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A right-hand-dominant female presented 5 weeks following a right middle finger intralesional cantharidin injection for a common wart by a dermatologist. The patient experienced progressive stiffness, blistering, swelling, pain, and ultimately, full-thickness skin necrosis surrounding the injection site. Careful debridement followed by a full-thickness skin graft was performed with no evidence of involvement of the germinal matrix or terminal extensor tendon. At the 7-month postoperative mark, the patient's graft exhibited favorable healing and improved functionality that did not require further follow-up. Intralesional injection of cantharidin solutions for digital warts leads to progressive skin necrosis. Our case required prompt debridement and defect coverage. Involvement of the underlying anatomical structures was also a concern. Dermatologists and hand surgeons should be familiar with this complication as intralesional cantharidin injections are contraindicated.

Introduction: Hyperhemolysis syndrome (HHS) is a rare complication of repeat blood transfusions in sickle cell disease (SCD). This can occur acutely or have a delayed presentation and often goes unrecognized in the emergency department (ED) due to its rapid progression and similarity to acute chest syndrome and other common complications of SCD. Case Report: We present a case of a 20-year-old male with SCD who presented to the ED with pain and tenderness in his lower extremities one day after discharge for a crisis. Unbeknownst to the ED team, during his admission he had received a blood transfusion. On presentation he was noted to have hyperkalemia, hyperbilirubinemia, anemia, and uncontrolled pain, and was admitted for sickle cell pain crisis. Over the next 36 hours, his hemoglobin dropped precipitously from 8.9 grams per deciliter (g/dL) to 4.2 g/dL (reference range: 11.5-14.5 g/dL), reticulocyte count from 11.7 % to 3.8% (0.4-2.2%), and platelets from 318,000 per cubic centimeter (K/cm3) to 65 K/cm3 (140-350 K/cm3). He also developed a fever, hypoxia, transaminitis, a deteriorating mental status, and severe lactic acidosis. Hematology was consulted and he was treated with methylprednisolone, intravenous immunoglobulin, two units of antigen-matched red blood cells, fresh frozen plasma, and cryoprecipitate. He was transferred to an outside hospital for exchange transfusion and remained hospitalized for 26 days with acute liver failure, bone marrow necrosis, and a fever of unknown origin. Conclusion: Because of the untoward outcomes associated with delay in HHS diagnosis and the need for early initiation of steroids, it is important for emergency providers to screen patients with hemoglobinopathies for recent transfusion at ED presentation. Asking the simple question about when a patient’s last transfusion occurred can lead an emergency physician to include HHS in the differential and work-up of patients with sickle cell disease complications.

The Earth's population will become more than 80% urban during this century. This threshold is often regarded as sufficient justification for pursuing urban ecology. However, pursuit has primarily focused on building empirical richness, and urban ecology theory is rarely discussed. The Baltimore Ecosystem Study (BES) has been grounded in theory since its inception and its two decades of data collection have stimulated progress toward comprehensive urban theory. Emerging urban ecology theory integrates biology, physical sciences, social sciences, and urban design, probes interdisciplinary frontiers while being founded on textbook disciplinary theories, and accommodates surprising empirical results. Theoretical growth in urban ecology has relied on refined frameworks, increased disciplinary scope, and longevity of interdisciplinary interactions. We describe the theories used by BES initially, and trace ongoing theoretical development that increasingly reflects the hybrid biological-physical-social nature of the Baltimore ecosystem. The specific mix of theories used in Baltimore likely will require modification when applied to other urban areas, but the developmental process, and the key results, will continue to benefit other urban social-ecological research projects.

Background: The rise in xylazine-adulterated heroin and fentanyl poses novel challenges to hand surgeons and a rising epidemic of necrotic upper-extremity wounds. While prior case studies have focused on particularly severe and complex xylazine-associated necrotic (XAN) wounds, the aim of this consecutive case series was to characterize the variability of presentations (ranging from mild to severe) at a single institution at the epicenter of the xylazine epidemic. Methods: Patients presenting to a tertiary referral center for XAN upper-extremity wounds were retrospectively identified from emergency department visits and hospital admissions between January 2021 and December 2023. Patient characteristics, clinical findings, treatment, and hospitalization-related measures were recorded. Wounds were classified according to the depth, density, size, and presence of osteomyelitis. All of the variables were quantified using descriptive statistics. Results: In total, 82 patients with 125 XAN wounds were included in the study. The mean age was 40.3 ± 8.2 years, and 57% of the patients were men. Of the 125 wounds, 54% had associated osteomyelitis, 78% were confluent, and 47%involved more than two-thirds of the anatomic region. Surgery was recommended for 78% of the patients and was performed in 62%, with 13% undergoing amputation. Complications rates were high (77%) and included bacteremia (40%) and death (5%). Patients were hospitalized a mean of 4.1 times and were discharged against medical advice 2.8 times per year. Conclusions: This study presents a broad perspective on demographic, social, and medical factors in patients with XAN wounds of the upper extremity. Given the complexity and burden of this public health crisis, early intervention is important to prevent complications and mitigate costs. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence. [ABSTRACT FROM AUTHOR]

For more than a century, observations of cloudbursts have contributed to understanding physical processes producing "the sudden heavy fall of rain" – the American Meteorological Society definition of a cloudburst. Keen observers of cloudbursts include pioneers in the hydrological sciences, notably Robert Horton, G.K. Gilbert, Luna Leopold and John Hack. Horton transformed early 20th century understanding of cloudbursts into a conceptual model of thunderstorms that provided the foundation for his conclusion that "there is a natural limitation to rain intensity for any duration." The notion of bounds on rainfall and flood peaks has been ingrained in the philosophy of engineering design for high-hazard dams. The evolution of ideas linking cloudburst rainfall to the properties of short-duration rainfall extremes is examined in this paper through the lens of Robert Horton's cloudburst research, which provides useful insights to 21st century problems tied to cloudbursts and extreme, short-duration rainfall. [ABSTRACT FROM AUTHOR]

This paper presents a dynamic Excel visual. The visual has three graphs that are all driven by the same data, so students can see how changes (via Slider controls) in data appear on a univariate graph, a bivariate graph, and a graph that shows a ratio of two variables on one axis. The visual has macros that let a statistics teacher reveal parts of the visual separately. The paper discusses how the visual helps students learn about five conceptual issues. Concluding comments are provided to help teachers who might wish to use the visual.

Background: While complexity of distal radius fractures varies, volar plating is the most prevalent surgical option in adult injuries. The time between date of injury and surgical intervention varies according to several factors, including the timing of presentation and the surgeon's availability. This study aims to understand the impact of a delay in surgical intervention on operative time, patient-reported outcomes, and reoperation rates. Methods: A retrospective review was performed on patients treated with volar plating of distal radius fractures from 2017 to 2020 at a single institution by multiple surgeons. Perioperative medical records were reviewed. Patients were divided into 2 groups using a cut-off date of surgery performed 12 days after injury. Descriptive analyses were used to compare demographics, fracture characteristics, operative information, and outcome data including postoperative Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores and reoperation rates between groups. Results: A total of 257 patients were included. There was no difference in age, gender, smoking status, fracture type, or postoperative QuickDASH scores between groups. Patients fixed at 12 days or more after injury had a higher rate of reoperation, higher American Society of Anesthesiologists scores, and more surgeon experience. Conclusions: Volar distal radius fixation at 12 or more days after injury had no discernible differences with fracture type, operative time, or tourniquet time; however, a higher rate of reoperation was found in this group compared to earlier intervention. These data may provide important prognostic information that can be used to educate patients who present in a delayed fashion. [ABSTRACT FROM AUTHOR]

While research on the hydrologic impact of different types of stormwater control measures (SCMs) is extensive, little research exists linking urbanization, widespread implementation of SCMs and channel stability in headwater streams. This study evaluated whether the unified stormwater sizing criteria (USSC) regulations in the state of Maryland, USA, which require the use of both end‐of‐pipe and distributed, small‐scale SCMs, protect channel stability. To achieve this goal, a coupled hierarchical modelling approach utilizing the Storm Water Management Model (SWMM) and the Hydrologic Engineering Center River Analysis System 6.3 (HEC‐RAS) was developed to predict changes in streamflow and sediment transport dynamics in a first‐order gravel‐bed, riffle‐pool channel. Storm event discretization revealed that 88% of observed storm events during the 16 years (2004–2020) had durations less than 18 h and that the greatest peak flows resulted from storm events with durations less than 24 h. HEC‐RAS simulation results also showed that both channel degradation and aggradation, as high as 1.2 m, will likely occur due to regulations which require the use of 24 h duration design storms with a target stormwater detention time rather than bed material sediment transport limits. Overall, this study provides valuable insights into the complex interactions between SCM practises, flow regimes and sediment transport dynamics in heavily urbanized watersheds. It is recommended that SCMs be designed using a continuous simulation model with at least 10 years of continuous rainfall data. Furthermore, to protect channel stability, the SCM design goal should focus on maintaining pre‐development sediment transport regimes across a range of flows. [ABSTRACT FROM AUTHOR]

Despite the significant attention they have drawn, big-bucket lot-sizing problems remain notoriously difficult to solve. Previous literature contained results (computational and theoretical) indicating that what makes these problems difficult are [...]