Hand and finger, ultrasound-guided, percutaneous core needle biopsies: A safe procedure with high diagnostic accuracy.

Introduction/Purpose: To determine the diagnostic accuracy and complication rates of ultrasound-guided, percutaneous core needle biopsies of soft tissue masses in the hand and fingers. Methods: Reports from all ultrasound-guided procedures between 21 May 2014 and 17 March 2022 were queried for keywords including "hand", OR "finger", AND "biopsy". Patient demographics, lesion size and location, biopsy needle gauge and the number of cores obtained were recorded. The final pathology of the mass excision was then compared with the core needle biopsy (CNB) for each patient. Results: Sixty-six records were reviewed, and 37 patients met inclusion criteria. Maximum lesion diameter averaged 1.45 cm with a range between 0.4 and 4.3 cm. The frequency of needle gauges used was 14G (14%), 16G (24%), 18G (38%), 20G (11%) and 'not reported' (14%). The mean number of tissue cores obtained was 2.9 (SD 1.2; range 1 to 6), excluding nine cases that reported 'multiple'. The frequency of CNB diagnoses included tenosynovial giant cell tumour (TGCT) at 30%, ganglion cyst at 11% and epidermal inclusion cyst at 5%. CNB was 100% sensitive in detecting the three (8%) malignancies. Of the 37 tumours biopsied, 16 were surgically excised. One angiomyoma was originally diagnosed as a haemangioma on CNB, but all other histologic results were concordant for a diagnostic accuracy of 97%. Discussion: Small soft tissue masses in the hands and fingers, even those less than 1 cm, are often amenable to ultrasound-guided CNB. Performance under image guidance facilitates retrieval of core specimens adquate for histologic diagnosis with relatively few passes using higher gauge needles. Conclusion: Overall, ultrasound-guided CNB of the hand and fingers is safe and highly accurate in diagnosing soft tissue tumours. The accuracy is unrelated to the needle's gauge, the number of passes and the size of the lesions.

Montgomery's Aperture: An External Anatomic Landmark for Surgical Identification of the Anterior Commissure.

OBJECTIVES: This study evaluates the consistency of palpable identification of an external landmark for the anterior commissure (AC), termed Montgomery's aperture (MA), in cadaveric and surgical settings. METHODS: Part 1: In human cadaveric larynges, palpation of the external laryngeal framework was used to identify MA by three blinded otolaryngologists. The vertical height (VH) of the thyroid cartilage and distance from MA to the inferior border of the thyroid cartilage were measured, larynges were bisected, and the AC was identified and measured. Surface anatomy was demonstrated visually using 3D imaging. Part 2: Retrospectively collected case series used palpation of MA in thyroplasty type 1 (TT1) and compared the result to ½ VH. RESULTS: Part 1: MA was identified in seven cadavers by three surgeons. In four of seven MA was palpated at the location of AC. The average difference between the AC and MA was -0.95 ± 0.96 mm. The average difference between AC and ½VH was 0.08 ± 0.72 mm. Part 2: In 49 patients (57% females) who underwent TT1, MA correlated within ½VH in 67% of cases. MA was inferior to ½VH in 27% of cases, on average 1.08 mm ± 0.51 mm below ½VH. MA was not palpable in 6% (3 of 49) of patients. CONCLUSION: We define the MA as the external indentation or flattening of the thyroid cartilage located within 1 millimeter inferior or at ½ VH of the thyroid cartilage. MA is a reliable, reproducible, palpable landmark for the anterior commissure. It serves as an important landmark that can be used in laryngoplastic surgery in which accurate prediction of the glottis is important.

Telemedicine in orthopaedic surgery during the COVID-19 pandemic : patient attitudes and barriers.

AIMS: This study assesses patient barriers to successful telemedicine care in orthopaedic practices in a large academic practice in the COVID-19 era. METHODS: In all, 381 patients scheduled for telemedicine visits with three orthopaedic surgeons in a large academic practice from 1 April 2020 to 12 June 2020 were asked to participate in a telephone survey using a standardized Institutional Review Board-approved script. An unsuccessful telemedicine visit was defined as patient-reported difficulty of use or reported dissatisfaction with teleconferencing. Patient barriers were defined as explicitly reported barriers of unsatisfactory visit using a process-based satisfaction metric. Statistical analyses were conducted using analysis of variances (ANOVAs), ranked ANOVAs, post-hoc pairwise testing, and chi-squared independent analysis with 95% confidence interval. RESULTS: The survey response rate was 39.9% (n = 152). The mean age of patients was 51.1 years (17 to 85), and 55 patients (38%) were male. Of 146 respondents with completion of survey, 27 (18.5%) reported a barrier to completing their telemedicine visit. The majority of patients were satisfied with using telemedicine for their orthopaedic appointment (88.8%), and found the experience to be easy (86.6%). Patient-reported barriers included lack of proper equipment/internet connection (n = 13; 8.6%), scheduling difficulty (n = 2; 1.3%), difficulty following directions (n = 10; 6.6%), and patient-reported discomfort (n = 2; 1.3%). Barriers based on patient characteristics were age > 61 years, non-English primary language, inexperience with video conferencing, and unwillingness to try telemedicine prior to COVID-19. CONCLUSION: The barriers identified in this study could be used to screen patients who would potentially have an unsuccessful telemedicine visit, allowing practices to provide assistance to patients to reduce the risk of an unsuccessful visit. Cite this article: Bone Jt Open 2021;2(9):745-751.

Impact on percutaneous coronary intervention for acute coronary syndromes during the COVID-19 outbreak in a non-overwhelmed European healthcare system: COVID-19 ACS-PCI experience in Ireland.

AIMS: To evaluate temporal trends of acute coronary syndromes (ACS) treated via percutaneous coronary intervention (PCI) throughout the COVID-19 outbreak in a European healthcare system affected but not overwhelmed by COVID-19-related pathology. METHODS AND RESULTS: We performed a retrospective multicentre analysis of the rates of PCI for the treatment of ACS within the period 2 months pre and post the first confirmed COVID-19 case in Ireland, as well as comparing PCI for ST-elevation myocardial infarction (STEMI) with the corresponding period in 2019. During the 2020 COVID-19 period (29 February-30 April 2020), there was a 24% decline in PCI for overall ACS (incidence rate ratio (IRR) 0.76; 95% CI 0.65 to 0.88; p<0.001), including a 29% reduction in PCI for non-ST-elevation ACS (IRR 0.71; 95% CI 0.57 to 0.88; p=0.002) and an 18% reduction in PCI for STEMI (IRR 0.82; 95% CI 0.67 to 1.01; p=0.061), as compared with the 2020 pre-COVID-19 period (1 January-28 February 2020). A 22% (IRR 0.78; 95% CI 0.65 to 0.93; p=0.005) reduction of PCI for STEMI was seen as compared with the 2019 reference period. CONCLUSION: This study demonstrates a significant reduction in PCI procedures for the treatment of ACS since the COVID-19 outbreak in Ireland. The reasons for this decline are still unclear but patients need to be encouraged to seek medical attention when cardiac symptoms appear, in order to avoid incremental cardiac morbidity and mortality due to a reduction in coronary revascularisation for the treatment of ACS.

Transient bilateral chorea secondary to digoxin toxicity in a female with acute kidney injury: a case report.

BACKGROUND: Chorea secondary to digoxin toxicity is rare, with only three published cases describing the phenomenon. We report the case of a 78-year-old female presenting with intermittent vomiting and diarrhoea for 4 weeks. She had a history of chronic kidney disease and digoxin use for atrial fibrillation. CASE SUMMARY: A 78-year-old lady presented to the emergency department with a 4-week history of intermittent vomiting and diarrhoea. These symptoms commenced after a course of antibiotics prescribed by her general practitioner for a urinary tract infection. Her admission electrocardiogram demonstrated atrial fibrillation at a rate of 32, with evidence of digitalis toxicity. Her creatinine was 396 µmol/L (44-80 µmol/L) with digoxin level 8.1 nmol/L (0.77-1.5 nmol/L). Initially, treatment was with digoxin-specific antibody (FAB) and fluid resuscitation. Within 24 h, she developed transient head, neck, and bilateral upper limb chorea. Review of medications revealed no other likely causative agent. Neuroimaging showed no new ischaemia, but stable established bilateral infarcts of the basal ganglia. Haloperidol 0.5 mg twice daily was commenced. Three days later as digoxin levels normalized, the chorea resolved entirely without recurrence. DISCUSSION: We have identified three reported cases of digoxin-induced chorea. Our case resembles two of the published cases where a transient bilateral chorea, associated with digitalis toxicity and resolving within a few days of normalization of digoxin levels was demonstrated. There were no other focal neurological signs or symptoms. It has been postulated that an alteration to dopaminergic neuronal activity is a potential mechanism, as digoxin also demonstrates neuropsychiatric side effects such as psychosis and depression.

FOXE1 polymorphism rs965513 predisposes to thyroid cancer in a European cohort.

Objective: FOXE1 is an intronless gene on chromosome 9 which plays a significant role in thyroid morphogenesis. Mutations in FOXE1 are associated with thyroid phenotypes including congenital hypothyroidism, thyroid dysgenesis and thyroid cancer. This study aims to investigate the frequency and impact of a SNP (rs965513, G>A) at 9q22.23 in a Western European cohort of patients with differentiated thyroid cancer(DTC), compared to controls. Design: This is a candidate gene case control study. Methods: 277 patients with histologically confirmed DTC were recruited from tertiary referral centres in Ireland and France. 309 cancer-free controls were recruited from the community. DNA was extracted from buccal swabs or whole blood of control subjects and patients with DTC. Allelic and genotypic frequencies among patients were compared with controls, to assess the risk for disease conferred by homozygous and heterozygous carriers compared to WT genotypes. Genotyping was performed using Taqman-based PCR. Results: 277 patients with confirmed DTC and 309 non-cancer controls were genotyped for the variant (rs965513). The frequency of the minor allele among cases was 0.45 compared to 0.34 among controls. The genotypic odds ratio for heterozygotes was 1.66 (CI 1.16-2.39, P =0.00555), increasing to 2.93 (CI 1.70-5.05, P =0.00007) for rare homozygotes. All subjects were in Hardy-Weinberg equilibrium (±χ2, P =0.09, P =0.07 respectively). Conclusions: This FOXE1 polymorphism is a low penetrance variant associated with DTC susceptibility in this cohort. The minor allele was identified among patients with thyroid cancer significantly more frequently than controls. An allele dosage effect was observed, with rare homozygous genotypes conferring greater risk than heterozygotes.

Differentiated Thyroid Cancer: How Do Current Practice Guidelines Affect Management?

BACKGROUND: International best-practice guidelines recommend completion thyroidectomy and radioiodine remnant ablation (RRA) for patients with differentiated thyroid cancer (DTC) > 4 cm or with specific risk factors. Patients with DTC < 1 cm without risk factors are recommended for lobectomy alone. Indications for aggressive surgery and RRA are less clearly defined for tumours measuring 1-4 cm. A personalised approach to decision-making is recommended. OBJECTIVES: This study assesses therapeutic approaches to DTC as compared to the current British Thyroid Association (BTA) clinical practice guidelines. We ascertained the effect of equivocal guidance in the 1-4 cm tumour cohort on contemporary practice patterns. METHODS: Data were obtained from a prospectively maintained thyroid cancer database of patients treated for DTC in a tertiary referral centre at the University Hospital Galway. Consecutive patients attending a dedicated thyroid cancer clinic between August 2014 and August 2017 were included. Clinicopathological characteristics and management strategies were assessed. RESULTS: Ninety-four percent (n = 168/178) of patients were surgically managed in adherence with guidelines. A minority (n = 10) received surgery not aligned with guidelines. Ninety-seven percent (n = 172/178) of RRA treatment decisions were in accordance with guidelines. The BTA guidelines recommended a personalised decision-making approach for 18.0% (n = 32) and 44.9% (n = 80) of surgery and RRA treatment decisions, respectively. The more aggressive, treatment-driven approach was typically favoured by the multidisciplinary team, with 97% (n = 31/32) undergoing completion thyroidectomy and 100% (n = 80) proceeding to RRA. CONCLUSIONS: Management of DTC at our institution closely adheres to contemporary clinical practice guidelines. The finding of more aggressive management in those requiring a personalised decision-making approach highlights the requirement for improved risk stratification in this cohort to ratio-nalise management strategies.

Six-year review of traumatic brain injury in a regional trauma unit: demographics, contributing factors and service provision in Ireland.

BACKGROUND: Traumatic brain injury (TBI) represents a significant burden of care for acute surgical services, particularly in the absence of on-site neurosurgical cover or sufficient post-acute rehabilitation facilities. We examine factors contributing to TBI, prolonged lengths of stay (LoS) and implications for hospital resources. Long-term outcomes are assessed. METHODS: This is a retrospective cohort study of patients admitted to a regional trauma unit with TBI from 2008 to 2013. Patients with LoS > 48 h were assessed. Demographic, clinical and longitudinal mortality data were collected using electronic clinical and radiological systems and chart review. RESULTS: A total of 690 patients presented with TBI from 2008 to 2013; 213 patients with LoS > 48 h were assessed. One hundred and thirty (61%) were male. Mean age was 56 years (±SD 24). Mechanical fall was the most frequent injury mechanism (n = 120/213, 56%). Twenty-five per cent were associated with alcohol consumption; these were more likely to be male, involved in an Road Traffic Accident (RTA) or assault and necessitate transfer to a neurosurgical unit (p < 0.001, p = 0.029, p < 0.001, p = 0.05). A total of 112 patients(53%) had a prolonged LoS (>2 weeks). Mean LoS was 20 days (±SD 35), increasing to 39 days for patients requiring neurosurgical intervention. The 12-month all-cause mortality rate was 12%. CONCLUSIONS: TBIs result in significant utilisation of acute inpatient bed days. Improved rehabilitation services and strategies to reduce acute hospital LoS are warranted.

Accuracy in precordial ECG lead placement: Improving performance through a peer-led educational intervention.

BACKGROUND AND OBJECTIVES: Inaccurate electrocardiography (ECG) lead placement may lead to erroneous diagnoses, such as poor R wave progression. We sought to assess the accuracy of precordial ECG lead placement amongst hospital staff members, and to re-evaluate performance after an educational intervention. METHODS AND RESULTS: 100 randomly selected eligible staff members placed sticker dots on a mannequin, their positions were recorded on a radar plot and compared to the correct precordial lead positions. The commonest errors were placing V1 and V2 leads too superiorly, and V5 and V6 leads too medially.Following an educational intervention with the aid of moderated poster presentations and volunteer patients, the study was repeated six months later. 60 subjects correctly placed all leads, compared to 10 in the pre-intervention cohort (P<0.0001) with the proportion achieving correct placement of any lead rising from 0.34 to 0.83, (p<0.0001 for all leads). CONCLUSION: Incorrect ECG lead placement is common. This may be addressed through regular training incorporated into annual induction processes for relevant health care professionals.

Influence of radial anatomy on pain experienced during transradial coronary angiography.

BACKGROUND: The transradial route has become the primary approach for coronary angiography with the presence of radial artery anomalies found to be 10-20%. There has been limited study on the influence of these anomalies on procedural pain. Our aims were to determine local prevalence of the high radial origin (HRO) anatomical variant; to investigate factors influencing transradial procedural pain; and to determine if HRO specifically was associated with increased pain. METHODS: Radial artery anatomy was characterized by arteriography in sequential patients undergoing angiography. Patients were asked to mark their perceived procedural pain on a visual analog scale, which was converted to a pain score. RESULTS: 382 patients were enrolled, 5 were excluded. There were 259 males (68.7%) and 118 females (31.3%). HRO was present in 51 patients (13.5%). Overall mean pain score was 2.6 (SD 2.5). HRO was associated with a higher mean pain score than normal anatomy (3.3 (SD 2.9) vs. 2.4 (SD 2.4) p=0.027). HRO was not associated with increased procedural failure, screening time or procedure time. When pain score was dichotomized into mild pain (<4.0) and moderate-to-severe pain (≥4.0), HRO was associated with almost double the frequency of moderate-to-severe pain (37.2% vs. 21.1%, p=0.012). Using a logistic regression model, only female gender, younger age and HRO remained significant predictors of moderate-to-severe pain. CONCLUSIONS: There was significantly increased pain in patients with HRO without increased procedure/screening time or procedural failure. Female gender and younger age were also found to be significant predictors of increased pain.

Ultrasound-guided aspiration of wrist ganglions: a follow-up survey of patient satisfaction and outcomes.

BACKGROUND: Ganglion cysts are one of the most frequently occurring masses of the wrist, often causing pain and interfering with daily activity. Ultrasound (US)-guided aspiration is a treatment for ganglion cysts of the wrist. PURPOSE: To examine the results and patient satisfaction of US-guided aspiration of wrist ganglion cysts. MATERIAL AND METHODS: Medical records from August 2009 through December 2013 were reviewed to identify all adult patients referred to a single musculoskeletal radiologist for US-guided aspiration of a painful wrist ganglion cyst. Records were reviewed for patient demographics, cyst size, location, and morphology. Outcomes and patient satisfaction were evaluated using a telephone questionnaire at a minimum of 9 months after the procedure. RESULTS: Of 56 consecutive patients identified, follow-up data were available for 39 patients (69%) at a minimum of 9 months. There were 21 volar and 18 dorsal ganglion cysts. The overall recurrence rate was 20% (8 of 39 patients) and only five patients reported a pain score of greater than 2 out of 10. The mean age of patients with recurrence of the cyst was greater than that of patients without recurrence (52 vs. 35 years, P = 0.03). Satisfaction with the outcome was high and varied by recurrence. There were no acute complications including infection, hemorrhage, or allergic reaction. CONCLUSION: US-guided aspiration is a safe and potentially effective treatment for ganglion cysts of the wrist, with high patient satisfaction. US-guided aspiration may be particularly advantageous for volar ganglion cysts, and in patients who are poor surgical candidates.

National trends in ambulatory surgery for upper extremity fractures: a 10-year analysis of the US National Survey of Ambulatory Surgery.

BACKGROUND: Upper extremity fractures are increasing in frequency and have profound socioeconomic implications. The purpose of this study was to assess trends in ambulatory upper extremity fracture fixation in the USA from 1996 to 2006 using data from the National Survey of Ambulatory Surgery (NSAS). METHODS: The NSAS was used to identify cases of closed forearm, carpal, metacarpal, and phalanx fractures treated with open or closed reduction with internal fixation in 1996 and 2006. Data were analyzed for trends in fracture location, age, gender, facility type, payor status, and anesthesia type. US census data were used to obtain national population estimates. RESULTS: Over the 10-year study period, there was a 54.4 % increase in the population-adjusted rate of upper extremity fractures treated with internal fixation (34.6 to 53.4 per 100,000 capita). There was a 173 % increase in the age-adjusted rate of patients over 55 years treated with internal fixation. There was a 505 % increase in the number of cases performed at freestanding surgical centers compared to hospital-based facilities. Though the majority of cases involved general anesthesia, regional anesthesia (16.6 versus 20.6 %) and monitored anesthesia care (7.1 versus 11.8 %) increased in frequency. Private insurance groups funded the majority of surgeries in both study years. CONCLUSION: The volume of ambulatory surgery for upper extremity fractures has increased dramatically from 1996 to 2006. Operative treatment of upper extremity fractures has increased markedly. Our analysis provides valuable information for providers and policy-makers for allocating the appropriate resources to help sustain this volume.

Fracture, inflation and floatation embolisation of PTCA balloon.

This case outlines an unusual complication of coronary intervention, the likely mechanisms leading to this and possible retrieval options. It is the first case to the best of our knowledge reporting this complication. A 78-year-old Caucasian man underwent coronary stenting. During the procedure kinking and subsequent fracture of a non-compliant percutaneous transluminal coronary angioplasty (PTCA) balloon occurred. Injection of contrast down the guide to opacify the coronary arteries resulted in 'inflation' of the balloon with air, and embolisation of the inflated balloon into the proximal left anterior descending artery. The embolised balloon was retrieved by removal of the guide catheter and wire as a unit. The patient had a good angiographic outcome. This case highlights risks associated with usage of kinked balloons catheters, and describes for the first time to our knowledge, the inflation of a PTCA balloon with air from its shaft within the catheter, causing 'floatation' embolisation into the coronary artery.

Functional outcomes of replantation following radiocarpal amputation.

PURPOSE: To assess the long-term functional and clinical outcomes of patients who have undergone replantation after radiocarpal amputation. METHODS: We performed a retrospective review of radiocarpal joint amputations at a level 1 trauma center over a 13-year period. Medical records of patients treated with replantation were queried for injury data, operative reports, complications, and clinical progress. Patients who met inclusion criteria were contacted for long-term follow-up. We measured total active motion of each digit, strength (grip and pinch), and 2-point discrimination. Functional outcomes were assessed with Disabilities of Arm, Shoulder, and Hand score, Mayo Wrist Score, Patient-Rated Wrist Evaluation, and Michigan Hand Questionnaire. Descriptive statistics were calculated, including frequencies for categorical variables and means and ranges for continuous variables. RESULTS: Six patients met the inclusion criteria. The mean age was 36 years (range, 26-50 y). Five patients were available at a mean follow-up of 3.9 years (range, 1.0-6.9 y). Compared with the contralateral uninjured extremity, total active motion of the hand was 38% (range, 26% to 59%) and grip strength was 9% (range, 0% to 18%). Neither tip nor key pinch was present. Mean 2-point discrimination was 10.6 mm (range, 8-12 mm). All mean outcome scores indicated moderate disability, including Disabilities of Arm, Shoulder, and Hand (76; range, 45-82), Mayo Wrist Score (23; range, 5-50), Patient-Rated Wrist Evaluation (86; range, 56-98), and Michigan Hand Questionnaire (27; range, 15-55). Two patients were able to return to work and 3 were permanently disabled. All patients were satisfied with the hand function. CONCLUSIONS: Successful replantation for a radiocarpal joint amputation is associated with major restriction of motion, decreased strength, and moderate disability on functional outcome assessments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

A liquid crystal-based passive badge for personal monitoring of exposure to hydrogen sulfide.

A new liquid crystal (LC)-based passive dosimeter badge for personal monitoring of exposure to hydrogen sulfide (H2S) gas is reported. When a thin film of LC supported on a surface functionalized with lead perchlorate Pb(ClO4)2 (the LC sensor) is exposed to H2S, the orientation of LC molecules in the film changes from perpendicular to parallel. This reorientation induces a change in the appearance of the LC film when viewed between crossed polarizers. A H2S dosimeter was fabricated by pairing a LC sensor with a glass substrate forming a headspace between the two surfaces, to control diffusion of H2S across the LC film. When the dosimeter is exposed to H2S, a bright front appears as a function of exposure time. An algorithm has been developed to correlate this response length and exposure dose. The dosimeters are functionally stable when subjected to extreme temperature and humidity fluctuations, and are immune to a number of potentially interfering chemicals, except mercaptans. These dosimeters detect H2S at 0.2 ppm TWA (8 hr) with ±20% overall accuracy. The dosimeters were used to monitor the personal exposure of personnel working in an oil refinery. The TWA concentrations measured by the LC-based dosimeters correlate strongly with the NIOSH 1063 method that uses a sorbent tube and a pump followed by laboratory analysis. Thus, the LC-based dosimeters can provide a sensitive tool for on-site assessment of personal exposure to H2S in different environments.

Predictors of stage and the application of curative-intent surgery in pancreatic cancer: a population-based analysis from the Arkansas Cancer Registry.

BACKGROUND: The purpose of this study was to describe the characteristics of pancreatic cancer subjects within the state of Arkansas. METHODS: Pancreatic cancer patients diagnosed from 5/1997 to 12/2007 were identified from the Arkansas Cancer Registry. Analysis was performed to identify variables associated with advanced-stage and curative-intent surgery. RESULTS: For 3,227 subjects, only grade was associated with advanced stage pancreatic cancer. Age > 80, pancreatic cancer site not specified, and grade were associated with curative-intent surgery. CONCLUSIONS: Studies utilizing the Arkansas Cancer Registry are feasible and can identify variables associated with stage and treatment.

Resident selection of Hand Surgery Fellowships: a survey of the 2011, 2012, and 2013 Hand Fellowship graduates.

BACKGROUND: We desired information from the recent, current, and future matched hand surgery fellows regarding their residency training, number of interviews, position matched, cost of interviewing, influences, opinions on future hand training models, and post-fellowship job information. METHODS: Institutional review board approval was obtained from our institution to submit an online survey. An email was sent to the coordinators of all US Hand Fellowships to be forwarded to their fellows with graduation years 2011, 2012, and 2013, as well as directly to the fellows if their email addresses were provided. Data on the application process, relative importance of program attributes, and opinions regarding optimal training of a hand surgeon were collected. Statistical analysis was performed with respect to the training background and graduation year of the respondent. RESULTS: The survey was completed by 137 hand surgery fellows. Seventy-one percent of the survey responders were from an orthopedic residency background, 20 % from plastic, and 7 % from general surgery. Forty-four percent of all of the respondents matched into their first choice. The type of operative cases performed by the current fellows was most often selected as very important when making their rank list. Seventy-seven percent of the respondents reflected their personal preference in fellowship model to be a 1-year fellowship program. CONCLUSIONS: The field of hand surgery is unique in that it has residents from multiple training backgrounds who all apply to one fellowship. The current fellowship model allows for diversity of training and the possibility of obtaining a second fellowship if desired.

A New Sensor for the Assessment of Personal Exposure to Volatile Organic Compounds.

To improve our understanding of indoor and outdoor personal exposures to common environmental toxicants released into the environment, new technologies that can monitor and quantify the toxicants anytime anywhere are needed. This paper presents a wearable sensor to provide such capabilities. The sensor can communicate with a common smart phone and provides accurate measurement of volatile organic compound concentration at a personal level in real time, providing environmental toxicants data every three minutes. The sensor has high specificity and sensitivity to aromatic, alkyl, and chlorinated hydrocarbons with a resolution as low as 4 parts per billion (ppb), with a detection range of 4 ppb to 1000 ppm (parts per million). The sensor's performance was validated using Gas Chromatography and Selected Ion Flow Tube - Mass Spectrometry reference methods in a variety of environments and activities with overall accuracy higher than 81% (r(2) > 0.9). Field tests examined personal exposure in various scenarios including: indoor and outdoor environments, traffic exposure in different cities which vary from 0 to 50 ppmC (part-per-million carbon from hydrocarbons), and pollutants near the 2010 Deepwater Horizon's oil spill. These field tests not only validated the performance but also demonstrated unprecedented high temporal and spatial toxicant information provided by the new technology.

Ulnar nerve component to innervation of thumb carpometacarpal joint.

PURPOSE: Thumb carpometacarpal (CMC) joint arthritis is one of the most common problems addressed by hand surgeons. The gold standard of treatment for thumb CMC joint arthritis is trapeziectomy, ligament reconstruction and tendon interposition. Denervation of the thumb CMC joint is not currently used to treat arthritis in this joint due to the failure of the procedure to yield significant symptomatic relief. The failure of denervation is puzzling, given that past anatomic studies show the radial nerve is the major innervation of the thumb CMC joint with the lateral antebrachial nerve and the median nerve also innervating this joint. Although no anatomic study has ever shown that the ulnar nerve innervates the CMC joint, due to both the failure of denervation and the success of arthroscopic thermal ablation, we suspect that previous anatomic studies may have overlooked innervation of the thumb CMC joint via the ulnar nerve. METHODS: We dissected 19 formalin-preserved cadaveric hand-to-mid-forearm specimens. The radial, median and ulnar nerves were identified in the proximal forearm and then followed distally. Any branch heading toward the radial side of the hand were followed to see if they innervated the thumb CMC joint. RESULTS: Eleven specimens (58%) had superficial radial nerve innervation to the thumb CMC joint. Nine specimens (47%) had median nerve innervation from the motor branch. Nine specimens (47%) had ulnar nerve innervation from the motor branch. CONCLUSIONS: We believe this is the first study to demonstrate that the ulnar nerve innervates the thumb CMC joint This finding may explain the poor results seen in earlier attempts at denervation of the thumb CMC, but the more favorable results with techniques such as arthroscopy with thermal ablation.