Advanced Solid-State Lasers: feature issue introduction.

This joint issue of Optics Express and Optical Materials Express features 23 peer-reviewed articles primarily by authors who participated in the Advanced Solid State Lasers conference, which was part of the Optica Laser Congress held in Tacoma, Washington, USA on October 8-12, 2023. This review provides a brief summary of these articles covering the latest developments in laser gain materials and nonlinear crystals, mode-locked lasers, fiber lasers and amplifiers, nonlinear optical sources, and novel concepts in laser design.

Advanced Solid-State Lasers: feature issue introduction.

This Joint Issue of Optics Express and Optical Materials Express features 40 peer-reviewed articles written by authors who participated in the Advanced Solid State Lasers Conference, part of the Optica Laser Congress and Exhibition held in Barcelona, Spain from December 11-15, 2022. This review provides a brief summary of these articles covering the latest developments in laser host and nonlinear crystals, structured materials, fiber lasers and amplifiers, ultrafast mode-locked lasers and optical parametric amplifiers, frequency-doubled Raman lasers, vortex beams, and novel concepts in laser design.

Outcomes of adjunct posterior wall isolation in atrial fibrillation patients with cardiac implantable electronic devices.

BACKGROUND: Although pulmonary vein isolation (PVI) remains the cornerstone of catheter ablation of atrial fibrillation (AF), several studies have illustrated clinical benefits associated with PVI with posterior wall isolation (PWI). METHODS: This retrospective study investigated the outcomes of PVI alone versus PVI+PWI performed using the cryoballoon in patients with cardiac implantable electronic devices (CIEDs) and paroxysmal AF (PAF) or persistent AF (PersAF). RESULTS: Acute PVI was achieved in all patients using cryoballoon ablation. Compared to PVI alone, PVI+PWI was associated with longer cryoablation, fluoroscopy, and total procedure times. Adjunct radiofrequency was required to complete PWI in 29/77 patients (37.7%). Adverse events were similar with PVI alone versus PVI+PWI. But at 24 ± 7 months of follow-up, not only cryoballoon PVI+PWI was associated with improved freedom from recurrent AF (74.3% vs. 46.0%, P = .007) and all atrial tachyarrhythmias (71.4% vs. 38.1%, P = .001) in patients with PersAF, cryoballoon PVI+PWI also yielded greater freedom from AF (88.1% vs. 63.7%, P = .003) and all atrial tachyarrhythmias (83.3% vs. 60.8%, P = .008) in those with PAF. Additionally, PVI+PWI was associated with higher reductions in atrial tachyarrhythmia burden (97.9% vs. 91.6%, P < .001), need for cardioversion (5.2% vs. 23.6%, P < .001) and repeat catheter ablation (10.4% vs. 26.1%, P = .005), and a longer time-to-arrhythmia recurrence (16 ± 6 months vs. 8 ± 5 months, P < .001) in both PersAF and PAF patients. CONCLUSION: In CIED patients with PersAF or PAF, cryoballoon PVI+PWI is associated with a greater freedom from recurrent AF and atrial tachyarrhythmias, as compared to PVI alone during long-term follow-up.

A head and neck treatment planning strategy for a CBCT-guided ring-gantry online adaptive radiotherapy system.

PURPOSE: A planning strategy was developed and the utility of online-adaptation with the Ethos CBCT-guided ring-gantry adaptive radiotherapy (ART) system was evaluated using retrospective data from Head-and-neck (H&N) patients that required clinical offline adaptation during treatment. METHODS: Clinical data were used to re-plan 20 H&N patients (10 sequential boost (SEQ) with separate base and boost plans plus 10 simultaneous integrated boost (SIB)). An optimal approach, robust to online adaptation, for Ethos-initial plans using clinical goal prioritization was developed. Anatomically-derived isodose-shaping helper structures, air-density override, goals for controlling hotspot location(s), and plan normalization were investigated. Online adaptation was simulated using clinical offline adaptive simulation-CTs to represent an on-treatment CBCT. Dosimetric comparisons were based on institutional guidelines for Clinical-initial versus Ethos-initial plans and Ethos-scheduled versus Ethos-adapted plans. Timing for five components of the online adaptive workflow was analyzed. RESULTS: The Ethos H&N planning approach generated Ethos-initial SEQ plans with clinically comparable PTV coverage (average PTVHigh V100%  = 98.3%, Dmin,0.03cc  = 97.9% and D0.03cc  = 105.5%) and OAR sparing. However, Ethos-initial SIB plans were clinically inferior (average PTVHigh V100%  = 96.4%, Dmin,0.03cc  = 93.7%, D0.03cc  = 110.6%). Fixed-field IMRT was superior to VMAT for 93.3% of plans. Online adaptation succeeded in achieving conformal coverage to the new anatomy in both SEQ and SIB plans that was even superior to that achieved in the initial plans (which was due to the changes in anatomy that simplified the optimization). The average adaptive workflow duration for SIB, SEQ base and SEQ boost was 30:14, 22.56, and 14:03 (min: sec), respectively. CONCLUSIONS: With an optimal planning approach, Ethos efficiently auto-generated dosimetrically comparable and clinically acceptable initial SEQ plans for H&N patients. Initial SIB plans were inferior and clinically unacceptable, but adapted SIB plans became clinically acceptable. Online adapted plans optimized dose to new anatomy and maintained target coverage/homogeneity with improved OAR sparing in a time-efficient manner.

Feature issue introduction: advanced solid-state lasers.

This joint issue of Optics Express and Optical Materials Express features 36 state-of-the art articles written by authors who participated in the international conference advanced solid state lasers held online from October 3-7, 2021. This review provides a summary of these articles covering a wide spectrum of topics around solid-state lasers from materials research to sources and from design innovation to applications.

Maintaining dosimetric quality when switching to a Monte Carlo dose engine for head and neck volumetric-modulated arc therapy planning.

Head and neck cancers present challenges in radiation treatment planning due to the large number of critical structures near the target(s) and highly heterogeneous tissue composition. While Monte Carlo (MC) dose calculations currently offer the most accurate approximation of dose deposition in tissue, the switch to MC presents challenges in preserving the parameters of care. The differences in dose-to-tissue were widely discussed in the literature, but mostly in the context of recalculating the existing plans rather than reoptimizing with the MC dose engine. Also, the target dose homogeneity received less attention. We adhere to strict dose homogeneity objectives in clinical practice. In this study, we started with 21 clinical volumetric-modulated arc therapy (VMAT) plans previously developed in Pinnacle treatment planning system. Those plans were recalculated "as is" with RayStation (RS) MC algorithm and then reoptimized in RS with both collapsed cone (CC) and MC algorithms. MC statistical uncertainty (0.3%) was selected carefully to balance the dose computation time (1-2 min) with the planning target volume (PTV) dose-volume histogram (DVH) shape approaching that of a "noise-free" calculation. When the hot spot in head and neck MC-based treatment planning is defined as dose to 0.03 cc, it is exceedingly difficult to limit it to 105% of the prescription dose, as we were used to with the CC algorithm. The average hot spot after optimization and calculation with RS MC was statistically significantly higher compared to Pinnacle and RS CC algorithms by 1.2 and 1.0 %, respectively. The 95% confidence interval (CI) observed in this study suggests that in most cases a hot spot of ≤107% is achievable. Compared to the 95% CI for the previous clinical plans recalculated with RS MC "as is" (upper limit 108%), in real terms this result is at least as good or better than the historic plans.

Same-day discharge after cryoballoon ablation of atrial fibrillation: A multicenter experience.

BACKGROUND: It is common practice to observe patients during an overnight stay (ONS) following a catheter ablation procedure for the treatment of atrial fibrillation (AF). OBJECTIVES: To investigate the safety and economic impact of a same-day discharge (SDD) protocol after cryoballoon ablation for treatment of AF in high-volume, geographically diverse US hospitals. METHODS: We retrospectively reviewed 2374 consecutive patients (1119 SDD and 1180 ONS) who underwent cryoballoon ablation for AF at three US centers. Baseline characteristics, acute procedure-related complications, and longer-term evaluations of safety were recorded during routine clinical follow-up. The mean cost of an ONS was used in a one-way sensitivity analysis to evaluate yearly cost savings as a function of the percentage of SDD cases per year. RESULTS: The SDD and ONS cohorts were predominately male (69% vs. 67%; p = .3), but SDD patients were younger (64 ± 11 vs. 66 ± 10; p < .0001) with lower body mass index (30 ± 6 vs. 31 ± 61; p < .0001) and CHA2 DS2 -VASc scores (1.4 ± 1.0 vs. 2.2 ± 1.4; p < .0002). There was no difference between SDD and ONS in the 30-day total complication rate (n = 15 [1.26%] versus n = 24 [2.03%]; p = .136, respectively). The most common complication was hematoma in both the SDD (n = 8; 0.67%) and ONS (n = 11; 0.93%) cohorts. Sensitivity analysis demonstrated that when 50% of every 100 patients treated were discharged the same day, hospital cost savings ranged from $45 825 to $83 813 per year across US hospitals. CONCLUSIONS: SDD following cryoballoon ablation for AF appears to be safe and is associated with cost savings across different US hospitals.

Spatio-temporal focal spot characterization and modeling of the NIF ARC kilojoule picosecond laser.

The advanced radiographic capability (ARC) laser system, part of the National Ignition Facility (NIF) at Lawrence Livermore National Laboratory, is a short-pulse laser capability integrated into the NIF. The ARC is designed to provide adjustable pulse lengths of ∼1-38ps in four independent beamlets, each with energies up to 1 kJ (depending on pulse duration). A detailed model of the ARC lasers has been developed that predicts the time- and space-resolved focal spots on target for each shot. Measurements made to characterize static and dynamic wavefront characteristics of the ARC are important inputs to the code. Modeling has been validated with measurements of the time-integrated focal spot at the target chamber center (TCC) at low power, and the space-integrated pulse duration at high power, using currently available diagnostics. These simulations indicate that each of the four ARC beamlets achieves a peak intensity on target of up to a few 1018W/cm2.

Injection laser system for Advanced Radiographic Capability using chirped pulse amplification on the National Ignition Facility.

We report on the design, performance, and qualification of the injection laser system designed to deliver joule-level chirped pulse beamlets arranged in dual rectangular beam formats into two main laser amplifier beamlines of the National Ignition Facility. The system is designed to meet the requirements of the Advanced Radiographic Capability upgrade with features that deliver performance, adjustability, and long-term reliability.

Outcomes of catheter ablation of ventricular tachycardia with mechanical hemodynamic support: An analysis of the Medicare database.

INTRODUCTION: There is a paucity of data in favor of mechanical support during catheter ablation of ventricular tachycardia (VT). This study investigated the outcomes of VT ablation associated with mechanical support using percutaneous ventricular assist device (PVAD) versus intra-aortic balloon pump (IABP). METHODS AND RESULTS: We retrospectively examined the outcomes of patients who underwent VT ablation associated with PVAD versus IABP from 2010 to 2013, captured by the Medicare Inpatient Standard Analytic File database. Data from 345 patients (PVAD = 230, IABP = 115) were examined. On admission, the incidence of heart failure was higher in PVAD (84.3% vs. 73.0%; P = 0.01) with similar rates of renal failure in PVAD versus IABP (33.0% vs. 37.4%; P = 0.42). However, PVAD was associated with reduced in-hospital cardiogenic shock (9.1% vs. 23.5%; P  <  0.001), renal failure (11.7% vs. 21.7%; P = 0.01), and length of stay (8.4 ± 7.9 vs. 10.6 ± 7.5; P < 0.001), but with greater hospital discharges to home/self-care (66.0% vs. 51.6%; P = 0.02). Index mortality (6.5% vs. 19.1%; P = 0.001) and mortality in patients with cardiogenic shock (18.2% vs. 41.2%; P = 0.03) were significantly lower with PVAD versus IABP. Furthermore, PVAD was associated with lower all-cause (27.0% vs. 38.7%; P = 0.04) and heart failure-related (21.4% vs. 33.3%; P = 0.03) 30-day hospital readmissions, but with similar redo-VT ablation rates at 1 year (10.2% vs. 14.0%; P = 0.34). CONCLUSION: Among the cases captured by the Medicare database, catheter ablation of VT associated with mechanical support using PVAD was associated with reduced in-hospital cardiogenic shock, renal failure, length of stay, hospital readmissions and mortality, but no difference in redo-VT ablation at 1 year.

Impact of Pulmonary Vein Cryoballoon Ablation on Bronchial Injury.

INTRODUCTION: There is a paucity of data on the mechanisms of cough and hemoptysis that sometimes ensue from cryoballoon ablation of pulmonary veins (Cryo-PV). This study specifically examined the impact of ultra-cold (≤-60 °C, 3 minutes), prolonged (>-55 °C, 6 minutes), and conventional (>-55 °C, 3 minutes) Cryo-PV on lung/bronchial injury. METHODS AND RESULTS: Four healthy adult swine underwent Cryo-PV. Each animal received Cryo-PV to the inferior common trunk and the right superior PV. In 2 animals, 1 PV was treated with 2 ultra-cold (Cryo-AUltra-cold ) and the other with 2 conventional (Cryo-AConventional ) cryoapplications. In the other 2 animals, 1 PV was ablated using 2 prolonged (Cryo-BProlonged ) and the other with 2 conventional (Cryo-BConventional ) applications. The nadir cryoballoon temperatures were lower in Cryo-AUltra-cold versus Cryo-AConventional (-66 ± 6 °C vs. -45 ± 5 °C; P = 0.001), but did not differ between Cryo-BProlonged and Cryo-BConventional (-46 ± 3 °C vs. -49 ± 3 °C; P = 0.123). Post-ablation bronchoscopy revealed immediate mucosal edema and erythema with/without bleeding in the adjacent bronchi in 100% of Cryo-AUltra-cold and 50% of Cryo-AConventional /Cryo-BConventional and Cryo-BProlonged . At 4 hours post-ablation, there were marked increases in bronchoalveolar macrophages (P <0.001), lymphocytes (P = 0.035) and neutrophils (P = 0.001). Furthermore, Cryo-AUltra-cold yielded the largest increase in the macrophage (P = 0.005) and neutrophil (P = 0.034) cell counts. While similar trends were seen in Cryo-BProlonged , these did not reach statistical significance. CONCLUSION: Cryo-PV can elicit acute bronchial inflammation, bleeding, and mucosal injury. While this was further augmented by ultra-cold cryoapplications, it was also evident to a lesser degree with prolonged and even conventional cryoapplications. The mechanism for this appears to be direct collateral injury.

Acute and Long-Term Outcomes of Catheter Ablation of Atrial Fibrillation Using the Second-Generation Cryoballoon versus Open-Irrigated Radiofrequency: A Multicenter Experience.

INTRODUCTION: There are limited comparative data on catheter ablation of atrial fibrillation (CAAF) using the second-generation cryoballoon (CB-2) versus point-by-point radiofrequency (RF). This study examines the acute/long-term CAAF outcomes using these 2 strategies. METHODS AND RESULTS: In this multicenter, retrospective, nonrandomized analysis, procedural and clinical outcomes of 1,196 patients (76% with paroxysmal AF) undergoing CAAF using CB-2 (n = 773) and open-irrigated, non-force sensing RF (n = 423) were evaluated. Pulmonary vein isolation was achieved in 98% with CB-2 and 99% with RF (P = 0.168). CB-2 was associated with shorter ablation time (40 ± 14 min vs. 66 ± 26 min; P < 0.001) and procedure time (145 ± 49 minutes vs. 188 ± 42 minutes; P < 0.001), but greater fluoroscopic utilization (29 ± 13 minutes vs. 23 ± 14 minutes; P < 0.001). While transient (7.6% vs. 0%; P < 0.001) and persistent (1.2% vs. 0%; P = 0.026) phrenic nerve palsy occurred exclusively with CB-2, other adverse event rates were similar between CB-2 (1.6%) and RF (2.6%); P = 0.207. However, freedom from AF/atrial flutter/tachycardia at 12 months following a single procedure without antiarrhythmic therapy was greater with CB-2 (76.6%) versus RF (60.4%); P < 0.001. While this difference was evident in patients with paroxysmal AF (P < 0.001), it did not reach significance in those with persistent AF (P = 0.089). Additionally, CB-2 was associated with reduced long-term need for antiarrhythmic therapy (16.7% vs. 22.0%; P = 0.024) and repeat ablations (14.6% vs. 24.1%; P < 0.001). CONCLUSION: In this multicenter, retrospective, nonrandomized study, CAAF using CB-2 coupled with RF as occasionally required was associated with greater freedom from atrial arrhythmias at 12 months following a single procedure without antiarrhythmic therapy when compared to open-irrigated, non-force sensing RF, alone.

Direct recording of concealed ventricular extrasystoles producing pacer inhibition.

We report a case of concealed extrasystoles recorded from a pacing lead. The concealed extrasystoles were observed with right ventricular pacing, biventricular unipolar, and biventricular bipolar pacing. The simultaneous surface EKG did not show manifest ventricular extrasystoles with the concealed intracardiac potentials. This case highlights a cause of oversensing that has been theoretically reported in the literature but never directly observed.

Three-dimensional mapping, recording and ablation in simulated and induced ventricular tachyarrhythmias during mechanical circulatory support using the percutaneous heart pump.

PURPOSE: Due to their internal rotating magnets, conventional impeller-driven percutaneous ventricular assist devices (PVADs) yield high-frequency electrogram artifact and electromagnetic interference (EMI) when used with magnetic-based 3D electroanatomic mapping systems. The new percutaneous heart pump (PHP; Abbott, Chicago, IL) is a 14-French, 5-L/min, impeller axial-flow PVAD with a novel design that utilizes an external motor. METHODS: We evaluated the feasibility of 3D mapping and radiofrequency ablation (RFA) in vivo during PHP mechanical circulatory support (MCS) in simulated ventricular tachycardia (pacing at 300 ms) and ventricular flutter (VFL, pacing at 200 ms) and also during ventricular fibrillation (VF) in a porcine model. Anterograde (right ventricular), transseptal, retrograde, and epicardial right and left ventricular 3D mapping (EnSite/CARTO) and RFA were performed in 6 swine using high-density mapping and force-sensing RFA catheters (TactiCath/ThermoCool). Surface and intracardiac electrograms and 3D maps were analyzed for noise/interference with and without MCS using PHP in sinus rhythm and simulated VT/VFL and VF. RESULTS: Mapping and RFA proved feasible in the presence of MCS using PHP. The mean arterial pressure in sinus rhythm was 55 ± 2 mmHg (baseline) and 84 ± 4 mmHg during MCS with PHP and well-maintained during simulated VT (73 ± 8 mmHg) and VFL (65 ± 2 mmHg) and even in VF (65 ± 5 mmHg). No electrogram noise/artifact, EMI, or 3D map distortions were observed during mapping/RFA with either of two mapping systems. CONCLUSIONS: Endocardial and epicardial 3D mapping and RFA in the presence of PHP are feasible and offer significant MCS during simulated VT/VFL and VF. Furthermore, PHP yielded no electrogram noise/artifact, EMI, or 3D mapping distortions in conjunction with magnetic-based 3D mapping systems.

Pulmonary Vein Isolation With and Without Posterior Wall Isolation in Paroxysmal Atrial Fibrillation: IMPPROVE-PAF Trial.

BACKGROUND: Prior studies have demonstrated clinical benefits associated with cryoballoon pulmonary vein isolation (PVI) and concomitant posterior wall isolation (PWI) in patients with persistent atrial fibrillation (AF). However, the role for this approach in patients with paroxysmal atrial fibrillation (PAF) remains unclear. OBJECTIVES: This study investigated the acute and long-term outcomes of PVI vs PVI+PWI using cryoballoon in patients with symptomatic PAF. METHODS: This retrospective study (NCT05296824) examined the outcomes of cryoballoon PVI (n = 1,342) vs cryoballoon PVI+PWI (n = 442) in patients with symptomatic PAF during long-term follow-up. Using the nearest-neighbor method, a 1:1 matched sample of patients receiving PVI alone and PVI+PWI was created. RESULTS: The matched cohort consisted of 320 patients (PVI: n = 160; PVI+PWI: n = 160). PVI+PWI was associated with longer cryoablation (23 ± 10 minutes vs 42 ± 11 minutes; P < 0.001) and procedure times (103 ± 24 minutes vs 127 ± 14 minutes; P < 0.001). In 39 (24.4%) of 160 patients, adjunct radiofrequency ablation was required for PVI+PWI. Adverse event rates were similar (PVI 3.8% vs PVI+PWI 1.9%; P = 0.31). Though there were no differences at 12 months, freedom from all atrial arrhythmias (67.5% vs 45.0%; P < 0.001) and AF (75.6% vs 55.0%; P < 0.001) were significantly greater with PVI+PWI vs PVI alone at 39 ± 9 months of follow-up. PVI+PWI was also associated with reduced long-term need for cardioversion (16.9% vs 27.5%; P = 0.02) and repeat catheter ablation (11.9% vs 26.3%; P = 0.001), and emerged as the only significant predictor of freedom from recurrent AF (HR: 2.79; 95% CI: 1.64-4.74; P < 0.001). CONCLUSIONS: Compared with cryoballoon PVI, cryoballoon PVI+PWI appears to be associated with greater freedom from recurrent atrial arrhythmias and AF in patients with PAF during long-term follow-up >3 years.

Fifth Metatarsal Jones Fractures: Diagnosis and Treatment.

A Jones fracture, located at the metaphyseal-diaphyseal junction of the fifth metatarsal, is at an increased risk for nonunion and continued pain. Even with excellent surgical technique and postoperative management, a delayed union and refracture can occur. These complications in athletes can have deleterious effects on performance and delay return to sport. This article reviews the classification, diagnosis, and treatment considerations for Jones fractures. Treatment options including nonsurgical management, intramedullary screw, and plate fixation will be covered. The authors preferred technique using intramedullary screw fixation will be discussed in depth. Emerging considerations including biologic augmentation, primary bone grafting, and refracture will be examined as well. Ideal rehabilitation protocols, orthoses, and shoe wear suggestions will be given to optimize patient outcomes.

Carotid plaque regression following 6-month statin therapy assessed by 3T cardiovascular magnetic resonance: comparison with ultrasound intima media thickness.

BACKGROUND: Cardiovascular magnetic resonance (CMR) allows volumetric carotid plaque measurement that has advantage over 2-dimensional ultrasound (US) intima-media thickness (IMT) in evaluating treatment response. We tested the hypothesis that 6-month statin treatment in patients with carotid plaque will lead to plaque regression when measured by 3 Tesla CMR but not by IMT. METHODS: Twenty-six subjects (67 ± 2 years, 7 females) with known carotid plaque (> 1.1 mm) and coronary or cerebrovascular atherosclerotic disease underwent 3T CMR (T1, T2, proton density and time of flight sequences) and US at baseline and following 6 months of statin therapy (6 had initiation, 7 had increase and 13 had maintenance of statin dosing). CMR plaque volume (PV) was measured in the region 12 mm below and up to 12 mm above carotid flow divider using software. Mean posterior IMT in the same region was measured. Baseline and 6-month CMR PV and US IMT were compared. Change in lipid rich/necrotic core (LR/NC) and calcification plaque components from CMR were related to change in PV. RESULTS: Low-density lipoprotein cholesterol decreased (86 ± 6 to 74 ± 4 mg/dL, p = 0.046). CMR PV decreased 5.8 ± 2% (1036 ± 59 to 976 ± 65 mm3, p = 0.018). Mean IMT was unchanged (1.12 ± 0.06 vs. 1.14 ± 0.06 mm, p = NS). Patients with initiation or increase of statins had -8.8 ± 2.8% PV change (p = 0.001) while patients with maintenance of statin dosing had -2.7 ± 3% change in PV (p = NS). There was circumferential heterogeneity in CMR plaque thickness with greatest thickness in the posterior carotid artery, in the region opposite the flow divider. Similarly there was circumferential regional difference in change of plaque thickness with significant plaque regression in the anterior carotid region in region of the flow divider. Change in LR/NC (R = 0.62, p = 0.006) and calcification (R = 0.45, p = 0.03) correlated with PV change. CONCLUSIONS: Six month statin therapy in patients with carotid plaque led to reduced plaque volume by 3T CMR, but ultrasound posterior IMT did not show any change. The heterogeneous spatial distribution of plaque and regional differences in magnitude of plaque regression may explain the difference in findings and support volumetric measurement of plaque. 3T CMR has potential advantage over ultrasound IMT to assess treatment response in individuals and may allow reduced sample size, duration and cost of clinical trials of plaque regression.

Measurement of the repeatability of the prompt flashlamp-induced wavefront aberration on beamlines at the National Ignition Facility.

We have undertaken a measurement campaign to determine the repeatability of the prompt flashlamp-induced wavefront aberration on beamlines at the National Ignition Facility (NIF) and determine the extent to which shot-to-shot variations in this aberration may degrade the performance of a proposed adaptive optics system for the short-pulse Advanced Radiographic Capability beamline on NIF. In this paper we will describe the unique NIF configuration that was required to make this measurement, present the results of the experiment, and discuss the implications of these results for the adaptive optics system design.

High-Energy Achilles Tendon Rupture With Associated Medial Malleolus Fracture and Traumatic Peroneal Dislocation: A Case Report.

Fracture, Achilles tendon rupture, or traumatic dislocation of the peroneal tendons are often seen in isolation after a trauma or sports-related injury. However, in rare circumstances, a combination of these injuries can occur simultaneously. Multiple previous case reports describe a combination of 2 of these injuries. Missed or delayed diagnosis is common in these combination injuries and can lead to significant patient morbidity and result in long-term consequences. We report a case of a 35-year-old man who sustained an Achilles tendon rupture with an associated medial malleolus fracture and traumatic peroneal dislocation after a snowboarding injury. These injuries were treated surgically, and at 9 months postoperatively, the patient had returned to all activities. Clinicians should have a high index of suspicion for concomitant injuries with higher-energy trauma to the ankle and should perform a thorough history, physical examination, and plain radiographs at a minimum.Levels of Evidence: LEVEL 5.

Concomitant Pulmonary Vein and Posterior Wall Isolation Using Cryoballoon With Adjunct Radiofrequency in Persistent Atrial Fibrillation.

OBJECTIVES: The aim of this multicenter, randomized, single-blind study was to prospectively evaluate the short-and long-term outcomes of pulmonary vein isolation (PVI) versus PVI with concomitant left atrial posterior wall isolation (PWI) using the cryoballoon in patients with symptomatic persistent/long-standing persistent atrial fibrillation (P/LSP-AF). BACKGROUND: Some studies have suggested a clinical benefit associated with PVI+PWI in patients with P/LSP-AF. However, there are limited safety and efficacy data on this approach using cryoballoon ablation. METHODS: The immediate and long-term outcomes in patients with P/LSP-AF randomized to PVI (n = 55) versus PVI+PWI (n = 55) using the cryoballoon were prospectively examined. RESULTS: Baseline characteristics were similar. PVI was achieved in all patients (21 ± 11 min). PWI was attained using 23 ± 8 min of cryoablation. Adjunct radiofrequency ablation was required in 4 of 110 patients (7.3%) to complete PVI (3 ± 2 min) and in 25 of 55 patients (45.5%) to complete PWI (4 ± 6 min). Although left atrial dwell time (113 ± 31 min vs. 75 ± 32 min; p < 0.001) and total procedure time (168 ± 34 min vs. 127 ± 40 min; p < 0.001) were longer with PVI+PWI, this cohort required fewer intraprocedural cardioversions (89.1% vs. 96.4%; p = 0.04). Adverse events occurred in 5.5% in each group (p = 1.00). However, the incidence of recurrent atrial fibrillation at 12 months was significantly lower with PVI+PWI (25.5% vs. 45.5%; p = 0.028). Additionally, in a multivariate analysis, PVI+PWI emerged as a significant predictor of freedom from recurrent atrial fibrillation (odds ratio: 3.67; 95% confidence interval: 1.44 to 9.34; p = 0.006). CONCLUSIONS: In patients with P/LSP-AF, PVI+PWI using the cryoballoon is associated with a significant reduction in atrial fibrillation recurrence, but similar safety, as compared with PVI alone.