RESUMEN
BACKGROUND: Work-related carpal tunnel syndrome (CTS) now accounts for more than 41% of all repetitive motion disorders in the United States. Carpal tunnel syndrome is also associated with obesity and many different medical diseases. PATIENTS AND METHODS: Two hundred ninety-seven patients medically certified with a work-related upper extremity industrial illness underwent a systematic search for concurrent medical diseases. Diagnoses of CTS were made using 4 separate case definitions. RESULTS: One hundred nine separate atraumatic illnesses (mainly hypothyroidism, diabetes mellitus, and various arthropathies) capable of causing arm pain or CTS were diagnosed in a third of all patients. Using record reviews and patient histories alone, 68% of these conditions would have been missed. One hundred ninety-eight patients had been diagnosed as having CTS 420 times in more than 1000 office visits, but diagnostic laboratory studies were ordered only 25 times. Every case definition of CTS was significantly associated with a related medical condition. Two definitions yielded more than 41% prevalence of concurrent disease (odds ratio, > or = 2.36; P < or = .004), and up to two thirds of these patients had either a medical disease or were obese (odds ratio, > or = 3.15; P < or = .001). Two cohorts totaling 114 patients (38%) working for companies employing nearly 19,000 people included all CTS claims filed during 2 evaluation periods. They did not differ from the other patients with CTS with respect to age, concurrent disease, or obesity. CONCLUSIONS: Routine patient histories and record reviews are inadequate for proper evaluation of work-related CTS. Unrecognized medical diseases capable of causing CTS are common. Studies asserting an association between occupational hand usage and CTS are of questionable validity unless they prospectively account for confounding disease and obesity.
Asunto(s)
Síndrome del Túnel Carpiano/etiología , Trabajo , Adulto , Síndrome del Túnel Carpiano/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Variaciones Dependientes del Observador , Oportunidad Relativa , Derivación y Consulta , Factores de RiesgoRESUMEN
Subacute meningitis was the first manifestation of illness in a young man with multisystem disease involving lung, kidney, eye, and central nervous system. Necrotizing granulomatous angiitis was found in tissue obtained at thoracotomy and the diagnosis of Wegener's granulomatosis was suggested. This patient had an excellent functional recovery with cyclophosphamide and prednisone.
Asunto(s)
Meningitis/diagnóstico , Adulto , Líquido Cefalorraquídeo/citología , Coriorretinitis/tratamiento farmacológico , Ciclofosfamida/uso terapéutico , Diagnóstico Diferencial , Granulomatosis con Poliangitis/líquido cefalorraquídeo , Granulomatosis con Poliangitis/diagnóstico , Granulomatosis con Poliangitis/tratamiento farmacológico , Humanos , Linfocitos , Masculino , Prednisona/uso terapéuticoRESUMEN
Two mishaps associated with closed-chest cardiac resuscitation are presented. One-pneumoperitoneum-became evident during life, created considerable diagnostic difficulty, and evoked treatment that possibly hastened the patient's death. The other-cardiac puncture-appeared at autopsy and its mechanism may be unique.
Asunto(s)
Lesiones Cardíacas/etiología , Masaje Cardíaco/efectos adversos , Neumoperitoneo/etiología , Osteofitosis Vertebral/complicaciones , Anciano , Femenino , Paro Cardíaco/complicaciones , Humanos , MasculinoRESUMEN
Previous studies evaluating workers' compensation care systems used retrospective controls. We performed a concurrent effectiveness study comparing a WC system that used visiting musculoskeletal specialists to assist primary care physicians with a typical discounted-fee, WC, managed-care system. In the new specialist-direct system, physicians could not profit from self-referral, but were paid 35% to 69% more per patient visit than doctors in the discounted-fee clinics. All claims filed by all employees of two hotels for 2 years were examined. Patients had self-selected either a specialist-direct or a discounted-fee clinic, and the entire cost of the claim was assigned to either system of care. Claim costs were 63% lower in the specialist-direct system (P < 0.001). Medical costs were 45% less (P < 0.014), and indemnity 85% less (P < 0.001), in this system. Claims were closed nearly 6 months faster in the specialist-direct system (P < 0.0001). Indemnity claims were more common in the discounted-fee system (P < 0.0001). Claimant and injury characteristics were not significantly different between the systems. This new care model is a cost-effective alternative to discounted WC managed care. Discounting the services of the primary treating physician may result only in cost-shifting, not cost-saving.
Asunto(s)
Economía Médica , Honorarios Médicos , Enfermedades Musculoesqueléticas/economía , Enfermedades Musculoesqueléticas/terapia , Especialización , Indemnización para Trabajadores/economía , Adulto , Distribución de Chi-Cuadrado , Ahorro de Costo , Análisis Costo-Beneficio , Costos y Análisis de Costo , Humanos , Formulario de Reclamación de Seguro , Programas Controlados de Atención en Salud , Oportunidad Relativa , Atención Primaria de Salud , Estados UnidosRESUMEN
Two patients originally diagnosed as having cellulitis involving the dorsum of the foot actually had bacterial arthritis of an underlying joint. In both patients, even after pyarthrosis was suspected, the wrong joint was aspirated. The arthropathies were located by subsequent 99mTc-phosphate bone imaging at a time when roentgenograms were normal. Early diagnosis and aggressive therapy of septic arthritis are essential to prevent joint destruction and osteomyelitis. Radionuclide bone imaging can identify inflammatory joint disease but it cannot specify etiology. In our patients, however, the differential diagnosis was between skin and joint infection. Radionuclide imaging was of great help in making this distinction.
Asunto(s)
Artritis Infecciosa/diagnóstico por imagen , Huesos/diagnóstico por imagen , Celulitis (Flemón)/diagnóstico por imagen , Adulto , Tobillo/diagnóstico por imagen , Diagnóstico Diferencial , Pie/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Cintigrafía , Infecciones Estafilocócicas/diagnóstico por imagen , Infecciones Estreptocócicas/diagnóstico por imagen , Streptococcus pyogenesAsunto(s)
Artritis Infecciosa , Artritis Infecciosa/diagnóstico , Artritis Infecciosa/terapia , Diarrea/complicaciones , Infecciones por Enterobacteriaceae/diagnóstico , Femenino , Gonorrea/diagnóstico , Gonorrea/tratamiento farmacológico , Hepatitis Viral Humana/complicaciones , Humanos , Persona de Mediana Edad , Micosis/diagnóstico , Rubéola (Sarampión Alemán)/complicaciones , Tuberculosis Osteoarticular/diagnóstico , Tuberculosis Osteoarticular/tratamiento farmacológicoRESUMEN
The reported incidence of work-related carpal tunnel syndrome has skyrocketed; however, many cases have an underlying systemic cause. A methodical investigation--including appropriate imaging studies and laboratory testing--can differentiate symptoms that are primarily occupational from those with associated medical illness or obesity.
Asunto(s)
Síndrome del Túnel Carpiano/diagnóstico , Hipotiroidismo/diagnóstico , Enfermedades Profesionales/diagnóstico , Síndrome del Túnel Carpiano/etiología , Síndrome del Túnel Carpiano/cirugía , Diagnóstico Diferencial , Femenino , Humanos , Hipotiroidismo/complicaciones , Persona de Mediana Edad , Enfermedades Profesionales/etiología , Enfermedades Profesionales/cirugía , Complicaciones Posoperatorias/diagnóstico , RecurrenciaRESUMEN
A case suggesting sequential infection of bone, synovial membranes, and finally synovial fluid is presented. Hematogenous osteomyelitis manifests itself differently in children than in adults. In children, the avascular epiphyseal cartilage in the growing long bone is an effective barrier to the spread of bone infection to the joint. After obliteration of the growth plate, vascular anastomoses form between metaphysis and epiphysis, and at maturity the entire bone shares a common blood supply with the capsule and synovium of the adjacent joint. In the adult with acute osteomyelitis, contiguous joint infection should be anticipated. In septic arthritis, unless caused by penetrating trauma, the synovium must be infected before the joint fluid. Even when bacterial joint infection is present, repeated arthrocenteses may be required over several days to confirm the diagnosis.