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Objectives: The reasons for nipple malposition after nipple-sparing mastectomy with implant-based reconstruction are not well characterized, and nipple asymmetry remains a source of patient dissatisfaction. This study employed mathematical simulation to analyze the variables that affect nipple position, developed countermeasures to improve symmetry, and tested them in a case-control cohort. Methods: Patients who underwent nipple-sparing mastectomy followed by two-stage tissue expander and implant reconstruction were recruited and divided into two groups. The study group (N = 57) underwent reconstructive surgery guided by our mathematical simulations and countermeasures. The control group (N = 32) underwent reconstructive surgery using conventional methods. Results: Morphological simulation revealed that the fundamental reason for nipple malposition is inadequate superior pole expansion. Thus, we developed a countermeasure: fixing the nipple areolar complex in a more inferior position, combined with inferior expander placement. Good or excellent symmetry was obtained in 45/57 (79%) patients in the study group and only 8/32 (25%) patients in the control group. In the control group, poorer results were associated with mastectomy weight (ρ = 0.47, P < 0.006), preoperative ptosis grade (ρ = 0.38, P = 0.037), and the difference between the superior pole length (B) and sub-mid-clavicle-to-inframammary fold length (l) (B-l; ρ = 0.067, P < 0.0001). In the study group, the results had no relation with those variables. Conclusions: Morphological simulation found that inadequate superior pole expansion is the primary reason for nipple malposition. On the basis of this result and the patient's breast measurements, we recommend fixing the nipple areolar complex in a more inferior position and possibly pulling the nipple inferiorly, combined with inferior expander placement.

Abstract Combined addition of interstitial-substitutional elements has been acknowledged to contribute to the increase in the strengths of steels. For further improvements in mechanical properties, their atomic-scale interaction mechanisms with dislocations are required to be examined. In this study, both high-resolution transmission electron microscopy and atom-probe tomography were used to correlate interstitial-substitutional elements with dislocation characteristics in austenitic stainless steels. Three types of dislocation core structures are identified and associated with their strain fields as well as N and Cr atoms in the N-added steels. It is revealed that N atoms interact elastically with the dislocations, followed by the segregation of Cr atoms via the chemical interaction between N and Cr atoms. This insight significantly improves the understanding of the multiple alloying mechanism in metallic materials such as interstitial alloys and high-entropy alloys.

“Non-tuberculous mycobacteria” (NTM) is a general term for pathogenic mycobacteria other than Mycobacterium tuberculosis and Mycobacterium leprae. Non-tuberculous mycobacteria are widely present in the natural environment, including soil and water, with over 150 reported species. Mycobacterium abscessus is rare among Non-tuberculous mycobacteria, and there are few reports of extrapulmonary lesions due to Mycobacterium abscessus. We describe a case of osteomyelitis in an adult woman's left first toe caused by Mycobacterium abscessus. The osteomyelitis developed due to an injury in a public bathing facility. A combination of surgical debridement and multidrug therapy was effective. When antimicrobial agents are ineffective in trauma linked to water or soil, mycobacterial infections, including Non-tuberculous mycobacteria, should be considered as differential diagnoses, and laboratory culture targeted to mycobacteria would be recommended.

ABSTRACTPurpose: Remarkable progress in healthcare technology has recently been made alongside changes in concepts related to drugs and medical devices. It is speculated that this progress benefits not only patients but also healthcare professionals, such as medical doctors. We performed a systematic review of the characteristics of current data assessment tools to measure medical doctors’ work-related quality of life (QOL).Methods: A literature search was conducted through PubMed and Ichushi-Web in 2020. The related search terms used were ‘medical doctor,’ ‘quality of work life,’ and ‘questionnaire/interview.’ Two reviewers independently screened the studies, and the characteristics of the QOL assessment tools used in the identified studies were qualitatively reviewed and summarized.Results: In total, 5,443 and 760 articles were retrieved from PubMed and Ichushi-Web, respectively, of which 82 studies were included in this review. Sixty-five (79%) studies used structured questionnaires, and 17 (21%) studies used semistructured questionnaires. In terms of the study purpose, the identified studies mainly included four: mental health, the work or labor situation, satisfaction, and QOL. Components used to measure work-related QOL included satisfaction, burnout, QOL, the work environment, stress, mental health, work-life balance, and others. None of the studies used an originally developed QOL questionnaire to assess the work-related benefits of medical doctors.Conclusion: This systematic review found that there is a lack of studies directly assessing the work-related QOL of medical doctors and a lack of effective data collection tools to assess all work-related QOL components.

In this paper, we present a new approach to data-driven update of table-typed controller gain in tracing control system. This type of control system is used in various precision processing systems for industrial products. It is important for a tracing control system to be maintained so as to achieve the accuracy of positioning for reducing the gap between the workpiece and the machining tool during the operation. In addition, it is also important to update the elements of the table in the controller as faciley from the practical points of view. The update of the controller by directly using the data without mathemaical models is one of the rational ways to realize them. From these backgrounds, we have previously applied FRIT (Fictitious Reference Iterative Tuning), which is a data-driven controller tuning method with only one-shot experiment, to update the table-typed controller in the tracing control system. However, this method requires calculations using a fictitious inverse system of an implemented controller, which leads to computational errors. In this paper, we propose a method utlizing VIMT (Virtual Internal Model Tuning) to update the table-typed controller without using its inverse system. Moerover, we update not only each gain in the table but also each corresponding range to improve the tracking accuracy of tracing control system.

Abstract Background Fingertip replantation has become a standard operation for well-experienced microsurgeons, but naturally there are some unsuccessful cases. Furthermore, younger surgeons need experience with this procedure, as replantations are often an emergency operation and experts may not be available to attend. Therefore, we reviewed our cases to determine the most effective procedure that can enable young surgeons to obtain a good outcome. Methods We retrospectively investigated 69 fingertip replantation cases treated between January 2006 and December 2014 at the Kyorin University Hospital. All operations were performed by several young surgeons who were instructed by one experienced surgeon (the principal author, T.S.). In this study, cases were divided into three groups according to vein graft usage. In group A, a long vein graft that reached the proximal phalanx was employed. In group B, a short vein graft that was almost as long as the arterial defect was employed. In group C, no vein graft was used. The differences in the survival rates of the fingertips between the groups were analyzed. Results The total fingertip survival rate was 93% (64 out of 69). All 42 (100%) fingertips in group A survived, 5 of 6 (83%) fingertips in group B survived, and 17 of 21 (81%) fingertips in group C survived. Conclusion Preferential use of a long vein graft could provide superior results and enable young surgeons to perform successful fingertip replantations, as it is a reliable and relatively an easy procedure compared with other techniques.

Background:. There have been many studies examining risk factors for complications in expander-based breast reconstruction after mastectomy, and some patient factors have been identified as risk factors. However, most of the previous studies were based on Caucasian patients. Methods:. Asian patients who had a tissue expander placed for immediate breast reconstruction between January 2006 and December 2015 (363 patients and 371 expanders) were analyzed retrospectively. Univariate and multivariate analyses were performed to elucidate risk factors for complications. Results:. The rate of skin necrosis was significantly higher in nipple-sparing mastectomy than in other types of mastectomies (12 patients among 107 patients, P = 0.001). The weight of the resected specimen was significantly higher in the group with complications than in the group without complications (444 g compared with 363 g, P = 0.027). Other factors (age, body mass index, smoking, expander type, preoperative chemotherapy, axillary dissection) had no significant effect on complications. Multivariate analysis with a logistic regression showed that a large breast (over 500 g) was the only significant risk factor for complications, with an odds ratio of 3.20 and a 95% confidence interval of 1.33–7.54 (P = 0.010). Conclusion:. In this series of Asian patients, breast size, rather than body mass index, is the most important predictor for complications in expander-based breast reconstruction.

Summary:. Penile amputation is a rare emergency, but the best method for its repair is required due to the organ’s functional and societal role. Since the first successful microsurgical replantation of the amputated penis, microsurgical techniques have matured and become the standard treatment for the penile replantation. However, the successful second microsurgical replantation for amputated penis has been rarely reported. We present the case of a 40-year-old man with schizophrenia who had a past history of penile self-mutilation and successful replantation at another hospital 2 years ago. After stopping oral medication for schizophrenia, he again cut his penis with a kitchen knife. We successfully replanted the amputated penis by anastomosing both circumflex arteries, the superficial dorsal vein, and the deep dorsal vein using microsurgical techniques. Postoperatively, the foreskin of the replanted penis gradually developed partial necrosis, requiring surgical debridement. The aesthetic and functional results were satisfactory and retrograde urethrography showed no evidence of leakage and stricture of the urethra. Although skin necrosis after penile replantation has been reported as an unavoidable process owing to the nature of injury, the rate would be higher after secondary replantation because of scar formation due to the previous operation. Therefore, our case of successful secondary replantation suggests that skin necrosis would be a predictable postoperative complication and the debridement timing of the devitalized foreskin should be closely monitored, and also secondary amputation is not a contraindication of replantation.

In trichothecene-producing fusaria, isotrichodermol (ITDol) is the first intermediate with a trichothecene skeleton. In the biosynthetic pathway of trichothecene, a 3-O-acetyltransferase, encoded by Tri101, acetylates ITDol to a less-toxic intermediate, isotrichodermin (ITD). Although trichothecene resistance has been conferred to microbes and plants transformed with Tri101, there are no reports of resistance in cultured mammalian cells. In this study, we found that a 3-O-acetyl group of trichothecenes is liable to hydrolysis by esterases in fetal bovine serum and FM3A cells. We transfected the cells with Tri101 under the control of the MMTV-LTR promoter and obtained a cell line G3 with the highest level of C-3 acetylase activity. While the wild-type FM3A cells hardly grew in the medium containing 0.40 μM ITDol, many G3 cells survived at this concentration. The IC50 values of ITDol and ITD in G3 cells were 1.0 and 9.6 μM, respectively, which were higher than the values of 0.23 and 3.0 μM in the wild-type FM3A cells. A similar, but more modest, tendency was observed in deoxynivalenol and 3-acetyldeoxynivalenol. Our findings indicate that the expression of Tri101 conferred trichothecene resistance in cultured mammalian cells.

Adjuvant chemotherapy is usually not considered for pT1a pN0 human epidermal growth factor receptor 2 (HER2)-positive breast cancer due to its low recurrence rate. The present report describes a case of pT1a hormone receptor-positive HER2-positive breast cancer with multiple recurrences in the axillary lymph nodes and liver within 1 year after radical surgery. A 58-year-old woman underwent left total mastectomy and sentinel lymph node biopsy for left breast cancer with pathological stage IA (pT1a pN0). The subtype corresponded to luminal B-like breast cancer with a nuclear grade of 3 and a Ki-67 labeling index of 37%. An aromatase inhibitor (letrozole) was planned to be administered for 5 years after surgery, but the patient was diagnosed with multiple liver and axillary lymph node metastases 11 months after surgery. After 1 year of chemotherapy (paclitaxel) in combination with anti-HER2 therapy (pertuzumab and trastuzumab), liver metastases resolved. A complete response of the liver lesion has been maintained 4 years after the anti-HER2 therapy initiation. The present case exhibited two poor prognostic factors: High Ki-67 labeling index and nuclear grade 3. Based on the 'Predict' tool, the present case would be expected to have a cancer-related mortality rate of 6% 10 years after surgery with adjuvant endocrine therapy. Although this value may be controversial for postoperative anti-HER2 therapy, the present case should not be considered to be a low-risk case. When the identification of high-risk pT1a pN0 HER2-positive breast cancer is possible, postoperative anti-HER2 therapy plus chemotherapy would be effective in decreasing the rate of recurrence. [ABSTRACT FROM AUTHOR]

Although the margin reflex distance (MRD) is widely used to assess blepharoptosis, it has some drawbacks (e.g. inaccuracy in severe ptosis). A new parameter is desired. We digitally analyzed pre- and post-operative photographs of 95 patients with blepharoptosis. We set a rectangle with the vertical sides at the lateral and medial canthus and the horizontal sides at the highest and lowest points of the eyelids. We calculated the percentage of the vertical side (height) to the horizontal side (width) and defined this value as the vertical percentage of the palpebral fissure. The MRD and the vertical percentage values were strongly correlated (correlation coefficient 0.766). In the 77 bilateral cases, both sides showed significant improvement in vertical percentage (from 28.9 to 37.3%, right) and (28.7 to 36.1%, left). In the 18 unilateral cases, the affected side showed significant improvement in vertical percentage (from 29.6 to 38.7%), while the unaffected side showed no change. In the eight patients who underwent re-operation, the revised side's vertical percentage was not improved after the first operation (from 28.0 to 31.3%), and the revision significantly changed the vertical percentage to 39.0%. In the re-operated patients, the difference between the right and left sides decreased significantly from 6.7 to 1.9% post-revision. The aspect ratio of each palpebral fissure (the percentage of height to width) reflected the progression of blepharoptosis and the post-operative changes. The aspect ratio thus has the potential to be a new parameter for blepharoptosis. [ABSTRACT FROM AUTHOR]