Sodium-glucose cotransporter 2 inhibitors: a practical guide for the Dutch cardiologist based on real-world experience.

Sodium-glucose cotransporter 2 (SGLT2) inhibitors include a relatively new class of glucose-lowering drugs that reduce plasma glucose concentrations by inhibiting proximal tubular reabsorption of glucose in the kidney, while increasing its excretion in urine. Recent large randomised controlled trials have demonstrated that many of these agents reduce the occurrence of major adverse cardiovascular events, hospitalisation for heart failure, cardiovascular death and/or chronic kidney disease progression in patients with and without type 2 diabetes mellitus (DM2). Given their unique insulin-independent mode of action and favourable efficacy and adverse-event profile, SGLT2 inhibitors are promising and they offer an interesting therapeutic approach for the cardiologist to incorporate into routine practice. However, despite accumulating data supporting this class of therapy, cardiologists infrequently prescribe SGLT2 inhibitors, potentially due to a lack of familiarity with their use and the reticence to change DM medication. Here, we provide an up-to-date practical guide highlighting important elements of treatment initiation based on real-world evidence and expert opinion. We describe how to change DM medication, including insulin dosing when appropriate, and how to anticipate any adverse events based on real-world experience in patients with DM2 in the Meander Medical Centre in Amersfoort, the Netherlands. This includes a simple algorithm showing how to initiate SGLT2 inhibitor treatment safely, while considering the consequence of the glucosuric effects of these inhibitors for the individual patient.

Haemodynamic and functional consequences of the iatrogenic atrial septal defect following Mitraclip therapy.

Percutaneous MitraClip placement for treatment of severe mitral regurgitation in high surgical risk patients is a commonly performed procedure and requires a transseptal puncture to reach the left atrium. The resulting iatrogenic atrial septal defect (iASD) is not routinely closed, yet the haemodynamic and functional consequences of a persisting defect are not fully understood. Despite positive effects such as acute left atrial pressure relief, persisting iASDs are associated with negative consequences, namely significant bidirectional shunting and subsequent worse clinical outcome. Percutaneous closure of the iASD may therefore be desirable in selected cases. In this review we discuss the available literature on this matter.

Stable-Isotope Analysis of a Combined Nitrification-Denitrification Sustained by Thermophilic Methanotrophs under Low-Oxygen Conditions.

To simulate growth conditions experienced by microbiota at O(inf2)-limited interfaces of organic matter in compost, an experimental system capable of maintaining dual limitations of oxygen and carbon for extended periods, i.e., a pO(inf2)-auxostat, has been used. (sup15)N tracer studies on thermophilic (53(deg)C) decomposition processes occurring in manure-straw aggregates showed the emission of dinitrogen gas from the reactor as a result of simultaneous nitrification and denitrification at low pO(inf2) values (0.1 to 2.0%, vol/vol). The N loss was confirmed by nitrogen budget studies of the system. Depending on the imposed pO(inf2), 0.6 to 1.4 mmol of N/day (i.e., 20 to 40% of input N) was emitted as N(inf2). When the pO(inf2) was raised, the rates of both nitrification and denitrification increased instantaneously, indicating that ammonia oxidation was limited by oxygen. In auxostats permanently running at pO(inf2) >= 2% (vol/vol), the free ammonium pool was almost completely oxidized and was converted to nitrite plus nitrate and N(inf2) gas. Labelling of the auxostat with [(sup13)C]carbonate was conducted to reveal whether nitrification was of autotrophic or heterotrophic origin. Incorporation of (sup13)CO(inf2) into population-specific cellular compounds was evaluated by profiling the saponifiable phospholipid fatty acids (FAs) by using capillary gas chromatography and subsequently analyzing the (sup13)C/(sup12)C ratios of the individual FAs, after their combustion to CO(inf2), by isotope ratio mass spectrometry. Apart from the observed label incorporation into FAs originating from a microflora belonging to the genus Methylococcus (type X group), supporting nitrification of a methylotrophic nature, this analysis also corroborated the absence of truly autotrophic nitrifying populations. Nevertheless, the extent to which ammonia oxidation continued to exist in this thermophilic community suggested that a major energy gain could be associated with it.

Anaerobic digestion of cellulose fraction of domestic refuse by means of rumen microorganisms.

The anaerobic digestion of a cellulose-enriched fraction of domestic refuse by means of rumen microorganisms in an "artificial rumen" digester was studied. Various combinations of solid and liquid retention times and loading rates were applied to establish optimum conditions for the acidogenic phase digestion of the refuse fraction. An optimal substrate conversion of about 72% was obtained at a loading rate of 23.4 g volatile solids (VS)/L d and a solids retention time of 90 h. Variation of dilution rate between 1.04 and 3.14 fermentor volume turnovers per day had no effect on degradation efficiency. At a loading rate of 23.4 g VS/L d a differential removal rate of solids and liquids appeared to be necessary to obtain an effective degradation of the refuse fraction.

High-Rate two-phase process for the anaerobic degradation of cellulose, employing rumen microorganisms for an efficient acidogenesis.

A novel two-stage anaerobic process for the microbial conversion of cellulose into biogas has been developed. In the first phase, a mixed population of rumen bacteria and ciliates was used in the hydrolysis and fermentation of cellulose. The volatile fatty acids (VFA) produced in this acidogenic reactor were subsequently converted into biogas in a UASB-type methanogenic reactor.A stepwise increase of the loading rate from 11.9 to 25.8 g volatile solids/L reactor volume/day (g VS/L/day) did not affect the degradation efficiency in the acidogenic reactor, whereas the methanogenic reactor appeared to be overloaded at the highest loading rate. Cellulose digestion was almost complete at all loading rates applied. The two-stage anaerobic process was also tested with a closed fluid circuit. In this instance total methane production was 0.438 L CH(4)g VS added, which is equivalent to 98% of the theoretical value. The application of rumen microorganisms in combination with a high-rate methane reactor is proposed as a means of efficient anaerobic degradation of cellulosic residues to methane. Because this newly developed two-phase system is based on processes and microorganisms from the ruminant, it will be referred to as "Rumen Derived Anaerobic Digestion" (RUDAD-) process.

Symbiosis of protozoa with hydrogen-utilizing methanogens.

The symbiotic interaction between bacteria and protozoa is a well-known phenomenon. Endosymbiosis of bacteria in the amoeba Pelomyxa was reported as early as 1902 by Pénard and since then endosymbiosis has been described for a variety of protozoa by many authors. Also episymbiosis of bacteria and protozoa has been observed frequently. However, surprisingly little is known about the physiological interaction of both partners in such a close association. This is mostly because of problems that arise in characterizing the bacteria, and the unknown nature of excretion products of one partner utilized by the other. The discovery of some unique fluorescent cofactors involved in methane biochemistry which are specific for methanogenic bacteria enabled recognition of these microorganisms by fluorescence microscopy. Using this technique, several symbiotic associations between anaerobic protozoa and methanogenic bacteria have been found. The aim of this paper is to review the field and to discuss the possible functions of symbiosis for both bacteria and protozoa.

Methanogenesis: surprising molecules, microorganisms and ecosystems.

Methanogenesis involves a novel set of coenzymes as one-carbon and electron carriers. Consequently, metabolic processes of methanogens deviate from those present in non-methanogenic bacteria. Methanogenic bacteria can be classified on the basis of substrate utilization. Group I (24 species) grows at the expense of hydrogen plus CO2 and/or formate and group II (7 species) uses methanol and/or acetate. Hydrogen-consuming methanogens are found as epi- or endosymbionts of anaerobic ciliates.

Significance of yeast peroxisomes in the metabolism of choline and ethanolamine.

The yeasts Candida utilis and Hansenula polymorpha were able to grow in media containing choline or ethanolamine as the sole nitrogen source. During growth in the presence of these substrates, large peroxisomes developed in the cells, and extracts of choline-grown C. utilis cells contained increased levels of amine oxidase and catalase. Incubation of whole cells with choline in the presence of the amine oxidase inhibitor aminoacetonitrile led to excretion of dimethylamine and methylamine. Cytochemical experiments in which spheroplasts prepared from choline-grown cells were incubated with CeCl3 and choline, trimethylamine, dimethylamine or methylamine revealed positively stained peroxisomes, whereas in the presence of 1 mM aminoacetonitrile staining was not observed. This indicated that choline was degraded via methylated amines and that peroxisomes played a role in its metabolism. A similar involvement of peroxisomes in choline degradation was observed in H. polymorpha. Cell-free extracts of ethanolamine-grown C. utilis and H. polymorpha also contained increased levels of amine oxidase and catalase. Ethanolamine was oxidized by cell-free extracts of both organisms after growth in the presence of ethanolamine or choline. Incubation of spheroplasts of ethanolamine- or choline-grown C. utilis with CeCl3 and ethanolamine resulted in positively stained peroxisomes. In this organism peroxisomes were therefore also involved in ethanolamine degradation.

Development of amine oxidase-containing peroxisomes in yeasts during growth on glucose in the presence of methylamine as the sole source of nitrogen.

The metabolism of methylamine as the nitrogen source for growth of the non-methylotrophic yeast Candida utilis and the methylotrophic yeast Hansenula polymorpha was investigated. Growth of both organisms in media with glucose and methylamine was associated with the presence of an amine oxidase in these cells. The enzyme catalyses the oxidation of methylamine by molecular oxygen into ammonia, formaldehyde and hydrogen peroxide and it is considered to be the key enzyme in methylamine metabolism in the organisms studied. In addition to synthesis of amine oxidase, derepression of catalase, formaldehyde and formate dehydrogenase was also observed upon transfer of cells of the two organisms from media containing ammonium ions into media containing methylamine as the nitrogen source. The synthesis of enzymes was paralleled by the development of a number of large microbodies in the cells. Cytochemical staining experiments indicated that the amine oxidase activity was located in the microbodies in both organisms. Catalase-activity was also demonstrated in these organelles, which can therefore be considered as peroxisomes. The present contribution is the first description of a peroxisomal amine oxidase.