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.

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.

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.

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.

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.

Global drivers of human pathogen richness and prevalence.

The differences in the richness and prevalence of human pathogens among different geographical locations have ramifying consequences for societies and individuals. The relative contributions of different factors to these patterns, however, have not been fully resolved. We conduct a global analysis of the relative influence of climate, alternative host diversity and spending on disease prevention on modern patterns in the richness and prevalence of human pathogens. Pathogen richness (number of kinds) is largely explained by the number of birds and mammal species in a region. The most diverse countries with respect to birds and mammals are also the most diverse with respect to pathogens. Importantly, for human health, the prevalence of key human pathogens (number of cases) is strongly influenced by disease control efforts. As a consequence, even where disease richness is high, we might still control prevalence, particularly if we spend money in those regions where current spending is low, prevalence is high and populations are large.

Measuring and monitoring illegal use of natural resources.

Illegal use of natural resources is a threat to biodiversity globally, but research on illegal activities has methodological challenges. We examined 100 studies that empirically identify targeted resources, techniques used to procure resources illegally, locations of illegal activities, characteristics of typical violators, incentives driving illegal use of resources, magnitude of the problem of illegal use (e.g., quantities used), or frequency of illegal activity. We based our evaluation of the methods used in these studies on their ability to provide these empirical data, relative labor demands, training and technology requirements, and levels of uncontrollable bias. We evaluated eight different methods: law-enforcement records, indirect observation, self-reporting, direct observation, direct questioning, randomized response technique (a survey method designed to improve accuracy of responses to sensitive questions), forensics, and modeling. Different situations favored different methods, each with distinct advantages and limitations. Six context-specific factors-location of resource use (in situ vs. ex situ), budget, technology and training capacity, ease of detection of illegal activity, scope of illegal activity (limited vs. widespread), and researchers' willingness to accept bias in results-help narrow the choice of methods. Several methodological concerns applied to any study of illegal resource use: regular monitoring can detect trends; modeling can incorporate sampling error and data uncertainties; researchers must manage levels of bias that vary between methods; triangulation of results from multiple methods can improve accuracy. No method is a panacea, but a combination of techniques can help address the lack of data on illegal activity. Researchers empirically compared results from different methods in only four studies, and no one has compared more than two methods simultaneously. Conservation would benefit from more research focused on: methods comparisons that include cost effectiveness, time efficiency, and statistical rigor; unique applications of the eight techniques currently in use; and testing of new methods.

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.

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.