Epidemiologic Trends of Cleft Lip and Palate in a Southern State: A 30-Year Follow-Up.

OBJECTIVES: Children's of Mississippi at the University of Mississippi Medical Center serves as the state's only American Cleft Palate-Craniofacial Association-approved cleft team at the only pediatric hospital in the state. The goal of this study is to report geographic and demographic patterns of patients with orofacial cleft (OFC) treated at Children's of Mississippi, which are lacking. METHODS: Patients with OFC treated at Children's of Mississippi from 2015 to 2020 were included. Demographic data were collected, including birth county and total live births from state data. Significant differences between incidence of OFC among public health regions of Mississippi were examined using analysis of variance (P < 0.05). Cases were compared with historical data from 1980 to 1989. RESULTS: There were 184 patients who presented with OFC, with a statewide incidence of 0.83 per 1000 live births among 222,819 live births in the state across 6 years. The incidence of OFC was 0.83/1000 for Whites and 0.82/1000 for non-Whites versus a historical rate of 1.36 and 0.54, respectively. Significantly fewer children in the northern region (0.25/1000) were born with OFC than in central (1.21; P < 0.001) and southern (0.86; P < 0.001) regions. CONCLUSIONS: Results from this study suggest changing regional patterns of OFC in Mississippi. Although rates increased among non-White infants, the overall incidence of OFC has decreased compared with historical data. The findings may reflect actual incidence patterns in the state or the proximity of certain regions to Children's of Mississippi. Further study may reveal regional differences in risk factors underlying OFC incidence, and/or issues with access to cleft care for different regions in the state.

The Fisher Subunit Anatomical Approach for Cleft Lip Revisions: An Evolution and Case Series.

ABSTRACT: Many techniques exist to reapproximate a cleft lip but can leave unsatisfactory results with nonanatomic scars and a short upper lip, creating a need for revision. Many revisions focus on adjacent tissue transfers and realignment of landmarks, but in the senior authors' experience, recreating the defect and utilizing the Fisher repair for revision have led to aesthetically pleasing results and less noticeable scars. A database was collected that included all cleft lip revisions performed at a large, comprehensive children's hospital from October 2018 to July 2021. Inclusion criteria included any cleft patient with a cleft lip revision performed by two craniofacial surgeons. Data collected included sex, characteristics of the cleft lip, age at initial and index repair, type of initial repair, previous revisions, type of revision with any additional tissue rearrangement, and any nose repair. Sixty-five patients were included in the study for analysis. The type of initial repair was known in sixty-four cases (98%), and fifty-four were Millard repairs (83%). Twenty-two patients (33%) had a previous revision prior to their index revision. Sixty patients (92%) underwent the Fisher repair technique for their index revision and forty-six patients (70%) underwent nasal revision. In follow-up, all patients demonstrated an improvement in lip aesthetics. This study demonstrates a large subset of patients that have undergone cleft lip revision using the Fisher technique. In the senior surgeons' experience, the Fisher repair technique in the setting of cleft lip revision is an ideal way to address the shortcomings of historical repair techniques.

Longitudinal Speech and Fistula Outcomes Following Primary Cleft Palate Repair at a Single Institution.

INTRODUCTION: Fistula formation and velopharyngeal insufficiency (VPI) are complications of cleft palate repair that often require surgical correction. The goal of the present study was to examine a single institution's experience with cleft palate repair with respect to fistula formation and need for surgery to correct velopharyngeal dysfunction. METHODS: Institutional review board approval was obtained. Patient demographics and operative details over a 10-year period were collected. Primary outcomes measured were development of fistula and need for surgery to correct VPI. Chi-square tests and independent t tests were utilized to determine significance (0.05). RESULTS: Following exclusion of patients without enough information for analysis, 242 patients were included in the study. Fistulas were reported in 21.5% of patients, and surgery to correct velopharyngeal dysfunction was needed in 10.7% of patients. Two-stage palate repair was associated with need for surgery to correct VPI (P = 0.014). Furlow palatoplasty was associated with decreased rate of fistula formation (P = 0.002) and decreased need for surgery to correct VPI (P = 0.014). CONCLUSION: This study reiterates much of the literature regarding differing cleft palate repair techniques. A 2-stage palate repair is often touted as having less growth restriction, but the present study suggests this may yield an increased need for surgery to correct VPI. Prior studies of Furlow palatoplasty have demonstrated an association with higher rates of fistula formation. The present study demonstrated a decreased rate of fistula formation with the Furlow technique, which may be due to the use of the Children's Hospital of Philadelphia modification. This study suggests clinically superior outcomes of the Furlow palatoplasty over other techniques.

Locoregional Flap Reconstruction of the Distal Third of the Leg - What Role Does it Have in a Modern Reconstructive Algorithm?

ABSTRACT: Reconstruction of traumatic defects of the lower third of the leg poses a challenge due to limited locoregional options. Failed coverage can be associated with prolonged hospital stay, infection, loss of function, and unplanned return to surgery. Over the last few decades, free tissue transfer has dominated reconstructive algorithms for such defects; however, locoregional flaps may provide equally effective coverage in select patients. In the wake of the CODID-19 pandemic, locoregional flaps gained more consideration due to limited resources. We present a literature review and discussion of locoregional flaps, with emphasis on the quality and efficacy of these reconstructive modalities compared with free tissue transfer and surgical indications.Soleus flaps, reverse sural flaps, and cutaneous perforator-based flaps are workhorses for small to medium size defects of the distal third of the leg, even in the setting of concomitant orthopedic trauma and exposed vital structures. It is important to consider such alternatives an integral part of the reconstructive algorithm as they can provide durable coverage with a favorable complication profile with less resource utilization. Appropriate patient selection requires consideration of the character of the defect, smoking status, preexisting vascular disease, and the zone of injury.

Targeted temperature control following traumatic brain injury: ESICM/NACCS best practice consensus recommendations.

AIMS AND SCOPE: The aim of this panel was to develop consensus recommendations on targeted temperature control (TTC) in patients with severe traumatic brain injury (TBI) and in patients with moderate TBI who deteriorate and require admission to the intensive care unit for intracranial pressure (ICP) management. METHODS: A group of 18 international neuro-intensive care experts in the acute management of TBI participated in a modified Delphi process. An online anonymised survey based on a systematic literature review was completed ahead of the meeting, before the group convened to explore the level of consensus on TTC following TBI. Outputs from the meeting were combined into a further anonymous online survey round to finalise recommendations. Thresholds of ≥ 16 out of 18 panel members in agreement (≥ 88%) for strong consensus and ≥ 14 out of 18 (≥ 78%) for moderate consensus were prospectively set for all statements. RESULTS: Strong consensus was reached on TTC being essential for high-quality TBI care. It was recommended that temperature should be monitored continuously, and that fever should be promptly identified and managed in patients perceived to be at risk of secondary brain injury. Controlled normothermia (36.0-37.5 °C) was strongly recommended as a therapeutic option to be considered in tier 1 and 2 of the Seattle International Severe Traumatic Brain Injury Consensus Conference ICP management protocol. Temperature control targets should be individualised based on the perceived risk of secondary brain injury and fever aetiology. CONCLUSIONS: Based on a modified Delphi expert consensus process, this report aims to inform on best practices for TTC delivery for patients following TBI, and to highlight areas of need for further research to improve clinical guidelines in this setting.

Posterior Vault Distraction in the Acute Setting.

ABSTRACT: Posterior vault distraction osteogenesis (PVDO) has been shown to resolve acute intracranial hypertension (AIH) while carrying an acceptable perioperative morbidity profile. PVDO has been associated with symptomatic improvement and fewer surgeries in those requiring ventriculoperitoneal shunts. The authors' experience using PVDO as an acute intervention is presented, demonstrating its safety and efficacy for management of AIH. Four cases of children with craniosynostosis that underwent PVDO in the acute setting are outlined. All patients presented with papilledema and symptoms of AIH. One patient with slit ventricle syndrome (SVS) presented with a nonfunctioning shunt following multiple shunt revisions. No intraoperative complications during distractor placement or removal were reported. Distraction protocol for all patients began on postoperative day 1 at 1-2 mm per day, resulting in an average total distraction of 30.25 mm. For the 3 cases with no shunt, the average length of stay was 7 days. As part of the planned treatment course, the patient with SVS required externalization of the shunt during distraction followed by early distractor removal and planned shunt replacement. One case of surgical site infection (in an immunocompromised patient) required premature distractor removal during the consolidation period. Computed tomography (CT) in all patients indicated increased intracranial volume following distraction, and symptomatic improvement was reported. Six-month follow-up showed resolution of papilledema in all patients. The authors' experience using PVDO in the acute setting is reported, alongside a review of current literature, in order to provide supporting evidence for the efficacy of PVDO as a tool for resolving AIH.

"Travel Burden to ACPA Approved Cleft and Craniofacial Teams: A Geospatial Analysis".

BACKGROUND: Despite the existence of American Cleft Palate and Craniofacial Association (ACPA)-approved Cleft and Craniofacial Teams, access to multidisciplinary team-based care remains challenging for patients from rural areas, leading to disparities in care. We investigated the geospatial relationship between U.S. counties and ACPA-approved centers. METHODS: The geographic location of all ACPA-approved cleft and craniofacial centers in the U.S. was identified. Distance between individual U.S. counties (n=3,142) and their closest ACPA-approved team was determined. Counties were mapped based on distance to nearest cleft or craniofacial team. Distance calculations were combined with U.S Census data to model the number of children served by each team and economic characteristics of families served. These relationships were analyzed using independent t-tests and ANOVA. RESULTS: Over 40% of U.S. counties did not have access to an ACPA-approved craniofacial team within a 100-mile radius (n=1,267) versus 29% for cleft teams (n=909). Over 90% of counties greater than 100 miles to a craniofacial team had a population <7,500 (n=1,150). Of the counties >100 miles from a cleft team, 64% had a child poverty rate greater than national average (n=579). Counties with the highest birth rate and >100 miles to travel to an ACPA team are in the Mountain West. CONCLUSIONS: Given the time-sensitive nature of operative intervention and access to multidisciplinary care, the lack of equitable distribution in certified cleft and craniofacial teams is concerning. Centers may better serve families from distant areas by establishing satellite clinics, telehealth visits, and training local primary care providers in referral practices.

Transcranial sonography in the critical patient.

Transcranial ultrasonography is a non-invasive, bedside technique that has become a widely implemented tool in the evaluation and management of neurocritically ill patients. It constitutes a technique in continuous growth whose fundamentals (and limitations) must be known by the intensivist. This review provides a practical approach for the intensivist, including the different sonographic windows and planes of insonation and its role in different conditions of the neurocritical patients and in critical care patients of other etiologies.

Prospective Study of Ultrasound Markers of Organ Congestion in Critically Ill Patients With Acute Kidney Injury.

Introduction: Organ congestion may be a mediator of adverse outcomes in critically ill patients with severe acute kidney injury (AKI). The presence of abnormal venous Doppler waveforms could identify patients with clinically significant organ congestion who may benefit from a decongestive strategy. Methods: This prospective multicenter cohort study enrolled patients with severe AKI defined as Kidney Disease: Improving Global Outcomes stage 2 or higher. Patients were not eligible if they received renal replacement therapy (RRT) for more than 72 hours at the time of screening. Participants underwent serial Doppler ultrasound examinations of the portal, hepatic and intrarenal veins during the week following enrolment. We calculated the venous excess ultrasound (VExUS) score based on these data. The primary outcome studied was major adverse kidney events at 30 days (MAKE30) defined as death, RRT dependence, or a persistent decrease in kidney function. Results: A total of 125 patients were included for whom 291 ultrasound assessments were performed. Severely abnormal venous waveforms were documented in 14.4% of portal vein assessments, 6.5% of intrarenal venous assessments, and 14.4% of hepatic vein assessments. The individual ultrasound markers were not associated with MAKE30. The VExUS score (grade 0-1: reference; grade 2: adjusted hazard ratio [aHR]: 4.03, confidence interval [CI]: 1.81-8.99; grade 3: aHR: 2.70, CI: 1.10-6.65; P = 0.03), as well as severely abnormal portal, hepatic and intrarenal vein Doppler were each independently associated with mortality. Conclusion: Although not significantly associated with MAKE30, venous Doppler abnormalities suggestive of venous congestion were associated with higher mortality in critically ill patients with severe AKI.

Limitation of life support treatments in Spanish Intensive Care Units: Analysis of the ETHICUS II study.

OBJECTIVE: The aim of this study is to describe the results of Spanish ICUs in ETHICUS II study. DESIGN: Planned substudy of patients from ETHICUS II study. SETTING: 12 Spanish ICU. PATIENTS OR PARTICIPANTS: Patients admitted to Spanish ICU who died or in whom a limitation of life-sustaining treatment (LLST) was decided during a recruitment period of 6 months. INTERVENTIONS: Follow-up of patients was performed until discharge from the ICU and 2 months after the decision of LLST or death. MAIN VARIABLES OF INTEREST: Demographic characteristics, clinical profile, type of decision of LLST, time and form in which it was adopted. Patients were classified into 4 categories according to the ETHICUS II study protocol: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, failed cardiopulmonary resuscitation and patients with brain death. RESULTS: A total of 795 patients were analyzed; 129 patients died after CPR, 129 developed brain death. LLST was decided in 537 patients, 485 died in the ICU, 90.3%. The mean age was 66.19 years ± 14.36, 63.8% of male patients. In 221 (41%) it was decided to withdraw life-sustaining treatments and in 316 (59%) withholding life-sustaining treatments. Nineteen patients (2.38%) had advance living directives. CONCLUSIONS: The predominant clinical profile when LTSV was established was male patients over 65 years with mostly cardiovascular comorbidity. We observed that survival was higher in LLST decisions involving withholding of treatments compared to those in which withdrawal was decided. Spain has played a leading role in both patient and ICU recruitment participating in this worldwide multicenter study.

Early mobilisation in critically ill COVID-19 patients: a subanalysis of the ESICM-initiated UNITE-COVID observational study.

BACKGROUND: Early mobilisation (EM) is an intervention that may improve the outcome of critically ill patients. There is limited data on EM in COVID-19 patients and its use during the first pandemic wave. METHODS: This is a pre-planned subanalysis of the ESICM UNITE-COVID, an international multicenter observational study involving critically ill COVID-19 patients in the ICU between February 15th and May 15th, 2020. We analysed variables associated with the initiation of EM (within 72 h of ICU admission) and explored the impact of EM on mortality, ICU and hospital length of stay, as well as discharge location. Statistical analyses were done using (generalised) linear mixed-effect models and ANOVAs. RESULTS: Mobilisation data from 4190 patients from 280 ICUs in 45 countries were analysed. 1114 (26.6%) of these patients received mobilisation within 72 h after ICU admission; 3076 (73.4%) did not. In our analysis of factors associated with EM, mechanical ventilation at admission (OR 0.29; 95% CI 0.25, 0.35; p = 0.001), higher age (OR 0.99; 95% CI 0.98, 1.00; p ≤ 0.001), pre-existing asthma (OR 0.84; 95% CI 0.73, 0.98; p = 0.028), and pre-existing kidney disease (OR 0.84; 95% CI 0.71, 0.99; p = 0.036) were negatively associated with the initiation of EM. EM was associated with a higher chance of being discharged home (OR 1.31; 95% CI 1.08, 1.58; p = 0.007) but was not associated with length of stay in ICU (adj. difference 0.91 days; 95% CI - 0.47, 1.37, p = 0.34) and hospital (adj. difference 1.4 days; 95% CI - 0.62, 2.35, p = 0.24) or mortality (OR 0.88; 95% CI 0.7, 1.09, p = 0.24) when adjusted for covariates. CONCLUSIONS: Our findings demonstrate that a quarter of COVID-19 patients received EM. There was no association found between EM in COVID-19 patients' ICU and hospital length of stay or mortality. However, EM in COVID-19 patients was associated with increased odds of being discharged home rather than to a care facility. Trial registration ClinicalTrials.gov: NCT04836065 (retrospectively registered April 8th 2021).

Allograft as an Adjunct for Free Omental Flaps for Lower Extremity Coverage of a Mangled Lower Extremity.

The utility of allograft for temporary coverage of soft tissue defects is well-established, most notably in the burn literature. Its utility as an adjunct to free tissue transfer for soft tissue defects has been described, but literature on the effectiveness of this hybrid approach for lower extremity salvage is limited. We present a series of two patients who underwent lower extremity salvage using an omental free flap and allograft followed by staged split-thickness skin grafting at our institution. Patient characteristics analyzed included age, smoking status, comorbidities, mechanism of injury, wound class, and wound surface area. Endpoints included partial or complete flap loss, number of days from allograft to autograft, postoperative infection, unplanned reoperation, and successful, functional extremity salvage.  Both patients were male, ages 50 and 35, with a BMI of 31 and 19.2 kg/m2, respectively. Both were active smokers and had contaminated Gustilo IIIB wounds with areas of over 300 cm2. Both flaps had partial necrosis, averaging 6cm2, that was debrided at the planned second stage. Neither had an unplanned return to surgery, and both patients returned to ambulation.  Allograft skin as a practical and effective adjunct to omental free flap for post-traumatic lower extremity reconstruction. It can facilitate the resolution of edema and prevent flap desiccation, allowing time demarcation of partial flap necrosis and confirmation of flap viability prior to definitive skin autograft. This is particularly useful for large surface area contaminated highly irregular traumatic lower extremity wounds.

Key steps and suggestions for a promising approach to a critical care mentoring program.

In critical care medicine, where there is a demanding career with a problematic work-life balance, mentoring is an important support tool to grow professionally, creating a network of support throughout the career. The mentoring process consists of evidence-based steps to guide critical care mentors and mentees and pair them with each other according to the correct selection and matching of participants.In order to focus on the active role of a young intensivist selected as a mentee at any level and to support their success in a mentoring relationship, the NEXT Committee of the European Society of Intensive Care Medicine (ESICM) developed 2012 a mentoring program.The critical steps of the mentoring program start from establishing a policy and program objectives, passing through the selection of participants, and matching with mentors up to the definition of the personal development plan supported by checklists, worksheets, and evaluation forms. The present manuscript provides key steps and tips for a good, essential based on our experience in the ESICM NEXT-Mentoring Program so that they guide for future mentoring programs conducted by other scientific societies. In addition, we discuss common challenges and how to avoid them.

Factor Structure and Measurement Invariance of the Spanish Burnout Inventory Among Professionals Across 17 Countries and Regions.

Studies on the prevalence of burnout in professionals in service organizations who work in direct contact with the clients or users of the organization have concluded that burnout is a serious health disorder that has increased due to the COVID-19 pandemic. A significant advantage of the Spanish Burnout Inventory (SBI) over other instruments is that it provides a broader conceptualization of burnout by including feelings of guilt as a dimension of burnout to explain its development. However, the measurement invariance of the SBI across countries has not been investigated. The purpose of this study was to test the measurement invariance of the SBI among professionals across 17 countries and regions in Europe, Latin America, and Asia, and in different languages. All the countries showed a good fit to the four-factor model, except the Indian sample, which was excluded from the measurement invariance study. Using the alignment method, it was possible to verify the scalar measurement invariance of the four SBI factors across 15 countries and one Spanish region (16 samples). The comparison of estimated latent means indicates that France is the country with the lowest scores on the Enthusiasm factor and the highest scores on the negative factors (Exhaustion, Indolence, and Guilt). In contrast, the Andean countries, Colombia, Peru, and Ecuador, show the highest latent means on the Enthusiasm factor and the lowest means on the negative factors. These results support the validity of the SBI in the countries and regions in Europe and Latin America included in this study.

Venous Doppler to Assess Congestion: A Comprehensive Review of Current Evidence and Nomenclature.

Organ congestion from venous hypertension is an important pathophysiological mechanism mediating organ injury in several clinical contexts including critical illness, congestive heart failure and end-stage chronic kidney disease. However, the practical evaluation of venous congestion is often challenging at the bedside because of the limitations of traditional methods. Point-of-care ultrasound (POCUS) enables the clinician to assess venous velocity profiles during the cardiac cycle using Doppler modalities. Venous Doppler profile abnormalities at multiple sites are detected when elevated venous pressure results in hemodynamic changes within the systemic venous circulation. The detection of these abnormal Doppler profiles may identify patients with clinically significant systemic venous congestion. These patients have been reported to be at increased risk of medical complications. Improving the evaluation of venous congestion may lead to individualized treatment and improved patient outcomes. In this review, we describe the physiologic principles necessary to understand venous Doppler assessment. We also propose a nomenclature for the description of venous Doppler profiles. Finally, we provide a narrative review of the current clinical evidence related to use of venous Doppler assessment in various clinical contexts.

Eficacia de la artemisina en modelos murinos de leishmaniasis cutánea experimental causada por Leishmania amazonensis / Artemisine efficacy in murine models of experimental cutaneous leishmaniasis caused by Leishmania amazonensis

Los limitados tratamientos disponibles para enfrentar la leishmaniasis requieren el desarrollo de investigaciones para buscar nuevos agentes terapéuticos. Una estrategia recomendada es el reposicionamiento farmacológico, en el que la artemisina figura como un posible candidato. El objetivo de este estudio es evaluar las potencialidades de la artemisina en dos modelos murinos de leishmaniasis cutánea experimental. Para ello, se emplearon ratones BALB/c (susceptibles) y C57BL/6 (resistentes) infectados con Leishmania amazonensis. El tratamiento se realizó por vía oral o intralesional con cinco dosis de artemisina a 30 mg/kg cada 4 días. Se determinó el comportamiento del peso, la evolución del tamaño de la lesión y la carga parasitaria. En ambos modelos animales se observó que el tratamiento con artemisina (oral e intralesional) disminuyó el tamaño de la lesión y la carga parasitaria con respecto a los grupos infectados sin tratamiento (p 0,05). Los ratones C57BL/6 tratados por vía oral fueron los únicos capaces de controlar las lesiones hasta el final del experimento. Se demuestra la eficacia in vivo de la artemisina en dos modelos de leishmaniasis cutánea inducida por L. amazonensis y se destaca la administración por vía oral en el control de la enfermedad. Se sugiere el futuro desarrollo de este fármaco para el tratamiento de la leishmaniasis cutánea.

The limited treatments available for leishmaniasis require the development of research for new therapeutic agents. One recommended strategy is the pharmacological repositioning, where artemisinin stands out as a possible candidate. The aim of this study is to evaluate the potential of artemisinin in two murine models of experimental cutaneous leishmaniasis. For this purpose, BALB/c (susceptible) and C57BL/6 (resistant) mice infected with Leishmania amazonensis were used. Oral or intralesional treatment was performed with five doses of artemisinin at 30 mg/kg every four days. Weight behavior, evolution of lesion size, and parasitic load were determined. In both animal models it was observed that treatment with artemisinin (oral and intralesional) decreased lesion size and parasitic load with respect to the untreated infected groups (p 0.05). Orally treated C57BL/6 mice were the only ones able to control lesions until the end of the experiment. The in vivo efficacy of artemisinin in two models of cutaneous leishmaniasis induced by L. amazonensis is demonstrated and oral administration is highlighted in the control of the disease. Further development of this drug for the treatment of cutaneous leishmaniasis is suggested.

Hemodynamic management of acute brain injury caused by cerebrovascular diseases: a survey of the European Society of Intensive Care Medicine.

BACKGROUND: The optimal hemodynamic targets and management of patients with acute brain injury are not completely elucidated, but recent evidence points to important impact on clinical outcomes. We performed an international survey with the aim to investigate the practice in the hemodynamic targets, monitoring, and management of patients with acute ischemic stroke (AIS), intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH). METHODS: This survey was endorsed by the European Society of Intensive Care (ESICM). An electronic questionnaire of 76 questions divided in 4 sections (general information, AIS, ICH, SAH specific questions) was available between January 2022 to March 2022 on the ESICM website. RESULTS: One hundred fifty-four healthcare professionals from 36 different countries and at least 98 different institutions answered the survey. Routine echocardiography is routinely performed in 37% of responders in AIS, 34% in ICH and 38% in SAH. Cardiac output monitoring is used in less than 20% of cases by most of the responders. Cardiovascular complications are the main reason for using advanced hemodynamic monitoring, and norepinephrine is the most common drug used to increase arterial blood pressure. Most responders target fluid balance to neutral (62% in AIS, 59% in ICH,44% in SAH), and normal saline is the most common fluid used. Large variability was observed regarding the blood pressure targets. CONCLUSIONS: Hemodynamic management and treatment in patients with acute brain injury from cerebrovascular diseases vary largely in clinical practice. Further research is required to provide clear guidelines to physicians for the hemodynamic optimization of this group of patients.

Persistent Median Artery With a Reversed Palmaris Longus and Volar Ganglion.

Being aware of the variants of upper extremity anatomy is of utmost importance to a surgeon. This case report describes a patient who presented with two separate wrist masses. Operative exploration was planned, and both the structures were investigated. The distal mass was identified as a volar wrist ganglion, and the more proximal mass was identified as the muscle belly of a reversed palmaris longus muscle. Incidentally, it was noted that the patient had a patent, persistent median artery. Although many variants of the palmaris longus have been described, as have been cases of a persistent median artery, both have not been previously documented in a single patient. Although this is rare, having knowledge of possible anatomic variations is valuable for any surgeon operating on the upper extremity.