Suitable Days for Plant Growth Disappear under Projected Climate Change: Potential Human and Biotic Vulnerability.

Ongoing climate change can alter conditions for plant growth, in turn affecting ecological and social systems. While there have been considerable advances in understanding the physical aspects of climate change, comprehensive analyses integrating climate, biological, and social sciences are less common. Here we use climate projections under alternative mitigation scenarios to show how changes in environmental variables that limit plant growth could impact ecosystems and people. We show that although the global mean number of days above freezing will increase by up to 7% by 2100 under "business as usual" (representative concentration pathway [RCP] 8.5), suitable growing days will actually decrease globally by up to 11% when other climatic variables that limit plant growth are considered (i.e., temperature, water availability, and solar radiation). Areas in Russia, China, and Canada are projected to gain suitable plant growing days, but the rest of the world will experience losses. Notably, tropical areas could lose up to 200 suitable plant growing days per year. These changes will impact most of the world's terrestrial ecosystems, potentially triggering climate feedbacks. Human populations will also be affected, with up to ~2,100 million of the poorest people in the world (~30% of the world's population) highly vulnerable to changes in the supply of plant-related goods and services. These impacts will be spatially variable, indicating regions where adaptations will be necessary. Changes in suitable plant growing days are projected to be less severe under strong and moderate mitigation scenarios (i.e., RCP 2.6 and RCP 4.5), underscoring the importance of reducing emissions to avoid such disproportionate impacts on ecosystems and people.

Predicting the suitable cultivation areas of breadfruit crops Artocarpus altilis (Moraceae) under future climate scenarios in Central Java, Indonesia.

Artocarpus altilis, commonly known as breadfruit, is a potential crop adapted to a wide variety of climates and widely spread, including in Indonesia. However, information on how this species can adapt to climate change, in particular in Central Java, is still limited. In Indonesia, Central Java is the center for cultivation areas for many crop species to support the 145 million people living on Java Island. One of the potential crops being developed in Central Java is breadfruit. To assess the suitable cultivation areas for breadfruit, species distribution modeling (SDM) was used to predict the current and future (2050-2070) distribution of breadfruit. Two climate change scenarios, including optimistic RCP2.6 and pessimistic RCP8.5 models, were considered to represent future climate change impacts. Based on the results for both optimistic and pessimistic scenarios, the breadfruit's suitable cultivation areas will expand eastward. Implementing a mitigation climate change scenario and limiting the temperature increase to only 1°C under RCP2.6 will provide 270.967 km2 more of suitable cultivation areas for breadfruit in 2050 and 133.296 km2 in 2070. To conclude, this study provides important information on the status and potential cultivation areas for breadfruit, mainly in the Southeast Asia region. The identification of suitable areas will guide land conservation for breadfruit to support food security in this region.

Evaluation of right ventricular strain in two separate cohorts with precapillary pulmonary hypertension.

Evaluation for right ventricular (RV) dysfunction is an important part of risk assessment in care of patients with pulmonary hypertension (PH) as it is associated with morbidity and mortality. Echocardiography provides a widely available and acceptable method to assess RV function. RV global longitudinal strain (RVGLS), a measure of longitudinal shortening of RV deep muscle fibers obtained by two-dimensional echocardiography, was previously shown to predict short-term mortality in patients with PH. The purpose of the current study was to assess the performance of RVGLS in predicting 1-year outcomes in PH. We retrospectively identified 83 subjects with precapillary PH and then enrolled 50 consecutive prevalent pulmonary arterial hypertension (PAH) subjects into a prospective validation cohort. Death as well as combined morbidity and mortality events at 1 year were assessed as outcomes. In the retrospective cohort, 84% of patients had PAH and the overall 1-year mortality rate was 16%. Less negative RVGLS was marginally better than tricuspid annular plane systolic excursion (TAPSE) as a predictor for death. However, in the prospective cohort, 1-year mortality was only 2%, and RVGLS was not predictive of death or a combined morbidity and mortality outcome. This study supports that RV strain and TAPSE have similar 1-year outcome predictions but highlights that low TAPSE or less negative RV strain measures are often false-positive in a cohort with low baseline mortality risk. While RV failure is considered the final common pathway for disease progression in PAH, echocardiographic measures of RV function may be less informative of risk in serial follow-up of treated PAH patients.

Effect of pulmonary hypertension on 5-year outcome of kidney transplantation.

Pulmonary hypertension affects about one in four patients with advanced chronic kidney disease and significantly increases the risk of death. Kidney transplantation is the recommended management option for patients with progressive or end-stage kidney disease. However, the resource-limited nature of kidney transplantation and its intensive peri-operative and posttransplantation management motivates careful consideration of potential candidates' medical conditions to optimally utilize available graft organs. Since pulmonary hypertension is known to increase peri-operative morbidity and mortality among patients living with chronic kidney disease, we performed a retrospective cohort study to assess the impact of pretransplantation pulmonary hypertension on posttransplantation outcome. All patients who underwent single-organ kidney transplantation at our center in calendar years 2010 and 2011 were identified and the presence of pulmonary hypertension was determined from pretransplantation echocardiography. Outcome was assessed at 5 years following kidney transplantation. Of 350 patients who were included, 117 (33%) had evidence of pulmonary hypertension. The risk of death, graft dysfunction, or graft failure at 5 years after kidney transplantation was higher among those with pulmonary hypertension, primarily owing to an increased risk of graft dysfunction. Importantly, in this institutional cohort of kidney transplant recipients, pretransplant pulmonary hypertension was not associated with a difference in posttransplant survival at 5 years. While institutional and regional differences in outcome can be expected, this report suggests that carefully selected patients with pulmonary hypertension receive similar long-term benefits from kidney transplantation.

Effects of COVID-19 restriction measures in Indonesia: A comparative spatial and policy analysis of selected urban agglomerations.

With higher densities, urban agglomerations account for the fastest rates of COVID-19 transmission. In Indonesia, one of the most rapidly urbanizing regions in the world, the national government issues overall policy on the pandemic. However, implementation is often contingent on local governments. Many policies aim to stem the spread of infection by controlling people's mobility or regulating their daily activities. Urban agglomerations are a strategic site of investigation in this light, because they consist of interconnected communities governed by various levels and jurisdictions. This paper analyzes the effects of policy interventions relative to confirmed cases in the seven major urban agglomerations in Indonesia (totaling 30 municipal/district governments). Data were collected from confirmed and fatality trends from March to mid-October 2020, which were contrasted with corresponding policies for each jurisdiction. By sorting the indicators of the spread of the pandemic and its corresponding control measures, we reach conclusions about which dimensions served to curb or trigger the surge of COVID-19 clusters. The analysis unsurprisingly shows that within each agglomeration, the main cities continue to represent the highest number of confirmed cases despite variations between them. This study also highlights two key findings. First, the effectiveness of distancing measures depends considerably on the capacity of governments to implement restrictions. For example, budget limitations resulted in uneven implementation of national mandates by decentralized authority. Facilities and services at different locations also influence our understanding of disease transmission. Second, people's ability and willingness to engage with a policy regime is contingent upon personal values or economic constraints. The study shows that viewing the spatial distribution of COVID-19 at the scale of urban agglomerations helps to explain key aspects of transmission and policy, pointing to recommendations about pursuing certain protocols. Nevertheless, key challenges remain to meet the full potential of this analytical approach, due to relatively low levels of testing and inadequate data collection measures in Indonesia.

BREEZE: Open-label clinical study to evaluate the safety and tolerability of treprostinil inhalation powder as Tyvaso DPI™ in patients with pulmonary arterial hypertension.

Inhaled treprostinil is an approved therapy for pulmonary arterial hypertension (PAH) and pulmonary hypertension associated with interstitial lung disease in the United States. Studies have confirmed the robust benefits and safety of nebulized inhaled treprostinil, but it requires a time investment for nebulizer preparation, maintenance, and treatment. A small, portable treprostinil dry powder inhaler has been developed for the treatment of PAH. The primary objective of this study was to evaluate the safety and tolerability of treprostinil inhalation powder (TreT) in patients currently treated with treprostinil inhalation solution. Fifty-one patients on a stable dose of treprostinil inhalation solution enrolled and transitioned to TreT at a corresponding dose. Six-minute walk distance (6MWD), device preference and satisfaction (Preference Questionnaire for Inhaled Treprostinil Devices [PQ-ITD]), PAH Symptoms and Impact (PAH-SYMPACT®) questionnaire, and systemic exposure and pharmacokinetics for up to 5 h were assessed at baseline for treprostinil inhalation solution and at Week 3 for TreT. Adverse events (AEs) were consistent with studies of inhaled treprostinil in patients with PAH, and there were no study drug-related serious AEs. Statistically significant improvements occurred in 6MWD, PQ-ITD, and PAH-SYMPACT. Forty-nine patients completed the 3-week treatment phase and all elected to participate in an optional extension phase. These results demonstrate that, in patients with PAH, transition from treprostinil inhalation solution to TreT is safe, well-tolerated, and accompanied by statistically significant improvements in key clinical assessments and patient-reported outcomes with comparable systemic exposure between the two formulations at evaluated doses (trial registration: clinicaltrials.gov identifier: NCT03950739).

Actor-center framing on measuring land use conflict visibility.

Land use conflict's visibility assessments are often reserved to descriptive reports in their measurement of a conflict depth. The existing literature has limited the ability to measure the degree of the conflict visibility. In light of this deficiency, we establish a technique to measure the degree of both latent and manifest conflicts using the actor-centered framing. This heuristics approach is focused on the gradation of interaction between conflicted actors by juxtaposing state and local community actors in defending their interest. We measure how state actors deploy policy instruments, mobilizing resources and interventions, and vice versa observing local actors that seek to internalize their issues and interests and getting public attention by building alliances and advocacy. This paper proposes a novel framework for exploring what is implied by latent and manifest tensions between local community and land use government institutions in greater depth. Practitioners will be able to get a better understanding of the conflict visibility, and to develop suitable intervention in conflict in order to reach a manageable situation. This paper also generates possible hypotheses for future research by examining how actors develop and utilize policy instruments for their interest in managing land use conflict. • Juxtaposing powerless and dominant actors. • The gradation points of latent and manifest in conflict visibility continuum. • Actors' tendencies toward the conflict.

Accuracy of Doppler echocardiography in the hemodynamic assessment of pulmonary hypertension.

RATIONALE: Transthoracic Doppler echocardiography is recommended for screening for the presence of pulmonary hypertension (PH). However, some recent studies have suggested that Doppler echocardiographic pulmonary artery pressure estimates may frequently be inaccurate. OBJECTIVES: Evaluate the accuracy of Doppler echocardiography for estimating pulmonary artery pressure and cardiac output. METHODS: We conducted a prospective study on patients with various forms of PH who underwent comprehensive Doppler echocardiography within 1 hour of a clinically indicated right-heart catheterization to compare noninvasive hemodynamic estimates with invasively measured values. MEASUREMENTS AND MAIN RESULTS: A total of 65 patients completed the study protocol. Using Bland-Altman analytic methods, the bias for the echocardiographic estimates of the pulmonary artery systolic pressure was -0.6 mm Hg with 95% limits of agreement ranging from +38.8 to -40.0 mm Hg. Doppler echocardiography was inaccurate (defined as being greater than +/-10 mm Hg of the invasive measurement) in 48% of cases. Overestimation and underestimation of pulmonary artery systolic pressure by Doppler echocardiography occurred with a similar frequency (16 vs. 15 instances, respectively). The magnitude of pressure underestimation was greater than overestimation (-30 +/- 16 vs. +19 +/- 11 mm Hg; P = 0.03); underestimates by Doppler also led more often to misclassification of the severity of the PH. For cardiac output measurement, the bias was -0.1 L/min with 95% limits of agreement ranging from +2.2 to -2.4 L/min. CONCLUSIONS: Doppler echocardiography may frequently be inaccurate in estimating pulmonary artery pressure and cardiac output in patients being evaluated for PH.

Long-term outcomes in pulmonary arterial hypertension by functional class: a meta-analysis of randomized controlled trials and observational registries.

Limited data about the long-term prognosis and response to therapy in pulmonary arterial hypertension patients with World Health Organization functional class I/II symptoms are available. PubMed and Embase were searched for publications of observational registries and randomized, controlled trials in pulmonary arterial hypertension patients published between January 2001 and January 2018. Eligible registries enrolled pulmonary arterial hypertension patients ≥18 years, N > 30, and reported survival by functional class. Randomized, controlled trial inclusion criteria were pulmonary arterial hypertension patients ≥18 years, ≥6 months of treatment, and morbidity, mortality, or time to worsening as end points reported by functional class. The primary outcomes were survival for registries and clinical event rates for randomized, controlled trials. Separate random effects models were calculated for registries and randomized, controlled trials. Four randomized, controlled trials (n = 2482) and 10 registries (n = 6580) were included. Registries enrolled 9%-47% functional class I/II patients (the vast majority being functional class II) with various pulmonary arterial hypertension etiologies. Survival rates for functional class I/II patients at one, two, and three years were 93% (95% confidence interval (CI): 91%-95%), 86% (95% CI: 82%-89%), and 78% (95% CI: 73%-83%), respectively. The hazard ratio for the treatment effect in randomized, controlled trials overall was 0.61 (95% CI: 0.51-0.74) and 0.60 (95% CI: 0.44-0.82) for functional class I/II patients and 0.62 (95% CI: 0.49-0.78) for functional class III/IV. The calculated risk of death of 22% within three years for functional class I/II patients underlines the need for careful assessment and optimal treatment of patients with functional class I/II disease. The randomized, controlled trial analysis demonstrates that current medical therapies have a beneficial treatment effect in this population.

Land and power framework for assessing Ecosystem Essential Area policy.

This paper outlines a land and power framework for assessing whether a new voluntary conservation area policy is a return to the classical bureaucratic status quo or anticipates the opportunity to establish new bureaucratic norms. The application of this conceptual framework produces two possibilities. The first possibility is that outcomes are tied to the conventional bureaucratic models of conservation with management regimes that remain unchanged. The second possibility is the anticipation of new management forms, in which goals are not to fulfill the bureaucratic process, but rather, produce adaptive outcomes reflective of the interests of diverse actors engaged in site-specific voluntary conservation initiatives.•The land and power framework methodology is rooted in an interest-based power framework.•The framework analyses the land and power inputs for both conservation bureaucracies or actors participating in multi-stakeholder arrangements struggling to achieve their interests and establish their agendas.•The framework proposes a conceptual framework to assess two possible process outcomes, namely that management regimes will either be tied to the conventional bureaucracy or that actors anticipate new bureaucratic norms that achieve outcomes accommodating their broader interests.

Sequential power analysis framework in assessing social forestry outcomes.

We extend the Actor-Centred Power framework to consider dimensions beyond the life of community natural resource management partnership initiatives by examining social forestry partnership projects in Indonesia. We do this by examining how power constellations realign across the temporal phases that operationalize project partnerships. We propose a sequential power analysis framework that examines power in three parts. The framework first proposes a method for historicizing actors into their power background. Second, we present mode for examining the arrival of a partnership scheme, which we call the power delivery phase. Third, we highlight approaches for examining the way power relations are adjusted, whether reinforced or reconfigured, by introducing an approach for examining programmatic outcomes of social forestry partnership schemes. This article thus provides broadly applicable but targeted guide for the researchers collecting data and seeking to make sense of power relations on community forest partnership schemes in various contexts. This framework is particularly useful for analysing equity and justice dimensions by highlighting who benefits and who loses.•Sequential Power Analysis (SPA) methodology is rooted in interest based and historical power framework.•SPA is consisted of three parts: power background, power delivery, and power adjustment•SPA framing provides a protocol for researchers to collect data.

Hyponatremia predicts right heart failure and poor survival in pulmonary arterial hypertension.

RATIONALE: Hyponatremia is associated with decompensated heart failure and poor prognosis in patients with left ventricular systolic dysfunction. OBJECTIVES: We sought to determine if hyponatremia is associated with right heart failure and worse prognosis in patients with pulmonary arterial hypertension (PAH). METHODS: We prospectively followed 40 patients with PAH and examined the relationship between serum sodium and right heart function as well as survival. MEASUREMENTS AND MAIN RESULTS: Subjects with hyponatremia (Na < or = 136 mEq/L) were more symptomatic (11/13 World Health Organization [WHO] class III/IV vs. 12/27 WHO class III/IV; P = 0.02), had more peripheral edema (69 vs. 26%; P = 0.009), and had higher hospitalization rates (85 vs. 41%; P = 0.009) than normonatremic subjects. Hyponatremic subjects had higher right atrial pressure (14 +/- 6 vs. 9 +/- 3 mm Hg; P < 0.001), lower stroke volume index (21 +/- 7 vs. 32 +/- 10 ml/m(2); P < 0.01), larger right ventricular:left ventricular area ratio (1.8 +/- 0.4 vs. 1.3 +/- 0.4; P < 0.001), and lower tricuspid annular plane systolic excursion (1.4 +/- 0.3 vs. 2.0 +/- 0.6 cm; P = 0.001), despite similar mean pulmonary artery pressure (49 +/- 10 vs. 47 +/- 12 mm Hg; P = 0.60). The 1- and 2-year survival estimates were 93% (95% confidence interval [CI], 73-98%) and 85% (95% CI, 65-94%), and 38% (95% CI, 14-63%) and 15% (95% CI, 2-39%) for normonatremic and hyponatremic subjects, respectively (log-rank chi(2) = 25.19, P < 0.001). The unadjusted risk of death (hazard ratio) in hyponatremic compared with normonatremic subjects was 10.16 (95% CI, 3.42-30.10, P < 0.001). Hyponatremia predicted outcome after adjusting for WHO class, diuretic use, as well as right atrial pressure and cardiac index. CONCLUSIONS: Hyponatremia is strongly associated with right heart failure and poor survival in PAH.

The bureaucratic politics of conservation in governing land conflict: A typology of capacities.

Recent land management policies around the world have experienced a broader political push to resolve forest and land tenure conflict through agrarian reform policy. As a result, conservation bureaucracies are responding with both formal and informal interventions to acknowledge the role of people in forests. In this methods paper, we provide a closer examination of the ways that conservation bureaucracies apply their political capacity in negotiating forest and land tenure conflicts. Our proposed method measures both the capacity and actions of conservation bureaucracies, combining formal dimensions (such as of legal status, budget availability, and the type of organization unit) with informal dimensions (including ways of gaining authority, donors and funding, and trust). The framing is rooted in theories of bureaucratic politics, and while culled from rich empirical experiences from Indonesia, the proposed method is also applicable in examining bureaucratic politics in other natural resource governance contexts. •We develop a method rooted in bureaucratic politics to measure the capacities of conservation agencies to manage forest land tenure conflict•The proposed typology guides forest and land use policy researchers to incorporate emergent governance issues such as land tenure reform into their assessments of changing conservation bureaucracies•The can be adapted for examination of bureaucratic capacities and actions in other contested natural resource contexts.

Safety and tolerability of transition from inhaled treprostinil to oral selexipag in pulmonary arterial hypertension: Results from the TRANSIT-1 study.

BACKGROUND: A long-term trial showed that the oral prostacyclin (PGl2) receptor (IP) agonist, selexipag, delayed disease progression in patients with pulmonary arterial hypertension (PAH). Transition to selexipag in patients treated with more burdensome inhaled therapies that target the prostacyclin pathway may be considered by patients and physicians. The Phase 3b, prospective, open-label TRANSIT-1 (Tolerability and Safety of the Transition From Inhaled Treprostinil to Oral Selexipag in Patients With Pulmonary Arterial Hypertension) study evaluated the safety and tolerability of transition from inhaled treprostinil to oral selexipag. METHODS: Patients receiving non-prostanoid oral PAH therapy and inhaled treprostinil at stable doses, in World Health Organization Functional Class II/III, with 6-minute walk distance ≥ 300 meters were enrolled. The 16-week main treatment period included downtitration of inhaled treprostinil over 8 weeks and parallel uptitration of selexipag over 12 weeks. Sustained treatment transition at Week 16 was defined as (1) receiving selexipag at Week 16; (2) no selexipag interruption(s) totaling ≥ 8 days; and (3) no inhaled treprostinil or other prostanoids after Week 8. Clinical parameters and patient-reported treatment satisfaction outcomes were assessed at Week 16. RESULTS: All 34 enrolled patients completed the study. At Week 16, 32 patients (94.1%) had stopped inhaled treprostinil and were receiving selexipag. Twenty-eight patients (82.4%) met all criteria for sustained treatment transition. During the study, 3 patients discontinued selexipag due to adverse events. Overall, most adverse events were typical of prostanoid therapies and started during the uptitration phase. In general, patients remained clinically stable throughout treatment and reported improved convenience. CONCLUSIONS: Transition to oral selexipag from inhaled treprostinil in PAH patients was successful and well tolerated in most patients, and associated with greater convenience. CLINICAL TRIAL NUMBER: NCT02471183.

Successful Thoracic Duct Ligation for Plastic Bronchitis in an Adult.

Plastic bronchitis is a rare and potentially life-threatening disease characterized by the development of obstructive fibrinous tracheobronchial casts and hypoxic respiratory failure. With its poorly understood cause and rare occurrence in the adult population, few treatment strategies have been described in adults with this condition. In this report, we present a case of successful treatment of an adult with plastic bronchitis, using thoracic duct ligation and resulting in full resolution of airway cast development.

Respiratory Complication in Liver Disease.

Cirrhosis, the twelfth leading cause of death, accounts for 1.1% of all deaths in the United States. Although there are multiple pulmonary complications associated with liver disease, the most important complications that cause significant morbidity and mortality are hepatopulmonary syndrome, hepatic hydrothorax, and portopulmonary hypertension. Patients with cirrhosis who complain of dyspnea should be evaluated for these complications. This article reviews these complications.

Tricuspid annular plane systolic excursion is a robust outcome measure in systemic sclerosis-associated pulmonary arterial hypertension.

OBJECTIVE: The tricuspid annular plane systolic excursion (TAPSE) strongly reflects right ventricular (RV) function and predicts survival in idiopathic pulmonary arterial hypertension (PAH). But its role in systemic sclerosis (SSc)-associated PAH has not been established. Our objective was to validate the TAPSE in the assessment of RV function and prediction of survival in SSc-PAH. METHODS: Fifty consecutive patients with SSc-PAH who underwent echocardiography with TAPSE measurement within 1 h of clinically indicated right heart catheterization were followed prospectively. The relationship between TAPSE and measures of RV function and measures of survival was assessed. RESULTS: The majority of the cohort were women in New York Heart Association class III/IV with severe PAH (mean cardiac index 2.4 ± 0.8 l/min/m(2)). RV function was significantly impaired (mean cardiac index 2.1 ± 0.7 vs 2.9 ± 0.8 l/min/m(2); p < 0.01) and RV afterload was significantly greater (mean pulmonary vascular resistance 11.1 ± 5.1 vs 5.8 ± 2.5 Wood units; p < 0.01) in subjects with a TAPSE ≤ 1.7 cm. The proportion surviving in the low TAPSE group was significantly lower [0.56 (95% CI 0.37-0.71) and 0.46 (95% CI 0.28-0.62) vs 0.87 (95% CI 0.55-0.96) and 0.79 (95% CI 0.49-0.93), 1- and 2-year survival, respectively]. TAPSE ≤ 1.7 cm conferred a nearly 4-fold increased risk of death (HR 3.81, 95% CI 1.31-11.1, p < 0.01). CONCLUSION: TAPSE is a robust measure of RV function and strongly predicts survival in patients with PAH-SSc. Future studies are needed to identify the responsiveness of TAPSE to PAH-specific therapy and to assess its diagnostic utility in PAH-SSc.