Advanced Method Optimization for Sampling and Analysis Instrumentation.

This work presents a generalized approach for analytical method optimization that branches the gap between techniques historically employed and accurate modern optimization techniques suitable for various applications. The novelty of the described strategy is the utilization of multivariate, multiobjective optimization with Karush-Kuhn-Tucker conditions to bound the optimization space to solutions within the physical limitations of instrumentation. Briefly, the basic steps outlined in this paper are to (1) determine the objective(s) that should be maximized or minimized based on the goals of the analytical application, (2) conduct a screening experiment, (3) perform ANOVA to determine the parameters which have a statistically significant effect on the objective, (4) conduct an experiment (e.g., Box-Behnken design) to collect data for fitting the objective equation, and (5) determine the physical constraints of the parameters and solve the Lagrangian to determine the optimal method parameters. A broad approach to optimization target selection allows for robust method tuning to develop improved data sets amenable for chemometrics and machine learning algorithm development. Gas chromatography-mass spectrometry was selected as a use case due to its broad use across scientific fields and time-consuming method development involving numerous parameters. This strategy can reduce the cost of research, improve data quality, and enable the rapid development of new analytical techniques.

Revision of failed reverse total shoulder arthroplasty with reverse: short-term clinical outcomes.

BACKGROUND: The prevalence of failed reverse total shoulder arthroplasty (rTSA) is increasing. This can often present a challenging clinical situation with substantial bone loss and limited reconstruction options. This study reports a single tertiary referral center's experience with revision of failed rTSA managed with revision rTSA of bone-interfacing components. METHODS: After institutional review board approval, all revision shoulder arthroplasty cases performed at a single institution between 2012 and 2020 were reviewed. Cases in which rTSA was revised to a new rTSA construct with revision of at least 1 bone-interfacing implant (humeral stem and/or baseplate) with a minimum 2-year follow-up were identified. Characteristics of revision cases-including indications, bony stock, revised components, and use of bone graft-were collected. All patients were contacted for patient-reported outcome measures at a minimum of 2 years after surgery. In addition, the incidence and indication for any reoperation after revision were determined. RESULTS: Thirty-three patients with an average age of 66 years (range: 46-82 years), with 19 (58%) being female, met the inclusion criteria and had a mean follow-up of 4.2 years (range: 2-8 years). The most common indication for revision rTSA included humeral component loosening (33%; 11/33), baseplate loosening (27%; 9/33), and instability (21%; 7/33). Prerevision infectious workup demonstrated no cases of periprosthetic shoulder infection. Thirteen cases had massive bone loss-5 treated with humeral allograft prosthetic composite, 5 with glenoid bone grafting, and 3 with custom glenoid implant. In total, 10 of 33 cases (30%) required reoperation at a mean of 13 months (range: 1-44 months) for instability (4), humeral loosening (2), infection (1), baseplate loosening (1), or periprosthetic fracture (1). The reoperation rate for patients with revised baseplates only, humerus only, or combined was 23% (3/13), 28% (5/18), and 27% (3/11), respectively. Overall, the visual analog scale pain score improved from 6.5 preoperatively to 2.0 (P < .001), and the American Shoulder and Elbow Surgeons score improved from 30.7 to 67.5 (P < .001). However, the postoperative Single Assessment Numeric Evaluation score averaged only 51.2% (range: 2-100%). CONCLUSION: This study demonstrates that failed rTSA can be salvaged with a revision rTSA. However, patient expectations for functional improvements should be tempered, and a high reoperation rate should be expected.

Study Characteristics and Impact of Pediatric Orthopaedic Society of North America Annual Meeting's "Best Papers" From 2009 to 2019.

OBJECTIVE: Award-winning abstracts are selected every year at the Pediatric Orthopaedic Society of North America (POSNA) annual meeting as "best paper" or poster. It is unknown how many achieve publication in peer-reviewed journals and the impact they have. We sought to determine the characteristics, including the level of evidence (LoE), publication rates, and the impact of award-winning abstracts on pediatric orthopaedic surgery practice from 2009 to 2019. METHODS: Award-winning abstracts or "best papers" from 2009 to 2019 were retrospectively reviewed from the POSNA website from abstract publication to manuscript publication. A search across Pubmed was used to match abstracts to their publications by comparing author names, titles, study design and methodology, results, and conclusions. Area of focus, abstract authors, institutions, publication status, LoE, time to publication, authors of publication, journals of publication, and the journal's latest Hirsch Index and impact factor were recorded. RESULTS: There have been 54 "best papers" at the POSNA annual meeting from 2009 to 2019. Of those, 39 have been published across 17 different journals for a publication rate of 72%. The average time from abstract presentation to publication was 21.2 months with a range of 0 to 121 months. Of the published award-winning abstracts, 64% (25) were published within 2 years, 87% (34) within 3 years, and 95% (37) within 4 years. Out of the published abstracts, 26% (10) were in the Journal of Pediatric Orthopaedics , 23% (9) were in the Journal of Bone and Joint Surgery , and 10% (4) were in the Journal of Child Orthopaedics . The median number of abstract authors was 4 and increased to a median of 6 authors once published. Most award-winning abstracts had a LoE of 3. The average journal impact factor for all publications was 4; the average Hirsch Index for the corresponding author was 29.9, and the average number of citations for a publication was 41 with a range of 0 to 270. CONCLUSIONS: The majority of the "best papers" presented at POSNA annual meetings from 2009 to 2019 were published in peer-reviewed journals within 2 years of presentation, with approximately half being published in the Journal of Pediatric Orthopaedics or Journal of Bone and Joint Surgery . The publication rate of "best papers" at the POSNA annual meeting was found to be higher than rates reported for abstracts presented at the annual meetings of POSNA, American Society for Surgery of the Hand and European Pediatric Orthopaedic Society, but similar to the rates observed for American Association of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, and Orthopaedic Trauma Association. Most of the selected "best papers" at the POSNA annual meeting are published and have a substantial impact on pediatric orthopaedic surgery practice. LEVEL OF EVIDENCE: Level IV.

Simple and Sensitive Method for Synchronous Quantification of Regulated and Unregulated Priority Disinfection Byproducts in Drinking Water.

Due to their elevated concentrations in drinking water, compared to other emerging environmental contaminants, disinfection byproducts (DBPs) have become a global concern. To address this, we have created a simple and sensitive method for simultaneously measuring 9 classes of DBPs. Haloacetic acids (HAAs) and iodo-acetic acids (IAAs) are determined using silylation derivatization, replacing diazomethane or acidic methanol derivatization with a more environmentally friendly and simpler treatment process that also offers greater sensitivity. Mono-/di-haloacetaldehydes (mono-/di-HALs) are directly analyzed without derivatization, along with trihalomethanes (THMs), iodo-THMs, haloketones, haloacetonitriles, haloacetamides, and halonitromethanes. Of the 50 DBPs studied, recoveries for most were 70-130%, LOQs for most were 0.01-0.05 µg/L, and relative standard deviations were <30%. We subsequently applied this method to 13 home tap water samples. Total concentrations of 9 classes of DBPs were 39.6-79.2 µg/L, in which unregulated priority DBPs contributed 42% of total DBP concentrations and 97% of total calculated cytotoxicity, highlighting the importance of monitoring their presence in drinking water. Br-DBPs were the dominant contributors to total DBPs (54%) and total calculated cytotoxicity (92%). Nitrogenous DBPs contributed 25% of total DBPs while inducing 57% of total calculated cytotoxicity. HALs were the most important toxicity drivers (40%), particularly four mono-/di-HALs, which induced 28% of total calculated cytotoxicity. This simple and sensitive method allows the synchronous analysis of 9 classes of regulated and unregulated priority DBPs and overcomes the weaknesses of some other methods especially for HAAs/IAAs and mono-/di-HALs, providing a useful tool for research on regulated and unregulated priority DBPs.

Algae impacted drinking water: Does switching to chloramination produce safer drinking water?

Harmful algal (cyanobacterial) blooms (HABs) are increasing throughout the world. HABs can be a direct source of toxins in freshwater sources, and associated algal organic matter (AOM) can act as precursors for the formation of disinfection by-products (DBPs) in drinking water. This study investigated the impacts of algae on DBP formation using treatment with chloramine, which has become a popular disinfectant in the U.S. and in several other countries because it can significantly lower the levels of regulated DBPs formed. Controlled laboratory chloraminations were conducted using live field-collected algal biomass dominated by either Phormidium sp. or Microseira wollei (formerly known as Lyngbya wollei) collected from Lake Wateree and Lake Marion, SC. Sixty-six priority, unregulated or regulated DBPs were quantified using gas chromatography (GC)-mass spectrometry (MS). The presence of HAB-dominated microbial communities in source waters led to significant increases in more toxic nitrogen-containing DBPs (1.5-5 fold) relative to lake waters collected in HAB-free waters. Compared to chlorinated Phormidium-impacted waters, chloraminated waters yielded lower total DBP levels (up to 123 µg/L vs. 586 µg/L for low Br-/I- waters), but produced a greater number of brominated, iodinated, and mixed halogenated DBPs in high Br-/I- waters. Among the DBPs formed in Phormidium-impacted chloraminated waters, dichloroacetic acid, trichloromethane, chloroacetic acid, chloropropanone, and dichloroacetamide were dominant. For Microseira wollei-impacted chloraminated waters, total DBP concentrations ranged from 33 to 145 µg/L (approximately 3-5 times lower than chlorination), with dichloroacetic acid, dichloroacetamide, and trichloromethane dominant. Overall, chloramination significantly reduced calculated cytotoxicity and genotoxicity in low Br- and I- waters, but produced 1.3 fold higher calculated cytotoxicity (compared to chlorine) with high Br-/I- waters due to increased formation of more toxic iodo- and mixed halogenated DBPs.

The impact of e-scooter injuries : a systematic review of 34 studies.

AIMS: Due to the recent rapid expansion of scooter sharing companies, there has been a dramatic increase in the number of electric scooter (e-scooter) injuries. Our purpose was to conduct a systematic review to characterize the demographic characteristics, most common injuries, and management of patients injured from electric scooters. METHODS: We searched PubMed, EMBASE, Scopus, and Web of Science databases using variations of the term "electric scooter". We excluded studies conducted prior to 2015, studies with a population of less than 50, case reports, and studies not focused on electric scooters. Data were analyzed using t-tests and p-values < 0.05 were considered significant. RESULTS: We studied 5,705 patients from 34 studies. The mean age was 33.3 years (SD 3.5), and 58.3% (n = 3,325) were male. The leading mechanism of injury was falling (n = 3,595, 74.4%). Injured patients were more likely to not wear a helmet (n = 2,114; 68.1%; p < 0.001). The most common type of injury incurred was bony injuries (n = 2,761, 39.2%), of which upper limb fractures dominated (n = 1,236, 44.8%). Head and neck injuries composed 22.2% (n = 1,565) of the reported injuries, including traumatic brain injuries (n = 455; 2.5%), lacerations/abrasions/contusions (n = 500; 7.1%), intracerebral brain haemorrhages (n = 131; 1.9%), and concussions (n = 255; 3.2%). Standard radiographs comprised most images (n = 2,153; 57.7%). Most patients were treated and released without admission (n = 2,895; 54.5%), and 17.2% (n = 911) of injured patients required surgery. Qualitative analyses of the cost of injury revealed that any intoxication was associated with higher billing costs. CONCLUSION: The leading injuries from e-scooters are upper limb fractures. Falling was the leading mechanism of injury, and most patients did not wear a helmet. Future research should focus on injury characterization, treatment, and cost.Cite this article: Bone Jt Open 2022;3(9):674-683.

Halocyclopentadienes: An Emerging Class of Toxic DBPs in Chlor(am)inated Drinking Water.

Although >700 disinfection by-products (DBPs) have been identified to date, most DBPs in drinking water are still unknown. Identifying unknown DBPs is an important step for improving drinking water quality because known DBPs do not fully account for the adverse health effects noted in epidemiologic studies. Using gas chromatography high-resolution mass spectrometry, six chloro- and bromo-halocyclopentadienes (HCPDs) were identified in chlorinated and chloraminated drinking water via non-target analysis; five HCPDs are reported for the first time as new alicyclic DBPs. Formation pathways were also proposed. Simulated disinfection experiments with Suwannee River natural organic matter (NOM) confirm that NOM is a precursor for these new DBPs. Further, HCPDs are more abundant in chlorinated drinking water (real and simulated) when compared to chloraminated drinking water due to the higher reactivity of chlorine. Of these new DBPs, 1,2,3,4,5,5-hexachloro-1,3-cyclopentadiene is approximately 100,000× more toxic (in vivo) than regulated trihalomethanes (THMs) and haloacetic acids (HAAs) and 20-2000× more toxic than halobenzoquinones, halophenols, and halogenated pyridinols using the available median lethal dose (LD50) and concentration for 50% of maximal effective concentration (EC50) of DBPs to aquatic organisms. The predicted bioconcentration factors of these HCPDs range from 384 to 3980, which are 2-3 orders of magnitude higher than those for regulated and priority DBPs (including THMs, HAAs, halobenzoquinones, haloacetonitriles, haloacetamides, halonitromethanes, haloacetaldehydes, iodo-THMs, and iodo-HAAs). Thus, HCPDs are an important emerging class of DBPs that should be studied to better understand their impact on drinking water quality and long-term human health exposure.

Program Directors' Perception of the Role of Personal Statements in the Orthopaedic Surgery Residency Selection Process.

The purpose of this study was (1) to determine how much emphasis is placed on the Personal Statement (PS) by program directors (PDs) and (2) to gain a better understanding of what factors within the PS are considered most important to PDs. An anonymous survey was distributed to PDs at allopathic orthopaedic residency programs in the United States using Survey Monkey (San Mateo, CA). Survey responses were received from 51 of 152 (34%) PDs. Forty-five (88.2%) identified as male, five (9.8%) identified as female, and one (1.9%) chose not to disclose. PDs reported the PS was of average importance, with an average score of 2.82 (range,1-4). Although the PS is still given consideration as part of the overall orthopaedic surgery residency application process, it does not play a major role in determining which applicants will be invited for an interview or how they will be ranked. (Journal of Surgical Orthopaedic Advances 31(2):090-095, 2022).

Do DBPs swim in salt water pools? Comparison of 60 DBPs formed by electrochemically generated chlorine vs. conventional chlorine.

Disinfectants are added to swimming pools to kill harmful pathogens. Although liquid chlorine (sodium hypochlorite) is the most commonly used disinfectant, alternative disinfection techniques like electrochemically generated mixed oxidants or electrochemically generated chlorine, often referred to as salt water pools, are growing in popularity. However, these disinfectants react with natural organic matter and anthropogenic contaminants introduced to the pool water by swimmers to form disinfection byproducts (DBPs). DBPs have been linked to several adverse health effects, such as bladder cancer, adverse birth outcomes, and asthma. In this study, we quantified 60 DBPs using gas chromatography-mass spectrometry and assessed the calculated cytotoxicity and genotoxicity of an indoor community swimming pool before and after switching to a salt water pool with electrochemically generated chlorine. Interestingly, the total DBPs increased by 15% upon implementation of the salt water pool, but the calculated cytotoxicity and genotoxicity decreased by 45% and 15%, respectively. Predominant DBP classes formed were haloacetic acids, with trichloroacetic acid and dichloroacetic acid contributing 57% of the average total DBPs formed. Haloacetonitriles, haloacetic acids, and haloacetaldehydes were the primary drivers of calculated cytotoxicity, and haloacetic acids were the primary driver of calculated genotoxicity. Diiodoacetic acid, a highly toxic iodinated DBP, is reported for the first time in swimming pool water. Bromide impurities in sodium chloride used to electrochemically generate chlorine led to a 73% increase in brominated DBPs, primarily driven by bromochloroacetic acid. This study presents the most extensive DBP study to-date for salt water pools.

How well does XAD resin extraction recover halogenated disinfection byproducts for comprehensive identification and toxicity testing?

Halogenated disinfection byproducts (DBPs) are an unintended consequence of drinking water disinfection, and can have significant toxicity. XAD resins are commonly used to extract and enrich trace levels of DBPs for comprehensive, nontarget identification of DBPs and also for in vitro toxicity studies. However, XAD resin recoveries for complete classes of halogenated DBPs have not been evaluated, particularly for low, environmentally relevant levels (ng/L to low µg/L). Thus, it is not known whether levels of DBPs or the toxicity of drinking water might be underestimated. In this study, DAX-8/XAD-2 layered resins were evaluated, considering both adsorption and elution from the resins, for extracting 66 DBPs from water. Results demonstrate that among the 7 classes of DBPs investigated, trihalomethanes (THMs), including iodo-THMs, were the most efficiently adsorbed, with recovery of most THMs ranging from 50%-96%, followed by halonitromethanes (40%-90%). The adsorption ability of XAD resins for haloacetonitriles, haloacetamides, and haloacetaldehydes was highly dependent on the individual species. The adsorption capacity of XAD resins for haloacetic acids was lower (5%-48%), even after adjusting to pH 1 before extraction. Recovery efficiency for most DBPs was comparable with their adsorption, as most were eluted effectively from XAD resins by ethyl acetate. DBP polarity and molecular weight were the two most important factors that determine their recovery. Recovery of trichloromethane, iodoacetic acid, chloro- and iodo-acetonitrile, and chloroacetamide were among the lowest, which could lead to underestimation of toxicity, particularly for iodoacetic acid and iodo-acetonitrile, which are highly toxic.

A balancing act: Optimizing free chlorine contact time to minimize iodo-DBPs, NDMA, and regulated DBPs in chloraminated drinking water.

Many drinking water treatment plants in the U.S. have switched from chlorination to chloramination to lower levels of regulated trihalomethane (THM) and haloacetic acid (HAA) disinfection byproducts (DBPs) in drinking water and meet the current regulations. However, chloramination can also produce other highly toxic/carcinogenic, unregulated DBPs: iodo-acids, iodo-THMs, and N-nitrosodimethylamine (NDMA). In practice, chloramines are generated by the addition of chlorine with ammonia, and plants use varying amounts of free chlorine contact time prior to ammonia addition to effectively kill pathogens and meet DBP regulations. However, iodo-DBPs and nitrosamines are generally not considered in this balancing of free chlorine contact time. The goal of our work was to determine whether an optimal free chlorine contact time could be established in which iodo-DBPs and NDMA could be minimized, while keeping regulated THMs and HAAs below their regulatory limits. The effect of free chlorine contact time was evaluated for the formation of six iodo-trihalomethanes (iodo-THMs), six iodo-acids, and NDMA during the chloramination of drinking water. Ten different free chlorine contact times were examined for two source waters with different dissolved organic carbon (DOC) and bromide/iodide. For the low DOC water at pH 7 and 8, an optimized free chlorine contact time of up to 1 h could control regulated THMs and HAAs, as well as iodo-DBPs and NDMA. For the high DOC water, a free chlorine contact time of 5 min could control iodo-DBPs and NDMA at both pHs, but the regulated DBPs could exceed the regulations at pH 7.

Microseira wollei and Phormidium algae more than doubles DBP concentrations and calculated toxicity in drinking water.

Warm weather and excess nutrients from agricultural runoff trigger harmful algal blooms, which can affect drinking water safety due to the presence of algal toxins and the formation of disinfection by-products (DBPs) during drinking water treatment. In this study, 66 priority, unregulated and regulated DBPs were quantified in chlorinated controlled laboratory reactions of harmful algae Microseira wollei (formerly known as Lyngbya wollei) and Phormidium using gas chromatography (GC)-mass spectrometry (MS). Live algae samples collected from algae-impacted lakes in South Carolina were chlorinated in both ultrapure water and real source waters containing natural organic matter. DBPs were also measured in finished water from a real drinking water plant impacted by a Microseira bloom. Results show that the presence of Microseira and Phormidium more than doubles total concentrations of DBPs formed by chlorination, with levels up to 586 µg/L formed in natural lake waters. Toxic nitrogen-containing DBPs also more than doubled in concentration, with levels up to 36.1, 3.6, and 37.9 µg/L for haloacetamides, halonitromethanes, and haloacetonitriles, respectively. In ultrapure water, DBPs also formed up to 314 µg/L when algae was chlorinated, demonstrating their ability to serve as direct precursors for these DBPs. When environmentally relevant levels of bromide and iodide were added to chlorination reactions, total DBPs increased 144, 51, and 24% for drinking water reservoir, Lake Marion and Lake Wateree Microseira respectively and 29% for Phormidium. Iodo-DBPs, bromochloroiodomethane, chloroiodoacetic acid, bromoiodoacetic acid, and diiodoacetic acid were observed in finished water from a drinking water plant impacted by Microseira, and bromochloroiodomethane and dibromoiodomethane were observed in chlorinated ultrapure water containing algae, bromide, and iodide. Notably, total calculated cytotoxicity tripled in Microseira-impacted waters and doubled for Phormidium-impacted waters. Calculated genotoxicity doubled for Microseira-impacted waters and more than doubled in Phormidium-impacted waters. Haloacetonitriles were major drivers of calculated cytotoxicity in algae-impacted waters, while haloacetic acids were major drivers of calculated genotoxicity in algae-impacted waters. These results provide the most extensive assessment of DBPs formed from chlorination of algae-impacted waters and highlight potential impacts to drinking water and human health. Results from this study are particularly applicable to drinking water treatment plants that employ pre-chlorination, which can cause the release of algal organic matter (AOM) precursors to form DBPs.

Analyzing the Orthopaedic Surgery Personal Statement: Do Residency Applicants See Value in Its Use?

Orthopaedic surgery is one of the most competitive specialties in the residency match. The personal statement (PS) is one component of the application. The significance of the PS to orthopaedic surgery residency applicants is unknown. This study evaluates applicant perceptions of the PS. Applicants to two separate United States orthopaedic residency programs for the 2019-2020 cycle were invited to participate. Survey was distributed via email. Twenty-one percent (204/978) of applicants completed the survey. Most were men (157/204, 77%), and most (125/204, 61%) spent up to 15 hours writing their PS. Many [79.4% (162/204)] believed the PS should continue to be included in the application. Women always edited their PS, while 7.0% (11/ 157) of men did not use any editors. Applicants believe the PS is valuable. The PS is time consuming but allows applicants to communicate details that otherwise may not be included in their application. (Journal of Surgical Orthopaedic Advances 31(1):034-041, 2022).

Achilles Injury and Access to Care in South Florida.

Introduction. Despite the amount of orthopaedic research evaluating access to care based on insurance status, no study quantifies the effects of insurance status on the care of acute Achilles tendon ruptures. Methods. Using Current Procedural Terminology codes, we identified all patients who underwent surgical management of Achilles tendon rupture between December 31, 2013, and December 31, 2018, and followed-up at either a county hospital-based orthopaedic surgery clinic and/or private university-based clinic. Inclusion criteria included patients who (1) underwent surgical management of an Achilles tendon rupture during this time period and (2) were at least 18 years of age at the time of surgery. A univariate 2-tailed t test was used to compare various groups. Statistical significance was set at P < 0.05. Results. When compared to adequately insured patients (private and Medicare), underinsured patients (uninsured and Medicaid) experienced a significantly greater time from the date of injury to first clinic visit (14.5 days vs 5.2 days, P < .001), first clinic visit to surgery (34.6 days vs 4.8 days, P < .002), injury to surgery date (48.9 days vs 9.8 days, P < .001), initial presentation to when magnetic resonance imaging was obtained (48.1 days vs 1.9 days, P < .002). Conclusions. Disparities in access to care for Achilles tendon ruptures are intimately related to insurance status. Uninsured and Medicaid patients are subject to institutional delays and decreased access to care when compared to patients with private insurance.Levels of Evidence: Level III: Prognostic, retrospective.

Optimizing the Virtual Interview Experience for Hand Surgery Fellowships.

Similar to many other medical training programs, fellowship interviews for hand surgery will be conducted virtually for a second consecutive year. We provide strategies for applicants to ideally portray themselves and to learn about fellowship programs. We include approaches for fellowship programs to identify candidates that match their values as a program, as well as ways to provide useful information to applicants about the program's culture. Given that components of virtual interviewing and recruitment will likely be an ongoing part of fellowship applications, we hope this article provides a framework to guide both applicants and program faculty for the 2021 to 2022 cycle and beyond.

Liquid Nitrogen Applied at Point of Sale: A New Presentation of Gastric Perforation in Children.

ABSTRACT: The August 30, 2018, US Food and Drug Administration advisory warned consumers to avoid eating, drinking, or handling food products prepared with liquid nitrogen (LN) (US FDA. Safety Alerts & Advisories: FDA Advises Consumers to Avoid Eating, Drinking, or Handling Food Products Prepared with Liquid Nitrogen at the Point of Sale. US Food and Drug Administration). We report on the case of a pediatric patient sustaining gastric perforation after ingestion of LN applied to food at the point of sale in the United States. "Dragon's Breath" is a popular snack of cereal puffs coated in LN giving the allusion of breathing smoke on ingestion. Instructions provided by vendors include avoidance of touching or drinking the liquid in the bottom of the cup. We report on a case of a 9-year-old girl presenting with peritonitis and gross pneumoperitoneum after consumption of Dragon's Breath with injury conferred secondary to LN ingestion. Intraoperative finding of a large perforation along the lesser curvature of the stomach was repaired primarily with an omental overlay. Her postoperative course was complicated by pneumonia and a surgical site infection. She was discharged 13 days after admission. A review of the literature of previous case reports of LN ingestion by intentional or accidental means is provided. This case report and review of the literature bring awareness of the dangers posed to pediatric patients exposed to LN applied at the point of sale.

The Importance of Mentorship and Interest Group Involvement for the Orthopedic Surgery Applicant.

Background: Mentorship in medical education is important for students' professional development career planning. Orthopedic Surgery Interest Groups (OSIG) exist as formal organizations and serve as a conduit for undergraduate mentorship, though the role of mentorship via OSIGs within orthopedic medicine has not been thoroughly evaluated. Similarly, OSIGs within institutions are not standardized nor well defined. We sought to answer: (1) What offerings does OSIG provide for students interested in orthopaedic surgery? (2) How does OSIG involvement impact the orthopaedic surgery residency applicant? (3) Does OSIG involvement increase match rates for orthopaedic surgery residency applicants? Methods: An online survey was distributed to faculty advisors at all allopathic US medical schools with available contact information. Results were analyzed using SPSS. Results: Of the 28 respondent organizations, the majority (53.6%) have between 1-25 student members. On average, OSIGS offer 3.64 + 1.59 (mode = 4) executive positions. The most important initiative for OSIG groups was clinical/surgical shadowing, followed by faculty mentorship, and guidance for the residency application. OSIG involvement does impact the applicant, as all faculty mentors believed this to be an important component of the residency application. Leadership positions within OSIG was not perceived as being equally important. OSIG involvement did increase match rates; the match rate for all students at the schools surveyed (n=17) was 81.21% while the match rate for students within OSIG (n=17) was 82.39% (p<0.05). Of all students who applied to orthopedic surgery residency programs, 98.9% were members of OSIG, and of all students who successfully matched into orthopedic surgery residency programs in the 2019-2020 cycle, 100% (p<0.05) of students (n=17) were involved in OSIG. Conclusion: This study indicates the importance of involvement in OSIG as a conduit for clinical exposure and mentorship throughout medical education, and is especially relevant for applicants given the impact of the COVID-19 pandemic on the residency application process. Data suggests that participation in an OSIG is a valuable experience for the medical student interested in orthopedics and that students involved in OSIGs are more likely to match into orthopedic residency programs. Level of Evidence: V.

Are Disinfection Byproducts (DBPs) Formed in My Cup of Tea? Regulated, Priority, and Unknown DBPs.

Globally, tea is the second most consumed nonalcoholic beverage next to drinking water and is an important pathway of disinfection byproduct (DBP) exposure. When boiled tap water is used to brew tea, residual chlorine can produce DBPs by the reaction of chlorine with tea compounds. In this study, 60 regulated and priority DBPs were measured in Twinings green tea, Earl Grey tea, and Lipton tea that was brewed using tap water or simulated tap water (nanopure water with chlorine). In many cases, measured DBP levels in tea were lower than in the tap water itself due to volatilization and sorption onto tea leaves. DBPs formed by the reaction of residual chlorine with tea precursors contributed ∼12% of total DBPs in real tap water brewed tea, with the remaining 88% introduced by the tap water itself. Of that 12%, dichloroacetic acid, trichloroacetic acid, and chloroform were the only contributing DBPs. Total organic halogen in tea nearly doubled relative to tap water, with 96% of the halogenated DBPs unknown. Much of this unknown total organic halogen (TOX) may be high-molecular-weight haloaromatic compounds, formed by the reaction of chlorine with polyphenols present in tea leaves. The identification of 15 haloaromatic DBPs using gas chromatography-high-resolution mass spectrometry indicates that this may be the case. Further studies on the identity and formation of these aromatic DBPs should be conducted since haloaromatic DBPs can have significant toxicity.