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.

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.

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.

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.

Stable Ischemic Heart Disease.

Stable ischemic heart disease (SIHD) is a leading cause of death in the United States and many other countries. The defining pathobiology is an imbalance between the metabolic demands of the myocardium and its oxygen supply, which most often results from coronary artery atherosclerosis. The classic presenting symptom of SIHD is angina, but clinical presentation varies greatly among patients. Since the last In the Clinic on SIHD in 2014, several new drugs have been approved to reduce ischemic complications, such as myocardial infarction and congestive heart failure.

Drivers of geographical patterns of North American language diversity.

Although many hypotheses have been proposed to explain why humans speak so many languages and why languages are unevenly distributed across the globe, the factors that shape geographical patterns of cultural and linguistic diversity remain poorly understood. Prior research has tended to focus on identifying universal predictors of language diversity, without accounting for how local factors and multiple predictors interact. Here, we use a unique combination of path analysis, mechanistic simulation modelling, and geographically weighted regression to investigate the broadly described, but poorly understood, spatial pattern of language diversity in North America. We show that the ecological drivers of language diversity are not universal or entirely direct. The strongest associations imply a role for previously developed hypothesized drivers such as population density, resource diversity, and carrying capacity with group size limits. The predictive power of this web of factors varies over space from regions where our model predicts approximately 86% of the variation in diversity, to areas where less than 40% is explained.

The ecology of religious beliefs.

Although ecological forces are known to shape the expression of sociality across a broad range of biological taxa, their role in shaping human behavior is currently disputed. Both comparative and experimental evidence indicate that beliefs in moralizing high gods promote cooperation among humans, a behavioral attribute known to correlate with environmental harshness in nonhuman animals. Here we combine fine-grained bioclimatic data with the latest statistical tools from ecology and the social sciences to evaluate the potential effects of environmental forces, language history, and culture on the global distribution of belief in moralizing high gods (n = 583 societies). After simultaneously accounting for potential nonindependence among societies because of shared ancestry and cultural diffusion, we find that these beliefs are more prevalent among societies that inhabit poorer environments and are more prone to ecological duress. In addition, we find that these beliefs are more likely in politically complex societies that recognize rights to movable property. Overall, our multimodel inference approach predicts the global distribution of beliefs in moralizing high gods with an accuracy of 91%, and estimates the relative importance of different potential mechanisms by which this spatial pattern may have arisen. The emerging picture is neither one of pure cultural transmission nor of simple ecological determinism, but rather a complex mixture of social, cultural, and environmental influences. Our methods and findings provide a blueprint for how the increasing wealth of ecological, linguistic, and historical data can be leveraged to understand the forces that have shaped the behavior of our own species.

Local perceptions of changes in traditional ecological knowledge: a case study from Malekula island, Vanuatu.

Traditional ecological knowledge (TEK) is a critical global resource that may be eroding amid social and environmental change. Here, we present data on local perceptions of TEK change from three communities on Malekula Island in Vanuatu. Utilizing a structured interview (n = 120), we find a common perception of TEK loss. Participants defined two key periods of TEK erosion (roughly 1940-1960 and 1980-present), and noted that TEK decline was driven both external (e.g., church) and internal (e.g., shifting values) processes. Erosion was perceived to more comprehensive in the worldview domain than in aspects of ethnobiological knowledge and practice. These data indicate the perceived fragility of TEK systems and the complexity of TEK change. TEK systems are critical to natural resource management, and data such as these will assist in designing nuanced responses to the ongoing loss of cultural knowledge and practice.

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.

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.).

Trade-offs between cattle production and bird conservation in an agricultural frontier of the Gran Chaco of Argentina.

Intensification of food production in tropical landscapes in the absence of land-use planning can pose a major threat to biological diversity. Decisions on whether to spatially integrate or segregate lands for production and conservation depend in part on the functional relations between biological diversity and agricultural productivity. We measured diversity, density, and species composition of birds along a gradient of production intensification on an agricultural frontier of the Argentine Chaco, where dry tropical forests are cleared for cattle production. Bird species diversity in intact forests was higher than in any type of cattle-production system. Bird species richness decreased nonlinearly as cattle yield increased. Intermediate-intensity silvopastoral systems, those in which forest understory is selectively cleared to grow pastures of non-native plants beneath the tree canopy, produced 80% of the mean cattle yield obtained in pastures on cleared areas and were occupied by 70-90% of the number of bird species present in the nearest forest fragments. Densities of >50% of bird species were significantly lower in open pastures than in silvopastoral systems. Therefore, intermediate-intensity silvopastoral systems may have the greatest potential to sustain cattle yield and conserve a large percentage of bird species. However, compared with low-intensity production systems, in which forest structure and extent were intact, intermediate-intensity silvopastoral systems supported significantly fewer forest-restricted bird species and fewer frugivorous birds. These data suggest that the integration of production and conservation through intermediate-intensity silvopastoral systems combined with the protection of forest fragments may be required to maintain cattle yield, bird diversity, and conservation of forest-restricted species in this agricultural frontier.

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.