Purpose: The purpose of this study was to investigate the displacement of the median nerve in the carpal tunnel during finger motion at varied wrist positions using transverse ultrasound in healthy volunteers, in order to clarify the appropriate position of a wrist splint in treating carpal tunnel syndrome. Methods: Fifty wrists of 25 asymptomatic volunteers were evaluated by transverse ultrasound. The location of the median nerve in the carpal tunnel was examined at 5 wrist positions (neutral, 60° dorsiflexion, 60° palmar flexion, 40° ulnar flexion, 10° radial flexion) with all 5 fingers in full extension, all 5 fingers in full flexion, and isolated thumb in full flexion, respectively. Results: The median nerve was located significantly (p<0.05) more dorsally at the wrist dorsal flexion position, more ulnopalmarly at the wrist palmar flexion position, more radially at the wrist radial flexion position, and more radially at the wrist ulnar flexion position than at the wrist neutral position in all 5 fingers at full extension. The median nerve moved the most significantly dorsally among all wrist positions during finger motion at the wrist dorsal flexion position (p<0.05). Conversely, the median nerve moved the most significantly ulnopalmarly at the wrist palmar flexion position with all 5 fingers in full flexion among all wrist positions during finger motion (p<0.05). This latter wrist and finger position induced significant displacement of the median nerve toward the transverse carpal ligament, and compressed it between the flexor tendons and the transverse carpal ligament. Conclusions: This study showed that there is a significant relationship between the median nerve displacement in the carpal tunnel and the motion of the wrist and fingers. This finding suggests that the compression or the shearing stress of the median nerve caused by the movement of the flexor tendons is reduced in the wrist dorsal flexion position compared with other wrist positions. This wrist dorsal flexion position could be the appropriate position for a wrist splint in the treatment for carpal tunnel syndrome. This ultrasound information provides further knowledge and understanding of the biomechanics and pathophysiology of the carpal tunnel. It could also help in the accurate analysis and assessment of diagnostic images and treatment for carpal tunnel syndrome.
Measurement of interrupter airway resistance (Rint) is a convenient alternative to standard spirometry for assessing respiratory function in uncooperative young children. The aim of the present prospective study was to establish the normative data and predictive equation of Rint in Japanese preschool children. A total of 214 children were enrolled from a single kindergarten; however, 129 were excluded because they met at least 1 of the exclusion criteria, such as wheezing history or recent common cold. Expiratory Rint values were assessed in 85 of the children, but technically unsatisfactory measurements were obtained in 5 of them. Thus, 80 healthy Japanese children (39 boys and 41 girls) without any history or symptoms of respiratory tract diseases were evaluated. Their age, body height, and body weight ranges (median) were 1.67 to 6.42 (4.38) years, 79.8 to 120.9 (102.5) cm, and 10.4 to 24.9 (15.8) kg, respectively. The mean Rint was 0.93±0.25 kPa/L/s (range=0.46-1.49 kPa/L/s). The Rint tended to decrease with increasing age and body height (r=-0.65; P<0.01), but sex played no significant role (P=0.71). The predictive equation based on body height derived by linear regression was expiratory Rint (kPa/L/s) =2.513-0.01567×body height (cm) (multiple correlation coefficient=0.653). Because 79 of the 80 measured Rint values were within 140% of the predictive Rint value, we calculated a 140% cut-off for predicting bronchoconstriction. Our results provide a reference value for evaluating the degree of airway obstruction in young Japanese children.
Background: Comatose acute stroke patients are at high risk of malnutrition, especially hypoproteinemia. However, when to start and how to provide nutrition to these patients are unclear. The purpose of this study was to determine the optimum timing and methods of nutritional supplementation to comatose acute stroke patients. Methods: A total of 273 comatose acute stoke patients who were unable to eat were enrolled. They received peripheral intravenous low-calorie solutions for the first 4 days after admission (days 0-3), and serum protein concentrations were measured on days 2, 3, and 4. From day 4, 5 different nutritional regimens were administered (25 kcal/kg/day), (including enteral nutrition [EN], total parenteral nutrition [TPN], tube feeding of 20% glucose solution, and combinations of these nutritional supplementations),. Serum concentrations of total protein and albumin were measured on days 10, 14, and 21. The patients who had EN until day 21 from day 4 were defined as EN group, and who had TPN were as TPN group. Results: Serum protein concentrations decreased slightly on day 2 and decreased significantly on days 3 and 4. From day 4 to 14, the recovery of serum protein was better in the TPN group than in the EN group. Conversely, after day 14, recovery from hypoproteinemia was better in the EN group than in the TPN group. However, when diarrhea was caused by EN, further hypoproteinemia occurred and caused patients to require TPN. The recovery from hypoproteinemia was earliest in patients receiving TPN with 20% glucose fed through a nasogastric tube from day 4 to 13 followed by EN after day 14. Hospitalization was statistically shorter for patients with a nutritionally early recovery than for patients with a delayed recovery, but clinical outcome did not differ significantly between the groups. Conclusion: It is nutritionally disadvantageous not to start nutritional support within 3 days after admission in comatose acute stroke patients. However, starting EN too early is not nutritionally beneficial, and TPN with 20% glucose fed through a tube is recommended as adequate nutrition for these patients. However, TPN should not be employed for longer than 10 days, because switching to EN after this period contributes to better nutritional recovery than continuing TPN.
A 61-year-old man with bilateral purpura of the lower limbs and subsequent edema, was hospitalization after renal dysfunction developed. The presence of hepatitis C virus (HCV) RNA and cryoglobulin and the finding of membranoproliferative glomerulonephritis on renal biopsy led to a diagnosis of HCV-related glomerulonephritis due to cryoglobulinemia. Because of the pre-existence of nephrotic syndrome and the continuously increasing serum level of creatinine, treatment with cryofiltration, interferon, and steroids was started. After 5 cryofiltration sessions, the cryocrit level had decreased to 1% and the levels of serum creatinine and proteinuria had also decreased. However, 3 weeks after the start of treatment, nephrotic syndrome developed again and was accompanied by lower-extremity mononeuropathy and renal dysfunction. Thereafter, the patient showed disorientation, an affective disorder, and delirium, and his condition gradually deteriorated. Radiological examination of the head and examination of the cerebrospinal fluid showed no abnormalities. Despite the withdrawal of the interferon therapy and the reduction of the steroid dose, the patient's conditions remained unchanged, and the level of consciousness deteriorated. Although cryofiltration had beneficial effects and plasma exchange was continuously performed, the patient died on the 74th hospital day. Because of the significant changes due to ventilatory support and hemorrhage associated with disseminated intravascular coagulation, the autopsy findings did not allow us to definitively determine whether the symptoms had been caused by the HCV-related membranoproliferative glomerulonephritis or the interferon therapy or both. We have reported this case to provide insight into whether interferon therapy should be administered for HCV-related membranoproliferative glomerulonephritis with marked neurological symptoms due to cryoglobulinemia.
Portal venous gas has traditionally been considered an indicator of a poor prognosis due to bowel necrosis. Portal venous gas has recently been detected in patients with various clinical conditions, such as Crohn's disease, chemotherapy, and blunt abdominal injury without bowel necrosis. We herein report the first case of a patient with rectal cancer in whom portal venous gas developed after low anterior resection without anastomotic leakage or bowel necrosis. A 66-year-old man who had undergone low anterior resection started having severe diarrhea the day after the operation. A fever was present for 2 days after the operation but resolved on postoperative day 3. The patient complained of abdominal pain 5 days postoperatively. Computed tomography showed portal venous gas. Emergency open laparotomy was performed, but only limited ascites fluid without leakage or bowel necrosis was found. We irrigated the abdominal cavity and performed an ileostomy with insertion of a drainage tube in the rectovesical pouch. Only serous ascites was discharged through the drainage tube. The portal venous gas disappeared 3 days after the second operation. The patient was discharged in good condition 21 days after the first operation. Portal venous gas can develop after rectal surgery without anastomotic leakage or bowel necrosis. Conservative treatment is reasonable for patients without signs of bowel necrosis or panperitonitis. However, patients with portal venous gas must be carefully observed because portal venous gas may be life threatening.
A 70-year-old woman who had been treated for bipolar disorder and dementia was admitted to the intensive care unit of a university hospital with severe dyspnea; pulmonary arterial hypertension was diagnosed after cardiac catheterization was performed. Computed tomography pulmonary angiography showed typical signs of chronic thrombosis in the proximal pulmonary artery without an adequate amount of fresh thrombi, which appeared to be the cause of the elevation in pulmonary artery pressure, and resulted in severe hypoxemia. Therefore, the pulmonary arterial hypertension was classified as belonging to the chronic thromboembolic pulmonary hypertension subgroup. Although the patient's respiratory condition was classified as World Health Organization class IV, she was treated with the combination of oral ambrisentan and tadalafil, rather than intravenous epoprostenol, which she was unable to tolerate. Consequently, both her symptom and hemodynamic status showed rapid improvement with only oral pulmonary vasodilators. This case demonstrates the efficacy of oral treatment alone in elderly patients with severe chronic thromboembolic pulmonary hypertension.
Pulmonary sequestration is a type of bronchopulmonary malformation defined as an isolated portion of lung tissue with systemic arterial supply and no bronchial communication. Carbohydrate antigen 19-9 (CA19-9) has been used for diagnosis and follow-up of gastrointestinal tumors. The current study presents a rare case of intralobar pulmonary sequestration associated with the marked elevation of CA19-9. A 39-year-old female patient was admitted to our hospital due to acute liver injury with marked elevation of serum CA19-9 (3,051.1 μmol/mL), and was then diagnosed with intralobar pulmonary sequestration after examination and surgery. After the pulmonary resection, the serum CA19-9 levels decreased to normal ranges. We briefly reviewed the literature on elevated serum CA19-9 levels and pulmonary sequestration since 1988. We found that serum CA19-9 levels are increased not only in patients with digestive tract cancers but also in those with nonmalignant diseases such as pulmonary sequestration.