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.

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.

Abstract 5214: Copper chelation overcomes the immunosuppressive tumor microenvironment in neuroblastoma

Immunotherapy remains a promising approach in the treatment of high-risk neuroblastoma, however efficacy is hampered by the immunosuppressive tumor microenvironment. We previously reported a link between intratumoral copper levels and Programmed Death-Ligand 1 (PD-L1) expression and therefore sought to elucidate the wider impact of copper chelation on immune evasion strategies (Voli et al 2020). Here we profile key elements of the neuroblastoma tumor microenvironment which work in concert to promote immunosuppression and tumor progression. Using the murine TH-MYCN model, animals were treated daily with the copper chelation agent tetraethylenepentamine (TEPA) for seven days before tumor resection and processing. Transcriptome analyses using single-cell RNA-sequencing revealed copper chelation positively skewed the functional status of tumor, immune and stromal compartments to enhance the anti-tumor immune response. This was supported by a tissue microarray screen using NanoString Digital Spatial Profiling which identified increased immune cell infiltration and regions of active tumor killing. High-resolution mass-spectrometry detected upregulation of major histocompatibility complex (MHC) proteins and exclusive antigenic signatures in peptide repertoires. A multiplex cytokine array indicated an improved anti-tumorigenic response underscored by T cell and Natural Killer cell activation. Importantly, combination of copper chelation and anti-GD2 antibody therapy led to tumor regression and significantly improved survival in vivo. Collectively, this study demonstrates the ability of copper chelation to successfully mitigate tumoral immune evasion strategies while providing remarkable insight into neuroblastoma biology. Findings provide crucial evidence in support of combining clinically approved copper chelators with immunotherapy to improve outcomes for neuroblastoma patients.

Citation Format: Jourdin R. Rouaen, Daniele Mercatelli, Federica Saletta, Ensieh M. Poursani, Jayne E. Murray, Nicodemus Tedla, Federico M. Giorgi, Orazio Vittorio. Copper chelation overcomes the immunosuppressive tumor microenvironment in neuroblastoma [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2022; 2022 Apr 8-13. Philadelphia (PA): AACR; Cancer Res 2022;82(12_Suppl):Abstract nr 5214.

Intratumoral Copper Modulates PD-L1 Expression and Influences Tumor Immune Evasion

Therapeutic checkpoint antibodies blocking programmed death receptor 1/programmed death ligand 1 (PD-L1) signaling have radically improved clinical outcomes in cancer. However, the regulation of PD-L1 expression on tumor cells is still poorly understood. Here we show that intratumoral copper levels influence PD-L1 expression in cancer cells. Deep analysis of the The Cancer Genome Atlas database and tissue microarrays showed strong correlation between the major copper influx transporter copper transporter 1 (CTR-1) and PD-L1 expression across many cancers but not in corresponding normal tissues. Copper supplementation enhanced PD-L1 expression at mRNA and protein levels in cancer cells and RNA sequencing revealed that copper regulates key signaling pathways mediating PD-L1-driven cancer immune evasion. Conversely, copper chelators inhibited phosphorylation of STAT3 and EGFR and promoted ubiquitin-mediated degradation of PD-L1. Copper-chelating drugs also significantly increased the number of tumor-infiltrating CD8⁺ T and natural killer cells, slowed tumor growth, and improved mouse survival. Overall, this study reveals an important role for copper in regulating PD-L1 and suggests that anticancer immunotherapy might be enhanced by pharmacologically reducing intratumor copper levels. SIGNIFICANCE: These findings characterize the role of copper in modulating PD-L1 expression and contributing to cancer immune evasion, highlighting the potential for repurposing copper chelators as enhancers of antitumor immunity. GRAPHICAL ABSTRACT: http://cancerres.aacrjournals.org/content/canres/80/19/4129/F1.large.jpg.

Drugging MYCN Oncogenic Signaling through the MYCN-PA2G4 Binding Interface

MYCN is a major driver for the childhood cancer, neuroblastoma, however, there are no inhibitors of this target. Enhanced MYCN protein stability is a key component of MYCN oncogenesis and is maintained by multiple feedforward expression loops involving MYCN transactivation target genes. Here, we reveal the oncogenic role of a novel MYCN target and binding protein, proliferation-associated 2AG4 (PA2G4). Chromatin immunoprecipitation studies demonstrated that MYCN occupies the PA2G4 gene promoter, stimulating transcription. Direct binding of PA2G4 to MYCN protein blocked proteolysis of MYCN and enhanced colony formation in a MYCN-dependent manner. Using molecular modeling, surface plasmon resonance, and mutagenesis studies, we mapped the MYCN-PA2G4 interaction site to a 14 amino acid MYCN sequence and a surface crevice of PA2G4. Competitive chemical inhibition of the MYCN-PA2G4 protein-protein interface had potent inhibitory effects on neuroblastoma tumorigenesis in vivo. Treated tumors showed reduced levels of both MYCN and PA2G4. Our findings demonstrate a critical role for PA2G4 as a cofactor in MYCN-driven neuroblastoma and highlight competitive inhibition of the PA2G4-MYCN protein binding as a novel therapeutic strategy in the disease. SIGNIFICANCE: Competitive chemical inhibition of the PA2G4-MYCN protein interface provides a basis for drug design of small molecules targeting MYC and MYCN-binding partners in malignancies driven by MYC family oncoproteins.

Polymorphisms in genes encoding drug metabolizing enzymes and their influence on the outcome of children with neuroblastoma

BACKGROUND

Although several studies have shown that drug metabolizing enzyme gene polymorphisms may influence the impact of therapy in childhood leukemia, no comprehensive investigations have been carried out in children with neuroblastoma. The aim of this study was to identify polymorphisms in the genes encoding phase I and II drug metabolizing enzymes associated with the risk of relapse or death in a cohort of 209 children with neuroblastoma.

METHODS

Real-time PCR allelic discrimination was used to characterize the presence of polymorphisms in DNA from children with neuroblastoma. Three broad gene categories were examined: cytochrome P450, glutathione-S-transferase and N-acetyltransferase. Cumulative event-free survival was computed by the Kaplan-Meier method. The influence of selected factors on event-free survival was tested using the Cox proportional hazards model.

RESULTS

As previously reported, amplification of MYCN (hazards ratio=4.25, 95% confidence interval=2.76-6.56, P<0.001), unfavorable stage (hazard ratio=4.14, 95% confidence interval=2.3-7.47, P<0.001) or age more than 1 year at diagnosis (hazard ratio=1.86, 95% confidence interval=1.19-2.92, P=0.007) were all associated with an increased risk of relapse or death. Carriers of a NAT1*11 allele variant were significantly less likely to relapse or die compared with those with NAT1*10 or other NAT1 allele variants (P<0.001). In multivariate analysis, children who were GSTM1 null were more likely to relapse or die during follow-up after adjusting for MYCN amplification, stage and age at diagnosis (hazard ratio=1.6, 95% confidence interval=1.02-2.9, P=0.04).

CONCLUSIONS

These observations suggest that the NAT1*11 variant and the GSTM1 wild-type genotype contribute to a more favorable outcome in patients treated for neuroblastoma and are the first to demonstrate a relationship between NAT1 and GSTM1 genotypes in childhood neuroblastoma.

Cell lines from MYCN transgenic murine tumours reflect the molecular and biological characteristics of human neuroblastoma

Overexpression of the human MYCN oncogene driven by a tyrosine hydroxylase promoter causes tumours in transgenic mice that recapitulate the childhood cancer neuroblastoma. To establish an in vitro model to study this process, a series of isogenic cell lines were developed from these MYCN-driven murine tumours. Lines were established from tumours arising in homozygous and hemizygous MYCN transgenic mice. Hemizygous tumours gave rise to cell lines growing only in suspension. Homozygous tumours gave rise to similar suspension lines as well as morphologically distinct substrate-adherent lines characteristic of human S-type neuroblastoma cells. FISH analysis demonstrated selective MYCN transgene amplification in cell lines derived from hemizygous mice. Comparative genomic hybridisation (CGH) and fluorescence in situ hybridisation (FISH) analysis confirmed a range of neuroblastoma-associated genetic changes in the various lines, in particular, gain of regions syntenic with human 17q. These isogenic lines together with the transgenic mice thus represent valuable models for investigating the biological characteristics of aggressive neuroblastoma.

The application of a vacuum-ultraviolet Fourier transform spectrometer and synchrotron-radiation source to measurements of bands of NO. VII. The final report

Photoabsorption measurements of NO bands have been made by vacuum-ultraviolet Fourier transform spectrometry with a resolution of 0.12 cm(-1) in the wavelength region of 166.2-196.2 nm. Accurate line positions are obtained for the delta(upsilon,0) bands with upsilon=2, 3, the epsilon(upsilon,0) bands with upsilon=2, 3, and the beta(upsilon,0) bands with upsilon=10,12,14. Absolute term values are found for the corresponding upper levels C(2,3), D(2,3), and B(10,12,14). Accurate rotational line integrated cross sections have also been obtained for the lines in these bands. Integrated cross sections reported in our earlier papers [J. Chem. Phys. 109, 1751 (1998); 112, 2251 (2000); 115, 3719 (2001); 116, 155 (2002); 117, 10621 (2002); 119, 8373 (2003)] have been revised, and the results reported here comprise the delta(upsilon,0) bands with upsilon=0-3, the epsilon(upsilon,0) bands with upsilon=0-3, the beta(upsilon,0) bands with upsilon=6,7,9-12,14, and the gamma(3,0) band. For each band, the band oscillator strength is obtained from the sum of the line strengths of all rotational lines, and these are compared with other published values.

Marital protection and marital selection: evidence from a historical-prospective sample of American men

Whether marriage causes people to live longer or whether healthier people select into marriage is an open question. In this study I followed a sample of men from age 18 to first marriage and ultimately to death. Health in early adulthood was represented by height and weight around age 20. The probability of ever marrying and the conditional probability of marriage in a given time period were lower for smaller men and greater for larger men. Marriage significantly lowered mortality risk even after controlling for health in early adulthood. Thus I found support both for selection into marriage and for protective effects of marriage.

Revisiting the perception of upside-down faces

In two experiments, the effect of orientation on face perception was assessed. Using a scale from 1 (normal) to 7 (bizarre), participants rated normal, unaltered faces and faces in which changes had been made to spatial-relational properties (eyes and mouth inverted or relative position of the eyes and mouth altered) or to component properties (eyes whitened and teeth blackened). For unaltered and component-distortion faces, bizarreness ratings increased linearly as orientation increased from 0 degree to 180 degrees. For spatial-distortion faces, a discontinuity in the function relating orientation and bizarreness was in evidence between 90 degrees and 120 degrees. The results provide support for the view that there is a qualitative difference in the processing of upright and inverted faces due to the disproportionate effect of inversion on the encoding of spatial-relational information.

Historic landmarks in clinical transplantation: conclusions from the consensus conference at the University of California, Los Angeles

The transplantation of organs, cells, and tissues has burgeoned during the last quarter century, with the development of multiple new specialty fields. However, the basic principles that made this possible were established over a three-decade period, beginning during World War II and ending in 1974. At the historical consensus conference held at UCLA in March 1999, 11 early workers in the basic science or clinical practice of transplantation (or both) reached agreement on the most significant contributions of this era that ultimately made transplantation the robust clinical discipline it is today. These discoveries and achievements are summarized here in six tables and annotated with references.

Surgeon scientist

The origins and development of the renal transplant program at the Peter Bent Brigham Hospital (now the Brigham and Women's Hospital) from the late 1940s to the present are reviewed. The program was initiated as a effort to understand hypertension as a cause of renal failure. The initial transplants were unmodified allogeneic grafts placed in the thigh, followed by extensive laboratory experiments on dogs. This research culminated with the first successful human transplant of a kidney between identical twins in 1954. In 1959 the first successful fraternal allogeneic graft was accomplished as part of a protocol utilizing total body irradiation and bone marrow replacement. Finally, with the development of immunosuppressive drugs, we were able to transplant a cadaveric kidney successfully in 1962. This was a major impetus in the study of organ transplantation worldwide, which currently involves kidneys, liver, heart, pancreas, heart/lung, and bone marrow.

Skilled nurses in schools: IDEA (Individuals with Disabilities Education Act) at work

Home care agencies have an opportunity to create a new revenue stream while helping disabled children receive their education within schools, instead of at home, through the Individuals with Disabilities Education Act. This article examines the law itself, related court cases, problems with implementation, and implications for home care providers. Home care agencies must demonstrate to schools that they can deliver the services the schools need to supplement their nursing staffs under IDEA.

Spatial filter pinhole development for the national ignition facility

We present results from a major experimental effort to understand the behavior of spatial filter pinholes and to identify and demonstrate a pinhole that will meet the requirements of the National Ignition Facility (NIF). We find that pinhole performance depends significantly on geometry and material. Cone pinholes are found to stay open longer and to cause less backreflection than pinholes of more conventional geometry. We show that a +/-150-microrad stainless-steel cone pinhole will pass a full-energy NIF ignition pulse with required margins for misalignment and for smoothing by spectral dispersion. On the basis of a model fitted to experimental results, a +/-125-microrad stainless-steel cone pinhole is also projected to meet these requirements.

Orientation-specific effects in picture matching and naming

In two experiments, subjects made timed decisions about the second of two sequentially presented rotated drawings of objects. When the two objects were physically identical, response times to decide whether the two drawings depicted the same object varied as a function of the shortest distance between the orientation of the second drawing and either the orientation of the previous drawing or the upright. This was found for both short (250-msec) and long (2-sec) interstimulus-intervals. The result was also obtained when subjects named the second drawing after deciding whether the first drawing faced left or right. Following repeated experience with the drawings in the left/right task over four blocks of trials, time to name the second drawing in the same-object sequences was independent of orientation. These results suggest that, initially, object- and orientation-specific representations can be formed following a single presentation of a rotated object and subsequently used to identify drawings of the same object at either the same or different orientations. Alignment of the second drawing with either the canonical representation or the new representation at the previous orientation is achieved by normalization through the shortest path. Following experience with the objects, orientation-invariant representations are formed.

Overpayment guidance for home health agencies

IPS brought many changes for home health providers, including intensified claims review and audits, resulting in overpayments. Agencies have several options despite the limited protection they have under Medicare, including challenging determinations, rebutting the decision, requesting a waiver, and appealing decisions.

Spatial filter pinhole for high-energy pulsed lasers

Spatial filters are essential components for maintaining high beam quality in high-energy pulsed laser systems. The long-duration (21 ns) high-energy pulses envisioned for future inertial-confinement fusion drive systems, such as the U.S. National Ignition Facility (NIF), are likely to lead to increased plasma generation and closure effects within the pinholes in the spatial filters. The design goal for the pinhole spatial filter for the NIF design is to remove small-angle scatter in the beam to as little as a ?100-murad divergence. It is uncertain whether this design requirement can be met with a conventional pinhole design. We propose a new pinhole architecture that addresses these issues by incorporating features intended to reduce the rate of plasma generation. Initial experiments with this design have verified its performance improvement relative to a conventional pinhole design.

Transfer of an ovine metallothionein-ovine growth hormone fusion gene into swine

An ovine metallothionein-1a (oMT1a)-ovine growth hormone (oGH) fusion gene was microinjected into 400 pig zygotes, the zygotes were transferred into recipient females, and 15 founder transgenic pigs were born. Of 12 transgenic pigs assayed, five expressed high levels of oGH (> 900 ng/mL plasma), one expressed low levels of oGH (10 to 30 ng/mL), and six did not express oGH. Dietary supplementation with 2,000 ppm of zinc for 6 d induced a 20-fold increase in plasma oGH in the transgenic pig with low expression but did not induce expression in the six transgenic pigs with no constitutive oGH expression. The average daily gain of five transgenic pigs with elevated oGH was similar to that of non-transgenic littermates during a 9-wk feeding trial (P = .52). The liver, kidney, adrenal, and thyroid weights were all significantly heavier for the oGH-expressing transgenic pigs than for non-transgenic littermates. Total carcass fat, longissimus muscle fat, subcutaneous backfat thickness, and loin eye area were lower and carcass protein and water content and beta R fiber area of longissimus muscle were higher in the transgenic pigs with elevated oGH than in their littermate controls (P < .05 for each). The data indicate that even though the oMT1a promoter was more inducible by zinc than was previously reported for the mouse MT promoter in swine, the former provided a higher level of oGH expression than the mouse MT promoter.

Flipping and spinning: spatial transformation procedures in the identification of rotated natural objects

The proposal that identification of inverted objects is accomplished by either a relatively slow rotation in the picture plane or a faster rotation in the depth plane about the horizontal axis was tested. In Experiment 1, subjects decided whether objects at 0 degree or 180 degrees corresponded to previously learned normal views of the upright objects, or were mirror images. Instructions to mentally flip an inverted object in the depth plane to the upright produced faster decision times than did instructions to mentally spin the object in the picture plane. In Experiment 2, the effects of orientation were compared across an object-naming task and a normal-mirror task for six orientations from 0 degree to 300 degrees. In the normal-mirror task, objects at 180 degrees were cued for rotation in the picture plane or in the depth plane in equal numbers. The naming function for one group of subjects did not differ from the normal-mirror function where inverted objects had been mentally rotated to the upright. For both functions, response time (RT) increased linearly from 0 degree to 180 degrees and the slopes did not differ. The naming function for a second group of subjects did not differ from the normal-mirror function where inverted objects had been mentally flipped to the upright. For both functions, RT increased linearly at a similar rate from 0 degree to 120 degrees, but decreased from 120 degrees to 180 degrees. The results are discussed in terms of theories of orientation-specific identification.

Microalbuminuria in type II diabetes

OBJECTIVE

To emphasize the prognostic significance of microalbuminuria in patients with type II diabetes and to summarize interventional studies in patients with non-insulin-dependent diabetes mellitus and nephropathy.

METHODS

The definition of microalbuminuria is reviewed, the implications of its presence are discussed, and published trials of medical intervention to treat proteinuria in patients with type II diabetes are outlined.

RESULTS

Microalbuminuria--defined as the presence of 30 to 300 mg of protein in a 24-hour urine specimen or a urinary albumin excretion rate of 20 to 200 mg/min--is frequently present in patients with non-insulin-dependent diabetes mellitus. It has been shown to be an independent cardiovascular risk factor as well as a predictor for the eventual development of renal failure. Intervention trials indicate that treatment with "tight" blood glucose control and antihypertensive agents, especially angiotensin-converting enzyme inhibitors, may be beneficial in reversing early proteinuria or at least in preventing the progression to renal failure.

CONCLUSION

The presence of microalbuminuria in patients with type II diabetes mellitus is associated with premature death from cardiovascular disease and the development of renal failure. Thus, aggressive therapy should be instituted.

The role of attention in the shift from orientation-dependent to orientation-invariant identification of disoriented objects

In two experiments, the naming of rotated line drawings of natural objects was examined after a training phase in which the objects were either attended or ignored. In the training phase of Experiment 1, subjects were presented with objects in a number of orientations over five repeated blocks of trials. In the center of each object, seven letters (Xs and Ts, colored red or blue) were presented in rapid succession. Half the subjects named aloud the rotated object and ignored the changing letter display (object-attend). The other half ignored the object and counted the number of red Ts, and then used this number to perform a simple multiplication (object-ignore). In the test phase, all subjects named the rotated objects. The results showed that in the first block of trials in the training phase, mean naming time in the object-attend condition increased the further an object was rotated from the upright. This effect of orientation for attended objects was much reduced in the later presentations of the test phase. In contrast, there was no such benefit of prior presentation observed for the naming of objects that had previously been ignored. Instead, a substantial orientation effect was shown for the naming of previously ignored objects, which was similar to the orientation effect observed for attended objects named in the first block. Similar results were found in Experiment 2, in which object-attend subjects in training covertly named the objects and then performed a letter count and multiplication task. In both experiments, performance on the letter count and multiplication task varied with the angle of the ignored object. The results suggest that full attentional resources must be allocated in order for orientation-invariant representations to be formed and used in the identification of rotated objects.

Stature and body-mass index among mid-nineteenth century south Chinese immigrants

Mean values of anthropometric measurements of 150 Chinese men, taken in 1864 or 1865, were recovered. The subjects had emigrated to California and were returning to China when they were measured. Comparisons were made to measurements of other Chinese men of the late nineteenth and early twentieth centuries. The men of this sample were much taller than those in other South Chinese samples, and about as tall as those in North Chinese samples.

Orientation-invariant transfer of training in the identification of rotated natural objects

The effects of stimulus orientation on naming were examined in two experiments in which subjects identified line drawings of natural objects following practice with the objects at the same or different orientations. Half the rotated objects were viewed in the orientation that matched the earlier presentations, and half were viewed at an orientation that mismatched the earlier presentations. Systematic effects of orientation on naming time were found during the early presentations. These effects were reduced during later presentations, and the size of this reduction did not depend on the orientation in which the object had been seen originally. The results are consistent with a dual-systems model of object identification in which initially large effects of disorientation are the result of a normalization process such as mental rotation, and in which attenuation of the effects is due to a shift from the normalization system to a feature/part-based system.

Intravaginal foreign body of long duration: a case report

Foul-smelling, bloody vaginal discharge and pelvic pain may indicate the presence of an unknown intravaginal foreign body. A case of an adult who underwent numerous examinations and a previous laparotomy without location of the foreign body is presented. Radiologic diagnosis and surgical removal of the object is described.

Failure of prostaglandin induction in an obstructive müllerian abnormality

Failure of prostaglandins E2 and F2 alpha to induce labor for intrauterine fetal death is infrequent. The factors contributing to these failures remain unclear. We describe a case of failed induction with the use of a combination of vaginal prostaglandin E2 and systemic prostaglandin F2 alpha in a 24-week intrauterine fetal death in association with a noncommunicating rudimentary uterine horn. The implications of this müllerian abnormality for theories of parturition are discussed.

Stature among members of a nineteenth century American Shaker commune

A set of heights of white men, women and children who lived in a Shaker commune near Albany, New York between 1840 and 1865 is analysed. Since the Shakers practiced celibacy, members were recruited from outside the commune, so that their stature to some extent reflects living standards in the antebellum northeast United States. Despite small sample sizes, some conclusions may be stated. Heights among birth cohorts of adult Shaker men fluctuated within a narrow range along the trends of military samples, but were much shorter than military samples. Successive birth cohorts of adult women became generally shorter over the first decades of the century, associated with the influx of very short urbanites. Shaker women, even in relative terms, were much shorter than Shaker men, which may reflect broader sexual differences in net nutrition. Although in weight-for-height terms entering Shaker children were not undernourished, they were shorter than children in samples for somewhat later American populations. Members of both sexes grew taller with a longer duration of Shaker upbringing.

A technique for laparoscopic pomeroy tubal ligation with endoloop sutures

A laparoscopic technique of Pomeroy tubal ligation using endoloop sutures was compared with the conventional technique of laparoscopic tubal ligation with Silastic rings. Fifty-three patients selected from a population undergoing tubal ligation were randomized to either the Pomeroy (N = 28) or ring (N = 25) group. Mean (+/- standard deviation) operative time for the Pomeroy group was 27.39 +/- 5.95 minutes, with a range of 18-40; for the ring group, the time was 23.11 +/- 11.53 minutes, with a range of 12-58. These times were not statistically different. Operative complication were encountered only in the ring group and included two lacerations of the mesosalpinx. There were no technical or method failures over a follow-up interval of 12-18 months. Specimens confirmed tubal histology in all cases in the Pomeroy group. Laparoscopic Pomeroy tubal ligation using endoloop sutures was easily performed, comparable to laparoscopic application of Silastic rings, and provided a surgical specimen to confirm tubal histology. This aspect may represent a medicolegal advantage of documentation not available with other laparoscopic techniques of tubal ligation.

The use of scapular and parascapular flaps for cheek reconstruction

This is a retrospective review of our experience with microvascular transfer of scapular and parascapular flaps for the correction of lateral facial contour deficiencies. Twenty-eight patients with congenital (n = 8) and acquired (n = 20) defects were treated with 30 flaps; two patients had bilateral flaps. The etiology of the defects included hemifacial microsomia (n = 2), oblique facial cleft (n = 1), Romberg's hemifacial atrophy (n = 5), neoplasm (n = 4), irradiation (n = 8), trauma (n = 4), tumor excision (n = 4), facial lipodystrophy (n = 2), and silicone granuloma (n = 2). The follow-up evaluation was from 2 to 13 years, with an average of 6 years. Fabrication of a facial moulage was part of the preoperative planning for each patient. These were compound flaps, including skin, deepithelialized skin, fat, fascia, and bone, if necessary. All flaps were constructed with an intact skin paddle for postoperative monitoring. Based on dissections and anatomic findings at operation, several variations in the level of emergence of the circumflex scapular artery from the triangular space and its branching patterns were noted. All flaps survived; changes in the patients' weights were reflected in the flaps. Twelve patients required secondary procedures: excision of skin monitor islands, scar revisions, debulking, or flap resuspension to the malar region. Bone grafts or alloplastic implants were necessary in four patients in whom the malar eminence could not be adequately corrected by transfer of a flap. The deepithelialized scapular/parascapular flap is preferred for correction of large lateral facial defects.

Patient selection for pancreas transplantation

Pancreas transplantation is the only currently available potential cure for type I diabetes. Because of the complications of the procedure and the toxicity of immunosuppression, patients must be carefully selected. The procedure can be justified in patients who already require immunosuppression for a renal allograft. The benefits of improved quality of life and protection from the development of nephropathy in the kidney allograft are significant. Pancreas transplantation alone is harder to justify; the risks of immunosuppression would seem to outweigh the known benefits of normalization of blood glucose. Before pancreas transplantation gains wide acceptance, the graft survival rates must improve. Currently, pancreas graft survival rates are greater than 80% at 1 year, but less than 50% 5 years after the transplantation. Improvement in these rates may occur with the development of more effective and less toxic immunosuppressive agents. Continued improvement in surgical technique should also contribute to overall pancreas transplantation success. Until then, however, pancreas transplantation should be viewed as a therapy for only selected patients in whom the benefits clearly outweigh the risks.

Medicaid EPSDT (Early and Periodic Screening, Diagnosis, and Testing) changes help home care

The changes to the Early and Periodic Screening, Diagnosis and Testing program legislated in April 1990 have been described as the most significant improvement to Medicaid since its inception--yet states are being very quiet about these changes. Why aren't they trumpeting what may be hope for expanding needed home care services?

Human organ transplantation: background and consequences

The story of the renal transplant program of the Peter Bent Brigham Hospital (now the Brigham and Women's Hospital) in Boston weaves together three distinct threads: the study of renal disease, the phenomenon of skin grafting in twins, and the development of surgical procedures ultimately leading to the use of chemical immunosuppression. The common leitmotiv is one of a single event or report proving to be decisive. Unanticipated consequences of successful human organ transplantation include the reorganization of clinical and nonclinical disciplines, national and international cooperation in organ preservation and distribution, tissue-typing as a marker for disease, redefinition of death in terms of brain function, better understanding of disease processes, and new health care quandaries that result from the scarcity of organ donors.