Satisfaction of Patients Who Received Breast-Conserving Surgery Using the Suture Scaffold Technique: A Single-Institution, Cross-Sectional Study.

BACKGROUND: Optimal cosmetic results after breast-conserving surgery (BCS) improve patient satisfaction. The suture scaffold technique (SST) is a breast reconstruction technique that all breast surgeons can perform without any extensive training in plastic surgery. OBJECTIVE: We aimed to investigate patient satisfaction after BCS and compare blood loss and operative duration between the SST, breast glandular flap technique (BGFT), and no oncoplastic technique (NOT). METHODS: This was a prospective, single-center, cross-sectional study. All patients who underwent BCS from August 2017 to September 2019 in our institution were included, with the exception of those with cT3 tumors or those who underwent nipple excision or bilateral breast surgery. The BREAST-Q™ was used to survey the patients, and the raw sum scale scores of the BREAST-Q™ were converted into BREAST-Q scores. RESULTS: Overall, we identified 421 eligible patients. The NOT was used in 47 (11.1%) patients, the BGFT was used in 231 (54.8%) patients, and the SST was used in 143 (33.9%) patients. In the univariable model, the BGFT and the SST had higher BREAST-Q scores than the NOT, while in the multivariable model, the SST had significantly higher BREAST-Q scores than the NOT (ß = +7.7, 95% confidence interval [CI] 0.9-13.7; p = 0.01). Blood loss was significantly less with the SST compared with the BGFT (ß = -4.4, 95% CI -7.3 to -1.4), and there was no difference in operative duration between the methods. CONCLUSIONS: Patient satisfaction with the SST was higher than with the NOT and was similar to the BGFT. The SST is an oncoplastic technique that all breast surgeons can perform and which requires comparable blood loss and operative duration in the NOT.

Fatal warm autoimmune hemolytic anemia in a child due to IgM-type autoantibodies.

Herein is described a case of immunoglobulin M (IgM) warm autoimmune hemolytic anemia (AIHA) in a child who consequently died within 3 days of clinical onset. A previously healthy 11-year-old boy presented with fever, anemia, jaundice, and deteriorating consciousness. On direct agglutination test against group O red blood cells, agglutination was seen even at 37°C in saline, which was abolished on dithiothreitol treatment of the serum, indicating that the responsible autoantibody was IgM and had a warm-reactive capacity. A diagnosis of IgM warm AIHA was therefore made. Hemagglutination in the visceral capillaries was considered as the direct cause of organ dysfunction. The patient died due to respiratory failure. IgM warm AIHA is a very severe condition that is difficult to reverse in an advanced state. Both prompt, definite diagnosis and intervention are therefore vital to prevent severe multi-organ dysfunction in cases of IgM warm AIHA.

Long-term prognostic value of the GenesWell BCT score in Asian women with hormone receptor-positive/HER2-negative early breast cancer.

BACKGROUND: Accurate prediction of the risk of recurrence is crucial for optimal treatment decisions in hormone receptor (HR)-positive/human epidermal growth factor receptor 2 (HER2)-negative early breast cancer. The GenesWell BCT is a molecular assay to predict the 10-year risk of distant metastasis. In this study, we evaluated the long-term prognostic value of the GenesWell BCT assay. METHODS: The BCT score was assessed in patients with HR-positive/HER2-negative early breast cancer who did not receive chemotherapy. We compared the 15-year distant metastasis-free survival (DMFS) between risk groups classified based on the BCT score. The risk of early (0-5 years) and late (5-15 years) recurrence was evaluated based on the BCT score classification. RESULTS: According to the BCT score, 366 patients from Japan and Korea were categorized as BCT low risk (83.6%) and high risk (16.4%) for distant metastasis. Median follow-up time was 17.4 years. The 15-year DMFS rate was significantly lower in the BCT high-risk group (63.3%) than in the BCT low-risk group (93.6%) (P < 0.001). The BCT risk group was an independent prognostic factor for 15-year DMFS (hazard ratio, 4.59; 95% confidence interval 2.13-9.88; P < 0.001). Furthermore, the BCT score was a significant predictor of late recurrence (5-15 years) in patients aged ≤ 50 years and those aged > 50 years, and added prognostic information to traditional clinical prognostic factors. CONCLUSION: The BCT score can identify patients at low risk for recurrence who may not require adjuvant chemotherapy or extended endocrine therapy, regardless of age.

Case report: Evolution of catatonic mutism and psychotic symptoms in an adolescent with Down syndrome: transition from Down syndrome disintegrative disorder to anti-N-methyl-D-aspartate receptor encephalitis.

During her first year of junior high school, a 12-year-old Japanese girl with Down syndrome experienced dizziness, gait disruption, paroxysmal weakness in her hands, and sluggish speaking. Regular blood tests and a brain MRI revealed no abnormalities, and she was tentatively diagnosed with adjustment disorder. Nine months later, the patient experienced a subacute sickness of chest pain, nausea, sleep problem with night terrors, and delusion of observation. Rapid deterioration then developed with simultaneous fever, akinetic mutism, loss of facial expression, and urine incontinence. These catatonic symptoms improved after a few weeks after admission and treatment with lorazepam, escitalopram, and aripiprazole. After discharge, nonetheless, daytime slumber, empty eyes, paradoxical laughter, and declined verbal communication persisted. Upon confirmation of the cerebrospinal N-methyl-D-aspartate (NMDA) receptor autoantibody, methylprednisolone pulse therapy was tried, but it had little effect. Visual hallucinations and cenesthopathy, as well as suicidal thoughts and delusions of death, have predominated in the following years. Cerebrospinal IL-1ra, IL-5, IL-15, CCL5, G-CSF, PDGFbb, and VFGF were raised in the early stage of initial medical attention with nonspecific complaints, but were less prominent in the later stages of catatonic mutism and psychotic symptoms. We suggest a disease concept of progression from Down syndrome disintegrative disorder to NMDA receptor encephalitis, based on this experience.

[The relationships between the basic checklist score, physical function, and improvement in physical function].

AIM: The objectives of this study were to examine the relationship between a screening score for frailty in the elderly, the Basic checklist, and physical function, and to investigate the factors associated with the effects of exercise intervention in community-dwelling frail elderly in Japan. METHODS: We enrolled 44 subjects aged 65 years and older (average age 73.9 ± 5.1) in this study. The subjects participated in exercise intervention, including high-intensity muscle strength training, twice a week for three months. The Basic checklist and functional performance measures (walking ability, balance functions, flexibility, leg strength), psychological tests (Geriatric Depression Scale (GDS), Modified Fall Efficacy Scale (MFES), and health-related quality of life test (SF-8)) were administered at the start and end of the intervention. We evaluated the correlation between the Basic checklist and other measurements at baseline. In addition, we evaluated any relationships between the Basic checklist and improvements in physical function. We used partial correlation analysis and multiple linear regression analysis to evaluate those relationships. RESULTS: The Basic checklist was significantly correlated with GDS, functional reach and one leg standing measurements at baseline. Functional performance measures were significantly improved after exercise intervention. Although there were weak negative relationships between the basic checklist and the amount of change in functional reach tests, we could not find a relationship between the Basic checklist and the improvement of physical function. CONCLUSION: These results suggest that there was little relation between the Basic checklist and physical functions, in particular the improvement of physical functions. Therefore, we should consider how we can assess the improvement of physical function. These results strongly support the need to assess physical function before exercise intervention.

[T-cell rich B-cell lymphoma associated with neutrophilia and thrombocytosis].

A 49-year-old man was admitted with high-grade fever, night sweating and cervical lymphadenopathy in September 2005. On examination, both neutrophilia and thrombocytosis were noted in the peripheral blood, a bone marrow examination revealed marked both myeloid and megakaryocytic hyperplasia. The sera obtained at initial presentation showed an elevated levels of granulocyte-colony stimulating factor (G-CSF) and interleukin-6 (IL-6). A pathologic diagnosis of T-cell rich B-cell lymphoma was made based on an inguinal lymph node biopsy. Following treatment with CHOP accompanied by rituximab (R-CHOP), both the neutrophilia and thrombocytosis subsided after 3 courses of R-CHOP, resulting in a complete remission after 4 courses of chemotherapy. Neutrophilia, thrombocytosis and T-cell rich B-cell lymphoma in this patient were considerably ameliorated with chemotherapy. We report here a patient with T-cell rich B-cell lymphoma associated with both neutrophilia and thrombocytosis, suggesting that the lymphoma triggered both myeloid and megakaryocytic hyperplasia.

Changes in expression of C2cd4c in pancreatic endocrine cells during pancreatic development.

C2cd4c, encoded by a gene belonging to the C2cd4 family, contains a C2 domain conserved across species and is localized to the cytoplasm. To examine the role of C2cd4c in the pancreas, we studied its localization and generated C2cd4c knockout (KO) mice. C2cd4c was expressed in pancreatic endocrine progenitors at early embryonic stages. When endocrine cells arise from their precursors, C2cd4c is gradually confined to the insulin- and pancreatic polypeptide-expressing cells of the endocrine. In the adult pancreas, C2cd4c is restricted to the beta cells. C2cd4c KO mice showed normal embryonic pancreatic development and adult pancreatic function. Thus, our results suggest that C2cd4c is dispensable for pancreatic development.

Metastatic breast carcinoma of the abdominal wall muscle: a case report.

Metastasis from breast carcinoma is an uncommon occurrence in skeletal muscle, compared to local invasion into muscle from direct tumor spread. A 49-year-old woman was referred to our hospital with an 8.5-cm mass in the right breast. Core needle biopsy revealed metaplastic carcinoma with squamous metaplasia. The mass was rapidly growing and metaplastic, so mastectomy with dissection of axillary lymph nodes was performed. Pathological examination showed metaplastic carcinoma, histological grade 3, triple negative, and a MIB-1 labeling index of 80%. Six months postoperatively, during adjuvant chemotherapy treatment, she reported numbness and pain in the right lateral thigh and a mass in the right lower abdomen. Computed tomography revealed multiple lined masses in the abdominal wall and iliac muscle. Core needle biopsy showed metastatic breast carcinoma. Radio- and chemotherapy were administered, but the mass in the muscle became enlarged. To control her pain, a combined treatment with morphine, fentanyl, ketamine, antiepilepsy drug, and NSAIDs was administered. Liver metastasis appeared 9 months (15 months postoperatively) after recognition of muscle metastasis, and the patient died 16 months postoperatively. Skeletal muscle metastasis is uncommon, and therapeutic intervention is mainly palliative. The most common symptom of skeletal muscle metastasis is pain; thus, pain control is a pivotal goal of treatment.

A Japanese girl with an early-infantile onset vanishing white matter disease resembling Cree leukoencephalopathy.

Vanishing white matter disease (VWM)/childhood ataxia with central hypomyelination (CACH) is an autosomal recessive leukoencephalopathy caused by mutations in one of five genes, EIF2B1-5, encoding the 5 subunits of eukaryotic translation initiation factor 2B (eIF2B). The classical phenotype is characterized by early childhood onset and chronic progressive neurological deterioration with cerebellar ataxia, spasticity, optic atrophy and epilepsy. However, the onset of disease varies from antenatal period to adulthood. Cree leukoencephalopathy (CLE) is a severe variant of VWM and caused by a homozygous mutation (R195H) in the EIF2B5 gene. The patient reported in this study developed lethargy, vomiting and seizure 3days after an oral poliovirus vaccination at the age of 4months. She presented with rapid neurological deterioration within a month of onset. Brain MRI showed abnormal white matter intensity. Whole-exome sequencing identified two heterozygous mutations in the EIF2B5 gene: a known mutation, c.584G>A (R195H, which is homozygous in CLE), and a novel mutation, c.1223T>C (I408T, which resides in the "I-patch"). Mutations in the "I-patch" encoded region of eIF2Bε may be related to an early-infantile onset phenotype. This patient exhibits an early-infantile onset and progressive disease course resembling CLE, suggesting a severe functional disruption of eIF2Bε caused by R195H as well as by I408T mutations.

Influence of fat and carbohydrate proportions on the metabolic profile in patients with type 2 diabetes: a meta-analysis.

OBJECTIVE: The effects of dietary macronutrient composition on metabolic profiles in patients with type 2 diabetes have been inconsistent. This meta-analysis aimed to elucidate the effect of replacing dietary fat with carbohydrate on glucose and lipid parameters in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: We searched for randomized trials that investigated the effects of two kinds of prescribed diets (a low-fat, high-carbohydrate [LFHC] diet and a high-fat, low-carbohydrate [HFLC] diet); in these studies, energy and protein intake did not differ significantly between the two dietary groups. Nineteen studies that included 306 patients met our inclusion criteria. Median diet composition of carbohydrate/fat in the LFHC and HFLC diets was 58%/24% and 40%/40%, respectively. RESULTS: Changes in values for A1C, fasting plasma glucose (FPG), and total and LDL cholesterol did not differ significantly between the LFHC and HFLC groups. However, the LFHC diet significantly increased fasting insulin and triglycerides by 8% (P = 0.02) and 13% (P < 0.001), respectively, and lowered HDL cholesterol by 6% (P < 0.001) compared with the HFLC diet. There were positive associations among the magnitude of changes in FPG, fasting insulin, and triglycerides for the diets analyzed. However, stratified analysis indicated that the increase in triglycerides was insignificant when accompanied by energy intake restriction. CONCLUSIONS: Our findings suggested that replacing fat with carbohydrate could deteriorate insulin resistance while the adverse effect on triglycerides from the LFHC diet could be avoided by restricting energy intake to a degree sufficient for the attainment of weight reduction.

Pd/C(en) catalyzed chemoselective hydrogenation in the presence of aryl nitriles.

Aromatic nitriles are not only important components of natural products, pharmaceuticals, herbicides and agrochemicals but also a synthetic equivalent of various functionalities. The development of synthetic methods of aromatic nitriles have been increasing in terms of its usefulness. Since aromatic nitriles are susceptible to the hydrogenation, it has been desired for the development of chemoselective hydrogenation method with retention of nitrile groups. Pd/C is one of the most popular catalysts for hydrogenation and many of reducible functional groups such as multiple bonds, benzyl ethers, N-Cbzs, nitro groups and so on could be easily reduced under the conditions. Therefore, it is very difficult to achieve the chemoselective hydrogenation of substrates containing two or more reducible functional groups. We have found that a Pd/C catalyst formed an isolable complex with ethylenediamine (en) employed as catalytic poison, and the complex [Pd/C(en)] catalyzed chemoselective hydrogenation of a variety of reducible functionalities distinguishing O-benzyl, N-Cbz and O-TBDMS protective groups, benzyl alcohols and epoxides. In the course of these investigations, we found the aryl nitriles could survive under the Pd/C(en)-catalyzed hydrogenation conditions in THF whose choice is important for the effective suppression. This methodology could be applied to the selective hydrogenation of alkene and alkyne functionalities in the presence of aromatic nitrile.

Effects of changes in skiing posture on the kinetics of the knee joint.

This study was performed to investigate the effects of changes in the skiing posture on mechanical stress across the knee joint. The aim of the present study was to establish a safer form of skiing for the prevention of injury to the anterior cruciate ligament of the knee (ACL). Ten healthy volunteers were placed on a force plate on an artificial slope, and assumed forward and backward bending postures with a single leg by changing their centre of gravity. The knee flexion angles were limited to approximately 30 degrees by orthotics in each posture. Joint moments of the lower extremity were analyzed using a motion analysis system, and the muscle activities of the lower extremity were recorded by EMG and digitised to integrated EMG in each posture. In addition, extrusion of the lower leg by the boot was measured using a force sensor sheet inserted behind the calf. We found that the extension moment of the hip and ankle joints, and muscular activity of the hamstrings were increased in forward bending, whereas the extension moment of the knee and muscular activity of the quadriceps were decreased. Conversely, the muscular activity of the quadriceps, the flexion moment of the hip, extension moment of the knee joint, and pressure of the boot were increased in backward bending, whereas muscular activity of the hamstrings was decreased. The dependency on the hamstrings increased in forward bending in a skiing posture on a slope with slight knee flexion. Therefore, forward bending seemed to be an advantageous posture for the prevention of ACL injury. Conversely, in a backward bending skiing posture, the extension moment of the knee joint produced by muscle contraction of the quadriceps also increased imbalance in the hamstrings. The results of this study suggest that the internal force exerted by the quadriceps, in addition to the passive factor of extrusion of the lower leg by the boot, may contribute to non-contact ACL injury in a backward bending posture while skiing.