Vasoactive agents for the management of acute variceal bleeding: A systematic review and meta-analysis

Background & Aims: Vasoactive agents with endoscopic therapy are used to treat acute variceal bleeding (AVB). There are two main groups of vasoactive agents: terlipressin and vasopressin (T-V), and octreotide and somatostatin (O-S). However, the benefit/harm balance is unclear. Our aim was to assess the efficacy and safety of T-V versus O-S for the management of AVB. Methods: We performed a systematic search for randomized controlled trials (RCTs) in PubMed, Scopus, and CENTRAL. Our main outcomes were mortality and adverse events. Secondary outcomes were bleeding control, rebleeding, blood transfusion, hospital stay. We evaluated the certainty of evidence using GRADE methodology. Results: We included 21 RCTs. The risk of mortality (RR: 1.01; 95%CI: 0.83-1.22), bleeding control (RR: 0.96; 95%CI: 0.91-1.02; I2=53%), early rebleeding (RR: 0.91; 95%CI: 0.66-1.24: I2=0%), late rebleeding (RR: 0.94; 95 CI: 0.56-1.60; I2=0%), blood transfusion (MD: 0.04; 95%CI:-0.31-0.39; I2=68%) and hospital stay (MD:-1.06; 95%CI:-2.80-0.69; I2=0%) were similar between T-V and O-S groups. Only 15 studies reported adverse events, which were significantly higher in the T-V compared to the O-S group (RR 2.39; 95%CI: 1.58-3.63; I2=57%). The certainty of evidence was moderate for the main outcomes, and low or very low for others. Conclusions: In cirrhotic patients with AVB, those treated with T-V had similar mortality risk compared to O-S. However, the use of T-V showed an increased risk of adverse events compared to O-S.Revisión por pare

Reducing adverse impacts of Amazon hydropower expansion

Proposed hydropower dams at more than 350 sites throughout the Amazon require strategic evaluation of trade-offs between the numerous ecosystem services provided by Earth\u27s largest and most biodiverse river basin. These services are spatially variable, hence collective impacts of newly built dams depend strongly on their configuration. We use multiobjective optimization to identify portfolios of sites that simultaneously minimize impacts on river flow, river connectivity, sediment transport, fish diversity, and greenhouse gas emissions while achieving energy production goals. We find that uncoordinated, dam-by-dam hydropower expansion has resulted in forgone ecosystem service benefits. Minimizing further damage from hydropower development requires considering diverse environmental impacts across the entire basin, as well as cooperation among Amazonian nations. Our findings offer a transferable model for the evaluation of hydropower expansion in transboundary basins

Imaging spectroscopy predicts variable distance decay across contrasting Amazonian tree communities

1. The forests of Amazonia are among the most biodiverse on Earth, yet accurately quantifying how species composition varies through space (i.e., beta‐diversity) remains a significant challenge. Here, we use high‐fidelity airborne imaging spectroscopy from the Carnegie Airborne Observatory to quantify a key component of beta‐diversity, the distance decay in species similarity through space, across three landscapes in Northern Peru. We then compared our derived distance decay relationships to theoretical expectations obtained from a Poisson Cluster Process, known to match well with empirical distance decay relationships at local scales. 2. We used an unsupervised machine learning approach to estimate spatial turnover in species composition from the imaging spectroscopy data. We first validated this approach across two landscapes using an independent dataset of forest composition in 49 forest census plots (0.1–1.5 ha). We then applied our approach to three landscapes, which together represented terra firme clay forest, seasonally flooded forest and white‐sand forest. We finally used our approach to quantify landscape‐scale distance decay relationships and compared these with theoretical distance decay relationships derived from a Poisson Cluster Process. 3. We found a significant correlation of similarity metrics between spectral data and forest plot data, suggesting that beta‐diversity within and among forest types can be accurately estimated from airborne spectroscopic data using our unsupervised approach. We also found that estimated distance decay in species similarity varied among forest types, with seasonally flooded forests showing stronger distance decay than white‐sand and terra firme forests. Finally, we demonstrated that distance decay relationships derived from the theoretical Poisson Cluster Process compare poorly with our empirical relationships. 4. Synthesis. Our results demonstrate the efficacy of using high‐fidelity imaging spectroscopy to estimate beta‐diversity and continuous distance decay in lowland tropical forests. Furthermore, our findings suggest that distance decay relationships vary substantially among forest types, which has important implications for conserving these valuable ecosystems. Finally, we demonstrate that a theoretical Poisson Cluster Process poorly predicts distance decay in species similarity as conspecific aggregation occurs across a range of nested scales within larger landscapes

High-accuracy determination of the neutron flux in the new experimental area n_TOF-EAR2 at CERN

A new high flux experimental area has recently become operational at the n_TOF facility at CERN. This new measuring station, n_TOF-EAR2, is placed at the end of a vertical beam line at a distance of approximately 20m from the spallation target. The characterization of the neutron beam, in terms of flux, spatial profile and resolution function, is of crucial importance for the feasibility study and data analysis of all measurements to be performed in the new area. In this paper, the measurement of the neutron flux, performed with different solid-state and gaseous detection systems, and using three neutron-converting reactions considered standard in different energy regions is reported. The results of the various measurements have been combined, yielding an evaluated neutron energy distribution in a wide energy range, from 2meV to 100MeV, with an accuracy ranging from 2%, at low energy, to 6% in the high-energy region. In addition, an absolute normalization of the n_TOF-EAR2 neutron flux has been obtained by means of an activation measurement performed with 197Au foils in the beam.Peer reviewe

Rarity of monodominance in hyperdiverse Amazonian forests.

Tropical forests are known for their high diversity. Yet, forest patches do occur in the tropics where a single tree species is dominant. Such "monodominant" forests are known from all of the main tropical regions. For Amazonia, we sampled the occurrence of monodominance in a massive, basin-wide database of forest-inventory plots from the Amazon Tree Diversity Network (ATDN). Utilizing a simple defining metric of at least half of the trees ≥ 10 cm diameter belonging to one species, we found only a few occurrences of monodominance in Amazonia, and the phenomenon was not significantly linked to previously hypothesized life history traits such wood density, seed mass, ectomycorrhizal associations, or Rhizobium nodulation. In our analysis, coppicing (the formation of sprouts at the base of the tree or on roots) was the only trait significantly linked to monodominance. While at specific locales coppicing or ectomycorrhizal associations may confer a considerable advantage to a tree species and lead to its monodominance, very few species have these traits. Mining of the ATDN dataset suggests that monodominance is quite rare in Amazonia, and may be linked primarily to edaphic factors

Understanding different dominance patterns in western Amazonian forests

Dominance of neotropical tree communities by a few species is widely documented, but dominant trees show a variety of distributional patterns still poorly understood. Here, we used 503 forest inventory plots (93,719 individuals ≥2.5 cm diameter, 2609 species) to explore the relationships between local abundance, regional frequency and spatial aggregation of dominant species in four main habitat types in western Amazonia. Although the abundance-occupancy relationship is positive for the full dataset, we found that among dominant Amazonian tree species, there is a strong negative relationship between local abundance and regional frequency and/or spatial aggregation across habitat types. Our findings suggest an ecological trade-off whereby dominant species can be locally abundant (local dominants) or regionally widespread (widespread dominants), but rarely both (oligarchs). Given the importance of dominant species as drivers of diversity and ecosystem functioning, unravelling different dominance patterns is a research priority to direct conservation efforts in Amazonian forests.Publisher PDFPeer reviewe

Geographic patterns of tree dispersal modes in Amazonia and their ecological correlates

Indaga sobre los patrones geográficos y los correlatos ecológicos en la distribución geográfica de los modos de dispersión arbórea más comunes en la Amazonia (endozoocoria, sinzoocoria, anemoocoria e hidrocoria). Se examina si la abundancia proporcional de estos modos de dispersión podría explicarse por la disponibilidad de agentes dispersores (hipótesis de disponibilidad de dispersores) y/o la disponibilidad de recursos para la poducción de frutos zoocorios (hipótesis de disponibilidad de recursos). Para ello se usaron parcelas de inventario de árboles establecidas entre 1934 y 2019, con un diámetro a la altura del pecho (DAP) ≥ 9,55 cm. Ubicados en las selvas tropicales de tierras bajas de la cuenca del río Amazonas y el Escudo Guayanés. Se asignaron modos de dispersión a un total de 5433 especies y morfoespecies en 1877 parcelas de inventario de árboles en bosques de abeto, inundados estacionalmente y permanentemente inundados. Se investigaron los patrones geográficos en la abundancia proporcional de los modos de dispersión. Se realizó una prueba de distancia media entre pares ponderada por abundancia (MPD) y ajustamos modelos lineales generalizados (GLM) para explicar la distribución geográfica de los modos de dispersión. La anemocoria se asoció significativa y positivamente con la velocidad media anual del viento, y la hidrocoria fue significativamente mayor en los bosques inundados. Los modos de dispersión no mostraron consistentemente asociaciones significativas con la disponibilidad de recursos para la construcción de frutos zoochorous. Una menor disimilitud en los modos de dispersión, resultante de una mayor dominancia de la endozoocoria, se produjo en los bosques de abeto (excluyendo los podzoles) en comparación con los bosques inundados. La hipótesis dispersor-disponibilidad fue bien apoyada para los modos de dispersión abióticos (anemochoria e hidrochoria). La disponibilidad de recursos para la construcción de frutos zoocorios parece una explicación poco probable para la distribución de los modos de dispersión en la Amazonia. La asociación entre los frugívoros y la abundancia proporcional de zoocoría requiere más investigación, ya que el reclutamiento de árboles no sólo depende de los vectores de dispersión, sino también de las condiciones que favorecen o limitan el reclutamiento de plántulas en los distintos tipos de bosque.Revisión por pares

Clinical phenotypes and prognosis of dilated cardiomyopathy caused by truncating variants in the TTN Gene.

Background: Truncating variants in the TTN gene (TTNtv) are the commonest cause of heritable dilated cardiomyopathy. This study aimed to study the phenotypes and outcomes of TTNtv carriers. Methods: Five hundred thirty-seven individuals (61% men; 317 probands) with TTNtv were recruited in 14 centers (372 [69%] with baseline left ventricular systolic dysfunction [LVSD]). Baseline and longitudinal clinical data were obtained. The primary end point was a composite of malignant ventricular arrhythmia and end-stage heart failure. The secondary end point was left ventricular reverse remodeling (left ventricular ejection fraction increase by ≥10% or normalization to ≥50%). Results: Median follow-up was 49 (18–105) months. Men developed LVSD more frequently and earlier than women (45±14 versus 49±16 years, respectively; P=0.04). By final evaluation, 31%, 45%, and 56% had atrial fibrillation, frequent ventricular ectopy, and nonsustained ventricular tachycardia, respectively. Seventy-six (14.2%) individuals reached the primary end point (52 [68%] end-stage heart failure events, 24 [32%] malignant ventricular arrhythmia events). Malignant ventricular arrhythmia end points most commonly occurred in patients with severe LVSD. Male sex (hazard ratio, 1.89 [95% CI, 1.04–3.44]; P=0.04) and left ventricular ejection fraction (per 10% decrement from left ventricular ejection fraction, 50%; hazard ratio, 1.63 [95% CI, 1.30–2.04]; P<0.001) were independent predictors of the primary end point. Two hundred seven of 300 (69%) patients with LVSD had evidence of left ventricular reverse remodeling. In a subgroup of 29 of 74 (39%) patients with initial left ventricular reverse remodeling, there was a subsequent left ventricular ejection fraction decrement. TTNtv location was not associated with statistically significant differences in baseline clinical characteristics, left ventricular reverse remodeling, or outcomes on multivariable analysis (P=0.07). Conclusions: TTNtv is characterized by frequent arrhythmia, but malignant ventricular arrhythmias are most commonly associated with severe LVSD. Male sex and LVSD are independent predictors of outcomes. Mutation location does not impact clinical phenotype or outcomes.pre-print1,66 M

Natural History of MYH7-Related Dilated Cardiomyopathy

BACKGROUND: Variants in myosin heavy chain 7 (MYH7) are responsible for disease in 1% to 5% of patients with dilated cardiomyopathy (DCM); however, the clinical characteristics and natural history of MYH7-related DCM are poorly described. OBJECTIVE: We sought to determine the phenotype and prognosis of MYH7-related DCM. We also evaluated the influence of variant location on phenotypic expression. METHODS: We studied clinical data from 147 individuals with DCM-causing MYH7 variants (47.6% female; 35.6 ± 19.2 years) recruited from 29 international centers. RESULTS: At initial evaluation, 106 (72.1%) patients had DCM (left ventricular ejection fraction: 34.5% ± 11.7%). Median follow-up was 4.5 years (IQR: 1.7-8.0 years), and 23.7% of carriers who were initially phenotype-negative developed DCM. Phenotypic expression by 40 and 60 years was 46% and 88%, respectively, with 18 patients (16%) first diagnosed at <18 years of age. Thirty-six percent of patients with DCM met imaging criteria for LV noncompaction. During follow-up, 28% showed left ventricular reverse remodeling. Incidence of adverse cardiac events among patients with DCM at 5 years was 11.6%, with 5 (4.6%) deaths caused by end-stage heart failure (ESHF) and 5 patients (4.6%) requiring heart transplantation. The major ventricular arrhythmia rate was low (1.0% and 2.1% at 5 years in patients with DCM and in those with LVEF of ≤35%, respectively). ESHF and major ventricular arrhythmia were significantly lower compared with LMNA-related DCM and similar to DCM caused by TTN truncating variants. CONCLUSIONS: MYH7-related DCM is characterized by early age of onset, high phenotypic expression, low left ventricular reverse remodeling, and frequent progression to ESHF. Heart failure complications predominate over ventricular arrhythmias, which are rare