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Based on a multi-dating and multi-proxy approach, we reconstruct Late Holocene environmental changes derived from sediments of Schweriner See, a large lowland lake in NE Germany, covering the past 3070+170/-210 years cal BP. We infer variations in large-scale atmospheric circulation systems by combining in-lake productivity indicators obtained from traditional and high-resolution techniques (e.g. LOI550, TOC, inc / coh), diatom assemblages, and compound-specific hydrogen isotopes (δ2HC25). Before 105+95/−75 cal BP (∼1850 CE), changes in productivity and the occurrence or disappearance of the diatom species Stephanocostis chantaicus reflect winter temperature variability, while variations in the compound-specific hydrogen isotopes suggest changes in the moisture source region. We observe distinct variations between (i) milder winter temperatures with a moisture source region in the southern–central North Atlantic and (ii) colder winter temperatures with a moisture source in the northern North Atlantic and/or Arctic regions. Such distinct variations in winter temperature and moisture source region are mainly modulated by the North Atlantic Oscillation (NAO). This affects, among others, westerly wind strength and pathways and, thereby, winter temperature and moisture source region for northern central Europe. Besides these long-term shifts in atmospheric conditions, short-term variations in titanium can be linked to lake-level variability, most likely influenced by changes in precipitation and/or evaporation, and after the 12th century to anthropogenic impacts. Since 105+95/-75 cal BP (∼1850 CE), productivity has been driven predominantly by nutrient availability related to anthropogenic activities masking the hydroclimatic signal.

Laser-induced magnetic dipole (LaserIMD) spectroscopy and light-induced double electron–electron resonance (LiDEER) spectroscopy are important techniques in the emerging field of light-induced pulsed dipolar electron paramagnetic resonance (EPR) spectroscopy (light-induced PDS). These techniques use the photoexcitation of a chromophore to the triplet state and measure its dipolar coupling to a neighboring electron spin, which allows the determination of distance restraints. To date, LaserIMD and LiDEER have been analyzed with software tools that were developed for a pair of two S=1/2 spins and that neglected the zero-field splitting (ZFS) of the excited triplet. Here, we explore the limits of this assumption and show that the ZFS can have a significant effect on the shape of the dipolar trace. For a detailed understanding of the effect of the ZFS, a theoretical description for LaserIMD and LiDEER is derived, taking into account the non-secular terms of the ZFS. Simulations based on this model show that the effect of the ZFS is not that pronounced in LiDEER for experimentally relevant conditions. However, the ZFS leads to an additional decay in the dipolar trace in LaserIMD. This decay is not that pronounced in Q-band but can be quite noticeable for lower magnetic field strengths in X-band. Experimentally recorded LiDEER and LaserIMD data confirm these findings. It is shown that ignoring the ZFS in the data analysis of LaserIMD traces can lead to errors in the obtained modulation depths and background decays. In X-band, it is additionally possible that the obtained distance distribution is plagued by long distance artifacts.

TBX5 is a transcription factor (TF) playing essential role during cardiogenesis. It is well known that TF mutations possibly result in non- or additional binding of the DNA due to conformational changes of the protein. We introduced a Holt-Oram Syndrome (HOS) patient-specific TBX5 mutation c.920_C > A heterozygously in a healthy induced pluripotent stell cell (iPSC) line. This TBX5 mutation results in conformational changes of the protein and displayed ventricular septal defects in the patient itself. Additionally we introduced a FLAG-tag on the TBX5 mutation-carrying allele. The resulting heterozygous TBX5-FLAG iPSC lines are a powerful tool to investigate altered TF activity bonding.

Although TBX5 plays a major role during human cardiogenesis and initiates and controls limb development, many of its interactions with genomic DNA and the resulting biological consequences are not well known. Existing anti-TBX5-antibodies work very inefficiently in certain applications such as ChIP-Seq analysis. To circumvent this drawback, we introduced a FLAG-tag sequence into the TBX5 locus at the end of exon 9 prior to the stop codon by CRISPR/Cas9. The expressed TBX5-FLAG fusion protein can effectively be precipitated by anti-FLAG antibodies. Therefore, these gene-edited iPSC lines represent powerful cellular in vitro tools to unravel TBX5:DNA interactions in detail.

Abstract Coulomb repulsion among conduction electrons in solids hinders their motion and leads to a rise in resistivity. A regime of electronic phase separation is expected at the first-order phase transition between a correlated metal and a paramagnetic Mott insulator, but remains unexplored experimentally as well as theoretically nearby T = 0. We approach this issue by assessing the complex permittivity via dielectric spectroscopy, which provides vivid mapping of the Mott transition and deep insight into its microscopic nature. Our experiments utilizing both physical pressure and chemical substitution consistently reveal a strong enhancement of the quasi-static dielectric constant ε 1 when correlations are tuned through the critical value. All experimental trends are captured by dynamical mean-field theory of the single-band Hubbard model supplemented by percolation theory. Our findings suggest a similar ’dielectric catastrophe’ in many other correlated materials and explain previous observations that were assigned to multiferroicity or ferroelectricity.

Despite the apparent simplicity of a H2O molecule, the mutual ferroelectric ordering of the molecules is unresolved. Here, the authors realize a macroscopic ferroelectric phase transition in a network of dipole-dipole coupled water molecules located in nanopores of gemstone.

Abstract Background Many patients suffering from exercise-induced asthma (EIA) have normal lung function at rest and show symptoms and a decline in FEV1 when they do sports or during exercise-challenge. It has been described that long-chain polyunsaturated fatty acids (LCPUFA) could exert a protective effect on EIA. Methods In this study the protective effect of supplementation with a special combination of n-3 and n-6 LCPUFA (sc-LCPUFA) (total 1.19 g/ day) were investigated in an EIA cold air provocation model. Primary outcome measure: Decrease in FEV1 after exercise challenge and secondary outcome measure: anti-inflammatory effects monitored by exhaled NO (eNO) before and after sc-LCPUFA supplementation versus placebo. Results Ninety-nine patients with exercise-induced symptoms aged 10 to 45 were screened by a standardized exercise challenge in a cold air chamber at 4 °C. Seventy-three patients fulfilled the inclusion criteria of a FEV1 decrease > 15% and were treated double-blind placebo-controlled for 4 weeks either with sc-LCPUFA or placebo. Thirty-two patients in each group completed the study. Mean FEV1 decrease after cold air exercise challenge and eNO were unchanged after 4 weeks sc-LCPUFA supplementation. Conclusion Supplementation with sc-LCPUFA at a dose of 1.19 g/d did not have any broncho-protective and anti-inflammatory effects on EIA. Trial registration Clinical trial registration number: NCT02410096. Registered 7 February 2015 at Clinicaltrial.gov

EPR distance determination in the nanometre region has become an important tool for studying the structure and interaction of macromolecules. Arbitrary waveform generators (AWGs), which have recently become commercially available for EPR spectrometers, have the potential to increase the sensitivity of the most common technique, double electron–electron resonance (DEER, also called PELDOR), as they allow the generation of broadband pulses. There are several families of broadband pulses, which are different in general pulse shape and the parameters that define them. Here, we compare the most common broadband pulses. When broadband pulses lead to a larger modulation depth, they also increase the background decay of the DEER trace. Depending on the dipolar evolution time, this can significantly increase the noise level towards the end of the form factor and limit the potential increase in the modulation-to-noise ratio (MNR). We found asymmetric hyperbolic secant (HS{1,6}) pulses to perform best for short DEER traces, leading to a MNR improvement of up to 86 % compared to rectangular pulses. For longer traces we found symmetric hyperbolic secant (HS{1,1}) pulses to perform best; however, the increase compared to rectangular pulses goes down to 43 %.

We generated an induced pluripotent stem cell (iPSC) line from a healthy male 29-year-old proband. Adipose fibroblasts (AFs) were reprogrammed using Sendai virus. Generated iPSCs showed typical stem cell morphology. From passage 9 on, iPSCs were free of virus. Pluripotency in the iPSCs was verified and spontaneous differentiation showed expression of all three germ layers. Karyotyping indicated no anomalies for the generated iPSCs. Many patient-specific iPSCs are generated from subcutaneous fat fibroblasts obtained during surgical procedure. The described control iPSC line was generated equally and therefore serves as an ideal control for adipose-fibroblast-based patient-specific iPSC lines in disease modeling.

The Holt-Oram syndrome (HOS) is a rare autosomal dominant disorder, mostly based on mutations in the TBX5 gene. Patients show malformation of at least one upper limb along with congenital heart defects. The established induced pluripotent stem cell (iPSC) line was generated from a patient displaying pronounced and typical features of HOS and carrying a single-nucleotide change c.920_C>A leading to an amino acid change from proline to threonine at amino acid position 85, which appeared de novo. Adipose fibroblasts from the patient were reprogrammed using Sendai virus. Pluripotency of the iPSCs was fully demonstrated.

We measure the real part ε^{′} of the dielectric permittivity of beryl crystals with heavy water molecules D_{2}O confined in nanosized cages formed by an ionic crystal lattice. The experiments are performed at a frequency of 1 MHz in the temperature interval from 300 down to 4 K under different hydrostatic pressures up to P=6.3 GPa. At high temperatures, a Curie-Weiss-like increase of ε^{′}(T) is observed upon cooling. Application of pressure leads to flattening of ε^{′}(T) at low temperatures due to quantum effects, i.e., tunneling of deuterium atoms in the hexagonal localizing potential. Analyzing the temperature behavior of ε^{′} with the Barrett expression allows us to obtain pressure dependencies of the quantum temperature T_{1}, the Curie-Weiss temperature T_{C}, and the Barrett constant C. The increase of T_{1} observed up to 4 GPa is associated with an enhanced azimuthal tunneling of the confined water molecules through the barriers of the potential. For P>4 GPa, T_{1}(P) levels off since the barriers disappear. Any further pressure increase does not affect the tunneling rate because of the absence of a barrier. The behavior is modeled by solving the Schrödinger equation for the water molecule in the azimuthal potential numerically. Small negative values of T_{C}≈−10 K obtained for P

In the last few years the involvement of the medial prefrontal cortex (mPFC) in memory processing has received increased attention. It has been shown to be centrally involved when we use prior knowledge (schemas) to improve learning of related material. With the mPFC also being one of the core hubs of the default mode network (DMN) and the DMN’s role in memory retrieval, we decided to investigate whether the mPFC in a schema paradigm acts independent of the DMN. We tested this with data from a cross-sectional developmental study with a schema paradigm. During retrieval of schema items, the mPFC decoupled from the DMN with the degree of decoupling predicting memory performance. This finding suggests that a demand specific reconfiguration of the DMN supports schema memory. Additionally, we found that in the control condition, which relied on episodic memory, activity in the parahippocampal gyrus was positively related to memory performance. We interpret these results as a demand specific network reconfiguration of the DMN: a decoupling of the mPFC to support schema memory and a decoupling of the parahippocampal gyrus facilitating episodic memory.

The ultrafast electronic decay of HCl molecules in the time domain after resonant core excitation was measured. Here, a Cl-2p core electron was promoted to the antibonding σ* orbital initiating molecular dissociation, and simultaneously, the electronic excitation relaxes via an Auger decay. For HCl, both processes compete on similar ultrashort femtosecond time scales. In order to measure the lifetime of the core hole excitation, we collinearly superimposed 40 fs soft x-ray pulses with intense terahertz (THz) radiation from the free-electron laser in Hamburg (FLASH). Electrons emitted from the molecules are accelerated (streaked) by the THz electric field where the resulting momentum change depends on the field's phase at the instant of ionization. Evaluation of a time-shift between the delay-dependent streaking spectra of photo- and Auger electrons yields a decay constant of (11 ± 2) fs for LMM Auger electrons. For further validation, the method was also applied to the MNN Auger decay of krypton. Reproduction of the value already published in the literature confirms that a temporal resolution much below the duration of the exciting x-ray pulses can be reached.

We studied the broadband optical conductivity of CaMnBi2, a material with two-dimensional Dirac electronic bands, and found that both components of the intraband conductivity follow a universal power law as a function of frequency at low temperatures. This conductivity scaling differs from the Drude(-like) behavior, generally expected for free carriers, but matches the predictions for the intraband response of an electronic system in a quantum critical region. Since no other indications of quantum criticality are reported for CaMnBi2 so far, the cause of the observed unusual scaling remains an open question.

Ferroelectric orders hardly exist in liquid or ice state of water, despite its enormous molecular electrical polarizability. Here, Gorshunov et al. report incipient ferroelectricity in chains of interacting water molecules by placing them in the structural channels of a beryl crystal.

The properties of organic conductors are often tuned by the application of chemical or external pressure, which change orbital overlaps and electronic bandwidths while leaving the molecular building blocks virtually unperturbed. Here, we show that, unlike any other method, light can be used to manipulate the local electronic properties at the molecular sites, giving rise to new emergent properties. Targeted molecular excitations in the charge-transfer salt κ-(BEDT-TTF)_{2}Cu[N(CN)_{2}]Br induce a colossal increase in carrier mobility and the opening of a superconducting optical gap. Both features track the density of quasiparticles of the equilibrium metal and can be observed up to a characteristic coherence temperature T^{*}≃50 K, far higher than the equilibrium transition temperature T_{C}=12.5 K. Notably, the large optical gap achieved by photoexcitation is not observed in the equilibrium superconductor, pointing to a light-induced state that is different from that obtained by cooling. First-principles calculations and model Hamiltonian dynamics predict a transient state with long-range pairing correlations, providing a possible physical scenario for photomolecular superconductivity.

We measured the reflectivity of the multifold semimetal RhSi in a frequency range from 80 to 20000cm^{−1} (10 meV–2.5 eV) at temperatures down to 10 K. The optical conductivity, calculated from the reflectivity, is dominated by the free-carrier (Drude) contribution below 1000 cm^{−1} (120 meV) and by interband transitions at higher frequencies. The temperature-induced changes in the spectra are generally weak: only the Drude bands narrow upon cooling, with an unscreened plasma frequency that is constant with temperature at approximately 1.4 eV, in agreement with a weak temperature dependence of the free-carrier concentration determined by Hall measurements. The interband portion of conductivity exhibits two linear-in-frequency regions below 5000 cm^{−1} (∼600 meV), a broad flat maximum at around 6000 cm^{−1} (750 meV), and a further increase starting around 10 000 cm^{−1} (∼1.2 eV). We assign the linear behavior of the interband conductivity to transitions between the linear bands near the band crossing points. Our findings are in accord with the predictions for the low-energy conductivity behavior in multifold semimetals and with earlier computations based on band structure calculations for RhSi.

We present a far-infrared magneto-optical study of the gapped nodal-line semimetal ZrSiS in magnetic fields B up to 7 T. The observed field-dependent features, which represent intra- (cyclotron resonance) and interband transitions, develop as sqrt[B] in increasing field and can be consistently explained within a simple two-dimensional Dirac band model with a gap of 26 meV and an averaged Fermi velocity of 3×10^{5} m/s. This indicates a rather narrow distribution of these parameters along the in-plane portions of the nodal line in the Brillouin zone. A field-induced feature with an energy position that does not depend on B is also detected in the spectra. Possible origins of this feature are discussed.

Tropical tree height-diameter (H:D) relationships may vary by forest type and region making large-scale estimates of above-ground biomass subject to bias if they ignore these differences in stem allometry. We have therefore developed a new global tropical forest database consisting of 39 955 concurrent H and D measurements encompassing 283 sites in 22 tropical countries. Utilising this database, our objectives were: 1. to determine if H:D relationships differ by geographic region and forest type (wet to dry forests, including zones of tension where forest and savanna overlap). 2. to ascertain if the H:D relationship is modulated by climate and/or forest structural characteristics (e.g. stand-level basal area, A). 3. to develop H:D allometric equations and evaluate biases to reduce error in future local-to-global estimates of tropical forest biomass. Annual precipitation coefficient of variation (PV), dry season length (SD), and mean annual air temperature (TA) emerged as key drivers of variation in H:D relationships at the pantropical and region scales. Vegetation structure also played a role with trees in forests of a high A being, on average, taller at any given D. After the effects of environment and forest structure are taken into account, two main regional groups can be identified. Forests in Asia, Africa and the Guyana Shield all have, on average, similar H:D relationships, but with trees in the forests of much of the Amazon Basin and tropical Australia typically being shorter at any given D than their counterparts elsewhere. The region-environment-structure model with the lowest Akaike's information criterion and lowest deviation estimated stand-level H across all plots to within amedian −2.7 to 0.9% of the true value. Some of the plot-to-plot variability in H:D relationships not accounted for by this model could be attributed to variations in soil physical conditions. Other things being equal, trees tend to be more slender in the absence of soil physical constraints, especially at smaller D. Pantropical and continental-level models provided less robust estimates of H, especially when the roles of climate and stand structure in modulating H:D allometry were not simultaneously taken into account.

The aim of the study was to investigate the effect of cyclic mechanical strain on differentiation markers in the presence or absence of dexamethasone. Human bone marrow stromal cells (BMSC) from seven donors (32.5±6.2 years) were cultivated with (D+) or without (D-) dexamethasone. A cyclic mechanical strain with an elongation of 2% (D+2; D-2) or 8% (D+8; D-8) was applied for three days with a stimulation time of three times two hours each day. Levels of alkaline phosphatase (ALP) and osteocalcin (OC) were compared after time intervals of four and seven days. mRNA expression of Collagen I, III and Cbfa1 was investigated after one, four, and seven days. ALP levels were significantly increased in the D+8 group after four and seven days (147.1±6.3%; p

The theoretical and experimental aspects of the microwave, terahertz, and infrared properties of superconductors are discussed. Electrodynamics can provide information about the superconducting condensate as well as about the quasiparticles. The aim is to understand the frequency dependence of the complex conductivity, the change with temperature and time, and its dependence on material parameters. We confine ourselves to conventional metallic superconductors, in particular, Nb and related nitrides and review the seminal papers but also highlight latest developments and recent experimental achievements. The possibility to produce well-defined thin films of metallic superconductors that can be tuned in their properties allows the exploration of fundamental issues, such as the superconductor-insulator transition; furthermore it provides the basis for the development of novel and advanced applications, for instance, superconducting single-photon detectors.

Charge order affects most of the electronic properties but is believed not to alter the spin arrangement since the magnetic susceptibility remains unchanged. We present electron-spin-resonance experiments on quasi-one-dimensional (TMTTF)2X salts (X= PF6, AsF6, and SbF6), which reveal that the magnetic properties are modified below TCO when electronic ferroelectricity sets in. The coupling of anions and organic molecules rotates the g-tensor out of the molecular plane creating magnetically nonequivalent sites on neighboring chains at domain walls. Due to anisotropic Zeeman interaction a novel magnetic interaction mechanism in the charge-ordered state is observed as a doubling of the rotational periodicity of ΔH.

The femtosecond nature of X-ray free electron laser (FEL) pulses opens up exciting research possibilities in time-resolved studies including femtosecond photoemission and diffraction. The recent developments of seeding X-ray FELs extend their capabilities by creating stable, temporally coherent, and repeatable pulses. This in turn opens the possibility of spectral engineering soft X-ray pulses to use as a probe for the control of quantum dynamics. We propose a method for extending coherent control pulse-shaping techniques to the soft X-ray spectral range by using a reflective geometry 4f pulse shaper. This method is based on recent developments in asymmetrically cut multilayer optic technology and piezoelectric substrates.

One of the most challenging tasks for extreme ultraviolet, soft and hard x-ray free-electron laser photon diagnostics is the precise determination of the photon pulse duration, which is typically in the sub 100 fs range. Nine different methods, able to determine such ultrashort photon pulse durations, were compared experimentally at FLASH, the self-amplified spontaneous emission free-electron laser at DESY in Hamburg, in order to identify advantages and disadvantages of different methods. Radiation pulses at a wavelength of 13.5 and 24.0 nm together with the corresponding electron bunch duration were measured by indirect methods like analyzing spectral correlations, statistical fluctuations, and energy modulations of the electron bunch and also by direct methods like autocorrelation techniques, terahertz streaking, or reflectivity changes of solid state samples. In this paper, we present a comprehensive overview of the various techniques and a comparison of the individual experimental results. The information gained is of utmost importance for the future development of reliable pulse duration monitors indispensable for successful experiments with ultrashort extreme ultraviolet pulses.

Background: In critically ill patients, deep sedation and mechanical ventilation suppress the brain-diaphragm-lung axis and are associated with cognitive issues in survivors., Methods: This exploratory crossover design study investigates whether phrenic nerve stimulation can enhance brain activity and connectivity in six deeply sedated, mechanically ventilated patients with acute respiratory distress syndrome., Results: Our findings indicate that adding phrenic stimulation on top of invasive mechanical ventilation in deeply sedated, critically ill, moderate acute respiratory distress syndrome patients increases cortical activity, connectivity, and synchronization in the frontal-temporal-parietal cortices., Conclusions: Adding phrenic stimulation on top of invasive mechanical ventilation in deeply sedated, critically ill, moderate acute respiratory distress syndrome patients increases cortical activity, connectivity, and synchronization. The observed changes resemble those during diaphragmatic breathing in awake humans. These results suggest that phrenic nerve stimulation has the potential to restore the brain-diaphragm-lung crosstalk when it has been shut down or impaired by mechanical ventilation and sedation. Further research should evaluate the clinical significance of these results., Competing Interests: Competing Interests The authors declare the following competing interests: T.B.: received a salary from Lungpacer Medical Inc. E.R.: consultant for Lungpacer Medical Inc. B.H.: consultant for Lungpacer Medical Inc. S.R.: co-inventor and received personal fees from Lungpacer Medical Inc., Vancouver, Canada A.D.: Medtronic, grants, personal fees and nonfinancial support from Philips, personal fees from Baxter, personal fees from Hamilton, personal fees and non-financial support from Fisher & Paykel, grants from French Ministry of Health, personal fees from Getinge, grants and personal fees from Respinor, grants and nonfinancial support from Lungpacer, outside the submitted work T.S.: reports personal fees for consulting and teaching activities from AstraZeneca France, Chiesi France, KPL consulting, Lungpacer Inc., OSO-AI, TEVA France, Vitalaire. He is a stock shareholder of startups Hephaï and Austral Dx. He is listed as inventor on issued patents (WO2008006963A3, WO2012004534A1, WO2013164462A1) describing EEG responses to experimental and clinical dyspnea. MDr: received personal fees from Lungpacer Medical Inc., Vancouver, Canada and was a member of the Clinical Advisory Board of Lungpacer Medical Inc., Vancouver, Canada. M.P., J.M., M.D., and J.H. declare no competing interests., (© 2024. The Author(s).)

Background: Morphine relieves dyspnea in various clinical circumstances. Whether or not this applies to patients admitted to intensive care units (ICUs) for acute respiratory failure (ARF) is unknown. We evaluated the efficacy and safety of low-dose morphine on dyspnea in patients admitted to the ICU for ARF., Methods: In this single-center, double-blind, phase 2, randomized, controlled trial, we assigned non-intubated adults admitted to the ICU for ARF with severe dyspnea, defined by a visual analog scale for dyspnea (dyspnea-VAS) from zero (no dyspnea) to 100 mm (worst imaginable dyspnea) ≥40 mm, to receive a low dose of Morphine Hydrochloride (intravenous titration followed by subcutaneous relay) or Placebo. All patients received standard therapy, including etiological treatment and non-invasive respiratory support., Results: Twenty-two patients were randomized, 11 in each group. The average dyspnea (median [interquartile range]) over 24 hours did not significantly differ between the two groups (40 [25 - 43] mm in the Morphine group vs. 40 [36 - 49] mm in the Placebo group, p=0.411). Dyspnea-VAS was lower in the Morphine group than in the Placebo group at the end of intravenous titration (30 [11 - 30] vs. 35 [30 - 44], p=0.044) and four hours later (18 [10 - 29] vs. 50 [30 - 60], p=0.043). The cumulative probability of intubation was higher in the Morphine group than in the Placebo group (p=0.046) CONCLUSION: In this phase 2 pilot trial, morphine did not improve 24-hour average dyspnea in adult patients with ARF, even though it had a statistically significant immediate effect. Of concern, Morphine use was associated with a higher intubation rate., Trial Registration: The protocol was declared on the ClinicalTrial.gov database (no. NCT04358133) and was published in September 2022., (© 2024. The Author(s).)

Background: In mechanically ventilated patients, diaphragm ultrasound can identify diaphragm weakness and predict weaning failure. We evaluated whether a novel operator-independent ultrasound-based medical device allowing continuous monitoring of the diaphragm (CUSdi) could reliably (1) measure diaphragm excursion (EXdi) and peak contraction velocity (PCVdi), (2) predict weaning outcome, and (3) approximate transdiaphragmatic pressure (Pdi)., Methods: In 49 mechanically ventilated patients, CUSdi was recorded during a 30-min spontaneous breathing trial (SBT), and EXdi and PCVdi were measured. In subgroups of patients, standard ultrasound measurement of EXdi and PCVdi was performed (n = 36), and Pdi derived parameters (peak and pressure time product, n = 30) were measured simultaneously., Results: The agreement bias between standard ultrasound and CUSdi for EXdi was 0.1 cm (95% confidence interval -0.7-0.9 cm). The regression of Passing-Bablok indicated a lack of systematic difference between EXdi measured with standard ultrasound and CUSdi, which were positively correlated (Rho = 0.84, p < 0.001). Weaning failure was observed in 54% of patients. One, two and three minutes after the onset of the SBT, EXdi was higher in the weaning success group than in the failure group. Two minutes after the onset of the SBT, an EXdi < 1.1 cm predicted weaning failure with a sensitivity of 0.83, a specificity of 0.68, a positive predictive value of 0.76, and a negative predictive value of 0.24. There was a weak correlation between EXdi and both peak Pdi (r = 0.22, 95% confidence interval 0.15 - 0.28) and pressure time product (r = 0.13, 95% confidence interval 0.06 - 0.20). Similar results were observed with PCVdi., Conclusions: Operator-independent continuous diaphragm monitoring quantifies EXdi reliably and can predict weaning failure with an identified cut-off value of 1.1 cm. Trial registration clinicaltrial.gov, NCT04008875 (submitted 12 April 2019, posted 5 July 2019) and NCT03896048 (submitted 27 March 2019, posted 29 March 2019)., (© 2024. The Author(s).)

Background: Lung protective ventilation aims at limiting lung stress and strain. By reducing the amount of pressure transmitted by the ventilator into the lungs, diaphragm neurostimulation offers a promising approach to minimize ventilator-induced lung injury. This study investigates the physiologic effects of diaphragm neurostimulation in acute respiratory distress syndrome (ARDS) patients. The hypothesis was that diaphragm neurostimulation would improve oxygenation, would limit the distending pressures of the lungs, and would improve cardiac output., Methods: Patients with moderate ARDS were included after 48 h of invasive mechanical ventilation and had a left subclavian catheter placed to deliver bilateral transvenous phrenic nerve stimulation. Two 60-min volume-controlled mechanical ventilation (control) sessions were interspersed by two 60-min diaphragm neurostimulation sessions delivered continually, in synchrony with the ventilator. Gas exchange, lung mechanics, chest electrical impedance tomography, and cardiac index were continuously monitored and compared across four sessions. The primary endpoint was the Pao2/fraction of inspired oxygen (Fio2) ratio at the end of each session, and the secondary endpoints were lung mechanics and hemodynamics., Results: Thirteen patients were enrolled but the catheter could not be inserted in one, leaving 12 patients for analysis. All sessions were conducted without interruption and well tolerated. The Pao2/Fio2 ratio did not change during the four sessions. Median (interquartile range) plateau pressure was 23 (20 to 31) cm H2O and 21 (17 to 25) cm H2O, driving pressure was 14 (12 to 18) cm H2O and 11 (10 to 13) cm H2O, and end-inspiratory transpulmonary pressure was 9 (5 to 11) cm H2O and 7 (4 to 11) cm H2O during mechanical ventilation alone and during mechanical ventilation + neurostimulation session, respectively. The dorsal/ventral ventilation surface ratio was 0.70 (0.54 to 0.91) when on mechanical ventilation and 1.20 (0.76 to 1.33) during the mechanical ventilation + neurostimulation session. The cardiac index was 2.7 (2.3 to 3.5) l · min-1 · m-2 on mechanical ventilation and 3.0 (2.4 to 3.9) l · min-1 · m-2 on mechanical ventilation + neurostimulation., Conclusions: This proof-of-concept study showed the feasibility of short-term diaphragm neurostimulation in conjunction with mechanical ventilation in ARDS patients. Diaphragm neurostimulation was associated with positive effects on lung mechanics and on hemodynamics., (Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved.)

Background: Diaphragm dysfunction and its effects on outcomes of ventilator weaning have been evaluated in mixed critical care populations using diaphragm thickening fraction (the ratio of the difference between ultrasound diaphragm thickness at end-inspiration and end-expiration to diaphragm thickness at end-expiration) or neuroventilatory efficiency (the ratio of tidal volume and peak electrical activity of the diaphragm). Such data are not available in bilateral-lung transplant recipients. The authors hypothesized that (1) diaphragm dysfunction, as defined by a diaphragm thickening fraction less than 29%, is more likely to occur in difficult weaning; (2) diaphragm thickening fraction and neuroventilatory efficiency predict weaning outcome; and (3) duration of mechanical ventilation before the first spontaneous breathing trial is associated with diaphragm dysfunction., Methods: Adult bilateral-lung transplant patients admitted to the intensive care unit were screened at the time of the first spontaneous breathing trial (pressure-support of 5 cm H2O and 0 positive end-expiratory pressure). At the fifth minute, diaphragm thickening fraction and neuroventilatory efficiency were measured during three respiratory cycles. Weaning was classified as simple, difficult, or prolonged (successful extubation at the first spontaneous breathing trial, within three or after three spontaneous breathing trials, respectively)., Results: Forty-four subjects were enrolled. Diaphragm dysfunction occurred in 14 subjects (32%), all of whom had difficult weaning (78% of the subgroup of 18 patients experiencing difficult weaning). Both diaphragm thickening fraction (24 [20 to 29] vs. 39 [35 to 45]%) and neuroventilatory efficiency (34 [26 to 45] vs. 55 [43 to 62] ml/µV) were lower in difficult weaning (both P < 0.001). The areas under the receiver operator curve predicting difficult weaning were 0.88 (95% CI, 0.73 to 0.99) for diaphragm thickening fraction and 0.85 (95% CI, 0.71 to 0.95) for neuroventilatory efficiency. The duration of ventilation demonstrated a linear inverse correlation with both diaphragm thickening fraction and neuroventilatory efficiency., Conclusions: Diaphragm dysfunction is common after bilateral-lung transplantation and associated with difficult weaning. In such patients, average values for diaphragm thickening fraction and neuroventilatory efficiency were reduced compared to patients with simple weaning. Both parameters showed similar accuracy for predicting success of ventilator weaning, demonstrating an inverse relationship with duration of ventilation., (Copyright © 2023 American Society of Anesthesiologists. All Rights Reserved.)

Side effects of mechanical ventilation, such as ventilator-induced diaphragmatic dysfunction (VIDD) and ventilator-induced lung injury (VILI), occur frequently in critically ill patients. Phrenic nerve stimulation (PNS) has been a valuable tool for diagnosing VIDD by assessing respiratory muscle strength in response to magnetic PNS. The detection of pathophysiologically reduced respiratory muscle strength is correlated with weaning failure, longer mechanical ventilation time, and mortality. Non-invasive electromagnetic PNS designed for diagnostic use is a reference technique that allows clinicians to measure transdiaphragm pressure as a surrogate parameter for diaphragm strength and functionality. This helps to identify diaphragm-related issues that may impact weaning readiness and respiratory support requirements, although lack of lung volume measurement poses a challenge to interpretation. In recent years, therapeutic PNS has been demonstrated as feasible and safe in lung-healthy and critically ill patients. Effects on critically ill patients' VIDD or diaphragm atrophy outcomes are the subject of ongoing research. The currently investigated application forms are diverse and vary from invasive to non-invasive and from electrical to (electro)magnetic PNS, with most data available for electrical stimulation. Increased inspiratory muscle strength and improved diaphragm activity (e.g., excursion, thickening fraction, and thickness) indicate the potential of the technique for beneficial effects on clinical outcomes as it has been successfully used in spinal cord injured patients. Concerning the potential for electrophrenic respiration, the data obtained with non-invasive electromagnetic PNS suggest that the induced diaphragmatic contractions result in airway pressure swings and tidal volumes remaining within the thresholds of lung-protective mechanical ventilation. PNS holds significant promise as a therapeutic intervention in the critical care setting, with potential applications for ameliorating VIDD and the ability for diaphragm training in a safe lung-protective spectrum, thereby possibly reducing the risk of VILI indirectly. Outcomes of such diaphragm training have not been sufficiently explored to date but offer the perspective for enhanced patient care and reducing weaning failure. Future research might focus on using PNS in combination with invasive and non-invasive assisted ventilation with automatic synchronisation and the modulation of PNS with spontaneous breathing efforts. Explorative approaches may investigate the feasibility of long-term electrophrenic ventilation as an alternative to positive pressure-based ventilation., (© 2023. The Author(s).)

Background: This study hypothesized that patients with extubation failure exhibit a loss of lung aeration and heterogeneity in air distribution, which could be monitored by chest EIT and lung ultrasound. Patients at risk of extubation failure were included after a successful spontaneous breathing trial. Lung ultrasound [with calculation of lung ultrasound score (LUS)] and chest EIT [with calculation of the global inhomogeneity index, frontback center of ventilation (CoV), regional ventilation delay (RVD) and surface available for ventilation] were performed before extubation during pressure support ventilation (H0) and two hours after extubation during spontaneous breathing (H2). EIT was then repeated 6 h (H6) after extubation. EIT derived indices and LUS were compared between patients successfully extubated and patients with extubation failure., Results: 40 patients were included, of whom 12 (30%) failed extubation. Before extubation, when compared with patients with successful extubation, patients who failed extubation had a higher LUS (19 vs 10, p = 0.003) and a smaller surface available for ventilation (352 vs 406 pixels, p = 0.042). After extubation, GI index and LUS were higher in the extubation failure group, whereas the surface available for ventilation was lower. The RVD and the CoV were not different between groups., Conclusion: Before extubation, a loss of lung aeration was observed in patients who developed extubation failure afterwards. After extubation, this loss of lung aeration persisted and was associated with regional lung ventilation heterogeneity. Trial registration Clinical trials, NCT04180410, Registered 27 November 2019-prospectively registered, https://clinicaltrials.gov/ct2/show/NCT04180410 ., (© 2023. The Author(s).)

Background: Venovenous extracorporeal membrane oxygenation (VV ECMO) is frequently associated with deep sedation and neuromuscular blockades, that may lead to diaphragm dysfunction. However, the prevalence, risk factors, and evolution of diaphragm dysfunction in patients with VV ECMO are unknown. We hypothesized that the prevalence of diaphragm dysfunction is high and that diaphragm activity influences diaphragm function changes., Methods: Patients with acute respiratory distress syndrome (ARDS) requiring VV ECMO were included in two centers. Diaphragm function was serially assessed by measuring the tracheal pressure in response to phrenic nerve stimulation (Ptr,stim) from ECMO initiation (Day 1) until ECMO weaning. Diaphragm activity was estimated from the percentage of spontaneous breathing ventilation and by measuring the diaphragm thickening fraction (TFdi) with ultrasound., Results: Sixty-three patients were included after a median of 4 days (3-6) of invasive mechanical ventilation. Diaphragm dysfunction, defined by Ptr, stim ≤ 11 cmH 2 O, was present in 39 patients (62%) on Day 1 of ECMO. Diaphragm function did not change over the study period and was not influenced by the percentage of spontaneous breathing ventilation or the TFdi during the 1 week. Among the 63 patients enrolled in the study, 24 (38%) were still alive at the end of the study period (60 days)., Conclusions: Sixty-two percent of patients undergoing ECMO for ARDS related to SARS CoV-2 infection had a diaphragm dysfunction on Day 1 of ECMO initiation. Diaphragm function remains stable over time and was not associated with the percentage of time with spontaneous breathing., Clinicaltrials: gov Identifier NCT04613752 (date of registration February 15, 2021)., (© 2023. The Author(s).)

During the COVID-19 pandemic, the use of non-invasive respiratory support (NIRS) became crucial in treating patients with acute hypoxemic respiratory failure. Despite the fear of viral aerosolization, non-invasive respiratory support has gained attention as a way to alleviate ICU overcrowding and reduce the risks associated with intubation. The COVID-19 pandemic has led to an unprecedented increased demand for research, resulting in numerous publications on observational studies, clinical trials, reviews, and meta-analyses in the past three years. This comprehensive narrative overview describes the physiological rationale, pre-COVID-19 evidence, and results of observational studies and randomized control trials regarding the use of high-flow nasal oxygen, non-invasive mechanical ventilation, and continuous positive airway pressure in adult patients with COVID-19 and associated acute hypoxemic respiratory failure. The review also highlights the significance of guidelines and recommendations provided by international societies and the need for further well-designed research to determine the optimal use of NIRS in treating this population.

Background: In patients on mechanical ventilation, positive end-expiratory pressure (PEEP) can decrease cardiac output through a decrease in cardiac preload and/or an increase in right ventricular afterload. Increase in central blood volume by fluid administration or passive leg raising (PLR) may reverse these phenomena through an increase in cardiac preload and/or a reopening of closed lung microvessels. We hypothesized that a transient decrease in PEEP (PEEP-test) may be used as a test to detect volume responsiveness., Methods: Mechanically ventilated patients with PEEP ≥ 10 cmH 2 O ("high level") and without spontaneous breathing were prospectively included. Volume responsiveness was assessed by a positive PLR-test, defined as an increase in pulse-contour-derived cardiac index (CI) during PLR ≥ 10%. The PEEP-test consisted in reducing PEEP from the high level to 5 cmH 2 O for one minute. Pulse-contour-derived CI (PiCCO2) was monitored during PLR and the PEEP-test., Results: We enrolled 64 patients among whom 31 were volume responsive. The median increase in CI during PLR was 14% (11-16%). The median PEEP at baseline was 12 (10-15) cmH 2 O and the PEEP-test resulted in a median decrease in PEEP of 7 (5-10) cmH 2 O, without difference between volume responsive and unresponsive patients. Among volume responsive patients, the PEEP-test induced a significant increase in CI of 16% (12-20%) (from 2.4 ± 0.7 to 2.9 ± 0.9 L/min/m 2 , p < 0.0001) in comparison with volume unresponsive patients. In volume unresponsive patients, PLR and the PEEP-test increased CI by 2% (1-5%) and 6% (3-8%), respectively. Volume responsiveness was predicted by an increase in CI > 8.6% during the PEEP-test with a sensitivity of 96.8% (95% confidence interval (95%CI): 83.3-99.9%) and a specificity of 84.9% (95%CI 68.1-94.9%). The area under the receiver operating characteristic curve of the PEEP-test for detecting volume responsiveness was 0.94 (95%CI 0.85-0.98) (p < 0.0001 vs. 0.5). Spearman's correlation coefficient between the changes in CI induced by PLR and the PEEP-test was 0.76 (95%CI 0.63-0.85, p < 0.0001)., Conclusions: A CI increase > 8.6% during a PEEP-test, which consists in reducing PEEP to 5 cmH 2 O, reliably detects volume responsiveness in mechanically ventilated patients with a PEEP ≥ 10 cmH 2 O. Trial registration ClinicalTrial.gov (NCT 04,023,786). Registered July 18, 2019. Ethics Committee approval CPP Est III (N° 2018-A01599-46)., (© 2023. The Author(s).)

Weaning is a critical stage of an intensive care unit (ICU) stay, in which the respiratory muscles play a major role. Weakness of the respiratory muscles, which is associated with significant morbidity in the ICU, is not limited to atrophy and subsequent dysfunction of the diaphragm; the extradiaphragmatic inspiratory and expiratory muscles also play important parts. In addition to the well-established deleterious effect of mechanical ventilation on the respiratory muscles, other risk factors such as sepsis may be involved. Weakness of the respiratory muscles can be suspected visually in a patient with paradoxical movement of the abdominal compartment. Measurement of maximal inspiratory pressure is the simplest way to assess respiratory muscle function, but it does not specifically take the diaphragm into account. A cut-off value of -30 cmH 2 O could identify patients at risk for prolonged ventilatory weaning; however, ultrasound may be better for assessing respiratory muscle function in the ICU. Although diaphragm dysfunction has been associated with weaning failure, this diagnosis should not discourage clinicians from performing spontaneous breathing trials and considering extubation. Recent therapeutic developments aimed at preserving or restoring respiratory muscle function are promising., Competing Interests: Conflicts of interest: M. Dres reports personal fees from Lungpacer Med. Inc. for participation to Clinical Advisory Board, research grants, and non-financial support for travel expenses, from Dräger for congress registration (SRLF 2021) and from Bioserenity for research grant, all not related to this work. M. Van Hollebeke and C. Bureau have no conflict of interest to disclose., (Copyright ©The authors 2023.)

Background: Proportional assist ventilation with load-adjustable gain factors (PAV+) is a mechanical ventilation mode that delivers assistance to breathe in proportion to the patient's effort. The proportional assistance, called the gain, can be adjusted by the clinician to maintain the patient's respiratory effort or workload within a normal range. Short-term and physiological benefits of this mode compared to pressure support ventilation (PSV) include better patient-ventilator synchrony and a more physiological response to changes in ventilatory demand., Methods: The objective of this multi-centre randomized controlled trial (RCT) is to determine if, for patients with acute respiratory failure, ventilation with PAV+ will result in a shorter time to successful extubation than with PSV. This multi-centre open-label clinical trial plans to involve approximately 20 sites in several continents. Once eligibility is determined, patients must tolerate a short-term PSV trial and either (1) not meet general weaning criteria or (2) fail a 2-min Zero Continuous Positive Airway Pressure (CPAP) Trial using the rapid shallow breathing index, or (3) fail a spontaneous breathing trial (SBT), in this sequence. Then, participants in this study will be randomized to either PSV or PAV+ in a 1:1 ratio. PAV+ will be set according to a target of muscular pressure. The weaning process will be identical in the two arms. Time to liberation will be the primary outcome; ventilator-free days and other outcomes will be measured., Discussion: Meta-analyses comparing PAV+ to PSV suggest PAV+ may benefit patients and decrease healthcare costs but no powered study to date has targeted the difficult to wean patient population most likely to benefit from the intervention, or used consistent timing for the implementation of PAV+. Our enrolment strategy, primary outcome measure, and liberation approaches may be useful for studying mechanical ventilation and weaning and can offer important results for patients., Trial Registration: ClinicalTrials.gov NCT02447692 . Prospectively registered on May 19, 2015., (© 2023. The Author(s).)

Importance: The ability to attract and retain university hospital faculty staff is in jeopardy because of the high levels of mental symptoms in this professional group., Objective: To examine the prevalence and determinants of symptoms of severe burnout, job strain, and suicidal ideation in tenured associate and full professors in university hospitals., Design, Setting, and Participants: This nationwide cross-sectional study offered online surveys to 5332 tenured university hospital faculty members in France from October 25, 2021, to December 20, 2021., Exposures: Burnout and job strain., Main Outcomes and Measures: Participants completed the 22-item Maslach Burnout Inventory and a 12-item job strain assessment tool, reported suicidal ideation, and used visual analog scales to evaluate unidimensional parameters. The primary outcome was presence of severe burnout symptoms. Factors associated with mental health symptoms were identified by multivariable logistic regression., Results: Completed questionnaires were returned by 2390 of 5332 faculty members (response rate, 45%; range, 43%-46%). Tenured associate professors were a median of 40 (IQR, 37-45) years old with a sex ratio of 1:1, whereas tenured full professors were a median of 53 (IQR, 46-60) years old with a sex ratio of 1:5. Of 2390 respondents, 952 (40%) reported symptoms of severe burnout. Symptoms of job strain (296 professors [12%]) and suicidal ideation (343 professors [14%]) were also reported. Compared with full professors, significantly more associate professors reported feeling overwhelmed at work (496 [73%] vs 972 [57%]; P < .001), considering resignation (365 [54%] vs 834 [49%]; P = .004), or considering a career change (277 [41%] vs 496 [29%]; P < .001). Factors independently associated with less burnout were a longer time being a professor (adjusted odds ratio [aOR], 0.97; 95% CI, 0.96-0.98 per year of age), sleeping well (aOR, 0.88; 95% CI, 0.83-0.92), feeling valued by colleagues (aOR, 0.91; 95% CI, 0.86-0.95 per visual analog scale point) or the public (aOR, 0.92; 95% CI, 0.88-0.96 per visual analog scale point), and accepting more tasks (aOR, 0.82; 95% CI, 0.72-0.93). Factors independently associated with more burnout were having a nonclinical position (OR, 2.48; 95% CI, 1.96-3.16), reporting work encroachment on private life (OR, 1.17; 95% CI, 1.10-1.25), feeling the need to constantly put on a brave face (OR, 1.82; 95% CI, 1.32-2.52), considering a career change (OR, 1.53; 95% CI, 1.22-1.92), and having experienced harassment (OR, 1.52; 95% CI, 1.22-1.88)., Conclusions and Relevance: These findings suggest that the psychological burden on tenured university hospital faculty staff in France is considerable. Hospital administrators and health care authorities should urgently develop strategies for burden prevention and alleviation and for attraction of the next generation.

Introduction: Studies regarding coronavirus disease 2019 (COVID-19) were mainly performed in the initial wave, but some small-scale data points to prognostic differences for patients in successive waves. We therefore aimed to study the impact of time on prognosis of ICU-admitted COVID-19 patients., Method: We performed a national retrospective cohort study, including all adult patients hospitalized in French ICUs from March 1, 2020 to June 30, 2021, and identified three surge periods. Primary and secondary outcomes were in-hospital mortality and need for invasive mechanical ventilation, respectively., Results: 105,979 critically ill ICU-admitted COVID-19 patients were allocated to the relevant three surge periods. In-hospital mortality for surges 1, 2, and 3 was, respectively, 24%, 27%, and 24%. Invasive mechanical ventilation was the highest level of respiratory support for 42%, 32%, and 31% (p < 0.001) over the whole period, with a decline in the use of vasopressors over time. Adjusted for age, sex, comorbidities, and modified Simplified Acute Physiology Score II at ICU admission, time period was associated with less invasive mechanical ventilation and a high risk of in-hospital death. Vaccination against COVID-19 was associated with a lower likelihood of invasive mechanical ventilation (adjusted sub-hazard ratio [aSHR] = 0.64 [0.53-0.76]) and intra-hospital death (aSHR = 0.80, [0.68-0.95])., Conclusion: In this large database of ICU patients admitted for COVID-19, we observed a decline in invasive mechanical ventilation, vasopressors, and RRT use over time but a high risk of in-hospital death. Vaccination was identified as protective against the risk of invasive mechanical ventilation and in-hospital death., (© 2023. The Author(s).)

Background: Dyspnea is common and severe in intensive care unit (ICU) patients managed for acute respiratory failure. Dyspnea appears to be associated with impaired prognosis and neuropsychological sequels. Pain and dyspnea share many similarities and previous studies have shown the benefit of morphine on dyspnea in patients with end-stage onco-hematological disease and severe heart or respiratory disease. In these populations, morphine administration was safe. Here, we hypothesize that low-dose opioids may help to reduce dyspnea in patients admitted to the ICU for acute respiratory failure. The primary objective of the trial is to determine whether the administration of low-dose titrated opioids, compared to placebo, in patients admitted to the ICU for acute respiratory failure with severe dyspnea decreases the mean 24-h intensity of dyspnea score., Methods: In this single-center double-blind randomized controlled trial with 2 parallel arms, we plan to include 22 patients (aged 18-75 years) on spontaneous ventilation with either non-invasive ventilation, high flow oxygen therapy or standard oxygen therapy admitted to the ICU for acute respiratory failure with severe dyspnea. They will be assigned after randomization with a 1:1 allocation ratio to receive in experimental arm administration of low-dose titrated morphine hydrochloride for 24 h consisting in an intravenous titration relayed subcutaneously according to a predefined protocol, or a placebo (0.9% NaCl) administered according to the same protocol in the control arm. The primary endpoint is the mean 24-h dyspnea score assessed by a visual analog scale of dyspnea., Discussion: To our knowledge, this study is the first to evaluate the benefit of opioids on dyspnea in ICU patients admitted for acute respiratory failure., Trial Registration: ClinicalTrials.gov NCT04358133 . Registered on 24 April 2020., (© 2022. The Author(s).)

Background: The objective of this study was to assess the feasibility and safety of a novel, removable, surgically implanted, temporary neurostimulation approach involving the distal portion of the phrenic nerve., Methods: Temporary phrenic nerve pacing electrodes were implanted surgically using an ovine model (4 animals). The primary endpoint was the ability to successfully match the animal's minute-ventilation upon implantation of both phrenic nerve pacers on day 1. Secondary endpoints were successful phrenic neurostimulation by both electrodes 15 and 30 days after initial implantation. We also assessed safe removal of the electrodes at 15 and 30 days after implementation., Results: In 3 of 4 animals, electrodes were successfully implanted in both right and left phrenic nerves. On day 1, median ventilation-minute induced by neurostimulation was not significantly different from baseline ventilation-minute [4.9 L·min -1 (4.4-5.5) vs. 4.4 L·min -1 (4.3-5.2); P=0.4] after 15 minutes. Neurostimulation was still possible 15 and 30 days after implementation in all left side phrenic nerves. On the right side, stimulation was possible at all times in 1 animal but not in the remaining 3 animals for at least one time point, possibly due to lead displacement. Analysis of pathology after percutaneous electrode removal showed integrity of the distal portion of all phrenic nerves., Conclusions: Efficient temporary neurostimulation through the distal portion of the phrenic nerve was possible at baseline. The main complication was the displacement of electrodes on the right phrenic nerve on two occasions, which was due to the anatomy of the ovine model. It compromised diaphragm pacing on day 15 and day 30. The electrodes could be safely removed percutaneously without damage to the phrenic nerves., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-21-1944/coif). All authors report funding of the experimental procedures by Atrotech (Tampere, Finland). The authors have no other conflicts of interest to declare., (2022 Journal of Thoracic Disease. All rights reserved.)

Background: Patients with ARDS due to COVID-19 may require tracheostomy and transfer to a weaning center. To date, data on the outcome of these patients are scarce. The objectives of this study were to determine the factors associated with time to decannulation and limb-muscle strength recovery., Methods: This was an observational retrospective study of subjects with COVID-19-related ARDS requiring tracheostomy after prolonged ventilation, who were subsequently transferred to a weaning center from April 4, 2020-May 30, 2020., Results: Forty-three subjects were included. Median age (interquartile range) was 61 (48-66) y; 81% were men, and median body mass index (BMI) was 30 (26-35) kg/m 2 . Tracheostomy was performed after a median of 19 (12-27) d of mechanical ventilation, and the median ICU length of stay prior to transfer to the weaning center was 30 (21-46) d. On admission to the weaning center, the median Medical Research Council (MRC) score was 36 (27-44). Time to decannulation was 9 (7-18) d after admission to the weaning center. The only factor independently associated with early decannulation was the MRC score on admission to the weaning center (odds ratio 1.16 [95% CI 1.06-1.31], P = .005). Two factors were independently associated with MRC gain ≥ 10: BMI (odds ratio 0.88 [95% CI 0.76-0.99], P = .045) and MRC on admission (odds ratio 0.91 [95% CI 0.82-0.98], P = .03. Three months after admission to the weaning center, 40 subjects (93%) were weaned from mechanical ventilation and 36 (84%) had returned home., Conclusions: MRC score at weaning center admission predicted both early decannulation and limb-muscle strength recovery., Competing Interests: Dr Faure discloses relationships GE Medical System, Pfizer, Bayer Healthcare, and Actelion. Dr Decavèle discloses a relationship with Isis Medical. Dr Dres discloses relationships with BioSerenity and Lungpacer. Dr Mayaux discloses a relationship with Gilead. Dr Caliez discloses a relationship with Oxyvie. Dr Similowski discloses relationships with ADEP Assistance, AstraZeneca France, Chiesi France, GlaxoSmithKline France, Lungpacer Canada, Novartis France, and Teva France. Dr Demoule discloses relationships with Philips, Baxter, Fisher & Paykel, French Ministry of Health, Getinge, Respinor, Lungpacer, Lowenstein, and Gilead. The remaining authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Background: The association between dyspnea and mortality has not been demonstrated in the ICU setting. We tested the hypothesis that dyspnea (self-reported respiratory discomfort) or its observational correlates (5-item intensive care Respiratory Distress Observation Scale [IC-RDOS]) assessed on ICU admission would be associated with ICU mortality., Methods: Ancillary analysis of single-center data prospectively collected from 220 communicative ICU subjects allocated to a derivation cohort of 120 subjects and a separate validation cohort of 100 subjects. Dyspnea was assessed dichotomously (yes/no), with a dyspnea visual analog scale (measured in mm), and IC-RDOS was calculated. Multivariate logistic regression was used to identify factors associated with ICU and hospital mortality., Results: Dyspnea was reported by 69 (58%; median 45 [interquartile range [IQR] 32-60] mm) and 47 (47%; 38 [IQR 26-48] mm) subjects in the derivation and validation cohorts, respectively. IC-RDOS was 2.3 (1.2-3.1) and 2.4 (1.3-2.8), respectively. IC-RDOS values were higher in subjects with dyspnea than in subjects without dyspnea in both the derivation cohort (2.6 [2.2-4.6] vs 1.4 [0.9-2.4], P < .001) and the validation cohort (2.6 [2.3-4.4] vs 2.2 [1.0-2.8], P < .001). On multivariate analysis of the derivation cohort, admission for hemorrhagic shock (odds ratio 13.98), IC-RDOS (odds ratio 1.77), and Simplified Acute Physiology Score II (odds ratio 1.10) was associated with ICU mortality. Areas under the receiving operating characteristic curve of IC-RDOS to predict ICU mortality were 0.785 and 0.794 in the derivation and validation cohorts, respectively., Conclusions: IC-RDOS, an observational correlate of dyspnea, but not dyspnea itself, was associated with higher mortality in ICU subjects., Competing Interests: Dr Decavèle discloses a relationship with ISIS Medical. Dr Similowski discloses relationships with AstraZeneca France, Boerhinger Ingelheim France, Novartis France, Teva France, Chiesi France, Lungpacer, ADEP Assistance, and Air Liquide Medical Systems. Dr Demoule discloses relationships with Philips, Baxter, Fisher & Paykel, French Ministry of Health, Getinge, Respinor, Lungpacer, Löwenstein, and Gilead. Dr Dres discloses relationships with Lungpacer and BioSerenity. Dr Morélot-Panzini discloses relationships with AstraZeneca, GlaxoSmithKline, SOS Oxygène, ADEP, ISIS, ResMed, Chiesi, Menarini, Vivisol, Air Liquide, Löwenstein, and Fisher & Paykel. Dr Mayaux discloses a relationship with Gilead France. The remaining authors have disclosed no conflicts of interest., (Copyright © 2022 by Daedalus Enterprises.)

Rationale: Dyspnea, a key symptom of acute respiratory failure, is not among the criteria for spontaneous breathing trial (SBT) failure. Here, we sought (1) to determine whether dyspnea is a reliable failure criterion for SBT failure; (2) to quantify the relationship between dyspnea and the respective electromyographic activity of the diaphragm (EMGdi), the parasternal (EMGpa) and the Alae nasi (EMGan)., Methods: Mechanically ventilated patients undergoing an SBT were included. Dyspnea intensity was measured by the Dyspnea-Visual Analogic Scale (Dyspnea-VAS) at the initiation and end of the SBT. During the 30-min SBT or until SBT failure, the EMGdi was continuously measured with a multi-electrode nasogastric catheter and the EMGan and EMGpa with surface electrodes., Results: Thirty-one patients were included, SAPS 2 (median [interquartile range]) 53 (37‒74), mechanically ventilated for 6 (3‒10) days. Seventeen patients (45%) failed the SBT. The increase in Dyspnea-VAS along the SBT was higher in patients who failed (6 [4‒8] cm) than in those who passed (0 [0‒1] cm, p = 0.01). The area under the receiver operating characteristics curve for Dyspnea-VAS was 0.909 (0.786-1.032). The increase in Dyspnea-VAS was significantly correlated to the increase in EMGan (Rho = 0.42 [0.04‒0.70], p < 0.05), but not to the increase in EMGpa (Rho = - 0.121 [- 0.495 to - 0.290], p = 0.555) and EMGdi (Rho = - 0.26 [- 0.68 to 0.28], p = 0.289)., Conclusion: Dyspnea is a reliable criterion of SBT failure, suggesting that Dyspnea-VAS could be used as a monitoring tool of the SBT. In addition, dyspnea seems to be more closely related to the electromyographic activity of the Alae nasi than of the diaphragm., (© 2022. The Author(s).)

Background: Whether dyspnea is present before starting a spontaneous breathing trial (SBT) and whether it may affect the outcome of the SBT is unknown. Mechanical Ventilation-Respiratory Distress Observation Scale (MV-RDOS) has been proposed as a reliable surrogate of dyspnea in non-communicative intubated patients. In the present study, we sought (1) to describe the evolution of the MV-RDOS during a SBT and (2) to investigate whether MV-RDOS can predict the outcome of the SBT., Methods: Prospective, single-center study in a twenty-two bed ICU in a tertiary center. Patients intubated since more 48 h who had failed a first SBT were eligible if they meet classical readiness to wean criteria. The MV-RDOS was assessed before, at 2-min, 15-min and 30-min (end) of the SBT. The presence of clinically important dyspnea was inferred by a MV-RDOS value ≥  2.6., Results: Fifty-eight patients (age 63 [51-70], SAPS II 66 [51-76]; med [IQR]) were included. Thirty-three (57%) patients failed the SBT, whose 18 (55%) failed before 15-min. Twenty-five (43%) patients successfully passed the SBT. A MV-RDOS ≥ 2.6 was present in ten (17%) patients before to start the SBT. All these ten patients subsequently failed the SBT. A MV-RDOS ≥ 2.6 at 2-min predicted a SBT failure with a 51% sensibility and a 88% specificity (AUC 0.741 95% confidence interval [CI] 0.616-0.866, p = 0.002). Best cut-off value at 2-min was 4.3 and predicted SBT failure with a 27% sensibility and a 96% specificity., Conclusion: Despite patients met classical readiness to wean criteria, respiratory distress assessed with the MV-RDOS was frequent at the beginning of SBT. Measuring MV-RDOS before to initiate a SBT could avoid undue procedure and reduce patient's exposure to unnecessary mechanical ventilation weaning failure and distress., (© 2022. The Author(s).)

Introduction: COVID-19 induces venous, arterial and microvascular thrombosis, involving several pathophysiological processes. In patients with severe COVID-19 without macrovascular thrombosis, escalating into high-dose prophylactic anticoagulation (HD-PA) or therapeutic anticoagulation (TA) could be beneficial in limiting the extension of microvascular thrombosis and forestalling the evolution of lung and multiorgan microcirculatory dysfunction. In the absence of data from randomised trials, clinical practice varies widely., Methods and Analysis: This is a French multicentre, parallel-group, open-label, randomised controlled superiority trial to compare the efficacy and safety of three anticoagulation strategies in patients with COVID-19. Patients with oxygen-treated COVID-19 showing no pulmonary artery thrombosis on computed tomography with pulmonary angiogram will be randomised to receive either low-dose PA, HD-PA or TA for 14 days. Patients attaining the extremes of weight and those with severe renal failure will not be included. We will recruit 353 patients. Patients will be randomised on a 1:1:1 basis, and stratified by centre, use of invasive mechanical ventilation, D-dimer levels and body mass index. The primary endpoint is a hierarchical criterion at day 28 including all-cause mortality, followed by the time to clinical improvement defined as the time from randomisation to an improvement of at least two points on the ordinal clinical scale. Secondary outcomes include thrombotic and major bleeding events at day 28, individual components of the primary endpoint, number of oxygen-free, ventilator-free and vasopressor-free days at day 28, D-dimer and sepsis-induced coagulopathy score at day 7, intensive care unit and hospital stay at day 28 and day 90, and all-cause death and quality of life at day 90., Ethics and Dissemination: The study has been approved by an ethical committee (Ethics Committee, Ile de France VII, Paris, France; reference 2020-A03531-38). Patients will be included after obtaining their signed informed consent. The results will be submitted for publication in peer-reviewed journals., Trial Registration Number: NCT04808882., Competing Interests: Competing interests: AMD reports lectures for Leo Pharma. EA reports personal fees from GBT, personal fees from Hemanext, both unrelated to the present study. GV received research grant from Bio-Mérieux, SOS Oxygène, Janssen, all unrelated to the present study; and advisory board fees from BioMérieux that are unrelated to the present study. VL receives advisory board fees from Amomed, unrelated to the present study., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Whether sepsis-associated diaphragm dysfunction may improve despite the exposure of mechanical ventilation in critically ill patients is unclear. This study aims at describing the diaphragm function time course of septic and non-septic mechanically ventilated patients., Methods: Secondary analysis of two prospective observational studies of mechanically ventilated patients in whom diaphragm function was assessed twice: within the 24 h after intubation and when patients were switched to pressure support mode, by measuring the endotracheal pressure in response to bilateral anterior magnetic phrenic nerve stimulation (Ptr,stim). Change in diaphragm function was expressed as the difference between Ptr,stim measured under pressure support mode and Ptr,stim measured within the 24 h after intubation. Sepsis was defined according to the Sepsis-3 international guidelines upon inclusion. In a sub-group of patients, the right hemidiaphragm thickness was measured by ultrasound., Results: Ninety-two patients were enrolled in the study. Sepsis upon intubation was present in 51 (55%) patients. In septic patients, primary reason for ventilation was acute respiratory failure related to pneumonia (37/51; 73%). In non-septic patients, main reasons for ventilation were acute respiratory failure not related to pneumonia (16/41; 39%), coma (13/41; 32%) and cardiac arrest (6/41; 15%). Ptr,stim within 24 h after intubation was lower in septic patients as compared to non-septic patients: 6.3 (4.9-8.7) cmH 2 O vs. 9.8 (7.0-14.2) cmH 2 O (p = 0.004), respectively. The median (interquartile) duration of mechanical ventilation between first and second diaphragm evaluation was 4 (2-6) days in septic patients and 3 (2-4) days in non-septic patients (p = 0.073). Between first and second measurements, the change in Ptr,stim was + 19% (- 13-61) in septic patients and - 7% (- 40-12) in non-septic patients (p = 0.005). In the sub-group of patients with ultrasound measurements, end-expiratory diaphragm thickness decreased in both, septic and non-septic patients. The 28-day mortality was higher in patients with decrease or no change in diaphragm function., Conclusion: Septic patients were associated with a more severe but reversible impaired diaphragm function as compared to non-septic patients. Increase in diaphragm function was associated with a better survival., (© 2022. The Author(s).)