A case report of effective intra-articular elcatonin administration in a patient with osteonecrosis of the lunate.

INTRODUCTION AND IMPORTANCE: Although corticosteroids are effective for bronchial asthma, they are associated with various side effects, such as osteonecrosis of the femoral head and tibial condyle and osteoporosis. Here, we report a patient who was on corticosteroids for a long period of time due to severe asthma, which was thought to have led to lunate osteonecrosis of both wrist joints. Calcitonin (elcatonin), an osteoporosis drug, was administered to the wrist joint. CASE PRESENTATION: Allergy to anesthetics and various non-steroidal anti-inflammatory drugs (NSAIDs) made surgical treatment not possible and pain control difficult. In addition, pain in the wrist joint interfered with activities of daily living (ADLs). When calcitonin was administered intra-articularly into the wrist joint, the pain in the wrist joint was relieved and ADLs were improved. However, the pain-suppressing effect lasted only 1 week, and pain returned to the original state by the second week after treatment. Repeated injections were necessary every 2 weeks. CLINICAL DISCUSSION: This is the first report of the effectiveness of intra-articular calcitonin in a patient with osteonecrosis of the lunate. This treatment may be applicable to patients with allergies to anesthesia and NSAIDs. CONCLUSION: In the present case, calcitonin administered intra-articularly to the wrist appeared to be effective in pain control for steroid-induced lunate osteonecrosis.

Carpal Tunnel Volume after Basal Joint Arthroplasty in Postmenopausal Women.

Background: Carpal tunnel syndrome is occasionally associated with basal joint arthritis and is more common in postmenopausal women than in the general population. Currently, more evidence is needed to describe changes in the carpal tunnel after basal joint arthroplasty (BJA) of the thumb and to determine whether it is better to combine the release of the flexor retinaculum. The purpose of this study was to clarify the changes in the carpal tunnel cross-sectional area and carpal tunnel shape after complete removal of the trapezium during BJA of the thumb, according to computed tomography (CT) findings. Methods: We retrospectively investigated the carpal tunnel cross-sectional area with CT findings obtained pre- and postoperatively in 20 postmenopausal women who underwent BJA of the thumb. Results: The average horizontal plane area of the carpal tunnel was 1.11 ± 0.19 cm2 preoperatively and increased to 1.23 ± 0.2 cm2 at 3 months postoperatively (p = 0.0411). The ratio of the longitudinal diameter to the horizontal diameter was significantly increased from 0.6 ± 0.13 preoperatively to 1.23 ± 0.2 postoperatively (p = 0.0439). Conclusions: The increase in the carpal tunnel cross-sectional area was confirmed after BJA of the thumb. This increased carpal tunnel cross-sectional area changed as the longitudinal diameter increased, without changes in the horizontal diameter. Level of Evidence: Level IV (Therapeutic).

Metaphyseal-diaphyseal Junctional Fractures of the Distal Humerus in Children: Two Case Series.

Introduction: Although there are few descriptions in textbooks and it is stated that the treatment of metaphyseal-diaphyseal junctional (MDJ) fracture is difficult, there is almost no detailed description on its treatment methods and precautions. Case Presentation: We encountered two patients, 9-year-old and 1-year and 11-month-old Japanese boys, with MDJ fractures of the distal humerus, which are very rare in children. Unlike supracondylar fractures of the distal humerus, the fractures were spiral fractures, which made percutaneous pinning very difficult. Open reduction was performed using a bilateral approach with two skin incisions. Both patients recovered completely and had no problems carrying out activities of daily living or playing sports. Conclusions: For patients that are old enough to receive a locking plate, we recommend fixation using a locking plate. In cases of unilateral pinning without cross-pinning, retrograde intramedullary nailing should be considered. MDJ fractures of the distal humerus should be treated as distal humeral shaft fractures, not as subtypes of supracondylar fractures of the humerus.

Different Attitudes of Patients and Psychiatrists Toward Benzodiazepine Treatment.

BACKGROUND: Concern regarding the benefit/risk ratio of the long-term use of benzodiazepines (BDZs) and Z-drugs is increasing. To prevent the risk of dependence in BDZ long-term use, it is essential to understand the attitudes of patients and psychiatrists toward BDZ treatment. The aims of this investigation were to 1) obtain information on patients' attitudes with long-term BDZ use and their referring psychiatrists' attitudes toward BDZ treatment, including their perception of the difficulty of reducing the dose of BDZs, and 2) identify discrepancies between patients' and psychiatrists' perceptions. METHODS: A brief questionnaire was constructed to investigate the attitudes of patients receiving BDZ treatment and their referring psychiatrists. Our sample comprised 155 patients who received BDZ treatment for more than one year and their referring eight psychiatrists. Both the patients and their psychiatrists completed our questionnaire between August 2017 and December 2017. RESULTS: Of the patients, 13% felt that it was more difficult to reduce the dose of BDZs than their referring psychiatrists (type A discrepancy), while 25% felt that it was less difficult (type B discrepancy). In the multivariate logistic regression analysis, the female sex and both the patients' ("psychotherapy plus BDZs was necessary" and "it was necessary to increase the dose of BDZs") and psychiatrists' beliefs ("short-term prescription was justified") were associated with type A discrepancies. Type B discrepancies were associated with psychiatrists' beliefs that the patient's wishes justified the use of BDZs and that the cessation of treatment with BDZs would lead to the deterioration of their rapport with their patients. CONCLUSION: To overcome the discrepancies in the attitudes of patients and psychiatrists toward the cessation of BDZ treatment, it is necessary to promote patient-centered care involving patient psychoeducation and practice guidelines for the decision-making process. Further studies investigating the promotion of patient-centered care to reduce BDZ use are needed.

A non-invasive technique for evaluating carpal tunnel pressure with ultrasound vibro-elastography for patients with carpal tunnel syndrome: A pilot clinical study.

Carpal tunnel syndrome (CTS) is a disorder that affects the median nerve at the wrist sufficient to cause impairment of nerve function. Elevated carpal tunnel pressure (CTP) leads to median nerve pathology, sensory, and motor changes in CTS patient. The techniques to quantify CTP used in clinic are invasive. This study aimed to investigate the feasibility of a noninvasive ultrasound vibro-elastography (UVE) to predict CTP in CTS patients and healthy individuals. The magnitudes of shear wave speed ratio (rSWS) of the 10 CTS patients (10 hands) and 6 healthy individuals (12 hands), and 10 cadaveric hands were compared using UVE. The ratios of intra to extra-carpal tunnel SWS in CTS patients was significantly higher than those in the healthy individuals (p = 0.0008) and cadaveric hands (p = 0.0015) with 500-g tendon tension. We estimated the CTP in the carpal tunnel using the mean rSWS of each group obtained from the present study and the linear approximation obtain from cadaveric hands data with 500-g tendon tension (y = 0.0036x + 1.1413). These results indicated that the elevated pressure applied to the 3rd flexor digitorum superficialis tendon in the carpal tunnel of CTS patients resulted in faster shear wave propagation. These results show that UVE was useful to indirectly estimate the CTP by measuring the rSWS; thus, they are potentially useful for the early diagnosis and assessment of CTS.

Vascularized Bone Grafting for Scaphoid Nonunion with Humpback Deformity: The Surgical Technique.

Background Scaphoid nonunion with humpback deformity and avascular necrosis (AVN) is a challenging problem. Correction of dorsal intercalated segment instability (DISI) requires grafting of a large and hard vascularized bone segment onto the volar side of the scaphoid. Purposes We have been treating the patients with one-incision vascularized bone grafting technique for scaphoid nonunion to improve blood supply and correct humpback deformity. We evaluated these cases retrospectively to the surgical efficacy of our procedure. Methods We harvested vascularized bone from the dorsal side of the radius using the method by Zaidemberg et al and inserted the cortical aspect into the scaphoid volar side using a direct lateral approach. Totally, 11 patients (nine males andtwo females) with a mean age of 40 years were recruited for this study. The mean time from fracture to treatment was 6 years and 3 months. The mean preoperative radiolunate angle was 25 degrees. All the patients showed AVN of the proximal scaphoid on T1-weighted images. An averaged follow-up period was 2 years and 3 months. Results Postoperative computed tomography revealed bony union in 10 patients (91% of union rate) with a mean modified Mayo'swrist score of 88 points (range, 75-100 points) and a mean disabilities of arm, shoulder, and hand (DASH) score of 4 points (range, 0-20 points). The mean radiolunate angle was corrected from 25 to 5 degrees. No adverse events were observed, except temporary mild paresthesia of the radial nerve territory in two patients. Conclusion This technique effectively corrected DISI in patients with scaphoid nonunion accompanied by humpback deformity and AVN.

Association Between the Serum Carnitine Level and Ammonia and Valproic Acid Levels in Patients with Bipolar Disorder.

PURPOSE: Valproic acid (VPA) is not only an antiepileptic drug but also a mood stabilizer for patients with bipolar disorder. Long-term VPA therapy can cause carnitine deficiency, which may result in an increase in the blood ammonia level, in patients with epilepsy. However, information about this effect in patients with bipolar disorder is limited. The aim of this study was to investigate the associations between the serum VPA level and the carnitine and ammonia levels in psychiatric adult patients with epilepsy. METHODS: The subjects were 182 consecutive Japanese adult patients (mean age 54.3 ± 19.5 years) diagnosed with bipolar disorder and treated with VPA. The serum VPA level, carnitine fraction, and plasma ammonia level were measured. Furthermore, the free carnitine and acylcarnitine fractions were measured using an enzyme cycling method. RESULTS: Sixty-nine patients (38%) had a low free carnitine level. There were significant differences in sex, height, VPA dose, serum VPA level, total carnitine level, acylcarnitine level, and acylcarnitine/free carnitine ratio between patients with a low free carnitine level and those with a normal range of free carnitine. The simple and multiple regression analyses revealed that the VPA dose and the serum VPA level were inversely and significantly correlated with the free carnitine level. The plasma ammonia level was correlated with the VPA dose, serum VPA level, and acylcarnitine level but not with the free carnitine level. CONCLUSIONS: These findings suggest that carnitine deficiency is associated with the VPA dose and the serum VPA level in patients with bipolar disorder. However, it is unlikely that carnitine deficiency is associated with hyperammonemia in patients with bipolar disorder.

Insulinoma resembling a rapid eye movement sleep behavior disorder: a case report.

Some patients with insulinoma present with neuropsychiatric symptoms and are often misdiagnosed with psychiatric disease. We present the case of a 72-year-old Japanese female who exhibited violent behavior while asleep and received a diagnosis of suspected rapid eye movement sleep behavior disorder (RBD). She was admitted to the psychiatry ward after receiving levomepromazine 25 mg intramuscularly. The patient's blood glucose level was 27 mg/dL at the time of hospitalization, and a biochemical examination revealed that her insulin level was 9.1 µU/mL and C-peptide level was 2.16 ng/mL. A contrast-enhanced computed tomography revealed a mass 8 mm in diameter in the pancreatic head. The diagnosis was changed from RBD to insulinoma. The sleep behavior disorder disappeared after continuous glucose administration. After enucleation of the insulinoma, the administration of glucose was discontinued, and her blood glucose levels recovered. This case suggests that insulinoma should be considered by physicians and psychiatrists in the differential diagnosis of patients with symptoms presenting as RBD.

Differences in etiological beliefs about schizophrenia among patients, family, and medical staff.

OBJECTIVES: To determine whether etiological beliefs are different among schizophrenia patients, their family, and medical staff. PATIENTS AND METHODS: A cross-sectional study was performed at five hospitals and one mental clinic and included 212 patients, 144 family members, and 347 medical staff other than psychiatrists. A questionnaire about the possible etiological causes of schizophrenia was used. RESULTS: There were significant differences in response scores among the three groups on using Angermeyer's and Goulding's classifications. Factor analyses revealed the following four subscales: Psychosocial, Biological, Environmental, and Cultural connotations. The structure varied among patients, family, and medical staff. CONCLUSION: The perspectives of schizophrenia etiology were different among patients, family, and medical staff.

Attitudes toward long-acting injectable antipsychotics among patients with schizophrenia in Japan.

BACKGROUND: Long-acting injectable antipsychotics (LAIs) are regarded as an important alternative to oral medication for patients with schizophrenia. However, LAIs remain under-utilized in clinical practice. AIMS: The aims of this investigation were to 1) obtain information on patients' attitudes toward LAIs and 2) assess factors associated with patients' acceptance of LAIs, and 3) identify predictors of the discrepancy between patients and referring psychiatrists' opinions regarding the appropriateness for LAIs. METHODS: Anonymized data were collected from a questionnaire distributed to 159 patients with schizophrenia and their referring psychiatrists at three psychiatric hospitals between February 2014 and July 2014. The patients completed an original questionnaire developed to evaluate their attitudes regarding LAIs. Regarding the appropriateness of LAI prescription, patients and their referring psychiatrists were asked to rate, on a 5-point scale, how appropriate they felt the depot prescription was for the patients. The participants also answered instruments to assess symptom severity, antipsychotic-induced extrapyramidal symptoms, functions, quality of life, and self-esteem levels. RESULTS: Patients currently on LAIs have favorable attitudes toward LAIs with respect to side effects, relapse prevention, efficacy, pain, and cost. Expectation of relapse prevention was significantly associated with patients' acceptance of LAIs (answering that those drugs are appropriate for their own treatment). In addition, the discrepancy between the patients' and referring psychiatrists' opinions regarding the appropriateness of LAI treatment was significantly associated with symptom severity, expectation of relapse prevention, belief that LAIs are painful, and belief that LAIs offer a reduced range of antipsychotic choices. CONCLUSION: Attitudes toward LAIs need to be considered when deciding whether to prescribe this formulation. Access to information on LAIs, including their benefit in relapse prevention, might enhance the acceptance and use of this formulation among patients with schizophrenia.

Comparison of two ways of altering carpal tunnel pressure with ultrasound surface wave elastography.

Higher carpal tunnel pressure is related to the development of carpal tunnel syndrome. Currently, the measurement of carpal tunnel pressure is invasive and therefore, a noninvasive technique is needed. We previously demonstrated that speed of wave propagation through a tendon in the carpal tunnel measured by ultrasound elastography could be used as an indicator of carpal tunnel pressure in a cadaveric model, in which a balloon had to be inserted into the carpal tunnel to adjust the carpal tunnel pressure. However, the method for adjusting the carpal tunnel pressure in the cadaveric model is not applicable for the in vivo model. The objective of this study was to utilize a different technique to adjust carpal tunnel pressure via pressing the palm and to validate it with ultrasound surface wave elastography in a human cadaveric model. The outcome was also compared with a previous balloon insertion technique. Results showed that wave speed of intra-carpal tunnel tendon and the ratio of wave speed of intra-and outer-carpal tunnel tendons increased linearly with carpal tunnel pressure. Moreover, wave speed of intra carpal tunnel tendon via both ways of altering carpal tunnel pressure showed similar results with high correlation. Therefore, it was concluded that the technique of pressing the palm can be used to adjust carpal tunnel pressure, and pressure changes can be detected via ultrasound surface wave elastography in an ex vivo model. Future studies will utilize this technique in vivo to validate the usefulness of ultrasound surface wave elastography for measuring carpal tunnel pressure.

Ultrasound elastography for carpal tunnel pressure measurement: A cadaveric validation study.

Carpal tunnel pressure is a key factor in the etiology of carpal tunnel syndrome. Numerous approaches have been conducted to measure carpal tunnel pressure. However, most techniques are invasive and take time and effort. We have developed an innovative approach to noninvasively assess the tunnel pressure by using the ultrasound surface wave elastography (USWE) technique. In a previous study it was shown that the shear wave speed in a tendon increased linearly with increasing tunnel pressure enclosed the tendon in a simple tendon model. This study aimed to examine the relationship between the carpal tunnel pressure and the shear wave speeds inside and outside the carpal tunnel in a human cadaveric model. The result showed that the shear wave speed inside the carpal tunnel increased linearly with created carpal tunnel pressure, while the shear wave speed outside the carpal tunnel remained constant. These findings suggest that noninvasive measurement of carpal tunnel pressure is possible by measuring the shear wave speed in the tendon. After fully establishing this technology and being applicable in clinic, it would be useful in the diagnosis of carpal tunnel syndrome. For that reason, further validation with this technique in both healthy controls and patients with carpal tunnel syndrome is required. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:477-483, 2018.

The quantitative evaluation of the relationship between the forces applied to the palm and carpal tunnel pressure.

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy occurring in upper limbs. The etiology, however, has not been fully understood yet. Median nerve could be compressed by either increase of carpal tunnel pressure (CTP) or direct impingement when it is forced toward to carpal ligament especially in wrist flexion leading to CTS development. Thus, the increase of carpal tunnel pressure is considered an important role in CTS development. It has been identified that forces applied to the palm would affect the CTP. However, the quantitative relationship between palmar contact force and CTP is not known. The purpose of this study was to quantitatively evaluate the relationship between palmar contact force and CTP. Eight human cadaveric hands were used. The CTP was measured with a diagnostic catheter-based pressure transducer inserted into the carpal tunnel. A custom made device was used to apply forces to the palm for the desired CTP. Palmar contact forces corresponding to the determined CTP level were recorded respectively. The testing was repeated with different ranges of tension applied to the flexor digitorum superficialis tendon of the third finger. The tensions were constant at 50 g for the other flexor tendons and median nerve. The results showed that CTP increased linearly with the force applied to the palm. When CTP was 30 mmHg, mean values of the contact force to the palm was 293 g (SD: 15.2) including all tensions. These results would help to understand the effect of daily activities with hands on CTP.

Relationship between quality of life and restless legs syndrome among a community-dwelling population in Japan.

OBJECTIVES: Restless legs syndrome (RLS) is a sensorimotor disturbance that causes the production of impulses and dysesthesia and makes the patients feel as though they must move their lower extremities. Because the symptoms of RLS in the lower limbs tend to develop at night, RLS could cause sleep disorders. We investigated an association between the symptoms of RLS and the health-related quality of life among community-dwelling individuals in Japan. METHODS: In this cross-sectional survey, we enrolled 985 volunteers who participated in the Iwaki Health Promotion Project in 2013. The symptoms of RLS were evaluated by the criteria of the International Restless Legs Syndrome Study Group. The assessments included an interview to obtain sociodemographic data, the second version of the Short Form Health Survey, the Center for Epidemiological Studies Depression scale, and the Pittsburgh Sleep Quality Index. A multiple regression analysis was used to assess the relationship between the symptoms of RLS and subscores of the Short Form Health Survey, Version 2. RESULTS: The overall prevalence of RLS in our participants was 1.0%. We found a significant and negative association between symptoms of RLS and physical functioning, role - physical functioning, bodily pain, social functioning, and the physical composite summary score. CONCLUSION: After adjusting for confounders such as age, sex, and comorbidity, the burden of RLS appears to be mainly a physical problem. Impaired health-related quality of life among community individuals with RLS emphasizes the importance of screening for these symptoms and evaluating the need for treatment.

The Effects of Fluvoxamine on the Steady-State Plasma Concentrations of Escitalopram and Desmethylescitalopram in Depressed Japanese Patients.

BACKGROUND: The aim of this study was to determine the impact of fluvoxamine, an inhibitor of Cytochrome P450 (CYP) 2C19 (CYP2C19), on the pharmacokinetics of escitalopram, a substrate of CYP2C19. METHODS: Thirteen depressed patients initially received a 20-mg/d dose of escitalopram alone. Subsequently, a 50-mg/d dose of fluvoxamine was administered because of the insufficient efficacy of escitalopram. Plasma concentrations of escitalopram and desmethylescitalopram were quantified using high-performance liquid chromatography before and after fluvoxamine coadministration. The QT and corrected QT (QTc) intervals were measured before and after fluvoxamine coadministration. RESULTS: Fluvoxamine significantly increased the plasma concentrations of escitalopram (72.3 ± 36.9 ng/mL versus 135.2 ± 79.7 ng/mL, P < 0.01) but not those of desmethylescitalopram (21.5 ± 7.0 ng/mL versus 24.9 ± 12.0 ng/mL, no significance [ns]). The ratios of desmethylescitalopram to escitalopram were significantly decreased during fluvoxamine coadministration (0.37 ± 0.21 versus 0.21 ± 0.10, P < 0.01). The CYP2C19 genotype did not fully explain the degree of the change. Fluvoxamine coadministration did not change the QT or QTc intervals. CONCLUSIONS: The results of this study suggest that adjunctive treatment with fluvoxamine increases the concentration of escitalopram. The QTc interval did not change in this condition.

Comparison of predictive equations for resting energy expenditure among patients with schizophrenia in Japan.

BACKGROUND: Recently, a relationship between obesity and schizophrenia has been reported. The prediction of resting energy expenditure (REE) is important to determine the energy expenditure of patients with schizophrenia. However, there is a lack of research concerning the most accurate REE predictive equations among Asian patients with schizophrenia. The purpose of the study reported here was to compare the validity of four REE equations for patients with schizophrenia taking antipsychotics. METHODS: For this cross-sectional study, we recruited patients (n=110) who had a Diagnostic and Statistical Manual of Mental Disorders, fourth edition, diagnosis of schizophrenia and were admitted to four psychiatric hospitals. The mean (± standard deviation) age of these patients was 45.9±13.2 years. Anthropometric measurements (of height, weight, body mass index) were taken at the beginning of the study. REE was measured using indirect calorimetry. Comparisons between the measured and estimated REEs from the four equations (Harris-Benedict, Mifflin-St Jeor, Food and Agriculture Organization/World Health Organization/United Nations University, and Schofield) were performed using simple linear regression analysis and Bland-Altman analysis. RESULTS: Significant trends were found between the measured and predicted REEs for all four equations (P<0.001), with the Harris-Benedict equation demonstrating the strongest correlation in both men and women (r=0.617, P<0.001). In all participants, Bland-Altman analysis revealed that the Harris-Benedict and Mifflin-St Jeor equations did not show a significant bias in the prediction of REE, however, a significant overestimation error was shown for the Food and Agriculture Organization/World Health Organization/United Nations University and Schofield equations. CONCLUSION: When estimating REE in patients with schizophrenia taking antipsychotics, the Harris-Benedict equation appears to be the most appropriate for clinical use.

Interaction between paliperidone and carbamazepine.

BACKGROUND: This aim of this study was to determine the impact of carbamazepine on the pharmacokinetics of paliperidone. METHODS: Six schizophrenic patients initially received a 6-12 mg/d dose of paliperidone alone. Subsequently, a 200 mg/d dose of carbamazepine was administered, and the carbamazepine dose was increased to 400 mg/d and then 600 mg/d. Plasma concentrations of paliperidone before and after carbamazepine coadministration were quantified using liquid chromatography tandem mass spectrometry (LC-MS/MS). RESULTS: Carbamazepine significantly reduced the plasma concentration of paliperidone. The plasma concentration of paliperidone at baseline and with coadministration of 200, 400, and 600 mg/d were 45.8 ± 11.7, 26.9 ± 13.7, 17.1 ± 8.2, and 15.9 ± 7.6 ng/mL, respectively. The concentration of paliperidone with carbamazepine coadministration at doses of 200, 400, and 600 mg/d were 55.7% ± 20.7%, 36.1% ± 12.2%, and 33.6% ± 10.4%, respectively, of baseline. This effect occurred even at the carbamazepine dose of 200 mg/d and reached a plateau at doses higher than 400 mg/d. However, carbamazepine coadministration exacerbated the psychotic symptoms in some patients. CONCLUSIONS: The results of the present study suggest that adjunctive treatment with carbamazepine reduces the concentration of paliperidone in a dose-dependent manner, most likely because of the induction of several drug-metabolizing enzymes and several drug transporters.

Interaction between paliperidone extended release and TS-1(®), an oral anticancer drug containing a 5-fluorouracil derivative, in a schizophrenic patient.

Until now there has been no information available on drug interaction between paliperidone and TS-1(®), an oral anticancer drug containing a 5-fluorouracil derivative. The patient in the case presented here was a 39-year-old man with a 15-year history of schizophrenia. The patient's usual treatment of 2 mg/day of risperidone was changed to 3 mg/day of paliperidone extended release. He experienced worsening psychotic symptoms after switching from risperidone to paliperidone while he was also receiving TS-1. Retrospective analyses showed plasma concentration of paliperidone was consistently lower during the treatment with TS-1 than without TS-1. This case suggests there is drug interaction between paliperidone extended-release tablets and TS-1.