What is the diagnostic value of ultrasonography compared to physical evaluation in patients with idiopathic carpal tunnel syndrome?

[EN] OBJECTIVE: Our hypothesis is that sonography performed by the rheumatologist in patients with suspected carpal tunnel syndrome (CTS) has higher diagnostic value compared to physical evaluation. METHODS: Adult patients with suspected idiopathic CTS, defined by sensory symptoms over the distribution of the median nerve with or without positive results with the Phalen and/or the Tinel's maneuvers were included. The diagnosis of CTS was indicated by typical symptoms daily for at least 3 months and a positive nerve conduction study. One rheumatologist unaware of the clinical and electrodiagnostic results performed an ultrasound examination of the median nerve for the area ranging from the inlet to the outlet of the carpal tunnel. Mean cross-sectional area at each level, flattening ratio and bowing of flexor retinaculum were obtained. RESULTS: Sixty-eight patients with 105 affected wrists were examined. Tinel's and Phalen's signs had a closer sensitivity (73% and 67% respectively) and specificity (40% and 30% respectively). The best swelling nerve cut-off by sonography was 9.7 mm2 at the tunnel inlet, with a sensitivity of 86%, a specificity of 48% and accuracy of 77%. A 100% positive predictive value was reached with a cross-sectional area of 13 mm2, involving 33 hands (31% of the whole sample). Maximal cross sectional area and the measurement of flexor retinaculum had an accuracy of 72% and 73% respectively. Combination of physical maneuvers and sonography not yielded more accuracy than cross-sectional area itself. CONCLUSION: In patients with clinical history of idiopathic CTS and positive nerve conduction study, sonography performed by the rheumatologist has higher diagnostic value than physical maneuvers.

Kinematic improvement following Botulinum Toxin-A injection in upper-limb spasticity due to stroke

Background Focal spasticity is a significant motor disorder following stroke, and Botulinum Toxin Type-A (BoNT-A) is a useful treatment for this. The authors evaluated kinematic modifications induced by spasticity, and whether or not there is any improvement following injection of BoNT-A. Methods Eight patients with stroke with upper-limb spasticity, showing a flexor pattern, were evaluated using kinematics before and after focal treatment with BoNT-A. A group of sex- and age-matched normal volunteers acted as a control group. Results Repeated-measures ANOVA showed that patients with stroke performed more slowly than the control group. Following treatment with BoNT-A, there was a significant improvement in kinematics in patients with stroke, while in the control group, performance remained unchanged. Conclusions Focal treatment of spasticity with BoNT-A leads to an adaptive change in the upper limb of patients with spastic stroke.

Distribution of radiodense contrast medium after perineural injection of the palmar and palmar metacarpal nerves (low 4-point nerve block): an in vivo and ex vivo study in horses

REASONS FOR PERFORMING STUDY: Evidence-based information is limited on distribution of local anaesthetic solution following perineural analgesia of the palmar (Pa) and palmar metacarpal (PaM) nerves in the distal aspect of the metacarpal (Mc) region ('low 4-point nerve block'). OBJECTIVES: To demonstrate the potential distribution of local anaesthetic solution after a low 4-point nerve block using a radiographic contrast model. METHODS: A radiodense contrast medium was injected subcutaneously over the medial or the lateral Pa nerve at the junction of the proximal three-quarters and distal quarter of the Mc region (Pa injection) and over the ipsilateral PaM nerve immediately distal to the distal aspect of the second or fourth Mc bones (PaM injection) in both forelimbs of 10 mature horses free from lameness. Radiographs were obtained 0, 10 and 20 min after injection and analysed subjectively and objectively. Methylene blue and a radiodense contrast medium were injected in 20 cadaver limbs using the same techniques. Radiographs were obtained and the limbs dissected. RESULTS: After 31/40 (77.5%) Pa injections, the pattern of the contrast medium suggested distribution in the neurovascular bundle. There was significant proximal diffusion with time, but the main contrast medium patch never progressed proximal to the mid-Mc region. The radiological appearance of 2 limbs suggested that contrast medium was present in the digital flexor tendon sheath (DFTS). After PaM injections, the contrast medium was distributed diffusely around the injection site in the majority of the limbs. In cadaver limbs, after Pa injections, the contrast medium and the dye were distributed in the neurovascular bundle in 8/20 (40%) limbs and in the DFTS in 6/20 (30%) of limbs. After PaM injections, the contrast and dye were distributed diffusely around the injection site in 9/20 (45%) limbs and showed diffuse and tubular distribution in 11/20 (55%) limbs. CONCLUSIONS AND POTENTIAL RELEVANCE: Proximal diffusion of local anaesthetic solution after a low 4-point nerve block is unlikely to be responsible for decreasing lameness caused by pain in the proximal Mc region. The DFTS may be penetrated inadvertently when performing a low 4-point nerve block.

[Disorders of the origin of the suspensory ligament in the horse: a diagnostic challenge]

Lameness in horses due to pain originating from the proximal metacarpal/metatarsal region remains a diagnostic challenge. In cases of obvious lameness the pain can be localised to this region by diagnostic anaesthesia. Because a variety of disorders can cause lameness in this region different imaging modalities including radiography, ultrasonography and scintigraphy should be used to arrive at an accurate diagnosis. Even though a precise anatomic-pathologic diagnosis can still be an enigma, because not only bone and joints, but also soft tissue structures including the proximal suspensory ligament, its origin at the proximal metacarpus/ metatarsus, its fascia, the superficial fascia, as well as the intermetacarpal/metatarsal ligaments, the accessory ligament of the deep digital flexor tendon and both digital flexor tendons may be involved. Magnet resonance tomography (MRT) shows a high diagnostic sensitivity in imaging soft tissue structures and bone. In horses MRT is still at the beginning. The MRT appearance of the proximal metacarpal/metatarsal region has not yet been evaluated in detail and there are only few anatomic studies of the origin of the suspensory ligament in horses. The first experiences showed, that more gross and histologic examinations are necessary to fully interpret MRT-images and to differentiate pathologic alterations from clinically not relevant variations.

Mesenteric lymphangitis and sepsis due to RTX toxin-producing Actinobacillus spp in 2 foals with hypothyroidism-dysmaturity syndrome

Actinobacillus suis-like organisms (ASLOs) have been isolated from the genital, respiratory, and digestive tracts of healthy adult horses, horses with respiratory disease, and septic foals. Two foals with congenital hypothyroidism-dysmaturity syndrome from separate farms developed ASLO infection. At necropsy, both had contracted carpal flexor tendons, thyroid hyperplasia, and thrombotic and necrotizing mesenteric lymphangitis and lymphadenitis; one foal also had mandibular prognathism. Numerous ASLOs were isolated from tissues from both foals, including intestine. Biochemical testing and mass spectrometric analysis of the two Actinobacillus isolates did not allow unequivocal identification. Comparative genetic analysis was done on these and similar isolates, including phylogeny based on 16S rRNA, rpoB and recN genes, as well as RTX (repeat in toxin) toxin typing of apxIA-apxIVA and aqxA genes. One isolate was identified as Actinobacillus suis sensu stricto, based on the presence of apxIA and apxIIA but not aqxA, whereas the other isolate had aqxA but neither apxIA nor apxIIA, consistent with A equuli ssp haemolyticus. Based on genotypic analysis of the isolates included for comparison, 3 of 3 equine ASLOs and 2 of 5 A equuli isolates were reclassified as A equuli subsp haemolyticus, emphasizing the importance of toxin genotyping in accurate classification of actinobacilli.

Diseases of the Tendons and Tendon Sheaths

Contracted flexor tendon leading to flexural deformity is a common congenital defect in cattle. Arthrogryposis is a congenital syndrome of persistent joint contracture that occurs frequently in Europe as a consequence of Schmallenberg virus infection of the dam. Spastic paresis has a hereditary component, and affected cattle should not be used for breeding purposes. The most common tendon avulsion involves the deep digital flexor tendon. Tendon disruptions may be successfully managed by tenorrhaphy and external coaptation or by external coaptation alone. Medical management alone is unlikely to be effective for purulent tenosynovitis.

Anatomic foveal reconstruction of the triangular fibrocartilage complex with a tendon graft

An acute injury to the triangular fibrocartilage complex (TFCC) with avulsion of the foveal attachment can produce distal radioulnar joint (DRUJ) instability. The avulsed TFCC is translated distally so the footprint will be bathed in synovial fluid from the DRUJ and will become covered in synovitis. If the TFCC fails to heal to the footprint, then persistent instability can occur. The authors describe a surgical technique indicated for the treatment of persistent instability of the DRUJ due to foveal detachment of the TFCC. The procedure utilizes a loop of palmaris longus tendon graft passed through the ulnar aspect of the TFCC and into an osseous tunnel in the distal ulna to reconstruct the foveal attachment. This technique provides stability of the distal ulna to the radius and carpus. We recommend this procedure for chronic instability of the DRUJ due to TFCC avulsion, but recommend that suture repair remain the treatment of choice for acute instability. An arthroscopic assessment includes the trampoline test, hook test, and reverse hook test. DRUJ ballottement under arthroscopic vision details the direction of instability, the functional tear pattern, and unmasks concealed tears. If the reverse hook test demonstrates a functional instability between the TFCC and the radius, then a foveal reconstruction is contraindicated, and a reconstruction that stabilizes the radial and ulnar aspects of the TFCC is required. The foveal reconstruction technique has the advantage of providing a robust anatomically based reconstruction of the TFCC to the fovea, which stabilizes the DRUJ and the ulnocarpal sag.

Reconstruction of Chronic Foveal TFCC Tears with an Autologous Tendon Graft

Background A triangular fibrocartilage complex (TFCC) injury can produce distal radioulnar joint (DRUJ) instability. If the foveal attachment is avulsed, it translates distally. The footprint is separated from its origin and will become covered in synovitis, preventing healing. The authors describe a surgical technique for the treatment of instability of the DRUJ due to chronic foveal detachment of the TFCC. Technique The procedure utilizes a loop of autologous palmaris longus tendon graft passed through the ulnar aspect of the TFCC and through an osseous tunnel in the distal ulna to reconstruct the fovel attachment. Patients and Methods We report on nine patients with a mean age of 42. Median follow-up was 13 months. Results The median pain scores measured were reduced from 8 to 3 postoperatively, and all had a stable DRUJ. Conclusions This technique provides stability of the distal ulna to the radius and carpus, with potential for biologic healing through osseous integration. It is a robust, anatomically based reconstruction of the TFCC to the fovea that stabilizes the DRUJ and the ulnar-carpal sag.

Ecos de la novela griega en el Renacimiento

La novela griega, género polifacético de ficción en prosa, que floreció del siglo I al IV d.C., tuvo su continuación en la literatura bizantina. La trascendencia de la novela llegó al Renacimiento con Longo y su Dafnis y Cloe, que influenció obras como la Arcadia de Sanazzaro, en Italia, o la Diana, de Jorge de Montemayor, en España; y tuvo cierto influjo en la Galatea de Cervantes e incluso en El Quijote. También la Arcadia de Sidney es tributaria del tema y la Astrea de Honoré d' Urfé, en Francia, refleja también este efecto. En esta comunicación quiero destacar la influencia de la novela griega en La Tempestad, comedia en cinco actos de Shakespeare, que revela gran afinidad con la novela de amor y aventuras, de Longo, Jenofonte de Éfeso y Aquiles Tacio, así como con la novela utópica

Ecos de la novela griega en el Renacimiento

La novela griega, género polifacético de ficción en prosa, que floreció del siglo I al IV d.C., tuvo su continuación en la literatura bizantina. La trascendencia de la novela llegó al Renacimiento con Longo y su Dafnis y Cloe, que influenció obras como la Arcadia de Sanazzaro, en Italia, o la Diana, de Jorge de Montemayor, en España; y tuvo cierto influjo en la Galatea de Cervantes e incluso en El Quijote. También la Arcadia de Sidney es tributaria del tema y la Astrea de Honoré d' Urfé, en Francia, refleja también este efecto. En esta comunicación quiero destacar la influencia de la novela griega en La Tempestad, comedia en cinco actos de Shakespeare, que revela gran afinidad con la novela de amor y aventuras, de Longo, Jenofonte de Éfeso y Aquiles Tacio, así como con la novela utópica

Ecos de la novela griega en el Renacimiento

La novela griega, género polifacético de ficción en prosa, que floreció del siglo I al IV d.C., tuvo su continuación en la literatura bizantina. La trascendencia de la novela llegó al Renacimiento con Longo y su Dafnis y Cloe, que influenció obras como la Arcadia de Sanazzaro, en Italia, o la Diana, de Jorge de Montemayor, en España; y tuvo cierto influjo en la Galatea de Cervantes e incluso en El Quijote. También la Arcadia de Sidney es tributaria del tema y la Astrea de Honoré d' Urfé, en Francia, refleja también este efecto. En esta comunicación quiero destacar la influencia de la novela griega en La Tempestad, comedia en cinco actos de Shakespeare, que revela gran afinidad con la novela de amor y aventuras, de Longo, Jenofonte de Éfeso y Aquiles Tacio, así como con la novela utópica

Marine diatoms in deep sea sediments

Long-term evolution is thought to take opportunities that arise as a consequence of mass extinction (as argued, for example, by Gould, 2002) and the following biotic recovery, but there is absolutely no evidence for this being the case. However, our study shows that eutrophication by oceanic mixing also played a part in the enhancement of several evolutionary events amongst marine organisms, and these results could indicate that the rates of oceanic biodiversification may be slowed if upwelling becomes weakened by future global warming. This paper defines three distinct evolutionary events of resting spores of the marine diatom genus Chaetoceros, to reconstruct past upwelling through the analysis of several DSDP, ODP and land-based successions from the North, South and equatorial Pacific as well as the Atlantic Ocean during the past 40 million years. The Atlantic Chaetoceros Explosion (ACE) event occurred across the E/O boundary in the North Atlantic, and is characterized by resting spore diversification that occurred as a consequence of the onset of upwelling following changes in thermohaline circulation through global cooling in the early Oligocene. Pacific Chaetoceros Explosion events-1 and -2 (PACE-1 and PACE-2) are characterized by relatively higher occurrences of iron input following the Himalayan uplift and aridification at 8.5 Ma and ca. 2.5 Ma in the North Pacific region. These events not only enhanced the diversification and increased abundance of primary producers, including that of Chaetoceros, other diatoms and seaweeds, but also stimulated the evolution of zooplankton and larger predators, such as copepods and marine mammals, which ate these phytoplankton and plants. Current thinking suggests new evolutionary niches open up after a mass extinction, but our study finds that eutrophication can also stimulate evolutionary diversification. Moreover, in the opposite fashion, our results show that as thermohaline circulation abates, global warming progresses and the ocean surface becomes warmer, many marine organisms will be affected by the environmental degradation.

Paleocene radiolarian distribution and biostratigraphy from offshore eastern New Zealand

A 100-m-thick Paleocene sequence of mainly pelagic sediments at ODP Site 1121, on the eastern flanks of the Campbell Plateau, contains few to common radiolarians of relatively low diversity in the lower 40 m (Early to early Late Paleocene) and abundant, diverse radiolarian assemblages in the upper 60 m (mid-Late Paleocene). The 150 taxa recorded from the entire Paleocene interval are thought to under-represent the actual species diversity by at least one half as many morphotypes have not been differentiated below the level of genus. Assemblages in the lower 40 m are similar to those described from onland New Zealand and DSDP Site 208 (northern Lord Howe Rise); they are correlated with South Pacific radiolarian zones RP4 and RP5. Assemblages in the upper 60 m differ from other known Late Paleocene assemblages in the great abundance of plagiacanthids and cycladophorids. Similarities are noted with later Cenozoic cool-water assemblages. This upper interval is correlated with South Pacific zone RP6, as revised herein, based on comparison with faunas from Site 208 and Marlborough, New Zealand. The interval is also correlated with the upper part of North Atlantic zone RP6 (RP6b-c) based on the presence of Aspis velutochlamydosaurus, Plectodiscus circularis and Pterocodon poculum. Other species, such as Buryella tetradica and Buryella pentadica, are valuable for local correlation but exhibit considerable diachroneity between the Pacific, Indian and Atlantic Oceans. An age model for the Paleocene interval at Site 1121, based on well-constrained nannofossil and radiolarian datums, indicates that the rate of compacted sediment accumulation doubles from 15 to 30 mm/ka at the RP5/RP6 zonal boundary. In large part this is due to a sudden and pronounced increase in accumulation rates for all siliceous fossils; radiolarians and larger diatoms increase from <100 to >10 000 specimens/cm2/ka. This apparent increase in biosiliceous productivity is age-equivalent to a mid-Paleocene cooling event (57-59 Ma) identified from global stable isotope records that is associated with the heaviest delta13C values for the entire Cenozoic.

Palynology, source vegetation, environment and age of ODP Site 188-1166 sediments

Twenty-three core catcher samples from Site 1166 (Hole 1166A) in Prydz Bay were analyzed for their palynomorph content, with the aims of determining the ages of the sequence penetrated, providing information on the vegetation of the Antarctic continent at this time, and determining the environments under which deposition occurred. Dinocysts, pollen and spores, and foraminiferal test linings were recovered from most samples in the interval from 142.5 to 362.03 meters below seafloor (mbsf). The interval from 142.5 to 258.72 mbsf yielded palynomorphs indicative of a middle-late Eocene age, equivalent to the lower-middle Nothofagidites asperus Zone of the Gippsland Basin of southeastern Australia. The Prydz Bay sequence represents the first well-dated section of this age from East Antarctica. Dinocysts belonging to the widespread "Transantarctic Flora" give a more confident late Eocene age for the interval 142.5-220.5 mbsf. The uppermost two cores within this interval, namely, those from 142.5 and 148.36 mbsf, show significantly higher frequencies of dinocysts than the cores below and suggest that an open marine environment prevailed at the time of deposition. The spore and pollen component may reflect a vegetation akin to the modern rainforest scrubs of Tasmania and New Zealand. Below 267 mbsf, sparse microfloras, mainly of spores and pollen, are equated with the Phyllocladidites mawsonii Zone of southeastern Australia, which is of Turonian to possibly Santonian age. Fluvial to marginal marine environments of deposition are suggested. The parent vegetation from this interval is here described as "Austral Conifer Woodland." The same Late Cretaceous microflora occurs in two of the cores above the postulated unconformity at 267 mbsf. In the core at 249.42 mbsf, the Late Cretaceous spores and pollen are uncontaminated by any Tertiary forms, suggesting that a clast of this older material has been sampled; such a clast may reflect transport by ice during the Eocene. At 258.72 mbsf, Late Cretaceous spores and pollen appear to have been recycled into the Eocene sediments.