Implementation of Patient Blood Management in Orthotopic Heart Transplants: A Single Centre Retrospective Observational Review.

BACKGROUND: Blood transfusion in the perioperative cardiothoracic setting has accepted risks including deep sternal wound infection, increased intensive care unit length of stay, lung injury, and cost. It has an immunomodulatory effect which may cause allo-immunisation. This may influence long-term survival through immune-mediated factors. Targeting coagulation defects to reduce unnecessary or inappropriate transfusions may reduce these complications. METHODS: In 2012, an institution-wide patient blood management evidence-based algorithmic bleeding management protocol was implemented at The Prince Charles Hospital, Brisbane, Australia. The benefit of this has been previously reported in our lung transplant and cardiac surgery (excluding transplants) cohorts. This study aimed to investigate the effect of this on our orthotopic heart transplant recipients. RESULTS: After the implementation of the protocol, despite no difference in preoperative haemoglobin levels and higher risk patients (EuroSCORE 20 vs 26; p=0.013), the use of packed red blood cells (13.0 U vs 4.4 U; p=0.046) was significantly lower postoperatively and fresh frozen plasma was significantly lower both intra- and postoperatively (7.4 U vs 0.6 U; p<0.001, and 3.3 U vs 0.6 U; p=0.011 respectively). Concurrently, the use of prothrombin complex concentrate (33% vs 78%; p<0.001) and desmopressin (5% vs 22%; p=0.0028) was significantly higher in the post-protocol group, while there was less use of recombinant factor VIIa (15% vs 4%; p=0.058). Intraoperative units of cryoprecipitate also rose from 0.9 to 2.0 (p=0.006). CONCLUSIONS: We have demonstrated that a targeted patient blood management protocol with point-of-care testing for heart transplant recipients is correlated with fewer blood products used postoperatively, with some increase in haemostatic products and no evidence of increased adverse events.

Simple left ventricular apical cannulation for temporary mechanical circulatory support.

Surgical management of cardiogenic shock, utilizing mechanical circulatory support, can provide a bridge to recovery, bridge to decision making and/or bridge to transplantation. Despite extracorporeal membrane oxygenation (ECMO) being a reliable, temporary form of support, intracardiac thrombosis is a devastating complication of veno-arterial ECMO. The use of a temporary left ventricular assist device (LVAD), although not immune to thrombosis, helps reduce intracardiac thrombosis, maintaining flow through the heart but importantly allowing for concurrent venting and drainage of the left ventricle. We demonstrate a technique for LV apical cannulation, as a part of a temporary LVAD circuit, aiming to prevent thrombotic complications secondary to cannula angulation.

Temporary biventricular mechanical circulatory support utilizing a simple left ventricular apical cannulation technique.

Surgical management of cardiogenic shock, utilizing mechanical circulatory support, can provide a bridge to recovery, a bridge to decision-making, and/or a bridge to transplantation. The management of advanced heart failure, employing either temporary or durable mechanical circulatory support, dominantly is directed towards supporting the left ventricular (LV) function. Unfortunately, right ventricular (RV) failure is not uncommon and significantly impacts morbidity and mortality. We demonstrate a technique to support biventricular failure, utilizing a simple LV apical cannulation technique, which may reduce thrombotic complications, and an RV cannulation strategy that offers the potential to improve recovery, in the form of early extubation, potential ambulation, and removal of the implanted device without having to reopen the patient's chest.

From Adsorption to Precipitation of U(VI): What is the Role of pH and Natural Organic Matter?

We investigated interfacial reactions of U(VI) in the presence of Suwannee River natural organic matter (NOM) at acidic and neutral pH. Laboratory batch experiments show that the adsorption and precipitation of U(VI) in the presence of NOM occur at pH 2 and pH 4, while the aqueous complexation of U by dissolved organic matter is favored at pH 7, preventing its precipitation. Spectroscopic analyses indicate that U(VI) is mainly adsorbed to the particulate organic matter at pH 4. However, U(VI)-bearing ultrafine to nanocrystalline solids were identified at pH 4 by electron microscopy. This study shows the promotion of U(VI) precipitation by NOM at low pH which may be relevant to the formation of mineralized deposits, radioactive waste repositories, wetlands, and other U- and organic-rich environmental systems.

Effect of Bicarbonate and Oxidizing Conditions on U(IV) and U(VI) Reactivity in Mineralized Deposits of New Mexico.

We investigated the effect of bicarbonate and oxidizing agents on uranium (U) reactivity and subsequent dissolution of U(IV) and U(VI) mineral phases in the mineralized deposits from Jackpile mine, Laguna Pueblo, New Mexico, by integrating laboratory experiments with spectroscopy, microscopy and diffraction techniques. Uranium concentration in solid samples from mineralized deposit obtained for this study exceeded 7000 mg kg-1, as determined by X-ray fluorescence (XRF). Results from X-ray photoelectron spectroscopy (XPS) suggest the coexistence of U(VI) and U(IV) at a ratio of 19:1 at the near surface region of unreacted solid samples. Analyses made using X-ray diffraction (XRD) and electron microprobe detected the presence of coffinite (USiO4) and uranium-phosphorous-potassium (U-P-K) mineral phases. Imaging, mapping and spectroscopy results from scanning transmission electron microscopy (STEM) indicate that the U-P-K phases were encapsulated by carbon. Despite exposing the solid samples to strong oxidizing conditions, the highest aqueous U concentrations were measured from samples reacted with 100% air saturated 10 mM NaHCO3 solution, at pH 7.5. Analyses using X-ray absorption spectroscopy (XAS) indicate that all the U(IV) in these solid samples were oxidized to U(VI) after reaction with dissolved oxygen and hypochlorite (OCl-) in the presence of bicarbonate (HCO3 -). The reaction between these organic rich deposits, and 100% air saturated bicarbonate solution (containing dissolved oxygen), can result in considerable mobilization of U in water, which has relevance to the U concentrations observed at the Rio Paguate across the Jackpile mine. Results from this investigation provide insights on the reactivity of carbon encapsulated U-phases under mild and strong oxidizing conditions that have important implication in U recovery, remediation and risk exposure assessment of sites.

Unplanned Autotransplantation for Complex Multi-Valve Replacement in a Super Morbid Obese Female: The Challenge of Intraoperative Decision Making.

Cardiac autotransplantation is a rare technique typically reserved for the treatment of malignant tumors of the left atrium and left ventricle. Even when well planned, it conveys a high risk to the patient. This report discusses the intraoperative progression to an unplanned autotransplant for mitral valve repair while considering some decision making processes that cardiac surgeons make.

In Vivo Evaluation of Active and Passive Physiological Control Systems for Rotary Left and Right Ventricular Assist Devices.

Preventing ventricular suction and venous congestion through balancing flow rates and circulatory volumes with dual rotary ventricular assist devices (VADs) configured for biventricular support is clinically challenging due to their low preload and high afterload sensitivities relative to the natural heart. This study presents the in vivo evaluation of several physiological control systems, which aim to prevent ventricular suction and venous congestion. The control systems included a sensor-based, master/slave (MS) controller that altered left and right VAD speed based on pressure and flow; a sensor-less compliant inflow cannula (IC), which altered inlet resistance and, therefore, pump flow based on preload; a sensor-less compliant outflow cannula (OC) on the right VAD, which altered outlet resistance and thus pump flow based on afterload; and a combined controller, which incorporated the MS controller, compliant IC, and compliant OC. Each control system was evaluated in vivo under step increases in systemic (SVR ∼1400-2400 dyne/s/cm(5) ) and pulmonary (PVR ∼200-1000 dyne/s/cm(5) ) vascular resistances in four sheep supported by dual rotary VADs in a biventricular assist configuration. Constant speed support was also evaluated for comparison and resulted in suction events during all resistance increases and pulmonary congestion during SVR increases. The MS controller reduced suction events and prevented congestion through an initial sharp reduction in pump flow followed by a gradual return to baseline (5.0 L/min). The compliant IC prevented suction events; however, reduced pump flows and pulmonary congestion were noted during the SVR increase. The compliant OC maintained pump flow close to baseline (5.0 L/min) and prevented suction and congestion during PVR increases. The combined controller responded similarly to the MS controller to prevent suction and congestion events in all cases while providing a backup system in the event of single controller failure.

Electron capture dissociation in a branched radio-frequency ion trap.

We have developed a high-throughput electron capture dissociation (ECD) device coupled to a quadrupole time-of-flight mass spectrometer using novel branched radio frequency ion trap architecture. With this device, a low-energy electron beam can be injected orthogonally into the analytical ion beam with independent control of both the ion and electron beams. While ions and electrons can interact in a "flow-through" mode, we observed a large enhancement in ECD efficiency by introducing a short ion trapping period at the region of ion and electron beam intersection. This simultaneous trapping mode still provides up to five ECD spectra per second while operating in an information-dependent acquisition workflow. Coupled to liquid chromatography (LC), this LC-ECD workflow provides good sequence coverage for both trypsin and Lys C digests of bovine serum albumin, providing ECD spectra for doubly charged precursor ions with very good efficiency.

Vegetation exerts a greater control on litter decomposition than climate warming in peatlands.

Historically, slow decomposition rates have resulted in the accumulation of large amounts of carbon in northern peatlands. Both climate warming and vegetation change can alter rates of decomposition, and hence affect rates of atmospheric CO2 exchange, with consequences for climate change feedbacks. Although warming and vegetation change are happening concurrently, little is known about their relative and interactive effects on decomposition processes. To test the effects of warming and vegetation change on decomposition rates, we placed litter of three dominant species (Calluna vulgaris, Eriophorum vaginatum, Hypnum jutlandicum) into a peatland field experiment that combined warming.with plant functional group removals, and measured mass loss over two years. To identify potential mechanisms behind effects, we also measured nutrient cycling and soil biota. We found that plant functional group removals exerted a stronger control over short-term litter decomposition than did approximately 1 degrees C warming, and that the plant removal effect depended on litter species identity. Specifically, rates of litter decomposition were faster when shrubs were removed from the plant community, and these effects were strongest for graminoid and bryophyte litter. Plant functional group removals also had strong effects on soil biota and nutrient cycling associated with decomposition, whereby shrub removal had cascading effects on soil fungal community composition, increased enchytraeid abundance, and increased rates of N mineralization. Our findings demonstrate that, in addition to litter quality, changes in vegetation composition play a significant role in regulating short-term litter decomposition and belowground communities in peatland, and that these impacts can be greater than moderate warming effects. Our findings, albeit from a relatively short-term study, highlight the need to consider both vegetation change and its impacts below ground alongside climatic effects when predicting future decomposition rates and carbon storage in peatlands.

Successful use of pre and post-operative ECMO for pulmonary endarterectomy, mitral valve replacement and myomectomy in a patient with chronic thromboembolic pulmonary hypertension and hypertrophic cardiomyopathy.

As a salvage strategy, extracorporeal membrane oxygenation (ECMO) permits the recovery of end-organ perfusion, whilst allowing the surgeon time for patient reassessment and surgical planning. We report upon the first known case in which VA ECMO was instituted as peri-operative supportive therapy for a young patient, in-extremis, with surgically correctable Chronic Thromboembolic Pulmonary Hypertension (CTEPH) and Hypertrophic Cardiomyopathy (HOCM).

Extracorporeal life support devices and strategies for management of acute cardiorespiratory failure in adult patients: a comprehensive review.

Evolution of extracorporeal life support (ECLS) technology has added a new dimension to the intensive care management of acute cardiac and/or respiratory failure in adult patients who fail conventional treatment. ECLS also complements cardiac surgical and cardiology procedures, implantation of long-term mechanical cardiac assist devices, heart and lung transplantation and cardiopulmonary resuscitation. Available ECLS therapies provide a range of options to the multidisciplinary teams who are involved in the time-critical care of these complex patients. While venovenous extracorporeal membrane oxygenation (ECMO) can provide complete respiratory support, extracorporeal carbon dioxide removal facilitates protective lung ventilation and provides only partial respiratory support. Mechanical circulatory support with venoarterial (VA) ECMO employed in a traditional central/peripheral fashion or in a temporary ventricular assist device configuration may stabilise patients with decompensated cardiac failure who have evidence of end-organ dysfunction, allowing time for recovery, decision-making, and bridging to implantation of a long-term mechanical circulatory support device and occasionally heart transplantation. In highly selected patients with combined severe cardiac and respiratory failure, advanced ECLS can be provided with central VA ECMO, peripheral VA ECMO with timely transition to venovenous ECMO or VA-venous ECMO upon myocardial recovery to avoid upper body hypoxia or by addition of an oxygenator to the temporary ventricular assist device circuit. This article summarises the available ECLS options and provides insights into the principles and practice of these techniques. One should emphasise that, as is common with many emerging therapies, their optimal use is currently not backed by quality evidence. This deficiency needs to be addressed to ensure that the full potential of ECLS can be achieved.

In vitro and in vivo characterization of three different modes of pump operation when using a left ventricular assist device as a right ventricular assist device.

Dual rotary left ventricular assist devices (LVADs) have been used clinically to support patients with biventricular failure. However, due to the lower vascular resistance in the pulmonary circulation compared with its systemic counterpart, excessively high pulmonary flow rates are expected if the right ventricular assist device (RVAD) is operated at its design LVAD speed. Three possible approaches are available to match the LVAD to the pulmonary circulation: operating the RVAD at a lower speed than the LVAD (mode 1), operating both pumps at their design speeds (mode 2) while relying on the cardiovascular system to adapt, and operating both pumps at their design speeds while restricting the diameter of the RVAD outflow graft (mode 3). In this study, each mode was characterized using in vitro and in vivo models of biventricular heart failure supported with two VentrAssist LVADs. The effect of each mode on arterial and atrial pressures and flow rates for low, medium, and high vascular resistances and three different contractility levels were evaluated. The amount of speed/diameter adjustment required to accommodate elevated pulmonary vascular resistance (PVR) during support with mode 3 was then investigated. Mode 1 required relatively low systemic vascular resistance to achieve arterial pressures less than 100 mm Hg in vitro, resulting in flow rates greater than 6 L/min. Mode 2 resulted in left atrial pressures above 25 mm Hg, unless left heart contractility was near-normal. In vitro, mode 3 resulted in expected arterial pressures and flow rates with an RVAD outflow diameter of 6.5 mm. In contrast, all modes were achievable in vivo, primarily due to higher RVAD outflow graft resistance (more than 500 dyn·s/cm(5)), caused by longer cannula. Flow rates could be maintained during instances of elevated PVR by increasing the RVAD speed or expanding the outflow graft diameter using an externally applied variable graft occlusion device. In conclusion, suitable hemodynamics could be produced by either restricting or not restricting the right outflow graft diameter; however, the latter required an operation of the RVAD at lower than design speed. Adjustments in outflow restriction and/or RVAD speed are recommended to accommodate varying PVR.

Niche specialization of terrestrial archaeal ammonia oxidizers.

Soil pH is a major determinant of microbial ecosystem processes and potentially a major driver of evolution, adaptation, and diversity of ammonia oxidizers, which control soil nitrification. Archaea are major components of soil microbial communities and contribute significantly to ammonia oxidation in some soils. To determine whether pH drives evolutionary adaptation and community structure of soil archaeal ammonia oxidizers, sequences of amoA, a key functional gene of ammonia oxidation, were examined in soils at global, regional, and local scales. Globally distributed database sequences clustered into 18 well-supported phylogenetic lineages that dominated specific soil pH ranges classified as acidic (pH <5), acido-neutral (5 ≤ pH <7), or alkalinophilic (pH ≥ 7). To determine whether patterns were reproduced at regional and local scales, amoA gene fragments were amplified from DNA extracted from 47 soils in the United Kingdom (pH 3.5-8.7), including a pH-gradient formed by seven soils at a single site (pH 4.5-7.5). High-throughput sequencing and analysis of amoA gene fragments identified an additional, previously undiscovered phylogenetic lineage and revealed similar pH-associated distribution patterns at global, regional, and local scales, which were most evident for the five most abundant clusters. Archaeal amoA abundance and diversity increased with soil pH, which was the only physicochemical characteristic measured that significantly influenced community structure. These results suggest evolution based on specific adaptations to soil pH and niche specialization, resulting in a global distribution of archaeal lineages that have important consequences for soil ecosystem function and nitrogen cycling.

Ground water contamination with (238)U, (234)U, (235)U, (226)Ra and (210)Pb from past uranium mining: cove wash, Arizona.

The objectives of the study are to present a critical review of the (238)U, (234)U, (235)U, (226)Ra and (210)Pb levels in water samples from the EPA studies (U.S. EPA in Abandoned uranium mines and the Navajo Nation: Red Valley chapter screening assessment report. Region 9 Superfund Program, San Francisco, 2004, Abandoned uranium mines and the Navajo Nation: Northern aum region screening assessment report. Region 9 Superfund Program, San Francisco, 2006, Health and environmental impacts of uranium contamination, 5-year plan. Region 9 Superfund Program, San Franciso, 2008) and the dose assessment for the population due to ingestion of water containing (238)U and (234)U. The water quality data were taken from Sect. "Data analysis" of the published report, titled Abandoned Uranium Mines Project Arizona, New Mexico, Utah-Navajo Lands 1994-2000, Project Atlas. Total uranium concentration was above the maximum concentration level for drinking water (7.410-1 Bq/L) in 19 % of the water samples, while (238)U and (234)U concentrations were above in 14 and 17 % of the water samples, respectively. (226)Ra and (210)Pb concentrations in water samples were in the range of 3.7 × 10(-1) to 5.55 × 102 Bq/L and 1.11 to 4.33 × 102 Bq/L, respectively. For only two samples, the (226)Ra concentrations exceeded the MCL for total Ra for drinking water (0.185 Bq/L). However, the (210)Pb/(226)Ra ratios varied from 0.11 to 47.00, and ratios above 1.00 were observed in 71 % of the samples. Secular equilibrium of the natural uranium series was not observed in the data record for most of the water samples. Moreover, the (235)U/(total)U mass ratios ranged from 0.06 to 5.9 %, and the natural mass ratio of (235)U to (total)U (0.72 %) was observed in only 16 % of the water samples, ratios above or below the natural ratio could not be explained based on data reported by U.S. EPA. In addition, statistical evaluations showed no correlations among the distribution of the radionuclide concentrations in the majority of the water samples, indicating more than one source of contamination could contribute to the sampled sources. The effective doses due to ingestion of the minimum uranium concentrations in water samples exceed the average dose considering inhalation and ingestion of regular diet for other populations around the world (1 µSv/year). The maximum doses due to ingestion of (238)U or (234)U were above the international limit for effective dose for members of the public (1 mSv/year), except for inhabitants of two chapters. The highest effective dose was estimated for inhabitants of Cove, and it was almost 20 times the international limit for members of the public. These results indicate that ingestion of water from some of the sampled sources poses health risks.

Mycobacterium avium subspecies paratuberculosis is widely distributed in British soils and waters: implications for animal and human health.

In the first comprehensive geographical survey of distribution in Great Britain, Mycobacterium avium ssp. paratuberculosis (MAP) was detected in 115 of 1092 (10.5%) soil cores, in the range of 5 × 10(2) to 3 × 10(6) MAP cell equivalents (CE) g(-1) wet weight soil with the majority of the positive PCR reactions (n = 75; 65%) occurring around the limit of detection (500-5000 CE g(-1) wet weight soil). The distribution of MAP significantly increased from North to South and was significantly correlated with increasing cattle numbers over the same longitudinal axis. Similarly MAP occurrence significantly increased towards easterly latitudes although none of the parameters measured were associated. Comparisons of land use indicated that MAP was widely distributed in both farming and non-farming areas. Soil core samples taken from the rivers Wyre and Douglas catchments (Lancashire, UK) and river Tywi (South Wales) were negative for MAP. However, river monitoring showed a consistent presence of MAPs throughout those catchments over a 6-month period. We concluded that MAP is widely distributed within and outside the confines of the farming environment; its geographical distribution is wider than originally anticipated and; monitoring rivers describes the MAP status of catchment better than individual soil samples.

Cardiac Autotransplantation and Commando Operation for Complex Multivalvular Infective Endocarditis.

This report describes a patient with destructive multivalvular endocarditis with multiorgan dysfunction. Intraoperatively, severe unexpected adhesions due to pancarditis precluded the standard Commando operation. The approach of combining autotransplantation with a Commando operation was used to facilitate adequate débridement of infected tissues and reconstruction in a reasonable time and with satisfactory prosthetic valvular function. This approach may be considered in other cases of challenging destructive endocarditis with severe adhesions. We speculate that this approach may also be useful in redo surgeries.

The bacterial biogeography of British soils.

Despite recognition of the importance of soil bacteria to terrestrial ecosystem functioning there is little consensus on the factors regulating belowground biodiversity. Here we present a multi-scale spatial assessment of soil bacterial community profiles across Great Britain (> 1000 soil cores), and show the first landscape scale map of bacterial distributions across a nation. Bacterial diversity and community dissimilarities, assessed using terminal restriction fragment length polymorphism, were most strongly related to soil pH providing a large-scale confirmation of the role of pH in structuring bacterial taxa. However, while α diversity was positively related to pH, the converse was true for ß diversity (between sample variance in α diversity). ß diversity was found to be greatest in acidic soils, corresponding with greater environmental heterogeneity. Analyses of clone libraries revealed the pH effects were predominantly manifest at the level of broad bacterial taxonomic groups, with acidic soils being dominated by few taxa (notably the group 1 Acidobacteria and Alphaproteobacteria). We also noted significant correlations between bacterial communities and most other measured environmental variables (soil chemistry, aboveground features and climatic variables), together with significant spatial correlations at close distances. In particular, bacterial and plant communities were closely related signifying no strong evidence that soil bacteria are driven by different ecological processes to those governing higher organisms. We conclude that broad scale surveys are useful in identifying distinct soil biomes comprising reproducible communities of dominant taxa. Together these results provide a baseline ecological framework with which to pursue future research on both soil microbial function, and more explicit biome based assessments of the local ecological drivers of bacterial biodiversity.

Presentation with pulsatile xiphisternal bruise-Survival with a chronic ventricular rupture.

Ventricular free wall rupture is an acute, severe complication of myocardial infarction (MI). Accounting for 20-30% of MI mortality, ventricular rupture is fatal if not detected early and repaired surgically. The unique case of a delayed, chronic rupture is reported in a 64 year-old male who presented with a painless, pulsatile, sub-xiphisternal bruise, five years post MI. Trans-thoracic echocardiography (TTE) revealed haematoma extending posteriorly with only contrast echocardiography revealing an active communication between the sub-dermal area and the heart. Urgent surgery and a prolonged period in ICU enabled sufficient enough recovery for discharge.

Unexpected giant cell aortitis in a young patient.

INTRODUCTION AND IMPORTANCE: Giant cell aortitis is a rare cause of ascending aortic aneurysm disease. Patients presenting with aneurysms caused by giant cell aortitis are at high risk of devastating complications. CASE PRESENTATION: A 35-year-old female with an ascending aortic aneurysm, underwent an aortic root and ascending aorta replacement and subsequently was found to have giant cell aortitis on histopathology. DISCUSSION AND CONCLUSION: This case illustrates a very rare cause for aortopathy in a young healthy patient, who may have ruptured or dissected, if not for timely operative intervention.

Infrared irradiation in the collision cell of a hybrid tandem quadrupole/time-of-flight mass spectrometer for declustering and cleaning of nanoelectrosprayed protein complex ions.

Herein we report the performance of a hybrid quadrupole time-of-flight tandem mass spectrometer with an improved designed for coaxial infrared laser introduction for the characterization and dissociation of large protein complex ions and their aggregates formed under nanoelectrospray ionization. The major improvement from the original design (Raspopov, S. A.; El-Faramawy, A.; Thomson, B. A.; Siu, K. W. M. Anal. Chem. 2006, 78, 4572-4577) involves the use of a hollow silica waveguide and physical isolation of the infrared laser. Large model protein complex ions and their aggregates examined include alcohol dehydrogenase, avidin, GroEL, and others. Gentle heating of these complexes with the infrared laser facilitated declustering and resulted in better resolved mass spectral peaks and more accurate molecular-weight measurements.