Plastic Forming of Metals at the Nanoscale: Interdiffusion-Induced Bending of Bimetallic Nanowhiskers.

Controlled plastic forming of nanoscale metallic objects by applying mechanical load is a challenge, since defect-free nanocrystals usually yield at near theoretical shear strength, followed by stochastic dislocation avalanches that lead to catastrophic failure or irregular, uncontrolled shapes. Herein, instead of mechanical load, we utilize chemical stress from imbalanced interdiffusion to manipulate the shape of nanowhiskers. Bimetallic Au-Fe nanowhiskers with an ultrahigh bending strength were synthesized employing the molecular beam epitaxy technique. The one-sided Fe coating on the defect-free, single-crystalline Au nanowhisker exhibited both single- and polycrystalline regions. Annealing the bimetallic nanowhiskers at elevated temperatures led to gradual change of curvature and irreversible bending. At low homological temperatures at which grain boundary diffusion is a dominant mode of mass transport this irreversible bending was attributed to the grain boundary Kirkendall effect during the diffusion of Au along the grain boundaries in the Fe layer. At higher temperatures and longer annealing times, the bending was dominated by intensive bulk diffusion of Fe into the Au nanowhisker, accompanied by a significant migration of the Au-Fe interphase boundary toward the Fe layers. The irreversible bending was caused by the concentration dependence of the lattice parameter of the Au(Fe) alloy and by the volume effect associated with the interphase boundary migration. The results of this study demonstrate a high potential of chemical interdiffusion in the controlled plastic forming of ultrastrong metal nanostructures. By design of the thickness, microstructure, and composition of the coating as well as the parameters of heat treatment, bimetallic nanowhiskers can be bent in a controlled manner.

When Hiring New Trauma and Surgical Critical Care Fellowship Graduates, What Qualities Are Most Desirable? A Survey of Trauma Directors and Trauma Program Administrators.

A general surgeon shortage exists and fewer surgical residents specialize in trauma and surgical critical care (TSCC). We conducted a survey of trauma directors and administrators to determine what qualities are most desirable when hiring new TSCC fellowship graduates. METHODS: The survey, entitled "A Survey of Directors of Trauma on Hiring New Attending Trauma Surgeons," was submitted to the Eastern Association for the Surgery of Trauma (EAST) and distributed to the association members in January 2016. Categorical data were summarized using frequency counts and percentages. Comparisons of responses were analyzed using the chi-squared or Fisher's exact test. Statistical significance was denoted by P < 0.05. RESULTS: A total of 317 respondents from 1364 submitted surveys presented a response rate of 23.2 per cent. Of these respondents, 85.8 per cent (n = 272) decide whether or not a new trauma surgeon is hired and 33.7 per cent were trauma directors. In all, 82.9 per cent work at academic centers and have an Accreditation Council for Graduate Medical Education-approved general surgery residency and 58.4 per cent have an Accreditation Council for Graduate Medical Education-approved surgical critical care or acute care surgery fellowship. In total, 72.6 per cent work in American College of Surgeons-verified trauma centers and 45.0 per cent hire new trauma surgeons as needed. Of the 272 respondents who decide whether or not a new trauma surgeon is hired, the recommendation of the residency and fellowship program director is important. Word of mouth was the most important manner of finding a new hire and the most important qualities of a new TSCC physician were personality and likeability. CONCLUSION: The survey revealed that well-trained, likeable, enthusiastic, and personable TSCC physicians are the best candidates for hire.

A comparison of burn related injuries following the natural disaster Super Storm Hurricane Sandy to the National Burn Repository of the American Burn Association.

BACKGROUND: Burn related injuries from natural disasters are not well described and natural disasters are not identified as an etiology of burn injury in the National Burn Repository (NBR) of the American Burn Association. The natural disaster Super Storm Hurricane Sandy had devastating effects. Our goal was to detail the burn related injuries following this natural disaster and to compare the data to the NBR. METHODS: This was a retrospective chart review of thirty four patients who sustained burn related injuries following Super Storm Hurricane Sandy (SSHS) and were managed at Staten Island University Hospital Burn Center. Institutional Review Board approval was obtained. Data variables included age, gender, race, past medical history (PMHx), burn type, percentage total body surface area (%TBSA), hospital length of stay (HLOS), and mortality. We compared data from SSHS to the 2003-2013 NBR. Categorical data were summarized using frequency counts, percentages and Clopper-Pearson 95 % confidence interval for proportion. Continuous outcome data were summarized by descriptive statistics. Data analyses performed with SAS® System Version 9.3 (SAS Institute Inc., Cary, NC) and p < 0.05 was significant. RESULTS: In the SSHS group, average age was 36 + 24 years, range 1-80 years, and 44.1 % were males (15/34, 95 % CI: 27.2 - 62.1). Caucasians comprised 58.8 %, (20/34, 95 % CI: 40.7, 75.4) and 73.5 % had no PMHx (25/34, 95 % CI: 55.6, 87.1). The most common burn type was scald, 55.9 %, (19/34, 95 % CI: 37.9, 72.8) and %TBSA ranged 1 %-47 %, average of 7 % + 12 %. The average HLOS was 13 + 26 days, range of 1-113 days. Mortality was 2.9 % (1/34, 95 % CI: 0.07-15). In comparison, the NBR reported an average age of 32 years and 69 % were males. Caucasians comprised 59.1 %. The most common burn type was flame, 43.2 % and the %TBSA ranged 1 %-9.9 %. HLOS ranged 8.4-10.2 days and mortality was 3.4 %. CONCLUSION: We conclude that burn related injuries following a natural disaster differ as compared to those most commonly reported in the NBR.

Implementation of a Trauma Service Activation and Admission Policy for Very Elderly Trauma Patients: Impact on Hospital Efficiency and Patient Outcomes.

Very elderly trauma patients (VETs) were routinely admitted to nonsurgical services at our institution; therefore, a trauma service activation and admission policy was implemented. Our goal was to determine policy success and impact on efficiency and outcomes. VETs, defined as trauma patients aged >89 years, admitted before and after policy implementation were reviewed. Demographics included age, gender, Injury Severity Score, Glasgow Coma Score, admission diagnosis, mechanism of injury, admission service, and comorbidities. Efficiency included intensive care unit length of stay (ICU-LOS) and hospital length of stay (H-LOS). Outcomes included complications, discharge disposition, and mortality. Statistical analysis included Chi square, Fisher's exact test, and regression analyses, significance denoted by P < 0.05. 375 VETs were investigated. Demographic analysis revealed differences in Injury Severity Score (9.4 + 5.4 vs 7.2 + 4.0, P < 0.001), coronary artery disease (2.1% vs 38.2%, P < 0.001), neurologic disease (7.4% vs 28.24%, P < 0.001), and intracranial hemorrhage (15.6% vs 6.1%, P = 0.01). The most common mechanism of injury and admission diagnosis was fall and femur fracture. VETs admitted to the trauma service increased from 28.3 per cent to 40.5 per cent, P = 0.02. Efficiency analysis revealed differences in ICU-LOS (4.0 + 4.2 days vs 0.7 + 1.3 days, P < 0.001) and H-LOS (7.3 + 4.9 days vs 6.3 + 5.5 days, P = 0.005). Outcomes analysis revealed differences in pneumonia (0.8% vs 5.3%, P = 0.01), acute respiratory distress syndrome (0% vs 2.3%, P = 0.04), discharge to skilled nursing facility (75.8% vs 57.3%, P < 0.001), but no difference in mortality. Regression analyses revealed that trauma service admission was associated with decreased ICU-LOS and H-LOS. The trauma service activation and admission policy for VETs led to improved hospital efficiency.

Implementation of an Acute Care Surgery Service in a Community Hospital: Impact on Hospital Efficiency and Patient Outcomes.

A service led by acute care surgeons managing trauma, critically ill surgical, and emergency general surgery patients via an acute care surgery model of patient care improves hospital efficiency and patient outcomes at university-affiliated hospitals and American College of Surgeons-verified trauma centers. Our goal was to determine whether an acute care surgeon led service, entitled the Surgical Trauma and Acute Resuscitative Service (STARS) that implemented an acute care surgery model of patient care, could improve hospital efficiency and patient outcomes at a community hospital. A total of 492 patient charts were reviewed, which included 230 before the implementation of the STARS [pre-STARS (control)] and 262 after the implementation of the STARS [post-STARS (study)]. Demographics included age, gender, Acute Physiology and Chronic Health Evaluation 2 score, and medical comorbidities. Efficiency data included length of stay in emergency department (ED-LOS), length of stay in surgical intensive care unit (SICU-LOS), and length of stay in hospital (H-LOS), and total in hospital charges. Average age was 64.1 + 16.4 years, 255 males (51.83%) and 237 females (48.17%). Average Acute Physiology and Chronic Health Evaluation 2 score was 11.9 + 5.8. No significant differences in demographics were observed. Average decreases in ED-LOS (9.7 + 9.6 hours, pre-STARS versus 6.6 + 4.5 hours, post-STARS), SICU-LOS (5.3 + 9.6 days, pre-STARS versus 3.5 + 4.8 days, post-STARS), H-LOS (12.4 + 12.7 days, pre-STARS versus 11.4 + 11.3 days, post-STARS), and total in hospital charges ($419,602.6 + $519,523.0 pre-STARS to $374,816.7 + $411,935.8 post-STARS) post-STARS. Regression analysis revealed decreased ED-LOS-2.9 hours [P = 0.17; 95% confidence interval (CI): -7.0, 1.2], SICU-LOS-6.3 days (P < 0.001; 95% CI: -9.3, -3.2), H-LOS-7.6 days (P = 0.001; 95% CI: -12.1, -3.1), and 3.4 times greater odds of survival (P = 0.04; 95% CI: 1.1, 10.7) post-STARS. In conclusion, implementation of the STARS improved hospital efficiency and patient outcomes at a community hospital.

Hyperammonemia as a Marker of Subclinical Seizures After Traumatic Cardiac Arrest.

This report details the presence of hyperammonemia in a patient who sustained cardiac arrest after a traumatic amputation. Serum ammonia levels may rise due to numerous etiologies; however, few reports detail its usefulness in diagnosing subclinical seizures. In this case, we successfully utilized persistently elevated serum ammonia levels as a marker of subclinical seizures in a patient who sustained traumatic cardiac arrest.

Improved removal rates for retrievable inferior vena cava filters with the use of a 'filter registry'.

The American Association for the Surgery of Trauma challenged the trauma community to improve a 22 per cent average removal rate for retrievable inferior vena cava filters (r-IVCFs). Since 2006, we maintained a "filter registry" documenting all IVCFs placed in trauma patients. Our goal was to improve removal rates for r-IVCF. Patients receiving an IVCF before implementation of filter registry, 2003-2005, comprised the control group. Patients receiving an IVCF after implementation of filter registry, 2006-2009, comprised the study group. Data obtained included age, gender, Injury Severity Score (ISS), length of stay (LOS), mortality, filter inserted, placement indication, removal rates, and reasons why removal did not occur. Fisher exact test and chi square were used for nominal variables. Stepwise logistic regression analysis was used to define predictors of removing and not removing an IVCF. Three hundred seven patients received an IVCF, 142 preregistry and 165 postregistry. No significant difference existed between groups in age, gender, ISS, placement indication, or mortality. A significant difference existed between groups in LOS and presence of deep vein thrombosis (DVT) and pulmonary embolism. A total of 98.2 per cent of postregistry patients received a Günther Tulip filter and all retrievals were performed by Interventional Radiology. Retrieval rates improved, 15.5 to 31.5 per cent post registry (P < 0.001). No differences existed in lost to follow-up (LTF) between groups. Univariate analysis identified age, IVC clot, DVT, and LTF as predictors for not removing a filter. Stepwise logistic regression revealed the filter registry independently predicts the removal of an r-IVCF. A filter registry is effective in improving rates of removal for r-IVCFs.

Massive postpartum hemorrhage: recombinant factor VIIa use is safe but not effective.

OBJECTIVE: Postpartum hemorrhage is a leading cause of maternal mortality. Massive transfusion in obstetric patients is rare. Recombinant Factor VIIa (rFVIIa) use in trauma patients with massive transfusion is efficacious. Our goal was to evaluate the safety and efficacy of rFVIIa use in obstetric patients with massive postpartum hemorrhage (MPH). METHODS: Patients records with MPH from 2003 to 2006 were reviewed. Data collected were demographics, APACHE II scores, International Normalized Ratio (INR), fibrinogen level, blood product administration, rates of pulmonary embolism (PE), deep vein thrombosis (DVT), myocardial infarction (MI), hysterectomy, and mortality. Continuous variables within groups were analyzed with paired t-test, and independent t-test between groups. Categorical variables were compared via chi2 or Fishers Exact test and significance was denoted by a p < or = 0.05. RESULTS: Twenty-seven patients with MPH were investigated, eight received rFVIIa (study group) and 19 did not (control group). All patients received a massive transfusion, six units of packed red blood cells (pRBCs), via a massive transfusion protocol. The study group's mean APACHE II score 25.8 +/- 8.5, predicted mortality of 56.2 percent, was higher than control, p = 0.009. An increase in transfused units of cryoprecipitate, p < 0.001, pRBCs, p = 0.004, decrease in INR, p < 0.001, and length of stay in the high risk obstetrical unit, p = 0.019, existed in the study group. Hysterectomy was required in 85.7 percent of the study group. No patients developed a DVT, PE, or MI and all survived. CONCLUSIONS: Recombinant Factor VIIa use in MPH is safe, improves coagulopathy, was not effective in decreasing blood product transfusion requirements, and may contribute to an improved predicted mortality.

Inframesocolic Abdominal Aortic Injury and Lumbar Vertebral Body Fracture Secondary to Hyperextension with Blunt Trauma.

This case study describes an abdominal aortic injury and lumbar vertebral body fracture after blunt trauma. Abdominal aortic pseudoaneurysm is a rare complication of blunt abdominal trauma. Recent data reveal seven other reports in the literature. We describe a case of an inframesocolic abdominal aortic injury and lumbar vertebral body fracture from blunt trauma in a 16-year-old male after a hyperextension injury while body board surfing.

A multidisciplinary approach to adverse drug events in pediatric trauma patients in an adult trauma center.

BACKGROUND: Adult trauma centers are major providers of medical management for pediatric trauma patients in the United States. Medication administration in this patient population is complex and fraught with potential error. METHODS: We designed a multidisciplinary team consisting of a pediatric hospitalist, pediatric care coordinator, pediatric nurse, pharmacist, and the trauma service to manage pediatric trauma patients from admission until discharge. The team mandated collective decision making for medication dosing and administration, weight documentation, and implemented a medication error reporting system. Our goal was to derive and implement a multidisciplinary practice and education-based model of pediatric trauma patient care to identify and decrease adverse medication events. RESULTS: Two hundred fifty-nine pediatric trauma patients were studied from January 1, 2003 to December 31, 2004, 125 pre-team implementation (control group) and 134 post-team implementation (study group). There were no significant differences in age, sex, mechanism of injury, injury severity score, or hospital length of stay between groups. There were significant reductions in number of medication prescribing errors (25 vs 15 errors; P = 0.05) and number of medication administration errors (19 vs 9 errors; P = 0.05) in the study group. Weight documentation improved significantly in the study group (90% vs 81%; P = 0.048). CONCLUSIONS: Instituting a multidisciplinary approach to pediatric trauma patient care is practical and can significantly decrease adverse medication events.

Are there still selected applications for resuscitative thoracotomy in the emergency department after blunt trauma?

Resuscitative thoracotomy has an integral role for open cardiac massage and can be preformed after penetrating trauma with cardiovascular collapse. Its role in blunt trauma is questionable. We performed a retrospective chart review of patients who underwent an emergency department (ED) resuscitative thoracotomy. The goal was to define the role of resuscitative thoracotomy in blunt trauma at our institution. Forty-two patients underwent a resuscitative thoracotomy, 26 penetrating trauma (61.9%) and 16 blunt trauma (38.1%). Of these (n=16), there were 13 thoracic injuries (81.2%), eight cardiac injuries (50.0%), seven isolated abdominal injuries (43.7%) and 13 multiple (two or more locations) injuries (81.2%). Therapeutic interventions included pericardiotomy in 14 (87.5%), cardiac repair in three (18.7%), and pulmonary laceration repair in two (12.5%). All study patients had signs of life in the field; 13 maintained signs of life in transit (81.3%) and 12 upon admission to ED (75%). Average time from field to ED was 10.72 +/- 5.74 minutes. There were two survivors after blunt trauma (12.5%) and one after penetrating trauma (3.8%). Signs of life in the field and a cardiac repair were independent predictors of survival after blunt trauma (p=0.001 and p=0.004 respectively). We conclude that in select trauma patients after blunt injury with cardiovascular collapse, resuscitative thoracotomy still has a vital role.

A protocol for the rapid normalization of INR in trauma patients with intracranial hemorrhage on prescribed warfarin therapy.

Trauma patients on prescribed warfarin therapy sustaining intracranial hemorrhage can be difficult to manage. Rapid normalization of coagulopathy is imperative to operative intervention and may affect outcomes. To identify and expedite warfarin reversal, we designed a protocol to administer a prothrombin complex concentrate. A Proplex T protocol was instituted in May 2004. It dictated that trauma patients with an International Normalized Ratio (INR) greater than 1.5, history of prescribed warfarin therapy, and intracranial hemorrhage on CT scan receive a prothrombin complex concentrate for reversal of their coagulopathy. Neither the protocol nor the factor concentrate was validated for use in this subset of trauma patients; therefore, adherence to the protocol and use of the factor concentrate was not mandatory. Patients not administered the prothrombin complex concentrate received vitamin K and fresh-frozen plasma. The protocol resulted in an increased number of patients receiving Proplex T (54.3% vs 35.4%, P = 0.047). Protocol patients had improved times to normalization of INR (331.3 vs 737.8 minutes, P = 0.048), number of patients with reversal of coagulopathy (73.2% vs 50.9%, P = 0.026), and time to operative intervention (222.6 vs 351.3 minutes, P = 0.045) compared with control subjects. There were no differences in intensive care unit (ICU) days, hospital days, or mortality. The Proplex T protocol increased the number of patients who received prothrombin complex concentrate, provided rapid normalization of INR, and improved time to operative intervention.

Hemoptysis secondary to pulmonary artery pseudoaneurysm after necrotizing pneumonia.

This case documents the occurrence of hemoptysis secondary to pulmonary artery pseudoaneurysm in a 19-year-old man who was admitted for hypertriglyceridemic pancreatitis. The pseudoaneurysm derived from a necrotizing pneumonia within the same pulmonary segment. After an extensive workup, the pseudoaneurysm was diagnosed by pulmonary angiography and treated with coil embolization.

Self-assembled lamellar MoS2, SnS2 and SiO2 semiconducting polymer nanocomposites.

Lamellar nanocomposites based on semiconducting polymers incorporated into layered inorganic matrices are prepared by the co-assembly of organic and inorganic precursors. Semiconducting polymer-incorporated silica is prepared by introducing the semiconducting polymers into a tetrahydrofuran (THF)/water homogeneous sol solution containing silica precursor species and a surface-active agent. Semiconducting polymer-incorporated MoS(2) and SnS(2) are prepared by Li intercalation into the inorganic compound, exfoliation and restack in the presence of the semiconducting polymer. All lamellar nanocomposite films are organized in domains aligned parallel to the substrate surface plane. The incorporated polymers maintain their semiconducting properties, as evident from their optical absorption and photoluminescence spectra. The optoelectronic properties of the nanocomposites depend on the properties of both the inorganic host and the incorporated guest polymer as demonstrated by integrating the nanocomposite films into light-emitting diodes. Devices based on polymer-incorporated silica and polymer-incorporated MoS(2) show no diode behaviour and no light emission due to the insulating and metallic properties of the silica and MoS(2) hosts. In contrast, diode performance and electroluminescence are obtained from devices based on semiconducting polymer-incorporated semiconducting SnS(2), demonstrating that judicious selection of the composite components in combination with the optimization of material synthesis conditions allows new hierarchical structures to be tailored for electronic and optoelectronic applications.

Inhibition of energy transfer between conjugated polymer chains in host/guest nanocomposites generates white photo- and electroluminescence.

The generation of white light requires the combination of two or more chromophores that emit simultaneously. The observed color of a mixture of light-emitting molecules, however, originates generally only from the lowest band-gap species because of efficient energy transfer between the chromophores which is difficult to avoid. Here we report on a nanocomposite material designed to yield pure and stable white photo- and electroluminescence. In this material, red, green, and blue emitting conjugated polymers are confined within the galleries of a layered semiconducting host matrix. The host hinders polymer pi-pi interactions which are responsible for the energy transfer between polymer chains, consequently, emission from the three chromophores is observed simultaneously resulting in white photoluminescence. The efficacy of the nanocomposites is demonstrated in simple single-layer white-emitting polymer diodes. The mechanism suggested here for white light generation, supported by extensive luminescence measurements, is in contrast to that previously reported in white-emitting polymer diodes where efficient energy transfer between polymer chains was essential for obtaining white light.

Electrochemical potential tuned solar water splitting.

As a fundamental step towards a clean, renewable source of H2, a novel physical chemical process within molten NaOH in which an external single, small bad gap photosentizer, such as Si, can drive the energetics of water cleavage is demonstrated, and is accomplished by tuning (decreasing) the water splitting electrochemical potential, EH2O, rather than tuning the photosensitizer band gap; this diminished potential is due to (i) a thermodynamic temperature induced decrease of EH2O with increasing temperature, and (ii) a partial recombination of the cleavage products.