William C. Tallent Outpatient Clinic

INTRODUCTION: The purpose of this study was to develop an evidence-based guideline for the use of neuromuscular ultrasound in the diagnosis of carpal tunnel syndrome (CTS). METHODS: Two questions were asked: (1) What is the accuracy of median nerve cross-sectional area enlargement as measured with ultrasound for the diagnosis of CTS? (2) What added value, if any, does neuromuscular ultrasound provide over electrodiagnostic studies alone for the diagnosis of CTS? A systematic review was performed, and studies were classified according to American Academy of Neurology criteria for rating articles of diagnostic accuracy (question 1) and for screening articles (question 2). RESULTS: Neuromuscular ultrasound measurement of median nerve cross-sectional area at the wrist is accurate and may be offered as a diagnostic test for CTS (Level A). Neuromuscular ultrasound probably adds value to electrodiagnostic studies when diagnosing CTS and should be considered in screening for structural abnormalities at the wrist in those with CTS (Level B).

Social support is becoming recognized as a positive influence on health and health maintenance. Forms of support which bolster the patient's sense of personal efficacy should enhance the alcoholic's ability to cope with a specific stressor (i.e., overcoming his or her addiction). Patients reporting higher levels of social support during alcoholism treatment, especially support that enhances his or her self-esteem, should therefore demonstrate improved outcome compared to patients with lower levels. Sixty-one consecutive admissions to an inpatient alcoholism treatment program at a rural midwestern medical center completed an assessment of six forms of social support (Guidance, Reliable Alliance, Reassurance of Worth, Opportunity for Nurturance, Attachment, and Social Integration) in terms of support obtained from family and friends and from the treatment environment. For each patient, additional information concerning age, marital status, financial support, and previous alcohol-related hospitalizations was also obtained. Outcome of treatment was measured by readmission for an alcohol-related diagnosis within 1 year of discharge. Survival analysis found that reassurance of worth from family and friends and number of previous hospitalizations were independent and significant predictors of time to readmission. Higher levels of reassurance of worth or esteem support significantly lengthened time to readmission, with the reverse relationship found for number of previous hospitalizations. These results suggest that specific sources (family and friends) and forms (reassurance of worth) of social support are important to the recovering alcoholic and that the effect of social support on treatment outcome is independent of the alcoholic's history of prior treatment failure. Interventions or program modifications should be designed specifically to bolster these facets of social support rather than addressing more general forms of support.

BACKGROUND: While cigarette smoking is recognized as being detrimental to oral health, the effects of cigar and pipe smoking on tooth-loss risk, alveolar bone loss and periodontal disease are not known. The authors conducted this study to determine whether cigar and pipe smokers were at greater risk of experiencing tooth loss and alveolar bone loss than were nonsmokers. METHODS: The authors studied 690 dentate men who participate in the Veterans Affairs Dental Longitudinal Study. Subjects are not VA patients, and they receive medical and dental care in the private sector. A board-certified periodontist conducted clinical examinations triennially for 23 years. These examinations included the number of teeth remaining, number of decayed and filled surfaces per tooth, and indicator scores for plaque, calculus, pocket probing depth, gingival bleeding and tooth mobility. Alveolar bone loss was assessed at each examination on intraoral periapical radiographs using the Schei ruler method, which measures loss of bone height in 20 percent increments. Multivariate analyses of tooth-loss rates and alveolar bone loss controlled for demographic and oral hygiene measures. RESULTS: The relative risk, or RR, of tooth loss compared with that of nonsmokers was significantly elevated in cigar smokers (RR = 1.3, 95 percent confidence interval, or CI, = 1.2, 1.5), pipe smokers (RR = 1.6, 95 percent CI = 1.4, 1.9) and cigarette smokers (RR = 1.6, 95 percent CI = 1.5, 1.7). The percentages of mesial and distal sites with moderate-to-severe progression of alveolar bone loss (a change of 40 percent or more from baseline) were 8 +/- 1 percent (mean +/- standard error) in nonsmokers, 16 +/- 3 percent in cigar smokers (P < .05), 13 +/- 4 percent in pipe smokers (P = .17), and 16 +/- 3 percent in cigarette smokers (P < .001). Pipe and cigar smokers did not differ significantly from nonsmokers with respect to the percentage of sites at baseline with moderate-to-severe scores for calculus, pocket probing depth, gingival bleeding or tooth mobility. Pipe smokers had fewer sites with moderate-to-severe plaque accumulation than did nonsmokers (7 +/- 11 vs. 13 +/- 17, P < .05). CONCLUSIONS: The authors found that men who smoke cigars or pipes were at increased risk of experiencing tooth loss. Cigar smokers also were at increased risk of experiencing alveolar bone loss. These elevations in risk are similar in magnitude to those observed in cigarette smokers. CLINICAL IMPLICATIONS: The increases in risk related to cigar and pipe smoking provide a strong rationale for targeting smoking prevention and smoking cessation programs to smokers of all tobacco products.

BACKGROUND: Programmed cell death ligand 1 (PD-L1) expression in primary cutaneous squamous cell carcinoma has not been described. METHODS: We reviewed immunohistochemical stained sections of 40 primary and five metastatic cutaneous squamous cell carcinomas using antibody to PD-L1 and classified the staining pattern according to the DAKO tumor proportion score method. We compared the staining results with microscopic staging parameters associated with risk of metastasis including tumor diameter, histologic grade, tumor thickness and perineural invasion. RESULTS: PD-L1 expression was present in 4 of 20 low risk tumors (20%), all of which showed low expression. PD-L1 expression was present in 14 of 20 high risk tumors (70%), 12 of which showed low expression and 2 of which showed high expression, 5 of 5 metastases (100%), with three showing low expression and two showing high expression. CONCLUSIONS: This survey documents PD-L1 expression in cutaneous squamous cell carcinoma and shows a positive correlation between the degree PD-L1 expression and pathologic findings related to risk of metastasis including large diameter, higher histological grade and tumor thickness.

We report our preliminary clinical results on positron emission tomography of human cerebral tumors with 11C-tagged amino acids. Carbon-11-DL-valine and 11C-DL-tryptophan were used for imaging the tumors. Some attempts at quantitation of the uptake were also carried out. The implications of these observations are discussed.

This study of 561 rural North Carolina adolescents examined relationships among race, parental educational level, family structure, parental discipline, family violence exposure, and dating violence experiences. The sample was predominantly female (77%), with 40% black and 58% white. The subjects ranged in age from 15 to 20 years; 80% of the adolescents were 16-18. Dating violence experiences were assessed by a researcher-constructed instrument measuring warning signs of potential violence and actual violent experiences. The results suggested that recognition of abusive relationships is difficult, with many adolescents denying such a relationship but actually reporting numerous abusive events. Sixty percent had experienced violent acts during dating relationships; 24% reported extreme violence (episodes of rape, use of weapons). More than 20% of the adolescents reported family violence and 2.2% reported family sexual abuse. The study suggests new avenues for research in adolescent date violence, and for interventions with high risk groups.

While acute confusion (AC) is frequently studied in the hospitalized elderly population, this phenomena has been largely ignored in elders who are residents in long-term care (LTC) facilities. The purpose of this study was to estimate the prevalence of AC in older LTC residents, the antecedent conditions present at the time of the AC event and the recognition rate of AC when assessed by staff nurses in two LTC facilities. This is a descriptive, longitudinal study with a 14 day follow-up period which incorporates a screening algorithm using AC instruments with established psychometric properties. A behavioral symptom instrument was also used in order to classify AC cases into clinical subtypes: hyperkinetic, hypokinetic and mixed. Staff nurses, using traditional assessment techniques and blinded to the case screening algorithm outcome, were asked to randomly evaluate both residents who were "clear" and those experiencing AC. Screening was conducted at both daytime and evening time-points. Of the 37 subjects followed. 15 (40.5%) screened positive for AC. Those AC cases with compromised cortical functioning indicative of Alzheimer's disease (n = 4) were particularly vulnerable to poor fluid intake. High risk medications (n = 7) and urinary tract infections (n = 7) were the most frequent antecedents. Most of the subjects experienced two or more antecedent conditions at the time of their AC. Staff nurses were able to identify 4 (26.7%) of the 15 instrument-positive residents, none of which were of a hypokinetic clinical subtype. These early results suggest a high prevalence of AC among elders in LTC, which may go unrecognized by bedside care providers.

BACKGROUND: The 'gold standard' for the diagnosis of melanocytic lesions is dermatopathology. Although most of the diagnostic criteria are clearly defined, the interpretation of histopathology slides may be subject to interobserver variability. OBJECTIVES: The aim of this study was to determine the variability among dermatopathologists in the interpretation of clinically difficult melanocytic lesions. METHODS: This study used the database of MelaFind®, a computer-vision system for the diagnosis of melanoma. All lesions were surgically removed and sent for independent evaluation by four dermatopathologists. Agreement was calculated using kappa statistics. RESULTS: A total of 1,249 pigmented melanocytic lesions were included. There was a substantial agreement among expert dermatopathologists: two-category kappa was 0.80 (melanoma vs. non-melanoma) and three-category kappa was 0.62 (malignant vs. borderline vs. benign melanocytic lesions). The agreement was significantly greater for patients ≥40 years (three-category kappa = 0.67) than for younger patients (kappa = 0.49). In addition, the agreement was significantly lower for patients with atypical mole syndrome (AMS) (kappa = 0.31) than for patients without AMS (kappa = 0.76). LIMITATIONS: The data were limited by the inclusion/exclusion criteria of the MelaFind® study. This might represent a selection bias. The agreement was evaluated using kappa statistics. This is a standard method for evaluating agreement among pathologists, but might be considered controversial by some statisticians. CONCLUSIONS: Expert dermatopathologists have a high level of agreement when diagnosing clinically difficult melanocytic lesions. However, even among expert dermatopathologists, the current 'gold standard' is not perfect. Our results indicate that lesions from younger patients and patients with AMS may be more problematic for the dermatopathologists, suggesting that improved diagnostic criteria are needed for such patients.

Male white Swiss mice that had previously been made aggressive by several weeks of individual housing were allowed to fight for 5 to 10 minutes each day for 5, 10, or 14 consecutive days; fighting caused a marked enlargement of their adrenals, spleens, and hearts, and a large increase in adrenal catecholamines; brain catecholamines were slightly increased. Long-term group caging, under conditions where the mice did not fight, caused changes that were directionally the same but of smaller magnitude. Similar sociophysiological influences may be important in natural populations. Fighting mice, used under well-defined and closely controlled conditions, may be useful for studying normal mechanisms of neuroendocrine adaptation and control, and, possibly, for studying some forms of hypertension and cardiovascular-renal disease.

The subscapularis muscle is the primary internal rotator of the shoulder and plays a key role in causing adduction, internal rotation, and pain in the hemiplegic patient. Spasticity and pain can be reduced by performing motor point blocks to the subscapularis. Two patients with spastic hemiplegic shoulder showed reduction in pain and immediate improvement in external rotation, abduction, and flexion after phenol motor point blocks to the subscapularis muscle. This preliminary report describes a method of performing subscapularis motor point blocks using a medial scapular approach.

The ways in which data are collected concerning the incidence and prevalence of Child Sexual Abuse (CSA) are critically examined. Consideration is given to the consistency of results across studies, and to confounding variables such as underreporting, that may compromise validity. It is concluded that the ways in which data on the incidence and prevalence of CSA have been collected, analyzed, and reported have been flawed to the extent that few reliable conclusions can be made. Suggestions for improvement in data collection, including modificalion of the National Crime Victimization Survey format (formerly the National Crime Survey; a source of potential data that has been neglected in the literature on CSA), are presented.

Sixty-five healthy males (31 to 75 years old) memorized lists of six letters (familiar or unfamiliar organization). Letters were then presented singly, and subjects responded yes or no according to whether a given letter was in the memorized set. Subjects of all ages took longer to respond in the case of the unfamiliar list. This was disproportionately true for the oldest subjects, consistent with the idea that the age-related differences in the unfamiliar condition could not be wholly accounted for by psychomotor factors. The distributions of response latencies in the oldest groups had greater variance and skew.

Segmental reflex regulation in 37 patients with idiopathic scoliosis and 8 patients with nonidiopathic scoliosis was studied by recording evoked reflex muscle potentials from four muscle groups in each lower extremity during partial neuromuscular blockade. Effects on reflex activity mediated through descending systems arising in the brain stem were investigated by recording from proximal-distal and flexor-extensor muscles. Ipsilateral and contralateral long-latency complex polysynaptic activity was present in all 37 patients with idiopathic scoliosis. This reflex activity was absent in eight nonidiopathic scoliosis patients. Long-latency reflex activity may represent segmental disinhibition. The presence of long-latency reflex activity in patients with idiopathic scoliosis and the absence of this activity in nonidiopathic scoliosis patients with curves of equal magnitude demonstrates that the curve per se is not responsible for the activity. This would imply that abnormal reflex processing may play a role in the development of the spinal deformity in patients with idiopathic scoliosis.

The biological identity of nanoparticles depends on the organic compounds bound to the surface; however, compounds other than proteins are largely uninvestigated. This study highlights the presence of unique compound profiles within the corona of the tested nanoparticles.

PURPOSE: To assess diagnostic performance of dedicated breast magnetic resonance (MR) imaging at breast imaging centers by using a dedicated 1.5-T breast MR system that used high-spatial-resolution, high-contrast-resolution spiral trajectory acquisitions. MATERIALS AND METHODS: The study was institutional review board approved and HIPAA compliant, with waiver of informed consent. Diagnostic performance was retrospectively assessed for 934 consecutive screening (n=347) and diagnostic (n=587) examinations performed from April 2006 to December 2007 in women aged 25-89 years old from four sites for which dedicated breast MR imaging reports and ground truth (biopsy for cancer cases, 1-year follow-up with negative results for cases with negative findings) were available. The sensitivity, specificity, and receiver operating characteristic (ROC) for breast MR imaging were determined. RESULTS: The sensitivity and specificity for the dedicated breast MR imaging system were 92% (92 of 100) and 88.8% (741 of 834). For all cases, the negative predictive value (NPV) was 98.9% (741 of 749). The NPV for screening cases was 100% (326 of 326). The area under the ROC curve was 0.942. Of the 93 cases with false-positive findings seen at dedicated breast MR imaging, 25 (27%) were high-risk histologic findings for which excision is often recommended. The false-positive rate was 93 of 834 (11.2%) for all cases, but only 16 of 326 (4.9%) for the screening cohort. CONCLUSION: High accuracy was achieved by using dedicated breast MR imaging.

STUDY DESIGN: Lower extremity polysynaptic reflexes and descending neurogenic motor and ascending somatosensory activity were recorded. OBJECTIVE: Two cases are presented to illustrate the intraoperative use of lower extremity reflex recordings for detecting compromise of spinal cord function. SUMMARY OF BACKGROUND DATA: Lower extremity reflex processing can be used to measure integrated spinal cord activity, whereas descending neurogenic and ascending somatosensory potentials measure only long tract function. METHODS: Eight channels of lower extremity polysynaptic reflex activity were recorded simultaneously after unilateral lower extremity mixed nerve stimulation. Sequential descending neurogenic and ascending somatosensory activity was recorded simultaneously with reflex recordings. RESULTS: In these two patients with idiopathic scoliosis, intraoperative reflexes changed before descending neurogenic and before ascending somatosensory activity changed. High-amplitude synchronous persistent reflex activity correlated with a postoperative neurologic deficit. Low-amplitude asynchronous transient reflex activity was not associated with a postoperative neurologic deficit. CONCLUSION: Intraoperative lower extremity reflex changes are more sensitive to spinal cord compromise than are changes in long tract function. Lower extremity polysynaptic reflexes monitor the integrated activity of the spinal cord that is responsible for the control of complex motor behavior.

BACKGROUND: The purpose of this study was to provide additional data on the experience with frameless copper and levonorgestrel (LNG) intrauterine devices (IUDs) in nulliparous and adolescent women. METHODS: Nulliparous and adolescent women, 25 years of age or younger, using the frameless copper IUD or the frameless LNG-releasing intrauterine system (IUS), were selected from previous studies and a current multicenter post-marketing study with the frameless copper IUD. The small copper-releasing GyneFix(®) 200 IUD consists of four copper cylinders, each 5 mm long and only 2.2 mm wide. The frameless FibroPlant(®) LNG-IUS consists of a fibrous delivery system releasing the hormone levonorgestrel (LNG-IUS). The main features of these intrauterine contraceptives are that they are frameless, flexible, and anchored to the fundus of the uterus. RESULTS: One hundred and fifty-four nulliparous and adolescent women participated in the combined study. One pregnancy occurred with the GyneFix 200 IUD after unnoticed early expulsion of the device (cumulative pregnancy rate 1.1 at one year). Two further expulsions were reported, one with the GyneFix 200 IUD and the other with the FibroPlant LNG-IUS. The cumulative expulsion rate at one year was 1.1 with the copper IUD and 2.2 with the LNG-IUS. The total discontinuation rate at one year was low (3.3 and 4.3 with the copper IUD and LNG-IUS, respectively) and resulted in a high rate of continuation of use at one year (96.7 with the copper IUD and 95.7 with the LNG-IUS, respectively). Continuation rates for both frameless copper IUD and frameless LNG-IUS remained high at 3 years (>90%). There were no cases of perforations or pelvic inflammatory disease reported during or following insertion. CONCLUSION: This report confirms earlier studies with frameless devices and suggests that the high user continuation rate is attributable to the optimal relationship between the IUD and the uterine cavity. IUD studies have shown that an IUD that does not fit well will often lead to side effects (ie, pain, bleeding, embedment, expulsion) and subsequent removal of the IUD. Early discontinuation is not the aim of long-acting reversible contraception.

A demonstrated period of abstinence is often viewed as a good prognostic sign in alcoholism. For example, short-term abstinence is one factor often considered important as a selection criteria for alcoholics who are being evaluated as liver transplant candidates. However, the prognostic validity of short-term abstinence is unclear. We evaluated the effects of 3 and 6 months of abstinence on readmission rates in a series of 299 alcoholics following discharge from inpatient treatment. Readmission rates were stratified using a 3-factor model of alcoholism severity. This 3-factor model defined groups with 1-year readmission rates, ranging from 15.8% to 62.7%. Short-term abstinence did not have strong effects on readmission rates for the most severe alcoholics, nor did short-term abstinence produce clinically significant reduction for readmission rates for the least severe alcoholics. We conclude that short-term abstinence has minimal effect on prognosis for alcoholics with various levels of baseline severity.

We apply chaotic time series analysis (CTSA) to human electroencephalogram (EEG) data. Three epoches were examined: epileptic seizure, non-seizure, and transition from non-seizure to seizure. The CTSA tools were applied to four forms of these data: raw EEG data (e-data), artifact data (f-data) via application of a quadratic zero-phase filter of the raw data, artifact-filtered data (g- data) and that was the residual after subtracting f-data from e-data, and a low-pass-filtered version (h-data) of g-data. Two different seizures were analyzed for the same patient. Several nonlinear measures uniquely indicate an epileptic seizure in both cases, including an abrupt decrease in the time per wave cycle in f-data, an abrupt increase in the Kolmogorov entropy and in the correlation dimension for e-h data, and an abrupt increase in the correlation dimension for e-h data. The transition from normal to seizure state also is characterized by distinctly different trends in the nonlinear measures for each seizure and may be potential seizure predictors for this patient. Surrogate analysis of e-data shows that statistically significant nonlinear structure is present during the non-seizure, transition , and seizure epoches.

The frequency of inpatient hospital care for three years before and three years after alcoholism treatment was evaluated for a group of 255 patients of predominantly lower socioeconomic status treated for alcoholism at a rural midwestern medical center in 1983. Subjects were interviewed while in treatment to obtain information regarding alcoholism history and demographics. Hospital care was ascertained from an electronic data file of discharges from 172 acute care hospitals throughout the United States and Puerto Rico. One-third of the sample was never hospitalized for an alcohol-related condition in the years prior to or after alcoholism treatment, and 23% of the sample experienced no hospitalizations at all other than the treatment episode when interviewed. The majority of hospital stays before and after treatment were attributed to alcohol abuse. The frequency and total hospital length of stay for alcohol-related admissions increased yearly before treatment, peaked in the year after treatment, and then declined, but not to earliest pretreatment levels. Subjects experienced significantly more hospitalizations and length of stay after alcoholism treatment than before when comparing both the two three-year periods and the immediate 12 months before and after treatment. More frequent hospital care was also significantly associated with higher levels of daily alcohol consumption and drinking duration but not with sociodemographic indicators.