MOLECULAR MECHANISMS OF A ROOT SYSTEM TO SOIL ADAPTATION

Contrairement aux animaux, les plantes sont des organismes sessiles qui ne possèdent pas de mécanismes de fuite quand les conditions environnementales ne sont plus optimales. Les plantes sont physiquement ancrées à l'endroit où elles ont germées et aux conditions environnementales qui parfois peuvent être extrêmes. Les possibilités d'acclimatation de différentes espèces, parfois même de groupes de plantes au sein d'une même espèce, peuvent varier mais repose sur une adaptation génétique de la plante. L'adaptation est un long processus qui repose sur l'apparition spontanée de mutations génétiques, leur mise à l'épreuve face aux conditions environnementales, et dans le cas où la mutation a un impact positif sur la survie dans cet habitat particulier, elle sera maintenue dans une population donnée de plantes. De telles populations, appelées écotypes, sont le matériel de départ pour la découverte de gènes qui induisent un bénéfice pour la plante dans un environnement donné. La plante la plus étudiée en biologie moléculaire est Arabidopsis thaliana, l'arabette des prés. Dans une étude précédente, les racines d'écotypes naturels d'Arabidopsis ont été comparées et un écotype, Uk-1, avait le système racinaire le plus particulier. Cet écotype possède des racines beaucoup plus courtes et plus ramifiées que tous les autres écotypes. Des analyses plus poussées ont montré qu'une seule mutation dans un gène était la cause de ce phénotype, le gène BREVIS RADIX (BRX), mot latin signifiant 'racine courte'. Bien que l'on connaisse le gène BRX, on connaît finalement peu de choses sur son importance adaptative. Dans cette étude, nous avons montré que la mutation dans le gène BRX rend la plante plus résistante aux sols acides. Dans l'optique de mieux comprendre cette valeur adaptative du mutant brx, nous avons analysé dans quels tissus le gène BRX jouait un rôle important. Nous avons pu mettre en évidence que BRX est important pour le développement du protophloème. Le protophloème est un élément du système vasculaire de la plante. En général, les plantes supérieures possèdent deux systèmes de transport à longue distance. L'un d'eux, appelé xylème, transporte l'eau et les nutriments absorbés du sol par les racines vers les feuilles. Les feuilles sont le siège du processus de photosynthèse au cours duquel sont produits des sucres qui devront être distribués partout dans les autres parties de la plante. Le tissu cellulaire chargé de livrer les produits de la photosynthèse, ainsi que les régulateurs de croissance, est le phloème. Ce dernier regroupe le métaphloème et le protophloème. Le protophloème est essentiel pour la livraison des sucres synthétisés ainsi que des signaux de croissance aux pointes des racines, centres organogéniques responsables de la production de nouvelles cellules durant la phase de croissance de la racine. La structure du protophloème peut être décrite comme des tubes continus, vides et résistants, faits de cellules spécialisées qui permettent un transport efficace et rapide. Nous avons montré que dans les mutants brx ces canaux de transports sont discontinus car certaines cellules n'ont pas terminé leur cycle de différenciation. Ces cellules obstruent le conduit ce qui fait que les sucres et les signaux de croissance, comme l'auxine, ne peuvent plus être transportés aux méristèmes. En conséquence, la prolifération de l'activité des méristèmes est compromise, ce qui explique les racines courtes. Au lieu d'être délivré aux méristèmes, l'auxine se concentre en amont des méristèmes où cela provoque l'apparition de nouvelles racines branchées et, très probablement, l'activation des pompes à protons. Sur des sols acides, la concentration en ion H+ est très élevée. Ces ions entrent dans les cellules de la racine par diffusion et perturbent notablement la croissance des racines et de la plante en général. Si les cellules de la racine possédaient des pompes à protons hyperactives, elles seraient capable d'évacuer le surplus d'ions H+ en dehors de la cellule, ce qui leur assurerait de meilleures chances de survie sur sols acides. De fait, le mutant brx est capable d'acidifier le milieu de culture dans lequel il est cultivé plus efficacement que la plante sauvage. Ce mutant est également capable de donner plus de progéniture sur ce type de milieu de croissance que les plantes sauvages. Finalement, nous avons trouvé d'autres mutants brx en milieu naturel poussant sur sols acides, ce qui suggère fortement que la mutation du gène BRX est une des causes de l'adaptation aux sols acides. -- Plants as sessile organisms have developed different mechanisms to cope with the complex environmental conditions in which they live. Adaptation is the process through which traits evolve by natural selection to functionally improve in a given environmental context. An adaptation to the environment is characterized by the genetic changes in the entire populations that have been fixed by natural selection over many generations. BREVIS RADIX (BRX) gene was found through natural Arabidopsis accessions screen and was characterized as a root growth regulator since loss-of-function mutants exhibit arrested post-embryonic primary root growth in addition to a more branched root system. Although brx loss-of-function causes a complete alteration in root architecture, BRX activity is only required in the root vasculature, in particular in protophloem cell file. Protophloem is a part of the phloem transport network and is responsible for delivery of photo-assimilates and growth regulators, coming from the shoot through mature phloem component - metaphloem, to the all plant primary meristems. In order to perform its function, protophloem is the first cell file to differentiate within the root meristem. During this process, protophloem cells undergo a partial programmed cell death, during which they build a thicker cell wall, degrade nucleus and tonoplast while plasma membrane stays functional. Interestingly, protophloem cells enter elongation process only after differentiation into sieve elements is completed. Here we show that brx mutants fail to differentiate protophloem cell file properly, a phenotype that can be distinguished by a presence of a "gap" cells, non-differentiated cells between two flanking differentiated cells. Discontinuity of protophloem differentiation in brx mutants is considered to be a consequence of local hyperactivity of CLAVATA3/EMBRYO SURROUNDING REGION 45 (CLE45) - BARELY ANY MERISTEM 3 (BAM3) signaling module. Interestingly, a CLE45 activity, most probably at the level of receptor binding, can be modulated by apoplastic pH. Altogether, our results imply that the activity of proton pumps, expressed in non-differentiated cells of protophloem, must be maintained under certain threshold, otherwise CLE45-BAM3 signaling pathway will be stimulated and in turn protophloem will not differentiate. Based on vacuolar morphology, a premature cell wall acidification in brx mutants stochastically prevents the protophloem differentiation. Only after protophloem differentiates, proton pumps can be activated in order to acidify apoplast and to support enucleated protophloem multifold elongation driven by surrounding cells growth. Finally, the protophloem differentiation failure would result in an auxin "traffic jam" in the upper parts of the root, created from the phloem-transported auxin that cannot be efficiently delivered to the meristem. Physiologically, auxin "leakage" from the plant vasculature network could have various consequences, since auxin is involved in the regulation of almost every aspect of plant growth and development. Thus, given that auxin stimulates lateral roots initiation and growth, this scenario explains more branched brx root system. Nevertheless, auxin is considered to activate plasma membrane proton pumps. Along with this, it has been shown that brx mutants acidify media much more than the wild type plants do, a trait that was proposed as an adaptive feature of naturally occurring brx null alleles in Arabidopsis populations found on acidic soils. Additionally, in our study we found that most of accessions originally collected from acidic sampling sites exhibit hypersensitivity to CLE45 treatment. This implies that adaptation of plants to acidic soil involves a positive selection pressure against upstream negative regulators of CLE45-BAM3 signaling, such as BRX. Perspective analysis of these accessions would provide more profound understanding of molecular mechanisms underlying plant adaptation to acidic soils. All these results are suggesting that targeting of the factors that affect protophloem differentiation is a good strategy of natural selection to change the root architecture and to develop an adaptation to a certain environment. -- Les plantes comme organismes sessiles ont développé différents mécanismes pour s'adapter aux conditions environnementales complexes dans lesquelles elles vivent. L'adaptation est le processus par lequel des traits vont évoluer via la sélection naturelle vers une amélioration fonctionnelle dans un contexte environnemental donné. Une adaptation à l'environnement est caractérisée par des changements génétiques dans des populations entières qui ont été fixés par la sélection naturelle sur plusieurs générations. Le gène BREVIS RADIX (BRX) a été identifié dans le crible d'une collection d'accessions naturelles d'Arabidopsis et a été caractérisé comme un régulateur de la croissance racinaire étant donné que le mutant perte-de-fonction montre une croissance racinaire primaire arrêtée au stade post-embryonnaire et présente de plus un système racinaire plus ramifié que la plante sauvage. Bien que le mutant perte-de-fonction brx cause une altération complète de l'architecture racinaire, l'activité de BRX n'est requise que dans la vascularisation racinaire, en particulier au niveau du protophloème. Le protophloème est un composant du réseau de transport du phloème et est responsable du transit des dérivés de la photosynthèse ainsi que des régulateurs de croissances, venant de la partie aérienne par le phloème mature (métaphloème) vers tous les méristèmes primaires de la plante. Pour pouvoir réaliser sa fonction, le protophloème est la première file de cellules à se différencier à l'intérieur du méristème de la racine. Pendant ce processus, les cellules du protophloème subissent une mort cellulaire programmée partielle durant laquelle elles épaississent leur paroi cellulaire, dégradent le noyau et le tonoplaste tandis que la membrane plasmique demeure fonctionnelle. De manière intéressante, les cellules du protophloème entament le processus d'allongement seulement après que la différenciation en tubes criblés soit complète. Ce travail montre que le mutant brx est incapable de mener à bien la différenciation de la file de cellules du protophloème, phénotype qui peut être visualisé par la présence de cellules 'trous', de cellules non différenciées entourées de deux cellules différenciées. La discontinuité de la différenciation du phloème dans le mutant brx est considérée comme la conséquence de l'hyperactivité localisée du module de signalisation CLA VA TA3/EMBRYO SURROUNDING REGION 45 (CLE45) - BARELY ANY MERISTEM 3 (BAM3). De manière intéressante, l'activité de CLE45, très probablement au niveau de la liaison avec le récepteur, peut être modulé par le pH apoplastique. Pris ensemble, nos résultats impliquent que l'activité des pompes à protons, actives dans les cellules non différenciées du protophloème, doit être maintenue en dessous d'un certain seuil autrement la cascade de signalisation CLE45-BAM3 serait stimulée, en conséquence de quoi le protophloème ne pourrait se différencier. D'après la morphologie vacuolaire, une acidification prématurée de la paroi cellulaire dans le mutant brx empêche la différenciation du protophloème de manière stochastique. Une fois que le protophloème se différencie, les pompes à protons peuvent alors être activées afin d'acidifier l'apoplaste et ainsi faciliter l'allongement des cellules énuclées du protophloème, entraînées par la croissance des cellules environnantes. Finalement, la différenciation défectueuse du protophloème produit une accumulation d'auxine dans la partie supérieure de la racine car le phloème ne peut plus acheminer efficacement l'auxine au méristème. Physiologiquement, la 'fuite' d'auxine à partir du réseau vasculaire de la plante peut avoir des conséquences variées puisque l'auxine est impliquée dans la régulation de la majorité des aspects de la croissance et développement de la plante. Etant donné que l'auxine stimule l'initiation et développement des racines latérales, ce scénario pourrait expliquer le système racinaire plus ramifié du mutant brx. En plus, l'auxine est considérée comme un activateur des pompes à protons. Par ailleurs, nous avons montré que les mutants brx ont la capacité d'acidifier le milieu plus efficacement que les plantes sauvages, une caractéristique des populations sauvages <¥Arabidopsis poussant sur des sols acides et contenant les allèles délétés brx. De plus, dans nos résultats nous avons mis en évidence que la plupart des accessions collectées originellement sur des sites acidophiles montre une hypersensibilité au traitement par CLE45. Ceci implique que l'adaptation des plantes aux sols acides repose sur la pression de sélection positive à rencontre des régulateurs négatifs de CLE45- BAM3, situés en amont de la cascade, tel le produit du gène BRX. Les analyses de ces accessions pourraient aboutir à une meilleure compréhension des mécanismes moléculaires responsables de l'adaptation des plantes aux sols acides. Tous nos résultats suggèrent que le ciblage des facteurs affectant la différenciation du protophloème serait une stratégie gagnante dans la sélection naturelle pour changer l'architecture de la racine et ainsi s'adapter efficacement à un nouvel environnement.

Randomized controlled study demonstrating failure of LPV/r monotherapy in HIV: the role of compartment and CD4-nadir.

BACKGROUND: Long-term side-effects and cost of HIV treatment motivate the development of simplified maintenance. Monotherapy with ritonavir-boosted lopinavir (LPV/r-MT) is the most widely studied strategy. However, efficacy of LPV/r-MT in compartments remains to be shown. METHODS: Randomized controlled open-label trial comparing LPV/r-MT with continued treatment for 48 weeks in treated patients with fully suppressed viral load. The primary endpoint was treatment failure in the central nervous system [cerebrospinal fluid (CSF)] and/or genital tract. Treatment failure in blood was defined as two consecutive HIV RNA levels more than 400 copies/ml. RESULTS: The trial was prematurely stopped when six patients on monotherapy (none in continued treatment-arm) demonstrated a viral failure in blood. At study termination, 60 patients were included, 29 randomized to monotherapy and 13 additional patients switched from continued treatment to monotherapy after 48 weeks. All failures occurred in patients with a nadir CD4 cell count below 200/microl and within the first 24 weeks of monotherapy. Among failing patients, all five patients with a lumbar puncture had an elevated HIV RNA load in CSF and four of six had neurological symptoms. Viral load was fully resuppressed in all failing patients after resumption of the original combination therapy. No drug resistant virus was found. The only predictor of failure was low nadir CD4 cell count (P < 0.02). CONCLUSION: Maintenance of HIV therapy with LPV/r alone should not be recommended as a standard strategy; particularly not in patients with a CD4 cell count nadir less than 200/microl. Further studies are warranted to elucidate the role of the central nervous system compartment in monotherapy-failure.

Does less frequent routine monitoring of patients on a stable, fully suppressed cART regimen lead to an increased risk of treatment failure?

OBJECTIVE: To investigate whether HIV-infected patients on a stable and fully suppressive combination antiretroviral therapy (cART) regimen could safely be monitored less often than the current recommendations of every 3 months. DESIGN: Two thousand two hundred and forty patients from the EuroSIDA study who maintained a stable and fully suppressed cART regimen for 1 year were included in the analysis. METHODS: Risk of treatment failure, defined by viral rebound, fall in CD4 cell count, development of new AIDS-defining illness, serious opportunistic infection or death, in the 12 months following a year of a stable and fully suppressed regimen was assessed. RESULTS: One hundred thirty-one (6%) patients experienced treatment failure in the 12 months following a year of stable therapy, viral rebound occurred in 99 (4.6%) patients. After 3, 6 and 12 months, patients had a 0.3% [95% confidence interval (CI) 0.1-0.5], 2.2% (95% CI 1.6-2.8) and 6.0% (95% CI 5.0-7.0) risk of treatment failure, respectively. Patients who spent more than 80% of their time on cART with fully suppressed viraemia prior to baseline had a 38% reduced risk of treatment failure, hazard ratio 0.62 (95% CI 0.42-0.90, P = 0.01). CONCLUSION: Patients who have responded well to cART and are on a well tolerated and durably fully suppressive cART regimen have a low chance of experiencing treatment failure in the next 3-6 months. Therefore, in this subgroup of otherwise healthy patients, it maybe reasonable to extend visit intervals to 6 months, with cost and time savings to both the treating clinics and the patients.

Fibrose rétropéritonéale: cause rare d'insuffisance rénale postrénale, a ne pas méconnaître [Retroperitoneal fibrosis: a rare cause of postrenal kidney failure, no to be missed].

We report the observation of a fifty years old man, admitted in the emergency room for bilateral lumbar pain and hyperkaliemic metabolic acidosis, and postrenal kidney failure induced by bilateral hydronephrosis. Radiographic exploration and histologic studies of biopsy confirmed an idiopathic retroperitoneal fibrosis that clinically and biologicaly responded to three seances of hemodialysis, and insertion in each uretere of one double J stent, and long term corticotherapy. The retroperitoneal fibrosis is a little common inflammatory disease, characterized by the development of a fibrous mass around the retroperitoneal structures. His diagnostic means evolved. On the other hand, his treatment was the object of no checked controlled and randomized trial. This article proposes an updating of the knowledge on this subject.

Effects of erythropoietin on muscle O2 transport during exercise in patients with chronic renal failure.

Erythropoietin (rHuEPO) has proven to be effective in the treatment of anemia of chronic renal failure (CRF). Despite improving the quality of life, peak oxygen uptake after rHuEPO therapy is not improved as much as the increase in hemoglobin concentration ([Hb)] would predict. We hypothesized that this discrepancy is due to failure of O2 transport rates to rise in a manner proportional to [Hb]. To test this, eight patients with CRF undergoing regular hemodialysis were studied pre- and post-rHuEPO ([Hb] = 7.5 +/- 1.0 vs. 12.5 +/- 1.0 g x dl-1) using a standard incremental cycle exercise protocol. A group of 12 healthy sedentary subjects of similar age and anthropometric characteristics served as controls. Arterial and femoral venous blood gas data were obtained and coupled with simultaneous measurements of femoral venous blood flow (Qleg) by thermodilution to obtain O2 delivery and oxygen uptake (VO2). Despite a 68% increase in [Hb], peak VO2 increased by only 33%. This could be explained largely by reduced peak leg blood flow, limiting the gain in O2 delivery to 37%. At peak VO2, after rHuEPO, O2 supply limitation of maximal VO2 was found to occur, permitting the calculation of a value for muscle O2 conductance from capillary to mitochondria (DO2). While DO2 was slightly improved after rHuEPO, it was only 67% of that of sedentary control subjects. This kept maximal oxygen extraction at only 70%. Two important conclusions can be reached from this study. First, the increase in [Hb] produced by rHuEPO is accompanied by a significant reduction in peak blood flow to exercising muscle, which limits the gain in oxygen transport. Second, even after restoration of [Hb], O2 conductance from the muscle capillary to the mitochondria remains considerably below normal.

How to interprete subclinical thyroid dysfunction in the prevention and management of heart failure events? Individual participant data analysis from six prospective cohorts

Background: Guidelines of the Diagnosis and Management of Heart Failure (HF) recommend investigating exacerbating conditions, such as thyroid dysfunction, but without specifying impact of different TSH levels. Limited prospective data exist regarding the association between subclinical thyroid dysfunction and HF events. Methods: We performed a pooled analysis of individual participant data using all available prospective cohorts with thyroid function tests and subsequent follow-up of HF events. Individual data on 25,390 participants with 216,247 person-years of follow-up were supplied from 6 prospective cohorts in the United States and Europe. Euthyroidism was defined as TSH 0.45-4.49 mIU/L, subclinical hypothyroidism as TSH 4.5-19.9 mIU/L and subclinical hyperthyroidism as TSH <0.45 mIU/L, both with normal free thyroxine levels. HF events were defined as acute HF events, hospitalization or death related to HF events. Results: Among 25,390 participants, 2068 had subclinical hypothyroidism (8.1%) and 648 subclinical hyperthyroidism (2.6%). In age- and gender-adjusted analyses, risks of HF events were increased with both higher and lower TSH levels (P for quadratic pattern<0.01): hazard ratio (HR) was 1.01 (95% confidence interval [CI] 0.81-1.26) for TSH 4.5-6.9 mIU/L, 1.65 (CI 0.84-3.23) for TSH 7.0-9.9 mIU/L, 1.86 (CI 1.27-2.72) for TSH 10.0-19.9 mIUL/L (P for trend <0.01), and was 1.31 (CI 0.88-1.95) for TSH 0.10-0.44 mIU/L and 1.94 (CI 1.01-3.72) for TSH <0.10 mIU/L (P for trend=0.047). Risks remained similar after adjustment for cardiovascular risk factors. Conclusion: Risks of HF events were increased with both higher and lower TSH levels, particularly for TSH ≥10 mIU/L and for TSH <0.10 mIU/L. Our findings might help to interpret TSH levels in the prevention and investigation of HF.

Heart failure and community-acquired pneumonia: cases for home hospital?

BACKGROUND: Home hospital is advocated in many western countries in spite of limited evidence of its economic advantage over usual hospital care. Heart failure and community-acquired pneumonia are two medical conditions which are frequently targeted by home hospital programs. While recent trials were devoted to comparisons of safety and costs, the acceptance of home hospital for patients with these conditions remains poorly described. OBJECTIVE: To document the medical eligibility and final transfer decision to home hospital for patients hospitalized with a primary diagnosis of heart failure or community-acquired pneumonia. DESIGN: Longitudinal study of patients admitted to the medical ward of acute care hospitals, up to the final decision concerning their transfer. SETTING: Medical departments of one university hospital and two regional teaching Swiss hospitals. PATIENTS: All patients admitted over a 9 month period to the three settings with a primary diagnosis of heart failure (n= 301) or pneumonia (n=441). MEASUREMENTS: Presence of permanent exclusion criteria on admission; final decision of (in)eligibility based on medical criteria; final decision regarding the transfer, taking into account the opinions of the family physician, the patient and informal caregivers. RESULTS: While 27.9% of heart failure and 37.6% of pneumonia patients were considered to be eligible from a medical point of view, the program acceptance by family physicians, patients and informal caregivers was low and a transfer to home hospital was ultimately chosen for just 3.8% of heart failure and 9.6% of pneumonia patients. There were no major differences between the three settings. CONCLUSIONS: In the case of these two conditions, the potential economic advantage of home hospital over usual inpatient care is compromised by the low proportion of patients ultimately transferred.

Failure of voriconazole to cure disseminated zygomycosis in an immunocompromised child.

Voriconazole is increasingly used as a first-line agent for empirical antifungal therapy of prolonged febrile neutropenia in paediatric cancer patients. We describe the case of a 9-year-old patient with stage IV Burkitt lymphoma, who developed pulmonary and splenic zygomycosis while receiving voriconazole for persistent febrile neutropenia. The causative agent, Absidia corymbifera, was identified by broad-range fungal PCR in a lung biopsy sample. The patient was successfully treated with a combination of partial resection of the left upper lobe and antifungal therapy with high-dose liposomal amphotericin B followed by oral itraconazole as demonstrated by resolving pulmonary infiltrates on serial high resolution CT scans. CONCLUSION: This case emphasises that the lack of in vitro activity of voriconazole against zygomycetes is clinically relevant. Failure of voriconazole in suspected fungal infection should be investigated for the possibility of zygomycosis. Broad-range polymerase chain reaction may be able to identify the causative organism when cultures remain sterile.

Does short-term virologic failure translate to clinical events in antiretroviral-naïve patients initiating antiretroviral therapy in clinical practice?

OBJECTIVE: To determine whether differences in short-term virologic failure among commonly used antiretroviral therapy (ART) regimens translate to differences in clinical events in antiretroviral-naïve patients initiating ART. DESIGN: Observational cohort study of patients initiating ART between January 2000 and December 2005. SETTING: The Antiretroviral Therapy Cohort Collaboration (ART-CC) is a collaboration of 15 HIV cohort studies from Canada, Europe, and the United States. STUDY PARTICIPANTS: A total of 13 546 antiretroviral-naïve HIV-positive patients initiating ART with efavirenz, nevirapine, lopinavir/ritonavir, nelfinavir, or abacavir as third drugs in combination with a zidovudine and lamivudine nucleoside reverse transcriptase inhibitor backbone. MAIN OUTCOME MEASURES: Short-term (24-week) virologic failure (>500 copies/ml) and clinical events within 2 years of ART initiation (incident AIDS-defining event, death, and a composite measure of these two outcomes). RESULTS: Compared with efavirenz as initial third drug, short-term virologic failure was more common with all other third drugs evaluated; nevirapine (adjusted odds ratio = 1.87, 95% confidence interval (CI) = 1.58-2.22), lopinavir/ritonavir (1.32, 95% CI = 1.12-1.57), nelfinavir (3.20, 95% CI = 2.74-3.74), and abacavir (2.13, 95% CI = 1.82-2.50). However, the rate of clinical events within 2 years of ART initiation appeared higher only with nevirapine (adjusted hazard ratio for composite outcome measure 1.27, 95% CI = 1.04-1.56) and abacavir (1.22, 95% CI = 1.00-1.48). CONCLUSION: Among antiretroviral-naïve patients initiating therapy, between-ART regimen, differences in short-term virologic failure do not necessarily translate to differences in clinical outcomes. Our results should be interpreted with caution because of the possibility of residual confounding by indication.

Enteral nutrition and cardiovascular failure: from myths to clinical practice.

Cardiovascular failure and low flow states may arise in very different conditions from both cardiac and noncardiac causes. Systemic hemodynamic failure inevitably alters splanchnic blood flow but in an unpredictable way. Prolonged low splanchnic blood flow causes intestinal ischemia, increased mucosal permeability, endotoxemia, and distant organ failure. Mortality associated with intestinal ischemia is high. Why would enteral nutrition (EN) be desirable in these complex patients when parenteral nutrition could easily cover energy and substrate requirements? Metabolic, immune, and practical reasons justify the use of EN. In addition, continuous enteral feeding minimizes systemic and myocardial oxygen consumption in patients with congestive heart failure. Further, early feeding in critically ill mechanically ventilated patients has been shown to reduce mortality, particularly in the sickest patients. In a series of cardiac surgery patients with compromised hemodynamics, absorption has been maintained, and 1000-1200 kcal/d could be delivered by enteral feeding. Therefore, early EN in stabilized patients should be attempted, and can be carried out safely under close clinical monitoring, looking for signs of incipient intestinal ischemia. Energy delivery and balance should be monitored, and combined feeding considered when enteral feeds cannot be advanced to target within 4-6 days.

Lung Function and Risk for Heart Failure Among Older Adults: The Health ABC Study.

BACKGROUND: The impact of abnormal spirometric findings on risk for incident heart failure among older adults without clinically apparent lung disease is not well elucidated.METHODS: We evaluated the association of baseline lung function with incident heart failure, defined as first hospitalization for heart failure, in 2125 participants of the community-based Health, Aging, and Body Composition (Health ABC) Study (age, 73.6 +/- 2.9 years; 50.5% men; 62.3% white; 37.7% black) without prevalent lung disease or heart failure. Abnormal lung function was defined either as forced vital capacity (FVC) or forced expiratory volume in 1(st) second (FEV1) to FVC ratio below lower limit of normal. Percent predicted FVC and FEV1 also were assessed as continuous variables.RESULTS: During follow-up (median, 9.4 years), heart failure developed in 68 of 350 (19.4%) participants with abnormal baseline lung function, as compared with 172 of 1775 (9.7%) participants with normal lung function (hazard ratio [HR] 2.31; 95% confidence interval [CI], 1.74-3.07; P <.001). This increased risk persisted after adjusting for previously identified heart failure risk factors in the Health ABC Study, body mass index, incident coronary heart disease, and inflammatory markers (HR 1.83; 95% CI, 1.33-2.50; P <.001). Percent predicted (%) FVC and FEV 1 had a linear association with heart failure risk (HR 1.21; 95% CI, 1.11-1.32 and 1.18; 95% CI, 1.10-1.26, per 10% lower % FVC and % FEV1, respectively; both P <.001 in fully adjusted models). Findings were consistent in sex and race subgroups and for heart failure with preserved or reduced ejection fraction.CONCLUSIONS: Abnormal spirometric findings in older adults without clinical lung disease are associated with increased heart failure risk. (C) 2011 Elsevier Inc. All rights reserved. The American Journal of Medicine (2011) 124, 334-341

U.S. 151 Cascade to Dubuque, Dubuque County : project concept and assessment of impacts, 1994

This project concept and assessment of impacts includes information on future four-lane construction of U.S. 151 from the existing four-lane section near Cedar Rapids to Dubuque.