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.

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.

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.

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.

Hospitalized insanity acquittees' level of functioning.

Since 1975 in New Jersey, similar legal criteria apply to the discharge of insanity acquittees as those patients who are civilly committed. Based on contact with insanity acquittees (NGRIs) in a regional state hospital, we had the impression that they appeared to be functioning better than the general inpatient population. The purpose of this study was to assess the length of inpatient stay and the level of functioning for the NGRIs and contrast it to a comparison group selected to for variables such as age, ethnicity, Axis I diagnosis, and history of substance abuse, which could impact on our variables of interest. We obtained psychiatrist-rated clinical global impression (CGI) scores and nursing-rated specific level of functioning (SLOF) scores in a group of 62 NGRIs and in a matched group of 62 controls. The NGRIs had significantly better CGI scores, and higher "personal care skills" and "social acceptability" SLOF section scores. The social acceptability subscale includes items for aggressiveness towards others, self, and property, all of which were significantly better for the NGRIs. Thus, in our setting, inpatient NGRIs displayed some evidence of better clinical functioning, including less perceived aggressiveness, than the control inpatients. Although the NGRIs has been in the regional state hospital for a shorter period than the controls, the NGRIs had spent an average of over three continuous years in secure facilities before transfer to the regional state hospital. We discuss our findings in view of high rates of paranoid subtypes of psychotic disorders among the NGRI group, and the high prevalence of substance abuse.

Nonemergent forcible medication in an acute hospital.

Nonemergent forcible medication is a controversial procedure that has received somewhat less study in acute hospitals and in states where a simple in-house "treatment-driven" clinical review procedure is followed. We reviewed the charts of all patients so medicated by the New Jersey "Rennie" process on a large general acute adult psychiatric service, finding 43 (3%) of 1420 admitted patients so treated. Compared with a population of next-admitted individuals, these "Rennie" patients more frequently had previously required extended emergent forcible medication, had significantly longer hospitalizations (70 versus 26 days), not accounted for by the duration of treatment refusal, but improved with treatment so that almost all were discharged directly back to the community. Rennie patients appeared more likely to be diagnosed with schizophrenia and were significantly more likely to have a known history of assault, threatened assault, or property damage, but significantly less likely to have a known history of suicide threat or attempt. They were also significantly less likely to have a principal or secondary diagnosis of personality disorder or substance use disorder.