WMJ : official publication of the State Medical Society of Wisconsin最新文献

Introduction: Carpal tunnel syndrome is the most common peripheral entrapment neuropathy, often associated with structural and functional changes in the median nerve and thenar muscles. Neuromuscular ultrasound is increasingly used to complement nerve conduction studies in carpal tunnel syndrome evaluation, yet its potential for assessing muscle integrity remains underexplored. This pilot study examined correlations between median nerve cross-sectional area (MNCSA) and abductor pollicis brevis (APB) muscle characteristics on ultrasound.

Methods: Veterans were enrolled at the Clement J. Zablocki VA Medical Center from July to November 2023. Inclusion criteria were age ≥18 years, carpal tunnel syndrome confirmed by nerve conduction studies, and planned carpal tunnel release. Exclusion criteria included prior carpal tunnel release, upper limb trauma or surgery, hand deformities, peripheral neuropathy, and diabetes. Ultrasound images of the median nerve and APB were obtained. Using Adobe Photoshop, APB echogenicity (grayscale value, black/white ratio) and cross-sectional area in longitudinal and transverse views were calculated and analyzed for correlation with MNCSA.

Results: Ten participants were included. Strong negative correlations were observed between MNCSA and APB cross-sectional area in longitudinal and transverse views (Pearson coefficients, -0.51 and -0.50, respectively). Weak to moderate positive associations were found between MNCSA and APB echogenicity values (0.32 and 0.24, respectively).

Conclusions: APB characteristics on ultrasound, including echogenicity and cross-sectional area, may serve as complementary indicators of carpal tunnel syndrome. Future research should include larger samples, control groups, and assessment of correlations with carpal tunnel syndrome severity on nerve conduction studies.

Introduction: Choroidal rupture is a vision-threatening complication of blunt ocular trauma but is rarely reported in association with fishing-related injuries. We describe a case of choroidal rupture following ocular trauma from a fishing lure.

Case presentation: A 9-year-old boy presented with a penetrating fishhook right eye injury from a treble hook lure. Ophthalmic examination and imaging confirmed choroidal rupture. Initial visual acuity was 20/200 in the right eye and improved to 20/60 at 2 months postinjury. At 6 months, visual acuity declined to hand motions, and optical coherence tomography showed choroidal neovascularization (CNV). The patient underwent anti-vascular endothelial growth factor (VEGF) injection under general anesthesia. At most recent follow-up visual acuity was 20/50.

Discussion: Fishing injuries typically cause vision loss through penetrating or perforating ocular trauma. Although blunt trauma is a recognized cause of choroidal rupture and vision loss, this mechanism from a fishing lure is rarely described. Close monitoring for secondary CNV is essential, and anti-VEGF therapy can effectively reduce subretinal and intraretinal fluid, resolve hemorrhage, and treat choroidal neovascularization.

Conclusions: This case highlights the potential for blunt ocular trauma from fishing lures to cause choroidal rupture and vision loss. Preventive strategies, including eye protection and adult supervision, are critical to reduce the risk of similar injuries.

Background: Health care settings are not immune to workplace violence, and emergency department workers are especially susceptible. In 2021, Wisconsin Act 209 made it a felony to "intentionally cause bodily harm or threaten to cause bodily harm to a person who works in a health care facility." We conducted a study of emergency department workers to assess their experiences with violence and the perceived effects of Act 209.

Methods: We developed a survey for health care workers (nurses, physicians, and advanced practice providers) who were currently practicing in a Wisconsin emergency department. The reporting timeframe was March 23, 2022, through June 30, 2023.

Results: A total of 194 Wisconsin emergency department workers responded; 70.6% reported experiencing bodily harm, threats of bodily harm, or both. The median number of bodily harm incidents was 2, and 51.4% did not report these incidents. The median number of threats reported was 4, and 66.7% did not report them. Nurses experienced more threats of bodily harm than physicians. Overall, 40.2% of respondents were unaware of Act 209, and 67.6% indicated that abuse toward health care workers occurred at the same rate after its enactment as before. The most frequent barrier to reporting was "Person has a medical condition that might complicate application of the law."

Discussion: Most workers reported experiencing bodily harm or threats, and most did not report these incidents. Beyond clinical factors and time constraints, limited law enforcement bandwidth and perceptions of law enforcement as obstructive were the next most cited barriers. Only 1.2% of respondents reported feeling "definitely safer" after Act 209.

Conclusions: Violence against health care workers has become an expected consequence of working in the field. Legislative action is one tool to attempt to curb this trend. Further efforts to identify strategies that ensure the safety and wellness of health care workers should be a priority.

Introduction: Rhabdomyolysis is a common but complex medical condition that typically presents with asymptomatic muscle enzyme elevation and follows a benign course. Cases of rhabdomyolysis associated with mononeuropathy, mononeuropathy multiplex, and peripheral neuropathy are uncommon.

Case presentation: We present the case of a 28-year-old man with focal weakness of the left leg that developed after he fell to the floor and was immobilized on his left side for a prolonged length of time (ie, 6-8 hours). Further evaluation revealed rhabdomyolysis associated with unilateral sciatic neuropathy but no evidence of compartment syndrome.

Discussion: Severe cases of rhabdomyolysis, with or without compartment syndrome, can result in compressive neuropathies. We provide a detailed anatomic description of the sciatic nerve and review its associated clinical syndromes.

Conclusions: In cases of rhabdomyolysis associated with focal limb weakness that follows a myotomal distribution, compressive mononeuropathy should be considered in the differential diagnosis.

Introduction: Rural-based health care systems face unique concerns, including the struggle to recruit and retain quality clinicians. We evaluated health care providers' perceptions of their service line directors (SLDs) in the Marshfield Clinic Health System to understand how these perceptions affect job satisfaction in a rural health care setting.

Methods: Utilizing quantitative and qualitative methods, we reached out to providers within the health system, excluding SLDs to prevent bias. The survey, with a 43% response rate, encompassed 14 questions focusing on 8 domains of engagement. Data analyses included chi-squared tests, t tests, analysis of variance, and correlation matrices. To delve deeper into perceptions, a qualitative approach was employed, analyzing open-ended feedback.

Results: Of the 457 respondents, 70% reported satisfaction with their SLDs. High meeting frequencies with SLDs were positively correlated with satisfaction. The majority acknowledged the positive attributes of SLDs in domains like availability, recognition, and feedback. However, significant variations in perceptions arose between physicians and advanced practice clinicians and between surgeon and non-surgeon SLDs. Qualitative feedback elucidated themes including engagement, communication, and advocacy. Positive attributes, such as competence and proactivity, were mentioned frequently, while negatives highlighted disconnectedness and being uninformed.

Conclusions: The quality of interactions with SLDs significantly influences clinician satisfaction. Regular, meaningful interactions - especially recognizing and providing feedback - enhance satisfaction. However, certain groups like advanced practice clinicians under surgeon SLDs felt less engaged. Our findings underscore the importance of tailored leadership training for SLDs and suggest organizational strategies to boost satisfaction, potentially affecting recruitment and retention in rural health care settings.

Introduction: Tick-borne relapsing fever is a zoonotic infection caused by members of the Borrelia genus of spirochetes found predominantly in the southwestern United States.

Case presentation: A 65-year-old woman presented to a Wisconsin emergency department with a 2-day history of fevers and altered mental status after returning from a 5-week stay in Colorado. Initial labs were notable for elevated transaminases, thrombocytopenia, mild hyponatremia, mild hypokalemia, and elevated procalcitonin.

Discussion: Rapid identification of patients with tick-borne relapsing fever is essential to minimize morbidity and mortality. Peripheral blood smear - especially during a febrile episode - can serve as a quick and accurate way to diagnose the illness with direct visualization of spirochetes.

Conclusions: Early analysis of a peripheral blood smear can lead to a swift diagnosis of tick-borne relapsing fever, particularly in nonendemic states such as Wisconsin.

Introduction: Epidural lipomatosis is a relatively rare condition resulting in the accumulation of unencapsulated fatty tissue within the epidural space. Steroids, either exogenous or endogenous, have been reported as a cause for this accumulation. The diagnosis is confirmed by computed tomography or magnetic resonance imaging. Symptomatic epidural lipomatosis has been reported to present with radiculopathy, myelopathy, claudication, cauda equina syndrome, or paraplegia. It is usually managed conservatively, including weight loss and avoidance of steroids.

Case presentation: We report the case of a patient with sarcoidosis on oral prednisone who was referred for low back and leg pain of multifactorial origin. After addressing his low back pain, a fluoroscopically guided lumbar epidural steroid injection was performed for his neurogenic claudication. This provided 3 months of complete pain relief. But the patient also developed unilateral foot drop, possibly secondary to worsening epidural lipomatosis.

Conclusions: Epidural lipomatosis may result in complications that include neurological deficits. Although various disease states may cause it, prudence is advised in the use of exogenous steroids.

Introduction: Electronic cigarettes (e-cigarettes) are the most common tobacco product used by adolescents, yet no evidence-based cessation treatment for adolescents exists.

Methods: Wisconsin residents aged 13 to 17 (N = 227) completed an online survey assessing e-cigarette use, knowledge, motivations around using and quitting, and recommendations for cessation intervention content.

Results: Most of our sample never vaped (76.2%), reporting concerns with health effects and addiction as motivations preventing initiation. Among adolescents who used e-cigarettes, friend use was the main motivation for initiation, and mental health symptoms promoted ongoing use. Motivations for quitting included health harms, cost, and addiction.

Conclusions: This study identified various topics that motivate and demotivate e-cigarette use among adolescents. This information can be incorporated into prevention and treatment strategies tailored to adolescents.

Introduction: Efficient discharges lead to decreased length of stay and improved hospital flow. An efficient discharge requires timely recognition of medical readiness for discharge (MRD) and effective preparation. The objective of this study was to better understand pediatric hospital medicine discharges by (1) analyzing the time of MRD and discharge throughout the day, (2) assessing the time from MRD to discharge, and (3) categorizing commonly identified discharge delays.

Methods: A retrospective chart review of pediatric hospital medicine patients with the diagnoses of asthma, "brief resolved unexplained event," hyperbilirubinemia, or "rule out sepsis neonates" was completed. MRD was determined by reviewing the patient's chart for completion of diagnosis-specific discharge criteria. MRD was compared to the time of discharge order and discharge. Delayed discharges were reviewed further to identify reasons for the delay.

Results: One hundred discharge events were analyzed - 25 from each of the 4 selected diagnoses. MRD occurred throughout the day (33% morning, 43% afternoon, 14% evening, and 10% night). The median time from MRD to discharge was 1.7 hours (0.5 hours from MRD to discharge order and 0.9 hours from order to discharge), with the longest MRD to discharge time in asthma patients. Forty percent of patients had a delayed discharge, and identified reasons for delays were further categorized.

Conclusions: MRD occurred throughout the day, suggesting the MRD to discharge time may be an informative metric of discharge efficiency. Next steps include developing forward-facing electronic health record alerts noting MRD for improved tracking and real-time communication and targeted interventions to address reasons for discharge delays.

Introduction: Hypertension is a leading cause of morbidity and mortality worldwide. Although it is often asymptomatic, adequate blood pressure control can help decrease the risk of cardiovascular, renal, and neurologic diseases. Clinical pharmacists can play a critical role in blood pressure management and have been shown to help patients meet their goals. Despite this, patients often disengage from pharmacy services, and reasons for this are not well understood. This study sought to evaluate characteristics of patients who are referred but not engaged in a primary care pharmacy antihypertensive service and explore potential reasons for disengagement.

Methods: Data from the 2023 fiscal year (July 1, 2022 - June 30, 2023) were collected from UW Health's electronic health record. Inclusion criteria were prespecified to include adults referred by their primary care provider to pharmacy services but who did not engage in care. Retrospective chart reviews were performed to gather demographic information on this population, and descriptive statistics were used for data analysis.

Results: Of the 168 individuals who met the inclusion criteria, 66.1% of participants were not currently at their blood pressure goal. The majority of patients did not engage in pharmacist services due to lack of patient interest (n = 114, 67.9%) or being managed by another health care member team (n = 36, 21.4%).

Conclusions: The majority of patients who did not engage with a pharmacist for hypertension medication management despite referral from their primary care provider are not achieving their blood pressure goal.