Combination of Parenteral Amino Acid Infusion and Intermittent Loading Exercise Ameliorates Progression of Postoperative Sarcopenia in Rat Model.

Postoperative sarcopenia is associated with poor outcomes in hospitalized patients. However, few studies have focused on short-term postoperative sarcopenia. Furthermore, the influence of nutritional management using amino acids (AAs) comprising a peripheral parenteral nutrition (PPN) solution and its combination with exercise (Exc) is unclear. Hence, we established a postoperative sarcopenic rat model to evaluate the effects of parenteral AA infusion combined with Exc on skeletal muscles and investigate the underlying mechanisms involved in the amelioration of muscle atrophy. Male F344 rats underwent surgery followed by hindlimb suspension (HS) for 5 days. The rats were divided into AA (-), AA (+), AA (-)-Exc, and AA (+)-Exc groups. They were continuously administered a PPN solution with or without AA at 98 kcal/kg/day. The Exc groups were subjected to intermittent loading for 1 h per day. Postoperative sarcopenic rats exhibited decreased muscle strength and mass and an upregulated ubiquitin-proteasome system, autophagy-lysosome system, and fast-twitch fiber-related genes, especially in the AA (-) group. The AA (+)-Exc group exhibited attenuated decreased muscle strength, increased gastrocnemius mass, and a suppressed upregulation of muscle atrophy- and fast-twitch fiber-related genes. Therefore, parenteral AA infusion combined with Exc may be effective in preventing postoperative sarcopenia in hospitalized patients.

Achievement of adequate nutrition contributes to maintaining the skeletal muscle area in patients with sepsis undergoing early mobilization: a retrospective observational study.

BACKGROUND: The onset of muscle loss in critically ill patients, known as intensive care unit-acquired weakness (ICU-AW), worsens their outcomes. Preventing muscle loss, which begins in the early phase of critical illness, is crucial in patient care. Adequate nutrition management may contribute to maintaining muscles; however, its evidence in patients with sepsis is insufficient. This study aimed to analyze the association between energy achievement rate in the first 7-days of critical care and muscle area changes evaluated by computed tomography (CT). METHODS: This was a retrospective observational study. Patients with sepsis admitted to the intensive care (ICU) of a tertiary care hospital in Japan were included. They were divided into three groups according to tertiles of the first 7-day energy achievement rate calculated using administered energy doses and basement energy expenditure. Skeletal muscle area (SMA) and changes in SMA were determined by CT on ICU admission and within days 7-10 of ICU admission. SMA maintenance was defined as SMA change ≥ 100%. Logistic regression analyses were performed to analyze the association of energy achievement rate with SMA changes (primary outcome) and in-hospital 28-day mortality (secondary outcome). RESULTS: Patients (n = 93) were classified into low, middle, and high groups according to their 7-day energy achievement rate (median rates, 16.8%, 38.8%, and 73.4%, respectively). The CT scans showed that SMA decreased between the CT scans in the low and middle groups, whereas it was maintained in the high group (median changes, -8.5%, -11.7%, and 2.8%, respectively). Univariate and multivariate logistic regression analyses showed that high energy achievement rate was significantly associated with SMA maintenance (reference, middle energy achieved group; univariate, odds ratio [95% confidence interval] 6.23 [2.04-19.10], P = 0.0013; multivariate, odds ratio [95% confidence interval] 5.92 [1.90-18.40], P = 0.0021). There was no significant difference in the association between energy achievement rate and mortality among the three groups. CONCLUSIONS: Our study found that a fulfillment of energy achievement in the first 7 days of hospitalization was associated with maintenance of muscle area. Thus, satisfying adequate energy should be considered even in patients with sepsis.

Study of the Responsiveness and Minimal Clinically Important Difference of the Trunk Impairment Scale in Patients With Acute Stroke.

Background: Trunk function is a prerequisite for functional activity; thus, it is crucial to carry out proper assessments and interventions. However, there is no clear indicator for trunk function evaluation in patients with stroke. To understand the effects of interventions over time, it is important to adopt responsive clinical indicators. Purpose: To examine the Trunk Impairment Scale (TIS) (Fujiwara version) in terms of responsiveness and the minimal clinically important difference (MCID). Methods: In total, 55 patients who experienced an acute stroke were evaluated on the seventh day of hospitalization and the day before discharge. The responsiveness of the TIS was assessed by the effect size and standardized response mean (SRM). Additionally, an MCID study was conducted to examine the amount of change in TIS scores required to indicate a clinically meaningful change, which was determined by the presence or absence of improvement in the activities of daily living. Results: The SRM of the TIS was 1.42. Additionally, the MCID was determined to be 3 points. Conclusion: The TIS score improved over time and a 3-point improvement in the TIS score was associated with improvement in the activities of daily living. Thus, this scale's clinical sensitivity and MCID have been established in patients with stroke.

DYNAMIC METABOLIC CHANGES OBSERVED IN AN LPS-INDUCED SYSTEMIC INFLAMMATION RAT MODEL USING CONTINUOUS LONG-TERM INDIRECT CALORIMETRY EXPERIMENTS.

ABSTRACT: Background : Nutritional management is crucial for severely ill patients. Measuring metabolism is believed to be necessary for the acute sepsis phase to accurately estimate nutrition. Indirect calorimetry (IDC) is assumed to be useful for acute intensive care; however, there are few studies on long-term IDC measurement in patients with systemic inflammation. Methods : Rats were categorized into the LPS received or control groups; LPS rats were categorized into underfeeding (UF), adjusted feeding (AF), and overfeeding (OF) groups. Indirect calorimetry measurement was performed until 72 or 144 h. Body composition was measured at -24 and 72 or 144 h, and tissue weight was measured at 72 or 144 h. Results : Low energy consumption and loss of diurnal variation of resting energy expenditure were observed in the LPS group compared with the control group until 72 h, after which the LPS group recovered. The resting energy expenditure in the OF group was higher than that in the UF and AF groups. In the first phase, low energy consumption was observed in all groups. In the second and third phases, higher energy consumption occurred in the OF group than in the UF and AF groups. In the third phase, diurnal variation recovered in all groups. Muscle atrophy caused body weight loss, but fat tissue loss did not occur. Conclusions : We observed metabolic changes with IDC during the acute systemic inflammation phase owing to differences in calorie intake. This is the first report of long-term IDC measurement using the LPS-induced systemic inflammation rat model.

Effects of amino acids and albumin administration on albumin metabolism in surgically stressed rats: A basic nutritional study.

BACKGROUND: Nutrition therapy and administration of albumin preparations are common in postsurgical patients. However, the effects of these interventions on albumin metabolism are unclear. We elucidated the effect of postoperative albumin and/or parenteral nutrition administration on it. METHODS: Sprague-Dawley rats underwent surgery involving intestinal rubbing followed by intestinal exposure. Subsequently, they were administered experimental solutions for 48 h, their blood samples were collected at 24 and 48 h, and livers were excised at 48 h. Based on experimental solutions, rats were divided into five groups: non-surgical (Non-surg); glucose and electrolyte solution (GE); amino acid, glucose, and electrolyte solution (AGE); GE + rat serum albumin (Alb) (GE + Alb); and AGE + Alb. Their plasma albumin concentrations; albumin fractional synthesis rate (ALB FSR); mercaptoalbumin/total albumin ratio (MA ratio); and messenger RNA (mRNA) expressions of albumin and hepatocyte nuclear factor-1 (HNF-1) in the liver were measured. RESULTS: The GE and AGE groups showed significant decline in albumin concentrations. ALB FSR was significantly enhanced in the AGE group compared with the GE group. The mRNA expression of albumin was similar to ALB FSR in all groups and that of HNF-1 was significantly decreased in the GE + Alb and AGE + Alb groups compared with the Non-surg group. The MA ratio in the AGE group was similar to the Non-surg group. CONCLUSION: The administration of amino acids comprising parenteral nutrition after surgery augmented ALB FSR and maintained the MA ratio only without simultaneous albumin administration.

Determination of Peak Oxygen Uptake in Patients with Acute Myocardial Infarction: The Role of Arterial Stiffness in Cardio-Vascular-Skeletal Muscle Coupling.

The relationship between arterial stiffness and oxygen uptake (VO2) in patients with acute myocardial infarction (AMI) remains unclear. We aimed to investigate this relationship and factors contributing to VO2 in patients with AMI. The role of arterial stiffness in cardio-skeletal muscle coupling during exercise was then elucidated. Upon discharge, we measured exercise capacity using cardiopulmonary exercise testing (CPX), assessed arterial stiffness with the cardio-ankle vascular index (CAVI), and determined body composition to assess the skeletal muscle mass of 101 patients with AMI. Patients were categorized based on their CAVI scores into three groups: (i) normal (CAVI: ≤7.9), (ii) borderline (CAVI: 8.0-8.9), and (iii) abnormal (CAVI: ≥9.0). Subsequently, VO2 was compared among these groups. The relationship between the CAVI and VO2 Peak during CPX and factors contributing to VO2 Peak were investigated. The abnormal CAVI group had a significantly lower VO2 Peak than the normal and borderline groups. The CAVI was associated with VO2 Peak. Furthermore, the CAVI was found to be a factor contributing to VO2 Peak. These findings suggest that arterial stiffness in tissue blood distribution and blood supply causes systemic exercise limits in patients with AMI. This suggests that arterial stiffness plays a significant role in cardio-vascular-skeletal muscle coupling.

Perioperative Oral ß-Hydroxy-ß-Methylbutyrate Supplementation Ameliorates Sarcopenia in Rats Undergoing Major Hepatectomy.

ß-Hydroxy-ß-methylbutyrate (HMB), a metabolite of leucine, is known to increase muscle mass and strength. However, the effect of perioperative HMB supplementation in liver surgery is unclear. Moreover, the impact of HMB on the skeletal muscle fiber type also remains unclear. We investigated the impact of HMB on the body composition and skeletal muscle fiber type in sarcopenic rats undergoing major hepatectomy. Nine-week-old male F344/NSlc rats were maintained in hindlimb suspension (HLS) and were forcedly supplemented with HMB calcium salt (HMB-Ca, 0.58 g/kg×2 times) or distilled water in addition to free feeding. After 2 wk of HLS, the rats underwent 70% hepatectomy and were sacrificed 3 d after surgery. Body composition factors and the proportion of slow-twitch fibers in hindlimb muscles were evaluated. HMB maintained the body composition and hindlimb force and acted against their deterioration in sarcopenic rats, exerting a particular effect on lean mass weight, which was significant. In the histological study, HMB significantly increased the proportion of slow-twitch fibers in the soleus (p=0.044) and plantaris (p=0.001) of sarcopenic rats. HMB ameliorated deterioration of the body composition and increased the proportion of slow-twitch fibers in sarcopenic rats undergoing major hepatectomy.

The Adjustment of the Rotational Alignment of the Distal End of the Extramedullary Guide to the Anteroposterior Axis of the Proximal Tibia in Total Knee Arthroplasty.

The optimal placement within 3 degrees in coronal alignment was reportedly achieved in only 60 to 80% of patients when using an extramedullary alignment guide for the tibial side in total knee arthroplasty (TKA). This probably occurs because the extramedullary alignment guide is easily affected by the position of the ankle joint which is difficult to define by tibial torsion. Rotational direction of distal end of the extramedullary guide should be aligned to the anteroposterior (AP) axis of the proximal tibia to acquire optimal coronal alignment in the computer simulation studies; however, its efficacy has not been proven in a clinical setting. The distal end of the guide can be overly displaced from the ideal position when using a conventional guide system despite the alignment of the AP axis to the proximal tibia. This study investigated the effect of displacement of the distal end of extramedullary guide relative to the tibial coronal alignment while adjusting the rotational alignment of the distal end to the AP axis of the proximal tibia in TKA. A total of 50 TKAs performed in 50 varus osteoarthritic knees using an image-free navigation system were included in this study. The rotational alignment of the proximal side of the guide was adjusted to the AP axis of the proximal tibia. The position of the distal end of the guide was aligned to the center of the ankle joint as viewed from the proximal AP axis (ideal position) and as determined by the navigation system. The tibial intraoperative coronal alignments were recorded as the distal end was moved from the ideal position at 3-mm intervals. The intraoperative alignments were 0.5, 0.9, and 1.4 degrees in valgus alignment with 3-, 6-, and 9-mm medial displacements, respectively. The intraoperative alignments were 0.7, 1.2, and 1.7 degrees in varus alignment with 3-, 6-, and 9-mm lateral displacements, respectively. In conclusion, the acceptable tibial coronal alignment (within 2 degrees from the optimal alignment) can be achieved, although some displacement of the distal end from the ideal position can occur after the rotational alignment of the distal end of the guide is adjusted to the AP axis of the proximal tibia.

Comparison of the Incidence of Intra-operative Fractures in Hip Hemi-arthroplasty Performed in Supine and Lateral Positions.

PURPOSE: The difficulty of femoral preparation with supine-position hip hemi-arthroplasty (HA) often leads to intra-operative fractures (IOFs). We aimed to clarify the incidence and types of IOFs in HA for hip fractures performed in the supine and lateral positions. MATERIALS AND METHODS: We retrospectively investigated cases of HA for acute femoral neck fractures from June 2013 to May 2018. We examined the incidence and types of IOFs according to different approaches. We defined supine-position in HA as the supine and hip-hyperextended (over-range) femoral preparation position, and lateral position as the lateral and hip-flexed femoral preparation position. We used a short tapered wedged stem. RESULTS: Supine-position HA was used in 46 patients (23.7%) and lateral-position HA in 148 patients (76.3%). IOFs in supine-position HA occurred in 8 patients (17.4%) and included five Vancouver AGT and three Vancouver B2 fractures. IOFs in lateral-position HA occurred in 3 patients (2.0%) and included one Vancouver AGT and two Vancouver B fractures. Supine-position HA was a risk factor for IOFs (adjusted odds ratio, 9.71; 95% confidence interval, 2.37-39.8; P<0.01). CONCLUSION: Supine-position in HA is an IOF risk factor and significantly increases the incidence of great trochanter fractures of Vancouver type A.

Transient epiphyseal lesion of the femoral head after traumatic hip dislocation: A case report.

INTRODUCTION: We experienced a rare case in which magnetic resonance imaging (MRI) showed a transient epiphyseal lesion of the femoral head four months after traumatic hip dislocation. To our knowledge, there have been no previously published reports on the development of such transient lesions after traumatic hip dislocation involving no abnormalities just after dislocation. PRESENTATION OF CASE: We report a 22-year-old man who showed a transient epiphyseal lesion of the femoral head after traumatic hip dislocation. On MRI performed two days after dislocation, no bony injuries were observed around the hip joint. Four months after dislocation, the patient suddenly experienced right hip pain without any new trauma or injury. A low-intensity band convex to the articular surface was apparent above the epiphyseal scar on T1-weighted imaging, and bone marrow edema was observed around the band lesion on short-tau inversion recovery imaging. Following a two-month period of non-surgical conservative therapy, the patient's hip pain resolved and the low-intensity band was no longer observed on follow-up MRI. DISCUSSION: Although the detailed pathogenesis of this transient changes was unclear, we speculate that prolonged rest after traumatic hip dislocation may contribute to bone insufficiency, resulting in an insufficiency fracture of the femoral head. CONCLUSION: This study suggests that transient epiphyseal lesions of the femoral head may occur in patients with a history of traumatic hip dislocation associated with an adapted long-term rest.

Long-term Effect of Ubiquinol on Exercise Capacity and the Oxidative Stress Regulation System in SAMP1 Mice.

[Purpose] This study examined how exercise capacity and the oxidative stress regulation system are affected by different amounts of dietary Ubiquinol (reduced form of coenzyme Q10, H2CoQ10: QH) over the long term. [Subjects and Methods] Twenty-three senescence-accelerated mouse P1 (SAMP1) mice were randomly divided into two groups: one consuming a relatively high amount of QH (300 mg/kg; Group A) and the other a relatively low amount (30 mg/kg, Group B). Food and tap water were provided ad libitum. Both groups were made to run on a treadmill until exhaustion, and total running duration was measured. For the oxidative stress regulation system, the d-ROM test value (degree of oxidative stress) and BAP test value (antioxidant potential) were measured in a resting state, and then the BAP/d-ROM ratio (B/R ratio) was calculated. The values of plasma QH and plasma ubiquinone (plasma oxidized form of CoQ10) were also measured, and the reduced ratio was calculated. Measurements were taken 3 times: at the start of the study when the animals were 39 weeks old (baseline), after consumption of QH for 7 months (7 mo), and after consumption of QH for 10 months (10 mo). [Results] The senescence score at 10 mo was significantly lower in Group A. Comparison of the mean percentage change in running time showed a difference of 15.1% between the 2 groups. At 10 mo, the d-ROM test value was significantly increased and the B/R ratio was significantly decreased in Group B. Significant increases in the plasma QH value and reduced ratio were seen in Group A. [Conclusion] Group A showed a greater decrease in the d-ROM test and increase in the reduced ratio than Group B. Thus, a dose-dependent effect of QH consumption was demonstrated.

Effects of combined training with breathing resistance and sustained physical exertion to improve endurance capacity and respiratory muscle function in healthy young adults.

[Purpose] In this study, combined training with breathing resistance and sustained physical exertion was carried out to evaluate its physiological effects and its effect on improve endurance capacity. [Subjects and Methods] The subjects were nine healthy adults (mean age 20.4, SD ± 1.7 years). The combined training group (n = 5) carried out 6 weeks of combined training using a cycle ergometer, with exercise load tests and respiratory function tests performed before and after the training. The results of the training were compared to a control group (n = 4) that only performed the cycling exercise without the combined training with breathing resistance. [Results] In the combined training group, ventilatory threshold, maximal load of the cycle ergometer in exercise load tests, and maximal voluntary ventilation increased after training. These increases after training were all significant, but none of these variables changed significantly in the control group. [Conclusion] The results imply that in comparison to conventional training methods, combined training with breathing resistance and sustained physical exertion is beneficial for increasing endurance capacity and respiratory muscle function. This result provides important information regarding the effects of the new training method for improving endurance capacity.

A new method for measuring torsional deformity in scoliosis.

BACKGROUND: The importance of spinal rotational and torsional deformity in the etiology and the management of scoliosis are well-recognized. For measuring the posterior spinal component rotation, Ho's method was reported to be reliable. However, there is no practical method to measure the anterior spinal component rotation. Moreover, there is also no method to quantify the spinal torsional deformity in scoliosis. The goal of this study is to characterize scoliosis and its deformity to hypothesize the etiology and the development of scoliosis, and to establish a new method for the measurement of the vertebral body rotation and spinal torsional deformity in scoliosis using CT scans. METHODS: Pre-operative CT scans of 25 non-congenital scoliosis patients were recruited and the apical vertebral rotation was measured by a newly developed method and Ho's method. Ho's method adopts the laminae as the rotational landmark. For a new method to measure the apical vertebral rotation, the posterior point just beneath each pedicle was used as a landmark. For quantifying the spinal torsional deformity angle, the rotational angle difference between the two methods was calculated. RESULTS: Intraobserver and interobserver reliability analyses showed both methods to be reliable. Apical vertebral rotation revealed 13.9 ± 6.8 (mean ± standard deviation) degrees by the new method and 7.9 ± 6.3 by Ho's method. Right spinal rotation was assigned a positive value. The discrepancy of rotation (6.1 ± 3.9 degrees), meaning that the anterior component rotated more than the posterior component, was considered to express the spinal torsional deformity to the convex side. CONCLUSIONS: We have developed an easy, reliable and practical method to measure the rotation of the spinal anterior component using a CT scan. Furthermore, we quantified the spinal torsional deformity to the convex side in scoliosis by comparing the rotation between the anterior and posterior components.