Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study

BACKGROUND

Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation.

METHODS

WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109.

FINDINGS

Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital.

INTERPRETATION

In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates.

FUNDING

European Society of Intensive Care Medicine, European Respiratory Society.

The Third Dimension of Ferroelectric Domain Walls

Ferroelectric domain walls are quasi-2D systems that show great promise for the development of nonvolatile memory, memristor technology, and electronic components with ultrasmall feature size. Electric fields, for example, can change the domain wall orientation relative to the spontaneous polarization and switch between resistive and conductive states, controlling the electrical current. Being embedded in a 3D material, however, the domain walls are not perfectly flat and can form networks, which leads to complex physical structures. In this work, the importance of the nanoscale structure for the emergent transport properties is demonstrated, studying electronic conduction in the 3D network of neutral and charged domain walls in ErMnO₃ . By combining tomographic microscopy techniques and finite element modeling, the contribution of domain walls within the bulk is clarified and the significance of curvature effects for the local conduction is shown down to the nanoscale. The findings provide insights into the propagation of electrical currents in domain wall networks, reveal additional degrees of freedom for their control, and provide quantitative guidelines for the design of domain-wall-based technology.

Peptide Drug Thymalin Regulates Immune Status in Severe COVID-19 Older Patients

Peptide drug Thymalin, isolated from the calve thymus, is successfully used for the treatment of various immunopathologies, including those in older age groups. The molecular mechanism of the Thymalin immunoprotective action is due to the effects of the short peptides KE, EW, EDP in its composition. These short peptides can specifically bind to double-stranded DNA and/or histone proteins and regulate gene expression, synthesis of immune system proteins, activity of gerontogenes, and stimulate stem cell differentiation. Regulation of immunogenesis is a key factor preventing the development of the “cytokine storm” that develops in severe COVID-19. The purpose of this work is to study the effectiveness of Thymalin in severe COVID-19 in older patients. Patients administered with Thymalin against the background of a standard therapy (n = 36) manifested a more rapid clinical improvement, higher proportions of recovery from lymphopenia, faster normalization of the concentration of C-reactive protein, D-dimer, the number of lymphocytes and NK-cells in the blood, compared to patients who received a standard therapy only (n = 44). Thymalin halved hospital mortality in older patients with severe COVID-19. The results obtained showed the effectiveness of Thymalin administration in the complex therapy of patients with severe COVID-19.

Mobile and immobile boundaries in ferroelectric films

The intrinsic mobile interfaces in ferroelectrics—the domain walls can drive and enhance diverse ferroelectric properties, essential for modern applications. Control over the motion of domain walls is of high practical importance. Here we analyse theoretically and show experimentally epitaxial ferroelectric films, where mobile domain walls coexist and interact with immobile growth-induced interfaces—columnar boundaries. Whereas these boundaries do not disturb the long-range crystal order, they affect the behaviour of domain walls in a peculiar selective manner. The columnar boundaries substantially modify the behaviour of non-ferroelastic domains walls, but have negligible impact on the ferroelastic ones. The results suggest that introduction of immobile boundaries into ferroelectric films is a viable method to modify domain structures and dynamic responses at nano-scale that may serve to functionalization of a broader range of ferroelectric films where columnar boundaries naturally appear as a result of the 3D growth.

Conductivity control via minimally invasive anti-Frenkel defects in a functional oxide

Utilizing quantum effects in complex oxides, such as magnetism, multiferroicity and superconductivity, requires atomic-level control of the material's structure and composition. In contrast, the continuous conductivity changes that enable artificial oxide-based synapses and multiconfigurational devices are driven by redox reactions and domain reconfigurations, which entail long-range ionic migration and changes in stoichiometry or structure. Although both concepts hold great technological potential, combined applications seem difficult due to the mutually exclusive requirements. Here we demonstrate a route to overcome this limitation by controlling the conductivity in the functional oxide hexagonal Er(Mn,Ti)O₃ by using conductive atomic force microscopy to generate electric-field induced anti-Frenkel defects, that is, charge-neutral interstitial-vacancy pairs. These defects are generated with nanoscale spatial precision to locally enhance the electronic hopping conductivity by orders of magnitude without disturbing the ferroelectric order. We explain the non-volatile effects using density functional theory and discuss its universality, suggesting an alternative dimension to functional oxides and the development of multifunctional devices for next-generation nanotechnology.

Publisher Correction: Conductivity control via minimally invasive anti-Frenkel defects in a functional oxide

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Visualization of moiré superlattices

Moiré superlattices in van der Waals heterostructures have given rise to a number of emergent electronic phenomena due to the interplay between atomic structure and electron correlations. Indeed, electrons in these structures have been recently found to exhibit a number of emergent properties that the individual layers themselves do not exhibit. This includes superconductivity^1,2, magnetism³, topological edge states^4,5, exciton trapping⁶ and correlated insulator phases⁷. However, the lack of a straightforward technique to characterize the local structure of moiré superlattices has thus far impeded progress in the field. In this work we describe a simple, room-temperature, ambient method to visualize real-space moiré superlattices with sub-5-nm spatial resolution in a variety of twisted van der Waals heterostructures including, but not limited to, conducting graphene, insulating boron nitride and semiconducting transition metal dichalcogenides. Our method uses piezoresponse force microscopy, an atomic force microscope modality that locally measures electromechanical surface deformation. We find that all moiré superlattices, regardless of whether the constituent layers have inversion symmetry, exhibit a mechanical response to out-of-plane electric fields. This response is closely tied to flexoelectricity wherein electric polarization and electromechanical response is induced through strain gradients present within moiré superlattices. Therefore, moiré superlattices of two-dimensional materials manifest themselves as an interlinked network of polarized domain walls in a non-polar background matrix.

Observation of Uncompensated Bound Charges at Improper Ferroelectric Domain Walls

Low-temperature electrostatic force microscopy (EFM) is used to probe unconventional domain walls in the improper ferroelectric semiconductor Er_0.99Ca_0.01MnO₃ down to cryogenic temperatures. The low-temperature EFM maps reveal pronounced electric far fields generated by partially uncompensated domain-wall bound charges. Positively and negatively charged walls display qualitatively different fields as a function of temperature, which we explain based on different screening mechanisms and the corresponding relaxation time of the mobile carriers. Our results demonstrate domain walls in improper ferroelectrics as a unique example of natural interfaces that are stable against the emergence of electrically uncompensated bound charges. The outstanding robustness of improper ferroelectric domain walls in conjunction with their electronic versatility brings us an important step closer to the development of durable and ultrasmall electronic components for next-generation nanotechnology.

Topological Defects in Hexagonal Manganites: Inner Structure and Emergent Electrostatics

Diverse topological defects arise in hexagonal manganites, such as ferroelectric vortices, as well as neutral and charged domain walls. The topological defects are intriguing because their low symmetry enables unusual couplings between structural, charge, and spin degrees of freedom, holding great potential for novel types of functional 2D and 1D systems. Despite the considerable advances in analyzing the different topological defects in hexagonal manganites, the understanding of their key intrinsic properties is still rather limited and disconnected. In particular, a rapidly increasing number of structural variants is reported without clarifying their relation, leading to a zoo of seemingly unrelated topological textures. Here, we combine picometer-precise scanning-transmission-electron microscopy with Landau theory modeling to clarify the inner structure of topological defects in Er_1-xZr_xMnO₃. By performing a comprehensive parametrization of the inner atomic defect structure, we demonstrate that one primary length scale drives the morphology of both vortices and domain walls. Our findings lead to a unifying general picture of this type of structural topological defects. We further derive novel fundamental and universal properties, such as unusual bound-charge distributions and electrostatics at the ferroelectric vortex cores with emergent U(1) symmetry.

Bent Ferroelectric Domain Walls as Reconfigurable Metallic-Like Channels

Use of ferroelectric domain-walls in future electronics requires that they are stable, rewritable conducting channels. Here we demonstrate nonthermally activated metallic-like conduction in nominally uncharged, bent, rewritable ferroelectric-ferroelastic domain-walls of the ubiquitous ferroelectric Pb(Zr,Ti)O3 using scanning force microscopy down to a temperature of 4 K. New walls created at 4 K by pressure exhibit similar robust and intrinsic conductivity. Atomic resolution electron energy-loss spectroscopy confirms the conductivity confinement at the wall. This work provides a new concept in "domain-wall nanoelectronics".

Elastic coupling between nonferroelastic domain walls

We reveal a strong elastic interaction between nonferroelastic domain walls in ferroelectric thin films. This interaction, having no analogue in bulk materials, is governed by elastic fields that are associated with the domain walls and extends to distances comparable to the film thickness. Such elastic widening of the nonferroelastic domain walls is shown to be particularly strong in common ferroelectric perovskites. The results are especially relevant for the control of domain wall propagation and the understanding of polarization dynamics.