On-Disc Observations of Flux Rope Formation Prior to Its Eruption.

Coronal mass ejections (CMEs) are one of the primary manifestations of solar activity and can drive severe space weather effects. Therefore, it is vital to work towards being able to predict their occurrence. However, many aspects of CME formation and eruption remain unclear, including whether magnetic flux ropes are present before the onset of eruption and the key mechanisms that cause CMEs to occur. In this work, the pre-eruptive coronal configuration of an active region that produced an interplanetary CME with a clear magnetic flux rope structure at 1 AU is studied. A forward-S sigmoid appears in extreme-ultraviolet (EUV) data two hours before the onset of the eruption (SOL2012-06-14), which is interpreted as a signature of a right-handed flux rope that formed prior to the eruption. Flare ribbons and EUV dimmings are used to infer the locations of the flux rope footpoints. These locations, together with observations of the global magnetic flux distribution, indicate that an interaction between newly emerged magnetic flux and pre-existing sunspot field in the days prior to the eruption may have enabled the coronal flux rope to form via tether-cutting-like reconnection. Composition analysis suggests that the flux rope had a coronal plasma composition, supporting our interpretation that the flux rope formed via magnetic reconnection in the corona. Once formed, the flux rope remained stable for two hours before erupting as a CME. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s11207-017-1093-4) contains supplementary material, which is available to authorized users.

Neuroblastoma arising in a mature cystic teratoma of the ovary.

A case is described of a neuroblastoma which appeared to arise in a mature cystic teratoma of the ovary. The literature concerning neural tumours of the ovary is briefly reviewed and the grounds for believing that the development of such neoplasms is an indication of the presence of immature neuroepithelial components in a teratoma, rather than a result of malignant change in a fully mature teratoma, are discussed.

Biliary complications after liver transplantation: with special reference to the biliary cast syndrome and techniques of secondary duct repair.

In 93 consecutive cases of orthotopic liver transplantation, there were 24 example of biliary obstruction and eight of bile fistula formation. Six of the obstructed livers developed biliary cast formation so extensive that the smaller intrhepatic ducts became plugged to an extent that they could no longer have been treated by surgical mena. In each of the six cases, the most important causative factor was neglected obstruction of the large bile ducts with the intrahepatic lesions apparently being late and secondary. Stone and/or cast formation also occurred in other obstructed livers in the presence of bile fustulas, but these deposits were limited to the large ducts where they could have been or were removed. Although homograft bile undoubtedly has increased lithogenicity at certain posoperative times, the data from the present study have shown that biliary sludge formation essentially is always associated with defective bile duct reconstruction, and the observations have underscored the urgency with which reoperation must be considered. Techniques of secondary intervention have been described, with emphasis on conversion of cholecystojejunostomy to choledochojejunostomy. This operation has permitted salvage of homografts in eight of nine trials and the survival of seven patients.

Changes in coagulation effects by venoms of Crotalus atrox as snakes age.

Venom samples separately collected at monthly intervals from three Crotalus atrox specimens as they aged from 2 to 22 months showed many quantitative changes of biological activities. But more important were qualitative changes of coagulation activity. Up to 8 months the venoms clotted fibrinogen solutions directly. At 9 to 10 months, plasma was clotted but not fibrinogen. Subsequently the venoms no longer clotted plasma. Qualitative venom changes with growth of snakes could explain some of the conflicting reports both on clinical aspects of snake bite in man and on experimental venom work. The findings emphasize the importance for clinicians dealing with snake bite to monitor the clot-quality of their patient's blood--a simple bedside test for defibrinogenation, no-clot indicating zero fibrinogen and speck-clot representing fibrinogen concentrations under 50 mg/100 ml. With strongly defibrinating venoms, non-clotting blood is a very sensitive sign of systemic envenoming. In contrast, the relatively feeble defibrinating activity of juvenile C. atrox venom suggests that, if the blood is non-clotting in C. atrox bites, this indicates the victim has received a potentially lethal or near-lethal dose of venom urgently requiring effective antivenom therapy.

Metastatic malignant melanoma in a mandarin duck (Aix galericulata).

A biopsy taken from a mass on the dorsal surface of the bill of an adult female mandarin duck (Aix galericulata) was diagnosed as a malignant melanoma by light microscopy. Two months later, the tumor had enlarged considerably; the duck developed severe dyspnea and was euthanatized. At necropsy, there were metastases to lymphoid tissues in the lower regions of the neck. To our knowledge, this is the first report of a malignant melanoma in a mandarin duck.

Indications and efficacy of continuous subcutaneous insulin infusion (CSII) therapy in Type 1 diabetes mellitus: a clinical audit in a specialist service.

AIM: To determine if current guidelines correctly identify patients who will benefit from continuous subcutaneous insulin infusion (CSII) therapy by comparing outcomes between Type 1 diabetic patients with recurrent severe hypoglycaemia (SH) indications with those without; and between patients without and with classic contraindications to CSII managed in a single multidisciplinary pump clinic. METHODS: Changes in biomedical outcomes [glycated haemoglobin (HbA1c), hypoglycaemia, diabetic ketoacidosis (DKA) rates], from before CSII to the end of the study (median duration 20.5 months, range 1-192), were analysed retrospectively from data collected from notes and interviews of 40 patients. Quality of life was assessed by three validated questionnaires at study end (33 patients). RESULTS: Twenty-five out of forty patients were started for reasons other than SH and 15 out of 40 had contraindications to CSII. Overall, CSII was associated with a reduction in HbA1c (9.6 +/- 2.7% to 8.3 +/- 1.2%, P = 0.011), SH (6.45 +/- 16.15/year to 0.34 +/- 1.01/year, P = 0.034) and DKA (1.83 +/- 4.48/year to 0.27 +/- 1.12/year, P = 0.036). The fall in SH was greater for patients started for SH (P < 0.001). However, only patients started for other indications showed a fall in HbA1c (P = 0.001). The fall in DKA rate was greater in patients with contraindications (P = 0.042), and they did not lose the other benefits of CSII therapy, including quality of life. CONCLUSIONS: In the setting of a specialist multidisciplinary service, CSII can be an effective and safe therapy. It confers benefit outside the setting of severe hypoglycaemia and can confer benefit in some patients with classic contraindications. This questions the validity of criteria that may exclude these patients in such a service.

Antivenom in sea-snake bit poisoning.

Among a series of 101 patients bitten by sea-snakes in Malaya in the years 1957-64, 80% were fishermen. Bathers and divers are occasionally bitten. Before sea-snake antivenom became available the mortality-rate (despite the high toxicity of sea-snake venom) was only 10%; however, of 11 with serious poisoning, 6 died. Subsequently 10 patients with serious poisoning received specific sea-snake antivenom; 2 patients, admitted moribund, temporarily improved but died, and 8 patients recovered dramatically. In serious poisoning the suitable dosage of intravenous sea-snake antivenom is 3000-10,000 units; in mild poisoning 1000-2000 units should suffice.

Epidemiology of sea-snake bites.

Epidemiological features as reflected by 101 patients with unequivocal sea-snake bite received in north-west Malaya are reviewed. Enhydrina schistosa caused over half the bites, including seven of the eight fatal bites. It is the most dangerous sea-snake to man. Over 90 per cent of the victims were male and 80 of the 101 patients were fishermen bitten at their job. Most victims were bitten on the lower limb through treading on the snake, and this resulted in more cases of serious poisoning than upper limb bites (caused through handling nets, sorting fish and so on). Only 14 cathers were bitten (through treading on the sea-snake; no bathers were bitten while swimming). In patients coming to hospital more than six hours after the bite, there was a four-fold increase in serious poisoning compared with patients coming within six hours of the bite. Thus, as time elapses after the bite, the victim is less likely to seek medical help unless poisoning is severe. Despite the lethal toxicity of sea-snake venom, in patients seen during 1957-61 before sea-snake antivenom became available, the mortality was only 10 per cent. Trivial or no poisoning followed in 80 per cent of the bites. On the other hand, of 11 patients (20 per cent) with serious poisoning, over half (six patients) died despite supportive hospital treatment. These epidemiological features observed in Malaya probably apply to most fishing folk along Asian coastlines where sea-snakes abound. If this is so, sea-snake bite must be a common hazard feared by millions of fishing folk, and a common cause of illness and death. But it is unlikely that the extent of this problem will be revealed to orthodox medicine for many decades because most fishing villages are far from medical centres; and even if hospitals or medical centres are available, fishing folk are usually reluctant to attend them. Only one species of sea-snake, Pelamis platurus, extends to the east coasts of Africa and west coasts of the tropical Americas, but for various reasons this species does not appear to constitute much of a hazard to fishing folk in these areas. Although bathers are occasionally bitten along Asian coasts, when they inadvertently tread on a sea-snake, the risk of sea-snake bite in this area is extremely low. The prevention of sea-snake bite and poisoning is considered. Highly effective antivenom is now available for treating victims with serious poisoning; death should not occur provided adequate medical treatment is given within a few hours of the bite. The main problem is provision of adequate medical care at rural medical centres and overcoming the reluctance fishing folk often have in attending these centres.

Bites by foreign venomous snakes in Britain.

In 1970-7 17 people in Britain were the victims of 32 bites by foreign venomous snakes. Crotalus atrox caused eight of these bites, Bitis arietans five, and the remaining 19 bites were caused by 12 different species. All the victims were bitten while handling the snake, and 24 bites were incurred by private individuals in their own homes. Poisoning was negligible in 17 of the 32 bites but life-threatening in at least two cases. Thus in the early stages snake bite may be unpredictable as a clinical problem. All victims of snake bite should be observed for at least 12 hours to assess the severity of poisoning and to ensure rational treatment. Local necrosis developed in six cases and resulted in prolonged illness in five of these cases; local incision was carried out and many have been a casual factor. Comprehensive stocks of antivenoms for treating bites by foreign venomous snakes are held by the National Health Services in Liverpool and London. Antivenom is indicated (a) for potentially serious systemic poisoning, as evidenced by hypotension, electrocardiographic changes, neurtrophilia, and acidosis (after viper or elapid bites), abnormal bleeding or non-clotting blood after viper bites; and ptosis or glossopharyngeal palsy after elapid bites; and (b) for bites from snakes whose venom causes local necrosis, to prevent or minimise this unpleasant complication. For effective antivenom treatment intravenous infusion is mandatory.

Adder bites in Britain.

Ninety-five cases of adder bite that have occurred in Britain over the past 100 years are reviewed. Most bites occurred in men who foolishly picked up the adder. Three-quarters of the victims reached hospital within two hours of the bite. When venom is injected the early symptoms include local swelling and discoloration, vomiting, diarrhoea, and early collapse, which often resolves spontaneously. In severe poisoning persistent or recurrent shock is the main feature. Children recover quickly but adults may take weeks or months to recover, during which there may be considerable disability in the bitten limb. Deaths are rare: only 14 deaths from poisoning were recorded in the past 100 years. In England and Wales only one death from adder bite was recorded in 1950-72, but there were 61 deaths from bee or wasp stings. In most cases simple symptomatic treatment is enough, but all patients should be carefully monitored. With persistent or recurrent shock Zagreb antivenom is indicated; and it should also be considered in adults seen within two hours of the bite to minimise morbidity from local effects.

The management of snake bite.

The present article reviews current knowledge on the epidemiology, pathophysiology, and treatment of snake bite, with particular reference to the situation in developing countries. There is little reliable information on the incidence of snake bite in many parts of the world, and epidemiological studies are needed, using enzyme-linked immunosorbent assay to identify and quantify serum levels of venom antigen and antibody. The pathophysiology and clinical features of envenoming by medically important snakes are discussed. Antivenom, if used correctly, can reverse systemic poisoning even if given days after the bite. It is therefore wise to wait for the appearance of signs of systemic poisoning before administering antivenom, rather than using it routinely. WHO has designated the Liverpool School of Tropical Medicine as a Collaborating Centre for the Control of Antivenoms, and this Centre now holds a collection of reference venoms from several important snake species. Characterization of these and of standard antivenoms should significantly improve the management of snake bite throughout the world.