Identifying leverage points for sustainable nutrient policy integration in Canada.

Addressing the 'wicked problem' of nutrient pollution requires coordinated policies spanning across diverse sectors and environmental systems. Using a case study of Canadian legislation, we apply semantic network analysis to identify thematic links across an inventory of 245 nutrient-related policies. Our analysis identifies twelve topics with unique types of connections across multiple facets of Canadian society. 'Hub' policies include broad environmental protection, land use planning, and climate-related legislation with close ties to multiple other topics. 'Bridge' policies create connections among otherwise disconnected topics in the network, representing opportunities to inform new policy proposals. Some legislation, such as food processing regulations, indirectly relates to nutrient use but could inform policy integration towards more coordinated and holistic nutrient management across the food system. A computational text network approach can be useful for addressing challenges in complex policy analysis, including by identifying unique entry points to guide more cross-cutting nutrient policy development.

Research needs for a food system transition.

The global food system, and animal agriculture in particular, is a major and growing contributor to climate change, land system change, biodiversity loss, water consumption and contamination, and environmental pollution. The copious production and consumption of animal products are also contributing to increasingly negative public health outcomes, particularly in wealthy and rapidly industrializing countries, and result in the slaughter of trillions of animals each year. These impacts are motivating calls for reduced reliance on animal-based products and increased use of replacement plant-based products. However, our understanding of how the production and consumption of animal products, as well as plant-based alternatives, interact with important dimensions of human and environment systems is incomplete across space and time. This inhibits comprehensively envisioning global and regional food system transitions and planning to manage the costs and synergies thereof. We therefore propose a cross-disciplinary research agenda on future target-based scenarios for food system transformation that has at its core three main activities: (1) data collection and analysis at the intersection of animal agriculture, the environment, and societal well-being, (2) the construction of target-based scenarios for animal products informed by these new data and empirical understandings, and (3) the evaluation of impacts, unintended consequences, co-benefits, and trade-offs of these target-based scenarios to help inform decision-making.

Federated benchmarking of medical artificial intelligence with MedPerf.

Medical artificial intelligence (AI) has tremendous potential to advance healthcare by supporting and contributing to the evidence-based practice of medicine, personalizing patient treatment, reducing costs, and improving both healthcare provider and patient experience. Unlocking this potential requires systematic, quantitative evaluation of the performance of medical AI models on large-scale, heterogeneous data capturing diverse patient populations. Here, to meet this need, we introduce MedPerf, an open platform for benchmarking AI models in the medical domain. MedPerf focuses on enabling federated evaluation of AI models, by securely distributing them to different facilities, such as healthcare organizations. This process of bringing the model to the data empowers each facility to assess and verify the performance of AI models in an efficient and human-supervised process, while prioritizing privacy. We describe the current challenges healthcare and AI communities face, the need for an open platform, the design philosophy of MedPerf, its current implementation status and real-world deployment, our roadmap and, importantly, the use of MedPerf with multiple international institutions within cloud-based technology and on-premises scenarios. Finally, we welcome new contributions by researchers and organizations to further strengthen MedPerf as an open benchmarking platform.

Exploring Trade-Offs Between Profit, Yield, and the Environmental Footprint of Potential Nitrogen Fertilizer Regulations in the US Midwest.

Multiple strategies are available that could reduce nitrogen (N) fertilizer use in agricultural systems, ranging from voluntary adoption of new N management practices by farmers to government regulations. However, these strategies have different economic and political costs, and their relative effectiveness in decreasing N leaching has not been evaluated at scale, particularly concerning potential trade-offs in crop yield and profitability. To inform policy efforts in the US Midwest, we quantified the effects of four policy scenarios designed to reduce fertilizer N inputs without sacrificing maize yields below 95%. A simulated dataset for economically optimum N rates and corresponding leaching losses was developed using a process-based crop model across 4,030 fields over 30 years. Policy scenarios were (1) higher N prices, (2) N leaching fee, (3) N balance fee, and (4) voluntary reduction of N use by farmers, each implemented under a range of sub-levels (low to high severity). Aggregated results show that all policies decreased N rates and N leaching, but this was associated with an exponential increase in economic costs. Achieving an N leaching reduction target of 20% has an estimated pollution control cost of 30-37 US$/ha, representing 147 million US$/year when scaled up to the state level, which is in the range of current government payments for existing conservation programs. Notably, such control of N losses would reduce the environmental impact of agriculture on water quality (externalities) by an estimated 524 million US$/year, representing an increase in society welfare of 377 million US$/year. Among the four policies, directly charging a fee on N leaching helped mitigate economic losses while improving the point source reduction effect (i.e., targeting fields that were leaching hotspots) and better internalization effect (i.e., targeting fields with higher environmental impact costs). This study provides actionable data to inform the development of cost-effective N fertilizer regulations by integrating changes in crop productivity and N losses in economic terms at the field level.

Corrigendum: Exploring trade-offs between profit, yield, and the environmental footprint of potential nitrogen fertilizer regulations in the US Midwest.

[This corrects the article DOI: 10.3389/fpls.2022.852116.].

Fertilizer overuse in Chinese smallholders due to lack of fixed inputs.

Fertilizer overuse by smallholder farmers is widespread in China, leading to significant financial losses and threatening the environment. Understanding what mechanism behind this is critical for agricultural and environmental sustainability. By using a fixed effect panel model of over 20,000 rural households in China from 1995 to 2016, we found that the low ratio of fixed inputs such as machinery and knowledge to total inputs is the key factor leading to over-fertilization in smallholder farms. Low fixed input can result in or interact with nutrient-unbalanced fertilization, low agricultural income ratio and more cash crops that further aggravate fertilizer overuse. Smallholders lack fixed inputs, then compensate by over-applying fertilizer to attempt to achieve their yield goals. Thus, improving fixed input via increasing the average farm size to 3.8 ha or advanced service rental could save not only 45% fertilizers but also increase 16% agricultural net profit, benefiting agricultural and environmental sustainability.

Implications of a food system approach for policy agenda-setting design.

A call to governments to enact a strategy for a sustainable food system is high on the global agenda. A sustainable food system presupposes a need to go beyond a view of the food system as linear and narrow, to comprehend the food system as dynamic and interlinked, which involves understanding social, economic and ecological outcomes and feedbacks of the system. As such, it should be accompanied by strategic, collaborative, transparent, inclusive, and reflexive agenda-setting process. The concepts of, directionality relating to an agreed vision for a future sustainable food system, and, reflexivity which describes the capacity for critical deliberation and responsiveness, are particularly important. Based on those concepts, this paper proposes an evaluative framework to assess tools and instruments applied during the agenda-setting stage. We apply the evaluative framework to recent food policy processes in Finland and Sweden, revealing that their agenda-setting design cannot be assessed as fully addressing both directionality and reflexivity, thus possibly falling short of the policy design needed for enable more transformative policy approaches.

Global mapping of crop-specific emission factors highlights hotspots of nitrous oxide mitigation.

Mitigating soil nitrous oxide (N2O) emissions is essential for staying below a 2 °C warming threshold. However, accurate assessments of mitigation potential are limited by uncertainty and variability in direct emission factors (EFs). To assess where and why EFs differ, we created high-resolution maps of crop-specific EFs based on 1,507 georeferenced field observations. Here, using a data-driven approach, we show that EFs vary by two orders of magnitude over space. At global and regional scales, such variation is primarily driven by climatic and edaphic factors rather than the well-recognized management practices. Combining spatially explicit EFs with N surplus information, we conclude that global mitigation potential without compromising crop production is 30% (95% confidence interval, 17-53%) of direct soil emissions of N2O, equivalent to the entire direct soil emissions of China and the United States combined. Two-thirds (65%) of the mitigation potential could be achieved on one-fifth of the global harvested area, mainly located in humid subtropical climates and across gleysols and acrisols. These findings highlight the value of a targeted policy approach on global hotspots that could deliver large N2O mitigation as well as environmental and food co-benefits.

Health promotion and preventive health care service guidelines for the care of people with spina bifida.

Individuals with Spina Bifida (SB) have unique lifelong medical and social needs. Thus, when considering how to promote health and offer preventive care, providers must adapt general healthcare screening and counseling recommendations to their patients' physical and cognitive impairments along with discerning how to monitor secondary or chronic conditions common to the population. This article provides an update on the health promotion and preventive health care guidelines developed as part of the Spina Bifida Association's fourth edition of the Guidelines for the Care of People with Spina Bifida. The guidelines highlight accommodations needed to promote general preventive health, common secondary/chronic conditions such as obesity, metabolic syndrome, hypertension, musculoskeletal pain, and considerations for preventing acute care utilization for the SB population throughout the lifespan. Further research is needed to understand the effectiveness of preventive care interventions in promoting positive health outcomes and mitigating potentially preventable acute care utilization.

Nitrogen futures in the shared socioeconomic pathways 4.

Humanity's transformation of the nitrogen cycle has major consequences for ecosystems, climate and human health, making it one of the key environmental issues of our time. Understanding how trends could evolve over the course of the 21st century is crucial for scientists and decision-makers from local to global scales. Scenario analysis is the primary tool for doing so, and has been applied across all major environmental issues, including nitrogen pollution. However, to date most scenario efforts addressing nitrogen flows have either taken a narrow approach, focusing on a singular impact or sector, or have not been integrated within a broader scenario framework - a missed opportunity given the multiple environmental and socio-economic impacts that nitrogen pollution exacerbates. Capitalizing on our expanding knowledge of nitrogen flows, this study introduces a framework for new nitrogen-focused narratives based on the widely used Shared Socioeconomic Pathways that include all the major nitrogen-polluting sectors (agriculture, industry, transport and wastewater). These new narratives are the first to integrate the influence of climate and other environmental pollution control policies, while also incorporating explicit nitrogen-control measures. The next step is for them to be used as model inputs to evaluate the impact of different nitrogen production, consumption and loss trajectories, and thus advance understanding of how to address environmental impacts while simultaneously meeting key development goals. This effort is an important step in assessing how humanity can return to the planetary boundary of this essential element over the coming century.

The influence of red blood cell deformability on hematocrit profiles and platelet margination.

The influence of red blood cell (RBC) deformability in whole blood on platelet margination is investigated using confocal microscopy measurements of flowing human blood and cell resolved blood flow simulations. Fluorescent platelet concentrations at the wall of a glass chamber are measured using confocal microscopy with flowing human blood containing varying healthy-to-stiff RBC fractions. A decrease is observed in the fluorescent platelet signal at the wall due to the increase of stiffened RBCs in flow, suggesting a decrease of platelet margination due to an increased fraction of stiffened RBCs present in the flow. In order to resolve the influence of stiffened RBCs on platelet concentration at the channel wall, cell-pair and bulk flow simulations are performed. For homogeneous collisions between RBC pairs, a decrease in final displacement after a collision with increasing membrane stiffness is observed. In heterogeneous collisions between healthy and stiff RBC pairs, it is found that the stiffened RBC is displaced most. The influence of RBC deformability on collisions between RBCs and platelets was found to be negligible due to their size and mass difference. For a straight vessel geometry with varying healthy-to-stiff RBC ratios, a decrease was observed in the red blood cell-free layer and platelet margination due to an increase in stiffened RBCs present in flow.

Pediatric Application of Coding and Valuation Systems.

The American Academy of Pediatrics provides this revised policy statement to address health care changes that impact procedural and visit coding and valuation as well as the incorporation of coding principles into innovative, newer payment models. This policy statement focuses solely on recommendations, and an accompanying technical report provides supplemental coding and valuation background.

Pediatric Application of Coding and Valuation Systems.

The American Academy of Pediatrics provides this technical report as supplemental background to the accompanying coding and valuation system policy statement. The rapid evolution in health care payment modeling requires that clinicians have a current appreciation of the mechanics of service representation and valuation. The accompanying policy statement provides recommendations relevant to this area, and this technical report provides a format to outline important concepts that allow for effective translation of bedside clinical events into physician payment.

Dietary Intervention for Overweight and Obese Adults: Comparison of Low-Carbohydrate and Low-Fat Diets. A Meta-Analysis.

BACKGROUND: Reduced calorie, low fat diet is currently recommended diet for overweight and obese adults. Prior data suggest that low carbohydrate diets may also be a viable option for those who are overweight and obese. PURPOSE: Compare the effects of low carbohydrate versus low fats diet on weight and atherosclerotic cardiovascular disease risk in overweight and obese patients. DATA SOURCES: Systematic literature review via PubMed (1966-2014). STUDY SELECTION: Randomized controlled trials with ≥8 weeks follow up, comparing low carbohydrate (≤120gm carbohydrates/day) and low fat diet (≤30% energy from fat/day). DATA EXTRACTION: Data were extracted and prepared for analysis using double data entry. Prior to identification of candidate publications, the outcomes of change in weight and metabolic factors were selected as defined by Cochrane Collaboration. Assessment of the effects of diets on predicted risk of atherosclerotic cardiovascular disease risk was added during the data collection phase. DATA SYNTHESIS: 1797 patients were included from 17 trials with <1 year follow up in 12. Compared with low fat diet, low carbohydrate was associated with significantly greater reduction in weight (Δ = -2.0 kg, 95% CI: -3.1, -0.9) and significantly lower predicted risk of atherosclerotic cardiovascular disease events (p<0.03). Frequentist and Bayesian results were concordant. The probability of greater weight loss associated with low carbohydrate was >99% while the reduction in predicted risk favoring low carbohydrate was >98%. LIMITATIONS: Lack of patient-level data and heterogeneity in dropout rates and outcomes reported. CONCLUSIONS: This trial-level meta-analysis of randomized controlled trials comparing LoCHO diets with LoFAT diets in strictly adherent populations demonstrates that each diet was associated with significant weight loss and reduction in predicted risk of ASCVD events. However, LoCHO diet was associated with modest but significantly greater improvements in weight loss and predicted ASCVD risk in studies from 8 weeks to 24 months in duration. These results suggest that future evaluations of dietary guidelines should consider low carbohydrate diets as effective and safe intervention for weight management in the overweight and obese, although long-term effects require further investigation.

Reducing Nitrogen Pollution while Decreasing Farmers' Costs and Increasing Fertilizer Industry Profits.

Nitrogen (N) pollution is emerging as one of the most important environmental issues of the 21st Century, contributing to air and water pollution, climate change, and stratospheric ozone depletion. With agriculture being the dominant source, we tested whether it is possible to reduce agricultural N pollution in a way that benefits the environment, reduces farmers' costs, and increases fertilizer industry profitability, thereby creating a "sweet spot" for decision-makers that could significantly increase the viability of improved N management initiatives. Although studies of the economic impacts of improved N management have begun to take into account farmers and the environment, this is the first study to consider the fertilizer industry. Our "sweet spot" hypothesis is evaluated via a cost-benefit analysis of moderate and ambitious N use efficiency targets in U.S. and China corn sectors over the period 2015-2035. We use a blend of publicly available crop and energy price projections, original time-series modeling, and expert elicitation. The results present a mixed picture: although the potential for a "sweet spot" exists in both countries, it is more likely that one occurs in China due to the currently extensive overapplication of fertilizer, which creates a greater potential for farmers and the fertilizer industry to gain economically from improved N management. Nevertheless, the environmental benefits of improving N management consistently dwarf the economic impacts on farmers and the fertilizer industry in both countries, suggesting that viable policy options could include incentives to farmers and the fertilizer industry to increase their support for N management policies.

The economic and environmental consequences of implementing nitrogen-efficient technologies and management practices in agriculture.

Technologies and management practices (TMPs) that reduce the application of nitrogen (N) fertilizer while maintaining crop yields can improve N use efficiency (NUE) and are important tools for meeting the dual challenges of increasing food production and reducing N pollution. However, because farmers operate to maximize their profits, incentives to implement TMPs are limited, and TMP implementation will not always reduce N pollution. Therefore, we have developed the NUE Economic and Environmental impact analytical framework (NUE) to examine the economic and environmental consequences of implementing TMPs in agriculture, with a specific focus on farmer profits, N fertilizer consumption, N losses, and cropland demand. Our analytical analyses show that impact of TMPs on farmers' economic decision-making and the environment is affected by how TMPs change the yield ceiling and the N fertilization rate at the ceiling and by how the prices of TMPs, fertilizer, and crops vary. Technologies and management practices that increase the yield ceiling appear to create a greater economic incentive for farmers than TMPs that do not but may result in higher N application rates and excess N losses. Nevertheless, the negative environmental impacts of certain TMPs could be avoided if their price stays within a range determined by TMP yield response, fertilizer price, and crop price. We use a case study on corn production in the midwestern United States to demonstrate how NUE can be applied to farmers' economic decision-making and policy analysis. Our NUE framework provides an important tool for policymakers to understand how combinations of fertilizer, crop, and TMP prices affect the possibility of achieving win-win outcomes for farmers and the environment.

A post-Kyoto partner: considering the stratospheric ozone regime as a tool to manage nitrous oxide.

Nitrous oxide (N2O) is the largest known remaining anthropogenic threat to the stratospheric ozone layer. However, it is currently only regulated under the 1997 Kyoto Protocol because of its simultaneous ability to warm the climate. The threat N2O poses to the stratospheric ozone layer, coupled with the uncertain future of the international climate regime, motivates our exploration of issues that could be relevant to the Parties to the ozone regime (the 1985 Vienna Convention and its 1987 Montreal Protocol) should they decide to take measures to manage N2O in the future. There are clear legal avenues to regulate N2O under the ozone regime as well as several ways to share authority with the existing and future international climate treaties. N2O mitigation strategies exist to address the most significant anthropogenic sources, including agriculture, where behavioral practices and new technologies could contribute significantly to reducing emissions. Existing policies managing N2O and other forms of reactive nitrogen could be harnessed and built on by the ozone regime to implement N2O controls. There are several challenges and potential cobenefits to N2O control which we discuss here: food security, equity, and implications of the nitrogen cascade. The possible inclusion of N2O in the ozone regime need not be viewed as a sign of failure of the United Nations Framework Convention on Climate Change to adequately deal with climate change. Rather, it could represent an additional valuable tool in sustainable development diplomacy.

Interpreting abnormal proteinuria in pregnancy: the need for a more pathophysiological approach.

This review and opinion article focuses on the definitions and meanings of abnormal protein excretion in pregnancy, asking the following questions: Are our tests to determine abnormal proteinuria adequately performed? Are current guidelines for diagnosis of excessive proteinuria, especially when used to identify preeclampsia, supported by adequate data? Can the magnitude of proteinuria be used as a reliable clinical biomarker of the gravity of preeclampsia? Should timed urine collections, primarily 24-hour excretions, be supplanted by the urine protein/creatinine ratio in clinical practice? The answers to most of these questions are: We are not sure, or some guidelines are poorly supported by data and may prove erroneous. We suggest a more physiologic approach to assessment of proteinuria and believe that if clinicians and investigators looked at proteinuria in terms of how the kidney handles protein in health and disease it would lead to a more rational and evidence-based approach to proteinuria in pregnancy. Finally, we recommend that current cutoff for abnormal proteinuria be used to diagnose preeclampsia, but the level of proteinuria should not guide management. Other variables, such as status of blood pressure control, evidence of increasing organ damage in the liver and hematological systems, evidence of falling glomerular filtration rate, and signs of neurological involvement, are more reliable indicators of severity of preeclampsia.