Takotsubo syndrome as an overlooked and elusive cause of a single episode of dyspnea in young women: a case report.

BACKGROUND: Dyspnea is a common symptom in patients presenting to the emergency department. It has a variety of causes that range from non-urgent to life-threatening. One episode of dyspnea in a healthy young person is easy to overlook. However, if the symptoms occur after physically or emotionally stressful events, careful evaluation needs to be undertaken because it may be associated with Takotsubo syndrome, which is rarely expected but can be fatal. Herein, we report the case of Takotsubo syndrome in a healthy young woman who arrived at the emergency department after experiencing a short single episode of dyspnea following a minor surgery. CASE PRESENTATION: A 23-year old woman with no underlying chronic disease underwent closed reduction surgery for a nasal bone fracture under general anesthesia (with sevoflurane as the anesthetic). Approximately 5 h later, she presented to the emergency department with dyspnea, which improved soon upon arrival at the emergency department. There were no other symptoms. The dyspnea occurred about 5 h after being discharged on observation, with an uneventful postoperative course. Her electrocardiogram and chest X-ray findings were unremarkable. On testing, troponin I and creatine kinase myocardial band levels were elevated at 6.122 ng/mL and 11.2 µg/L (reference ranges: 0.000-0.046 ng/mL and 0.0-5.0 µg/L), respectively. Bedside echocardiography revealed an ejection fraction of 25%, with mid-ventricular and apical akinesia and basal hyperkinesia. The pulmonary and coronary angiographic computed tomographic scans were unremarkable. Hence, apical Takotsubo syndrome was suspected. A follow-up echocardiogram taken 5 days after admission showed full recovery with a normalized ejection fraction (60%) and no regional wall motion abnormality. The patient was discharged on the sixth day with no other complications. CONCLUSION: When atypical symptoms, such as transient dyspnea, manifest, it becomes necessary to suspect and diagnose Takotsubo syndrome to ensure timely and appropriate medical management, especially when a preceding stressful event, such as minor surgery has occurred. It might be helpful to perform bedside point-of-care echocardiography to check for regional wall motion abnormalities that are typically associated with Takotsubo syndrome.

Relation between preoperative electromyographic activity of the deltoid and upper trapezius muscle and clinical results in patients treated with reverse shoulder arthroplasty.

BACKGROUND: If patients susceptible to poor clinical outcomes could be predicted before reverse shoulder arthroplasty (RSA), it would help to set reasonable postsurgical patient expectations in the preoperative setting. Our hypothesis was that the preoperative electromyographic (EMG) activity of the deltoid and upper trapezius muscles would be correlated with clinical outcomes of patients undergoing RSA. METHODS: EMG activity of the deltoid and upper trapezius muscles was measured in 25 patients scheduled to undergo RSA during 3 motions: shrugging, forward flexion, and abduction. Their postoperative clinical results were assessed prospectively during regular outpatient visits, including strength, active range of motion (ROM), pain, and functional scores. The correlations between the preoperative EMG activities and clinical results were analyzed. RESULTS: Postoperative shoulder strength after RSA was increased in patients with greater preoperative EMG activity of the middle deltoid and upper trapezius. Preoperative EMG activity of the anterior or middle deltoid muscle was associated with active ROM in flexion or abduction, whereas EMG activity of the posterior deltoid was associated with active ROM in external rotation. CONCLUSIONS: Shoulder strength after RSA was positively correlated with preoperative EMG activity of the deltoid and upper trapezius. Active ROM after RSA was positively correlated with preoperative EMG activity of the deltoid. Therefore, preoperative EMG measurements of the deltoid and upper trapezius may predict clinical outcomes after RSA.

Polydeoxyribonucleotide Injection in the Treatment of Chronic Supraspinatus Tendinopathy: A Case-Controlled, Retrospective, Comparative Study With 6-Month Follow-Up.

OBJECTIVE: To determine the efficacy of polydeoxyribonucleotide (PDRN) injection for rotator cuff disease (RCD). DESIGN: Case-controlled, retrospective, comparative study. SETTING: Outpatient clinic at a university-affiliated tertiary care hospital. PARTICIPANTS: Patients (N=106) with chronic nontraumatic refractory RCD who were unresponsive to at least 1 month of conservative treatment: 55 patients received PDRN injection (PDRN group) and 51 continued conservative treatment (control group). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Shoulder Pain and Disability Index, score on a visual analog scale of the average shoulder pain level, number of analgesic ingestions per day, isometric strength of shoulder abductor, active range of motion (flexion, abduction, internal rotation, external rotation), and maximal tear size of tendon on ultrasonography at pretreatment and 3 and 6 months postinjection. RESULTS: There was no significant difference between the 2 groups in terms of age, sex, shoulder affected, duration of symptoms, and ultrasonographic findings at pretreatment. Compared with the control group, the treatment group showed a significant improvement in Shoulder Pain and Disability Index, visual analog scale score, and number of analgesic ingestions per day. However, there was no difference in isometric strength, active range of motion, and maximal tear size of tendon. No adverse events were reported. CONCLUSIONS: To our knowledge, this is the first study to assess the efficacy of PDRN injection for patients with RCD. The PDRN injection group showed improvement in pain and subjective disability in patients with RCD and continued to show improvement for 3 months thereafter; the PDRN injection can be an optional treatment for patients with chronic RCD who show no response to other treatments.

Relation Between Subacromial Bursitis on Ultrasonography and Efficacy of Subacromial Corticosteroid Injection in Rotator Cuff Disease: A Prospective Comparison Study.

OBJECTIVE: To evaluate the correlations between subacromial bursitis (bursal thickening and effusion) on ultrasonography and its response to subacromial corticosteroid injection in patients with rotator cuff disease. DESIGN: Prospective, longitudinal comparison study. SETTING: University-affiliated tertiary care hospital. PARTICIPANTS: Patients with rotator cuff disease (N=69) were classified into 3 groups based on ultrasonographic findings; (1) normative bursa group (group 1, n=23): bursa and effusion thickness <1mm; (2) bursa thickening group (group 2, n=22): bursa thickness >2mm and effusion thickness <1mm; and (3) bursa effusion group (group 3, n=24): bursa thickness <1mm and effusion thickness >2mm. INTERVENTION: A single subacromial injection with 20mg of triamcinolone acetonide. MAIN OUTCOME MEASURES: Visual analog scale (VAS) of shoulder pain, Shoulder Disability Questionnaire (SDQ), angles of active shoulder range of motion (flexion, abduction, external rotation, and internal rotation), and bursa and effusion thickness at pre- and posttreatment at week 8. RESULTS: There were no significant differences between the 3 groups in demographic characteristics pretreatment. Groups 2 and 3 showed a significant difference compared with group 1 in changes on the VAS and abduction; group 3 showed a significant difference compared with group 1 in changes of the SDQ, internal rotation, and external rotation; and all groups showed significant differences when compared with each other (groups 1 and 3, 2 and 3, and 1 and 2) in changes of thickness. CONCLUSIONS: A patient with ultrasonographic observation of subacromial bursitis, instead of normative bursa, can expect better outcome with subacromial corticosteroid injection. Therefore, we recommend a careful selection of patients using ultrasonography prior to injection.

Capsule-Preserving Hydrodilatation With Corticosteroid Versus Corticosteroid Injection Alone in Refractory Adhesive Capsulitis of Shoulder: A Randomized Controlled Trial.

OBJECTIVE: To determine whether capsule-preserved hydrodilatation with corticosteroid improves pain and function in patients with refractory adhesive capsulitis (AC) better than intra-articular corticosteroid injection (IACI) alone. DESIGN: Prospective randomized controlled study. SETTING: University-affiliated tertiary care hospital. PARTICIPANTS: Subjects with primary AC (N=64) with shoulder pain level of visual analog scale (VAS) score ≥5, even after the initial administration of IACI alone. INTERVENTIONS: Participants randomly received ultrasound-guided IACI alone with 1mL of 40mg/mL triamcinolone acetonide and 3mL of 1% lidocaine (n=32) or ultrasound-guided capsule-preserved hydrodilatation with corticosteroid with a mixture of 1mL of 40mg/mL triamcinolone acetonide, 6mL of 1% lidocaine, and normative saline (n=32). MAIN OUTCOME MEASURES: The primary outcome measure was the Shoulder Pain and Disability Index score. Secondary outcomes were the VAS of shoulder pain level and angles of shoulder passive range of motion, including flexion, abduction, extension, external rotation, and internal rotation at pretreatment and weeks 3, 6, and 12 of posttreatment. RESULTS: There were no significant differences between the 2 groups in terms of demographic characteristics (age, sex, duration of symptoms, shoulder affected, and body mass index) at baseline. Repeated-measures analysis of variance showed significant effect of time in all outcome measurements in both groups. However, group-by-time interactions were not significantly different for any of the outcomes between groups. CONCLUSIONS: This study shows that compared with pretreatment, all outcome measures improved significantly in both groups by time; however, there was no significant difference between the 2 groups. Therefore, we recommend IACI alone over capsule-preserved hydrodilatation with corticosteroid when considering the corticosteroid injection as a secondary option after the initial IACI fails to improve symptoms for patients with refractory AC.

Evaluation of Adhesive Capsulitis of the Shoulder With Fat-Suppressed T2-Weighted MRI: Association Between Clinical Features and MRI Findings.

OBJECTIVE: The purpose of this study was to examine the association between clinical features and MRI findings in adhesive capsulitis of the shoulder. MATERIALS AND METHODS: This study included 103 patients (41 men, 62 women) with adhesive capsulitis. The MRI findings were correlated with pain intensity, range of motion, and clinical stage. Joint capsule edema in the axillary recess, extracapsular edema, obliteration of the subcoracoid fat triangle, and effusion in the long head biceps tendon sheath were assessed by two radiologists using fat-suppressed T2-weighted images. Joint capsule thickness in the axillary recess and degree of external rotation during MRI were also measured. Intraclass correlation coefficient and kappa values were obtained. Associations between MRI findings and clinical features were assessed by statistical analyses. RESULTS: Anterior extracapsular edema was associated with range of motion on external rotation and abduction (p < 0.01). Joint capsule edema in the humeral portion of the axillary recess was associated with range of motion on external rotation (p = 0.01). Joint capsule thickness in the humeral portion of the axillary recess and height of the axillary recess were associated with pain intensity (p < 0.05). Joint capsule edema in the humeral portion of the axillary recess and obliteration of the subcoracoid fat triangle were significantly more common in the early stages of adhesive capsulitis (p < 0.05). Joint capsule thickness in the humeral portion of the axillary recess at stage 1 (4.67 ± 1.73 mm) was significantly different from the thickness at the later stages (stage 2, 3.73 ± 1.49 mm; stages 3 and 4, 3.67 ± 1.44 mm) (p < 0.05). CONCLUSION: MRI is useful for assessing clinical impairment and predicting the clinical stage of adhesive capsulitis.

Supine Versus Standing Radiographs for Detecting Ischiofemoral Impingement: A Propensity Score-Matched Analysis.

OBJECTIVE: The purpose of this study was to assess parameters of ischiofemoral impingement on supine and standing anteroposterior hip radiographs and to suggest optimal cutoff points for detection of ischiofemoral impingement. MATERIALS AND METHODS: A retrospective study included patients with a clinical history of hip pain. All hip joints with evidence of quadratus femoris muscle edema on MR images were included in the ischiofemoral impingement patient group. An age- and sex-matched control group was derived from the same cohort by propensity score matching. On radiographs, two readers independently measured the following parameters: ischiofemoral space, quadratus femoris space, hamstring tendon area, ischiofemoral distance on supine radiograph, ischiofemoral distance on standing radiograph, and femoral neck-shaft angle. Group differences in parameters were assessed by Mann-Whitney U test. The intraclass correlation coefficient and the ROC AUC were obtained. Correlations between radiographic and MRI measures were assessed with Pearson correlation and Bland-Altman plot analyses. The Youden J index was used to select optimum cutoff points for each parameter. RESULTS: There were 30 patients (44 hip joints; mean age, 54.8 ± 11 years) in the ischiofemoral impingement group and 88 patients (88 hip joints; mean age, 51.8 ± 13.4 years) in the control group. There were significant group differences in ischiofemoral space, quadratus femoris space, ischiofemoral distance on supine radiograph, ischiofemoral distance on standing radiograph, and neck-shaft angle (p < 0.05). Ischiofemoral distance on supine and standing radiographs exhibited good discriminative ability (AUC > 0.80). The optimal cutoff points for ischiofemoral distances on supine and standing radiographs were 19.9 and 19.1 mm for reader 1 and 21.1 and 17.0 mm for reader 2. Ischiofemoral space, quadratus femoris space, ischiofemoral distance on supine radiograph, and ischiofemoral distance on standing radiograph exhibited nearly perfect interobserver agreement (r > 0.8). CONCLUSION: Ischiofemoral distances on supine and standing hip radiographs had good diagnostic performance and can be used as a screening tool, with optimal cutoff points.

Prolotherapy for Refractory Rotator Cuff Disease: Retrospective Case-Control Study of 1-Year Follow-Up.

OBJECTIVE: To determine the efficacy of prolotherapy for refractory rotator cuff disease. DESIGN: Retrospective case-control study. SETTING: University-affiliated tertiary care hospital. PARTICIPANTS: Patients with nontraumatic refractory rotator cuff disease (N=151) who were unresponsive to 3 months of aggressive conservative treatment. Of the patients, 63 received prolotherapies with 16.5% dextrose 10-ml solution (treatment group), and 63 continued conservative treatment (control group). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Visual analog scale (VAS) score of the average shoulder pain level for the past 1 week, Shoulder Pain and Disability Index (SPADI) score, isometric strength of the shoulder abductor, active range of motion (AROM) of the shoulder, maximal tear size on ultrasonography, and number of analgesic ingestions per day. RESULTS: Over 1-year follow-up, 57 patients in the treatment group and 53 in the control group were analyzed. There was no significant difference between the 2 groups in age, sex, shoulder dominance, duration of symptoms, and ultrasonographic findings at pretreatment. The average number of injections in the treatment group is 4.8±1.3. Compared with the control group, VAS score, SPADI score, isometric strength of shoulder abductor, and shoulder AROM of flexion, abduction, and external rotation showed significant improvement in the treatment group. There were no adverse events. CONCLUSIONS: To our knowledge, this is the first study to assess the efficacy of prolotherapy in rotator cuff disease. Prolotherapy showed improvement in pain, disability, isometric strength, and shoulder AROM in patients with refractory chronic rotator cuff disease. The results suggest positive outcomes, but one should still take caution in directly interpreting it as an effective treatment option, considering the limitations of this nonrandomized retrospective study. To show the efficacy of prolotherapy, further studies on prospective randomized controlled trials will be required.

An in vitro comparative study of T2 and T2* mappings of human articular cartilage at 3-Tesla MRI using histology as the standard of reference.

OBJECTIVE: The aim of this study was to evaluate the correlations between T2 value, T2* value, and histological grades of degenerated human articular cartilage. MATERIALS AND METHODS: T2 mapping and T2* mapping of nine tibial osteochondral specimens were obtained using a 3-T MRI after total knee arthroplasty. A total of 94 ROIs were analyzed. Histological grades were assessed using the David-Vaudey scale. Spearman's rho correlation analysis and Pearson's correlation analysis were performed. RESULTS: The mean relaxation values in T2 map with different histological grades (0, 1, 2) of the cartilage were 51.9 ± 9.2 ms, 55.8 ± 12.8 ms, and 59.6 ± 10.2 ms, respectively. The mean relaxation values in T2* map with different histological grades (0, 1, 2) of the cartilage were 20.3 ± 10.3 ms, 21.1 ± 12.4 ms, and 15.4 ± 8.5 ms, respectively. Spearman's rho correlation analysis confirmed a positive correlation between T2 value and histological grade (ρ = 0.313, p < 0.05). Pearson's correlation analysis revealed a significant negative correlation between T2 and T2* (r = -0.322, p < 0.05). Although T2* values showed a decreasing trend with an increase in cartilage degeneration, this correlation was not statistically significant in this study (ρ = -0.192, p = 0.129). CONCLUSIONS: T2 mapping was correlated with histological degeneration, and it may be a good biomarker for osteoarthritis in human articular cartilage. However, the strength of the correlation was weak (ρ = 0.313). Although T2* values showed a decreasing trend with an increase in cartilage degeneration, the correlation was not statistically significant. Therefore, T2 mapping may be more appropriate for the initial diagnosis of articular cartilage degeneration in the knee joint. Further studies on T2* mapping are needed to confirm its reliability and mechanism in cartilage degeneration.

Assessment of the proarrhythmic effects of repurposed antimalarials for COVID-19 treatment using a comprehensive in vitro proarrhythmia assay (CiPA).

Due to the outbreak of the SARS-CoV-2 virus, drug repurposing and Emergency Use Authorization have been proposed to treat the coronavirus disease 2019 (COVID-19) during the pandemic. While the efficiency of the drugs has been discussed, it was identified that certain compounds, such as chloroquine and hydroxychloroquine, cause QT interval prolongation and potential cardiotoxic effects. Drug-induced cardiotoxicity and QT prolongation may lead to life-threatening arrhythmias such as torsades de pointes (TdP), a potentially fatal arrhythmic symptom. Here, we evaluated the risk of repurposed pyronaridine or artesunate-mediated cardiac arrhythmias alone and in combination for COVID-19 treatment through in vitro and in silico investigations using the Comprehensive in vitro Proarrhythmia Assay (CiPA) initiative. The potential effects of each drug or in combinations on cardiac action potential (AP) and ion channels were explored using human induced pluripotent stem cell-derived cardiomyocytes (hiPSC-CMs) and Chinese hamster ovary (CHO) cells transiently expressing cardiac ion channels (Nav1.5, Cav1.2, and hERG). We also performed in silico computer simulation using the optimized O'Hara-Rudy human ventricular myocyte model (ORd model) to classify TdP risk. Artesunate and dihydroartemisinin (DHA), the active metabolite of artesunate, are classified as a low risk of inducing TdP based on the torsade metric score (TMS). Moreover, artesunate does not significantly affect the cardiac APs of hiPSC-CMs even at concentrations up to 100 times the maximum serum concentration (Cmax). DHA modestly prolonged at APD90 (10.16%) at 100 times the Cmax. When considering Cmax, pyronaridine, and the combination of both drugs (pyronaridine and artesunate) are classified as having an intermediate risk of inducing TdP. However, when considering the unbound concentration (the free fraction not bound to carrier proteins or other tissues inducing pharmacological activity), both drugs are classified as having a low risk of inducing TdP. In summary, pyronaridine, artesunate, and a combination of both drugs have been confirmed to pose a low proarrhythmogenic risk at therapeutic and supratherapeutic (up to 4 times) free Cmax. Additionally, the CiPA initiative may be suitable for regulatory use and provide novel insights for evaluating drug-induced cardiotoxicity.

Pathologically confirmed pancreatic hamartoma after surgical resection with an aldosterone-producing adrenal tumor: a case report.

Pancreatic hamartoma is a benign tumor of the pancreas with an extremely low incidence and is commonly diagnosed by pathologic examination after surgery. This report describes the case of a 57-year-old female who was referred for the evaluation of a pancreatic mass and an adrenal incidentaloma. Further imaging studies suggested pancreatic neuroendocrine tumor and aldosterone-producing adrenal tumor. Pylorus-preserving pancreaticoduodenectomy was performed with the initial impression of a pancreatic neuroendocrine tumor. However, pathology results revealed a pancreatic hamartoma. Multiple endocrine neoplasia type 1 syndrome was discussed as a probable explanation for tumor masses in both the pancreas and adrenal gland.

Dissonance in views between healthcare professionals and adults with a spinal cord injury with their understanding and interpretation of exercise intensity for exercise prescription.

Objectives: To evaluate the difference between healthcare professionals (HCPs) and adults with spinal cord injury (SCI) in Asia regarding knowledge and interpretation of 'exercise intensity' for aerobic exercise prescription. Methods and study design: A survey was distributed to practising HCP and adults with SCI. It was completed in participants' local language on topics related to the importance of exercise frequency, intensity, time and type; methods for monitoring and terms related to exercise intensity prescription. χ2 analysis was used to detect differences in HCP or those with SCI. Results: 121 HCP and 107 adults with an SCI ≥1 years (C1-L4) participated. Responses revealed 61% of all HCP ranked 'intensity' being most important whereas only 38% respondents from the SCI group ranked it as high importance (p=0.008). For those with SCI, 'frequency' was most important (61%) which was significantly higher than the 45% selected by HCPs (p=0.030). Of the 228 respondents on average only 34% believed that the terms, 'moderate' and 'vigorous' provided enough information for aerobic exercise intensity prescription. HCP most often used HR methods compared with the SCI group (90% vs 54%; p<0.01). Both groups frequently used the subjective measures of exercise intensity, for example, Ratings of Perceived Exertion (8%3 vs 76% for HCP and SCI), HCP also frequently used speed (81%) and SCI also frequently relied on 'the affect' or feelings while exercising (69%). Conclusions: These differences must be considered when developing clinical-practice exercise guidelines and health referral educational pathways for adults with SCI in Asia.

Usefulness of dynamic contrast-enhanced MRI in differentiating between septic arthritis and transient synovitis in the hip joint.

OBJECTIVE: The purpose of this study was to show the usefulness of dynamic contrast-enhanced MRI (DCE-MRI) and to determine the optimal time window in MRI for differentiating between septic arthritis and transient synovitis in painful hip joints. MATERIALS AND METHODS: Eighteen patients who underwent DCE-MRI were enrolled, and the final diagnoses were septic arthritis (n = 7) and transient synovitis (n = 11). The enhancement patterns of DCE-MRI were dichotomized according to the shape of the time-signal intensity curves. The time at the maximal difference in the signal intensity between two time-signal intensity curves of both femoral heads was recorded. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were calculated. Receiver operating characteristic curves were calculated. RESULTS: Six of seven patients with septic arthritis in the hip joint had decreased enhancement during the early phase of DCE-MRI. The enhancement difference between the two patient groups was statistically significant (p = 0.0498). The time at the maximal difference in the signal intensity between two time-signal intensity curves of both femoral heads was approximately 3.5 minutes. The area under the receiver operating characteristic curve for predicting septic arthritis was 0.792. CONCLUSION: DCE-MRI is useful in differentiating between septic hip arthritis and transient synovitis. If static contrast-enhanced coronal MRI is used, the optimal time for the acquisition of contrast-enhanced coronal MRI is approximately 3.5 minutes.

Subacromial corticosteroid injection on poststroke hemiplegic shoulder pain: a randomized, triple-blind, placebo-controlled trial.

OBJECTIVE: To evaluate the effect of subacromial corticosteroid injection on hemiplegic shoulder pain (HSP). DESIGN: Multicenter, randomized, triple-blind, placebo-controlled trial. SETTING: Three primary and 1 university-affiliated tertiary-care hospitals. PARTICIPANTS: Poststroke HSP patients (N=58) with evidence of rotator cuff disorder. INTERVENTIONS: Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone 40mg (treatment group, n=29), or lidocaine (placebo group, n=29). After a single injection, participants were followed up for 8 weeks. MAIN OUTCOME MEASURES: Visual analog scale (VAS) of the average shoulder pain level at day and night (VAS-day/night, the primary outcome measures), Modified Barthel Index, Shoulder Disability Questionnaire (SDQ), and angles of shoulder active range of motion (flexion, abduction, external rotation, and internal rotation) at pretreatment and weeks 2, 4, and 8 posttreatment. RESULTS: There was no significant difference between the 2 groups in the main outcome measures at pretreatment. Compared with the placebo group, VAS-day/night, SDQ, flexion, external rotation, and internal rotation showed significant improvement in the treatment group. CONCLUSIONS: To our knowledge, this is the first randomized, placebo-controlled study to assess the efficacy of subacromial injection in HSP patients with evidence of rotator cuff disorder. Subacromial corticosteroid injection showed improvement in pain, disability, and active range of motion, and the duration of its efficacy continued up to 8 weeks.

Transforming growth factor­ß family and stem cell­derived exosome therapeutic treatment in osteoarthritis (Review).

Osteoarthritis (OA), although extensively researched, still lacks an effective and safe treatment. The only current treatment option available for advanced OA is joint replacement surgery. This surgery may pose the risks of persistent pain, surgical complications and limited implant lifespan. Transforming growth factor (TGF)­ß has a crucial role in multiple cellular processes such as cell proliferation. Any deterioration in TGF­ß signaling pathways can have an immense impact on OA. Owing to the crucial role of TGF­ß in cartilage homeostasis, targeting it could be an alternative therapeutic approach. Additionally, stem cell­based therapy has recently emerged as an effective treatment strategy that could replace surgery. A number of recent findings suggest that the tissue regeneration effect of stem cells is attributed to the paracrine secretion of anti­inflammatory and chondroprotective mediators or trophic factors, particularly nanosized extracellular vesicles (i.e., exosomes). Literature searches were performed in the MEDLINE, EMBASE, Cochrane Library and PubMed electronic database for relevant articles published before September 2021. Multiple investigators have confirmed TGF­ß3 as a promising candidate which has the chondrogenic potential to repair articular cartilage degeneration. Combining TGF­ß3 with bone morphogenetic proteins­6, which has synergistic effect on chondrogenesis, with an efficient platform such as exosomes, which themselves possess a chondroprotective function, offers an innovative and more efficient approach to treat injured cartilage. In addition, multiple findings stating the role of exosomes in chondroprotection has also verified a similar fact showing exosomes may be a more favorable choice than the source itself. In the present review, the importance of TGF­ß family in OA and the possibility of therapeutic treatment using stem cell­derived exosomes are described.

Efficacy of Adductor Canal Block on Medial Knee Pain in Patients with Knee Osteoarthritis: A Randomized Single-Blind Placebo-Controlled Study.

BACKGROUND: This study aimed to confirm the efficacy of ultrasound-guided adductor canal block (ACB) as a treatment option for medial knee pain caused by knee osteoarthritis (KOA). METHODS: In total, 31 participants with medial knee pain due to KOA were randomized to either the ACB (ultrasound-guided ACB, n = 15) or placebo group (1 mL of 1% lidocaine, n = 16). The primary outcome was a numerical rating scale (NRS) for knee pain intensity comparing before and 4 weeks after injection. The secondary outcomes were the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), average daily number of analgesics consumed, average daily opioid consumption, and Timed Up and Go (TUG) test results before and 4 weeks after injection. RESULTS: Participants' baseline characteristics were not significantly different between the groups, except for age. At 4 weeks post-injection, the NRS score in the ACB group significantly improved compared to that in the placebo group (p = 0.009). However, the WOMAC, average daily number of analgesics consumed, average daily opioid consumption, and TUG test results did not show significant differences. CONCLUSION: ACB can be an effective treatment for reducing medial knee pain in patients with KOA.

Cultural validation and language translation of the scientific SCI exercise guidelines for use in Indonesia, Japan, Korea, and Thailand.

CONTEXT: Indonesia, Japan, Korea, Thailand. OBJECTIVE: To culturally validate and translate the Scientific Exercise Guidelines for Adults with Spinal Cord Injury (SEG-SCI) for use in four Asian countries. DESIGN: Systematic Review. PARTICIPANTS: N/A. METHODS: A systematic review was conducted to identify all published English- and local-language studies conducted in Indonesia, Japan, Korea, and Thailand, testing the effects of exercise training interventions on fitness and cardiometabolic health in adults with acute or chronic SCI. Protocols and results from high-quality controlled studies were compared with the SEG-SCI. Forward and backward translation processes were used to translate the guidelines into Bahasa Indonesian, Japanese, Korean and Thai languages. RESULTS: Fifteen studies met the review criteria. At least one study from each country implemented exercise prescriptions that met or exceeded the SEG-SCI. Two were controlled studies. In those two studies, relative to control conditions, participants in exercise conditions achieved significant improvements in fitness or cardiometabolic health outcomes only when the exercise intervention protocol met or exceeded the SEG-SCI. During the language translation processes, end-users confirmed that SEG-SCI language and terminology were clear. CONCLUSION: Clinical researchers in Indonesia, Japan, Korea and Thailand have implemented exercise protocols that meet or exceed the SCI-SEG. Results of high-quality studies align with the SEG-SCI recommendations. Based on this evidence, we recommend that the SEG-SCI be adopted in these countries. The cultural validation and translation of the SEG-SCI is an important step towards establishing consistent SCI exercise prescriptions in research, clinical and community settings around the world.

Comparison of high- and low-dose corticosteroid in subacromial injection for periarticular shoulder disorder: a randomized, triple-blind, placebo-controlled trial.

OBJECTIVE: To determine whether subacromial injection with high-dose corticosteroid in patients with periarticular shoulder disorders is better than low-dose corticosteroid or placebo in improving pain, function, and active range of motion (AROM). DESIGN: Multicenter, randomized, triple-blind, placebo-controlled trial. SETTING: Primary (n=2) and university-affiliated (n=1) tertiary-care hospitals. PARTICIPANTS: Volunteers (N=79) with periarticular shoulder disorders with at least 1 month's duration of pain. INTERVENTION: Participants were randomly assigned to receive ultrasound-guided subacromial injection with triamcinolone acetonide, 40 or 20mg, or placebo. After a single injection, participants were followed up for 8 weeks. MAIN OUTCOME MEASURES: Visual analog scale (VAS) of average shoulder pain level during the past 1 week, Shoulder Disability Questionnaire (SDQ), and angles of shoulder AROM (including flexion, abduction, external rotation, internal rotation) pre- and posttreatment at weeks 2, 4, and 8. RESULTS: There were no significant differences among the 3 groups (triamcinolone acetonide, 40mg, group 1, n=27; triamcinolone acetonide, 20mg, group 2, n=25; placebo, group 3, n=27) in terms of demographic and clinical characteristics at baseline. (1) Within-group comparison: VAS score, SDQ score, and AROM for groups 1 and 2 significantly improved at weeks 2, 4, and 8 (P<.0167). However, there was no difference in VAS score, SDQ score, and AROM scores for group 3. (2) Between-group comparison: significant differences in VAS score, SDQ score, and abduction, external rotation, and internal rotation of AROM were shown between groups 1 and 2 and group 3 at weeks 2, 4, and 8 (P<.05). CONCLUSIONS: This was the first study to assess the efficacy of corticosteroid according to 2 different doses, which are the most widely used in subacromial injection for participants with periarticular shoulder disorders. This study showed no significant differences between the high- (triamcinolone acetonide, 40mg) and low-dose (20mg) corticosteroid groups, indicating preferred use of a low dose at the initial stage.

Functional improvement of bilateral frozen shoulder by unilateral intra-articular corticosteroid injection: a retrospective study.

OBJECTIVE: Bilateral frozen shoulder (FS) is often treated with intra-articular corticosteroid injection (IACI). No studies have been performed to establish whether IACI must be administered in both shoulders or in only one shoulder to improve function. This study was therefore performed to determine whether unilateral IACI improves shoulder pain and passive range of motion (pROM) in bilateral FS. METHODS: The medical records of 165 patients with bilateral primary FS who underwent ultrasonography-guided IACI (2 mL of 10-mg/mL triamcinolone acetonide mixed with 5 mL of 1% lidocaine) in one shoulder were retrospectively reviewed. The outcome measures, namely the numeric rating scale (NRS) scores and pROM values (abduction, external rotation, flexion, hyperextension, and internal rotation), were evaluated pre- and post-injection. RESULTS: The patients' mean age was 54.0 ± 8.0 years. The mean symptom duration was 6.5 ± 2.8 months. The mean follow-up period after injection was 6.7 ± 0.8 weeks. The NRS scores and pROM values significantly improved in both the injected and non-injected shoulders. CONCLUSIONS: This study showed that unilateral IACI in patients with bilateral FS improves the clinical outcome of the non-injected shoulder. We suggest that physicians observe the non-injected shoulder after unilateral injection rather than performing bilateral injections.

Use of botulinum toxin type A injection for neuropathic pain after trigeminal nerve injury.

OBJECTIVE: To present a case that neuropathic pain following traumatic injury of the inferior alveolar nerve, which was relieved by the injection of BTX-A. DESIGN: Case report. SETTING: Tertiary care University hospital. SUBJECT: A 62-year-old female was referred by her general dentist to our clinic due to numbness and pain over the left side of her lower lip and chin region. INTERVENTION: Botulinum toxin type A injected into the middle of chin area subcutaneously. RESULTS: At 1 month after BTX-A injection, the affected area had decreased in size. And at 2 months, the patient reported a slight decreased in pain, and CPT differences being sustained at a reduced level. CONCLUSIONS: This case report suggests an effective new modality for treating neuropathic pain after trigeminal nerve injury. A further randomized controlled study involving a large number of patients is needed.