Cascading hazards of a major Bengal basin earthquake and abrupt avulsion of the Ganges River.

Earthquakes present severe hazards for people and economies and can be primary drivers of landscape change yet their impact to river-channel networks remains poorly known. Here we show evidence for an abrupt earthquake-triggered avulsion of the Ganges River at ~2.5 ka leading to relocation of the mainstem channel belt in the Bengal delta. This is recorded in freshly discovered sedimentary archives of an immense relict channel and a paleo-earthquake of sufficient magnitude to cause major liquefaction and generate large, decimeter-scale sand dikes >180 km from the nearest seismogenic source region. Precise luminescence ages of channel sand, channel fill, and breached and partially liquefied floodplain deposits support coeval timing of the avulsion and earthquake. Evidence for reorganization of the river-channel network in the world's largest delta broadens the risk posed by seismic events in the region and their recognition as geomorphic agents in this and other tectonically active lowlands. The recurrence of comparable earthquake-triggered ground liquefaction and a channel avulsion would be catastrophic for any of the heavily populated, large river basins and deltas along the Himalayan arc (e.g., Indus, Ganges, Brahmaputra, Ayeyarwady). The compounding effects of climate change and human impacts heighten and extend the vulnerability of many lowlands worldwide to such cascading hazards.

Clinical Pathways and Outcomes of Andexanet Alfa Administration for the Reversal of Critical Bleeding in Patients on Oral Direct Factor Xa Inhibitors.

Background Andexanet is U.S. Food and Drug Administration (FDA) approved for the reversal of critical bleeding from factor Xa inhibitors and off-label for surgical reversal. Data are lacking on andexanet administration processes. Methods We retrospectively studied patients at a 23-hospital system who received andexanet from November 2019 to March 2023. Abstractors coded demographics, comorbidities, anticoagulant use, andexanet indication, and process times. The primary outcome was presentation-to-andexanet time; diagnosis, ordering, and administration times were calculated. Secondary outcomes included in-hospital postandexanet major thromboembolism/bleeding and mortality. Results In total, 141 patients were analyzed. Andexanet indications were predominantly neurologic bleeding (85.8%). Twenty-four patients (17.0%) were transferred from nontertiary/academic centers to tertiary/academic centers. The median presentation-to-administration time was 192.5 minutes (interquartile range [IQR]: 108.0-337.0 minutes). Components were as follows: 72.5 minutes (IQR: 39.0-137.5 minutes) for bleeding diagnosis; 35.5 minutes (IQR: 0-96.5 minutes) for andexanet ordering; and 53.0 minutes (IQR: 38.5-78.5 minutes) for administration, which was longer at tertiary/academic hospitals (ratio 1.5, 95% confidence interval [CI]: 1.2-2.0, p = 0.002). Gastrointestinal or other critical bleeding (ratio 2.59, 95% CI: 1.67-4.02, p < 0.001), and tertiary/academic center treatment (ratio 1.58, 95% CI: 1.15-2.18, p = 0.005), were associated with increased time. Major thromboembolism, bleeding, and mortality occurred in 10.6, 12.0, and 22.9% of patients, respectively. Conclusions In our cohort, the median presentation-to-administration time was over 3 hours. Cumulative times were longer at tertiary/academic hospitals and for gastrointestinal/other bleeding. Postandexanet major thromboembolism/bleeding occurred more at tertiary/academic hospitals, possibly related to transfers. Prospective studies may elucidate clinical decision-making bottlenecks.