Utilization of Shock Team and Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) in the Management of Cardiogenic Shock in Northern Ontario.

Background: Despite advancements in critical care and coronary revascularization, cardiogenic shock (CS) outcomes remain poor. Implementing a shock team and use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been associated with improved CS outcomes, but its feasibility in remote and rural areas remains unknown. Methods: This retrospective study included patients with CS who required mechanical circulatory support (MCS) at Health Sciences North, Sudbury, Ontario. The analysis aimed to accomplish 2 objectives: first, to review the outcomes associated with use of Impella (Abiomed, Danvers, MA) and, second, to assess the feasibility of establishing a shock team to facilitate the local implementation of VA-ECMO. The primary endpoint was in-hospital mortality. Results: The outcomes of 15 patients with CS who received Impella between 2015 and 2021 were reviewed. Their average age was 65 years (standard deviation [SD]: 13), and 8 patients (53%) were female. CS was ischemic in 12 patients (80%). Transfemoral Impella CP (cardiac power) was the most frequently used (93%). Thirteen patients (87%) died during the index hospital stay post-Impella because of progressive circulatory failure. The shock team was established following consultations with several Canadian MCS centres, leading to the development of a protocol to guide use of MCS. There have been 4 cases in which percutaneous VA-ECMO using Cardiohelp (Getinge/Maquet, Wayne, NJ) has been used; 3 (75%) survived beyond the index hospitalization. Conclusions: This analysis demonstrated the feasibility of implementing a shock team in remote Northern Ontario, enabling the use of VA-ECMO with success in a centre with a sizeable rural catchment area. This initiative helps address the gap in cardiac care outcomes between rural and urban areas in Ontario.

Introduction: En dépit des avancées des soins aux patients en phase critique et de la revascularisation coronarienne, les résultats du choc cardiogénique (CC) semblent mauvais. La mise en place d'une équipe de choc et l'utilisation de l'oxygénation extracorporelle (ECMO, de l'anglais extracorporeal membrane oxygenation) par voie veino-artérielle (VA) (VA-ECMO) ont été associées à de meilleurs résultats du CC, mais on ignore sa faisabilité dans les régions éloignées et rurales. Méthodes: La présente étude rétrospective portait sur des patients en CC qui ont eu besoin d'une assistance circulatoire mécanique (ACM) à Horizon Santé-Nord, à Sudbury, en Ontario. L'analyse visait 2 objectifs : le premier objectif était de passer en revue les résultats associés à l'utilisation de Impella (Abiomed, Danvers, MA) et, le deuxième était d'évaluer la faisabilité de la mise en place d'une équipe de choc pour faciliter la mise en œuvre locale de la VA-ECMO. Le principal critère d'évaluation était la mortalité intrahospitalière. Résultats: Nous avons passé en revue les résultats cliniques de 15 patients ayant subi un CC qui avaient reçu une Impella entre 2015 et 2021. L'âge moyen était de 65 ans (écart type [ET] : 13), et 8 patients (53 %) étaient des femmes. Le CC était d'origine ischémique chez 12 patients (80 %). L'Impella CP (cardiac power, soit la pompe cardiaque) par voie transfémorale était la plus fréquemment utilisée (93 %). Treize patients (87 %) sont morts durant le séjour de référence à l'hôpital après l'utilisation de l'Impella en raison d'insuffisance circulatoire progressive. La mise en place de l'équipe de choc à la suite des consultations dans plusieurs centres canadiens d'ACM a mené à l'élaboration d'un protocole d'utilisation de l'ACM. Il y a eu 4 cas chez lesquels la VA-ECMO par voie percutanée à l'aide de Cardiohelp (Getinge/Maquet, Wayne, New Jersey, É.-U.) a été utilisée ; 3 (75 %) ont survécu après l'hospitalisation de référence. Conclusions: Cette analyse a démontré la faisabilité de la mise en place d'une équipe de choc dans les régions éloignées du nord de l'Ontario, qui a permis d'utiliser efficacement la VA-ECMO dans un centre d'une circonscription hospitalière rurale non négligeable. Cette initiative aide à remédier à l'écart des résultats en soins cardiaques entre les régions rurales et urbaines de l'Ontario.

Electrochemically decoupled reduction of CO2 to formate over a dispersed heterogeneous bismuth catalyst enabled via redox mediators.

Electrochemical CO2 reduction is a topic of major interest in contemporary research as an approach to use renewably-derived electricity to synthesise useful hydrocarbons from waste CO2. Various strategies have been developed to optimise this challenging reaction at electrode interfaces, but to-date, decoupled electrolysis has not been demonstrated for the reduction of CO2. Decoupled electrolysis aims to use electrochemically-derived charged redox mediators - electrical charge and potential vectors - to separate catalytic product formation from the electrode surface. Utilising an electrochemically generated highly reducing redox mediator; chromium propanediamine tetraacetate, we report the first successful application of decoupled electrolysis to electrochemical CO2 reduction. A study of metals and metal composites found formate to be the most accessible product, with bismuth metal giving the highest selectivity. Copper, tin, gold, nickel and molybdenum carbide heterogeneous catalysts were also investigated, in which cases H2 was found to be the major product, with minor yields of two-electron CO2 reduction products. Subsequent optimisation of the bismuth catalyst achieved a high formate selectivity of 85%. This method represents a radical new approach to CO2 electrolysis, which may be coupled directly with renewable energy storage technology and green electricity.

Exploring the Electrochemistry of Iron Dithiolene and Its Potential for Electrochemical Homogeneous Carbon Dioxide Reduction.

In this work, the dithiolene complex iron(III) bis-maleonitriledithiolene [Fe(mnt)2] is characterised and evaluated as a homogeneous CO2 reduction catalyst. Electrochemically the Fe(mnt)2 is reduced twice to the trianionic Fe(mnt)2 3- state, which is correspondingly found to be active towards CO2. Interestingly, the first reduction event appears to comprise overlapping reversible couples, attributed to the presence of both a dimeric and monomeric form of the dithiolene complex. In acetonitrile Fe(mnt)2 demonstrates a catalytic response to CO2 yielding typical two-electron reduction products: H2, CO and CHOOH. The product distribution and yield were governed by the proton source. Operating with H2O as the proton source gave only H2 and CO as products, whereas using 2,2,2-trifluoroethanol gave 38 % CHOOH faradaic efficiency with H2 and CO as minor products.

Estimating proportion of days covered (PDC) using real-world online medicine suppliers' datasets.

BACKGROUND: The proportion of days covered (PDC) is used to estimate medication adherence by looking at the proportion of days in which a person has access to the medication, over a given period of interest. This study aimed to adapt the PDC algorithm to allow for plausible assumptions about prescription refill behaviour when applied to data from online pharmacy suppliers. METHODS: Three PDC algorithms, the conventional approach (PDC1) and two alternative approaches (PDC2 and PDC3), were used to estimate adherence in a real-world dataset from an online pharmacy. Each algorithm has different denominators and increasing levels of complexity. PDC1, the conventional approach, is the total number of days between first dispensation and a defined end date. PDC2 counts the days until the end of supply date. PDC3 removes from the denominator specifically defined large gaps between refills, which could indicate legitimate reasons for treatment discontinuation. The distribution of the three PDCs across four different follow-up lengths was compared. RESULTS: The dataset included people taking ACE inhibitors (n = 65,905), statins (n = 100,362), and/or thyroid hormones (n = 30,637). The proportion of people taking ACE inhibitors with PDC ≥ 0.8 was 50-74% for PDC1, 81-91% for PDC2, and 86-100% for PDC3 with values depending on drug and length of follow-up. Similar ranges were identified in people taking statins and thyroid hormones. CONCLUSION: These algorithms enable researchers and healthcare providers to assess pharmacy services and individual levels of adherence in real-world databases, particularly in settings where people may switch between different suppliers of medicines, meaning an individual supplier's data may show temporary but legitimate gaps in access to medication. Accurately identifying problems with adherence provides the foundation for opportunities to improve experience, adherence and outcomes and to reduce medicines wastage. Research with people taking medications and prescribers is required to validate the algorithms' assumptions.

Dithiolene Complexes of First-Row Transition Metals for Symmetric Nonaqueous Redox Flow Batteries.

Five metal complexes of the dithiolene ligand maleonitriledithiolate (mnt2- ) with M=V, Fe, Co, Ni, Cu were studied as redox-active materials for nonaqueous redox flow batteries (RFBs). All five complexes exhibit at least two redox processes, making them applicable to symmetric RFBs as single-species electrolytes, that is, as both negolyte and posolyte. Charge-discharge cycling in a small-scale RFB gave modest performances for [(tea)2 Vmnt ], [(tea)2 Comnt ], and [(tea)2 Cumnt ] whereas [(tea)Femnt ] and [(tea)2 Nimnt ] (tea=tetraethylammonium) failed to hold any significant capacity, indicating poor stability. Independent negolyte- and posolyte-only battery cycling of a single redox couple, as well as UV/Vis spectroscopy, showed that for [(tea)2 Vmnt ] the negolyte is stable whereas the posolyte is unstable over multiple charge-discharge cycles; for [(tea)2 Comnt ], [(tea)2 Nimnt ], and [(tea)2 Cumnt ], the negolyte suffers rapid capacity fading although the posolyte is more robust. Identifying a means to stabilize Vmnt 3-/2- as a negolyte, and Comnt 2-/1- , Nimnt 2-/1- , and Cumnt 2-/1- as posolytes could lead to their use in asymmetric RFBs.

The Effects of Exercise Intensity vs. Metabolic State on the Variability and Magnitude of Left Ventricular Twist Mechanics during Exercise.

Increased left ventricular (LV) twist and untwisting rate (LV twist mechanics) are essential responses of the heart to exercise. However, previously a large variability in LV twist mechanics during exercise has been observed, which complicates the interpretation of results. This study aimed to determine some of the physiological sources of variability in LV twist mechanics during exercise. Sixteen healthy males (age: 22 ± 4 years, [Formula: see text]O2peak: 45.5 ± 6.9 ml∙kg-1∙min-1, range of individual anaerobic threshold (IAT): 32-69% of [Formula: see text]O2peak) were assessed at rest and during exercise at: i) the same relative exercise intensity, 40%peak, ii) at 2% above IAT, and, iii) at 40%peak with hypoxia (40%peak+HYP). LV volumes were not significantly different between exercise conditions (P > 0.05). However, the mean margin of error of LV twist was significantly lower (F2,47 = 2.08, P < 0.05) during 40%peak compared with IAT (3.0 vs. 4.1 degrees). Despite the same workload and similar LV volumes, hypoxia increased LV twist and untwisting rate (P < 0.05), but the mean margin of error remained similar to that during 40%peak (3.2 degrees, P > 0.05). Overall, LV twist mechanics were linearly related to rate pressure product. During exercise, the intra-individual variability of LV twist mechanics is smaller at the same relative exercise intensity compared with IAT. However, the absolute magnitude (degrees) of LV twist mechanics appears to be associated with the prevailing rate pressure product. Exercise tests that evaluate LV twist mechanics should be standardised by relative exercise intensity and rate pressure product be taken into account when interpreting results.

Calcium-insensitive splice variants of mammalian E1 subunit of 2-oxoglutarate dehydrogenase complex with tissue-specific patterns of expression.

The 2-oxoglutarate dehydrogenase (OGDH) complex is an important control point in vertebrate mitochondrial oxidative metabolism, including in the citrate cycle and catabolism of alternative fuels including glutamine. It is subject to allosteric regulation by NADH and the ATP/ADP ratio, and by Ca(2+) through binding to the E1 subunit. The latter involves a unique Ca(2+)-binding site which includes D(114)ADLD (site 1). Here, we describe three splice variants of E1 in which either the exon expressing this site is replaced with another exon (loss of site 1, LS1) or an additional exon is expressed leading to the insertion of 15 amino acids just downstream of site 1 (Insert), or both changes occur together (LS1/Insert). We show that all three variants are essentially Ca(2+)-insensitive. Comparison of massive parallel sequence (RNA-Seq) databases demonstrates predominant expression of the Ca(2+)-sensitive archetype form in heart and skeletal muscle, but substantial expression of the Ca(2+)-insensitive variants in brain, pancreatic islets and other tissues. Detailed proteomic and activity studies comparing OGDH complexes from rat heart and brain confirmed the substantial difference in expression between these tissues. The evolution of OGDH variants was explored using bioinformatics, and this indicated that Ca(2+)-sensitivity arose with the emergence of chordates. In all species examined, this was associated with the co-emergence of Ca(2+)-insensitive variants suggesting a retained requirement for the latter in some settings. Tissue-specific expression of OGDH splice variants may thus provide a mechanism that tunes the control of the enzyme to the specialized metabolic and signalling needs of individual cell types.

Arginine side chain interactions and the role of arginine as a gating charge carrier in voltage sensitive ion channels.

Gating charges in voltage-sensing domains (VSD) of voltage-sensitive ion channels and enzymes are carried on arginine side chains rather than lysine. This arginine preference may result from the unique hydration properties of the side chain guanidinium group which facilitates its movement through a hydrophobic plug that seals the center of the VSD, as suggested by molecular dynamics simulations. To test for side chain interactions implicit in this model we inspected interactions of the side chains of arginine and lysine with each of the 19 non-glycine amino acids in proteins in the protein data bank. The arginine guanidinium interacts with non-polar aromatic and aliphatic side chains above and below the guanidinium plane while hydrogen bonding with polar side chains is restricted to in-plane positions. In contrast, non-polar side chains interact largely with the aliphatic part of the lysine side chain. The hydration properties of arginine and lysine are strongly reflected in their respective interactions with non-polar and polar side chains as observed in protein structures and in molecular dynamics simulations, and likely underlie the preference for arginine as a mobile charge carrier in VSD.

A suite of de novo c-type cytochromes for functional oxidoreductase engineering.

Central to the design of an efficient de novo enzyme is a robust yet mutable protein scaffold. The maquette approach to protein design offers precisely this, employing simple four-α-helix bundle scaffolds devoid of evolutionary complexity and with proven tolerance towards iterative protein engineering. We recently described the design of C2, a de novo designed c-type cytochrome maquette that undergoes post-translational modification in E. coli to covalently graft heme onto the protein backbone in vivo. This de novo cytochrome is capable of reversible oxygen binding, an obligate step in the catalytic cycle of many oxygen-activating oxidoreductases. Here we demonstrate the flexibility of both the maquette platform and the post-translational machinery of E. coli by creating a suite of functional de novo designed c-type cytochromes. We explore the engineering tolerances of the maquette by selecting alternative binding sites for heme C attachment and creating di-heme maquettes either by appending an additional heme C binding motif to the maquette scaffold or by binding heme B through simple bis-histidine ligation to a second binding site. The new designs retain the essential properties of the parent design but with significant improvements in structural stability. Molecular dynamics simulations aid the rationalization of these functional improvements while providing insight into the rules for engineering heme C binding sites in future iterations. This versatile, functional suite of de novo c-type cytochromes shows significant promise in providing robust platforms for the future engineering of de novo oxygen-activating oxidoreductases. This article is part of a Special Issue entitled Biodesign for Bioenergetics--the design and engineering of electron transfer cofactors, proteins and protein networks, edited by Ronald L. Koder and J.L. Ross Anderson.