Graspable foods and tools elicit similar responses in visual cortex.

The extrastriatal visual cortex is known to exhibit distinct response profiles to complex stimuli of varying ecological importance (e.g. faces, scenes, and tools). Although food is primarily distinguished from other objects by its edibility, not its appearance, recent evidence suggests that there is also food selectivity in human visual cortex. Food is also associated with a common behavior, eating, and food consumption typically also involves the manipulation of food, often with hands. In this context, food items share many properties with tools: they are graspable objects that we manipulate in self-directed and stereotyped forms of action. Thus, food items may be preferentially represented in extrastriatal visual cortex in part because of these shared affordance properties, rather than because they reflect a wholly distinct kind of category. We conducted functional MRI and behavioral experiments to test this hypothesis. We found that graspable food items and tools were judged to be similar in their action-related properties and that the location, magnitude, and patterns of neural responses for images of graspable food items were similar in profile to the responses for tool stimuli. Our findings suggest that food selectivity may reflect the behavioral affordances of food items rather than a distinct form of category selectivity.

Straightforward Synthesis of 2- and 2,8-Substituted Tetracenes.

A simple regiospecific route to otherwise problematic substituted tetracenes is described. The diverse cores (E)-1,2-Ar1 CH2 (HOCH2 )C=C(CH2 OH)I (Ar1 =Ph, 4-MePh, 4-MeOPh, 4-FPh) and (E)-1,2-I(HOCH2 )C=C(CH2 OH)I, accessed from ultra-low cost HOCH2 C≡CCH2 OH at multi-gram scales, allow the synthesis of diol libraries (E)-1,2-Ar1 CH2 (HOCH2 )C=C(CH2 OH)CH2 Ar2 (Ar2 =Ph, 4-MePh, 4-iPrPh, 4-MeOPh, 4-FPh, 4-BrPh, 4-biphenyl, 4-styryl; 14 examples) by efficient Negishi coupling. Copper-catalysed aerobic oxidation cleanly provides dialdehydes (E)-1,2-Ar1 CH2 (CHO)C=C(CHO)CH2 Ar2 , which in many cases undergo titanium(IV) chloride-induced double Bradsher closure, providing a convenient method for the synthesis of regiochemically and analytically pure tetracenes (12 examples). The sequence is typically chromatography-free, scalable, efficient and technically simple to carry out.

Diversification of ortho-Fused Cycloocta-2,5-dien-1-one Cores and Eight- to Six-Ring Conversion by σ Bond C-C Cleavage.

Sequential treatment of 2-C6 H4 Br(CHO) with LiC≡CR(1) (R(1) =SiMe3 , tBu), nBuLi, CuBr⋅SMe2 and HC≡CCHClR(2) [R(2) =Ph, 4-CF3 Ph, 3-CNPh, 4-(MeO2 C)Ph] at -50 °C leads to formation of an intermediate carbanion (Z)-1,2-C6 H4 {CA (=O)C≡CB R(1) }{CH=CH(CH(-) )R(2) } (4). Low temperatures (-50 °C) favour attack at CB leading to kinetic formation of 6,8-bicycles containing non-classical C-carbanion enolates (5). Higher temperatures (-10 °C to ambient) and electron-deficient R(2) favour retro σ-bond C-C cleavage regenerating 4, which subsequently closes on CA providing 6,6-bicyclic alkoxides (6). Computational modelling (CBS-QB3) indicated that both pathways are viable and of similar energies. Reaction of 6 with H(+) gave 1,2-dihydronaphthalen-1-ols, or under dehydrating conditions, 2-aryl-1-alkynylnaphthlenes. Enolates 5 react in situ with: H2 O, D2 O, I2 , allylbromide, S2 Me2 , CO2 and lead to the expected C-E derivatives (E=H, D, I, allyl, SMe, CO2 H) in 49-64 % yield directly from intermediate 5. The parents (E=H; R(1) =SiMe3 , tBu; R(2) =Ph) are versatile starting materials for NaBH4 and Grignard C=O additions, desilylation (when R(1) =SiMe) and oxime formation. The latter allows formation of 6,9-bicyclics via Beckmann rearrangement. The 6,8-ring iodides are suitable Suzuki precursors for Pd-catalysed C-C coupling (81-87 %), whereas the carboxylic acids readily form amides under T3P® conditions (71-95 %).

One-Pot Cannizzaro Cascade Synthesis of ortho-Fused Cycloocta-2,5-dien-1-ones from 2-Bromo(hetero)aryl Aldehydes.

An intramolecular Cannizzaro-type hydride transfer to an in situ prepared allene enables the synthesis of ortho-fused 4-substituted cycloocta-2,5-dien-1-ones with unprecedented technical ease for an eight-ring carboannulation. Various derivatives could be obtained from commercially available (hetero)aryl aldehydes, trimethylsilylacetylene, and simple propargyl chlorides in good yields.

Anionic sigmatropic-electrocyclic-Chugaev cascades: accessing 12-aryl-5-(methylthiocarbonylthio)tetracenes and a related anthra[2,3-b]thiophene.

1,4-Diols resulting from the double addition of ArCCLi (Ar = Ph, substituted phenyl, 2-thienyl) to ortho-C6H4(CHO)2 undergo cascades to tetracenes on simple admixture of LiHDMS, CS2 and MeI. Acene formation proceeds by [3,3]-sigmatropic rearrangement of xanthate anions followed by 6π electrocyclisations. The reactions are terminated by E2 or anionic Chugaev-type eliminations. Structural packing motifs and electronic properties are reported for the tetracenes.

Focused Assessment with Sonography for Trauma (FAST) Exam: Image Acquisition.

Over the past twenty years, the Focused Assessment with Sonography for Trauma (FAST) exam has transformed the care of patients presenting with a combination of trauma (blunt or penetrating) and hypotension. In these hemodynamically unstable trauma patients, the FAST exam permits rapid and noninvasive screening for free pericardial or peritoneal fluid, the latter of which implicates intra-abdominal injury as a likely contributor to the hypotension and justifies emergent abdominal surgical exploration. Further, the abdominal portion of the FAST exam can also be used outside of the trauma setting to screen for free peritoneal fluid in patients who become hemodynamically unstable in any context, including after procedures that may inadvertently injure abdominal organs. These "non-trauma" situations of hemodynamic instability are often triaged by providers from specialties other than emergency medicine or trauma surgery who are not familiar with the FAST exam. Therefore, there is a need to promulgate knowledge about the FAST exam to all clinicians caring for critically ill patients. Toward this end, this article describes FAST exam image acquisition: patient positioning, transducer selection, image optimization, and exam limitations. Since the free fluid is likely to be found in specific anatomic locations that are unique for each canonical FAST exam view, this work centers on the unique image acquisition considerations for each window: subcostal, right upper quadrant, left upper quadrant, and pelvis.

Staff perceptions towards virtual reality-motivated treadmill exercise for care home residents: a qualitative feedback study with key stakeholders and follow-up interview with technology developer.

OBJECTIVES: Health and care resources are under increasing pressure, partly due to the ageing population. Physical activity supports healthy ageing, but motivating exercise is challenging. We aimed to explore staff perceptions towards a virtual reality (VR) omnidirectional treadmill (MOTUS), aimed at increasing physical activity for older adult care home residents. DESIGN: Interactive workshops and qualitative evaluation. SETTINGS: Eight interactive workshops were held at six care homes and two university sites across Cornwall, England, from September to November 2021. PARTICIPANTS: Forty-four staff participated, including care home, supported living, clinical care and compliance managers, carers, activity coordinators, occupational therapists and physiotherapists. INTERVENTIONS: Participants tried the VR treadmill system, followed by focus groups exploring device design, potential usefulness or barriers for care home residents. Focus groups were audio-recorded, transcribed verbatim and thematically analysed. We subsequently conducted a follow-up interview with the technology developer (September 2022) to explore the feedback impact. RESULTS: The analysis produced seven key themes: anticipated benefits, acceptability, concerns of use, concerns of negative effects, suitability/unsuitability, improvements and current design. Participants were generally positive towards VR to motivate care home residents' physical activity and noted several potential benefits (increased exercise, stimulation, social interaction and rehabilitation). Despite the reported potential, staff had safety concerns for frail older residents due to their standing position. Participants suggested design improvements to enhance safety, usability and accessibility. Feedback to the designers resulted in the development of a new seated VR treadmill to address concerns about falls while maintaining motivation to exercise. The follow-up developer interview identified significant value in academia-industry collaboration. CONCLUSION: The use of VR-motivated exercise holds the potential to increase exercise, encourage reminiscence and promote meaningful activity for care home residents. Staff concerns resulted in a redesigned seated treadmill for those too frail to use the standing version. This novel study demonstrates the importance of stakeholder feedback in product design.

Utilizing the Army Physical Fitness Test as a Primary Outcome in Surgical Clinical Research.

Functional data as part of clinical outcomes such as Activities of Daily Living and Quality of Life (QOL) frequently depend on surveys and are thus inherently limited by self-reporting and patient subjectivity. Specifically, the 12-Item Short Form Survey (SF-12), 36-Item Short Form Survey (SF-36), and Carolinas Comfort Scale are validated instruments for assessing medical and surgical QOL outcomes. However, performance-based measures of disability are lacking. We propose the Army Physical Fitness Test (APFT) as a novel clinical measure of function following surgical intervention. We believe that studies using the APFT as a surgical outcome can potentially provide novel, relevant insights that may guide the utilization of specific surgical interventions and that the use of APFT data in surgical research will meet contemporary ethical standards.

Mechanism of injury affects acute coagulopathy of trauma in combat casualties.

BACKGROUND: Recent evidence suggests trauma involving total body tissue damage increases the acute coagulopathy of trauma (ACOT) by various mechanisms, especially in massive transfusion (MT). Our hypothesis was that MT patients injured by explosion will have a higher international normalization ratio (INR) at admission than MT patients injured by gunshot wound (GSW). METHODS: A retrospective review was performed on US military injured in Operation Iraqi Freedom/Operation Enduring Freedom from March 2003 to September 2008, who received MT (≥ 10 red blood cells in 24 hours) and had an INR on admission. Two cohorts were created based on mechanism. Admission vital signs, labs, transfusion, and mortality data were compared. RESULTS: Seven hundred fifty-one MT patients were identified. Four hundred fifty patients had admission INR and were injured by either GSW or explosion. Patients demonstrated similar injury severity scale and Glasgow Coma Scale. Patients injured by explosion presented with higher INR, greater base deficit, and more tachycardic than patients injured by GSW. Transfusion of blood products was similar between both groups. CONCLUSIONS: The primary finding of this study is that patients injured by explosion presented with a higher INR than those injured by GSW, even with similar injury severity scale. In addition, patients injured by explosion presented more tachycardic and with a greater base deficit. These findings support the theory that ACOT is affected by the amount of tissue injured. Further research is needed into the pathophysiology of ACOT because this may impact care of patients with total body tissue damage/hypoxia and improve the treatment of their coagulopathy while minimizing the attendant complications.

Plasma-to-red cell ratio and mechanism of injury in massively transfused combat casualties.

STUDY DESIGN: A retrospective review of 930 combat casualties from March 2003 to September 2009 who received a massive transfusion. Mechanism was categorized as explosion (EXPL) (712), gunshot wound (GSW) (190), and blunt trauma (28). Cohorts were also categorized by fresh frozen plasma (FFP) to red blood cell (RBC) ratio: low, ≤1:1.5 and high, >1:1.5. Patient characteristics and in-hospital mortality rates were compared among groups. Propensity matching was used to control for confounding variables. RESULTS: Cohorts were similar in demographics, admission vital signs, and laboratory values. Median injury severity score was higher in EXPL compared to GSW. High FFP:RBC ratio was associated with improved survival compared to low ratio in the EXPL group (p < 0.01). The GSW group had similar survival in the high and low FFP:RBC ratio groups (p = 0.06). After propensity matching, a high FFP:RBC ratio was associated with improved survival compared to low ratio in both the EXPL (p < 0.01) and GSW groups (p = 0.05). CONCLUSIONS: High FFP:RBC ratios are associated with improved survival in combat casualties regardless of injury mechanism.

Mucormycosis attributed mortality: a seven-year review of surgical and medical management.

INTRODUCTION: Historically, mucormycosis infections have been associated with high mortality. The purpose of this study was to determine the incidence, associated mortality, and management strategies of mucormycosis in a major burn center. METHODS: A retrospective review was performed via obtaining all patients with mucormycosis admitted from January 2003 to November 2009 at our adult burn center was performed obtaining demographic data relevant to fungal burn wound infection or colonization. RESULTS: The incidence of mucormycosis at our facility was 4.9 per 1000 admissions; specifically, 11 military casualties and one civilian were diagnosed with mucormycosis. The median percentage Total Body Surface Area (TBSA) burned, 11 patients, or open wound, one patient, was 60 (IQR, 54.1-80.0), and the incidence of documented inhalation injury was 66.7% (8 of 12). Ten patients had surgical amputations. A median of eight days (IQR, 3.5-74.5) elapsed from diagnosis of mucormycosis until death in the 11 patients who expired. The overall mortality was 92%; however, autopsy attributed mucormycosis mortality was 54.5% (6 of 11) with all six patients having invasive mucormycosis. CONCLUSION: Aggressive surgical intervention should be undertaken for invasive mucormycosis; additionally, implementation of standardized protocols for patients with large soft tissue injuries may mitigate mucormycosis superimposition.

Outcomes after cardiac arrest in an adult burn center.

OBJECTIVE: Adult burn patients who experience in-hospital cardiac arrest (CA) and undergo cardiopulmonary resuscitation (CPR) represent a unique patient population. We believe that they tend to be younger and have the added burden of the burn injury compared to other populations. Our objective was to determine the incidence, causes and outcomes following cardiac arrest (CA) and cardio-pulmonary resuscitation (CPR) within this population. METHODS: We conducted a retrospective review at the US Army Institute of Surgical Research (ISR) burn intensive care unit (BICU). Charts from 1st January 2000 through 31st August 2009 were reviewed for study. Data were collected all on adult burn patients who experienced in-hospital CA and CPR either in the BICU or associated burn operating room. Patients undergoing CPR elsewhere in our burn unit were excluded because we could not validate the time of CA since they are not routinely monitored with real-time rhythm strips. The study population included civilian burn patients from the local catchment area and burn casualties from the conflicts in Iraq and Afghanistan, but patients with do-not-resuscitate (DNR) orders were excluded. RESULTS: We found 57 burn patients who had in-hospital CA and CPR yielding an incidence of one or more in-hospital CA of 34 per 1000 admissions (0.34%). Fourteen of these patients (25%) survived to discharge while 43 (75%) died. The most common initial cardiac rhythm was pulseless electrical activity (50.9%). The most common etiology of CA among burn patients was respiratory failure (49.1%). The most significant variable affecting survival to discharge was duration of CPR (P < 0.01) with no patient surviving more than 7 min of CPR. CONCLUSIONS: CPR in burn patients is sometimes effective, and those patients who survive are likely to have good neurological outcomes. However, prolonged CPR times are unlikely to result in return of spontaneous circulation and may be considered futile. Further, those who experience multiple CA are unlikely to survive to discharge.

Compartment syndrome performance improvement project is associated with increased combat casualty survival.

BACKGROUND: In 2008, we showed that incomplete or delayed extremity fasciotomies were associated with mortality and muscle necrosis in war casualties with limb injury. Subsequently, we developed an education program focused on surgeon knowledge gaps regarding the diagnosis of compartment syndrome and prophylactic fasciotomy. The program included educational alerts, classroom training, video instruction, and a research publication. We compared casualty data before and after the program implementation to determine whether the education altered outcomes. METHODS: Similar to the previous study, a case series was made from combat casualty medical records. Casualties were US military servicemen with fasciotomies performed in Iraq, Afghanistan, or Germany between two periods (periods 1 and 2). RESULTS: In both periods, casualty demographics were similar. Most fasciotomies were performed to the lower leg and forearm. Period 1 had 336 casualties with 643 fasciotomies, whereas Period 2 had 268 casualties with 1,221 fasciotomies (1.9 vs. 4.6 fasciotomies per casualty, respectively; p < 0.0001). The mortality rate decreased in Period 2 (3%, 8 of 268 casualties) from Period 1 (8%, 26 of 336 casualties; p = 0.0125). Muscle excision and major amputation rates were similar in both periods (p > 0.05). Rates of casualties with revision fasciotomy decreased to 8% in Period 2, (22 of 268 casualties) versus 15% in Period 1 (51 of 336 casualties; p = 0.009). CONCLUSION: Combat casualty care following implementation of a fasciotomy education program was associated with improved survival, higher fasciotomy rates, and fewer revisions. Because delayed fasciotomy rates were unchanged, further effort to educate providers may be indicated. LEVEL OF EVIDENCE: Therapeutic study, level IV.

An experience in the management of the open abdomen in severely injured burn patients.

Few descriptions of temporary abdominal closure for planned relaparotomy have been reported in burned patients. The purpose of this study is to describe our experience and outcomes in the management of burned patients with an open abdomen. The authors performed a retrospective review of all admissions to our burn center from March 2003 to June 2008, identifying patients treated by laparotomy with temporary abdominal closure. The authors collected data on patient demographics, indication for laparotomy, methods of temporary and definitive abdominal closure, and outcomes. Of 2,104 patients admitted, 38 underwent a laparotomy with temporary abdominal closure. Their median TBSA was 55%, and the incidence of inhalation injury was 58%. Abdominal compartment syndrome was the most common indication for laparotomy (82%) followed by abdominal trauma (16%). The in-hospital mortality associated with an open abdomen was 68%. Temporary abdominal closure was performed most commonly using negative pressure wound therapy (90%). Fascial closure was performed in 21 patients but was associated with a 38% rate of failure requiring reexploration. Of 12 survivors, fascial closure was achieved in seven patients and five were managed with a planned ventral hernia. Burned patients who necessitate an open abdomen management strategy have a high morbidity and mortality. Fascial closure was associated with a high rate of failure but was successful in a select group of patients. Definitive abdominal closure with a planned ventral hernia was associated with no increased mortality and remains an option when "tension-free" fascial closure cannot be achieved.

Combat readiness for the modern military surgeon: data from a decade of combat operations.

OBJECTIVE: Hundreds of general surgeons from the army, navy, and air force have been deployed during the past 10 years to support combat forces, but little data exist on their preparedness to handle the challenging injuries that they are currently encountering. Our objective was to assess operative and operational experience in theater with the goal of improving combat readiness among surgeons. METHODS: A detailed survey was sent to 246 active duty surgeons from the army, navy, and air force who have been deployed at least once in the past 10 years, requesting information on cases performed, perceptions of efficacy of predeployment training, knowledge deficits, and postdeployment emotional challenges. Survey data were kept confidential and analyzed using standard statistical methods. RESULTS: Of 246 individuals, 137 (56%) responded and 93 (68%) have been deployed two or more times. More than 18,500 operative procedures were reported, with abdominal and soft tissue cases predominating. Many surgeons identified knowledge or practice gaps in predeployment vascular (46%), neurosurgical (29.9%), and orthopedic (28.5%) training. The personal burden of deployment manifested itself with both family (approximately 10% deployment-related divorce rate) and personal (37 surgeons [27%] with two or more symptoms of posttraumatic stress syndrome) stressors. CONCLUSION: These data support modifications of predeployment combat surgical training to include increased exposure to open vascular procedures and curriculum traditionally outside general surgery (neurosurgery and orthopedics). The acute care surgical model may be ideal for the military surgeon preparing for deployment. Further research should be directed toward identifying factors contributing to psychological stress among military medics.

Acidogenic potential of "sugar-free" cough drops.

A patient presented with extensive marginal ditching around restorations recently placed during whole-mouth rehabilitation. The patient was not xerostomic and was otherwise normal except for the self-reported excessive use of "sugar-free" cough drops sweetened with sorbitol and Isomalt® (an equimolar mix of glucosyl-mannitol and glucosylsorbitol). This prompted an in vitro investigation to determine whether Streptococcus sobrinus 6715, a cariogenic streptococcus, could grow and produce acid in growth medium containing an aqueous extract of such "sugar-free" cough drops. The results indicate that S. sobrinus 6715 uses Isomalt® and sorbitol extensively, producing terminal culture pH as low as 4.2 when grown on medium with cough drop extract containing these sugars. This pH is sufficient to demineralize dental enamel. Patients should be cautioned against the chronic overuse of "sugar-free" cough drops and other "sugar-free" confections sweetened with a mixture of Isomalt® and sorbitol.