Resilience and Equity in a Time of Crises: Investing in Public Urban Greenspace Is Now More Essential Than Ever in the US and Beyond.

The intersecting negative effects of structural racism, COVID-19, climate change, and chronic diseases disproportionately affect racial and ethnic minorities in the US and around the world. Urban populations of color are concentrated in historically redlined, segregated, disinvested, and marginalized neighborhoods with inadequate quality housing and limited access to resources, including quality greenspaces designed to support natural ecosystems and healthy outdoor activities while mitigating urban environmental challenges such as air pollution, heat island effects, combined sewer overflows and poor water quality. Disinvested urban environments thus contribute to health inequity via physical and social environmental exposures, resulting in disparities across numerous health outcomes, including COVID-19 and chronic diseases such as cancer and cardiovascular diseases (CVD). In this paper, we build off an existing conceptual framework and propose another conceptual framework for the role of greenspace in contributing to resilience and health equity in the US and beyond. We argue that strategic investments in public greenspaces in urban neighborhoods impacted by long term economic disinvestment are critically needed to adapt and build resilience in communities of color, with urgency due to immediate health threats of climate change, COVID-19, and endemic disparities in chronic diseases. We suggest that equity-focused investments in public urban greenspaces are needed to reduce social inequalities, expand economic opportunities with diversity in workforce initiatives, build resilient urban ecosystems, and improve health equity. We recommend key strategies and considerations to guide this investment, drawing upon a robust compilation of scientific literature along with decades of community-based work, using strategic partnerships from multiple efforts in Milwaukee Wisconsin as examples of success.

Vacant lot to community garden conversion and crime in Milwaukee: a difference-in-differences analysis.

BACKGROUND: Vacant lots generate the perception of neglect and are often opportunistic locations for crime. Evidence is building to suggest that greening vacant lots, especially through community engaged approaches, is associated with reductions in some types of crime. METHODS: Using a retrospective quasi-experimental approach, we compared the conversion of vacant lots into community gardens (n=53) with a group of matched control lots (n=159) to examine the effect of this intervention on police reported theft, violent and nuisance crime in Milwaukee, Wisconsin. Conversions often involved the addition of planter boxes to create a garden, and sometimes included benches, paths, works of art or other landscaping features. Public crime data were used to generate crime rates within 100 m and 250 m around each lot. RESULTS: Violent and nuisance crime rates are lower near treatment lots based on an unadjusted difference-in-differences analysis of means and two Poisson regression models. While no substantial effects were observed among theft crimes, the most consistent crime rate reductions were found among violent crime within 250 m, ranging between 3.7% and 6.4% across analyses. CONCLUSIONS: Despite the small number of interventions, community-driven vacant lot to garden conversions were associated with slight reductions in crime. Urban greening initiatives may be a promising strategy to reduce urban crime and warrant further study.

New-onset Psychosis in an Immunosuppressed Patient With Kidney Transplantation: An Educational Case Report.

RATIONALE: New-onset psychosis in an immunosuppressed patient post-kidney transplantation (KT) is a diagnostic challenge. A broad differential diagnosis merits consideration; however, an approach to this differential diagnosis remains to be outlined in the literature. Also, when and how to modify the maintenance immunosuppressive regimen remains a significant area of controversy. PRESENTING CONCERNS: A 23-year-old male, known for X-linked Alport syndrome for which he had undergone KT 1 year prior, presented with a 1-week history of disorganized speech, bizarre behavior, religious delusions, and visual hallucinations. DIAGNOSES: After ruling out infectious, metabolic, autoimmune, and structural causes, immunosuppressant medications were changed from tacrolimus to cyclosporine. The patient did not improve after this change, and a second opinion consultation with a transplant psychiatrist led to a diagnosis of primary first-episode psychosis, later refined to bipolar disorder type I. INTERVENTIONS: The patient was started on risperidone, which led to a significant improvement in his symptoms. OUTCOMES: Twelve months after discharge, his mood and behavior had returned to baseline on aripiprazole, bupropion, and citalopram. However, he developed acute allograft rejection, prompting a change from cyclosporine back to tacrolimus, with stability of his mental state and graft function. TEACHING POINTS: This report offers learners an extensive and organized differential diagnosis to the work up of psychosis post kidney transplantation. A complete history, with input from collateral sources, and a systematic approach to the differential diagnosis, are crucial and should not be overshadowed by the risk of immunosuppressant-related neurotoxicity. We underscore the importance of multi-disciplinary management and comprehensive psychosocial assessment and re-assessment to refine the diagnosis. We also report the successful re-introduction of tacrolimus once the diagnosis of a primary psychiatric disorder is confirmed. Finally, we offer a simplified approach that can aid in distinguishing between a primary psychiatric diagnosis versus tacrolimus-associated psychosis.

CONTEXTE: Le diagnostic d'un premier épisode psychotique chez un patient immunosupprimé en raison d'une transplantation rénale (TR) est complexe; un diagnostic différentiel doit alors être envisagé. L'approche à adopter pour établir un diagnostic différentiel reste à définir de façon plus précise dans la littérature. De plus, une controverse subsiste quant au moment et à la manière de procéder pour changer le traitement immunosuppresseur. PRÉSENTATION DU CAS: Nous présentons le cas d'un patient de 23 ans atteint du syndrome d'Alport lié à l'X, lequel avait mené à une TR un an auparavant. Depuis une semaine, le sujet manifestait des comportements inhabituels, avait un discours incohérent, était pris de délires religieux et souffrait d'hallucinations visuelles. DIAGNOSTIC: Après avoir écarté les causes infectieuses, métaboliques, auto-immunes et structurelles, le traitement immunosuppresseur de tacrolimus a été changé pour la cyclosporine. L'état du patient ne s'étant pas amélioré après le changement de médication, un second avis a été demandé. Une consultation avec un psychiatre spécialisé en transplantation a permis de diagnostiquer un premier épisode psychotique et ultérieurement, un trouble bipolaire de type 1. INTERVENTIONS: L'administration de risperidone a grandement amélioré les symptômes du patient. RÉSULTATS: La prise d'aripiprazole, de bupropione et de citalopram avait rétabli l'humeur et le comportement du patient douze mois après son congé de l'hôpital. Le développement d'une réaction aigüe de rejet de l'allogreffe a toutefois entraîné le remplacement immédiat de la cyclosporine pour le tacrolimus. L'état mental du patient et la fonction du greffon se sont stabilisés. ENSEIGNEMENTS TIRÉS: La présentation de ce cas offre aux apprenants un diagnostic différentiel complet et organisé pour l'étude de la psychose chez les patients greffés. Une évaluation approfondie de la condition clinique, avec l'apport de sources parallèles, et une approche systématique du diagnostic différentiel sont essentielles et ne devraient jamais être éclipsées par le risque de neurotoxicité associé aux traitements immunosuppresseurs. Nous insistons sur l'importance d'une prise en charge multidisciplinaire, d'une évaluation psychosociale complète et d'une ré-évaluation pour préciser le diagnostic. Nous rapportons également la réintroduction réussie du tacrolimus une fois le diagnostic du premier épisode psychotique confirmé. Enfin, nous fournissons une approche simplifiée pour aider à distinguer un premier épisode psychotique d'une psychose associée à la prise de tacrolimus.

Management of venous thromboembolism: a systematic review for a practice guideline.

BACKGROUND: New treatments are available for treatment of venous thromboembolism. PURPOSE: To review the evidence on the efficacy of interventions for treatment of deep venous thrombosis (DVT) and pulmonary embolism. DATA SOURCES: MEDLINE, MICROMEDEX, the Cochrane Controlled Trials Register, and Cochrane Database of Systematic Reviews from the 1950s through June 2006. STUDY SELECTION: Randomized, controlled trials; systematic reviews of trials; and observational studies; all restricted to English-language articles. DATA EXTRACTION: Paired reviewers assessed study quality and abstracted data. The authors pooled results about optimal duration of anticoagulation. DATA SYNTHESIS: This review includes 101 articles. Low-molecular-weight heparin (LMWH) is modestly superior to unfractionated heparin at preventing recurrent DVT and is at least as effective as unfractionated heparin for treatment of pulmonary embolism. Outpatient treatment of venous thromboembolism is likely to be effective and safe in carefully chosen patients, with appropriate services available. Inpatient or outpatient use of LMWH is cost-saving or cost-effective compared with unfractionated heparin. In observational studies, catheter-directed thrombolysis safely restored vein patency in select patients. Moderately strong evidence supports early use of compression stockings to reduce postthrombotic syndrome. Limited evidence suggests that vena cava filters are only modestly efficacious for prevention of pulmonary embolism. Conventional-intensity oral anticoagulation beyond 12 months may be optimal for patients with unprovoked venous thromboembolism, although patients with transient risk factors benefit little from more than 3 months of therapy. High-quality trials support use of LMWH in place of oral anticoagulation, particularly in patients with cancer. Little evidence is available to guide treatment of venous thromboembolism during pregnancy. LIMITATIONS: The authors could not address all management questions, and excluded non-English-language literature. CONCLUSIONS: The strength of evidence varies across the study questions but generally is strong.