Management of chronic lunotriquetral ligament tears

Treatment of chronic disruptions of the lunotriquetral (LT) ligament is not well-defined. Eleven patients treated by LT fusion with use of a compression screw are reported. The injury frequently resulted from hyperextension of the wrist. Pain on the ulnar side of the wrist, limited motion, and tenderness over the LT joint exacerbated by ballottement were present. Standard radiographs were normal. Arthrography showed the ligamentous tear in all cases. After operation, immobilization was continued until fusion was apparent radiographically. Fusion was achieved in all cases between 2 and 5 months. Four patients were free of pain, four patients had pain only at the extremes of motion, and three patients had persistent pain. Mean wrist motion was as follows (preoperative/postoperative): flexion (53 degrees/45 degrees), extension (60 degrees/49 degrees), radial deviation (17 degrees/21 degrees), and ulnar deviation (25 degrees/18 degrees). Maximum grip strength as a percentage of the uninjured side was 73% preoperatively and 59% postoperatively. LT tears can exist de novo or as part of the ulnar impaction syndrome; a method for differentiation is presented.     

Headache after spinal anesthesia for cesarean section: a comparison of the 27-gauge Quincke and 24-gauge Sprotte needles.

A high incidence of postdural puncture headache (PDPH) occurs after spinal anesthesia for cesarean section. To examine this problem, a study was conducted with the recently developed 24-gauge Sprotte and 27-gauge Quincke needles in patients undergoing elective and emergency cesarean section (n = 298). The needle to be used was assigned in a random manner: group I, 27-gauge Quincke (n = 147); group II, 24-gauge Sprotte (n = 151). During the postoperative period, patients were visited daily and asked specifically about the presence and severity of headache. The overall incidence of PDPH was 2% (n = 6), five in the Quincke group (3.5%) and one in the Sprotte group (0.7%). There was no significant difference in the incidence of PDPH between the two groups. Five headaches were classified as mild, and only one was moderate to severe. All headaches resolved quickly with conservative management and without blood patch. The authors conclude that the choice between a 27-gauge Quincke and a 24-gauge Sprotte needle does not influence the incidence of PDPH after spinal anesthesia for cesarean section.     

Identifying potential indicators of the quality of end-of-life cancer care from administrative data.

PURPOSE: To explore potential indicators of the quality of end-of-life services for cancer patients that could be monitored using existing administrative data. METHODS: Quality indicators were identified and assessed by literature review for proposed indicators, focus groups with cancer patients and family members to assess candidate indicators and generate new ideas, and an expert panel ranking the meaningfulness and importance of each potential indicator using a modified Delphi approach. RESULTS: There were three major concepts of poor quality of end-of-life cancer care that could be examined using currently-available administrative data (such as Medicare claims): institution of new anticancer therapies or continuation of ongoing treatments very near death; a high number of emergency room visits, inpatient hospital admissions, or intensive care unit days near the end of life; and a high proportion of patients never enrolled in hospice, only admitted in the last few days of life, or dying in an acute-care setting. Concepts such as access to psychosocial and other multidisciplinary services and pain and symptom control are important and may eventually be feasible, but they cannot currently be applied in most data systems. Indicators based on limiting the use of treatments with low probability of benefit or indicators based on economic efficiency were not acceptable to patients, family members, or physicians. CONCLUSION: Several promising claims-based quality indicators were identified that, if found to be valid and reliable within data systems, could be useful in identifying health-care systems in need of improving end-of-life services.     

Compartmentalization of single muscle units in cat lateral gastrocnemius

Summary The distribution of muscle fibers in single muscle units in cat lateral gastrocnemius (LG) muscle was analyzed using the method of glycogen depletion. Single, type FF motor units in LG were identified by stimulation of dissected ventral rootlets and then activated to produce depletion of glycogen in their innervated muscle fibers. Serial histological sections were made of the entire triceps surae muscles and then reacted for the demonstration of glycogen. Projected tracings of the sections were used to compare the distribution of glycogen depleted muscle fibers to the heads of the LG muscle. Results of analysis of single muscle units indicate that the muscle fibers innervated by single cat LG type FF motor units are distributed to the same regions of muscle which are innervated by primary branches of the nerve to the LG muscle. The single units are thus compartmentalized. These results support the hypothesis that each of the neuromuscular compartments of LG contains a unique population of motor units. It is suggested that compartmentalization of muscles about primary branches of their muscle nerves may from a major organizational principle in the design of skeletal muscles.