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loma) or thickening of connective tissue in rheumatoid arthritis, acromegaly, amyloidosis, mucopolysaccharidosis, and hypothyroidism are less commonly identi ed causes. It is not uncommon for the condition to make its appearance during pregnancy. In elderly individuals, the cause of the carpal tunnel syndrome is often not apparent. According to Kremer and colleagues, it was McArdle, in 1949, who rst suggested that the cause of this syndrome was a compression of the median nerve at the wrist and that the symptoms would be relieved by division of the exor retinaculum forming the ventral wall of the carpal tunnel. Dysesthesias and pain in the ngers, referred to for many years as acroparesthesiae and attributed to cervical ribs, came to be recognized as a syndrome of median nerve compression only in the early 1950s. The syndrome is essentially a sensory one; the loss or impairment of super cial sensation affects the palmar aspect of the thumb, and the index, and middle ngers (especially the index nger) and may or may not split the ring nger (splitting does not occur with a plexus or root lesion). The paresthesias are characteristically worse during the night. As pointed out in Chap. 11, the pain in carpal tunnel syndrome may radiate into the forearm and even into the region of the biceps and rarely to the shoulder. Weakness and atrophy of the abductor pollicis brevis and other medianinnervated muscles occur in only the most advanced cases of compression. Electrophysiologic testing con rms the diagnosis by demonstrating prolonged sensory conduction across the wrist and explains cases in which operation has failed (see also the review by Stevens). Several provocative tests are useful. The Phalen maneuver consists of hyper exion of the wrist for 30 to 60 s usually performed by opposing the outer surfaces of the hands with the wrists exed. The Tinel sign is elicited by lightly tapping the volar aspect of the wrist at the transverse carpal ligament (distal to the rst wrist crease). Both of these tests are meant to elicit pain or paresthesias over the digits innervated by the median nerve. The sensitivity of these tests is close to 50 percent but their speci city is considerably higher. Other tests involving prolonged pressure over the median nerve have been devised but they are of uncertain value, e.g., Durken s test of the Phelan maneuver combined with digital compression of the nerve. Treatment Surgical division of the carpal ligament with decompression of the nerve is curative but is required only in severe and protracted cases. Splinting of the wrist, to avoid exion, almost always relieves the discomfort but denies the patient the full use of the hand for some time. It is a useful temporizing measure, however, as is the injection of hydrocortisone into the carpal tunnel. Studies of oral corticosteroids have given con icting results. Treatment of an underlying condition such as arthritis, hypothyroidism, possibly diabetes, is often helpful. Some patients have bene ted, paradoxically, from the stopping of corticosteroids or estrogen. Also, some practitioners favor the use of nonsteroid anti-in ammatory medication but we have been generally unimpressed with the results. Most often, splinting and local steroid injections are very satisfactory in the short-term, especially if the symptoms are of recent onset. Another less common site of compression of the median nerve is at the elbow, where the nerve passes between the two heads of the pronator teres, or just above that point behind the bicipital aponeurosis. It gives rise to the pronator syndrome, in which forceful pronation of the forearm produces an aching pain (see Table 468). There is weakness of the abductor pollicis brevis and opponens muscles and numbness of the rst three digits and palm.
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Most college and university faculty members can be categorized into four academic ranks: professor, associate professor, assistant professor, and instructor. These positions are usually considered to be tenure-track positions. A small number of faculty members, called lecturers, are not usually on the tenure track. According to the 2006 NAAB study, architecture faculty members have the following average annual earnings:
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