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Objective Given the tremendous medical, social and financial costs of surgical site infections, the pressure to minimize these complications has been mounting. There remains a substantial gap in evidence-based practice for postoperative wound care after orthopaedic trauma surgery. The purpose of this study is to determine what standards are currently in practice for postoperative wound management. Methods A 16-question web-based survey was published on the Orthopaedic Trauma Association website and disseminated to members through the association's quarterly email. The survey gathered data on postoperative wound care practices; specifically, when wound checks are performed, and when providers allow patients to get the incisions wet. Results 102 Orthopaedic surgeons completed the survey. Ninety-one percent were trauma fellowship trained, and 95% worked at either a Level I (76%) or Level II (19%) trauma center. There were over 100 different proposed protocols captured by the survey. The majority of surgeons (54%) perform a wound check within the first three days after surgery. Additionally, half of surgeons (50%) do not permit patients to get their incisions wet until sutures and staples are removed. Conclusion Wound care routines following surgical management of orthopaedic trauma injuries are highly variable. Diverse protocols are performed at the discretion of the treating surgeon without scientific basis. This study defines immense variability in one aspect of peri-operative care that could play an important role in surgical site infections and provides a foundation for future studies to explore the potential influence of standardized wound care routines on post-operative infections and wound healing.

Dr. Thomas Whitesides was a pioneer in general orthopedics and spine surgery. He brought the anterior approach to the United States in the management of thoracolumbar trauma, a revolutionary step at the time. At Emory, he taught 100s of residents and fellows using the Socratic method. Dr. Whitesides remains a valuable consultant for complex spine cases to this day.

Purpose The purpose of this study is to evaluate the reliability of magnetic resonance imaging (MRI) in predicting the location of ACL tears in preoperative planning for anterior cruciate ligament (ACL) repair. Methods Thirty-four patients who underwent ACL repair were retrospectively analyzed to compare intraoperative arthroscopic findings with preoperative MRIs. Results For identifying type I tears, the sensitivity of MRI was 9.0% and the accuracy of MRI was 8.8%. There was moderate interrater agreement between MRI findings for tear location and tear degree. Conclusion MRI alone may not necessarily be accurate in identifying which ACL tears are amenable to repair. Study design Retrospective case series; Level of Evidence: IV

Complaints of neck and back pain in children are commonly seen in the office and hospital setting. Typically, pain is self-limiting and does not routinely require additional workup with advanced imaging or intervention. A proper history and physical examination can identify “red flag” signs and symptoms such as new or progressive deformity, radicular pain, night pain, and neurological deficits. If positive, advanced imaging is indicated.

Category: Midfoot/Forefoot; Bunion Introduction/Purpose: Minimally invasive surgery (MIS) is being increasingly used for bunion deformity correction. New third generation minimally invasive chevron/akin (MICA) techniques are used but limited data on patient outcomes have been reported. The goal of this IRB-approved study was to look at outcomes of percutaneous, extra-articular distal metatarsal osteotomies for mild to moderate bunion deformity, including the degree of deformity correction obtained, patient pain control, and complication rates. We also describe strategies for avoiding the intra-operative and post-operative complications that may arise with MIS bunion surgery. Methods: The participants were the treating surgeon’s first 75 consecutive patients 18 years and older who were treated with MICA procedures. Via retrospective chart review, outcome measures including pre and final post-operative intermetatarsal angles (IMA), hallux valgus angles (HVA), visual analogue scale (VAS) score, and complication rates were assessed. Statistical analysis was done utilizing student’s t-test for continuous variables and chi square test for categorical variables. Results: Average follow-up was 105.0 days. VAS scores dropped one week post-operatively, from 5.4 pre-operatively to 2.5 (p< 0.05). IMA angles improved from 12.7 degrees (range 6.1-18.1) pre-op to 6.1 (range 1.2-12.5) at final follow-up (p< 0.05). HVA angles improved from 27.2 degrees (range 9.7-43.4) to 10.4 (range 1.3-25.9) (pConclusion: Our data suggests that MICA osteotomies are associated with rapid, significant improvement in pain scores, significant deformity correction, and low frequency of major complications. While there is a learning curve, MICA is a reproducible technique, is safe, and allows immediate post-operative weightbearing. All osteotomies achieved union, and there were no tendon injuries. Only two patients required a second surgery. We also present strategies to avoid and limit pitfalls and complications encountered with the procedure. Although our data is exciting, additional studies looking at long-term outcomes, larger sample sizes, and more physicians should be conducted.

The COVID-19 pandemic created unprecedented challenges for the healthcare system. In order to meet capacity demands, hospitals around the world suspended surgeries deemed to be “elective.” In hand surgery, there are numerous pathologies treated on an elective basis, but a delay or absence of care may result in poorer outcomes. We present here an ethical framework for prioritizing elective surgery during a period of resource scarcity. Instead of using the term elective, we define procedures that can be safely delayed based on three considerations. First, a safe delay is only possible if deferral will not result in permanent injury. Second, a delay in care will come with tolerable costs and impositions that can be appropriately managed in the future. Third, a safe delay will preserve the bioethical principle of patient autonomy. In considering these criteria, three case examples are discussed taking into account individual patient characteristics and the pathophysiology of the condition. This framework design is applicable to ambulatory surgery in any period of crises that may strain resources, but further considerations may be important if an operation requires hospital admission.

STUDY DESIGN This was a narrative review. OBJECTIVE The aim was to discuss current methods and review updated outcome studies regarding posterior decompression in the management of cervical myelopathy. SUMMARY OF BACKGROUND DATA Progressive myelopathy in the cervical segments is an indication for urgent surgical management. Although nonoperative treatment is an option in mild to moderate cases, the majority of patients will experience deterioration in neurological function requiring surgical decompression. METHODS A review of the literature was performed using PubMed to provide updated information regarding posterior cervical decompression in the management of myelopathy. RESULTS There are numerous studies comparing outcome data between cervical laminectomy and fusion with laminoplasty. While each technique has advantages and disadvantages, both provide adequate decompression and good long-term outcomes in patients meeting appropriate criteria. CONCLUSIONS Posterior decompression is an important approach for spine surgeons to have in their toolkits when treating cervical myelopathy.

The thread–link–cut (TLC) approach has previously shown promise as a novel method to synthesize molecular knots. The modular second-generation approach to small trefoil knots described herein involves electrostatic interactions between an electron-rich bis-macrocyclic host compound and electron-deficient guests in the threading step. The bis-macrocyclic host was synthesized in eight steps and 6.6% overall yield. Ammonium and pyridinium guests were synthesized in 4–5 steps. The TLC knot-forming sequence was carried out and produced a product with the expected molecular weight, but, unfortunately, further characterization did not produce conclusive results regarding the topology of the product.

Minimally invasive fusion techniques for degenerative lumbar pathology commonly involve the placement of pedicle screws. Percutaneous placement of these screws allows the surgeon to minimize soft tissue trauma, improving postoperative recovery for patients. This review will cover the indications and techniques for percutaneous pedicle screw instrumentation of the lumbar spine, and will highlight the advantages and potential contraindications to using percutaneous instrumentation.

Objective Exposure to ultrafine particles (UFP) in secondhand smoke (SHS) and traffic-related air pollution (TRAP) may elicit chronic inflammation. It was hypothesized that the association between these exposures would be potentiated in overweight versus normal-weight children. Methods Average lifetime exposure to TRAP and SHS and objective, physician-diagnosed asthma were determined for 575 children at age 7. Overweight was defined as having a body mass index (BMI) >85th percentile for age and gender. The association between TRAP and SHS exposure and asthma was examined by logistic regression stratified by BMI. Results A total of 131 children were overweight; the prevalence of asthma was 24.4% and 14.2% among overweight and normal-weight children, respectively. Exposure to SHS was significantly associated with asthma among overweight (adjusted odds ratio [adjOR] = 3.0; 95% confidence interval [CI] = 1.2, 7.4) but not normal-weight children (adjOR = 1.1; 95% CI = 0.4, 2.7). In contrast, TRAP was significantly associated with asthma among normal-weight (adjOR = 1.8; 95% CI = 1.0, 3.4) but not overweight children (adjOR = 0.7; 95% CI = 0.4, 2.7). Conclusions The association between SHS and TRAP exposure and asthma is modified by children's weight. Children's time-activity patterns, including time spent indoors or outdoors, may vary by weight and play an important role in these UFP exposures.

Exposure to ultrafine particles (UFP) in secondhand smoke (SHS) and traffic-related air pollution (TRAP) may elicit chronic inflammation. It was hypothesized that the association between these exposures would be potentiated in overweight versus normal-weight children.Average lifetime exposure to TRAP and SHS and objective, physician-diagnosed asthma were determined for 575 children at age 7. Overweight was defined as having a body mass index (BMI)85th percentile for age and gender. The association between TRAP and SHS exposure and asthma was examined by logistic regression stratified by BMI.A total of 131 children were overweight; the prevalence of asthma was 24.4% and 14.2% among overweight and normal-weight children, respectively. Exposure to SHS was significantly associated with asthma among overweight (adjusted odds ratio [adjOR] = 3.0; 95% confidence interval [CI] = 1.2, 7.4) but not normal-weight children (adjOR = 1.1; 95% CI = 0.4, 2.7). In contrast, TRAP was significantly associated with asthma among normal-weight (adjOR = 1.8; 95% CI = 1.0, 3.4) but not overweight children (adjOR = 0.7; 95% CI = 0.4, 2.7).The association between SHS and TRAP exposure and asthma is modified by children's weight. Children's time-activity patterns, including time spent indoors or outdoors, may vary by weight and play an important role in these UFP exposures.

The clinical diagnosis of hypersensitivity to the food dye tartrazine in 16 subjects correlated with levels of tartrazine-specific IgD antibodies determined by a solid phase radioimmunoassay inhibition test. This is the first study associating hypersensitivity to a low molecular weight chemical with an antibody response of the IgD class. There was little or no correlation between clinical sensitivity and IgE antibodies.

1.1. The composition of the principal synthetic resins manufactured in the United States and their chief uses have been stated. 2.2. The process of manufacture of phenol-formaldehyde and ureaformaldehyde resins which account for many cases of contact dermatitis have been described. 3.3. Preventive measures have been pointed out.

1.1. The method of administration of 1:500 epinephrine in gelatin is discussed. 2.2. The action of epinephrine in gelatin and its effect on the blood sugar, pulse rates, blood pressure, and bronchial tree are discussed. 3.3. The advantages and disadvantages of 1:500 epinephrine in gelatin are reported. 4.4. Some unusual reactions following the injection of 1:500 epinephrine in gelatin mixture are described.

1.1. Epinephrine hydrochloride solution 1:100 is modified by the addition of 5 per cent glycerin, which often presents irritation and dryness of the throat. 2.2. Irritation and dryness of the throat occurred 82 per cent less frequently among the patients who used 5 per cent glycerinized 1:100 epinephrine hydrochloride than when epinephrine hydrochloride 1:100 alone was used.

Nine asymptomatic asthmatic men and 9 normal men were given an intravenous infusion of epinephrine 0.1 μg per kilogram per minute for 10 minutes. Blood samples were taken every 10 minutes for an hour and analyzed for glucose, free fatty acids, and glycerol. Initial values of these metabolites were similar in both groups, but the rise in glucose was smaller in the asthmatic group. There was no difference in the rise in free fatty acid and glycerol. Six asthmatic men and 9 normal men were given 7 μg per kilogram glucagon intravenously. The blood glucose response was smaller in the asthmatic group, but the difference was not statistically significant. The diminished hyperglycemic response to epinephrine in patients with asthma who were not receiving sympathomimetics or corticosteroid drugs and who were asymptomatic at the time of the study indicates that asthma itself is associated with a diminished glycemic response to epinephrine.

Pertussis vaccine accelerates rather than retards, of antigen from the circulation and enhances the secondary as well as the primary response. Pertussis vaccine alone has an anamnestic effect and is capable of causing the appearance of homocytotropic antibody which reacts with antigens to which the animal has previously made a primary response. The effects of pertussis and Freund's adjuvant are additive. Increased insulin levels are not necessary for the adjuvant effect as alloxan diabetic animals are quite capable of enhanced antibody response after pertussis vaccine. Beta adrenergic blocking drugs increase and adrenergic agonists reduce antibody response slightly. It is concluded that pertussis exerts its effect directly on the precursor of the antibody-forming cells by increasing their rate of cell division Impairment of beta adrenergic receptors may be the mechanism of the effect.

1. If you can possibly do so, avoid the use of immunizing agents containing horse serum. It is indeed surprising how many calls allergists receive from physicians and pharmacists asking for confirmation that tetanus toxoid does not contain horse serum. (IT DOES NOT.) Apparently some believe it does. 2. Skin testing for horse serum sensitivity is done only to try to uncover those who may be in danger of experiencing life-threatening 'hypersensitivity reactions. The literature contains reports of anaphylaxis following a skin test dose alone. It might also be necessary to mention that for highly sensitive individuals a test dose of no more than 0.02 ml. of a 1:500 or 1:5,000 dilution should be used for the skin test.2 On rare occasions, equine antitoxins are still, necessary for treatment of venomous snake bites, black widow spider bites, diphtheria, gas gangrene, and botulism, even in the presence of a sensitivity to horses, or of a positive skin test for horse serum.* Cutter Laboratories now has available a rabies immune globulin (human) and it is anticipated that Lederle Laboratories will be licensed to manufacture this product in the near future.' 3. A course of tetanus toxoid should be recommended for persons sensitive to horses or horse serum. Routine booster doses should be given at ten-year intervals. 4. The use of egg-containing vaccines in egg-sensitive patients: (1) Avoid giving unnecessary injections of egg-containing vaccines, such as influenza, to allergics. (2) Avoid the use of vaccines grown on eggs to individuals with a known history of constitutional reactions to egg-containing vaccines. 5. Scratch and endermal tests with vaccines are generally useless. If you do skin tests with the egg-containing vaccines, make serial dilutions of the vaccine with buffered saline. 6. Smallpox vaccination: Smallpox vaccination is not too frequently used any more in this country but is usually safe for almost everyone unless there is active dermatitis in the patient, his or her siblings, or other members of the family. (Eczema vaccinatum is serious, especially if the cornea becomes involved.) The most serious complication of smallpox vaccination, encephalitis, may be indeed an allergic type of response. Also, vaccinia necrosum may occur in persons receiving therapy with immunosuppressive agents including ACTH and cortisone or its derivatives, and some allergic sufferers may be receiving such drugs. Smallpox vaccination is contraindicated for anyone receiving any type of immunosuppressive3 therapy. 7. A strict dosage technique should be employed whenever there is any history of reaction and it is decided to proceed with needed immunization. In this instance, it may become necessary to repeat small doses of serum or of a

SummaryDifficulties in obtaining adequate volumes of blood for serial analysis often restrict the design of experiments using small animals. The techniques of bleeding rats and mice from the tail and guinea pigs from the toenail can be improved by warming the animals. Prior warming in an incubator at 40-45°C and gentle handling allow repeated collection of generous quantities of blood quickly.

Urinary excretion of epinephrine was measured in 5 subjects after subcutaneous injection of epinephrine and various doses of an aerosol delivered from a pressurized cartridge. Base-line epinephrine excretion was 10 ± 4 ng. per minute. After 480 μg of epinephrine by injection, the maximal excretion was 240 ± 55 ng. per minute; while after the recommended dose of 3 inhalations, excretion was 13 ± 4 ng. per minute, and after 15 inhalations (2,400 μg) only 20 ± 5 ng. per minute were excreted. We conclude that while aerosol epinephrine may be of value from direct contact in upper airway obstruction, it would be unwise to rely on pressurized cartridges as a first aid measure in systemic anaphylaxis. Epinephrine by subcutaneous injection remains the preferred treatment.

To the Editor:— The castor bean, the seed of Ricinus communis , is one of the most potent of the antigens that cause anaphylactic type of hypersensitivity in man. 1 Usually patients encounter the antigen at their work 2,3 or by living in the vicinity of castor bean processing plants, 4-6 but this patient's contact with the bean was in an exotic way. The source of the allergic symptoms went unrecognized until she had an acute, severe reaction. Report of a Case: A 21-year-old woman student was admitted to the University Hospitals because facial itching and swelling of her eyelids suddenly developed. Approximately one half hour before the patient arrived at the emergency room she had itching of her eyes and tearing immediately after one of the seed beads of a necklace she was wearing crumbled in her fingers. After attempting to remove the powder of the bead from her fingers