Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt

Pyrosequencing and comparative analysis of Xylella fastidiosa genomes

Xylella fastidiosa é uma bactéria Gram-negativa, do subgrupo das Gama-Proteobactérias, não-flagelada, que coloniza o xilema de diversas plantas cultivadas e silvestres, podendo ser causadora de doenças. Sua disseminação é feita por insetos conhecidos como cigarrinhas. Genomas de cepas de X. fastidiosa isoladas de distintos hospedeiros já foram sequenciados completa ou parcialmente: 9a5c de citros; Temecula-1 e GB514 de videira; Dixon, M12 e M23 de amendoeira; Ann-1 de espirradeira e EB92-1, isolada de sabugueiro e utilizada como bio-controle para Doença de Pierce de videiras. Estudos de genômica comparativa associados a abordagens de genômica funcional e de genética molecular têm possibilitado o estudo detalhado de mecanismos potencialmente relevantes tanto para a colonização de plantas e insetos por este fitopatógeno como para o desenvolvimento de sintomas associados a doenças específicas em seus respectivos hospedeiros vegetais. Exceto o genoma de 9a5c, todos os demais genomas conhecidos são de cepas isoladas na América do Norte. Neste trabalho descrevemos o pirossequenciamento dos genomas da cepa J1a12, que exibe fenótipo não-virulento em citros, e das cepas Pr8x e Hib4, isoladas, respectivamente, de ameixeira e hibisco. A cepa J1a12 possui além de seu cromossomo principal de 2.788.789 pb dois plasmídeos, pXF51 e pXF27, respectivamente de 51.180 pb e 27.268 pb. pXF51 já foi descrito também na cepa de citros 9a5c e pXF27 tem similaridade com outros plasmídeos de cepas de X. fastidiosa norte-americanas isoladas de amoreira e videira. A cepa Pr8x possui além de seu cromossomo principal de 2.666.242 pb um plasmídeo, pXF39, de 39.580 pb, o qual contém a maioria das CDS presentes no pXF51. A cepa Hib4, isolada de hibisco, tem o maior cromossomo (2.813.297 pb) e também o maior plasmídeo (pXF64 com 64.251 pb) já descritos para X. fastidiosa. pXF64 apresenta extensa similaridade com o plasmídeo pBVIE04 de Burkholderia vietnamensis cepa G4, sendo descrito pela primeira vez em cepas de X. fastidiosa. Análises comparativas destes genomas possibilitaram a identificação de alterações que podem ser correlacionadas com os fenótipos exibidos por estas cepas, além da variedade e diversidade de regiões relacionadas a bacteriófagos e de plasmídeos que co-existem nas diferentes cepas deste fitopatógeno.Xylella fastidiosa is a Gram-negative bacteria, of the Gamma-proteobacterium subgroup, non-flagellated that colonizes the xylem of several cultivated and wild plants, where may cause disease. The bacterium is spread by insects known as sharpshooters. Genomes of X. fastidiosa strains isolated from different hosts have been completely or partially sequenced: 9a5c from citrus; Temecula-1 and GB514 from grapevine; Dixon, M12 and M23 from almond tree; Ann-1 from oleander and EB92-1, isolated from elderberry and used as bio-control for Pierce\'s disease of grapevines. Comparative genomics studies associated with approaches from functional genomics and molecular genetics have allowed a detailed study of mechanisms potentially relevant to the colonization of plants and insects by this pathogen as well as to the development of symptoms associated with specific diseases in their respective host plants. Except for 9a5c, all other known genomes are from strains isolated in North America. Here we describe the pyrosequencing of the genomes of strain J1a12, which displays non-virulent phenotype in citrus and of Pr8x and Hib4 strains isolated, respectively, from plum and hibiscus. J1a12 has a main chromosome of 2,788,789 bp and two plasmids, pXF51 and pXF27, respectively of 51,180 bp and 27,268 bp. pXF51 has been described also in the citrus strain 9a5c and pXF27 has similarity with other plasmids found in North American strains isolated from mulberry tree and grapevine. The strain Pr8x has a main chromosome of 2,666,242 bp and one plasmid, pXF39, of 39,580 bp which present similarities with pXF51. Hib4, the strain isolated from hibiscus, has the largest chromosome (2,813,297 bp) and the largest plasmid (pXF64 with 64,251 bp) described for X. fastidiosa. pXF64 shows extensive similarity with the plasmid pBVIE04 of Burkholderia vietnamensis G4 strain and is described for the first time in X. fastidiosa. Comparative analyzes of these genomes have identified several differences that may be correlated with the phenotypes displayed by these strains, in addition to the variety and diversity of regions related to bacteriophages and plasmids that co-exist in different strains of this pathogen

Comparative transcriptomic of Xylella fastidiosa strains

O fitopatógeno Xylella fastidiosa coloniza o lúmen dos vasos do xilema de seus hospedeiros e o aparelho bucal do inseto-vetor. É responsável por doenças de extrema gravidade em videira, laranjeira, e oliveira, entre outras plantas de relevância econômica. Há evidência de especificidade entre cepas de X. fastidiosa e as diferentes espécies de plantas que colonizam, mas as bases moleculares desta interação são desconhecidas. O objetivo central deste trabalho foi elucidar o repertório completo de genes expressos e/ou diferencialmente expressos por diferentes cepas X. fastidiosa em meios e tempos de cultivo distintos e relacionar as respostas transcricionais a mecanismos de virulência, patogenicidade e especificidade ao hospedeiro. Foram sequenciados, analisados e comparados os transcritomas de cepas de laranjeiras (9a5c, J1a12, U24d e Fb7), de cafeeiro (3124), de hibisco (Hib4), ameixeira (Pr8x) e de videira (Temecula1), no início e fim da fase a exponencial de crescimento populacional em meio rico PWG e em meio mínimo PIM6, que mimetiza a seiva do xilema. Foi observado que a maioria dos genes de X. fastidiosa é expressa, ainda que, dependendo da cepa e da condição experimental, 40-80% dos transcritos sejam pouco abundantes. Por outro lado, foi verificado um conjunto de transcritos muito abundantes, uma parte deles comuns a todas as cepas, e que incluem os ncRNAs 6S e RNAse P, além de transcritos de microcinas, proteases, lipases, proteínas de resposta a estresse e proteínas de função desconhecida. Além da definição de perfis transcricionais, foram descritas as regiões 5\' e 3\' não-traduzidas dos transcritos. As estruturas de 545 e 386 operons expressos, respectivamente pelas cepas 9a5c e Temecula1, também foram mapeadas, e pela primeira vez foi obtido o perfil de sRNAs expressos por X. fastidiosa. As análises de expressão diferencial entre transcritomas das duas fases de crescimento no mesmo meio indicam que o estresse gerado pela limitação nutricional do meio PIM6 exigiu mudanças mais drásticas na expressão gênica do que no meio PWG. Foi também observado que diferentes cepas respondem de maneiras distintas a uma mesma condição, indicando que genes ortólogos são regulados de formas diferentes. Além disso, a transcritômica comparativa revelou diferenças relevantes na regulação gênica de cepas de hospedeiros vegetais distintos que podem estar relacionadas à especificidade ao hospedeiro. Por fim, as análises dos transcritomas evidenciaram vários genes candidatos que poderão ser futuramente investigados quanto ao seu papel na biologia e na virulência de X. fastidiosa.The phytopathogenXylella fastidiosa colonizes the lumen of xylem vessels from its hosts and the mouth apparatus of the insect-vector. It is responsible for severe diseases in grapevine, orange and olive trees, among other plants of economic relevance. There is evidence for specificity between X. fastidiosa strains and the different plant species they colonize, but the molecular bases of this interaction are unknown. The main objective of this work was elucidate the complete repertoire of expressed and/or differentially expressed genes by different X. fastidiosa strains in distinct media and growth times and associate transcriptional responses to virulence mechanisms, pathogenicity and host specificity. Transcriptomes of orange strains (9a5c, J1a12, U24d and Fb7), coffee (3124), hibiscus (Hib4), plum (Pr8x) and grapevine (Temecula1), were sequenced, analyzed and compared from cells at the beginning and end stages of exponential growth phase in rich medium PWG and in minimum medium PIM6, which mimics xylem sap. It was observed that the majority of X. fastidiosa genes is expressed, although, depending of the strain and experimental condition, 40-80% of transcripts are less abundant. On the other hand, it was verified a set of more abundant transcripts, some of them shared by all strains, including 6S and RNAse P ncRNAs as well as transcripts for microcins, proteases, lipases, stress response proteins and proteins of unknown function. Besides the definition of transcriptional profiles, 5\' and 3\' untranslated regions of transcripts were described. The structure of 545 and 386 expressed operons, respectively for 9a5c and Temecula1 strains, were also mapped, and for the first time the expressed profile of sRNAs in X. fastidiosa was obtained. The differential expression analyzes between transcriptomes of two growth phases in the same medium indicate that the stress generated by nutritional limitation of PIM6 medium required more drastic changes in gene expression than PWG medium. It was also observed that different strains respond in distinct manners to a same condition, indicating that orthologous genes are regulated in different ways. Moreover, comparative transcriptomics revealed relevant differences in gene regulation of strain of distinct plant hosts that can be related to host specificity. Lastly, transcriptomic analyzes pointed to several gene candidates that could be further investigated for their roles in X. fastidiosa biology and virulence

Transcriptome and Secretome Analyses of Endophyte <i>Methylobacterium mesophilicum</i> and Pathogen <i>Xylella fastidiosa</i> Interacting Show Nutrient Competition

Xylella fastidiosa is the causal agent of several plant diseases affecting fruit and nut crops. Methylobacterium mesophilicum strain SR1.6/6 was isolated from Citrus sinensis and shown to promote plant growth by producing phytohormones, providing nutrients, inhibiting X. fastidiosa, and preventing Citrus Variegated Chlorosis. However, the molecular mechanisms involved in the interaction among these microbes are still unclear. The present work aimed to analyze physiological and molecular aspects of M. mesophilicum SR1.6/6 and X. fastidiosa 9a5c in co-culture. The transcriptome and secretome analyses indicated that X. fastidiosa down-regulates cell division and transport genes and up-regulates stress via induction of chaperones and pathogenicity-related genes including, the lipase-esterase LesA, a protease, as well as an oligopeptidase in response to M. mesophilicum competition. On the other hand, M. mesophilicum also down-regulated transport genes, except for iron uptake, which was up-regulated. Secretome analysis identified four proteins in M. mesophilicum exclusively produced in co-culture with X. fastidiosa, among these, three are related to phosphorous uptake. These results suggest that M. mesophilicum inhibits X. fastidiosa growth mainly due to nutrient competition for iron and phosphorous, thus promoting X. fastidiosa starvation, besides producing enzymes that degrade X. fastidiosa cell wall, mainly hydrolases. The understanding of these interactions provides a direction for control and management of the phytopathogen X. fastidiosa, and consequently, helps to improve citrus growth and productivity

The XadA trimeric autotransporter adhesins in Xylella fastidiosa differentially contribute to cell aggregation, biofilm formation, insect transmission and virulence to plants.

Surface adhesion strategies are widely employed by bacterial pathogens during establishment and systemic spread in their host. A variety of cell surface appendages such as pili, fimbriae and afimbrial adhesins are involved in these processes. The phytopathogen Xylella fastidiosa employs several of these structures for efficient colonization of its insect and plant hosts. Among the adhesins encoded in the X. fastidiosa genome, three afimbrial adhesins, XadA1, Hsf/XadA2, and XadA3, are predicted to be trimeric autotransporters with a C-terminal YadA-anchor membrane domain. We analyzed the individual contributions of XadA1, XadA2, and XadA3 to various cellular behaviors both in vitro and in vivo. Using isogenic X. fastidiosa mutants, we found that cell-cell aggregation and biofilm formation were severely impaired in the absence of XadA3. No significant reduction of cell-surface attachment was found with any mutant under flow conditions. Acquisition by insect vectors and transmission to grapevines were reduced in the XadA3 deletion mutant. While the XadA3 mutant was hypervirulent in grapevines, XadA1 or XadA2 deletion mutants conferred lower disease severity than the wild-type strain. This insight of the importance of these adhesive proteins and their individual contributions to different aspects of X. fastidiosa biology should guide new approaches to reduce pathogen transmission and disease development

Xylella fastidiosa subsp. pauca Strains Fb7 and 9a5c from Citrus Display Differential Behavior, Secretome, and Plant Virulence.

Xylella fastidiosa colonizes the xylem of various cultivated and native plants worldwide. Citrus production in Brazil has been seriously affected, and major commercial varieties remain susceptible to Citrus Variegated Chlorosis (CVC). Collective cellular behaviors such as biofilm formation influence virulence and insect transmission of X. fastidiosa. The reference strain 9a5c produces a robust biofilm compared to Fb7 that remains mostly planktonic, and both were isolated from symptomatic citrus trees. This work deepens our understanding of these distinct behaviors at the molecular level, by comparing the cellular and secreted proteomes of these two CVC strains. Out of 1017 identified proteins, 128 showed differential abundance between the two strains. Different protein families were represented such as proteases, hemolysin-like proteins, and lipase/esterases, among others. Here we show that the lipase/esterase LesA is among the most abundant secreted proteins of CVC strains as well, and demonstrate its functionality by complementary activity assays. More severe symptoms were observed in Nicotiana tabacum inoculated with strain Fb7 compared to 9a5c. Our results support that systemic symptom development can be accelerated by strains that invest less in biofilm formation and more in plant colonization. This has potential application in modulating the bacterial-plant interaction and reducing disease severity

Rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART): Study protocol for a randomized controlled trial

Background: Acute respiratory distress syndrome (ARDS) is associated with high in-hospital mortality. Alveolar recruitment followed by ventilation at optimal titrated PEEP may reduce ventilator-induced lung injury and improve oxygenation in patients with ARDS, but the effects on mortality and other clinical outcomes remain unknown. This article reports the rationale, study design, and analysis plan of the Alveolar Recruitment for ARDS Trial (ART). Methods/Design: ART is a pragmatic, multicenter, randomized (concealed), controlled trial, which aims to determine if maximum stepwise alveolar recruitment associated with PEEP titration is able to increase 28-day survival in patients with ARDS compared to conventional treatment (ARDSNet strategy). We will enroll adult patients with ARDS of less than 72 h duration. The intervention group will receive an alveolar recruitment maneuver, with stepwise increases of PEEP achieving 45 cmH(2)O and peak pressure of 60 cmH2O, followed by ventilation with optimal PEEP titrated according to the static compliance of the respiratory system. In the control group, mechanical ventilation will follow a conventional protocol (ARDSNet). In both groups, we will use controlled volume mode with low tidal volumes (4 to 6 mL/kg of predicted body weight) and targeting plateau pressure <= 30 cmH2O. The primary outcome is 28-day survival, and the secondary outcomes are: length of ICU stay; length of hospital stay; pneumothorax requiring chest tube during first 7 days; barotrauma during first 7 days; mechanical ventilation-free days from days 1 to 28; ICU, in-hospital, and 6-month survival. ART is an event-guided trial planned to last until 520 events (deaths within 28 days) are observed. These events allow detection of a hazard ratio of 0.75, with 90% power and two-tailed type I error of 5%. All analysis will follow the intention-to-treat principle. Discussion: If the ART strategy with maximum recruitment and PEEP titration improves 28-day survival, this will represent a notable advance to the care of ARDS patients. Conversely, if the ART strategy is similar or inferior to the current evidence-based strategy (ARDSNet), this should also change current practice as many institutions routinely employ recruitment maneuvers and set PEEP levels according to some titration method.13Hospital do Coracao (HCor) as part of the Program 'Hospitais de Excelencia a Servico do SUS (PROADI-SUS)'Brazilian Ministry of Healt