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School nurses are uniquely positioned to support lesbian, gay, bisexual, transgender, and questioning/queer (LGBTQ) students. One approach is involvement in Gender and Sexuality Alliances (GSAs). GSAs have been found to improve outcomes for LGBTQ students. The purposes of this quality improvement project were to build infrastructure for GSAs by implementing a GSA Support Plan including a digital resource binder, GSA advisor trainings, and establishment of an Advisor Leadership Committee and increase the number of schools with a GSA. The binder was distributed electronically to 95 advisors. Forty-nine participants attending virtual trainings. A statistically significant increase in all measures of participant confidence occurred between the pre- and post-training surveys. The Advisor Leadership Committee was established. This paper adds to the literature by showing that support for GSAs is important to aiding LGBTQ students. Further, authors suggest ways in which school nurses can harness their expertise to be involved with GSAs.

The effect of cobalt aluminate inoculant addition and melt-pouring temperature on the structure and mechanical properties of Ni-based superalloy was studied. The first major move to control the quality of investment cast blades and vanes was the control of grain size. Cobalt aluminate (CoAl2O4) is the most frequently utilized inoculant in the lost-wax casting process of Ni-based superalloys. The inoculant in the prime coat of moulds and pouring temperature play a significant role in grain size control. The finest surface grains were obtained when the internal surface of shell mould was coated with cobalt aluminate and subsequently pouring was at 1480°C. The influence of selected casting parameters and inoculant addition on mechanical properties was investigated on the basis of tensile, creep and hardness testing. The effect of grain refinement on mechanical properties were consistent with established theories. Tests conducted at ambient temperature indicated a beneficial effect of grain refinement both on tensile strength and hardness. In contrast at elevated temperature during creep, the reverse trend was observed.

Education is associated with improved health outcomes. However, fewer non-Hispanic Black Americans earn high school diplomas, baccalaureate, or advanced degrees than White Americans, placing them at higher risk for poor health outcomes. Racial disparities in education have been linked to social injustice and structural racism. Through the Framework for the 21st Century School Nursing Practice[TM], school nurses can impact academic success and college readiness for Black youth. An integrative review of the literature was conducted to describe programs to promote college readiness for Black high school students and evaluate school nurse involvement. Findings of the eighteen unique studies included in this review were: programs included mostly female participants, and most yielded improvements in students' non-cognitive skills (i.e. sense of belonging/confidence) and college knowledge. None of the programs included school nurse involvement. School nurses can advocate for anti-racist college readiness programs with intentional, asset-based approaches to position youth for success in college.

Data on school health policy implementation are limited due to the absence of a validated measurement tool. The purpose of this study was to create and pilot a school health policy implementation survey. A modified, four-round Delphi process was used to achieve consensus on content and format of the survey. The final 76-item survey was piloted in 655 schools with a return rate of 57.1% (n = 378). Seven schools participated in environmental audits. Based on the audits, survey responses represented an accurate description of school practices for 84.2% (n = 64) of questions. The remaining 15.8% (n = 12) of survey items were eliminated or revised. This measurement tool begins to fill the research gap between the evaluation of written school health policy and implementation. Further, this tool may be used by school nurses in alignment with the Framework for 21st Century School Nursing Practice.

Pyocyanin is an important virulence factor in the resistance of Pseudomonas aeruginosa to antibiotics. Pyocyanin is a planar three ring aromatic molecule that occurs as zwitterionic (PYO) or protonated species (PYOH + ). Our earlier studies have shown that montmorillonite, through adsorption and transformation, can inactivate both PYO and PYOH + in the interlayer space. The objective of this study was to elucidate the interaction mechanisms between montmorillonite and the adsorbed pyocyanin and to characterize the structure of the pyocyanin-montmorillonite complex via molecular dynamics (MD) simulations. The MD simulations were performed for the complexes of hydrated Na-montmorillonite (HM) with (i) neutral pyocyanin (HMP) and (ii) protonated pyocyanin (HMPH); and dehydrated Na-montmorillonite (DM) with (iii) neutral pyocyanin (DMP) and (iv) protonated pyocyanin (DMPH). The simulations indicated that in dry conditions, both PYO and PYOH + were well-ordered in the midplane of the interlayer of montmorillonite, with the three aromatic rings almost parallel to the basal surface and sandwiched in-between basal surface-adsorbed Na + planes. In humid conditions, the pyocyanin and Na + were solvated in the interlayer space and the pyocyanin was less ordered compared to dehydrated models. Ion-dipole interaction (Na-O) was the dominant interaction for the dehydrated complexes DMPH and DMP but the interaction was stronger in the latter. The Na-O ion-dipole interaction remained the dominant interaction in hydrated HMP while in HMPH, water outcompeted PYOH + for Na + resulting in water-Na interaction being the dominant interaction. These results revealed the arrangement of the two species of pyocyanin in the interlayer spaces of montmorillonite and the mechanism of interaction between the pyocyanin and montmorillonite.

In this work, three melt-pouring temperatures (1450 °C, 1480 °C, 1520 °C) and CoAl 2 O 4 inoculant contents in the shell mold's primary coating (0 wt%, 5 wt%, and 10 wt%) were selected to study microstructural and mechanical property changes of the Inconel 713C ® nickel-based superalloy. The castings' phase transformation temperatures, phase constitution, microstructure, and mechanical properties at room and elevated temperatures were investigated via thermodynamical simulations, differential thermal analysis, light and scanning electron microscopy, energy-dispersive X-ray spectroscopy, and tensile and stress-rupture tests. The pouring temperature and inoculant content strongly influenced the mean equiaxed grain size, which ranged between 2.36 and 6.55 mm. The primary microstructure of Inconel 713C ® castings, owing to its complex chemical composition, comprised multiple phases, including γ, γ', MC, M 3 B 2 , and Ni 7 Zr 2 . The mean size of γ' was in the 0.446-0.613 μm range, depending on the casting variant. Grain refinement with CoAl 2 O 4 at ambient temperature for each melt-pouring temperature led to increased yield strength (YS) and ultimate tensile strength (UTS). YS was in the range of 775-835 MPa, while UTS was in the range of 868-1010 MPa. A reverse trend was observed in samples that crept in 982 °C/152 MPa, while for each variant, the time to rupture exceeded 30 h. The maximum time to rupture was 46.1 h obtained in the unmodified casting poured at 1480 °C.

The as-cast microstructure, alloying element segregation, solidification behavior, and thermal stability of model superalloys based on Inconel 740 with various Al/Ti ratios (0.7, 1.5, 3.4) and Ta (2.0, 3.0, 4.0 wt%) concentrations were investigated via ThermoCalc simulations, scanning and transmission electron microscopy, energy-dispersive X-ray spectroscopy, dilatometry, and differential scanning calorimetry. The solidification of the superalloys began with the formation of primary γ dendrites, followed by MC carbides. The type of subsequently formed phases depended on the superalloys' initial Al/Ti ratio and Ta concentration. The results obtained from solidification simulations were compared to the obtained microstructures. For all castings, the dendritic regions consisted of fine γ' precipitates, with their size mainly depending on the initial Al/Ti ratio, whereas in the interdendritic spaces, (Nb, Ta, Ti)C carbides and Nb-rich Laves phase precipitates were present. In high Al/Ti ratio superalloys, β-NiAl precipitates, strengthened by η and α-Cr phases, were observed. Based on dilatometric results, the dissolution of γ' precipitates was accompanied by a substantial increase in the coefficient of thermal expansion. The end of the dilatation effect took place around the γ' solvus temperature, as determined via calorimetry. Moreover, the bulk solidus temperature was preceded by the dissolution of the Laves phase, which may be accompanied by local melting.

The microstructure of a René 108 Ni-based superalloy was systematically investigated by X-ray diffraction, light microscopy, energy-dispersive X-ray spectroscopy, and electron microscopy techniques. The material was investment cast in a vacuum and then solution treated (1200 °C-2h) and aged (900 °C-8h). The γ matrix is mainly strengthened by the ordered L1 2 γ' phase, with the mean γ/γ' misfit, δ, +0.6%. The typical dendritic microstructure with considerable microsegregation of the alloying elements is revealed. Dendritic regions consist of secondary and tertiary γ' precipitates. At the interface of the matrix with secondary γ' precipitates, nano M 5 B 3 borides are present. In the interdendritic spaces additionally primary γ' precipitates, MC and nano M 23 C 6 carbides were detected. The γ' precipitates are enriched in Al, Ta, Ti, and Hf, while channels of the matrix in Cr and Co. The highest summary concentration of γ'-formers occurs in coarse γ' surrounding MC carbides. Borides M 5 B 3 contain mostly W, Cr and Mo. All of MC carbides are enriched strongly in Hf and Ta, with the concentration relationship between these and other strong carbide formers depending on the precipitate's morphology. The nano M 23 C 6 carbides enriched in Cr have been formed as a consequence of phase transformation MC + γ → M 23 C 6 + γ' during the ageing treatment.

In situ X-ray diffraction and transmission electron microscopy has been used to investigate René 108 Ni-based superalloy after short-term annealing at high-homologous temperatures. Current work is focused on characterisation of γ' precipitates, their volume fraction, evolution of the lattice parameter of γ and γ' phases and misfit parameter of γ' in the matrix. Material in the initial condition is characterised by a high-volume fraction (over 63%) of γ' precipitates. Irregular distribution of alloying elements was observed. Matrix channels were strongly enriched in Cr, Co, W and Mo, whereas precipitates contain large amount of Al, Ti, Ta and Hf. Exposure to high-homologous temperatures in the range 1100-1250 °C led to the dissolution of the precipitates, which influenced the change of lattice parameter of both γ and γ' phases. The lattice parameter of the matrix continuously grew during holding at high temperatures, which had a dominant influence on the more negative misfit coefficient.

The chemical composition of standard Inconel 740 superalloy was modified by changes in the Al/Ti ratio (0.7, 1.5, 3.4) and addition of Ta (2.0, 3.0, 4.0%). Remelted Inconel 740 (A0) and nine variants with various chemical compositions were fabricated by lost-wax casting. The microstructure, microsegregation, phase transformation temperatures, thermal expansion coefficients and hardness of the superalloys were investigated by scanning electron microscopy, energy dispersive X-ray spectroscopy, differential scanning calorimetry, dilatometry and Vickers measurements. Typical dendritic microstructure was revealed with microsegregation of the alloying elements. Segregation coefficient k i for Ti, Nb and Ta did not exceed unity, and so precipitates enriched mainly in these elements were found in interdendritic spaces. The Nb-rich blocky precipitates, MC carbides, MN nitrides, oxides, and fine γ' was in all modified castings. Presence of other microstructural features, such as Ti-rich needles, eutectic γ-γ' islands, small Al-rich and Cr-rich precipitates depended on the casting composition. The lowest solidus and liquidus temperatures were observed in superalloys with a high Al/Ti ratio. Consequently, in A7-A9 variants, the solidification range did not exceed 100 °C. In the A0 variant the difference between liquidus and solidus temperature was 138 °C. Hardness of all modified superalloys was at least 50% higher than for the remelted Inconel 740 (209 HV10).

Laparoscopic appendectomy (LA) for treatment of acute appendicitis has gained acceptance with its considerable benefits over open appendectomy. LA, however, can involve some adverse outcomes: morbidity, prolonged length of hospital stay (LOS) and hospital readmission. Identification of predictive factors may help to identify and tailor treatment for patients with higher risk of these adverse events. Our aim was to identify risk factors for serious morbidity, prolonged LOS and hospital readmission after LA. A database compiled information of patients admitted for acute appendicitis from eighteen Polish and German surgical centers. It included factors related to the patient characteristics, peri- and postoperative period. Univariate and multivariate logistic regression models were used to identify risk factors for serious perioperative complications, prolonged LOS, and hospital readmissions in acute appendicitis cases. 4618 laparoscopic appendectomy patients were included. First, although several risk factors for serious perioperative complications (C-D III-V) were found in the univariate analysis, in the multivariate model only the presence of intraoperative adverse events (OR 4.09, 95% CI 1.32-12.65, p = 0.014) and complicated appendicitis (OR 3.63, 95% CI 1.74-7.61, p = 0.001) was statistically significant. Second, prolonged LOS was associated with the presence of complicated appendicitis (OR 2.8, 95% CI: 1.53-5.12, p = 0.001), postoperative morbidity (OR 5.01, 95% CI: 2.33-10.75, p < 0.001), conversions (OR 6.48, 95% CI: 3.48-12.08, p < 0.001) and reinterventions after primary procedure (OR 8.79, 95% CI: 3.2-24.14, p < 0.001) in the multivariate model. Third, although several risk factors for hospital readmissions were found in univariate analysis, in the multivariate model only the presence of postoperative complications (OR 10.33, 95% CI: 4.27-25.00), reintervention after primary procedure (OR 5.62, 95% CI: 2.17-14.54), and LA performed by resident (OR 1.96, 95% CI: 1.03-3.70) remained significant. Laparoscopic appendectomy is a safe procedure associated with low rates of complications, prolonged LOS, and readmissions. Risk factors for these adverse events include complicated appendicitis, postoperative morbidity, conversion, and re-intervention after the primary procedure. Any occurrence of these factors during treatment should alert the healthcare team to identify the patients that require more customized treatment to minimize the risk for adverse outcomes.

Acute appendicitis (AA) is the most common surgical emergency and can occur at any age. Nearly all of the studies comparing outcomes of appendectomy between younger and older patients set cut-off point at 65 years. In this multicenter observational study, we aimed to compare laparoscopic appendectomy for AA in various groups of patients with particular interest in the elderly and very elderly in comparison to younger adults.Our multicenter observational study of 18 surgical units assessed the outcomes of 4618 laparoscopic appendectomies for AA. Patients were divided in 4 groups according to their age: Group 1-<40 years old; Group 2-between 40 and 64 years old; Group 3-between 65 and 74 years old; and Group 4-75 years old or older. Groups were compared in terms of peri- and postoperative outcomes.The ratio of complicated appendicitis grew with age (20.97% vs 37.50% vs 43.97% vs 56.84%, P < .001). Similarly, elderly patients more frequently suffered from perioperative complications (5.06% vs 9.3% vs 10.88% vs 13.68%, P < .001) and had the longest median length of stay (3 [Interquartile Range (IQR) 2-4] vs 3 [IQR 3-5], vs 4 [IQR 3-5], vs 5 [IQR 3-6], P < .001) as well as the rate of patients with prolonged length of hospital stay (LOS) >8 days. Logistic regression models comparing perioperative results of each of the 3 oldest groups compared with the youngest one showed significant differences in odds ratios of symptoms lasting >48 hours, presence of complicated appendicitis, perioperative morbidity, conversion rate, prolonged LOS (>8 days).The findings of this study confirm that the outcomes of laparoscopic approach to AA in different age groups are not the same regarding outcomes and the clinical picture. Older patients are at high risk both in the preoperative, intraoperative, and postoperative period. The differences are visible already at the age of 40 years old. Since delayed diagnosis and postponed surgery result in the development of complicated appendicitis, more effort should be placed in improving treatment patterns for the elderly and their clinical outcome.

The aim of this work was to characterize the microstructure of the as-cast Haynes ® 282 ® alloy. Observations and analyses were carried out using techniques such as X-ray diffraction (XRD), light microscopy (LM), scanning electron microscopy (SEM), transmission electron microscopy (TEM), X-ray spectroscopy (EDS), wave length dispersive X-ray spectroscopy (WDS), auger electron spectroscopy (AES) and electron energy-loss spectrometry (EELS). The phases identified in the as-cast alloy include: γ (gamma matrix), γ' (matrix strengthening phase), (TiMoCr)C (primary carbide), TiN (primary nitride), σ (sigma-TCP phase), (TiMo)₂SC (carbosulphide) and a lamellar constituent consisting of molybdenum and chromium rich secondary carbide phase together with γ phase. Within the dendrites the γ' appears mostly in the form of spherical, nanometric precipitates (74 nm), while coarser (113 nm) cubic γ' precipitates are present in the interdendritic areas. Volume fraction content of the γ' precipitates in the dendrites and interdendritic areas are 9.6% and 8.5%, respectively. Primary nitrides metallic nitrides (MN), are homogeneously dispersed in the as-cast microstructure, while primary carbides metallic carbides (MC), preferentially precipitate in interdendritic areas. Such preference is also observed in the case of globular σ phase. Lamellar constituents characterized as secondary carbides/γ phases were together with (TiMo)₂SC phase always observed adjacent to σ phase precipitates. Crystallographic relations were established in-between the MC, σ, secondary carbides and γ/γ' matrix.

Effective communication between providers and patients has been linked to improved outcomes. Previous reviews of quality improvement strategies, including health information technology (health IT), have not focused on the needs of low-income children. The authors conducted a systematic review of the literature on studies of communication surrounding the care of low-income children, with an emphasis on interventions and health IT.The search yielded six studies that focused on low-income children; three of the studies used health IT. Key informant interviews provided insight to the current use of health IT for provider-patient communication in geographically diverse, underresourced settings.The authors identify gaps between existing literature and clinical practice. Future research should focus on the specific impact of health IT in pediatric medicine, particularly in underresourced and safety net settings. These efforts should focus on the use of technological innovations to improve care for low-income children and their families.

Disparities in provider-patient communication have been shown to exist among Asian Americans, especially those who are low-income and have limited English proficiency. These disparities have resulted in unmet health care needs and poor quality care. To identify strategies for improving provider-patient communication in this population, we conducted a systematic review of the literature and in-depth interviews with key informants. Little published literature on interventions focused on Asian Americans was found. Most interventions were conducted among White populations and occurred in the waiting room before patients' visits with their providers. Interventions ranged from a leaflet encouraging patients to ask more questions, to more intensive face-to-face coaching before office visits. Health information technology (health IT) has not been widely used to improve communication, especially among patients with limited English proficiency. More research is needed using new health IT strategies to improve care for Asian Americans and other vulnerable populations.

Background: It is unknown whether physicians' attitudes about the management of atrial fibrillation (AF) reflect the recommendations of published guidelines., Methods: To obtain information about physicians' attitudes about management of AF, a questionnaire was returned by 904 (20.1%) of 4500 physicians involved in managing AF (385 cardiologists, 326 internists, and 193 electrophysiologists). The cardiologists and internists were from Massachusetts or California; the electrophysiologists were from around the United States. The questionnaire called for 86 separate answers about use of resources and drug therapy for different types of AF, including recent-onset AF, paroxysmal AF, and chronic AF of less than 6 months' and more than 3 years' duration., Results: Transthoracic echocardiography and thyroid function were requested by more than 90% of physicians; transesophageal echocardiography and catheterization were requested by 10% of physicians. To control ventricular response, digoxin was the overwhelming first-line therapy; calcium channel blockers were favored over beta-blockers for adjunct therapy. To prevent thromboemboli, warfarin sodium was preferred for chronic AF; warfarin or aspirin were equally considered for paroxysmal AF. In considering sinus rhythm, respondents agreed about factors determining whether to revert, the number of drug trials, and the first-line drug choice (quinidine sulfate) but disagreed about second-line antiarrhythmic drugs and whether to hospitalize the patient before initiating drug therapy., Conclusions: Physicians ranging from primary care providers to subspecialists agree on issues of AF management such as heart rate control and anticoagulation. Attitudes vary widely about issues such as antiarrhythmic drugs.

Objective: To determine the prevalence of domestic violence among patients seen in three university-affiliated ambulatory care internal medicine clinics and to assess the personal characteristics of those patients affected by domestic violence., Design: Survey using a self-administered, anonymous questionnaire., Setting: Three university-affiliated internal medicine clinics at the University of California Irvine Medical Center., Participants: We asked all patients on randomly selected days during the three-month study to participate. 453 (72%) of the 629 eligible English- and Spanish-speaking patients completed the questionnaire., Measurements and Main Results: 28% of participants had experienced domestic violence at some time in their lives, and 14% were currently experiencing domestic violence. Logistic regression analysis showed that female gender, unmarried status, and poverty were important predictors of domestic violence. However, domestic violence occurred in all groups regardless of sex, ethnicity, age, or socioeconomic status., Conclusions: The study found an unexpectedly high prevalence of domestic violence in the three internal medicine clinics. Physicians should ask their patients routinely about domestic violence and, when domestic violence is present, should offer emotional support, information about social service agencies, and psychological care.