Ultrasound-guided deployment of ProGlide™ device in transfemoral transcatheter aortic valve implantation and risk reduction of vascular complications: A propensity-matched cohort study.

BACKGROUND: ProGlide is a percutaneous suture-mediated closure device used in arterial and venous closure following percutaneous intervention. Risk of vascular complications from use, particularly related to failure in hemostasis, or acute vessel closure, remains significant and often related to improper suture deployment. We describe a technique of ultrasound-guided ProGlide deployment in transfemoral transcatheter aortic valve implantation (TF-TAVI). AIMS: The aim of this study is to assess vascular outcomes for ultrasound-guided deployment of ProGlide vascular closure devices in patients undergoing TF-TAVI. METHODS: We collected relevant clinical data of patients undergoing TAVI in a large volume centre. PRIMARY OUTCOME: main access Valve Academic Research Consortium 3 (VARC-3) major vascular complication. SECONDARY OUTCOME: any major/minor VARC-3 vascular complication, its type (bleed or ischemia), and treatment required (medical, percutaneous, or surgical). We performed inverse weighting propensity score analysis to compare the population undergoing ultrasound-guided versus conventional ProGlide deployment for main TAVI access. Ultrasound technique for ProGlide insertion was performed as described below. RESULTS: Five hundred and seventeen patients undergoing TF-TAVI were included. PRIMARY OUTCOME: In 126 (ultrasound-guided) and 391 (conventional ProGlide insertion), 0% versus 1.8% (p < 0.001) had a major VARC-3 vascular complication, respectively. SECONDARY OUTCOME: 0.8% (one minor VARC-3 bleed) vs 4.1% (13 bleeds and three occlusions) had any VARC-3 vascular complication (major and minor) (p < 0.001). Surgical treatment of vascular complication was required in 0.8% versus 1.3% (p = NS). CONCLUSIONS: Ultrasound-guided deployment of ProGlide for vascular closure reduced the risk of major vascular complications in a large population undergoing TAVI.

Clinical Outcomes and Registry Data in Total Ankle Arthroplasty.

Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis consistently demonstrating good to excellent outcomes, even when considering factors such as deformity, patient age, bilaterality, and arthritis etiology. There is little consensus in the literature with regard to preferred patient-reported outcome metrics (PROMs) for assessing outcomes, although all metrics generally improve following TAA. Several countries have successful registries to track longevity of TAA in populations; however, PROMs are generally not successfully tracked in registries. A trend toward consensus on outcome metrics and collaborative registries is warranted to optimize patient selection and outcomes in TAA.

Performance and Interpretation of Sonography in the Practice of Nephrology: Core Curriculum 2024.

Ultrasonography is increasingly being performed by clinicians at the point of care, and nephrologists are no exception. This Core Curriculum illustrates how ultrasonography can be incorporated into clinical decision making across the spectrum of kidney disease to optimize the care nephrologists provide to patients. Sonography is valuable in outpatient and inpatient settings for the diagnosis and management of acute and chronic kidney disease, evaluation of cystic disease, urinary obstruction, pain, hematuria, proteinuria, assessment of volume status, and in providing guidance for kidney biopsy. As kidney disease advances, ultrasound is useful in the placement and maintenance of temporary and permanent access for dialysis. After kidney transplantation, ultrasonography is critical for evaluation of allograft dysfunction and for biopsies. Sonography skills expedite patient care and enhance the practice of nephrology and are relatively easily acquired with training. It is our hope that this curriculum will encourage nephrologists to learn and apply this valuable skill.

Client experience of food assistance programs among adults in the United States: a qualitative evidence synthesis protocol.

Introduction: Policymakers, health practitioners, and other key partners are increasingly focused on ensuring that clients of food assistance programs have positive experiences, a key aspect of high-quality programming. The objectives of this review are to describe the experiences of clients participating in food assistance programs in the United States (US) and to identify ways that these programs promote or hinder positive experiences. Methods and analysis: We will conduct a qualitative evidence synthesis with partners from food security organizations and community members. Peer-reviewed literature will be systematically searched in Scopus, CINAHL, and AGRICOLA. To identify grey literature, we will use Google's programmable search engine. This review will consider sources that present results of primary qualitative studies that focus on at least one food assistance program in the US and explore the perspectives of adult clients. Only sources published in English or Spanish from 2007 onward will be included. Multiple reviewers will screen articles for inclusion and extract data from articles that meet the inclusion criteria, using a structured data extraction tool. Thematic synthesis or meta-ethnography may be appropriate approaches for synthesizing the extracted data. The final selection of synthesis method will be determined once the set of primary qualitative studies to be included in the review is complete and the type of data presented in these studies is known. We will assess the methodological quality of the included studies using the CASP (Critical Appraisal Skills Programme) tool for qualitative studies and assess the confidence in the review findings using the GRADE-CERQual (Confidence in Evidence from Reviews of Qualitative research) approach. Discussion: The findings of this review will inform the development of measures to assess client experience and quality improvement efforts.

A Mobile Application Adjunct to Augment Cognitive-Behavioral Group Therapy for Adolescents with Social Anxiety: Feasibility and Acceptability Results from the Wiring Adolescents with Social Anxiety via Behavioral Interventions Pilot Trial.

Objective: Cognitive-Behavioral Group Therapy (CBGT) is an established treatment for Social Anxiety (SA). However, diagnostic recovery rate is only 20.5% in CBGT, and up to 50% of patients remain symptomatic posttreatment. Using videocalls to deliver digital CBGT (dCBGT) is feasible, cost-effective, and efficacious. Yet, the impact of dCBGT on social functioning remains limited, as dCBGT does not offer opportunities for monitoring cognition and behavior in social situations. Wiring Adolescents with Social Anxiety via Behavioral Interventions (WASABI), a clinician-assisted application that uses ecological momentary assessments (EMAs), cognitive bias tests, and clinical self-reports, was investigated as an adjunct to dCBGT. Methods: A prospective, parallel arm, double-blind randomized controlled trial was employed in 24 SA adolescents randomly assigned to dCBGT versus dCBGT plus WASABI. Results: Study completion rates (83%) and exit survey data indicated that WASABI is feasible and acceptable. Engagement with EMAs varied from four to 244 EMAs completed per person. Cognitive bias tests and clinical self-reports were completed at least weekly by 53% and 69% of participants, respectively. While standard tests did not reveal statistically significant differences between dCBGT plus WASABI and dCBGT alone, effect sizes were greater for dCBGT plus WASABI on symptom severity, social skills, and functioning. Conclusions: Despite the small sample, preliminary results suggest that WASABI is feasible, acceptable, and may be an effective augmentation tool for treating SA in teenagers.

Ras-dependent activation of BMAL2 regulates hypoxic metabolism in pancreatic cancer.

To identify novel drivers of malignancy in pancreatic ductal adenocarcinoma (PDAC), we employed regulatory network analysis, which calculates the activity of transcription factors and other regulatory proteins based on the integrated expression of their positive and negative target genes. We generated a regulatory network for the malignant epithelial cells of human PDAC using gene expression data from a set of 197 laser capture microdissected human PDAC samples and 45 low-grade precursors, for which we had matched histopathological, clinical, and epidemiological annotation. We then identified the most highly activated and repressed regulatory proteins (e.g. master regulators or MRs) associated with four malignancy phenotypes: precursors vs. PDAC (initiation), low-grade vs. high grade histopathology (progression), survival post resection, and association with KRAS activity. Integrating across these phenotypes, the top MR of PDAC malignancy was found to be BMAL2, a member of the PAS family of bHLH transcription factors. Although the canonical function of BMAL2 is linked to the circadian rhythm protein CLOCK, annotation of BMAL2 target genes highlighted a potential role in hypoxia response. We previously demonstrated that PDAC is hypovascularized and hypoperfused, and here show that PDAC from the genetically engineered KPC model exists in a state of extreme hypoxia, with a partial oxygen pressure of <1mmHg. Given the close homology of BMAL2 to HIF1ß (ARNT) and its potential to heterodimerize with HIF1A and HIF2A, we investigated whether BMAL2 plays a role in the hypoxic response of PDAC. Indeed, BMAL2 controlled numerous hypoxia response genes and could be inhibited following treatment with multiple RAF, MEK, and ERK inhibitors, validating its association with RAS activity. Knockout of BMAL2 in four human PDAC cell lines led to defects in growth and invasion in the setting of hypoxia. Strikingly, BMAL2 null cells failed to induce glycolysis upon exposure to severe hypoxia and this was associated with a loss of expression of the glycolytic enzyme LDHA. Moreover, HIF1A was no longer stabilized under hypoxia in BMAL2 knockout cells. By contrast, HIF2A was hyper-stabilized under hypoxia, indicating a dysregulation of hypoxia metabolism in response to BMAL2 loss. We conclude that BMAL2 is a master regulator of hypoxic metabolism in PDAC, serving as a molecular switch between the disparate metabolic roles of HIF1A- and HIF2A-dependent hypoxia responses.

Measuring quality of gout management in residential aged care facilities.

Objective: Gout, a common form of arthritis, can be controlled successfully with pharmacotherapy and is thus an ideal model for examining chronic disease management. Our aim was to examine treatment of gout evaluated in accordance with general management guidelines for gout as applied to Australian residential aged care facilities. Methods: Electronic health record data linked with aged care clinical notes and electronic medication administration information (11 548 residents in 68 residential aged care facilities, >65 years of age) were interrogated to identify people with gout, other chronic conditions and gout medication use. The outcomes examined were the proportion receiving urate-lowering therapy (ULT; preventative medication) and/or colchicine/non-steroidal anti-inflammatory drug (NSAID) (to treat gout flares), the number of ULT and colchicine/NSAID treatment episodes (periods of continuous days of medication use) and the duration of these treatment episodes. Results: The cohort included 1179 residents with gout, of whom 62% used a ULT, with a median of one episode of use for a very short duration [median = 4 days, median of use in total (i.e. repeated use) = 52 days]. Among residents with gout, 9% also used colchicine or an NSAID. Female residents were less likely to receive ULT and for shorter periods. Conclusion: Nearly one-third of residents with gout did not receive ULT. In those receiving ULT, recurrent short courses were common. Overall, management of gout in aged care residents appears to be suboptimal, largely owing to intermittent and short exposure to ULT, and with female residents at greater risk of poor gout management.

Point-of-care ultrasonography in nephrology comes of age.

The physical exam is changing. Many have argued that the physical exam of the 21st century should include point-of-care ultrasound (POCUS). POCUS is being taught in medical schools and has been endorsed by the major professional societies of internal medicine. In this review we describe the trend toward using POCUS in medicine and describe where the practicing nephrologist fits in. We discuss what a nephrologist's POCUS exam should entail and we give special attention to what nephrologists can gain from learning POCUS. We suggest a 'nephro-centric' approach that includes not only ultrasound of the kidney and bladder, but of the heart, lungs and vascular access. We conclude by reviewing some of the sparse data available to guide training initiatives and give suggested next steps for advancing POCUS in nephrology.

Predominance of Methanomicrobiales and diverse hydrocarbon-degrading taxa in the Appalachian coalbed biosphere revealed through metagenomics and genome-resolved metabolisms.

Coalbed deposits are a unique subsurface environment and represent an underutilized resource for methane generation. Microbial communities extant in coalbed deposits are responsible for key subsurface biogeochemical cycling and could be utilized to enhance methane production in areas where existing gas wells have depleted methane stores, or in coalbeds that are unmined, or conversely be utilized for mitigation of methane release. Here we utilize metagenomics and metagenome-assembled genomes (MAGs) to identify extant microbial lineages and genome-resolved microbial metabolisms of coalbed produced water, which has not yet been explored in the Appalachian Basin (AppB). Our analyses resulted in the recovery of over 40 MAGs from 8 coalbed methane wells. The most commonly identified taxa among samples were hydrogenotrophic methanogens from the order Methanomicrobiales and these dominant MAGs were highly similar to one another. Conversely, low-abundance coalbed bacterial populations were taxonomically and functionally diverse, mostly belonging to a variety of Proteobacteria classes, and encoding various hydrocarbon solubilization and degradation pathways. The data presented herein provides novel insights into AppB coalbed microbial ecology, and our findings provide new perspectives on underrepresented Methanocalculus species and low-relative abundance bacterial assemblages in coalbed environments, and their potential roles in stimulation or mitigation of methane release.

Point-of-Care Ultrasound Training during Nephrology Fellowship: A National Survey of Fellows and Program Directors.

BACKGROUND AND OBJECTIVES: Point-of-care ultrasound (POCUS)-performed by a clinician during a patient encounter and used in patient assessment and care planning-has many potential applications in nephrology. Yet, US nephrologists have been slow to adopt POCUS, which may affect the training of nephrology fellows. This study sought to identify the current state of POCUS training and implementation in nephrology fellowships. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Concise survey instruments measuring attitudes toward POCUS, its current use, fellow competence, and POCUS curricula were disseminated to (1) 912 US nephrology fellows taking the 2021 Nephrology In-Training Examination and (2) 229 nephrology training program directors and associate program directors. Fisher exact, chi-squared, and Wilcoxon rank sum tests were used to compare the frequencies of responses and the average responses between fellows and training program directors/associate program directors when possible. RESULTS: Fellow and training program directors/associate program directors response rates were 69% and 37%, respectively. Only 38% of fellows (240 respondents) reported receiving POCUS education during their fellowship, and just 33% of those who did receive POCUS training reported feeling competent to use POCUS independently. Similarly, just 23% of training program directors/associate program directors indicated that they had a POCUS curriculum in place, although 74% of training program directors and associate program directors indicated that a program was in development or that there was interest in creating a POCUS curriculum. Most fellow and faculty respondents rated commonly covered POCUS topics-including dialysis access imaging and kidney biopsy-as "important" or "very important," with the greatest interest in diagnostic kidney ultrasound. Guided scanning with an instructor was the highest-rated teaching strategy. The most frequently reported barrier to POCUS program development was the lack of available instructors. CONCLUSIONS: Despite high trainee and faculty interest in POCUS, the majority of current nephrology fellows are not receiving POCUS training. Hands-on training guided by an instructor is highly valued, yet availability of adequately trained instructors remains a barrier to program development. PODCAST: This article contains a podcast at https://www.asn-online.org/media/podcast/CJASN/2022_09_21_CJN01850222.mp3.

Recovery of Severe Acute Kidney Injury in a Patient with COVID-19: Role of Lung Ultrasonography.

Acute kidney injury (AKI) is recognized as a complication of COVID-19 among hospitalized patients. Lung ultrasonography (LUS) can be a useful tool in the management of COVID-19 pneumonia when interpreted correctly. However, the role of LUS in management of severe AKI in the setting of COVID-19 remains to be defined. We report a 61-year-old male who was hospitalized with acute respiratory failure from COVID-19 pneumonia. In addition to requiring invasive mechanical ventilation, our patient developed AKI and severe hyperkalemia requiring urgent dialytic therapy during his hospital stay. Our patient remained dialysis dependent despite subsequent recovery of lung function. Three days following discontinuation of mechanical ventilation, our patient developed a hypotensive episode during his maintenance hemodialysis treatment. A point of care LUS performed soon after the intradialytic hypotensive episode found no extravascular lung water. Hemodialysis was discontinued and the patient was initiated on intravenous fluids for one week. AKI subsequently resolved. We consider LUS an important tool in identifying COVID-19 patients that would benefit from intravenous fluids following recovery of lung function.

Role of Point of Care Ultrasonography in Patients with COVID-19 Associated Acute Kidney Injury.

The severe acute respiratory virus covariate-2 (SARS CoV-2) that causes Corona Virus Disease 2019 (COVID-19) has affected more than 194 million people worldwide and has attributed to or caused more than 4 million deaths. Acute kidney injury (AKI) is a common complication of COVID-19. Point of care ultrasonography (POCUS) can be a useful tool for the nephrologist. POCUS can be used to elucidate the cause of kidney disease and then also help to manage volume status. Here, we review pearls and pitfalls of using POCUS to manage COVID-19 associated AKI with special attention to kidney, lung, and cardiac ultrasound.

Can 2-Pyridyl-1,2,3-triazole "Click" Ligands be Used to Develop Cu(I)/Cu(II) Molecular Switches?

Molecular switching processes are important in a range of areas including the development of molecular machines. While there are numerous organic switching systems available, there are far less examples that exploit inorganic materials. The most common inorganic switching system remains the copper(I)/copper(II) switch developed by Sauvage and co-workers over 20 years ago. Herein, we examine if bidentate 2-(1-benzyl-1H-1,2,3-triazol-4-yl)pyridine (pytri) and tridentate 2,6-bis[(4-phenyl-1H-1,2,3-triazol-1-yl)methyl]pyridine (tripy) moieties can be used to replace the more commonly exploited polypyridyl ligands 2,2'-bypyridine (bpy)/1,10-phenanthroline (phen) and 2,2';6',2″-terpyridine (terpy) in a copper(I)/(II) switching system. Two new ditopic ligands that feature bidentate (pytri, L1 or bpytri, L2) and tridentate tripy metal binding pockets were synthesized and used to generate a family of heteroleptic copper(I) and copper(II) 6,6'-dimesityl-2,2'-bipyridine (diMesbpy) complexes. Additionally, we synthesized a series of model copper(I) and copper(II) diMesbpy complexes. A combination of techniques including nuclear magnetic resonance (NMR) and UV-vis spectroscopies, high-resolution electrospray ionization mass spectrometry, and X-ray crystallography was used to examine the behavior of the compounds. It was found that L1 and L2 formed [(diMesbpy)Cu(L1 or L2)]2+ complexes where the copper(II) diMesbpy unit was coordinated exclusively in the tridenate tripy binding site. However, when the ligands (L1 and L2) were complexed with copper(I) diMesbpy units, a complex mixture was obtained. NMR and MS data indicated that a 1:1 stoichiometry of [Cu(diMesbpy)]+ and either L1 or L2 generated three complexes in solution, the dimetallic [(diMesbpy)2Cu2(L1 or L2)]2+ and the monometallic [(diMesbpy)Cu(L1 or L2)]+ isomers where the [Cu(diMesbpy)]+ unit is coordinated to either the bidentate or tridentate tripy binding sites of the ditopic ligands. The dimetallic [(diMesbpy)2Cu2(L1 or L2)](PF6)2 complexes were structurally characterized using X-ray crystallography. Both complexes feature a [Cu(diMesbpy)]+ coordinated to the bidentate (pytri or bpytri) pocket of the ditopic ligands (L1 or L2), as expected. They also feature a second [Cu(diMesbpy)]+ coordinated to the nominally tridentate tripy binding site in a four-coordinate hypodentate κ2-fashion. Competition experiments with model complexes showed that the binding strength of the bidentate pytri is similar to that of the κ2-tripy ligand, leading to the lack of selectivity. The results suggest that the pytri/tripy and bpytri/tripy ligand pairs cannot be used as replacements for the more common bpy/phen-terpy partners due to the lack of selectivity in the copper(I) state.

6,6'-Ditriphenylamine-2,2'-bipyridine: Coordination Chemistry and Electrochemical and Photophysical Properties.

A 2,2'-bipyridine with bulky triphenylamine substituents in the 6 and 6' positions of the ligand (6,6'-ditriphenylamine-2,2'-bipyridine, 6,6'-diTPAbpy) was generated. Despite the steric bulk, the ligand readily formed bis(homoleptic) complexes with copper(I) and silver(I) ions. Unfortunately, efforts to use the 6,6'-diTPAbpy system to generate heteroleptic [Cu(6,6'-diTPAbpy)(bpy)]+ complexes were unsuccessful with only the [Cu(6,6'-diTPAbpy)2](PF6) complex observed. The 6,6'-diTPAbpy ligand could also be reacted with 6-coordinate metal ions that featured small ancillary ligands, namely, the [Re(CO)3Cl] and [Ru(CO)2Cl2] fragments. While the complexes could be formed in good yields, the steric bulk of the TPA units does alter the coordination geometry. This is most readily seen in the [(6,6'-diTPAbpy)Re(CO)3Cl] complex where the Re(I) ion is forced to sit 23° out of the plane formed by the bpy unit. The electrochemical and photophysical properties of the family of compounds were also examined. 6,6'-diTPAbpy exhibits a strong ILCT absorption band (356 nm, 50 mM-1 cm-1) which displays a small increase in intensity for the homoleptic complexes ([Cu(6,6'-diTPAbpy)2]+; 353 nm, 72 mM-1 cm-1, [Ag(6,6'-diTPAbpy)2]+; 353 nm, 75 mM-1 cm-1), despite containing 2 equiv of the ligand, attributed to an increased dihedral angle between the TPA and bpy moieties. For the 6-coordinate complexes the ILCT band is further decreased in intensity and overlaps with MLCT bands, consistent with a further increased TPA-bpy dihedral angle. Emission from the 1ILCT state is observed at 436 nm (τ = 4.4 ns) for 6,6'-diTPAbpy and does not shift for the Cu, Ag, and Re complexes, although an additional 3MLCT emission is observed for [Re(6,6'-diTPAbpy)(CO)3Cl] (640 nm, τ = 13.8 ns). No emission was observed for [Ru(6,6'-diTPAbpy)(CO)2Cl2]. Transient absorption measurements revealed the population of a 3ILCT state for the Cu and Ag complexes (τ = 80 ns). All assignments were supported by TD-DFT calculations and resonance Raman spectroscopic measurements.

Structural Basis of WLS/Evi-Mediated Wnt Transport and Secretion.

Wnts are evolutionarily conserved ligands that signal at short range to regulate morphogenesis, cell fate, and stem cell renewal. The first and essential steps in Wnt secretion are their O-palmitoleation and subsequent loading onto the dedicated transporter Wntless/evenness interrupted (WLS/Evi). We report the 3.2 Å resolution cryogenic electron microscopy (cryo-EM) structure of palmitoleated human WNT8A in complex with WLS. This is accompanied by biochemical experiments to probe the physiological implications of the observed association. The WLS membrane domain has close structural homology to G protein-coupled receptors (GPCRs). A Wnt hairpin inserts into a conserved hydrophobic cavity in the GPCR-like domain, and the palmitoleate protrudes between two helices into the bilayer. A conformational switch of highly conserved residues on a separate Wnt hairpin might contribute to its transfer to receiving cells. This work provides molecular-level insights into a central mechanism in animal body plan development and stem cell biology.

Outcomes Among Patients Hospitalized With COVID-19 and Acute Kidney Injury.

RATIONALE & OBJECTIVE: Outcomes of patients hospitalized with coronavirus disease 2019 (COVID-19) and acute kidney injury (AKI) are not well understood. The goal of this study was to investigate the survival and kidney outcomes of these patients. STUDY DESIGN: Retrospective cohort study. SETTING & PARTICIPANTS: Patients (aged≥18 years) hospitalized with COVID-19 at 13 hospitals in metropolitan New York between March 1, 2020, and April 27, 2020, followed up until hospital discharge. EXPOSURE: AKI. OUTCOMES: Primary outcome: in-hospital death. SECONDARY OUTCOMES: requiring dialysis at discharge, recovery of kidney function. ANALYTICAL APPROACH: Univariable and multivariable time-to-event analysis and logistic regression. RESULTS: Among 9,657 patients admitted with COVID-19, the AKI incidence rate was 38.4/1,000 patient-days. Incidence rates of in-hospital death among patients without AKI, with AKI not requiring dialysis (AKI stages 1-3), and with AKI receiving dialysis (AKI 3D) were 10.8, 31.1, and 37.5/1,000 patient-days, respectively. Taking those without AKI as the reference group, we observed greater risks for in-hospital death for patients with AKI 1-3 and AKI 3D (HRs of 5.6 [95% CI, 5.0-6.3] and 11.3 [95% CI, 9.6-13.1], respectively). After adjusting for demographics, comorbid conditions, and illness severity, the risk for death remained higher among those with AKI 1-3 (adjusted HR, 3.4 [95% CI, 3.0-3.9]) and AKI 3D (adjusted HR, 6.4 [95% CI, 5.5-7.6]) compared with those without AKI. Among patients with AKI 1-3 who survived, 74.1% achieved kidney recovery by the time of discharge. Among those with AKI 3D who survived, 30.6% remained on dialysis at discharge, and prehospitalization chronic kidney disease was the only independent risk factor associated with needing dialysis at discharge (adjusted OR, 9.3 [95% CI, 2.3-37.8]). LIMITATIONS: Observational retrospective study, limited to the NY metropolitan area during the peak of the COVID-19 pandemic. CONCLUSIONS: AKI in hospitalized patients with COVID-19 was associated with significant risk for death.