Setting expectations following endoscopic cubital tunnel release

Background

The objective was to evaluate recovery characteristics of patients undergoing endoscopic cubital tunnel release (ECuTR) by determining the following: (1) return to work (RTW) times following ECuTR compared with RTW times of patients that underwent anterior transposition of the ulnar nerve (ATUN), (2) satisfaction rates and factors affecting satisfaction, (3) resolution rates of common preoperative complaints and findings, and (4) effect of preoperative ulnar nerve subluxation on postoperative outcomes.

Methods

A total of 172 cases in 148 patients undergoing ECuTR were prospectively enrolled including 56 women and 92 men. Kaplan-Meier analyses were performed to determine RTW time for ECuTR patients and for a cohort of 15 patients that underwent ATUN. Patients were evaluated for subjective and objective complaints preoperatively and postoperatively. Cases were grouped by Dellon’s classification preoperatively and modified by Bishop’s postoperatively.

Results

Half of ECuTR patients returned to normal work within 8 days postoperatively versus 71 days following ATUN. Variables significantly negatively affecting RTW were male sex, manual labor, and worker’s compensation status. Dellon’s was the best predictor of postoperative satisfaction. Complete resolution of symptoms occurred in 86 % of patients for weakness, 81 % for pain, 79 % for numbness and tingling (N/T), 78 % for atrophy, 76 % for abnormal two-point discrimination, and 65 % for Wartenberg’s. Preoperative ulnar nerve subluxation had no effect on outcome.

Conclusions

Improved RTW time following ECuTR versus ATUN indicates potential and substantial cost-saving implications with respect to reduced worker productivity loss. Patients with more severe preoperative Dellon’s classification can expect less optimal results regarding postoperative satisfaction and resolution rates of N/T and pain.     

Correlates of Self-Efficacy for Condom Use Among Male Clients of Female Sex Workers in Tijuana,Mexico

Male clients of female sex workers (FSWs) in Tijuana, Mexico engage in high levels of unprotected sex. While behavioral change theories posit that self-efficacy predicts condom use, correlates of self-efficacy for condom use remain largely unstudied. We examined these correlates among male clients of FSWs in Tijuana. Eligible male clients were at least 18 years of age, HIV-negative, lived in Tijuana or San Diego, reported unprotected sex with a Tijuana FSW at least once in the past 4 months, and agreed to be treated for sexually transmitted infections (STIs). Participants completed an interviewer-administered questionnaire including demographics, substance use, psychosocial and psychosexual characteristics (e.g., outcome expectancies for negotiation of safer sex, social support, and sexual sensation seeking), and sexual behaviors. Participants also underwent HIV/STI testing. A stepwise hierarchical multiple regression analysis identified correlates of self-efficacy for condom use. Of 393 male clients, median age was 37 years. Participants were mostly Spanish-speaking and employed. Factors independently associated with higher self-efficacy for condom use were higher positive outcome expectancies for negotiation of safer sex, lower sexual sensation seeking scores, and higher social support scores. Both psychosocial and psychosexual factors may influence self-efficacy for condom use among male clients of FSWs. These factors represent central constructs in sociocognitive models that explain behavioral change and could be intervention targets for improving self-efficacy for condom use and, ultimately, safer sex behavior.     

Impact of Lift Assist Calls on Paramedic Services: A Descriptive Study

Introduction: The aging population in Canada is steadily increasing and is placing greater demand on paramedic services, especially through the growing number of non-emergent lift assist (LA) calls. A LA occurs when a person calls paramedic services and requests assistance to get up or mobilize, usually after experiencing a fall. The patient refuses transport to the emergency department for further medical attention. LA calls are time consuming and are non-reimbursable. The increase in number of this call type, specifically amongst older adults, is placing strain on paramedic services. Objectives: The purpose of this study was to describe the characteristics of LA calls in patients aged 65 and older and determine their impact on paramedic services. Methods: A dataset of 1,121 LA calls of patients aged 65 and older was extracted from Middlesex-London Emergency Medical Services (MLEMS) database of electronic patient care reports collected over 1 year in 2015. Statistical and qualitative analyses were performed to describe LAs, perform time analysis, and extract dominant themes from the text in report notes written by paramedics. Results: The LA calls were generated from 611 individuals: 334 women (54.7%) and 275 men (45%), of which 192 (32%) individuals called more than one time. On average, a LA call lasted 43?minutes and ranged from 6?minutes to 2?hours and 23?minutes. In 2015, paramedics spent 801?hours, or the equivalent of 33 days (24?hours/day), solely conducting LAs for older adults. Text analysis determined that the bedroom (24.9%) and bathroom (17.0%) were the most common locations where LAs occurred. Most frequently, LAs were caused by a collapse or drop (28.7%), slide (25.7%), slip (16.7%), or trip (11.7%). Conclusion: LAs consume the time of paramedics, preventing them from responding to more urgent emergency calls. Alternative solutions are needed to reduce the negative impact of LAs on paramedic services.     

Dose-ranging evaluation of the substituted benzamide dazopride when used as an antiemetic in patients receiving anticancer chemotherapy

Summary Dazopride, a substituted benzamide structurally related to metoclopramide, is a potent gastric prokinetic agent that prevents cisplatin-induced emesis in animals. Unlike metoclopramide, dazopride has no effect on dopamine receptors and therefore should not produce extrapyramidal side effects. In this dose-ranging trial, 23 patients with cancer receiving chemotherapy known to produce nausea and vomiting received three i.v. infusions of dazopride every 2 h beginning 30 min before the chemotherapy. Seven dose levels were explored ranging from 0.5 to 4.0 mg/kg in each of the three infusions. Toxicities were mild and included sedation, dizziness, visual disturbances, and headaches. All side effects were transient and were not dose-related. Antiemetic effects were observed. Dazopride can be safely given on this schedule at doses of up to 4.0 mg/kg to patients receiving chemotherapy. On the basis of the results of this trial, further studies of this agent are warranted.Supported in part by NIH grant CA-09 149-15, by HHS grant CA-05 826, by the A. H. Robins Co., and by the Bihari Fellowship Fund     

Outcome prediction following radical nephroureterectomy for upper tract urothelial carcinoma

ObjectiveTo predict overall survival, cancer, and metastasis specific survival in upper tract urothelial carcinoma (UTUC) following radical nephroureterectomy (RNU).Materials and MethodsAll nonmetastatic UTUC patients who underwent RNU with a curative intent at 1 institution between December 1998 and January 2017 were included.  Detailed data were collected. End points for this study included OS, CCS, and MFS. Univariate and multivariate analysis were conducted. Log Rank tests and Kaplan-Meier curves were generated. Backward elimination and boot strapping was used to identify the most parsimonious model with the smallest number of variables in order to predict the outcomes of interest. A separate second institution data base was used for external validation.ResultsThere were 218 patients in the development cohort. Mean follow-up was 42 months (±39.6). There was 99 (45.4%) deaths, 28 (12.8%) cancer related deaths, 72 (33%) recurrences, and 54 (24.8%) metastases. The c-index for our model was 0.71 for OS, 0.72 for MFS and 0.74 for CSS. The nomograms did not show significant deviation from actual observations using our calibration plots. We divided the patient into 3 different groups (low, intermediate and high risk) based on their final total score for each outcome and compared them. On external validation our accuracy was 78.4%, 71.4%, and 75.3% for OS, CSS, and MFS survival respectively.ConclusionWe designed a predictive model for survival outcomes following RNU in UTUC. This model uses simple, readily available data for patients without the need for expensive or additional testing.     

Distribution of weakness in the upper and lower limbs post-stroke

Objective. To assess the distribution of weakness in the upper and lower limbs post-stroke and the factors associated with weakness.

Method. The design was a prospective cross-sectional survey. A consecutive sample of 75 patients (37 (49%) men, mean age 71.5 (SD 12.2) years, 46 (61%) left hemiplegics) with a first-time anterior-circulation stroke, tested 2 – 4 weeks post-stroke, were recruited from two NHS trusts.

Main outcome measures. Weakness (Motricity Index, MI).

Results. Mean MI score was 58.5 (SD 39.6) and 69.1 (SD 33.6) for the upper and lower limb (p < 0.001), but examination of individual data indicated 36 (48%) had no/ negligible difference (0 +/? 9 points) in MI score between the limbs. When there was a difference, the lower limb was more frequently the stronger. There was no significant difference between the proximal and distal joints in either limb (p < 0.217 and 0.410). Severity of weakness was not associated with the subjects' demographics or stroke pathology, but was associated with neglect and sensation.

Conclusions. Although group analysis showed that the leg was significantly stronger than the arm, individual analysis showed that most participants had a similar degree of weakness in both limbs. When there was a difference, the lower limb was more frequently the stronger. Proximal joints were not more severely affected than distal joints. Patient demographics and stroke pathology factors were not associated with weakness, but stroke-related impairments were.