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Background Single-center data demonstrates that regional analgesia (RA) techniques are associated with reduced risk of delirium in older patients with multiple rib fractures. We hypothesized that a similar effect between RA and delirium would be identified in a larger cohort of patients from multiple level I trauma centers. Methods Retrospective data from seven level I trauma centers were collected for intensive care unit (ICU) patients 65 years or older with ≥3 rib fractures from January 2012 to December 2016. Those with a head and/or spine injury Abbreviated Injury Scale (AIS) score of ≥ 3 or a history of dementia were excluded. Delirium was defined as one positive Confusion Assessment Method for the Intensive Care Unit score in the first 7 days of ICU care. Poisson regression with robust standard errors was used to determine the association of RA (thoracic epidural or paravertebral catheter) with delirium incidence. Results Data of 574 patients with a median age of 75 years (interquartile range [IQR], 69-83), Injury Severity Score of 14 (IQR, 11-18), and ICU length of stay of 3 days (IQR, 2-6 days) were analyzed. Among the patients, 38.9% were women, 15.3% were non-White, and 31.4% required a chest tube. Regional analgesia was used in 19.3% patients. Patient characteristics did not differ by RA use; however, patients with RA had more severe chest injury (chest AIS, flail segment, hemopneumothorax, thoracostomy tube). In univariate analysis, there was no difference in the likelihood of delirium between the RA and no RA groups (18.9% vs. 23.8% p = 0.28). After adjusting for age, sex, Injury Severity Score, maximum chest AIS, thoracostomy tube, ICU length of stay, and trauma center, RA was associated with reduced risk of delirium (incident rate ratio [IRR], 0.65; 95% confidence interval [CI], 0.44-0.94) but not with in-hospital mortality (IRR, 0.42; 95% CI, 0.14-1.26) or respiratory complications (IRR, 0.70; 95% CI, 0.42-1.16). Conclusion In this multicenter cohort of injured older adults with multiple rib fractures, RA use was associated with a 35% lower risk of delirium. Further studies are needed to standardize protocols for optimal pain management and prevention of delirium in older adults with severe thoracic injury. Level of evidence Therapeutic, level IV; Epidemiologic, level III.

We aim to describe interpersonal violence-related injury patterns in the pediatric trauma population and to identify predictors of recidivism.In this retrospective analysis from a single institution, we included pediatric patients (≤17 years) treated (2006-2020) for traumatic injury related to interpersonal violence (IPV). Patient characteristics were compared among mechanism types and between recidivists and non recidivists using two sample t-tests, Wilcoxon rank-sum tests, and Pearson's chi-squared. Multivariate analysis was performed using logistic regression to identify predictors of repeat injury.We identified 635 pediatric patients who sustained injuries owning to IPV: firearm (N = 266), assault (stab/blunt; N = 243), and abuse (N = 126). The average age of the firearm, assault, and abuse groups was 15.5, 14.7, and 1.1 years (SD = 2.2, 3.4, 2.4 years), respectively. Majority of the overall cohort was male (77.5%) and publicly- or un insured (67.8%), with 28.0% being Black. Of the 489 firearm and assault patients who survived the first injury, 30 (6.1%) had repeat injury owning to IPV requiring treatment at our center with a median time of 40 months (IQR 17-62 months) between first and second injury. The majority of recidivists (83.3%) were victims of gun violence whereas the distribution between assault and firearm in the non recidivists was more even at 51 and 49%, respectively (p 0.001). Eighteen (60.0%) of the recidivist patients had the same mechanism between the first and second injury. In the logistic regression analysis, Black race and firearm injury were associated with greater than 3-fold higher likelihood of repeat injury compared to white race after adjusting for age, sex, insurance, and child opportunity index.We found that survivors of firearm injuries and assault comprise a vulnerable patient cohort at risk for repeat injury, and Black race is an independent predictor of repeat injury owning to IPV. These findings provide guidance for developing violence prevention programs.Retrospective Comparative Study LEVEL OF EVIDENCE: Level III.

BackgroundOlder patients compose approximately 30% of trauma patients treated in the USA but make up nearly 50% of deaths from trauma. To help standardize and elevate care of these patients, the American College of Surgeons (ACS) Trauma Quality Improvement Program’s best practice guidelines for geriatric trauma management was published in 2013 and that for palliative care was published in 2017. Here, we discuss how palliative care and geriatrics quality metrics can be tracked and used for performance improvement and leveraged as a strength for trauma verification.MethodsWe discuss the viewpoint of the ACS Verification, Review, and Consultation and three case studies, with practical tips and takeaways, of how these measures have been implemented at different institutions.ResultsWe describe the use of (1) targeted educational initiatives, (2) development of a consultation tool based on institutional resources, and (3) application of a nurse-led frailty screen.DiscussionSpecialized care and attention to these vulnerable populations is recommended, but the implementation of these programs can take many shapes.Level of evidence V

There is growing interest in, and need for, integrating palliative care (PC) into the care of patients undergoing emergency surgery and those with traumatic injury. Thus, PC consults for these populations will likely grow in the coming years. Understanding the nuances and unique characteristics of these two acutely ill populations will improve the care that PC clinicians can provide. Using a modified Delphi technique, this article offers 10 tips that experts in the field, based on their broad clinical experience, believe PC clinicians should know about the care of trauma and emergency surgery patients.

BackgroundAngioembolization has been the gold standard for management of pelvic arterial bleeding, but applicability has been limited by delays in access at many trauma centers. We hypothesized that a quality improvement program to reduce time to start of angiography would be associated with lower in-hospital mortality in patients with pelvic fractures and shock.MethodsRetrospective study of adults with a pelvic fracture and vital signs consistent with shock admitted to a level I trauma center after the initiation of a quality improvement project to reduce the time to angioembolization (2012 to 2016). Time from admission to procedure start for hemorrhage control was examined based on destination and time of day. In-hospital mortality was the primary outcome and was compared with US benchmarks in the literature.ResultsThe study group included 424 patients with a mean Injury Severity Score of 41±14. Of these, 212 (50%) responded to resuscitation and were admitted to the intensive care unit; 143 (34%) patients went directly to interventional radiology (IR) with a median time to start of angiography of 86 minutes (IQR 66 to 116); and 69 (16%) patients went directly to the OR with a median time to start of operation of 52 minutes (IQR 37 to 73). There were no significant differences in time to procedures based on time of day or transfer status. In-hospital mortality for patients in shock on admission was 15%.DiscussionPatients with pelvic fracture and hemorrhagic shock, with a median time to angioembolization of Study typeCase series.Level of evidenceIV.

The aim of this study was to examine the risk of delirium in geriatric trauma patients with rib fractures treated with systemic opioids compared with those treated with regional analgesia (RA).Delirium is a modifiable complication associated with increased morbidity and mortality. RA may reduce the need for opioid medications, which are associated with delirium in older adults.Cohort study of patients ≥65 years admitted to a regional trauma center from 2011 to 2016. Inclusion factors were ≥ 3 rib fractures, blunt trauma mechanism, and admission to intensive care unit (ICU). Exclusion criteria included head AIS ≥3, spine AIS ≥3, dementia, and death within 24 hours. The primary outcome was delirium positive ICU days, defined using the CAM-ICU assessment. Delirium incident rate ratios (IRRs) and 95% confidence intervals (95% CIs) were estimated using generalized linear mixed models with Poisson distribution and robust standard errors.Of the 144 patients included in the study, 27 (19%) received Acute Pain Service consultation and RA and 117 (81%) received opioid-based systemic analgesia. Patients with RA had more severe chest injury than those without. The risk of delirium decreased by 24% per day per patient with use of RA (IRR 0.76, 95% CI 0.61 to 0.96). Individual opioid use, as measured in daily morphine equivalents (MEDs), was significantly reduced after initiation of RA (mean difference -7.62, 95% CI -14.4 to -0.81).Although use of RA techniques in geriatric trauma patients with multiple rib fractures was associated with higher MED, opioid use decreased after RA initiation and Acute Pain Service consultation, and the risk of delirium was lower.

Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival.Retrospective cohort of trauma patients.Single center, level 1 trauma center.Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4.None.Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33-65 yr) and Injury Severity Score was 19 (11-29). Median respiratory failure duration was 3 days (2-6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9-9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality.Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.

Patients with critical illness or injury deserve excellent symptom management, psychosocial support, and expert guidance in decision-making. Palliative care addresses the needs of patients and families at all stages of serious illness, including at the end of life or alongside life-prolonging treatments. All physicians should be comfortable providing primary palliative care to critically ill patients and engaging in shared decision-making. Surgeons can use structured communication tools to conduct patient-centered goals of care discussions and to facilitate provision of treatment recommendations that align with patient values. Specialized palliative care teams can support surgical teams in delivering high-quality care by addressing potentially unfamiliar issues such as existential suffering, spiritual unrest, and challenging family dynamics. Surgeons have a responsibility to prioritize patient autonomy within the context of serious illness and to ensure avoidance of unwanted burdensome treatments at the end of life.

The benefits of palliative care for critically ill patients are well recognized, yet acceptance into surgical culture is lagging. With the increasing proportion of geriatric trauma patients, integration of palliative medicine within daily intensive care services to facilitate goal-concordant care is imperative.Misconceptions of palliative medicine as it applies to trauma patients linger among trauma surgeons and many continue to practice without routine consultation of a palliative care service. Aggressive end-of-life care does not correlate with an improved family perception of medical care received near death. Additionally, elderly patients near the end of life often prefer palliative treatments over life-extending therapy, and their treatment preferences are often not achieved. A new geriatric-specific prognosis calculator estimates the risk of mortality after trauma, which is useful in starting goals of care discussions with older patients and their families.Shifting our quality focus from 30-day mortality rates to measurements of symptom control and achievement of patient treatment preferences will prioritize patient beneficence and autonomy. Ownership of surgical palliative care as a service provided by acute care surgeons will ensure that our patients with incurable injury and illness will receive optimal patient-centered care.

A new family of materials has been developed to serve as a wet-developable bottom antireflective coating (D-BARC) for patterning levels that have a strong need to avoid dry-etch processes for BARC-open steps. Such include some implant levels, where dry-etch introduces surface damage that consequently affects the final electrical performance of a device. Other levels that might benefit from all-wet patterning are those using special substrates such as high-k metal-gate (HKMG) levels. Our design of D-BARC materials combines the unique properties of traditional BARC as well as those of a photoresist to deliver a D-BARC solution that is photoimageable in nature. It was found that isotropically developable (i.e., non-imageable) D-BARCs do not provide viable solutions that satisfy the resolution requirements of the current 32 nm technology node and provide the extendibility to future nodes. The optical properties of the D-BARC material are critical for reflectivity control but high optical density can negatively impact the imaging performance of the material. Therefore a balance is needed where the D-BARC is co-optimized with the photoresist as a system, achieves good reflectivity control, residue-free imaging and process gains.

In 1929 Rabindranath Tagore came to Vancouver to address a conference of the National Council of Education of Canada. This article analyzes his reception as reported in the news media, but primarily examines the educational priorities he chose to elaborate. One major theme that he emphasized was ‘freedom’ in education: physical, mental, spiritual, and moral freedom, and freedom from racial and national prejudice. In particular he stressed the role of leisure in education and human life at large, in contrast to relentless competition for material advantage. He urged that imagination and creativity, especially artistic creativity, be nurtured, reflecting his own experience of growing up in a remarkably creative Bengali Indian family.

Background Thoracostomy tube (TT) for drainage of hemopneumothorax is the most common intervention in thoracic trauma. Postpull pneumothorax or effusion (PPP/PPE) is common after removal of a TT. The natural history of PPP/PPE after discharge has not been described. This study evaluates the outcomes and management of PPP/PPE after discharge. Methods Trauma patients with TT placed from July 1, 2008, to June 30, 2013, were identified from an administrative database and trauma registry. PPP/PPE was defined as the presence of air or fluid in the chest on a postpull imaging. The electronic medical record and final radiology interpretation were reviewed to confirm PPP/PPE during index admission and at discharge. Clinical follow-up and imaging were reviewed for the presence of persistent PPP/PPE. Interventions directed toward PPP/PPE and readmissions were recorded for patients with and without a PPP/PPE. Multivariate logistic regression was performed to identify factors for chest-related readmission. Results Seven hundred ten patients surviving to discharge had a TT placed during the study time frame. Of the 151 patients (21.3%) with documented PPP/PPE on discharge, 115 patients had follow-up data available. Outpatient imaging was obtained in 35 patients, with persistent PPP/PPE noted in 16 patients (45.7%). Six patients (4%) with PPP/PPE at discharge required reintervention. Patients without documented PPP/PPE at discharge had a lower readmission rate (0.7% vs. 6.6%, p = 0.02). Multivariate logistic regression noted the presence of persistent PPP/PPE at follow-up (p = 0.001) to be associated with readmission. Conclusion PPP/PPE is a common occurrence following removal of a TT. While patients discharged with PPP/PPE have a statistically higher reintervention rate, the absolute value remains low. This should be considered when treating clinically stable, asymptomatic PPP/PPE. Level of evidence Epidemiologic study, level IV.

This analysis of the Global Terrorism Database evaluates differences in the use of firearms in terrorist attacks between the United States, Canada, Europe, Australia, and New Zealand.

In the previous paper we discussed the relationship between blob defect count and the receding angle of a resist surface after development with an alkaline developer solution. This paper summarizes additional test results from our continued efforts in developing next generation embedded barrier layer (EBL) materials that render a resist film with even higher receding angle to further facilitate high speed and high acceleration scanning. How to reach a higher receding angle without sacrificing a low post development receding angle is also discussed in this paper. The ability for an EBL material to switch from a high receding angle to a receding angle of lower than 20° upon development is considered a very important attribute of an EBL, which is the key to reduce blob defect count by ensuring good dynamic wetting of a resist surface to DI water during a post development rinsing step. Resist formulations with different receding angles were studied for lithography performance and defectivity under different process conditions with varying wet processes. Both good lithography performance and low defectivity were obtained for contact hole resists including those with a surface receding angle of 78°.

Herein, we investigate the dissolution behavior of 193-nm chemically amplified resist in different organic solvents at a mechanistic level. We previously reported the effect of solvent developers on the negative tone development (NTD) process in both dry and immersion lithography, and demonstrated various resist performance parameters such as photospeed, critical dimension uniformity, and dissolution rate contrast are strongly affected by chemical nature of the organic developer. We further pursued the investigation by examining the dependence of resist dissolution behavior on their solubility properties using Hansen Solubility Parameter (HSP). The effects of monomer structure, and resist composition, and the effects of different developer chemistry on dissolution behaviors were evaluated by using laser interferometry and quartz crystal microbalance. We have found that dissolution behaviors of methacrylate based resists are significantly different in different organic solvent developers such as OSDTM-1000 Developer* and n-butyl acetate (nBA), affecting their resist performance. This study reveals that understanding the resist dissolution behavior helps to design robust NTD materials for higher resolution imaging.

OBJECTIVE To judge how reliably patients perform capillary blood glucose testing over time with recurrent practice at home and to assess if a clinic glucose meter is an acceptable alternative to the clinical laboratory for monitoring patient performance. RESEARCH DESIGN AND METHODS We compared capillary blood glucose readings obtained by patients with their own equipment and the venous blood glucose determinations by the clinical laboratory at three biweekly visits during the initial phase in 40 subjects attending the diabetes clinic at the Veterans' Affairs Medical Center in Phoenix, Arizona. We also compared patient-generated readings using their own equipment and the readings obtained by the clinic glucose meter and strips at five weekly visits during the second phase in 11 subjects who continued further participation. Error grid analysis was used for both comparisons. Capillary blood glucose readings obtained with clinic glucose meter and strips on one hand were correlated with venous blood glucose levels determined by the clinical laboratory. RESULTS During the initial phase, 30 subjects consistently obtained clinically acceptable comparisons (zone A on the error grid, i.e., within 20% of the laboratory value) or improved over time, 9 subjects showed deterioration, and 1 subject failed to obtain zone A results on any of the visits. Three subjects who had consistently obtained zone A results during the initial phase maintained their performance, whereas eight subjects who had failed to achieve zone A values by the end of the initial phase gradually improved and ultimately achieved zone A values by the end of the study. A highly significant correlation was noted between clinic meter readings and laboratory values (r = 0.93, P < 0.00001). CONCLUSIONS Clinically acceptable user proficiency in capillary blood glucose testing can be maintained in most subjects, with recurrent intensive education during follow-up clinic visits. Therefore, we recommend that these comparisons be performed and patient's technique be observed at each visit to monitor their performance. The clinic glucose meter is a suitable alternative to a clinical laboratory for user proficiency checks.

When patterning critical layers at hyper NA, a multilayer antireflectant system is required in order to control complex reflectivity resulting from various incident angles. Multilayer antireflectants typically consist of an organic antireflectant and inorganic substrates. However, there are still some applications which need a single organic antireflectant over high reflective substrates. A 2P2E application in double patterning is one of them. Even though the pitch for double patterning is relatively loose, the reflectivity control is still challenging in terms of profiles and overall process window. The optical constants and thickness of antireflectants should be well optimized depending on applications. We have investigated several organic antireflectants for a single antireflectant over high reflective substrates. The organic films differ in terms of n, k, thickness to cover both the 1st minimum and the 2nd minimum applications. The overall patterning performance including profiles and process window has been evaluated. ASML 1900i was used to perform lithography. Simulation was performed using ProlithTM software.

Purpose: Bcl-xL overexpression is common in head and neck squamous cell carcinomas (HNSCC) and correlates with resistance to chemotherapy. Thus, a nonpeptidic, cell-permeable small molecule that mimics the BH3 domain of proapoptotic proteins may inhibit Bcl-xL function and have therapeutic potential for HNSCC by overcoming drug-resistance. (−)-Gossypol, the levorotatory isomer of a natural product isolated from cottonseeds and roots, was recently discovered to bind to the BH3 binding groove of Bcl-xL and Bcl-2. Experimental Design: We investigated the in vitro effects of (−)-gossypol on HNSCC cell lines as well as on fibroblast and keratinocyte cultures by using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) cell survival assays and assessed the results with respect to Bcl-2 family protein expression. Results: We observed dose-dependent growth inhibition of 10 HNSCC cell lines at biologically achievable doses (2.5–10 μmol/L). (−)-Gossypol doses required to inhibit the growth of human fibroblast cell lines by 50% were 2- to 10-fold higher than for HNSCC cell lines. To inhibit human oral keratinocyte growth by 50%, (−)-gossypol concentrations were 2-to 3-fold higher than for HNSCC cell lines. Conclusions: There is a direct correlation between Bcl-xL-to-Bcl-xS ratios and sensitivity to (−)-gossypol. This agent induced apoptosis in a much higher proportion of cells with wild-type p53. Importantly, cell lines resistant to cisplatin were very sensitive to (−)-gossypol. These results demonstrate that (−)-gossypol has potent antitumor activity in HNSCC in vitro. This agent may be developed as a novel therapeutic agent for HNSCC, either alone or in combination with existing chemotherapeutic agents.

We present experimental results for the transmission T, haze H, sheet resistance Rs, and its spatial fluctuations ΔRs for silver nanowire films. Mie light scattering theory of nanowires is developed to predict both T and H as a function of diameter D of wires and the surface fraction ϕs covered by the wires. Percolation theory is used to derive an equation for Rs in terms of D, the aspect ratio of wires D/L and ϕs. The critical exponent t for percolation of Rs is found to be 1.23 in close agreement with theoretical results for 2D random resistive networks (t = 1.3). These equations show the importance of both the distributions of diameter ⟨D⟩ and aspect ratio of wires ⟨D⟩⟨L⟩/⟨L2⟩ to predict the optical and electrical properties. Spatial fluctuations ΔRs/Rs can also be significant in these films and be greater than 10% as ϕs approaches the critical percolation concentration ϕc. We show that the calculated T versus Rs and H versus Rs curves are in good agreement with the experimental data. We propose figures of merit for percolating nanowire films in terms of high T, low H, and low Rs to order the quality of films for touch screen applications. The results show that D 5 μm are needed to achieve low haze H 90%, together with low Rs ∼ 100 Ω/sq for touch screen applications. Finally, we present experimental and theoretical results of the real and imaginary refractive indices of AgNW/polymer nanocomposites, and find that the Van De Hulst model is more accurate than the Maxwell Garnett models.

In a preferential looking experiment, identical patterns (vertical stripes) were presented to both eyes on one of two screens while orthogonal patterns (vertical stripes in one eye and horizontal stripes in the other) were presented on the other screen. Most infants younger than 3.5 months of age originally showed a preference for the dichoptic (interocularly orthogonal) pattern. At an average age of 3.5 months, however, they showed a sudden shift of preference from this pattern to the interocularly identical pattern. The full shift from a preference for one stimulus to the other (both statistically significant) occurred within a few weeks in most cases. The onset age of the shift in preference agreed with the onset age of fusion-rivalry discrimination found in a previous study (Birch et al., 1985). The original preference for the bincularly orthogonal patterns may be interpreted as a preference for a grid (interocularly emergent intersections) over a grating, judging from results of two control experiments. These data suggest that the pre-stereoptic system non-selectively combines information from the two eyes without regard to edge orientation because it loses eye-of-origin information at a relatively early stage of binocular visual processing. Thus, the pre-stereoptic system does not have the capability of interocular suppression. The theoretical and clinical significance of the new findings are discussed along with a neuronal model of cortical development of ocular segregation and binocular pathways.

SYNOPSIS. Cryoprotectants were tested in both complex and semidefined media for the trypanosomatid Crithidia fasciculata. Near log-phase or end-of-log-phase cultures were frozen for 24–48 hr at ∼ -20 C, then warmed in air to room temperature. Immediate motility was correlated with viability. The best protectant of the 83 tested was glycerol at ∼ 10% (w/v). Survival without cryoprotectant was rare. Outstanding cryoprotectants (perhaps also useful solvents for drugs poorly soluble in water) were: ethylene glycol; 2,2′-dioxyethanol (diethylene glycol); 1,2,4-butanetriol; 1,4-cyclohexanediol; dimethylsulfoxide; propylene glycol; and N-acetylethanolamine. Several sugars were active, e.g., D-arabinose, sucrose, and sorbitol. Trypanosomes tolerated cryoprotectants much less; tolerance was better in growth media than in suspension media. Trypanosoma gambiense was grown in blood-enriched media + 2-2.5% glycerol, suspended in 20% (w/v) glycerol. then frozen; this permitted 3-week survival. T. conorhini survived 4 weeks after growth in media containing glycerol 2.5%+ ethylene glycol 4%+ rutin 1.0 mg per 100 ml.