Persistent Pulmonary Hypertension in Corrected Valvular Heart Disease: Hemodynamic Insights and Long-Term Survival.

Background The determinants and consequences of pulmonary hypertension after successfully corrected valvular heart disease remain poorly understood. We aim to clarify the hemodynamic bases and risk factors for mortality in patients with this condition. Methods and Results We analyzed long-term follow-up data of 222 patients with pulmonary hypertension and valvular heart disease successfully corrected at least 1 year before enrollment who had undergone comprehensive hemodynamic and imaging characterization as per the SIOVAC (Sildenafil for Improving Outcomes After Valvular Correction) clinical trial. Median (interquartile range) mean pulmonary pressure was 37 mm Hg (32-44 mm Hg) and pulmonary artery wedge pressure was 23 mm Hg (18-26 mm Hg). Most patients were classified either as having combined precapillary and postcapillary or isolated postcapillary pulmonary hypertension. After a median follow-up of 4.5 years, 91 deaths accounted for 4.21 higher-than-expected mortality in the age-matched population. Risk factors for mortality were male sex, older age, diabetes mellitus, World Health Organization functional class III and higher pulmonary vascular resistance-either measured by catheterization or approximated from ultrasound data. Higher pulmonary vascular resistance was related to diabetes mellitus and smaller residual aortic and mitral valve areas. In turn, the latter correlated with prosthetic nominal size. Six-month changes in the composite clinical score and in the 6-minute walk test distance were related to survival. Conclusions Persistent valvular heart disease-pulmonary hypertension is an ominous disease that is almost universally associated with elevated pulmonary artery wedge pressure. Pulmonary vascular resistance is a major determinant of mortality in this condition and is related to diabetes mellitus and the residual effective area of the corrected valve. These findings have important implications for individualizing valve correction procedures. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT00862043.This study was funded by the Instituto de Salud Carlos III, Ministerio de Ciencia e Innovación, Spain, the European Union–European Regional Development Fund (EC07/90772 and PI19/00649), and the Consorcio de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV).S

Egg Eviction Imposes a Recoverable Cost of Virulence in Chicks of a Brood Parasite

Background: Chicks of virulent brood parasitic birds eliminate their nestmates and avoid costly competition for foster parental care. Yet, efforts to evict nest contents by the blind and naked common cuckoo Cuculus canorus hatchling are counterintuitive as both adult parasites and large older cuckoo chicks appear to be better suited to tossing the eggs and young of the foster parents. Methodology/Principal Findings: Here we show experimentally that egg tossing imposed a recoverable growth cost of mass gain in common cuckoo chicks during the nestling period in nests of great reed warbler Acrocephalus arundinaceus hosts. Growth rates of skeletal traits and morphological variables involved in the solicitation of foster parental care remained similar between evictor and non-evictor chicks throughout development. We also detected no increase in predation rates for evicting nests, suggesting that egg tossing behavior by common cuckoo hatchlings does not increase the conspicuousness of nests. Conclusion: The temporary growth cost of egg eviction by common cuckoo hatchlings is the result of constraints imposed by rejecter host adults and competitive nestmates on the timing and mechanism of parasite virulence.Michael G. Anderson, Csaba Moskát, Miklós Bán, Tomáš Grim, Phillip Cassey and Mark E. Haube

A922 Sequential measurement of 1 hour creatinine clearance (1-CRCL) in critically ill patients at risk of acute kidney injury (AKI)

Meeting abstrac

Habitat-dependent changes in vigilance behaviour of Red-crowned Crane influenced by wildlife tourism

The Endangered Red-crowned Crane (Grus japonensis) is one of the most culturally iconic and sought-after species by wildlife tourists. Here we investigate how the presence of tourists influence the vigilance behaviour of cranes foraging in Suaeda salsa salt marshes and S. salsa/Phragmites australis mosaic habitat in the Yellow River Delta, China. We found that both the frequency and duration of crane vigilance significantly increased in the presence of wildlife tourists. Increased frequency in crane vigilance only occurred in the much taller S. salsa/P. australis mosaic vegetation whereas the duration of vigilance showed no significant difference between the two habitats. Crane vigilance declined with increasing distance from wildlife tourists in the two habitats, with a minimum distance of disturbance triggering a high degree of vigilance by cranes identified at 300 m. The presence of wildlife tourists may represent a form of disturbance to foraging cranes but is habitat dependent. Taller P. australis vegetation serves primarily as a visual obstruction for cranes, causing them to increase the frequency of vigilance behaviour. Our findings have important implications for the conservation of the migratory red-crowned crane population that winters in the Yellow River Delta and can help inform visitor management

Four Dimensions of Journalistic Convergence: A preliminary approach to current media trends at Spain

Convergence is a very polysemous concept that has been used to describe various trends in journalism that have something in common: the blurring of the limits between different media, professional skills and roles. This paper proposes to analytically structure convergence into four dimensions: integrated production, multiskilled professionals, multiplatform delivery and active audience. This analytical grid can help in exploring convergence avoiding deterministic assumptions and allowing to map its development in different media companies as an open process with diverse outcomes. A sample of 58 Spanish cases is studied using the conceptual framework. Multiplatform delivery is the most popular convergence strategy, and in any given dimension developments tend not to radically change established professional routines and values. Integration and multiskilling dimensions seem to be closely related and mainly developed in local and regional media with small staffs. Delivery and audience strategies are more complex in national media

Treatment with tocilizumab or corticosteroids for COVID-19 patients with hyperinflammatory state: a multicentre cohort study (SAM-COVID-19)

Objectives: The objective of this study was to estimate the association between tocilizumab or corticosteroids and the risk of intubation or death in patients with coronavirus disease 19 (COVID-19) with a hyperinflammatory state according to clinical and laboratory parameters. Methods: A cohort study was performed in 60 Spanish hospitals including 778 patients with COVID-19 and clinical and laboratory data indicative of a hyperinflammatory state. Treatment was mainly with tocilizumab, an intermediate-high dose of corticosteroids (IHDC), a pulse dose of corticosteroids (PDC), combination therapy, or no treatment. Primary outcome was intubation or death; follow-up was 21 days. Propensity score-adjusted estimations using Cox regression (logistic regression if needed) were calculated. Propensity scores were used as confounders, matching variables and for the inverse probability of treatment weights (IPTWs). Results: In all, 88, 117, 78 and 151 patients treated with tocilizumab, IHDC, PDC, and combination therapy, respectively, were compared with 344 untreated patients. The primary endpoint occurred in 10 (11.4%), 27 (23.1%), 12 (15.4%), 40 (25.6%) and 69 (21.1%), respectively. The IPTW-based hazard ratios (odds ratio for combination therapy) for the primary endpoint were 0.32 (95%CI 0.22-0.47; p < 0.001) for tocilizumab, 0.82 (0.71-1.30; p 0.82) for IHDC, 0.61 (0.43-0.86; p 0.006) for PDC, and 1.17 (0.86-1.58; p 0.30) for combination therapy. Other applications of the propensity score provided similar results, but were not significant for PDC. Tocilizumab was also associated with lower hazard of death alone in IPTW analysis (0.07; 0.02-0.17; p < 0.001). Conclusions: Tocilizumab might be useful in COVID-19 patients with a hyperinflammatory state and should be prioritized for randomized trials in this situatio

Registro ACESUR: atención de pacientes adultos con crisis epilépticas en servicios de urgencias: diferencias entre primer episodio y recurrencia

Objetivo. Describir las características y la atención recibida de pacientes adultos que consultan por crisis epiléptica (CE) en los servicios de urgencias hospitalarios (SUH), diferenciando entre primera crisis y recurrencia en epiléptico conocido. Método. ACESUR es un registro observacional de cohortes multipropósito, prospectivo y multicéntrico con un muestreo sistemático, los días pares de febrero y julio alternando con los impares de abril y octubre de 2017. Se incluyeron pacientes 18 años con diagnóstico de CE en los SUH. Se recogieron variables clínico-asistenciales de la visita índice de pacientes, distinguiendo entre primera CE y recurrencia en epiléptico. Resultados. El registro ACESUR recogió a 664 pacientes procedentes de 18 SUH españoles, 229 (34, 5%) con primera CE y 435 (65, 5%) con CE recurrentes. Los pacientes con primera CE fueron de mayor edad (p < 0, 001), presentaron motivos de consulta distintos (p < 0, 001) y requirieron más traslados en ambulancia (p < 0, 001). La atención recibida en el SUH fue diferente, en pacientes con primera CE se solicitó con mayor probabilidad una prueba complementaria específica (OR ajustada = 13, 94; IC95%:7, 29-26, 7; p < 0, 001) y se necesitó mayor hospitalización o estancia prolongada en el SUH (OR ajustada = 1, 69; IC95%:1, 11-2, 58; p = 0, 015). No hubo diferencias en cuanto al tratamiento farmacológico en fase aguda ni preventivo (OR ajustada = 1, 40; IC95%:0, 94-2, 09; p = 0, 096). Se inició tratamiento con fármacos antiepiépticos (FAE) en 100 pacientes (43, 7%) tras primera CE y se reinició o modificó añadiendo nuevo FAE en 142 pacientes (32, 6%) con CE recurrentes. Conclusiones. Las características clínicas y la atención recibida de pacientes adultos con primera CE en SUH en España difieren de las recurrencias en epiléptico conocido. Objective. To describe the characteristics of care received by patients who come to the emergency department with a first epileptic seizure versus a recurrent seizure in a patient with diagnosed epilepsy. Methods. ACESUR (Acute Epileptic Seizures in the Emergency Department) is a prospective multicenter, multipurpose registry of cases obtained by systematic sampling on even days in February and July 2017 and on odd days in April and October 2017. Patients were aged 18 years or older and had an emergency department diagnosis of epileptic seizure. We recorded clinical variables and details related to care given during each patient''s visit, including whether the event was a first or recurrent seizure. Results. A total of 664 patients attended by 18 Spanish emergency departments were entered into the ACESUR registry. Two hundred twenty-nine (34.5%) were first seizures and 435 (65.5%) were recurrences. Patients who were attended for first seizures were older, consulted for a wider variety of reasons, and were transported in ambulances (P<.001, all comparisons). Care received differed between patients with first seizures versus recurrent seizures. Specific complementary testing was more likely in patients with first seizures (adjusted odds ratio [aOR], 13.94; 95% CI, 29-26.7; P<.001), and they were more often hospitalized or stayed longer in the emergency department, (aOR, 1.69; 95% CI, 1.11-2.58; P=.015). Pharmacologic treatment did not differ between the groups, either in the acute phase or for prevention (aOR, 1.40; 95% CI, 0.94-2.09; P=.096). Antiepileptic drugs were given to 100 patients (43.7%) after a first seizure and were restarted or changed in 142 patients with recurrent seizure (32.6%). Conclusions. The clinical characteristics of adults attended for a first epileptic seizure differ from those of patients with diagnosed epilepsy who were attended for recurrent seizures in Spain. The care received also differs

Riociguat treatment in patients with chronic thromboembolic pulmonary hypertension: Final safety data from the EXPERT registry

Objective: The soluble guanylate cyclase stimulator riociguat is approved for the treatment of adult patients with pulmonary arterial hypertension (PAH) and inoperable or persistent/recurrent chronic thromboembolic pulmonary hypertension (CTEPH) following Phase

Risk model of seizure cluster or status epilepticus and intervention in the emergency department

Objectives: To identify possible predictors of seizure cluster or status epilepticus (SE) and to evaluate whether these patients receive greater interventions in emergency departments. Methodology: We conducted a secondary analysis of the ACESUR Registry, a multipurpose, observational, prospective, multicentre registry of adult patients with seizures from 18 emergency departments. Clinical and care-related variables were collected. We identified risk factors and risk models for seizure cluster or SE and assessed the effect of interventions by prehospital emergency services and the hospital emergency department. Results: We identified a total of 186 (28%) patients from the ACESUR registry with seizure cluster (126 [19%]) or SE (60 [9%]); the remaining 478 patients (72%) had isolated seizures. The risk model for seizure cluster or SE in the emergency department included Charlson Comorbidity Index scores ≥ 3 (OR: 1.60; 95% CI, 1.05–2.46; P = .030), ≥ 2 habitual antiepileptic drugs (OR: 2.29; 95% CI, 1.49–3.51; P < .001), and focal seizures (OR: 1.56; 95% CI, 1.05–2.32; P = .027). The area under the curve of the model was 0.735 (95% CI, 0.693–0.777; P = .021). Patients with seizure cluster and SE received more aggressive interventions both by prehospital emergency services (OR: 2.89; 95% CI, 1.91–4.36; P < .001) and at the emergency department (OR: 4.41; 95% CI, 2.69–7.22; P < .001). Conclusions: This risk model may be of prognostic value in identifying adult patients at risk of presenting seizure cluster or SE in the emergency department. In our sample, these patients received more aggressive treatment than adult patients with isolated seizures before arriving at hospital, and even more so in the emergency department. Resumen: Objetivos: Identificar posibles factores predictores de crisis epilépticas en acúmulos o Estado Epiléptico (EE) y evaluar si estos pacientes reciben una mayor intervención en urgencias. Metodología: Análisis secundario del Registro ACESUR el cual es un registro observacional de cohortes multipropósito, prospectivo y multicéntrico de pacientes adultos con crisis epilépticas en 18 servicios de urgencias. Se recogen variables clínico-asistenciales. Se identifican factores y modelo de riesgo de presentar crisis en acúmulos o EE y se avalúa el efecto de intervención en servicios de urgencias extrahospitalarios (SUEH) y hospitalarios (SUH). Resultados: Del registro ACESUR se analizan 186 (28%) con crisis en acúmulos (126 (19%)) o EE (60 (9%)) frente a 478 (72%) pacientes con crisis aislada. El modelo de riesgo de crisis en acúmulo o EE en urgencias incluyó la presencia de alta comorbilidad según índice de Charlson ≥ 3 (OR: 1,60; IC95%: 1,05-2,46; p = 0,030), ≥ 2 fármacos antiepilépticos habituales (OR: 2,29; IC95%: 1,49-3,51; p < 0,001) y crisis focal (OR: 1,56; IC95%: 1,05-2,32; p = 0,027). El ABC del modelo fue de 0,735 (IC95%: 0.693-0.777; p = 0,021). La intervención en pacientes con crisis en acúmulos y EE fue mayor en los SUEH (OR: 2,89; IC95%: 1,91-4,36; p < 0,001) y en los SUH (OR: 4,41; IC95%: 2,69-7,22; p < 0,001). Conclusiones: El modelo presentado podría ser una herramienta con valor predictivo de utilidad para identificar al paciente adulto con riesgo de presentar crisis en acúmulos o estado epiléptico en urgencias. Estos pacientes recibieron una mayor intervención frente a pacientes con crisis epiléptica aislada por parte de los SUEH y más aún por los SUH en nuestra muestra