Band Gap and Edge Engineering via Ferroic Distortion and Anisotropic Strain: The Case of SrTiO3_{3}

The effects of ferroic distortion and biaxial strain on the band gap and band edges of SrTiO$_{3}$ (STO) are calculated using density functional theory and many-body perturbation theory. Anisotropic strains are shown to reduce the gap by breaking degeneracies at the band edges. Ferroic distortions are shown to widen the gap by allowing new band edge orbital mixings. Compressive biaxial strains raise band edge energies, while tensile strains lower them. To reduce the STO gap, one must lower the symmetry from cubic while suppressing ferroic distortions. Our calculations indicate that for engineered orientation of the growth direction along [111], the STO gap can be controllably and considerably reduced at room temperature.Comment: 5 pages, 5 figures. To be published in Phys. Rev. Let

Effect of P2Y12 inhibitors on organ support-free survival in critically ill patients hospitalized for COVID-19: A randomized clinical trial

IMPORTANCE: Platelet activation is a potential therapeutic target in patients with COVID-19. OBJECTIVE: To evaluate the effect of P2Y12 inhibition among critically ill patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS: This international, open-label, adaptive platform, 1:1 randomized clinical trial included critically ill (requiring intensive care-level support) patients hospitalized with COVID-19. Patients were enrolled between February 26, 2021, through June 22, 2022. Enrollment was discontinued on June 22, 2022, by the trial leadership in coordination with the study sponsor given a marked slowing of the enrollment rate of critically ill patients. INTERVENTION: Participants were randomly assigned to receive a P2Y12 inhibitor or no P2Y12 inhibitor (usual care) for 14 days or until hospital discharge, whichever was sooner. Ticagrelor was the preferred P2Y12 inhibitor. MAIN OUTCOMES AND MEASURES: The primary outcome was organ support-free days, evaluated on an ordinal scale that combined in-hospital death and, for participants who survived to hospital discharge, the number of days free of cardiovascular or respiratory organ support up to day 21 of the index hospitalization. The primary safety outcome was major bleeding, as defined by the International Society on Thrombosis and Hemostasis. RESULTS: At the time of trial termination, 949 participants (median [IQR] age, 56 [46-65] years; 603 male [63.5%]) had been randomly assigned, 479 to the P2Y12 inhibitor group and 470 to usual care. In the P2Y12 inhibitor group, ticagrelor was used in 372 participants (78.8%) and clopidogrel in 100 participants (21.2%). The estimated adjusted odds ratio (AOR) for the effect of P2Y12 inhibitor on organ support-free days was 1.07 (95% credible interval, 0.85-1.33). The posterior probability of superiority (defined as an OR \u3e 1.0) was 72.9%. Overall, 354 participants (74.5%) in the P2Y12 inhibitor group and 339 participants (72.4%) in the usual care group survived to hospital discharge (median AOR, 1.15; 95% credible interval, 0.84-1.55; posterior probability of superiority, 80.8%). Major bleeding occurred in 13 participants (2.7%) in the P2Y12 inhibitor group and 13 (2.8%) in the usual care group. The estimated mortality rate at 90 days for the P2Y12 inhibitor group was 25.5% and for the usual care group was 27.0% (adjusted hazard ratio, 0.96; 95% CI, 0.76-1.23; P = .77). CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of critically ill participants hospitalized for COVID-19, treatment with a P2Y12 inhibitor did not improve the number of days alive and free of cardiovascular or respiratory organ support. The use of the P2Y12 inhibitor did not increase major bleeding compared with usual care. These data do not support routine use of a P2Y12 inhibitor in critically ill patients hospitalized for COVID-19. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04505774

Anesthetic considerations for robot-assisted gynecologic and urology surgery

Robotic surgery was first conceived by the United States military in the 1980s. It rapidly developed in both complexity and utility and, in the early 21st century, modern robotic surgery for gynecologic and urologic surgery gained approval in the United States. Today, an ever-increasing number and variety of surgical procedures enlist robotic-assistance. Numerous anesthetic considerations for robotic surgery exist. A few of the most important aspects of conducting a safe anesthetic include: investigating the patient’s co-morbid conditions, realizing the risks associated with the robotic equipment, and positioning the patient with care. This manuscript reviews the current literature on robotic-assisted surgery for gynecologic and urologic procedures with emphasis on history, marketplace, type, variety, and expansion of surgery in these fields. The review focuses on practical considerations for the anesthesiologist caring for patients undergoing robotic surgery. Preoperative, intraoperative and postoperative issues are explored in detail. The rapid expansion of robotic surgery worldwide requires thoughtful consideration of the technique’s weaknesses and associated risks. This review provides a roadmap to adequately prepare anesthesiologists for care of gynecologic and urologic patients undergoing robot-assisted surgery

Ultrasound imaging of the sciatic nerve division in the popliteal fossa: A volunteer study

Background and Objectives: A sciatic nerve block at the level of the popliteal fossa is frequently administered for post-operative analgesia for surgery below the knee. While ultrasound continues to gain popularity as the technique of choice for guiding needle positioning during peripheral nerve blocks, practitioners can begin to utilize ultrasound to look for patterns of anatomical significance. Recognizing anatomical variations among different demographic populations can help practitioners improve in performing nerve blocks. We aim to determine if predictable variability exists in sciatic nerve bifurcation location and depth at the level of the popliteal fossa. Methods: After IRB approval, eligible subjects were screened for ASA I or II status and demographic data was collected. Fifty subjects were enrolled. The SonoSite MicroMaxx® with 38-mm broadband linear array, 13-6 MHz probe with color Doppler and image capturing capabilities was used for ultrasound measurements. With subject lying prone, the location of the sciatic nerve in relation to the popliteal crease and skin-to-nerve distance were assessed via ultrasound. Two independent investigators confirmed nerve location for measurements. Analyses were performed with SAS version 9.1 using Pearson Correlation Coefficients and regression analysis. Results: Gender stratification revealed that, while males were both taller and heavier, skin-nerve measurements for depth were consistently deeper in females (p-value 0.02). Independent of the right or left leg, male gender and increased height decreases the skin-nerve distance, while increased weight increases the distance. There was no correlation between patient characteristics and crease-nerve distance. In some subjects, variability of crease-nerve distance even existed between their right and left leg. Conclusion: We show that significant variability exists for actual sciatic nerve bifurcation location, or target injection site, with consistently deeper skin depth values for female patients when compared to male patients, accounting for height and weight. These findings suggest visualization techniques such as ultrasound may lead to better localization of ideal injection sites

Variations in D/H and D/O from New FUSE Observations

We use data obtained with the Far Ultraviolet Spectroscopic Explorer (FUSE) to determine the interstellar abundances of DI, NI, OI, FeII, and H2 along the sigh tlines to WD1034+001, BD+393226, and TD132709. Our main focus is on determining the D/H, N/H, O/H, and D/O ratios along these sightlines, with log N(H) > 20.0, that probe gas well outside of the Local Bubble. Hubble Space Telescope (HST) and International Ultraviolet Explorer (IUE) archival data are used to determine the HI column densities along the WD1034+001 and TD132709 sightlines, respectively. For BD+393226, a previously published N(HI) is used. We find (D/H)x10^5 = 2.14 + 0.53 - 0.45, 1.17 + 0.31 - 0.25, and 1.86 + 0.53 - 0.43, and (D/O)x10^2 = 6.31 + 1.79 - 1.38, 5.62 + 1.61 - 1.31, and 7.59 + 2.17 - 1.76, for the WD1034+001, BD+393226, and TD132709 sightlines, respectively (all 1 si gma). The scatter in these three D/H ratios exemplifies the scatter that has been found by other authors for sightlines with column densities in the range 19.2 < log N(H) < 20.7. The D/H ratio toward WD1034+001 and all the D/O ratios derived here are inconsistent with the Local Bubble value and are some of the highest in the literature. We discuss the implications of our measurements for the determination of the present-epoch abundance of deuterium, and for the different scenarios that try to explain the D/H variations. We present a study of D/H as a function of the average sightline gas density, using the ratios derived in this work as well as ratios from the literature, which suggests that D/H decreases with increasing gas volume density. Similar behaviors by other elements such Fe and Si have been interpreted as the result of depletion into dust grains.Comment: Accepted for publication in the Ap

International clinical rotations during U.S. residency training: Creating an accreditation council for graduate medical education-approved rotation

Healthcare professionals increasingly report interest in global health and participation in international healthcare delivery. Growth opportunities exist for trainees to improve knowledge, skills and attitudes through international experiences. Professional development via international medicine may have lasting effects on patient care and practice patterns following training. In 2010, the first resident took part in an international, exchange elective between The George Washington University’s Department of Anesthesiology in Washington, DC and La Universidad de San Francisco’s Department of Anesthesiology in Quito, Ecuador. This resident elective rotation resulted from a strategic partnership, initiated in 2008, between two training institutions with an established track record of medical student educational exchange programs. The goal of any resident elective rotation should be to enhance an educational experience, to improve upon a perceived training deficiency, or to create a unique offering that takes advantage of local assets and connections. International electives, if properly conceived, can accomplish all three goals. This guide for program leadership addresses the rationale and challenges, from concept to Accreditation Council for Graduate Medical Education approval, of creating an international clinical rotation for residents

The crucial role of bilateral infraclavicular nerve blocks in the anesthetic management of a trauma patient

Bilateral brachial plexus blocks and regional anesthesia in trauma patients are rarely performed due to potential complications when using these techniques. We illustrate a case in which bilateral infraclavicular nerve blocks were placed as part of a multimodal approach to pain management in a trauma patient. We discuss potential hazards, important considerations, and rationale for attempting this procedure. Ultimately, performing bilateral brachial plexus nerve blocks in trauma patients is a viable option when choosing pain management techniques

Divergence-Free Adaptive Mesh Refinement for Magnetohydrodynamics

In this paper we present a full-fledged scheme for the second order accurate, divergence-free evolution of vector fields on an adaptive mesh refinement (AMR) hierarchy. We focus here on adaptive mesh MHD. The scheme is based on making a significant advance in the divergence-free reconstruction of vector fields. In that sense, it complements the earlier work of Balsara and Spicer (1999) where we discussed the divergence-free time-update of vector fields which satisfy Stoke's law type evolution equations. Our advance in divergence-free reconstruction of vector fields is such that it reduces to the total variation diminishing (TVD) property for one-dimensional evolution and yet goes beyond it in multiple dimensions. Divergence-free restriction is also discussed. An electric field correction strategy is presented for use on AMR meshes. The electric field correction strategy helps preserve the divergence-free evolution of the magnetic field even when the time steps are sub-cycled on refined meshes. The above-mentioned innovations have been implemented in Balsara's RIEMANN framework for parallel, self-adaptive computational astrophysics which supports both non-relativistic and relativistic MHD. Several rigorous, three dimensional AMR-MHD test problems with strong discontinuities have been run with the RIEMANN framework showing that the strategy works very well.Comment: J.C.P., figures of reduced qualit

Cardiovascular outcomes among elderly patients with heart failure and coronary artery disease and without atrial fibrillation: a retrospective cohort study

Background Coronary artery disease accelerates heart failure progression, leading to poor prognosis and a substantial increase in morbidity and mortality. This study was aimed to assess the impact of coronary artery disease on all-cause mortality, myocardial infarction (MI), and ischemic stroke (IS) among hospitalized newly-diagnosed heart failure (HF) patients with left ventricular systolic dysfunction (LVSD). Methods This retrospective cohort study included Medicare patients (aged ≥65 years) with ≥1 inpatient heart failure claim (index date = discharge date) during 01JAN2007-31DEC2013. Patients were required to have continuous enrollment for ≥1-year pre-index date (baseline: 1-year pre-index period) without a prior heart failure claim (in the 1 year pre-index prior to the index hospital admission); follow-up ran from the index date to death, disenrollment from the health plan, or the end of the study period, whichever occurred first. HF with LVSD patients, identified with diagnosis codes of systolic dysfunction (excluding baseline atrial fibrillation), were stratified based on prevalent coronary artery disease at baseline into coronary artery disease and non-coronary artery disease cohorts. Main outcomes were occurrence of major adverse cardiovascular events including all-cause mortality, myocardial infarction, and ischemic stroke. Propensity score matching (PSM) was used to balance patient characteristics. Kaplan-Meier curves of ACM and cumulative incidence distribution of MI/IS were presented. Results Of 22,230 HF with LVSD patients, 15,827 (71.2%) had coronary artery disease and were overall more likely to be younger (79.8 vs 80.9 years), male (49.6% vs. 35.6%), white (86.2% vs 81.4%), with more prevalent comorbidities including hypertension (80.7% vs 74.3%), hyperlipidemia (67.7% vs 46.7%), and diabetes (46.3% vs 35.8%) (all p < 0.0001). After propensity score matching, cohorts included 5792 patients each. The coronary artery disease cohort had significantly higher cumulative incidence of myocardial infarction and ischemic stroke at the end of 7-year follow-up vs non-coronary artery disease (myocardial infarction = 50.0% vs 18.0%; ischemic stroke = 23.3% vs 18.7%; all p < 0.0001). Follow-up all-cause mortality rates were similar between the two cohorts. Conclusions HF with LVSD patients with coronary artery disease had significantly higher incidence of ischemic stroke and myocardial infarction, but similar all-cause mortality compared to those without coronary artery disease