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The effects of global warming are the ecological and social changes caused by the rise in global temperatures. Evidence of climate change includes the instrumental temperature record, rising sea levels, and decreased snow cover in the Northern Hemisphere.[6] According to the Intergovernmental Panel on Climate Change (IPCC), most of the observed increase in global average temperatures since the mid-20th century is very likely due to the observed increase in human greenhouse gas concentrations.[7] Projections of future climate change suggest further global warming, sea level rise, and an increase in the frequency of some extreme weather events.[8] Parties to the United Nations Framework Convention on Climate Change (UNFCCC) have agreed to implement policies designed to reduce their emissions of greenhouse gases to avoid dangerous climate change.
In this article, the phrase "climate change" is used to describe a change in the climate, measured in terms of its statistical properties, e.g., the global mean surface temperature.[9] In this context, "climate" is taken to mean the average weather. Climate can change over period of time ranging from months to thousands or millions of years. The classical time period is 30 years, as defined by the World Meteorological Organization. The climate change referred to may be due to natural causes, e.g., changes in the sun's output, or due to human activities, e.g., changing the composition of the atmosphere.[10] Any human-induced changes in climate will occur against the "background" of natural climatic variations (see attribution of recent climate change for more information).
In this article, the phrase "global warming" refers to the change in the Earth's global average surface temperature.[11] Measurements show a global temperature increase of 1.4 °F (0.78 °C) between the years 1900 and 2005. Global warming is closely associated with a broad spectrum of other climate changes, such as increases in the frequency of intense rainfall, decreases in snow cover and sea ice, more frequent and intense heat waves, rising sea levels, and widespread ocean acidification.[12]
Also, the term "anthropogenic forcing" refers to the influence exerted on a habitat or chemical environment by humans, as opposed to a natural process.[13]
This article breaks down some of the impacts of climate change according to different levels of future global warming. This way of describing impacts has, for instance, been used in the IPCC's Assessment Reports on climate change.[15] The instrumental temperature record shows global warming of around 0.6 °C over the entire 20th century.[16]
The future level of global warming is uncertain, but a wide range of estimates (projections) have been made.[17] The IPCC's "SRES" scenarios have been frequently used to make projections of future climate change.[18]:22-24 The SRES scenarios are "baseline" (or "reference") scenarios, which means that they do not take into account any current or future measures to limit GHG emissions (e.g., the UNFCCC's Kyoto Protocol and the Cancún agreements).[19] Emissions projections of the SRES scenarios are broadly comparable in range to the baseline emissions scenarios that have been developed by the scientific community.[17][20]
In the IPCC Fourth Assessment Report, changes in future global mean temperature were projected using the six SRES "marker" emissions scenarios.[21] Emissions projections for the six SRES "marker" scenarios are representative of the full set of forty SRES scenarios.[22] For the lowest emissions SRES marker scenario ("B1" - see the SRES article for details on this scenario), the best estimate for global mean temperature is an increase of 1.8 °C (3.2 °F)[21] by the end of the 21st century. This projection is relative to global temperatures at the end of the 20th century.[23] The "likely" range (greater than 66% probability, based on expert judgement)[24] for the SRES B1 marker scenario is 1.1–2.9 °C (2–5.2 °F).[21] For the highest emissions SRES marker scenario (A1FI), the best estimate for global mean temperature increase is 4.0 °C (7.2 °F), with a "likely" range of 2.4–6.4 °C (4.3–11.5 °F).[21]
The range in temperature projections partly reflects the different choice of emissions scenario.[18]:22-24 Different scenarios make different assumptions of future social and economic development (e.g., economic growth, population level, energy policies), which in turn affects projections of greenhouse gas (GHG) emissions.[18]:22-24 The range also reflects uncertainty in the response of the climate system to past and future GHG emissions (measured by the climate sensitivity).[18]:22-24
The projected rate of warming under these scenarios would very likely be without precedent during at least the last 10,000 years (see footnote 1).[25] The most recent warm period comparable to these projections was the mid-Pliocene, around 3 million years ago.[26] At that time, models suggest that mean global temperatures were about 2–3 °C warmer than pre-industrial temperatures.[27]
Working Group I's contribution to the IPCC Fourth Assessment Report, published in 2007, concluded that warming of the climate system was "unequivocal."[6] This was based on the consistency of evidence across a range of observed changes, including increases in global average air and ocean temperatures, widespread melting of snow and ice, and rising global average sea level.[29]
Human activities have contributed to a number of the observed changes in climate.[30] This contribution has principally been through the burning of fossil fuels, which has led to an increase in the concentration of GHGs in the atmosphere.[31] Another human influence on the climate are sulfur dioxide emissions, which are a precursor to the formation of sulfate aerosols in the atmosphere.[32]
Human-induced warming could potentially lead to some impacts that are abrupt or irreversible (see the section on Abrupt or irreversible changes).[33][34] The probability of warming having unforeseen consequences increases with the rate, magnitude, and duration of climate change.[35]
The effect of human activities on the climate system can be measured by radiative forcing: Energy is constantly flowing into the atmosphere in the form of sunlight that always shines on half of the Earth's surface.[36] Some of this sunlight is reflected back to space and the rest is absorbed by the planet. Some energy from the Earth is also radiated back out into space as invisible infrared light. Radiative forcing is a measure of the energy flowing into the Earth-atmosphere system, minus the energy flowing out. A positive radiative forcing will tend to warm the climate, while a negative forcing will tend to cool the climate.[37] Anthopogenic forcing (i.e., the radiative forcing due to human activities) was estimated to have been positive (i.e., an overall warming effect) in the year 2005.[37] This is relative to the estimated forcings at the start of the industrial era, taken as the year 1750. Anthropogenic forcing of the climate has likely contributed to a number of observed changes, including sea level rise, changes in climate extremes (such as warm and cold days), declines in Arctic sea ice extent, and to glacier retreat.[30]
Observations show that there have been changes in weather.[38] As climate changes, the probabilities of certain types of weather events are affected.
Changes have been observed in the amount, intensity, frequency, and type of precipitation.[18]:18 Widespread increases in heavy precipitation have occurred, even in places where total rain amounts have decreased. Authors of the IPCC Fourth Assessment Report concluded that human influences had, more likely than not (greater than 50% probability, based on expert judgement),[24] led to an increase in the frequency of heavy precipitation events.[39] Projections of future changes in precipitation show overall increases in the global average, but with substantial shifts in where and how precipitation falls. Also, increased extremes of summer dryness and winter wetness are projected for much of the globe, meaning a generally greater risk of droughts and floods.[18]:24 Climate models tend to project increasing precipitation at high latitudes and in the tropics (e.g., the south-east monsoon region and over the tropical Pacific) and decreasing precipitation in the sub-tropics (e.g., over much of North Africa and the northern Sahara).[40] Using the Palmer Drought Severity Index, a 2010 study by the National Center for Atmospheric Research projects increasingly dry conditions across much of the globe in the next 30 years, possibly reaching a scale in some regions by the end of the century that has rarely, if ever, been observed in modern times.[41]
Evidence suggests that, since the 1970s, there have been substantial increases in the intensity and duration of tropical storms and hurricanes.[42] Models project a general tendency for more intense but fewer storms outside the tropics.[18]:24
Since the late 20th century, changes have been observed in the trends of some extreme weather and climate events, e.g., heat waves.[43] Human activities have, with varying degrees of confidence, contributed to some of these observed trends. Projections for the 21st century suggest continuing changes in trends for some extreme events. Solomon et al. (2007),[43] for example, projected the following likely (greater than 66% probability, based on expert judgement)[24] changes:
Projected changes in extreme events will have predominantly adverse impacts on ecosystems and human society.[44][45]
Authors of the IPCC Fourth Assessment Report (AR4) found that, on average, mountain glaciers and snow cover had decreased in both the northern and southern hemispheres.[6] This widespread decrease in glaciers and ice caps had contributed to observed sea level rise. With very high or high confidence (see footnote 2), authors of the IPCC Working Group II Assessment (IPCC AR4 WG2 2007)[46] and Synthesis Report (IPCC AR4 SYR 2007)[47] made a number of projections relating to future changes in glaciers:
The retreat of glaciers and ice caps can cause increased volcanism. Reduction in ice cover reduces the confining pressure exerted on the volcano, increasing deviatoric stresses and potentially causing the volcano to erupt. This reduction of pressure can also cause decompression melting of material in the mantle, resulting in the generation of more magma.[48] Researchers in Iceland have shown that the rate of volcanic rock production there following deglaciation (10,000 to 4500 years before present) was 20–30 times greater than that observed after 2900 years before present.[49] While the original study addresses the first reason for increased volcanism (reduced confining pressure), scientists have more recently shown that these lavas have unusually high trace element concentrations, indicative of increased melting in the mantle.[50] This work in Iceland has been corroborated by a study in California, in which scientists found a strong correlation between volcanism and periods of global deglaciation.[51] The effects of current sea level rise could include increased crustal stress at the base of coastal volcanoes from a rise in the volcano's water table (and the associated saltwater intrusion), while the mass from extra water could activate dormant seismic faults around volcanoes. In addition, the wide-scale displacement of water from melting in places such as West Antarctica is likely to slightly alter the Earth's rotational period and may shift its axial tilt on the scale of hundreds of metres, inducing further crustal stress changes.[52][53]
Current melting of ice is predicted to increase the size and frequency of volcanic eruptions.[54] In particular, lateral collapse events at stratovolcanoes are likely to increase,[54][55] and there are potential positive feedbacks between the removal of ice and magmatism.[54]
A numerical modeling study has demonstrated that seismicity increases during unloading, such as that due to the removal of ice.[56]
The role of the oceans in global warming is a complex one. The oceans serve as a sink for carbon dioxide, taking up much that would otherwise remain in the atmosphere, but increased levels of CO2 have led to ocean acidification. Furthermore, as the temperature of the oceans increases, they become less able to absorb excess CO2. The ocean have also acted as a sink in absorbing extra heat from the atmosphere. This extra heat has been added to the climate system due to the build-up of GHGs. More than 90 percent of warming that occurred over 1960–2009 is estimated to have gone into the oceans.[28]:4
Global warming is projected to have a number of effects on the oceans. Ongoing effects include rising sea levels due to thermal expansion and melting of glaciers and ice sheets, and warming of the ocean surface, leading to increased temperature stratification. Other possible effects include large-scale changes in ocean circulation.
About one-third of the carbon dioxide emitted by human activity has already been taken up by the oceans.[57] As carbon dioxide dissolves in sea water, carbonic acid is formed, which has the effect of acidifying the ocean, measured as a change in pH. The uptake of human carbon emissions since the year 1750 has led to an average decrease in pH of 0.1 units.[58] Projections using the SRES emissions scenarios suggest a further reduction in average global surface ocean pH of between 0.14 and 0.35 units over the 21st century.
The effects of ocean acidification on the marine biosphere have yet to be documented.[58] Laboratory experiments suggest beneficial effects for a few species, with potentially highly detrimental effects for a substantial number of species.[57] With medium confidence, Fischlin et al. (2007)[59] projected that future ocean acidification and climate change would impair a wide range of planktonic and shallow benthic marine organisms that use aragonite to make their shells or skeletons, such as corals and marine snails (pteropods), with significant impacts particularly in the Southern Ocean.
The amount of oxygen dissolved in the oceans may decline, with adverse consequences for ocean life.[60][61]
There is strong evidence that global sea level rose gradually over the 20th century.[62] With high confidence, Bindoff et al. (2007)[63] concluded that between the mid-19th and mid-20th centuries, the rate of sea level rise increased. Authors of the IPCC Fourth Assessment Synthesis Report (IPCC AR4 SYR, 2007)[16] reported that between the years 1961 and 2003, global average sea level rose at an average rate of 1.8 mm per year (mm/yr), with a range of 1.3–2.3 mm/yr. Between 1993 and 2003, the rate increased above the previous period to 3.1 mm/yr (range of 2.4–3.8 mm/yr). Authors of IPCC AR4 SYR (2007)[16] were uncertain whether the increase in rate from 1993 to 2003 was due to natural variations in sea level over the time period, or whether it reflected an increase in the underlying long-term trend.
There are two main factors that have contributed to observed sea level rise.[62] The first is thermal expansion: as ocean water warms, it expands.[64] The second is from the contribution of land-based ice due to increased melting. The major store of water on land is found in glaciers and ice sheets. Anthropogenic forcing very likely (greater than 90% probability, based on expert judgement)[24] contributed to sea level rise during the latter half of the 20th century.[30]
There is a widespread consensus that substantial long-term sea level rise will continue for centuries to come.[65] In the Fourth Annual Review the IPCC[66] projected sea level rise to the end of the 21st century using the SRES emissions scenarios. Across the six SRES marker scenarios, sea level was projected to rise by 18 to 59 cm (7.1 to 23.2 in), relative to sea level at the end of the 20th century.[67] Thermal expansion is the largest component in these projections, contributing 70-75% of the central estimate for all scenarios.[68] Due to a lack of scientific understanding, this sea level rise estimate does not include all of the possible contributions of ice sheets (see the section on abrupt or irreversible changes).
An assessment of the scientific literature on climate change was published in 2010 by the US National Research Council (NRC, 2010).[69] NRC (2010)[69] described the projections in AR4 (i.e., those cited in the above paragraph) as "conservative," and summarized the results of more recent studies. Cited studies suggested a great deal of uncertainty in projections.[69] A range of projections suggested possible sea level rise by the end of the 21st century of between 0.56 and 2 m, relative to sea levels at the end of the 20th century.[69]
From 1961 to 2003, the global ocean temperature has risen by 0.10 °C from the surface to a depth of 700 m. There is variability both year-to-year and over longer time scales, with global ocean heat content observations showing high rates of warming for 1991–2003, but some cooling from 2003 to 2007.[70] The temperature of the Antarctic Southern Ocean rose by 0.17 °C (0.31 °F) between the 1950s and the 1980s, nearly twice the rate for the world's oceans as a whole.[71] As well as having effects on ecosystems (e.g. by melting sea ice, affecting algae that grow on its underside), warming reduces the ocean's ability to absorb CO2.[citation needed] It is likely (greater than 66% probability, based on expert judgement)[24] that anthropogenic forcing contributed to the general warming observed in the upper several hundred metres of the ocean during the latter half of the 20th century.[30]
Regional effects of global warming vary in nature. Some are the result of a generalised global change, such as rising temperature, resulting in local effects, such as melting ice. In other cases, a change may be related to a change in a particular ocean current or weather system. In such cases, the regional effect may be disproportionate and will not necessarily follow the global trend.
There are three major ways in which global warming will make changes to regional climate: melting or forming ice, changing the hydrological cycle (of evaporation and precipitation) and changing currents in the oceans and air flows in the atmosphere. The coast can also be considered a region, and will suffer severe impacts from sea level rise.
With very high confidence, Rosenzweig et al. (2007)[73] concluded that physical and biological systems on all continents and in most oceans had been affected by recent climate changes, particularly regional temperature increases. Impacts include earlier leafing of trees and plants over many regions; movements of species to higher latitudes and altitudes in the Northern Hemisphere; changes in bird migrations in Europe, North America and Australia; and shifting of the oceans' plankton and fish from cold- to warm-adapted communities.[74]
The human influence on the climate can be seen in the geographical pattern of observed warming, with greater temperature increases over land and in polar regions rather than over the oceans.[75]:6 Using models, it is possible to identify the human "signal" of global warming over both land and ocean areas.[75]:6
Projections of future climate changes at the regional scale do not hold as high a level of scientific confidence as projections made at the global scale.[75]:9 It is, however, expected that future warming will follow a similar geographical pattern to that seen already, with greatest warming over land and high northern latitudes, and least over the Southern Ocean and parts of the North Atlantic Ocean.[76] Nearly all land areas will very likely warm more than the global average.[77]
The Arctic, Africa, small islands and Asian megadeltas are regions that are likely to be especially affected by climate change.[78] Adverse impacts of climate change are expected to fall disproportionately upon developing countries.[77] Within other areas, even those with high incomes, some people can be particularly at risk from climate change, such as the poor, young children and the elderly.[78]
The impacts of climate change can be thought of in terms of sensitivity and vulnerability. "Sensitivity" is the degree to which a particular system or sector might be affected, positively or negatively, by climate change and/or climate variability. "Vulnerability" is the degree to which a particular system or sector might be adversely affected by climate change.[79]
The sensitivity of human society to climate change varies. Sectors sensitive to climate change include water resources, coastal zones, human settlements, and human health. Industries sensitive to climate change include agriculture, fisheries, forestry, energy, construction, insurance, financial services, tourism, and recreation.[80][81]
Climate change will impact agriculture and food production around the world due to: the effects of elevated CO2 in the atmosphere, higher temperatures, altered precipitation and transpiration regimes, increased frequency of extreme events, and modified weed, pest, and pathogen pressure.[82] In general, low-latitude areas are at most risk of having decreased crop yields.[83]
So far, the effects of regional climate change on agriculture have been relatively limited.[73] Changes in crop phenology provide important evidence of the response to recent regional climate change.[84] Phenology is the study of natural phenomena that recur periodically, and how these phenomena relate to climate and seasonal changes.[85] A significant advance in phenology has been observed for agriculture and forestry in large parts of the Northern Hemisphere.[73]
With low to medium confidence, Schneider et al. (2007)[15] projected that for about a 1 to 3 °C increase in global mean temperature (by the years 2090-2100, relative to temperature in the years 1990–2000), there would be productivity decreases for some cereals in low latitudes, and productivity increases in high latitudes. With medium confidence, global production potential was projected to:[15]
Most of the studies on global agriculture assessed by Schneider et al. (2007)[83] had not incorporated a number of critical factors, including changes in extreme events, or the spread of pests and diseases. Studies had also not considered the development of specific practices or technologies to aid adaptation to climate change.[83]
Easterling et al. (2007)[88] assessed studies that made quantitative projections of climate change impacts on food security. It was noted that these projections were highly uncertain and had limitations. However, the assessed studies suggested a number of fairly robust findings. The first was that climate change would likely increase the number of people at risk of hunger compared with reference scenarios with no climate change. Climate change impacts depended strongly on projected future social and economic development. Additionally, the magnitude of climate change impacts was projected to be smaller compared to the impact of social and economic development. In 2006, the global estimate for the number of people undernourished was 820 million.[89] Under the SRES A1, B1, and B2 scenarios (see the SRES article for information on each scenario group), projections for the year 2080 showed a reduction in the number of people undernourished of about 560-700 million people, with a global total of undernourished people of 100-240 million in 2080. By contrast, the SRES A2 scenario showed only a small decrease in the risk of hunger from 2006 levels. The smaller reduction under A2 was attributed to the higher projected future population level in this scenario.
Human beings are exposed to climate change through changing weather patterns (temperature, precipitation, sea-level rise and more frequent extreme events) and indirectly through changes in water, air and food quality and changes in ecosystems, agriculture, industry and settlements and the economy (Confalonieri et al., 2007:393).[90] According to an assessment of the scientific literature by Confalonieri et al. (2007:393),[90] the effects of climate change to date have been small, but are projected to progressively increase in all countries and regions.
A study by the World Health Organization (WHO, 2009)[91] estimated the effect of climate change on human health. Not all of the effects of climate change were included in their estimates, for example, the effects of more frequent and extreme storms were excluded. Climate change was estimated to have been responsible for 3% of diarrhoea, 3% of malaria, and 3.8% of dengue fever deaths worldwide in 2004. Total attributable mortality was about 0.2% of deaths in 2004; of these, 85% were child deaths.
With high confidence, authors of the IPCC AR4 Synthesis report[92]:48 projected that climate change would bring some benefits in temperate areas, such as fewer deaths from cold exposure, and some mixed effects such as changes in range and transmission potential of malaria in Africa. Benefits were projected to be outweighed by negative health effects of rising temperatures, especially in developing countries.
With very high confidence, Confalonieri et al. (2007)[90]:393 concluded that economic development was an important component of possible adaptation to climate change. Economic growth on its own, however, was not judged to be sufficient to insulate the world's population from disease and injury due to climate change. Future vulnerability to climate change will depend not only on the extent of social and economic change, but also on how the benefits and costs of change are distributed in society.[93] For example, in the 19th century, rapid urbanization in western Europe lead to a plummeting in population health.[93] Other factors important in determining the health of populations include education, the availability of health services, and public-health infrastructure.[90]:393
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With high confidence, Confalonieri et al. (2007) projected that malnutrition would increase due to climate change.[90] This link is associated with climate variability and change.[94] Drought reduces variety in diets and reduces overall consumption. This can lead to micronutrient deficiencies.
The World Health Organization (Campbell-Lendrum et al., 2003)[95] conducted a regional and global assessment to quantify the amount of premature morbidity and mortality due to a range of factors, including climate change. Projections were made over future climate change impacts. Limited adjustments for adaptation were included in the estimates based on these projections. Projected relative risks attributable to climate change in 2030 varied by health outcome and region. Risks were largely negative, with most of the projected disease burden due to increases in diarrhoeal disease and malnutrition. These increases were primarily in low-income populations already experiencing a large burden of disease.
With high confidence, Confalonieri et al. (2007) projected that climate change would increase the number of people suffering from death, disease and injury from heatwaves, floods, storms, fires and droughts.[90]
Floods are low-probability, high-impact events that can overwhelm physical infrastructure and human communities.[96] Confalonieri et al. (2007) reported that major storm and flood disasters have occurred in the last two decades.
The impacts of weather disasters is considerable and unequally distributed.[96] For example, natural disasters have been shown to result in increased domestic violence against - and post-traumatic stress disorders in – women. In terms of deaths and populations affected, floods and tropical cyclones have the greatest impact in South Asia and Latin America. Vulnerability to weather disasters depends on the attributes of the person at risk, including where they live and their age, as well as other social and environmental factors. High-density populations in low-lying coastal regions experience a high health burden from weather disasters.
Hot days, hot nights and heatwaves have become more frequent.[97] Heatwaves are associated with marked short-term increases in mortality. For example, in August 2003, a heatwave in Europe resulted in excess mortality in the range of 35,000 total deaths.
Heat-related morbidity and mortality is projected to increase.[98] The health burden could be relatively small for moderate heatwaves in temperate regions, because deaths occur primarily in susceptible persons.
The effects of drought on health include deaths, malnutrition, infectious diseases and respiratory diseases.[94] Countries within the "Meningitis Belt" in semi-arid sub-Saharan Africa experience the highest endemicity and epidemic frequency of meningococcal meningitis in Africa, although other areas in the Rift Valley, the Great Lakes, and southern Africa are also affected.[99] The spatial distribution, intensity, and seasonality of meningococcal (epidemic) meningitis appear to be strongly linked to climate and environmental factors, particularly drought. The cause of this link is not fully understood.
In some regions, changes in temperature and precipitation are projected to increase the frequency and severity of fire events.[100] Forest and bush fires cause burns, damage from smoke inhalation and other injuries.
With high confidence, Confalonieri et al. (2007)[90] projected that climate change would continue to change the range of some infectious disease vectors. Vector-borne diseases (VBD) are infections transmitted by the bite of infected arthropod species, such as mosquitoes, ticks, triatomine bugs, sandflies, and blackflies.[101] There is some evidence of climate-change-related shifts in the distribution of tick vectors of disease, of some (non-malarial) mosquito vectors in Europe and North America. Climate change has also been implicated in changes in the breeding and migration dates of several bird species. Several species of wild bird can act as carriers of human pathogens as well as of vectors of infectious agents.
With low confidence, Confalonieri et al. (2007) concluded that climate change would increase the number of people at risk of dengue.[90] Dengue is the world's most important vector-borne viral disease.[102] Several studies have reported associations between dengue and climate, however, these associations are not entirely consistent.
The spatial distribution, intensity of transmission, and seasonalty of malaria is influenced by climate in Sub-saharan Africa.[103] Rainfall can be a limiting factor for mosquito populations and there is some evidence of reductions in transmission associated with decadal decreases in rainfall. The effects of observed climate change on the geographical distribution of malaria and its transmission intensity in highland regions remains controversial. There is no clear evidence that malaria has been affected by climate change in South America or in continental regions of the Russian Federation. There is still much uncertainty about the potential impact of climate change on malaria at local and global scales.
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A paper by researchers from the University of Oxford and the University of Florida published in Nature in May 2010 concluded that claims that a warming climate has led to more widespread disease and death due to malaria are largely at odds with the evidence, and that "predictions of an intensification of malaria in a warmer world, based on extrapolated empirical relationships or biological mechanisms, must be set against a context of a century of warming that has seen marked global declines in the disease and a substantial weakening of the global correlation between malaria endemicity and climate."[104][105]
There is good evidence that diseases transmitted by rodents sometimes increase during heavy rainfall and flooding because of altered patterns of human-pathogen-rodent contact.[106]
With very high confidence, Confalonieri et al. (2007)[90] concluded that climate change would have mixed effects on malaria. Malaria is a complex disease to model and all of the published models assessed by Confalonieri et al. (2007) had limited parametrization of some key factors.[107] Parametrization is used in climate models because the resolution of models is insufficient to resolve some physical processes.[108] Given this limitation, models assessed by Confalonieri et al. (2007) projected that, particularly in Africa, climate change would be associated with geographical expansions of the areas suitable for Plasmodium falciparum malaria in some regions, and contractions in other regions. Projections also suggested that some regions would experience a longer season of transmission. Projections suggested expansions in vector species that carry dengue for parts of Australia and New Zealand.
With medium confidence, Confalonieri et al. (2007)[90] concluded that climate change would increase the burden of diarrhoeal diseases. Childhood mortality due to diarrhoea in low-income countries, especially in Sub-Saharan Africa, remains high.[109] This is despite improvements in care. Several studies have shown that transmission of enteric pathogens is higher during the rainy season. Some studies have found that higher temperature was strongly associated with increased episodes of diarrhoeal disease in adults and children in Peru. Campbell-Lendrum et al. (2003)[95] projected that climate change would increase the burden of diarrhoeal diseases in low-income regions by approximately 2 to 5% in 2020.
With high confidence, Confalonieri et al. (2007)[90] projected that climate change would increase cardio-respiratory morbidity and mortality associated with ground-level ozone. Ground-level ozone is both naturally occurring and is the primary constituent of urban smog.[110] Ozone in smog is formed through chemical reactions involving nitrogen oxides and other compounds. The reaction is a photochemical reaction, meaning that it involves electromagnetic radiation, and occurs in the presence of bright sunshine and high temperatures. Exposure to elevated concentrations of ozone is associated with increased hospital admissions for pneumonia, chronic obstructive pulmonary disease, asthma, allergic rhinitis and other respiratory diseases, and with premature mortality.
Background levels of ground-level ozone have risen since pre-industrial times because of increasing emissions of methane, carbon monoxide and nitrogen oxides.[111] This trend is expected to continue into the mid-21st century.
Cold-waves continue to be a problem in northern latitudes, where very low temperatures can be reached in a few hours and extend over long periods.[112] Reductions in cold-deaths due to climate change are projected to be greater than increases in heat-related deaths in the UK.[98]
A number of climate-related trends have been observed that affect water resources. These include changes in precipitation, the crysosphere and surface waters (e.g., changes in river flows).[113] Observed and projected impacts of climate change on freshwater systems and their management are mainly due to changes in temperature, sea level and precipitation variability.[114] Sea level rise will extend areas of salinization of groundwater and estuaries, resulting in a decrease in freshwater availability for humans and ecosystems in coastal areas. In an assessment of the scientific literature, Kundzewicz et al. (2007)[114] concluded, with high confidence, that:
General circulation models project that the future climate change will bring wetter coasts, drier mid-continent areas, and further sea level rise.[115] Such changes could result in the gravest effects of climate change through sudden human migration. Millions might be displaced by shoreline erosions, river and coastal flooding, or severe drought.
Migration related to climate change is likely to be predominantly from rural areas in developing countries to towns and cities.[115]:407[116] In the short term climate stress is likely to add incrementally to existing migration patterns rather than generating entirely new flows of people.[116]:110
It has been argued that environmental degradation, loss of access to resources (e.g., water resources),[117] and resulting human migration could become a source of political and even military conflict.[118] Factors other than climate change may, however, be more important in affecting conflict. For example, Wilbanks et al. (2007)[119] suggested that major environmentally influenced conflicts in Africa were more to do with the relative abundance of resources, e.g., oil and diamonds, than with resource scarcity. Scott et al. (2001) placed only low confidence in predictions of increased conflict due to climate change.[118]
Aggregating impacts adds up the total impact of climate change across sectors and/or regions. [120] Examples of aggregate measures include economic cost (e.g., changes in gross domestic product (GDP) and the social cost of carbon), changes in ecosystems (e.g., changes over land area from one type of vegetation to another),[121] human health impacts, and the number of people affected by climate change.[122] Aggregate measures such as economic cost require researchers to make value judgements over the importance of impacts occurring in different regions and at different times.
Global losses reveal rapidly rising costs due to extreme weather-related events since the 1970s.[123] Socio-economic factors have contributed to the observed trend of global losses, e.g., population growth, increased wealth.[124] Part of the growth is also related to regional climatic factors, e.g., changes in precipitation and flooding events. It is difficult to quantify the relative impact of socio-economic factors and climate change on the observed trend.[124] The trend does, however, suggest increasing vulnerability of social systems to climate change.[124]
The total economic impacts from climate change are highly uncertain.[125] With medium confidence, Smith et al. (2001)[126] concluded that world GDP would change by plus or minus a few percent for a small increase in global mean temperature (up to around 2 °C relative to the 1990 temperature level). Most studies assessed by Smith et al. (2001)[126] projected losses in world GDP for a medium increase in global mean temperature (above 2-3 °C relative to the 1990 temperature level), with increasing losses for greater temperature increases. This assessment is consistent with the findings of more recent studies, as reviewed by Hitz and Smith (2004).[127]
Economic impacts are expected to vary regionally.[127][128] For a medium increase in global mean temperature (2-3 °C of warming, relative to the average temperature between 1990–2000), market sectors in low-latitude and less-developed areas might experience net costs due to climate change.[15] On the other hand, market sectors in high-latitude and developed regions might experience net benefits for this level of warming. A global mean temperature increase above about 2-3 °C (relative to 1990-2000) would very likely result in market sectors across all regions experiencing either declines in net benefits or rises in net costs.[129]
Aggregate impacts have also been quantified in non-economic terms. For example, climate change over the 21st century is likely to adversely affect hundreds of millions of people through increased coastal flooding, reductions in water supplies, increased malnutrition and increased health impacts.[45]
With very high confidence, Rosenzweig et al. (2007) concluded that recent warming had strongly affected natural biological systems.[73] Hundreds of studies have documented responses of ecosystems, plants, and animals to the climate changes that have already occurred.[130] For example, in the Northern Hemisphere, species are almost uniformly moving their ranges northward and up in elevation in search of cooler temperatures.[131] Humans are very likely causing changes in regional temperatures to which plants and animals are responding.[131]
By the year 2100, ecosystems will be exposed to atmospheric CO2 levels substantially higher than in the past 650,000 years, and global temperatures at least among the highest of those experienced in the past 740,000 years.[132] Significant disruptions of ecosystems are projected to increase with future climate change.[133] Examples of disruptions include disturbances such as fire, drought, pest infestation, invasion of species, storms, and coral bleaching events. The stresses caused by climate change, added to other stresses on ecological systems (e.g., land conversion, land degradation, harvesting, and pollution), threaten substantial damage to or complete loss of some unique ecosystems, and extinction of some critically endangered species.[133]
Climate change has been estimated to be a major driver of biodiversity loss in cool conifer forests, savannas, mediterranean-climate systems, tropical forests, in the Arctic tundra, and in coral reefs.[134] In other ecosystems, land-use change may be a stronger driver of biodiversity loss at least in the near-term.[134] Beyond the year 2050, climate change may be the major driver for biodiversity loss globally.[134]
A literature assessment by Fischlin et al. (2007)[132] included a quantitative estimate of the number of the number of species at increased risk of extinction due to climate change. With medium confidence, it was projected that approximately 20 to 30% of plant and animal species assessed so far (in an unbiased sample) would likely be at increasingly high risk of extinction should global mean temperatures exceed a warming of 2 to 3 °C above pre-industrial temperature levels.[132] The uncertainties in this estimate, however, are large: for a rise of about 2 °C the percentage may be as low as 10%, or for about 3 °C, as high as 40%, and depending on biota (all living organisms of an area, the flora and fauna considered as a unit)[135] the range is between 1% and 80%.[134] As global average temperature exceeds 4 °C above pre-industrial levels, model projections suggested that there could be significant extinctions (40-70% of species that were assessed) around the globe.[134]
Assessing whether future changes in ecosystems will be beneficial or detrimental is largely based on how ecosystems are valued by human society.[136] For increases in global average temperature exceeding 1.5 to 2.5 °C (relative to global temperatures over the years 1980-1999)[137] and in concomitant atmospheric CO2 concentrations, projected changes in ecosystems will have predominantly negative consequences for biodiversity and ecosystems goods and services, e.g., water and food supply.[138]
Physical, ecological and social systems may respond in an abrupt, non-linear or irregular way to climate change.[139] This is as opposed to a smooth or regular response. A quantitative entity behaves "irregularly" when its dynamics are discontinuous (i.e., not smooth), nondifferentiable, unbounded, wildly varying, or otherwise ill-defined.[139] Such behaviour is often termed "singular." Irregular behaviour in Earth systems may give rise to certain thresholds, which, when crossed, may lead to a large change in the system.
Some singularities could potentially lead to severe impacts at regional or global scales.[140] Examples of "large-scale" singularities are discussed in the articles on abrupt climate change, climate change feedback and runaway climate change. It is possible that human-induced climate change could trigger large-scale singularities, but the probabilities of triggering such events are, for the most part,[141] poorly understood.[140]
With low to medium confidence, Smith et al. (2001)[139] concluded that a rapid warming of more than 3 °C above 1990 levels would exceed thresholds that would lead to large-scale discontinuities in the climate system. Since the assessment by Smith et al. (2001), improved scientific understanding provides more guidance for two large-scale singularities: the role of carbon cycle feedbacks in future climate change (discussed below in the section on biogeochemical cycles) and the melting of the Greenland and West Antarctic ice sheets.[127]
Climate change may have an effect on the carbon cycle in an interactive "feedback" process. A feedback exists where an initial process triggers changes in a second process that in turn influences the initial process. A positive feedback intensifies the original process, and a negative feedback reduces it.[92]:78 Models suggest that the interaction of the climate system and the carbon cycle is one where the feedback effect is positive.[142]:792
Using the A2 SRES emissions scenario, Schneider et al. (2007)[142]:789 found that this effect led to additional warming by the years 2090-2100 (relative to the 1990–2000) of 0.1–1.5 °C. This estimate was made with high confidence. The climate projections made in the IPCC Fourth Assessment Report summarized earlier of 1.1–6.4 °C account for this feedback effect. On the other hand, with medium confidence, Schneider et al. (2007)[142]:789 commented that additional releases of GHGs were possible from permafrost, peat lands, wetlands, and large stores of marine hydrates at high latitudes.
With medium confidence, authors of AR4[129] concluded that with a global average temperature increase of 1–4 °C (relative to temperatures over the years 1990–2000), at least a partial deglaciation of the Greenland ice sheet, and possibly the West Antarctic ice sheets would occur. The estimated timescale for partial deglaciation was centuries to millennia, and would contribute 4 to 6 metres (13 to 20 ft) or more to sea level rise over this period.
The Atlantic Meridional Overturning Circulation (AMOC) is an important component of the Earth's climate system, characterized by a northward flow of warm, salty water in the upper layers of the Atlantic and a southward flow of colder water in the deep Atlantic.[144]:5 The AMOC is equivalently known as the thermohaline circulation (THC).[127] Potential impacts associated with MOC changes include reduced warming or (in the case of abrupt change) absolute cooling of northern high-latitude areas near Greenland and north-western Europe, an increased warming of Southern Hemisphere high-latitudes, tropical drying, as well as changes to marine ecosystems, terrestrial vegetation, oceanic CO2 uptake, oceanic oxygen concentrations, and shifts in fisheries.[145] According to an assessment by the US Climate Change Science Program (CCSP, 2008b),[144]:5 it is very likely (greater than 90% probability, based on expert judgement)[144]:12 that the strength of the AMOC will decrease over the course of the 21st century. Warming is still expected to occur over most of the European region downstream of the North Atlantic Current in response to increasing GHGs, as well as over North America. Although it is very unlikely (less than 10% probability, based on expert judgement)[144]:12 that the AMOC will collapse in the 21st century, the potential consequences of such a collapse could be severe.[144]:5
Emissions of GHGs are a potentially irreversible commitment to sustained radiative forcing in the future.[146] The contribution of a GHG to radiative forcing depends on the gas's ability to trap infrared (heat) radiation, the concentration of the gas in the atmosphere, and the length of time the gas resides in the atmosphere.[146]
CO2 is the most important anthropogenic GHG.[39] While more than half of the CO2 emitted is currently removed from the atmosphere within a century, some fraction (about 20%) of emitted CO2 remains in the atmosphere for many thousands of years.[147] Consequently, CO2 emitted today is potentially an irreversible commitment to sustained radiative forcing over thousands of years.
This commitment may not be truly irreversible should techniques be developed to remove CO2 or other GHGs directly from the atmosphere, or to block sunlight to induce cooling.[148] Techniques of this sort are referred to as geoengineering. Little is known about the effectiveness, costs or potential side-effects of geoengineering options.[149] Some geoengineering options, such as blocking sunlight, would not prevent further ocean acidification.[149]
Human-induced climate change may lead to irreversible impacts on physical, biological, and social systems.[150] There are a number of examples of climate change impacts that may be irreversible, at least over the timescale of many human generations.[151] These include the large-scale singularities described above - changes in carbon cycle feedbacks, the melting of the Greenland and West Antarctic ice sheets, and changes to the AMOC.[151] In biological systems, the extinction of species would be an irreversible impact.[151] In social systems, unique cultures may be lost due to climate change.[151] For example, humans living on atoll islands face risks due to sea-level rise, sea-surface warming, and increased frequency and intensity of extreme weather events.[152]
1 this statement applies to the SRES global mean temperature projections given in the IPCC Third Assessment Report (TAR) using all of the SRES scenarios.[153] This is a range of 1.4–5.8 °C between the years 1990–2100.[153] The projected temperature range in the TAR is slightly different to the "likely" range given in the IPCC Fourth Assessment Report (AR4). This is warming of 1.1 °C (by the end of the 21st century, relative to global mean temperature averaged over the 1980 to 1999 time period) for the lowest emissions SRES "marker" scenario and 6.4 °C for the highest emissions SRES "marker" scenario.[21] However, the two sets of temperature projections are broadly comparable in size.
2 The TAR[154] and AR4[24] that are referred to in this article use specific and quantitative language to describe uncertainty. This language is intended to provide an indication of the level of confidence that IPCC authors have about a particular finding. The qualitative language used to describe uncertainty has a quantitative scale associated with it. The quantitative values for qualitative terms are intended to ensure that confidence levels are interpreted correctly. The is because qualitative statements, e.g., using the word "likely," can be interpreted differently in quantitative terms.[155]:44
Quantitative values for confidence statements made in AR4 are listed below:[24]
A slightly different set of confidence levels are used in the TAR:[156]
The quantitative values used by IPCC authors are "subjective" probabilities,[24][154][157] also known as "personalist" or "Bayesian" probabilities,[158] and reflect the expert judgement of IPCC authors. In this formulation, probability is not only a function of an event, but also the state of information that is available to the person making the assessment.[158] In this framework, assigned probabilities may change as more or different information becomes available.[158]
The IPCC also uses another scale to describe the likelihood of a particular event occurring.[24] This is different from the confidence scales described above, and it is possible to assign confidence values to statements of likelihood. For example, the judgement that an event is improbable (e.g., rolling a dice twice and getting a six both times) may be assigned a high level of scientific confidence.[24] Also, the probability that an event has an even chance of occurring (e.g., a tossed coin coming up heads) may also be assigned a high level of confidence.[24]
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○ Anagrammes
○ jokers, mots-croisés
○ Lettris
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Lettris est un jeu de lettres gravitationnelles proche de Tetris. Chaque lettre qui apparaît descend ; il faut placer les lettres de telle manière que des mots se forment (gauche, droit, haut et bas) et que de la place soit libérée.
Il s'agit en 3 minutes de trouver le plus grand nombre de mots possibles de trois lettres et plus dans une grille de 16 lettres. Il est aussi possible de jouer avec la grille de 25 cases. Les lettres doivent être adjacentes et les mots les plus longs sont les meilleurs. Participer au concours et enregistrer votre nom dans la liste de meilleurs joueurs ! Jouer
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Rectangular 25mm 1500 x 800 Stone Resin Shower Tray and Waste
This stunning 25mm shower tray has a central waste and is modern in design, this is supplied with comprehensive fitting instructions. This roduct is outstanding quality and comes with a Lifetime Manufacturer Guarantee. This tray is ideal for elderley or infirm due to the slim edge, this includes a stainless steel self cleaning waste, water removal has also been tested at over 30l per minute.
- 25mm ultra low profile
- 100% natural stone resin
- Waste Included
- The minimalist ultra stylish Slab tray is manufactured by hand in the UK from the finest natural materials
- The Slab is load bearing and is installed the same way as any standard stone resin shower tray
- Bespoke 90mm easy clean waste and stainless steel cover is supplied as standard for the ultimate minimal look
- For fitting on concrete or wooden floors (comprehensive fitting instructions included)
- A tough gel coat smooth surface/durable/repairable and easy clean
- This is available in 36 sizes and also available in Antislip Finish
- Lowest UK Price Guaranteed

subset: commoncrawl


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Matagorda County spotlight
Energy and Waterways in Southeast Texas
We like to highlight regions of Texas and industry sectors that make this state so interesting for people to come live and do business here. This month we are highlighting Matagorda County, which is located in South East Texas just two hours South of Houston.
Matagorda County is home to one of Texas' energy clusters, as well as two important waterways, the Port of Bay City and the Port of Palacios. Both of these ports have land available for industrial development. Together these ports give Matagorda County access to the Gulf Intracoastal Waterway and Colorado River. Matagorda County is located on the coast of the Gulf of Mexico, about 65 miles southwest of Houston.
The energy cluster in Matagorda County includes a nuclear plant, gas processing plants, oil and gas well production, a pipeline network, and large tracts of land available for solar, wind and algae-to-green fuels production. Top industrial employers include Lyondell Basell, Oxea Chemicals, Celanese Chemical Products and Tenaris.
Dutch companies can benefit from Matagorda County's assets that have been set aside to promote its industrial, agricultural, aquaculture and marine fishery sectors.The county is actively seeking individuals and companies seeking opportunities in these sectors.
Attractive features for companies considering Matagorda County include its large tracts of flat land and logistics infrastructure. Logistic advantages of the county include commercial barge service, rail service, an extensive pipeline network and an existing heavy electric power line network.
In addition to these features, Matagorda County also offers grants for skill development training for employees and has programs to promote a skilled labor force. The workforce in Matagorda County is used to working 24-hour shift work. There are 20 higher education institutions within 100 miles of Matagorda County that offer certification and degree programs. Specialty degrees are offered at many of these institutions that focus on the energy sector.
Read more about the region on the county website.


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With the latest service build (7.1.67) of PrimalScript 2015 we introduced a new feature; custom PrimalSense. In the first part of this series we showed you how to create a simple list and what options you have for providing data for these lists. If you missed the post, click here.
If your list has just a single type of items an image is not really necessary, but if you have different types, it would be nice to give these items a visual distinction.
Let's take a look at the 'machines' example that gets installed with PrimalScript.
We have different icons for workstations and network servers in this example, so let's see how this is done.
The data file, machines.csv, has the same basic setup with the strings and an image index for each item.
This time however we also have an additional configuration file, machines.ini. As you can probably guess the file's base names (machines) tie them together.
The format of this is very simply, I am sure you can figure out what item controls what setting. The important part now is the 'imagelist' entry.
It points to a file called icons.bmp.
As you can see index 0 and 4 are the icons we see in our example. These bitmap files contain image that are 16 by 16 pixels, that is what PrimalScript uses for PrimalSense lists.
They are bitmap files (BMP) because that is what Microsoft Windows wants for list control image lists. Last but not least, the background (RGB value 255,0,255) is what is mapped to transparent. You cannot use jpeg or png files here, sorry.
Another setting you can see in this sample ini file is that multiselect is set to 1. That is what makes the checkboxes show up. Normally PrimalSense lists are single select. You select and press Enter to insert the item chosen. If you have computer names, you may need more than one, so you can check the ones you want, press Enter and all items checked get inserted. The separator, which defaults to a space, is used to concatenate the items into a string.
It is all very simple. As an exercise, look at the functions.xml file we provided and make it multi-select. This way you can select the functions you want to insert into your code. With a little work you can make this into a poor man's code wizard that inserts the standard functions you need for a new script. Think of it as a selective snippet.
In the next part of this series I will show you how you can make these lists dynamic and generate data on the fly.


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We strive to cater to your every need so will always do our best to accommodate special requirements. As a result we are more than happy to arrange special packages. Please feel free to contact us with your requirements if you don't see what you're looking for listed.
Wedding Parties
Every bride's wedding is a special occasion and should be kept that way. We are more than happy to cater for bridal parties and can arrange custom packages to suit your needs with the best in quality and value.
Makeup Lessons
Everyone learns how to apply makeup in their own way. Many learn fantastic tricks to get the best look for them and make be cautious to venture away from this. However we offer Makeup Lessons for individuals or groups in order to share the best techniques to maximize your potential. So if you want to improve your skills or just want to learn a whole new approach then we are more than happy to help.
Stuck for Time
It can be a challenge to fit everything into a busy week so we have created a fantastic package for when you need life to be a little bit more flexible.
Sit back and enjoy a file and polish on your finger nails, your choice of colour or a french polish finish. While your nails are drying, we will apply your eye make up and false lashes, to your taste, as subtle or dramatic as you wish. This package is aimed at the busy client, who can do her own make up but prefers the professional touch with the eye make up and nails. This package is €35 so why not get all dolled up with us.
We can tailor make packages for your needs. If you wish to treat a mommy-to-be to a day of pampering and relaxation or have special requirements please contact us.
Out of Hours
Due to hectic schedules and last minute changes you may need an early or late appointment. In order to ensure the best service for our clients we are more than happy to arrange Out of Hours appointments to meet your needs.
Please contact us on 087 977 54 89 to arrange your booking.


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PWC's volunteer department can be reached at (513) 351-7921 or contact us online
Available Year Round: Field Service VolunteerWork around your schedule! If you have a flexible schedule during the weekday or are retired and have solid home repair skills, please consider becoming a regular field service volunteer. You can help tackle our Wish List of maintenance or small repair jobs requested by our clients. Projects can include installing grab bars and handrails, fixing leaking plumbing, patching concrete steps and are located around the Tri-State area. These requests come in all year long and we need your help to make them happen! Call the Volunteer Dept. at (513) 351-7921.


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A Learning Management System (LMS) is a software application that's used to organize and deliver online training. It helps businesses create, manage and deliver customised e-learning courses for their employees.
An LMS is an invaluable business tool that can be used for all kinds of learning activities. Once you know what it can do for your business, you can start the process of Learning Management System software selection.
So, if you want to deliver efficient and employee-friendly e-training courses, here are a few ways that an LMS can help.
Deliver training anywhere, anytime
Staff training doesn't have to mean a day out of the office for your employees, stuck in a dusty conference room. An LMS is a game-changer when it comes to learning, and helps you reach users all over the globe, whatever the hour.
LMSs are also device-agnostic - which means your employees have 24/7 access to courses, whether working non-standard hours, travelling, or even based abroad.
Mix and match your modules
Users learn better and are more engaged when they have access to a variety of resources. These could be videos, e-books, podcasts or downloadable PDFs, in addition to standard e-learning modules.
An LMS lets you as administrator assign each learner a completely personalised learning experience that's right for them, according to their role and department.
Help employees stay connected
Although e-learning is usually undertaken alone, the training process doesn't need to be isolating for your employees.
Social communication features such as live chat, discussion groups and integration of social media are all possible within a customisable LMS. These help learners connect better with their colleagues, share ideas and post their progress and achievements.
Stay in touch with your learners
Your virtual 'dashboard' let you keep up with your employees' training. As administrator, you can use the dashboard to let users know their progress, helping them keep their performance on track.
It can also be used to highlight updates such as training schedules, announcements, reviews, surveys, polls, and so on.
It's not limited to the dashboard, either - you can also set up your LMS so that whenever a course is assigned to a group of users, or any other big change happens, email notifications are sent to each of them automatically.
Generate customised training reports
Finally, an LMS lets you generate custom reports and documents, such as course completion certificates, personal grade reports, activity or progress logs, course access reports and so on.
These help you and your employees keep tabs on their course statistics and celebrate their achievements - for a more effective training experience.
Sponsored post. Copyright © 2018 Article made possible by Christopher Pappas, founder of eLearning Industry Inc - the online community for eLearning professionals.


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Reviewed 7/2/2020
Cervical cancer: True or false?
Each year, about 13,000 women in the U.S. are diagnosed with cervical cancer—or cancer of the cervix. Fortunately, there are ways to prevent, detect and stop it early on. How much do you know about cervical cancer?
True or false: HPV (human papillomavirus) infections cause most cervical cancers.
True. HPV is a group of viruses that can be transmitted during vaginal, oral or anal sex. HPV infection is very common, and it usually disappears on its own. But certain types can cause cervical cancer when they don't go away. That's why HPV vaccination is a big part of cervical cancer prevention.
True or false: Cervical cancer is the easiest gynecological cancer to prevent.
True. Routine Pap test screening can help a doctor find and treat abnormal cells early on—before they turn into cancer. In addition, an HPV test is available. Another easy, but important, form of prevention is getting an HPV vaccination at the recommended age.
True or false: Vaginal pain and bleeding are usually the first symptoms of cervical cancer.
True. However, often there are no symptoms at all, especially in its early stages. In its later stages, symptoms can include vaginal discharge, bleeding, pain during sex and problems urinating.
True or false: You can't get cervical cancer if you've had a hysterectomy.
False. Not all hysterectomies include removal of the cervix, which means you may still be at risk for cervical cancer. Women who have had a total hysterectomy—removal of the uterus and cervix—can stop having Pap tests, unless the hysterectomy was performed because of cervical cancer.
True or false: An abnormal Pap test means you have cervical cancer.
False. Cervical cancer isn't the only thing that can cause an abnormal Pap test. Other possible reasons include irritation, an infection or a mistake in the preparation of the test. In most cases, an abnormal Pap test means you'll be asked to repeat the test.
Most women should begin having Pap tests to screen for cervical cancer when they turn 21. Your screening routine can depend on your age and risk factors.
Sources: American Cancer Society; Centers for Disease Control and Prevention; Office on Women's Health


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Influence: Anywhere & Everywhere
Tue, 10/18/2016
Influence stands atop the new world of digital communications. In its rise, it has shattered the traditional world order in the communications industry, claiming new omni-channel powers and remarkable sales potential.
With origins in the world of public relations, influence is bringing new respect to the industry and driving new interest among marketers.
Influence comes from anywhere and everywhere. It's what your neighbor thinks. What the car reviewer says. What the mommy blogger recommends. These spark trends, cause actions, and can determine the fame and fortunes of brands around the world.
This is not your father's influence. It's not even your big brother's or sister's influence. It's totally modern. It's digital. It's tech-driven. And yes, it's based around earned media and content. What's new is that it means business, literally millions in revenue.
Today's influence has become so crucial to the bottom line that advertisers, digital experts, and media buyers are all looking at it critically.
The great news is that some of the top thinkers from around the world are engaged. For the PR pro who is not used to this newfound attention, the question is how to best collaborate on joint solutions. For those who are industry insiders, this isn't surprising. Our content has always been the most credible and authoritative.
Customers are influencers with the power to change your brand's fortunes
Before social media – and, yes, hard as it is to believe, there was life before social media – customer opinions were certainly vital to every brand, but the avenues by which companies would get that feedback were limited to the store or the phone.
Today, consumers talk about you 24-7, 365. It's a never ending conversation where opinions and ideas are shared about your brand. Those conversations, which shape fellow consumers' opinions and can directly impact their actions, take place with or without you – so you better be a part of it and be ready to act upon it.
Why? Because every single person involved in those conversations has influence. Today, customers are influencers with the power to change your brand's fortunes more than ever before.
Relationships still hold the keys
Above all else, brands must understand that they no longer can control the message because consumers are increasingly skeptical of anything that feels contrived. But even with letting go, brands can maintain enough control to feel comfortable.
The key : relationships. A great way to create relationships with consumers is to build relationships with the right influencers. Obviously, research needs to be done to identify those key individuals, but once you do, you have an avenue to current and potential customers.
One really smart way to go about this is for a brand to hook up with an influencer outside its niche. As Stephanie McCratic , CEO of Acorn: An Influence Company , told PRWeek in it's "The New Influencers" feature this past February: "Sometimes, when a message comes from an unexpected source, if it is connected to that source in a smart way, it is really strong and lasting." She went on to note that such influencers can truly impact a broad swath of consumers because any person who would deviate from their usual content to discuss a product outside it must really love that product.
Tell a great story; create a unique experience
One thing a brand can still control directly is the narrative it builds about itself. With brand content, nothing trumps good stories. They are so influential because they tap emotions that stay with a consumer right up until that moment of purchase and beyond. Stories are also a gateway to what consumers really want out of brands – and will want more of in the future: experiences.
Brands no longer sell products. They sell experiences. They offer a path to feel a certain way. They empower consumers to change their worlds. Lists of specs and stats will never accomplish that. Only stories can.
However, stories need to be relevant to each individual recipient. Stories need to be told in a manner that empowers influencers to tell them in their own words. And if brands establish relationships in the manner referenced earlier, they can ensure their stories remain true to the brand, regardless of who is telling them and how they are told.
When influence sparks, spark it again
PR pros are often focused on the initial get – the story, the blog post, the customer or influencer-created content. But what happens when the campaign succeeds and results in some powerful – and influential – earned media or earned content? Most pros today resort to an amplification strategy, ensuring other influencers see and share the post. However, amplification has become much more sophisticated than it was even just a few short years ago. This is where paid media colleagues can come in with advanced solutions – such as programmatic buying – that allow the best content to be properly scaled and targeted to drive commerce.
An exciting new future
A number of rising trends are destined to shape influence in new ways. Authenticity will remain a huge mandate as brands seek to influence consumers – and a key path to authenticity, at least how the public perceives it, is working with influencers to drive consumer trust. Brands will increase efforts to help position influencers in manners that will help both their own brand and the individual influencer stand out.
Taken a step further, brands will increasingly focus on amplifying influencer voices, again, understanding that their messages become more powerful when told by others. Of course, a new mandate brands have to meet is the consistent development of new influencers. Savvy consumers will quickly recognize when a brand sticks with the same influencer for a long period of time. Eventually, people will tune them out, too.
And going back to relationships, a trend that will have to continue in the near and distant future: marketing disciplines will have to increasingly work together to ensure maximum brand influence.
Numerous questions remain. What kind of content delivers the most influence to drive a specific consumer action? What role can technology play in the delivery and spread of influence? How can influence be scaled and targeted to the right consumers? How can it be measured?
The real advancement in the science of influence may come from the sophisticated re-engineering of how influence spreads.
The important new solution Conversation2Commerce is designed to help brands overcome two key obstacles to influence: the lack of scale for the best brand stories and the difficulty in ensuring it reaches the right targets at the right place and time to drive action.
This article is a part of MSLGROUP ebook – How Influence Works in Brand New Ways developed in partnership with PR Week and Campaign magazine.
About Conversation2Commerce
C2C is MSLGROUP's influence-to-impact performance platform . With earned media at the core, it is powered by the services and newest technnologies from Publicis Communications and Publicis Media.
To learn more about how Conversation2Commerce can boost your brand and commerce, contact: Erin B. Lanuti , Chief Influence Strategist, MSLGROUP.


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Please note: Below are contact details for Cambridge Network staff only. If you would like to contact one of our members, please find the company in our directory and follow the link to contact them via their own website.
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When we were growing up in Italy we lived a more sustainable life. My mother cooked all the food from scratch and used low energy light bulbs – I can remember waiting for them to light up. But it wasn't specifically an environmental awareness; it was just that we were a big family and only my father worked so she was doing it to save money.
Italians buy locally and eat seasonally just because they taste much better and cost less than imported food. It was a normal lifestyle in that period in Italy.
I have always been quite obsessed with tech things, breaking my toys and putting them back together. A teacher at school got me interested in renewable technologies and when I was 13 I built a solar panel for a school exam.
I never considered myself a green person or campaigner, I just find those issues very interesting. I didn't see at the time that this would be my path for the future.
I studied business at university and I just thought a sustainable, green economy would be the business of the future. It's not just worrying about climate change, it's about respecting people who work in the factory and producing good products.
I have behaved badly in the past. When I moved to London nine years ago I was cleaning the toilets in a production company. I shopped in Primark and places like that because I didn't have any money. I am just a normal person and if I can change my behaviour, anyone can.
When people buy today, they just want to buy, use and throw away and that's not really interesting. It doesn't make you happy and it's not justifiable. Spend your time with your wife instead of going out shopping.
There is a small premium to pay for being sustainable, but it's not as big as people might think. A hand-made, customised piece of furniture will last forever and you can give it to your children. They just have to plan their finances in advance.
When we opened the shop (www.eco-age.co.uk) nobody realised we were eco, they just thought it was a nice shop and that was a kind of achievement. If the products are nice then they will buy them.
We made a zero-impact recording studio for Katie Tunstall for her house in the countryside powered by a seven kilo watt solar panel and the furniture was all custom-made.
People need to be scared about climate change but there should be more effort in giving people a positive solution rather than just telling what to give up in life. You have to scare people and then show them what they can do about it.
Latin and Catholic countries are very family-orientated. My sister Livia helped me set up Eco Age and my twin brother Alessandro works here too. My sister's husband Colin Firth is one of the partners and the other is a close family friend. It's a family business and we are a very, very, very happy family.
Colin is a very good PR instrument. He is one of the company's partners and is very informed about everything he does, he's not just a celebrity face behind a brand. He even helps out sometimes behind the tills.
My Tips
A lot of people like me have to fly for business so every time I take a flight I not only carbon offset it but also I buy a plant for my house and as a result I have very beautiful house.
We've just launched a range of electric scooters, which are perfect for commuting, they are fun to ride and they are cheaper than normal scooters.
Sign up for River Ford Organic scheme where they deliver a box of organic food to your door with seasonal and local food. It's often cheaper than buying food from the supermarkets and it tastes so much better.
Don't buy all your Christmas presents in November because you end up buying more and more. Buy less stuff and be more thoughtful about it. Christmas is the most consumerist time of the year so just try and be sensible about it all.


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Hemophagocytic Lymphohistiocytosis in Adults: Low Incidence of Primary Neoplasm as a Trigger in a Case Series from Turkey
Ferhat Arslan1, Sehnaz Alp2, Yahya Büyükasık3, Melda Comert Ozkan4, Fahri Şahin4, Seniha Basaran5, Arif Atahan Cagatay5, Ömer Haluk Eraksoy5, Kenan Aksu6, Barış Ertunç7, Volkan Korten8, Bahadır Ceylan9 and Ali Mert9.
1 Department
of Infectious Diseases and Clinical Microbiology, Faculty of Medicine,
Istanbul Medeniyet University, Istanbul, Turkey.
2 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
3 Department of Hematology, Faculty of Medicine, Hacettepe University, Ankara, Turkey.
4 Department of Hematology, Faculty of Medicine, Ege University, İzmir, Turkey.
5 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul University, Istanbul, Turkey.
6 Department of Internal Medicine, Division of Rheumatology, Faculty of Medicine, Ege University, İzmir, Turkey.
7 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey.
8 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Marmara University, Istanbul, Turkey.
9 Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, Istanbul Medipol University, Istanbul, Turkey.
Received: February 22, 2018
Accepted: July 11, 2018
Mediterr J Hematol Infect Dis 2018, 10(1): e2018047 DOI 10.4084/MJHID.2018.047
This article is available on PDF format at:
| This is an Open Access article distributed
under the terms of the Creative Commons Attribution License
(https://creativecommons.org/licenses/by-nc/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Lymphohistiocytosis (HLH) is an indicator of an exaggerated immune
response and eventually adverse outcomes. This study aimed to
investigate the clinical and laboratory features and outcomes of
patients with HLH. The medical records of 26 HLH adult patients (≥ 16
years of age) were retrospectively analyzed. Gender, age, the duration
of fever, time to diagnosis, etiology and laboratory data were
extracted from the records. The mean age was 38 ± 18 years, and 15
(58%) patients were female. A total of nine cases had infectious
diseases; four cases had rheumatologic diseases, three cases had
hematological malignancies while nine cases could not have a definitive
diagnosis. The median time to detection of HLH was 20 days (IQR: 8-30
d). Of the 25 patients, 11 (44%) died. The erythrocyte sedimentation
rates of the surviving and non-surviving patients were 39 ± 22 mm/h and
15 ± 13 mm/h, respectively. When a long-lasting fever is complicated by
bicytopenia or pancytopenia (especially), clinicians should promptly
consider the possibility of HLH syndrome to improve patients'
The clinical features of HLH include fever, hepatosplenomegaly, lymphadenopathy, neurological symptoms, and skin manifestations. Cytopenia, elevated liver enzymes, high serum ferritin levels, hypertriglyceridemia, and hypofibrinogenemia are laboratory abnormalities that have frequently been reported in HLH patients.[4] Although extremely elevated ferritin levels represent a highly sensitive marker of HLH, this disease may be difficult to recognize and diagnose.[5] Early diagnosis and prompt treatment of the underlying cause are important to decrease morbidity and mortality in patients with HLH.[6] In this study, we aimed to investigate the clinical features and outcomes of patients with HLH in tertiary care centers in Turkey through a retrospective chart review.
Materials and Methods
Infectious disease, rheumatology, and hematology specialists were contacted for the records. The Istanbul Medipol University Ethical Committee approved this study.
All the patients who met the diagnostic guidelines of the Histiocyte Society (HLH-2004) were included in this study (Table 1).[7] Molecular parameters, such as NK cell activity and soluble CD25, were not available in this study due to a lack of laboratory facilities. The following features were evaluated: fever (type, duration), time to diagnosis, splenomegaly, hepatomegaly, lymphadenopathy, rash, serosal involvement, respiratory symptoms, neurological symptoms, and opportunistic infections. Hepatomegaly and splenomegaly were defined as the long axis of the organs exceeding 155 mm and 130 mm on radiological investigations, respectively.[8]
|Table 1. Hemophagocytic Lymphohistiocytosis 2004 Trial Diagnostic and Modified Criteria.
Hemogram, ferritin, lactate dehydrogenase (LDH), transaminase, bilirubin, triglyceride, high-density lipoprotein (HDL), and fibrinogen levels and erythrocyte sedimentation rates (ESRs) were analyzed. Hemophagocytosis was defined as histological evidence of activated macrophages engulfing blood cells in the bone marrow and/or other tissues.
Opportunistic infections were defined as a new clinical condition with ongoing immunosuppression due to HLH. When positron emission tomography with computed tomography (PET/CT) was performed, the presence of fluorodeoxyglucose (FDG) uptake was evaluated. Underlying triggering diseases and treatment modalities, including types of initial therapy, secondary therapy, and adjunctive therapy (supportive or underlying disease-specific treatment), were evaluated. Patients without both ferritin and triglyceride levels in their medical records were excluded.
The basic statistical analysis was performed using R version 3.0.4. Results are expressed as numbers (percentages) for categoric variable and as mean (standard deviation) or median (interquartile range) for continuous variables. The chi-square test and contingency table were used to compare subgroups of patients. p values of less than 0.05 were considered as statistically significant.
Fever was the most common sign among the HLH patients. It was the primary presenting symptom in all cases. The median duration of fever was 19 days (IQR, 10-30), and the median time to diagnosis was 21 days (IQR 8-30). Hepatomegaly and splenomegaly were detected in 21 (84%), and 23 (92%) patients, respectively, and 18 (72%) patients had lymphadenopathies (peripheral in 2 patients and systemic in 16 patients).
Neurological manifestations, including encephalopathy, seizures, and an altered level of consciousness, were observed in nine cases (38%). Bilaterally thalamic involvement and demyelinization findings were revealed in two different patients who had not apparent neurological symptoms. In two patients, the neurological findings were associated with herpes simplex virus (HSV) reactivation. HSV DNA was detected in the cerebrospinal fluid (CSF) and blood of two patients with encephalitis. Eight patients who received immunosuppressive drugs for HLH developed concomitant opportunistic infections (CMV in three patients, HSV in three patients, invasive aspergillosis in one patient, and Pneumocystis jiroveci pneumonia in one patient).
The erythrocyte sedimentation rates of the surviving and non-surviving patients were 39 ± 22 mm/h and 16 ± 14 mm/h, respectively. The median ferritin level was 8826 ng/ml (IQR 1656-27386 ng/ml, range 566-100000 ng/ml), the median LDH level was 1562 IU/ml (range; 342-5251 IU/ml) and total bilirubin level median was 1.85 mg/dl (IQR 0.8-6.1 mg/dl). The mean triglyceride level was 528±321 mg/dl, and the median HDL levels were 7 mg/dl (IQR 5-12 mg/dl).
Bone marrow biopsy showed hemophagocytosis in 22 of 26 (84%) patients. Additionally, there was bone marrow involvement in two of the lymphoma cases. Activated macrophages with maturation arrest (in 2 patients) and chronic lymphoproliferation were the other findings in bone marrow biopsies. Hemophagocytosis and hemosiderosis were observed in liver biopsies of two of these patients.
Of the 26 patients, eight were evaluated by PET/CT scans; their findings are summarized in Table 2.
All the patients with HLH received specific treatment for the hemophagocytic syndrome. Three patients (12%) were treated only with glucocorticoids, whereas the others received both glucocorticoids and another drug(s) as initial treatment. The underlying diseases, HLH-associated laboratory values and initial, secondary, and adjunctive treatment modalities of the patients after HLH diagnosis are summarized in Table 2.
|Table 2. Underlying Diseases, PET/CT Involvement, Treatments and Outcomes of Hemophagocytic Lymphohistiocytosis Patients.
Many clinical and laboratory features were consistent with those reported previously, e.g., high fever, cytopenia, splenomegaly, hepatomegaly, and hyperferritinemia.[4] Fever was the primary presenting symptom in all of our patients, which is similar to a report from Riviere et al.[4] Hyperferritinemia is a sensitive marker of HLH. No cutoff value has been defined as critical; however, high levels of ferritin (> 50,000 µg/L) are associated with a poor prognosis.[13] Hypofibrinogenemia is the main factor for blood cells velocity that also stated as bad prognostic factor for HLH. Riviere et al. found higher LDH levels in patients with hemophagocytic syndrome (positive cases) than in negative and undetermined patients.[4]
In our case series, the baseline ESR values, the median ferritin, LDH and total bilirubin levels of the non-survivors were higher than those of the survivors. But, due to limited numbers of patients to conclude statistical significance with parametric and non-parametric tests, we do not give any hypothetical test results here. We may say that more tissue destruction like liver as cholestatic hepatitis and blood cells hemolysis can explain the higher LDH and total bilirubin levels in non-survivors as bad prognostic factors.
Neurological symptoms may manifest as different clinical presentations, ranging from depression and convulsions to progressive encephalopathy. In one study, HSV reactivation was not found in patients with hemophagocytosis and multi-organ failure.[14] In contrast, two of the five cases with neurological findings in our study involved HSV reactivation.
Hemophagocytosis has been demonstrated in HLH patients, especially in the bone marrow, spleen, liver, and lymph nodes. It is a diagnostic criterion. Hemophagocytosis was reported in bone marrow aspirates in 84% of HLH cases of the literature, which is similar to our findings. Hemophagocytosis by itself is not a pathognomonic finding for the diagnosis of HLH.[15] Because hemophagocytosis may be a late finding in progressive HLH, repeat biopsies may be needed to confirm the diagnosis in some cases.[1]
PET/CT is a recently developed technique that is especially useful in cases of malignancy, and this method may be valuable for diagnosing underlying malignancies versus isolated HLH. In several reported cases, the diffuse involvement of the bone marrow associated with spleen, liver, and lymph node involvement has been found on PET/CT scans, which is consistent with hemophagocytosis.[16] Little information is available regarding whether PET/CT findings were related to underlying or opportunistic diseases versus HLH. The underlying conditions of our patients may have been responsible for the PET/CT findings; however, one idiopathic case showed a diffuse involvement of the reticuloendothelial system, which was considered to be associated with HLH (Figure 1).
|Figure 1. (Maximum intensity projection) The anterior view of a patient showing diffuse F18-FDG uptake of the liver with a SUVmaxvalue of 4.5 (normal: 3.2±0.8) and an increase in liver dimensions.
In 2004, a new HLH treatment protocol was published (HLH-2004).[7] Corticosteroids, cyclosporine, and etoposide constitute the backbone of treatment. Among our cases, only two patients were treated with this backbone therapy, and they recovered completely with good prognoses. Etoposide-based steroid combination regimens have been confirmed to improve HLH-associated outcomes in most trials.[17]
All the patients had been treated with at least one antibiotic regimen preceding the diagnosis of suspected sepsis (data not presented). Of the 25 patients, 3 received only high-dose corticosteroids as initial management, and only 1 case (a CCHF patient) resolved clinically. All the patients with rheumatologic disease-related HLH responded to treatment with good prognoses. While etoposide and cyclosporine combination with high dose corticosteroid is the recommended regime for HLH, in our study, eight patients were treated with etoposide containing regimes, and six of them died. Mortality in rheumatological diseases is significantly lower than that in infection- or malignancy-related HLH.[18]
The reported mortality of secondary HLH in adult case series varies from 20-74.8%, which is similar to the rate of 44% in our case series.[4,11] Our cases with underlying rheumatological diseases also showed a good prognosis.
Advanced age, the presence of lymphoma or infectious disease, transplantation, and persistent fever within three days after the first treatment have been clinically defined as poor prognostic factors.[4] Although a statistical comparison was not possible, ten of the fatal cases in this study had an infectious (~50%) and idiopathic (~50%) etiology.
This retrospective case series study was intended to present an additional adult HLH case series to the literature. Its retrospective nature and small sample size are important limitations. In conclusion, HLH occurs secondary to many diseases observed in internal medicine practice. When a long-lasting fever is complicated by bicytopenia or pancytopenia (especially), clinicians must promptly consider the possibility of HLH syndrome since early diagnosis improves patients' prognosis. Especially low ESR levels and infectious or idiopathic etiology may be alarmed conditions for unfavorable outcome in the management of HLH.
- Rosado FGN, Kim AS: Hemophagocytic
lymphohistiocytosis: an update on diagnosis and pathogenesis. Am J Clin
Pathol 2013; 139:713–727 https://doi.org/10.1309/AJCP4ZDKJ4ICOUAT PMid:23690113
- Basheer A, Padhi S, Boopathy V, Mallick S, Nair S, Varghese RG, Kanungo R. Hemophagocytic Lymphohistiocytosis: an Unusual Complication of Orientia tsutsugamushi Disease (Scrub Typhus). Mediterr J Hematol Infect Dis. 2015 ;7(1):e2015008. https://doi.org/10.4084/MJHID.2015.008. eCollection 2015.
- Hayden A, Park S, Giustini D, et al.: Hemophagocytic syndromes (HPSs) including hemophagocytic lymphohistiocytosis (HLH) in adults: A systematic scoping review. Blood Rev 2016; 30:411–420 https://doi.org/10.1016/j.blre.2016.05.001 PMid:27238576
- Rivière S, Galicier L, Coppo P, et al.: Reactive hemophagocytic syndrome in adults: A multicenter retrospective analysis of 162 patients. Am J Med 2014 https://doi.org/10.1016/j.amjmed.2014.04.034 PMid:24835040
- Wormsbecker AJ, Sweet DD, Mann SL, et al.: Conditions associated with extreme hyperferritinemia (>3000 μg/L) in adults. Intern Med J 2015; 45:828–833 https://doi.org/10.1111/imj.12768 PMid:25851400
- Trottestam H, Horne A, Aricò M, et al.: Chemoimmunotherapy for hemophagocytic lymphohistiocytosis: long-term results of the HLH-94 treatment protocol. Blood 2011; 118:4577–4584 https://doi.org/10.1182/blood-2011-06-356261 PMid:21900192 PMCid:PMC3208276
- Henter J-I, Horne A, Aricó M, et al.: HLH-2004: Diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2007; 48:124–131 https://doi.org/10.1002/pbc.21039 PMid:16937360
- Dick R, Watkinson A: The liver and spleen. Textb Radiol Imaging 2002; 981–1028
- Song Y, Pei R-J, Wang Y-N, et al.: Central Nervous System Involvement in Hemophagocytic Lymphohistiocytosis in Adults: A Retrospective Analysis of 96 Patients in a Single Center. Chin Med J (Engl) 2018; 131:776–783 https://doi.org/10.4103/0366-6999.228234 PMid:29578120 PMCid:PMC5887735
- Lorenz F, Klimkowska M, Pawłowicz E, et al.: Clinical characteristics, therapy response, and outcome of 51 adult patients with hematological malignancy-associated hemophagocytic lymphohistiocytosis: a single institution experience. Leuk Lymphoma 2018; 1–11 https://doi.org/10.1080/10428194.2017.1403018
- Ramos-Casals M, Brito-Zerón P, López-Guillermo A, et al.: Adult haemophagocytic syndrome. Lancet 2014; 383:1503–1516 https://doi.org/10.1016/S0140-6736(13)61048-X
- Ozen S, Dai A, Coskun E, Oztuzcu S, Ergun S, Aktekin E, Yavuz S, Bay A.Importance of hyperbilirubinemia in differentiation of primary and secondary hemophagocytic lymphohistiocytosis in pediatric cases. Mediterr J Hematol Infect Dis. 2014;6 :e2014067. doi: 10.4084/MJHID.2014.067. eCollection 2014 https://doi.org/10.4084/mjhid.2014.067
- Sackett K, Cunderlik M, Sahni N, et al.: Extreme Hyperferritinemia: Causes and Impact on Diagnostic Reasoning. Am J Clin Pathol 2016; 145:646–650 https://doi.org/10.1093/ajcp/aqw053 PMid:27247369
- François B, Trimoreau F, Desachy A, et al.: [Hemophagocytosis during multiple organ failure: M-CSF overproduction or viral reactivation?]. Ann Fr Anesthèsie Rèanimation 2001; 20:514–519 https://doi.org/10.1016/S0750-7658(01)00410-5
- Ho C, Yao X, Tian L, et al.: Marrow assessment for hemophagocytic lymphohistiocytosis demonstrates poor correlation with disease probability. Am J Clin Pathol 2014; 141:62–71 https://doi.org/10.1309/AJCPMD5TJEFOOVBW PMid:24343738
- Kim J, Yoo SW, Kang S-R, et al.: Clinical implication of F-18 FDG PET/CT in patients with secondary hemophagocytic lymphohistiocytosis. Ann Hematol 2014; 93:661–66. https://doi.org/10.1007/s00277-013-1906-y PMid:24061788
- Bergsten E, Horne A, Aricó M, et al.: Confirmed efficacy of etoposide and dexamethasone in HLH treatment: long-term results of the cooperative HLH-2004 study. Blood 2017; 130:2728–2738 https://doi.org/10.1182/blood-2017-06-788349 PMid:28935695 PMCid:PMC5785801
- Ishii E, Ohga S, Imashuku S, et al.: Nationwide survey of hemophagocytic lymphohistiocytosis in Japan. Int J Hematol 2007; 86:58–65 https://doi.org/10.1532/IJH97.07012 PMid:17675268


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