Optimizing Valve Selection in Valve-in-Valve Transcatheter Aortic Valve Replacement: A Case Study on Addressing Patient-Prosthesis Mismatch and Early Structural Valve Deterioration in a Morbidly Obese Patient.

Transcatheter aortic valve replacement (TAVR) has increasingly become a fundamental approach for treating aortic valve stenosis (AVS), especially in high surgical risk patients. This case study underscores the criticality of meticulous procedural planning and precise valve selection in patients with severe AVS compounded by obesity. We report a case of a patient who, after receiving a 26 mm Edwards Sapiens 3 valve, presented with worsening exertional dyspnea and a declining indexed effective orifice area (EOAi). This deterioration indicated early structural valve deterioration (SVD), presumably due to patient-prosthesis mismatch (PPM). A subsequent valve-in-valve (ViV) TAVR using a 29 mm Medtronic Evolut Fx valve was successfully executed, leading to a notable improvement in EOAi. This case study emphasizes the complexities inherent in valve choice and sizing in TAVR, particularly highlighting the impact of PPM on obese patients and its potential to precipitate early SVD. The report further explores the emerging strategies in addressing TAVR valve dysfunctions via ViV interventions, shedding light on the nuanced and dynamic nature of TAVR management in obese patients. It advocates for tailored treatment strategies in managing such intricate cases, demonstrating the evolving landscape of TAVR procedures.

Use of classical bird census transects as spatial replicates for hierarchical modeling of an avian community.

New monitoring programs are often designed with some form of temporal replication to deal with imperfect detection by means of occupancy models. However, classical bird census data from earlier times often lack temporal replication, precluding detection-corrected inferences about occupancy. Historical data have a key role in many ecological studies intended to document range shifts, and so need to be made comparable with present-day data by accounting for detection probability. We analyze a classical bird census conducted in the region of Murcia (SE Spain) in 1991 and 1992 and propose a solution to estimating detection probability for such historical data when used in a community occupancy model: the spatial replication of subplots nested within larger plots allows estimation of detection probability. In our study, the basic sample units were 1-km transects, which were considered spatial replicates in two aggregation schemes. We fit two Bayesian multispecies occupancy models, one for each aggregation scheme, and evaluated the linear and quadratic effect of forest cover and temperature, and a linear effect of precipitation on species occupancy probabilities. Using spatial rather than temporal replicates allowed us to obtain individual species occupancy probabilities and species richness accounting for imperfect detection. Species-specific occupancy and community size decreased with increasing annual mean temperature. Both aggregation schemes yielded estimates of occupancy and detectability that were highly correlated for each species, so in the design of future surveys ecological reasons and cost-effective sampling designs should be considered to select the most suitable aggregation scheme. In conclusion, the use of spatial replication may often allow historical survey data to be applied formally hierarchical occupancy models and be compared with modern-day data of the species community to analyze global change process.

Nest sites as a key resource for population persistence: A case study modelling nest occupancy under forestry practices.

Natural nest sites are important breeding resource in terms of population dynamics, especially in forest systems where nest trees limit populations or timber harvesting destroys nests. Nest structures usually have a long life and can be reused by breeding pairs across multiple breeding seasons, so studying their dynamics is of relevance for biodiversity conservation. In this study, we develop a dynamic model to evaluate nest site availability and its influence on the breeding settlement of a forest raptor community composed of booted eagle (Hieraaetus pennatus), common buzzard (Buteo buteo) and northern goshawk (Accipiter gentilis) in a Mediterranean forest ecosystem in southeast Spain. This model approach is also applied to analyse the influence of forestry practices on the dynamics of occupied nests for a simulated period (2010-2050). The simulated scenarios include unmanaged forest and timber harvesting practices of clearcuttings every ten years considering two factors: the age class of trees for clearcutting (40, 50, 60 and 70 years old) and the type of forest management (with or without nest protection). Our simulated results show that the number of breeding pairs is constant during the period without timber harvest, whereas breeding pairs gradually decrease in the scenario of clearcutting trees aged from 70 to 50-years without nest protection, and populations become extinct with the clearcutting of 40-year old trees. Considering the practice of clearcutting and nest protection, nest occupancy can reach the maximum number of occupied nests for the scenarios of cutting 70 and 60-year old trees, and maintain populations without extinction for the scenarios of cutting 40-year old trees. We conclude that nest sites (whether occupied or not) are key resources for increasing the occupancy of the forest raptor community and that nest protection measures buffer the effects of clearcuttings, thus preventing population extinction.

Setting Up a Population-Based Program to Optimize ST-Segment Elevation Myocardial Infarction Care.

The development of ST-segment elevation myocardial infarction (STEMI) systems of care at the city, region, or nation levels has not only improved the speed of reperfusion but also enhanced the reach of primary angioplasty to areas far from percutaneous coronary intervention (PCI) centers. Setting up a STEMI system of care is a sophisticated process that requires a solid PCI hospital and emergency medical services infrastructure, disciplined collaboration, and a focus on outcomes measurement and continuous quality improvement. This article reviews the accumulated evidence supporting the development of STEMI systems of care and offers practical insights into this process.

Efficiency of a protected-area network in a Mediterranean region: a multispecies assessment with raptors.

Three different systems of designating protected areas in a Mediterranean region in southeastern Spain were studied, referring to their effectiveness and efficiency for protecting both the breeding territories and the suitable habitat of a set of ten raptor species. Taking into consideration the varying degrees of endangerment of these species, a map of multispecies conservation values was also drawn up and superimposed on the three protected-area systems studied. In order to compare the levels of protection afforded by the three systems, we considered two indices that measured their relative effectiveness and efficiency. The effectiveness estimated the proportion of territories or optimal habitat protected by the networks while efficiency implicitly considered the area of each system (percentage of breeding territories or optimal habitat protected per 1% of land protected). Overall, our results showed that the most efficient system was that formed by the set of regional parks and reserves (17 protected breeding territories per 100 km²), although, given its small total area, it was by far the least effective (only protecting the 21% of the breeding territories of all species and 17% of the area of high conservation value). The systems formed by the Special Protection Areas (designated under the EU "Birds Directive") and by the Special Conservation Areas (designated under the EU "Habitats Directive") notably increased the percentages of protected territories of all species (61%) and area of high conservation value (57%), but their efficiency was not as high as expected in most cases. The overall level of protection was high for all species except for the Lesser Kestrel (Falco naumanni), an endangered falcon that inhabits pseudo-steppe and traditional agricultural habitats, which are clearly underrepresented in the protected-area network of the study region.