Development of a Conversion Table Linking Functional Independence Measure Scores to International Classification of Functioning, Disability, and Health Qualifiers: Insights from a Survey of Healthcare Professionals.

In clinical practice, patient assessments rely on established scales. Integrating data from these scales into the International Classification of Functioning, Disability, and Health (ICF) framework has been suggested; however, a standardized approach is lacking. Herein, we tested a new approach to develop a conversion table translating clinical scale scores into ICF qualifiers based on a clinician survey. The survey queried rehabilitation professionals about which functional independence measure (FIM) item scores (1-7) corresponded to the ICF qualifiers (0-4). A total of 458 rehabilitation professionals participated. The survey findings indicated a general consensus on the equivalence of FIM scores with ICF qualifiers. The median value for each item remained consistent across all item groups. Specifically, FIM 1 had a median value of 4; FIM 2 and 3 both had median values of 3; FIM 4 and 5 both had median values of 2; FIM 6 had a median value of 1; and FIM 7 had a median value of 0. Despite limitations due to the irreconcilable differences between the frameworks of existing scales and the ICF, these results underline the ICF's potential to serve as a central hub for integrating clinical data from various scales.

Clinical Efficacy of Beta-1 Selective Beta-Blockers Versus Propranolol in Patients With Thyroid Storm: A Retrospective Cohort Study.

OBJECTIVES: Thyroid storm is the most severe manifestation of thyrotoxicosis. Beta-blockers are among the standard treatment regimens for this condition, with propranolol being the historically preferred option. However, 2016 guidelines issued by the Japan Thyroid Association and the Japan Endocrine Society recommend the use of beta-1 selective beta-blockers over nonselective beta-blockers, such as propranolol. Nevertheless, evidence supporting this recommendation is limited. Herein, we aimed to investigate the in-hospital mortality of patients with thyroid storms based on the choice of beta-blockers. DESIGN: Retrospective cohort study. SETTING: The Diagnosis Procedure Combination database, a national inpatient database in Japan. PATIENTS: Patients hospitalized with thyroid storm between April 2010 and March 2022. INTERVENTIONS: Propensity-score overlap weighting was performed to compare in-hospital mortality between patients who received beta-1 selective beta-blockers and those who received propranolol. Subgroup analysis was also conducted, considering the presence or absence of acute heart failure. MEASUREMENTS AND MAIN RESULTS: Among the 2462 eligible patients, 1452 received beta-1 selective beta-blockers and 1010 received propranolol. The crude in-hospital mortality rates were 9.3% for the beta-1 selective beta-blocker group and 6.2% for the propranolol group. After adjusting for baseline variables, the use of beta-1 selective beta-blockers was not associated with lower in-hospital mortality (6.3% vs. 7.4%; odds ratio, 0.85; 95% CI, 0.57-1.26). Furthermore, no significant difference in in-hospital mortality was observed in patients with acute heart failure. CONCLUSIONS: In patients with thyroid storm, the choice between beta-1 selective beta-blockers and propranolol did not affect in-hospital mortality, regardless of the presence of acute heart failure. Therefore, both beta-1 selective beta-blockers and propranolol can be regarded as viable treatment options for beta-blocker therapy in cases of thyroid storm, contingent upon the clinical context.

Potassium Iodide Use and Patient Outcomes for Thyroid Storm: An Observational Study.

PURPOSE: Iodine, combined with antithyroid drugs, is recommended as an initial pharmacologic treatment for thyroid storm according to some clinical guidelines. However, the clinical efficacy of iodine in managing thyroid storm remains unexplored. This study aimed to determine whether early potassium iodide (KI) use is associated with mortality in patients hospitalized for thyroid storm. METHODS: Using the Japanese Diagnosis Procedure Combination database, we identified patients hospitalized with thyroid storm between July 2010 and March 2022. We compared in-hospital mortality, length of stay, and total hospitalization costs between patients who received KI within two days of admission (KI group) versus those who did not (non-KI group). Prespecified subgroup analyses were performed based on the presence of the diagnosis of Graves' disease. RESULTS: Among 3,188 eligible patients, 2,350 received KI within two days of admission. The crude in-hospital mortality was 6.1% (143/2,350) in the KI group and 7.8% (65/838) in the non-KI group. After adjusting for potential confounders, KI use was not significantly associated with in-hospital mortality (odds ratio [OR] for KI use, 0.91; 95% confidence interval [CI], 0.62-1.34). In patients with the diagnosis of Graves' disease, in-hospital mortality was lower in the KI group than in the non-KI group (OR, 0.46; 95% CI, 0.25-0.88). No significant difference in in-hospital mortality was observed in patients without the diagnosis of Graves' disease (OR, 1.11; 95% CI, 0.67-1.85). Length of stay was shorter (subdistribution hazard ratio, 1.15; 95% CI, 1.05-1.27), and total hospitalization costs were lower (OR, 0.92; 95% CI, 0.85-1.00) in the KI group compared with the non-KI group. CONCLUSION: Our findings suggest that KI may reduce in-hospital mortality among patients hospitalized for thyroid storm with Graves' disease.

Successful Conservative Management of Emphysematous Cystitis With Pneumoperitoneum: A Case Report and Literature Review.

Emphysematous cystitis is a rare type of urinary tract infection that is characterized by the accumulation of gas within the walls and lumen of the urinary bladder. In rarer instances, pneumoperitoneum may accompany emphysematous cystitis. When pneumoperitoneum is suspected through imaging studies in patients with emphysematous cystitis, surgical abdominal exploration is frequently performed considering the possibility of bladder perforation or coexistence of intestinal perforation. We successfully managed a case of emphysematous cystitis accompanied with pneumoperitoneum conservatively. A 90-year-old woman hospitalized with a gastric ulcer developed abrupt lower abdominal pain and hematuria. Contrast-enhanced CT revealed gas within the bladder wall, which was consistent with emphysematous cystitis, and pneumoperitoneum. No obvious bowel or bladder perforation was observed in the CT scan. Regarding her high surgical risk and clinical stability, surgical abdominal exploration was not performed, and she was managed conservatively with urethral catheter placement and antibiotics. She recovered with the treatment, and CT imaging obtained on day 18 demonstrated resolution of the bladder wall emphysema and no signs of pneumoperitoneum. We performed a literature review using MEDLINE and Japana Centra Revuo Medicina Web and confirmed 13 previously reported cases of emphysematous cystitis and pneumoperitoneum. Based on the review of these 13 cases and our case, it is difficult to predict the presence of bladder perforation solely based on peritoneal signs in physical findings or ascites on CT scans. Therefore, it would be preferable to perform surgical abdominal exploration to make a definite diagnosis and select an appropriate treatment. However, the fact that at least eight out of the 10 cases managed conservatively survived suggests that there is a specific clinical entity among patients who present with emphysematous cystitis and pneumoperitoneum that can be safely managed conservatively. Further accumulation of cases and research is necessary to determine which cases can be treated conservatively.

Association between use of transdermal tulobuterol and short-term outcomes in patients with stroke and underlying chronic obstructive pulmonary disease: A retrospective cohort study.

Transdermal tulobuterol, a long-acting beta agonist in a transdermal form, is available in some countries, including Japan, Korea, and China. It may provide an alternative treatment option for the management of chronic obstructive pulmonary disease (COPD) in patients who are unable to effectively use inhalers, such as those with acute stroke. This study examined the short-term outcomes of transdermal tulobuterol in patients hospitalized with acute stroke and underlying COPD. Using the Diagnosis Procedure Combination database, a national inpatient database in Japan, we identified patients with stroke and underlying COPD who were hospitalized between July 2010 and March 2021. We performed propensity-score overlap weighting to compare in-hospital death, COPD exacerbation, pneumonia, and cardiac complications between patients who initiated transdermal tulobuterol within 2 days of admission and those who did not use it during hospitalization. Of the 1878 eligible patients, 189 received transdermal tulobuterol within 2 days of admission. After adjusting for baseline variables, transdermal tulobuterol was not associated with a reduction in in-hospital death (18.3% vs 16.1%; odds ratio, 1.17; 95% confidence interval, 0.72-1.90). Additionally, we observed no significant difference in COPD exacerbation, pneumonia, and cardiac complications between both groups. Transdermal tulobuterol was not associated with improving short-term outcomes in patients with acute stroke and underlying COPD. Our study does not support the routine use of transdermal tulobuterol in this patient group. However, further research investigating the long-term efficacy of transdermal tulobuterol in patients with stroke and underlying COPD could help establish its role for the management of these patients.

Spontaneous Recovery of Hemophagocytic Lymphohistiocytosis Due to Primary Epstein-Barr Virus Infection in an Adult Patient.

BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening systemic hyperinflammatory condition. Most adult HLH cases are secondary to infection, malignancy, and rheumatic diseases. Epstein-Barr virus (EBV) infection is the most frequent cause of infection-induced HLH. Early treatment with dexamethasone, etoposide, and cyclosporine is generally recommended for adult patients with HLH. However, this treatment regimen was established based on pediatric clinical trial data; thus, its efficacy and validity in adults remain unclear. Because little is known about the disease course of untreated adult EBV-associated HLH (EBV-HLH), we report a case of an adult patient who recovered from EBV-HLH spontaneously without specific treatment and discuss potential treatment strategies. CASE REPORT A 34-year-old man presented to the emergency department with a 7-day history of fever, headache, and sore throat. The main laboratory test abnormalities were elevated liver enzymes, hyperbilirubinemia, hypertriglyceridemia, and hyperferritinemia. Serologic tests confirmed acute primary EBV infection. He was diagnosed with EBV-HLH based on the HLH-2004 diagnostic criteria and the HLH probability calculator (HScore). Because he was clinically stable, we did not initiate immunosuppressive/cytotoxic treatment targeting HLH. High-grade fever persisted, but the abnormalities in his laboratory data improved spontaneously, and he did not develop major organ failure. His fever resolved on day 29 without HLH-specific treatment. CONCLUSIONS In clinically stable adult patients with EBV-HLH without major organ failure, it might be an acceptable alternative to observe the patient for several weeks before initiating HLH-specific treatment. Further research is required to better predict the subset of patients who can be safely observed without treatment.

Portal and Mesenteric Vein Thrombosis Associated with Hyperthyroidism.

BACKGROUND Non-malignant and non-cirrhotic portal and mesenteric vein thrombosis is rare. It has been reported that the hyperthyroid state is associated with increased risks of venous thrombosis due to increases in levels of various coagulation and anti-fibrinolytic factors. Particularly, changes in levels of these factors are also reported in cases of portal and mesenteric vein thrombosis. Although hyperthyroidism is not known as a risk factor for portal and mesenteric vein thrombosis, it might be an underlying pathogenesis of hyperthyroidism-associated portal and mesenteric vein thrombosis. CASE REPORT A 59-year-old Japanese man with a history of Grave's disease presented with acute portal and mesenteric vein thrombosis and hyperthyroidism. Anticoagulation therapy was initiated and the dose of antithyroid drug was increased. He underwent various tests to identify causes of portal and mesenteric vein thrombosis. However, all test results were within normal range except for hyperthyroidism. Therefore, we discontinued anticoagulation therapy after normalization of thyroid hormone status. After 3 years, he experienced recurrence of portal vein thrombosis concomitant with hyperthyroidism. CONCLUSIONS Hyperthyroidism might be associated with portal vein thrombosis. Thyroid function tests should be performed in cases of portal and mesenteric vein thrombosis in the absence of other risk factors.

Unique presentation of cricoid cartilage fracture causing intermittent dyspnea without preceding trauma.

Cricoid cartilage fracture is generally caused by significant neck trauma and causes continuous dyspnea, neck pain, or hoarseness developing immediately after the traumatic episode. A 69-year-old woman without any history of trauma was admitted to our hospital with intermittent dyspnea. Six months before admission she had started to complain of dyspnea occurring several times a month without warning, improving spontaneously within a few hours without treatment. Her primary care doctor diagnosed asthma and she was treated with inhaled short-acting beta agonists and glucocorticoids, without improvement. On initial evaluation at our hospital, the cause of dyspnea was unclear. Laryngoscopy was performed, which excluded vocal cord dysfunction. A further attack of dyspnea occurred on the fourth admission day. Stridor was evident during the attack, and bronchoscopy revealed subglottic narrowing of the trachea on both inspiration and expiration with no mass or foreign objects. Computed tomography (CT) of the neck revealed cricoid cartilage fracture causing airway narrowing and dyspnea. She was orally intubated, and tracheostomy was performed 2 weeks later to maintain her airway, which resolved her dyspnea. This patient's presentation was unique in two aspects. First, there was no history of trauma that may cause her cricoid cartilage fracture. Second, her symptoms of dyspnea were intermittent rather than continuous. These aspects led to suspicions of other diseases such as asthma or vocal cord dysfunction, thus delaying the diagnosis. Cricoid cartilage fracture should be considered in patients with dyspnea of unknown cause, irrespective of continuous or intermittent symptoms and preceding traumatic episodes.

Low-frequency repetitive TMS plus anodal transcranial DCS prevents transient decline in bimanual movement induced by contralesional inhibitory rTMS after stroke.

BACKGROUND: Low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected motor cortex may improve motor function of the paretic hand after stroke. However, low-frequency rTMS might adversely affect bimanual movement by decreasing transcallosal function. OBJECTIVE: The authors investigated whether combined administration of rTMS and transcranial direct current stimulation (tDCS) prevents deterioration of bimanual movement induced by low-frequency rTMS over the unaffected hemisphere. METHODS: A total of 27 participants with chronic subcortical stroke were randomly assigned to receive either 1 Hz rTMS over the unaffected hemisphere, anodal tDCS over the affected hemisphere, or a combination of rTMS and tDCS. All patients performed a pinching motor-training task after stimulation. Bimanual movement and transcallosal inhibition (TCI) were evaluated after stimulation. RESULTS: rTMS and rTMS-tDCS enhanced the motor training effect on the paretic hand. rTMS decreased bimanual coordination and reduced TCI from the unaffected to the affected hemisphere (TCI(unaff-aff)). rTMS-tDCS changed TCI balance of both hemispheres but did not affect bimanual coordination or TCI(unaff-aff). The change in bimanual coordination was negatively correlated with TCI(unaff-aff). Following stimulation, improvement in the pinch force in the paretic hand was negatively correlated with TCI balance. CONCLUSIONS: Inhibitory rTMS over the unaffected hemisphere transiently caused deterioration of bimanual movements for the current task in stroke patients. This short-term decline was prevented by combined administration of low-frequency rTMS over the unaffected hemisphere and anodal tDCS over the affected hemisphere. These responses to bihemispheric stimulation suggest possible caution and opportunities for the rehabilitation of hand function after stroke.

Repetitive transcranial magnetic stimulation over bilateral hemispheres enhances motor function and training effect of paretic hand in patients after stroke.

OBJECTIVE: The interhemispheric competition model proposes that the functional recovery of motor deficits in patients after stroke can be achieved by increasing the excitability of the affected hemisphere or decreasing the excitability of the unaffected hemisphere. We investigated whether bilateral repetitive transcranial magnetic stimulation might improve the paretic hand in patients after stroke. DESIGN: A double-blind study. PATIENTS: Thirty patients with chronic subcortical stroke. METHODS: The patients were randomly assigned to receive 1 Hz repetitive transcranial magnetic stimulation over the unaffected hemisphere, 10 Hz repetitive transcranial magnetic stimulation over the affected hemisphere, or bilateral repetitive transcranial magnetic stimulation comprising both the 1 Hz and 10 Hz repetitive transcranial magnetic stimulation. All patients underwent motor training following repetitive transcranial magnetic stimulation. RESULTS: Bilateral repetitive transcranial magnetic stimulation and 1 Hz repetitive transcranial magnetic stimulation immediately improved acceleration in the paretic hand. Compared with 1 Hz repetitive transcranial magnetic stimulation, bilateral repetitive transcranial magnetic stimulation decreased the inhibitory function of the affected motor cortex and enhanced the effect of motor training on pinch force. Moreover, this effect of motor training lasted for one week. On the other hand, 10 Hz repetitive transcranial magnetic stimulation had no effect on the motor function. CONCLUSION: Bilateral repetitive transcranial magnetic stimulation improved the motor training effect on the paretic hand of patients after stroke more than unilateral stimulation in pinch force; this might indicate a new neurorehabilitative strategy for stroke.

Inhibition of the unaffected motor cortex by 1 Hz repetitive transcranical magnetic stimulation enhances motor performance and training effect of the paretic hand in patients with chronic stroke.

OBJECTIVE: Recent reports demonstrated that low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere improved the affected hand function in chronic stroke patients. We investigated whether 1 Hz rTMS improved the motor learning of the affected hand in patients after stroke. DESIGN: A double-blind study. PATIENTS: Twenty patients with chronic subcortical stroke. METHODS: The patients were randomly assigned to receive either a sub-threshold rTMS over the unaffected hemisphere (1 Hz, 25 minutes) or sham stimulation, and all patients performed a pinching task after stimulation. We evaluated the motor function of the affected hand and the excitatory and inhibitory function of the affected motor cortex by transcranial magnetic stimulation. RESULTS: Compared with sham stimulation, rTMS induced an increase in the excitability of the affected motor cortex(p < 0.001) and an improvement in acceleration of the affected hand (p = 0.006). Moreover, the effect of motor training on pinch force was enhanced by rTMS (p < 0.001). These improvement in the motor function lasted for one week after rTMS and motor training (p < 0.001). CONCLUSION: rTMS improved the motor learning of the affected hand in patients after stroke; thus, it can apply as anew rehabilitation strategy for patients after stroke.

Repetitive transcranial magnetic stimulation of the unaffected hemisphere in a patient who was forced to use the affected hand.

We present a case report of a 56-yr-old chronic stroke patient with right hemiparesis who was treated with repetitive transcranial magnetic stimulation (rTMS) therapy. Before stroke, the patient had suffered an accident that led to paralysis and contracture of the left upper limb, and, subsequently, he was forced to use only his right upper limb for routine activities, despite right hemiparesis. We performed subthreshold rTMS (1 Hz, 25 mins) and sham stimulation of the contralesional primary motor cortex (M1) at different times. Immediately after rTMS, the patient was able to write characters with increased speed and accuracy, and this effect continued for more than 7 days; however, this was not the case after sham stimulation. Moreover, the writing practice after rTMS improved the patient's pinch force.

Disinhibition of the premotor cortex contributes to a maladaptive change in the affected hand after stroke.

BACKGROUND AND PURPOSE: The mechanism of reorganization after stroke remains uncertain. Several studies that have measured reaction time (RT) delay by transcranial magnetic stimulation (TMS) have revealed some substrates responsible for the reorganization of motor recovery. In this study, we evaluated the RT delay and inhibitory functions by examining the silent period (SP) in the primary motor cortex (M1) and premotor cortex (PMC) of the affected hemisphere. Using these data, we investigated whether a change in the inhibitory system might influence motor recovery. METHODS: This study was performed in 20 patients with chronic subcortical stroke. To evaluate the RT delay, TMS was applied to the affected hemisphere 100 ms after showing the cue that indicated paretic finger movement. The SP was induced by TMS over the affected hemisphere during voluntary contraction of the paretic hand. RESULTS: The RT delays of the PMC were more prominent in patients with greater disability. The ratio of SP duration to RT delay in the PMC decreased with the decline in motor function. Moreover, upper arm function was better than hand function in patients with a decreased SP in the PMC. CONCLUSIONS: The inhibitory function of the PMC was disturbed in patients with poor motor function. Stroke patients with poor motor ability appeared to depend not only on the motor pathway from M1 but also on other parallel motor circuits to move the paretic side. However, this brain reorganization might result in the sacrifice of function of the affected hand.

Measurement of transcallosal inhibition in traumatic brain injury by transcranial magnetic stimulation.

PRIMARY OBJECTIVE: To study whether transcallosal inhibition (TCI) can evaluate the severity of traumatic brain injury (TBI). RESEARCH DESIGN: Case-control study. METHODS AND PROCEDURES: Twenty patients with a chronic TBI and 20 control subjects were studied. The following transcranial magnetic stimulation parameters were checked; resting motor threshold, central motor latency times, onset latency of TCI, duration of TCI, transcallosal conduction times and amount of TCI. The severity of TBI was evaluated using the Glasgow Coma Scale (GCS). MAIN OUTCOME AND RESULTS: The amount of TCI was significantly lower in the patients than the control subjects (p < 0.001). The amount of TCI was highly correlated with the GCS (r = 0.787, p < 0.001). CONCLUSION: An assessment of TCI was found to be a more sensitive and useful method for an evaluation of the severity of TBI.

Repetitive transcranial magnetic stimulation of contralesional primary motor cortex improves hand function after stroke.

BACKGROUND AND PURPOSE: A recent report has demonstrated that the contralesional primary motor cortex (M1) inhibited the ipsilesional M1 via an abnormal transcallosal inhibition (TCI) in stroke patients. We studied whether a decreased excitability of the contralesional M1 induced by 1 Hz repetitive transcranial magnetic stimulation (rTMS) caused an improved motor performance of the affected hand in stroke patients by releasing the TCI. METHODS: We conducted a double-blind study of real versus sham rTMS in stroke patients. After patients had well- performed motor training to minimize the possibility of motor training during the motor measurement, they were randomly assigned to receive a subthreshold rTMS at the contralesional M1 (1 Hz, 25 minutes) or sham stimulation. RESULTS: When compared with sham stimulation, rTMS reduced the amplitude of motor-evoked potentials in contralesional M1 and the TCI duration, and rTMS immediately induced an improvement in pinch acceleration of the affected hand, although a plateau in motor performance had been reached by the previous motor training. This improvement in motor function after rTMS was significantly correlated with a reduced TCI duration. CONCLUSIONS: We have demonstrated that a disruption of the TCI by the contralesional M1 virtual lesion caused a paradoxical functional facilitation of the affected hand in stroke patients; this suggests a new neurorehabilitative strategy for stroke patients.