Purpose: We assessed the indications, efficacy, safety, and durability of hyaluronic acid gel filler injections in the periorbital region. Efficacy was evaluated through subjective patient satisfaction and objective symptom improvement. Methods: We conducted a retrospective analysis of the medical records of patients who underwent periorbital hyaluronic acid gel filler injections between February 2011 and June 2023. Patient demographics, indications for treatment, pre-injection symptoms, post-injection outcomes (including patient satisfaction), complications, and filler durability were collected and analyzed. Results: In total, 125 patients underwent 177 injection sessions. The mean age of patients was 49.0 years, with female predominance (71.2%). The most common indications were lid retraction (26.55%), enophthalmos (22.03%), and tear trough deformity (12.99%). Overall patient satisfaction was high (89.27%), and undercorrection was the primary reason for dissatisfaction (10/177); subsequent injections successfully addressed undercorrection in all patients. Symptom improvement was observed in 94.35% of injections, and 7 cases required surgery for persistent symptoms. Enophthalmos correction was 1.07 mm per injection and 1.15 mm per 1 cc of filler. Lid retraction improved by 1.41 ± 0.82 mm with an average of 0.51 ± 0.36 cc of filler per session. Common complications included pain, bruising, nausea, vomiting, and swelling. The mean filler durability was 46.3 weeks. Conclusions Lid retraction, enophthalmos, and tear trough deformity were common indications for periorbital hyaluronic acid gel filler injections. Most patients reported symptom improvement and high satisfaction. These findings suggest that periorbital filler injections can be a safe and effective outpatient treatment option for various periorbital conditions.

Purpose: We assessed the indications, efficacy, safety, and durability of hyaluronic acid gel filler injections in the periorbital region. Efficacy was evaluated through subjective patient satisfaction and objective symptom improvement. Methods: We conducted a retrospective analysis of the medical records of patients who underwent periorbital hyaluronic acid gel filler injections between February 2011 and June 2023. Patient demographics, indications for treatment, pre-injection symptoms, post-injection outcomes (including patient satisfaction), complications, and filler durability were collected and analyzed. Results: In total, 125 patients underwent 177 injection sessions. The mean age of patients was 49.0 years, with female predominance (71.2%). The most common indications were lid retraction (26.55%), enophthalmos (22.03%), and tear trough deformity (12.99%). Overall patient satisfaction was high (89.27%), and undercorrection was the primary reason for dissatisfaction (10/177); subsequent injections successfully addressed undercorrection in all patients. Symptom improvement was observed in 94.35% of injections, and 7 cases required surgery for persistent symptoms. Enophthalmos correction was 1.07 mm per injection and 1.15 mm per 1 cc of filler. Lid retraction improved by 1.41 ± 0.82 mm with an average of 0.51 ± 0.36 cc of filler per session. Common complications included pain, bruising, nausea, vomiting, and swelling. The mean filler durability was 46.3 weeks. Conclusions Lid retraction, enophthalmos, and tear trough deformity were common indications for periorbital hyaluronic acid gel filler injections. Most patients reported symptom improvement and high satisfaction. These findings suggest that periorbital filler injections can be a safe and effective outpatient treatment option for various periorbital conditions.

Purpose: We assessed the indications, efficacy, safety, and durability of hyaluronic acid gel filler injections in the periorbital region. Efficacy was evaluated through subjective patient satisfaction and objective symptom improvement. Methods: We conducted a retrospective analysis of the medical records of patients who underwent periorbital hyaluronic acid gel filler injections between February 2011 and June 2023. Patient demographics, indications for treatment, pre-injection symptoms, post-injection outcomes (including patient satisfaction), complications, and filler durability were collected and analyzed. Results: In total, 125 patients underwent 177 injection sessions. The mean age of patients was 49.0 years, with female predominance (71.2%). The most common indications were lid retraction (26.55%), enophthalmos (22.03%), and tear trough deformity (12.99%). Overall patient satisfaction was high (89.27%), and undercorrection was the primary reason for dissatisfaction (10/177); subsequent injections successfully addressed undercorrection in all patients. Symptom improvement was observed in 94.35% of injections, and 7 cases required surgery for persistent symptoms. Enophthalmos correction was 1.07 mm per injection and 1.15 mm per 1 cc of filler. Lid retraction improved by 1.41 ± 0.82 mm with an average of 0.51 ± 0.36 cc of filler per session. Common complications included pain, bruising, nausea, vomiting, and swelling. The mean filler durability was 46.3 weeks. Conclusions Lid retraction, enophthalmos, and tear trough deformity were common indications for periorbital hyaluronic acid gel filler injections. Most patients reported symptom improvement and high satisfaction. These findings suggest that periorbital filler injections can be a safe and effective outpatient treatment option for various periorbital conditions.

Purpose: To introduce punch biopsy, which can be easily performed in an outpatient setting, and to evaluate its clinical usefulness. Methods: A retrospective study was performed in 33 patients with atypical eyelid disorders who underwent punch biopsy. Results: This study included 33 eyes (33 patients; male:female = 12:21) with a mean age of 57.27 ± 19.12 years. There were 19 (57.6%) right eye, 14 (42.4%) left eye, 15 (45.5%) upper eyelid, and 18 (54.5%) lower eyelid lesions. The biopsy approaches were percutaneous and transconjunctival in 24 (72.7%) and nine (27.3%) eyes, respectively. Benign and malignant lesions were found in 21 (63.6%) and 12 (36.4%) eyes, respectively. The benign lesions included chalazion (52.4%), acute and chronic inflammation (23.8%), acanthosis (4.8%), and ectopic cillia (4.8%), and were treated conservatively by intralesional steroid injections or incision and drainage. The malignant lesions included sebaceous carcinomas (33.3%), squamous cell carcinomas (25%), and basal cell carcinomas (16.7%), with various treatments, including surgical resections, chemotherapy, and radiation therapy. Conclusions Punch biopsy is a safe and quick procedure that can easily be performed in the office setting for patients who require a pathologic diagnosis for eyelid diseases, including malignancies. It may be useful for diagnosis and treatment planning.

If cardiac sympathetic activity increases after myocardial injury, a ventricular electrical storm (VES) may occur. The stellate ganglion block is a minimally invasive technique performed to control VES through temporary sympathetic cessation. This case was treated after 3 stellate ganglion blocks in VES developed after non-ST elevation myocardial infarction. This patient underwent prophylactic stellate ganglion block prior to radical nephrectomy for a renal mass found during hospitalization, and the operation was safely completed. Stellate ganglion block is expected to be a safe treatment option for patients with unstable VES.

Background: In non-alcoholic fatty liver disease (NAFLD), transient elastography (TE) is an accurate non-invasive method to identify patients at risk of advanced fibrosis (AF). We developed a diabetes-specific, non-invasive liver fibrosis score based on TE to facilitate AF risk stratification, especially for use in diabetes clinics where TE is not readily available. Methods: Seven hundred sixty-six adults with type 2 diabetes and NAFLD were recruited and randomly divided into a training set (n=534) for the development of diabetes fibrosis score (DFS), and a testing set (n=232) for internal validation. DFS identified patients with AF on TE, defined as liver stiffness (LS) ≥9.6 kPa, based on a clinical model comprising significant determinants of LS with the lowest Akaike information criteria. The performance of DFS was compared with conventional liver fibrosis scores (NFS, FIB-4, and APRI), using area under the receiver operating characteristic curve (AUROC), sensitivity, specificity, positive and negative predictive values (NPV). Results: DFS comprised body mass index, platelet, aspartate aminotransferase, high-density lipoprotein cholesterol, and albuminuria, five routine measurements in standard diabetes care. Derived low and high DFS cut-offs were 0.1 and 0.3, with 90% sensitivity and 90% specificity, respectively. Both cut-offs provided better NPVs of >90% than conventional fibrosis scores. The AUROC of DFS for AF on TE was also higher (P<0.01) than the conventional fibrosis scores, being 0.85 and 0.81 in the training and testing sets, respectively. Conclusion Compared to conventional fibrosis scores, DFS, with a high NPV, more accurately identified diabetes patients at-risk of AF, who need further evaluation by hepatologists.

Purpose: Adenosine monophosphate-activated protein kinase (AMPK) is thought to inhibit cell proliferation or promote cell death, but the details remain unclear. In this study, we propose that AMPK inhibits the expression of anti-apoptotic B-cell lymphoma 2 (Bcl-2) by relying on the hypoxia-inducible factor 1 alpha (HIF-1α)-induced caveolin-1 (Cav-1) expression pathway in noninvasive human bladder tumor (RT4) cells. Methods: In cells exposed to a hypoxic environment (0.5% oxygen), the levels of expression and phospho-activity of the relevant signaling enzymes were examined via Western blots and reverse transcription-polymerase chain reaction. Cell proliferation was assessed using a Cell Counting Kit-8 assay. Results: The level of expression of Cav-1 was very low or undetectable in RT4 cells. Hypoxia was associated with significantly decreased cell growth, along with marked induction of HIF-1α and Cav-1 expression; additionally, it suppressed the expression of the antiapoptotic marker Bcl-2 while leaving AMPK activity unchanged. Under hypoxic conditions, HIF-1α acts as a transcription factor for Cav-1 mRNA gene expression. The cell growth and Bcl-2 expression suppressed under hypoxia were reversed along with decreases in the induced HIF-1α and Cav-1 levels by AMPK activation with metformin (1mM) or phenformin (0.1mM). In addition, pretreatment with AMPK small interfering RNA not only increased the hypoxia-induced expression of HIF-1α and Cav-1, but also reversed the suppression of Bcl-2 expression. These results suggest that HIF-1α and Cav-1 expression in hypoxic environments is regulated by basal AMPK activity; therefore, the inhibition of Bcl-2 expression cannot be expected when AMPK activity is suppressed, even if Cav-1 expression is elevated. Conclusions For the first time, we find that AMPK activation can regulate HIF-1α induction as well as HIF-1α-induced Cav1 expression, and the hypoxia-induced inhibitory effect on the antiapoptotic pathway in RT4 cells is due to Cav-1-dependent AMPK activity.

Purpose: Adenosine monophosphate-activated protein kinase (AMPK) is thought to inhibit cell proliferation or promote cell death, but the details remain unclear. In this study, we propose that AMPK inhibits the expression of anti-apoptotic B-cell lymphoma 2 (Bcl-2) by relying on the hypoxia-inducible factor 1 alpha (HIF-1α)-induced caveolin-1 (Cav-1) expression pathway in noninvasive human bladder tumor (RT4) cells. Methods: In cells exposed to a hypoxic environment (0.5% oxygen), the levels of expression and phospho-activity of the relevant signaling enzymes were examined via Western blots and reverse transcription-polymerase chain reaction. Cell proliferation was assessed using a Cell Counting Kit-8 assay. Results: The level of expression of Cav-1 was very low or undetectable in RT4 cells. Hypoxia was associated with significantly decreased cell growth, along with marked induction of HIF-1α and Cav-1 expression; additionally, it suppressed the expression of the antiapoptotic marker Bcl-2 while leaving AMPK activity unchanged. Under hypoxic conditions, HIF-1α acts as a transcription factor for Cav-1 mRNA gene expression. The cell growth and Bcl-2 expression suppressed under hypoxia were reversed along with decreases in the induced HIF-1α and Cav-1 levels by AMPK activation with metformin (1mM) or phenformin (0.1mM). In addition, pretreatment with AMPK small interfering RNA not only increased the hypoxia-induced expression of HIF-1α and Cav-1, but also reversed the suppression of Bcl-2 expression. These results suggest that HIF-1α and Cav-1 expression in hypoxic environments is regulated by basal AMPK activity; therefore, the inhibition of Bcl-2 expression cannot be expected when AMPK activity is suppressed, even if Cav-1 expression is elevated. Conclusions For the first time, we find that AMPK activation can regulate HIF-1α induction as well as HIF-1α-induced Cav1 expression, and the hypoxia-induced inhibitory effect on the antiapoptotic pathway in RT4 cells is due to Cav-1-dependent AMPK activity.

Purpose: To investigate the postoperative changes in diplopia and evaluate factors that affect diplopia after isolated inferior orbital wall fracture. Methods: A retrospective study was conducted on 200 patients who underwent reconstruction surgery for isolated inferior orbital wall fracture between March 2001 and December 2020. Diplopia was categorized into peripheral, central, and full-degree types based on the history and binocular single vision. The natural course of diplopia was analyzed pre-operatively and at 1 day, 6 weeks, and 6 months postoperatively. We analyzed the orbital computed tomography images to determine fracture size (small, medium, or large), fracture site (anterior, middle, posterior, or mixed), extraocular muscle (EOM) size (swelling or deformity), EOM site (incarcerated or prolapsed), and EOM tenting. Results: Diplopia was seen in 144 out of 200 patients (72.0%) before surgery; peripheral diplopia was seen in 57 patients (39.6%), central diplopia in 46 (24.3%), and full-degree diplopia in 20 (13.9%). Pre-operative diplopia differed according to the pre-operative limitation of range of motion (LOM) (p < 0.001) and EOM site (p = 0.022). Pre-operative diplopia type differed according to the LOM direction (p = 0.018) and EOM size (p = 0.020). Diplopia persisted in 33 patients (16.5%) 6 months after the surgery. Recovery was faster in patients with peripheral diplopia compared to those with central or full-degree diplopia. Conclusions The presence of diplopia was associated with the pre-operative LOM and EOM site but the type of diplopia was associated with LOM direction and EOM size. These factors can be used to predict the progression of diplopia in patients with isolated inferior orbital wall fracture.

The metabolic syndrome, by definition, is not a disease but is a clustering of individual metabolic risk factors including abdominal obesity, hyperglycemia, hypertriglyceridemia, hypertension, and low high-density lipoprotein cholesterol levels. These risk factors could dramatically increase the prevalence of type 2 diabetes and cardiovascular disease. The reported prevalence of the metabolic syndrome varies, greatly depending on the definition used, gender, age, socioeconomic status, and the ethnic background of study cohorts. Clinical and epidemiological studies have clearly demonstrated that the metabolic syndrome starts with central obesity. Because the prevalence of obesity has doubly increased worldwide over the past 30 years, the prevalence of the metabolic syndrome has markedly boosted in parallel. Therefore, obesity has been recognized as the leading cause for the metabolic syndrome since it is strongly associated with all metabolic risk factors. High prevalence of the metabolic syndrome is not unique to the USA and Europe and it is also increasing in most Asian countries. Insulin resistance has elucidated most, if not all, of the pathophysiology of the metabolic syndrome because it contributes to hyperglycemia. Furthermore, a major contributor to the development of insulin resistance is an overabundance of circulating fatty acids. Plasma fatty acids are derived mainly from the triglycerides stored in adipose tissues, which are released through the action of the cyclic AMP-dependent enzyme, hormone sensitive lipase. This review summarizes the latest concepts in the definition, pathogenesis, pathophysiology, and diagnosis of the metabolic syndrome, as well as its preventive measures and therapeutic strategies in children and adolescents.