Transposable elements contribute to the establishment of the glycine shuttle in Brassicaceae species.

C3 -C4 intermediate photosynthesis has evolved at least five times convergently in the Brassicaceae, despite this family lacking bona fide C4 species. The establishment of this carbon concentrating mechanism is known to require a complex suite of ultrastructural modifications, as well as changes in spatial expression patterns, which are both thought to be underpinned by a reconfiguration of existing gene-regulatory networks. However, to date, the mechanisms which underpin the reconfiguration of these gene networks are largely unknown. In this study, we used a pan-genomic association approach to identify genomic features that could confer differential gene expression towards the C3 -C4 intermediate state by analysing eight C3 species and seven C3 -C4 species from five independent origins in the Brassicaceae. We found a strong correlation between transposable element (TE) insertions in cis-regulatory regions and C3 -C4 intermediacy. Specifically, our study revealed 113 gene models in which the presence of a TE within a gene correlates with C3 -C4 intermediate photosynthesis. In this set, genes involved in the photorespiratory glycine shuttle are enriched, including the glycine decarboxylase P-protein whose expression domain undergoes a spatial shift during the transition to C3 -C4 photosynthesis. When further interrogating this gene, we discovered independent TE insertions in its upstream region which we conclude to be responsible for causing the spatial shift in GLDP1 gene expression. Our findings hint at a pivotal role of TEs in the evolution of C3 -C4 intermediacy, especially in mediating differential spatial gene expression.

Implantation of the heartmate II in a patient of 34 years after a Mustard procedure.

A growing number of patients have undergone the Mustard procedure for transposition of the great arteries, after which the morphologic right ventricle serves as the systemic ventricle. If this ventricle fails, ventricular assist device support may be necessary, but implanting the inflow cannula can be challenging in these patients because of the moderator band and trabeculation of the morphologic right ventricle. We describe successful assist device implantation in a 34-year-old patient who had undergone the Mustard procedure in infancy.

Effects of dietary carnitine supplementation on semen output and quality of boars.

Carnitine is an amino acid derivative that performs the functions of increasing energy production as well as acting as an antioxidant for sperm cells. This study was conducted to investigate the effects of the inclusion of carnitine in boar diets on semen output and quality. Sixty-four purebred and hybrid boars at a commercial boar stud were blocked by age and semen quality and randomly allotted to receive a daily 30 g top-dress of either soybean meal (CON) or soybean meal and 625 mg of L-Carnitine (CARN). Supplementation lasted for 12 weeks from May to July 2021 during which weekly semen collection was performed. Semen was evaluated in the stud for concentration and motility parameters using computer-assisted semen analysis (CASA). Samples were shipped to Purdue University for detailed morphology, viability, and CASA analysis performed in samples stored at 17 °C for 5 days. PROC Mixed (SAS v 9.4) was used to analyze data, with boar nested within treatment used in repeated measures analysis. Semen quality estimates from the week before supplementation were used as covariates in the statistical model. Tukey-Kramer adjustment was used for means separation. Carnitine supplementation had no effects on total sperm produced (P = 0.35). Percentage of motile sperm cells (P = 0.63), morphologically normal sperm (P = 0.42), viable sperm (P = 0.43), or sperm with normal acrosomes (P = 0.61) in the ejaculates were not different among treatments. Sperm kinematics in CARN ejaculates tended to have greater straight-line velocity and distance (P = 0.06 and P = 0.07, respectively). There were several interactions of treatment and day of storage for the kinematic parameters. However, these interactions do not show observable trends for CARN to improve or depress sperm function. Overall, the inclusion of 625 mg/d of carnitine in the diet of boars for 12 weeks had no effects on sperm output or quality with minor changes to sperm cell kinematics.

Contemporary relevancy of carotid-subclavian bypass defined by an experience spanning five decades.

BACKGROUND: The contemporary impact of and indications for carotid-subclavian bypass (CSB) are essential considerations in decision making for brachiocephalic reconstruction. METHODS: We analyzed operative outcomes, long-term graft patency, and the extended epidemiological impact of the primary disease process in 287 consecutive patients (mean age, 60.6 years; 43.2% male) who received CSB for symptomatic brachiocephalic disease. RESULTS: Technical success was achieved in each patient. Operative mortality was 1.0% (3/287) and total (ipsilateral [1.4%, 4/287] plus contralateral [0.7%, 2/287]) stroke rate was 2.1% (6/287). Primary patency rates at 5, 10, and 15 years were 94.2 ± 1.9%, 88.6 ± 3.2%, and 86.5 ± 3.8%, respectively. Kaplan-Meier freedom from specific events at 15 years was as follows: restenosis, 86.5 ± 3.8%; death, 67.5 ± 5.2%; coronary revascularization, 59.6 ± 6.3%; myocardial infarction, 82.8 ± 3.9%; stroke, 85.6 ± 4.9%; other vascular procedure, 60.0 ± 5.5%; adverse cardiac outcome (death, myocardial infarction, or coronary revascularization), 44.5 ± 5.5%; and adverse vascular outcome (restenosis, stroke, or other vascular procedure), 48.7 ± 5.3%. CONCLUSIONS: CSB produces excellent long-term patency and extended symptom relief, with acceptably low operative morbidity and mortality. Despite the durability and success of CSB, the primary disease process has an adverse impact on long-term prognosis and significantly influences decision making with regard to management. The proven durability may offer extended symptom relief to the relatively younger patient, a survival advantage associated with preservation of internal mammary artery perfusion in patients at risk for myocardial revascularization, optimal durability in patients requiring a concomitant open procedure, and preservation of limb function in patients who require aortic endovascular graft placement.

Why choose cardiothoracic surgery as a career?

The future of cardiothoracic surgery faces a lofty challenge with the advancement of percutaneous technology and minimally invasive approaches. Coronary artery bypass grafting (CABG) surgery, once a lucrative operation and the driving force of our specialty, faces challenges with competitive stenting and poor reimbursements, contributing to a drop in applicants to our specialty that is further fueled by the negative information that members of other specialties impart to trainees. In the current era of explosive technological progress, the great diversity of our field should be viewed as a source of excitement, rather than confusion, for the upcoming generation. The ideal future cardiac surgeon must be a "surgeon-innovator," a reincarnation of the pioneering cardiac surgeons of the "golden age" of medicine. Equipped with the right skills, new graduates will land high-quality jobs that will help them to mature and excel. Mentorship is a key component at all stages of cardiothoracic training and career development. We review the main challenges facing our specialty--length of training, long hours, financial hardship, and uncertainty about the future, mentorship, and jobs--and we present individual perspectives from both residents and faculty members.

Absence of crystals in the phase behavior of hollow microgels.

Solutions of microgels have been widely used as model systems to gain insight into atomic condensed matter and complex fluids. We explore the thermodynamic phase behavior of hollow microgels, which are distinguished from conventional colloids by a central cavity. Small-angle neutron and x-ray scattering are used to probe hollow microgels in crowded environments. These measurements reveal an interplay among deswelling, interpenetration, and faceting and an unusual absence of crystals. Monte Carlo simulations of model systems confirm that, due to the cavity, solutions of hollow microgels more readily form a supercooled liquid than for microgels with a cross-linked core.

Revascularization treatment recommendations based on atherosclerotic disease distribution: coronary artery bypass grafting versus stenting.

In patients with coronary artery disease, the need for more accurately defined treatment recommendations based on the distribution of atherosclerotic disease has given rise to multiple trials designed to evaluate the efficacy of medical therapy versus percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). To clarify these treatment recommendations, we reviewed relevant trials. Patients with chronic stable angina who have one-vessel or two-vessel coronary artery disease without involvement of the left main or left anterior descending coronary arteries fare similarly regardless of treatment modality. In contrast, patients with multivessel disease and inducible ischemia are better served by revascularization by either CABG or PCI. In patients who have left main involvement, diffuse disease with severe atherosclerosis, diabetes mellitus, advanced age, or left ventricular dysfunction, the outcome with regard to survival, anginal relief, and freedom from additional intervention is better with CABG than with PCI.

Survivorship, late effects and cancer of the cervix.

As the prevention and treatment of cervical cancer improves, there is increasing focus on the months and years after cancer treatment. Of those women living after a diagnosis of cancer, 10% will have a gynaecological malignancy and although the incidence of cervix cancer has dropped over the last 20 years, so has the age at diagnosis, with more than 60% surviving at least 5 years. In a recent report, 63% of 231 064 US survivors of cervix cancer were more than 10 years from diagnosis. More survivors are living long enough to develop chronic treatment-related conditions. The 2007 English Cancer Reform Strategy highlighted the importance of cancer survivorship and uses the US National Coalition for Cancer Survivorship definition-'living through and beyond cancer'. The emerging picture is of populations living after a diagnosis of cancer without active disease, still having similar health and disability profiles to populations with a diagnosis of a chronic illness. This offers new challenges in identifying and meeting their needs.

Placement of a continuous-flow ventricular assist device in the failing ventricle of an adult patient with complex cyanotic congenital heart disease.

For patients with end-stage heart failure and contraindications to transplantation, insertion of a continuous-flow left ventricular assist device (LVAD) is an effective treatment strategy. We present a case of LVAD insertion in a 46-year-old man with cyanotic complex congenital heart disease and an extensive surgical history who presented with failure of his systemic ventricle. The insertion of an LVAD in our patient restored cardiac output and improved cyanosis and native ventricular function. As the number of patients with congenital heart defects surviving to adulthood increases, destination LVAD therapy may be increasingly considered as an alternative.

Electroneutrality and phase behavior of colloidal suspensions.

Several statistical mechanical theories predict that colloidal suspensions of highly charged macroions and monovalent microions can exhibit unusual thermodynamic phase behavior when strongly deionized. Density-functional, extended Debye-Hückel, and response theories, within mean-field and linearization approximations, predict a spinodal phase instability of charged colloids below a critical salt concentration. Poisson-Boltzmann cell model studies of suspensions in Donnan equilibrium with a salt reservoir demonstrate that effective interactions and osmotic pressures predicted by such theories can be sensitive to the choice of reference system, e.g., whether the microion density profiles are expanded about the average potential of the suspension or about the reservoir potential. By unifying Poisson-Boltzmann and response theories within a common perturbative framework, it is shown here that the choice of reference system is dictated by the constraint of global electroneutrality. On this basis, bulk suspensions are best modeled by density-dependent effective interactions derived from a closed reference system in which the counterions are confined to the same volume as the macroions. Lower-dimensional systems (e.g., monolayers, clusters), depending on the strength of macroion-counterion correlations, may be governed instead by density-independent effective interactions tied to an open reference system with counterions dispersed throughout the reservoir, possibly explaining the observed structural crossover in colloidal monolayers and anomalous metastability of colloidal crystallites.

C-ring mitral annuloplasty: 27-year follow-up.

We report the long-term follow-up of a patient with rheumatic mitral valve disease who underwent annuloplasty with a specially developed C-ring (the Cooley C-ring) for mitral valve repair in 1977. The repaired valve remained competent and unobstructed for 27 years before requiring replacement.

Aortic root surgery with circulatory arrest: Predictors of prolonged postoperative hospital stay.

OBJECTIVE: Little is known about the outcomes of aortic root operations that involve inducing hypothermic circulatory arrest for relatively extensive proximal aortic surgery. We attempted to identify predictors of postoperative hospital length of stay (LOS) and factors that affect postoperative recovery. METHODS: During 2006-2014, 247 of 265 patients (93.2%) with disease extending into the aortic arch survived aortic root operations (206 elective, 41 urgent/emergent) in which hypothermic circulatory arrest with moderate hypothermia was used. Stepwise multivariate regression analysis was performed to identify predictors of LOS (as a continuous variable) and prolonged LOS (defined as LOS >9 days, the median for the cohort). By this definition, 111 patients (45%) had prolonged LOS and 136 (55%) did not. RESULTS: Preoperative factors that independently predicted longer LOS in the entire cohort included age (P = .0014), redo sternotomy (P = .0047), and intraoperative packed red blood cell (PRBC) transfusion (P = .0007). Redo sternotomy and intraoperative PRBC transfusion also predicted longer LOS in 3 subgroup analyses: one of elective cases, one from which total arch replacement procedures were excluded, and one limited to patients who were discharged home. Age predicted longer LOS in the non-total arch (hemiarch) replacement patients. Ventilator support >48 hours (P < .0001) was associated with longer LOS. Elective aortic valve-sparing root replacement predicted a shorter LOS than valve replacement in multivariate regression analysis (P = .028). CONCLUSIONS: In patients undergoing aortic root surgery with hypothermic circulatory arrest for disease extending into the aortic arch, reducing intraoperative PRBC transfusion except when absolutely necessary may reduce postoperative LOS and expedite recovery. Performing aortic valve-sparing root replacement, when feasible, may also reduce LOS.

Moderate hypothermia at warmer temperatures is safe in elective proximal and total arch surgery: Results in 665 patients.

OBJECTIVE: To evaluate adverse outcomes after elective aortic arch surgery performed at higher or lower temperatures (24.0°C-28.0°C vs 20.1°C-23.9°C) within the wide range of moderate hypothermia. METHODS: Over a 9-year period, a total of 665 patients underwent elective proximal (n = 479) or total (n = 186) arch replacement with moderate hypothermia and antegrade cerebral perfusion. Circulatory arrest was initiated at an actual temperature of 20.1°C to 23.9°C in the lower-temperature group (n = 334; 223 proximal, 111 total) and at 24.0°C to 28.0°C in the higher-temperature group (n = 331; 256 proximal, 75 total). Composite adverse outcome was defined as operative mortality or persistent neurologic event or persistent hemodialysis at discharge. Multivariate logistic regression analysis was used to model adverse outcome. In addition to the actual temperature, a new, balanced variable, "predicted temperature," was analyzed to eliminate surgeon bias. We used this variable in a propensity score-matching analysis to validate the multivariate analysis results. RESULTS: A composite adverse outcome occurred in 7.2% of cases. Operative mortality was 5.1%. The rate of postoperative persistent neurologic deficits was 2.4%. No significant differences were found between the lower- and higher-predicted temperature groups within the moderate hypothermia range in the propensity score-matching analysis. The higher-actual temperature group had a lower rate of ventilator support at >48 hours (P = .036) and less need for tracheostomy (P = .023). Packed red blood cell transfusion and previous coronary artery bypass independently predicted composite adverse outcome (P = .0053 and .0002, respectively), operative mortality (P = .0051 and .0041), and postoperative stroke (P = .045 and .048). Cardiopulmonary bypass time independently predicted composite outcome (P = .0005), operative mortality (P < .0001), ventilatory support for >48 hours (P < .0001), and renal dysfunction (P = .0005). CONCLUSIONS: In elective proximal or total arch surgery, higher temperatures (≥24.0°C-28.0°C) within the wide range of moderate hypothermia (20.1°C-28°C) are safe and, compared with colder temperatures, not associated with significantly different rates of composite and adverse outcomes.

Phase separation in charge-stabilized colloidal suspensions: influence of nonlinear screening.

The phase behavior of charge-stabilized colloidal suspensions is modeled by a combination of response theory for electrostatic interparticle interactions and variational theory for free energies. Integrating out degrees of freedom of the microions (counterions, salt ions), the macroion-microion mixture is mapped onto a one-component system governed by effective macroion interactions. Linear response of microions to the electrostatic potential of the macroions results in a screened-Coulomb (Yukawa) effective pair potential and a one-body volume energy, while nonlinear response modifies the effective interactions [A. R. Denton, Phys. Rev. E 70, 031404 (2004)]. The volume energy and effective pair potential are taken as input to a variational free energy, based on thermodynamic perturbation theory. For both linear and first-order nonlinear effective interactions, a coexistence analysis applied to aqueous suspensions of highly charged macroions and monovalent microions yields bulk separation of macroion-rich and macroion-poor phases below a critical salt concentration, in qualitative agreement with predictions of related linearized theories [R. van Roij, M. Dijkstra, and J.-P. Hansen, Phys. Rev. E 59, 2010 (1999); P. B. Warren, J. Chem. Phys. 112, 4683 (2000)]. It is concluded that nonlinear screening can modify phase behavior but does not necessarily suppress bulk phase separation of de-ionized suspensions.

Evolution of an audit and monitoring tool into an infection prevention and control process.

BACKGROUND: In 2010, an infection prevention and control team in an acute hospital trust integrated an audit and monitoring tool (AMT) into the management regime for patients with Clostridium difficile infection (CDI). AIM: To examine the mechanisms through which the implementation of an AMT influenced the care and management of patients with CDI. METHODS: A constructivist grounded theory approach was used, employing semi-structured interviews with ward staff (N=8), infection prevention and control practitioners (IPCPs) (N=7) and matrons (N=8), and subsequently a theoretical sample of senior managers (N=4). All interviews were transcribed verbatim and analysed using a constant comparison approach until explanatory categories emerged. FINDINGS: The AMT evolved into a daily review process (DRP) that became an essential aspect of the management of all patients with CDI. Participants recognized that the DRP had positively influenced the care received by patients with CDI. Two main explanatory themes emerged to offer a framework for understanding the influence of the DRP on care management: education and learning, and the development and maintenance of relationships. CONCLUSION: The use of auditing and monitoring tools as part of a daily review process may enable ward staff, matrons, and IPCPs to improve patient outcomes and achieve the required levels of environmental hygiene if they act as a focal point for interaction, education, and collaboration. The findings offer insights into the behavioural changes and improved patient outcomes that ensue from the implementation of a DRP.

Superficial warming and cooling of the leg affects walking speed and neuromuscular impairments in people with spastic paraparesis.

BACKGROUND: People with hereditary and spontaneous spastic paraparesis (HSSP) report that their legs are stiffer and walking is slower when their legs are cold. OBJECTIVES: This study explored the effects of prolonged superficial cooling and warming of the lower leg on walking speed and local measures of neuromuscular impairments. METHODS: This was a randomised pre- and post-intervention study of 22 HSSP participants and 19 matched healthy controls. On 2 separate occasions, one lower leg was cooled or warmed. Measurements included walking speed and measures of lower limb impairment: ankle movement, passive muscle stiffness, spasticity (stretch reflex size), amplitude and rate of force generation in dorsi- and plantarflexors and central and peripheral nerve conduction time/velocity. RESULTS: For both participants and controls, cooling decreased walking speed, especially for HSSP participants. For both groups, cooling decreased the dorsiflexor rate and amplitude of force generation and peripheral nerve conduction velocity and increased spasticity. Warming increased dorsiflexor rate of force generation and nerve conduction velocity and decreased spasticity. CONCLUSIONS: Superficial cooling significantly reduced walking speed for people with HSSP. Temperature changes were associated with changes in neuromuscular impairments for both people with spastic paraparesis and controls. This study does not support the use of localised cooling in rehabilitation for people with spastic paraparesis as reported in other neurological conditions. Rehabilitation interventions that help prevent heat loss (insulation) or improve limb temperature via passive or active means, particularly when the legs and/or environment are cool, may benefit people with spastic paraparesis.

Outcomes of 3309 thoracoabdominal aortic aneurysm repairs.

OBJECTIVE: Since the pioneering era of E. Stanley Crawford, our multimodal strategy for thoracoabdominal aortic aneurysm repair has evolved. We describe our approximately 3-decade single-practice experience regarding 3309 thoracoabdominal aortic aneurysm repairs and identify predictors of early death and other adverse postoperative outcomes. METHODS: We analyzed retrospective (1986-2006) and prospective data (2006-2014) obtained from patients (2043 male; median age, 67 [59-73] years) who underwent 914 Crawford extent I, 1066 extent II, 660 extent III, and 669 extent IV thoracoabdominal aortic aneurysm repairs, of which 723 (21.8%) were urgent or emergency. Repairs were performed to treat degenerative aneurysm (64.2%) or aortic dissection (35.8%). The outcomes examined included operative death (ie, 30-day or in-hospital death) and permanent stroke, paraplegia, paraparesis, and renal failure necessitating dialysis, as well as adverse event, a composite of these outcomes. RESULTS: There were 249 operative deaths (7.5%). Permanent paraplegia and paraparesis occurred after 97 (2.9%) and 81 (2.4%) repairs, respectively. Of 189 patients (5.7%) with permanent renal failure, 107 died in the hospital. Permanent stroke was relatively uncommon (n = 74; 2.2%). The rate of the composite adverse event (n = 478; 14.4%) was highest after extent II repair (n = 203; 19.0%) and lowest after extent IV repair (n = 67; 10.2%; P < .0001). Estimated postoperative survival was 83.5% ± 0.7% at 1 year, 63.6% ± 0.9% at 5 years, 36.8% ± 1.0% at 10 years, and 18.3% ± 0.9% at 15 years. CONCLUSIONS: Repairing thoracoabdominal aortic aneurysms poses substantial risks, particularly when the entire thoracoabdominal aorta (extent II) is replaced. Nonetheless, our data suggest that thoracoabdominal aortic aneurysm repair, when performed at an experienced center, can produce respectable outcomes.

Moderate hypothermia ≥24 and ≤28°C with hypothermic circulatory arrest for proximal aortic operations in patients with previous cardiac surgery.

OBJECTIVES: To determine whether, in patients with previous cardiac operations, moderate hypothermia (between 24 and 28°C) for hypothermic circulatory arrest (HCA) during antegrade cerebral perfusion (ACP) is safe for use during surgery on the proximal aorta and transverse aortic arch. METHODS: Over a 7-year period, 118 patients underwent ascending aortic and hemiarch repair (n = 70; 59.3%), total arch replacement (n = 47; 39.8%) or ascending aortic replacement to treat porcelain aorta (n = 1; 0.9%). Simultaneous procedures included aortic root repair or replacement (n = 33; 28.0%) and coronary artery bypass grafting (n = 21; 17.8%). All patients had previously undergone cardiac operations via a median sternotomy. Eighteen patients (15.3%) had more than 1 previous sternotomy, and 24 patients (20.3%) required emergent/urgent operation. Median cardiopulmonary bypass, cardiac ischaemic, circulatory arrest and ACP times (min) were 136.0 [118-180 interquartile range (IQR)], 91.0 (68-119 IQR), 34.0 (21-59 IQR) and 33.5 (20-59 IQR), respectively. The median temperature when HCA was initiated was 24.2°C (24.1-24.8°C IQR). RESULTS: The operative mortality rate was 10.2% (n = 12). Six patients (5.1%) had a permanent stroke, and 16 patients (13.6%) had a composite adverse outcome (operative mortality and/or a permanent neurological event and/or permanent haemodialysis at discharge). Preoperative renal disease was significantly more prevalent (P= 0.020) and the median circulatory arrest time significantly longer (48.5 vs 33 min; P= 0.058) in patients with composite adverse outcomes. Multivariable analysis of the redo patients showed that age (P =0.025), preoperative renal disease (P =0.024) and ACP time (P =0.012) were independent risk factors for a new postoperative renal injury. CONCLUSIONS: Moderate hypothermia for HCA during ACP is being used with increasing frequency, but has not been thoroughly evaluated in patients undergoing cardiovascular reoperations. Our experience suggests that in patients with previous cardiac surgery who are undergoing hemiarch and total aortic arch operations, moderate hypothermia is safe and produces respectable results.