Hypothenar hammer syndrome: proposed etiology.

PURPOSE: Finger ischemia caused by embolic occlusion of digital arteries originating from the palmar ulnar artery in a person repetitively striking objects with the heel of the hand has been termed hypothenar hammer syndrome (HHS). Previous reports have attributed the arterial pathology to traumatic injury to normal vessels. A large experience leads us to hypothesize that HHS results from trauma to intrinsically abnormal arteries. METHODS: We reviewed the arteriography, histology, and clinical outcome of all patients treated for HHS in a university clinical research center study of hand ischemia, which prospectively enrolled more than 1300 subjects from 1971 to 1998. RESULTS: Twenty-one men had HHS. All had occupational (mechanic, carpenter, etc) or avocational (woodworker) exposure to repetitive palmar trauma. All patients underwent upper-extremity and hand arteriography, unilateral in eight patients (38%) and bilateral in 13 patients (62%). By means of arteriogram, multiple digital artery occlusions were shown in the symptomatic hand, with either segmental ulnar artery occlusion in the palm or characteristic "corkscrew" elongation, with alternating stenoses and ectasia. Similar changes in the contralateral asymptomatic (and less traumatized) hand were shown by means of 12 of 13 bilateral arteriograms (92%). Twenty-one operations, consisting of segmental ulnar artery excision in the palm and vein grafting, were performed on 19 patients. Histology was compatible with fibromuscular dysplasia with superimposed trauma. Patency of arterial repairs at 2 years was 84%. One patient (5%) required amputative debridement of necrotic finger tips. No other tissue loss occurred. There have been no recurrences of ischemia in patients with patent bypass grafts. CONCLUSION: To our knowledge, this is the largest reported group of HHS patients. The characteristic angiographic appearance, histologic findings, and striking incidence of bilateral abnormalities in patients with unilateral symptoms lead us to conclude that HHS occurs when persons with preexisting palmar ulnar artery fibrodysplasia experience repetitive palmar trauma. This revised theory for the etiology of HHS explains why HHS does not develop in most patients with repetitive palmar trauma.

Raynaud's syndrome in workers who use vibrating pneumatic air knives.

PURPOSE: The use of vibrating tools has been shown to cause Raynaud's syndrome (RS) in a variety of workers, including those who use chain saws, chippers, and grinders. The diagnosis of RS in workers who use vibrating tools is difficult to document objectively. We studied a patient cohort with RS caused by the use of a vibrating pneumatic air knife (PAK) for removal of automobile windshields and determined our ability to document RS in these workers by means of digital hypothermic challenge testing (DHCT), a vascular laboratory study that evaluates digital blood pressure response to cooling. METHODS: Sixteen male autoglass workers (mean age, 36 years) with RS were examined by means of history, physical examination, arm blood pressures, digital photoplethysmography, screening serologic studies for underlying connective tissue disorder, and DHCT. RESULTS: No patient had RS before they used a PAK. The mean onset of RS (color changes, 100%; pain, 93%; parathesias, 75%) with cold exposure was 3 years (range, 1.5 to 5 years) after initial PAK use (mean estimated PAK use, 2450 hours). Fifty-six percent of workers smoked cigarettes. The findings of the physical examination, arm blood pressures, digital photoplethysmography, and serologic testing were normal in all patients. At 10 degrees C cooling with digital cuff and patient cooling blanket, a significant decrease in digital blood pressure was shown by means of DHCT in 100% of test fingers versus normothermic control fingers (mean decrease, 75%; range, 25% to 100%; normal response, less than 17%; P <.001). The mean follow-up period was 18 months (range, 1 to 47 months). No patient continued to use the PAK, but symptoms of RS were unchanged in 69% and worse in 31%. CONCLUSION: PAK use is a possible cause of vibration-induced RS. The presence of RS in workers who use the PAK was objectively confirmed by means of DHCT. Cessation of PAK use in the short term did not result in symptomatic improvement.

Relationships between operative approaches and outcomes in esophageal cancer.

BACKGROUND: Controversy exists whether patients with esophageal carcinoma are best managed with Ivor-Lewis (IL) or transhiatal (TH) esophagectomy. The TH approach is presumed to be superior with respect to operative time, leak rates, morbidity/mortality, and length of stay (LOS), but may represent an inferior cancer operation compared with formal IL. Accordingly, we reviewed the results of our esophageal resections to compare these outcome parameters for each operative approach. METHODS: We performed a retrospective review of all esophagectomies performed at Oregon Health Sciences University and Portland Veterans Affairs Medical Center between 1987 and 1996. Survival was determined by the Kaplan-Meier method, and comparisons between the IL and TH groups were made with Student's t test, Fisher's exact test, and log-rank analysis. RESULTS: Seventy-eight patients were identified. Forty patients had IL and 38 had TH. Fifty-eight patients had adenocarcinoma, 19 had squamous cell, and 1 had an unknown histology. Mean operative time was 389 minutes for IL versus 275 minutes for TH (P = 0.0001). Leak rates were 7.5% for IL and 13% for TH (P = 0.21). There were no significant differences between IL and TH with respect to other types of complications, operative deaths, blood loss, need for transfusion, LOS, stricture rates, or need for dilatation. Overall mean survival was 12 months. Mean survival rates were 8 months for IL and 12 for TH (P = NS), and were also equivalent when compared by histology and stage for stage. CONCLUSIONS: We conclude that IL and TH are comparable operations with equivalent survival rates. The TH approach did not decrease the incidence of complications, transfusions, leaks, strictures, or subsequent dilatations. Although TH requires less operating room time, this does not translate into a decrease in LOS. Either approach appears to be acceptable depending on surgeons' preferences and appropriate patient selection.

Adaptive air travel transportation systems for persons with disabilities.

The Air Carrier Access Act ensures that no air carrier may discriminate against persons with disabilities. This Act specifies rules and regulations that remove architectural barriers to persons with disabilities. Other important considerations in the comprehensive adaptive air travel system for persons with disabilities include (1) aircraft boarding environment, (2) boarding chairs, (3) collapsible aircraft wheelchairs, (4) aircraft stowage procedures for battery-powered wheelchairs, and (5) airport shuttle bus or van service. Educational curricula must be developed that describe the comprehensive operation of this system. Evaluation of the performance of the system for persons with disabilities is mandatory to ensure that persons with disabilities have the same level of services as those without disabilities.