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In the context of climate change, the effects of prolonged or more severe droughts on pest and pathogen damage are a major concern for forest ecosystems. To date, there is great uncertainty about the direction, magnitude and sources of variation in responses to drought by insects and fungi. We report the outcomes of a meta-analysis of 100 pairwise comparisons of insect pest or pathogen damage to water-stressed and control trees from 40 publications. The type of feeding substrate for insects and fungi and the water stress severity emerged as the main factors influencing the level of damage in water-stressed trees. Overall, primary damaging agents living in wood caused significantly lower damage to the water-stressed trees compared with the control, whereas primary pests and pathogens living on foliage caused more damage to water-stressed trees, in all cases irrespective of stress severity. In contrast, damage by secondary agents increased with stress severity, which was best estimated by the ratio between the predawn leaf water potential in stressed trees and the xylem pressure inducing 50% loss in hydraulic conductance due to cavitation, a species-specific index of drought tolerance. Insect and fungus feeding behaviour, affected tree part, and water stress severity are therefore proposed as three important predictors of forest damage in drought conditions. [ABSTRACT FROM AUTHOR]

This study investigates Cu isotope ratio variations in the high-grade, vein-type Cu-Ag deposit of Dikulushi, Democratic Republic of Congo. The Dikulushi deposit consists of a Cu-Pb-Zn-Fe mineralization, comprising sphalerite, chalcopyrite, bornite, and chalcocite that precipitated under reducing conditions. This mineralization was partly remobilized in more oxidizing conditions into a Cu-Ag mineralization phase, which is dominated by Ag-rich chalcocite. The upper part of the deposit is strongly reworked by weathering. Sulfides from the two types of mineralization and Cu carbonates/-silicates from the weathering zone display significant Cu isotope ratio variations. Chalcopyrite and ch'alcocite from the Cu-Pb-Zn-Fe and Cu-Ag mineralization types are characterized by variable low Cu isotope compositions (0.00 to -2.3% δ65Cu). The Cu isotope composition for some chaleocite from the Cu-Ag mineralization deviates to lower δ65Cu values relative to that of chalcocite from the Cu-Pb-Zn-Fe mineralization. This deviation is likely related to remobilization of the Cu-Pb-Zn-Fe mineralization in an oxidizing environment. The isotopic composition of Cu in chalcocite from both mineralization types becomes higher toward the center of the orebody and as a function of depth. This variation could be related to physicochemical changes in the precipitation environment as a consequence of interaction of the reduced mineralizing brine with the oxidized host rock or might have been induced by supergene processes afterward. The supergene mineralization is composed of malachite, azurite, and chrysocolla that are enriched in 65Cu (1.37-2.65% δ65Cu). [ABSTRACT FROM AUTHOR]

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Percutaneous pulmonary valve implantation (PPVI) is a challenging intervention, especially in Tetralogy of Fallot (TOF) patients with large native outflow tract. We assess the ability of 3D printing to predict PPVI success. We retrospectively printed 15 cardiac models with flexible photopolymer resine from tomodensitometry. Patients (Median age 40 years old [26-56]) had TOF with large regurgitant native outflow tract. Especially patients with complex PPVI procedures were selected. Printing method was adjusted to mimic pulmonary artery elasticity. Balloon sizing was performed under fluoroscopy on the models and in patients. Models analysis were performed blinded to outcome. Median minimal landing zone diameter was 25 mm [22-27]. Two patients were referred for elective surgical valve replacement (outflow tract measured at 32 mm after sizing in one and at 34 mm after prestenting in the second). Sapien 3 valves were implanted in 13 patients after prestenting. Shape of the outflow tract was described as tubular (n = 8), sandglass (n = 1), chicane (n = 2), funnel-shaped (n = 2) and ballooning (n = 1) on models. Correlation between invasive and models balloon calibration was not significant. Using Bland-Altman analysis, mean difference between the 2 techniques was 0.4 ± 3.9 mm (Fig. 1). Two patients were considered unsuitable for PPVI based on models. These 2 patients matched with the 2 referred for surgery. Assessing size and shape of the models, 2 interventionalists rated the expected complexity of PPVI from straightforward (n = 10), to moderate (n = 2) and complex (n = 2). Analysis of outcome confirmed challenging procedures in 2 and uneventful in 12. Kappa agreement coefficient was 0.44, P = 0.007. 3D printed cardiac models are useful to predict challenging PPVI but lacks accuracy to size the outflow tract. Prospective studies are needed to corroborate these preliminary results and better define the interest of this new tool before PPVI. [ABSTRACT FROM AUTHOR]

• A new concept of empowerment based upon the perspective of patients with epilepsy. • Ideas of how to incorporate empowerment into care for patients with epilepsy. • New understandings of what a person-centered perspective implies for clinical care. The aim of the study was to develop a new conceptual framework of empowerment based upon the perspective of patients with refractory epilepsy at the medical-social center of La Teppe (France). A qualitative research methodology was used, which consisted of focused ethnography and in-depth interviews. The 19 patients interviewed came from three hospital services and were in the age range of 20–60. Ten interviews were also conducted with healthcare providers, which included neurologists, psychiatrists, nurses, and social educators. Results were analyzed via an intuitive process of thematic analysis. The researcher also constructed narrative cases of the patient interview to better understand patient responses in context. The results show that patients understood empowerment as the ability to develop and take advantage of opportunities in their overall lives. This included searching to be healthy by reducing their seizures, developing their practical reason in order to be able to make more autonomous life choices, and living with and toward others in positive social relationships. The patient's perspective on empowerment encompasses but also goes beyond their medical care. We therefore propose a novel conceptual framework for empowerment as the patient's capabilities to develop and make their life choices, with help as needed from their support network. In order to help patients toward empowerment, clinical care can include discussions and dedicate resources that help patients work toward their overall life projects. Several methodologies, including the use of a personalized project and therapeutic patient education, are elaborated to give ideas for empowerment programming in epilepsy care. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is available in the text. Background: Children treated with cardiac catheterization procedures have now a long life expectancy and consequently potential long-term radiation-induced risks. We projected lifetime attributable risks (LARs) of cancer incidence from the most frequent procedures in pediatrics: atrial septal defect closure, patent ductus arteriosus occlusion, or pulmonary valvuloplasty. Methods and Results: Organ equivalent doses were estimated for 1251 procedures performed in children aged ≤15 years at 2 reference catheterization centers in France from 2009 to 2013. Sex-specific LARs were projected in lifelong nonsmokers using extended Committee on Biological Effects of Ionizing Radiation VII risk models and considering various sources of risk projection uncertainties and dose variability (Radiation Risk Assessment Tool software). Median LARs ranged between 0.3 and 1.4 (atrial septal defect closure), 0.6 and 5.0 (patent ductus arteriosus occlusion), and 1.0 and 12.0 (pulmonary valvuloplasty) per 1000 procedures, depending on patient sex and age at treatment. These radiation-related risks would represent 0.4% to 6.0% of children's total lifetime cancer risk. For the 10% of procedures (all types combined) with highest exposures, LARs reached 4.2 per 1000 (95% uncertainty interval, 0.8–13.1) in boys and 22.2 per 1000 (95% uncertainty interval, 7.4–45.6) in girls. In boys, lung cancer accounted for 70% to 80% of the projected LARs, whereas in girls it accounted for 20% to 60% and breast cancer for 30% to 80% of the excess risks, depending on the type of procedure and patient age. Conclusions: Radiation exposure may lead to substantial radiation doses and increased cancer risks in some cases. This suggests the need for dose reporting to support recommendations for long-term surveillance and prevention strategies when it is necessary. [ABSTRACT FROM AUTHOR]

Background The SAPIEN 3 valve (S3) is the latest iteration of the SAPIEN valve family. It is deployed using a low profile flexible Commander delivery system. Hemodynamic outcomes and device durability are promising with SAPIEN valves, but percutaneous pulmonary valve implantation (PPVI) remains difficult. Moreover, the lack of valve covering increases the risk of tricuspid valve injury. Objectives To described the early results of a modified procedure for PPVI of the SAPIEN S3 valve using a delivery sheath. Methods We report the first consecutive cases of a modified procedure for PPVI of the SAPIEN S3 valve using a DryGore Seal 26French 65 cm delivery sheath. The sheath was used to stent the right ventricular outflow tract and then for the valve implantation. Results PPVI was performed using the modified technique in 15 patients (mean age 31 yo; mean weight 72.5 kg). The most common diagnoses were conotruncal defect (53.3%) and congenital aortic valve disease with Ross surgery (13.3%). A right-ventricle-to-pulmonary-artery tube had been inserted in 20.0% and a homograft or bioprosthesis implanted in 13.3% and 17.7% of patients, respectively. PPVI was performed on the native or patched RVOT in 73.3% of patients. Prestenting was performed in 12 cases with Andrastent XXL in 11 cases and eV3 LD max in 1 case. Prestenting was performed during the same procedure in all cases. While advancing the sheath through the stent, stent embolization occurred in one case. The stent was impacted and moved back with post dilatation and implantation of a second stent. SAPIEN 3 No. 23, No. 26 and No. 29 were implanted in 2, 3 and 10 cases. Valves were successfully implanted in all cases using the delivery sheath. Mean post valve gradient was 3 mmHg. Minor paravalvular leak was reported in 2 cases. Mean fluoroscopy time was 26.8 min. Groin hematoma were reported in 4 cases (26.7%). Conclusion A delivery sheath allows a fast and safe PPVI of SAPIEN S3 valve. [ABSTRACT FROM AUTHOR]

Background Multiple surgical revisions are often necessary in individuals with congenital heart defects affecting the right ventricular outflow tract (RVOT) or pulmonary valve. To prolong the need for additional open heart interventions, percutaneous pulmonary valve implantation (PPVI) may be performed as a less invasive alternative. No multi-patient studies currently report the feasibility and safety of this procedure using the new generation SAPIEN 3 (S3) transcatheter heart valve. Methods and Results Pulmonic S3 is a multicentre observational registry of patients undergoing PPVI with the S3 valve across Europe, and Canada started in March 2016. Until end of January 2018, data for 81 patients with a mean age of 26.5 years was obtained. The most common underlying diagnosis was Tetralogy of Fallot (ToF) (58.0%), with only 16.3% of patients having native RVOT anatomy. 90% received pre-stenting. Procedural success was 100%. Prosthesis dislodgement (without need for open surgery) occurred in one patient, with another experiencing conduit perforation. Both were successfully resolved and no other procedural complications, endocarditis, stent fracture or mortality were reported up to two years. The peak systolic gradient over the RVOT fell from 45.6 mmHg pre-procedurally to 16.2 mmHg post-procedurally, the proportion of patients with moderate/severe pulmonary regurgitation from 89.2% to 0.0% and those with an NYHA class ≥ II from 86.8% to 15.9%. Conclusions PPVI with the S3 valve appears feasible and safe in a wide range of patients with congenital heart defects, with good short-term haemodynamic and functional outcomes. Longer-term outcomes remain to be described. Clinicaltrials.gov identifier NCT02777892. [ABSTRACT FROM AUTHOR]

Introduction: Percutaneous pulmonary valve implantation (PPVI) with a SAPIEN 3 valve is effective for treating treat right ventricle outflow (RVOT) dysfunction. A modified technique was developed without prestenting using a protective valve delivery method. We aimed to compare the procedural results of the modified technique group (MTG) to those of patients in a conventional technique group (CTG). Methods: We designed a matched before–after study. All consecutive PPVI with SAPIEN 3 performed in the MTG over 9 months were matched, based on the RVOT type and size, to consecutive procedures performed previously with SAPIEN 3. Results: A total of 54 patients were included, equally distributed in the two groups. The sizes of the SAPIEN 3 valves were 23 mm (n = 9), 26 mm (n = 9), 29 mm (n = 36). The two groups were similar regarding demographic data, RVOT type, and pre-procedure hemodynamics. PPVI was performed in a single procedure in all patients of the MTG, whereas six (22.2%) patients of the CTG group underwent prestenting as a first step and valve implantation later (p = 0.02). The procedures were successful in all cases. Stent embolization was reported in two patients (7.4%) in the CTG, which were impacted in pulmonary arteries. In one case (3.7%), in the MTG, an unstable 29 mm SAPIEN 3 valve was stabilized with two stents and additional valve-in-valve implantation. The hemodynamics results were good in all cases, without significant differences between the two groups. The procedures' durations and fluoroscopy times were significantly reduced in the MTG (48.1 versus 82.6 min, p < 0.0001; 15.2 versus 29.8 min, p = 0.0002). During follow-up, neither stent fracture nor valve dysfunction was noticed in either group. Conclusion: PPVI without prestenting and with a protective delivery method of the SAPIEN 3 valve significantly reduces the procedure's complexity, the duration, and the irradiation while maintaining excellent hemodynamics results in selected cases. [ABSTRACT FROM AUTHOR]

Transcatheter pulmonary valve implantation (TPVI) is effective for treating right ventricle outflow tract (RVOT) dysfunction. Factors associated with long-term valve durability remain to be investigated. Consecutive patients successfully treated by TPVI with Melody valves (n = 32) and SAPIEN valves (n = 182) between 2008 and 2020 at a single tertiary centre were included prospectively and monitored. The 214 patients had a median age of 28 years (range, 10–81). The RVOT was a patched native pulmonary artery in 96 (44.8%) patients. Median follow-up was 2.8 years (range, 3 months–11.4 years). Secondary pulmonary valve replacement (sPVR) was performed in 23 cases (10.7%), due to stenosis (n = 22, 95.7%) or severe regurgitation (n = 1, 4.3%), yielding an incidence of 7.6/100 patient-years with melody valves and 1.3/100 patient-years with SAPIEN valves (P = 0.06). The 5- and 10-year sPVR-freedom rates were 78.1% and 50.4% with Melody vs. 94.3% and 82.2% with SAPIEN, respectively (P = 0.06). The incidence of infective endocarditis (IE) was 5.5/100 patient-years with Melody and 0.2/100 patient-years with SAPIEN (P < 0.0001). Factors associated with sPVR by univariate analysis were RV obstruction before TPVI (P = 0.04), transpulmonary maximal velocity > 2.7 m/s after TPVI (p = 0.0005), valve diameter ≤ 22 mm (P < 0.003), IE (P < 0.0001), and age < 25 years at TPVI (P = 0.04). By multivariate analysis adjusted for IE occurrence, transpulmonary maximal velocity remained associated with sPVR. TPVI is effective for treating RVOT dysfunction. Incidence of sPVR is higher in patients with residual RV obstruction or IE. IE add a substantial risk of TPVI graft failure and is mainly linked to the Melody valve. Transcatheter pulmonary valve implantation is effective for treating right ventricular outflow tract dysfunction in patients with congenital heart diseases. Incidence of secondary valve replacement is higher in patients with residual obstruction or infective endocarditis. [Display omitted] [ABSTRACT FROM AUTHOR]

Background Atrial septal defects (ASDs) can be symptomatic in small children in cases of co-morbidities. Transcatheter closure remains controversial for large defects in small children. Objective To describe transcatheter closure of ASDs in children with device/weight ratio ≥1.5. Methods We retrospectively studied between January 2000 and January 2016 all cases of percutaneous ASD closure with device/weight ratio ≥1.5 in 6 European centres. Results Forty patients were included with female/male ratio of 1.2. Median age and weight were 30.9 months (4.1–102.0) and 11.0 kg respectively (3.8–19.0). Median device size/weight ratio was 1.7 (1.5–2.3). All patients were symptomatic, with pulmonary hypertension in 13 (33%). Procedures were performed under general anesthesia or light sedation (n = 4), with transthoracic (n = 25) or transesophageal echocardiography (n = 15) guidance. Balloon stretched diameter (n = 32) was larger than the echocardiographic diameter (19 versus 15 mm, R = 0.6; p < 0.001). Deficient rims other than the anterior-superior one were found in 33% of cases. Device implantation was successful in 39 patients (97.5%). Minor complications occurred in 10% of cases, whereas severe complications rate was 5%: Complete atrioventricular block in one patient that resolved after surgical extraction of the device and thrombosis in the inferior vena cava in one patient. During a median follow-up of 52 months, there was no residual shunt. No case of erosion or embolization was reported and pulmonary hypertension resolved in all patients. Conclusion Percutaneous closure of large ASD in small and symptomatic children is feasible and allows clinical improvement with acceptable rate of complications in high risk population. [ABSTRACT FROM AUTHOR]

Oysters ( Crassostrea gigas ) farmed in a clean reference estuary were exposed to different combinations of 63 Cu and 107 Ag stable isotope spikes in seawater at environmentally relevant concentrations during 28 days in order to study short-term bioaccumulation kinetics. Oysters were sampled, dissected and analyzed for Cu and Ag concentrations and isotope ratios ( 63/65 Cu; 107/109 Ag) after 7, 14, 21 and 28 days of exposure. Isotope ratios in oyster tissues showed significant differences from natural isotope ratios even after only 7 days of exposure, with relatively similar signals independent from the tissue. The changes in isotope ratios combined with conventional concentration measurements allowed precise quantification of 63 Cu and 107 Ag concentrations before experimental exposure, in the same individual oyster tissue. The high sensitivity and the possibility to precisely follow short-term accumulation at environmental levels of several (non radioactive) different metals in individual organisms are major advantages. Relatively constant Cu/Ag ratios in oysters exposed to the lowest Cu and Ag concentrations were observed. However, interactions between Cu and Ag accumulation occurred with (i) a synergy effect increasing Ag accumulation in the presence of high Cu concentrations and (ii) antagonism resulting in lower Cu accumulation at a given Cu exposure when Ag exposure levels increase. Comparison of experimentally accumulated Cu/Ag ratios ( 63 Cu acc / 107 Ag acc ) with Cu/Ag in wildlife oysters along the French Atlantic coast (data provided by the national mussel watch program RNO/ROCCH) suggests that such metal ratios reflect, to a certain extent, exposure levels and proportions in the environment. As such, element ratios may indicate contamination sources better than metal concentrations alone. Metal accumulation in the different oyster tissues (mantle, muscle, gills, digestive gland and gonads) was rather homogeneous during the short-term direct exposure experiment, whereas wild oysters from the Gironde Estuary show very strong differences in metal accumulation between tissues, i.e. maximum Ag accumulation in digestive gland. This suggests that the trophic pathway (metals contaminating oysters through the food intake) may play a major role in wildlife oyster contamination. [ABSTRACT FROM AUTHOR]