The prognostic impact of non-driver gene mutations and variant allele frequency in primary myelofibrosis.

Prognostic impact of non-MPN driver gene mutations in primary myelofibrosis. MIPSS70: Mutation-Enhanced International Prognostic Score System.

Correlation Between Tacrolimus Levels in Blood Samples Obtained from Central Catheter and Peripheral Venipuncture in Lung Transplant Patients (Ven-Cat Study).

BACKGROUND: Following lung transplantation (LT), receiving immunosuppressive therapy is crucial. Tacrolimus is considered a drug with a narrow therapeutic range and its use requires constant monitoring. This study aimed to evaluate the correlation between tacrolimus levels obtained from central venous catheter and direct venipuncture in adult patients undergoing LT. METHODS: This prospective study included LT patients hospitalized in conventional ward carrying a central catheter through which no intravenous tacrolimus was administered. Trough samples were obtained through direct puncture and from the central catheter. Pearson correlation coefficient was calculated to quantify the mean difference between the 2 measures. RESULTS: A total of 54 sample pairs from 16 LT patients were obtained, mostly male (81.3%) and bilateral transplant recipients (93.8%); the transplant procedure was the primary reason for admission (81.3%). The difference in tacrolimus levels between both samples was 0.3 (0.1-0.6) mcg/L, with the measurement for the samples obtained through venipuncture being mostly higher than that for those obtained from the catheter. A strong correlation was observed between the tacrolimus levels in the samples obtained from the catheter and through venipuncture (Pearson correlation coefficient, 0.991; P < 0.001; R2 = 0.982). CONCLUSIONS: There is an excellent correlation between tacrolimus levels obtained from venipuncture and those obtained from central venous catheter in LT patients undergoing oral tacrolimus therapy.

Bathymetric origin shapes the physiological responses of Pterygophora californica (Laminariales, Phaeophyceae) to deep marine heatwaves.

Kelp communities are experiencing exacerbated heat-related impacts from more intense, frequent, and deeper marine heatwaves (MHWs), imperiling the long-term survival of kelp forests in the climate change scenario. The occurrence of deep thermal anomalies is of critical importance, as elevated temperatures can impact kelp populations across their entire bathymetric range. This study evaluates the impact of MHWs on mature sporophytes of Pterygophora californica (walking kelp) from the bathymetric extremes (8-10 vs. 25-27 m) of a population situated in Baja California (Mexico). The location is near the southernmost point of the species's broad distribution (from Alaska to Mexico). The study investigated the ecophysiological responses (e.g., photobiology, nitrate uptake, oxidative stress) and growth of adult sporophytes through a two-phase experiment: warming simulating a MHW and a post-MHW phase without warming. Generally, the effects of warming differed depending on the bathymetric origin of the sporophytes. The MHW facilitated essential metabolic functions of deep-water sporophytes, including photosynthesis, and promoted their growth. In contrast, shallow-water sporophytes displayed metabolic stress, reduced growth, and oxidative damage. Upon the cessation of warming, certain responses, such as a decline in nitrate uptake and net productivity, became evident in shallow-water sporophytes, implying a delay in heat-stress response. This indicates that variation in temperatures can result in more prominent effects than warming alone. The greater heat tolerance of sporophytes in deeper waters shows convincing evidence that deep portions of P. californica populations have the potential to serve as refuges from the harmful impacts of MHWs on shallow reefs.

Insights into the Importance of Native Passivation Layer and Interface Reactivity of Metallic Lithium by Electrochemical Impedance Spectroscopy.

Lithium-metal batteries offer substantial advantages over lithium-ion batteries in terms of gravimetric and volumetric energy densities. However, their widespread practical use is hindered by safety concerns, often attributed to the poor stability of the metallic lithium interface, where electrochemical impedance spectroscopy (EIS) can provide crucial information. The EIS spectra of metallic lithium electrodes proved to be more complex than expected, especially when studying thin lithium metal foils. Here, it is identified that charge-transfer impedance becomes one of the main components of the EIS spectra, the magnitude of which is found to be strongly dependent on the native passivation layer of metallic lithium and on the nature of electrolyte. "Asymmetricity" of the EIS spectra in symmetric cells when separated the working and counter electrode contributions to the total impedance using three-electrode cells is also identified.

Shading by giant kelp canopy can restrict the invasiveness of Undaria pinnatifida (Laminariales, Phaeophyceae).

The spread of non-indigenous and invasive seaweeds has increased worldwide, and their potential effects on native seaweeds have raised concern. Undaria pinnatifida is considered among the most prolific non-indigenous species. This species has expanded rapidly in the Northeast Pacific, overlapping with native communities such as the iconic giant kelp forests (Macrocystis pyrifera). Canopy shading by giant kelp has been argued to be a limiting factor for the presence of U. pinnatifida in the understory, thus its invasiveness capacity. However, its physiological plasticity under light limitation remains unclear. In this work, we compared the physiology and growth of juvenile U. pinnatifida and M. pyrifera sporophytes transplanted to the understory of a giant kelp forest, to juveniles growing outside of the forest. Extreme low light availability compared to that outside (~0.2 and ~4.4 mol photon ⋅ m-2 ⋅ d-1 , respectively) likely caused a "metabolic energy crisis" in U. pinnatifida, thus restricting its photoacclimation plasticity and nitrogen acquisition, ultimately reducing its growth. Despite M. pyrifera juveniles showing photoacclimatory responses (e.g., increases in photosynthetic efficiency and lower compensation irradiance, Ec ), their physiological/vegetative status deteriorated similarly to U. pinnatifida, which explains the low recruitment inside the forest. Generally, our results revealed the ecophysiological basis behind the limited growth and survival of juvenile U. pinnatifida sporophytes in the understory.

Natural Products as Modulators of Nrf2 Signaling Pathway in Neuroprotection.

Neurodegenerative diseases (NDs) affect the West due to the increase in life expectancy. Nervous cells accumulate oxidative damage, which is one of the factors that triggers and accelerates neurodegeneration. However, cells have mechanisms that scavenge reactive oxygen species (ROS) and alleviate oxidative stress (OS). Many of these endogenous antioxidant systems are regulated at the gene expression level by the transcription factor Nrf2 (nuclear factor erythroid 2-related factor 2). In the presence of prooxidant conditions, Nrf2 translocates to the nucleus and induces the transcription of genes containing ARE (antioxidant response element). In recent years, there has been an increase in the study of the Nrf2 pathway and the natural products that positively regulate it to reduce oxidative damage to the nervous system, both in in vitro models with neurons and microglia subjected to stress factors and in vivo models using mainly murine models. Quercetin, curcumin, anthocyanins, tea polyphenols, and other less studied phenolic compounds such as kaempferol, hesperetin, and icariin can also modulate Nrf2 by regulating several Nrf2 upstream activators. Another group of phytochemical compounds that upregulate this pathway are terpenoids, including monoterpenes (aucubin, catapol), diterpenes (ginkgolides), triterpenes (ginsenosides), and carotenoids (astaxanthin, lycopene). This review aims to update the knowledge on the influence of secondary metabolites of health interest on the activation of the Nrf2 pathway and their potential as treatments for NDs.

Immunomodulatory, Anti-Inflammatory, and Anti-Cancer Properties of Ginseng: A Pharmacological Update.

Ginseng, a medicinal plant of the genus Panax, boasts a rich historical record of usage that dates back to the Paleolithic period. This botanical is extensively acknowledged and consumed in Eastern countries for its therapeutic properties, and, in Western countries, it is becoming increasingly popular as a remedy for fatigue and asthenia. This review provides an update on current research pertaining to ginseng and its isolated compounds, namely, ginsenosides and polysaccharides. The primary focus is on three crucial pharmacological activities, namely, immunomodulation, anti-inflammatory, and anti-cancer effects. The review encompasses studies on both isolated compounds and various ginseng extracts obtained from the root, leaves, and berries.

Modifications of CD4 T cells, CD4/CD8 ratio and serum levels of soluble CD14 in HIV-HCV-coinfected patients after sustained HCV response induced by direct-acting antiviral agents: influence of liver cirrhosis.

To analyze the modifications of CD4 T cell, CD4/CD8 ratio, and serum levels of soluble CD14 (sCD14) in HIV/HCV-coinfected patients after treatment with direct anti-HCV antiviral agents. Consecutive cases of HIV/HCV-coinfected patients, attended at the University Hospital, who achieved sustained virological responses with interferon-free hepatitis C antiviral drugs, were analyzed. Thirty-five percent of patients (n = 39) had been diagnosed with liver cirrhosis. The evaluation criteria were changes in CD4 T-cell counts and percentages and inflammation (measured by serum sCD14 levels) or immune activation indexes (determined by CD4/CD8 ratio) from beginning anti-HCV therapy to 12 months later. One hundred twelve patients were included (87% male; median age, 54 years; median time from the infection diagnosis, 22 years; previous drug users, 87%). Significant increases in CD4 T cell count and percentage were detected only in individuals without liver cirrhosis. No significant differences in CD4/CD8 ratios or sCD14 levels were observed in patients with or without cirrhosis. The proportion of patients with less than 500 CD4 T cell/mm3 before therapy who achieved more than 500 CD4 T cell/mm3 after it increased only in the group without liver cirrhosis. The finding that CD4 T cell count and percentage were improved only in patients without liver cirrhosis supports the idea that treatment against HCV in HIV/HCV-coinfected patients is needed in the early phases of liver disease.

Short-term stress responses and recovery of giant kelp (Macrocystis pyrifera, Laminariales, Phaeophyceae) juvenile sporophytes to a simulated marine heatwave and nitrate scarcity1.

The frequency of marine heatwaves (MHWs) is increasing due to climate change. Although seaweeds are resilient to environmental changes, an increasing body of evidence shows that rising sea surface temperatures have deleterious effects on temperate kelp species. However, information on the vulnerability of juvenile kelp to these stressors and their population stability is limited. This study summarizes findings on the ability of juvenile sporophytes of Macrocystis pyrifera to survive and recover from simulated MHW conditions (22°C, 5 d) in combination with nitrate limitation (<1 µM) by evaluating photosynthetic capacity, nitrate uptake, tissue composition, bio-optical properties, and oxidative stress of single-blade juvenile sporophytes (<20 cm). Temperature, nitrate availability, and their interaction had significant effects on the physiological status of juvenile sporophytes after the exposure and recovery periods. Overall, as expected, the photosynthetic capacity of juvenile sporophytes decreased with increased temperature and lower nitrate availability. Short-term exposure to simulated MHWs resulted in oxidative damage and reduced growth. The termination of the experimental warming allowed partial recovery to control values, indicating high physiological resilience. However, the interaction of both high temperature and nitrate scarcity induced irreversible damage to their photosynthetic capacity, with an increase in compensation irradiance, highlighting potential limitations in the carbon balance of juvenile sporophytes.

Persistent organic and inorganic pollutants in the effluents from the textile dyeing industries: Ecotoxicology appraisal via a battery of biotests.

Today, the textile industry is considered as a leading economic sector in Tunisia. However, this sector demands a huge volume of water and a wide spectrum of chemicals, which is converted into potentially toxic wastewater leading to environmental perturbation and human health toxicity. Assessment of the environmental risks associated with textile wastewater becomes a necessity. In this study, textile dyeing wastewater samples were collected before and after the physico-chemical treatment carried out by textile companies located in Monastir-city-Tunisia and subjected to chemical analyzes in order to determine their physicochemical characteristics and the content of metals and textile dyes. The ecotoxicological assessment was performed using four organisms, namely Selenastrum capricornutum, Vibrio fischeri, Daphnia magna and Lepidium sativum, to represent different trophic levels. Based on chemical data, some physicochemical parameters (e.g. TSS, COD and TSS levels) and metals (e.g. Cr, Hg and Sb) in the textile dyeing effluents were revealed not in compliance with the Tunisian standard. Moreover, high quantities of three disperse dyes have been detected even in the textile dyeing wastewater samples before and after treatments. The ecotoxicological data confirmed that the textile dyeing influents displayed toxic effects to all the test organisms, with Selenastrum capricornutum being the most sensitive organism. While, the above toxic effects were decreased slightly when evaluating the treated effluents. Metals and textile disperse dyes could be associated with the observed toxic effects of the textile influents and effluents. In fact, the treatment process applied by the evaluated companies was only partially efficient at removing metals, disperse dyes and effluent ecotoxicity, suggesting potential risks to aquatic biota. These findings emphasize the importance of applying integrated chemical and biological approaches for continuous evaluation of the toxicity of the treated effluents to predict hazards on the environment.

Similarities and differences between HIV and SARS-CoV-2.

In the last 50 years we have experienced two big pandemics, the HIV pandemic and the pandemic caused by SARS-CoV-2. Both pandemics are caused by RNA viruses and have reached us from animals. These two viruses are different in the transmission mode and in the symptoms they generate. However, they have important similarities: the fear in the population, increase in proinflammatory cytokines that generate intestinal microbiota modifications or NETosis production by polymorphonuclear neutrophils, among others. They have been implicated in the clinical, prognostic and therapeutic attitudes.

The Effects of COVID-19 on Healthcare Workers and Non-Healthcare Workers in Mexico: 14 Months into the Pandemic.

Background and Objectives: Healthcare workers (HCWs) play important roles in mitigating the COVID-19 pandemic and are more likely to become infected with COVID-19. Mexico, among other countries, had a high incidence and prevalence of cases and deaths from this disease. Material and Methods: This retrospective study evaluated the clinical characteristics as well as the geographical distribution of cases, deaths, and active cases of COVID-19 in HCWs and non-HCWs using official information from the Ministry of Health of Mexico. Results: A total of 235,343 cases of COVID-19 were reported in healthcare workers, and 2,094,191 cases were reported in non-healthcare workers. A total of 76.0% of cases in healthcare workers occurred in those who were between 25 and 50 years of age, and 71.4% of deaths occurred in those who were 50 to 69 years of age. Among healthcare workers, the most frequent comorbidities were obesity (15.2%), hypertension (10.9%), and diabetes (6.8%). Nurses were the group with the most cases (39.7%), followed by other healthcare workers (30.6%), physicians (26%), and dentists (1.6%). Physicians were the group with the most deaths (46%), followed by other professionals (30%), nurses (19%), and dentists (3%). Conclusion: These findings are likely the result of healthcare workers in Mexico being at a greater risk of exposure to SARS-CoV-2.

HIV antibodies level as a marker of HIV persistence: the role of hepatitis C virus coinfection.

Human immunodeficiency virus (HIV) antibodies have been proposed as a measure of the size of the HIV reservoir. The aim of our study is to quantify the anti-HIV antibodies level in a cohort of people living with HIV (PLWH), stratified based on the presence of continuous undetectable HIV viral load and the co-existence of hepatitis C virus infection. A sample of 229 HIV-monoinfected (n = 114) or HIV/HCV-coinfected [either with resolved HCV infection (n = 75) or active HCV coinfection (n = 40)] patients, followed up a median of 34 (IQR 20-44) months, was studied. Anti-HIV index was obtained as the 1:800 dilution of HIV antibodies. CD4+ T cell count, time with undetectable HIV viral load, annual increase of CD4+ T cell count, anti-HCV therapy, and diagnosis of cirrhosis were analyzed. Patients with a continued suppressed HIV viral load had significant lower anti-HIV index compared with those with virologic failure during the follow-up. Significant higher CD4+ T cell increase was observed in those with a lower anti-HIV index. HIV-monoinfected patients showed an anti-HIV index significantly lower than patients with HCV coinfection. Resolved HCV infection after interferon-based therapy, but not with direct acting antivirals, was associated with a lower anti-HIV index. HIV/HCV-coinfected patients showed higher HIV antibodies level when compared with HIV-monoinfected individuals. A decrease in anti-HIV index in HIV/HCV-coinfected patients was detected when a sustained virological HCV response was obtained after interferon-based therapy, in possible relation with the direct or indirect effect of interferon on PLWH CD4 T cells.

Photoacclimation and Photoprotection of Juvenile Sporophytes of Macrocystis pyrifera (Laminariales, Phaeophyceae) Under High-light Conditions During Short-term Shallow-water Cultivation1.

This study was designed to understand better if and how juvenile sporophytes of Macrocystis pyrifera can photoacclimate to high-light conditions when transplanted from 10 to 3 meters over 7 d. Acclimation of adult sporophytes to light regimes in the bathymetric gradient has been extensively documented. It primarily depends on photoacclimation and translocation of resources among blades. Among other physiological differences, juvenile sporophytes of M. pyrifera lack the structural complexity shown by adults. As such, juveniles may primarily depend on their photoacclimation capacities to maintain productivity and even avoid mortality under changing light regimes. However, little is known about how these mechanisms operate in young individuals. The capacity of sporophytes to photoacclimate was assessed by examining changes in their photosynthetic performance, pigment content, and bio-optical properties of the blade. Sporophytes nutritional status and oxidative damage were also determined. Results showed that juvenile sporophytes transplanted to shallow water were able to regulate light harvesting by reducing pigment concentration, and thus, absorptance and photosynthetic efficiency. Also, shallow-water sporophytes notably enhanced the dissipation of light energy as heat (NPQ) as a photoprotective mechanism. Generally, these adjustments allowed sporophytes to manage the absorption and utilization of light energy, hence reducing the potential for photo-oxidative damage. Furthermore, no substantial changes were found in the internal reserves (i.e., soluble carbohydrates and nitrogen) of these sporophytes. To our knowledge, these results are the first to provide robust evidence of photoprotective and photoacclimation strategies in juveniles of M. pyrifera, allowing them to restrict or avoid photodamage during shallow-water cultivation.

Effects of Heat Waves and Light Deprivation on Giant Kelp Juveniles (Macrocystis pyrifera, Laminariales, Phaeophyceae).

Due to climate change, the incidence of marine heat waves (MHWs) has increased, yet their effects on seaweeds are still not well understood. Adult sporophytes of Macrocystis pyrifera, the species forming the iconic giant kelp forests, can be negatively affected by thermal stress and associated environmental factors (e.g., nutrient depletion, light deprivation); however, little is known about the tolerance/vulnerability of juvenile sporophytes. Simultaneously to MHWs, juveniles can be subjected to light limitation for extended periods of time (days-weeks) due to factors causing turbidity, or even because of shading by understory canopy-forming seaweeds. This study evaluated the effects of a simulated MHW (24°C, 7 d) in combination (or not) with light deprivation, on the photosynthetic capacities, nutrient uptake, and tissue composition, as well as oxidative stress descriptors of M. pyrifera juvenile sporophytes (single blade stage, up to 20 cm length). Maximum quantum yield (Fv /Fm ) decreased in juveniles under light at 24°C, likely reflecting some damage on the photosynthetic apparatus or dynamic photoinhibition; however, no other sign of physiological alteration was found in this treatment (i.e., pigments, nutrient reserves and uptake, oxidative stress). Photosynthetic capacities were maintained or even enhanced in plants under light deprivation, likely supported by photoacclimation (pigments increment); by contrast, nitrate uptake and internal storage of carbohydrates were strongly reduced, regardless of temperature. This study indicated that light limitation can be more detrimental to juvenile survival, and therefore recruitment success of M. pyrifera forests, than episodic thermal stress from MHWs.

Incidence of lymphoma in HIV-HCV-infected patients. Modifications in function of the anti-hepatitis C virus therapy.

The change in the incidence of lymphomas in function of the presence or absence of sustained virological response after anti-hepatitis C therapy in a cohort of human immunodeficiency (HIV)-hepatitis C (HCV) viruses coinfected patients was analyzed. A prospective cohort of 755 HIV-HCV coinfected patients who received their first anti-HCV therapy, based on interferon + ribavirin schemas, was evaluated. Incidence and histologic types of lymphomas were analyzed in two periods: (1) before administration of anti-HCV therapy and (2) after anti-HCV therapy. The association between lymphoma incidence and demographic, HIV- (minimum CD4+ cell count and CD4+ cell count at diagnosis of lymphoma, antiretroviral therapy, maximal HIV load and HIV load at diagnosis of lymphoma) and HCV-related variables (HCV load, genotype, sustained viral response to anti-HCV therapy) were analyzed. A total of 13 lymphomas [incidence rate (95% confidence interval), 0.72 (0.33-1.11) × 1000 person-years, time from HIV diagnosis to lymphoma diagnosis (median, interquartile range), 15 (11-19) years] were diagnosed. Nine of them were non-Hodgkin and four Hodgkin lymphomas. The median CD4+ T cell count at diagnosis of lymphoma was 457/mm3, with only two cases with values lower than 200/mm3. The incidence rate of non-Hodgkin lymphomas was similar pre- and post-anti HCV therapy [0.33 (0.00-0.65) vs 0.68 (0.08-1.26) × 1000 person-years, respectively, p > 0.05]. Patients with sustained virologic HCV response showed similar incidence rate of lymphomas than that of those without anti-HCV response. In conclusion, anti-HCV therapy does not modify the incidence rate of lymphomas in HIV-HCV coinfected patients.

Tools used to assess the quality of peer review reports: a methodological systematic review.

BACKGROUND: A strong need exists for a validated tool that clearly defines peer review report quality in biomedical research, as it will allow evaluating interventions aimed at improving the peer review process in well-performed trials. We aim to identify and describe existing tools for assessing the quality of peer review reports in biomedical research. METHODS: We conducted a methodological systematic review by searching PubMed, EMBASE (via Ovid) and The Cochrane Methodology Register (via The Cochrane Library) as well as Google® for all reports in English describing a tool for assessing the quality of a peer review report in biomedical research. Data extraction was performed in duplicate using a standardized data extraction form. We extracted information on the structure, development and validation of each tool. We also identified quality components across tools using a systematic multi-step approach and we investigated quality domain similarities among tools by performing hierarchical, complete-linkage clustering analysis. RESULTS: We identified a total number of 24 tools: 23 scales and 1 checklist. Six tools consisted of a single item and 18 had several items ranging from 4 to 26. None of the tools reported a definition of 'quality'. Only 1 tool described the scale development and 10 provided measures of validity and reliability. Five tools were used as an outcome in a randomized controlled trial (RCT). Moreover, we classified the quality components of the 18 tools with more than one item into 9 main quality domains and 11 subdomains. The tools contained from two to seven quality domains. Some domains and subdomains were considered in most tools such as the detailed/thorough (11/18) nature of reviewer's comments. Others were rarely considered, such as whether or not the reviewer made comments on the statistical methods (1/18). CONCLUSION: Several tools are available to assess the quality of peer review reports; however, the development and validation process is questionable and the concepts evaluated by these tools vary widely. The results from this study and from further investigations will inform the development of a new tool for assessing the quality of peer review reports in biomedical research.

Adherence to reporting guidelines increases the number of citations: the argument for including a methodologist in the editorial process and peer-review.

BACKGROUND: From 2005 to 2010, we conducted 2 randomized studies on a journal (Medicina Clínica), where we took manuscripts received for publication and randomly assigned them to either the standard editorial process or to additional processes. Both studies were based on the use of methodological reviewers and reporting guidelines (RG). Those interventions slightly improved the items reported on the Manuscript Quality Assessment Instrument (MQAI), which assesses the quality of the research report. However, masked evaluators were able to guess the allocated group in 62% (56/90) of the papers, thus presenting a risk of detection bias. In this post-hoc study, we analyse whether those interventions that were originally designed for improving the completeness of manuscript reporting may have had an effect on the number of citations, which is the measured outcome that we used. METHODS: Masked to the intervention group, one of us used the Web of Science (WoS) to quantify the number of citations that the participating manuscripts received up December 2016. We calculated the mean citation ratio between intervention arms and then quantified the uncertainty of it by means of the Jackknife method, which avoids assumptions about the distribution shape. RESULTS: Our study included 191 articles (99 and 92, respectively) from the two previous studies, which all together received 1336 citations. In both studies, the groups subjected to additional processes showed higher averages, standard deviations and annual rates. The intervention effect was similar in both studies, with a combined estimate of a 43% (95% CI: 3 to 98%) increase in the number of citations. CONCLUSIONS: We interpret that those effects are driven mainly by introducing into the editorial process a senior methodologist to find missing RG items. Those results are promising, but not definitive due to the exploratory nature of the study and some important caveats such as: the limitations of using the number of citations as a measure of scientific impact; and the fact that our study is based on a single journal. We invite journals to perform their own studies to ascertain whether or not scientific repercussion is increased by adhering to reporting guidelines and further involving statisticians in the editorial process.

Thrombus straddling a patent foramen ovale and massive pulmonary embolism: Venous arterial extracorporeal membrane oxygenation as a valuable support tool.

Thrombus straddling a patent foramen ovale and massive pulmonary embolism is a very rare and life-threatening condition. Optimal management can be controversial because different therapeutic options are available and individual approach based in individual risk is needed. We present a case of a thrombus straddling the patent foramen ovale with massive pulmonary embolism, hemodynamic instability, and upper extremity embolism. We performed surgical pulmonary embolectomy, and venous arterial extracorporeal membrane oxygenation was needed to successfully overcome severe right ventricular impairment and pulmonary injury.