change with the spectral distribution of the light source through a first-order approximation and then directly compensates for the measurement errors by performing two additional quasi-monochromatic phase-measuring interferometric measurements. Experimental results prove that the proposed compensation method is capable of reducing the measurement error in step height gauging to +/-5 nm or less.

Chronic recording of EMG activity from large numbers of forelimb muscles in awake macaque monkeys

Studies of the neural control of movement often require or benefit from long-term recording of EMG activity from large numbers of muscles involved in a particular motor task. While chronic recording of EMG activity has been described in a number of previous monkey studies, the number of muscles recorded has been somewhat limited and the implantation approach has been highly invasive procedures. This paper presents two EMG implant fabrication and surgical implantation methods that are suitable for use in monkeys, relatively non-traumatic and capable of simultaneous recording from 24 or more muscles.

Induction of reproductive organ-preferential histone genes by wounding or methyl jasmonate

A cDNA clone CaH2B, which is highly expressed in floral buds, was isolated from hot pepper plants (Capsicum annuum) by the mRNA differential display method. Sequence analysis of CaH2B revealed that the clone contains an open reading frame of 145 amino acid residues, which are 77% identical to a maize H2B histone. The CaH2B mRNA was barely detectable in roots, was more abundant in anthers than in seedlings, and was expressed highest in floral buds and fruits. An in situ analysis of CaH2B in floral buds indicated that the transcript is highly present in the pollen and petals. Northern analysis of CaH4, a pepper H4 histone cDNA, which was obtained during the expressed sequence tag (EST) analysis of anther tissues, showed that the expression pattern was very similar to that of CaH2B, although the expression level was slightly different. Both histone genes were examined for inducibility by wounding, methyl jasmonate (MJ), or phytohormones. CaH2B and CaH4 were induced by wounding, and maximally induced ca. 3 h after wound treatment both in vitro and in planta. Airborne MJ greatly induced the expression of the genes as well. The inducing effect by wounding was suppressed by MJ, suggesting that wounding and MJ might have different roles in signal transduction for the histone gene induction. Southern blot hybridization showed that both H2B and H4 genes are comprised of multigene families in the hot pepper.

Intravesical bacille Calmette-Guérin therapy for muscle invasive bladder cancer

OBJECTIVES

This investigation attempted to determine whether the degree of fibronectin expression in the bladders of patients with invasive transitional cell carcinoma correlated with their clinical response to intravesical bacille Calmette-Guerin (BCG) therapy.

METHODS

Following transurethral resection of all invasive disease, 13 patients with Stages T2-T4 bladder cancer were administered intravesical BCG (fo 6 weeks followed by monthly instillations). Fibronectin expression in the patients' resected tumors and normal mucosa was determined by immunohistochemical staining techniques. Minimum disease-free follow-up was 60 months.

RESULTS

Only 1 of 13 patients had neither local nor systemic disease recurrence; 10 of 13 patients developed systemic disease and 7 patients died from metastases. Fibronectin expression was not correlated with the clinical response to BCG.

CONCLUSIONS

Intravesical BCG therapy for the treatment of muscle invasive transitional cell carcinoma of the bladder is ineffective. Fibronectin expression in the bladder of patients with invasive disease is variable and does not correlate significantly with the clinical response to BCG therapy.

Fibronectin expression on surgical specimens correlated with the response to intravesical bacillus Calmette-Guerin therapy

Attachment of bacillus Calmette-Guerin (BCG) organisms to the bladder during intravesical therapy is thought to be mediated exclusively by the glycoprotein fibronectin, which is expressed variably on epithelial surfaces and on basement membranes. We examined the relationship between the degree of fibronectin expressed on surgical specimens obtained from 50 candidates for BCG therapy and the subsequent clinical response. Immunoperoxidase staining for fibronectin was performed on tumor, nonadjacent normal mucosa and basement membrane tissues, and the intensity of the staining was scored on a scale of 0 to 3+ (control 2+). In the absence of recurrence at quarterly surveillance cystoscopy, a course of Tice BCG therapy consisted of 6 weekly and 12 monthly instillations. Recurrence of noninvasive tumor prompted a second BCG course. Followup ranged from 24 to 66 months (median 40 months). Of the 50 patients (11 with carcinoma in situ) disease progression occurred in 9 (none with carcinoma in situ). Compared to the results for tumors or for basement membranes, the degree of fibronectin expression on normal mucosa was well correlated with the clinical response (r = 0.59, p < 0.001 by Kendall Tau B). Routine assessment of fibronectin expression on the normal mucosa associated with superficial bladder cancer may be useful for predicting the clinical response to BCG therapy.

Primary non-Hodgkin's malignant lymphoma of the vulva--a case report

A case of primary non-Hodgkin's malignant lymphoma of the vulva which occurred in a 68-year-old woman is presented. Non-Hodgkin's malignant lymphoma is infrequently involved in the female genital tract. Moreover, primary vulvar involvement of this tumor is very rare. To date only 6 cases have been reported in the literature. To our knowledge this is the first reported case of a non-Hodgkin's malignant lymphoma of the vulva in Korea.

Isolation and characterization of a novel lipoprotein particle from human placental extracts

While it is believed that placental tissue is very active in lipid metabolism, the nature of lipid containing particles secreted (if any) by this tissue is not known. Lipoprotein profile of human placental tissue was analysed by gel filtration, gel electrophoresis and electron microscopy. Our studies demonstrated the presence of lipoproteins with unusual compositions. A novel major lipoprotein (which eluted in the same position on plasma VLDL) was characterized. While this lipoprotein floated at density greater than 1.006 gr/ml and contained apo B (same as plasma VLDL) it differed from plasma VLDL in a) size, b) contining a significant amount of apo Al, and c) carried bulk of the cholesterol (80% in free form) and phospholipids. This study suggests that placental tissue might contain unique lipoproteins perhaps serving specific metabolic needs.

Lecithin:cholesterol acyltransferase in familial HDL deficiency (Tangier disease)

These studies were performed to investigate the relationship between the enzyme lecithin:cholesterol acyltransferase and plasma lipoproteins in Tangier disease, a condition characterized by a virtual absence of high-density lipoproteins (HDLs) and an accumulation of cholesteryl esters in peripheral tissues. Apolipoprotein A-I was nearly absent from the patient's plasma (1% of the normal levels were found). However, apolipoprotein A-I purified from the plasma of the Tangier disease patient, was found to activate both purified and the plasma enzyme. At lower apolipoprotein concentrations (up to 25 micrograms/ml), about twice the amount of Tangier apolipoprotein A-I was required to achieve a certain level of lecithin:cholesterol acyltransferase activity as compared with the activating potential of the normal apolipoprotein. Gel chromatography studies revealed that as in normal plasma, lecithin:cholesterol acyltransferase in Tangier plasma was associated with an HDL-size lipoprotein fraction. However, unlike in normal plasma, this lipoprotein complex (containing lecithin:cholesterol acyltransferase) was not removed from Tangier plasma by immunoaffinity chromatography utilizing immobilized anti-apolipoprotein A-I antibodies. Plasma incubation studies showed that free cholesterol was primarily supplied by LDL in normal plasma, whereas both LDL and VLDL donated the free cholesterol for lecithin:cholesterol acyltransferase reaction in Tangier plasma. The majority of the cholesteryl esters, generated during the incubation experiments, were transferred back to LDL in normal plasma, whereas in Tangier plasma both LDL and VLDL served as cholesteryl ester acceptors. The cholesteryl ester transfer from HDL to lower-density lipoproteins was lower in Tangier plasma as compared to this process in a normal control, suggesting that a minimal cholesteryl ester core may be required for the stability of HDL.

Fecal protoporphyrin excretion in erythropoietic protoporphyria: effect of cholestyramine and bile acid feeding

The effect of cholestyramine and bile acid feeding upon fecal, red blood cell, and plasma protoporphyrin levels was evaluated in a patient with erythropoietic protoporphyria and evidence of hepatic damage. After a basal period on a controlled diet, bile acids alone were administered (300-900 mg) daily for 9 days, followed by cholestyramine (12 g) plus bile acids (900 mg) daily for 7 days, and cholestyramine alone (12 g) daily for 6 days. There was no substantial change in either the red blood cell or plasma protoporphyrin concentrations during any treatment period. However, cholestyramine and cholestyramine combined with bile acids caused a threefold increase in fecal protoporphyrin excretion, whereas bile acids alone had no effect in this regard. After 1 yr of cholestyramine therapy, fecal excretion of protoporphyrin remained elevated with concurrent improvement in liver function tests and photosensitivity. This study indicates that cholestyramine but not bile acids can substantially increase protoporphyrin excretion and therefore may be capable of ameliorating the hepatotoxicity that may occur in selected patients with erythropoietic protoporphyria.

Effects of detergents on the lecithin:cholesterol acyltransferase reaction

This paper describes the effect of an ionic (sodium dodecyl sulfate; SDS) and a nonionic detergent (Triton X-100) on the substrate and enzyme components of the lecithin: cholesterol acyltransferase (LCAT) reaction. When the enzyme sources (purified or partially purified) or the respective substrates [high-density lipoproteins (HDL) or proteoliposomes] were preincubated with detergents, a consistent trend in LCAT activity was only seen when partially purified LCAT was used as the enzyme source. This trend indicated an approximately 25% increase in enzyme activity over the control when 10(-4) M SDS and 2 X 10(-3)% Triton X-100 were present in the preincubation mixtures, respectively. Those observations suggested that, during the preincubations and subsequent assays, the enzyme (in the presence of detergents) was allowed to dissociate from the endogenous substrate and subsequently interact with the exogenous substrate molecules. Additional experiments utilizing molecular-sieve chromatography with whole plasma and partially purified enzyme also showed that dissociation of LCAT/lipoprotein complexes occurred in the presence of detergent. SDS was also shown to enhance the reaction of LCAT in whole plasma with anti-LCAT antibody in an enzyme-linked immunoassay system, indicating that the detergent treatment facilitated the exposure of additional antigenic sites, perhaps via dissociation of the enzyme from plasma lipoproteins.