Climate, climate change and the global diversity of human houses.

Globally, human house types are diverse, varying in shape, size, roof type, building materials, arrangement, decoration and many other features. Here we offer the first rigorous, global evaluation of the factors that influence the construction of traditional (vernacular) houses. We apply macroecological approaches to analyse data describing house features from 1900 to 1950 across 1000 societies. Geographic, social and linguistic descriptors for each society were used to test the extent to which key architectural features may be explained by the biophysical environment, social traits, house features of neighbouring societies or cultural history. We find strong evidence that some aspects of the climate shape house architecture, including floor height, wall material and roof shape. Other features, particularly ground plan, appear to also be influenced by social attributes of societies, such as whether a society is nomadic, polygynous or politically complex. Additional variation in all house features was predicted both by the practices of neighouring societies and by a society's language family. Collectively, the findings from our analyses suggest those conditions under which traditional houses offer solutions to architects seeking to reimagine houses in light of warmer, wetter or more variable climates.

IV Diuresis in Alternative Treatment Settings for the Management of Heart Failure: Implications for Mortality, Hospitalizations and Cost.

BACKGROUND: Recent advances in heart failure (HF) care have sought to shift management from inpatient to outpatient and observation settings. We evaluated the association among HF treatment in the (1) inpatient; (2) observation; (3) emergency department (ED); and (4) outpatient settings with 30-day mortality, hospitalizations and cost. METHODS: Using 100% Medicare inpatient, outpatient and Part B files from 2011-2018, 1,534,708 unique patient encounters in which intravenous (IV) diuretics were received for a primary diagnosis of HF were identified. Encounters were sorted into mutually exclusive settings: (1) inpatient; (2) observation; (3) ED; or (4) outpatient IV diuretic clinic. The primary outcome was 30-day all-cause mortality. Secondary outcomes included 30-day hospitalization and total 30-day costs. Multivariable logistic and linear regression were used to examine the association between treatment location and the primary and secondary outcomes. RESULTS: Patients treated in observation and outpatient settings had lower 30-day mortality rates (observation OR 0.67, 95% CI 0.66-0.69; P < 0.001; outpatient OR 0.53, 95% CI 0.51-0.55; P < 0.001) compared to those treated in inpatient settings. Observation and outpatient treatment were also associated with decreased 30-day total cost compared to inpatient treatment. Observation relative cost -$5528.77, 95% CI -$5613.63 to -$5443.92; outpatient relative cost -$7005.95; 95% CI -$7103.94 to -$6907.96). Patients treated in the emergency department and discharged had increased mortality rates (OR 1.15, 95% CI 1.13-1.17; P < 0.001) and increased rates of hospitalization (OR 1.72, 95% CI 1.70-1.73; P < 0.001) compared to patients treated as inpatients. CONCLUSIONS: Medicare beneficiaries who received IV diuresis for acute HF in the outpatient and observation settings had lower mortality rates and decreased costs of care compared to patients treated as inpatients. Outpatient and observation management of acute decompensated HF, when available, is a safe and cost-effective strategy in certain populations of patients with HF.

Populism and De Facto Central Bank Independence.

Although central bank independence is a core tenet of monetary policy-making, it remains politically contested: In many emerging markets, populist governments are in frequent public conflict with the central bank. At other times, the same governments profess to respect the monetary authority's independence. We model this conflict drawing on the crisis bargaining literature. Our model predicts that populist politicians will often bring a nominally independent central bank to heel without having to change its legal status. To provide evidence, we build a new data set of public pressure on central banks by classifying over 9000 analyst reports using machine learning. We find that populist politicians are more likely than non-populists to exert public pressure on the central bank, unless checked by financial markets, and also more likely to obtain interest rate concessions. Our findings underscore that de jure does not equal de facto central bank independence in the face of populist pressures.

A Focus on the Right Atrium: Right Atrial Diverticulum and Atrial Flutter.

We report a case of a 70-year-old woman who presented for a cavotricuspid isthmus atrial flutter ablation that was aborted prematurely. On subsequent imaging, she was discovered to have a right atrial diverticulum, which was present on prior imaging but not reported, likely due to unfamiliarity with the entity. (Level of Difficulty: Intermediate.).

Identifying socioeconomic and biophysical factors driving forest loss in protected areas.

Protected areas (PAs) are a commonly used strategy to confront forest conversion and biodiversity loss. Although determining drivers of forest loss is central to conservation success, understanding of them is limited by conventional modeling assumptions. We used random forest regression to evaluate potential drivers of deforestation in PAs in Mexico, while accounting for nonlinear relationships and higher order interactions underlying deforestation processes. Socioeconomic drivers (e.g., road density, human population density) and underlying biophysical conditions (e.g., precipitation, distance to water, elevation, slope) were stronger predictors of forest loss than PA characteristics, such as age, type, and management effectiveness. Within PA characteristics, variables reflecting collaborative and equitable management and PA size were the strongest predictors of forest loss, albeit with less explanatory power than socioeconomic and biophysical variables. In contrast to previously used methods, which typically have been based on the assumption of linear relationships, we found that the associations between most predictors and forest loss are nonlinear. Our results can inform decisions on the allocation of PA resources by strengthening management in PAs with the highest risk of deforestation and help preemptively protect key biodiversity areas that may be vulnerable to deforestation in the future.

Identificación de los factores biofísicos y socioeconómicos que impulsan la pérdida de bosques en las áreas protegidas Resumen Las áreas protegidas son una estrategia de uso común para hacer frente a la conversión forestal y la pérdida de biodiversidad. Aunque determinar los factores que impulsan la pérdida de bosques es fundamental para el éxito de la conservación, su comprensión se ve limitada por los supuestos de modelación convencionales. Utilizamos la regresión de bosques aleatorios para evaluar los posibles impulsores de la deforestación en las áreas protegidas de México, considerando las relaciones no lineales y las interacciones de orden superior que subyacen a los procesos de deforestación. Los impulsores socioeconómicos (densidad de carreteras, densidad de población humana) y las condiciones biofísicas subyacentes (precipitaciones, distancia al agua, elevación, pendiente) fueron predictores más fuertes de la pérdida de bosques que las características de las áreas protegidas, como la edad, el tipo y la efectividad de la gestión. Dentro de las características de las áreas protegidas, las variables que reflejan una gestión colaborativa y equitativa y el tamaño del área protegida fueron los predictores más potentes de la pérdida de bosques, aunque con menor poder explicativo que las variables socioeconómicas y biofísicas. A diferencia de los métodos utilizados anteriormente, que suelen basarse en el supuesto de relaciones lineales, observamos que las asociaciones entre la mayoría de los predictores y la pérdida de bosques no son lineales. Nuestros resultados pueden servir de base para la toma de decisiones sobre la asignación de los recursos para las áreas protegidas, reforzando la gestión en las zonas protegidas con mayor riesgo de deforestación y ayudando a proteger de forma preventiva zonas clave para la biodiversidad que pueden ser vulnerables a la deforestación en el futuro.

Patterns of Recovery in Cardiovascular Care after the COVID-19 Pandemic Surge.

BACKGROUND: Cardiovascular disease remains the number one cause of death globally. Patients with cardiovascular disease are at risk of poor outcomes from deferral of healthcare during the coronavirus disease 2019 (COVID-19) pandemic. Little is known about recovery of cardiovascular hospitalizations or procedural volume following the COVID-19 surges. We sought to examine the cardiovascular diagnoses requiring healthcare utilization surrounding the first and second COVID-19 waves and characterize trends in return to pre-pandemic levels at a tertiary care center in Massachusetts. MATERIALS AND METHODS: Using electronic health records and administrative claims data, we performed a retrospective analysis of patients undergoing cardiovascular procedures and admitted to inpatient cardiology services throughout the first two COVID surges. ICD-10 codes were used to categorize admissions. RESULTS: Patients who presented for care during the initial COVID-19 surge were younger, had higher comorbidity burden, and longer length-of-stay compared with pre- and post-surge. Marked declines in admissions in the first wave (to 29% of pre-surge levels) followed eventually by complete recovery were noted across all cardiac diagnoses, with smaller declines seen in the second wave. Cardiac procedural volume declined significantly during the initial surge but quickly rebounded post-surge, eventually eclipsing pre-COVID volume. CONCLUSIONS: There was a gradual but initially incomplete recovery to pre-surge levels of hospitalizations and procedures during the reopening phase, which eventually rebounded to meet or exceed pre-COVID-19 levels. To the extent that this reflects deferred or foregone essential care, it may adversely affect long-term cardiovascular outcomes. These results should inform planning for cardiovascular care delivery during future pandemic surges.

Introduction of a standardized protocol for cardiac risk assessment in candidates for liver transplant - A retrospective cohort analysis.

INTRODUCTION: Recommendations on non-invasive imaging to assess pre-operative cardiac risk among liver transplant candidates vary amongst societal guidelines and individual institutional practices. In 2018, a standardized pre-transplant coronary evaluation protocol was established at Beth Israel Deaconess Medical Center, Boston MA, to ensure appropriate and consistent pre-operative testing was performed. METHODS: All patients who underwent liver transplant evaluation between January 1st, 2016 and December 31st, 2019, were retrospectively analyzed and divided into three cohorts; before the introduction of the protocol (prior to 2018), initial protocol favoring invasive coronary angiography (ICA) (2018), and amended protocol favoring coronary computed tomography angiography (CCTA) (post-2018). We described clinical characteristics, candidacy for transplant, and cardiovascular complications during follow-up. As an unadjusted exploratory analysis, the Cochran-Armitage Exact Trend Test was used to examine univariate differences across time. RESULTS: A total of 462 patients underwent liver transplant evaluation during the study period. Among these, 218 (47.2%) patients underwent stress test, 50 (10.8%) underwent CCTA, and 68 (14.8%) underwent ICA. Across the three time periods, there was an increase in the proportion of CCTAs performed (3%, 6.3%, and 26.3% respectively; p <0.001) and proportion of patients diagnosed with obstructive CAD using CCTA (0%, 30%, and 51.4% respectively; p = 0.04). There was no significant difference in post-transplant cardiac complications among patients evaluated before 2018, during 2018, and after 2018 (5.9% vs. 5.6 vs. 6.0%; p=1.0). CONCLUSION: Our findings suggest it is reasonable to shift practice to a less invasive approach utilizing CCTA or nuclear stress testing when assessing liver transplant candidates at increased cardiovascular risk.

Quality and diagnostic performance of coronary computed tomography angiogram (CCTA): A comparison between pre-liver and pre-kidney transplant patients.

PURPOSE: Assess and compare the quality and diagnostic performance of CCTA between pre-liver and pre-kidney transplant patients, and gauge impact of CCTA on ICA requirements. METHODS: Patients without known coronary artery disease (CAD) were selected for CCTA if considered high-risk or after abnormal stress testing. All pre-liver and pre-kidney CCTAs between March 2018 and August 2020 were retrospectively included. CCTA quality was qualitatively graded as excellent/good/fair/poor, and CAD graded as < or ≥50% stenosis. Heart rate, coronary artery calcium (CAC) scores, and fractional flow reserve CT (FFRCT) results were collected. CAD stenosis was graded on invasive coronary angiogram (ICA) images, with ≥50% stenosis defined as significant. RESULTS: 162 pre-transplant patients (91 pre-liver, 71 pre-kidney). Pre-kidney patients had poorer CCTA quality (p = 0.04) and higher heart rate (median: 65 bpm vs 60 bpm, p < 0.001). Out of 147 diagnostic CCTAs (pre-liver: 84, pre-kidney: 63), 73 (49.7%) had a ≥50% stenosis (pre-liver: 38 (45.2%), pre-kidney:35 (55.6%)). 12/38 (31.6%) had a significantly reduced FFRCT, and 19/53 (35.8%) had ≥50% stenosis on ICA. Among patients whose CCTA was diagnostic and had ICA, stenosis severity was concordant in 10/23 (43.5%) pre-liver and 10/25 (40%) pre-kidney patients. All discordant cases had stenosis 'over-called' on CCTA. CONCLUSION: Diagnostic-quality CCTAs in high-risk pre-transplant patients are achievable and can greatly reduce ICA requirements by excluding significant CAD. CCTA quality is poorer in pre-kidney transplant patients compared to pre-liver, possibly due to higher heart rate.

Wood-Derived Hydrogels as a Platform for Drug-Release Systems.

Wood (cellulose and lignin)-based hydrogels were successfully produced as platforms for drug-release systems. Viscoelastic and cross-linking behaviors of precursor solutions were tuned to produce highly porous hydrogel architectures via freeze-drying. Pore sizes in the range of 100-160 µm were obtained. Varying lignin molecular structure played a key role in tailoring swelling and mechanical performance of these gels with organosolv-type lignin showing optimum properties due to its propensity for intermolecular cross-linking, achieving a compressive modulus around 11 kPa. Paracetamol was selected as a standard drug for release tests and its release rate was improved with the presence of lignin (50% more compared to pure cellulose hydrogels). This was attributed to a reduction in molecular interactions between paracetamol and cellulose. These results highlight the potential for the valorization of lignin as a platform for drug-release systems.

Cost-effectiveness of Dapagliflozin for the Treatment of Heart Failure With Reduced Ejection Fraction.

Importance: Heart failure with reduced ejection fraction produces substantial morbidity, mortality, and health care costs. Dapagliflozin is the first sodium-glucose cotransporter 2 inhibitor approved for the treatment of heart failure with reduced ejection fraction. Objective: To examine the cost-effectiveness of adding dapagliflozin to guideline-directed medical therapy for heart failure with reduced ejection fraction in patients with or without diabetes. Design, Setting, and Participants: This economic evaluation developed and used a Markov cohort model that compared dapagliflozin and guideline-directed medical therapy with guideline-directed medical therapy alone in a hypothetical cohort of US adults with similar clinical characteristics as participants of the Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction (DAPA-HF) trial. Dapagliflozin was assumed to cost $4192 annually. Nonparametric modeling was used to estimate long-term survival. Deterministic and probabilistic sensitivity analyses examined the impact of parameter uncertainty. Data were analyzed between September 2019 and January 2021. Main Outcomes and Measures: Lifetime incremental cost-effectiveness ratio in 2020 US dollars per quality-adjusted life-year (QALY) gained. Results: The simulated cohort had a starting age of 66 years, and 41.8% had diabetes at baseline. Median (interquartile range) survival in the guideline-directed medical therapy arm was 6.8 (3.5-11.3) years. Dapagliflozin was projected to add 0.63 (95% uncertainty interval [UI], 0.25-1.15) QALYs at an incremental lifetime cost of $42 800 (95% UI, $37 100-$50 300), for an incremental cost-effectiveness ratio of $68 300 per QALY gained (95% UI, $54 600-$117 600 per QALY gained; cost-effective in 94% of probabilistic simulations at a threshold of $100 000 per QALY gained). Findings were similar in individuals with or without diabetes but were sensitive to drug cost. Conclusions and Relevance: In this study, adding dapagliflozin to guideline-directed medical therapy was projected to improve long-term clinical outcomes in patients with heart failure with reduced ejection fraction and be cost-effective at current US prices. Scalable strategies for improving uptake of dapagliflozin may improve long-term outcomes in patients with heart failure with reduced ejection fraction.

Prestige and content biases together shape the cultural transmission of narratives.

Cultural transmission biases such as prestige are thought to have been a primary driver in shaping the dynamics of human cultural evolution. However, few empirical studies have measured the importance of prestige relative to other effects, such as content biases present within the information being transmitted. Here, we report the findings of an experimental transmission study designed to compare the simultaneous effects of a model using a high- or low-prestige regional accent with the presence of narrative content containing social, survival, emotional, moral, rational, or counterintuitive information in the form of a creation story. Results from multimodel inference reveal that prestige is a significant factor in determining the salience and recall of information, but that several content biases, specifically social, survival, negative emotional, and biological counterintuitive information, are significantly more influential. Further, we find evidence that reliance on prestige cues may serve as a conditional learning strategy when no content cues are available. Our results demonstrate that content biases serve a vital and underappreciated role in cultural transmission and cultural evolution. Social media summary: Storyteller and tale are both key to memorability, but some content is more important than the storyteller's prestige.

Pathways to social inequality.

Social inequality is ubiquitous in contemporary human societies, and has deleterious social and ecological impacts. However, the factors that shape the emergence and maintenance of inequality remain widely debated. Here we conduct a global analysis of pathways to inequality by comparing 408 non-industrial societies in the anthropological record (described largely between 1860 and 1960) that vary in degree of inequality. We apply structural equation modelling to open-access environmental and ethnographic data and explore two alternative models varying in the links among factors proposed by prior literature, including environmental conditions, resource intensification, wealth transmission, population size and a well-documented form of inequality: social class hierarchies. We found support for a model in which the probability of social class hierarchies is associated directly with increases in population size, the propensity to use intensive agriculture and domesticated large mammals, unigeniture inheritance of real property and hereditary political succession. We suggest that influence of environmental variables on inequality is mediated by measures of resource intensification, which, in turn, may influence inequality directly or indirectly via effects on wealth transmission variables. Overall, we conclude that in our analysis a complex network of effects are associated with social class hierarchies.

Reframing the Wilderness Concept can Bolster Collaborative Conservation.

Indigenous territories represent ~45% of land categorized as wilderness in the Amazon, but account for <15% of all forest loss on this land. At a time when the Amazon faces unprecedented pressures, overcoming polarization and aligning the goals of wilderness defenders and Indigenous peoples is paramount, to avoid environmental degradation.

The Position-Reputation-Information (PRI) scale of individual prestige.

Prestige is a key concept across the social and behavioral sciences and has been implicated as an important driver in the processes governing human learning and behavior and the evolution of culture. However, existing scales of prestige fail to account for the full breadth of its potential determinants or focus only on collective social institutions rather than the individual-level perceptions that underpin everyday social interactions. Here, we use open, extensible methods to unite diverse theoretical ideas into a common measurement tool for individual prestige. Participants evaluated the perceived prestige of regional variations in accented speech using a pool of candidate scale items generated from free-listing tasks and a review of published scales. Through exploratory and confirmatory factor analyses, we find that our resulting 7-item scale, composed of dimensions we term position, reputation, and information ("PRI"), exhibits good model fit, scale validity, and scale reliability. The PRI scale of individual prestige contributes to the integration of existing lines of theory on the concept of prestige, and the scale's application in Western samples and its extensibility to other cultural contexts serves as a foundation for new theoretical and experimental trajectories across the social and behavioral sciences.

Cultural transmission and ecological opportunity jointly shaped global patterns of reliance on agriculture.

The evolution of agriculture improved food security and enabled significant increases in the size and complexity of human groups. Despite these positive effects, some societies never adopted these practices, became only partially reliant on them, or even reverted to foraging after temporarily adopting them. Given the critical importance of climate and biotic interactions for modern agriculture, it seems likely that ecological conditions could have played a major role in determining the degree to which different societies adopted farming. However, this seemingly simple proposition has been surprisingly difficult to prove and is currently controversial. Here, we investigate how recent agricultural practices relate both to contemporary ecological opportunities and the suitability of local environments for the first species domesticated by humans. Leveraging a globally distributed dataset on 1,291 traditional societies, we show that after accounting for the effects of cultural transmission and more current ecological opportunities, levels of reliance on farming continue to be predicted by the opportunities local ecologies provided to the first human domesticates even after centuries of cultural evolution. Based on the details of our models, we conclude that ecology probably helped shape the geography of agriculture by biasing both human movement and the human-assisted dispersal of domesticates.

Cardiovascular Risk Assessment in Renal and Liver Transplant Candidates: A Multidisciplinary Institutional Standardized Approach.

In the modern era, renal and liver transplant candidates present with a greater medical complexity driven in part by a higher prevalence of cardiovascular conditions, including coronary artery disease, valvular heart disease, and cardiomyopathies. In fact, cardiovascular disease is the most common cause of death after kidney transplantation worldwide. Similarly, an increase in the number of patients being listed with end-stage liver disease from nonalcoholic steatohepatitis and a rising model for end-stage liver disease scores at the time of liver transplant in the United States parallel an increasing cardiovascular disease risk profile for liver transplant candidates. A large degree of variation exists among clinical practice guidelines and transplant center practice patterns regarding patient selection for routine cardiac testing and the choice of testing modalities. Here, we review the clinical practice guidelines established at our center by a multidisciplinary group, including transplant nephrology, hepatology, and surgery, as well as general and interventional cardiology, with the goal of improving patient selection and reducing adverse cardiac events posttransplant.