									Chief Resident in General Surgery

									Department of Cardiothoracic Surgery

									Department of Pulmonary Medicine

									Seton Hall University School of Graduate Medical Education

									General Surgery Program at St. Francis Medical Center

Primary pulmonary low-grade B-cell lymphomas of mucosa associated lymphoid tissue (MALT) represent a distinct subset of non-Hodgkin’s lymphomas. These rare tumors generally remain localized in their primary extranodal site, allowing local resection to be curative in most cases; however, making the proper diagnosis can prove challenging due to the tumor’s ability to produce IgM monoclonal proteins, which are seen 

with a variety of other conditions. The authors report the case of a patient who presented with a persistent cough and a new interstitial infiltrate. The patient was initially thought to have 

 was identified. After medical intervention failed, the patient underwent a right thoracotomy, and pathologic evaluation of the lung tissue revealed MALT lymphoma. The authors conclude that the presence of an IgM monoclonal protein in serum should lead clinicians to direct the workup toward genetic and immunohistochemical techniques so that a definitive diagnosis can be obtained.

	Primary pulmonary non-Hodgkin’s lymphomas are rare, estimated to account for only 3.6% of extranodal lymphomas.

 Kurtin and colleagues suggest that the true frequency of primary pulmonary mucosa associated lymphoid tissue (MALT) lymphoma may be as low as 0.49%.

	Diagnosis is made by histopathologic examination with immunohistochemical analysis of tissue samples. The histopathologic hallmark of extranodal MALT lymphoma is tumor cell infiltration of parenchymal epithelium with formation of lymphoepithelial lesions. Additionally, centrocyte-like or small-cleaved lymphocytes in a parafollicular distribution are characteristic of this low-grade B-cell lymphoma.

	MALT lymphomas have indolent clinical courses and usually maintain sustained localization in their primary extranodal site. These characteristics led Saltzstein to coin the term “pseudolymphomas,” and these do not require aggressive therapy.

 Limited local excision, with or without low-dose chemotherapy, has been shown to be curative. We present a rare case of primary pulmonary low-grade B-cell lymphoma of the MALT variety, associated with an IgM kappa monoclonal gammopathy.

 A 75-year-old black man presented to the department of pulmonary medicine reporting weakness and a persistent, sputum-producing cough. He had been hospitalized recently for exacerbation of chronic obstructive pulmonary disease and since then had grown progressively weaker and had a notably decreased appetite.

	His chest radiograph showed a new interstitial pulmonary infiltrate at the right lung base, superimposed upon severe underlying interstitial fibrosis (Figure 1). Subsequent computed tomography (CT) scans confirmed the findings and provided evidence of end-stage pulmonary fibrosis with honeycomb changes (Figure 2). There was also consolidation of the right lower lung, consistent with lobar pneumonia, a small right pleural effusion, and cystic changes in the right upper lung, secondary to bronchiectasis. A bronchoscopy revealed no endobronchial lesions, and transbronchial biopsies showed no evidence of tumor. Cultures of the bronchoscopic specimens returned no evidence of mycobacterial, fungal, or other bacterial etiology for the pulmonary infiltrate. A presumptive diagnosis of community-acquired pneumonia was made and the patient was treated with antibiotics.

	The patient’s pulmonary infiltrate did not improve, and further diagnostic testing was undertaken. His serum IgM level was elevated to 2,769 mg/dL (average level for males older than 13 years is 22—240 mg/dL and 33–293 mg/dL for females older than 13 years). Serum protein electrophoresis demonstrated a monoclonal protein. Serum protein immunofixation electrophoresis revealed a monoclonal gammopathy of the IgM kappa type. Urine protein immunofixation electrophoresis found monoclonal-free kappa light chains. Bone marrow biopsy showed an abnormal, increased small lymphocyte population. Cytogenetic analysis demonstrated a translocation between the long arm of chromosome 11 at region 2, band 1, and the long arm of chromosome 18 at region 2, band 1 [t(11;18)(q21;q21)].

	Based on these findings, a diagnosis of Waldenström’s macroglobulinemia (WM) was made, and the patient was treated with fludarabine (an antimetabolite). The pulmonary infiltrate persisted, and the patient underwent a right thoracotomy, with a right lower lobe wedge lung biopsy. The lung tissue showed a diffuse, interstitial small lymphocyte infiltration of the interalveolar septae and bronchioles (Figure 3), which corresponded to the new infiltrate seen on his chest radiograph. No lymphocytoplasmic features were present. Immunohistochemical stains showed the lymphocyte infiltration was composed of uniform small B-cell lymphocytes that were positive for CD20 (Figure 4) and bcl-2. These cells were negative for CD3, CD5, CD10, and bcl-1 (cyclin D1). Based on the histopathologic, immunohistochemical, and cytogenetic findings, the diagnosis of a primary extranodal low-grade B-cell marginal zone lymphoma (MZL) of the MALT variety was made.

	The patient had a normal recovery and was discharged to home in stable condition on postoperative day 7; however, 1 month later, the patient was readmitted with exacerbation of chronic obstructive pulmonary disease and intubated. At the request of his family, all ventilatory support was withdrawn, and the patient died on hospital day 7.

 In the early 1990s, 19 European and American hematopathologists met to establish an updated classification of lymphoid neoplasia. The group was known as the International Lymphoma Study Group, and their new classification came to be known as the Revised European and American Classification of Lymphoid Neoplasms (REAL).

 REAL differed from the Kiel classification because it was based not only on morphology but also on genetic and immunologic criteria. REAL defines seven major categories of non-Hodgkin’s B-cell lymphoma: chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL), B-prolymphocytic leukemia, mantle cell lymphoma (MCL), MZL, lymphoplasmacytoid lymphoma (LPL), follicle center lymphoma (FCL), and hairy cell leukemia (HCL).

 Today, REAL is widely accepted by hematologists and pathologists. Morphologic, immunophenotypic, cytologic, and genetic data are obtained and integrated for a precise diagnosis and classification.

	MZL is further divided into extranodal (MALT), nodal, and splenic types. MALT lymphoma is characterized by a monoclonal B-cell proliferation in and around various mucosal tissues. The lymphoma cells have been described as “centrocyte-like,” due to their small size and slight nuclear clefting. The diagnosis of extranodal MZL, MALT type, includes the histopathologic observation of a diffuse sheet-like infiltrate of marginal zone B-cells with the characteristic lymphoepithelial lesions. The lymphomatous infiltrate may be found within the epithelium of the gastrointestinal tract, bronchioles, or salivary glands. Paradoxically, MALT lymphomas rarely arise where MALT is normally present. The reason for this seems to be that MALT lymphomas generally arise in lymphoid tissue that has been altered as a result of some preexisting inflammatory disorder, such as 

colonization in the stomach or follicular bronchiectasis in the lungs.

	Immunohistochemical testing of tissue samples will be positive for CD20; negative for CD5, CD10, bcl-1, and bcl-6; and positive or negative for bcl-2 (Figure 5). CD20 is positive in all small B-cell lymphomas. The protein bcl-1, characteristic of MCL, is universally negative for MZL. CD5 is useful at this level to differentiate MZL from SLL. There have been reports of CD5-positive MZL, but these are uncommon.

 CD10 and bcl-6 are useful for differentiating FCL from MZL. Expression of the bcl-2 protein is not helpful, because both FCL and MZL may express bcl-2 in a large percentage of cases.

	One of the most recent keys in diagnosing extranodal MZL of the MALT type is finding a structural karyotype abnormality in the presence of the clinical and pathologic features previously outlined. One focus of current genetic research is the resistance of 

 to antibiotic therapy. It previously has been shown that eradicating 

 with antibiotics leads to regression and cure of gastric MALT lymphoma in 75% of cases.

 Subsequent studies have shown that a large proportion of antibiotic-resistant MALT lymphomas have genetic anomalies that may confer this resistance. Many genetic abnormalities have been reported, including t(9;14)(p13;q32), t(11;18)(q21;q21), t(1;14)(p22;q32), or 6q21 deletions.

	Cytogenetic studies have shown that t(9;14)(p13;q32) is associated with LPL in approximately half of patients who lack a monoclonal paraprotein.

 REAL classifies WM, which is characterized by the presence of an IgM paraprotein, as an LPL. This specific translocation up-regulates the PAX-5 gene, known to be involved in multiple neoplasias.

 The PAX-5 gene encodes for a transcription factor, B-cell-specific activation protein (BSAP), which is needed for B-cell development. Up-regulation of BSAP appears to increase B-cell proliferation.

 Studies of gastric MALT lymphoma have shown t(11;18)(q21;q21) in approximately 30% of cases.

 This translocation leads to the expression of a chimeric transcript fusing the 5’ end of the apoptosis inhibitor-2 gene to the 3’ end of the novel MALT lymphoma-associated translocation gene. Liu and associates report that, although infrequently, t(1;14)(p22;q32) has been found in association with MALT-type lymphoma.

 This translocation deregulates another novel gene, bcl-10, which is proapoptotic. A 2002 study showed that between 42% and 63% of MALT lymphomas studied had deletions of 6q21.

 Fluorescence in situ hybridization (FISH) and reverse transcriptase polymerase chain reaction (RT-PCR) are the current technologies used to detect these karyotype abnormalities.

	In 1948, Waldenström described a malignancy of lymphoplasmacytoid cells that produce IgM monoclonal proteins.

 The sex and age distribution of WM among patients is similar to MZL in that the disease is slightly more common in men and the incidence increases with age.

 The clinical manifestations and laboratory abnormalities are related to direct tumor infiltration and to the amount and specific properties of IgM.

WM is often associated with lymphadenopathy and hepatosplenomegaly. The most serious clinical manifestation is hyperviscosity syndrome, due to the large size of the IgM protein molecule. Patients who progress to this syndrome may present with the classical triad of visual changes, mental status changes, and bleeding.

 Monoclonal IgM immunoglobulins may also cause cold agglutinin disease and cryoglobinemia. WM may involve bone marrow, as originally described by Waldenström, but unlike multiple myeloma, it does not cause lytic bone lesions or hypercalcemia.

 A serum IgM monoclonal protein is present in the serum in excess of 30 g/L (average for males older than 13 years is 0.22—2.40 g/L and 0.33”-”2.93 g/L for females older than 13 years). Renal excretion of the corresponding light chains is uncommon but is found in up to 20% of patients, of whom 80% excrete free monoclonal light chains of the kappa isotype.

	LPL and CLL/SLL may cause WM. Some authors have suggested that it can also be caused by extranodal MZL (MALT type) and that this entity should be considered when making the differential diagnosis for patients who exhibit the clinicopathologic features of WM.

	The treatment of WM differs greatly from the treatment of MALT lymphoma. An effective treatment for WM is chemotherapy with 25 mg/m

 of fludarabine daily for 5 days, every 4 weeks. Because 80% of the IgM paraprotein is intravascular, plasmapheresis may be used in cases of serious hyperviscosity.

 Extranodal MALT lymphomas often take an indolent course and remain localized at their primary site for a long time, making local surgical excision highly effective. MZL also responds to low-dose (30—36 Gy) radiation therapy, and a 2002 study showed an overall 5-year survival rate of 83% to 90%, regardless of clinical stage.

 Newer treatments have shown promise, including cladribine (2-chlorodeoxyadenosine), a purine analog that has revolutionized treatment of HCL, inducing complete remission in 84% of patients studied.

 Hyper-CVAD protocol consists of administering 300 mg/m

 fractionated cyclophosphamide twice daily for 3 days, 50 g/m

 doxorubicin on day 4, 2 mg vincristine on days 4 and 11, and 40 mg dexamethasone on days 1 through 4 and 11 through 14. This regimen, combined with stem cell transplantation, has also been shown to improve prognosis.

 Although primary pulmonary low-grade B-cell lymphomas of the MALT variety are rare, they represent a distinct subset of non-Hodgkin’s lymphomas. Their propensity to remain indolent in their primary extranodal site makes local resection curative in most cases. The clinical presentation of these lymphomas and their ability to produce IgM monoclonal proteins can make definitive diagnosis challenging. In our case, a monoclonal IgM gammopathy was initially interpreted as indicative of WM. Of patients with MALT lymphoma, 43% may have a monoclonal gammopathy, with half of these patients having an IgM isotype.

 The presence of an IgM monoclonal protein in serum may be seen in a variety of conditions and should direct the workup toward genetic and immunohistochemical techniques to obtain a definitive diagnosis.

 1. Freeman C, Berg JW, Cutler SJ. Occurrence and prognosis of extranodal lymphomas. 

	2. Murakawa T, Nakajima J, Tanaka M, et al. Primary low-grade B-cell lymphoma in mucosa-associated lymphoid tissue of the lung.

	3. Kurtin PJ, Myers JL, Adlakha H, et al. Pathologic and clinical features of primary pulmonary extranodal marginal zone B-cell lymphoma of MALT type. 

	4. Saltzstein SL. Pulmonary malignant lymphomas and pseudolymphomas: classification, therapy, and prognosis. 

	5. Chan JK, Banks PM, Cleary ML, et al. A revised European-American classification of lymphoid neoplasms proposed by the International Lymphoma Study Group. A summary version. 

Articles

Surgical Rounds

Scott M. Schulze, Chief Resident in General Surgery ; Mathew M. Edavettal, Resident in General Surgery, ; Louis Fares II, Chairman of Surgery,  Joseph Costic, Chief of Thoracic Surgery, Department of Cardiothoracic Surgery; Robert Moser, Medical Director of Pathology, Director of Medical Informatics, Department of Pathology; Joseph Steeger, Chief of Pulmonary Medicine, Department of Pulmonary Medicine, Seton Hall University School of Graduate Medical Education, 

malt Lymphoma of the Lung Presenting With an igm Monoclonal Gammopathy

								Division of Trauma, Emergency Surgery, and Surgical Critical Care

Injury to the thoracic aorta after blunt trauma is rarely caused by rib frac

tures. The authors report a unique case of such an injury and review the literature, which yielded six similar cases. Most of these patients had delayed presentations. Although expectant management has been used with some success when foreign objects are found abutting large vessels, rib fractures should be considered differently. Based on the few cases reported in the literature, reduction of the displaced rib under controlled circumstances by a team prepared for a rapid thoracotomy offered the best chance for survival. 

	Thoracic aortic injury is usually a deceleration injury that occurs after blunt trauma. These injuries are typically located at points of aortic fixation, such as the ligamentum arteriosum. The presence of first and second rib fractures is considered an indicator of high-energy transfer and cited as a risk factor for blunt injury to the thoracic aorta. Lower rib fractures may coexist with thoracic aortic injuries but are not considered risk factors when other findings, such as a widened mediastinum, are absent. On rare occasions, the sharp edges of rib fractures have caused aortic lacerations.

 In all such cases, a significant mechanism of injury, multiple rib fractures, and associated injuries were present. We report a case of delayed aortic rupture from a posterior rib fracture following a low-level fall. The cumulative literature suggests that a displaced posterior rib fracture adjacent to the aorta requires intervention to prevent aortic injury.

 A 62-year-old woman presented to the emergency department of another hospital reporting moderate left posterior chest wall pain after falling 5 feet from a stepladder while cleaning her windows. The patient was hemodynamically stable. A plain chest radiograph was unremarkable. A computed tomography (CT) scan of her chest identified left-sided fractures of ribs 9 through 12, with the posterior spiked edge of the 10th rib adjacent to the descending aorta (Figure 1). There was a small left hemothorax but no periaortic hematoma or evidence of aortic injury. A CT scan of her pelvis showed a right sacral ala fracture and a left superior ramus fracture. She had a calculated Injury Severity Score (ISS) of 5 and was transferred to our hospital 6 hours after the injury.

	The patient was hemodynamically stable upon arrival at our institution and had a blood pressure of 132/77 mm Hg, heart rate of 75 beats per minute, and a score of 15 on the Glasgow Coma Scale. The patient was in moderate discomfort due to pain. Following review of the CT scans, different management options were contemplated; however, the decision was made to treat her expectantly, mostly due to her excellent condition many hours after the injury and the absence of any radiographic evidence of aortic injury. Her initial hematocrit was 37.1%, and a follow-up hematocrit several hours later was 31.4%. An interim chest radiograph showed no evidence of increasing effusion, but the patient was admitted to the surgical intensive care unit and a follow-up CT scan was ordered.

	The next morning (nearly 24 hours after the injury), as the patient was being prepared for transfer to the CT suite, she coughed and immediately reported left-sided chest pain. Within minutes she became hypotensive to a blood pressure of 60/40 mm Hg. A left tube thoracostomy drained over 1 L of blood, and the patient momentarily regained a blood pressure above 90 mm Hg. As urgent preparations to move her to the operating room were being made, she lost vital signs, and an emergency left thoracotomy was performed at the bedside. Upon entry into the chest, a large amount of fresh blood was encountered and evacuated, and the aorta was cross-clamped. Her heart was empty and would not restart despite massage, intracardiac epinephrine, and defibrillation. A Foley catheter was placed in the right atrium for rapid infusion of blood, but to no avail.

	Simultaneous examination of the de-scending aorta revealed a 2-cm ragged laceration adjacent to a sharp, isolated, protruding edge of the fractured 10th rib (Figure 2). The patient was pronounced dead. No other chest injuries were identified.

 It is understandable how a penetrating, on-blunt mechanism of injury can cause a fractured rib and descending aortic laceration, but one would think that the mechanism of injury must be significant to cause fracture and displacement of a rib at this posterior?almost paraspinal?location. As shown by our report, even seemingly minor mechanisms of injury can result in rib fracture and aortic laceration. Elderly patients with fragile osteoporotic ribs may be at particular risk. It is possible that aortic perforations from rib fractures are more common than currently thought but remain undiscovered because patients do not reach the hospital alive due to immediate exsanguination from the aortic laceration or from other associated injuries.

	The literature contained six reports of aortic injury from a rib fracture in the setting of significant blunt trauma.

 All but one of those cases manifested in a delayed fashion (3 to 15 days after injury). The rib fractures were identified on hospital admission, and, in most cases, CT scans of the chest showed the rib fragment in close proximity to the aorta. In one case, a patient with an ISS of 4 underwent thoracoscopy 8 days after a fall from a tree for drainage of a left hemopneumothorax seen by chest radiograph only.

 Rib fractures were found, but no aortic injury or source of bleeding was observed at that time. One week later (post-trauma day 15), recurrent hemothorax prompted a repeat thoracoscopy, which was converted to a thoracotomy and revealed an actively bleeding aortic laceration at the site of a 9th rib fracture. The aorta was repaired primarily and the rib fragment was resected.

	In another case, sudden shock developed 3 days after a motorcycle accident in a patient with an initial ISS of 9.

 During thoracotomy, an aortic laceration with a surrounding pseudoaneurysm was found adjacent to a sharp 6th rib fracture.

 Although it was clearly the source of a large hemothorax, it was not actively bleeding at the time of the operation. No CT scans of the chest had been done during admission.

	A third case involved a motor vehicle collision where the patient sustained multiple bilateral rib fractures, which resulted in flail chest, lung contusions, and bilateral small hemopneumothoraxes requiring thoracentesis.

 The patient had an estimated ISS of 9, and sudden shock occurred 10 days after the injury following a "body position change." An emergency thora-cotomy identified an aortic laceration adjacent to the sharp edge of a fractured left 8th rib, which was repaired primarily.

	The fourth reported case involved an 8-foot fall, and the patient had an ISS of 4.

 Aortic injury was identified by aortography, and a CT scan of the patient's chest showed the injury adjacent to a displaced left 6th-rib fracture. At initial presentation, a chest tube had been placed for a small left hemothorax. Seven hours later, after a "body position change," the chest tube suddenly drained over 1,000 cc of blood; the patient died on the way from the angiography suite to the operating room.

	The fifth case resulted from a motorcycle accident.

 A left chest tube was placed for a small hemopneumothorax, and 11 days after injury, the patient became hemodynamically unstable during chest physiotherapy and the chest tube suddenly drained 2 L of blood. Emergency thoracotomy revealed a puncture site on the posterior aspect of the aorta, adjacent to the spiculated end of a fractured rib. The aorta was repaired primarily.

	The last case involved a patient who presented in shock after a 15-foot fall.

 A left chest tube was placed for a large hemothorax, which drained more than 1,500 cc of blood. The patient was immediately transported to the operating room where thoracotomy revealed an actively bleeding aortic laceration adjacent to a rib fracture. The injury was repaired primarily and the rib fragment was resected.

	Five of the six patients discussed were successfully resuscitated, and all but one demonstrated no evidence of aortic injury on admission. In these cases of delayed aortic bleeding, it is unclear whether the perforation of the aorta was present but sealed at the time of admission or if it occurred later due to movement or cough; the latter scenario may be more likely. If a laceration existed from the beginning, one would expect the initial CT scan to show evidence of aortic injury, such as a small pseudoaneurysm or periaortic hematoma. On the other hand, inspection of our patient's rugged laceration did not give the macroscopic impression of a fresh laceration.

	The management of thoracic aortic injuries following blunt trauma is controversial. Although expectant management has been safely undertaken when foreign objects such as bullets or shrapnel are abutting large vessels, this strategy does not appear to be safe when rib fractures abut the aorta. On the other hand, a full thoracotomy might have unacceptable morbidity if the aorta is not found to be injured and the operation is done only to reduce one rib. Performing rib reduction or resection through a local extrapleural incision may be the optimal choice. This procedure can cause acute bleeding during manipulation of the rib, particularly if the edge of the rib is tamponading the laceration; thus, this operation must be performed with a team capable of rapidly opening the chest and addressing the bleeding. Unfortunately, even under the best circumstances, an aortic laceration bleeding freely into the thoracic cavity may produce death within minutes.

 Our case of aortic laceration from a rib fracture is unique because it involved a patient who experienced a minor traumatic event and had few associated injuries. Although such cases are rare, when a fractured rib is abutting the aorta, catastrophic outcomes are possible even when there is no evidence of direct vascular injury. There is no ideal therapeutic option to treat such patients, but the risk-to-benefit ratio seems to indicate that reduction of the displaced rib under controlled circumstances in the operating room, fully prepared for a rapid thoracotomy, yields the best outcome.

 1. Iyoda A, Satoh N, Yamakawa H, et al. Rupture of the descending thoracic aorta caused by blunt chest trauma: report of a case. 

	2. Marco JV, Gregory JS. Posterior fracture of the left sixth rib causing late aortic laceration: case report. 

	3. Kigawa I, Fukuda I, Fujii Y, et al. A sharp edge of the fractured ribs caused the aortic injury at body-position change: a case report [in Japanese]. 

	4. Hsu YP, Chen RJ, Bullard MJ, et al. Traumatic thoracic aortic injury caused by a sharp edge of left fractured rib on body position change: case report. 

	5. Ashrafian H, Kumar P, Sarkar PK, et al. Delayed penetrating intrathoracic injury from multiple rib fractures. 

	6. Kern JA, Chan BB, Kron IL, et al. Successful treatment of exsanguinating aortic injury from a fractured rib. 

	Choose the best answer for each question or incomplete statement.

1. Rib resection to prevent aortic injury should be considered in which one of the following patients?

 Those with a displaced protruding fracture of the left lateral 7th rib.

 Those with a displaced protruding fracture of the right posterior 7th rib.

 Those with a displaced protruding fracture of the left posterior 7th rib.

 Those with a nondisplaced fracture of the right lateral 7th rib.

 Those with a nondisplaced fracture of the left posterior 7th rib.

2. Injury to the aorta in the setting of a displaced rib fragment can occur at all of the following time points except:

 1 day post-trauma, when resuming physical therapy.

 on admission to the emergency department.

3. Following penetrating injuries to the chest, emergency resuscitative thoracotomy at the bedside is indicated when:

 The blood pressure (BP) is less than 90 mm Hg even if the patient is mentating.

 The BP is less than 70 mm Hg even if the patient is mentating.

 The BP is more than 70 mm Hg but immediate chest tube output is higher than 2 L.

 The BP is unrecordable for at least 30 minutes.

 The BP is less than 60 mm Hg, the patient is not mentating, and the operating room transport time is more than 10 minutes.

4. Fractured and spiculated ribs can produce any of the following injuries except:

Elizabeth A. Sailhamer, General Surgery Resident, Department of Surgery, Massachusetts General Hospital; George C. Velmahos, Professor and Chief, Division of Trauma, Emergency Surgery, and Surgical Critical Care, Massachusetts General Hospital, Harvard Medical School, Boston, MA 

Rib Fracture Causing Delayed Aortic Laceration

	Although the bursting of the Inter?-?net stock bubble during the "roaring 90s" left a bad taste in the mouths of investors everywhere, the authors of 

 (John Wiley & Sons; 2006) assert that too many people are unaware of the looming and inevitable risks of today's economy. The authors examine the characteristics of economic bubbles and explain that America's current economy is one giant bubble comprised of many smaller ones, and these smaller bubbles are teetering towers of instability destined to come crashing down. The authors refer to the resulting giant financial shakeup as a "bubblequake." Besides describing the classic characteristics of finance?-?related bubbles, the book outlines important pitfalls to sidestep, such as the use of adjustable?-?rate debt, purchasing real estate other than for personal use, and dependency on fixed?-?payment pensions. 

 helps investors understand bubbles and how to profit from them without getting crushed by their inevitable collapse. The authors don't promise pie?-?in?-?the?-?sky riches; they simply offer lucid, commonsense explanations of why our bubble economy is so unstable and how smart surgeon investors can profit from its inevitable pop.

 One of the most recent Internet scams is known as "brand spam," in which scammers use a well?-?known company logo (eg, Home Depot, Starbucks) to lure na?ve Web surfers into forking over their personal information. According to 

, the scammers send out e?-?mails that propose such wonders as a $500 Home Depot gift card if you fill out a simple survey on their Web site, which is entirely bogus. When you enter your personal data to obtain that free gift card, you give the scammers everything they need to sell your information to other spammers. Many of these phony offers include user agreements that coerce you into signing up other people for the promo, which adds to the cycle of swindle. Many of the companies whose familiar logos are being used, such as Wal?-?Mart, warn consumers that they never offer Internet giveaways such as these. So, if you should ever receive an e?-?mail offer?-? ing you $100 in free Starbucks coffee, do yourself a favor and delete it immediately.

Discover The Best Place To Keep Your Cash

	Top Wall Street strategists are advising surgeon investors more strongly than ever to keep a quarter of their money in cash, but deciding where to store that hard?-?earned cash may be confusing. According to the 

, there are quite a few options a cash?-?conscious surgeon should consider. The classic savings account now resides primarily online through sites such as INGdirect.com, HSBCdirect.com, and Emigrant.com. When choosing this option, the 

 suggests transferring money back and forth between your checking and savings accounts, maximizing the money earned but keeping just enough money in your checking account to cover bills. Another cash option is to place your funds in one of the various money market accounts (MMAs). These include bank MMAs, which offer privileges much like checking accounts but with higher annual percentage yields (APYs), and the number of transactions you can make per month is limited. The other MMA option includes mutual funds, which can offer either taxable or tax?-?free yields. These funds make the most sense if you want to store your stock proceeds before moving the money to another stock. The 

 indicates that CDs offer the best yield, because you can earn an APY of up to 5%; however, since you are required to leave your cash in a CD for at least 6 months or face stiff penalties, this option demands patience. When shopping for the best rates, don't forget to check out some of the smallest banks, such as Millennium Bank and State Bank of India. Small banks sometimes offer the highest rates of return.

	When it comes to financing major purchases such as a house or car, most surgeons are concerned only with their credit score, but there is a secondary score that consumers should be aware of, because it can influence what they can buy: the bankruptcy risk score. According to Bankrate.com, financial institutions use bankruptcy risk scores when they want to dig deeper into a consumer's credit history. This score is more specific than a credit score because it gauges how likely someone is to file for bankruptcy; however, unlike credit scores, this score is not available to the public. The reasoning for this is cloudy, but experts think that the firms that spent a great deal of time and money researching the scoring model want to protect the value of their research. Despite this, Experian is considering making bankruptcy risk scores available to consumers so they can get a better idea of their debt. You can improve your bankruptcy risk score in much the same way as your credit score by paying your bills on time, keeping debt low, and opening accounts only when needed.

Protect Yourself From Mishaps With Accidental Death Insurance 

 Many cautious?-?minded people out there would love to have insurance before they embark on a potentially unsafe situation, such as a commercial flight. The good news, according to Bankrate.com, is that you most likely already have such an insurance policy in your wallet. Accidental death and dismemberment (AD&D) insurance is offered in some form with each of the four major credit card brands: Visa, MasterCard, American Express, and Discover. The AD&D coverage differs depending on which credit card brand you use, providing anywhere from $100,000 to $1 million in insurance coverage. As long as you purchase your ticket with a credit card that has AD&D insurance locked in, you are covered. This applies to any type of travel deemed a "common carrier conveyance," which includes commercial flights, trains, buses, or boats. In a worst?-?case scenario, it is a nice little piece of insurance that you probably didn't even know you had. Check with your credit card issuer to see if your card includes an AD&D policy.

Mortgage Lenders Still Making High?-?Risk Loans

, when the housing market quieted down and interest rates went up, many experts predicted that there would be a slew of mortgage foreclosures and bank losses, but this has not happened yet. However, delinquency rates have begun to creep up, jumping to 4.7% in the fourth quarter of 2005. Despite the housing market slowdown, many lenders are still forging ahead with the aggressive loans they relied on during the housing boom. Although this is good news for a surgeon with subpar credit who is trying to get a loan approved, the Federal Reserve is angry that lenders are persuading prospective borrowers to accrue even more debt by offering loan terms such as low minimum payments and little or no documentation required. The bad news is that repayment terms on $1.3 trillion of adjustable?-?rate loans will go up this year and the next, meaning some borrowers will have to pay up to 150% more than their current monthly payment. This could lead to many borrowers defaulting on their loans, which would cause serious financial troubles for aggressive lenders.

Banks Reel In New Customers With A Variety Of Tricks

	The days of offering customers free toasters for opening a new bank account are over. Banks now attract new customers in more creative ways. According to 

, many banks have given themselves extreme makeovers, going from a cold institution to something more akin to a coffee shop, complete with digital music kiosks and cybercaf?s. They have hired behaviorists to profile customers and technology consultants to incorporate cutting?-?edge gadgetry and systems in their branches. Banking corporations are using new technology to monitor transactions, such as credit card purchases, online inquiries, and call?-?center complaints, so they can form a picture of what the individual customer wants. In a 

 example, if a couple uses a credit card to purchase flowers, an expensive cake, and a vacation in a short span of time, they are likely newlyweds and may soon need a mortgage; if someone shops at Home Depot several times a month, the bank may offer them a home equity product. Banks are taking their cue from retailers, who have long used consumer data and profiles to determine what customers want, what they'll do, and when they'll do it.

	Your children may soon be taught about the stock market and investing in between lectures on the Pythagorean theorem and 

, and major corporations are eager to become their teachers. Personal finance courses have already been incorporated into some public school curriculums, offering students the opportunity to learn about the dangers and perks of money management. According to the 

, in March 2006 Texas started screening personal finance programs developed by companies such as Wells Fargo & Co, Citigroup Inc, and Visa USA Inc. Schools in South Carolina, Missouri, and Virginia will soon follow suit. In South Dakota, personal finance classes are set to become a graduation requirement, and students will be offered courses on using credit cards, analyzing health insurance, and calculating taxes. People younger than 25 years of age constitute one of the fastest growing groups of bankruptcy filers, and individuals between the ages of 18 and 24 have seen their credit card debt increase more than 100% in the past decade, according to recent research published in the 

. Although many may suspect the educational material developed by banks, financial advisors, and credit card issuers of exerting commercial influence, most companies are sensitive to the issue and maintain that they are not leaving brochures behind. These companies also do not link their corporate Web sites to tutorial programs.

	With all the talk of overseas investing in countries such as China and India, many surgeon investors are overlooking financial opportunities in their own backyard. Municipal bonds (ie, bonds issued by state and local governments to help fund state spending) are a solid way to increase the returns provided by your fixed?-?income investments, particularly at a time when the gap in the yield between short?-? and long?-?term Treasury bonds is negligible. According to the 

, municipal bonds (munis) are exempt from federal, state, and local taxes if you purchase them in your home state. Because of this, munis compare favorably with Treasury bonds. Munis are especially attractive to investors in high tax brackets, a category that includes most surgeons, due to their tax?-?exempt status. Munis have attracted little interest from foreign investors, which means they offer a degree of protection in the event of a bond?-?market selloff. The 

 advises you to keep munis out of your retirement accounts, such as your 401(k) and IRA plans, because the tax advantages of munis will be nullified when you withdraw funds. Instead, hold munis in a taxable account, such as a brokerage account.

	If you're like many surgeons, you initially entered medicine as a way to contribute something positive to the world. Wouldn't it be nice if your financial portfolio could reflect that ideal while still bringing in competitive returns? It can, says a 

 magazine article on socially responsible investments (SRIs). SRIs that invest in large-cap companies brought in an average return of 11.99% over the past 5 years, a mere 0.61% difference from their regular counterparts (at 12.60%). Investors have taken notice of this, and SRIs grew a staggering 321% between 2000 (at $9.5 billion) and 2005 ($40 billion) according to Morningstar. In that same period, the number of funds available expanded from 78 to 222. Some of Morningstar's top 1-year performers included Amana Growth, Winslow Green Growth, Alger Socially Responsible Growth Institutional (Share Class I), Amana Income, and Amana Socially Responsible Growth Institutional (Share Class R). Since there are no standards for what constitutes an SRI, be sure to read your prospectus carefully.

Use Annuities To Enhance Retirement Income

	There likely isn't a surgeon out there who is completely comfortable with his or her finances heading into retirement. An 

article finds a good solution to retirement income in annuities. Firms currently offer variable annuities that are evolving in inventive ways to meet the needs of the retiring baby boom generation. In the past, annuities offered living benefits in one of three categories:

	 Guaranteed minimum-income benefit?This guarantees that you won't receive less than a minimum level of annual income for life, despite the annuity's performance.

	Guaranteed minimum-accumulation benefit?This one guarantees that you will receive the greater of the contract value no matter how the annuity performs or the return of your initial investment, provided the contract is held for a specified amount of time.

	 Guaranteed minimum-withdrawal benefit?This benefit guarantees the return of your principal through a series of withdrawals that are subject to an annual limit, usually 5% to 7% of the guaranteed amount of the contract.

	Recently, hybrid annuities have been introduced that merge the principal protection of the accumulation benefit with the earning power of the income and withdrawal benefits. These plans provide more flexibility than past annuities and let you choose how to take your money during the distribution phase and make immediate withdrawals.

	The changing colors of leaves in the fall, the white coating of trees in the winter, the budding flora in the spring, and the sizzling sand of beaches in the summer come at a steep price in the Northeast. According to CNNMoney. com, this year the Tax Foundation found that five of the ten least tax-friendly places to live are Maine, New York, Rhode Island, Connecticut, and Vermont. The Foundation determines its rankings by calculating what residents pay as a percentage of per capita income in property, sales, income, and other personal taxes imposed at the state and local levels. Results also include the portion of business taxes passed on to state residents through higher prices, lower wages, or lower profits. If you're a surgeon looking to retire in a tax-friendly state, Alaska, New Hampshire, Delaware, Tennessee, and Alabama made up the top five?beating out the most notable retirement haven, Florida. ?

	The cost of gas today can be aggravating and financially taxing. Although driving fewer miles or trading in your SUV will help keep costs down, these are impractical solutions, especially for busy surgeons who are constantly on- call. A recent article in the 

?offers the following tips for those whose pain at the pump cannot be alleviated easily:

	Invest in energy stocks (eg, Devon Energy, Whiting Petroleum, El Paso, or Energy Partners). Sometimes gains will more than make up for the extra fuel costs.

	Compare local pump prices on Web sites such as gasbuddy.com or gaspricewatch.com. A difference of a few cents can go a long way, but only if you do not have to go out of your way to get to the cheaper gas station.

	Apply for a credit card that refunds 5% of all gas purchases (eg, Chase, CitiCards, American Express, or Discover). If a card caps your annual refund, hit the limit, retire the card, and start over with a competitor's card.

The Long And Short Of Making Money With Funds 

	Surgeon investors looking to preserve capital may want to consider the split-personality world of long-short funds. According to the Wall Street Journal, long-short funds make money by betting that some stocks will increase in price while others will decrease. The "long" half refers to investments in securities, while "short" refers to short selling, where a borrowed stock is sold in hopes of buying it later at a lower price to return to the lender. This bizarre approach to investing is actually more conservative than it appears. Long-short funds could help your portfolio remain diversified and possibly rise in value during expansive market declines. Currently, long-short funds are only offered by a few firms; more widely known fund companies such as American Century Investments and Janus Capital Group have announced plans to introduce their own long-short funds soon. Long-short funds do have shortcomings, including complicated strategies and higher fees than regular stock funds.

Land Tax Benefits With Conservation Easements 

Surgeon's Bulletin Board

     Your column in the July 2006 issue of 

 is right on the      money! In an extensive bariatric surgical practice that started with the      jejunoileal bypass in the early 60s, it was soon apparent that these      patients were at serious risk of developing significant      metabolic side effects.?I performed?about 150 of these operations, and I      called upon colleagues&#8212;mainly gastro&shy;enterologists&#8212;not      infrequently during the follow-up months and years. I never considered it      necessary or helpful to involve dietitians.   

     The gastric bypass operation is more physiological than      the jejunoileal bypass.?Gastric bypass patients require meticulous      instruction on how to eat after surgery. I would spend extra time with them      and their family members explaining that patients would have a miniscule      stomach, which they needed to heed. They were told to desist eating as soon      as they felt full and not to eat more than three tiny meals daily.?  

     Unrequested were the dietitians, who would promptly      sabotage me! They would interview the patients at the hospital, offering      several handouts advising that they should take &#8220;small meals every 2      hours.&#8221; I was trying to limit the patients to approximately 800      calories a day, knowing full well they would exceed that.?Why anyone      expects that dietitians, and for that matter &#8220;weight?doctors,&#8221;      can help the morbidly obese lose weight and maintain a significant amount      of weight loss over an extended period of time escapes me.?The published      results show an extremely high recidivism rate. Dieticians and      nutritionists may be good at helping cachectic patients regain health, but      they have an extremely poor ability to get patients to lose weight. I agree      with you that &#8220;the role of dietitians in hospital care is greatly      exaggerated.&#8221;      

     Following July&#8217;s editorial &#8220;Carrots,&#8221;      I strongly feel the need to respond on behalf of the nation&#8217;s      registered dietitians. I appreciate Dr. Jaffe stating that he respects the      &#8220;concept and the scientific field of dietetics.&#8221; Your readers      may be interested in some of the realities of dietetics as well.  

     For a multifactorial disease state such as obesity, the      key for successful patient outcomes is teamwork. Just as surgery is not a      stand-alone cure, we know one or two visits to a registered dietitian will      not lead to long-term success; however, consultations with a registered      dietitian do lead to success when a patient continues to follow up over      time. According to the American Dietetic Association&#8217;s (ADAs)      position on weight management, &#8220;For effective weight management      treatment, the client should be assessed by a multidisciplinary team,      including a physician, registered dietitian, exercise physiologist, and a      behavioral therapist. Through the team approach, issues such as nutrition,      physical activity, and change in eating behavior can be coordinated.&#8221;        

     ADA&#8217;s new Adult Weight Management practice      guidelines, based on a rigorous evaluation of the available science,      identify what we know works and what does not, paying particular attention      to nutrition assessment factors, dietary interventions, selected dietary      approaches, physical activity, behavioral interventions, medication, and      planning for bariatric surgeries. The following recommendation for      practitioners is based on what ADA concludes is strong evidence:      &#8220;Weight loss and weight maintenance therapy should be based on a      comprehensive weight management program including diet, physical activity,      and behavior therapy. The combination therapy is more successful than using      any one intervention alone.&#8221;      

Judith A. Gilbride, PhD, RD, CDN           

   President, American Dietetic Association    

     As a fellow &#8220;gastric bypass surgeon,&#8221; I      read your editorial in the July issue of Surgical      Rounds with considerable interest.      Although I believe that dietitians can be quite helpful to postoperative      gastric bypass patients, I agree with most everything else in your      editorial. I was particularly interested in your comment that the routine      notes by hospital dietitians, which are required/legislated in New Jersey      and perhaps nationwide, can serve as a source of professional liability.      Fortunately, I have not had any personal experience in that area. However,      I agree that these notes (which I also never read) contribute substantially      to increased hospital costs. I am not sure how we can get the attention of      the legislators and administrators who seem to think that there is value in      these notes. Although I appreciate the contributions of hospital-based      dietitians to the care of my malnourished patients, their role in charting      on well-nourished, healthy patients who are admitted for elective      orthopedic operations is a total waste of time and money.      

	Hypothenar hammer syndrome is a rare condition that is caused by repeatedly using the base of the palm like a hammer, which damages the ulnar artery and may cause an aneurysm to form. Patients generally present with loss of sensation in the affected hand and painful digits that are cyanotic and sensitive to cold due to aneurysm thrombosis, embolization, or both. Although the condition can sometimes be treated medically, surgery may be required. The following case report is of symptomatic hypothenar hammer syndrome in a male patient who required surgery. A review of the literature is also provided.

 A 68-year-old man came to the emergency department reporting acute pain in his left ring finger, which he had been experiencing for the previous 4 to 6 hours. The pain developed suddenly that morning while he was fishing and progressively worsened. He also lost sensation in that finger. Although he reported no traumatic injury, he stated, “I always use my hands as a hammer when in my boat.”

	The patient was hypertensive and an ex-smoker. His surgical history was significant for coronary artery bypass graft surgery and aortic valve replacement in 1996. He had no history of myocardial infarction, cerebrovascular accident, transient ischemic attack, claudication, or previous hand and finger pain or discoloration. He was taking hydrochlorothiazide, atenolol, and warfarin.

	On physical examination, the patient was in some distress because of the pain. His blood pressure was 162/94 mm Hg; his heart rate was 72 beats per minute and regular. Carotid pulses were present without carotid or subclavian bruits on auscultation. Palpable axillary, brachial, radial, and ulnar pulses were present bilaterally. The patient’s left ring finger had decreased sensation and was cold, cyanotic, and severely tender to passive range of motion exercises. There was a large, pulsatile, tender, and tense mass with a thrill in the left hypothenar area. His prothrombin time was 12.6 seconds with an international normalized ratio of 1.2. An electrocardiogram revealed normal sinus rhythm. A presumptive diagnosis of hypothenar hammer syndrome with thromboembolism of the distal ulnar and digital arteries was made, and the patient was brought to the operating room.

	Under general anesthesia, a longitudinal skin incision was made over the pulsatile mass, and a 2.0 x 2.7-cm saccular ulnar artery aneurysm was discovered. Proximal and distal control was obtained with vessel loops. By this time, the aneurysm was no longer pulsatile and was excised. Although excellent inflow was noted, there was no back bleeding distally. A size 2 Fogarty catheter was passed distally, a large thrombus was removed, and brisk back bleeding was observed. An end-to-end anastomosis was preformed using size 7-0 polypropylene sutures in a running fashion. The artery exhibited an excellent pulse and the ischemic finger showed immediate improvement.

	The patient was discharged to home on postoperative day 2, on his maintenance warfarin dose. At 14-month follow-up, there was a palpable pulse with no evidence of ischemia.

 In 1934, Von Rosen first described posttraumatic ulnar artery aneurysms and their resection.

 In 1970, Conn and associates used the term hypothenar hammer syndrome to describe finger ischemia caused by embolic occlusion of the digital arteries originating from the ulnar artery in a person who was repeatedly striking objects with the heel of the hand.

 Fewer than 100 cases of ulnar artery aneurysms have been reported in the literature and most are related to repetitive trauma.

 Intimal injury can lead to thrombosis or aneurysm formation. Von Rosen suggested that damage to the intima would result in thrombosis, whereas damage to the media would produce an aneurysm. Similar injuries have been reported in baseball, handball, and volleyball players.

 Patients are typically men, who present with acute onset of signs and symptoms related to digital ischemia.

-The hand obtains its arterial supply through the ulnar and radial arteries (Figure). The ulnar artery and nerve pass through Guyon’s canal next to the hamate bone before dividing into the superficial and deep palmar branches. Just distal to the canal, a short segment of the superficial branch that forms the origin of the superficial palmar arch is unprotected between the skin and the bone in the hypothenar area. Chronic trauma to this area can lead to aneurysm formation in the ulnar artery.

	The incidence of traumatic ulnar artery aneurysms is unknown because many individuals remain asymptomatic. People affected are frequently employed in the automotive or construction industries, where using pneumatic tools or repetitively striking objects with the dominant hand is characteristic of the syndrome. Ferris and colleagues studied the arteriography and histology in 21 patients with hypothenar hammer syndrome and concluded that this condition results from trauma to an artery in individuals with pre-existing fibromuscular dysplasia.

 Although patients with fibromuscular dysplasia are predominantly women, whereas hypothenar hammer syndrome is seen primarily in younger men, this theory may explain why the syndrome does not develop in most patients who experience repetitive palmar trauma. Little and Ferguson used Allen’s test and performed Doppler examinations on 79 workers who regularly used their hand as a hammer.

 They  found only a 14% prevalence of subclinical ulnar artery occlusion.

	Digital ischemia, pain, discoloration, and cold intolerance are the most common symptoms of hypothenar hammer syndrome. Aneurysm thrombosis may lead to arterial occlusion, but chronic embolization of the second through fifth digits is more common. In cold climates, this can produce symptoms of Raynaud syndrome. Discovery of an asymptomatic palmar mass or neuropathy from ulnar nerve compression are less common findings.

-Hypothenar hammer syndrome is often readily evident based on the patient’s history and physical examination. A complete blood count, metabolic profile, sedimentation rate, autoimmune assays, and hypercoagulopathy profile should be obtained. Arterial Doppler examinations of the upper extremities are generally normal, but photoplethysmography of the index, long, and ring fingers reveals obstructive patterns in one or more digits. Catheter-based selective contrast angiography is the study of choice for four reasons: (1) to exclude the possibility of embolic events originating from the subclavian artery, such as atherosclerosis, aneurysm, or thoracic outlet syndrome; (2) to confirm the exact location of the vascular damage at the end of the ulnar artery; (3) to distinguish thrombosis from aneurysm; and (4) to evaluate embolic events in the digital arteries.

 Computed tomography angiography and magnetic resonance angiography could also be considered; however, the presence of digit-threatening ischemia may prohibit preoperative diagnostic studies.

-Optimal treatment for hypothenar hammer syndrome has not been determined and remains a point of controversy mostly due to the rarity of the condition. Traditionally, this syndrome has been treated with observation, ligation and thoracic sympathetectomy, or aneurysm resection (with or without initial thrombolysis) with either primary anastomosis or interposition vein grafting.

 The goal of treatment is to reestablish flow to the palmar arch while eliminating the source of future embolization. Observation alone runs the risk of recurrent embolization and is generally not recommended. Ligation may result in worsening ischemia to the fourth and fifth digits if adequate collaterals are absent or occlusive disease exists in the radial artery. An Allen test should first be performed if one is considering this option, although these tests have an approximate 20% false-positive rate. Thrombolytic therapy before reconstruction may help improve the distal vascular perfusion.

	The advantages of resection and vascular reconstruction include removing the source of embolism and the painful mass and relieving ulnar nerve compression. If an interposition graft is required, a vein from the dorsum of the foot provides adequate caliber. Patients should be counseled regarding the need to avoid repetitive hand trauma; this may mean a change in occupation and ceasing smoking, which is a major risk factor for the development of arterial occlusive disease.  

 1. Von Rosen S. Ein Fall von thrombase in der Arteria Ulnaris nach einwirkung von stumpfer gewalt.

	2. Conn J Jr, Bergan JJ, Bell JL. Hypothenar hammer syndrome: posttraumatic digital ischemia.

	3. Ferris BL, Taylor LM Jr, Oyama K, et al. Hypothenar hammer syndrome: proposed etiology. 

	4. May JW Jr, Grossman JA, Costas B. Cyanotic painful index and long fingers associated with an asymptomatic ulnar artery aneurysm: case report.

	5. Lowrey CW, Chadwick RO, Waltman EN. Digital vessel trauma from repetitive impact in baseball catchers.

	6. Buckhout BC, Warner MA. Digital perfusion of handball players. Effects of repeated ball impact on structures of the hand.

	7. Kostianen S, Orava S. Blunt injury of the radial and ulnar arteries in volley ball players. A report of three cases of the antebrachial-palmar hammer syndrome. 

	8. Little JM, Ferguson DA. The incidence of the hypothenar hammer syndrome. 

	9. Vayssairat M, Debure C, Cormier JM, et al. Hypothenar hammer syndrome: seventeen cases with long-term follow-up. 

	10. Nehler MR, Dalman RL, Harris EJ, et al. Upper extremity arterial bypass distal to the wrist.

	11. Mehlhoff TL, Wood MB. Ulnar artery thrombosis and the role of interposition vein grafting: patency with microsurgical technique.

	12. Lawhorne TW Jr, Sanders RA. Ulnar artery aneurysm complicated by distal embolization: management with regional thrombolysis and resection. 

Mojtaba Gashti, Attending Vascular Surgeon, Department of Vascular Surgery, Union Memorial Hospital, Baltimore, MD

October 2006

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