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Criticism: Spillover benefits generated by LSMPAs could be absorbed by fishers operating on their margins ( Agardy 2017

The phenomenon of “fishing-the-line” around MPAs is well documented and enables fishers to benefit from the spillover, or net emigration, of commercially valuable species (Di Lorenzo et al. 2016 ). Such a response is rational: They can fish more effectively at less expense through reduced fuel and time spent searching for fish due to greater stock densities. Furthermore, fishing-the-line provides evidence that an MPA is appropriately located for the target fish species and indicates management effectiveness.

Fishing-the-line may be perceived as disadvantageous to a nation that has established a LSMPA because many, but not all, extend to EEZ boundaries. Any spillover benefits at their outer boundaries will therefore accrue beyond national jurisdiction. This could be remedied by making the outer strongly or fully protected limits within national waters or by zoning the protected area to allow domestic fleets to benefit. In the Galapagos Marine Reserve, for example, the tuna purse-seine fleet (66 vessels from 10 nationalities) can be seen fishing-the-line around the reserve (Boerder et al. 2017 ), suggesting that Ecuador is benefiting financially through granting access.

Although fishing-the-line may limit the geographic spread of spillover, it should not affect the overall amount unless fishers catch more fish than can be biologically sustained or concentrate in particularly sensitive areas. Nor will it affect the export of eggs and larvae to surrounding areas, which is one of the major and spatially most far-reaching benefits of protection (Di Lorenzo et al. 2016 ). Fishing-the-line also offers the opportunity to encourage stakeholder support for protective measures, although in overexploited fisheries, reductions in total fishing effort will likely be required to ensure sustainability (Kellner et al. 2007 ).

Global food security, particularly of lower-income countries, is already threatened by overexploitation of fish stocks, and this is likely to worsen under climate change (Golden et al. 2016 ). The fishery benefits of LSMPAs are an emerging field of study. However, in areas with high fishing effort, LSMPAs may already be providing localized fishery benefits (Ban et al. 2017 ). For example, the western and southwestern boundary of the Galapagos Marine Reserve attracts greater tuna fishing effort and supports a higher catch per unit effort than the remainder of Ecuador's EEZ, although declines in catch per unit effort are occurring throughout Ecuador's waters (Boerder et al. 2017 ). Other LSMPAs, such as the Palau National Marine Sanctuary, have been designed to enhance local seafood supplies. Spatial protection has long been a tool in fisheries management, and LSMPAs are no exception. Given that effective protection of important areas, such as spawning or nursery grounds, combined with good fishery management can help rebuild exploited fish stocks, LSMPAs may, in fact, contribute to increasing seafood supply while simultaneously achieving many other benefits, such as habitat protection and climate resilience. (Sumaila et al. 2015 , Cheung et al. 2017 ).

Table 35 summarizes the relative clinical contraindications to the use of DES.

The optimal duration of DAPT after DES implantation is not known. Convincing data exist only for continuation up to 6 months [ 237 ]. Possibly, under some circumstances or with some DES, DAPT for 3 months could be sufficient but the evidence is not robust [ 219 ]. Recent evidence shows that (very) late stent thrombosis results from delayed hypersensitivity to components of the drug-polymer-device combination that causes necrotizing vasculitis and late malapposition [ 238 ]. Diabetics may require a longer duration of DAPT.

For situations listed in Table 35 , a number of alternative approaches have been tested. The Genous bio-engineered BMS carries a layer of murine, monoclonal, antihuman CD34 antibody, aimed at capturing circulating endothelial CD34+ progenitor cells, possibly increasing the rate of healing. The single-centre pilot TRIAS RCT did not confirm initial promising results in patients at high risk of coronary restenosis [ 239 ].

The rationale of using drug-eluting balloons is based on the concept that with highly lipophilic drugs, even short contact times between the balloon and the vessel wall are sufficient for effective drug delivery. Using a paclitaxel-eluting balloon, three RCTs have targeted in-stent restenosis following BMS implantation: PACCOCATH-I and -II [ 174 , 175 ] and PEPCAD-II [ 240 ]. As with DES, one cannot assume a class effect for all drug-eluting balloons. In the randomized PEPCAD III study, the combination of a drug-eluting balloon with cobalt chromium stent implantation was inferior to SES for de novo indications.

Although some brands already provide a biodegradable polymer, current DES remain permanent implants that cannot be extracted like pacemakers or artificial heart valves. Furthermore, stents force the cardiac surgeons to anastomose bypass grafts more distally. Stents create disruptive artefacts on cardiac CT and magnetic resonance images. Therefore, fully biodegradable stents are in development [ 241 ].

Whereas angiography depicts only a two-dimensional lumen silhouette, IVUS allows tomographic assessment of lumen area, plaque size, and distribution. IVUS is a valuable adjunct to angiography, providing further insights into both diagnosis and therapy, including stent implantation. Interventional cardiologists have learnt much from IVUS, but it has been difficult to demonstrate that this knowledge acquired routinely translates into reduced MACE. Multiple studies have addressed the potential of IVUS to reduce restenosis and adverse events after BMS implantation, but conflicting results were obtained with the largest of these trials showing no difference between groups with or without IVUS guidance. For DES, it was recently shown that the threshold of stent expansion predictive of late events including restenosis and stent thrombosis is lower than for BMS (5.0–5.5mm 2 ). In a retrospective analysis of a multicentre registry comparing PCI with surgery for unprotected LM, IVUS-guided stent implantation was associated with a significant mortality reduction at 3 years [ 242 ]. No properly designed RCT has compared the clinical value of IVUS-guided stent implantation in the DES era.

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Some available evidence suggests that high consumption of ultra-processed foods (UPFs) is associated with a higher risk of obesity. Collectively, this association and the nutritional characteristics of UPFs suggest that UPFs might also be associated with hypertension.


We prospectively evaluated the relationship between UPF consumption and the risk of hypertension in a prospective Spanish cohort, the Seguimiento Universidad de Navarra project. We included 14,790 Spanish adult university graduates who were initially free of hypertension at baseline who were followed for a mean of 9.1 years (SD, 3.9 years; total person-years: 134,784). UPF (industrial formulations of chemical compounds which, beyond substances of common culinary use such as salt, sugar, oils, and fats, include substances also derived from foods but not used in culinary preparations) consumption was assessed using a validated semi-quantitative 136-item food-frequency questionnaire. Cox proportional hazards models were used to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs) for hypertension incidence.


During follow-up, 1,702 incident cases of hypertension were identified. Participants in the highest tertile of UPF consumption had a higher risk of developing hypertension (adjusted HR, 1.21; 95% CI, 1.06, 1.37; P for trend = 0.004) than those in the lowest tertile after adjusting for potential confounders.


In this large prospective cohort of Spanish middle-aged adult university graduates, a positive association between UPF consumption and hypertension risk was observed. Additional longitudinal studies are needed to confirm our results.

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Hypertension accounts for approximately 10.4 million deaths, 208.1 million disability-adjusted life-years, and 7% of the disease burden worldwide. 1 , 2 Moreover, hypertension is a risk factor for cardiovascular disease and responsible for at least 45% and 51% of deaths due to heart disease and stroke, respectively. 3 The prevalence of hypertension was approximately 22% worldwide in 2014 and 25% in the European region. 1

Modifiable risk factors for hypertension include an unhealthy diet (consumption of foods containing excess salt and saturated fat and insufficient fruit and vegetables intake), harmful alcohol use, lack of physical activity, and excess weight. 4 In several countries, ultra-processed foods (UPFs) are common sources of salt. According to Monteiro et al. UPFs are defined as drink and food products which, beyond substances of common culinary use such as salt, sugar, oils, and fats, include substances also derived from foods but not used in culinary preparation and are ready to eat, drink, or heat. 5–7 They have high amounts of salt, total fat, saturated fat, and trans fat, free sugar, and high energy density, and low fiber and micronutrients content. 8–11

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