Initial Signs Research Articles

Emergency department early mortality model for patients admitted after presenting to a tertiary medical center emergency department

AbstractObjectivesIdentifying patients in the emergency department (ED) at higher risk for in‐hospital mortality can inform shared decision making and goals‐of‐care discussions. Electronic health record systems allow for integrated multivariable logistic regression (LR) modeling, which can provide early predictions of mortality risk in time for crucial decision making during a patient's initial care. Many commonly used LR models require blood gas analysis values, which are not frequently obtained in the ED. The goal of this study was to develop an all‐cause mortality prediction model, derived from commonly collected ED data, which can assess mortality risk early in ED care.MethodsData were obtained for all patients, age 18 and older, admitted from the ED to Atrium Health Wake Forest Baptist from April 1, 2016, through March 31, 2020. Initial vital signs including heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse oximetry, weight, body mass index, comprehensive metabolic panel, and a complete blood count were electronically retrieved for all patients. The prediction model was developed using LR. The ED early mortality (EDEM) model was compared with the rapid Emergency Medicine Score (REMS) for performance analysis.ResultsA total of 45,004 patients met inclusion criteria, comprising a total of 77,117 admissions. In this cohort, 52.8% of patients were male and 47.2% were female. The model used 35 variables and yielded an area under the receiver operating characteristic curve (AUC) of 0.889 (95% CI 0.874–0.905) with a sensitivity of 0.828 (95% CI 0.791–0.860), a specificity of 0.788 (95% CI 0.783–0.794), a negative predictive value of 0.995 (95% CI 0.994–0.996), and a positive predictive value of 0.084 (95% CI 0.076–0.092). This outperformed REMS in this data set, which yielded an AUC of 0.500 (95% CI 0.455–0.545).ConclusionsThe EDEM model was predictive of in‐hospital mortality and was superior to REMS.

Morbidity and mortality associated with ESBL Klebsiella pneumoniae infection in different administration routes in albino rats.

Klebsiella pneumoniae is a non-motile, encapsulated, environmental gram-negative bacterium. Once the bacteria have infiltrated the body, they can display substantial degrees of resistance to drugs and virulence. Extended Spectrum Beta-Lactamases (ESBLs) are most typically seen in K. pneumoniae. The objective of this study was to investigate the morbidity and mortality associated with ESBL K. pneumoniae infection in different albino rat administration route groups. Four cohorts of albino rats were acquired and categorized into the subsequent groups: inhalation, oral administration via food, water, and control group. Each group was infected independently and the isolate administration lasted 6 days. The clinical diagnosis revealed the presence of K. pneumoniae infection. Within one day of infection, the inhalation group exhibited the initial clinical signs and symptoms, such as red eyes, coughing, and closed eyelids. Subsequently, the infection was verified through the process of sample cultivation. Additionally, blood clinical findings, including blood tests such as CBC, lipid profile, CRP, and kidney and liver function tests, further supported the confirmation of the infection. The K. pneumoniae isolates had a severe influence on the CBC, liver, and kidney functioning causing elevated liver enzymes, and high RBC levels with impaired kidney functioning. Due to K. pneumonia's affinity for lung tissue, it had the greatest impact in the albino rat inhalation group.

Significant Calcification of an Entire Aortic Tree with Renal Artery Subocclusion: Acute Kidney Injury, Ischemic Kidney Disease, and the Tissue Viability Question—A Case Report

Background: Undiagnosed and untreated atherosclerotic renal artery stenosis (ARAS) can result in end-stage kidney disease (ESKD). To obtain an accurate diagnosis, it is crucial to recognize the symptoms and signs suggesting renal artery stenosis (RAS) and perform appropriate diagnostic and treatment procedures afterward. Case Presentation: We present a case of a 60-year-old female patient with hypertensive crisis, acute heart failure (HF), and pulmonary edema as the initial signs of acute kidney injury (AKI) caused by right RAS and left renal artery occlusion in the presence of severe aortic atherosclerosis revealed on computed tomography angiography (CTA) of the abdomen. The patient’s renal function recovered completely following percutaneous transluminal angioplasty (PTA) with stent implantation in the right renal artery at the site of subocclusion. Conclusions: Even in patients with concomitant disorders like type-2 diabetes mellitus (T2DM), hypertension (HTN), or HF, the dilatation of significantly narrowed renal arteries due to severe calcifications can result in complete renal function recovery.

Outbreak of ruminal acidosis in cattle caused by the ingestion of hedge lucerne (Desmanthus virgatus L. Willd.) in Northeastern Brazil

This study describes the epidemiological, clinical, and pathological aspects of an outbreak of ruminal acidosis and ruminitis caused by the ingestion of hedge lucerne (Desmanthus virgatus L.) in 70 cattle in the state of Paraiba, Northeastern Brazil. The herd had been transported from the state of Piauí to Paraiba. The deaths of the cattle occurred 15 days after the animals were introduced to a native pasture containing D. virgatus. All animals exhibited ruminal atony, which ranged from mild to severe. A total of 35 cattle died, with five undergoing necropsy. Initial clinical signs included apathy, followed by a marked increase in left abdominal volume, consistent with ruminal distension, absence of rumination (ruminal atony), lateral recumbency, and ultimately death. All affected animals were treated with oral administration of rumen fluid, enteral fluid therapy, and oral antacids. During this period, twenty animals succumbed to the condition, and an additional 15 died after being relocated, resulting in a 50% fatality rate. Significant gross pathological findings were observed primarily in the digestive system. The forestomachs were markedly distended, containing large amounts of reddish, pasty, and serous ingesta. A demarcation line was evident in the esophagus, separating the pale and bloodless distal esophagus from the congested proximal esophagus at the thoracic inlet, corresponding to the "bloat line." Frothy material was present in the tracheal lumen, indicating pulmonary edema. Additionally, rectal prolapse was noted. Histopathological examination revealed marked edema and severe hydropic (ballooning) degeneration of the basal layer in the forestomachs, along with intercellular edema. Separation of the epithelium from the lamina propria, forming multiple clefts, was observed, accompanied by areas of lymphoplasmacytic inflammatory infiltrate in the submucosa. This study demonstrates that this plant can cause severe gastrointestinal disturbances in cattle unaccustomed to its consumption and ingesting large quantities of the plant's shoots.

New Trauma Scoring System for Geriatric Trauma and Massive Transfusion Prediction.

Early identification of massive transfusion (MT) requirement in geriatric patients with severe trauma is challenging. Existing systems for predicting MT need in trauma patients have not been systematically evaluated for their relevance to the geriatric population. This study aimed to evaluate the predictive accuracy of initial vital signs and the Glasgow coma scale (GCS) in geriatric trauma patients for predicting MT. We conducted a retrospective review involving data from geriatric patients with severe trauma admitted to our Level I trauma center for an observational study and to develop a prognostic model for MT using logistic regression. The new trauma scoring system was compared with the existing scoring systems. A total of 193 patients with exhaustive medical records were included in the analysis; 19 (9.8%) of them received MT. A new trauma scoring system, RHG, was calculated, which involved GCS score, heart rate, and respiratory rate. Compared with existing trauma scores, our novel model, RHG, yielded the highest area under the receiver operating characteristic (ROC) curve for the prediction of MT (0.861; 95% confidence interval [CI], 0.788 - 0.933). The RHG exhibited a robust sensitivity of 90.0% and a respectable specificity of 75.3% in identifying MT. The RHG scoring system is a simplified, yet powerful, tool for predicting the necessity of MT in geriatric patients with severe trauma. By utilizing just the GCS score, heart rate, and respiratory rate, it offers an early indicator of MT requirement, eliminating the need for sophisticated equipment.

Unveiling shadows: A data-driven insight on depression among Bangladeshi university students.

Depression is more than just feeling sad. It is a severe and multifaceted mental health condition that impacts millions of individuals around the globe. Regrettably, it can even be more prevalent in university students of underdeveloped and developing countries like Bangladesh because of academic pressure, family and societal expectations, financial limitations, stigmatized social and cultural norms, unemployment concerns, lack of mental health awareness, etc. Each of these factors can play a significant role in leading someone towards depression, with their impact varying from person to person. This research, along with detecting depression and gaining insights into the reasons behind the prevalence of depression in this specific population, also focuses on providing simple yet important and tailored recommendations to those who need them. To achieve these objectives, a survey was meticulously designed in collaboration with psychologists, counselors, and therapists. Seven machine learning models, including Support Virtual Machine (SVM), K-Nearest Neighbor (K-NN), Gaussian Naive Bayes (GNB), Decision Tree (DT), Random Forest Classifier (RFC), Artificial Neural Network (ANN), and Gradient Boosting (GB), were trained and tested using the collected data (n=750) to identify the most effective method for predicting depression. After rigorous analysis, Random Forest emerged as the best-performing algorithm, exhibiting remarkable accuracy (87%), precision (78%), recall (95%), and f1-score (86%). This research mainly strives to identify the initial signs of depressive symptoms among Bangladeshi university-going students and facilitate timely and targeted interventions for the affected individuals. By doing so, it ultimately aims to contribute to building a brighter, healthier, and more resilient educational environment in the country.

ASTROCYTOMA OF THE CERVICAL SPINAL CORD IN AN INFANT WITH TORTICOLLIS

The relevance of the problem is determined by the rather high prevalence of central nervous system (CNS) tumors in children and the need for oncologic vigilance. The presentation of the clinical case illustrates the need for careful analysis of the initial clinical signs, which are usually nonspecific and may resemble symptoms of other diseases. A case from practice describes the timely diagnosis of pilocytic astrocytoma in a child of the first year of life with torticollis as the debut of the disease. The diagnosis was made on the basis of a thorough clinical, neurological, and immunohistochemical examination and the use of neuroimaging techniques with the goal of further surgical, medical, and radiation treatment. The aim of the work. Description of a clinical case of astrocytoma of the cervical spinal cord, which manifested itself as torticollis in a child in the first year of life. Material and methods of the research. Clinical, biochemical, immunohistochemical, and imaging examination of a child of toddler age. Results of the research. A child with manifestations of torticollis at the age of eleven months was studied. Variants of congenital and acquired torticollis and inflammatory diseases of the central nervous system were excluded. According to clinical, neurological, and neuroimaging examinations, the diagnosis was made: benign intramedullary neoplasm of the spinal cord, pilocytic astrocytoma C5-Th2. Surgical intervention was performed with partial removal of the tumor with histochemical examination, followed by restorative therapy and observation in the distant postoperative period. Conclusions. Sudden appearance of symptoms of torticollis in a child in the first year of life may indicate the presence of a CM tumor. Early diagnosis allows to provide the child with highly specialized care, perform surgical intervention, and contribute to the improvement of the general condition and quality of life.

Mechanism and treatment methods of cyanide poisoning

A powerful toxin, cyanide can be ingested accidentally or on purpose. By attaching to cytochrome oxidase in mitochondria, it prevents ATP synthesis and forces cells into anaerobic metabolism even in the presence of sufficient oxygen. Headache, lightheadedness, and dyspnea are the initial signs of cyanide poisoning, which can escalate to seizures and unconsciousness. Sodium nitrite, sodium thiosulfate, and hydroxocobalamin are effective therapies for cyanide poisoning. Research has demonstrated its effectiveness in human and animal models. However, more studies are needed to confirm its efficiency in various cyanide exposure scenarios. While sodium thiosulfate transforms cyanide into the less poisonous thiocyanate, facilitating detoxification, sodium nitrite causes the synthesis of methemoglobin, which sequesters cyanide from cytochrome oxidase. Studies on animals show that intramuscular injections of sodium thiosulfate and sodium nitrite can effectively reverse the effects of cyanide toxicity and improve lifespan. These countermeasures are essential for both treating and averting the deadly consequences of acute cyanide poisoning. This research will discuss the mechanism of cyanide poisoning and its treatment methods.

The effect of Moringa oleifera leaves extract and low level laser therapy on rheumatoid arthritis healing: Research on laboratory rats

Background. Rheumatoid arthritis (RA) is the most common form of autoimmune disease. Both laser therapy and Moringa leaf extracts are effective in promoting various mechanisms, such as cartilage repair, DNA synthesis, and analgesic and anti-inflammatory effects, at both the cellular and systemic levels. Objective. This study aimed to investigate the effects of low-level laser therapy and Moringa oleifera leaf extract on lipid profile changes and RA healing in male Wistar albino rats. Subjects and methods. RA was induced in 40 laboratory rats, which were divided equally into four groups. The first group was left untreated as the positive control. The second group was treated with low-level laser therapy (LLLT). The third group was treated with M. oleifera leaf extract, and the fourth group was treated with both LLLT and M. oleifera leaf extract. Blood was drawn from the animals before and during the treatment period to monitor changes in the lipid profile. Results. The results showed a change in the levels of blood lipids (cholesterol, triglycerides (TG), low-density lipoproteins (LDL), very low-density lipoproteins (VLDL), and high-density lipoproteins (HDL)) after the disease was confirmed, with a return to normal levels in the treatment groups at varying proportions. Conclusions. The results demonstrate the potential for using LLLT and Moringa leaf extracts to treat arthritis and resist high oxidative stress, particularly in the early stages of infection. Arthritis can be controlled and its progression limited through the use of laser therapy and Moringa oleifera leaf extract, both of which have shown therapeutic effectiveness and the ability to return disease-associated changes to normal levels. The average Rf post-induction was approximately 258.43 ± 27.09 on the 14th day, showing significant differences compared to the control group. WBC and ESR levels increased in all groups following the initial signs of the disease and returned to normal in the treatment groups, with notable differences between these groups.

Restitution of agricultural and forest land in the Republic of Serbia

This paper examines the solutions provided by the Serbian legislator for the restitution process, with a specific focus on agricultural and forest land. It traces the origins of this process to state interventionist measures such as agrarian reform and confiscation, which led to the creation of an agrarian fund used for land redistribution in line with socialist ideology. Although initial signs of the restitution process appeared in the early 1990s, no significant progress was achieved until the early 2000s. Rather than adopting a single, uniform law on restitution, the Serbian legislator chose to regulate the process through three separate laws: one addressing confessional restitution, another one dealing with general restitution, and a third one governing the return of property confiscated from Holocaust victims to Jewish communities. This paper outlines the key substantive and procedural provisions of these restitution laws and addresses certain contentious issues that have arisen during their practical implementation. The analysis is supported by the case law of the Restitution Agency and domestic courts. The conclusion emphasises that, despite its duration, the restitution process has yielded considerable results, particularly with respect to the restitution of agricultural land, where restitution in kind has been achieved in the vast number of cases.

Remodeling of the brachiocephalic arteries on the background of arterial hypertension in electric train drivers who have been ill with COVID-19

Over the more than three-year period of the coronavirus pandemic, researchers have identified the relationship between cardiovascular diseases and the severity of coronavirus infection, especially in people who have had COVID-19 in a hospital setting. One of the complications of patients with coronavirus infection is an increase in blood pressure, which can lead to the formation of hypertension. It is known that arterial hypertension occupies a leading position among workers in the transport sector, including electric train drivers, in our country. The cardiovascular system of machinists is influenced by industrial risk factors (noise, vibration, psycho-emotional stress, etc.) and often non-industrial: smoking, increased body weight. The combination of these factors: coronavirus infection, industrial and non-industrial risk factors can accelerate the development of cardiovascular diseases in electric train drivers. The study aims are the results of duplex scanning of brachiocephalic arteries in electric train drivers who have been ill with various forms of new coronavirus infection. The authors have conducted the study on an outpatient basis among 12 male machinists aged 43.4±5.0 years working in the Central Federal District, who who have been ill with COVID-19 in the first and second quarters of 2021, and are currently continuing their work as an "electric train driver". The subjects were divided into 2 groups: the 1st group consisted of workers who had suffered a mild form of COVID-19, the 2nd group consisted of workers who had suffered a severe form of COVID-19. Scientists conducted duplex scanning of brachiocephalic arteries with color Doppler mapping for workers, and they also studied outpatient charts of workers, analyzed blood pressure data. The research was conducted in the period 2022–2023. The employees involved in the studies had risk factors such as smoking, increased body weight and high blood pressure. Scientists have revealed higher blood pressure indicators in workers of the 2nd group (severe form), in contrast to the indicators of the 1st group (mild form), while both groups had "grade I arterial hypertension". Ultrasound examination of the brachiocephalic arteries in group 2 workers, unlike group 1 workers, revealed the initial signs of vascular remodeling at the extracranial level in the form of a diffuse increase in the echogenicity of the intima-media complex and its thickening to 1 mm in the common carotid artery, deformations of the common and internal carotid arteries, in the form of wavy C-S‑shaped tortuosity, initial ectasia of the common carotid arteries, a decrease in linear indicators of blood flow velocity, an increase in the resistance index. And also in workers who have had a severe form of coronavirus infection, when visualizing the vertebral arteries, an indirect linear course in the interosseous canal is traced, which is not observed in workers who have had a mild form of COVID-19. A study of the middle cerebral artery at the intracranial level in group 1 workers indicates the absence of hemodynamic changes, and in group 2 workers there was a decrease in speed indicators and an increase in the resistance index. In the machinists who suffered both severe and mild forms of COVID-19, scientists established "grade I arterial hypertension", which required the appointment of antihypertensive therapy. In workers who have undergone severe COVID-19, blood pressure indicators are higher, which led to remodeling of the brachiocephalic arteries in the form of thickening of the intima-media complex of the common carotid artery, minor ectasia and the development of deformities of the carotid arteries, increased resistance to blood flow, which is not present in workers who have undergone a mild form. Workers who have developed complications in the post-СOVID period need annual duplex scanning with color Doppler mapping of the brachiocephalic arteries, which will help identify abnormalities at the extra- and intracranial level. Limitations. There are quantitative limitations due to the number of COVID-19 patients. Ethics. The study was approved by the local Ethics Committee of the Izmerov Research Institute of Occupational Health (Protocol No.1 dated February 16, 2022).

Multiple Osteoporotic Fractures in Cushing Syndrome: A Case Report and a Review of the Literature

Background: Osteoporotic fractures are a common clinical sign of Cushing syndrome (CS). However, Cushing diagnosis can occur years after this clinical manifestation. Methods: Herein, we present the case of a 45-year-old woman who was referred to our department for further diagnosis and treatment. Results: The patient was already under treatment for arterial hypertension and osteoporosis and was recently diagnosed with dyslipidemia and type 2 diabetes. She reported several previous fractures starting already 8 years before presentation. An adrenal CS was diagnosed, and the patient was treated with laparoscopic adrenalectomy, with a subsequent complete remission of her hypercortisolism. This case report presenting a particularly long time gap between initial osteoporosis signs and the final diagnosis underlines the need for an investigation into secondary osteoporosis in low-energy fractures also in the peripheral skeleton. In this context, we performed a literature review, including case reports with fragility fractures that were attributed to endogenous CS. Conclusions: In summary, a delayed diagnosis of CS in patients with a previous accumulation of such fractures is a worrisome observation and should be considered in everyday clinical practice in order to improve the timely diagnosis and treatment of CS.

Injuries from blank cartridge shots in suicide attempts within the South Korean military: a case series of five patients.

Blank cartridges are designed to produce the sound and gas flare of a gunshot without firing a bullet. However, blank cartridge shots (BCS) can still cause injuries ranging from minor to life-threatening. Within the South Korean military, most BCS-related injuries have occurred during suicide attempts. This study documents a case series of patients who sustained injuries from BCS during such attempts. We examined the medical records of Korean soldiers at a military trauma center between April 2022 and April 2024 who had sustained injuries from BCS during suicide attempts. The analyzed data included general characteristics, injury site, surgical and psychiatric interventions, and length of hospitalization. The case series included five patients between 19 and 20 years old (mean age, 19.6±0.55 years). Four of these patients sustained self-inflicted gunshot wounds to the submandibular area, while one targeted the right temporal area. Although initial vital signs and laboratory findings were unremarkable, computed tomography scans revealed injuries from projectile gas and gunpowder, including burns, subcutaneous emphysema, and major structural damage. Cases 1 and 2 required emergency surgery for foreign body removal and debridement. The average length of hospitalization was 35.2±12.11 days. Patients were first admitted to the trauma surgery department for BCS injury management, and then transferred to the psychiatry department for emotional support. The average stay was 15.6±15.87 days in trauma surgery and 19.6±14.99 days in psychiatry. This study highlights the consequences of BCS from suicide attempts in the South Korean military and provides valuable insights for medical personnel who may encounter patients with BCS injuries.

Prevalence of a delayed diagnosis of caffeine poisoning in the emergency department of a Japanese hospital

AbstractBackgroundMost cases of acute caffeine poisoning are easily diagnosed at initial hospital visits. Nonetheless, accurate diagnosis is sometimes delayed in some patients with this condition. Therefore, our aim was to determine the prevalence of delayed diagnosis of acute caffeine poisoning in the emergency department (ED).MethodsA single‐center retrospective observational study was conducted. All consecutive patients with acute caffeine poisoning who were admitted to our hospital from January 2016 to March 2024 were included. The primary outcome was the proportion of patients who did not receive a correct diagnosis initially in the ED.ResultsA total of 30 patients were included. The median age was 23 years (IQR 19–27), 24 (80%) were women, and 18 (60%) had psychiatric disorders. The diagnosis of acute caffeine poisoning was delayed in three patients (10%, 95% CI 0%–21%), among whom the initial diagnoses were encephalitis (n = 1), epileptic seizures (n = 1), and altered consciousness for unknown reasons (n = 1). Patients with delayed diagnoses experienced seizures more frequently during their ED stay than patients without delayed diagnoses did (p < 0.001).ConclusionThe initial diagnosis is missed in 1 of every 10 patients with acute caffeine poisoning. The presence of seizure as the initial sign was associated with delayed diagnosis of acute caffeine poisoning.

Isolated advanced chest wall recurrence with a rectified reconstruction

In developed nations, breast cancer stands as the primary cause of cancer-related death among females. Local recurrence is often considered an initial sign of treatment ineffectiveness, occurring on the chest wall, axilla, or ipsilateral breast post Breast-Conserving Surgery (BCS). Local recurrence is observed in approximately 30% of patients with locally advanced breast cancer. A 58-year-old postmenopausal woman, who is a known case of triple negative breast cancer presented to us with an ulcerative lesion over left chest wall. In the past, she underwent neoadjuvant chemotherapy followed by left MRM and received adjuvant chemotherapy for left breast carcinoma. The staging of her previous disease is yT2N1aM0. Now presenting as locally advanced recurrent infiltrating lesion in the anterior wall of pericardium with sternal erosion of size 7.7×9.7×15 cms. Isolated chest wall recurrences of breast cancer can be surgically treated with chest wall resection, sternal resection, and reconstruction, providing a good quality of life and disease-free survival. Titanium mesh, gaining recent popularity as a reliable and promising bone replacement, was utilized in this case.

Heart rate variability indices in professional football players under various anaerobic testing modes in dinamics of the preparatory period

Objective: to study the dynamics of performance and its regulatory neurovegetative support in professional football players under various anaerobic energy supply regimes at the stages of the preparatory period.Materials and methods: in a prospective study, 16 male athletes aged 18–20 years, first sports category, the main squad of the Smolensk State University of Sports football team at a special preparatory stage of the training and competition cycle were examined. Athletes performed anaerobic tests lasting 6, 15, and 45 seconds to assess, respectively, speed-strength abilities, maximum alactic power and glycolytic endurance on a modernized version of the Ergomedic 894E “Monark” bicycle ergometer. The functional state of athletes in the dynamics of the tests was assessed by diagnosing heart rate variability indicators using the “Varicard 2.6” device.Results: the initial values of anaerobic performance in qualified football players were high during all three tests and corresponded to their qualification. Intensive training factors of the preparatory period were reflected in the potentiation of their special performance. At the same time, the least “trainable” in the dynamics of the preparatory period, but the most stable and less “costly” in the neurovegetative provision of muscle activity were speed-strength abilities. With the transition to the test assessment of the dynamics of maximum alactic power (MAP) and glycolytic endurance in football players, more significant increases in the values of the corresponding indicators were noted, most pronounced by the end of the special preparatory period. However, such progress in anaerobic performance indicators was accompanied by negative dynamics in HRV indicators (a significant decrease in HF values, the most pronounced increase in LF, LF / HF, VLF), which can be assessed as an overstrain of autonomic regulation, initial signs of overtraining.Conclusion: the most difficult in terms of the tension of autonomous regulation is recognized as a 45-second anaerobic test, during which the metabolism switches to glycolysis. The obtained results prove the validity of modifications of training regimes of football players at the preparatory stage, aimed at optimizing/reducing the loads of alactate and glycolytic orientation in favor of aerobic training, in order to “bring out” athletes to the best test sports results while maintaining an adequate functional state.

(Invited) Low Temperature SiGe:B Epitaxy for Next-Generation Logic Devices

Epitaxy at low temperatures (< 400°C) will be essential to enable advanced node CMOS logic architectures such as gate-all-around and complementary field effect transistors [1]. Beyond complying with the related thermal budget limitations, the non-thermal-equilibrium conditions drastically increase the attainable active doping level in epitaxially grown source/drain (S/D) materials. This is a crucial benefit for minimizing the contact resistivity ρC between S/D and contact metal, which, with shrinking device dimensions, becomes the major contributor to parasitic resistance [1] . Another strategy for ρC reduction in p-type S/D is reducing the Schottky barrier height (SBH), for which SiGe:B layers with very high Ge content, up to Ge:B, have been considered [2]. In this work, we report on achieving unprecedented active doping NA = 4.2×1021 cm-3 (Hall Scattering Factor [HSF] = 1) with Ge contents as high as 80% - a dual benefit for ρC reduction. In this context, we furthermore demonstrate two in-line methods for non-contact and non-destructive characterization of composition and electrical parameters in highly doped SiGe:B thin films.We first discuss the general benefits of low temperature epitaxy, highlighting the improvements in attainable active doping and layer resistivity depicted inFig. 1. We then demonstrate how the high concentration of dopants enables metrology techniques for characterization of composition and electrical parameters of low-temperature SiGe:B thin films, that were so far mainly used for thicker layers or different material systems: Wavelength-dispersive x-ray fluorescence (WDXRF) and Fourier-transform infrared spectroscopy (FTIR). Fig. 2 demonstrates how the WDXRF detection of Ge was calibrated with SiGe films and transferred to SiGe:B. Fig. 3 demonstrates the application of the WDXRF for LT-SiGe:B films, and the direct detection of B concentration by XRF. In Fig. 4, the results of FTIR measurements based on a Drude dispersion model approach are shown for layer resistivity and NA. Systematic differences between the active doping are explained by respective assumptions of HSF equal to 1 and the effective hole mass as 0.37me. FTIR shows better agreement with the substitutional B concentration as extracted from x-ray diffraction, calculated from a three-component Vegard’s law assuming aB = 3.806 Å, as displayed in Fig. 5.We proceed to demonstrate the usefulness of WDXRF and FTIR in process development. We previously reported on low-temperature selective epitaxial growth of SiGe:B with Ge = 60%, NA = 2.9×1021 cm-3 (Hall, HSF=1) with resulting contact resistivity below 5×10-10 Ω-cm2 measured by ladder transmission line method [3 ,4], based on conventional precursors. In a fundamental change to the process, we introduced novel precursor material. Fig. 6 demonstrates, for a similar Ge content around 70%, the drastic increase of total incorporated B per supplied B precursor when using the new precursor configuration by use of WDXRF. The reduction in ‘apparent’ Ge (strain compensated by B) content, reduction in attainable resistivity and increase in NA measured by FTIR prove enhanced substitutional (active) Boron concentration. The NA as of Hall measurement is also drastically increased in absolute value, but in saturation, which may be explained by the HSF increasing for high concentrations of B [5]. The newly developed process exhibits drastic enhancement of achievable NA in conjunction with increased Ge concentration of the layer up to 80% compared to previously reported process types [1,3 ,4], as shown in Fig. 7. Fig. 8 displays the relation between NA and hole mobility (HSF=1) for the process types involving the new precursor, and conventional precursors, proving that electrical conductivity is generally improved with introduction of the new precursor.Reciprocal space maps for two ~15nm thick layers with Ge = 80% in Fig. 9 prove the transition from initial signs of relaxation to a fully strained layer by doubling the B precursor flow, while SIMS results show a 1.7x increase in incorporated B, highlighting the strain compensation effect of B. A transmission electron micrograph demonstrates perfect quality of the 15nm thick SiGe:B thin film, and defect-free substrate-to-film interface.Finally, fully selective growth on a full patterned wafer with a Si/SiNx/SiO2 structure is depicted in a transmission electron micrograph in Fig. 10.[1] C. Porret et al., 2022 IEDM, 34.1.1-34.1.4, [2] O. Gluschenkov et al., 2016 IEDM, 17.2.1-17.2.4,[3] R. Khazaka et al., 2022 ECS Trans. 109 87 [4] G. Zheng et al., 2023 VLSI, 1-2 [5] F. Severac et al., J. Appl. Phys. 105, 043711 (2009) Figure 1

Automated Early Diabetic Retinopathy Detection Using a Deep Hybrid Model

Recently, the primary reason for blindness in adults has been diabetic retinopathy (DR) disease. Therefore, there is an increasing demand for a real-time efficient classification and detection system for diabetic retinopathy (DR) to overcome fast-growing disease (DR). We introduced a novel deep hybrid model for auto-mated diabetic retinopathy (DR) disease recognition and classification. Our model leverages the power of CNN architectures: Inception V3 and VGG16 models by combining their strengths to cater to exact requirements. VGG16 model efficiently captures fine features and wide-ranging features such as textures and edges, crucial for classifying initial signs of DR. Similarly, Inception V3’s architecture is proficient at detecting multiscale patterns, providing an extensive setting for shaping the occurrence of more complex DR severity stages. Our deep hybrid model allows the extraction of various appearance features in retinal images, which can better assist the classification and detection of DR. Our proposed model evaluated on diverse datasets, including EyePACS1 and APTOS2019, demonstrating confident performance of 99.63% accuracy in classifying the DR severity levels on EyePACS1 dataset, while 98.70% accuracy on the APTOS2019 dataset, indicating that our proposed deep hybrid model well distinguished different stages and highly efficient in DR detection. This model helps clinicians and medical experts to classify and identify diabetic retinopathy DR stages and severity levels early. This automatic system helps to manage and treat the patient more effectively and introduces timely treatment.

Abstract 4138310: Successful Endovascular Closure of Ascending Aortic Pseudoaneurysm Using Atrial Septal Defect Occluder

Introduction: Ascending aortic pseudoaneurysms are mostly related to either surgery or non-surgical trauma. Any pseudoaneurysm arising from graft anastomoses, regardless of size or location, must be repaired due to the potential for catastrophic rupture. Traditional surgical intervention has a high mortality rate, but percutaneous treatment has emerged as an alternative. We present such a case of pseudoaneurysm treated by percutaneous intervention using a 6-mm Amplatzer device. Case: A 77-year-old female with a history of type A aortic dissection s/p emergent repair with a 32 mm tube graft one year ago presented with chest pain radiating to her back. Initial vital signs showed a BP of 185/105, SaO2 98% on RA, 98.3 F, HR 98 bpm, and RR 24/min. A chest CT scan suggested a pseudoaneurysm at the proximal anastomotic site of the aortic graft (Figs. 1A and B). Serial troponin and EKGs were unremarkable for acute ischemia. Multiple quaternary centers declined intervention due to the high risk of redo sternotomy for open repair and patient frailty. After multidisciplinary discussions, it was felt that percutaneous closure with an Amplatzer device was possible without coronary obstruction. In the catheterization lab, a TEE probe was placed to visualize the pseudoaneurysm of the ascending aorta (Fig. 1C). Angiography showed the aneurysm coming off the posterior aorta just above the noncoronary cusp, with the neck measuring ~6 mm (Fig. 1D). The aneurysm was successfully engaged using an 8-French sheath and an 8-French AL1. Based on measurements from the TEE and the angiogram, a 6 mm ASO device was used. After device deployment and release, aortograms showed that the pseudoaneurysm was excluded (Fig. 1H). Assessment with TEE and CTA showed no residual flow in the pseudoaneurysm (Fig. 1 E–G). Conclusion: Using an atrial septal occluder, endovascular intervention may be a safe and effective alternative to surgery for treating the ascending aortic pseudoaneurysm, especially in patients with a high prohibitive surgical risk. Longitudinal follow-ups are needed to comment on long-term mortality benefits for these individuals.

Coexisting metabolic dysfunction-associated steatotic liver disease exacerbates in-hospital outcomes in patients with heat stroke.

This study aimed to investigate the impact of coexisting metabolic dysfunction-associated steatotic liver disease (MASLD) on in-hospital mortality and organ injury markers in patients with heat stroke (HS). HS patients were retrospectively identified between July 1, 2022 and September 30, 2023 at West China Hospital, Sichuan University. Baseline characteristics, such as demographics, initial vital signs, and organ functional indicators were collected. Outcome events included organ injury and in-hospital mortality. The Least Absolute Shrinkage and Selection Operator (Lasso) method was employed to identify the optimal predictors for in-hospital mortality in HS patients. Subsequently, multivariable logistic regression analysis was performed to assess the relationship between the presence of MASLD and in-hospital mortality as well as organ function indicators. A total of 112 patients were included in the study, in which 27 (24.1%) had coexisting MASLD. Compared to those without MASLD, patients with MASLD had higher levels of various organ injury markers such as aspartate aminotransferase, urea nitrogen, serum cystatin C, creatinine, uric acid, myoglobin, creatine kinase and its isoenzymes upon admission (P < 0.05). The multivariable Logistic regression analysis indicated that the presence of MASLD is an independent risk factor for in-hospital mortality in HS patients. This study firstly indicated that coexisting MASLD may exacerbate organ injury in HS patients and serve as an independent risk factor for in-hospital mortality.