Effect of Oral Prednisolone after Collagenase Injection for Dupuytren's Contracture: A Randomized, Controlled Trial with a 1-Year Follow-Up.

Introduction This study verified the effectiveness of oral prednisolone after collagenase clostridium histolyticum (CCH) (10 mg/day for 2 weeks) for Dupuytren's contracture with a 1-year follow-up. Materials and Methods This study included 31 patients with a contracture of the metacarpophalangeal joint of ≥ 30 degrees. A total of 16 patients were allocated randomly to treatment with prednisolone and 15 patients were treated without prednisolone (control group). Results At day 7, mean total active motion (TAM) was 235 degrees in the prednisolone group and 228 degrees in the control group. Mean Visual Analog Scale was 3.3 in the prednisolone group and 4.6 in the control group. There was significant difference between two groups. At day 30, mean TAM was 241 degrees in the prednisolone group and 233 degrees in the control group. There were significant difference between two groups The mean QuickDASH score was significantly higher in the control group (5.8 vs. 3.4). Recurrence was observed in 2/16 patients (13%) in the prednisolone group and 5/15 patients (33%) in the control group; there was no significant difference. Conclusion The administration of prednisolone decreased the likelihood of adverse effects, and also improved finger flexion range of motion and reduced pain after CCH.

Deuterium labelling to extract local stereochemical information by VCD spectroscopy in the C-D stretching region: a case study of sugars.

Stereochemical elucidation of molecules with multiple chiral centers is difficult. Even with VCD spectroscopy, excluding all but one diastereomeric structural candidate is challenging because the stereochemical inversion of one chiral center among many centers does not always result in noticeable differences in their VCD spectra. This work demonstrates that the introduction of a suitable VCD chromophore with absorption in the 2300-1900 cm-1 region can be used for extracting local stereochemical information and for the stereochemical assignment of the C-1 position of various sugars as a case study. Through studies on a series of epimeric pairs of monosaccharides and their derivatives, we found that the introduction of one -OCD3 group to each C-1 position produced almost mirror-image VCD patterns in the 2300-1900 cm-1 region depending on the C-1 stereochemistry irrespective of the other molecular moieties. This work also shows that comparison of the observed VCD signals and the calculated ones enables the stereochemical assignment of a chiral center in the vicinity of the chromophore. This study provides a proof of concept that the use of a VCD chromophore in the 2300-1900 cm-1 region enables the analysis of selected stereochemistry of suitable molecular systems. Further studies on this concept should lead to the development of a method useful for the structural elucidation of other types of complex molecules.

Chd4 choreographs self-antigen expression for central immune tolerance.

Autoreactive T cells are eliminated in the thymus to prevent autoimmunity by promiscuous expression of tissue-restricted self-antigens in medullary thymic epithelial cells. This expression is dependent on the transcription factor Fezf2, as well as the transcriptional regulator Aire, but the entire picture of the transcriptional program has been obscure. Here, we found that the chromatin remodeler Chd4, also called Mi-2ß, plays a key role in the self-antigen expression in medullary thymic epithelial cells. To maximize the diversity of self-antigen expression, Fezf2 and Aire utilized completely distinct transcriptional mechanisms, both of which were under the control of Chd4. Chd4 organized the promoter regions of Fezf2-dependent genes, while contributing to the Aire-mediated induction of self-antigens via super-enhancers. Mice deficient in Chd4 specifically in thymic epithelial cells exhibited autoimmune phenotypes, including T cell infiltration. Thus, Chd4 plays a critical role in integrating Fezf2- and Aire-mediated gene induction to establish central immune tolerance.

Comparison of Treatment Outcomes after Collagenase Injection and Percutaneous Needle Fasciotomy for Dupuytren's Contracture: Objective and Subjective Comparisons with a 3-Year Follow-Up.

BACKGROUND: This study compared the effectiveness of injectable collagenase clostridium histolyticum and percutaneous needle fasciotomy in the treatment of Dupuytren's contracture. METHODS: Patients with a total passive extension deficit of 30 degrees or more in a single digital ray were enrolled and assigned randomly to receive either collagenase clostridium histolyticum injections or percutaneous needle fasciotomy. Preoperative severity of proximal interphalangeal joint contracture for Dupuytren's disease was classified according to the British Society for Surgery of the Hand as less than 30 degrees (stage I) or 30 degrees or more (stage II). RESULTS: Of the 70 patients enrolled, 36 patients with 46 joints received collagenase clostridium histolyticum injections and 34 patients with 48 joints received percutaneous needle fasciotomy. At day 30, successful corrections were obtained in only 50 percent of the injection group and 67 percent of the fasciotomy group for stage II proximal interphalangeal joints. Recurrences were frequent among patients with stage II joint contractures. The mean Quick Disabilities of the Arm, Shoulder and Hand questionnaire score at day 30 was significantly higher in the injection group compared with the fasciotomy group (7.5 versus 4.2, respectively). In the injection group, adverse events were reported for all patients. In the fasciotomy group, complications were reported for 15 percent of patients. CONCLUSIONS: The collagenase clostridium histolyticum and percutaneous needle fasciotomy groups had similar outcomes for Dupuytren's contracture with 3 years' follow-up. Recurrences were frequent among patients with stage II proximal interphalangeal joint contractures. The Unité Rhumatologique des Affections de la Main scale and Quick Disabilities of the Arm, Shoulder and Hand questionnaire score decreased significantly for both groups at final follow-up. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Outer Membrane Protein of Gut Commensal Microorganism Induces Autoantibody Production and Extra-Intestinal Gland Inflammation in Mice.

Gut commensal microorganisms have been linked with chronic inflammation at the extra-intestinal niche of the body. The object of the study was to investigate on the chronic effects of a gut commensal Escherichia coli on extra-intestinal glands. The presence of autoimmune response was diagnosed by autoantibody levels and histological methods. Repeated injection of E. coli induced mononuclear cell inflammation in the Harderian and submandibular salivary glands of female C57BL/6 mice. Inflammation was reproduced by adoptive transfer of splenocytes to immune-deficient Rag2 knockout mice and CD4⁺ T cells to mature T cell-deficient TCRß-TCRδ knockout mice. MALDI TOF mass spectrometry of the protein to which sera of E. coli-treated mice reacted was determined as the outer membrane protein A (OmpA) of E. coli. Multiple genera of the Enterobacteriaceae possessed OmpA with high amino-acid sequence similarities. Repeated injection of recombinant OmpA reproduced mononuclear cell inflammation of the Harderian and salivary glands in mice and elevation of autoantibodies against Sjögren's-syndrome-related antigens SSA/Ro and SSB/La. The results indicated the possibility of chronic stimuli from commensal bacteria-originated components as a pathogenic factor to elicit extra-intestinal autoimmunity.

Development and evaluation of an overseas clinical rotation program for undergraduate pharmacy students in Japan.

BACKGROUND AND PURPOSE: Internationalization of pharmacists, as well as pharmacy students, in terms of both the knowledge to care for international patients and to have medical information literacy, is a current concern in Japan. EDUCATIONAL ACTIVITY AND SETTING: Keio University Faculty of Pharmacy has developed an elective course for pharmacy students, based on written agreements with the United States and Thailand that establish a student clinical rotation exchange program. The exchange program lasts for four to six weeks and involves clinical rotations in hospitals abroad during the students' sixth year. Rotations follow a four-week didactic preparatory course. The course objectives are to acquire the knowledge, skills, and attitude needed to function as leading pharmacists with an international perspective. METHODS: We asked students to complete a feedback survey inquiring about the usefulness of preparatory courses, self-evaluation pre- and post-rotation satisfaction with the program, and overall self-assessment. FINDINGS: Twenty-four out of 41, i.e., 58.5% of the students replied with feedback. All respondents replied that the preparatory course was useful. They also replied that, based on their self-evaluation, they were satisfied with their level of English language skill improvement after the rotation. Pharmaceutical knowledge satisfaction, however, was slightly decreased. All respondents replied that this program was of a satisfactory nature, with 71%, 63%, and 92% of the respondents replying that they could acquire the knowledge, skills, and attitude program objectives respectively. SUMMARY: It is possible to successfully develop an overseas clinical rotation program. Students were quite satisfied upon completion and achieved the expected objectives.

Management of Intra-Articular Distal Radius Fractures: Volar or Dorsal Locking Plate-Which Has Fewer Complications?

BACKGROUND: The aim of this study was to compare the functional outcomes and complications of volar and dorsal plating for the management of intra-articular distal radius fractures, with special regard to indications for dorsal plating. Furthermore, we examine the rationale for choosing dorsal plating and its frequency of use. METHODS: Clinical assessments included range of motion measurements at the wrist; grip strength; the Quick Disabilities of the Arm, Shoulder, and Hand score; and the Gartland and Werley score. Clinical results were compared with those achieved using a volarly placed locking plate system. According to Lutsky's plate theory, the rationale for choosing dorsal plating was based on 4 types of pathologic fractures. RESULTS: Of 112 patients, 38 patients were treated with open reduction internal fixation via a dorsal approach and 68 patients were treated using a volar approach. Except for wrist flexion, there were no other statistical differences in the clinical results between groups for both subjective and objective parameters. There were no statistically significant differences in the complication rates between the volar and dorsal plated groups. One serious complication occurred after volar plating. The most common reason for choosing dorsal plating was irreducible dorsal die-punch fractures. CONCLUSIONS: The treatment of displaced intra-articular distal radius fractures with a dorsally versus a volarly placed interlocking plate system demonstrated similar clinical results. Postoperative complications were not readily observed in the patients treated with a dorsal locking plate. Certain fracture patterns are more appropriately stabilized using a dorsal plate fixation.

Dual Plating Technique for Volar Rim Fracture of the Distal Radius Using DePuy-Synthes 2.0 m and 2.4 mm Locking Plates.

BACKGROUND: To assess the surgical results of distal radius fractures with the involvement of a volar rim fragment using the DePuy-Synthes 2.0 mm and 2.4 mm locking plates. METHODS: Subjects were six women and one man of average age 57 years (range, 31-83 y) and a mean follow-up period of 9 months (range, 5-19 mo) with AO B3 (volar shearing) distal radius fractures. Time of the procedure, physical examination of wrist range of motion, grip strength compared with the contralateral healthy wrist, and radiographic evaluation (volar tilt, radial inclination, and ulnar variance) were evaluated. The Visual Analog Scale (VAS: 0 points represents no pain, 100 points represents the worst pain possible) and the Quick Disability of the Arm, Shoulder, and Hand questionnaire (QuickDASH, 0 = no disability, 100 = extreme disability) were completed by patients at the final follow-up. RESULTS: The average time of the procedure was 74 min. There were no perioperative complications. Average radiographic measures were: volar tilt, 8°; radial inclination, 23°, and ulnar variance, 0 mm. Wrist range of motion averaged 63° in wrist extension (range, 55-80°) and 55° in wrist flexion (range, 45-65°). Grip strength averaged 81% of the contralateral side at final evaluation (range, 67-100%). The mean QuickDASH score was 3.0 points (range, 0-9.1 points) and the mean VAS for pain was 9.3 at final follow-up. CONCLUSIONS: Open reduction internal fixation with the DePuy-Synthes 2.0 mm and 2.4 mm locking plates is an effective means of fixing a distal radius fracture that includes a volar rim fragment without interfering with flexor tendon gliding.

Asymptomatic Flexor Tendon Damages after Volar Locking Plate Fixation of Distal Radius Fractures.

BACKGROUND: To investigate asymptomatic flexor tendon damages after volar locking plate fixation of distal radius fractures in 32 wrists of 32 patients with distal radius fractures fixed using two plate types. Sixteen patients received the Acu-Loc volar distal radius plate, and the remaining 16 patients received the Aptus distal radius correction plate. METHODS: The flexor pollicis longus (FPL) tendon and flexor digitorum profundus were evaluated according to intraoperative findings at plate removal. Ultrasonography was used to measure the distance between the FPL tendon and distal edge of the plates (FPL plate distance) before plate removal, the distance between the FPL tendon and distal edge of the radius (FPL radius distance) after plate removal, in the contralateral wrist, and the angle between an extension line of a volar surface line on the proximal FPL tendon and a second volar surface line on the distal FPL tendon (FPL angles). RESULTS: Erosion of the FPL tendon was identified in four wrists, and erosion of the flexor digitorum profundus of the index finger was identified in one wrist. All five cases of wrists with flexor tendon damage had Acu-Loc plates installed. The average FPL angle before plate removal was 15.4° in the wrists with tendon damage, which was statistically significantly larger than the average FPL angle in the wrists without erosion. CONCLUSIONS: The type of plate and larger FPL angle on ultrasonography may be the risk factors for flexor tendon damage.

Novel Suture Anchor Technique with Continuous Locking Stitch for Collateral Ligament Repair.

Collateral ligaments are difficult to repair due to large amount of fraying in detached ligaments and attenuated stumps that may not provide enough strength after the repair. Although strong locking sutures are used to repair the ligament with proper tension, these damages can cause pull-out failure or relaxation of the repaired ligaments even from undersized load that may extend postoperative splinting or casting time. Furthermore, current suture techniques can repair varus or valgus instability of the elbow and radial or ulnar instability of the fingers, but these techniques do not offer rotatory stability of these areas. We have developed a novel suture anchor technique that has overcome this problem of current suture techniques, and this can be used to correct rotatory instability in the elbow and fingers. We used this procedure in seven cases with injury of collateral ligament in the elbow and eight cases with detached collateral ligaments of finger joint. No patient experienced rerupture or any kind of residual instability. We believe that the proposed method can produce much stronger repair and may shorten the postoperative immobilization period.

Closed mallet thumb injury: Our experience of 10 patients treated with surgery and a systematic review.

OBJECTIVE: This retrospective study reports 10 patients with closed mallet thumb injury treated with surgery and compares the clinical outcomes achieved with those of previously described patients who were treated with either conservative therapy or surgery. METHODS: We report the outcomes of a series of 10 patients who received surgical treatment at our institutions. Due to the rarity of closed mallet thumb, a systematic review was conducted, and the results of a literature search were compared with our case series to strengthen our conclusions. The previously described patients were categorized into two groups: the surgically treated group (16 patients) and the conservatively treated group (10 patients). The following patient and injury characteristics were documented: age, gender, injured side, time from injury to treatment, mechanism of injury, extension lag at first visit, postoperative range of motion (ROM) of the interphalangeal joint, immobilization period, and follow-up period. RESULTS: Statistical analyses showed no significant differences in the clinical results, except for shorter immobilization periods between our series and the previously described patients involving conservative treatment (4.9 ± 0.9 vs. 9.5 ± 2.3 weeks, respectively; P = 0.0053). CONCLUSIONS: This study suggests that surgery may result in more rapid recovery.

Clinical results of a percutaneous technique for trigger digit release using a 25-gauge hypodermic needle with corticosteroid infiltration.

Clinical results of a percutaneous needle trigger digit release (PNTDR) technique using a 25-gauge needle with corticosteroid infiltration are reported. This prospective study assessed 52 digits that underwent PNTDR. Experimental results were compared with those of a control group with only steroid injection. Patients who underwent PNTDR were divided into diabetic and nondiabetic groups, and assessed after 1 week, and 1, 2, 3, and 6 months post surgery. The quick disability of the arm, shoulder, and hand (QuickDASH) questionnaire and visual analog scale (VAS) score for pain were completed both before and after surgery. PNTDR showed better statistical results than the control group. At final follow-up, 94% of patients were rated as excellent or good, recurrence was observed in 3 digits, and QuickDASH and VAS score significantly decreased. This technique was equally effective in patients with moderate or well-controlled diabetes with favorable results.

A Simple, Easy, and Reliable Technique of Phalangeal Corrective Osteotomy for Overlapping Fingers.

BACKGROUND: The theory that malrotation is best assessed by making a fist and looking for digital overlap was the basis for devising a simple, easy, and reliable technique for phalangeal corrective osteotomy. METHODS: This study assessed the phalangeal corrective osteotomy technique in 7 digits, involving 7 cases in 6 patients; 1 patient required treatment bilaterally. This technique required the use of a small hologram 2-row plate and screws to maintain stable fixation during aggressive postoperative therapy. Evaluation of the clinical results was based on the total range of active motion (%TAM), the grading of results according to Büchler, and the severity of pain reported by patients using the visual analog scale. The disability of the arm, shoulder, and hand questionnaire was completed preoperatively and at final follow-up by patients. RESULTS: Corrective osteotomy corrected the overlapping of digits in all of the patients. There were no perioperative complications. Bone union was obtained in all cases, on average 13.4 weeks after surgery. Two osteotomies required secondary tenocapsulolysis concomitant with implant removal surgery. In light of total range of active motion and Büchler's grade, all the patients had excellent to good results for both criteria at final follow-up. No patient complained about pain. Mean disability of the arm, shoulder, and hand scores significantly decreased from 16.9 (range, 11.3-26.5) preoperatively to 3.9 (range, 0-7.6) postoperatively. CONCLUSIONS: Phalangeal corrective osteotomy was performed using a simple, easy, and reliable technique.

Clinical Results of Percutaneous Needle Fasciotomy for Dupuytren's Disease in Japanese Patients.

BACKGROUND: Clinical results of percutaneous needle fasciotomy (PNF) in Japanese patients with Dupuytren's disease are reported. METHODS: In this prospective study, 51 patients (103 fingers: 1 index, 9 middle, 47 ring, and 46 small) underwent PNF at 99 metacarpophalangeal (MCP) and 68 proximal interphalangeal (PIP) joints. Patients were assessed postoperatively after 1 day, at 1, 2, 4, 6, and 8 weeks, and at 3, 6, 9, and 12 months. Correction of contracture was measured in degrees, and an improvement index (% improvement) was described previously by Tonkin et al. A correction of the contracture to 5° or less at each joint and at each digital ray represented a successful correction. The recurrence rates in MCP and PIP joints were also evaluated. Correlations between the Tubiana classification stage and successful correction, % improvement, and recurrence rate were evaluated. The relationships between recurrence rate and the diathesis score (more/less than 5 points) and between recurrence rate and age at surgery (<50/≥50 years) were also examined. RESULTS: In MCP and PIP joints, the improvement maintained at final follow-up was 89% and 57%, respectively, with successful corrections in 89% and 76%, respectively. PNF corrected digital rays at various Tubiana stages: stage 1 = 100%, stage 2 = 82%, stage 3 = 46%, and stage 4 = 0%. Improvements were preserved in stage 1 = 83%; stage 2 = 62%; stage 3 = 58%, and stage 4 = 60%. Recurrence of Dupuytren's disease was significant for the PIP joint, severe Tubiana stage, and younger patients. CONCLUSIONS: Clinical results of PNF in Japanese patients with Dupuytren's contractures were similar to those of whites.

Surgical Technique and Clinical Results for Trapeziometacarpal Arthrodesis Using Locking Plate Fixation in Women Aged 50 Years or Older.

BACKGROUND: The authors hypothesized that locking plates have the potential to decrease the risk of nonunion for trapeziometacarpal joint arthrodesis and eliminate the period of postoperative immobilization. The surgical technique is described and the clinical results are reported for Eaton stage III trapeziometacarpal joint arthrodesis using locking plate fixation in elderly women. METHODS: The outcomes of 18 fusion operations with a 2-year follow-up were assessed during this prospective study. Patients were evaluated for bone union, grip strength, tip and key pinch strength, and Kapandji opposition scores. The Disabilities of the Arm, Shoulder and Hand questionnaire and visual analogue scale pain scores were obtained from the patients and evaluated. In addition, complications were assessed. RESULTS: Bone unions were obtained for 16 of 18 fusions. Grip strength was 18.3 kg (range, 12.5 to 26.0 kg), tip pinch strength was 5.6 kg (range, 3.5 to 7.5 kg), and key pinch strength was 6.4 kg (range, 4.0 to 7.5 kg). The Kapandji opposition score was 8.3 points (range, 8 to 10). Disabilities of the Arm, Shoulder and Hand questionnaire score decreased from 54.2 (range, 68.8 to 39.4) to 8.8 (range, 3.9 to 22.0), and visual analogue scale pain scores decreased from 8.3 (range, 8 to 10) preoperatively to 0.9 (range, 0 to 4) postoperatively. Malpositioned devices were removed from two patients. One symptomatic patient required removal of the fixation device as a result of hardware loosening. CONCLUSION: The results for arthrodesis with a locking plate are comparable to results with a nonlocking plate and are quite satisfactory in the appropriate hands. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A case report of acute cubital tunnel syndrome caused by venous thrombosis.

Compression neuropathy of the ulnar nerve at the elbow is well-recognised as cubital tunnel syndrome (CuTS). Many causes of ulnar neuropathy at the elbow have been identified. A previously unreported finding of ulnar nerve compression in the cubital tunnel caused by a thrombosed proximal ulnar recurrent artery vena comitans is described.

Elucidation of molybdosilicate complexes in the molybdate yellow method by ESI-MS.

The formation of molybdosilicate in the molybdate yellow method is elucidated by ESI-MS. Polymeric silicic acids were hydrolyzed to monomers, and molybdosilicates with a Keggin structure were formed. Each step of the formation reaction of molybdosilicate from molybdic and silicic acids between pH 1 and 2 was clarified by ESI-MS at the molecular level. In a solution below pH 0.5, the polymers of the molybdic acids were decomposed because of the high concentration of sulfuric acid. Excess sulfuric acid prevented the formation of molybdosilicate. Thus, none of the silicic acids reacted to form molybdosilicate at this pH, despite the presence of silicic acid and sulfate ions in the solution. Above pH 2, the condensation of molybdic acids occurred to form α-molybdosilicate. ESI-MS provides information on the formation of molybdosilicate and the individual reaction species present in the reaction mixture.

Thumb opposition in severe carpal tunnel syndrome with undetectable APB-CMAP.

Thumb opposition does not always represent the function of the median nerve due to variations in thenar muscle innervation. One hundred and thirty hands of 109 idiopathic carpal tunnel syndrome (CTS) patients with an undetectable compound muscle action potential of the abductor pollicis brevis (APB-CMAP) were classified into one of four groups; Type 1 (86.2%) had thenar muscle atrophy and could not perform thumb opposition; Type 2 (10.8%) had thenar muscle atrophy but could perform thumb opposition; Type 3 (2.3%) did not have thenar muscle atrophy and could perform thumb opposition, but needle electromyography of the APB showed neurogenic changes and Type 4 (0.8%) had no thenar muscle atrophy, could perform thumb opposition, and needle electromyography showed no neurogenic changes. Over 10% of severe CTS patients have mild or no muscle atrophy and intact thumb opposition. The purpose of this study was to investigate the variations in thenar muscle innervation in patients with severe CTS.

[Survey report on magnetic resonance equipment damage in areas in Miyagi Prefecture affected by the Great East Japan Earthquake].

A questionnaire comprising 14 items, inquiring about the state of damage, whether safety could be ensured, and progress of repair and restoration was distributed to 984 facilities in seven prefectures on the Pacific coast as part of a fact-finding survey of damage caused to magnetic resonance (MR) devices by the Great East Japan Earthquake. In all, 458 responses (46.6%) were collected. In Miyagi Prefecture alone, 65 responses from 105 questionnaires were collected (response rate: 61.9%). The overall incidence of damage was 19.2%, with 57 facilities (12.4%) reporting that displacement of the magnets was the most common problem. The damage event rate in Miyagi Prefecture was 51.3%, with displacement of the magnet being highest at 17 cases (26.2%). There was a high rate of 13 cases (26.5%) of chiller and air conditioning failures and a rapid loss of He in ten MR scanners (20.4%). Notably, 87.8% of facilities in Miyagi Prefecture (24.5% of the total) were affected by earthquakes exceeding 6 on the Japanese Seismic Intensity Scale. Flood damage caused by the tsunami was also seen along the Sanriku coast to Sendai City (six MR scanners, 50% of the total), and was typical of the damage seen in Miyagi Prefecture.