Today I tried to arrange an MRI for one of my elderly patients. She had foraminal stenosis with bad sciatic pain, as was confirmed by a CT scan that took 3 months to get and an EMG that took 2 months. The orthopod refuses to see her without an MRI in hand, and so onto an MRI waiting list she goes. She doesn't have insurance nor the $750 it would cost to go privately. The hospital waiting list for such a non-urgent case will be at least six months, more likely nine. So she'll wait.
It's common knowledge that carpal tunnel syndrome (CTS) is significantly more frequent among patients with diabetes, hypothyroidism, and connective tissue disease (CTD). For this reason, we're all taught to screen CTS patients for these diseases, especially if the condition is bilateral. A recent study in the Journal of Neurology Neurosurgery and Psychiatry asked whether this approach is really justified. Rijk et al. studied 516 CTS patients retrospectively to see if any of the abovementioned diseases was diagnosed by blood testing done at the time of CTS diagnosis.
Of 432 patients with no prior history of diabetes, 10 patients had raised glucose, but subsequent testing confirmed the diagnosis in only 2 patients. Of 468 patients with no history of thyroid disease, 9 patients had an abnormal TSH, but only 2 actual cases were confirmed. In 472 patients with no history of CTD, 40 patients were found to have an elevated ESR but no cases of any CTD were made.
The PPV of CTS for diabetes was .5%, and 216 patients had to be tested for each diagnosis made. For hypothyroidism the PPV was .4%, and 234 patients were tested for each case found.
Overall a rather meagre success rate given that the prevalence of the diseases in the general population is about 4% for diabetes and 9% for hypothyroidism. The false positive rate was rather high as well which ran up the costs because of follow-up testing. The authors put it at about 1400 Euros to make a single diagnosis of hypothyroidism and about 350 Euros per case of diabetes. They didn't do any further calculations on CTD because none were found and because they probably realized how dumb it was in the first place to look for them based on an ESR.
Seriously now, how hard can it be to decide on the spelling of this common medical condition. Both terms are used interchangeably in the medical and lay literature which would suggest that both are okay, but really, should we really be tossing vowels about willy-nilly as if it doesn't matter. I can't think of any other inflammatory diseases that have two spellings, and for good reason. If proctitis was spelled prictitis we might be scoping the wrong organ. Gingovitis sounds like a hip hopper with gum disease. Rhinitis becomes rhonitis and now we're talking about two different river systems altogether aren't we. It makes no sense. I suggest we decide once and for all, here and now. But which way is best.
Some months ago I considered posting about the strange association between quinolone antibiotic use and tendon rupture. I had seen a case of achilles tendon rupture with a tenuous link to previous antibiotics and wanted to get a better handle on the numbers. The literature on the subject was, however, sketchy at best. I did come away with the vague notion that the risk with quinolones of tendon rupture was about four to five times the norm, about 10-15/100,000 treated. This risk increased significantly in patients over sixty, and even more so in corticosteroid treated patients. The whole endeavour was rather unsatisfying though because, aside from the dubious numbers, the pathophysiology question remained a complete mystery. Pathology shows nothing exceptional, no different from your run-of-the-mill tendon damage. How could an antibiotic snap a tendon within days of treatment. Anyway, I canned the idea of blogging on the subject until more illuminating data surfaced.
I recently sent one of my patients for an evaluation at the pain clinic of one of our university hospitals. Apparently the interview did not go well. The consultation letter sent back to me included the following paragraph:
I'm waiting for it to all fall apart. I know it's going to happen some day.