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The growth of In2 O3 islands on (001)-oriented Y-stabilized cubic ZrO2 has been investigated using high-resolution x-ray diffraction and the results compared with those from atomic force microscopy and electron microscopy. Measurements were performed with wave-vector transfer both parallel to and perpendicular to the surface normal. Transverse scans around the epilayer (004) and (008) reflections gave a characteristic three-peak structure for wave-vector transfer along the [110] direction but a two-peak structure when the scan was performed along the [100] direction. These results suggest that the atomic planes of the islands are not parallel to those of the substrate but are tilted at an angle of about 0.7° from the four different in-plane 〈 110 〉 directions. Tilting was also observed in real space by high-resolution transmission electron microscopy. The tilt helps to relieve tensile strain arising from a -1.6% lattice mismatch between the epilayer and the substrate. The tilt direction is shown to be determined by the elastic constants of the epilayer, which favor strain along 〈 110 〉 directions rather than 〈 100 〉 directions. The x-ray results also indicated that the islands imaged by atomic force microscopy are each built up from microdomains so that the coherence length deduced from x-ray scattering is much smaller than the island size. Thus for islands with a thickness of 2500 Å the coherence length was estimated to be about 500 Å. © 2010 The American Physical Society.

During the 15 years from 1971 through 1985, 114 patients with rupture of the thoracic aorta caused by blunt trauma were admitted to the Shock Trauma Center of the Maryland Institute for Emergency Medical Services Systems. Mean age was 31.3 years (range, 15 to 80). Ninety were male and 24 were female, a 3.75:1 ratio. Of the 114, 89 (78.1%) survived initial resuscitation in the admitting area. Twenty five of the 89 initial survivors (28.1%) died during or after surgical repair. Paraplegia occurred in 11 of the 78 operating room survivors (14.1%). Further analysis was done of the 83 patients admitted in the 10-year period from 1976 through 1985. Mean Injury Severity Score, excluding aortic injury, was 18.2. Twenty-five of the 83 (30.1%) died during resuscitation in the admitting area or operating room. Seven others died during surgical repair and 12 died postoperatively, leaving 39 survivors (39/83 [47%] of total admissions and 39/58 [67.2%] of survivors of resuscitation). Paraplegia/paresis developed postoperatively in six of 34 (17.6%) cases involving shunt and four of 17 (23.5%) without shunt. Other major complications occurred in 21 of the operating room survivors. Statistically significant risk of death or major complication was associated with female sex, higher Injury Severity Score, lower admission blood pressure, larger hemothorax on admission, less qualified surgeon, major operation before aortic repair, use of shunt, and transfer directly from scene of injury. There was no advantage in this series to using or not using a shunt in preventing paraplegia. Mortality rates are realistic for a highly developed trauma system. Better techniques are needed to manage exsanguination and prevent paraplegia.

SUMMARY In summary, two incidents selected from many reported in the literature serve as arguments for the value of the EMS primary phase response.

Over a seven-year period from 1973 through 1979, 31 patients with blunt gallbladder trauma were treated at the Maryland Institute for Emergency Medical Services Systems. Twenty patients had contusions, ten patients had avulsions and one patient had a perforation of the gallbladder. None of the gallbladder injuries were suspected preoperatively. Twenty-eight of the 31 patients had a diagnostic peritoneal lavage performed on admission, all were positive for blood; bile was not grossly evident. Among the 30 patients, there were 75 associated intraabdominal injuries; there were 25 liver injuries. Five patients died, none as a result of their gallbladder injury. Cholecystectomy is suggested as the definitive procedure of choice for severe contusions and for perforating and avulsive injuries to the gallbladder. Cholecystostomy is indicated in a few patients and should be regarded as a temporary procedure. A review of the English literature shows a total of 101 patients (including the 31 of this study) with gallbladder injuries secondary to blunt trauma. The most commonly reported injury was perforation. The 20 contusions described in the present study are the first such injuries reported.

The early 1970's, as an outgrowth of the American military experience, several pioneer regional trauma/EMS programs showed the way for better planning, organization, and resource deployment for trauma/EMS systems in the civilian community. The experience of the mid and late 1970's has brought an even wider implementation and modeling of trauma/EMS care systems with identification of specific patient problems, designation of trauma service centers, development of protocols, and professional teams on a regionwide basis. Currently, the acceptance of regionalized systems of care for trauma makes it a potentially manageable disease with greater prospect for developing even better systems of trauma care and control in the 1980's. The progressive impact on improving trauma care for this nation will in large part be due to the continued planning and development of regional trauma/EMS systems which have as a key focus the designation of an appropriate limited number of trauma service centers for geographic regions and the nation.

✓ Cerebral vasomotor responses to alterations in arterial carbon dioxide (PaCO2), as manifested by intraventricular pressure changes, were studied in a group of patients with head injuries. These patients could be classified into three types based on various degrees of responsiveness thought to reflect the integrity of their cerebral vasomotor reactivity.

Massive pulmonary embolism was produced in 16 dogs using autologous blood clots. Survival rate in this group was 50 per cent. Sixteen dogs were embolized in a similar fashion and were treated with oxygen under three atmospheres absolute. The survival rate was increased to 69 per cent. The improvement in survival rate was correlated with improvement in the hemodynamic, biochemical and electrocardiographic changes.

In the context of developing a mass casualty evaluation methodology and in the pursuit of increased realism in the field, a system of casualty time cards has been developed. These cards capture most elements of the physician evaluation and free decision-making from the ambiguity that necessarily accompanies having a doctor 'evaluate' mock victims. They manifest the deterioration or death of the victim as time goes by and condition the risks and outcomes to depend upon treatment.

Sepsis and upper gastrointestinal hemorrhage due to duodenal-caval fistula complicated delayed treatment of an abdominal gunshot wound. Gastric and duodenal decompression, external drainage of the duodenal repair, and caval ligation are preferred for delayed treatment of combined duodenal and infrarenal vena caval injuries.

In recent years the syndrome of overwhelming post-splenectomy sepsis has been increasingly reported in adults. Since more than 50% of these infections are caused by pneumococcus these post-splenectomy patients are considered a suitable group to receive the pneumococcal vaccine. Previous studies of the response obtained in post-splenectomy patients have been conflicting and we found no study that looked at the response to immediate vaccination in this group of patients. Sixteen consecutive multitraumatized patients received polyvalent pneumococcal vaccine 0.5 ml IM within 72 hours of splenectomy and 10 normal controls were given 0.5 cc polyvalent pneumococcal vaccine. Patients received an average of 19.2 units of blood and blood products; seven were on steroids for concomitant head injury. Antibody was measured by the radioimmune assay. Most of the subjects of both groups responded to at least seven of the 12 measured antigens and no patient in the control group and only one in the splenectomized group responded to all 12 antigens. When rate of response to individual serotypes was compared no difference was found between the two groups. Comparison of geometric mean fold rise and fold rise between the two groups for each of the 12 serotypes revealed essentially no difference. We conclude the response to polyvalent pneumococcal vaccine among polytrauma splenectomized patients is similar to that of normal controls, and that the vaccine can be administered immediately post-splenectomy.

The authors discuss the setting, patients, and staff, and the role of psychiatric consultants in intensive care units and trauma centers. They point out the similarities and differences between patients with multiple trauma and those who have had open-heart surgery and head or spinal cord injuries. They also deal with the question of an element of self-destructive behavior in accidents and offer suggestions for the psychiatric management of severely traumatized patients. The authors conclude that the role and obligation of the psychiatrist of the the future will lie in crisis intervention within the medical-biological model. Language: en

During an 11-month period 31 cases of nosocomial empyema were identified in 29 of 741 multiply traumatized patients who remained in our unit for more than 3 days. Nosocomial empyema was defined as purulent culture-positive material drained from the pleural space after five days' hospitalization. All patients had fever and leukocytosis. Possible risk factors included previous aspiration in five patients but none developing pneumonia, prior respiratory tract infection in nine but none with the same pathogen as their empyema, prior antibiotic use in over 50% of the patients, and severe head or chest injury in two thirds of the patients. Thirty-eight pathogens were recovered: S. aureus, 14; beta-streptococci, three; Pseudomonas, six; Klebsiella, two; Enterobacter, two; E. coli, two; other Gram-negative bacilli, six; and anaerobes, three. Fourteen infections were polymicrobic and bacteremia occurred in 42% of the patients. Of these 29 patients, 27 had chest tubes inserted for fluid in the pleural cavity before development of empyema; nine for hemo- or pneumothorax secondary to chest trauma, 11 for pneumothorax while on ventilators, and seven for unexplained sterile pleural effusion. If empyema complicated a prior hemothorax it was usually caused by Staphylococcus aureus and occurred about 10 days after draining blood from the pleural cavity. If empyema was a complication of pneumothorax or serothorax it was usually due to Gram-negative organisms colonizing the upper respiratory tract and occurred within 4 days of draining the fluid. Sixteen per cent of all patients who had chest tubes placed for fluid in their pleural cavity subsequently developed empyema.(ABSTRACT TRUNCATED AT 250 WORDS)

Twelve patients developed acute cholecystitis complicating trauma. Acute acalculus cholecystitis was present in 11 patients. Nine patients died. A review of 20 reports comprising 98 patients shows 86.7% had acute acalculus cholelithiasis, and 61.1% had necrosis, gangrene, and/or perforation of the gallbladder. The overall mortality was 33.3% and only 16.1% of patients treated by cholecystectomy died. The etiology of acute cholecystitis complicating trauma is multifactorial. Gallstones are present infrequently whereas shock, increased bile pigment load, drugs, surgery, and (other) trauma are common precursors. Diagnosis is difficult and depends upon clinical suspicion and the physical examination. Immediate surgical intervention is required. Cholecystectomy is the procedure of choice. We recommend cholecystectomy at initial laparotomy whenever there is evidence of trauma to the gallbladder, or if the right or common hepatic artery is ligated for hepatic bleeding.