Efficacy of Repetitive Trans-spinal Magnetic Stimulation for Patients with Parkinson's Disease: a Randomised Controlled Trial.

We evaluated the effect of repetitive trans-spinal magnetic stimulation (rTSMS) in patients with Parkinson's disease (PD) in a randomised, single-blind study. Participants were hospitalised and administered a single trial of rTSMS or sham treatment 2 days a week for 4 weeks. In addition, all participants underwent rehabilitation 5 days a week for 4 weeks. The primary outcome was the difference between the two groups in the mean change from baseline to post-training in the total score on the Unified Parkinson's Disease Rating Scale (UPDRS). Secondary endpoints included the differences between the two groups in the mean change on the UPDRS part III (motor) score and the Timed Up and Go (TUG) score. Eligible participants were randomly assigned to either the rTSMS group (n = 50) or sham group (n = 50). The between-group difference in mean change in the total UPDRS score was 10.28 (95% confidence interval (CI), 4.42 to 16.13; P = 0.014) immediately after intervention from baseline, 5.04 (95% CI, - 5.41 to 15.50; P = 0.024) 3 months after intervention from baseline and 2.38 (95% CI, 7.18 to 11.85; P = 0.045) 6 months after intervention from baseline. Significant differences between groups in UPDRS part III and TUG scores were maintained more strictly than those in the UPDRS total score. These results strongly indicate that rTSMS promotes the effect of rehabilitation on motor function in patients with PD.

Sociability-based fitness approach in Parkinson's disease: Comparison with conventional rehabilitation.

BACKGROUND AND PURPOSE: The effect of a sociability-based fitness approach on parkinsonian disability in patients with Parkinson's disease (PD) was assessed. METHODS: Eighty patients diagnosed with PD were randomly assigned to either the group-based rehabilitation (GBR) group (n = 40) or the individual-based rehabilitation (IBR) group (n = 40). The primary outcome was the difference between the two groups in the mean change from baseline to post-training in the total score on the Unified Parkinson's Disease Rating Scale (UPDRS). The secondary outcomes included the change in mental status and the difference in the mean change from baseline to month 3 and month 6 in the total score on the UPDRS. RESULTS: The mean (±SD) UPDRS scores were 72.0 ± 21.0 in the GBR group and 72.1 ± 18.6 in the IBR group. The UPDRS scores from baseline to post-training were 22.8 ± 13.5 in the GBR group and 10.9 ± 8.8 in the IBR group (difference 11.8 points; 95% confidence interval [CI] 5.0-18.6; p = 0.001). The difference between the groups from baseline to month 3 (difference 10.06 points; 95% CI 3.3-16.8) and the difference between the groups from baseline to month 6 (difference 11.7 points; 95% CI 4.9-18.5) were also significant (p = 0.004 and p = 0.001, respectively). The scores of cognitive function and depression had not changed significantly. CONCLUSIONS: Patients receiving GBR demonstrated significant improvements in parkinsonian symptoms, suggesting that the sociability-based fitness can be applied to clinical treatment by sustaining the motivation in PD.

Evaluation of Temporomandibular Joint Movement After Mandibular Reconstruction.

Mandibular head dislocation and problems with mouth opening may develop after mandibular reconstruction. The authors investigated dislocation of the mandibular head and amount of protrusive sliding (excursion) and their effect on mouth opening. The authors divided 55 mandibular reconstruction patients into 3 groups on the basis of the extent of masticatory muscle and mandibular resection and investigated mandibular head dislocation. On the other hand, the authors focused on mandibular head protrusive excursion as a function of a reconstructed mandible. Protrusive excursion was measured by plain radiography in 29 patients. The extent of mouth opening was measured between the central incisors. Fluoroscopy was performed in 9 patients and the motions of the mandible were analyzed with video-analysis software. Mandibular head dislocation was observed in 15 patients (27.2%) who underwent resection of the mandibular ramus and coronoid process. The extent of mouth opening did not vary significantly among the 3 groups but was lower than that in healthy persons. Mandibular excursion was restricted in patients with conserved temporalis and lateral pterygoid muscles. Protrusive excursion was correlated with the extent of mouth opening. Structural problems involving dislocation of the mandibular head are caused by severing the coronoid process and protrusive excursion disorders are important factors causing mouth opening problems. Physiological sliding and other motions were observed in reconstructed models. The authors believe that when the ramus is resected, there is a greater chance of articular head dislocation. These findings suggest that dislocation of the mandibular head and protrusive excursion disorders arise from imbalances of the remaining masticatory muscles.

Postmastectomy radiation therapy and breast reconstruction with autologous tissue.

Immediate breast reconstruction is an important tool for patients to accept and overcome their breast cancer, as well as for cosmetic reasons. However, its use in patients who require postmastectomy radiation therapy (PMRT) is not yet clear. The purpose of this study was to analyze the effects of PMRT and reconstruction on each other. The time of initiation of PMRT, the prognosis, and the cosmetic results were investigated in patients who underwent immediate reconstruction using autologous tissue. In the case of delayed reconstruction using autologous tissue after PMRT, radiation damage of the chest skin, design of the flap, and cosmetic results were investigated. In 38 patients who underwent immediate reconstruction and PMRT between 2006 and 2015, 20 patients received neoadjuvant chemotherapy, and their mean time before starting PMRT was 9.7 weeks after surgery (range 7-18 weeks). Three patients underwent delayed PMRT (more than 12 weeks) due to partial flap necrosis and wound infection. Of 28 patients (2006-2010), 23 were disease free (stage I: 2/2, stage II: 15/16, stage III: 6/10), one patient (stage III) had distant metastases, and 4 patients died of primary disease (stage II: 1/16, stage III: 3/10). Unacceptable deformation of the reconstructed breast was observed in 4 patients who had partial fat necrosis of the grafted flap or skin necrosis of the mastectomy flap. In 20 patients who underwent delayed reconstruction between 2006 and 2015, 15 (75%) patients underwent replacement of irradiated chest skin with flap skin to reconstruct a soft and natural shape breast. The flap survival rate was 100%, and unacceptable deformation of the reconstructed breast was not seen. In the case of immediate reconstruction using autologous tissue, it is important to graft a flap with a good blood supply to avoid delaying PMRT and achieving a good cosmetic result, because flap necrosis or wound infection delays PMRT and causes scar contracture after PMRT. In the case of delayed reconstruction after PMRT, chest wall skin with radiation damage should be resected and replaced by flap skin.

A new method for inframammary fold recreation using a barbed suture.

BACKGROUND: There are inherent limitations with previously reported inframammary fold (IMF) recreation methods. The IMF is firmly fixed to the chest wall, but not physiologically, and it is difficult to determine the correct IMF position in the supine position and in the absence of an implant. METHODS: With our new IMF reconstruction method (i.e., drawstring method), the IMF is recreated by drawing a barbed suture, penetrating the dermis, along the IMF. The barbed suture is fixed to the costal cartilage at the medial IMF, and the head is drawn and cut externally at the lateral IMF. The IMF level and depth can be finely adjusted by the tension, in a seated position after implant insertion. Furthermore, the approach can be from a small incision, and a smooth IMF curve is reconstructed. RESULTS: Our drawstring method was performed in 102 patients who underwent reconstruction using a breast implant (n = 95) or flap (n = 7). The mean patient age was 52.0 years (range 33-77 years) and the follow-up period was 12 months (range 3-18 months). Suture or implant infection or exposure did not occur. Suture slack occurred in ten patients with implant-based reconstruction; their IMF became shallow. Insufficient skin expansion (P < 0.005) and strong traction of the barbed suture from the caudal side (P < 0.05) were related to IMF slack. The total revision rate was 2.9 %. CONCLUSIONS: With sufficient skin expansion, the drawstring method using a barbed suture enables smooth and symmetrical IMF reconstruction. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Two cases with dropped head syndrome caused by hypokalemic myopathy].

We reported two women (78 and 85 years of age) with dropped head syndrome caused by hypokalemic myopathy restricted to the posterior cervical muscles. Both presented with relatively rapid onset of severe neck extensor weakness. Needle EMG demonstrated myogenic changes in the cervical paraspinal muscles and there were high intensity signals in the posterior cervical muscles on the neck MRI. Dropped head syndrome resolved in both patients as potassium normalized. One of the patients relapsed 11 months later with recurrent hypokalemia, but recovered rapidly with supplementation of potassium. Focal myopathy localized in the posterior cervical muscles due to hypokalemia should be considered as one of the possible causes of dropped head syndrome.

Late-onset CMT2 associated with a novel missense mutation in the cytoplasmic domain of the MPZ gene.

Phenotypic variations have been reported in Charcot-Marie-Tooth disease type 2 (CMT2) including age-at-onset, disease progression and severity. Sporadic cases with CMT2 have also been demonstrated by genetic test. We here report a patient with late-onset CMT2 without family history, who developed gait disturbance at the age of 68. Sequence analysis revealed a novel heterozygous Arg198Gly mutation in the cytoplasmic domain of the major peripheral myelin protein zero (MPZ). The mutation is located in the protein kinase C (PKC) alpha substrate motif (RSTK) of MPZ, presumably leading to the loss of PKC-mediated phosphorylation in adhesion. Routine genetic test for CMT is not recommended for every patient with late-onset peripheral neuropathy without known causes, however, the genetic test may be taken into consideration if the patient shows a clinical phenotype similar to that of CMT, and the possibility of a de novo mutation cannot be excluded.