Achievement of Target Gain Larger than Unity in an Inertial Fusion Experiment

On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Land use drives differential resource selection by African elephants in the Greater Mara Ecosystem, Kenya

Understanding drivers of space use by African elephants is critical to their conservation and management, particularly given their large home-ranges, extensive resource requirements, ecological role as ecosystem engineers, involvement in human-elephant conflict and as a target species for ivory poaching. In this study we investigated resource selection by elephants inhabiting the Greater Mara Ecosystem in Southwestern Kenya in relation to three distinct but spatially contiguous management zones: (i) the government protected Maasai Mara National Reserve (ii) community-owned wildlife conservancies, and (iii) elephant range outside any formal wildlife protected area. We combined GPS tracking data from 49 elephants with spatial covariate information to compare elephant selection across these management zones using a hierarchical Bayesian framework, providing insight regarding how human activities structure elephant spatial behavior. We also contrasted differences in selection by zone across several data strata: sex, season and time-of-day. Our results showed that the strongest selection by elephants was for closed-canopy forest and the strongest avoidance was for open-cover, but that selection behavior varied significantly by management zone and selection for cover was accentuated in human-dominated areas. When contrasting selection parameters according to strata, variability in selection parameter values reduced along a protection gradient whereby elephants tended to behave more similarly (limited plasticity) in the human dominated, unprotected zone and more variably (greater plasticity) in the protected reserve. However, avoidance of slope was consistent across all zones. Differences in selection behavior was greatest between sexes, followed by time-of-day, then management zone and finally season (where seasonal selection showed the least differentiation of the contrasts assessed). By contrasting selection coefficients across strata, our analysis quantifies behavioural switching related to human presence and impact displayed by a cognitively advanced megaherbivore. Our study broadens the knowledge base about the movement ecology of African elephants and builds our capacity for both management and conservation.

Lawson Criterion for Ignition Exceeded in an Inertial Fusion Experiment

For more than half a century, researchers around the world have been engaged in attempts to achieve fusion ignition as a proof of principle of various fusion concepts. Following the Lawson criterion, an ignited plasma is one where the fusion heating power is high enough to overcome all the physical processes that cool the fusion plasma, creating a positive thermodynamic feedback loop with rapidly increasing temperature. In inertially confined fusion, ignition is a state where the fusion plasma can begin "burn propagation" into surrounding cold fuel, enabling the possibility of high energy gain. While "scientific breakeven" (i.e., unity target gain) has not yet been achieved (here target gain is 0.72, 1.37 MJ of fusion for 1.92 MJ of laser energy), this Letter reports the first controlled fusion experiment, using laser indirect drive, on the National Ignition Facility to produce capsule gain (here 5.8) and reach ignition by nine different formulations of the Lawson criterion.

Evaluating expert-based habitat suitability information of terrestrial mammals with GPS-tracking data

AIM

Macroecological studies that require habitat suitability data for many species often derive this information from expert opinion. However, expert-based information is inherently subjective and thus prone to errors. The increasing availability of GPS tracking data offers opportunities to evaluate and supplement expert-based information with detailed empirical evidence. Here, we compared expert-based habitat suitability information from the International Union for Conservation of Nature (IUCN) with habitat suitability information derived from GPS-tracking data of 1,498 individuals from 49 mammal species.

LOCATION

Worldwide.

TIME PERIOD

1998-2021.

MAJOR TAXA STUDIED

Forty-nine terrestrial mammal species.

METHODS

Using GPS data, we estimated two measures of habitat suitability for each individual animal: proportional habitat use (proportion of GPS locations within a habitat type), and selection ratio (habitat use relative to its availability). For each individual we then evaluated whether the GPS-based habitat suitability measures were in agreement with the IUCN data. To that end, we calculated the probability that the ranking of empirical habitat suitability measures was in agreement with IUCN's classification into suitable, marginal and unsuitable habitat types.

RESULTS

IUCN habitat suitability data were in accordance with the GPS data (> 95% probability of agreement) for 33 out of 49 species based on proportional habitat use estimates and for 25 out of 49 species based on selection ratios. In addition, 37 and 34 species had a > 50% probability of agreement based on proportional habitat use and selection ratios, respectively.

MAIN CONCLUSIONS

We show how GPS-tracking data can be used to evaluate IUCN habitat suitability data. Our findings indicate that for the majority of species included in this study, it is appropriate to use IUCN habitat suitability data in macroecological studies. Furthermore, we show that GPS-tracking data can be used to identify and prioritize species and habitat types for re-evaluation of IUCN habitat suitability data.

Landscape Dynamics (landDX) an open-access spatial-temporal database for the Kenya-Tanzania borderlands

The savannas of the Kenya-Tanzania borderland cover >100,000 km² and is one of the most important regions globally for biodiversity conservation, particularly large mammals. The region also supports >1 million pastoralists and their livestock. In these systems, resources for both large mammals and pastoralists are highly variable in space and time and thus require connected landscapes. However, ongoing fragmentation of (semi-)natural vegetation by smallholder fencing and expansion of agriculture threatens this social-ecological system. Spatial data on fences and agricultural expansion are localized and dispersed among data owners and databases. Here, we synthesized data from several research groups and conservation NGOs and present the first release of the Landscape Dynamics (landDX) spatial-temporal database, covering ~30,000 km² of southern Kenya. The data includes 31,000 livestock enclosures, nearly 40,000 kilometres of fencing, and 1,500 km² of agricultural land. We provide caveats and interpretation of the different methodologies used. These data are useful to answer fundamental ecological questions, to quantify the rate of change of ecosystem function and wildlife populations, for conservation and livestock management, and for local and governmental spatial planning.

Measurement(s)	livestock enclosures • agriculture • fence
Technology Type(s)	digital curation
Sample Characteristic - Environment	savanna
Sample Characteristic - Location	East Africa

Machine-accessible metadata file describing the reported data: 10.6084/m9.figshare.16828204

Risk perception and tolerance shape variation in agricultural use for a transboundary elephant population

To conserve wide-ranging species in human-modified landscapes, it is essential to understand how animals selectively use or avoid cultivated areas. Use of agriculture leads to human-wildlife conflict, but evidence suggests that individuals may differ in their tendency to be involved in conflict. This is particularly relevant to wild elephant populations. We analysed GPS data of 66 free-ranging elephants in the Serengeti-Mara ecosystem to quantify their use of agriculture. We then examined factors influencing the level of agricultural use, individual change in use across years and differences in activity budgets associated with use. Using clustering methods, our data grouped into four agricultural use tactics: rare (<0.6% time in agriculture; 26% of population), sporadic (0.6%-3.8%; 34%), seasonal (3.9%-12.8%; 31%) and habitual (>12.8%; 9%). Sporadic and seasonal individuals represented two-thirds (67%) of recorded GPS fixes in agriculture, compared to 32% from habitual individuals. Increased agricultural use was associated with higher daily distance travelled and larger home range size, but not with age or sex. Individual tactic change was prevalent and the habitual tactic was maintained in consecutive years by only five elephants. Across tactics, individuals switched from diurnal to nocturnal activity during agricultural use, interpreted as representing similar risk perception of cultivated areas. Conversely, tactic choice appeared to be associated with differences in risk tolerance between individuals. Together, our results suggest that elephants are balancing the costs and benefits of crop usage at both fine (e.g. crop raid events) and long (e.g. yearly tactic change) temporal scales. The high proportion of sporadic and seasonal tactics also highlights the importance of mitigation strategies that address conflict arising from many animals, rather than targeted management of habitual crop raiders. Our approach can be applied to other species and systems to characterize individual variation in human resource use and inform mitigations for human-wildlife coexistence.

658 Managing the Acute Surgical Patient – How has COVID-19 Changed Our Approach?

Aim

COVID-19 has changed how surgical admissions are triaged and treated. This retrospective cohort study aims to detail the effects of a national lockdown on emergency general surgical referrals at a tertiary centre.

Method

A retrospective search identified all emergency general surgery referrals prior to and during the UK national lockdown. Pre (10-23 Feb 2020;PLG) and intra-lockdown (30 Mar-12 Apr 2020;ILG) groups were compared using descriptive statistics and significance was quantified with Chi-squared.

Results

600 patients were included of which 426 (71%) presented in the PLG. The PLG had proportionally fewer ED referrals (40.8%vs.51.1%, p = 0.02) and less cross-sectional imaging performed (31.5%vs.40.8%, p = 0.03). There was a significant reduction in non-specific abdominal pain (NSAP) during lockdown (25.12%vs.14.94%, p = 0.007). GP referrals (48.8%vs.46.6%, p = 0.61), admission (46.2%vs.44.8%, p = 0.09) and operative intervention (21.4% vs.17.24%, p = 0.25) showed no disparity.

Conclusions

Predictably, the advent of lockdown resulted in a reduction in hospital attendance and surgical referrals. Our data showed a similar proportion of referred patients admitted pre- and intra-lockdown despite a reduction in absolute terms. This may be due to a trend towards later presentation coupled with a focus on conservative management and prevention of admission. The decrease in NSAP raises questions that require further exploration. Cross-sectional imaging was used more freely as an adjunct in the ILG suggesting increasing acuity and delayed presentation or may result from a tendency towards image-guided discharge. Admissions have since trended towards pre-lockdown levels, but it is yet to be seen if a reduction in elective operating will lead to an increase in emergency admissions.

Human footprint and protected areas shape elephant range across Africa

Over the last two millennia, and at an accelerating pace, the African elephant (Loxodonta spp. Lin.) has been threatened by human activities across its range.^1-7 We investigate the correlates of elephant home range sizes across diverse biomes. Annual and 16-day elliptical time density home ranges⁸ were calculated by using GPS tracking data collected from 229 African savannah and forest elephants (L. africana and L. cyclotis, respectively) between 1998 and 2013 at 19 sites representing bushveld, savannah, Sahel, and forest biomes. Our analysis considered the relationship between home range area and sex, species, vegetation productivity, tree cover, surface temperature, rainfall, water, slope, aggregate human influence, and protected area use. Irrespective of these environmental conditions, long-term annual ranges were overwhelmingly affected by human influence and protected area use. Only over shorter, 16-day periods did environmental factors, particularly water availability and vegetation productivity, become important in explaining space use. Our work highlights the degree to which the human footprint and existing protected areas now constrain the distribution of the world's largest terrestrial mammal.^9,10 A habitat suitability model, created by evaluating every square kilometer of Africa, predicts that 18,169,219 km² would be suitable as elephant habitat-62% of the continent. The current elephant distribution covers just 17% of this potential range of which 57.4% falls outside protected areas. To stem the continued extirpation and to secure the elephants' future, effective and expanded protected areas and improved capacity for coexistence across unprotected range are essential.

Detection of cardiac amyloidosis by PET/CT imaging using 124I-p5+14 peptide

Introduction

Systemic amyloidosis is characterized by the deposition of protein fibrils in abdominothoracic organs, notably the heart, leading to organ dysfunction and significant morbidity. Patients who present with light chain (AL) amyloid-associated cardiomyopathy have a poor prognosis and median survival of only ∼ 9 mos. Cardiac amyloidosis is also present in many of the other forms of the disease and may be ever present in patients with transthyretin-associated amyloidosis (ATTR). Currently, no radiotracers are approved for the quantitative imaging of cardiac amyloid load.

To address these needs, we have developed a synthetic amyloid-reactive peptide radiotracer, 124I-p5+14, suitable for PET/CT imaging. The peptide binds the three major forms of amyloid (AL, ATTR and ALECT2), as well as other, less common, types through multivalent electrostatic interactions with amyloid-associated glycosaminoglycans and fibrils. Herein we report safety, dosimetry, and efficacy data on the first 22 patients from the ongoing Phase 1, first-in-human trial of 124I-p5+14 in patients with systemic amyloidosis (NCT 03678259).

Methods

Patients &gt;18 years of age with a confirmed diagnosis of systemic amyloidosis and not requiring heparin therapy are eligible. Subjects received &lt;2 mg of 124I-p5+14 (&lt;2 mCi) administered as a single IV bolus. PET/CT images for the initial cohort (n=3) were acquired from 25 min to 48h post injection. The second cohort of patients were imaged at ∼5 h and 24 h post injection. Image data were acquired using a Biograph 16 PET/CT scanner with a low dose CT. Uptake of radiotracer in the left ventricular wall was performed by automated image segmentation and standard uptake value ratios (SUVR) were calculated using blood pool as the reference tissue.

Results

To date, 22 patients (13 AL, 5 ATTR, and 4 other) patients have been evaluated. The gender-averaged mean whole body effective dose was 0.24 mSv/MBq. Cardiac uptake of the radiotracer was visually detected by a reader blinded to the patients' organ involvement in 85% and 100% of patients with AL and ATTR respectively, including patients with asymptomatic cardiac involvement - no cardiac symptoms or elevated cardiac biomarkers. The mean myocardium SUVR for visually positive AL and ATTR patients were 2.2±0.6 and 2.6±0.4. For visually negative AL patients the SUVRs were 1.0 and 0.9. In addition to cardiac amyloid, 124I-p5+14 uptake was observed in the nerves, ligaments, liver, spleen, adrenal glands, kidneys, pancreas, pituitary, and lung, with overall abdominothoracic organ-specific sensitivity of &gt;90% based on clinical presentation. Sensitivity in the heart was 100%.

Conclusions

PET/CT imaging of 124I-p5+14 provides excellent visualization of AL and ATTR cardiac amyloidosis which can be readily quantified as a means of monitoring response to therapy or disease progression. The 124I-p5+14 radiotracer was also capable of detecting amyloid in other abdominothoracic organs.

AL and ATTR cardiac amyloidosis

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Heart Lung and Blood Institute, National Institutes of Health; ACTP Gift Fund at the UTGSM

Cystic squamous cell carcinoma of the orbit

Both primary and secondary squamous cell carcinoma (SCC) of the orbit are rare entities, though cystic SCC is even more so. It may provide a significant diagnostic conundrum to oculoplastic surgeons. We present a case of an 86 year old male with a supero-medial transilluminating cystic lesion of the orbit. There was a preceding history of a moderately differentiated SCC of the cheek, excised 3 months prior. Computed tomography (CT) demonstrated no bone erosion. The cyst was excised aided by fibrin glue. This demonstrated a poorly differentiated cystic SCC with perineural infiltration. The patient elected for palliative aspirations of the cyst and is alive 12 months later. Cystic SCC of the orbit may present to a number of specialties, including maxillofacial and orbital surgeons. Both diagnosis and management may be challenging. We review common patterns in previous cases and discuss management.

Moving in the Anthropocene: Global reductions in terrestrial mammalian movements

Animal movement is fundamental for ecosystem functioning and species survival, yet the effects of the anthropogenic footprint on animal movements have not been estimated across species. Using a unique GPS-tracking database of 803 individuals across 57 species, we found that movements of mammals in areas with a comparatively high human footprint were on average one-half to one-third the extent of their movements in areas with a low human footprint. We attribute this reduction to behavioral changes of individual animals and to the exclusion of species with long-range movements from areas with higher human impact. Global loss of vagility alters a key ecological trait of animals that affects not only population persistence but also ecosystem processes such as predator-prey interactions, nutrient cycling, and disease transmission.

Association of the clinical frailty scale with hospital outcomes

BACKGROUND

The clinical frailty scale (CFS) was validated as a predictor of adverse outcomes in community-dwelling older people. In our hospital, the use of the CFS in emergency admissions of people aged ≥ 75 years was introduced under the Commissioning for Quality and Innovation payment framework.

AIM

We retrospectively studied the association of the CFS with patient characteristics and outcomes.

DESIGN

Retrospective observational study in a large tertiary university National Health Service hospital in UK.

METHODS

The CFS was correlated with transfer to specialist Geriatric ward, length of stay (LOS), in-patient mortality and 30-day readmission rate.

RESULTS

Between 1st August 2013 and 31st July 2014, there were 11 271 emergency admission episodes of people aged ≥ 75 years (all specialties), corresponding to 7532 unique patients (first admissions); of those, 5764 had the CFS measured by the admitting team (81% of them within 72 hr of admission). After adjustment for age, gender, Charlson comorbidity index and history of dementia and/or current cognitive concern, the CFS was an independent predictor of in-patient mortality [odds ratio (OR) = 1.60, 95% confidence interval (CI): 1.48 to 1.74, P < 0.001], transfer to Geriatric ward (OR = 1.33, 95% CI: 1.24 to 1.42, P < 0.001) and LOS ≥ 10 days (OR = 1.19, 95% CI: 1.14 to 1.23, P < 0.001). The CFS was not a multivariate predictor of 30-day readmission.

CONCLUSIONS

The CFS may help predict in-patient mortality and target specialist geriatric resources within the hospital. Usual hospital metrics such as mortality and LOS should take into account measurable patient complexity.

Novel opportunities for wildlife conservation and research with real-time monitoring

The expansion of global communication networks and advances in animal-tracking technology make possible the real-time telemetry of positional data as recorded by animal-attached tracking units. When combined with continuous, algorithm-based analytical capability, unique opportunities emerge for applied ecological monitoring and wildlife conservation. We present here four broad approaches for algorithmic wildlife monitoring in real time--proximity, geofencing, movement rate, and immobility--designed to examine aspects of wildlife spatial activity and behavior not possible with conventional tracking systems. Application of these four routines to the real-time monitoring of 94 African elephants was made. We also provide details of our cloud-based monitoring system including infrastructure, data collection, and customized software for continuous tracking data analysis. We also highlight future directions of real-time collection and analysis of biological, physiological, and environmental information from wildlife to encourage further development of needed algorithms and monitoring technology. Real-time processing of remotely collected, animal biospatial data promises to open novel directions in ecological research, applied species monitoring, conservation programs, and public outreach and education.

MAGNAMOSIS IV: magnetic compression anastomosis for minimally invasive colorectal surgery

BACKGROUND AND STUDY AIMS

MAGNAMOSIS forms a compression anastomosis using self-assembling magnetic rings that can be delivered via flexible endoscopy. The system has proven to be effective in full-thickness porcine small-bowel anastomoses. The aim of this study was to show the feasibility of the MAGNAMOSIS system in hybrid endoscopic colorectal surgery and to compare magnetic and conventional stapled anastomoses.

METHODS

A total of 16 swine weighing 35 - 50 kg were used following animal ethical committee approval. The first animal was an acute model to establish the feasibility of the procedure. The subsequent 15 animals were survival models, 10 of which underwent side-to-side anastomoses (SSA) and 5 of which underwent end-to-side (ESA) procedures. Time to patency, surveillance endoscopy, burst pressure, compression force, and histology were assessed. Histology was compared with conventional stapled anastomoses. Magnetic compression forces were measured in various anastomosis configurations.

RESULTS

Colorectal anastomoses were performed in all cases using a hybrid NOTES technique. The mean operating time was 71 minutes. Mean time to completion of the anastomosis was similar between the SSA and ESA groups. Burst pressure at 10 days was greater than 95 mmHg in both groups. One complication occurred in the ESA group. Compression force among various configurations of the magnetic rings was significantly different (P < 0.05). Inflammation and fibrosis were similar between magnetic SSA and conventional stapled anastomoses.

CONCLUSION

MAGNAMOSIS was feasible in performing a hybrid NOTES colorectal anastomosis. It has the advantage over circular staplers of precise endoscopic delivery throughout the entire colon. SSA was reliable and effective. A minimum initial compression force of 4 N appears to be required for reliable magnetic anastomoses.

Prospective experimental study of transrectal viscerotomy closure using transanal endoscopic suture vs. circular stapler: a step toward NOTES

BACKGROUND AND STUDY AIM

Endoluminal full-thickness closure of the rectal wall is critical in emerging procedures including endoscopic submucosal dissection and transrectal natural orifice transluminal endoscopic surgery (NOTES). This study aimed to compare manual suture using the transanal endoscopic operation platform (TEO; Karl Storz, Tüttlingen, Germany) with the end-to-end anastomosis hemorrhoid circular stapler (EEA; Covidien, Dublin, Ireland) for closure of the rectal viscerotomy during transrectal NOTES segmental colectomy.

MATERIALS AND METHODS

A total of 12 swine underwent transrectal hybrid NOTES partial colectomies. Animals were divided into two groups according to the viscerotomy closure technique: 1) TEO manual suture; 2) EEA circular stapler closure.

RESULTS

Mean (± SD) viscerotomy closure time was 67.5 ± 59.5 minutes and 31.5 ± 19.6 minutes for TEO and EEA, respectively. There was one conversion to laparoscopy in the TEO group and a misfiring in the EEA group that required a TEO salvage suture. There was one positive air-leak test in each group. Peritoneal fluid collected at the end of the procedure tested positive for bacterial contamination in all cases. A mild stenosis was present in 4 /6 viscerotomies (67 %) in the TEO group and in 1/6 (17 %) in the EEA group on endoscopic control. Inflammatory changes were mild in 3/5 (60 %) and 4/5 (80 %) viscerotomies in the TEO and EEA groups, respectively, whereas severe inflammation was found in 2/5 (TEO) and 1 /5 (EEA).

CONCLUSION

Transrectal viscerotomy closure using the EEA circular stapler technique is feasible, easy to perform, and histologically comparable to suture closure through a TEO platform. It may offer an attractive alternative for NOTES segmental colectomies and endoscopic resections.

Transanal extraction of the specimen during laparoscopic colectomy

AIM

To assess the current state of the art of transanal specimen extraction in colonic resections.

METHOD

A systematic literature search was conducted including the terms 'transrectal or transanal specimen extraction', 'Natural Orifice Specimen Extraction' and 'laparoscopic colectomy' for the period from 1955 to May 2011. Exclusion criteria were abdomino-perineal resections, pull-through technique, experimental studies and paediatric population.

RESULTS

Nineteen studies met the inclusion criteria, representing 154 patients. The overall postoperative complication rate was 10%. The risks of peritoneal contamination and sphincter dysfunction were evaluated by a single study of each.

CONCLUSION

Transanal extraction is a feasible option to minimize incisions in colorectal surgery.

Transvaginal specimen extraction in colorectal surgery: current state of the art

BACKGROUND

The expected benefit of transvaginal specimen extraction is reduced incision-related morbidity.

OBJECTIVES

A systematic review of transvaginal specimen extraction in colorectal surgery was carried out to assess this expectation.

SEARCH STRATEGY

The following keywords, in various combinations, were searched: NOSE (natural orifices specimen extraction), colorectal, colon surgery, transvaginal, right hemicolectomy, left hemicolectomy, low anterior resection, sigmoidectomy, ileocaecal resection, proctocolectomy, colon cancer, sigmoid diverticulitis and inflammatory bowel diseases.

SELECTION CRITERIA

SELECTION CRITERIA included large bowel resection with transvaginal specimen extraction, laparoscopic approach, human studies and English language. Exclusion criteria were experimental studies and laparotomic approach or local excision. All articles published up to February 2011 were included.

RESULTS

Twenty-three articles (including a total of 130 patients) fulfilled the search criteria. The primary diagnosis was colorectal cancer in 51% (67) of patients, endometriosis in 46% (60) of patients and other conditions in the remaining patients. A concurrent gynaecological procedure was performed in 17% (22) of patients. One case of conversion to laparotomy was reported. In two patients, transvaginal extraction failed. In left- and right-sided resections, the rate of severe complications was 3.7% and 2%, respectively. Two significant complications, one of pelvic seroma and one of rectovaginal fistula, were likely to have been related to transvaginal extraction. The degree of follow up was specified in only one study. Harvested nodes and negative margins were adequate and reported in 70% of oncological cases.

CONCLUSION

Vaginal extraction of a colorectal surgery specimen shows potential benefit, particularly when associated with a gynaecological procedure. Data from prospective randomized trials are needed to support the routine use of this technique.

Rituximab treatment in patients with active Graves' orbitopathy: effects on proinflammatory and humoral immune reactions

In active Graves' orbitopathy (GO), proinflammatory cytokines predominate. Circulating thyroid stimulating hormone (TSH)-receptor antibodies (TRAb) have been correlated with GO clinical activity and severity. In preliminary studies rituximab (RTX), an anti-CD 20 monoclonal antibody, has induced clinical improvement of active GO without a change in serum anti-thyroid antibodies. We have studied whether RTX in GO acts by affecting proinflammatory cytokines and thyroid and orbital-directed antibodies. Ten patients with GO were treated with RTX, administered twice intravenously (i.v.) (1000 mg) at days 1 and 15, and 20 with methylprednisolone, administered weekly i.v. (500 mg), for 16 weeks. Patients were studied before treatment, at B cell depletion and at 4, 8, 16, 20, 30 and 50 weeks. Peripheral lymphocytes, serum interleukin (sIL)-6, sIL-6r, chemokine (C-X-C motif) ligand 10 (CXCL10), TRAb and stimulating antibodies (TSAb) and autoantibodies against orbital calsequestrin, collagen XIII and flavoprotein subunit of succinate dehydrogenase (FP-SDH) were measured at baseline and after treatment. Serum IL-6 and sIL-6R concentrations did not change after RTX [P = not significant (n.s.)]. Serum CXCL10 increased after RTX at B cell depletion and at 30 weeks (P < 0·003). Serum TSAb did not change in relation to TRAb, nor did antibodies against orbital antigens (P = n.s.). In conclusion, this study shows that RTX in GO does not affect humoral reactions. The observed increase of serum CXCL10 concentrations at B cell depletion may result from cell lysis. We suggest that RTX may exert its effect in GO by inhibiting B cell antigen presentation.

Imaging single atoms using secondary electrons with an aberration-corrected electron microscope

Aberration correction has embarked on a new frontier in electron microscopy by overcoming the limitations of conventional round lenses, providing sub-angstrom-sized probes. However, improvement of spatial resolution using aberration correction so far has been limited to the use of transmitted electrons both in scanning and stationary mode, with an improvement of 20-40% (refs 3-8). In contrast, advances in the spatial resolution of scanning electron microscopes (SEMs), which are by far the most widely used instrument for surface imaging at the micrometre-nanometre scale, have been stagnant, despite several recent efforts. Here, we report a new SEM, with aberration correction, able to image single atoms by detecting electrons emerging from its surface as a result of interaction with the small probe. The spatial resolution achieved represents a fourfold improvement over the best-reported resolution in any SEM (refs 10-12). Furthermore, we can simultaneously probe the sample through its entire thickness with transmitted electrons. This ability is significant because it permits the selective visualization of bulk atoms and surface ones, beyond a traditional two-dimensional projection in transmission electron microscopy. It has the potential to revolutionize the field of microscopy and imaging, thereby opening the door to a wide range of applications, especially when combined with simultaneous nanoprobe spectroscopy.

Case report: successful use of hyperbaric oxygen therapy for a complete scalp degloving injury

We report a case of a complete scalp degloving injury in a 43-year-old previously healthy, tobacco-using female whose hair was caught in a tractor power take-off causing an instantaneous total scalping injury. Microsurgical replantation was started 4 hours after injury with the surgical procedure lasting 4 hours. Only the superficial temporal arteries were reanastomosed with no venous anastomosis possible. Hyperbaric oxygen (HBO2) treatment at 2.5 atmospheres absolute (ATA) for 90 minutes was administered immediately after surgery due to duskiness of the flap. Further HBO2 treatments were administered twice daily for seven days and then once daily for 30 days. Additionally, leech therapy was used for the first ten postoperative days. The patient's right auricle and most of the left auricle were completely lost. Despite the tenuous vascular inflow and initially absent venous drainage, at 3 month follow-up there was reepithelialization of her scalp except for an area of granulation tissue in the occipitoparietal area. At one year follow-up the area of granulation tissue was reduced, but there was no detectable hair growth or nerve function. We propose that HBO2 may facilitate tissue survival in scalp degloving injuries in the face of incomplete surgical revascularization.

Direct electron imaging in electron microscopy with monolithic active pixel sensors

A new imaging device for dynamic electron microscopy is in great demand. The detector should provide the experimenter with images having sufficient spatial resolution at high speed. Immunity to radiation damage, accumulated during exposures, is critical. Photographic film, a traditional medium, is not adequate for studies that require large volumes of data or rapid recording and charge coupled device (CCD) cameras have limited resolution, due to phosphor screen coupling. CCD chips are not suitable for direct recording due to their extreme sensitivity to radiation damage. This paper discusses characterization of monolithic active pixel sensors (MAPS) in a scanning electron microscope (SEM) as well as in a transmission electron microscope (TEM). The tested devices were two versions of the MIMOSA V (MV) chip. This 1M pixel device features pixel size of 17 x 17 microm(2) and was designed in a 0.6 microm CMOS process. The active layer for detection is a thin (less than 20 microm) epitaxial layer, limiting the broadening of the electron beam. The first version of the detector was a standard imager with electronics, passivation and interconnection layers on top of the active region; the second one was bottom-thinned, reaching the epitaxial layer from the bottom. The electron energies used range from a few keV to 30 keV for SEM and from 40 to 400 keV for TEM. Deterioration of the image resolution due to backscattering was quantified for different energies and both detector versions.

A randomized phase II trial comparing every 3-weeks carboplatin/paclitaxel with every 3-weeks carboplatin and weekly paclitaxel in advanced non-small cell lung cancer

BACKGROUND

The optimal schedule of taxane administration has been an area of active interest in several recent clinical trials.

METHODS

To address a pure schedule question, we randomized 161 patients with advanced stage IIIB or IV non-small-cell lung cancer (NSCLC) to either paclitaxel 225 mg/m2 every 3 weeks x 4 cycles or 75 mg/m2/week x 12 (cumulative dose on each arm = 900 mg/m2). Both arms received concurrent carboplatin AUC 6 every 3 weeks x 4 cycles.

RESULTS

The two arms were well-balanced in terms of known prognostic factors. The overall response rate and survival outcomes were similar on the two arms. There was significantly more grade 3/4 thrombocytopenia and grade 2-4 anemia on the weekly arm but less severe myalgias/arthralgias and alopecia. No difference in the rates of peripheral neuropathy was observed; however, patients on the every 3 weeks arm reported significantly more taxane therapy-related side-effects on the functional assessment of cancer therapy taxane subscale.

CONCLUSIONS

This randomized trial exploring schedule-related issues with carboplatin/paclitaxel confirms the versatility of this regimen.

The clinicopathologic basis of Graves' ophthalmopathy: a review

PURPOSE

Graves' ophthalmopathy (GO) is a controversial disease, with disagreement within the medical community regarding its pathogenesis, diagnosis, and treatment.

METHODS

We reviewed recent literature on clinical and pathological aspects of GO from both the endocrinologist's and ophthalmologist's perspective.

RESULTS

Investigations into the pathogenesis of GO have included possible antigenic targets, orbital cell types, and development of animal models. Diagnosis has been improved recently with new tools and grading systems, but can be complicated by conditions that may simulate one or more of the findings of GO. The new findings of clinical studies also compel practitioners to reassess commonly used GO treatments such as orbital irradiation.

CONCLUSIONS

Improved understanding of the pathogenic mechanisms of GO should hopefully lead to new diagnostic and therapeutic approaches to this problematic condition.

Modelling induction of a rotor in cardiac muscle by perpendicular electric shocks

A strong, properly timed shock applied perpendicularly to a propagating wavefront causes a rotor in the canine myocardium. Experimental data indicate that the induction of this rotor relies on the shock exciting tissue away from the electrodes. The computational study reproduced such direct excitation in a two-dimensional model of a 2.7 x 3 cm sheet of cardiac muscle. The model used experimentally measured extracellular potentials to represent 100 and 150 V shocks delivered through extracellular electrodes. The shock-induced transmembrane potential was computed according to two mechanisms, the activating function and the unit-bundle sawtooth potential. The overall process leading to initiation of a rotor was the same in model and experiment. For the 100 V shock, the directly excited region extended 2.26 cm away from the electrode; the centre of the rotor ('critical point') was 1.28 cm away, where the electric field Ecr was 4.54 Vcm(-1). Increasing the shock strength to 150 V moved the critical point 1.02 cm further and decreased Ecr by 0.39 Vcm(-1). The results are comparable with experimental data. The model suggests that the unit-bundle sawtooth is responsible for the creation of the directly excited region, and the activating function is behind the dependence of Ecr on shock strength.