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James Goodnight, chairman and chief executive of SAS Institute Inc., has won national acclaim for the success of his Cary-based technology company and his progressive workplace policies. Last week, the [...]

Q MY company is tiny compared with SAS. Are still things I can do to create a progressive culture? Ann-Marie Faiola, founder and CEO, Bramble Berry, Bellingham, Washington To be [...]

BACKGROUND Women are increasingly entering the surgical profession. OBJECTIVE To assess professional and personal/family life situations, perceptions, and challenges for women vs men surgeons. DESIGN National survey of American Board of Surgery–certified surgeons. PARTICIPANTS A questionnaire was mailed to all women and men surgeons who were board certified in 1988, 1992, 1996, 2000, or 2004. Of 3507 surgeons, 895 (25.5%) responded. Among these, 178 (20.3%) were women and 698 (79.7%) were men. RESULTS Most women and men surgeons would choose their profession again (women, 82.5%; men, 77.5%; P = .15). On multivariate analysis, men surgeons (odds ratio [OR], 2.5) and surgeons of a younger generation (certified in 2000 or 2004; OR, 1.3) were less likely to favor part-time work opportunities for surgeons. Most of the surgeons were married (75.6% of women vs 91.7% of men, P < .001). On multivariate analysis, women surgeons (OR, 5.0) and surgeons of a younger generation (OR, 1.9) were less likely to have children. More women than men surgeons had their first child later in life, while already in surgical practice (62.4% vs 32.0%, P < .001). The spouse was the offspring's primary caretaker for 26.9% of women surgeons vs 79.4% of men surgeons (P < .001). More women surgeons than men surgeons thought that maternity leave was important (67.8% vs 30.8%, P < .001) and that child care should be available at work (86.5% vs 69.7%, P < .001). CONCLUSIONS Women considering a surgical career should be aware that most women surgeons would choose their profession again. Strategies to maximize recruitment and retention of women surgeons should include serious consideration of alternative work schedules and optimization of maternity leave and child care opportunities.Arch Surg. 2009;144(7):635-642--

Functional electric stimulation is a new method for dynamic rehabilitation of paralyzed muscles. The output of such prosthetic devices needs to be modulated by some index of the muscle movement. In facial paralysis a measure of the muscle contractions of the normal contralateral side seems to be an appropriate input. In the rabbit, we simultaneously measured the compound action potential of the buccal branch of the facial nerve, the electromyogram of the zygomaticus major muscle, and the muscle twitch tension through strain gauge. The compound action potential, electromyogram, and strain gauge each had a sigmoidal relationship to stimulus intensity. The compound action potential peak-to-peak amplitude was found to have a linear correlation to the peak twitch tension of the corresponding facial muscle. The electromyogram response, although more variable, also had a linear correlation with muscle contraction. The possibility of predicting the contraction of facial muscles before they actually occur is discussed in the context of available and future functional electric rehabilitation models.

OBJECTIVE: To prospectively evaluate the ability for immunoscintigraphy with monoclonal antibody CYT-103 labeled with indium 111 to detect tumor presence in 15 patients with ovarian cancer undergoing second-look surgery. DESIGN: Prospective, open-label, nonrandomized trial. SETTING: Hospital-based nuclear medicine facility and operating room. STUDY PARTICIPANTS: Patients with previous ovarian cancer scheduled for second-look surgery. MAIN OUTCOME MEASURE: Correctness of prediction of immunoscintigraphy for presence or absence of ovarian cancer compared with serum CA 125 titer and computed tomography. RESULTS: Immunoscintigraphy, computed tomography, and serum CA 125 titer had respective sensitivities of 92%, 42%, and 42%; specificities of 67%, 100%, and 100%; accuracies of 87%, 53%, and 53%; and diagnostic values of 59%, 42%, and 42%. The full regional extent of recurrent tumor was correctly detected in 45% of patients by immunoscintigraphy and in none of the patients by computed tomography. Immunoscintigraphy detected miliary tumor in two of four patients and computed tomography, as expected, was unable to detect miliary disease. CONCLUSIONS: Recurrent ovarian cancer often presents as multiple small lesions throughout the abdominal cavity. In this subset of patients, immunoscintigraphy may be particularly well suited for detection of the presence of recurrent tumor.(Arch Surg. 1993;128:819-823)

• To evaluate whether intraoperative autologous transfusion increases the risk of hematogenous dissemination of tumor we reviewed the risk of lung metastasis as well as disease-free and long-term survival of patients who underwent resection of malignant hepatic neoplasms with this technique. A retrospective review of patients undergoing liver resection for malignant disease revealed 39 patients in whom intraoperative autologous transfusion was used. The 2-year actuarial survival in the patients in this series, as calculated with the Kaplan-Meier method, was predicted to be 75%. Two-year actuarial disease-free survival was predicted to be 28%, and the risk of developing lung metastasis at 3 years was estimated to be 40%. The predicted overall survival and risk of recurrence in this series compare favorably with published data for patients in whom intraoperative autologous transfusion was not used.(Arch Surg. 1993;128:206-211)

Options in the management of bile duct carcinoma include resection, passage of tubes through the tumor to maintain internal bile drainage, hepatic-enteric bypass, and percutaneous tube drainage. Complete removal of the tumor produces more long-term survivors than other procedures, but most patients still succumb to their disease.

In most instances, hemobilia presents as a complication of liver injury, blunt abdominal trauma, or liver surgery. The diagnosis of hemobilia is confirmed by endoscopy and selective angiography. Treatment is primarily surgical, with direct exploration of the liver, ligation of the bleeding point, and relief of bile duct obstruction.

Immunotherapy using a variety of agents may be beneficial in controlling accessible cutaneous melanoma metastases and may have potential for limiting the growth of systemic disease when used in the adjuvant setting. Approximately 20% of patients with metastases limited to the skin can be brought into complete remission with local, intralesional BCG immunotherapy. Dinitrochlorobenzene (DNCB), vaccinia virus,C. parvum,and transfer factor have also been tested for activity in local immunotherapy. BCG, DNCB, and vaccinia virus appear to be the most effective. Adjuvant immunotherapy has shown some promise, particularly with regard to improvement in survival. In a study of adjuvant immunotherapy with BCG in patients with stage II disease, recurrence rates were similar, but of those patients who developed recurrences, those who received BCG lived significantly longer. Immunotherapy, used either alone or in combination with chemotherapeutic agents, has shown little or no activity in the treatment of metastatic malignant melanoma.

Inbred rat strains, Fischer 344 (F-344) and Lewis (LEW), share the serologicalAg-Bl allele and react very weakly in mixed lymphocyte culture (MLC). Despite this apparent identity atAg-B, these strains differ markedly in their immune responses to anAg-B disparate third strain Marshall 520 (M-520) (Ag-B6). F-344 recipients allowed M-520 heart grafts an extended survival, whereas LEW recipients rejected them rapidly. F-344 and M-520 showed a weak response in MLC in contrast to a strong response for LEW and M-520. F-344 produced antisera in response to injection of M-520 cells that had a relatively high antibody titer but low cytotoxic activity. F-344 responded to another strain, Buffalo (BUF) (alsoAg-B6), in a similar fashion. F-344 apparently can produce a strong allogeneic response, as it was able to rapidly reject heart grafts from (LEW x Brown-Norway) F1 donors (LBN) (Ag-B 1/3). The low response of F-344 to M-520 probably was not due to shared antigens between the two strains because M-520 heart grafts underwent rapid rejection in LEW hosts highly tolerant to F-344. To explain the contrasting response of F-344 and LEW to theAg-B6 disparity, we propose that it is controlled by an immune-response gene(s); that F-344 has a low-responding allele and LEW has a high-responding allele. The data do not reveal a location for this proposed gene. The high-responding allele appears to be dominant, as M-520 hearts were rejected rapidly by (F-344 x LEW) F1 recipients.

Long-term survival of Ag-B compatible rat heart allografts was obtained by short-term treatment of the recipients with antilymphocytic serum (ALS). Graft survival apparently was based on a specific change in the hosts rather than on persistent nonspecific effects of ALS. The hosts were not fully tolerant in that they were able to reject secondary skin allografts from the heart donor strain, although in a delayed fashion. The long-surviving heart allografts retained their immunogenicity as they were rejected when retransplanted to new hosts. The passive transfer of serum from long-term heart graft acceptors to new hosts receiving fresh allografts delayed rejection by several days. This effect was seen only with the serum from long-term acceptors suggesting that serum-blocking factors were involved in long-term survival of the heart allografts. However, the ability of adoptively transferred lymphoid cells to break tolerance to a heart allograft residing in a classically tolerant host was tested. In contrast to normal lymphoid cells, cells from the long-term acceptors were unable to break tolerance, suggesting that a specific cellular tolerance had been induced in this cell population. Moreover, serum from the long-term acceptors failed to block the breakage of tolerance by normal lymphoid cells.

• After extensive resection due to extremity sarcoma, the inability to cover the defect for satisfactory healing and limb function has been an indication for amputation rather than limb salvage. We report herein our experience with seven limb-salvage cases in which we closed difficult and complex defects with composite tissue transfers utilizing microvascular techniques. Free-flap transfers were used to cover soft-tissue defects after extensive resection of primary and locally recurrent tumor and to manage radiation-induced complications. The grafts healed well when infected irradiated tissue was covered, and the grafts tolerated postoperative irradiation. Composite tissue transfer also provided soft-tissue coverage around distal joints that would not have been adequately protected with a skin graft. Complications were minimal, and all patients maintained good extremity function. No patient who underwent composite tissue transfer has had a local recurrence. A free-flap composite tissue transfer can extend the indications for limb-salvage surgery and offers an alternative to amputation in selected patients.(Arch Surg. 1991;126:639-641)

Several letters to the editor are presented in response to various articles in the previous issues, including "Can You Top This for Cost-Efficient Management?" in the April 20, 1998 issue, "Wretched Excess," in the April 20, 1998 issue, and "Forbes 101," in the April 6, 1998 issue.

• Immunosuppressive therapy was discontinued in six patients for an average of 27 months. In these six patients, only two rejections have occurred. A survey of other transplant centers showed that in such patients rejection was often delayed weeks or months after therapy was stopped. Once immunosuppressive therapy has been stopped, for whatever reason, and rejection has not occurred, consideration should be given to not resuming therapy unless signs of rejection appear.(Arch Surg 110:1450-1451, 1975)