Murray, Peter M.

Hand gangrene following vascular cannula placement is uncommon and is usually the result of thrombotic occlusion of an artery. We describe a case of hand gangrene resulting in wrist disarticulation, following multiple unsuccessful attempts at internal jugular vein cannulation in a critically ill patient.

Abstract The economics of medicine have drastically changed during the past quarter century. Institutions may be faced with difficult decisions concerning graduate medical education (GME), particularly as it relates to the growth of existing programs and the creation of new programs. The authors describe a tool that they developed that can consistently measure the value of individual training programs while aligning with an institution's strategic priorities. This tool, the assessment metric scorecard, permits the annual prioritization of GME programs by the leadership of Mayo Clinic, Jacksonville, Florida. The scorecard also provides valuable data regarding the strengths and weaknesses of individual programs. The metric seeks to evaluate GME programs on the basis of four broad areas: Research, Teaching, Patient Service, and a General category. The assessment metric scorecard has been used since 2004; this article reports on its use for the academic years 2004–2005 and 2005–2006. The scorecard has proved to be a helpful tool for the yearly evaluation and prioritization of GME programs at the authors' institution. The overall mean score of the GME programs increased, which suggests a positive trend. This scorecard is flexible; modifications of the relative weights of the metrics can be made to align it with the strategic priorities of other institutions. The resources necessary to implement the scorecard are minimal.

A unique case of combined intrauterine vascular insufficiency and complete brachial plexus palsy is described in a newborn delivered by cesarean section. Intrauterine vascular insufficiency resulted in a right below elbow amputation at 3 weeks of age. Amputation length was preserved after a pedicled thoracoabdominal flap. Function of the C5, C6, and C7 nerve roots returned to normal by 3 months of age.

The purpose of this study was to evaluate the cost-effectiveness of routine wrist radiography in the evaluation of patients with a wrist ganglion. In the setting of a University-based hand surgery practice, 103 consecutive patients with a dorsal or volar wrist ganglion underwent posteroanterior, lateral, and oblique radiographs of the involved wrist. There were 24 men and 79 women with an average age of 34 years (range 4–67 years). A retrospective review of the medical records was performed. Abnormalities on plain radiographs were noted in only 13 patients (13%). Findings included six cases of thumb carpometacarpal joint arthritis and one case each of an enchondroma, congenital distal radioulnar joint (DRUJ) anomaly, DRUJ degenerative changes, intraosseous ganglion, carpal boss, radiocarpal arthritis, and thumb metacarpophalangeal joint osteoarthritis. In only one case (1%) did the findings alter the management. At our institution, the professional and technical charge for three views of the wrist is $172. This confers a cost of $17,716 per therapeutically significant finding in our series. We conclude that routinely performing wrist radiography is not cost-effective in the evaluation and treatment decision-making process in patients with a wrist ganglion.