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I started out drawing for fun as little kids do. I read western comics, watched cartoons and anime, and visited the library often with my brother. As a result, I was heavily influenced by the stories and visuals I took in. They were also probably a little mature for my age, but that also likely played a role in my fascination and curiosity for consuming artistic works.
My influences are numerous and far too many to pinpoint precisely what has brought me to this point. Though, I have learned through exploration and experimentation what I prefer as an artist. As for mediums, like many, I gravitate towards the simplicity of graphite and ink, which can clearly present my ideas to others.
My future plans… For the foreseeable future, I will be attending an art college, most likely in California. There, I hope to improve on my work ethic and time management for creative works. Meanwhile, building friendships and acquaintanceships within a creative community and industry will also be beneficial.
In five years, I would have a degree and be working, though I may pursue graduate school as well. By then, I would hope to have improved even more in artistic techniques, building my portfolio and helping me find employment.
In general, learning, exploring, and experimenting with art will always be a priority for me. Certain obstacles may impede me for some aspirations, but my dedication to art will stay.
My advice for my younger OCSA Classmates-
If you’re a new OCSA student, don’t block the stairs, and if your item is stuck in the vending machine, you can get a refund. Also, make sure to try your best. Four years go by surprisingly quickly, so be sure to not only pay attention in classes and get good grades but also to self-reflect and figure out your relationship with others. Understand your own motivations and feelings so that you may better understand others as well.


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We are looking to recruit a hands-on leader to spearhead assay development for a breakthrough molecular diagnostics platform. This is a hands-on leadership role with the opportunity to translate your life sciences insights into practical engineered solutions. You will drive the direction of PCR assay development within the company.
* Substantial experience in the development of PCR and molecular diagnostic assays in a commercial / industrial environment
* Excellent laboratory skills and familiarity with common molecular assay methodologies with a PhD in a relevant field
* Demonstratable experience that you have managed complex projects under time pressure in a pragmatic manner
For further details contact Polytec directly.
[ Royston, Hertfordshire, Salary £neg. | vacancy reference : 32551 ]

domain: chemistry


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Chronic inflammation also plays a role in the development of cognitive conditions like dementia and Alzheimer’s Disease. That’s why a crucial aspect of preserving long-term brain health is cutting down on inflammatory triggers wherever you can. You’re probably already doing this in a few ways: quitting smoking, limiting your alcohol use, getting enough sleep, cutting down on stress, and staying active. There are also some simple choices you can make at the grocery store that will be a net-positive for your brain health and your relationship with inflammation.
A new study out of the American Academy of Neurology found that people who follow an anti-inflammatory diet, rich in a few key ingredients, had a lower risk of developing dementia later in life. In the study, researchers surveyed more than 1,000 people in Greece about the types of food they ate over the course of three years. They sought to elicit the kinds of food people were eating most regularly, including dairy products, cereals, fruits, vegetables, meats, fish, legumes, alcoholic beverages, and sweets. The participants were then broken up into stratified groups and given scores based on how inflammatory their overall diets were.
Over the course of the study, 62 people—around six percent of study participants—developed dementia. These people just so happened to be those in the group representing the most inflammatory diets. In fact, those who ate the most inflammatory foods during the study were found to be three times more likely to develop dementia when compared to people who maintained anti-inflammatory diets.
The best and most effective way to reduce your intake of inflammatory foods is to eliminate highly-processed foods like fast foods, saturated fats, and sugary beverages, as these are some of the most common food triggers that increase inflammation.
As is the case with one-off studies such as this one, more research is needed before we draw any definitive conclusions. But the findings in this study certainly jive with our growing understanding of the inflammation-brain connection: When the body is inflamed, so is the brain. The researchers have even gone so far as to say these results should inform dietary recommendations for the long-term preservation of cognitive health.
“Our results are getting us closer to characterizing and measuring the inflammatory potential of people’s diets,” said study author Nikolaos Scarmeas, MD, PhD, of the National and Kapodistrian University of Athens in Greece. “That, in turn, could help inform more tailored and precise dietary recommendations and other strategies to maintain cognitive health.”
The study highlighted three key food groups and two beverages that were present across the brain-boosting, anti-inflammatory diets. And while these may come as no surprise to already-healthy eaters, it is certainly good for us to refresh our minds about each their benefits.
Here are the 5 top anti-inflammatory foods and drinks linked to long-term brain health.
Yup, no surprise here. Try to include at least four to five servings of fruit in your diet per week. If optimal anti-inflammatory benefits are what you’re after, strawberries, blueberries, raspberries, and blackberries are all excellent options. The entire berry family contains antioxidants called anthocyanins, which are compounds that have powerful anti-inflammatory effects.
Particularly of the leafy green variety—think broccoli, spinach, kale, and collards. These verdant superfoods are filled with vitamin E, another natural antioxidant that has been shown to reduce processes of inflammation and calm overactive immune systems.
Beans have a bad reputation when it comes to inflammation. It has been suspected that beans cause inflammation because they contain lectins, a protein that binds to carbohydrates and is difficult for the body to break down. In reality, soaking, sprouting or cooking beans—which is most often how they are prepared—neutralized these lectins and prevents them from binding. Beans and legumes are not only full of nutrients and antioxidants, but they are also densely packed with fiber and protein—all of which are crucial elements of any anti-inflammatory diet.
4. Coffee and tea
Caffeine dependents can rejoice, because members of the study who demonstrated long-term cognitive health were also found to be coffee and tea drinkers. Coffee has been a suspected anti-inflammation agent for some time, as it contains polyphenols, which are naturally occurring anti-inflammatory compounds. Tea, on the other hand, possesses antioxidants called catechins, which reduce inflammation. Green tea, in particular, contains something called EGCG, the most powerful type of catechin. While other teas also have EGCG, green tea packs the biggest punch when it comes to inflammation.
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domain: food


On January 10th, 2012, Beth Trombold applied for a job as commissioner on the Public Utilities Commission of Ohio (PUCO). Her application letter said “My political party affiliation is Republican.” We printed the letter here last month.
Party affiliation is important because state law requires that no more than three of the five PUCO commissioners come from the same political party.
Trombold didn’t get the job. Kasich instead chose to appoint Republican State Rep. Lynn Slaby, using up the last of the three Republican slots.
Almost exactly one year later, we were the first to report that Ms. Trombold was again on the list for an empty seat on the commission. But because three Republicans were already serving, the seat was reserved for a Democrat or Independent.
This time Ms. Trombold was calling herself an “Independent”.
The PD asked her about the change: “Trombold said she miscast herself as a Republican when applying to fill last year’s vacancy”. “In hindsight, it’s probably not the most accurate description”, said Trombold.
I’ll give Beth the benefit of the doubt and assume at least ONE of the two answers she gave was actually true. But that means the other was false i.e. she lied – sorry, “miscast herself” – on one of her job applications.
I don’t know what your employer is like, but I can tell you for a fact: if my employer knew a potential candidate lied on his/her job application, that candidate would be disqualified immediately.
John Kasich not only knows about the lie, it seems he cheerfully endorses it through this appointment.
Kasich has stacked the deck with his PUCO appointments, choosing climate change deniers and political hacks who dream about killing solar energy projects and gutting energy efficiency standards. And now he’s trying to squeeze another Republican on the commission with his latest appointment.
The Ohio Democratic Party has threatened to sue over the likely-illegal appointment of Trombold. And I certainly hope they do.
The spirit of the law is important. The letter even more so. In our opinion, Kasich has ignored both by appointing Trombold to the PUCO.
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Master of coins Do you ever remember the pirate king game who was famous on Facebook and who had a lot of players? Coin Master is a game developed on the basis of this idea. Posted by publisher Moon Active, this is a publisher who has published many products in the genre of arcade games. Although it is a new editor, with this unique game you will not get bored of the experience that the game brings. It will provide you with moments of fun entertainment after a stressful work schedule. This game is totally entertaining so that you can enjoy it right on any Android mobile device because it is one of the best games that will help you every day to to be stressful after your work you can't try without any problem This is the latest update of this great android game totally updated.
This game has over 50 million Worldwide Coin Master downloads only on the Android platform and has over 1 million votes, with an average rating of 4.6 *, including up to 90% positive player reviews for the game. Just the numbers above, you saw the appeal of the game for gamers. Weighing less than 60MB since this game has totally been around the world as it is super easy to entertain and you will spend many hours fully connected as it also allows you to play with your friends and family without any problem as it is fully connected. available for any smartphone with Android and also for iOS, try the new Premium update with everything unlocked, one of the best experiences you can get directly in this game for your mobile and spend a lot of time fully connected without errors.
Regarding the graphics of the game Coin Master, the game is built with 2D graphics. The character model is designed in the Chibi model, which is very user-friendly and eye-catching. In the game, the god of thunder Thor appears in Norse mythology holding Mjolnir the sacred hammer. The game takes place in a medieval environment in the middle of the sea, where the islands are very close to each other, and the warships of the ancient Vikings are always ready to fight over food and food conflicts so that their village becomes each time more expensive and become the leader. you must try to defend your village so that no one approaches one of the best bosses the game brings is that it allows you to create your own types of ships to be able to protect your village and no one to come near to get all the control and be the leader and always rule one of the best games totally interesting entertaining and the best thing that you are is going to spend a lot of time fully connected as it allows you to connect with any type of person in the world.
Coin Master game sound is added by manufacturer, from background music to sound or rotation; the sound of the skills implemented is very well done. The heroic soundtrack, when experience is applied, will bring you the thrill of playing. There is a lot of soft background music to help you relax; the shift from light to hero will bring players unexpected suspense when playing. Not to mention the sound of the spinning and skills performed, the sound it's done meticulously. Simple gameplay, the game is totally super easy to play because you can't implement it differently, but it also includes totally relaxing background music to be able to enter the environment with this amazing game, one of the best versions which you can find right now with everything complete as it is a super simple farm entertainment game to get your own custom village and protect it from all invaders.
With simple gameplay, Coin Master but skill effects created are unique and make players admire. The skill fact isn't really made like other games, but it has chibi graphics, so these effects are still highly rated over a lot of its siblings. Most of the interactions in the game are simple and well designed. With a simple game, it suffices to mark and plunder other villages to build your own empire, So the design of the game is not too complicated and the creator arranges it in a logical and accessible way to see you spin the object and fly the enemy. Simple truth? This is one of the totally smart games that you have to learn to be able to get a lot of food ship type rewards because it is a war that is continuously obtained with different types of villages in this new update, you will directly get everything unlimited so that you can directly build your village and protect it from anyone who wants to enter it.
Coin Master is a game that can be played with a lot of your Facebook friends and millions other players around the world. Save energy to spin the luck to find items of power and strength and go to sea to fight in lands full of magic. Complete the path to become the strongest after beating them all and stepping on the glory of the most active pirate of all. It is totally entertaining game which helps you relax everyday and connect with all kinds of people around the world, you can also directly link it with your Facebook account to play with your friends and invite them to come to your village and experience this amazing game for any smartphone.

domain: entertainment


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Department of Cell and Molecular Physiology
CAROL A. OTEY, Interim Chair
Eva Anton (76) Molecular Analysis of Neuronal Migration and Development of the Cerebral Cortex
William J. Arendshorst (25) Cell and Integrative Biology of Vascular and Nephron Function, Interactions of Endothelial and Vascular Smooth Muscle Cells, Receptors and Signal Transduction, Regulation of Cytosolic Calcium Concentration, Pathogenic Mechanisms of Hypertension
Richard E. Cheney (69) Motor Proteins, Cytoskeleton, Neuronal Cell Biology
James E. Faber (49) Vascular Physiology, Signal Transduction of Vascular Smooth Muscle and Fibroblast Cells, Atherosclerosis, Adrenergic Receptors
Michael F. Goy (60) Biochemistry and Physiology of Excitable Cells, Second Messenger Mechanisms in Signal Transduction, Epithelial Biology, Natriuretic Peptides
Susan J. Henning (98), Intestinal Stem Cells—Biological Properties and Potential for Therapeutic Application
Pauline K. Lund (50) Growth Factors, Cytokines, Gastrointestinal Growth, Molecular Biology, Signal Transduction, Aging and Memory Loss
Paul Manis (81) Cellular Mechanisms of Auditory Information Processing, Synaptic Plasticity, Ion Channels
Gerhard W. D. Meissner (26) Mechanisms in Excitation-Contraction Coupling in Muscle, Ion Channels
Roy C. Orlando (99) Ion Transport and Barrier Function as Mucosal Defense in Esophageal and Barrett’s Epithelium; Mechanisms by Which Acid/Pepsin Injures Squamous Epithelium Leading to Esophagitis and Alters Barrett’s Epithelium, Promoting Dysplasia and Malignancy
Carol A. Otey (72) Mechanisms of Cell Adhesion, Cell Migration and Cytoskeletal Organization, and Neuronal Cell Biology
Daniel N. Pomp (89) Genetics of Growth, Obesity, and Body Weight Regulation in Animal Models
Lola M. Reid (67) Hepatic Stem Cell and Maturational Lineage Biology, Synergies between Extracellular Matrix and Hormones in the Regulation of Gene Expression
Aldo Rustioni (30) Somatosensory System; Connections, Neurotransmitters, and Interneuronal Integration
Robert Sealock (32) Cell Biology and Biochemistry of the Neuromuscular Junction, Proteins Involved in Duchenne Muscular Dystrophy
William Snider (74) Developmental Regulation by Neuronal Growth Factors
Barry L. Whitsel (23) Neuronal Mechanisms of Somatic Sensation
Kathleen Caron (80) Gene Targeted Models of Human Disease, Reproductive Biology, Cardiovascular Biology, G-Protein Coupled Receptor Signaling
Benjamin Philpot (82) Mechanisms of Experience-Dependent Synaptic Plasticity in Visual Cortex
Scott Randell (75) Airway Epithelial Cell Biology-Stem Cells, Host Defense and Response to Injury
Nobuyuki Takahashi (84) Mechanism of Hypertension, Diabetic Complications, and Obesity Using Genetically Engineered Animals
Eleni Tzima (88) Mechanisms of Vascular Endothelial Cell Signaling and Angiogenesis in Response to Hemodynamic Stimuli
Mark J. Zylka (90) Molecules and Mechanisms for Pain
Andrew C. Dudley (103) Tumor Microenvironment, Tumor Angiogenesis, Vascular Stem Cells
Flavio Frohlich (106) Cortical Neurophysiology, Computational Neuroscience, Brain Stimulation, Epilepsy
John F. Rawls (91) Molecular and Genetic Analysis of Host-Microbial Interactions in the Vertebrate Digestive Tract
Spencer Smith (105) Neuroscience and Neuroengineering
C. William Davis (51) Airway Epithelial Cell Physiology
Research Associate Professor
Nicholas G. Moss (94) Biological Signal Transduction
Research Assistant Professor
Scott Magness (104) Stem Cells/Bioengineered Tissue Scaffolds
Andrea Azcárate Peril (102) Defining Fundamental Mechanisms of Probiosis
Sarah Street (107) Molecules and Mechanisms for Pain
Robert Tarran (87) Regulation of Airway Epithelial Ion and Mucus Transport
Hua Zhang (108) Collateral Vascular Biology: Effects of Aging on Collaterals, Assessing Collateral Endothelial Phenotype, Role of Primary Cilia
Robert G. Faust
Paul B. Farel
Enid R. Kafer
David L. McIlwain
Edward R. Perl
Ann E. Stuart
Lloyd R. Yonce
Physiology is the study of the biological, chemical, and physical processes that underlie the functions of living cells and organs. Research in physiology uses tools from chemistry, mathematics, molecular biology, and physics to identify regulatory mechanisms that operate at levels of complexity ranging from the subcellular to the organismic.
The Department of Cell and Molecular Physiology offers a program of study leading to the Ph.D. or M.D./Ph.D. degree. The M.S. degree is offered only under special circumstances. Research opportunities cover molecular, cellular, and systems physiology with an emphasis on mechanisms of disease. Faculty specialties include neurophysiology, endocrinology, and gastrointestinal, cardiovascular, and renal physiology. The Ph.D. program typically requires four to five years of study. The first two years of graduate study include core and elective course work, laboratory rotations, seminar courses, and research. The curriculum is individualized to develop the analytical, research, and communication skills necessary to carry out successful dissertation research. All students typically take the following courses: a foundational course in physiology (PHYI 702, 703), a presentation skills class (PHYI 705, 706), and electives in year two. Requirements may be waived for students with previous graduate-level course work.
Journal clubs, a class in oral and written communication, the seminar program, and a research-in-progress series provide mechanisms for students to develop research and analytical skills. Teaching experience is available in preprofessional courses, graduate school, and medical school courses. The qualifying examination is scheduled during the second year. Students submit the dissertation proposal in year three and complete research and writing in years four and five.
The department is located in the Medical Biomolecular Research Building and the adjoining Neuroscience Research Building. Faculty laboratories are equipped for research and training in all methods of biological research, including biophysics, molecular biology, biochemistry, immunochemistry, and whole-animal studies. UNC–Chapel Hill has outstanding centers for the development and breeding of transgenic and gene-knockout mice for molecular biology/recombinant DNA-related research, cardiovascular biology, and cystic fibrosis and pulmonary medicine as well as resources such as the microbiome core and the zebrafish acquaculture core facilities. Researchers in the department routinely collaborate with members of other School of Medicine departments and centers, with laboratories at Duke University, and with researchers at NIEHS in nearby Research Triangle Park.
All students in good academic standing receive a stipend, tuition scholarship, and health insurance. Many students compete successfully for individual predoctoral fellowships from the AHA, NIH, and NSF, and for competitive awards from The Graduate School. Interdisciplinary training grants in vascular biology, nutrition, cell and molecular biology, and integrative medicine support students across the campus. In addition, the department and individual labs provide funds for students to attend national and international research meetings and specialty courses on- and off-campus.
Placement of Graduates
Recent graduates are working as postdoctoral fellows and faculty members at colleges and universities, as bench scientists in the biotechnology and pharmaceutical sectors, and as scientific advisers in both clinical and basic research settings.
Requirements for Admission
Applications for all 12 School of Medicine basic science graduate programs are processed through the Biomedical and Biological Sciences Program (BBSP), and students spend their first year in that program before transferring to a degree program. Majors in cell and molecular physiology typically have an undergraduate record that includes course work in organic chemistry and biochemistry, two semesters of calculus and physics, and appropriate course work in the biological sciences, typically including zoology, genetics, cell biology, and molecular biology. All applicants are required to submit scores on the GRE aptitude test, a written statement, transcripts, and a minimum of three letters of recommendation. Application details can be found on the BBSP website at www.med.unc.edu/bbsp and The Graduate School website at gradschool.unc.edu/admissions.
Courses for Graduate and Advanced Undergraduate Students
643 Cell Structure, Function, and Growth Control I (BIOC 643, CBIO 643, MCRO 643, PHCO 643) (3). See CBIO 643 for description.
644 Cell Structure, Function, and Growth Control II (BIOC 644, CBIO 644, MCRO 644, PHCO 644) (3). See CBIO 644 for description.
Courses for Graduate Students
701 Physiology Laboratory Rotation (1–6). Permission of the director of graduate studies. Rotations in faculty laboratories introduce methods and techniques in physiology. Individual projects provide an opportunity to explore potential dissertation topics.
702 Experimental Physiology of Human Health and Disease (4). Principles of cell, organ, and systems physiology and pathophysiology required to identify important areas of biomedical research, using model systems, common disease examples (schizophrenia, hypertension, diabetes), and current research opportunities.
703 Experimental Physiology of Human Health and Disease (4). Permission of the instructor. Molecular and cellular basis of organ system function; integration of systems to maintain the normal state. Understanding of normal physiology is amplified by examples from human disease and mouse models. Principles of cell, organ, and integrative physiology and how these principles apply to translational research.
705 Communicating Scientific Results (1). Practice in oral and written communication evaluated by peers and faculty. Includes delivery of coached presentations on topics in physiology and preparation of writing assignments typically encountered in scientific life.
706 Communicating Scientific Results (1). Practice in oral and written communication evaluated by peers and faculty. Includes delivery of coached presentations on topics in physiology and preparation of writing assignments typically encountered in scientific life.
710 Medical Neurobiology (NBIO 710) (1–3). Permission of the instructor. A special section (for physiology graduate students only) of the neurobiology course for medical students. Structural and functional organization is analyzed at the level of the cell membrane, the neuron, and integrated neuronal systems.
712A Special Topics in Physiology (NBIO 891) (1–5). Permission of the instructor. Individually arranged in-depth programs of study of selected topics such as membrane function, transport physiology, renal physiology, etc.
712B Special Topics in Physiology (NBIO 892) (1–5). See NBIO 892 for description.
712C Organ System Physiology in Health and Disease: Respiratory Physiology (1). The course begins with the basic physiology of respiration and gas transport, then applies that understanding to in-depth discussions of common respiratory diseases. Format is lecture plus journal club.
714 Physiology (DENT 114) (4). This basic physiology course introduces students to the functions of and interactions between the various systems of the body. Particular emphasis is placed on those concepts of specific relevance for students and practitioners of dentistry. The course also provides students with a solid physiological background for subsequent courses within the dentistry curriculum.
720 Human Physiology (1–5). Permission of the instructor. A special section (for physiology graduate students only) of the course for medical students. The course provides a general consideration of cell function and systemic physiology. Six lecture hours per week.
721 Stem Cells and Maturational Lineage Biology (4). Prerequisites, BIOL 111; CHEM 101, 102, and 241. All tissues are organized with stem cell compartments giving rise to maturational cell lines with lineage-dependent phenotypic characteristics. Investigators discuss research in stem cell biology and regenerative medicine.
722 Cellular and Molecular Neurobiology I (PHCO 722) (2–6). See PHCO 722 for description.
722A Cellular and Molecular Neurobiology: Introduction (BIOC 722A, NBIO 722A, PHCO 722A) (2). See NBIO 722A for description.
722B Cellular and Molecular Neurobiology: Postsynaptic Mechanisms-Receptors (BIOC 722B, NBIO 722B, PHCO 722B) (2). See NBIO 722B for description.
722C Cellular and Molecular Neurobiology: Electrical Signaling (BIOC 722C, NBIO 722C, PHCO 722C) (2). See NBIO 722C for description.
723 Cellular and Molecular Neurobiology II (PHCO 723) (2–6). Lecture/discussion course on the physiology, pharmacology, biochemistry, and molecular biology of the nervous system. Topics include function and structure of ion channels, neurotransmitter biosynthesis and release mechanisms, neurotransmitter receptors and intracellular signaling pathways.
723A Synaptic Mechanisms and Intracellular Signaling (BIOC 723A, NBIO 723A, PHCO 723A) (3). See NBIO 723A for description.
723B Anatomy and Function of Sensory and Motor Systems (BIOC 723B, NBIO 723B, PHCO 723B) (3). See NBIO 723B for description.
724 Developmental Neurobiology (NBIO 724) (3). Prerequisite, NBIO 722. Permission of the instructor. A survey of nervous system development emphasizing detailed analysis of selected research topics such as neuronal induction, neural crest development, neuronal differentiation, synapse formation, neurotrophic factors, glial development, and the effects of experience.
751 Seminar in Physiology (1). Permission of the director of graduate studies.
752 Seminar in Physiology (1). Permission of the director of graduate studies.
800 Teaching Physiology (1–3). Permission of the instructor. Introduces the principles of teaching physiology. Provides students the opportunity to plan instruction and to teach with increasing degrees of responsibility. The teaching internship is under the direct supervision of a faculty mentor
832 Respiratory Physiology: Defense Mechanisms in the Airways (1–4). Prerequisite, PHYI 703. The integrated defense mechanisms that protect the airways and lung from inhaled allergens, irritants, particulates, and pathogens. Topics include transepithelial ion transport, mucociliary clearance, and innate immune responses.
833 Gastrointestinal Physiology: Growth, Cancer, Inflammation, and the Microbiome (1–3). Prerequisite, PHYI 703. Roles of growth factor and cytokine signaling, and the intestinal microbiome in normal intestinal growth, inflammation, or colon cancer. Molecular, cellular, genomic, model organisms and translational medicine approaches.
834 Pain and Somatic Sensation (NBIO 824) (1–21). Prerequisite, PHYI 720. Permission of the instructor. Consideration of peripheral and central neural mechanisms for somatic sensation with particular emphasis on pain.
835 CNS Organization (1). Primary literature explores how the nervous system is organized, integrates information, and adapts.
836 Excitable Membranes, Receptors, Channels and Synapses (1–4). Basic neurophysiology of excitable membranes, channels, and synapse as the basis of neuronal communication.
839 Endothelial Cells in Health and Disease (1). Prerequisite, PHYI 703. Literature-based survey of endothelial cell biology including development, angiogenesis, environmental influences, and disease models.
840 Renal/Cardiovascular Systems (1–4). Prerequisite, PHYI 703. Permission of the instructor. Blood pressure control in normal, diseased, and genetically modified animals. Physiology and pathophysiology of the renal and cardiovascular systems.
850 Seminar in Neurobiology (BIOL 850, NBIO 850, PHCO 850) (3). See NBIO 850 for description.
901 Research in Physiology (3–10).
902 Research in Physiology (3–10).
903 Research in Physiology (3–10).
951 Research in Neurobiology (BIOL 951, NBIO 951, PHCO 951) (3–12). See NBIO 951 for description.
993 Master’s Thesis (3–21).
994 Doctoral Dissertation (3–21).

domain: medical


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I’m not exactly sure why people think the unsurprising fact that Pakistani elements are supporting the Taliban (whom the Pakistani intelligence service, the ISI, created and supported in the first place) argues in favor of a withdrawal from the region.
It should be clear now that rebuilding Afghanistan into some kind of western democracy can’t happen given hhe political realities of the NATO coalition members’ domestic politics. We just cannot do the heavy lifting. Given that, we should stop trying. I do think, however, that it would be a large mistake to withdraw from the region.
The only cold war in any significant danger of going nuclear hot at the moment is the Indo-Pakistan conflict. And remember, Afghanistan is where the terrorists who actually attacked us were based. Our interests require a presence. They do not require a continued “state building” mission.
There sure is a strong whiff of both.
Obama’s agenda is law. Obama may have over-learned the lessons of the Clinton administration by ignoring social issues and getting the stimulus passed immediately. GOP obstruction began right away, and watered the measure down to the point here it may not be enough. But it passed. This turned out to be a precedent for everything Obama would do up until now.
He would not go to the mat for things. He would spend political capital instead of earning it by forcing the GOP to take the blame for something being blocked. Yet, in the end, financial reform, health care reform (especially this) and the stimulus are law. Unless something goes wildly astray, he will have made two easy Supreme Court appointments.
Last week, I received a text message from the Obama campaign urging me to contact my senator about the unemployment extension. Earlier this week, I saw Obama give a relatively vicious speech on the issue. But by then, the measure was sure to pass!
It appears that it will be signed into law sometime early next week. Another win.
So, Obama has enacted his agenda. But has the White House gotten so used to letting one voice of objection change his plans? Take the cases of Shirley Sherrod and Elizabeth Warren. The first case was fabricated, the latter’s virtues are exactly what rankles some. Yet the WH’s reaction in both cases appears to be to mostly stay behind the scenes and find someone else.
Obama may never enact another significant piece of legislation. It’s not entirely certain he will get to appoint anyone else to the Supreme Court. It is time for him to start standing up for things that matter, even if they lose. You could argue before that it was worth it to get things into law, especially on health care.
It’s time for him to quit letting the media burn his people instantly. It’s time for him to make the Right have some Pyrrhic victories for once. Clinton was the master at the latter, most especially when it came to himself. Obama may have learned how to avoid some of Clinton’s mistakes, but he still needs to learn from his successes.
Just as the news from Israel keeps getting worse on the surface, there are a lot of behind-the-scenes noises that sound like a two-state solution (at least in the West Bank) might be near. But let me look in to my crystal ball on this:
Palestine has almost no natural resources. It’s primary industry, in terms of GDP, would be tourism. That is easily disrupted by terrorism, should that occur. Even if Gaza is integrated into Palestine, it is only by leave of Israel (in fact if not in law) that Palestine would have access to the seas. Good behavior on the part of the Jordanians and Egyptians is absolutely required.
My prediction is that after the glow of any peace wears off, after the Nobel prizes are handed out, the stories instead will continue to focus on the refugee camps outside of Palestine on the one hand and on the economic disparity between Israelis (including the Arab ones) and Palestinians. I don’t think the Israelis will come out looking like the good guys in the end no matter what they do. Does anyone think that an EU membership is in the offing, for example?
Things will also stop glowing for Palestine. While there will surely be a hard core of people who will never let go of the conflict, there will be a lot of disappointment here too. Women’s issues and other civil rights issues will be exposed. There will be corruption. There will be strife between Christian and Muslim Palestinians. And my guess is that if any Jews try to stay in Palestine, they will be kicked out. Palestine will not be the enlightened European satellite that people think it will be.
A lot of this is my speculation, but most of it is just based on looking at the things as they are that will matter after the politics of a peace deal cease to matter. It’s not a rosy picture. But it should give some explanation as to why leaders on both sides aren’t in a rush to resolve the situation beyond just the evil motives ascribed to them.
If Israel had peace with Palestine and Syria, it would finally have to confront the fact of its being taken over by the Charedi minority. If Palestine finally had peace with Israel, it would have to confront the fact of failure with no one else to blame.

domain: news


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Free Matinee Show w/ Level Best
Sun Mar 19 2023 at 01:00 pm
Sweetwater Music Hall | Corte Madera, CA
AdvertisementGood fortune has brought the veteran East Coast bluegrass band Level Best to our shores where they’re making their first Bay Area appearance. They have played major bluegrass festivals, toured Ireland, and are about to embark on their second European tour. Level Best is Wally Hughes on fiddle and Dobro, Lisa Kay Howard-Hughes on mandolin, Ed Lick on banjo, and James Field on guitar. Everybody sings.
Where is it happening?Sweetwater Music Hall, 19 Corte Madera Ave,Mill Valley,CA,United States, Corte Madera, United States
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superDimension is a medical device company that develops and markets minimally-invasive pulmonology devices that enable the diagnosis and potentially the treatment of distal lung disease. The company's product line, the i-Logic System, includes both capital equipment and disposables, addressing a total available market of more than 8 million patients. In March 2012, superDimension was acquired by Covidien. The valuation of superDimension was $300 million. Other terms of the deal were not releaed
superDimension has filed 11 patents.
Endoscopy, Medical equipment, Digestive system procedures, Surgical procedures and techniques, Gastroenterology
Endoscopy, Medical equipment, Digestive system procedures, Surgical procedures and techniques, Gastroenterology
Latest superDimension News
Sep 5, 2023
Gabriel Ortiz-Jaimes,1,* Janani Reisenauer1,2,* 1Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA; 2Division of Thoracic Surgery, Mayo Clinic, Rochester, MN, USA *These authors contributed equally to this work Correspondence: Janani Reisenauer, Division of Pulmonary and Critical Care Medicine, Division of Thoracic Surgery, Mayo Clinic, 200 1st St, SW, Rochester, MN, 55905, USA, Email [email protected] Abstract: The approach to peripheral pulmonary lesions (PPL) has been evolving continuously. Advanced bronchoscopic navigational techniques have improved the airway-based approaches to these lesions. Robotic Assisted Bronchoscopy (RAB) can be considered the current pinnacle of this evolution; allowing for a safer approach to sampling lesions previously considered outside of bronchoscopic reach. We present a comprehensive review of the changing epidemiology of lung cancer and the importance of early tissue sampling, the evolution of sampling and navigational bronchoscopic techniques, technical considerations and evidence pertaining to the use of RAB, and adjunct techniques in the diagnosis of lung cancer. Complications and future applications of RAB are also discussed. Keywords: lung cancer, navigational bronchoscopy, pulmonary nodule, robotic bronchoscopy Epidemiologic Considerations Lung cancer continues to be the leading cause of cancer-associated death worldwide. 1 Recent developments in screening, diagnosis, and treatment, along with decades of efforts to reduce tobacco use, have been fruitful in improving outcomes. In 2022, 236,740 new cases were diagnosed, and 130,180 lives were lost due to lung cancer in the US, representing an improvement from 160,340 deaths in 2016. This improvement in lung cancer mortality has been the major factor in reducing overall cancer mortality; statistics show a decrease in lung cancer death rate of 56% in men (1990–2019) and 32% in women (2002–2019). 2 Nonetheless, it is estimated that yearly there will be 1.8 million new lung cancer cases diagnosed and 1.6 million deaths worldwide, more than those caused by tuberculosis, malaria, and HIV. There is a direct correlation between the stage at diagnosis and mortality, which has shaped the staging systems over time. The challenge of early diagnosis continues to be one of the most pertinent, as lung cancer continues to be diagnosed at an advanced stage up to 74% of the time, with metastatic disease present in 46% of cases. 3 While 5-year survival for prostate, breast, and colorectal cancer approaches >95%, 90%, and 65%, respectively, Stage I lung cancer is not entirely comparable to these malignancies ranging from 58–73%. In comparison, overall 5-year survival for all stages is 23.7%, and 7% for advanced distant disease alone. 3 While survival is heterogeneous by lung cancer type, the recent decline in the mortality rate for non-small cell lung cancer (NSCLC) suggests that advances in diagnosis and treatment have been impactful in improving cancer-specific survival. On the other hand, small cell lung cancer (SCLC) associated mortality has declined almost exclusively due to a decline in incidence with no improvements in cancer-specific survival, reflecting less significant advances in treatment. 4 Therefore, developing techniques that allow for a more precise diagnosis at earlier stages is of paramount relevance. Robotic-assisted navigational bronchoscopy (RAB) has been one of these major advancements in diagnosis and continues to demonstrate potential for ongoing novel developments in diagnosis and treatment. Lung Cancer Screening and the Need for Earlier and More Precise Diagnostic Strategies The significant decrease in cancer-specific mortality since 2013 has coincided with two important changes in the approach to lung cancer, the first being the recommendation for lung cancer screening in 2014. 4 After the failure of periodic chest X-rays in lung cancer screening in the Prostate, Lung, Colorectal, and Ovarian cancer screening (PLCO) trial, 5 2 major studies with low-dose chest CT (LDCT) scans have changed the practice in recent years. The National Lung Screening (NLST) trial demonstrated a higher detection of benign and malignant lesions in 53,454 high-risk individuals, with an odds ratio for cancer diagnosis of 1.13 in the LDCT-screened group compared to chest radiographs. Detection, diagnosis, and treatment of these cancers led to significant decreases in relative lung cancer-specific mortality of 20% and all-cause mortality of 6.7%. 6 The European-based NELSON trial, utilizing a different interval LDCT schedule with volumetric analysis in 15,789 high-risk individuals, demonstrated a cancer-specific mortality benefit in the screening group (OR 0.76) for up to 10 years of follow-up. 7 In the NELSON trial, the most common stage of cancer at diagnosis was IA (46%) in the screening group vs stage IV (45%) in the un-screened population. Similarly, in the NLST, 40% of the cancers diagnosed in the screened arm were stage IA vs 11% IIIB and 21% IV, whereas, in the x-ray arm, 36% were diagnosed in stage IV (the most common stage at diagnosis) and only 21% in Stage Ia. Based upon the NELSON trial, the United States Preventive Services Taskforce recommends screening for lung cancer based on a 20-pack per year history instead of 30. This will lead to the screening of approximately 14.5 million individuals, an increment of 6.5 million people compared to previous screening parameters. Subsequently, this will result in 40,000 diagnoses of early lung cancers per year. 8 This epidemiological trend of increased proportions of early-stage disease will continue to generate the need for tissue sampling in smaller lesions which may be more challenging to differentiate from benign lesions pre-biopsy. As the likelihood of cancer decreases when sampling smaller lesions, a higher degree of precision is necessary, particularly in the case of PPL. The Importance of Early Tissue Sampling for Molecular Markers The second significant event thought to have decreased lung cancer mortality was the recommendation for epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) mutation testing in adenocarcinoma lesions, and the FDA approval of targeted therapies, such as EGFR inhibitors as first-line therapies in 2013. 1 , 4 The identification of mutations, particularly of the EGFR gene, or rearrangements in the ALK gene and the c- ROS-1 oncogene, has been shown to have prognostic implications. 9 Along with the above, programmed cell death ligand (PD-L1) expression levels have also demonstrated the ability to predict response to therapies targeted at these anomalies, significantly improving clinical outcomes, including mortality. 10 Current guidelines recommend testing of all lesions containing any component of adenocarcinoma or in patients who have no or minimal smoking history. Testing for at least these three driver mutations should be carried out in samples with acceptable cellularity of at least 20% or more malignant cells. 11 Mediastinal and hilar curvilinear endobronchial ultrasound (C-EBUS) transbronchial needle aspiration (TBNA) samples obtained during the staging of suspicious or known malignant lesions are frequently adequate for molecular analysis in a meta-analysis including 28 studies with 2698 patients, 94.5% of the samples were suitable for EGFR and 94.9% for ALK mutation detection. 12 Previously, the treatment of node-negative early peripheral lesions relied on molecular analysis of surgical pathology after resection, frequently having to proceed with primary surgical diagnosis and resection in the same procedure. Patients with targetable mutations can now benefit from the recent approval of adjuvant targeted therapy and immunotherapy in addition to standard chemotherapy after resection. The CheckMate 816 trial included 682 patients with stage IB to IIIA resectable NSCLC and found that neoadjuvant chemoimmunotherapy, including the fully human anti-PD-1 antibody nivolumab as conjunction immunotherapy led to a longer and significant improvement in event-free survival of 31.6 vs 20.8 months when compared with neoadjuvant chemotherapy alone (hazard ratio for death, progression, or recurrence 0.63 95% CI 0.43–0.91 p 0.005). The intervention arm was associated with a higher likelihood of having no viable tumoral tissue on resected specimens (24% vs 2.2%, odds ratio 13.94). Thirty-five percent of these patients were randomized at stage IB or II, and the surgical resection cancellation rates due to disease progression were under 10%. Notably, the 7th edition staging system was used, making most of the IB lesions a stage IIA under the current 8th edition. The PD-1 expression level by immunohistochemistry was a significant predictor of success in the nivolumab arm, with expression levels <1% not correlating with a beneficial effect (HR 0.85 95% CI 0.54–1.32) and expression >50% strongly correlating with significant event-free survival (HR 0.24 95% CI 0.1–0.61). Given concerns with mutual exclusion for simultaneous therapy in patients with EGFR and ALK mutations, and the potential differentiating role of PD-L1 expression levels, all patients required sufficient tissue for molecular analysis long before their surgical resections. 13 Similarly, the KEYNOTE-671 trial 14 demonstrated positive findings when utilizing neoadjuvant pembrolizumab in 797 patients as early as Stage II (29.7% in the treatment arm), 37% of the patients had N0 nodal status, thus, relying only on biopsies of the primary site. Improved event-free (local progression, unresectable tumor, progression or recurrence, or death) survival (62.4% vs 40.6%, p<0.001) and overall survival (80.9% vs 77.6% p=0.02) at 24 months were found. The PD-L1 status significantly impacted the hazard ratio for death (non-significant in <1% and more significant in >50% vs 1–49%). PD-L1 expression testing cannot be performed on liquid biopsy samples. In the NELSON and NSLT studies, smaller primary lesions and node-negative cancer stages represented most of the cases detected via screening, stage I accounting for 40.4–50% in the screened populations, as opposed to 13.5–31.1% in the un-screened groups. The growing role of neoadjuvant chemoimmunotherapy, even in early-stage lung cancer, calls for a more aggressive approach to tissue sampling of primary lesions; obtaining appropriate samples for molecular analysis will become paramount when nodal disease is absent. These scenarios, in particular stages IB and non-surgical, node-negative stages II and IIIA, are situations in which guided and robotic bronchoscopy techniques can significantly contribute. Traditional Tissue Sampling Techniques: CT Guided Transthoracic Needle Biopsy (CT-TTNB) CT-TTNB has been the most traditional way to biopsy PPL non-surgically. The diagnostic yield (DY) depends on factors such as nodule size and characteristics, cancer prevalence, and number of needle passes. Sensitivity for cancer is greater than 90% with wide variation (65–94%) with a specificity close to 100% (96–100%), Non diagnostic results occur with a median frequency of 20.5%, however, they are five times more frequent in nonmalignant cases (44% vs 8%). 15 CT-TTNB is, however, a procedure with a significant risk of complications. A database review of 15,865 TTNB reported an incidence of bleeding of 1%, with 17.8% of them requiring transfusions. The most common and relevant complication is pneumothorax; this series reported an incidence of 15% (95% CI 14–16%), with 6.6% (95% CI 6–7.2%) of all biopsies requiring a chest drain, leading to significant increases in length of stay and respiratory failure. 16 A meta-analysis of 23,104 patients reports a higher rate of pneumothorax of 25.9%, with a similar rate of chest tube placement of 6.9%. Lesion-specific risk factors for pneumothorax included: size smaller than 4 cm (OR 2.09), no pleural contact (OR 1.73), and deeper location (>3 cm, OR 2.38); 17 features that could be more approachable with precise endobronchial techniques. Standard and Non-Robotically Guided Bronchoscopic Techniques Multiple approaches have been developed to attempt tissue sampling of PPL utilizing bronchoscopy; however, incorporating new technology has not always translated into improvements in DY. Using a probable anatomical location with white light bronchoscopy and 2D fluoroscopy has limited value in evaluating PPL. A systematic review of 35 studies with 4507 patients found an initial sensitivity of 88% in central lesions. In PPL, the yield was significantly lower; when combined with fluoroscopy, 34 studies with 5742 patients demonstrated an overall sensitivity of 78%; however, when discriminated by size, the yield for lesions <2cm was only 34%. 18 In a multicenter randomized trial of 221 patients in 5 sites, this approach had only a 37% DY. 19 The development of image-based airway maps, with subsequent intraprocedural tracking of the real-time position of certain bronchoscopic elements, led to the creation of electromagnetic navigational bronchoscopy (ENB/EMN), which received approval for use in the US in 2004. 20 ENB and its combination with imaging modalities have increased the yield of bronchoscopic sampling of PPL. 15 Currently available non-robotic technologies include ENB and virtual bronchoscopy (VB), which can be combined with R-EBUS with or without a guiding sheath. VB and R-EBUS can also be used with thin (4 mm) or ultrathin (3mm) bronchoscopes to allow maneuverability in distal airways. However, these have not demonstrated a significant increase in diagnostic performance. 19 The presence of bronchus sign has been one of the most critical factors in biopsy success using these techniques (OR 2.09), only surpassed by the adjunct of a radial EBUS (REBUS) positive signal (OR 8.56). However, historical cohorts have demonstrated a decrease in the prevalence of the bronchus sign, 21 reflecting potentially smaller and more challenging lesions being considered for bronchoscopic biopsy and a prior intrinsic selection bias. ENB uses CT images to reconstruct the tracheobronchial tree and plan a pathway to the target lesion. The patient is located within an electromagnetic field, and different sensors can track the bronchoscope position in real-time. The two most utilized manual ENB systems are the SuperDimension (Medtronic, Minneapolis, MN) and the SPiNDrive (Veran Medical Technologies, St Louis, MO). The former uses a sensor loaded into a steerable extended working channel passed through a therapeutic bronchoscope and generates a navigational pathway based on a preprocedural inspiratory CT. The patient lies over a magnetic board, and a predetermined algorithm estimates their respiratory movement. The locatable sensor is removed when biopsy tools are advanced through the channel ( Figure 1 ). The SPiNDrive system requires inspiratory and expiratory CT images and adjusts for respiratory motion using fiducial pads on the patient’s chest; the navigational sensor is located at the tip of special bronchoscopes, which allows for continued tracking of position during the sampling phase. 20 Figure 1 SuperDimension ENB (Medtronic, Minneapolis, MN) utilized for biopsy and dye marking of a left upper lobe lesion. (Courtesy of Dr. Ryan Kern, Mayo Clinic, Rochester, MN). NAVIGATE was a multicenter, single-arm study utilizing the SuperDimension system and the largest ENB study to date, including 1338 patients, and using R-EBUS in 50.6% of the cases. The DY was 67.8%, and sensitivity for malignancy was 62.6%, with close to 50% of the lesions being < 2 cm. The system was also utilized to mark lesions with fiducial markers and dye. 22 Wang et al conducted a meta-analysis of 39 studies and 3052 lesions evaluating the performance of guided bronchoscopy techniques, including ENB, VB, Ultrathin bronchoscopy, R-EBUS, and a guiding sheath. The pooled DY of all methods was 70%. Although there was significant variability among studies, only VB (72%) and R-EBUS (71.1%) had a higher than overall yield, surprisingly higher than ENB (67%). The weighted DY was higher in lesions >20 mm (82.5%) vs <20 mm (60.9%). This demonstrated a significant improvement in PPL sampling compared to standard bronchoscopy with fluoroscopy. 23 An updated analysis of this work in 2023 showed similar findings (discussed later). 24 Folch et al meta-analyzed 40 studies (including NAVIGATE) with 3.342 patients and found a higher DY for ENB of 77% (95% CI 72–82%) with an area under the ROC curve of 0.95 and adequate sampling for ancillary testing in 90% of the cases, 38 studies used the SuperDimension system, and the average lesion size was 23.2 mm. 25 This could represent an improvement in technical implementation, as ROSE, R-EBUS, or fluoroscopy did not perform better. Additional techniques are in development to improve the yield of EMN bronchoscopy. For example, in a recent direct retrospective comparison with RAB, the use of digital tomosynthesis imaging with the SuperDimension system increased the DY to similar levels reached with SS-RAB when done without cone beam CT (CBCT) guidance (80% vs 77%). 26 The 2013 lung cancer diagnosis guidelines provide a grade IC recommendation to proceed with ENB if expertise and technologies are available. 18 Robotically Assisted Bronchoscopy (RAB): Available Technologies In 2018 and 2019, the Food and Drug Administration (FDA) approved two platforms via a 510 (K) based on “substantial equivalence” between RAB and ENB. 27 These have undergone substantial clinical testing in multiple environments ( Table 1 ). Table 1 Characteristics of Commercially-Available Robotic Platforms The Monarch robotic system (Auris Health Inc, Redwood City, CA) utilizes EMN technology via an electromagnetic field generator and reference sensors in the patient’s thorax to determine the position of the target lesion; the catheter is associated with an electromagnetic signal, and the system’s computer adjusts the position, angulation, and distance to target variability with respiration. Pre-procedural CT scans with a recommended slice thickness of 1–1.25 mm and intervals of 0.8–1 mm are used to create an airway pathway. The bronchoscope has a mother-daughter telescopic design with an outer 6 mm catheter with 130° angulation capabilities and an inner 4.2 mm with 180° flexion that can be extended further into distal areas. There is a 2.1 mm working channel, and the catheter has an incorporated video transmission system allowing for an “always on” frontal white light view during the biopsy. Monarch is the EMN-based robotic bronchoscopy (EMN-RAB) prototype 28–30 ( Figure 2 ). Figure 2 Monarch Robotic System (Auris Health Inc, Redwood City, CA). The Ion Endoluminal System (Intuitive Surgical, Sunnyvale, CA) utilizes a novel shape sensing technique (ssRAB) that allows for real-time location of a 3.5mm bronchoscopic catheter based on its deformation while navigating the airways. It utilizes the proprietary PlanPoint planning software, requiring a CT scan with a slice thickness of 0.5–1mm at an interval of 0.5–0.8mm, from which it creates a 3D airway map with target selection and pathway creation options. The catheter is driven via a pedestal-type controller with two controlling mechanisms: a rolling wheel and a trackball to control the advancement, withdrawal, and flexion of the catheter, respectively ( Figure 3 ). The catheter has a flexion of 180° with a 2mm working channel, which can house a 1,8mm vision probe with a visual field of 120°; this probe needs to be removed to allow insertion of biopsy instruments. The company produces proprietary TBNA needles (Flexision) in 19, 21, and 23-gauges. 28 , 31 Figure 3 Ion Endoluminal System (Intuitive Surgical, Sunnyvale, CA). Notes: Reproduced with permission from Duke JD, Reisenauer J. Review: Technology and Techniques for Robotic-assisted Bronchoscopy. Journal of Lung Health and Diseases. 2022;6(1):1–5. 28 The Galaxy system (Noah Medical, San Carlos, CA) has recently received FDA 510k clearance. Although EMN-based, its main advantage is the incorporation of digital tomosynthesis-based augmented fluoroscopy with real time target position update, designed to address the possible shortcomings of EMN and CT to body divergence (TiLT+: Tool-in-lesion TechnologyTM). It utilizes standard fluoroscopy to generate a 3D reconstruction and a simulated target. Preclinical testing in animal models (MATCH study) with an average pigmented nodule size of 16 mm found 100% success of navigation, with a final Tool-in-lesion (TIL) rate of 95% and pigment present in 100% of the samples. 32 It also offers vision during biopsy and a disposable single-use bronchoscopic catheter. 29 Further human clinical data is not currently available. Pre-Procedural Planning Based on pre-procedural CT scans, different platforms are used to generate navigational airway pathways to reach the target lesion. These tools create a virtual bronchoscopy-based 3D airway map, of which a key factor is the ability to generate as many airway generations as required to reach the lesion and to provide the best transbronchial point of parenchymal entry. The user can highlight the target lesion, select and edit the pathways, and add potential airways not depicted by the automatic rendering process. Occasionally, successful pathways can be created by adding “occult airways” to maps based on the course of vascular structures (“vessel sign”). 33 , 34 In the largest study by our group, navigation through an average of 7 airway generations was accomplished. 35 The planned pathways and data are then transferred to the robotic console. The ATLAS Study 36 compared the final distance to target in 41 PPL among automatic pathways generated by three different planning systems: PlanPoint v1.1.0 (used by the ion ssRAB platform), SPiN Planning v4.2.0 (utilized by SPiNDrive ENB) and the SuperDimension ENB system v7.1; 73% of the lesions were located in the outer third of the thorax. Despite all systems being able to similarly generate an average of 3.3 segmental airway generations (p 0.19), the PlanPoint platform used in RAB was superior to the ENB-based systems, with an average distance-to-target of 9.4 ± 5.7mm (compared to 14.2 ± 12.9 and 17.2 ±15.6mm achieved by the other systems respectively, p <0.01). This exemplifies why pathway generation is highly heterogeneous and not only dependent on the ability to map and render more distal airways but also on the efficiency of the navigational plans. This adds a layer of complexity to adequate navigation and highlights the importance of imaging confirmation strategies. Procedural Considerations Although procedural steps are highly variable, general principles are frequently followed. 28 , 30 , 31 , 37 , 38 The patient undergoes general anesthesia, most commonly with total intravenous anesthesia, a large endotracheal tube, and commonly neuromuscular blockade, to guarantee appropriate apneic pauses and prevent inadvertent motion of the target and tools. Anesthetic techniques to decrease CT-to-body divergence will be discussed separately. In our practice, the location of the lesion can dictate the level of PEEP utilized; most commonly, values close to 10 are used for upper lobe lesions and closer to 15 for the lower lobes. The use of tidal volumes close to 10 mL/kg of ideal body weight is frequent. However, the VESPA (Ventilatory Strategy to Prevent Atelectasis) trial demonstrated that a formal ventilatory strategy utilizing a recruitment maneuver, reducing the FiO2 and having PEEP levels of at least 8 cmH2O was effective, and tidal volumes used in this study were lower. 39 At this point, it is essential to ensure that the lesion is centered in the fluoroscopic field of view in all axes to avoid the need for any additional bed movements during navigation. 40 The robotic catheter is inserted, and a live registration is performed to locate airway landmarks and calibrate the position of the catheter. Simultaneous and coordinated virtual and endobronchial views are offered to allow for ease of navigation ( Figures 4 and 5 ). Discrepancies can present between the plan and the endobronchial views. Navigation can differ between platforms; Monarch offers the possibility of utilizing the outer catheter to splint the more proximal airways. Ion offers a virtual 3D airway map that demonstrates the position of the catheter, the lesion, and the pleural margins, allowing for manipulations when the endobronchial view is suboptimal; it also allows for previewing further steps in the virtual pathway, which can be helpful when the alignment with the endobronchial view is not exact. To prevent tissue injury from forceful advancement in the absence of tactile feedback, Monarch provides buckling errors, and Ion provides continuous measurements of driving force and tip articulation radius. If navigation proves difficult due to the collapse of the airway, insufflation of air through the working channel has been reported. 30 In the largest study, a second navigation pathway had to be attempted in 16% of the cases, and 86% of the nodules were extrinsic to the airways. 35 , 40 Figure 4 Monarch system interface displaying endobronchial, virtual bronchoscopic views, navigational pathway, preprocedural CT, and distance to target. Notes: Reproduced with permission from Duke JD, Reisenauer J. Review: Technology and Techniques for Robotic-assisted Bronchoscopy. Journal of Lung Health and Diseases. 2022;6(1):1–5. 28 Figure 5 Ion system interface displaying endobronchial, virtual bronchoscopic views, navigational pathway, pleural margins, and distance to target. Notes: Reproduced with permission from Duke JD, Reisenauer J. Review: Technology and Techniques for Robotic-assisted Bronchoscopy. Journal of Lung Health and Diseases. 2022;6(1):1–5. 28 If a lesion without an endobronchial component is sampled, once the closest airway is reached, an initial assessment with confirmatory tools can be made before biopsying (R-EBUS, CBCT). Occasionally, re-registration of the target position and minor articulations of the catheter position are required. It is essential to ensure that the catheter tip is abutting and indenting the airway wall before sampling, guaranteeing adequate parenchymal penetration and preventing the biopsy instruments from gliding along the airway walls without reaching the lesion. All studies have utilized an aspirating transbronchial needle as a biopsy tool, as it can be the best initial tool to pierce through the airway wall when there is no endobronchial component. At this point, confirmatory imaging is used to ensure a tool-in-lesion (TIL) position. Needle biopsies are generally performed using aspiration, but the exclusive use of capillary action with the stylet has been described. At this point, other biopsy tools can be utilized; the number of needle and/or biopsy passes is primarily influenced by Rapid On-Site Evaluation (ROSE) results and clinical suspicion. Clinical Evidence in Robotic Bronchoscopy Since multiple diagnostic possibilities exist (benign, malignant, and non-diagnostic), the most reported metric in RAB literature is the overall diagnostic yield (DY). One of the most commonly used definitions includes a summation of the true positive and true negative results, utilizing the entire clinical picture and evolution of the lesion and/or radiographic and clinical outcomes after follow-up. 22 There is marked heterogeneity in the literature even when this is considered one of the main outcomes. 41 A recent effort to standardize DY has subdivided it into: Strict: a malignant or specific benign diagnosis (granulomatous inflammation) can be made definitively at the time of the procedure; all others are considered non-diagnostic. Intermediate: non-specific benign results (non-specific inflammation) are considered diagnostic if confirmed upon follow-up. Liberal: Non-diagnostic samples (normal tissue) are considered diagnostic if confirmed non-malignant after follow-up. 42 A remarkably high specificity for positive malignant results is common to all studies; this contrasts with variable proportions of benign and non-diagnostic results, which affect the DY and sensitivity. Procedural adjuncts such as R-EBUS and confirmatory images have an essential impact on DY and have been variably utilized in different studies. After initial experiences with cadaver and simulated models, 43 clinical studies utilizing both platforms have reported varying DY rates and sensitivities for malignancy. Table 2 summarizes the studies available on RAB in PPL. DY has been reported between 69.1% 44 and 96%. 37 Heterogeneity is widely present in terms of procedural technique, including various forms of imaging and adjunct tools for visualization. The prevalence of malignancy and the pretest probability for a specific malignant or benign diagnosis will unavoidably affect the DY of the procedure. It also influences how persistent the procedural team might be in terms of biopsy attempts or instruments utilized. Reported prevalences of malignancy, when followed longitudinally or when considered in conjunction with other diagnostic techniques, oscillates between 54.5% and 88%. Prospective and retrospective data is available, and some studies have followed patients up to 12 months after the procedure, mainly to corroborate the validity of results based on clinical progression. No direct comparison is available between platforms thus far. Table 2 Studies Reporting the Diagnostic Yield and Performance of Robotic Bronchoscopy in Pulmonary Lesions As with other techniques, Chadda found that the most significant predictors of a successful and diagnostic biopsy were the presence of a bronchus sign (OR 2.3 95% CI 1–5.3 p 0.04) and the R-EBUS signal, with a concentric signal being the most robust predictor (OR 10.0 95% CI 3.2–31.1 p <0.001) followed by an eccentric signal (OR 7.4 95% CI 2.4–22.9 p <0.001), the DY was only 26.9% when no signal was encountered. 44 This should be contrasted against other studies where only 25% to 48% of patients had a demonstrable bronchus sign present, despite similar DY outcomes (these studies have used the Ion platform). 47 , 48 , 51 Other confirmation techniques or sampling instruments could optimize success rates despite the absence of a bronchus sign. Agrawal encountered a similar pattern with an 85%, 84%, and 38% DY of robotic biopsies for concentric, eccentric, and absent R-EBUS signals (p<0.001 for the trend), in this study after 12 months of follow-up and multivariate analysis, the R-EBUS signal and lesion size were the most important predictors of accuracy (87% in lesions >20 mm vs 82% in lesions <20mm). 55 As mentioned, a crucial parameter in current diagnostic success is the possibility of performing molecular analyses of the samples. In a retrospective study of 104 primary lung cancers and 24 metastatic lesions biopsied with ssRAB, Connolly found that 84% (108) of the samples were adequate for molecular testing. PCR-based testing for KRAS and EGFR mutations in adenocarcinomas was successful in 94% of the cases, and hybrid capture next-generation sequencing of 505 cancer genes was successful in 96% of the attempted samples. In addition, PD-L1 immunohistochemistry was successful in 91% of the attempted samples. Adequacy on ROSE was a predictor of greater tumor cellularity and success in molecular analyses (there was no difference with the use of larger bore 19-Gauge TBNA needles or more needle passes). 57 This is similar to the NAVIGATE ENB trial findings and EBUS TBNA data. An essential clinical dilemma is assessing the value of a nonmalignant pathology result after RAB. This question requires longitudinal follow-up to ascertain the reliability of nonmalignant diagnoses, in addition to other confirmatory diagnostic techniques and evaluation of the clinical progression of the patient. In the study by Reisenauer, 32% of the ssRAB diagnoses were nonmalignant, with a false negative rate of 12%. 58 A second study that followed patients for 12 months found a 32% incidence of benign and 30% of nondiagnostic findings. This study had no false positives, with specificities and positive predictive values of 100%. Of 59 lesions negative for malignancy upon RAB sampling, 29 were later found to have malignant pathology upon follow-up (49% false negative rate). 55 Khan followed 264 patients after Monarch RAB, with 43% malignant, 41% benign (including specific: granulomas and infection, and non-specific: inflammation, organizing pneumonia, interstitial disease, etc. ), and 15% non-diagnostic (normal tissue, atypical cells) results. The initial DY was 85%. After 12 months, benign nonspecific diagnoses had a false negative rate of 26%, with at least 17% (14/78) receiving a subsequent malignant diagnosis or radiographic progression. Non-diagnostic cases had a false negative rate of 43% (14/39). The final 12-month DY was 79% and varied when different definitions were used. 41 In general, positive RAB results for malignancy are highly reliable. Unfortunately, false negatives are not uncommon and have been reported between 11–49%. Therefore, the decision to proceed with additional sampling methods and/or longitudinal follow-up after a negative or non-malignant RAB result should be based on patient characteristics, pretest probability, and multidisciplinary discussion. Only one study has directly compared the performance of ssRAB vs CT-TTB. This retrospective study included 225 lesions and analyzed the diagnostic accuracy and sensitivity for malignancy at 12 months. Radial EBUS, CBCT, and ROSE were utilized universally. Sensitivities and NPV for detecting cancer of ssRAB and CT-TTB were similar (82.1% vs 88.5%, p 0.674 and 71.4 vs 62.9%, p 0.17). No false positives were encountered, yielding a specificity of 100% for both techniques. As discussed above, one of the most important clinical factors to consider is the likelihood of false negative results and the credibility of a nonmalignant result; in this study, the incidence of false negatives was similar in the two groups (12.3% vs 11.6%), with a true negative incidence of 30% for the ssRAB and 19.6% for the CCTB group. The incidence of complications was significantly higher in the CT-TTB group (17% vs 4.4%), with a pneumothorax rate of 16% vs 3% in the ssRAB group (OR 5.2). This study also highlights the advantageous possibility of performing only one procedure, including C-EBUS nodal staging at the time of RAB, as 37.5% of patients who underwent CT-TTB required a subsequent bronchoscopy with C-EBUS for staging. 58 An updated meta-analysis including 16,389 PPL from 126 studies, of which six involved RAB (483 PPL), reported an overall DY of 77.6% (95% CI 70.4–84.8%). There was no significant difference when compared with R-EBUS, ENB with or without R-EBUS, VB, ultrathin or thin bronchoscopy with or without R-EBUS and/or virtual bronchoscopy. The pooled DY for all guided bronchoscopic procedures was 69.2%. 24 There was no statistically significant difference in the DY of bronchoscopic procedures before and after 2012. 23 The risks of selection bias, heterogeneity of studies, and lesion characteristics are also highlighted in these analyses. The largest and most recent meta-analysis, including 10,682 nodules in 95 studies using navigational techniques, found a DY of 70.9%. RAB was utilized in 558 patients, with a yield of 76.5 (95% CI 60.4–87.4%). 59 Most importantly, the use of RAB, CBCT, or digital tomosynthesis (DT) guided EMN (discussed later) had a significantly higher DY than EMN alone and VB (77.5% vs 68.8%, respectively, p<0.001). When the newly proposed definitions were explored, the immediate/strict DY of all navigational techniques (based solely on results from the index procedure) was 68.6% for nodules >20 mm and 66.7% for smaller PPL when the intermediate definition was utilized at 12 months of follow up, the yields were 72.1% and 69.7% respectively. Although unable to make comparisons for significance, RAB and CBCT achieved the highest DY. 42 , 59 This meta-analysis highlights the clinical impact of improving the overall diagnostic performance when techniques such as robotic navigation or confirmation imaging (including its combination with other methods) are utilized. Biopsy Tools Our knowledge of tool performance in PPL biopsy originates primarily from non-RAB studies. However, newer evidence from RAB studies is arising. In the NAVIGATE study, additional tools were utilized, such as the superDimension triple needle cytology brush in 303 cases, the GenCut core biopsy system (Medtronic, Minneapolis, MN) in 214 cases, and needle tipped cytology brushes in 241 patients, with 71% of the cases requiring at least three biopsy tools. 22 A subsequent analysis encountered that the use of multiple tools (6 instruments, including the above) had a higher DY for malignancy (86.8%) when compared to a restricted number of tools (biopsy forceps, standard cytology brush, and BAL) without increasing complications. The tools that contributed with the highest true positive rates were the biopsy forceps (86.9%) and aspirating needle (86.6%). 60 In a study at our institution utilizing the Ion ssRAB platform, concordance between ROSE and final histopathology was similar when needle and cold forceps were compared (89% for needle, 85% for forceps, and 92% overall). 61 The use of parenchymal cryo-biopsies has demonstrated value in the diagnosis of interstitial and diffuse parenchymal lung diseases. With the development of a smaller flexible 1.1 mm cryoprobe (Erbe, Tuebingen, Germany), distal cryo-biopsies through >1,2 mm working channels are possible, with the potential of obtaining a radial sample devoid of crush artifact as opposed to forceps samples. Oberg reported a retrospective analysis of 120 peripheral nodules sampled with this probe utilizing ssRAB and R-EBUS guidance. The DY was 90%, and 18% of the diagnoses were made exclusively from the cryo-biopsy sample, with all cryo-biopsy samples demonstrating larger size, fewer artifacts, and sufficient material for molecular analysis. 51 The first prospective study is currently underway at the Mayo Clinic utilizing this mini-cryoprobe with the Ion ssRAB platform. (ROBOCOP study, NCT05399082). Confirmatory Techniques and Ancillary Imaging The diagnostic success obtained from CT-TTB stems from the ability to reach the lesion with a straight pathway independent of airway anatomy and visualizing the target lesion and needle position during the procedure in real-time, allowing for confirmation of successful TIL. In RAB, it is ideal to have real-time confirmatory tools to demonstrate a TIL position, followed by the use of adequate tissue acquisition instruments ( Figure 6 ). 31 Figure 6 Left: Room setup including the Ion ssRAB and the CIOS 3D-Spin Mobile CBCT (Siemens Healthineers, Malvern, PA). Right: CBCT images demonstrating a tool-in-lesion needle position (Courtesy of Dr. David Midthun. Mayo Clinic, Rochester, MN). As planning and navigation rely almost exclusively on CT imaging, one of the most important concepts pertaining to confirmatory imaging and accuracy is the concept of “CT to body divergence”, by which the predominantly end-inspiratory and rapidly acquired helical images obtained in a high-resolution CT scanner can differ substantially from the situation of the patient in the procedural table. 62 Multiple factors can affect the actual position of the target lesions during the procedure: respiratory motion, positive pressure ventilation, and, more importantly, the acute development of atelectasis. In the I-LOCATE study, after a mean anesthesia time of only 33 minutes, 89% of the patients developed atelectasis in at least one segment. Up to 58% in 5 segments, with the superior, lateral, and posterior segments of the lower lobes being affected most commonly; this makes approaching lesions in these dependent areas more difficult, as pre-planned pathways and presumed lesion position would differ substantially from the pre-procedural CT. 63 Optimization of breath hold maneuvers by utilizing the pressure-limiting valve with adequate preoxygenation is important, the use of post-intubation recruitment maneuvers, and PEEP levels of 10–12cmH2O, and occasionally higher for the lower lobes (commonly 15cmH2O), as well as adequate timing of end-inspiratory breath holds during intraprocedural imaging are anesthetic techniques that can help reduce atelectasis-associated CT to body divergence. 64 The VESPA trial used a postintubation recruitment maneuver consisting of 10 breaths at a pressure control of 40cmH2O with a PEEP of 20cmH2O, PEEP was maintained at 8–10cmH2O, tidal volumes 6–8mL/Kg, and the FiO2 was titrated to <100%; this strategy, compared with zero PEEP and 100% FiO2 reduced the incidence of atelectasis on R-EBUS and CT from 84.2% to 28.9% (p<0.0001). 39 , 64 Using the lowest tolerated FiO2 could theoretically reduce the incidence of resorption atelectasis. Another crucial resource in addressing CT-to-body divergence is the use of confirmatory imaging. Intraprocedural tomographic imaging can corroborate a TIL position when attempting biopsies and aid in guiding instruments to the target. CBCT creates a 360° view by rotating a C-arm 180° plus the beam width, emitting cones of X-rays resulting in a series of 2D images, which are later reconstructed into a 3D series that can be reformatted into coronal, sagittal, axial, and volumetric images to locate and redirect the position of the target and the bronchoscopic/biopsy instruments. It differs from diagnostic CT, in which a helical source emits a thin fan beam X-ray array; CBCT cannot be used for diagnostics as there is reduced contrast, and the longer acquisition time produces more frequent motion artifacts but can generate a reconstruction significantly faster than DT. 40 DT is a form of augmented fluoroscopy that utilizes limited exposure 2D fluoroscopic images with a limited angle of acquisition to yield images similar to conventional CT with a smaller area-focused field of view without requiring a complete 360° rotation, allowing for visualization and preprocedural location of fluoroscopically occult lesions; it has been used principally in combination with ENB, improving its performance. Recently, the use of tomosynthesis-augmented fluoroscopy using a conventional C-arm that can register the position of the nodule in real time and fuse the navigational images with the preprocedural CT (Illumisite, Medtronic, Minneapolis, MN) has allowed for real-time location of the nodule and bronchoscopic instruments and tracking of the position of the bronchoscope in the tomographic images. 65 In initial studies, this has improved the DY of ENB; its use with RAB is under investigation. 66 , 67 The RELIANT trial aims to compare the DY of the Illumisite with the ssRAB Ion Platform (NCT05705544). The TILT+TM Technology of the Galaxy system was discussed above. In 2022, the FDA approved the integration of the Ion platform with the CIOS 3D-Spin Mobile CBCT (Siemens-Healthineers, Malvern, PA); this allows for review of CBCT images in the robotic console, with the possibility for re-registering target and instrument positions for renavigation, further reducing divergence. 68 Several studies have variably utilized axial reconstruction techniques in addition to conventional fluoroscopy with both RAB platforms ( Table 2 ). 52 , 56 , 68 Benn et al encountered that in at least 15% of the cases, the CBCT image prompted changes in catheter position to target the lesion adequately. 46 CT to body divergence was common in a pilot study at our institution utilizing the Ion/CIOS combination. Defined as >10 mm separation between the target location on the preprocedural CT and its location on CBCT, divergence was present in 60% of the cases, with a median separation in the upper lobes of 10mm and 21mm in the lower lobes. Intraprocedural CBCT-guided adjustments of the robotic catheter allowed for a TIL success rate of 96.7% in 30 nodules with an average size of 17mm. The lower lobes had a divergence incidence of up to 82%, highlighting the importance of an intraprocedural imaging strategy to corroborate target and instrument position in real-time. 48 DT-based studies have shown comparable results, with mean divergences of 7–13 mm in the upper lobes and 14–16 mm in the lower lobes. 66 , 67 A new artificial intelligence-based augmented fluoroscopy platform able to assist with intra-procedural localization of the target and pathway generation (LungVision, Body Vision Medical, Ramat Ha Sharon, Israel) allows for real-time visualization of the lesion during the biopsy, creating an electronically highlighted target; 65 it increased the DY of a non ENB flexible bronchoscopic procedure up to 78.4% and measured a lower CT to body divergence distance than intraprocedural CBCT (5.9 vs 14.5 mm). 69 This system was recently utilized in patients undergoing ENB-RAB with a DY of 91%. 70 Augmented fluoroscopy features are currently being integrated into CBCT systems ( Figure 7 ), including 3D fluoroscopy, allowing for improved real-time redirection of the instruments with >90% success rates. 48 , 71 Figure 7 Ion – CIOS CBCT integration demonstrating an augmented fluoroscopy live overlay of the catheter and the target lesion (automatic pleural border distance and tip Bend radius are displayed). The role of ROSE has been evaluated in other contexts, allowing for fewer biopsy attempts without impacting overall procedural success. Specifically in RAB, in our institution, Vu et al found a concordance of 92% between ROSE and final pathology results in 110 ssRABs for PPL when combining all sampling instruments regardless of lesion size; only 9 cases were discordant. ROSE results were malignant in 70% of the cases and benign in 4%; importantly, non-diagnostic results were present in 26% of lesions by ROSE and pathology; upon follow-up, only a third of these resulted to be malignant, and 48% remained under observation without a malignant diagnosis. 61 In contrast, Aggarwal found that adequate ROSE specimens were obtained in 56% of the cases, with a concordance of 69% for those with a definitive malignant diagnosis. 55 This illustrates the ample variability in ROSE correlation with histopathology results and highlights its primary value in evaluating specimen adequacy. Complications in RAB The most common clinically significant complication of RAB is iatrogenic pneumothorax; Table 2 summarizes the rate of pneumothoraces and intervention requirements. In the largest study with 270 PPL, the pneumothorax rate was 3,3%, and only one patient (0.4%) required a drain. 35 These rates are significantly lower than those associated with CT-TTNB. The position of the target lesion with respect to the pleural margins is a significant risk factor; both platforms have specific indicators that estimate the distance of the robotic catheter to the closest pleural surface. Airway and parenchymal bleeding can rarely occur in RAB; in the mentioned study, 0.8% of the patients had bleeding of the airway that stopped within 5 minutes of tamponade, and no patient required additional hemostatic therapies. 35 In another study, with 24% of patients taking aspirin and 3% having pulmonary hypertension, significant bleeding was encountered only in 2.4% of the cases, and none required transfusions, endobronchial blockers, or other advanced therapies. 44 Some studies have not encountered any significant bleeding. 54 These findings suggest that bleeding with RAB is significantly less common and severe than in CT-TTB, being inconsequential in most cases. Derived from standard definitions of bleeding after transbronchial biopsy based on the duration of bleeding and the impact of required maneuvers, 72 efforts at preventing and optimizing the approach to bleeding have been made. Utilizing this grading system, an overall bleeding rate of 3.2% (4 patients) with only one patient having grade 2 bleeding was reported in a study of 95 PPL. 55 Optimization of hemostasis with potentially higher platelet thresholds (>50.000), the use of viscoelastic monitoring techniques, as well as strategies such as the use of parallel flexible bronchoscopy with the potential for rapid endobronchial occlusion have been proposed for high-risk cases and warrant further investigation. 73 , 74 Combination of studies and databases will be required to develop tools to predict bleeding risk due to its low incidence. Al-ghoula et al performed a search in the FDA’s MAUDE (Manufacturer and User Facility Device Experience) database for both platforms since their approval; a total of 513 incidents have been reported, pneumothorax being the most common (comprising 66.8% of all reported complications) followed by bleeding (10%). Only 12 deaths have been reported worldwide during or immediately following robotic bronchoscopy, five associated with pneumothorax. Forty-eight technical problems have been reported in this database, most commonly detachment or disconnection; unintended catheter movement has been reported in 8 cases. 75 A large study with a target population of 1200 is underway to evaluate the incidence of severe and intervention-warranting procedural complications using the Monarch platform (TARGET study NCT04182815). Therapeutic RAB Applications RAB can deliver fiducial markers for radiotherapy with imaging confirmation and lower risk than other techniques. Special dyes such as Indocyanine green (ICG) injected after bronchoscopic localization confirmation allow for easier and more reliable lesion localization during thoracoscopic resection procedures by utilizing near-infrared fluorescence imaging. 76 The ongoing REPLACING study aims at evaluating the feasibility of ICG injection into PPL using the Ion platform with CBCT (NCT04987281). This could have future impacts in better guidance for more conservative resections at a time when sub-lobar resections could be reconsidered and have shown comparable outcomes in adequately selected early lesions (Stage IA). 77 There has been a proposed “one-stop” approach, in which during a single anesthetic procedure, the patient undergoes a diagnostic RAB with ICG marking and EBUS staging, followed by a thoracoscopic (frequently robotic) resection if appropriate. 78 Multiple ablative therapies have been proposed for early-stage NSCLC, initially delivered via the transthoracic route; they have been recently employed endobronchially, including cryoablation, radiofrequency ablation, and microwave ablation (MWA). 79 These have been studied with ENB with promising results, including high success and low progression rates; 80 RAB has the additional advantages of stabilization and confirmation of accurate delivery of therapy when combined with imaging techniques, and the potential for fewer complications, the main disadvantage being the lack of pathologic confirmation before treatment. 81 The POWER (Prospective Transbronchial Microwave + Robotic-Assisted Bronchoscopy) study is currently recruiting patients to assess the ablative efficacy of utilizing the Monarch platform with CBCT to deliver the NEUWAVE FLEX MWA system (NeuWave Medical, Madison, WI) to oligometastatic PPL located in the outer 2/3 of the thorax with >1 cm separation from the pleural surface (NCT05299606). Pulsed electrical field therapy through a peripheral TBNA needle (PeriView Flex, Olympus, Center Valley, PA) has been undertaken trans-bronchoscopically in the INCITE ES trial (NCT04732520), producing tumor cell death with preservation of the surrounding tissue and potential stimulation of a more immunogenic response, based on a higher number of tertiary lymphoid structure formation within the tumors, 82 leading to the FDA 510(K) clearance of the Aliya system (Galvanize Therapeutics, San Carlos, CA). Endobronchial delivery of chemotherapy and intratumoral therapies to PPL is being explored after initial efforts injecting agents to lesions in the proximal airways and lymphadenopathies using C-EBUS were completed. Transbronchial injections of standard cytotoxic agents such as cisplatin to early-stage lesions are being employed (NCT04809103). 83 Furthermore, therapies such as immunotherapy, oncolytic viruses, and gene therapies are being considered when a reliable endobronchial tumor localization can be achieved, such as that offered by RAB. 84 Conclusion RAB results from a long trajectory of innovation in advanced and navigational bronchoscopy. With the changing epidemiology of lung cancer, prompted by more aggressive detection and treatment strategies, tools that provide precise tissue diagnosis in earlier and smaller lesions are a growing need. RAB allows for a combination of multiple technologies (EBUS, confirmatory imaging, and ROSE) to improve precision, achieving variable DY and high specificities contingent on the lesion and patient factors. Future developments in RAB and new combinations with other techniques are expected to improve its performance and expand its field of application with diagnostic and therapeutic purposes, likely translating into improvements in patient outcomes and satisfaction. Funding
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superDimension raised a total of $58.04M.
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Investors of superDimension include Covidien, Pitango Venture Capital, Medica Partners, Oxford Bioscience Partners, Covidien Ventures and 15 more.
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Professor Larycia Hawkins, a Christian Professor at Wheaton College, was suspended this week after wearing a hijab to show solidarity with Muslim Americans.
Wheaton College is a private Christian college based in Chicago. Professor Hawkins is a tenured political science professor.
As she posted on her Facebook page, Professor Hawkins wore the hijab to show she stands “in religious solidarity with Muslims because they, like me, a Christian, are people of the book.”
“I don’t love my Muslim neighbor because s/he is American. I love my Muslim neighbor because s/he deserves love by virtue of her/his human dignity.”
Her actions originally showed positive results, with many students at the college spreading a message from campus student leaders that promoted love and solidarity with “Muslim brothers and sisters.”
However, Wheaton College administration did not agree and placed Hawkins on administrative leave.
A spokesperson for the college released the following statement:
“In response to significant questions regarding the theological implications of statements that Associate Professor of Political Science Dr. Larycia Hawkins has made about the relationship of Christianity to Islam, Wheaton College has placed her on administrative leave, pending the full review to which she is entitled as a tenured faculty member.
Wheaton College faculty and staff make a commitment to accept and model our institution’s faith foundations with integrity, compassion and theological clarity. As they participate in various causes, it is essential that faculty and staff engage in and speak about public issues in ways that faithfully represent the College’s evangelical Statement of Faith.”
The college maintains that it was due to her statements on Facebook, not her attire, that prompted them to suspend her.
Students at the college delivered a letter to Wheaton College President, Philip Ryken, demanding Professor Hawkins’ reinstatement. One part of the letter states:
“Dr. Hawkins has and continues to be an invaluable resource to the students of Wheaton College, particularly to those of color,” the letter said. “She is known for her sharp intelligence, her challenging intellect, and her ability to encourage those around her to live an incarnational faith.
“We believe there is nothing in Dr. Hawkins’ public statements that goes against the belief in the power and nature of God, Christ, or the Holy Spirit that the Statement of Faith deems as a necessary requirement for affiliation with Wheaton College.”
Professor Hawkin’s response to her suspension was the following:

domain: sociology