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BACKGROUND Historically, hemorrhage has been attributed as the leading cause (40%) of early death. However, a rigorous, real-time classification of the cause of death (COD) has not been performed. This study sought to prospectively adjudicate and classify COD to determine the epidemiology of trauma mortality. METHODS Eighteen trauma centers prospectively enrolled all adult trauma patients at the time of death during December 2015 to August 2017. Immediately following death, attending providers adjudicated the primary and contributing secondary COD using standardized definitions. Data were confirmed by autopsies, if performed. RESULTS One thousand five hundred thirty-six patients were enrolled with a median age of 55 years (interquartile range, 32-75 years), 74.5% were male. Penetrating mechanism (n = 412) patients were younger (32 vs. 64, p < 0.0001) and more likely to be male (86.7% vs. 69.9%, p < 0.0001). Falls were the most common mechanism of injury (26.6%), with gunshot wounds second (24.3%). The most common overall primary COD was traumatic brain injury (TBI) (45%), followed by exsanguination (23%). Traumatic brain injury was nonsurvivable in 82.2% of cases. Blunt patients were more likely to have TBI (47.8% vs. 37.4%, p < 0.0001) and penetrating patients exsanguination (51.7% vs. 12.5%, p < 0.0001) as the primary COD. Exsanguination was the predominant prehospital (44.7%) and early COD (39.1%) with TBI as the most common later. Penetrating mechanism patients died earlier with 80.1% on day 0 (vs. 38.5%, p < 0.0001). Most deaths were deemed disease-related (69.3%), rather than by limitation of further aggressive care (30.7%). Hemorrhage was a contributing cause to 38.8% of deaths that occurred due to withdrawal of care. CONCLUSION Exsanguination remains the predominant early primary COD with TBI accounting for most deaths at later time points. Timing and primary COD vary significantly by mechanism. Contemporaneous adjudication of COD is essential to elucidate the true understanding of patient outcome, center performance, and future research. LEVEL OF EVIDENCE Epidemiologic, level II.

The origin of the disks around Be stars is still not known. Further progress requires a proper parametrization of their structure, both spatially and kinematically. This is challenging as the disks are very small. Here we assess whether a novel method is capable of providing these data. We obtained spectro astrometry around the Pa beta line of two bright Be stars, alpha Col and zeta Tau, to search for disk signatures. The data, with a pixel to pixel precision of the centroid position of 0.3..0.4 milliarcsecond is the most accurate such data to date. Artefacts at the 0.85 mas level are present in the data, but these are readily identified as they were non-repeatable in our redundant datasets. This does illustrate the need of taking multiple data to avoid spurious detections. The data are compared with simple model simulations of the spectro astrometric signatures due to rotating disks around Be stars. The upper limits we find for the disk radii correspond to disk sizes of a few dozen stellar radii if they rotate Keplerian. This is very close to observationally measured and theoretically expected disk sizes, and this paper therefore demonstrates that spectro-astrometry, of which we present the first such attempt, has the potential to resolve the disks around Be stars., 6 pages, A&A accepted

We utilise Midcourse Space Experiment mid-IR imaging and published data to discuss the (massive) star formation region at galactic longitude ~305˚, apparently associated with the Wolf Rayet WR 48a and the attendant clusters Danks 1 and 2. A spectacular three lobed wind blown bubble surrounds the aforementioned sources, for which we may infer a minimum age of ~3 Myr from the presence of the WCL star. Near IR data reveals the presence of numerous embedded sources on the periphery of the wind blown bubble. The presence of coincindent H2O, OH and methanol maser emission is suggestive of ongoing massive star formation, which is suppported by the fluxes of the associated IR sources, and the requisite LyC flux required to support the emission from the subset that have associated ucH II regions. Consideration of the integrated radio flux of the complex implies that a minimum of 31 O7V stars must be present, under the assumption of no photon leakage. Given the age and morphology of the complex and in particular the observation that the central exciting clusters have entirely cleared their natal material, we expect this assumption will be violated, and hence that the true population of massive stars is likely to be significantly larger. If confirmed, the G305 complex represents one of the most massive regions of ongoing triggered star formation currently identified in the galaxy.

Two models of the circumstellar disc around supergiant B[e] stars are discussed: an equatorial wind model produced by wind bi-stability, and a Keplerian viscous disc model. Both models are successful in providing a site for dust formation once they have cooled sufficiently. However, the optical--infra-red continuum is calculated and it is found that both models have significant trouble in accounting for observations. In particular the optical--near-IR emission is accounted for, but the dust emission is underestimated by at least an order of magnitude. Variations in the structure of the models (the temperature variation with radius, the density structure and the dust opacity) are investigated to assess how (in)appropriate the standard models are for supergiant B[e] star discs. Changing the temperature structure, and making simple dust opacity changes within the disc has little effect on the resultant continuum emission. By altering the density structure of the discs, the continuum may be accounted for by both models: the equatorial wind model requires a very flat density profile which is impossible to explain with any accelerating wind, and the viscous disc model's density structure is required to fall off less steeply with radius than would have been expected, although this may be explained from consideration of viscous processes in the disc. It is recognised that both theoretical interpretations have difficulties and unsolved problems., 9 pages, 6 figures, accepted by Astronomy and Astrophysics

We present infra-red (JHK) photometry of 52 isolated Be stars of spectral types O9--B9 and luminosity classes III--V. We describe a new method of reduction, enabling separation of interstellar reddening and circumstellar excess. Using this technique we find that the disc emission makes a maximum contribution to the optical (B-V) colour of a few tenths of a magnitude. We find strong correlations between a range of emission lines (H\alpha, Br\gamma, Br11, and Br18) from the Be stars' discs, and the circumstellar continuum excesses. We also find that stellar rotation and disc excess are correlated., Comment: 10 pages, 9 figures, accepted for publication in Astronomy and Astrophysics. Other papers in this series can be obtained at http://cwis.livjm.ac.uk/astro/research/environs.html

While the content of fatty streaks and fibrous plaques has been extensively studied in autopsied specimens, little is known about the lipid composition of advanced human atherosclerotic plaques requiring surgical removal. We have analyzed free cholesterol, cholesteryl ester, and the cholesteryl ester fatty acid content in 19 carotid and 7 femoral obliterative plaques obtained at endarterectomy. These were compared with values from each subject's plasma and from xanthomas removed from eight patients. The total cholesterol content was 75.1 mg/g dry weight for carotid plaques, 56.0 mg/g for femoral plaques, and 106.8 mg/g for xanthomas. The free cholesterol content was 56.6% and 50.4% of the total cholesterol for carotid and femoral plaques, respectively, while the free cholesterol of xanthomas was only 25.5%. The fatty acids of cholesteryl esters were analyzed in an attempt to identify the site of their esterification, i.e., within plasma or within plaque. This can be determined using the ratio of linoleic acid (18:2) to oleic acid (18:1) in the cholesteryl ester. The ratios were 0.36 for xanthoma, 1.62 for carotid plaque, 1.73 for femoral plaque, and 2.51 in plasma. These data emphasize two chemical changes occurring with evolution of the atherosclerotic process: 1) The cholesteryl ester fatty acid composition of the plaque becomes increasingly similar to that of plasma, and 2) there is a continuing increase in the percentage of free cholesterol. These alterations reflect a decreased metabolic efficiency within atherosclerotic lesions and may initiate events that enhance plaque progression.

Purpose: Antiphospholipid antibodies (APLs), which consist of anticardiolipin antibodies (ACLs) or lupus anticoagulant (LA), are associated with venous thrombosis, stroke, and cardiac events. Although they are present in many patients with lower extremity atherosclerotic occlusive disease (LEAOD), the relationship between APL and the progression of LEAOD has not been reported. A comparison of progression of LEAOD as determined with direct imaging studies in patients with and without APL forms the basis for this report. Methods: APL+ patients (immunoglobulin M [IgM] or IgA or IgG ACL > 3 SD units above control mean or positive LA) who underwent lower extremity bypass grafting between January 1990 and June 1999 (n = 79) were compared with an APL control group (n = 68). Members of the study and control groups were similar with respect to age, procedure, sex, length of follow-up, and multiple atherosclerosis risk factors. Progression of LEAOD was determined by comparing preoperative arteriograms with postoperative imaging studies (arteriograms or duplex scanning). External iliac, common femoral, superficial femoral and popliteal arteries were graded as < 50% stenosis, ≥ 50% stenosis, or occluded. Posterior tibial and anterior tibial arteries were graded as patent or occluded. Progression was defined as any increase in stenosis category. Results: The mean follow-up period was 31 months for APL+ and 35 months for APL– patients (P = not significant). Progression of LEAOD occurred in 58 (73%) of 79 APL+ patients and in 25 (37%) of 68 APL– patients (P

Purpose: Duplex surveillance of lower extremity reversed vein bypass grafts (LERVG) is a means of identifying patients at risk for occlusion. The perceived accuracy of duplex scan as a means of identifying stenoses has led many surgeons to perform graft revision on the basis of duplex scan alone. This may result in missing additional lesions that are threatening patency. To assess the role of duplex scan as the sole imaging method before revision of LERVGs, we reviewed consecutive patients undergoing revisions who underwent preoperative arteriography after identification of duplex scan abnormalities. Methods: Duplex scan results, operative reports, and preoperative arteriograms for patients undergoing LERVG revision from January 1990 to December 1997 were reviewed. A standard duplex scan surveillance protocol was followed, and attempts were made to survey the entire graft, including inflow and outflow. Duplex scan results were compared with the results of preoperative arteriograms and the operation performed to determine if all significant lesions were identified by means of duplex scan alone. Results: Two hundred five LERVG revisions were performed. The 5-year assisted primary patency rate was 91%. In 119 cases (58%), arteriography did not contribute significantly to duplex scan findings. Arteriography significantly contributed to operative planning in 86 cases (42%). In 38 cases (19%), only a low-flow state was identified by means of duplex scan, and a correctable stenosis was identified by means of arteriography. In 48 cases (23%), additional significant lesions corrected at operation were identified by means of arteriography. These included 26 inflow, 16 graft, and 8 outflow lesions. Arteriography was most useful as a means of determining the revision procedure performed when there were inflow lesions (P < .05) or when the proximal anastomosis was to the profunda or superficial femoral arteries (P < .05). All frequently performed bypass graft configurations had some discrepancy between arteriographic and duplex scan findings. Conclusion: Available data do not permit prediction of which LERVG are immune from missed lesions in a duplex scan surveillance protocol. This suggests to us that arteriography is mandatory before LERVG revisions. (J Vasc Surg 1999;29:270-81.)

Restoring blood flow is the most effective means to limit damage to ischemic tissue. Since the 1960s, surgical placement of bypass grafts for coronary artery disease (CAD) and peripheral vascular disease has effectively and durably restored blood flow to ischemic tissue. Nonsurgical