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The spectrum of disease severity and the insidiousness of clinical presentation make it difficult to recognize patients with coronavirus disease 2019 (COVID-19) at higher risk of worse outcomes or death when they are seen in the early phases of the disease. There are now well-established risk factors for worse outcomes in patients with COVID-19. These should be factored in when assessing the prognosis of these patients. However, a more precise prognostic assessment in an individual patient may warrant the use of predictive tools. In this manuscript, we conduct a literature review on the severity of illness scores and biomarkers for the prognosis of patients with COVID-19. Several COVID-19-specific scores have been developed since the onset of the pandemic. Some of them are promising and can be integrated into the assessment of these patients. We also found that the well-known pneumonia severity index (PSI) and CURB-65 (confusion, uremia, respiratory rate, BP, age ≥ 65 years) are good predictors of mortality in hospitalized patients with COVID-19. While neither the PSI nor the CURB-65 should be used for the triage of outpatient versus inpatient treatment, they can be integrated by a clinician into the assessment of disease severity and can be used in epidemiological studies to determine the severity of illness in patient populations. Biomarkers also provide valuable prognostic information and, importantly, may depict the main physiological derangements in severe disease. We, however, do not advocate the isolated use of severity of illness scores or biomarkers for decision-making in an individual patient. Instead, we suggest the use of these tools on a case-by-case basis with the goal of enhancing clinician judgment.

The use of artificial intelligence in healthcare is rapidly growing, with great potential to assist medical professionals in diagnosis and treatment of complex medical conditions. In this case report, the recommendations of a pulmonary consultation are compared to the recommendations from a large language model (LLM), ChatGPT, in regards to a case of non-resolving pneumonia. The recommendations by ChatGPT were found to be consistent with the pulmonary consultation, and no recommendations given were inappropriate. As shown in this case report, early generations of LLM such as ChatGPT were able to provide appropriate recommendations for the management of a patient with a complex medical condition.

Purpose: To assess whether exposure to the 2010 Deepwater Horizon oil spill (DHOS) was related to parents’ self-rated health over time. Design: 3 waves of panel data were drawn from the Gulf Coast Population Impact study (2014) and Resilient Children, Youth, and Communities study (2016, 2018). Setting: Coastal Louisiana communities in high-impact DHOS areas. Participants: Respondents were parents or guardians aged 18 - 84, culled from a probability sample of households with a child aged 4 to 18 (N = 526) at the time of the 2010 DHOS. Measures: Self-rated health was measured at each wave. Self-reported physical exposure to the DHOS, economic exposure to the DHOS, and control variables were measured in 2014. Analysis: We used econometric random effects regression for panel data to assess relationships between DHOS exposures and self-rated health over time, controlling for potentially confounding covariates. Results: Both physical exposure (b = −0.39; P < 0.001) and economic exposure (b = −0.34; P < 0.001) to the DHOS had negative associations with self-rated health over the study period. Physical exposure had a larger effect size. Conclusion: Parents’ physical contact with, and economic disruption from, the 2010 DHOS were tied to long-term diminished health.

The historic 2010 BP Deepwater Horizon Oil Spill (DHOS) led to public distress regarding potential impacts on children in nearby Gulf Coast communities. Using a community-based South Louisiana panel study of households with children, we examined the effect of fishing industry employment on changes in a subjective measure of general child health and whether economic and physical DHOS exposures played a mediating role. Fishing industry employment had a negative effect on child health compared to other industries. Economic exposure and physical exposure both mediated the effects of the fishing industry on child health, with economic exposure mediating a larger share (49.3%) of the relationship compared to physical exposure (40.5%). The importance of economic oil spill exposure in these findings highlights the significance of social determinants of health at the intersection of disasters and child vulnerability.

Purpose: To assess whether trajectories of children’s physical health problems differ by parental college degree attainment in Louisiana areas highly impacted by the 2010 BP Deepwater Horizon oil spill (BP-DHOS). Design: Three waves of panel data (2014, 2016, and 2018) from the Gulf Coast Population Impact / Resilient Children, Youth, and Communities studies. Setting: BP-DHOS-impacted communities in coastal Louisiana. Participants: Parents of children aged 4-18 in a longitudinal probability sample (n = 392). Measures: Reported child physical health problems from the BP-DHOS, parental college degree attainment, and covariates. Analysis: Linear growth curve models are used to assess initial levels of and the rate of change in child physical unknown. The current study uses 3 waves physical health problems by parental college degree attainment. Explanatory variables are measured at baseline and the outcome variable is measured at all 3 waves. Results: Compared to children of parents without college degrees, children of college graduates had fewer initial health problems in 2014 (b = −.33; p = .02). Yet, this health advantage decreased over time, as indicated by their positive rate of change (b = .22; p = .01), such that the higher education health advantage was not statistically significant by 2018. Conclusion: Children of college graduates experienced a physical health advantage following the BP-DHOS, but this gap closed over time. The closure of the gap was due to the children of college graduates experiencing significant increases in reported health problems over the study period.

Objective: This study examines family strategies for coping and adaptation to social disruption from the 2010 Deepwater Horizon oil spill (DHOS) in south Louisiana. Background: The DHOS is a technological disaster of unprecedented scale and ongoing impact, including the socioeconomic disruption of families. Method: Using data from focus groups, grounded‐theory methods informed a thematic analysis of spill‐related economic loss and coping mechanisms among families in the spill‐affected region. Results: Key findings were as follows: (a) long‐term economic impacts persisted but were nuanced and differed across places; (b) for families living in multistressor environments, concerns about the DHOS spilled over into other aspects of social functioning and became enmeshed with perceptions of other environmental stressors; and (c) economic exposure after the DHOS affected families differently based on social position and community social structure. Conclusion: This study contributes to existing knowledge on technological disaster and family resilience in the face of environmental shocks and stressors, underscoring the utility of the conservation of resources model of stress in this area of research. Implications: This research offers information about family‐level response to oil spill impacts and may be of interest to policymakers and practitioners who work to support resilience in disaster contexts.

Endovascular thrombectomy (ET) for acute large vessel occlusion reduces infarct size, and it should hypothetically decrease the incidence of major ischemic strokes requiring decompressive craniectomy (DC). The aim of this retrospective cohort study is to determine trends in the utilization of ET versus DC for stroke in the United States over a 10-year span.We extracted data from the Nationwide Inpatient Sample using International Classification of Diseases-9/10 codes from 2006-2016. Patients with a primary diagnosis of stroke were included. Baseline demographics, outcomes, and hospital charges were analyzed.The study cohort comprised 14,578,654 patients diagnosed with stroke. During the study period, DC and ET were performed in 124,718 and 62,637 patients, respectively. The number of stroke patients who underwent either ET or DC increased by 266% from 2006 to 2016. During that time period, the ET utilization rate increased (0.19% in 2006 to 14.07% in 2016, P0.0004), whereas the DC utilization rate decreased (7.07% in 2006 to 6.43% in 2016, P0.0001). In 2015, the utilization rate of ET (9.73%) exceeded that of DC (9.67%). ET-treated patients had shorter hospitalization durations (mean 8.8 vs. 16.8 days, P0.0001), lower mortality (16.2% vs. 19.3%), higher likelihood of discharge home (27.1% vs. 24.1%, P0.0001), and reduced hospital charges (mean $189,724 vs. $261,314, P0.0001).We identified an inverse relationship between national trends in rising ET and diminishing DC utilization for stroke treatment over a recent decade. Although direct causation cannot be inferred, our findings suggest that ET curtails the necessity for DC.

The West Kowloon Cultural District Artist Square Bridge (ASB) is a part of Hong Kong’s new art and cultural district development. It forms a primary pedestrian link between the adjacent MTR station and the new development. ASB is a design-and-build project consisting of a 78m clear spanning, 8m wide footbridge, an access lift tower and a 30m long staircase and escalators. The footbridge is a covered, dual steel arch and Vierendeel truss footbridge, that crosses an existing flyover, connecting the station shopping mall to the new development. During construction of ASB, very limited space was available on the new development site to accommodate the construction of ASB. These posed engineering challenges to the design and construction team. This paper presents the design of the ASB structures with particular focus on the main footbridge, and the challenges encountered during the design and construction of ASB and how incremental launching solution was developed to tackle these challenges.

S. pneumoniae is a primary etiologic agent of CAP in immunocompromised adults (ICA). Data on clinical outcomes of ICA hospitalized with pneumococcal pneumonia (PP) is limited. The objectives of this study were (1) to define clinical presentation and outcomes of ICA hospitalized with PP and (2) to compare the data to non-immunocompromised adults (non-ICA) hospitalized with PP. This was a case–control study of ICA hospitalized with PP (cases) and non-ICA hospitalized with PP (controls). Data were collected on clinical presentation, treatment, and outcomes. Evaluated clinical outcomes included time to clinical stability (TCS), length of hospitalization (LOH), clinical failure (CF), cardiovascular events (CE), and in-hospital mortality (IHM). One ICA was matched to two non-ICA through propensity score matching. A total of 93 ICA hospitalized with PP and 186 non-ICA hospitalized with PP were evaluated. Antibiotic therapy was appropriate in all patients. Clinical outcomes for ICA versus non-ICA were as follows: TCS 2 days vs. 2 days (p = 0.392), LOH 5 days vs. 5 days (p = 0.067), CF 4% vs. 6% (p = 0.618), CE 10% vs. 6% (p = 0.375), and IHM 5% vs. 3% (p = 0.296). In hospitalized patients with PP who are treated with appropriate antibiotic therapy, the presence of an abnormal immune system does influence clinical outcomes.

Family resilience raises the question of how family units adapt to external shocks. One notable form of such shocks are disasters. Research shows that disasters are occurring with greater frequency and severity throughout the world. Natural and human-made hazards pose an ongoing threat to positive family functioning everywhere, making it difficult to ignore the importance of disaster resilience for research and practice concerning family wellbeing. In this chapter, we examine the issue of family resilience in the context of disaster. We begin by articulating what is meant by hazards and disasters and how that links to family resilience. In doing so, we stress the importance of adaptive capacity and trajectories over time. We then provide an illustration of ongoing research related to the Resilient Children, Youth, and Communities (RCYC) project, a joint venture between researchers at Louisiana State University (LSU) and Columbia University’s National Center for Disaster Preparedness (NCDP), concerning family resilience in the context of the BP Deepwater Horizon oil spill. We close by outlining considerations for research, policy, and practice.

BACKGROUND Preoperative depression is a risk factor for poor outcomes after spine surgery. OBJECTIVE To understand effects of depression on spine surgery outcomes and healthcare resource utilization. METHODS Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use. RESULTS Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery. CONCLUSION EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.

Following the Deepwater Horizon oil spill on April 20, 2010, information was widely broadcast through social media platforms such as Twitter. This study aimed to gain insights into the content and flow of the tweets that had shaped the conversation related to the oil spill within the first 4 months of the rig explosion and to understand how these online interactions may have contributed to disaster response and resilience. A set of tweets (n = 876,298) was identified and processed to yield 736,324 clean tweets. The study used a mixed-methods approach, including human coding, machine learning and social network analysis to examine the online discourse. Visualizations were used to present the patterns and connections within the dataset into a more readable and interpretable format. Our analysis revealed that popular themes such as environmental and economic concerns, clean-up and volunteering, health impacts and frustration towards BP had contributed to the shaping of the discourse. The Twitter users included seekers and providers of information and resources. Another group of users, local volunteers and digital activists, functioned as boundary spanners by facilitating information flow between the seekers and the providers. Additionally, Twitter had been used for risk communication and the dissemination of factual health information. The online communication and coordination efforts may have contributed to the mitigation of the impacts of the oil spill. Our findings suggest that social media empowered community-based users, affording access to power brokers, reliable information, the formation of online networks and social capital and potentially contributed to their resilience.

The BP Deepwater Horizon oil spill (DHOS) created widespread concern about threats to health among residents of the Louisiana Gulf Coast. This study uses data from the Resilient Children, Youth, and Communities study—a longitudinal cohort survey of households with children in DHOS-affected areas of South Louisiana—to consider the effect of DHOS exposure on health trajectories of children, an especially vulnerable population subgroup. Results from latent linear growth curve models show that family DHOS exposure via physical contact and job/income loss both negatively influenced initial child health. However, the effects of physical exposure dissipated over time while the effects of job/income loss persisted. This pattern holds for both general child health and the number of recent physical health problems children had experienced. These findings help to bridge the literature on disaster impacts and resilience/vulnerability, with the literature on socioeconomic status as a fundamental cause of health outcomes over the life course.

Many nanotoxicological studies have assessed the acute toxicity of nanoparticles (NPs) at high exposure concentrations. There is a gap in understanding NP chronic environmental effects at lower exposure concentrations. This study reports life-cycle chronic toxicity of sublethal exposures of polyvinylpyrrolidone-coated silver nanoparticles (PVP-AgNPs) relative to dissolved silver nitrate (AgNO3) for the estuarine meiobenthic copepod, Amphiascus tenuiremis, over a range of environmentally relevant concentrations, i.e., 20, 30, 45, and 75 µg-Ag L−1. A concentration-dependent increase in mortality of larval nauplii and juvenile copepodites was observed. In both treatment types, significantly higher mortality was observed at 45 and 75 µg-Ag L−1 than in controls. In AgNO3 exposures, fecundity declined sharply (1.8–7 fold) from 30 to 75 µg Ag L−1. In contrast, fecundity was not affected by PVP-AgNPs exposures. A Leslie matrix population-growth model predicted sharply 60–86% of decline in overall population sizes and individual life-stage numbers from 30–75 µg-Ag L−1 as dissolved AgNO3. In contrast, no population growth suppressions were predicted for any PVP-AgNPs exposures. Slower release of dissolved Ag from PVP-AgNPs and/or reduced Ag uptake in the nanoform may explain these sharp contrasts in copepod response.

The Small Subunit Ribosomal RNA gene (SSU rDNA) is a widely used tool to reconstruct phylogenetic relationships among foraminiferal species. Recently, the highly variable regions of this gene have been proposed as DNA barcodes to identify foraminiferal species. However, the resolution of these barcodes has not been well established, yet. In this study, we evaluate four SSU rDNA hypervariable regions (37/f, 41/f, 43/e, and 45/e) as DNA barcodes to distinguish among species of the genus Bolivina, with particular emphasis on Bolivina quadrata for which ten new sequences (KY468817-KY468826) were obtained during this study. Our analyses show that a single SSU rDNA hypervariable sequence is insufficient to resolve all Bolivina species and that some regions (37/f and 41/f) are more useful than others (43/e and 45/e) to distinguish among closely related species. In addition, polymorphism analyses reveal a high degree of variability. In the context of barcoding studies, these results emphasize the need to assess the range of intraspecific variability of DNA barcodes prior to their application to identify foraminiferal species in environmental samples; our results also highlight the possibility that a longer SSU rDNA region might be required to distinguish among species belonging to the same taxonomic group (i.e., genus). This article is protected by copyright. All rights reserved.

Crude oil and its water-accommodated fractions (WAF) have the potential to cause catastrophic damage to aquatic ecosystems when released. A new nanomaterial (NM), composed of polyvinylpyrrolidone-coated iron oxide, has been successfully used to remediate oil-contaminated waters. In this study, the toxicity of these NMs, crude oil WAF, and their mixtures was evaluated using an acute toxicity assay based on the estuarine copepod Amphiascus tenuiremis. Results showed that the NMs had no significant effect on copepod survival up to concentrations of 25 mg L−1 over 4 days. For comparison, optimal oil removal from the aqueous phase was shown to be at 18 mg L−1 over 1 hour. WAF was highly-toxic to copepods (mortality 95 ± 5%). Mixing and magnetic removal of NMs within 1 hour of exposure to WAF resulted in a >90% reduction in toxicity compared to the control sample that contained WAF with no NMs. Addition of NMs to WAF at times up to 72 hours without magnetic separation also resulted in significantly reduced toxicity, suggesting that the physical form of the oil : NM mixture influenced toxicity. The addition of oil degrading-bacteria to WAF treated with NMs resulted in significant stimulation of bacterial growth relative to WAF without NMs, likely because of the input of additional available Fe and C sources. These initial data suggest that under realistic environmental conditions, these NMs could be added rapidly to oil spills in marine systems to reduce acute oil toxicity and increase oil degradation.

In August 2017, Hurricane Harvey struck the US Gulf Coast and caused more than US $125 billion in damages in Texas. The loss of lives and the economic damages resulted in an outpouring of support for the recovery efforts in the form of federal assistance and private donations. The latter has supported more creative approaches to recovery. Organizations that normally would not receive funding were able to obtain resources to use in novel manners. Using the framework of Dynes typology to identify groups and their respective structures and tasks, this report from the field analyzes Hurricane Harvey and the financial support mechanisms used to support recovery efforts in Texas, what organizations were funded to do, and where they fit into Dynes typology. The authors close by noting the importance of these emerging organizations and the need to support diversity in funding disaster response and recovery efforts beyond large nonprofit organizations.

PLoS pathogens 15(3), e1007620 - (2019). doi:10.1371/journal.ppat.1007620, Published by PLoS, Lawrence, Kan.

The release of platinum group elements, including platinum nanoparticles (PtNPs), has been increasing over recent decades. However, few studies have investigated the fate, behavior and effects of PtNPs in environmental media. Here, we report a protocol for the synthesis of five different sizes (8.5 ± 1.2, 10.3 ± 1.3, 20.0 ± 4.8, 40.5 ± 4.1, and 70.8 ± 4.2 nm) of monodispersed citrate- and polyvinylpyrrolidone (PVP)-coated PtNPs, together with a characterization of their behaviors using a multi method approach in relevant biological and toxicological media. In general, PtNPs sizes measured using dynamic light scattering, field flow fractionation, single-particle inductively-coupled plasma-mass spectroscopy, transmission electron microscopy and atomic force microscopy, were all in good agreement when PtNP sizes were larger than the size detection limits of each analytical technique. Slight differences in sizes measured were attributable to differences in analytical techniques, measuring principles, NP shape and NP permeability. The thickness of the PVP layer increased (from 4.4 to 11.35 nm) with increases in NP size. The critical coagulation concentration of cit-PtNPs was independent of NP size, possibly due to differences in PtNPs surface charges as a function of NP size. PtNPs did not undergo significant dissolution in any media tested. PtNPs did not aggregate significantly in Dulbecco's modified Eagle's medium; but they formed aggregates in moderately hard water and in 30 ppt synthetic seawater, and aggregate size increased with increases in PtNPs concentration. Overall, this study describes a general model NP system (i.e., PtNPs) of different controlled NP sizes and coatings that is predictable, stable and useful to investigate the fate, behavior, uptake, and eco-toxicity of NPs in the environment.

Little is known about environmental biodegradability or biotransformations of single-walled carbon nanotubes (SWNT). Because of their strong association with aquatic organic matter, detailed knowledge of the ultimate fate and persistence of SWNT requires investigation of possible biotransformations (i.e., biodegradation) in environmental media. In the present study, [14C]SWNT were utilized to track biodegradation over 6 mo by pure liquid culture of the fungus Trametes versicolor and mixed bacterial isolates from field-collected sediment or aerated wastewater treatment plant sludge. The mixed cultures were chosen as more environmentally relevant media where SWNT will likely be deposited under both aerobic and anaerobic conditions. Activity of [14C] was assessed in solid, aqueous, and 14CO2 gaseous phases to determine amounts of intact SWNT, partially soluble SWNT degradation products, and mineralized SWNT, respectively, during the 6 mo of the experiment. Mass balances based on radiocarbon activity were approximately 100% over 6 mo, and no significant degradation of SWNT was observed. Approximately 99% of the [14C] activity remained in the solid phase, 0.8% in the aqueous phase, and less than 0.1% was mineralized to 14CO2, regardless of culture type. These results suggest that SWNT are not readily biodegraded by pure fungal cultures or environmental microbial communities, and are likely persistent in environmental media. Environ Toxicol Chem 2014;9999:1–5. © 2014 SETAC

Detection and quantification of engineered nanoparticles (NPs) in environmental systems is challenging and requires sophisticated analytical equipment. Furthermore, dissolution is an important environmental transformation process for silver nanoparticles (AgNPs) which affects the size, speciation and concentration of AgNPs in natural water systems. Herein, we present a simple approach for the detection, quantification and measurement of dissolution of PVP-coated AgNPs (PVP-AgNPs) based on monitoring their optical properties (extinction spectra) using UV-vis spectroscopy. The dependence of PVP-AgNPs extinction coefficient (ɛ) and maximum absorbance wavelength (λmax) on NP size was experimentally determined. The concentration, size, and extinction spectra of PVP-AgNPs were characterized during dissolution in 30ppt synthetic seawater. AgNPs concentration was determined as the difference between the total and dissolved Ag concentrations measured by inductively coupled plasma-mass spectroscopy (ICP-MS); extinction spectra of PVP-AgNPs were monitored by UV-vis; and size evolution was monitored by atomic force microscopy (AFM) over a period of 96h. Empirical equations for the dependence of maximum absorbance wavelength (λmax) and extinction coefficient (ɛ) on NP size were derived. These empirical formulas were then used to calculate the size and concentration of PVP-AgNPs, and dissolved Ag concentration released from PVP-AgNPs in synthetic seawater at variable particle concentrations (i.e. 25-1500μgL-1) and in natural seawater at particle concentration of 100μgL-1. These results suggest that UV-vis can be used as an easy and quick approach for detection and quantification (size and concentration) of sterically stabilized PVP-AgNPs from their extinction spectra. This approach can also be used to monitor the release of Ag from PVP-AgNPs and the concurrent NP size change. Finally, in seawater, AgNPs dissolve faster and to a higher extent with the decrease in NP concentration toward environmentally relevant concentrations.

In large-scale disasters that include but are not limited to detonation of an improvised nuclear device, a major earthquake, or another large hurricane striking a major US city, we will simultaneously lose health care system capacity with damage to facilities while needing to care for a surge of injured and ill people seeking care. This cannot be accomplished by a single or few facilities, but requires a region-wide plan.

ObjectiveThis collective case study examined how and why specific organizational decision-making processes transpired at 2 large suburban county health departments in lower New York State during their response to Hurricane Sandy in 2012. The study also examined the relationships that the agencies developed with other emerging and established organizations within their respective health systems.MethodsIn investigating these themes, the authors conducted in-depth, one-on-one interviews with 30 senior-level public health staff and first responders; reviewed documentation; and moderated 2 focus group discussions with 17 participants.ResultsAlthough a natural hazard such as a hurricane was not an unexpected event for these health departments, they nevertheless confronted a number of unforeseen challenges during the response phase: prolonged loss of power and fuel, limited situational awareness of the depth and breadth of the storm’s impact among disaster-exposed populations, and coordination problems with a number of organizations that emerged in response to the disaster.ConclusionsPublic health staff had few plans or protocols to guide them and often found themselves improvising and problem-solving with new organizations in the context of an overburdened health care system (Disaster Med Public Health Preparedness. 2016;10:436–442).

Correspondence avoid surgery in rapidly progressive or chemo-insensitive disease. 4 Genotyping of pancreatic tumours via fine needle aspiration could influence the clinical management of pancreatic cancer. Fine-needle aspiration sequencing was used to identify subgroups of patients with specific actionable mutations related to resectable or locally advanced tumours. 5 In patients with radiologically resectable or borderline resectable tumours, preoperative fine-needle aspiration sequencing could distinguish between patients with a genetic pattern associated with micrometastatic tumours, who should undergo neoadjuvant therapy, and those with a truly localised disease that would be amenable to a surgery-first strategy. Michele Reni has served as a consultant for or on the advisory boards of Celgene, Boehringer-Ingelheim, Lilly, Genentech, Baxalta, Novocure, Astra-Zeneca, Pfizer, and Merck-Serono, and has received honoraria from Celgene. Massimo Falconi has received honoraria from Celgene, Ipsen and Novartis. The other authors declare no competing interests. *Stefano Crippa, Michele Reni, Gianpaolo Balzano, Claudio Doglioni, Massimo Falconi crippa1.stefano@hsr.it Division of Pancreatic Surgery, IRCCS San Raffaele Hospital, Milan, Italy (SC, GB, MF); Medical Oncology Department, IRCCS San Raffaele Hospital , Milan, Italy (MR); Department of Pathology, IRCCS San Raffaele Hospital , Milan, Italy (CD); Clinical and Translational Research Program on Pancreatic Cancer, IRCCS San Raffaele Hospital, Milan, Italy (SC, MR, GB, CD, MF) e178 Barreto SG, Windsor JA. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24 Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefit of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; 103: 179–91. Bapat AA, Hostetter G, Von Hoff DD, Han H. Perineural invasion and associated pain in pancreatic cancer. Nat Rev Cancer 2011; Sohal DP, Walsh RM, Ramanathan RK, Khorana AA. Pancreatic adenocarcinoma: treating a systemic disease with systemic therapy. J Natl Cancer Inst 2014; 106: dju011 Valero V, Saunders TJ, He J, et al. Reliable detection of somatic mutations in fine needle aspirates of pancreatic cancer with next-generation sequencing: implications for surgical management. Ann Surg 2016; Author’s reply Stefano Crippa and colleagues, in responding to our manuscript, 1 agree that increasing the radicality of surgery for pancreatic ductal adenocarcinoma, including synchronous vein resection, is suspect. Indeed, a recent meta-analysis 2 indicates that synchronous vein resection, as reported, increases mortality and decreases survival. Crippa and colleagues put forward two interesting ideas that warrant further discussion. The first is that the surgery-first approach for pancreatic ductal adenocarcinoma might ultimately be retired, given that pancreatic ductal adenocarcinoma is usually systemic at presentation, local treatments have little effect, and neoadjuvant therapy has possible benefits. For now, the absence of high-level evidence for neoadjuvant therapy leaves largely theoretical benefits; namely that neoadjuvant therapy will reveal the biology (ie, those patients that can progress on neoadjuvant therapy will avoid futile surgery), or alter the biology (ie, those patients that are downstaged will become resectable). The preliminary results of the ALLIANCE trial 3 damages the lustre of these purported benefits with no improvement in the number of resections (10 [50%] of 20 patients who completed all preoperative therapy), and no rescue of aggressive tumour biology. This leads to the second idea, in which Crippa and colleagues suggest a biological (rather than radiological) basis for selecting patients for neoadjuvant therapy with a view to reduce the number of synchronous vein resections. Endoscopic ultrasonography- guided genotyping is a possible way to select subgroups of patients with heterogenous pancreatic ductal adenocarcinoma 4 who will benefit from neoadjuvant therapy. In support of this method, Hruban and colleagues 5 suggested that an intact SMAD4/DPC4 gene might be used to select surgery because there is lesser risk of distant metastases for this genotype. 6 In the future, we hope to more accurately select a subgroup of patients in whom a surgery-first approach, and even synchronous vein resection, is justified, but it is much more likely that precision neoadjuvant therapy will ultimately result in less radical surgery and the introduction of non-surgical techniques to support the response to neoadjuvant therapy. We declare no competing interests. Savio G Barreto, *John A Windsor j.windsor@auckland.ac.nz Department of Gastrointestinal Surgery, Gastrointestinal Oncology, and Bariatric Surgery, Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, The Medicity, Gurgaon, India (SGB); Hepatobiliary Pancreatic and Upper GI Unit, Department of General Surgery, Auckland City Hospital, Auckland, New Zealand (JAW) Barreto S, Windsor J. Justifying vein resection with pancreatoduodenectomy. Lancet Oncol 2016; 17: e118–24. Giovinazzo F, Turri G, Katz MH, Heaton N, Ahmed I. Meta-analysis of benefits of portal-superior mesenteric vein resection in pancreatic resection for ductal adenocarcinoma. Br J Surg 2016; Varadhachary G, Fleming J, Crane C, et al. Phase II study of preoperation mFOLFIRINOX and chemoradiation for high-risk resectable and borderline resectable pancreatic adenocarcinoma. Proc Am Soc Clin Oncol 2015; 33 (suppl 3): abstr 362. Killock D. Pancreatic cancer: a problem quartered—new subtypes, new solutions? Nat Rev Clin Oncol 2016; 13: 201. Hruban RH, Adsay NV. Molecular classification of neoplasms of the pancreas. Hum Pathol Iacobuzio-Donahue CA, Fu B, Yachida S, et al. DPC4 gene status of the primary carcinoma correlates with patterns of failure in patients with pancreatic cancer. J Clin Oncol 2009; The US Cancer Moonshot initiative We recently sent the following letter to Vice President of the USA, Joe Biden, to state that we, as Deans and Directors of Public Health schools and programmes around the USA, strongly support the goals of the Cancer Moonshot initiative to www.thelancet.com/oncology Vol 17 May 2016

Professional training development, whether for a classroom, work environment, or other setting, typically follows a validated instructional design model that includes an assessment of learner needs before the development of a training. This foundational principle is integrated into federal guidance documents for emergency preparedness training. That said, local preparedness resources are sometimes in misalignment with this principle. Funding tends to favor nationally defined priorities as a proxy for the assessment of local needs. This letter explores this dynamic in the context of the response to Superstorm Sandy, and proposes a revised funding paradigm to support training development.

Adsorption of hydrophobic organic contaminants (HOCs) to black carbon is a well-studied phenomenon. One emerging class of engineered black carbon materials are single-walled carbon nanotubes (SWNTs). Little research has investigated the potential of SWNT to adsorb and sequester HOCs in complex environmental systems. This study addressed the capacity of SWNT, amended to polychlorinated biphenyl (PCB)-contaminated New Bedford Harbor (NBH) sediment, to reduce the toxicity and bioaccumulation of these HOCs to benthic organisms. Overall, SWNT amendments increased the survival of two benthic estuarine invertebrates, Americamysis bahia and Ampelisca abdita, and reduced the accumulation of PCBs to the benthic polychaete, Nereis virens. Reduction in PCB bioaccumulation by SWNT was independent of Kow. Further, passive sampling-based estimates of interstitial water concentrations indicated that SWNT reduced PCB bioavailability. Results from this study suggest that SWNT are a good adsorbent for PCBs and might be useful for remediation in the future once SWNT manufacturing technology improves and costs decrease.

Several of the most disconcerting and compelling news events of the 21st century pertain to natural and human-caused disasters. However, these themes are generally absent in the social studies, civics, science, or mathematics curricula of most U.S. K-12 schools. Similarly, discussions about ways to incorporate new digital tools, such as mobile tablet computers and apps into such discussions are also overlooked. This chapter provides a roadmap for considering disaster-oriented themes in the K-12 curriculum and then provides several examples of apps that can be included in classroom lessons along with guidelines for incorporating these digital tools into pedagogical practices. The authors have framed their analysis within the context of mLearning as a way to address cross-disciplinary themes via mobile technologies.