Combination therapy with oral treprostinil for pulmonary arterial hypertension. A double-blind placebo-controlled clinical trial

Rationale: Oral treprostinil improves exercise capacity in patients with pulmonary arterial hypertension (PAH), but the effect on clinical outcomes was unknown. Objectives: To evaluate the effect of oral treprostinil compared with placebo on time to first adjudicated clinical worsening event in participants with PAH who recently began approved oral monotherapy. Methods: In this event-driven, double-blind study, we randomly allocated 690 participants (1:1 ratio) with PAH to receive placebo or oral treprostinil extended-release tablets three times daily. Eligible participants were using approved oral monotherapy for over 30 days before randomization and had a 6-minute-walk distance 150 m or greater. The primary endpoint was the time to first adjudicated clinical worsening event: death; hospitalization due to worsening PAH; initiation of inhaled or parenteral prostacyclin therapy; disease progression; or unsatisfactory long-term clinical response. Measurements and Main Results: Clinical worsening occurred in 26% of the oral treprostinil group compared with 36% of placebo participants (hazard ratio, 0.74; 95% confidence interval, 0.56–0.97; P = 0.028). Key measures of disease status, including functional class, Borg dyspnea score, and N-terminal pro–brain natriuretic peptide, all favored oral treprostinil treatment at Week 24 and beyond. A noninvasive risk stratification analysis demonstrated that oral treprostinil–assigned participants had a substantially higher mortality risk at baseline but achieved a lower risk profile from Study Weeks 12–60. The most common adverse events in the oral treprostinil group were headache, diarrhea, flushing, nausea, and vomiting. Conclusions: In participants with PAH, addition of oral treprostinil to approved oral monotherapy reduced the risk of clinical worsening. Clinical trial registered with www.clinicaltrials.gov (NCT01560624)

Baseline characteristics of patients in the reduction of events with darbepoetin alfa in heart failure trial (RED-HF)

<p>Aims: This report describes the baseline characteristics of patients in the Reduction of Events with Darbepoetin alfa in Heart Failure trial (RED-HF) which is testing the hypothesis that anaemia correction with darbepoetin alfa will reduce the composite endpoint of death from any cause or hospital admission for worsening heart failure, and improve other outcomes.</p> <p>Methods and results: Key demographic, clinical, and laboratory findings, along with baseline treatment, are reported and compared with those of patients in other recent clinical trials in heart failure. Compared with other recent trials, RED-HF enrolled more elderly [mean age 70 (SD 11.4) years], female (41%), and black (9%) patients. RED-HF patients more often had diabetes (46%) and renal impairment (72% had an estimated glomerular filtration rate <60 mL/min/1.73 m2). Patients in RED-HF had heart failure of longer duration [5.3 (5.4) years], worse NYHA class (35% II, 63% III, and 2% IV), and more signs of congestion. Mean EF was 30% (6.8%). RED-HF patients were well treated at randomization, and pharmacological therapy at baseline was broadly similar to that of other recent trials, taking account of study-specific inclusion/exclusion criteria. Median (interquartile range) haemoglobin at baseline was 112 (106–117) g/L.</p> <p>Conclusion: The anaemic patients enrolled in RED-HF were older, moderately to markedly symptomatic, and had extensive co-morbidity.</p&gt

Methods to assess tropical rain forest canopy structure: an overview

Forest canopy structure (sensu latu) is the combination of forest texture (the qualitative and quantitative composition of the vegetation as to different morphological elements), and forest structure (sensu strictu, the spatial arrangement of these elements). Scale is an aspect of major importance. At a regional scale forest types can be distinguished, like broadleaf or coniferous forest. At local scale, distribution and size and shape of tree crowns, and the spatial distribution of leaves and branches within tree crowns determine to a large extent the canopy structure. Which components and sub-components are used, and also the scale at which their spatial arrangements are studied, is of great importance for the possible outcome of the analysis of canopy structure. This is specially the case when canopy structure is needed as a correlate to ecological questions, e.g., on habitat specificity of animals, or epiphytes. Methods available for describing and analysing canopy structure are discussed. At large scale levels remote sensing data are used to describe differences in structure. High-resolution radar images are used to describe canopy structure in detail and over large areas. Repeated measurements over time can be used for monitoring purposes. Ways to measure the three dimensional structure of (components within) individual trees in detail are being developed, and are coupled to physiological models. Currently, use of such methods is only feasible for small plants. Forest tomography (where the vegetation occupation and empty spaces are determined in horizontal and vertical slices of the forest) is proposed as a way to describe vertical and horizontal structure. Vegetation cover and occupation is analysed above grid points in a forest. As an example the vertical structure of a Cameroonian forest is described at several levels of detail. The research question asked should govern completely the choice of the parameters and the methods used for the description of forest canopy structure

The AMMA-CATCH Gourma observatory site in Mali: Relating climatic variations to changes in vegetation, surface hydrology, fluxes and natural resources

The Gourma site in Mali is one of the three instrumented meso-scale sites deployed in West-Africa as part of the African Monsoon Multi-disciplinary Analysis (AMMA) project. Located both in the Sahelian zone sensu stricto, and in the Saharo–Sahelian transition zone, the Gourma meso-scale window is the northernmost site of the AMMA-CATCH observatory reached by the West African Monsoon. The experimental strategy includes deployment of a variety of instruments, from local to meso-scale, dedicated to monitoring and documentation of the major variables characterizing the climate forcing, and the spatio-temporal variability of surface processes and state variables such as vegetation mass, leaf area index (LAI), soil moisture and surface fluxes. This paper describes the Gourma site, its associated instrumental network and the research activities that have been carried out since 1984. In the AMMA project, emphasis is put on the relations between climate, vegetation and surface fluxes. However, the Gourma site is also important for development and validation of satellite products, mainly due to the existence of large and relatively homogeneous surfaces. The social dimension of the water resource uses and governance is also briefly analyzed, relying on field enquiry and interviews. The climate of the Gourma region is semi-arid, daytime air temperatures are always high and annual rainfall amounts exhibit strong inter-annual and seasonal variations. Measurements sites organized along a north–south transect reveal sharp gradients in surface albedo, net radiation, vegetation production, and distribution of plant functional types. However, at any point along the gradient, surface energy budget, soil moisture and vegetation growth contrast between two main types of soil surfaces and hydrologic systems. On the one hand, sandy soils with high water infiltration rates and limited run-off support almost continuous herbaceous vegetation with scattered woody plants. On the other hand, water infiltration is poor on shallow soils, and vegetation is sparse and discontinuous, with more concentrated run-off that ends in pools or low lands within structured endorheic watersheds. Land surface in the Gourma is characterized by rapid response to climate variability, strong intra-seasonal, seasonal and inter-annual variations in vegetation growth, soil moisture and energy balance. Despite the multi-decadal drought, which still persists, ponds and lakes have increased, the grass cover has largely recovered, and there are signs of increased tree cover at least in the low lands