Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication.

BACKGROUND: The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society. METHODS: The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS: The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature. CONCLUSIONS: The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

[Mitral Valve Regurgitation Exacerbated by Aortic Dissection:Report of a Case].

The patient was a 74-year-old woman who was originally followed up for hypertrophic cardiomyopathy and mitral regurgitation without subjective symptoms. With the onset of acute aortic dissection, the mitral regurgitation was exacerbated with systolic anterior motion. In addition to aortic dissection surgery, mitral valve surgery was performed. The mitral valve was approached through a right-sided left atrial incision and replaced with a bioprosthetic valve. For aortic dissection, ascending aortic replacement was performed. The postoperative course was uneventful, and the patient was discharged on foot after rehabilitation. Simultaneous mitral valve surgery for acute aortic dissection is rare, but by intervening simultaneously, we were able to achieve a favorable postoperative course.

Endovascular rescue for malpositioned frozen elephant trunk into the false lumen.

We describe a case of frozen elephant trunk deployment unintentionally malpositioned into the false lumen. An 83-year-old man underwent total arch repair with a frozen elephant trunk for type A acute aortic dissection complicated by mesenteric malperfusion. However, intraoperative transesophageal echocardiography showed expansion of the false lumen in the descending aorta, suggesting a malpositioned frozen elephant trunk into the false lumen. Endovascular fenestration of the dissecting flap and subsequent endograft deployment from the inside of the malpositioned frozen elephant trunk graft to the true lumen of the descending aorta was successfully performed under intravascular ultrasound guidance.

[Adhesion Prevention Effect of Circular Pericardial Drainage].

Pericardial adhesions can pose serious problems during cardiac reoperation. Here, we report three cases where circular pericardial drainage (CPD) was performed during the initial surgery and no pericardial adhesions were found during reoperation. All three patients had initially undergone an aortic valve replacement with CPD. Case 1:An 80-year-old female was reoperated this time for an aneurysm of the ascending aorta. A replacement of the ascending aorta was performed. Case 2:A 76-year-old male underwent a second aortic valve repair indicated for prosthetic valve infection. Case 3:The patient was an 82-year-old female. This time, mitral valve replacement, indicated for severe mitral valve stenosis, was performed. In these three cases, there were almost no adhesions in the CPD route. The diaphragmatic pericardial surface, the oblique sinus of pericardium, and the lateral side of the left ventricle were also adhesion-free. CPD can effectively drain postoperative pericardial hemorrhage and thus prevent pericardial adhesions.

[Traction-assisted Negative Pressure Wound Therapy for Pediatric Poststernotomy Mediastinitis:Report of Two Cases].

We herein report two cases of pediatric poststernotomy mediastinitis treated by traction-assisted negative pressure wound therapy (NPWT) with Zip Surgical Skin Closure (Zip), which is a non-invasive skin closure device. We used this device with NPWT in cases of pediatric poststernotomy mediastinitis to stabilize the sternum and reduce the natural retractive forces of the skin. The patients were two boys (two and three months old), with an onset of infection at 13 and eight postoperative days, respectively. The culture examination detected methicillin-susceptible Staphylococcus aureus in both cases. Traction-assisted NPWT with Zip was performed at-75 mmHg for 16 and 33 days, and the wounds healed completely. In conclusion, this modification was successfully applied to treat pediatric poststernotomy mediastinitis and may help reduce the duration of treatment.

Multiple graft injury due to migrated nonbroken sternal wires 2 years after cardiac surgery.

The migration of sternal wires into vital structures is a rare but potentially life-threatening complication and associated with infection in some cases. While a few cases have been reported the sternal wires were broken in those cases. To our knowledge, this is the first report of multiple, nonbroken, migrated sternal wires stabbing vascular grafts.

[Thoracic Endovascular Repair for Chronic Aortic Dissection with Aberrant Origin of the Left Vertebral Artery;Report of a Case].

We herein report a case of thoracic endovascular aortic repair( TEVAR) for chronic aortic dissection with an aberrant left vertebral artery( LVA) originating from the aortic arch. A 51-year-old man with a medical history of Stanford type B acute aortic dissection 2 years ago was transferred to our institution for the treatment of an aortic expansion. Computed tomography showed a large entry just distal to the takeoff of the left subclavian artery and a dilated dissected thoracic aorta. A left cervical incision over the anterior border of the sternocleidomastoid was made, and the LVA was identified. The proximal LVA was ligated and anastomosed to the left common carotid artery in an end-to-side fashion. After completion of the carotid-subclavian bypass, TEVAR was performed in the usual fashion. The postoperative course was uneventful without stroke or spinal cord injury. At the 1-year follow-up, the false lumen had shrunk and the LVA remained patent.

[Tricuspid Valve Replacement Preserving the Leaflets in a Congenitally Corrected Transposition of the Great Arteries;Report of a Case].

In patients with a congenitally corrected transposition of the great arteries (ccTGA), the regurgitation of the systemic atrioventricular valve (SAVV) increases and anatomical right ventricular (ARV) dysfunction often progressively develops. A low systemic ventricular ejection fraction( SVEF) is a risk factor for mortality. However, in patients with a low ejection fraction of ARV, it is unclear how to best perform valve replacement for patients with regurgitation of SAVV. A 70-year-old female with respirator discomfort was admitted to our hospital and diagnosed to have situs solitus ccTGA, severe SAVV regurgitation, and ARV dysfunction. Her ARV ejection fraction was 25% and she was therefore dependent on inotropic agents. We successfully performed a tricuspid valve replacement while preserving the leaflets, the chorda tendineae's, and papillary muscles, and placing the lead for cardiac resynchronization therapy on the ARV. Her postoperative course was uneventful. Thereafter, she was discharged 6 weeks after surgery.

Intervention using behavior modification techniques to improve the lifestyle of high-risk metabolic syndrome patients.

[Purpose] The present study examined the effects of a 12-week intervention combined with behavior modification techniques to improve the lifestyle and biochemical indicators, of high-risk metabolic syndrome patients. [Participants and Methods] The 21 participants (10 participants in the intervention group and 11 participants in the control group) were provided with information about metabolic syndrome. Participants in the intervention group were asked to set goals to improve their lifestyle (dietary and exercise) and their self-efficacy. The participants completed and submitted a weekly, self-monitoring sheet and were provided with feedback on their lifestyle. [Results] Following intervention, the values of body mass index and abdominal circumference were significantly lower for the intervention group as compared to the control group. There were no differences in the total physical activity level, total energy intake, or blood levels of lipids between the two groups. [Conclusion] According to Motivational Interviewing, to modify and continue behaviors, it is important for people to recognize "their significance" and have "confidence". In the present study, information about metabolic syndrome was provided to enable the recognition of the importance of behaviors. Moreover, participants in the intervention group were required to set goals to increase their self-efficacy. We attribute the participants' weight loss and decrease in abdominal circumference to this.

Correlation between serum galectin-9 levels and liver fibrosis.

BACKGROUND AND AIM: Chronic liver diseases progress from chronic inflammation to fibrosis to tumorigenesis. Galectin-9, a ß-galactoside-specific animal lectin, is indicated to contribute to all three steps of progression. The aim of this study was to determine which of the three steps was most dominant in elevating the serum galectin-9 concentration and to test the possibility of galectin-9 as a serum biomarker. METHODS: Japanese patients with chronic hepatitis, liver cirrhosis, hepatocellular carcinoma (HCC), non-alcoholic fatty liver disease, or alcoholic liver disease who provided informed consent were enrolled in this study. Serum galectin-9 levels were measured using a sandwich ELISA. Multiple regression analyses were performed using ezr to identify factors that determined serum galectin-9 concentration. RESULTS: One hundred one patients with 50 of chronic hepatitis and 51 of liver cirrhosis were enrolled; the cohort included 45 cases of hepatitis C virus infection, 13 cases of hepatitis B virus infection, and 46 cases with HCC-related complications. The median serum galectin-9 concentration was 77.54 pg/mL (interquartile range: 18.89-241.9 pg/mL). Multiple linear regression analyses proved Fibrosis-4 index and aspartate aminotransferase to platelet ratio index, indexes of liver fibrosis, were able to predict the serum galectin-9 levels with statistical significance. A multiple logistic regression analysis determined 10 pg/mL increase in the serum galectin-9 concentration presented an odds ratio of 3.90 for liver fibrosis progression. CONCLUSIONS: The serum galectin-9 concentration represents a potential biomarker of liver fibrosis in patients with chronic liver diseases, regardless of chronic inflammation or the presence of HCC complications. Furthermore, higher serum galectin-9 levels are a predictor for liver fibrosis progression.

Chemical Design and Example of Transparent Bipolar Semiconductors.

Transparent bipolar semiconductors (TBSCs) are in demand for transparent electronics to serve as the basis for next generation optoelectronic devices. However, the poor carrier controllability in wide-bandgap materials makes the realization of a bipolar nature difficult. Only two materials, CuInO2 and SnO, have been reported as TBSCs. To satisfy demand for the coexistence of transparency and bipolarity, we propose a design concept with three strategies; choice of early transition metals (eTM) such as Y3+ and Zr4+ for improving controllability of carrier doping, design of chemical bonds to obtain an appropriate band structure for bipolar doping, and use of a forbidden band-edge transition to retain transparency. This approach is verified through a practical examination of a candidate material, tetragonal ZrOS, which is chosen by following the criteria. ZrOS exhibits an excellent controllability of the electrical conductivity (10-7-10-2 S cm-1), p- or n-type nature with ∼10-2 S cm-1 by Y or F doping, respectively, and optically wide gap (below 10-4 cm-1 up to ∼2.5 eV). This concept provides a new kind of TBSC based on eTM ionic compounds.

Arcuate Na+,K+-ATPase senses systemic energy states and regulates feeding behavior through glucose-inhibited neurons.

Feeding is regulated by perception in the hypothalamus, particularly the first-order arcuate nucleus (ARC) neurons, of the body's energy state. However, the cellular device for converting energy states to the activity of critical neurons in ARC is less defined. We here show that Na(+),K(+)-ATPase (NKA) in ARC senses energy states to regulate feeding. Fasting-induced systemic ghrelin rise and glucose lowering reduced ATP-hydrolyzing activity of NKA and its substrate ATP level, respectively, preferentially in ARC. Lowering glucose concentration (LG), which mimics fasting, decreased intracellular NAD(P)H and increased Na(+) concentration in single ARC neurons that subsequently exhibited [Ca(2+)]i responses to LG, showing that they were glucose-inhibited (GI) neurons. Third ventricular injection of the NKA inhibitor ouabain induced c-Fos expression in agouti-related protein (AgRP) neurons in ARC and evoked neuropeptide Y (NPY)-dependent feeding. When injected focally into ARC, ouabain stimulated feeding and mRNA expressions for NPY and AgRP. Ouabain increased [Ca(2+)]i in single NPY/AgRP neurons with greater amplitude than in proopiomelanocortin neurons in ARC. Conversely, the specific NKA activator SSA412 suppressed fasting-induced feeding and LG-induced [Ca(2+)]i increases in ARC GI neurons. NPY/AgRP neurons highly expressed NKAα3, whose knockdown impaired feeding behavior. These results demonstrate that fasting, via ghrelin rise and LG, suppresses NKA enzyme/pump activity in ARC and thereby promotes the activation of GI neurons and NPY/AgRP-dependent feeding. This study identifies ARC NKA as a hypothalamic sensor and converter of metabolic states to key neuronal activity and feeding behaviour, providing a new target to treat hyperphagic obesity and diabetes.

Peripheral oxytocin activates vagal afferent neurons to suppress feeding in normal and leptin-resistant mice: a route for ameliorating hyperphagia and obesity.

Oxytocin (Oxt), a neuropeptide produced in the hypothalamus, is implicated in regulation of feeding. Recent studies have shown that peripheral administration of Oxt suppresses feeding and, when infused subchronically, ameliorates hyperphagic obesity. However, the route through which peripheral Oxt informs the brain is obscure. This study aimed to explore whether vagal afferents mediate the sensing and anorexigenic effect of peripherally injected Oxt in mice. Intraperitoneal Oxt injection suppressed food intake and increased c-Fos expression in nucleus tractus solitarius to which vagal afferents project. The Oxt-induced feeding suppression and c-Fos expression in nucleus tractus solitarius were blunted in mice whose vagal afferent nerves were blocked by subdiaphragmatic vagotomy or capsaicin treatment. Oxt induced membrane depolarization and increases in cytosolic Ca(2+) concentration ([Ca(2+)]i) in single vagal afferent neurons. The Oxt-induced [Ca(2+)]i increases were markedly suppressed by Oxt receptor antagonist. These Oxt-responsive neurons also responded to cholecystokinin-8 and contained cocaine- and amphetamine-regulated transcript. In obese diabetic db/db mice, leptin failed to increase, but Oxt increased [Ca(2+)]i in vagal afferent neurons, and single or subchronic infusion of Oxt decreased food intake and body weight gain. These results demonstrate that peripheral Oxt injection suppresses food intake by activating vagal afferent neurons and thereby ameliorates obesity in leptin-resistant db/db mice. The peripheral Oxt-regulated vagal afferent neuron provides a novel target for treating hyperphagia and obesity.

[Evaluation of Radiation Dose during Stent-graft Treatment Using a Hybrid Operating Room System].

In recent years, aortic aneurysm treatment with stent graft grafting in the X-ray fluoroscopy is increasing. This is an endovascular therapy, because it is a treatment which includes the risk of radiation damage, having to deal with radiation damage, to know in advance is important. In this study, in order to grasp the trend of exposure stent graft implantation in a hybrid operating room (OR) system, focusing on clinical data (entrance skin dose and fluoroscopy time), was to count the total. In TEVAR and EVAR, fluoroscopy time became 13.40 ± 7.27 minutes, 23.67 ± 11.76 minutes, ESD became 0.87 ± 0.41 mGy, 1.11 ± 0.57 mGy. (fluoroscopy time of EVAR was 2.0 times than TEVAR. DAP of EVAR was 1.2 times than TEVAR.) When using the device, adapted lesions and usage are different. This means that care changes in exposure-related factors. In this study, exposure trends of the stent graft implantation was able to grasp. It can be a helpful way to reduce/optimize the radiation dose in a hybrid OR system.

[Effects of exercise intervention on exercise behavior in community-dwelling elderly subjects: a randomized controlled trial].

AIM: The objective of the present study was to evaluate the long-term effectiveness of an exercise program in modifying the exercise behavior of the community-dwelling elderly subjects. METHODS: This study was a single-blinded randomized controlled trial. The subjects included 52 males and 65 females 65 years of age or over who were randomly assigned to an exercise-intervention group or a health-education group. The stages of change in exercise behavior were evaluated before and one-year after the intervention period. The subjects' physical function (muscle strength, balance, walking speed) and self-efficacy in each domain of the physical function were measured during the intervention period. RESULTS: There were no significant differences in the stages of change before the intervention between the two groups. Significant differences in the stages of change were observed in "relapse" of stages at two points in time between the two groups (p<.01). A logistic regression analysis showed that "progression" of stages was associated with improvements in the timed up and go test (AOR 2.7; 95% CI 1.3-5.8) and sit and reach (AOR 1.14; 95%CI 1.0-1.3), while "relapse" of stages was associated with the group allocation (AOR 4.6; 95%CI 1.1-18.8), self-efficacy in "Walking" (AOR 1.54; 95%CI 1.0-2.3) and "Stair climbing" (AOR 0.68; 95%CI 0.5-0.9) with respect to physical activity during the intervention period. CONCLUSIONS: The results suggest that exercise intervention in community-dwelling elderly subjects is effective in preventing "relapse" of exercise behavior over long periods.

Potential clinical benefits of warfarin in end-stage cancers: A retrospective analysis.

Background and Aims: Coagulopathy and thromboembolism are common comorbidities in cancer, and anticoagulants, such as warfarin, are needed in specific situations. This study aimed to determine the clinical relevance of prothrombin time (PT) monitoring and the clinical usefulness of warfarin in patients with malignancy. Methods: We retrospectively investigated patients with PT lower than 10% treated in our hospital between April 2006 and March 2013. Cases of false coagulopathy, including those due to technical errors during blood sampling, were excluded. The cause of coagulopathy was determined or estimated by physicians. Results: This study included 338 cases comprising 155 females and 183 males with a median age was 68 (0-97) years. Among them, 89 (26.3%) had cancer, and 163 (48.2%) received warfarin at a median dose of 2.23 (0.5-8.0) mg/day. PT prolongation caused by warfarin overdose and malignancy exacerbation were observed in 75 (22.2%) and 64 (18.9%) patients, respectively. The leading reasons for warfarin administration were arterial fibrillation, chronic heart failure, and deep vein thrombosis. Univariate analysis revealed that the overall survival was higher in the warfarin and nononcology groups than in the nonwarfarin and oncology groups (both p < 0.001). In multivariate analysis, survival was significantly decreased in older adults (p = 0.049), those with malignancy (p < 0.001), and those without warfarin therapy (p < 0.001). Early mortality (within 3 days after PT prolongation) was observed in 65 patients and was mostly related to emergent diseases (36.9%, 24/65) and end-stage malignancy (32.3%, 21/65). Conclusion: Patients with malignancy may experience subclinical PT prolongation upon disease progression. Warfarin treatment mitigates panic PT values in patients with malignancy. Conversely, those not treated with warfarin have poor survival, suggesting that coagulopathy without warfarin treatment can lead to death. Warfarin enhances hemostatic conditions, thereby preventing malignancy-related lethal hemorrhagic or thromboembolic events.

[Relationships between nutritional status and the effects of exercise training in frail elderly people].

AIM: The objectives of this study were to examine the relationship between nutritional status indicators such as body mass index (BMI) and serum albumin, and the effects of exercise intervention in community-dwelling frail elderly people. METHODS: We enrolled 44 subjects aged 65 years and older (average age 73.9±5.1 years) in this study. The subjects participated in exercise intervention, including muscle strength training twice a week for 3 months. We evaluated various functional performance measures at the start and end of the intervention, and calculated the measurement differences. We then evaluated any relationships between nutritional status and the amount of changes. RESULTS: Some physical functions improved after exercise intervention, even in participants with under-nutritional status. There were no significant differences or relationships found between nutritional status and improvements in physical function. CONCLUSIONS: These results suggest that the physical functions of frail elderly people can improve regardless of their nutritional status. Further study is necessary to evaluate the influence of nutritional status on exercise effects, and the optimal method of applying exercise interventions, primarily for community-dwelling frail older people.

Chronic contained rupture of abdominal aortic aneurysm that developed from chronic abdominal aortic dissection.

A chronic contained rupture is an extremely rare subtype of abdominal aortic aneurysm rupture. We report the case of a 59-year-old man with a medical history of traumatic lumber fracture 7 years ago. He presented to us with an asymptomatic irregular abdominal aortic aneurysm, and surgery was performed 1 week after he was hospitalized. Based on the medical history, imaging, blood tests, and pathologic results, we determined that the chronic contained rupture progressed from a localized abdominal aortic dissection. This case illustrates the need to follow the morphology of aortic aneurysms if chronic abdominal aortic dissection is observed.

Effects of bilirubin configurational photoisomers on the measurement of direct bilirubin by the vanadate oxidation method.

BACKGROUND: Direct-reacting bilirubin concentrations measured using vanadate chemical oxidation method do not exactly match the conjugated bilirubin concentration. One of the causes is the effect of bilirubin photoisomers. However, the quantitative evaluation of the effects of these photoisomers has not been sufficiently conducted. In particular, the influence of bilirubin configurational isomers on direct bilirubin is the most critical factor. METHODS: Sixteen residual serum samples were used. For quantitative analysis based on the change in direct bilirubin and bilirubin configurational isomer, samples were irradiated via blue light-emitting diodes to suppress the production of bilirubin structural isomers. Total bilirubin and direct bilirubin concentrations were measured using the vanadate chemical oxidation method. Concentrations of 4Z,15Z-bilirubin IXα and its photoisomers were measured using high-performance liquid chromatography. The sum of 4Z,15E-bilirubin IXα and 4E,15Z-bilirubin IXα was notated as bilirubin configurational isomer, and the differences between the measured values of the irradiated and non-irradiated samples were calculated and notated as ΔDB and ΔBCI. RESULTS: In non-irradiated and irradiated samples, total bilirubin and direct bilirubin concentrations were 10.73 mg/dL with significant a decrease to 10.60 mg/dL and 0.69 mg/dL with a significant increase to 0.78 mg/dL, while bilirubin configurational isomer values were 1.00 mg/dL and 1.52 mg/dL, respectively. The linear regression equation revealed a significant positive correlation of Y = 0.187X-0.006 between ΔDB (Y) and ΔBCI (X). CONCLUSION: Applying the vanadate chemical oxidation method affected approximately 19% of the bilirubin configurational isomer concentration for direct bilirubin. Extreme caution is necessary when interpreting the measured values of samples indicative of unconjugated hyperbilirubinaemia.

Lineage switch from precursor B cell acute lymphoblastic leukemia to acute monocytic leukemia at relapse.

A lineage switch in leukemia, in which the leukemic cell lineage at onset converts to another lineage at a later time, is an uncommon type of hybrid (mixed) leukemia regarded as a variation of bilineage leukemia. We present a case of a 60-year-old female diagnosed with precursor B cell acute lymphoblastic leukemia (ALL), whose markers in flow cytometry shifted from their original status of CD19+, 22+, 79a+, 13+, HLA-DR+, and TdT+. Although her bone marrow achieved remission after induction therapy, there was a small residual population of leukemic cells in the liver. Residual disease was proved by biopsy and pathologically shown to have an immature phenotype of CD5+, CD10-, CD20-, CD79a- and myeloperoxidase negativity. Two weeks after liver biopsy, blast cells progressively appeared in the peripheral blood; these cells had a monocytoid morphology and phenotype (CD13, 14) but were accompanied by myeloid (CD33) and lymphoid (CD2, 4, 20) cells. Markers CD7, 10 and 19 were negative by flow cytometry. This phenotypical conversion from B-ALL to hybrid leukemia featuring monocytoid characteristics is known as a lineage switch. This case suggests that leukemic subclones tend to carry out dedifferentiation, occasionally in extramedullary sites, which serve as a hotbed for the selection of resistant clones.