Staircase Approach Research Articles

Flexural properties and fatigue limit of 3D-printed and milled resin-based materials.

The purpose of this study was to evaluate the flexural strength (FS), flexural modulus (FM), and fatigue limit (FL) of 3D-printed resin-based polymers and composites and compare them to 3D-printed composites. A bar-shaped specimen (25×2×2mm) was CAD designed according to ISO 4049:2019, and 60 duplicates of the 3D model were nested at a 45-degree angle with the printing platform and 3D-printed with three materials: denture teeth resin (Denture Teeth, Formlabs), temporary crown and bridge resin (Temporary CB, Formlabs), and composite (Flexcera Smile Ultra+, Desktop Health). The 3D model was also imported into a dental CAM software, duplicated 60 times, nested, and milled from a 3D-milled composite puck (Ivotion Denture Teeth, Ivoclar). All specimens were post-processed following the manufacturer's recommendation. The specimens were then subjected to a three-point bending test until failure using a Universal Testing Machine at a crosshead speed of 0.75mm/min, and FS and FM were calculated. The remaining thirty specimens were tested for Fatigue Limit using the staircase approach starting at 50% FS maximum up to 1.2M cycles at 10Hz. The data were analyzed using one-way ANOVA and the Weibull distribution (α = 0.05). The results showed that Ivotion and Flexcera had higher FS (110.3 ± 7.1MPa and 107.6 ± 6.4MPa, respectively) and FM (3.3 ± 0.1GPa and 3.0 ± 0.2GPa, respectively) compared to the 3D-printed Denture Teeth (FS = 66.4 ± 18.5MPa and FM = 1.8 ± 0.1GPa) and Temporary CB (FS = 79.6 ± 12.1MPa and FM = 2.7 ± 0.4GPa). Weibull analysis showed that the Ivotion and Flexcera had a more uniform and narrower spatial distribution of defects (m: 27.98 and 29.19) than the printed materials, which had m values of 8.17 and 4.11 for Temporary CB and Denture Teeth, respectively. Although no differences were found in the static properties (FS and FM) between Ivotion and Flexcera, Ivotion presented a higher endurance limit than Flexcera (51.43 vs. 40.95MPa). The Temporary CB presented 21.08MPa and Denture Teeth presented 17.80MPa of endurance limit. 3D-milled (Ivotion Denture Teeth) and 3D-printed (Flexcera Smile Ultra+) composites outperformed 3D-printed resins (Formlabs Denture Teeth and Temporary Crown & Bridge) in terms of flexural properties and fatigue resistance. 3D-milled (Ivotion) and 3D-printed (Flexcera) composites exhibited similar flexural properties, but 3D-milled composites showed a 25% higher fatigue endurance limit, suggesting improved clinical longevity.

Therapy Intensity Level Scale for Traumatic Brain Injury: Clinimetric Assessment on Neuro-Monitored Patients Across 52 European Intensive Care Units.

Intracranial pressure (ICP) data from traumatic brain injury (TBI) patients in the intensive care unit (ICU) cannot be interpreted appropriately without accounting for the effect of administered therapy intensity level (TIL) on ICP. A 15-point scale was originally proposed in 1987 to quantify the hourly intensity of ICP-targeted treatment. This scale was subsequently modified-through expert consensus-during the development of TBI Common Data Elements to address statistical limitations and improve usability. The latest 38-point scale (hereafter referred to as TIL) permits integrated scoring for a 24-h period and has a five-category, condensed version (TIL(Basic)) based on qualitative assessment. Here, we perform a total- and component-score analysis of TIL and TIL(Basic) to: 1) validate the scales across the wide variation in contemporary ICP management; 2) compare their performance against that of predecessors; and 3) derive guidelines for proper scale use. From the observational Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study, we extract clinical data from a prospective cohort of ICP-monitored TBI patients (n = 873) from 52 ICUs across 19 countries. We calculate daily TIL and TIL(Basic) scores (TIL24 and TIL(Basic)24, respectively) from each patient's first week of ICU stay. We also calculate summary TIL and TIL(Basic) scores by taking the first-week maximum (TILmax and TIL(Basic)max) and first-week median (TILmedian and TIL(Basic)median) of TIL24 and TIL(Basic)24 scores for each patient. We find that, across all measures of construct and criterion validity, the latest TIL scale performs significantly greater than or similarly to all alternative scales (including TIL(Basic)) and integrates the widest range of modern ICP treatments. TILmedian outperforms both TILmax and summarized ICP values in detecting refractory intracranial hypertension (RICH) during ICU stay. The RICH detection thresholds which maximize the sum of sensitivity and specificity are TILmedian ≥ 7.5 and TILmax ≥ 14. The TIL24 threshold which maximizes the sum of sensitivity and specificity in the detection of surgical ICP control is TIL24 ≥ 9. The median scores of each TIL component therapy over increasing TIL24 reflect a credible staircase approach to treatment intensity escalation, from head positioning to surgical ICP control, as well as considerable variability in the use of cerebrospinal fluid drainage and decompressive craniectomy. Since TIL(Basic)max suffers from a strong statistical ceiling effect and only covers 17% (95% confidence interval [CI]: 16-18%) of the information in TILmax, TIL(Basic) should not be used instead of TIL for rating maximum treatment intensity. TIL(Basic)24 and TIL(Basic)median can be suitable replacements for TIL24 and TILmedian, respectively (with up to 33% [95% CI: 31-35%] information coverage) when full TIL assessment is infeasible. Accordingly, we derive numerical ranges for categorising TIL24 scores into TIL(Basic)24 scores. In conclusion, our results validate TIL across a spectrum of ICP management and monitoring approaches. TIL is a more sensitive surrogate for pathophysiology than ICP and thus can be considered an intermediate outcome after TBI.

Fatigue behaviour of a self-healing dental composite.

Novel self-healing resin-based composites containing microcapsules have been developed to improve the mechanical performance of dental restorations. However, the long-term fatigue behaviour of these self-healing composites has still been hardly investigated. Therefore, this manuscript studied the fatigue behaviour of self-healing composites containing microcapsules by subjecting the specimens to traditional staircase tests and ageing in a custom-designed chewing simulator (Rub&Roll) to simulate oral ageing physiologically relevant conditions. To prepare self-healing composite, poly(urea-formaldehyde) microcapsules containing acrylic self-healing liquids were synthesized. Subsequently, these microcapsules (10wt%) and initiator (benzoyl peroxide, BPO, 2wt%) were incorporated into a commercial flowable resin-based composite. Microcapsule-free resin-based composites with and without BPO were also prepared as control specimens. A three-point flexural test was used to measure the initial flexural strength (Sinitial). Subsequently, half of the specimens were used for fatigue testing using a common staircase approach to measure the fatigue strengths (FS). In addition, the other specimens were aged in the Rub&Roll machine for four weeks where after the final flexural strength (Sfinal) was measured. Compared to Sinitial, FS of all tested specimens significantly decreased as measured through staircase testing. After 4 weeks of ageing in the Rub&Roll machine, Sfinal was significantly reduced compared to Sinitial for microcapsule-free resin-based composites, but not for the self-healing composites (p=0.3658). However, the self-healing composites are still in the experimental phase characterized by a low mechanical strength, which still impedes further clinical translation. Self-healing composites containing microcapsules exhibit improved fatigue resistance compared to microcapsule-free non-self-healing composites.

Mechanical properties of 3D-printed and milled composite resins for definitive restorations: An in vitro comparison of initial strength and fatigue behavior.

To evaluate the flexural strength and fatigue behavior of a novel 3D-printed composite resin for definitive restorations. Fifty disc-shaped specimens were manufactured from each of a nanohybrid composite resin (NHC), polymer-infiltrated ceramic network (PICN), and 3D-printed composite resin (3D) with CAD-CAM technology. Biaxial flexural strength (σin ) (n = 30 per group) and biaxial flexural fatigue strength (σff ) (n = 20 per group) were measured using piston-on-three-balls method, employing a staircase approach of 105 cycles. Weibull statistics, relative-strength degradation calculations, and fractography were performed. The results were analyzed with 1-way ANOVA and Games-Howell post hoc test (α = 0.05). Significant differences in σin and σff among the groups (p < 0.001) were detected. The NHC group provided the highest mean ± standard deviation σin and σff (237.3 ± 31.6 MPa and 141.3 ± 3.8 MPa), followed by the PICN (140.3 ± 12.9 MPa and 73.5 ± 9.9 MPa) and the 3D (83.6 ± 18.5 MPa and 37.4 ± 23.8 MPa) groups. The 3D group exhibited significantly lower Weibull modulus (m = 4.7) and up to 15% higher relative strength degradation with areas of nonhomogeneous microstructure as possible fracture origins. The 3D-printed composite resin exhibited the lowest mechanical properties, where areas of nonhomogeneous microstructure developed during the mixing procedure served as potential fracture origins. The clinical indications of the investigated novel 3D-printed composite resin should be limited to long-term provisional restorations. A cautious procedure for mixing the components is crucial before the 3D-printing process, since nonhomogeneous areas developed during the mixing could act as fracture origins.

Reducing Sedentary Behavior and Increasing Physical Activity Among Low Active, Underserved Adults: A Staircase Approach.

Reducing Sedentary Behavior and Increasing Physical Activity Among Low Active, Underserved Adults: A Staircase Approach.

Study of the Effect of L-PBF Technique Temporal Evolution on Microstructure, Surface Texture, and Fatigue Performance of Ti gr. 23 Alloy

Titanium alloys are widely used in various technological fields due to their excellent performance. Since the early stages of the 3D printing concept, these alloys have been intensively used as materials for these processes. In this work, the evolution of the performance of the 3D printing process has been studied by analysing the microstructure and the mechanical properties, fatigue and tensile, of the Ti gr. 23 alloy produced by two different models of Concept Laser M2 Cusing machines (an old model and a more recent one). The process parameters recommended by the manufacturer were adopted for each machine. Both microstructural and surface texture characterisations were carried out to better correlate the differences with the production process technique. For the same purpose, tensile tests and microhardness profiles were obtained, while the dynamic mechanical properties were evaluated by means of fatigue tests aimed at determining the fatigue limit of the material using a staircase approach. The mechanical tests were carried out on specimens with three different orientations with respect to the building platform, using two different SLM techniques. The fatigue behaviour was then analysed by evaluating the fracture surfaces and, in particular, the crack nucleation sites. By comparing the calculated fatigue values with the results of local fatigue calculations, an estimate of the residual stresses near the crack nucleation site was obtained. The results showed that the specimens produced on a newer machine had lower roughness (about 10%), slightly higher ductility, and a higher fatigue limit (10–20 MPa) compared to the specimens produced with the same material but on older equipment.

Two-body wear resistance and fatigue survival of new Y-TZP and ATZ ceramics made with a new slip-casting method

BackgroundDental zirconium oxide restorations are milled from pre-sintered blocks or disks which are produced either with high isostatic pressure (HIP) or, simpler, a slurry technique. The objective was to perform a fatigue test and an in vitro wear simulation of two ceramics, yttria-stabilized tetragonal zirconia polycrystal (3Y-TZP) ceramic and a hybrid zirconium oxide-aluminum oxide ceramic, (ATZ) both produced either the classical way using high isostatic pressure (HIP, control) or with a slurry technique. Materials and methodsTen discs/group were subjected to a cyclic biaxial fatigue test using a staircase approach under water at 37 °C in a dynamic universal testing machine. The 2-body wear test was performed on eight lapped 12 mm thick cylindrical samples subjected to spherical (ø 6 mm) leucite ceramic antagonists in a CS-4 chewing simulator at 49 N force and 0.7 mm lateral movement for 600 k cycles and 4167 thermal cycles (5–55 °C). Volumetric wear was calculated based on laser-scanned surfaces. Selected samples of both tests were viewed in SEM. ResultsAll the ceramic specimens produced using the HIP method survived up to 1.2 M cycles with the maximum load of the equipment (1000 N) loading the specimens up to 1527 MPa. The fatigue limit stress at 1.2 M cycles for the Slurry ATZ samples was 946 MPa. For the Slurry Y-TZP samples the fatigue limit stress at 1.2 M cycles was 658 MPa. At 600 k cycles, all zirconium oxide ceramics showed no measurable wear and had a highly polished appearance. The leucite ceramic antagonists wear developed in a linear way. There was no difference between the materials produced with the slurry and the HIP process. ATZ ceramic produced significantly more wear than 3Y- TZP ceramic. ConclusionsThe HIP method provided higher fatigue strength than the Slurry manufacturing method. All HIP ceramics surpassed the limit threshold (1527 MPa) of the testing machine. The tested ceramics did not show any measurable wear but had worn the leucite reinforced glass ceramic antagonists for a considerable amount.

Novel Synthetic and Natural Therapies for Traumatic Brain Injury

Traumatic brain injury (TBI) is a major cause of disability and death worldwide. The initial mechanical insult results in tissue and vascular disruption with hemorrhages and cellular necrosis that is followed by dynamic secondary brain damage that presumably results in additional destruction of the brain. In order to minimize deleterious consequences of the secondary brain damage-such as inflammation, bleeding or reduced oxygen supply. The old concept of the -staircase approach- has been updated in recent years by most guidelines and should be followed as it is considered the only validated approach for the treatment of TBI. Besides, a variety of novel therapies have been proposed as neuroprotectants. The molecular mechanisms of each drug involved in the inhibition of secondary brain injury can result as a potential target for the early and late treatment of TBI. However, no specific recommendation is available on their use in the clinical setting. The administration of both synthetic and natural compounds, which act on specific pathways involved in the destructive processes after TBI, even if usually employed for the treatment of other diseases, can show potential benefits. This review represents a massive effort towards current and novel therapies for TBI that have been investigated in both pre-clinical and clinical settings. This review aims to summarize the advancement in therapeutic strategies based on specific and distinct -target of therapies-: brain edema, ICP control, neuronal activity and plasticity, anti-inflammatory and immunomodulatory effects, cerebral autoregulation, antioxidant properties, and future perspectives with the adoption of mesenchymal stromal cells.

Dynamic fatigue of 3D-printed splint materials

ObjectivesPrinted splints may be an alternative treatment for functional disorders. In addition to the selection of materials, the influence of cleaning or polymerisation can affect the dynamic behaviour and fatigue limit of printed materials. Material and Methods96 discs (n = 6 per group, 16mmx2mm) were printed (P30+ DLP-printer, Straumann, CH; 100 μm layer) from splint materials (M1: Luxaprint OrthoPlus, DMG, G; M2: V-Print Splint, Voco, G). Specimens were either automatically cleaned (C1: Straumann P Wash, Straumann, CH) or manually cleaned (C2: Voco Pre-/Main-Clean protocol, Voco, G). Post polymerisation was performed with LED (P1: Cure, Straumann, CH) or Xenon light (P2: Otoflash N171, Ernst Hinrichs Dental, G). The flexural fatigue limit was determined under cyclic loading in terms of a staircase approach with a piston-on-3-ball-test according to ISO 6872 after 24 h or 60 days water storage (37 °C). Specimens were preloaded with 50N and dynamic force was applied for 105 loadings per step (f = 3Hz; steps 1: 50N–100N, 2: 50N–150N, 3: 50N–200N, 4: 50N–250N; F1000, Prematec, G; water at 37 °C). Statistics: Kaplan Maier Log Rank (Mantel-Cox) test, ANOVA, Pearson correlations, Levene-test (α = 0.05, SPSS 26.0, IBM, Armonk, NY, USA)). ResultsMean survival cycles after 24 h of storage varied between 40388 (M1C2P2) and 195140 (M2C2P1) cycles and after 60 d decreased to 14022 (M1C2P2) and 173237 (M2C1P1). Kaplan Maier Log Rank test revealed significant differences between the material combinations. For M1 cleaning (Pearson: 0.346, p = 0.016) and for M2 polymerisation (Pearson: 0.616, p = 0.000) significantly influenced the number of loading cycles. Intermediate effects were found for material (p = 0.026), cleaning (p = 0.024) and polymerisation (p = 0.000) as well as the combination of material and polymerisation (p = 0.008). ConclusionsThe results show that the number of possible loading cycles of additively manufactured splint specimens depends on the type of material, their cleaning and post-polymerisation. Clinical significanceMaterials, cleaning and post-polymerisation of additive manufacturing processes should be matched to improve dynamic loading performance of splint materials.

17-4 PH SS Manufactured via Selective Laser Melting: High Cycle Fatigue Properties

In the recent years, Additive Manufacturing (AM) is becoming an emerging technology and more and more material powders are available on the market. The knowledge of their specific mechanical behaviour is a fundamental aspect for their large-scale adoption, also considering the lack of reliable data and dedicated standards.In this work the High Cycle Fatigue characterization of a 17-4 PH Stainless Steel (SS) is presented. The cylindrical samples used were manufactured via Selective Laser Melting (SLM) technology using an EOS M280 machine. Two separate series of samples differing in terms of surface finishing were tested. The first series of samples was used in the as-build condition while the second series was machined in order to obtain a better surface finishing.The effect of the surface finishing on the fatigue behaviour of AM materials is fundamental considering that in most of the applications the parts – reticular or lattice structures with complex geometries – are set into operation in the as-build condition because a surface finishing is not feasible. The comparison of the results obtained for the two different series of specimens allows the quantification of the reduction of the mechanical performances due to the actual limits of the SLM technology. The fatigue limit was obtained with the short stair-case approach according to the Dixon statistical method. The maximum number of cycles (run-out) was set equal to 5000000. The left part of the Wöhler diagram was also studied by means of additional tests at higher stress levels.Additional quasi-static tests were performed in order to characterise the static behaviour.

High and low-cycle-fatigue properties of 17\u20134 PH manufactured via selective laser melting in as-built, machined and hipped conditions

In the last years, additive manufacturing (AM) has turned into an emerging technology and an increasing number of classes of material powders are now available for this manufacturing process. For large-scale adoption, an accurate knowledge of the mechanical behaviour of the resulting materials is fundamental, also considering that reliable data are often lacking and dedicated standards are still missing for these AM alloys. In this regard, the aim of the present work is to characterize both the high-cycle-fatigue (HFC) and the low-cycle-fatigue (LCF) behaviour of AM 17–4 PH stainless steel (SS). To better understand the performance of the selected alloy, four series of cylindrical samples were manufactured. Three series were produced via selective laser melting (SLM), better known as laser-based powder bed fusion of metals technology using an EOS M280 machine. The first series was tested in the as-built condition, the second was machined before testing to obtain a better surface finishing, while the third series was post-processed via hot isostatic pressing (HIP). Finally, a fourth series of samples was produced from the wrought 17–4 PH material counterpart, for comparison. The understanding and assessment of the influence of surface finishing on the fatigue behaviour of AM materials are fundamental, considering that in most applications the AM parts may present reticular or lattice structures, internal cavities or complex geometries, which must be set into operation in the as-built conditions, since a surface finishing postprocess is not convenient or not feasible at all. On the other side, a HIP process is often suggested to reduce the internal porosities and, therefore, to improve the resulting mechanical properties. The high-cycle-fatigue limits were obtained with a short staircase approach according to the Dixon statistical method. The maximum number of cycles (run-out) was set equal to 50,00,000. The part of the Wöhler diagram relative to finite life was also characterized by means of additional tests at higher stress levels. On the other side, the low-cycle tests allowed to tune the Ramberg–Osgood cyclic curves and the Basquin–Coffin–Manson LCF curves. The results obtained for the four different series of specimens permitted to quantify the reduction of the mechanical performance due to the actual limits of the laser-based powder bed fusion technology (surface quality, internal porosity, different solidification) with respect to traditional manufacturing and could be used to improve design safety and reliability, granting structural integrity of actual applications under elastic and elasto-plastic fatigue loads.

Acute Intracranial Hypertension During Pregnancy: Special Considerations and Management Adjustments.

Pregnancy is associated with a number of pathophysiological changes (including modification of vascular resistance, increased vascular permeability, and coagulative disorders) that can lead to specific (eclampsia, preeclampsia) or not specific (intracranial hemorrhage) neurological complications. In addition to these disorders, pregnancy can affect numerous preexisting neurologic conditions, including epilepsy, brain tumors, and intracerebral bleeding from cerebral aneurysm or arteriovenous malformations. Intracranial complications related to pregnancy can expose patients to a high risk of intracranial hypertension (IHT). Unfortunately, at present, the therapeutic measures that are generally adopted for the control of elevated intracranial pressure (ICP) in the general population have not been examined in pregnant patients, and their efficacy and safety for the mother and the fetus is still unknown. In addition, no specific guidelines for the application of the staircase approach, including escalating treatments with increasing intensity of level, for the management of IHT exist for this population. Although some of basic measures can be considered safe even in pregnant patients (management of stable hemodynamic and respiratory function, optimization of systemic physiology), some other interventions, such as hyperventilation, osmotic therapy, hypothermia, barbiturates, and decompressive craniectomy, can lead to specific concerns for the safety of both mother and fetus. The aim of this review is to summarize the neurological pathophysiological changes occurring during pregnancy and explore the effects of the possible therapeutic interventions applied to the general population for the management of IHT during pregnancy, taking into consideration ethical and clinical concerns as well as the decision for the timing of treatment and delivery.

Application of lattice Boltzmann method to curved boundaries for simulating nanofluid flow in an L-Shape enclosure

PurposeThis paper aims to use the Lattice Boltzmann method (LBM) to numerically simulate the natural convection heat transfer of Cu-water nanofluid in an L-shaped enclosure with curved boundaries.Design/methodology/approachLBM on three different models of curved L-shape cavity using staircase approach is applied to perform a comparative investigation for the effects of curved boundary on fluid flow and heat transfer. The staircase approximation is a straightforward and efficient approach to simulating curved boundaries in LBM.FindingsThe effect of curved boundary on natural convection in different parameter ranges of Rayleigh number and nanoparticle volume fraction is investigated. The curved L-shape results are also compared to the rectangular L-shape results that were also achieved in this study. The curved boundary LBM simulation is also validated with existing studies, which shows great accuracy in this study. The results show that the top curved boundary in curved L-shape models causes a notable increase in the Nusselt number values.Originality/valueBased on existing literature, there is a lack of comparative studies which would specifically examine the effects of curved boundaries on natural convection in closed cavities. Particularly, the application of curved boundaries to an L-shape cavity has not been examined. In this study, curved boundaries are applied to the sharp corners of the bending section in the L-shape and the results of the curved L-shape models are compared to the simple rectangular L-shape model. Hence, a comparative evaluation is performed for the effect of curved boundaries on fluid flow in the L-shape enclosure.

Bird expertise does not increase motion sensitivity to bird flight motion.

While motion information is important for the early stages of vision, it also contributes to later stages of object recognition. For example, human observers can detect the presence of a human, judge its actions, and judge its gender and identity simply based on motion cues conveyed in a point-light display. Here we examined whether object expertise enhances the observer's sensitivity to its characteristic movement. Bird experts and novices were shown point-light displays of upright and inverted birds in flight, or upright and inverted human walkers, and asked to discriminate them from spatially scrambled point-light displays of the same stimuli. While the spatially scrambled stimuli retained the local motion of each dot of the moving objects, it disrupted the global percept of the object in motion. To estimate a detection threshold in each object domain, we systematically varied the number of noise dots in which the stimuli were embedded using an adaptive staircase approach. Contrary to our predictions, the experts did not show disproportionately higher sensitivity to bird motion, and both groups showed no inversion cost. However, consistent with previous work showing a robust inversion effect for human motion, both groups were more sensitive to upright human walkers than their inverted counterparts. Thus, the result suggests that real-world experience in the bird domain has little to no influence on the sensitivity to bird motion and that birds do not show the typical inversion effect seen with humans and other terrestrial movement.

Escalate and De-Escalate Therapies for Intracranial Pressure Control in Traumatic Brain Injury.

Severe traumatic brain injury (TBI) is frequently associated with an elevation of intracranial pressure (ICP), followed by cerebral perfusion pressure (CPP) reduction. Invasive monitoring of ICP is recommended to guide a step-by-step “staircase approach” which aims to normalize ICP values and reduce the risks of secondary damage. However, if such monitoring is not available clinical examination and radiological criteria should be used. A major concern is how to taper the therapies employed for ICP control. The aim of this manuscript is to review the criteria for escalating and withdrawing therapies in TBI patients. Each step of the staircase approach carries a risk of adverse effects related to the duration of treatment. Tapering of barbiturates should start once ICP control has been achieved for at least 24 h, although a period of 2–12 days is often required. Administration of hyperosmolar fluids should be avoided if ICP is normal. Sedation should be reduced after at least 24 h of controlled ICP to allow neurological examination. Removal of invasive ICP monitoring is suggested after 72 h of normal ICP. For patients who have undergone surgical decompression, cranioplasty represents the final step, and an earlier cranioplasty (15–90 days after decompression) seems to reduce the rate of infection, seizures, and hydrocephalus.

An overview of management of intracranial hypertension in the intensive care unit.

Intracranial hypertension (IH) is a clinical condition commonly encountered in the intensive care unit, which requires immediate treatment. The maintenance of normal intracranial pressure (ICP) and cerebral perfusion pressure in order to prevent secondary brain injury (SBI) is the central focus of management. SBI can be detected through clinical examination and invasive and non-invasive ICP monitoring. Progress in monitoring and understanding the pathophysiological mechanisms of IH allows the implementation of targeted interventions in order to improve the outcome of these patients. Initially, general prophylactic measures such as patient’s head elevation, fever control, adequate analgesia and sedation depth should be applied immediately to all patients with suspected IH. Based on specific indications and conditions, surgical resection of mass lesions and cerebrospinal fluid drainage should be considered as an initial treatment for lowering ICP. Hyperosmolar therapy (mannitol or hypertonic saline) represents the cornerstone of medical treatment of acute IH while hyperventilation should be limited to emergency management of life-threatening raised ICP. Therapeutic hypothermia could have a possible benefit on outcome. To control elevated ICP refractory to maximum standard medical and surgical treatment, at first, high-dose barbiturate administration and then decompressive craniectomy as a last step are recommended with unclear and probable benefit on outcomes, respectively. The therapeutic strategy should be based on a staircase approach and be individualized for each patient. Since most therapeutic interventions have an uncertain effect on neurological outcome and mortality, future research should focus on both studying the long-term benefits of current strategies and developing new ones.

High load frequency at 20Hz: Its effects on the fatigue behavior of a leucite-reinforced glass-ceramic

Considering the long time spent in low frequency cyclic fatigue tests, this study aimed to evaluate the influence of loading frequency (2 Hz and 20 Hz) on the flexural fatigue strength (FFS) and on the time and number of cycles to failure of a leucite-reinforced glass-ceramic. Disc-shaped specimens were produced using leucite-reinforced glass-ceramic CAD/CAM blocks (IPS Empress CAD), according to ISO 6872/2015. Two fatigue tests were performed. The FFS (n = 17) was determined by staircase approach at a lifetime of 500,000 cycles, for 2 Hz (control – chewing frequency estimative) and 20 Hz (accelerated approach). To determine the time and the number of cycles to failure in flexural fatigue, discs (n = 20) were submitted to a cyclic loading ranging from 10 MPa to 99 MPa (60% of the monotonic strength), until a maximum of 500,000 cycles. Means, standard deviation and confidence intervals (CI) at 95% for FFS were calculated, whereas statistical differences were detected based on maximum likelihood estimations and overlapping of 95% CIs. Kaplan Meier (α = 0.05) and log rank post-hoc tests were used to analyze the time (in minutes) and the number of cycles to failure in the lifetime test. FFS did not differ significantly between 2 Hz (mean: 78 MPa; 95% CI: 69–88 MPa) and 20 Hz (mean: 84 MPa; 95% CI: 78–90 MPa). Regarding the lifetime test, there was no difference (p = 0.3) in the time to failure for 2 Hz (mean: 13 min; 95% CI: 6–20 min) and 20 Hz (mean: 69 min; 95% CI: 9–128 min). However, the group tested with 20 Hz survived a significantly (p < 0.01) higher number of cycles (mean: 82,247 cycles; 95% CI: 11,450–153,044) than the group tested with 2 Hz (mean: 1588 cycles; 95% CI: 779–2397). Therefore, in leucite-reinforced glass-ceramic fatigue strength tests, limited to a lifetime of 500,000 cycles, the use of loading frequencies up to 20 Hz did not influence the FFS estimations when compared to 2 Hz (chewing frequency estimative), and may be an alternative to accelerate data collection in this type of mechanical test. However, in lifetime tests, the use of higher loading frequencies, as 20 Hz, did not save time, since a higher number of cycles was necessary to promote the failure, when compared to 2 Hz.

Successful intervention for overwhelming postsplenectomy infection caused by non-vaccine pneumococcal serotype 23A

The spleen plays an important role in the body’s immune defense against invasive infections, particularly those caused by encapsulated bacteria. Encapsulated bacterial infection in asplenic patients is a medical emergency called overwhelming postsplenectomy infection (OPSI) and has a mortality rate of 50–70%. Here, we report the case of a 51-year-old Asian man who complained of emesis and diarrhea as primary symptoms. He rapidly progressed to coma and was eventually diagnosed with OPSI (pyogenic ventriculitis/spondylitis) caused by non-vaccine pneumococcal serotype 23A. Aggressive management, including empiric antibiotic therapy, a staircase approach for intracranial pressure-targeted therapy and laminectomy/laminoplasty, resulted in a good recovery. Our report highlights that non-vaccine pneumococcal serotypes can cause disease in vaccinated patients.

The Role of Supplier Base Rationalisation in Operational Performance in the Retail Sector in Zimbabwe

This research aimed at adding to the existing inventory of literature in the arena of procurement management to find out the role of supplier base rationalisation in operational performance in the retail sector in Zimbabwe. A cross-industry survey of retail supermarkets in Zimbabwe was done. A supplier base rationalisation key variables model incorporating five variables that are, the twenty/eighty rule, improve or else approach triage approach, competency staircase approach and spend categorization was tested in operational performance in Zimbabwe’s retail sector. Research variables were discussed under the conceptual underpinning. The target population constitutes of retail supermarkets employees involved in procurement operation with a sample size of 59 procurement practitioners using Krejcie and Morgan [1] formula. Purposive sampling was carried out. The research instruments that were used are close-ended questionnaires to all procurement practitioners in the retail sector and open-ended interviews with procurement managers only. Data collected were analyzed using descriptive and inferential statistical tools and Statistical Package for Social Science software (SPSS) version 24 was used to process the collected data and presented in tables. Correlation analysis indicated that 76.2% of the change of operational performance was explained by the five supplier base rationalisation variables and revealed that they have a positive significant effect in operational performance. This research recommends that the procurement should move towards overall effective and efficient supplier base rationalisation practices that focus on boosting operational performance.

The Mechanical Performance of a Novel Self-Adhesive Restorative Material.

The development of a novel material requires a comprehensive pre-clinical assessment of clinical longevity before any market release. This study aimed to investigate the mechanical performance of a novel self-adhesive restorative material (ASAR MP4). Fracture strength (FS), flexural fatigue strength (FFS) and fracture toughness (KIc) were measured for the experimental material ASAR MP4 in self-cure (SC) and light-cure (LC) mode. ASAR MP4 was processed in capsules. Three direct resin composites (CeramX mono+, DentsplySirona; Heliomolar, IvoclarVivadent; Filtek Supreme XTE, 3M) and two glass-ionomer-cement (GIC) based materials (Equia Forte, GC; Fuji II LC, GC) were selected for comparison with ASAR MP4. FS specimens (n = 15) were tested in a 4-point bending configuration according to ISO 4049 and 9917. FFS specimens (n = 25) were additionally stressed for 104 loading cycles using the staircase approach. The single-edge-notch beam (SENB) configuration was selected for determining KIc according to ISO 13586. All specimens were stored for 14 days at 37°C. Data were analyzed using Weibull statistics (FS), ANOVA (FS, KIc), and the non-parametric Mann-Whitney U-test (FFS). The FS, FFS and KIc data of the ASAR MP4 material reveal a mechanical performance in the range of the successful permanent direct resin composites CeramX mono+ and Heliomolar. The results for ASAR MP4 in SC mode were superior to the LC mode. A fine-grained and pore-free microstructure was observed. Within the limitations of this study we conclude that the novel self-adhesive restorative material ASAR MP4 exhibits mechanical performance close to that of the resin composites Heliomolar and CeramX mono+, both indicated for permanent use in the load-bearing posterior region. Processing the material in either self-cure or light-cure mode led to superior performance over glass-ionomer cements.