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Post-operative delirium (POD) is common yet often underdiagnosed following vascular surgery. Elderly patients with advanced peripheral artery disease may be at particular risk for POD yet understanding of the clinical predictors and impact of POD is incomplete. We sought to identify POD predictors and associated resource utilization after infrainguinal lower extremity bypass.This single center retrospective analysis included all infrainguinal bypass cases performed for peripheral arterial disease from 2012-2020. The primary outcome was inpatient POD. Delirium sequelae were also evaluated. Key secondary outcomes were length of stay, nonhome discharge, readmission, 30-day amputation, post-operative myocardial infarction, mortality, and 2-year survival. Regression analysis was used to evaluate risk factors for delirium in addition to association with 2-year survival and amputation free survival.Among 420 subjects undergoing infrainguinal lower extremity bypass, 105 (25%) developed POD. Individuals with POD were older and more likely to have non-elective surgery (P 0.05). On multivariable analysis, independent predictors of POD were age 60-89 years old, chronic limb threatening ischemia, female sex, and nonelective procedure. Consultations for POD took place for 25 cases (24%); 13 (52%) were with pharmacists, and only 4 (16%) resulted in recommendations. The average length of stay for those with POD was higher (17 days vs. 9 days; P 0.001). POD was associated with increased non-home discharge (61.8% vs. 22.1%; P 0.001), 30-day major amputation (6.7% vs. 1.6%; P 0.01), 30-day postoperative myocardial infarction (11.4% vs. 4.1%; P 0.01), and 90-day mortality (7.6% vs. 2.9%; P = 0.03). Survival at 2 years was lower in those with delirium (89% vs. 75%; P 0.001). In a Cox proportional hazards model, delirium was independently associated with decreased survival (HR = 2.0; 95% CI = 1.15-3.38; P = 0.014) and decreased major-amputation free survival (HR = 1.9; 95% CI = 1.18-2.96; P = 0.007).POD is common following infrainguinal lower extremity bypass and is associated with other adverse post-operative outcomes and increased resource utilization, including increased hospital length of stay, nonhome discharge, and worse 2-year survival. Future studies should evaluate the role of routine multidisciplinary care for high-risk patients to improve perioperative outcomes for vulnerable older adults undergoing infrainguinal lower extremity bypass.

Racial and ethnic disparities have been well-documented in the outcomes for chronic limb threatening ischemia (CLTI). One purported explanation has been the disease severity at presentation. We hypothesized that the disparities in major adverse limb events (MALE) after peripheral vascular intervention (PVI) for CLTI would persist despite controlling for disease severity at presentation using the WIfI (wound, ischemia, foot infection) stage.The Vascular Quality Initiative PVI dataset (2016-2021) was queried for CLTI. Patients were excluded if they were missing the WIfI stage. The primary end point was the incidence of 1-year MALE, defined as major amputation (through the tibia or fibula or more proximally) or reintervention (endovascular or surgical) of the initial treatment limb. A multivariate hierarchical Fine-Gray analysis was performed, controlling for hospital variation, competing risk of death, and presenting WIfI stage, to assess the independent association of Black/African American race and Latinx/Hispanic ethnicity with MALE. A Cox proportional hazard regression model was used for the 1-year survival analysis.Overall, 47,830 patients (60%) had had WIfI scores reported (73% White, 20% Black, and 7% Latinx). The 1-year unadjusted cumulative incidence of MALE was 13.1% (95% confidence interval [CI], 12.6%-13.5%) for White, 14.3% (95% CI, 13.5%-15.3%) for Black, and 17.0% (95% CI, 15.3%-18.9%) for Latinx patients. On bivariate analysis, the occurrence of MALE was significantly associated with younger age, Black race, Latinx ethnicity, coronary artery disease, cerebrovascular disease, congestive heart failure, hypertension, diabetes, dialysis, intervention level, any prior minor or major amputation, and WIfI stage (P .001). The cumulative incidence of 1-year MALE increased by increasing WIfI stage: stage 1, 11.7% (95% CI, 10.9%-12.4%); stage 2, 12.4% (95% CI, 11.8%-13.0%); stage 3, 14.8% (95% CI, 13.8%-15.8%); and stage 4, 15.4% (95% CI, 14.3%-16.6%). The cumulative incidence also increased by intervention level: inflow, 10.7% (95% CI, 9.8%-11.7%), femoropopliteal, 12.3% (95% CI, 11.7%-12.9%); and infrapopliteal, 14.1% (95% CI, 13.5%-14.8%). After adjustment for WIfI stage only, Black race (subdistribution hazard ratio [SHR], 1.30; 95% CI, 1.17-1.44; P .001) and Latinx ethnicity (SHR, 1.58; 95% CI, 1.37-1.81; P .001) were associated with an increased 1-year hazard of MALE compared with White race. On adjusted multivariable analysis, MALE disparities persisted for Black/African American race (SHR, 1.12; 95% CI, 1.01-1.25; P = .028) and Latinx/Hispanic ethnicity (SHR, 1.34; 95% CI, 1.16-1.54; P .001) compared with White race.Black/African American and Latinx/Hispanic patients had a higher associated hazard of MALE after PVI for CLTI compared with White patients despite an adjustment for WIfI stage at presentation. These results suggest that disease severity at presentation does not account for disparities in outcomes. Further work should focus on better understanding the underlying mechanisms for disparities in historically marginalized racial and ethnic groups presenting with CLTI.

Despite the shared pathogenesis of peripheral arterial disease (PAD) and vascular dementia, there is little data on cognitive impairment in PAD patients. We hypothesized that cognitive impairment will be common and previously unrecognized.Cognitive impairment screening was prospectively performed for Veterans presenting to a single Veterans Affairs outpatient vascular surgery clinic from 2020-2021 for PAD consultation or disease surveillance. Overall, 125 Veterans were screened. Cognitive impairment was defined as a score of26 on the Montreal Cognitive Assessment (MoCA) survey. A multivariable logistic regression assessed for independent risk factors for cognitive impairment.Overall, 77 (61%) had cognitive impairment, 92% was previously unrecognized. Cognitive impairment was associated with increased age (74.4 vs. 71.8 years, p=0.03), Black vs. White race (94% vs. 54%, p0.01), hypertension (66% vs. 31%, p=0.01), prior stroke/TIA (79% vs. 58%, p=0.03), diabetes treated with insulin (79% vs. 58%, p=0.05), and post-traumatic stress disorder (PTSD) (80% vs. 57%, p=0.04). On multivariable analysis, risk factors for newly diagnosed cognitive impairment included age ≥ 70 years, diabetes treated with insulin, PTSD, and Black race.Many Veterans with PAD have evidence of cognitive impairment and is overwhelmingly underdiagnosed. This study suggests cognitive impairment is an unrecognized issue in a VA population with PAD, requiring more study to determine cognitive impairment's impact on surgical outcomes, and how it can be mitigated and incorporated into clinical care.

With the evolution in vascular surgery toward increased endovascular therapy and decreased open surgical training, comfort with open procedures by current trainees is declining. A proposed method to improve this discomfort is simulator training. We hypothesized that open, cadaver, and endovascular surgery simulation would be associated with increased self-perceived comfort in performing corresponding procedures.Integrated (0 + 5) vascular surgery residents and recent graduates in the United States were asked to complete a survey quantifying comfort via a Likert scale with procedures and experience with simulation training. Simulation groups were then matched using coarsened exact matching. Ordinal logistic regression assessed the association between simulation experience and comfort in performing procedures.Surveys were completed by 68 trainees and 20 attending surgeons in their first 5 years of practice. On unmatched analyses, there were no significant differences in comfort in performing any open or endovascular aorto-mesenteric or peripheral vascular procedures between respondents who reported experience with open or endovascular simulation, respectively. However, respondents who reported cadaver simulation experience (58%, 51/88) had a significantly higher reported comfort score performing open juxtarenal aortic repair (2.4 vs. 1.7), superior mesenteric artery thrombectomy or bypass (2.5 vs. 1.9), inferior vena cava or iliac vein repair (2.2 vs. 1.7), axillary-femoral artery bypass (3.4 vs. 2.5), femoral-popliteal artery bypass (3.7 vs. 2.8), and inframalleolar artery bypass (2.8 vs. 2.1; all P 0.05). After matching on training level, number of abdominal cases completed, and number of open vascular cases completed, ordinal logistic regression demonstrated that previous cadaver simulation was significantly associated with increased comfort in performing open aortic repairs, venous repair, visceral revascularization, and peripheral bypasses.In this nationally representative sample, cadaver, but not open or endovascular, simulation was associated with increased comfort in performing open vascular surgery. Providing cadaver simulation to trainees may help to improve comfort levels in performing open surgery. Integrated vascular surgery training programs should consider implementing these experiences into their curriculum.

Progress in particle and nuclear physics 124, 103947 - (2022). doi:10.1016/j.ppnp.2022.103947, This review demonstrates the unique role of the neutrino by discussing in detail the physics of and with neutrinos. We deal with neutrino sources, neutrino oscillations, absolute masses, interactions, the possible existence of sterile neutrinos, and theoretical implications. In addition, synergies of neutrino physics with other research fields are found, and requirements to continue successful neutrino physics in the future, in terms of technological developments and adequate infrastructures, are stressed., Published by Pergamon Press, Frankfurt, M.

The purpose was to examine the incidence of positive cultures in a highly susceptible subset of trauma patients admitted to the surgical intensive care unit (SICU) for mechanical ventilation and to examine the impact of their timing on outcomes.A retrospective review was conducted of blunt trauma patients admitted to the SICU for mechanical ventilation at a level I trauma center over a five-year period. All urine, blood, and sputum cultures were abstracted. Patients with at least one positive culture were compared with those with negative or no cultures. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to calculate the adjusted hazard ratio (AHR).The median age of 635 patients meeting inclusion criteria was 46 and 74.2% were male. A total of 298 patients (46.9%) had at least one positive culture, with 28.9% occurring within two days of admission. Patients with positive cultures were more likely to be severely injured with an injury severity score (ISS) ≥16 (68.5% vs. 45.1%, p 0.001). Overall mortality was 22%. Patients who had their first positive culture within two and three days from admission had a significantly higher AHR for mortality (AHR: 14.46, p 0.001 and AHR: 10.59, p = 0.028, respectively) compared to patients with a positive culture at day six or later.Early positive cultures are common among trauma patients requiring mechanical ventilation and are associated with higher mortality. Early identification with "damage control cultures" obtained on admission to aid with early targeted treatment might be justified.

Background Massive transfusion protocols (MTPs) are necessary for hemodynamically unstable trauma patients with active bleeding. Thrombotic events have been associated with blood transfusion; however, the risk factors for the development of venous thromboembolism (VTE) in trauma patients receiving MTP are unknown. Methods A retrospective review was conducted by reviewing the electronic medical records of all trauma patients admitted to a Level I trauma center who received MTP from 2011 to 2016. Data were collected on patient demographics, mechanism of injury, injury severity scores, quantity of blood products transfused during MTP activation, incidence of VTE, intensive care unit length of stay (LOS), hospital LOS, and ventilator days. The primary outcome was VTE. Results Of the 59 patients who had MTP activated, 15 (25.4%) developed a VTE during their hospital admission. Patients who developed VTE were compared with those who did not. Age (40 y versus 35 y, P = 0.59), sex (60% versus 73% male, P = 0.52), and mechanism of injury (47% versus 59% blunt, P = 0.40) were similar. Intensive care unit LOS, hospital LOS, and ventilator days were longer in the patients who were diagnosed with a VTE. Multivariable analysis revealed an increase in the odds for developing a VTE with increasing packed red blood cell transfusion (adjusted odds ratio = 2.61, P = 0.03). Conclusions The risk for VTE in trauma patients requiring massive transfusion is proportional to the number of packed red blood cells transfused. Liberal screening protocols and maintenance of a high index of suspicion for VTE in these high-risk patients is justified.

The use of vasopressors (VP) in the resuscitation of massively transfused trauma patients might be considered a marker of inadequate resuscitation. We sought to characterize the utilization of VP in patients receiving massive transfusion and examine the association of their use with mortality.Trauma patients admitted from January 2011 to October 2016 receiving massive transfusion, defined as 3 units of pRBC within the first hour from admission, were selected for analysis. Demographics, admission vital signs and labs, use of VP, surgical interventions and outcomes were collected. Standard statistical tools were utilized.Over the 5-year study period, 120 trauma patients met inclusion criteria. The median age was 39 years with 77% being male and 41% sustaining a penetrating injury. Patients who received VP [VP (+)] were more likely to have a lower admission GCS (median 4.5 vs. 14.0, p0.01) and less likely to have a penetrating injury (31% vs. 54%, p=0.02). The overall mortality was 49% and significantly higher in the VP (+) cohort (60% vs. 34%, AHR: 9.9, adjusted p=0.03). Mortality increased in a stepwise fashion with increasing number of VP utilized, starting at 34% for no VP, to 78% for 3 VP, and 100% for 5 or more. The majority of deaths in the VP (-) group (88%) occurred within one day from admission. For the VP (+) group, 57% of deaths occurred within one day, with the remaining 43% occurring at a later time.In the era of massive transfusion protocols, vasopressors are commonly utilized in exsanguinating trauma patients and their use is associated with a higher mortality risk. Deaths in patients receiving vasopressors are more likely to occur later compared to those in patients who do not receive vasopressors. Further research to characterize the role of these agents in the resuscitation of trauma patients is required.

Introduction Rigid cervical collars are routinely placed in the pre-hospital setting after significant blunt trauma. Patients who are deemed competent by field personnel (Glasgow Coma Scale (GCS) ≥13, no major distracting injury and not grossly intoxicated) may refuse cervical collar placement. Material and methods A retrospective review was conducted of all adult trauma patients presenting to a Level 1 trauma center after blunt trauma with a GCS≥13 and no distracting injury or gross intoxication from January 2014 to December 2014. Pre-hospital data was collected from emergency medical service reports and hospital data from patient charts. Cervical spine injury was identified by International Classification of Disease-9th Revision codes. Patients refusing cervical spine immobilization prior to arrival are compared to those who were compliant. Results A total of 629 patients met inclusion criteria. Cervical spine immobilization was refused by 28 patients, while 601 complied. There were 16 cervical spine injuries (2.5%), with 3 (10.7%) in noncompliant patients and 13 (2.2%) among those who were complaint (p = 0.03). Conclusion The incidence of cervical spine injuries in patients refusing cervical collar immobilization is higher than in compliant patients. Patients arriving for initial evaluation having refused cervical collar immobilization should be treated with caution.

Patients with traumatic brain injury (TBI) are often resuscitated with crystalloids in the emergency department (ED) to maintain cerebral perfusion. The purpose of this study was to evaluate whether crystalloid resuscitation volume impacts mortality in TBI patients. This was a retrospective study of trauma patients with head abbreviated injury scale score ≥2, who received crystalloids during ED resuscitation between 2004 and 2013. Clinical characteristics and volume of crystalloids received in the ED were collected. Patients who received

Background High-flow nasal cannula (HFNC) is increasingly used to reduce reintubations in patients with respiratory failure. Benefits include providing positive end expiratory pressure, reducing anatomical dead space, and decreasing work of breathing. We sought to compare outcomes of critically ill surgical patients extubated to HFNC versus conventional therapy. Methods A retrospective review was conducted in the surgical intensive care unit of an academic center during August 2015 to February 2016. Data including demographics, ventilator days, oxygen therapy after extubation, reintubation rates, surgical intensive care unit and hospital length of stay, and mortality were collected. Self and palliative extubations were excluded. Characteristics and outcomes, with the primary outcome being reintubation, were compared between those extubated to HFNC versus cool mist/nasal cannula (CM/NC). Results Of the 184 patients analyzed, 46 were extubated to HFNC and 138 to CM/NC. Mean age and days on ventilation before extubation were 57.8 years and 4.3 days, respectively. Both cohorts were similar in age, sex, and had a similar prevalence of cardiopulmonary diagnoses at admission. Although prior to extubation HFNC had lengthier ventilation requirements (7.1 versus 3.4 days, P Conclusions Ventilated patients at risk for recurrent respiratory failure have reduced reintubation rates when extubated to HFNC. Patients with prolonged intubation or those with high-risk comorbidities may benefit from extubation to HFNC.

Purpose The purpose of the study is to determine if excessive fluid administration is associated with a prolonged hospital course and worse outcomes. Materials and methods In July 2013, all normotensive trauma patients admitted to the surgical intensive care unit (ICU) were administered crystalloids at 30 mL/h (“to keep open [TKO]”) and were compared to patients admitted during the preceding 6 months who were placed on a rate between 125 mL/h to 150 mL/h (non-TKO). The primary outcomes were ICU, hospital, and ventilator days. Results A total of 101 trauma patients met inclusion criteria: 56 (55.4%) in the TKO and 45 (44.6%) in the non-TKO group. Overall, the 2 groups were similar in regard to age, Injury Severity Score, Acute Physiology and Chronic Health Evaluation IV scores, and the need for mechanical ventilation. TKO had no effect on renal function compared to non-TKO with similarities in maximum hospital creatinine. TKO patients had lower ICU stay (2.7 ± 1.5 vs 4.1 ± 4.6 days; P = .03) and ventilator days (1.4 ± 0.5 vs 5.5 ± 4.8 days; P Conclusions A protocol that encourages admission basal fluid rate of TKO or 30 mL/h in normotensive trauma patients is safe, reduces fluid intake, and may be associated with a shorter intensive care unit course and fewer ventilator days.

Postharvest foliar nitrogen (urea) is often applied to apple leaves immediately after picking for bud fertilising and/or during leaf fall for Venturia inaequalis control During 20132016 ethylene diamine tetraacetic acid copper (EDTACu to enhance leaf abscission) urea calcium nitrate and BudWiser foliar treatments were applied alone or in combination to determine their effects on leaf scar infection by Neonectria ditissima in Braeburn (201314) Scifresh and Royal Gala (201516) orchards In 201314 leaf scar infection increased sixfold when 5 urea was added to EDTACu and sprayed at the onset of leaf fall In 201516 up to a ninefold increase in leaf scar infections was observed The timing of application was more important than the amount or form of nitrogen used As a result of this research the use of ureabased foliar nitrogen fertilisers for V inaequalis before leaf fall are not recommended and growers should consider all factors affecting Neonectria ditissima infections before applying nitrogen immediately after harvest

Background Adequate venous thromboembolism (VTE) prophylaxis is essential after trauma, especially in patients with lower extremity and/or pelvic fractures. We sought to investigate if prophylactic enoxaparin dosed by anti -Xa trough levels could reduce clinically evident VTE in trauma patients with lower extremity or pelvic injury. Methods Prospective data was collected on trauma patients admitted for at least two days with any lower extremity and/or pelvic fracture and who received enoxaparin for VTE prophylaxis between October 2013 and January 2016. Patients in the control cohort received enoxaparin at 30 mg twice daily. Patients in the adjustment cohort had anti -Xa trough levels measured after three or more consecutive doses of enoxaparin. Those with a trough level of 0.1 IU/mL or lower had their dosage increased by 10-mg increments. Results Of the 159 patients included, 58 (36.5%) were monitored with anti -Xa trough levels. The cohorts were similar in age, sex, regional AIS, ISS score, ICU and hospital length of stay, proportion of patients with diagnostic testing for VTE, and time to first enoxaparin dose. Initial enoxaparin dosing in the majority of patients (84.5%) who had anti -Xa trough levels measured was subprophylactic. Patients receiving enoxaparin dosed by anti -Xa trough level had a significantly lower VTE rate than those who did not (1.7% v. 13.9%, p = 0.03). Conclusions Prophylactic enoxaparin adjusted by anti -factor Xa level may lead to a decreased rate of clinically evident VTE among trauma patients with lower extremity and/or pelvic fractures. Our findings indicate that the initial dose of enoxaparin was frequently too low.

BACKGROUND Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the United States, especially in the elderly, who have the highest rates of TBI-related hospitalizations and deaths among all age groups. Sepsis is one of many risk factors that is associated with higher mortality and longer length of hospital stay in this population partially due to the immunosuppressive effects of TBI. The significance of early indicators of infection, such as a positive blood, sputum, or urine culture, is not well described. The purpose of this study was to determine if early positive cultures predict higher mortality in elderly patients with TBI. METHODS All trauma patients aged ≥65 years with TBI, admitted between January 1, 2009 and December 31, 2013 to the surgical intensive care unit, were retrospectively reviewed. Clinical data including results from sputum, blood, and urine cultures were reviewed. RESULTS Overall, 288 elderly patients with TBI were identified, and 92 (32%) had a positive culture. Patients with positive cultures had longer intensive care unit (median 6.0 versus 2.0 days, P

The physical vulnerability of roads to debris flow may be expressed through fragility functions that relate flow volume to damage probabilities. Fragility relationships are essential components of quantitative risk assessments as they allow for the estimation of risk within a consequence-based framework. To the best of the authors’ knowledge, this is the first time that fragility curves have been produced in order to provide the conditional probability for a road to be in, or to exceed, a certain damage state for a given debris flow volume. Preliminary assessments were undertaken by means of a detailed questionnaire. A total of 47 returns were received from experts in 17 countries: 32 % academia, 51 % the commercial sector and 17 % governments. Fragility curves have been defined for three damage states (limited damage, serious damage and destroyed) for each of low-speed and high-speed roads in order to cover the typical characteristics of roads vulnerable to debris flow. The probability of any given damage state being reached or exceeded by a debris flow of a given volume (10–100,000 m3) was derived from the mean of the responses received. Inevitably there was a degree of scatter in the results, and the treatment of such variation, or ‘experimental errors’, was crucial to understanding the data and developing the fragility curves. Fragility curves are quantitative expressions of vulnerability. The method adopted is based upon qualitative, expert judgment of quantitative probabilities. In addition to an assessment of the probabilities of given damage states being exceeded, respondents to the questionnaire were polled as to their level of experience and confidence in their ability to provide a valid and coherent set of answers to the questions posed. The development of the fragility curves and their validation are described in the paper.

During the 2013 spring two different nitrogen sources (calcium nitrate and BreakNtrade;) were applied using a motorised knapsack sprayer to dormant blackcurrants with and without the addition of a super penetrant surfactant (Engulfreg;) for dormancy breaking Trials were conducted in Nelson at two grower sites consisting of Ben Ard and Magnus blackcurrant varieties Bud break and flowering was advanced by 510 days with the combination of the super penetrant surfactant and either nitrogen source A Nitrogen source applied alone did not influence bud break or flowering The length of flowering was condensed on Magnus and a more even and earlier fruit maturity occurred on both varieties with the combination of the super penetrant surfactant and nitrogen The importance of these findings for the blackcurrant industry is discussed

While assault is commonly reported or suspected in children with traumatic wounds, a recent overview of these injuries, especially those requiring trauma surgery consultation is lacking in the literature.Explore the incidence, demographics and injury patterns of children presenting to trauma centers following an assault.Retrospective review of the National Trauma Data Bank 2007 to 2011.Subjects up to 18 years old with "assault" reported as the intent of injury. Patients were divided into infants (2 years), young children (2-5 years), children (6-11 years), and adolescents (12-18 years).Mechanism of injury, injury severity and mortality based on age groups and race.Of 609,207 children, 58,299 (9.6%) were victims of an assault. The median age was 16 years and 81% were male, with a median injury severity score (ISS) of 8. The majority of patients were adolescents (76%), followed by infants (17%) and young children (4%). There was a stepwise increase in the proportion of assaulted Black children with increasing age (23.2% for infants and up to 46.7% for adolescents, trend p 0.01, effect size: 0.175) while the opposite applied for White children (46.0% for infants and down to 19.5% for adolescents, trend p 0.01, effect size: -0.230). With increasing age, White subjects had the highest trend of being assaulted during an unarmed fight or brawl (p 0.01, effect size: 0.393), while for Black victims the highest trend was noted for assault with a firearm (p 0.01, effect size: 0.323). Almost 2 out of 3 infants sustained severe head trauma (59%). The overall mortality was 8%, highest among young children, where it reached 16% (p 0.01).Up to 10% of children admitted following trauma are victims of assault with traumatic brain injuries predominant in infants and firearm injuries predominant in adolescents. Injury patterns largely correlate to age and race. Assault in children is associated with a high mortality risk. These data highlight the magnitude of the problem and calls for further involvement of trauma surgeons to improve outcomes, bring awareness and promote preventative strategies to eliminate assault in children.

Liberal emergency department (ED) resuscitation after trauma may lead to uncontrolled hemorrhage, reduced organ perfusion, and compartment syndrome. Recent guidelines reduced the standard starting point for crystalloid resuscitation from 2 L to 1 L and emphasized "balanced" resuscitation. The purpose of this study was to characterize how an urban, Level 1 trauma center has responded to changes in crystalloid resuscitation practices over time and to describe associated patient outcomes.This is a retrospective review of trauma patients who sustained moderate to severe injury (ISS 9) and received crystalloid resuscitation in the ED during 1/2004-12/2013 at an urban, Level 1 trauma center. Patient data collected included age, gender, Glasgow Coma Scale (GCS) score, initial systolic blood pressure (SBP), mechanism of injury, regional Abbreviated Injury Scale (AIS) score, Injury Severity Score (ISS), volume of blood products and crystalloids administered in the ED. Patients who received2 L of crystalloid were considered low-volume while those who received ≥2 L were high-volume patients. Clinical characteristics and outcomes were compared between high- and low-volume cohorts, and multivariate regression was used to adjust for confounders. Trend analysis examined changes in variables over time.1571 moderate to severely injured patients received crystalloid resuscitation; 1282 (82%) were low-volume and 289 (18%) were high-volume. Compared to high-volume patients, low-volume patients presented with a higher median SBP (134 vs. 122 mmHg, p 0.001) and GCS (15 vs. 14, p 0.001). Low-volume patients also had lower median ISS (15 vs. 19, p 0.001). Unadjusted mortality was lower in the low-volume cohort (7% vs. 19%, p 0.001). Multivariate analysis demonstrated that high-volume patients had increased odds of mortality compared to low-volume patients (AOR 1.88, p = 0.008). Decreased rates of high-volume resuscitation and overall mortality were demonstrated over the 10-year study period.The observed decrease in high-volume crystalloid resuscitations in the ED paralleled a reduction in mortality over the ten-year period. In addition, adjusted mortality was higher in those receiving high-volume resuscitation.

Background Spinal motion restriction (SMR) after traumatic injury has been a mainstay of prehospital trauma care for more than 3 decades. Recent guidelines recommend a selective approach with cervical spine clearance in the field when criteria are met. Materials and methods In January 2014, the Department of Health Services of the City of Los Angeles, California, implemented revised guidelines for cervical SMR after blunt mechanism trauma. Adult patients (aged ≥18 y) with an initial Glasgow Coma Scale (GCS) score of ≥13 presented to a single level I trauma center after blunt mechanism trauma over the following 1-y period were retrospectively reviewed. Demographics, injury data, and prehospital data were collected. Cervical spine injury (CSI) was identified by International Classification of Disease, Ninth Revision, codes. Results Emergency medical services transported 1111 patients to the emergency department who sustained blunt trauma. Patients were excluded if they refused c-collar placement or if documentation was incomplete. A total of 997 patients were included in our analysis with 172 (17.2%) who were selective cleared of SMR per protocol. The rate of Spinal Cord Injury was 2.2% (22/997) overall and 1.2% (2/172) in patients without SMR. The sensitivity and specificity of the protocol are 90.9% (95% confidence interval: 69.4-98.4) and 17.4% (95% confidence interval: 15.1-20.0), respectively, for CSI. Patients with CSI who arrived without immobilization having met field clearance guidelines, were managed without intervention, and had no neurologic compromise. Conclusions Guidelines for cervical SMR have high sensitivity and low specificity to identify CSI. When patients with injuries were not placed on motion restrictions, there were no negative clinical outcomes.

Time-restricted feeding ameliorates the deleterious effects of a high-fat diet on body weight and metabolism in young adult mice. Because obesity is highly prevalent in the middle-aged population, this study tested the hypothesis that time-restricted feeding alleviates the adverse effects of a high-fat diet in male middle-aged (12months) mice. C57BL6/J mice were fed one of three diets for 21-25weeks: 1) high-fat diet (60% total calories from fat) ad-libitum (HFD-AL), 2) HFD, time-restricted feeding (HFD-TRF), and 3) low-fat diet (10% total calories from fat) ad-libitum (LFD-AL) (n=15 each). HFD-TRF mice only had food access for 8h/day during their active period. HFD-TRF mice gained significantly less weight than HFD-AL mice (~20% vs 55% of initial weight, respectively). Caloric intake differed between these groups only during the first 8weeks and accounted for most but not all of their body weight difference during this time. TRF of a HFD lowered glucose tolerance in terms of incremental area under the curve (iAUC) (p

The development of a method to simulate desired approach flow characteristics in a multiple controlled fan boundary layer wind tunnel (MCFWT) is described. A MCFWT uses flow control techniques to impart the desired turbulence characteristics in lieu of using a roughness grid upwind of the test section to generate a boundary layer. In contrast to other MCWFT techniques, the proposed approach (a) relies on the direct simulation of scaled wind speed and direction records and (b) implements a closed-loop proportional-integral-derivative controller to modulate the wind speed and control the turbulence characteristics. A case study is presented using a 1:10 scale model of the Full-Scale Test Facility at the Insurance Institute for Business & Home Safety Research Center. Simulation of marine, open and suburban approach boundary layer flow yields good agreement between the model and measured values, including mean velocity and turbulence intensity profiles, integral length scales and power spectra. Control of longitudinal and lateral fluctuations is considered herein; Good agreement between the target and measured vertical turbulence intensity profiles was also achieved after the longitudinal and lateral turbulence profiles were matched.

The design of active sites has been carried out using quantum mechanical calculations to predict the rate-determining transition state of a desired reaction in presence of the optimal arrangement of catalytic functional groups (theozyme). Eleven versatile reaction targets were chosen, including hydrolysis, dehydration, isomerization, aldol, and Diels-Alder reactions. For each of the targets, the predicted mechanism and the rate-determining transition state (TS) of the uncatalyzed reaction in water is presented. For the rate-determining TS, a catalytic site was designed using naturalistic catalytic units followed by an estimation of the rate acceleration provided by a reoptimization of the catalytic site. Finally, the geometries of the sites were compared to the X-ray structures of related natural enzymes. Recent advances in computational algorithms and power, coupled with successes in computational protein design, have provided a powerful context for undertaking such an endeavor. We propose that theozymes are excellent candidates to serve as the active site models for design processes.

Brian Hope-Taylor’s report (1977) on his excavations at Yeavering was received with a unanimous fanfare of approval from reviewers. No general reassessment of the buildings appears to have been conducted subsequently to judge by the bibliography in a later study of the site (Frodsham and O'Brien 2005), although one or two have been tentatively reconstructed on paper and an abortive attempt was made to reconstruct the largest of them, A4, at the Bedesworld museum. Nevertheless a careful reading of the text reveals inadequacies of description and analysis of the buildings - a surprising number in the light of the reviews and to anyone accustomed to the interpretation of ground plans and structures, the report of an excavation justly famous for its brilliant technique leaves much to be desired. The purpose of this paper is to consider how plan and structure developed at Yeavering and to draw some tentative conclusions about their significance, setting aside the historical references and using only the evidence of the buildings. Excluded is the square shrine at the western ring-ditch cemetery in Phase I and the assembly structure in Phases II-IV, which do not require interpretation in the same way.

Equivalent dipole polarizabilities are a succinct way to summarize the inductive response of an isolated conductive body at distances greater than the scale of the body. At any time lag or frequency, an equivalent dipole polarizability response is comprised of nine parameters: six specifying an equivalent dipole polarizability matrix (which is symmetric) and three specifying the apparent location of the body center. Smith and Morrison have given equations for calculating uncertainties in equivalent dipole polarizability and position based on analysis of an iterative linearized inversion. Here, the root mean squared uncertainty in polarizability is weighted and summed over a number of control points and minimized using an evolutionary algorithm for a number of instrument designs. Three families of designs are presented: single-transmitter systems for use on a two-dimensional grid of positions with negligible error in relative instrument location, two-transmitter systems for use on a line of positions with negligible error in relative instrument location, and three-transmitter systems for stand alone use. Results for the one- and two-transmitter systems are strongly degraded by errors in instrument position, whereas the three-transmitter systems are insensitive to instrument positioning errors.

Equivalent dipole polarizability matrices and equivalent dipole location are a convenient way to interpret magnetic field data due to currents induced in isolated conductive objects. The uncertainties in polarizability estimates and in the equivalent dipole location provide a quantitative measure of the performance of different configurations of transmitters and receivers. In another paper, we estimate these uncertainties using a linearized inversion. For many systems, consisting of one or more rectangular loop transmitters and a number of dipole receivers, sited on a horizontal grid, equivalent dipole depth is determined to 10% accuracy to depths approximately 20% deeper than the depths at which polarizability matrix elements can be determined to the same precision. Systems that have a lower product of rms polarizability uncertainty and square root of their number of transmitter-receiver pairs are considered more effective for the number of transmitter-receiver pairs. Among the systems studied, a system with three orthogonal transmitter loops and a three-component receiver is the most effective, for objects shallower than 0.6 times the instrument siting grid spacing, yielding an rms polarizability uncertainty 0.04 times that of a single-transmitter single-receiver system. At intermediate depths, a system with two vertical component receivers on the diagonal of a square horizontal transmitter loop is most effective for its number of transmitter-receiver pairs, yielding an rms polarizability uncertainty 0.07 times that of a single receiver system. At depths greater than 2.5 times, the siting grid spacing a three-orthogonal loop transmitter with a single vertical component receiver is about the most effective for its number of transmitter-receiver pairs, yielding an rms polarizability uncertainty 0.08 times that of a single-transmitter system.

Away from a conductive body, secondary magnetic fields due to currents induced in the body by a time-varying external magnetic field are approximated by (equivalent) magnetic dipole fields. Approximating the external magnetic field by its value at the location of the equivalent magnetic dipoles, the equivalent magnetic dipoles' strengths are linearly proportional to the external magnetic field, for a given time dependence of external magnetic field, and are given by the equivalent dipole polarizability matrix. The polarizability matrix and its associated equivalent dipole location are estimated from magnetic field measurements made with at least three linearly independent polarizations of external magnetic fields at the body. Uncertainties in the polarizability matrix elements and its equivalent dipole location are obtained from analysis of a linearized inversion for polarizability and dipole location. Polarizability matrix uncertainties are independent of the scale of the polarizability matrix. Dipole location uncertainties scale inversely with the scale of the polarizability matrix. Uncertainties in principal polarizabilities and directions are obtained from the sensitivities of eigenvectors and eigenvalues to perturbations of a symmetric matrix. In application to synthetic data from a magnetic conducting sphere and to synthetic data from an axially symmetric elliptic conducting body, the estimated polarizability matrices, equivalent dipole locations, and principal polarizabilities and directions are consistent with their estimated uncertainties.

This work makes a theoretical and experimental contribution to the problem of rotor–blades dynamic interaction. A validation procedure of mathematical models is carried out with the help of a simple test rig, built by a mass–spring system attached to four flexible rotating blades. With this test rig, it is possible to highlight some dynamic effects and experimentally simulate the structural behaviour of a windmill in two dimensions (2-D model). Only lateral displacement of the rotor in the horizontal direction is taken into account. Gyroscopic effect due to angular vibrations of the rotor is eliminated in the test rig by attaching the rigid rotor to a flexible foundation. The blades are modelled as Euler–Bernoulli beams. Using three different approaches to describe the beam deformation one achieves: (a) a linear model; (b) a linear beam model with second order terms; (c) a fully non-linear model. Tip masses at the end of the blades emphasize the coupling between the dynamic and elastic terms. The shape functions are chosen in order to reduce the mathematical model, so that only the first bending mode of the beam is taken into account. The resulting equations of motion have five degrees of freedom and illustrate linear, non-linear and time-dependent terms in a very transparent way. Although neither gyroscopic effect due to rotor angular vibrations nor higher blade mode shapes are considered in the analysis, the equations of motion of the rotor–blades system are still general enough for the purpose of the work: validation of different linear and non-linear models with time dependent (periodic) coefficients. Experiments are carried out in the time and frequency domains while the rotor operates with different constant angular velocities.

Importance Continuous renal replacement therapy (CRRT) benefits patients with renal failure who are too hemodynamically unstable for intermittent hemodialysis. The duration of therapy beyond which continued use is futile, particularly in a population of patients admitted to and primarily cared for by a surgical service (hereinafter referred to as surgical patients), is unclear. Objective To analyze proportions of and independent risk factors for survival to discharge after initiation of CRRT among patients in a surgical intensive care unit (SICU). Design, Setting, and Participants This retrospective cohort study included all patients undergoing CRRT from July 1, 2012, through January 31, 2016, in an SICU of an urban tertiary medical center. The population included patients treated before or after general surgery and patients admitted to a surgical service during inpatient evaluation and care before liver transplant. The pretransplant population was censored from further survival analysis on receipt of a transplant. Exposures Continuous renal replacement therapy. Main Outcomes and Measures Hospital mortality among patients in an SICU after initiation of CRRT. Results Of 108 patients (64 men [59.3%] and 44 women [40.7%]; mean [SD] age, 62.0 [12.7] years) admitted to the SICU, 53 were in the general surgical group and 55 in the pretransplant group. Thirteen of the 22 patients in the pretransplant group who required 7 or more days of CRRT died (in-hospital mortality, 59.1%); among the 12 patients in the general surgery group who required 7 or more days of CRRT, 12 died (in-hospital mortality, 100%). In the general surgical group, each day of CRRT was associated with an increased adjusted odds ratio of death of 1.39 (95% CI, 1.01-1.90; P = .04). Conclusions and Relevance Continuous renal replacement therapy is valuable for surgical patients with an acute and correctable indication; however, survival decreases significantly with increasing duration of CRRT. Duration of CRRT does not correlate with survival among patients awaiting liver transplant.

The European Union's decision to limit future growth in the use within Europe of old airliners modified to meet current noise standards has given rise to lively controversy. This article provides a technical point of view to set against the ongoing political and economic arguments. It offers the reader some information and analysis, derived from objective data on the environmental performance of various aircraft (including most of the modified older aircraft currently in use) which may be helpful in evaluating the various claims and arguments that are being made.

This paper reviews two sets of failure information, the GMTF (a parameter obtained from time-to-failure results) and GMBD stress (a parameter that is calculated from AC breakdown test results), and suggests a correlation. The test results were obtained from accelerated aging experiments on full-sized medium voltage cables in carefully controlled and monitored water-filled tanks. Results show that the ambient temperature AC breakdown strength for equivalently aged cables is influenced primarily by voltage stress during aging-not by the aging temperature. The AC breakdown strength on equivalently aged cables was also shown to decrease with reductions in the aging voltage at all aging temperatures.