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1 General introduction topenlarge
A fracture wound, whether traumatic or surgical, that becomes infected almost always results in prolonged treatment and a suboptimal outcome.
Any surgeon who treats fractures should be aware of risk factors for infection. Every effort should be made to reduce the risk of infection by following the basic surgical principles of fracture care.
Débridement: definition
The factors that reduce a patient's ability to resist infection should be corrected whenever possible.
All necrotic, and infected, tissue should be removed surgically. The surgical removal of infected tissue is the mainstay of management of infected fractures. Such surgery is frequently referred to as débridement. Unfortunately this term, although an official Current Procedural Terminology (CPT) code of the American Medical Association, is open to interpretation and denotes different procedures in different surgical contexts and is not clearly defined.
Débridement, as used in this discussion, means the surgical exposure of the whole pathological zone and the removal of all necrotic, contaminated, damaged and/or infected tissue, whether bony or soft-tissue. All loosened hardware should be removed as well.
Infected wounds should never be closed until all infection is overcome and their condition permits.
Fractures should be stabilized surgically. Internal fixation devices can compromise local host resistance, and need to be removed unless they provide absolute stability, and the infection responds promptly to treatment. If an internal fixation device has to be removed prior to bone healing, then fracture stabilization by external fixation becomes necessary.
Infecting microorganisms should be identified, their antibiotic sensitivities defined, and appropriate specific antibiotics administered as an adjunct to surgical treatment.
It is now appreciated that not all infecting micro-organisms are free in the wound tissues and fluids. Those that are free, and therefore likely to be detectable by standard culture techniques, are called, in modern terminology, planktonic micro-organisms.
Many of the bacteria that inhabit chronic wounds set up complex polymicrobial biofilm communities that can only be detected by culture techniques when they happen to detach a sufficient bolus of planktonic cells that can be grown on conventional culture media.
A major problem in bony infections is the fact that biofilm bacteria cannot be recovered by standard culture techniques, which means that fracture repairs often yield negative culture results even when multiple clinical signs point to infection. New techniques such as sonication can increase the yield of the cultures. It is important to realize culture results are affected if the patient is being treated with antibiotics at the time of culture.
2 Diagnosis of wound infection topenlarge
Early identification of a wound infection is the first step towards the prompt intensive treatment necessary for optimal results. Any wound communicating with a fracture, whether due to the injury, or created by a surgeon, is at risk of becoming infected.
Recognition of those factors that predispose to infection should increase the surgeon's alertness to the possibility of infection. Early signs of infection are not specific and may easily be misinterpreted, as an inflammatory response is normally present in the region of a fracture, even without infection. Often, the first sign of wound infection is that the inflammation fails to resolve as quickly as expected. Certainly, increasing signs of inflammation (wound drainage, redness, swelling, pain and tenderness, fever) must be regarded as indicators of likely infection.
If the surgeon is concerned about infection, all steps to diagnose, or exclude, this possibility must be taken, as a matter of urgency.
Evaluation of possible infection
The presence of bacteria in an inflammatory wound exudate is proof of infection. Often this is most readily obtained by sterile aspiration of the wound, or preferably by surgical exploration. Microscopic examination (Gram's stain) of the exudate, and appropriate microbiological cultures may provide evidence of bacterial presence. It has to be borne in mind, however, that there may be few planktonic bacteria in the wound and that most bacteria may be trapped in biofilms (see General introduction).
Prior antibiotic treatment may interfere with microbiological studies. Occasionally, increasing inflammation is evident without recoverable bacteria, but infection must be assumed if the clinical indicators are strong.
Systemic signs of inflammation, often associated with infection, are provided by several laboratory studies (see below). By themselves, none of these proves, or excludes, infection. The diagnosis of such infections is dynamic and based on serial clinical and laboratory observations. It is the duty of any fracture surgeon to monitor each patient closely for this serious complication.
Note: PCR
Rapid advances in the use of molecular detection techniques have recently become available to clinical laboratories, using real-time polymerase chain reactions (PCR) and appropriately selected microarrays. This technology can rapidly identify selected bacteria, based on their DNA, as well as any antibiotic resistance. Microbiological culture is not necessary to use these techniques. As examples, it is possible to discover methicillin-resistance of S. aureus within a few hours, as well as to identify fastidious microbes, and those suppressed by antibiotics. Working with microbiologists using PCR, surgeons may well improve adjunctive antibiotic treatment, as well as improve diagnosis and classification of skeletal infections.
Relevant observations include:
- Serial wound examinations under aseptic conditions
- Maximal daily temperature reading
- Full blood count (FBC) with differential white cell count
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP)
- Bacteriology (gram's stain, culture and sensitivity)
- Imaging - Plain x-rays, (PET), CT scan, MRI, Indium111-labelled white blood cell scan, Technetium 99m labeled phosphate bone scan.
Classification of infection
An important guide to treatment is provided by the discipline of classifying an infection according to several parameters:
- duration of infection
- anatomical location
- host resistance to infection
- infecting organism(s)
- status of fixation
- status of bone healing
- viability of bone and soft tissues
Optimal management of an infected fracture or infected nonunion requires assessment of each of these factors.
Clinical examination
Serial observations of clinical symptoms and signs are most important for identifying the presence of infection. Increasing pain, seepage (either purulent or serosanguinous), swelling, redness, warmth and tenderness all suggest the possibility of a wound infection. Progressive worsening of one, or more, of these parameters is confirmatory. While some inflammation is caused by a fracture and by any operation to treat it, its severity should normally progressively decrease.
In the diagnosis of early infections, x-ray imaging plays a negligible role. Radiographic findings of infection are usually not evident until at least 2 weeks after the onset of infection, even though bone involvement has already occurred.
Imaging becomes important in the later stages of infection. It is helpful to examine serial x-rays for progressive changes that could suggest infection.
Radiographic signs are neither sensitive nor specific for infection; e.g., radiographic evidence of implant loosening may be present as a result of instability, infection, or both.
Ultrasound is useful to identify any accumulation of fluid (hidden abscess). The method is non-invasive and may image deeper layers, especially in the thigh. Ultrasound can be helpful for guiding diagnostic needle aspiration.
Computed tomography offers a cross-sectional guide for exploration and excision, particularly of bone fragments (sequestrum).
As with plain radiographs, CT scans offer no specific diagnostic signs for, or against, infection, and is rarely useful in early infections.
MRI offers improved imaging of soft-tissue abnormalities and can show greater anatomical detail than other imaging methods. Again, MRI signs of infection are non-specific. A disadvantage of MRI is the problem of artifact related to ferrous metallic implants. Titanium implants produce less interference.
Bone scan
Uptake of technetium 99m-labelled phosphate compounds (TCN-MDP) by bone is increased in areas of higher vascularity, including infections and bone healing. With infection, a 3-phase bone scan shows increased uptake of labelling in all 3 scan phases.
Absence of uptake suggests impaired vascularity, or bone necrosis. Bone scanning detects increased bone remodeling that is present around all fractures for 12-24 months. Bone scanning cannot differentiate aseptic hardware loosening from infection. Bone scans are of negligible value in the early postoperative period of acute fractures.
Indium111-labelled white blood cell scans are more specific for inflammation and infection. The illustration shows a larger area of uptake, surrounding hyperemia and inflammation with TCN-MDP (b) than with the indium111 white blood cell technique (a). However, false positives and false negatives still occur, and such scans can be positive in un-united fractures.
If an infected area is to be explored, preoperative aspirate of fluid accumulation and especially intraoperative tissue sampling from several potentially infected sites, prior to the start of any antibiotics, provide the best material for detecting the infecting microorganism(s). At least 5 specimens should be taken for microbiology testing. One sample should be sent for histopathology. Both aerobic and anaerobic cultures should be undertaken. PCR, if available will speed up, and make more reliable, the characterization
of the organisms. If hardware is removed, this can be cultured as well preferably after sonication.
Histological investigation can reveal a bacterial etiology, even if the microbiological tests are negative. Superficial wound swabs should be avoided because of low sensitivity and frequent contamination by surface organisms. Ideally, prior to tissue sampling for culture, it is important to discontinue any antibiotic therapy for at least a week.
Septic arthritis
If the infection is suspected to involve a joint cavity, there is a need for drainage, surgical clearance and irrigation of that space. At the slightest suspicion of septic arthritis, joint aspiration should be performed to evaluate the affected joint. If infected fibrinous deposits (cloudy aspirate) are present with positive cultures, then arthroscopic or open irrigation should be performed repeatedly, every 2-3 days, until the infection resolves. If arthroscopic clearance is unsuccessful, one should proceed
with open synovectomy.
If there is articular cartilage degradation, arthrodesis may become unavoidable.
3 Classification of fracture wound infection topenlarge
A variety of factors can influence the prognosis of fracture wound infections. Unlike hematogenous osteomyelitis, a fracture wound begins with damaged soft tissue and bone, and consequent, locally-reduced resistance to infection. There may also be necrotic bone, and perhaps foreign material, where bacteria are protected from host defenses and blood-borne antibiotics, often sheltering in biofilms (see General introduction).
Factors to consider in categorizing infections are:
- duration of infection
- anatomical area of bony involvement
- host resistance (systemic and/or local)
- status of fracture fixation
- status of fracture healing
- microbiology
Classification according to chronology of onset of infection
The time of onset of fracture-site infection is relevant, since progressive infection leads to additional tissue damage and spread of infection outwards from the original infected locus. The diagnosis of infection within 2 weeks of injury or the first open intervention is to be regarded as an early infection. Diagnosis after two weeks may suggest that the infection was dormant for a period before declaring itself. The diagnosis of late infection generally implicates more extensive tissue pathology than if picked up earlier.
Early presentation of infection
Infection, diagnosed in the first two weeks after injury or after the first surgical intervention, is likely to have caused less tissue damage, than if discovered later.
The treatment of all fracture wound infections is urgent and is primarily surgical, with antibiotics as an adjunct.
There is no place for the administration of antibiotics and a "wait and see" approach.
Click here to read more about early presentation of infection.
Later presentation of infection
Infection may not be seen until several weeks after surgery.
More extensive and intensive treatment is usually necessary.
Click here to read more about delayed presentation of infection.
Chronic fracture wound infection
Late presentation, chronic infection is associated with extensive infection of tissues and dead bone, sometimes sequestered.
Treatment relies on
- total surgical removal of all dead and infected tissue, including bone
- removal of implants
- placement of an antibiotic spacer
- re-stabilization of the fracture, using external fixation
- appropriate adjunctive antibiotic therapy
Click here to read more about chronic fracture site infection.
Recurrent osteomyelitis
Posttraumatic osteomyelitis may recur, sometimes years after the original infection appeared to have resolved.
Treatment depends on:
- fracture healing
- implants
- sequestra
Treatment relies on:
- Surgical removal of all infected and dead tissue
- Identification of the responsible microorganism from cultures of biopsies
- Fracture stabilization, as necessary, with external fixation
- The use of appropriate adjunctive antibiotics
- Soft-tissue reconstruction, once infection is eradicated
Click here to read more about recurrent osteomyelitis.
Cierny's classifications
Cierny has classified fracture site infections according to a number of criteria:
- anatomical
- host resistance
- microbiology and
- the status of fracture healing.
These are all important factors to be taken into consideration.
4 Treatment - initial surgery for fracture wound infection topenlarge
If an infection is strongly suspected, the surgeon must proceed urgently to exploration of the wound, obtaining tissue for culture, and removing all non-viable tissue and exudates.
Such débridement (see below) involves the surgical excision of all necrotic and/or infected tissue from the wound.
Débridement must include:
- Wide exposure of the whole pathological zone
- Removal of all exudate (hematoma and pus)
- Removal of the abscess membrane
- Removal of sinus tracts
- Removal of granulation tissue
- Removal of unhealthy wound margins
- Removal of all dead bone
- Removal of loosened hardware
Look carefully for dead bone and any remaining foreign material. Preserve nerves, identifiable blood vessels and viable tendons.
The surgical excision must be complete and thorough.
Adequate, timely débridement is the most important element of the treatment of a fracture-wound infection.
With well-established infections, there may not be a clear demarcation between viable and non-viable tissue. Radical excision may be necessary to eliminate infection, even though it may increase the complexity of reconstruction.
After débridement, the surgical site should be thoroughly irrigated with normal saline solution to reduce the bacterial population. The use of pulsatile lavage has been questioned as the water jet might transport bacteria deeper into the soft tissue. In cases with large amounts of dead tissue, or grossly purulent wounds, repeated surgical clearances are indicated. Deciding what tissue to remove and what tissue to retain is the essential challenge of débridement. Such decision-making is learned from experienced surgeons and by practice. Common errors are failure to remove enough compromised tissue, and/or to do so in a way that injures the retained tissue. An organized approach that proceeds in orderly steps through tissue levels is required. Any non-viable skin is excised. The incision should be extended, as necessary, for adequate exposure of the whole infected zone. The depths of the wound are then exposed, and must include all of the previous surgical exposure. Any extension of hematoma, pus, or necrotic tissue, should be explored fully.
With acute wound infections, internal fixation devices may be retained, if they continue to provide absolute mechanical stability. If the implants are loose, and in more established infections, it is advisable to remove all hardware and to re-stabilize with an external fixator. Make sure to position the pins far enough from the infected wounds, while still maintaining adequate stability.
Excise the surface of the exposed tissue to leave clearly viable margins of subcutaneous tissue, fascia and muscle. Non-viable bone must also be removed with a high-speed burr (suitably irrigated to cool the tissue), or preferably osteotomes, until bone bleeding is encountered. Small bleeding osseous vessels ("paprika sign") indicate viable bone.
Copious irrigation with Ringer-lactate solution helps to remove bacteria, bits of dead tissue and blood clot, and improves the surgeon's ability to examine the wound.
A "second look" and possibly further débridements should be undertaken, until the wound surface is completely viable. Staged surgical clearance is illustrated.
Local débridement of an infected nonunion is characterized by:
a) The nonunion is covered by granulation tissue, stained with methylene blue, previously injected into the sinus.
b) After excision of the granulation tissue, the necrotic bone adjacent to the nonunion contrasts directly with the vital bone.
c) After complete surgical clearance, only vital bleeding bone and soft tissue is seen.
5 Treatment - management of the fracture wound topenlarge
Initial antibiotic treatment
Before starting therapeutic antibiotics, it is important to obtain adequate cultures, or PCR characterization (if available). At least 5 samples should be obtained in the operating room from different locations in the wound. Only if the patient has evidence of septicemia should antibiotics be given before wound exploration.
Selection of antibiotics for initial treatment is based on the antibiotic sensitivities of likely infecting organisms, including any results of previously positive cultures.
Generally, broad-spectrum, intravenous antibiotics are advisable as soon as cultures have been obtained. Initial antibiotics are selected, based on the results of gram's stain, and on institutional frequency statistics (see table on left; Trampuz A, Zimmerli W (2006) Diagnosis and treatment of infections associated with fracture-fixation devices. Injury. 37 Suppl 2:S59-66.).
Methicillin-sensitive S. aureus (MSSA) is still the most likely infecting organism in most areas. Institutionalized patients have a higher risk of methicillin-resistant S. aureus (MRSA), in which cases vancomycin may be advisable.
Coverage with antibiotics active against gram-negative microorganisms is wise for hospital-acquired infections.
All of the above should be considered provisional treatment until culture results become available.
Definitive antibiotic treatment
Once culture results and sensitivities are known, choose the optimal antibiotic for the infection, in consultation with an infectious-disease specialist. Remember that antibiotics are but an adjunct to adequate surgical clearance, and recognize that an infection that does not respond will need repeat surgical exploration and clearance.
If laboratory services are limited, then the choice of antibiotics is determined by the most appropriate available for the most likely organisms.
Prolonged intravenous antibiotics (e.g., six weeks), the use of combinations of drugs, and continued oral medication after initial intravenous therapy may be necessary.
Dead space within the wound
After the first surgical clearance of an infected fracture wound, it is essential to defer suture closure or other definitive soft-tissue cover. Closure may be considered when final clearance has resulted in resolution of the infection.
Empty space ("dead space") under tissue flaps, or within bony cavities, within the excised wound allows further accumulation of exudate and is likely to become a reservoir of bacteria. Antibiotic levels will be low in this poorly-perfused accumulation of fluid.
Filling this dead space is an important part of wound management. Alternative treatment strategies include the use of antibiotic beads, or other temporary space fillers (calcium sulphate, bone cement, etc.). The wound itself should be covered to avoid desiccation, or secondary contamination. This can be done with an impermeable dressing (adherent plastic), or with vacuum-assisted closure (VAC), as illustrated. The latter, by applying suction, reduces dead space volume in pliable tissues.
Dead space in bone
A significant bone defect may be filled with antibiotic beads, or other space fillers.
Recently, the technique of Masquelet has become popular. This involves the insertion into the bony defect of a solid antibiotic-containing cement spacer, which is left in place for 6-8 weeks while a membrane develops around it. The spacer is then removed and the surrounding membrane is filled with autologous bone graft. (The membrane has been studied extensively and it has been suggested that this membrane has osteogenic capacity.) This often consolidates when used for small to medium-size defects.
For more details see: Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R (2011) Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury 42(6):591-8. Case taken from article with permission from Elsevier.
Antibiotic cement plug in place. Make sure the cement fills the defect and also covers a few mmm of the cortex on either side of the plug. The cement can be prepared with addition of heat-stable antibiotics of choice.
Membrane incised 6 weeks later
Membrane retracted, cavity healthy for bone grafting
6 Treatment - implant retention or removal topenlarge
Implant retention or removal: plates and screws
For as long as a plate and screws provide absolute stability, fracture healing can usually take place despite the presence of treated infection, notwithstanding the presence of a metallic foreign body. It appears that in most cases, stability is more important than the negative effects of the foreign body upon host defense.
Typically, fixation remains stable in early infections. However, at any stage, if the implants are loose, they must be removed. External fixation stabilizes the fracture while avoiding a metallic foreign body in the infected fracture wound, and is the best choice for early fracture destabilization in the presence of infection.
Stabilization with external fixation
The diagram demonstrates an ideal external fixation placement. The pins do not hamper surgical access to the infected zone, and are well-separated within each fragment, so as to provide optimal stability. Two bars also improve the strength of the fixation. The configuration should be planned carefully.
An external fixator can be used either as a temporary, or as a definitive, stabilizer. Even if definitive external fixation is planned, a temporary fixator may be best after initial débridement. This aids repeated clearance and wound care. Once further wound access is no longer required, a new fixator that provides optimal stability can be applied.
Mistakes in pin insertion for external fixation are:
- Drilling at excessive speeds or with a blunt drill bit (A), producing thermal necrosis of bone.
- Insertion of the Schanz screws, or pins, without adequate pre-drilling (B) causing microfractures, as well as excessive heat, which results in small necrotic bone fragments, or ring sequestra.
Correct pre-drilling and correct pin/screw insertion (C) minimize the risk of pin tract infection.
Plates and screws
If an identified infection is treated early, and its fixation remains stable, then with appropriate surgical clearance and antibiotics, the infection is likely to respond and to remain suppressed during fracture healing. Despite successful fracture healing, later recurrent infection can lead to the need for hardware removal.
After the "infected hardware" is removed from the united fracture, and any necessary further excision of questionable tissue and/or bone has been undertaken, the infection usually resolves satisfactorily with a low risk of recurrence.
The pictures to the left: Plated tibia fracture. Early infection debrided. Plate was stable and left in situ. Eventual granulation over bone and then partial thickness skin grafting.
Implant retention or removal: IM nails
If a wound infection develops after intramedullary nailing, it is likely that the infection has spread along the medullary cavity. The infection may be early, or late, before or after union. Adequate surgical clearance requires removal of the nail and reaming of the medullary canal.
During initial clearance, a distal opening is created at the lower end of the nail tract, in order to allow debris from reaming to escape, and to drain the "sump". The canal is then reamed to a diameter 1.5 mm larger than the removed nail, and is thoroughly and copiously washed out with Ringer-lactate solution. If there are obvious cortical sequestra, these need removal by open procedure.
An external fixator should be applied for stability, if the fracture is not healed.
If the infection is early and due to a less virulent bacterium, then renailing might be considered.
If the infection is late, or due to resistant organisms, external fixation is preferable to renailing.
An alternative is to insert temporarily a reinforced, antibiotic-containing polymethylmethacrylate (PMMA) "nail" into the medullary canal, after reaming out the infective membrane and thorough lavage of the IM canal, also excising any sinus tract and any sequestra. An antibiotic-loaded PMMA nail is prepared by injecting liquid bone cement, pre-mixed with antibiotics (e.g. tobramycin 1 g per cement batch) into both ends of an appropriately sized chest tube which is vented in the middle to allow complete filling. A small-diameter flexible rod (e.g., nailing guide wire) is inserted before the cement hardens. The chest tube is then cut off.
The "nail" can be left in situ until the fracture has healed, or until the infection is under control, and then replaced with a solid metallic nail – a solid nail is used in order to avoid the hollow nail's becoming a hiding place for bacteria.
Implant retention or removal: external fixators
Since external fixator pins are usually distant from the fracture wound, their removal is rarely required, but adjustment, or reinforcement, of the frame may be required to ensure alignment and stability.
Should an external fixator pin tract become infected, the pin should be removed, the pin site surgically cleared, and a new fixation pin placed into healthy bone. The pin tract clearance is best achieved with a drill and a bit slightly larger than the residual pin hole, together with copious irrigation. If it is anticipated that external fixator will be in place for longer (2-3 months) one can consider the use of hydroxy apatite coated pins. They have been shown to be less prone to loosen.
7 Treatment - wound closure and definitive stabilization topenlarge
Wound closure
Following infection after ORIF (A, B) and after débridement has been satisfactorily completed, in one or more procedures (C), consideration must be given to choosing the best means of wound closure. Suture closure, particularly with skin tension, carries very high risks of wound healing problems. If possible, delayed primary suture closure can be considered. If this is chosen, however, the surgeon must watch carefully for wound breakdown, or recurrent infection.
A safer alternative is to leave the wound open and allow it to heal by second intention (D), or with the use of split-thickness skin grafts. This is appropriate for wounds without exposed hardware, bone, cartilage, or other sensitive tissues.
If the wound is widely open, or tissue protection is necessary, some form of flap coverage will probably be necessary. A VAC can be used to reduce the size of an open wound and to promote granulation tissue. A clean granulating wound with a healthy viable base may be covered with a split-thickness skin graft. An alternative temporary dressing for an open wound is an impermeable adhesive drape to create a space (bead pouch) for antibiotic beads.
Closure with local, or free, flaps is often appropriate for larger and more complicated wounds, once the infection has been adequately cleared surgically.
It is important to close a complex wound as soon as is safe, rather than leave it open too long and risk secondary infection. The timing of these stages requires mature surgical judgment.
Fill dead space
Antibiotic beads
Surgical débridement of unhealthy soft tissue and/or bone may leave dead space between bone ends, or under flaps.
When the excised infected wound presents "dead space", antibiotic-laden cement is frequently used, both to fill the space and to deliver locally high doses of antibiotic. A common technique is the use of antibiotic-laden polymethylmethacrylate (PMMA) beads.
Antibiotic-impregnated beads may be purchased in some countries (at some expense), or made by the surgeon more cheaply. One gram of cefazolin (a first generation cephalosporin), or 1.2 g. of Tobramycin is mixed with each standard package of PMMA and, as it hardens, beads of 5 mm are carefully wrapped around a non-absorbable heavy nylon stitch (see adjacent photograph), knotted at intervals to prevent sliding of the "beads".
Definitive stabilization
The anatomical classification ( see Cierny classification) of adult bone infection helps to determine the method of definitive stabilization when the fracture has not united.
Medullary osteomyelitis (type I) is usually associated with an intramedullary nail, which may, or may not, have been removed during initial surgery for infection. Once the tissue is healthy, the bacteria are sensitive, and the patient is systemically healthy, it may be appropriate to restabilize the fracture with another nail.
Superficial osteomyelitis (type II) is typical of a healed fracture with superficial bone necrosis, often deep to a plate. After removal of the plate, this superficial necrotic bone is removed with a burr, or a chisel, until underlying bleeding bone is reached. Replacement fixation is only needed if fracture healing is tenuous.
Wound coverage (closure, or partial thickness skin grafting) may follow soon after such superficial surgical excision, once resolution of the infection is assured.
Localized, full-thickness osteomyelitis (type III) may be associated with a ununited fracture. Surgical excision back to bleeding bone may remove so much cortex that the structural integrity of the bone is compromised and pathological fracture is a risk. Mechanical protection will then be necessary, using an external fixator. More complex options for soft-tissue closure (local or free flaps) may be required.
Bone grafting is often necessary, but should be delayed until soft-tissue coverage is healed and stable, and the infection has healed.
Diffuse osteomyelitis (type IV) causes widespread areas of infected and/or necrotic bone, so that extensive surgical clearance is necessary. This may result in a segmental defect. Such defects will require bone grafting, bone transport, or fixing in a shortened position if loss of length is acceptable.
Wounds associated with type IV posttraumatic osteomyelitis often need complex soft-tissue flaps for closure. Such widespread infection may justify amputation, especially in under-resourced healthcare environments.
8 Treatment - bone and soft-tissue reconstruction topenlarge
After eradication of infection by surgery, combined with appropriate antibiotics, and the creation of a viable and stable soft-tissue environment, skeletal reconstruction comes next.
During the program to eradicate the infection, bear in mind the likely reconstructive options (bone graft, bone transport, or amputation), planning carefully incision placement and external fixator pin locations, etc., provided this does not compromise infection control.
Skeletal stability facilitates
- fracture healing
- enhanced wound care
- final reconstructive surgery (soft tissue and bony)
- functional aftercare
External fixation
In surgery for bone infection, external fixation may need to remain in situ for long periods. It may be necessary to replace one, or more, pins during the course of treatment.
There are 3 basic systems:
- external fixation with Schanz pins and tubular frames
- ring fixators anchored with tensioned wires
- hybrid ring fixators (using both tensioned wires and Schanz pins)
All three systems have advantages and disadvantages. The ring fixator frame is much more difficult to install, but can be used for compression and lengthening. They are also quite uncomfortable for the patient when ambulating. Hybrid frames are simpler and tensioned wires may have fewer pin-related problems, while external fixation with Schanz pins is the simplest and is very adaptable.
These frames must provide stability, just as in any other fracture fixation situation. If instability occurs (loosening, or infection) then they must be replaced.
Internal fixation with plates and nails
Plates and nails involve implantation into the site of the treated infection. They are rarely used in any previously infected wound as this increases the risk of infection recurrence.
Bony reconstruction
Eradication of infection, restoration of stability, and soft-tissue closure should be achieved before limb reconstruction.
At this stage, bone grafting, or bone transport, is performed, as needed, to achieve union, and/or to reconstruct a defect.
Initially, it may be helpful to accept some limb shortening to achieve wound closure, stability, and/or fracture healing. If the shortening is excessive, or if it involves angulation, these can be corrected with distraction histogenesis (Ilizarov technique), as a final stage of reconstruction.
Bone graft options
Autogenous cancellous bone graft, harvested from any standard donor site is the material of choice for promoting union and filling smaller defects.
For treating tibial fractures, posterolateral, or central placement, adjacent to healthy muscle, may avoid the infected focus. For the humerus, femur, or forearm, the best position of the graft depends on the defect, the soft-tissue envelope and the fixation.
Bone defects remaining after resection of dead, or infected, bone are challenging to treat. The longer the defect, the more difficult the treatment.
Circumferential defects of 1-6 cm in long bones usually heal if filled with autogenous bone graft, and stabilized appropriately. Defects greater than this usually need distraction osteogenesis, or free vascularized bone transfer.
Open cancellous bone grafting (Papineau technique), leaving the graft exposed beneath a non-adherent dressing, is a well-tried technique for reconstructing defects. It is best used for strengthening partial segmental defects. It can achieve bony bridging and secondary soft-tissue coverage concurrently, since granulation tissue should form over the graft and under the moist dressing. A split-thickness skin graft can then be applied.
Some of the superficial bone graft is inevitably lost and will have to be removed before granulation occurs. This technique has a fairly high reported success rate.
A more modern adaptation is to use a VAC over cancellous bone graft.
This case shows an infected subtalar fusion treated by Papineau technique, using vacuum assisted closure.
The case illustrations are taken from Archdeacon MT, Messerschmitt P (2006) Modern Papineau technique with vacuum-assisted closure. J Orthop Trauma; 20(2):134-7.
Healed soft tissue defect.
Underlying healed talus fracture.
Bone transport with distraction osteogenesis
Slow distraction of an osteotomy with stable (usually external) fixation creates new bone. Distraction rate is usually limited to 1 mm per day.
Soft-tissue reconstruction
Soft-tissue coverage
As a rule, soft-tissue coverage without complete surgical clearance of the underlying infection is useless.
A further rule is that wound closure under tension will always fail. The wound edges will die, the wound re-opens and secondary infection is unavoidable.
Direct suture closure is rarely possible, or desirable. Consider split-thickness skin grafts, rotational muscle flaps, fascio-cutaneous flaps, or free vascularized flaps.
Negative pressure dressings (NPWT) (vacuum-assisted closure (VAC)) are very useful over some open wounds, or open soft-tissue defects. As experience with these VACs is increasing, it seems that prolonged VAC usage (>10 days) should be avoided.
Split-thickness skin grafting and secondary wound healing
If an open wound involves loss of skin and subcutaneous tissue, but has a base of healthy muscle, fascia, or tendon sheath, granulation tissue will form on the base and a split-thickness skin graft (STSG) can be applied, or the wound can be allowed to heal in from its sides (second intention).
Bare bone (without periosteum), exposed blood vessels, nerves and tendons (without paratenon) are all harmed by desiccation and do not support granulation tissue and STSG. These tissues should never be left exposed, and should be kept moist with appropriate dressings. Alternative coverage techniques should be used. Definitive coverage should be achieved as soon as possible.
The "reconstructive ladder" shown on the left presents in increasing order of complexity the options available for wound closure, and is helpful for treatment planning.
Other than STSG and some local rotation flaps, the more complex soft-tissue reconstructions should be undertaken by surgeons experienced in these techniques, e.g., plastic surgeons.
9 Treatment - amputation topenlarge
Amputation for osteomyelitis
It is rare for systemic infection to flare out of control in patients with chronic osteomyelitis. For such patients, amputation is almost never an urgent, life-or-death decision. However, should repeated attempts to control infection, secure bone healing and restore function be unsuccessful, amputation may prove to be the best way to restore function and help the patient to resume a more normal life.
The informed decision to amputate should be considered carefully and individually, including both the patient and family.
The surgeon's job is to inform the patient about realistic expectations.
Different cultures, countries and religions bring different perspectives to this controversy. In many parts of the world, simple inexpensive but useful prosthesis can be made locally.
This illustration shows a basic below knee prosthesis from Africa and the celebrated Jaipur foot from India, each made locally.
If the patient makes the informed decision to proceed to amputation, the surgeon should plan the most functional level of amputation proximal to the diseased tissue. Consultation with a prosthetist may be helpful. The patient may wish to discuss amputation with another person who has undergone this procedure at a similar level.
The patient should attain optimal possible nutritional and physiological condition, with suppression of active infection by antibiotics, further surgical clearance, or even a preliminary amputation just above the infected zone.
Once all of the infected tissue has been amputated, continued infection treatment is no longer required.


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Flavel Windsor Contemporary HE Gas Fire Manual Control Pebble/Silver
1 review
£334.98 (Inc. VAT)
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Flavel Gas Fires carry the peace of mind of a 7 year guarantee and the Flavel Airwatch System (on all living flame effect fires). The Airwatch cuts off the gas supply in the unlikely event of the flame being extinguished through blockage.
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All Flavel gas fires are independently tested, approved and verified by the British Standards Institution (BSI) to meet the latest standards for performance, safety and efficiency.
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Technical Drawings
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|West Midlands Electrical Superstore
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1 Product Review
Sherry Hewitt
Looks stunning when its on or off. Very efficient when on, even sitting on opposite side of room. Would definitely recommend.

subset: commoncrawl


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The International Council of Nurses (ICN) acknowledges that telenurses using information and communication technologies (ICT) extend nursing's reach and improve access to care. In telenursing, ICT ranges from the simple telephone to sophisticated voice and video interactive systems and can make care delivery more efficient and potentially more effective. ICN recognizes that telenursing represents a new age in healthcare delivery. By capitalizing on the power of technology and collaboration among health care professionals, telenursing is well positioned to address current and emerging health system challenges such as those related to aging populations and chronic illnesses; community and home based care; access problems related to geographical, social and financial circumstances; increasing costs and reduced funding; and nursing shortages.
ICN published a monograph, Telehealth and Telenursing: Nursing and Technology Advance Together, in 2000 and the International Professional Standards for Telenursing Programmes in 2001. Both were developed by Kathleen Milholland Hunter. Following an International Telenursing Role Survey in 36 countries and a thorough literature review, ICN published International Competencies for Telenursing in 2007, developed by Loretta Schlachta-Fairchild. Through these publications, telenursing was recognized as an important contributor to the ICN mission of advancing nursing and health worldwide.
ICN is pleased to support the work of telenurses, to promote opportunities for exchange of ideas and expertise, and to support the professional goal of integrating telenursing roles into global nursing practice.


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Due to the ever changing nature of the operating system, network, installation hardware, third-party software, and more we cannot guarantee that the information posted here is up to date and will apply to every version of software you are using.


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HELSINKI (AP) -- Nokia Corp. says it has completed the 5.44 billion-euro ($7.5 billion) sale of its cellphone and services division to Microsoft Corp.
Friday's closure of the deal, which includes a license to a portfolio of Nokia patents, follows delays in global regulatory approvals, including from China.
The sale ends the production of all Nokia mobile phones by the former world leader, which has lost in the lucrative smartphone race against Samsung, Apple's iPhone and cheaper manufacturers in Asia.
The Finnish company will focus on networks, mapping services and technology development and licenses. It is expected to unveil future plans when it releases first-quarter earnings on April 29 — the last report to include the ailing devices and services division.


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The American Law Institute Archives
Questions about our collections? Contact the archives.
The Archives of the American Law Institute (ALI) are located at the Biddle Law Library at Penn Law. Under the terms of a custodial agreement between the Institute and the University, the archives were moved from the Institute to the Biddle Law Library in May 1994 and are currently maintained by the Library's Archives Department. The collection contains records of the Institute since its inception in 1923, as well as the archives of American Law Institute-American Bar Association on Continuing Professional Education, an educational program administered by the Institute since 1947 to 2012.
History of the American Law Institute
The American Law Institute (ALI) was founded in 1923 in response to a perceived uncertainty and complexity in American law. An association of practitioners and scholars known as the "Committee on the Establishment of a Permanent Organization for Improvement of Law" published a study that recommended a lawyers' organization be formed to improve the law and its administration. The committee was chaired by Elihu Root and counted Learned Hand, Benjamin Cardozo, and Samuel Williston among its members.
The ALI was conceived as a representative gathering of the American bar (including judges, lawyers, and law professors) for the stated mission "to promote the clarification and simplification of the law and its better adaptation to social needs, to secure the better administration of justice and to encourage and carry on scholarly and scientific legal work." Former Penn Law Dean William Draper Lewis was the Institute's first director, running the organization's operations out of his campus office.
Restatements of the Law and Other ALI Projects
The Institute's first project was a comprehensive Restatement of the Law, completed in 1944. The nine broad areas of the common law analyzed and restated were Agency, Conflict of Laws, Contracts, Judgments, Property, Restitution, Security, Torts, and Trusts. In the 1950s, the Institute began work on the Second Restatement series, which updated the original Restatements, reflected new analyses and concepts, and expanded upon the authorities used in reaching the conclusions set forth. The Second Restatement also treated some subjects not included in its predecessor, such as Foreign Relations Law and Landlord and Tenant Law. In 1987 the Institute began its Third Restatement of the Lawl work on that series continues.
Eventually, the ALI grew to encompass other projects in addition to the Restatements, codification projects such the Model Code of Evidence and Model Penal Code. Since 1944, the Institute has cooperated with the National Conference of Commissioners on Uniform State Laws in developing and monitoring the Uniform Commercial Code, or UCC.
The Institute also engages in intensive examination and analysis of legal areas thought to need reform. This type of study generally culminates in extensive recommendations for change in the law and usually is published as Principles of the Law . These projects have dealt with topics such as Aggregate Litigation, Corporate Governance, Family Dissolution, Software Contracts, Transnational Civil Procedure, Transnational Insolvency, and Transnational Intellectual Property, as well as a proposed revision of selected portions of the Federal Judicial Code.
In addition, from 1947 to 2012 the ALI worked with the American Bar Association to provide continuing legal education to lawyers, via a joint venture named American Law Institute-American Bar Association Continuing Professional Education (ALI-ABA). Inspired by the need to refresh returning WWII lawyer-veterans on the law, ALI-ABA provided the first national program of post-admission legal education and underscored the importance of continuing education to all lawyers. In 2012, by mutual agreement, the ALI and the ABA chose to move forward separately in their CLE efforts, with the intellectual content of ALI-ABA being absorbed into the CLE group of the ALI.
Scope and Content
The collection consists of over 500 linear feet. The largest portion of material relates to the creation of the Restatements of the Law and the Uniform Commercial Code and contains drafts, meeting minutes, audio tapes, and correspondence. There is also material from all of the other codes and projects, including the minutes of the Council and the Executive Committee.
Collection Gudies
To search the ALI Archives, click here.
President's Office (ALI.00)
- Roswell B. Perkins Files, 1983-1993 (ALI.00.001)
Council Records (ALI.01)
Executive Office Files (ALI.02)
- Geoffrey C. Hazard Director's Files, 1982-1999 (ALI.02.004)
Committee Records (ALI.03)
Restatements and Other Codification Projects, 1923-2003 (ALI.04)
- First Restatement of the Law Records, 1923-1959 (ALI.04.001)
- Second Restatement of the Law Records, 1947-1990 (ALI.04.002)
- Restatement, Third Records, 1977-2003 (ALI.04.003)
- Uniform Commercial Code Records, 1935-2003 (ALI.04.004)
- Model Penal Code Records, 1942-1985 (ALI.04.005)
- "Statement of Essential Human Rights" Records, 1929-1987 (bulk: 1941-1945) (ALI.04.006)
- Study of the Division of Jurisdiction Between State and Federal Courts Records, 1959-1969 and undated (ALI.04.007)
- Model Land Development Code Records, 1960-1974 and undated (ALI.04.008)
- Model Code of Pre-Arraignment Procedure Records, 1965-1975 (ALI.04.009)
- Model Code of Evidence Records, 1939-1954 (ALI.04.010)
- Federal Income, Estate, and Gift Tax Project Records, 1946-1981 (bulk: 1949-1969) (ALI.04.011)
- Federal Income Tax Project Records, 1974-1991 (ALI.04.012)
- Uniform Property Act Records, 1936-1938 (ALI.04.013)
- Law of Airflight Records, 1937-1939 (ALI.04.014)
- "Paths to a Better Way" Study Records, 1986-1988 (ALI.04.015)
- Administration of the Criminal Law Drafts, 1930-1935 (ALI.04.016)
- Model Peer Review System Drafts, 1978-1979 (ALI.04.017)
- Uniform Contribution Among Tortfeasors Act Records, 1937-1941 (ALI.04.018)
- Restatement in the Courts Volumes, 1937-1976 (ALI.04.019)
- Future of the Institute Records, 1929-1968 and undated (bulk: 1929-1948) (ALI.04.020)
- Keeping the Restatement Up-To-Date Records, 1946-1947 (ALI.04.021)
- Federal Securities Code Records, 1968-1981 (ALI.04.022)
- Principles of Corporate Governance Records, 1981-1990 (ALI.04.023)
- Criminal Justice—Youth Committee Records, 1935-1959 (ALI.04.024)
- Code of Criminal Procedure Records, circa 1925-1959 (ALI.04.025)
- Enterprise Responsibility for Personal Injury Records, 1985-1992 (ALI.04.026)
- Records of the Principles of the Law of Family Dissolution: Analysis and Recommendations, 1985-2000 (ALI.04.027)
- Federal Judicial Code Revision Project Records, 1995-2001 (ALI.04.028)
- Anti-Trust and Patent Law Project Records, 1950-1963 (ALI.04.029)
- Principles and Rules of Transnational Civil Procedure Records, 1996-2004 (ALI.04.030)
- Complex Litigation Project Records, 1986-1993 (ALI.04.031)
- Transnational Insolvency Project Records, 1991-1997(ALI.04.032)
- Recognition and Enforcement of Foreign Judgments Project Records, 2002 September 30 (ALI.04.033)
- Model Penal Code: Sentencing Records, 2002-2003 (ALI.04.034)
- Principles of the Law of Nonprofit Organizations Records, 2002-2003 (ALI.04.035)
ALI-ABA Committee on Continuing Legal Education (ALI.05)
- "The Practical Lawyer" Editorial Office Files, 1950-1983 (ALI.05.001)
Publications Department (ALI.06)
Membership Department (ALI.07)
Finances (ALI.08)
Annual Meeting Records (ALI.09)
Reporters' Papers (ALI.10)
- Aaron D. Twerski Papers, 1991-1997 (ALI.10.001)
- Mary Kay Kane Papers, 1988-1993 (ALI.10.002)
- Louis Henkin Papers, 1973-1990 (ALI.10.003)
- Michael D. Green Papers, 1994-2000 (ALI.10.004)
- Deborah A. DeMott Papers, 1994-2007, undated (ALI.10.006)
Reel-to-Reel Audio, 1958-1992 (ALI.11)
Oral Histories, 1989-1993 (ALI.12)
Digital Collections
Council and Executive Meeting Minutes, 1922-1992


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McCain Presses for Immigration Overhaul This Year
Sen. John McCain (R., Ariz.) Sunday rejected the notion that an overhaul of immigration laws is off the table this year.
"I won't give up," said Mr. McCain, who has long supported overhauling the nation's immigration system. "We have the broadest coalition of support of any legislation I've ever been involved in: big business, small business, evangelicals, the Catholic Church," Mr. McCain said on CNN's "State of the Union."


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For sale is offered a wonderful 2 bedroom apartment (full finishing) constructed to the highest standard situated in a quiet residential area in Riga on street Valdemara in one of the most elegant residential building – The Valdemara Residence (Valdemāra Rezidence)! The apartment with overall area of 95,2 square meters (without a balcony) conveniently located on the 1st floor of the 6-story building. Thanks to the efforts of restorers, the historical part of the Valdemara Residence Apartments building has recovered its brilliance, supplemented now with elegant high-tech solutions that ensure the comforts that are automatically associated with the best class of residential flats.
The Valdemara Residence is renovated historical building, which offers a modern and technologically perfect living environment in the heart of beauty and prestige.
A special element of these building is that it has an infrastructure that is absolutely perfect for their residents – full hotel services, club facilities for various events, a home cinema, a common lounge with fire-place, storage rooms, as well as a wine-cellar.
You will receive the highest class of services and assistance: 24/7 Hotel Valdemars room service offering you the widest range of services, including housekeeping, dry cleaning, ordering of food and drinks and many other services that will be perfect for people who love their comfort and have pressing needs in terms of their time.
All flats have individual ventilation and heating systems, large ancillary rooms, the possibility of full interior finishing in accordance with the buyer's desires. The floor space of the flats is between 52,6 sq. m. and 211 sq. m.
We can offer all flats available for sale/rent in this project. Please do not hesitate to contact us to receive information about new offers in the project.
Click here to get more information about the Valdemara Residence apartments.


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Upland Headshot Photography – 951-817-0957
Providing Upland area Headshots for Business people, Actors, Entertainers, Corporate Executives and Models. Your headshot has to seize the attention of Business Prospects, Casting Directors, Art Directors and talent/modeling agents. Your headshots needs to put you in your best light and reveal, not just your face, but the person you are.We know how to make your headshot capture attention in an instant to get you in the door!


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Yacht Club Profiles and Stories
The rich history of American sailing has grown and developed from yacht clubs and sailing organizations. Every club and organization has a unique story to tell. Telling these stories uncovers the feats of individual sailors, events that shaped America's history, adventures of determined characters, achievements by juniors, and amazing ideas from those that grew our sport from wooden boats, small boathouses, and rocky shores across the nation. The National Sailing Hall of Fame is committed to gathering those stories, presenting them to the public and archiving them for future generations.
NSHOF and Gowrie Group Partner to Collect and Preserve Yacht Club Stories
The National Sailing Hall of Fame, with the support of Gowrie Group , is committed to preserving America's sailing legacy by gathering the stories that yacht clubs have to tell, and presenting them to the public in digital and print formats for future generations to enjoy.
Click here to read the press release (PDF). Click here to read the press release (PDF).
Featured Story - The Alberg 30 Association
The Chesapeake Bay Alberg 30 One-Design Association held a 50-year celebration at the National Sailing Hall of Fame at the Annapolis City dock in 2014. The event included a parade around the harbor on Saturday and an "old-timers" race on Sunday. The Mayor of Annapolis proclaimed August 9, 2014 as "The Chesapeake Bay Alberg 30 One-Design Association Day."
Read the rest of the story on the Alberg 30 Association's Story Page
Your Club is Invited to Become a Founding Member
Your club or sailing organization can become a Founding Member of the National Sailing Hall of Fame. Participation will enable us to move the project forward at our site adjacent to Annapolis City Dock.
Founding Members & Contributors to date .


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Personalised Cakes
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Karma Cupcakes on the Gold Coast
Phone/ Fax
07 5591 7313
Unit 2/ 39-41 Olympic Cct
Southport, Qld. 4215
PO Box 399
Biggera Waters Qld. 4216
For anyone with a sweet tooth, it can hardly be denied that cupcakes are one of the most perfect and adorable ways to celebrate nearly anything. From wedding and baby showers to graduation and anniversaries, a gorgeous platter of cupcakes is the perfect way to show your love and appreciation! We've got an incredible variety of cupcakes that can be delivered along the Gold Coast so wherever you are, you can enjoy these beautiful treats. Do you need more reasons to include cupcakes in your life? We've got plenty for you.» Read more
Customised cupcakes
Are you looking for the perfect treat to surprise your loved one? Imagine their delight when you present them with personalised cupcakes made just for them. You might surprise your spouse on your anniversary, or even use cupcakes to propose to your sweet heart. Get creative! We can personalise and customise your cupcakes for that perfect occasion, and then you can enjoy our delicious gourmet cakes Gold Coast with your loved ones.
Gluten free and vegan
Do you love the idea of cupcakes but hardly get the chance to indulge because of health reasons? We believe that everyone should get to enjoy these delightful treats, so we've created special cupcakes that are gluten free and vegan, without sacrificing any of the delicious flavour of the originals. Our certified gluten free flour and high quality ingredients will make sure that you are getting the very best gourmet cupcakes available.
Cake Delivery Gold Coast
We strive to make sure that our gourmet cupcakes are available to anyone on the Gold Coast, regardless of their proximity to our store. So we enthusiastically deliver to a huge number of locations on the Gold Coast. Our mission is based on pride and passion for what we do, and you'll notice this right away. Our cupcakes are more than just a dessert; they represent a social movement in connecting people and providing opportunities!


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The Weekend Dish: 5/28/2011
Happy long Memorial Day weekend to all of the folks in the U.S. and happy regular weekend to those of you elsewhere! This is the official-unofficial start to summer here and it looks like the weather is going to cooperate nicely here in the east. What are your weekend plans? Any cookouts or picnics? I enjoyed putting together some seasonal recipes this week, using rhubarb for the first time this year, whipping up a root beer float cake (which is now going to be a summer dessert staple for me!) and new ice cream. In related news, I managed to bake all week without using my KitchenAid mixer once (except to churn my ice cream, but that was using the attachment). I think that's some sort of record!
In blogging news, a few food bloggers have put together a non-profit charity group called Bloggers without Borders. It will officially launch in July, but they are currently raising funds for the victims of the Joplin, MO tornado tragedy. To learn more, check out the post on Simple Bites. Kudos ladies, on a fabulous idea.
As always, you'll find a recap of what was posted to the site this week as well as some bookmarked recipes from other blogs. Enjoy!
On Brown Eyed Baker This Week
Top 10 List: Favorite Cupcake Recipes – Another installment of the Top 10 series. This time, all of my favorite cupcake recipes!
Peanut Butter Brownies – Fabulous fudgy brownies with huge chunks of peanut butter filling swirled throughout.
Rhubarb Pie-Tartlets – Lovely little rustic free-form tarts taking full advantage of peak rhubarb season.
Root Beer Float Cake – Root beer bundt cake topped with root beer fudge frosting. Add a scoop of vanilla ice cream and you have the perfect summer dessert!
Roasted Banana Ice Cream – Fabulous ice cream that tastes like a frozen piece of banana bread. Delicious!
Most Viewed Post This Week: Top 10 List: Favorite Cupcake Recipes
What I Bookmarked This Week
Recipes from other blogs that I thought looked especially delicious and that I thought you would like too:
Bourbon Peaches and Cream Popsicles (Endless Simmer)
I love boozy sweets. Frozen boozy sweets are especially delicious for hot summer days!
Maple Custard Pie & Candied Bacon (raspberri cupcakes)
I have yet to make a custard pie, but this maple version paired with sweet bacon looks like a perfect first for me!
Peanut Butter Crunch S'mores Bars (Bakergirl)
Oh my. Super genius! Love using the graham cracker base for these, they must taste just like s'mores!
Strawberry Cream Pie (Willow Bird Baking)
I am loving all of the strawberry recipes I keep seeing lately. This pie is no exception, and bonus that it's an old family recipe – love those!
Have a delicious and safe holiday weekend!


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Diamond Hogs Stay Alive In NCAA Regional
Spoon, Stanek guide Arkansas past Wichita State
The Arkansas baseball team needed a win Saturday in order to stay alive in the NCAA Tournament, and they turned to their best starting pitcher to get it done.
Junior right-hander Ryne Stanek delivered, limiting Wichita State to only one run in a 3-1 win Saturday.
The Razorbacks (38-21) took a 2-0 lead on a 2-run single by freshman right fielder Tyler Spoon with two outs in the top of the first inning. Spoon fouled off four straight pitches before lining a hanging breaking ball to right center field on a 2-2 count.
"We put together some quality at-bats and punched in a couple runs," Coach Dave Van Horn said. "[Spoon] battled to get to that pitch. That was good for us to get the lead and relax a little bit."
"He finally left one up and I was able to take advantage of it and just line it to center," said Spoon, who drove in his team-leading 46th and 47th runs of the season. "We finally get some momentum at the plate offensively and get some runs for Stanek, and he basically takes care of the rest."
Stanek worked around six walks and two hits with three strikeouts in 7.1 innings. Wichita State scored their only run on a solo homerun by Casey Gillaspie in the fourth inning. It was the first run he allowed in over 26 innings.
"He didn't have his best stuff," Van Horn said of his starter. "He usually doesn't walk that many people. But he's done a great job all year of getting out of jams. It's kind of his thing. We leave him in a lot longer than other guys because he just finds a way."
Michael Gunn replaced Stanek with one out in the eighth, promptly picking off Daniel Kihle at first base and striking out Tyler Baker to end the inning. Colby Suggs pitched a perfect ninth to earn his 13th save, breaking the team single season record previously held by Philip Stidham and Tim Deitz.
Arkansas will face Bryant Sunday afternoon at 2:05 for the right to advance to the Regional Final against Kansas State. The game will be televised on ESPN3.


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Every year, in retrospect, can seem impressive (condensing 12 months of articles into 10 highlights will do that). However, 2013 seemed like an especially notable year for stories involving or affecting modern Pagans. Here are the ten stories that I feel were the most relevant, the most impactful on our day-to-day lives. That said, I would encourage folks wanting to get a taste of where we were at in 2013 to read through my Pagan Community Notes and Pagan Voices archives to track the conversations and achievements that marked our community. I also want to quickly note that I've decided not to number the stories, or rank them in any order. They each hold their own importance, and this year I wanted to shy away from the idea that one took some precedence over another.
Now then, on to the top ten…
Heathen Politician Dan Halloran Arrested, Charged With Fraud and Bribery: "In a shocking turn of events this morning, New York City Councilman Dan Halloran, along with State Sen. Malcolm Smith, were arrested on charges of fraud and bribery in connection to an alleged plot to fix the mayoral race. The arrests came after an FBI-led investigation, one in which U.S. Attorney Preet Bharara claims Halloran "quarterbacked" the drive to find party officials willing to be bribed. In a meeting with an informant, Halloran allegedly expounded at length on what it takes to "grease the wheels" of New York City politics. […] Halloran is the highest elected official in the United States who also happens to openly be an adherent of a Pagan/Heathen religion. Specifically, he was for a time a prominent (and eventually prominently controversial) member of the Théodish belief system, a faith that seeks to practice Germanic pre-Christian religion. Though Halloran never denied being a Théodish Heathen, he also wasn't very transparent about it in the beginning, causing a great deal of havoc when he was "outed" by the local press during his city council run. His beliefs were often sensationalized by the press, including Village Voice cover art depicting Halloran with a dead sacrificed goat, ceremonial robe and runic cloak." More on this story here.
Maetreum of Cybele Wins Tax Fight: "The Maetreum of Cybele, Magna Mater, which has been in an ongoing battle with the Town of Catskill, New York, over religious property tax exemptions, was today vindicated in their multi-year struggle when a State Supreme Court ruling against them on this issue was overturned on appeal. The decision, which was issued on Thursday by the New York Supreme Court's Appellate Divsion, says the religious organization "satisfied the legal requirements in order to receive a real property tax exemption." […] This is a huge reversal of fortune for the Maetreum, which has been fought relentlessly by the Town of Catskill on this issue. By the Maetreum's estimate, the town has spent hundreds of thousands of dollars in legal costs, and when the initial Supreme Court victory was handed down to them last year, their lawyer crowed to local press that he "does not expect much protest from pro-pagan groups now that a judge has carefully analyzed the evidence." Even some Pagans were skeptical of the Maetreum's chances after that decision, but the Maetreum of Cybele were determined to fight on, and with some fiscal help from the larger Pagan community, they moved forward with their appeal." More on the Maetreum here.
Town of Greece Prayer Case Heard Before the Supreme Court: "Today's the day. The Supreme Court of the United States will hear oral arguments in the case of Town of Greece v. Galloway, which centers on the role of prayer at government meetings, and could shape the legal landscape on this issue for decades to come. I have written extensively on this case, and you can find a round-up of my coverage here. […] No matter what the decision, it will no doubt have a major effect on prayer policy. Repercussions that will deeply affect all religious minorities, including Pagans, who have played an outsize role in the development of this case." For more, read "The Supreme Court Case With A Wiccan Angle." Quote: "This case directly involves modern Pagans, specifically Wiccans, in the case and in the legal maneuvers that led to it. Something I've been harping on for some time, even to the point of chastising religion reporters for not picking up on it."
Thor's Hammer Approved for Use On Military Headstones and Grave Markers: "In 2007, after a decade-long struggle, Pagan and Wiccan organizations succeeded in getting the Pentacle approved for military veteran headstones and markers. After that victory, in July of 2007, a rally was held to start the push for two more symbols: the Druid Awen and the Heathen Thor's Hammer. Two Heathen organizations, The Troth and the Asatru Folk Assembly, were represented at that rally, and from it a wider movement to get the Thor's Hammer approved emerged. Now, after a six-year journey which included some inter-organizational tensions within the Heathen community and a U.S. Dept. of Veterans Affairs rule change, it appears the symbol has finally been approved." More on how this came about here. Quote: "We know that the listing went up on May 2nd, and thanks to a statement sent to The Wild Hunt from the Guardian of The Northern Winds Hearth we now know the circumstances of the emblem's approval."
Wicca and Paganism Leaving the Occult Section, Heading For Religion: "So the occult section (hence the "OCC" prefix code), which in time became known as the "New Age" section, and finally, the "Mind, Body, Spirit" section, will soon see an exodus of Wiccan and Pagan books to the religion section. For most of us who still visit brick-and-mortar stores that most likely means your local Barnes & Noble (or possibly Books-A-Million) will soon be seeing some changes. How quickly these changes will happen remains to be seen, and it may take some time as stock rotates in and out of the stores." For more, read Elysia Gallo's reporting. Quote: "Wicca, in the eyes of the book selling industry, is now a religion. It crossed over from OCC026000 Body, Mind & Spirit / Wicca and Witchcraft, to two separate BISAC codes. One remains in the occult section – OCC026000 is now simply Body, Mind & Spirit / Witchcraft. But Wicca itself is now REL118000, or Religion / Wicca. […] there's more. The BISAC code that used to be OCC036020 Body, Mind & Spirit / Spirituality / Paganism & Neo-Paganism (a relatively recent addition on its own) is also now listed in Religion, as REL117000, or Religion / Paganism & Neo-Paganism."
UK Pagans Organize Against the Practice of 'Fracking': "We, as Pagans, believe that the natural world is profoundly sacred. In particular though, sites such as Chalice Well are our holy places. To have them desecrated is a direct attack upon our ways and upon us. Fracking will not alleviate fuel poverty, nor will it provide us with greater fuel security. Its long lasting destruction to land and water is neither needed nor wanted. There are many practical alternatives, yet they are being ignored (with catastrophic consequences) because of corruption and ideological extremism within the government. Corporations should not dictate state policy. Around the world on the 28th of September, rituals (both large and small) will be held to protect these sacred islands from harm. Although we all come from many different pagan paths, on that day we will speak with one voice. The Warrior's Call is that unified voice. And it sings with the blessings of the Gods and Goddesses." Warrior's Call now has a website up and running, with resources for Pagan who want to fight the practice of "fracking."
Tempest Smith Foundation Closes its Doors: "In February 2014, the Tempest Smith Foundation (TSF) will be holding its very last ConVocation fundraiser before permanently closing its doors. Annette Crossman, TSF's current executive director and widow of founder Denessa Smith, says that it is "time for the torch to be passed on …and return to normal life." For over ten years, TSF has been a voice for diversity tolerance in its Michigan community and an advocate of anti-bullying campaigns. Launched in 2003, The Tempest Smith Foundation was the brain-child of Denessa Smith, the mother of bullying-victim Tempest Smith. In February of 2001, Tempest committed suicide after enduring 6 years of persistent abuse in school. Over the following two years Denessa was able to transform her grief into building a foundation that would advocate for tolerance – a foundation that might save other children from her daughter's fate." Follow-up article.
Asatru Added to Religion Stylebook: "Back in July, PRI's The World did a story on the U.S. Dept. of Veteran's Affairs approving the Thor's Hammer emblem for veteran's grave markers and headstones (here's The Wild Hunt's reporting on that story). The story didn't interview any Heathens, was somewhat flippant towards the faith, and included a picture of someone dressed like the comic book/movie version of Thor. This led Dr. Karl E.H. Seigfried of the Norse Mythology Blog to lodge a (entirely justified) complaint campaign, and it ultimately pushed PRI to do a somewhat more respectful follow-up to their original piece. Now, this incident has led to what might be an even bigger win for practitioners of Asatru, inclusion in the Religion Newswriters Association's official Religion Stylebook. At the Norse Mythology Blog Dr. Seigfried, who wrote the stylebook entires, explains how this came about. The ten terms added to the stylebook include Æsir, Ásatrú, blót, Eddas, and goði, and are live on the stylebook's site as we speak. Dr. Seigfried worked with Heathens in Iceland, Germany, and the United States to shape the definitions he would use."
The Passing of Olivia Robertson: "On Friday, the Fellowship of Isis announced the passing of their co-founder, 96-year-old Olivia Robertson. Robertson, along with brother Lawrence Durdin-Robertson, and his wife, Pamela, founded the Fellowship of Isis on the Vernal Equinox of 1976 with a goal of reintroducing Goddess worship into the world. This development came for the trio after working together since the early 1960s on metaphysical and spiritual projects, including the Huntington Castle Centre for Meditation and Study. Over the next 20 years the FOI grew a diverse international membership, and in 1993 Olivia Robertson was on-hand at the Parliament of the World's Religions representing the Fellowship, and spoke at the opening plenary representing modern Goddess Religion. Part of a delegation of groups that introduced modern Pagan religions to the international interfaith community. In addition, Robertson was an accomplished artist, writer, and liturgist, who deeply shaped the organization she helped found with her creative vision. A legacy that will continue with the organization she helped found. You can find Robertson's full official biography at the Fellowship of Isis website, here."
Pagans Help Save the Parliament of the World's Religions: "While final negotiations and discussions with lawyers are still underway, it appears that the Council for a Parliament of the World's Religions has successfully raised enough money by their deadline to save the organization from a sudden fiscal crisis. As the Religion News Service reports, modern Pagans played a large role in making that happen. 'With the help of pagans, Jains and people of a range of other faiths, the Council for a Parliament of the World's Religions has raised more than $144,000 in two weeks using a crowdsourcing campaign in a desperate bid to survive a financial crisis […] Two pagan groups alone raised more than $16,000. A Jain board member raised $6,300. […] As of Tuesday (April 16), the council had raised more than $144,000 of the $150,000 it needed, and had received permission from a donor to use additional funds from an operational grant, if necessary, to make the final debt repayment.' While we didn't single-handedly save the Parliament, we were instrumental in doing so, and now the world knows it. Notable Pagans from across the world spoke up to mobilize their communities, including Margot Adler, T. Thorn Coyle, Christopher Penczak, and representatives from Covenant of the Goddess, the Pagan Federation, Pagan Federation International, Pagan Pride Italia, and more, added their voices to a chorus of Pagans who realized the importance of this moment."
Obviously, there are many more stories I could mention: The regulation of psychic services, Doreen Valiente's commemorative plaque, Teo Bishop's high-profile leave-taking from our community, and the With Love From Salem documentary, to name just a selection. But I feel these 10 stories will resonate beyond this year, and collectively shape us. Feel free to share what you thought were the biggest Pagan stories of 2013 in the comments. Now then, on to 2014!


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ROCKFORD — Manufacturing Day 2014 has received four new sponsors, according to an Aug. 12 news release.
The Society of Manufacturing Engineers and the Precision Machined Products Association became silver sponsors, and the American Welding Society and the SME Education Foundation joined as bronze sponsors.
The Oct. 3 event is a national program executed at the local level that hosts open houses to showcase modern manufacturing technology and careers.
For information: mfgday.com.


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Inspirato gains $20 million in venture capital
Inspirato, a Denver-based luxury destination club, has secured a $20 million venture capital investment from California's Institutional Venture Partners, the company said Tuesday.
Inspirato said the funding will help it add at least 180 new properties this year to its portfolio of homes at vacation destinations around the globe.
"We are on target to add at least one new home or hotel suite to our portfolio every other day in 2012," Brent Handler, Inspirato's founder and CEO, said in a press release. "Inspirato already doubled its portfolio to more than 100 properties since opening our doors a year ago."
The company said Todd Chaffee, general partner at Institutional Venture Partners, will join its board of directors. Chaffee has led venture investments in companies such ArcSight, Ariba, ComScore, HomeAway, Kayak, Netflix, Nuance, Omniture, Twitter, Verisign and Yahoo.
Inspirato leases rather than owns vacation properties, which they company said keeps membership fees and rates low. In October, Inspirato received $17.5 million in equity funding led by Kleiner Perkins Caufield & Beyers.


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Elisa Barboux, a spokeswoman for the Hospital Samaritano in Rio de Janeiro, confirmed Niemeyer's death and said the cause was a respiratory infection. He had been hospitalized for several weeks and also on separate occasions earlier this year, suffering from kidney problems, pneumonia and dehydration.
Dr. Fernando Gjorup, Niemeyer's physician, said the architect worked on pending projects in the days before his death, taking visits from engineers and other professionals.
"The most impressive thing is that his body suffered but his mind was lucid," Gjorup said at a press conference. "He didn't talk about death, never talked about death. He talked about life."
FILE - This Aug 14, 2007 file photo, shows a view of the Brazil's National Congress, designed by Brazilian architect Oscar Niemeyer and inaugurated in 1960, in Brasilia, Brazil.
In works from Brasilia's crown-shaped cathedral to the undulating French Communist Party building in Paris, Niemeyer shunned the steel-box structures of many modernist architects, finding inspiration in nature's crescents and spirals. His hallmarks include much of the United Nations complex in New York and the Museum of Modern Art in Niteroi, which is perched like a flying saucer across Guanabara Bay from Rio de Janeiro.
"Right angles don't attract me. Nor straight, hard and inflexible lines created by man," he wrote in his 1998 memoir "The Curves of Time." "What attracts me are free and sensual curves. The curves we find in mountains, in the waves of the sea, in the body of the woman we love."
2. FILE - This Oct. 8, 2007 file photo, the Ibirapuera Auditorium designed by Brazilian architect Oscar Niemeyer is seen in Sao Paulo, Brazil.
His curves give sweep and grace to Brasilia, the city that opened up Brazil's vast interior in the 1960s and moved the nation's capital from coastal Rio.
Niemeyer designed most of the city's important buildings, while French-born, avant-garde architect Lucio Costa crafted its distinctive airplane-like layout. Niemeyer left his mark in the flowing concrete of the Cabinet ministries and the monumental dome of the national museum.
As the city grew to 2 million, critics said it lacked "soul" as well as street corners, "a utopian horror," in the words of art critic Robert Hughes.
FILE - In this April 21, 2003 file photo, the statues of the apostles are seen in front of the Cathedral of Brasilia, an architectural landmark created by architect Oscar Niemeyer, in Brasilia, Brazil.
Niemeyer shrugged off the criticism.
"If you go to Brasilia you might not like it, say there's something better, but there's nothing just like it," he said in an interview with O Globo newspaper in 2006 at age 98. "I search for surprise in my architecture. A work of art should cause the emotion of newness."
Even late in life, Niemeyer was striving for renewal. In 2009, he came under heavy criticism for proposing to build a "Plaza of Sovereignty" in the heart of Brasilia.
FILE - In this Dec. 30, 1971 file photo, the complex of buildings forming the United Nations headquarters is reflected in the East River in New York City.One of Niemeyer's hallmarks includes much of the United Nations complex.
Preservationists said the 330-foot-tall (100-meter) obelisk he envisioned would mar the very skyline the architect created a half-century earlier. Niemeyer relented on the plaza, only to unveil new plans for a 165-foot-tall (50-meter) tower in the same spot.
Living well past the century mark, Niemeyer's journey mirrored that of his beloved Brazil, and his restless modernism captured the developing country's sweeping ambitions.
With hundreds of his buildings dotting the landscape, arguably no other architect shared as tight a bond with a country as Niemeyer did with Brazil.
5. FILE - In this April 5, 2006 file photo is seen the Palacio da Alvorada, or Palace of Dawn, the official residence of Brazilian presidents which was designed by architect Oscar Niemeyer in Brasilia, Brazil.
Oscar Niemeyer Soares Filho was born on Dec. 15, 1907, in Rio de Janeiro, and earned his architecture degree at Rio's School of Fine Arts.
Working in Costa's office in 1936, he helped design a Rio education ministry building that was a classic of functionalist horizontal and vertical lines. With modernist giant Le Corbusier, Niemeyer developed the "brise soleil," a heat protector that enhanced the building's grid design and became an architectural standard in the 1960s.
Niemeyer teamed up again with Le Corbusier in 1947 to design much of the United Nations complex in New York. After months of squabbling with architects - most notably Le Corbusier - Niemeyer came up with the final plan for the complex, including the Secretariat, General Assembly and conference buildings and the Dag Hammarskjold Library.
But Niemeyer already was chafing at the limits of form-follows-function architecture.
6. FILE - In this Oct. 5, 2007 file photo, the Niteroi Contemporary Art Museum, designed by Oscar Niemeyer, overlooks the famed landmark Sugar Loaf, left, in Niteroi, Brazil.
His first solo project was the Pampulha complex of buildings set on an artificial lake in the central Brazilian city of Belo Horizonte, now Brazil's third-largest metro area. For the first time, Niemeyer employed the curves and arches that would become his hallmark.
Not everyone was pleased. The St. Francis church, built in a series of parabolic arches resembling waves, was shunned for years by Catholics who considered it an offense to Christianity. Finished in 1944, the church wasn't inaugurated as a place of worship until the late 1950s.
"If you examine Pampulha, you will feel the freedom of the forms used there," Niemeyer said. "In the lightness of the exposed structure, you will sense that something new sprang up in Brazilian architecture."
In the 1950s, Niemeyer was summoned by President Juscelino Kubitschek to design a new capital on Brazil's empty central high plains. Costa became the project's urban planner.
With the slogan of "50 years in five," Kubitschek hoped to prod Brazil into a great leap forward - and inward, away from the coast.
7. FILE - In this Dec. 20, 1967 file photo, architect Oscar Niemeyer, designer of Brasilia's public buildings, is seen in Rio de Janeiro, Brazil.
Niemeyer rose to the challenge, testing new forms and technical limits for reinforced concrete. His cone-shaped Metropolitan Cathedral is a circle of curved concrete pillars set like tepee poles with glass mosaic in between.
"I didn't want an old-style cathedral - dark, a reminder of sin," he said in an interview in the 1990s. "I wanted something happier."
Perhaps his best-known creation was the National Congress building, designed as two giant white bowls, one facing up and another facing down, with twin 330-foot-tall (100-meter) towers rising between them.
In 1987, UNESCO declared Brasilia a World Heritage Landmark.
"If you pick up the pencil thinking only of the solution, you will draw without an idea. What's important in architecture is intuition," he said. "I have my system of work ... based on fantasy, but always feeling logical."
After a 1964 coup plunged Brazil into a 21-year military dictatorship, Niemeyer, a lifelong communist, decided to spend more time in Europe than Brazil. While living in France in 1965, he designed the headquarters of the French Communist Party. During the dictatorship he also designed the center of the Mondadori publishing house in Italy, Constantine University in Algeria and other projects in Israel, Lebanon, Germany and Portugal.
He won the Gold Medal from the American Institute of Architecture in 1970, the Pritzker Architecture Prize from Chicago's Hyatt Foundation in 1988 and the Gold Medal of the Royal Institute of British Architects in 1998.
After 1974, Niemeyer turned his attention again to Brazil. In 1984, Rio inaugurated the 60,000-seat Sambadrome he designed for Rio's annual Carnival parade, and hundreds of graceful concrete public schools based on his prefabricated model.
Although he never liked flying and gradually stopped traveling by air, Niemeyer never ceased working. He also never abandoned his faith in communism, befriending Cuban leader Fidel Castro. His Brasilia monument to Kubitschek, a statue in an elevated curve of stone, was criticized by the military regime for its similarity to the communist hammer-and-sickle.
In a 2006 article for the Brazilian daily Folha de S. Paulo, Niemeyer wrote: "Life is more important than architecture. ... One day the world will be more just and will take life to a superior stage, no longer limited to governments and dominant classes."
Hunched over and walking slowly, he went to his office daily, designing and following his projects by videoconference.
Until the end, he embraced architecture as a humanist endeavor and rejected criticism that his buildings were more enjoyable to look at than to live or work in.
"The architect ... must feel that human beings also are important," he said. "Because nothing (else) is important. Life lasts but a minute."


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Over the years, Lawrence Township has been the nesting ground for some of soccer's greatest innovators.
Glenn 'Mooch' Myernick, Tom Bartolino and Tim Murphy are just a few of the game's influential figures who began in Lawrenceville. In an effort to carry on the long lineage of the nationally respected soccer tradition, the Lawrence Hamnett Soccer Association continues to foster the development of more than 700 boys and girls in both recreational and competitive soccer.
To make it all work, a club needs good teachers, and the Hamnett is fortunate to have many. One has caught the attention of the National Soccer Coaches Association of America (NSCAA).
Chris Thomas, a volunteer coach for the Hamnett, was named National Recreation Soccer Coach of the Year by the NSCAA in Indianapolis at its annual convention dinner last month.
'It is really nice to see Chris receive recognition for all his hard work. He not only volunteers his time to the many players in our rec program, but he's also made a commitment to improving himself through acquiring advanced coaching certifications,' said club president Rico Scardelletti.
What makes Thomas so effective on the training ground is his continued effort to further his soccer education. Last year, Thomas traveled to Florida to receive his National C coaching license. He is the head coach of three teams ranging from 9- to 13-year-olds, each of which play two games every weekend during the rec seasons. He is the division-wide trainer and spends three hours working with more than 40 players during training sessions. He also implemented a new technical training session, offered one night per week, which focuses on technical development. Thomas also handles various logistical responsibilities for the club, serving as a field marshal between games, serving on the club's board and writing the training curriculum. In addition, Thomas still manages his professional career in the music industry.
'The award is an appreciated acknowledgement of the success that Lawrence Hamnett has had in developing skilled soccer players of strong character. LHSA has a long and rich history in the national soccer community, and it is an honor to bring this recognition to the club and the kids in our community who continue to show their dedication year after year,' said Thomas.
Thomas, who does not have any children currently playing for the club, has volunteered countless hours and is brilliant in how he can relate to players on an individual basis, getting them to understand their decision making process on the field rather than trying to dictate their every move.
'Chris' (Thomas) style and the environment he creates are very conducive to kids learning and having fun. He's a humble and earnest guy who does things on and off the field to benefit our players, like putting together player development programs and curriculums and then implements them. This is no ordinary coach,' said Scardelletti
Most importantly, Thomas makes the game fun for the kids; keeping them at the forefront of all his coaching decisions and making them feel good about their participation in youth soccer and the development of their skills. He is role model for how youth soccer coaches should behave.
'Our focus on providing players with a pathway to development through the various programs we have implemented in recent years has been incredibly rewarding,' said Thomas.
Thomas, who was named NJYS Recreation Coach of the Year in 2012, is not the only coach who has been recognized for his work with you. Scardelletti won the McNulty Coach of the Year award in 2004. The Hamnett's Vice President of Recreation Sue Glass, is also a former winner of the Recreation Coach of the Year award.
Thomas and all the volunteer coaches at the Hamnett will continue to develop himself as a coach as well as help his players learn and love the game, ultimately continuing the tremendous soccer tradition that resides in Lawrence Township.


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WASHINGTON (AP) — President Barack Obama has met with Latino leaders ahead of an upcoming trip to Mexico and Costa Rica.
Obama met Monday at the White House with leaders from National Council of La Raza, the National Hispanic Council on Aging and the League of United Latin American Citizens, plus seven other groups. The White House says they discussed economic interests the U.S. shares with Latin American nations, plus progress on poverty and inequality.
Obama also assured the leaders that he'll make immigration legislation a top priority. A bipartisan overhaul is headed to votes in the Senate Judiciary Committee that would create a path to citizenship for the estimated 11 million immigrants now in the U.S. illegally.
Obama leaves Thursday for a three-day trip to Mexico and Costa Rica.