Effective re-induction regimen for children with recurrent medulloblastoma.

Background: There is no standard treatment for the recurrence of medulloblastoma, the most common malignant childhood brain tumor, and prognosis remains dismal. In this study, we introduce a regimen that is well-tolerated and effective at inducing remission. Methods: The primary objectives of this study were to assess tolerability of the regimen and overall response rate (ORR). A retrospective chart review of patients with recurrent medulloblastoma, treated at two institutions with a re-induction regimen of intravenous irinotecan and cyclophosphamide with oral temozolomide and etoposide, was performed. Demographic, clinicopathologic, toxicity, and response data were collected and analyzed. Results: Nine patients were identified. Median age was 5.75 years. Therapy was well-tolerated with no therapy-limiting toxicities and no toxic deaths. Successful stem cell collection was achieved in all 5 patients in whom it was attempted. ORR after 2 cycles was 78%. Three patients had a complete response, 4 patients had a partial response, 1 patient had stable disease, and 1 patient had progressive disease. Four patients are alive with no evidence of disease (NED), 2 patients are alive with disease, 2 patients have died of disease, and 1 patient died of toxicity related to additional therapy (NED at time of death). Conclusions: This regimen is well-tolerated and effective. Tumor response was noted in the majority of cases, allowing patients to proceed to additional treatment with no or minimal disease. Further study of this regimen in a clinical trial setting is an important next step.

TNM stage in the Nordic Cancer Registries 2004-2016: Registration and availability.

BACKGROUND AND PURPOSE: Stage at cancer diagnosis is an important predictor of cancer survival. TNM stage is constructed for anatomic solid cancer diagnoses from tumor size (T), nodal spread (N) and distant metastasis (M) and categorized in groups 0-I, II, II and IV. TNM stage is imperative in cancer diagnosis, management and control, and of high value in cancer surveillance, for example, monitoring of stage distributions. This study yields an overview of TNM availability and trends in stage distribution in the Nordic countries for future use in monitoring and epidemiologic studies. MATERIAL AND METHODS: TNM information was acquired from the cancer registries in Denmark, Norway, Sweden, and Iceland during 2004-2016 for 26 cancer sites in the three former countries and four in Iceland. We studied availability, comparability, and distribution of TNM stage in three periods: 2004-2008, 2009-2013, and 2014-2016, applying a previously validated algorithm of 'N0M0 for NXMX'. For cancers of colon, rectum, lung, breast, and kidney, we examined TNM stage-specific 1-year relative survival to evaluate the quality in registration of TNM between countries. RESULTS: Denmark, Sweden, and Iceland exhibited available TNM stage proportions of 75-95% while proportions were lower in Norway. Proportions increased in Sweden over time but decreased in Denmark. One-year relative survival differed substantially more between TNM stages than between countries emphasizing that TNM stage is an important predictor for survival and that stage recording is performed similarly in the Nordic countries. INTERPRETATION: Assessment and registration of TNM stage is an imperative tool in evaluations of trends in cancer survival between the Nordic countries.

Disease Evolution Monitored by Serial Cerebrospinal Fluid Liquid Biopsies in Two Cases of Recurrent Medulloblastoma.

Medulloblastoma is the most common malignant brain tumor in childhood. Initial treatment generally includes surgery, irradiation, and chemotherapy. Approximately 20-30% of patients will experience a recurrence, which portends a very poor prognosis. The current standard of care for evaluation for relapse includes radiographic surveillance with magnetic resonance imaging at regular intervals. The presence of circulating tumor DNA in the cerebrospinal fluid has been demonstrated to be a predictor of a higher risk of progression in a research setting for patients with medulloblastoma treated on a prospective single institution clinical trial. We have previously published and clinically validated a liquid-biopsy-based genetic assay utilizing low-pass whole genome sequencing to detect copy number alterations in circulating tumor DNA. Here, we present two teenage patients with posterior fossa medulloblastoma with recurrent disease who have been monitored with serial liquid biopsies showing tumor evolution over time, demonstrating the clinical utility of these approaches.

Divergent responses of pelagic and benthic fish body-size structure to remoteness and protection from humans.

Animal body-size variation influences multiple processes in marine ecosystems, but habitat heterogeneity has prevented a comprehensive assessment of size across pelagic (midwater) and benthic (seabed) systems along anthropic gradients. In this work, we derive fish size indicators from 17,411 stereo baited-video deployments to test for differences between pelagic and benthic responses to remoteness from human pressures and effectiveness of marine protected areas (MPAs). From records of 823,849 individual fish, we report divergent responses between systems, with pelagic size structure more profoundly eroded near human markets than benthic size structure, signifying greater vulnerability of pelagic systems to human pressure. Effective protection of benthic size structure can be achieved through MPAs placed near markets, thereby contributing to benthic habitat restoration and the recovery of associated fishes. By contrast, recovery of the world's largest and most endangered fishes in pelagic systems requires the creation of highly protected areas in remote locations, including on the High Seas, where protection efforts lag.

Prediction of clinically significant recurrence after partial nephrectomy. Data from the Cancer Registry of Norway with more than five years of follow-up.

OBJECTIVE: To determine recurrence incidence after partial nephrectomy (PN) for renal cell carcinoma and identify predictors for local recurrence (LR) and metastasis. MATERIAL AND METHODS: We retrospectively evaluated a cohort of 524 patients from the Cancer Registry of Norway, who underwent PN between January 2014 and December 2015 and were followed-up for >6 years. Patient demographics and pathological characteristics were correlated with recurrence and progression-free survival using Kaplan-Meier and Cox regression analyses. RESULTS: Median patient age was 64 years, and the median tumour size was 2.6 cm. A positive surgical margin (PSM) was observed in 11% of the cases, while the LR and metastasis rates were 3.4% and 3.2%, respectively. PSM (hazard ratio [HR], 55.4; 95% confidence interval [CI], 12.55-244.6), tumour number (HR, 45.4; 95% CI, 6.5-316.1) and stage (HR, 33.5; 95% CI, 5.4-205.3) were independent predictors for LR. Undetermined margin status was also a risk factor for LR. Tumour stage (HR, 41.05; 95% CI, 8.52-197.76), tumour necrosis (HR, 1.3; 95% CI, 0.4-4.31) and age (HR, 1.07; 95% CI, 1.01-1.14) were predictors for metastasis. CONCLUSIONS: Both local and distant recurrences after PN were rare, and the pT stage was a common predictor. PSM or indeterminate surgical margin and tumour number were LR predictors, while age at surgery and the presence of tumour necrosis predicted metastasis.

Examining the residual radiological footprint of a former colliery: An industrial nuclear archaeology investigation.

Nuclear industrial archaeology utilises radiation mapping and characterisation technologies to gain an insight into the radiological footprint of industrial heritage sites. Increased concentrations of naturally occurring radioactive materials at legacy mine sites are the result of elemental enrichment during coal mining and subsequent combustion. Public safety is of concern around these sites, and therefore, an increased understanding of their associated hazard is essential. Using coincident laser scanning and gamma detection technologies, this study sought to assess the radiological legacy of a coal mine located in Bristol, UK. From this, we can increase our understanding of the residual footprints associated with the local coal mining industry. Samples taken from inside the site were characterised using high resolution gamma spectrometry, wherein the radionuclide content and activities of samples were then quantified. An area of elevated low-level radioactivity was observed at and around buildings believed to belong to the colliery, while Th, U, and K are confirmed at the site from photopeak's of daughter radionuclides. Activities of the radionuclides K-40, U-238, and Th-232 were further quantified during subsequent laboratory analysis. Results highlight an enrichment of naturally occurring radionuclides when compared with global averages for unburned coal. Employing these techniques at further legacy sites would enable an increased understanding of the lasting traces of the coal mining industry, with a focus on NORM enrichment in residual fly ash.

Changes in illegal fishing dynamics in a large-scale MPA during COVID-19.

Global socio-ecological shocks, such as the COVID-19 pandemic, can threaten progress in protecting vulnerable marine environments by altering behaviour of resource users1. When government priorities shift from environmental protection towards safeguarding human populations, control of illegal activity in protected areas can alter. Resulting increases in illegal fishing in large-scale marine protected areas (MPAs) are of particular concern as they contain a large proportion of marine protected area globally2. Here, we report on average 19 times as many suspected illegal fishing vessels per month in 2022 (n = 19) compared with 2010 to 2020 (n = 1) in an Indian Ocean MPA. Although illegal fishing has been a pervasive problem, the current spike in Indian vessels targeting a broad trophic diversity of reef-associated species is of particular concern and we suggest such changes in illegal activity in MPAs globally may persist over long timescales unless management is broad and adaptive to individual context. When considering potential solutions, widespread adoption of technology, such as remote surveillance of vessels, can mitigate illegal activities but remains unfeasible for many MPAs globally due to financial and political barriers. Instead, we suggest broader approaches, including a renewed focus on regional approaches to combating illegal fishing, formal bilateral agreements between competent authorities in relevant countries and an increase in community-based work.

Translational considerations for immunotherapy clinical trials in pediatric neuro-oncology.

While immunotherapy for pediatric cancer has made great strides in recent decades, including the FDA approval of agents such as dinutuximab and tisgenlecleucel, these successes have rarely impacted children with pediatric central nervous system (CNS) tumors. As our understanding of the biological underpinnings of these tumors evolves, new immunotherapeutics are undergoing rapid clinical translation specifically designed for children with CNS tumors. Most recently, there have been notable clinical successes with oncolytic viruses, vaccines, adoptive cellular therapy, and immune checkpoint inhibition. In this article, the immunotherapy working group of the Pacific Pediatric Neuro-Oncology Consortium (PNOC) reviews the current and future state of immunotherapeutic CNS clinical trials with a focus on clinical trial development. Based on recent therapeutic trials, we discuss unique immunotherapy clinical trial challenges, including toxicity considerations, disease assessment, and correlative studies. Combinatorial strategies and future directions will be addressed. Through internationally collaborative efforts and consortia, we aim to direct this promising field of immuno-oncology to the next frontier of successful application against pediatric CNS tumors.

Prolonged low temperature exposure de-sensitises ABA-induced stomatal closure in soybean, involving an ethylene-dependent process.

Chilling can decrease stomatal sensitivity to abscisic acid (ABA) in some legumes, although hormonal mechanisms involved are unclear. After evaluating leaf gas exchange of 16 European soybean genotypes at 14°C, 6 genotypes representing the range of response were selected. Further experiments combined low (L, 14°C) and high (H, 24°C) temperature exposure from sowing until the unifoliate leaf was visible and L or H temperature until full leaf expansion, to impose four temperature treatments: LL, LH, HL, and HH. Prolonged chilling (LL) substantially decreased leaf water content but increased leaf ethylene evolution and foliar concentrations of the ethylene precursor 1-aminocyclopropane-1-carboxylic acid, indole-3-acetic acid, ABA and jasmonic acid. Across genotypes, photosynthesis linearly increased with stomatal conductance (Gs), with photosynthesis of HH plants threefold higher than LL plants at the same Gs. In all treatments except LL, Gs declined with foliar ABA accumulation. Foliar ABA sprays substantially decreased Gs of HH plants, but did not significantly affect LL plants. Thus low temperature compromised stomatal sensitivity to endogenous and exogenous ABA. Applying the ethylene antagonist 1 methyl-cyclopropene partially reverted excessive stomatal opening of LL plants. Thus, chilling-induced ethylene accumulation may mediate stomatal insensitivity to ABA, offering chemical opportunities for improving seedling survival in cold environments.

Influence of various assumptions for the individual TNM components on the TNM stage using Nordic cancer registry data.

BACKGROUND: The stage at diagnosis is one of the most important predictors for cancer survival. TNM stage is constructed from T (tumor size), N (nodal spread), and M (distant metastasis) components. In many notifications to cancer registries, TNM information is incomplete with unknown N and/or M. We aimed to evaluate the influence of various assumptions for recoding missing N (NX) and M (MX) as N0 and M0 on the proportion with available TNM stage, stage-distribution, and stage-specific relative survival. MATERIAL AND METHODS: We identified 140,201 patients diagnosed with incident cancer of the colon, rectum, lung, breast, or kidney during 2014-2016 in Denmark, Norway, Sweden, or Iceland. Information on TNM were obtained from cancer registry records used for an update of the Nordic cancer statistics database NORDCAN. Patients were followed for death or emigration through 2017. We calculated proportions of available TNM stage, stage distribution, and stage-specific relative survival under different approaches for each cancer site and country. RESULTS: Application of the assumptions yielded higher numbers of cases with available TNM stage for stages 0-I, II, and III. We observed only minor differences in stage-specific one-year relative survival when applying N0M0 for missing N and M, especially for high completeness of TNM registrations, whereas relative survival for remaining cases with missing TNM stage declined substantially. CONCLUSION: We found no major changes in stage-specific one-year relative survival applying N0M0 for NXMX. We conclude that complete TNM information is preferable to making assumptions, but it seems reasonable to consider assuming N0M0 for missing N and M in future studies based on the Nordic cancer registries. An automatic algorithm, though, is not recommended without considering potential area-specific reasons for frequent use of NX and MX. Clinicians should be urged to report complete TNM information to improve surveillance of the TNM stage.

Contrasting ecological information content in whaling archives with modern cetacean surveys for conservation planning and identification of historical distribution changes.

Many species are restricted to a marginal or suboptimal fraction of their historical range due to anthropogenic impacts, making it hard to interpret their ecological preferences from modern-day data alone. However, inferring past ecological states is limited by the availability of robust data and biases in historical archives, posing a challenge for policy makers . To highlight how historical records can be used to understand the ecological requirements of threatened species and inform conservation, we investigated sperm whale (Physeter macrocephalus) distribution in the Western Indian Ocean. We assessed differences in information content and habitat suitability predictions based on whale occurrence data from Yankee whaling logs (1792-1912) and from modern cetacean surveys (1995-2020). We built maximum entropy habitat suitability models containing static (bathymetry-derived) variables to compare models comprising historical-only and modern-only data. Using both historical and modern habitat suitability predictions  we assessed marine protected area (MPA) placement by contrasting suitability in- and outside MPAs. The historical model predicted high habitat suitability in shelf and coastal regions near continents and islands, whereas the modern model predicted a less coastal distribution with high habitat suitability more restricted to areas of steep topography. The proportion of high habitat suitability inside versus outside MPAs was higher when applying the historical predictions than the modern predictions, suggesting that different marine spatial planning optimums can be reached from either data sources. Moreover, differences in relative habitat suitability predictions between eras were consistent with the historical depletion of sperm whales from coastal regions, which were easily accessed and targeted by whalers, resulting in a modern distribution limited more to steep continental margins and remote oceanic ridges. The use of historical data can provide important new insights and, through cautious interpretation, inform conservation planning and policy, for example, by identifying refugee species and regions of anticipated population recovery.

Contrastes del contenido de información ecológica entre los archivos de la caza de ballenas y los censos actuales de cetáceos para la planeación de la conservación y la identificación de cambios en la distribución histórica Resumen Muchas especies están restringidas a una fracción marginal o subóptima de su área de distribución histórica debido a impactos antropogénicos. Esto dificulta interpretar sus preferencias ecológicas con sólo usar los datos actuales. Sin embargo, la inferencia de estados ecológicos pasados está limitada a la disponibilidad de datos sólidos y a los sesgos de los archivos históricos, lo que plantea un reto para la conservación y los responsables de las políticas. Analizamos la distribución del cachalote (Physeter macrocephalus) en el Océano Índico occidental para resaltar cómo pueden utilizarse los registros históricos para comprender los requisitos ecológicos de las especies amenazadas y direccionar su conservación. Evaluamos las diferencias en el contenido de la información y las predicciones de idoneidad del hábitat basadas en los datos de presencia de ballenas de los registros balleneros Yanquis (1792-1912) y de los estudios actuales sobre cetáceos (1995-2020). Construimos modelos de idoneidad de hábitat con máxima entropía que incluían variables estáticas (derivadas de la batimetría) para comparar los modelos que abarcan datos históricos y actuales. Evaluamos la ubicación de las áreas marinas protegidas (AMP) contrastando las predicciones dentro y fuera de ellas con los modelos históricos y actuales de la idoneidad del hábitat. El modelo histórico predijo una alta idoneidad del hábitat en las regiones costeras y de la plataforma continental cercanas a los continentes e islas, mientras que el modelo moderno predijo una distribución menos costera con una alta idoneidad del hábitat más restringida a las zonas de topografía escarpada. La proporción de hábitats de alta idoneidad dentro y fuera de las AMP fue mayor con la aplicación de las predicciones históricas que con la de las modernas, lo que sugiere que se pueden alcanzar diferentes niveles óptimos de ordenación del espacio marino a partir de ambas fuentes de datos. Además, las diferencias entre los periodos en las predicciones relacionadas con la idoneidad del hábitat fueron coherentes con la reducción histórica de los cachalotes en las regiones costeras, las cuales eran fácilmente accesibles para los balleneros, lo que resultó en una distribución actual más limitada a los márgenes continentales escarpados y a las crestas oceánicas remotas. El uso de datos históricos puede aportar nuevos e importantes conocimientos e informar, mediante una interpretación prudente, a la planificación y la política de conservación; por ejemplo, con la identificación de especies refugiadas y regiones de recuperación poblacional.

Simulations of Test Reduction Using Pooled Heavy Metals Analysis in Cannabis.

BACKGROUND: Cannabis species have a propensity to bioaccumulate toxic heavy metals from their growth media. Increased testing for these metals is required to improve the safety of the legal medical and recreational cannabis industries. However, the current methods used for mandated heavy metals tests are not efficient for a large framework. As a result, there is limited testing capacity, high testing costs, and long wait times for results across North America. OBJECTIVE: This study aimed to demonstrate that pooling strategies can be used to increase the throughput in cannabis testing labs and reduce some of the strain on the industry. METHODS: This paper presents an algorithm to simulate different pooling strategies. The algorithm was applied to real world data sets collected from Washington and California state testing labs. RESULTS: Using a single pooling method, a pool size of three samples on average resulted in a 23.8% reduction in tests required for 100 samples for the Washington lab. For the California lab, pooling four samples on average resulted in a 54.1% reduction in tests required for 100 samples. CONCLUSION: The algorithms generated from the Washington and California lab data demonstrated that pooled testing strategies can be developed on a case-by-case method to reduce the time, effort, and costs associated with heavy metals tests. HIGHLIGHTS: The benefits of pooled testing will vary depending on the region and rate of contamination seen in each testing lab. Overall, our results demonstrate pooled testing has the potential to reduce the fiscal costs of testing through increased efficiency, allowing increased testing, leading to greater safety.

Survival trends of patients with non-metastatic gastric adenocarcinoma in the US and European countries: the impact of decreasing resection rates.

BACKGROUND: We previously observed decreasing resection rates of non-metastatic gastric adenocarcinoma (GaC) in the US and some European countries. If and to what extent these trends affect the trends in overall survival (OS) of patients with non-metastatic GaC at the population level remain unclear. This large international population-based cohort study aimed to assess the impact of the previously observed decreasing resection rates on multivariable-adjusted trends in the long-term OS of patients with non-metastatic GaC. METHODS: Individual-level data of patients with non-metastatic GaC were obtained from the national cancer registries of the Netherlands, Belgium, Sweden, Norway, and Slovenia, and the US Surveillance, Epidemiology, and End Results database. We analyzed data for each country separately. Associations between year of diagnosis and OS were assessed using Cox proportional hazards regression model with adjustment for multiple prognostic variables, with and without including resection and chemotherapy as potential explanatory variables. RESULTS: A total of 66,398 non-metastatic GaC patients diagnosed in 2003-2016 were analyzed, with an accumulated follow-up of 172,357 person-years. Without adjustment for resection, OS was improved only slightly in the US [hazard ratio (HR)per year = 0.99; HR≥vs.<2010 = 0.96], and no improvement was observed in the investigated European countries, with OS even worsening in Sweden (HRper year = 1.03; HR≥vs.<2010 = 1.17). After adjusting for resection, the increasing OS trend became stronger in the US (HRper year = 0.98; HR≥vs.<2010 = 0.88), and the temporal trend became insignificant in Sweden. In Slovenia (HRper year = 0.99; HR≥vs.<2010 = 0.92) and Norway (HRper year = 0.97; HR≥vs.<2010 = 0.86), improved OS over time emerged after resection adjustment. Improved OS in patients undergoing resection was observed in the US, the Netherlands, and Norway. Adjustment for chemotherapy did not alter the observed associations. Stratified analyses by tumor location showed mostly similar results with the findings in all patients with non-metastatic GaCs regarding the associations between year of diagnosis and survival. CONCLUSIONS: OS of patients with non-metastatic GaC mostly did not improve in selected European countries and was even worsened in Sweden, while it was slightly increased in the US in the early 21st century. Progress in OS of patients with non-metastatic GaC seems to have been impeded to a large extent by decreasing rates of resection.

The Utilization of Critical Care Resources in Pediatric Neurocritical Care Patients.

OBJECTIVES: To define the prevalence of neurologic diagnoses and evaluate the utilization of critical care and neurocritical care (NCC) resources among children admitted to the PICU. DESIGN: Retrospective cohort analysis. SETTING: Data submitted to the Virtual Pediatric Systems (VPS) database. PATIENTS: All children entered in VPS during 2016 (January 1, 2016, to December 31, 2016). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 128,688 patients entered into VPS and were comprised of 24.3% NCC admissions and 75.7% general PICU admissions. The NCC cohort was older, represented more scheduled admissions, and was more frequently admitted from the operating room. The NCC cohort also experienced a greater decline in prehospitalization to posthospitalization functional status and required more frequent use of endotracheal intubation, arterial lines, and foley catheters but had an overall shorter duration of PICU and hospital length of stay with a higher mortality rate. One thousand seven hundred fifteen patients at 12 participating institutions were entered into a novel, pilot NCC module evaluating sources of secondary neurologic injury. Four hundred forty-eight patients were manually excluded by the data entrant, leaving 1,267 patients in the module. Of the patients in the module, 75.8% of patients had a NCC diagnosis as their primary diagnosis; they experienced a high prevalence of pathophysiologic events associated with secondary neurologic insult (ranging from hyperglycemia at 10.5% to hyperthermia at 36.8%). CONCLUSIONS: In children admitted to a VPS-contributing PICU, a diagnosis of acute neurologic disease was associated with greater use of resources. We have identified the most common etiologies of acute neurologic disease in the 2016 VPS cohort, and such admissions were associated with significant decrease in functional status, as well as an increase in mortality.

Survival trends in patients diagnosed with colon and rectal cancer in the nordic countries 1990-2016: The NORDCAN survival studies.

BACKGROUND: Survival of patients with colon and rectal cancer has improved in all Nordic countries during the past decades. The aim of this study was to further assess survival trends in patients with colon and rectal cancer in the Nordic countries by age at diagnosis and to present additional survival measures. METHODS: Data on colon and rectal cancer cases diagnosed in the Nordic countries between 1990 and 2016 were obtained from the NORDCAN database. Relative survival was estimated using flexible parametric models. Both age-standardized and age-specific measures for women and men were estimated from the models, as well as reference-adjusted crude probabilities of death and life-years lost. RESULTS: The five-year age-standardized relative survival of colon and rectal cancer patients continued to improve for women and men in all Nordic countries, from around 50% in 1990 to about 70% at the end of the study period. In general, survival was similar across age and sex. The largest improvement was seen for Danish men and women with rectal cancer, from 41% to 69% and from 43% to 71%, respectively. The age-standardized and reference-adjusted five-year crude probability of death in colon cancer ranged from 30% to 36% across countries, and for rectal cancer from 20% to 33%. The average number of age-standardized and reference-adjusted life-years lost ranged between six and nine years. CONCLUSION: There were substantial improvements in colon and rectal cancer survival in all Nordic countries 1990-2016. Of special note is that the previously observed survival disadvantage in Denmark is no longer present.

Changes in Distensibility Index During an Incremental POEM Myotomy.

BACKGROUND: A longer myotomy for the treatment of achalasia is associated with worse gastroesophageal reflux disease despite palliating dysphagia. Recently, clinical outcomes have been correlated to the distensibility of the distal esophagus, which is measured intra-operatively using an endoscopic functional luminal image probe (EndoFLIP). We aimed to determine the minimum per oral endoscopic myotomy (POEM) length to allow for adequate distensibility index (DI). METHODS: A 6-cm myotomy conducted in 2-cm increments during POEM was performed for patients with achalasia I and II from 2017 to 2019. The EndoFLIP was used to measure the DI intra-operatively: (1) prior to intervention, (2) following creation of the submucosal tunnel, (3) following transection of the high-pressure zone (HPZ), (4) following the distal extension, and (5) following the proximal esophageal extension. RESULTS: A total of 16 patients underwent POEM. Ages ranged from 21 to 78 years, 10 were male, and 13 had type II achalasia. The median DI was 2.7 (1.4-3.6) mm2/mmHg prior to intervention; 2.4 (1.4-3.3) mm2/mmHg following the submucosal tunnel; 3.2 (1.6-4.4) mm2/mmHg following transection of the HPZ; 3.8 (2.6-4.5) mm2/mmHg following the gastric extension; and 4.5 (3.3-7.1) mm2/mmHg following the proximal extension. Our target range DI was achieved for 50% of patients after transection of the HPZ. CONCLUSIONS: Distensibility changed with each myotomy increment and fell within the target range for most patients following a 2-4-cm myotomy. This suggests that a shorter myotomy may be appropriate for select patients, and the use of the EndoFLIP intra-operatively may allow for a tailored myotomy length.

Quantifying impacts of titanium dioxide nanoparticles on natural assemblages of riverine phytobenthos and phytoplankton in an outdoor setting.

Impacts of widespread release of engineered titanium dioxide nanoparticles (nTiO2) on freshwater phytoplankton and phytobenthic assemblages in the field, represents a significant knowledge gap. Using outdoor experiments, we quantified impacts of nTiO2 on phytoplankton and periphyton from UK rivers, applied at levels representative of environmentally realistic concentrations (0.05 mg/L) and hot spots of accumulation (5.0 mg/L). Addition of nTiO2 to river water led to rapid temporal size changes in homoagglomerates and many heteroaggregates of nTiO2 with cells in the phytoplankton, including green algae, pennate and centric diatoms, increasing settlement of some cells. Changes in phytoplankton composition were evident after 72-h resulting from a significant decline in the relative abundance of very small phytoplankton cells (1-3 µm), often accompanied by increases in centric diatoms at both concentrations. Significant changes detected in the composition of the phytobenthos after 12 days, following nTiO2 treatments, were not evident when using benthic diatoms alone after 56 days. A lack of inhibition in the maximum quantum yield (Fv/Fm) in phytobenthos after 72-h exposures contrasted with a significant inhibition in Fv/Fm in 75% of phytoplankton samples, the highest recorded in Rutile nTiO2 exposures at both concentrations of nTiO2. After 12 days, strong positive stimulatory responses were recorded in the maximum relative electron transport rate (rETRmax) and the maximum non-photochemical coefficient (NPQmax), in phytoplankton and phytobenthos samples exposed to the higher Anatase nTiO2 concentration, were not measured in Rutile exposed biota. Collectively, these results indicate that the Rutile phase of nTiO2 has more negative impacts on freshwater algae than the Anatase form, at specific time scales, and phytoplankton may be more impacted by nTiO2 than phytobenthos. We caution that repeated release of nTiO2, could lead to significant changes in riverine algal biomass and species composition, dependent on the phase and concentration of nTiO2.

Risk of multiple myeloma and other malignancies among first- and second-degree relatives of patients with multiple myeloma: A population-based study.

OBJECTIVES: We conducted a population-based study to assess the risk for multiple myeloma (MM) and other cancers in first- and second-degree relatives of MM patients, and to investigate whether evidence of anticipation is present in familial MM. METHODS: We retrieved 24 845 first-degree relatives and 41 008 second-degree relatives of 7847 MM patients, and 86 984 first-degree relatives, and 138 660 second-degree relatives of 26 511 matched controls. A Cox model was used to assess the risk for MM and other cancers in relatives of MM patients. Anticipation was assessed by a Cox model, where all parents and offspring of MM patients were included in the risk set. RESULTS: In second-degree relatives of MM patients, no overall significant association with an MM diagnosis was observed (HR 1.99; 95%CI:0.86-4.57). In parents and offspring of MM patients, we found no significant difference in the ages at onset of MM (HR 1.28;95% CI:0.50-3.28). In affected parent-offspring pairs, we observed no statistically significant difference in overall survival between the generations (HR 0.74; 95%CI:0.20-2.69). CONCLUSIONS: Overall, second-degree relatives of MM patients were not associated with an increased risk for MM. Our study supports that genetic anticipation is not present in familial MM.

Scenario-Based Evaluation of Team Health Information Technology to Support Pediatric Trauma Care Transitions.

BACKGROUND: Clinicians need health information technology (IT) that better supports their work. Currently, most health IT is designed to support individuals; however, more and more often, clinicians work in cross-functional teams. Trauma is one of the leading preventable causes of children's death. Trauma care by its very nature is team based but due to the emergent nature of trauma, critical clinical information is often missed in the transition of these patients from one service or unit to another. Teamwork transition technology can help support these transitions and minimize information loss while enhancing information gathering and storage. In this study, we created a large screen technology to support shared situational awareness across multiple clinical roles and departments. OBJECTIVES: This study aimed to examine if the Teamwork Transition Technology (T3) supports teams and team cognition. METHODS: We used a scenario-based mock-up methodology with 36 clinicians and staff from the different units and departments who are involved in pediatric trauma to examine T3. RESULTS: Results of the evaluation show that most participants agreed that the technology helps achieve the goals set out in the design phase. Respondents thought that T3 organizes and presents information in a different way that was helpful to them. CONCLUSION: In this study, we examined a health IT (T3) that was designed to support teams and team cognition. The results of our evaluation show that participants agreed that T3 does support them in their work and increases their situation awareness.

The impact of body mass index and height on risk for primary tumours of the spinal cord, spinal meninges, spinal and peripheral nerves in 1.7 million norwegian women and men: a prospective cohort study.

BACKGROUND: Primary tumours of the spinal cord, spinal meninges, spinal and peripheral nerves comprise a heterogenous group of pathology, dominantly represented by meningioma, nerve sheath tumours (NST) and glioma. Body height and body mass index (BMI) are risk factors for certain brain tumour subgroups, but no other study has specifically assessed height and BMI in relation to primary tumours of the spine and peripheral nerves in women and men. METHODS: In this prospective population-based cohort study height and weight were measured in 1.7 million adult Norwegian women and men at baseline. Incident cases of primary tumours arising from the spinal cord, spinal meninges, spinal and peripheral nerves during follow-up were identified by linkage to the National Cancer Registry. Tumour risk was assessed by Cox regression analyses in relation to height and BMI. RESULTS: During 49 million person-years of follow-up, 857 primary tumours of the spinal cord, spinal meninges, spinal and peripheral nerves were identified. Overweight and obesity were not associated with risk for all tumours or any tumour subgroup. Height was positively associated with risk for all tumours (HR per 10 cm increase: 1.30, 95% CI 1.16-1.46). The association between height and tumour risk varied between tumour subgroups: while height was not significantly associated with NST, height increased the risk for meningioma (HR 1.42, 95% CI 1.13-1.78) and glioma (HR 1.56, 95% CI 1.06-2.28). The strongest association between height and tumour risk was found for the glioma subgroup of ependymoma in women (HR 3.38, 95% CI 1.64-6.94). CONCLUSION: This study could not identify overweight and obesity as risk factors for primary tumours of the spinal cord, spinal meninges, spinal and peripheral nerves in women or men. Increasing body height was associated with increased tumour risk overall, but not universal for all tumour subgroups.Importance of the studyPrimary tumours of the spinal cord, spinal meninges, spinal and peripheral nerves have received little focus in epidemiologic studies, although the incidence and histo-pathological tumour subgroups differ significantly from primary brain tumours. Risk factors for these tumours have hardly been assessed in previous studies. Height, overweight and obesity are known risk factors for several cancers, including certain brain tumour subgroups, such as meningioma.This is the first study to report the association between height, overweight and obesity and primary tumours of the spinal cord, spinal meninges, spinal and peripheral nerves. This includes tumour subgroups of meningioma, nerve sheath tumour, glioma and the most common spinal glioma subgroup of ependymoma. While overweight and obesity were not associated with either of the tumour subgroups, an association between increasing body height and risk for spinal meningioma and glioma, including ependymoma, was found. Nerve sheath tumour risk was not associated with increasing body height.