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    • In general consensus patients who are refractory

    2018-11-12

    In general consensus, patients who are refractory to nonsurgical treatment are suggested to receive surgical decompression of the carpal tunnel. For the patients associated with long-term hemodialysis, some authors prefer ECTR, but the others advocate pursuing OCTR or extensive OCTR as a standard approach. Nonetheless, there is still no randomized trial or well-established guideline for treating CTS with long-term hemodialysis. Theoretically, extended OCTR may have better visualization of the median nerve, and decompression along with thorough neurolysis and synovectomy are feasible with the open approach. However, the effectiveness with or without thorough neurolysis and synovectomy for symptomatic relief of the hemodialysis-related CTS is still controversial. Some reports even mentioned that extensive synovectomy or neurolysis are not necessarily indicated for every hemodialysis-related CTS patient. Moreover, the extensive procedures may increase the risk of short-term and long-term morbidities after the operation. ECTR was first described by Okutsu et al in 1989. The authors further reported the effectiveness and safety of ECTR in hemodialysis-related CTS and yielded similar results as in idiopathic CTS. Nonetheless, evidence comparing the effectiveness between ECTR and OCTR is usually limited to Level V reports, in which a minimum of self-reported questionnaires were included for the outcomes study. The outcomes of different surgical approaches were mostly evaluated and reported by the operative surgeons. Possible observation bias in reporting a true result could not be ruled out. Therefore a standardized measurement that demonstrates reproducibility and validity is necessary. In addition to the direct response from the patients in the clinics, we also chose the self-administered questionnaire as one of our main assessment tools. Since Levine devised the CTS instrument in 1993, the application of a self-administered questionnaire has been emphasized and widely used. In this order Quercetin dihydrate study, we employed the Boston questionnaire, and we also adopted the QuickDASH, for double evaluation. Subjectively, ECTR was effective in both groups of patients, but the severity of their preoperative status, especially with advanced involvement, may compromise the objective results. In our study, hemodialysis-related patients presented inferior electrophysiological results, even though they reported the satisfactory postoperative outcome by HOS and by the self-administered questionnaires. These patients are more susceptible to compression neuropathy because of their underlying uremic polyneuropathy. Theoretically, the electrophysiological findings could be correlated to the clinical results, and perhaps it could more objectively reflect the true relief of the entrapment from CTS. Contradictory results have been reported by a few studies, suggesting that the severity of electrophysiologic findings is not parallel to the subjective symptoms, especially for mild CTS patients. Moreover, in the cases of long-term hemodialysis, proximal invasion of uremic neuropathy has been reported by some studies when hemodialysis is for longer than 10 years. Most of our patients have had hemodialysis for longer than 10 years (81.8%). Therefore, even though we conducted the surgical relief of the carpal tunnel, proximal nerve function may still be progressively impaired. Although the results from the self-administered questionnaires and the electrophysiological findings are inconsistent in these hemodialysis-related patients, it is possible to have satisfactory results in symptoms and questionnaires but with the less satisfactory electrophysiological outcome.
    Acknowledgments
    Introduction Extramammary Paget\'s disease (EMPD) is a tumor affecting mainly the genital region including the vulva, penis, scrotum, and perianal area. Most patients with EMPD have a good prognosis because the tumor cells generally extend only into the epidermis. For patients with an in situ tumor, wide local excision with a safe margin is the treatment of choice. However, a complete surgical excision is not always practical because the reported local recurrence rate is still high. Importantly, appropriate flap reconstruction after a wide local excision is needed if the tumor is very extensive. By contrast, a small proportion of EMPD is association with underlying or internal visceral carcinomaconsis. Several investigators posit the existence of primary and secondary EMPD.