Surface Finishing and Coating Parameters Impact on Additively Manufactured Binder-Jetted Steel-Bronze Composites.

In this paper, electroless nickel plating is explored for the protection of binder-jetting-based additively manufactured (AM) composite materials. Electroless nickel plating was attempted on binder-jetted composites composed of stainless steel and bronze, resulting in differences in the physicochemical properties. We investigated the impact of surface finishing, plating solution chemistry, and plating parameters to attain a wide range of surface morphologies and roughness levels. We employed the Keyence microscope to quantitatively evaluate dramatically different surface properties before and after the coating of AM composites. Scanning electron microscopy revealed a wide range of microstructural properties in relation to each combination of surface finishing and coating parameters. We studied chempolishing, plasma cleaning, and organic cleaning as the surface preparation methods prior to coating. We found that surface preparation dictated the surface roughness. Taguchi statistical analysis was performed to investigate the relative strength of experimental factors and interconnectedness among process parameters to attain optimum coating qualities. The quantitative impacts of phosphorous level, temperature, surface preparation, and time factor on the roughness of the nickel-plated surface were 17.95%, 8.2%, 50.02%, and 13.21%, respectively. On the other hand, the quantitative impacts of phosphorous level, temperature, surface preparation, and time factor on the thickness of nickel plating were 35.12%, 41.40%, 3.87%, and 18.24%, respectively. The optimum combination of the factors' level projected the lowest roughness of Ra at 7.76 µm. The optimum combination of the factors' level projected the maximum achievable thickness of ~149 µm. This paper provides insights into coating process for overcoming the sensitivity of AM composites in hazardous application spaces via robust coating.

Machine Learning-Enabled Quantitative Analysis of Optically Obscure Scratches on Nickel-Plated Additively Manufactured (AM) Samples.

Additively manufactured metal components often have rough and uneven surfaces, necessitating post-processing and surface polishing. Hardness is a critical characteristic that affects overall component properties, including wear. This study employed K-means unsupervised machine learning to explore the relationship between the relative surface hardness and scratch width of electroless nickel plating on additively manufactured composite components. The Taguchi design of experiment (TDOE) L9 orthogonal array facilitated experimentation with various factors and levels. Initially, a digital light microscope was used for 3D surface mapping and scratch width quantification. However, the microscope struggled with the reflections from the shiny Ni-plating and scatter from small scratches. To overcome this, a scanning electron microscope (SEM) generated grayscale images and 3D height maps of the scratched Ni-plating, thus enabling the precise characterization of scratch widths. Optical identification of the scratch regions and quantification were accomplished using Python code with a K-means machine-learning clustering algorithm. The TDOE yielded distinct Ni-plating hardness levels for the nine samples, while an increased scratch force showed a non-linear impact on scratch widths. The enhanced surface quality resulting from Ni coatings will have significant implications in various industrial applications, and it will play a pivotal role in future metal and alloy surface engineering.

Pharmacological Emergency management of Agitation in Children and Young people: protocol for a randomised controlled trial of intraMuscular medication (PEAChY-M).

INTRODUCTION: Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of intramuscular olanzapine is more effective than intramuscular droperidol at successfully sedating young people with ASBD requiring intramuscular sedation. METHODS AND ANALYSIS: This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of intramuscular olanzapine and intramuscular droperidol. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management.Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1 hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. ETHICS AND DISSEMINATION: Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/69948/RCHM-2021). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001238864.

Pharmacological emergency management of agitation in children and young people: protocol for a randomised controlled trial of oral medication (PEAChY-O).

INTRODUCTION: Acute severe behavioural disturbance (ASBD) is a condition seen with increasing frequency in emergency departments (EDs) in adults and young people. Despite the increasing number of presentations and significant associated risks to patients, families and caregivers, there is limited evidence to guide the most effective pharmacological management in children and adolescents. The aim of this study is to determine whether a single dose of oral olanzapine is more effective than a dose of oral diazepam at successfully sedating young people with ASBD. METHODS AND ANALYSIS: This study is a multicentre, open-label, superiority randomised controlled trial. Young people aged between 9 years and 17 years and 364 days presenting to an ED with ASBD who are deemed to require medication for behavioural containment will be recruited to the study. Participants will be randomised in a 1:1 allocation between a single weight-based dose of oral olanzapine and oral diazepam. The primary outcome is the proportion of participants who achieve successful sedation at 1-hour post randomisation without the need for additional sedation. Secondary outcomes will include assessing for adverse events, additional medications provided in the ED, further episodes of ASBD, length of stay in the ED and hospital and satisfaction with management.Effectiveness will be determined using an intention-to-treat analysis, with medication efficacy determined as part of the secondary outcomes using a per-protocol analysis. The primary outcome of successful sedation at 1 hour will be presented as a percentage within each treatment group, with comparisons presented as a risk difference with its 95% CIs. ETHICS AND DISSEMINATION: Ethics approval was received from the Royal Children's Hospital Human Research Ethics Committee (HREC/66478/RCHM-2020). This incorporated a waiver of informed consent for the study. The findings will be disseminated in a peer-reviewed journal and at academic conferences. TRIAL REGISTRATION NUMBER: ACTRN12621001236886.

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned.

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

Acute Ischemic and Hemorrhagic Stroke in COVID-19: Mounting Evidence.

The novel coronavirus disease of 2019 (COVID-19) is caused by the binding of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) to angiotensin-converting enzyme 2 (ACE2) receptors present on various locations such as the pulmonary alveolar epithelium and vascular endothelium. In COVID-19 patients, the interaction of SARS-CoV-2 with these receptors in the cerebral blood vessels has been attributed to stroke. Although the incidence of acute ischemic stroke is relatively low, ranging from 1% to 6%, the mortality associated with it is substantially high, reaching as high as 38%. This case series describes three distinct yet similar scenarios of COVID-19 positive patients with several underlying comorbidities, wherein two of the patients presented to our hospital with sudden onset right-sided weakness, later diagnosed with ischemic stroke, and one patient who developed an acute intracerebral hemorrhage during his hospital stay. The patients were diagnosed with acute stroke as a complication of COVID-19 infection. We also provide an insight into the possible mechanisms responsible for the life-threatening complication. Physicians should have a low threshold for suspecting stroke in COVID-19 patients, and close observation should be kept on such patients particularly those with clinical evidence of traditional risk factors.

Delirium Monitoring in Neurocritically Ill Patients: A Systematic Review.

OBJECTIVES: The Society of Critical Care Medicine recommends routine delirium monitoring, based on data in critically ill patients without primary neurologic injury. We sought to answer whether there are valid and reliable tools to monitor delirium in neurocritically ill patients and whether delirium is associated with relevant clinical outcomes (e.g., survival, length of stay, functional independence, cognition) in this population. DATA SOURCES: We systematically reviewed Cumulative Index to Nursing and Allied Health Literature, Web of Science, and PubMed. STUDY SELECTION AND DATA EXTRACTION: Inclusion criteria allowed any study design investigating delirium monitoring in neurocritically ill patients (e.g., neurotrauma, ischemic, and/or hemorrhagic stroke) of any age. We extracted data relevant to delirium tool sensitivity, specificity, negative predictive value, positive predictive value, interrater reliability, and associated clinical outcomes. DATA SYNTHESIS: Among seven prospective cohort studies and a total of 1,173 patients, delirium was assessed in neurocritically patients using validated delirium tools after considering primary neurologic diagnoses and associated complications, finding a pooled prevalence rate of 12-43%. When able to compare against a common reference standard, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the test characteristics showed a sensitivity of 62-76%, specificity of 74-98%, positive predictive value of 63-91%, negative predictive value of 70-94%, and reliability kappa of 0.64-0.94. Among four studies reporting multivariable analyses, delirium in neurocritically patients was associated with increased hospital length of stay (n = 3) and ICU length of stay (n = 1), as well as worse functional independence (n = 1) and cognition (n = 2), but not survival. CONCLUSIONS: These data from studies of neurocritically ill patients demonstrate that patients with primary neurologic diagnoses can meet diagnostic criteria for delirium and that delirious features may predict relevant untoward clinical outcomes. There is a need for ongoing investigations regarding delirium in these complicated neurocritically ill patients.

Sustainability of a nurse-driven early progressive mobility protocol and patient clinical and psychological health outcomes in a neurological intensive care unit.

OBJECTIVES: To determine sustainable impact of an early progressive mobility protocol on mobility level and clinical outcomes. DESIGN/METHODS: Prospective, longitudinal, comparative study using three time points (pre-, immediate post-intervention and 12-month post-intervention sustainability). Analyses included comparative statistics and multivariable modelling. Data were collected by clinical nurses, from administrative databases. Psychological health data were collected using a valid, reliable tool. SETTING: Patients treated in a 22-bed Neurological Intensive Care Unit of a quaternary-care medical centre. OUTCOME MEASURES: Highest mobility level, length of stay, mortality, discharge disposition, quality metrics and psychological profile including depression, anxiety, and hostility. RESULTS: Amongst 260 pre-intervention, 377 post-implementation, and 480 twelve-month post-implementation patients (N = 1117) walking increased post-implementation and was sustained at the eight-month assessment, p < .001. After multivariable adjustment, unit and hospital length of stay and psychological distress were reduced compared to the pre-early mobility programmes (all p < .001). There were no differences in discharge disposition (i.e., home vs skilled nursing facility), mortality or quality metrics. CONCLUSION: Ongoing implementation of an early mobility programme in a neurological intensive care environment led to sustained improvement in patients' level of mobility, length of unit and hospital stay, depression, anxiety and hostility levels.

The Effect of Patient Navigation on the Likelihood of Engagement in Clinical Care for HIV-Infected Individuals Leaving Jail.

OBJECTIVES: To compare the effectiveness of patient navigation-enhanced case management in supporting engagement in HIV care upon release from jail relative to existing services. METHODS: We randomized 270 HIV-infected individuals to receive navigation-enhanced case management for 12 months or standard case management for 90 days following release from jail between 2010 and 2013. Participants were interviewed at 2, 6, and 12 months after release. We abstracted medical data from jail and city health records. RESULTS: Patient navigation-enhanced case management resulted in greater linkage to care within 30 days of release (odds ratio [OR] = 2.15; 95% confidence interval [CI] = 1.23, 3.75) and consistent retention over 12 months (OR = 1.95; 95% CI = 1.11, 3.46). Receipt of treatment for substance use disorders in jail also resulted in early linkage (OR = 4.06; 95% CI = 1.93, 8.53) and retention (OR = 2.52; 95% CI = 1.21, 5.23). Latinos were less likely to be linked to (OR = 0.35; 95% CI = 0.14, 0.91) or retained in (OR = 0.28; 95% CI = 0.09, 0.82) HIV care. CONCLUSIONS: Patient navigation supports maintaining engagement in care and can mitigate health disparities, and should become the standard of care for HIV-infected individuals leaving jail.

Family Planning in the Context of Latin America's Universal Health Coverage Agenda.

BACKGROUND: Countries in Latin America and the Caribbean (LAC) have substantially improved access to family planning over the past 50 years. Many have also recently adopted explicit declarations of universal rights to health and universal health coverage (UHC) and have begun implementing UHC-oriented health financing schemes. These schemes will have important implications for the sustainability and further growth of family planning programs throughout the region. METHODS: We examined the status of contraceptive methods in major health delivery and financing schemes in 9 LAC countries. Using a set of 37 indicators on family planning coverage, family planning financing, health financing, and family planning inclusion in UHC-oriented schemes, we conducted a desk review of secondary sources, including population surveys, health financing assessments, insurance enrollment reports, and unit cost estimates, and interviewed in-country experts.Findings: Although the modern contraceptive prevalence rate (mCPR) has continued to increase in the majority of LAC countries, substantial disparities in access for marginalized groups remain. On average, mCPR is 20% lower among indigenous women than the general population, 5% lower among uninsured women than insured, and 7% lower among the poorest women than the wealthiest. Among the poorest quintile of women, insured women had an mCPR 16.5 percentage points higher than that of uninsured women, suggesting that expansion of insurance coverage is associated with increased family planning access and use. In the high- and upper-middle-income countries we reviewed, all modern contraceptive methods are typically available through the social health insurance schemes that cover a majority of the population. However, in low- and lower-middle-income countries, despite free provision of most family planning services in public health facilities, stock-outs and implicit rationing present substantial barriers that prevent clients from accessing their preferred method or force them to pay out of pocket. CONCLUSION: Leveraging UHC-oriented schemes to sustain and further increase family planning progress will require that governments take deliberate steps to (1) target poor and informal sector populations, (2) include family planning in benefits packages, (3) ensure sufficient financing for family planning, and (4) reduce nonfinancial barriers to access. Through these steps, countries can increase financial protection for family planning and better ensure the right to health of poor and marginalized populations.

Can differentiated care models solve the crisis in HIV treatment financing? Analysis of prospects for 38 countries in sub-Saharan Africa.

INTRODUCTION: Rapid scale-up of antiretroviral therapy (ART) in the context of financial and health system constraints has resulted in calls to maximize efficiency in ART service delivery. Adopting differentiated care models (DCMs) for ART could potentially be more cost-efficient and improve outcomes. However, no study comprehensively projects the cost savings across countries. We model the potential reduction in facility-level costs and number of health workers needed when implementing two types of DCMs while attempting to reach 90-90-90 targets in 38 sub-Saharan African countries from 2016 to 2020. METHODS: We estimated the costs of three service delivery models: (1) undifferentiated care, (2) differentiated care by patient age and stability, and (3) differentiated care by patient age, stability, key vs. general population status, and urban vs. rural location. Frequency of facility visits, type and frequency of laboratory testing, and coverage of community ART support vary by patient subgroup. For each model, we estimated the total costs of antiretroviral drugs, laboratory commodities, and facility-level personnel and overhead. Certain groups under four-criteria differentiation require more intensive inputs. Community-based ART costs were included in the DCMs. We take into account underlying uncertainty in the projected numbers on ART and unit costs. RESULTS: Total five-year facility-based ART costs for undifferentiated care are estimated to be US$23.33 billion (95% confidence interval [CI]: $23.3-$23.5 billion). An estimated 17.5% (95% CI: 17.4%-17.7%) and 16.8% (95% CI: 16.7%-17.0%) could be saved from 2016 to 2020 from implementing the age and stability DCM and four-criteria DCM, respectively, with annual cost savings increasing over time. DCMs decrease the full-time equivalent (FTE) health workforce requirements for ART. An estimated 46.4% (95% CI: 46.1%-46.7%) fewer FTE health workers are needed in 2020 for the age and stability DCM compared with undifferentiated care. CONCLUSIONS: Adopting DCMs can result in significant efficiency gains in terms of reduced costs and health workforce needs, even with the costs of scaling up community-based ART support under DCMs. Efficiency gains remained flat with increased differentiation. More evidence is needed on how to translate analyzed efficiency gains into implemented cost reductions at the facility level.

Teleneurocritical care and telestroke.

Telestroke and teleneurologic intensive care units (teleneuro-ICUs) optimize the diagnosis and treatment of neurologic emergencies. Establishment of a telestroke or teleneuro-ICU program relies on investment in experienced stroke and neurocritical care personnel as well as advanced telecommunications technologies. Telemanagement of neurologic emergencies can be standardized to improve outcomes, but it is essential to have a relationship with a tertiary care facility that can use endovascular, neurosurgical, and neurocritical care advanced therapies after stabilization. The next stage in telestroke/teleneuro-ICU management involves the use of mobile stroke units to shorten the time to treatment in neurocritically ill patients.

Complicating the coming out narrative: becoming oneself in a heterosexist and cissexist world.

Traditional stage models of LGBTQ identity development have conceptualized coming out as a linear process from "closeted" to "out" that all queer/trans individuals must follow if they are to be considered healthy and well adjusted. These stage models have been critiqued for their rigidity and absence of a dynamic understanding of the coming out process. In this article we explore the findings from a qualitative photovoice study with 15 LGBTQ youths in a small urban center in Ontario that supports these critiques. We explore the efficacy of the photovoice technique in investigating questions of sexual and gender identity. This article identifies some contextual factors that are important in understanding coming out as a social (rather than internal) process; it also identifies some of the ways in which these youths' experiences challenge normative understandings of the "good, out queer."

Clinical and psychological effects of early mobilization in patients treated in a neurologic ICU: a comparative study.

OBJECTIVE: To determine if an early mobilization protocol increased mobility and improved clinical and psychological outcomes. Currently, there is minimal research on the effects of early mobilization in patients with primary neurologic injury. DESIGN: Prospective, two-group pre/post comparative design with data collection 4 months pre- and postintervention with a 4-month run-in period. SETTING: Twenty-two-bed neurologic ICU in a 1,200-bed urban, quaternary-care, academic hospital in Northeast Ohio. SUBJECTS: Critically ill patients with primary neurologic injury admitted to the neurologic ICU. INTERVENTION: An early mobility program included a progressive mobility protocol, written orders, and staff (clinical nurse specialist clinical technician) who advocated for and assisted with mobility. Highest mobility achieved was assessed daily for 13 days, clinical outcomes were retrieved from electronic databases, and psychological profile was collected by valid, reliable questionnaire at/after neurologic ICU discharge. Analyses included comparative statistics and multivariable modeling. MEASUREMENTS AND MAIN RESULTS: Of 637 patients, 260 were preintervention and 377 were postintervention. Patient characteristics were similar between groups, except postintervention group patients had less history of using walking aids and more gait abnormalities, and were less likely to require mechanical ventilation in the neurologic ICU (all p≤0.006). Compared with preintervention, postintervention patients had higher mobility levels and decreased hospital and neurologic ICU length of stay; were more likely to be discharged home (all p≤0.002); had decreased bloodstream infection, hospital-acquired pressure ulcer, and anxiety rates (all p<0.03); and had no change in mortality, ventilator-associated pneumonia, deep vein thrombosis, depression, and hostility. In multivariable analyses, postintervention patients had higher mobility levels (p<0.001), had shorter mean hospital and neurologic ICU length of stay (both p<0.001), and were more likely to be discharged home (p=0.033) compared with preintervention patients. CONCLUSIONS: A neurologic ICU early mobility protocol increased highest neurologic ICU mobility and discharge home and decreased length of stay, but did not improve quality metrics or psychological profile.

Different shades of oxide: from nanoscale wetting mechanisms to contact printing of gallium-based liquid metals.

Gallium-based liquid metals are of interest for a variety of applications including flexible electronics, soft robotics, and biomedical devices. Still, nano- to microscale device fabrication with these materials is challenging because, despite having surface tension 10 times higher than water, they strongly adhere to a majority of substrates. This unusually high adhesion is attributed to the formation of a thin oxide shell; however, its role in the adhesion process has not yet been established. In this work, we demonstrate that, dependent on dynamics of formation and resulting morphology of the liquid metal-substrate interface, GaInSn adhesion can occur in two modes. The first mode occurs when the oxide shell is not ruptured as it makes contact with the substrate. Because of the nanoscale topology of the oxide surface, this mode results in minimal adhesion between the liquid metal and most solids, regardless of substrate's surface energy or texture. In the second mode, the formation of the GaInSn-substrate interface involves rupturing of the original oxide skin and formation of a composite interface that includes contact between the substrate and pieces of old oxide, bare liquid metal, and new oxide. We demonstrate that in this latter mode GaInSn adhesion is dominated by the intimate contact between new oxide and substrate. We also show that by varying the pinned contact line length using varied degrees of surface texturing, the adhesion of GaInSn in this mode can be either decreased or increased. Lastly, we demonstrate how these two adhesion modes limit microcontact printing of GaInSn patterns but can be exploited to repeatedly print individual sub-200 nm liquid metal drops.

Improved microchip design and application for in situ transmission electron microscopy of macromolecules.

Understanding the fundamental properties of macromolecules has enhanced the development of emerging technologies used to improve biomedical research. Currently, there is a critical need for innovative platforms that can illuminate the function of biomedical reagents in a native environment. To address this need, we have developed an in situ approach to visualize the dynamic behavior of biomedically relevant macromolecules at the nanoscale. Newly designed silicon nitride devices containing integrated "microwells" were used to enclose active macromolecular specimens in liquid for transmission electron microscopy imaging purposes.We were able to successfully examine novel magnetic resonance imaging contrast reagents, micelle suspensions, liposome carrier vehicles, and transcribing viral assemblies. With each specimen tested, the integrated microwells adequately maintained macromolecules in discrete local environments while enabling thin liquid layers to be produced.

Pain, sedation, and delirium management in the neurocritically ill: lessons learned from recent research.

Critically ill patients with a primary neurological injury or illness pose unique challenges for pain, agitation, and delirium management in intensive care units (ICUs). Detection and monitoring can be limited by contextual level of consciousness (LOC) alterations, cognition, expression, or language deficits. Recent data suggest that existing pain assessment tools may not be applicable to all neurocritically ill patients, especially in those with LOC alterations and atypical pain-associated behaviors. Targeted sedation goals may be neurologically disease specific; for instance, intracranial pressure (ICP) targets will supersede sedation titration by other criteria. Technology such as bispectral index (BIS) may be beneficial in avoiding excessive medication administration in deeply sedated neurologically injured ICU patients. Given the wide variety of pathology in the neurocritically ill patients, it is unclear if delirium can be diagnosed and unequivocally differentiated from symptoms of the underlying neurological pathology. However, delirium symptoms may herald life-threatening primary insult progression or result from a new secondary neurological injury and should be monitored. Patients with neurological injury or illness are often excluded from ICU studies addressing pain, sedation, and delirium, but this need not be the case. We review what is understood in this area based on current evidence.

Effects of ligand monolayers on catalytic nickel nanoparticles for synthesizing vertically aligned carbon nanofibers.

Vertically aligned carbon nanofibers (VACNFs) were synthesized using ligand-stabilized Ni nanoparticle (NP) catalysts and plasma-enhanced chemical vapor deposition. Using chemically synthesized Ni NPs enables facile preparation of VACNF arrays with monodisperse diameters below the size limit of thin film lithography. During pregrowth heating, the ligands catalytically convert into graphitic shells that prevent the catalyst NPs from agglomerating and coalescing, resulting in a monodisperse VACNF size distribution. In comparison, significant agglomeration occurs when the ligands are removed before VACNF growth, giving a broad distribution of VACNF sizes. The ligand shells are also promising for patterning the NPs and synthesizing complex VACNF arrays.