Use of Immediate Postpartum Long-Acting Reversible Contraception Before and After a State Policy Mandated Inpatient Access.

OBJECTIVE: To assess the rate of immediate postpartum long-acting reversible contraceptive (LARC) use in a multihospital health care system 2 years before and after the policy was implemented, and to assess factors associated with LARC use and repeat pregnancy rates within 12 months after delivery. METHODS: We conducted a retrospective chart review of all patients giving birth at three Cleveland Clinic Ohio hospitals from July 1, 2015, to June 30, 2019. We reviewed the inpatient medication reconciliation to identify the LARC initiation rate. We compared all patients who received inpatient postpartum LARC to a 1:3 matched sample of patients who did not receive LARC, matched by delivery date and location, to identify patient characteristics associated with LARC use. The electronic medical record (Epic) was reviewed to identify new pregnancies occurring within 12 months postdelivery. RESULTS: We identified 17,848 deliveries prepolicy and 18,555 deliveries postpolicy. Immediate postpartum LARC was used by 0.5% (monthly range 0-2.1%) of patients prepolicy and 11.6% (monthly range 8.3-15.4%) of patients postpolicy. Levonorgestrel intrauterine devices (IUDs) were used by 56.5%, implants by 29.1%, and copper IUDs by 14.5% of LARC users. Characteristics associated with LARC use included younger age, public insurance, non-White race, Hispanic or Latina ethnicity, higher body mass index, sexually transmitted infection in pregnancy, and tobacco use. Long-acting reversible contraceptive users had a lower rate of repeat pregnancy at 12 months postpartum compared with the non-LARC group (1.9% vs 3.6%, P<.001). CONCLUSION: Immediate postpartum LARC use increased after a state policy change mandated universal access and was associated with decreased pregnancy rates in the first year postdelivery.

Vaccination in pregnancy: A call to all providers for help.

Vaccination in pregnancy is an important part of maternity care, but maternal immunization rates continue to be below national benchmarks. Influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccinations have been shown to be safe and provide important protections to pregnant women, the fetus, and neonates. Although obstetrician-gynecologists provide the bulk of pregnancy care, general internists and medical specialists have frequent clinical encounters with maternity patients and should assist in immunization education and administration.

Thermal Atomic Layer Deposition of Gold: Mechanistic Insights, Nucleation, and Epitaxy.

An in situ microbalance and infrared spectroscopic study of alternating exposures to Me2Au(S2CNEt2) and ozone illuminates the organometallic chemistry that allows for the thermal atomic layer deposition (ALD) of gold. In situ quartz crystal microbalance (QCM) studies resolve the nucleation delay and island growth of Au on a freshly prepared aluminum oxide surface with single cycle resolution, revealing inhibition for 40 cycles prior to slow nucleation and film coalescence that extends over 300 cycles. In situ infrared spectroscopy informed by first-principles computation provides insight into the surface chemistry of the self-limiting half-reactions, which are consistent with an oxidized Au surface mechanism. X-ray diffraction of ALD-grown gold on silicon, silica, sapphire, and mica reveals consistent out-of-plane oriented crystalline film growth as well as epitaxially directed in-plane orientation on closely lattice-matched mica at a relatively low growth temperature of 180 °C. A more complete understanding of ALD gold nucleation, surface chemistry, and epitaxy will inform the next generation of low-temperature, nanoscale, textured depositions that are applicable to high surface area supports.

Tracking-A Flexible Obstetrics and Gynecology Residency Curriculum.

Residency programs across the United States are searching for ways to improve surgical skills and operative experiences in obstetrics and gynecology residencies. We developed an obstetrics and gynecology residency program that offers a flexible curriculum, referred to as tracking, to address these needs. Curriculum content was developed using a modified Delphi method, using input from experts in medical education and obstetrics and gynecology. Outcome data were collected on trainees who graduated between 2016 and 2019, including postgraduate fellowship placement and our residents' achievement of surgical minimum requirements based on procedure logs. Trainees from this program have consistently exceeded minimal surgical requirements in all areas, regardless of tracking preference. Since the beginning of the program in 2012, more than 60% of graduates have matriculated into fellowships. Flexible curricula, such as tracking, offer one approach to a changing climate of medicine. The ability to offer flexible, focused, and individualized training is an approach with great potential to produce graduates who excel in all areas of obstetrics and gynecology while sharpening skills specific to their areas of interest.

Microfluidic electrochemical cell for in situ structural characterization of amorphous thin-film catalysts using high-energy X-ray scattering.

Porous, high-surface-area electrode architectures are described that allow structural characterization of interfacial amorphous thin films with high spatial resolution under device-relevant functional electrochemical conditions using high-energy X-ray (>50 keV) scattering and pair distribution function (PDF) analysis. Porous electrodes were fabricated from glass-capillary array membranes coated with conformal transparent conductive oxide layers, consisting of either a 40 nm-50 nm crystalline indium tin oxide or a 100 nm-150 nm-thick amorphous indium zinc oxide deposited by atomic layer deposition. These porous electrodes solve the problem of insufficient interaction volumes for catalyst thin films in two-dimensional working electrode designs and provide sufficiently low scattering backgrounds to enable high-resolution signal collection from interfacial thin-film catalysts. For example, PDF measurements were readily obtained with 0.2 Šspatial resolution for amorphous cobalt oxide films with thicknesses down to 60 nm when deposited on a porous electrode with 40 µm-diameter pores. This level of resolution resolves the cobaltate domain size and structure, the presence of defect sites assigned to the domain edges, and the changes in fine structure upon redox state change that are relevant to quantitative structure-function modeling. The results suggest the opportunity to leverage the porous, electrode architectures for PDF analysis of nanometre-scale surface-supported molecular catalysts. In addition, a compact 3D-printed electrochemical cell in a three-electrode configuration is described which is designed to allow for simultaneous X-ray transmission and electrolyte flow through the porous working electrode.

Resolving the Chemically Discrete Structure of Synthetic Borophene Polymorphs.

Atomically thin two-dimensional (2D) materials exhibit superlative properties dictated by their intralayer atomic structure, which is typically derived from a limited number of thermodynamically stable bulk layered crystals (e.g., graphene from graphite). The growth of entirely synthetic 2D crystals, those with no corresponding bulk allotrope, would circumvent this dependence upon bulk thermodynamics and substantially expand the phase space available for structure-property engineering of 2D materials. However, it remains unclear if synthetic 2D materials can exist as structurally and chemically distinct layers anchored by van der Waals (vdW) forces, as opposed to strongly bound adlayers. Here, we show that atomically thin sheets of boron (i.e., borophene) grown on the Ag(111) surface exhibit a vdW-like structure without a corresponding bulk allotrope. Using X-ray standing wave-excited X-ray photoelectron spectroscopy, the positions of boron in multiple chemical states are resolved with sub-angström spatial resolution, revealing that the borophene forms a single planar layer that is 2.4 Å above the unreconstructed Ag surface. Moreover, our results reveal that multiple borophene phases exhibit these characteristics, denoting a unique form of polymorphism consistent with recent predictions. This observation of synthetic borophene as chemically discrete from the growth substrate suggests that it is possible to engineer a much wider variety of 2D materials than those accessible through bulk layered crystal structures.

Mechanistic understanding of tungsten oxide in-plane nanostructure growth via sequential infiltration synthesis.

Tungsten oxide (WO3-x) nanostructures with hexagonal in-plane arrangements were fabricated by sequential infiltration synthesis (SIS), using the selective interaction of gas phase precursors with functional groups in one domain of a block copolymer (BCP) self-assembled template. Such structures are highly desirable for various practical applications and as model systems for fundamental studies. The nanostructures were characterized by cross-sectional scanning electron microscopy, grazing-incidence small/wide-angle X-ray scattering (GISAXS/GIWAXS), and X-ray absorption near edge structure (XANES) measurements at each stage during the SIS process and subsequent thermal treatments, to provide a comprehensive picture of their evolution in morphology, crystallography and electronic structure. In particular, we discuss the critical role of SIS Al2O3 seeds toward modifying the chemical affinity and free volume in a polymer for subsequent infiltration of gas phase precursors. The insights into SIS growth obtained from this study are valuable to the design and fabrication of a wide range of targeted nanostructures.

Measuring Dipole Inversion in Self-Assembled Nano-Dielectric Molecular Layers.

A self-assembled nanodielectric (SAND) is an ultrathin film, typically with periodic layer pairs of high-k oxide and phosphonic-acid-based π-electron (PAE) molecular layers. IPAE, having a molecular structure similar to that of PAE but with an inverted dipole direction, has recently been developed for use in thin-film transistors. Here we report that replacing PAE with IPAE in SAND-based thin-film transistors induces sizable threshold and turn-on voltage shifts, indicating the flipping of the built-in SAND polarity. The bromide counteranion (Br-) associated with the cationic stilbazolium portion of PAE or IPAE is of great importance, because its relative position strongly affects the electric dipole moment of the organic layer. Hence, a set of X-ray synchrotron measurements were designed and performed to directly measure and compare the Br- distributions within the PAE and IPAE SANDs. Two trilayer SANDs, consisting of a PAE or IPAE layer sandwiched between an HfOx and a ZrOx layer, were deposited on the SiOx surface of Si substrates or periodic Si/Mo multilayer substrates for X-ray reflectivity and X-ray standing wave measurements, respectively. Along with complementary DFT simulations, the spacings, elemental (Hf, Br, and Zr) distributions, molecular orientations, and Mulliken charge distributions of the PAE and IPAE molecules within each of the SAND trilayers were determined and correlated with the dipole inversion.

An original valveless artificial heart providing pulsatile flow tested in mock circulatory loops.

PURPOSE: We present the test bench results of a valveless total artificial heart that is potentially compatible with the pediatric population. METHODS: The RollingHeart is a valveless volumetric pump generating pulsatile flow. It consists of a single spherical cavity divided into 4 chambers by 2 rotating disks. The combined rotations of both disks produce changes in the volumes of the 4 cavities (suction and ejection). The blood enters/exits the spherical cavity through 4 openings that are symmetrical to the fixed rotation axis of the first disk.Mock circulatory system: The device pumps a 37% glycerin solution through 2 parallel circuits, simulating the pulmonary and systemic circulations. Flow rates are acquired with a magnetic inductive flowmeter, while pressure sensors collect pressure in the left and right outflow and inflow tracts.In vitro test protocol: The pump is run at speeds ranging from 20 to 180 ejections per minute. The waveform of the pressure generated at the inflow and outflow of the 4 chambers and the flow rate in the systemic circulation are measured. RESULTS: At an ejection rate of 178 min-1, the RollingHeart pumps 5.3 L/min for a systemic maximal pressure gradient of 174 mmHg and a pulmonary maximal pressure gradient of 75 mmHg. The power input was 14 W, corresponding to an efficiency of 21%. CONCLUSIONS: The RollingHeart represents a new approach in the domain of total artificial heart. This preliminary study endorses the feasibility of a single valveless device acting as a total artificial heart.

Antibiotic treatment for uncomplicated and mild complicated diverticulitis: outpatient treatment for everyone.

PURPOSE: Antibiotic treatment is the treatment of choice for uncomplicated diverticulitis (uD) and can be performed for mild complicated diverticulitis (mcD). In several cases, outpatient treatment (OT) can be undertaken. This study assessed the 1-month failure rate of OT for uD/mcD compared to inpatient treatment (IT), and identified predictive factors for treatment failure. METHODS: All consecutive patients (2006-2012) diagnosed with uD/mcD by CT scan were retrospectively analyzed. Acute uD was defined as absence of the following: abscess, fistula, extraluminal contrast, pneumoperitoneum, and need for immediate percutaneous drainage/surgery. Acute mcD was defined as complicated diverticulitis with abscess <4 cm or pneumoperitoneum <2 cm. All patients received antibiotherapy. Treatment failure was defined as (re)hospitalization the first month after treatment onset or need of drainage/surgery during hospitalization. All patients were contacted using a standardized questionnaire. RESULTS: Out of 540 uD/mcD, IT was offered to 369 patients (68%) and OT to 171 patients (32%). The IT group had higher median age, more women, higher median Charlson Index, more severe median Ambrosetti score, longer median time in the emergency room, and higher median CRP. Response rates to the questionnaire were 56% (IT) vs. 62% (OT), p = 0.18. Failure rates were 32% in IT vs. 10% in OT group, p < 0.01. Among the uD/mcD patients, admission/CT time between midnight and 6 AM, Ambrosetti score of 4, and free air around the colon were risk factors for failure. CONCLUSIONS: Outpatient treatment for uncomplicated/mild complicated diverticulitis is feasible and safe. Prognostic factors of failure necessitating closer follow-up were admission/CT time, Ambrosetti score of 4, and free air around the colon.

Low-Temperature Atomic Layer Deposition of MoS2 Films.

Wet chemical screening reveals the very high reactivity of Mo(NMe2 )4 with H2 S for the low-temperature synthesis of MoS2 . This observation motivated an investigation of Mo(NMe2 )4 as a volatile precursor for the atomic layer deposition (ALD) of MoS2 thin films. Herein we report that Mo(NMe2 )4 enables MoS2 film growth at record low temperatures-as low as 60 °C. The as-deposited films are amorphous but can be readily crystallized by annealing. Importantly, the low ALD growth temperature is compatible with photolithographic and lift-off patterning for the straightforward fabrication of diverse device structures.

Inhibiting Metal Oxide Atomic Layer Deposition: Beyond Zinc Oxide.

Atomic layer deposition (ALD) of several metal oxides is selectivity inhibited on alkanethiol self-assembled monolayers (SAMs) on Au, and the eventual nucleation mechanism is investigated. The inhibition ability of the SAM is significantly improved by the in situ H2-plasma pretreatment of the Au substrate prior to the gas-phase deposition of a long-chain alkanethiol, 1-dodecanethiol (DDT). This more rigorous surface preparation inhibits even aggressive oxide ALD precursors, including trimethylaluminum and water, for at least 20 cycles. We study the effect that the ALD precursor purge times, growth temperature, alkanethiol chain length, alkanethiol deposition time, and plasma treatment time have on Al2O3 ALD inhibition. This is the first example of Al2O3 ALD inhibition from a vapor-deposited SAM. The inhibitions of Al2O3, ZnO, and MnO ALD processes are compared, revealing the versatility of this selective surface treatment. Atomic force microscopy and grazing-incidence X-ray fluorescence further reveal insight into the mechanism by which the well-defined surface chemistry of ALD may eventually be circumvented to allow metal oxide nucleation and growth on SAM-modified surfaces.

Low-Temperature Atomic Layer Deposition of CuSbS2 for Thin-Film Photovoltaics.

Copper antimony sulfide (CuSbS2) has been gaining traction as an earth-abundant absorber for thin-film photovoltaics given its near ideal band gap for solar energy conversion (∼1.5 eV), large absorption coefficient (>104 cm-1), and elemental abundance. Through careful in situ analysis of the deposition conditions, a low-temperature route to CuSbS2 thin films via atomic layer deposition has been developed. After a short (15 min) postprocess anneal at 225 °C, the ALD-grown CuSbS2 films were crystalline with micron-sized grains, exhibited a band gap of 1.6 eV and an absorption coefficient >104 cm-1, as well as a hole concentration of 1015 cm-3. Finally, the ALD-grown CuSbS2 films were paired with ALD-grown TiO2 to form a photovoltaic device. This photovoltaic device architecture represents one of a very limited number of Cd-free CuSbS2 PV device stacks reported to date, and it is the first to demonstrate an open-circuit voltage on par with CuSbS2/CdS heterojunction PV devices. While far from optimized, this work demonstrates the potential for ALD-grown CuSbS2 thin films in environmentally benign photovoltaics.

Conformal Coating of a Phase Change Material on Ordered Plasmonic Nanorod Arrays for Broadband All-Optical Switching.

Actively tunable optical transmission through artificial metamaterials holds great promise for next-generation nanophotonic devices and metasurfaces. Plasmonic nanostructures and phase change materials have been extensively studied to this end due to their respective strong interactions with light and tunable dielectric constants under external stimuli. Seamlessly integrating plasmonic components with phase change materials, as demonstrated in the present work, can facilitate phase change by plasmonically enabled light confinement and meanwhile make use of the high sensitivity of plasmon resonances to the variation of dielectric constant associated with the phase change. The hybrid platform here is composed of plasmonic indium-tin-oxide nanorod arrays (ITO-NRAs) conformally coated with an ultrathin layer of a prototypical phase change material, vanadium dioxide (VO2), which enables all-optical modulation of the infrared as well as the visible spectral ranges. The interplay between the intrinsic plasmonic nonlinearity of ITO-NRAs and the phase transition induced permittivity change of VO2 gives rise to spectral and temporal responses that cannot be achieved with individual material components alone.

Liquid Water- and Heat-Resistant Hybrid Perovskite Photovoltaics via an Inverted ALD Oxide Electron Extraction Layer Design.

Despite rapid advances in conversion efficiency (>22%), the environmental stability of perovskite solar cells remains a substantial barrier to commercialization. Here, we show a significant improvement in the stability of inverted perovskite solar cells against liquid water and high operating temperature (100 °C) by integrating an ultrathin amorphous oxide electron extraction layer via atomic layer deposition (ALD). These unencapsulated inverted devices exhibit a stable operation over at least 10 h when subjected to high thermal stress (100 °C) in ambient environments, as well as upon direct contact with a droplet of water without further encapsulation.

Layer-by-Layer Assembled Films of Perylene Diimide- and Squaraine-Containing Metal-Organic Framework-like Materials: Solar Energy Capture and Directional Energy Transfer.

We demonstrate that thin films of metal-organic framework (MOF)-like materials, containing two perylenediimides (PDICl4, PDIOPh2) and a squaraine dye (S1), can be fabricated by layer-by-layer assembly (LbL). Interestingly, these LbL films absorb across the visible light region (400-750 nm) and facilitate directional energy transfer. Due to the high spectral overlap and oriented transition dipole moments of the donor (PDICl4 and PDIOPh2) and acceptor (S1) components, directional long-range energy transfer from the bluest to reddest absorber was successfully demonstrated in the multicomponent MOF-like films. These findings have significant implications for the development of solar energy conversion devices based on MOFs.

Porphyrins as Templates for Site-Selective Atomic Layer Deposition: Vapor Metalation and in Situ Monitoring of Island Growth.

Examinations of enzymatic catalysts suggest one key to efficient catalytic activity is discrete size metallo clusters. Mimicking enzymatic cluster systems is synthetically challenging because conventional solution methods are prone to aggregation or require capping of the cluster, thereby limiting its catalytic activity. We introduce site-selective atomic layer deposition (ALD) on porphyrins as an alternative approach to grow isolated metal oxide islands that are spatially separated. Surface-bound tetra-acid free base porphyrins (H2TCPP) may be metalated with Mn using conventional ALD precursor exposure to induce homogeneous hydroxide synthetic handles which acts as a nucleation point for subsequent ALD MnO island growth. Analytical fitting of in situ QCM mass uptake reveals island growth to be hemispherical with a convergence radius of 1.74 nm. This growth mode is confirmed with synchrotron grazing-incidence small-angle X-ray scattering (GISAXS) measurements. Finally, we extend this approach to other ALD chemistries to demonstrate the generality of this route to discrete metallo island materials.

A modular reactor design for in situ synchrotron x-ray investigation of atomic layer deposition processes.

Synchrotron characterization techniques provide some of the most powerful tools for the study of film structure and chemistry. The brilliance and tunability of the Advanced Photon Source allow access to scattering and spectroscopic techniques unavailable with in-house laboratory setups and provide the opportunity to probe various atomic layer deposition (ALD) processes in situ starting at the very first deposition cycle. Here, we present the design and implementation of a portable ALD instrument which possesses a modular reactor scheme that enables simple experimental switchover between various beamlines and characterization techniques. As first examples, we present in situ results for (1) X-ray surface scattering and reflectivity measurements of epitaxial ZnO ALD on sapphire, (2) grazing-incidence small angle scattering of MnO nucleation on silicon, and (3) grazing-incidence X-ray absorption spectroscopy of nucleation-regime Er2O3 ALD on amorphous ALD alumina and single crystalline sapphire.

Keeping primary care "in the loop": General practitioners want better communication with specialists and hospitals when caring for people diagnosed with cancer.

AIM: To investigate general practitioners' (GP) perceptions about communication when providing cancer care. METHODS: A self-report survey, which included an open response section, was mailed to a random sample of 1969 eligible Australian GPs. Content analysis of open response comments pertaining to communication was undertaken in order to ascertain GPs' views about communication issues in the provision of cancer care. RESULTS: Of the 648 GPs who completed the survey, 68 (10%) included open response comments about interprofessional communication. Participants who commented on communication were a median age of 50 years and worked 33 h/week; 28% were male and 59% practiced in the metropolitan area. Comments pertaining to communication were coded using five non-mutually exclusive categories: being kept in the loop; continuity of care; relationships with specialists; positive communication experiences; and strategies for improving communication.GPs repeatedly noted the importance of receiving detailed and timely communication from specialists and hospitals, particularly in relation to patients' treatment regimes and follow-up care. Several GPs remarked that they were left out of "the information loop" and that patients were "lost" or "dumped" after referral. CONCLUSION: While many GPs are currently involved in some aspects of cancer management, detailed and timely communication between specialists and GPs is imperative to support shared care and ensure optimal patient outcomes. This research highlights the need for established channels of communication between specialist and primary care medicine to support greater involvement by GPs in cancer care.

New Insights into Sequential Infiltration Synthesis.

Sequential infiltration synthesis (SIS) is a process derived from ALD in which a polymer is infused with inorganic material using sequential, self-limiting exposures to gaseous precursors. SIS can be used in lithography to harden polymer resists rendering them more robust towards subsequent etching, and this permits deeper and higher-resolution patterning of substrates such as silicon. Herein we describe recent investigations of a model system: Al2O3 SIS using trimethyl aluminum (TMA) and H2O within the diblock copolymer, poly(styrene-block-methyl methacrylate) (PS-b-PMMA). Combining in-situ Fourier transform infrared absorption spectroscopy, quartz-crystal microbalance, and synchrotron grazing incidence small angle X-ray scattering with high resolution scanning transmission electron microscope tomography, we elucidate important details of the SIS process: 1) TMA adsorption in PMMA occurs through a weakly-bound intermediate; 2) the SIS kinetics are diffusion-limited, with desorption 10× slower than adsorption; 3) dynamic structural changes occur during the individual precursor exposures. These findings have important implications for applications such as SIS lithography.