Critique of the Allen test for continuity of the palmar arch assessed by doppler ultrasound

The arterial circulation of both hands of 128 adults was assessed by the Allen test, a modified Allen test emphasizing proper hand position and by Doppler ultrasound. Full extension of the fingers during the Allen test resulted incomplete capillary refilling of the hand in 73 per cent of the patients. The modified Allen test, avoiding hyperextension of the wrist and fingers, revealed interruption of the palmar arch in only one patient with absence of the left radialy artery. There was complete concordance of findings by Doppler ultrasound and the modified Allen test, emphasizing the importance of maintaining proper hand position to avoid false interpretations of incomplete circulation of the palmar arch.     

Reconstruction of a congenital hypoplastic thumb with use of a free vascularized metatarsophalangeal joint

Reconstruction of a Blauth type-IIIB hypoplastic thumb with use of a free vascularized metatarsophalangeal joint was performed in four patients (four hands). Several tendon transfers also were performed, either primarily or secondarily, to mobilize the reconstructed thumb. Three patients (three hands) were followed for at least two years after the reconstruction; the results for these three patients were compared with those for four patients (six hands) who had been managed with pollicization of the index finger because of a similar deformity of the thumb. The patients were evaluated with regard to grip strength, key-pinch strength, and the range of motion of the joints of the thumb in the operatively treated and contralateral hands as well as with regard to skill in performing activities of daily living as assessed with use of the Kobe hand-function test. Although the appearance of the thumb was closer to normal in the group that had had the pollicization procedure, total function of the hand and grip strength were greater in the group that had had the transfer procedure. We believe that reconstruction of an unstable hypoplastic (Blauth type-IIIB) thumb with use of a vascularized metatarsophalangeal joint is an acceptable alternative to pollicization of the index finger.     

Macrodactyly of the feet and hands

We reviewed the records of 16 patients with true macrodactyly and analyzed the typical clinical features and methods of treatment. Fourteen feet were involved in 13 patients (one was bilaterally affected). Three hands were involved in three patients. Clinically, all lesions in the hands and lesions in 11 of 14 feet involved the preaxial side. There was multiple digit involvement in two hands and 11 feet. Progressive macrodactyly (10 feet and two hands) was more common than the static type (four feet and one hand). Proximal involvement of the sole or palm occurred in seven feet and one hand; all cases were of progressive macrodactyly. Enlargement of the metatarsals or the metacarpals was frequent (11 feet and two hands). The growth behavior and extent of bony involvement were similar in patients with hand involvement and those with foot involvement. Fourteen patients had additional clinodactyly, either medial or lateral. The toes of eight feet had angular deformities in the sagittal plane; most were angulated dorsally. Nine patients underwent surgery and two had repeated surgery. The reduction procedures included debulking, ray resection, toe resection, phalangeal resection, and phalangeal epiphysiodesis; the corrective procedures included wedge osteotomy, interdigitalization, and split thickness skin graft. Of the nine patients surgically treated, five had good results and four had fair results. Of the seven patients without surgical repair, three had fair results and four had poor results. Surgical debulking, phalangeal resection, ray resection, and phalangeal epiphysiodesis produced significant improvement in macrodactyly of the feet and hands. Toe resection was not as beneficial.     

The peripheral pulse following arterial injury

There has been little attention paid to the persistence of the pulse following complete forearm arterial transection, and we found no report that has established the etiology or frequency of this phenomenon. Eighteen patients with documented complete radial or ulnar artery transections were evaluated. Nine of the 18 patients had persistently palpable pulse distal to the transections. Seven of the pulses were due to retrograde flow and two were due to transmission from the proximal arterial stump or large collaterals. The Allen test was accurate in demonstrating arterial occlusion in each case. Digital compression of the intact artery eliminated the pulse in those cases due to retrograde flow. Documentation of flow direction and collateral vessels was performed with the Doppler directional velocity meter. The fallibility of the peripheral pulse following complete arterial injury is stressed. The Allen test, digital compression of the intact artery, and Doppler studies should be performed on patients with suspected arterial injuries. The exploration of all wounds in the region of major arteries from which profuse bleeding has occurred is recommended.     

Review of Intentional Changes.

Reviews the book, Intentional Changes by Allen Tough (1982). In this book, Allen Tough intends to reach an academic and professional audience with a plea for recognition of the importance of self-initiated changes. To support his "power to the person" message, Tough presents a large body of data from 150 intensive interviews in England, Canada, and the United States. Another 180 interviews contributed to the development of a formal interview schedule and of ideas. He identifies four major themes that emerge from his data--themes that underlie his arguments for greater personal freedom and for the provision of non-intrusive help to facilitate the use of that freedom. The reviewer found the book to be an interesting and worthwhile book to read, although the data presented are too flawed to be persuasive. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Surgical hand disinfection with alcohols at various concentrations: parallel experiments using the new proposed European standards method

OBJECTIVES: To establish the concentration of isopropanol that exerts the same immediate and sustained effects as n-propanol 60% v/v in surgical scrubbing, and to assess the performance of the test method proposed as the European standard in parallel experiments. DESIGN: Isopropanol at concentrations of 70%, 80%, and 90% v/v was tested in comparison with n-propanol 60%, the proposed reference preparation, in the draft method proposed by the European standard. A Latin square design was used with four balanced blocks of five volunteers each in four experimental runs that were spaced by intervals of 1 week each. Volunteers were allotted randomly to one of the four blocks. Independently, the volunteers' right and left hands also were randomized into two groups for the assessment of either immediate or sustained effects. SETTING: Two laboratories supervised by two investigators, one from Vienna, Austria, and one from London, The United Kingdom. METHOD: The release of skin flora from the fingertips of clean hands was assessed before and after treatment by immediate sampling from one hand and by sampling of the other, gloved hand after 3 hours. The mean log10 reductions (RF) of bacterial release achieved by rubbing the alcoholic preparations for 3 minutes onto the hands were established. RESULTS: For both experiments, the immediate effects of isopropanol 70% (RF, 2.0 and 2.1, respectively) were significantly smaller than those of the reference n-propanol 60% (RF, 2.4 and 2.6, respectively). This also was found with the sustained effects (RF, 0.7 and 1.1 vs 1.0 and 1.6, respectively). At 90%, isopropanol equalled the immediate effect of n-propanol 60%, whereas at 80% it proved slightly (although not significantly) less active. There were no significant differences in the results of both investigators. The sustained effects of isopropanol 80% and 90% were both larger than the reference in Vienna but were found smaller by the London investigator; none of the differences were significant. Mean RFs were significantly different between Vienna and London with n-propanol 60% and isopropanol 70%, but not with isopropanol at 80% or 90%. CONCLUSIONS: At 90%, isopropanol is as effective as n-propanol 60%, which was proposed by the European Committee for Standardization as a reference in testing products for surgical hand disinfection. It could, therefore, serve as an alternative if the proposed agent is undesirable for any reason. In parallel experiments by two investigators, the proposed test method proved well workable; the results were very similar and the conclusions identical.     

Localization of unique functional determinants in the calmodulin lobes to individual EF hands

We have investigated the functional interchangeability of EF hands I and III or II and IV, which occupy structurally analogous positions in the native I-II and III-IV EF hand pairs of calmodulin. Our approach was to functionally characterize four engineered proteins, made by replacing in turn each EF hand in one pair by a duplicate of its structural analog in the other. In this way functional determinants we define as unique were localized to the component EF hands in each pair. Replacement of EF hand I by III reduces calmodulin-dependent activation of cerebellar nitric oxide synthase activity by 50%. Replacement of EF hand IV by II reduces by 60% activation of skeletal muscle myosin light chain kinase activity. There appear to be no major unique determinants for activation of these enzyme activities in the other EF hands. Replacement of EF hand III by I or IV by II reduces by 50-80% activation of smooth muscle myosin light chain kinase activity, and replacement of EF hand I by III or II by IV reduces by 90% activation of this enzyme activity. Thus, calmodulin-dependent activation of each of the enzyme activities examined, even the closely related kinases, is dependent upon a distinct pattern of unique determinants in the four EF hands of calmodulin. All the engineered proteins examined bind four Ca2+ ions with high affinity. Comparison of the Ca2+-binding properties of native and engineered CaMs indicates that the Ca2+-binding affinity of an engineered I-IV EF hand pair and a native I-II pair are similar, but an engineered III-II EF hand pair is intermediate in affinity to the native III-IV and I-II pairs, minimally suggesting that EF hands I and III contain unique determinants for the formation and function of EF hand pairs. The residues directly coordinating Ca2+ ion appear to play little or no role in establishing the different Ca2+-binding properties of the EF hand pairs in calmodulin.     

The impact of hemiparalysis on the expression of osteoarthritis

OBJECTIVE: Primary generalized osteoarthritis (OA), the most prevalent joint disease, is usually symmetric. Sporadic case reports mention decreased OA manifestations in limbs in which there are neurologic deficits, but no systematic research has been published. The aim of the present study was to examine these observations in a planned and controlled survey in a group of patients with OA. METHODS: Seventy-five geriatric patients with a history of stroke and hemiparalysis were studied clinically and radiographically (hand radiographs; graded according to a modified Altman method) for the presence and the degree of OA in the hands. Detailed clinical and radiologic scores were calculated for each hand. Demographic, occupational, and neurologic data were collected. Patients with other joint or neurologic conditions were excluded. A group of 55 elderly patients without stroke were similarly studied (controls). Scores in the paralyzed hand were compared with those in the nonparalyzed hand in the stroke patients and subgroups (by Student's paired t-test and Wilcoxon test). Scores in the dominant hands were compared with those in the nondominant hands in stroke patients and control subjects (by Student's paired t-test and Mann-Whitney test). Correlation between the degree of neurologic damage and OA asymmetry (Pearson's correlation coefficient) was also sought. RESULTS: Paralyzed hands showed significantly fewer OA changes than nonparalyzed hands, both clinically and radiologically. This trend, accentuated in patients with more severe paralysis, disappeared in those with mild residual paresis. Asymmetry of OA was more pronounced in patients with flaccid, compared with spastic, paralysis. The degree of paralysis and loss of muscle strength correlated with the degree of OA asymmetry. Women had significantly higher OA scores than men. In the control group, dominant hands had higher OA scores, but this finding was concealed among hemiparalyzed patients. Lifetime gross occupational load and present grip strength did not correlate with the degree of OA. CONCLUSION: In elderly patients, hemiparalysis reduces ipsilateral hand expression of OA, while OA is accentuated (or increased) in the dominant hand of patients without paralysis. This first systematic study confirms the findings of previous case reports and lends support to the role of biomechanical factors in the development of OA.     

Skin symptoms on the hands of female house-cleaning personnel]

Skin symptoms on the hands were studied in questionnaire-based studies conducted in 1989 and 1991 among female cleaners employed at Danish nursing homes, schools and offices. Eleven hundred and sixty-six participated in 1989 and 1011 of them participated in 1991. The average age was 45 years and the average length of five employed as a cleaner was ten years. Forty-three percent reported to have had at least one out of four skin symptoms during a one year period. Seventy percent reported improvement during week-ends and holidays. A positive correlation was found between hours per week spent with wet hands and skin symptoms. During the follow-up period the risk of developing skin symptoms was higher in the group who remained cleaners compared with the group who left the cleaning job. Similarly, the prognosis was better in the group which left the cleaning job compared with the group which remained cleaners. There is a future need to develop and implement new work organisation and cleaning methods to reduce the time spent with wet hands.     

Natural history of median nerve sensory conduction in industry: relationship to symptoms and carpal tunnel syndrome in 558 hands over 11 years

We evaluated the natural history of median nerve sensory conduction, hand/wrist symptoms, and carpal tunnel syndrome (CTS) in an 11-year longitudinal study of 289 workers from four industries. Twenty hands which had carpal tunnel release surgery were excluded, leaving 558 hands for the primary study group. Overall, the trend was for mean sensory latencies and prevalence of slowing to increase, the prevalence of symptoms to decrease, and the prevalence of CTS to remain unchanged. Among individual hands, nerve conduction abnormalities tended to persist (82% 11-year persistence), while symptoms fluctuated widely (13% 11-year persistence). There was a strong, direct linear correlation between initial severity of slowing and subsequent development of CTS; however, most workers who developed de novo slowing did not develop symptoms or CTS. We conclude that changes in conduction status of the median nerve occur naturally with increasing age and do not necessarily lead to symptoms and CTS.     

Effect of personal hygiene on blood lead levels of workers at a lead processing facility

The relationship between personal hygiene and blood lead levels was tested at a lead processing facility. During the workers' semiannual respirator fit test, when they were confident their hands were clean, the amount of lead on their right hands was measured. Samples were obtained by cleaning one entire hand with a wiping towel treated with a proprietary mixture of alcohol, surfactants, and ethylenediaminetetraacetic acid. Wipe samples were analyzed for total lead and then compared with the worker's blood lead level. Each worker's personal habits at rest were also observed. Workers with more than 1 year's experience had a significantly positive correlation between lead on the hand tested and their blood level. The study strongly suggests that lead on the skin ultimately enters the bloodstream. The route of entry was not investigated. Personal habits of the workers with high blood lead levels were observed to include actions that would quickly contaminate their hands shortly after washing.     

Effects of a protective foam on scrubbing and gloving

OBJECTIVE: To test the effects of a skin protectant on surgical scrub and glove integrity. DESIGN: Forty-nine healthy adult volunteers were assigned (12 subjects per group) to apply a protective foam (DermaMed; Benchmark Enterprises, Salt Lake City, Utah) in conjunction with surgical scrub in one of the following formulations: 70% isopropyl alcohol, a liquid detergent base containing 4% chlorhexidine gluconate, a liquid detergent base containing 7.5% povidone-iodine, or a nonantimicrobial liquid soap (control). According to a standard protocol, subjects performed a surgical scrub on 3 days (every other day). Foam was applied after surgical scrub on day 1 and before surgical scrub on day 3. No foam was applied on day 2. Subjects were gloved for 2 hours after surgical scrub. SETTING: Laboratory setting. RESULTS: On all test days, there were significant differences in bacterial reduction by products (chlorhexidine gluconate or alcohol > povidone-iodine > control). When controlling for baseline counts and products used, there were no significant differences in colony-forming unit counts on hands with or without foam immediately after scrubbing or at 2 hours after scrub on gloved or ungloved hands, nor were there differences in glove leakage rates when foam was on hands. CONCLUSIONS: Such protectants can be used without detrimental effects to scrub effectiveness or glove integrity.     

Long-term results of surgical treatment of thumb polydactyly

One hundred thirteen hands exhibiting thumb polydactyly were treated and followed up for an average of 49 months. Of these, 109 hands were treated by resection of a supernumerary hypoplastic thumb. Radial thumbs were resected in 107 hands and ulnar thumbs in 2 hands. Four hands were treated using a modified Bilhaut procedure. According to a modified Tada's evaluation, the results were evaluated as good in 97 hands, fair in 12 hands, and poor in 4 hands. Patients and/or their parents were satisfied with the results in 100 hands and dissatisfied with the results in 13 hands. The factors that influenced the surgical results were analyzed. The incidence of unsatisfactory results was relatively high in Wassel types 3, 5, and 6 and triphalangeal-type thumb polydactyly. It was higher when the ulnar digit was removed than when the radial digit was removed. The results for those patients treated between 1983 and 1991 were better than for those treated between 1976 and 1982. The type of deformity, type of procedure, and skillfulness of the surgeon were factors in the results after surgery.     

Pollicisation of the index finger. A 27-year follow-up study

We have reviewed 11 patients with congenital absence of the thumb, treated by pollicisation of the index finger, after follow-up for 20 to 38 years. Seven of the hands also had an associated radial club-hand deformity. Function as assessed by the Percival score was excellent in six, good in three, fair in two and poor in four; three of the poor results were in patients with radial club hand. Ten of the 15 transfers were used as normal thumbs, but in five hands function required trick movements. Of the seven unilateral cases, two transplants were used as the dominant hand, and in another two thumb strength was more than 50% of that on the opposite side. For patients with isolated congenital absence of the thumb, pollicisation of the index finger gives good functional and cosmetic results which are maintained. The results are less reliable for those with radial club hand.     

Peripheral nerve stimulation in a whole-body echo-planar imaging system

Echo-planar techniques in MRI use a rapidly oscillating frequency-encoding gradient with the potential to produce peripheral nerve stimulation. To evaluate the incidence, type, and location of stimulation in a commercial whole-body scanner, we studied two groups: (a) 173 consecutive individuals scanned by echo-planar imaging for other purposes and (b) seven subjects who were scanned with an extensive set of 36 echo-planar sequences (with prompting after each scan to report any peripheral nerve stimulation) to test the effects of various parameters. Although only 5% of group A reported symptoms of peripheral nerve stimulation, all in group B experienced some type of stimulation, dependent primarily on direction of the oscillating gradient and location of the body within the gradient coil. Maximum stimulation typically occurred 30 to 40 cm from isocenter in the region of maximum dB/dt. Generally, y gradients produced truncal stimulation, and x gradients produced stimulation in the head. When hands were clasped over the abdomen, a tingling in the hands occasionally was felt. Patients should be instructed to keep their hands apart.     

Influence of different racing positions on metabolic cost in elite cyclists

The spectacular improvements of the 1-h world record in cycling in the last four years have highlighted the importance of aerodynamics in modern bicycle racing. We have investigated the metabolic consequences of the low-crouched aero-positions necessary to reduce air drag. In this study, 14 elite male bicycle racers (24.0 +/- 1.0 yr, VO2max 69.4 +/- 0.5 mL.kg-1.min-1) were tested for oxygen consumption (VO2) and heart rate (HR) at 70% (302.6 +/- 5.3 W) of their individual VO2max in three different riding positions during a single test run. The subjects rode their racing bicycles on a wind braked roller; the sequence of the three following positions was randomized: 1) upright cycling (UP), cadence 90 rpm; 2) hands on drops (DP), 90 rpm; and 3) hands on clip-on aero-handlebars (AP), 90 rpm. VO2 and HR values in AP were significantly higher by 1.5 mL.kg-1.min-1 and 5 beats.min-1, respectively, compared with UP. We concluded that riding a bicycle in an extreme aero-position increases the metabolic cost of cycling when wind resistance is not taken into account. However, when the mechanical power losses of 9 W (estimated by the VO2 increase) are compared with the expected aerodynamic power savings of approximately 100 W, it appears that aerodynamic advantages by far outweight their metabolic cost.     

Osteoarthritis of the hands in early populations

A study of the distribution of osteoarthritis of the hands was carried out in a series of 168 skeletons (77 males, 87 females, four unknown sex) from archaeological sites in England. There were substantial differences in the distribution of the disease between the sexes, but the only significant differences between the hands were shown for the second and third metacarpophalangeal joints, which were more often affected on the right side. In the males, the disease was predominantly unifocal (in 45 of the 77 cases), but in the females it was predominantly multifocal (56 of the 87 cases). Where only a single joint was affected, it was most often the first carpometacarpal joint in females, whereas in males, this joint and the first metacarpophalangeal joints were equally likely to be involved. Single-linkage cluster analysis showed that the strongest link in males was between the trapezoscaphoid and trapezoidoscaphoid joints; in the females, the strongest links were between the first carpometacarpal, the distal interphalangeal and the first metacarpophalangeal joints.     

The origins of confusion.

Repeats previous criticism of the work of S. Dinitz, H. Goldman, H. E. Allen, and L. A. Lindner as resting on an inadequate data base. A series of published reports by the group are ostensibly independent but seem to be derived from a single study, a 1969 dissertation by Allen. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Coronary angiography by left radial approach. A bi-center prospective pilot study

The aim of this study was to assess prospectively the feasibility, safety and quality of coronary angiography performed by a left radial arterial approach. The investigation was performed under local anesthesia with a Lidocaine gel using Judkins 5f catheter. A bolus of heparin was injected intravenously at the start of the procedure (no heparin in phase 0.2 to 3.000 IU during phase 1 and 5.000 IU in phase 2). Between March 1994 and January 1996, after exclusion of 108 patients (15.1%) mainly because of an abnormal Allen test, coronary angiography was carried out in 540 patients aged 58.4 +/- 11.7 years, 85% of whom were men. The failure rate was 8%. The quality of opacification of the left coronary artery (scale 1 to 3) was 2.91 +/- 0.27 and of the right coronary artery was 2.96 +/- 0.18. There were no complications during the procedure. Analysis of the learning curve showed a failure rate decreasing to less than 5% after 60 procedures/operator. In the last 100 procedures, the failure rate fell to 3%, the canulation time was 2.2 +/- 2.5 min, the duration of fluoroscopy was 6.5 +/- 3.9 min and the duration of the procedure was 17.5 +/- 4.7 min (14.7 +/- 3.8 min, p < 0.01, by the femoral approach). Clinical and Doppler ultrasonographic follow-up revealed one in-hospital complication (a spontaneously regressive compressive haematoma). No clinical complications were observed at 3 months. Doppler ultrasonography showed the radial artery occlusion rate to be 71% in phase 0.32% in phase 1 and 3.2% in phase 2 (p < 0.0001). These results show that the left radial arterial approach for coronary angiography is safe and effective but requires a period of training. A 5.000 IU dose of heparin limits the risk of radial artery occlusion to 3%. The absence of complications in this large series which included the training period and the patient comfort suggest that this technique may be an excellent alternative to the femoral approach and especially the brachial approach when the Allen test is normal.     

Nonmonotonic behavior of the dose dependence of the radiation effect on cells in vitro exposed to pulsed laser radiation at lambda = 820 nm

The relationship of measures of pressure perception to hand function was evaluated by correlating the results of the Mayo Dexterity Test and a timed object recognition test with the one- and two-point static and moving touch thresholds for the index finger pulp of 44 hands. The Mayo Dexterity Test permits the use of vision, while the object recognition test does not. Quantitative sensory testing was done with the Pressure-specifying Sensory Device. Cutaneous pressure threshold measurements with this device had a statistically significant correlation with the small-object subset of the Mayo Dexterity Test (p < 0.006) and with the object recognition test (p < 0.001), demonstrating that the Pressure-specifying Sensory Device is a valid tool for evaluating the sensory aspect of hand function.