Early experiences with robot-assisted prosthetic breast reconstruction

Robotic surgery facilitates surgical procedures by employing flexible arms with multiple degrees of freedom and providing high-quality 3-dimensional imaging. Robot-assisted nipplesparing mastectomy with immediate reconstruction is currently performed to avoid breast scars. Four patients with invasive ductal carcinoma underwent robot-assisted nipple-sparing mastectomy and immediate robot-assisted expander insertion. Through a 6-cm incision along the anterior axillary line, sentinel lymph node biopsy and nipple-sparing mastectomy were performed by oncologic surgeons. The pectoralis major muscle was elevated, an acellular dermal matrix (ADM) sling was created with robotic assistance, and an expander was inserted into the subpectoral, sub-ADM pocket. No patients had major complications such as hematoma, seroma, infection, capsular contracture, or nipple-areolar necrosis. The mean operation time for expander insertion was 1 hour and 20 minutes, and it became shorter with more experience. The first patient completed 2-stage prosthetic reconstruction and was highly satisfied with the unnoticeable scar and symmetric reconstruction. We describe several cases of immediate robot-assisted prosthetic breast reconstruction. This procedure is a feasible surgical option for patients who want to conceal surgical scars.

Antifungal Mechanism of Action of Lauryl Betaine Against Skin-Associated Fungus Malassezia restricta

Betaine derivatives are considered major ingredients of shampoos and are commonly used as antistatic and viscosity-increasing agents. Several studies have also suggested that betaine derivatives can be used as antimicrobial agents. However, the antifungal activity and mechanism of action of betaine derivatives have not yet been fully understood. In this study, we investigated the antifungal activity of six betaine derivatives against Malassezia restricta, which is the most frequently isolated fungus from the human skin and is implicated in the development of dandruff. We found that, among the six betaine derivatives, lauryl betaine showed the most potent antifungal activity. The mechanism of action of lauryl betaine was studied mainly using another phylogenetically close model fungal organism, Cryptococcus neoformans, because of a lack of available genetic manipulation and functional genomics tools for M. restricta. Our genome-wide reverse genetic screening method using the C. neoformans gene deletion mutant library showed that the mutants with mutations in genes for cell membrane synthesis and integrity, particularly ergosterol synthesis, are highly sensitive to lauryl betaine. Furthermore, transcriptome changes in both C. neoformans and M. restricta cells grown in the presence of lauryl betaine were analyzed and the results indicated that the compound mainly affected cell membrane synthesis, particularly ergosterol synthesis. Overall, our data demonstrated that lauryl betaine influences ergosterol synthesis in C. neoformans and that the compound exerts a similar mechanism of action on M. restricta.

Effective professional intraoral tooth brushing instruction using the modified plaque score: a randomized clinical trial

PURPOSE: The purpose of this study was to evaluate the efficacy of the modified plaque score (MPS) for assessing the oral hygiene status of periodontitis patients. METHODS: A total of 116 patients were included in this study. After evaluation of the Löe and Silness gingival index (GI), Silness and Löe plaque index (PlI), O'Leary plaque control record (PCR), and MPS, patients were randomly assigned to either a conventional tooth brushing instruction (C-TBI) group (n=56) or a professional intraoral tooth brushing instruction (P-TBI) group (n=60). The MPS and clinical parameters were re-evaluated after scaling and a series of root planing. The convergent validity of MPS with the PlI and PCR was assessed. The measurement time for MPS and PCR was compared according to the proficiency of the examiner. RESULTS: After root planing, the GI, PlI, PCR, and MPS improved from their respective baseline values in both groups. Three different plaque indices including the MPS, showed significant differences between the C-TBI group and the P-TBI group after root planing. The MPS showed significant concurrence with the PCR and PlI. The mean time for PCR measurement was 2.76±0.71 times longer than that for MPS measurement after 2 weeks of training. CONCLUSIONS: MPS seems to be a practical plaque scoring system compared with the PlI and PCR. These findings suggest that repetitive plaque control combined with an easily applicable plaque index (MPS) may facilitate more effective oral hygiene education and improved periodontal health.

Causing Factors to Determine Whether to Administer Analgesics for Patients with Isolated Long Bone Fracture in Emergency Department

PURPOSE: Many patients complain of pain due to fracture in the emergency department (ED). However, pain management in these patients has not been performed well. The objective of this study is to describe analgesic utilization and assess factors associated with analgesic use in patients with isolated long-bone fractures during the ED visit. METHODS: We retrospectively reviewed electronic medical records of patients presenting to two EDs with an isolated long bone fracture from January to December 2012. A total of 358 patients were enrolled, and sex, age, arrival route, mechanism of injury, fracture type, fracture location, drug used for pain control, arrival time, physician in charge primary care, and disposition were analyzed. RESULTS: Analgesics were administered to 50% of patients between 20~60 years, whereas 11.3% of patients under 20 years old and 38.7% above 60 years old (p<0.01) received analgesics. Better pain control was achieved in females, young adults, patients cared for by emergency medicine residents, and visits made by emergency medical service or at dawn. CONCLUSION: The pain control rate of children is lower than that of adults in patients with an isolated long bone fracture. Active strategies for pain management are necessary by triage physicians from this time forward.

B Cells Promote Th1- Skewed NKT Cell Response by CD1d-TCR Interaction

CD1d expressing dendritic cells (DCs) are good glyco-lipid antigen presenting cells for NKT cells. However, resting B cells are very weak stimulators for NKT cells. Although alpha-galactosylceramide (alpha-GalCer) loaded B cells can activate NKT cells, it is not well defined whether B cells interfere NKT cell stimulating activity of DCs. Unexpectedly, we found in this study that B cells can promote Th1-skewed NKT cell response, which means a increased level of IFN-gamma by NKT cells, concomitant with a decreased level of IL-4, in the circumstance of co-culture of DCs and B Cells. Remarkably, the response promoted by B cells was dependent on CD1d expression of B cells.

Delayed-Onset Subdural Hematoma and Oculomotor Nerve Palsy After Improving Spontaneous Intracranial Hypotension

Spontaneous intracranial hypotension (SIH) is a well-known disorder improving with conservative treatment or epidural blood patch in the majority of cases. However, SIH may develop neurological complications such as cranial nerve palsy, subdural hematoma, and altered consciousness. Subdural hematoma in SIH is usually found during intracranial hypotension state and delayed subdural hematoma is rarely reported. We report a case of delayed subdural hematoma and oculomotor nerve palsy after improving spontaneous intracranial hypotension.

Rosai-Dorfman Disease in the Breast with Increased IgG4 Expressing Plasma Cells: A Case Report

Rosai-Dorfman disease (RDD) can present in any anatomic site, but breast involvement is rarely reported. Recently, a relationship between RDD and IgG4-related sclerosing disease has been suggested. Here we report another case of RDD with overlapping features of IgG4-related sclerosing disease occurring in a right breast of a 62-year-old female. On microscopic examination, the mass demonstrated a characteristic zonal pattern of proliferation of large polygonal histiocytes and lymphoplasma cells with stromal fibrosis. Emperipolesis was observed in histiocytes with abundant cytoplasm, which showed immunoreactivity for S-100 protein and CD68; the diagnosis of RDD was made. Sheets of plasma cells in the fibrotic stroma demonstrated positive reactions for IgG and IgG4. The mean count of IgG4-positive plasma cells was 100.2/high power field, and the ratio of IgG4/IgG was 56.7%. Additional findings of stromal fibrosis and obliteration of preexisting breast lobules suggested overlapping features with IgG4-related sclerosing disease.

Dystonia Associated With HIV Infection in a Patient With Schizophrenia

No abstract available.

TGF-beta-treated antigen presenting cells suppress collagen-induced arthritis through the promotion of Th2 responses

Collagen-induced arthritis (CIA) is mediated by self-reactive CD4+ T cells that produce inflammatory cytokines. TGF-beta2-treated tolerogenic antigen-presenting cells (Tol-APCs) are known to induce tolerance in various autoimmune diseases. In this study, we investigated whether collagen-specific Tol-APCs could induce suppression of CIA. We observed that Tol-APCs could suppress the development and severity of CIA and delay the onset of CIA. Treatment of Tol-APCs reduced the number of IFN-gamma- and IL-17-producing CD4+ T cells and increased IL-4- and IL-5-producing CD4+ T cells upon collagen antigen stimulation in vitro. The suppression of CIA conferred by Tol-APCs correlated with their ability to selectively induce IL-10 production. We also observed that treatment of Tol-APCs inhibited not only cellular immune responses but also humoral immune responses in the process of CIA. Our results suggest that in vitro-generated Tol-APCs have potential therapeutic value for the treatment of rheumatoid arthritis as well as other autoimmune diseases.

The requirement of natural killer T-cells in tolerogenic APCs-mediated suppression of collagen-induced arthritis

TGF-beta-induced tolerogenic-antigen presenting cells (Tol-APCs) could induce suppression of autoimmune diseases such as collagen-induced arthritis (CIA) and allergic asthma. In contrast, many studies have shown that NKT cells are involved in the pathogenesis of Th1-mediated autoimmune joint inflammation and Th2-mediated allergic pulmonary inflammation. In this study, we investigated the effect of CD1d-restricted NKT cells in the Tol-APCs-mediated suppression of autoimmune disease using a murine CIA model. When CIA-induced mice were treated with Tol-APCs obtained from CD1d+/- or CD1d-/- mice, unlike CD1d+/- APCs, CD1d-/- Tol-APCs failed to suppress CIA. More specifically, CD1d-/- Tol-APCs failed to suppress the production of inflammatory cytokines and the induction of Th2 responses by antigen-specific CD4 T cells both in vitro and in vivo. Our results demonstrate that the presence of CD1d-restricted NKT cells is critical for the induction of Tol-APCs-mediated suppression of CIA.

The presence of CD8+ invariant NKT cells in mice

Invariant natural killer T (iNKT) cells develop in the thymus upon recognition of CD1d expressed on developing thymocytes. Although CD4 and CD8 coreceptors are not directly involved in the interaction between CD1d and the T cell receptors (TCRs) of iNKT cells, a conspicuous lack of CD8+ iNKT cells in mice raised the question of whether CD8+ iNKT cells are excluded due to negative selection during their thymic development, or if there is no lineage commitment for the development of murine CD8+ iNKT cells. To address this question, we analyzed iNKT cell-specific TCR Valpha14+ transgenic mice, where the Valpha14 transgene forces the generation of iNKT cells. This allows detailed study of the iNKT cell repertoire. We were able to identify CD8+ iNKT cells which respond to the NKT cell-specific glycolipid ligand alpha-galactosylceramide. Unlike conventional iNKT cells, CD8+ iNKT cells produce predominantly IFN-gamma but not IL-4 upon antigen stimulation. We also confirmed the presence of CD8+ iNKT cells in wild type mice. Our results suggest that CD8+ NKT cells do exist in mice, although their population size is quite small. Their Th1-skewed phenotype might explain why the population size of this subtype needs to be controlled tightly.

A New Reporter Vector System Based on Flow-Cytometry to Detect Promoter Activity

In this study, we report the development of a new dual reporter vector system for the analysis of promoter activity. This system employs green fluorescence emitting protein, EGFP, as a reporter, and uses red fluorescence emitting protein, DsRed, as a transfection control in a single vector. The expression of those two proteins can be readily detected via flow cytometry in a single analysis, with no need for any further manipulation after transfection. As this system allows for the simultaneous detection of both the control and reporter proteins in the same cells, only transfected cells which express the control protein, DsRed, can be subjected to promoter activity analysis, via the gating out of all un-transfected cells. This results in a dramatic increase in the promoter activity detection sensitivity. This novel reporter vector system should prove to be a simple and efficient method for the analysis of promoter activity.

Anti-tumor immunostimulatory effect of heat-killed tumor cells

As a part of our ongoing search for a safe and efficient anti-tumor vaccine, we attempted to determine whether the molecular nature of certain tumor antigens would influence immune responses against tumor cells. As compared with freeze-thawed or formaldehyde-fixed tumor antigens, heat-denatured tumor antigens elicited profound anti-tumor immune responses and greatly inhibited the growth of live tumor cells. The heat-denatured tumor antigens induced a substantial increase in the anti-tumor CTL response in the absence of any adjuvant material. This response appears to be initiated by strong activation of the antigen-presenting cells, which may recognize heat-denatured protein antigens. Upon recognition of the heat-denatured tumor antigens, macrophages and dendritic cells were found to acutely upregulate the expression of co-stimulatory molecules such as B7.2, as well as the secretion of inflammatory cytokines such as IL-12 and TNF-alpha. The results of this study indicate that heat-denatured tumor extracts might elicit protective anti-tumor adaptive immune responses and also raise the possibility that a safe and efficient adjuvant-free tumor vaccine might be developed in conjunction with a dendritic cell-based tumor vaccine.

A modified free gingival graft technique for the treatment of oro-antral sinus track: A case report / 대한치주과학회지

PURPOSE: Surgical intervention into the maxillary posterior area can lead to inadvertent communication with the maxillary sinus. Spontaneous healing of 1 to 2 mm openings can occur. However, in patients with larger oro-antral communications and those with a history of sinus disease, surgical closure is often indicated. MATERIALS AND METHODS: In this case, a modified free gingival graft technique was used. The oro-antral sinus track after extraction was about 2x4 mm. But the patient had a history of Caldwell-Luc operation. Immediately after extraction, a modified free gingival graft was used for the closure of oro-antral sinus track. RESULT: A modified free gingival graft technique was successfully used for the closure of oro-antral sinus track. With this technique, esthetic results including similar colors, textures were achieved. CONCLUSION: It is thought that this technique is very useful in the closure of oro-antral sinus track.

Surgical Experiences of Functioning Neuroendocrine Neoplasm of the Pancreas

We present our surgical experiences with functioning neuroendocrine neoplasms of the pancreas to define its natural history, and to suggest its proper management. From June 1990 to June 2005, patients with diagnosis of functioning neuroendocrine (islet cell) neoplasms of the pancreas were retrospectively reviewed. Fourteen patients (5 men and 9 women) with a median age of 49 years (range, 12 - 68 years) were identified. Twelve patients (86%) had insulinoma, two (14%) had gastrinoma. One (7%) with pancreatic insulinoma was multiple endocrine neoplasia type 1. Intraoperative ultrasound scan (sensitivity, 83%) was the most powerful modality for tumor localization. Fifteen neoplasms with median tumor size 1 cm (range 0-3 cm) were resected. Four insulinomas (26.7%) were located in the head of the pancreas and 5 (36%), in the tail. Another 5 (36%) insulinomas and 1 (7%) gastrinoma were located around the neck area near the SMV or PV. Eleven patients (79%) underwent enucleation, and 2 patients (14%), distal pancreatectomy with splenectomy. 100% of patients with functioning neuroendocrine neoplasms of the pancreas have survived. The overall disease free 10-year survival was found to be about 81%. Exact localization of tumor by intraoperative ultrasound and surgical removal are promising for good prognosis.

Surgical Experiences of Functioning Neuroendocrine Neoplasm of the Pancreas

We present our surgical experiences with functioning neuroendocrine neoplasms of the pancreas to define its natural history, and to suggest its proper management. From June 1990 to June 2005, patients with diagnosis of functioning neuroendocrine (islet cell) neoplasms of the pancreas were retrospectively reviewed. Fourteen patients (5 men and 9 women) with a median age of 49 years (range, 12 - 68 years) were identified. Twelve patients (86%) had insulinoma, two (14%) had gastrinoma. One (7%) with pancreatic insulinoma was multiple endocrine neoplasia type 1. Intraoperative ultrasound scan (sensitivity, 83%) was the most powerful modality for tumor localization. Fifteen neoplasms with median tumor size 1 cm (range 0-3 cm) were resected. Four insulinomas (26.7%) were located in the head of the pancreas and 5 (36%), in the tail. Another 5 (36%) insulinomas and 1 (7%) gastrinoma were located around the neck area near the SMV or PV. Eleven patients (79%) underwent enucleation, and 2 patients (14%), distal pancreatectomy with splenectomy. 100% of patients with functioning neuroendocrine neoplasms of the pancreas have survived. The overall disease free 10-year survival was found to be about 81%. Exact localization of tumor by intraoperative ultrasound and surgical removal are promising for good prognosis.

Alteration of Innate Immune T and B Cells in the NC/Nga Mouse

BACKGROUND: Millions of people in the world are suffering from atopic dermatitis (AD), which is a chronic inflammatory skin disease triggered by Th2 immune responses. The NC/Nga mouse is the most extensively studied animal model of AD. Like human AD, NC/Nga mice demonstrate increased levels of IgE, a hallmark of Th2 immune responses. Adaptive immunity cannot be generated without help of innate immunity. Especially natural killer T (NKT) cells and marginal zone B (MZB) cells have been known to play important roles in linking innate immunity to adaptive immunity. METHODS: Through flow cytometric analysis and ELISA assay, we investigated whether these lymphocytes might be altered in number in NC/Nga mice. RESULTS: Our data demonstrated that the number of NKT cells was reduced in NC/Nga mice and IFNgamma production by NKT cells upon alpha-GalCer stimulation decreased to the levels of CD1d KO mice lacking in NKT cells. However, reduction of NKT cells in NC/Nga mice was not due to CD1d expression, which was normal in the thymus. Interestingly, there was a significant increase of CD1d(high)B220+ cells in the spleen of NC/Nga mice. Further, we confirmed that CD1d(high)B220+ cells are B cells, not dendritic cells. These CD1d(high)B220+ B cells show IgM(high)CD21(high)CD23low, a characteristic phenotype of MZB cells. CONCLUSION: We provide the evidence that there are decreased activities of NKT cells and increased number of MZB cells in the NC/Nga mice. Our findings may thus explain why NC/Nga mice are susceptible to AD.

Malignant Fibrous Histiocytoma with Type I Neurofibromatosis

Type I neurofibromatosis is an autosomal dominant disorder that occurs in 1 of 3, 000 births. It is characterized by multiple cutaneous neurofibromas, cafe-au-lait spots of the skin. Patients with neurofibromatosis are at increased risk of developing malignancies, particularly neural crest and other non-neural crest neoplasms. The term `malignant fibrous histiocytoma' was first introduced in 1963 to refer to a group of soft tissue tumors characterized by a storiform or cartwheel like growth pattern. Malignant fibrous histiocytomas are the most common type of soft tissue sarcoma that occurs in late adult life. Herein, our recent experienced a case of a malignant fibrous histiocytoma in a 28 year-old female with type I neurofibromatosis is reported, with a review of the literature.

Prognostic Factors in Axillary Lymph Node Negative Breast Cancer / 한국유방암학회지

PURPOSE: With the increase of early breast cancer patients, the number of node negative breast cancer patients is also on the rise. However, reports show that there is a 20~30% recurrence in node negative breast cancer. Thus, we have attempted to determine the prognostic factors that may affect recurrence and relapse free survival. METHODS: From January, 1980, to June, 1999, 1110 node negative breast cancer patients who underwent curative surgery at the Severance Hospital, Yonsei University College of Medicine, were selected. A retrospective study was done to determine the effects of factors, such as operation method, age, size, type, histologic grade, intraductal components, ER, PR, c-erbB-2, number of lymph nodes removed, adjuvant chemotherapy, hormonal therapy and radiation therapy. RESULTS: The mean age was 47.2 years. The median follow- up period was 88 months. Recurrence occurred in 161 patients. Locoregional recurrence occurred in 64 patients, and systemic recurrence in 129 patients, while 32 patients had both. The 5 years overall survival rate was 93.3%. The rate of locoregional recurrence for a 10 year-period was significantly lower in the mastectomy group compared with that in the breast conservation therapy group (94.7% vs 79.6%, P=0.000). No other prognostic factors except the age affected in locoregional recurrence. There was less systemic recurrence in patients with the age greater than 35, with the histologic grade I, and with the intraductal components greater than 20%. Thus, 10-years distant relapse free survival rates were 87.4% vs 79.8% (P=0.039), 93.5% vs 85.5% (P=0.024), and 94.4% vs 82.0% (P=0.007), respectively. There was no statistical significance in the other prognostic factors that influence systemic recurrence. CONCLUSION: The patients' age was determined to be an independent prognostic value in the lymph node negative breast cancer. The histologic grade and intraductal components showed to have significance as prognostic factors for systemic recurrence.

Percutaneous Cholecystostomy Using Central Venous Catheterization Set with Blue FlexTip Catheter / 한국간담췌외과학회지

PURPOSE: Percutaneous cholecystostomy (PC) using a pig-tail catheter is indicated for high risk acute cholecystitis. However, this procedure is time consuming, expensive and requires radiological equipment. This study compared PC using a pig-tail catheter with central venous catheterization set. METHODS: From January 1992 to June 2003, 44 patients underwent PC without a malignancy or a combined hepato- biliary-pancreatic disease were selected. A retrospective study was performed on the time interval to procedure, cost, complications and therapeutic results of the central venous catheter group (A, 15) and the pig-tail catheter group (B, 29) RESULTS: The time interval was 1.8 days in group A, 3.52 in group B (p=0.002). The cost was 188,684 won in group A, 327,814 won in group B. There were 4 complications in group A (2 leakage, 1 dislodgment, 1 malfunction) while 5 in group B (2 dislodgement, 1 sepsis, 2 malfunction). Although PC, 2 in group A and 5 in group B were discharged hopelessly or died due to the progression of the underlying disease. Twenty-two patients underwent a delayed cholecystectomy with 7 patients in group A (3 laparoscopy, 4 open) and 15 in group B (6 laparoscopy, 8 open, 1 conversion to open). The complication rate was slightly high in group A but there were no statistical significance, no clinical problems and no difference in the mortality rate and surgical method. CONCLUSION: In high risk acute cholecystitis, PC using central venous catheter is easy, economic, effective and performed at early stage in the emergency room by medical doctors or surgeons.