A sensitive new median-ulnar technique for diagnosing mild Carpal Tunnel Syndrome.

Carpal Tunnel Syndrome (CTS) is easily the most common focal peripheral nerve compression. The primary diagnostic tool is electrodiagnosis, although 13-27% of patients with symptoms and signs of CTS have normal electrodiagnostic results. The goal of this study was to create a more sensitive and specific latency difference criteria without any additional testing beyond the minimum. Statistical theory indicates that this would occur by comparing the latency most sensitive to CTS to the least sensitive latency. Data was evaluated from 68 normal hands, 23 hands of patients with symptoms and signs of CTS but normal standard results, and 88 hands of patients with CTS symptoms and signs of CTS with the diagnosis confirmed with standard criteria. The Median Sensory latency was the most sensitive parameter, while the Ulnar Motor Latency varied least in the presence of CTS, making the (Median Sensory-Ulnar Motor) latency difference the criteria of choice. Setting a cutoff value of 0.8 msecs for this difference correctly classified all normals, and all hands with CTS by standard criteria, and classified as abnormal 19/23 (82%) of hands with symptoms and signs of CTS but negative results by standard criteria. Overall the (Median Sensory-Ulnar Motor) Latency difference is a simple, easy, sensitive and specific test for CTS.

Age and the severity of carpal tunnel syndrome.

Several studies have shown an increased incidence of Carpal Tunnel Syndrome (CTS) with increasing age, as well as a longer Median sensory latency in older CTS patients. In this study, data was analyzed from 19 patients with bilaterally normal UE EMG/NCS and no symptoms of CTS (38 hands), as well as 18 patients with unilateral CTS and 21 with bilateral CTS (60 hands) to determine the effect of age on the severity of nerve conduction abnormalities associated with CTS. Most of these parameters showed increasing severity with age. Median motor latency rises sharply with age (r = .41, p = .001), and amplitude falls (r = .34, p = .008). Median sensory rises significantly with age in CTS patients (r = .42, p = .001) and amplitude falls (r = .29, p = .022). Furthermore, the (Median-Ulnar) motor and sensory latency differences both rise with age (r = .40, p = .001, and r = .35, p = .004 respectively). This is crucial, for an increase in Median motor or sensory latency with age could represent a similar degree of pathologic slowing superimposed on normally slower conduction with age. However, the sharp rise in the (Median-Ulnar) latency differences (from 2.2 msecs at age 40 to 3.8 msecs at age 70 for motor, and 1.6 msecs to 2.5 msecs for sensory) shows that the compression is more severe with age.

Median nerve compression at the wrist: is it ever unilateral?

OBJECTIVE: Carpal Tunnel Syndrome (CTS) is commonly bilateral, but symptoms and EMG/NCS abnormalities may be seen unilaterally. This study was designed to determine whether there are any subclinical nerve conduction abnormalities on the "uninvolved" side. DESIGN: Statistical analysis of electrodiagnostic data. SETTING: Outpatient academic electrodiagnostic laboratory. PATIENTS: Twenty-two successive patients referred for bilateral upper extremity NCS/EMG with no symptoms or physical signs of CTS and totally normal results, and ten successive patients with an EMG/NCS diagnosis of CTS on one side, and completely normal EMG/NCS on the contralateral side. RESULTS: The median motor and sensory latencies at the wrist were significantly longer in the contralateral "uninvolved" limb than normals (median motor latency 3.75 vs. 3.30 msecs, p = 0.0005, median sensory latency 3.40 vs 3.00 msecs, p = 0.0002). Median sensory amplitude was smaller in the contralateral limb (30.5 uV vs. 41.5 uV, p = 0.0062). The (median-radial) D1 sensory latency difference was greater in the contralateral wrist (0.2 vs. 0.0 msecs, p = 0.0217). The (median-ulnar) sensory latency difference was not significantly increased (0.15 vs. 0.10 msecs, p = 0.2020). CONCLUSIONS: The contralateral limbs of patients with unilateral CTS show significant differences from normals in 4 out of 5 nerve conduction parameters. There is evidence of frequent subclinical median nerve compression in this group.

Marshfield Clinic, physician networks, and the exercise of monopoly power.

OBJECTIVE: Antitrust enforcement can improve the performance of large, vertically integrated physician-hospital organizations (PHOs). Objective: To examine the recent court decisions in the Blue Cross and Blue Shield United of Wisconsin v. Marshfield Clinic antitrust case to understand better the benefits and costs of vertical integration in healthcare. SUMMARY AND CONCLUSIONS: Vertical integration in the Marshfield Clinic may have had the benefits of reducing transactions and uncertainty costs while improving the coordination between ambulatory and inpatient visits, but at the cost of Marshfield Clinic's monopolizing of physician services and foreclosing of HMO entry in northwest Wisconsin. The denial of hospital staff privileges to non-Marshfield Clinic physicians combined with certificate-of-need regulations impeded physician entry and solidified Marshfield Clinic's monopoly position. Enforcement efforts of recent antitrust guidelines by the U.S. Department of Justice and the Federal Trade Commission will need to address carefully the benefits and costs of vertically integrated systems.

Dialogue. Industry consolidation: what's at stake for consumers and purchasers?

The behavioral healthcare field has undergone massive consolidation, especially in the last year. Health plans, hospital systems, and community-based organizations have all been affected. Economists argue that consolidation is a logical consequence of the current, competitive healthcare market. But consumers and purchasers wonder if the mergers and acquisitions will benefit them. Efficient markets are supposed to stimulate competition in ways that reward purchasers and consumers of services. When prices go down and quality improves as a result of competitive market forces, then the market has functioned properly and has served its purpose. Behavioral healthcare, however, is an essential human service, not a commodity. And the consumers and purchasers of healthcare are typically not the same person or entity, which also makes the healthcare market different from the markets for cars, computers, food, or any other type of consumer product. More than 100 million Americans now receive managed behavioral health benefits from only three companies. With such intense power concentrated in the hands of such a small number of providers, the time has come to evaluate the impact of the consolidation trend. In the following dialogue article, leaders, representing different interest groups review the benefits and risks of massive industry consolidation, and propose solutions to the critical challenges that it raises.

Specificity of aminoglycoside antibiotics for the A-site of the decoding region of ribosomal RNA.

BACKGROUND: Aminoglycoside antibiotics bind to the A-site of the decoding region of 16S RNA in the bacterial ribosome, an interaction that is probably responsible for their activity. A detailed study of the specificity of aminoglycoside binding to A-site RNA would improve our understanding of their mechanism of antibiotic activity. RESULTS: We have studied the binding specificity of several aminoglycosides with model RNA sequences derived from the 16S ribosomal A-site using surface plasmon resonance. The 4,5-linked (neomycin) class of aminoglycosides showed specificity for wild-type A-site sequences, but the 4,6-linked class (kanamycins and gentamicins), generally showed poor specificity for the same sequences. Methylation of a cytidine in the target RNA, as found in the Escherichia coli ribosome, had negligible effects on aminoglycoside binding. CONCLUSIONS: Although both 4,5- and 4, 6-linked aminoglycosides target the same ribosomal site, they appear to bind and effect antibiotic activity in different manners. The aminoglycosides might recognize different RNA conformations or the interaction might involve different RNA tertiary structures that are not equally sampled in our ribosome-free model. These results imply that models of ribosomal RNA must be carefully designed if the data are expected to accurately reflect biological activity.

Computed tomographic evaluation of dinosaur egg shell integrity.

The purpose of this study was to determine whether computed tomography (CT) could be used to identify hatching holes in partially embedded dinosaur eggs. One Faveololithus and two Dendroolithus eggs were examined using a fourth generation CT scanner. The eggs were partially embedded in a fossilized sediment matrix, with the exposed portion of the shell appearing intact. In CT images of all three eggs, the shells appeared hyperdense relative to the matrix. Hatching holes were visible as large gaps in the embedded portion of the shell, with inwardly displaced shell fragments. It was concluded that CT is an effective technique for nondestructively assessing dinosaur egg shell integrity.

Patients' attitudes toward having been forcibly medicated.

Forced antipsychotic medication procedures are generally perceived to be clinically necessary options, albelt violations of individuals' bodies and autonomy. Previous studies have explored forcibly medicated patients' attitudes concerning these procedures, but as patients were interviewed while still in the hospital, this may have affected their responses. We interviewed consecutively forcibly medicated English-speaking acute-care inpatients after their discharge to the community. The interviews were conducted by telephone by a clinician not involved with their treatment. Of 65 such patients, 7 had already been rehospitalized, 3 could not recall the procedure, and 25 others refused the interview or were not locatable. Of the 30 who were successfully interviewed, only 47 percent had received any forced injections; the remainder had accepted oral medication under duress. Recollecting their experiences, 57 percent professed fear of side effects, 17 percent feared "addiction," and 17 percent objected to others' controlling them. Forty percent recalled feeling angry, 33 percent helpless, 23 percent fearful, 13 percent embarrassed, but 23 percent were relieved. Surprisingly, 60 percent retrospectively agreed with having been coerced, 53 percent stating they were more likely to take medication voluntarily in the future. Other forcibly medicated patients had poorer outcomes, such as rapid readmission or discharge to a state hospital: those patients may have harbored more negative feelings. However, a substantial fraction of the patients who were reached in the community appeared to support having received medication forcibly as inpatients.

Development and submission of a nonclinical (pharmacology/toxicology) CANDA.

The experience with the submission of a nonclinical (pharmacology and toxicology) computer-assisted New Drug Application (CANDA) is reviewed. This system consisted of a stand-alone personal computer running several commercial programs in Microsoft Windows to access both text and data. WordPerfect was used as the word processor that contained all the documents and data tables (in read-only format) that were submitted in hard copy, and Andyne GQL was used as a tool to query the data in an Oracle relational database. Microsoft Excel was provided as a spreadsheet for graphics and analysis of data. Documents appeared virtually identical to those in the hard copy NDA submission. Searching the text was facilitated by the use of buttons on the screen, which allowed the NDA to be searched for a particular term. Data could be located either in WordPerfect documents, or in an Oracle database (using Andyne GQL) by querying the data. The data queries could be performed ad hoc, in which the reviewer selected all the parameters for a search, or with predefined query buttons, which retrieved data for principal treatment-related changes. This type of system also could serve as a useful model for both in-house nonclinical review and the submission of INDs and IND amendments.

Adjustment disorder as an admission diagnosis.

OBJECTIVE: The authors' goal was to study subtyping, demographic variables, suicidality, diagnostic stability, and 2-year rehospitalization outcome for inpatients given the admission diagnosis of adjustment disorder at their institution. METHOD: They reviewed the charts of 54 adolescent and 102 adult inpatients given the diagnosis of adjustment disorder at admission and compared them with the charts of 156 matched comparison subjects given other admission diagnoses. RESULTS: Adolescents and adults with adjustment disorder had significantly shorter index hospitalizations and more presenting suicidality than the comparison subjects. Adults but not adolescents with adjustment disorder had significantly fewer psychiatric readmissions and fewer rehospitalization days 2 years after discharge than comparison subjects, and more adults with adjustment disorder had diagnoses of comorbid substance use disorder. Forty percent of the patients admitted with the diagnosis of adjustment disorder were discharged with different diagnoses. Only 18% of the inpatients with adjustment disorder who were rehospitalized were given that diagnosis at readmission. CONCLUSIONS: Adjustment disorder diagnoses were associated with suicidality, shorter lengths of stay, and, in adults, more substance use disorders and fewer rehospitalizations.

Mercy Healthcare's CARE 2000: an evolution in progress.

In a learning environment of shared governance, continuous quality improvement, and redesign principle application, disciplines of Mercy Healthcare San Diego produced their patient care delivery redesign model, Creative Actions Reflecting Excellence. Nurses, pharmacists, medical technologists, respiratory care practitioners, physicians, educators, managers, and many other professional and technical partners converted change and transition into opportunities. As disciplines understood and appreciated each other's unique and shared contributions, quality of care, stakeholder satisfaction, and process efficiencies increased.

The response of the dominant firm to competition: the Ocean State case.

The Ocean State antitrust case illustrates the operation of the competitive marketplace in health insurance. Blue Cross, the dominant firm in Rhode Island, responded competitively to the entrance of a new competitor, Ocean State, in three ways: 1) a most-favored-nation clause, 2) creation of a PPO offering similar benefits as Ocean State, and 3) an adverse selection policy. These actions are assessed to be legitimate competitive responses and the decisions of the higher courts overturning the jury verdict against Blue Cross are supported.

Irregular discharges from a dual diagnosis unit.

Irregular discharges, previously studied on psychiatric or substance abuse treatment units, are a particular problem for dual diagnosis units. We examined demographic and clinical variables for their association with irregular discharge from an acute dual diagnosis inpatient unit, retrospectively reviewing 316 consecutive admissions. One hundred and nineteen patients (37.7%) were irregularly discharged (61 AMA, 31 administrative, 27 elopements), staying an average of 18.8 days compared with 51.4 days for those regularly discharged (p < .001). Younger age (p = .007) and discharge diagnosis of antisocial personality disorder (p < .001) were associated with irregular discharge; the attending psychiatrist was also significant (p = .016). Demographic variables (sex, ethnicity, marital status, religion, employment, education, living circumstances), Axis I diagnosis, and type and number of substances abused were not predictive of discharge type. Patients irregularly discharged within the first week (40% of irregular discharges) were significantly less likely to have known legal involvement (p = .006). No significant temporal clustering of irregular discharges was found on a daily, weekly, or monthly basis, nor was a seasonal pattern detected. These findings are generally consistent with several pre-DSM-III studies on nondual diagnosis units, but more specifically highlight the diagnosis of antisocial personality. Regarding program completion, they suggest that risk factors for irregular discharge (substance abuse, antisocial personality, characteristics of the doctor-patient relationship, problems of younger patients) have not been adequately addressed simply by creating dual diagnosis units. Further programming study appears warranted to address the problem of patient retention on dual diagnosis units.