Aims
The aim of this study was to investigate the clinical picture and outcome of cardiogenic shock and to develop a risk prediction score for short‐term mortality.
Methods and results
The CardShock ...study was a multicentre, prospective, observational study conducted between 2010 and 2012. Patients with either acute coronary syndrome (ACS) or non‐ACS aetiologies were enrolled within 6 h from detection of cardiogenic shock defined as severe hypotension with clinical signs of hypoperfusion and/or serum lactate >2 mmol/L despite fluid resuscitation (n = 219, mean age 67, 74% men). Data on clinical presentation, management, and biochemical variables were compared between different aetiologies of shock. Systolic blood pressure was on average 78 mmHg (standard deviation 14 mmHg) and mean arterial pressure 57 (11) mmHg. The most common cause (81%) was ACS (68% ST‐elevation myocardial infarction and 8% mechanical complications); 94% underwent coronary angiography, of which 89% PCI. Main non‐ACS aetiologies were severe chronic heart failure and valvular causes. In‐hospital mortality was 37% (n = 80). ACS aetiology, age, previous myocardial infarction, prior coronary artery bypass, confusion, low LVEF, and blood lactate levels were independently associated with increased mortality. The CardShock risk Score including these variables and estimated glomerular filtration rate predicted in‐hospital mortality well (area under the curve 0.85).
Conclusion
Although most commonly due to ACS, other causes account for one‐fifth of cases with shock. ACS is independently associated with in‐hospital mortality. The CardShock risk Score, consisting of seven common variables, easily stratifies risk of short‐term mortality. It might facilitate early decision‐making in intensive care or guide patient selection in clinical trials.
Trial registration
NCT01374867.
To use parsimony analysis of endemicity and cladistic analysis of distributions and endemism to evaluate two hypotheses addressing biogeographical relationships among Amazonia, the Caatinga forest ...enclaves, Pernambuco Centre and the southern Atlantic Forest. North-eastern Brazil, South America. To find the most parsimonious areagram we analysed a matrix composed of the presence (1) or absence (0) of 745 taxa (i.e. 293 genera and 452 species of woody plants) within 16 localities belonging to the four large regions addressed in this study. One most parsimonious areagram was found and it shows a basal separation between the southern Atlantic Forest and all other regions. This break is followed by a separation between all Caatinga forest enclaves (except Baturité) from a cluster composed of Baturité, the Pernambuco Centre and Amazonia. In this cluster, the most basal separation isolates Baturité from the cluster formed by localities from Amazonia and the Pernambuco Centre. The biogeographical relationships among sites could not be explained by either a random distribution of species among sites or by the geographical distance between sites. We found strong cladistic signal within the raw distribution and phylogenetic data used in our analysis, indicating structured species assemblages in the surveyed localities. They have resulted from the fragmentation of an ancestral biota that was once widely distributed in the region. Our results also support the hypothesis that Atlantic Forest is not a biogeographically natural area, because the Pernambuco Centre is more closely related to Amazonia than to the southern Atlantic Forest. Finally, our data do not support the notion that Caatinga forest enclaves comprise a single biogeographical region, because one Caatinga forest enclave (Baturité) is much more closely related to the cluster formed by Amazonia and the Pernambuco Centre than to other sites. These relationships suggest the occurrence of forest connections between Amazonia and the Atlantic Forests across Caatinga during several periods of the Tertiary and Quaternary. However, palaeoecological data currently available for the Caatinga region are still scarce and do not have either the spatial or temporal resolution required to reconstruct the history of connections among the forests in north-eastern Brazil.
One of the main goals of modern sustainability science is to generate knowledge that societies can use to move toward more sustainable development pathways; however, there are few quantitative ...methods available to assess such pathways. This paper proposes a new index (the Sustainable Development Pathway Index, SDPI) that uses the Euclidean norm to measure the distance between the ideal and the actual development pathways of any geopolitical unit in a determined time frame. We test the new index by evaluating the development pathways of the 517 municipalities of the Brazilian Amazon, one of the world's last economic frontiers, from 1991 to 2010, by simultaneously analyzing indicators of ecological and socioeconomic infrastructures. We show that the region can be described as a mosaic of geopolitical units following distinct development pathways in response to the economic activities and extensive land transformations advancing from the region's southern and eastern borders to its center. This general pattern aligns well with the region's recent history. We outline a research agenda for using the SDPI to document the broad patterns of development pathways and the processes that make them sustainable or unsustainable.
•The Sustainable Development Pathway Index (SDPI) is proposed.•SDPI measures the sustainability of place-based development pathways.•The Brazilian Amazon is used to test the new index.•SDPI is sensitive to local conditions and can be applied worldwide.
Abstract Background Although most patients in the PARADIGM-HF (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial had mild ...symptoms, there is a poor correlation between reported functional limitation and prognosis in heart failure. Objectives The aim of this study was to examine the spectrum of risk in PARADIGM-HF and the effect of LCZ696 across that spectrum. Methods This study analyzed rates of the primary composite outcome of cardiovascular death or heart failure hospitalization, its components, and all-cause mortality using the MAGGIC (Meta-Analysis Global Group in Chronic Heart Failure) and EMPHASIS-HF (Eplerenone in Mild Patients Hospitalization and Survival Study in Heart Failure) risk scores to categorize patients. The authors determined whether risk, on the basis of these scores, modified the treatment effect of LCZ696. Results The complete MAGGIC risk score was available for 8,375 of the 8,399 patients in PARADIGM-HF. The median MAGGIC score was 20 (IQR: 16 to 24). An increase of 1 point was associated with a 6% increased risk for the primary endpoint (p < 0.001) and a 7% increased risk for cardiovascular death (p < 0.001). The benefit of LCZ696 over enalapril for the primary endpoint was similar across the spectrum of risk (p = 0.159). Treating 100 patients for 2 years with LCZ696 instead of enalapril led to 7 fewer patients in the highest quintile of risk experiencing primary outcomes, compared with 3 in the lowest quintile. Analyses using the EMPHASIS-HF risk score gave similar findings. Conclusions Although most PARADIGM-HF patients had mild symptoms, many were at high risk for adverse outcomes and obtained a large absolute benefit from LCZ696, compared with enalapril, over a relatively short treatment period. LCZ696’s benefit was consistent across the spectrum of risk. (PARADIGM-HF trial Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure; NCT01035255 )
The ability of national governments to set and implement policies that protect biodiversity is currently facing widespread scepticism within the conservation movement. Here, we review the literature ...from several disciplines to outline a positive agenda for how the global conservation movement can address this. We combine the strengths of the people-centred and science-led conservation approaches to develop a framework that emphasizes the importance of ecological infrastructure for the long-term prosperity of human societies in an ever-changing world. We show that one of the major goals of the conservation movement (enhancing global ecological infrastructure to end species and ecosystem loss) remains central and irreplaceable within the broad sustainable development agenda. Then, we argue that the conservation community is now more prepared than ever to face the challenge of supporting societies in designing the ecological infrastructure they need to move towards more sustainable states. Because it is where global and local priorities meet, the national level is where impactful changes can be made. Furthermore, we point out two priorities for the conservation movement for the next decade: (1) substantially increase the amount of financial resources dedicated to conservation; and (2) advance the next generation of policies for ecological infrastructure.
In a world where changes in land cover and climate happen faster than ever due to the expansion of human activities, narrowly distributed species are predicted to be the first to go extinct. Studies ...projecting species extinction in tropical regions consider either habitat loss or climate change as drivers of biodiversity loss but rarely evaluate them together. Here, the contribution of these two factors to the extinction risk of narrowly distributed species (with ranges smaller than 10,000 km
) of seed plants endemic to a fifth-order watershed in Brazil (microendemics) is assessed. We estimated the Regional Climate Change Index (RCCI) of these watersheds (areas with microendemics) and projected three scenarios of land use up to the year 2100 based on the average annual rates of habitat loss in these watersheds from 2000 to 2014. These scenarios correspond to immediate conservation action (scenario 1), long-term conservation action (scenario 2), and no conservation action (scenario 3). In each scenario, areas with microendemics were classified into four classes: (1) areas with low risk, (2) areas threatened by habitat loss, (3) areas threatened by climate change, and (4) areas threatened by climate change and habitat loss. We found 2,354 microendemic species of seed plants in 776 areas that altogether cover 17.5% of Brazil. Almost 70% (1,597) of these species are projected to be under high extinction risk by the end of the century due to habitat loss, climate change, or both, assuming that these areas will not lose habitat in the future due to land use. However, if habitat loss in these areas continues at the prevailing annual rates, the number of threatened species is projected to increase to more than 85% (2,054). The importance of climate change and habitat loss as drivers of species extinction varies across phytogeographic domains, and this variation requires the adoption of retrospective and prospective conservation strategies that are context specific. We suggest that tropical countries, such as Brazil, should integrate biodiversity conservation and climate change policies (both mitigation and adaptation) to achieve win-win social and environmental gains while halting species extinction.
•We evaluated changes in human welfare in the Brazilian Amazonia from 2005 to 2012.•Signals of a boom-and-bust pattern are weak at the regional and state level.•Urbanization does not lead to positive ...changes in human welfare.•Public investments and agriculture are negatively associated with human welfare growth.•State-level policies influence regional trends in human welfare.
The relationship between human welfare and deforestation in the Brazilian Amazonia has traditionally been thought to follow a boom-and-bust pattern. According to this pattern, forest clearing triggers rapid increases in human welfare levels (“the boom”) due to short-term economic gains; these levels then drop to below national or regional averages (“the bust”) after the forest stocks have declined, thus causing the local populations to become deprived of ecosystem services. However, recent studies have questioned the validity of this boom-and-bust pattern. In this paper, we use panel data and simultaneous autoregressive models to evaluate the effects of deforestation, urbanization, public investments, agriculture, and state policies on temporal changes in human welfare that occurred across multiple municipalities in the Brazilian Amazonia from 2005 to 2012, a period during which governments implemented a set of strategies aimed at controlling deforestation across the region. We found that: (a) signals of a boom-and-bust pattern are weak at the regional level, and therefore this pattern cannot be generalized across the entire region; (b) human welfare is increasing more rapidly in low-development municipalities than in high-development cities, and all municipalities are converging on at least one regional average rather than on a national average; (c) urbanization does not lead to positive changes in human welfare, which indicates that the infrastructure available in regional urban centers is limited; (d) public investments are negatively associated with human welfare growth, thus signifying that if public investments are not used to leverage the potential of other sectors of the local economy, human welfare will not improve; (e) agriculture is negatively associated with positive changes in human welfare at the local level, possibly due to the dominance of cattle-ranching as the predominant economic activity of this sector; and (f) state-level policies matter, and future analyses of regional trends in the realm of development and conservation across this region should take such policies into account. Finally, we suggest that although human welfare and deforestation retain a weak statistical relationship, we cannot contend that they have been fully decoupled. Forest loss across the region is still pervasive, and institutions are too weak to sustain the transition from a frontier development model to a conservation-centered model.
The prevalence of pre-diabetes mellitus and its consequences in patients with heart failure and reduced ejection fraction are not known. We investigated these in the Prospective Comparison of ARNI ...With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial.
We examined clinical outcomes in 8399 patients with heart failure and reduced ejection fraction according to history of diabetes mellitus and glycemic status (baseline hemoglobin A1c HbA1c: < 6.0% < 42 mmol/mol, 6.0%-6.4% 42-47 mmol/mol; pre-diabetes mellitus, and ≥ 6.5% ≥ 48 mmol/mol; diabetes mellitus), in Cox regression models adjusted for known predictors of poor outcome. Patients with a history of diabetes mellitus (n = 2907 35%) had a higher risk of the primary composite outcome of heart failure hospitalization or cardiovascular mortality compared with those without a history of diabetes mellitus: adjusted hazard ratio, 1.38; 95% confidence interval, 1.25 to 1.52; P < 0.001. HbA1c measurement showed that an additional 1106 (13% of total) patients had undiagnosed diabetes mellitus and 2103 (25%) had pre-diabetes mellitus. The hazard ratio for patients with undiagnosed diabetes mellitus (HbA1c, > 6.5%) and known diabetes mellitus compared with those with HbA1c < 6.0% was 1.39 (1.17-1.64); P < 0.001 and 1.64 (1.43-1.87); P < 0.001, respectively. Patients with pre-diabetes mellitus were also at higher risk (hazard ratio, 1.27 1.10-1.47; P < 0.001) compared with those with HbA1c < 6.0%. The benefit of LCZ696 (sacubitril/valsartan) compared with enalapril was consistent across the range of HbA1c in the trial.
In patients with heart failure and reduced ejection fraction, dysglycemia is common and pre-diabetes mellitus is associated with a higher risk of adverse cardiovascular outcomes (compared with patients with no diabetes mellitus and HbA1c < 6.0%). LCZ696 was beneficial compared with enalapril, irrespective of glycemic status.
URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
Ecosystems as infrastructure Silva, José Maria Cardoso da; Wheeler, Emily
Perspectives in ecology and conservation,
January-March 2017, 2017-01-00, 2017-01-01, Letnik:
15, Številka:
1
Journal Article
Recenzirano
Odprti dostop
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•The concept of ecosystems as infrastructure is reviewed.•The terms green, ecological, natural, and blue have been used in the literature.•Green infrastructure is the most commonly ...used name.•A more inclusive concept for green infrastructure is proposed.•Design principles for green infrastructure at all spatial scales are suggested.
Infrastructure is usually defined as all elements of interrelated systems that provide goods and services essential to enabling, sustaining or enhancing societal living conditions. Although traditionally, infrastructure included only all human-made assets, since the 1980s, both scientists and conservationists have suggested that ecosystems should be also considered as a type of infrastructure. Here we review the evolution of the concepts of ‘ecological’, ‘green’, ‘natural’ and ‘blue’ infrastructures and evaluate how these concepts have been used in the scientific literature. We found that although the term ‘ecological infrastructure’ was the most used until 2004, ‘green infrastructure’ became the dominant one after then. All terms have been applied mostly to urban settings, terrestrial ecosystems and emphasised supporting and regulating ecosystem services, with a strong emphasis on the mediation of water flows in urban centres and the maintenance of species lifecycles, habitat and gene pool protection. We suggest that green infrastructure should be the term adopted to facilitate communication between scientists, conservationists and decision-makers. We also suggest a general concept for green infrastructure aligned with the major global conventions alongside a set of design principles.
Vasopressors and inotropes remain a cornerstone in stabilization of the severely impaired hemodynamics and cardiac output in cardiogenic shock (CS). The aim of this study was to analyze current ...real-life use of these medications, and their impact on outcome and on changes in cardiac and renal biomarkers over time in CS.
The multinational CardShock study prospectively enrolled 219 patients with CS. The use of vasopressors and inotropes was analyzed in relation to the primary outcome, i.e., 90-day mortality, with propensity score methods in 216 patients with follow-up data available. Changes in cardiac and renal biomarkers over time until 96 hours from baseline were analyzed with linear mixed modeling.
Patients were 67 (SD 12) years old, 26 % were women, and 28 % had been resuscitated from cardiac arrest prior to inclusion. On average, systolic blood pressure was 78 (14) and mean arterial pressure 57 (11) mmHg at detection of shock. 90-day mortality was 41 %. Vasopressors and/or inotropes were administered to 94 % of patients and initiated principally within the first 24 hours. Noradrenaline and adrenaline were given to 75 % and 21 % of patients, and 30 % received several vasopressors. In multivariable logistic regression, only adrenaline (21 %) was independently associated with increased 90-day mortality (OR 5.2, 95 % CI 1.88, 14.7, p = 0.002). The result was independent of prior cardiac arrest (39 % of patients treated with adrenaline), and the association remained in propensity-score-adjusted analysis among vasopressor-treated patients (OR 3.0, 95 % CI 1.3, 7.2, p = 0.013); this was further confirmed by propensity-score-matched analysis. Adrenaline was also associated, independent of prior cardiac arrest, with marked worsening of cardiac and renal biomarkers during the first days. Dobutamine and levosimendan were the most commonly used inotropes (49 % and 24 %). There were no differences in mortality, whether noradrenaline was combined with dobutamine or levosimendan.
Among vasopressors and inotropes, adrenaline was independently associated with 90-day mortality in CS. Moreover, adrenaline use was associated with marked worsening in cardiac and renal biomarkers. The combined use of noradrenaline with either dobutamine or levosimendan appeared prognostically similar.
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