The fate of rice crop residues and context-dependent greenhouse gas emissions: Model-based insights from Eastern India

Crop residue burning is a common practice in many parts of the world that causes air pollution and greenhouse gas (GHG) emissions. Regenerative practices that return residues to the soil offer a 'no burn' pathway for addressing air pollution while building soil organic carbon (SOC). Nevertheless, GHG emissions in rice-based agricultural systems are complex and difficult to anticipate, particularly in production contexts with highly variable hydrologic conditions. Here we predict long-term net GHG fluxes for four rice residue management strategies in the context of rice-wheat cropping systems in Eastern India: burning, soil incorporation, livestock fodder, and biochar. Estimations were based on a combination of Tier 1, 2, and 3 modelling approaches, including 100-year DNDC simulations across three representative soil hydrologic categories (i.e., dry, median, and wet). Overall, residue burning resulted in total direct GHG fluxes of 2.5, 6.1, and 8.7 Mg CO2-e in the dry, median, and wet hydrologic categories, respectively. Relative to emissions from burning (positive values indicate an increase) for the same dry to wet hydrologic categories, soil incorporation resulted in a -0.2, 1.8, or 3.1 Mg CO2-e change in emissions whereas use of residues for livestock fodder increased emissions by 2.0, 2.1, or 2.3 Mg CO2-e. Biochar reduced emissions relative to burning by 2.9 Mg CO2-e in all hydrologic categories. This study showed that the production environment has a controlling effect on methane and, therefore, net GHG balance. For example, wetter sites had 2.8-4.0 times greater CH4 emissions, on average, than dry sites when rice residues were returned to the soil. To effectively mitigate burning without undermining climate change mitigation goals, our results suggest that geographically-target approaches should be used in the rice-based systems of Eastern India to incentivize the adoption of regenerative 'no burn' residue management practices.

The Use of Palliative Radiotherapy in the Treatment of Lung Cancer

There have been significant advances in the systemic treatment of stage IV lung cancer, which is now recommended first line in patients with adequate fitness. This includes some patients with brain metastases due to the increased understanding of the central nervous system penetration of targeted therapies. The trials evidence base for palliative radiotherapy pre-dated this routine use of systemic therapy in our practice, which means that the sequence and role of palliative radiotherapy are not currently well defined in the first-line treatment setting. However, due to its efficacy in symptom control, radiotherapy remains a core component in the palliative management of lung cancer, particularly in the second-line setting and those unsuited to primary systemic treatment. This overview focuses on the evidence behind palliative radiotherapy to the thorax and brain for non-small cell and small cell lung cancer and the potential for future studies, including the TOURIST Trial Platform, to guide the future direction of these treatments.

Land-based measures to mitigate climate change: Potential and feasibility by country

Land-based climate mitigation measures have gained significant attention and importance in public and private sector climate policies. Building on previous studies, we refine and update the mitigation potentials for 20 land-based measures in >200 countries and five regions, comparing "bottom-up" sectoral estimates with integrated assessment models (IAMs). We also assess implementation feasibility at the country level. Cost-effective (available up to $100/tCO₂ eq) land-based mitigation is 8-13.8 GtCO₂ eq yr^-1 between 2020 and 2050, with the bottom end of this range representing the IAM median and the upper end representing the sectoral estimate. The cost-effective sectoral estimate is about 40% of available technical potential and is in line with achieving a 1.5°C pathway in 2050. Compared to technical potentials, cost-effective estimates represent a more realistic and actionable target for policy. The cost-effective potential is approximately 50% from forests and other ecosystems, 35% from agriculture, and 15% from demand-side measures. The potential varies sixfold across the five regions assessed (0.75-4.8 GtCO2eq yr^-1 ) and the top 15 countries account for about 60% of the global potential. Protection of forests and other ecosystems and demand-side measures present particularly high mitigation efficiency, high provision of co-benefits, and relatively lower costs. The feasibility assessment suggests that governance, economic investment, and socio-cultural conditions influence the likelihood that land-based mitigation potentials are realized. A substantial portion of potential (80%) is in developing countries and LDCs, where feasibility barriers are of greatest concern. Assisting countries to overcome barriers may result in significant quantities of near-term, low-cost mitigation while locally achieving important climate adaptation and development benefits. Opportunities among countries vary widely depending on types of land-based measures available, their potential co-benefits and risks, and their feasibility. Enhanced investments and country-specific plans that accommodate this complexity are urgently needed to realize the large global potential from improved land stewardship.

Greenhouse Gas Inventory Model for Biochar Additions to Soil

Stabilizing the global climate within safe bounds will require greenhouse gas (GHG) emissions to reach net zero within a few decades. Achieving this is expected to require removal of CO2 from the atmosphere to offset some hard-to-eliminate emissions. There is, therefore, a clear need for GHG accounting protocols that quantify the mitigation impact of CO2 removal practices, such as biochar sequestration, that have the potential to be deployed at scale. Here, we have developed a GHG accounting methodology for biochar application to mineral soils using simple parameterizations and readily accessible activity data that can be applied at a range of scales including farm, supply chain, national, or global. The method is grounded in a comprehensive analysis of current empirical data, making it a robust method that can be used for many applications including national inventories and voluntary and compliance carbon markets, among others. We show that the carbon content of biochar varies with feedstock and production conditions from as low as 7% (gasification of biosolids) to 79% (pyrolysis of wood at above 600 °C). Of this initial carbon, 63-82% will remain unmineralized in soil after 100 years at the global mean annual cropland-temperature of 14.9 °C. With this method, researchers and managers can address the long-term sequestration of C through biochar that is blended with soils through assessments such as GHG inventories and life cycle analyses.

The Role of Synthetic Biology in Atmospheric Greenhouse Gas Reduction: Prospects and Challenges

The long atmospheric residence time of CO2 creates an urgent need to add atmospheric carbon drawdown to CO2 regulatory strategies. Synthetic and systems biology (SSB), which enables manipulation of cellular phenotypes, offers a powerful approach to amplifying and adding new possibilities to current land management practices aimed at reducing atmospheric carbon. The participants (in attendance: Christina Agapakis, George Annas, Adam Arkin, George Church, Robert Cook-Deegan, Charles DeLisi, Dan Drell, Sheldon Glashow, Steve Hamburg, Henry Jacoby, Henry Kelly, Mark Kon, Todd Kuiken, Mary Lidstrom, Mike MacCracken, June Medford, Jerry Melillo, Ron Milo, Pilar Ossorio, Ari Patrinos, Keith Paustian, Kristala Jones Prather, Kent Redford, David Resnik, John Reilly, Richard J. Roberts, Daniel Segre, Susan Solomon, Elizabeth Strychalski, Chris Voigt, Dominic Woolf, Stan Wullschleger, and Xiaohan Yang) identified a range of possibilities by which SSB might help reduce greenhouse gas concentrations and which might also contribute to environmental sustainability and adaptation. These include, among other possibilities, engineering plants to convert CO2 produced by respiration into a stable carbonate, designing plants with an increased root-to-shoot ratio, and creating plants with the ability to self-fertilize. A number of serious ecological and societal challenges must, however, be confronted and resolved before any such application can be fully assessed, realized, and deployed.

Impact of Peer Review in Reducing Uncertainty in the Definition of the Lung Target Volume Among Trainee Oncologists

AIMS

To evaluate the impact of peer review and contouring workshops on reducing uncertainty in target volume delineation for lung cancer radiotherapy.

MATERIALS AND METHODS

Data from two lung cancer target volume delineation courses were analysed. In total, 22 trainees in clinical oncology working across different UK centres attended these courses with priori experience in lung cancer radiotherapy. The courses were made up of short presentations and contouring practice sessions. The participants were divided into two groups and asked to first individually delineate (IND) and then individually peer review (IPR) the contours of another participant. The contours were discussed with an expert panel consisting of two consultant clinical oncologists and a consultant radiologist. Contours were analysed quantitatively by measuring the volume and local distance standard deviation (localSD) from the reference expert consensus contour and qualitatively through visual analysis. Feedback from the participants was obtained using a questionnaire.

RESULTS

All participants applied minor editing to the contours during IPR, leading to a non-statistically significant reduction in the mean delineated volume (IND = 140.92 cm3, IPR = 125.26 cm3, P = 0.211). The overall interobserver variation was similar, with a localSD of 0.33 cm and 0.38 cm for the IND and IPR, respectively (P = 0.848). Six participants (29%) carried out correct major changes by either including tumour or excluding healthy tissue. One participant (5%) carried out an incorrect edit by excluding parts of the tumour, while another observer failed to identify a major contour error. The participants' level of confidence in target volume delineation increased following the course and identified the discussions with the radiologist and colleagues as the most important highlights of the course.

CONCLUSION

IPR could improve target volume delineation quality among trainee oncologists by identifying most major contour errors. However, errors were also introduced after IPR, suggesting the need to further discuss major changes with a multidisciplinary team.

Effects of initial microbial biomass abundance on respiration during pine litter decomposition

Microbial biomass is increasingly used to predict respiration in soil organic carbon (SOC) models. Its increased use combined with the difficulty of accurately measuring this variable points a need to directly assess the importance of microbial biomass abundance for carbon (C) cycling. To test the hypothesis that the initial microbial biomass abundance (i.e. biomass abundance on new plant litter) is a strong driver of plant litter C cycling, we manipulated biomass abundance by 10 and 100-fold dilution and composition using 12 source communities on sterile pine litter and measured respiration in microcosms for 30 days. In the first two days of microbial growth on fresh litter, a 100-fold difference in initial biomass abundance caused an average difference in respiration of nearly 300%, but the effect rapidly declined to less than 30% in 10 days and to 14% in 30 days. Parallel simulations with a soil carbon model, SOMIC 1.0, also predicted a 14% difference over 30 days, consistent with the experimental results. Model simulations predicted convergence of cumulative CO₂ to within 10% in three months and within 4% in three years. Rapid microbial growth, evidenced by appearance of visible microbial mats on the litter during the first week of incubation, likely attenuates the effects of large initial differences in biomass abundance. In contrast, the persistence of source community as an explanatory factor in driving differences in respiration across microcosms supports the importance of microbial composition in C cycling. Overall, the results suggest that the initial abundance of microbial biomass on litter is a weak driver of C flux from litter decomposition over long timescales (months to years) when litter communities have equal nutrient availability. By extension, slight variation in the timing of microbial dispersal to fresh litter is likely to be a minor factor in long-term C flux.

Microbial models with minimal mineral protection can explain long-term soil organic carbon persistence

Soil organic carbon (SOC) models currently in widespread use omit known microbial processes, and assume the existence of a SOC pool whose intrinsic properties confer persistence for centuries to millennia, despite evidence from priming and aggregate turnover that cast doubt on the existence of SOC with profound intrinsic stability. Here we show that by including microbial interactions in a SOC model, persistence can be explained as a feedback between substrate availability, mineral protection and microbial population size, without invoking an unproven pool that is intrinsically stable for centuries. The microbial SOC model based on this concept reproduces long-term data (r² = 0.92; n = 90), global SOC distribution (rmse = 4.7 +/− 0.6 kg C m⁻²), and total global SOC in the top 0.3 m (822 Pg C) accurately. SOC dynamics based on a microbial feedback without stable pools are thus consistent with global SOC distribution. This has important implications for carbon management, suggesting that relatively fast cycling, rather than recalcitrant, SOC must form the primary target of efforts to build SOC stocks.

Biological and thermochemical conversion of human solid waste to soil amendments

Biological and thermochemical sanitization of source-separated human solid waste (HSW) are effective technologies for unsewered communities. While both methods are capable of fecal pathogen sterilization, the agronomically-beneficial properties of waste sanitized between methods remains unclear. Therefore, this study compared recovery and quality of soil amendments produced by compostation, torrefaction, and pyrolysis of HSW, established their financial value, and quantified tradeoffs between product value and conversion efficiency. Temperature and associated mass losses significantly affected the physical and chemical properties of thermochemically-treated HSW. Thermophilic composting, a biological sanitation method practiced in informal settlements in Nairobi, Kenya, produced an amendment that contained between 16 and 858-fold more plant-available nitrogen (N; 214.5 mg N/kg) than HSW pyrolyzed between 300 and 700 °C (0.2-15.2 mg N/kg). Conversely, HSW pyrolyzed at 600 °C had four-fold higher plant-available phosphorus (P; 3117 mg P/kg) and five-fold higher plant-available potassium (K; 7403 mg K/kg) than composted HSW (716 mg P/kg and 1462 mg K/kg). Wide variation between international fertilizer prices on the low end and regional East African prices on the high end resulted in broad-spaced quantiles for the value of agronomic components in HSW amendments. Phosphorus and K comprised a disproportionate amount of the value, 52-87%, compared to plant-available N, which contributed less than 2%. The total value of treated HSW, summed across all agronomic components per unit weight amendment, was greatest for thermochemically-treated HSW at 600 °C, averaging 220 USD/Mg, more than four-fold that of composted HSW, 53 USD/Mg. In contrast, torrefaction provided the highest monetary value per unit weight feedstock, 144 USD/Mg, as low heating temperatures engender minimal mass loss and higher nutrient densities per unit weight feedstock, compared to composted or pyrolyzed HSW. When benchmarked against total N, P, and K of eight commonly-applied organic amendments, including sewage-sludge (Milorganite), compost, and alfalfa meal, HSW pyrolyzed at 700 °C was of greatest value per unit weight of amendment, 365 USD/Mg, compared to 89 USD/Mg for composted HSW, and contained 2.9% total N (0.5 mg available N/kg), 3.1% total P (7640 mg available P/kg), 3.5% total K (17,671 mg available K/kg).

Hypofractionated radiotherapy for localized prostate cancer using three-dimensional conformal radiotherapy technique: 3 years toxicity analysis

BACKGROUND

Hypofractionated radiotherapy in the radical treatment of localized prostate cancer has potential biological advantages relative to conventional fractionation. We report prospectively collected toxicity data from a cohort of patients treated with a 3D conformal technique (3DCRT).

MATERIALS AND METHODS

90 patients receiving curative intent hypofractionated radiotherapy with 57Gy in 19 daily fractions over 3.8 weeks were evaluated prospectively for the development of radiation related toxicity over a 3 year period.

RESULTS

All patients completed treatment. Maximal acute toxicity experienced was 58.6, 10 and 1.1% for grade 1, 2 and 3 genitourinary (GU) toxicity respectively and 75.6, 9 and 0% for gastrointestinal (GI) toxicity. For late toxicity the three year actuarial rates of grade 1, 2 and 3 GU and GI toxicity respectively were 47.3, 2.4 and 0%; and 40, 9.3 and 4.7%. There were no grade 4 or worse acute or late toxicities. 97.6% of evaluable patients remained free of biochemical failure 36 months post radiotherapy.

CONCLUSIONS

A 57Gy in 19 daily fraction radiotherapy schedule using 3D conformal radiotherapy for the definitive treatment of localized prostate cancer has acceptable early and late toxicity.

Biofuels from pyrolysis in perspective: trade-offs between energy yields and soil-carbon additions

Coproduction of biofuels with biochar (the carbon-rich solid formed during biomass pyrolysis) can provide carbon-negative bioenergy if the biochar is sequestered in soil, where it can improve fertility and thus simultaneously address issues of food security, soil degradation, energy production, and climate change. However, increasing biochar production entails a reduction in bioenergy obtainable per unit biomass feedstock. Quantification of this trade-off for specific biochar-biofuel pathways has been hampered by lack of an accurate-yet-simple model for predicting yields, product compositions, and energy balances from biomass slow pyrolysis. An empirical model of biomass slow pyrolysis was developed and applied to several pathways for biochar coproduction with gaseous and liquid biofuels. Here, we show that biochar production reduces liquid biofuel yield by at least 21 GJ Mg(-1) C (biofuel energy sacrificed per unit mass of biochar C), with methanol synthesis giving this lowest energy penalty. For gaseous-biofuel production, the minimum energy penalty for biochar production is 33 GJ Mg(-1) C. These substitution rates correspond to a wide range of Pareto-optimal system configurations, implying considerable latitude to choose pyrolysis conditions to optimize for desired biochar properties or to modulate energy versus biochar yields in response to fluctuating price differentials for the two commodities.

Sustainable biochar to mitigate global climate change

Production of biochar (the carbon (C)-rich solid formed by pyrolysis of biomass) and its storage in soils have been suggested as a means of abating climate change by sequestering carbon, while simultaneously providing energy and increasing crop yields. Substantial uncertainties exist, however, regarding the impact, capacity and sustainability of biochar at the global level. In this paper we estimate the maximum sustainable technical potential of biochar to mitigate climate change. Annual net emissions of carbon dioxide (CO(2)), methane and nitrous oxide could be reduced by a maximum of 1.8 Pg CO(2)-C equivalent (CO(2)-C(e)) per year (12% of current anthropogenic CO(2)-C(e) emissions; 1 Pg=1 Gt), and total net emissions over the course of a century by 130 Pg CO(2)-C(e), without endangering food security, habitat or soil conservation. Biochar has a larger climate-change mitigation potential than combustion of the same sustainably procured biomass for bioenergy, except when fertile soils are amended while coal is the fuel being offset.

The use of symptoms to predict colorectal cancer site. Can we reduce the pressure on our endoscopy services?

OBJECTIVE

Our objective was to determine the value of gastrointestinal symptoms and signs in predicting the site of colorectal cancer (CRC). These symptoms can subsequently be used in determining first-line investigation with either sigmoidoscopy or colonoscopy.

METHOD

We interrogated the endoscopic and CRC databases ('Infoflex'), for patients diagnosed with CRC between April 2005 and March 2006 inclusive. These patients were cross-referenced with the pathology database and patient records. Information gathered from these databases include: age, gender, symptoms, site of cancer, histology, Duke's grading, blood parameters, diagnostic tool and treatment.

RESULTS

One hundred fifty-three patients were diagnosed with CRC between April 2005 and March 2006. One hundred twenty-six were initially seen in the out-patient department, of whom 38 (29%) were right-sided (proximal to the splenic flexure), and 88 (70%) were left-sided (splenic flexure and beyond). Change in bowel habit (diarrhoea and constipation) and rectal bleeding were significantly associated with left-sided cancers (P < 0.0024 and P < 0.0001, respectively). Haemoglobin (P < 0.0001) and mean corpuscular volume (P < 0.0001) were significantly lower in right-sided cancers. Weight loss, pain and obstruction were not associated with cancer site. C-reactive protein, albumin and carcinoembryonic antigen are not predictive of cancer site, Duke's stage or influenced by patient age or gender.

DISCUSSION

Symptoms can accurately predict site of cancer, allowing investigations to be tailored accordingly. We would recommend that patients with altered bowel habit and/or rectal bleeding, and no other symptoms, risk factors or anaemia, can be investigated with a flexible sigmoidoscopy to confirm or refute a diagnosis of colorectal cancer.

The cognitive and behavioural phenotype of Roifman syndrome

BACKGROUND

Roifman syndrome (OMIM 300258) is a multi-system disorder with a physical phenotype that includes Beta-cell immunodeficiency, intra-uterine and postnatal growth retardation, spondyloepiphyseal dysplasia, retinal dystrophy and characteristic facial dysmorphism. So far, six cases, all boys, have been reported in the literature. Roifman postulated that the syndrome may be due to a mutation in an X-linked gene or an autosomal gene giving rise to a sex-limited trait, but the definitive pathogenetic mechanism has still not been elucidated. Very little is known about the cognitive and behavioural phenotype of Roifman syndrome and no standardized measures of cognitive abilities have been reported.

METHODS

We report the seventh case of a boy with Roifman syndrome and present the first systematic documentation of the cognitive and behavioural phenotype of an individual with the syndrome.

RESULTS

In spite of having been reported as appearing intellectually 'able', formal evaluation showed very significant intellectual disability and neuropsychological impairment across cognitive domains.

CONCLUSIONS

The findings suggest that Roifman syndrome may be an example of an X-linked mental retardation syndrome (XLMRS).

Quality of Life in Patients Treated with First-Line Antiretroviral Therapy Containing Nevirapine And/Or Efavirenz

Objective

To assess whether differences in safety profiles between nevirapine (NVP) and efavirenz (EFV), as observed in the 2NN study, translated into differences in ‘health related quality of life’ (HRQoL).

Design

A sub-study of the 2NN study, with antiretro-viral-naive patients randomly allocated to NVP (once or twice daily), EFV or NVP+EFV, in addition to stavudine and lamivudine.

Methods

Comparing differences in changes of HRQoL over 48 weeks as measured with the Medical Outcomes Study HIV Health Survey (MOS-HIV) questionnaire, using analysis of variance.

Results

The 2NN study enrolled 1216 patients. No validated questionnaires were available for 244 patients, and 55 patients had no HRQoL data at all, leaving 917 patients eligible for this sub-study. A total of 471 (51%) had HRQoL measurements both at baseline and week 48. The majority (69%) of patients without HRQoL measurements did, however, complete the study. The change in the physical health score (PHS) was 3.9 for NVP, 3.4 for EFV and 2.4 for NVP+EFV ( P=0.712). For the mental health score (MHS) these values were 6.1, 7.0 and 3.9, respectively ( P=0.098). A baseline plasma HIV-1 RNA concentration (pVL) ≥100 000 copies/ml and a decline in pVL (per log10) were independently associated with an increase of PHS. An increase of MHS was only associated with pVL decline. Patients experiencing an adverse event during follow-up had a comparable change in PHS but a significantly smaller change in MHS, compared with those without an adverse event.

Conclusions

First-line ART containing NVP and/or EFV leads to an improvement in HRQoL. The gain in HRQoL was similar for NVP and EFV, but slightly lower for the combination of these drugs.

Human keratinocytes lack the components to produce leukotriene B4

The cellular origin of leukotriene B4 (LTB4), a potent pro-inflammatory molecule present in psoriatic lesions, has yet to be determined. In the present study, cultured human keratinocytes were evaluated for their ability to produce LTB4. Keratinocytes stimulated under a variety of conditions did not produce detectable amounts of LTB4, as measured by enzyme immunoassay and liquid chromatographic techniques. Prostaglandin E2 and 15-hydroxyeicosatetraenoic acid were the only eicosanoids detected. The capacity of keratinocytes to synthesize 5-lipoxygenase (5-LO) products, or lack thereof, was further evaluated by preparing subcellular fractions and examining them for the presence of 5-LO activity and the proteins responsible for LTB4 production. Using Western blot analysis, we detected no bands that migrated with the 78-kDa 5-LO enzyme. Subcellular fractions were also examined for the presence of the 5-LO-activating protein (FLAP). This protein, which is essential to 5-LO activity, could not be detected in any keratinocyte preparation examined. Consistent with the absence of proteins, the mRNAs for 5-LO and FLAP were undetectable by reverse transcriptase polymerase chain reactions analysis. These results demonstrate that human keratinocytes lack the crucial proteins necessary for LTB4 production.

Pancreatitis in patients with organic acidemias

STUDY OBJECTIVE

The discovery of pancreatitis in two children with methylmalonic acidemia led us to review the experience with pancreatitis in a large number of patients with organic acidemias to determine whether pancreatitis is an important complication of these disorders.

DESIGN

Case series.

SETTING

Pediatric metabolism services at five tertiary care centers.

PATIENTS

Records of all patients with organic acidemias followed at the five institutions during the past 10 years were reviewed. Pancreatitis was recognized by symptoms and laboratory findings and confirmed by imaging studies, surgery, or autopsy. At three institutions all cases of pancreatitis in children younger than 10 years were reviewed.

MEASUREMENTS AND RESULTS

Nine children with pancreatitis (seven with acute and two with chronic cases) were identified among 108 children with branched-chain organic acidemias. They ranged in age from 13 months to 9 years. Five had methylmalonic acidemia, three had isovaleric acidemia, and one had maple syrup urine disease. There were three deaths; acute hemorrhagic pancreatitis occurred in two children, and chronic pancreatitis was found at autopsy in a third. All three patients with isovaleric acidemia and pancreatitis were identified after the occurrence of pancreatitis. The survey of pancreatitis at three institutions found 57 other patients (none with an inborn error) in addition to three patients with inborn errors included in this study.

CONCLUSIONS

Acute or chronic pancreatitis may complicate branched-chain organic acidemias and must be considered in the assessment of patients with these disorders who have acute clinical deterioration and vomiting, abdominal pain, encephalopathy or shock, or milder symptoms. Conversely, an inborn error of organic acid metabolism should be considered in children with pancreatitis of unknown origin.

Pulmonary hypertension associated with non-cirrhotic portal hypertension in systemic lupus erythematosus

A case of non-cirrhotic portal hypertension in a patient with systemic lupus erythematosus, the first of our knowledge, is described. Severe pulmonary hypertension was associated with the portal hypertension and with markers of active auto-immunity. Pulmonary hypertension has not previously been associated with non-cirrhotic portal hypertension. The coexistence of vasculopathy of the portal and pulmonary vascular beds in this patient with active autoimmunity supports the postulate that portal-pulmonary hypertension may be immunologically mediated.

Generalized lymphangiomatosis and chylothorax in the pediatric age group

Four patients with generalized lymphangiomatosis presenting with chylothoraces are described. All four had bone involvement, two had involvement of the spleen, and one of the pericardium. The diagnosis was confirmed by typical radiology, histology, and in three patients by immunohistochemistry. Treatment was mainly palliative. Three patients died within 1/2 to three years of presentation.