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Chapter 1 argues that thinking about boxes will allow us to comprehend the reparative work that comics can do in approaching transgenerational Holocaust memory and trauma. What would it mean to read Maus as a Jewish text in our moment of global attention to Jewish identity and Holocaust memory? Building upon Hillary Chute’s landmark scholarship on Spiegelman’s Maus and comics and/as archives, I show how Spiegelman’s slippery, evocative metaphor of comics panels as built boxes links his magnum opus to Jewish traditions surrounding the material preservation and transmission of historical texts. Reconsidering Maus together with boxes, in light of what can – and can’t – be enclosed and contained, illuminates formal congruences between Maus, the architected space of the Mishkan, and the textual practice of Midrash. Unpacking these congruences in turn reveals Spiegelman’s survivor’s “tale” as a text, commentary, object, memorial, testimony, even a kind of secular phylactery or reliquary, through which the son of survivors negotiates his inherited trauma and his own Jewishness.
Chapter 3 examines an absurd, tic-tac-toe-faced avatar created by Art Spiegelman, known as “OXO.” I argue that Spiegelman’s adoption of the “OXO” persona functions as a coded emblem of his process of coming to terms with traumatic loss. The figure of “OXO” and his tic-tac-toe-faced family first appeared in 1983, contemporaneously with Spiegelman’s work on Maus. Conjugating comics with tic-tac-toe yields a new understanding of the comics grid itself as an alternating game of reading and looking: a game that undisciplines the grid and makes it playful. Moreover, perceived as a face, tic-tac-toe embodies the complexities of inherited identity, or an identity dictated by the play of external forces. OXO’s symbolic richness helps Spiegelman revisit his 1972 “Prisoner on the Hell Planet: A Case History,” the first comic he produced on his long road to Maus. This chapter presents an extended case study of a one-page “OXO” comic, “Lost,” in which the cartoonist reenters and reimagines both recent and distant memories of loss, in an ongoing and necessarily incomplete effort to master them.
This book places the larger autobiographical projects of Art Spiegelman and Alison Bechdel alongside each other for the first time, drawing on a range of previously unanalyzed works. It argues that the structurally layered, word-and-image form of comics is particularly well-suited to negotiate complex filial inheritances and manage identity in the face of transgenerational trauma. Each chapter is organized around a different formal trope that highlights an aspect of the visual language of comics and its material processes: boxes, spirals, tic-tac-toe, mirrors, and webs. From Jewishness to gender, from high modernism to lesbian feminist communities, Filial Linesshows how the comics form is capacious enough to accommodate the push–pull of inheritance and invention, enabling both creators to negotiate their place in (or beyond) various lines of familial, cultural, and artistic descent. Integrating formalist and psychoanalytic frameworks, and parsing alignments and differences with different forms of practice, the book situates today’s graphic memoir canon as an unexpected outpost – and expansion – of avant-garde formalism long after the modernist moment of form.
This chapter addresses the issue of linguistic and structural experimentation in Time’s Arrow and Night Train. Going beyond the apparent differences between the two novels (reflected in the criticism devoted to them), it demonstrates that they are characterised by an experimental vein relying on the same pillars, that is, stylistic virtuosity, narrative inversion, and doubling. It argues in favour of Amis’s use of experimental gestures as geared to the experiential manifestation of a distinctive narrative ethics.
Early (before age 6) potentially traumatic events (PTEs) may interact with hypothalamic–pituitary–adrenal (HPA) axis functioning to shape outcomes involving externalizing problems and anxiety. However, directions of effects remain unclear. This study examined associations between aspects of HPA axis reactivity, anxiety, and externalizing problems over two years by early PTE exposure history, while statistically capturing the co-occurrence of symptom domains. Youth (N = 189; Mage = 10.96 years, SD = 2.51, Range = 8–15; 52.4% female, 47.1% male; 50.3% White, 35.4% Black/African American, 6.4% Other; 7.4% Hispanic/Latine) were included if they had early PTE exposure (n = 107) or had never experienced a PTE (n = 82). HPA axis reactivity to social stress was calculated using area under the curve with respect to ground (AUCg) and increase (AUCi). For youth with early PTE exposure, higher AUCg was concurrently associated with more externalizing symptoms and greater predominance of externalizing over anxiety. Blunted AUCi predicted increasing predominance of externalizing for the early PTE group, but elevated AUCi predicted increases in anxiety for the no PTE group. Findings highlight distinct roles of overall and reactive HPA axis functioning in shaping outcomes following early trauma.
War has a complex relationship to creativity and the arts. War is a mythic and hallowed subject of art, where it is often depicted in sacred terms as the testing ground of foundational leaders and the cauldron from which societies emerge. Yet based as it is in killing and destruction, war damages both society and creative faculties. War ends lives, destroys cultural treasures, disrupts artistic careers, and wreaks havoc on social networks through which artists develop and share work. War’s violence inflicts physical and psychological disabilities that limit creative expression. Those negative impacts can, paradoxically, spur creativity: war experience pushes artists to invent new forms of expression and has led to whole artistic movements (such as Surrealism). War also leads to creative interventions in fields like medicine, technology, and communication. War also changes how societies conceptualize creativity itself. “Creativity” emerged as a social scientific concept during World War II and became an important area of Cold War investigation, one cultivated to impart competitive edge. Creativity research will continue to deepen our understanding of how humans make and survive war.
Hospital mass casualty incident (MCI) plans must be able to remain operational during wartime. This study examined the impact of the October 7, 2023, attacks on the activation and execution of an MCI protocol in a hospital in southern Israel.
Methods
This qualitative study employed thematic analysis of semi-structured interviews conducted with 19 Emergency Department (ED) staff members who worked on October 7, 2023. Interview questions were developed by the authors, based on their professional experiences as physicians, with input from personnel involved in the October 7, 2023, response. Thematic saturation was considered achieved when consecutive interviews yielded no new themes.
Results
Three themes were identified. Threats to staff safety affected staff mobilization and prevented evacuation of patients from the ED. The prolonged and evolving nature of the attacks created unpredictability. Limited official information was partially compensated for through alternative information sources. Finally, a culture of frequent MCI drills contributed to maintaining patient flow and standards of care.
Conclusions
During wartime, MCI plans can remain effective by prioritizing staff safety and mitigating burnout. Information should be collected from multiple sources to compensate for uncertainty and limited situational awareness. Frequent, realistic drills help to maintain operational performance under the extreme stress of war.
Clinical decision support (CDS) tools have been demonstrated to improve patient care and outcomes yet remain under-utilized in many clinical domains, including en route care.
Study Objective:
This study evaluated whether a decision-tree CDS tool integrated within the government-created Battlefield Assisted Trauma Distributed Observation Kit (BATDOK; AFRL) clinical care software improves adherence to Joint Trauma System (JTS) guidelines for severe traumatic brain injury (TBI).
Methods:
In a randomized crossover simulation of military clinicians (N = 24), paired participants managed a patient with elevated intracranial pressure (ICP) using either usual care (UC) or BATDOK with TBI CDS in a simulated fixed-wing air transport mission. Outcomes included completion of critical actions by simulation conclusion, time to completion of critical actions, adherence to tiered interventions as outlined in JTS Clinical Practice Guideline (CPG), and user evaluations of the CDS tool using the validated instrument, System Usability Scale (SUS).
Results:
There were no significant differences in the primary outcome, percentage of critical items completed. Teams completed a median 83.3% of the critical items in the UC scenario, compared to 91.7% in the CDS scenario (P = 0.58; median difference 4.2%, 95% CI of the difference -8.1% to 16.4%). The mean SUS score for the CDS platform was 77.6 (SD = 16.0), which is associated with a “good” usability rating. Most participants rated the CDS platform favorably on every item of the SUS.
Conclusion:
The BATDOK with TBI CDS did not statistically increase completion of critical tasks in this initial evaluation of usability. However, these data suggest that BATDOK enhanced with CDS improved tiered guideline-concordant sequencing of ICP interventions outlined by the JTS CPG and was favorably rated by users, suggesting feasibility for operational integration.
This chapter examines the intersections between Indigeneity, Indigenization and CRT as paths to uncover structural racism and inequities, to resist and neutralize decolonizing ways. Indigeneity and Indigenization are grounded in radical remembering and reconceptualizing social work’s ethical and moral fortitude. They represent Indigenous identities, lifeways and values calling on us to examine all aspects of racism, power distribution, and wellbeing with the intent of strengthening communities. The dualism of CRT, white vs. black and other people of color, neglects Indigenous world views and perpetuates colonial dynamics by excluding ways of being and thinking beyond race. In this way, CRT detracts energy from restoration, securing of ancestral lands, revitalizing Indigenous languages and cultural practices, and impedes intergenerational healing. Indigenously defined social work practice holds the promise of universal wellbeing and opportunities to diversify a socially just agenda.
This article revisits the 2019 Anti-Extradition Law Amendment Bill Movement in Hong Kong through the lens of trauma. It argues that both the pro-democracy and pro-government camps framed themselves as victims and engaged in dehumanizing and infra-humanizing narratives, intensifying conflict and emotional harm. Although the movement ended with the National Security Law and the COVID-19 outbreak, the trauma remains unresolved. Post-movement policies, especially in education, have often exacerbated rather than healed the divisions. This study calls for government-led reconciliation efforts to move beyond mutual victimhood and foster genuine recovery for Hong Kong society.
This chapter explores the lives of ordinary men and women in Song China – the majority whose experiences were far less documented than those of the elite. What was daily life like for them? What brought them happiness, and what were their fears? Drawing on the remarkably rich materials from the Yijian zhi 夷堅志 (Record of the Listener), this chapter weaves together the life stories of ordinary people in Song China by examining their livelihoods, spiritual world, and emotional trauma. Through these narratives, it reveals how grand historical forces – commercialization, religious integration, and the brutality of war – shaped the everyday experiences of Song China’s non-elite population.
The perimenopause is an individual experience, influenced by life circumstances, cultural context, family history and narrative. The perimenopause can last many years and women, as well as health professionals, can be poorly prepared for this potentially challenging period. Most people know to expect hot flushes, and maybe genitourinary symptoms. However, if the emotional symptoms, such as, reduced ability to cope, irritability and sudden anger, arise first, years before the expected hot flushes, it can be difficult to understand and have a detrimental effect on a woman’s life. We explore widespread physical symptoms of perimenopause and highlight symptoms that are regulated in the brain: hot flushes, body temperature regulation, sleep disturbances, libido. We focus on emotional symptoms, such as mood changes, depression, anxiety, agitation, irritability, a sense of overwhelm and losing the ability to cope, and explore their impact on suicidality. We briefly look at cognitive symptoms and explore the influence of trauma and the differences in experience by ethnicity and cultural influence. Finally, we look at the experience of premature ovarian insufficiency.
This is an emergency medicine oral board-style case of severe facial trauma. An intoxicated patient presents to the emergency department with facial swelling and bleeding after trauma and is found to have a Le Fort III fracture with significant facial swelling, ecchymosis, missing teeth, and bleeding from the oropharynx. Successful completion of the case includes suctioning the airway, repositioning the patient, opening the airway, intubating the patient using an awake or facilitated look technique, and obtaining CTs of the head, C-spine, and facial bones. The patient’s final diagnosis is Le Fort III fracture and facial hemorrhage. The oropharynx continues to bleed, requiring packing and emergent otolaryngology or oral maxillofacial surgery consultation. This chapter discusses specific considerations for difficult airway management in the setting of significant facial trauma.
This chapter synthesizes the known examples of skeletal paleopathology in Neandertals including nonspecific stress indicators (mainly dental enamel hypoplasias), oral pathology (periodontal disease, caries, and tooth loss), osteoarthritis, trauma, infections and inflammations, neoplasms, and congenital disorders. Frequencies of lesions can be assessed for the dental/oral pathologies based on their larger sample sizes, but the other examples are predominately individual cases. Issues of the “osteological paradox,” mortality profiles, taphonomy, burial versus incidental preservation, and behavior must also be weighed when attempting to reconstruct aspects of Neandertal health and trauma from bony and dental lesions. Considering these skeletal pathologies together provides an indication of the levels of risk and general health experienced during the Middle Paleolithic as well as the larger biosocial implications of a foraging subsistence strategy in the Pleistocene. Overall, these abnormalities are not unique to Neandertals and reflect larger hunter-gatherer skeletal biology patterns.
Appropriate, evidence-based care of traumatically injured patients in the prehospital setting is essential to saving lives and yielding better outcomes. There exists mixed evidence on the outcome differences between ambulance and helicopter prehospital transport, and on the effects of transport time on outcomes. The purpose of this paper is to examine these in patients presenting to an urban Level-1 trauma center.
Methods:
A retrospective analysis was conducted with three years of patient information from a trauma registry maintained by a Level-1 trauma center in St. Louis, Missouri (USA). Propensity matching was used to compare helicopter versus ground ambulance outcomes, while regression analysis was used to investigate transport time.
Results:
After propensity matching to injury severity, helicopter transport was associated with improved prehospital survival (OR = 4.1; [95% CI, 1.2-21]; P = 0.02), though no difference in in-hospital survival (OR = 0.9; [95% CI, 0.4-1.8]; P = 0.71), intensive care unit (ICU) stay (difference = 0.8 days; [95% CI, -0.9-2.5]; P = 0.36), or hospital length-of-stay (difference = 51 hours; [95% CI, -7-109]; P = 0.08). Decreased transport time was not associated with increased survival (P = 0.31), but when transport times were less than 30 minutes, further reductions were significantly associated with shorter hospital stays (r2 = 0.02; P = 0.05) and fewer ICU days (r2 = 0.02; P = 0.05).
Conclusions:
Decreased injury to hospital arrival time and increased use of helicopter transport in specific situations may improve patient outcomes; this indicates the need for prospective studies.
Adverse childhood experiences (ACEs) are associated with increased risk of psychotic-like experiences (PLEs), but the relationship between specific adversities and the persistence of PLEs in young people remains unclear. We examined associations between distinct ACEs and the persistence of PLEs until 24 years old.
Methods
Using longitudinal data from participants in the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort with at least one PLE datapoint, we used group-based trajectory modeling to estimate longitudinal trajectories of PLEs from age 12–24. We examined their associations with bullying victimization, maltreatment, parental mental health problems, parental substance abuse, parental separation, and parental intimate partner violence prior to first PLE experiences.
Results
Among 4,448 participants, a three-group trajectory model provided the best fit, revealing low, increasing and persistent PLE groups from ages 12–24. In fully adjusted multinomial logistic regression models, those exposed to bullying were more likely to belong to either the increasing (relative risk ratio [RRR]: 1.83, 95%CIs: 1.26–2.66) or high (RRR: 1.78, 95%CIs: 1.07–2.93) PLEs group than the low PLE group; those exposed to maltreatment were more likely to be in the increasing PLE group (RRR: 1.47, 95%CIs: 1.03–2.10). No other ACEs were associated with PLE trajectories.
Conclusions
Bullying was associated with persistent PLEs up to 24 years old, independent of other forms of childhood adversity, with timing-specific effects of maltreatment on increasing symptoms emerging later in adolescence. Findings provide further evidence for the importance of prioritizing bullying and maltreatment reduction as public health targets.
Systemic inflammation is hypothesized to contribute to post-traumatic stress disorder (PTSD) vulnerability. Few studies have examined inflammation shortly after trauma as a predictor of later PTSD symptoms. We examined whether inflammation from the emergency department (ED) post-trauma is associated with PTSD symptom severity over the following 6 months.
Methods
Our sample included 742 AURORA participants, a longitudinal cohort of patients in 29 EDs across the United States after a traumatic stressor, followed up to 6 months. Plasma cytokines were assessed from a study blood draw in the ED: an inflammatory index (standardized sum of generally pro-inflammatory markers interleukin [IL]-6, IL-8, tumor necrosis factor alpha [TNF-α], interferon gamma [IFN-γ]), and generally anti-inflammatory IL-10. PTSD symptoms were self-reported at 2 weeks, 8 weeks, 3 months, and 6 months post-ED. Covariate-adjusted repeated-measures regressions estimated associations between inflammation and PTSD symptoms, overall and sex-stratified.
Results
Among 742 participants (age m = 40.0 [13.7]; 479 [64.6%] female), PTSD symptoms were elevated then modestly decreased over follow-up. Higher ED inflammation was associated with higher PTSD symptoms across follow-up (standardized symptoms β = 0.05, 95% CI: 0.01–0.09), adjusted for potential confounders. Higher pro-inflammatory index levels and IL-6, IL-8, and TNF-α were associated with higher PTSD symptoms in males only, while higher IL-10 was associated with higher PTSD symptoms in females only.
Conclusions
Pro-inflammatory levels shortly after traumatic stress are associated with heightened PTSD symptoms, particularly among males. Inflammatory markers may prove useful additions to prediction models for PTSD following trauma, with attention to sex differences.
Mass casualty incidents (MCIs) continue to pose significant operational challenges for health care facilities, particularly when compounded by electronic health record (EHR) downtime or cyberattacks. Despite advancements in technology, providers may consider using simple, paper-based patient triage and tracking methods during an MCI. This study describes the implementation of a paper-based triage and patient tracking tool, integrated into a broader MCI Toolkit, to support operational continuity.
Methods
Developed by NYU Langone Hospital—Brooklyn Emergency Department in collaboration with Emergency Management, the tool was deployed in 6 full-scale exercises (2021–2025) and 2 real-world MCIs across trauma and non-trauma ED settings. The tool follows a 3-step process: rapid triage using Simple Triage and Rapid Treatment (START), documentation of acuity and location, and post-triage identity reconciliation. The MCI Toolkit includes operational resources such as contact lists, patient placement maps, and job action sheets. After each event, feedback was gathered from clinical staff and senior leadership.
Results
In the feedback sessions, the tool was noted to be intuitive and required minimal training. It enabled rapid triage, patient placement, and real-time situational awareness for Incident Command. During a downtime simulation, it supported a seamless transition from electronic to manual processes. Across incidents, it improved patient throughput, ensured appropriate team assignment, and supported role flexibility when leadership was unavailable.
Conclusions
Our experience using the paper-based Triage Tracker showed it reliably maintained patient tracking without electronic systems. Its ease of use and integrated resources supported coordination, patient flow, and operational continuity during MCIs and EHR disruptions.
This Element investigates the challenges and possibilities of writing histories of trauma. Interpreting trauma as not only an event but also as an analytical framework and an apparatus for working on suffering, it explores how the historiography of trauma intersects with pressing matters of postcolonialism, historical subjectivity, and modernity. It is designed to illuminate the pressing theoretical matters that histories of trauma touch upon, whether explicitly or implicitly. Drawing from histories of trauma as well as foundational theoretical work in literary studies and memory studies, it argues that thinking traumatic histories requires a commitment on the part of historians to theoretical self-reflexivity, to querying not just the past or the archive for the traces of trauma, but the concept itself in its historical and historiographical modulations.
A fundamental dilemma in both the radiology reading room as well as the courtroom is whether a potential abusive head or spinal injury may be mistaken for other entities – both pathological processes and also normal anatomical or physiological variants.
A number of differential diagnoses, or mimics, for abusive head trauma may be apparent radiologically, but many may not be. Striving to achieve a medical “diagnosis” of an abusive injury requires the interplay between the radiologist and numerous other clinical specialties. The wide differentials which we discuss include accidental trauma, coagulopathies – both congenital and acquired, metabolic disorders, sepsis and vascular malformations, with all needing to be excluded before reaching a conclusion of nonaccidental trauma.
The experienced radiologist and clinician working in the challenging field of child protection also recognises that it is not always possible to reach a clear-cut decision and learning to communicate levels of uncertainty is essential. Part of this process is to always be alert to diagnostic mimics that may mislead the inexperienced and unwary.