Formation and energetics of head-to-head and tail-to-tail domain walls in hafnium zirconium oxide.

180 ∘ domains walls (DWs) of head-to-head/tail-to-tail (H-H/T-T) type in ferroelectric (FE) materials are of immense interest for a comprehensive understanding of the FE attributes as well as harnessing them for new applications. Our first principles calculation suggests that such DW formation in hafnium zirconium oxide (HZO) based FEs depends on the unique attributes of the HZO unit cell, such as polar-spacer segmentation. Cross pattern of the polar and spacer segments in two neighboring domains along the polarization direction (where polar segment of one domain aligns with the spacer segment of another) boosts the stability of such DWs. We further show that low density of oxygen vacancies at the metal-HZO interface and high work function of metal electrodes are conducive for T-T DW formation. On the other hand, high density of oxygen vacancy and low work function of metal electrode favor H-H DW formation. Polarization bound charges at the DW get screened when band bending from depolarization field accumulates holes (electrons) in T-T (H-H) DW. For a comprehensive understanding, we also investigate their FE nature and domain growth mechanism. Our analysis suggests that a minimum thickness criterion of domains has to be satisfied for the stability of H-H/T-T DW and switching of the domains through such DW formation.

Complex management of pulmonary embolism in APLA syndrome: a case study of ECMO and bivalirudin utilization.

We report a case of a 22-year-old female with antiphospholipid antibody (APLA) syndrome who presented with severe dyspnea. Diagnostic imaging confirmed pulmonary embolism (PE), and treatment comprised unfractionated heparin and apixaban. APLA syndrome was diagnosed based on clinical, serological, and radiological findings. During evaluation, the patient developed cardiogenic shock necessitating catheter-directed thrombolysis, followed by veno-arterial extracorporeal membrane oxygenation (VA-ECMO) due to deteriorating condition and suspected heparin-induced thrombocytopenia (HIT). Surgical embolectomy with bivalirudin use followed, and a hybrid veno-arterial-venous (VAV) ECMO setup was implemented. Postoperatively, the patient improved, transitioning to veno-venous (VV) ECMO and eventually ECMO withdrawal. ECMO is a valuable tool for managing complex cardiorespiratory cases like PE. In the context of HIT and APLA syndrome, prompt anticoagulant transition is vital, and bivalirudin is an effective heparin alternative. Our study highlights the challenges involved in managing patients needing ECMO support with immunothrombotic conditions like HIT and APLA syndrome.

Cardiac magnetic resonance imaging for myocardial viability assessment: Optimizing surgical revascularization in ischemic heart disease.

BACKGROUND: Patients with poor ejection fraction undergoing coronary artery bypass grafting carry higher operative risk and have poor long-term survival. Cardiac magnetic resonance is a useful modality to assess viability which can identify patients likely to benefit most from revascularization. In this study, we aimed to assess the outcome in patients selected for surgical revascularization by cardiac magnetic resonance imaging and identify predictors associated with poor outcomes. METHODS: The study included patients with severely impaired left ventricular function but with at least six viable segments. Patients requiring emergency surgery, undergoing combined procedures, or where cardiopulmonary bypass was required were excluded. Cardiac magnetic resonance was carried out both preoperatively and at six months postoperatively by the same radiologist in all cases. Late gadolinium enhancement was used for the evaluation of myocardial viability. RESULTS: Amongst a total of 493 segments studied, there were 89 (18.1%) non-viable, 117 (23.7%) hibernating and 287 (58.2%) viable segments. At six months, the number of non-viable segments changed from 89 (18.1%) to 97 (19.7%), with an increase in viable segments from 287 (58.2%) to 374 (75.8%) and a corresponding reduction of hibernating segments from 117 (23.7%) to 22 (4.5%). There was improvement in ejection fraction from 28 ± 5.54 to 37 ± 5.86 (p < 0.0001) in the entire cohort at six months. Overall mortality was 1 (3.2%). Preoperative left ventricular end-systolic volume had the strongest negative correlation with post-operative ejection fraction. CONCLUSION: Cardiac magnetic resonance aided revascularization is associated with low mortality. Preoperative left ventricular end-systolic volume is an important determinant of postoperative ejection fraction.

Myxofibrosarcoma or myxoma: malignant transformation or misdiagnosis.

Inadequate excision, seeding, multicentricity and malignancy are often ascribed for recurrence of atrial myxomas. Differentiation between benign myxomas and malignant myxofibrosarcomas can be challenging, and a high index of clinical suspicion and vimentin staining on immunohistochemistry is needed to confirm the diagnosis. Early recurrence is common in these patients and completeness of excision is the key. Prognosis despite successful excision is poor. We report a benign atrial myxoma in a young female patient which upon recurrence turned out to be a myxofibrosarcoma.

On-pump beating heart versus off-pump myocardial revascularization-a propensity-matched comparison.

OBJECTIVE: On-pump beating heart (OP-BH) coronary artery bypass grafting (CABG) is often undertaken as an alternative between off-pump coronary artery bypass (OPCAB) and conventional on-pump coronary artery bypass grafting (On-pump CABG), especially in India. However, outcome data following OP-BH surgery is sparse. The aim of this study was to compare the outcomes of OP-BH CABG with OPCAB. METHODS: From our institutional database, all patients undergoing OP-BH CABG (n = 531) were identified. A propensity-matched cohort undergoing OPCAB (n = 531) was identified from the database. Nearest neighbor matching technique was used and the groups were matched for variables including age, gender, body mass index, EuroSCORE, history of recent myocardial infarction or unstable angina, hypertension, peripheral vascular disease, chronic obstructive airway disease, diabetes, pre-op renal impairment, pre-op neurological events, and left ventricular function. RESULTS: The propensity-matched groups were well matched in terms of baseline characteristics. The mean EuroSCORE was 3.17 and 3.20 in the OP-BH and the OPCAB groups. The unadjusted 30-day mortality in the propensity-matched OPCAB group was 2.07% (11/531) while mortality in the on-pump beating heart group was significantly higher at 6.9% (37/531). Multivariate analysis showed that OP-BH CABG was an independent risk factor for 30-day mortality as well as major adverse post-operative outcomes including renal, neurological, and respiratory outcomes and post-operative atrial fibrillation. CONCLUSIONS: OP-BH CABG is associated with worse clinical outcomes compared to patients undergoing OPCAB.

Mid-term clinical and health-related quality of life outcomes for the Trifecta bioprosthesis.

BACKGROUND: The Trifecta valve has been reported to have excellent hemodynamics. Controversy exists on occurrence of patient-prosthesis mismatch (PPM) and data on mid-term outcome is sparse. Health-related quality of life (HRQoL) assessment for the Trifecta valve has not been reported before. The aim of this study was to report the mid-term clinical and HRQoL outcomes in patients undergoing Trifecta valve implantation at our institution. METHODS: In this prospective, observational study, patients undergoing an aortic valve replacement (AVR) using the Trifecta valve were included. Data collection was retrospective from prospectively collected institutional database. Clinical and echocardiographic data were collected prospectively during follow-up. Quality of life was assessed using the Short Form-36 (SF-36) questionnaire. RESULTS: Forty-seven patients were included in the study of which 9 (19%) were women. Isolated AVR was carried out in 33 (70%) patients. In-hospital mortality and 30-day mortality were 1 (2.1%) and 2 (4.2%), respectively. With a mean indexed effective orifice area (iEOA) 0.96 ± 0.1, none of the patients had severe PPM. Moderate PPM was seen in 19%. The mean follow-up was 3 ± 1.7 years. The 5-year survival estimate was 83.2% in the overall cohort, 81.4% in the isolated and 87.5% in the concomitant procedure group. Freedom from re-operation and structural valve degeneration at 5 years was 95.7% and 97.8%. The mean physical health composite was 69.24 ± 2 and the mean mental health composite was 69.7 ± 25, indicating excellent mental and physical well-being among patients. CONCLUSION: The Trifecta valve provides satisfactory hemodynamics, survival and freedom from re-operation and excellent HRQoL at mid-term follow-up.

COVID-19 pandemic lockdown-induced altered sleep/wake circadian rhythm, health complaints and stress among traffic police personnel in India.

COVID-19 is a highly contagious disease caused by Severe Acute Respiratory Syndrome coronavirus-2, capable of high human transmission. To protect against the COVID-19 pandemic, the World Health Organization proposed intervening guidance that included movement restrictions, isolation, restriction of national and international travel or movement, and full or partial closure of organizations and institutions. Police personnel play a vital role in safeguarding the spread of COVID-19; thus, potentially causing severe stress due to increased consignment and direct exposure to infection during duty. The study aimed to determine the effect of the added stress of the COVID-19 pandemic and population lockdown on the sleep/wake 24 h rhythm of traffic police. A concise online questionnaire survey was conducted among the traffic police personnel of India. Collected data were analyzed statistically. Disorientation of working schedule, fear of being vulnerable to disease, pressure of maintaining law, and orders during lockdown increased stress level. The survey identified discontinuation of sleep, shift of mid-sleep time, increase in depression, plus stress and anxiety among traffic police personnel that affected their chronobiological milieu. Proper awareness of adequate health and safety measures, use of personnel protection equipment, regular conversation with family members, and meditation can help reduce stress during this pandemic situation.

Multi-Domain Negative Capacitance Effects in Metal-Ferroelectric-Insulator-Semiconductor/Metal Stacks: A Phase-field Simulation Based Study.

We analyze the ferroelectric domain-wall induced negative capacitance (NC) effect in Metal-FE-Insulator-Metal (MFIM) and Metal-FE-Insulator-Semiconductor (MFIS) stacks through phase-field simulations by self-consistently solving time-dependent Ginzburg Landau equation, Poisson's equation and semiconductor charge equations. Considering Hf0.5Zr0.5O2 as the ferroelectric material, we study 180° ferroelectric domain formation in MFIM and MFIS stacks and their polarization switching characteristics. Our analysis signifies that the applied voltage-induced polarization switching via soft domain-wall displacement exhibits non-hysteretic characteristics. In addition, the change in domain-wall energy, due to domain-wall displacement, exhibits a long-range interaction and thus, leads to a non-homogeneous effective local negative permittivity in the ferroelectric. Such effects yield an average negative effective permittivity that further provides an enhanced charge response in the MFIM stack, compared to Metal-Insulator-Metal. Furthermore, we show that the domain-wall induced negative effective permittivity is not an intrinsic property of the ferroelectric material and therefore, is dependent on its thickness, the gradient energy coefficient and the in-plane permittivity of the underlying insulator. Similar to the MFIM stack, MFIS stack also exhibits an enhanced charge/capacitance response compared to Metal-Oxide-Semiconductor (MOS) capacitor. Simultaneously, the multi-domain state of the ferroelectric induces non-homogeneous potential in the underlying insulator and semiconductor layer. At low applied voltages, such non-homogeneity leads to the co-existence of electrons and holes in an undoped semiconductor. In addition, we show that with the ferroelectric layer being in the 180° multi-domain state, the minimum potential at the ferroelectric-dielectric interface and hence, the minimum surface potential in the semiconductor, does not exceed the applied voltage (in-spite of the local differential amplification and charge enhancement).

Room-Temperature Electrocaloric Effect in Layered Ferroelectric CuInP2S6 for Solid-State Refrigeration.

A material with reversible temperature change capability under an external electric field, known as the electrocaloric effect (ECE), has long been considered as a promising solid-state cooling solution. However, electrocaloric (EC) performance of EC materials generally is not sufficiently high for real cooling applications. As a result, exploring EC materials with high performance is of great interest and importance. Here, we report on the ECE of ferroelectric materials with van der Waals layered structure (CuInP2S6 or CIPS in this work in particular). Over 60% polarization charge change is observed within a temperature change of only 10 K at Curie temperature. Large adiabatic temperature change (|ΔT|) of 3.3 K and isothermal entropy change (|ΔS|) of 5.8 J kg-1 K-1 at |ΔE| = 142.0 kV cm-1 and at 315 K (above and near room temperature) are achieved, with a large EC strength (|ΔT|/|ΔE|) of 29.5 mK cm kV-1. The ECE of CIPS is also investigated theoretically by numerical simulation, and a further EC performance projection is provided.

Preoperative Glycosylated Hemoglobin: A Risk Factor for Patients Undergoing Coronary Artery Bypass.

BACKGROUND: The prevalence of diabetes in the population of patients presenting with coronary artery disease continues to rise. The aim of this study was to assess whether high Glycosylated hemoglobin (HbA1c) was associated with adverse outcomes in patients undergoing elective coronary artery bypass grafting. METHODS: A retrospective observational study on prospectively collected data in 4,678 patients undergoing elective, isolated coronary artery bypass graft procedures in a single institution over a 4-year period was conducted. Patients were grouped into those with adequate preoperative control of hyperglycemia (HbA1c <6.5%) and those with suboptimal control (HbA1c ≥6.5%). Multivariable analysis using HbA1c as a binary independent variable was undertaken in the whole group. A subgroup analysis in diabetic patients and in nondiabetic patients was performed. The effect of HbA1c on outcomes at higher levels (HbA1c ≥8.0% and HbA1c ≥9.0%) was also assessed. RESULTS: A total of 4,678 patients (mean age, 58.8; male, 4,254) were included in the study. HbA1c was less than 6.5% in 2,476 (52.93%) patients and 6.5% or higher in 2,202 (47.07%) patients. On multivariate analysis, there was no difference in mortality rates between the groups (odds ratio, 1.36; 95% confidence interval [CI], 0.95 to 1.953; p = 0.08). Overall, an HbA1c of 6.5% or higher was an independent risk factor for respiratory complications (odds ratio, 1.05; 95% CI, 1.008 to 4.631; p = 0.01) and sternal dehiscence (odds ratio, 2.161; 95% CI, 1.008 to 4.63; p = 0.04). An association between HbA1c levels and adverse outcomes was not seen in nondiabetic patients. No additional adverse postoperative complications were seen with increasing HbA1c levels (HbA1c ≥8.0% and HbA1c ≥9.0%). CONCLUSIONS: An HbA1c level of 6.5% or higher in patients presenting for coronary artery bypass grafting was associated with a significant increase in the incidence of deep sternal wound infection and respiratory complications.