Treating Carpal Tunnel Syndrome

"Patients with carpal tunnel syndrome who have mild symptoms and no neurologic deficit may need only reassurance. A splint that holds the wrist in the neutral position is often effective for nocturnal symptoms. Some patients are helped by periodic injections of glucocorticoids into the carpal ligament. Surgical sectioning of the carpal ligament (a low-risk procedure) is widely used and seems to result in substantial, long-lasting improvement in most patients; there is conflicting evidence about whether endoscopic techniques allow for faster recovery than open surgical procedures.1 Surgery is advised for patients with troublesome symptoms that are unresponsive to nonsurgical treatments and for those with progressive motor or sensory deficits."

An Association Between Homocysteine and Fractures

"These findings suggest an association between homocysteine levels and fractures in elders, but whether this association is causal is unclear. One causal theory holds that homocysteine interferes with collagen cross-linking and thereby weakens bone. Alternatively, homocysteine might be an innocent bystander: That is, dietary or metabolic abnormalities that result in elevated plasma homocysteine levels also might predispose to fractures. The practical question, which hasn't been studied, is whether homocysteine-lowering therapies (e.g., folic acid supplementation) lower fracture risk."

Joint Lavage vs JL Plus Corticoids in Patients With Knee OA

"The results of this work suggest the absence of significant differences between the two treatments, such that both joint lavage alone and with infiltration with corticoids can be concluded as similarly effective for the symptomatic management of osteoarthritis of the knee."

Should Thresholds for Bone Mineral Density Treatment Be Lowered?

Should Thresholds for Bone Mineral Density Treatment Be Lowered?: "Current World Health Organization guidelines suggest a bone-mineral density (BMD) threshold of 2.5 standard deviations below the mean for a young adult (i.e., T score, -2.5) to diagnose osteoporosis; it is unclear whether using this level as a treatment threshold will prevent most osteoporotic fractures. In a longitudinal observational study, sponsored by the manufacturer of an osteoporosis treatment, researchers examined fracture risk among 149,524 white women (mean age, 65). The women's peripheral (heel, forearm, or finger) BMD was measured using one of several types of absorptiometry or ultrasound equipment; they reported any new fractures at 12-month follow-up."

Medscape Orthopaedics Journal Scan: June 2004

"Journal Scan Orthopaedics, June 2004"

Screening Approach Eradicates MRSA in UK Orthopedic Ward

"An infection control strategy referred to as 'ring fencing' has been effective in eradicating MRSA and reducing postoperative infections in an orthopedic ward, according to UK researchers. Moreover, the team believes that its applicability could extend to any elective surgery ward."

Vancomycin Therapy and the Progression

"Vancomycin therapy is the standard treatment for methicillin-resistant Staphylococcus aureus (MRSA), the most common cause of vertebral osteomyelitis, an increasingly frequent complication of nosocomial bacteremia. We report five recent cases suggesting that, while giving the appearance of success by conventional clinical and laboratory criteria (eg, resolution of fever and leukocytosis), vancomycin monotherapy may in fact be insufficient to prevent or reverse the progression of hematogenous MSRA vertebral osteomyelitis. A review of the literature and possible therapeutic alternatives are also discussed."

The Use of As-Needed Range Orders in the Management of Acute Pain: A Consensus Statement of the American Society of Pain Management Nursing and the Am

Table 1. Considerations for Writing and Interpreting PRN Range Orders for Opioid Analgesics

Reasonable range. The maximum dose in a range order for an opioid should be at least 2 times, but generally no larger than 4 times, the smallest dose. This range is large enough to provide appropriate options for effective dose titration and small enough to establish a safe dose in an individual. Patient's prior drug exposure. If the patient is opioid-nave, the first dose administered should be the lowest dose in the range; if the patient is opioid tolerant, or has received a recent dose with inadequate pain relief and tolerable side effects, a dose on the higher end of the range should be administered. Prior response. Inquire about the patient's response to previous doses. How much relief did prior doses provide, and how long did it last? Did the patient experience side effects? Age. For very young or elderly patients, "start low and go slow"—begin with a low dose and titrate up slowly and carefully. More frequent reassessments are indicated for more fragile or less resilient patients. Liver and renal function. If the patient has hepatic or renal insufficiency, anticipate a more pronounced peak effect and a longer duration of action. Pain severity. As a general rule, for moderate to severe pain, increase the dose by 50% to 100%; do not increase by >100% at one time; to "fine-tune" the dose once pain is at a mild level, increase or decrease by 25%. Anticipated pain duration. Is the pain acute, chronic, or progressive (likely to worsen)? In other words, is the patient likely to require more or less analgesic over time? Kinetics. Know the onset, peak, and duration of action for the specific drug ordered. Doses of short-acting opioids can be increased at each specified dosing interval, unlike scheduled long-acting opioid formulations. Comorbidities that may affect patient response. Example: Debilitated patients, or those with respiratory insufficiency, may be at more risk for hypoxia if oversedated. Concomitant administration of other sedating drugs. When other CNS depressants are administered in combination with opioids, the dose of each medication required to achieve the desired effect may be 30% to 50% less than if either drug was administered alone. Combination drugs. Limit doses of combination drugs (e.g., opioids with acetaminophen or an NSAID). Average adults should not receive more than 4,000 mg of acetaminophen in 24 hours. Combination drugs may contain as much as 750 mg of acetaminophen per tablet. If substantial upward dose titration is required or anticipated, use opioid-only preparations. EXAMPLE: Opioid-nave patient arrives on unit with order: Morphine sulfate 2 mg to 6 mg IV every 2h PRN pain. Give 2 mg for first dose. Assess effects after 5 to 15 minutes. If adequate relief, reassess in 1 to 2 hours. If no side effects but inadequate relief, may give additional 4 mg at time of peak effect from first dose. Total dose is 6 mg in a 2-hour period.

Pharmacological Disruption of Insulin-like Growth Factor 1

"A small, nonpeptide pharmacological inhibitor of IGF/IGFBP interaction restored or enhanced the IGF-1-dependent proteoglycan synthesis by human osteoarthritic chondrocytes. This finding offers a rationale for pharmacological intervention in the treatment of cartilage repair in osteoarthritis and potentially of other joint-related diseases and shows that IGFBPs are pertinent target candidates for this purpose."

Alendronate-Induced Central Nervous System Toxicity

A 79-year-old Caucasian woman who had been taking alendronate 10 mg/day for over 2 years to prevent osteoporosis reported hearing "voices in her head" along with red-colored visual disturbances. These auditory hallucinations and visual disturbances began shortly after her regimen was changed from alendronate 10 mg/day to 70 mg once/week. Assessment of causality using the Naranjo and Jones algorithms revealed a "probable" and "highly probable" relationship, respectively, between this adverse drug event and the switch from daily to weekly alendronate therapy. Other bisphosphonates, such as etidronate and pamidronate, have caused both reversible and irreversible auditory, visual, and olfactory hallucinations beginning 2 hours–1 week after drug administration. The mechanism behind these adverse effects is unknown but is thought to be independent of calcium homeostasis. Clinicians should be aware of central nervous system toxicity as a rare but potential adverse effect associated with bisphosphonates.

Articular Hypermobility Protects Against Hand Osteoarthritis

Articular hypermobility protects against hand osteoarthritis (OA), according to the results of a family-based study published in the July issue of Arthritis & Rheumatism.

“It is widely believed that premature OA may be a direct consequence of hypermobility,” write V. B. Kraus, MD, PhD, from Duke University Medical Center in Durham, North Carolina, and colleagues. “Very few studies have evaluated the association of articular hypermobility and radiographic OA in humans.”

I presume that I'm at a lower risk for wrist OA. It is music to my ears from my guitars forever then.

Cauda Equina Syndrome Caused by Primary and Metastatic Neoplasms

Cauda equina syndrome (CES) is defined as the constellation of symptoms that includes low-back pain, sciatica, saddle anesthesia, decreased rectal tone and perineal reflexes, bowel and bladder dysfunction, and variable amounts of lower-extremity weakness. There are several causes of this syndrome including trauma, central disc protrusion, hemorrhage, and neoplastic invasion. In this manuscript the authors reviewed CES in the setting of both primary and secondary neoplasms. They examined the various primary tumor types in this region as well as those representative of metastatic spread. Both surgical and nonsurgical management in this setting were studied. Read more >>

Repair of Atlantoaxial Dislocation Improves Outcomes in RA...

Repair of atlantoaxial dislocation improves prognosis in rheumatoid arthritis patients with myelopathy, according to the results of a matched controlled comparative study published in the July 15 issue of Spine.

'Occipitocervical fusion associated with C1 laminectomy for patients with rheumatoid arthritis is useful for decreasing nuchal pain, reducing myelopathy, and improving prognosis,' write Shunji Matsunaga, MD, PhD, from Kagoshima University in Kagoshima City, Japan, and colleagues.

Of 40 patients with rheumatoid arthritis and myelopathy caused by irreducible atlantoaxial dislocation with or without upward migration of the odontoid process, 19 patients received C1 laminectomy and occipitocervical fusion using a rectangular rod, and 21 matched patients received conservative treatment at another hospital. Read more >>

There are a couple of terms that I don't understand in the article. One is the atlantodental interval. The other is the Redlund-Johnell values. Any ideas about these?