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.

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.

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.

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.

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.

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.

A Rare Case of Severe Nontropical Isolated Right Ventricular Endomyocardial Fibrosis.

We present a case of late presentation nontropical endomyocardial fibrosis isolated to the right ventricle and tricuspid valve (TV). In response to deteriorating hemodynamics, surgical debulking and TV removal were performed before initiation of centralized venoarterial extracorporeal membrane oxygenation support. Definitive endomyocardial resection with a TV prosthesis was then successfully completed. (Level of Difficulty: Advanced.).

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.

Soil bacterial networks are less stable under drought than fungal networks.

Soil microbial communities play a crucial role in ecosystem functioning, but it is unknown how co-occurrence networks within these communities respond to disturbances such as climate extremes. This represents an important knowledge gap because changes in microbial networks could have implications for their functioning and vulnerability to future disturbances. Here, we show in grassland mesocosms that drought promotes destabilising properties in soil bacterial, but not fungal, co-occurrence networks, and that changes in bacterial communities link more strongly to soil functioning during recovery than do changes in fungal communities. Moreover, we reveal that drought has a prolonged effect on bacterial communities and their co-occurrence networks via changes in vegetation composition and resultant reductions in soil moisture. Our results provide new insight in the mechanisms through which drought alters soil microbial communities with potential long-term consequences, including future plant community composition and the ability of aboveground and belowground communities to withstand future disturbances.

Bacterial Physiological Adaptations to Contrasting Edaphic Conditions Identified Using Landscape Scale Metagenomics.

Environmental factors relating to soil pH are important regulators of bacterial taxonomic biodiversity, yet it remains unclear if such drivers affect community functional potential. To address this, we applied whole-genome metagenomics to eight geographically distributed soils at opposing ends of a landscape soil pH gradient (where "low-pH" is ~pH 4.3 and "high-pH" is ~pH 8.3) and evaluated functional differences with respect to functionally annotated genes. First, differences in taxonomic and functional diversity between the two pH categories were assessed with respect to alpha diversity (mean sample richness) and gamma diversity (total richness pooled for each pH category). Low-pH soils, also exhibiting higher organic matter and moisture, consistently had lower taxonomic alpha and gamma diversity, but this was not apparent in assessments of functional alpha and gamma diversity. However, coherent changes in the relative abundances of annotated genes between low- and high-pH soils were identified; with strong multivariate clustering of samples according to pH independent of geography. Assessment of indicator genes revealed that the acidic organic-rich soils possessed a greater abundance of cation efflux pumps, C and N direct fixation systems, and fermentation pathways, indicating adaptations to both acidity and anaerobiosis. Conversely, high-pH soils possessed more direct transporter-mediated mechanisms for organic C and N substrate acquisition. These findings highlight the distinctive physiological adaptations required for bacteria to survive in soils of various nutrient availability and edaphic conditions and more generally indicate that bacterial functional versatility with respect to functional gene annotations may not be constrained by taxonomy.IMPORTANCE Over a set of soil samples spanning Britain, the widely reported reductions in bacterial taxonomic richness at low pH were found not to be accompanied by significant reductions in the richness of functional genes. However, consistent changes in the abundance of related functional genes were observed, characteristic of differential ecological and nutrient acquisition strategies between high-pH mineral soils and low-pH organic anaerobic soils. Our assessment at opposing ends of a soil gradient encapsulates the limits of functional diversity in temperate climates and identifies key pathways that may serve as indicators for soil element cycling and C storage processes in other soil systems. To this end, we make available a data set identifying functional indicators of the different soils; as well as raw sequences, which given the geographic scale of our sampling should be of value in future studies assessing novel genetic diversity of a wide range of soil functional attributes.

Development of a Branched Radio-Frequency Ion Trap for Electron Based Dissociation and Related Applications.

Collision-induced dissociation (CID) is the most common tool for molecular analysis in mass spectrometry to date. However, there are difficulties associated with many applications because CID does not provide sufficient information to permit details of the molecular structures to be elucidated, including post-translational-modifications in proteomics, as well as isomer differentiation in metabolomics and lipidomics. To face these challenges, we are developing fast electron-based dissociation devices using a novel radio-frequency ion trap (i.e., a branched ion trap). These devices have the ability to perform electron capture dissociation (ECD) on multiply protonated peptide/proteins; in addition, the electron impact excitation of ions from organics (EIEIO) can be also performed on singly charged molecules using such a device. In this article, we review the development of this technology, in particular on how reaction speed for EIEIO analyses on singly charged ions can be improved. We also overview some unique, recently reported applications in both lipidomics and glycoproteomics.

Soil networks become more connected and take up more carbon as nature restoration progresses.

Soil organisms have an important role in aboveground community dynamics and ecosystem functioning in terrestrial ecosystems. However, most studies have considered soil biota as a black box or focussed on specific groups, whereas little is known about entire soil networks. Here we show that during the course of nature restoration on abandoned arable land a compositional shift in soil biota, preceded by tightening of the belowground networks, corresponds with enhanced efficiency of carbon uptake. In mid- and long-term abandoned field soil, carbon uptake by fungi increases without an increase in fungal biomass or shift in bacterial-to-fungal ratio. The implication of our findings is that during nature restoration the efficiency of nutrient cycling and carbon uptake can increase by a shift in fungal composition and/or fungal activity. Therefore, we propose that relationships between soil food web structure and carbon cycling in soils need to be reconsidered.

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.

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).

Rhizosphere bacterial carbon turnover is higher in nucleic acids than membrane lipids: implications for understanding soil carbon cycling.

Using a pulse chase (13)CO2 plant labeling experiment we compared the flow of plant carbon into macromolecular fractions of rhizosphere soil microorganisms. Time dependent (13)C dilution patterns in microbial cellular fractions were used to calculate their turnover time. The turnover times of microbial biomolecules were found to vary: microbial RNA (19 h) and DNA (30 h) turned over fastest followed by chloroform fumigation extraction-derived soluble cell lysis products (14 days), while phospholipid fatty acids (PLFAs) had the slowest turnover (42 days). PLFA/NLFA (13)C analyses suggest that both mutualistic arbuscular mycorrhizal and saprophytic fungi are dominant in initial plant carbon uptake. In contrast, high initial (13)C enrichment in RNA hints at bacterial importance in initial C uptake due to the dominance of bacterial derived RNA in total extracts of soil RNA. To explain this discrepancy, we observed low renewal rate of bacterial lipids, which may therefore bias lipid fatty acid based interpretations of the role of bacteria in soil microbial food webs. Based on our findings, we question current assumptions regarding plant-microbe carbon flux and suggest that the rhizosphere bacterial contribution to plant assimilate uptake could be higher. This highlights the need for more detailed quantitative investigations with nucleic acid biomarkers to further validate these findings.

Plant diversity increases soil microbial activity and soil carbon storage.

Plant diversity strongly influences ecosystem functions and services, such as soil carbon storage. However, the mechanisms underlying the positive plant diversity effects on soil carbon storage are poorly understood. We explored this relationship using long-term data from a grassland biodiversity experiment (The Jena Experiment) and radiocarbon ((14)C) modelling. Here we show that higher plant diversity increases rhizosphere carbon inputs into the microbial community resulting in both increased microbial activity and carbon storage. Increases in soil carbon were related to the enhanced accumulation of recently fixed carbon in high-diversity plots, while plant diversity had less pronounced effects on the decomposition rate of existing carbon. The present study shows that elevated carbon storage at high plant diversity is a direct function of the soil microbial community, indicating that the increase in carbon storage is mainly limited by the integration of new carbon into soil and less by the decomposition of existing soil carbon.

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.

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.