Women in Hand Surgery: Leadership and Legacy.

Although women have existed in medicine and surgery for thousands of years, challenges continue to persist to date. Despite being discouraged and excluded from training, sponsorship, and opportunities, throughout the history of Hand Surgery, female surgeons have found ways to contribute significantly to science, our organizations, each other, changing the culture, and engaging the next generation of female trainees. This article integrates historical facts with oral history about Hand Surgery training, national societies, interest groups, achievements, and lived experiences to tell the history and legacy of women in Hand Surgery.

Persistence of cognitive impairment after resolution of overt hepatic encephalopathy.

BACKGROUND & AIMS: In patients with cirrhosis, hepatic encephalopathy (HE) has acute but reversible as well as chronic components. We investigated the extent of residual cognitive impairment following clinical resolution of overt HE (OHE). METHODS: Cognitive function of cirrhotic patients was evaluated using psychometric tests (digit symbol, block design, and number connection [NCT-A and B]) and the inhibitory control test (ICT). Improvement (reduction) in ICT lures and first minus second halves (DeltaL(1-2)) were used to determine learning of response inhibition. Two cross-sectional studies (A and B) compared data from stable cirrhotic patients with or without prior OHE. We then prospectively assessed cognitive performance, before and after the first episode of OHE. RESULTS: In study A (226 cirrhotic patients), 54 had experienced OHE, 120 had minimal HE, and 52 with no minimal HE. Despite normal mental status on lactulose after OHE, cirrhotic patients were cognitively impaired, based on results from all tests. Learning of response inhibition (DeltaL(1-2) > or =1) was evident in patients with minimal HE and no minimal HE but was lost after OHE. In study B (50 additional patients who developed > or =1 documented OHE episode during follow-up), the number of OHE hospitalizations correlated with severity of residual impairment, indicated by ICT lures (r = 0.5, P = .0001), digit symbol test (r = -0.39, P = .002), and number connection test-B (r = 0.33, P = .04). In the prospective study (59 cirrhotic patients without OHE), 15 developed OHE; ICT lure response worsened significantly after OHE (12 before vs 18 after, P = .0003), and learning of response inhibition was lost. The 44 patients who did not experience OHE did not have deteriorations in cognitive function in serial testing. CONCLUSIONS: In cirrhosis, episodes of OHE are associated with persistent and cumulative deficits in working memory, response inhibition, and learning.

Melanoma in Pregnancy and Pediatrics.

Rare variants of melanoma include melanoma in pregnancy and pediatric melanoma. Because of their low incidence, treatment recommendations are based on standards of treatment for cutaneous melanoma; however, each of these forms requires specific considerations during diagnosis, staging, and treatment.

Minimal hepatic encephalopathy is associated with motor vehicle crashes: the reality beyond the driving test.

UNLABELLED: Patients with minimal hepatic encephalopathy (MHE) have impaired driving skills, but association of MHE with motor vehicle crashes is unclear. Standard psychometric tests (SPT) or inhibitory control test (ICT) can be used to diagnose MHE. The aim was to determine the association of MHE with crashes and traffic violations over the preceding year and on 1-year follow-up. Patients with cirrhosis were diagnosed with MHE by ICT (MHEICT) and SPT (MHESPT). Self and department-of-transportation (DOT)-reports were used to determine crashes and violations over the preceding year. Agreement between self and DOT-reports was analyzed. Patients then underwent 1-year follow-up for crash/violation occurrence. Crashes in those with/without MHEICT and MHESPT were compared. 167 patients with cirrhosis had DOT-reports, of which 120 also had self-reports. A significantly higher proportion of MHEICT patients with cirrhosis experienced crashes in the preceding year compared to those without MHE by self-report (17% vs 0.0%, P = 0.0004) and DOT-reports (17% vs 3%, P = 0.004, relative risk: 5.77). SPT did not differentiate between those with/without crashes. A significantly higher proportion of patients with crashes had MHEICT compared to MHESPT, both self-reported (100% vs 50%, P = 0.03) and DOT-reported (89% vs 44%, P = 0.01). There was excellent agreement between self and DOT-reports for crashes and violations (Kappa 0.90 and 0.80). 109 patients were followed prospectively. MHEICT patients had a significantly higher future crashes/violations compared to those without (22% vs 7%, P = 0.03) but MHESPT did not. MHEICT (Odds ratio: 4.51) and prior year crash/violation (Odds ratio: 2.96) were significantly associated with future crash/violation occurrence. CONCLUSION: Patients with cirrhosis and MHEICT have a significantly higher crash rate over the preceding year and on prospective follow-up compared to patients without MHE. ICT, but not SPT performance is significantly associated with prior and future crashes and violations. There was an excellent agreement between self- and DOT-reports.

Utilization of excimer laser debulking for critical lesions unsuitable for standard renal angioplasty.

BACKGROUND: The energy emitted by ultraviolet laser is avidly absorbed in atherosclerotic plaques. Conceptually, it could be applied for debulking of selected atherosclerotic renal artery stenoses. We describe early experience with revascularization of critical renal artery lesions deemed unsuitable for standard renal angioplasty. Institutional Review Board permission to conduct the data analysis was obtained. METHODS: Among 130 percutaneous renal artery interventions with balloon angioplasty and adjunct stenting, there were 12 (9%) patients who underwent laser debulking prior to stenting. These patients presented with critical (95+/-3.5% stenoses) lesions (11 de novo, 1 stent restenosis) deemed unsuitable for standard renal angioplasty because of marked eccentricity and presence of thrombus. Indications for intervention included preservation of kidney function, treatment of uncontrolled hypertension, management of congestive heart failure, and treatment of unstable angina. Blood pressure and estimated glomerular filtration rate (eGFR) were measured pre- and 3 weeks post-intervention. RESULTS: A baseline angiographic stenosis of 95+/-3.5% was reduced to 50+/-13% with laser debulking. There were no laser-induced complications. Post-stenting the angiographic residual stenosis was 0%. The mean gradient across the lesions was reduced from baseline 85+/-40 to 0 mmHg. A normal post-intervention antegrade renal flow was observed in all patients. Baseline mean systolic BP of 178+/-20 mmHg decreased to 132+/-12 mmHg (P<0.0001) and mean diastolic pressure of 85+/-16 mmHg reduced to 71+/-9 mmHg (P = 0.01). A pre-intervention mean eGFR of 47.7+/-19 ml/min/1.73 m(2) increased to 56+/-20.4 ml/min/1.73 m(2) (P = 0.05) post-procedure. The interventions were not associated with major renal or cardiac adverse events. During follow-up one patient developed transient contrast-induced nephropathy. CONCLUSIONS: Debulking of select renal artery stenoses with laser angioplasty followed by adjunct stenting is feasible. Further prospective, randomized studies will be required to explore the role of debulking and laser angioplasty in renal artery revascularization.

Origin of a common trunk for the inferior phrenic arteries from the right renal artery: a new anatomic vascular variant with clinical implications.

The inferior phrenic arteries constitute a pair of important vessels, supplying multiple organs including the diaphragm, adrenal glands, esophagus, stomach, liver, inferior vena cava, and retroperitoneum. The vast majority (80-90%) of inferior phrenic arteries originate as separate vessels with near equal frequency from either the abdominal aorta or the celiac trunk. Infrequently, the right and left inferior phrenic arteries can arise in the form of a common trunk from the aorta or from the celiac trunk. We herein present three patients with a new anatomic vascular variant: a common trunk of the inferior phrenic arteries arising from the right renal artery. In one case, the left inferior phrenic branch of the common trunk provided collaterals connecting with a supra-diaphragmatic branch of the left internal mammary artery and in another with the lateral wall of the pericardium. Angiographic identification of a common trunk for the inferior phrenic arteries arising from the right renal artery is important for proper diagnosis and clinical management. The presence of this unique vascular variant can impact revascularization of the renal arteries.

Beware of the B(e)all valve: mistaken valve identity, 30-year survival, and valve replacement.

Effective management of patients after the implantation of mechanical cardiac valves includes correct recognition of each valve and its related complications. Herein, we present the case of a patient who had undergone implantation of a floating-disc Beall-Surgitool mitral valve in 1976 and developed multiple valve-related complications. Over 30 years and in multiple medical centers, the device was mistakenly assumed to be a "ball" valve. The correct identification of the prosthesis led to the recognition of valvular failure, and the patient underwent its replacement with an On-X bileaflet carbon valve. Pathologic and microscopic examination of the explanted Beall valve showed massive pannus formation that extended over the sewing cuff on the atrial and ventricular side, preventing complete disc closure; disrupted fabric coating of the sewing ring, with exposure of the underlying metal; and a marked inflammatory reaction. We report one of the longest intervals on record between the implantation and replacement of a Beall-Surgitool valve.