The introduction of photonic technologies into mature electronic circuits is in high demand to accelerate on-chip information networking and even computing. Great difficulty lies in the fact that the ...optoelectronic coupling at their interfaces requires a substantial charging energy determined by their capacitance. Optoelectronic devices have been too large to reduce the integrated capacitance down to the femtofarad scale. Here we use a photonic-crystal platform to demonstrate the first experimental proof of optoelectronic integration at only 2 fF. This allows us to realize a record-low attojoule-energy electro-optic modulator (an electrical-to-optical or E–O converter) and an amplifier-free photoreceiver (an optical-to-electrical, or O–E converter), which leads to ultralow-energy signal conversion. By integrating these O–E/E–O devices, we demonstrate femtofarad ‘O–E–O transistors’ with optical signal gain that show various optical nonlinear functions, including as all-optical switches, wavelength converters and cascadable optical repeaters with a femtojoule-per-bit energy consumption. These femtofarad-scale O–E/E–O/O–E–O devices promise tightly coupled photonic–electronic integration for new fields of energy-saving information processing.A photonic-crystal platform enables attojoule-energy electro-optic modulators and amplifier-free photoreceivers.
The Society of Thoracic Surgeons (STS)-Interagency Registry for Mechanically Assisted Circulatory Support (Intermacs) 2020 Annual Report reviews outcomes on 25,551 patients undergoing primary ...isolated continuous-flow left ventricular assist device (LVAD) implantation between 2010 and 2019. In 2019, 3198 primary LVADs were implanted, which is the highest annual volume in Intermacs history. Compared with the previous era (2010-2014), patients who received an LVAD in the most recent era (2015-2019) were more likely to be African American (26.8% vs 22.9%, P < .0001) and more likely to be bridged to durable LVAD with temporary mechanical support devices (36.8% vs 26.0%, P < .0001). In 2019, 50% of patients were INTERMACS Profile 1 or 2 before durable LVAD, and 73% received an LVAD as destination therapy. Magnetic levitation technology has become the predominant design, accounting for 77% of devices in 2019. The 1- and 2-year survival in the most recent era has improved compared with 2010 to 2014 (82.3% and 73.1% vs 80.5% and 69.1%, respectively; P < .0001). Major bleeding and infection continue to be the leading adverse events. Incident stroke has declined in the current era to 12.7% at 1 year. STS-Intermacs research publications are highlighted, and the new quality initiatives are introduced.
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Photonic integration has long been pursued, but remains immature compared with electronics. Nanophotonics is expected to change this situation. However, despite the recent success of nanophotonic ...devices, there has been no demonstration of large-scale integration. Here, we describe the large-scale and dense integration of optical memories in a photonic crystal chip. To achieve this, we introduce a wavelength-addressable serial integration scheme using a simple cavity-optimization rule. We fully exploit the wavelength-division-multiplexing capability, which is the most important advantage of photonics over electronics, and achieve an extremely large wavelength-channel density. This is the first demonstration of the large-scale photonic integration of nanophotonic devices coupled to waveguides in a single chip, and also the first dense wavelength-division-multiplexing nanophotonic devices other than filters. This work paves the way for optical random-access memories and for a large-scale wavelength-division-multiplexing photonic network-on-chip.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Increasing the modulation speed of semiconductor lasers has attracted much attention from the viewpoint of both physics and the applications of lasers. Here we propose a membrane distributed ...reflector laser on a low-refractive-index and high-thermal-conductivity silicon carbide substrate that overcomes the modulation bandwidth limit. The laser features a high modulation efficiency because of its large optical confinement in the active region and small differential gain reduction at a high injection current density. We achieve a 42 GHz relaxation oscillation frequency by using a laser with a 50-μm-long active region. The cavity, designed to have a short photon lifetime, suppresses the damping effect while keeping the threshold carrier density low, resulting in a 60 GHz intrinsic 3 dB bandwidth (f3dB). By employing the photon–photon resonance at 95 GHz due to optical feedback from an integrated output waveguide, we achieve an f3dB of 108 GHz and demonstrate 256 Gbit s−1 four-level pulse-amplitude modulations with a 475 fJ bit−1 energy cost of the direct-current electrical input.Directly modulated membrane distributed reflector lasers are fabricated on a silicon carbide platform. The 3 dB bandwidth, four-level pulse-amplitude modulation speed and operating energy for transmitting one bit are 108 GHz, 256 Gbit s−1 and 475 fJ, respectively.
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GEOZS, IJS, IMTLJ, IZUM, KILJ, KISLJ, NLZOH, NUK, OILJ, PILJ, PNG, SAZU, SBCE, SBMB, UL, UM, UPUK, ZAGLJ
Left ventricular (LV) distention is a feared complication in patients receiving venoarterial (VA) extracorporeal membrane oxygenation (ECMO). LV unloading can be achieved indirectly with intra-aortic ...balloon pump (IABP) or directly with an Impella device (Abiomed, Danvers, Mass). We sought to assess the clinical and hemodynamic effects of IABP and Impella devices on patients supported with VA ECMO.
We conducted a retrospective review of VA ECMO patients at our institution from January 2015 to June 2020. Patients were categorized as either ECMO alone or ECMO with LV unloading. LV unloading was characterized as either ECMO with IABP or ECMO with Impella. We recorded baseline characteristics, survival, complications, and hemodynamic changes associated with device initiation.
During the study, 143 patients received ECMO alone whereas 140 received ECMO with LV unloading (68 ECMO with IABP, 72 ECMO with Impella). ECMO with Impella patients had a higher incidence of bleeding events compared with ECMO alone or ECMO with IABP (52.8% vs 37.1% vs 17.7%; P < .0001). Compared with ECMO alone, ECMO with IABP patients had better survival at 180 days (log rank P = .005) whereas survival in ECMO with Impella patients was not different (log rank P = .66). In a multivariable Cox hazard analysis, age (hazard ratio HR, 1.02; 95% confidence interval CI, 1.00-1.03; P = .015), male sex (HR, 0.54; 95% CI, 0.38-0.80; P = .002), baseline lactate (HR, 1.06; 95% CI, 1.02-1.11; P = .004), baseline creatinine (HR, 1.06; 95% CI, 1.00-1.11; P = .032), need for extracorporeal membrane oxygenation-cardiopulmonary resuscitation (HR, 2.09; 95% CI, 1.40-3.39; P = .001), and presence of pre-ECMO IABP (HR, 0.45; 95% CI, 0.25-0.83; P = .010) were associated with reduced mortality. There was no significant difference in hemodynamic changes in the ECMO with IABP versus ECMO with Impella cohorts.
Concomitant support with IABP might help reduce morbidity and improve 180-day survival in patients receiving VA ECMO for cardiogenic shock.
Display omitted Concomitant support with intra-aortic balloon pump (IABP) might help reduce morbidity and 180-day survival in patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO) for cardiogenic shock. Impella devices are from Abiomed (Danvers, Mass). LV, Left ventricular.
Summary Background Results from a previous phase 3 study suggested that prophylactic cranial irradiation reduces the incidence of symptomatic brain metastases and prolongs overall survival compared ...with no prophylactic cranial irradiation in patients with extensive-disease small-cell lung cancer. However, because of the absence of brain imaging before enrolment and variations in chemotherapeutic regimens and irradiation doses, concerns have been raised about these findings. We did a phase 3 trial to reassess the efficacy of prophylactic cranial irradiation in the treatment of extensive-disease small-cell lung cancer. Methods We did this randomised, open-label, phase 3 study at 47 institutions in Japan. Patients with extensive-disease small-cell lung cancer who had any response to platinum-based doublet chemotherapy and no brain metastases on MRI were randomly assigned (1:1) to receive prophylactic cranial irradiation (25 Gy in ten daily fractions of 2·5 Gy) or observation. All patients were required to have brain MRI at 3-month intervals up to 12 months and at 18 and 24 months after enrolment. Randomisation was done by computer-generated allocation sequence, with age as a stratification factor and minimisation by institution, Eastern Cooperative Oncology Group performance status, and response to initial chemotherapy. The primary endpoint was overall survival, analysed in the intention-to-treat population. This trial is registered with the UMIN Clinical Trials Registry, number UMIN000001755, and is closed to new participants. Findings Between April 3, 2009, and July 17, 2013, 224 patients were enrolled and randomly assigned (113 to prophylactic cranial irradiation and 111 to observation). In the planned interim analysis on June 18, 2013, of the first 163 enrolled patients, Bayesian predictive probability of prophylactic cranial irradiation being superior to observation was 0·011%, resulting in early termination of the study because of futility. In the final analysis, median overall survival was 11·6 months (95% CI 9·5–13·3) in the prophylactic cranial irradiation group and 13·7 months (10·2–16·4) in the observation group (hazard ratio 1·27, 95% CI 0·96–1·68; p=0·094). The most frequent grade 3 or worse adverse events at 3 months were anorexia (six 6% of 106 in the prophylactic cranial irradiation group vs two 2% of 111 in the observation group), malaise (three 3% vs one <1%), and muscle weakness in a lower limb (one <1% vs six 5%). No treatment-related deaths occurred in either group. Interpretation In this Japanese trial, prophylactic cranial irradiation did not result in longer overall survival compared with observation in patients with extensive-disease small-cell lung cancer. Prophylactic cranial irradiation is therefore not essential for patients with extensive-disease small-cell lung cancer with any response to initial chemotherapy and a confirmed absence of brain metastases when patients receive periodic MRI examination during follow-up. Funding The Ministry of Health, Labour and Welfare of Japan.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
A low operating energy is needed for nanocavity lasers designed for on-chip photonic network applications. On-chip nanocavity lasers must be driven by current because they act as light sources driven ...by electronic circuits. Here, we report the high-speed direct modulation of a lambda-scale embedded active region photonic-crystal (LEAP) laser that holds three records for any type of laser operated at room temperature: a low threshold current of 4.8 µA, a modulation current efficiency of 2.0 GHz µA-0.5 and an operating energy of 4.4 fJ bit-1 . Five major technologies make this performance possible: a compact buried heterostructure, a photonic-crystal nanocavity, a lateral p-n junction realized by ion implantation and thermal diffusion, an InAlAs sacrificial layer and current-blocking trenches. We believe that an output power of 2.17 µW and an operating energy of 4.4 fJ bit-1 will enable us to realize on-chip photonic networks in combination with the recently developed highly sensitive receivers.
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IZUM, KILJ, NUK, PILJ, PNG, SAZU, UL, UM, UPUK
Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to ...improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.
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EMUNI, FIS, FZAB, GEOZS, GIS, IJS, IMTLJ, KILJ, KISLJ, MFDPS, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, SBMB, SBNM, UKNU, UL, UM, UPUK, VKSCE, ZAGLJ