Introduction: Carpal tunnel syndrome (CTS) is the most common peripheral nerve entrapment seen within the outpatient orthopaedic clinic; therefore assessment and management of this common condition is of significant importance. Traditionally diagnosis has been made through detailed questioning; clinical examination and nerve conduction studies (NCS). There is however no true consensus as to the gold standard assessment of CTS and the use of NCS can confer additional costs and delay treatment. Previous studies have explored methods of predicting the presence of CTS including the clinician-administered Carpal Tunnel Questionnaire (CTQ) (Kamath and Stothard, 2003). The aim of the present studies is therefore to explore the versatility of the CTQ to see how a novel Patient-completed Version of the CTQ compares to the original Clinican-completed version. Psychometric properties of the questionnaire will be explored together the economic impact of integrating both versions within an orthopaedic care pathway. A further aim is to answer whether the CTQ more effective and cost-effective than NCS for patients referred to an orthopaedic clinic with suspected CTS. Method: 100 patients referred for further investigation of suspected CTS were assessed using parallel patient and clinician-completed versions of the CTQ and results were subsequently compared with those obtained from NCS. Item analysis explored each of the nine constructs of the questionnaire and the original scoring algorithm was validated using binary logistic regression and compared with alternative algorithms. Sensitivity and specificity of the questionnaire when compared to results of NCS was explored using Receiver Operating Characteristic (ROC) analyses. Inter-rater reliability was explored through Pearson’s correlation coefficient. Economic analysis and modelling was carried out to explore potential cost savings of use of the questionnaire rather than NCS for those with suspected CTS. Results demonstrated sensitivity of 92% and specificity of 54.67% (positive predictive value 95.35%) for the patient-completed questionnaire and 96% sensitivity with 70.67% specificity (98.15 positive predictive value) for the clinician-completed questionnaire when used to predict the outcome of NCS. Binary logistic regression confirmed the original scoring algorithm and a revised algorithm did not significantly improve sensitivity. Adoption of the clinician-completed CTQ would have screen out 54% of referrals for NCS, which in the case of the study site would have conferred cost savings of £73,305 per annum (base upon a referral rate of 750 per annum). The patient-completed CTQ in the current sample resulted in 43% of referrals with suspected CTS not requiring NCS to assist in diagnosis with a potential saving of £58,372.5 per annum. There are further considerations of the reduction in waiting times, which are explored further within the analysis. Conclusion: Economic evaluation is complex due to the variety of pathways adopted by different orthopaedic departments. While the results of the Patient-complete version of the CTQ may not be as convincing as the clinician completed the study does provide validation for its use and expands the versatility of this useful adjunct to the assessment of CTS. Both versions could potentially confer significant cost savings and reduce demands on investigative services, reducing waiting times and improving the patient journey in suspected CTS.

Orientador: Humberto Santo Neto / Tese (doutorado) - Universidade Estadual de Campinas, Instituto de Biologia / Made available in DSpace on 2018-08-18T14:45:14Z (GMT). No. of bitstreams: 1 Luz_MarcusAlexandreMendes_D.pdf: 10387090 bytes, checksum: fb422b3999d7ad8433ea938ee8b28b9f (MD5) Previous issue date: 2011 / Resumo: A região carpal anterior apresenta dois túneis delimitados por tecido fibroso: o túnel do carpo e o túnel ulnar. A importância clínica e cirúrgica dessa região está diretamente ligada às síndromes de compressão nos túneis do carpo e ulnar, comprometendo a função motora. Contudo, a abordagem clínica, tanto para diagnóstico como para o tratamento dessas lesões baseia-se em dados anatômicos de indivíduos adultos, sendo escassas as descrições em crianças. Assim sendo, o presente trabalho tem por objetivo descrever anatomicamente e histologicamente o túnel do carpo e o túnel ulnar em crianças. Foram analisadas 33 mãos de crianças de 2 a 11 anos de idade sem identificação de sexo, provenientes do Laboratório de Anatomia Humana do Departamento de Anatomia, Biologia Celular e Fisiologia e Biofísica do Instituto de Biologia da UNICAMP. Uma amostra de sete peças foi submetida à técnica de ressonância magnética e dissecadas, 14 foram dissecadas e 12 destinadas à histologia. A análise histomorfométrica das estruturas em secção transversal revelou que 58,1% da área do túnel do carpo é ocupada pelos tendões dos músculos flexores superficial e profundo dos dedos, tendão do músculo flexor radial do carpo e tendão do músculo flexor longo do polegar, sendo que 12,1% dessa área é ocupada pelo nervo mediano. Nos dados obtidos das imagens por ressonância magnética, observou-se que o nervo mediano pode assumir duas posições no túnel do carpo: lateral (71,4%) e mediana (28,5%). O túnel ulnar revelou localização palmar, e em 93,8% dos casos observou-se que o limite inferior desse túnel se constitui do retináculo dos músculos flexores e do hâmulo do hamato. Em 16% das amostras analisadas observou-se a artéria acompanhante do nervo mediano persistente, ocupando 1,1% da área do canal do carpo. Em 41,6% das amostras, a densidade de volume de tecido conjuntivo não variou na área de túneis do carpo com maior e menor dimensão, independente do espaço ocupado pelos componentes tendinosos nesse compartimento. De acordo com os dados obtidos, podemos concluir que a anatomia dos componentes neurovasculares dos túneis do carpo e ulnar em crianças apresentam particularidades em relação aos descritos em adultos e devem ser consideradas nas intervenções cirúrgicas / Abstract: The anterior carpal region has two tunnels limited by fibrous tissue: the carpal tunnel and the ulnar tunnel. The clinical and surgical importance of this region is related to the carpal and ulnar tunnel syndromes, both able to impair motor and sensitive functions. The diagnosis and clinical approach to treat these syndromes are mainly based on anatomical features of the tunnels in adults. In children, little is known about the anatomy of these tunnels. In the present study, we describe the anatomy and histology of the carpal and ulnar tunnels in children. Thirty-three hands from children between ages 2 and 11 were studied. Seven samples were submitted to magnetic resonance and dissected; 14 samples were dissected and 12 processed to histology. The histomorphometric analysis in transversal sections showed 58.1% of the areas of the carpal tunnel are occupied by tendons of both superficial and deep flexor muscles of the fingers, by the tendon of the carpal radial flexor muscle and the tendon of the long flexor muscle of the thumb. The median nerve occupied 12.1% of the tunnel area. Magnetic resonance analysis showed that the median nerve was positioned either lateral (71,4%) or median (28,5%) in the carpal tunnel. The ulnar tunnel revealed a palmar location and 93.8% of the samples the inferior limit of the ulnar tunnel was made by the retinaculum of flexor muscles and of the hook of the hamate. In 16% of the samples, an accompanying artery of the median nerve persisted, occupying 1.1% of the area of the carpal tunnel. In 41,6% of the samples the density of the volume of the conjunctive tissue did not change in relation to the dimensions of the carpal tunnel or in relation to the space occupied by the tendons. According to these data, we concluded that the anatomy of the neurovascular components of carpal tunnel and ulnar tunnel in children have individual in relation to those described in adults and these differences may be of relevance to perform safer surgical approaches to the treatment of carpal and ulnar tunnel syndromes / Doutorado / Anatomia / Doutor em Biologia Celular e Estrutural

Muscarinic ligand binding sites in fragments of rat hypothalamus and pituitary were studied using [3H]quinuclidinyl benzilate (QNB). In the hypothalamus, the highest amount of specific QNB binding was to n. paraventricularis and n. dorsomedialis. Specific QNB binding in other hypothalamic regions varied within a relatively narrow range. Fragments of whole pituitary also bound QNB but to a much smaller degree than brain. Pituitary binding of QNB was blocked by atropine but not by hexamethonium or d-tubocurarine. Within the pituitary, specific QNB binding to posterior pituitary was three times greater than to anterior pituitary. These findings are consistent with the operation of cholinergic mechanisms in hypothalamic and pituitary function.

A plot that includes multiple location and spread statistics can provide useful information about the shape of a distribution, not only with respect to location and variability but also with respect to skewness and kurtosis. We propose a plot containing the interquartile range, mean absolute deviation, standard deviation, and range of a dataset. The comparison of the spread statistics gives information about kurtosis and the comparison of the location statistics gives information about skewness. After the distribution has been divided into two parts by the median, the interquartile range can be thought of as the distance between the medians in each half of the distribution. We explain how the mean absolute deviation with respect to the median can similarly be visualized as half the distance between the means in each half of the distribution. An R function to produce the polyplot is available as an online supplement.

A new confidence interval for the coefficient of dispersion (mean absolute deviation from the median divided by median) is proposed and is shown to perform better than the BCa bootstrap confidence interval.

The small-sample bias and root mean squared error of several distribution-free estimators of the variance of the sample median are examined. A new estimator is proposed that is easy to compute and tends to have the smallest bias and root mean squared error.

This thesis explores the origins of the International Meridian Highway, now U.S. Highway 81, from its naissance in 1911 until the late 1920s. In these two decades, regional boosters in the middle of the United States joined a national movement, the Good Roads Movement, to promote new, democratic understandings of space and geography. The boosters of the International Meridian Highway promoted their road as a “Main Street of North America,” centering the focus of both movement and activity through the middle of the United States. While these boosters were successful in developing and promoting their highway, ultimately they became victims of their own success. As the fervor for highways spread, the United States government took control of road development and the International Meridian Highway Association faded into obscurity. However, their actions as boosters still mark a significant movement in self-promotion of middle America.

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As a branch of statistics, functional data analysis (FDA) studies observations regarded as curves, surfaces, or other objects evolving over a continuum. Although one has seen a flourishing of methods and theories on FDA, two issues are observed. Firstly, the functional data are sampled from common time grids; secondly, methods developed only for univariate functional data are challenging to be applied to multivariate functional data. After exploring model-based fitting for regularly observed multivariate functional data, we explore new visualization tools, clustering, and multivariate functional depths for irregularly observed (sparse) multivariate functional data. The four main chapters that comprise the dissertation are organized as follows. First, median polish for functional multivariate analysis of variance (FMANOVA) is proposed with the implementation of multivariate functional depths in Chapter 2. Numerical studies and environmental datasets are considered to illustrate the robustness of median polish. Second, the sparse functional boxplot and the intensity sparse functional boxplot, as practical exploratory tools that make visualization possible for both complete and sparse functional data, are introduced in Chapter 3. These visualization tools depict sparseness characteristics in the proportion of sparseness and relative intensity of fitted sparse points inside the central region, respectively. Third, a robust distance-based robust two-layer partition (RTLP) clustering of sparse multivariate functional data is introduced in Chapter 4. The RTLP clustering is based on our proposed elastic time distance (ETD) specifically for sparse multivariate functional data. Lastly, the multivariate functional integrated depth and the multivariate functional extremal depth based on multivariate depths are proposed in Chapter 5. Global and local formulas for each depth are explored, with theoretical properties being proved and the finite sample depth estimation for irregularly observed multivariate functional data being investigated. In addition, the simplified sparse functional boxplot and simplified intensity sparse functional boxplot for visualization without data reconstruction are introduced. Together, these four extensions to multivariate functional data make them more general and of applicational interest in exploratory multivariate functional data analysis.

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