F-waves persistence in peripheral sensory syndromes.

BACKGROUND: The distinction between sensory neuronopathies (SN), which is by definition purely sensory, and sensory polyneuropathies (SP) and sensory multineuropathies (SM) is important for etiologic investigation and prognosis estimation. However, this task is often challenging in clinical practice. We hypothesize that F-wave assessment might be helpful, since it is able to detect subtle signs of motor involvement, which are found in SP and SM, but not in SN. OBJECTIVE: The aim of the present study was to determine whether F-waves are useful to distinguish SN from SP and SM. METHODS: We selected 21 patients with SP (12 diabetes mellitus, 4 transthyretin familial amyloid polyneuropathy, 4 others), 22 with SM (22 leprosy), and 26 with SN (13 immune-mediated, 10 idiopathic, 3 others) according to clinical-electrophysiological-etiological criteria. For every subject, we collected data on height and performed 20 supramaximal distal stimuli in median, ulnar, peroneal, and tibial nerves, bilaterally, to record F-waves. Latencies (minimum and mean) and persistences were compared across groups using the Kruskal-Wallis and Bonferroni tests. P-values < 0.05 were considered significant. RESULTS: All groups were age, gender, and height-matched. Overall, there were no significant between-group differences regarding F-wave latencies. In contrast, F-wave persistence was able to stratify the groups. Peroneal F-wave persistence was higher, bilaterally, in the SN group compared to SM and SP (p < 0.05). In addition, F-waves persistence of the ulnar and tibial nerves was also helpful to separate SN from SP (p < 0.05). CONCLUSION: F-wave persistence of the peroneal nerves might be an additional and useful diagnostic tool to differentiate peripheral sensory syndromes.

ANTECEDENTES: A distinção entre neuronopatias sensitivas (SN) e polineuropatias sensitivas (SP) e multineuropatias sensitivas (SM) é importante para a investigação etiológica e para o prognóstico. Contudo, esta tarefa é desafiadora na prática clínica. Hipotetizou-se que a avaliação das ondas-F pode ser útil, por ser capaz de detectar envolvimento motor nas SP e SM, mas não nas SN. OBJETIVO: Determinar se as ondas-F podem ajudar a distinguir entre SN, SP e SM. MéTODOS: Selecionou-se 21 pacientes com SP (12 diabetes mellitus, 4 ATTR-FAP e 4 com outras neuropatias), 22 com SM (22 hanseníases) e 26 com SN (13 imunomediadas, 10 idiopáticas e 3 com outras neuronopatias), de acordo com critérios clínicos, etiológicos e eletrofisiológicos. Para cada indivíduo, foi aferida a altura e foram aplicados 20 estímulos distais supramáximos nos nervos mediano, ulnar, fibular e tibial, bilateralmente, para registrar as ondas-F. Uma comparação foi feita, por grupo, das latências (mínimas e médias) e persistências pelos testes Kruskal-Wallis e Bonferroni. Valores de p < 0.05 foram considerados estatisticamente significativos. RESULTADOS: Todos os grupos foram pareados por idade, sexo e altura. Não houve diferença estatística significativa entre os grupos quanto às latências das ondas-F. A persistência da onda-F foi capaz de estratificar os grupos, sendo as dos nervos fibulares bilateralmente maiores no grupo SN que nos grupos SM e SP (p < 0.05). Adicionalmente, a persistência das ondas-F dos nervos ulnares e tibiais também foi útil para distinguir SN de SP (p < 0.05). CONCLUSãO: A persistência das ondas-F dos nervos fibulares pode ser uma ferramenta adicional e útil para diferenciar síndromes sensitivas periféricas.

Role of Nerve Conduction Studies in Hansen's Disease.

Background and Objective: To report the role of nerve conduction study (NCS) in diagnosis, monitoring, and prognosis of Hansen's disease (HD). Materials and Methods: In a hospital-based prospecive observational study, the patients with HD as per World Health Organization (WHO) criteria were included; muscle wasting power, reflexes, and sensations were recorded. Motor NCS of median, ulnar, and peroneal nerves and sensory NCS of ulnar, median, and sural nerves were recorded. Disability was graded using WHO grading scale. The outcome was assessed after 6 months using modified Rankin scale. Results: In the present study, 38 patients with a median age of 40 (15-80) years and five females were included. The diagnosis was tuberculoid in seven, borderline tuberculoid in 23, borderline lepromatous in two, and borderline in six patients. The disability was grade 1 and 2 in 19 patients each. Out of 480 nerves studied, NCS was normal in 139 sensory (57.4%) and 160 (67.2%) motor nerves. NCSs were axonal in seven sensory and eight motor nerves, demyelinating in three nerves, and mixed in one in seven patients who had lepra reaction. NCS findings did not correlate with disability (p = 1.0) or outcome (0.304) and provided additional information in 11 nerves (seven patients). Peripheral nerves were enlarged in 79. NCSs were normal in 32 (29.90%) in thickened nerves. Conclusion: In HD, NCS abnormalities correlated with respective sensory or motor abnormality but related with neither disability nor the outcome.

Sonographic pattern of median nerve enlargement in Hansen's neuropathy.

OBJECTIVES: Median nerve enlargement in leprosy seems to be more proximal than in carpal tunnel syndrome (CTS), but this feature has not been studied systematically. The aim of the study was to compare the sites of median nerve enlargement in patients with leprosy with that of patients with CTS. MATERIALS AND METHODS: Transverse sections of the median nerve were recorded from wrist to the mid-forearm (at distal wrist crease and at 2-cm: M1, 4-cm: M2, 6-cm: M3, 8-cm: M4 and 10-cm: M5, proximal to the distal wrist crease in the forearm) in patients with leprosy, CTS and healthy subjects using high-resolution ultrasound. RESULTS: Twenty-six patients each with leprosy and CTS were compared with healthy controls. Patients with leprosy included 6 (23.1%), 7 (26.9%), 7 (26.9%) and 6 (23.1%) patients with borderline tuberculoid, borderline-borderline, borderline lepromatous and lepromatous leprosy, respectively. Cross-sectional area (CSA) of median nerve was increased in all patients with leprosy as compared to healthy controls at all points of measurement. CSA was higher among patients with leprosy as compared to CTS at all points except at the wrist. In patients with leprosy, the maximal enlargement was noted 2-cm (M1) proximal to the wrist crease with gradual tapering of the CSA proximally (p < .05). In contrast, in patients with CTS the median nerve was maximally enlarged at the distal wrist crease (p<.05). CONCLUSIONS: Median nerve enlargement 2-cm proximal to the distal wrist crease distinguishes leprosy from CTS. This important discriminating sign can be used at point-of-care to identify patients with leprosy.

Coexistence of Nerve Enlargement and Neuratrophy Detected by Ultrasonography in Leprosy Patients.

The purpose of this study was to evaluate peripheral neural impairment in leprosy patients by ultrasonography (US). The cross-sectional areas (CSAs) of the median (M), ulnar (U) and common fibular (CF) nerves were compared in 71 leprosy patients and 29 healthy controls, and the data were analyzed between the leprosy, multibacillary (MB)/paucibacillary (PB), reaction (R)/no reaction (NR), disability (D)/no disability (ND), and longer/shorter duration groups after treatment. We found that for the nerves located in upper limbs, the CSAs were significantly increased in the leprosy patients vs the controls; the PB group vs the MB group; the R group vs the NR group; the ND group vs the D group; and the longer duration group vs the shorter duration group at some positions of the M nerve and U nerve. In contrast, for the nerves located in lower limbs, the CSAs were significantly reduced in the leprosy patients vs the controls and in the longer duration group vs the shorter duration group at some positions of the CF nerve. This result indicated that nerve enlargement and neuratrophy coexist in leprosy patients.

Ultrasound elastography assessment of the median nerve in leprosy patients.

INTRODUCTION: We sought to compare median nerve elasticity between leprosy patients (LPs) and healthy volunteers (HVs) using ultrasound elastography (UE). METHODS: Two radiologists independently measured the strain ratio of the median nerve/flexor digitorum superficialis muscle (MN/FDSM) of 18 LP and 18 HV using real-time freehand UE. Statistical analysis included intra-class correlation coefficients (ICC) and Mann-Whitney test. RESULTS: The MN/FDSM strain ratios of the LP and HV were 2.66 ± 1.30 and 3.52 ± 0.93, respectively (P < 0.05). We observed a significantly lower MN/FDSM strain ratio in LP with reactions (types 1 and 2 cutaneous reactions associated with or without neuritis) (2.30 ± 0.91) compared with LP without reactions (3.60 ± 1.70). We found no significant differences between HV and LP without reactions. The intra- and inter-observer ICCs were 0.50 (95% confidence interval [CI], 0.11-0.72) and 0.34 (95% CI, 0.28-0.52), respectively. CONCLUSIONS: MN/FDSM strain ratios were significantly lower in LP with reactions. UE may be useful for nerve elasticity evaluation in leprosy. Muscle Nerve 56: 393-398, 2017.

Desempenho funcional de pacientes com deformidades visíveis na hanseníase / Functional performance of patients with visible deformities in leprosy

Esse estudo tem por objetivo avaliar a capacidade funcional da mão das pessoas atingidas pela hanseníase na realização das atividades básicas e instrumentais da vida diária. A amostra foi constituída por 50 pacientes, maiores de 18 anos, que estavam sendo acompanhados no ambulatório do Instituto Lauro de Souza Lima. Para avaliação das características sociodemográficas e clínicas foi elaborado um questionário próprio. As dificuldades manuais para realizar atividades nas áreas de vestuário, alimentação, higiene pessoal, cuidados com a casa, escrita e outros foram avaliados por meio da Avaliação Funcional das Mãos em Hanseníase. Os resultados demonstram que em todas as atividades houve algum grau de dificuldade, porém, a maioria dos pacientes as realiza com independência. As atividades consideradas mais difíceis de serem executadas pelos pacientes com garra ulnar foram: pegar objetos pequenos em superfície plana, abrir/fechar fecho de corrente e cortar unhas. Na população de pacientes com garra ulnar/mediano foram: pegar objetos pequenos em superfície plana, abotoar/desabotoar, dar laço/ amarrar cadarço e abrir/fechar fecho de corrente. As atividades são realizadas com algum grau de dificuldade, porém, com independência pela maioria dos indivíduos que tem ou tiveram hanseníase e apresentam deformidades visíveis. Muitas dessas dificuldades podem ser minimizadas por meio de transferências tendinosas ou pela indicação, confecção e uso de tecnologia assistiva(AU).

This study aims to assess the functional capacity of the hand of people affected by leprosy in carrying out basic and instrumental activities of daily living. The sample consisted of 50 patients, aged over 18, who were being followed up at the outpatient clinic of the Instituto Lauro de Souza Lima. A questionnaire was developed to assess sociodemographic and clinical characteristics. Manual difficulties in carrying out activities in the areas of clothing, food, personal hygiene, home care, writing and others were assessed through the Functional Hand Assessment in Leprosy. The results show that in all activities there was some degree of difficulty, however, most patients perform them independently. The activities considered most difficult to be performed by patients with an ulnar claw were: picking up small objects on a flat surface, opening / closing the chain clasp and cutting nails. In the population of patients with an ulnar / median claw were: picking up small objects on a flat surface, buttoning / unbuttoning, looping / tying shoelaces and opening / closing chain fastening. The activities are performed with some degree of difficulty, however, independently by the majority of individuals who have or have had leprosy and have visible deformities. Many of these difficulties can be minimized by means of tendon transfers or by the indication, preparation and use of assistive technology(AU).

Asymmetric Nerve Enlargement: A Characteristic of Leprosy Neuropathy Demonstrated by Ultrasonography.

BACKGROUND: Neurological involvement occurs throughout the leprosy clinical spectrum and is responsible for the most feared consequences of the disease. Ultrasonography (US) provides objective measurements of nerve thickening and asymmetry. We examined leprosy patients before beginning multi-drug therapy aiming to describe differences in US measurements between classification groups and between patients with and without reactions. METHODOLOGY/PRINCIPAL FINDINGS: Eleven paucibacillary (PB) and 85 multibacillary (MB) patients underwent nerve US. Twenty-seven patients had leprosy reactions (type 1, type 2 and/or acute neuritis) prior to US. The ulnar (at the cubital tunnel-Ut-and proximal to the tunnel-Upt), median (M) and common fibular (CF) nerves were scanned to measure cross-sectional areas (CSAs) in mm2 and to calculate the asymmetry indexes ΔCSA (absolute difference between right and left CSAs) and ΔUtpt (absolute difference between Upt and Ut CSAs). MB patients showed greater (p<0.05) CSAs than PB at Ut (13.88±11.4/9.53±6.14) and M (10.41±5.4/6.36±0.84). ΔCSAs and ΔUtpt were similar between PB and MB. The CSAs, ΔCSAs and ΔUtpt were similar between PB patients with reactions compared to PB patients without reactions. MB patients with reactions showed significantly greater CSAs (Upt, Ut and M), ΔCSAs (Upt and Ut) and ΔUtpt compared to MB patients without reactions. PB and MB showed similar frequencies of abnormal US measurements. Patients with reactions had higher frequency of nerve thickening and similar frequency of asymmetry to those without reactions. CONCLUSIONS/SIGNIFICANCE: This is the first study to investigate differences in nerve involvement among leprosy classification groups using US before treatment. The magnitude of thickening was greater in MB and in patients with reactions. Asymmetry indexes were greater in patients with reactions and did not significantly differ between PB and MB, demonstrating that asymmetry is a characteristic of leprosy neuropathy regardless of its classification.

Minimally invasive carpal tunnel surgery in leprosy / Cirurgia minimamente invasiva do túnel do carpo em lepra

Evaluate carpal tunnel release in leprosy. Methods: The authors operated upon 60 patientswith median nerve involvement by leprosy between February 2008 and February 2012. The outpatientswere under local anesthesia submitted to carpal tunnel release. Results: All the patients showed postoperativeimprovement in pain and sensation. Conclusion: The surgical approach is a cost effectivenessprocedure adequate to developing countries...

Avaliar a descompressão do túnel do carpo na lepra. Métodos: Os autores operaram 60pacientes ambulatoriais com envolvimento do nervo mediano pela lepra, entre fevereiro de 2008 efevereiro de 2012. Os pacientes foram submetidos a anestesia local e cirurgia de túnel do carpo.Resultados: Todos os pacientes experimentaram melhora no pós-operatório da sensibilidade e da dor.Conclusão: A abordagem cirúrgica é um procedimento de custo-efetividade satisfatório, adequadapara países em desenvolvimento...

New sonographic measures of peripheral nerves: a tool for the diagnosis of peripheral nerve involvement in leprosy.

To evaluate ultrasonographic (US) cross-sectional areas (CSAs) of peripheral nerves, indexes of the differences between CSAs at the same point (∆CSAs) and between tunnel (T) and pre-tunnel (PT) ulnar CSAs (∆TPTs) in leprosy patients (LPs) and healthy volunteers (HVs). Seventy-seven LPs and 49 HVs underwent bilateral US at PT and T ulnar points, as well as along the median (M) and common fibular (CF) nerves, to calculate the CSAs, ∆CSAs and ∆TPTs. The CSA values in HVs were lower than those in LPs (p < 0.0001) at the PT (5.67/9.78 mm2) and T (6.50/10.94 mm2) points, as well as at the M (5.85/8.48 mm2) and CF (8.17/14.14 mm2) nerves. The optimum CSA- receiver operating characteristic (ROC) points and sensitivities/specificities were, respectively, 6.85 mm2 and 68-85% for the PT point, 7.35 mm2 and 71-78% for the T point, 6.75 mm2 and 62-75% for the M nerve and 9.55 mm2 and 81-72% for the CF nerve. The ∆CSAs of the LPs were greater than those of the HVs at the PT point (4.02/0.85; p = 0.007), T point (3.71/0.98; p = 0.0005) and CF nerve (2.93/1.14; p = 0.015), with no difference found for the M nerve (1.41/0.95; p = 0.17). The optimum ∆CSA-ROC points, sensitivities, specificities and p-values were, respectively, 1.35, 49%, 80% and 0.003 at the PT point, 1.55, 55-85% and 0.0006 at the T point, 0.70, 58-50% and 0.73 for the M nerve and 1.25, 54-67% and 0.022 for the CF nerve. The ∆TPT in the LPs was greater than that in the HVs (4.43/1.44; p <0.0001). The optimum ∆TPT-ROC point was 2.65 (90% sensitivity/41% specificity, p < 0.0001). The ROC analysis of CSAs showed the highest specificity and sensitivity at the PT point and CF nerve, respectively. The PT and T ∆CSAs had high specificities (> 80%) and ∆TPT had the highest specificity (> 90%). New sonographic peripheral nerve measurements (∆CSAs and ∆TPT) provide an important methodological improvement in the detection of leprosy neuropathy.

New sonographic measures of peripheral nerves: a tool for the diagnosis of peripheral nerve involvement in leprosy

To evaluate ultrasonographic (US) cross-sectional areas (CSAs) of peripheral nerves, indexes of the differences between CSAs at the same point (∆CSAs) and between tunnel (T) and pre-tunnel (PT) ulnar CSAs (∆TPTs) in leprosy patients (LPs) and healthy volunteers (HVs). Seventy-seven LPs and 49 HVs underwent bilateral US at PT and T ulnar points, as well as along the median (M) and common fibular (CF) nerves, to calculate the CSAs, ∆CSAs and ∆TPTs. The CSA values in HVs were lower than those in LPs (p < 0.0001) at the PT (5.67/9.78 mm2) and T (6.50/10.94 mm2) points, as well as at the M (5.85/8.48 mm2) and CF (8.17/14.14 mm2) nerves. The optimum CSA- receiver operating characteristic (ROC) points and sensitivities/specificities were, respectively, 6.85 mm2 and 68-85% for the PT point, 7.35 mm2 and 71-78% for the T point, 6.75 mm2 and 62-75% for the M nerve and 9.55 mm2 and 81-72% for the CF nerve. The ∆CSAs of the LPs were greater than those of the HVs at the PT point (4.02/0.85; p = 0.007), T point (3.71/0.98; p = 0.0005) and CF nerve (2.93/1.14; p = 0.015), with no difference found for the M nerve (1.41/0.95; p = 0.17). The optimum ∆CSA-ROC points, sensitivities, specificities and p-values were, respectively, 1.35, 49%, 80% and 0.003 at the PT point, 1.55, 55-85% and 0.0006 at the T point, 0.70, 58-50% and 0.73 for the M nerve and 1.25, 54-67% and 0.022 for the CF nerve. The ∆TPT in the LPs was greater than that in the HVs (4.43/1.44; p <0.0001). The optimum ∆TPT-ROC point was 2.65 (90% sensitivity/41% specificity, p < 0.0001). The ROC analysis of CSAs showed the highest specificity and sensitivity at the PT point and CF nerve, respectively. The PT and T ∆CSAs had high specificities (> 80%) and ∆TPT had the highest specificity (> 90%). New sonographic peripheral nerve measurements (∆CSAs and ∆TPT) provide an important methodological improvement in the detection of leprosy neuropathy.

An unusual cause of mononeuritis multiplex.

A middle-aged man of South Asian decent presented with a 4-month history of bilateral sensory disturbance affecting the median nerve distribution and dorsum of both feet. Neurological examination was otherwise normal. A patchy absence of sensory responses was noted on nerve conduction studies and electromyogram (NCS/EMG). Over the next 3 months sensory symptoms progressed to involve median, radial, ulnar, sural and peroneal nerves bilaterally. Repeat NCS/EMG confirmed a mononeuritis multiplex predominantly involving the sensory fascicles. Areas of hypopigmentation, a right-lower motor facial weakness and ophthalmic branch trigeminal nerve involvement were noted on examination. Punch skin biopsy as well as sural nerve biopsy demonstrated chronic granulomatous inflammation without evidence of Mycobacterium. A slit skin smear test demonstrated Mycobacterium leprae consistent with a diagnosis of primary neuritic leprosy. In the appropriate clinical context, leprosy should be included in the differential diagnosis of mononeuritis multiplex.

Decompression of peripheral nerve trunks in leprosy prevents the development and progression of deformities?

Peripheral nerve involvement results in deformities formation in leprosy. High doses of (40-60 mg) steroids along with the anti-leprosy drugs is preferred even though the 70-75% cases develop deformity with the above treatment. 772 ulnar nerves, 120 median nerves and 108 posterior tibial nerves not responding to above medical treatment in 12 weeks, were undertaken for external and internal nerve trunk decompression. These cases were followed-up for 5-20 years at various intervals. The pain in nerves (neuritis) recovered in all cases of ulnar, median and posterior tibial nerves. Full sensory recovery with pin prick/feather or cotton wool touch was seen in 50% cases of all the three nerves. 20% cases maintain the pre-operative levels of sensory status. Plantar ulcers healed within 6 months after decompression of posterior tibial nerve. Only 6 cases showed reoccurrence. Overall motor recovery in ulnar nerve was seen 89% and 70% in median nerve. The sensory recovery restores protective sensation which prevents secondary injuries. The improvement of motor power gave better functional hands and improved the appearance which in absence of surgical intervention was not possible.

Questionário para avaliação funcional da mão em lesão de nervos / Questionnaire to evaluate hand function in nerve lesions

OBJETIVO: elaborar um questionário de avaliação funcional para analisar as dificuldades manuais encontradas na realização de atividades cotidianas de indivíduos ocidentais adultos com lesão dos nervos ulnar, mediano ou radial.MÉTODO: foi realizada entrevista com 50 pessoas, idade entre 21 e 65 anos, portadoras de lesão nos nervos ulnar, mediano ou radial para identificar as dificuldades manuais ao realizar as tarefas cotidianas. Em seguida, seis cirurgiões de mão e nove terapeutas de mão, analisaram as tarefas listadas pelos entrevistados e as classificaram em níveis de importância para uma avaliação funcional das mãos. Posteriormente, o questionário foi elaborado baseado nessa classificação.RESULTADOS: o "Questionário de avaliação da mão com lesão de nervo" é constituído por 30 questões objetivas divididas em domínios de tarefas (vestuário, alimentação, higiene pessoal, tarefas domésticas, escrita, uso de computador e atividades diversas). As respostas são atribuídas de acordo com o grau de dificuldade na realização das tarefas listadas no instrumento. O questionário foi respondido por 32 pessoas com idade entre 18 e 65 anos apresentando sequela de hanseníase. O cálculo do alfa de Cronbach foi utilizado para avaliar a confiabilidade do instrumento. Após a remoção de duas questões relacionadas ao uso de computador, o resultado do alfa de Cronbach aumentou para 0,90.CONCLUSÃO: o "Questionário de avaliação da mão com lesão de nervo" apresenta alta consistência interna. Além disso, é conciso, de fácil preenchimento não necessitando a presença de profissional especializado para sua aplicação e permite a verificação do nível de independência do indivíduo com lesão de nervo periférico na mão na realização de suas tarefas habituais.

OBJECTIVE: to develop a functional evaluation questionnaire to limitations in hand function by western adults individuals with lesions of the ulnar, median or radial nerves in their routine tasks.DESIGN: an interview was conducted with 50 patients of 21-65 years of age with ulnar, median and radial nerve lesions to identify any manual difficulties in their performance of routine daily tasks. Six hand surgeons and nine hand therapists then analyzed the tasks listed by the patients and graded them in levels of importance for the evaluation of hand function, after which a questionnaire based on this classification was drawn up.RESULTS: the instrument Evaluation of Hand with Nerve Damage Questionnaire, consists of 30 objective questions divided into task domains (dressing, feeding, personal hygiene, housework, writing, use of computers and "others"), answers being classified according to degree of difficulty. The questionnaire was completed by 32 patients of 18-65 years of age with sequelae of Hansen's disease. Cronbach's coefficient alpha was used to assess the reliability of the instrument. Following removal of two questions regarding computer use, Cronbach's coefficient alpha increased to 0.90.CONCLUSION: the Evaluation of Hand with Nerve Damage Questionnaire shows a high internal consistency. In addition it is concise, easy to fill instrument not requiring specialized professional to apply and allows evaluation of the degree of independence of the individual with peripheral nerve lesion in the hand in performing routine daily tasks.

Digital neuropathy of the median and ulnar nerves caused by Dupuytren's contracture: Case report.

INTRODUCTION: Digital neuropathy is a pure sensory neuropathy of a digital nerve. It may be caused by acute or chronic local trauma or pressure, or accompany systemic illnesses such as rheumatoid disease, leprosy, Raynaud disease, dysproteinemia, or diabetes mellitus. We describe an extraordinary case of digital neuropathy of the median and ulnar nerves caused by Dupuytren contracture. CASE REPORT: A 56-year-old right-handed man was presented with numbness and tingling of the little finger of the right and ring finger of the left hand. The clinical and EMG findings in this patient were consistent with a lesion of the median and ulnar palmar digital nerves of the right and left ring and little fingers. CONCLUSION: Dupuytren tissue usually affects the palmar fascia, superficial to the digital nerves, and it may rarely affect the spiral cord in the digits. A spiral cord may cause sensory loss due to impingement of digital nerves or Dupuytren tissue may have been compressing the palmar digital nerves against the relatively inelastic deep transverse metacarpal ligament. As a result, digital neuropathy can develop in those with Dupuytren's contracture, and nerve conduction studies should also be performed to determine the condition. New studies are needed to provide better diagnostic criteria for the condition.

Development and validation of a severity scale for leprosy type 1 reactions.

OBJECTIVES: To develop a valid and reliable quantitative measure of leprosy Type 1 reactions. METHODS: A scale was developed from previous scales which had not been validated. The face and content validity were assessed following consultation with recognised experts in the field. The construct validity was determined by applying the scale to patients in Bangladesh and Brazil who had been diagnosed with leprosy Type 1 reaction. An expert categorized each patient's reaction as mild or moderate or severe. Another worker applied the scale. This was done independently. In a subsequent stage of the study the agreement between two observers was assessed. RESULTS: The scale had good internal consistency demonstrated by a Cronbach's alpha >0.8. Removal of three items from the original scale resulted in better discrimination between disease severity categories. Cut off points for Type 1 reaction severities were determined using Receiver Operating Characteristic curves. A mild Type 1 reaction is characterized using the final scale by a score of 4 or less. A moderate reaction is a score of between 4.5 and 8.5. A severe reaction is a score of 9 or more. CONCLUSIONS: We have developed a valid and reliable tool for quantifying leprosy Type 1 reaction severity and believe this will be a useful tool in research of this condition, in observational and intervention studies, and in the comparison of clinical and laboratory parameters.