Grassland intensification effects cascade to alter multifunctionality of wetlands within metaecosystems.

Sustainable agricultural intensification could improve ecosystem service multifunctionality, yet empirical evidence remains tenuous, especially regarding consequences for spatially coupled ecosystems connected by flows across ecosystem boundaries (i.e., metaecosystems). Here we aim to understand the effects of land-use intensification on multiple ecosystem services of spatially connected grasslands and wetlands, where management practices were applied to grasslands but not directly imposed to wetlands. We synthesize long-term datasets encompassing 53 physical, chemical, and biological indicators, comprising >11,000 field measurements. Our results reveal that intensification promotes high-quality forage and livestock production in both grasslands and wetlands, but at the expense of water quality regulation, methane mitigation, non-native species invasion resistance, and biodiversity. Land-use intensification weakens relationships among ecosystem services. The effects on grasslands cascade to alter multifunctionality of embedded natural wetlands within the metaecosystems to a similar extent. These results highlight the importance of considering spatial flows of resources and organisms when studying land-use intensification effects on metaecosystems as well as when designing grassland and wetland management practices to improve landscape multifunctionality.

Climate vs Energy Security: Quantifying the Trade-offs of BECCS Deployment and Overcoming Opportunity Costs on Set-Aside Land.

Bioenergy with carbon capture and storage (BECCS) sits at the nexus of the climate and energy security. We evaluated trade-offs between scenarios that support climate stabilization (negative emissions and net climate benefit) or energy security (ethanol production). Our spatially explicit model indicates that the foregone climate benefit from abandoned cropland (opportunity cost) increased carbon emissions per unit of energy produced by 14-36%, making geologic carbon capture and storage necessary to achieve negative emissions from any given energy crop. The toll of opportunity costs on the climate benefit of BECCS from set-aside land was offset through the spatial allocation of crops based on their individual biophysical constraints. Dedicated energy crops consistently outperformed mixed grasslands. We estimate that BECCS allocation to land enrolled in the Conservation Reserve Program (CRP) could capture up to 9 Tg C year-1 from the atmosphere, deliver up to 16 Tg CE year-1 in emissions savings, and meet up to 10% of the US energy statutory targets, but contributions varied substantially as the priority shifted from climate stabilization to energy provision. Our results indicate a significant potential to integrate energy security targets into sustainable pathways to climate stabilization but underpin the trade-offs of divergent policy-driven agendas.

Advances in field-based high-throughput photosynthetic phenotyping.

Gas exchange techniques revolutionized plant research and advanced understanding, including associated fluxes and efficiencies, of photosynthesis, photorespiration, and respiration of plants from cellular to ecosystem scales. These techniques remain the gold standard for inferring photosynthetic rates and underlying physiology/biochemistry, although their utility for high-throughput phenotyping (HTP) of photosynthesis is limited both by the number of gas exchange systems available and the number of personnel available to operate the equipment. Remote sensing techniques have long been used to assess ecosystem productivity at coarse spatial and temporal resolutions, and advances in sensor technology coupled with advanced statistical techniques are expanding remote sensing tools to finer spatial scales and increasing the number and complexity of phenotypes that can be extracted. In this review, we outline the photosynthetic phenotypes of interest to the plant science community and describe the advances in high-throughput techniques to characterize photosynthesis at spatial scales useful to infer treatment or genotypic variation in field-based experiments or breeding trials. We will accomplish this objective by presenting six lessons learned thus far through the development and application of proximal/remote sensing-based measurements and the accompanying statistical analyses. We will conclude by outlining what we perceive as the current limitations, bottlenecks, and opportunities facing HTP of photosynthesis.

A review of transformative strategies for climate mitigation by grasslands.

Grasslands can significantly contribute to climate mitigation. However, recent trends indicate that human activities have switched their net cooling effect to a warming effect due to management intensification and land conversion. This indicates an urgent need for strategies directed to mitigate climate warming while enhancing productivity and efficiency in the use of land and natural (nutrients, water) resources. Here, we examine the potential of four innovative strategies to slow climate change including: 1) Adaptive multi-paddock grazing that consists of mimicking how ancestral herds roamed the Earth; 2) Agrivoltaics that consists of simultaneously producing food and energy from solar panels on the same land area; 3) Agroforestry with a reverse phenology tree species, Faidherbia (Acacia) albida, that has the unique trait of being photosynthetically active when intercropped herbaceous plants are dormant; and, 4) Enhanced Weathering, a negative emission technology that removes atmospheric CO2 from the atmosphere. Further, we speculate about potential unknown consequences of these different management strategies and identify gaps in knowledge. We find that all these strategies could promote at least some of the following benefits of grasslands: CO2 sequestration, non-CO2 GHG mitigation, productivity, resilience to climate change, and an efficient use of natural resources. However, there are obstacles to be overcome. Mechanistic assessment of the ecological, environmental, and socio-economic consequences of adopting these strategies at large scale are urgently needed to fully assess the potential of grasslands to provide food, energy and environmental security.

Emerging approaches to measure photosynthesis from the leaf to the ecosystem.

Measuring photosynthesis is critical for quantifying and modeling leaf to regional scale productivity of managed and natural ecosystems. This review explores existing and novel advances in photosynthesis measurements that are certain to provide innovative directions in plant science research. First, we address gas exchange approaches from leaf to ecosystem scales. Leaf level gas exchange is a mature method but recent improvements to the user interface and environmental controls of commercial systems have resulted in faster and higher quality data collection. Canopy chamber and micrometeorological methods have also become more standardized tools and have an advanced understanding of ecosystem functioning under a changing environment and through long time series data coupled with community data sharing. Second, we review proximal and remote sensing approaches to measure photosynthesis, including hyperspectral reflectance- and fluorescence-based techniques. These techniques have long been used with aircraft and orbiting satellites, but lower-cost sensors and improved statistical analyses are allowing these techniques to become applicable at smaller scales to quantify changes in the underlying biochemistry of photosynthesis. Within the past decade measurements of chlorophyll fluorescence from earth-orbiting satellites have measured Solar Induced Fluorescence (SIF) enabling estimates of global ecosystem productivity. Finally, we highlight that stronger interactions of scientists across disciplines will benefit our capacity to accurately estimate productivity at regional and global scales. Applying the multiple techniques outlined in this review at scales from the leaf to the globe are likely to advance understanding of plant functioning from the organelle to the ecosystem.

Grazing alters net ecosystem C fluxes and the global warming potential of a subtropical pasture.

The impact of grazing on C fluxes from pastures in subtropical and tropical regions and on the environment is uncertain, although these systems account for a substantial portion of global C storage. We investigated how cattle grazing influences net ecosystem CO2 and CH4 exchange in subtropical pastures using the eddy covariance technique. Measurements were made over several wet-dry seasonal cycles in a grazed pasture, and in an adjacent pasture during the first three years of grazer exclusion. Grazing increased soil wetness but did not affect soil temperature. By removing aboveground biomass, grazing decreased ecosystem respiration (Reco ) and gross primary productivity (GPP). As the decrease in Reco was larger than the reduction in GPP, grazing consistently increased the net CO2 sink strength of subtropical pastures (55, 219 and 187 more C/m2 in 2013, 2014, and 2015). Enteric ruminant fermentation and increased soil wetness due to grazers, increased total net ecosystem CH4 emissions in grazed relative to ungrazed pasture (27-80%). Unlike temperate, arid, and semiarid pastures, where differences in CH4 emissions between grazed and ungrazed pastures are mainly driven by enteric ruminant fermentation, our results showed that the effect of grazing on soil CH4 emissions can be greater than CH4 produced by cattle. Thus, our results suggest that the interactions between grazers and soil hydrology affecting soil CH4 emissions play an important role in determining the environmental impacts of this management practice in a subtropical pasture. Although grazing increased total net ecosystem CH4 emissions and removed aboveground biomass, it increased the net storage of C and decreased the global warming potential associated with C fluxes of pasture by increasing its net CO2 sink strength.

The impact of water management practices on subtropical pasture methane emissions and ecosystem service payments.

Pastures are an extensive land cover type; however, patterns in pasture greenhouse gas (GHG) exchange vary widely depending on climate and land management. Understanding this variation is important, as pastures may be a net GHG source or sink depending on these factors. We quantified carbon dioxide (CO2 ) and methane (CH4 ) fluxes from subtropical pastures in south Florida for three wet-dry seasonal cycles using eddy covariance, and estimated two annual budgets of CO2 , CH4 , and GHG equivalent emissions. We also estimated the impact of water retention practices on pasture GHG emissions and assessed the impact of these emissions on stakeholder payments for water retention services in a carbon market framework. The pastures were net CO2 sinks sequestering up to 163 ± 54 g CO2 -C·m-2 ·yr-1 (mean ± 95% CI), but were also strong CH4 sources emitting up to 23.5 ± 2.1 g CH4 -C·m-2 ·yr-1 . Accounting for the increased global warming potential of CH4 , the pastures were strong net GHG sources emitting up to 584 ± 78 g CO2 -C eq.·m-2 ·yr-1 , and all CO2 uptake was offset by wet season CH4 emissions from the flooded landscape. Our analysis suggests that CH4 emissions due to increased flooding from water management practices is a small component of the pasture GHG budget, and water retention likely contributes 2-11% of net pasture GHG emissions. These emissions could reduce water retention payments by up to ~12% if stakeholders were required to pay for current GHG emissions in a carbon market. It would require at least 93.7 kg CH4 -C emissions per acre-foot water storage (1 acre-foot = 1233.48 m3 ) for carbon market costs to exceed water retention payments, and this scenario is highly unlikely as we estimate current practices are responsible for 11.3 ± 7.2 kg CH4 -C emissions per acre-foot of water storage. Our results demonstrate that water retention practices aimed at reducing nutrient loading to the Everglades are likely only responsible for a minor increase in pasture GHG emissions and would have a small economic consequence in a carbon market.

The influence of drought and heat stress on long-term carbon fluxes of bioenergy crops grown in the Midwestern USA.

Perennial grasses are promising feedstocks for bioenergy production in the Midwestern USA. Few experiments have addressed how drought influences their carbon fluxes and storage. This study provides a direct comparison of ecosystem-scale measurements of carbon fluxes associated with miscanthus (Miscanthus × giganteus), switchgrass (Panicum virgatum), restored native prairie and maize (Zea mays)/soybean (Glycine max) ecosystems. The main objective of this study was to assess the influence of a naturally occurring drought during 2012 on key components of the carbon cycle and plant development relative to non-extreme years. The perennials reached full maturity 3-5 years after establishment. Miscanthus had the highest gross primary production (GPP) and lowest net ecosystem exchange (NEE) in 2012 followed by similar values for switchgrass and prairie, and the row crops had the lowest GPP and highest NEE. A post-drought effect was observed for miscanthus. Over the duration of the experiment, perennial ecosystems were carbon sinks, as indicated by negative net ecosystem carbon balance (NECB), while maize/soybean was a net carbon source. Our observations suggest that perennial ecosystems, and in particular miscanthus, can provide a high yield and a large potential for CO2 fixation even during drought, although drought may negatively influence carbon uptake in the following year, questioning the long-term consequence of its maintained productivity.

Nitrogen deposition and greenhouse gas emissions from grasslands: uncertainties and future directions.

Increases in atmospheric nitrogen deposition (Ndep) can strongly affect the greenhouse gas (GHG; CO2, CH4, and N2O) sink capacity of grasslands as well as other terrestrial ecosystems. Robust predictions of the net GHG sink strength of grasslands depend on how experimental N loads compare to projected Ndep rates, and how accurately the relationship between GHG fluxes and Ndep is characterized. A literature review revealed that the vast majority of experimental N loads were higher than levels these ecosystems are predicted to experience in the future. Using a process-based biogeochemical model, we predicted that low levels of Ndep either enhanced or reduced the net GHG sink strength of most grasslands, but as experimental N loads continued to increase, grasslands transitioned to a N saturation-decline stage, where the sensitivity of GHG exchange to further increases in Ndep declined. Most published studies represented treatments well into the N saturation-decline stage. Our model results predict that the responses of GHG fluxes to N are highly nonlinear and that the N saturation thresholds for GHGs varied greatly among grasslands and with fire management. We predict that during the 21st century some grasslands will be in the N limitation stage where others will transition into the N saturation-decline stage. The linear relationship between GHG sink strength and N load assumed by most studies can overestimate or underestimate predictions of the net GHG sink strength of grasslands depending on their N baseline status. The next generation of global change experiments should be designed at multiple N loads consistent with future Ndep rates to improve our empirical understanding and predictive ability.

The theoretical limit to plant productivity.

Human population and economic growth are accelerating the demand for plant biomass to provide food, fuel, and fiber. The annual increment of biomass to meet these needs is quantified as net primary production (NPP). Here we show that an underlying assumption in some current models may lead to underestimates of the potential production from managed landscapes, particularly of bioenergy crops that have low nitrogen requirements. Using a simple light-use efficiency model and the theoretical maximum efficiency with which plant canopies convert solar radiation to biomass, we provide an upper-envelope NPP unconstrained by resource limitations. This theoretical maximum NPP approached 200 tC ha(-1) yr(-1) at point locations, roughly 2 orders of magnitude higher than most current managed or natural ecosystems. Recalculating the upper envelope estimate of NPP limited by available water reduced it by half or more in 91% of the land area globally. While the high conversion efficiencies observed in some extant plants indicate great potential to increase crop yields without changes to the basic mechanism of photosynthesis, particularly for crops with low nitrogen requirements, realizing such high yields will require improvements in water use efficiency.

Gap filling strategies and error in estimating annual soil respiration.

Soil respiration (Rsoil ) is one of the largest CO2 fluxes in the global carbon (C) cycle. Estimation of annual Rsoil requires extrapolation of survey measurements or gap filling of automated records to produce a complete time series. Although many gap filling methodologies have been employed, there is no standardized procedure for producing defensible estimates of annual Rsoil . Here, we test the reliability of nine different gap filling techniques by inserting artificial gaps into 20 automated Rsoil records and comparing gap filling Rsoil estimates of each technique to measured values. We show that although the most commonly used techniques do not, on average, produce large systematic biases, gap filling accuracy may be significantly improved through application of the most reliable methods. All methods performed best at lower gap fractions and had relatively high, systematic errors for simulated survey measurements. Overall, the most accurate technique estimated Rsoil based on the soil temperature dependence of Rsoil by assuming constant temperature sensitivity and linearly interpolating reference respiration (Rsoil at 10 °C) across gaps. The linear interpolation method was the second best-performing method. In contrast, estimating Rsoil based on a single annual Rsoil - Tsoil relationship, which is currently the most commonly used technique, was among the most poorly-performing methods. Thus, our analysis demonstrates that gap filling accuracy may be improved substantially without sacrificing computational simplicity. Improved and standardized techniques for estimation of annual Rsoil will be valuable for understanding the role of Rsoil in the global C cycle.

Plastic and adaptive responses of plant respiration to changes in atmospheric CO(2) concentration.

The concentration of atmospheric CO2 has increased from below 200 microl l(-1) during last glacial maximum in the late Pleistocene to near 280 microl l(-1) at the beginning of the Holocene and has continuously increased since the onset of the industrial revolution. Most responses of plants to increasing atmospheric CO2 levels result in increases in photosynthesis, water use efficiency and biomass. Less known is the role that respiration may play during adaptive responses of plants to changes in atmospheric CO2. Although plant respiration does not increase proportionally with CO2-enhanced photosynthesis or growth rates, a reduction in respiratory costs in plants grown at subambient CO2 can aid in maintaining a positive plant C-balance (i.e. enhancing the photosynthesis-to-respiration ratio). The understanding of plant respiration is further complicated by the presence of the alternative pathway that consumes photosynthate without producing chemical energy [adenosine triphosphate (ATP)] as effectively as respiration through the normal cytochrome pathway. Here, we present the respiratory responses of Arabidopsis thaliana plants selected at Pleistocene (200 microl l(-1)), current Holocene (370 microl l(-1)), and elevated (700 microl l(-1)) concentrations of CO2 and grown at current CO2 levels. We found that respiration rates were lower in Pleistocene-adapted plants when compared with Holocene ones, and that a substantial reduction in respiration was because of reduced activity of the alternative pathway. In a survey of the literature, we found that changes in respiration across plant growth forms and CO2 levels can be explained in part by differences in the respiratory energy demand for maintenance of biomass. This trend was substantiated in the Arabidopsis experiment in which Pleistocene-adapted plants exhibited decreases in respiration without concurrent reductions in tissue N content. Interestingly, N-based respiration rates of plants adapted to elevated CO2 also decreased. As a result, ATP yields per unit of N increased in Pleistocene-adapted plants compared with current CO2 adapted ones. Our results suggest that mitochondrial energy coupling and alternative pathway-mediated responses of respiration to changes in atmospheric CO2 may enhance survival of plants at low CO2 levels to help overcome a low carbon balance. Therefore, increases in the basal activity of the alternative pathway are not necessarily associated to metabolic plant stress in all cases.

Reduction in door-to-needle time to meet clinical guideline recommendations. Outcomes after 1 year.

The aim of this study was to reduce the door-to-needle time in patients with ST-elevation acute myocardial infarction by setting up a chest pain service. We compared the door-to-needle time and outcomes at the end of first year of follow-up in patients who received fibrinolysis in the 2 years before implementation of the service (Group 1) and those who received fibrinolysis in the 2 years after its creation (Group 2). In Group 1, the median door-to-needle time was 40 min (P(25-75), 23-52 min); in Group 2, it was 27 min (P(25-75), 15-43 min; P=.003). In addition, the use of reperfusion therapy increased from 55.2% in Group 1 to 64.7% in Group 2 (P< .01). After a follow-up period of 1 year, there was no difference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality.

Reducción del tiempo puerta-aguja a los objetivos recomendados en las guías clínicas. Pronóstico a 1 año de seguimiento / Reduction in Door-To-Needle Time to Meet Clinical Guideline Recommendations. Outcomes After 1 Year

El objetivo del estudio es disminuir el tiempo puerta-aguja en el infarto con elevación del ST mediante la creación de un box de dolor torácico. Se compara el tiempo puerta-aguja entre los pacientes que recibieron fibrinolisis en los 2 años previos a la creación del box (grupo 1) y los que se sometieron a trombolisis en los 2 años siguientes (grupo 2), y el pronóstico a 1 año de ambos grupos.En el grupo 1, la mediana de tiempo puerta-aguja fuede 40 (P25-75, 23-52) min y en el grupo 2, 27 (15-43) min(p = 0,003). Se incrementó el tratamiento de reperfusióndel 55,2% en el grupo 1 al 64,7% en el grupo 2 (p <0,01). A 1 año de seguimiento, no hubo diferencias en larevascularización, el reingreso, el reinfarto o la muerte de causa cardiovascula

The aim of this study was to reduce the door-to-needletime in patients with ST-elevation acute myocardialinfarction by setting up a chest pain service. Wecompared the door-to-needle time and outcomes at theend of first year of follow-up in patients who receivedfibrinolysis in the 2 years before implementation of theservice (Group 1) and those who received fibrinolysis inthe 2 years after its creation (Group 2). In Group 1, themedian door-to-needle time was 40 min (P25-75, 23-52min); in Group 2, it was 27 min (P25-75, 15-43 min;P=.003). In addition, the use of reperfusion therapyincreased from 55.2% in Group 1 to 64.7% in Group 2(P<.01). After a follow-up period of 1 year, there was nodifference in the rate of revascularization, hospital readmission, reinfarction or cardiovascular mortality (AU)

Changes in respiratory mitochondrial machinery and cytochrome and alternative pathway activities in response to energy demand underlie the acclimation of respiration to elevated CO2 in the invasive Opuntia ficus-indica.

Studies on long-term effects of plants grown at elevated CO(2) are scarce and mechanisms of such responses are largely unknown. To gain mechanistic understanding on respiratory acclimation to elevated CO(2), the Crassulacean acid metabolism Mediterranean invasive Opuntia ficus-indica Miller was grown at various CO(2) concentrations. Respiration rates, maximum activity of cytochrome c oxidase, and active mitochondrial number consistently decreased in plants grown at elevated CO(2) during the 9 months of the study when compared to ambient plants. Plant growth at elevated CO(2) also reduced cytochrome pathway activity, but increased the activity of the alternative pathway. Despite all these effects seen in plants grown at high CO(2), the specific oxygen uptake rate per unit of active mitochondria was the same for plants grown at ambient and elevated CO(2). Although decreases in photorespiration activity have been pointed out as a factor contributing to the long-term acclimation of plant respiration to growth at elevated CO(2), the homeostatic maintenance of specific respiratory rate per unit of mitochondria in response to high CO(2) suggests that photorespiratory activity may play a small role on the long-term acclimation of respiration to elevated CO(2). However, despite growth enhancement and as a result of the inhibition in cytochrome pathway activity by elevated CO(2), total mitochondrial ATP production was decreased by plant growth at elevated CO(2) when compared to ambient-grown plants. Because plant growth at elevated CO(2) increased biomass but reduced respiratory machinery, activity, and ATP yields while maintaining O(2) consumption rates per unit of mitochondria, we suggest that acclimation to elevated CO(2) results from physiological adjustment of respiration to tissue ATP demand, which may not be entirely driven by nitrogen metabolism as previously suggested.

[Complete atrioventricular block secondary to pulmonary embolism]. / Bloqueo auriculoventricular completo secundario a tromboembolia pulmonar.

We describe a 73-year-old woman with a history of breast cancer and metastatic disease diagnosed in January 2002 (stable when we saw her) who was admitted for sudden dyspnea and presyncope. Complete atrioventricular block was documented, and a temporary pacemaker was implanted. Eight hours after admission she recovered sinus rhythm with left bundle branch block as seen in previous recordings. Computed tomography showed bilateral pulmonary thromboembolism. An electrophysiological study showed normal atrioventricular conduction. We suggest that in this patient, who had previous left bundle branch block, pulmonary thromboembolism may have induced transient right bundle branch block, which in turn caused atrioventricular block.

Bloqueo auriculoventricular completo secundario a tromboembolia pulmonar / Complete atrioventricular block secondary to pulmonary embolism

Paciente de 73 años, con antecedentes de neoplasia de mama y enfermedad metastásica diagnosticada en enero de 2002, estable actualmente. Ingresa por disnea súbita y sensación pre sincopal; se documenta la existencia de un bloqueo auriculo-ventricular completo, que requiere la implantación de marcapasos temporal. A las 8 h recupera el ritmo sinusal con bloqueo de rama izquierda ya conocido. Una tomografía computarizada de muestra la existencia de una tromboembolia pulmonar bilateral. Un estudio electrofisiológico muestra conducción auriculo-ventricularnormal. Sugerimos que en presencia de bloqueo de rama izquierda, una tromboembolia pulmonar, que pudo cursar con bloqueo de rama derecha transitorio, provocó este bloqueo completo paroxístico

We describe a 73-year-old woman with a history of breast cancer and metastatic disease diagnosed in January2002 (stable when we saw her) who was admitted for sudden dyspnea and presyncope. Complete atrioventricular block was documented, and a temporary pacemaker was implanted. Eight hours after admission she recovered sinus rhythm with left bundle branch block as seen in previous recordings. Computed tomography showed bilateral pulmonary thromboembolism. An electrophysiological study showed normal atrioventricular conduction. We suggest that in this patient, who had previous left bundle branch block, pulmonary thromboembolism may have induced transient right bundle branch block, which in turn caused atrioventricular block

Effects of Helicobacter pylori eradication on platelet activation and disease recurrence in patients with acute coronary syndromes.

BACKGROUND: Platelet activation is consistently observed in animal models of Helicobacter pylori infection and could help to explain the alleged epidemiological association between H. pylori and coronary heart disease. MATERIALS AND METHODS: Ninety-two patients with recent acute coronary syndromes were enrolled. Helicobacter pylori-positive patients were randomized to receive a 7-day course of omeprazole, amoxycillin and metronidazole or placebos. Two months later, H. pylori status was reassessed and baseline parameters, including soluble P-selectin and platelet surface expression of CD62P, CD63 and CD41, were measured again. Patients were followed-up for 1 year or until death or readmission. RESULTS: No baseline differences were observed between H. pylori-positive and -negative cases. Among H. pylori-positive patients, 18 received placebo and 31 received active medication resulting in eradication in 21 cases. No differences were observed in inflammatory parameters or platelet activation markers between patients with persistent or resolved H. pylori infection. However, coronary events recurred at 6 and 12 months, respectively, in 35% and 55% of patients with persisting H. pylori infection compared with 10% and 25% of patients in whom H. pylori was either absent or eradicated (p = .01). Only final H. pylori status [RR 3.07 (95% CI 1.35-98)] and number of coronary risk factors [RR 2.58 (95% CI 1.51-4.41)] were independent predictors of recurrence. CONCLUSIONS: Infection with H. pylori does not induce significant platelet activation in patients treated for coronary disease. Helicobacter pylori-infected patients, however, may have an increased risk of recurrence of coronary events.