Geoeconomic variations in epidemiology, ventilation management, and outcomes in invasively ventilated intensive care unit patients without acute respiratory distress syndrome: a pooled analysis of four observational studies

Background: Geoeconomic variations in epidemiology, the practice of ventilation, and outcome in invasively ventilated intensive care unit (ICU) patients without acute respiratory distress syndrome (ARDS) remain unexplored. In this analysis we aim to address these gaps using individual patient data of four large observational studies. Methods: In this pooled analysis we harmonised individual patient data from the ERICC, LUNG SAFE, PRoVENT, and PRoVENT-iMiC prospective observational studies, which were conducted from June, 2011, to December, 2018, in 534 ICUs in 54 countries. We used the 2016 World Bank classification to define two geoeconomic regions: middle-income countries (MICs) and high-income countries (HICs). ARDS was defined according to the Berlin criteria. Descriptive statistics were used to compare patients in MICs versus HICs. The primary outcome was the use of low tidal volume ventilation (LTVV) for the first 3 days of mechanical ventilation. Secondary outcomes were key ventilation parameters (tidal volume size, positive end-expiratory pressure, fraction of inspired oxygen, peak pressure, plateau pressure, driving pressure, and respiratory rate), patient characteristics, the risk for and actual development of acute respiratory distress syndrome after the first day of ventilation, duration of ventilation, ICU length of stay, and ICU mortality. Findings: Of the 7608 patients included in the original studies, this analysis included 3852 patients without ARDS, of whom 2345 were from MICs and 1507 were from HICs. Patients in MICs were younger, shorter and with a slightly lower body-mass index, more often had diabetes and active cancer, but less often chronic obstructive pulmonary disease and heart failure than patients from HICs. Sequential organ failure assessment scores were similar in MICs and HICs. Use of LTVV in MICs and HICs was comparable (42\ub74% vs 44\ub72%; absolute difference \u20131\ub769 [\u20139\ub758 to 6\ub711] p=0\ub767; data available in 3174 [82%] of 3852 patients). The median applied positive end expiratory pressure was lower in MICs than in HICs (5 [IQR 5\u20138] vs 6 [5\u20138] cm H2O; p=0\ub70011). ICU mortality was higher in MICs than in HICs (30\ub75% vs 19\ub79%; p=0\ub70004; adjusted effect 16\ub741% [95% CI 9\ub752\u201323\ub752]; p<0\ub70001) and was inversely associated with gross domestic product (adjusted odds ratio for a US$10 000 increase per capita 0\ub780 [95% CI 0\ub775\u20130\ub786]; p<0\ub70001). Interpretation: Despite similar disease severity and ventilation management, ICU mortality in patients without ARDS is higher in MICs than in HICs, with a strong association with country-level economic status. Funding: No funding

Riverine Settlement in the Evolution of Prehistoric Land-Use Systems in the Middle Rio Grande Valley, New Mexico

Ecosystem management should be based on the fullest possible knowledge of ecological structures and processes. In prehistoric North America, the involvement of Indian populations in ecosystem processes ranged from inadvertent alteration of the distribution and abundance of species to large-scale management of landscapes. The knowledge needed to manage ecosystems today is incomplete without understanding past human involvement in ecological processes, and the adjustments of ecosystems to human components. This paper describes changes in prehistoric land use in part of the Middle Rio Grande Valley, New Mexico. Processes of economic change, land-use intensification, and regional abandonment suggest that there were periods of significant prehistoric disturbance to both upland and valley ecosystems

Introduction: Prehistoric Societies as Evolving Complex Systems

This chapter discusses some topics of significance in understanding cultural complexity. Cultural complexity is different in some respects from complexity in other living systems, and is perhaps more enigmatic. The development of cultural complexity is an economic process: complexity levies costs and yields benefits. The fact that complexity is a benefit/cost equation influences cultural evolution in at least two major ways. The first is that the cost of becoming more complex must always have tended to inhibit the development of cultural complexity. The economic nature of cultural complexity influences human history in a second way: investment in increasing complexity can reach the point of diminishing returns. The cumulative total of cultural changes, many of which were reversible only under great hardship, comprises the evolution of Southwestern societies from small foraging bands to sedentary pueblo communities and regional networks. The chapter also presents an overview of the key concepts discussed in this book