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Hemorrhage inside the mammillary bodies (MMBs) is known to be one of the findings of Wernicke encephalopathy. Brain MRI of two patients with Wernicke-Korsakoff syndrome (WKS) demonstrated high susceptibility values representing hemosiderin deposition in MMBs by using quantitative susceptibility mapping (QSM). QSM provided additional information of susceptibility values to susceptibility-weighted imaging in diagnosis of WKS.

Background: Clinical guidelines recommend regular serum lithium monitoring every 3 to 6 months. However, in the real world, only a minority of patients receive adequate monitoring. Objective: This study aims to examine whether the use of the electronic health record (EHR)–nested reminder system for serum lithium monitoring can help achieve serum lithium concentrations within the therapeutic range for patients on lithium maintenance therapy. Methods: We conducted an unblinded, single-center, EHR-nested, parallel-group, superiority randomized controlled trial comparing EHR-nested reminders with usual care in adult patients receiving lithium maintenance therapy for mood disorders. The primary outcome was the achievement of therapeutically appropriate serum lithium levels between 0.4 and 1.0 mEq/L at 18 months after enrollment. The key secondary outcomes are included as follows: the number of serum lithium level monitoring except for the first and final monitoring; exacerbation of the mood disorder during the study period, defined by hospitalization, increase in lithium dose, addition of antipsychotic drugs or mood stabilizers, or addition or increase of antidepressants; adherence defined by the proportion of days covered by lithium carbonate prescription during the study period. Results: A total of 111 patients were enrolled in this study. A total of 56 patients were assigned to the reminder group, and 55 patients were assigned to the usual care group. At the follow-up, 38 (69.1%) patients in the reminder group and 33 (60.0%) patients in the usual care group achieved the primary outcome (odds ratio 2.14, 95% CI 0.82-5.58, P=.12). The median number of serum lithium monitoring was 2 in the reminder group and 0 in the usual care group (rate ratio 3.62; 95% CI 2.47-5.29, P<.001). The exacerbation of mood disorders occurred in 17 (31.5%) patients in the reminder group and in 16 (34.8%) patients in the usual care group (odds ratio 0.97, 95% CI 0.42-2.28, P=.95). Conclusions

[Background] Electroconvulsive therapy (ECT) is one of the most effective treatments for depression and schizophrenia, particularly in urgent or treatment-resistant cases. After ECT, regional gray matter volume (GMV) increases have been repeatedly reported both in depression and schizophrenia. However, the interpretation of these findings remains entangled because GMV changes do not necessarily correlate with treatment effects and may be influenced by the intervention itself. We hypothesized that the comparison of longitudinal magnetic resonance imaging data between the two diagnostic groups will provide clues to distinguish diagnosis-specific and transdiagnostic changes. [Method] Twenty-nine Japanese participants, including 18 inpatients with major depressive disorder and 11 with schizophrenia, underwent longitudinal voxel-based morphometry before and after ECT. We investigated GMV changes common to both diagnostic groups and those specific to each group. Moreover, we also evaluated potential associations between GMV changes and clinical improvement for each group. [Results] In both diagnostic groups, GMV increased in widespread areas after ECT, sharing common regions including: anterior temporal cortex; medial frontal and anterior cingulate cortex; insula; and caudate nucleus. In addition, we found a schizophrenia-specific GMV increase in a region including the left pregenual anterior cingulate cortex, with volume increase significantly correlating with clinical improvement. [Conclusions] Transdiagnostic volume changes may represent the effects of the intervention itself and pathophysiological changes common to both groups. Conversely, diagnosis-specific volume changes are associated with treatment effects and may represent pathophysiology-specific impacts of ECT.

Purpose: To provide an overview of how electroconvulsive therapy (ECT) practice in Japan has changed as the coronavirus disease 2019 (COVID-19) pandemic continues. Patients and Methods: We surveyed healthcare institutions, primarily university and general hospitals, regarding changes in the number of patients undergoing ECT and infection control measures in the early (August 2020) and recent (August 2021) stages of the COVID-19 pandemic. Data for the early and recent stages were also compared between urban and non-urban areas. Results: Among 32 facilities, the number of patients undergoing ECT decreased in 11 facilities (34.4%) from April 2020 to March 2021 compared with the previous year, whereas the number increased in 12 (37.5%) from April to June 2021 compared with the previous year. As of August 2021, some facilities had ongoing restrictions. Compared with non-urban facilities, the number of patients undergoing ECT decreased more in urban facilities, which also had more ECT restrictions. Maintenance ECT was used at the same rate as before the pandemic for 23 (82.1%) of 28 institutions. Regarding infection control measures, many facilities considered polymerase chain reaction testing before ECT and required all staff to wear surgical masks and eye shields during ECT. Conclusion: The COVID-19 pandemic in Japan greatly affected the use of ECT in 2020; however, by the summer of 2021, infection control measures were relatively well established, the number of ECT cases stabilized and increased, and the decision to use ECT was again possible.

[Introduction] Lurasidone has few metabolic adverse effects and is recommended as an alternative when other antipsychotic drugs considerably increase body weight or blood sugar concentrations. [Case presentation] An 81-year-old man with bipolar disorder developed hyperosmolar hyperglycemic syndrome as a side effect of lurasidone. Routine monitoring of blood glucose concentrations led to the early detection and treatment of this disease, preventing life-threatening complications. [Discussion and conclusion] We describe a rare case of lurasidone-induced hyperosmolar hyperglycemic syndrome. The mortality rate of this syndrome is estimated to be up to 20%. This rate is significantly higher than that of diabetic ketoacidosis (currently <2%). Although lurasidone is considered to have a low risk of raising blood glucose concentrations, symptoms of hyperglycemia must be evaluated and blood glucose concentrations should be monitored regularly.

Risa Hirata,1 Hirotsugu Kawashima,1,5 Takashi Tsuboi,2,5 Ken Wada,3,5 Minoru Takebayashi,4,5 Taro Suwa1,5 1Department of Psychiatry, Kyoto University Hospital, Kyoto, Japan; 2Department of Neuropsychiatry, Kyorin University School of Medicine, Tokyo, Japan; 3Department of Psychiatry, Hiroshima Citizens Hospital, Hiroshima City Hospital Organization, Hiroshima, Japan; 4Department of Neuropsychiatry, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan; 5ECT Committee, Japanese Society of General Hospital Psychiatry (JSGHP), Tokyo, JapanCorrespondence: Taro Suwa, Department of Psychiatry, Kyoto University Hospital, 54, Shogoin Kawahara-cho, Sakyo-ku, Kyoto-shi, Kyoto, Japan, Tel +81-75-751-3386, Fax +81-75-751-3246, Email tarosuwa@kuhp.kyoto-u.ac.jpPurpose: To provide an overview of how electroconvulsive therapy (ECT) practice in Japan has changed as the coronavirus disease 2019 (COVID-19) pandemic continues.Patients and Methods: We surveyed healthcare institutions, primarily university and general hospitals, regarding changes in the number of patients undergoing ECT and infection control measures in the early (August 2020) and recent (August 2021) stages of the COVID-19 pandemic. Data for the early and recent stages were also compared between urban and non-urban areas.Results: Among 32 facilities, the number of patients undergoing ECT decreased in 11 facilities (34.4%) from April 2020 to March 2021 compared with the previous year, whereas the number increased in 12 (37.5%) from April to June 2021 compared with the previous year. As of August 2021, some facilities had ongoing restrictions. Compared with non-urban facilities, the number of patients undergoing ECT decreased more in urban facilities, which also had more ECT restrictions. Maintenance ECT was used at the same rate as before the pandemic for 23 (82.1%) of 28 institutions. Regarding infection control measures, many facilities considered polymerase chain reaction testing before ECT and required all

A 76-year-old woman underwent ¹²³I-FP-CIT brain SPECT due to postural reflex impairment. The transverse slices demonstrated increased uptake in the right middle cerebral artery territory. MR images obtained 2 weeks earlier showed cerebral infarction in the corresponding area. ¹²³I-FP-CIT has high binding affinity for dopamine transporters, especially in the nerve endings of nigrostriatal dopaminergic neurons.

Hirotsugu Kawashima,1 Taro Suwa,2 Toshiya Murai,2 Ryuichi Yoshioka1 1Department of Psychiatry, Toyooka Hospital, Hyogo, Japan; 2Department of Psychiatry, Graduate School of Medicine, Kyoto University, Kyoto, Japan Abstract: Inducing adequate therapeutic seizures during electroconvulsive therapy is sometimes difficult, even at the maximum stimulus charge, due to a high seizure threshold. Here, we describe two patients with very poor seizure responses at the maximum charge using conventional stimulus parameters in whom responses were successfully augmented by widening the pulse width at the same or even lower stimulus charge. This strategy could be an additional option for seizure augmentation in clinical practice. The potential clinical utility of stimulus parameter modifications should be further investigated. Keywords: electroconvulsive therapy, pulse frequency, pulse width, stimulus parameter, seizure threshold