Transforming medical students' speaking-up behaviors in medical errors: The impact of simulation and personalized debriefing.

INTRODUCTION: Sharing mental models is essential for high-performance teams, and speaking up is key for exchanging critical insights, especially during medical errors. Understanding how health providers and trainees voice their concerns is crucial for improving speaking-up behavior. This study aims to fill a gap in the literature by examining how medical students speak up when they encounter medical errors and assessing the impact of training on their speaking-up patterns. METHOD: A quasi-experimental study involving 146 students, who were divided into two groups, was conducted in Northern Taiwan. One group of students encountered life-threatening scenario before intervention, followed by a faculty-led personalized debriefing session, then a non-life-threatening scenario after the intervention. Another group of students underwent these sessions in the reverse order. Students' Speaking-up patterns, including expression style, form and attitude, and their speaking-up confidence were assessed at pre- and post-intervention scenarios. RESULTS: During pre-intervention scenario, in expression style, 50 students (34.5%) addressed their concerns to medical errors with direct expression and 14 students (9.7%) utilized indirect hint to express their concerns. In expression form, 31 students (21.4%) addressed their concerns to medical errors with affirmative sentences and 33 students (22.8%) asked questions to express their concerns. In speaking-up attitude, 47 students (32.4%) used unoffensive words, while 17 students (11.7%) used offensive words. After intervention, significantly change of speaking-up styles, forms, and attitude were observed along with their speaking-up confidence (p < 0.001). DISCUSSION: Medical students are inclined to speak up in the event of medical errors using more direct expression and affirmative sentences, along with increased speaking-up confidence after simulation scenario learning and faculty-led personalized debriefing. Healthcare educators can focus more on discussing with students the advantages and disadvantages of various approaches of speaking-up in medical errors, helping them to develop effective speaking-up behaviors in a variety of medical contexts.

Early Identification of Sepsis-Induced Acute Kidney Injury by Using Monocyte Distribution Width, Red-Blood-Cell Distribution, and Neutrophil-to-Lymphocyte Ratio.

Sepsis-induced acute kidney injury (AKI) is a common complication in patients with severe illness and leads to increased risks of mortality and chronic kidney disease. We investigated the association between monocyte distribution width (MDW), red-blood-cell volume distribution width (RDW), neutrophil-to-lymphocyte ratio (NLR), sepsis-related organ-failure assessment (SOFA) score, mean arterial pressure (MAP), and other risk factors and sepsis-induced AKI in patients presenting to the emergency department (ED). This retrospective study, spanning 1 January 2020, to 30 November 2020, was conducted at a university-affiliated teaching hospital. Patients meeting the Sepsis-2 consensus criteria upon presentation to our ED were categorized into sepsis-induced AKI and non-AKI groups. Clinical parameters (i.e., initial SOFA score and MAP) and laboratory markers (i.e., MDW, RDW, and NLR) were measured upon ED admission. A logistic regression model was developed, with sepsis-induced AKI as the dependent variable and laboratory parameters as independent variables. Three multivariable logistic regression models were constructed. In Model 1, MDW, initial SOFA score, and MAP exhibited significant associations with sepsis-induced AKI (area under the curve [AUC]: 0.728, 95% confidence interval [CI]: 0.668-0.789). In Model 2, RDW, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.712, 95% CI: 0.651-0.774). In Model 3, NLR, initial SOFA score, and MAP were significantly correlated with sepsis-induced AKI (AUC: 0.719, 95% CI: 0.658-0.780). Our novel models, integrating MDW, RDW, and NLR with initial SOFA score and MAP, can assist with the identification of sepsis-induced AKI among patients with sepsis presenting to the ED.

Monocyte Distribution Width in Children With Systemic Inflammatory Response: Retrospective Cohort Examining Association With Early Sepsis.

OBJECTIVES: To investigate the association between increased monocyte distribution width (MDW) and pediatric sepsis in the emergency department (ED). DESIGN: Retrospective cohort study. SETTING: A single academic hospital study. PATIENTS: Patients from birth to the age of 18 years who presented at the ED of an academic hospital with systemic inflammatory response syndrome (SIRS) were consecutively enrolled. Sepsis was diagnosed using the International Pediatric Surviving Sepsis Campaign criteria. INTERVENTIONS: Antibiotic treatment was administrated once infection was suspected. MEASUREMENTS AND MAIN RESULTS: Routine complete blood cell count, neutrophil-to-lymphocyte ratio (NLR), and MDW, a new inflammatory biomarker, were evaluated in the ED. Logistic regression models were used to explore associations with early pediatric sepsis. We included 201 patients with sepsis and 1,050 without sepsis. In the multivariable model, MDW greater than 23 U (odds ratio [OR], 4.97; 95% CI, 3.42-7.22; p < 0.0001), NLR greater than 6 (OR, 2.06; 95% CI, 1.43-2.94; p = 0.0001), WBC greater than 11,000 cells/µL (OR, 6.52; 95% CI, 4.45-9.53; p < 0.0001), and the SIRS score (OR, 3.42; 95% CI, 2.57-4.55; p < 0.0001) were associated with pediatric sepsis. In subgroup analysis, MDW greater than 23 U remained significantly associated with sepsis for children 6-12 years old (OR, 6.76; 95% CI, 2.60-17.57; p = 0.0001) and 13-18 years (OR, 17.49; 95% CI, 7.69-39.76; p = 0.0001) with an area under the receiver operating curve of 0.8-0.9. CONCLUSIONS: MDW greater than 23 U at presentation is associated with the early diagnosis of sepsis in children greater than or equal to 6 years old. This parameter should be considered as a stratification variable in studies of pediatric sepsis.

Fever, Tachypnea, and Monocyte Distribution Width Predicts Length of Stay for Patients with COVID-19: A Pioneer Study.

(1) Background: Our study investigated whether monocyte distribution width (MDW) could be used in emergency department (ED) settings as a predictor of prolonged length of stay (LOS) for patients with COVID-19. (2) Methods: A retrospective cohort study was conducted; patients presenting to the ED of an academic hospital with confirmed COVID-19 were enrolled. Multivariable logistic regression models were used to obtain the odds ratios (ORs) for predictors of an LOS of >14 days. A validation study for the association between MDW and cycle of threshold (Ct) value was performed. (3) Results: Fever > 38 °C (OR: 2.82, 95% CI, 1.13−7.02, p = 0.0259), tachypnea (OR: 4.76, 95% CI, 1.67−13.55, p = 0.0034), and MDW ≥ 21 (OR: 5.67, 95% CI, 1.19−27.10, p = 0.0269) were robust significant predictors of an LOS of >14 days. We developed a new scoring system in which patients were assigned 1 point for fever > 38 °C, 2 points for tachypnea > 20 breath/min, and 3 points for MDW ≥ 21. The optimal cutoff was a score of ≥2. MDW was negatively associated with Ct value (ß: −0.32 per day, standard error = 0.12, p = 0.0099). (4) Conclusions: Elevated MDW was associated with a prolonged LOS.

Periappendiceal fat-stranding models for discriminating between complicated and uncomplicated acute appendicitis: a diagnostic and validation study.

BACKGROUND: Recent studies have reported promising outcomes of non-operative treatment for uncomplicated appendicitis; however, the preoperative prediction of complicated appendicitis is challenging. We developed models by incorporating fat stranding (FS), which is commonly observed in perforated appendicitis. MATERIAL AND METHODS: We reviewed the data of 402 consecutive patients with confirmed acute appendicitis from our prospective registry. Multivariate logistic regression was performed to select clinical and radiographic factors predicting complicated acute appendicitis in our model 1 (involving backward elimination) and model 2 (involving stepwise selection). We compared c statistics among scoring systems developed by Bröker et al. (in J Surg Res 176(1):79-83. https://doi.org/10.1016/j.jss.2011.09.049 , 2012), Imaoka et al. (in World J Emerg Surg 11(1):1-5, 2016), Khan et al. (in Cureus. https://doi.org/1010.7759/cureus.4765 , 2019), Kim et al. (in Ann Coloproctol 31(5):192, 2015), Kang et al. (in Medicine 98(23): e15768, 2019), Atema et al. (in Br J Surg 102(8):979-990. https://doi.org/10.1002/bjs.9835 , 2015), Avanesov et al. (in Eur Radiol 28(9):3601-3610, 2018), and Kim et al. (in Abdom Radiol 46:1-12, 2020). Finally, we examined our models by performing the integrated discrimination improvement (IDI) test. RESULTS: Among enrolled patients, 64 (15.9%) had complicated acute appendicitis. We developed new 10-point scoring models by including the following variables: C-reactive protein, neutrophil to lymphocyte ratio, and computed tomography features of FS, ascites, and appendicolith. A cutoff score of ≥ 6 exhibited a high sensitivity of 82.8% and a specificity of 82.8% for model 1 and 81.3% and 82.3% for model 2, respectively, with c statistics of 0.878 (model 1) and 0.879 (model 2). Compared with the model developed by Bröker et al. which included C-reactive protein and the abdominal pain duration (c statistic: 0.778), the models developed by Atema et al. (c statistic: 0.826, IDI: 5.92%, P = 0.0248), H.Y Kim et al. (c statistics: 0.838, IDI: 13.82%, P = 0.0248), and our two models (IDI: 18.29%, P < 0.0001) demonstrated a significantly higher diagnostic accuracy. CONCLUSION: Our models and the scoring systems developed by Atema et al. and Kim et al. were validated to have a high diagnostic accuracy; moreover, our models included the lowest number of variables.

Facile Growth of Cu2ZnSnS4 Thin-Film by One-Step Pulsed Hybrid Electrophoretic and Electroplating Deposition.

The use of costly and rare metals such as indium and gallium in Cu(In,Ga)Se2 (CIGS) based solar cells has motivated research into the use of Cu2ZnSnS4 (CZTS) as a suitable replacement due to its non-toxicity, abundance of compositional elements and excellent optical properties (1.5 eV direct band gap and absorption coefficient of ~10(4) cm(-1)). In this study, we demonstrate a one-step pulsed hybrid electrodeposition method (PHED), which combines electrophoretic and electroplating deposition to deposit uniform CZTS thin-films. Through careful analysis and optimization, we are able to demonstrate CZTS solar cells with the VOC, JSC, FF and η of 350 mV, 3.90 mA/cm(2), 0.43 and 0.59%, respectively.

A facile chemical-mechanical polishing lift-off transfer process toward large scale Cu(In,Ga)Se2 thin-film solar cells on arbitrary substrates.

The fabrication of Cu(In,Ga)Se2 (CIGS) solar cells on flexible substrates is a non-trivial task due to thermal and ion diffusion related issues. In order to circumvent these issues, we have developed a chemical-mechanical polishing lift-off (CMPL) transfer process, enabling the direct transfer of CIGS solar cells from conventional soda-lime glass (SLG) onto arbitrary flexible substrates up to 4 cm(2) in size. The structural and compositional nature of the pre- and post-transferred films is examined using electron microscopy, X-ray diffraction analysis, Raman and photoluminescence spectroscopy. We demonstrate the fabrication of solar cells on a range of flexible substrates while being able to maintain 75% cell efficiency (η) when compared to pre-transferred solar cells. The results obtained in this work suggest that our transfer process offers a highly promising approach toward large scale fabrication of CIGS-based solar cells on a wide variety of flexible substrates, suitable for use in the large scale CIGS photovoltaic industry.

Enhanced Conversion Efficiency of Cu(In,Ga)Se2 Solar Cells via Electrochemical Passivation Treatment.

Defect control in Cu(In,Ga)Se2 (CIGS) materials, no matter what the defect type or density, is a significant issue, correlating directly to PV performance. These defects act as recombination centers and can be briefly categorized into interface recombination and Shockley-Read-Hall (SRH) recombination, both of which can lead to reduced PV performance. Here, we introduce an electrochemical passivation treatment for CIGS films that can lower the oxygen concentration at the CIGS surface as observed by X-ray photoelectron spectrometer analysis. Temperature-dependent J-V characteristics of CIGS solar cells reveal that interface recombination is suppressed and an improved rollover condition can be achieved following our electrochemical treatment. As a result, the surface defects are passivated, and the power conversion efficiency performance of the solar cell devices can be enhanced from 4.73 to 7.75%.

Electrochemical synthesis of ultrafast and gram-scale surfactant-free tellurium nanowires by gas-solid transformation and their applications as supercapacitor electrodes for p-doping of graphene transistors.

We herein report a gas-solid transformation mechanism for the surfactant-free synthesis of Te NWs at room temperature by electrolysis of bulk Bi2Te3 using H2Te gas. Te NWs, with an average diameter below 20 nm, grow along the [001] direction due to the unique spiral chains in the crystal structure and show an enhanced Raman scattering effect, a broad absorption band over the range of 350-750 nm and an emission band over the range of 400-700 nm in the photoluminescence spectrum. In terms of device applications, we demonstrate how Te NWs can be directly applied as a p-type dopant source in order to shift the Dirac point in ambipolar field effect graphene transistors. Finally, the favorable capacitive properties of Te NWs are established as supercapacitor electrodes with negligible internal resistance and excellent electrochemical reversibility and a specific capacitance of 24 F g(-1).

Large-scale micro- and nanopatterns of Cu(In,Ga)Se2 thin film solar cells by mold-assisted chemical-etching process.

A reactive mold-assisted chemical etching (MACE) process through an easy-to-make agarose stamp soaked in bromine methanol etchant to rapidly imprint larger area micro- and nanoarrays on CIGS substrates was demonstrated. Interestingly, by using the agarose stamp during the MACE process with and without additive containing oil and triton, CIGS microdome and microhole arrays can be formed on the CIGS substrate. Detailed formation mechanisms of microstructures and the chemical composition variation after the etching process were investigated. In addition, various microand nanostructures were also demonstrated by this universal approach. The microstructure arrays integrated into standard CIGS solar cells with thinner thickness can still achieve an efficiency of 11.22%, yielding an enhanced efficiency of ∼18% compared with that of their planar counterpart due to an excellent absorption behavior confirmed by the simulation results, which opens up a promising way for the realization of high-efficiency micro- or nanostructured thin-film solar cells. Finally, the complete dissolution of agarose stamp into hot water demonstrates an environmentally friendly method by the mold-assisted chemical etching process through an easy-to-make agarose stamp.

Large-scale and patternable graphene: direct transformation of amorphous carbon film into graphene/graphite on insulators via Cu mediation engineering and its application to all-carbon based devices.

Chemical vapour deposition of graphene was the preferred way to synthesize graphene for multiple applications. However, several problems related to transfer processes, such as wrinkles, cleanness and scratches, have limited its application at the industrial scale. Intense research was triggered into developing alternative synthesis methods to directly deposit graphene on insulators at low cost with high uniformity and large area. In this work, we demonstrate a new concept to directly achieve growth of graphene on non-metal substrates. By exposing an amorphous carbon (a-C) film in Cu gaseous molecules after annealing at 850 °C, the carbon (a-C) film surprisingly undergoes a noticeable transformation to crystalline graphene. Furthermore, the thickness of graphene could be controlled, depending on the thickness of the pre-deposited a-C film. The transformation mechanism was investigated and explained in detail. This approach enables development of a one-step process to fabricate electrical devices made of all carbon material, highlighting the uniqueness of the novel approach for developing graphene electronic devices. Interestingly, the carbon electrodes made directly on the graphene layer by our approach offer a good ohmic contact compared with the Schottky barriers usually observed on graphene devices using metals as electrodes.

Single CuO(x) nanowire memristor: forming-free resistive switching behavior.

CuOx nanowires were synthesized by a low-cost and large-scale electrochemical process with AAO membranes at room temperature and its resistive switching has been demonstrated. The switching characteristic exhibits forming-free and low electric-field switching operation due to coexistence of significant amount of defects and Cu nanocrystals in the partially oxidized nanowires. The detailed resistive switching characteristics of CuOx nanowire systems have been investigated and possible switching mechanisms are systematically proposed based on the microstructural and chemical analysis via transmission electron microscopy.

Large scale and orientation-controllable nanotip structures on CuInS2, Cu(In,Ga)S2, CuInSe2, and Cu(In,Ga)Se2 by low energy ion beam bombardment process: growth and characterization.

One-step facile methodology to create nanotip arrays on chalcopyrite materials (such as CuInS2, Cu(In,Ga)S2, CuInSe2, and Cu(In,Ga)Se2) via a low energy ion beam bombardment process has been demonstrated. The mechanism of formation for nanotip arrays has been proposed by sputtering yields of metals and reduction of metals induced by the ion beam bombardment process. The optical reflectance of these chalcopyrite nanotip arrays has been characterized by UV-vis spectrophotometer and the efficient light-trapping effect has been observed. Large scale (∼4'') and high density (10(10) tips/cm(2)) of chalcopyrite nanotip arrays have been obtained by using low ion energy (< 1 kV), short processing duration (< 30 min), and template-free. Besides, orientation and length of these chalcopyrite nanotip arrays are controllable. Our results can be the guide for other nanostructured materials fabrication by ion sputtering and are available for industrial production as well.

Growth of large-scale nanotwinned Cu nanowire arrays from anodic aluminum oxide membrane by electrochemical deposition process: controllable nanotwin density and growth orientation with enhanced electrical endurance performance.

Densely nanotwinned Cu nanowire (NW) arrays with an identical diameter of ∼55 nm were fabricated by pulse electrochemical deposition at low temperature using anodic aluminum oxide as a template. Different growth orientations of nanotwinned Cu nanowire arrays were investigated. The endurance of the electrical current density before breakdown of the nanotwinned Cu NWs can reach up to 2.4 × 10(8) A cm(-2). The formation of highly dense nanotwins is attributed to relaxation of coalescence induced stress and twin fault stacking when Cu NWs grow by two-dimensional kinetics. A mechanism based on the twinning structure effect on the electromigration was proposed to explain the improved electrical endurance of Cu. The result demonstrates that the formation of nanotwins into Cu NWs can effectively suppress the void growth, leading to extended life time for use in electronic devices.

Fabrication of large-scale single-crystal bismuth telluride (Bi2Te3) nanosheet arrays by a single-step electrolysis process.

Nanolizing of thermoelectric materials is one approach to reduce the thermal conductivity and hence enhance the figure of merit. Bismuth telluride (Bi2Te3)-based materials have excellent figure of merit at room temperature. For device applications, precise control and rapid fabrication for the nanostructure of thermoelectric materials are essential issues. In the present study, we demonstrate a one-step electrolysis process to directly form Bi2Te3 nanosheet arrays (NSAs) on the surface of bulk Bi2Te3 with controllable spacing distance and depth by tuning the applied bias and duration. The single sheet of NSAs reveals that the average thickness and electrical resistivity of single crystalline Bi2Te3 in composition are 399.8 nm and 137.34 µΩ m, respectively. The formation mechanism of NSAs has been proposed. A 1.12% efficiency of quantum dot-sensitized solar cells with Bi2Te3 NSAs for counter electrode has been demonstrated, indicating that Bi2Te3 NSAs from top-down processing with a high ratio of surface area to volume are a promising candidate for possible applications such as thermoelectrics, dye-sensitized solar cells (DSSCs), and lithium-ion batteries.

Resistive switching of Au/ZnO/Au resistive memory: an in situ observation of conductive bridge formation.

A special chip for direct and real-time observation of resistive changes, including set and reset processes based on Au/ZnO/Au system inside a transmission electron microscope (TEM), was designed. A clear conducting bridge associated with the migration of Au nanoparticles (NPs) inside a defective ZnO film from anode to cathode could be clearly observed by taking a series of TEM images, enabling a dynamic observation of switching behaviors. A discontinuous region (broken region) nearby the cathode after reset process was observed, which limits the flow of current, thus a high resistance state, while it will be reconnected to switch the device from high to low resistance states through the migration of Au NPs after set process. Interestingly, the formed morphology of the conducting bridge, which is different from the typical formation of a conducting bridge, was observed. The difference can be attributed to the different diffusivities of cations transported inside the dielectric layer, thereby significantly influencing the morphology of the conducting path. The current TEM technique is quite unique and informative, which can be used to elucidate the dynamic processes in other devices in the future.