Emergent veno-venous extracorporeal membrane oxygenation during aortic valve replacement following severe re-expansion pulmonary edema: A case report

Re-expansion pulmonary edema is defined as pulmonary edema that occurs when a chronically collapsed lung rapidly re-expands, most commonly following chest tube placement for pneumothorax, re-expansion of severe atelectasis, and evacuation of pleural effusion. Though it is very rare, the sudden onset and clinical features of re-expansion pulmonary edema make it a lethal complication that requires urgent treatment. We present a 60-year-old patient who underwent an aortic valve replacement with pre-existing large bilateral pleural effusions. Intraoperatively, upon evacuation of the pleural effusions, the patient developed worsening lung compliance, refractory hypoxemia, and hypercapnia that required emergent veno-venous extracorporeal membrane oxygenation support.

Anoxygenic phototroph of the Chloroflexota uses a type I reaction centre

Scientific exploration of phototrophic bacteria over nearly 200 years has revealed large phylogenetic gaps between known phototrophic groups that limit understanding of how phototrophy evolved and diversified1,2. Here, through Boreal Shield lake water incubations, we cultivated an anoxygenic phototrophic bacterium from a previously unknown order within the Chloroflexota phylum that represents a highly novel transition form in the evolution of photosynthesis. Unlike all other known phototrophs, this bacterium uses a type I reaction centre (RCI) for light energy conversion yet belongs to the same bacterial phylum as organisms that use a type II reaction centre (RCII) for phototrophy. Using physiological, phylogenomic and environmental metatranscriptomic data, we demonstrate active RCI-utilizing metabolism by the strain alongside usage of chlorosomes3 and bacteriochlorophylls4 related to those of RCII-utilizing Chloroflexota members. Despite using different reaction centres, our phylogenomic data provide strong evidence that RCI-utilizing and RCII-utilizing Chloroflexia members inherited phototrophy from a most recent common phototrophic ancestor. The Chloroflexota phylum preserves an evolutionary record of the use of contrasting phototrophic modes among genetically related bacteria, giving new context for exploring the diversification of phototrophy on Earth.

Pioneering the Integration of Artificial Intelligence in Medical Oral Board Examinations

We evaluated the use of ChatGPT-4, an advanced artificial intelligence (AI) language model, in medical oral examinations, specifically in anesthesiology. Initially proven adept in written examinations, ChatGPT-4's performance was tested against oral board sample sessions of the American Board of Anesthesiology. Modifications were made to ensure responses were concise and conversationally natural, simulating real patient consultations or oral examinations. The results demonstrate ChatGPT-4's impressive adaptability and potential in oral board examinations as a training and assessment tool in medical education, indicating new avenues for AI application in this field.

The Year in Cardiothoracic and Vascular Anesthesia: Selected Highlights From 2023

This special article is the 16th in an annual series for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr. Kaplan, and the editorial board for the opportunity to continue this series, namely the research highlights of the past year in the specialty of cardiothoracic and vascular anesthesiology. The major themes selected for 2023 are outlined in this introduction, and each highlight is reviewed in detail in the main article. The literature highlights in the specialty for 2023 begin with an update on perioperative rehabilitation in cardiothoracic surgery, with a focus on novel methods to best assess patients in the preoperative and postoperative periods, and the impact of rehabilitation on outcomes. The second major theme is focused on cardiac surgery, with the authors discussing new insights into inhaled pulmonary vasodilators, coronary revascularization surgery, and discussion of causes of coronary graft failure after surgery. The third theme is focused on cardiothoracic transplantation, with discussions focusing on bridge-to-transplantation strategies. The fourth theme is focused on mechanical circulatory support, with discussions focusing on both temporary and durable support. The fifth and final theme is an update on medical cardiology, with a focus on outcomes of invasive approaches to heart disease. The themes selected for this article are only a few of the diverse advances in the specialty during 2023. These highlights will inform the reader of key updates on various topics, leading to improved perioperative outcomes for patients with cardiothoracic and vascular disease.

Comparison of Time to Intubation of a Double-Lumen Endobronchial Tube Utilizing C-MAC® Versus GlideScope® Versus Macintosh Blade: A Randomized Crossover Manikin Study

BACKGROUND

Macintosh blade direct laryngoscopy is widely used for endotracheal intubation. It may, however, provide an incomplete view of the glottis in patients with challenging airway anatomy. Consequently, various video laryngoscopes have been developed to enhance the visualization of the glottis and facilitate intubation. Yet, the effectiveness of these video laryngoscopes for intubation using a double-lumen endotracheal tube (DLT), which is longer, larger, and more rigid and has a linear configuration as opposed to the naturally semicircular curvature of a single-lumen endotracheal tube, remains uncertain. We hypothesized that video laryngoscopes would be more efficient for DLT intubation compared to the Macintosh blade in an adult manikin.

METHODS

Ninety-four anesthesia providers, comprising 67 residents, 15 fellows, and 12 attendings, attempted to intubate an adult manikin with normal airway anatomy (Laerdal, Wappingers Falls, NY, USA) using a 37 Fr left-sided DLT. Three different intubation devices were used: the C-MAC® video laryngoscope (Karl Storz GmbH & Co. KG, Tuttlingen, Germany), the GlideScope® video laryngoscope (Verathon Inc., Bothell, WA), and the Macintosh blade direct laryngoscope-were used. Each participant intubated a manikin once with each of the three devices. Participants were randomized via a crossover design with the order of devices determined by using a Latin square design. Time to intubation and the number of failed intubations (esophageal intubation) were compared across the three different devices.

RESULTS

Mean times to intubation for the C-MAC®, GlideScope®, and Macintosh blades were 18.57 ± 0.77, 36.26 ± 2.69, and 20.76 ± 0.96 seconds, respectively. There was a statistically significant difference (P<0.001) between the GlideScope® and the other two laryngoscopes. The times for C-MAC® and Macintosh blades were not significantly different. There were two instances of first-attempt failed intubation with the Macintosh.

CONCLUSION

Both the C-MAC® and the Macintosh blades proved more efficient in terms of time to DLT intubation in the manikin with normal airway anatomy, when compared to the GlideScope®. Considering the occurrence of first-attempt failed intubation, the C-MAC® was the most effective device among the three laryngoscopes for timely successful DLT intubation in the adult manikin. Further studies are needed to confirm these results in human subjects.

Transesophageal echocardiography for thoracic spinal cord imaging and confirmation of epidural catheter placement in pediatrics

INTRODUCTION

Transesophageal echocardiography (TEE) use continues to expand to include extracardiac applications. However, there is limited research investigating the use of TEE as a tool to confirm the position of the epidural catheter. This prospective observational study aimed to evaluate whether TEE could be used to visualize the anatomy of the thoracic spinal canal in pediatrics. A subsequent prospective case series was conducted to evaluate whether TEE could be used to assist in the placement of epidural catheters in pediatric surgical patients.

METHODS

Seventy-five patients (50 pediatric and 25 adult subjects) were enrolled. The operators attempted to identify four structures (spinal cord, cerebrospinal fluid, dura mater, epidural space) within the thoracic spinal canal with TEE. After demonstrating the feasibility of this technique for observing the spinal anatomy, 20 pediatric surgical patients were enrolled in a case series. These patients had epidural catheter placement, and the final catheter position was confirmed with TEE.

RESULTS

The total number of thoracic spinal segment visualized in pediatric patients was 542 out of 550 (99%) segments, and 191 out of 275 (70%) segments in adult subjects (difference, 29% [95% confidence interval, 23-34]; p < 0.001). Additionally, a case series of 20 pediatric surgical patients demonstrated successful caudal or epidural catheter placement at target spinal level in 17 cases.

CONCLUSIONS

This observational study demonstrated the successful visualization of the thoracic spinal cord at virtually every level in pediatric patients. A subsequent case series demonstrated that TEE could be used to successfully confirm the position of the epidural catheter in the targeted thoracic spinal segment for pediatric surgical patients.

Transesophageal Echocardiography Assisting in the Identification of Intraabdominal Bleeding During Cardiac Surgery

We present a case in which intraoperative transesophageal echocardiography (TEE) helped detect intraabdominal bleeding, a rare complication in cardiac surgery. A patient undergoing ascending aortic aneurysm and aortic valve repair had increasing vasopressor and transfusion requirement during sternal closure with TEE imaging revealing a nonspecific, hypoechoic fluid-like collection anterior to the stomach. Discussion between the anesthesiology and surgical teams prompted further investigation including a diagnostic laparoscopy which confirmed the presence of intraabdominal bleeding. Hemostasis was later achieved after identifying the source of bleeding from a pre-peritoneal vein and associated peritoneal defect adjacent to a mediastinal chest tube placed earlier in the operation.

Muscle blood flow and vasodilation are blunted at the onset of exercise following an acute bout of ischemia-reperfusion

Ischemia-reperfusion (I/R) injury can attenuate endothelial function and impair nitric oxide bioavailability. We tested the hypothesis that I/R also blunts the rapid and steady-state hyperemic and vasodilatory responses to handgrip exercise. Ten subjects (8M/2F; 24 ± 4 yr) performed handgrip exercises before and after I/R (20 min of ischemia/20 min of reperfusion) and time control (40-min supine rest) trials. Forearm blood flow (FBF) and forearm vascular conductance (FVC) were assessed with Doppler ultrasound during single forearm contractions and 3 min of rhythmic handgrip exercise. Venous blood samples were drawn at rest and during exercise to assess plasma [nitrite]. Peak ΔFBF (from baseline) and ΔFVC following single contractions were attenuated following I/R (134 ± 48 vs. 103 ± 42 mL·min-1; 160 ± 55 vs. 118 ± 48 mL·min-1·100 mmHg-1, P < 0.05 for both), but not following time control (115 ± 63 vs. 124 ± 57 mL·min-1; 150 ± 80 vs. 148 ± 64 mL·min-1·100 mmHg-1, P = 0.16 and P = 0.95, respectively). Steady-state ΔFBF and ΔFVC during rhythmic exercise were unchanged in both I/R (192 ± 52 vs. 190 ± 53 mL·min-1; 208 ± 56 vs. 193 ± 60 mL·min-1·100 mmHg-1) and time control (188 ± 54 vs. 196 ± 48 mL·min-1; 206 ± 60 vs. 207 ± 49 mL·min-1·100 mmHg-1) trials (group × time interactions P = 0.34 and 0.21, respectively). Plasma [nitrite] under resting conditions and during steady-state rhythmic exercise was attenuated following I/R (P < 0.05 for both), but not following time control (P = 0.54 and 0.93). These data indicate that I/R blunts hyperemia and vasodilation at the onset of muscle contractions but does not attenuate these responses during steady-state exercise.NEW & NOTEWORTHY Ischemia-reperfusion can impair endothelial function; however, it remains unknown whether exercise hyperemia and vasodilation are also impaired. This study presents novel findings that ischemia-reperfusion blunts the hyperemic and vasodilatory responses at the onset of muscle contractions but not during steady-state exercise. Plasma [nitrite] was also blunted at baseline and during steady-state exercise following ischemia-reperfusion compared with time control. These attenuated responses at the onset of exercise may be associated with ischemia-reperfusion reductions in NO bioavailability.

Photoinduced properties of anodized Ti alloys for biomaterial applications

The photocatalytic properties of anodic oxides on a newly developed TiNbSn and commonly used Ti6Al4V alloys as biomaterials were investigated. The alloys were anodized in an electrolyte of sodium tartrate acid with H2O2 at a high voltage and the mechanism of the photocatalytic and antiviral activities was studied. The anodized TiNbSn and Ti6Al4V exhibited highly crystallized rutile TiO2 and poorly crystallized anatase TiO2, respectively. X-ray photoelectron spectroscopy analysis revealed the presence of oxides of the alloying elements in addition to TiO2. The anodized TiNbSn exhibited higher activities than Ti6Al4V, and electron spin resonance spectra indicated that the number of hydroxyl radicals (⋅OH) generated from the anodized TiNbSn was higher than that from the anodized Ti6Al4V. The results can be explained by two possible mechanisms: the higher crystallinity of TiO2 on TiNbSn than that on the Ti6Al4V reduces the number of charge recombination sites and generates abundant ⋅OH; charge separation in the anodic oxide on TiNbSn due to the electronic band structure between TiO2 and the oxides of alloying elements enhances photo activities. The excellent photoinduced characteristics of the anodized TiNbSn are expected to contribute to the safe and reliable implant treatment.

Prophylactic Use of Continuous Positive Airway Pressure to Operative Lung During One-Lung Ventilation Can Minimize Bleomycin Pulmonary Toxicity: A Report of Two Cases

Bleomycin, a common antineoplastic agent, is known to cause bleomycin pulmonary toxicity when the lungs are exposed to a high fraction of inspired oxygen (FiO₂) level. Thus, intraoperative one-lung ventilation (OLV) is challenging in a patient with bleomycin treatment because maintaining high FiO₂ during OLV is a common practice in thoracic surgery to ensure adequate oxygenation while providing adequate lung isolation. We report two thoracic surgical cases where prophylactic continuous positive airway pressure (CPAP) was applied on the non-dependent lung during OLV while limiting FiO₂ to prevent postoperative respiratory complications.

Roseomonas fluvialis sp. nov., an aerobic bacteriochlorophyll a-containing freshwater bacterium isolated from river epilithic biofilm

A strictly aerobic bacteriochlorophyll a-containing alphaproteobacterium, designated strain S08^T, was isolated from a biofilm sampled at Tama River in Japan. The non-motile and rod-shaped cells formed pink-beige pigmented colonies on agar plates containing organic compounds and showed in vivo absorption maxima at 798 and 866 nm in the near-infrared region, typical for the presence of bacteriochlorophyll a. The new bacterial isolate is Gram-negative, oxidase-negative and catalase-positive. Phylogenetic analysis based on 16S rRNA gene sequences showed that strain S08^T was closely related to species in the genus Roseomonas. The closest phylogenetic relative of strain S08^T was Roseomonas lacus TH-G33^T (98.2 % sequence similarity). The major cellular fatty acids were C_16 : 0, C_18 : 1 2-OH and summed feature 8 (C_18 : 1  ω7c/C_18 : 1  ω6c). The predominant respiratory quinone was ubiquinone-9. The major polar lipids contained diphosphatidylglycerol, phosphatidylglycerol, phosphatidylethanolamine, phosphatidylcholine and an aminolipid. The G+C content of the genomic DNA was 70.6 mol%. The average nucleotide identity and digital DNA-DNA hybridization values between strain S08^T and the related Roseomonas type strains were all far lower than the cut-off value for the delineation of species. The results of polyphasic comparisons showed that strain S08^T was clearly distinguishable from other members of the genus Roseomonas. Therefore, we propose a new species in the genus Roseomonas, namely, Roseomonas fluvialis sp. nov. The type strain is S08^T (=DSM 111902^T=NBRC 112025^T).

Transcriptome and Deletion Mutant Analyses Revealed that an RpoH Family Sigma Factor Is Essential for Photosystem Production in Roseateles depolymerans under Carbon Starvation

Roseateles depolymerans is an obligately aerobic bacterium that produces a photosynthetic apparatus only under the scarcity of carbon substrates. We herein examined changes in the transcriptomes of R. depolymerans cells to clarify the expression of photosynthesis genes and their upstream regulatory factors under carbon starvation. Transcriptomes 0, 1, and 6‍ ‍h after the depletion of a carbon substrate indicated that transcripts showing the greatest variations (a 500-fold increase [6 h/0 h]) were light-harvesting proteins (PufA and PufB). Moreover, loci with more than 50-fold increases (6 h/0‍ ‍h) were fully related to the photosynthetic gene cluster. Among 13 sigma factor genes, the transcripts of a sigma 70 family sigma factor related to RpoH (SP70) increased along photosynthesis genes under starvation; therefore, a knockout experiment of SP70 was performed. ΔSP70 mutants were found to lack photosynthetic pigments (carotenoids and bacteriochlo-rophyll a) regardless of carbon starvation. We also examined the effects of heat stress on ΔSP70 mutants, and found that SP70 was also related to heat stress tolerance, similar to other RpoH sigma factors (while heat stress did not trigger photosystem production). The deficient accumulation of photosynthetic pigments and the heat stress tolerance of ΔSP70 mutants were both complemented by the introduction of an intact SP70 gene. Furthermore, the transcription of photosynthetic gene operons (puf, puh, and bch) was markedly reduced in the ΔSP70 mutant. The RpoH homologue SP70 was concluded to be a sigma factor that is essential for the transcription of photosynthetic gene operons in R. depolymerans.

Eight weeks of inorganic nitrate/nitrite supplementation improves aerobic exercise capacity and the gas exchange threshold in patients with type 2 diabetes

Patients with type 2 diabetes mellitus (T2DM) have reduced exercise capacity, indexed by lower maximal oxygen consumption (V̇o2max) and achievement of the gas exchange threshold (GET) at a lower % V̇o2max. The ubiquitous signaling molecule nitric oxide (NO) plays a multifaceted role during exercise and, as patients with T2DM have poor endogenous NO production, we investigated if inorganic nitrate/nitrite supplementation (an exogenous source of NO) improves exercise capacity in patients with T2DM. Thirty-six patients with T2DM (10F, 59 ± 9 yr, 32.0 ± 5.1 kg/m2, HbA1c = 7.4 ± 1.4%) consumed beetroot juice containing either inorganic nitrate/nitrite (4.03 mmol/0.29 mmol) or a placebo (0.8 mmol/0.00 mmol) for 8 wk. A maximal exercise test was completed before and after both interventions. V̇o2max was determined by averaging 15-s data, whereas the GET was identified using the V-slope method and breath-by-breath data. Inorganic nitrate/nitrite increased both absolute (1.96 ± 0.67 to 2.07 ± 0.75 L/min) and relative (20.7 ± 7.0 to 21.9 ± 7.4 mL/kg/min, P < 0.05 for both) V̇o2max, whereas no changes were observed following placebo (1.94 ± 0.40 to 1.90 ± 0.39 L/min, P = 0.33; 20.0 ± 4.2 to 19.7 ± 4.6 mL/kg/min, P = 0.39). Maximal workload was also increased following inorganic nitrate/nitrite supplementation (134 ± 47 to 140 ± 51 W, P < 0.05) but not placebo (138 ± 32 to 138 ± 32 W, P = 0.98). V̇o2 at the GET (1.11 ± 0.27 to 1.27 ± 0.38L/min) and the %V̇o2max in which GET occurred (56 ± 8 to 61 ± 7%, P < 0.05 for both) increased following inorganic nitrate/nitrite supplementation but not placebo (1.10 ± 0.23 to 1.08 ± 0.21 L/min, P = 0.60; 57 ± 9 to 57 ± 8%, P = 0.90) although the workload at GET did not achieve statistical significance (group-by-time P = 0.06). Combined inorganic nitrate/nitrite consumption improves exercise capacity, maximal workload, and promotes a rightward shift in the GET in patients with T2DM. This manuscript reports data from a registered Clinical Trial at ClinicalTrials.gov ID: NCT02804932.NEW & NOTEWORTHY We report that increasing nitric oxide bioavailability via 8 wk of inorganic nitrate/nitrite supplementation improves maximal aerobic exercise capacity in patients with type 2 diabetes mellitus. Similarly, we observed a rightward shift in the gas exchange threshold. Taken together, these data indicate inorganic nitrate/nitrite may serve as a means to improve fitness in patients with type 2 diabetes mellitus.

Effects of Combined Inorganic Nitrate and Nitrite Supplementation on Cardiorespiratory Fitness and Skeletal Muscle Oxidative Capacity in Type 2 Diabetes: A Pilot Randomized Controlled Trial

Nitric oxide (NO) stimulates mitochondrial biogenesis in skeletal muscle. However, NO metabolism is disrupted in individuals with type 2 diabetes mellitus (T2DM) potentially contributing to their decreased cardiorespiratory fitness (i.e., VO2max) and skeletal muscle oxidative capacity. We used a randomized, double-blind, placebo-controlled, 8-week trial with beetroot juice containing nitrate (NO3−) and nitrite (NO2−) (250 mg and 20 mg/day) to test potential benefits on VO2max and skeletal muscle oxidative capacity in T2DM. T2DM (N = 36, Age = 59 ± 9 years; BMI = 31.9 ± 5.0 kg/m2) and age- and BMI-matched non-diabetic controls (N = 15, Age = 60 ± 9 years; BMI = 29.5 ± 4.6 kg/m2) were studied. Mitochondrial respiratory capacity was assessed in muscle biopsies from a subgroup of T2DM and controls (N = 19 and N = 10, respectively). At baseline, T2DM had higher plasma NO3− (100%; p < 0.001) and lower plasma NO2− levels (−46.8%; p < 0.0001) than controls. VO2max was lower in T2DM (−26.4%; p < 0.001), as was maximal carbohydrate- and fatty acid-supported oxygen consumption in permeabilized muscle fibers (−26.1% and −25.5%, respectively; p < 0.05). NO3−/NO2− supplementation increased VO2max (5.3%; p < 0.01). Further, circulating NO2−, but not NO3−, positively correlated with VO2max after supplementation (R2= 0.40; p < 0.05). Within the NO3−/NO2− group, 42% of subjects presented improvements in both carbohydrate- and fatty acid-supported oxygen consumption in skeletal muscle (vs. 0% in placebo; p < 0.05). VO2max improvements in these individuals tended to be larger than in the rest of the NO3−/NO2− group (1.21 ± 0.51 mL/(kg*min) vs. 0.31 ± 0.10 mL/(kg*min); p = 0.09). NO3−/NO2− supplementation increases VO2max in T2DM individuals and improvements in skeletal muscle oxidative capacity appear to occur in those with more pronounced increases in VO2max.

Association between the changes in walking speed during 6 months after discharge and subsequent prognosis in older patients with heart failure: report from a multicenter prospective cohort study

Background

Walking speed (WS) is one of the key components of physical frailty associated with a prognosis in patients with heart failure (HF). However, the prognostic impact of changes in WS after discharge in patients with HF remains to be examined.

Purpose

The purpose of this study was to examined the association between the change in WS during 6 months after discharge and subsequent prognosis in older patients with HF.

Methods

This study was performed as a sub-analysis of the multicenter cohort study in Japan (FLAGSHIP). We analyzed patients hospitalized for HF aged ≥65 years whose WS was measured at discharge and after 6 months of discharge. Based on the patterns of WS at the two points, patients were divided into four groups (A: WS ≥0.98 m/s both at discharge and 6-month; B: ≥0.98 m/s at discharge, &lt;0.98 m/s at 6-month; C: &lt;0.98 m/s at discharge, ≥0.98 m/s at 6-month; D: &lt;0.98 m/s both at discharge and 6-month). WS &lt;0.98 m/s has been identified as a cut-off value predicting the prognosis of HF in the main analysis of the FLAGSHIP. Kruskal - Wallis test was used to compare among groups. Furthermore, Cox proportional hazards model was performed to evaluate the association between the WS subgroups and HF rehospitalization after 6-month of discharge. Additionally, adjustments were made for age and sex in model 1, and for age, sex, cognitive function (Mini-mental state examination, MMSE ≤23), past HF hospitalization, rehospitalization within 6 months after discharge, and variables with a p value &lt;0.05 both at discharge and 6 months in univariate analysis in model 2.

Results

A total of 890 patients were included in this study (Group A: n=386, B: n=51, C: n=143, D: n=310). There was a significant difference in HF rehospitalization after 6-month of discharge among the four groups (Log-rank test, p=0.01, Figure 1). In the crude model, hazard ratio (HR) of group B compared with A was 2.26 [95% confidence interval: 1.19–4.27, p=0.013], HR of C was 1.00 [0.56–1.77, p=0.988], and HR of D was 1.66 [1.11–2.47, p=0.013]. In model 1, HR of B was 2.12 [1.11–4.07, p=0.023], HR of C was 0.99 [0.56–1.75, p=0.964], and HR of D was 1.56 [1.01–2.42, p=0.047]. In model 2, HR of B was 0.95 [0.45–1.97, p=0.897], HR of C was 0.67 [0.35–1.26, p=0.212], and HR of D was [0.25–0.80, p=0.007].

Conclusion

Although slow WS is associated with poor prognosis, the prognosis might be improved if WS increases by 6 months after discharge.

Funding

This study is supported by a Grant-in-Aid for Scientific Research (A) from the Japanese Society for the Promotion of Science [16H01862].

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): The Japanese Society for the Promotion of Science

Dietary Inorganic Nitrate/Nitrite Supplementation Reduces Central and Peripheral Blood Pressure in Patients With Type 2 Diabetes Mellitus

BACKGROUND

Patients with type 2 diabetes mellitus (T2DM) have increased cardiovascular risk due to elevated blood pressure (BP). As low levels of nitric oxide (NO) may contribute to increased BP, we determined if increasing NO bioavailability via eight weeks of supplementation with beetroot juice containing inorganic nitrate/nitrite (4.03 mmol nitrate, 0.29 mmol nitrite) improves peripheral and central BP relative to nitrate/nitrite-depleted beetroot juice.

METHODS

Peripheral and central BP were assessed at heart-level in supine subjects using a brachial artery catheter and applanation tonometry, respectively.

RESULTS

Nitrate/nitrite supplementation reduced peripheral systolic BP (148 ± 16 to 142 ± 18 mm Hg, P < 0.05) but not placebo (150 ± 19 to 149 ± 17 mm Hg, P = 0.93); however, diastolic BP was unaffected (supplement-by-time P = 0.08). Central systolic BP (131 ± 16 to 127 ± 17 mm Hg) and augmented pressure (13.3 ± 6.6 to 11.6 ± 6.9 mm Hg, both P < 0.05) were reduced after nitrate/nitrite, but not placebo (134 ± 17 to 135 ± 16 mm Hg, P = 0.62; 14.1 ± 6.6 to 15.2 ± 7.4 mm Hg, P = 0.20); central diastolic BP was unchanged by the interventions (supplement-by-time P = 0.16). Inorganic nitrate/nitrite also reduced AIx (24.3 ± 9.9% to 21.0 ± 9.6%) whereas no changes were observed following placebo (24.6 ± 9.3% to 25.6 ± 9.9%, P = 0.46).

CONCLUSIONS

Inorganic nitrate/nitrite supplementation improves peripheral and central BP as well as AIx in T2DM.

CLINICAL TRIALS REGISTRATION

Trial Number NCT02804932.

Hydrogenophilus thiooxidans sp. nov., a moderately thermophilic chemotrophic bacterium unable to grow on hydrogen gas, isolated from hot spring microbial mats

A novel thermophilic chemotrophic bacterium, strain SS56T, was isolated from Nakabusa Hot Spring, Japan. The isolate was a rod-shaped (1.5–2.1×0.6–0.8 µm), Gram-stain-negative bacterium. The cells of this strain grew chemoheterotrophically under aerobic and anaerobic conditions. Autotrophic growth was observed with thiosulphate and elemental sulphur under aerobic conditions but not with H2 as the electron donor. Heterotrophic growth in the presence of O2 occurred on yeast extract, tryptone, polypeptone and organic acids. Strain SS56T used nitrite as an alternative electron acceptor under anaerobic chemoheterotrophic conditions. The isolate grew between 35 and 65 °C, with the optimum at 55 °C. The pH range for growth was pH 6.0–9.0; optimal growth occurred at pH 7.0–8.0. The 16S rRNA gene sequence of strain SS56T was 98.9% identical to that of Hydrogenophilus thermoluteolus TH-1T. The draft genome sequence of 2401804 bp for strain SS56T gave values of 53.7% for digital DNA–DNA hybridization, 92.9% for average nucleotide identity and 93.6% for average amino acid identity compared with the genome sequence of 2223143 bp for H. thermoluteolus TH-1T. Based on the information described above, strain SS56T (=DSM 111892T=JCM 34254T) is proposed as the type strain of a novel species, Hydrogenophilus thiooxidans sp. nov.

Concomitant aortic valve repair for aortic insufficiency and implantation of left ventricle mechanical support

Background

Moderate to severe aortic valve insufficiency (AI) in patients undergoing left ventricular assist device (LVAD) implantation is a significant complication which occurs in up to 10.7% of patients in the INTERMACS database and has profound consequences for survival. Preoperative Impella use is associaed with greater post‐LVAD AI.

Case Presentation

56 y/o Caucasian female with acute exacerbation of chronic congestive heart failure who needed urgent Impella placement followed by elective Heartmate III LVAD.

Conclusion

Patients who have aortic valve regurgitation at the time of implantation have been handled by several methods, including aortic valve leaflets approximation, to aortic valve replacement or even valve closure. We report a case of geometric ring annuloplasty for repair of a regurgitant aortic valve during destination LVAD implantation.

Neotabrizicola shimadae gen. nov., sp. nov., an aerobic anoxygenic phototrophic bacterium harbouring photosynthetic genes in the family Rhodobacteraceae, isolated from a terrestrial hot spring

A bacteriochlorophyll-containing bacterium, designated as strain N10^T, was isolated from a terrestrial hot spring in Nagano Prefecture, Japan. Gram-stain-negative, oxidase- and catalase-positive and ovoid to rod-shaped cells showed the features of aerobic anoxygenic phototrophic bacteria, i.e., strain N10^T synthesised bacteriochlorophylls under aerobic conditions and could not grow anaerobically even under illumination. Genome analysis found genes for bacteriochlorophyll and carotenoid biosynthesis, light-harvesting complexes and type-2 photosynthetic reaction centre in the chromosome. Phylogenetic analyses based on the 16S rRNA gene sequence and 92 core proteins revealed that strain N10^T was located in a distinct lineage near the type species of the genera Tabrizicola and Xinfangfangia and some species in the genus Rhodobacter (e.g., Rhodobacter blasticus). Strain N10^T shared < 97.1% 16S rRNA gene sequence identity with those species in the family Rhodobacteraceae. The digital DNA-DNA hybridisation, average nucleotide identity and average amino acid identity values with the relatives, Tabrizicola aquatica RCRI19^T (an aerobic anoxygenic phototrophic bacterium), Xinfangfangia soli ZQBW^T and R. blasticus ATCC 33485^T were 19.9-20.7%, 78.2-79.1% and 69.1-70.1%, respectively. Based on the phenotypic features, major fatty acid and polar lipid compositions, genome sequence and phylogenetic position, a novel genus and species are proposed for strain N10^T, to be named Neotabrizicola shimadae (= JCM 34381^T = DSM 112087T). Strain N10^T which is phylogenetically located among aerobic anoxygenic phototrophic bacteria (Tabrizicola), bacteriochlorophyll-deficient bacteria (Xinfangfangia) and anaerobic anoxygenic phototrophic bacteria (Rhodobacter) has great potential to promote studies on the evolution of photosynthesis in Rhodobacteraceae.

Thoracic epidural analgesia in a patient with von Hippel-Lindau disease

von Hippel-Lindau disease (VHLD) is an autosomal dominant disorder characterized by central nervous system hemangioblastomas and renal tumors. Here, we report a case of thoracic epidural placement in a 35-year-old woman with VHLD presenting for left open heminephrectomy for renal masses. We also reviewed the literature on this topic.

Elioraea tepida, sp. nov., a Moderately Thermophilic Aerobic Anoxygenic Phototrophic Bacterium Isolated from the Mat Community of an Alkaline Siliceous Hot Spring in Yellowstone National Park, WY, USA

Strain MS-P2T was isolated from microbial mats associated with Mushroom Spring, an alkaline siliceous hot spring in Yellowstone National Park, WY, USA. The isolate grows chemoheterotrophically by oxygen-dependent respiration, and light stimulates photoheterotrophic growth under strictly oxic conditions. Strain MS-P2T synthesizes bacteriochlorophyll a and the carotenoid spirilloxanthin. However, photoautotrophic growth did not occur under oxic or anoxic conditions, suggesting that this strain should be classified as an aerobic anoxygenic phototrophic bacterium. Strain MS-P2T cells are motile, curved rods about 0.5 to 1.0 μm wide and 1.0 to 1.5 μm long. The optimum growth temperature is 45-50 °C, and the optimum pH for growth is circum-neutral (pH 7.0-7.5). Sequence analysis of the 16S rRNA gene revealed that strain MS-P2T is closely related to Elioraea species, members of the class Alphaproteobacteria, with a sequence identity of 96.58 to 98%. The genome of strain MS-P2T is a single circular DNA molecule of 3,367,643 bp with a mol% guanine-plus-cytosine content of 70.6%. Based on phylogenetic, physiological, biochemical, and genomic characteristics, we propose this bacteriochlorophyll a-containing isolate is a new species belonging to the genus Elioraea, with the suggested name Elioraeatepida. The type-strain is strain MS-P2T (= JCM33060T = ATCC TSD-174T).

Combined inorganic nitrate/nitrite supplementation blunts α-mediated vasoconstriction during exercise in patients with type 2 diabetes

AIMS

Patients with type 2 diabetes mellitus (T2DM) have reduced vasodilatory responses during exercise partially attributable to low nitric oxide (NO) levels. Low NO contributes to greater α-adrenergic mediated vasoconstriction in contracting skeletal muscle. We hypothesized boosting NO bioavailability via 8wks of active beetroot juice (BR_A, 4.03 mmol nitrate, 0.29 mmol nitrite, n = 19) improves hyperemia, via reduced α-mediated vasoconstriction, during handgrip exercise relative to nitrate/nitrite-depleted beetroot juice (BR_P, n = 18) in patients with T2DM.

METHODS

Forearm blood flow (FBF) and vascular conductance (FVC) were calculated at rest and during handgrip exercise (20%max, 20contractions·min^-1). Phenylephrine (α₁-agonist) and dexmedetomidine (α₂-agonist) were infused intra-arterially during independent trials to determine the influence of α-mediated vasoconstriction on exercise hyperemia. Vasoconstriction was quantified as the percent-reduction in FVC during α-agonist infusion, relative to pre-infusion, as well as the absolute change in %FVC during exercise relative to the respective rest trial (magnitude of sympatholysis).

RESULTS

ΔFBF (156 ± 69 to 175 ± 73 ml min^-1) and ΔFVC (130 ± 54 to 156 ± 63 ml min^-1·100 mmHg^-1, both P < 0.05) during exercise were augmented following BR_A, but not BR_P (P = 0.96 and 0.51). Phenylephrine-induced vasoconstriction during exercise was blunted following BR_A (-17.1 ± 5.9 to -12.6 ± 3.1%, P < 0.01), but not BR_P (P = 0.58) supplementation; the magnitude of sympatholysis was unchanged by either (beverage-by-time P = 0.15). BR_A supplementation reduced dexmedetomidine-induced vasoconstriction during exercise (-23.3 ± 6.7 to -19.7 ± 5.2%) and improved the corresponding magnitude of sympatholysis (25.3 ± 11.4 to 34.4 ± 15.5%, both P < 0.05).

CONCLUSIONS

BR_A supplementation improves the hyperemic and vasodilatory responses to exercise in patients with T2DM which appears to be attributable to reduced α-adrenergic mediated vasoconstriction in contracting skeletal muscle.

Need for preoperative anemia management clinics in Japan: initiatives at a university hospital in the USA

Untreated preoperative anemia increases the risk of morbidity and mortality and there is increasing evidence that early intervention for preoperative anemia improves outcomes after major surgery. Accordingly, anemia management clinics have been established in various institutions in the USA. As an example, the University of Iowa Hospitals and Clinics outpatient clinic treats pre-surgical anemic patients, who undergo major surgery with anticipated blood loss of more than 500 mL, by providing effective standardized care in a timely manner. This standardized care is an integral part of patient blood management to reduce perioperative blood transfusion and improve patient outcomes. The importance of preoperative anemia management has not yet been sufficiently recognized in Japan. Timely intervention for preoperative anemia should be incorporated into routine pre-surgical patient care in Japan.

Genomic and Phenotypic Characterization of Chloracidobacterium Isolates Provides Evidence for Multiple Species

Chloracidobacterium is the first and until now the sole genus in the phylum Acidobacteriota (formerly Acidobacteria) whose members perform chlorophyll-dependent phototrophy (i.e., chlorophototrophy). An axenic isolate of Chloracidobacterium thermophilum (strain B T ) was previously obtained by using the inferred genome sequence from an enrichment culture and diel metatranscriptomic profiling analyses in situ to direct adjustments to the growth medium and incubation conditions, and thereby a defined growth medium for Chloracidobacterium thermophilum was developed. These advances allowed eight additional strains of Chloracidobacterium spp. to be isolated from microbial mat samples collected from Mushroom Spring, Yellowstone National Park, United States, at temperatures of 41, 52, and 60°C; an axenic strain was also isolated from Rupite hot spring in Bulgaria. All isolates are obligately photoheterotrophic, microaerophilic, non-motile, thermophilic, rod-shaped bacteria. Chloracidobacterium spp. synthesize multiple types of (bacterio-)chlorophylls and have type-1 reaction centers like those of green sulfur bacteria. Light harvesting is accomplished by the bacteriochlorophyll a-binding, Fenna-Matthews-Olson protein and chlorosomes containing bacteriochlorophyll c. Their genomes are approximately 3.7 Mbp in size and comprise two circular chromosomes with sizes of approximately 2.7 Mbp and 1.0 Mbp. Comparative genomic studies and phenotypic properties indicate that the nine isolates represent three species within the genus Chloracidobacterium. In addition to C. thermophilum, the microbial mats at Mushroom Spring contain a second species, tentatively named Chloracidobacterium aggregatum, which grows as aggregates in liquid cultures. The Bulgarian isolate, tentatively named Chloracidobacterium validum, will be proposed as the type species of the genus, Chloracidobacterium. Additionally, Chloracidobacterium will be proposed as the type genus of a new family, Chloracidobacteriaceae, within the order Blastocatellales, the class Blastocatellia, and the phylum Acidobacteriota.

Vestiges of Adaptation to the Mesophilic Environment in the Genome of Tepiditoga spiralis gen. nov., sp. nov

A novel anaerobic heterotrophic strain, designated strain sy52^T, was isolated from a hydrothermal chimney at Suiyo Seamount in the Pacific Ocean. A 16S rRNA gene analysis revealed that the strain belonged to the family Petrotogaceae in the phylum Thermotogae. The strain was mesophilic with optimum growth at 48°C and the phylum primarily comprised hyperthermophiles and thermophiles. Strain sy52^T possessed unique genomic characteristics, such as an extremely low G+C content and 6 copies of rRNA operons. Genomic analyses of strain sy52^T revealed that amino acid usage in the predicted proteins resulted from adjustments to mesophilic environments. Genomic features also indicated independent adaptions to the mesophilic environment of strain sy52^T and Mesotoga species, which belong to the mesophilic lineage in the phylum Thermotogae. Based on phenotypic and phylogenetic evidence, strain sy52^T is considered to represent a novel genus and species in the family Petrotogaceae with the proposed name Tepiditoga spiralis gen. nov., sp. nov.

In-Situ Metatranscriptomic Analyses Reveal the Metabolic Flexibility of the Thermophilic Anoxygenic Photosynthetic Bacterium Chloroflexus aggregans in a Hot Spring Cyanobacteria-Dominated Microbial Mat

Chloroflexus aggregans is a metabolically versatile, thermophilic, anoxygenic phototrophic member of the phylum Chloroflexota (formerly Chloroflexi), which can grow photoheterotrophically, photoautotrophically, chemoheterotrophically, and chemoautotrophically. In hot spring-associated microbial mats, C. aggregans co-exists with oxygenic cyanobacteria under dynamic micro-environmental conditions. To elucidate the predominant growth modes of C. aggregans, relative transcription levels of energy metabolism- and CO₂ fixation-related genes were studied in Nakabusa Hot Springs microbial mats over a diel cycle and correlated with microscale in situ measurements of O₂ and light. Metatranscriptomic analyses indicated two periods with different modes of energy metabolism of C. aggregans: (1) phototrophy around midday and (2) chemotrophy in the early morning hours. During midday, C. aggregans mainly employed photoheterotrophy when the microbial mats were hyperoxic (400–800 µmol L⁻¹ O₂). In the early morning hours, relative transcription peaks of genes encoding uptake hydrogenase, key enzymes for carbon fixation, respiratory complexes as well as enzymes for TCA cycle and acetate uptake suggest an aerobic chemomixotrophic lifestyle. This is the first in situ study of the versatile energy metabolism of C. aggregans based on gene transcription patterns. The results provide novel insights into the metabolic flexibility of these filamentous anoxygenic phototrophs that thrive under dynamic environmental conditions.

Glycemic management is inversely related to skeletal muscle microvascular endothelial function in patients with type 2 diabetes

Microvascular endothelial dysfunction precipitates cardiovascular disease mortality in patients with type 2 diabetes mellitus (T2DM). However, the relationship between glycemic management and microvascular endothelial function of these patients remains ill defined. We investigated the association between skeletal muscle microvascular endothelial function with glycemic management (HbA1c) and responses to an oral glucose challenge (OGTT) in 30 patients with T2DM (59 ± 9 years, 31.2 ± 5.1 kg/m² , HbA1c = 7.3 ± 1.3%). On study day 1, microvascular endothelial function was quantified as the increase (Δ from rest) in forearm vascular conductance (FVC, ml/min/100 mmHg) during intra-arterial acetylcholine infusion at 4.0 and 8.0 μg/dl forearm volume/min (ACh4 and ACh8, respectively). [Glucose] and [insulin] were measured in a fasted state as well as following a 75 g OGTT on a second day with an additional fasting blood sample collected to measure HbA1c. FVC increased (Δ) 221 ± 118 and 251 ± 144 ml/min/100 mm Hg during ACh4 and ACh8 trials, respectively (p < 0.05 between doses). [Glucose] and [insulin] increased at the 1-h time point, relative to fasting levels, and remained elevated 2 h post-consumption (p < 0.05 for both variables and time points). [Glucose] nor [insulin], fasting or during the OGTT, were associated with ΔFVC during ACh4 or ACh8, respectively (p = 0.11-0.86), although HbA1c was inversely related (r = -0.47 and -0.46, respectively, p < 0.01 for both). Patients whose HbA1c met the ADA's therapeutic target of ≤7.0% had greater ΔFVC to ACh4 (272 ± 147 vs. 182 ± 74 ml/100 mm Hg/min) and ACh8 (324 ± 171 vs. 196 ± 90 ml/100 mm Hg/min, p < 0.05 for both trials) compared to those with >7.0%, respectively. Our data show glycemic management is related to acetylcholine-mediated vasodilation (e.g., microvascular endothelial function) in skeletal muscle of patients with T2DM.

Litoreibacter roseus sp. nov., a novel bacteriochlorophyll a-containing bacterium

A strictly aerobic, bacteriochlorophyll (BChl) a-containing alphaproteobacterium, designated strain K6^T, was isolated from seawater around an aquaculture site in the Uwa Sea in Japan. The novel strain grew optimally at 30 °C at pH 7.0-7.5 and in the presence of 2.0 % (w/v) NaCl. The nonmotile and coccoid or rod-shaped cells formed pink-pigmented colonies on agar plates containing organic compounds. Cells showed an in vivo absorption maximum at 870 nm in the near-infrared region, indicating the presence of BChl a in the light-harvesting 1 complex. The new bacterial strain was Gram-stain-negative and oxidase- and catalase-positive. Phylogenetic analysis based on the 16S rRNA gene sequence showed that strain K6^T was closely related to species in the genus Litoreibacter. The closest phylogenetic relatives of strain K6^T were Litoreibacter ponti GJSW-31^T (98.56 % sequence similarity), Litoreibacter janthinus KMM 3842^T (97.63 %) and Litoreibacter albidus KMM 3851^T (96.88 %). The G+C content of the genomic DNA was 58.26 mol%. The average nucleotide identity value of strain K6^T with the type strain of L. ponti was 77.16 % (SD 4.79 %). The digital DNA-DNA hybridization value of strain K6^T with the type strain of L. ponti was 19.40 %. The respiratory quinone was ubiquinone-10. The major cellular fatty acids were C_18 : 1 ω7c, C_16 : 0 and 11-methyl C_18 : 1 ω7c. The dominant polar lipids were phosphatidylcholine and phosphatidylglycerol. On the basis of the genetic and phenotypic data obtained in the present study, we propose a new species in the genus Litoreibacter: Litoreibacter roseus sp. nov., whose type strain is K6^T (=DSM 110109^T=NBRC 114114^T). Strain K6^T represents the first confirmed species that produces BChl a within the genus Litoreibacter.

Perioperative Right Ventricular Dysfunction: Analysis of Outcomes

Right ventricular dysfunction (RVD) is a well-known prognostic factor for adverse outcomes in cardiovascular medicine. The right ventricle (RV) in medically managed heart failure patients and in surgical patients perioperatively generally is overshadowed by left ventricular disease. However, with advancement of various diagnostic tools and better understanding of its functional anatomy, the role of the RV is emerging in many clinical conditions. The failure of one ventricle has significant effect on the function of the other ventricle and it is predominantly due to ventricular interdependence.¹ The etiology of RVD is multifactorial and irrespective of etiology. RVD has been associated with significant increases in morbidity and mortality in various clinical scenarios.^2,3 The primary objective of this comprehensive review is to analyze various etiology-related outcomes of RVD in the perioperative population.

Acute inorganic nitrate supplementation and the hypoxic ventilatory response in patients with obstructive sleep apnea

Patients with obstructive sleep apnea (OSA) have increased cardiovascular disease risk largely attributable to hypertension. Heightened peripheral chemoreflex sensitivity (i.e., exaggerated responsiveness to hypoxia) facilitates hypertension in these patients. Nitric oxide blunts the peripheral chemoreflex, and patients with OSA have reduced nitric oxide bioavailability. We therefore investigated the dose-dependent effects of acute inorganic nitrate supplementation (beetroot juice), an exogenous nitric oxide source, on blood pressure and cardiopulmonary responses to hypoxia in patients with OSA using a randomized, double-blind, placebo-controlled crossover design. Fourteen patients with OSA (53 ± 10 yr, 29.2 ± 5.8 kg/m², apnea-hypopnea index = 17.8 ± 8.1, 43%F) completed three visits. Resting brachial blood pressure and cardiopulmonary responses to inspiratory hypoxia were measured before, and 2 h after, acute inorganic nitrate supplementation [∼0.10 mmol (placebo), 4.03 mmol (low dose), and 8.06 mmol (high dose)]. Placebo increased neither plasma [nitrate] (30 ± 52 to 52 ± 23 μM, P = 0.26) nor [nitrite] (266 ± 153 to 277 ± 164 nM, P = 0.21); however, both increased following low (29 ± 17 to 175 ± 42 μM, 220 ± 137 to 514 ± 352 nM) and high doses (26 ± 11 to 292 ± 90 μM, 248 ± 155 to 738 ± 427 nM, respectively, P < 0.01 for all). Following placebo, systolic blood pressure increased (120 ± 9 to 128 ± 10 mmHg, P < 0.05), whereas no changes were observed following low (121 ± 11 to 123 ± 8 mmHg, P = 0.19) or high doses (124 ± 13 to 124 ± 9 mmHg, P = 0.96). The peak ventilatory response to hypoxia increased following placebo (3.1 ± 1.2 to 4.4 ± 2.6 L/min, P < 0.01) but not low (4.4 ± 2.4 to 5.4 ± 3.4 L/min, P = 0.11) or high doses (4.3 ± 2.3 to 4.8 ± 2.7 L/min, P = 0.42). Inorganic nitrate did not change the heart rate responses to hypoxia (beverage-by-time P = 0.64). Acute inorganic nitrate supplementation appears to blunt an early-morning rise in systolic blood pressure potentially through suppression of peripheral chemoreflex sensitivity in patients with OSA.NEW & NOTEWORTHY The present study is the first to examine the acute effects of inorganic nitrate supplementation on resting blood pressure and cardiopulmonary responses to hypoxia (e.g., peripheral chemoreflex sensitivity) in patients with obstructive sleep apnea (OSA). Our data indicate inorganic nitrate supplementation attenuates an early-morning rise in systolic blood pressure potentially attributable to blunted peripheral chemoreflex sensitivity. These data show proof-of-concept that inorganic nitrate supplementation could reduce the risk of cardiovascular disease in patients with OSA.

Caldichromatium japonicum gen. nov., sp. nov., a novel thermophilic phototrophic purple sulphur bacterium of the Chromatiaceae isolated from Nakabusa hot springs, Japan

A novel thermophilic phototrophic purple sulphur bacterium was isolated from microbial mats (56 °C) at Nakabusa hot springs, Nagano prefecture, Japan. Cells were motile, rod-shaped, stain Gram-negative and stored sulphur globules intracellularly. Bacteriochlorophyll a and carotenoids of the normal spirilloxanthin series were the major pigments. Dense liquid cultures were red in colour. Strain No.7^T was able to grow photoautotrophically using sulfide, thiosulfate, sulfite and hydrogen (in the presence of sulfide) as electron donors and bicarbonate as the sole carbon source. Optimum growth occurred under anaerobic conditions in the light at 50 °C (range, 40-56 °C) and pH 7.2 (range, pH 7-8). Major fatty acids were C_16 : 0 (46.8 %), C_16 : 1 ω7c (19.9 %), C_18 : 1 ω7c (21.1 %), C_14 : 0 (4.6 %) and C_18 : 0 (2.4 %). The polar lipid profile showed phosphatidylglycerol and unidentified aminophospholipids to be the major lipids. The only quinone detected was ubiquinone-8. 16S rRNA gene sequence comparisons indicated that the novel bacterium is only distantly related to Thermochromatium tepidum with a nucleotide identity of 90.4 %. The phylogenetic analysis supported the high novelty of strain No.7^T with a long-branching phylogenetic position within the Chromatiaceae next to Thermochromatium tepidum. The genome comprised a circular chromosome of 2.99 Mbp (2 989 870 bp), included no plasmids and had a DNA G+C content of 61.2 mol%. Polyphasic taxonomic analyses of the isolate suggested strain No.7^T is a novel genus within the Chromatiaceae. The proposed genus name of the second truly thermophilic purple sulphur bacterium is Caldichromatium gen. nov. with the type species Caldichromatium japonicum sp. nov. (DSM 110881=JCM 39101).

Anoxygenic photosynthesis and iron-sulfur metabolic potential of Chlorobia populations from seasonally anoxic Boreal Shield lakes

Aquatic environments with high levels of dissolved ferrous iron and low levels of sulfate serve as an important systems for exploring biogeochemical processes relevant to the early Earth. Boreal Shield lakes, which number in the tens of millions globally, commonly develop seasonally anoxic waters that become iron rich and sulfate poor, yet the iron-sulfur microbiology of these systems has been poorly examined. Here we use genome-resolved metagenomics and enrichment cultivation to explore the metabolic diversity and ecology of anoxygenic photosynthesis and iron/sulfur cycling in the anoxic water columns of three Boreal Shield lakes. We recovered four high-completeness and low-contamination draft genome bins assigned to the class Chlorobia (formerly phylum Chlorobi) from environmental metagenome data and enriched two novel sulfide-oxidizing species, also from the Chlorobia. The sequenced genomes of both enriched species, including the novel "Candidatus Chlorobium canadense", encoded the cyc2 gene that is associated with photoferrotrophy among cultured Chlorobia members, along with genes for phototrophic sulfide oxidation. One environmental genome bin also encoded cyc2. Despite the presence of cyc2 in the corresponding draft genome, we were unable to induce photoferrotrophy in "Ca. Chlorobium canadense". Genomic potential for phototrophic sulfide oxidation was more commonly detected than cyc2 among environmental genome bins of Chlorobia, and metagenome and cultivation data suggested the potential for cryptic sulfur cycling to fuel sulfide-based growth. Overall, our results provide an important basis for further probing the functional role of cyc2 and indicate that anoxygenic photoautotrophs in Boreal Shield lakes could have underexplored photophysiology pertinent to understanding Earth's early microbial communities.

Greater α1-adrenergic-mediated vasoconstriction in contracting skeletal muscle of patients with type 2 diabetes

Findings presented in this article are the first to show patients with type 2 diabetes mellitus have blunted hyperemic and vasodilatory responses to dynamic handgrip exercise. Moreover, we illustrate greater α1-adrenergic-mediated vasoconstriction may contribute to our initial observations. Collectively, these data suggest patients with type 2 diabetes may have impaired functional sympatholysis, which can contribute to their reduced exercise capacity.

Roseobacter cerasinus sp. nov., isolated from a fish farm

An obligate aerobic and bacteriochlorophyll a-containing bacterium, designated strain AI77^T, was isolated from a fish farm in Uwa Sea, Japan. Cells were Gram-stain-negative, coccoid- to oval-shaped, and showed no motility. Phylogenetic analysis based on the 16S rRNA gene sequences revealed that strain AI77^T is a member of the genus Roseobacter and closely related to Roseobacter ponti MM-7^T (97.8 %), Roseobacter denitrificans OCh 114^T (97.3 %) and Roseobacter litoralis OCh 149^T (97.3 %). The G+C content of strain AI77^T was 61.0 mol%. The average amino acid identity values of the genome in strain AI77^T with those in R. denitrificans OCh 114^T and R. litoralis OCh 149^T were 73.26 % (SD 16.46) and 72.63 % (SD 16.76), respectively. The digital DNA-DNA hybridization values of strain AI77^T with the type strains R. denitrificans OCh 114^T and R. litoralis OCh 149^T were 18.70 and 18.50 %, respectively. The dominant fatty acids (>10 % of total fatty acids) of AI77^T were summed feature 8 (C_18 : 1 ω7c and/or C_18 : 1 ω6c) and saturated fatty acid C_16 : 0. The sole respiratory quinone was ubiquinone-10. The predominant polar lipids were phosphatidylcholine, phosphatidylglycerol and diphosphatidylglycerol. Based on the genetic and phenotypic data obtained herein, we conclude that strain AI77^T represents a new species of the genus Roseobacter, for which we propose the name Roseobacter cerasinus sp. nov.; the type strain is AI77^T (=DSM 110091^T=NBRC 114115^T).

Aerobic exercise offsets endothelial dysfunction induced by repetitive consumption of sugar-sweetened beverages in young healthy men

Consumption of a single, sugar-sweetened beverage (SSB) impairs vascular endothelial function. Regular aerobic exercise improves endothelium-dependent vasodilation; however, it is unknown whether these beneficial effects persist with frequent SSB consumption. Therefore, the purpose of this study was twofold; we studied the effects of repetitive SSB consumption (75 g d-glucose, 3 times/day) for 1 wk (Glu, n = 13, 23 ± 4 yr, 23.5 ± 3.4 kg/m²) on endothelium-dependent vasodilation (FMD). Then, in a separate cohort, we investigated whether 45 min of moderate-intensity aerobic exercise on five separate days offset the hypothesized decrease in FMD during the Glu protocol (Glu+Ex, n = 11, 21 ± 3 yr, 23.8 ± 2.4 kg/m²). Baseline, fasting [glucose] (P = 0.15), [insulin] (P = 0.25), %FMD (P = 0.48), absolute FMD (P = 0.66), and shear rate area under the curve (SR_AUC; P = 0.82) were similar between groups. Following the interventions, fasting [glucose] (Glu: 94 ± 6 to 92 ± 6 mg/dL, Glu+Ex: 89 ± 8 to 87 ± 6 mg/dL, P = 0.74) and [insulin] (Glu: 11.3 ± 6.2 to 11.8 ± 8.9 μU/mL, Glu+Ex: 8.7 ± 2.9 to 9.4 ± 3.2 μU/mL, P = 0.89) were unchanged. %FMD was reduced in Glu (6.1 ± 2.2 to 5.1 ± 1.3%) and increased in Glu+Ex (6.6 ± 2.2 to 7.8 ± 2.4%, P < 0.05 for both). SR_AUC increased similarly in both Glu [17,715 ± 8,275 to 22,922 ± 4,808 arbitrary units (A.U.)] and Glu+Ex (18,216 ± 4,516 to 21,666 ± 5,392 A.U., main effect of time P < 0.05). When %FMD was adjusted for SR_AUC, attenuation was observed in Glu (0.41 ± 0.18 to 0.23 ± 0.08%/s × 103, P < 0.05) but not Glu+Ex (0.38 ± 0.14 to 0.38 ± 0.13%/s × 103, P = 0.88). Despite unchanged fasting [glucose] and [insulin], repeated consumption of SSBs impaired conduit artery vascular endothelial function. Additionally, subjects who engaged in regular moderate-intensity aerobic exercise did not demonstrate the same SSB-induced endothelial dysfunction. Collectively, these data suggest aerobic exercise may offset the deleterious effects of repetitive SSB consumption.

Impact of high spinal anesthesia technique on fast-track strategy in cardiac surgery: retrospective study

BACKGROUND AND OBJECTIVES

Although high spinal anesthesia (HSA) has been used in cardiac surgery, the technique has not yet been widely accepted. This retrospective study was designed to investigate the impact of HSA technique on fast-track strategy in cardiac surgery.

METHODS

Elective cardiac surgery cases (n=1025) were divided into two groups: cases with HSA combined with general anesthesia (GA) (HSA group, n=188) and cases with GA only (GA group, n=837). In the HSA group, bupivacaine and morphine were intrathecally administered immediately before GA was induced. Outcomes included fast-track extubation (less than 6 hours), extubation in the operating room, fast-track discharge from the intensive care unit (ICU) (less than 48 hours) and hospital (less than 7 days).

RESULTS

In the HSA group, 60.1% were extubated in less than 6 hours after ICU admission, as compared with 39.9% in the GA group (p<0.001). In the HSA group, 33.0% were extubated in the operating room, as compared with 4.4% in the GA group (p<0.001). LOS in the ICU was less than 48 hours in 67.6% in the HSA group, as compared with 57.2% of those in the GA group (p=0.033). LOS in the hospital was less than 7 days in 63.3% in the HSA group, as compared with 53.5% in the GA group (p=0.084).

CONCLUSIONS

HSA technique combined with GA in cardiac surgery increased the rate of fast-track extubation (less than 6 hours) when compared with GA only.

Vertical Distribution and Diversity of Phototrophic Bacteria within a Hot Spring Microbial Mat (Nakabusa Hot Springs, Japan)

Phototrophic microbial mats are assemblages of vertically layered microbial populations dominated by photosynthetic microorganisms. In order to elucidate the vertical distribution and diversity of phototrophic microorganisms in a hot spring-associated microbial mat in Nakabusa (Japan), we analyzed the 16S rRNA gene amplicon sequences of the microbial mat separated into five depth horizons, and correlated them with microsensor measurements of O₂ and spectral scalar irradiance. A stable core community and high diversity of phototrophic organisms dominated by the filamentous anoxygenic phototrophs, Roseiflexus castenholzii and Chloroflexus aggregans were identified together with the spectral signatures of bacteriochlorophylls (BChls) a and c absorption in all mat layers. In the upper mat layers, a high abundance of cyanobacteria (Thermosynechococcus sp.) correlated with strong spectral signatures of chlorophyll a and phycobiliprotein absorption near the surface in a zone of high O₂ concentrations during the day. Deeper mat layers were dominated by uncultured chemotrophic Chlorobi such as the novel putatively sulfate-reducing “Ca. Thermonerobacter sp.”, which showed increasing abundance with depth correlating with low O₂ in these layers enabling anaerobic metabolism. Oxygen tolerance and requirements for the novel phototroph “Ca. Chloroanaerofilum sp.” and the uncultured chemotrophic Armatimonadetes member type OS-L detected in Nakabusa hot springs, Japan appeared to differ from previously suggested lifestyles for close relatives identified in hot springs in Yellowstone National Park, USA. The present study identified various microenvironmental gradients and niche differentiation enabling the co-existence of diverse chlorophototrophs in metabolically diverse communities in hot springs.

Aquabacterium pictum sp. nov., the first aerobic bacteriochlorophyll a-containing fresh water bacterium in the genus Aquabacterium of the class Betaproteobacteria

A strictly aerobic, bacteriochlorophyll a-containing betaproteobacterium, designated strain W35^T, was isolated from a biofilm sampled at Tama River in Japan. The non-motile and rod-shaped cells formed pink-beige pigmented colonies on agar plates containing organic compounds, and showed an in vivo absorption maximum at 871 nm in the near-infrared region, typical for the presence of bacteriochlorophyll a. The new bacterial strain is Gram-negative, and oxidase- and catalase-positive. Phylogenetic analysis based on 16S rRNA gene sequence showed that strain W35^T was closely related to species in the genus Aquabacterium. The closest phylogenetic relatives of strain W35^T were Aquabacterium commune B8^T (97.9 % sequence similarity), Aquabacterium citratiphilum B4^T (97.2 %) and Aquabacterium limnoticum ABP-4^T (97.0 %). The major cellular fatty acids were C_{16  :  1}ω7c (50.4 %), C_{16  :  0} (22.7 %), summed feature 8 (C_{18  :  1}ω7c/C_{18  :  1}ω6c; 9.7 %), C_{18  :  3}ω6c (5.5 %), C_{12  :  0} (5.3 %) and C_{10  :  0} 3OH (2.7 %). The respiratory quinone was ubiquinone-8. Predominant polar lipids were phosphatidylethanolamine, phosphatidylglycerol and diphosphatidylglycerol. The G+C content of the genomic DNA was 70.4 mol% (genome data) and 71.4 mol% (HPLC). The genome size of strain W35^T is 6.1 Mbp and average nucleotide identity analysis indicated genome similarities of strain W35^T and related Aquabacterium type strains to be 78-79 %. The results of polyphasic comparisons showed that strain W35^T was clearly distinguishable from other members of the genus Aquabacterium. Therefore, we propose a new species in the genus Aquabacterium, namely, Aquabacterium pictum sp. nov. The type strain is W35^T (=DSM 106757^T=NBRC 111963^T). The description of the genus Aquabacterium is also emended.

Sulfide-dependent Photoautotrophy in the Filamentous Anoxygenic Phototrophic Bacterium, Chloroflexus aggregans

Chloroflexus aggregans is a thermophilic filamentous anoxygenic phototrophic bacterium frequently found in microbial mats in natural hot springs. C. aggregans often thrives with cyanobacteria that engage in photosynthesis to provide it with an organic substrate; however, it sometimes appears as the dominant phototroph in microbial mats without cyanobacteria. This suggests that C. aggregans has the ability to grow photoautotrophically. However, photoautotrophic growth has not been observed in any cultured strains of C. aggregans. We herein attempted to isolate a photoautotrophic strain from C. aggregansdominated microbial mats in Nakabusa hot spring in Japan. Using an inorganic medium, we succeeded in isolating a new strain that we designated "ACA-12". A phylogenetic analysis based on 16S rRNA gene and 16S-23S rRNA gene internal transcribed spacer (ITS) region sequences revealed that strain ACA-12 was closely related to known C. aggregans strains. Strain ACA-12 showed sulfide consumption along with autotrophic growth under anaerobic light conditions. The deposited elemental sulfur particles observed by microscopy indicated that sulfide oxidation occurred, similar to that in photoautotrophic strains in the related species, C. aurantiacus. Moreover, we found that other strains of C. aggregans, including the type strain, also exhibited a slight photoautotrophic growing ability, whereas strain ACA-12 showed the fastest growth rate. This is the first demonstration of photoautotrophic growth with sulfide in C. aggregans. The present results strongly indicate that C. aggregans is associated with inorganic carbon incorporation using sulfide as an electron donor in hot spring microbial mats.

Early Graft Dysfunction Following Heart Transplant: Prevention and Management

Heart transplant can be considered as the “gold standard” treatment for end-stage heart failure, with nearly 5.7 million adults in the United States carrying a diagnosis of heart failure. According to the International Society for Heart and Lung Transplantation registry, nearly 3300 orthotopic heart transplants were performed in 2016 in North America. In spite of significant improvements in overall perioperative care of heart transplant recipients for the past few decades, the risk of 30-day mortality remains 5% to 10%, primarily related to early failure of the allograft. Early graft dysfunction (EGD) occurs within 24 hours after transplant, manifesting as left ventricular dysfunction, right ventricular dysfunction, or biventricular dysfunction. EGD is further classified into primary and secondary graft dysfunction. This review focus on describing overall incidences of EGD, potential risk factors associated with EGD, perioperative preventive measures, and various management options.

Bioactive TiNbSn alloy prepared by anodization in sulfuric acid electrolytes

The bioactivity of anodized near-β TiNbSn alloy with low Young's modulus prepared in sulfuric acid electrolytes was examined to explore the osseointegration mechanism with a focus on the role of anodic oxide. Hydroxyapatite (HA) precipitated on the surface of anodic oxide following immersion in Hank's solution, and precipitation accelerated with increase in the sulfuric acid concentration of the electrolyte. HA is formed on the surface of as-anodized oxide without subsequent annealing or hot water (HW) treatment. This outcome differs from that of a previous study using anodized TiNbSn alloy prepared in acetic acid electrolytes requiring for subsequent HW treatment. It was found that the oxide anodized in sulfuric acid electrolyte contains a large amount of internal pores and is highly crystallized thick TiO₂, whereas the same prepared in the acetic acid electrolyte is low crystalline thin TiO₂ containing a small amount of pores. The present anodized TiNbSn alloy is preferred for maintaining the low Young's modulus of the alloy and eliminating the subsequent treatment to increase the Young's modulus. A model to rationalize the bioactivity of the present anodic oxide is proposed based on the series of studies. It is concluded that the sulfuric acid electrolyte is favorable for both HA formation and low Young's modulus, and the bioactivity is attributed to the anodic TiO₂ that facilitates incorporation of bone ingredients.

"Candidatus Thermonerobacter thiotrophicus," A Non-phototrophic Member of the Bacteroidetes/Chlorobi With Dissimilatory Sulfur Metabolism in Hot Spring Mat Communities

In this study we present evidence for a novel, thermophilic bacterium with dissimilatory sulfur metabolism, tentatively named “Candidatus Thermonerobacter thiotrophicus,” which is affiliated with the Bacteroides/Ignavibacteria/Chlorobi and which we predict to be a sulfate reducer. Dissimilatory sulfate reduction (DSR) is an important and ancient metabolic process for energy conservation with global importance for geochemical sulfur and carbon cycling. Characterized sulfate-reducing microorganisms (SRM) are found in a limited number of bacterial and archaeal phyla. However, based on highly diverse environmental dsrAB sequences, a variety of uncultivated and unidentified SRM must exist. The recent development of high-throughput sequencing methods allows the phylogenetic identification of some of these uncultured SRM. In this study, we identified a novel putative SRM inhabiting hot spring microbial mats that is a member of the OPB56 clade (“Ca. Kapabacteria”) within the Bacteroidetes/Chlorobi superphylum. Partial genomes for this new organism were retrieved from metagenomes from three different hot springs in Yellowstone National Park, United States, and Japan. Supporting the prediction of a sulfate-reducing metabolism for this organism during period of anoxia, diel metatranscriptomic analyses indicate highest relative transcript levels in situ for all DSR-related genes at night. The presence of terminal oxidases, which are transcribed during the day, further suggests that these organisms might also perform aerobic respiration. The relative phylogenetic proximity to the sulfur-oxidizing, chlorophototrophic Chlorobi further raises new questions about the evolution of dissimilatory sulfur metabolism.