Narrow QRS Tachycardia with Alternate Wide QRS Beats: What is the Mechanism?

A 44-year old lady underwent electrophysiology study for recurrent palpitations and documented narrow QRS regular tachycardia. The baseline ECG showed subtle preexcitation that was easily manifest on atrial pacing. The retrograde atrial activation sequence during ventricular pacing was eccentric suggesting retrograde conduction over the accessory pathway. A regular narrow QRS tachycardia with cycle length 280 ms was easily inducible on programmed atrial stimulation. The earliest ventricular activation during sinus rhythm & atrial pacing, and the retrograde atrial activation during ventricular pacing & tachycardia were diagnostic of left free wall accessory pathway and orthodromic atrioventricular reciprocating tachycardia (AVRT). During an episode of tachycardia, an ablation catheter was placed in the region of the lateral mitral annulus using retrograde trans-aortic approach. Once the ablation catheter was stabilized in that region, an interesting change in the AVRT was seen with appearance of wide QRS complexes of right bundle branch block (RBBB) morphology and left axis deviation in the alternate beats (Figure 1). The atrial activation sequence during both narrow and wide QRS beats was same with earliest activation in the distal coronary sinus. What is the mechanism of the alternate wide QRS beats during the AVRT

Open-source high-performance software packages for direct and inverse solving of horizontal capillary flow

This work introduces Fronts, a set of open-source numerical software packages for nonlinear horizontal capillary-driven flow problems in unsaturated porous media governed by the Richards equation. The software uses the Boltzmann transformation to solve such problems in semi-infinite domains. The scheme adopted by Fronts allows it to be faster and easier to use than other tools, and provide continuous functions for all involved fields. The software is capable of solving problems that appear in hydrology, but also in other particular domains of interest such as paper-based microfluidics. As the first known open-source implementation to adopt this approach, Fronts has been validated against analytical solutions as well as existing software achieving remarkable results in terms of computational costs and numerical precision, and is meant to aid the study and modeling of capillary flow. Fronts can be freely downloaded and installed, and offers a friendly environment for new users with its complete documentation and tutorial cases.Cited as: Gerlero, G. S., Berli, C. L. A., Kler, P. A. Open-source high-performance software packages for direct and inverse solving of horizontal capillary flow. Capillarity, 2023, 6(2): 31-40. https://doi.org/10.46690/capi.2023.02.0

Patients using antifungals following laryngectomy : a qualitative study of community pharmacists in the North of England

Objective: To explore community pharmacists’ understanding and opinions in relation to prevention of fungal colonisation of voice prostheses amongst laryngectomy patients. Method: Semi-structured interviews were conducted on a purposive sample of 12 community pharmacists from the North of England. Interviews were undertaken until data saturation was reached and responses were transcribed verbatim and analysed using a thematic approach. Key findings: Six themes emerged from the data analysis. These were: terminology confusion about laryngectomy, stoma and voice prostheses; smoking as a risk factor for the development of laryngeal cancer; using nystatin to prevent biofilm formation; counselling information related to nystatin; prescription intervention and additional education in relation to laryngectomy. The theme of counselling information related to nystatin use and additional education was a key finding: our data show that when dispensing nystatin to patients with a voice prosthesis, community pharmacists would either give no advice related to medication use or would give incorrect advice that may lead to premature prosthesis failure amongst this patient group. Conclusion: This study highlights that community pharmacists lack understanding in relation to laryngectomy and are unaware of the off-label doses and administration methods of the drugs (specifically nystatin) used to prevent fungal colonisation on voice prostheses. Additional information sources – possibly obtained through the local Speech and Language Therapy Department – in the form of an educational leaflet would be perceived as a valuable resource to support community pharmacists who are required to manage these patients in the community

Photocatalytic degradation of metoprolol tartrate in suspensions of two TiO2-based photocatalysts with different surface area. Identification of intermediates and proposal of degradation pathways.

This study investigates the efficiency of the photocatalytic degradation of metoprolol tartrate (MET), a widely used β 1-blocker, in TiO 2 suspensions of Wackherr's " Oxyde de titane standard" and Degussa P25. The study encompasses transformation kinetics and efficiency, identification of intermediates and reaction pathways. In the investigated range of initial concentrations (0.01-0.1mM), the photocatalytic degradation of MET in the first stage of the reaction followed approximately a pseudo-first order kinetics. The TiO 2 Wackherr induced a significantly faster MET degradation compared to TiO 2 Degussa P25 when relatively high substrate concentrations were used. By examining the effect of ethanol as a scavenger of hydroxyl radicals (OH), it was shown that the reaction with OH played the main role in the photocatalytic degradation of MET. After 240min of irradiation the reaction intermediates were almost completely mineralized to CO 2 and H 2O, while the nitrogen was predominantly present as NH4+. Reaction intermediates were studied in detail and a number of them were identified using LC-MS/MS (ESI+), which allowed the proposal of a tentative pathway for the photocatalytic transformation of MET as a function of the TiO 2 specimen

Study design and baseline characteristics of patients on dialysis in the ASCEND-D trial

BACKGROUND: The Anemia Studies in chronic kidney disease (CKD): Erythropoiesis via a Novel prolyl hydroxylase inhibitor (PHI) Daprodustat-Dialysis (ASCEND-D) trial will test the hypothesis that daprodustat is non-inferior to comparator epoetin alfa or darbepoetin alfa for two co-primary endpoints: haemoglobin efficacy and cardiovascular safety. METHODS: We report the trial design, key demographic, clinical, and laboratory findings, and baseline therapies of 2964 patients randomised in the open-label (sponsor-blinded) active-controlled, parallel-group, randomised ASCEND-D clinical trial. We also compare baseline characteristics of ASCEND-D patients with patients who are on dialysis (CKD G5D) enrolled in other large cardiovascular outcome trials (CVOTs) and in the most relevant registries. RESULTS: The median age of patients was 58 years, 43% were female; 67% were white and 16% were black. The median haemoglobin at baseline was 10.4 g/dL. Among randomised patients, 89% were receiving haemodialysis and 11% peritoneal dialysis. Among key co-morbidities, 42% reported a history of diabetes mellitus, and 45% a history of cardiovascular disease. Median blood pressure was 134/74 mmHg. The median weekly dose of epoetin was 5751 units. Intravenous and oral iron use was noted in 64% and 11% of patients, respectively. Baseline demographics were similar to patients with CKD G5D enrolled in other CVOTs and renal patient registries. CONCLUSION: ASCEND-D will evaluate the efficacy and safety of daprodustat compared with epoetin alfa or darbepoetin alfa in the treatment of patients with anaemia with CKD G5D

The ASCEND-ND trial: Study design and participant characteristics

BACKGROUND: Anaemia is common in chronic kidney disease (CKD), and assessment of the risks and benefits of new therapies is important. METHODS: The Anaemia Study in CKD: Erythropoiesis via a Novel prolyl hydroxylase inhibitor Daprodustat-Non-Dialysis (ASCEND-ND) trial includes adult patients with CKD Stages 3-5, not using erythropoiesis-stimulating agents (ESAs) with screening haemoglobin (Hb) 8-10 g/dL, or receiving ESAs with screening Hb of 8-12 g/dL. Participants were randomised to daprodustat or darbepoetin alfa (1:1) in an open- label trial (steering committee- and sponsor-blinded), with blinded endpoint assessment. The co-primary endpoints are mean change in Hb between baseline and evaluation period (average over Weeks 28 to 52) and time to first adjudicated major adverse cardiovascular (CV) event. Baseline characteristics were compared with those of participants in similar anaemia trials. RESULTS: Overall, 3872 patients were randomised from 39 countries (median age 67 years, 56% female; 56% White, 27% Asian, and 10% Black). Median baseline Hb was 9.9 g/dL, blood pressure was 135/74 mmHg and eGFR was 18 mL/min/1.73 m2. Among randomised patients, 53% were ESA non-users, 57% had diabetes and 37% had a history of CV disease. At baseline, 61% of participants were using renin- angiotensin system blockers, 55% were taking statin and 49% oral iron. Baseline demographics were similar to those in other large non-dialysis anaemia trials. CONCLUSION: ASCEND-ND will define the efficacy and safety of daprodustat compared with darbepoetin alfa in the treatment of patients with anaemia associated with CKD not on dialysis

Characterization techniques for studying the properties of nanocarriers for systemic delivery

Nanocarriers have attracted a huge interest in the last decade as efficient drug delivery systems and diagnostic tools. They enable effective, targeted, controlled delivery of therapeutic molecules while lowering the side effects caused during the treatment. The physicochemical properties of nanoparticles determine their in vivo pharmacokinetics, biodistribution and tolerability. The most analyzed among these physicochemical properties are shape, size, surface charge and porosity and several techniques have been used to characterize these specific properties. These different techniques assess the particles under varying conditions, such as physical state, solvents etc. and as such probe, in addition to the particles themselves, artifacts due to sample preparation or environment during measurement. Here, we discuss the different methods to precisely evaluate these properties, including their advantages or disadvantages. In several cases, there are physical properties that can be evaluated by more than one technique. Different strengths and limitations of each technique complicate the choice of the most suitable method, while often a combinatorial characterization approach is needed

Identifying Where REDD+ Financially Out Competes Oil Palm in Floodplain Landscapes Using a Fine-Scale Approach

Reducing Emissions from Deforestation and forest Degradation (REDD+) aims to avoid forest conversion to alternative land-uses through financial incentives. Oil-palm has high opportunity costs, which according to current literature questions the financial competitiveness of REDD+ in tropical lowlands. To understand this more, we undertook regional finescale and coarse-scale analyses (through carbon mapping and economic modelling) to assess the financial viability of REDD+ in safeguarding unprotected forest (30,173 ha) in the Lower Kinabatangan floodplain in Malaysian Borneo. Results estimate 4.7 million metric tons of carbon (MgC) in unprotected forest, with 64% allocated for oil-palm cultivations. Through fine-scale mapping and carbon accounting, we demonstrated that REDD+ can outcompete oil-palm in regions with low suitability, with low carbon prices and low carbon stock. In areas with medium oil-palm suitability, REDD+ could outcompete oil palm in areas with: very high carbon and lower carbon price; medium carbon price and average carbon stock; or, low carbon stock and high carbon price. Areas with high oil palm suitability, REDD + could only outcompete with higher carbon price and higher carbon stock. In the coarse-scale model, oil-palm outcompeted REDD+ in all cases. For the fine-scale models at the landscape level, low carbon offset prices (US $3 MgCO2e) would enable REDD+ to outcompete oil-palm in 55$27 million to secure these areas for 25 years. Higher carbon offset price (US $30 MgCO2e) would increase the competitiveness of REDD+ within the landscape but would still only capture between 69$380–416 million in carbon financing. REDD+ has been identified as a strategy to mitigate climate change by many countries (including Malaysia). Although REDD+ in certain scenarios cannot outcompete oil palm, this research contributes to the global REDD+ debate by: highlighting REDD+ competitiveness in tropical floodplain landscapes; and, providing a robust approach for identifying and targeting limited REDD+ funds

High Cooperativity of the SV40 Major Capsid Protein VP1 in Virus Assembly

SV40 is a small, non enveloped DNA virus with an icosahedral capsid of 45 nm. The outer shell is composed of pentamers of the major capsid protein, VP1, linked via their flexible carboxy-terminal arms. Its morphogenesis occurs by assembly of capsomers around the viral minichromosome. However the steps leading to the formation of mature virus are poorly understood. Intermediates of the assembly reaction could not be isolated from cells infected with wt SV40. Here we have used recombinant VP1 produced in insect cells for in vitro assembly studies around supercoiled heterologous plasmid DNA carrying a reporter gene. This strategy yields infective nanoparticles, affording a simple quantitative transduction assay. We show that VP1 assembles under physiological conditions into uniform nanoparticles of the same shape, size and CsCl density as the wild type virus. The stoichiometry is one DNA molecule per capsid. VP1 deleted in the C-arm, which is unable to assemble but can bind DNA, was inactive indicating genuine assembly rather than non-specific DNA-binding. The reaction requires host enzymatic activities, consistent with the participation of chaperones, as recently shown. Our results demonstrate dramatic cooperativity of VP1, with a Hill coefficient of ∼6. These findings suggest that assembly may be a concerted reaction. We propose that concerted assembly is facilitated by simultaneous binding of multiple capsomers to a single DNA molecule, as we have recently reported, thus increasing their local concentration. Emerging principles of SV40 assembly may help understanding assembly of other complex systems. In addition, the SV40-based nanoparticles described here are potential gene therapy vectors that combine efficient gene delivery with safety and flexibility

The ASCEND-ND trial: study design and participant characteristics

Background: Anaemia is common in chronic kidney disease (CKD), and assessment of the risks and benefits of new therapies is important. Methods: The Anaemia Study in CKD: Erythropoiesis via a Novel prolyl hydroxylase inhibitor Daprodustat-Non-Dialysis (ASCEND-ND) trial includes adult patients with CKD Stages 3–5, not using erythropoiesis-stimulating agents (ESAs) with screening haemoglobin (Hb) 8–10 g/dL, or receiving ESAs with screening Hb of 8–12 g/dL. Participants were randomised to daprodustat or darbepoetin alfa (1:1) in an open- label trial (steering committee- and sponsor-blinded), with blinded endpoint assessment. The co-primary endpoints are mean change in Hb between baseline and evaluation period (average over Weeks 28 to 52) and time to first adjudicated major adverse cardiovascular (CV) event. Baseline characteristics were compared with those of participants in similar anaemia trials. Results: Overall, 3872 patients were randomised from 39 countries (median age 67 years, 56% female; 56% White, 27% Asian, and 10% Black). Median baseline Hb was 9.9 g/dL, blood pressure was 135/74 mmHg and eGFR was 18 mL/min/1.73 m2. Among randomised patients, 53% were ESA non-users, 57% had diabetes and 37% had a history of CV disease. At baseline, 61% of participants were using renin– angiotensin system blockers, 55% were taking statin and 49% oral iron. Baseline demographics were similar to those in other large non-dialysis anaemia trials. Conclusion: ASCEND-ND will define the efficacy and safety of daprodustat compared with darbepoetin alfa in the treatment of patients with anaemia associated with CKD not on dialysis