Identification and Preliminary Characterization of Novel Type III Secreted Effector Proteins in Chlamydia trachomatis.

Chlamydia trachomatis is an obligate intracellular pathogen that replicates in a host-derived vacuole termed the inclusion. Central to pathogenesis is a type III secretion system that translocates effector proteins into the host cell, which are predicted to play major roles in host cell invasion, nutrient acquisition, and immune evasion. However, until recently, the genetic intractability of C. trachomatis hindered identification and characterization of these important virulence factors. Here, we sought to expand the repertoire of identified effector proteins and confirm they are secreted during C. trachomatis infection. Utilizing bioinformatics, we identified 18 candidate substrates that had not been previously assessed for secretion, of which we show four to be secreted, using Yersinia pseudotuberculosis as a surrogate host. Using adenylate cyclase (CyaA), BlaM, and glycogen synthase kinase (GSK) secretion assays, we identified nine novel substrates that were secreted in at least one assay. Interestingly, only three of the substrates, shown to be translocated by C. trachomatis, were similarly secreted by Y. pseudotuberculosis. Using large-scale screens to determine subcellular localization and identify effectors that perturb crucial host cell processes, we identified one novel substrate, CT392, that is toxic when heterologously expressed in Saccharomyces cerevisiae. Toxicity required both the N- and C-terminal regions of the protein. Additionally, we show that these newly described substrates traffic to distinct host cell compartments, including vesicles and the cytoplasm. Collectively, our study expands the known repertoire of C. trachomatis secreted factors and highlights the importance of testing for secretion in the native host using multiple secretion assays when possible.

Ticagrelor and primidone interaction masquerading as dual antiplatelet therapy noncompliance.

Ticagrelor and aspirin is a common dual antiplatelet therapy regimen for patients who undergo percutaneous coronary intervention. Despite its ability to significantly reduce cardiovascular complications, ticagrelor response may be altered by other medications causing subtherapeutic effects. Traditionally, ticagrelor is thought to have fewer drug-drug interactions compared to other thienopyridine antiplatelet medications such as clopidogrel. Primidone, metabolized into phenobarbital, is a strong CYP-3A inducer that can reduce serum concentrations of ticagrelor resulting in ineffective antiplatelet therapy. We present a 67-year-old male who suffered in-stent thrombosis after percutaneous intervention possibly due to the interaction between primidone and ticagrelor.

Ticagrelor and aspirin is a common antiplatelet regimen for patients who undergo coronary intervention and stent implantation. Ticagrelor is typically less associated with drug­drug interactions; however, our case illustrates an interaction between ticagrelor and primidone causing acute in-stent thrombosis to recently implanted drug-eluting stents.

Intermediate Follow-Up of Balloon-Expandable Versus Self-Expanding Transcatheter Aortic Valve Implantation in Patients With Small Aortic Annuli.

The clinical impact of prosthesis-patient mismatch (PPM) in patients with small aortic annuli who underwent transcatheter aortic valve (AV) implantation with either balloon-expandable (BE) or self-expanding (SE) valves remains controversial. We assessed in-hospital and intermediate clinical outcomes in 573 patients with transfemoral transcatheter AV implantation with a small AV annulus, defined as an AV annulus area ≤430 mm2. A total of 337 patients treated with a 23-mm BE valve (SAPIEN 3, Ultra) were compared with 236 patients treated with a 26-mm SE valve (Evolut series). Valve-in-valve cases were excluded, and late echo follow-up (mean 674 ± 438 days) was assessed in a subset of 292 patients (51.0%). Well-matched BE and SE cohorts did not differ with respect to major in-hospital outcomes, other than a borderline increase in vascular complications and composite bleeding in patients with SE. Patients with BE had a higher incidence of severe PPM on discharge echocardiography (16.9% vs 6.8%, p <0.002). The mean AV gradient at 30 days was higher for patients with BE (12.2 ± 4.2 vs 6.2 ± 7.9 mm Hg, p <0.001) and at late follow-up (14.0 ± 8.2 vs 7.2 ± 3.5 mm Hg, p <0.001). The follow-up left ventricular ejection fraction and incidence of >mild aortic insufficiency were similar. All-cause mortality for the 2 cohorts was similar, with an overall mean (95% confidence interval) survival time of 61.2 months (57.8 to 64.5; p = 0.98). There were no significant survival differences between combined patients with BE and SE with no, moderate, or severe PPM, with an overall mean (95% confidence interval) survival time of 32.5 (30.5 to 34.5) months combining valve types (p = 0.23). In conclusion, despite an increased incidence of PPM with higher mean AV gradients that persist on late echocardiography in the BE cohort, patients with BE and SE with small aortic annuli have similar clinical outcomes at intermediate follow-up. Moderate and severe PPM had no impact on survival at a mean follow-up of 32.5 months.

Transcarotid Versus Transfemoral Transcatheter Aortic Valve Replacement (from a Propensity-Matched Comparison).

Previous reports comparing transcarotid (TC) versus transfemoral (TF) approaches for patients undergoing transcatheter aortic valve replacement have had inconsistent conclusions. We compared in-hospital and 1-year clinical outcomes, changes in quality of life, and direct hospital costs for 138 TC versus 1,926 TF procedures. Propensity matching based on the Society of Thoracic Surgery Predicted Risk of Mortality was used to compare 130 patients who underwent TC with 813 patients who underwent TF. Matched TC versus TF cohorts did not differ with respect to in-hospital mortality (0.0% vs 1.4%, p = 0.380), stroke (2.3% vs 2.5%, p = 0.917), major vascular complications (0.8% vs 2.2%, p = 0.268), composite bleeding complications (4.6% vs 6.4%, p = 0.647), requirement for permanent pacemaker (14.6% vs 12.9%, p = 0.426), postoperative hospital length of stay (3.3 ± 3.4 vs 3.1 ± 3.3 days, p = 0.467), or direct hospital costs ($52,899 ± 9,560 vs $50,464 ± 10,997, p = 0.230). Similarly, at 1-year, patients who underwent TC versus patients who underwent TF did not differ with respect to all-cause mortality (7.6% vs 6.4%, p = 0.659), hospital readmission (20.0% vs 23.9%, p = 0.635), or quality of life as measured by the Kansas City Cardiomyopathy Questionnaire score (84.0 ± 17.1 vs 88.4 ± 13.9, p = 0.062). Patients who underwent TC and TF did not differ with respect to in-hospital complications, length of hospital stay, and direct hospital costs, as well as 1-year mortality, readmission, and quality of life. These data add to ongoing support for the TC approach as the optimal alternative access for patients with transcatheter aortic valve replacement deferred from a transfemoral approach.

First report of Avian metapneumovirus type B in Iraqi broiler flocks with swollen head syndrome.

Background and Aim: Swollen head syndrome (SHS) is a complex disease caused by various agents, including bacterial and viral pathogens, as well as environmental factors. Avian metapneumovirus (aMPV) is one of the most important causes of respiratory diseases and SHS in poultry and one of the most widespread viruses worldwide; however, it has not been recorded in Iraq. This study aimed at the molecular identification and subtyping of aMPV in poultry, with the objectives of investigating the prevalence of aMPV in infected broiler flocks with SHS and molecular typing using primers specific to the study of the prevalence of subtypes A, B, and C of aMPV. Materials and Methods: This study was performed on 67 broiler farms that reported typical SHS from September 2018 to August 2019. Swabs were collected from the trachea, infraorbital sinuses, and lung, then uploaded on FTA cards and subjected to an RNA extraction protocol. Results: aMPV was detected in 16 (23.8%) samples. Molecular typing using primers specific to the attachment glycoprotein (G) gene showed that all positive samples belonged to subtype B, as assessed using the real-time polymerase chain reaction technique. Conclusion: aMPV may be the main etiological factor causing SHS in poultry. Moreover, this was the first report of the prevalence of subtype B aMPV strains in broiler farms in Iraq.

High solids loading biorefinery for the production of cellulosic sugars from bioenergy sorghum.

A novel process applying high solids loading in chemical-free pretreatment and enzymatic hydrolysis was developed to produce sugars from bioenergy sorghum. Hydrothermal pretreatment with 50% solids loading was performed in a pilot scale continuous reactor followed by disc refining. Sugars were extracted from the enzymatic hydrolysis at 10% to 50% solids content using fed-batch operations. Three surfactants (Tween 80, PEG 4000, and PEG 6000) were evaluated to increase sugar yields. Hydrolysis using 2% PEG 4000 had the highest sugar yields. Glucose concentrations of 105, 130, and 147 g/L were obtained from the reaction at 30%, 40%, and 50% solids content, respectively. The maximum sugar concentration of the hydrolysate, including glucose and xylose, obtained was 232 g/L. Additionally, the glucose recovery (73.14%) was increased compared to that of the batch reaction (52.74%) by using two-stage enzymatic hydrolysis combined with fed-batch operation at 50% w/v solids content.

A comparative account of glucose yields and bioethanol production from separate and simultaneous saccharification and fermentation processes at high solids loading with variable PEG concentration.

A process strategy to aid in optimal enzymatic hydrolysis through the addition of polyethylene glycol (PEG6000) was tested for separate hydrolysis and fermentation (SHF) and simultaneous saccharification and fermentation (SSF). Pretreated wheat straw at 30% solids (w/w) loading was enzymatically hydrolyzed with 0, 0.5, 1, 1.5, 2 and 2.5% of PEG6000 through SHF and SSF. During SHF, bioethanol concentration of 107.5 g/L (2.5% PEG6000) was achieved. SSF ethanol concentration were about 113 g/L at 1.5% PEG6000 addition. A technoeconomic feasibility showed a return on investment (ROI) of 8.13% using 0.5% PEG6000 for SHF (96 h) and 12.25% ROI for SSF control (72 h). Life cycle assessment for the various scenarios indicated higher environmental gains for best cases of SSF over SHF. The study shows the SSF approach (0% PEG6000; 72 h) facilitates higher process efficiencies; technoeconomic gains and high environmental sustainability for future scale-up and commercial realization.

A novel method for real-time estimation of insoluble solids and glucose concentrations during enzymatic hydrolysis of biomass.

The study describes a novel method using instantaneous mixing torque and rotational speed to estimate insoluble solids and glucose concentrations during enzymatic hydrolysis of biomass. This method is cost-effective for real-time monitoring and control of enzymatic hydrolysis and potentially scalable. The model was developed using biomass slurries at three solids loading (20, 30 and 45%) at various rotational speeds from 50 to 400 rpm. The results showed a significant drop in mixing torque at 12 h with high solids loading. Maximum glucose concentration (205 g/l) during hydrolysis was achieved at 45% solids loading. Insoluble solids and glucose concentration as a function of torque and rotational speeds were modeled using a modified Herschell-Bulkley model. The model describes the experimental observations with high fidelity (R2 = 0.84) and can be used for real time monitoring of many multiphase reaction systems as enzymatic hydrolysis of lignocellulosic biomass and dry grind corn ethanol processes.

Effect of solids loading on ethanol production: Experimental, economic and environmental analysis.

This study explores the effect of high-solids loading for a fed batch enzymatic hydrolysis and fermentation. The solids loading considered was 19%, 30% and 45% using wheat straw and corn stover as a feedstock. Based on the experimental results, techno-economic analysis and life cycle assessments were performed. The experimental results showed that 205±25.8g/L glucose could be obtained from corn stover at 45% solids loading after 96h which when fermented yielded 115.9±6.37g/L ethanol after 60h of fermentation. Techno-economic analysis showed that corn stover at 45% loading yielded the highest ROI at 8% with a payback period less than 12years. Similarly, the global warming potential was lowest for corn stover at 45% loading at -37.8gCO2 eq./MJ ethanol produced.

Self-inflicted vertebral artery dissection: a case report and review of literature.

Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed leading to adverse consequences. Dissections are usually preceded by trauma or mechanical stress; the vascular stressors may be trivial as this condition has been described in association with manipulation and stretching of the neck. Early recognition of VAD is paramount, as timely initiation of appropriate anticoagulation can be crucial in ensuring full recovery. We present a case of self-inflicted vertebral artery dissection complicated by multiple embolic strokes where early treatment with anticoagulation led to a complete neurological recovery.

The effect of head-upright tilt table testing for vasovagal syncope on P-wave duration.

Fluid shifts in vasovagal syncope may be reflected in electrocardiographic P-wave duration. We examined the effect of head-upright tilt-table testing (HUT) on P-wave duration among patients with positive or negative HUT. P-wave duration was measured at baseline and several post-HUT time points. In patients with a positive HUT, the test was immediately discontinued. P-wave duration measurements obtained at the completion of the test or when symptoms occurred were compared to baseline measurements. The P-wave duration among patients with a positive HUT was significantly reduced at the onset of symptoms as compared to baseline (-14.0 ms, P = .0054) and 2-minute tilt measurements (-11.3 ms, P = .0246). P-wave duration measurements were not reduced in patients experiencing a negative HUT at any follow-up time. We showed a significant reduction in P-wave duration among patients experiencing positive HUT that suggests a dynamic relationship between atrial volume and P-wave duration.