Complications related to carpal tunnel release

Complications of operative carpal tunnel release continue to occur in the clinical practice of hand surgery. Anatomic localization of nerve injury has been reviewed in the area of the palmar cutaneous nerve, the median motor branch, and in the combined sensory/motor median nerve itself. Diagnosis and appropriate treatment plans have been reviewed to facilitate early appropriate treatment which usually diminishes disability. General complications have also been discussed including recurrent scar formation which is probably the most commonly encountered complication following carpal tunnel release. Possible neurovascular complications involving the development of reflex sympathetic dystrophy have received some attention in this presentation in order to alert the clinical surgeon to the possibility of this entity providing further disability to an already injured median nerve.

Analytical laboratory quality: Part I. General quality practices

Once a biotechnology product reaches the final stages of development, the types of quality practices required in the laboratories performing the analytical testing are clearly defined in the applicable regulations. Long before this stage, though, there are innumerable tests and studies conducted in biomolecular facilities that provide critical information upon which product development decisions are made. While sound scientific practices will guide the management of the best of these laboratories, there are several additional operational elements that can significantly enhance the utility of the data to commercial clients. Such laboratory quality practices can also provide considerable benefit to the facility itself, engendering higher confidence in the day-to-day operations within the laboratory. Most of these practices can be simply implemented with pens, notebooks, and diligence.

Oral tolerance: elucidation of mechanisms and application to treatment of autoimmune diseases

Oral tolerance is the phenomenon of systemic, antigen specific, immunological hyporesponsiveness that results from oral administration of a protein. The mechanism by which tolerance is generated depends on the amount of antigen administered; low doses favor induction of regulatory T cells while higher doses favor clonal deletion and anergy. The regulatory T cells induced by low doses of oral antigen are triggered by the same antigen to secrete cytokines that suppress, in an antigen nonspecific manner, inflammation in the microenvironment where the triggering antigen is located. This makes possible the targeted delivery of antiinflammatory cytokines to a specific tissue without the requirement for identifying the antigen causing the inflammation. This attribute makes active suppression an attractive mechanism for developing therapies for autoimmune diseases. Orally administered autoantigens have been shown to suppress a wide variety of experimental autoimmune diseases and have recently been applied to the treatment of human autoimmune diseases with promising early results.

The built environment as a component of quality care: understanding and including the patient's perspective

BACKGROUND

Although there has been little systematic assessment of how the built environment of health care facilities affects the quality of care, the built environment is a major element of structure of care--one of three facets of quality. Yet in contrast to the growing trend of using consumer perceptions of both processes and outcomes of care in QI activities, quality assessments of the structure of care do not currently rely on patient feedback. PURPOSE OF PROJECT: During the initial phase of a multiphase project, nine focus groups were conducted in 1997 to identify the salient dimensions of experience from the patient's perspective. The content of these focus groups guided the development of assessment tools in the second phase of the project, which began in February 1998.

FINDINGS

Participants in three focus groups that were held in each of three settings--ambulatory care, acute care, and long term care--described in detail a variety of reactions to the built environment. Analysis revealed eight consistent themes in what patients and family member consumers look for in the built environment of health care. In all three settings, they want an environment, for example, that facilitates a connection to staff and caregivers, is conducive to a sense of well-being, and facilitates a connection to the outside world.

DISCUSSION

Data derived from the focus group research has guided the development of quantitative survey and assessment tools. For each setting, patient-centered checklists and questionnaires are designed to help institutions set priorities for the improvement of facility design from the patient's perspective.

Wound care for persons with diabetes

This article addresses local wound care in people with diabetes mellitus. An approach is proposed that uses wound depth and color to determine the goals of local wound treatment. Principles of cleansing, debridement, and the use of moisture retentive dressings are discussed. Infection, a significant problem in the diabetic patient, is addressed as an essential part of local wound care in these patients.

Managing diabetic foot ulcers

This article discusses optimal care for a diabetic foot wound including use of a protocol with standards for assessment, treatment, and prevention. Patient and family education is also pivotal to the plan's success.

Wound infection: a nurse's perspective

There is clinical uncertainty about the involvement of bacteria in open wounds. Frequently asked questions are: Is this wound infected? Should I culture the wound? How should I clean the wound? Do I need to use sterile technique when I perform local wound care? Using available science and common sense, a practical approach is proposed to answer these questions.

Comparing claims data and self-reported data with the medical record for Pap smear rates

The objective of this study was to assess and compare the relative accuracy of claims data and patient self-reported information with medical records for Pap smear rates. A retrospective analysis of information obtained from administrative claims files, patient medical records, and a telephone survey was performed of 400 women age 19 through 75 years who were randomly selected for participation in the study. The data were obtained from a large multispecialty group practice in Minneapolis, Minnesota for the study years 1991 through 1993. Information from administrative claims regarding Pap smear status corresponded highly with information in the medical record (sensitivity 95% or higher; specificity 95% or higher; kappa 0.896 or better). Self-reported information from the telephone survey did not correspond well with medical record information nor with results in administrative claims.

Energy expenditure during walking by children who have proximal femoral focal deficiency

The energy expended during walking by sixteen children who had proximal femoral focal deficiency was measured to compare the outcomes after Syme amputation (seven subjects) with those after Van Nes rotational osteotomy (nine subjects). Multivariate regression analysis revealed that the subjects who had had a Van Nes procedure had a mean oxygen cost (energy per unit of body mass expended per distance walked) that was 0.12 milliliter per kilogram of body mass per meter lower than that of the subjects who had had a Syme amputation (p = 0.001). The subjects who had had a Van Nes procedure tended to walk faster (p = 0.07). A significant decrease in the oxygen cost as a function of increasing age was observed for both groups (p < 0.0001, r2= 0.79). We believe that the reduced energy expenditure associated with the Van Nes rotational osteotomy is one of several factors to consider when deciding which operation should be done for children who have proximal femoral focal deficiency.

Taking health status into account when setting capitation rates: a comparison of risk-adjustment methods

OBJECTIVE

To compare performance of different health status measures for risk-adjusting capitation rates.

DESIGN

Cross-sectional study. Health status measures derived from 1 year were used to predict resources for that year and the next.

SETTING

Group-network health maintenance organization in Minnesota.

PARTICIPANTS

Sample of 18- to 64-year-old (n=3825) and elderly (aged > or = 65 years; n=1955) members enrolled in a network-model health maintenance organization in Minnesota.

MAIN OUTCOME MEASURES

Total expenditures in the year concurrent with the health status survey (July 1991 through June 1992) and total expenditures in the year following the survey (July 1992 through June 1993).

RESULTS

Capitation adjustment based on demographic measures performed least well. Both self-reported health status measures and diagnoses predicted future expenditures twice as well as demographics. When predicting costs for groups of patients rather than individuals, the demographic model worked well for average groups but tended to overpredict healthier groups and underpredict sicker groups. Ambulatory Care Groups based on diagnoses performed better than self-reported health status both in the retrospective models and across healthier and sicker groups.

CONCLUSIONS

Without risk adjustment, capitation rates are likely to overpay or underpay physicians for certain patient groups. It is possible to improve prediction using health status measures for risk adjustment. When selection bias is suspected and administrative data are available, we recommend a risk-adjustment method based on diagnostic information. If diagnostic data are not available, we recommend a system based on simple self-reported measures, such as chronic conditions, rather than complex functional status measures.

Physical therapy to improve functioning of older people in residential care facilities

BACKGROUND AND PURPOSE

The purpose of this study was to determine the effectiveness of an individualized physical therapy mobility training program on the gait, balance, and functional performance of elderly individuals living in residential care facilities.

SUBJECTS

Twenty-seven elderly individuals with impaired balance and difficulty performing at least one functional activity participated in the study. The subjects ranged in age from 71 to 97 years (mean = 87.1, SD = 6.7).

METHODS

Balance and gait speed were assessed at baseline and following physical therapy that consisted of exercises to improve specific functional limitations. Outcomes were reassessed 1 month following completion of the physical therapy.

RESULTS

Gait and balance outcomes were analyzed using a one-way repeated-measures analysis of variance. Improvement was obtained in balance, which was maintained at 1 month follow-up. Gait speed did not improve to a level of statistical significance.

CONCLUSION AND DISCUSSION

After physical therapy, subjects improved in balance and functional performance. An improvement in gait speed may require a longer duration of treatment.

Using wound debridement to help achieve the goals of care

The removal of devitalized tissue, particulate matter, or foreign materials from a wound, debridement, is often the first goal of wound care. Debridement can be accomplished surgically (instrument/sharp), chemically, mechanically or by means of autolysis. Each procedure has distinct advantages, disadvantages, indications for use and risks, and a combination of methods will often expedite the process while limiting the chance of complications. Depending on the method used as well as a variety of local and systemic factors, chronic wound debridement can take anywhere from a few days to more than a month. Even though wound debridement is often discussed separately, particularly when managing patients with chronic wounds, it should not be viewed in isolation. Rather, it is one aspect of total patient care. Measures to facilitate the healing process in general should be employed at all times, because debridement and wound healing can occur simultaneously.

Screening for balance and mobility impairment in elderly individuals living in residential care facilities

BACKGROUND AND PURPOSE

The rapid growth of the elderly population has resulted in a corresponding rise in the number of elderly individuals who experience disability during their lifetimes. The purpose of this study was to test the usefulness of four established clinical measures of balance, gait, and subjective perceptions of fear of falling as screening methods for referring community-dwelling elderly individuals living in residential care facilities for detailed physical therapy evaluation and possible intervention.

SUBJECTS

The subjects were a convenience sample of 53 elderly individuals living in two residential care facilities for the elderly.

METHODS

Subjects were tested on each of four clinical measures of balance and mobility. Their performance on these measures was compared with a physical therapist's brief evaluation of disability and appropriateness for more detailed evaluation. The usefulness of these tools as screening methods was determined by calculating sensitivity and specificity levels using the physical therapist's evaluation as a standard.

RESULTS

The sensitivity and specificity levels of the four clinical measures in their application as screening tests for referral to physical therapy were as follows: Berg Balance Scale, 84% and 78%; balance subscale of the Tinetti Performance-Oriented Mobility Assessment, 68% and 78%; gait speed, 80% and 89%; and Tinetti Fall Efficacy Scale, 59% and 82%. The combination of two tests, Berg Balance Scale and gait speed, yielded the highest sensitivity of 91% and the highest specificity of 70% when a subject tested positive on at least one test.

CONCLUSION AND DISCUSSION

These findings indicate the feasibility of developing screening methods for referring community-dwelling elderly individuals for a detailed physical therapy evaluation based on established clinical assessment measures, with a combination of tests measuring balance and gait demonstrating the most promising results.

Biotechnology core facilities: trends and update

A survey of 128 biotechnology core facilities has provided data on the finances, services, space requirements, and personnel. An average facility had four full-time personnel and 7.5 major instrument systems, and occupied 969 sq. ft. Average total income was $244,000/year, but annual user fee income was only $125,000. Typically, facilities required substantial institutional support or grants. Cost recovery (user fee income divided by total income) averaged 49%. During the last 5 years user fee income, total income, and cost recovery have increased. In-house charges for protein sequencing and peptide synthesis increased approximately 30%, while oligonucleotide synthesis charges decreased by 74%. The costs (charges corrected for subsidy from non-user fee income) for most services did not significantly change, except that oligonucleotide synthesis costs decreased by 25% in 1992. DNA synthesis had the highest throughout per month (116 samples), followed by amino acid analysis (86 samples) and DNA sequencing (67 samples). Other services averaged from 5 to 60 samples. DNA synthesis and purification were the services used by the greatest number of principal investigators. A number of services including DNA sequencing, mass spectrometry, capillary electrophoresis, RNA synthesis, electroblotting, and carbohydrate analysis have been introduced in the last 3 years. Although these services are characterized by high levels of methods development and non-user runs, they are offered by twice the percentage of facilities as in 1989, and are increasingly contributing to facility income.

Depressant insect selective neurotoxins from scorpion venom: chemistry, action, and gene cloning

The present study examines the similarity in the symptoms and binding properties between the depressant and excitatory insect-selective neurotoxins, derived from scorpion venom. A comparison of their primary structures and neuromuscular effects is presented. A new depressant toxin (LqhIT2) was purified from the venom of the scorpion Leiurus quinquestriatus hebraeus. The effects of this toxin on a prepupal housefly neuromuscular preparation mimic its effects on the intact insect, i.e, a brief period of repetitive bursts of regular junction potentials (JPs) is followed by reduced amplitude JPs ending with a block of the neuromuscular transmission. "Loose" patch clamp recordings indicate that the repetitive activity has a presynaptic origin (the motor nerve) and resembles the effect of the excitatory toxin AaIT. The final synaptic block is supposed to be the end result of neuronal membrane depolarization. Such an effect is not caused by an excitatory toxin, which induces long "trains" of repetitive firing. The amino acid sequences of three depressant toxins were determined by automatic Edman degradation indicating a high degree of sequence homology. This conservation differs from those of other groups of scorpion toxins. The opposing pharmacological effects of depressant toxins are discussed in light of the above neuromuscular effects and sequence analysis. A genetic approach in the study of the structure-function relationships of the depressant toxins was initiated by isolating cDNA clones encoding the LqhIT2 and BjIT2 toxins. Their sequence analysis revealed the precursor form of these toxins: A 21 amino acid residue signal peptide followed by a 61 amino acid region of the mature toxin, and three additional amino acids at the carboxy terminus.