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Abstract Mounting evidence suggests that win‐wins are elusive and trade‐offs are the norm in marine conservation development practice. The status quo involves trade‐offs, and any change brought to ecosystems, economies and societies will alter the distribution of costs and benefits, creating other winners and losers among ecosystem services, sectors and people. While studies are increasingly acknowledging the prevalence of trade‐offs, this article analyses how practitioners working for conservation development agencies consider, facilitate and make trade‐off decisions a priori and post hoc when designing and implementing marine conservation development programmes in Southeast Asia. We find that these practitioners recognize both substantive trade‐offs, which are diverse social and ecological trade‐offs resulting from their programmes, and process trade‐offs, related to how they design programmes, including between their prioritization of different locations; between strategic relationships; and between the efficacy, equity and sustainability of projects. Existing decision support tools only capture a limited range of substantive (mainly ecological) trade‐offs, however, and are not widely used. Typically, social trade‐offs are not systematically assessed. Instead, they are implicitly identified by participants and beneficiaries voicing their concerns during consultation processes. Importantly, whether a trade‐off is then deemed acceptable is not determined through transparent assessment of trade‐offs and principles of equity or justice but by the uneven political power of stakeholders to project their values in decision‐making processes. The article concludes that practitioners should facilitate inclusive, transparent and systematic identification and deliberation of the social acceptability of multidimensional trade‐offs, and formulate response options to avoid or minimize adverse consequences. Tackling trade‐offs in this way has the potential to make invisible trade‐offs visible and improve the sustainability and legitimacy of marine conservation development programmes while promoting the interests of the most marginalized in efforts to achieve the sustainable development goals. Read the free Plain Language Summary for this article on the Journal blog.

O-FEES (O-FEES) è una procedura endoscopica, concepita per visualizzare direttamente la fase orale della deglutizione. Nella prospettiva di un utilizzo clinico, la fattibilità, la sicurezza e laccettabilità dellO-FEES è stata inizialmente valutata. Successivamente, la procedura è stata confrontata con il gold standard radiologico. Laccettabilità dellO-FEES è stata confrontata con quello della FEES per mezzo di un questionario a dieci punti, sottoposto ad un campione di 52 pazienti ambulatoriali che lamentavano di disturbi della deglutizione. Il modello Repeated measure analysis of variance (rm-ANOVA) è stato utilizzato per testare la differenza media di accettabilità delle due procedure nello stesso soggetto. Successivamente un altro campione di 8 pazienti ambulatoriali di sesso maschile, è stato sottoposto alla registrazione simultanea di O-FEES e videfluoroscopia (VFSS). Laffidabilità inter-individuale, utilizzando 10 parametri radiologici di riferimento, fra O-FEES e VFSS, è stata determinata alla cieca tra due giudici. La concordanza inter-individuale tra i due giudici, per i punteggi di O-FEES e della VFSS è stata determinata con il Single score intra-class correlation coefficient (ICC). Le differenze FEES e O-FEES tra le risposte per ogni domanda e tra tutte le domande considerate, sono risultate statisticamente significative (rm-ANOVA; F-statistica p < 0,001). La concordanza inter-individuale fra la valutazione endoscopica e radiologiche tra i due valutatori, ha mostrato una forte correlazione intra-classe (ICC) (intervallo di confidenza al 95%): 0,875 (0,373-0,979) e 0,921 (0,542-0,986) rispettivamente. Il test di Bland-Altman suggerisce che le due metodiche producono risultati analoghi. Nella pratica clinica e confrontata con la FEES, lO-FEES è una procedura tollerata e sicura. Rispetto al gold standard radiologico, lO-FEES offre informazioni affidabili sulla preparazione e propulsione orale del bolo.

L’obiettivo di questo studio era quello di confrontare la Videofluoroscopia (VFS), la valutazione endoscopica a fibre ottiche della deglutizione (FEES) e la scintigrafia oro-faringo-esofagea (OPES) per quanto riguarda la caduta pre-deglutitoria, il ristagno post-deglutitorio e l’aspirazione, al fine di valutare l’attendibilità di questi test nel rilevare la disfagia orofaringea. Sessanta pazienti, affetti da disfagia di varia origine, sono stati arruolati nello studio e sottoposti a VFS, FEES e OPES utilizzando un bolo liquido e uno semi-solido. Abbiamo usato la VFS come esame di riferimento. La FEES e la OPES hanno entrambe mostrato una buona sensibilità, con valori complessivi elevati (rispettivamente ≥ 80% e ≥ 90%). Il confronto tra FEES e VFS relativamente alla caduta pre-deglutitoria ha evidenziato una buona specificità (84,4% per i semi-solidi e 86,7% per i liquidi). Nel caso di ristagni post-deglutitori, il confronto tra FEES e VFS ha rivelato una buona validità complessiva (75% per i semi-solidi), con specificità e sensibilità ben equilibrate per i semi-solidi. Il confronto tra OPES e VFS ha dimostrato buona sensibilità (88,6%) e validità complessiva (76,7%) per i liquidi. Il confronto dei dati ottenuti tra FEES e VFS, relativamente all’ aspirazione, ha evidenziato una bassa validità complessiva (≤ 65%). D’altra parte, la OPES ha mostrato una validità complessiva apprezzabile (71,7%). VFS, FEES e OPES sono in grado di rilevare la disfagia oro-faringea. La FEES ha fornito risultati significativi nella valutazione dei ristagni post-deglutitori.

Abstract Background GATA3 is pivotal for the development of T lymphocytes. While its effects in later stages of T cell differentiation are well recognized, the role of GATA3 in the generation of early T cell precursors (ETP) has only recently been explored. As aberrant GATA3 mRNA expression has been linked to cancerogenesis, we investigated the role of GATA3 in early T cell precursor acute lymphoblastic leukemia (ETP-ALL). Methods We analyzed GATA3 mRNA expression by RT-PCR (n = 182) in adult patients with T-ALL. Of these, we identified 70 of 182 patients with ETP-ALL by immunophenotyping. DNA methylation was assessed genome wide (Illumina Infinium® HumanMethylation450 BeadChip platform) in 12 patients and GATA3-specifically by pyrosequencing in 70 patients with ETP-ALL. The mutational landscape of ETP-ALL with respect to GATA3 expression was investigated in 18 patients and validated by Sanger sequencing in 65 patients with ETP-ALL. Gene expression profiles (Affymetrix Human genome U133 Plus 2.0) of an independent cohort of adult T-ALL (n = 83) were used to identify ETP-ALL and investigate GATA3low and GATA3high expressing T-ALL patients. In addition, the ETP-ALL cell line PER-117 was investigated for cytotoxicity, apoptosis, GATA3 mRNA expression, DNA methylation, and global gene expression before and after treatment with decitabine. Results In our cohort of 70 ETP-ALL patients, 33 % (23/70) lacked GATA3 expression and were thus defined as GATA3low. DNA methylation analysis revealed a high degree of GATA3 CpG island methylation in GATA3low compared with GATA3high ETP-ALL patients (mean 46 vs. 21 %, p

The main objective of this study was to assess the impact of biochar rate (0, 8, 16 and 32 Mg ha−1) on the water retention capacity (WRC) of a sandy loam Dystric Plinthosol. The applied biochar was a by-product of slow pyrolysis (∼450 °C) of eucalyptus wood, milled to pass through a 2000 μm sieve that resulted in a material with an intrinsic porosity ≤10 μm and a specific surface area of ∼3.2 m2 g−1. The biochar was incorporated into the top 15 cm of the soil under an aerobic rice system. Our study focused on both the effects on WRC and rice yields 2 and 3 years after its application. Undisturbed soil samples were collected from 16 plots in two soil layers (5–10 and 15–20 cm). Soil water retention curves were modelled using a nonlinear mixed model which appropriately accounts for uncertainties inherent of spatial variability and repeated measurements taken within a specific soil sample. We found an increase in plant-available water in the upper soil layer proportional to the rate of biochar, with about 0.8% for each Mg ha−1 biochar amendment 2 and 3 years after its application. The impact of biochar on soil WRC was most likely related to an effect in overall porosity of the sandy loam soil, which was evident from an increase in saturated soil moisture and macro porosity with 0.5 and 1.6% for each Mg ha−1 of biochar applied, respectively. The increment in soil WRC did not translate into an increase in rice yield, essentially because in both seasons the amount of rainfall during the critical period for rice production exceeded 650 mm. The use of biochar as a soil amendment can be a worthy strategy to guarantee yield stability under short-term water-limited conditions. Our findings raise the importance of assessing the feasibility of very high application rates of biochar and the inclusion of a detailed analysis of its physical and chemical properties as part of future investigations.

To determine how percutaneous tracheostomy (PT) impacts on respiratory system compliance (C rs ) and end-expiratory lung volume (EELV) during volume control ventilation and to test whether a recruitment maneuver (RM) at the end of PT may reverse lung derecruitment. This is a single center, prospective, applied physiology study. 25 patients with acute brain injury who underwent PT were studied. Patients were ventilated in volume control ventilation. Electrical impedance tomography (EIT) monitoring and respiratory mechanics measurements were performed in three steps: (a) baseline, (b) after PT, and (c) after a standardized RM (10 sighs of 30 cmH 2 O lasting 3 s each within 1 min). End-expiratory lung impedance (EELI) was used as a surrogate of EELV. PT determined a significant EELI loss (mean reduction of 432 arbitrary units p = 0.049) leading to a reduction in C rs (55 ± 13 vs. 62 ± 13 mL/cmH 2 O; p < 0.001) as compared to baseline. RM was able to revert EELI loss and restore C rs (68 ± 15 vs. 55 ± 13 mL/cmH 2 O; p < 0.001). In a subgroup of patients (N = 8, 31%), we observed a gradual but progressive increase in EELI. In this subgroup, patients did not experience a decrease of C rs after PT as compared to patients without dynamic inflation. Dynamic inflation did not cause hemodynamic impairment nor raising of intracranial pressure. We propose a novel and explorative hyperinflation risk index (HRI) formula. Volume control ventilation did not prevent the PT-induced lung derecruitment. RM could restore the baseline lung volume and mechanics. Dynamic inflation is common during PT, it can be monitored real-time by EIT and anticipated by HRI. The presence of dynamic inflation during PT may prevent lung derecruitment., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer Nature B.V.)

Objectives: To compare respiratory system compliance (C rs ) calculation during controlled mechanical ventilation (MV) and, subsequently, during assisted MV., Design: This is a single-center, retrospective, observational study., Setting: This study was conducted on patients admitted to Neuro-ICU of Niguarda Hospital (tertiary referral hospital)., Patients: We analyzed every patient greater than or equal to 18 years old having a C rs measurement in controlled and in assisted MV within 60 minutes. Plateau pressure (P plat ) was considered reliable if it was deemed visually stable for at least 2 seconds., Interventions: Inspiratory pause was incorporated to detect P plat in controlled and assisted MV. Calculation of C rs and driving pressure were achieved., Measurements and Main Results: A total of 101 patients were studied. An acceptable agreement was found (Bland-Altman plot bias -3.9, level of agreement upper 21.6, lower -29.6). C rs in assisted MV was 64.1 (52.6-79.3) and in controlled MV it was 61.2 (50-71.2) mL/cm H 2o ( p = 0.006). No statistical difference was found in C rs (assisted vs controlled MV) when peak pressure was lower than P plat nor when peak pressure was higher than P plat ., Conclusions: A P plat visually stable for at least 2 seconds leads to reliable C rs calculation during assisted MV., Competing Interests: Dr. Fumagalli disclosed work for hire. The remaining authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2023 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.)

Background: Impairment of ventilation and perfusion (V/Q) matching is a common mechanism leading to hypoxemia in patients with acute respiratory failure requiring intensive care unit (ICU) admission. While ventilation has been thoroughly investigated, little progress has been made to monitor pulmonary perfusion at the bedside and treat impaired blood distribution. The study aimed to assess real-time changes in regional pulmonary perfusion in response to a therapeutic intervention., Methods: Single-center prospective study that enrolled adult patients with ARDS caused by SARS-Cov-2 who were sedated, paralyzed, and mechanically ventilated. The distribution of pulmonary perfusion was assessed through electrical impedance tomography (EIT) after the injection of a 10-ml bolus of hypertonic saline. The therapeutic intervention consisted in the administration of inhaled nitric oxide (iNO), as rescue therapy for refractory hypoxemia. Each patient underwent two 15-min steps at 0 and 20 ppm iNO, respectively. At each step, respiratory, gas exchange, and hemodynamic parameters were recorded, and V/Q distribution was measured, with unchanged ventilatory settings., Results: Ten 65 [56-75] years old patients with moderate (40%) and severe (60%) ARDS were studied 10 [4-20] days after intubation. Gas exchange improved at 20 ppm iNO (PaO 2 /FiO 2 from 86 ± 16 to 110 ± 30 mmHg, p = 0.001; venous admixture from 51 ± 8 to 45 ± 7%, p = 0.0045; dead space from 29 ± 8 to 25 ± 6%, p = 0.008). The respiratory system's elastic properties and ventilation distribution were unaltered by iNO. Hemodynamics did not change after gas initiation (cardiac output 7.6 ± 1.9 vs. 7.7 ± 1.9 L/min, p = 0.66). The EIT pixel perfusion maps showed a variety of patterns of changes in pulmonary blood flow, whose increase positively correlated with PaO 2 /FiO 2 increase (R 2  = 0.50, p = 0.049)., Conclusions: The assessment of lung perfusion is feasible at the bedside and blood distribution can be modulated with effects that are visualized in vivo. These findings might lay the foundations for testing new therapies aimed at optimizing the regional perfusion in the lungs., Competing Interests: Declaration of competing interest CCAM and MA disclose receiving research grants by Timpel., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Among mechanically ventilated patients, asymmetrical lung injury is probably extremely frequent in the intensive care unit but the lack of standardized measurements does not allow to describe any prevalence among mechanically ventilated patients. Many past studies have focused only on unilateral injury and have mostly described the effect of lateral positioning. The good lung put downward might receive more perfusion while the sick lung placed upward receive more ventilation than supine. This usually results in better oxygenation but can also promote atelectasis in the healthy lung and no consensus has emerged on the clinical indication of this posture. Recently, electrical impedance tomography (EIT) has allowed for the first time to precisely describe the distribution of ventilation in each lung and to better study asymmetrical lung injury. At low positive-end-expiratory pressure (PEEP), a very heterogeneous ventilation exists between the two lungs and the initial increase in PEEP first helps to recruit the sick lung and protect the healthier lung. However, further increasing PEEP distends the less injured lung and must be avoided. The right level can be found using EIT and transpulmonary pressure. In addition, EIT can show that in the two lungs, airway closure is present but with very different airway opening pressures (AOPs) which cannot be identified on a global assessment. This may suggest a very different PEEP level than on a global assessment. Lastly, epidemiological studies suggest that in hypoxemic patients, the number of quadrants involved has a strong prognostic value. The number of quadrants is more important than the location of the unilateral or bilateral nature of the involvement for the prognosis, and hypoxemic patients with unilateral lung injury should probably be considered as requiring lung protective ventilation as classical acute respiratory distress syndrome., Competing Interests: LB's laboratory received research grant from Medtronic and Drager, equipment from Sentec, Fisher Paykel, Philps, and fees for lectures from Fisher Paykel., (Thieme. All rights reserved.)

Background: External chest-wall compression (ECC) is sometimes used in ARDS patients despite lack of evidence. It is currently unknown whether this practice has any clinical benefit in patients with COVID-19 ARDS (C-ARDS) characterized by a respiratory system compliance (C rs ) < 35 mL/cmH 2 O., Objectives: To test if an ECC with a 5 L-bag in low-compliance C-ARDS can lead to a reduction in driving pressure (DP) and improve gas exchange, and to understand the underlying mechanisms., Methods: Eleven patients with low-compliance C-ARDS were enrolled and underwent 4 steps: baseline, ECC for 60 min, ECC discontinuation and PEEP reduction. Respiratory mechanics, gas exchange, hemodynamics and electrical impedance tomography were recorded. Four pigs with acute ARDS were studied with ECC to understand the effect of ECC on pleural pressure gradient using pleural pressure transducers in both non-dependent and dependent lung regions., Results: Five minutes of ECC reduced DP from baseline 14.2 ± 1.3 to 12.3 ± 1.3 cmH 2 O (P < 0.001), explained by an improved lung compliance. Changes in DP by ECC were strongly correlated with changes in DP obtained with PEEP reduction (R 2  = 0.82, P < 0.001). The initial benefit of ECC decreased over time (DP = 13.3 ± 1.5 cmH 2 O at 60 min, P = 0.03 vs. baseline). Gas exchange and hemodynamics were unaffected by ECC. In four pigs with lung injury, ECC led to a decrease in the pleural pressure gradient at end-inspiration [2.2 (1.1-3) vs. 3.0 (2.2-4.1) cmH 2 O, P = 0.035]., Conclusions: In C-ARDS patients with C rs  < 35 mL/cmH 2 O, ECC acutely reduces DP. ECC does not improve oxygenation but it can be used as a simple tool to detect hyperinflation as it improves C rs and reduces P pl gradient. ECC benefits seem to partially fade over time. ECC produces similar changes compared to PEEP reduction., (© 2022. The Author(s).)

Rationale: Reverse triggering dyssynchrony (RT) is a patient-ventilator interaction where a respiratory muscle contraction is triggered by a passive mechanical insufflation. Its impact on diaphragm structure and function is unknown. Objectives: To establish an animal model of RT with lung injury receiving lung-protective ventilation and to assess its impact on the structure and function of the diaphragm. Methods: Lung injury was induced by surfactant depletion and high-stress ventilation in 32 ventilated pigs. Animals were allocated to receive passive mechanical ventilation (Vt: 10 ml/kg; respiratory rate [RR]: 30-35 breaths/min; n  = 8) or a more lung-protective strategy (Vt: 6-8 ml/kg; n  = 24) with adjustments in RR to facilitate the occurrence of RT for 3 hours. Diaphragm function (transdiaphragmatic pressure [Pdi] during phrenic nerve stimulation [force/frequency curve]) and structure (biopsies) were assessed. The impact of RT on diaphragm function was analyzed according to the breathing effort assessed by the pressure-time product. Measurements and Main Results: Compared with passive ventilation, the protective ventilation group with RT received significantly lower Vt (7 vs. 10 ml/kg) and higher RR (45 vs. 31 breaths/min). An entrainment pattern of 1:1 was the most frequently occurring in 83% of the animals. Breathing effort induced by RT was highly variable across animals. RT with the lowest tercile of breathing effort was associated with 23% higher twitch Pdi compared with passive ventilation, whereas RT with high breathing effort was associated with a 10% lower twitch Pdi and a higher proportion of abnormal muscle fibers. Conclusions: In a reproducible animal model of RT with variable levels of breathing effort and entrainment patterns, RT with high effort is associated with impaired diaphragm function, whereas RT with low effort is associated with preserved diaphragm force.

Background: An abrupt lung deflation in rodents results in lung injury through vascular mechanisms. Ventilator disconnections during endo-tracheal suctioning in humans often cause cardio-respiratory instability. Whether repeated disconnections or lung deflations cause lung injury or oedema is not known and was tested here in a porcine large animal model., Methods: Yorkshire pigs (~ 12 weeks) were studied in three series. First, we compared PEEP abruptly deflated from 26 cmH 2 O or from PEEP 5 cmH 2 O to zero. Second, pigs were randomly crossed over to receive rapid versus gradual PEEP removal from 20 cmH 2 O. Third, pigs with relative volume overload, were ventilated with PEEP 15 cmH 2 O and randomized to repeated ETT disconnections (15 s every 15 min) or no disconnection for 3 h. Hemodynamics, pulmonary variables were monitored, and lung histology and bronchoalveolar lavage studied., Results: As compared to PEEP 5 cmH 2 O, abrupt deflation from PEEP 26 cmH 2 O increased PVR, lowered oxygenation, and increased lung wet-to-dry ratio. From PEEP 20 cmH 2 O, gradual versus abrupt deflation mitigated the changes in oxygenation and vascular resistance. From PEEP 15, repeated disconnections in presence of fluid loading led to reduced compliance, lower oxygenation, higher pulmonary artery pressure, higher lung wet-to-dry ratio, higher lung injury score and increased oedema on morphometry, compared to no disconnects., Conclusion: Single abrupt deflation from high PEEP, and repeated short deflations from moderate PEEP cause pulmonary oedema, impaired oxygenation, and increased PVR, in this large animal model, thus replicating our previous finding from rodents. Rapid deflation may thus be a clinically relevant cause of impaired lung function, which may be attenuated by gradual pressure release., (© 2022. The Author(s).)

Rationale: The physiological basis of lung protection and the impact of positive end-expiratory pressure (PEEP) during pronation in acute respiratory distress syndrome are not fully elucidated. Objectives: To compare pleural pressure (Ppl) gradient, ventilation distribution, and regional compliance between dependent and nondependent lungs, and investigate the effect of PEEP during supination and pronation. Methods: We used a two-hit model of lung injury (saline lavage and high-volume ventilation) in 14 mechanically ventilated pigs and studied supine and prone positions. Global and regional lung mechanics including Ppl and distribution of ventilation (electrical impedance tomography) were analyzed across PEEP steps from 20 to 3 cm H 2 O. Two pigs underwent computed tomography scans: tidal recruitment and hyperinflation were calculated. Measurements and Main Results: Pronation improved oxygenation, increased Ppl, thus decreasing transpulmonary pressure for any PEEP, and reduced the dorsal-ventral pleural pressure gradient at PEEP < 10 cm H 2 O. The distribution of ventilation was homogenized between dependent and nondependent while prone and was less dependent on the PEEP level than while supine. The highest regional compliance was achieved at different PEEP levels in dependent and nondependent regions in supine position (15 and 8 cm H 2 O), but for similar values in prone position (13 and 12 cm H 2 O). Tidal recruitment was more evenly distributed (dependent and nondependent), hyperinflation lower, and lungs cephalocaudally longer in the prone position. Conclusions: In this lung injury model, pronation reduces the vertical pleural pressure gradient and homogenizes regional ventilation and compliance between the dependent and nondependent regions. Homogenization is much less dependent on the PEEP level in prone than in supine positon.

Rationale: Asymmetrical lung injury is a frequent clinical presentation. Regional distribution of Vt and positive end-expiratory pressure (PEEP) could result in hyperinflation of the less-injured lung. The validity of esophageal pressure (Pes) is unknown. Objectives: To compare, in asymmetrical lung injury, Pes with directly measured pleural pressures (Ppl) of both sides and investigate how PEEP impacts ventilation distribution and the regional driving transpulmonary pressure (inspiratory - expiratory). Methods: Fourteen mechanically ventilated pigs with lung injury were studied. One lung was blocked while the contralateral one underwent surfactant lavage and injurious ventilation. Airway pressure and Pes were measured, as was Ppl in the dorsal and ventral pleural space adjacent to each lung. Distribution of ventilation was assessed by electrical impedance tomography. PEEP was studied through decremental steps. Measurements and Results: Ventral and dorsal Ppl were similar between the injured and the noninjured lung across all PEEP levels. Dorsal Ppl and Pes were similar. The driving transpulmonary pressure was similar in the two lungs. Vt distribution between lungs was different at zero end-expiratory pressure (≈70% of Vt going in noninjured lung) owing to different respiratory system compliance (8.3 ml/cm H 2 O noninjured lung vs. 3.7 ml/cm H 2 O injured lung). PEEP at 10 cm H 2 O with transpulmonary pressure around zero homogenized Vt distribution opening the lungs. PEEP ≥16 cm H 2 O equalized distribution of Vt but with overdistension for both lungs. Conclusions: Despite asymmetrical lung injury, Ppl between injured and noninjured lungs is equalized and esophageal pressure is a reliable estimate of dorsal Ppl. Driving transpulmonary pressure is similar for both lungs. Vt distribution results from regional respiratory system compliance. Moderate PEEP homogenizes Vt distribution between lungs without generating hyperinflation.