Rehabilitation of a Patient with Pirogoff Amputation and Two-year Follow-up: A Case Report.

BACKGROUND: Pirogoff amputation is a calcaneal amputation invented by Nicolás Pirogoff that involves partial preservation of the calcaneus. CASE: A 59-year-old woman was diagnosed with left Lisfranc and Chopart joint fracture-dislocation 9 months after a fall. The patient underwent debridement together with Pirogoff amputation and surgery to place an Ilizarov external fixator. Five months later, the patient was transferred to a rehabilitation hospital. Because of inadequate bone fusion, for 3 months after the amputation the patient underwent gait training with a patellar tendon weight-bearing orthosis to avoid loading the amputated side. After fusion of the bone, the patient was able to walk using a Syme prosthesis and a cane. Three months after discharge from the rehabilitation hospital, the patient was diagnosed with hallux osteomyelitis of the other foot that was associated with the exacerbation of hallux valgus. The patient underwent hallux correction surgery. Three and a half months after the second hospital admission, the patient was again admitted to the rehabilitation hospital. At the end of the rehabilitation program, the patient was able to walk using a cane and a prosthesis. DISCUSSION: Appropriate orthotic treatment and care of the non-amputated limb are of great importance in patients who have undergone a partial foot amputation.

The Effects of Timing of a Leucine-Enriched Amino Acid Supplement on Body Composition and Physical Function in Stroke Patients: A Randomized Controlled Trial.

The combination of exercise and nutritional intervention is widely used for stroke patients, as well as frail or sarcopenic older persons. As previously shown, supplemental branched chain amino acids (BCAAs) or protein to gain muscle mass has usually been given just after exercise. This study investigated the effect of the timing of supplemental BCAAs with exercise intervention on physical function in stroke patients. The participants were randomly assigned to two groups based on the timing of supplementation: breakfast (n = 23) and post-exercise (n = 23). The supplement in the breakfast group was provided at 08:00 with breakfast, and in the post-exercise group it was provided just after the exercise session in the afternoon at 14:00-18:00. In both groups, the exercise intervention was performed with two sessions a day for two months. The main effects were observed in body fat mass (p = 0.02, confidence interval (CI): 13.2-17.7), leg press strength (p = 0.04, CI: 94.5-124.5), and Berg balance scale (p = 0.03, CI: 41.6-52.6), but no interaction with intake timing was observed. Although the effect of the timing of supplementation on skeletal muscle mass was similar in both groups, BCAA intake with breakfast was effective for improving physical performance and decreasing body fat mass. The results suggest that a combination of BCAA intake with breakfast and an exercise program was effective for promoting rehabilitation of post-stroke patients.

Changes of intravaginal microbiota and inflammation after self-replacement ring pessary therapy compared to continuous ring pessary usage for pelvic organ prolapse.

AIM: Continuous usage of a ring pessary for pelvic organ prolapse may cause a disturbance of intravaginal microbiota and intravaginal mucosal damage. To avoid the side effects of continuous ring pessary therapy, daily self-replacement of the ring pessary is recommended. The purpose of this study is to evaluate the outcomes of self-replacement versus continuous ring usage, by analysing clinical findings and intravaginal microbiota. METHODS: Thirty seven patients who managed self-replacement ring pessary therapy and 13 patients with continuous ring pessary therapy participated in this study. The clinical symptoms were checked at 1 month after the initial ring pessary insertion. The changes in the intravaginal microbiota were evaluated by conventional methods, i.e. pH in the vagina, Lactobacillary grade, Nugent score, inflammatory cell counts, and culture-based bacterial detection methods. In addition, our clone library method using 16S rRNA sequencing of vaginal fluid was performed. RESULTS: Patients were divided into four groups: self-replacement pre/post-menopause and continuous and pre/post-menopause. Five patients of the self-replacement group (n = 37) and all patients of the continuous use group (n = 13) complained of increased discharge. However, both the conventional methods and the clone library method revealed that the number of the self-replacement group patients who had abnormal intravaginal microbiota were not significantly different from that of the continuous use group. CONCLUSION: Daily self-replacement ring pessary therapy prevented adverse clinical symptoms. However, abnormal intravaginal microbiota was frequently observed during self-replacement of ring pessary therapy as with continuous usage. Regardless, pelvic examinations should be performed routinely.

Relation between change in exercise capacity and change in blood amino acids in patients with chronic heart failure.

[Purpose] Although cardiac rehabilitation (CR) is recommended for patients with chronic heart failure (CHF), adequate exercise effect cannot be obtained in elderly patients. Administration of amino acids (AA) to CHF patients has been reported to improve exercise capacity, but the changes in AA composition in plasma before and after CR had not been reported. This study aimed to measure plasma levels of AA in CHF patients and compare with values of normal range. In addition the relationship between the change of exercise capacity and AA were examined. [Subjects and Methods] Twelve CHF patients (60% males, aged 68 ± 12 years) were studied. The correction between the rates of changes in exercise capacity parameters and in plasma AA levels was investigated. [Results] Anaerobic threshold (AT) and peak oxygen uptake (VO2) improved significantly after CR. The AA profile showed no specific pattern, and citrulline (Cit) was the amino acid showing a significant positive correlation with exercise capacity (∆Cit vs. ∆AT: r=0.602, ∆Cit vs. ∆AT-work rate (WR): r=0.681, ∆Cit vs. ∆VO2/WR: r=0.635). A tendency of positive correlation was observed between ∆Cit and ∆peak VO2 (r=0.456). [Conclusion] The AA profile showed no specific pattern, but a relationship between change in exercise capacity and Cit were found.

Effects of pelvic organ prolapse ring pessary therapy on intravaginal microbial flora.

INTRODUCTION AND HYPOTHESIS: The purpose of this paper is to report our evaluation of changes in intravaginal microbial flora after ring pessary therapy for pelvic organ prolapse (POP) using conventional and our clone library method. METHODS: Thirteen patients with POP who were fitted with a ring pessary participated in this longitudinal study that incorporates data from before and 1 month after beginning ring pessary therapy. Changes in intravaginal microbial flora were evaluated by conventional methods, i.e., vaginal pH, lactobacillary grade (LAC grade), Nugent score, and culture-based bacterial detection methods. In addition, we performed our clone library method using 16S ribosomal RNA (rRNA) sequencing of vaginal fluid. RESULTS: Conventional methods revealed that most patients had abnormal intravaginal microbial flora. Mean numbers of detected bacterial species by the culture-based and our clone library method were 3.1 (1-6) and 11.8 (1-25), respectively. Our clone library method showed that Lactobacillus spp. increased in four and decreased in two cases after ring pessary therapy but reappeared after therapy in two cases; no Lactobacillus spp. were detected in five cases. CONCLUSIONS: Our study showed that ring pessary therapy did not always disturb intravaginal microbial flora, especially for patients with Lactobacillus spp. prior to ring pessary insertion. Anaerobic circumstances in the vagina after therapy seem to have induced the growth of anaerobic bacteria.

Impact of chronic kidney disease and anemia on physical function in patients with chronic heart failure.

OBJECTIVE: The aim of this study was to confirm the effects of chronic kidney disease (CKD) and anemia on physical function and to clarify whether the interaction between CKD and anemia has an additive effect. DESIGN: Eligible subjects were chronic heart failure (HF) patients who were discharged between March 2007 and August 2009. A total of 102 chronic HF patients (33% females; mean age: 68 ± 14 years) were enrolled in the present study. CKD was defined as an estimated glomerular filtration rate of <60 ml/min/1.73 m(2), and anemia was defined as a hemoglobin level of <12 g/dl in males and of <11 g/dl in females. The Short Physical Performance Battery (SPPB) was used to assess physical function. RESULTS: The adjusted mean SPPB score was lower in patients with both CKD and anemia than in those with neither of the diseases or with either disease alone (p < 0.05). CONCLUSION: This study found that CKD and anemia are independently associated with reduced physical function.

Evaluation of intestinal microbiotas of healthy Japanese adults and effect of antibiotics using the 16S ribosomal RNA gene based clone library method.

Intestinal microbiotas of human subjects and effect of antibiotic treatment on them have been reported with cultivation independent methods. However, Japanese fecal microbiotas have not been studied enough. We have constructed a clone library method to obtain results within 3 d. In this study, intestinal microbiotas of 29 healthy Japanese adults, whose fecal samples were collected twice at 5 month intervals from each subject, were analyzed with our clone library method, and using those data as a benchmark effect of antibiotic treatment on intestinal microbiotas was evaluated. The fifty-eight fecal microbiotas were assessed based on percentages at genus level, and the variability was analyzed with a principal component analysis (PCA). PCA showed that the microbiotas divided into three groups depending on the large eigenvectors (genera Ruminococcus, Bacteroides, and Prevotella), and the dual samples from the twenty-two individuals have belonged to the same PCA group. It suggests that almost Japanese adults have own stable intestinal microbiota. The genera Ruminococcus and Bacteroides were present in almost subjects, while the genus Prevotella was found only in nine subjects (approximately 30%) which was preserved with 5 months intervals. Next, the microbiotas before and after antibiotic treatment were evaluated comparing with the 58 healthy adult microbiotas. The results showed that beta-lactams influenced profoundly on intestinal microbiotas and the effect of macrolides depended on the cases. It suggests that our clone library method could show overview of intestinal microbiota and would give us useful information about the effect of antibiotic treatment for daily clinical diagnosis.

Intravaginal microbial flora by the 16S rRNA gene sequencing.

OBJECTIVE: Conventional diagnosis of bacterial vaginosis contains some controversial points. To understand accurately the relationship between clinical stages and the microbiotas, the intravaginal microbial flora was analyzed by the clone library method. STUDY DESIGN: Vaginal fluid samples from 31 patients were examined. Lactobacillary grade, Nugent score, culture-based method, and clone library analysis using the 16SrRNA gene sequencing were performed and were compared with each other. RESULTS: Patients were categorized by Lactobacillary grade as I (normal) (n = 6), II (intermediate) (n = 11), and III (bacterial vaginosis) (n = 14). The clone library analysis detected 36 bacterial genera and 60 species from all 31 samples. A principal component analysis of the microbial proportions revealed a novel classification, which suggested the significance of the relative ratio of Lactobacillus iners, Atopobium vaginae and anaerobes in bacterial vaginosis. CONCLUSION: Clone library analysis in combination with the conventional method provides substantial information for diagnosis of bacterial vaginosis.

Influence of menstruation on the microbiota of healthy women's labia minora as analyzed using a 16S rRNA gene-based clone library method.

The aim of this study was to determine the influence of menstruation on the bacterial population of healthy Japanese women's vulvas, especially the labia minora. Labia minora swabs were obtained from 10 premenopausal, nonpregnant Japanese women at premenstruation and on day 2 of menstruation. Vaginal swabs were also obtained from 3 out of the 10 women. No significant difference was found in the average bacterial cell count between the menstruation and premenstruation samples. Molecular analysis using a 16S rRNA gene-based clone library method detected 22 genera from the labia minora swabs (total 20), with the genus Lactobacillus being predominant at both premenstruation and during menstruation in 7 out of the 10 women. Of the other 3 women, 2 showed various kinds of bacterial species, including oral and fecal bacteria, with Atopobium vaginae and Gardnerella vaginalis predominating in the remaining woman's vulva in both conditions. In total, 6 out of 10 cases (60%) showed significantly different microbiota of the labia minora between the two conditions. These results imply that menstruation may promote a distortion of the bacterial flora around the vulva, although it causes no significant increase of the bacterial count.

Experience of rehabilitation for Guillain-Barré syndrome during and after pregnancy: a case study.

PURPOSE: Guillain-Barré syndrome (GBS) in pregnancy is very rare, and there is no detailed description of rehabilitation in the literature. We report a case of GBS involving a pregnant, 34-year-old woman. CASE DESCRIPTION: She was diagnosed with Hughes grade 5 GBS during the 20th week of gestation (GW). Almost all basic motions showed total dependence. The motor functional independence measure (motor FIM) score was 31. We developed a training programme that considered the pregnancy-associated increase in her weight. RESULTS: At the 34th GW, her transfer activity became independent and she began gait training. At the 37th GW, she delivered a healthy baby spontaneously. She nursed her baby independently using a sling. After the motor FIM improved to 84, the mother and infant were discharged together 5 weeks after delivery and home-visit rehabilitation was performed while using a baby-sitter. One month after discharge, she became able to walk alone over a short distance. Finally, her endurance improved, facilitating her return to office work 15 months after discharge. CONCLUSION: We are following the patient, providing training in the movements needed for child care and suggesting environmental improvements for the mother and infant. As a result, her recovery from disability has been promoted.

After omental flap transposition, respiratory function and exercise capacity decrease.

PURPOSE: To evaluate the effect of respiratory function and exercise capacity after omental flap transposition. METHODS: From October 2005 to December 2006, we classified mediastinitis patients treated with omental flap transposition (OT group; n = 10) and patients who underwent only cardiovascular surgery without developing complications (control group; n = 25). Percent vital capacity (%VC) was evaluated from the day of returning to the general ward for 5 consecutive days and on 14 days. The day of a 200 m walk was investigated, and the cardiopulmonary exercise test was conducted after discharge. Load and oxygen consumption (VO) at anaerobic threshold (i.e., AT load and AT VO), peak load, and peak VO were measured. RESULTS: %VC significantly decreased in the OT group compared with the control group (P <0.05). An interaction effect between the 2 groups on the change in %VC was observed (F = 2.71, P <0.05). Three patients failed to accomplish a 200 m walk in the ward after omental flap transposition. AT VO and peak VO were significantly lower (P <0.05 and P <0.01, respectively) in the OT group than in the control group. CONCLUSION: After omental flap transposition, %VC and VO decreased.

[Effectiveness of learning of nursing-work as early exposure by the 1st year medical students at a university hospital].

We conducted a half day program included in the subject of "nursing and care" as early exposure at clinical sites for the 1st year medical students at a university hospital. This program aimed at understanding what nursing is through visit for study and what patients expect through doctor-patient communication. In order to evaluate the program and to clarify problems to be solved, comments and impressions reported by the medical students were analyzed qualitatively and inductively. As a result, we found that the students recognized the importance of communication with patients and of mental care for them. As for nursing, the students also realized the characteristics and significance of nursing. It is noteworthy that they acquired clear images of a medical doctor, including their roles in team-based medical care. We conclude that this program of early exposure to clinical sites is instructive for 1st year medical students.