Background A recent randomized trial used the Fistula Risk Score (FRS) to develop guidelines for selective drainage based on clinically relevant fistula (CR-POPF) risk. Additionally, postoperative ...day (POD) 1 drain and serum amylase have been identified as accurate postoperative predictors of CR-POPF. This study sought to identify patients who may benefit from selective drainage, as well as the optimal timing for drain removal after pancreatoduodenectomy. Study Design One hundred six pancreatoduodenectomies from a previously reported RCT were assessed using risk-adjustment. The incidence of CR-POPF was compared between FRS risk cohorts. Drain and serum amylase values from POD 1 were evaluated using receiver operating characteristic (ROC) analysis to establish cut-offs predictive of CR-POPF occurrence. A regression analysis compared drain removal randomizations (POD 3 vs POD 5). Results Three-quarters of patients had moderate/high CR-POPF risk. This group had a CR-POPF rate of 36.3% vs 7.7% among negligible/low risk patients (p = 0.005). The areas under the ROC curve for CR-POPF prediction using POD 1 drain and serum amylase values were 0.800 (p = 0.000001; 95% CI 0.70–0.90) and 0.655 (p = 0.012; 95% CI 0.55–0.77), respectively. No significant serum amylase cut-offs were identified. Moderate/high risk patients with POD 1 drain amylase ≤5,000 U/L had significantly lower rates of CR-POPF when randomized to POD 3 drain removal (4.2% vs 38.5%; p = 0.003); moreover, these patients experienced fewer complications and shorter hospital stays. Conclusions A clinical care protocol is proposed whereby drains are recommended for moderate/high FRS risk patients, but may be omitted in patients with negligible/low risk. Drain amylase values in moderate/high risk patients should then be evaluated on POD 1 to determine the optimal timing for drain removal. Moderate/high risk patients with POD 1 drain amylase ≤5,000 U/L have lower rates of CR-POPF with POD 3 (vs POD ≥ 5) drain removal; early drain removal is recommended for these patients.
National greenhouse gas inventories (GHGIs) are submitted annually to the
United Nations Framework Convention on Climate Change (UNFCCC). They are
estimated in compliance with Intergovernmental Panel ...on Climate Change (IPCC) methodological guidance using activity data, emission factors and
facility-level measurements. For some sources, the outputs from these
calculations are very uncertain. Inverse modelling techniques that use
high-quality, long-term measurements of atmospheric gases have been developed to provide independent verification of national GHGIs. This is considered good practice by the IPCC as it helps national inventory compilers to verify reported emissions and to reduce emission uncertainty. Emission estimates from the InTEM (Inversion Technique for Emission Modelling) model are presented for the UK for the hydrofluorocarbons (HFCs) reported to the UNFCCC (HFC-125, HFC-134a, HFC-143a, HFC-152a, HFC-23, HFC-32, HFC-227ea, HFC-245fa, HFC-43-10mee and HFC-365mfc). These HFCs have high global warming potentials (GWPs), and the global background mole fractions of all but two are increasing, thus highlighting their relevance to the climate and a need for increasing the accuracy of emission estimation for regulatory purposes. This study presents evidence that the long-term annual increase in growth of HFC-134a has stopped and is now decreasing. For HFC-32 there is an early indication, its rapid global growth period has ended, and there is evidence that the annual increase
in global growth for HFC-125 has slowed from 2018. The inverse modelling
results indicate that the UK implementation of European Union regulation of
HFC emissions has been successful in initiating a decline in UK emissions from 2018. Comparison of the total InTEM UK HFC emissions in 2020 with the average from 2009–2012 shows a drop of 35 %, indicating progress toward the target of a 79 % decrease in sales by 2030. The total InTEM HFC emission estimates (2008–2018) are on average 73 (62–83) % of, or 4.3 (2.7–5.9) Tg CO2-eq yr−1 lower than, the
total HFC emission estimates from the UK GHGI. There are also
significant discrepancies between the two estimates for the individual HFCs.
Background Complete macroscopic tumor resection is one of the most relevant predictors of long-term survival in pancreatic ductal adenocarcinoma. Because locally advanced pancreatic tumors can ...involve adjacent organs, “extended” pancreatectomy that includes the resection of additional organs may be needed to achieve this goal. Our aim was to develop a common consistent terminology to be used in centers reporting results of pancreatic resections for cancer. Methods An international panel of pancreatic surgeons working in well-known, high-volume centers reviewed the literature on extended pancreatectomies and worked together to establish a consensus on the definition and the role of extended pancreatectomy in pancreatic cancer. Results Macroscopic (R1) and microscopic (R0) complete tumor resection can be achieved in patients with locally advanced disease by extended pancreatectomy. Operative time, blood loss, need for blood transfusions, duration of stay in the intensive care unit, and hospital morbidity, and possibly also perioperative mortality are increased with extended resections. Long-term survival is similar compared with standard resections but appears to be better compared with bypass surgery or nonsurgical palliative chemotherapy or chemoradiotherapy. It was not possible to identify any clear prognostic criteria based on the specific additional organ resected. Conclusion Despite increased perioperative morbidity, extended pancreatectomy is warranted in locally advanced disease to achieve long-term survival in pancreatic ductal adenocarcinoma if macroscopic clearance can be achieved. Definitions of extended pancreatectomies for locally advanced disease (and not distant metastatic disease) are established that are crucial for comparison of results of future trials across different practices and countries, in particular for those using neoadjuvant therapy.
Systemic lupus erythematosus (SLE) is an autoimmune disease characterized by the production of autoantibodies to certain cellular macromolecules, such as the small nuclear ribonucleoprotein particles ...(snRNPs), which had been considered to be passive targets of the autoimmune response. SLE is also characterized by the increased expression of type I interferon (IFN), which appears to be associated with the development and severity of disease. Here, we show that specific, highly conserved RNA sequences within snRNPs can stimulate Toll-like receptors (TLRs) 7 and 8 as well as activate innate immune cells, such as plasmacytoid dendritic cells (pDCs), which respond by secreting high levels of type I IFN. SLE patient sera containing autoantibodies to snRNPs form immune complexes that are taken up through the Fc receptor gammaRII and efficiently stimulate pDCs to secrete type I IFNs. These results demonstrate that a prototype autoantigen, the snRNP, can directly stimulate innate immunity and suggest that autoantibodies against snRNP may initiate SLE by stimulating TLR7/8.
We present the organization, instrumentation, datasets, data interpretation, modeling, and accomplishments of the multinational global atmospheric measurement program AGAGE (Advanced Global ...Atmospheric Gases Experiment). AGAGE is distinguished by its capability to measure globally, at high frequency, and at multiple sites all the important species in the Montreal Protocol and all the important non-carbon-dioxide (non-CO2) gases assessed by the Intergovernmental Panel on Climate Change (CO2 is also measured at several sites). The scientific objectives of AGAGE are important in furthering our understanding of global chemical and climatic phenomena. They are the following: (1) to accurately measure the temporal and spatial distributions of anthropogenic gases that contribute the majority of reactive halogen to the stratosphere and/or are strong infrared absorbers (chlorocarbons, chlorofluorocarbons – CFCs, bromocarbons, hydrochlorofluorocarbons – HCFCs, hydrofluorocarbons – HFCs and polyfluorinated compounds (perfluorocarbons – PFCs), nitrogen trifluoride – NF3, sulfuryl fluoride – SO2F2, and sulfur hexafluoride – SF6) and use these measurements to determine the global rates of their emission and/or destruction (i.e., lifetimes); (2) to accurately measure the global distributions and temporal behaviors and determine the sources and sinks of non-CO2 biogenic–anthropogenic gases important to climate change and/or ozone depletion (methane – CH4, nitrous oxide – N2O, carbon monoxide – CO, molecular hydrogen – H2, methyl chloride – CH3Cl, and methyl bromide – CH3Br); (3) to identify new long-lived greenhouse and ozone-depleting gases (e.g., SO2F2, NF3, heavy PFCs (C4F10, C5F12, C6F14, C7F16, and C8F18) and hydrofluoroolefins (HFOs; e.g., CH2 = CFCF3) have been identified in AGAGE), initiate the real-time monitoring of these new gases, and reconstruct their past histories from AGAGE, air archive, and firn air measurements; (4) to determine the average concentrations and trends of tropospheric hydroxyl radicals (OH) from the rates of destruction of atmospheric trichloroethane (CH3CCl3), HFCs, and HCFCs and estimates of their emissions; (5) to determine from atmospheric observations and estimates of their destruction rates the magnitudes and distributions by region of surface sources and sinks of all measured gases; (6) to provide accurate data on the global accumulation of many of these trace gases that are used to test the synoptic-, regional-, and global-scale circulations predicted by three-dimensional models; and (7) to provide global and regional measurements of methane, carbon monoxide, and molecular hydrogen and estimates of hydroxyl levels to test primary atmospheric oxidation pathways at midlatitudes and the tropics. Network Information and Data Repository: http://agage.mit.edu/data or http://cdiac.ess-dive.lbl.gov/ndps/alegage.html (https://doi.org/10.3334/CDIAC/atg.db1001).
Halocarbons contribute to global warming and stratospheric ozone depletion. They are emitted to the atmosphere by various anthropogenic
activities. To determine Swiss national halocarbon emissions, ...we applied top-down methods, which rely on atmospheric concentration observations
sensitive to the targeted emissions. We present 12 months (September 2019 to August 2020) of continuous atmospheric observations of
28 halocarbons from a measurement campaign at the Beromünster tall tower in Switzerland. The site is sensitive to the Swiss Plateau, which is the most densely populated area of Switzerland. Therefore, the measurements are well suited to derive Swiss halocarbon emissions. Emissions were calculated by two different top-down methods, i.e. a tracer ratio method (TRM), with carbon monoxide (CO) as the independent tracer, and a Bayesian inversion (BI), based on atmospheric transport simulations using FLEXPART–COSMO. The results were compared to previously reported top-down emission estimates, based on measurements at the high-Alpine site of Jungfraujoch, and to the bottom-up Swiss national greenhouse gas (GHG) inventory, as annually reported to the United Nations Framework Convention on Climate Change (UNFCCC). We observed moderately elevated concentrations of chlorofluorocarbons (CFCs) and hydrochlorofluorocarbons (HCFCs), both banned from production and consumption in Europe. The corresponding emissions are likely related to the ongoing outgassing from older foams and refrigerators and confirm the widespread historical use of these substances. For
the major hydrofluorocarbons (HFCs), HFC-125 (CHF2CF3) and HFC-32 (CH2F2), our calculated emissions of 100 ± 34 and 45 ± 14 Mg yr−1 are in good agreement with the numbers reported in the Swiss inventory, whereas, for HFC-134a
(CH2FCF3), our result of 280 ± 89 Mg yr−1 is more than 30 % lower than the Swiss inventory. For HFC-152a
(CH3CHF2), our top-down result of 21 ± 5 Mg yr−1 is significantly higher than the number reported in the Swiss inventory. For the other investigated HFCs, perfluorocarbons (PFCs), SF6 and NF3, Swiss emissions were small and in agreement with the inventory. Finally, we present the first country-based emission estimates for three recently phased-in, unregulated hydrofluoroolefins
(HFOs), HFO-1234yf (CF3CF=CH2), HFO-1234ze(E) ((E)-CF3CH=CHF), and HCFO-1233zd(E)
((E)-CF3CH=CHCl). For these three HFOs, we calculated Swiss emissions of 15 ± 4, 34 ± 14, and
7 ± 1 Mg yr−1, respectively.
Molecular hydrogen (H2), its stable isotope signature (δD), and the key combustion parameters carbon monoxide (CO), carbon dioxide (CO2), and methane (CH4) were measured from various combustion ...processes. H2 in the exhaust of gas and oil-fired heaters and of waste incinerator plants was generally depleted compared to ambient intake air, while CO was significantly elevated. These findings contradict the often assumed co-occurring net H2 and CO emissions in combustion processes and suggest that previous H2 emissions from combustion may have been overestimated when scaled to CO emissions. For the gas and oil-fired heater exhausts, H2 and δD generally decrease with increasing CO2, from ambient values of ~0.5 ppm and +130‰ to 0.2 ppm and −206‰, respectively. These results are interpreted as a combination of an isotopically light H2 source from fossil fuel combustion and a D/H kinetic isotope fractionation of hydrogen in the advected ambient air during its partial removal during combustion. Diesel exhaust measurements from dynamometer test stand driving cycles show elevated H2 and CO emissions during cold-start and some acceleration phases. While H2 and CO emissions from diesel vehicles are known to be significantly less than those from gasoline vehicles (on a fuel-energy base), we find that their molar H2/CO ratios (median 0.026, interpercentile range 0.12) are also significantly less compared to gasoline vehicle exhaust. Using H2/CO emission ratios, along with CO global emission inventories, we estimate global H2 emissions for 2000, 2005, and 2010. For road transportation (gasoline and diesel), we calculate 8.3 ± 2.2 Tg, 6.0 ± 1.5 Tg, and 3.8 ± 0.94 Tg, respectively, whereas the contribution from diesel vehicles is low (0.9–1.4%). Other fossil fuel emissions are believed to be negligible but H2 emissions from coal combustion are unknown. For residential (domestic) emissions, which are likely dominated by biofuel combustion, emissions for the same years are estimated at 2.7 ± 0.7 Tg, 2.8 ± 0.7 Tg, and 3.0 ± 0.8 Tg, respectively. For biomass burning H2 emissions, we derive a mole fraction ratio ΔH2/ΔCH4 (background mole fractions subtracted) of 3.6 using wildfire emission data from the literature and support these findings with our wood combustion results. When combining this ratio with CH4 emission inventories, the resulting global biomass burning H2 emissions agree well with published global H2 emissions, suggesting that CH4 emissions may be a good proxy for biomass burning H2 emissions.
Summary
Background
Few studies have addressed prognostic markers and none has correlated molecular status and prognosis in vulvar melanomas.
Objectives
To evaluate the clinicopathological features of ...95 cases of vulvar melanoma.
Methods
p53, CD117, Ki‐67, neurofibromin, brafv600e and nrasq61r immunostains, and molecular analyses by either targeted next‐generation or direct sequencing, were performed on available archival materials.
Results
Molecular testing detected mutations in KIT (44%), BRAF (25%), NF1 (22%), TP53 (17%), NRAS (9%) and TERT promoter (9%). Co‐mutation of KIT and NF1 and of KIT and NRAS were identified in two and one cases, respectively. KIT mutations were significantly associated with better progression‐free survival in univariate analyses. In multivariate analyses CD117 expression was significantly associated with better progression‐free survival. Tumour thickness was significantly associated with worse progression‐free and overall survival, and perineural invasion significantly correlated with reduced melanoma‐specific survival and reduced overall survival. Cases were from multiple centres and only a subset of samples was available for molecular testing.
Conclusions
KIT mutations and CD117 overexpression are markers of better progression‐free survival. In addition to its prognostic value, molecular testing may identify cases that might respond to targeted agents or immunotherapeutic approaches.
What's already known about this topic?
Vulvar melanomas are rare, with poorer prognoses than conventional cutaneous melanomas.
To date, few studies have addressed prognostic markers and none has correlated molecular status and prognosis in vulvar melanomas.
What does this study add?
This study, involving 10 clinical institutions from the U.S.A., Spain and Poland, shows that KIT mutations and CD117 overexpression are markers of better progression‐free survival for vulvar melanoma.
What is the translational message?
CD117 immunostaining and KIT mutational analysis can potentially serve as prognostic markers of vulvar melanoma.
Targeted inhibitors may have a therapeutic role in cases harbouring actionable mutations.
Respond to this article
Methyl chloroform (MCF) is a man-made chlorinated solvent contributing to the destruction of stratospheric ozone and is controlled under the "Montreal Protocol on Substances that Deplete the Ozone ...Layer" and its amendments, which called for its phase-out in 1996 in developed countries and 2015 in developing countries. Long-term, high-frequency observations of MCF carried out at three European sites show a constant decline in the background mixing ratios of MCF. However, we observe persistent non-negligible mixing ratio enhancements of MCF in pollution episodes, suggesting unexpectedly high ongoing emissions in Europe. In order to identify the source regions and to give an estimate of the magnitude of such emissions, we have used a Bayesian inversion method and a point source analysis, based on high-frequency long-term observations at the three European sites. The inversion identified southeastern France (SEF) as a region with enhanced MCF emissions. This estimate was confirmed by the point source analysis. We performed this analysis using an 11-year data set, from January 2002 to December 2012. Overall, emissions estimated for the European study domain decreased nearly exponentially from 1.1 Gg yr−1 in 2002 to 0.32 Gg yr−1 in 2012, of which the estimated emissions from the SEF region accounted for 0.49 Gg yr−1 in 2002 and 0.20 Gg yr−1 in 2012. The European estimates are a significant fraction of the total semi-hemisphere (30–90° N) emissions, contributing a minimum of 9.8% in 2004 and a maximum of 33.7% in 2011, of which on average 50% are from the SEF region. On the global scale, the SEF region is thus responsible for a minimum of 2.6% (in 2003) and a maximum of 10.3% (in 2009) of the global MCF emissions.
We have developed a chemical mechanism describing the tropospheric degradation of chlorine containing very short‐lived substances (VSLS). The scheme was included in a global atmospheric model and ...used to quantify the stratospheric injection of chlorine from anthropogenic VSLS ( ClyVSLS) between 2005 and 2013. By constraining the model with surface measurements of chloroform (CHCl3), dichloromethane (CH2Cl2), tetrachloroethene (C2Cl4), trichloroethene (C2HCl3), and 1,2‐dichloroethane (CH2ClCH2Cl), we infer a 2013 ClyVSLS mixing ratio of 123 parts per trillion (ppt). Stratospheric injection of source gases dominates this supply, accounting for ∼83% of the total. The remainder comes from VSLS‐derived organic products, phosgene (COCl2, 7%) and formyl chloride (CHClO, 2%), and also hydrogen chloride (HCl, 8%). Stratospheric ClyVSLS increased by ∼52% between 2005 and 2013, with a mean growth rate of 3.7 ppt Cl/yr. This increase is due to recent and ongoing growth in anthropogenic CH2Cl2—the most abundant chlorinated VSLS not controlled by the Montreal Protocol.
Key Points
Stratospheric Cl from short‐lived chemicals has increased significantly
Increasing Cl due to rapid growth in surface emissions of CH2Cl2
COCl2 and HCl from VSLS make a nonzero contribution to stratospheric Cl
PDF
