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Introduction: Acetaminophen poisoning is commonly treated by emergency physicians. First-line therapy is N-acetylcysteine (NAC), traditionally administered intravenously via a US Food and Drug Administration (FDA)-approved three-bag protocol in which each bag has a unique concentration and infusion duration. Recently, simplified, off-label two-bag NAC infusion protocols have become more common. The purpose of this review is to summarize the effectiveness and safety of two-bag NAC.Methods: We undertook a comprehensive search of PubMed, EMBASE, and MEDLINE from inception to December 13, 2022, for articles describing human acetaminophen poisonings treated with two-bag NAC, defined as any regimen involving two discrete infusions in two separate bags. Outcomes included effectiveness (measured by incidence of liver injury); incidence of non-allergic anaphylactoid reactions (NAAR); gastrointestinal, cutaneous, and systemic reactions; treatments for NAARs; incidence of NAC-related medication errors; and delays or interruptions in NAC administration.Results: Twelve articles met final inclusion, 10 of which compared two-bag NAC to the three-bag regimen. Nine articles evaluated the two-bag/20-hour regimen, a simplified version of the FDA-approved three-bag regimen in which the traditional first and second bags are combined into a single four-hour infusion. Nine articles assessed comparative effectiveness of two-bag NAC in terms of liver injury, most commonly assessed for by incidence of hepatotoxicity (aspartate aminotransferase or alanine aminotransferase >1,000 international units per liter). No difference in liver injury was observed between two-bag and three-bag regimens. Of nine articles comparing incidence of NAARs, eight demonstrated statistically fewer NAARs with two-bag regimens, and one showed no difference. In seven articles evaluating treatment for NAARs (antihistamines, corticosteroids, epinephrine), all showed that patients received fewer medications for NAARs with two-bag NAC. Three articles evaluated NAC-related medication errors; two demonstrated no difference, while one study evaluating only children showed fewer errors with two-bag NAC. Two studies evaluated delays and/or interruptions in NAC infusions; both favored two-bag NAC.Conclusion: For patients with acetaminophen poisoning, two-bag NAC regimens appear to have similar outcomes to the traditional three-bag regimen in terms of liver injury. Two-bag NAC regimens are associated with fewer adverse events and fewer treatments for those events than the three-bag regimen and fewer interruptions in antidotal therapy.

Here, we report that the LynB splice variant of the Src-family kinase Lyn exerts a dominant immunosuppressive function in vivo, whereas the LynA isoform is uniquely required to restrain autoimmunity in female mice. We used CRISPR-Cas9 gene editing to constrain lyn splicing and expression, generating single-isoform LynA knockout (LynAKO) or LynBKO mice. Autoimmune disease in total LynKO mice is characterized by production of antinuclear antibodies, glomerulonephritis, impaired B cell development, and overabundance of activated B cells and proinflammatory myeloid cells. Expression of LynA or LynB alone uncoupled the developmental phenotype from the autoimmune disease: B cell transitional populations were restored, but myeloid cells and differentiated B cells were dysregulated. These changes were isoform-specific, sexually dimorphic, and distinct from the complete LynKO. Despite the apparent differences in disease etiology and penetrance, loss of either LynA or LynB had the potential to induce severe autoimmune disease with parallels to human systemic lupus erythematosus (SLE).

Background: Proper diagnosis in primary care is crucial due to the large number of skin cancer diagnoses each year and its associated growing economic burden. Understanding how primary care providers can be best trained in dermoscopy is instrumental in helping primary care providers differentiate benign and malignant cutaneous lesions so that appropriate action can be taken (eg, biopsy/referral to dermatology or reassurance). Objective: To assess the success of concise dermoscopy training among primary care providers. Design: A cohort study was conducted in primary care at Mayo Clinic, Rochester, including primary care physicians, nurse practitioners, and physician assistants in internal medicine and family medicine. Diagnostic accuracy was measured on standardized testing through image-based recognition and in clinical practice through observation of referral and biopsy patterns both before and after dermoscopy education, focused on the TADA plus method. Results: Forty-three primary care providers completed the image-based recognition tests, with significant improvement in mean score measured after dermoscopy training workshop (20%). Among the thirteen primary care providers who continued to use dermoscopy in clinical practice, a significant improvement (31%) in mean clinical diagnostic accuracy was observed comparing 1 year of practice data before versus after dermoscopy training. Conclusion: Improvement in diagnostic accuracy with utilization of the TADA plus method translates into clinical practice. Therefore, training primary care providers in dermoscopy may improve the dermatologic care patients receive in primary care, especially in rural or medically underserved areas where access to dermatology is limited. [ABSTRACT FROM AUTHOR]

Whole air drawn from four heights within the high elevation (3,340 m asl), deep, winter snowpack at Niwot Ridge, Colorado, were sampled into stainless steel canisters, and subsequently analyzed by gas chromatography for 51 volatile inorganic and organic gases. Two adjacent plots with similar snow cover were sampled, one over bare soil and a second one from within a snow-filled chamber where Tedlar/Teflon-film covered the ground and isolated it from the soil. This comparison allowed for studying effects from processes in the snowpack itself versus soil influences on the gas concentrations and fluxes within and through the snowpack. Samples were also collected from ambient air above the snow surface for comparison with the snowpack air. Analyzed gas species were found to exhibit three different kinds of behavior: (1) One group of gases, i.e., carbon dioxide (CO₂), chloroform (CHCl₃), dimethylsulfide (CH₃)₂S, carbondisulfide (CS₂), and dichlorobromomethane (CHBrCl₂), displayed higher concentrations inside the snow, indicating a formation of these species and release into the atmosphere. (2) A second group of compounds, including carbon monoxide (CO), carbonyl sulfide (COS), the hydrocarbons methane, ethane, ethyne, benzene, and the halogenated compounds methylchloride (CH₃Cl), methylbromide (CH₃Br), dibromomethane (CH₂Br₂), bromoform (CHBr₃), tetrachloromethane (CCl₄), CFC-11, CFC-12, HCFC-22, CFC-113, 1,2-dichloroethane, methylchloroform, HCFC-141b, and HCFC-142b, were found at lower concentrations in the snow, indicating that the snow and/or soil constitute a sink for these gases. (3) For 21 other gases absolute concentrations, respectively concentration gradients, were too low to unequivocally identify their uptake or release behavior. For gases listed in the first two groups, concentration gradients were incorporated into a snowpack gas diffusion model to derive preliminary estimates of fluxes at the snow-atmosphere interface. The snowpack gradient flux technique was found to offer a highly sensitive method for the study of these surface gas exchanges. Microbial activities below this deep, winter snowpack appear to be the driving mechanism behind these gas sources and sinks. Flux results were applied to a simple box model to assess the potential contribution of the snowpack uptake rates to atmospheric lifetimes of these species.

Measurements of organic carbon compounds in both the gas and particle phases made upwind, over and downwind of North America are synthesized to examine the total observed organic carbon (TOOC) in the atmosphere over this region. These include measurements made aboard the NOAA WP-3 and BAe-146 aircraft, the NOAA research vessel Ronald H. Brown, and at the Thompson Farm and Chebogue Point surface sites during the summer 2004 ICARTT campaign. Both winter and summer 2002 measurements during the Pittsburgh Air Quality Study are also included. Lastly, the spring 2002 observations at Trinidad Head, CA, surface measurements made in March 2006 in Mexico City and coincidentally aboard the C-130 aircraft during the MILAGRO campaign and later during the IMPEX campaign off the northwestern United States are incorporated. Concentrations of TOOC in these datasets span more than two orders of magnitude. The daytime mean TOOC ranges from 4.0 to 456 mu gCm(-3) from the cleanest site (Trinidad Head) to the most polluted (Mexico City). Organic aerosol makes up 3-17% of this mean TOOC, with highest fractions reported over the northeastern United States, where organic aerosol can comprise up to 50% of TOOC. Carbon monoxide concentrations explain 46 to 86% of the variability in TOOC, with highest TOOC/CO slopes in regions with fresh anthropogenic influence, where we also expect the highest degree of mass closure for TOOC. Correlation with isoprene, formaldehyde, methyl vinyl ketone and methacrolein also indicates that biogenic activity contributes substantially to the variability of TOOC, yet these tracers of biogenic oxidation sources do not explain the variability in organic aerosol observed over North America. We highlight the critical need to develop measurement techniques to routinely detect total gas phase VOCs, and to deploy comprehensive suites of TOOC instruments in diverse environments to quantify the ambient evolution of organic carbon from source to sink.

We present data collected from a number of snow-covered environments including two polar locations (Summit, Greenland and the South Pole) and two mid-latitude regions (a remote site in northern Michigan, and Niwot Ridge, Colorado). At each site, concentrations of CH3 I and C2 H5 I were enhanced within the interstitial air near the snow surface, compared to levels in boundary layer air. Fluxes of CH3 Br from surface snow to the atmosphere were observed at each site except Niwot Ridge, where CH3 Br appeared to have a sink. The mid-latitude sites showed significant emissions of CH3 Cl, mostly originating at the ground surface and traveling up through the snow, while at the polar locations CH3 Cl emissions from firn air were relatively small. In general, methyl halide mixing ratios in firn air were significantly greater at Summit than at the South Pole, with Summit showing a strong diurnal cycle in the production of alkyl halides that was well correlated with actinic radiation and firn temperature. We suggest that the most likely route to alkyl halide formation is through an acid catalyzed nucleophilic substitution of an alcohol type function by a halide, both of which should be preferentially segregated to the quasi-liquid layer at the surface of the snow grains. A series of experiments using a snow-filled quartz chamber irradiated by natural sunlight allowed estimation of emission trends that were hard to measure in the natural snowpack. These static chamber experiments confirmed significant production of the primary alkyl halides, following the order CH3 Cl > CH3 Br > C2 H5 Cl > CH3 I > C2 H5 Br > C2 H5 I > 1 - C3 H7 Br > 1 - C3 H7 I. Our observations at all four locations, including polar and mid-latitude sites, imply that alkyl halide production may be associated with all surface snows. © 2007 Elsevier Ltd. All rights reserved.

Experiments were performed at Summit, Greenland (72°34′ N, 38°29′ W) to investigate hydroxyl mixing ratios in the sunlit surface snowpack (or firn). We added a carefully selected mixture of hydrocarbon gases (with a wide range of hydroxyl reactivities) to a UV and visible light transparent flow chamber containing undisturbed natural firn. The relative decrease in mixing ratios of these gases allowed estimation of the lower limit mixing ratio of hydroxyl radicals in the near-surface firn pore spaces. Hydroxyl mixing ratios in the firn air followed a diurnal cycle in summer 2003 (10-12 July), with peak values of more than 3.2×106 molecules cm-3 between 13:00 and 16:00 local time. The minimum value estimated was 1.1×106 molecules cm-3 at 20:00 local time. Results during spring of 2004 showed lower, but rapidly increasing, peak hydroxyl mixing ratios of 1.1×106 molecules cm-3 in the early afternoon on 15 April and 1.5×106 molecules cm-3 on 1 May. Our firn hydroxyl estimates were similar to directly measured above-snow ambient levels during the spring field season, but were only about 30% of ambient levels during summer. © 2007 Elsevier Ltd. All rights reserved.

Volatile organic compounds (VOCs) were measured at the South Pole (SP) from late Austral spring to mid-summer 2000 as part of the Investigation of Sulfur Chemistry in the Antarctic Troposphere Program (ISCAT-2000). This paper focuses on VOCs that are directly emitted from the ocean, specifically dimethyl sulfide (DMS), methyl nitrate (CH3ONO2), methyl iodide (CH 3I) and bromoform (CHBr3). A partial seasonal cycle of these gases was also recorded during the year following ISCAT-2000. During the summer, the SP periodically receives relatively fresh marine air containing short-lived oceanic trace gases, such as DMS (τ≈1 day). However, DMS was not detected at the SP until January even though DMS emissions from the Southern Ocean typically start peaking in November and elevated levels of other ocean-derived VOCs, including CH3ONO2 and CHBr 3, were observed in mid-November. We speculate that in November and December most of the DMS is oxidized before it reaches the SP: a strong correlation between CH3ONO2 and methane sulfonate (MSA), an oxidation product of DMS, supports this hypothesis. Based on a limited number of samples taken over the course of one year, CH3ONO2 apparently accumulates to a quasi-steady-state level over the SP in winter, most likely due to continuing emissions of the compound coupled with a lower rate of photochemical destruction. Oceanic emissions were concluded to be the dominant source of alkyl nitrates at the SP; this is in sharp contrast to northern high latitudes where total alkyl nitrate mixing ratios are dominated by urban sources. © 2004 Elsevier Ltd. All rights reserved.

Concentration measurements of nitric oxide (NO), nitrogen dioxide (NO 2), nitrous acid (HONO), nitric acid (HNO3), formaldehyde (HCHO), hydrogen peroxide (H2O2), formic acid (HCOOH) and acetic acid (CH3COOH) were performed in air filtered through the pore spaces of the surface snowpack (firn air) at Summit, Greenland, in summer 2000. In general, firn air concentrations of NO, NO2, HONO, HCHO, HCOOH, and CH3COOH were enhanced compared to concentrations in the atmospheric boundary layer above the snow. Only HNO3 and H 2O2 normally exhibited lower concentrations in the firn air. In most cases differences were highest during the day and lowest during nighttime hours. Shading experiments showed a good agreement with a photochemical NOx source in the surface snow. Patterns of H 2O2, CH3COOH, and HNO3 observed within the surface snow-firn air system imply that the number of molecules in the snow greatly exceeded that in the firn air. Deduced partitioning indicates that the largest fractions of the acids were present at the ice grain-air interface. In all cases, the number of molecules located at the interface was significantly higher than the amount in the firn air. Therefore, snow surface area and surface coverage are important parameters, which must be considered for the interpretation of firn air concentrations. © 2004 Elsevier Ltd. All rights reserved.

Measurements at Summit, Greenland, performed from June-August 1999, showed significant enhancement in concentrations of several trace gases in the snowpack (firn) pore air relative to the atmosphere. We report here measurements of alkenes, halocarbons, and alkyl nitrates that are typically a factor of 2-10 higher in concentration within the firn air than in the ambient air 1-10m above the snow. Profiles of concentration to a depth of 2m into the firn show that maximum values of these trace gases occur between the surface and 60cm depth. The alkenes show highest pore mixing ratios very close to the surface, with mixing ratios in the order ethene>propene>1-butene. Mixing ratios of the alkyl iodides and alkyl nitrates peak slightly deeper in the firn, with mixing ratios in order of methyl>ethyl>propyl. These variations are likely consistent with different near-surface photochemical production mechanisms. Diurnal mixing ratio variations within the firn correlate well with actinic flux for all these gases, with a temporal offset between the solar maximum and peak concentrations, lengthening with depth. Using a snow-filled chamber under constant flow conditions, we calculated production rates for the halocarbons and alkenes that ranged between 103-105 and 106molecules cm-3s-1, respectively. Taken together, these results suggest that photochemistry associated with the surface snowpack environment plays an important role in the oxidative capacity of the local atmospheric boundary layer, and influences post-depositional chemistry, which in turn may affect the interpretation of certain aspects of the ice core records collected previously at Summit. © 2002 Elsevier Science Ltd. All rights reserved.

Nonmethane hydrocarbons (NMHCs) and selected halocarbons were measured in whole air samples collected over the remote Pacific Ocean during NASA's Global Tropospheric Experiment (GTE) Pacific Exploratory Mission-Tropics B (PEM-Tropics B) in March and early April 1999. The large-scale spatial distributions of NMHCs and C2Cl4 reveal a much more pronounced north-south interhemispheric gradient, with higher concentrations in the north and lower levels in the south, than for the late August to early October 1996 PEM-Tropics A experiment. Strong continental outflow and winter-long accumulation of pollutants led to seasonally high Northern Hemisphere trace gas levels during PEM-Tropics B. Observations of enhanced levels of Halon 1211 (from developing Asian nations such as the PRC) and CH3Cl (from SE Asian biomass burning) support a significant southern Asian influence at altitudes above 1 km and north of 10° N. By contrast, at low altitude over the North Pacific the dominance of urban/industrial tracers, combined with low levels of Halon 1211 and CH3Cl, indicate a greater influence from developed nations such as Japan, Europe, and North America. Penetration of air exhibiting aged northern hemisphere characteristics was frequently observed at low altitudes over the equatorial central and western Pacific south to ∼5° S. The relative lack of southern hemisphere biomass burning sources and the westerly position of the South Pacific convergence zone contributed to significantly lower PEM-Tropics B mixing ratios of the NMHCs and CH3Cl south of 10° S compared to PEM-Tropics A. Therefore the trace gas composition of the South Pacific troposphere was considerably more representative of minimally polluted tropospheric conditions during PEM-Tropics B. Copyright 2001 by the American Geophysical Union.