Heart failure management at home: a non-randomised prospective case-controlled trial (HeMan at Home).

BACKGROUND/OBJECTIVES: Heart failure (HF) is a growing clinical and economic burden for patients and health systems. The COVID-19 pandemic has led to avoidance and delay in care, resulting in increased morbidity and mortality among many patients with HF. The increasing burden of HF during the COVID-19 pandemic led us to evaluate the quality and safety of the Hospital at Home (HAH) for patients presenting to their community providers or emergency department (ED) with symptoms of acute on chronic HF (CHF) requiring admission. DESIGN/OUTCOMES: A non-randomised prospective case-controlled of patients enrolled in the HAH versus admission to the hospital (usual care, UC). Primary outcomes included length of stay (LOS), adverse events, discharge disposition and patient satisfaction. Secondary outcomes included 30-day readmission rates, 30-day ED usage and ED dwell time. RESULTS: Sixty patients met inclusion/exclusion criteria and were included in the study. Of the 60 patients, 40 were in the HAH and 20 were in the UC group. Primary outcomes demonstrated that HAH patients had slightly longer LOS (6.3 days vs 4.7 days); however, fewer adverse events (12.5% vs 35%) compared with the UC group. Those enrolled in the HAH programme were less likely to be discharged with postacute services (skilled nursing facility or home health). HAH was associated with increased patient satisfaction compared with Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score in North Carolina. Secondary outcomes of 30-day readmission and ED usage were similar between HAH and UC. CONCLUSIONS: The HAH pilot programme was shown to be a safe and effective alternative to hospitalisation for the appropriately selected patient presenting with acute on CHF.

The use of the reds noninvasive lung fluid monitoring system to assess readiness for discharge in patients hospitalized with acute heart failure: A pilot study.

BACKGROUND: Inadequate decongestion is common in hospitalized heart failure (HF) patients and may contribute to readmissions. Our purpose was to use remote dielectric sensing (ReDS) technology to measure lung congestion at discharge in patients admitted with acute HF and to see if a device-targeted intervention could reduce HF readmission rates. METHODS: We conducted a prospective pilot study of patients admitted with acute decompensated HF randomized to receive standard therapy or ReDS-guided therapy to determine the timing of hospital discharge based on the amount of lung congestion present after diuresis. ReDS measurement was performed for all patients once they were deemed ready for discharge. Patients in the treatment arm with residual lung congestion defined by ReDS ≥39% had HF consultation and further diuresis. RESULTS: Of 108 HF patients (50% male, age 73.6 ±â€¯12.6 years, BMI 29.3 ±â€¯4.3 kg/m2, EF 38.5 ±â€¯15.1%, BNP 1138 ±â€¯987 pg/mL), 32% demonstrated residual lung congestion at the time of proposed hospital discharge. ReDS guided therapy triggered additional diuresis in 30% (18/60) of the patients in the treatment arm (average weight loss 5.6 pounds, p = 0.02). 30-day HF readmission rates were similar in the treatment and the control arms (1.7% vs 4.2%; p = 0.44). Patients discharged as planned with residual lung congestion with ReDS ≥39% had higher 30-day readmission rate compared to patients who were adequately decongested at discharge with ReDS <39% (11.8% vs. 1.4%, p = 0.03). CONCLUSION: In our single-center cohort, ReDS testing demonstrated that 32% of HF patients deemed ready for discharge have clinically significant residual lung congestion which was associated with a higher risk of readmission. ReDS-guided management was associated with significant decongestion but not a reduction in HF readmissions in this sample.

Prospective Evaluation of a Fixed-Dose 4-Factor Prothrombin Complex Concentrate Protocol for Urgent Vitamin K Antagonist Reversal.

BACKGROUND: Four-factor prothrombin complex concentrate (4F-PCC) is the standard of care for reversal of vitamin K antagonists (VKAs). Research has demonstrated noninferior efficacy with the use of lower, fixed-dose strategies for 4F-PCC dosing. OBJECTIVES: We compared a fixed-dose 4F-PCC protocol to weight-based dosing at our institution. METHODS: This was a multicenter, noninferiority, interventional, quasiexperimental cohort study including subjects who were administered 4F-PCC for VKA reversal. The retrospective cohort consisted of subjects given a weight-based dose of 4F-PCC dependent on international normalized ratio (INR). The prospective cohort was managed with a fixed-dose protocol. The fixed dose was 1500 units of factor IX unless subjects weighed >100 kg or had a baseline INR >7.5, in which case the dose was 2000 units of factor IX. The primary endpoint was achievement of a postinfusion INR of <2. Secondary endpoints included achievement postinfusion INR <1.5, mean 24-h INR, 7-day mortality, and 7-day venous thromboembolic events. RESULTS: Twenty-four subjects were enrolled in the prospective cohort and 30 in the retrospective cohort. A postinfusion INR <2 was achieved in 96% of subjects in the retrospective cohort and 95% in the prospective cohort (p = 0.0035 for noninferiority). A postinfusion INR <1.5 occurred in 90% of subjects in the retrospective cohort and 75% in the prospective cohort (p > 0.4 for noninferiority). There were no significant differences in 24-h postinfusion INRs, mortality, or venous thromboembolic events. CONCLUSION: The use of a fixed-dose 4F-PCC protocol is safe and effective for the rapid reversal of VKA-associated anticoagulation.

First integrative trend analysis for a great ape species in Borneo.

For many threatened species the rate and drivers of population decline are difficult to assess accurately: species' surveys are typically restricted to small geographic areas, are conducted over short time periods, and employ a wide range of survey protocols. We addressed methodological challenges for assessing change in the abundance of an endangered species. We applied novel methods for integrating field and interview survey data for the critically endangered Bornean orangutan (Pongo pygmaeus), allowing a deeper understanding of the species' persistence through time. Our analysis revealed that Bornean orangutan populations have declined at a rate of 25% over the last 10 years. Survival rates of the species are lowest in areas with intermediate rainfall, where complex interrelations between soil fertility, agricultural productivity, and human settlement patterns influence persistence. These areas also have highest threats from human-wildlife conflict. Survival rates are further positively associated with forest extent, but are lower in areas where surrounding forest has been recently converted to industrial agriculture. Our study highlights the urgency of determining specific management interventions needed in different locations to counter the trend of decline and its associated drivers.

Managing water services in tropical regions: From land cover proxies to hydrologic fluxes.

Watershed investment programs frequently use land cover as a proxy for water-based ecosystem services, an approach based on assumed relationships between land cover and hydrologic outcomes. Water flows are rarely quantified, and unanticipated results are common, suggesting land cover alone is not a reliable proxy for water services. We argue that managing key hydrologic fluxes at the site of intervention is more effective than promoting particular land-cover types. Moving beyond land cover proxies to a focus on hydrologic fluxes requires that programs (1) identify the specific water service of interest and associated hydrologic flux; (2) account for structural and ecological characteristics of the relevant land cover; and, (3) determine key mediators of the target hydrologic flux. Using examples from the tropics, we illustrate how this conceptual framework can clarify interventions with a higher probability of delivering desired water services than with land cover as a proxy.

Effects of high-frequency understorey fires on woody plant regeneration in southeastern Amazonian forests.

Anthropogenic understorey fires affect large areas of tropical forest, yet their effects on woody plant regeneration post-fire remain poorly understood. We examined the effects of repeated experimental fires on woody stem (less than 1 cm at base) mortality, recruitment, species diversity, community similarity and regeneration mode (seed versus sprout) in Mato Grosso, Brazil. From 2004 to 2010, forest plots (50 ha) were burned twice (B2) or five times (B5), and compared with an unburned control (B0). Stem density recovered within a year after the first burn (initial density: 12.4-13.2 stems m(-2)), but after 6 years, increased mortality and decreased regeneration--primarily of seedlings--led to a 63 per cent and 85 per cent reduction in stem density in B2 and B5, respectively. Seedlings and sprouts across plots in 2010 displayed remarkable community similarity owing to shared abundant species. Although the dominant surviving species were similar across plots, a major increase in sprouting occurred--almost three- and fourfold greater in B2 and B5 than in B0. In B5, 29 species disappeared and were replaced by 11 new species often present along fragmented forest edges. By 2010, the annual burn regime created substantial divergence between the seedling community and the initial adult tree community (greater than or equal to 20 cm dbh). Increased droughts and continued anthropogenic ignitions associated with frontier land uses may promote high-frequency fire regimes that may substantially alter regeneration and therefore successional processes.

Understanding the impacts of land-use policies on a threatened species: is there a future for the Bornean orang-utan?

The geographic distribution of Bornean orang-utans and its overlap with existing land-use categories (protected areas, logging and plantation concessions) is a necessary foundation to prioritize conservation planning. Based on an extensive orang-utan survey dataset and a number of environmental variables, we modelled an orang-utan distribution map. The modelled orang-utan distribution map covers 155,106 km(2) (21% of Borneo's landmass) and reveals four distinct distribution areas. The most important environmental predictors are annual rainfall and land cover. The overlap of the orang-utan distribution with land-use categories reveals that only 22% of the distribution lies in protected areas, but that 29% lies in natural forest concessions. A further 19% and 6% occurs in largely undeveloped oil palm and tree plantation concessions, respectively. The remaining 24% of the orang-utan distribution range occurs outside of protected areas and outside of concessions. An estimated 49% of the orang-utan distribution will be lost if all forest outside of protected areas and logging concessions is lost. To avoid this potential decline plantation development in orang-utan habitats must be halted because it infringes on national laws of species protection. Further growth of the plantation sector should be achieved through increasing yields in existing plantations and expansion of new plantations into areas that have already been deforested. To reach this goal a large scale island-wide land-use masterplan is needed that clarifies which possible land uses and managements are allowed in the landscape and provides new standardized strategic conservation policies. Such a process should make much better use of non-market values of ecosystem services of forests such as water provision, flood control, carbon sequestration, and sources of livelihood for rural communities. Presently land use planning is more driven by vested interests and direct and immediate economic gains, rather than by approaches that take into consideration social equity and environmental sustainability.

Committed carbon emissions, deforestation, and community land conversion from oil palm plantation expansion in West Kalimantan, Indonesia.

Industrial agricultural plantations are a rapidly increasing yet largely unmeasured source of tropical land cover change. Here, we evaluate impacts of oil palm plantation development on land cover, carbon flux, and agrarian community lands in West Kalimantan, Indonesian Borneo. With a spatially explicit land change/carbon bookkeeping model, parameterized using high-resolution satellite time series and informed by socioeconomic surveys, we assess previous and project future plantation expansion under five scenarios. Although fire was the primary proximate cause of 1989-2008 deforestation (93%) and net carbon emissions (69%), by 2007-2008, oil palm directly caused 27% of total and 40% of peatland deforestation. Plantation land sources exhibited distinctive temporal dynamics, comprising 81% forests on mineral soils (1994-2001), shifting to 69% peatlands (2008-2011). Plantation leases reveal vast development potential. In 2008, leases spanned ∼65% of the region, including 62% on peatlands and 59% of community-managed lands, yet <10% of lease area was planted. Projecting business as usual (BAU), by 2020 ∼40% of regional and 35% of community lands are cleared for oil palm, generating 26% of net carbon emissions. Intact forest cover declines to 4%, and the proportion of emissions sourced from peatlands increases 38%. Prohibiting intact and logged forest and peatland conversion to oil palm reduces emissions only 4% below BAU, because of continued uncontrolled fire. Protecting logged forests achieves greater carbon emissions reductions (21%) than protecting intact forests alone (9%) and is critical for mitigating carbon emissions. Extensive allocated leases constrain land management options, requiring trade-offs among oil palm production, carbon emissions mitigation, and maintaining community landholdings.

Soil nutrients affect spatial patterns of aboveground biomass and emergent tree density in southwestern Borneo.

Studies on the relationship between soil fertility and aboveground biomass in lowland tropical forests have yielded conflicting results, reporting positive, negative and no effect of soil nutrients on aboveground biomass. Here, we quantify the impact of soil variation on the stand structure of mature Bornean forest throughout a lowland watershed (8-196 m a.s.l.) with uniform climate and heterogeneous soils. Categorical and bivariate methods were used to quantify the effects of (1) parent material differing in nutrient content (alluvium > sedimentary > granite) and (2) 27 soil parameters on tree density, size distribution, basal area and aboveground biomass. Trees > or =10 cm (diameter at breast height, dbh) were enumerated in 30 (0.16 ha) plots (sample area = 4.8 ha). Six soil samples (0-20 cm) per plot were analyzed for physiochemical properties. Aboveground biomass was estimated using allometric equations. Across all plots, stem density averaged 521 +/- 13 stems ha(-1), basal area 39.6 +/- 1.4 m(2) ha(-1) and aboveground biomass 518 +/- 28 Mg ha(-1) (mean +/- SE). Adjusted forest-wide aboveground biomass to account for apparent overestimation of large tree density (based on 69 0.3-ha transects; sample area = 20.7 ha) was 430 +/- 25 Mg ha(-1). Stand structure did not vary significantly among substrates, but it did show a clear trend toward larger stature on nutrient-rich alluvium, with a higher density and larger maximum size of emergent trees. Across all plots, surface soil phosphorus (P), potassium, magnesium and percentage sand content were significantly related to stem density and/or aboveground biomass (R (Pearson) = 0.368-0.416). In multiple linear regression, extractable P and percentage sand combined explained 31% of the aboveground biomass variance. Regression analyses on size classes showed that the abundance of emergent trees >120 cm dbh was positively related to soil P and exchangeable bases, whereas trees 60-90 cm dbh were negatively related to these factors. Soil fertility thus had a significant effect on both total aboveground biomass and its distribution among size classes.

Long-term reproductive behaviour of woody plants across seven Bornean forest types in the Gunung Palung National Park (Indonesia): suprannual synchrony, temporal productivity and fruiting diversity.

For 68 months, we observed the reproductive behaviour of 7288 woody plants (172 figs, 1457 climbers and 5659 trees) spanning major soil and elevational gradients. Two 2-3 month community-wide supra-annual fruiting events were synchronized across five forest types, coinciding with ENSO events. At least 27 genera in 24 families restricted their reproduction to these events, which involved a substantial proportion of tree diversity (> 80% of phylogenetic diversity). During these events, mean reproductive levels (8.5%) represented an almost four-fold increase compared with other months. These patterns indicate a strong behavioural advantage to this unusual reproductive behaviour. Montane forest experienced a single, separate fruiting peak while the peat swamp forest did not participate. Excluding these events, no temporal reproductive pattern was detectable, at either the landscape or forest type. These phenological patterns have major implications for the conservation of frugivore communities, with montane and swamp forests acting as 'keystone' forests.

Effects of partial throughfall exclusion on the phenology of Coussarea racemosa (Rubiaceae) in an east-central Amazon rainforest.

Severe droughts may alter the reproductive phenology of tropical tree species, but our understanding of these effects has been hampered by confounded variation in drought, light and other factors during natural drought events. We used a large-scale experimental reduction of throughfall in an eastern-central Amazon forest to study the phenological response to drought of an abundant subcanopy tree, Coussarea racemosa. We hypothesized that drought would alter the production and the timing of reproduction, as well as the number of viable fruits. The study system comprised two 1-ha plots in the Tapajos National Forest, Para, Brazil: a dry plot where 50% of incoming precipitation (80% throughfall) was diverted from the soil during the six-month wet season beginning in January 2000, and a wet plot that received natural rainfall inputs. Fruit production of C. racemosa was quantified every 15 days using 100 litter traps (0.5 m(2)) in each plot. The production of new leaves and flowers was recorded monthly for C. racemosa individuals. Soil water, pre-dawn leaf water potential and solar radiation were measured to help interpret phenological patterns. Over the approximately 3.5-year period (April 2000 through December 2003), total fruit production remained similar between plots, declining by 12%. In 2003, production was four times higher in both plots than in previous years. In the dry plot, fruit fall shifted 40 and 60 days later into the dry season in 2002 and 2003, respectively. Total fruit fall dry mass production was variable across the study period. Foliage and flower production coincided with peak irradiance early in the dry season until delays in flowering appeared in the dry plot in 2002 and 2003. Plant water stress, through its influence on leaf developmental processes and, perhaps, inhibition of photosynthesis, appears to have altered both the timing of fruit fall and the quality and number of seeds produced.

Modelling conservation in the Amazon basin.

Expansion of the cattle and soy industries in the Amazon basin has increased deforestation rates and will soon push all-weather highways into the region's core. In the face of this growing pressure, a comprehensive conservation strategy for the Amazon basin should protect its watersheds, the full range of species and ecosystem diversity, and the stability of regional climates. Here we report that protected areas in the Amazon basin--the central feature of prevailing conservation approaches--are an important but insufficient component of this strategy, based on policy-sensitive simulations of future deforestation. By 2050, current trends in agricultural expansion will eliminate a total of 40% of Amazon forests, including at least two-thirds of the forest cover of six major watersheds and 12 ecoregions, releasing 32 +/- 8 Pg of carbon to the atmosphere. One-quarter of the 382 mammalian species examined will lose more than 40% of the forest within their Amazon ranges. Although an expanded and enforced network of protected areas could avoid as much as one-third of this projected forest loss, conservation on private lands is also essential. Expanding market pressures for sound land management and prevention of forest clearing on lands unsuitable for agriculture are critical ingredients of a strategy for comprehensive conservation.

Cenários de desmatamento para a Amazônia / Deforestation scenarios for Amazonia

A AMAZÕNIA está entrando em uma era de rápidas mudanças impulsionadas pela previsão de asfaltamento de rodovias que estimularão a expansão da fronteira agrícola e de exploração madeireira. O declínio do custo de transporte tem importantes implicações para a biodiversidade, emissão de gases que contribuem para o efeito estufa e prosperidade da sociedade da Amazônia a longo prazo. Para analisar esse contexto, foi desenvolvido um modelo de simulação de desmatamento na bacia Amazônica, sensível a diferentes cenários de políticas públicas frente à expansão da infra-estrutura de transporte pela região. Resultados do modelo indicam que, dentro de um cenário pessimista, o desmatamento projetado pode eliminar, até meados deste século, 40 por cento dos atuais 5,4 milhões de km² de florestas da Amazônia, liberando o equivalente a 32 Pg (10(9) toneladas) de carbono para atmosfera. A modelagem de cenários alternativos aponta que a expansão de uma rede de áreas protegidas, efetivamente implementadas, poderia reduzir em até 1/3 as perdas florestais projetadas. Contudo, outras medidas de conservação são ainda necessárias para se manter a integridade funcional das paisagens e bacias hidrográficas amazônicas. Atuais experimentos em conservação florestal em propriedades privadas, mercados de serviços ambientais e zoneamento agro-ecológico devem ser refinados e multiplicados a fim de se buscar uma conservação extensiva.