TENAYA and LUCERNE: Two-Year Results from the Phase 3 Neovascular Age-Related Macular Degeneration Trials of Faricimab with Treat-and-Extend Dosing in Year 2.

PURPOSE: To evaluate 2-year efficacy, durability, and safety of the bispecific antibody faricimab, which inhibits both angiopoietin-2 and VEGF-A. DESIGN: TENAYA (ClinicalTrials.gov identifier, NCT03823287) and LUCERNE (ClinicalTrials.gov identifier, NCT03823300) were identically designed, randomized, double-masked, active comparator-controlled phase 3 noninferiority trials. PARTICIPANTS: Treatment-naive patients with neovascular age-related macular degeneration (nAMD) 50 years of age or older. METHODS: Patients were randomized (1:1) to intravitreal faricimab 6.0 mg up to every 16 weeks (Q16W) or aflibercept 2.0 mg every 8 weeks (Q8W). Faricimab fixed dosing based on protocol-defined disease activity at weeks 20 and 24 up to week 60, followed up to week 108 by a treat-and-extend personalized treatment interval regimen. MAIN OUTCOME MEASURES: Efficacy analyses included change in best-corrected visual acuity (BCVA) from baseline at 2 years (averaged over weeks 104, 108, and 112) and proportion of patients receiving Q16W, every 12 weeks (Q12W), and Q8W dosing at week 112 in the intention-to-treat population. Safety analyses included ocular adverse events (AEs) in the study eye through study end at week 112. RESULTS: Of 1326 patients treated across TENAYA/LUCERNE, 1113 (83.9%) completed treatment (n = 555 faricimab; n = 558 aflibercept). The BCVA change from baseline at 2 years was comparable between faricimab and aflibercept groups in TENAYA (adjusted mean change, +3.7 letters [95% confidence interval (CI), +2.1 to +5.4] and +3.3 letters [95% CI, +1.7 to +4.9], respectively; mean difference, +0.4 letters [95% CI, -1.9 to +2.8]) and LUCERNE (adjusted mean change, +5.0 letters [95% CI, +3.4 to +6.6] and +5.2 letters [95% CI, +3.6 to +6.8], respectively; mean difference, -0.2 letters [95% CI, -2.4 to +2.1]). At week 112 in TENAYA and LUCERNE, 59.0% and 66.9%, respectively, achieved Q16W faricimab dosing, increasing from year 1, and 74.1% and 81.2%, achieved Q12W or longer dosing. Ocular AEs in the study eye were comparable between faricimab and aflibercept groups in TENAYA (55.0% and 56.5% of patients, respectively) and LUCERNE (52.9% and 47.5% of patients, respectively) through week 112. CONCLUSIONS: Treat-and-extend faricimab treatment based on nAMD disease activity maintained vision gains through year 2, with most patients achieving extended dosing intervals. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Faricimab Treat-and-Extend for Diabetic Macular Edema: Two-Year Results from the Randomized Phase 3 YOSEMITE and RHINE Trials.

PURPOSE: To evaluate the 2-year efficacy, durability, and safety of dual angiopoietin-2 and vascular endothelial growth factor (VEGF) A pathway inhibition with intravitreal faricimab according to a personalized treat-and-extend (T&E)-based regimen with up to every-16-week dosing in the YOSEMITE and RHINE (ClinicalTrials.gov identifiers, NCT03622580 and NCT03622593, respectively) phase 3 trials of diabetic macular edema (DME). DESIGN: Randomized, double-masked, noninferiority phase 3 trials. PARTICIPANTS: Adults with visual acuity loss (best-corrected visual acuity [BCVA] of 25-73 letters) due to center-involving DME. METHODS: Patients were randomized 1:1:1 to faricimab 6.0 mg every 8 weeks, faricimab 6.0 mg T&E (previously referred to as personalized treatment interval), or aflibercept 2.0 mg every 8 weeks. The T&E up to every-16-week dosing regimen was based on central subfield thickness (CST) and BCVA change. MAIN OUTCOME MEASURES: Included changes from baseline in BCVA and CST, number of injections, durability, absence of fluid, and safety through week 100. RESULTS: In YOSEMITE and RHINE (n = 940 and 951, respectively), noninferior year 1 visual acuity gains were maintained through year 2; mean BCVA change from baseline at 2 years (weeks 92, 96, and 100 average) with faricimab every 8 weeks (YOSEMITE and RHINE, +10.7 letters and +10.9 letters, respectively) or T&E (+10.7 letters and +10.1 letters, respectively) were comparable with aflibercept every 8 weeks (+11.4 letters and +9.4 letters, respectively). The median number of study drug injections was lower with faricimab T&E (YOSEMITE and RHINE, 10 and 11 injections, respectively) versus faricimab every 8 weeks (15 injections) and aflibercept every 8 weeks (14 injections) across both trials during the entire study. In the faricimab T&E arms, durability was improved further during year 2, with > 60% of patients receiving every-16-week dosing and approximately 80% receiving every-12-week or longer dosing at week 96. Almost 80% of patients who achieved every-16-week dosing at week 52 maintained every-16-week dosing without an interval reduction through week 96. Mean CST reductions were greater (YOSEMITE/RHINE weeks 92/96/100 average: faricimab every 8 weeks -216.0/-202.6 µm, faricimab T&E -204.5/-197.1 µm, aflibercept every 8 weeks -196.3/-185.6 µm), and more patients achieved absence of DME (CST < 325 µm; YOSEMITE/RHINE weeks 92-100: faricimab every 8 weeks 87%-92%/88%-93%, faricimab T&E 78%-86%/85%-88%, aflibercept every 8 weeks 77%-81%/80%-84%) and absence of intraretinal fluid (YOSEMITE/RHINE weeks 92-100: faricimab every 8 weeks 59%-63%/56%-62%, faricimab T&E 43%-48%/45%-52%, aflibercept every 8 weeks 33%-38%/39%-45%) with faricimab every 8 weeks or T&E versus aflibercept every 8 weeks through year 2. Overall, faricimab was well tolerated, with a safety profile comparable with that of aflibercept. CONCLUSIONS: Clinically meaningful visual acuity gains from baseline, anatomic improvements, and extended durability with intravitreal faricimab up to every 16 weeks were maintained through year 2. Faricimab given as a personalized T&E-based dosing regimen supports the role of dual angiopoietin-2 and VEGF-A inhibition to promote vascular stability and to provide durable efficacy for patients with DME. FINANCIAL DISCLOSURE(S): Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Efficacy, durability, and safety of intravitreal faricimab up to every 16 weeks for neovascular age-related macular degeneration (TENAYA and LUCERNE): two randomised, double-masked, phase 3, non-inferiority trials.

BACKGROUND: Faricimab is a bispecific antibody that acts through dual inhibition of both angiopoietin-2 and vascular endothelial growth factor A. We report primary results of two phase 3 trials evaluating intravitreal faricimab with extension up to every 16 weeks for neovascular age-related macular degeneration (nAMD). METHODS: TENAYA and LUCERNE were randomised, double-masked, non-inferiority trials across 271 sites worldwide. Treatment-naive patients with nAMD aged 50 years or older were randomly assigned (1:1) to intravitreal faricimab 6·0 mg up to every 16 weeks, based on protocol-defined disease activity assessments at weeks 20 and 24, or aflibercept 2·0 mg every 8 weeks. Randomisation was performed through an interactive voice or web-based response system using a stratified permuted block randomisation method. Patients, investigators, those assessing outcomes, and the funder were masked to group assignments. The primary endpoint was mean change in best-corrected visual acuity (BCVA) from baseline averaged over weeks 40, 44, and 48 (prespecified non-inferiority margin of four letters), in the intention-to-treat population. Safety analyses included patients who received at least one dose of study treatment. These trials are registered with ClinicalTrials.gov (TENAYA NCT03823287 and LUCERNE NCT03823300). FINDINGS: Across the two trials, 1329 patients were randomly assigned between Feb 19 and Nov 19, 2019 (TENAYA n=334 faricimab and n=337 aflibercept), and between March 11 and Nov 1, 2019 (LUCERNE n=331 faricimab and n=327 aflibercept). BCVA change from baseline with faricimab was non-inferior to aflibercept in both TENAYA (adjusted mean change 5·8 letters [95% CI 4·6 to 7·1] and 5·1 letters [3·9 to 6·4]; treatment difference 0·7 letters [-1·1 to 2·5]) and LUCERNE (6·6 letters [5·3 to 7·8] and 6·6 letters [5·3 to 7·8]; treatment difference 0·0 letters [-1·7 to 1·8]). Rates of ocular adverse events were comparable between faricimab and aflibercept (TENAYA n=121 [36·3%] vs n=128 [38·1%], and LUCERNE n=133 [40·2%] vs n=118 [36·2%]). INTERPRETATION: Visual benefits with faricimab given at up to 16-week intervals demonstrates its potential to meaningfully extend the time between treatments with sustained efficacy, thereby reducing treatment burden in patients with nAMD. FUNDING: F Hoffmann-La Roche.

Efficacy, durability, and safety of intravitreal faricimab with extended dosing up to every 16 weeks in patients with diabetic macular oedema (YOSEMITE and RHINE): two randomised, double-masked, phase 3 trials.

BACKGROUND: To reduce treatment burden and optimise patient outcomes in diabetic macular oedema, we present 1-year results from two phase 3 trials of faricimab, a novel angiopoietin-2 and vascular endothelial growth factor-A bispecific antibody. METHODS: YOSEMITE and RHINE were randomised, double-masked, non-inferiority trials across 353 sites worldwide. Adults with vision loss due to centre-involving diabetic macular oedema were randomly assigned (1:1:1) to intravitreal faricimab 6·0 mg every 8 weeks, faricimab 6·0 mg per personalised treatment interval (PTI), or aflibercept 2·0 mg every 8 weeks up to week 100. PTI dosing intervals were extended, maintained, or reduced (every 4 weeks up to every 16 weeks) based on disease activity at active dosing visits. The primary endpoint was mean change in best-corrected visual acuity at 1 year, averaged over weeks 48, 52, and 56. Efficacy analyses included the intention-to-treat population (non-inferiority margin 4 Early Treatment Diabetic Retinopathy Study [ETDRS] letters); safety analyses included patients with at least one dose of study treatment. These trials are registered with ClinicalTrials.gov (YOSEMITE NCT03622580 and RHINE NCT03622593). FINDINGS: 3247 patients were screened for eligibility in YOSEMITE (n=1532) and RHINE (n=1715). After exclusions, 940 patients were enrolled into YOSEMITE between Sept 5, 2018, and Sept 19, 2019, and 951 patients were enrolled into RHINE between Oct 9, 2018, and Sept 20, 2019. These 1891 patients were randomly assigned to faricimab every 8 weeks (YOSEMITE n=315, RHINE n=317), faricimab PTI (n=313, n=319), or aflibercept every 8 weeks (n=312, n=315). Non-inferiority for the primary endpoint was achieved with faricimab every 8 weeks (adjusted mean vs aflibercept every 8 weeks in YOSEMITE 10·7 ETDRS letters [97·52% CI 9·4 to 12·0] vs 10·9 ETDRS letters [9·6 to 12·2], difference -0·2 ETDRS letters [-2·0 to 1·6]; RHINE 11·8 ETDRS letters [10·6 to 13·0] vs 10·3 ETDRS letters [9·1 to 11·4] letters, difference 1·5 ETDRS letters [-0·1 to 3·2]) and faricimab PTI (YOSEMITE 11·6 ETDRS letters [10·3 to 12·9], difference 0·7 ETDRS letters [-1·1 to 2·5]; RHINE 10·8 ETDRS letters [9·6 to 11·9], difference 0·5 ETDRS letters [-1·1 to 2·1]). Incidence of ocular adverse events was comparable between faricimab every 8 weeks (YOSEMITE n=98 [31%], RHINE n=137 [43%]), faricimab PTI (n=106 [34%], n=119 [37%]), and aflibercept every 8 weeks (n=102 [33%], n=113 [36%]). INTERPRETATION: Robust vision gains and anatomical improvements with faricimab were achieved with adjustable dosing up to every 16 weeks, demonstrating the potential for faricimab to extend the durability of treatment for patients with diabetic macular oedema. FUNDING: F Hoffmann-La Roche.

The Ongoing Development of Strength-Based Approaches to People Who Hold Systemically Marginalized Identities.

ACADEMIC ABSTRACT: Personality and social psychology have historically viewed individuals' systemically marginalized identities (e.g., as people of color, as coming from a lower-income background) as barriers to their success. Such a deficit-based perspective limits psychological science by overlooking the broader experiences, value, perspectives, and strengths that individuals who face systemic marginalization often bring to their societies. The current article aims to support future research in incorporating a strength-based lens through tracing psychology's journey away from an emphasis on deficits among people who contend with systemic marginalization and toward three distinct strength-based approaches: the universal strengths, difference-as-strength, and identity-specific strengths approaches. Through distinguishing between each approach, we advance scholarship that aims to understand systemically marginalized identities with corresponding implications for addressing inequality. Strength-based approaches guide the field to recognize the imposed limitations of deficit-based ideologies and advance opportunities to engage in research that effectively understands and values systemically marginalized people. PUBLIC ABSTRACT: Inequalities, including those between people from higher- and lower-income backgrounds, are present across society. From schools to workplaces, hospitals to courtrooms, people who come from backgrounds that are marginalized by society often face more negative outcomes than people from more privileged backgrounds. While such inequalities are often blamed on a lack of hard work or other issues within marginalized people themselves, scientific research increasingly demonstrates that this is not the case. Rather, studies consistently find that people's identities as coming from groups that face marginalization in society often serve as a valuable source of unique strengths, not deficiencies, that can help them succeed. Our article reviews these studies to examine how future research in psychology may gain a broader understanding of people who contend with marginalization. In doing so, we outline opportunities for psychological research to effectively support efforts to address persistent inequalities.

Non-traditional factors affecting referral for coronary angiography following SPECT myocardial perfusion imaging.

BACKGROUND: The use of myocardial perfusion imaging (MPI) in the management of coronary artery disease (CAD) is well established. Although prior studies have shown disparities in the use of invasive angiography in patients with acute MI, data on factors affecting referral to angiography post-MPI are lacking. We sought to evaluate the primary determinants of referral to invasive angiography post-MPI and specifically assess the role of non-traditional non-clinical factors such as race/ethnicity, socioeconomic factors, insurance status, and marital status. METHODS: All patients without known CAD who underwent stress SPECT MPI over 15 years were reviewed and the performance of coronary angiography within 90 days of their MPI was recorded. Multiple factors were analyzed for an association with referral to angiography, including exercise and MPI results, baseline demographics, traditional cardiac risk factors, and non-traditional factors such as ethnicity, insurance, marital and socioeconomic status. In a secondary analysis, these factors were assessed with regard to abnormal MPI results. RESULTS: Out of 27,895 total patients, 2,150 (7.7%) underwent invasive coronary angiography. On multivariate analysis, inpatient location, positive ECG response, and abnormal MPI results were the strongest predictors of angiography. Non-traditional factors such as race/ethnicity and insurance status had a significant association with referral to angiography with Caucasians (OR 1.42, 95% CI 1.18-1.71, P < .0001) and those with private insurance (OR 1.35, 95% CI 1.13-1.62, P = .001) or Medicare (OR 1.30, 95% CI 1.08-1.56, P = .006) having higher rates of angiography despite controlling for traditional risk factors and test results. CONCLUSION: Our study results indicate that non-traditional factors such as race/ethnicity and insurance status influence patient management decisions and impact the performance of downstream cardiac invasive testing after stress MPI. Higher rates of angiography in Caucasians, privately insured and Medicare patients were seen despite controlling for traditional risk factors and abnormal test results. Further research is needed to better understand these disparities, especially in the current healthcare environment.

Postpartum Mental Health in Rural South Africa: Socioeconomic Stressors and Worsening Mental Health.

OBJECTIVES: This study aimed to characterize patterns of worsening mental health during the postpartum period among women in rural areas of Limpopo Province, South Africa, and to identify correlates with household demographic factors. METHODS: We collected data on maternal mental health symptoms shortly after birth and then again 7 months postpartum using the World Health Organization self-reporting questionnaire (SRQ-20) from December 2017 to November 2018. The absolute change in SRQ-20 symptom score was calculated to determine worsening mental health over the postpartum period. Linear regressions were performed to investigate factors associated with mental health symptom scores at varying postpartum time points. RESULTS: We found increased reporting of poor mental health symptoms at 7 months postpartum as compared to shortly after birth (n = 224). Worsening maternal mental health over the postpartum period was associated with higher SRQ-20 symptom score shortly after birth (p < 0.001) and reported food insecurity at 7 months (p < 0.001). SRQ-20 symptom scores in the postpartum period were not associated with breastfeeding in the past 24 h reported at 7 months postpartum (p = 0.08). CONCLUSIONS FOR PRACTICE: Women in rural South Africa, like women in many settings, may be vulnerable to worsening postpartum mental health when they lack sufficient socioeconomic resources and when they have pre-existing depressive/anxiety symptoms.

An experimental demonstration of the positive consequences of guiding students to conceptualize education as connection.

INTRODUCTION: Educators often struggle to sustain students' motivation during adolescence. Students may view school tasks as insignificant because learning, achievement, and success feel detached from valued social connections. Previous findings in the study of development demonstrate that young people derive meaning from key sources of social support and connection. Finding ways to link how students approach their educational goals to meaningful social connections may strengthen responses to daily learning opportunities with positive implications for achievement. METHOD: A randomized-controlled experiment and daily diary survey evaluated the consequences of guiding students to conceptualize educational pursuits as linked to their social connections. A group of ninth-grade students in the United States (N = 39; 58.97 % girls, 30.77 % boys, 2.56 % non-binary, 7.69 % did not disclose) were randomly assigned to one of two brief programs designed to cultivate goals and motivation. RESULTS: Participants randomly assigned to a healthy achievement condition (including an emphasis on the importance of social support and connection as part of achievement and success) reported more productive responses to daily academic difficulty than participants in a standard motivation condition on a daily diary survey over one year after the program. This led to an indirect increase in actual daily support, which was associated with earning higher grades. CONCLUSIONS: The results suggest that a reconceptualization of education as an endeavor grounded in social connection would help keep students engaged in learning.

Transmission of a New Polerovirus Infecting Pepper by the Whitefly Bemisia tabaci.

Many animal and plant viruses depend on arthropods for their transmission. Virus-vector interactions are highly specific, and only one vector or one of a group of vectors from the same family is able to transmit a given virus. Poleroviruses (Luteoviridae) are phloem-restricted RNA plant viruses that are exclusively transmitted by aphids. Multiple aphid-transmitted polerovirus species commonly infect pepper, causing vein yellowing, leaf rolling, and fruit discoloration. Despite low aphid populations, a recent outbreak with such severe symptoms in many bell pepper farms in Israel led to reinvestigation of the disease and its insect vector. Here we report that this outbreak was caused by a new whitefly (Bemisia tabaci)-transmitted polerovirus, which we named Pepper whitefly-borne vein yellows virus (PeWBVYV). PeWBVYV is highly (>95%) homologous to Pepper vein yellows virus (PeVYV) from Israel and Greece on its 5' end half, while it is homologous to African eggplant yellows virus (AeYV) on its 3' half. Koch's postulates were proven by constructing a PeWBVYV infectious clone causing the pepper disease, which was in turn transmitted to test pepper plants by B. tabaci but not by aphids. PeWBVYV represents the first report of a whitefly-transmitted polerovirus.IMPORTANCE The high specificity of virus-vector interactions limits the possibility of a given virus changing vectors. Our report describes a new virus from a family of viruses strictly transmitted by aphids which is now transmitted by whiteflies (Bemisia tabaci) and not by aphids. This report presents the first description of polerovirus transmission by whiteflies. Whiteflies are highly resistant to insecticides and disperse over long distances, carrying virus inoculum. Thus, the report of such unusual polerovirus transmission by a supervector has extensive implications for the epidemiology of the virus disease, with ramifications concerning the international trade of agricultural commodities.

Hypokalemia unmasking underlying premature ventricular contraction induced polymorphic ventricular tachycardia: Low potassium is not always the culprit!

Hypokalemia is prevalent in patients resuscitated from out-of-hospital cardiac arrest and can contribute to polymorphic ventricular tachycardia (PMVT) by prolonging the QT interval. We present an interesting scenario of malignant ventricular arrythmia initially attributed to moderate hypokalemia that persisted after correction of potassium. Subsequent electrophysiological study showed two frequent PMVT-triggering PVCs mapped to the base of the antero-lateral papillary muscle and the para-Hisian region of the right side of the interventricular septum. The patient underwent catheter ablation to prevent further recurrences and dual chamber ICD implantation for secondary prevention.

Agency and clientship in public encounters: co-constructing 'neediness' and 'worthiness' in shelter placement meetings.

This article seeks to develop our understanding of the agency of vulnerable groups who at first sight may not seem to have much agency in their lives. It explores the co-constructed nature of agency in three Danish homeless shelters. Unlike earlier interview-based studies, our research is based on naturalistic data drawn from 23 video-recorded placement meetings. Using concepts from Goffman, we examine how versions of the neediness and worthiness of homeless people are negotiated verbally and bodily between staff and clients. We find that homeless people have to juggle two partly contradictory roles when they are given or take the roles of either a (active) citizen or a (passive) client. Clientship is actively negotiated by both parties and demonstrates the agency of homeless people: they can collaborate with (as clients) or challenge (as citizens) the staff's attempts to formulate solutions to their troubles. We further examine how the professional ideology of client centredness affects the meeting between the two parties. However, we show that, like any discourse, client centredness has no intrinsic meaning and is played out by actors in very different ways. In work with the homeless, the discourse of client centredness is related to discourses of 'neediness', 'worthiness' and 'value for money' that define agency in different ways and make three different client positions available: the resolute client, the acquiescent client and the passive client.

Substrate Binding Mode and Molecular Basis of a Specificity Switch in Oxalate Decarboxylase.

Oxalate decarboxylase (OxDC) catalyzes the conversion of oxalate into formate and carbon dioxide in a remarkable reaction that requires manganese and dioxygen. Previous studies have shown that replacing an active-site loop segment Ser(161)-Glu(162)-Asn(163)-Ser(164) in the N-terminal domain of OxDC with the cognate residues Asp(161)-Ala(162)-Ser-(163)-Asn(164) of an evolutionarily related, Mn-dependent oxalate oxidase gives a chimeric variant (DASN) that exhibits significantly increased oxidase activity. The mechanistic basis for this change in activity has now been investigated using membrane inlet mass spectrometry (MIMS) and isotope effect (IE) measurements. Quantitative analysis of the reaction stoichiometry as a function of oxalate concentration, as determined by MIMS, suggests that the increased oxidase activity of the DASN OxDC variant is associated with only a small fraction of the enzyme molecules in solution. In addition, IE measurements show that C-C bond cleavage in the DASN OxDC variant proceeds via the same mechanism as in the wild-type enzyme, even though the Glu(162) side chain is absent. Thus, replacement of the loop residues does not modulate the chemistry of the enzyme-bound Mn(II) ion. Taken together, these results raise the possibility that the observed oxidase activity of the DASN OxDC variant arises from an increased level of access of the solvent to the active site during catalysis, implying that the functional role of Glu(162) is to control loop conformation. A 2.6 Å resolution X-ray crystal structure of a complex between oxalate and the Co(II)-substituted ΔE162 OxDC variant, in which Glu(162) has been deleted from the active site loop, reveals the likely mode by which the substrate coordinates the catalytically active Mn ion prior to C-C bond cleavage. The "end-on" conformation of oxalate observed in the structure is consistent with the previously published V/K IE data and provides an empty coordination site for the dioxygen ligand that is thought to mediate the formation of Mn(III) for catalysis upon substrate binding.

Ventilation-Induced Modulation of Pulse Oximeter Waveforms: A Method for the Assessment of Early Changes in Intravascular Volume During Spinal Fusion Surgery in Pediatric Patients.

BACKGROUND: Scoliosis surgery is often associated with substantial blood loss, requiring fluid resuscitation and blood transfusions. In adults, dynamic preload indices have been shown to be more reliable for guiding fluid resuscitation, but these indices have not been useful in children undergoing surgery. The aim of this study was to introduce frequency-analyzed photoplethysmogram (PPG) and arterial pressure waveform variables and to study the ability of these parameters to detect early bleeding in children during surgery. METHODS: We studied 20 children undergoing spinal fusion. Electrocardiogram, arterial pressure, finger pulse oximetry (finger PPG), and airway pressure waveforms were analyzed using time domain and frequency domain methods of analysis. Frequency domain analysis consisted of calculating the amplitude density of PPG and arterial pressure waveforms at the respiratory and cardiac frequencies using Fourier analysis. This generated 2 measurements: The first is related to slow mean arterial pressure modulation induced by ventilation (also known as DC modulation when referring to the PPG), and the second corresponds to pulse pressure modulation (AC modulation or changes in the amplitude of pulse oximeter plethysmograph when referring to the PPG). Both PPG and arterial pressure measurements were divided by their respective cardiac pulse amplitude to generate DC% and AC% (normalized values). Standard hemodynamic data were also recorded. Data at baseline and after bleeding (estimated blood loss about 9% of blood volume) were presented as median and interquartile range and compared using Wilcoxon signed-rank tests; a Bonferroni-corrected P value <0.05 was considered statistically significant. RESULTS: There were significant increases in PPG DC% (median [interquartile range] = 359% [210 to 541], P = 0.002), PPG AC% (160% [87 to 251], P = 0.003), and arterial DC% (44% [19 to 84], P = 0.012) modulations, respectively, whereas arterial AC% modulations showed nonsignificant increase (41% [1 to 85], P = 0.12). The change in PPG DC% was significantly higher than that in PPG AC%, arterial DC%, arterial AC%, and systolic blood pressure with P values of 0.008, 0.002, 0.003, and 0.002, respectively. Only systolic blood pressure showed significant changes (11% [4 to 21], P = 0.003) between bleeding phase and baseline. CONCLUSIONS: Finger PPG and arterial waveform parameters (using frequency analysis) can track changes in blood volume during the bleeding phase, suggesting the potential for a noninvasive monitor for tracking changes in blood volume in pediatric patients. PPG waveform baseline modulation (PPG DC%) was more sensitive to changes in venous blood volume when compared with respiration-induced modulation seen in the arterial pressure waveform.

Structural and biophysical characterization of the α-carbonic anhydrase from the gammaproteobacterium Thiomicrospira crunogena XCL-2: insights into engineering thermostable enzymes for CO2 sequestration.

Biocatalytic CO2 sequestration to reduce greenhouse-gas emissions from industrial processes is an active area of research. Carbonic anhydrases (CAs) are attractive enzymes for this process. However, the most active CAs display limited thermal and pH stability, making them less than ideal. As a result, there is an ongoing effort to engineer and/or find a thermostable CA to fulfill these needs. Here, the kinetic and thermal characterization is presented of an α-CA recently discovered in the mesophilic hydrothermal vent-isolate extremophile Thiomicrospira crunogena XCL-2 (TcruCA), which has a significantly higher thermostability compared with human CA II (melting temperature of 71.9°C versus 59.5°C, respectively) but with a tenfold decrease in the catalytic efficiency. The X-ray crystallographic structure of the dimeric TcruCA shows that it has a highly conserved yet compact structure compared with other α-CAs. In addition, TcruCA contains an intramolecular disulfide bond that stabilizes the enzyme. These features are thought to contribute significantly to the thermostability and pH stability of the enzyme and may be exploited to engineer α-CAs for applications in industrial CO2 sequestration.

NMR studies of active-site properties of human carbonic anhydrase†II by using (15) N-labeled 4-methylimidazole as a local probe and histidine hydrogen-bond correlations.

By using a combination of liquid and solid-state NMR spectroscopy, (15) N-labeled 4-methylimidazole (4-MI) as a local probe of the environment has been studied: 1) in the polar, wet Freon CDF3 /CDF2 Cl down to 130 K, 2) in water at pH 12, and 3) in solid samples of the mutant H64A of human carbonic anhydrase II (HCA II). In the latter, the active-site His64 residue is replaced by alanine; the catalytic activity is, however, rescued by the presence of 4-MI. For the Freon solution, it is demonstrated that addition of water molecules not only catalyzes proton tautomerism but also lifts its quasidegeneracy. The possible hydrogen-bond clusters formed and the mechanism of the tautomerism are discussed. Information about the imidazole hydrogen-bond geometries is obtained by establishing a correlation between published (1) H and (15) N chemical shifts of the imidazole rings of histidines in proteins. This correlation is useful to distinguish histidines embedded in the interior of proteins and those at the surface, embedded in water. Moreover, evidence is obtained that the hydrogen-bond geometries of His64 in the active site of HCA II and of 4-MI in H64A HCA II are similar. Finally, the degeneracy of the rapid tautomerism of the neutral imidazole ring His64 reported by Shimahara et al. (J. Biol. Chem.- 2007, 282, 9646) can be explained with a wet, polar, nonaqueous active-site conformation in the inward conformation, similar to the properties of 4-MI in the Freon solution. The biological implications for the enzyme mechanism are discussed.

Activity and anion inhibition studies of the α-carbonic anhydrase from Thiomicrospira crunogena XCL-2 Gammaproteobacterium.

Thiomicrospira crunogena XCL-2 expresses an α-carbonic anhydrase (TcruCA). Sequence alignments reveal that TcruCA displays a high sequence identity (>30%) relative to other α-CAs. This includes three conserved histidines that coordinate the active site zinc, a histidine proton shuttling residue, and opposing hydrophilic and hydrophobic sides that line the active site. The catalytic efficiency of TcruCA is considered moderate relative to other α-CAs (k(cat)/K(M)=1.1×10(7) M(-1) s(-1)), being a factor of ten less efficient than the most active α-CAs. TcruCA is also inhibited by anions with Cl(-), Br(-), and I(-), all showing Ki values in the millimolar range (53-361 mM). Hydrogen sulfide (HS(-)) revealed the highest affinity for TcruCA with a Ki of 1.1 µM. It is predicted that inhibition of TcruCA by HS(-) (an anion commonly found in the environment where Thiomicrospira crunogena is located) is a way for Thiomicrospira crunogena to regulate its carbon-concentrating mechanism (CCM) and thus the organism's metabolic functions. Results from this study provide preliminary insights into the role of TcruCA in the general metabolism of Thiomicrospira crunogena.

Catalytic mechanism of α-class carbonic anhydrases: CO2 hydration and proton transfer.

The carbonic anhydrases (CAs; EC 4.2.1.1) are a family of metalloenzymes that catalyze the reversible hydration of carbon dioxide (CO2) and dehydration of bicarbonate (HCO3 (-)) in a two-step ping-pong mechanism: [Formula: see text] CAs are ubiquitous enzymes and are categorized into five distinct classes (α, ß, γ, δ and ζ). The α-class is found primarily in vertebrates (and the only class of CA in mammals), ß is observed in higher plants and some prokaryotes, γ is present only in archaebacteria whereas the δ and ζ classes have only been observed in diatoms.The focus of this chapter is on α-CAs as the structure-function relationship is best understood for this class, in particular for humans. The reader is referred to other reviews for an overview of the structure and catalytic mechanism of the other CA classes. The overall catalytic site structure and geometry of α-CAs are described in the first section of this chapter followed by the kinetic studies, binding of CO2, and the proton shuttle network.

The Association Between Baseline Left Atrial Volume Index and All-Cause Mortality in Patients with Heart Failure: A Meta-Analysis.

BACKGROUND: Enlargement of the left atrium is a marker of mortality in the general population. Left atrial volume index (LAVI) has long been proposed as a measure of prognosis in patients with heart failure (HF). The aim of this meta-analysis was to assess the utility of using baseline LAVI as an independent predictor of all-cause mortality in patients with HF. METHODS: A search of Medline and Embase bibliographic databases was performed to identify studies meeting the following inclusion criteria: 1) studies evaluating a cohort of patients with HF (both reduced and preserved ejection fraction); 2) studies conducting multivariate analysis or patient matching to determine the relationship between baseline LAVI measured by echocardiography and all-cause mortality; and 3) studies reporting data on the relationship between baseline LAVI (per difference in mL/m2) and all-cause mortality. Adjusted hazard ratios depicting the association between baseline LAVI and all-cause mortality were pooled using traditional random-effects meta-analysis. RESULTS: 1,188 publications were reviewed from which four studies were included in the present meta-analysis. We found each 10 mL/m2 increase in baseline LAVI was associated with a 22% increased adjusted hazard of all-cause mortality (95% confidence interval, 13% to 31%, I2 = 14%). CONCLUSION: Baseline LAVI is an important independent predictor of all-cause mortality in patients with heart failure and should be reported routinely in these patients undergoing echocardiography.

Thioarsenic species associated with increased arsenic release during biostimulated subsurface sulfate reduction.

Introduction of acetate into groundwater at the Rifle Integrated Field Research Challenge (Rifle, CO) has been used for biostimulation aimed at immobilizing uranium. While a promising approach for lowering groundwater-associated uranium, a concomitant increase in soluble arsenic was also observed at the site. An array of field data was analyzed to understand spatial and temporal trends in arsenic release and possible correlations to speciation, subsurface redox conditions, and biogeochemistry. Arsenic release (up to 9 µM) was strongest under sulfate reducing conditions in areas receiving the highest loadings of acetate. A mixture of thioarsenate species, primarily trithioarsenate and dithioarsenate, were found to dominate arsenic speciation (up to 80%) in wells with the highest arsenic releases; thioarsenates were absent or minor components in wells with low arsenic release. Laboratory batch incubations revealed a strong preference for the formation of multiple thioarsenic species in the presence of the reduced precursors arsenite and sulfide. Although total soluble arsenic increased during field biostimulation, the termination of sulfate reduction was accompanied by recovery of soluble arsenic to concentrations at or below prestimulation levels. Thioarsenic species can be responsible for the transient mobility of sediment-associated arsenic during sulfidogenesis and should be considered when remediation strategies are implemented in sulfate-bearing, contaminated aquifers.

Analysis of plethysmographic waveform changes induced by beach chair positioning under general anesthesia.

During shoulder surgery, patients typically are placed in the beach chair position. In rare cases, this positioning has resulted in devastating outcomes of postoperative cerebral ischemia (Cullen and Kirby in APSF Newsl 22(2):25-27, 2007; Munis in APSF Newsl 22(4):82-83, 2008). This study presents a method to noninvasively and continuously hemodynamically monitor patients during beach chair positioning by using the photoplethysmograph signal recorded from a commercial pulse oximeter. Twenty-nine adults undergoing shoulder surgery were monitored before and after beach chair positioning with electrocardiogram, intermittent blood pressure, end tidal carbon dioxide, and photoplethysmograph via Nellcor finger pulse oximeter. Fast Fourier transform (FFT) was used to perform frequency-domain analysis on the photoplethysmograph (PPG) signal for data segments taken 80-120 s before and after beach chair positioning. The amplitude density of respiration-associated PPG oscillations was quantified measuring the height of the FFT peak at respiratory frequency. Results were reported as (median, interquartile range) and statistical analysis was performed using Wilcoxon sign rank test. Data were also collected when vasoactive drugs phenylephrine and ephedrine were used to maintain acceptable mean arterial pressure during a case. With beach chair positioning, all subjects who did not receive vasoactive drugs showed an increase in the FFT amplitude density of respiration-associated PPG oscillations (p < 0.0001) without change in pulse-associated PPG oscillations. The PPG was more accurate at monitoring the change to beach chair position than blood pressure or heart rate. With vasoactive drugs, pulse-associated PPG oscillations decreased only with phenylephrine while respiration-associated oscillations did not change. Frequency domain analysis of the PPG signal may be a better tool than traditional noninvasive hemodynamic parameters at monitoring patients during beach chair position surgery.