Turgor loss point and vulnerability to xylem embolism predict species-specific risk of drought-induced decline of urban trees

Increasing frequency and severity of drought events is posing risks to trees' health, including those planted in urban settlements. Drought-induced decline of urban trees negatively affects ecosystem services of urban green spaces and implies cost for maintenance and removal of plants. We aimed at identifying physiological traits that can explain and predict the species-specific vulnerability to climate change in urban habitats. We assessed the relationships between long-term risk of decline of different tree species in a medium-sized town and their key indicators of drought stress tolerance, i.e. turgor loss point (TLP) and vulnerability to xylem embolism (P₅₀ ). Starting from 2012, the study area experienced several summer seasons with positive anomalies of temperature and negative anomalies of precipitation. This trend was coupled with increasing percentages of urban trees showing signs of crown die-back and mortality. The species-specific risk of decline was higher for species with less negative TLP and P₅₀ values. The relationship between species-specific risk of climate change-induced decline of urban trees and key physiological indicators of drought tolerance confirms findings obtained in natural forests and highlights that TLP and P₅₀ are useful indicators for species selection for tree plantation in towns, to mitigate negative impacts of climate change.

Comparative Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin Among Adults With Cancer and Atrial Fibrillation

BACKGROUND

While clinical guidelines recommend direct-acting oral anticoagulants (DOAC) over warfarin to treat isolated nonvalvular atrial fibrillation, guidelines are silent regarding nonvalvular atrial fibrillation treatment among individuals with cancer, reflecting the paucity of evidence in this setting. We quantified relative risk of ischemic stroke or systemic embolism and major bleeding (primary outcomes), and all-cause and cardiovascular death (secondary outcomes) among older individuals with cancer and nonvalvular atrial fibrillation comparing DOACs and warfarin.

METHODS

This retrospective cohort study used Surveillance, Epidemiology, and End Results cancer registry and linked US Medicare data from 2010 through 2016, and included individuals diagnosed with cancer and nonvalvular atrial fibrillation who newly initiated DOAC or warfarin. We used inverse probability of treatment weighting to control confounding. We used competing risk regression for primary outcomes and cardiovascular death, and Cox proportional hazard regression for all-cause death.

RESULTS

Among 7675 individuals included in the cohort, 4244 (55.3%) received DOACs and 3431 (44.7%) warfarin. In the inverse probability of treatment weighting analysis, there was no statistically significant difference among DOAC and warfarin users in the risk of ischemic stroke or systemic embolism (1.24 versus 1.19 events per 100 person-years, adjusted hazard ratio 1.41 [95% CI, 0.92-2.14]), major bleeding (3.08 versus 4.49 events per 100 person-years, adjusted hazard ratio 0.90 [95% CI, 0.70-1.17]), and cardiovascular death (1.88 versus 3.14 per 100 person-years, adjusted hazard ratio 0.82 [95% CI, 0.59-0.1.13]). DOAC users had significantly lower risk of all-cause death (7.09 versus 13.3 per 100 person-years, adjusted hazard ratio 0.81 [95% CI, 0.69-0.94]) compared to warfarin users.

CONCLUSIONS

Older adults with cancer and atrial fibrillation exposed to DOACs had similar risks of stroke and systemic embolism and major bleeding as those exposed to warfarin. Relative to warfarin, DOAC use was associated with a similar risk of cardiovascular death and a lower risk of all-cause death.

Functional xylem characteristics associated with drought-induced embolism in angiosperms

Hydraulic failure resulting from drought-induced embolism in the xylem of plants is a key determinant of reduced productivity and mortality. Methods to assess this vulnerability are difficult to achieve at scale, leading to alternative metrics and correlations with more easily measured traits. These efforts have led to the longstanding and pervasive assumed mechanistic link between vessel diameter and vulnerability in angiosperms. However, there are at least two problems with this assumption that requires critical re-evaluation: (1) our current understanding of drought-induced embolism does not provide a mechanistic explanation why increased vessel width should lead to greater vulnerability, and (2) the most recent advancements in nanoscale embolism processes suggest that vessel diameter is not a direct driver. Here, we review data from physiological and comparative wood anatomy studies, highlighting the potential anatomical and physicochemical drivers of embolism formation and spread. We then put forward key knowledge gaps, emphasising what is known, unknown and speculation. A meaningful evaluation of the diameter-vulnerability link will require a better mechanistic understanding of the biophysical processes at the nanoscale level that determine embolism formation and spread, which will in turn lead to more accurate predictions of how water transport in plants is affected by drought.

Stem and leaf xylem of angiosperm trees experiences minimal embolism in temperate forests during two consecutive summers with moderate drought

Drought events may increase the likelihood that the plant water transport system becomes interrupted by embolism. Yet our knowledge about the temporal frequency of xylem embolism in the field is frequently lacking, as it requires detailed, long-term measurements. We measured xylem embolism resistance and midday xylem water potentials during the consecutive summers of 2019 and 2020 to estimate maximum levels of embolism in leaf and stem xylem of ten temperate angiosperm tree species. We also studied vessel and pit membrane characteristics based on light and electron microscopy to corroborate potential differences in embolism resistance between leaves and stems. Apart from A. pseudoplatanus and Q. petraea, eight species experienced minimum xylem water potentials that were close to or below those required to initiate embolism. Water potentials corresponding to ca. 12% loss of hydraulic conductivity (PLC) could occur in six species, while considerable levels of embolism around 50% PLC were limited to B. pendula and C. avellana. There was a general agreement in embolism resistance between stems and leaves, with leaves being equally or more resistant than stems. Also, xylem embolism resistance was significantly correlated to intervessel pit membrane thickness (T_PM ) for stems, but not to vessel diameter and total intervessel pit membrane surface area of a vessel. Our data indicate that low amounts of embolism occur in most species during moderate summer drought, and that considerable levels of embolism are uncommon. Moreover, our experimental and T_PM data show that leaf xylem is generally no more vulnerable than stem xylem.

Posterior cerebral artery embolism resulting in bilateral paramedian thalamic infarction: A case report

RATIONALE

Bilateral thalamic infarcts are not easily recognized, it have diverse clinical manifestations and relatively severe symptoms. It may leave long-term drowsiness, cognitive impairment, and speech impairment. We report a case of bilateral paramedian thalamic infarction with impaired consciousness as the main symptom. The digital subtraction angiography suggested that the left superior cerebellar artery and posterior cerebral artery (PCA) were occluded.

PATIENTS CONCERN

A previously 67-year-old man was taken to our hospital after 9.5 hours of acute dizziness and loss of consciousness.

DIAGNOSIS

The cranial DWI + MRA suggested acute cerebral infarction in bilateral thalamus and bilateral midbrain, and the left posterior cerebral artery was not clearly visualized. The patient was diagnosed with posterior cerebral artery embolism.

INTERVENTIONS

A mechanical thrombectomy was performed.

OUTCOME

The patient's symptoms did not completely improve after revascularization, followed by fluctuating consciousness.

LESSONS

Recurrent lethargy in patients after endovascular treatment may be a clinical manifestation of damage to thalamic structures or due to the presence of ineffective recanalization.

Left atrial appendage closure for stroke prevention in nonvalvular atrial fibrillation: A current overview

Atrial fibrillation (AF) is the most common arrhythmia encountered in clinical practice and its prevalence increases with age. AF causes palpitations, heart failure, and cardiogenic embolism. Of them, the most critical and fatal complication is a cardio-embolic event. Oral anticoagulation plays a central role in reducing stroke risk in AF patients. Recently, when oral anticoagulation is considered in patients with non-valvular AF who are eligible for direct oral coagulations, they are preferred to vitamin K antagonist based on accumulating evidence. Although many patients can tolerate oral anticoagulation, there is a subset of patients who cannot tolerate long-term oral anticoagulation. Such a subset has a higher bleeding risk as indicated by the HAS-BLED score under oral anticoagulation. This subset of patients requires effective and safe non-pharmacological alternative therapies for stroke prevention. One of the promising non-pharmacological therapies is left atrial appendage closure. Three randomized controlled trials demonstrated non-inferiority of percutaneous left atrial appendage closure using WATCHMAN family to oral anticoagulation (Boston Scientific, Marlborough, MA, USA). WATCHMAN FLX, which was innovated following WATCHMAN 2.5, was associated with fewer safety events and a higher success rate of effective appendage closure. Nevertheless, several unsolved issues remain, including device-related thrombosis, post-treatment antithrombotic therapy, and peri-device leakage. Left atrial appendage closure for patients with non-valvular AF may be an alternative therapy to avoid cardiac embolism for high bleeding risk patients with contraindications to long-term oral anticoagulation therapy.

Stroke prevention of thoracoscopic left atrial appendage clipping in patients with non-valvular atrial fibrillation at high risk of stroke and bleeding: study protocol for a non-randomised controlled clinical trial

INTRODUCTION

Non-valvular atrial fibrillation (NVAF) is a high-risk factor for ischaemic stroke. The 2016 European Society of Cardiology Atrial Fibrillation Management guidelines recommend oral anticoagulants (OACs) to prevent stroke in men with CHA₂DS₂-VASc scores ≥2 and women ≥3. However, in patients with a high risk of stroke and a high risk of bleeding (HAS-BLED (Hypertension, Abnormal renal/liver function, Stroke, Bleeding history or predisposition, Labile international normalized ratio, Elderly (> 65 years), Drugs/alcohol concomitantly) score≥3), OAC had a higher risk of bleeding. Left atrial appendage closure (LAAC) is non-inferior to OAC as a means of preventing stroke in several studies. As a minimally invasive intervention to prevent stroke, transthoracic LAAC (TS-LAAC) has a high successful closure rate, but there is a lack of literature reports directly comparing it with OAC. Our research compares TS-LAAC with novel oral anticoagulants (NOACs) and provides an appropriate programme for stroke prevention in a specific population.

METHODS AND ANALYSIS

This is a non-randomised controlled trial study protocol, and we will conduct this study from April 2022 to April 2025. The study included 186 patients with confirmed NVAF, 93 of whom completed thoracoscopic LAAC, and the control group treated with NOACs. The primary outcome was the incidence of stroke and systemic embolism, as well as the composite endpoint events (stroke, systemic embolism, myocardial infarction, bleeding, cardiovascular death, etc). Secondary outcomes were ischaemic stroke, haemorrhagic stroke, any bleeding events, death from cardiovascular causes, death from all causes, residual root rate in the surgery group, device-related thrombosis in the surgery group, changes in blood pressure, cardiac chamber size changes, etc. Each subject completed at least 1 year of follow-up.

ETHICS AND DISSEMINATION

The study has been approved by the Medical Ethics Committee of Beijing Tiantan Hospital, Capital Medical University, China (approval number: KY2022-013-02). The results from this study will be disseminated through manuscript publications and national/international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2200058109.

Impact of freeze-thaw-induced pit aspiration on stem water transport in the subalpine conifer Abies veitchii

During winter, subalpine conifers experience frequent freeze-thaw cycles in stem xylem that may cause embolism and pit aspiration due to increased water volume during the sap to ice transition. This study examined the occurrence and ecological impacts of a combination of freeze-thaw-induced pit aspiration and embolism triggered by natural and artificial stem freezing. In subalpine Veitch's fir (Abies veitchii) trees, the fraction of closed pits and embolized tracheids as well as conductivity losses were measured to examine pit aspiration and its effects. When trees incurred mild drought stress in February and early March, 70%-80% of stem conductivity was lost. Cryo-scanning electron microscopy indicated <20% embolized tracheids but ∼90% closed pits. Severe drought stress in late March caused 96% ± 1.2% (mean ± standard error) loss of stem conductivity, while the fraction of embolized tracheids increased to 64% ± 6.6%, and aspirated pit fraction decreased to 23% ± 5.6%. Experimental freeze-thaw cycles also increased pit aspiration from 7.1% ± 0.89% to 49% ± 10%, and the fraction of closed pits was positively correlated to the percent loss of stem hydraulic conductivity. The results indicated that freezing-induced pit aspiration is an important factor for stem xylem dysfunction under mild drought, and upon severe drought in winter; stem water transport is predominantly inhibited by xylem embolism.

Permeation-Enhanced Degassing Method Based on Xylem Embolism Repair and Gas Permeable Materials

Microfluidic devices have developed a wide range of applications in the fields of biomedicine, chemistry, and analytical science. But it is easy to form and accumulate bubbles in microfluidic devices. These bubbles could decrease the detection sensitivity, cause inaccurate analysis results, and even damage the functional region of the device. Inspired by the embolism repair mechanism of angiosperms and the permeability of gas permeable materials, this work proposes a bioinspired permeation-enhanced degassing method. Bionic redundant pits are used in this method to keep bubbles from spreading between microchannels and maintain the continuity of the flow. A hydrophobic gas permeable material is used to enhance the bubble capture capability and accelerate the degassing process. This method can eliminate bubbles automatically and continuously in real time without auxiliary equipment. Compared to the bubble removal only depending on solution in water, the degassing effect of the permeation-enhanced degassing method shows about 1.6 times improvement in the same conditions, and the capability of trapping bubbles is improved by 1.33 times. In this paper, this method was integrated into a concentration gradient generator and a cell culture device. The results show that the concentration gradient generator with degassing structures can dissolve bubbles in a rapid way and reach the stability of the concentration gradient within 5-15 min. The degassing method can run for a long time and improve the cell density and cell viability of HeLa cells up to 2.64 and 1.12 times, respectively. The method has a broad application prospect in microfluidic fields including biomedical fluid processing, virus detection, and microscale reactor operation.

Conduit position and connectivity affect the likelihood of xylem embolism during natural drought in evergreen woodland species

BACKGROUND AND AIMS

Hydraulic failure is considered a main cause of drought-induced forest mortality. Yet, we have a limited understanding of how the varying intensities and long time scales of natural droughts induce and propagate embolism within the xylem.

METHODS

X-ray computed tomography (microCT) images were obtained from different aged branch xylem to study the number, size and spatial distribution of in situ embolized conduits among three dominant tree species growing in a woodland community.

KEY RESULTS

Among the three studied tree species, those with a higher xylem vulnerability to embolism (higher water potential at 50 % loss of hydraulic conductance; P50) were more embolized than species with lower P50. Within individual stems, the probability of embolism was independent of conduit diameter but associated with conduit position. Rather than the occurrence of random or radial embolism, we observed circumferential clustering of high and low embolism density, suggesting that embolism spreads preferentially among conduits of the same age. Older xylem also appeared more likely to accumulate embolisms than young xylem, but there was no pattern suggesting that branch tips were more vulnerable to cavitation than basal regions.

CONCLUSIONS

The spatial analysis of embolism occurrence in field-grown trees suggests that embolism under natural drought probably propagates by air spreading from embolized into neighbouring conduits in a circumferential pattern. This pattern offers the possibility to understand the temporal aspects of embolism occurrence by examining stem cross-sections.

Seasonal adjustment of leaf embolism resistance and its importance for hydraulic safety in deciduous trees

Embolism resistance is often viewed as seasonally stable. Here we examined the seasonality in the leaf xylem vulnerability curve (VC) and turgor loss point (Ψ_TLP ) of nine deciduous species that originated from Mediterranean, temperate, tropical, or sub-tropical habitats and were growing on the Volcani campus, Israel. All four Mediterranean/temperate species exhibited a shift of their VC to lower xylem pressures (Ψ_x ) along the dry season, in addition to two of the five tropical/sub-tropical species. In three of the species that exhibited VC seasonality, it was critical for avoiding embolism in the leaf. In total, seven out of the nine species avoided embolism. The seasonal VC adjustment was over two times higher as compared with the seasonal adjustment of Ψ_TLP , resulting in improved hydraulic safety as the season progressed. The results suggest that seasonality in the leaf xylem vulnerability is common in species that originate from Mediterranean or temperate habitats that have large seasonal environmental changes. This seasonality is advantageous because it enables a gradual seasonal reduction in the Ψ_x without increasing the danger of embolism. The results also highlight that measuring the minimal Ψ_x and the VC at different times can lead to erroneous estimations of the hydraulic safety margins. Changing the current hydraulic dogma into a seasonal dynamic in the vulnerability of the xylem itself should enable physiologists to understand plants' responses to their environment better.

Pit characters determine drought-induced embolism resistance of leaf xylem across 18 Neotropical tree species

Embolism spreading in xylem is an important component of plant drought resistance. Since embolism resistance has been shown to be mechanistically linked to pit membrane characters in stem xylem, we speculate that similar mechanisms account for leaf xylem. We conducted transmission electron microscopy to investigate pit membrane characters in leaf xylem across 18 Neotropical tree species. We also conducted gold perfusion and polar lipid detection experiments on three species covering the full range of leaf embolism resistance. We then related these observations to previously published data on embolism resistance of leaf xylem. We also incorporated previously published data on stem embolism resistance and stem xylem pit membranes to investigate the link between vulnerability segmentation (i.e. difference in embolism resistance) and leaf-stem anatomical variation. Maximum pit membrane thickness (Tpm,max) and the pit membrane thickness-to-diameter ratio (Tpm,max/Dpm) were predictive of leaf embolism resistance, especially when vestured pits were taken into account. Variation in Tpm,max/Dpm was the only trait predictive of vulnerability segmentation between leaves and stems. Gold particles of 5- and 10-nm infiltrated pit membranes in three species, while the entry of 50-nm particles was blocked. Moreover, polar lipids were associated with inner conduit walls and pits. Our results suggest that mechanisms related to embolism spreading are determined by Tpm, pore constrictions (i.e. the narrowest bottlenecks along pore pathways), and lipid surfactants, which are largely similar between leaf and stem xylem and between temperate and tropical trees. However, our mechanistic understanding of embolism propagation and the functional relevance of Tpm,max/Dpm remains elusive.

Seeing is believing: what visualising bubbles in the xylem has revealed about plant hydraulic function

Maintaining water transport in the xylem is critical for vascular plants to grow and survive. The drought-induced accumulation of embolism, when gas enters xylem conduits, causes declines in hydraulic conductance (K ) and is ultimately lethal. Several methods can be used to estimate the degree of embolism in xylem, from measuring K in tissues to directly visualising embolism in conduits. One method allowing a direct quantification of embolised xylem area is the optical vulnerability (OV) technique. This method has been used across different organs and has a high spatial and temporal resolution. Here, we review studies using the OV technique, discuss the main advantages and disadvantages of this method, and summarise key advances arising from its use. Vulnerability curves generated by the OV method are regularly comparable to other methods, including the centrifuge and X-ray microtomography. A major advantage of the OV technique over other methods is that it can be simultaneously used to determine in situ embolism formation in leaves, stems and roots, in species spanning the phylogeny of land plants. The OV method has been used to experimentally investigate the spreading of embolism through xylem networks, associate embolism with downstream tissue death, and observe embolism formation in the field.

In situ, direct observation of seasonal embolism dynamics in Aleppo pine trees growing on the dry edge of their distribution

Xylem embolism impairs hydraulic conductivity in trees and drives drought-induced mortality. While embolism has been monitored in vivo in potted plants, and research has revealed evidence of embolism in field-grown trees, continuous in situ monitoring of cavitation in forests is lacking. Seasonal patterns of embolism were monitored in branchlets of Aleppo pine (Pinus halepensis) trees growing in a dry Mediterranean forest. Optical visualization (OV) sensors were installed on terminal branches, in addition to monthly sampling for micro computed tomography scans. We detected 208 cavitation events among four trees, which represented an embolism increase from zero to c. 12% along the dry season. Virtually all the cavitation events occurred during daytime hours, with 77% occurring between 10:00 and 17:00 h. The probability for cavitation in a given hour increased as vapor pressure deficit (VPD) increased, up to a probability of 42% for cavitation when VPD > 5 kPa. The findings uniquely reveal the instantaneous environmental conditions that lead to cavitation. The increased likelihood of cavitation events under high VPD in water-stressed pines is the first empirical support for this long hypothesized relationship. Our observations suggest that low levels of embolism are common in Aleppo pine trees at the dry edge of their distribution.

[A case of cerebral embolism treated with early surgical intervention for aneurysm of sinus of Valsalva as embolic source]

The patient was a 78-year-old man. He was transferred to the emergency room presenting with aphasia and right hemiplegia. Head CT and CT angiography demonstrated a narrow territory of early ischemic signs and occlusion of the horizontal segment of the left middle cerebral artery (MCA), respectively. Endovascular thrombectomy was performed and complete recanalization of MCA was achieved. After admission, transthoracic echocardiography revealed a cystic mass near the left coronary apex of the aortic valve, which was diagnosed as an aneurysm of the sinus of Valsalva (ASV) by contrast-enhanced chest computed tomography. Transesophageal echocardiography showed a severe smoke-like echo within ASV, despite being in sinus rhythm. Intravenous anticoagulant therapy was started, and patch closure was performed by cardiovascular surgeons on the 13th day despite of early period after stroke onset. During the operation, no thrombus was seen around the inlet of ASV. On the two days after the operation, paroxysmal atrial fibrillation was detected and anticoagulant therapy was continued. In this patient, ASV was regarded as the embolic source of cerebral embolism, and anticoagulant therapy and surgical intervention were selected in the early period after stroke onset to prevent embolism recurrence, resulting in a favorable clinical course.

Pit aspiration causes an apparent loss of xylem hydraulic conductivity in a subalpine fir (Abies mariesii Mast.) overwintering at the alpine timberline

Conifers growing at the alpine timberline are exposed to combinatorial stresses that induce embolism in xylem during winter. We collected branches of Abies mariesii Mast. at the timberline on Mt Norikura of central Japan to evaluate the seasonal changes in the loss of xylem hydraulic conductivity (percent loss of hydraulic conductivity; PLC). Concurrently, we evaluated the distribution of embolized tracheids in native samples via cryo-scanning electron microscopic (cryo-SEM) observation in comparison with the drought-induced embolism samples used for the vulnerability curve. The twigs collected in late winter showed 100 PLC at a water potential of ~-3 MPa, and air-filled tracheids were observed sporadically in the cryo-SEM images. The cryo-SEM images also showed that nearly all pits of the samples from the timberline were aspirated in the xylem with 100 PLC. Conversely, in drought-induced samples used for vulnerability analysis, lower frequency of aspirated pits was observed at similar water potentials and all tracheids in the earlywood of xylem with 100 PLC were filled with air. We hypothesized that pit aspiration is the primary cause of the pronounced winter xylem conductivity loss at the timberline when water potential is near, but still above, the drought-induced vulnerability threshold. Pit aspiration before water loss may be an adaptation to severe winter conditions at timberlines to prevent widespread xylem embolism. The possible causes of pit aspiration are discussed in relation to complex stresses under harsh winter conditions at timberlines.

Detection of acoustic events in lavender for measuring xylem vulnerability to embolism and cellular damage

Acoustic emission analysis is promising to investigate the physiological events leading to drought-induced injury and mortality. However, their nature and source are not fully understood, making this technique difficult to use as a direct measure of the loss of xylem hydraulic conductance. Acoustic emissions were recorded during severe dehydration in lavender plants (Lavandula angustifolia) and compared with the dynamics of embolism development and cell damage. The timing and characteristics of acoustic signals from two independent recording systems were compared by principal component analysis (PCA). Changes in water potential, branch diameter, loss of hydraulic conductance, and cellular damage were also measured to quantify drought-induced damages. Two distinct phases of acoustic emissions were observed during dehydration: the first one associated with a rapid loss of diameter and a significant increase in loss of xylem conductance (90%), and the second with slower changes in diameter and a significant increase in cellular damage. Based on PCA, a developed algorithm discriminated hydraulic-related acoustic signals from other sources, proposing a reconstruction of hydraulic vulnerability curves. Cellular damage preceded by hydraulic failure seems to lead to a lack of recovery. The second acoustic phase would allow detection of plant mortality.

High safety margins to drought-induced hydraulic failure found in five pasture grasses

Determining the relationship between reductions in stomatal conductance (g_s ) and leaf water transport during dehydration is key to understanding plant drought responses. While numerous studies have analysed the hydraulic function of woody species, minimal research has been conducted on grasses. Here, we sought to characterize hydraulic vulnerability in five widely-occurring pasture grasses (including both C3 and C4 grasses) and determine whether reductions in g_s and leaf hydraulic conductance (K_leaf ) during dehydration could be attributed to xylem embolism. Using the optical vulnerability (OV) technique, we found that all species were highly resistant to xylem embolism when compared to other herbaceous angiosperms, with 50% xylem embolism (P_X50 ) occurring at xylem pressures ranging from -4.4 to -6.1 MPa. We observed similar reductions in g_s and K_leaf under mild water stress for all species, occurring well before P_X50 . The onset of xylem embolism (P_X12 ) occurred consistently after stomatal closure and 90% reduction of K_leaf . Our results suggest that factors other than xylem embolism are responsible for the majority of reductions in g_s and K_leaf during drought and reductions in the productivity of pasture species under moderate drought may not be driven by embolism.

XaMINA: A Real-World, Prospective, Observational Study of Treatment-Naïve Patients Treated with Rivaroxaban for Stroke Prevention in Atrial Fibrillation in Asia

INTRODUCTION

The efficacy and safety of rivaroxaban for the prevention of stroke and systemic embolism have been demonstrated in Asian and non-Asian patients with non-valvular atrial fibrillation (NVAF) in multiple studies. However, limited published data exist on its use specifically in treatment-naïve patients from the Asia region. Patients in South Korea and Taiwan can now receive rivaroxaban as first-line therapy, allowing for data generation in this patient group.

METHODS

XaMINA was a prospective, real-world, multicenter, single-arm, observational cohort study of patients with NVAF in South Korea and Taiwan naïve to anticoagulation and initiating rivaroxaban. The primary outcome was major bleeding; secondary outcomes included all-cause mortality, symptomatic thromboembolic events, and treatment persistence.

RESULTS

In total, 1094 patients were included and the follow-up was 1 year. The baseline mean CHADS₂ score was 1.63 ± 0.98, mean CHA₂DS₂-VASc score was 2.92 ± 1.42, and mean HAS-BLED score was 1.00 ± 0.75. The primary outcome occurred in 20 (1.8%) patients [incidence rate 2.1 events per 100 patient-years (95% CI 1.35-3.25)]. Thromboembolic events occurred in 9 (0.8%) patients, of whom 5 (0.5%) had stroke, 3 (0.3%) myocardial infarction, and 1 (0.1%) a transient ischemic attack. There were no cases of non-central nervous system systemic embolism, and 735 (67.2%) patients persisted with rivaroxaban treatment for 1 year.

CONCLUSION

XaMINA demonstrated low incidence rates of major bleeding events and thromboembolic events in patients with NVAF newly initiating rivaroxaban in South Korea and Taiwan, consistent with previous real-world studies reconfirming the results of the ROCKET AF study.

TRIAL REGISTRATION

The trial was registered on ClinicalTrials.gov (identifier NCT03284762) on 15 September 2017.

Duplex ultrasound and clinical outcomes of medical management of pediatric lower extremity arterial thrombosis

OBJECTIVES

Natural history and duplex ultrasound (DU) findings of pediatric lower extremity arterial thrombosis (PLEAT) are not well-defined. We describe acute and short-term DU findings of PLEAT to aid duplex interpretation and patient management.

METHODS

From August 2018 to April 2021 children with suspected PLEAT were identified prospectively. All had DU studies and were divided into group 1 (with DU-confirmed PLEAT) and group 2 (without DU-confirmed PLEAT). Patient demographics and DU findings were compared. Those with PLEAT and follow-up DU studies were also evaluated for recanalization and post recanalization DU findings.

RESULTS

We included 76 children (102 limbs) who had suspected PLEAT; 32 in group 1 and 44 group in 2. Fifty-seven percent had congenital heart disease, 26% a history prematurity (87%, 34% group 1; 11%, 14% group 2), with 14% of group 1 premature at PLEAT diagnosis and 68% aged less than 3 years-29 (94%) in group 1 and 23 (52%) in group 2. None had an arterial procedure to restore flow. Limb salvage was 100% with five group 1 mortalities unrelated to PLEAT. In group 1, 12 PLEATs were associated with an arterial line and 15 with cardiac catheterization. Occluded arteries included 7 external iliac, 20 common femoral, and 5 superficial femoral arteries (SFA). Peak systolic velocities (PSVs) distal to occluded segments in group 1 were lower than corresponding group 2 PSVs. SFA 18 ± 21 cm/s vs 84 ± 39 cm/s; popliteal artery (PA) 24 ± 18 cm/s vs 78 ± 38 cm/s; posterior tibial artery (PTA) 10 ± 8 cm/s versus 49 ± 27 cm/s (all P < .001). Twenty-one patients in group 1 had follow-up studies. Twelve (57%) were recanalized: 4 (19%) in less than 1 week and 10 (48%) by 6 months. Eighty-one percent of PLEATs were treated with anticoagulation (AC) and 57% recanalized. Fifty-nine percent of patients on AC recanalized, and 60% not on AC recanalized. Age, primary diagnosis, instrumentation type, and AC were not associated with failure to recanalize. After recanalization, PSVs in the CFA were not different than PSVs found in group 2 in the CFA (109 ± 50 cm/s vs 107 ± 57 cm/s; P = .88), but remained decreased in the SFA, PA, and PTA (SFA 68 ± 32 cm/s vs 83 ± 38 cm/s [P = .04]; PA 33 ± 13 cm/s vs 78 ± 37 [P = .0004]; and PTA 21 ± 8 cm/s vs 43 ± 20 cm/s [P = .0008]).

CONCLUSIONS

PLEAT occurs in young children, results in low distal PSVs, and often does not recanalize, but does not lead to short-term limb loss or mortality or necessarily require AC for recanalization. Normalization of CFA PSVs indicates recanalization while PSVs in segments distal to the CFA do not seem to return to normal.

[Double hit; a case report-A history of numerous embolic events during a COVID-19 illness]

This case report is about an 81-year-old male patient that was brought into the emergency room. Paramedics and an emergency doctor were alarmed because of unconsciousness of unclear origin. Additionally, ST-elevation were detected preclinically, raising the suspicion of an intercerebral hemorrhage; however, the clinical work-up revealed a different and unsuspected cause.

Hydraulic vulnerability segmentation in compound-leaved trees: Evidence from an embolism visualization technique

The hydraulic vulnerability segmentation (HVS) hypothesis implies the existence of differences in embolism resistance between plant organs along the xylem pathway and has been suggested as an adaptation allowing the differential preservation of more resource-rich tissues during drought stress. Compound leaves in trees are considered a low-cost means of increasing leaf area and may thus be expected to show evidence of strong HVS, given the tendency of compound-leaved tree species to shed their leaf units during drought. However, the existence and role of HVS in compound-leaved tree species during drought remain uncertain. We used an optical visualization technique to estimate embolism occurrence in stems, petioles, and leaflets of shoots in two compound-leaved tree species, Manchurian ash (Fraxinus mandshurica) and Manchurian walnut (Juglans mandshurica). We found higher (less negative) water potentials corresponding to 50% loss of conductivity (P50) in leaflets and petioles than in stems in both species. Overall, we observed a consistent pattern of stem > petiole > leaflet in terms of xylem resistance to embolism and hydraulic safety margins (i.e. the difference between mid-day water potential and P50). The coordinated variation in embolism vulnerability between organs suggests that during drought conditions, trees benefit from early embolism and subsequent shedding of more expendable organs such as leaflets and petioles, as this provides a degree of protection to the integrity of the hydraulic system of the more carbon costly stems. Our results highlight the importance of HVS as an adaptive mechanism of compound-leaved trees to withstand drought stress.

Periprocedural Pericardial Effusion Complicating Transcatheter Left Atrial Appendage Occlusion: A Report From the NCDR LAAO Registry

BACKGROUND

Pericardial effusion (PE) is a potential complication of transcatheter left atrial appendage occlusion. The objective of this study was to investigate the incidence, associated characteristics, and outcomes of PE following left atrial appendage occlusion.

METHODS

Patients in the NCDR LAAO Registry who underwent a Watchman procedure between January 1, 2016 and December 31, 2019 were included. The primary outcome was in-hospital PE requiring intervention (percutaneous drainage or surgery). Odds ratios (ORs) were calculated for adverse event rates associated with PE.

RESULTS

The study population consisted of 65 355 patients. The mean patient age was 76.2±8.1 years, and the mean CHA2DS2-VASc score was 4.6±1.5. PE occurred in 881 patients (1.35%). Clinical variables independently associated with PE included older age, female sex, left ventricular function, paroxysmal atrial fibrillation, prior bleeding, lower serum albumin, and preprocedural dual antiplatelet therapy; procedural variables included number of delivery sheaths used, sinus rhythm during the procedure, and moderate sedation rather than general anesthesia. PE was associated with increased risk of in-hospital stroke (OR, 6.58 [95% CI, 3.32-13.06]; P<0.0001), death (OR, 56.88 [95% CI, 39.79-81.32]; P<0.0001), and the composite of death, stroke, or systemic embolism (OR, 28.64 [95% CI, 21.24-38.61]; P<0.0001). PE during the index hospitalization was associated with increased risk of death (OR, 3.52 [95% CI, 2.23-5.54]; P<0.0001) and the composite of death, stroke, or systemic embolism (OR, 3.42 [95% CI, 2.31-5.07]; P<0.0001) between discharge and 45-day follow-up.

CONCLUSIONS

In-hospital PE during transcatheter left atrial appendage occlusion is infrequent but associated with a substantially higher risk of adverse events, including in-hospital and early postdischarge mortality. Strategies to minimize PE are critical to improve the risk-benefit ratio for this therapy.

Response of four evergreen savanna shrubs to an incidence of extreme drought: high embolism resistance, branch shedding and maintenance of nonstructural carbohydrates

Extreme drought events are becoming frequent globally, resulting in widespread plant mortality and forest dieback. Although savanna vegetation cover ~20% of the earth's land area, their responses to extreme drought have been less studied than that of forests. Herein, we quantified branch dieback, individual mortality and the associated physiological responses of four evergreen shrubs (Tarenna depauperate Hutch., Maytenus esquirolii (H. Lév.) C.Y. Cheng, Murraya exotica L., Jasminum nudiflorum Lindl.) in a savanna ecosystem in Southwest China to an incidence of extreme drought during 2019 and 2020. We found that 80-100% of the individuals of these species exhibited branch dieback, whereas individual mortality was only found in T. depauperate (4.5%). All species showed high resistance to stem embolism (P50, water potential at 50% loss of hydraulic conductivity ranged from -5.62 to -8.6 MPa), whereas the stem minimum water potentials reached -7.6 to ca -10.0 MPa during the drought. The low water potential caused high native embolism levels (percentage loss of hydraulic conductivity (PLC) 23-65%) in terminal branches, and the remaining stems maintained 15-35% PLC at the end of the drought. Large within-individual variations in stem vulnerability to embolism were detected, and shedding of vulnerable branches could be a mechanism for shrubs to reduce water and carbon consumption. Overall, the content of total nonstructural carbohydrates (NSC) and their components in the stem were generally comparable to or higher than those in the rainy season in three of the four species. Because the leaves were turgor-less for most time during the drought, high NSC levels during the drought could be due to recycling of NSC from dead branches or translocation from roots. Our results suggest high tolerance of savanna shrub species to extreme drought, which could be facilitated by high embolism resistance in some stems and shedding of vulnerable branches to maintain individual water and carbon balance.