Addiction Medicine

Poverty and Excess Length of Hospital Stay in Neonatal Opioid Withdrawal Syndrome Objectives: To study the impact of sociodemographic factors on length of stay (LOS) for infants with neonatal opioid withdrawal syndrome (NOWS) secondary to fetal opioid exposure. Methods: In this retrospective cohort study, we included term infants with NOWS, excluding those with other significant medical issues. Comprehensive clinical and sociodemographic data were collected. Multivariate regression modeling was used to identify factors which contributed to excess LOS, which was defined as the number of days beyond the standard monitoring and/or treatment protocol. Results: In all, 129 infants were identified; mean gestational age of 37.9 ± 1.3 weeks and mean body weight of 2880 ± 496 g. Among them, 68% of infants were exposed to opioids; 27% were exposed to methadone; and 67% required pharmacologic treatment. The degree of poverty was assessed using the Area Deprivation Index (ADI) based on the mother's address at the time of birth. Median LOS for treated infants was 23 days versus 8 days for those who did not need pharmacologic treatment. The median excess LOS was 4 days (range 0–24). Excess hospital days were strongly correlated with degree of deprivation in the mother's community (r = 0.55, P < 0.01). ADI remained a strong predictor of excess LOS, even when controlling for pharmacologic treatment, placement in state's custody, race, and gestational age at birth. Conclusions: These results suggest poverty is associated with excess LOS and that early allocation of resources for at-risk families may help to reduce overall length of hospital stay. Send correspondence to: Zachary A. Vesoulis, MD, Department of Pediatrics, Washington University School of Medicine, 1 Children's Place, St. Louis, MO 63110. E-mail: vesoulis_z@kids.wustl.edu. Received 10 January, 2019 Accepted 11 March, 2019 Funding: This work was supported by the following grants: Washington University Institute of Clinical and Translational Sciences KL2 Training Program (NIH/NCATS KL2 TR000450); the Barnes-Jewish Hospital Foundation and the Washington University Institute of Clinical and Translational Sciences Clinical and Translational Funding Program (NIH/NCATS UL1 TR000448). The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

How Might Maternal Poverty Impact the Course of Neonatal Opioid Withdrawal Syndrome? Neonatal Opioid Withdrawal Syndrome (NOWS) is an increasing problem in the midst of the current opioid epidemic, frequently associated with pharmacologic treatment and prolonged hospitalizations. NOWS is a highly variable condition with many clinical and genetic variables contributing to the clinical course. Social variables such as maternal poverty remain understudied. In this commentary, we review one of the first studies of the association between maternal poverty and infant hospital length of stay in infants with NOWS. This has important implications for designing population level interventions to improve NOWS outcomes. Send correspondence to Elisha M. Wachman, MD, Boston Medical Center, 771 Albany Street, Dowling 4103, Boston, MA 02118. E-mail: Elisha.Wachman@bmc.org Received 26 March, 2019 Accepted 31 March, 2019 Financial disclosures: No funding was provided for this manuscript. Dr Wachman has no conflicts of interest to disclose. © 2019 American Society of Addiction Medicine

The Role of Hospitalists in Treating Opioid Use Disorder No abstract available

The Role of Hospitalists in Treating Opioid Use Disorder No abstract available

Exploring the Effects of Vitamin D Supplementation on Cognitive Functions and Mental Health Status in Subjects Under Methadone Maintenance Treatment Objectives: Vitamin D deficiency may be linked to several mental complications including cognitive deficits, depression, and anxiety in patients under methadone maintenance treatment (MMT). This study was designed to explore the effect of vitamin D supplementation on cognitive functions and mental health parameters in subjects under MMT. Methods: This randomized, double-blinded, placebo-controlled clinical trial was carried out among 64 patients under MMT. Participants were randomly allocated to receive either 50,000 IU vitamin D supplements (n = 32) or placebo (n = 32) every 2 weeks for 24 weeks. Cognitive functions and mental health parameters were taken at baseline and posttreatment to evaluate relevant variables. Results: After the 24-week intervention, compared with the placebo, serum 25(OH) vitamin D levels significantly increased in participants who received vitamin D supplements (β 14.50; 95% confidence interval [CI], 13.17–15.83; P < 0.001). In addition, compared with the placebo, subjects who received vitamin D had a significant reduction in Iowa Gambling Task (β −6.25; 95% CI, −8.60 to −3.90; P < 0.001), and significant increases in Verbal Fluency Test (β 2.82; 95% CI, 0.78–4.86; P = 0.007), Immediate Logic Memory (β 1. 32; 95% CI, 0.27–2.37; P = 0.01), Reverse Digit Span (β 2.06; 95% CI, 1.18–2.94; P < 0.001) and visual working memory (β 0.75; 95% CI, 0.33–1.16; P = 0.001). Also, vitamin D supplementation significantly improved BDI (β −2.76; 95% CI, −3.97 to −1.55; P < 0.001) compared with the placebo. When we applied Bonferroni correction, LM-Immediate (P = 0.07) became nonsignificant, and other mental health parameters did not alter. Conclusions: Overall, taking 50,000 IU vitamin D supplements every 2 weeks for 24 weeks by patients under MMT had beneficial effects on cognitive functions and some mental health parameters. Further studies are needed to confirm our findings. Send correspondence to Zatollah Asemi, PhD, Research Center for Biochemistry and Nutrition in Metabolic Diseases, Kashan University of Medical Sciences, Kashan, Iran. E-mail: asemi_r@yahoo.com Received 8 May, 2018 Accepted 9 May, 2019 The authors report no conflicts of interest. Clinical trial registration number: www.irct.ir: IRCT2017101133079N4. © 2019 American Society of Addiction Medicine

Editor's note: Congratulations to the 2019 Author and Reviewer Award Winners No abstract available

Prenatal Practice Staff Perceptions of Three Substance Use Screening Tools for Pregnant Women Objective: There is a need to identify an acceptable and comprehensive substance use screening tool for pregnant women in the United States. This qualitative study sought to better understand prenatal practice staff perceptions of three existing substance use screening tools for use among pregnant women in an outpatient practice setting. Methods: Eight focus groups with 40 total participants were conducted with clinical and administrative staff of 2 diverse Maryland prenatal practices to determine the acceptability and usability of 3 substance use screening tools (4P's Plus, NIDA-Modified Alcohol, Smoking and Substance Involvement Screening Test, and the Substance Use Risk Profile-Pregnancy scale). The focus groups were digitally recorded, transcribed, coded, and analyzed using thematic analysis. Results: Participant perceptions of screening tools were dependent upon screening tool length, tone, comprehensiveness, subjectivity, time frame of questions, and scoring and clinician instructions. Most participants preferred the 4P's Plus screening tool because it is brief, comprehensive, easy for the patient to understand, and excludes judgmental language and subjective questions. Conclusions: These results provide valuable insight into the specific needs and preferences of prenatal practice staff as it relates to prenatal substance use screening and provides evidence that the 4P's Plus may be a preferred screening tool for standardized use in prenatal care. Send correspondence to Victoria H. Coleman-Cowger, PhD, The Emmes Company, LLC, 401N. Washington Street, Suite 700, Rockville, MD 20850. E-mail: vcolemancowger@emmes.com Received 7 December, 2018 Accepted 18 March, 2019 Funding: Research reported in this publication was supported by the National Institute on Drug Abuse of the National Institutes of Health under Award Number R01DA041328. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the Health Resources and Services Administration. The authors report no conflicts of interest. © 2019 American Society of Addiction Medicine

Job Satisfaction Among Methadone Maintenance Treatment Clinic Service Providers in Jiangsu, China: A Cross-sectional Survey Objective: Service providers' job satisfaction is critical to the stability of the work force and thereby the effectiveness of methadone maintenance treatment (MMT) programs. This study aimed to explore MMT clinic service providers' job satisfaction and associated factors in Jiangsu, China. Methods: This secondary study used baseline data of a randomized interventional trial implemented in Jiangsu, China. A survey was conducted among 76 MMT service providers using the computer-assisted self-interview (CASI) method. Job satisfaction responses were assessed via a 30-item scale, with a higher score indicating a higher level of job satisfaction. Perceived institutional support and perceived stigma due to working with drug users were measured using a 9-item scale. Correlation and multiple linear regression analyses were performed to identify factors associated with job satisfaction. Results: Correlation analyses found a significant association between job satisfaction and having professional experience in the prevention and control of HIV, other sexually transmitted infections, or other infectious diseases (P = 0.046). Multiple regression analyses revealed that working at MMT clinics affiliated with Center for Disease Control and Prevention sites was associated with a lower level of job satisfaction (P = 0.014), and perception of greater institutional support (P = 0.001) was associated with a higher level of job satisfaction. Conclusion: Job satisfaction among MMT clinic service providers was moderate in our study. Our findings suggest that institutional support for providers should be improved, and that acquisition of additional expertise should be encouraged. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0 Send correspondence to Zunyou Wu, PhD National Center for AIDS/STD Control and Prevention, Chinese Center for Disease Control and Prevention, 155 Changbai Road, Beijing 102206, China. E-mail: wuzy@263.net, wuzunyou@chinaaids.cn Received 25 April, 2018 Revised 11 November, 2018 Accepted 5 December, 2018 The authors declare no conflicts of interest. © 2019 American Society of Addiction Medicine

The Association Between Antenatal Maternal Self-reported Substance Use, Maternal Characteristics, and Obstetrical Variables Background: Substance use disorders during pregnancy are a concern both to the public and medical community, because the negative consequences can be detrimental to both mother and the fetus. The accurate identification of prenatal drug exposure is necessary to determine appropriate medical and psychosocial intervention, and to identify risk factors that may affect outcomes for the mother and her newborn. The prevalence of prenatal drug exposure is very difficult to estimate because of flaws in all methods of identification. Objective: The study is designed to identify risk factors and demographic variables that contribute to nondisclosure of illicit and nonillicit substance use. In addition, this study aims to determine if nondisclosure leads to adverse neonatal outcomes. Study design: Newborns delivered with a positive meconium or urine toxicology, and/or known maternal exposure to illicit and nonillicit substances, were identified. Maternal records were reviewed for disclosure of substance use during pregnancy at admission for delivery along with other medical and demographic variables. Women with antenatal prescription drug use that may alter toxicology screens were excluded from analysis. Pediatric records were also reviewed to obtain neonatal variables. Results: One hundred sixty-eight newborns were identified as having prenatal exposure to an illicit or nonillicit substance over the 4-year period. Eighty-six per cent (145/168) of women tested positive or their newborn tested positive for at least 1 illicit substance, and 49% (82/168) tested positive for multiple illicit substances. Fifty-four per cent (91/168) of women did not disclose using at least one illicit drug for which she or her newborn tested positive. With regards to maternal characteristics, there was no statistically significant difference between age (P = 0.958), parity (P = 0.300), or race (P = 0.531), and disclosure or failure to disclose about illicit drug use. However, patients who did not report prenatal illicit drug use (33/82 = 40%) were less likely (P = 0.049) to receive complete prenatal care (defined as 3 or more visits) compared with those who acknowledged their substance use (40/70 = 57%). Conclusion: Substance use disorders during pregnancy are an often underestimated cause of maternal, fetal, and neonatal complications. Limited studies have examined the relationship between maternal characteristics and associated illicit or nonillicit drug use. The absence of correlation between maternal demographics and disclosure of illicit substance use demonstrates the fact that all antepartum patients are at risk for these behaviors. Furthermore, the fact that women who did not disclose their illicit drug use were less likely to seek complete prenatal care reflects the need for physicians to provide a destigmatized healthcare environment, encouraging pregnant women to disclose their substance use so they can be provided with appropriate counseling and treatment. Send correspondence to Alexandra Berra, MD, 6651 Main Street, Houston, TX 77030. E-mail: aberraeras@gmail.com Received 10 May, 2018 Accepted 5 December, 2018 Central Association of Obstetricians and Gynecologists, 84th Annual Meeting, Scottsdale, Arizona, October 18–21, 2017. The authors have nothing to disclose. © 2019 American Society of Addiction Medicine

Pain Anxiety as a Mechanism Linking Pain Severity and Opioid Misuse and Disability Among Individuals With Chronic Pain Objective: Chronic pain affects a significant number of individuals in the United States and is associated with several negative health-related outcomes, including possibility of opioid misuse and disability. The identification of factors associated with both opioid misuse and disability is of critical public health importance, and significant research suggests that pain severity has been shown to be associated with both. Pain-related anxiety has been uniquely associated with both opioid misuse and disability, yet little research has examined pain-related anxiety as a potential mechanism linking pain severity with opioid misuse and disability. Method: Therefore, the current study examined whether pain-related anxiety explains, in part, the relationship between pain severity, opioid misuse, and disability among 396 adults with chronic pain (55.8% female, Mage 36.61, SD 11.40). Results: Cross-sectional analyses indicated that pain-related anxiety significantly mediated the relationship between pain severity, opioid misuse outcomes, and psychosocial disability, but not physical disability. Conclusions: These results build upon the literature indicating the importance of pain-related anxiety in those with chronic pain by suggesting this construct may account, in part, for the relation of pain intensity to opioid misuse and psychosocial disability. Future research should longitudinally examine these associations. Send correspondence and reprint requests to: Kevin E. Vowles, PhD, Department of Psychology, University of New Mexico, MSC03-2220 Logan Hall, Albuquerque, NM 87131-0001. E-mail: k.e.vowles@gmail.com. Received 9 December, 2018 Accepted 11 March, 2019 The authors declare no conflicts of interest. © 2019 American Society of Addiction Medicine

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Trauma and Acute Care Surgery

Unfractionated heparin attenuates histone-mediated cytotoxicity in vitro and prevents intestinal microcirculatory dysfunction in histone-infused rats Abstract: Background Extracellular histones are major mediators of organ dysfunction and death in sepsis, and they may cause microcirculatory dysfunction. Heparins have beneficial effects in sepsis and have been reported to bind to histones and neutralize their cytotoxicity. The aim of this study was to investigate the impact of histones on intestinal microcirculation and the intestinal endothelium and to discuss the protective effect of unfractionated heparin (UFH) on the endothelial cytotoxicity and microcirculatory dysfunction induced by histones. Methods Anesthetized rats were infused with 30 mg/kg calf thymus histones, and UFH was administered intravenously at a concentration of 100 IU/kg/hour. The intestinal microcirculation was visualized and measured with incident dark field microscope. Plasma von Willebrand factor (vWF) and soluble thrombomodulin (sTM) were detected, and structural changes in the rat intestinal microvascular endothelium were examined. The effects of histones and UFH on cell survival rates, vWF release and calcium influx were investigated in human intestinal microvascular endothelial cells (HIMECs). Results Histone infusion caused severe intestinal microcirculatory dysfunction in the absence of obvious hemodynamic changes, and UFH protected intestinal microcirculation in histone-infused rats. Concentrations of the plasma endothelial injury markers vWF and sTM were elevated, and structural abnormalities were found in the intestinal microvascular endothelium in the histone-infused rats. These events were attenuated by UFH. In vitro, UFH significantly reduced the histone-induced cytotoxicity of HIMECs, reduced the release of vWF from the cytoplasm into the culture medium, and inhibited calcium influx into HIMECs. Conclusions Histones induce intestinal microcirculatory dysfunction followed by direct injury to the endothelial cells; UFH protects the intestinal microcirculation partly by antagonizing the endothelial toxicity of histones. Level of evidence This is a basic science paper; it does not require a level of evidence. Corresponding author at: Department of Critical Care Medicine, The First Affiliated Hospital, China Medical University, North Nanjing Street 155, Shenyang 110001, Liaoning Province, China. E-mail address:icusubscript@hotmail.com (Xiaochun Ma). Telephone number: 86-13504998906. Fax: 86-24-83282631 Level of Evidence: not applicable (pre-clinical study) Conflicts of Interest: The authors declare that they have no conflict of interest. Funding: The research was supported by the National Nature Science Foundation of China (Grant No.81671936) Meeting presentations: None © 2019 Lippincott Williams & Wilkins, Inc.

The Role of Psychological Support Interventions in Trauma Patients on Mental Health Outcomes: A Systematic Review and Meta-Analysis Background The recovery and rehabilitation of trauma survivors may be long and challenging. Patients may be prone to psychiatric disorders, cognitive impairments, and decreased quality of life. The objective of this review was to determine whether there is a role for psychological interventions in reducing the incidence and severity of psychiatric sequelae in trauma survivors. Methods MEDLINE, PubMed, SCOPUS, and Google Scholar were searched for published articles. We searched for articles published between 1990 and 2018 with adult subjects, and limited our search to articles published in English. Randomized controlled trials that evaluated various psychiatric interventions in trauma patients on the effects of psychiatric outcomes were included for analysis. The articles were independently reviewed for eligibility by two different reviewers. A meta-analysis was performed on nine studies with similar interventions, outcomes measured, and patient populations. Results Nine hundred thirty-four articles were identified [830 articles identified through database search, and 107 through article references]. Sixty-nine full-text articles were reviewed for eligibility. Of these, 33 were included for qualitative analysis. Thirteen studies evaluating the effect of cognitive-behavioral therapy (CBT)-based interventions on the severity of PTSD, anxiety, and depression symptoms underwent meta-analysis. While CBT-treated patients experienced clinically significant decreases in symptom severity, there were no statistically significant differences between treatment and control groups at follow-up for PTSD, anxiety, and depression. Conclusions Compared to usual care, CBT-based interventions may not be effective in decreasing or preventing PTSD, anxiety, or depression symptoms in trauma survivors. Level of Evidence Systematic Review, level III Conflict of Interest: There are no conflicts of interest. Meetings: None Disclosure of Funding: None. Corresponding Author: Catherine M. Kuza, MD, Keck School of Medicine of the University of Southern California, Department of Anesthesiology, 1450 San Pablo Street, Suite 3600, Los Angeles, CA 90033, (323) 442-7400, (323) 442-7411, E-mail: Catherine.kuza@med.usc.edu © 2019 Lippincott Williams & Wilkins, Inc.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) Induced Myocardial Injury is Mitigated by Endovascular Variable Aortic Control (EVAC) Background The cardiac effects of resuscitative endovascular balloon occlusion of the aorta (REBOA) are largely unknown. We hypothesized that increased afterload from REBOA would lead to cardiac injury, and that partial flow using endovascular variable aortic control (EVAC) would mitigate this injury. Methods Eighteen anesthetized swine underwent controlled 25% blood volume hemorrhage. Animals were randomized to either Zone 1 REBOA, Zone 1 EVAC, or no intervention (control) for 45 minutes. Animals were then resuscitated with shed blood, observed during critical care, and euthanized after a six-hour total experimental time. Left ventricular function was measured with a pressure-volume catheter and blood samples were drawn at routine intervals. Results The average cardiac output during the intervention period was higher in the REBOA group [9.3 (8.6-15.4) L/min] compared to the EVAC group [7.2 (5.8-8.0) L/min, P=0.01] and the control group [6.8 (5.8-7.7) L/min, P<0.01]. At the end of the intervention, the preload recruitable stroke work (PRSW) was significantly higher in both the REBOA and EVAC groups compared to the control group [111.2 (102.5-148.6) and 116.7 (116.6-141.4) versus 67.1 (62.7-87.9), P=0.02 and P<0.01, respectively]. The higher PRSW was maintained throughout the experiment in the EVAC group, but not in the REBOA group. Serum troponin concentrations after six hours were higher in the REBOA group compared to both the EVAC and control groups (6.26±5.35 ng/mL versus 0.92±0.61 ng/mL and 0.65±0.38 ng/mL, P=0.05 and P=0.03, respectively). Cardiac intramural hemorrhage was higher in the REBOA group compared to the control group (1.67±0.46 vs 0.17±0.18, P=0.03), but not between the EVAC and control groups. Conclusions In a swine model of hemorrhagic shock, complete aortic occlusion resulted in cardiac injury, although there was no direct decrease in cardiac function. EVAC mitigated the cardiac injury and improved cardiac performance during resuscitation and critical care. Level of Evidence not applicable for basic science study Name and address for correspondence: Carl A Beyer, 2315 Stockton Boulevard, Room OP 512, Sacramento, CA 95817, 916-734-2724 | Fax: 916-734-5633, E-mail: cbeyer@ucdavis.edu Disclaimer: The views expressed in this material are those of the authors and do not reflect the official policy of the US Government, the Department of Defense, the Department of the Air Force, the Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., the University of California Davis, or Wake Forest University. Meetings: Awarded second prize at the 16th biennial Strandness Symposium, March 3-7, 2019, Wailea, HI. © 2019 Lippincott Williams & Wilkins, Inc.

Point-of-care Resuscitation Research: From Extreme to Mainstream: Trauma Association of Canada Fraser Gurd Lecture 2019 The Gurd Family surgical legacy was deeply intertwined with National service in both World Wars. My own personal research mission has attempted to emulate such service, by enhancing the tools and techniques available to facilitate point-of-care (POC) diagnosis and resuscitation in extreme and adverse environments. Our efforts involving POC diagnosis/resuscitation and the telementored guidance of those remotely responding to catastrophic injury have included collaborations with NASA, the Canadian Space Agency, the Canadian Forces, its democratic allies, and non-governmental surgical organizations. Research has been conducted in resuscitative suites and operating theatres, research laboratories, parabolic flight aircraft, on humanitarian surgical missions, and from ski-hills and firehalls. The initial phases of these efforts involved inaugural studies in resuscitative sonography including defining the EFAST examination. Although the original work was commissioned for Space Medicine, generalization to mainstream practice further justifies space medicine research. Iterative steps in advancing telementored resuscitation have subsequently involved the maturation of space mandated telementored ultrasound support (TMUS), exploration of TMUS in terrestrial clinical practice, and the creation of increasingly mobile (hand-held) TMUS solutions. Subsequently it was recognized that tele-ultrasound is simply one informatic dimension of remote telemedicine, and current efforts are focused in a Program known as TeleMentored Ultrasound Supported Medical Interactions (TMUSMI) of remote responders required to intervene with catastrophic trauma. While this research program has yielded many techniques and findings that have benefited mainstream terrestrial practice, these investigations are currently ongoing, and we hope to demonstrate that TMUSMI may benefit all Canadians especially those in remote areas, as well as potentially every global inhabitant without immediate access to care. Further, we propose that to abstract fully utilize these techniques, a new specialty, that of the remote medical mentor will be required, a new specialty that will require the creation and scientific validation of its principles and techniques. Address for Correspondence AW Kirkpatrick Regional Trauma Services EG 23 Foothills Medical Services 1403 29 ST NW Calgary, Alberta T2N 2T9 This manuscript was an invited Podium Presentation at the Annual Scientific Meeting of the Trauma Association of Canada, as the named Fraser Gurd Lecture 2019. Conflict of Interest No funding of any kind was provided to prepare this manuscript. AW Kirkpatrick continues to serve in the Canadian Forces Medical Services. AW Kirkpatrick has consulted for the Acelity and Innovative Trauma Care Corporations. © 2019 Lippincott Williams & Wilkins, Inc.

Ketamine Infusion for Pain Control in Adult Patients with Multiple Rib Fractures No abstract available

Promotility Agents For The Treatment Of Ileus In Adult Surgical Patients: A Practice Management Guideline From The Eastern Association For The Surgery Of Trauma Background Ileus is a common challenge in adult surgical patients with estimated incidence to be 17%-80%. The main mechanisms of the postoperative ileus pathophysiology are fluid overload, exogenous opioids, neurohormonal dysfunction, gastrointestinal stretch and inflammation. Management includes addressing the underlying cause and supportive care. Multiple medical interventions have been proposed, but effectiveness is uncertain. A working group of the Eastern Association for the Surgery of Trauma (EAST) aimed to evaluate the effectiveness of metoclopramide, erythromycin, and early enteral nutrition (EEN) on ileus in adult surgical patients and to develop recommendations applicable in a daily clinical practice. Methods Literature search identified 45 papers appropriate for inclusion. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was applied to evaluate the effect of metoclopramide, erythromycin, and EEN on the resolution of ileus in adult surgical patients based on selected outcomes: return of normal bowel function, attainment of enteral feeding goal, and hospital length of stay (LOS). The recommendations were made based on the results of a systematic review, a meta-analysis, and evaluation of levels of evidence. Results The level of evidence for all PICOs was assessed as low. Neither metoclopramide nor erythromycin were effective in expediting the resolution of ileus. Analyses of 32 randomized controlled trials showed that EEN facilitates return of normal bowel function, achieving enteral nutrition goals, and reducing hospital LOS. Conclusion In patients who have undergone abdominal surgery, we strongly recommend EEN to expedite resolution of Ileus, but we cannot recommend for or against the use of either metoclopramide or erythromycin to hasten the resolution of ileus in these patients. Level of Evidence Level II Type of Study Therapeutic Corresponding Author: Nikolay Bugaev, MD, Division of Trauma & Acute Care Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, nbugaev@tuftsmedicalcenter.org, 800 Washington St, #4488, Boston, MA, 02111, Tel. 617-636-4488, Fax 617-636-8172 Conflict of Interests: no conflicts to disclose The manuscript was presented as a podium presentation at the 31st Eastern Association for the Surgery of Trauma (EAST) Annual Scientific Assembly. January 11, 2018: Lake Buena Vista, Florida. Disclosures of Funding: nothing to disclose. © 2019 Lippincott Williams & Wilkins, Inc.

Variability in international normalized ratio and activated partial thromboplastin time after injury are not explained by coagulation factor deficits Introduction Conventional coagulation assays (CCAs), PT/INR (prothrombin time/international normalized ratio) and aPTT (activated partial thromboplastin time), detect clotting factor (CF) deficiencies in hematologic disorders. However, there is controversy about how these CCAs should be used to diagnose, treat and monitor trauma-induced coagulopathy. Study objectives were to determine whether CCA abnormalities are reflective of deficiencies of coagulation factor activity in the setting of severe injury. Methods Patients without previous CF deficiency within a prospective database at an ACS verified Level 1 trauma center had CF activity levels, PT/INR, aPTT, and fibrinogen levels measured upon Emergency Department arrival from 2014-2017. Linear regression assessed how CF activity explained the aPTT and PT/INR variation. Prolonged CCA values were set as INR>1.3 and aPTT>34sec. CF deficiency was defined as <30% activity, except for fibrinogen, defined as <150mg/dL. Results Sixty patients with a mean age of 35.8 (std dev:13.6) years and median new injury severity score (NISS) of 32 (IQR:12-43) were included; 53.3% sustained blunt injuries, 23.3% required massive transfusion, and mortality was 11.67%. Overall, 44.6% of the PT/INR variance and 49.5% of the aPTT variance remained unexplained by CF activity. Deficiencies of CFs were: common pathway 25%; extrinsic pathway 1.7%, and intrinsic pathway 6.7%. The positive predictive value for CF deficiencies were: 1)PT/INR>1.3:4.4% for extrinsic pathway, 56.5% for the common pathway; 2) aPTT>34 sec:16.7% for the intrinsic pathway, 73.7% for the common pathway. Conclusion Almost half of the variances of PT/INR and aPTT were unexplained by CF activity. Prolonged PT/INR and aPTT were poor predictors of deficiencies in the intrinsic or extrinsic pathways, however, they were indicators of common pathway deficiencies. Corresponding Author: Ernest E Moore, MD, Email: ernest.moore@dhha.org Phone: 303-724-2685, Fax: 303-720-2682, Mailing Address: 655 Bannock Street Denver, CO 80203 Disclosure: Research reported in this publication was supported in part by the National Institute of General Medical Sciences grants: T32-GM008315 and P50-GM49222, the National Heart Lung and Blood Institute UM1-HL120877, in addition to the Department of Defense USAMRAA and W81XWH-12-2-0028. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health, the National Heart, Lung, and Blood institute, or the Department of Defense. Additional research support was provided by Haemonetics (Haemonetics, Niles, IL, USA) with shared intellectual property. © 2019 Lippincott Williams & Wilkins, Inc.

Blunt Rupture of Two Cardiac Chambers Following a Motor Vehicle Collision No abstract available

Reply to Letter: Observing Pneumothoraces: The 35 Millimeter Rule Is Safe for Both Blunt and Penetrating Chest Trauma No abstract available

A Preliminary Analysis of Level IV Trauma Centers within an Organized Trauma System Background The effect of Level IV trauma center (TC) accreditation within an existing trauma network remains understudied. This study compared pre- to post-accreditation data from Level IV TCs within a mature trauma system in Pennsylvania to determine whether TC designation affected time to and/or rate of transfer to definitive care. Level IV TCs were hypothesized to have a decreased time to transfer following accreditation and improved mortality. Methods The Pennsylvania Trauma Systems Foundation (PTSF) collects pre- and post-designation data from hospitals pursuing accreditation. Data from PTSF between 2012 and 2017 was analyzed. Variables of interest included patient demographics, injury severity, mortality and incidence of surgical interventions pre- to post-credentialing. A multilevel mixed-effects logistic regression model assessed the adjusted impact of Level IV TC accreditation on transfer rate. ArcGIS Desktop was used for geospatial mapping of lives and geographic area covered by the addition of Level IV TCs in Pennsylvania Results Five hospitals underwent Level IV credentialing from 2012-2017, providing data on 5,076 cases (Pre: 2,395 [47.2%]; Post: 2,681 [52.8%]). No significant difference in age, admission Glasgow Coma Scale score, or shock index was observed pre to post-accreditation. A difference in transfer rate was observed after credentialing in unadjusted (62.7% vs. 63.3%; p<0.014) and adjusted analyses (AOR: 1.13, p=0.389). There was a trend toward reduced odds of mortality post-credentialing (AOR: 0.59, p=0.261). Major surgical intervention decreased (Pre: 0.42%, Post: 0.04%; p=0.004). Conclusion Level IV TC accreditation has beneficial effects on increased transfer rates and may improve mortality. It is important to continue to observe the impact of Level IV TCs on patient outcomes within a mature trauma system. Level of Evidence III; prognostic and epidemiological Corresponding Author: Frederick B. Rogers, MD, MS, MA, FACS; Frederick.Rogers@pennmedicine.upenn.edu, 555 N. Duke St., Lancaster, PA 17602, 717-544-5945 (tel), 717-544-5944 (fax) All authors have neither conflict of interest nor disclosure of funding or proprietary interest to declare on the materials or subject matter discussed herein. This study was accepted for a Quick Shot presentation at the 32nd Annual Scientific Assembly of the Eastern Association for the Surgery of Trauma held in Austin, Texas from January 15-19, 2019. © 2019 Lippincott Williams & Wilkins, Inc.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Hazardous Materials

Reduction of phoxim pesticide residues from grapes by atmospheric pressure non-thermal air plasma activated water Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Yongping Zheng, Songjie Wu, Jie Dang, Shifang Wang, Zhengxin Liu, Jing Fang, Ping Han, Jue Zhang Abstract In this study, we propose a novel strategy, plasma activated water (PAW) to reduce pesticide residues on agricultural products. To validate its feasibility and effectiveness, we employee high-performance liquid chromatography (HPLC) to detect phoxim on grapes. HPLC results suggest that the reduction of phoxim on grapes achieve 73.60% after treated 10 min by PAW prepared 30 min, and the concentration of phoxim decreased significantly (p <  0.05) with the preparation time of PAW. Furthermore, HPLC-MS analysis shows that the reduction effect of phoxim by PAW is dominated by the degradation of phoxim. Combined with analyzing the physicochemical properties of PAW, one possible degradation pathway is proposed under the present experimental conditions, mediated by reactive oxygen and nitrogen species. The acidic environment (pH < 3) and high oxidation capacity (ORP > 500 mV) are suggested to be a benefit to the reduction of phoxim. Besides, the experimental results regarding color, firmness, sugar, vitamin C, and superoxide dismutase of grapes demonstrate that the PAW treatment will not significantly affect the quality of grapes. In conclusion, phoxim pesticide residues on grapes could be effectively reduced by the PAW strategy and without a significant (p <  0.05) effect on grapes quality. Graphical abstract

Thermal and pH dual-responsive cellulose microfilament spheres for dye removal in single and binary systems Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Yuan Li, Huining Xiao, Yuanfeng Pan, Min Zhang, Yongcan Jin Abstract Cellulose microfilaments/poly(N-Isopropylacrylamide-co-acrylic acid) spheres (MPNAA) were prepared via the in-situ synthesis of semi-interpenetrating networks (semi-IPN). The free radical copolymerization of acrylic acid (AA) (for pH-sensitive chain segments) and N-isopropylacrylamide (NIPAM) (for temperature-sensitive chain segments) was conducted in a microwave-reactor in the presence of porous cellulose/microfilament composite spherical beads pre-prepared. The surface morphology and adsorption properties of the as-prepared spheres were systematically characterized. The adsorption behaviors of resulting MPNAA towards dyes, methylene blue (MB) and methyl violet (MV), were pH sensitive; and the optimal adsorption occurred at pH 9. The dynamic adsorption processes could be well fitted with pseudo-second-order kinetic, Elovich and simplified intraparticle diffusion models. Meanwhile, Langmuir, Temkin, Freundlich, and Dubinin-Raduskevich models were used to fit the adsorption isotherms at 25, 40, and 55 °C, respectively. The results indicated that the adsorption capacities of MPNAA towards MB and MV could reach as high as 497.5 and 840.3 mg g−1, respectively, in single systems; and high adsorption capacity was maintain in binary systems with the favorable adsorption of MV. Overall, the semi-IPN MPNAA spheres are promising as novel pH- and temperature-responsive adsorbents, facilitating the controllable adsorption/desorption processes. Graphical abstract

Enhancing the performance of soil microbial fuel cells by using a bentonite-Fe and Fe3O4 modified anode Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Bao Yu, Yanhong Li, Liu Feng Abstract To improve the performance of soil microbial fuel cells (SMFCs), Fe3O4 and bentonite-Fe were selected as anode modifiers, and correspondingly, graphite felt (GF), GF + Fe3O4 (GFF), and GF + bentonite-Fe (GFB) anodes were created and applied to the SMFCs system. The stable voltages of SMFCs were 249 mV for GFF and 324 mV for GFB, thus representing an increase by 8.26% (GFF) and 40.87% (GFB) in comparison with those of GF. Moreover, the maximum power density in the modified treatment increased from 10.6 mW·m−2 to 18.28 mW·m−2 (GFF) and 29.98 mW·m−2 (GFB), and the internal resistance was reduced to 395 Ω for GFF and 219 Ω for GFB. The degradation efficiency clearly improved after being modified, especially by bentonite-Fe, and the removal ratios of the total petroleum hydrocarbon (TPH), anthracene, phenanthrene and pyrene reached 31.42%, 36.62%, 32.48% and 26.24%, respectively, after the SMFCs had run for 45 days. Both modifications contributed to the enrichment of electricigens on the anodes; however, there was minimal difference between them, which resulted in a similar microbial community on the modified anodes. The results demonstrated that Fe3O4 and bentonite-Fe could enhance the potential of SMFCs in soil remediation, and bentonite-Fe outperformed Fe3O4. Graphical abstract

Atrazine degradation using Fe3O4-sepiolite catalyzed persulfate: Reactivity, mechanism and stability Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Ximeng Xu, Weiming Chen, Shaoyan Zong, Xu Ren, Dan Liu Abstract In this study, with sepiolite as a support, a novel magnetic Fe3O4-sepiolite composite was fabricated by coprecipitation method. The characterization results reveal that the sepiolite support could anchor Fe3O4 nanoparticles with good dispersion. The composite was used as a catalyst to activate persulfate (PS) for atrazine (ATZ) degradation. 71.6% of ATZ and 20.9% of solution TOC could be removed after 60 min with 92 mmol/L of PS ([ATZ]0= 10 mmol/L). Due to the good adsorption capacity of Fe3O4-sepiolite composite toward ATZ, the degradation was considered to be facilitated by an adsorption process, since the adsorbed ATZ can be more easily transported to the active sites and be degraded in situ. Operation factors, including PS dose and solution pH, were investigated and found to be influential for the ATZ removal. The Fe3O4-sepiolite composite maintained its catalytic activity and structural stability with negligible Fe leaching during the recycling batch experiments. The intermediate products were further identified and the possible transformation pathway was then proposed based on the results. The findings of this research promote the application of Fe3O4-sepiolite composite as efficient and recyclable heterogeneous catalyst for organic degradation, and provide insights into the development of alternative catalysts with good adsorptive properties.

Auto-ignition behaviors of nitromethane in diluted oxygen in a rapid compression machine: Critical conditions for ignition, ignition delay times measurements, and kinetic modeling interpretation Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Meng Yang, Yingtao Wu, Chenglong Tang, Yang Liu, Zuohua Huang Abstract In this work, the weakest thermodynamic conditions for the auto-ignition of mixtures containing nitromethane were experimentally determined by using the rapid compression machine facility. Results show there is a narrow weak ignition region between ignition and non-ignition. The weak ignition region would disappear with the increase of the EOC (end of compression) pressure and nitromethane concentration. In addition, the ignition delay times for successful auto-ignition for different nitromethane concentrations and equivalence ratio mixtures were measured and compared. Results show that the dependence of nitromethane ignition on the equivalence ratio is weak. Subsequently, the measured ignition delay time data were employed to validate several kinetic models in literature and our previous model shows better agreement with experimental results, as well as other available literature data. Sensitivity analysis for the model reveals the importance of unimolecular decomposition and H-abstraction reactions for the ignition delay times in the temperature range studied herein. Finally, critical conditions for nitromethane ignition under extended conditions that are beyond the ability of the experimental facility were predicted.

Transient–state operation of an anoxic biotrickling filter for H2S removal Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Ramita Khanongnuch, Francesco Di Capua, Aino-Maija Lakaniemi, Eldon R. Rene, Piet N.L. Lens Abstract The application of an anoxic biotrickling filter (BTF) for H2S removal from contaminated gas streams is a promising technology for simultaneous H2S and NO3− removal. Three transient–state conditions, i.e. different liquid flow rates, wet–dry bed operations and H2S shock loads, were applied to a laboratory–scale anoxic BTF. In addition, bioaugmentation of the BTF with a H2S removing–strain, Paracoccus MAL 1HM19, to enhance the biomass stability was investigated. Liquid flow rates (120, 60 and 30 L d−1) affected the pH and NO3− removal efficiency (RE) in the liquid phase. Wet–dry bed operations at 2–2 h and 24–24 h reduced the H2S elimination capacity (EC) by 60–80%, while the operations at 1–1 h and 12–12 h had a lower effect on the BTF performance. When the BTF was subjected to H2S shock loads by instantly increasing the gas flow rate (from 60 to 200 L h−1) and H2S inlet concentration (from 112 (± 15) to 947 (± 151) ppmv), the BTF still showed a good H2S RE (>93%, EC of 37.8 g S m–3 h–1). Bioaugmentation with Paracoccus MAL 1HM19 enhanced the oxidation of the accumulated S0 to sulfate in the anoxic BTF.

Surface treatment by the Fe(III)/sulfite system for flotation separation of hazardous chlorinated plastics from the mixed waste plastics Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Maozhi Luo, Hui Wang, Yingshuang Zhang, Yiwei Zhong, Kangyu Wang Abstract A novel advanced oxidation process by a combination of Fe(III) and sulfite for surface treatment of waste plastic mixtures is proposed. The Fe(III)/sulfite system has been found to enhance hydrophilicity of the mixed waste plastics, including acrylonitrile butadiene styrene (ABS), polystyrene (PS) and polycarbonate (PC), while it has little effect on hazardous polyvinyl chloride (PVC), thus promoting separation of PVC from the mixed waste plastics by flotation. Radical scavenging experiments indicate that sulfate radicals are the main reactive species. Fourier transform infrared (FT-IR) and X-ray photoelectron spectroscopy (XPS) results imply the formation of CO or CO groups on the treated plastics surface except for PVC and a plausible mechanism for oxidizing plastics with sulfate radicals is proposed. PVC with 100.00% recovery and 99.84% purity is achieved under optimum surface treatment conditions of sodium sulfite concentration 10 mM, ferric sulfate concentration 0.4 mM, pH 6.0, temperature 25 °C and treatment time 15 min. Consequently, surface treatment by the Fe(III)/sulfite system is an effective technology for separating hazardous PVC from the mixed waste plastics by flotation. Graphical abstract

Plasma-enhanced steam reforming of different model tar compounds over Ni-based fusion catalysts Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Lina Liu, Yawen Liu, Jianwei Song, Shakeel Ahmad, Jie Liang, Yifei Sun Abstract Tar formation during biomass gasification is undesirable due to the decreased energy efficiency and increased costs for maintaining downstream equipment. The hybrid non-thermal plasma-catalysis method is considered to be a promising alternative, since it overcomes the disadvantages arising from both catalyst deactivation during catalytic reforming and the formation of undesirable liquid by-products in plasma reforming. SiO2- and ZSM-5-supported Ni-based catalysts with different Ni loadings (0.5, 1, 3, and 5 wt%) were prepared by thermal fusion and applied to the steam reforming of toluene. Different characterizations of fresh and spent catalysts including XRD, H2-TPR, N2 adsorption-desorption, SEM, TEM, XPS and TGA were conducted to show the properties of catalysts. The results indicated that Ni/ZSM-5 exhibited better performance than Ni/SiO2, due to the increased dispersion of Ni particles and the stronger metal-support interaction of Ni/ZSM-5, which was confirmed by the TEM and H2-TPR results. In addition, the performances of the catalysis-only (CatO), plasma-only (PlO), and in-plasma-catalysis (IPC) systems in steam reforming of different model tar compounds including benzene, toluene, furfural, naphthalene, fluorene and pyrene were compared using Ni(5 wt%)/ZSM-5. Obvious synergistic effects between DBD plasma and Ni(5 wt%)/ZSM-5 was observed for syngas production in the IPC system.

Sandwich membranes based on PVDF-g-4VP and surface modified graphene oxide for Cu(II) adsorption Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Yuexin Guo, Zhiqian Jia, Shuhuan Wang, Yabin Su, Hongcui Ma, Liguang Wang, Wei Meng Abstract UV photo-preactivation/thermally-induced grafting was employed for grafting 4-vinylpyridine (4-VP) on polyvinylidene fluoride (PVDF), and graphene oxide (GO) was modified with 4'-carboxy-2,2':6',2"-terpyridine (CTPy). Then sandwich PVDF-g-4VP/GO-CTPy/polytetrafluoroethylene (PTFE) membrane was fabricated for adsorption of Cu (II) as a model. The membrane formation, static adsorption thermodynamics, kinetics and dynamic adsorption/desorption were studied. The results showed that, the addition of polyethylene glycol (PEG 4000) as porogen can significantly increase the porosity and adsorption capacity of the membranes. The adsorption could be well described by the Langmuir model and pseudo-second-order kinetic model. The breakthrough volume and saturated volume increased with rising GO-CTPy contents. The adsorption capacity of sandwich membranes was much higher than that of mixed matrix membranes. The sandwich membrane also exhibited excellent reusability in dynamic adsorption/desorption cycles, demonstrating great potential in adsorption of trace Cu (II). Graphical abstract

Analysis of radially convergent tracer test in a two-zone confined aquifer with vertical dispersion effect: Asymmetrical and symmetrical transports Publication date: 5 September 2019 Source: Journal of Hazardous Materials, Volume 377 Author(s): Ching-Sheng Huang, Chenchen Tong, Wei-Shan Hu, Hund-Der Yeh, Tao Yang Abstract Radially convergent tracer test (RCT) with an extraction well and a tracer injection well is commonly conducted for determining aquifer dispersivity associated with the spreading of contamination plume. A variety of analytical models for RCT have been proposed, but the effects of skin zone and vertical dispersion are rarely explored. In addition, little attention is paid to the validity of those analytical models assuming asymmetrical tracer transport (ATT) as radially symmetrical transport (RST) toward the pumping well. This study develops a new analytical model for RCT subject to the above-mentioned effects in a confined aquifer with a skin zone around the wellbore. The Laplace-domain solution of the model for a continuous or instantaneous input is developed. A finite element solution (FES) for ATT is also developed to verify the Laplace-domain solution based on RST. Results suggest ATT can be regarded as RST in predicting the breakthrough curve (BTC) at the pumping well when four quantitative conditions are met. A lumped dimensionless parameter dominates those two effects on the BTC. Both the FES and Laplace-domain solution agree with monitored concentration data from a field RCT.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Prehistory

Luobi Cave, South China: A Comparative Perspective on a Novel Cobble-Tool Industry Associated with Bone Tool Technology during the Pleistocene–Holocene Transition Abstract The nature of Paleolithic cultures in South China and their relationship with mainland Southeast Asia remains ill-defined. The lithic industry of South China has been characterized as a simple 'cobble-tool' industry, persisting from the early Pleistocene to the Holocene, while the most representative Southeast Asian industry was also marked by a pebble-tool techno-complex, the Hoabinhian, during the Late Pleistocene–Early Holocene. A possible cultural link between the two regions has been proposed by some scholars but the technological characteristics of the two industries remained elusive, as did the variability within them. In this paper we conduct technological analysis of a 'cobble-tool' industry associated with a bone tool technology from Luobi Cave, Hainan Island, dated to c. 11–10 ka, and compare it with the well-studied typical Hoabinhian site of Laang Spean in Cambodia. While there is a slight similarity in operational sequence (chaîne opératoire), a major difference is that the Luobi Cave site can be rejected as a potential Hoabinhian site. The excavated material indicates a high degree of innovation and demonstrates a new sort of variability in the tool-kit of modern human groups during the Late Pleistocene–Early Holocene transition in South China and Southeast Asia. This study represents an initial attempt to decipher the technological cultural variability in this region. We suggest that the emergence of behavioral modernity and cultural variability should be evaluated at both regional and sub-regional scales, instead of defining them as uniform, progressive and incremental, processes. Here we present, firstly, the variability of operational sequences (chaînes opératoires) within the lithic production of Luobi Cave, and then compare this assemblage with typical and well-studied Hoabinhian assemblages from Laang Spean Cave in Cambodia to make clear the regional variability or complexity of human technological behaviors. Secondly, we then discuss the role of these technological behaviors as strategies for adapting to diverse ecology and environments from the Late Pleistocene to the Holocene.

History, Chronology and Techno-Typology of the Upper Paleolithic Sequence in the Shuidonggou Area, Northern China Abstract The timing and behavioral markers of the Upper Paleolithic in different parts of the world are of great importance to research on modern human dispersals. The pattern of behavioral developments in the Upper Paleolithic in northern China differs in important ways from the patterns observed in West Eurasia, Africa, and South Asia. Shuidonggou (SDG), a cluster of Paleolithic sites in northern China, contains several of the most important Upper Paleolithic sites in the region. Various localities yield evidence of three major cultural components dated by 14C, uranium-series, and optically stimulated luminescence (OSL) methods to between roughly 46 ka and 10 ka. The oldest component, blade assemblages with western Eurasian early Upper Paleolithic characteristics, appears to be intrusive from Siberia and/or Mongolia, beginning at least 41 ka (e.g., SDG 1 and SDG 9). Advanced core and flake assemblages may mark the appearance of an indigenous Late Paleolithic of North China beginning at around 33 ka (e.g., SDG 2 and SDG 8). Finally, around 10.5 ka, microblade technology arrived in the area (SDG 12), although we are not sure of its origins at present. Other typical Upper Paleolithic cultural remains, such as bone tools and body decorations, have been found at various localities in the SDG area as well (e.g., ostrich eggshell beads from SDG 2, 7, and 8). Information from this cluster of occupations increases our understanding of cultural variability, adaptation, and demographic dynamics of modern humans in Late Pleistocene northern Asia.

Diversification, Intensification and Specialization: Changing Land Use in Western Africa from 1800 BC to AD 1500 Abstract Many societal and environmental changes occurred between the 2nd millennium BC and the middle of the 2nd millennium AD in western Africa. Key amongst these were changes in land use due to the spread and development of agricultural strategies, which may have had widespread consequences for the climate, hydrology, biodiversity, and ecosystem services of the region. Quantification of these land-use influences and potential feedbacks between human and natural systems is controversial, however, in part because the archaeological and historical record is highly fragmented in time and space. To improve our understanding of how humans contributed to the development of African landscapes, we developed an atlas of land-use practices in western Africa for nine time-windows over the period 1800 BC–AD 1500. The maps are based on a broad synthesis of archaeological, archaeobotanical, archaeozoological, historical, linguistic, genetic, and ethnographic data, and present land use in 12 basic categories. The main differences between categories is the relative reliance on, and variety of, domesticated plant and animal species utilized, and the energy invested in cultivating or keeping them. The maps highlight the irregular and frequently non-linear trajectory of land-use change in the prehistory of western Africa. Representing an original attempt to produce rigorous spatial synthesis from diverse sources, the atlas will be useful for a range of studies of human–environment interactions in the past, and highlight major spatial and temporal gaps in data that may guide future field studies.

The Emergence of Early Pottery in East Asia: New Discoveries and Perspectives Abstract The appearance of the oldest pottery in the world is a major focus of Early Neolithic archaeology. So far, most discoveries of early pottery have occurred in South China, North China, the Russian Far East, Japan and Korea. The discovery of very thick, low-fired, fibre-tempered pottery dated from around 10,000 BP at the Houtaomuga Site, in Jilin Province, fills an important gap in the distribution of early pottery in northeast China. Based on multi-disciplinary research and an important series of dates, this article establishes the chronology of the early pottery remains discovered at the Houtaomuga Site and their morphological and technical characteristics, and sheds light on their function. Finally, the authors compare them to the other early pottery sherds discovered in the surrounding region, and throughout East Asia, in order to discuss the significance of this discovery and its implications for the subsistence mode developed in the northwest of the Jilin Province at the very beginning of the Neolithic.

From Iberia to the Southern Levant: The Movement of Silver Across the Mediterranean in the Early Iron Age Abstract The origins of the silver trade across the Mediterranean, and the role of the Phoenicians in this phenomenon, remain contentious. This is partly because of difficulties encountered when trying to assign archaeological silver to its geological sources. Here we present a reanalysis of Iron Age silver hoards in the southern Levant, which demonstrates not only that recycling of silver was widespread in the Early and Late Iron Age, but that the components of this mixed silver originated from the Aegean, Anatolia and the western Mediterranean. An assessment of lead isotope analyses combined with compositional data allows the identification of mixing lines based on gold levels in the silver and the Pb crustal age (or, more loosely, geological age) of the ore from which the silver originated. It is shown that, from as early as the 11th century BC, these mixed silver signatures derive from the Taurus mountains in Anatolia, from Iberia and an unknown source—with Sardinia as an additional possibility—and Laurion in Greece in the Late Iron Age. In contrast to copper, which was deliberately alloyed with silver, gold appears to have been mixed unintentionally, through the melting down of silver objects with gold parts. It is suggested that vertical mixing lines (with constant Pb crustal age but variable Au), may indicate the melting down and mixing of silver in times of unrest, both here and in other contexts. Gold and lead concentrations in the silver indicate that native silver from Iberia was most likely used in the Early Iron Age, suggesting that the first people to convey silver to the southern Levant were not miners but traders who had acquired silver directly from the indigenous Bronze Age inhabitants of Iberia. However, evidence of the exploitation of jarosite also supports that silver ore mining and cupellation was ongoing in Iberia at a similar time, and continued in the Late Iron Age—potentially a result of technological transfer from the East. In essence, the western Mediterranean origin of the silver in these Early Iron Age southern Levantine hoards supports an emerging picture of Mediterranean interactions and trade relations in the increasingly bright Dark Ages (c. 1200–800 BC).

Midden or Molehill: The Role of Coastal Adaptations in Human Evolution and Dispersal Abstract Coastal adaptations have become an important topic in discussions about the evolution and dispersal of Homo sapiens. However, the actual distribution and potential relevance of coastal adaptations (broadly, the use of coastal resources and settlement along shorelines) in these processes remains debated, as is the claim that Neanderthals exhibited similar behaviors. To assess both questions, we performed a systematic review comparing coastal adaptations of H. sapiens during the African Middle Stone Age (MSA) with those of contemporaneous Neanderthals during the European Middle Paleolithic. In both species, systematic use of marine resources and coastal landscapes constitutes a consistent behavioral signature over ~ 100,000 years (MIS 6–3) in several regions of Africa and Europe. We found more similarities than differences between Neanderthals and modern humans, with remaining disparities all in degree rather than kind. H. sapiens exploited a wider range of marine resources—particularly shellfish—more intensively. MSA shellfish-bearing sites are also more often associated with intense occupations on coastal landscapes, and more evidence of complex material culture such as shell beads. In terms of broader ramifications, Pleistocene coastal adaptations are best conceived of as an 'add-on' to previous adaptive strategies, complementing more frequently exploited inland resources and landscapes. Still, Neanderthals and modern humans increased their dietary breadth and quality, and added options for occupation and range expansion along coastlines. Potential evolutionary implications of these multi-generational behaviors include higher intakes of brain-selective nutrients as a basis for neurobiological changes connected to increased cognitive capacities, but also greater reproductive success, dispersal abilities and behavioral flexibility. Whether gradual differences between modern humans and Neanderthals stimulated different evolutionary trajectories is a question for future research.

Eurasian Steppe Chariots and Social Complexity During the Bronze Age Abstract This paper aims to examine some societal principles that underlie the development of horse-drawn chariots in Inner Eurasia during the Middle and Late Bronze Age (cal. 2050–1750 BC). Analysis is based on an evaluation and re-examination of the archaeological evidence for horse-drawn chariots, and the social constructs they entail. Chariots were developed in the zone of the Northern Eurasian steppes before c. 2000 BC in the context of complex but stateless societies. Because chariots depend on a set of developed skills, valuable resources, and complicated technologies, which involve several outstanding improvements to previously known solutions, they require specific conditions for their development and maintenance in social life. Most fundamentally, they require a group of people with an interest in this complex technology: a class of military elites characterized by aggrandizing behavior. The competition between collectives of military elites for resources, power and prestige brought into life the earliest chariot complex in the world.

Polished Stone Axes in Caput Adriae from the Neolithic to the Copper Age Abstract This paper reports the results of a long-term project on the stone axes from Caput Adriae. Available data show that jade axes originating in the western Alps reached the Neolithic groups of Friuli Venezia Giulia and coastal Istria as early as the second half of the 6th millennium BC, during the Danilo/Vlaška culture. The exchange of this and other classes of lithic artefacts testifies that in this period this area was fully integrated into long-distance exchange systems that used mainly coastal routes. These systems would have continued in the 5th millennium BC, as indicated by a few oversized jade axe blades and other materials. Far from the coast, jade axes entered central Slovenia, probably reaching sites of the Sava Group of the Lengyel culture in the first half of the 5th millennium BC. In roughly the same period, shaft-hole axes made of Bohemian metabasites (BM) spread over central and southeastern Europe, crossed the Alps and reached Italy. According to different Neolithic traditions, during the 5th millennium BC Europe appears to be divided into a jade-using western area and a central-eastern BM-using one. During the 4th millennium BC, the exchange networks of Caput Adriae are increasingly influenced by the eastern Alpine and Balkan world, where the raw material sources of the main groups of shaft-hole axes are located. The association of the rocks used for axe production and copper ore suggests that the changes in raw material exploitation strategies during the Copper Age were probably related to the development of the first metallurgy.

Introduction: A Social History of the Irish and British Mesolithic

Living Mesolithic Time: Narratives, Chronologies and Organic Material Culture Abstract British and Irish Mesolithic studies have long been characterized by a reliance on broad-scale lithic typologies, both to provide chronologies, and in discussion of 'cultural' groups. More recently, traditional narrative structures—period definitions of 'Early' and 'Late', or culture typologies—have been complemented by a host of other evidence. This has included new studies of site stratigraphy, evidence for seasonality, and material culture chaîne opératoire chronologies, which place a greater emphasis on both temporal precision and the lived experiences of Mesolithic peoples. This paper will consider how the study of organic artefacts forces these narrative scales into acute focus, and presents an opportunity to explore the challenges in synthesizing different forms of data. We discuss how the evidence from sites in Ireland and Britain allows for new approaches, and highlight some of the challenges that this evidence presents, not least the perennial issue of moving from site-specific data to broader narratives. While the nature of earlier prehistoric evidence makes this an especially obvious issue for Mesolithic studies, it is one which generally besets archaeology. We suggest that in order to move beyond this in earlier prehistoric studies specifically, we need to make better use of all evidence sources, however seemingly prosaic, including antiquarian collections in museums, and chance and casual finds. Only by including the raft of available data, and recognizing its utility beyond the sum of individual apparently uninspiring parts, can we begin to move from generalizing narratives to more nuanced archaeological understandings of past material worlds.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com

Emergencies, Trauma, and Shock

What's new in emergencies trauma and shock? Point of care imaging in out-of-hospital cardiac arrest Vivek Chauhan Journal of Emergencies, Trauma, and Shock 2019 12(2):95-96

Alcohol and drug testing in the national trauma data bank: Does it matter? Adel Elkbuli, Brianna Dowd, Rudy Flores, Dessy Boneva, Shaikh Hai, Mark Mckenney Journal of Emergencies, Trauma, and Shock 2019 12(2):97-97

Recreational drugs and outcomes in trauma patients Quinn Fujii, Andrew McCague Journal of Emergencies, Trauma, and Shock 2019 12(2):98-100 Objective: The objective of the study is to determine if marijuana, methamphetamine, or cocaine is associated with worse outcomes following trauma. Methods: A retrospective cross-sectional study was conducted on 731 trauma patients. Data collected from Natividad Medical Center's trauma registry were used to analyze reports of adult patients from July 1, 2014, to July 1, 2017. Analyzed endpoints were mortality, rates of major trauma, mean Injury Severity Score (ISS), and length of stay (LOS). Results: Odds ratios for mortality contained null value in each group. Odds ratios for suffering major trauma for marijuana and amphetamines were 1.2 and 2.6, respectively.P values for ISS were >0.05 for each group.P values for LOS were >0.05 for marijuana and cocaine and 0.01 for amphetamines. Conclusions: A positive screen for marijuana, amphetamine, or cocaine is not associated with increased mortality for victims of trauma. Amphetamines are associated with higher rates of major trauma and longer LOS. Marijuana is associated with higher rates of major trauma. Cocaine is not associated with the likelihood of suffering major trauma or length of stay.

Evaluation of traumatic spine by magnetic resonance imaging and its correlation with cliniconeurological outcome Bukke Ravindra Naik, Anil Kumar Sakalecha, Shivaprasad Gangadhar Savagave Journal of Emergencies, Trauma, and Shock 2019 12(2):101-107 Background: Spinal trauma is associated with long-term disability. Early detection can lead to prompt and accurate diagnosis, expeditious management, and avoidance of unnecessary procedures. Magnetic resonance imaging (MRI) helps to accurately depict the presence and extent of spinal cord injury (SCI) in these patients. Purpose: This study was aimed to look for various MRI findings which are predictive of initial neurological deficit in patients with spinal trauma and to correlate the findings with resultant neurological outcome. Materials and Methods: The present study was conducted over a period of 18 months from January 2016 to June 2017 in 57 patients with spinal trauma who underwent MRI spine. Neurological status of patients was assessed at the time of admission and discharge in accordance with the American Spine Injury Association (ASIA) impairment scale. Various MRI parameters were evaluated for correlation with the severity of the spinal injury. Results: Patients with cord transection, cord hemorrhage, and epidural hematoma had initial high-grade ASIA impairment scale. Patients with cord transection and cord hemorrhage did not show any improvement in their neurological status during their hospital stay. Patients with only cord edema and epidural hematoma showed favorable neurological outcome. Cord contusion showed lesser neurological recovery, as compared with cord edema and normal cord. Conclusion: MRI findings in acute SCI correlated well with the initial neurological deficits on admission and at the time of discharge. MRI should be recommended in all patients with suspected spinal trauma both as a diagnostic and prognostic indicator.

Factors affecting mortality following necrotizing soft-tissue infections: Randomized prospective study Sukha Ram Barupal, Murari Lal Soni, Rekha Barupal Journal of Emergencies, Trauma, and Shock 2019 12(2):108-116 Background and Aim: Necrotizing soft-tissue infections (NSTIs) are common in the Indian subcontinent and are associated with high morbidity and mortality. The aim of this paper was to correlate clinical factors and Acute Physiology Health and Chronic Health Evaluation (APACHE) II score with mortality following NSTI. Methodology: Patients presenting to our tertiary-care center between November 1, 2014, and December 1, 2016, with NSTI and between the age of 15 and 90 years were included and entered into a prospectively maintained database. Fifty random patients were selected from the database and were divided according to the survival outcome into two groups: Group 1-survivors and Group 2-nonsurvivors. The two groups were compared for clinical factors and APACHE II score to identify the variable which correlated with the survival. Results: Mean age of the study cohort (n = 50, 44 males) was 50.8 ± 17.1 years. Fournier's gangrene was the most common manifestation (64%), followed by lower limb (14%). Infection was leading cause (34%) followed by trauma (16%) and prior surgery (14%). There were 16 in-hospital deaths (32%). Two groups were similar regarding age and sex. At presentation, nonsurvival group had significantly higher body surface area involvement (P = 0.001), anemia (P = 0.023), metabolic acidosis (P < 0.0001), serum creatinine (P = 0.007), and mean APACHE II score (P < 0.001). There was no difference between time from presentation to the first debridement. Conclusions: We found that APACHE II is a significant predictor of mortality. Early diagnosis and prompt aggressive treatment is the only way to improve outcome. Further studies with larger sample size are warranted.

Gunshot injuries in Lebanon: Does intent affect characteristics, injury patterns, and outcomes in victims? Hady Zgheib, Sami Shayya, Cynthia Wakil, Rana Bachir, Mazen J El Sayed Journal of Emergencies, Trauma, and Shock 2019 12(2):117-122 Introduction: Lebanon lacks a national database of gunshot injuries (GSIs), which limits injury prevention initiatives. Objectives: This study examines patient characteristics, injury patterns, and clinical outcomes in GSI victims and evaluates the impact of intent on clinical outcomes with the aim of improving awareness among emergency department (ED) physicians about the importance of inquiring about intent to predict prognosis. Materials and Methods: We conducted a retrospective cohort study of GSI victims presenting to the ED of a tertiary care center in Beirut, Lebanon. Descriptive and bivariate analyses were done to identify differences based on intent. Results: A total of 83 patients were included, 59% with intentional GSI, 22% with unintentional GSI, and 19% with unspecified intent. They were mostly males (89.2%), with a mean age of 31.7 years, and mostly presenting during summer seasons. Females were more commonly victims of unintentional GSI. All victims sustaining multiple GSIs were in the intentional group. When compared to unintentional GSI, intentional and unspecified GSIs were found to result in more ICU admissions (46.9%, 31.3%, and 16.7%,P = 0.096), significantly longer hospital stays (18.2, 26.3, and 5.6 days;P = 0.001) and higher mortality (11.6%, 18.2%, and 6.7%;P = 0.747). The rates of surgical procedures were similar between the three groups although more victims of intentional and unspecified GSI underwent multiple surgeries. Conclusion: GSIs have different features, resource utilization, and clinical outcomes depending on the intentionality of injuries. All GSI victims suffer from substantial morbidity and mortality, but intentionally harmed victims sustain more severe injuries with worse outcomes.

Understanding the knowledge and attitude of prehospital sepsis care among emergency medical service personnel Hadeel Sameeh Ghazal, Atheer Abdulaziz Alkhunein, Ahmed Abdullah Alkhazi, Salman Abdulmajeed Aldeheshi, Faisal Ahmed M. Alhusain, Nawfal Al Jerian Journal of Emergencies, Trauma, and Shock 2019 12(2):123-127 Background: Sepsis represents a huge burden for the health-care system. Septic patients presented by emergency medical services (EMS) are usually sicker in comparison to patients arriving by other means. Knowledge of sepsis is a key factor in recognizing and providing the appropriate care; it is not the only barrier as EMS providers do not have access to the proper diagnostic investigation. This work highlighted the level of knowledge, awareness, and attitude of EMS providers regarding prehospital care of sepsis in Riyadh, Saudi Arabia. Methods: This study was a cross-sectional study that conducted among EMS personnel of Saudi Red Crescent Authority and King Abdulaziz Medical City. One hundred and ninety-seven individuals were sampled (99 were technicians and 98 were paramedics). Results: Most participants (71%) were aware of the term “sepsis;” however, only 48% of participants correctly defined sepsis (30% between emergency medical technicians [EMTs] vs. 66% paramedics group,P < 0.01). Paramedics were noted to have a better understanding of signs, symptoms, and management of sepsis. Most of the participants thought that sepsis can be identified during prehospital care (55%) and 75% suggested that they should be involved in the management of septic patients. About 80% responded that their intervention would result in a better outcome for patients and would influence the behavior of emergency department medical care. Most of the participants (83%) were willing to be actively engaged in the prehospital care of septic patients. Conclusion: This study showed an insufficient level of knowledge and awareness regarding sepsis care in the EMS field in Saudi Arabia. Paramedics had more knowledge and awareness about sepsis care compared to EMT personnel. Future work should focus on exploring the reasons behind this, as well as implementing plans to improve education about sepsis for EMS personnel.

Do the care process and survival chances differ in patients arriving to a level 1 Indian trauma center, during-hours and after-hours? Kapil Dev Soni, Santosh Mahindrakar, Gaurav Kaushik, Subodh Kumar, Sushma Sagar, Amit Gupta Journal of Emergencies, Trauma, and Shock 2019 12(2):128-134 Introduction: Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country. Methodology: Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded. Results: Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan–Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST. Conclusions: Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.

An analysis using modified rapid ultrasound for shock and hypotension for patients with endogenous cardiac arrest Youichi Yanagawa, Hiromichi Ohsaka, Hiroki Nagasawa, Ikuto Takeuchi, Kei Jitsuiki, Kazuhiko Omori Journal of Emergencies, Trauma, and Shock 2019 12(2):135-140 Aims: We prospectively investigated whether or not a rapid ultrasound for shock and hypotension (RUSH) examination is useful for managing patients with endogenous cardiac arrest (CA). Settings and Design: A prospective medical chart review in a single hospital. Materials and Methods: From March 2016 to December 2017, we performed a modified RUSH for all patients with out-of-hospital endogenous CA. We investigated the frequency of positive findings on modified RUSH and what kind of diseases could most easily be pinpointed as the cause of CA by the modified RUSH. Results: During the investigation period, 194 participants were enrolled in the present study. They were primarily male, with an average age of 68.8-year-old, and 178/194 (91.7%) died as outpatients. The most frequent cause of CA was cardiogenic, followed by aortic disease, respiratory failure, and stroke except for unknown. There were 14/26 (54%) aortic disease patients who showed positive RUSH findings. Among cases of the aortic disease, only aortic dissections had positive findings. Aside from aortic disease, there were no cases of positive findings of the modified RUSH among the remaining diseases, and all patients with positive findings died. Only pulseless electrical activity (PEA) was a statistically significant factor for positive findings of the modified RUSH in cases of the aortic disease. Conclusions: The present study revealed that, among patients with out-of-hospital endogenous CA, modified RUSH is useful for diagnosing ascending aortic dissection for the detection of hemothorax and/or cardiac tamponade, especially with PEA.

The influence of cervical collar immobilization on optic nerve sheath diameter Joseph Yard, Peter B Richman, Ben Leeson, Kimberly Leeson, Guy Youngblood, Jose Guardiola, Michael Miller Journal of Emergencies, Trauma, and Shock 2019 12(2):141-144 Background: Prior research has revealed that cervical collars elevate intracranial pressure (ICP) in patients with traumatic brain injury. Two recent small studies evaluated the change in optic sheath nerve diameter (ONSD) measured by ultrasound as a proxy for ICP following cervical collar placement in healthy volunteers. Objective: We sought to validate the finding that ONSD measured by ultrasound increases after cervical collar placement within an independent data set. Methods: This was a prospective, crossover study involving volunteers. Participants were randomized to either have the ONSD measured first without a cervical collar or initially with a cervical collar. Two sonographers performed independent ONSD diameter measurements. Continuous data were analyzed by matched-paired t-tests. Alpha was set at 0.05. The primary outcome parameter was the overall mean difference between ONSD measurements with the cervical collar on and off. Multiple linear regression was performed to examine the relationship between variables and the primary outcome parameter. Results: There were 30 participants enrolled in the study. Overall mean ONSD for participants without the collar was 0.365 ± 0.071 cm and with the collar was 0.392 ± 0.081 cm. The mean change in ONSD for participants with and without the collar was 0.026 ± 0.064 cm (95% confidence interval of difference: 0.015–0.038;P < 0.001). Multiple regression analysis did not identify any variables associated with the variation in ONSD observed for collar versus noncollar. Conclusions: We confirmed that ONSD does vary by a measurable amount with placement of a rigid cervical collar on healthy volunteers when assessed by ultrasound.

Alexandros Sfakianakis
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