Subjective and employment outcome following secondary carpal tunnel surgery

Forty-five patients (50 hands) who had undergone secondary carpal tunnel surgery participated in a telephone questionnaire survey. The mean follow-up time from the second carpal tunnel surgery was 31 months (range, 9-92 mo). Only 24 patients (53%) reported significant improvement in their symptoms. Thirty-nine patients were unemployed workers who had experienced an average time off work of 28.7 months (+/- 4) before their secondary carpal tunnel surgery. Eleven of the 39 previously unemployed workers (28%) returned to work after the secondary carpal tunnel surgery. Factors associated with poor subjective and employment outcome included worker's compensation case involvement (p < 0.003). Occupations associated with repetitive hand movements or vibrating tools were associated with poor employment outcomes (p < 0.006). Although secondary surgery for carpal tunnel syndrome can be effective in relieving symptoms, patients and surgeons must have realistic expectations of the procedure, especially with respect to long-term employment goals.

Understanding patient-centered care in the context of total quality management and continuous quality improvement

BACKGROUND

Implementing patient-centered care (PCC) requires a fundamental shift in thinking-from how to best provide a wide variety of independent services to how to effectively combine individual service components into an integrated health care experience that meets patient needs and preferences.

DISCUSSION

PCC attempts to improve patient care by organizationally and physically moving selected service functions such as basic laboratory, pharmacy, admitting/discharge, medical records, housekeeping, and material support services to patient care areas, thus effecting an organizational restructuring. PCC creates teams composed of multiskilled or cross-trained individuals capable of providing more of the services directly on the patient care unit. Extensive redesign of the basic work processes as proposed by PCC advocates may result in significant changes in employee job scope, task responsibilities, professional autonomy, and reporting relationships. From the employee's perspective such changes may be neither warranted nor welcomed. Therefore, critical PCC implementation issues include obtaining employee buy-in and establishing appropriate incentive structures to facilitate the desired changes. How does PCC fit in with the popular improvement philosophies of total quality management (TQM) and continuous quality improvement (CQI)? Inherent within TQM and CQI is the belief that it is wiser to maximize efforts to design a product or process to be right the first time and to minimize resources devoted to inspection and repair caused by poor processes. PCC builds upon previous TQM/CQI health care efforts by focusing on ways to reduce the white space handoff problem by examining what, if any, changes in underlying structures and processes may be required. In the PCC hospital, TQM/CQI can function as intended, as a methodology for examining and improving the process of care and patient-care outcomes, regardless of internal departmental or profession-based organizational boundaries.

CONCLUSION

For hospitals to remain competitive in today's rapidly changing environment, it is becoming necessary to reevaluate both how they are organized and how their work processes have been designed and controlled. The groundwork already laid by TQM/CQI initiatives will facilitate the more fundamental and long-lasting improvements derived from the redesign of the patient-care unit as prescribed by the goals of PCC.

[Multiresistant tuberculosis]

Multiresistant tuberculosis has been recognized since the advent of triple-drug therapy with isoniazid, streptomycin and PAS in the fifties, but the recently observed strains of Mycobacterium tuberculosis resistant both to isoniazid and to rifampicin, the rapid spread of the infection and the development of severe disease in HIV infected patients have raised grave problems in controlling tuberculosis in the world. The disease is difficult and expansive to treat in industrialized countries and is incurable in many developing countries. The increased prevalence of resistant strains in southeast Asia or in Subsahara Africa is a real disaster as both the incidence of tuberculosis and of HIV infection is high. It is extremely difficult or even impossible to deal with such a disaster without new antituberculosis drugs and improved means of prevention. Only a few countries have maintained surveillance of resistant strains of tuberculous bacilli and we do not have any precise and reliable image of the importance of multiresistance in the world. It is nevertheless clear that in certain major urban areas such as New York City multiresistance has increased rapidly. In order to improve on this situation, or to prevent it, it is important to recognize that resistant tuberculosis is induced by man himself directly via insufficient quality control Two types of measures are required: 1. The clinician must prescribe a therapeutic regimen including at least two, and preferably three, drugs active against the infecting strain. 2. Patient compliance to both dose and frequency is mandatory.(ABSTRACT TRUNCATED AT 250 WORDS)

The Rorschach Search for the Borderline Holy Grail: An Examination of Personality Structure, Personality Style, and Situation

Much of the research on the use of the Rorschach to diagnose borderline disturbance has sought to discover a specific borderline pattern or Rorschach configuration. Given our increased understanding of borderline functioning representing a level of personality organization (or personality structure), this single pattern approach is excessively simplistic. It fails to consider the complex interaction between personality structure, personality style, and situational variables. An approach to the Rorschach assessment of borderline functioning is presented using a clinical example. The patient was tested at the onset of psychotherapy and then some 4 years into treatment. Results from the two testings were compared using Weiner and Exner's (1991) Rorschach variable clusters for assessing change in psychotherapy.

Osteoid osteoma of the hamate: report of a case and review of the literature

There are 7 reported patients with osteoid osteoma of the hamate. Only 1 of these has involved the hook of the hamate. This article reports the second patient with osteoid osteoma involving the hook of the hamate. The clinical features, the diagnostic problems, and the management of this lesion are reviewed.

Epidermal growth factor acts directly on the sheep ovary in vivo to inhibit oestradiol-17 beta and inhibin secretion and enhance progesterone secretion

Epidermal growth factor (EGF) is a potential intra-ovarian modulator of gonadotroph action on differentiated follicular cells. Specific binding sites have been identified in the ovary and functional differentiation in cultured granulosa cells can be modulated by treatment with EGF. The aim of this study was to determine if EGF was capable of altering ovarian function in vivo during the follicular phase of the sheep oestrous cycle. Fourteen cross-bred ewes with ovarian autotransplants were treated with progestagen pessaries for 12 days. Three ewes were infused with murine EGF (mEGF) via the jugular vein (75 micrograms/kg bodyweight per 12 h) during the 12 h preceding progestagen pessary withdrawal, and received an injection of a prostaglandin analogue at 0 h to induce luteolysis. Over the same time-period, two doses of EGF were administered to other groups of ewes by infusion into the ovarian artery (low: 6 micrograms/12 h, n = 3 and high: 60 micrograms/12 h, n = 3). The remaining five ewes were not infused with EGF (controls). Jugular and ovarian venous blood samples were taken at 10-min intervals at two stages during the follicular phase (21-27 h and 38-42 h after pessary withdrawal) and every 2 h from 44 to 76 or 86 h. mEGF, LH, FSH, inhibin, androstenedione, oestradiol-17 beta and progesterone concentrations in plasma were determined using radioimmunoassays. The secretion rates of androstenedione, oestradiol, progesterone and inhibin by the ovary were calculated. EGF acted directly on the ovary in a dose-dependent manner. Oestradiol secretion was inhibited following treatment with EGF but androstenedione secretion was unaffected. EGF appears therefore to act within the granulosa cells to inhibit aromatization. Inhibin secretion was also suppressed by treatment with EGF, though it was not possible to determine if this was caused by a direct or indirect action of EGF on granulosa cells. The rate of progesterone secretion increased in ewes receiving systemic (i.e. via the jugular vein) and high-dose intra-arterial infusions of EGF, even though a preovulatory LH surge was not observed in these animals during the entire experimental period. Concomitant increases in both LH and FSH secretion were associated with these effects of EGF on ovarian function. In conclusion, EGF appears to act directly on the granulosa cells of the follicle to inhibit aromatization and also to inhibit inhibin production. The low levels of oestradiol and inhibin in the presence of high levels of gonadotrophin indicate that atresia may have been induced in medium to large antral follicles.(ABSTRACT TRUNCATED AT 400 WORDS)

An evaluation of rapid exchange and simultaneous grip tests

The usefulness of the rapid exchange grip test and a modification of this test, the rapid simultaneous grip test, in detecting submaximal grip efforts was evaluated. Uninjured subjects giving maximal or submaximal grip efforts were tested at grip rates of 80 and 100 repetitions per minute. Rapid exchange grip at 80 repetitions per minute yielded a sensitivity of 86% and a specificity of 97%. Rapid simultaneous grip at 80 repetitions per minute yielded a sensitivity of 81% and a specificity of 93%. Poorer sensitivities and specificities resulted when a clinical population of patients was tested. Patients who were not giving maximal efforts tended not to comply with the test protocol. The rapid exchange and rapid simultaneous grip tests do assist in detecting submaximal grip efforts; limits to these tests are emphasized.

Pulmonary edema associated with salt water near-drowning: new insights

In this case report we describe the clinical and laboratory findings of a man who nearly drowned after aspirating a large quantity of seawater. The aspiration of salt water, which is strongly hypertonic with respect to plasma, resulted in severe pulmonary edema, both from the quantity of aspirated seawater and the osmotically driven ultrafiltrate of plasma that accumulated in the air spaces. The initial concentration of protein in the edema fluid sample was very low, 0.7 g/dl, consistent with only a minimal increase in epithelial permeability. Approximately 4 h later, there was a marked increase in the concentration of protein in the residual alveolar fluid associated with improvement in several clinical indices, indicating that the excess alveolar fluid was reabsorbed very rapidly. In addition, the magnesium concentration was markedly elevated because of the aspiration of magnesium-containing seawater, which may have diagnostic importance for near-drowning in salt water. The data from this case provide evidence for well-preserved alveolar epithelial barrier function after aspiration of large quantities of hypertonic salt water.

Toward a synthetic approach to the Rorschach: the case of a psychotic child

Much Rorschach research on case material focuses on the utility of a single scoring system, set of variables, or scale in isolation from other systems, scales, or perspectives. This approach fails to acknowledge the complexity of the Rorschach and to reflect the manner in which sophisticated clinicians select and synthesize various perspectives during the clinical inference and decision-making process. A case of a psychotic child is presented to illustrate the utility of a synthetic approach to the Rorschach. The strengths and weaknesses of various Rorschach perspectives in addressing specific diagnostic issues is explored through the case material.

Can NBME scores distinguish students who choose a practice-based clerkship?

The National Board of Medical Examiners (NBME) examination Part II scores of students taking a two- to three-month community practice-based third-year family practice clerkship were compared with the scores of comparison students who had been matched on the basis of NBME Part I results. No significant differences between groups were seen for the total score or the scores in medicine or surgery. Significantly higher scores were seen for the clerkship students in the public health section. Significantly lower scores were obtained by this group on the psychiatry section, probably since many of the clerkship students did not take the regular psychiatry clerkship prior to taking the NBME Part II examination. No significant changes were seen in the scores for medicine or surgery. The results for ob/gyn and pediatrics were inconsistent. Taking this community practice-based clerkship appears to provide an equivalent amount of cognitive information.

An emerging global programme against tuberculosis: agenda for research, including the impact of HIV infection

During the last 5 years, a worldwide resurgence of tuberculosis has been convincingly documented. Increased numbers of cases have been reported from several industrialized countries and there has been a veritable explosion of tuberculosis in the developing countries of sub-Saharan Africa. The fact that most of this increase is attributable to coexisting infection with the human immunodeficiency virus (HIV) should come as no surprise, because of the role played by cell-mediated immunity in protecting against tuberculosis and the depletion of this immunity by HIV infection. The World Health Organization estimates that there are more than 3 million persons in the world dually infected with HIV and tubercle bacilli. To combat this problem, there needs to be an expansion of programmes designed to identify and treat all patients with tuberculosis, whether HIV infected or not. In addition, the prospects for further advances in basic research, clinical research, epidemiological research and operations research, which have broad application to clinical medicine, are great, and these results will help combat the dual scourges of HIV infection and tuberculosis.

Internal neurolysis fails to improve the results of primary carpal tunnel decompression

This prospective, randomized study compares two treatment methods in patients with primary carpal tunnel syndrome. Decompression of the transverse carpal ligament was done in thirty-two hands (thirty patients) and decompression of the transverse carpal ligament with the addition of an internal neurolysis of the median nerve was done in thirty-one hands (twenty-nine patients). Relief of symptoms was described in eighty-eight percent of the patients with carpal ligament release and eighty-one percent of patients with carpal ligament release plus internal neurolysis. Improvement in hand sensibility testing, in thenar muscle strength, and atrophy was noted in both treatment groups with no statistical difference between groups. The addition of an internal neurolysis to division of the transverse carpal ligament does not add significant improvement in the sensory or motor outcome of patients with primary carpal tunnel syndrome.

[A cursed duo: HIV infection and tuberculosis]

Tuberculosis remains a health problem of extraordinary magnitude, especially in developing countries. Unfortunately, many of the same countries have the additional burden of a remarkably high prevalence of HIV infection. Because of the inherent capacity of tubercle bacilli to take advantage of deficiencies in cell-mediated immunity, tuberculosis has become an extremely important infectious complication of HIV disease in those developing countries in which the two infections coexist; the same is true, although to a lesser extent, in developed countries among those groups of patients with HIV infection, in which there is also a high prevalence of remotely acquired tuberculosis.

Tuberculosis and human immunodeficiency virus infection during the 1990's

Among the many infectious complications of infection with human immunodeficiency virus (HIV), tuberculosis is now recognized as one of the most important. Coexisting HIV infection is believed responsible for the soaring incidence of tuberculosis in Africa, and for the increase in the number of reported cases in the United States. As HIV-induced immunosuppression worsens, tuberculosis may supervene by reactivation of remotely acquired infection or failure to defend against newly acquired Mycobacterium tuberculosis. Both mechanisms undoubtedly occur in Africa where the rate of exposure is high; the former prevails in the United States. The risk of tuberculous infection progressing to tuberculous disease is about six times higher in HIV seropositive than seronegative persons. Although not incontrovertibly established, tuberculosis probably also has a deleterious effect on coexisting HIV infection, either by accelerating the rate of destruction of CD4+ lymphocytes and/or promoting the release of new virions from HIV-infected macrophages. Tuberculosis, whether HIV-linked or not, can be controlled by the traditional means of case-finding and treatment, vaccination with BCG, and chemoprophylaxis. HIV infection can be controlled by eliminating high-risk behavior, and using uncontaminated blood and other medical supplies. An extensive campaign is needed to prevent further spread of these dual scourges that are overwhelming already meager health resources in many parts of the world.

Elevated von Willebrand factor antigen is an early plasma predictor of acute lung injury in nonpulmonary sepsis syndrome

In this prospective study of 45 patients, we tested the hypothesis that markedly elevated levels of plasma von Willebrand antigen (vWf-Ag) a marker of endothelial cell injury, might predict the development of acute lung injury in patients with nonpulmonary sepsis syndrome. Acute lung injury was quantified on a four-point scoring system. At the time of entry into the study, none of the 45 patients had evidence of lung injury. Subsequently, 15 patients developed lung injury and 30 patients did not develop lung injury. The mean plasma vWf-Ag level was markedly elevated in the 15 patients who developed lung injury compared with the 30 patients who did not develop lung injury (588 +/- 204 vs. 338 +/- 196, percentage of control, P less than 0.01). Furthermore, a plasma vWf-Ag level greater than or equal to 450 was 87% sensitive and 77% specific for predicting the development of acute lung injury in the setting of nonpulmonary sepsis. In addition, the combination of a plasma vWf-Ag greater than 450 and nonpulmonary organ failure at the time of entry into the study had a positive predictive value of 80% for acute lung injury. Also, a plasma vWf-Ag level greater than 450 had a positive predictive value of 80% for identifying nonsurvivors. Thus, in patients with nonpulmonary sepsis, an elevated level of plasma vWf-Ag is a useful, early biochemical marker of endothelial injury and it has both predictive and prognostic value.

Effects of aerosolized artificial surfactant on repeated oleic acid injury in sheep

We studied the effects of an artificial surfactant, Exosurf, administered as an aerosol on respiratory system compliance (Crs), total respiratory resistance (RT), and gas exchange (PO2) in anesthetized, paralyzed sheep with oleic acid (OA)-induced lung injury. Paired experiments with OA were performed in 10 sheep, 5 of which received Exosurf in the first experiment and aerosolized 0.9% NaCl in the second; in the other 5 sheep the order of Exosurf and NaCl was reversed. Paired experiments without OA were performed in 6 additional sheep that served as controls. In the first set of experiments, OA caused significant abnormalities, compared to control and baseline values (p less than 0.02), in Crs, RT, and PO2; there was no difference between animals that received Exosurf and those that received NaCl. Baseline values for PO2 and Crs during the second set of experiments with OA were lower than controls (p less than 0.002), indicating that the animals had not fully recovered from their initial injury. After OA, the animals that received NaCl (i.e., the ones that received Exosurf the first time) had higher PO2 and Crs values (p less than 0.01) than those that received NaCl first and Exosurf second. There was no difference in postmortem lung water content between the animals that received Exosurf or NaCl first, both of which were higher than control (p less than 0.01). Studies in 3 additional sheep showed peripheral deposition of aerosol. Thus, we failed to show an acutely beneficial effect of aerosolized Exosurf in OA-induced lung injury; Exosurf did, however, appear to provide protection against some of the consequences of repeated lung injury.

Cursed duet: HIV infection and tuberculosis

Tuberculosis remains a health problem of extraordinary magnitude, especially in developing countries. Unfortunately, many of the same countries have the additional burden of a remarkably high prevalence of HIV infection. Because of the inherent capacity of tubercle bacilli to take advantage of deficiencies in cell-mediated immunity, tuberculosis has become an extremely important infectious complication of HIV disease in those developing countries in which the two infections coexist; the same is true, although to a lesser extent, in developed countries among those groups of patients with HIV infection in which there is also a high prevalence of remotely acquired tuberculosis. Prof. Chrétien helped call attention to the link between tuberculosis and HIV infection in France. Now, it is obvious that his cogent observations extend to much of the rest of the world.

Plasma tumor necrosis factor in patients with septic shock. Mortality rate, incidence of adult respiratory distress syndrome, and effects of methylprednisolone administration

We assayed serial plasma samples from 86 patients, who were enrolled in a prospective randomized trial of the effects of methylprednisolone (MPSS) in septic shock, for the presence of cytokine tumor necrosis factor (TNF) using an enzyme-linked immunosorbent assay. TNF was present in the plasma of 27 of the 74 patients with septic shock, but in only 1 of the 12 patients with shock due to other causes. TNF was detected with equal frequency in patients with shock from gram-negative or from gram-positive bacillary sepsis. TNF levels were highest on the initial sample and decreased significantly over the subsequent 24 h in both the patients treated with MPSS and in those given placebo. Patients with detectable TNF had a higher incidence and severity of the adult respiratory distress syndrome and a higher mortality rate than did patients without detectable TNF.