Influence of motivation on rehabilitation outcomes after subacute stroke in convalescent rehabilitation wards.

Background: The motivation for rehabilitation is important in encouraging stroke patients to participate in rehabilitation; however, its relationship with outcomes is not well known. In addition, changes in patient motivation during hospitalization have not been examined. Aim: To examine the relationship between motivation and rehabilitation outcomes for subacute stroke patients and to investigate the changes in motivation. Design: Prospective cohort study. Setting: Subacute rehabilitation hospital. Population: The study enrolled a consecutive sample of patients (n = 201) with stroke admitted to a subacute rehabilitation ward from October 2017 to March 2019. Methods: The functional independence measure and motivation in stroke patients for rehabilitation scale was evaluated at admission; at one, two, and three months after admission; and at discharge. The effectiveness and efficiency of the functional independence measure were calculated as rehabilitation outcomes. The effect of motivation on outcomes and the change in motivation in stroke patients for rehabilitation scale scores over time were analyzed using a linear mixed model. Results: The median (interquartile range) converted motivation in stroke patients for rehabilitation scale scores (converted to a range of 0-100) at admission; one, two, and three months after admission; and discharge was 86 (76-95), 83 (77-94), 81 (74-95), 81 (71-93), and 84 (75-95), respectively. The median (interquartile range) of effectiveness and efficiency of the functional independence measure from admission to discharge was 0.82 (0.68-0.91) and 0.41 (0.30-0.59), respectively. Motivation in stroke patients for rehabilitation scale scores were not significantly associated with the effectiveness and efficiency of the functional independence measure (p > 0.05). Motivation in stroke patients for rehabilitation scale scores were significantly lower at two (ß = -3.1, 95% confidence interval [-5.3, -0.9], p = 0.005) and three (ß = -4.4, 95% confidence interval [-7.3, -1.6], p = 0.002) months after admission than at admission. Conclusion: Motivation might not directly affect rehabilitation outcomes assessed by the functional independence measure. Furthermore, many participants remained highly motivated, although their motivation decreased at one or three months after admission. Clinical rehabilitation impact: Assumptions that rehabilitation is ineffective because of low motivation may not be correct. To examine the influence on outcomes, both motivation and daily activities should be considered.

Effects of Alternating Bilateral Training Between Non-Paretic and Paretic Upper Limbs in Patients with Hemiparetic Stroke: A Pilot Randomized Controlled Trial.

OBJECTIVE: To examine whether alternating training with both the non-paretic and paretic sides (alternating bilateral training), expecting trial-to-trial inter-limb transfer of training effects from the nonparetic to the paretic side, improves upper-limb motor performance in post-stroke patients, compared with unilateral training involving only the paretic side. DESIGN: An assessor-blinded pilot randomized controlled trial. SUBJECTS: Twenty-four right-handed post-stroke patients with hemiparesis. METHODS: Participants were randomly allocated to either an alternating bilateral training group or a unilateral training group (n = 12/group). Participants underwent dexterity training of the paretic arm using the Nine-Hole Peg Test, completing 10 trials/day for 7 consecutive days. The alternating bilateral training group additionally performed alternating trials with the non-paretic limb. Performance change, assessed 1 day and 1 week after the 7-day training period, was compared between groups. RESULTS: Although the improvement was comparable in both groups at both post-training time-points, a sub-analysis in which those with left hemiparesis and those with right hemiparesis were analyzed separately revealed potential benefits of the alternating bilateral training, specifically for those with left hemiparesis. CONCLUSION: Alternating bilateral training may augment training effects and improve upper-limb motor function in patients with left hemiparesis.

Reliability of the Modified Nine Hole Peg Test in Healthy Adults and Individuals with Hemiparetic Stroke.

Objectives: This study examined whether the reliability of the Nine Hole Peg Test (NHPT) is improved by a modification (mNHPT) that confines the peg insertion/removal order to one way to reduce the degree of freedom of spatial strategies. Methods: Participants performed the NHPT and mNHPT three times each in two sessions with an interval of 3-5 days. Healthy adults used their non-dominant hand (n=40), while those with hemiparetic stroke used their affected (n=40) or unaffected hand (n=40). The mean value of three trials from each session was used for analyses. The reliabilities of the NHPT and mNHPT during the two sessions were assessed via intraclass correlation coefficients (ICCs) and Bland-Altman analysis. Results: The ICCs of the NHPT and mNHPT were 0.49 and 0.66, respectively, in healthy participants, and 0.91 and 0.94, respectively, in participants with stroke, regardless of the hand used. A significant fixed bias between the sessions was observed in both tests, except for participants with stroke who used their affected hand. Proportional biases were noted in the mNHPT results of healthy participants and in the NHPT and mNHPT results of participants with stroke who used their affected hand. The limits of agreement (lower, upper) in the affected hand were -11.0 and 9.5 for the NHPT and -8.0 and 6.2 for the mNHPT. Conclusions: Reduced degrees of freedom in the spatial strategy improved the relative reliability and reduced measurement errors in the NHPT. However, fixed and proportional biases were still evident.

Cumulative Risk And Associated Factors For Fall-Related Fractures In Stroke Survivors After Discharge From Rehabilitation Wards: A Retrospective Study With A 6-Year Follow-Up.

OBJECTIVE: To investigate the long-term cumulative risk and factors associated with fall-related fractures in stroke survivors discharged from convalescent rehabilitation wards. DESIGN: Retrospective cohort study. PARTICIPANTS: A total of 786 stroke survivors discharged from a rehabilitation hospital. METHODS: Data regarding fall-related fractures posthospital discharge were collected using self-reported questionnaires. The Kaplan-Meier method was used to calculate the cumulative incidence of fall-related fractures, and risk factors were analysed using Cox proportional hazard regression analysis. RESULTS: Of 1,861 consecutive stroke survivors who had been discharged from hospital, 786 (42.2%) provided information concerning fall-related fractures. Duration from time of discharge to time of collection of questionnaires ranged from 1 to 6 years (mean 38.0 months). The cumulative incidence of fall-related fractures at 1-, 2-, 3-, 4-, and 5-years post-discharge was 4.2%, 7.9%, 10.8%, 12.5% and 13.7%, respectively. Cox proportional hazard regression analysis indicated that female sex (hazard ratio (HR) 1.69) and moderate lower limb paresis (HR 3.08) were significant risk factors. CONCLUSION: The cumulative risk of fall-related fractures in stroke survivors post-discharge from a rehabilitation hospital was notably high. Intensive preventive intervention should be considered for female stroke survivors with moderate lower limb paresis.

Development and validation of new evaluation scale for measuring stroke patients' motivation for rehabilitation in rehabilitation wards.

OBJECTIVE: This study aimed to develop the Motivation in stroke patients for rehabilitation scale (MORE scale), following the Consensus-based standards for the selection of health measurement instruments (COSMIN). METHOD: Study participants included rehabilitation professionals working at the convalescent rehabilitation hospital and stroke patients admitted to the hospital. The original MORE scale was developed from an item pool, which was created through discussions of nine rehabilitation professionals. After the content validity of the scale was verified using the Delphi method with 61 rehabilitation professionals and 22 stroke patients, the scale's validity and reliability were examined for 201 stroke patients. The construct validity of the scale was investigated using exploratory factor analysis (EFA), confirmatory factor analysis (CFA), and item response theory analysis. Cronbach's alpha confirmed its internal consistency. Regarding convergent, discriminant, and criterion validity, Spearman's rho was calculated between the MORE scale and the Apathy Scale (AS), Self-rating Depression Scale (SDS), and Visual Analogue Scale (VAS), which rates the subjective feelings of motivation. RESULTS: Using the Delphi method, 17 items were incorporated into the MORE scale. According to EFA and CFA, a one-factor model was suggested. All MORE scale items demonstrated satisfactory item response, with item slopes ranging from 0.811 to 2.142, and item difficulty parameters ranging from -3.203 to 0.522. Cronbach's alpha was 0.948. Regarding test-retest reliability, a moderate correlation was found between scores at the beginning and one month after hospitalization (rho = 0.612. p < 0.001). The MORE scale showed significant correlation with AS (rho = -0.536, p < 0.001), SDS (rho = -0.347, p < 0.001), and VAS (rho = 0.536, p < 0.001), confirming the convergent, discriminant, and criterion validity, respectively. CONCLUSIONS: The MORE scale was verified as a valid and reliable scale for evaluating stroke patients' motivation for rehabilitation.

Effects of Balance Exercise Assist Robot training for patients with hemiparetic stroke: a randomized controlled trial.

BACKGROUND: Robot-assisted rehabilitation for patients with stroke is promising. However, it is unclear whether additional balance training using a balance-focused robot combined with conventional rehabilitation programs supplements the balance function in patients with stroke. The purpose of this study was to compare the effects of Balance Exercise Assist Robot (BEAR) training combined with conventional inpatient rehabilitation training to those of conventional inpatient rehabilitation only in patients with hemiparetic stroke. We also aimed to determine whether BEAR training was superior to intensive balance training. METHODS: This assessor-blinded randomized controlled trial included 60 patients with first-ever hemiparetic stroke, admitted to rehabilitation wards between December 2016 and February 2019. Patients were randomly assigned to one of three groups, robotic balance training and conventional inpatient rehabilitation (BEAR group), intensive balance training and conventional inpatient rehabilitation (IBT group), or conventional inpatient rehabilitation-only (CR group). The intervention duration was 2 weeks, with assessments conducted pre- and post-intervention, and at 2 weeks follow-up. The primary outcome measure was a change in the Mini-Balance Evaluation Systems Test (Mini-BESTest) score from baseline. RESULTS: In total, 57 patients completed the intervention, and 48 patients were evaluated at the follow-up. Significant improvements in Mini-BESTest score were observed in the BEAR and IBT groups compared with in the CR group post-intervention and after the 2-week follow-up period (P < 0.05). CONCLUSIONS: The addition of balance exercises using the BEAR alongside conventional inpatient rehabilitation improved balance in patients with subacute stroke. TRIAL REGISTRATION: https://www.umin.ac.jp/ctr ; Unique Identifier: UMIN000025129. Registered on 2 December 2016.

Motivation for Rehabilitation in Patients With Subacute Stroke: A Qualitative Study.

Background: Motivation is essential for patients with subacute stroke undergoing intensive rehabilitation. Although it is known that motivation induces behavioral changes toward rehabilitation, detailed description has been lacking. Motivation can be intrinsic or extrinsic; however, it is unclear which type of factors mainly motivates patients' daily rehabilitation. Purpose: This study aimed to examine the factors influencing patients' motivation and to explore the behavioral changes induced by motivation, especially age-related differences. Method: Twenty participants (mean age 65.8 years [standard deviation 13.7]) who had a subacute stroke and underwent rehabilitation at a convalescent hospital were recruited using convenience sampling. Semi-structured interviews were conducted by an occupational therapist with an interview topic guide regarding factors influencing motivation and how it affects behavioral change. Interviews were recorded, transcribed to text, and analyzed by three occupational therapists using thematic analysis. The participants were divided into two groups: aged patients (aged ≥ 65 years) and middle-aged patients (aged < 65 years), and data were analyzed according to the groups. This study was conducted according to the consolidated criteria for reporting qualitative research. Results: Seven core categories were identified as factors influencing patients' motivation: patients' goals, experiences of success and failure, physical condition and cognitive function, resilience, influence of rehabilitation professionals, relationships between patients, and patients' supporters. The first four and last three core categories were further classified as personal and social-relationship factors, respectively. The categories related to intrinsic motivation such as enjoyment of rehabilitation itself were not derived. In both age-groups, motivation affected the frequency of self-training and activity in daily lives. In some aged patients, however, high motivation restrained their self-training to conserve their physical strength for rehabilitation by professionals. Some aged patients do not express their high motivation through their facial expressions and conversations compared to middle-aged patients; therefore, motivation is not always observable in aged patients. Conclusions: Interventions tailored to extrinsic factors are important for maintaining patients' motivation. Observational evaluation may lead to mislabeling of their motivation, especially for aged patients. Rehabilitation professionals should use validated evaluation scales or patients' narratives to assess patients' motivation.

A novel α-fetoprotein-derived helper T-lymphocyte epitope with strong immunogenicity in patients with hepatocellular carcinoma.

α-Fetoprotein (AFP) is considered a good target for immunotherapy strategies against hepatocellular carcinoma (HCC); however, no immunodominant AFP-derived MHC class II-restricted helper T-lymphocyte (HTL) epitope has been reported. Therefore, we identified novel AFP-derived HTL epitopes possessing high immunogenicity. HTL epitopes were predicted using the online service, and peptides were subsequently synthesized. Four newly synthesized peptides showed positive reactivity in >20% patients on ELISPOT using peripheral blood mononuclear cells (PBMCs). Among these, the highest rate was shown by AFP1 (MKWVESIFLIFLLNFTESRT), which also showed the highest positive rate in cell proliferation assays. Binding assays demonstrated that AFP1 had strong binding properties toward MHC molecules. Further, blocking assays performed using an anti-HLA-DR antibody showed that immune response decreased, confirming the binding of AFP1 to HLA-DR molecules. Furthermore, the survival rates of patients with stages II-IV HCC indicated that T cell response against AFP1 led to significantly greater survival that of patients without T cell response. When evaluating immune response against AFP1 before and after HCC treatment, an increase in the frequency of peptide-specific T cells was observed after treatment in patients with HLA-DRB1*1502, *0405, and *0901 alleles. In conclusion, the identified epitopes may be useful for immunotherapy strategies against HCC.

Effects of Urea on the Reactions of Nucleosides with Hypobromous Acid.

Hypobromous acid (HOBr) is generated not only by eosinophils but also by neutrophils in the presence of Br- at the plasma concentration. Reactivity of HOBr is greatly modulated by coexistent compounds such as amines and amides. In this study, we investigated effects of urea in the reaction of nucleosides with HOBr. When nucleosides were incubated with HOBr without urea in potassium phosphate buffer at pH 7.4 and 37°C, the reactions almost completed within 10 min, with consumptions in the order of 2'-deoxyguanosine > 2'-deoxycytidine > 2'-deoxythymidine > 2'-deoxyadenosine, generating 8-bromo-2'-deoxyguanosine and 5-bromo-2'-deoxycytidine. In the presence of urea, the reaction of nucleosides with HOBr was relatively slow, continuing over several hours. When HOBr was preincubated without urea in potassium phosphate buffer at pH 7.4 and 37°C for 48 h, the preincubated HOBr solution did not react with nucleosides. However, a similar preincubated solution of HOBr with urea reacted with nucleosides to generate 8-bromo-2'-deoxyguanosine and 5-bromo-2'-deoxycytidine. These results imply that a reactive bromine compound with a long life, probably bromourea, is generated by HOBr in neutral urea solution and reacts with nucleosides, resulting in brominated nucleosides.

Immune response to human telomerase reverse transcriptase-derived helper T cell epitopes in hepatocellular carcinoma patients.

BACKGROUND AND AIMS: Human telomerase reverse transcriptase is a catalytic enzyme involved in telomere elongation. It is expressed in many tumours, including hepatocellular carcinoma. The purpose of the present study was to identify major histocompatibility complex class II-restricted helper T cell epitopes derived from human telomerase reverse transcriptase in patients with hepatocellular carcinoma. METHODS: TEPITOPE software was used to predict helper T cell epitopes based on the entire amino acid sequence of human telomerase reverse transcriptase, and peptides were synthesized based on the predicted sequence. Interferon (IFN)-γ enzyme linked immunospot assay was performed to examine the T cell response to each of the synthesized peptides in peripheral blood mononuclear cells. Furthermore, the peptides were labelled with fluorescein isothiocyanate to test their binding affinity for major histocompatibility complex class II molecules. Lastly, the association between patient characteristics and the level of immune response to these epitopes was examined. RESULTS: Positive T cell response (>10% enzyme linked immunospot positivity) was detected against 4 of 10 peptides. Among all peptides, positive T cell response to the hTERT68 peptide was detected most frequently. While hTERT68 was HLA-DRB1*0405-restricted, it also bound to other MCH class II molecules. Positive helper T cell response was detected most frequently in hepatocellular carcinoma patients with a low serum alpha-foetoprotein level. Several treatments for hepatocellular carcinoma enhanced the immune response against the peptides. CONCLUSION: Our findings indicate that helper T cell epitopes identified in the present study may be useful to investigate immune responses and for immunotherapy in hepatocellular carcinoma patients.

A case of diaphragmatic hernia following colonoscopy.

An 89-year-old woman with a history of traumatic injury was referred to our hospital for further evaluation of anemia. Two days after colonoscopy, she complained of intermittent abdominal pain. An abdominal computed tomography confirmed a left diaphragmatic defect with a herniated transverse colon. She underwent elective laparoscopic repair of the diaphragmatic hernia. Colonoscopy rarely causes or worsens a diaphragmatic hernia. This is a rare case where we observed the development and exacerbation of a diaphragmatic hernia. It is important to pay attention to the development of a diaphragmatic hernia after colonoscopy for patients with a history of traumatic injury.

[A case of poorly-differentiated neuroendocrine carcinoma of the ascending colon with multiple liver metastases successfully treated with cisplatin and irinotecan].

A 74-year-old woman diagnosed with poorly-differentiated neuroendocrine carcinoma originating from the ascending colon was referred to our hospital. She had felt anorexia, abdominal pains and her (ECOG) performance status was 3. Her CT scan showed that some abdominal lymph nodes were swelling and that there were many metastatic lesions occupying most of the liver. We started chemotherapy with cisplatin and irinotecan according to a regimen for small cell lung cancer. Considering her poor PS, both of the drugs were administered at 30mg/m² twice 4 weeks in the first course of chemotherapy. Her anorexia and abdominal pains immediately disappeared, and CT scan showed that all of the metastases were decreased in size. After 4 courses, however, some of the metastatic lesions were increased in size. She died 8 months after diagnosis. The tumor marker doubling time was 17 days.