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PMC11277661_p5
|
PMC11277661
|
sec[0]/p[5]
|
1. Introduction
| 4.054688 |
biomedical
|
Study
|
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This study aims to scrutinize the risk of complications, including neurological sequelae, and early and late mortality among patients with antecedent stroke subjected to cardiac surgical interventions with extracorporeal support.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p6
|
PMC11277661
|
sec[1]/p[0]
|
2. Material and Methods
| 4.046875 |
biomedical
|
Study
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A single-center retrospective study was conducted on 10,685 patients who had undergone cardiac surgery with extracorporeal circulation at the Department of Cardiac Surgery of the University Clinical Hospital No. 2 of the Pomeranian Medical University in Szczecin between 2010 and 2021. Table 1 outlines the inclusion and exclusion criteria for the study. According to the study protocol, patients were excluded if they had undergone urgent surgery (620 cases) or emergency surgery (139 cases) or if they had undergone other complex cardiac surgical procedures (97 cases). All patients included in this study were self-sufficient in terms of satisfying their basic needs and required at most minor assistance in activities of daily life.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
PMC11277661_p7
|
PMC11277661
|
sec[1]/p[1]
|
2. Material and Methods
| 2.763672 |
biomedical
|
Study
|
[
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The analysis included a group of 9829 patients who had undergone cardiac surgery with extracorporeal circulation according to the study’s inclusion criteria.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
PMC11277661_p8
|
PMC11277661
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sec[1]/sec[0]/p[0]
|
2.1. Collecting Data
| 4.019531 |
biomedical
|
Study
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Demographic and comorbidity data were obtained through medical interviews and analysis of patient medical records. The severity of angina pectoris was assessed using the CCS (Canadian Cardiovascular Score) scale. EuroScore Logistics 2 was utilized to evaluate perioperative risk. Based on measurements of height and weight taken during the hospital stay, the BMI for each patient was calculated using the standard formula: BMI = body mass [kg]/height 2 [m].
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p9
|
PMC11277661
|
sec[1]/sec[0]/p[1]
|
2.1. Collecting Data
| 3.681641 |
biomedical
|
Study
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Postoperative-course data analyzed included intubation time, length of hospitalization, and stay in an intensive care unit, as well as in-hospital, 30-day, and long-term mortality (one-year follow-up). The occurrence of postoperative complications (cardiac, pulmonary, renal, cerebral, and infectious) was also evaluated.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
PMC11277661_p10
|
PMC11277661
|
sec[1]/sec[1]/p[0]
|
2.2. Study Group
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biomedical
|
Study
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The study population was divided into two groups. The first group comprised all patients eligible for cardiac surgery with extracorporeal circulation. The second group ( n = 546) consisted of patients with a preoperative history of stroke (diagnosed according to ICD-10). The division into groups is presented in Figure 1 .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
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PMC11277661_p11
|
PMC11277661
|
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|
2.3. Ethical Issues
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The study adhered to the principles outlined in the Declaration of Helsinki and Good Clinical Practice. It received an exemption from the Bioethical Committee of the Pomeranian Medical University due to its retrospective observational nature , Prior to surgery, each patient provided written informed consent for the procedure and anesthesia, which included consent for the collection of personal data. To ensure patient anonymity, data analysis was conducted in an anonymized form.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
PMC11277661_p12
|
PMC11277661
|
sec[1]/sec[3]/p[0]
|
2.4. Statistical Analysis
| 4.015625 |
biomedical
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Study
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The data were analyzed using licensed Statistica 13 software (StatSoft Inc., Tulsa, OK, USA). The normality of variable distribution was assessed using the Shapiro−Wilk test. Categorical variables were presented as numbers and percentages, and between-group comparisons were performed using the Chi-square test; Yates’s correction was applied if subgroup sizes were inadequate. Continuous variables were expressed as means, standard deviations, medians, and quartiles, with characteristics compared between patients with and without a stroke history using the Mann−Whitney U test. Single-factor and multiple-factor logistic regression analyses were conducted, with the latter adjusted for confounding variables (age, EF, ESL, comorbidities). Kaplan−Meier analysis was employed to estimate survival probability. Statistical significance was defined as p < 0.05.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p13
|
PMC11277661
|
sec[2]/p[0]
|
3. Results
| 4.160156 |
biomedical
|
Study
|
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Table 2 presents demographic data, comorbidities, and intraoperative data in the patients with and without a history of preoperative stroke. Patients eligible for surgery following a stroke incident were older ( p = 0.003), exhibited higher operative risk ( p < 0.001), and had lower ejection fractions ( p = 0.001). Stroke patients more frequently presented with NYHA class III and IV heart failure ( p = 0.028), ICA stenosis ( p < 0.001), ICA occlusion ( p < 0.001), prior carotid artery endarterectomy ( p < 0.001), diabetes treated with oral medications ( p < 0.001) or insulin ( p < 0.001), arterial hypertension ( p = 0.032), atrial fibrillation ( p < 0.001), and extracardiac arteriopathy ( p < 0.001). Intra- and postoperative data revealed differences in intubation time and reintubation rates. Patients with a history of preoperative stroke experienced significantly prolonged postoperative ventilation ( p < 0.001) and were notably more likely to require reintubation ( p < 0.001).
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
PMC11277661_p14
|
PMC11277661
|
sec[2]/p[1]
|
3. Results
| 4.058594 |
biomedical
|
Study
|
[
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Patients with a history of preoperative stroke had higher preoperative ( p < 0.001) and postoperative ( p < 0.001) creatinine levels. Conversely, significantly lower values were observed preoperatively for RBC ( p = 0.049), hemoglobin ( p < 0.001), and hematocrit ( p < 0.001). These data are presented in Table 3 .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p15
|
PMC11277661
|
sec[2]/p[2]
|
3. Results
| 4.152344 |
biomedical
|
Study
|
[
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Table 4 presents the number of complications based on the occurrence of postoperative stroke. A greater number of patients with a history of preoperative stroke after surgery exhibited delirium (21.3% vs. 15.7%; p < 0.001), respiratory failure (13.2% vs. 6.8%; p < 0.001), pneumonia (15.8% vs. 8.8%; p < 0.001), renal failure (14.8% vs. 8.8%; p < 0.001), 30-day mortality (8.1% vs. 4.2%; p < 0.001), 90-day mortality (11.9% vs. 5.8%; p < 0.001), and 1-year mortality (16.1% vs. 7.9%; p < 0.001).
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
PMC11277661_p16
|
PMC11277661
|
sec[2]/p[3]
|
3. Results
| 4.117188 |
biomedical
|
Study
|
[
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Logistic regression analysis was performed, and the results are presented in Table 5 . The table displays both single-factor and multifactorial models for risk of postoperative complications. In the multifactorial assessment adjusted by ESL, sex, and comorbidities, a statistically significant association was demonstrated between preoperative stroke and the occurrence of postoperative pneumonia (OR = 1.482, p = 0.006), respiratory failure (OR = 1.497, p = 0.006), renal failure (OR = 1.391, p = 0.019), 30-day mortality (OR = 1.528, p = 0.026), 90-day mortality (OR = 1.658, p < 0.001), and one-year mortality (OR = 1.706, p < 0.001).
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p17
|
PMC11277661
|
sec[2]/p[4]
|
3. Results
| 4.183594 |
biomedical
|
Study
|
[
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Significant complications were analyzed in patients with a history of preoperative stroke undergoing CABG surgery according to the type of cardiac surgery performed ( Table 6 ), and the results show significantly higher risks of delirium (OR = 1.425, p = 0.015), TIA (OR = 4.127, p = 0.005), EPI (OR = 3.609, p = 0.010), respiratory failure (OR = 2.215, p < 0.001), pneumonia (OR = 2.178, p < 0.001), and renal failure (OR = 1.839, p = 0.002), as well as 30-day mortality (OR = 2.290, p = 0.001), 90-day mortality (OR = 2.517, p < 0.001), and 1-year mortality (OR = 2.430, p < 0.001). Patients undergoing complex coronary artery bypass grafting (CABG) surgery and those with valvular defects and preoperative stroke had significantly higher risks of myocardial infarction (OR = 2.047, p = 0.043), respiratory failure (OR = 2.443, p = 0.001), pneumonia (OR = 1.675, p = 0.045), renal failure (OR = 1.720, p = 0.021), 30-day mortality (OR = 2.226, p = 0.006), 90-day mortality (OR = 2.106, p = 0.004), and 1-year mortality (OR = 2.242, p = 0.001). Patients with valvular defects and preoperative stroke had increased risks of postoperative stroke (OR = 2.052, p = 0.042) and RIND (OR = 8.172, p = 0.013). Patients undergoing aortic aneurysm surgery had the highest risk of extensive stroke (OR = 4.387, p = 0.048), renal failure (OR = 2.372, p = 0.040), 90-day mortality (OR = 3.179, p = 0.006), and 1-year mortality (OR = 2.486, p = 0.030).
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
PMC11277661_p18
|
PMC11277661
|
sec[2]/p[5]
|
3. Results
| 3.464844 |
biomedical
|
Study
|
[
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The Kaplan−Meier curves are depicted in Figure 2 , Figure 3 and Figure 4 . Among patients with a history of preoperative stroke, significantly shorter survival times at 30 days, 90 days, and one year were observed.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
PMC11277661_p19
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PMC11277661
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sec[3]/p[0]
|
4. Discussion
| 4.058594 |
biomedical
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Study
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Considering the increasing prevalence of elderly patients with multiple comorbidities undergoing cardiac surgeries, it is crucial to assess perioperative risk and treatment outcomes for this demographic. In our investigation, we focused on examining how preoperative cerebral stroke influences the perioperative risk associated with on-pump cardiac surgery and subsequent treatment outcomes in these patients. A significant finding of our study was that preoperative cerebral stroke elevates the risk of postoperative complications and negatively impacts patients’ survival rates post-surgery. A cohort of 9829 patients included in this study was hospitalized in our facility over the course of eleven years . There were no significant changes to operating techniques or to the equipment used during the surgery in our facility during this time.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
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PMC11277661_p20
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sec[3]/p[1]
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4. Discussion
| 4.085938 |
biomedical
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Study
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Notably, the existing EuroScore II formula utilized to estimate cardiac-surgery risk does not incorporate cerebral stroke . Messerotti Benvenuti et al., in their analysis of EuroScore and Stroke Index in cardiac-surgery patients, emphasize the necessity of assessing preoperative cognitive function, anxiety, and depression among patients scheduled for cardiac surgery. They suggest that psychological assessments should be tailored according to patients’ age and education level . In our study, we observed substantial differences in EuroScore outcomes, with patients who had experienced preoperative stroke exhibiting higher scores and experiencing increased complication rates. Chang et al., assessing frailty through slow gait speed, demonstrated an over two-times-greater risk of in-hospital mortality and significantly elevated risk of complications following cardiac surgery (acute kidney injury, prolonged intubation, sternal-wound infection, prolonged ICU stay) compared to individuals with normal gait speed. They suggest that frailty assessment should be a routine part of preoperative evaluation in cardiac surgery .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
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sec[3]/p[2]
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4. Discussion
| 4.078125 |
biomedical
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Study
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Our study’s results indicate that prior cerebral stroke significantly influences overall operative outcomes and should be factored into patient qualification for surgery and risk−benefit assessment of such interventions. We identified an increased risk of postoperative renal failure (OR = 1.391) among patients with a history of preoperative stroke. Similarly, O’Neil et al. list previous stroke as one of the risk factors for acute kidney injury , a finding supported by Shurle et al. .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
PMC11277661_p22
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sec[3]/p[3]
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4. Discussion
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In our patient cohort with a history of preoperative stroke, individuals required prolonged mechanical ventilation and were more frequently reintubated due to respiratory failure in the early postoperative period. This led to a higher incidence of pneumonia (OR = 1.482) and respiratory failure (OR = 1.497). Our results support the findings of Knapik et al., who analyzed the impact of preoperative risk factors on risk of prolonged ventilation and found that patients with a history of preoperative stroke or TIA had a higher risk of prolonged ventilation (>48 h) . Similar results were presented by Fernandez-Zamora et al., who identified significant associations between prolonged ventilation (>24 h) and a history of stroke . Thanavaro et al. described predictive factors for postoperative respiratory failure, aiding in identifying patients who should be extubated as soon as possible to reduce the risk of reintubation . Szylińska et al. observed that risk factors for ischemic stroke, such as atrial fibrillation, circulatory failure, and renal impairment, are also risk factors for chronic obstructive pulmonary disease . Given these observations and the characteristics of the patient groups included in our study, it is reasonable to assume that the multimorbidity of these patients also increases the risk of respiratory complications, directly affecting the survival times of these patients.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p23
|
PMC11277661
|
sec[3]/p[4]
|
4. Discussion
| 4.101563 |
biomedical
|
Study
|
[
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[
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In our patient group with a history of preoperative stroke undergoing isolated CABG surgery, there was a high risk of TIA incidence (OR = 4.127). Patients undergoing complex CABG surgery with valve repair exhibited a high risk of respiratory failure. Individuals undergoing valve surgery had an eight-times-higher risk of RIND occurrence (OR = 8.172). Patients undergoing aortic aneurysm repair surgery had a high risk of extensive cerebral stroke (OR = 4.387).
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p24
|
PMC11277661
|
sec[3]/p[5]
|
4. Discussion
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biomedical
|
Study
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The application of appropriate surgical techniques significantly influences the occurrence of complications. Letsou et al. reported a low incidence of strokes in off-pump, pump-assisted, and combined off-pump/pump-assisted coronary artery bypass grafting procedures. Perioperative mortality rates were comparable across the three techniques. The authors concluded that aortic clamping may be crucial in reducing the frequency of CABG-related strokes . Svensson et al. describe pump time as the primary predictive factor for adverse events post-ascending or aortic arch operations; aortic-wall debris increases the risk of postoperative stroke .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p25
|
PMC11277661
|
sec[3]/p[6]
|
4. Discussion
| 4.09375 |
biomedical
|
Study
|
[
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Our study demonstrated an association between preoperative stroke and 30-day (OR = 1.528), 90-day (OR = 1.658), and one-year (OR = 1.706) mortality rates. The survival curve also significantly differed among patients who had experienced preoperative stroke versus those without a prior stroke history. Patients who had experienced a previous stroke exhibited significantly shorter 30-day, 90-day, and one-year survival times. Conversely, Bottle et al. observed increased mortality in patients with a history of preoperative stroke undergoing CABG .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
PMC11277661_p26
|
PMC11277661
|
sec[3]/p[7]
|
4. Discussion
| 3.972656 |
biomedical
|
Study
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[
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Regarding the higher incidence of postoperative renal failure among patients with a history of preoperative cerebral stroke, this group had significantly higher initial creatinine concentrations. Multivariate regression analysis, which included incidence of chronic kidney disease, was used to assess the connection between preoperative cerebral stroke and postoperative complications.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
PMC11277661_p27
|
PMC11277661
|
sec[3]/p[8]
|
4. Discussion
| 4.09375 |
biomedical
|
Study
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This study also revealed a statistically significant association between preoperative ischemic stroke and the occurrence of postoperative delirium. Among various neurological disorders, ischemic stroke is the most significant risk factor for delirium. Delirium poses a significant clinical challenge, especially for patients undergoing cardiac surgeries. Factors directly influencing delirium onset include systemic inflammation, pathological responses to stress, changes in synaptic activity, temperature fluctuations, hemodynamic disturbances including ischemia and reperfusion, older patient age, and the presence of other diseases that are common in cardiac patients. Therefore, obtaining an appropriate preoperative history allows the identification of patients at the highest risk of delirium, and this information can then be conveyed to the surgical and postoperative teams to aid in the targeted monitoring and management of patients affected by this condition .
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
PMC11277661_p28
|
PMC11277661
|
sec[4]/p[0]
|
5. Limitations
| 4.058594 |
biomedical
|
Study
|
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In addition to the limitations associated with retrospective studies, the main constraint of this work is the lack of multicenter research. Another limitation is the lack of data regarding preoperative functioning in the daily lives of patients. Routine data collection does not include information regarding the date of stroke occurrence and the outcome in terms of the NIHHS scale (National Institutes of Health Stroke Scale) and mRS (modified Rankin Scale) for patients with a history of preoperative stroke. The development of minimally invasive surgery and the qualification of patients for multidisciplinary Heart Teams have direct impacts on surgical results. The results presented in the study were also significantly influenced by the qualifications of the patients assessed by the Heart Team. Changes in pre- and postoperative fluid management and shorter times of mechanical ventilation are attributable to the cooperation of the cardiac surgeon, cardiovascular anesthesiologist, and cardiologist.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
PMC11277661_p29
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PMC11277661
|
sec[5]/p[0]
|
6. Conclusions
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biomedical
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Study
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Patients with a history of preoperative stroke more frequently experienced renal failure and respiratory-system complications such as pneumonia and respiratory failure. The survival time of patients with a history of preoperative stroke was shorter compared to that of the control group during the analyzed 30-day, 90-day, and one-year observation periods.
|
[
"Jerzy Pacholewicz",
"Paweł Walerowicz",
"Aleksandra Szylińska",
"Jakub Udzik",
"Paweł Wańkowicz",
"Ewelina Kuligowska",
"Ewelina Szuba",
"Mariusz Listewnik"
] |
https://doi.org/10.3390/jcm13144045
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p0
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39063739
|
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|
1. Introduction
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biomedical
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Study
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Aluminum–gallium nitride (Al x Ga 1−x N, where 0 < x < 1) combines the properties of gallium nitride (GaN) and aluminum nitride (AlN), thus creating a useful alloy for modern electronics and optoelectronics. Its application depends on the aluminum content. In optoelectronics, this alloy is crucial for the fabrication of quantum wells present in UV light devices like LEDs or lasers which find applications in surface disinfection, water purification, disease detection, material hardening, and counterfeit money detection . It is said that a relaxed, free-standing Al x Ga 1−x N substrate could enable the fabrication of continuous-wave (CW) operation of UV lasers and better performing UV light emitting diodes capable of operation at higher output powers through the combination of self-heating suppression and the reduction in series resistance . As for the field of electronics, Al x Ga 1−x N is used in high-voltage transistor designs which are important for more demanding, high-power applications . It also plays a key role in improving the reliability of some semiconductor device designs by reducing strain in their epitaxial structures .
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
39063739_p1
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39063739
|
sec[0]/p[1]
|
1. Introduction
| 4.003906 |
biomedical
|
Study
|
[
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[
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Regardless of the specific application, the use of the Al x Ga 1−x N is limited to epitaxy carried out at the device structure building stage . The semiconductor device designs based on the native Al x Ga 1−x N substrate remain unexplored which originates from the fact that wafers with the desired Al composition are not available. This situation is due to difficulties in crystallizing bulk Al x Ga 1−x N alloy which are fundamentally related to the thermodynamic stability of the two constituent nitrides: AlN and GaN. Aluminum nitride is thermodynamically stable at a high temperature at a nitrogen (N 2 ) pressure of 1 atm. For GaN, thermodynamic stability is lost at 800 °C in the same pressure conditions. At higher temperatures, the equilibrium partial pressure of N 2 becomes higher for GaN. Therefore, the growth of GaN at high temperatures (>800 °C) requires a high N 2 pressure or a high nitrogen activity .
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39063739_p2
|
39063739
|
sec[0]/p[2]
|
1. Introduction
| 4.375 |
biomedical
|
Study
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[
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Nowadays, bulk GaN is predominantly crystallized on a large scale with the use of the halide vapor phase epitaxy (HVPE) method . Meanwhile, AlN crystals are primarily obtained using the physical vapor transport (PVT) method. It should be noted that the crystallization of AlN by HVPE still exists only within the realm of laboratory research . Applying the HVPE method for the crystallization of A x lGa 1−x N appears to be challenging. Differences in the thermodynamic properties of both nitrides dictate the differences in conditions for their stable growth. Gallium nitride is crystallized using the HVPE method at a relatively low temperature and in the excess of ammonia (NH 3 ) to protect against its decomposition. Stable growth of HVPE-AlN occurs at a much higher temperature , which necessitates greater mobility of Al atoms on the seed surface and at significantly lower NH 3 flows limiting the gas-phase reaction of the Al precursor with NH 3 . Combining these two systems for the simultaneous crystallization of AlN and GaN results in a situation where GaN loses its thermodynamic stability at high temperatures favorable for AlN crystallization. In these conditions, the desorption of Ga atoms from the seed surface begins to dominate over the adsorption of the Ga precursor. On the other hand, at low temperatures favorable for stable GaN crystallization, one can expect the dominance of Al precursor adsorption processes on the seed surface or even the reaction of the Al precursor with NH 3 in the gas phase. The crystallization process of A x lGa 1−x N is feasible from a thermodynamic perspective. First, thermodynamic analysis of crystallization using AlCl 3 , GaCl and NH 3 as precursors was described by Koukitu et al. . The presented calculations showed that a controllable growth of Al x Ga 1−x N was possible using a low partial pressure of hydrogen (up to 10% of H 2 diluted in the carrier gas, i.e., N 2 ). Experimental confirmation of HVPE growth of A x lGa 1−x N on sapphire seeds using an AlCl 3 –GaCl–NH 3 system was also reported by Koukitu et al. . Results confirmed that the alloy composition could be controlled in all ranges from GaN to AlN, only when a low partial pressure of H 2 carrier gas was used. A typical growth rate was noted to be approximately 30 µm/h at 1100 °C. The morphology of the crystallized layers was not analyzed.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p3
|
39063739
|
sec[0]/p[3]
|
1. Introduction
| 4.28125 |
biomedical
|
Study
|
[
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[
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A supplement to the calculations described by Koukitu et al. with a broader analysis of the influence of individual factors such as: temperature, the type of the carrier gas, the input partial pressures of NH 3 , and the Al and Ga precursors are discussed by Washiyama et al. . In the referenced work, the supersaturation of Ga and Al during Al x Ga 1−x N growth for given growth conditions was estimated. The calculations revealed that the Ga phase was close to the chemical equilibrium (supersaturation close to zero), while the Al supersaturation ratio was as high as 10 10 . Such a disparity in the supersaturation of reaction species can play a significant role in the stability of the growth of the ternary alloy. The calculations also showed that with low NH 3 flow rates and two different diluent gases (H 2 and N 2 ), Al x Ga 1−x N growth is in the thermodynamically limited growth regime at temperatures above 1040 °C. This implies that maintaining a constant ratio of Al and Ga precursors in the gas phase resulted in an observable increase in the Al content of the crystallized layers as the temperature rose. Several experimental groups sought to define a framework for process parameters that would allow the stable crystallization of Al x Ga 1−x N with up to 30 at.% of Al content . Most commonly, the growth temperature was set at 1100 °C so as to increase the mobility of Al atoms on the surface, therefore lowering the supersaturation for GaN crystallization. Layers with a thickness range of 1 to 20 µm were obtained. The use of a lower growth temperature was presented by Fujikura et al. . In that work, the authors presented results which coincide with the thermodynamic calculations regarding the effect of the carrier gas on the relationship between the ratio of gaseous Al and Ga precursors and the final Al content of the crystallized layers. The authors used a growth temperature of 1050 °C for the crystallization Al x Ga 1−x N.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p4
|
39063739
|
sec[0]/p[4]
|
1. Introduction
| 4.148438 |
biomedical
|
Study
|
[
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[
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This article provides an experimental supplement to thermodynamic calculations presented by Koukitu et al. and Washiyama et al. for of HVPE-Al x Ga 1−x N crystallization . The study focuses on presenting the impact of two growth parameters, NH 3 flow rate and the reactants’ total pressure in the reactor, on the morphology of the Al x Ga 1−x N growth. Additionally, the influence of these parameters on growth rates and Al content will also be commented on. The most optimal parameters for the growth of Al x Ga 1−x N will be discussed along with a variety of problems encountered during research. The purpose of this work is to establish a framework of process parameters in which the post-growth morphology of Al x Ga 1−x N layers is smooth and free of defects or other potential problems, while also retaining growth rate higher than Al x Ga 1−x N grown by Metalorganic Vapor Phase Epitaxy (i.e., >1 µm/h). The state of morphology reflects the quality of crystal growth; therefore, problem-free morphology is the first step towards obtaining high-quality, free-standing Al x Ga 1−x N crystals in the long-term.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39063739_p5
|
39063739
|
sec[1]/p[0]
|
2. Experimental Details
| 4.097656 |
biomedical
|
Study
|
[
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[
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For this work a quartz horizontal HVPE reactor (built in-house) with inserted quartz doping tubes was used . The reactor is divided into three zones with varying temperatures. Solid cylindrical rods (6N purity, 10 cm length, 6 mm diameter) were used as the source of Al in the system. The Al rods were placed in the 1st Zone (temperature range 450–500 °C), where AlCl 3 was synthetized according to the equation (Equation (1)). Liquid Ga was placed in the 2nd Zone, where GaCl was synthetized at 850 °C according to the equation (Equation (2)). Two key reactions occur in the 3rd Zone at 1050 °C, which ultimately result in the crystallization of Al x Ga 1−x N according to the equation (Equations (3) and (4)) . 2Al(s) + 3Cl 2 (g) → 2AlCl 3 (g) (1) 2Ga(l) + Cl 2 (g) → 2GaCl(g) (2) GaCl(g) + NH 3 (g) → GaN(s) + H 2 (g) + HCl(g) (3) 2AlCl 3 (g) + 2NH 3 (g) → 2AlN(s) + 3HCl(g) (4)
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p6
|
39063739
|
sec[1]/p[1]
|
2. Experimental Details
| 4.125 |
biomedical
|
Study
|
[
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[
0.99951171875,
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The research was conducted in two series (A and B), each consisting of five growth experiments. The parameters defining these experiments are two variables commonly occurring in the scientific literature related to crystallization of Al x Ga 1−x N, the R parameter and the V/III ratio. In the physical sense, the R parameter represents how much aluminum compared to gallium is introduced into the system. It can be used to compare the concentration of aluminum in gas and solid phases. The R parameter and V/III ratios are defined by Equations (5) and (6), respectively. (5) R = p 0 A l C l 3 p 0 G a C l + p 0 A l C l 3 (6) V / I I I = p 0 N H 3 p 0 G a C l + p 0 A l C l 3 where the individual components were defined as: p 0 G a C l —the input partial pressures of Ga precursor, p 0 A l C l 3 —the input partial pressures of Al precursor, and p 0 N H 3 —the input partial pressures of NH 3 .
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p7
|
39063739
|
sec[1]/p[2]
|
2. Experimental Details
| 4.128906 |
biomedical
|
Study
|
[
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[
0.99951171875,
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The main parameter separating the series of experiments was the V/III ratio (A: V/III = 59, B: V/III = 21). The change in V/III ratio was mainly realized by regulating the NH 3 flow; therefore, the article uses the concepts of decreasing (or increasing) V/III and decreasing (or increasing) NH 3 flow interchangeably. In other words, within the context of this article, a decrease in NH 3 flow results in a decrease of the V/III ratio and vice versa. Three experiments in each series were conducted at different total pressures within the reactor (800, 400 and 200 mbar). In experiments A4, A5, B4 and B5, the flow over either the Ga or Al precursors was shut off so as to analyze the crystallization of non-alloyed GaN and AlN in the system at 200 mbar. In addition to the former, non-alloyed GaN growth was tested in the system at 800 mbar (A0, B0) using two different V/III ratios as a reference for the other experiments. In order to maintain a constant V/III ratio, the flow of NH 3 was reduced accordingly. The growth temperature, process time and N 2 , used as a carrier gas for all reagents, remained unchanged between the experiments. The defined growth process parameters are summarized in Table 1 . Processes 1, 2 and 3 consisted of two growth stages. Initially, GaN layer was deposited for 15 min on a template composed of GaN grown by metalorganic vapor phase epitaxy on a sapphire substrate. Then, the precursor flow over metallic Al was turned on, and growth was conducted for 105 min. In the case of experiment 4 and 5 in both series, the total growth time lasted 120 min for GaN or AlN, respectively.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p8
|
39063739
|
sec[1]/p[3]
|
2. Experimental Details
| 4.085938 |
biomedical
|
Study
|
[
0.98974609375,
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[
0.9990234375,
0.0006380081176757812,
0.00018584728240966797,
0.000040650367736816406
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The morphology of the layers obtained from the processes described in Table 1 was characterized using Nikon Eclipse LV100ND Differential Interference Contrast (DIC) optical microscope (OM) with Nomarski contrast and both visible (VIS) and ultraviolet (UV) light. UV light was utilized for estimating the thickness of the deposited layers. The Al content of Al x Ga 1−x N layers was determined using a Zeiss Ultra Plus scanning electron microscope (SEM) equipped with a Bruker Quantax400 Energy Dispersive Spectroscopy (EDS) module.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p9
|
39063739
|
sec[2]/p[0]
|
3. Results
| 2.083984 |
biomedical
|
Study
|
[
0.94921875,
0.0015544891357421875,
0.049407958984375
] |
[
0.7421875,
0.25439453125,
0.002315521240234375,
0.0012159347534179688
] |
Figure 2 contains the top-down photographs of crystals A1, A3, B1, B3 which were grown according to the conditions outlined in Table 1 .
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p10
|
39063739
|
sec[2]/p[1]
|
3. Results
| 3.365234 |
biomedical
|
Study
|
[
0.87646484375,
0.0008988380432128906,
0.1224365234375
] |
[
0.99755859375,
0.00206756591796875,
0.00018703937530517578,
0.000080108642578125
] |
The cracking of the layer was observed for crystals grown in p > 200 mbar and V/III ratio of 21. An example of the cracking for the crystal grown in 800 mbar is shown in Figure 2 c. Moreover, the white powder was observed on the surface of the crystals grown in pressures higher than 200 mbar regardless of the V/III ratio. Figure 2 a,c contains black circles which mark places with the aforementioned powder observable on the surfaces of the crystals. The composition and origin of the white powder will be discussed in the following sections. The morphology of crystals A1, A2, A3, B1, B2 and B3 was characterized by a DIC microscope. The results are presented in Figure 3 . The lowercase figure classifications correspond to the uppercase letters corresponding to a crystal .
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p11
|
39063739
|
sec[2]/p[2]
|
3. Results
| 3.671875 |
biomedical
|
Study
|
[
0.8486328125,
0.0008649826049804688,
0.1505126953125
] |
[
0.998046875,
0.0017538070678710938,
0.0002770423889160156,
0.0000743865966796875
] |
Figure 3 a–c present the evolution of morphology of grown layers in different pressures and V/III ratio equal to 59. In these figures, continuous layers with multiple hillocks are observable. They are decorated by numerous black dots. Two types of black dots can be distinguished . The dots enclosed in the rectangles a and b are presented again in Figure 4 a and Figure 4 b, respectively, where they are further investigated using a higher magnification by SEM. Black dots are the largest and most numerous for the layer grown in 800 mbar. The black dots become progressively smaller with the reduction in total system pressure . Both, size and quantity of these black dots are the smallest for the growth process conducted in the lowest pressure. Separately from the black dots, cracks are also present in the layer . Figure 3 c contains a region of interest which is further investigated with SEM in Figure 4 , just like the rectangles a and b previously presented in Figure 3 a.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p12
|
39063739
|
sec[2]/p[3]
|
3. Results
| 3.646484 |
biomedical
|
Study
|
[
0.81298828125,
0.000728607177734375,
0.1861572265625
] |
[
0.99609375,
0.003299713134765625,
0.00029659271240234375,
0.00007486343383789062
] |
Figure 3 d–f show the evolution of morphology in the A x lGa 1−x N layers grown using V/III = 21 and pressures of 800, 400 and 200 mbar, respectively. The growth morphology shown in Figure 3 d depicts a uniform, granular surface. Uniformity is retained with the reduction in pressure, although the morphology ceases to be granular . The layer in Figure 3 e is smooth, but the presence of cracks is noted. Small hillocks are present along the cracks. Lastly, Figure 3 f contains a smooth, continuous layer with distinct macro-steps. Cracks are also present in the form of dark, intersecting lines. Figure 4 contains SEM images of the features marked in rectangles a, b and c described in the previous paragraph .
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p13
|
39063739
|
sec[2]/p[4]
|
3. Results
| 3.248047 |
biomedical
|
Study
|
[
0.81640625,
0.0009984970092773438,
0.182373046875
] |
[
0.99169921875,
0.00791168212890625,
0.000362396240234375,
0.00012290477752685547
] |
Figure 4 a contains a closer view of the object enclosed in rectangle a in Figure 3 a. A group of small, hexagonal crystallites are present. They are mutually connected, forming a large object with an irregular shape. In Figure 4 b , numerous crystallites with a regular hexagonal shape are observable. They appear to be embedded into the continuous layer. Figure 4 c, which depicts rectangle c from Figure 3 c, shows small triangular crystallites that are also partially inside in the crystal layer. These crystallites have well-defined facets and are crystallographically oriented . SEM imaging was used for the detailed analysis of morphology in the layers in which the crystallites were absent. Figure 5 presents SEM images of these samples.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p14
|
39063739
|
sec[2]/p[5]
|
3. Results
| 3.785156 |
biomedical
|
Study
|
[
0.92236328125,
0.0006551742553710938,
0.0767822265625
] |
[
0.99658203125,
0.0029144287109375,
0.0002593994140625,
0.00007146596908569336
] |
Figure 5 a shows a magnification of the granular morphology previously demonstrated in Figure 3 d. Numerous growth hills are present on the surface of the sample. The layer grown in the reduced pressure of 400 mbar exhibits similar growth hillocks, although with a smaller population. The layer grown in 200 mbar is almost completely featureless. Its surface contained neither growth hills like in Figure 5 a or Figure 5 b, nor crystallites which are present in the samples grown in V/III = 59 . Figure 5 c depicts one of the very few regions on the sample where small imperfections are observable. The two imperfections in Figure 5 c are likely to be crystallites.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p15
|
39063739
|
sec[2]/p[6]
|
3. Results
| 2.476563 |
biomedical
|
Study
|
[
0.60107421875,
0.0010690689086914062,
0.39794921875
] |
[
0.98388671875,
0.015594482421875,
0.00035071372985839844,
0.00019788742065429688
] |
Four supplementary experiments were performed in order to better understand how the growth of AlN and GaN proceeds in the system. In these experiments, non-alloyed AlN or GaN crystals were grown in two different pressures 800 mbar and 200 mbar (see: A4, A5, B4, B5 in Table 1 ). These crystals were later analyzed using DIC, OM and SEM.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999999 |
39063739_p16
|
39063739
|
sec[2]/p[7]
|
3. Results
| 4.164063 |
biomedical
|
Study
|
[
0.9638671875,
0.0007047653198242188,
0.03558349609375
] |
[
0.99951171875,
0.00036597251892089844,
0.0002415180206298828,
0.0000388026237487793
] |
Figure 6 a,b show the morphology of the GaN layer from processes conducted using high and low V/III ratios, respectively, at a pressure of 200 mbar, without Cl 2 flow over the Al rod. Well-defined growth hillocks are visible in Figure 6 a (V/III = 59). A significantly different morphology with well-developed macro-steps can be observed for the layer grown in V/III = 21 . Figure 6 c,d show the morphology of the AlN layer from processes conducted using high and low V/III ratios, respectively, at a pressure of 200 mbar, without Cl 2 flow over the liquid Ga. Figure 6 c depicts a granular morphology, which is presented again in higher magnification as seen on SEM . The morphology consists of a non-continuous, porous layer covered entirely with small hexagonal flakes. The flakes cover both the dark areas (depressions) and the bright areas (elevations). In contrast, the magnification of the morphology presented in Figure 6 f reveals significantly larger and irregular flakes evenly distributed across the entire surface of the layer. Energy dispersive spectroscopy measurements confirmed that the layers crystallized in processes A4 and A5 are composed of pure GaN and the flakes which crystallized in experiments B4 and B5 constitute pure AlN. A summary of the results concerning the growth rates and Al content is presented in Table 2 . The Al content refers to the atomic percentage within the continuous layer, not the individual crystallites.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p17
|
39063739
|
sec[2]/p[8]
|
3. Results
| 4.101563 |
biomedical
|
Study
|
[
0.98486328125,
0.0005168914794921875,
0.01441192626953125
] |
[
0.99951171875,
0.0003058910369873047,
0.00025963783264160156,
0.000032782554626464844
] |
Comparing the experiments in series A, a decrease in the growth rate was observed both after introducing AlCl 3 into the system (A0 vs. A1) and after the reduction in the total reactor pressure (A0 vs. A4). In both cases, the decrease was 25% and 29%, respectively. The same comparison for the experiments in series B shows a similar decrease in the growth rate of 31% and 27%, respectively. A comparison of the growth rates of GaN layers from the A and B series (A0 vs. A3, B0 vs. B3) obtained from processes at high total pressure (800 mbar) against Al x Ga 1−x N obtained from processes at low total pressure (200 mbar) indicated a comparable decrease in the average growth rate of 63% and 65%, respectively.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p18
|
39063739
|
sec[3]/p[0]
|
4. Discussion
| 4.230469 |
biomedical
|
Study
|
[
0.99658203125,
0.0005960464477539062,
0.002655029296875
] |
[
0.99951171875,
0.00014793872833251953,
0.00035452842712402344,
0.00004965066909790039
] |
The results describe two series of experiments which demonstrate the impact of the total pressure in the reactor and the NH 3 flow rate in the growth zone on the morphology and Al content in the crystallized layers. Both parameters appear to have a significant influence on the supersaturation of Ga and Al in the system, impacting both the crystallization of GaN and AlN. Through the comparison of experiments A1, A2 and A3, an increase in the Al content in the crystallized layer is observed as the total pressure is reduced. Based on thermodynamic calculations, it can be stated that in the standard conditions for GaN crystallization , the supersaturation for AlN is extremely high as it was predicted by Washiyama et al. . Furthermore, the diffusion of Al atoms on the seed surface is extremely limited. These theoretical considerations are reflected in this work, particularly when considering the case of the layers grown in the V/III ratio of 59. The analysis of morphology presented in Figure 3 a (800 mbar), Figure 3 b (400 mbar) and Figure 3 c (200 mbar) suggests the formation of solid particles in the gas phase or direct nucleation of crystallites on the epitaxial layer. Similar observations were reported by Fujikura et al. . The reason for the formation of these precipitates in the gas phase is still unknown. On the one hand, there is no thermodynamic basis for determining the presence of an AlN molecule in the gas phase. On the other hand, the process is carried out in the presence of NH 3 . This implies the possibility of the formation of stable solid complexes as a result of the reaction of AlCl 3 and NH 3 . These complexes can be a source of nucleation in the gas phase. Then, formed particles can be the site of further nucleation and in the course of the process can lead to the development of small crystals, resulting in numerous Al x Ga 1−x N crystallites visible on the surface in SEM or even in the macroscopic scale . Although, it should be noted that the reduction in pressure does reduce the quantity and size of the precipitates—suggesting that reducing pressure also reduces the formation of particles in the gas phase. Nevertheless, they were observed on all samples grown using V/III = 59. The crystallites likely fall on the surface during their formation, become embedded into the growing continuous layer, and then become new sources for further nucleation. This supposition is validated by the incoherent crystals which are partially submerged in the continuous layer shown in Figure 4 b.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p19
|
39063739
|
sec[3]/p[1]
|
4. Discussion
| 4.21875 |
biomedical
|
Study
|
[
0.9921875,
0.0005488395690917969,
0.00750732421875
] |
[
0.99951171875,
0.0002532005310058594,
0.00017023086547851562,
0.00004315376281738281
] |
A reduction in the number of particles visible on the layer after growth and a decrease in their size is accompanied by a measurable increase in Al content in the continuous layer. The explanation for this phenomenon might be based on the fact that microparticles that form in certain growth conditions are more likely to consume the available AlCl 3 in the system for their own expansion and consequently diminish the Al content in the growing continuous layer. With the lower pressure, and thus less formation of particles, the Al content in the layer from process A2 is higher than A1. A further increase in the Al content was observed in experiment A3, where the supersaturation for Al was further lowered to the point where formation of solid particles was effectively diminished. In experiment A3, the crystallites exhibit different features than the crystallites observed in processes A1 and A2. For one, they appear to have well-defined crystallographic orientation . Presumably, the combination of low pressure ( p = 200 mbar) and high V/III = 59 results in the AlN nucleation processes on the surface of the seed. One of the consequences of surface nucleation of AlN is the rapid growth nuclei as the growth process progresses.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p20
|
39063739
|
sec[3]/p[2]
|
4. Discussion
| 4.160156 |
biomedical
|
Study
|
[
0.9951171875,
0.0005526542663574219,
0.00449371337890625
] |
[
0.99951171875,
0.0001806020736694336,
0.0001513957977294922,
0.00003987550735473633
] |
A radical change in the growth morphology was observed when the V/III ratio was reduced, while the pressure was kept constant (experiments A1 and B1). In process B1, formation in the gas-phase was not observed. Instead, the growth proceeded on numerous hillocks of small size. As the pressure was reduced in the experiments with a lower V/III ratio = 21, the population of hillocks decreased while the Al content in the layer increased (experiment B2). This observation suggests that a significant portion of the AlCl 3 precursor was consumed by the nucleation of AlN on the surface of the crystal grown as part of experiment B1. The formed nuclei could have become sources for the formation of growth hillocks, thus increasing their quantity. Further pressure reduction to 200 mbar (experiment B3) resulted in an Al x Ga 1−x N layer, where not only were the crystallites absent but also no hillock formation was observed. The smooth surface obtained in the process B3 (V/III = 21 and p = 200 mbar) also exhibited the highest Al content and observable macro-steps.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39063739_p21
|
39063739
|
sec[3]/p[3]
|
4. Discussion
| 4.175781 |
biomedical
|
Study
|
[
0.9521484375,
0.0005550384521484375,
0.047454833984375
] |
[
0.99853515625,
0.0011816024780273438,
0.00021255016326904297,
0.000037610530853271484
] |
High Al supersaturation observable for AlN crystallization at a relatively low temperature is associated with the strong bonding of Al atoms to the surface and their low mobility on the surface. Moreover, the supersaturation for AlN under standard GaN growth conditions (process A1) is significantly higher than that for GaN. As proven by the analysis of growth morphology (process A1), a reduction in supersaturation is necessary. It is crucial to note that changing parameters affecting the Al supersaturation for the growth of AlN also impacts the Ga supersaturation for the growth of GaN. Therefore, determining the parameters in which the supersaturation for AlN is sufficiently low so that neither the formation and expansion of particles in the gas phase nor surface nucleation can occur while maintaining stable conditions for GaN crystallization is critical for the successful crystallization of Al x Ga 1−x N with a smooth morphology.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999999 |
39063739_p22
|
39063739
|
sec[3]/p[4]
|
4. Discussion
| 4.222656 |
biomedical
|
Study
|
[
0.99755859375,
0.0005316734313964844,
0.0019407272338867188
] |
[
0.99951171875,
0.00020694732666015625,
0.00024390220642089844,
0.000052928924560546875
] |
Reducing the pressure from 800 to 400 mbar, while maintaining a high V/III ratio, does not cause significant changes in the growth rate of the crystallized layers ( Table 2 ). In these conditions, the process is still conducted in an excess of NH 3 , and considering the thermodynamics involved in the growth, it is controlled by the transport of GaCl and AlCl 3 to the surface of the growing layer. An increase in the Al content in the obtained layer was also observed. Therefore, it can be assumed that this change mainly results in the reduction in Al supersaturation, thus causing a reduction in particle formation in the gas phase. Further reduction in the pressure to 200 mbar results in the halving of the growth rate (from 18 to 9 µm/h), while also increasing the Al content in the obtained layer. This effect may be associated either with the reduction in the precursor’s contact time with the surface (due to higher gas velocities) or with the lowering of the equilibrium partial pressure of Ga or a combination of both of these effects. The shortening of contact time is associated with an order of magnitude increase in flow velocity with reactor pressure reduction from 800 to 200 mbar. The latter aspect is related to an increase in the desorption processes of Ga atoms from the surface. In these conditions, the rate at which Al atoms desorb from the surface also rises, although not as significantly as the desorption rate for Ga atoms. Consequently, it can be inferred that after reducing the pressure to 200 mbar, the surface nucleation of GaN slows down relative to the crystallization of AlN. For the latter, a transition from the nucleation regime to the crystal growth is observed.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p23
|
39063739
|
sec[3]/p[5]
|
4. Discussion
| 4.078125 |
biomedical
|
Study
|
[
0.98974609375,
0.0004944801330566406,
0.0095367431640625
] |
[
0.99951171875,
0.00023043155670166016,
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0.00003629922866821289
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The experimental results showed that reducing the NH 3 flow (V/III: 59 → 21) did not significantly affect the growth rate neither in experiments focused on the growth of non-alloyed GaN (A0, A4 vs. B0, B4) nor Al x Ga 1−x N (experiments A1, A2, A3 vs. B1, B2, B3) per the results shown in Table 2 . Nonetheless, as the V/III ratio decreases the formation of particles in the gas phase and their expansion on the surface are suppressed. With the further reduction in pressure and lower V/III, the surface nucleation of AlN is also eliminated. It could be concluded that the reduction in the V/III ratio, or the NH 3 flow in practical terms, shifts the growth conditions towards equilibrium conditions for A x lGa 1−x N synthesis, albeit remaining distant from them.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39063739_p24
|
39063739
|
sec[3]/p[6]
|
4. Discussion
| 4.25 |
biomedical
|
Study
|
[
0.9970703125,
0.0005273818969726562,
0.002376556396484375
] |
[
0.99951171875,
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0.00004500150680541992
] |
It should be noted that lowering the pressure to 200 mbar is crucial for the reduction in Al supersaturation in the system. However, it should also be noted that reducing total pressure in the reactor without adjusting gas flows can limit the diffusion of reactants to the surface, ultimately halting growth or even leading to the decomposition of the substrate. Therefore, excessively lowering the pressure is not an advisable approach either. Consequently, reducing the input partial pressure of NH 3 , considering its excess relative to stoichiometric ratios, proved to be a prudent approach. A radical reduction in NH 3 flow brings the process conditions closer to equilibrium conditions. This supposition is validated by the results from processes A4 and A5, as well as B4 and B5. The exclusion of AlCl 3 from the system results in the crystallization of a continuous GaN layer. It is important that in both cases (V/III = 59 and 21) the growth rates of the GaN layer doubled, when compared to the processes that also included the flow of AlCl 3 (A3 vs. A4 and B3 vs. B4). Based on these observations, it can be assumed that the presence of AlCl 3 (Al atoms on the seed surface) acts as a GaN growth inhibitor. In fact, this is further reflected in Table 2 , where growth rates of experiments in which AlCl 3 was absent (A0, B0, A4, B4) are higher than in their corresponding sister experiments (same V/III and pressure) where AlCl 3 was present regardless of incorporated Al concentration. On the other hand, removing the GaCl flow from the system results in the co-occurring decomposition of GaN and the crystallization of small hexagonal flakes (experiment A5). In process B5, the decomposition of GaN is also observed, but the crystallization of AlN in the form of flakes of a larger size than those observed in A5 is seen. This indicates that merely reducing the input partial pressure of NH 3 causes a shift in Al supersaturation, which shifts preferential growth from island based (Volmer–Weber) mode to layer-by-layer based (Frank–van der Merwe) mode.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39063739_p25
|
39063739
|
sec[3]/p[7]
|
4. Discussion
| 4.222656 |
biomedical
|
Study
|
[
0.98779296875,
0.000682830810546875,
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] |
[
0.99951171875,
0.00023353099822998047,
0.0003459453582763672,
0.00004774332046508789
] |
A framework of process parameters with which a crystallite-free morphology with no hillocks and approximately 4 at.% aluminum content was obtained on a 18 μm thick Al x Ga 1−x N layer. These results constitute an experimental foundation based on which further research aimed at obtaining thicker Al x Ga 1−x N layers, and eventually free-standing Al x Ga 1−x N, is planned. In this work, the main focus was on the detailed analysis of sample morphology using different total pressure of reactants and V/III ratios as variables. The presented results offer a new insight into Al x Ga 1−x N growth morphology, which is rarely given attention in the scientific literature, using variables and growth conditions which are uncommon (e.g., total pressure of reactants as a variable, no admixture of H 2 in N 2 atmosphere). This research is complementary to calculation-based works and experimental works published in the scientific research, but not directly comparable to them. Nonetheless, some parallels with the existing published literature can be drawn. For example, the problems with parasitic nucleation are mirrored in ref. . The authors do not elaborate on the composition of crystallites but note that the introduction of an enhanced etching effect by varying NH 3 and H 2 flows in the system has effectively suppressed the formation of crystallites. In this work, the suppression of crystallites was realized by lowering the total pressure of reactants and also the NH 3 flow. Both solutions are fundamentally based on balancing the Al and Ga supersaturations so as to change the morphology of the growing crystals to prevent the formation of hillocks and crystallites on the surface. Our experimental results do not fully reflect the calculations-based works in refs. , which can be explained by, among other things, different growth conditions. These works served as an important reference for the choice of parameters which were investigated in this research. The presented effect of total pressure in the reactor and V/III ratio on supersaturation is in full agreement with the findings of authors in ref. . The supersaturation was observed to decrease as either the pressure of reactants (p Tot in ref. ) or the V/III ratio is reduced. References suggest that the observed solid phase composition of aluminum should be higher than observed, resembling the value of the R parameter. The discrepancy can be explained by several factors, for example different reactor geometries and higher temperature in the growth zone . However, the goal of this work was not to find process parameters in which aluminum content is the highest, but where the post-growth morphology is promising for further research aimed at crystallizing a free-standing Al x Ga 1−x N crystal.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39063739_p26
|
39063739
|
sec[4]/p[0]
|
5. Summary
| 4.246094 |
biomedical
|
Study
|
[
0.99609375,
0.0007739067077636719,
0.0031757354736328125
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[
0.99951171875,
0.0001615285873413086,
0.0002906322479248047,
0.00006127357482910156
] |
This study was conducted to understand how total pressure and NH 3 flow rate (expressed as changes in V/III ratio) affect the growth characteristics and Al content of crystallized Al x Ga 1−x N layers. The results revealed that both the total pressure and NH 3 flow rate have significant effects on the supersaturation levels governing AlN and GaN crystallization, which translated into profound changes in morphology and Al incorporation. It was shown that lowering the total pressure increased the Al content of the crystallized layers, due to diminished formation of particles in the gas phase and their expansion. This was proven by changes occurring in the morphology of the layers, with the reduced pressure that led to fewer and smaller incoherent crystallites embedded in the continuous layers and an increase in its Al content. A reduction in the V/III ratio produced a radical change in the growth morphology for the samples grown in p = 800 mbar. The morphology transformed from being covered by crystallites formed in the process of gas-phase nucleation growth, to a hillock-dominated surface for the growth in 400 mbar. A completely smooth layer was obtained by a further reduction in the total pressure to 200 mbar. This suggests that at lower pressures AlCl 3 is mainly consumed in the surface crystallization processes of A x lGa 1−x N, which led to smoother layers with a higher Al content. The experiments also highlighted the delicate balance between maintaining conditions favorable for GaN growth while reducing the Al supersaturation so as to prevent the formation of particles in the gas phase and promote layer by layer growth. Lowered pressure and adjusted NH 3 flow were the key components to achieve this balance. The reduction in pressure to 200 mbar proved to be particularly effective for the successful crystallization of AlN, without a significant negative impact on GaN growth. In the end, Al x Ga 1−x N layers featuring macro-steps on the surface, approximately 4% Al content (x = 0.04) and a thickness of 18 μm, were successfully crystallized as part of this work.
|
[
"Arianna Jaroszynska",
"Michal Dabrowski",
"Petro Sadovy",
"Michal Bockowski",
"Robert Czernecki",
"Tomasz Sochacki"
] |
https://doi.org/10.3390/ma17143446
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999999 |
39058375_p0
|
39058375
|
sec[0]/p[0]
|
INTRODUCTION
| 2.103516 |
biomedical
|
Other
|
[
0.9853515625,
0.0059051513671875,
0.00862884521484375
] |
[
0.003917694091796875,
0.9912109375,
0.004123687744140625,
0.0009307861328125
] |
Simulation in health has become a training method explored in teaching laboratories and simulation centers, with the aim of developing technical and non-technical skills, bringing benefits to the learning process and contributing to professional training and improvement ( 1 , 2 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p1
|
39058375
|
sec[0]/p[1]
|
INTRODUCTION
| 3.087891 |
biomedical
|
Study
|
[
0.81787109375,
0.0009317398071289062,
0.181396484375
] |
[
0.55810546875,
0.2335205078125,
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0.0007104873657226562
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Realistic simulation has been described as a stressful experience ( 3 ) . Stress is associated with negative cognitive impacts, such as decreased concentration, memory degradation, increased errors and delayed response to stimuli ( 4 ) . However, and up to a specific point, stress may improve concentration on the task, focus on communication and contribute to problem-solving ( 5 ) . Furthermore, circumstances perceived as threatening tend to trigger negative emotions, while evaluations of challenge are correlated with more positive emotional responses ( 6 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999994 |
39058375_p2
|
39058375
|
sec[0]/p[2]
|
INTRODUCTION
| 2.951172 |
biomedical
|
Study
|
[
0.9619140625,
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[
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Furthermore, in a randomized clinical trial that investigated adding emotional stressors in a simulation, participants were able to recall the events of the scenarios that failed, indicating that emotional stress can improve the ability to recall these memories ( 7 ) . For that reason, moderate levels of stress are essential for effectiveness in active student learning ( 8 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p3
|
39058375
|
sec[0]/p[3]
|
INTRODUCTION
| 2.585938 |
biomedical
|
Study
|
[
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0.0596923828125
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[
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However, the causal meaning of the relationship remains undetermined: is high performance associated with a lower experience of stress, or is the constant presence of stress in an individual associated with a lower tendency to make mistakes ( 9 ) . It is also unclear whether additional stressors can have any detrimental effect on performance, since performance limitations can have an immediate effect on the quality of care provided to patients ( 10 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p4
|
39058375
|
sec[0]/p[4]
|
INTRODUCTION
| 3.900391 |
biomedical
|
Review
|
[
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[
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The literature defines stress as a state of divergence between perceived demands, the individual’s reactions and the ability to adapt to stressors ( 3 ) and is closely linked to emotions, involving emotional and physiological responses to a stressor ( 11 ) . Furthermore, stressful conditions trigger the activation of the endocrine, nervous and immune systems, a phenomenon widely recognized as a stress response ( 12 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p5
|
39058375
|
sec[0]/p[5]
|
INTRODUCTION
| 3.771484 |
biomedical
|
Study
|
[
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[
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The human body allows to find biochemical markers of stress. Cortisol is a stress hormone produced in the adrenal cortex, and its concentration in saliva is strongly correlated with its concentration in blood plasma ( 3 ) . Salivary cortisol levels have been used extensively as an objective measure of stress in simulation, making it an ideal assay for research ( 13 ) . By acting as a biological marker, cortisol levels increase in response to stress and the numerous changes in the simulation environment ( 8 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p6
|
39058375
|
sec[0]/p[6]
|
INTRODUCTION
| 2.375 |
biomedical
|
Review
|
[
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[
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Initially, observational studies identified increases in participants’ cortisol levels ( 14 – 17 ) . However, a systematic review showed that the stress experienced in a simulation is still undefined ( 18 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p7
|
39058375
|
sec[0]/p[7]
|
INTRODUCTION
| 3.210938 |
biomedical
|
Review
|
[
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[
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It is therefore important to synthesize the relationship between cortisol and the participant’s performance through a systematic review of intervention studies using group analysis, given that participants may have different physiological responses to different experiences and perceptions during simulations.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
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|
39058375
|
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|
INTRODUCTION
| 3.650391 |
biomedical
|
Study
|
[
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[
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Against this backdrop, the aim of this study was to identify how stress measured by salivary cortisol during education based on clinical simulation or simulation and another teaching method, impacts on performance.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999999 |
39058375_p9
|
39058375
|
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|
Registration and Protocol
| 4.011719 |
biomedical
|
Review
|
[
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[
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This is a systematic review studying the association between simulation and cortisol levels and performance, conducted in accordance with the recommendations of the Cochrane Collaboration ( 19 ) and described in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses - PRISMA ( 20 ) . The protocol was registered in the International Prospective Register of Systematic Reviews under the number CRD42022319886.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p10
|
39058375
|
sec[1]/sec[1]/p[0]
|
Development of the Research Question
| 3.357422 |
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|
Study
|
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The question was guided by the PICO strategy, considering “P” (patient or problem) students or health professionals; “I” (intervention) realistic simulation; “C” (control) was not applied, and “O” (result or outcome) as the association between cortisol and performance. Thus, the guiding question was: What is the association between salivary cortisol levels and the performance of participants in simulation-based education?
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p11
|
39058375
|
sec[1]/sec[2]/p[0]
|
Eligibility Criteria
| 3.980469 |
biomedical
|
Review
|
[
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[
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The systematic review included randomized clinical trials (RCTs) that assessed stress through salivary cortisol (SC) in the following contexts: (a) realistic simulations carried out with (medical., nursing) students; (b) simulations for training resident medical professionals; (c) simulations that included professionals from other health areas; (d) simulations within institutional laboratories – hospital setting; and (e) low, medium and high-fidelity simulation.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p12
|
39058375
|
sec[1]/sec[2]/p[1]
|
Eligibility Criteria
| 2.171875 |
biomedical
|
Study
|
[
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[
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Studies were excluded due to the following criteria: (a) unavailability; (b) conference abstract; (c) virtual simulation; (d) not being an RCT; (e) not being developed in the context of realistic simulation; (f) assessing alpha amylase; (g) not assessing performance; (h) assessing anxiety.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p13
|
39058375
|
sec[1]/sec[3]/p[0]
|
Databases and Search Strategy
| 2.365234 |
biomedical
|
Study
|
[
0.98974609375,
0.0008091926574707031,
0.0092315673828125
] |
[
0.97607421875,
0.0161590576171875,
0.00733184814453125,
0.00037169456481933594
] |
The search was carried out in the following electronic databases: PubMed, LIVIVO, Scopus, EMBASE, Latin American and Caribbean Health Sciences Literature (LILACS), Web of Science (Social Sciences Citation Index). Additional searches of gray literature were carried out on Google Scholar and Proquest. The list of references of the selected studies was analyzed manually to identify potentially relevant ones that could have been missed in the electronic database searches. Duplicate references were removed using Rayyan ® .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p14
|
39058375
|
sec[1]/sec[4]/p[0]
|
Search Strategy
| 2.300781 |
biomedical
|
Study
|
[
0.98974609375,
0.0008444786071777344,
0.00940704345703125
] |
[
0.97705078125,
0.018768310546875,
0.0037364959716796875,
0.0003509521484375
] |
The search terms were adapted for use in the different electronic databases, combined with specific filters for controlled trials when available. Studies were selected in Portuguese, English and Spanish, and without a time cut-off to cover a broad spectrum of national and international publications. All the searches in the electronic databases were carried out on March 20, 2023, and the strategies are shown in Chart 1 .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p15
|
39058375
|
sec[1]/sec[5]/p[0]
|
Selection Process
| 3.904297 |
biomedical
|
Study
|
[
0.99853515625,
0.0002949237823486328,
0.001155853271484375
] |
[
0.998046875,
0.0012598037719726562,
0.0007524490356445312,
0.00004786252975463867
] |
The studies were selected in two phases using the online application Rayyan ® (Qatar Computing Research Institute), a program that speeds up the initial screening of studies through a semi-automated process, which guarantees the reliability of the selection. In the first phase, two researchers independently examined the titles and abstracts of all the studies retrieved from the databases and identified those that met the inclusion criteria. In the second phase, the same researchers independently read the full text of all the selected studies and excluded those that did not meet the inclusion criteria. Any discrepancies at this stage would be resolved by discussion between the researchers and a specialist, who would also independently assess the study in full text.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p16
|
39058375
|
sec[1]/sec[6]/p[0]
|
Data Collection Process
| 2.998047 |
biomedical
|
Study
|
[
0.99462890625,
0.0013875961303710938,
0.00421905517578125
] |
[
0.6376953125,
0.0362548828125,
0.3251953125,
0.0009946823120117188
] |
Two researchers independently extracted the data from the studies included in this systematic review, using a data collection instrument of their own creation. Any disagreements were resolved by discussion and mutual agreement. A third author was involved when necessary to make a final decision.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p17
|
39058375
|
sec[1]/sec[6]/p[1]
|
Data Collection Process
| 3.916016 |
biomedical
|
Review
|
[
0.99609375,
0.0015878677368164062,
0.0024356842041015625
] |
[
0.09295654296875,
0.00202178955078125,
0.90478515625,
0.0004019737243652344
] |
The variables collected included: characteristics of the participants (groups and sample); characteristics of the study (authors, country, year of publication, objective, design, randomization and inclusion and exclusion criteria); intervention (type of simulation, simulator, area of expertise); collection (cortisol measurement); and characteristics of the results (main results and main conclusions). If the necessary data was not complete, contact was made with the authors to obtain any relevant information. Based on this data, the results of this systematic review are presented descriptively in Table 1 .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p18
|
39058375
|
sec[1]/sec[7]/p[0]
|
Risk of Bias
| 4.070313 |
biomedical
|
Study
|
[
0.9990234375,
0.0005679130554199219,
0.0001913309097290039
] |
[
0.994140625,
0.0021343231201171875,
0.003753662109375,
0.0001462697982788086
] |
The critical appraisal tool used was the Collaboration Risk of Bias Tool (RoB 2. tool) ( 21 ) . This is an appraisal tool to assess the risk of bias of the included studies, which makes it possible to evaluate the process of generating sequences, allocation concealment, blinding of participants, personnel and evaluators, incomplete results data and selective reporting of randomized clinical trials. Two researchers independently assessed the quality of each study, and any disagreement was resolved by the third researcher.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p19
|
39058375
|
sec[2]/p[0]
|
RESULTS
| 3.626953 |
biomedical
|
Review
|
[
0.99169921875,
0.0023651123046875,
0.005695343017578125
] |
[
0.047119140625,
0.00555419921875,
0.94677734375,
0.0005979537963867188
] |
The searches carried out in the eight electronic databases used in this systematic review retrieved 8.514 articles. After removing duplicates, 3147 articles were available for screening. From this, 61 studies were selected for full reading, of which 11 met all the eligibility criteria for this review. The process of searching and selecting the studies is detailed in Figure 1 .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p20
|
39058375
|
sec[2]/p[1]
|
RESULTS
| 3.876953 |
biomedical
|
Study
|
[
0.99951171875,
0.0002703666687011719,
0.0003974437713623047
] |
[
0.90234375,
0.001682281494140625,
0.09564208984375,
0.00023853778839111328
] |
All the included studies were RCTs and used the SC as the standard for measuring stress. The studies mentioned measures that could influence cortisol reactivation. Among these measures were progesterone and estrogen in salivary samples ( 22 ) , general infections, diseases of the immune system, endocrine or metabolic diseases, allergies, medications in use (except oral contraceptives), history of neurological disease or psychiatric disorder, smoking, regular consumption of alcohol and drugs, practicing strenuous sports, individuals preparing for exams six weeks before the study, as well as pregnant women, and those who had undergone an examination in the last six weeks ( 9 ) , medical conditions involving the hypothalamic-pituitary-adrenal axis, recent exposure to exogenous glucocorticoids, mineralocorticoids, anabolic steroids ( 23 ) , endocrine diseases, pregnancy, medications such as inhaled and systemic steroids and beta-blockers ( 24 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p21
|
39058375
|
sec[2]/p[2]
|
RESULTS
| 2.908203 |
biomedical
|
Study
|
[
0.998046875,
0.00112152099609375,
0.0007648468017578125
] |
[
0.9306640625,
0.0673828125,
0.0015726089477539062,
0.0005831718444824219
] |
In addition, some guidelines were given to study participants, such as refraining from eating, drinking caffeinated liquids and fruit juices, smoking and sleeping 4 hours before taking part in the study, not drinking alcohol or doing any heavy activity 24 hours before each experimental session ( 9 ) , not consuming food, alcohol and/or nicotine half an hour before the evaluation and not exercising 24 hours before collection ( 25 ) , refraining from eating and drinking for 1 hour before the study period ( 9 , 10 , 22 ) and rinsing the mouth with water 10 minutes before sample collection ( 22 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p22
|
39058375
|
sec[2]/p[3]
|
RESULTS
| 1.950195 |
biomedical
|
Study
|
[
0.97509765625,
0.0011987686157226562,
0.0238037109375
] |
[
0.6767578125,
0.124267578125,
0.1971435546875,
0.0019397735595703125
] |
The studies were published between 2009 and 2017 ( 6 , 9 , 10 , 22 – 29 ) , carried out in the United States ( 23 ) , Canada ( 6 , 10 , 22 , 24 ) , Singapore ( 26 ) , Germany ( 9 , 27 ) , South Korea ( 28 ) and Belgium ( 25 , 29 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p23
|
39058375
|
sec[2]/p[4]
|
RESULTS
| 2.138672 |
biomedical
|
Study
|
[
0.98583984375,
0.0011730194091796875,
0.01284027099609375
] |
[
0.951171875,
0.0298004150390625,
0.0181732177734375,
0.0006837844848632812
] |
Ten additional studies used some kind of simulator ( 6 , 9 , 10 , 22 –24,26– 28 ) and another two studies used standardized patients ( 25 , 29 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p24
|
39058375
|
sec[2]/p[5]
|
RESULTS
| 2.265625 |
biomedical
|
Study
|
[
0.994140625,
0.0027484893798828125,
0.0032196044921875
] |
[
0.978515625,
0.0183868408203125,
0.0024166107177734375,
0.0005044937133789062
] |
The participants were nursing ( 28 ) and medical ( 9 , 23 , 29 ) students, Intensive Care Unit (ICU) physicians ( 27 ) , medical and emergency residents ( 10 ) , pediatric residents ( 22 ) , neonatal and perinatal residents ( 6 ) , oncology residents ( 25 ) , anesthesiology residents ( 26 ) , and ICU residents ( 24 ) . Nine studies were funded ( 9 , 10 , 22 - 27 , 29 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999994 |
39058375_p25
|
39058375
|
sec[2]/p[6]
|
RESULTS
| 2.365234 |
biomedical
|
Study
|
[
0.984375,
0.0021076202392578125,
0.01346588134765625
] |
[
0.919921875,
0.019744873046875,
0.0594482421875,
0.0007305145263671875
] |
The duration of the simulation sessions varied between the included studies, being 10 minutes ( 6 , 27 ) , 15 minutes ( 9 , 28 ) , 20 minutes ( 25 ) , or 12 to 15 minutes ( 26 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p26
|
39058375
|
sec[2]/p[7]
|
RESULTS
| 2.953125 |
biomedical
|
Study
|
[
0.9951171875,
0.0014638900756835938,
0.0035953521728515625
] |
[
0.986328125,
0.0050201416015625,
0.00823974609375,
0.0003237724304199219
] |
Technical performance was measured objectively using a scenario-related checklist ( 10 , 23 , 27 , 29 ) , European Resuscitation Council guidelines ( 9 ) , advanced megacode evaluation (NRP) ( 22 ) , or using the Korean nursing licensing exam ( 28 ) . In addition, one study assessed performance subjectively, using a self-reported questionnaire ( 25 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p27
|
39058375
|
sec[2]/p[8]
|
RESULTS
| 3.335938 |
biomedical
|
Study
|
[
0.99658203125,
0.002227783203125,
0.0011110305786132812
] |
[
0.9775390625,
0.0208282470703125,
0.001220703125,
0.00046062469482421875
] |
Non-technical skills were assessed using the Anesthesiologist Non-Technical Skills (ANTS) assessment tool ( 6 , 10 , 23 , 26 , 27 ) , the Ottawa Global Crisis Resource Management Scale (Ottawa GRS) ( 24 ) and a likert scale for cognitive assessment ( 10 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p28
|
39058375
|
sec[2]/sec[0]/p[0]
|
Data Synthesis
| 2.537109 |
biomedical
|
Study
|
[
0.99609375,
0.000545501708984375,
0.003437042236328125
] |
[
0.9580078125,
0.01229095458984375,
0.0291290283203125,
0.0003330707550048828
] |
All the studies analyzed assessed participants’ stress using physiological measures. Other measures were also used to assess stress, such as psychological and self-reported measures. The risk of bias of the studies was assessed as low, high or unclear .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p29
|
39058375
|
sec[2]/sec[0]/p[1]
|
Data Synthesis
| 3.964844 |
biomedical
|
Study
|
[
0.9990234375,
0.00046896934509277344,
0.0006690025329589844
] |
[
0.99609375,
0.0004076957702636719,
0.0035247802734375,
0.00008416175842285156
] |
No association was found between performance and stress in low-fidelity scenarios compared to high-fidelity scenarios (p = 0.17) ( 6 ) , nor in resuscitation scenarios (p = .098) ( 24 ) . However, in other studies, participants performed significantly worse in the high-stress condition (p < 0.012), indicating that the high-stress situation can be seen as a threat, leading to impaired performance ( 10 ) . In simulated outpatient consultations, medical students experienced deleterious effects on clinical reasoning in high-stress conditions ( 29 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p30
|
39058375
|
sec[2]/sec[0]/p[2]
|
Data Synthesis
| 3.865234 |
biomedical
|
Study
|
[
0.99853515625,
0.000835418701171875,
0.0005259513854980469
] |
[
0.99560546875,
0.0008106231689453125,
0.003368377685546875,
0.0001360177993774414
] |
In postpartum neonatal resuscitation scenarios with simulated death (p = 0.23) or survival (p = 0.33), performance was similar in 1st and 2nd year medical residents compared to the performance of 3rd and 4th year residents ( 22 ) . In another study, there was no statistically significant difference between medical students in the death group compared to survival (p = 0.89) ( 23 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p31
|
39058375
|
sec[2]/sec[0]/p[3]
|
Data Synthesis
| 3.857422 |
biomedical
|
Study
|
[
0.99853515625,
0.0003502368927001953,
0.0012464523315429688
] |
[
0.99853515625,
0.0003600120544433594,
0.0012845993041992188,
0.00006389617919921875
] |
Additionally, in a high-fidelity emergency scenario compared to laboratory stress, cortisol increased in both conditions, but no association was found between stress and performance during the simulation (p = 0.631) ( 9 ) . In another emergency simulation study, after one day’s training, participants produced significant stress and performance improved (p < 0.01) ( 27 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p32
|
39058375
|
sec[2]/sec[0]/p[4]
|
Data Synthesis
| 4 |
biomedical
|
Study
|
[
0.9990234375,
0.00020694732666015625,
0.0005464553833007812
] |
[
0.9970703125,
0.00024509429931640625,
0.002655029296875,
0.000055670738220214844
] |
Higher cortisol levels in nursing students were associated with greater knowledge attainment in a childbirth training and simulation scenario (p < 0.001) ( 28 ) . Communication skills training has an effect on physiological arousal. After simulated training, cortisol levels increased significantly compared to the control group, improving self-efficacy and communication skills (p = 0.026) ( 25 ) . In another study, performance was similar in non-technical skills between the active versus observer roles ( 26 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p33
|
39058375
|
sec[2]/sec[0]/p[5]
|
Data Synthesis
| 4.054688 |
biomedical
|
Study
|
[
0.9990234375,
0.0004706382751464844,
0.0005588531494140625
] |
[
0.9931640625,
0.0003228187561035156,
0.006587982177734375,
0.0000947117805480957
] |
The risk of bias was assessed per study. In relation to the selected studies, one study ( 6 ) presented a high risk of bias in two domains because there was a difference between the sex of the participants (more female participants) and the groups had “clues” provided by the facilitators in the scenarios, but the clues may have been less obvious in one of the groups, which may have created a discrepancy in the participants’ understanding. In another study ( 24 ) , there was a low bias risk and an uncertain bias risk, the study population was heterogeneous (participants from various levels of training and specialties) and the person supervising the simulation sessions gave feedback to the residents. This may have been perceived as a source of stress and influenced the results. In others, there was an uncertain bias risk, the participants were of various levels of training ( 10 ) ; there was insufficient information about the randomization process ( 25 , 29 ) ; one participant was excluded because his cortisol was 10 times higher, no sensitivity test was reported in the study ( 26 ) ; the allocation of participants was by random draw ( 27 ) , and another factor that produced a high risk of bias, was that approximately 29% of the participants who consented to the study did not complete the simulation sessions, resulting in a loss of follow-up of the participants. We don’t know if all the events of interest were adequately captured and correctly scored ( 22 ) and voluntary selection has been shown to be a risk of bias ( 28 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p34
|
39058375
|
sec[3]/p[0]
|
DISCUSSION
| 3.935547 |
biomedical
|
Review
|
[
0.990234375,
0.0036563873291015625,
0.005970001220703125
] |
[
0.013092041015625,
0.0018033981323242188,
0.98486328125,
0.0003380775451660156
] |
This is a systematic review of the available evidence on cortisol levels and participant performance in realistic simulations, evaluated in 11 randomized clinical trials.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
39058375_p35
|
39058375
|
sec[3]/p[1]
|
DISCUSSION
| 3.833984 |
biomedical
|
Study
|
[
0.99755859375,
0.00018477439880371094,
0.002231597900390625
] |
[
0.9931640625,
0.0005545616149902344,
0.00616455078125,
0.000064849853515625
] |
High-fidelity simulation has been shown to be significantly stressful, as evidenced by increased cortisol levels ( 9 , 10 , 22 - 27 , 29 ) . In other studies, high- and low-fidelity scenarios triggered significant stress responses ( 6 , 24 , 30 , 31 ) , suggesting that high-fidelity simulation is not superior to low-fidelity ( 6 ) . In addition, in the medium-fidelity simulation, cortisol increased significantly ( 28 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p36
|
39058375
|
sec[3]/p[2]
|
DISCUSSION
| 2.308594 |
biomedical
|
Study
|
[
0.99609375,
0.000797271728515625,
0.0029449462890625
] |
[
0.8017578125,
0.140625,
0.056396484375,
0.0012750625610351562
] |
With regard to trends in studies over time, it can be seen that there has been an increase in the number of studies comparing high-fidelity and low-fidelity, as well as high-stress and low-stress simulation, the emerging field being medicine. In terms of sub-groups, the study population was mostly made up of residents from different areas of medicine and medical students.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999999 |
39058375_p37
|
39058375
|
sec[3]/p[3]
|
DISCUSSION
| 3.859375 |
biomedical
|
Study
|
[
0.98779296875,
0.0003333091735839844,
0.01210784912109375
] |
[
0.9296875,
0.0019893646240234375,
0.068359375,
0.0001289844512939453
] |
In some studies, no correlation was found between physiological markers of stress and the participants’ performance ( 6 , 9 , 22 –24, 26 ) . In this context, it is essential to recognize that the absence of this correlation between stress and performance in certain studies can be attributed to various conditions. For example, the heterogeneity of the sample, made up of participants with different levels of training and different specialties, who may vary in their performance due to their different backgrounds. In addition, the varied nature of the stresses used in the studies may have triggered divergent physiological and psychological responses among the participants, resulting in different effects on performance and, consequently, significantly impacting the results ( 24 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
39058375_p38
|
39058375
|
sec[3]/p[4]
|
DISCUSSION
| 4.039063 |
biomedical
|
Study
|
[
0.9990234375,
0.00030517578125,
0.0006785392761230469
] |
[
0.998046875,
0.0002818107604980469,
0.0016574859619140625,
0.000048041343688964844
] |
Furthermore, it is important to note that the non-completion of the simulation sessions by some participants and the non-blinding of the reviewers to the nature of the study, and to the identification of the participants and the scenario are additional factors that may have introduced potential biases in the assessment of performance ( 21 ) . The small number of participants and larger representation of female members may influence the external validity of the findings ( 6 ) , since stress responses and adaptation mechanisms may vary between genders. Another point to be made is that the clues provided by the facilitators to the participants in the simulation scenario may have been less obvious between the groups, creating potential discrepancies between the participants’ understanding of the patient’s underlying physiological state ( 6 ) . These methodological issues need to be properly considered when interpreting the results in order to ensure a more comprehensive and accurate understanding of the relationships between stress and performance in the specific contexts addressed.
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p39
|
39058375
|
sec[3]/p[5]
|
DISCUSSION
| 2.929688 |
biomedical
|
Study
|
[
0.9970703125,
0.001247406005859375,
0.00164031982421875
] |
[
0.666015625,
0.1331787109375,
0.198974609375,
0.0018520355224609375
] |
Nevertheless, other studies have identified that high levels of acute stress can critically impair medical decision-making ( 10 ) and have been associated with changes in clinical reasoning, causing doctors to be less able to establish diagnoses ( 29 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
39058375_p40
|
39058375
|
sec[3]/p[6]
|
DISCUSSION
| 2.212891 |
biomedical
|
Study
|
[
0.9814453125,
0.0012693405151367188,
0.017333984375
] |
[
0.86767578125,
0.06988525390625,
0.06121826171875,
0.0010509490966796875
] |
However, in other studies, stress has been shown to be beneficial to participants’ performance. High levels of stress resulted in improved clinical and non-technical performance ( 27 ) , basic knowledge ( 28 ) and improved communication of bad news ( 25 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p41
|
39058375
|
sec[3]/p[7]
|
DISCUSSION
| 3.839844 |
biomedical
|
Study
|
[
0.998046875,
0.000213623046875,
0.001972198486328125
] |
[
0.89013671875,
0.06732177734375,
0.042327880859375,
0.0002529621124267578
] |
Responses to stress, determined by the individual’s perception of demands and resources ( 10 ) are considered ideal for detecting warning signs and mitigating responses. Coping skills can be improved to maintain allostasis, while ineffective coping, related to changes in the regulation and responsiveness of the hypothalamic-pituitary-adrenal (HPA) axis and release of the hormone cortisol, are associated with impaired performance ( 32 , 33 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999995 |
39058375_p42
|
39058375
|
sec[3]/p[8]
|
DISCUSSION
| 3.833984 |
biomedical
|
Study
|
[
0.9970703125,
0.0003857612609863281,
0.0025844573974609375
] |
[
0.87890625,
0.0158538818359375,
0.10504150390625,
0.0002779960632324219
] |
The impact of acute stress on performance is still debated ( 34 ) . Failure to fully understand the impact of student stress on training performance involves the danger of impairing learning and the acquisition of clinical skills during training, and may result in individuals being inadequately prepared to deal with real situations ( 34 ) . It is already known that performance in high acuity situations can be improved or impaired, depending on the perception of the demand and resources of the individuals ( 35 ) assuming that performance increases with the level of stress up to a certain limit beyond which performance decreases, suggesting that stress puts the person at a point of cognitive deficit ( 36 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999998 |
39058375_p43
|
39058375
|
sec[3]/p[9]
|
DISCUSSION
| 4.160156 |
biomedical
|
Study
|
[
0.99658203125,
0.0002903938293457031,
0.0029888153076171875
] |
[
0.99072265625,
0.0023059844970703125,
0.006710052490234375,
0.00006937980651855469
] |
Despite the inherent importance of simulation teaching, a lack of experience and emotional mastery can trigger a stress reaction, potentially impacting student performance ( 37 ) . The anticipation of critical situations and the perception of being watched induce activation of the autonomic nervous system (ANS) and the hypothalamic-pituitary-adrenal (HPA) axis associated with higher cortical functions ( 38 ) . The sympathetic response of the autonomic system leads to an increase in blood pressure, heart rate, skin temperature and anaerobic metabolism, while activation of the HPA results in increased secretion of cortisol into the blood, which is then diffused into saliva over a period of minutes ( 34 , 38 , 39 ) . The increase in cortisol levels has an impact on brain regions closely related to cognitive processes, including the amygdala, hippocampus and prefrontal cortex ( 34 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p44
|
39058375
|
sec[3]/p[10]
|
DISCUSSION
| 2.164063 |
biomedical
|
Study
|
[
0.94970703125,
0.0011425018310546875,
0.049072265625
] |
[
0.5673828125,
0.28125,
0.1497802734375,
0.0016460418701171875
] |
For these reasons, stress management training has been shown to be effective in reducing stress ( 40 ) , with positive effects not only on stress indicators, but also on performance ( 41 – 43 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p45
|
39058375
|
sec[3]/p[11]
|
DISCUSSION
| 3.576172 |
biomedical
|
Review
|
[
0.9921875,
0.003875732421875,
0.004070281982421875
] |
[
0.0287628173828125,
0.0889892578125,
0.88134765625,
0.0010938644409179688
] |
Acute stress can be a risk factor for diagnostic errors ( 29 ) and impaired patient safety ( 10 ) . On the other hand, it can improve clinical performance and non-technical skills ( 27 ) , can prepare residents to deal with death ( 22 ) , can improve advanced life support skills ( 23 ) , knowledge retention and consolidation ( 26 ) , as well as offering greater clinical skills in deliveries ( 28 ) and verbal communication ( 25 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p46
|
39058375
|
sec[3]/p[12]
|
DISCUSSION
| 1.711914 |
biomedical
|
Other
|
[
0.7607421875,
0.001224517822265625,
0.238037109375
] |
[
0.42822265625,
0.55615234375,
0.01439666748046875,
0.0012674331665039062
] |
The effects of stress depend on a number of factors, including gender, previous experience, personality traits, psychological assessment, assigned role and team attribution ( 10 , 33 ) . However, it is still difficult to know the precise origin of stress ( 44 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999997 |
39058375_p47
|
39058375
|
sec[3]/p[13]
|
DISCUSSION
| 4.042969 |
biomedical
|
Study
|
[
0.99853515625,
0.0004267692565917969,
0.0008573532104492188
] |
[
0.958984375,
0.0011816024780273438,
0.03985595703125,
0.00016427040100097656
] |
With regard to additional stressors, the presence of observers, filming, team dynamics and the perception of evaluation may have influenced stress ( 6 , 26 , 31 ) . However, in a simulation of laparoscopic surgery, noise did not cause changes in stress levels ( 45 ) . Another study ( 46 ) showed that distractions such as telephone calls during the simulation caused changes in physiological parameters. In the study by Piquette and colleagues ( 24 ) , these stressors appeared to be weak enough to provoke a stress response among residents used to a hectic environment. Therefore, the stressors themselves may not lead to impaired performance ( 10 ) . Performance can be impacted by mental stress, with the addition of elements to the scenario that put the cognitive system at risk of overload. In this context, in stressful episodes, attention can be directed exclusively to specific tasks, resulting in the possible neglect of other potentially relevant information ( 18 ) . Therefore, caution is needed when designing scenarios, taking care to eliminate as many potential distractions as possible from these clinical environments ( 10 ) , being aware of the mechanism of stress and offering resources for its management ( 46 ) .
|
[
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil",
"Jackson Gois Teixeira",
"Lucas Tomaz Benigno Lima",
"Elaine Carvalho Cunha",
"Flavia Oliveira de Almeida Marques da Cruz",
"Karen Karoline Gouveia Carneiro",
"Laiane Medeiros Ribeiro",
"Guilherme da Costa Brasil"
] |
https://doi.org/10.1590/1980-220X-REEUSP-2023-0279en
|
N/A
|
https://creativecommons.org/licenses/by/4.0/
|
en
| 0.999996 |
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