Utilization and safety of off-label prothrombin complex concentrate (four-factor prothrombin complex concentrate) in a surgical population.

The aim of this study is to evaluate and describe the utilization and safety of 4F-PCC in a nonanticoagulated, surgical patient population at an academic, tertiary care center. This retrospective, single-center chart review evaluated nonanticoagulated adult patients at least 18 years of age who had at least one dose of 4F-PCC administered between 1 January 2017 and 30 September 2022 for a surgical or peri-procedural indication. Hemostatic efficacy following 4F-PCC administration was the primary outcome, assessed by subsequent blood product administration and hemoglobin and hematocrit reduction. Secondary outcomes included an assessment of thrombotic events within 30 days post-4F-PCC administration, in-hospital mortality, and the length of hospital stay. A total of 71 patients met the inclusion criteria, with 61 patients receiving 4F-PCC for cardiac surgery and 10 patients for other intraoperative or peri-procedural indications. The mean total 4F-PCC dose was 25.0 U/kg. For the primary outcome of hemostatic efficacy, 81% of patients had excellent hemostasis; however, blood product administration was reported in 95.8% of patients post-4F-PCC. Thromboembolic events occurred in 10 (14.1%) patients and 21.1% of patients expired prior to discharge in the total cohort. Off-label 4F-PCC use in nonanticoagulated patients is reported despite a lack of robust guidance for use. Following 4F-PCC administration, hemostatic efficacy based on hemoglobin and hematocrit changes was observed; however, blood product use was frequent, and 4F-PCC administration was not without risks, including thromboembolic complications such deep vein thrombosis (DVT), pulmonary embolism, and stroke. Further studies are needed to validate the off-label administration of 4F-PCC in nonanticoagulated patients.

Utilization and safety of off-label prothrombin complex concentrate (4F-PCC) in a nonsurgical population.

The aim of this study was to evaluate and describe the utilization and safety of 4F-PCC in a nonanticoagulated, nonsurgical patient population at an academic, tertiary care center. This retrospective, single-center chart review evaluated nonanticoagulated adult patients at least 18 years of age who had at least one dose of 4F-PCC administered between January 1, 2017, and September 30, 2022, for a nonsurgical indication. Hemostatic efficacy following 4F-PCC administration was the primary outcome, and secondary outcomes included an assessment of blood product administration, thrombotic events within 30 days post4F-PCC administration, in-hospital mortality, and the length of hospital stay. A total of 59 patients met the inclusion criteria, and 10 patients received 4F-PCC for coagulopathy associated with liver disease, 34 for intracranial hemorrhage (ICH), and 15 for other indications. For the primary outcome of hemostatic efficacy, 17 non-ICH patients (85%) had achieved hemostasis post-4F-PCC, and among the ICH patient population, 18 (64%) did not show expansion on repeat CT post4F-PCC, suggesting hemostasis. Blood product and hemostatic agent usage was frequent, with 72.9% of patients requiring products post-4F-PCC. Acute thromboembolic events occurred in six patients (10.2%), and in-hospital mortality occurred in 55.9% of patients. Off-label 4F-PCC use is common despite a lack of robust guidance for use. Following 4F-PCC administration, blood product use was frequent, the incidence of in-hospital mortality was high, and thromboembolic complications such deep vein thrombosis (DVT), pulmonary embolism (PE), and stroke were reported. Further studies are needed to validate the off-label administration of 4F-PCC in nonanticoagulated patients.

The social anatomy of climate change denial in the United States.

Using data from Twitter (now X), this study deploys artificial intelligence (AI) and network analysis to map and profile climate change denialism across the United States. We estimate that 14.8% of Americans do not believe in climate change. This denialism is highest in the central and southern U.S. However, it also persists in clusters within states (e.g., California) where belief in climate change is high. Political affiliation has the strongest correlation, followed by level of education, COVID-19 vaccination rates, carbon intensity of the regional economy, and income. The analysis reveals how a coordinated social media network uses periodic events, such as cold weather and climate conferences, to sow disbelief about climate change and science, in general. Donald Trump was the strongest influencer in this network, followed by conservative media outlets and right-wing activists. As a form of knowledge vulnerability, climate denialism renders communities unprepared to take steps to increase resilience. As with other forms of misinformation, social media companies (e.g., X, Facebook, YouTube, TikTok) should flag accounts that spread falsehoods about climate change and collaborate on targeted educational campaigns.

Scale up urban agriculture to leverage transformative food systems change, advance social-ecological resilience and improve sustainability.

Scaling up urban agriculture could leverage transformative change, to build and maintain resilient and sustainable urban systems. Current understanding of drivers, processes and pathways for scaling up urban agriculture, however, remains fragmentary and largely siloed in disparate disciplines and sectors. Here we draw on multiple disciplinary domains to present an integrated conceptual framework of urban agriculture and synthesize literature to reveal its social-ecological effects across scales. We demonstrate plausible multi-phase developmental pathways, including dynamics, accelerators and feedback associated with scaling up urban agriculture. Finally, we discuss key considerations for scaling up urban agriculture, including diversity, heterogeneity, connectivity, spatial synergies and trade-offs, nonlinearity, scale and polycentricity. Our framework provides a transdisciplinary roadmap for policy, planning and collaborative engagement to scale up urban agriculture and catalyse transformative change towards more robust urban resilience and sustainability.

Deforestation, certification, and transnational palm oil supply chains: Linking Guatemala to global consumer markets.

Although causal links between tropical deforestation and palm oil are well established, linking this land use change to where the palm oil is actually consumed remains a distinct challenge and research gap. Supply chains are notoriously difficult to track back to their origin (i.e., the 'first-mile'). This poses a conundrum for corporations and governments alike as they commit to deforestation-free sourcing and turn to instruments like certification to increase supply chain transparency and sustainability. The Roundtable on Sustainable Palm Oil (RSPO) offers the most influential certification system in the sector, but whether it actually reduces deforestation is still unclear. This study used remote sensing and spatial analysis to assess the deforestation (2009-2019) caused by oil palm plantation expansion in Guatemala, a major palm oil source for international consumer markets. Our results reveal that plantations are responsible for 28% of deforestation in the region and that more than 60% of these plantations encroach on Key Biodiversity Areas. RSPO-certified plantations, comprising 63% of the total cultivated area assessed, did not produce a statistically significant reduction in deforestation. Using trade statistics, the study linked this deforestation to the palm oil supply chains of three transnational conglomerates - Pepsico, Mondelez International, and Grupo Bimbo - all of whom rely on RSPO-certified supplies. Addressing this deforestation and supply chain sustainability challenge hinges on three measures: 1) reform of RSPO policies and practices; 2) robust corporate tracking of supply chains; and 3) strengthening forest governance in Guatemala. This study offers a replicable methodology for a wide-range of investigations that seek to understand the transnational linkages between environmental change (e.g. deforestation) and consumption.

Food production and resource use of urban farms and gardens: a five-country study.

There is a lack of data on resources used and food produced at urban farms. This hampers attempts to quantify the environmental impacts of urban agriculture or craft policies for sustainable food production in cities. To address this gap, we used a citizen science approach to collect data from 72 urban agriculture sites, representing three types of spaces (urban farms, collective gardens, individual gardens), in five countries (France, Germany, Poland, United Kingdom, and United States). We answered three key questions about urban agriculture with this unprecedented dataset: (1) What are its land, water, nutrient, and energy demands? (2) How productive is it relative to conventional agriculture and across types of farms? and (3) What are its contributions to local biodiversity? We found that participant farms used dozens of inputs, most of which were organic (e.g., manure for fertilizers). Farms required on average 71.6 L of irrigation water, 5.5 L of compost, and 0.53 m2 of land per kilogram of harvested food. Irrigation was lower in individual gardens and higher in sites using drip irrigation. While extremely variable, yields at well-managed urban farms can exceed those of conventional counterparts. Although farm type did not predict yield, our cluster analysis demonstrated that individually managed leisure gardens had lower yields than other farms and gardens. Farms in our sample contributed significantly to local biodiversity, with an average of 20 different crops per farm not including ornamental plants. Aside from clarifying important trends in resource use at urban farms using a robust and open dataset, this study also raises numerous questions about how crop selection and growing practices influence the environmental impacts of growing food in cities. We conclude with a research agenda to tackle these and other pressing questions on resource use at urban farms. Supplementary Information: The online version contains supplementary material available at 10.1007/s13593-022-00859-4.

Where does your guacamole come from? Detecting deforestation associated with the export of avocados from Mexico to the United States.

The United States (U.S.) imports 87 percent of its avocados from a single Mexican region, Michoacán. Although environmental and social costs associated with avocado production are significant, consumers and retailers in the U.S. cannot clearly discern them in part due to complex, opaque supply chains. In this paper, we use a novel methodology, TRAcking Corporations Across Space and Time (TRACAST), to reconstruct avocado supply chains between the U.S. retailers and Mexican producers and exporters. Using remote sensing and machine learning, we document how avocado plantations are associated with deforestation in Michoacán, whose forests are important reservoirs for biodiversity, especially for the Monarch butterfly (Danaus plexippus). We estimate that ~20% of the total deforestation in Michoacán between 2001 and 2017 is associated with the expansion of avocado plantations. Despite these impacts, interviews reveal that industry associates (namely, representatives of firms and associations) do not consider avocado production to be a driver of deforestation in the region. This disconnect between actual and perceived environmental impacts can be addressed by the U.S. governmental agencies that play influential roles in regulating avocado imports for sanitary and health purposes and by the vertically integrated avocado trading firms that connect Michoacán packing houses to Kroger, Costco, and other prominent U.S. grocers. Key measures to make the U.S.-Mexico avocado supply chain more sustainable include conventional regulatory tools, greater transparency, and improved governance through multi-stakeholder initiatives.

The carbon footprint of household energy use in the United States.

Residential energy use accounts for roughly 20% of greenhouse gas (GHG) emissions in the United States. Using data on 93 million individual households, we estimate these GHGs across the contiguous United States and clarify the respective influence of climate, affluence, energy infrastructure, urban form, and building attributes (age, housing type, heating fuel) in driving these emissions. A ranking by state reveals that GHGs (per unit floor space) are lowest in Western US states and highest in Central states. Wealthier Americans have per capita footprints ∼25% higher than those of lower-income residents, primarily due to larger homes. In especially affluent suburbs, these emissions can be 15 times higher than nearby neighborhoods. If the electrical grid is decarbonized, then the residential housing sector can meet the 28% emission reduction target for 2025 under the Paris Agreement. However, grid decarbonization will be insufficient to meet the 80% emissions reduction target for 2050 due to a growing housing stock and continued use of fossil fuels (natural gas, propane, and fuel oil) in homes. Meeting this target will also require deep energy retrofits and transitioning to distributed low-carbon energy sources, as well as reducing per capita floor space and zoning denser settlement patterns.

Quantifying the Urban Food-Energy-Water Nexus: The Case of the Detroit Metropolitan Area.

The efficient provision of food, energy, and water (FEW) resources to cities is challenging around the world. Because of the complex interdependence of urban FEW systems, changing components of one system may lead to ripple effects on other systems. However, the inputs, intersectoral flows, stocks, and outputs of these FEW resources from the perspective of an integrated urban FEW system have not been synthetically characterized. Therefore, a standardized and specific accounting method to describe this system is needed to sustainably manage these FEW resources. Using the Detroit Metropolitan Area (DMA) as a case, this study developed such an accounting method by using material and energy flow analysis to quantify this urban FEW nexus. Our results help identify key processes for improving FEW resource efficiencies of the DMA. These include (1) optimizing the dietary habits of households to improve phosphorus use efficiency, (2) improving effluent-disposal standards for nitrogen removal to reduce nitrogen emission levels, (3) promoting adequate fertilization, and (4) enhancing the maintenance of wastewater collection pipelines. With respect to water use, better efficiency of thermoelectric power plants can help reduce water withdrawals. The method used in this study lays the ground for future urban FEW analyses and modeling.

Safety and Efficiency of Intravenous Push Lacosamide Administration.

BACKGROUND/OBJECTIVE: Intravenous (IV) lacosamide use for status epilepticus has increased in recent years and is recommended for refractory status epilepticus by current guidelines. Per the lacosamide package labeling, the preferred route of administration is diluted and infused over 30-60 min; however, administration undiluted is also acceptable and recent literature demonstrated safety at a maximum rate of 80 mg per minute (Kellinghaus et al. in Acta Neurol Scand 123:137-141, 2011). Undiluted administration as an IV push has potential to increase efficiency of administration to patients needing urgent seizure control since it may be dispensed from automatic dispensing cabinets in patient care areas. This study aims to compare safety outcomes and efficiency of administration in patients receiving lacosamide IV push compared to IV piggyback. METHODS: We present a single-center, retrospective cohort study of patients receiving lacosamide via IV piggyback or IV push from June 2016 to July 2017. Baseline characteristics, data related to potential safety concerns and timing of ordering, verification, and administration were collected. The primary safety outcomes were incidence of infusion site reactions, hypotension (systolic blood pressure [SBP] < 90 mm Hg), and bradycardia (heart rate [HR] < 50 beats per minute) documented within 2 h of each lacosamide dose. Secondary safety outcomes included the incidence of PR interval prolongation in patients with at least one electrocardiogram measured. The primary efficiency outcome was the time between order verification and administration. RESULTS: Patients in the IV piggyback (n = 88) and IV push (n = 78) groups had similar baseline characteristics, initial dose, SBP, and HR. Hypotension (8 vs. 10.3%) and bradycardia (2.3 vs. 2.6%) rates were similar among both groups (p > 0.05). Only one patient in each group had documented PR prolongation, and no documented infusion reactions occurred. Median time from order verification to administration was significantly reduced in the IV push group (35 min vs. 1 h 49 min; p < 0.001). CONCLUSIONS: Administration of lacosamide via IV push results in similar adverse effect rates to IV piggyback preparations with more efficient time to administration.

Use of Aerosolized Antibiotics in Gram-Negative Ventilator-Associated Pneumonia in Trauma Patients.

Ventilator-associated pneumonia (VAP) is associated with significant morbidity (ventilator days, ICU days, and cost) and mortality increase in trauma patients. Multidrug-resistant strains of causative VAP pathogens are becoming increasingly common. Aerosolized antibiotics achieve high alveolar concentrations and provide valuable adjuncts in the treatment of VAP. This study examined the impact of aerosolized antibiotics in the treatment of VAP in trauma patients. Patients with either Acinetobacter baumannii or Pseudomonas aeruginosa VAP over 10 years treated with aerosolized antibiotics (cases) were stratified by age, severity of shock, and injury severity. A frequency-matched (by causative pathogen) control group treated without aerosolized antibiotics was used for comparison. Multivariable logistic regression was used to identify predictors for the use of aerosolized antibiotics. One hundred twenty VAP episodes were identified in 100 patients. Microbiologic resolution was achieved in all patients treated with aerosolized antibiotics. There was no difference in mortality (14.5% vs 15.7%, P = 0.87) and no antibiotic-related complications in either group. Multivariable logistic regression identified VAP persistence and relapse as independent predictors for the use of aerosolized antibiotics. Combined with systemic therapy, aerosolized antibiotics broaden the spectrum of therapy. They are valuable adjuncts with minimal risk of antibiotic resistance and/or systemic complications.

A Mixed Application of Geographically Weighted Regression and Unsupervised Classification for Analyzing Latex Yield Variability in Yunnan, China.

This paper introduces a mixed method approach for analyzing the determinants of natural latex yields and the associated spatial variations and identifying the most suitable regions for producing latex. Geographically Weighted Regressions (GWR) and Iterative Self-Organizing Data Analysis Technique (ISODATA) are jointly applied to the georeferenced data points collected from the rubber plantations in Xishuangbanna (in Yunnan province, south China) and other remotely-sensed spatial data. According to the GWR models, Age of rubber tree, Percent of clay in soil, Elevation, Solar radiation, Population, Distance from road, Distance from stream, Precipitation, and Mean temperature turn out statistically significant, indicating that these are the major determinants shaping latex yields at the prefecture level. However, the signs and magnitudes of the parameter estimates at the aggregate level are different from those at the lower spatial level, and the differences are due to diverse reasons. The ISODATA classifies the landscape into three categories: high, medium, and low potential yields. The map reveals that Mengla County has the majority of land with high potential yield, while Jinghong City and Menghai County show lower potential yield. In short, the mixed method can offer a means of providing greater insights in the prediction of agricultural production.

The 'Geographic Emission Benchmark' model: a baseline approach to measuring emissions associated with deforestation and degradation.

This paper proposes a new land-change model, the Geographic Emission Benchmark (GEB), as an approach to quantify land-cover changes associated with deforestation and forest degradation. The GEB is designed to determine 'baseline' activity data for reference levels. Unlike other models that forecast business-as-usual future deforestation, the GEB internally (1) characterizes 'forest' and 'deforestation' with minimal processing and ground-truthing and (2) identifies 'deforestation hotspots' using open-source spatial methods to estimate regional rates of deforestation. The GEB also characterizes forest degradation and identifies leakage belts. This paper compares the accuracy of GEB with GEOMOD, a popular land-change model used in the UN-REDD (Reducing Emissions from Deforestation and Forest Degradation) Program. Using a case study of the Chinese tropics for comparison, GEB's projection is more accurate than GEOMOD's, as measured by Figure of Merit. Thus, the GEB produces baseline activity data that are moderately accurate for the setting of reference levels.

Factors predicting the capacity of Los Angeles city-region recreation programs to promote energy expenditure.

An audit of recreation programs with moderate or higher levels of physical activity (PA) in Los Angeles area cities (N=82) was conducted using internet, telephone, and survey methods. Metabolic Equivalents (METs) were used to code programs׳ physical activity intensity. MET-hours per recreation program was associated with required age for enrollment, percent of residents >64 years of age, and fiscal capacity of cities. Capacity to promote energy expenditure may depend on targeted age groups, age of population, and municipal fiscal capacity. Cities with lower fiscal capacity might offer those higher MET-hour activities which require less specialized equipment and seek outside funding to offer higher MET programs.