Extracorporeal life support in trauma: Indications and techniques.

BACKGROUND: Clarity about indications and techniques in extracorporeal life support (ECLS) in trauma is essential for timely and effective deployment, and to ensure good stewardship of an important resource. Extracorporeal life support deployments in a tertiary trauma center were reviewed to understand the indications, strategies, and tactics of ECLS in trauma. METHODS: The provincial trauma registry was used to identify patients who received ECLS at a Level I trauma center and ECLS organization-accredited site between January 2014 and February 2021. Charts were reviewed for indications, technical factors, and outcomes following ECLS deployment. Based on this data, consensus around indications and techniques for ECLS in trauma was reached and refined by a multidisciplinary team discussion. RESULTS: A total of 25 patients underwent ECLS as part of a comprehensive trauma resuscitation strategy. Eighteen patients underwent venovenous ECLS and seven received venoarterial ECLS. Nineteen patients survived the ECLS run, of which 15 survived to discharge. Four patients developed vascular injuries secondary to cannula insertion while four patients developed circuit clots. On multidisciplinary consensus, three broad indications for ECLS and their respective techniques were described: gas exchange for lung injury, extended damage control for severe injuries associated with the lethal triad, and circulatory support for cardiogenic shock or hypothermia. CONCLUSION: The three broad indications for ECLS in trauma (gas exchange, extended damage control and circulatory support) require specific advanced planning and standardization of corresponding techniques (cannulation, circuit configuration, anticoagulation, and duration). When appropriately and effectively integrated into the trauma response, ECLS can extend the damage control paradigm to enable the management of complex multisystem injuries. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.

Prediction of successful veno-venous extracorporeal life support liberation using the oxygen challenge test.

BACKGROUND: The oxygen challenge test (OCT) is an underutilized measure of lung recovery, easily performed prior to proceeding with a trial-off V-V ECLS as part of a weaning algorithm. Evidence-based thresholds for OCT results which support continuing with V-V ECLS weaning are lacking, making interpretation of these tests challenging in clinical practice. METHODS: We performed a retrospective review of patients commenced on V-V ECLS as a bridge-to-recovery at Vancouver General Hospital from 2015-2019. The absolute PaO2 post-OCT and change in PaO2 proportional to incremental FiO2 change on the ventilator (∆PaO2 ) were evaluated as predictive screening metrics for identifying conditions favorable for successful trial-off of V-V ECLS. RESULTS: An optimal cut-off of PaO2 ≥ 240 mm Hg post-OCT (AUC 0.77) and ∆PaO2 ≥ 250 mm Hg (AUC 0.76) was identified as a threshold for predicting successful trials-off. A total of 26 and 24 patients achieved post-OCT PaO2 and ∆PaO2 thresholds, and 100% of these patients were liberated successfully from ECLS during their admission. CONCLUSIONS: The OCT can serve as an effective screen of shunt reduction and native lung recovery which can be used alongside other measures of ventilation to assess for suitability of liberation from V-V ECLS prior to a trial-off. Achieving a PaO2 ≥ 240 mm Hg post-OCT is a strong prognostic indicator for successful liberation from V-V ECLS during ICU admission.

Seventy-seven days on veno-venous extracorporeal membrane oxygenation for severe acute respiratory distress syndrome from SARS-CoV-2.

Throughout the COVID-19 pandemic veno-venous extracorporeal membrane oxygenation (VV ECMO) has emerged as a valid supportive intervention for severe COVID-19 pneumonia. In this report we describe the use of prolonged ECMO (77 days) to support a patient with COVID-19, ultimately resulting in lung recovery and discharge home. This report also emphasizes the value of physiotherapy in patients on ECMO and the importance of collaboration between ECMO programs and lung transplant teams in the care of these patients.

Optimization of translation enhancing element use to increase protein expression in a vaccinia virus system.

Since the successful use of vaccinia virus (VACV) in the immunization strategies to eliminate smallpox, research has been focused on the development of recombinant VACV strains expressing proteins from various pathogens. Attempts at decreasing the side effects associated with exposure to recombinant, wild-type viral strains have led to the development of attenuated viruses. Yet while these attenuated VACV's have improved safety profiles compared to unmodified strains, their clinical use has been hindered due to efficacy issues in stimulating a host immune response. This deficiency has largely been attributed to decreased production of the target protein for immunization. Efforts to increase protein production from attenuated VACV strains has largely centered around modulation of viral factors, while manipulation of the translation of viral mRNAs has been largely unexplored. In this study we evaluate the use of translation enhancing element hTEE-658 to increase recombinant protein production in an attenuated VACV system. Optimization of the use of this motif is also attempted by combining it with strategies that have demonstrated effectiveness in previous research. We show that extension of the 5' leader sequence containing hTEE-658 does not improve motif function, nor does the combination with other known translation enhancing elements. However, the sole use of hTEE-658 in an attenuated VACV system is shown to increase protein expression levels beyond those of a standard viral promoter when used with a wild-type virus. Taken together these results highlight the potential for hTEE-658 to improve the effectiveness of attenuated VACV vaccine candidates and give insights into the optimal sequence context for its use in vaccine design.

Aptamer-Mediated Polymeric Vehicles for Enhanced Cell-Targeted Drug Delivery.

BACKGROUND: The search for smart delivery systems for enhanced pre-clinical and clinical pharmaceutical delivery and cell targeting continues to be a major biomedical research endeavor owing to differences in the physicochemical characteristics and physiological effects of drug molecules, and this affects the delivery mechanisms to elicit maximum therapeutic effects. Targeted drug delivery is a smart evolution essential to address major challenges associated with conventional drug delivery systems. These challenges mostly result in poor pharmacokinetics due to the inability of the active pharmaceutical ingredients to specifically act on malignant cells thus, causing poor therapeutic index and toxicity to surrounding normal cells. Aptamers are oligonucleotides with engineered affinities to bind specifically to their cognate targets. Aptamers have gained significant interests as effective targeting elements for enhanced therapeutic delivery as they can be generated to specifically bind to wide range of targets including proteins, peptides, ions, cells and tissues. Notwithstanding, effective delivery of aptamers as therapeutic vehicles is challenged by cell membrane electrostatic repulsion, endonuclease degradation, low pH cleavage, and binding conformation stability. OBJECTIVE: The application of molecularly engineered biodegradable and biocompatible polymeric particles with tunable features such as surface area and chemistry, particulate size distribution and toxicity creates opportunities to develop smart aptamer-mediated delivery systems for controlled drug release. RESULTS: This article discusses opportunities for particulate aptamer-drug formulations to advance current drug delivery modalities by navigating active ingredients through cellular and biomolecular traffic to target sites for sustained and controlled release at effective therapeutic dosages while minimizing systemic cytotoxic effects. CONCLUSION: A proposal for a novel drug-polymer-aptamer-polymer (DPAP) design of aptamer-drug formulation with stage-wise delivery mechanism is presented to illustrate the potential efficacy of aptamer- polymer cargos for enhanced cell targeting and drug delivery.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support.

PURPOSE: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) may provide benefit to patients in refractory cardiac arrest and cardiogenic shock. We aim to summarize our center's 6-year experience with resuscitative VA-ECMO. MATERIALS AND METHODS: A retrospective medical record review (April 2009 to 2015) was performed on consecutive non-cardiotomy patients who were managed with VA-ECMO due to refractory in- or out-of-hospital cardiac (IHCA/OHCA) arrest (E-CPR) or refractory cardiogenic shock (E-CS) with or without preceding cardiac arrest. Our primary outcome was survival to hospital discharge and good neurological status (Cerebral Performance Category 1-2). RESULTS: There were a total of 22 patients who met inclusion criteria of whom 9 received E-CPR (8 IHCA, 1 OHCA) and 13 received E-CS. The median age for E-CPR patients was 52 [IQR 45, 58] years, and 54 [IQR 38, 64] years for E-CS patients. Cardiac arrest duration was 70.33 (SD 39.56) min for the E-CPR patients, and 24.67 (SD 26.73) min for the 9 patients treated with E-CS who had previously arrested. Initial cardiac arrest rhythms were pulseless electrical activity (39%), ventricular fibrillation (33%), or ventricular tachycardia (28%). A total of 18/22 patients were successfully weaned from VA-ECMO (78%); 16 patients survived to hospital discharge (73%) with 15 in good neurological condition. CONCLUSION: The initiation of VA-ECMO at our center for treatment of refractory cardiac arrest and cardiogenic shock yielded a high proportion of survivors and favorable neurological outcomes.

Biophysical characterization of layer-by-layer synthesis of aptamer-drug microparticles for enhanced cell targeting.

Targeted delivery of drug molecules to specific cells in mammalian systems demonstrates a great potential to enhance the efficacy of current pharmaceutical therapies. Conventional strategies for pharmaceutical delivery are often associated with poor therapeutic indices and high systemic cytotoxicity, and this result in poor disease suppression, low surviving rates, and potential contraindication of drug formulation. The emergence of aptamers has elicited new research interests into enhanced targeted drug delivery due to their unique characteristics as targeting elements. Aptamers can be engineered to bind to their cognate cellular targets with high affinity and specificity, and this is important to navigate active drug molecules and deliver sufficient dosage to targeted malignant cells. However, the targeting performance of aptamers can be impacted by several factors including endonuclease-mediated degradation, rapid renal filtration, biochemical complexation, and cell membrane electrostatic repulsion. This has subsequently led to the development of smart aptamer-immobilized biopolymer systems as delivery vehicles for controlled and sustained drug release to specific cells at effective therapeutic dosage and minimal systemic cytotoxicity. This article reports the synthesis and in vitro characterization of a novel multi-layer co-polymeric targeted drug delivery system based on drug-loaded PLGA-Aptamer-PEI (DPAP) formulation with a stage-wise delivery mechanism. A thrombin-specific DNA aptamer was used to develop the DPAP system while Bovine Serum Albumin (BSA) was used as a biopharmaceutical drug in the synthesis process by ultrasonication. Biophysical characterization of the DPAP system showed a spherical shaped particulate formulation with a unimodal particle size distribution of average size ∼0.685 µm and a zeta potential of +0.82 mV. The DPAP formulation showed a high encapsulation efficiency of 89.4 ± 3.6%, a loading capacity of 17.89 ± 0.72 mg BSA protein/100 mg PLGA polymeric particles, low cytotoxicity and a controlled drug release characteristics in 43 days. The results demonstrate a great promise in the development of DPAP formulation for enhanced in vivo cell targeting. © 2017 American Institute of Chemical Engineers Biotechnol. Prog., 34:249-261, 2018.

Towards targeted cancer therapy: Aptamer or oncolytic virus?

Cancer is a leading cause of global mortality. Whilst anticancer awareness programs have increased significantly over the years, scientific research into the development of efficient and specific drugs to target cancerous cells for enhanced therapeutic effects has not received much clinical success. Chemotherapeutic agents are incapable of acting specifically on cancerous cells, thus causing low therapeutic effects accompanied by toxicity to surrounding normal tissues. The search for smart, highly specific and efficient cancer treatments and delivery systems continues to be a significant research endeavor. Targeted cancer therapy is an evolving treatment approach with great promise in enhancing the efficacy of cancer therapies via the delivery of therapeutic agents specifically to and into desired tumor cells using viral or non-viral targeting elements. Viral oncotherapy is an advanced cancer therapy based on the use of oncolytic viruses (OV) as elements to specifically target, replicate and kill malignant cancer cells selectively without affecting surrounding healthy cells. Aptamers, on the other hand, are non-viral targeting elements that are single-stranded nucleic acids with high specificity, selectivity and binding affinity towards their cognate targets. Aptamers have emerged as a new class of bioaffinity targeting elements can be generated and molecularly engineered to selectively bind to diverse targets including proteins, cells and tissues. This article discusses, comparatively, the potentials and impacts of both viral and aptamer-mediated targeted cancer therapies in advancing conventional drug delivery systems through enhanced target specificity, therapeutic payload, bioavailability of the therapeutic agents at the target sites whilst minimizing systemic cytotoxicity. This article emphasizes on effective site-directed targeting mechanisms and efficacy issues that impact on clinical applications.

SELEX Modifications and Bioanalytical Techniques for Aptamer-Target Binding Characterization.

The quest to improve the detection of biomolecules and cells in health and life sciences has led to the discovery and characterization of various affinity bioprobes. Libraries of synthetic oligonucleotides (ssDNA/ssRNA) with randomized sequences are employed during Systematic Evolution of Ligands by Exponential Enrichment (SELEX) to select highly specific affinity probes called aptamers. With much focus on the generation of aptamers for a variety of target molecules, conventional SELEX protocols have been modified to develop new and improved SELEX protocols yielding highly specific and stable aptamers. Various techniques have been used to analyze the binding interactions between aptamers and their cognate molecules with associated merits and limitations. This article comprehensively reviews research advancements in the generation of aptamers, analyses physicochemical conditions affecting their binding characteristics to cellular and biomolecular targets, and discusses various field applications of aptameric binding. Biophysical techniques employed in the characterization of the molecular and binding features of aptamers to their cognate targets are also discussed.

Deploying aptameric sensing technology for rapid pandemic monitoring.

The genome of virulent strains may possess the ability to mutate by means of antigenic shift and/or antigenic drift as well as being resistant to antibiotics with time. The outbreak and spread of these virulent diseases including avian influenza (H1N1), severe acute respiratory syndrome (SARS-Corona virus), cholera (Vibrio cholera), tuberculosis (Mycobacterium tuberculosis), Ebola hemorrhagic fever (Ebola Virus) and AIDS (HIV-1) necessitate urgent attention to develop diagnostic protocols and assays for rapid detection and screening. Rapid and accurate detection of first cases with certainty will contribute significantly in preventing disease transmission and escalation to pandemic levels. As a result, there is a need to develop technologies that can meet the heavy demand of an all-embedded, inexpensive, specific and fast biosensing for the detection and screening of pathogens in active or latent forms to offer quick diagnosis and early treatments in order to avoid disease aggravation and unnecessary late treatment costs. Nucleic acid aptamers are short, single-stranded RNA or DNA sequences that can selectively bind to specific cellular and biomolecular targets. Aptamers, as new-age bioaffinity probes, have the necessary biophysical characteristics for improved pathogen detection. This article seeks to review global pandemic situations in relation to advances in pathogen detection systems. It particularly discusses aptameric biosensing and establishes application opportunities for effective pandemic monitoring. Insights into the application of continuous polymeric supports as the synthetic base for aptamer coupling to provide the needed convective mass transport for rapid screening is also presented.

A review on immobilised aptamers for high throughput biomolecular detection and screening.

The discovery of Systematic Evolution of Ligands by Exponential Enrichment (SELEX) assay has led to the generation of aptamers from libraries of nucleic acids. Concomitantly, aptamer-target recognition and its potential biomedical applications have become a major research endeavour. Aptamers possess unique properties that make them superior biological receptors to antibodies with a plethora of target molecules. Some specific areas of opportunities explored for aptamer-target interactions include biochemical analysis, cell signalling and targeting, biomolecular purification processes, pathogen detection and, clinical diagnosis and therapy. Most of these potential applications rely on the effective immobilisation of aptamers on support systems to probe target species. Hence, recent research focus is geared towards immobilising aptamers as oligosorbents for biodetection and bioscreening. This article seeks to review advances in immobilised aptameric binding with associated successful milestones and respective limitations. A proposal for high throughput bioscreening using continuous polymeric adsorbents is also presented.

Semantic representation of monogenean haptoral Bar image annotation.

BACKGROUND: Digitised monogenean images are usually stored in file system directories in an unstructured manner. In this paper we propose a semantic representation of these images in the form of a Monogenean Haptoral Bar Image (MHBI) ontology, which are annotated with taxonomic classification, diagnostic hard part and image properties. The data we used are basically of the monogenean species found in fish, thus we built a simple Fish ontology to demonstrate how the host (fish) ontology can be linked to the MHBI ontology. This will enable linking of information from the monogenean ontology to the host species found in the fish ontology without changing the underlying schema for either of the ontologies. RESULTS: In this paper, we utilized the Taxonomic Data Working Group Life Sciences Identifier (TDWG LSID) vocabulary to represent our data and defined a new vocabulary which is specific for annotating monogenean haptoral bar images to develop the MHBI ontology and a merged MHBI-Fish ontologies. These ontologies are successfully evaluated using five criteria which are clarity, coherence, extendibility, ontology commitment and encoding bias. CONCLUSIONS: In this paper, we show that unstructured data can be represented in a structured form using semantics. In the process, we have come up with a new vocabulary for annotating the monogenean images with textual information. The proposed monogenean image ontology will form the basis of a monogenean knowledge base to assist researchers in retrieving information for their analysis.

An ontology for protein data models.

Accelerating availability of protein sequences and structures has transformed both the theory and practice of computational biology. The current systems of nomenclature for proteins remain divergent even when the experts appreciate the underlying similarities. Interoperability of protein databases is limited to lack of progress in the way the biologists describe and conceptualize the shared biological elements in protein data. The goal of the proposed protein ontology is a step forward to address these concerns by is producing a structured vocabulary that can be applied to all proteins even as the knowledge of protein roles in the cells is still accumulating and changing. A Database of 10 Major Prion Proteins available in various Protein data sources, based on the vocabulary provided by Protein Ontology is made available.