Efficacy of an external chromia layer in reducing nitridation of high temperature alloys

Six high temperature alloys have been exposed in N2/H2 environments at 900 \ub0C. In order to study the efficacy of a chromia barrier layer against nitrogen ingress, experiments were performed in two environments having the same N2/H2 ratio but slightly different water content, chromia formation being spontaneous in one case only. The samples were evaluated by SEM/STEM/EDX, XRD, gravimetry and GD-OES. The presence of an external chromia scale reduced nitridation of the alloy by 50–95%. Furthermore, in the presence of a continuous alumina layer no nitridation of the alloy was detected

Tanezumab: a selective humanized mAb for chronic lower back pain

Chronic lower back pain is a significant disease that affects nearly 20% of the worldwide population. Along with hindering patients’ quality of life, chronic lower back pain is considered to be the second most common cause of disability among Americans. Treating chronic lower back pain is often a challenge for providers, especially in light of our current opioid epidemic. With this epidemic and an increased aging population, there is an imminent need for development of new pharmacologic therapeutic options, which are not only effective but also pose minimal adverse effects to the patient. With these considerations, a novel therapeutic agent called tanezumab has been developed and studied. Tanezumab is a humanized monoclonal immunoglobulin G2 antibody that works by inhibiting the binding of NGF to its receptors. NGF is involved in the function of sensory neurons and fibers involved in nociceptive transduction. It is commonly seen in excess in inflammatory joint conditions and in chronic pain patients. Nociceptors are dependent on NGF for growth and ongoing function. The inhibition of NGF binding to its receptors is a mechanism by which pain pathways can be interrupted. In this article, a number of recent randomized controlled trials are examined relating to the efficacy and safety of tanezumab in the treatment of chronic lower back pain. Although tanezumab was shown to be an effective pain modulator in major trials, several adverse effects were seen among different doses of the medication, one of which led to a clinical hold placed by the US Food and Drug Administration. In summary, tanezumab is a promising agent that warrants further investigation into its analgesic properties and safety profile

Responsible, Safe, and Effective Use of Biologics in the Management of Low Back Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

BACKGROUND: Regenerative medicine is a medical subspecialty that seeks to recruit and enhance the body\u27s own inherent healing armamentarium in the treatment of patient pathology. This therapy\u27s intention is to assist in the repair, and to potentially replace or restore damaged tissue through the use of autologous or allogenic biologics. This field is rising like a Phoenix from the ashes of underperforming conventional therapy midst the hopes and high expectations of patients and medical personnel alike. But, because this is a relatively new area of medicine that has yet to substantiate its outcomes, care must be taken in its public presentation and promises as well as in its use. OBJECTIVE: To provide guidance for the responsible, safe, and effective use of biologic therapy in the lumbar spine. To present a template on which to build standardized therapies using biologics. To ground potential administrators of biologics in the knowledge of the current outcome statistics and to stimulate those interested in providing biologic therapy to participate in high quality research that will ultimately promote and further advance this area of medicine. METHODS: The methodology used has included the development of objectives and key questions. A panel of experts from various medical specialties and subspecialties as well as differing regions collaborated in the formation of these guidelines and submitted (if any) their appropriate disclosures of conflicts of interest. Trustworthy standards were employed in the creation of these guidelines. The literature pertaining to regenerative medicine, its effectiveness, and adverse consequences was thoroughly reviewed using a best evidence synthesis of the available literature. The grading for recommendation was provided as described by the Agency for Healthcare Research and Quality (AHRQ). SUMMARY OF EVIDENCE: Lumbar Disc Injections: Based on the available evidence regarding the use of platelet-rich plasma (PRP), including one high-quality randomized controlled trial (RCT), multiple moderate-quality observational studies, a single-arm meta-analysis and evidence from a systematic review, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best-evidence synthesis. Based on the available evidence regarding the use of medicinal signaling/ mesenchymal stem cell (MSCs) with a high-quality RCT, multiple moderate-quality observational studies, a single-arm meta-analysis, and 2 systematic reviews, the qualitative evidence has been assessed as Level III (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Epidural Injections Based on one high-quality RCT, multiple relevant moderate-quality observational studies and a single-arm meta-analysis, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Lumbar Facet Joint Injections Based on one high-quality RCT and 2 moderate-quality observational studies, the qualitative evidence for facet joint injections with PRP has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. Sacroiliac Joint Injection Based on one high-quality RCT, one moderate-quality observational study, and one low-quality case report, the qualitative evidence has been assessed as Level IV (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis. CONCLUSION: Based on the evidence synthesis summarized above, there is Level III evidence for intradiscal injections of PRP and MSCs, whereas the evidence is considered Level IV for lumbar facet joint, lumbar epidural, and sacroiliac joint injections of PRP, (on a scale of Level I through V) using a qualitative modified approach to the grading of evidence based on best evidence synthesis.Regenerative therapy should be provided to patients following diagnostic evidence of a need for biologic therapy, following a thorough discussion of the patient\u27s needs and expectations, after properly educating the patient on the use and administration of biologics and in full light of the patient\u27s medical history. Regenerative therapy may be provided independently or in conjunction with other modalities of treatment including a structured exercise program, physical therapy, behavioral therapy, and along with the appropriate conventional medical therapy as necessary. Appropriate precautions should be taken into consideration and followed prior to performing biologic therapy. Multiple guidelines from the Food and Drug Administration (FDA), potential limitations in the use of biologic therapy and the appropriate requirements for compliance with the FDA have been detailed in these guidelines. KEY WORDS: Regenerative medicine, platelet-rich plasma, medicinal signaling cells, mesenchymal stem cells, stromal vascular fraction, bone marrow concentrate, chronic low back pain, discogenic pain, facet joint pain, Food and Drug Administration, minimal manipulation, evidence synthesis

The Initial Oxide Scale Development on a Model FeNiCrAl Alloy at 900 degrees C in Dry and Humid Atmosphere: A Detailed Investigation

The investigated alumina forming FeNiCrAl model alloy shows protective oxidation behavior in dry and humid environment at 900 A degrees C. Hence, this type of alloy may replace conventional chromia forming austenitic alloys in aggressive oxidizing/reducing environments. A detailed investigation of the oxide scale development reveals a complex initial scale development. Firstly, at alloy grain boundaries, a thin Al rich oxide forms which is replaced by transient alumina platelets in dry and equiaxed alpha-Al2O3 crystallites in humid atmosphere. The scale at alloy grain centers develops via a layered scale of external chromia:Fe/Ni metal inclusions:internal alumina to a layered external spinel:internal alumina scale in dry atmosphere. In humid condition an additional oxide feature appears on the center of large alloy grains i.e. thick oxide protrusions. Despite the initially different phase compositions a continuous protective alpha-Al2O3 scale forms both atmospheres

The Initial Oxide Scale Development on a Model FeNiCrAl Alloy at 900 degrees C in Dry and Humid Atmosphere: A Detailed Investigation

The investigated alumina forming FeNiCrAl model alloy shows protective oxidation behavior in dry and humid environment at 900 A degrees C. Hence, this type of alloy may replace conventional chromia forming austenitic alloys in aggressive oxidizing/reducing environments. A detailed investigation of the oxide scale development reveals a complex initial scale development. Firstly, at alloy grain boundaries, a thin Al rich oxide forms which is replaced by transient alumina platelets in dry and equiaxed alpha-Al2O3 crystallites in humid atmosphere. The scale at alloy grain centers develops via a layered scale of external chromia:Fe/Ni metal inclusions:internal alumina to a layered external spinel:internal alumina scale in dry atmosphere. In humid condition an additional oxide feature appears on the center of large alloy grains i.e. thick oxide protrusions. Despite the initially different phase compositions a continuous protective alpha-Al2O3 scale forms both atmospheres

The Initial Oxide Scale Development on a Model FeNiCrAl Alloy at 900 degrees C in Dry and Humid Atmosphere: A Detailed Investigation

The investigated alumina forming FeNiCrAl model alloy shows protective oxidation behavior in dry and humid environment at 900 A degrees C. Hence, this type of alloy may replace conventional chromia forming austenitic alloys in aggressive oxidizing/reducing environments. A detailed investigation of the oxide scale development reveals a complex initial scale development. Firstly, at alloy grain boundaries, a thin Al rich oxide forms which is replaced by transient alumina platelets in dry and equiaxed alpha-Al2O3 crystallites in humid atmosphere. The scale at alloy grain centers develops via a layered scale of external chromia:Fe/Ni metal inclusions:internal alumina to a layered external spinel:internal alumina scale in dry atmosphere. In humid condition an additional oxide feature appears on the center of large alloy grains i.e. thick oxide protrusions. Despite the initially different phase compositions a continuous protective alpha-Al2O3 scale forms both atmospheres

Consensus Statement for Clinical Pathway Development for Perioperative Pain Management and Care Transitions

The perioperative surgical home (PSH) model has been created with the intention to reduce costs and to improve efficiency of care and patient experience in the perioperative period. The PSH is a comprehensive model of care that is team-based and patient-centric. The team in each facility should be multidisciplinary and include the input of perioperative services leadership, surgical services, and support personnel in order to provide seamless care for the patient from the preoperative period when decision to undergo surgery is initially made to discharge and, if needed after discharge from the hospital, until full recovery is achieved. PSH is discussed in this consensus article with the emphasis on perioperative care coordination of patients with chronic pain conditions. Preoperative optimization can be successfully undertaken through patient evaluation, screening, and education. Many important positive implications in the PSH model, in particular for those patients with increased potential morbidity, mortality, and high-risk populations, including those with a history of substance abuse or anxiety, reflect a more modern approach to health care. Newer strategies, such as preemptive and multimodal analgesic techniques, have been demonstrated to reduce opioid consumption and to improve pain relief. Continuous catheters, ketamine, methadone, buprenorphine, and other modalities can be best delivered with the expertise of an anesthesiologist and a support team, such as an acute pain care coordinator. A physician-led PSH is a model of care that is patient-centered with the integration of care from multiple disciplines and is ideally suited for leadership from the anesthesia team. Optimum pain control will have a significant positive impact on the measures of the PSH, including lowering of complication rates, lowering of readmissions, improved patient satisfaction, reduced morbidity and mortality, and shortening of hospital stays. All stakeholders should work together and consider the PSH model to ensure the best quality of health care for patients undergoing surgery in the future. The pain management physician’s role in the postoperative period should be focused on providing optimal analgesia associated with improved patient satisfaction and outcomes that result in reduced health care costs

Multimodal analgesia, current concepts, and acute pain considerations

Management of acute pain following surgery using a multimodal approach is recommended by the American Society of Anesthesiologists whenever possible. In addition to opioids, drugs with differing mechanisms of actions target pain pathways resulting in additive and/or synergistic effects. Some of these agents include alpha 2 agonists, NMDA receptor antagonists, gabapentinoids, dexamethasone, NSAIDs, acetaminophen, and duloxetine.Alpha 2 agonists have been shown to have opioid-sparing effects, but can cause hypotension and bradycardia and must be taken into consideration when administered. Acetaminophen is commonly used in a multimodal approach, with recent evidence lacking for the use of IV over oral formulations in patients able to take medications by mouth. Studies involving gabapentinoids have been mixed with some showing benefit; however, future large randomized controlled trials are needed. Ketamine is known to have powerful analgesic effects and, when combined with magnesium and other agents, may have a synergistic effect. Dexamethasone reduces postoperative nausea and vomiting and has been demonstrated to be an effective adjunct in multimodal analgesia. The serotonin-norepinephrine reuptake inhibitor, duloxetine, is a novel agent, but studies are limited and further evidence is needed. Overall, a multimodal analgesic approach should be used when treating postoperative pain, as it can potentially reduce side effects and provide the benefit of treating pain through different cellular pathways