Trends and geographic variation in adverse impacts of nitrogen use in Europe on human health, climate, and ecosystems: A review

This paper presents a review of the trends and geographic variation of impacts of reactive nitrogen (N) inputs on in Europe through impacts on air, soil and water quality. It illustrates those impacts, by assessing temporal and spatial variation in air, soil and water quality indicators and their exceedances of critical thresholds in view of impacts on human health, terrestrial and aquatic ecosystems, during 1990-2019. Trends are derived from regular inventory and monitoring data and from simulated trends in air quality using the EMEP model. Well quantified adverse impacts of increased N use are: (i) the effects on human health due to increased tropospheric concentrations of NOx and ozone, and N-induced increases in fine particulate matter, (ii) the contribution of N2O to climate change and stratospheric ozone depletion, (iii) the loss of plant and faunal diversity both in terrestrial and aquatic ecosystems via direct and soil mediated impacts, (iv) the acidification of forest soils, with impacts on tree forest nutrition, tree growth and tree vitality, and (v) the eutrophication of marine ecosystems, and associated biodiversity loss and occurrence of harmful algae blooms. Over the period 1990-2019, N inputs to agriculture stayed relatively constant, but the emissions of ammonia (NH3) decreased by 27%, while emissions of nitrogen oxides (NOx) decreased by 57%. In response to those reductions, concentrations of NOx, and of N in particulate matter also declined, although less than 50%. In contrast, the reduction in NOx-induced ozone concentrations and ozone related indicators (AOT40, SOMO35 and POD) was much less (ca 15-20%). Exceedances of critical ozone concentrations for human health and of critical AOT40 and POD vales for vegetation reduced in a similar order of magnitude. Despite decreasing NH3 emissions, NH3 concentrations showed a slight and steady increase from 1995 onwards, due to the large reduction in SOx emissions. Nitrogen deposition and exceedances of critical N loads for terrestrial ecosystems decreased by ca 60%, but the area exceeding critical N loads only reduced by ca 10%. Unlike N, the area exceeding critical acid loads has declined by more than 90% due to high reduction in SOx and NOx emissions. Trends in nitrate (NO3) concentrations in groundwater varied across Europe, but showed overall limited changes over the last two decades. However, N concentrations in surface water and the area exceeding critical levels in view of aquatic biodiversity has decreased and the same holds for N concentrations in coastal regions. Nevertheless, the eutrophication condition of coastal waters has overall not improved due to adverse impacts of elevated phosphorus inputs. Finally the negative impacts of N induced N2O emissions on climate are estimated to be outweighed by the positive effects of N induced CO2 sequestration, mainly in forests, and this holds for the whole period 1990-2019. Nitrogen hotspots, being areas with high exceedances in critical levels and loads of N compounds in air and water, are concentrated in intensive agricultural areas with high livestock densities and in urban region with strong industrial and traffic activities. Cost-benefit analysis shows that environmental costs of reactive N release to the environment are substantial and tend to exceed the direct economic benefits for agriculture. Given the relevance of N for safeguarding food production it is key to develop integrated and targeted plant nutrition strategies following a food system approach and practices that minimize trade-offs between productivity and the environment. In addition, targeted strategies to further reduce NOx emissions are needed to reduce air quality related health and biodiversity impacts

Clinical management of chronic mesenteric ischemia

This: This Dutch Mesenteric Ischemia Study group consists of: Ron Balm, Academic Medical Center, Amsterdam Gert Jan de Borst, University Medical Center Utrecht, Utrecht Juliette T Blauw, Medisch Spectrum Twente, Enschede Marco J Bruno, Erasmus MC University Medical Center, Rotterdam Olaf J Bakker, St Antonius Hospital, Nieuwegein Louisa JD van Dijk, Erasmus MC University Medical Center, Rotterdam Hessel CJL Buscher, Gelre Hospitals, Apeldoorn Bram Fioole, Maasstad Hospital, Rotterdam Robert H Geelkerken, Medisch Spectrum Twente, Enschede Jaap F Hamming, Leiden University Medical Center, Leiden Jihan Harki, Erasmus MC University Medical Center, Rotterdam Daniel AF van den Heuvel, St Antonius Hospital, Nieuwegein Eline S van Hattum, University Medical Center Utrecht, Utrecht Jan Willem Hinnen, Jeroen Bosch Hospital, ‘s-Hertogenbosch Jeroen J Kolkman, Medisch Spectrum Twente, Enschede Maarten J van der Laan, University Medical Center Groningen, Groningen Kaatje Lenaerts, Maastricht University Medical Center, Maastricht Adriaan Moelker, Erasmus MC University Medical Center, Rotterdam Desirée van Noord, Franciscus Gasthuis & Vlietland, Rotterdam Maikel P Peppelenbosch, Erasmus MC University Medical Center, Rotterdam André S van Petersen, Bernhoven Hospital, Uden Pepijn Rijnja, Medisch Spectrum Twente, Enschede Peter J van der Schaar, St Antonius Hospital, Nieuwegein Luke G Terlouw, Erasmus MC University Medical Center, Rotterdam Hence JM Verhagen, Erasmus MC University Medical Center, Rotterdam Jean Paul PM de Vries, University Medical Center Groningen, Groningen Dammis Vroegindeweij, Maasstad Hospital, Rotterdam review provides an overview on the clinical management of chronic mesenteric ischemia (CMI). CMI is defined as insufficient blood supply to the gastrointestinal tract, most often caused by atherosclerotic stenosis of one or more mesenteric arteries. Patients classically present with postprandial abdominal pain and weight loss. However, patients may present with, atypically, symptoms such as abdominal discomfort, nausea, vomiting, diarrhea or constipation. Early consideration and diagnosis of CMI is important to timely treat, to improve quality of life and to prevent acute-on-chronic mesenteric ischemia. The diagnosis of CMI is based on the triad of clinical symptoms, radiological evaluation of the mesenteric vasculature and if available, functional assessment of mucosal ischemia. Multidisciplinary consensus on the diagnosis of CMI is of paramount importance to adequately select patients for treatment. Patients with a consensus diagnosis of single-vessel or multi-vessel atherosclerotic CMI are preferably treated with endovascular revascularization

Tacrolimus versus mycophenolate for AutoImmune hepatitis patients with incompLete response On first-line therapy (TAILOR study): a study protocol for a phase III, open-label, multicentre, randomised controlled trial

BackgroundAutoimmune hepatitis (AIH) is a rare, chronic inflammatory disease of the liver. The treatment goal is reaching complete biochemical response (CR), defined as the normalisation of aspartate and alanine aminotransferases and immunoglobulin gamma. Ongoing AIH activity can lead to fibrosis and (decompensated) cirrhosis. Incomplete biochemical response is the most important risk factor for liver transplantation or liver-related mortality. First-line treatment consists of a combination of azathioprine and prednisolone. If CR is not reached, tacrolimus (TAC) or mycophenolate mofetil (MMF) can be used as second-line therapy. Both products are registered for the prevention of graft rejection in solid organ transplant recipients. The aim of this study is to compare the effectiveness and safety of TAC and MMF as second-line treatment for AIH.MethodsThe TAILOR study is a phase IIIB, multicentre, open-label, parallel-group, randomised (1:1) controlled trial performed in large teaching and university hospitals in the Netherlands. We will enrol 86 patients with AIH who have not reached CR after at least 6 months of treatment with first-line therapy. Patients are randomised to TAC (0.07 mg/kg/day initially and adjusted by trough levels) or MMF (max 2000 mg/day), stratified by the presence of cirrhosis at inclusion. The primary endpoint is the difference in the proportion of patients reaching CR after 12 months. Secondary endpoints include the difference in the proportion of patients reaching CR after 6 months, adverse effects, difference in fibrogenesis, quality of life and cost-effectiveness.DiscussionThis is the first randomised controlled trial comparing two second-line therapies for AIH. Currently, second-line treatment is based on retrospective cohort studies. The rarity of AIH is the main issue in clinical research for alternative treatment options. The results of this trial can be implemented in existing international clinical guidelines.Trial registrationClinicalTrials.gov NCT05221411. Retrospectively registered on 3 February 2022; EudraCT number 2021-003420-33. Prospectively registered on 16 June 2021.Personalised Therapeutic

The Fluorescence Detector of the Pierre Auger Observatory

The Pierre Auger Observatory is a hybrid detector for ultra-high energy cosmic rays. It combines a surface array to measure secondary particles at ground level together with a fluorescence detector to measure the development of air showers in the atmosphere above the array. The fluorescence detector comprises 24 large telescopes specialized for measuring the nitrogen fluorescence caused by charged particles of cosmic ray air showers. In this paper we describe the components of the fluorescence detector including its optical system, the design of the camera, the electronics, and the systems for relative and absolute calibration. We also discuss the operation and the monitoring of the detector. Finally, we evaluate the detector performance and precision of shower reconstructions.Comment: 53 pages. Submitted to Nuclear Instruments and Methods in Physics Research Section

Type 2 Endoleak With or Without Intervention and Survival After Endovascular Aneurysm Repair

Objective: The aims of the present study were to examine the impact of type 2 endoleaks (T2EL) on overall survival and to determine the need for secondary intervention after endovascular aneurysm repair (EVAR). Methods: A multicentre retrospective cohort study in the Netherlands was conducted among patients with an infrarenal abdominal aortic aneurysm (AAA) who underwent EVAR between 2007 and 2012. The primary endpoint was overall survival for patients with (T2EL+) or without (T2EL-) a T2EL. Secondary endpoints were sac growth, AAA rupture, and secondary intervention. Kaplan–Meier survival and multivariable Cox regression analysis were used. Results: A total of 2 018 patients were included. The median follow up was 62.1 (range 0.1 – 146.2) months. No difference in overall survival was found between T2EL+ (n = 388) and T2EL- patients (n = 1630) (p =.54). The overall survival estimates at five and 10 years were 73.3%/69.4% and 45.9%/44.1% for T2EL+/T2EL- patients, respectively. Eighty-five of 388 (21.9%) T2EL+ patients underwent a secondary intervention. There was no difference in overall survival between T2EL+ patients who underwent a secondary intervention and those who were treated conservatively (p =.081). Sac growth was observed in 89 T2EL+ patients and 44/89 patients (49.4%) underwent a secondary intervention. In 41/44 cases (93.1%), sac growth was still observed after the intervention, but was left untreated. Aneurysm rupture occurred in 4/388 T2EL patients. In Cox regression analysis, higher age, ASA classification, and maximum iliac diameter were significantly associated with worse overall survival. Conclusion: No difference in overall survival was found between T2EL+ and T2EL- patients. Also, patients who underwent a secondary intervention did not have better survival compared with those who did not undergo a secondary intervention. This study reinforces the need for conservative treatment of an isolated T2EL and the importance of a prospective study to determine possible advantages of the intervention

Nitrogen - grasping the challenge. A manifesto for science-in-action through the International Nitrogen Management System. Summary report

Report published by Centre for Ecology & Hydrology, Edinburgh, UK on behalf of the International Nitrogen Management System (INMS). Freely available to download from the Official link