Knee Osteotomy Decreases Joint Inflammation Based on Synovial Histology and Synovial Fluid Analysis.

PURPOSE: To examine the biological changes in the joints of patients with knee osteoarthritis (OA) before and after around-knee osteotomy (AKO), focusing on synovial fluid (SF) and synovial pathological changes. METHODS: Patients who underwent AKO for medial compartment knee OA between 2019 and 2021 were examined. SF and synovium were obtained at the time of AKO and plate removal after bone union (mean, 16.8 months [range: 11-38 months] postoperatively). SF volume and interleukin (IL)-6 concentrations in SF were assayed using enzyme-linked immunosorbent assay. Synovitis was assessed histologically using a semiquantitative scoring system. Macrophage infiltration was assessed by immunohistochemistry using a semiquantitative score for F4/80 expression. The M1/M2 ratio was calculated using percentage of cells positive for CD80 and CD163. The expression of proinflammatory cytokines was assessed by the percentage of IL-1ß- and IL-6-positive cells. The number of vascular endothelial growth factor-positive luminal structures was counted to assess angiogenesis. The change in each parameter was compared before and after AKO using the Wilcoxon matched-pairs signed-rank test. RESULTS: Twenty-four knees of 21 patients were included. SF volume and IL-6 concentration significantly decreased postoperatively (12.6 ± 2.1 mL vs 4.2 ± 0.6 mL; P < .0001 and 50.5 ± 8.6 pg/mL vs 20.7 ± 3.8 pg/mL; P = .0001, respectively). A significant reduction in synovitis score (P = .0001), macrophage infiltration (P < .0003), M1/M2 ratio (P < .0007), angiogenesis (P < .0001), and the percentage of IL-1ß- and IL-6-positive cells in the intima (P < .008 and P < .002, respectively) was found after AKO. CONCLUSIONS: SF volume and IL-6 concentrations in the SF decreased and inflammatory synovium pathology improved after AKO. In addition to biomechanical changes, the biological environment of the joint can be improved after AKO. LEVEL OF EVIDENCE: Level IV, retrospective therapeutic case series.

The coronal lateral collateral ligament sign in the anterior cruciate ligament-injured knees was observed regardless of the knee laxity based on the quantitative measurements.

PURPOSE: The coronal lateral collateral ligament (LCL) sign has been reported to be associated with deviated position of the tibia on MRI due to anterior cruciate ligament (ACL) injuries. However, the relationships between LCL sign and clinical knee laxity evaluations are still unclear. The purpose of the study was to investigate the relationship between the coronal LCL sign and knee laxity measurements. METHODS: A retrospective review of unilateral ACL injured patients who underwent ACL reconstruction was performed. The coronal LCL sign was determined using magnetic resonance imaging (MRI). Clinical grading of the pivot-shift test, KT-1000 measurements, and quantitative measurements of the Lachman test and the pivot-shift test using an electromagnetic system, were compared between patients with positive and negative coronal LCL sign. A subgroup analysis of different age groups was then performed, dividing patients to adolescent (age ≤ 18 years) and adult (age > 18 years) groups. RESULTS: A total of 85 patients were enrolled, of which 45 patients had coronal LCL signs. The coronal LCL sign was not associated with the pivot-shift test clinical grading (n.s), KT-1000 measurement (n.s), the tibial translation during the Lachman test (n.s), or with tibia acceleration (n.s) and translation (n.s) during the pivot-shift test. The subgroup analysis also showed that the aforementioned parameters were not associated with the coronal LCL sign in either adolescent or adult subgroups. CONCLUSION: The occurrence of coronal LCL sign in MRI did not imply greater clinical knee laxity evaluations in patients with ACL tears. The knee laxity should routinely be evaluated regardless the coronal LCL sign. LEVEL OF EVIDENCE: Level III.

Analysis of bone union after medial closing wedge distal femoral osteotomy using a new radiographic scoring system.

INTRODUCTION: To compare bone union after medial closing wedge distal femoral osteotomy (MCWDFO) with that after lateral closing wedge distal femoral osteotomy (LCWDFO) using a novel scoring system. MATERIALS AND METHODS: The data of 30 patients who received biplanar MCWDFO for valgus knees (MCWDFO group) were retrospectively examined and compared to that of 22 patients (25 knees) who underwent biplanar LCWDFO via a double-level osteotomy (DLO) for varus knees (LCWDFO group). The progression of bone union of the transverse osteotomy plane in the femur was assessed using a newly developed scoring system using radiographs taken immediately after surgery and 3 and 6 months postoperatively. The scoring system is based on a scale of zero to six points with higher scores indicating better bone union. The incidence of hinge fractures was assessed using CT images, and the rates of reoperation were evaluated using medical record data. RESULTS: The mean bone union score was significantly lower in the MCWDFO group than in the LCWDFO group 3 months (2.1 ± 1.9 vs. 3.7 ± 1.7, P < 0.01) and 6 months (3.8 ± 2.1 vs 4.9 ± 1.5, P < 0.05) postoperatively. The incidence ratio of hinge fractures was significantly higher in the MCWDFO group than in the LCWDFO group (70.0% vs. 32.0%, P < 0.01). Two patients in the MCWDFO group underwent reoperation for delayed bone union or non-union. CONCLUSION: Bone union progression was slower and hinge fractures were more frequently observed after MCWDFO than after LCWDFO via DLO. MCWDFO is technically challenging, and patients must be monitored closely during and after surgery.

GABAergic and glycinergic systems regulate ON-OFF electroretinogram by cooperatively modulating cone pathways in the amphibian retina.

The network mechanisms underlying how inhibitory circuits regulate ON- and OFF-responses (the b- and d-waves) in the electroretinogram (ERG) remain unclear. The purpose of this study was to investigate the contribution of inhibitory circuits to the emergence of the b- and d-waves in the full-field ERG in the newt retina. To this end, we investigated the effects of several synaptic transmission blockers on the amplitudes of the b- and d-waves in the ERG obtained from newt eyecup preparations. Our results demonstrated that (a) L-APB blocked the b-wave, indicating that the b-wave arises from the activity of ON-bipolar cells (BCs) expressing type six metabotropic glutamate receptors; (b) the combined administration of UBP310/GYKI 53655 blocked the d-wave, indicating that the d-wave arises from the activity of OFF-BCs expressing kainate-/AMPA-receptors; (c) SR 95531 augmented both the b- and the d-wave, indicating that GABAergic lateral inhibitory circuits inhibit both ON- and OFF-BC pathways; (d) the administration of strychnine in the presence of SR 95531 attenuated the d-wave, and this attenuation was prevented by blocking ON-pathways with L-APB, which indicated that the glycinergic inhibition of OFF-BC pathway is downstream of the GABAergic inhibition of the ON-system; and (e) the glycinergic inhibition from the ON- to the OFF-system widens the response range of OFF-BC pathways, specifically in the absence of GABAergic lateral inhibition. Based on these results, we proposed a circuitry mechanism for the regulation of the d-wave and offered a tentative explanation of the circuitry mechanisms underlying ERG formation.

Patellofemoral Osteoarthritis Progresses After Medial Open-Wedge High Tibial Osteotomy: A Systematic Review.

PURPOSE: To investigate the progression of patellofemoral (PF) osteoarthritis (OA) after medial open-wedge high tibial osteotomy (OWHTO) and whether PF OA progression has an influence on clinical outcomes. METHODS: According to the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA), EMBASE, PubMed, and Cochrane Library were searched in June 2020 for English-language studies that presented data on PF OA or cartilage degeneration before and after OWHTO. Descriptive statistics are presented. RESULTS: Twenty studies comprising 1,173 patients were included. The mean age was 57.1 years (range 18-84) with 826 (70.4%) female. The mean follow-up was 27.1 months (range 7-144). Ten studies reported the trochlear International Cartilage Research Society (ICRS) scores, with each of these studies reporting a greater proportion of patients with grades 2-4 OA postoperatively compared with preoperatively (relative risk = 1.19-2.76, I2 = 1.9%). Similarly, 7 studies reported patellar ICRS scores and found a greater proportion with grades 2-4 OA postoperatively (relative risk = 1.08-2.44, I2 = 0%). Four studies assessed PF Kellgren-Lawrence grade, each of which reported a greater proportion of patients with grades 2-4 OA postoperatively (relative risk = 1.25-21.0, I2 = 31%). The PF OA assessments were heterogenous, and studies using classifications except the ICRS score or Kellgren-Lawrence grade were not included in statistical analysis. Fifteen studies assessed patellar height; 10 studies reported significant decrease in patellar height after OWHTO. Only 3 studies reported clinical outcomes for patients with and without PF OA progression. Outcome reporting was variable across these studies, and a relationship between PF OA progression and clinical outcome could not be definitively determined. CONCLUSIONS: Patients appear to have progression of PF OA after medial OWHTO. However, there are currently insufficient studies with inconsistent measurements of outcomes to make meaningful conclusions regarding the impact of PF OA on clinical outcomes. LEVEL OF EVIDENCE: Level IV, systematic review of Level III-IV studies.

The TRPM1 Channel Is Required for Development of the Rod ON Bipolar Cell-AII Amacrine Cell Pathway in the Retinal Circuit.

Neurotransmission plays an essential role in neural circuit formation in the central nervous system (CNS). Although neurotransmission has been recently clarified as a key modulator of retinal circuit development, the roles of individual synaptic transmissions are not yet fully understood. In the current study, we investigated the role of neurotransmission from photoreceptor cells to ON bipolar cells in development using mutant mouse lines of both sexes in which this transmission is abrogated. We found that deletion of the ON bipolar cation channel TRPM1 results in the abnormal contraction of rod bipolar terminals and a decreased number of their synaptic connections with amacrine cells. In contrast, these histological alterations were not caused by a disruption of total glutamate transmission due to loss of the ON bipolar glutamate receptor mGluR6 or the photoreceptor glutamate transporter VGluT1. In addition, TRPM1 deficiency led to the reduction of total dendritic length, branch numbers, and cell body size in AII amacrine cells. Activated Goα, known to close the TRPM1 channel, interacted with TRPM1 and induced the contraction of rod bipolar terminals. Furthermore, overexpression of Channelrhodopsin-2 partially rescued rod bipolar cell development in the TRPM1-/- retina, whereas the rescue effect by a constitutively closed form of TRPM1 was lower than that by the native form. Our results suggest that TRPM1 channel opening is essential for rod bipolar pathway establishment in development.SIGNIFICANCE STATEMENT Neurotransmission has been recognized recently as a key modulator of retinal circuit development in the CNS. However, the roles of individual synaptic transmissions are not yet fully understood. In the current study, we focused on neurotransmission between rod photoreceptor cells and rod bipolar cells in the retina. We used genetically modified mouse models which abrogate each step of neurotransmission: presynaptic glutamate release, postsynaptic glutamate reception, or transduction channel function. We found that the TRPM1 transduction channel is required for the development of rod bipolar cells and their synaptic formation with subsequent neurons, independently of glutamate transmission. This study advances our understanding of neurotransmission-mediated retinal circuit refinement.

Factors influencing mother-child communication about fathers with neurobehavioural sequelae after brain injury.

OBJECTIVE: The present study clarified factors related to mother-child communication openness when fathers suffer neurobehavioural sequelae after stroke or traumatic brain injury. RESEARCH DESIGN: A cross-sectional study using self-report anonymous questionnaires was conducted. METHODS AND PROCEDURES: Forty-one mothers with 6-22-year-old children participated. The questionnaire examined personal factors (mother's psychological distress), social/family factors (family support functioning), illness-related factors (father's time at home and neurobehavioural sequelae severity) and mother's perceived level of open communication. Multiple regression was used to analyse factors related to mother-child communication openness. RESULTS: Mother-child open communication was explained by family support functioning (ß = 0.449), father's time at home (ß = -0.325) and mother's psychological distress (ß = -0.303). Neurobehavioural sequelae severity was not associated with mother-child open communication. CONCLUSIONS: Personal, social/family and illness-related factors were related to mother-child communication about paternal illness. Professionals should promote optimal family support functioning, connect families with external resources and assess families' interaction processes.

Repetitive Peripheral Magnetic Stimulation With Intensive Swallowing Rehabilitation for Poststroke Dysphagia: An Open-Label Case Series.

OBJECTIVE: The purpose of this pilot study was to determine the safety and feasibility of a six-day protocol of in-hospital repetitive peripheral magnetic stimulation combined with intensive swallowing rehabilitation (rPMS-ISR) for poststroke dysphagia. METHODS: The subjects were eight patients with dysphagia caused by bilateral cerebral infarction (age: 62-70; time from onset of stroke: 27-39 months). rPMS was applied to the suprahyoid muscles, at strength set at 90% of the minimal intensity that elicited pain with a parabolic coil. One train of stimuli comprised 20 Hz for 3 sec followed by 27-sec rest. A single session included delivery of repetitive 20 trains of stimuli over 10 min, followed by 20 min of swallowing rehabilitation. Each patient received this combination treatment twice daily, morning and afternoon, over six consecutive days. Swallowing function was evaluated before and after intervention. RESULTS: rPMS-ISR induced significant improvement in swallowing ability, laryngeal elevation delay time, penetration aspiration scale, and swallowing quality of life (p < 0.01), but had no significant effect on the functional oral intake scale. CONCLUSION: The six-day in-hospital RPMS-ISR protocol seems safe and feasible for poststroke patients with dysphagia. The combination protocol improved swallowing function. Further larger studies are needed to confirm its efficacy.

Clinical management provided by board-certificated physiatrists in early rehabilitation is a significant determinant of functional improvement in acute stroke patients: a retrospective analysis of Japan rehabilitation database.

BACKGROUND: Early rehabilitation for acute stroke patients is widely recommended. We tested the hypothesis that clinical outcome of stroke patients who receive early rehabilitation managed by board-certificated physiatrists (BCP) is generally better than that provided by other medical specialties. METHODS: Data of stroke patients who underwent early rehabilitation in 19 acute hospitals between January 2005 and December 2013 were collected from the Japan Rehabilitation Database and analyzed retrospectively. Multivariate linear regression analysis using generalized estimating equations method was performed to assess the association between Functional Independence Measure (FIM) effectiveness and management provided by BCP in early rehabilitation. In addition, multivariate logistic regression analysis was also performed to assess the impact of management provided by BCP in acute phase on discharge destination. RESULTS: After setting the inclusion criteria, data of 3838 stroke patients were eligible for analysis. BCP provided early rehabilitation in 814 patients (21.2%). Both the duration of daily exercise time and the frequency of regular conferencing were significantly higher for patients managed by BCP than by other specialties. Although the mortality rate was not different, multivariate regression analysis showed that FIM effectiveness correlated significantly and positively with the management provided by BCP (coefficient, .35; 95% confidence interval [CI], .012-.059; P < .005). In addition, multivariate logistic analysis identified clinical management by BCP as a significant determinant of home discharge (odds ratio, 1.24; 95% CI, 1.08-1.44; P < .005). CONCLUSIONS: Our retrospective cohort study demonstrated that clinical management provided by BCP in early rehabilitation can lead to functional recovery of acute stroke.

Functional magnetic stimulation using a parabolic coil for dysphagia after stroke.

OBJECTIVES: Recently, the usefulness of neuromuscular electrical stimulation and repetitive transcranial magnetic stimulation for poststroke dysphagia has been reported. However, there is no report that describes the effectiveness of functional magnetic stimulation (FMS) for dysphagia. The purpose of this study is to clarify the effectiveness of FMS for poststroke dysphagia. METHODS: Twenty poststroke dysphagic patients (age at treatment: 51-80 years; interval between onset of stroke and treatment: 6 to 36 months) were randomly assigned to a real group or a sham group. In the real group, FMS of 30 Hz was applied for suprahyoid muscles in a 20-sec train using a parabolic coil for 10 min (total 1200 pulses). In the sham group, sham stimulation was applied for 10 min at the same site. Swallowing function was evaluated by the timed water swallow test, interswallow interval (ISI), swallowing volume velocity (speed), and volume per swallow (capacity) were measured before and after stimulation. RESULTS: All patients completed the stimulation and none showed any adverse reactions throughout the stimulation. The improvement of speed and capacity of swallowing after stimulation was significantly larger in the real group compared with the sham group (all p < 0.05). However, no significant difference in the ISI was found between the groups. CONCLUSIONS: FMS using a parabolic coil can potentially improve swallowing function in poststroke dysphagic patients.

Survey on diagnosis of post-brain injury "higher brain dysfunction" in patients with cognitive impairment. Family/caregiver response.

In Japan, the diagnostic criteria for the higher brain dysfunction (HBD) emerged in 2005 in response to social needs for support for the patients and their families. The issue of cognitive dysfunction after brain trauma is not unique to Japan. The purpose of this study was to reveal the current status of family members of HBD patients from their perspective, focusing on the changes before and after the establishment of diagnostic criteria in Japan. We conducted a questionnaire survey for family members supporting the HBD patients. The questionnaire included the causative condition, explanation on HBD by health professionals, and problems/difficulties they encountered. This research involved family members of 278 HBD cases (males = 211, age 49 years). The major underlying cause was head injury (n = 139). Compared to patients diagnosed pre-2005, a significantly larger proportion of family members after 2005 received information on the condition during the acute phase (within one month) (p < 0.001), including that from physicians (p < 0.001). Nearly half of the families cited a lack of awareness of HBD among the professionals as a problem. In Japan, awareness of HBD in the society is gradually increasing especially after the current diagnostic criteria were implemented, and there has been a steady increase over time in early diagnosis. Yet, there still remain those not appropriately diagnosed. To salvage those patients and the families left behind, we are suggesting several recommendations to further augment clinical practice and the healthcare systems in Japan.

A 10-Year Study of the Trend of Accidental Falls in the Elderly in a Japanese Hospital.

Elderly people are prone to falls. We established the Falls Prevention Working Group (FPWG) at our hospital in 2015 to reduce the number of falls during hospitalization. This study compared the trend of in-hospital falls in the elderly in two time periods (2008/9 and 2018/9) and determined the effects of FPWG-implemented measures. Using medical records, we counted the monthly number of falls suffered by patients during hospitalization in April 2008-March 2009 and April 2018-March 2019. We also categorized the falls according to the severity of fall-related complications.A total of 3609 hospital falls were recorded during the 2008-2019 period (2008/9: n = 433, 2018/9: n = 324). Falls were more common in patients aged 70-79 in 2008/9 but were noted in those aged ≥ 80 in 2018/9. The mean number of falls/month (27.3 ± 6.4, range: 12-45) was stable throughout the year. The incidence of falls in 2018/9 (1.90/1000 per persons per day) was significantly lower than in 2008/9 (2.30/1000, p = 0.006). Level ≥ 3b accidents, reflecting serious accidents with complications, were encountered in 12 of 433 accidents in 2008/9 compared with significantly fewer accidents (2 of the same severity among 324 accidents) in 2018/9 (p = 0.030).Our results showed a decrease in in-hospital falls in 2018/9 and that the sufferers were older relative to 10 years earlier. A multidisciplinary team should recommend measures to prevent falls and an environment "resilient" to falls, and encourage patients to be aware of possible falls.

Injuries to both anterolateral ligament and Kaplan fiber of the iliotibial band do not increase preoperative pivot-shift phenomenon in ACL injury.

Background: To assess the incidence of anterolateral ligament (ALL) and Kaplan fiber of the iliotibial band (KF) injuries in patients with acute anterior cruciate ligament (ACL) injury on magnetic resonance imaging (MRI), and to investigate the association between these injuries and the magnitude of preoperative pivot-shift test. Method: One-hundred and five patients with primary ACL injury were retrospectively reviewed. ALL injury and KF injury were assessed by preoperative MRI, and subjects were allocated into four groups: Group A, neither injury; Group B, only ALL injury; Group C, only KF injury; Group D, simultaneous ALL and KF injuries. Before ACL reconstruction, tibial acceleration during the pivot-shift test was measured by an electromagnetic measurement system, and manual grading was recorded according to the International Knee Documentation Committee (IKDC) guideline. Results: In MRI, the ALL was identified in 104 patients (99.1%) and KF in 99 patients (94.3%). ALL and KF injuries were observed in 43 patients (43.9%) and 23 patients (23.5%), respectively. Patient distribution to each group was as follows; Group A: 43 patients (43.9%), Group B: 32 patients (32.7%), Group C: 12 patients (12.2%), Group D: 11 patients (11.2%). No significant differences were observed in tibial acceleration, and manual grading among the four groups. Conclusion: Simultaneous injury to both ALL and KF was uncommon, and preoperative pivot-shift phenomenon did not increase even in those patients. The finding suggests that the role of ALL and KF in controlling anterolateral rotatory knee laxity may be less evident in the clinical setting compared to a biomechanical test setting.

High-frequency rTMS applied over bilateral leg motor areas combined with mobility training for gait disturbance after stroke: a preliminary study.

OBJECTIVE: A double cone coil enables delivery of magnetic stimulation to leg motor areas and modulates neural activities of the areas. It is expected that combined application of facilitatory rTMS with the coil and physical therapy would improve walking function after stroke. The purpose of this study is to clarify the clinical effect of an in-patient protocol featuring rTMS with a double cone coil and mobility training for gait disturbance after stroke. SUBJECTS AND METHODS: Nineteen post-stroke hemiparetic patients with gait disturbance were studied (aged 56.2 ± 11.9 years). During the 13-day hospitalization, each patient received 20 sessions of high-frequency rTMS and mobility training featuring treadmill training. In one rTMS session, 2000 pulses of 10-Hz rTMS were delivered over bilateral leg motor areas using the double cone coil. Walking velocity, Physiological Cost Index (PCI) and Timed Up and Go Test (TUG) were evaluated on the day of admission and discharge. RESULTS: The protocol was completed without any adverse effects in all patients. The combination treatment significantly increased walking velocity (p < 0.05) and decreased PCI (p < 0.05), decreased the performance time for TUG (p < 0.05). CONCLUSIONS: The protocol featuring high-frequency rTMS and mobility training is safe and feasible and can improve walking function after stroke.

Multimodal treatment, including extracorporeal shock wave therapy, for refractory chronic tension-type headache: a case report.

BACKGROUND: Few reports have described multidisciplinary treatment, including extracorporeal shock wave therapy, for patients with refractory chronic tension-type headache. In this study, we conducted multidisciplinary treatment for a patient with chronic tension-type headache who suffered from chronic headache refractory to treatment. CASE PRESENTATION: The patient was a 45-year-old Japanese male suffering from 20 years of headache. As his headache had worsened recently, he visited a local clinic. With the diagnosis of suspected tension-type headache, its treatment was unsuccessful and he was referred to our hospital. The neurology department confirmed the tension-type headache and prescribed another medication, but he showed no improvement. Then, the patient was referred to the rehabilitation medicine department for consultation. At the initial visit, we identified multiple myofascial trigger points in his bilateral posterior neck and upper back regions. At the initial visit, he was prescribed 10 mL of 1% lidocaine injected into the muscles in these areas. In addition, he received 2000 extracorporeal shock wave therapy into bilateral trapezius muscles, and was instructed to take oral Kakkonto extract granules, benfotiamine, pyridoxine hydrochloride, and cyanocobalamin. Cervical muscle and shoulder girdle stretches and exercises were also recommended. At follow-up treatment visits, we used extracorporeal shock wave therapy to bilateral trapezius muscles, which led to immediate pain relief. After 11 weeks, he was not taking any medication and his headache was subjectively improved and his medical treatment ended. CONCLUSION: A patient with chronic tension-type headache refractory to regular treatment was successfully treated with a multimodal approach including extracorporeal shock wave therapy in addition to standard treatment. For patients with tension-type headache accompanied by myofascial trigger points, it may be recommended to promptly consider aggressive multimodal treatment that includes extracorporeal shock wave therapy.

[Early onset of anti- erythropoietin antibody-mediated pure red cell aplasia after commencement of subcutaneous administration of epoetin-ß].

We report a 73-year-old Japanese man with early onset pure red cell aplasia (PRCA) caused by subcutaneous administration of recombinant epoetin-ß. Two months after the start of epoetin therapy, he developed PRCA. Anti-erythropoietin (EPO) antibody, detected in the patient's serum by enzyme immunoassay and radioimmunoprecipitation method, inhibited EPO-dependent growth of AS-E2 cells in vitro. Treatment with prednisone (1 mg/kg) significantly reduced antibody levels 3 months later. It is important to have an awareness of antibody-mediated PRCA. Our case shows that subcutaneous epoetin administration produces this complication in the early period of therapy.

Rehabilitation therapy for a severe case of coronavirus disease 2019: a case report.

BACKGROUND: Patients with severe coronavirus disease 2019 (COVID-19) infection require a long period of time to return to work and society due to significant physical weakness even after recovery. Here we report a patient with a history of nephrectomy who developed severe COVID-19 infection associated with muscle weakness but was able to return to society after rehabilitation therapy. CASE PRESENTATION: A Japanese man in his 40s was admitted to the hospital with PCR-based COVID-19 diagnosis. The respiratory condition worsened rapidly and was treated with extracorporeal membrane-assisted ventilation in the intensive case unit. On admission to the Rehabilitation Department on day T + 30 [T: day patient became febrile (38 °C)], he was unable to stand for a long time and used a walker. Rehabilitation therapy was postponed to prevent COVID-19 spread, but the patient was encouraged to exercise during isolation to improve trunk and lower extremity muscle strength. Physical therapy commenced on day T + 49 to improve gait and trunk and lower limb muscle strength. He was able to walk independently and later returned to work following discharge on day T + 53. A computed tomography scan showed an increase in psoas muscle volume from 276 before to 316 cm3 after physical therapy, together with a decrease in whole-body extracellular water:total body weight ratio from 0.394 to 0.389. CONCLUSIONS: We have described the beneficial effects of rehabilitation therapy in a patient with severe COVID-19 infection. In addition to exercise, we believe that nutrition is even more important in increasing skeletal muscle mass. Rehabilitation therapy is recommended to enhance the return of severely ill COVID-19 patients to routine daily activity.

Facilitatory Effect of Extending the Course Duration on Dissemination of Educational Content.

The physiological practice course at Saitama Medical University provides students with the opportunity to learn physiological principles through wet labs and discussions. To develop a more effective method for maximizing learning outcomes, we extended the course's schedule from one day (1d) to two days (2d) per theme, evaluated self-administered questionnaires between two different years (pre and post-change), and examined whether the increased course length affected learning outcomes. Within the 2018 curriculum year, every theme of the course was completed in a day, including experiments in the wet lab and discussions. In 2019, each theme was assessed for two days. The second-year undergraduate medical students anonymously submitted the self-assessment questionnaire that addressed several aspects, such as understanding of the theme, through a 5-point Likert scale. The average Likert scores varied from 4 to 4.5 point for all questions, and significant differences were not found between the 1d and 2d courses. However, the ratio of students with the highest points increased for one question of the 2d course: 43.6% (1d) to 53.4% (2d) for understanding. Further, the standard deviation (SD) values decreased in the 2d course for every question: 0.29 (1d) to 0.15 (2d) for interest, 0.33 (1d) to 0.19 (2d) for understanding, 0.30 (d) to 0.17 (d) for communication, 0.34 (1d) to 0.19 (2d) for general evaluation. This reduction in the SD values indicated that the educational content was imparted more efficiently to students in the 2d course. Thus, we concluded that extending the course time facilitated dissemination of educational content for every theme. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-022-01563-4.

Influence of Injury to the Kaplan Fibers of the Iliotibial Band on Anterolateral Rotatory Knee Laxity in Anterior Cruciate Ligament Injury: A Retrospective Cohort Study.

BACKGROUND: Biomechanical cadaveric studies have shown that Kaplan fibers (KFs) of the iliotibial band play a role in controlling anterolateral rotatory knee laxity in anterior cruciate ligament (ACL) injury. However, in the clinical setting, the contribution of injury to KFs on anterolateral rotatory laxity remains unclear. PURPOSE: To use magnetic resonance imaging (MRI) scans to detect concomitant KF injury in ACL-injured knees and to then examine the effect of KF injury on anterolateral rotatory laxity as measured by the pivot-shift test in a clinical setting. STUDY DESIGN: Cross-sectional study; Level of evidence, 3. METHODS: The study enrolled 91 patients with primary ACL tears (mean age 25 ± 11 years; 46 male and 45 female) whose MRI was conducted within 90 days after injury. KF injury was assessed by MRI according to previously reported criteria, and the patients were allocated to a KF injury group and a no-KF injury group. At the time of ACL reconstruction, the pivot-shift test was performed with the patient under anesthesia and quantitatively evaluated by tibial acceleration using an electromagnetic measurement system. Manual grading of the pivot-shift test was assessed according to guidelines of the International Knee Documentation Committee. The data were statistically compared between the 2 groups using Mann-Whitney U test and Fisher exact test (P < .05). RESULTS: KFs were identified in 85 patients (93.4%), and KF injury was detected in 20 of the 85 patients (23.5%). No significant differences were observed between the KF injury group (n = 20) and the no-KF injury group (n = 65) in demographic characteristics, the period from injury to MRI (8.0 ± 14.0 days vs 8.9 ± 12.1 days, respectively), the rate of meniscal injury (50.0% vs 53.8%), or the rate of anterolateral ligament injury (45.0% vs 44.6%). Regarding the pivot-shift test, no significant differences were observed in tibial acceleration (1.2 m/s2 [interquartile range, 0.5-2.1 m/s2] vs 1.0 m/s2 [interquartile range, 0.6-1.7 m/s2], respectively) or manual grading between the 2 groups. CONCLUSION: Concomitant KF injury did not significantly affect the pivot-shift phenomenon in acute ACL-injured knees. The findings suggest that the contribution of KF injury to anterolateral rotatory knee laxity may be limited in the clinical setting.

Relationship between psychosomatic complaints and circadian rhythm irregularity assessed by salivary levels of melatonin and growth hormone.

BACKGROUND: In university health care settings, students with psychosomatic complaints often have chronotypic problems. For this reason, we investigated a potential connection between psychosomatic complaints and circadian rhythm irregularity assessed by salivary levels of melatonin and growth hormone. METHODS: Fifteen healthy students between 21 and 22 years of age were examined for physiological parameters of chronotypes based on melatonin and growth hormone secretion patterns, using a fluorescence enzyme immunoassay. Salivary samples were collected from subjects at home five times each day (20:00, 24:00, 04:00, 08:00, and 12:00 h). In addition, the subjects rated their psychosomatic symptoms twice (at 08:00 and 20:00 h). RESULTS: A group with irregular circadian rhythm of melatonin (ICR) showed more psychosomatic complaints than a group with the regular circadian rhythm (RCR), especially for anxiety. CONCLUSION: Psychosomatic symptoms, particularly anxiety, may be associated with irregularity in melatonin and growth hormone rhythms, which can be altered by basic lifestyle habits even in healthy students.