The Cost Does Not Outweigh the Benefit: Pathologic Evaluation of Wrist Ganglion Cysts Should Not Be Routine.

BACKGROUND: As health care costs in the United States continue to rise, there is increasing attention on cost-saving measures. One area of investigation is the utility of pathologic examination of specimens from routine procedures with a suspected benign pathology. We assessed the utility and cost of routine pathologic analysis for wrist ganglion cyst excision. METHODS: A retrospective cohort study of all wrist ganglion cyst excisions performed by seven hand surgeons was conducted from 2015 to 2019 at Penn State Hershey Medical Center. Preoperative and intraoperative diagnoses, pathologic diagnosis, and pathology cost were assessed. RESULTS: A total of 407 patients underwent ganglion cyst excision, with 318 (78.1%) specimens sent for pathologic review. Of the 318, 317 (99.6%) specimens were concordant with the preoperative or intraoperative diagnosis of ganglion cyst. One specimen (0.3%) resulted as a benign cystic vascular malformation. The charge per specimen was $258, totaling $81,786 spent confirming benign pathology that was clinically correctly diagnosed by the operating surgeon in 99.6% of cases. CONCLUSIONS: Routine pathologic analysis is not indicated in cases in which surgeons have a high clinical suspicion for ganglion cyst based on preoperative and intraoperative findings. Pathologic review should be reserved for cases with atypical presentations or intraoperative findings.

The Teaching of Ethics and Professionalism in Plastic Surgery Residency: A Cross-Sectional Survey.

BACKGROUND: The ethical practice of medicine has always been of utmost importance, and plastic surgery is no exception. The literature is devoid of information on the teaching of ethics and professionalism in plastic surgery. In light of this, a survey was sent to ascertain the status of ethics training in plastic surgery residencies. METHODS: A 21-question survey was sent from the American Council of Academic Plastic Surgeons meeting to 180 plastic surgery program directors and coordinators via email. Survey questions inquired about practice environment, number of residents, presence of a formal ethics training program, among others. Binary regression was used to determine if any relationships existed between categorical variables, and Poisson linear regression was used to assess relationships between continuous variables. Statistical significance was set at a P value of 0.05. RESULTS: A total of 104 members responded to the survey (58% response rate). Sixty-three percent were program directors, and most (89%) practiced in academic settings. Sixty-two percent in academics reported having a formal training program, and 60% in private practice reported having one. Only 40% of programs with fewer than 10 residents had ethics training, whereas 78% of programs with more than 20 residents did. The odds of having a training program were slightly higher (odds ratio, 1.1) with more residents (P = 0.17). CONCLUSIONS: Despite the lack of information in the literature, formal ethics and professionalism training does exist in many plastic surgery residencies, although barriers to implementation do exist. Plastic surgery leadership should be involved in the development of standardized curricula to help overcome these barriers.

200 kHz commercial sonar systems generate lower frequency side lobes audible to some marine mammals.

The spectral properties of pulses transmitted by three commercially available 200 kHz echo sounders were measured to assess the possibility that marine mammals might hear sound energy below the center (carrier) frequency that may be generated by transmitting short rectangular pulses. All three sounders were found to generate sound at frequencies below the center frequency and within the hearing range of some marine mammals, e.g. killer whales, false killer whales, beluga whales, Atlantic bottlenose dolphins, harbor porpoises, and others. The frequencies of these sub-harmonic sounds ranged from 90 to 130 kHz. These sounds were likely detectable by the animals over distances up to several hundred meters but were well below potentially harmful levels. The sounds generated by the sounders could potentially affect the behavior of marine mammals within fairly close proximity to the sources and therefore the exclusion of echo sounders from environmental impact analysis based solely on the center frequency output in relation to the range of marine mammal hearing should be reconsidered.

Feasibility of tracking fish with acoustic transmitters in the Ice Harbor Dam tailrace.

The Juvenile Salmon Acoustic Telemetry System (JSATS) has been used at many dams but has never been deployed in the near-dam tailrace environment. The use of JSATS in the tailrace is of interest to fishery managers to evaluate downstream passage behavior of juvenile salmonids and dam approach behavior of upstream migrating adult salmon and lamprey. The acoustic noise level and detection range of JSATS were studied to determine the feasibility of deploying JSATS in the Ice Harbor Dam tailrace. The noise level measured from the powerhouse deck was less than 104 dB re 1 µPa except for the turbine outlet near the spillway, and 350 m downstream of the dam, the noise level was less than 106 dB. The measured noise levels would allow a theoretical detection range of 100 m to 350 m and 85 m to 320 m, respectively. Validation experiments showed that the detection range is 113 to 184 m using hydrophones deployed from the powerhouse deck and 148 m using hydrophones deployed 500 m downstream of the dam.

The sternocleidomastoid myocutaneous "patch esophagoplasty" for cervical esophageal stricture.

Esophageal strictures may be caused by many etiologies. Patients suffer from dysphagia and many are tube-feed dependent. Cervical esophageal reconstruction is challenging for the plastic surgeon, and although there are reports utilizing chest wall flaps or even free flaps, the use of a sternocleidomastoid (SCM) myocutaneous flap provides an ideal reconstruction in select patients who require noncircumferential "patch" cervical esophagoplasty. We present two cases of esophageal reconstruction in which we demonstrate our technique for harvesting and insetting the SCM flap, with particular emphasis on design of the skin paddle and elucidation of the vascular anatomy. We believe that the SCM flap is simple, reliable, convenient, and technically easy to perform. There is minimal donor site morbidity with no functional loss. The SCM myocutaneous flap is a viable option for reconstructing partial esophageal defects and obviates the need to perform staged procedures or more extensive operations such as free tissue transfer.

Is the tendon embryogenesis process resurrected during tendon healing?

The process of embryonic tendon development, including the nature and purpose of collagen fibril segments, is reviewed. It is proposed that tendon fibrillogenesis of repair is related to the fibrillogenesis of tendon embryonic development. The assembly of collagen fibril segment units into longer fibers occurs on the surface of tendon fibroblasts in embryonic tendon development. The biochemist's view of tendon healing, whereby the spontaneous polymerization of tropocollagen monomers regenerates lost tendon collagen fibers, needs to be reconsidered. Furthermore, the importance of direct fibroblast involvement in collagen fiber reassembly during tendon healing needs to be studied in tendon intrinsic regenerative repair.