Combination of Superior and Posterior Capsular Release Versus Superior Capsular Release Alone in Arthroscopic Repair of Large-to-Massive Rotator Cuff Tears.

Background: Superior capsular release has been used to reduce tendon tension, especially in arthroscopic repair of large-to-massive rotator cuff tears. Some clinicians have used a more extensive release of capsules in arthroscopic cuff repair for adequate reduction of torn tendons to footprints. Purpose: To explore the effects of additional posterior capsular release for superior capsular release in arthroscopic repair of large-to-massive rotator cuff tears. Study Design: Cohort study; Level of evidence, 3. Methods: We compared 26 shoulders that underwent superior and posterior capsular release (group S&P) with 26 shoulders that underwent superior capsular release alone (group S) in arthroscopic repair of large-to-massive rotator cuff tears between January 23, 2013 and December 2, 2015. The visual analog scale for pain, American Shoulder and Elbow Surgeons score, Constant score, and range of motion (ROM) and muscle power were checked preoperatively and at 2 years postoperatively. Follow-up ultrasound was checked at 2 years postoperatively. Results: In both groups, the overall mean functional outcomes improved from preoperatively to postoperatively. Patients in group S&P showed more pre- to postoperative improvement than patients in group S with regard to internal rotation ROM (mean difference, 30.0° vs 20.6°; P < .001) and internal rotation power (3.4 vs 1.8 kgf; P = .001). Patients in group S had a higher retear rate on the follow-up ultrasound than patients in group S&P, but this difference did not reach statistical significance (23.1% vs 11.5%, respectively; P = .465). Conclusion: In the current study, patients who underwent superior and posterior capsular release in arthroscopic repair of large-to-massive rotator cuff tears had greater postoperative improvement in internal rotation ROM and power compared with patients who underwent superior capsular release alone.

Comparison of the effectiveness of extensor muscle strengthening exercise by itself, exercise with polydeoxyribonucleotide injection, and exercise with extracorporeal shockwave therapy in lateral epicondylitis: a randomized controlled trial.

BACKGROUND: Extensor muscle strengthening exercises with counterforce braces (EX) is a conventional conservative treatment for lateral epicondylitis (LE) of the elbow. In addition, polydeoxyribonucleotide (PDRN) or extracorporeal shockwave therapy (ESWT) has been recently used for LE. METHODS: Sixty-three patients with chronic LE participated in this study and randomly allocated in three groups (G1: EX, G2: EX+PDRN injection, and G3: EX+ESWT). All of the three groups were taught to perform EX at the first out-patient department (OPD) visit. Group 2 was injected with 3 mL PDRN (5.625 mg/3 mL), while group 3 received ESWT at the first OPD visit. Visual analog scale pain score, Mayo elbow performance score (MEPS), and ultrasonographic examination were checked before, 6 weeks, and 12 weeks after the treatments. RESULTS: Overall functional scores and ultrasonographic findings in all three groups improved after treatment. The mean MEPS in group 2 improved more than groups 1 and 3 at 6 weeks (G1, 56.9>62.4; G2, 54.3>65.0; G3, 55.7>62.6), and more than group 1 at 12 weeks (G1, 56.9>67.9; G2, 54.3>73.6). The mean common extensor tendon depth (CETD) on ultrasonography in group 2 increased more than groups 1 and 3 at 6 and 12 weeks (6 weeks: G1, 0.385>0.386; G2, 0.332>0.392; G3, 0.334>0.357; 12 weeks: G1, 0.385>0.409; G2, 0.332>0.438; G3, 0.334>0.405 [cm]). CONCLUSIONS: PDRN injections combined with EX exhibited a greater improvement in mean MEPS and mean CETD compared to EX only or EX combined with ESWT for LE within the 12 weeks follow-up.

Factors affecting the health-related quality of life in community-dwelling elderly people.

OBJECTIVE: The purpose of this study was to investigate the determinants of the health-related quality of life of elderly people in Korea by applying the Andersen model. DESIGN AND SAMPLE: This study was a descriptive survey. Participants were 240 elderly people over 65 years of age living in a community. MEASURES: A hierarchical multiple regression was performed to analyze the factors related to the health-related quality of life, including predisposing, enabling, and need factors, and health behaviors. RESULTS: Need factors, that is, self-reported health status, were the most significant in influencing the health-related quality of life of the elderly people; predisposing factors were age and education level, and enabling factors were income and activities of daily living. CONCLUSION: The findings of this study can be used to develop a community-based intervention program and to establish a policy for improving the quality of life of elderly people.

Effect of Wnt3a on keratinocytes utilizing in vitro and bioinformatics analysis.

Wingless-type (Wnt) signaling proteins participate in various cell developmental processes. A suppressive role of Wnt5a on keratinocyte growth has already been observed. However, the role of other Wnt proteins in proliferation and differentiation of keratinocytes remains unknown. Here, we investigated the effects of the Wnt ligand, Wnt3a, on proliferation and differentiation of keratinocytes. Keratinocytes from normal human skin were cultured and treated with recombinant Wnt3a alone or in combination with the inflammatory cytokine, tumor necrosis factor α (TNFα). Furthermore, using bioinformatics, we analyzed the biochemical parameters, molecular evolution, and protein-protein interaction network for the Wnt family. Application of recombinant Wnt3a showed an anti-proliferative effect on keratinocytes in a dose-dependent manner. After treatment with TNFα, Wnt3a still demonstrated an anti-proliferative effect on human keratinocytes. Exogenous treatment of Wnt3a was unable to alter mRNA expression of differentiation markers of keratinocytes, whereas an altered expression was observed in TNFα-stimulated keratinocytes. In silico phylogenetic, biochemical, and protein-protein interaction analysis showed several close relationships among the family members of the Wnt family. Moreover, a close phylogenetic and biochemical similarity was observed between Wnt3a and Wnt5a. Finally, we proposed a hypothetical mechanism to illustrate how the Wnt3a protein may inhibit the process of proliferation in keratinocytes, which would be useful for future researchers.

Incidental thyroid lesions identified by ultrasound in patients with non-thyroidal head and neck cancer.

BACKGROUND: Thyroid cancer is one of the common head and neck malignancies and may be found incidentally with other head and neck cancers. PURPOSE: To evaluate the prevalence and risk of malignancy in incidental thyroid lesions identified by ultrasound (US) in patients with head and neck cancer. MATERIAL AND METHODS: We retrospectively reviewed medical records of all patients with head and neck cancer other than of thyroid origin between January 2004 and December 2011. A total of 690 patients (537 men and 153 women; mean age, 58.9 ± 12.9 years) underwent US of the neck for the evaluation of cervical lymph node status (including thyroid gland). We evaluated the prevalence of patients with incidental thyroid lesions identified by US and the risk of malignancy in these patients. RESULTS: Of the 690 patients with head and neck cancer, 234 (33.9%) had incidental thyroid lesions on US. Based on US findings, 61 patients underwent fine-needle aspiration, with 39 eventually undergoing thyroidectomy. Among these thyroid lesions, 24 incidental thyroid lesions of 22 patients were histologically proven to be malignant (23 papillary and 1 follicular carcinomas). The risk of malignancy was 9.4% on a patient-by-patient basis. CONCLUSION: Screening of the thyroid gland should be included in the preoperative US examination for cervical lymph node metastases in patients with non-thyroidal head and neck cancer.

Positioning patient-perceived medical services to develop a marketing strategy.

In today's medical market, marketing philosophy is being rapidly transformed from customer searching to patient satisfaction and service improvement. The principal objective of this study was to contribute to the establishment of a desirable medical marketing strategy, through the factors of customer satisfaction and the positioning of patients' perceptions by marketing institutions. The data were collected from 282 students of the College of Public Health and Medicine in Seoul. The survey tools were developed using the SERVQUAL scale. Analysis in this study involved both statistical and network analysis. The former was used to verify the determinants of service satisfaction as perceived by respondents, via factor analysis and multiple regression analysis. The latter was obtained using a positioning map and 2-mode network analysis with the matrix data converted from raw data. The determining factors for patient satisfaction were identified as facilities, accessibility, process, physicians, and medical staff. The regression equation was significant (R = 0.606), and the most influential variable was the service quality of physicians (ß = .569). According to multidimensional scaling, the positioning of medical institutions indicated that patients' perceptions were affected by hospital size and specialization. By recognizing and managing patient satisfaction, medical institutions are able to foster customer loyalty and, in turn, to enhance service quality. It is necessary to develop an adequate marketing mix to provide better medical services and to overcome medical competition among institutions.

Neuroradiologic and neurophysiologic findings of neuralgic amyotrophy.

OBJECTIVE: Neuralgic amyotrophy (NA) is a distinct clinical syndrome that is characterized by the acute onset of shoulder and arm pain, weakness, and sensory loss. The purpose of this study was to assess the clinical characteristics of NA and to determine appropriate diagnostic modalities. METHODS: We reviewed the medical and radiologic records of 10 patients diagnosed with NA retrospectively. Neurophysiologic studies were performed in all patients and magnetic resonance neurography was performed in the last three patients. RESULTS: A total of 10 patients were enrolled in our study. All patients had clinical findings compatible with NA. The most common clinical presentation was severe shoulder pain and weakness in seven patients (70%). Neurophysiologic study results were abnormal in all patients. Brachial plexus magnetic resonance neurography showed that the affected brachial plexus showed a thickened and hyper-intense trunk. All patients were managed conservatively with analgesics and physical therapy. The pain and paralysis of all patients improved clinically within 6 months of the initiation of treatment. CONCLUSION: NA is a rare disease but the symptoms of NA can mimic those of other diseases. Neurophysiologic studies and magnetic resonance neurography are extremely useful tools for the diagnosis of NA.

Altered IL-7Ralpha expression with aging and the potential implications of IL-7 therapy on CD8+ T-cell immune responses.

We investigated the effects of aging on the IL-7-mediated CD8+ T-cell survival pathway and of IL-7 therapy on T-cell immunity. Cells expressing IL-7 receptor (IL-7R) alphahigh and alphalow were identified in a CD45RA+ effector memory (EM(CD45RA+), CD45RA+CCR7-) CD8+ T-cell subset. Elderly subjects (65 years and older) had an increased frequency of EM(CD45RA+) IL-7Ralphalow) CD8+ T cells, leading to decreased STAT5 phosphorylation and survival responses to IL-7 compared with young subjects (40 years and younger). These EM(CD45RA+) IL-7Ralphalow cells were largely antigen experienced (CD27-CD28-), replicatively senescent (CD57+), and perforinhigh CD8+ T cells that had decreased IL-7Ralpha mRNA, independent of guanine and adenine binding protein alpha (GABPalpha) and growth factor independence-1 (GFI1) expression. In measuring T-cell receptor (TCR) repertoires of EM(CD45RA+) CD8+ T cells, the elderly had a limited repertoire in IL-7Ralphahigh and IL-7Ralphalow cells, whereas the young had a diverse repertoire in IL-7Ralphahigh but not in IL-7Ralphalow cells. These findings suggest that aging affects IL-7Ralpha expression by EM(CD45RA+) CD8+ T cells, leading to impaired signaling and survival responses to IL-7, and that IL-7 therapy may improve the survival of EM(CD45RA+) CD8+ T cells with a diverse TCR repertoire in the young but not in the elderly.

Age-associated changes in the frequency of naïve, memory and effector CD8+ T cells.

We investigated age-associated changes in the frequency of CD8+ T cell subsets with different functions. Based on expression of CD45RA and CCR7, naïve (CD45RA+ CCR7+), central memory (CM, CD45RA- CCR7+), effector memory (EM, CD45RA- CCR7-) and effector (CD45RA+ CCR7-) CD8+ T cells were identified in peripheral blood from healthy young (n = 17) and elderly (n = 17) people using flow cytometry. The elderly had a decreased frequency of naïve and an increased frequency of EM and effector CD8+ T cells compared to the young. However, both groups had a similar frequency of CM cells. These findings suggest that age-associated changes in CD8+ T cell subsets occur, which could be a potential explanation for altered CD8+ T cell function in the elderly.

Age-associated change in the frequency of memory CD4+ T cells impairs long term CD4+ T cell responses to influenza vaccine.

We investigated the relationship of memory CD4+ T cells with the evolution of influenza virus-specific CD4+ T cell responses in healthy young and elderly people. Elderly individuals had a similar frequency of CD69+CD4+ T cells producing IFN-gamma and TNF-alpha at 1 wk, but a lower frequency of these CD4+ T cells at 3 mo after influenza vaccination. Although the elderly had a higher frequency of central memory (CM; CCR7+CD45RA-) CD4+ T cells, they had a significantly lower frequency of effector memory (EM; CCR7-CD45RA-) CD4+ T cells, and the frequency of the latter memory CD4+ T cells positively correlated with the frequency of influenza virus-specific CD69+CD4+ T cells producing IFN-gamma at 3 mo. These findings indicate that the elderly have an altered balance of memory CD4+ T cells, which potentially affects long term CD4+ T cell responses to the influenza vaccine. Compared with the young, the elderly had decreased serum IL-7 levels that positively correlated with the frequency of EM cells, which suggests a relation between IL-7 and decreased EM cells. Thus, although the healthy elderly mount a level of CD4+ T cell responses after vaccination comparable to that observed in younger individuals, they fail to maintain or expand these responses. This failure probably stems from the alteration in the frequency of CM and EM CD4+ T cells in the elderly that is related to alteration in IL-7 levels. These findings raise an important clinical question about whether the vaccination strategy in the elderly should be modified to improve cellular immune responses.

Defective control of latent Epstein-Barr virus infection in systemic lupus erythematosus.

EBV infection is more common in patients with systemic lupus erythematosus (SLE) than in control subjects, suggesting that this virus plays an etiologic role in disease and/or that patients with lupus have impaired EBV-specific immune responses. In the current report we assessed immune responsiveness to EBV in patients with SLE and healthy controls, determining virus-specific T cell responses and EBV viral loads using whole blood recall assays, HLA-A2 tetramers, and real-time quantitative PCR. Patients with SLE had an approximately 40-fold increase in EBV viral loads compared with controls, a finding not explained by disease activity or immunosuppressive medications. The frequency of EBV-specific CD69+ CD4+ T cells producing IFN-gamma was higher in patients with SLE than in controls. By contrast, the frequency of EBV-specific CD69+ CD8+ T cells producing IFN-gamma in patients with SLE appeared lower than that in healthy controls, although this difference was not statistically significant. These findings suggest a role for CD4+ T cells in controlling, and a possible defect in CD8+ T cells in regulating, increased viral loads in lupus. These ideas were supported by correlations between viral loads and EBV-specific T cell responses in lupus patients. EBV viral loads were inversely correlated with the frequency of EBV-specific CD69+ CD4+ T cells producing IFN-gamma and were positively correlated with the frequencies of CD69+ CD8+ T cells producing IFN-gamma and with EBV-specific, HLA-A2 tetramer-positive CD8+ T cells. These results demonstrate that patients with SLE have defective control of latent EBV infection that probably stems from altered T cell responses against EBV.