Unilateral asterixis associated with a mesencephalic syndrome.

Unilateral asterixis due to a focal brain lesion is a rare occurrence. Acute asterixis restricted to the left upper extremity appeared in a patient in association with signs of acute midbrain dysfunction, without changes in mental status or in the EEG, and in the absence of metabolic or toxic disturbance. Electromyography disclosed features typical of asterixis due to metabolic causes.

Establishing a function-based mental health service line in a VA medical center.

From 1994 through 1996, a general Veterans Affairs (VA) medical center reorganized its mental health services from a traditional discipline-based structure to a unitary service line organized around patient care functions. A comparison of data from 1993 and 1997 indicated increased efficiency, substantial transfer of patients from inpatient to outpatient care, and growth in academic programs not explainable solely by temporal, regional, or national trends or by trends within the VA medical center. Although the results should be interpreted conservatively because of the observational nature of the study, the reorganization appeared to facilitate the positive changes that occurred over the study period.

Iopamidol in lumbar myelography.

Iopamidol is a new, nonionic, water-soluble contrast material currently undergoing clinical trials for intravascular and intrathecal use in Europe and the United States. In this study, 12 patients underwent lumbar myelography with this agent. For each subject, up to 12 mL of iopamidol (at 200 mg I/mL) was employed. The myelograms obtained were highly satisfactory. No serious adverse reactions were observed. The most common side effect--headache--occurred in seven patients. However, six of the seven headaches were mild and transient, and did not require treatment. Nausea occurred in two patients, back pain in two patients, hypotension and hypertension each in one patient. All of these reactions were mild and self-limited. Iopamidol appears to be a safe and conveniently used agent for lumbar myelography.

Blink reflex latency after exposure to trichloroethylene in well water.

The electrophysiological measurement of the blink reflex (BR) can quantify the conduction latency in the reflex arc involving the Vth (trigeminal) and VIIth (facial) cranial nerves. We measured the electrophysiological BR in a population (N = 21), which had alleged chronic exposure to trichloroethylene (TCE) through the public drinking water at levels 30-80 times higher than the Environmental Protection Agency (EPA) Maximum Contamination Level (MCL). A highly significant difference was observed in the conduction latency means of the BR components (p less than .0001), when the study population was compared with laboratory controls (N = 27). This difference suggests a subclinical alteration of the Vth cranial nerve function due to chronic, environmental exposure to TCE.

Neurologic evaluation of a population exposed to arsenic in Alaskan well water.

One hundred forty-seven persons exposed to arsenic from well water were evaluated by neurologic examination and nerve conduction studies. Total arsenic concentrations in well water ranged from 1 to 4781 micrograms/L and from 6 to 4964 micrograms/L in urine; a calculated index of arsenic ingestion ranged from 1 to 4521 micrograms/day. No dose-response relationship existed between arsenic ingestion and symptoms or physical findings compatible with peripheral neuropathy. Five of six persons with symptoms or physical findings suggestive of sensory neuropathy had normal nerve conduction velocities. Thirteen persons with elevated arsenic ingestion but no signs or symptoms of neuropathy had one or more abnormal nerve conduction velocities. No dose-response relationship, however, existed between arsenic ingestion and nerve conduction velocities. The authors concluded that arsenic ingestion from well water at the concentrations found in this Alaskan community did not result in clinical or subclinical neuropathy.

Stimulation SFEMG in myasthenia gravis.

The diagnostic usefulness of single-fiber electromyography (SFEMG) in the diagnosis of neuromuscular transmission disorders is well established. Increased jitter is one of the earliest indications of abnormality. In patients with severe weakness, tremor, or altered consciousness, performance of the study is difficult because of the degree of cooperation needed. We studied five patients and eight normal subjects with voluntary and stimulation SFEMG techniques. Our results, in search of normal values and changes with pathology, revealed differences in the values of jitter and the percentage of abnormal fibers between both techniques. The mean consecutive difference (MCD) is smaller (on average 30% less), and the percentage of abnormal fibers is lower (on average 10% less) with the stimulation technique. These differences are largely explained by the jitter measurement of one endplate with the stimulation technique versus two endplates with the voluntary. They may also be related, however, to the difference in motor unit populations sampled with each technique.

Risk assessment in electronic assembly workers: carpal tunnel syndrome.

Symptoms that develop in workers after repeated mechanical injury may be overlooked until the disability affects their productivity and safety. Modifications in the design of hand-operated tools or adaptations in production ergonomics may prevent further damage and permit affected workers to recover while avoiding the development of repetitive cumulative trauma in workers who are new to the job task. This article describes the results of an on-site survey, a biomechanical analysis, and a special neurologic assessment in an electronic assembly plant and provides a structured approach to worker surveillance and intervention to reduce the risk of carpal tunnel syndrome caused by repetitive motions.

Generic screening as an integral part of quality management.

Comprehensive quality management programs are vital to the evaluation and improvement of the delivery of health care today and in the future. These programs must address issues which include quality assurance, risk management, and utilization management. The programs should be designed to promote and assist in the safe delivery of patient care as well as the provision of a safe environment for all patients, visitors, and employees. Various methodologies have been advocated to ensure quality care, the majority of which are retrospective evaluations. One of the more recent methodologies developed is generic screening. The Boston Veterans Medical Center has utilized generic screening since 1986 in its Quality Management Program. Our generic screening program has been successful as a result of multidisciplinary collaboration, commitment, and support from the medical center's top management, both administrative and clinical. We have developed a credible system that may be used to fulfill many requirements of both internal and external reviews. The program is easily reproducible and provides a basis for trend analysis within specific groups in order to better plan and meet patient care needs, minimize risk, and maximize outcome.