A Case of Super-giant Basal Cell Carcinoma Initially Diagnosed as Multiple Traumas.

Basal cell carcinoma (BCC), which is relatively easy to diagnose in a clinical setting, is the most common malignant tumor in the skin. Conversely, a giant BCC, a tumor beyond 5 cm in diameter, is a rare disease. In particular, a giant BCC beyond 20 cm in diameter is called a super-giant BCC, which frequently invades into deeper tissues, including the dermis, bones, or muscles. Here, we present a case of a 71-year-old patient who was initially diagnosed with multiple traumas with a large periosteal defect of the head. The ulcer was surrounded by malodorous necrotic tissue and slough, and several bacteria that caused necrotizing fasciitis were detected. Mapping biopsies after extensive debridement yielded BCC, and therefore, he was finally diagnosed with a super-giant BCC. A careful consultation revealed a history of ulcer on the head after a head injury approximately 10 years ago. He underwent radical dissection including the external table of the skull, followed by a free latissimus dorsi muscle flap with a meshed split-thickness skin graft. Because of the slow and chronic development of a super-giant BCC, accurate diagnosis is often difficult. Careful attention should be paid in patients with long-sustained ulcers.

Nonincisional Osteotomy for Gradual Lengthening by Callus Distraction for Congenital Brachymetatarsia.

Gradual lengthening by distraction osteogenesis is widely used for congenital brachymetatarsia. The usual presenting complaint is the patient's cosmetic appearance. Osteotomy is an integral element. A nonincisional surgical approach for osteotomy can reduce dorsal longitudinal scarring and help preserve the periosteal blood supply to the bone during surgical dissection. Between June 2003 and January 2019, we performed gradual lengthening by callus distraction with nonincisional osteotomy for congenital brachymetatarsia on 13 digits in 5 patients. All 5 patients were female, and their average age was 18 years old. The lengthened bones involved 3 first metatarsals, 2 third metatarsal, and 8 fourth metatarsal bones. The mean gain in length was 15.2 mm (10-21 mm). The mean duration of distraction was 36.2 days (30-48 days). The mean duration of consolidation was 62.8 days (28-103 days). The lengthened segment consolidated in all cases. One patient had early consolidation and did not wish to undergo further surgery. There were no cases of trouble due to drilling for osteotomy. All patients had a normal gait and were satisfied with the cosmetic results.

Reconstruction of the Midfoot Area with Vascularized Chimeric Osteocutaneous Scapula Flap: A Case Report.

We report a case of reconstruction of a left midfoot defect with a chimeric partial scapula and skin flap in a 20-year-old man. After radical debridement, bone and soft tissue defects were reconstructed with a chimeric scapula and skin flap. The postoperative course was uneventful. The patient could walk well without support, and bone union was achieved 6 months after surgery. In 14 months of follow-up, no clinical complications (including new ulcer or stress fracture) were noted and full ambulation was achieved, with the patient returning to his previous work. We suggest that the chimeric scapula and skin flap may be a useful alternative option for midfoot reconstruction.

Reconstruction of E. coli Osteomyelitis of Costa: A Case Report.

We report a case of E. coli osteomyelitis of the ribs in an immunocompetent 66-year-old man. After radical surgical debridement, bone and soft-tissue defects were covered with a rectus abdominis muscle flap. The postoperative course was uneventful, and there was no recurrence of chest symptoms. Among the various types of osteomyelitis, Gram-negative bacteria such as E. coli osteomyelitis is a relatively rare disease. Osteomyelitis is known to supervene in trauma or postoperative infection and to frequently begin with cellulitis, vascular access, endocarditis, or urinary tract infection, which spreads through the blood to the bone. To add to the difficulty of making a correct diagnosis, the early symptoms of osteomyelitis are often non-specific. We should never forget osteomyelitis in the differential diagnosis of these antecedent infections.

N-terminal pro-BNP is a novel biomarker for integrated cardio-renal burden and early risk stratification in patients admitted for cardiac emergency.

BACKGROUND: The expanding role of cardiac markers - cytosolic [heart-type fatty acid-binding protein (H-FABP) and creatine kinase MB (CK-MB)], myofibril [troponin T (TnT)], and cardio-endocrine [N-terminal pro-B-type natriuretic peptide (NT-proBNP)] - has been clarified in patients with acute coronary syndrome and those with heart failure. However, these applications for early risk stratification in the cardiac emergency, and the influence of renal function on these evaluations have not been fully investigated. PATIENTS AND METHODS: We investigated the prognostic value of these representative cardiac markers and influence of renal function on these evaluations in 165 consecutive patients who were admitted for cardiac emergency because of chest pain or dyspnea. RESULTS: There were significant correlations between TnT and CK-MB (r=0.512, p<0.001), and between H-FABP and TnT (r=0.409, p<0.001) and CK-MB (r=0.254, p<0.01); however, NT-proBNP levels did not show significant correlations with other cardiac markers. There were significant correlations between estimated glomerular filtration rate and NT-proBNP (r=-0.466, p<0.001) and H-FABP (r=-0.235, p<0.001) levels, and between left ventricular ejection fraction (LVEF) and NT-proBNP (r=-0.407, p<0.001) and H-FABP (r=-0.253, p<0.01) levels. Kaplan-Meier analysis showed that median of NT-proBNP, H-FABP, and CK-MB significantly discriminated in-hospital cardiovascular death, and multivariate analysis revealed NT-proBNP and LVEF as independent prognostic predictors. CONCLUSION: NT-proBNP is a novel biomarker for integrated cardio-renal burden, and extremely useful for early risk stratification in the situation of cardiac emergency.

Solubilization of n-alkylbenzenes into decanoyl-N-methylglucamide (Mega-10) solution; temperature dependence.

Solubilization of benzene, toluene, ethylbenzene, n-propylbenzene, n-butylbenzene, n-pentylbenzene, and n-hexylbenzene into micelles of decanoyl-N-methylglucamide (Mega-10) was studied at 303.2, 308.2, 313.2, and 318.2K, where equilibrium concentrations of the above solubilizates were determined spectrophotometrically. The concentration of the above solubilizates remained constant below the critical micelle concentration (cmc) and increased linearly with an increase in Mega-10 concentration above the cmc at each temperature above. The Gibbs free energy change of the solubilizates from aqueous bulk to their liquid solubilizate phase was evaluated from dependence of their aqueous solubility on alkyl chain length of the solubilizates, which leads to the DeltaG(CH0)(2) values (-3.60 to -3.38 kJ mol(-1)), the energy change per CH2 group of the alkyl chain with no strong temperature dependence. The first stepwise solubilization constant (K1) was evaluated from the slope for the change of solubilizate concentration vs. Mega-10 concentration. The Gibbs free energy change (DeltaG(0,s)) for the solubilization decreased linearly with the carbon number of alkyl chain of the solubilizates, and the DeltaG(CH0)(2)(s) values (-2.71 to -2.54 kJ mol(-1)) obtained from the linearity showed a slight increase with temperature. The DeltaG(CH0)(2) values are less than the DeltaG(CH0)(2)(s) values, where the latter values clearly indicate that the location of alkyl chain is a hydrophobic micellar core. The fact is also supported by the absorption spectrum of the solubilized molecules. Temperature dependence of DeltaG(0,s) indicated that the solubilization is entropy-driven for the solubilizates with shorter alkyl chains, while it becomes enthalpy-driven for those with longer alkyl chains.

Hydrolysis of ionized deoxycholic acid in the aqueous phase and rate analysis for transfer of neutralized deoxycholic acid into the benzene phase across the benzene/water interface.

Sodium deoxycholate in water dissociates into sodium cation and deoxycholate anion in the aqueous phase, and then, the latter anions partially hydrolyze to form deionized deoxycholic acids. The acids move into the benzene phase, when liquid benzene is placed upon the aqueous phase, and finally the partition equilibrium is reached. The above processes were traced by pH change in the aqueous phase by a pH meter or the change in [OH-] with time, from which the rate for transfer of neutralized acid to the organic phase was analyzed. From the trace, the rate constants for hydrolysis of acid anion ( kf), neutralization of acid ( kb), transfer of neutralized acid from the aqueous phase to the organic phase ( kin*), and its back-transfer from the organic phase to the aqueous phase ( kut*) were evaluated; kf = 2.18 x 10 (-4) mol (-1) dm (3) min (-1), kb = 1.24 x 10 (5) mol (-1) dm (3) min (-1), kin* = 4.06 x 10 (-1) min (-1) cm (-2), and kout*) = 8.00 x 10 (-2) min (-1) cm (-2). The above values are supported by the partition constant of deoxycholic acid between the benzene phase and the aqueous phase.

Solubilization of n-alkylbenzenes into decanoyl-N-methylglucamide (Mega-10) solution.

Solubilization of benzene, toluene, ethylbenzene, n-propylbenzene, n-butylbenzene, n-pentylbenzene, and n-hexylbenzene into micelles of decanoyl-N-methylglucamide (Mega-10) was studied, where equilibrium concentrations of the above solubilizates were determined spectrophotometrically at 303.2 K. The concentration of the above solubilizates remained constant below the critical micelle concentration (cmc) and increased linearly with an increase in Mega-10 concentration above the cmc. The Gibbs free energy change of the solubilizates from the aqueous bulk to the liquid solubilizate phase was evaluated from the dependence of their aqueous solubility on the alkyl chain length of the solubilizates, which leads to -3.46 kJ mol-1 for DeltaG(0)(CH), the energy change per CH2 group of the alkyl chain. The first stepwise solubilization constant (K(overline)1 ) was evaluated from the slope of the change of solubilizate concentration versus Mega-10 concentration. The Gibbs free energy change (DeltaG(0,s)) for the solubilization decreased linearly with the carbon number of the alkyl chain of the solubilizates, from which DeltaG(0,s)(CH2) as evaluated to be -2.71 kJ mol-1. The similar values above clearly indicate that the location of the alkyl chain is a hydrophobic micellar core, which is also supported by the absorption spectrum of the solubilized molecules.

Difference in elevation of N-terminal pro-BNP and conventional cardiac markers between patients with ST elevation vs non-ST elevation acute coronary syndrome.

BACKGROUND: N-terminal pro-B-type natriuretic peptide (NT-proBNP) is elevated in patients with acute coronary syndrome (ACS), and is a powerful predictor of long-term mortality. Differences in the clinical utility and pathophysiological implication of NT-proBNP and conventional cardiac markers in patients with ST elevation (STE) vs non-STE (NSTE) ACS were investigated in the present study. METHODS AND RESULTS: Ninety consecutive patients admitted with acute chest pain and a diagnosis of unstable angina or acute myocardial infarction were analyzed. Patients with >or=Killip class II were excluded to focus on the effect of myocardial ischemia on the release of cardiac markers. The markers were measured on admission and analyzed according to the time from onset. Conventional cytosolic marker (creatine kinase-MB) and myofibril marker (troponin T: TnT) were both significantly higher in STE-ACS patients compared with NSTE-ACS patients. Conversely, NT-proBNP was significantly higher in NSTE-ACS patients than STE-ACS especially within 3 h of onset, suggesting a larger ischemic insult despite the smaller extent of myocardial necrosis compared with STE-ACS patients. There was no significant correlation between NT-proBNP level and left ventricular ejection fraction (LVEF) obtained at acute-phase echocardiography in either NSTE-ACS patients (LVEF 57.7+/-11.2%) or STE-ACS patients (LVEF 55.1+/-12.7%). Comparison between NT-proBNP and TnT levels revealed a marked difference of elevations, with significantly augmented elevation of NT-proBNP (p<0.001) in NSTE-ACS patients as compared with prominent elevation of TnT in STE-ACS patients. CONCLUSIONS: NT-proBNP is an early sensitive marker of myocardial ischemia that rises much higher in the earlier phase as compared with conventional markers of myocardial damage, especially in NSTE-ACS patients.

[Multi-biomarker approach to acute coronary syndrome].

High-risk acute coronary syndrome is characterized by vulnerable-plaque with subocclusive thrombus and down-stream microemboli spreading minor myocardial damage, resulting in non-ST-elevation myocardial infarction. Advances in the understanding of the pathogenesis and consequences of acute coronary syndrome have stimulated development of novel biomarkers, and expanded their role in the different spectrum of the underlying pathophysiology, namely multi-biomarker strategy; consisted of biomarkers for 1) myocardial necrosis(membrane damage to myofibril necrosis), 2) plaque destabilization, 3) myocardial stress(ischemic stress per se and end-diastolic atrial or ventricular wall stress), 4) myocardial ischemia, and 5) inflammatory process. In this article, we review clinical importance of novel biomarkers referring our previous clinical investigation and other reports, especially troponin T for detection of minor myocardial damage associated with vulnerable plaque with thrombus/embolus, heart-type fatty acid -binding protein for earlier detection of myocardial damage and it's role for the rule-out triage, N-terminal pro-BNP for earlier risk stratification in cardiac emergency, and soluble CD40 ligand for earlier identification of plaque destabilization with platelet activation in non-ST-elevation acute coronary syndrome.

A kinetic and thermodynamic study on hydrolysis of sodium laurate in aqueous phase accompanied by transfer into oil phases containing different organic additives (I).

The kinetic and thermodynamic behavior at the interface between an aqueous solution of sodium laurate (NaLA) and various oil phases comprised primarily of benzene (Bz) and/or different organic compounds including amphiphiles has been investigated in regard to the hydrolysis of NaLA accelerated at the interface, transfer of lauric acid (LA) into oil phase and reverse transfer of Bz into aqueous phase in addition to interface tension. The contact of aqueous NaLA solution with the oil phase was found to accompany the mass transfer of LA and simultaneously promote the hydrolysis of NaLA in water phase. Analysis of the change of OH- ion concentration ([OH-]) over time allowed us to treat the events as a first order reaction. From the rate constant data the activation parameters such as the activation enthalpy and entropy, both of which control the transfer of LA molecules, were determined. The parameters were found to depend greatly on varied situations of the oil phase, being clearly able to explain the physicochemical behavior of the interface. Comparing the cases where the oil phase is one of the respective single systems such as Bz, dodecane (C12) and dodecylbenzene (C12Bz), C12Bz resulted in the lowest rate constant. The transfer (or hydrolysis) rate was measured for the amphiphile-added oil systems as a function of amphiphile concentration. When 0.206 M C16OH-Bz came in contact with aqueous phase, emulsion formation at the interface layer was brought about with approximately zero activation enthalpy, leading to facile or spontaneous transfer of LA. In addition, UV absorbance representing the transfer of Bz from the oil phase to the aqueous phase also demonstrated the effects of added amphiphiles on the action of the interface.

Application of NT-proBNP and BNP measurements in cardiac care: a more discerning marker for the detection and evaluation of heart failure.

BACKGROUND: Measurement of brain natriuretic peptide (BNP) has become a potent diagnostic aid as a means of identifying patients with systolic or diastolic dysfunction. Due to better stability in circulating blood, we reasoned that measurement of N-terminal proBNP (NT-proBNP) may be a more discerning marker for the detection and evaluation of chronic heart failure. METHODS: The relationships between plasma concentrations of NT-proBNP and BNP, and aetiology, New York Heart Association (NYHA) classification, and left ventricular ejection fraction (LVEF) were analyzed in 105 patients with chronic heart failure. Sixty-seven healthy volunteers were studied as the controls. RESULTS: Both NT-proBNP and BNP showed progressive increases (P<0.001) in proportion to the NYHA classification; the increment of NT-proBNP was larger than that of BNP. Elevated NT-proBNP significantly correlated with BNP (r=0.737, P<0.001). Receiver operating characteristics analysis to detect LVEF<40% showed similar values (area under the curve, AUC: NT-proBNP 0.754 vs. BNP 0.770), however, AUC to detect LVEF<50% tended to be greater for NT-proBNP than that for BNP (NT-proBNP 0.820 vs. BNP 0.794). CONCLUSION: NT-proBNP may be a more discerning marker for the detection and evaluation of heart failure than BNP.