Effect of Dialysate and Plasma Sodium on Mortality in a Global Historical Hemodialysis Cohort.

SIGNIFICANCE STATEMENT: This large observational cohort study aimed to investigate the relationship between dialysate and plasma sodium concentrations and mortality among maintenance hemodialysis patients. Using a large multinational cohort of 68,196 patients, we found that lower dialysate sodium concentrations (≤138 mmol/L) were independently associated with higher mortality compared with higher dialysate sodium concentrations (>138 mmol/L). The risk of death was lower among patients exposed to higher dialysate sodium concentrations, regardless of plasma sodium levels. These results challenge the prevailing assumption that lower dialysate sodium concentrations improve outcomes in hemodialysis patients. The study confirms that until robust evidence from randomized trials that are underway is available, nephrologists should remain cautious in reconsideration of dialysate sodium prescribing practices to optimize cardiovascular outcomes and reduce mortality in this population. BACKGROUND: Excess mortality in hemodialysis (HD) patients is largely due to cardiovascular disease and is associated with abnormal fluid status and plasma sodium concentrations. Ultrafiltration facilitates the removal of fluid and sodium, whereas diffusive exchange of sodium plays a pivotal role in sodium removal and tonicity adjustment. Lower dialysate sodium may increase sodium removal at the expense of hypotonicity, reduced blood volume refilling, and intradialytic hypotension risk. Higher dialysate sodium preserves blood volume and hemodynamic stability but reduces sodium removal. In this retrospective cohort, we aimed to assess whether prescribing a dialysate sodium ≤138 mmol/L has an effect on survival outcomes compared with dialysate sodium >138 mmol/L after adjusting for plasma sodium concentration. METHODS: The study population included incident HD patients from 875 Fresenius Medical Care Nephrocare clinics in 25 countries between 2010 and 2019. Baseline dialysate sodium (≤138 or >138 mmol/L) and plasma sodium (<135, 135-142, >142 mmol/L) concentrations defined exposure status. We used multivariable Cox regression model stratified by country to model the association between time-varying dialysate and plasma sodium exposure and all-cause mortality, adjusted for demographic and treatment variables, including bioimpedance measures of fluid status. RESULTS: In 2,123,957 patient-months from 68,196 incident HD patients with on average three HD sessions per week dialysate sodium of 138 mmol/L was prescribed in 63.2%, 139 mmol/L in 15.8%, 140 mmol/L in 20.7%, and other concentrations in 0.4% of patients. Most clinical centers (78.6%) used a standardized concentration. During a median follow-up of 40 months, one third of patients ( n =21,644) died. Dialysate sodium ≤138 mmol/L was associated with higher mortality (multivariate hazard ratio for the total population (1.57, 95% confidence interval, 1.25 to 1.98), adjusted for plasma sodium concentrations and other confounding variables. Subgroup analysis did not show any evidence of effect modification by plasma sodium concentrations or other patient-specific variables. CONCLUSIONS: These observational findings stress the need for randomized evidence to reliably define optimal standard dialysate sodium prescribing practices.

Modulating Electrostatic Properties and Noncovalent Interactions via Structural Isomerism: The Microwave Spectra and Molecular Structures of (E)- and (Z)-1,2,3,3,3-Pentafluoropropene and Their Gas-Phase Heterodimers with the Argon Atom.

Microwave spectra of both the E and Z isomers of 1,2,3,3,3-pentafluoropropene along with all three of the singly substituted 13C isotopologues for each are obtained using broadband chirped-pulse Fourier transform microwave spectroscopy from 2.0-18.1 GHz. Associated quantum chemistry calculations show that the barrier to internal rotation of the CF3 group is significantly higher for the Z isomer, which is stabilized by an intramolecular hydrogen bond, although the barriers in both isomers are sufficiently high to prevent the observation of any effects due to internal rotation. The normal isotopologues of the argon heterodimers for both isomers are also observed in the broadband spectrum and a Balle-Flygare cavity Fourier transform microwave spectrometer is used to obtain the 5.0-20.6 GHz spectra of the corresponding 13C isotopologues. In each case, the argon atom locates so as to maximize its interactions with areas of significant electron density. However, mapped electrostatic potential surfaces indicate that the areas of greatest nucleophilicity are different for the two isomers, suggesting that they may interact differently in forming heterodimers with protic acids.

Preserving the symmetry of cis-1,2-difluoroethylene in the gas-phase heterodimer with hydrogen chloride: A microwave rotational study revealing a novel structure.

The microwave spectra of three isotopologues of the gas-phase heterodimer formed between cis-1,2-difluoroethylene and hydrogen chloride are obtained in the 5-21 GHz region using Fourier transform microwave spectroscopy. The molecular structure, determined from the analysis of the spectra and supported by quantum chemistry calculations, has the hydrogen atom of the hydrogen chloride molecule interacting with both fluorine atoms of the fluoroethylene and no interaction between the chlorine atom and the olefin. Although the equilibrium structure has two inequivalent H⋯F interactions, zero-point motion averages over the two equivalent choices for these interactions, rendering the pairs of like atoms (C, H, and F) of the fluoroethylene equivalent, retaining the C2v symmetry of the olefin. This results in only one unique singly substituted 13C isotopologue and in the observed effects on transition intensities due to nuclear spin statistics. The heterodimer structure allows for a strong, linear hydrogen bond between the HCl donor and the fluoroethylene acceptor that is more important here than in the analogous acetylene containing complex, where the interaction between the π electrons of acetylene and an electrophilic hydrogen atom on the olefin compensates for the loss of linearity required for binding to a geminal F/H pair.

HapticWhirl, a Flywheel-Gimbal Handheld Haptic Controller for Exploring Multimodal Haptic Feedback.

Most haptic actuators available on the market today can generate only a single modality of stimuli. This ultimately limits the capacity of a kinaesthetic haptic controller to deliver more expressive feedback, requiring a haptic controller to integrate multiple actuators to generate complex haptic stimuli, with a corresponding complexity of construction and control. To address this, we designed a haptic controller to deliver several modalities of kinaesthetic haptic feedback using a single actuator: a flywheel, the orientation of which is controlled by two gimbals capable of rotating over 360 degrees, in combination with a flywheel brake. This enables the controller to generate multiple haptic feedback modalities, such as torque feedback, impact simulation, low-frequency high-amplitude vibrations, inertial effects (the sensation of momentum), and complex haptic output effects such as the experience of vortex-like forces (whirl effects). By combining these diverse haptic effects, the controller enriches the haptic dimension of VR environments. This paper presents the device's design, implementation, and characterization, and proposes potential applications for future work.

Rationale for and use of the lumenless 3830 pacing lead.

Most currently available pacing and defibrillation leads utilize a stylet-based design that facilitates implantation. This has advantages, but also increases the lead diameter and adds the potential for metal fatigued-based conductor failure. A systematic literature search was conducted, and the authors add their twenty-year experience with this lead design. The global experience with lumenless leads was reviewed both for "standard" positioning and with conduction system pacing. Methods for both placement and system modification are reviewed. Lumenless leads have the potential to improve the durability of endocardial pacing and facilitate conduction system pacing.

Molecular Structures and Microwave Spectra of the Gas-Phase Homodimers of 3-Fluoro-1,2-epoxypropane and 3,3-Difluoro-1,2-epoxypropane.

Molecular structures for the heterochiral and homochiral gas-phase homodimers of 3-fluoro-1,2-epoxypropane and 3,3-difluoro-1,2-epoxypropane are investigated using both ab initio and density functional quantum chemistry calculations. Although microwave spectra for the heterochiral dimers are not observed as the lowest-energy isomers lack an electric dipole moment and others are presumably too high in energy, rotational spectra are observed for the homochiral dimers of each molecule that are consistent with the lowest-energy isomers of each. The presence of hydrogen atoms in the fluoromethyl groups makes it possible for these groups to participate in the intermolecular interactions that stabilize these dimers, resulting in a distinctly different bonding motif than is observed in the homodimers of 3,3,3-trifluoro-1,2-epoxypropane where the lack of a hydrogen atom prevents this possibility. The rotational spectra and energy ordering of the dimers are sufficiently well predicted with modest calculational methods to enable straightforward assignment of the observed spectra and to identify the molecular carrier of an assigned spectrum.

Microwave Spectrum and Novel Molecular Structure of (Z)-1-Chloro-3,3,3-trifluoropropene-Acetylene.

The gas-phase heterodimer formed between (Z)-1-chloro-3,3,3-trifluoropropene and acetylene is investigated using quantum chemistry calculations and observed via chirped-pulse Fourier transform microwave (FTMW) spectroscopy. Subsequent analysis of higher resolution spectra, including those using a sample enriched in H13C13CH, obtained with a Balle-Flygare FTMW spectrometer reveals a novel structure, as predicted by theory, for the complex, in which the acetylene functions as the gas-phase (Lewis) base and the halopropene as the acid. In the equilibrium structure, the acetylene molecule is located perpendicular to the symmetry plane of (Z)-1-chloro-3,3,3-trifluoropropene with the triple bond interacting with the two olefinic hydrogens. Mapped electrostatic potential surfaces suggest that this structure results from a reduction in the nucleophilicity of the halogen atoms as compared to previously studied acetylene halo-olefin complexes and a concomitant increase in the electrophilicity of the hydrogen atoms.

Examining the gas-phase homodimers of 3,3,3-trifluoro-1,2-epoxypropane using quantum chemistry and microwave spectroscopy.

Gas phase homodimers of 3,3,3-trifluoro-1,2-epoxypropane (TFO), a molecule which has shown promise as an effective chiral tag for determining the absolute stereochemistry and the enantiomeric composition of chiral analytes, are explored using a variety of quantum chemistry models and rotational spectroscopy. The potential surface governing the interaction of the two molecules is rapidly explored using the artificial bee colony algorithm for homodimer candidates that are subsequently optimized by quantum chemistry methods. Although all model chemistries employed agree that the lowest energy form of the heterochiral homodimer of TFO (RS or SR) is lower in energy than that of the homochiral dimer (RR or SS), the energy spacings among the lower energy isomers of each and indeed the absolute energy ordering of the isomers of each are very model dependent. The experimental results suggest that the B3LYP-D3BJ/def2-TZVP model chemistry is the most reliable and provides excellent estimates of spectroscopic constants. In accord with theoretical predictions the non-polar lowest energy form of the heterochiral homodimer is not observed, while two isomers of the homochiral dimer are observed and spectroscopically characterized. Observation and assignment of the spectra for all three unique singly-substituted 13C isotopologues, in addition to that of the most abundant isotopologue for the lowest energy isomer of the homochiral homodimer of TFO, provide structural information that compares very favorably with theoretical predictions, most notably that the presence of three fluorine atoms on the trifluoromethyl group removes their direct participation in the intermolecular interactions, which instead comprise two equivalent pairs of CH⋯O hydrogen bonds between the two epoxide rings augmented by favorable dispersion interactions between the rings themselves.

Three-year extraction experience of a novel substernal extravascular defibrillation lead in sheep.

BACKGROUND: The extravascular implantable cardioverter-defibrillator (EV ICD) with lead implantation in the substernal space may provide an alternative to transvenous and subcutaneous systems. This is the first-reported chronic extraction experience for EV ICD leads. The aim of the study is to evaluate the chronic encapsulation and extractability of EV ICD leads. METHODS: Two EV ICD leads and one transvenous lead were implanted in each of 24 mature sheep. A subset of animals was evaluated yearly for histology and lead extractability. Extractions were performed using simple traction or extraction tools. Histology evaluated the encapsulating tissue. RESULTS: At 1 year, extraction was performed successfully for two of five EV ICD leads with traction alone using ≤3.1 kg-force (kgf) and the remainder extracted successfully with extraction tools; no transvenous leads were removed with traction alone. At 2 years, no EV ICD or transvenous leads were extracted with traction alone, while at 3 years, one of eight EV ICD leads and two of four transvenous leads were extracted with traction (0.8 and ≤2.3 kgf, respectively). There was one observation of hemopericardium resulting in tamponade with EV ICD extraction but without injury to cardiovascular structures and related to the unique implant tract. Among transvenous leads, inversion of the ventricle with loss of cardiac output resulted in abandonment of traction for two animals. CONCLUSIONS: Chronic extraction of EV ICD leads from the substernal space was successfully performed using traction and simple tools through 3 years in sheep with one observation of hemopericardium that did not originate from cardiovascular injury.

Home Versus Facility Dialysis and Mortality in Australia and New Zealand.

RATIONALE & OBJECTIVE: Mortality is an important outcome for all dialysis stakeholders. We examined associations between dialysis modality and mortality in the modern era. STUDY DESIGN: Observational study comparing dialysis inception cohorts 1998-2002, 2003-2007, 2008-2012, and 2013-2017. SETTING & PARTICIPANTS: Australia and New Zealand (ANZ) dialysis population. EXPOSURE: The primary exposure was dialysis modality: facility hemodialysis (HD), continuous ambulatory peritoneal dialysis (CAPD), automated PD (APD), or home HD. OUTCOME: The main outcome was death. ANALYTICAL METHODS: Cause-specific proportional hazards models with shared frailty and subdistribution proportional hazards (Fine and Gray) models, adjusting for available confounding covariates. RESULTS: In 52,097 patients, the overall death rate improved from ~15 deaths per 100 patient-years in 1998-2002 to ~11 in 2013-2017, with the largest cause-specific contribution from decreased infectious death. Relative to facility HD, mortality with CAPD and APD has improved over the years, with adjusted hazard ratios in 2013-2017 of 0.88 (95% CI, 0.78-0.99) and 0.91 (95% CI, 0.82-1.00), respectively. Increasingly, patients with lower clinical risk have been adopting APD, and to a lesser extent CAPD. Relative to facility HD, mortality with home HD was lower throughout the entire period of observation, despite increasing adoption by older patients and those with more comorbidities. All effects were generally insensitive to the modeling approach (initial vs time-varying modality, cause-specific versus subdistribution regression), different follow-up time intervals (5 year vs 7 year vs 10 year). There was no effect modification by diabetes, comorbidity, or sex. LIMITATIONS: Potential for residual confounding, limited generalizability. CONCLUSIONS: The survival of patients on PD in 2013-2017 appears greater than the survival for patients on facility HD in ANZ. Additional research is needed to assess whether changing clinical risk profiles over time, varied dialysis prescription, and morbidity from dialysis access contribute to these findings.

Relationship between measured and prescribed dialysate sodium in haemodialysis: a systematic review and meta-analysis.

BACKGROUND: Dialysate sodium (DNa) prescription policy differs between haemodialysis (HD) units, and the optimal DNa remains uncertain. We sought to summarize the evidence on the agreement between prescribed and delivered DNa, and whether the relationship varied according to prescribed DNa. METHODS: We searched MEDLINE and PubMed from inception to 26 February 2020 for studies reporting measured and prescribed DNa. We analysed results reported in aggregate with random-effects meta-analysis. We analysed results reported by individual sample, using mixed-effects Bland-Altman analysis and linear regression. Pre-specified subgroup analyses included method of sodium measurement, dialysis machine manufacturer and proportioning method. RESULTS: Seven studies, representing 908 dialysate samples from 10 HD facilities (range 16-133 samples), were identified. All but one were single-centre studies. Studies were of low to moderate quality. Overall, there was no statistically significant difference between measured and prescribed DNa {mean difference = 0.73 mmol/L [95% confidence interval (CI) -1.12 to 2.58; P = 0.44]} but variability across studies was substantial (I2 = 99.3%). Among individually reported samples (n = 295), measured DNa was higher than prescribed DNa by 1.96 mmol/L (95% CI 0.23-3.69) and the 95% limits of agreement ranged from -3.97 to 7.88 mmol/L. Regression analysis confirmed a strong relationship between prescribed and measured DNa, with a slope close to 1:1 (ß = 1.16, 95% CI 1.06-1.27; P < 0.0001). CONCLUSIONS: A limited number of studies suggest that, on average, prescribed and measured DNa are similar. However, between- and within-study differences were large. Further consideration of the precision of delivered DNa is required to inform rational prescribing.

Straining to Put the Pieces Together: The Molecular Structure of (E)-1-Chloro-1,2-difluoroethylene-Acetylene from Microwave Spectroscopy.

The microwave, rotational spectrum between 5.6 and 19.7 GHz of the gas-phase heterodimer formed between acetylene and (E)-1-chloro-1,2-difluoroethylene is obtained using both broadband, chirped-pulse and narrow band, Balle-Flygare Fourier transform microwave spectrometers. The structure of the complex is determined from the rotational constants obtained via the analysis of the spectra for the normal isotopologue of the complex and three isotopically substituted species: the singly substituted 37Cl isotopologue, obtained in natural abundance, and two isotopologues singly substituted with 13C, obtained using an isotopically enriched HC13CH sample. The acetylene forms a hydrogen bond with the fluorine atom on singly halogenated carbon and a secondary interaction with the hydrogen atom on that same carbon. The angle strain induced in forming the secondary interaction is offset by the favorable electrostatics of the hydrogen bond to fluorine. Comparisons with acetylene complexes of 1,1,2-trifluoroethylene and cis-1,2-difluoroethylene show the effects of halogen substitution at the remote carbon on this bonding motif.

Effect of Low-Sodium versus Conventional Sodium Dialysate on Left Ventricular Mass in Home and Self-Care Satellite Facility Hemodialysis Patients: A Randomized Clinical Trial.

BACKGROUND: Fluid overload in patients undergoing hemodialysis contributes to cardiovascular morbidity and mortality. There is a global trend to lower dialysate sodium with the goal of reducing fluid overload. METHODS: To investigate whether lower dialysate sodium during hemodialysis reduces left ventricular mass, we conducted a randomized trial in which patients received either low-sodium dialysate (135 mM) or conventional dialysate (140 mM) for 12 months. We included participants who were aged >18 years old, had a predialysis serum sodium ≥135 mM, and were receiving hemodialysis at home or a self-care satellite facility. Exclusion criteria included hemodialysis frequency >3.5 times per week and use of sodium profiling or hemodiafiltration. The main outcome was left ventricular mass index by cardiac magnetic resonance imaging. RESULTS: The 99 participants had a median age of 51 years old; 67 were men, 31 had diabetes mellitus, and 59 had left ventricular hypertrophy. Over 12 months of follow-up, relative to control, a dialysate sodium concentration of 135 mmol/L did not change the left ventricular mass index, despite significant reductions at 6 and 12 months in interdialytic weight gain, in extracellular fluid volume, and in plasma B-type natriuretic peptide concentration (ratio of intervention to control). The intervention increased intradialytic hypotension (odds ratio [OR], 7.5; 95% confidence interval [95% CI], 1.1 to 49.8 at 6 months and OR, 3.6; 95% CI, 0.5 to 28.8 at 12 months). Five participants in the intervention arm could not complete the trial because of hypotension. We found no effect on health-related quality of life measures, perceived thirst or xerostomia, or dietary sodium intake. CONCLUSIONS: Dialysate sodium of 135 mmol/L did not reduce left ventricular mass relative to control, despite improving fluid status. CLINICAL TRIAL REGISTRY NAME AND REGISTRATION NUMBER: The Australian New Zealand Clinical Trials Registry, ACTRN12611000975998.

Icodextrin Versus Glucose Solutions for the Once-Daily Long Dwell in Peritoneal Dialysis: An Enriched Systematic Review and Meta-analysis of Randomized Controlled Trials.

RATIONALE & OBJECTIVE: The efficacy and safety of icodextrin versus glucose-only peritoneal dialysis (PD) regimens is unclear. The aim of this study was to compare once-daily long-dwell icodextrin versus glucose among patients with kidney failure undergoing PD. STUDY DESIGN: Systematic review of randomized controlled trials (RCTs), enriched with unpublished data from investigator-initiated and industry-sponsored studies. SETTING & STUDY POPULATIONS: Individuals with kidney failure receiving regular PD treatment enrolled in clinical trials of dialysate composition. SELECTION CRITERIA FOR STUDIES: Medline, Embase, CENTRAL, Ichushi Web, 10 Chinese databases, clinical trials registries, conference proceedings, and citation lists from inception to November 2018. Further data were obtained from principal investigators and industry clinical study reports. DATA EXTRACTION: 2 independent reviewers selected studies and extracted data using a prespecified extraction instrument. ANALYTIC APPROACH: Qualitative synthesis of demographics, measurement scales, and outcomes. Quantitative synthesis with Mantel-Haenszel risk ratios (RRs), Peto odds ratios (ORs), or (standardized) mean differences (MDs). Risk of bias of included studies at the outcome level was assessed using the Cochrane risk-of-bias tool for RCTs. RESULTS: 19 RCTs that enrolled 1,693 participants were meta-analyzed. Ultrafiltration was improved with icodextrin (medium-term MD, 208.92 [95% CI, 99.69-318.14] mL/24h; high certainty of evidence), reflected also by fewer episodes of fluid overload (RR, 0.43 [95% CI, 0.24-0.78]; high certainty). Icodextrin-containing PD probably decreased mortality risk compared to glucose-only PD (Peto OR, 0.49 [95% CI, 0.24-1.00]; moderate certainty). Despite evidence of lower peritoneal glucose absorption with icodextrin-containing PD (medium-term MD, -40.84 [95% CI, -48.09 to-33.59] g/long dwell; high certainty), this did not directly translate to changes in fasting plasma glucose (-0.50 [95% CI, -1.19 to 0.18] mmol/L; low certainty) and hemoglobin A1c levels (-0.14% [95% CI, -0.34% to 0.05%]; high certainty). Safety outcomes and residual kidney function were similar in both groups; health-related quality-of-life and pain scores were inconclusive. LIMITATIONS: Trial quality was variable. The follow-up period was heterogeneous, with a paucity of assessments over the long term. Mortality results are based on just 32 events and were not corroborated using time-to-event analysis of individual patient data. CONCLUSIONS: Icodextrin for once-daily long-dwell PD has clinical benefit for some patients, including those not meeting ultrafiltration targets and at risk for fluid overload. Future research into patient-centered outcomes and cost-effectiveness associated with icodextrin is needed.

Haemodialysis withdrawal in Australia and New Zealand: a binational registry study.

BACKGROUND: Withdrawal from dialysis is an increasingly common cause of death in patients with end-stage kidney disease (ESKD). As most published reports of dialysis withdrawal have been outside the Oceania region, the aims of this study were to determine the frequency, temporal pattern and predictors of dialysis withdrawal in Australian and New Zealand patients receiving chronic haemodialysis. METHODS: This study included all people with ESKD in Australia and New Zealand who commenced chronic haemodialysis between 1 January 1997 and 31 December 2016, using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Competing risk regression models were used to identify predictors of dialysis withdrawal mortality, using non-withdrawal cause of death as the competing risk event. RESULTS: Among 40 447 people receiving chronic haemodialysis (median age 62 years, 61% male, 9% Indigenous), dialysis withdrawal mortality rates increased from 1.02 per 100 patient-years (11% of all deaths) during the period 1997-2000 to 2.20 per 100 patient-years (32% of all deaths) during 2013-16 (P < 0.001). Variables that were significantly associated with a higher likelihood of haemodialysis withdrawal were older age {≥70 years subdistribution hazard ratio [SHR] 1.77 [95% confidence interval (CI) 1.66-1.89]; reference 60-70 years}, female sex [SHR 1.14 (95% CI 1.09-1.21)], white race [Asian SHR 0.56 (95% CI 0.49-0.65), Aboriginal and Torres Strait Islander SHR 0.83 (95% CI 0.74-0.93), Pacific Islander SHR 0.47 (95% CI 0.39-0.68), reference white race], coronary artery disease [SHR 1.18 (95% CI 1.11-1.25)], cerebrovascular disease [SHR 1.15 (95% CI 1.08-1.23)], chronic lung disease [SHR 1.13 (95% CI 1.06-1.21)] and more recent era [2013-16 SHR 3.96 (95% CI 3.56-4.48); reference 1997-2000]. CONCLUSIONS: Death due to haemodialysis withdrawal has become increasingly common in Australia and New Zealand over time. Predictors of haemodialysis withdrawal include older age, female sex, white race and haemodialysis commencement in a more recent era.

Temporal changes in dialysate [Na+] prescription from 1996 to 2018 and their clinical significance as judged from a meta-regression of clinical trials.

Over the last two decades, the clinical care of dialysis patients has refocused sharply on fluid volume control. Dialysate [Na+] is a key, albeit under-investigated, clinical tool for manipulation of fluid volume on dialysis. In the article, we firstly use data from the Dialysis Outcomes and Practice Patterns Study to document the global decrease in dialysate [Na+] that has occurred from 1996 to 2018, and demonstrate the virtual disappearance of [Na+] profiling from routine dialysis practice over the same period. Second, we used data from previously synthesized randomized clinical trial evidence combined with that of a more recently published trail to assess the clinical significance of these changes, estimating the effects of different levels of low dialysate [Na+] on key clinical outcomes. Our analyses suggest that current levels of dialysate [Na+] in some health jurisdictions are possibly causing harm to many patients, especially given that real world populations are significantly less robust and more vulnerable than clinical trial ones. To quote a recent editorial, "more evidence needed before lower dialysate sodium concentrations can be recommended." That evidence is coming, and no further changes should be made to default customary practice until it is available.

The Importance of How the Pieces Fit Together: The Microwave Spectrum and Molecular Structure of 2-Chloro-1,1-Difluoroethylene-Acetylene.

Fourier transform microwave spectroscopy is used to obtain the rotational spectrum of the gas-phase heterodimer formed between 2-chloro-1,1-difluoroethylene and acetylene between 5.1 and 20.0 GHz. Rotational constants derived from the analysis of the spectra for the normal isotopologue, the singly substituted 37Cl isotopologue, observed in natural abundance, and two isotopologues singly substituted with 13C, obtained using an isotopically enriched HC13CH sample, are used to determine the structure of the complex. Although the formation of a hydrogen bond to fluorine, considered in isolation, would be electrostatically favored, the angle strain induced in forming the secondary interaction between the acetylene triple bond and the hydrogen atom on 2-chloro-1,1-difluoroethylene coupled with the relaxed steric requirements of hydrogen bonding to chlorine lead to the heterodimer adopting what we have previously termed the side-binding configuration as the lowest energy structure. In this arrangement, the acetylene forms a hydrogen bond with the chlorine atom and a secondary interaction with the hydrogen atom, which is geminal to the chlorine. Comparisons with acetylene complexes of (Z)-1-chloro-2-fluoroethylene and vinyl chloride show the effects of increasing fluorine substitution on this bonding motif.

Microwave Spectrum and Molecular Structure of 3-Fluoro-1,2-epoxypropane and the Unexpected Structure of Its Complex with the Argon Atom.

In common with the homologous 3,3-difluoro- and 3,3,3-trifluoro-species, 3-fluoro-1,2-epoxypropane is a small chiral molecule with a simple rotational spectrum, making it potentially useful for chiral analysis via conversion of enantiomers into spectroscopically distinct diastereomers through formation of noncovalently bound complexes. The rotational spectrum of 3-fluoro-1,2-epoxypropane (FO) and of its heterodimer with the argon atom are obtained, along with several isotopologues of each, using Fourier transform microwave spectroscopy from 5.6 to 18.1 GHz, and their structures determined. Surprisingly, the structure of 3-fluoro-1,2-epoxypropane-argon does not show a strong similarity to those previously determined for 3,3-difluoro-1,2-epoxypropane-argon and 3,3,3-trifluoro-1,2-epoxypropane-argon but instead is more analogous to that of propylene oxide-argon. Equilibrium structural parameters and mapped electrostatic potential surfaces obtained via quantum chemistry calculations are used in rationalizing this result.

Percutaneous epicardial placement of a prototype miniature pacemaker under direct visualization: An infant porcine chronic survival study.

INTRODUCTION: Pacemaker implantation in infants typically consists of surgical epicardial lead placement with an abdominal generator. Here, we describe the chronic performance of our minimally invasive prototype miniature pacemaker implanted under direct visualization in an immature porcine model. METHODS: Twelve piglets underwent miniature pacemaker implantation. A self-anchoring two-channel access port was inserted into a 1 cm incision in the subxiphoid space, and a thoracoscope was inserted into the main channel to visualize the thoracic cavity under insufflation. The pacemaker leadlet was inserted through a sheath via secondary channel and affixed against the epicardium using a helical side-biting electrode. The miniature pacemaker was tucked into the incision, which was sutured closed. Ventricular sensing, leadlet impedance, and capture thresholds were measured biweekly. A limited necropsy was performed after euthanasia. RESULTS: Nine piglets were followed for a median of 78 (IQR 52-82) days and gained 6.6 ± 3.2 kg. Three animals were censored from the analysis due to complications unrelated to the procedure. Capture thresholds rose above maximal output after a median of 67 (IQR 40-69) days. At termination, there was a significant decrease in R-wave amplitude (P = .03) and rise in capture thresholds at 0.4 ms (P = .01) and 1.0 ms pulse widths (P = .02). There was no significant change in leadlet impedance (P = .74). There were no wound infections. CONCLUSIONS: There were no infections following minimally invasive implantation of our prototype miniature pacemaker. Improvements to epicardial fixation are necessary to address diminished leadlet efficacy over time.

Exploring the sterically disfavored binding of acetylene to a geminal olefinic hydrogen-fluorine atom pair: The microwave spectrum and molecular structure of cis-1,2-difluoroethylene-acetylene.

The microwave rotational spectrum of the gas-phase bimolecular heterodimer formed between cis-1,2-difluoroethylene and acetylene is obtained using Fourier transform microwave spectroscopy from 5.9 to 21.2 GHz. Rotational constants derived from the analysis of the spectra for the normal isotopologue and singly substituted 13C isotopologues, obtained in natural abundance, allow the determination of the structure of the complex, which, in the absence of a fluorine-hydrogen atom pair located cis to each other, adopts a sterically disfavored geometry ("side-binding") in which the acetylene interacts with a geminal fluorine-hydrogen atom pair. Structural details are found to be similar to those of previously studied heterodimers with side-binding of acetylene to fluorine while reflecting the degree of halosubstitution. A detailed comparison with the (Z)-1-chloro-2-fluoroethylene-acetylene complex reveals information regarding the relaxed steric requirements for hydrogen bonding to chlorine as opposed to hydrogen bonding to fluorine.