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Audience: This simulation is intended for 4th year medical students.Introduction: Headache is the fifth most common chief complaint in the emergency room, and the vast majority are ultimately diagnosed as benign primary headaches.1,2 However, subarachnoid hemorrhage (SAH) is one of several critical diagnoses which can present as a headache. With a case fatality rate of up to 66.7% in some instances, SAH is considered a “can’t miss” diagnosis.3Subarachnoid hemorrhage is classically associated with a thunderclap headache, one definition of which is a headache that reaches maximal intensity within one minute or less and reaches a seven out of ten in severity.1 Unfortunately, a thunderclap headache is not as sensitive nor specific for SAH as is often taught. In one study, only 50% of patients with an aneurysmal subarachnoid hemorrhage presented with a thunderclap headache and an additional 19% of SAH headache came on more gradually over the course of five minutes.4 A second study found that only 66% of SAH patients reported a thunderclap headache.2 Thunderclap headaches can also be associated with other intercranial pathology including intracerebral hemorrhage, cerebral venous thrombosis, cervical artery dissection, posterior reversible encephalopathy syndrome, meningitis, and temporal arteritis among others.1,2 In a large observational study, SAH accounted for 32% of the serious pathology cases identified in patients with a thunderclap headache. Even among the thunderclap headache cohort, however, 88% of patients ultimately had a benign diagnosis (compared to 93% of patients who did not report a thunderclap headache).2Additional signs and symptoms of SAH include seizures in 6-9% of patients, vomiting, neck pain and stiffness, visual disturbances, loss of consciousness, and focal cranial nerve or supratentorial deficits.1,5 A non- contrasted computer tomography (CT) of the head within six hours of headache onset can have a sensitivity of 98.7 to 100%; however, the sensitivity decreasedto86%atthe24-48hourmark.1,6 Ameta-analysisfound a pooled six hour sensitivity of 1.0 and asserts that a head CT interpreted as negative by an attending radiologist effectively rules out SAH in neurologically intact patients with a defined onset of a thunderclap headache.6 Some guidelines in the United States still recommend shared decision making with the patient to choose between a Lumbar Puncture (LP), Computer Tomography Angiogram (CTA), or no further testing to rule out SAH in the case of a negative head CT.2 The more time that has elapsed between onset and CT imaging, the stronger the recommendation to pursue further testing. A negative head CT followed by a negative LP approaches 100% sensitivity for ruling out SAH, and a negative head CT with a negative CTA has a 99.4% probability of ruling out SAH.1,3 Thus it is an important learning point that if a headache has been ongoing for more than six hours and there is a high pre-test probability for an SAH, a negative head CT is not sufficient to rule out the diagnosis, and a secondary test should be ordered.Status epilepticus is defined as five minutes of continuous seizure activity or repeated seizures without return to baseline between seizures.7 The immediate priorities for a seizing patient include providing supplemental oxygen, considering intubation if patient is unable to protect airway, obtaining IV access if not previously established, and checking glucose.7 The main priority for a patient in status epilepticus is to stop the seizure with seizure abortive medications, typically benzodiazepines, and treat life-threatening causes of status epilepticus.7 This simulation will enable learners to diagnose SAH that is not the classical “worst headache of my life” and manage an actively seizing patient.Educational Objectives: At the conclusion of the simulation leaners will be able to:1. Efficiently take a history from the patient and perform a physical exam (including a complete neurological exam) 2. Identify red flag symptoms in a patient complaining of a headache 3. Order and interpret the results of a CT of the head and either a CT angiogram of the brain or a lumbar puncture to make the diagnosis of subarachnoid hemorrhage 4. Demonstrate appropriate management of a seizure a. Check a fingerstick glucose b. Provide supplemental oxygen c. Administer an IV or IM benzodiazepine to treat the seizure5. Utilize the I-PASS framework to communicate with the inpatient team during the transition of careEducational Methods: This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). It was performed with 4th year medical students at the conclusion of their required month-long emergency medicine (EM) clerkship. This scenario joined eight other scenarios in our pool of potential cases. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. The students complete the assessment in groups of three or four with each student acting as the team lead for one scenario. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology. A Gather-Analyze-Summarize technique was used for the debriefing session.8Research Methods: Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation. Learners completed a standard evaluation issued by the College of Medicine for the entire session rather than for individual scenarios. These evaluations were reviewed for the first year of implementation of this new case. Over the year, 209 students completed the summative simulation exercise, and 84 of those students completed this simulation as part of the overall exercise.Results: Overall, our facilitators felt the case fit well into our pool of simulation cases. They felt they were adequately able to assess the students’ ability to respond to a seizing patient and thought the difficulty level was appropriate for fourth year medical students. Students are asked to assess the simulation session as a whole using a standard evaluation form from the College of Medicine. The simulation assessment exercise as a whole was highly rated by the students, with 93% of students rating the overall quality of the session as Very Good or Excellent. Of the students who completed the SAH scenario, 96% rated the overall quality of the session as Very Good or Excellent. None of the comments specifically mention the SAH case.Discussion: Our department has run formative simulations during the 4th year EM clerkship for over ten years. Our primary objective is to assess 4th year students’ competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). This simulation case was written to replace another SAH case which was a more straightforward and typical presentation of a subarachnoid hemorrhage as “the worst headache of my life.” The previous case also did not require seizure management. The inclusion of the seizure management better allowed faculty to assess the students’ response to a patient’s acute decompensation, which is more in line with EPA 10, than simply making a critical diagnosis.Our facilitators did notice that many groups initially work the patient up for meningitis but ultimately make the correct diagnosis with the lumbar puncture (LP) results. Because the students have correctly identified that the patient requires more extensive work up, and meningitis is certainly on the differential diagnoses, students are not penalized for following this line of clinical reasoning.This simulation proved to be highly engaging for 4th year medical students, and students seemed to perform at a similar level as previous summative simulations. Overall, we felt this simulation successfully achieved the objectives of the simulation session as whole, and it was integrated into our 4th year EM clerkship simulation curriculum.

Audience: This simulation is intended for 4th year medical students.Background: Shock is the result of inadequate circulation and failure to perfuse tissues, leading to cellular and organ dysfunction.1 Anaphylactic shock specifically is a type of distributive shock secondary to an IgE (immunoglobulin E) dependent reaction, which can result in respiratory compromise and cardiovascular collapse. The National Institute of Allergy and Infectious Diseases/Food Allergy and Anaphylaxis Network (NIAID/FAAN) laid out three diagnostic criteria for the diagnosis of anaphylaxis. Fulfillment of any one of the three following criteria likely indicates anaphylaxis: 1) acute onset of illness with skin findings and either respiratory compromise or reduced blood pressure, 2) involvement of two or more organ systems after exposure to a likely allergen, 3) reduced blood pressure after exposure to a known allergen.2 While not a required component of the pathology, hives and cutaneous findings often prompt clinicians to consider anaphylaxis in their differential diagnosis. However, skin findings are absent in 10-20% of cases of anaphylaxis.3 It is therefore important for physicians to quickly recognize anaphylactic shock and begin appropriate management in a timely manner even in the absence of skin findings. A previous study of fatal anaphylactic reactions showed a median time to respiratory or cardiac arrest as 30 minutes for foods, 15 minutes for envenomations, and five minutes for iatrogenic reactions.4 Drugs are the most common reported cause of fatal anaphylaxis in the United States,5 and penicillin allergy is the most common drug allergy reported by patients.6 This simulation will help learners recognize an atypical presentation of anaphylactic shock, encourage them to consider anaphylaxis in their differential diagnosis for decompensated patients, and reinforce the correct management of anaphylaxis.Educational Objectives: At the conclusion of the simulation, learners will be able to: 1) demonstrate ability to efficiently review patient records to optimize patient care and identify relevant details to current presentation, 2) rapidly assess a patient when there is a change in clinical status, 3) recognize the need to start resuscitative fluids for undifferentiated hypotension, 4) identify anaphylaxis, 5) demonstrate the medical management of anaphylaxis, 6) utilize the I-PASS framework to communicate with the inpatient team during the transition of care.Educational Methods: This summative simulation was designed to assess competence in two of the core Entrustable Professional Activities (EPAs), as defined by the Association of American Medical Colleges (AAMC). These include EPA 8 (Give or Receive a Patient Handover to Transition Care Responsibility) and EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). It was performed with 4th year medical students at the conclusion of their month-long emergency medicine (EM) clerkship. This scenario joined seven other scenarios in our pool of potential cases. These sessions are conducted using a high-fidelity manikin as the patient and a confederate/actor in the nursing role. After each scenario concludes, there is a post-simulation debriefing session on the presentation, differential diagnosis, physical exam findings, and management of the target pathology. A Gather-Analyze-Summarize technique was used for the debriefing session.7Research Methods: Facilitators provided informal feedback to the scenario developers after the case was introduced into the assessment rotation. Learners completed a standard evaluation issued by the College of Medicine for the entire session, rather than for individual scenarios. These evaluations were reviewed in aggregate for the first year of implementation. Over this time frame, approximately half the students were run through this scenario.Results: Overall, our facilitators felt the case fit well into our pool of simulation cases. They felt they were adequately able to assess the students’ ability to respond to a decompensating patient and thought the difficulty level was appropriate for 4th year medical students. The simulation assessment exercise as a whole was highly rated by the students. Of the 198 students who completed an evaluation, 93% rated the overall quality of the session as Very Good or Excellent.Discussion: Our department has run formative simulations during the 4th year EM clerkship for over ten years. Our primary objective is to assess 4th year students’ competence in EPA 10 (Recognize a Patient Requiring Urgent or Emergent Care and Initiate Evaluation and Management). This case was developed to replace another scenario of anaphylaxis which was felt to be too straightforward and easier than other scenarios in our repertoire. By making the scenario more difficult and the presentation of anaphylaxis a bit atypical, we were able to reinforce the need to include anaphylaxis in the differential diagnosis for any patient who rapidly decompensates. We are also able to review the diagnostic criteria for anaphylaxis and the appropriate treatment, including stopping the exposure to the antigen. This simulation proved to be highly engaging for 4th year medical students, and students seemed to perform at a similar level as previous summative simulations. Overall, we felt this simulation successfully achieved the objectives of the simulation session as a whole, and it was integrated into our 4th year EM clerkship simulation curriculum.Topics: Medical simulation, emergency medicine, anaphylaxis, anaphylactic shock, allergic reaction, penicillin allergy.

The sensitivity of lead dioxide coating properties to the deposition conditions and electrolyte composition has allowed the preparation of coatings with different properties for different applications. In this study, the effects of electrolyte additives on the electrodeposition process were investigated using electrochemical measurements such as cyclic voltammetry, chronoamperometry and electrochemical impedance spectroscopy. The results showed that the presence of fluoride ions significantly reduce the possibility of TiO2 formation. The addition of copper ions not only prevents lead loss at the cathode, but also leads to the formation of copper oxide on the surface at initial stages, which hinders nucleation of PbO2. The presence of sodium dodecyl sulfate (SDS) also interferes with the nucleation process as it occupies active nucleation sites. The α-PbO2 interlayer prevents copper oxidation and solves the problem of lead dioxide nucleation. Finally, it was found that the simultaneous use of all additives together with the α-PbO2 interlayer has a positive effect on the coating process.

Human assets have become the foremost source of competitive advantage in today's world trade environment. The rise and improvement of the unused concept of maintainable human asset administration is one of the concepts that puts the organization in line with maintainable advancement. For this reason, analysts, senior directors, and administration specialists, by emphasizing and tending to the issue of human resource administration, look to attain the sustainable development of organizations. This research advances the field of Sustainable Human Resource Management (SHRM) by addressing a notable theoretical gap: the integration of social sustainability factors using the Fuzzy DEMATEL approach. Despite the extensive literature on SHRM, there is a scarcity of frameworks that systematically incorporate social sustainability. Our study employs a Systematic Literature Review (SLR) methodology, meticulously outlining inclusion and exclusion criteria for article selection, spanning from 1984 to 2020. We adopted a mixed-method approach combining qualitative assessments with quantitative Fuzzy DEMATEL analysis. Data were gathered through a survey distributed among 17 experts in both corporate and academic settings, ensuring a robust evaluation of social sustainability factors within HRM practices. The research identified critical social sustainability indicators and examined their interrelationships, providing a nuanced understanding of their dynamics within organizations. The findings not only bridge the existing theoretical void but also offer practical frameworks for organizations aiming to enhance their sustainability through HRM. Recommendations for both practice and future research are discussed, emphasizing the need for more empirical studies to validate the proposed framework.

Abstract In present times, Radio‐Frequency Identification (RFID) systems have seen a significant rise in their usage. There has been an increasing interest in developing even lighter RFID protocols suitable for resource‐constrained environments. Ensuring security and privacy remain critical challenges in RFID‐based systems. Recently proposed lightweight authentication schemes, namely LRSAS+ and LRARP+, are ideally suited for constrained devices. However, this article investigates these schemes and reveals certain vulnerabilities: LRSAS+ is susceptible to tag impersonation, desynchronization, and traceability attacks, while LRARP+ can fall prey to traceability and secret disclosure attacks. An enhanced version of these authentication systems is proposed that tackles their inherent weaknesses by leveraging the χper function. To verify the security of the proposed scheme, a formal analysis is conducted using Gong–Needham–Yahalom logic (GNY logic) and an automated security protocol verification tool, ProVerif. The improved scheme's effectiveness is also compared with multiple contemporary lightweight systems. The results indicate that the enhanced scheme not only meets the security requirements for lightweight authentication schemes but also achieves this with minimal computational overhead.

Metabolic health is highly dependent on intestinal and hepatic handling of dietary and endogenous lipids and lipoproteins. Disorders of lipid and lipoprotein metabolism are commonly observed in patients with insulin resistant states such as obesity, metabolic syndrome, and type 2 diabetes. Evidence from both animal models and human studies indicates that a major underlying factor in metabolic or diabetic dyslipidemia is the overproduction of hepatic and intestinal apolipoprotein (apo)B-containing lipoprotein particles. These particles are catabolized down into highly proatherogenic remnants, which can be taken up into the arterial intima and promote plaque development. Several gut-derived peptides have been identified as key regulators of energy metabolism; one such peptide is the incretin hormone glucagon-like peptide (GLP)-1. Our laboratory has previously demonstrated that GLP-1 can signal both centrally and peripherally to reduce postprandial and fasting lipoprotein secretion. Moreover, we have demonstrated that GLP-1 receptor (GLP-1R) agonists can ameliorate diet-induced dyslipidemia. Recently, we published evidence for a novel vagal neuroendocrine signalling pathway by which native GLP-1 may exert its anti-lipemic effects. Furthermore, we demonstrated a novel role for other gut-derived peptides in regulating intestinal lipoprotein production. Overall, ample evidence supports a key role for GLP-1R on the portal vein afferent neurons and nodose ganglion in modulating intestinal fat absorption and lipoprotein production and identifies other gut-derived peptides as novel regulators of postprandial lipemia. Insights from these data may support identification of potential drug targets and the development of new therapeutics targeting treatment of diabetic dyslipidemia.

Despite the advantage of neuroimaging-based machine learning (ML) models as pivotal tools for investigating brain-behavior relationships in neuropsychiatric studies, these data-driven predictive approaches have yet to yield substantial, clinically actionable insights for mental health care. A notable impediment lies in the inadequate accommodation of most ML research to the natural heterogeneity within large samples. Although commonly thought of as individual-level analyses, many ML algorithms are unimodal and homogeneous and thus incapable of capturing the potentially heterogeneous relationships between biology and psychopathology. We review the current landscape of computational research targeting population heterogeneity and argue that there is a need to expand from brain subtyping and behavioral phenotyping to analyses that focus on heterogeneity at the relational level. To this end, we review and suggest several existing ML models with the capacity to discern how external environmental and sociodemographic factors moderate the brain-behavior mapping function in a data-driven fashion. These heterogeneous ML models hold promise for enhancing the discovery of individualized brain-behavior associations and advancing precision psychiatry.

Agroecosystems are the largest source of anthropogenic N2O fluxes. While cover crops (CC) offer benefits for soil health, their impacts on greenhouse gas fluxes are inconsistent. In the southeastern US, where intensive agriculture and low CC adoption are prevalent, few studies have investigated CC impact on soil N2O fluxes. Our study explored the effects of CC species and management practices on soil N2O fluxes during the winter CC growing season in Mississippi, which was conducted in a non-tilled corn cropping system with seven CC treatments. We measured in situ soil N2O fluxes, along with soil moisture and temperature, throughout the CC growing season from 2022 to 2023. Surface soil samples were also collected to analyze soil mineral nitrogen (N) content and enzyme activity. Over the study period (a total of 188 days), cumulative N2O fluxes were 0.50–1.03 ​kg N2O–N ha−1, with the lowest values from the annually-rotated Elbon rye treatment and the highest from the annually-rotated Austrian winter pea. Our results show that both CC treatments and sampling time significantly affected soil N2O fluxes. There was a strong positive correlation (r ​= ​0.34, p ​

In pre-adolescence, repeated anesthesia may be required for therapeutic interventions. Adult cognitive and neurobehavioral problems may result from preadolescent exposure to anesthetics. This study examined the long-term morphological and functional effects of repeated sub-anesthetic doses of ketamine exposure on male and female rat adults during pre-adolescence. Weaned 48 pre-adolescent rats from eight mothers and were randomly divided into four equal groups: control group and the ketamine group of males and females (20 mg/kg daily for 14 days); then animals received care for 20–30 days. Repeated exposure to sub-anesthetic doses of ketamine on cognitive functions was assayed using Social discrimination and novel object tests. Besides, an elevated plus maze and fear conditioning apparatus were utilized to determine exploratory and anxiety-like behavior in adults. Toluidine blue stain was used to evaluate the number of dead neurons in the hippocampus, and the effects of ketamine on synaptic plasticity were compared in the perforant pathway of the CA1 of the hippocampus. Our study indicates that repeated exposure to sub-anesthetic doses of ketamine during pre-adolescence can result in neurobehavioral impairment in male and female rat adulthood but does not affect anxiety-like behavior. We found a significant quantifiable increase in dark neurons. Recorded electrophysiologically, repeat sub-anesthetic doses of ketamine resulted in hampering long-term potentiation and pair pulse in male adult animals. Our results showed that repeated exposure to sub-anesthetic doses of ketamine during pre-adolescence can induce hippocampus and neuroplasticity changes later in adulthood. This study opens up a new line of inquiry into potential adverse outcomes of repeated anesthesia exposure in pre-adolescent rats.

Abstract The construction of covalent organic frameworks with special geometery and optical properties is of high interest, due to their unique physicochemical and biological properties. In this work, we report on a new method for the construction of triazine frameworks with defined topologies using coordination chemistry. Ball milling and wet chemical reactions between cyanuric chloride and melamine were directed in spatial arrangements and opposite optical activity. Cobalt was used as a directing agent to drive reactions into special morphologies, optical properties and biological activity. The enantiorecognition ability of triazine frameworks that was manifested in their activities against bacteria, demonstrated a new way for the construction of materials with specific interactions at biointerfaces.

Abstract Background Oral candidiasis (OC) is a prevalent opportunistic infection in patients with human immunodeficiency virus (HIV) infection. The increasing resistance to antifungal agents in HIV-positive individuals suffering from OC raised concerns. Thus, this study aimed to investigate the prevalence of drug-resistant OC in HIV-positive patients. Methods Pubmed, Web of Science, Scopus, and Embase databases were systematically searched for eligible articles up to November 30, 2023. Studies reporting resistance to antifungal agents in Candida species isolated from HIV-positive patients with OC were included. Baseline characteristics, clinical features, isolated Candida species, and antifungal resistance were independently extracted by two reviewers. The pooled prevalence with a 95% confidence interval (CI) was calculated using the random effect model or fixed effect model. Results Out of the 1942 records, 25 studies consisting of 2564 Candida species entered the meta-analysis. The pooled prevalence of resistance to the antifungal agents was as follows: ketoconazole (25.5%, 95% CI: 15.1–35.8%), fluconazole (24.8%, 95% CI: 17.4–32.1%), 5-Flucytosine (22.9%, 95% CI: -13.7-59.6%), itraconazole (20.0%, 95% CI: 10.0–26.0%), voriconazole (20.0%, 95% CI: 1.9–38.0%), miconazole (15.0%, 95% CI: 5.1–26.0%), clotrimazole (13.4%, 95% CI: 2.3–24.5%), nystatin (4.9%, 95% CI: -0.05-10.3%), amphotericin B (2.9%, 95% CI: 0.5–5.3%), and caspofungin (0.1%, 95% CI: -0.3-0.6%). Furthermore, there were high heterogeneities among almost all included studies regarding the resistance to different antifungal agents (I2 > 50.00%, P

In this study, the effect of the weight percentage of SiC on the high-temperature oxidation behavior of MoSi2-Xwt. % SiC composite (X = 0, 10, 20, 30) was studied. The composites were produced from elemental powder compacts of molybdenum, silicon and carbon (where applicable) by combustion synthesis and subsequent sintering method. Additionally, a series of each synthesized powder was mixed with 5 wt% bentonite and consequently sintered. The sintered specimens were then subjected to oxidation at 1100 °C. Microstructure and phase analysis of the oxidized samples were investigated by X-ray diffraction (XRD) and a scanning electron microscope equipped with energy-dispersive spectroscopy (SEM-EDS). Surface and cross-sectional examinations of the samples after oxidation revealed that all samples possessed good oxidation resistance in the way that no spallation was observed between the oxide layer and the substrate. The highest oxidation resistance at 1100 °C was observed in the sample with MoSi2 (without SiC) containing bentonite (AB0). This sample showed only 0.75% weight gain after 50 h of oxidation, which is probably due to the effective role of bentonite in decreasing the open porosities, and further reducing the oxygen penetration path during the oxidation process.

Combustion synthesis (CS) is a well-known technique for manufacturing intermetallic compounds and intermetallic-matrix composite materials. This research focuses on fabricating NiAl-matrix composites with varying TiC/TiB2 contents as reinforcement, achieved by the combustion synthesis method. The chemical reactions that yield the final NiAl–TiC–TiB2 compounds were interpreted using thermodynamic calculations. The phase analysis and morphology of the composites were investigated using X-ray diffractometry (XRD) and scanning electron microscopy (SEM) characterization techniques, respectively. The findings demonstrate that the NiAl matrix contains evenly distributed TiC–TiB2 ceramic-based particles, and no oxidation of reactants occurred during the combustion reaction. With an increase in the TiC–TiB2 reinforcement phases from 0 to 15 wt %, the hardness of the NiAl–TiC–TiB2 product significantly rose from 496 to 1015 Vickers, while the porosity increased from 24% to 39%, attributed to the reduced quantity of melted NiAl available to fill the pores. Examining tribological behavior in synthesized composites involved combining experimental-numerical methods, utilizing sliding wear tests and artificial neural network (ANN) modeling. The wear results revealed decreasing wear rates with reduced loads (from 35 N to 25, and 15 N) and higher TiC/TiB2 ceramic content. Iron traces at C0 and C10 worn samples were 2.47 and 26.18 wt % respectively, which indicates enhanced hardness. The experimental data were used to train and test an artificial neural network (ANN) and statistical analysis revealed a remarkable accuracy of 91% for the ANN model in predicting friction coefficients within SHS-processed composites, as indicated by the R2 value of 0.91 and a MAPE of 6.47.