The Reality of Critical Cancer Patients in a Polyvalent Intensive Care Unit.

Background and objective With the increasing incidence of cancer and the rise in the survival rates of cancer patients, more and more oncological candidates are being considered for admission to intensive care units (ICU). Several studies have demonstrated no difference in the outcomes of cancer patients compared to non-cancer patients. Our study aimed to describe and analyze the outcomes related to cancer patients in a polyvalent ICU. Methods We conducted a retrospective study of consecutive oncological patients admitted to a polyvalent ICU (2013-2017). Cox model and receiver operating characteristic (ROC) curve analysis were performed to analyze the results. Results A total of 236 patients were included in the study; the mean age of the patients was 53.5 ± 15.3 years, and 65% of them were male. The main cancer types were those related to the central nervous system (CNS; 31%), as well as gastrointestinal (18%), genitourinary (17%), and hematological (15%). Curative/diagnostic surgeries (49%) and sepsis/septic shock (17%) were the main reasons for admission. The Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) scores in hematological patients vs. solid tumors were as follows: 30 vs. 20 and 63 vs. 38, respectively (p<0.005). Vasopressors, invasive mechanical ventilation (IMV), and renal replacement therapy (RRT) were used more widely in hematological patients compared to solid-tumor patients. Length of stay was longer in hematological patients vs. solid-tumor patients (12.8 vs. 7 days, p=0.002). The median overall survival in hematological patients was one month and that in solid-tumor patients was 5.8 months (p<0.005). The survival rate at six months was better than described in the existing literature (48 vs. 32.4%). Conclusion Both SAPS II and APACHE II scores were reasonably accurate in predicting mortality, demonstrating their value in cancer patients.

Physiological Basis of Extracorporeal Membrane Oxygenation and Extracorporeal Carbon Dioxide Removal in Respiratory Failure.

Extracorporeal life support (ECLS) for severe respiratory failure has seen an exponential growth in recent years. Extracorporeal membrane oxygenation (ECMO) and extracorporeal CO2 removal (ECCO2R) represent two modalities that can provide full or partial support of the native lung function, when mechanical ventilation is either unable to achieve sufficient gas exchange to meet metabolic demands, or when its intensity is considered injurious. While the use of ECMO has defined indications in clinical practice, ECCO2R remains a promising technique, whose safety and efficacy are still being investigated. Understanding the physiological principles of gas exchange during respiratory ECLS and the interactions with native gas exchange and haemodynamics are essential for the safe applications of these techniques in clinical practice. In this review, we will present the physiological basis of gas exchange in ECMO and ECCO2R, and the implications of their interaction with native lung function. We will also discuss the rationale for their use in clinical practice, their current advances, and future directions.

Keeping pace with forestry: Multi-scale conservation in a changing production forest matrix.

The multi-scale approach to conserving forest biodiversity has been used in Sweden since the 1980s, a period defined by increased reserve area and conservation actions within production forests. However, two thousand forest-associated species remain on Sweden's red-list, and Sweden's 2020 goals for sustainable forests are not being met. We argue that ongoing changes in the production forest matrix require more consideration, and that multi-scale conservation must be adapted to, and integrated with, production forest development. To make this case, we summarize trends in habitat provision by Sweden's protected and production forests, and the variety of ways silviculture can affect biodiversity. We discuss how different forestry trajectories affect the type and extent of conservation approaches needed to secure biodiversity, and suggest leverage points for aiding the adoption of diversified silviculture. Sweden's long-term experience with multi-scale conservation and intensive forestry provides insights for other countries trying to conserve species within production landscapes.

Correction to: Keeping pace with forestry: Multi-scale conservation in a changing production forest matrix.

In the original published article, the sentence "Nevertheless, semi-natural forest remnants continue to be harvested and fragmented (Svensson et al. 2018; Jonsson et al. 2019), and over 2000 forest-associated species (of 15 000 assessed) are listed as threatened on Sweden's red-list, largely represented by macro-fungi, beetles, lichens and butterflies (Sandström 2015)."under the section Introduction was incorrect. The correct version of the sentence is "Nevertheless, semi-natural forest remnants continue to be harvested and fragmented (Svensson et al. 2018; Jonsson et al. 2019), and approximately 2000 forest-associated species (of 15 000 assessed) are on Sweden's red-list, largely represented by macro-fungi, beetles, lichens and butterflies (Sandström 2015)."

Global Ultrasound Check for the Critically lll (GUCCI)-a new systematized protocol unifying point-of-care ultrasound in critically ill patients based on clinical presentation.

Ultrasound technology is an essential tool in the management of critically ill patients. Point-of-care ultrasonography (POCUS) enables data collection from different anatomic areas to achieve the most probable diagnosis and administer the right therapy at the right time. Despite the increasing utilization of POCUS, there is still a lack of standards to establish how to use different bedside ultrasound protocols, and it is imperative to develop a unifying protocol. Thus, the aim of this paper is to establish a new systematized approach that can be adopted by all physicians to implement POCUS for critically ill patient management. To achieve this, we propose a new systematized approach-Global Ultrasound Check for the Critically Ill (GUCCI)-that integrates multiple protocols. This protocol is organized based on three syndromes (acute respiratory failure, shock, and cardiac arrest) and includes ultrasound-guided procedures.

Modified forest rotation lengths: Long-term effects on landscape-scale habitat availability for specialized species.

We evaluated the long-term implications from modifying rotation lengths in production forests for four forest-reliant species with different habitat requirements. By combining simulations of forest development with habitat models, and accounting both for stand and landscape scale influences, we projected habitat availability over 150 years in a large Swedish landscape, using rotation lengths which are longer (+22% and +50%) and shorter (-22%) compared to current practices. In terms of mean habitat availability through time, species requiring older forest were affected positively by extended rotations, and negatively by shortened rotations. For example, the mean habitat area for the treecreeper Certhia familiaris (a bird preferring forest with larger trees) increased by 31% when rotations were increased by 22%, at a 5% cost to net present value (NPV) and a 7% decrease in harvested volume. Extending rotation lengths by 50% provided more habitat for this species compared to a 22% extension, but at a much higher marginal cost. In contrast, the beetle Hadreule elongatula, which is dependent on sun-exposed dead wood, benefited from shortened rather than prolonged rotations. Due to an uneven distribution of stand-ages within the landscape, the relative amounts of habitat provided by different rotation length scenarios for a given species were not always consistent through time during the simulation period. If implemented as a conservation measure, prolonging rotations will require long-term strategic planning to avoid future bottlenecks in habitat availability, and will need to be accompanied by complementary measures accounting for the diversity of habitats necessary for the conservation of forest biodiversity.

Projecting biodiversity and wood production in future forest landscapes: 15 key modeling considerations.

A variety of modeling approaches can be used to project the future development of forest systems, and help to assess the implications of different management alternatives for biodiversity and ecosystem services. This diversity of approaches does however present both an opportunity and an obstacle for those trying to decide which modeling technique to apply, and interpreting the management implications of model output. Furthermore, the breadth of issues relevant to addressing key questions related to forest ecology, conservation biology, silviculture, economics, requires insights stemming from a number of distinct scientific disciplines. As forest planners, conservation ecologists, ecological economists and silviculturalists, experienced with modeling trade-offs and synergies between biodiversity and wood biomass production, we identified fifteen key considerations relevant to assessing the pros and cons of alternative modeling approaches. Specifically we identified key considerations linked to study question formulation, modeling forest dynamics, forest processes, study landscapes, spatial and temporal aspects, and the key response metrics - biodiversity and wood biomass production, as well as dealing with trade-offs and uncertainties. We also provide illustrative examples from the modeling literature stemming from the key considerations assessed. We use our findings to reiterate the need for explicitly addressing and conveying the limitations and uncertainties of any modeling approach taken, and the need for interdisciplinary research efforts when addressing the conservation of biodiversity and sustainable use of environmental resources.

Varying rotation lengths in northern production forests: Implications for habitats provided by retention and production trees.

Because of the limited spatial extent and comprehensiveness of protected areas, an increasing emphasis is being placed on conserving habitats which promote biodiversity within production forest. For this reason, alternative silvicultural programs need to be evaluated with respect to their implications for forest biodiversity, especially if these programs are likely to be adopted. Here we simulated the effect of varied rotation length and associated thinning regimes on habitat availability in Scots pine and Norway spruce production forests, with high and low productivity. Shorter rotation lengths reduced the contribution made by production trees (trees grown for industrial use) to the availability of key habitat features, while concurrently increasing the contribution from retention trees. The contribution of production trees to habitat features was larger for high productivity sites, than for low productivity sites. We conclude that shortened rotation lengths result in losses of the availability of habitat features that are key for biodiversity conservation and that increased retention practices may only partially compensate for this. Ensuring that conservation efforts better reflect the inherent variation in stand rotation lengths would help improve the maintenance of key forest habitats in production forests.

Evaluating citizen science data for forecasting species responses to national forest management.

The extensive spatial and temporal coverage of many citizen science datasets (CSD) makes them appealing for use in species distribution modeling and forecasting. However, a frequent limitation is the inability to validate results. Here, we aim to assess the reliability of CSD for forecasting species occurrence in response to national forest management projections (representing 160,366 km2) by comparison against forecasts from a model based on systematically collected colonization-extinction data. We fitted species distribution models using citizen science observations of an old-forest indicator fungus Phellinus ferrugineofuscus. We applied five modeling approaches (generalized linear model, Poisson process model, Bayesian occupancy model, and two MaxEnt models). Models were used to forecast changes in occurrence in response to national forest management for 2020-2110. Forecasts of species occurrence from models based on CSD were congruent with forecasts made using the colonization-extinction model based on systematically collected data, although different modeling methods indicated different levels of change. All models projected increased occurrence in set-aside forest from 2020 to 2110: the projected increase varied between 125% and 195% among models based on CSD, in comparison with an increase of 129% according to the colonization-extinction model. All but one model based on CSD projected a decline in production forest, which varied between 11% and 49%, compared to a decline of 41% using the colonization-extinction model. All models thus highlighted the importance of protected old forest for P. ferrugineofuscus persistence. We conclude that models based on CSD can reproduce forecasts from models based on systematically collected colonization-extinction data and so lead to the same forest management conclusions. Our results show that the use of a suite of models allows CSD to be reliably applied to land management and conservation decision making, demonstrating that widely available CSD can be a valuable forecasting resource.

Relative contributions of set-asides and tree retention to the long-term availability of key forest biodiversity structures at the landscape scale.

Over previous decades new environmental measures have been implemented in forestry. In Fennoscandia, forest management practices were modified to set aside conservation areas and to retain trees at final felling. In this study we simulated the long-term effects of set-aside establishment and tree retention practices on the future availability of large trees and dead wood, two forest structures of documented importance to biodiversity conservation. Using a forest decision support system (Heureka), we projected the amounts of these structures over 200 years in two managed north Swedish landscapes, under management scenarios with and without set-asides and tree retention. In line with common best practice, we simulated set-asides covering 5% of the productive area with priority to older stands, as well as ∼5% green-tree retention (solitary trees and forest patches) including high-stump creation at final felling. We found that only tree retention contributed to substantial increases in the future density of large (DBH ≥35 cm) deciduous trees, while both measures made significant contributions to the availability of large conifers. It took more than half a century to observe stronger increases in the densities of large deciduous trees as an effect of tree retention. The mean landscape-scale volumes of hard dead wood fluctuated widely, but the conservation measures yielded values which were, on average over the entire simulation period, about 2.5 times as high as for scenarios without these measures. While the density of large conifers increased with time in the landscape initially dominated by younger forest, best practice conservation measures did not avert a long-term decrease in large conifer density in the landscape initially comprised of more old forest. Our results highlight the needs to adopt a long temporal perspective and to consider initial landscape conditions when evaluating the large-scale effects of conservation measures on forest biodiversity.

The legacy of logging--estimating arboreal lichen occurrence in a boreal multiple-use landscape on a two century scale.

In northern Sweden, the availability of arboreal lichens (Bryoria fuscescens, Alectoria sarmentosa) as winter grazing resources is an important element in reindeer husbandry. With the industrialization of forestry, forests rich in arboreal lichens have diminished considerably. Here, we analyze how forestry has impacted lichen availability from the 1920's to the present day and model its future development assuming different forest management scenarios.We recorded the current occurrence of B. fuscescens in 144 sampling plots, stratified by forest age class and dominant tree species in a 26,600 ha boreal forest landscape that is used for both reindeer herding and forestry. Lichen abundance was visually estimated in four classes: none, sparse, moderate and abundant. A binary logistic model using forest age as the independent variable was developed to predict the probability of lichens being present. Using this model, we found that lichens were present in stands that are at least 63 years old. Because of the relative paucity of stands rich in arboreal lichens, it was not possible to reliably determine how age affects the variation in abundance of older forest stands. The historical development of forests where arboreal lichens could potentially occur was studied using historic forestry records dating back 80 years. Between 1926 and the present day, forestry has reduced the cover of forests older than 60 years from 84% to 34%. The likely future spatial coverage of these stands over the next 120 years was estimated for two different management scenarios and an unmanaged reference scenario, using the Heureka strategic planning program. Under both the "business as usual" scenario and that involving more intensive forestry, continued decreases in lichen availability are projected. Our results emphasize the importance of alternative forestry practices, such as prolonged rotation periods, to increase the availability of arboreal lichens as a grazing resource for reindeer.