bluuebunny/crossref_metadata_2025 huggingface dataset:
Activation of the ceramic surface to improve its wetting and brazing
Authors:   Frantsevich Institute for Problems of Materials Science, National Academy of Sciences of Ukraine, 3 Omeliana Pritsaka street, 03142 Kyiv, Ukraine, Krasovskyy Vitaliy
Published: August 2024

Brazing is a physicochemical process that combines adsorption, diffusion, dissolution, wetting, capillary flow, adhesion, melting and crystallization. The joining of materials of different nature, despite significant progress in this direction, still requires detailed fundamental research - physical, chemical, technological and improvement of already existing technological processes and solders, development of new multi-component solders, metallization coatings and methods of their application [1–4] . The purpose of this work is to find means of reducing the destruction of the surface of a ceramics during its metallization by rubbing with new designs of tools for rubbing, to determine their effect on wetting and brazing modes of oxide ceramics with metal solders. Three new types of Ti tools for grinding non-metals using a spongy porous structure and a foil with a thickness of 0.07-0.10 mm have been produced. Samples of A995 and VK94-1 high-alumina ceramics metallized by the proposed method were obtained. It was established that the surface roughness of non-metals affects the composition and microstructure of the applied coating in air. As the roughness decreases, both the density and oxidation of the coating increase. Wetting of ceramics with this coating with PSr72 solder (copper-silver eutectic) was studied, soldered joints were obtained, and the microstructure of the metal-oxide contact zone was studied. Studies of the microstructure of the soldered joint showed that the PSr72 melt permeates the titanium coating, saturates with Ti and wets the ceramics. That is, such metallization does not require coating density and accelerates the saturation of the melt with Ti. The main role of metallization by rubbing is to supply Ti to the base of the solder melt. The advantages of rubbing ceramics with titanium in the form of a porous spongy structure and foil in comparison with a compact metal tool are given. The best results are obtained using a tool made of porous Ti.
Thermo-kinetics of decomposition to AlN sub-micron powders of vacuum-aluminothermic origin
Authors:   Frantsevich Institute for Problems of Materials Science, National Academy of Sciences of Ukraine, 3 Omeliana Pritsaka street, 03142 Kyiv, Ukraine, Sydorenchuk Vera , Kuzmenko Lyudmila
Published: August 2024

The synthesis of AlN/B₁₂Al=3:1 (wt.) powder took place as a result of topological exothermic vacuum reactions of Al-thermic in the "BN-Al" system according to the conditions [1]. Dark gray submicron AlN powder was extracted by selective decomposition of B₁₂Al with HNO₃:H₂O=1:10 solution. The equipment and technique for measuring the mass fraction or degree of nitrogen extraction (w N₂ or q N₂) by the method of pulse-reduction extraction with carbon by gas chromatography in a helium flow at 1000-4000 K met the requirements of regulatory documents [2].The experimental procedure and calculations were carried out accordingly [3]. Reliable experimental data under equilibrium conditions of reactions of high-temperature dissociation of AlN-micro powders without the participation of carbon and with the formation of Al₄C₃ are given in the monograph [4]. The values of the standard heat content of the reactions were ΔH⁰298K AlN→Al+0.5N₂ = 323 kJ/mol and ΔH⁰298K AlN+0.75С→0.25Al₄С₃+0.5N₂ = 277 kJ/mol, respectively.The obtained average results of measurements in the field of pulse heating at temperatures of 2500-3500K were ΔH⁰298K AlN→Al+0.5N₂ = 345 kJ/mol. That is, the dissociation reaction of submicron AlN powder, despite the strikingly different properties of interaction with alkalis and acids, does not differ from the characteristics of thermal decomposition for micro powders without the participation of carbon.
Thermal stability of powdery CrB2, TiB2 HfB2 and ZrB2
Authors:   Frantsevich Institute for Problems of Materials Science, National Academy of Sciences of Ukraine, 3 Omeliana Pritsaka street, 03142 Kyiv, Ukraine, Sudavtsova Valentina , Mishchenko Dmytro , Bogachenko Oleksiy , Goncharov Ihor , Neylo Inna , Kudin Volodymyr
Published: August 2024

Powdery metal borides have high hardness, so they can be used as abrasives. Thus, the goal of this study was investigation of oxidation of chrome, titanium, zirconium and hafnium borides on air in the range of temperatures 25–1000°C in non-isothermal conditions using the derivatograph Q-1500 with the heating rates 5 and 10 K/min with simultaneous differential thermal analysis. Powdery CrB2, TiB2 ZrB2, HfB2 of “pure 99% were used. The sizes of the studied powders were determined by granulometric analysis. It turned out that particles with a diameter of 5-10 microns predominate in all powders. The studied powders of compounds interact with atmospheric oxygen in different ways. It is shown that powders TiB2 and ZrB2 begin oxidized at 540, 560°C, and CrB2, HfB2 –at 508, 780°C respectively. From TG curves calculated oxidation degree ().The composition of oxidation products was determined by the X-ray method using the DRON-3 device. According to X-ray data, the following oxides are formed: MO2(M=Ti,Zr,Hf), Cr2O3 i B2O3. Using the DTA-curves, calculated the heat effects of oxidation processes. At 1000°C, the oxidation degrees of the studied borides are as follows: CrB2(0,13), TiB2(0,15), HfB2 (0,41), ZrB2(0,81). From the obtained DTA curves, the thermal effects of the studied oxidation processes MB2 were calculated. Proportionality coefficient k between the thermal effect and the peak area under the DTA curve were assessed using similar data obtained from derivatographic studies of KCl and Na2WO4, the melting enthalpies of which are known. Taking into account the degree of transformation of the studied substances, we calculated the heat that was released in the studied processes during the complete oxidation of 1 mole of MB2. These data are qualitatively with those calculated according to Hess’s law.
Laser-enhanced electrodeposition of composite nickel coatings
Authors:   National Technical University Dnipro Polytechnic, Tytarenko Valentyna
Published: August 2024

The solution to the surface hardening problem is the modification of the metal matrix with particles of the dispersed phase to obtain composite electrolytic coatings [1, 2]. The purpose of this work is to study the effect of laser radiation on the process of co-deposition of metal ions and ultradispersed diamond particles, structure, mechanical and protective properties of electrodeposited composite nickel coatings. Electrodeposition of composite coatings was carried out from sulphate nickel-plating electrolyte out under external exposure to radiation from a CO2 gas-discharge laser generating in a continuous mode at a wavelength of 10,6 μm at a laser radiation power of 25 W. X-ray microanalysis was performed using a JSM-64901LV scanning electron microscope (Japan). The increase in the concentration of smaller ultradispersed diamonds (UDD) particles (~0,25–1 μm) in the coating formed under laser-assisted deposition is due to the potential gradient and rise in the diffusion coefficient. The increase in the flux density of complexes formed as a result of the adsorption of metal ions on the surfaces of UDD particles leads to an increase in oversaturation at the crystallization front. The formed coating is reached by smaller size UDD particles that block the growth of nuclei of the crystalline phase, which leads to the formation of a more densely packed coating and changes the cross-sectional growth structure from columnar to microlayer. The formation of finer crystalline coatings and change of cross-sectional growth structure from columnar to microlayer at laser-assisted deposition process resulted in improvement of mechanical and protective properties of carbon-containing nickel coatings (coating microhardness increased from 1800-1950 MPa to 2500-3700 MPa, corrosion resistance increased 2 times, and the wear of coatings decreased 3 times).
Corrosion of Ti-xSi alloys in marine water
Authors:   Frantsevich Institute for Problems of Materials Science, National Academy of Sciences of Ukraine, 3 Omeliana Pritsaka street, 03142 Kyiv, Ukraine, Talash Victor , Kuzmenko Mykola , Rudenko Julia , Shvets Vira
Published: August 2024

Titanium alloys of the Ti-xSi double system with different silicon content are the basis for the creation of new complex-alloyed alloys for various functional purposes – corrosion-resistant, heat-resistant, heat-resistant, wear-resistant and biocompatible medical.[1]. Ti-xSi alloys were made on the basis of commercial alloy BT1-0 and silicon grade KR1 by plasma-arc method in an argon atmosphere. Electrochemical studies of the obtained alloys (Ti-1.1Si, Ti-3.6Si, Ti-5.7Si, and Ti-2.5Si-2.5Al) were carried in a 3% NaCl solution that simulates natural environments, marine water in particular [2]. The experiments have shown that all the resulting alloys are corrosion-resistant. The composition of Ti-5.7Si turned out to be the most corrosion-resistant among the studied alloys, the composition of Ti-1.Si was comparatively less stable, and the composition of Ti-3.6Si in terms of its corrosion resistance in seawater occupied a position between the first two. As the silicon content of Ti-xSi alloys increases, their corrosion resistance increases. The addition of aluminum in the amount of 2.5% to the Ti-2.5Si alloy leads to an increase in the corrosion resistance of this composition compared to other studied alloys in the range from the stationary potential to the beginning of the anodic dissolution process, after which the Ti-2.5Si-2.5Al alloy becomes similar to other studied Ti-xSi compositions in its corrosion resistance. The carried out studies have shown that the processes of formation of oxides of the component on the surfaces of nanofilms have a decisive role in the growth of corrosion resistance of Ti-xSi alloys.
Photoluminescent studies in the wide temperature range (20-300 K) of hydrogen and nitrogen doped C₆₀ fullerite.
Authors:   B.Verkin Institute for Low Temperature Physics and Engineering of NAS of Ukraine, Zorianskyi Viktor , Zinoviev Peter
Published: August 2024

The optical properties of C₆₀ single crystals saturated with hydrogen and nitrogen molecules were studied by the spectral-luminescence method in the temperature range of 20–230 K. The saturation was carried out under a pressure of 30 atm at different temperatures from 200 °C to 550 °C. Early it have been established of C₆₀ fullerite intercalated with H₂ [1] and N₂ [2] molecules that the temperature limit of the adsorption crossover is about 300 °C and 420 °C, respectively (transition from the diffusion mechanism of intercalation - physisorption to chemical interaction - chemisorption). At saturation temperatures higher than this temperature limit the process of chemical interaction of H₂ or N₂ impurity molecules and the C₆₀ matrix occurs with the formation of a new chemical compounds - C₆₀Hₓ and (C₅₉N)₂. For the first time we present the results of the photoluminescent properties of new C₆₀ fullerite intercalated with N₂ and H₂ molecules - hydrofullerite C₆₀Hₓ and biazafullerite (C₅₉N)₂. In C₆₀Hₓ compound the integrated radiation intensity is independent from temperature has been recorded. This behavior of integrated radiation intensity have been explained by the absence of an orientational phase transition and the transition to a glassy state in hydrofullerite. In (C₅₉N)₂ compound the temperature dependence of the integral radiation intensity has been registered. Also in biazafullerite the low temperature quenching of photoluminescence has been detected. The new effect of low-temperature quenching of photoluminescence has been explained by the appearance of effective capture centers of the excitons which occurs as a result of the chemical interaction of N₂ impurity molecules and the C₆₀ matrix, and the non-radiative deactivation of electronic excitation [3].
Thermodynamic approach to studying of processes of contact interaction between W – C filler and iron-based binder of composite materials during infiltration
Authors:   Ukrainian State University of Science and Technologies, Syrovatko Yuliya ,   Dnipropetrovsk Branch of the State Institution “Soil Protection Institute of Ukraine”, Shtapenko Eduard
Published: August 2024

Higher performance characteristics of the composite materials with iron-based binders can be achieved by reducing the fragility of contact interaction zones through changing of the structure of granules of the W – C filler alloy. Previous experimental work showed the lower rate of dissolution of phases of the microcrystalline W – C filler alloy in the binder, compared to the crystalline W – C filler alloy [1]. The entropy of microcrystalline and crystalline structures of W – C alloys was determined by scanning of their digital photo-images with the use of TLC_Manager software. Further, statistical distribution of the probability density for the optical absorption coefficients was formed. Based on the fact, that logarithmic representation of the normal distribution functions is of the form of quadratic functions, we calculated the statistical distribution parameters [2]. It allowed calculating the entropy of structures at 300 K. Obtained values were 82 and 76 J/(mol∙К) for the crystalline and microcrystalline structures, accordingly. On the other hand, using the Debye model representations, we expressed the Helmholtz free energy and entropy as the functions of temperature and Debye temperature. From these expressions, knowing the values of entropy of the structures at 300 K, we found the Debye temperatures of structures, as well as the values of entropy, free energy and Gibbs energy of these W – C alloys at the temperature of infiltration of composite materials (1523 К). W – C filler and iron binder of the composite materials during infiltration were considered as two systems being in diffusion and thermal contact. The larger the difference in the chemical potentials of these systems, the more intense are the processes of diffusion and dissolution occurring at the interface of the systems [3]. It is found that the difference in chemical potentials of the microcrystalline filler alloy and the binder is less than that of the crystalline filler alloy.
The mixed spin-1/2 and spin-1 Ising model for CuInP₂S₆ ferrielectrics
Authors:   Institute for Solid State Physics and Chemistry, Uzhhorod National University, Vysochanskii Yulian , Liubachko Vitalii , Hryts Viacheslav , Medulych Mykola , Kohutych Anton
Published: August 2024

The temperature behavior of Sn₂P₂S₆ ferroelectrics was previously explained using the Blume-Capel model with pseudospin S=1, which is related to the local three-well potential for spontaneous polarization fluctuations [1-3]. For CuInP₂S₆ crystals, the mixed Ising model [4,5] can be applied, which uses spins s=1/2 and S=1. These spins are related to the ordering dynamics of Cu⁺ cations in the double-well potential (pseudospins s=1/2) and to the displacive dynamics of In³⁺ cations in the three-well local potential (pseudospins S=1). The quantum anharmonic oscillator model was used to accomplish this task. Additionally, data from a light scattering study is incorporated. Based on the temperature dependence of the pseudospin fluctuations spectra, it can be concluded that the In³⁺ cations experience anharmonic disordering/displacements in the local asymmetric three-well potential at temperatures below 150K. This leads to specific lattice anharmonicity phenomena, which alter the temperature behavior of the lattice vibrations and cause the thermal expansion coefficient to change sign. Additionally, a dipole glassy appearance is observed in the deeply cooled ferrielectric phase. The contribution of Cu⁺ cations to the calculated pseudospin fluctuation spectra is found to evolve with heating above 150K, supporting the activation of ionic conductivity in CuInP₂S₆ crystals. Notably, the same species, namely copper cations, participate in both spontaneous polarization and ionic conductivity creation. The variation of the pseudospin fluctuation spectra upon heating to 150K is consistent with the softening of the Raman low-frequency spectral lines related to the cationic sublattice dynamics of indium and a broadening of the spectral line above this temperature due to the disorder in the copper sublattice.
Venous Thromboembolism in Patients Diagnosed with Coronavirus Disease 2019
Authors: Koujane Radwa , Pudar Julia , Fernandez Ryan , Jackson Nancy M , Flynn Jeffrey C , Sankari Abdulghani
Published: August 2024

Background

Coronavirus disease 2019 (Covid-19) infection is associated with an increased risk of venous thromboembolism (VTE). However, it is unclear if mild Covid-19 infection is a significant risk factor for VTE. Our goal was to investigate the overall incidence of VTE in Covid-19 patients at our community hospital and assess its correlates.

Methods

We retrospectively reviewed the medical records of patients 18 years and older who tested positive for Covid-19 at our hospital between March 2020 and September 2021.

Results

A total of 5926 patients aged 18 to 99 years had Covid-19. Of these patients, 64 (incidence of 1.08%) had VTE; 63% were male and 58% were African Americans. The highest rate of VTE was seen in patients with cardiovascular risk factors (n=47, 73%) followed by a history of thromboembolism (n=19, 30%); patients (n=6, 9%) with mild Covid-19 also developed VTE.

Conclusions

In our study of a predominantly African American population, the VTE incidence (1.08%) was ten times higher than the general population’s rate of 0.1%. Covid-19 infection, even mild category, not requiring hospitalization was a risk factor for VTE. The risk was increased in men and those who have cardiovascular risk factors and/or prior history of thromboembolism.
Assessment of Quality Improvement and Patient Safety Resources, including Event Reporting Systems, in Graduate Medical Education Training Programs - An Institutional National Survey
Authors: Atkins Megan , Akrawe Silvy , Flynn Jeffrey C , Sankari Abdulghani , Mittal Vijay K
Published: August 2024

Background

Quality improvement (QI) and patient safety (PS) education were requirements implemented in 2017 by the Accreditation Council for Graduate Medical Education (ACGME) for residents and fellows. Trainees must receive training and experience in QI processes, including an understanding of healthcare disparities, but how training and experience occur remains largely unknown. Our study aimed to determine how institutions have integrated these requirements into medical education.

Methods

A Google Forms survey was emailed to the Designated Institutional Officials (DIOs) of 650 United States’ institutions with ACGME accredited programs in September 2021. The survey consisted of 34 multiple choice questions related to QI and PS parameters and the event reporting system (ERS); a Likert scale was used.

Results

More than half (n=392) of the emails were undeliverable, leaving only 258 possible responders; 51 responses were received, and all but one met the inclusion criteria of having at least one training program, which translated to a response rate of 19% (=50/257). The survey found that while 90% of institutions had an institutional QI/PS Committee, only 30% of these institutions also had a Graduate Medical Education-specific QI/PS Committee as well. Most institutions provided QI (88%) or PS training (94%), but only 71% and 83%, respectively, had mandatory training. Most institutions utilized an ERS (96%). While one of the less common methods was education on the ERS, approximately two-thirds of responding DIOs believed that by providing education on the ERS, resident/fellow participation in event reporting would improve, as well as contribute to their total education.

Conclusions

Further ERS education is warranted to encourage resident/fellow participation to develop various protocols related to QI and PS parameters.
Radiologist Accuracy in Predicting Pathology in Breast Imaging
Authors: Dhingra Kirti , Lin Jeffrey , Brannan Grace , Gari Nedi , Singh Evita
Published: August 2024

Introduction: Breast cancer, the most prevalent cancer in women and second only to lung cancer in female mortality, has seen rising incidence, especially during the 1980s and 1990s due to increased mammography screening. Screening’s primary goal is early tumor detection, reducing mortality by over 40%. Yet, it has downsides, including false-positive cases of benign biopsies and potential increased patient anxiety and stress. The average recall rate from screening mammograms is 5-10%. Among women requiring biopsy, the anticipated rate of malignant findings range between 30-50%. With the evolution of image-guided breast biopsy techniques, concerns have risen regarding the escalating frequency of breast biopsies. The possible causes are overlapping imaging characteristics of benign and malignant pathologies, patients’ anxiety, litigation risk and radiologist years of experience. A radiologists’ ability to predict breast histology from imaging findings remains an understudied domain.

This study’s core purpose is to comprehensively analyze the ability of a radiologist to predict benign versus malignant results to provide guidance in reducing the number of benign biopsies.

Methods: This prospective study involved radiologists completing survey sheets when recommending biopsies and when performing the biopsy, predicting benign vs malignant, specific pathology, with confidence interval. Predictions were compared to the final biopsy results to determine accuracy. All patients who underwent biopsy at our institutions were included in the data. Data was categorized as either concordant or discordant when comparing predicted pathology results to actual.

Results: The accuracy of radiologist prediction from initial diagnostic imaging when compared to actual pathology results in the study population is 71% (95% CI,61.8%-79.37%) with a sensitivity of 75 % (95% CI, 60.4%-86.36%). The accuracy of radiologist prediction at biopsy when compared to actual pathology results is 80.79% (95% CI, 75.89%-85.08%) with sensitivity of 79.77% (95% CI, 73%-85.49%). The accuracy of less to moderately experienced radiologists to highly experienced radiologists is similar, 78.2% vs 81.0%. Further analysis of specific pathology prediction reveals that fibroadenoma is the most common benign pathology encountered, the prediction of which by imaging alone/at biopsy is 65%/68%. In the malignant category, invasive ductal carcinoma is the most common pathology encountered where the prediction is 68%/85%.

Conclusions: This data will potentially help radiologists gain confidence in watching likely benign lesions based on imaging features (assigned as BIRADS 3) to reduce benign biopsies.
Diagnostic Performance of Cardiac Stress Testing Following Exclusion of Acute Myocardial Infarction with a 0/1-Hour, High-Sensitivity Cardiac Troponin Protocol
Authors: Nassereddine Hashem , Miller Joseph , Cook Bernard , Klausner Howard , Gunaga Satheesh , Morton Thayer , Tuttle Jacob , Mohammed Husna , Husain Arqam , McCord James
Published: August 2024

Background: Rapid exclusion of acute myocardial infarction (AMI) is critical for patients presenting to emergency departments (EDs) with chest pain or other anginal equivalents. High-sensitivity cardiac troponin (hs-cTn) protocols have been widely adopted in the United States for this purpose. These protocols allow for early identification and exclusion of patients with AMI using a 0 and 1-hour hs-cTn measurement. However, little is known about the use of cardiac stress testing in patients who ruled-out for AMI within 1 hour with very low hs-cTn values. This study analyzed the diagnostic performance of cardiac stress tests in this population.

Methods: We performed a secondary analysis of the RACE-IT trial, a stepped-wedge cluster randomized trial performed across 9 EDs in a large metropolitan health system from July 2020 through March 2021. The eligibility criteria for the trial mirrored the real-world use of hs-cTn testing, including both patients complaining of chest pain and/or other anginal equivalents. All adults with a hs-cTnI and electrocardiogram (ECG) completed in the ED were enrolled, while patients with ST- segment elevation AMI, trauma, or pregnancy were excluded. In the interventional arm of the trial, AMI was excluded if hs-cTnI was <4 ng/L at presentation or =4 ng/L at presentation with a 1-hour value < 8 ng/L. The trial followed all patients through 30 days to assess for AMI or death and captured all cardiac testing. We compared stress testing results to invasive coronary imaging with or without revascularization.

Results: 10,444 study patients (43.61%) ruled out for AMI in the ED within 1 hour and were included in this analysis. There were 320 (3.0%) patients who had a stress test within 30 days, with few ischemic findings (25, 0.24%) or revascularization procedures (5, 0.05%). The positive predictive value of stress testing in this population to identify the need for revascularization was 10.1% (95% CI 2.8% - 29.4%). Table 1 displays the proportion of ischemic stress tests and overall test performance in this population. The rate of 30-day death or AMI was low (17, 0.20%) among those discharged from the ED or placed in observation (n=8,553).

Conclusions: Our study highlights the infrequent use and low diagnostic yield of stress testing in patients who have been ruled out for AMI within 1 hour using an accelerated hs-cTn protocol in the ED.
Assessing the Efficacy of Farnesoid X Receptor Agonists in the Management of Metabolic Dysfunction-Associated Steatotic Liver Disease: A Systematic Review and Meta-Analysis
Authors: Kumar Jai , Hasan Misha , Mohsin Sana , Nagar Tripti , Tegeltija Vesna , Kumar Sarwan
Published: August 2024

Background: Several randomized clinical trials have been conducted assessing the potential efficacy of X receptor (FXR) agonists in patients with metabolic dysfunction-associated liver disease (MASLD). A comprehensive review and analysis were needed to evaluate the findings of these trials. Hence, this systematic review and meta-analysis aim to study the association between FXR agonists and hepatic outcomes in patients with MASLD.

Introduction: Metabolic dysfunction-associated liver disease (MASLD) involves abnormal lipid accumulation in the liver, potentially progressing to metabolic dysfunction-associated steatohepatitis (MASH) with severe outcomes. X receptors (FXR), activated by bile acids, regulate liver metabolism and inflammation, offering a promising therapeutic target. Clinical trials with FXR agonists like obeticholic acid and tropifexor show potential in improving MASH histology. However, a comprehensive analysis of FXR modulation’s impact on liver pathology and metabolism in MASLD and MASH is lacking. This systematic review aims to address this gap, informing future therapeutic approaches.

Methods: Systematic review and meta-analysis evaluating the efficacy of FXR agonists in 1,227 patients assigned to the FXR intervention group compared to 650 patients in the placebo group. Changes in liver enzymes and hepatic steatosis assessed by MRI-PDFF were evaluated.

Results: FXR agonist use was associated with a significant reduction in levels of AST, (WMD= -4.51, 95% CI=[-8.39,-0.63], P=0.02); ALT (WMD= -13.02, 95% CI=[-17.85,-8.19], P<0.00001); GGT (WMD= -32.20, 95% CI=[-38.63,-25.98], P<0.00001); MRI-PDFF, (SMD= -1.14, 95% CI=[-1.92,-0.35], P=0.005). FXR agonists did not significantly affect ALP levels, (WMD= 25.04, 95% CI= [19.22,30.87], P<0.00001}.

Conclusions: Results show promising evidence supporting the efficacy of FXR agonists in reducing hepatic steatosis and biomarkers of hepatic injury such as ALT, AST, and GGT.
The Effects of the STREAMLINE™ Surgical System versus Endoscopic Cyclophotocoagulation in Primary and Secondary Glaucoma
Authors: Beckman Jamie
Published: August 2024

Introduction: Glaucoma is an optic neuropathy that is the second most common cause of blindness worldwide and affects over three million Americans. Currently, the only known modifiable risk factor to prevent glaucomatous damage is to decrease the intraocular pressure (IOP). The STREAMLINE™ Surgical System (SSS) is a microinvasive glaucoma (MIGs) device that can create a goniotomy and dilates the drainage system of the eye to reduce IOP.

Question & Significance: This study aims to compare the effects on intraocular pressure of patients that had cataract surgery combined the SSS, endoscopic cyclophotocoagulation (ECP), or ECP with SSS in patients with primary and secondary glaucoma’s for 6 months post operatively.

Methods: This is a retrospective chart review of patients that had cataract surgery with either ECP, SSS, or SSS + ECP from April 1st, 2022 through April 1st, 2023. Primary endpoints were mean IOP reductions and medication reliance at 6 months compared to baseline. Secondary outcomes were best corrected visual acuity (BCVA), number of patients with  20% decrease in IOP, number of patients with a decrease in IOP lower medications, and significant complications after treatment.

Results: Comparing 6-month post-operative mean IOPs in these treatment groups, a significant reduction was noted only in the ECP group at the 6-month visit (p<0.003). No statistically significant reduction was found in either the SSS (p=0.333) or SSS+ECP (p=0.134) groups. The percent of patients having a  20% decrease in IOP from baseline were 52%, 10%, and 38% for ECP, SSS, and SSS+ECP groups, respectively.

Conclusions: In the SSS only group, we found a significantly smaller proportion of patients able to achieve the  20% IOP reduction at only 10% of patients compared to other previous studies. This difference is likely due no medication washout in our study. This study did find similar decrease in IOP lowering medications.
Implementation of a Standardized Feeding Protocol in a Level III Neonatal Intensive Care Unit
Authors: Rahimo Maryam , Miliara Evgenia , Piatek Monika , Pappas Athina
Published: August 2024

Introduction: The nutritional management of preterm infants in the Neonatal Intensive Care Unit (NICU) can be challenging and can often lead to extrauterine growth restriction (EUGR). A new feeding protocol was recently established and implemented at Ascension St. John’s NICU. Objectives: 1.) To determine the association of a standardized feeding protocol in the NICU and feeding intolerance, as well as growth outcomes and the number of days on parenteral nutrition; and 2.) To determine the association of a standardized feeding protocol and the development of necrotizing enterocolitis and central line associated infections.

Methods: This study was a historical cohort study done by retrospective chart review. The pre-feeding protocol period included infants <32 weeks gestation and <1500g who were in the NICU between 1/1/2018 to 12/31/2020. The post-feeding protocol period was from 1/1/2021 to 11/15/2023. Data were recorded on demographics; and measurements at birth, 34 weeks postmenstrual age, and at discharge. Nutritional milestones and clinical outcomes were collected. Statistical analysis was done using Student’s t-test, the chi-squared test, the Mann-Whitney U test and repeated measures analysis of variance.

Results: A total of 243 infants were included: 158 pre-implementation and 85 post-implementation of protocol. The mean gestational age was 27.7 ± 2.3 weeks, 61.7% of infants were black and 53.5% were female; there were no significant differences by time period. Results show no statistically significant difference in growth outcomes, days when infants received nothing by mouth; necrotizing enterocolitis, or sepsis. There was a delay in fortification and reaching full feeds, longer parental nutrition and central line days, and higher number of central line associated infections in the post-implementation period. Rates of intraventricular hemorrhage, retinopathy of prematurity and pulmonary outcomes were improving.

Conclusions: The data suggest that implementation of a standardized feeding protocol can improve short term morbidities in high-risk neonates. Future studies are needed to optimize feeding protocols with the goal of improving growth, nutrition, and neurodevelopmental outcomes of this high-risk population.
Radiological Evaluation and Comparative Analysis of First Metatarsal-Cuneiform Fusion Constructs: Assessing Outcomes and Stability Across Varied Fusion Techniques
Authors: Lyons Katherine , Adelman Ronald , Nguyen Hoang , Cleypool Katelyn
Published: August 2024

Background: The Lapidus procedure has become a cornerstone in the surgical management of hallux valgus, especially in cases with associated tarsometatarsal instability. This study investigates and compares the radiographic outcomes following three distinct Lapidus constructs, aiming to provide valuable insights into the optimal fusion configurations for achieving long-term stability improvement and maintaining intermetatarsal angle post operatively.

Methods: In this retrospective study, the objective is to assess and compare the outcomes of three different fusion constructs employed in the Lapidus procedure: Group 1: Transverse screw fixation, Group 2: Metatarsal cuneiform screw fixation, and Group 3: Combined transverse and metatarsal cuneiform screw fixation. The study encompasses a total of 32: 11 feet in group 1, 8 feet in group 2, and 13 feet in group 3. The primary focus is to evaluate postoperative stability through radiographic imaging, complemented by clinical assessments and an examination of complications. Statistical analyses were used to compare outcomes across the three fixation groups at immediate post-op, 3 months, 6 months, and 1-year post-op.

Results: The study found that TMT fusion using these 3 constructs was effective in correcting the hallux valgus deformity and restoring medial midfoot stability to the tarsometatarsal joint. Radiographic assessments demonstrated successful fusion, and patients reported improvements in pain, function, and overall satisfaction with the procedure. Complication rates were within an acceptable range. The intermetatarsal angle (IMA) in all three groups exhibited a significant reduction postoperatively compared to preoperative measurements. Group 3, characterized by combined transverse and metatarsal cuneiform screw fixation, demonstrated a notably stronger initial reduction in the intermetatarsal angle compared to Groups 1 and 2. This difference became evident by the 3-month mark and persisted, maintaining significant distinctions among the three techniques at the final follow-up. Radiological assessments indicated that Group 3 maintained stable IMA values and exhibited a lower recurrence rate compared to the other two groups.

Conclusions: The findings of this study endorse the utilization of TMT fusion with these 3 constructs, particularly with combined transverse and metatarsal cuneiform screw fixation, as a dependable and efficacious surgical approach in addressing hallux valgus with concomitant tarsometatarsal instability.
Lactate Expression, Mortality, and Length of Stay in Emergency Department Patients with Sepsis and Intubation
Authors: Ahdi Heaveen , Berger David , Talia Nadine , Zhao Lili , Otero Ronny
Published: August 2024

Introduction: Patients in septic shock with a lactate <2 have a mortality of 20-46%. Our prior work reported that emergency department (ED) patients with a second lactate ≥2 (lac) have a two-fold increase in 30-day mortality when compared to patients with a second lactate <2 (alac). On secondary analysis, we found that intubated patients with a second lactate ≤2 have a longer hospital length of stay (LOS). Our objective is to further scrutinize this 30-day mortality and LOS.

Methods: This is a retrospective cohort study of an eight-hospital health system using data from the electronic medical record. Inclusion criteria consisted of patients ≥18 years of age who presented to the ED from 1/1/2017 to 11/30/2022 with ≥2 lactate levels measured in the ED, were diagnosed with sepsis, and admitted to the intensive care unit within 24 hours. Patients were classified based on their lactate values. Multivariable regression analysis was performed for 30-day mortality and LOS, adjusting for vitals, BMI, DNR status, and intubation timing.

Results: 1285 patients met inclusion criteria, were intubated, and categorized based on their lactate expression: alac-> alac (reference; 111/1285, 8.9%), alac-> lac (28/1285, 2.2%), lac-> alac (259/1285, 20.2%), and lac-> lac (887/1285, 69.0%). Lac-> lac had a significantly higher 30-day mortality (OR = 2.058, 95% CI = [1.353, 3.154]) compared to alac-> alac. Lac-> alac had a significantly increased LOS (OR = 1.133 (95% CI = [1.003, 1.280]) compared to alac-> alac.

Conclusions: Patients in the lac-> lac group had a two-fold increase in 30-day mortality when compared to alac-> alac. The lac-> alac group consistently had a greater LOS compared to alac-> alac. However, no further associations existed between the lactate expression category and LOS. Our prior work did not adjust for DNR and intubation timing, which may have spuriously augmented the LOS differences.
Trainee Preparedness to Enter Physiatry Residency: Early Findings from a National Cross-Sectional Survey Study
Authors: Jung Jungyoon , Roskos P Tyler
Published: August 2024

Introduction: This national survey study investigates the transition of PM&R residents from as they transition into residency, aiming to identify associated factors influencing their preparedness. The transition to residency can be stressful, and insufficient preparedness is associated with a higher risk of burnout. While existing research has examined this transition in large specialties like internal medicine and surgery, there is a gap in understanding preparedness for PM&R residency in PGY-2. PM&R residency offers diverse routes, and not all medical schools have PM&R departments, leading to varied exposure and experience among incoming residents.

Methods: To address this gap, a voluntary national survey study was conducted, collecting data from 55 residents across the USA from PGY-2 to PGY-4.

Results: Participants reported their overall preparedness, with 51% feeling prepared and 49% feeling unprepared for clinical care at the start of residency. The prepared group demonstrated higher emotional and clinical preparedness, particularly in performing neuro/musculoskeletal physical examinations, managing rehabilitation issues, and interpreting imaging. Experience as an intern emerged as the most critical factor influencing preparedness. There were no significant differences between the prepared and unprepared groups in terms of age, gender, medical degree, timing of PM&R exposure, participation in PM&R interest group, type of internship pursued (transitional, medicine, surgery, or categorical), or academic versus community hospital during intern year.

Conclusions: Incoming residents who self-identified as unprepared may specifically benefit from early check-ins with residents about wellbeing and early focused education on the neuro/musculoskeletal physical examination, management of common rehabilitation related issues, and interpretation of neuromusculoskeletal imaging, given the differences in responses we observed between prepared and unprepared groups in these domains. Residents trended toward feeling unprepared in handling rapid responses, pediatric rehabilitation patients, and therapy prescriptions and precautions at the start of PM&R residency.
Expediting Discharges on the Inpatient Medicine Teaching Services
Authors: Khan Misha , Daniel Emmanuel , Janardan Veena , Al-Sous Ola
Published: August 2024

Introduction: Delayed discharges can adversely affect patient flow throughout the hospital. Late afternoon discharges may lead to high hospital occupancy, admission bottlenecks, ER overcrowding, and disrupted ICU transfers. Discharge by noon (DBN) is key to enhancing hospital capacity, bed utilization, and patient satisfaction and outcomes. Last year, DBN for patients returning home with or without home care services (HHC) was chosen as one of three annual priorities for our hospital medicine division. This was implemented in October 2023 but did not gain momentum among the medical resident teaching services (MTS), paving the way for our QI project.

Model for Improvement: Baseline data on the percentage of MTS DBN to home and HHC were available from November 2023 to January 2024. We surveyed our residents/faculty and conducted a root-cause analysis. The main barriers to DBN included a lack of planning and motivation, delayed communication with case management, and prolonged rounding.

Aims Statement: Our goal was to increase the median percentage of MTS discharge orders placed by noon to home and HHC from 22% to 35% within 3 months.

Measures: Our primary outcome measure was the percentage of MTS DBN to home and HHC. Weekly EMR-generated reports were collected. The outcome measure was then calculated and uploaded weekly on a run chart for analysis. Qualitative process measures included assessing if residents were planning discharges and documenting the number of discharges completed before noon.

Changes: Our interventions targeted the lack of planning and motivation. These included introducing the expedited initiative and its importance to residents/faculty through conferences. In addition, a process was created where potential next-day discharges were discussed at afternoon sign-out and a tracking chart of DBN orders was designed for each team room.

Tests of Change: Our pre-intervention median percentage of MTS DMB to home and HHC was 22% and improved to 40% post-intervention. While we observed a variation in discharge practice based on the rounding attending, we had notably sustained an upward shift in practice from our baseline when data was plotted on a run chart. We are currently continuing data collection to track sustainability and variability among rounding physicians.

Conclusion: We attained an upward shift in the percentage of MTS DBN to home and HHC post-intervention. Although an upward shift has been achieved, we are looking to sustain and further improve it. In future PDSA cycles, we will look at individualizing feedback and optimizing interdisciplinary rounds. We plan on further investigating balancing measures such as bed availability, discharge timing for rehabilitation destinations, and patient and staff satisfaction.
Quality Initiative to Improve Emergency Department Sepsis Bundle Compliance Through Resident Education and Awareness
Authors: Basal Yasmeen , Ruedisueli Maria , Farooqui Zainab , Ghiardi Martina , Santiago-Rivera Olga , Butki Nikolai , Gotlib Ari
Published: August 2024

Introduction: Timely recognition of sepsis is important for physicians as each hour of delay before sepsis is treated is associated with a 4-9% increase in mortality. In order to monitor the care provided in critically ill patients, the Centers for Medicare & Medicaid Services (CzMS) designed Hospital Quality Initiatives which include The Severe Sepsis and Septic Shock Management Bundle (SEP-1). A prior study conducted by Alexander et al at McLaren Oakland Hospital’s Emergency Department (ED) demonstrated improvement in bundle compliance with standardization in documentation and order entry in EMR in the form of Sepsis Macros. Subsequently, the compliance rates with the SEP-1 bundle at McLaren Oakland were found to have fluctuated monthly. This fluctuation affects both patient outcomes and reimbursement for the care provided. Therefore, we hypothesized further education needed to be provided to ensure quality care of septic patients.

Objectives: Our project aimed to improve sepsis bundle compliance at McLaren Oakland by providing education to the PGY-1 class and off-service residents on how to accurately utilize the pre-populated sepsis macro and order sets in EMR in order to recognize and treat sepsis in a timely manner.

Methods: We developed a Sepsis Education sheet sent in the form of a monthly educational email. This initiative targeted PGY-1s, instructing them on how to appropriately use the new sepsis macro to have timely recognition of sepsis and appropriate orders placed to meet compliance guidelines. Our monthly educational email was sent from August 2022 to February 2023.

Results: Sepsis Compliance data was analyzed from August 2022 to February 2023 and compared to August 2021 to February 2022. After implementation of the Sepsis Education sheet, the mean of compliance rates actually decreased from 64% (SD= 0.101 95% CI: 0.575 to 0.719) to 47% (SD= 0.116 95% CI: 0.388 to 0.560) during intervention (p-value = 0.0101).

Conclusion: Our intervention was not successful in increasing compliance with SEP-1 bundle requirements. We therefore determined that PGY-1 awareness of sepsis and use of macros is not the limiting factor in sepsis compliance for McLaren Oakland Hospital’s ED. Further investigation regarding limiting factors in sepsis bundle compliance at our institution will need to be conducted.
Improving the Safety and Convenience of Emergency Anesthesia Codes by Implementing a Portable Glidescope Bag
Authors: Cerna Ugne , Kaminski Edward
Published: August 2024

Anesthesia providers such as residents, CRNAs, fellows, and attendings are responsible to quickly arrive to anesthesia STATs, code blues and trauma pages and are responsible for securing the airway if needed. In emergent situations like these the providers are expected to provide efficient and safe care Almost always we come with no information on patient history, airway, age, etc. Multiple studies have shown higher intubation success rates in adults and children by using a glidescope on the first attempt (1). Currently at Childrens Hospital of Michigan in Detroit Michigan, in such scenarios many providers take the glide-scope on wheels with them to emergency overhead calls while some choose not to take it mostly due to the cumbersome task of wheeling the glide-scope and being forced to take the elevator which delays the arrival to the patient. This quality initiative project highlights improvements made by a plan do study act which implements a small bag with a portable handheld glide-scope device inside that attaches to the trauma backpack. This will eliminate the cumbersome task of wheeling the glidescope to emergencies, decrease the time to get to the patient, increase first time intubation success rate by having a glidescope available when needed and decreasing attempts by non-anesthesia providers before the anesthesia provider gets to the scene. In the preintervention survey most attendings stated that they do not take the glides-cope to emergencies due to the transportation issue mostly and those attendings did also state that they would consider taking it if its easier to transport. Most residents do take the large glidescope on wheels to emergencies but they did admit that they feel like it takes them longer to get to codes/traumas and anesthesia STATs due them having to wait for the elevator. By adding this glide-scope portable bag to our existing code bags I believe it will take less time to get to the anesthesia emergency, increase the intubation success rate & decrease attempts to intubation hence will reduce trauma to the airway, prolonged hypoxia and morbidity.