The Impact of Obesity on Success of Immediate Lymphatic Reconstruction for Prevention of Breast Cancer-Related Lymphedema.

BACKGROUND: Breast cancer-related lymphedema (BRCL) is a potential sequela of high-risk breast cancer treatment. Preventive treatment with immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection (ALND) has emerged as the standard of care; however, there is relatively little known about factors that may contribute to procedural failure. METHODS: A retrospectively maintained, institutional review board-approved study followed patients who underwent ILR at the time of ALND at our tertiary care center between May 2018 and May 2023. Patients who presented for at least one follow-up visit in our multidisciplinary lymphedema clinic met the criteria for inclusion. Patients who developed lymphedema despite ILR and potential contributing factors were further explored. RESULTS: 349 patients underwent ILR at our institution between May 2018 and May 2023. 341 of these patients have presented for follow-up in our multidisciplinary lymphedema clinic. 32 (9.4%) patients developed lymphedema despite ILR. This cohort was significantly more likely to be obese (56% vs 35%, P = 0.04). Multivariate logistic regression demonstrates increased odds of procedural failure in patients with a body mass index (BMI) ≥30 kg/m2 (odds ratio 2.6 [1.2-5.5], P = 0.01). CONCLUSION: These data comment upon our institutions outcomes following ILR. Patients who develop lymphedema despite ILR tend to have a higher BMI, with a significantly increased risk in patients with a BMI of 30 or greater. Consideration of these data is critical for preprocedural counseling and may support a BMI cutoff when considering candidacy for ILR going forward, as well as when optimizing failures for secondary lymphedema procedures.

Breastfeeding Ability After Breast Reductions: What does the Literature Tell us in 2023?

INTRODUCTION: Reduction mammaplasties are routinely performed on women of child-bearing age, yet there still exists some uncertainty regarding a patient's ability to breastfeed following the procedure. This is due to inconsistent definitions of "successful" breastfeeding, a variety of pedicles implemented, and inadequate follow-up in the published literature. Our aim was to summarize the current data and provide clear recommendations for counseling patients on expected breastfeeding outcomes following reduction mammaplasty. METHODS: A systematic review and meta-analysis in accordance with the PRISMA guidelines was conducted. We included papers that reported proportion of breastfeeding ability following reduction mammaplasty. RESULTS: We identified 33 papers that met our inclusion criteria. We found that women who undergo reduction mammaplasty are at a 3.5 times increased odds of not being able to breastfeed compared to controls. Overall, reduction mammaplasty patients have a breastfeeding success rate of 62%. The breastfeeding success rate for patients with inferior pedicles was 64%, superior pedicles was 59%, and lateral pedicles was 55%. No conclusions could be drawn regarding medial, central, vertical, and horizontal pedicles on breastfeeding ability. CONCLUSION: Current data suggest that women undergoing reduction mammaplasty have an increased odds of unsuccessful breastfeeding when compared to similar women who have not undergone the procedure. Based on the current literature, pedicle type does play a role in rate of breastfeeding success, although there is a need for further research on the aforementioned pedicles. Physicians should be aware of the likelihood of successful breastfeeding following reduction mammaplasty so that patients can be more thoroughly counseled prior to a decision for surgery. LEVEL OF EVIDENCE I: 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 .

Immediate Lymphatic Reconstruction in 77 Consecutive Breast Cancer Patients: 2-year Follow-up.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a cyclical, progressive disease that begins at the time of axillary dissection and worsens in the setting of adjuvant oncologic therapies. The paradigm of lymphedema management in these patients is shifting from therapeutic surgeries and decongestive therapy to preventative surgery with immediate lymphatic reconstruction (ILR). METHODS: After institutional review board approval, a prospective database was maintained of all patients undergoing ILR. Patients were excluded if they had preoperative lymphedema or expired during the study period. All ILR were performed by the senior author. A control group was established with standardized physician delivered phone surveys of patients who had axillary dissection for breast cancer (same oncologic surgeon cohort) prior to the implementation of ILR at the same institution. The study and control groups were matched based on history of adjuvant radiation and body mass index. RESULTS: A cohort of patients between 2016 and 2019 with 2 years of follow-up after undergoing ILR (77 patients) were matched with those who did not undergo lymphatic reconstruction (94 patients). The incidence of lymphedema in the study group undergoing ILR was 10% (N = 8). In comparison, the incidence in the cohort who did not undergo lymphatic reconstruction was 38% (N = 36; p < 0.01). Patients with ILR had 92% lower odds of developing lymphedema (p < 0.01). CONCLUSION: ILR can significantly reduce the risk of developing BRCL in high-risk patients at 2 years of follow-up. Patients receiving adjuvant radiation therapy are more likely to develop BCRL after ILR compared with those who do not. Ongoing studies include investigation aimed at identifying patients most at risk for the development of BRCL to help target intervention as well as elucidate factors that contribute to the success of ILR.

Syringe Suction Yields Greater Adipocyte Viability for Fat Grafting: Fact or Fiction?

ABSTRACT: Autologous fat grafting is a technique that can be used for cosmetic and reconstructive indications such as oncologic defects, aging, trauma, and congenital malformations. However, there is no standardized technique, and one of the main challenges is the unpredictable rate of fat resorption. When using fat grafting, it is crucial to understand the different factors that contribute to adipocyte viability. A literature search, using PubMed, was conducted in 2022 with variations of the terms "autologous fat grafting," "fat harvesting," "fat processing," and "fat injection." Articles in the English language that presented original data about different factors that may affect adipocyte viability for fat grafting were included in this review. Syringe suction harvests (lower pressures), compared with other methods with higher pressures, were found to have increased adipocyte counts and viability, but this did not translate clinically during in vivo studies. The studies have shown that, despite our efforts in optimizing fat harvest, processing, and injection, no statistical or clinical differences have been found. Additional studies are still needed to determine a universal protocol for optimal fat graft survival.

Reliable Location of Upper Extremity Lymphatic Channels for Use in Immediate Lymphatic Reconstruction.

BACKGROUND: Breast cancer-related lymphedema (BCRL) is a limiting sequelae of breast cancer treatment that may negatively impact 30% to 50% of high-risk breast cancer survivors. Risk factors for development of BCRL include axillary lymph node dissection (ALND), and recently, axillary reverse lymphatic mapping and immediate lymphovenous reconstruction (ILR) at time of ALND have been implemented to prevent BCRL. Reliable anatomy of neighboring venules has been commented on in the literature; however, little information exists about anatomical location of local lymphatic channels amenable for bypass. METHODS: After institutional review board approval, patients who underwent ALND with axillary reverse lymphatic mapping and ILR at a tertiary cancer center from November 2021 to August 2022 were applicable for this study. The location and number of lymphatic channels used for ILR were identified and measured intraoperatively with the arm abducted to 90 degrees and soft tissue under no tension. Four measurements were taken to localize each lymphatic and were based on relationship with reliable anatomic landmarks including 4th rib, anterior axillary line, and lower border of the pectoralis major muscle. Demographics, oncologic treatments, intraoperative factors, and outcomes were prospectively maintained. RESULTS: Twenty-seven patients met inclusion for this study by August 2022 with a total of 86 lymphatic channels identified. Patients were on average 50 ± 12 years old with a body mass index of 30 ± 6 and had an average of 1 vein and 3 identifiable lymphatic channels amenable to bypass. Seventy percent of lymphatic channels were found in a cluster of 2 or more channels. The average horizontal location was 4.5 ± 1.4 cm lateral to the 4th rib. The average vertical location was 1.3 ± 0.9 cm from the superior border of the 4th rib. CONCLUSIONS: These data comment upon intraoperatively identified and consistent location of upper extremity lymphatic channels used for ILR. These lymphatic channels are often found in clusters with 2 or more lymphatic channels at the same location. Such insight may aid in easier intraoperative identification of amenable vessels for the unexperienced surgeon, decrease in intraoperative time, and higher success of ILR.

Efficacy of Immediate Lymphatic Reconstruction in Prevention of Breast Cancer-Related Lymphedema.

INTRODUCTION: Breast cancer-related lymphedema (BCRL) is a chronic condition that can negatively affect the quality of life of breast cancer survivors. Immediate lymphatic reconstruction (ILR) at the time of axillary lymph node dissection is emerging as a technique for the prevention of BCRL. This study compared the incidence of BRCL in patients who received ILR and those who were not amenable to ILR. METHODS: Patients were identified through a prospectively maintained database between 2016 and 2021. Some patients were deemed nonamenable to ILR due to a lack of visualized lymphatics or anatomic variability (eg, spatial relationships or size discrepancies). Descriptive statistics, independent t test, and Pearson χ 2 test were used. Multivariable logistic regression models were created to assess the association between lymphedema and ILR. A loose age-matched subsample was created for subanalysis. RESULTS: Two hundred eighty-one patients were included in this study (252 patients who underwent ILR and 29 patients who did not). The patients had a mean age of 53 ± 12 years and body mass index of 28.6 ± 6.8 kg/m 2 . The incidence of developing lymphedema in patients with ILR was 4.8% compared with 24.1% in patients who underwent attempted ILR without lymphatic reconstruction ( P = 0.001). Patients who did not undergo ILR had significantly higher odds of developing lymphedema compared with those who had ILR (odds ratio, 10.7 [3.2-36.3], P < 0.001; matched OR, 14.2 [2.6-77.9], P < 0.001). CONCLUSIONS: Our study showed that ILR was associated with lower rates of BCRL. Further studies are needed to determine which factors place patients at highest risk of developing BCRL.

Complications of Medical Tourism in Aesthetic Surgery: A Systematic Review.

INTRODUCTION: As medical cost continues to rise, so has the use of medical tourism by patients as a more cost-effective alternative. While the upfront cost savings attract many unsuspecting patients from their country of origin, there are significant patient safety issues surrounding short- and long-term follow-up, as well as the management and cost of complications. METHODS: A systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses on complications that presented after cosmetic surgeries performed abroad. The literature search was performed on October 18, 2022, using the databases of PubMed, Google Scholar, and Embase. RESULTS: From the 44 studies that were included, 589 patients were identified who presented with complications after having a cosmetic procedure abroad. Infection was the most prevalent complication in this study followed by wound dehiscence, seroma/hematoma, and tissue necrosis. Ninety-eight percent of the infectious organisms were bacterial, and 81% of them were from the Mycobacterium genus. CONCLUSIONS: Cosmetic tourism is a global phenomenon. This systematic review highlights the nature of complications following cosmetic tourism, the surgeries that resulted in complications, the countries that the primary procedures took place in, and the countries of origin of the patients. To aid in reducing morbidity and mortality from cosmetic tourism, regulatory bodies should educate and empower the public to aid them in making educated medical conditions when seeking care.

On the fat saturation effect in quantitative ultrashort TE MR imaging.

PURPOSE: To investigate the effect of fat saturation (FatSat) on quantitative UTE imaging of variable knee tissues on a 3T scanner. METHODS: Three quantitative UTE imaging techniques, including the UTE multi-echo sequence for T2∗ measurement, the adiabatic T1ρ prepared UTE sequence for T1ρ measurement, and the magnetization transfer (MT)-prepared UTE sequence for MT ratio (MTR) and macromolecular proton fraction (MMF) measurements were used in this study. Twelve samples of cartilage and twelve samples of meniscus, as well as six whole knee cadaveric specimens, were imaged with the three above-mentioned UTE sequences with and without FatSat. The difference, correlation, and agreement between the UTE measurements with and without FatSat were calculated to investigate the effects of FatSat on quantification. RESULTS: Fat was well-suppressed using all three UTE sequences when FatSat was deployed. For the small sample study, the quantification difference ratio (QDR) values of all the measured biomarkers ranged from 0.7% to 12.6%, whereas for the whole knee joint specimen study, the QDR values ranged from 0.2% to 12.0%. Except for T1ρ in muscle and MMF in meniscus (p > 0.05), most of the measurements showed statistical differences for T1ρ , MTR, and MMF (p < 0.05) between FatSat and non-FatSat scans. Most of the measurements for T2∗ showed no significant differences (p > 0.05). Strong correlations were found for all the biomarkers between measurements with and without FatSat. CONCLUSION: The UTE biomarkers showed good correlation and agreement with some slight differences between the scans with and without FatSat.

Complication Profile of Total Submuscular Versus Prepectoral Tissue Expander Placement: A Retrospective Cohort Study.

BACKGROUND: We sought to compare the safety profile of prepectoral breast reconstruction with total submuscular tissue expander reconstruction, previously our standard. Primary outcomes of interest in this retrospective cohort study were incidence of infection, hematoma, seroma, mastectomy flap necrosis, and reconstruction loss. METHODS: Total submuscular and prepectoral with acellular dermal matrix reconstructions consecutively performed by a single surgeon (P.D.S.) between January 1, 2016, and December 31, 2019, were compared. Demographic and clinical characteristics, as well as complications and complication types, were extracted for all patients. A t test was used to assess differences in continuous variables. Multivariate logistics regression was used to assess the association between type of reconstruction and complication rate. The statistical significance was set at 0.05 for all comparisons. RESULTS: A total of 133 patients (234 breasts) were included. There was a significantly greater incidence of infection (16.5% vs 5.5%, P < 0.01) in the prepectoral/acellular dermal matrix cohort. However, reconstructive loss was low in both cohorts (2.5% and 3.0%, P = 0.83). Adjusted odds ratio for complications in the prepectoral cohort was 2.26, but this was not statistically significant (adjusted P = 0.24). CONCLUSIONS: Prepectoral breast reconstruction shares an overall complication profile that is not greater than that of total submuscular reconstruction. It is associated with a greater risk of infection; however, the ability to salvage the reconstruction with early, aggressive intervention results in low rates of reconstructive loss, comparable with those of total submuscular reconstruction.

The immunologic response to severe acute respiratory syndrome coronavirus 2.

Background: The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has precipitated the worst global pandemic in a century, which has caused millions of infections and deaths as well as massive economic repercussions. Objective: As with any pathogenic virus, it is crucial to understand its unique interactions with the human immune system so that pharmaceutical and prophylactic interventions can be deployed to effectively control the pandemic. Methods: A literature search by using PubMed was conducted in 2020 with variants of the terms "COVID-19," "SARS-CoV-2," and "immunological response." English language articles that presented original data about the immunologic response to coronavirus disease 2019 (COVID-19) were selected for review. This article reviewed the current understanding of the innate and adaptive immune responses to SARS-CoV-2 infection, including their relationship to current therapeutic and diagnostic strategies. Results: SARS-CoV-2 uses several unique molecular techniques to evade detection by the innate immune system early in the course of infection, and upregulation of these innate immune pathways may possibly accelerate the time to recovery and prevent severe disease. Although the majority of cases results in the patients' recovery, a significant proportion of infections result in deaths prompted by the host's inflammatory overreaction to the infection, a response that can be attenuated with corticosteroids and potentially other immune modulators. Conclusion: Current work by the scientific community to further understand how SARS-CoV-2 interacts with the human immune system will be invaluable to our response and preparedness for future coronavirus pandemics.

Novel fluorescent staining protocol for thick sections of human osteochondral tissues to facilitate correlation with MRI and CT.

OBJECTIVE: To describe a novel fluorescent histochemical protocol to visualize osteoclasts, vasculature, and nerves in thick sections of human osteochondral tissues and to demonstrate its feasibility for use in radiologic-pathologic research correlation studies. MATERIALS AND METHODS: Consecutive patients scheduled for total knee arthroplasty surgeries underwent pre-operative MRI. CT imaging was performed after tissue collection, and abnormal osteochondral regions were sectioned to 1-2 mm in thickness and decalcified. Fluorescent labeling of osteoclasts was performed by staining for tartrate-resistant alkaline phosphatase activity with a fluorescent substrate. Vascular structure was visualized with fluorescently labeled lectin Ulex europaeus Agglutinin I (UEA-I). Immunostaining was performed for proteins including smooth muscle actin expressed in smooth muscle cells surrounding arterioles and fibrotic myofibroblasts, as well as for neuropeptide Y expressed in sympathetic nerves. Sections were then recut at 5 µm and stained with hematoxylin and eosin (H&E). RESULTS: Edema-like and cyst-like regions identified with MRI and CT were easily located in fluorescent images and appeared to have increased osteoclast activity. Fibrotic regions were identified with thickened arterioles and increased myofibroblasts. Sympathetic nerve fibers traveled alongside arborizing blood vessels. Stained sections became transparent in a water-based refractive index-matched medium, permitting deep 3D visualization of the elaborate neurovascular network in bone. Sequential staining procedures were successfully performed with the same sections, demonstrating the potential to compare multiple cellular markers from the same locations. Routine H&E staining could be performed after the fluorescent staining protocol. CONCLUSION: We have developed a multimodal framework to facilitate comparisons between histology and clinical MRI and CT.

Preservation of the Implant in Nipple-Sparing Mastectomies: A Retrospective Cohort Study.

BACKGROUND: Mastectomies are an integral part of breast cancer treatment for many patients.1 Of those patients, a significant number have previously undergone breast augmentation before being diagnosed with breast cancer. Therefore, we developed the novel technique of performing nipple- and implant-sparing mastectomies (NISMs) for women with prior breast augmentations. This study will assess the plausibility of using NISMs versus nipple-sparing mastectomies (NSMs) in this subgroup of patients by comparing the complication rates. METHODS: Data were collected on age, tumor size, tumor grade, receptors, and the interval between mastectomy and implant exchange for both groups. Descriptive statistics were used to summarize patient characteristics. Independent samples t tests, χ2 tests, and Fisher exact tests were used to compare the NISM and NSM cohorts. Logistic regression was used to assess the association between complications and mastectomy type and was summarized as an odds ratio with a 95% confidence interval. RESULTS: Fifteen patients underwent an NISM and 35 patients underwent an NSM. The overall rate of complications was less in NISM cases than in NSM cases (20% vs 27%). However, this difference was not statistically significant (odds ratio, 0.54; 95% confidence interval, 0.18-1.64; P = 0.278). CONCLUSIONS: The overall complication rate was lower with NISMs compared with NSMs. Nipple- and implant-sparing mastectomy is a novel, viable, and safe option for patients with breast cancer and a history of submuscular breast augmentation.

The Learning Curve: Trends in the First 100 Immediate Lymphatic Reconstructions Performed at a Single Institution.

BACKGROUND: Cancer-related lymphedema will affect 10% to 50% of breast cancer survivors. Early data show that immediate lymphatic reconstruction may help prevent breast cancer lymphedema; however, the details have not been fully elucidated. The purpose of this study was to evaluate the cohort of our first 100 patients for trends in demographics, treatment, and technique. METHODS: At a tertiary care cancer center, high-risk breast cancer-related lymphedema patients underwent axillary reverse lymphatic mapping and immediate lymphatic reconstruction. After institutional review board approval, demographics, technique, and outcomes were recorded. The first 100 patients were analyzed to compare the differences between the first 50 versus the second 50 patient cohorts. RESULTS: Of the first 100 axillary reverse lymphatic mapping performed, there was a significant difference in neoadjuvant chemotherapy with 81% in the earlier cohort versus 98% in the later cohort (P = 0.01). An arborized technique was used more frequently in the second cohort (82% vs 54%, P = 0.01). The incidence of lymphedema was lower in the latter cohort (7 patients vs 1 patient, P = 0.03). The first cohort was 12.2 times more likely to develop lymphedema despite lymphatic reconstruction than the second cohort (P = 0.03). CONCLUSIONS: The data demonstrate multiple trends in the learning curve associated with immediate lymphatic reconstruction at a single institution including improvements in identifying and dissecting lymphatic structures, performing more anastomoses per patient, using the arborized technique more frequently, performing the operation with shorter operative times, and reducing the incidence of lymphedema.

Fast quantitative three-dimensional ultrashort echo time (UTE) Cones magnetic resonance imaging of major tissues in the knee joint using extended sprial sampling.

The purpose of this study is to investigate the effect of extending the spiral sampling window on quantitative 3D ultrashort echo time (UTE) Cones imaging of major knee joint tissues including articular cartilage, menisci, tendons and ligaments at 3 T. Nine cadaveric human whole knee specimens were imaged on a 3 T clinical MRI scanner. A series of quantitative 3D UTE Cones imaging biomarkers including T2 *, T1 , adiabatic T1ρ , magnetization transfer ratio (MTR) and macromolecular fraction (MMF) were estimated using spiral sampling trajectories with various durations. Errors in UTE MRI biomarkers as a function of sampling time were evaluated using a nonstretched spiral trajectory as a reference standard. No significant differences were observed by increasing the spiral sampling window from 1116 to 2232 µs in the calculated T2 *, T1 , adiabatic T1ρ , MTR and MMF, as all P-values were over .05 as assessed by ANOVA with two-sided Dunnett's test. Although extending the sampling window results in signal loss for short T2 components, there was limited effect on the calculated quantitative biomarkers, with error percentages typically smaller than 5% in all the evaluated tissues. The total scan time can be reduced by up to 54% with quantification errors of less than 5% in any evaluated major tissue in the knee joint, suggesting that 3D UTE Cones MRI techniques can be greatly accelerated by using a longer spiral sampling window without causing additional quantitative bias.

Rotator Cuff Tendon Assessment in Symptomatic and Control Groups Using Quantitative MRI.

BACKGROUND: Relatively weak correlations between patient symptoms and rotator cuff tendon (RCT) tearing have been reported; however, the relationship between symptoms and tendinosis has been less well-studied. PURPOSE/HYPOTHESIS: To use quantitative MRI to assess the bilateral RCTs in shoulders of both patients with unilateral symptomatic tendinopathy and control subjects. We hypothesized that quantitative MRI measures would differ between symptomatic patients and controls. STUDY TYPE: Prospective imaging study. POPULATION/SUBJECTS: In all, 48 shoulders from 24 subjects (mean age, 32.8 years), including 14 patients with unilateral symptomatic tendinopathy and 10 asymptomatic controls. FIELD STRENGTH/SEQUENCE: 3T/3D ultrashort echo time Cones sequence with magnetization transfer preparation (UTE-Cones-MT) and Carr-Purcell-Meiboom-Gill. ASSESSMENT: Macromolecular fraction (MMF) and T2 relaxation were measured in four regions of the superior RCT, including all-segments, and lateral-third, bursal-sided, and articular-sided segments. The Western Ontario Rotator Cuff (WORC) index and visual analog scale were assessed. STATISTICAL TESTS: Three shoulder groups were evaluated, including symptomatic shoulders, contralateral asymptomatic shoulders in patients, and asymptomatic controls. MMF and T2 values were compared between groups using a bootstrap-based comparison of means. RESULTS: Significant differences were found in both MMF and T2 values between symptomatic and control RCTs when analyzing all-segments (P = 0.027 and P = 0.006, respectively) and articular-sided segments (both P = 0.001). Significant differences between asymptomatic RCTs in patients and control RCTs were also found, including MMF in all four anatomic regions analyzed (P = 0.024-0.044), as well as T2 in all-segments (P = 0.003), bursal-sided segments (P = 0.021), and articular-sided segments (P = 0.002). No significant differences in MMF (P = 0.420-0.950) or T2 (P = 0.380-0.910) were seen between ipsilateral symptomatic and contralateral asymptomatic RCTs in patients. DATA CONCLUSION: Symptomatic RCTs showed significantly lower MMF values and higher T2 values compared with control RCTs. In patients with unilateral symptomatic tendinopathy, the contralateral shoulder can demonstrate asymptomatic tendinopathy, which can be quantified using MMF or T2 . EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 2. J. Magn. Reson. Imaging 2020;52:864-872.

Impact of socioeconomic status on psychological functioning in survivorship following breast cancer and reconstruction.

Socioeconomic status (SES) remains an important population health risk factor and impacts a patient's experience of care during breast cancer. This study explored the relationship between SES and quality of life and satisfaction in survivorship following breast cancer and reconstruction. All patients underwent breast reconstruction at a single academic center from 2013 to 2017. Patients completed the five quality of life and satisfaction domains of the BREAST-Q, a validated patient-reported outcome measure. Estimated home value using a web-based real estate website was used to approximate a patient's socioeconomic status. Correlations were evaluated using Pearson's correlation methods, where appropriate, as well as analysis of covariance. Data were stratified for comparison utilizing t tests and linear regression models. Significance was defined as P ≤ .05. Four hundred patients underwent 711 breast reconstructions during the study time period. Satisfaction with the breast (P = .038) and psychosocial well-being (P = .012) had significant positive correlations with increasing socioeconomic status. When stratifying patients' socioeconomic status into thirds, the upper third had significantly higher psychosocial well-being (P = .001), satisfaction with breasts (P = .010), and physical well-being of the chest (P = .001) than the lower third. Significance persisted even after controlling for cancer stage, treatment, complications, and baseline comorbidities. Higher socioeconomic status is associated with greater satisfaction with breast reconstruction and psychosocial well-being following breast cancer treatment. Providing added social, psychological, and emotional support networks may be beneficial long after the initial cancer treatment and reconstruction are complete. Patients of lower socioeconomic status may benefit from additional resources.

A 79-year-old man with persistent eosinophilia and elevated immunoglobulin E.

The differential diagnoses for eosinophilia include allergic, infectious, autoimmune, and neoplastic diseases. We presented the case of a 79-year-old man with eosinophilia and elevated immunoglobulin E that persisted despite adequate treatment for possible environmental exposures. Further specialized testing based on his initial workup led to his diagnosis. This case highlights the importance of sequential and targeted testing to evaluate for rare causes of eosinophilia.

The Not-So-Soft Spot: Pathophysiology of the Bulging Fontanelle in Association With Roseola.

Roseola infantum is a clinical syndrome characterized by high fever followed by the emergence of a rash. Case reports have documented an association between bulging fontanelles and roseola. We propose a novel mechanism for the development of intracranial hypertension caused by human herpesvirus 6-induced cytokine elevation leading to increased cerebrospinal fluid production.

Cryptogenic Intracranial Hemorrhagic Strokes Associated with Hypervitaminosis E and Acutely Elevated α-Tocopherol Levels.

OBJECTIVES: Up to 41% of intracerebral hemorrhages (ICH) are considered cryptogenic despite a thorough investigation to determine etiology. Certain over-the-counter supplements may increase proclivity to bleeding, and we hypothesize that specifically vitamin E may have an association with ICH and acutely elevated serum levels of α-tocopherol. Our aim is to report 3 cases of recently admitted patients with hypervitaminosis E and otherwise cryptogenic ICH. METHODS: At our institution between January and December 2018, 179 patients were admitted with ICH with 73 imputed to be "cryptogenic" (without clear etiology as per Structural vascular lesions, Medication, Amyloid angiopathy, Systemic disease, Hypertension, or Undetermined and Hypertension, Amyloid angiopathy, Tumor, Oral anticoagulants, vascular Malformation, Infrequent causes, and Cryptogenic criteria). Of these, we found 3 (4.1%) clearly admitted to consistent use of vitamin E supplementation for which α-tocopherol levels were checked. We describe the clinical presentation and course of these patients and their etiologic and diagnostic evaluations including neuroimaging and α-tocopherol laboratory data. RESULTS: All patients in this series were consistently consuming higher than recommended doses of vitamin E and developed acute ICH. The first 2 patients both had subcortical (thalamic) intraparenchymal hemorrhages while the third had an intraventricular hemorrhage. Serum α-tocopherol levels in patient A, B, and C were elevated at 30.8, 46.7, and 23.3 mg/L, respectively (normal range 5.7-19.9 mg/L) with a mean of 33.6 mg/L. No clear alternate etiologies to their ICH could be conclusively determined despite thorough workups. CONCLUSIONS: In patients with cryptogenic ICH, clinicians should consider hypervitaminosis E and check serum α-tocopherol level during admission. Reviewing the patient's pharmacologic history, including over-the-counter supplements such as vitamin E, may help identify its association, and its avoidance in the future may mitigate risk. With its known vitamin K antagonism, hypo-prothrombinemic effect, cytochrome p-450 interaction, and antiplatelet activity, vitamin E may not be as benign as presumed. Its consumption in nonrecommended doses may increase ICH risk, which may be underestimated and under-reported.

Three-dimensional ultrashort echo time imaging with tricomponent analysis for human cortical bone.

PURPOSE: To investigate tricomponent analysis of human cortical bone using a multipeak fat signal model with 3D ultrashort TE Cones sequences on a clinical 3T scanner. METHODS: Tricomponent fitting of bound water, pore water, and fat content using a multipeak fat spectra model was proposed for 3D ultrashort TE imaging of cortical bone. Three-dimensional ultrashort TE Cones acquisitions combined with tricomponent analysis were used to investigate bound and pore water T2∗ and fractions, as well as fat T2∗ and fraction in cortical bone. Feasibility studies were performed on 9 human cortical bone specimens with regions of interest selected from the endosteum to the periosteum in 4 circumferential regions. Microcomputed tomography studies were performed to measure bone porosity and bone mineral density for comparison and validation of the bound and pore water analyses. RESULTS: The oscillation of the signal decay was well-fitted with the proposed tricomponent model. The sum of the pore water and fat fractions from tricomponent analysis showed a high correlation with microcomputed tomography porosity (R = 0.74, P < 0.01). Estimated bound-water fraction also demonstrated a high correlation with bone mineral density (R = 0.70, P < 0.01). CONCLUSION: Tricomponent analysis significantly improves the estimation of bound-water and pore-water fractions in human cortical bone.