Deletion of adipose triglyceride lipase abolishes blood flow increase after β3-adrenergic stimulation in visceral adipose tissue of mice

Dynamic changes in adipose tissue blood flow (ATBF) with nutritional status play a role in the regulation of metabolic and endocrine functions. Activation of the sympathetic nervous system via β-adrenergic receptors (β-AR) contributes to the control of postprandial enhancement of ATBF. Herein, we sought to identify the role of each β-AR subtype in the regulation of ATBF in mice. We monitored the changes in visceral epididymal ATBF (VAT BF), induced by local infusion of dobutamine, salbutamol, and CL316,243 (a selective β1-, β2-, and β3-AR agonist, respectively) into VAT of lean CD-1 mice and global adipose triglyceride lipase (ATGL) knockout (KO) mice, using laser Doppler flowmetry. Administration of CL316,243, known to promote lipolysis in adipocytes, significantly increased VAT BF of CD-1 mice to a greater extent compared to that of the vehicle, whereas administration of dobutamine or salbutamol did not produce significant differences in VAT BF. The increase in VAT BF induced by β3-AR stimulation disappeared in ATGL KO mice as opposed to their wild-type (WT) littermates, implying a role of ATGL-mediated lipolysis in the regulation of VAT BF. Different vascular reactivities occurred despite no significant differences in vessel density and adiposity between the groups. Additionally, the expression levels of the angiogenesis-related genes were significantly higher in VAT of ATGL KO mice than in that of WT, implicating an association of ATBF responsiveness with angiogenic activity in VAT. Our findings suggest a potential role of β3-AR signaling in the regulation of VAT BF via ATGL-mediated lipolysis in mice.

Deletion of adipose triglyceride lipase abolishes blood flow increase after β3-adrenergic stimulation in visceral adipose tissue of mice

Dynamic changes in adipose tissue blood flow (ATBF) with nutritional status play a role in the regulation of metabolic and endocrine functions. Activation of the sympathetic nervous system via β-adrenergic receptors (β-AR) contributes to the control of postprandial enhancement of ATBF. Herein, we sought to identify the role of each β-AR subtype in the regulation of ATBF in mice. We monitored the changes in visceral epididymal ATBF (VAT BF), induced by local infusion of dobutamine, salbutamol, and CL316,243 (a selective β1-, β2-, and β3-AR agonist, respectively) into VAT of lean CD-1 mice and global adipose triglyceride lipase (ATGL) knockout (KO) mice, using laser Doppler flowmetry. Administration of CL316,243, known to promote lipolysis in adipocytes, significantly increased VAT BF of CD-1 mice to a greater extent compared to that of the vehicle, whereas administration of dobutamine or salbutamol did not produce significant differences in VAT BF. The increase in VAT BF induced by β3-AR stimulation disappeared in ATGL KO mice as opposed to their wild-type (WT) littermates, implying a role of ATGL-mediated lipolysis in the regulation of VAT BF. Different vascular reactivities occurred despite no significant differences in vessel density and adiposity between the groups. Additionally, the expression levels of the angiogenesis-related genes were significantly higher in VAT of ATGL KO mice than in that of WT, implicating an association of ATBF responsiveness with angiogenic activity in VAT. Our findings suggest a potential role of β3-AR signaling in the regulation of VAT BF via ATGL-mediated lipolysis in mice.

Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema / 한국유방암학회지

Purpose@#Sentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm. @*Methods@#Prospectively collected medical records of 910 patients were reviewed.Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic. @*Results@#Together with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs.breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p = 0.111). @*Conclusion@#The risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.

Association between Number of Retrieved Sentinel Lymph Nodes and Breast Cancer-related Lymphedema / 한국유방암학회지

Purpose@#Sentinel lymph node biopsy (SLNB) has become a standard axillary staging surgery for early breast cancer, and the proportion of patients requiring axillary lymph node dissection (ALND) is decreasing. We aimed to evaluate the association between the number of sentinel lymph nodes (SLNs) retrieved and the risk of lymphedema of the ipsilateral arm. @*Methods@#Prospectively collected medical records of 910 patients were reviewed.Lymphedema was defined as a difference in circumference > 2 cm compared to the contralateral arm and/or having clinical records of lymphedema treatment in the rehabilitation clinic. @*Results@#Together with an objective and subjective assessment of lymphedema, 36 patients (6.1%) had lymphedema in the SLNB group and 85 patients (27.0%) had lymphedema in the ALND group (p < 0.001). In a multivariate analysis of the whole cohort, risk factors significantly associated risk with the development of lymphedema were body mass index, mastectomy (vs.breast-conserving surgery), ALND, and radiation therapy. In logistic regression models in the SLNB group only, there was no correlation between the number of retrieved SLNs and the incidence of lymphedema. In addition, in the Pearson correlation analysis, no correlation was observed between the number of retrieved SLNs and the difference in circumference between the ipsilateral and contralateral upper extremities (correlation coefficients = 0.067, p = 0.111). @*Conclusion@#The risk of lymphedema in breast cancer surgery and adjuvant treatments is multifactorial. The number of retrieved lymph nodes during sentinel biopsy was not associated with the incidence of lymphedema.

Correction: Effect of an Inpatient Rehabilitation Program for Recovery of Deconditioning in Hematologic Cancer Patients After Chemotherapy

After publication of the article, the authors found two errors of funding acknowledgment and IRB number.

Effect of an Inpatient Rehabilitation Program for Recovery of Deconditioning in Hematologic Cancer Patients After Chemotherapy

OBJECTIVE: To investigate the effect of a rehabilitation program in terms of De Morton Mobility Index (DEMMI) score, in hematologic cancer patients after chemotherapy. METHODS: Hematologic cancer patients admitted for chemotherapy were reviewed. They received a rehabilitation program during their hospital stay. DEMMI score measurement was performed, before and after rehabilitation. Demographics, diagnosis, chemotherapy information, rehabilitation program duration, mortality, body mass index (BMI), and laboratory test results were collected. For analysis, patients were classified according to diagnosis (multiple myeloma, leukemia, and others), mortality, and additional chemotherapy. RESULTS: There was statistically significant improvement in DEMMI score of 10.1 points (95% confidence interval, 5.9–14.3) after rehabilitation. It was more evident in the multiple myeloma group, and they revealed less mortality. When patients were divided according to mortality, survivors received the program earlier, and in a shorter period than in mortality cases. Although survivors revealed higher initial DEMMI score, improvement after rehabilitation did not differ significantly. CONCLUSION: In hematologic cancer patients, rehabilitation program was effective for recovery from deconditioning, revealing significant increase in DEMMI score. Multiple myeloma patients may be good candidates for rehabilitation. Rehabilitation could be sustained during chemotherapy and for high-risk patients.

Current Practice and Barriers in Cancer Rehabilitation: Perspectives of Korean Physiatrists / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to assess clinical practice and barriers associated with cancer rehabilitation from the perspective of Korean physiatrists. MATERIALS AND METHODS: All active members of the Korean Academy of Rehabilitation Medicine were invited to complete an online survey developed after focus group discussions. RESULTS: A total of 97 physiatrists (72 males and 25 females) in Korea completed the survey. Of these, 77% reported familiarity with the term 'cancer survivors.' More than 50% of respondents reported that they provided rehabilitation services for patients with breast cancer (61.9%), brain tumors (64.9%), and spinal tumors (63.9%), whereas 86.6% of respondents reported that they had never or rarely provided rehabilitation programs for patients with gynecological, colorectal, or prostate cancer. Physiatrists who received referrals from a well-organized cooperative referral system reported providing services such as exercise programs for patients with gynecological cancer (odds ratio [OR], 2.16; p=0.044) as well as education regarding lymphedema (OR, 1.81; p=0.047) and neuropathic pain (OR, 1.96; p=0.026). CONCLUSION: Although most of the physiatrists surveyed believed that they should contribute to the management of cancer patients, they considered themselves ill equipped to provide appropriate rehabilitation services. This lack of understanding of the effectiveness of rehabilitation services for cancer patients and absence of a cooperative referral system are the major barriers to providing rehabilitation services to cancer survivors in Korea.

Effect of Magnetic Stimulation in Spinal Cord on Limb Angiogenesis and Implication: A Pilot Study

OBJECTIVE: To investigate the effect of repetitive magnetic stimulation (rMS) of the spinal cord on limb angiogenesis in healthy rats and explore its implication for the treatment of lymphedema. METHOD: Twelve adult male Sprague-Dawley rats were divided into four groups as follows: sham rMS followed by tissue harvest 5 minutes later (group 1, n=2), 1 Hz rMS and tissue harvest 5 minutes later (group 2, n=3), 20 Hz rMS and tissue harvest 5 minutes later (group 3, n=3), 20 Hz rMS and tissue harvest 30 minutes later (group 4, n=4). Animals were treated with 20-minute rMS with 120% of the motor threshold on their left side of upper lumbar spinal cord. Expression of angiogenic factors, that is, Akt, phospho-Akt (pAkt), endothelial nitric oxide synthase (eNOS), phospho-eNOS (p-eNOS) were measured by western blot. Bilateral hindlimb muscles (quadriceps and gastrocnemius) were harvested. RESULTS: Expression of Akt in left quadriceps increased in group 4 compared with group 2 and 3 (3.4 and 5.3-fold each, p=0.026). Expression of eNOS in left plus right quadriceps markedly increased in group 3 and 4 compared with group 1 and 2 (p=0.007). Expressions of eNOS, Akt and p-eNOS, pAkt in gastrocnemius were not comparable between four groups (p>0.05). CONCLUSION: Repetitive magnetic stimulation of the spinal cord may exert an angiogenic effect closely linked to lymphangiogenesis. It has clinical implication for the possible therapy of lymphedema caused by breast, cervical or endometrial cancer operation. Future studies with the specific lymphatic endothelial cell markers are required to confirm the effect of rMS on lymphangiogenesis.

Quality of Life, Upper Extremity Function and the Effect of Lymphedema Treatment in Breast Cancer Related Lymphedema Patients

OBJECTIVE: To evaluate quality of life (QOL), upper extremity function and the effect of lymphedema treatment in patients with breast cancer related lymphedema. METHOD: The basic data comprised medical records (detailing age, sex, dominant side, location of tumor, cancer stage, operation record, cancer treatment and limb circumferences) and questionnaires (lymphedema duration, satisfaction, self-massage). Further to this, we measured upper extremity function and QOL, administered the DASH (Disabilities of Arm Shoulder and Hand outcome measure) and used the EORTC (European Organization for Research and Treatment of Cancer)-QLQ-C30 and the EORTC-QLQ-Br23. Results of these were calculated as main outcome variables. RESULTS: The questionnaire responses and arm circumferences of 59 patients with breast cancer related lymphedema were analyzed. In the DASH questionnaire, it was found that the older the lymphedema patient was, the lower their upper extremity function. On the EORTC-QLQ, patients with metastasis had significantly lower scores in physical functioning and role functioning. In terms of upper extremity circumference, there was a significant upper extremity size reduction after lymphedema treatment. CONCLUSION: There were several dissociations between some subscales of quality of life questionnaires and those of upper extremity functions. Upper extremity function was correlated with the age of breast cancer patients and QOL was influenced by M-stage. Lymphedema treatment was found to be effective in reducing edema in patients with breast cancer related lymphedema.

Predicting the Effect of Stellate Ganglion Block on the Lymphoscintigraphic Findings for Lymphedema in Post-Mastectomy Patients

OBJECTIVE: To evaluate the effect of stellate ganglion block (SGB) on the lymphoscintigraphic findings in patients with secondary lymphedema after breast cancer treatment. METHOD: Fourteen patients were included in this retrospective study. Consecutive SGBs were performed three times, once every two weeks. The parameters for the lymphoscintigraphic findings included the extent of dermal backflow (small extent/large extent group), the presence of a washout pattern (washout/non-washout group) and visualization of lymph nodes on the 3-hour image (visualized/non-visualized group). The upper arm and forearm circumferences were used as the outcome parameters. We investigated the relationship between the lymphoscintigraphic findings and the arm circumferences. RESULTS: Regardless of the extent of dermal backflow, significant decreases of the upper arm and forearm circumferences were observed between the initial and final follow-up data. The small extent group showed a significant decrease of the forearm circumference at the first follow-up. The large extent group showed a pattern of significant decrease of the forearm circumference since the second follow-up. The washout group showed a decrease in both the upper arm and forearm circumferences, while the non-washout group showed a decrease only in the forearm circumference at the last follow-up. No difference was observed between the visualized and the non-visualized group. CONCLUSION: The extent of dermal backflow and the presence of a washout pattern on lymphoscintigraphy showed correlation with the change of arm circumference. Lymphoscitigraphy prior to performance of SGB for lymphedema patients might be helpful to predict the outcome of SGB.

Clinical Outcomes of Cervical Stellate Ganglion Block in Patients with Secondary Lymphedema: A Pilot Study

OBJECTIVE: To investigate the clinical effect of stellate ganglion block in patients with secondary lymphedema after breast cancer treatment. METHOD: In a prospective clinical trial, the consecutive stellate ganglion block (SGB) was performed every two weeks to 10 patients (Mean age 46.0+/-9.4 (yr)) who was diagnosed as of secondary lymphedema after breast cancer treatment. The parameters were the circumstance of arm and the thickness of skin and subcutaneous tissue of the affected arm measured by ultrasonography. We measured these parameters with baseline value before SGB treatment and repeated the evaluation after each SGB treatment. And the subjective data of satisfaction, softness and improvement were obtained by questionnaires. RESULTS: 10 patients were treated with stellate ganglion block. The mean circumferences of upper arm and forearm after three consecutive SGB treatments reduced significantly: upper arm from 31.39 cm to 29.72, forearm from 25.14 cm to 23.64 cm (p <0.05). And the thickness of subcutaneous tissue of upper arm significantly decreased under no- compression measuring technique after three SGB treatments (p <0.05). The compliance of superficial tissue showed significant change with serial procedure. Almost all of the patients had a satisfaction and feeling of softness in their affected arm after treatments. CONCLUSION: The cervical stellate-ganglion block reduced the circumstance and the thickness of arm with lymphedema and satisfied almost lymphedema patients. So this treatment presents a favorable outcome to the breast cancer-related lymphedema patient clinically.

Comparison of the Ultrasonographic Study and the Electrodiagnostic Study on the Ulnar Neuropathy around the Elbow Region

OBJECTIVE: To evaluate the relationship between the electrophysiologic findings and the ultrasonographic findings of the ulnar neuropathy around the elbow. METHOD: We examed 20 elbows with the ulnar neuropathy around the elbow and 22 healthy elbows. We measured the cross-sectional area (CSA) and the diameters of the long, short axis of the ulnar nerve at the swollen portion and the compressed portion by ultrasonography. RESULTS: The CSA, diameters on the longitudinal and transverse view of the swollen portion of the ulnar nerve of the patients group was larger than that of the control group (p0.05). There was significant correlation between the decrement of the nerve conduction velocity across elbow and the increment of the diameter on the swollen portion on the longitudinal and transverse view (r=0.541, 0.466, p<0.05, respectively). CONCLUSION: The difference of diameter between swollen and compressed portion of the ulnar nerve on the ultrasonography was correlated with the conduction velocity decrement on the electrophysiologic study.

Analysis of Characteristics and Effect of Treatment for Shoulder Pain Patient Classified by Sonographic Findings

OBJECTIVE: This study was designed to observe the general characteristic of patients with shoulder pain, interrelation between the ultrasonographic findings, physical examination and radiological findings, and the effect of treatment of shoulder pain classified by ultrasonographic findings. METHOD: We examined 334 patients (165 male and 169 female) with shoulder pain who had been consulted to us. We examined degenerative changes such as subacromial spur, greater tuberosity sclerosis using radiological method. We classified patients into three categories -capsular, noncapsular and mixed - in accordance to physical examination and ultrasonographic findings. In order to estimate the effect of treatment, VAS change one week after injection, treatment duration, and frequency of injection were checked. RESULTS: The mean age of patients was 54.4 (range: 22~77) years. The average VAS change, duration of treatment, and frequency of injection were 4.68+/-2.93, 6.14 +/- 4.83 weeks, 3.59 +/- 2.70 times. There was meaningful correlation between diagnosis done with physical examination and ultrasonography in cases showing capsular and noncapsular patterns. Although there was meaningful difference of treatment effect classified by ultrasonographic findings, no meaningful difference in treatment effect was ween in patients classified by physical examination. CONCLUSION: Ultrasonography is an useful tool supporting diagnosis based on physical examination. The ultrasonography of shoulder could predict progress and prognosis of patients with shoulder pain.

Comparison of the Efficacy of Epidural Injection according to the Distribution of Dye in the Epidural Space

OBJECTIVE: To compare the efficacy of epidural injection in accordance the distribution of dye in the epidural space for low back pain patient. METHOD: Twenty nine patients with herniated nucleus pulposus or spinal stenosis confirmed by the radiologic studies were treated with epidural injection of steroid. The patients were divided into two groups: 1) patients whose distribution of dye was in the posterior part of epidural space and 2) patients whose distribution of dye was in the anterior and posterior parts of epidural space. RESULTS: The efficacy of epidural injection was assessed using the visual analog scale (VAS) and straight leg raising test (SLR) on pre-treatment and post-treatment. The VAS and SLR change of pre-treatment and post-treatment in the first group was from 7.81 +/- 1.54 and 50.00 +/- 18.97 degrees to 4.45 +/- 2.16 and 75.00 +/- 17.61 degrees (p0.05). CONCLUSION: The different distribution of dye in epidural space had no significant difference in treating patients with low back pain.

Change of Current Perception Threshold of Median Nerve after Transcutaneous Electrical Nerve Stimulation

OBJECTIVE: We measured current perception threshold (CPT) with transcutaneous electrical nerve stimulation (TENS) to prove the selective increment of the threshold of C sensory fiber and to determine onset time and duration of effect for application of TENS. METHOD: TENS were applied to fifteen control volunteers for 20 minutes on hand three times per week for 2 weeks duration. The CPT was tested at the distal interphalangeal joint of the second finger with 5 Hz, 250 Hz, and 2,000 Hz in frequency, respectively. The test was repeated immediately and 30 minutes after cessation of TENS. These tests were performed on the first, eighth, and fifteenth day on application of TENS. RESULTS: The baseline CPT of C fiber was 32.7 +/- 6.4 10 2 mA, A gamma fiber 23.2 +/- 9.4 10(-2) mA, and A beta fiber 83.9 +/- 18.1 10(-2) mA. At 30 minutes after cessation of TENS in the fifteenth day, the CPT of C fiber increased markedly and that of A gamma fiber increased a little. The CPT of A beta fiber didn't increase for 2 weeks. CONCLUSION: With application of TENS, the threshold of C and A gamma fibers selectively increased, especially 30 minutes after removal of TENS application. This effect was outstanding after 2 weeks' application.

The Correlation between Outcome and Ultrasonographic Findingsin Congenital Muscular Torticollis

OBJECTIVE: The ultrasonographic (US) findings of the sternoocleidomastoid muscles (SCM) in patients with congenital torticollis were studied to evaluate the correlation between the US findings and outcome of physical theraphy. METHOD: We studied 52 patients diagnosed as congenital muscular torticollis. We evaluated the thickness, mass, echogenicity and echotexture of both SCM muscles. The US findings of the SCM muscles were divided into 5 grades according to the severity. The physical theraphy included heat theraphy and passive stretching of involved muscle. The outcomes of the treatment were evaluated by physical examination and follow-up US examination. RESULTS: Neck rotation of lesion site comparing to non-lesion site was improved significantly from 83.0+/-16.5% to 94.9+/-7.16% and lateral flexion from 77.9+/-18.1% to 90.5+/-12.4% after the treatment. In 20 US follow-up cases, thickness ratio of the involved SCM muscle decreased significantly from 177.8+/-46.2% to 158.3+/-83.1%. The therapeutic effect tends to be low with higher grades of the US findings. But, there were no significant statistical correlation between age and treatment outcome. CONCLUSION: The US findings of the SCM muscles had a significant correlation with the outcome and the duration of treatment.

Ultrasound and Pathologic Findings of Nodules in the Medial Hamstring Muscle of the Rabbit: Experimental Study for Myofascial Pain Syndrome

OBJECTIVE: To establish the objective method of diagnosing the myofascial pain syndrome through diagnostic ultrasound and pathology. METHOD: Hamstring muscles of 7 female house rabbits, weighing 2.5~3.0 Kg, were studied. The existence of nodule was confirmed by palpation and through diagnostic ultrasound. A horizontal length, vertical length, thickness, and an area of hyperechoic region were measured. Hyperechoic regions were biopsied and stained with hematoxylin-eosin. RESULTS: All examined rabbits had muscular nodules in the medial hamstring. Characteristic increase of echogenecity was observed in the medial hamstring muscles. Some uneven hyperechoic areas were seen in the lateral hamstring muscles. Fatty degeneration and giant round cells were observed in the medial hamstring where the echogenecity was increased. The giant round cells were observed only in the lateral hamstring. CONCLUSION: Increased echogenecity of the medial hamstring muscle is probably contributed by muscles cells with fatty degeneration and giant round cells, and some portions of hyperechogenecity of lateral hamstring requires further study.

Ultrasonographic Compressibility of Heel Pads in Patients with Diabetes Mellitus

OBJECTIVE: This study was designed to evaluate the compressibility of heel pads in patients with diabetes mellitus. METHOD: The subject were twenty control subjects and 20 patients with diabetes mellitus diagnosed at least 5 years previously, over the age of 40. The thickness of heel pads was measured by ultrasonography without pressure and with pressure of 1 kg, 2 kg and 3 kg at the line connecting the second toe and the mid-heel point. The ratio of the thickness of the heel pad with pressure of 1 kg, 2 kg, 3 kg and without pressure, R1 (ratio of the thickness of heel pad with 1 kg and without pressure), R2 (2 kg) and R3 (3 kg), was compared between controls and diabetics. RESULTS: There was no significant difference of heel pad thickness between controls and diabetics without pressure in sole. The diabetics had greater ratio, less compressibility than controls (p<0.05). The ratio of the control group was R1; 0.67+/- 0.07, R2; 0.53+/-0.07 and R3; 0.45+/-0.07, whereas that ratio of the diabetic group was R1; 0.80+/-0.09, R2; 0.68+/-0.09 and R3; 0.58+/-0.09. CONCLUSION: The evaluation of compressibility of heel pad of the patients with diabetes mellitus compared with the control group will help to make a treatment of heel pain or discomfort.

Quantitative Measurement of Current Perception Threshold in Carpal Tunnel Syndrome

OBJECTIVE: To compare current perception threshold with nerve conduction study, we measured current perception threshold (CPT) in healthy control and patients with carpal tunnel syndrome (CTS). METHOD: Twenty control subjects and twenty patients with CTS were included. Latency and amplitude of median and ulnar motor and sensory nerves were measured. The sensory current perception threshold was measured at the distal interphalangeal joint of third and fifth fingers and the palm with electrical current of 5 Hz, 250 Hz, and 2,000 Hz in frequency. We compared the results of the nerve conduction study with the data of the CPT. RESULTS: We found that measuring of the sensory threshold might detect carpal tunnel syndrome, especially with 2,000 Hz and 250 Hz stimulation and that CPT data correlated to sensory latency and amplitude of the median nerve. CONCLUSION: The sensory threshold test might be useful for diagnosis and follow up test in carpal tunnel syndrome.