Japanese Orthopaedic Association (JOA) clinical practice guidelines on the management of lateral epicondylitis of the humerus - Secondary publication.

BACKGROUND: The guidelines presented herein provide recommendations for the management of patients with lateral epicondylitis of the humerus. These recommendations are endorsed by the Japanese Orthopaedic Association (JOA) and Japan Elbow Society. METHODS: The JOA lateral epicondylitis guideline committee revised the previous guidelines on the basis of the "Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014", which emphasized the importance of the balance between benefit and harm, and proposed a desirable method for preparing clinical guidelines in Japan. These guidelines consist of 11 clinical questions (CQs), 9 background questions (BQs), and 3 future research questions (FRQs). For each CQ, outcomes from the literature were collected and evaluated systematically according to the adopted study design. RESULTS: The committee proposed recommendations for each CQ by determining the level of evidence and assessing the consensus rate. Physical therapy was the best recommendation with the best evidence. The BQs and FRQs were answered by collecting evidence based on the literature. CONCLUSIONS: The guidelines presented herein were reviewed systematically, and recommendations were proposed for each CQ. These guidelines are expected to be widely used not only by surgeons or physicians but also by other healthcare providers, such as nurses, therapists, and athletic trainers.

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.

Reliability of radiographic measurement of lateral capitellohumeral angle in healthy children.

This retrospective cohort study was designed to validate the reliability of measurement of the lateral capitellohumeral angle (LCHA), an index of sagittal angulation of the elbow, in healthy children. The results were compared to the Baumann angle (BA), which is a similar concept to LCHA.Sixty-two radiographs of the elbow in healthy children (range, 2-11 years) were reviewed by 6 examiners at 2 sessions. The mean value and reliability of the measurement of LCHA and BA were assessed. Intraobserver reliability and interobserver reliability were calculated using intraclass correlation coefficients (ICCs).The mean LCHA value was 45° (range, 22° to 70°) and the mean BA was 71° (range, 56° to 86°). The ICCs for intraobserver reliability of the LCHA measurements were almost perfect for 2 examiners, substantial for 3 examiners, and moderate for 1 examiner with a mean value of 0.77 (range, 0.57-0.95). For BA measurements, the ICCs were almost perfect for 1 examiner and substantial for 5 examiners with a mean value of 0.74 (range, 0.66-0.83). The ICCs for interobserver reliability between the first and second measurements were both moderate for LCHA (0.56 and 0.51) and for BA (0.52 and 0.50).LCHA showed almost the same reliability in measurement as BA, which is the gold standard assessment for coronal alignment of the elbow. LCHA showed moderate-to-good reliability in the evaluation of sagittal plane elbow alignment.

Sauvé-Kapandji procedure with headless compression screw in patients with rheumatoid arthritis.

OBJECTIVE: We examined the surgical outcomes of the Sauvé-Kapandji (S-K) procedure using a headless compression screw and a metal cancellous screw in patients with rheumatoid arthritis (RA). METHODS: This retrospective study included 41 RA patients who underwent the S-K procedure for distal radioulnar joint disorders with two screws: headless compression screws (HCS group, n = 20) and cannulated cancellous screws (CCS group, n = 21). Clinical and radiographic outcomes were assessed 1 year after surgery. Radiographic outcomes included bony union of the distal radioulnar joint (DRUJ), bone resorption around the screw, a screw back-out, and use of additional K-wire. We investigated any complications related to the screw head. RESULTS: All 20 patients in the HCS group showed bone fusion of the DRUJ. In the CCS group, an asymptomatic non-union was observed in one patient and additional K-wire was needed to stabilize the DRUJ in three patients. No patients complained of any complications related to the screw head in the HCS group, while the CCS group demonstrated the hardware protrusion in two patients who complained of tenderness or discomfort at the screw head. CONCLUSIONS: The use of a headless compression screw in the S-K procedure is useful in patients with RA.

Acute Compartment Syndrome of Upper Extremities with Tendon Ruptures.

BACKGROUND: It is well known that acute compartment syndrome is associated with fracture of the forearm, while involvement of soft tissue injury including musculotendinous injury remains unclear. The purpose of this study was to evaluate the soft tissue involvement, including musculotendinous ruptures, in acute compartment syndrome of the upper limb. METHODS: We retrospectively enrolled 16 patients who underwent surgical treatment for acute compartment syndrome of the upper extremity. The average age of the patients was 47 years (range, 14 to 79) and the mean follow-up period after the surgery was 15 months (range, 12 to 29). Complications included at least one presentation at the final follow up of sensory disturbances or motor disturbances. We examined the presence of musculotendinous injury mechanism of injury, presence of fracture, the performance of skin grafting, and complications. RESULTS: Mechanism of injury of "caught in a machine" was found in six cases. Three of these patients had musculotendinous ruptures and all muscle tears were revealed by intraoperative findings. No patients had muscle ruptures with other injury mechanisms. Seven out of 16 patients (44%) developed complications at final follow-up. Skin grafting was performed in six patients, and five of these patients developed complications. Only one of the nine patients without complications underwent skin grafting. CONCLUSIONS: In cases of high-energy injuries, the surgeon should suspect the presence of a musculotendinous injury prior to surgery.

Predictors of postoperative outcomes of cubital tunnel syndrome treatments using multiple logistic regression analysis.

BACKGROUND: This retrospective study was designed to investigate prognostic factors for postoperative outcomes for cubital tunnel syndrome (CubTS) using multiple logistic regression analysis with a large number of patients. METHODS: Eighty-three patients with CubTS who underwent surgeries were enrolled. The following potential prognostic factors for disease severity were selected according to previous reports: sex, age, type of surgery, disease duration, body mass index, cervical lesion, presence of diabetes mellitus, Workers' Compensation status, preoperative severity, and preoperative electrodiagnostic testing. Postoperative severity of disease was assessed 2 years after surgery by Messina's criteria which is an outcome measure specifically for CubTS. Bivariate analysis was performed to select candidate prognostic factors for multiple linear regression analyses. Multiple logistic regression analysis was conducted to identify the association between postoperative severity and selected prognostic factors. RESULTS: Both bivariate and multiple linear regression analysis revealed only preoperative severity as an independent risk factor for poor prognosis, while other factors did not show any significant association. CONCLUSIONS: Although conflicting results exist regarding prognosis of CubTS, this study supports evidence from previous studies and concludes early surgical intervention portends the most favorable prognosis.

Reliability and Validity of Radiographic Measurement of the Humerus-Elbow-Wrist Angle in Healthy Children.

This article was updated on May 4, 2017, because of a previous error. The proximal line drawn in Figure 1 was different from the line described in the Materials and Methods section, which reads "The proximal line was drawn at the level of the radial tuberosity, and the distal line was made at the level of the top of the radial bowing (Fig. 1)." The correct figure is presented in this version of the article. An erratum has been published: JBJS Open Access. 2017 May 26;2(2):e0012ER. BACKGROUND: We conducted a retrospective cohort study to evaluate the normal value, range, reliability, and validity of measurement of the humerus-elbow-wrist angle, an index of valgus-varus angulation of the elbow, in healthy children. This measurement has been used to assess postoperative radiographic results. METHODS: Radiographs of the elbow in 62 healthy children ranging from 2 to 11 years of age were reviewed by 6 examiners at 2 sessions. The mean value and the reliability of measurement of the humerus-elbow-wrist angle, the carrying angle, and the Baumann angle were assessed. Intraobserver and interobserver reliability were calculated with use of intraclass correlation coefficients (ICCs). To determine concurrent validity, the association between the humerus-elbow-wrist angle and carrying angle measurements was examined with use of Pearson correlation coefficients. RESULTS: The mean humerus-elbow-wrist angle value was 12.0° (range, 1° to 24°), and the mean carrying angle was 14.6° (range, 4° to 28°). The ICCs for intraobserver measurements of the humerus-elbow-wrist angle were almost perfect for 4 examiners and were substantial for 2 examiners, with a mean value of 0.85 (range, 0.73 to 0.94). The ICCs for interobserver reliability with regard to the first and second measurements of the humerus-elbow-wrist angle were both substantial (0.76 and 0.78). A significant association between the humerus-elbow-wrist angle and the carrying angle was observed, with the Pearson correlation coefficients ranging from 0.74 to 0.90 (p < 0.001). CONCLUSIONS: Measurement of the humerus-elbow-wrist angle demonstrated good reliability and validity. The humerus-elbow-wrist angle is a reliable radiographic measure of coronal alignment of the humerus and forearm.

Cigarette Smoking Is Associated With Cubital Tunnel Syndrome.

INTRODUCTION: The aim of this study was to validate the potential association between cigarette smoking and cubital tunnel syndrome (CubTS). METHODS: One hundred patients with CubTS were compared with 100 controls with ulnar abutment syndrome matched for age, gender, and body mass index. The smoking status was compared between patients and controls using the sign test and the Wilcoxon signed rank test. Conditional logistic regression was used to calculate the association between CubTS and pack-years smoked. RESULTS: A significant association was found between increased pack-years smoked and CubTS. A significant difference in the number of never smokers and ever smokers was observed between the patients with CubTS and controls. The difference in mean pack-years in the patients and controls was highly significant. A dose-dependent association with pack-years was found between patients and controls. CONCLUSIONS: High cumulative cigarette smoking is associated with CubTS. Muscle Nerve 54: 1136-1138, 2016.

Subcutaneous flexor tendon rupture in patients with rheumatoid arthritis.

OBJECTIVE: We examined the clinical features and functional outcomes of surgically repaired subcutaneous flexor tendon ruptures in patients with rheumatoid arthritis (RA). METHODS: This retrospective study included 41 fingers of 24 RA patients who underwent surgical treatment for flexor tendon ruptures. Evaluations performed at the time of presentation following rupture were C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and disease activity score in 28 joints (DAS28)-ESR, as well as Larsen grading for carpal bone destruction. The ruptured tendon and postoperative active range of motion (ROM) of digits were also examined. RESULTS: The mean CRP was 2.4 mg/dl, ESR was 52 mm/h, and the DAS28-ESR was 4.5. Carpal bone destruction according to Larsen grade IV-V was observed in 18/24 patients. Affected digits were most commonly the thumb (12) and the ring and little fingers (9 each). Tendon ruptures were most common in the carpal tunnel in zone IV. The mean postoperative finger ROM (flexion/extension) was 38°/2° for the interphalangeal (IP) joint of the thumb and 23°/-2° for the distal interphalangeal joint of the other four fingers. CONCLUSIONS: Patients with flexor tendon ruptures present with high disease activity and advanced bone destruction. It is important to reduce the risk of progressive bone destruction and subsequent tendon rupture via tight control of disease activity.

Differences between bipolar and unipolar depression on Rorschach testing.

BACKGROUND: The bipolar-unipolar distinction in patients with a major depressive episode is the most important issue related to the diagnosis and treatment of mood disorders, but remains unresolved. This study was undertaken to compare bipolar and unipolar depression on Rorschach testing using the Comprehensive System with reference to healthy Japanese controls. METHODS: Patients with bipolar or unipolar depression who had undergone the Rorschach test for routine clinical purposes were followed up naturalistically for a long period. Based on diagnostic confirmation after long-term follow-up, scores on this test for patients with bipolar and unipolar depression were compared with those published elsewhere for healthy Japanese controls. RESULTS: The bipolar depression group showed significantly higher scores or positive findings in five variables of the Rorschach test, ie, WSum6, DR2 > 0, (CF + C) > FC + 2, PureC > 1, and Populars > 7, as assessed using the Comprehensive System, than did the unipolar depression group and healthy controls. These scores did not differ between the unipolar depression and control groups. CONCLUSION: The results of this study show thought disorder or cognitive slippage and marked laxness in modulating emotion in bipolar depression, indicating the psychopathological characteristics of bipolar disorder.

The valproate serum level in maintenance therapy for bipolar disorder in Japan.

The appropriate therapeutic serum valproate level in maintenance therapy for bipolar disorder is not well known. We studied the serum valproate levels in seventeen bipolar I and twenty-four bipolar II disorder outpatients who had been treated with stable doses of valproate successfully for at least 12 months as prophylactic therapy. The trough serum valproate levels were 52.2 +/- 20.4 microg/ml in bipolar I, and 41.0 +/- 18.3 microg/ml in bipolar II disorder patients, respectively. A greater trend towards a higher trough level (p = 0.07) was indicated in the bipolar I disorder group. We speculate that these valproate levels may be an approximation to the appropriate valproate levels in maintenance therapy and that there may be a correlation between the level of valproate required for stabilization and the subtype of the bipolar disorder. However, when interpreting these findings, certain limitations to this study? Need to be taken into account as follows. The sample size was small. We could not look at a group on valproate that had relapsed and a group that had dropped out of maintenance therapy. Further studies are needed.

[Cellular calcium signaling in bipolar disorder].

Many discussions have been made related to diagnosis of bipolar disorder in recent years. Especially, much attention has been devoted to the activation syndrome induced by antidepressants and the bipolar spectrum disorder proposed by Gahemi. Differential diagnosis between bipolar depression and monopolar depression is extremely important when planning treatment strategy, but it is difficult to differentiate between them using symptomatic information alone. Therefore, if an easily-accessible biological marker can differentiate between them, it is expected to be extremely useful in clinical practice. Several trait biological markers associated with the pathophysiology of bipolar disorder have been identified with a high evidence level. Abnormality of cellular calcium signaling is regarded as one such replicable trait marker. Especially because human platelets are easily accessible, increasingly numerous reports describe studies of intracellular calcium concentration increase induced by various agonists in patients with bipolar disorder. Summarizing previous reports, the agonist-stimulated calcium response is enhanced significantly in patients with bipolar disorder compared to normal subjects, although resting intraplatelet calcium concentration does not differ between them. Moreover, serotonin-induced calcium response in monopolar depression and the other psychiatric diseases is not significantly different from that in normal subjects, which suggests that the enhanced calcium response to serotonin is specific to bipolar disorder among various diseases. However, several problems arise in using this marker as a supplemental tool of clinical diagnosis. First, the calcium response has a fairly common distribution between bipolar depression and monopolar depression groups although the means of the responses are significantly different. Consequently, it is difficult to differentiate clearly between bipolar depression and monopolar depression merely by setting a discriminating value. Second, it is necessary to measure calcium response as soon as possible after blood collection. Third, drugs taken at the time of blood collection might affect the calcium response. Finally little evidence exists showing whether functions in peripheral tissue actually reflect brain function. Therefore, many obstacles remain to be solved before using this marker in clinical practice.

Long-term naturalistic follow-up of lithium augmentation: relevance to bipolarity.

BACKGROUND: Whether bipolarity (unrecognized bipolar disorder) is related to the treatment response to lithium augmentation in antidepressant-refractory depression remains unclear. This study of responders and non-responders to lithium augmentation of 29 antidepressant-refractory patients with major depression, whom we had studied during 1995-1997, compared the bipolar diagnosis at the follow-up based on diagnostic confirmation after long-term follow-up. METHODS: Before being classified as stage 2 treatment-resistant depression, these patients had been treated adequately with at least two tricyclic or heterocyclic antidepressants from different pharmacological classes (a minimum of the equivalent of 150 mg of imipramine for 4 weeks). During 1995-1997, 29 patients received lithium augmentation. Their treatment responses were recorded. Mean follow-up was 8.0 years (range, 1-13 years). Bipolar conversion and full remission were evaluated. RESULTS: After the long-term follow-up, diagnoses were changed to bipolar depression in 3 of 4 lithium responders and 3 of 25 lithium non-responders; lithium augmentation was more effective for unrecognized bipolar patients. Only the family history of bipolar disorder predicted subsequent bipolar conversion. LIMITATIONS: Treatment was not controlled in this naturalistic study, which had a small sample size. CONCLUSIONS: Results of this long-term follow-up study suggest that bipolarity is related to a positive response to lithium augmentation in stage 2 treatment-resistant major depression. The family history of bipolar disorder suggests false unipolar depression, and therefore indicates lithium responders.

Pramipexole for stage 2 treatment-resistant major depression: an open study.

OBJECTIVE: To examine the effectiveness and safety of adjunctive pramipexole in the treatment of stage 2 treatment-resistant major depressive disorder. METHODS: This study included patients with moderate or non-psychotic severe major depressive disorder according to DSM-IV-TR criteria despite at least two adequate treatment trials with antidepressants from different pharmacological classes. Pramipexole 0.25 to 2 mg daily was added to antidepressant therapy. Previous treatments were continued unchanged, but no new treatments were allowed. We conducted assessments at baseline and at weeks 2, 4, 6, and 8. We defined response as a 50% or greater reduction on the Montgomery-Åsberg Depression Rating Scale (MADRS). RESULTS: Ten patients (4 men, 6 women) aged 43.7±11.4 years received pramipexole at mean dose of 1.3±0.6 mg/d. Mean MADRS scores improved significantly from baseline to endpoint (mean differences=11.4, 95% CI [4.1, 18.7], P=0.0064). At the endpoint, six of 10 (60%) were responders on MADRS (≥50% reduction). Two patients (20%) terminated early due to mild somatic and psychiatric adverse effects. CONCLUSION: These preliminary data suggest that the addition of pramipexole to antidepressant treatment may be effective and well tolerated in patients with stage 2 treatment-resistant major depressive disorder.

Depressive patients are more impulsive and inconsistent in intertemporal choice behavior for monetary gain and loss than healthy subjects--an analysis based on Tsallis' statistics.

OBJECTIVES: Depression has been associated with impaired neural processing of reward and punishment. However, to date, little is known regarding the relationship between depression and intertemporal choice (delay discounting) for gain and loss. This examination is potentially important for advances in neuroeconomics of intertemporal choice, because depression is associated with reduced serotonergic activities in the brain. DESIGN AND SETTING: We compared impulsivity and inconsistency in intertemporal choice for monetary gain and loss between depressive patients and healthy control subjects. METHODS: We conducted delay discounting tasks for gain and loss in depressed and healthy control subjects. We then quantified impulsivity and inconsistency in the delay discounting with parameters in the q-exponential discount function based on Tsallis' statistics. RESULTS: We observed that depressive patients were more impulsive and time-inconsistent in intertemporal choice action for gain and loss, in comparison to healthy controls. MAIN FINDINGS: Depressed patients were more irrational in temporal discounting. CONCLUSIONS: The usefulness of the q-exponential discount function for assessing the impaired decision-making by depressive patients was demonstrated. Furthermore, biophysical mechanisms underlying the altered intertemporal choice by depressive patients are discussed in relation to impaired serotonergic neural systems.

A possible association between missense polymorphism of the breakpoint cluster region gene and lithium prophylaxis in bipolar disorder.

Lithium is one of the most commonly used drugs for the treatment of bipolar disorder. To prescribe lithium appropriately to patients, predictors of response to this drug were explored, and several genetic markers are considered to be good candidates. We previously reported a significant association between genetic variations in the breakpoint cluster region (BCR) gene and bipolar disorder. In this study, we examined a possible relationship between response to maintenance treatment of lithium and Asn796Ser single-nucleotide polymorphism in the BCR gene. Genotyping was performed in 161 bipolar patients who had been taking lithium for at least 1 year, and they were classified into responders for lithium mono-therapy and non-responders. We found that the allele frequency of Ser796 was significantly higher in non-responders than in responders. Further investigation is warranted to confirm our findings.