Diagnostic Considerations in Compressive Neuropathies.

Peripheral nerve compression of the upper extremity is a common pathology often necessitating surgical intervention, much is known, but much more is left to understand. For the more common pathologies, carpal tunnel syndrome, cubital tunnel syndrome, and ulnar tunnel syndrome, research and clinical efforts directed toward standardization and reduction of resource use have been attempted with varied success. Diagnosis of many of these syndromes is largely based on a proper history and physical examination. Electrodiagnostic studies continue to have value, but proportionally less than previous decades. In addition, emerging technologies, including magnetic resonance neurography, novel ultrasound evaluation techniques, and ultrasound-guided diagnostic injections, are beginning to demonstrate their ability to add value to the diagnostic algorithm, particularly when less common compressive neuropathies are present and/or the diagnosis is in question.

Custom 3D-Printed Total Talar Prostheses Restore Normal Joint Anatomy Throughout the Hindfoot.

BACKGROUND:: Third generation total talar prostheses (TTPs) are viable options for talar avascular necrosis (AVN) in the absence of neighboring joint pathology. The use of modern three-dimensional (3D) printing allows the production of custom implants that exactly mimic the patient's anatomy. The aim of this study is to determine the accuracy of 3D printing in reproducing a synthetic talus and, in doing so, restoring more normal anatomical relationships. We hypothesize that this mode of replication will restore and maintain normal radiographic alignment of the ankle, subtalar, and forefoot joints in the setting of talar AVN. METHODS:: A retrospective analysis was performed on all patients undergoing TTP implantation for the treatment of talar AVN between 2016 and 2017. Radiographic measurements were taken preoperatively and postoperatively to determine native talar dimensions, TTP implant dimensions, and the corresponding radiographic alignment about the forefoot, hindfoot, and ankle. RESULTS:: A total of 14 patients were identified in our cohort. Talar arc length and width were not found to be significantly changed; however, talar height was significantly increased with use of TTP. Five alignment dimensions were measured, of which, only talar tilt angle was significantly changed. Instances of Meary's angle correction were observed in cavus and planus foot deformity. CONCLUSION:: As a proof of concept, 3D-printed TTP was successful in restoring talar height and talar tilt in the setting of AVN. Additionally, the procedure maintained normal alignment in nonpathological joints. TTPs, based on our cohort, are a viable option to restore more normal anatomical alignment. LEVELS OF EVIDENCE:: Level IV: Case series.

The Use of Modern Intramedullary Nailing in Distal Fibula Fracture Fixation.

Background. Lateral malleolus (LM) fixation is necessary for unstable ankle fractures. Traditional fixation relies on the use of plates through a lateral incision, wound healing can be an issue for such incisions. A novel intramedullary (IM) fixation device has been developed that can be placed through a minimal incision. The purpose of this study was to demonstrate the clinical efficacy of this device. Methods. A retrospective analysis was performed on patients who received IM fixation for isolated fibula, bimalleolar (BM), and trimalleolar (TM) fractures. Pertinent demographic information, operative factors, complications, and clinical outcomes were recorded. Results. Sixteen patients were included in the study with an average age of 59 years (range 35-86 years). Six patients presented with isolated LM fractures, four patients had a BM fracture with a syndesmotic injury, 2 patients sustained a LM fracture with an associated syndesmotic injury, 2 patients had a BM fracture, and 2 patients had a TM fracture with a syndesmotic injury. There was a 100% healing rate of the lateral malleolus without any cases of malunion or shortening. There were no cases of sural nerve or peroneal tendon injuries, nor any wound complications found. Conclusion. These findings demonstrate the safe and efficacious use of a novel intramedullary fixation device for fibula fractures with lower wound complications compared with published outcomes found with lateral fibular plating. The features of this device allow for reliable fixation of the fibula, maintaining length and minimizing wound issues. Levels of Evidence: Level IV: Case series.

Weightbearing CT Scan Assessment of Foot Alignment in Patients With Hallux Rigidus.

BACKGROUND: An association between hallux rigidus and metatarsus primus elevatus (MPE) has been suggested, although there remains no general consensus about the nature of this relationship. Past studies were limited due to inaccuracies of assessing MPE on 2-dimensional radiographs. The aims of this study were to (1) assess and compare foot alignment in patients with and without hallux rigidus using 3-dimensional (3D) reconstructions from weightbearing computed tomography (CT) and (2) assess intraobserver and interobserver reliability of these measurements. METHODS: A prospective study was performed in 50 consecutive patients with symptomatic hallux rigidus and 50 control patients who underwent a weightbearing CT. Two investigators measured first and second metatarsal declination angles, first and second metatarsal lengths, first to second intermetatarsal angle (IMA), hallux valgus angle (HVA), and foot width on 3D CT reconstructions. Measurements were repeated after 1 month. Student t tests were performed to compare hallux rigidus and control groups. Intraclass and interclass correlation coefficients were calculated to evaluate reliability. RESULTS: The first to second metatarsal declination ratio was less in patients with hallux rigidus (mean, 0.81) than controls (mean, 0.92; P < .001). Patients with Coughlin and Shurnas grade 3 and 4 hallux rigidus had greater first metatarsal declination than patients with grade 1 and 2 hallux rigidus. Last, IMA was higher (mean, 13 degrees) but HVA was lower (mean, 11 degrees) in patients with hallux rigidus than controls (IMA mean, 12 degrees; HVA mean, 15 degrees; P = .04). Intraobserver (ICC1,1 ≥ 0.93) and interobserver (ICC3,1 ≥ 0.85) reliability were good to excellent for all measured parameters. CONCLUSIONS: Patients with hallux rigidus had MPE. Patients with grade 3 and 4 hallux rigidus had more MPE than patients with grade 1 and 2 hallux rigidus. There was no clear correlation between hallux rigidus and bunions. Finally, weightbearing CT proved to be a reliable method of assessing all measured parameters. LEVEL OF EVIDENCE: II, prospective comparative series.

Accurate Measurement of First Metatarsophalangeal Range of Motion in Patients With Hallux Rigidus.

BACKGROUND: The reliability of range of motion (ROM) measurements has not been established for the hallux metatarsophalangeal (MTP) joint in patients with hallux rigidus. The aim of the present study was to prospectively assess the clinical versus radiographic difference in ROM of the arthritic hallux MTP joint. METHOD: One hundred consecutive patients who presented with any grade of hallux rigidus were included in this prospective study to determine the hallux MTP range of motion. Clinical range of motion using a goniometer and radiographic range of motion on dynamic x-rays was recorded. RESULTS: The mean difference between clinical and radiographic dorsiflexion was 13 degrees (P < .001). For all measurements, clinical dorsiflexion was equal to or less than radiographically measured dorsiflexion. The difference was significantly greater in patients with a clinical dorsiflexion of less than 30 degrees than in patients with 30 degrees or more. Radiographic measurement of hallux dorsiflexion had an excellent intra- and interobserver reliability. CONCLUSION: We describe a reliable, reproducible, and straightforward method of measuring hallux MTP ROM that improved upon measuring clinical ROM. LEVEL OF EVIDENCE: Level II, prospective comparative study.

The epidemiology and type of medication errors reported to the National Poisons Information Centre of Ireland.

INTRODUCTION: Medication errors are widely reported for hospitalised patients, but limited data are available for medication errors that occur in community-based and clinical settings. Epidemiological data from poisons information centres enable characterisation of trends in medication errors occurring across the healthcare spectrum. AIM: The objective of this study was to characterise the epidemiology and type of medication errors reported to the National Poisons Information Centre (NPIC) of Ireland. METHODS: A 3-year prospective study on medication errors reported to the NPIC was conducted from 1 January 2007 to 31 December 2009 inclusive. Data on patient demographics, enquiry source, location, pharmaceutical agent(s), type of medication error, and treatment advice were collated from standardised call report forms. Medication errors were categorised as (i) prescribing error (i.e. physician error), (ii) dispensing error (i.e. pharmacy error), and (iii) administration error involving the wrong medication, the wrong dose, wrong route, or the wrong time. RESULTS: Medication errors were reported for 2348 individuals, representing 9.56% of total enquiries to the NPIC over 3 years. In total, 1220 children and adolescents under 18 years of age and 1128 adults (≥ 18 years old) experienced a medication error. The majority of enquiries were received from healthcare professionals, but members of the public accounted for 31.3% (n = 736) of enquiries. Most medication errors occurred in a domestic setting (n = 2135), but a small number occurred in healthcare facilities: nursing homes (n = 110, 4.68%), hospitals (n = 53, 2.26%), and general practitioner surgeries (n = 32, 1.36%). In children, medication errors with non-prescription pharmaceuticals predominated (n = 722) and anti-pyretics and non-opioid analgesics, anti-bacterials, and cough and cold preparations were the main pharmaceutical classes involved. Medication errors with prescription medication predominated for adults (n = 866) and the major medication classes included anti-pyretics and non-opioid analgesics, psychoanaleptics, and psychleptic agents. Approximately 97% (n = 2279) of medication errors were as a result of drug administration errors (comprising a double dose [n = 1040], wrong dose [n = 395], wrong medication [n = 597], wrong route [n = 133], and wrong time [n = 110]). Prescribing and dispensing errors accounted for 0.68% (n = 16) and 2.26% (n = 53) of errors, respectively. CONCLUSION: Empirical data from poisons information centres facilitate the characterisation of medication errors occurring in the community and across the healthcare spectrum. Poison centre data facilitate the detection of subtle trends in medication errors and can contribute to pharmacovigilance. Collaboration between pharmaceutical manufacturers, consumers, medical, and regulatory communities is needed to advance patient safety and reduce medication errors.

Mushroom poisoning in Ireland: the collaboration between the National Poisons Information Centre and expert mycologists.

BACKGROUND: Occasionally, mycologist assistance is requested to reliably identify mushroom species in symptomatic cases where there is a concern that a toxic species is involved. The aim of this study was to describe the epidemiology of mushroom poisoning in Ireland, to describe the working arrangement between the National Poisons Information Centre (NPIC) and professional mycologists and to present a case series detailing the circumstances when mycologists were consulted. METHODS: Computerised records from 1 January 2004 to 31 December 2009 were retrospectively reviewed and data on patient demographics, circumstances, and mushroom species collated. In 1999, the NPIC established a national registry of volunteer professional mycologists who are available 24 h/day for mushroom identification. The NPIC staff liaises directly with the mycologist and arranges transport of mushroom material. Digital photographic images are requested if there is likely to be a delay in arranging transportation of mushroom material, and the images are subsequently emailed to a mycologist. Five cases of suspected mushroom poisoning were chosen to demonstrate the inter-professional collaboration between the NPIC and mycologists. RESULTS: From 2004 to 2009, the NPIC was consulted about 70 cases of suspected mushroom exposures. Forty-five children ingested unknown mushrooms, 12 adults and 2 children ingested hallucinogenic mushrooms and 11 adults ingested wild toxic mushrooms that were incorrectly identified or confused with edible species. The mycologists were consulted 10 times since 1999. In this series, Amanita species were identified in two cases. In three cases, the species identified were Clitocybe nebularis, Coprinus comatus and Panaeolina foenisecii, respectively, and serious poisoning was excluded. Incorrect mushroom identification by a health care professional using the Internet occurred in two cases. The mycologists assisted Poisons Information Centres in Northern Ireland and the United Kingdom in two cases. Digital photographs facilitated tentative mushroom identification in two cases. CONCLUSION: Poison information centres should maintain a registry of expert mycologists who are available for consultation following potentially serious mushroom intoxications. Health care workers should not attempt to identify toxic mushroom species using the Internet as erroneous identification can occur. Digital photography may help with mushroom identification when there is likely to be a delay organising a physical examination of mushroom tissue.

The availability of toxicological analyses for poisoned patients in Ireland.

BACKGROUND: The National Poisons Information Service and the Association of Clinical Biochemists in the United Kingdom published guidelines on laboratory analyses for poisoned patients in 2002. In 2003, U.S. guidelines were prepared by an expert panel of analytical toxicologists and emergency department (ED) physicians. Some professional associations in different countries quote these guidelines but there are no data to support adherence to these recommendations in the medical literature. OBJECTIVE: To analyze the availability of 15 quantitative laboratory analyses, specifically relating to the management of the poisoned patient, in Ireland. METHODS: A questionnaire relating to the provision of toxicological analyses was compiled and distributed to 39 acute care hospital laboratories in Ireland. The availability of 15 quantitative analyses (carbamazepine, carboxyhemoglobin, digoxin, ethanol, ethylene glycol, iron, lithium, methemoglobin, methanol, paracetamol, paraquat, phenobarbital, salicylate, theophylline, and valproic acid), specifically relating to the management of the poisoned patient, was analyzed. The reporting units for these analyses were also collected. The acute care hospitals were sorted into groups according to their number of ED attendances: A) <20,000, B) 20,000-30,000, C) 30,000-40,000, D) 40,000-50,000, and E) >50,000 based on ED activity data for 2008. The median number of assays provided by each hospital group was calculated. RESULTS: The response rate was 100%, allowing complete national data to be ascertained. Hospital laboratories provided a more comprehensive testing service when ED attendances exceeded 30,000 per annum. Sixteen hospital laboratories (41.0%) performed at least 10 of the 15 toxicological investigations. The most widely available assay was paracetamol (74.4%, n = 29) and the least widely available assays were methanol, ethylene glycol, and paraquat (2.6%, n = 1). Only one hospital laboratory provided all 15 analyses. Hospital laboratories in groups A and B carried out a median number of 3/15 assays (range 0-8) and 4/15 assays (range 0-10), respectively. Hospital laboratories where ED attendances exceeded 30,000 per annum carried out a median number of 11/15 toxicological assays (range 1-15). There was a lack of consistency in the reporting units with both molar and mass units used. CONCLUSION: There is wide availability of toxicological analyses among hospital laboratories in Ireland. Most analyses were provided with 24-h availability. Hospitals with ED attendances in excess of 30,000 provided a more comprehensive laboratory service with respect to the number of analyses performed. The lack of consistency with units used by Irish hospital laboratories could present challenges with the reporting and interpretation of quantitative results. This study could be carried out in other countries to establish what analyses are available for the treatment of poisoned patients.

Zyban-- is there a cause for concern?

Bupropion hydrochloride is a monocyclic antidepressant which is used in a slow-release formulation as a smoking cessation aid. Its side effects include insomnia and dry mouth with seizures occurring in 1 in 1000 patients. In overdose, it can cause tachycardia, conduction defects and convulsions. It is, however, effective in smoking cessation in approximately 20% of patients and may be more effective if combined with nicotine replacement therapy. The key question is whether the risks associated with the drug are justified by the obvious benefits to health from smoking cessation.