Survival after active surveillance versus upfront surgery for incidental small pancreatic neuroendocrine tumours.

BACKGROUND: The safety of observing small non-functioning pancreatic neuroendocrine tumours (NF-Pan-NETs) remains under debate. METHODS: This was a multicentre retrospective study of patients with small incidental NF-Pan-NETs. Survival of patients who underwent upfront surgery versus active surveillance was compared. The risk of death was matched with that in the healthy population. The excess hazard rate and probability of a normal lifespan (NLP) were calculated. Propensity score matching (PSM) with a 1 : 1 ratio was used to minimize the risk of selection bias. RESULTS: Some 222 patients (43.7 per cent) underwent upfront surgery and 285 (56.3 per cent) were observed. The excess hazard rate for the entire cohort was quantifiable as 0.04 (95 per cent c.i. 0 to 0.08) deaths per 1000 persons per year, and the NLP was 99.7 per cent. Patients in the active surveillance group were older (median age 65 versus 58 years; P < 0.001), and more often had co-morbidity (45.3 versus 24.8 per cent; P = 0.001), and smaller tumours (median 12 versus 13 mm; P < 0.001), less frequently located in the pancreatic body-tail (59.5 versus 69.6 per cent; P = 0.008, 59.3 versus 73.9 per cent; P = 0.001). Median follow-up was longer for patients who underwent upfront surgery (5.6 versus 2.7 years; P < 0.001). After PSM, 118 patients per group were included. The excess hazard rates were 0.2 and 0.9 deaths per 1000 persons per year (P = 0.020) for patients in the active surveillance and upfront surgery groups respectively. Corresponding NLPs were 99.9 and 99.5 per cent respectively (P = 0.011). CONCLUSION: Active surveillance of small incidental NF-Pan-NETs is a reasonable alternative to resection.

Prognostic Role of Examined and Positive Lymph Nodes after Distal Pancreatectomy for Non-Functioning Neuroendocrine Neoplasms.

BACKGROUND: The most appropriate nodal staging system for non-functioning pancreatic neuroendocrine tumours (NF-PanNETs) remains unclear. Despite some evidence is available for pancreaticoduodenectomy, the adequate nodal staging is still unknown for distal pancreatectomy (DP). The aim of the present study was to evaluate the prognostic impact of the number of positive lymph nodes (PLNs) after DP for NF-PanNETs and to define the minimal number of lymph nodes to be harvested for an appropriate nodal staging. METHODS: Data were retrospectively collected from patients who underwent DP with curative intent (R0-R1) for sporadic well-differentiated NF-PanNETs in 4 European high-volume centres. NF-PanNETs with nodal involvement (N+) were subclassified into N1 (1-3 PLNs) and N2 (4 or more PLNs). Univariate and multivariate analyses of disease-free survival (DFS) were performed. RESULTS: Of 271 patients in the study, 62 (23%) had nodal involvement (N+). A higher probability of N+ was associated with the following factors: grading, resection margin status, perineural and microvascular invasion, and the number of examined lymph nodes. Three-year DFS rate for N0, N1, and N2 patients was 92, 72, and 50%, respectively (p < 0.001). At multivariate analysis, independent predictors of DFS were grading, T stage, presence of necrosis, and nodal status. For patients with ≥12 examined/resected lymph nodes, the N status remained a significant predictor of disease recurrence (p < 0.001), while it failed to predict recurrence in patients with <12 lymph nodes examined/resected (p = 0.116). CONCLUSIONS: A minimal number of 12 nodes should be harvested in case of DP for NF-PanNET for an appropriate nodal staging. The number of positive lymph nodes is an independent predictor of DFS after DP for NF-PanNET, and the N0/N1/N2 nodal classification seems to be more relevant than the current N0/N+ staging.

Co-creating sustainability indicators for the local water-energy-food nexus.

Sustainability indicators have become essential tools to deal with compartmentalized resources planning and management in cities. The development of water, energy, and food nexus (WEF nexus) indicators is a prominent goal of current research, but the focus is mainly on economic issues and material flows. Attention to the local scale and context, social aspects, and the inclusion of non-academic actors is mostly lacking. To address these gaps, this paper reports and reflects on the co-creation of sustainability indicators related to the WEF nexus in the city of São Paulo, Brazil. With a transdisciplinary approach, non-academic actors were included in the different stages of the process using the Urban Living Lab methodology, to improve the usability of the produced indicators' set. The case of São Paulo concerned on-going actions in the peri-urban and rural areas of the city which seek to improve environmental protection by stimulating more sustainable forms of agriculture. Thirty-four indicators were developed through a sequence of interactive activities, such as workshops, meetings, and field trips. The presented process aims to strongly enhance usability by actively involving users from the start, connecting the nexus approach to previous knowledge and familiar frameworks, paying attention to the local scale and context, and to social aspects, and by anticipating future use in various ways.

The clinical and economic impact of surgical site infections after distal pancreatectomy.

BACKGROUND: The present study aimed to evaluate surgical site infections' clinical and economic impact after distal pancreatectomy. METHODS: The study was a prospective, monocentric, observational study, including all adult patients who underwent distal pancreatectomy. According to the American Centers for Disease Control and Prevention definition, the surgical site infection assessment was prospectively performed by trained personnel. The Accordion Severity Grading System was used to evaluate the clinical burden of surgical site infection. The hospitalization's total costs were calculated using the hospital expenditure report, excluding the intraoperative costs. RESULTS: During the study period, 414 distal pancreatectomies were performed. The overall incidence of surgical site infection was 26% (106 patients). Surgical site infections were associated with a higher body mass index (P = .022, odds ratio 1.2), positive preoperative rectal swab for multidrug resistant bacteria (P = .010, odds ratio 4.2), and increased operative time (P = .037, odds ratio 1.1). Using the Accordion Severity Grading System, surgical site infections contributed significantly to the total clinical burden (25.5%) and prolonged hospitalization (P < .001). Furthermore, surgical site infection doubled the costs (12.915 vs 6.888 euros, P < .001). CONCLUSION: Surgical site infection has a high clinical burden, negatively impacting the postoperative course. The costs and length of stay proportionally increased with the surgical site infection severity, doubling the hospitalization expenses.

'Opening up' the governance of water-energy-food nexus: Towards a science-policy-society interface based on hybridity and humility.

The governance of the nexus between water, energy, and food (hereafter, 'the nexus') is permeated by complex interactions of knowledge at a science-policy-society interface. This paper starts from a literature review to find the main narratives that allow us to understand what is at stake in this interface. By thematically synthesising 19 select articles, we reached three layers of knowledge interaction: 'knowledge application', 'knowledge integration', and 'knowledge transformation'. To avoid misleading simplifications, we discussed the constraints on this debate and some pressures for what we consider as 'closing down' knowledge about the nexus. We then developed a conceptual framework based on the 'technologies of humility' proposed by Jasanoff (2003, 2007) to create opportunities to 'open up' the nexus approach. Finally, we illustrated the four pillars proposed by some studies to describe what we have termed 'nexus of humility': framing, vulnerability, distribution, and learning. These foci seek to enable a humbler appreciation on all sides of the persistent sources of uncertainty, divergence, and conditionality in sustainability governance. This framework also contributes towards necessary transformations of knowledge about nexus and its challenging implementation.