Health Care Proxies, Powers of Attorney, and Living Wills: Making Health Care Decisions: A Satellite Program

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Successful Desensitization to Docetaxel after Severe Hypersensitivity Reactions in Two Patients

Purpose Two cases of successful desensitization to docetaxel after severe hypersensitivity reactions are reported. Summary Two patients with gynecological malignancies (uterine leiomyosarcoma and ovarian adenocarcinoma) experienced severe hypersensitivity reactions with docetaxel, including flushing, numbness, sharp radiating pain, severe nausea and vomiting, apnea, and unresponsiveness. Both patients received ondansetron before docetaxel. One patient received dexamethasone, diphenhydramine, and famotidine premedication before docetaxel, as she had previously reacted to paclitaxel. Docetaxel infusions were stopped, and the reactions were treated with diphenhydramine and dexamethasone (one patient also received famotidine). After resolution of symptoms, the docetaxel was not reinitiated due to the nature of the reactions. For the next cycle, both patients received a graded drug challenge or desensitization. Both were pre-medicated with dexamethasone, diphenhydramine, and famotidine. The docetaxel was given as infusions of 0.1%, 1%, and 10% of the dose, with each infusion given over one hour. After this, the remainder of the dose was infused over one hour. Both patients tolerated this desensitization well and completed a total of three and four cycles each. The first patient to receive the desensitization did complain of chest pain during the first desensitization, and the infusion rate was decreased to administer the drug over two hours. After she tolerated two cycles of two-hour infusions, the infusion rate was increased to administer each docetaxel infusion over one hour. Conclusion Two patients who had severe hypersensitivity reactions to docetaxel successfully received further docetaxel doses via a desensitization procedure that involved the sequential administration of solutions containing increasing concentrations of the drug

Aspect Differences in Vegetation Type Drive Higher Evapotranspiration on a Pole‐Facing Slope in a California Oak Savanna

Abstract: Quantifying evapotranspiration (ET) is critical to accurately predict vegetation health, groundwater recharge, and streamflow generation. Hillslope aspect, the direction a hillslope faces, results in variable incoming solar radiation and subsequent vegetation water use that drive ET. Previous work in watersheds with a single dominant vegetation type (e.g., trees) have shown that equator‐facing slopes (EFS) have higher ET compared to pole‐facing slopes (PFS) due to higher evaporative demand. However, it remains unclear how differences in vegetation type (i.e., grasses and trees) influence ET and water partitioning between hillslopes with opposing aspects. Here, we quantified ET and root‐zone water storage deficits between a PFS and EFS with contrasting vegetation types within central coastal California. Our results suggest that the cooler PFS with oak trees has higher ET than the warmer EFS with grasses, which is counter to previous work in landscapes with a singule dominant vegetation type. Our root‐zone water storage deficit calculations indicate that the PFS has a higher subsurface storage deficit and a larger seasonal dry down than the EFS. This aspect difference in subsurface water storage deficits may influence the subsequent replenishment of dynamic water storage, groundwater recharge and streamflow generation. In addition, larger subsurface water deficits on PFS may reduce their ability to serve as hydrologic refugia for oaks during multi‐year droughts. This research provides a novel integration of field‐based and remotely‐sensed estimates of ET required to properly quantify hillslope‐scale water balances. These findings emphasize the importance of resolving hillslope‐scale vegetation structure within Earth system models, especially in landscapes with diverse vegetation types

Ultrathin Stable Ohmic Contacts for High-Temperature Operation of β\beta-Ga2_2O3_3 Devices

Beta gallium oxide ($\beta$-Ga$_2$O$_3$) shows significant promise in the high-temperature, high-power, and sensing electronics applications. However, long-term stable metallization layers for Ohmic contacts at high temperature present unique thermodynamic challenges. The current most common Ohmic contact design based on 20 nm of Ti has been repeatedly demonstrated to fail at even moderately elevated temperatures (300-400$^{\circ}$C) due to a combination of non-stoichiometric Ti/Ga$_2$O$_3$ interfacial reactions and kinetically favored Ti diffusion processes. Here we demonstrate stable Ohmic contacts for Ga$_2$O$_3$ devices operating up to 500-600$^{\circ}$C using ultrathin Ti layers with a self-limiting interfacial reaction. The ultrathin Ti layer in the 5nm Ti / 100nm Au contact stack is designed to fully oxidize while forming an Ohmic contact, thereby limiting both thermodynamic and kinetic instability. This novel contact design strategy results in an epitaxial conductive anatase titanium oxide interface layer that enables low-resistance Ohmic contacts that are stable both under long-term continuous operation (>500 hours) at 600$^{\circ}$C in vacuum ($\leq$ 10$^{-4}$ Torr), as well as after repeated thermal cycling (15 times) between room temperature and 550$^{\circ}$C in flowing N$_2$. This stable Ohmic contact design will accelerate the development of high-temperature devices by enabling research focus to shift towards rectifying contacts and other interfacial layers.Comment: 25 Pages, 7 Figure

Explaining Myanmar's Regime Transition: The Periphery is Central

In 2010, Myanmar (Burma) held its first elections after 22 years of direct military rule. Few compelling explanations for this regime transition have emerged. This article critiques popular accounts and potential explanations generated by theories of authoritarian ‘regime breakdown’ and ‘regime maintenance’. It returns instead to the classical literature on military intervention and withdrawal. Military regimes, when not terminated by internal factionalism or external unrest, typically liberalise once they feel they have sufficiently addressed the crises that prompted their seizure of power. This was the case in Myanmar. The military intervened for fear that political unrest and ethnic-minority separatist insurgencies would destroy Myanmar’s always-fragile territorial integrity and sovereignty. Far from suddenly liberalising in 2010, the regime sought to create a ‘disciplined democracy’ to safeguard its preferred social and political order twice before, but was thwarted by societal opposition. Its success in 2010 stemmed from a strategy of coercive state-building and economic incorporation via ‘ceasefire capitalism’, which weakened and co-opted much of the opposition. Having altered the balance of forces in its favour, the regime felt sufficiently confident to impose its preferred settlement. However, the transition neither reflected total ‘victory’ for the military nor secured a genuine or lasting peace

Modification and pathways of Southern Ocean Deep Waters in the Scotia Sea

An unprecedented high-quality, quasi-synoptic hydrographic data set collected during the ALBATROSS cruise along the rim of the Scotia Sea is examined to describe the pathways of the deep water masses flowing through the region, and to quantify changes in their properties as they cross the sea. Owing to sparse sampling of the northern and southern boundaries of the basin, the modification and pathways of deep water masses in the Scotia Sea had remained poorly documented despite their global significance. Weddell Sea Deep Water (WSDW) of two distinct types is observed spilling over the South Scotia Ridge to the west and east of the western edge of the Orkney Passage. The colder and fresher type in the west, recently ventilated in the northern Antarctic Peninsula, flows westward to Drake Passage along the southern margin of the Scotia Sea while mixing intensely with eastward-flowing Circumpolar Deep Water (CDW) of the antarctic circumpolar current (ACC). Although a small fraction of the other WSDW type also spreads westward to Drake Passage, the greater part escapes the Scotia Sea eastward through the Georgia Passage and flows into the Malvinas Chasm via a deep gap northeast of South Georgia. A more saline WSDW variety from the South Sandwich Trench may leak into the eastern Scotia Sea through Georgia Passage, but mainly flows around the Northeast Georgia Rise to the northern Georgia Basin. In Drake Passage, the inflowing CDW displays a previously unreported bimodal property distribution, with CDW at the Subantarctic Front receiving a contribution of deep water from the subtropical Pacific. This bimodality is eroded away in the Scotia Sea by vigorous mixing with WSDW and CDW from the Weddell Gyre. The extent of ventilation follows a zonation that can be related to the CDW pathways and the frontal anatomy of the ACC. Between the Southern Boundary of the ACC and the Southern ACC Front, CDW cools by 0.15°C and freshens by 0.015 along isopycnals. The body of CDW in the region of the Polar Front splits after overflowing the North Scotia Ridge, with a fraction following the front south of the Falkland Plateau and another spilling over the plateau near 49.5°W. Its cooling (by 0.07°C) and freshening (by 0.008) in crossing the Scotia Sea is counteracted locally by NADW entraining southward near the Maurice Ewing Bank. CDW also overflows the North Scotia Ridge by following the Subantarctic Front through a passage just east of Burdwood Bank, and spills over the Falkland Plateau near 53°W with decreased potential temperature (by 0.03°C) and salinity (by 0.004). As a result of ventilation by Weddell Sea waters, the signature of the Southeast Pacific Deep Water (SPDW) fraction of CDW is largely erased in the Scotia Sea. A modified form of SPDW is detected escaping the sea via two distinct routes only: following the Southern ACC Front through Georgia Passage; and skirting the eastern end of the Falkland Plateau after flowing through Shag Rocks Passage

Dosimetric Consequences of 3D Versus 4D PET/CT for Target Delineation of Lung Stereotactic Radiotherapy

Introduction:Lung tumor delineation is frequently performed using 3D positron emission tomography (PET)/computed tomography (CT), particularly in the radiotherapy treatment planning position, by generating an internal target volume (ITV) from the slow acquisition PET. We investigate the dosimetric consequences of stereotactic ablative body radiotherapy (SABR) planning on 3D PET/CT in comparison with gated (4D) PET/CT.Methods:In a prospective clinical trial, patients with lung metastases were prescribed 26 Gy single-fraction SABR to the covering isodose. Contemporaneous 3D PET/CT and 4D PET/CT was performed in the same patient position. An ITV was generated from each data set, with the planning target volume (PTV) being a 5-mm isotropic expansion. Dosimetric parameters from the SABR plan derived using the 3D volumes were evaluated against the same plan applied to 4D volumes.Results:Ten lung targets were evaluated. All 3D plans were successfully optimized to cover 99% of the PTV by the 26 Gy prescription. In all cases, the calculated dose delivered to the 4D target was less than the expected dose to the PTV based on 3D planning. Coverage of the 4D-PTV by the prescription isodose ranged from 74.48% to 98.58% (mean of 90.05%). The minimum dose to the 4D-ITV derived by the 3D treatment plan (mean = 93.11%) was significantly lower than the expected dose to ITV based on 3D PET/CT calculation (mean = 111.28%), p < 0.01. In all but one case, the planned prescription dose did not cover the 4D-PET/CT derived ITV.Conclusions:Target delineation using 3D PET/CT without additional respiratory compensation techniques results in significant target underdosing in the context of SABR