Morton Hospital

See the Reply by Dzeng et al.

INTRODUCTION Foot care nursing, like all specialty areas, has unique terminology. Some terms referring to the toenails can appear deceivingly simple. Developing mastery of nail-specific terminology is a key to understanding and correctly answering certification examination questions. When preparing for the WOCNCB foot care certification examination, knowledge and mastery of foot care terminology and nail care are a first step and are listed as a critical area on the WOCNCB foot care examination content outline under Domain 1, Task 2 (www.wocncb.org). Breaking down terms into their components is a practical way to mastering terminology that may be helpful for examination preparation. Understanding the base components of a term can help determine meaning and aid in choosing the correct answer option. Look at the prefix, the root, and the suffix of a word. Prefixes and suffixes commonly encountered in nail care include “onych” and “onycho,” which simply mean pertaining to the nail.1 Another commonly used root word is “ungula.” An example commonly encountered is the descriptor subungual, which means under the nail. The presence of these prefixes or suffixes should alert the test taker that the question refers to the nails. Nail pathology, which is part of the WOCNCB foot care certification examination, is often defined using these same prefixes/suffixes. Consider 3 common nail abnormalities, onychocryptosis, paronychia, and onychomycosis. Onchocyrptosis refers to an ingrown nail.2 The prefix “oncho” means nail, “crypto” means hidden or behind, and the final suffix “sis” simply means a condition. Combining the etymologic components of this term informs the test taker that the nail has grown under surrounding nail tissue and is hidden. A question that asks about paronychia is asking about an infection of soft tissue surrounding the nail. The prefix “par” refers to beyond, the root “onych” indicates a nail, with “ia” on the end of the word meaning condition. If the word onychomycosis appears in a question-answer option, the symptoms listed in the stem should be consistent with a fungal infection of the nail. The root of the word is “onycho,” referring to the nail and suffix “mycosis” means disease by a fungus. Each of the sample questions in this Getting Ready for Certification employs language specific to toenails. The rationales of each question will explain how to improve your test-taking skills by breaking apart the terminology used in order to choose the correct answer. PRACTICE QUESTIONS 1. The foot care nurse should describe the distal margin of superficial skin extending over the base of the toenail as: subungual periungual perionychium eponychium Content Outline: Domain 1, Task 2, 010204 Cognitive Level: Knowledge Answer D: Rationale: The correct answer is eponychium. The question stem asks about tissue surrounding the nail that extends over the base of the nail. All of the answer options have a word root that refers to the nail, “onychium” and “ungual.” To best answer the question, the prefix of each term needs to be identified and defined. The prefix “sub” refers to under the nail and the prefix “peri” refers to around the nail. The options that use these prefixes are thus not correct. Only the correct answer option, eponychium, with its prefix “ep” meaning over, refers to the skin covering the root of the nail. Cuticle is another name for the eponychium. 2. A certified foot care nurse is caring for a patient with onychocryptosis. Where on the toes should the nurse expect to see a deviation from normal? Subungual area Periungual area Perionychium Eponychium Content Outline: Domain 1, Task 2, 010204 Cognitive Level: Application Answer B: Rationale: To answer this question, the test taker should first define the term “onychocryptosis.” The prefix of the term tells the test taker that this is nail pathology and the root “crypto” meaning hidden or buried. Onychocryptosis is a nail deformity where the lateral nail curves inward into adjacent tissue, causing pain, inflammation, and (in some cases) infection. It is commonly referred to as an ingrown toenail. All of the answer options refer to different parts of the nail and the toe that would be part of the foot care nurse's assessment. Subungual assessment would look at what is underneath the nail plate, and periungual is assessment of tissue around the nail. Assessment of the perionychium required inspection of the skin that overlays the nail plate on the sides. Assessment of the eponychium requires inspection of the base of the nail, also known as the cuticle. The correct answer reflects the pathology consistent with onychocryptosis, periungual inflammation, or inflammation around the nail. 3. A homeless person presents at the foot screening clinic and reports being unable to keep the nails trimmed. Assessment reveals thickened yellow toenail that has curved lateral, causing irritation on the adjacent toe. What nail condition is most likely? Pes planus Onychogryphosis Hallux valgus Onycholysis Content Outline: Domain 2, Task 4, 020402 Cognitive Level: Analysis Answer B: Rationale: The question stem asks about a nail condition. A review of the answer options shows that only 2 options relate to toenails. Hallux valgus is a common condition of the toes but not the nails. It is an outgrowth of the first metatarsophalangeal joint (big toe and the foot) most commonly called a bunion. Pes planus, frequently referred to as flat foot, is characterized by foot pain on the back of the heel or bottom of the foot. There are 2 options that refer to toenails identified by use of the prefix “onycho.” Onychogryphosis is characterized by thickened, curved nails that appear claw-like or like a curved ram's horn. The root of the word “grypho” refers to curving. A major risk factor to onychogryphosis is inadequate nail care. Onycholysis describes a nail that has lifted from its bed and has an irregular border between the pink portion of the nail and the white outside edge of the nail. A greater portion of the nail is opaque, either whitened or discolored to yellow or green. The nail is usually smooth. Onycholysis has many possible causes that range from systemic diseases, dermatologic conditions, mechanical trauma, and drug-associated nail changes. A careful reading of the question stem reveals that the patient is homeless and unable to adequately trim the toenails. Based upon the information available in the answer stem, onychogryphosis is the most accurate answer. 4. Assessment of the foot of a 52-year-old woman with diabetes mellitus reveals a thickened, brittle, discolored nail on the second toe. After trimming the nails, the foot care nurse reviews the assessment with the health care provider and microscopic evaluation of nail scrapings is ordered to confirm the diagnosis of: hyperkeratosis onychopathy onychomycosis onychocryptosis Content Outline: Domain 2, Task 4, 020402 Cognitive Level: Application Answer C: Rationale: All answer options refer to toenail conditions. Three of the 4 answer options include the prefix “onycho” that clearly identifies these answer options as pertaining to the nail. “Hyperkeratosis” is a general term that describes the process behind thickened nails. “Onychopathy” is another general term that refers to any nail condition. When answering certification examination questions, it is best to look for the answer option that is the most specific to the details given in the question stem. The question stem describes a thickened, brittle, and discolored nail. Onychocryptosis is commonly known as an ingrown toenail and does not match the description given in the stem and since it is not an infectious condition, it does not require scrapings to best define treatment. The only nail condition listed that is consistent with the description in the question stem and would require microscopic evaluation of nail scrapings prior to systemic treatment would be onychomycosis. Onychomycosis is a nail fungal disease caused by dermatophytic fungi, nondermotophyic fungi, or yeast. The treating clinician may be considering both topical and systemic treatments to best penetrate the hyperkeratotic layers of the affected nail.

Author Affiliation: Director, Patient Care Services, Morton Hospital and Medical Center, Taunton, Massachusetts.FigureCorrespondence: Morton Hospital and Medical Center, 88 Washington St, Taunton, MA 02780 ([email protected]).

To assess the association of cardiovascular autonomic balance with perceived functional impairment and pain among patients with chronic low back pain. A cross-sectional analysis of working patients with chronic low back pain. Forty-six consecutive patients aged 24-45 years with chronic low back pain fulfilling the inclusion criteria. A total of 39 subjects had technically acceptable electrocardiographic recordings during periods of rest and standard provocations. Perceived functional disability was assessed with the Oswestry disability index and pain with a numerical rating scale. Autonomic nervous function was assessed by measuring heart rate variability with short recordings. The total power of heart rate variability was lower among those with moderate perceived disability (Oswestry 20-40%) compared with those with minimal disability (Oswestry < 20%). However, heart rate variability did not differ significantly among those with numerical rating scale values < or = 5/10 from those with values > 5/10. The power of the high-frequency component (0.15-0.4 Hz) of heart rate variability was lower among those with moderate perceived functional impairment. A significant association existed between heart rate variability and perceived physical impairment, but not between heart rate variability and pain. Proportionally reduced high-frequency activity was found to reflect decreased parasympathetic activity or increased sympathetic activity. This resulted in sympathetic dominance among the patients with higher subjective disability. The possible clinical implications of this observation are discussed.

To evaluate whether the COL9A3 tryptophan allele (Trp3 allele) is associated with a specific radiologic phenotype among patients with sciatica. One hundred fifty-three patients with sciatica were evaluated for the presence of Trp3 allele, Scheuermann disease, intervertebral disk degeneration, Schmorl nodules, dorsal anular tears, hyperintense lesions, and endplate degeneration on sagittal T2-weighted lumbar magnetic resonance images. The Trp3 genotype was determined by means of sequencing the COL9A3 gene. Radiologic phenotypes were evaluated while blinded to the genotype. Scheuermann disease was diagnosed if either endplate irregularities or Schmorl nodules and two of the other three criteria (disk space narrowing, disk dehydration, and wedging of anterior vertebral body margins) were present at three or more adjacent disk levels from T10-11 to L3-4. Disk degeneration was evaluated separately for each disk (T11-12 to L5-S1) and for all disks combined. Frequencies of radiologic phenotypes between individuals with or without Trp3 allele were compared. Thirty-four patients had at least one Trp3 allele. When compared with the matched control subjects, they had an increased likelihood of Scheuermann disease (P =.035) and an increased number of degenerated disks from T11 to S1 (P =.021). Comparisons at individual disks showed a statistically significant increase in disk degeneration at T11-12 (analysis of all grades of degeneration [graded], P =.018; analysis of any degeneration vs none [dichotomous], P =.039) and L4-5 (graded, P =.011; dichotomous, P =.016). Prevalences of anular tears, endplate degeneration, Schmorl nodules, and hyperintense lesions were comparable. The results of this study indicate that the presence of Trp3 allele is associated with Scheuermann disease and intervertebral disk degeneration. No associations were found for other radiologic phenotypes.

It is well established that the anatomical correlations between brain and skull are very poor and so variable as to made precise topometry difficult and doubtful. Thus, all exact topographical measurement of brain structures requires a careful choice of reliable anatomical reference points. Therefore, any precise topographical analysis of brain structures ought to be performed according to judicious and definite cerebral reference lines based on cutaneous, cranial as well as brain landmarks (Tamraz and Comair).