Extended Follow-up of Local Steroid Injection for Carpal Tunnel Syndrome: A Randomized Clinical Trial.

Importance: Local steroid injection is commonly used in treating patients with idiopathic carpal tunnel syndrome, but evidence regarding long-term efficacy is lacking. Objective: To assess the long-term treatment effects of local steroid injection for carpal tunnel syndrome. Design, Setting, and Participants: This exploratory 5-year extended follow-up of a double-blind, placebo-controlled randomized clinical trial was conducted from November 2008 to March 2012 at a university hospital orthopedic department. Participants included patients aged 22 to 69 years with primary idiopathic carpal tunnel syndrome and no prior treatment with local steroid injections. Data were analyzed from May 2018 to August 2018. Interventions: Patients were randomized to injection of 80 mg methylprednisolone, 40 mg methylprednisolone, or saline. Main Outcomes and Measures: The coprimary outcomes were the symptom severity score and rate of subsequent carpal tunnel release surgery on the study hand at 5 years. Secondary outcomes were time from injection to surgical treatment, SF-36 bodily pain score, and score on the 11-item disabilities of the arm, shoulder, and hand scale. Results: A total of 111 participants (mean [SD] age at follow-up, 52.9 [11.6] years; 81 [73.0%] women and 30 [27.0%] men) were randomized, with 37 in the 80 mg methylprednisolone group, 37 in the 40 mg methylprednisolone group, and 37 in the saline placebo group. Complete 5-year follow-up data were obtained from all 111 participants with no dropouts (100% follow-up). At baseline, mean (SD) symptom severity scores were 2.93 (0.85) in the 80 mg methylprednisolone group, 3.13 (0.70) in the 40 mg methylprednisolone group, and 3.18 (0.75) in the placebo group, and at the 5-year follow up, mean (SD) symptom severity scores were 1.51 (0.66) in the 80 mg methylprednisolone group, 1.59 (0.63) in the 40 mg methylprednisolone group, and 1.67 (0.74) in the placebo group. Compared with placebo, there was no significant difference in mean change in symptom severity score from baseline to 5 years for the 80 mg methylprednisolone group (0.14 [95%CI, -0.17 to 0.45]) or the 40 mg methylprednisolone group (0.12 [95%CI, -0.19 to 0.43]). After injection, subsequent surgical treatment on the study hand was performed in 31 participants (83.8%) in the 80 mg methylprednisolone group, 34 participants (91.9%) in the 40 mg methylprednisolone group, and 36 participants (97.3%) in the placebo group; the number of participants who underwent surgical treatment between the 1-year and 5-year follow-ups was 4 participants (10.8%) in the 80 mg methylprednisolone group, 4 participants (10.8%) in the 40 mg methylprednisolone group, and 2 participants (5.4%) in the placebo group. All surgical procedures were conducted while participants and investigators were blinded to type of injection received. The mean (SD) time from injection to surgery was 180 (121) days in the 80 mg methylprednisolone group, 185 (125) days in the 40 mg methylprednisolone group, and 121 (88) days in the placebo group. Kaplan-Meier survival curves showed statistically significant difference in time to surgical treatment (log-rank test: 80 mg methylprednisolone vs placebo, P = .002 ; 40 mg methylprednisolone vs placebo, P = .02; methylprednisolone 80 mg vs 40 mg, P = .37). Conclusions and Relevance: These findings suggest that in idiopathic carpal tunnel syndrome, local methylprednisolone injection resulted in statistically significant reduction in surgery rates and delay in need for surgery. Trial Registration: ClinicalTrials.gov Identifiers: NCT00806871 and NCT02652390.

Enantioseparation of benzofurys and other novel psychoactive compounds by CE and sulfobutylether ß-cyclodextrin as chiral selector added to the BGE.

The illicit drug market of psychoactive substances for human abuse is continuously expanding and developing. Besides already known substance classes like cathinones, amphetamines or synthetic cannabinoids, further derivatives such as benzofurys, thiophenes, and structural analogues of methylphenidate entered the global market recently. As many of these new compounds contain a stereogenic centre it is supposed that their isomers may differ in their pharmacological effects as it is the case with amphetamines or several chiral active pharmaceutical ingredients, for instance. In the course of this study, a method for the chiral separation of a set of 16 recreational drugs by CE was developed. The aim was to separate the analytes into their enantiomers at equal conditions within short time. Sulfobutylether ß-cyclodextrin served as chiral selector in an aqueous ammonium acetate solution containing ACN. For method optimization, methedrone and ethylphenidate were used as model compounds to find the appropriate concentration of chiral selector. Moreover, the influence of the pH value on enantioseparation was tested. Fourteen or 16 mM sulfobutylether ß-cyclodextrin, 50 mM ammonium acetate solution (pH 4.5) with 10% ACN were found to be optimal for enantioseparation of seven benzofurys, four cathinones, two diphenidines, ethylphenidate, methiopropamine, and thiothinone. Most of them were baseline resolved at migration times below 25 min.

Methylprednisolone injections for the carpal tunnel syndrome: a randomized, placebo-controlled trial.

BACKGROUND: Steroid injections are used in idiopathic carpal tunnel syndrome (CTS), but evidence of efficacy beyond 1 month is lacking. OBJECTIVE: To assess the efficacy of local methylprednisolone injections in CTS. DESIGN: Randomized, placebo-controlled trial. (ClinicalTrials.gov: NCT00806871). SETTING: Regional referral orthopedic department in Sweden. PATIENTS: Patients aged 18 to 70 years with CTS but no previous steroid injections. INTERVENTION: Three groups (37 patients each) received 80 mg of methylprednisolone, 40 mg of methylprednisolone, or placebo. The patients and treating surgeons were blinded. MEASUREMENTS: Primary end points were the change in CTS symptom severity scores at 10 weeks (range, 1 to 5) and rate of surgery at 1 year. Three patients had missing 10-week data. All patients had 1-year data. RESULTS: Improvement in CTS symptom severity scores at 10 weeks was greater in patients who received 80 mg of methylprednisolone and 40 mg of methylprednisolone than in those who received placebo (difference in change from baseline, -0.64 [95% CI, -1.06 to -0.21; P = 0.003] and -0.88 [CI, -1.30 to -0.46; P < 0.001], respectively), but there were no significant differences at 1 year. The 1-year rates of surgery were 73%, 81%, and 92% in the 80-mg methylprednisolone, 40-mg methylprednisolone, and placebo groups, respectively. Compared with patients who received placebo, those who received 80 mg of methylprednisolone were less likely to have surgery (odds ratio, 0.24 [CI, 0.06 to 0.95]; P = 0.042). With time to surgery incorporated, both the 80- and 40-mg methylprednisolone groups had lower likelihood of surgery (hazard ratio, 0.46 [CI, 0.27 to 0.77; P = 0.003] and 0.57 [CI, 0.35 to 0.94; P = 0.026], respectively). LIMITATION: The study was conducted at 1 center, and wrist splinting had previously failed for all patients. CONCLUSION: Methylprednisolone injections for CTS have significant benefits in relieving symptoms at 10 weeks and reducing the rate of surgery 1 year after treatment, but 3 out of 4 patients had surgery within 1 year. PRIMARY FUNDING SOURCE: Region of Scania Research and Development Foundation and Hässleholm Hospital Organization.

Self-control as predictor of school grades, life balance, and flow in adolescents.

BACKGROUND: Recently, several studies have shown that strength of self-control is a crucial factor in determining positive outcomes in individuals' lives. Most attention has been directed to the relationships that self-control has with learning and academic achievement. AIMS: This article analyses the effects of self-control not only on school grades but also on the experience of life balance and flow. It is theorized that students with a higher level of self-control are better able to distribute their time in a satisfying way over academic and leisure matters, and are better able to shield their studying against distractions. SAMPLES: A total of 697 eighth graders with a mean age of 13.4 years participated in the longitudinal study. METHOD: Students completed a questionnaire containing measures of self-control, school grades, subjective life balance, and flow while studying at the beginning and at the end of the school year. Structural equation modelling was used to analyse the relationships between the constructs. RESULTS AND CONCLUSIONS: Results of cross-lagged analyses show that self-control predicted school grades, life balance, and flow. The findings suggest that self-control may assist adolescents to be better prepared, not only for school, but also for coordinating their investments in different areas of their lives.

Relationship between distal radius fracture malunion and arm-related disability: a prospective population-based cohort study with 1-year follow-up.

BACKGROUND: Distal radius fracture is a common injury and may result in substantial dysfunction and pain. The purpose was to investigate the relationship between distal radius fracture malunion and arm-related disability. METHODS: The prospective population-based cohort study included 143 consecutive patients above 18 years with an acute distal radius fracture treated with closed reduction and either cast (55 patients) or external and/or percutaneous pin fixation (88 patients). The patients were evaluated with the disabilities of the arm, shoulder and hand (DASH) questionnaire at baseline (concerning disabilities before fracture) and one year after fracture. The 1-year follow-up included the SF-12 health status questionnaire and clinical and radiographic examinations. Patients were classified into three hypothesized severity categories based on fracture malunion; no malunion, malunion involving either dorsal tilt (>10 degrees) or ulnar variance (≥ 1 mm), and combined malunion involving both dorsal tilt and ulnar variance. Multivariate regression analyses were performed to determine the relationship between the 1-year DASH score and malunion and the relative risk (RR) of obtaining DASH score ≥ 15 and the number needed to harm (NNH) were calculated. RESULTS: The mean DASH score at one year after fracture was significantly higher by a minimum of 10 points with each malunion severity category. The RR for persistent disability was 2.5 if the fracture healed with malunion involving either dorsal tilt or ulnar variance and 3.7 if the fracture healed with combined malunion. The NNH was 2.5 (95% CI 1.8-5.4). Malunion had a statistically significant relationship with worse SF-12 score (physical health) and grip strength. CONCLUSION: Malunion after distal radius fracture was associated with higher arm-related disability regardless of age.

Local steroid injection for moderately severe idiopathic carpal tunnel syndrome: protocol of a randomized double-blind placebo-controlled trial (NCT 00806871).

BACKGROUND: Patients with idiopathic carpal tunnel syndrome (CTS) are commonly treated with steroid injection into or proximal to the carpal tunnel. However, evidence for its efficacy beyond one month has not been established in randomized placebo-controlled trials. The primary aim of this randomized trial is to assess the efficacy of steroid injection into the carpal tunnel in relieving symptoms of CTS in patients with symptoms of such severity to warrant surgical treatment but have not been treated with steroid injection. METHODS/DESIGN: The study is a randomized double-blind placebo-controlled trial. Patients referred to one orthopedic department because of CTS are screened. Eligibility criteria are age 18 to 70 years, clinical diagnosis of primary idiopathic CTS and abnormal nerve conduction tests or clinical diagnosis made independently by two orthopedic surgeons, failed treatment with wrist splinting, symptom severity of such magnitude that the patient is willing to undergo surgery, no severe sensory loss or thenar muscle atrophy, and no previous steroid injection for CTS. A total of 120 patients will be randomized to injection of 80 mg Methylprednisolone, 40 mg Methylprednisolone, or normal saline, each also containing 10 mg Lidocaine. Evaluation at baseline and at 5, 10, 24 and 52 weeks after injection includes validated questionnaires (CTS symptom severity scale, QuickDASH and SF-6D), adverse events, physical examination by a blinded assessor, and nerve conduction tests. The primary outcome measures are change in the CTS symptom severity score at 10 weeks and the rate of surgery at 52 weeks. The secondary outcome measures are the score change in the CTS symptom severity scale at 52 weeks, time to surgery, and change in QuickDASH and SF-6D scores and patient satisfaction at 10 and 52 weeks. The primary analysis will be carried out using mixed model analysis of repeated measures. DISCUSSION: This paper describes the rationale and design of a double-blind, randomized placebo-controlled trial that aims to determine the efficacy of two different doses of steroid injected into the carpal tunnel in patients with moderately severe idiopathic CTS. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT00806871.

Reciprocal relationships between value orientation and motivational interference during studying and leisure.

BACKGROUND: Motivational interference is defined as the amount of impairment in a target activity due to the incentives of a non-chosen attractive alternative. The amount to which pupils experience motivational interference while studying or while performing a leisure activity in a school-leisure conflict situation is seen as depending on the values they attach to achievement and well-being. At the same time, values may also be effects of frequent experience of motivational interference in the respective areas. AIMS: The study is aimed at investigating the reciprocal relationship between personal value orientations and the experience of motivational interference during studying and leisure. SAMPLE: A total of 363 pupils (sixth to eighth graders at the time of first measurement) completed the same questionnaire twice in a 2-year interval. METHOD: The questionnaire included measures of achievement and well-being value orientation and the experience of motivational interference during studying and during leisure in school-leisure conflicts. For this, two scenarios were created. In regression analyses, achievement and well-being value orientations as well as their interaction terms were used as predictors for experience of motivational interference at t(2) while controlling for experience of motivational interference at t(1), and vice versa. Additionally in path models, these relations were tested in an integrative way. RESULTS: Pupils' achievement value orientations were connected to differential changes in experiencing motivational interference during leisure and during studying in one scenario but only for pupils low or medium in well-being value orientation. Conversely, experience of motivational interference at t(1) was related to changes in value orientations 2 years later. High motivational interference during studying led to an increase in well-being value orientation, while high motivational interference during leisure was followed by a decrease in well-being value orientation and an increase in achievement value orientation. Overall, path models supported these results. CONCLUSIONS: The results are discussed in terms of value change and are linked to self-control and motivation research.

Open compared with 2-portal endoscopic carpal tunnel release: a 5-year follow-up of a randomized controlled trial.

PURPOSE: The purpose of this investigation was to extend the previously reported short-term randomized trial of open and endoscopic carpal tunnel release in patients with carpal tunnel syndrome (CTS) to compare outcomes 5 years after surgery. METHODS: In a single-center randomized controlled trial, 128 patients (25 to 60 years) with clinically diagnosed and electrophysiologically confirmed idiopathic CTS were randomized immediately before surgery to open or 2-portal endoscopic release. The outcome measures included the validated CTS questionnaire's symptom severity and functional status scales (scored from 1 to 5) completed at baseline and 1 year postoperatively. At the extended follow-up of the trial 5 years after surgery, 2 patients had died and the other 126 participants (63 patients in each group) completed the CTS questionnaire. RESULTS: At the 5-year follow-up no difference between the groups was found in the CTS symptom severity score. The mean (SD) score in the open group was 1.42 (0.7) and in the endoscopic group was 1.45 (0.7), and the mean difference in score change from baseline was 0.03 (95% confidence interval, -0.21 to 0.27). Between 1 year and 5 years postoperatively, the CTS symptom severity score had deteriorated by at least 0.4 point in 9 patients in the open group and in 10 patients in the endoscopic group. The mean (SD) CTS functional status score was 1.29 (0.5) in the open group and 1.30 (0.5) in the endoscopic group. At 5 years, 11 patients in the open group and 10 patients in the endoscopic group reported persistent pain in the scar or proximal palm. Three patients in each group had repeat surgery on the operated hand because of persistent or recurrent symptoms. CONCLUSIONS: The improvements in symptoms of CTS and hand-related disability 5 years after open and 2-portal endoscopic carpal tunnel release were equivalent. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic I.

Individual values, learning routines and academic procrastination.

BACKGROUND: Academic procrastination, the tendency to postpone learning activities, is regarded as a consequence of postmodern values that are prominent in post-industrialized societies. When students strive for leisure goals and have no structured routines for academic tasks, delaying strenuous learning activities becomes probable. AIMS: The model tested in this study posits that postmodern value orientations are positively related to procrastination and to a lack of daily routines concerning the performance of academic activities. In contrast, modern values are negatively related to procrastination and positively to learning routines. Academic procrastination, in-turn, should be associated with the tendency to prefer leisure activities to schoolwork in case of conflicts between these two life domains. SAMPLE: Seven hundred and four students from 6th and 8th grade with a mean age of 13.5 years participated in the study. The sample included students from all tracks of the German educational system. METHOD: Students completed a questionnaire containing two value prototypes as well as scales on learning routines and procrastination. Decisions in motivational conflicts were measured using two vignettes. RESULTS AND CONCLUSIONS: Results from structural equation modelling supported the proposed model for the whole sample as well as for each school track. A planned course of the day can prevent procrastination and foster decisions for academic tasks in case of conflicts. Students' learning takes place within a societal context and reflects the values held in the respective culture.

Wrist-bridging versus non-bridging external fixation for displaced distal radius fractures: a randomized assessor-blind clinical trial of 38 patients followed for 1 year.

BACKGROUND: Non-bridging external fixation has been introduced to achieve better fracture fixation and functional outcomes in distal radius fractures, but has not been specifically evaluated in a randomized study in the elderly. The purpose of this trial was to compare wrist-bridging and non-bridging external fixation for displaced distal radius fractures. METHOD: The inclusion criteria were women >/= 50 or men >/= 60 years, acute extraarticular or intraarticular fracture, and dorsal angulation of >/=20 degrees or ulnar variance >/= 5 mm. The patients completed the disabilities of the arm, shoulder and hand (DASH) questionnaire before and at 10, 26 and 52 weeks after surgery. Pain (visual analog scale), range of motion and grip strength were measured by a blinded assessor. RESULTS: 38 patients (mean age 71 years, 31 women) were randomized at surgery (19 to each group). Mean operating time was shorter for wrist-bridging fixation by 10 (95% CI 3-17) min. There was no significant difference in DASH scores between the groups. No statistically significant differences in pain score, range of motion, grip strength, or patient satisfaction were found. The non-bridging group had a significantly better radial length at 52 weeks; mean difference in change in ulnar variance from baseline was 1.4 (95% CI 0.1-2.7) mm (p = 0.04). Volar tilt and radial inclination were similar in both groups. INTERPRETATION: For moderately or severely displaced distal radius fractures in the elderly, non-bridging external fixation had no clinically relevant advantage over wrist-bridging fixation but was more effective in maintaining radial length.

Finite-element simulation of wave propagation in periodic piezoelectric SAW structures.

Many surface acoustic wave (SAW) devices consist of quasiperiodic structures that are designed by successive repetition of a base cell. The precise numerical simulation of such devices, including all physical effects, is currently beyond the capacity of high-end computation. Therefore, we have to restrict the numerical analysis to the periodic substructure. By using the finite-element method (FEM), this can be done by introducing periodic boundary conditions (PBCs) at special artificial boundaries. To be able to describe the complete dispersion behavior of waves, including damping effects, the PBC has to be able to model each mode that can be excited within the periodic structure. Therefore, the condition used for the PBCs must hold for each phase and amplitude difference existing at periodic boundaries. Based on the Floquet theorem, our two newly developed PBC algorithms allow the calculation of both, the phase and the amplitude coefficients of the wave. In the first part of this paper we describe the basic theory of the PBCs. Based on the FEM, we develop two different methods that deliver the same results but have totally different numerical properties and, therefore, allow the use of problem-adapted solvers. Further on, we show how to compute the charge distribution of periodic SAW structures with the aid of the new PBCs. In the second part, we compare the measured and simulated dispersion behavior of waves propagating on periodic SAW structures for two different piezoelectric substrates. Then we compare measured and simulated input admittances of structures similar to SAW resonators.

Outcomes of endoscopic surgery compared with open surgery for carpal tunnel syndrome among employed patients: randomised controlled trial.

OBJECTIVES: To compare endoscopic and open carpal tunnel release surgery among employed patients with carpal tunnel syndrome. DESIGN AND SETTING: Randomised controlled trial at a single orthopaedic department. PARTICIPANTS: 128 employed patients aged 25-60 years with clinically diagnosed and electrophysiologically confirmed idiopathic carpal tunnel syndrome. MAIN OUTCOME MEASURES: The primary outcome was severity of postoperative pain in the scar or proximal palm and the degree to which pain or tenderness limits activities, each rated on a 4 point scale, transformed into a combined score of 0 (none) to 100 (severe pain or tenderness causing severe activity limitation). The secondary outcomes were length of postoperative work absence, severity of symptoms of carpal tunnel syndrome and functional status scores, SF-12 quality of life score, and hand sensation and strength (blinded examiner); follow-up at three and six weeks and three and 12 months. RESULTS: 63 patients were allocated to endoscopic surgery and 65 patients to open surgery, with no withdrawals or dropouts. Pain in the scar or proximal palm was less prevalent or severe after endoscopic surgery than after open surgery but the differences were generally small. At three months, pain in the scar or palm was reported by 33 patients (52%) in the endoscopic group and 53 patients (82%) in the open group (number needed to treat 3.4, 95% confidence interval 2.3 to 7.7) and the mean score difference for severity of pain in scar or palm and limitation of activity was 13.3 (5.3 to 21.3). No differences between the groups were found in the other outcomes. The median length of work absence after surgery was 28 days in both groups. Quality of life measures improved substantially. CONCLUSIONS: In carpal tunnel syndrome, endoscopic surgery was associated with less postoperative pain than open surgery, but the small size of the benefit and similarity in other outcomes make its cost effectiveness uncertain.