ABSTRACT
A powerful and flexible hard x-ray (HXR) camera has been recently installed and tested on the WEST tokamak (CEA, France) in collaboration with the Princeton Plasma Physics Laboratory. The diagnostic is a pinhole camera fielded with a 2D pixel detector equipped with a 1 mm thick CdTe sensor. The novelty of this diagnostic technique is the detector's capability of adjusting the threshold energy at the pixel level. This innovation provides great flexibility in the energy configuration, allowing simultaneous space, energy, and time resolved x-ray measurements. The novel camera has been used to measure the core radiation from non-Maxwellian (fast) electrons accelerated by Lower Hybrid (LH) waves and also the beam-target emission of tungsten in the divertor region produced by fast electron losses interacting with the target. In addition, anisotropic hard x-ray emission has been detected for the first time at the WEST core and edge plasma, with opposite toroidal intensity trends. Experimental vertical and toroidal HXR profiles have been successfully reproduced with the LH code LUKE.
ABSTRACT
Importance: Population studies have recorded an increased, unexplained risk of post-acute cardiovascular and thrombotic events, up to 1 year after acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Objectives: To search for clinical variables and biomarkers associated with late post-acute thrombotic and cardiovascular events after SARS-CoV-2 infection. Design: Retrospective cohort study. Setting: Third-level referral hospital in Bergamo (Italy). Participants: Analysis of an existing database of adult patients, who received care for SARS-CoV-2 infection at our institution between 20 February and 30 September 2020, followed up on a single date ("entry date") at 3-6 months. Exposure: Initial infection by SARS-CoV-2. Main outcomes and measures: Primary outcome: occurrence, in the 18 months after entry date, of a composite endpoint, defined by the International Classification of Diseases-9th edition (ICD-9) codes for at least one of: cerebral/cardiac ischemia, venous/arterial thrombosis (any site), pulmonary embolism, cardiac arrhythmia, heart failure. Measures (as recorded on entry date): history of initial infection, symptoms, current medications, pulmonary function test, blood tests results, and semi-quantitative radiographic lung damage (BRIXIA score). Individual clinical data were matched to hospitalizations, voluntary vaccination against SARS-CoV-2 (according to regulations and product availability), and documented reinfections in the following 18 months, as recorded in the provincial Health Authority database. A multivariable Cox proportional hazard model (including vaccine doses as a time-dependent variable) was fitted, adjusting for potential confounders. We report associations as hazard ratios (HR) and 95% confidence intervals (CI). Results: Among 1,515 patients (948 men, 62.6%, median age 59; interquartile range: 50-69), we identified 84 endpoint events, occurring to 75 patients (5%): 30 arterial thromboses, 11 venous thromboses, 28 arrhythmic and 24 heart failure events. From a multivariable Cox model, we found the following significant associations with the outcome: previous occurrence of any outcome event, in the 18 months before infection (HR: 2.38; 95% CI: 1.23-4.62); BRIXIA score ≥ 3 (HR: 2.43; 95% CI: 1.30-4.55); neutrophils-to-lymphocytes ratio ≥ 3.3 (HR: 2.60; 95% CI: 1.43-4.72), and estimated glomerular filtration rate < 45â ml/min/1.73â m2 (HR: 3.84; 95% CI: 1.49-9.91). Conclusions and relevance: We identified four clinical variables, associated with the occurrence of post-acute thrombotic and cardiovascular events, after SARS-CoV-2 infection. Further research is needed, to confirm these results.
ABSTRACT
WEST (tungsten environment in steady-state tokamak) is starting operation for the first time with a water-cooled full tungsten divertor, enabling long pulse operation. Heating is provided by radiofrequency systems, including lower hybrid current drive (LHCD). In this context, a compact multi-energy hard x-ray camera has been installed for energy and space-resolved measurements of the electron temperature, the fast electron tail density produced by LHCD and runaway electrons, and the beam-target emission of tungsten at the target due to fast electron losses interacting with the divertor plates. The diagnostic is a pinhole camera based on a 2D pixel array detector (Pilatus 3 CdTe CMOS Hybrid-Pixel detector produced by DECTRIS). The novelty of this diagnostic technique is the detector's capability of adjusting the threshold energy at pixel level. This innovation provides great flexibility in the energy configuration, allowing simultaneous space and energy-resolved x-ray measurements. This contribution details two important steps in the preparation of the diagnostic operation. First, the in-vessel spatial calibration that was carried out with a radioactive source. Second, the synthetic diagnostic is obtained by the suite of codes ALOHA/C3PO/LUKE/R5-X2, which simulates LH wave propagation and absorption, as well as the fast electron bremsstrahlung production.
ABSTRACT
A multi-energy soft x-ray pinhole camera has been designed, built, and deployed at the Madison Symmetric Torus to aid the study of particle and thermal transport, as well as MHD stability physics. This novel imaging diagnostic technique employs a pixelated x-ray detector in which the lower energy threshold for photon detection can be adjusted independently on each pixel. The detector of choice is a PILATUS3 100 K with a 450 µm thick silicon sensor and nearly 100 000 pixels sensitive to photon energies between 1.6 and 30 keV. An ensemble of cubic spline smoothing functions has been applied to the line-integrated data for each time-frame and energy-range, obtaining a reduced standard-deviation when compared to that dominated by photon-noise. The multi-energy local emissivity profiles are obtained from a 1D matrix-based Abel-inversion procedure. Central values of Te can be obtained by modeling the slope of the continuum radiation from ratios of the inverted radial emissivity profiles over multiple energy ranges with no a priori assumptions of plasma profiles, magnetic field reconstruction constraints, high-density limitations, or need of shot-to-shot reproducibility. In tokamak plasmas, a novel application has recently been tested for early detection, 1D imaging, and study of the birth, exponential growth, and saturation of runaway electrons at energies comparable to 100 × Te,0; thus, early results are also presented.
ABSTRACT
A compact multi-energy soft x-ray diagnostic is being installed on the W Environment in Steady-state Tokamak (WEST), which was designed and built to test ITER-like tungsten plasma facing components in a long pulse (â¼1000 s) scenario. The diagnostic consists of a pinhole camera fielded with the PILATUS3 photon-counting Si-based detector (â²100 kpixel). The detector has sensitivity in the range 1.6-30 keV and enables energy discrimination, providing a higher energy resolution than conventional systems with metal foils and diodes with adequate space and time resolution (â²1 cm and 2 ms). The lower-absorption cut-off energy is set independently on each one of the â¼100 kpixels, providing a unique opportunity to measure simultaneously the plasma emissivity in multiple energy ranges and deduce a variety of plasma parameters (e.g., Te, nZ, and ΔZeff). The energy dependence of each pixel is calibrated here over the range 3-22 keV. The detector is exposed to a variety of monochromatic sources-fluorescence emission from metallic targets-and for each pixel, the lower energy threshold is scanned to calibrate the energy dependence. The data are fit to a responsivity curve ("S-curve") that determines the mapping between the possible detector settings and the energy response for each pixel. Here, the calibration is performed for three energy ranges: low (2.3-6 keV), medium (4.5-13.5 keV), and high (5.4-21 keV). We determine the achievable energy resolutions for the low, medium, and high energy ranges as 330 eV, 640 eV, and 950 eV, respectively. The main limitation for the energy resolution is found to be the finite width of the S-curve.
ABSTRACT
A multi-energy hard x-ray pin-hole camera based on the PILATUS3 X 100K-M CdTe detector has been developed at the Princeton Plasma Physics Laboratory for installation on the Tungsten Environment in Steady State Tokamak. This camera will be employed to study thermal plasma features such as electron temperature as well as non-thermal effects such as fast electron tails produced by a lower hybrid radiofrequency current drive and the birth of runaway electrons. The innovative aspect of the system lies in the possibility of setting the threshold energy independently for each of the â¼100k pixels of the detector. This feature allows for the measurement of the x-ray emission in multiple energy ranges with adequate space and time resolution (â¼1 cm, 2 ms) and coarse energy resolution. In this work, the energy dependence of each pixel was calibrated within the range 15 keV-100 keV using a tungsten x-ray tube and emission from a variety of fluorescence targets (from yttrium to uranium). The data corresponding to pairs of Kα emission lines are fit to the characteristic responsivity ("S-curve"), which describes the detector sensitivity across the 64 possible energy threshold values for each pixel; this novel capability is explored by fine-tuning the voltage of a six-bit digital-analog converter after the charge-sensitive amplifier for each of the â¼100k pixels. This work presents the results of the calibration including a statistical analysis. It was found that the achievable energy resolution is mainly limited by the width of the S-curve to 3 keV-10 keV for threshold energies up to 50 keV, and to ≥20 keV for energies above 60 keV.
ABSTRACT
Polycythemia vera (PV) and essential thrombocythemia (ET) are myeloproliferative neoplasms with variable risk of evolution into post-PV and post-ET myelofibrosis, from now on referred to as secondary myelofibrosis (SMF). No specific tools have been defined for risk stratification in SMF. To develop a prognostic model for predicting survival, we studied 685 JAK2, CALR, and MPL annotated patients with SMF. Median survival of the whole cohort was 9.3 years (95% CI: 8-not reached-NR-). Through penalized Cox regressions we identified negative predictors of survival and according to beta risk coefficients we assigned 2 points to hemoglobin level <11 g/dl, to circulating blasts ⩾3%, and to CALR-unmutated genotype, 1 point to platelet count <150 × 109/l and to constitutional symptoms, and 0.15 points to any year of age. Myelofibrosis Secondary to PV and ET-Prognostic Model (MYSEC-PM) allocated SMF patients into four risk categories with different survival (P<0.0001): low (median survival NR; 133 patients), intermediate-1 (9.3 years, 95% CI: 8.1-NR; 245 patients), intermediate-2 (4.4 years, 95% CI: 3.2-7.9; 126 patients), and high risk (2 years, 95% CI: 1.7-3.9; 75 patients). Finally, we found that the MYSEC-PM represents the most appropriate tool for SMF decision-making to be used in clinical and trial settings.
Subject(s)
Polycythemia Vera/genetics , Polycythemia Vera/mortality , Primary Myelofibrosis/genetics , Primary Myelofibrosis/mortality , Thrombocythemia, Essential/genetics , Thrombocythemia, Essential/mortality , Adult , Aged , Aged, 80 and over , Biomarkers , Female , Follow-Up Studies , Humans , Male , Middle Aged , Mutation , Polycythemia Vera/diagnosis , Primary Myelofibrosis/diagnosis , Prognosis , Risk Factors , Survival Analysis , Thrombocythemia, Essential/diagnosisABSTRACT
Ruxolitinib is an oral Janus-activated kinase 1 (JAK1)/JAK2 inhibitor approved for the treatment of patients with myelofibrosis based on the results of two randomized clinical trials. However, discordant indications were provided by regulatory agencies and scientific societies for selecting the most appropriate candidates to this drug. The European LeukemiaNet and the Italian Society of Hematology shared the aim of building evidence-based recommendations for the use of ruxolitinib according to the GRADE methodology. Eighteen patient-intervention-comparator-outcome profiles were listed, each of them comparing ruxolitinib to other therapies with the aim of improving one of the three clinical outcomes: (a) splenomegaly, (b) disease-related symptoms, and (c) survival. Ruxolitinib was strongly recommended for improving symptomatic or severe (>15 cm below the costal margin) splenomegaly in patients with an International Prognostic Scoring System (IPSS)/dynamic IPSS risk intermediate 2 or high. Ruxolitinib was also strongly recommended for improving systemic symptoms in patients with an MPN10 score >44, refractory severe itching, unintended weight loss not attributable to other causes or unexplained fever. Because of weak evidence, the panel does not recommend ruxolitinib therapy for improving survival. Also, the recommendations given above do not necessarily apply to patients who are candidates for allogeneic stem cell transplant.
Subject(s)
Molecular Targeted Therapy , Primary Myelofibrosis/drug therapy , Protein Kinase Inhibitors/therapeutic use , Pyrazoles/therapeutic use , Comorbidity , Hemorrhage/etiology , Humans , Hypertension, Portal/etiology , Infections/etiology , Janus Kinase 1/antagonists & inhibitors , Janus Kinase 2/antagonists & inhibitors , Nitriles , Phenotype , Primary Myelofibrosis/diagnosis , Primary Myelofibrosis/metabolism , Primary Myelofibrosis/mortality , Protein Kinase Inhibitors/administration & dosage , Protein Kinase Inhibitors/adverse effects , Pyrazoles/administration & dosage , Pyrazoles/adverse effects , Pyrimidines , Splenomegaly , Treatment OutcomeSubject(s)
Mutation/genetics , Primary Myelofibrosis/genetics , Adult , Aged , Aged, 80 and over , Humans , Janus Kinase 2/genetics , Middle AgedABSTRACT
Wendelstein 7-X, a superconducting optimized stellarator built in Greifswald/Germany, started its first plasmas with the last closed flux surface (LCFS) defined by 5 uncooled graphite limiters in December 2015. At the end of the 10 weeks long experimental campaign (OP1.1) more than 20 independent diagnostic systems were in operation, allowing detailed studies of many interesting plasma phenomena. For example, fast neutral gas manometers supported by video cameras (including one fast-frame camera with frame rates of tens of kHz) as well as visible cameras with different interference filters, with field of views covering all ten half-modules of the stellarator, discovered a MARFE-like radiation zone on the inboard side of machine module 4. This structure is presumably triggered by an inadvertent plasma-wall interaction in module 4 resulting in a high impurity influx that terminates some discharges by radiation cooling. The main plasma parameters achieved in OP1.1 exceeded predicted values in discharges of a length reaching 6 s. Although OP1.1 is characterized by short pulses, many of the diagnostics are already designed for quasi-steady state operation of 30 min discharges heated at 10 MW of ECRH. An overview of diagnostic performance for OP1.1 is given, including some highlights from the physics campaigns.
ABSTRACT
A beam emission spectroscopy system on thermal helium (He) and neon (Ne) has been set up at Wendelstein 7-X to measure edge electron temperature and density profiles utilizing the line-ratio technique or its extension by the analysis of absolutely calibrated line emissions. The setup for a first systematic test of these techniques of quantitative atomic spectroscopy in the limiter startup phase (OP1.1) is reported together with first measured profiles. This setup and the first results are an important test for developing the technique for the upcoming high density, low temperature island divertor regime.
ABSTRACT
Helium line-ratios for electron temperature (Te) and density (ne) plasma diagnostic in the Scrape-Off-Layer (SOL) and edge regions of tokamaks are widely used. Due to their intensities and proximity of wavelengths, the singlet, 667.8 and 728.1 nm, and triplet, 706.5 nm, visible lines have been typically preferred. Time-dependency of the triplet line (706.5 nm) has been previously analyzed in detail by including transient effects on line-ratios during gas-puff diagnostic applications. In this work, several line-ratio combinations within each of the two spin systems are analyzed with the purpose of eliminating transient effects to extend the application of this powerful diagnostic to high temporal resolution characterization of plasmas. The analysis is done using synthetic emission modeling and diagnostic for low electron density NSTX SOL plasma conditions by several visible lines. Quasi-static equilibrium and time-dependent models are employed to evaluate transient effects of the atomic population levels that may affect the derived electron temperatures and densities as the helium gas-puff penetrates the plasma. The analysis of a wider range of spectral lines will help to extend this powerful diagnostic to experiments where the wavelength range of the measured spectra may be constrained either by limitations of the spectrometer or by other conflicting lines from different ions.
ABSTRACT
We retrospectively studied 181 patients with polycythaemia vera (n=67), essential thrombocythaemia (n=67) or primary myelofibrosis (n=47), who presented a first episode of splanchnic vein thrombosis (SVT). Budd-Chiari syndrome (BCS) and portal vein thrombosis were diagnosed in 31 (17.1%) and 109 (60.3%) patients, respectively; isolated thrombosis of the mesenteric or splenic veins was detected in 18 and 23 cases, respectively. After this index event, the patients were followed for 735 patient years (pt-years) and experienced 31 recurrences corresponding to an incidence rate of 4.2 per 100 pt-years. Factors associated with a significantly higher risk of recurrence were BCS (hazard ratio (HR): 3.03), history of previous thrombosis (HR: 3.62), splenomegaly (HR: 2.66) and leukocytosis (HR: 2.8). Vitamin K-antagonists (VKA) were prescribed in 85% of patients and the recurrence rate was 3.9 per 100 pt-years, whereas in the small fraction (15%) not receiving VKA more recurrences (7.2 per 100 pt-years) were reported. Intracranial and extracranial major bleeding was recorded mainly in patients on VKA and the corresponding rate was 2.0 per 100 pt-years. In conclusion, despite anticoagulation treatment, the recurrence rate after SVT in myeloproliferative neoplasms is high and suggests the exploration of new avenues of secondary prophylaxis with new antithrombotic drugs and JAK-2 inhibitors.
Subject(s)
Budd-Chiari Syndrome/physiopathology , Polycythemia Vera/physiopathology , Primary Myelofibrosis/physiopathology , Thrombocythemia, Essential/physiopathology , Venous Thrombosis/physiopathology , Adult , Aged , Budd-Chiari Syndrome/etiology , Female , Humans , Male , Middle Aged , Polycythemia Vera/complications , Portal Vein/physiopathology , Primary Myelofibrosis/complications , Proportional Hazards Models , Recurrence , Retrospective Studies , Risk Factors , Thrombocythemia, Essential/complications , Venous Thrombosis/etiologyABSTRACT
Clinical evidence supports the need of changing the diagnostic criteria of the 2008 updated WHO classification for polycythemia vera (PV), essential thrombocythemia (ET) and primary myelofibrosis (PMF). In JAK2-mutated patients who show characteristic bone marrow (BM) morphology, clinical studies demonstrated that a hemoglobin level of 16.5g/dL in men and 16.0g/dl for women or a hematocrit value of 49% in men and 48% in women are the optimal cut off levels for distinguishing JAK2-mutated ET from "masked/prodromal" PV. Therefore BM morphology was upgraded to a major diagnostic criterion. Regarding ET the key issue was to improve standardization of prominent BM features enhancing differentiation between "true" ET and prefibrotic/early primary myelofibrosis (prePMF). These two entities have shown a different epidemiology and clinical outcomes. Concerning prePMF a more explicit clinical characterization of minor criteria is mandated for an improved distinction from ET and overt PMF and accurate diagnosis and outcome prediction.
Subject(s)
Myeloproliferative Disorders/diagnosis , Practice Guidelines as Topic , Disease Susceptibility , Humans , Myeloproliferative Disorders/etiology , World Health OrganizationABSTRACT
Ruxolitinib is a Janus kinase (JAK) (JAK1/JAK2) inhibitor that has demonstrated superiority over placebo and best available therapy (BAT) in the Controlled Myelofibrosis Study with Oral JAK Inhibitor Treatment (COMFORT) studies. COMFORT-II was a randomized (2:1), open-label phase 3 study in patients with myelofibrosis; patients randomized to BAT could crossover to ruxolitinib upon protocol-defined disease progression or after the primary end point, confounding long-term comparisons. At week 48, 28% (41/146) of patients randomized to ruxolitinib achieved ⩾35% decrease in spleen volume (primary end point) compared with no patients on BAT (P<0.001). Among the 78 patients (53.4%) in the ruxolitinib arm who achieved ⩾35% reductions in spleen volume at any time, the probability of maintaining response was 0.48 (95% confidence interval (CI), 0.35-0.60) at 5 years (median, 3.2 years). Median overall survival was not reached in the ruxolitinib arm and was 4.1 years in the BAT arm. There was a 33% reduction in risk of death with ruxolitinib compared with BAT by intent-to-treat analysis (hazard ratio (HR)=0.67; 95% CI, 0.44-1.02; P=0.06); the crossover-corrected HR was 0.44 (95% CI, 0.18-1.04; P=0.06). There was no unexpected increased incidence of adverse events with longer exposure. This final analysis showed that spleen volume reductions with ruxolitinib were maintained with continued therapy and may be associated with survival benefits.
Subject(s)
Primary Myelofibrosis/drug therapy , Pyrazoles/administration & dosage , Adult , Aged , Aged, 80 and over , Cross-Over Studies , Disease Progression , Female , Follow-Up Studies , Humans , Male , Middle Aged , Nitriles , Organ Size/drug effects , Primary Myelofibrosis/mortality , Pyrimidines , Spleen , Survival RateABSTRACT
The optimal duration of treatment with vitamin K antagonists (VKA) after venous thromboembolism (VTE) in patients with Philadelphia-negative myeloproliferative neoplasms (MPNs) is uncertain. To tackle this issue, we retrospectively studied 206 patients with MPN-related VTE (deep venous thrombosis of the legs and/or pulmonary embolism). After this index event, we recorded over 695 pt-years 45 recurrences, venous in 36 cases, with an incidence rate (IR) of 6.5 per 100 pt-years (95% confidence interval (CI): 4.9-8.6). One hundred fifty-five patients received VKA; the IR of recurrent thrombosis per 100 pt-years was 4.7 (95% CI: 2.8-7.3) on VKA and 8.9 (95% CI: 5.7-13.2) off VKA (P=0.03). In patients receiving VKA, the IR of recurrent thrombosis per 100 pt-years was 5.3 (95% CI: 3.2-8.4) among 108 patients on long-term VKA and 12.8 (95% CI: 7.3-20.7) after discontinuation among the 47 who ceased treatment (P=0.008), with a doubled risk of recurrence after stopping VKA (hazard ratio: 2.21, 95% CI: 1.19-5.30). The IR of major bleeding per 100 pt-years was 2.4 (95%: CI: 1.1-4.5) on VKA and 0.7 (95% CI: 0.08-2.5) off VKA (P=0.08). In conclusion, in MPN patients with VTE recurrent thrombosis is significantly reduced by VKA and caution should be adopted in discontinuation; however, the incidence of recurrence on treatment remains high, calling for clinical trials aimed to improve prophylaxis in this setting.
Subject(s)
Bone Marrow Neoplasms/complications , Fibrinolytic Agents/therapeutic use , Premedication/methods , Venous Thromboembolism/drug therapy , Vitamin K/antagonists & inhibitors , Adult , Aged , Aged, 80 and over , Cohort Studies , Female , Fibrinolytic Agents/administration & dosage , Humans , Male , Middle Aged , Myeloproliferative Disorders/complications , Pulmonary Embolism/drug therapy , Pulmonary Embolism/etiology , Recurrence , Retrospective Studies , Venous Thromboembolism/etiologyABSTRACT
The Philadelphia-negative myeloproliferative neoplasms (MPNs) are clonal disorders involving hematopoietic stem and progenitor cells and are associated with myeloproliferation, splenomegaly and constitutional symptoms. Similar signs and symptoms can also be found in patients with chronic inflammatory diseases, and inflammatory processes have been found to play an important role in the pathogenesis and progression of MPNs. Signal transduction pathways involving JAK1, JAK2, STAT3 and STAT5 are causally involved in driving both the malignant cells and the inflammatory process. Moreover, anti-inflammatory and immune-modulating drugs have been used successfully in the treatment of MPNs. However, to date, many unresoved issues remain. These include the role of somatic mutations that are present in addition to JAK2V617F, CALR and MPL W515 mutations, the interdependency of malignant and nonmalignant cells and the means to eradicate MPN-initiating and -maintaining cells. It is imperative for successful therapeutic approaches to define whether the malignant clone or the inflammatory cells or both should be targeted. The present review will cover three aspects of the role of inflammation in MPNs: inflammatory states as important differential diagnoses in cases of suspected MPN (that is, in the absence of a clonal marker), the role of inflammation in MPN pathogenesis and progression and the use of anti-inflammatory drugs for MPNs. The findings emphasize the need to separate the inflammatory processes from the malignancy in order to improve our understanding of the pathogenesis, diagnosis and treatment of patients with Philadelphia-negative MPNs.