Richard J. Hobbs

The EuroHeart Failure survey programme-- a survey on the quality of care among patients with heart failure in Europe. Part 1: patient characteristics and diagnosis.

BACKGROUND The European Society of Cardiology (ESC) has published guidelines for the investigation of patients with suspected heart failure and, if the diagnosis is proven, their subsequent management. Hospitalisation provides a key point of care at which time diagnosis and treatment may be refined to improve outcome for a group of patients with a high morbidity and mortality. However, little international data exists to describe the features and management of such patients. Accordingly, the EuroHeart Failure survey was conducted to ascertain if appropriate tests were being performed with which to confirm or refute a diagnosis of heart failure and how this influenced subsequent management. METHODS The survey screened consecutive deaths and discharges during 2000-2001 predominantly from medical wards over a 6-week period in 115 hospitals from 24 countries belonging to the ESC, to identify patients with known or suspected heart failure. RESULTS A total of 46788 deaths and discharges were screened from which 11327 (24%) patients were enrolled with suspected or confirmed heart failure. Forty-seven percent of those enrolled were women. Fifty-one percent of women and 30% of men were aged >75 years. Eighty-three percent of patients had a diagnosis of heart failure made on or prior to the index admission. Heart failure was the principal reason for admission in 40%. The great majority of patients (>90%) had had an ECG, chest X-ray, haemoglobin and electrolytes measured as recommended in ESC guidelines, but only 66% had ever had an echocardiogram. Left ventricular ejection fraction had been measured in 57% of men and 41% of women, usually by echocardiography (84%) and was <40% in 51% of men but only in 28% of women. Forty-five percent of women and 22% of men were reported to have normal left ventricular systolic function by qualitative echocardiographic assessment. A substantial proportion of patients had alternative explanations for heart failure other than left ventricular systolic or diastolic dysfunction, including valve disease. Within 12 weeks of discharge, 24% of patients had been readmitted. A total of 1408 of 10434 (13.5%) patients died between admission and 12 weeks follow-up. CONCLUSIONS Known or suspected heart failure comprises a large proportion of admissions to medical wards and such patients are at high risk of early readmission and death. Many of the basic investigations recommended by the ESC were usually carried out, although it is not clear whether this was by design or part of a general routine for all patients being admitted regardless of diagnosis. The investigation most specific for patients with suspected heart failure (echocardiography) was performed less frequently, suggesting that the diagnosis of heart failure is still relatively neglected. Most men but a minority of women who underwent investigation of cardiac function had evidence of moderate or severe left ventricular dysfunction, the main target of current advances in the treatment of heart failure. Considerable diagnostic uncertainty remains for many patients with suspected heart failure, even after echocardiography, which must be resolved in order to target existing and new therapies and services effectively.

The EuroHeart Failure Survey programme - a survey on the quality of care among patients with heart failure in Europe Part 2 : treatment

Background National surveys suggest that treatment of heart failure in daily practice differs from guidelines and is characterized by underuse of recommended medications. Accordingly, the Euro Heart Failure Survey was conducted to ascertain how patients hospitalized for heart failure are managed in Europe and if national variations occur in the treatment of this condition. Methods The survey screened discharge summaries of 11 304 patients over a 6-week period in 115 hospitals from 24 countries belonging to the ESC to study their medical treatment. Results Diuretics (mainly loop diuretics) were prescribed in 86.9% followed by ACE inhibitors (61.8%), beta-blockers (36.9%), cardiac glycosides (35.7%), nitrates (32.1%), calcium channel blockers (21.2%) and spironolactone (20.5%). 44.6% of the population used four or more different drugs. Only 17.2% were under the combination of diuretic, ACE inhibitors and beta-blockers. Important local variations were found in the rate of prescription of ACE inhibitors and particularly beta-blockers. Daily dosage of ACE inhibitors and particularly of beta-blockers was on average below the recommended target dose. Modelling-analysis of the prescription of treatments indicated that the aetiology of heart failure, age, co-morbid factors and type of hospital ward influenced the rate of prescription. Age 70 years, in patients with respiratory disease and increased in cardiology wards, in ischaemic heart failure and in male subjects. Prescription of cardiac glycosides was significantly increased in patients with supraventricular tachycardia/atrial fibrillation. Finally, the rate of prescription of antithrombotic agents was increased in the presence of supraventricular arrhythmia, ischaemic heart disease, male subjects but was decreased in patients over 70. Conclusion Our results suggest that the prescription of recommended medications including ACE inhibitors and beta-blockers remains limited and that the daily dosage remains low, particularly for beta-blockers. The survey also identifies several important factors including age, gender, type of hospital ward, co morbid factors which influence the prescription of heart failure medication at discharge.

Effects of Invasive Alien Plants on Fire Regimes

Abstract Plant invasions are widely recognized as significant threats to biodiversity conservation worldwide. One way invasions can affect native ecosystems is by changing fuel properties, which can in turn affect fire behavior and, ultimately, alter fire regime characteristics such as frequency, intensity, extent, type, and seasonality of fire. If the regime changes subsequently promote the dominance of the invaders, then an invasive plant–fire regime cycle can be established. As more ecosystem components and interactions are altered, restoration of preinvasion conditions becomes more difficult. Restoration may require managing fuel conditions, fire regimes, native plant communities, and other ecosystem properties in addition to the invaders that caused the changes in the first place. We present a multiphase model describing the interrelationships between plant invaders and fire regimes, provide a system for evaluating the relative effects of invaders and prioritizing them for control, and recommend ways to restore pre-invasion fire regime properties.

Novel ecosystems: implications for conservation and restoration.

Many ecosystems are rapidly being transformed into new, non-historical configurations owing to a variety of local and global changes. We discuss how new systems can arise in the face of primarily biotic change (extinction and/or invasion), primarily abiotic change (e.g. land use or climate change) and a combination of both. Some changes will result in hybrid systems retaining some original characteristics as well as novel elements, whereas larger changes will result in novel systems, which comprise different species, interactions and functions. We suggest that these novel systems will require significant revision of conservation and restoration norms and practices away from the traditional place-based focus on existing or historical assemblages.

Viewing invasive species removal in a whole-ecosystem context

Eradications of invasive species often have striking positive effects on native biota. However, recent research has shown that species removal in isolation can also result in unexpected changes to other ecosystem components. These secondary effects will become more likely as numbers of interacting invaders increase in ecosystems, and as exotics in late stages of invasion eliminate native species and replace their functional roles. Food web and functional role frameworks can be used to identify ecological conditions that forecast the potential for unwanted secondary impacts. Integration of eradication into a holistic process of assessment and restoration will help safeguard against accidental, adverse effects on native ecosystems.

Key issues and research priorities in landscape ecology: An idiosyncratic synthesis

Landscape ecology has made tremendous progress in recent decades, but as a rapidly developing discipline it is faced with new problems and challenges. To identify the key issues and research priorities in landscape ecology, a special session entitled “Top 10 List for Landscape Ecology in the 21st Century” was organized at the 16th Annual Symposium of the US Regional Association of International Association of Landscape Ecology, held at Arizona State University (Tempe, Arizona, USA) during April 25–29, 2001. A group of leading landscape ecologists were invited to present their views. This paper is intended to be a synthesis, but not necessarily a consensus, of the special session. We have organized the diverse and wide-ranging perspectives into six general key issues and 10 priority research topics. The key issues are: (1) interdisciplinarity or transdisciplinarity, (2) integration between basic research and applications,(3) Conceptual and theoretical development, (4) education and training, (5)international scholarly communication and collaborations, and (6) outreach and communication with the public and decision makers. The top 10 research topics are: (1) ecological flows in landscape mosaics, (2) causes, processes, and consequences of land use and land cover change, (3) nonlinear dynamics and landscape complexity, (4) scaling, (5) methodological development, (6) relating landscape metrics to ecological processes, (7) integrating humans and their activities into landscape ecology, (8) optimization of landscape pattern, (9)landscape sustainability, and (10) data acquisition and accuracy assessment. We emphasize that, although this synthesis was based on the presentations at the“Top 10 List” session, it is not a document that has been agreed upon by each and every participant. Rather, we believe that it is reflective of the broad-scale vision of the collective as to where landscape ecology is now and where it may be going in future.

Don't judge species on their origins

Conservationists should assess organisms on environmental impact rather than on whether they are natives, argue Mark Davis and 18 other ecologists.

What's new about old fields? Land abandonment and ecosystem assembly

Environmental and socio-economic changes are leading to increased levels of land abandonment worldwide. The assembly of plant communities on old fields has informed much ecological theory, which in turn has facilitated efforts at ecological restoration. The interaction of the cultivation legacy with inherent soil and vegetation characteristics will determine the dynamics of plant community assembly on old fields and indicate the level of effort required to restore historical vegetation states. The abandonment of traditional agricultural lands in some areas will create old fields that require limited or no restoration. Yet intensification of agriculture and rapid environmental change will lead to increasing numbers of old fields that show little recovery towards an historic vegetation state. The restoration of these old fields will pose significant scientific and policy challenges.

Management of novel ecosystems: are novel approaches required?

Most ecosystems are now sufficiently altered in structure and function to qualify as novel systems, and this recognition should be the starting point for ecosystem management efforts. Under the emerging biogeochemical configurations, management activities are experiments, blurring the line between basic and applied research. Responses to specific management manipulations are context specific, influenced by the current status or structure of the system, and this necessitates reference areas for management or restoration activities. Attempts to return systems to within their historical range of biotic and abiotic characteristics and processes may not be possible, and management activities directed at removing undesirable features of novel ecosystems may perpetuate or create such ecosystems. Management actions should attempt to maintain genetic and species diversity and encourage the biogeochemical characteristics that favor desirable species. Few resources currently exist to support the addition of proactive measures and rigorous experimental designs to current management activities. The necessary changes will not occur without strong input from stakeholders and policy makers, so rapid information transfer and proactive research–management activities by the scientific community are needed.

Threshold models in restoration and conservation: a developing framework

The recognition that a system can appear resilient to changes in the environment, only to reach a critical threshold of rapid and unexpected change, is spurring work to apply threshold models in conservation and restoration. Here we address the relevance of threshold models to habitat management. Work to date indicates these concepts are highly applicable: human impacts can widen the range of habitats where threshold dynamics occur and shift communities into new states that are difficult to reverse. However, in many applied settings, threshold concepts are being adopted without evaluation of evidence and uncertainty. We suggest a framework for incorporating threshold models that reflects an emphasis on applicability to decision making and management on relatively short timescales and in human-impacted systems.