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.

Trypanosoma cruzi infection diagnosed in dogs in nonendemic areas and results from a survey suggest a need for increased Chagas disease awareness in North America

OBJECTIVE

To describe the clinical presentation and outcome in dogs diagnosed with Trypanosoma cruzi infection in nonendemic areas and to survey veterinary cardiologists in North America for Chagas disease awareness.

ANIMALS

12 client-owned dogs; 83 respondents from a veterinary cardiology listserv.

PROCEDURES

A retrospective, multicenter medical records review to identify dogs diagnosed with American trypanosomiasis between December 2010 and December 2020. An anonymous online survey was conducted August 9 to 22, 2022.

RESULTS

Diagnosis was made using indirect fluorescent antibody titer (n = 9), quantitative PCR assay (1), or postmortem histopathology (2). Time spent in Texas was < 1 year (n = 7) or 2 to 8 years (5). Time in nonendemic areas prior to diagnosis was < 1 year (n = 10) and > 3 years (2). Eleven had cardiac abnormalities. Of the 12 dogs, 5 had died unexpectedly (range, 1 to 108 days after diagnosis), 4 were still alive at last follow-up (range, 60 to 369 days after diagnosis), 2 were euthanized because of heart disease (1 and 98 days after diagnosis), and 1 was lost to follow-up. Survey results were obtained from 83 cardiologists in North America, of which the self-reported knowledge about Chagas disease was limited in 49% (41/83) and 69% (57/83) expressed interest in learning resources.

CLINICAL RELEVANCE

Results highlight the potential for encountering dogs with T cruzi infection in nonendemic areas and need for raising awareness about Chagas disease in North America.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

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.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Are tomorrow's doctors prepared to prevent dementia? A cross-sectional study of Tasmanian medical students' knowledge of dementia risk factors

Tomorrow's doctors are unprepared to prevent dementia. This cross-sectional study invited medical students enrolled in the University of Tasmania 5-year medical degree (MBBS) to participate in an online questionnaire during 2019. This study measured students' recall of risk factors, prompted and unprompted, for dementia and cardiovascular disease (CVD), and Dementia Knowledge Assessment Scale (DKAS) score. Data were collected via an online survey comprising the DKAS, and risk factor questions adapted from the Alzheimer's Research UK National Monitor Survey, with questions on CVD risk factors added for comparison. Medical students (n = 82) proffered fewer unprompted risk factors for dementia than for CVD and were less proficient at recognizing dementia risk factors from a prompted list. Knowledge of vascular risk factors for dementia was particularly limited. Their broader dementia knowledge was generally adequate and DKAS scores were at the level of a qualified doctor by final year. Whilst medical students' general knowledge of dementia was satisfactory, their knowledge of modifiable risk factors of dementia was limited. If replicated elsewhere, this raises concerns about whether the future medical workforce is equipped to take a necessary lead role in managing dementia risk reduction. As dementia incidence rises worldwide, and 40% cases are attributable to modifiable risk factors, educational programs may need to urgently address these deficiencies.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

The effect of alterations in foot centre of pressure on lower body kinematics during the five-iron golf swing

The research aimed to evaluate the effects of an intervention aimed at altering pressure towards the medial aspect of the foot relating to stability mechanisms associated with the golf swing. We hypothesised that by altering the position of the foot pressure, the lower body stabilisation would improve which in turn would enhance weight distribution and underpinning lower body joint kinematics. Eight professional golf association (PGA) golf coaches performed five golf swings, recorded using a nine-camera motion analysis system synchronised with two force platforms. Following verbal intervention, they performed further five swings. One participant returned following a one-year intervention programme and performed five additional golf swings to provide a longitudinal case study analysis. Golf performance was unchanged evidenced by the velocity and angle of the club at ball impact (BI), although the one-year intervention significantly changed the percentage of weight experienced at each foot in the final 9% of downswing, which provided an even weight distribution at BI. This is a highly relevant finding as it indicates that the foot centre of pressure was central to the base of support and in-line with the centre of mass (CoM), indicating significantly increased stability when the CoM is near maximal acceleration.

Individualised assessment of response to clopidogrel in patients presenting with acute coronary syndromes: a role for short thrombelastography?

INTRODUCTION

There is considerable interindividual variation in response to the antiplatelet agent clopidogrel. Hyporesponse predicts negative outcomes in patients presenting with a variety of ischemic cardiac conditions and following intracoronary stent placement. Many tests of clopidogrel activity are time consuming and complex. Short thromboelastography (s-TEG) allows rapid measurement of platelet clopidogrel response.

AIMS

We initiated this study to investigate the utility of s-TEG in assessing the response to clopidogrel in patients presenting with acute coronary syndromes (ACS) and to compare these results with established clopidogrel monitoring techniques.

METHODS

Patients admitted with unstable angina (UA) or Non ST elevation myocardial infarction (NSTEMI) undergoing coronary angiography were recruited. After routine loading with clopidogrel, all patients were tested with s-TEG and Accumetrics Verify-Now rapid platelet function analyzer (VN-RPFA). We used the modified TEG technique of measuring area under the curve at 15 min (AUC15), which allows a rapid estimation of antiplatelet response. Vasodilator-stimulated phosphoprotein phosphorylation (VASP) was also tested in a subgroup of patients. Clinical follow-up was obtained at 1 year. s-TEG results were correlated with VN-RPFA and VASP findings.

RESULTS

A total of 49 patients (33 male, mean age 63) were recruited and tested with s-TEG and VN-RPFA and a total of 39 patients were also assessed with VASP. s-TEG readings correlated well with VN-RPFA (r(2)= 0.54, P < 0.0001) and VASP (r(2)= 0.26, P= 0.001).

CONCLUSION

s-TEG provides timely results which compare to current tests of clopidogrel activity. This technique can also be used to measure a variety of other clotting parameters and as such could develop into a valuable near patient test for the interventional cardiologist.

Formation of platelet-leukocyte conjugates in whole blood

The purpose of this investigation was to obtain information on platelet-leukocyte conjugate formation in whole blood and on factors that affect it. We also measured platelet and leukocyte activation by quantitating the expression of CD62P and CD11b. In both cases a flow cytometric approach was used. The results show that platelet-monocyte and platelet-polymorphonuclear leukocyte (PMNL) conjugate formation is enhanced by simply stirring blood, with optimum conjugate formation occurring after 10 min. In the case of monocytes,conjugate formation was enhanced by adenosine diphosphate (ADP). Both monocyte and PMNL conjugate formation was enhanced by phorbol myristate acetate (PMA), but L-formyl methionyl lysyl proline (FMLP) was either without effect (monocytes) or inhibitory (PMNL). EDTA also inhibited conjugate formation (implying involvement of divalent cations), as did dextran sulphate (implying involvement of P-selectin = CD62P). Interestingly GR144053F, which acts at GpIIb-IIIa on platelets to interfere with fibrinogen binding, and also glycyl prolyl arginyl proline (GPRP), a peptide that interferes with the interaction between CD11c on leukocytes and fibrinogen, did not inhibit platelet-monocyte conjugate formation, but did inhibit the platelet-PMNL interaction; this indicates that GpIIb-IIIa on platelets and CD11c on leukocytes and fibrinogen are involved in mediating the interaction between platelets and PMNL but not platelets and monocytes. Surprisingly arginyl-glycyl aspartyl serine (RGDS) inhibited the formation of both types of conjugate but this may be because it also inhibited both platelet and leukocyte activation as measured by CD62P and CD11b exposure and/or interferes with the binding of adhesion molecules other than fibrinogen. The results show that a flow cytometric procedure can be effective in obtaining rapid information on platelet-leukocyte conjugate formation in whole blood and on factors that are involved in its regulation. It is suggested that the technique may be applicable to the study of platelet-leukocyte conjugate formation in whole blood in disease, and also to study the effects of drugs interfering with conjugate formation.

Phase and interference properties of optical vortex beams

Laguerre-Gauss vortex beams carrying different topological charges are generated from Hermite-Gauss laser beams emitted by a gas laser, and their phase properties are explored by studying their interference with a plane wave. Interference of two Laguerre-Gauss vortex beams carrying equal but opposite topological charge is also studied by using a modified Mach-Zehnder interferometer. Experimentally recorded intensity profiles are in good agreement with the theoretically expected profiles.

Anatomically related grey and white matter abnormalities in adolescent-onset schizophrenia

Adolescent-onset schizophrenia provides an exceptional opportunity to explore the neuropathology of schizophrenia free from the potential confounds of prolonged periods of medication and disease interactions with age-related neurodegeneration. Our aim was to investigate structural grey and white matter abnormalities in adolescent-onset schizophrenia. Whole-brain voxel-wise investigation of both grey matter topography and white matter integrity (Fractional Anisotropy) were carried out on 25 adolescent-onset schizophrenic patients and 25 healthy adolescents. We employed a refined voxel-based morphometry-like approach for grey matter analysis and the recently introduced method of tract-based spatial statistics (TBSS) for white matter analysis. Both kinds of studies revealed widespread abnormalities characterized by a lower fractional anisotropy neuroanatomically associated with localized reduced grey matter in the schizophrenic group. The grey matter changes can either be interpreted as the result of a locally reduced cortical thickness or as a manifestation of different patterns of gyrification. There was a widespread reduction of anisotropy in the white matter, especially in the corpus callosum. We speculate that the anisotropy changes relate to the functional changes in brain connectivity that are thought to play a central role in the clinical expression of the disease. The distribution of grey matter changes was consistent with clinical features of the disease. For example, grey and white matter abnormalities found in the Heschl's gyrus, the parietal operculum, left Broca's area and the left arcuate fasciculus (similar to previous findings in adult-onset schizophrenia) are likely to relate to functional impairments of language and auditory perception. In addition, in contrast to earlier studies, we found striking abnormalities in the primary sensorimotor and premotor cortices and in white matter tracts susbserving motor control (mainly the pyramidal tract). This novel finding suggests a new potential marker of altered white matter maturation specific to adolescent-onset schizophrenia. Together, our observations suggest that the neuropathology of adolescent-onset schizophrenia involves larger and widespread changes than in the adult form, consistent with the greater clinical severity.

Measurement of platelet activation and adhesion to leukocytes during haemodialysis

In this study we used fluorescent-labelled antibodies to measure the extent of platelet adhesion to polymorphonuclear leukocytes (PMNLs), monocytes and lymphocytes. The activation of platelets, PMNLs and monocytes were also measured during the course of haemodialysis treatment using flow cytometric techniques established in our laboratory. Twenty patients were treated with either a cellulose membrane (TFU) or a polycarbonate filter (Pro 500). Blood samples were taken from the output line of the dialyser 2, 15, 30 and 180 min after commencing dialysis and just before starting treatment. Compared with the pre-dialysis sample, there was a marked increase in platelet-PMNL conjugate formation at 2 min, followed by a decrease in conjugates at 15 and 30 min, and a slight increase at 180 min. During extracorporeal circulation PMNLs become activated as measured by a CD11b upregulation at 15, 30 and 180 min, but not at 2 min. Platelet binding to monocytes was increased above 15 min after starting dialysis, and monocyte activation was slightly increased above basal levels during the same period. The activation state of circulating free platelets, as measured by surface P-selectin exposition, initially decreased slightly, but then returned to basal levels over the 3-h period. Changes in cell counts were also detected: there was a massive decrease in circulating PMNLs and monocytes, and a small decrease in circulating platelets, at 15 and 30 min. These reverted to basal values by the end of the 3-h period. There was no change in the number of circulating lymphocytes or erythrocytes. These results show that flow cytometric studies on whole blood samples may provide important information on the behaviour of circulating blood cells, which could supplement conventional clinical measurements, to give a better insight into changes that occur in the circulation during haemodialysis.

Assessment of satisfaction with care after inpatient treatment for oesophageal and gastric cancer

BACKGROUND

Patients' views are becoming increasingly important in the current health system. They provide information on effectiveness of healthcare and how it may be improved. This study aimed to measure patients' satisfaction with care received for treatment of oesophageal and gastric cancer, and to identify areas that contribute most to overall satisfaction scores.

METHODS

Consecutive inpatients with oesophageal and gastric cancer treated in one surgical unit were recruited prospectively during a 2-year period. The European Organization for Research and Treatment of Cancer 'satisfaction with in-hospital care' questionnaire (QLQ-SAT32) was completed following discharge. Scores ranged from 0 to 100 for each satisfaction scale. Univariable and multivariable analysis was used to define the relationships between the different dimensions of satisfaction with care and the overall score.

RESULTS

Ninety-one patients (mean age 67 years, 60 men) completed the questionnaire a mean of 40 days after treatment. The highest scores were for doctors (mean 72), nurses (mean 67) and overall satisfaction (mean 68). Univariable analysis showed that all dimensions of satisfaction with care contributed significantly to overall satisfaction (P < 0.001). Multivariable analyses, however, showed that most of the variation in overall satisfaction could be attributed to levels of satisfaction with doctors, nurses, and hospital comfort and cleanliness.

CONCLUSION

Satisfaction with care in these surgical patients was high and could be measured using a multidimensional instrument. Overall satisfaction was not influenced equally by all aspects of care. The strongest contributors to overall satisfaction in this study were doctors, nurses and hospital cleanliness.

The role of preoperative TIPSS to facilitate curative gastric surgery

The use of TIPSS to facilitate radical curative upper gastrointestinal surgery has not been reported. We describe a case in which curative gastric resection was performed for carcinoma of the stomach after a preoperative TIPSS and embolization of a large gastric varix in a patient with portal hypertension.

Advances in functional and structural MR image analysis and implementation as FSL

The techniques available for the interrogation and analysis of neuroimaging data have a large influence in determining the flexibility, sensitivity, and scope of neuroimaging experiments. The development of such methodologies has allowed investigators to address scientific questions that could not previously be answered and, as such, has become an important research area in its own right. In this paper, we present a review of the research carried out by the Analysis Group at the Oxford Centre for Functional MRI of the Brain (FMRIB). This research has focussed on the development of new methodologies for the analysis of both structural and functional magnetic resonance imaging data. The majority of the research laid out in this paper has been implemented as freely available software tools within FMRIB's Software Library (FSL).

Properties of microtubules assembled from mammalian tubulin synthesized in Escherichia coli

When isolated from tissues, the alpha beta-dimeric protein tubulin consists of multiple isoforms which originate from the expression and subsequent posttranslational modification of multiple polypeptide sequences. Microtubules studied in vitro consist of mixtures of these isoforms. It is therefore not known whether dimers composed of single sequences of alpha- and beta-tubulin can polymerize to form microtubules, or whether posttranslational modifications may be necessary for microtubule assembly. To initiate investigation of these questions, rabbit reticulocyte lysate, which contains the cytoplasmic chaperonin CCT and its cofactors, was employed to prepare substantial quantities (tens of micrograms) of active tubulin by in vitro folding of mouse alpha- and beta-tubulins recombinantly synthesized in E. coli. This recombinant tubulin is composed of only a single alpha-chain and a single beta-chain. When analyzed after folding by isoelectric focusing, each chain yielded only one band, indicating that neither was detectably posttranslationally modified in the course of the folding reaction. When subjected to assembly-promoting conditions, this tubulin formed microtubules without the addition of any exogenous protein. Electron microscopy showed them to be of normal morphology. Analysis of their protein composition showed that they are composed nearly entirely of recombinant tubulin. These results demonstrate that the naturally occurring mixtures of isoforms are not strictly required for the formation of microtubules. They also open a route to other studies, both biomedical and structural, of fully defined tubulin in vitro.

Inhibition of leukocyte chemiluminescence by platelets: role of platelet-bound fibrinogen

Tethering of PMNL by platelets via CD62P has been shown to cause PMNL activation. Co-incubation of purified PMNL with platelets that were activated with thrombin and then fixed and washed, resulted in the formation of platelet-PMNL conjugates as well as in a generation of reactive oxygen species that were measured as luminol-enhanced chemiluminescence. When platelets were thrombin activated in the presence of RGDS to prevent binding of fibrinogen to membrane receptors, they had a reduced capacity to adhere to PMNL, but ROS generation was enhanced. In samples of citrated whole blood RGDS as well as the more specific platelet fibrinogen receptor antagonist GR144053F or a dissociation of the platelet glycoprotein IIb/IIIa complex markedly enhanced ROS generation that was induced by stirring the samples for 10 min at 1000 rpm, by 175%, 95% and 138%, respectively. Removal of platelets from the whole blood samples also resulted in an enhancement of stirring-induced ROS generation, which was inversely correlated to the platelet count. These data provide some evidence that platelets are capable of inhibiting ROS generation in PMNL by a mechanism that involves platelet-bound fibrinogen and probably depends on fibrinogen-mediated platelet-PMNL contact.

Tomographic extreme-ultraviolet spectrographs: TESS

We describe the system of Tomographic Extreme Ultraviolet (EUV) SpectrographS (TESS) that are the primary instruments for the Tomographic Experiment using Radiative Recombinative Ionospheric EUV and Radio Sources (TERRIERS) satellite. The spectrographs were designed to make high-sensitivity {80 counts/s)/Rayleigh [one Rayleigh is equivalent to 10(6) photons/(4pi str cm(2)s)}, line-of-sight measurements of the oi 135.6- and 91.1-nm emissions suitable for tomographic inversion. The system consists of five spectrographs, four identical nightglow instruments (for redundancy and added sensitivity), and one instrument with a smaller aperture to reduce sensitivity and increase spectral resolution for daytime operation. Each instrument has a bandpass of 80-140 nm with approximately 2- and 1-nm resolution for the night and day instruments, respectively. They utilize microchannel-plate-based two-dimensional imaging detectors with wedge-and-strip anode readouts. The instruments were designed, fabricated, and calibrated at Boston University, and the TERRIERS satellite was launched on 18 May 1999 from Vandenberg Air Force Base, California.

Dietary intake at child-care centers and away: are parents and care providers working as partners or at cross-purposes?

OBJECTIVE

To examine how meals and snacks children consume before and after their time at a child-care facility complement the menu at the facility.

DESIGN

Dietary intake of children at and away from the child-care center was compared with recommended standards for child nutrition. Registered dietitians observed foods consumed at the center during 3 consecutive days. Parents reported foods consumed away from the center during the same 3 days.

SUBJECTS/SETTING

Six nonprofit child-care centers with strong menus (i.e., menus that come close to meeting dietary recommendations) and 6 with menus supplying less than 50% of the Recommended Dietary Allowance were selected for study. Five families at each center were invited to participate. Complete data sets were obtained for 51 children aged 3 to 6 years.

STATISTICAL ANALYSES PERFORMED

Descriptive and inferential statistics were calculated to compare the children's dietary intake during center time and family time and over a full day with recommended standards. Energy and nutrient profiles and food frequencies were included in the analysis.

RESULTS

Children consumed plenty of foods at the center and away from the following groups: meat, poultry, fish, dry beans, eggs, nuts; milk, yogurt, cheese; and fruit, fruit juice. Most children failed to consume enough vegetables. Nearly all the children failed to consume enough bread, cereal, pasta, and rice, especially while at the center. The majority ate more than sparing amounts of fats, oils, and sweets, especially during family time. Average percentage of energy from fat was 33 +/- 4. Intakes of concern for the full day were energy, iron, sodium, and zinc.

APPLICATIONS

Child-care menus are an appropriate target for increasing iron and zinc by serving more cereal and whole grains. Families are an appropriate target for reducing young children's consumption of fats, oils, and sweets. Nutrition education and advocacy are needed to strengthen the partnership between parents and caregivers.

Role of endoscopic ultrasound in the preoperative assessment of patients with oesophageal cancer

Despite encouraging results from Europe and America, endoscopic ultrasound (EUS) has yet to become established in the United Kingdom. The aims of this prospective study were to investigate its value in the assessment of patients with benign and malignant oesophageal conditions, and in particular to assess its reliability for local tumour (T) and lymph node (N) staging in patients with oesophageal cancer. EUS was performed in 90 patients: 23 were normal controls, 17 had benign oesophageal diseases and 50 had operable oesophageal cancer. Detailed measurements of the oesophageal wall and regional nodes were made and the accuracy of EUS for locoregional tumour staging was compared with final histology. EUS visualised the normal oesophageal wall as a multilayered structure, thicker distally than proximally. Distal stenotic conditions caused thickening of the proximal wall and loss of this gradient. EUS was highly accurate for both local tumour (92% correct) and lymph node staging (86% correct) and was better than computed tomography, magnetic resonance imaging and open staging performed by the surgeon. Fine needle aspiration biopsy using radial scanning EUS guidance was shown to be feasible. EUS is a valuable technique for investigation of both benign and malignant oesophageal conditions. It provides highly accurate local tumour and regional lymph node staging data in patients with oesophageal cancer.

Oesophageal cancer staging using endoscopic ultrasonography

BACKGROUND

Despite encouraging results from Europe and the USA, endoscopic ultrasonography has yet to become established in the UK for imaging gastrointestinal lesions. The aim of this prospective study was to investigate the accuracy of endoscopic ultrasonography for local tumour (T) and lymph node (N) staging of oesophageal cancer.

METHODS

Endoscopic ultrasonography was performed in 50 consecutive patients with operable oesophageal cancer. Its accuracy for locoregional tumour staging was assessed and a detailed analysis of the distribution of ultrasonographically detected lymph nodes performed.

RESULTS

Endoscopic ultrasonography was highly accurate for both local tumour (92 per cent correct T stage prediction) and lymph node (86 per cent correct N stage prediction) staging compared with final histology. The procedure was also superior to open surgical staging performed by the surgeon; it had a tendency to overestimate malignant involvement of individual lymph nodes and had only limited ability to identify small benign lymph nodes, particularly in the abdomen.

CONCLUSION

Endoscopic ultrasonography was reliable for both local tumour and lymph node staging of oesophageal cancer.

Influence of luminal obstruction on oesophageal cancer staging using endoscopic ultrasonography

BACKGROUND

Endoscopic ultrasonography is technically limited in patients with obstructing oesophageal cancers if the endoscope cannot pass beyond the lesion. This problem may be overcome by preliminary endoscopic tumour dilatation, or by the use of narrower calibre 'blind' endoscopic ultrasonographic telescopes or fine-bore endoscopic ultrasonographic miniprobes. These alternatives are either potentially hazardous or time consuming and expensive. The aim of this prospective study was to determine the effect of oesophageal obstruction on the locoregional staging accuracy of endoscopic ultrasonography for oesophageal cancer.

METHODS

Some 50 patients with oesophageal cancer underwent staging with endoscopic ultrasonography before oesophagectomy and the T and N stage determined by endoscopic ultrasonography was compared with final histology. In 11 cases of luminal obstruction no attempt was made to overcome the blockage and a limited mediastinal scan alone was performed.

RESULTS

Malignant obstruction of the oesophagus did not greatly reduce the staging accuracy of endoscopic ultrasonography. It correctly assessed local infiltration in all patients with obstruction, and correctly predicted nodal stage in nine of 11 patients.

CONCLUSION

Tumours large enough to cause luminal obstruction are nearly all full thickness (T3), and frequently have mediastinal lymph node metastases (N1) at the time of examination. This can usually be detected from limited endoscopic ultrasonography within the mediastinum.

Strategies for diagnosing and managing medication-induced headache

PROBLEM ADDRESSED

Headache is a common clinical disorder. Nearly 50% of patients with headaches use prescription medications, and 90% regularly use nonprescription drugs. Medication-induced headaches (MIH) are chronic daily headaches caused by overuse of medicine.

OBJECTIVES

To summarize the diagnostic criteria for MIH, to determine the investigations necessary to confirm the diagnosis and exclude other possible diagnoses, and to establish recommendations for managing MIH.

MAIN FINDINGS

Diagnosis of MIH is based on patient's history and the clinical characteristics of the headache. Treatment includes patient education and support, withdrawal of offending medications, relief of withdrawal symptoms, and specific treatment of residual headache. When migraine and other causes of headache are adequately addressed, patients will not seek additional pain relief.

CONCLUSION

Medication-induced headache is preventable. The key to prevention is appropriate drug therapy to relieve the primary headache. All patients with MIH can be treated and most cured.

CSF testosterone and 5-HIAA correlate with different types of aggressive behaviors

We studied the potential roles of testosterone and serotonin in various forms of aggressive and violent behaviors by measuring each biochemical and behaviour in free-ranging adolescent male nonhuman primates. Our results showed that (1) CSF free testosterone concentrations were positively correlated with overall aggressiveness, but not with measures of impulsivity. (2) CSF 5-HIAA concentrations were negatively correlated with impulsive behavior, and severe, unrestrained aggression, but not with overall rates of aggression. High rates of impulsive behavior were positively correlated with severe, unrestrained aggression, but not overall rates of aggression. (3) Dimensional analyses showed that while subjects with low CSF 5-HIAA exhibited high rates of aggression, high CSF testosterone further augmented rates and intensity of aggression in subjects with low CSF 5-HIAA. We conclude that high CSF free testosterone concentrations are associated with competitive aggression, while low CSF 5-HIAA concentrations are associated with severe aggression which results from impaired impulse control, and perseverance.

Excessive mortality in young free-ranging male nonhuman primates with low cerebrospinal fluid 5-hydroxyindoleacetic acid concentrations

BACKGROUND

The purpose of this study was to assess the impact of central serotonin turnover rate on survival to adulthood among nonhuman primates living in a large, free-ranging colony.

METHODS

The rate of mortality was ascertained over a 4-year period after obtaining blood and cisternal cerebrospinal fluid (CSF) samples from 49 free-ranging, 2-year-old prepubertal male rhesus monkeys. Cerebrospinal fluid was assayed for 5-hydroxyindoleacetic acid (5-HIAA), norepinephrine, 3-methoxy-4-hydroxyphenylgycol, and homovanillic acid. Blood plasma was assayed for adrenocorticotropic hormone, cortisol, and testosterone. Following the sampling of body fluids, records of scars and wounds and aggressive encounters were used to rank the subjects from low to high in aggressiveness. Direct observations of aggressive behavior were collected from 27 of the subjects over a 3-month period.

RESULTS

Four years later, 6 of the 49 subjects were known to be dead and an additional 5 had been missing for more than 2 years and were presumed dead. The CSF 5-HIAA concentrations were predictive of which subjects died, with 46% of the subjects with low CSF 5-HIAA concentrations dead or presumed dead. None of the subjects from the highest CSF 5-HIAA concentration quartile were dead or missing. Indeed, 91% of the dead subjects came from the 2 lowest quartiles of CSF 5-HIAA concentrations. Direct observations of aggressive behavior showed that dead or missing subjects had initiated escalated aggression, a measure of unrestrained aggression that has a high probability of trauma or injury, at a higher rate than subjects that were known to be alive. The cause of death could be ascertained for 6 of the 11 missing subjects. The 4 subjects that were known to die as a consequence of aggressive encounters came from the lowest quartile of CSF 5-HIAA concentrations and had been rated as more aggressive during their initial capture. Subjects captured more than once possessed lower CSF 5-HIAA concentrations, were rated as more aggressive, and were more likely to suffer early death than those captured only once.

CONCLUSION

These findings suggest that low CSF 5-HIAA concentrations quantified early in life is a powerful biological predictor of future excessive aggression, risk taking, and premature death among nonhuman primate males.