Strengthening Quality Measurement to Predict Success for Total Knee Arthroplasty: Results from a Nationally Representative Total Knee Arthroplasty Cohort.

BACKGROUND: When performed well on appropriate patients, total knee arthroplasty (TKA) can dramatically improve quality of life. Patient-reported outcome measures (PROMs) are increasingly used to measure outcome following TKA. Accurate prediction of improvement in PROMs after TKA potentially plays an important role in judging the surgical quality of the health-care institutions as well as informing preoperative shared decision-making. Starting in 2027, the U.S. Centers for Medicare & Medicaid Services (CMS) will begin mandating PROM reporting to assess the quality of TKAs. METHODS: Using data from a national cohort of patients undergoing primary unilateral TKA, we developed an original model that closely followed a CMS-proposed measure to predict success, defined as achieving substantial clinical benefit, specifically at least a 20-point improvement on the Knee injury and Osteoarthritis Outcome Score, Joint Arthroplasty (KOOS, JR) at 1 year, and an enhanced model with just 1 additional predictor: the baseline KOOS, JR. We evaluated each model's performance using the area under the receiver operator characteristic curve (AUC) and the ratio of observed to expected (model-predicted) outcomes (O:E ratio). RESULTS: We studied 5,958 patients with a mean age of 67 years; 63% were women, 93% were White, and 87% were overweight or obese. Adding the baseline KOOS, JR improved the AUC from 0.58 to 0.73. Ninety-four percent of those in the top decile of predicted probability of success under the enhanced model achieved success, compared with 34% in its bottom decile. Analogous numbers for the original model were less discriminating: 77% compared with 57%. Only the enhanced model predicted success accurately across the spectrum of baseline scores. The findings were virtually identical when we replicated these analyses on only patients ≥65 years of age. CONCLUSIONS: Adding a baseline knee-specific PROM score to a quality measurement model in a nationally representative cohort dramatically improved its predictive power, eliminating ceiling and floor effects and mispredictions for readily identifiable patient subgroups. The enhanced model neither favors nor discourages care for those with greater knee dysfunction and requires no new data collection. LEVEL OF EVIDENCE: Prognostic Level II . See Instructions for Authors for a complete description of levels of evidence.

Gross ecosystem product (GEP): Quantifying nature for environmental and economic policy innovation.

The large-scale loss of ecosystem assets around the world, and the resultant reduction in the provision of nature's benefits to people, underscores the urgent need for better metrics of ecological performance as well as their integration into decision-making. Gross ecosystem product (GEP) is a measure of the aggregate monetary value of final ecosystem-related goods and services in a specific area and for a given accounting period. GEP accounting captures the use of many ecosystem services in production processes across the economy, which are then valued in terms of their benefits to society. GEP has five key elements that make it transparent, trackable, and readily understandable: (1) a focus on nature's contributions to people; (2) the measurement of ecosystem assets as stocks and ecosystem services as flows; (3) the quantification of ecosystem service use; (4) an understanding of ecosystem service supply chains through value realization; and (5) the disaggregation of benefits across groups. Correspondingly, a series of innovative policies based on GEP have been designed and implemented in China. The theoretical and practical lessons provided by these experiences can support continued policy innovation for green and inclusive development around the world.

Sustainable poverty reduction models for the coordinated development of the social economy and environment in China.

Sustainable development in impoverished areas is still a global challenge owing to trade-offs between development and conservation. There are large poverty-stricken areas (PSAs) in China, which overlap highly with ecologically sensitive areas. China has made great efforts to alleviate poverty over the years. The coordinated relationship between the social economy and the environment in PSAs, however, remains under-recognized. This study developed a county-level index system encompassing the socioeconomic and environmental sectors of China's PSAs. The integrated indexes of the two sectors were developed to reveal the spatial-temporal socioeconomic and environmental patterns and coupling coordination degree (CCD) levels were calculated to assess the coordinated relationships between them. The CCD indicated the increasingly coordinated development of socioeconomic and environmental conditions in China's PSAs from 2000 to 2020. Meanwhile, although the socioeconomic index achieved considerable growth with a growth rate of 58.4%, the environmental index was mildly improved with a growth rate of 19.6%, instead of a reduction. PSAs still have a large gap in socioeconomic development compared to non-poor areas; however, PSAs perform better in environmental index. Overall, the increased coordinated development between the social economy and the environment from 2000 to 2020 can be attributed to China's long-term, large-scale, and targeted interventions in poverty reduction and environmental conservation. Further, benefiting from the geodiversity of China, we identified four poverty reduction models which include advantageously, sustained, periodic, and limited effective models, on the basis of CCD change patterns. The four models can provide valuable experience for the rest of the world in tackling similar trade-offs of poverty reduction and environmental challenges.

Comparison of robotic versus laparoscopic versus open distal gastrectomy for locally advanced gastric cancer: a prospective trial-based economic evaluation.

IMPORTANCE: It is largely unclear whether robotic distal gastrectomy (RDG) is cost-effective for locally advanced gastric cancer (LAGC). OBJECTIVE: To evaluate the cost-effectiveness of RDG, laparoscopic distal gastrectomy (LDG), and open distal gastrectomy (ODG) for patients with LAGC. DESIGN, SETTING, AND PARTICIPANTS: Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. A decision-analytic model was constructed to evaluate the cost-effectiveness of RDG, LDG, and ODG. EXPOSURES: RDG, LDG, and ODG. MAIN OUTCOMES AND MEASURES: Incremental cost-effectiveness ratio (ICER) and quality-adjusted life year (QALY). RESULTS: This pooled analysis of two randomized controlled trials included 449 patients: 117, 254, and 78 patients in the RDG, LDG, and ODG groups, respectively. After IPTW, RDG demonstrated its priority in terms of less blood loss, postoperative length, and complication rate (all P < 0.05). RDG also showed higher QOL with more cost, representing an ICER of $85,739.73 per QALY and $42,189.53 per QALY compared to LDG and ODG, respectively. In probabilistic sensitivity analysis, RDG achieved the best cost-effectiveness for patients with LAGC only when the willingness-to-pay threshold was > $85,739.73 per QALY, which significantly exceeded 3 times Chinese per capita GDP. Furthermore, one of the most important factors was the indirect costs of robotic surgery in terms of the cost-effectiveness of RDG compared to that of LDG or ODG. CONCLUSIONS AND RELEVANCE: Although improved short-term outcomes and QOL were seen in patients underwent RDG, the economic burden should be considered in the clinical decision-making regarding robotic surgery use for patients with LAGC. Our findings may vary in different health care settings and affordability. Trial registration CLASS-01 trial (ClinicalTrials.gov, CT01609309) and FUGES-011 trial (ClinicalTrials.gov, NCT03313700).

Assessment of Laparoscopic Spleen-Preserving Hilar Lymphadenectomy for Advanced Proximal Gastric Cancer Without Invasion Into the Greater Curvature: A Randomized Clinical Trial.

Importance: The survival benefit of laparoscopic total gastrectomy combined with spleen-preserving splenic hilar lymphadenectomy (LSTG) for locally advanced proximal gastric cancer (APGC) without invasion into the greater curvature remains uncertain. Objective: To compare the long-term and short-term efficacy of LSTG (D2 + No. 10 group) and conventional laparoscopic total gastrectomy (D2 group) for patients with APGC that has not invaded the greater curvature. Design, Setting, and Participants: In this open-label, prospective randomized clinical trial, a total of 536 patients with clinical stage cT2 to 4a/N0 to 3/M0 APGC without invasion into the greater curvature were enrolled from January 2015 to October 2018. The final follow-up was on October 31, 2021. Data were analyzed from December 2021 to February 2022. Interventions: Eligible patients were randomized to the D2 + No. 10 group or the D2 group. Main Outcomes and Measures: The primary outcome was 3-year disease-free survival (DFS). The secondary outcomes were 3-year overall survival (OS) and morbidity and mortality within 30 days after surgery. Results: Of 526 included patients, 392 (74.5%) were men, and the mean (SD) age was 60.6 (9.6) years. A total of 263 patients were included in the D2 + No. 10 group, and 263 were included in the D2 group. The 3-year DFS was 70.3% (95% CI, 64.8-75.8) for the D2 + No. 10 group and 64.3% (95% CI, 58.4-70.2; P = .11) for the D2 group, and the 3-year OS in the D2 + No. 10 group was better than that in the D2 group (75.7% [95% CI, 70.6-80.8] vs 66.5% [95% CI, 60.8-72.2]; P = .02). Multivariate analysis revealed that splenic hilar lymphadenectomy was not an independent protective factor for DFS (hazard ratio [HR], 0.86; 95% CI, 0.63-1.16) or OS (HR, 0.81; 95% CI, 0.59-1.12). Stratification analysis showed that patients with advanced posterior gastric cancer in the D2 + No. 10 group had better 3-year DFS (92.9% vs 39.3%; P < .001) and OS (92.9% vs 42.9%; P < .001) than those in the D2 group. Multivariate analysis confirmed that patients with advanced posterior gastric cancer could have the survival benefit from No. 10 lymph node dissection (DFS: HR, 0.10; 95% CI, 0.02-0.46; OS: HR, 0.12; 95% CI, 0.03-0.52). Conclusions and Relevance: Although LSTG could not significantly improve the 3-year DFS of patients with APGC without invasion into the greater curvature, patients with APGC located posterior gastric wall may benefit from LSTG. Trial Registration: ClinicalTrials.gov Identifier: NCT02333721.

Biodegradation of tylosin in swine wastewater by Providencia stuartii TYL-Y13: Performance, pathway, genetic background, and risk assessment.

Microbial bioremediation offers a solution to the problem of residual antibiotics in wastewater associated with animal farms. Efficient degradation of antibiotic residues depends upon the genetic make-up of microbial degraders, which requires a comprehensive understanding of the degradation mechanisms. In this study, a novel, efficient tylosin (TYL)-degrading bacterium, Providencia stuartii TYL-Y13 (Y13) was isolated, which could completely degrade 100 mg/L TYL within 15 h under optimal operating conditions at 40 â„ƒ, pH 7.0 %, and 1 % (v/v) bacterial inoculation rate. Whole genome sequencing revealed that strain Y13 consists of a circular chromosome and two plasmids. A new biodegradation pathway of TYL including desugarification, hydrolysis, and reduction reactions was proposed through the analysis of biodegradation products. It was demonstrated that strain Y13 gradually decreased the biotoxicity of TYL and its metabolites based on the results of the ecological structural activity relationships (ECOSAR) model analysis and toxicity assessment. Moreover, Y13 promoted the reduction of the target macrolide resistance genes in wastewater and disappeared within 84 h. These results shed new light on the mechanism of TYL biodegradation and better utilization of microbes to remediate TYL contamination.

Flexible pressure sensors via engineering microstructures for wearable human-machine interaction and health monitoring applications.

Flexible pressure sensors capable of transducing pressure stimuli into electrical signals have drawn extensive attention owing to their potential applications for human-machine interaction and healthcare monitoring. To meet these application demands, engineering microstructures in the pressure sensors are an efficient way to improve key sensing performances, such as sensitivity, linear sensing range, response time, hysteresis, and durability. In this review, we provide an overview of the recent advances in the fabrication and application of high-performance flexible pressure sensors via engineering microstructures. The implementation mechanisms and fabrication strategies of microstructures including micropatterned, porous, fiber-network, and multiple microstructures are systematically summarized. The applications of flexible pressure sensors with microstructures in the fields of wearable human-machine interaction, and ex vivo and in vivo healthcare monitoring are comprehensively discussed. Finally, the outlook and challenges in the future improvement of flexible pressure sensors toward practical applications are presented.

Assessment of the short-term outcomes of laparoscopic gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: A prospective single-armed clinical trial.

BACKGROUND: Laparoscopic surgical approaches for gastric cancer after neoadjuvant chemotherapy are increasing, yet there is limited evidence of their safety and effectiveness. METHODS: This prospective single-armed clinical trial enrolled 80 neoadjuvant chemotherapy patients who underwent laparoscopic gastrectomy. In addition, to better analyze the outcomes of this study, 1:2 propensity score matching was performed, and a contemporaneous historic control group containing 160 laparoscopic gastrectomy patients without neoadjuvant chemotherapy was established. RESULTS: Analyses were performed to compare the neoadjuvant chemotherapy group (n = 80) and the control group (n = 160). The general clinical data of both groups were comparable. The neoadjuvant chemotherapy group showed less intraoperative bleeding (P = .029) and recovered more quickly than the control group (all P < .05). The 2 groups did not exhibit major differences in terms of postoperative complications (P = .679) or severe complications (P = .055). The proportion of patients with ypT4 stage and ypN3 stage disease in the neoadjuvant chemotherapy group totaled 20.7% and 23.8%, respectively, which was significantly lower than that observed in the control group (P < .05). The number of metastatic lymph nodes was 4.8 ± 7.0 in the neoadjuvant chemotherapy group, which was lower than that in the control group (P < .001). In the neoadjuvant chemotherapy group, the major pathological regression rate was 27.5%, while the objective radiologic response rate (complete response + partial response) was 64.0%. In contrast to nonresponding patients, the patients who experienced an objective response had a shorter operation time (P < .001), less intraoperative bleeding (P < .001), and fewer metastatic lymph nodes (P = .005). The short-term effects observed in the nonresponding patients were similar to those observed in the control group. CONCLUSION: Laparoscopic gastrectomy could achieve improved short-term outcomes through NACT tumor downstaging without increasing the incidence of postoperative complications. Further multicenter and prospective clinical trials are warranted.

Twenty years of China's water pollution control: Experiences and challenges.

Water pollution is a major environmental problem worldwide, especially in developing countries. China's environmental protection strategies have been pushed to the highest priority in history, driving remarkable achievements in water pollution control, but were also coupled with new challenges. In this study, we analyzed diverse long-term data (i.e. water quality, WWTPs, pollutant discharge etc.) to systematically understand the process of water pollution control in China in the last twenty years. The results highlighted that the collection and treatment capacity of wastewater in China approached the developed country level, with the treatment rates exceeding 90% both in urban and country areas. The environmental quality of surface water was continuously improved, but water pollution problems remained in the river basins of eastern China, with remarkable economic progress. Rapid economic growth rather than population growth was the limiting factor for water pollution control in China. Therefore, more efforts should be made to further improve wastewater collection and treatment capacity and address the gap between effluent discharge limits for wastewater treatment plants and environmental quality standards for surface water. China's progress toward water pollution control provided important insights for other developing countries.

Physiological and transcriptomic analyses reveal the toxicological mechanism and risk assessment of environmentally-relevant waterborne tetracycline exposure on the gills of tilapia (Oreochromis niloticus).

With the increasing application of tetracycline (TC) in medical treatment, animal husbandry and aquaculture in recent decades, high quantities of TC have been frequently detected in the aquatic environment, and accordingly TC-related toxicity and environmental pollution have become a global concern. The present study was performed to explore the toxicological influences of TC exposure at its environmentally relevant concentrations on the gills of tilapia Oreochromis niloticus, based on the alteration in histopathology, oxidative stress, inflammatory response, cell cycle, mitochondrial function, apoptosis, and transcriptomic analysis. Our findings revealed that TC exposure damaged the structure and function, induced oxidative stress, affected inflammatory responses, and reduced Na+/K+-ATPase (NKA) activity in the gills. TC also caused the inhibition in cell cycle, resulted in mitochondrial dysfunction and activated apoptosis. Further transcriptomic analysis indicated the extensive influences of TC exposure on the gill function, and immune system was the main target to waterborne TC exposure. These results elucidated that environmental TC had more complex toxicological effects on gills of fish than previously assessed, and provided novel insight into molecular toxicology of TC on fish and good basis for assessing the environmental risk of TC.

Assessment of indocyanine green tracer-guided lymphadenectomy in laparoscopic gastrectomy after neoadjuvant chemotherapy for locally advanced gastric cancer: results from a multicenter analysis based on propensity matching.

BACKGROUND: This study evaluated the safety, effectiveness, and feasibility of indocyanine green (ICG) tracing in guiding lymph-node (LN) dissection during laparoscopic D2 radical gastrectomy in patients with advanced gastric cancer (AGC) after neoadjuvant chemotherapy (NAC). METHOD: We retrospectively analyzed data on 313 patients with clinical stage of cT1-4N0-3M0 who underwent laparoscopic radical gastrectomy after NAC between February 2010 and October 2020 from two hospitals in China. Grouped according to whether ICG was injected. For the ICG group (n = 102) and non-ICG group (n = 211), 1:1 propensity matching analysis was used. RESULTS: After matching, there was no significant difference in the general clinical pathological data between the two groups (ICG vs. non-ICG: 94 vs. 94). The average number of total LN dissections was significantly higher in the ICG group and lower LN non-compliance rate than in the non-ICG group. Subgroup analysis showed that among patients with LN and tumor did not shrink after NAC, the number of LN dissections was significantly more and LN non-compliance rate was lower in the ICG group than in the non-ICG group. Intraoperative blood loss was significantly lesser in the ICG group than in the non-ICG group, while the recovery and complications of the two groups were similar. CONCLUSION: For patients with poor NAC outcomes, ICG tracing can increase the number of LN dissections during laparoscopic radical gastrectomy, reduce the rate of LN non-compliance, and reduce intraoperative bleeding. Patients with AGC should routinely undergo ICG-guided laparoscopic radical gastrectomy.

Realizing high-performance and low-cost lithium-ion capacitor by regulating kinetic matching between ternary nickel cobalt phosphate microspheres anode with ultralong-life and super-rate performance and watermelon peel biomass-derived carbon cathode.

Lithium-ion capacitors (LICs) are emerging as one of the most advanced energy storage devices by combining the virtues of both supercapacitors (SCs) and lithium-ion batteries (LIBs). However, the kinetic and capacity mismatch between anode and cathode is the main obstacle to wide applications of LICs. Therefore, the effective strategy of constructing a high-performance LIC is to improve the rate and cycle performance of the anode and the specific capacity of the cathode. Herein, the nickel cobalt phosphate (NiCoP) microspheres anode is demonstrated with robust structural integrity, high electrical conductivity, and fast kinetic feature. Simultaneously, the watermelon-peel biomass-derived carbon (WPBC) cathode is demonstrated a sustainable synthesis strategy with high specific capacity. As expected, the NiCoP exhibits high specific capacities (567 mAh g-1 at 0.1 A g-1), superior rate performance (300 mAh g-1 at 1A g-1), and excellent cycle stability (58 mAh g-1 at 5 A g-1 after 15,000 cycles). The WPBC possesses a high specific surface area (SSA) of 3303.6 m2 g-1 and a high specific capacity of 226 mAh g-1 at 0.1 A g-1. Encouragingly, the NiCoP//WPBC-6 LIC device can deliver high energy density (ED) of 127.4 ± 3.3 and 67 ± 3.8Wh kg-1 at power density (PD) of 190 and 18240 W kg-1 (76.4% capacity retention after 7000 cycles), respectively.

Assessment of Robotic Versus Laparoscopic Distal Gastrectomy for Gastric Cancer: A Randomized Controlled Trial.

OBJECTIVE: To evaluate the short-term outcomes of patients with GC who received RDG or LDG. SUMMARY BACKGROUND DATA: Despite the increasing use of RDG in patients with GC, its safety and efficacy compared to those of LDG have not been elucidated in a randomized controlled trial. METHODS: Three hundred patients with cT1-4a and N0/+ between September 2017 and January 2020 were enrolled in this randomized controlled trial at a high-volume hospital in China. The short-term outcomes were compared between the groups. RESULTS: The modified intention-to-treat analysis included data from 283 patients (RDG group: n = 141) and (LDG group: n = 142). Patients in the RDG group exhibited faster postoperative recovery, milder inflammatory responses, and reduced postoperative morbidity (9.2% vs 17.6%, respectively, P = 0.039). Higher extraperigastric lymph nodes (LNs) were retrieved in the RDG group (17.6 ±â€Š5.8 vs 15.8 ±â€Š6.6, P = 0.018) with lower noncompliance rate (7.7% vs 16.9%, respectively, P = 0.006). Additionally, patients in the RDG group were more likely to initiate adjuvant chemotherapy earlier [median (interquartile range) postoperative days: 28 (24-32) vs 32 (26-42), P = 0.003]. Although total hospital costs were higher in the robotic group than in the laparoscopic group, the direct cost was lower for RDG than for LDG (all P < 0.001). CONCLUSIONS: RDG is associated with a lower morbidity rate, faster recovery, milder inflammatory responses, and improved lymphadenectomy. Additionally, faster postoperative recovery in the RDG group enables early initiation of adjuvant chemotherapy. Our results provide evidence for the application of RDG in patients with GC.

Using gross ecosystem product (GEP) to value nature in decision making.

Gross domestic product (GDP) summarizes a vast amount of economic information in a single monetary metric that is widely used by decision makers around the world. However, GDP fails to capture fully the contributions of nature to economic activity and human well-being. To address this critical omission, we develop a measure of gross ecosystem product (GEP) that summarizes the value of ecosystem services in a single monetary metric. We illustrate the measurement of GEP through an application to the Chinese province of Qinghai, showing that the approach is tractable using available data. Known as the "water tower of Asia," Qinghai is the source of the Mekong, Yangtze, and Yellow Rivers, and indeed, we find that water-related ecosystem services make up nearly two-thirds of the value of GEP for Qinghai. Importantly most of these benefits accrue downstream. In Qinghai, GEP was greater than GDP in 2000 and three-fourths as large as GDP in 2015 as its market economy grew. Large-scale investment in restoration resulted in improvements in the flows of ecosystem services measured in GEP (127.5%) over this period. Going forward, China is using GEP in decision making in multiple ways, as part of a transformation to inclusive, green growth. This includes investing in conservation of ecosystem assets to secure provision of ecosystem services through transregional compensation payments.

Using Ecosystem Service Flows to Inform Ecological Compensation: Theory & Application.

Ecological compensation is a crucial policy instrument that realigns the benefits of stakeholders to the ecosystem service provision. However, the spatial disconnections between locations where ecosystem services produced and used are common. The supply and demand for ecosystem services are calculated to reflect the status of the districts or counties based on ecosystem service flows. The replacement cost methods provide necessary technical supports for the calculation of compensation funds. The realigning of compensation funds between service-benefiting areas and service-providing areas not only identifies the beneficiaries and suppliers but also realizes the connection between them, which may be a feasible methodology. Fuzhou City is the study area, and two ecosystem services of water conservation and soil retention were taken into consideration. The prioritized development zone, Linchuan, and the key agricultural production zones paid ecological compensation funds. Linchuan paid the highest, 5.76 billion yuan. The key ecological function zones and the key agricultural production zones received the ecological compensation funds, of which Yihuang obtained the highest, 1.66 billion yuan. The realigning of compensation funds between the service benefiting and providing areas addresses the trade-offs between ecosystem services, social development, and ecosystem protection. Embedding the ecosystem service flows into the ecological compensation mechanism can most truly realize the value of ecosystem services, achieve the "beneficiary pays" principle, and be conducive to regional sustainable development.

A rapid and convenient derivatization method for quantitation of short-chain fatty acids in human feces by ultra-performance liquid chromatography/tandem mass spectrometry.

RATIONALE: Short-chain fatty acids (SCFAs) are associated with intestinal microbiota and diseases in humans. SCFAs have a low response in mass spectrometry, and in order to increase sensitivity, reduce sample consumption, shorten analysis time, and simplify sample preparation steps, a derivatization method was developed. METHODS: We converted seven SCFAs into amide derivatives with 4-aminomethylquinoline. The reaction occurred for 20 min at room temperature. The analytes were separated on a reversed-phase C18 column and quantitated in the positive ion electrospray ionization mode using multiple reaction monitoring. Acetic acid-d4 was used as the stable-isotope-labeled surrogate analyte for acetic acid in the working solutions, while the other stable-isotope-labeled standards were used as internal standards (ISs). RESULTS: Method validation showed that the intra-day and inter-day precision of quantitation for the seven SCFAs over the whole concentration range was ≤3.8% (n = 6). The quantitation accuracy ranged from 85.5% to 104.3% (n = 6). Most important, the collected feces were vortexed immediately with ethanol. CONCLUSIONS: This study provides a new derivatization method for a precise, accurate, and rapid quantitation of SCFAs in human feces using ultra-performance liquid chromatography/tandem mass spectrometry. This method successfully determined the concentration of SCFAs in human feces and could assist in the exploration of intestinal microbiota and diseases.

Synthetic vulnerability assessment to inform climate-change adaptation along an urbanized coast of Shenzhen, China.

Coastal zones are increasingly threatened by stressors from both climate change and human activities. Vulnerability assessment is central to the implementation of interventions for adapting climate change. However, synthetic vulnerability based on an integrative analysis of ecosystem service and socioeconomic characteristics in urban coastal zones with tightly coupled human-nature interactions is not fully understood. Based on the Coastal Vulnerability model of the InVEST (Integrated Valuation of Environmental Services and Tradeoffs) tool, a holistic framework for assessing coastal vulnerability to multiple hazards (sea level rise, waves and storm surge) was developed by integrating ecological, physical and socioeconomic factors into a single spatial representation and applied to the coast of Shenzhen, China. Based on the levels of biophysical exposure, sensitivity and adaptive capacity of coastal communities, a three-dimensional decision matrix was proposed for planning location-specific interventions. Results show that approximately 15% of the coastline were categorized as having high vulnerability. Spatial vulnerability heterogeneity was found within and across the coastal districts, with Yantian grouped into the most vulnerable district. The biophysical exposure has greater influences on the overall vulnerability than either sensitivity or adaptive capacity. This study highlights the significance of complex interactions between natural ecosystems and socioeconomic conditions in driving vulnerability and suggests that combined natural-based defenses and socioeconomic factors contribute to lower vulnerability. The results can help decision-makers prioritize coastal zones for interventions and identifying adaptive strategies that target drivers of vulnerability.

Pathologic Assessment After Neoadjuvant Chemotherapy for NSCLC: Importance and Implications of Distinguishing Adenocarcinoma From Squamous Cell Carcinoma.

INTRODUCTION: Major pathologic response after neoadjuvant chemotherapy (NAC) for NSCLC has been defined as 10% or less residual viable tumor without distinguishing between histologic types. We sought to investigate whether the optimal cutoff percentage of residual viable tumor for predicting survival differs between lung adenocarcinoma (ADC) and squamous cell carcinoma (SCC). METHODS: Tumor slides from 272 patients treated with NAC and surgery for clinical stage II-III NSCLC (ADC, n = 192; SCC, n = 80) were reviewed. The optimal cutoff percentage of viable tumor for predicting lung cancer-specific cumulative incidence of death (LC-CID) was determined using maximally selected rank statistics. LC-CID was analyzed using a competing-risks approach. Overall survival was evaluated using Kaplan-Meier methods and Cox proportional hazard analysis. RESULTS: Patients with SCC had a better response to NAC (median percentage of viable tumor: SCC versus ADC, 40% versus 60%; p = 0.027). Major pathologic response (≤10% viable tumor) was observed in 26% of SCC cases versus 12% of ADC cases (p = 0.004). The optimal cutoff percentage of viable tumor for LC-CID was 10% for SCC and 65% for ADC. On multivariable analysis, viable tumor 10% or less was an independent factor for better LC-CID (p = 0.035) in patients with SCC; in patients with ADC, viable tumor 65% or less was a factor for better LC-CID (p = 0.033) and overall survival (p = 0.050). CONCLUSIONS: In response to NAC, the optimal cutoff percentage of viable tumor for predicting survival differs between ADC and SCC. Our findings have implications for the pathologic assessment of resected specimens, especially in upcoming clinical trials design.

Assessment of treatment outcomes in patients with advanced hilar cholangiocarcinoma (stages III-IV): Clinical significance of interventional therapy.

The clinical significance of palliative interventional therapy in the management of patients with advanced hilar cholangiocarcinoma (HCCA; stages III-IV) has yet to be studied. The present work was aimed to compare the clinical outcomes of the patients treated with surgery or interventional therapy.A total of 90 patients with advanced HCCA, who admitted Fuyang First People's Hospital from May 2015 to February 2016, were enrolled. Forty-five of them were assigned to the experimental group receiving biliary drainage as the interventional therapy, and the remaining 45 patients were designated as the conventional group receiving radical/palliative surgery. Before and after the treatment total bilirubin from blood was measured. The length of treatment and medical cost were also examined. All patients were followed up for at least 1 year after the treatment.For both the experimental and conventional groups, the serum bilirubin levels after treatment were significantly lower than those before treatment (P < .05); however, no significant differences between groups were seen. There were no significant differences between experimental and conventional groups in the incidence of postoperative complications and survival outcomes. Of note, the length of treatment of the experimental group was substantially shorter than that of the conventional group (P < .05). The medical expense of the experimental group was only about one-third of that of the conventional group (P < .05).Although the interventional therapy does not improve patients' survivals and reduce the incidence of complications, it significantly shortens the treatment length, reducing substantially the medical expense. This finding provides new insights into the treatment strategy for patients with advanced HCCA.

China's response to a national land-system sustainability emergency.

China has responded to a national land-system sustainability emergency via an integrated portfolio of large-scale programmes. Here we review 16 sustainability programmes, which invested US$378.5 billion (in 2015 US$), covered 623.9 million hectares of land and involved over 500 million people, mostly since 1998. We find overwhelmingly that the interventions improved the sustainability of China's rural land systems, but the impacts are nuanced and adverse outcomes have occurred. We identify some key characteristics of programme success, potential risks to their durability, and future research needs. We suggest directions for China and other nations as they progress towards the Sustainable Development Goals of the United Nations' Agenda 2030.