Early functional factors for predicting outcome of independence in daily living after stroke: a decision tree analysis

OBJECTIVE

This study aimed to investigate the predictive functional factors influencing the acquisition of basic activities of daily living performance abilities during the early stages of stroke rehabilitation using classification and regression analysis trees.

METHODS

The clinical data of 289 stroke patients who underwent rehabilitation during hospitalization (164 males; mean age: 62.2 ± 13.9 years) were retrospectively collected and analysed. The follow-up period between admission and discharge was approximately 6 weeks. Medical records, including demographic characteristics and various functional assessments with item scores, were extracted. The modified Barthel Index on discharge served as the target outcome for analysis. A "good outcome" was defined as a modified Barthel Index score ≥ 75 on discharge, while a modified Barthel Index score < 75 was classified as a "poor outcome."

RESULTS

Two classification and regression analysis tree models were developed. The first model, predicting activities of daily living outcomes based on early motor functions, achieved an accuracy of 92.4%. Among patients with a "good outcome", 70.9% exhibited (i) ≥ 4 points in the "sitting-to-standing" category in the motor assessment scale and (ii) 32 points on the Berg Balance Scale score. The second model, predicting activities of daily living outcome based on early cognitive functions, achieved an accuracy of 82.7%. Within the "poor outcome" group, 52.2% had (i) ≤ 21 points in the "visuomotor organization" category of Lowenstein Occupational Therapy Cognitive Assessment, (ii) ≤ 1 point in the "time orientation" category of the Mini Mental State Examination.

CONCLUSION

The ability to perform "sitting-to-standing" and visuomotor organization functions at the beginning of rehabilitation emerged as the most significant predictors for achieving successful basic activities of daily living on discharge after stroke.

Comparison of biomechanical parameters in lower limb joints of stroke patients according to conventional evaluation scores during level walking

Objective: Patients with chronic stroke capable of independent gait were classified into functional ambulation category (FAC) 4 or 5, and the kinetic and kinematic data on their lower limb joints on the affected and unaffected sides were compared with that of healthy individuals. Finally, the qualitative changes in the gait of patients with stroke were investigated based on the differences in FAC scores. Methods: Twelve healthy participants and 19 patients with stroke capable of independent gait were included. The three-dimensional (3D) motion analysis and conventional assessment were conducted for all patients with stroke. Results: The FAC 5 group exhibited a larger range of motion (ROM) than the FAC 4 group in knee and hip joints on the affected side and only in the hip on the unaffected side. In the FAC 5 group, ROM differences in the healthy group on either the affected or unaffected side were absent. The peak of the hip flexion moment on the affected side in both the FAC 4 and 5 groups was smaller than that in the healthy group and in the FAC 4 group on the unaffected side. The absorption power minimum on the affected side was smaller only in the FAC 4 group than that in the healthy group and was larger in the FAC 5 group than that in the FAC 4 group. On the unaffected side, the absorption power minimum was smaller only in the FAC 4 group than that in the healthy group. Conclusion: Functional differences in gait were found in patients classified based on conventional evaluation capable of independent gait after post-stroke rehabilitation. Patients may not exhibit complete recovery in the kinetic indices even if they are judged to be normal in the conventional evaluation, and the kinematic gait indices indicate recovery. Evaluating kinetic indices in addition to kinematic indices is necessary, and joint power may be an especially useful index.

Energy absorption at lower limb joints in different foot contact strategies while descending stairs

BACKGROUND:

Joint loads in different walking strategies during stair descent have been investigated in terms of the joint moment in association with the risk of osteoarthritis. However, the absorption mechanisms of the potential energy loss are not known.

OBJECTIVE:

This study aims to compare the mechanical energy absorptions in lower limb joints in different initial foot contact strategies.

METHODS:

Nineteen young subjects walked down on instrumented stairs with two different strategies, i.e., forefoot and rearfoot strike. Power and energy at lower limb joints during stance phase were compared between strategies.

RESULTS:

Lower limb joints absorbed 73 ± 11% of the potential energy released by descending stairs and there was no difference between strategies. Rearfoot strategy absorbed less energy than forefoot strategy at the ankle joint in the 1st phase, which was compensated mainly by more energy absorption at the knee in the 2nd phase and less energy generation at the hip joints in the 3rd phase.

CONCLUSION:

The results suggest that a leg absorbs most of the potential energy while descending stairs irrespective of the walking strategies and that any reduction of energy absorption at one joint is compensated by other joints. Greater energy absorption at the knee joint compared to the other joints suggests high burden of knee joint muscles and connective tissues during stair-descent, which is even more significant for the rearfoot strike strategy.

The effect of sitting posture on the loads at cervico-thoracic and lumbosacral joints

BACKGROUND:

The sitting in an awkward posture for a prolonged time may lead to spinal or musculoskeletal disease. It is important to investigate the joint loads at spine while sitting.

OBJECTIVE:

The purpose of this study was to investigate the joint moment and antero-posterior (AP) reaction force at cervico-thoracic and lumbosacral joint for various sitting postures.

METHODS:

Twenty healthy males participated in this study. Six sitting postures were defined from three spinal curvatures (slump, flat, and lordosis) and two arm postures (arms-on-chest and arms-forward). Kinematic and kinetic data were measured in six sitting postures from which joint moment and AP reaction force were calculated by inverse dynamics.

RESULTS:

In the cervico-thoracic joint, joint moment and AP reaction force were greater in slump than the flat and lordosis postures (p< 0.001) and also in arms-forward posture compared to arms-on-chest posture. In the lumbosacral joint, joint moment and AP reaction force were greater in slump than flat and lordotic posture (p< 0.001) but there was no difference between different arm postures. The joint loads (moment and AP reaction force) at the cervico-thoriacic joint were closely related to the head flexion angle (r> 0.86) while those at the lumbosacral joint were correlated to the trunk flexion angle (r> 0.77). In slump posture, the joint moments were close to or over the extreme of the daily life such as sit-to-stand and walking. Consequently, if the slump is continued for a long time, it may cause pain and diseases at the cervico-thoracic and lumbosacral joints.

CONCLUSIONS:

The results of the study indicated that the lordosis or flat would be better spinal postures. Also, keeping arms close to body would be desirable to reduce joint loads.

A practical method for the detection of freezing of gait in patients with Parkinson's disease

Purpose

Freezing of gait (FOG), increasing the fall risk and limiting the quality of life, is common at the advanced stage of Parkinson’s disease, typically in old ages. A simple and unobtrusive FOG detection system with a small calculation load would make a fast presentation of on-demand cueing possible. The purpose of this study was to find a practical FOG detection system.

Patients and methods

A sole-mounted sensor system was developed for an unobtrusive measurement of acceleration during gait. Twenty patients with Parkinson’s disease participated in this study. A simple and fast time-domain method for the FOG detection was suggested and compared with the conventional frequency-domain method. The parameters used in the FOG detection were optimized for each patient.

Results

The calculation load was 1,154 times less in the time-domain method than the conventional method, and the FOG detection performance was comparable between the two domains (P=0.79) and depended on the window length (P<0.01) and dimension of sensor information (P=0.03).

Conclusion

A minimally constraining sole-mounted sensor system was developed, and the suggested time-domain method showed comparable FOG detection performance to that of the conventional frequency-domain method. Three-dimensional sensor information and 3–4-second window length were desirable. The suggested system is expected to have more practical clinical applications.

Analysis of antagonistic co-contractions with motorized passive movement device in patients with Parkinson's disease

Patients with Parkinson's disease (PD) suffer from an increased resistance to passive movement of a joint, called as rigidity. Stretch reflex and shortening reaction were suggested to be associated to the rigidity, however, the mechanism is still poorly understood. We hypothesized that the co-contraction of antagonistic muscle pairs is enhanced in patients with PD and this induces resistance persisting throughout its range of motion. To test the hypothesis, we developed a motorized device for application of passive movement of the wrist joint and investigated the co-contraction of muscles during passive movement. It consisted of a servo motor connected to a rotating axis with a timing belt, load cell for the measurement of resistance, and other elements for the fixation of arm and hand. Repetitive passive movement was applied to the wrist joint of patients. Co-contraction of antagonistic muscle pairs was significantly greater in patients than in normal subjects (p<0.001), suggesting that the enhanced co-contraction is associated with the mechanical resistance during passive movement, i.e. rigidity. Co-contraction during extended state was greater than the other states (p<0.001), which implies that the length-feedback mechanism may play the important role in co-contraction.

Quantitative evaluation of parkinsonian rigidity during intra-operative deep brain stimulation

This study aims at the quantification of fine change in parkinsonian rigidity at the wrist during deep brain stimulation (DBS) using a portable measurement system and objective mechanical measures. The rigidity of fourteen limbs was evaluated during DBS surgery. The resistive torque to imposed movement was measured for every setting where a reduction in rigidity was perceived by a neurologist. Quantitative mechanical measures derived from experimental data included viscoelastic properties, work, impulse and mechanical impedance. Most mechanical measures could discriminate the optimal setting from baseline (electrode at stereotactic initial position without electrical stimulation) and the highest significance was achieved by viscous damping constant (p<0.001). Spearman correlation coefficients between mechanical measures and clinical score for multiple settings (averaged for 14 limbs) were 0.51-0.77 and the best correlation was shown for viscosity (ρ=0.77 ± 0.22). The results suggest that intraoperative quantification of rigidity during DBS surgery is possible with the suggested system and measures, which would be helpful for the adjustment of electrode position and stimulation parameters.

Relevance of hepatoduodenal ligament lymph nodes in resectional surgery for gastric cancer

BACKGROUND

Hepatoduodenal lymph node (HDLN) positivity is considered distant metastasis in gastric cancer according to the seventh American Joint Committee on Cancer (AJCC) classification. In contrast, the International Union Against Cancer seventh edition and the Japanese Gastric Cancer Association both consider HDLN as a regional lymph node that can be included in the context of a curative resection. The purpose of this study was to determine whether there was justification for considering HDLN involvement as a distant metastasis for which resectional surgery could not have survival benefit.

METHODS

This study enrolled consecutive patients with gastric cancer having D2 or greater resections, with removal and pathological assessment of the HDLN, between 1989 and 2009. The pathological stage of all patients was determined based on the seventh AJCC criteria, with HDLN included as a regional lymph node.

RESULTS

A total of 1872 patients had their HDLN removed, of whom 68 had a metastatic lymph node in the hepatoduodenal ligament. The 5-year survival rate of these 68 patients was 30 per cent, compared with 47·7 per cent for those with stage III (P < 0·001) and 9·8 per cent for those with stage IV (P = 0·007) HDLN-negative tumours. The 5-year survival rate of 41 patients with HDLN metastasis and no evidence of distant metastasis at any other site was significantly higher than that among 120 patients with stage IV disease without HDLN metastasis (P < 0·001), whereas 5-year survival did not differ between the 41 patients with stage I-III disease with HDLN metastasis and 568 patients with stage III tumours without HDLN metastasis (P = 0·184). HDLN metastasis was not a significant factor for survival in multivariable analysis.

CONCLUSION

It is inappropriate to include the HDLN in the distant metastatic lymph node group in gastric cancer. The seventh AJCC criteria for node grouping should be revised.

Morphology and metabolism of hepatocytes microencapsulated with acrylic terpolymer-alginate using gelatin and poly(vinyl alcohol) as extracellular matrices

Microcapsules with good mechanical stability were prepared using an appropriate mixture of alginate and acrylic terpolymer. It was found from the microscopic observation that the microcapsules had a porous structure with interconnected pores, with a size of 50-150 nm. The results of the permeability experiment of microcapsules using FITC-dextrans showed that the capsule had a molecular mass cut-off of 120 kDa. The hepatocytes encapsulated in both alginate and acrylic terpolymer with gelatin and PVA rapidly aggregated in the core. The aggregated cells showed high albumin synthesis and ammonia removal, suggesting good metabolic function.

The role of small intestinal bacterial overgrowth in postgastrectomy patients

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is expected in postgastrectomy patients; however, its role has not been clarified. This study was to estimate the prevalence of SIBO and investigate the clinical role of SIBO in postgastrectomy patients.

METHODS

This prospective study involved 76 patients who underwent gastrectomy for early gastric cancer with no evidence of recurrence. An H(2)-CH(4) breath test with oral glucose challenge test was performed to diagnose SIBO and dumping syndrome. Sigstad dumping questionnaires, serum glucose, hematocrit and pulse rate were simultaneously monitored for every 30 min for 3 hours.

KEY RESULTS

There were significant differences in SIBO between the postgastrectomy patients and controls (77.6%vs 6.7%, P < 0.01). Abdominal fullness or borborygmus during oral glucose load were more common in SIBO-positive than in negative patients (50.8%vs 17.6%, P = 0.03), and were the independent factors for predicting SIBO in postgastrectomy patients (P = 0.02). The prevalences of dumping syndrome and hypoglycemia after oral glucose were 35 (46.1%) and 19 (25.0%), and were not different between both groups. However, the plasma glucose was significantly lower in SIBO-positive than in SIBO-negative patients at 120 and 150 min after oral glucose load (P < 0.05). No significant differences were observed in pulse rate and hematocrit in both groups.

CONCLUSIONS & INFERENCES

SIBO is common among postgastrectomy patients. It appears to be associated with postprandial intestinal symptoms and might aggravate late hypoglycemia. SIBO could be a new therapeutic target for managing intestinal symptoms in postgastrectomy patients.

The role of small intestinal bacterial overgrowth in postgastrectomy patients

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is expected in postgastrectomy patients; however, its role has not been clarified. This study was to estimate the prevalence of SIBO and investigate the clinical role of SIBO in postgastrectomy patients.

METHODS

This prospective study involved 76 patients who underwent gastrectomy for early gastric cancer with no evidence of recurrence. An H(2)-CH(4) breath test with oral glucose challenge test was performed to diagnose SIBO and dumping syndrome. Sigstad dumping questionnaires, serum glucose, hematocrit and pulse rate were simultaneously monitored for every 30 min for 3 hours.

KEY RESULTS

There were significant differences in SIBO between the postgastrectomy patients and controls (77.6%vs 6.7%, P < 0.01). Abdominal fullness or borborygmus during oral glucose load were more common in SIBO-positive than in negative patients (50.8%vs 17.6%, P = 0.03), and were the independent factors for predicting SIBO in postgastrectomy patients (P = 0.02). The prevalences of dumping syndrome and hypoglycemia after oral glucose were 35 (46.1%) and 19 (25.0%), and were not different between both groups. However, the plasma glucose was significantly lower in SIBO-positive than in SIBO-negative patients at 120 and 150 min after oral glucose load (P < 0.05). No significant differences were observed in pulse rate and hematocrit in both groups.

CONCLUSIONS & INFERENCES

SIBO is common among postgastrectomy patients. It appears to be associated with postprandial intestinal symptoms and might aggravate late hypoglycemia. SIBO could be a new therapeutic target for managing intestinal symptoms in postgastrectomy patients.

Impact of tumor infiltration pattern into the surrounding tissue on prognosis of the subserosal gastric cancer (pT2b)

BACKGROUND

The aim of this study was to clarify the impact of infiltration pattern on prognosis in patients with gastric carcinoma invading subserosa.

METHODS

Clinicopathologic findings in patients with ssgamma pattern (n = 144) were compared with those in patients with ssalpha/ssbeta cancers (n = 222). Prognostic factors of pT2b patients were analyzed by univariate and multivariate analysis.

RESULTS

Compared with the ssalpha/beta group, ssgamma gastric cancer exhibited more frequent undifferentiated histology, disseminated lymph node metastasis and perineural invasion. Frequency of postoperative peritoneal recurrence was significantly higher in ssgamma gastric cancer (P < 0.05). The 5-year survival rate for patients with ssgamma gastric cancer was significantly lower compared with ssalpha/beta group (63.2% vs. 74.8%, respectively; P < 0.05). Lymph node metastasis, vein invasion and infiltrative pattern (ssgamma) were significant independent prognostic factors affecting survival in pT2b patients.

CONCLUSION

In patients with gastric cancer invading the subserosa, infiltrative type growth pattern is closely related to carcinomatosis and poorer prognosis.

Clinical Analysis of PTEN, p53 and Her-2/neu Expressions in Thyroid Cancers

PURPOSE

The dual-specificity phosphatase PTEN/ MMAC1/TEP1 has recently been identified as the tumor suppressor gene most frequently mutated and/or deleted in human tumors. However, PTEN mutations have rarely been detected in sporadic thyroid cancers. Therefore, this study investigated the PTEN expression of thyroid cancer and the relationship between PTEN, clinical status and other biologic factors such as HER-2/neu and p53.

MATERIALS AND METHODS

The study samples consisted of 62 thyroid cancer specimens and 24 benign thyroid tumor specimens from patients who were operated on the Department of Surgery, Uijongbu St. Mary's hospital during the 5 years from January 1995 until January 2000. All tumors were studied by immunohistochemical staining using monoclonal antibodies against PTEN, HER-2/neu and p53. The results were analyzed statistically.

RESULTS

PTEN protein was found to be under-expressed more frequently in thyroid cancers (29%) than in benign thyroid tumors (4.2%). The reduction in PTEN expression in thyroid cancers was not significantly related with the recorded clinical factors such as size, age, lymph node metastasis and p53, except for HER-2 which was found to be significantly related (p=0.001). HER-2 over- expression was noted in thyroid cancer (83.8%) more frequently than in benign tumors (16.7%).

CONCLUSION

This study has demonstrated that the under-expression of PTEN protein and the over-expression of HER-2 protein may play a role in the carcinogenesis and development of thyroid cancer.

Pharyngo-enteral anastomosis for esophageal reconstruction in diffuse corrosive esophageal stricture

BACKGROUND

Diseases involving the entire esophagus usually require extensive surgical procedures to accomplish functional reconstruction. These procedures are extremely stressful for undernourished patients. We have utilized a simpler procedure for total esophageal reconstruction.

METHODS

This retrospective report reviews the experience in 8 patients who underwent esophageal reconstruction by pharyngo-colo-gastrostomy or jejunostomy without any resection of bony structures.

RESULTS

There was no operative or hospital death. Complications included anastomotic stenosis, transient leak from the ileal stump, and late enterocutaneous fistula, each in 1 patient. Laryngeal function was maintained without special treatments. After swallowing training for approximately 1 week, oral feeding was resumed. All patients have gained 7 to 21 kg at 35 to 67 months after surgery.

CONCLUSIONS

Our surgical procedure is shown to be safe and effective in undernourished patients with diffuse esophageal stricture.

A clinical analysis of gasless endoscopic thyroidectomy

Gasless endoscopic surgery was applied to a thyroidectomy. Compared with the previous method of endoscopic thyroidectomy, this method is superior in obtaining hemostasis and minimizing the possible complications of gas-insufflating surgery, such as a hypercapnia or massive subcutaneous emphysema. We successfully removed 37 thyroid tumors in 35 patients by gasless endoscopic surgery without any significant complications. No scars remained in the neck, and all patients were satisfied with the cosmetic results. Gasless endoscopic thyroidectomy is a safe and technically feasible alternative to conventional thyroidectomy for cases of benign thyroid tumors and has good cosmetic results.

Toxic amebic colitis coexisting with intestinal tuberculosis

A patient with a fulminant amebic colitis coexisting with intestinal tuberculosis had a sudden onset of crampy abdominal pain, mucoid diarrhea, anorexia, fever and vomiting with signs of positive peritoneal irritation. Fulminant amebic colitis occurring together with intestinal tuberculosis is an uncommon event and may present an interesting patho-etiological relationship. The diagnosis was proven by histopathologic examination of resected specimen. Subtotal colectomy including segmental resection of ileum, about 80 cm in length, followed by exteriorization of both ends, was performed in an emergency basis. Despite all measures, the patient died on the sixth postoperative day. The exact relationship of fulminant amebic colitis and intestinal tuberculosis is speculative but the possibility of a cause and effect relationship exists. Fulminant amebic colitis may readily be confused with other types of inflammatory bowel disease, such as idiopathic ulcerative colitis, Crohn's disease, perforated diverticulitis and appendicitis with perforation. This report draws attention to the resurgence of tuberculosis and amebiasis in Korea, and the need for the high degree of caution required to detect it.

Laparoscopic procedures during the third trimester of pregnancy

Pregnancy no longer is considered to be an absolute contraindication for laparoscopic procedures. Furthermore, clinically helpful guidelines are in place for laparoscopic procedures during pregnancy. However, laparoscopic operations in women in the third trimester have not yet been reported fully. We successfully operated on torsion of an ovarian cyst in a woman during her third trimester using laparascopic procedure. The patient experienced an uneventful recovery.

Ileo-rectal fistula complicating advanced ovarian carcinoma

Fistula between the bowels and an ovarian carcinoma is recognized but rare complication. Internal malignant fistula of the gastrointestinal tract involving two or more loops of different segments of the bowel and genitourinary structure are rare. The colon is frequently one of the participating loops. In reviewing the literature, however, we were unable to find a previous report of ileo-rectal fistula as a complication of an ovarian carcinoma. A case report and review of the English medical literature are presented with emphasis on the cause, clinical presentation, and management of advanced ovarian cancer with ileo-rectal involvement.

Enhanced adenoviral transduction efficiency in HER-2/neu-overexpressing human breast cancer cells not induced by an integrin pathway

Adenoviruses are currently widely used as vectors in gene therapy. The steps involved in adenoviral infection have been investigated, but the factors regulating viral entry to the cell have not been clearly identified. We observed a high adenoviral infection rate in HER-2/neu-overexpressing breast cancer cells in vitro (435.eb1 and MCF-7/H18) and in vivo (435.eb1). We used emodin, a tyrosine kinase inhibitor that suppresses autophosphorylation and transphosphorylation activities of the HER-2/neu tyrosine kinase, to test the role of HER-2/neu in adenoviral transduction. Emodin treatment resulted in a marked decrease in the transduction efficiency of HER-2/neu-overexpressing cells but not in the parental cells. Because previous studies have shown that epidermal growth factor and tumor growth factor-alpha increase the expression level of integrin. Because integrin alphav is known as a promotor of viral internalization, penetration, or both, we investigated whether the observed increased transduction rate in HER-2/neu transfectants was mediated through the increased expression of integrin alphav. To test this hypothesis, we examined the level of integrin alphav of in HER-2/neu overexpressing cells. We found that the level of integrin alphav expression detected in HER-2/neu overexpressing cells by immunoblot analysis was similar to the level of integrin alphav found in its parental cells. These results suggest that HER-2/neu expression may have a significant role in the viral transduction efficiency through an integrin alphav independent pathway.

Late development of umbilical metastasis after laparoscopic cholecystectomy for a gallbladder carcinoma

A periumbilical mass developed 47 months after laparoscopic cholecystectomy. Pathologic examination of this mass showed features of moderately differentiated papillary adenocarcinoma, similar to that identified within the previously removed early stage (pT1b) gallbladder carcinoma. The cause of this <late type recurrence> at the laparoscope port is unclear. <Late type recurrence> after laparoscopic cholecystectomy for gallbladder carcinoma has not been reported previously. We reported a case with late periumbilical tumor seeding at the navel trocar insertion site in a 65-year-old female. A review of the preventative information of tumor recurrence and management is discussed. The use of gasless laparoscopy, slow desufflation, trocar site washout, wound protector and specimen bags are recommended.

Mutation of the hMSH2 gene in two families with hereditary nonpolyposis colorectal cancer

We examined 18 unrelated individuals who have colorectal cancer or cancers associated with the HNPCC syndrome and have a family history of cancer for mutations in exon 13 of the hMSH2 gene. Two of the 18 individuals had the same previously unreported single-base deletion in codon 705 of hMSH2, resulting in a frame-shift mutation. Two other individuals had a T-to-C base change in the intron sequence at -6 position of the splice acceptor site at the 5' end of exon 13 which has previously been reported to be a polymorphism found in normal individuals (Leach et al., 1993). Nucleotide sequence changes were not detected in the remaining 14 individuals. We examined DNA from additional family members of the two subjects with codon 705 mutations. Of these, two individuals were identified with the mutation who were older than 50 years and who are apparently cancer free. The occurrence of breast cancer in both families (including one individual with a confirmed codon 705 mutation) suggests that breast cancer may be a part of the HNPCC syndrome. This is the first study to describe mutations in the hMSH2 gene in families that do not fit the definition of HNPCC. Because both families with the mutations at codon 705 failed to meet the Amsterdam criteria for HNPCC (Vasen et al., Dis Colon Rectum 34:424-425, 1991), our findings suggest that these criteria should now be reconsidered for purposes of diagnosis of HNPCC.