In recent work, asymmetric conjugate addition reactions to chiral 4-phenyl-N-enoyl-1,3-oxazolidinones have been shown to give different stereochemical outcomes depending on the conditions employed. Through the application of stereodivergent reaction conditions, the total synthesis of (+)-pilosinine and the formal synthesis of (-)-pilosinine has been completed from a single enantiomer of the 1,3-oxazolidinone auxiliary. (C) 2020 Elsevier Ltd. All rights reserved.

One of the most challenging injury patterns to emerge from the recent military conflicts in Iraq and Afghanistan is the dismounted complex blast injury (DCBI), with multiple proximal amputations, pelvic fractures, and extensive perineal wounds (Fig. 1).(1-5) Lessons learned from managing patients with this pattern of injury must be captured to minimize the morbidity and mortality of those suffering similar injuries in the future. These lessons also apply to civilian patients suffering open pelvic fractures and crush injuries to the pelvis. 6 The aim of this review was to detail the diagnostic work-up and initial multidisciplinary management of DCBI patients, to describe some of the most common complications after DCBI, and to discuss future research efforts to improve the survivability and outcomes of DCBI.

Background. Equestrian injury is commonly seen at trauma centers and the severity of injury is often high. We sought to determine the risk, incidence, and the influence of skill and experience on injury during horse-related activity (HRA). Methods. Members of horse clubs and individual equestrians in a three-state region (Oregon, Washington, and Idaho) were recruited via mailings and community advertisements to take a survey regarding their horse contact time and injuries over their entire riding career. Serious injury (SI) was defined by hospitalization, surgery, or long-term disability. Results. There were 679, equestrians with a median age of 44 years who reported a median of 20 hours of HRA per month with a mean of 24 years (1 to 75 years) experience. The cumulative risk of any injury (AI) was 81% and of SI was 21 %. The incidence of Al and SI were 1.6 +/- 0.1 (SE) and 0.26 +/- 0.02 per 10,000 hours, respectively. The incidence, per 10,000 hours, of Al was 7.6 +/- 2.7, 2.4 +/- 0.2, 1.5 +/- 0.1, and 1.0 +/- 0.1 at novice, intermediate, advanced, and professional levels, respectively (p < 0.001, analysis of variance [ANOVA]) and of SI was 1.03 +/- 0.52, 0.38 +/- 0.06, 0.21 +/- 0.03, and 0.19 +/- 0.04 at the respective skill levels (p < 0.001, ANOVA). There was a sharp decline in incidence of injury between 18 and 100 hours of experience. Helmet use was 74%, 61%, 58%, and 59% at the respective skill levels (NS, X2). Conclusion., One in five equestrians will be seriously injured during their riding career. Novice riders experienced a three-fold greater incidence of injury over intermediates, a five-fold greater incidence over advanced riders, and nearly eight-fold greater incidence over professional equestrians. Approximately 100 hours of experience are required to achieve a substantial decline in injury. These findings suggest that equestrian injury prevention efforts need more attention and should focus on novice equestrians.

OBJECTIVES To compare mortality rates of hospitalized injured aged 67 and older across commonly used follow-up periods (e.g., in-hospital, 30-day, 1-year) and to determine the postinjury time after which mortality rates stabilize. DESIGN Retrospective analysis of Medicare claims. SETTING Oregon and Washington Medicare patients. PARTICIPANTS Patients admitted to 171 Oregon and Washington facilities during 2001/02 with injuries identified according to International Classification of Diseases, Ninth Revision, code and followed for 1 year. MEASUREMENTS The primary outcome was in-hospital mortality and mortality at 30, 60, 90, 180, and 365 days. Kaplan-Meier survival curves and daily postadmission mortality rates were also evaluated. The rate of change (slope) of the survival curves and daily mortality rates were analyzed to select the point after which mortality rates were no longer decreasing. RESULTS There were 32,135 injured older adults hospitalized over the 2-year period, with a median age of 82 (interquartile range 77-88). Cumulative in-hospital mortality and at 30, 60, 90, 180, and 365 days was 4.1%, 9.7%, 13.6%, 16.1%, 21.3%, and 28.4%, respectively. Mortality rates stabilized by 6 months after injury, with 89% of the change occurring within 60 days. Although serious injuries, medical comorbidities, and preinjury nursing facility residence were all associated with higher mortality, they did not affect the pattern of mortality after injury. CONCLUSION In-hospital mortality is much lower than postdischarge mortality in injured older adults, with a substantial portion of persons dying shortly after discharge from the hospital. Mortality appears to stabilize by 6 months after injury, although 60-day postadmission follow-up captures most of the excess daily mortality rate.

Hypothesis: Survival until a fixed time after injury is a more useful outcome variable than survival until hospital discharge. Design: We sought to determine whether 30-day survival could be accurately predicted by hospital discharge status. Setting: Academic research. Patients: We analyzed Medicare fee-for-service records for patients 65 years or older admitted with a principal diagnosis of injury (International Classification of Diseases, Ninth Revision, Clinical Modification codes 800959, excluding 905-909, 930-939, and 958). Main Outcome Measures: Patients were classified by maximum Abbreviated Injury Score (range, 1-5) and Charlson comorbidity score (0, 1, 2, or >= 3). We modeled the conditional probability of survival at 30 days given hospitalization survival (P[S30 vertical bar SH]) as a function of census region, age, sex, maximum Abbreviated Injury Score, Charlson comorbidity score, length of stay, and discharge home or not. Results: A total of 436 104 patients met inclusion criteria, and a model was created using half the sample. For northeastern women aged 65 to 69 years with a maximum Abbreviated Injury Score of less than 3, Charlson comorbidity score of 0, and discharge home with length of stay less than 3 days, the model predicted P(S30 vertical bar SH) to be 0.998. The P(S30 vertical bar SH) was lower for other census regions, male sex, older age, more severe injury, and greater comorbidity. The equation had modest predictive ability when applied to individuals in the other half of the sample (area under the receiver operating characteristic curve, 0.75) and closely predicted P(S30 vertical bar SH) within numerous subpopulations. Conclusion: For injured patients insured by Medicare, P(S30 vertical bar SH) can be estimated using administrative data known at the time of hospital discharge.

Background: Studies of trauma systems have identified traumatic brain injury as a frequent cause of death or disability. Due to the heterogeneity of patient presentations, practice variations, and potential for secondary brain injury, the importance of early neurosurgical procedures upon survival remains controversial. Traditional observational outcome studies have been biased because injury severity and clinical prognosis are associated with use of such interventions. Objective: We used propensity analysis to investigate the clinical efficacy of early neurosurgical procedures in patients with traumatic brain injury. Methods: We analyzed a retrospectively identified cohort of 518 consecutive patients (ages 18-65 years) with blunt, traumatic brain injury (head Abbreviated Injury Scale score of >= 3) presenting to the emergency department of a Level-1 trauma center. The propensity for a neurosurgical procedure (i.e., craniotomy or ventriculostomy) in the first 24 h was determined (based upon demographic, clinical presentation, head computed tomography scan findings, intracranial pressure monitor use, and injury severity). Multivariate logistic regression models for survival were developed using both the propensity for a neurosurgical procedure and actual performance of the procedure. Results: The odds of in-hospital death were substantially less in those patients who received an early neurosurgical procedure (odds ratio [OR] 0.15; 95% confidence interval [CI] 0.05-0.41). The mortality benefit-of early neurosurgical intervention persisted after exclusion of patients who died within the first 24 h (OR 0.13; 95% CI 0.04-0.48). Conclusions: Analysis of observational data after adjustment using the propensity score for a neurosurgical procedure in the first 24 h supports the association of early neurosurgical intervention and patient survival in the setting of significant blunt, traumatic brain injury. Transfer of at-risk head-injured patients to facilities with high-level neurosurgical capabilities seems warranted. (C) 2009 Elsevier Inc.

Background: Patient outcomes are presumed to vary during early implementation of a trauma system because of fluctuations in processes of care. This study estimates risk-adjusted survival for injured geriatric patients during implementation of the Washington State trauma system. Methods: A presystem (1988-1992) versus early construction phase (1993-1995) retrospective cohort analysis of hospitalized geriatric injured patients in Washington State was conducted. Hospital data were cross-linked to death certificates, providing patient follow-up. A Cox proportional hazards model assessed survival to 60 days from hospital admission. Results: A total of 77,136 geriatric patients were assessed. No difference in survival was observed (before vs. after) for all geriatric injured patients. However, among severely injured patients (Injury Severity Score>15), survival during the implementation phase increased by 5.1% compared with patients admitted during the presystem years (p=0.03). Conclusion: This study demonstrates improved survival for seriously injured geriatric trauma patients during construction of the Washington State trauma system.

Injuries to major abdominal arteries and veins frequently are associated with exsanguinating hemorrhage and visceral ischemia. Expeditious management is the key to survival and good outcome. Knowledge of anatomic relationships between viscera and vessels forms the basis for directed dissection, optimal exposure, and lasting repair of vessels. Although penetrating mechanism of injury remains the most common cause of these injuries, trauma surgeons must be familiar with patterns of blunt trauma-mediated injury to avoid the devastating consequences of delayed management.

background: Logistic regression models, with coefficients developed from normative populations, can be applied to a trauma registry cohort to predict the risk-adjusted frequency of death. Quality of care is judged based on differences between predicted and observed mortality frequency. The goal of these analyses was to determine if decedents who died in the emergency department had independent variables associated with risk of death identical to those who died after hospital admission.