Genomes of ubiquitous marine and hypersaline Hydrogenovibrio, Thiomicrorhabdus and Thiomicrospira spp. encode a diversity of mechanisms to sustain chemolithoautotrophy in heterogeneous environments.

Chemolithoautotrophic bacteria from the genera Hydrogenovibrio, Thiomicrorhabdus and Thiomicrospira are common, sometimes dominant, isolates from sulfidic habitats including hydrothermal vents, soda and salt lakes and marine sediments. Their genome sequences confirm their membership in a deeply branching clade of the Gammaproteobacteria. Several adaptations to heterogeneous habitats are apparent. Their genomes include large numbers of genes for sensing and responding to their environment (EAL- and GGDEF-domain proteins and methyl-accepting chemotaxis proteins) despite their small sizes (2.1-3.1 Mbp). An array of sulfur-oxidizing complexes are encoded, likely to facilitate these organisms' use of multiple forms of reduced sulfur as electron donors. Hydrogenase genes are present in some taxa, including group 1d and 2b hydrogenases in Hydrogenovibrio marinus and H. thermophilus MA2-6, acquired via horizontal gene transfer. In addition to high-affinity cbb3 cytochrome c oxidase, some also encode cytochrome bd-type quinol oxidase or ba3 -type cytochrome c oxidase, which could facilitate growth under different oxygen tensions, or maintain redox balance. Carboxysome operons are present in most, with genes downstream encoding transporters from four evolutionarily distinct families, which may act with the carboxysomes to form CO2 concentrating mechanisms. These adaptations to habitat variability likely contribute to the cosmopolitan distribution of these organisms.

A Conceptual Framework: The Musical Self as a Unique Pathway to Outcomes in the Acute Pediatric Health Setting.

This article reports on a project at the Royal Children's Hospital Melbourne in which the music therapy team synthesized their practice and related theories to propose a new conceptual framework for music therapy in their acute pediatric setting. The impetus for the project was the realization that in the process of producing key statements about the non-musical benefits of music therapy, the cost was often the suppression of information about the patient's unique musical potential as the major (mediating) pathway from referral reason, to music therapy, and to effective outcomes. The purpose of the project was to articulate how this team of clinicians conceive of the patient's musical self as the major theoretical pathway for music therapy in an evidence-based acute medical setting. The clinicians' shared reflexive process across six months involved robust directed discussion, annotation of shared reading, and documentation of all engagement in words and diagrams. The outcome was a consensus framework including three constructs: the place of music in the life of the infant, child, and young people, Culture and Context, and Musical Manifestations. The constructs were tested in a clinical audit, and found to be robustly inclusive. In addition to the conceptual framework, this project serves to demonstrate a process by which clinical teams may reflect on their individual practice and theory together to create a consensus stance for the overall service they provide in the one setting.

Improved patient outcomes when transmyocardial revascularization is used as adjunctive revascularization.

BACKGROUND: Transmyocardial revascularization (TMR) has been recently used to treat patients with angina for whom angioplasty/stenting and/or coronary artery bypass grafting (CABG) is no longer an option. METHODS: A retrospective review of 255 consecutive patients who required CABG was done. Group 1 patients (n = 219) underwent complete revascularization with CABG alone. Group 2 patients (n = 36) received CABG plus TMR. TMR was performed in regions of nongraftable coronary targets. Indications for surgery in both groups were Canadian Cardiovascular Society angina scores III or IV and an ejection fraction > or = 30%. Exclusion criteria were an emergency procedure within 12 hours, unstable angina, or an acute myocardial infarction within 72 hours. Thirty-day outcomes of the two groups were compared. The means +/- SD of patient ages (63.3 +/- 1.6 years versus 65.4 +/- 1.4 years) and ejection fractions (51.6% +/- 0.9% versus 48.5% +/- 1.6%) were similar for the two groups. RESULTS: The number of grafts performed and operating room times for the two groups were similar (3.1 +/- 0.1 versus 2.9 +/- 0.1 and 276.7 +/- 4.4 minutes versus 272.3 +/- 10.7 minutes, respectively). Intensive care unit times and lengths of stay (emergency room to discharge) were significantly shorter in the CABG plus TMR group (2.1 +/- 0.2 days versus 1.6 +/- 0.2 days [P < .001] and 8.2 +/- 0.4 days versus 7.1 +/-0.6 days [P < .001], respectively). The 30-day readmission rate was lower in the CABG plus TMR group (7.8% versus 2.8%; P < .5). The frequency of atrial fibrillation was also significantly lower in the CABG plus TMR group (37.4% versus 16.7%; P < .025). Major adverse outcomes, such as reoperation for bleeding, respiratory failure, renal failure, stroke, and mortality were similar in the two groups, although there were no mortalities in the CABG plus TMR group. CONCLUSION: TMR as an adjunctive revascularization to CABG in selected patients with limited options may improve in-hospital outcomes.

Robotic-assisted off-pump sole transmyocardial revascularization: case report.

Thoracoscopic transmyocardial revascularization (TMR) has been recently demonstrated. We report 2 patients who underwent robotic-assisted thoracoscopic off-pump sole TMR. A 2-inch minimally invasive left anterolateral thoracotomy was made. Pericardial dissection and TMR were performed in an open manner facilitated by improved visualization using voice-activated robotic-assisted thoracoscopy (AESOP, Computer Motion, Santa Barbara, CA, USA). Patient 1 was a 73-year-old man with class IV angina who underwent coronary artery bypass grafting (CABG) x4 20 years earlier. Cardiac catheterization revealed occluded grafts, no native vessels that were amenable to percutaneous coronary intervention (PCI) or CABG, and an ejection fraction (EF) of 55%. Forty-five Holmium-Yag (CardioGenesis, Foothill Ranch, CA, USA) laser channels were created in the left ventricular wall. Total operating room (OR) time was 93 minutes. He was extubated in the OR and was discharged from the intensive care unit (ICU) in 18 hours and from the hospital on the second postoperative day angina free. Patient 2 was a 48-year-old woman with class IV angina who had undergone CABG x6 3 years earlier but who had persistent chest pain following the revascularization. After 12 cardiac readmissions in 1 year, including multiple PCIs, a recent catheterization showed patent grafts except for the circumflex branches and an EF of 45%. Forty-six channels were created in the left ventricle in a similar fashion. OR time was 62 minutes, ICU time was 20 hours, and postoperative length of stay was 2 days. The patient also was angina free at discharge. This report suggests that robotic-assisted thoracoscopy provides enhanced visualization and efficient delivery during off-pump sole TMR, and this technique may be associated with reduced operative times and improved recovery time.

Fast track minimally invasive transmyocardial revascularization.

OBJECTIVE: : We evaluated the initial results of a fast-track discharge protocol for patients undergoing minimally invasive transmyocardial revascularization (MiTMR). METHODS: : Fifteen male patients, aged 64.5 ± 9.2 years, with an ejection fraction of 46.8% ± 9.9%, underwent MiTMR through a mini-left anterior thoracotomy aided by robotic-controlled thoracoscopic assistance. A postoperative management protocol included immediate extubation, early chest tube and pulmonary artery catheter removal, and mobilization within 12 hours. RESULTS: : There were no operative arrhythmias or in-hospital mortalities. Three of 15 patients developed left lower lobe atelectasis, delaying discharge between 2 and 5 days. Overall hospital length of stay was 1.4 ± 1.2 days, although 12 of 15 patients (80%) were discharged to home in 23 hours. Mild-moderate cardiomyopathy (ejection fraction 30%-50%) was not associated with prolonged length of stay. Mean hospital profit margin was $1882.50. One 30-day readmission occurred on day 23 for rapid atrial fibrillation, and one death occurred on day 11. CONCLUSIONS: : Despite these high-risk patients having end-staged, ischemic coronary artery disease, most MiTMR patients can be discharged to home in less than 24 hours. Perioperative morbidity and mortality rates are relatively low, and hospital profit margins are modest.