Each positive answer is given one point, indicating a maximum of six points. We enrolled 41 intubated preterm infants  who were receiving mechanical ventilation support for over 24 h. Among them, 35 were successfully extubated, and 6 were not. After completing the extubation evaluation form and adjusting for birth weight and postextubation device, we observed that the total score of the form was significantly associated with successful extubation; the higher the score, the greater the chance of successful extubation. Thus, we infer that the extubation evaluation form may provide a more objective standard for extubation assessment in preterm infants.Given the limited availability of evidence-based methods for assessing the timing of extubation in intubated preterm infants, we aimed to standardize the extubation protocol in this single-center, retrospective study. To accomplish this, we established an extubation evaluation form to assess the suitability of extubation in preterm infants. The form comprises six indicators: improved clinical condition, spontaneous breath rate ≥ 30 breaths per minute, peak inspiratory pressure (PIP) ≤ 15 cmH Preterm infants often require intubation with mechanical ventilation support during respiratory failure treatment . HoweverA study of preterm infants with extremely low birth weights revealed a successful extubation rate of merely 60% . FurtherSpontaneous breathing trials, which have been regularly applied in assessing the extubation readiness of adults, lack the evidence necessary to be performed in preterm infants . HermetoIn preterm infants, delayed extubation may result in a longer duration of mechanical ventilation and increase the risks of severe bronchopulmonary dysplasia (BPD) and neurodevelopmental disability ,8. FurthThe purpose of this study is to standardize the protocol for extubation in preterm infants and reduce the amount of subjective influence in assessments of the conditions for extubation. We aim to objectively assess and predict the most suitable time for endotracheal extubation in preterm infants to reduce mortality and incidence of complications and, thereby, improve their subsequent development and quality of life.In this retrospective study, we analyzed the relevant factors in successful extubation in preterm infants and determined whether the extubation evaluation form developed by the neonatal intensive care unit of Kaohsiung Medical University Chung-Ho Memorial Hospital can effectively predict successful extubation.This retrospective study was reviewed and approved by the Institutional Review Board of Kaohsiung Medical University Chung-Ho Memorial Hospital -20200029, date: 30 June 2020). This project was drafted in accordance with the Human Subjects Research Act of Taiwan.This study adopted a retrospective research design and was performed at Kaohsiung Medical University Chung-Ho Memorial Hospital from 1 January 2014 to 24 April 2019. Preterm infants were eligible for the study if they had (1) gestational age less than 32 weeks and (2) birth weight less than 1500 g. PSIMV + PS mode was used before extubation . Those wBased on the results of their extubation, the subjects were divided into two groups: specifically extubation success (ES) and extubation failure (EF) groups. ES was defined as reintubation not being required within 72 h of the first extubation attempt, whereas EF was defined as endotracheal reintubation being required within 72 h of the first extubation attempt . BPD was2 greater than 65 mmHg with blood pH lower than 7.2; (2) continuous use of FiO2 at a concentration greater than 60% to sustain SpO2 at 88–92%; (3) frequent (more than 3–8 times per hour) apnea or severe apnea requiring positive pressure ventilation.Reintubation was considered necessary if the patients experienced any of the following: (1) PvCOBecause the decision to reintubate is made by the responsible physician and the conditions of preterm infants change rapidly and diversely, situations requiring reintubation may differ from the aforementioned standard.We assessed the effectiveness of the form in predicting successful extubation by using statistical analysis of the extubation results and the scores obtained from the extubation evaluation form. The extubation evaluation form is shown in 2O; (4) FiO2 ≤ 30%; (5) blood pH ≥ 7.2: the time of reference is 48 h before extubation to the moment of extubation; (6) PvCO2 < 70 mmHg: the time of reference is 48 h before extubation to the moment of extubation [The extubation indicators included in the extubation evaluation form were the following: (1) improved clinical condition: physicians and respiratory therapists would conduct daily integrated assessment of whether the principal diagnosis, cause of mechanical ventilation requirement, and chest X-ray had improved  as well as whether the C-reactive protein level had decreased; (2) spontaneous breath rate ≥ 30 breaths per minute (bpm); (3) PIP ≤ 15 cmHtubation .The extubation evaluation form consisted of the six presented indicators. One point was assigned for each indicator a patient met, with a total of six points possible. According to its design, when a patients’ total score is ≥4, extubation is recommended. However, in this study, attending physicians were not required to follow this evaluation form; they were given the option to use their own judgement to decide when to extubate in their patients.p < 0.05.Statistical analyses were performed using SPSS Statistics version 20  and JMP version 10 . All tests were two-tailed, with significance set at Fisher’s exact test and Wilcoxon’s rank-sum test were used to compare the characteristics of the ES and EF groups. The results are presented as frequency, median, percentage, and interquartile range. Logistic regression was used to analyze the factors associated with successful extubation. Receiver operating characteristic (ROC) curve analysis was used to analyze the cut-off point, sensitivity, and specificity and to examine the prediction effectiveness of the extubation evaluation form.A total of 41 subjects admitted from 1 January 2014 to 24 April 2019 met the inclusion criteria. Among them, 35 were successfully extubated and 6 had failed extubation, indicating a failure rate of 14.6%. The inclusion process is presented in p = 0.015).During the perinatal period, several variables did not significantly differ between the ES and EF groups, such as gestational age, gender, being born extremely preterm, being born with an extremely low birth weight, antenatal steroid administration, vaginal delivery, Apgar score at 5 min, Neonatal Therapeutic Intervention Scoring System score, surfactant use, aminophylline or caffeine use, patent ductus arteriosus, late-onset sepsis, and the administration of postextubation nasal intermittent positive pressure ventilation. The only exception was birth weight, with the ES group being significantly heavier than the EF group , FiO2 , and set respiratory rate . However, other variables, including days of life, postmenstrual age, body weight, and blood pH and PvCO2, did not significantly differ between the ES and EF groups. The results are organized in During the first extubation attempt, preterm infants in the ES group had significantly low peak inspiratory pressure (13 cmHp = 0.002), respiratory support device use  , and ICU  and hospital stays .The results obtained indicated that, compared with the ES group, the EF group had significantly longer cumulative mechanical ventilation  and moderate or severe BPD . The results are presented in With regard to complications, compared with the ES group, the EF group had significantly higher rates of developing ROP grade 3 or higher , bradycardia (33%), desaturation (83%), respiratory acidosis (50%), and increased work of breathing (50%).Three patients in the EF group experienced problems with their endotracheal tubes, such as leakage or difficulty maintaining proper position. As a result, extubation and noninvasive positive pressure ventilation were attempted for these infants, leading to a higher setting of mechanical ventilation before extubation in the EF group.2 ≤ 30%  and PIP ≤ 15 cmH2O  indicators than those of the EF group did. For improved clinical conditions, blood pH ≥ 7.2, spontaneous breath rate ≥ 30 bpm, and PvCO2 < 70 mmHg, no significant differences were observed between the two groups. The ES group had a significantly higher final total score than the EF group did We performed a Wilcoxon rank-sum test and a Fisher exact test to compare the total scores (median and interquartile range) of the two groups and the percentage of participants scoring positively on each indicator. The results are displayed in 2 before extubation , PIP before extubation , set respiratory rate before extubation , and total score of the extubation evaluation form . Other parameters, such as gestational age, postextubation device, pre-extubation days of life, pre-extubation postmenstrual age, and pre-extubation body weight did not show significance in the univariate logistic regression analysis of the present study. Nonetheless, they were included in the multivariate logistic regression analysis because they were considered critical factors in previous studies [A univariate logistic regression revealed that the parameters associated with successful extubation were birth weight (odds ratio (OR): 1.007, 95% CI: 1.001–1.014), FiO studies ,16.The aforementioned parameters were input into the multivariate logistic regression. After colinear combinations were removed and birth weight and postextubation device were adjusted for, the total score of the extubation evaluation form still exhibited a significant association with successful extubation . This indicates that extubation evaluation form scores can predict whether extubation will be successful, with a high score denoting a higher chance of success. The results are presented in Subsequently, ROC analysis was performed to obtain a prediction model for the total score of the extubation evaluation form after the birth weight and postextubation device were adjusted for. The area under curve (AUC) was 0.938 .The extubation evaluation form was then applied to the study group. The total score of the form was used to predict successful extubation . In the ROC analysis, the AUC was found to be 0.898, and the optimal cut-off point was 5. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were found to be 91.4%, 66.7%, 94.1%, 57.1%, and 87.8%, respectively. The results of the analyses are organized in 2 ≤ 30% and PIP ≤ 15 cmH2O were significant; their crude OR values (95% CI) were 30.0 (2.87–313.47) and 8.0 (1.21–52.88), respectively. We then employed multivariate logistic regression and discovered that only FiO2 ≤ 30% remained significant; its adjusted OR (95% CI) was 30.0 (2.87–313.47), as presented in We used the six indicators in the extubation evaluation form as independent variables and successful extubation as the dependent variable. First, we used univariate logistic regression to conduct an analysis and discovered that only FiO2 ≤ 30% and PIP ≤ 15 cmH2O exhibited an AUC greater than 0.7  and exhibited high individual predictive power for successful extubation [ROC analysis was conducted to determine the individual predictive power of the indicators on the extubation evaluation form. The results revealed that only FiOtubation . The oth2O continuous positive airway pressure. This is continued for 3–10 min, during which time clinicians observe for adverse clinical events, such as bradycardia or desaturation. Whether the trial is a success  is determined by the severity and duration of the adverse events. However, in this method, the mean airway pressure is reduced, and in preterm infants, for whom endotracheal tubes with a small inner diameter and large resistance are used, the spontaneous breathing trials may induce adverse clinical events [A common method for evaluating the suitability of preterm infants for extubation is spontaneous breathing trials . In thisl events .In a systematic review and meta-analysis including patients with a birth weight below 1250 g and a gestational age of 24–34 weeks, spontaneous breathing trials were used to predict successful extubation. The results obtained indicated an overall sensitivity and specificity of spontaneous breathing trials of 95% (95% CI = 87–99%) and 62% (95% CI = 38–82%), respectively [The present study used the extubation evaluation form to predict successful extubation for preterm infants with gestational age < 32 weeks and birth weight < 1500 g, with sensitivity and specificity of 91.4% and 66.7%, respectively. Compared with previous studies, the method adopted by the present study achieved similar predictive results for successful extubation without employing complex and risky spontaneous breathing trials. In addition, the readiness of intubated preterm infants for extubation can be assessed daily using the extubation evaluation form. Therefore, the form’s application will reduce the potential bias present in spontaneous breathing trials; generally, such trials are administered when a physician has determined that a patient may be ready for extubation. This may result in overestimated sensitivity and underestimated specificity [During the ROC analysis, we determined that the AUC was 0.898, with an optimal cut-off point of 5. Thus, for preterm infant populations that meet inclusion criteria similar to those in this study, when such populations achieve a total score of 5 or higher on the extubation evaluation form, extubation may be considered.The selection of the indicator “improved clinical condition” was based on the traditional approach of assessing the effectiveness of clinical treatment, which primarily focuses on the amelioration of preterm infants’ conditions necessitating medical intervention. This approach has gained widespread acceptance as the fundamental framework for evaluating the readiness for extubation in preterm infants ,4.The indicator named spontaneous breath rate ≥ 30 bpm was set based on the attending physician’s experience and the normal neonatal breath rate of 30–60 bpm . We beli2O was set by referencing the setting of mechanical ventilation before extubation in past research and physicians’ experiences. Previous studies have often regarded PIP ≤ 14–16 cmH2O as one of the requirements for the extubation of preterm infants [2O criterion in the ES group (than in the EF group) and had an AUC of 0.733 with regard to the prediction of successful extubation, this indicator was not statistically significant and was, thus, removed from the stepwise logistic regression model. This may be because the number of infants included in this study was small.The indicator named PIP ≤ 15 cmH infants ,22. Alth2 ≤ 30% was set by referencing the setting of mechanical ventilation before extubation in past research and physicians’ experiences [2 ≥ 90% while attempting to lower FiO2 [2 ≤ 30% was the only indicator that remained significant, indicating that it is a crucial indicator in the evaluation of extubation suitability. Nevertheless, in clinical practice, no single indicator should be used alone to determine if the patient is ready for extubation. If FiO2 is used without consideration of the potential for spontaneous breathing or blood gas, the risk of extubation failure may substantially increase [The indicator named FiOeriences . In our wer FiO2 . The resincrease .2 < 70 mmHg and blood pH value ≥ 7.2 were selected as indicators based on the strategy of permissive hypercapnia in the study. In the permissive hypercapnia ventilatory strategy, the ventilator is set at a reduced respiratory rate and tidal volume in the event of a lower pH (≥7.20) and higher PvCO2 (45–65 mmHg). This strategy can potentially reduce apnea and the duration of mechanical ventilation [2 standard to <70 mmHg to facilitate earlier weaning of mechanical ventilation.PvCOtilation ,26. In t2 < 70 mmHg, and blood pH ≥ 7.2—when used alone did not demonstrate sufficient predictive power for successful extubation. This may be because the small sample size of this study provided insufficient evidence for predicting successful extubation solely through those four indicators. The four indicators in this study—namely improved clinical conditions, spontaneous breath rate ≥ 30 bpm, PvCOIn the present study, compared with the ES group, the EF group had a lower birth weight, a longer duration of mechanical ventilation use, and a longer hospital stay. In addition, the EF group had a higher incidence of developing ROP grade 3 or higher and moderate or severe BPD. These phenomena were in line with those of past studies ,27.The study reported an extubation failure rate of 14.6% among preterm infants, indicating a substantial proportion experiencing extubation failure. Previous literature from 2014 documented a comparable population with an extubation failure rate of 25% ± 9% (mean ± standard deviation) , He, F.,Our study had several limitations. One significant limitation was the small sample size. The number of infants included in this study was small, and the ES group was much larger than the EF group. The EF group comprised only six infants. This small number of intubated preterm infants is likely the result of respiratory treatment for preterm infants shifting toward the early use of noninvasive respiratory support ,32. FurtThe assessment of the indicator “improved clinical condition” is performed by physicians and respiratory therapists with the aim of objectively evaluating the progression of preterm infants’ conditions. However, it is essential to acknowledge that, despite diligent efforts to uphold objectivity, a certain degree of subjectivity is inherent in this assessment.2 < 70 mmHg and blood pH ≥ 7.2) were considered lenient, and few physicians would extubate preterm infants who had not achieved these standards. In addition, these two indicators are theoretically affected by the setting of PIP. When the measurements of these two indicators improve, PIP can be reduced. Therefore, regarding effectiveness, PIP may have a more profound influence.Two of the indicators  in evaluating the severity and complications associated with RDS in preterm infants ,38. LUS This study recruited preterm infants from the neonatal ICU of the Kaohsiung Medical University Chung-Ho Memorial Hospital with gestational age < 32 weeks and birth weight < 1500 g. Therefore, whether results of this study may be applied to older infants or those having undergone several intubations and whether the results may be applied to neonatal ICUs in other hospitals with different care methods and standards require further study.In conclusion, the present study suggests that preterm infants who experience extubation failure may face prolonged mechanical ventilation and hospital stays, along with an increased risk of developing severe ROP and moderate-to-severe BPD. After adjusting for birth weight and postextubation respiratory device, the extubation evaluation form showed a significant association with successful extubation, indicating its potential as a predictive tool. However, further validation is needed to confirm the ability of the extubation evaluation form to predict successful extubation. These findings provide a foundation for future research on a larger scale.


Madakoala and Nimiokoala, as well as a new probable koala (?Phascolarctidae). The new taxon, Lumakoala blackae gen. et sp. nov., was comparable in size to the smallest-known phascolarctids, with body-mass estimates of 2.2–2.6 kg. Its bunoselenodont upper molars retain the primitive metatherian condition of a continuous centrocrista, and distinct stylar cusps B and D which lacked occlusion with the hypoconid. This structural arrangement: (1) suggests a morphocline within Phascolarctidae from bunoselenodonty to selenodonty; and (2) better clarifies the evolutionary transitions between molar morphologies within Vombatomorphia. We hypothesize that the molar form of Lumakoala blackae approximates the ancestral condition of the suborder Vombatiformes. Furthermore, it provides a plausible link between diprotodontians and the putative polydolopimorphians Chulpasia jimthorselli and Thylacotinga bartholomaii from the early Eocene Tingamarra Local Fauna , which we infer as having molar morphologies consistent with stem diprotodontians.Diprotodontians are the morphologically and ecologically most diverse order of marsupials. However, an approximately 30-million-year gap in the Australian terrestrial vertebrate fossil record means that the first half of diprotodontian evolution is unknown. Fossil taxa from immediately either side of this gap are therefore critical for reconstructing the early evolution of the order. Here we report the likely oldest-known koala relatives (Phascolarctidae), from the late Oligocene Pwerte Marnte Marnte Local Fauna . These include coeval species of  Much of the morphological and ecological diversity of Australian marsupials is manifested within the order Diprotodontia, which comprises two suborders of primarily herbivorous taxa—Vombatiformes  and Phalangerida (possums and kangaroos)—as well as Thylacoleonidae   Fig. . Molecul17, leaving a massive gap spanning virtually the entire window of Australian marsupial origins19. In this window, taxon descriptions have only been published for metatherians  from the early Eocene (55 mya) Tingamarra Local Fauna (LF) of south-eastern Queensland, all on the basis of isolated dental, periotic and tarsal specimens27. These elements have been interpreted to lack unequivocal synapomorphies linking them with ordinal-level marsupial taxa known from the Australian late Oligocene21. Of these early Eocene taxa, only Djarthia murgonensis has been referred to Australidelphia 22. Other Tingamarra LF marsupials have been argued to bear greater affinity with bunodont polydolopimorphians from South America27.Just two Australian fossil assemblages dating between 110 and 25 mya have yielded mammals29. The distinctiveness of their dental and skeletal morphologies, as well as molecular disparity among modern representatives, suggest long pre-Miocene divergence intervals31. Each family is characterized by a specialized molar dentition that occupies a unique region in a morphospace that includes selenodont (multiple crescents), bunodont (bulbous cusps) and bilophodont (two transverse crests) forms. Identifying homologies between these molar architectures, and reconstructing the transformations that led to their acquisition, has long been considered important to resolving the broader problem of diprotodontian interrelationships40. The vombatiform radiation has been of particular interest; the extant representatives  capture but a small amount of the total morphological diversity known to have existed.By the time the Australian terrestrial mammal record recommences, near the end of the Oligocene (c. 25 mya), most modern diprotodontian families are represented43). Winge44 considered the molar form of the modern koala to be the least specialized among known diprotodontians, being only slightly modified from that of the archetypal metatherian condition. This view was accepted by Archer32, who suggested that selenodonty in diprotodontians could have arisen directly from a peramelemorphian (bandicoot) type morphology. This was based largely on the observation that modern koala and bandicoot molars lack a continuous crest (centrocrista) connecting the paracone and metacone, with the postparacrista and premetacrista instead linked to a cusp in the stylar cusp C and D positions, respectively32. It has since become evident that this morphology is derived within Peramelemorphia47; nevertheless, the view that vombatiforms transitioned from selenodonty to lophodonty has been widely supported35.Koalas (Phascolarctidae) have selenodont molars, characterized by serial crescentic crests that function as leaf cutters during mastication , deriving from an unnamed geological formation on the southern flank of the James Range, Northern Territory, Australia.Local Fauna, and Age. Initial biochronological assessments have suggested that the Pwerte Marnte Marnte LF is late Oligocene age48, and may predate the oldest late Oligocene assemblages from the Etadunna and Namba Formations of the southern Lake Eyre Basin, perhaps corresponding to an as-yet-unnamed land mammal age immediately preceding the Etadunnan48.Genus Etymology. Luma is Latin for ‘thorn’, in reference to the morphology of stylar cusps B and D, and their distinction from the postparacrista and premetacrista, respectively. The gender of the genus is feminine.Species Etymology. Named for Karen Black, whose research has greatly extended our understanding of fossil phascolarctids and other vombatiforms. Genus Diagnosis. As for the species until another is recognized.Specific Diagnosis. A new species that appears most similar in upper molar morphology to members of the Phascolarctidae, with: a deep, U-shaped longitudinal valley between the primary buccal and lingual cusps, rather than being shallow and V-shaped as in selenodont vombatomorphians; and a paraconule on M1 ; more buccally situated protocone and metaconule apices, with a steeper buccal face of the protocone and metaconule compared with the lingual face (except L. garyjohnstoni); stylar cusp B taller than stylar cusp A on M2 ; a small cuspate paraconule that extends up the anterolingual face of the paracone on M1 (except species of Phascolarctos); lacking a neometaconule ; and lacking a hypertrophied anterobuccal terminus of the preprotocrista on M1 .Lumakoala blackae is most similar to Priscakoala lucyturnbullae, sharing: simple enamel surface ornamentation without a neometaconule; stylar cusp B taller than stylar cusp A; cuspate stylar cusps B and D; and a wide stylar shelf. In addition to the differences identified with respect to all phascolarctids, L. blackae differs from Priscakoala lucyturnbullae in having: fine crenulations on the lingual faces of the paracone and metacone; a paraconule on M1; a stylar cusp A that is considerably larger, being similar in height to stylar cusp D; a prominent crista that descends from the apex of the metacone down the anterolingual face; a short and sometimes cuspate rather than elongate lingual cingulum; and a metaconule reduced relative to protocone on M2, resulting in an anterior moiety of markedly greater width than the posterior moiety.Description. The upper molars of Lumakoala blackae . A linear postparacrista descends posterobuccally, meeting the premetacrista proximate to the lingual extremity of stylar cusps B and D. The postparacrista continues weakly beyond its juncture with the premetacrista towards stylar cusp D before terminating. In NTM P12013, the postparacrista is continuous with a crista descending anterolingually from stylar cusp D, which, together, close off stylar cusp B. The postparacrista and premetacrista are structurally independent from stylar cusps B and D, respectively.The metacone is the largest cusp, and the metaconule is the smallest Fig. . The bucStylar cusps B and D are somewhat conical;stylar cusp B is the tallest, being only c. 20% shorter than the paracone Fig. e–h. SeveThe protocone is positioned slightly more posteriorly than the paracone, and slightly more lingual than the metaconule Fig. . A crescAn anterolingual half of an upper molar (NTM P12014) has generally similar morphology to NTM P12012 and NTM P12013. This molar fragment is considered to represent an M1 on the basis that: the posterior moiety seems to have been wider than the anterior moiety; the paraconule is relatively more prominent; the depression on the anterior face deriving from the point of the contact with (presumably) the posterior face of P3, is small and circular . The paraconule is cuspate, positioned on the anterolingual face of the paracone. In common with specimen NTM P12014, two prominent cristae, aligned parallel one another, descend the anterolingual face of the metacone  are more similar in morphology to M. devisi than the upper molar specimens  as the sister taxon to a moderately supported Phascolarctidae + Vombatomorphia (BPP = 0.82); whereas, under maximum parsimony, it formed a polytomy (BS = 0.88) with Cercartetus lepidus, Thylacoleonidae, and a weakly supported Phascolarctidae + Vombatomorphia (BS = 14%). The placement of L. blackae outside of Phascolarctidae + Vombatomorphia was supported by two character-transformations: stC not linked to paracone on M2 (C.I. = 0.33: char. 41); and metacone not linked to stD on M2 (C.I. = 0.50: char. 47). Thylacotinga bartholomaii consistently formed the sister taxon to Diprotodontia .98 steps . The strteps  difference in character state distribution, as indicated by the one-sided Templeton test (P = 0.28–0.43). As such, the hypothesis that Lumakoala blackae is a phascolarctid cannot be rejected. Strict consensus of the most parsimonious trees from the constrained analysis recovered Phascolarctidae as a polytomy composed of Lumakoala blackae, Priscakoala lucyturnbullae, and a clade comprising the remaining koala taxa  of Riversleigh58. Surprisingly, the fossil sites from the late Oligocene  of Riversleigh have not yielded any phascolarctids56. From the late Oligocene Namba and Etadunna Formations of central Australia, phascolarctids are represented in most local faunas, with a single taxon in most, and two in some50. It has been suggested that the high early Miocene koala diversity from Riversleigh may correlate with greater plant diversity in these presumably rainforest communities54. The high phascolarctid diversity in the Pwerte Marnte Marnte LF may thus also indicate the presence of high plant diversity in a wooded paleoenvironment.The discovery of phascolarctids in the Pwerte Marnte Marnte fossil site provides the first record of koalas from the Northern Territory in both the historical and fossil records. Assuming Lumakoala blackae gen. et sp. nov. is a phascolarctid, it is the tenth genus and among the geologically oldest-known. Its discovery further emphasizes the well-noted59 phascolarctid turnover from the late Oligocene  to early Miocene . Lumakoala blackae was relatively small, yielding body mass estimates of 2.2–2.6 kg , and is markedly smaller than other reportedly plesiomorphic phascolarctids , all of which fall within the size range of the modern koala species (see54: 4.1–13.5 kg62). Indeed, L. blackae is among the smallest-known phascolarctids, together with species of Litokoala .The presence of this bunoselenodont molar morphology in a diprotodontian marsupial is phylogenetically significant. This is because the structural independence of stylar cusps B and D, and a continuous centrocrista (postparacrista + premetacrista), are unambiguous symplesiomorphies of the other australidelphian orders , as well as in Didelphimorphia and many other metatherian clades  on M2. Nevertheless, we argue that the upper molar morphology of L. blackae is, actually more plesiomorphic than that of P. lucyturnbullae, because it extends phascolarctid molar morphospace from variations on a strict selenodont form, to bunoselenodonty. From the more plesiomorphic to more derived end of this proposed phascolarctid morphocline, we observe: a reduction of the stylar shelf; integration of stylar cusps B and D into the postparacrista and premetacrista, respectively; reduction of stylar cusp B relative to stylar cusps A and D; and increasing obliquity of the angle formed at the postprotocrista–premetaconulecrista juncture  and Ilaria illumidens . Thylacoleonids have been interpreted, by some, as retaining the symplesiomorphic condition of a continuous centrocrista and a distinct stylar shelf66. It has also been suggested that that the small buccal-most structures on the M1 of thylacoleonids are actually neomorphic, and that the primary buccal cusps, traditionally referred to as the paracone and metacone, are actually stylar in origin5. Many early macropodoids and some phalangeroids bear a small cuspate ridge on the posterobuccal face of the paracone on M138, which has traditionally been identified as stylar cusp C67. However, many early phalangeriforms also bear central cusps on their upper molars, most commonly on the posterior moiety of M1. The latter configuration has led several authors to flag the possibility that the cusps traditionally referred to as the paracone and metacone may instead represent stylar cusps B and D, respectively69, and that any subsidiary structures buccal to them are neomorphic5.It is less clear how metatherian stylar cusp homologies translate to the somewhat bunolophodont molars of thylacoleonids and most early phalangeriforms  retained the symplesiomorphic australidelphian condition of structurally independent stylar cusps B and D, and a continuous centrocrista. If correct, the reduction and/or integration of stylar cusps B and D into proximate structures has occurred convergently in several diprotodontian lineages as they evolved distinct, specialized dentitions.In light of the stepwise morphocline observed between the molar topographies of phascolarctid genera Fig. , and mor12), but none have been identified from the associated Tingamarra LF21. The plesiomorphic molar form of L. blackae provides an unexpected link between the molar morphologies of the Tingamarran taxa Chulpasia jimthorselli and Thylacotinga bartholomaii and the earliest undoubted diprotodontians . Nevertheless, it is worth recognizing that Lorente et al.15 described isolated australidelphian marsupial tarsals, from the La Barda locality (which now appears to be ~ 43.5 mya or younger75) in southern Argentina, that fell within crown Diprotodontia in their phylogenetic analysis. Putative chulpasiines have not been described from La Barda or a second site with a taxonomically similar mammalian fauna, Laguna Fria76, and it is unclear whether the La Barda tarsals belong to any of the taxa from the site known from dental remains15.23, referred Chulpasiinae) together deriving from a microbiotherian-like ancestor83. However, the phylogenetic affinities of polydolopimorphians are quite controversial, both with respect to their ordinal relationships and their monophyly as a single clade74. Furthermore, phylogenomic and retroposon insertion data provides compelling evidence that Microbiotheria is sister to the modern Australian marsupial radiation as whole84 rather than just Diprotodontia specifically.It has also been hypothesized, though contentiously, that Diprotodontia may be allied to Polydolopimorphia  etching and mechanical methods, e.g., rock saws and pneumatic micro-jack toolsTerminology. Higher-level systematic nomenclature follows Aplin and Archer86, with the exception of: the use of the suborder Phalangeriformes Szalay87, sensu Woodburne88; the superfamily Vombatoidea for the clade that includes Vombatidae + Mukupirnidae + Maradidae following Beck et al.30 and Crichton et al.39; and the subordinal placement of Thylacoleonidae as Diprotodontia incertae sedis following Beck et al.5. We also use ?Wynyardiidae to refer to species within the genera Namilamadeta and Muramura, because their inclusion within the family Wynyardiidae has never been robustly demonstrated91. Biostratigraphic nomenclature follows Woodburne et al.28, Archer et al.92 and Travouillon et al.93. The ages of vertebrate bearing localities from the Namba and Etadunna Formations follows Woodburne et al.28 and Megirian et al.29, and those of Riversleigh World Heritage Area follow Archer et al.92 and Travouillon et al.93 sensu Woodhead et al.53.94. Molar cusp nomenclature follows Rich et al.95 with the exception of: the structure reported therein as the hypocone, which is here referred to as the metaconule following Tedford and Woodburne96; and the buccal-most cusps on the upper molars in diprotodontians, which are discussed in Molar position homology follows LuckettInstitution abbreviations. AR Archer Collection, University of New South Wales, Sydney, New South Wales; AMNH Department of Vertebrate Paleontology, American Museum of Natural History, New York, U.S.A.; FUR Palaeontology Department, College of Science and Engineering, Flinders University, Bedford Park, Adelaide, South Australia; NMV P Palaeontology, Museum Victoria, Melbourne; NTM P Museum of Central Australia, Museum and Art Gallery of the Northern Territory, Alice Springs; QM F, Queensland Museum Fossil Collection, Brisbane; S SAMA P Palaeontology, South Australian Museum, Adelaide, South Australia.Phylogenetic analyses. To assess the phylogenetic relationships of Lumakoala blackae, we adopted the morphological dataset from Crichton et al.39, built on that of Beck et al.30, comprising 124 craniodental and 20 postcranial characters, which were scored for 46 taxa. We included a further 13 taxa, for a total of 59, namely: Lumakoala blackae gen. et sp. nov., Koobor notabilis, Stelakoala riversleighensis and Invictokoala monticola (Phascolarctidae); Thylacotinga bartholomaii (putative polydolopimorphian); Djarthia murgonensis ; Naraboryctes philcreaseri (Notoryctemorphia); ‘Bulungu spp.’ (Peramelemorphia); Nimbacinus dicksoni, Muribacinus gadiyuli and Badjcinus turnbulli (Thylacinidae); as well as Keeuna woodburnei and Ankotarinja tirarensis (putative dasyuromorphians). To accommodate additional outgroup agreodontians, and changes to the homology of stylar cusp B in Diprotodontia, while minimizing pseudoreplication: three characters were deleted ; 19 were modified; and 17 were added. The resulting character matrix comprised 138 craniodental and 20 post cranial characters  approach, with gamma rate variability implemented for morphological data maintaining the assumption that only variable characters were scored. The Bayesian analyses were run for 15 million generations, using four independent runs of four chains , sampling trees every 1000 generations and a burn-in fraction of 25%. The post-burn-in trees were summarised using a majority rule consensus of all compatible groups, with Bayesian posterior probabilities as support values.Undated Bayesian analysis of the morphological dataset was carried out in MrBayes 3.2.7a 98. The tree search involved an initial “new technology” search with sectorial search, ratchet, drift, and tree fusing that was run until the same minimum tree length was found 1000 times. From these saved trees a “traditional” search was applied using the tree bisection resection (TBR) swapping algorithm, with the resulting most parsimonious trees combined into a strict consensus tree. Support values for branch nodes were calculated using 2000 standard bootstrap replicates, implemented using a “traditional” search, which results in output as absolute frequencies.Maximum parsimony analyses were also performed on the morphological dataset, in TNT version 1.5 99, to test whether there were significant differences in the tree length and character state distribution of an alternative topological hypothesis, which included a positive constraint enforcing Lumakoala blackae within Phascolarctidae. To statistically compare these phylogenetic hypotheses, a single most parsimonious tree was randomly chosen from the unconstrained analyses, and compared against 50 random equal-most parsimonious trees from the constrained analyses using a one-sided Templeton Test100. This differs from a pairwise Templeton test in that the P value is halved101.Additional parsimony analyses were implemented in PAUP 4.0a169Supplementary Information.


Transplantation of heart following donation after circulatory death (DCD) was recently introduced into clinical practice. Ex vivo reperfusion following DCD and retrieval is deemed necessary in order to evaluate the recovery of cardiac viability after the period of warm ischemia. We tested the effect of four different temperatures (4 °C—18 °C—25 °C—35 °C) on cardiac metabolism during 3-h ex vivo reperfusion in a porcine model of DCD heart. We observed a steep fall in high-energy phosphate (ATP) concentrations in the myocardial tissue at the end of the warm ischemic time and only limited regeneration during reperfusion. Lactate concentration in the perfusate increased rapidly during the first hour of reperfusion and slowly decreased afterward. However, the temperature of the solution does not seem to have an effect on either ATP or lactate concentration. Furthermore, all cardiac allografts showed a significant weight increase due to cardiac edema, regardless of the temperature. Donation after circulatory death (DCD) was recently introduced into clinical practice for cardiac transplantation and may allow a significant increase (up to 48%) in the number of procedures performed per year . Direct Currently, the only clinically available platform for cardiac EVMP is the Organ Care System , which allows a normothermic reperfusion. This system mainly relies on the inflow/outflow lactate levels, coronary flow and visual assessment of myocardial contraction of the unloaded heart which, in combination, act as markers of cardiac viability. Increasing lactate levels might reveal an ongoing anaerobic metabolism and are supposedly associated with poor cardiac recovery after transplantation . HoweverHypothermic oxygenated perfusion was previously implemented in DCD liver and kidney transplantation ,6. HypotDespite the successful clinical implementation of normothermic EVMP, the optimal perfusion temperature is yet unknown. The aim of this study was, therefore, to compare the metabolic profile of the graft with four different temperatures during EVMP in an animal model of DCD heart.This is a study on animals and we had the Ethical approval for this (reference: 2016/UCL/MD/024). The study was conducted in accordance with the guidelines outlined in the “Guide for the Care and Use of Laboratory Animals”, which were published by the National Institute of Health . We used 20 Landrace pigs weighing 50–60 kg. Anesthesia was induced via means of intramuscular injection of 6 mg/kg tiletamine and zolazepam . Following tracheal intubation, inhalation anesthesia was maintained using a composition of enflurane (0–1.5%), nitrous oxide and oxygen. Electrocardiogram was continuously recorded. After median sternotomy, the heart was exposed, and the systemic blood pressure was monitored through a catheter in the distal ascending aorta. Heparin was administered intravenously at 600 IU/kg. After three minutes, ventilation was stopped and cardiocirculatory arrest defined when invasive systolic blood pressure was constantly (>2 min) below 50 mmHg. After a stand-off period of 20 min, the ascending aorta was cross-clamped and the heart flushed with 1 L of cold (4 °C) crystalloid cardioplegia  delivered at a pressure of 65 mmHg via a 16-gauge cannula inserted into the proximal aorta. The heart was vented through an incision in the inferior vena cava and left atrial appendage and further cooled with cold topical saline solution. After termination of cardioplegia, the heart was retrieved in standard fashion and connected to the ex vivo machine perfusion. The timings of the different steps of the procedure are represented in The heart grafts were perfused on the HeartPort System©  .n = 5 in each group) with different perfusion temperatures and pressures  during EVMP. The pressure into the aortic root was checked at the beginning of the reperfusion in order to verify aortic valve competence and efficient coronary perfusion. The solution used was 1 L of KPS-1©  with a partial oxygen pressure between 150 and 200 mmHg maintained through means of the external oxygenator. The KPS-1© had the same composition as the University of Wisconsin (UW) solution originally formulated by Belzer [This perfusion system was previously described in ,10. In sy Belzer . The UW Cardiac metabolism was evaluated through dosage of high-energy phosphates in the myocardial tissue and serum lactate concentration. Five consecutive myocardial biopsies were conducted on the apex of left ventricle during the experiment. The baseline biopsy was taken in vivo on the donor pig before the onset of hypoxia. The 2nd biopsy was carried out after retrieval of the heart but before the onset of EVMP. The 3rd to 5th biopsies were carried out hourly after the beginning of EVMP. The timing of the biopsies is represented in The samples were quickly frozen with liquid nitrogen and stored at −80 °C until further analysis. Myocardial tissue high-energy phosphate content was measured in neutralized perchloric acid extracts of the frozen myocardium, as previously described . AdenosiSerum lactate concentration was also measured during the procedure. Baseline plasma lactate before the onset of hypoxia was measured in the systemic arterial blood and in venous blood from the coronary sinus. The 2nd lactate dosage was conducted at the onset of EVMP in both the perfusate solution on the ascending aorta (inflow) and the solution coming from the coronary sinus (outflow). The 3rd to 5th lactate levels were measured hourly after the beginning of EVMP in the same way. Lactate levels in the blood and perfusate solution samples were measured immediately with the iSTAT system . An increase in lactate concentration in the outflow perfusate revealed an anaerobic metabolism due to poor ATP regeneration following ischemia and was associated with poor recovery .The cardiac grafts were weighted after retrieval and before the onset of EVMP (dry weigh) and at the end of the preservation period (wet weigh). The wet–dry weight ratio was estimated.p < 0.05 were considered statistically significant. All analyses were performed using Stata/IC 15.1 .Continuous variables were expressed as a mean and standard deviation. Differences between groups in the preoperative continuous variables were assessed with a two-way analysis of variance (ANOVA) with additional Bonferroni post-hoc tests for multiple comparisons. The evolution of high-energy phosphates and lactate concentrations over time and differences between groups were assessed with a mixed-effect longitudinal model for repeated measurements. Values of After withdrawal of mechanical ventilation, cardiac arrest (systolic blood pressure < 50 mmHg) supervened after a mean of 6.6 ± 3.4 min with no difference between groups. The time from the withdrawal of ventilation to the cardioplegia injection  was 26.6 ± 3.4 min, with no difference between groups .p < 0.001) groups.Allograft weight before EVMP was significantly larger in Group C; however, the ratio between allograft weight and body weight was similar between groups. Animals in all groups showed an increase in the allograft’s weight at the end of EVMP, and the wet–dry ratio was significantly higher for mild hypothermia (25 °C) and tepid temperature (35 °C) groups compared to the moderate hypothermia (18 °C) and deep hypothermia (4 °C) (p < 0.001), with no difference between groups (1.16 ± 0.48 nmol/mg)  .p < 0.001), regardless of the perfusate temperature (p = 0.7). ADP concentration showed a similar trend, while the AMP concentration showed a slight increase towards the end of 3 h EVMP period   (p = 0.2) .p < 0.001) (4.5 ± 1.5 mmol/L); however, no significant difference was recorded between groups (p = 0.1). Furthermore, we observed a trend toward a slow diminution over the second and third hour of EVMP. There was no correlation between lactate and ATP levels over time. Moreover, the ischemic time was predictive of neither lactate levels nor ATP levels during EVMP (p = ns).Lactate concentration in the perfusate from the coronary sinus (outflow) increased significantly during the first hour of EVMP  group. Furthermore, lactate concentration in the coronary sinus, which is a marker of anaerobic metabolism, kept increasing during the first 2 h of EVMP and started to slowly decrease afterwards, despite no correlation with ATP regeneration. It is probable that the first-hour increase in lactate in the outflow represents the washout of lactate produced in the myocardial tissue during the warm ischemic time, rather than a continued anaerobic metabolism during the EVMP.Finally, we observed the development of myocardial edema as revealed through increased allograft weight after EVMP. Interestingly, we observed that the wet–dry allograft weight ratio, i.e., the ratio between the weight after and before EVMP, was significantly lower for Group A (deep hypothermia) than Group D (normothermia), with the other two groups’ values falling in between Group A and Group D. However, hypothermia groups failed to show improved metabolic profile, despite less edema, than the tepid temperature group.The development of tissue edema following ischemia–reperfusion injury during EVMP is a matter of concern, as it may have an important impact on the cardiac function in the clinical setting. Several elements play a role on tissue infiltration: endothelial dysfunction, which appears early after ischemia (WIT) and cannot be controlled , as wellReperfusion with autologous blood at tepid temperature has several potential advantages, such as highly effective oxygen transport, physiologic oncotic pressure and perfusion pressure. However, the autologous blood needed to prime the machine in the clinical setting (1.5 L) can only be retrieved after circulatory death; therefore, it carries high doses of lactate, cathecolamines, potassium and other metabolites reversed into the circulation from the whole body during the warm ischemic time, causing severe acidosis. Furthermore, platelets activation may cause microvascular obstruction and, nonetheless, at 35–36 °C the myocardial oxygen demand is higher, despite the unloaded state of the heart, than at lower temperatures. Normothermic reperfusion failed to show any significant benefit compared to static cold storage in the clinical setting of brain-death donation (DBD) . InteresFurthermore, hypothermic crystalloid perfusion provides the opportunity to precisely control certain conditions, such as the composition of the solution. Metabolic substrates, such as amino acids and Krebs-cycle intermediates, may be easily added beforehand to the crystalloid perfusion in order to enhance ATP regeneration. Targeted medications, such as vasodilators, anti-inflammatory and anti-platelets agents, and post-conditioning agents, such as glyceril-trinitrate, erythropoietin and zoniporide, may be added to the cardioplegia solution during EVMP in order to reduce IRI and improve cardiac recovery ,20.Although hyperkalemic solutions, such as the UW solution and St. Thomas’ solution, are widely used for heart preservation in the setting of DBD, they may have a detrimental effect in the setting of DCD exacerbating IRI ,22. A noThis study shows that after 26 min of warm ischemic time, ATP levels in myocardial tissue are very low. ATP regeneration is very limited during ex vivo machine perfusion. Lactate concentration keeps increasing during the first hour and descends slightly thereafter. All grafts showed weight increase, particularly with tepid temperature. Nonetheless, the temperature of perfusate seems to affect neither tissue energy recovery nor lactate production over time. The metabolic state of cardiac allografts following DCD is worrisome, and further strategies to improve cardiac recovery during ex vivo machine perfusion should be investigated.The main limitation of this study is the lack of a dynamic test on the allograft to show the extent of cardiac function recovery following EVMP. Therefore, we were not able to say if these allografts were ever able to generate a circulation. However, a Langendorff system and further heart transplantation in a swine model pose significant difficulties, not least the high number of animals needed. Nonetheless, with the machines currently available in the clinical setting, no functional tests can be performed, the heart is beating but unloaded, and evaluation of the allograft at the end of the ex- vivo perfusion is based on visual appreciation of contraction and the over-time trend in lactate production. The second major limitation is the small number of animals in each group, which means that the study is likely underpowered to detect significant differences between groups. Nonetheless, the discovery of very similar and worrisome metabolite concentrations in all groups regardless of the temperature are relevant.


Prehistoric colonization of East Polynesia represents the last and most extensive of human migrations into regions previously uninhabited. Although much of East Polynesia is tropical, the southern third, dominated by New Zealand—by far the largest Polynesian landmass—ranges from a warm- to cool-temperate climate with some islands extending into the Subantarctic. The substantial latitudinal variation implies questions about biocultural adaptations of tropical people to conditions in which most of their familiar resources were absent and their agriculture marginal. Perhaps the most basic question, but one which has never been explored, is the extent to which sailing out of the tropics on long-distance colonizing voyages imposed physiological stress on canoe crews and passengers. In this paper we use trajectories of simulated voyages from Tahiti to New Zealand and Tahiti to Hawaii to obtain along-trip environmental parameters which are then used to model the energy expenditure of these long overseas journeys. Results show that travelers to New Zealand are exposed to much harsher environmental conditions, leading to significantly greater in-trip thermoregulatory demands. For both destinations, travelers with larger body sizes exhibit lower modeled heat loss and hence obtain an energetic advantage, with greater gains for females. Such physiological features, notably of Samoans who probably formed the founding population in East Polynesia, may help explain successful voyaging to temperate latitudes. In migrations beginning ca. 3300 B.P., Austronesian speakers from Island Southeast Asia moved northeast into western Micronesia  and, in the ’Lapita’ migration, southeast through the Bismarck Archipelago as far as Tonga and Samoa . ColonizWhile the number of people that perished in colonizing Polynesia is unknown, it is likely that there were many failed voyages resulting from storms, loss of bearings, depletion of provisions, and other factors. Unfortunately, available archaeological evidence limits our knowledge about which islands were discovered and when. Failed voyages in which the crew perished will never be known  and isolation (frequency of contact) of islands . AmongstSelective pressures related to thermoregulatory demands associated with exposure to the oceanic environment during voyaging or routine utilization of nearshore resources could have influenced the morphology of Polynesian people. Anthropological history on how body shape and size vary by environment dates back to ecogeographical rules established, notably, by Bergmann  and AlleAlthough providing an explanation of the mismatch between Polynesian phenotypes and their tropical environments, the thrifty genotype hypothesis has been criticized for failing to consider archaeological and biological data. The basic tenet of this hypothesis is that early exploratory voyages led to accidental rather than planned settlement. However, evidence of trade and close interconnectedness between Melanesian and Western Polynesian islands can be traced back to 3000 BP through Lapita pottery and obsidian items. The rapid expansion of these artifacts across the southwestern Pacific suggests exchanges between remote islands for extended periods , 27 thatRecent findings of active brown adipose tissue (BAT) in Samoans, provide evidence for the potential role of this thermogenic trait in the migratory success of Polynesians , 30. BATEB), defined as the difference between basal metabolic rate (BMR) and heat loss flux (L). We adopt EB as an estimate of thermoregulatory energy demand to better understand the effort involved in reaching different islands in Polynesia. We analyze EB differences experienced by female and male travelers voyaging from Tahiti to Hawaii and from Tahiti to New Zealand  during these voyages. Lastly, we present results concerning how different environmental conditions would have affected thermoregulation on simulated trips to both Hawaii and New Zealand from Tahiti.In the adopted voyage simulation model , 40, vesTrip energy balance estimates adopt hourly, along-trip-trajectory values of surface wind speed, surface air temperature, and downward solar (shortwave) radiation at the surface. The solar radiation data account for the effects of cloud cover and include direct and diffuse radiation. All data have 0.25˚ × 0.25˚ spatial resolution and are from the same ERA5 ECMWF reanalysis project  used in EB, is given by the difference between Basal Metabolic Rate (BMR) and the rate of net body heat loss (L), with all values in Watts (W):Resting energy balance, BMR, is sex dependent and calculated with a version of the “Oxford Equations” derived from a sample containing 13.9 thousand individuals from 23 distinct ethnicities reported in 174 papers published between 1914 and 2001 [and 2001 :BMR=kcBM is body mass in kg. Kcd2W = 0.04843 and is used to convert the second term on the right-hand side of 2A and 2B from kilocalories per day  to W.The equation for net heat loss expands on the expression by Sørensen  as adoptLd and Lw are heat loss over the dry and wet fractions of the body respectively. Sa is shortwave radiative energy absorption and represents a heat gain, hence the negative sign.Ta is ambient temperature, in K, and Tc body core temperature .The expression in large brackets shared by 4A and 4B is the original  formulatBSA is body surface area, in m2, and a function of BM and height in cm (H):R is thermal resistance, in m2K/W, of all isolating layers, including body fat, and given by the sum:si, ki and cfri being thickness (in m), thermal resistance (in W/mK), and fraction of body covered by isolating layer I, respectively. The model accounts for two isolating layers: subcutaneous body fat (SCF) and clothing. For SCF cfr = 1; k = 0.2 W/mK [s varied in different estimates from 0.005 m to 0.0075 m. Isolation due to clothing is represented by a layer comprised of some type of bark cloth garment with k = 0.0357 W/mK; s = 0.0012 m; and cfr varying in different estimates from 0.25 to 0.50. Adopted cfr values aim to provide a reasonable range of body clothing coverage. Based on standard methods for allocation of surface area percentage to different body parts [crf could be associated, for example, with a cape covering the chest, upper back, and shoulders, while a 0.5 crf value could mean coverage of the whole torso plus arms or whole torso plus thighs. Clothing thermal resistance and thickness values come from Ficus natalensis bark cloth [0.2 W/mK ; and s vdy parts . A 0.25 rk cloth .C, heat loss due to convection in W/m2, is a function of wind speed in m/s (WS) and given by:The adopted reanalysis provides wind speeds at 10 m elevation, which tend to be higher than speeds closer to the surface, leading to a potential overestimation of convective heat loss. Prior to its use in WSz1 and WSz are wind speeds at elevations z1 and z. P = 0.11 and is empirically derived for the height dependency of wind speed over the ocean [Where z and z1 are elevations of the original and adjusted data, set here to 10 m and 1.5 m respectively; he ocean . The 1.5Wfr is the average fraction of the body assumed to have remained wet during trips. The increase in latent heat loss due to presence of water on clothing or skin is not accounted for in the original Sørensen [wfr values of 10% and 20%. These are averages in time so that, for example, a traveler with 40% of their body wet for 12 hours a day and who remained completely dry for the other 12 hours would have a wfr of 20%. The EB model only accounts for dry and wet body surfaces and makes no distinction between different types or levels of “wetness” .Sørensen  expressiSørensen , our modS is incoming solar radiation flux in W/m2; ifr is illuminated fraction of the body, or fraction of the BSA receiving sunlight, with estimates calculated from ifr = 0.3 and ifr = 0.4; α is skin albedo, or the fraction of incident sunlight reflected by the skin, so that 1-α is the fraction of incident sunlight absorbed by the body. Adopted ifr values represent estimates of the illuminated body fraction of travelers that are sitting down and receiving radiation on head, neck, and back (ifr = 0.3) or on the head, neck, chest, and abdomen (ifr = 0.4) [EB is calculated using α values of 0.3 and 0.25 in order to cover the range of skin α observed in present-day low-latitude populations [Where r = 0.4) . EB is culations , 52.EB is estimated for female and male bodies of different height (H), mass (BM), and subcutaneous fat layer thickness (SCF). Three body types are evaluated for each sex. Body types 1 (B1) are based on morphological data from Polynesian populations [2). B2 and B3 differ in their SCFs. In both cases, biometric data from 891 athletes covering 21 sport modalities [To evaluate the effect of body size on trip energy balance, ulations   meaning results are analyzed for every departure day and not specific vessels. EB is estimated for the six body types described in the section above  and low (Lhl) net heat loss EB values are generated. Estimates vary in adopted skin reflectivity and on three parameters that indicate the level of exposure to the elements: fraction of the body that remains wet, illuminated by the sun, and covered by clothing  and three male (B1-3 M) adopted body types. H, height; BM, body mass, BMI, body mass index; SCF, subcutaneous fat layer thickness. Bottom, parameters adopted for the high (Hhl) and low (Lhl) net heat loss The results of our simulations indicate that trips to Hawaii (~23.5 days) and New Zealand , an estimate of the total trip caloric demand of thermoregulation that accounts for trip duration. The distinct along-route environmental conditions  summer, reaching a seasonal minimum of ~965 kcal/day when averages of all heat loss estimates and body types are considered  of fish, ~680 g (1.5 lbs) of cooked taro root, or ~574 g (1.3 lbs) of boiled breadfruit seeds  or some~574 g 1. lbs of brom USDA . AssuminEB ? How can we better estimate success rates of voyages, particularly between tropical and more temperate regions, knowing that not all of them were successful?The region’s colonization history is replete with both exceptional and challenging voyages across the ocean. These range from the first forays into Remote Oceania with Lapita groups in the Southern Hemisphere and those settling western Micronesia  in the Northern Hemisphere between 3300–3000 BP. Later, pulses northward into central and eastern Micronesia  around 2000 BP, and the rapid dispersal c. 1200–1000 BP from Samoa and/or Tonga into East Polynesia after a 2000–1800 year “long pause” , 61, 62,It is clear that navigational (wayfinding) techniques  and boat construction  provided the means for Polynesians to sail long distances and often return home, but they did not guarantee successful passages. Our research demonstrates that energetic demands required to thermoregulate when moving from the tropics to temperate climates would have posed a significant obstacle for voyagers, particularly when traveling southward to New Zealand and nearby islands. The number of unsuccessful voyages will never be known, but it is likely that the greater fat content of East Polynesian voyagers, and their subsequent ability to thermoregulate more effectively, provided the necessary physiological advantages to overcome harsher and colder climates and help ensure survivability.S1 FileDetails of simulated trips including figures with sample trajectories, annual and interannual variability of average trip duration and speed. Table describing the morphological data adopted by the energy balance mode.(DOCX)Click here for additional data file.


Complete and consecutive observation of the gastrointestinal (GI) tract continues to present challenges for current endoscopy systems. We developed a novel upper and mid gastrointestinal (UMGI) capsule endoscopy using the modified detachable string magnetically controlled capsule endoscopy (DS-MCE) and inspection method and aimed to assess the clinical application.Patients were recruited to undergo UMGI capsule endoscopy followed by esophagogastroduodenoscopy. All capsule procedures in the upper gastrointestinal (UGI) tract were conducted under the control of magnet and string. The main outcome was technical success, and the secondary outcomes included visualization of the UMGI tract, examination time, diagnostic yield, compliance, and safety evaluation.Thirty patients were enrolled and all UMGI capsule procedures realized repeated observation of the esophagus and duodenum with detection rates of 100.0%, 80.0%, and 86.7% of Z-line, duodenal papilla, and reverse side of pylorus, respectively. String detachment was succeeded in 29 patients (96.7%) and the complete examination rate of UMGI tract was 95.45% (21/22). All UMGI capsule procedures were well tolerated with low discomfort score, and had a good diagnostic yield with per-lesion sensitivity of 96.2% in UGI diseases. No adverse events occurred.This new capsule endoscopy system provides an alternative screening modality for the UMGI tract, and might be indicated in cases of suspected upper and small bowel GI bleeding.Trial registration DS-MCE-UGI and SB, NCT04329468. Registered 27 March 2020, https://clinicaltrials.gov/ct2/results?cond=&term=NCT04329468. Patients with gastrointestinal (GI) bleeding are recommended to receive esophagogastroduodenoscopy (EGD), colonoscopy and capsule endoscopy , 2, and However, complete and consecutive observation of the GI tract continues to present challenges under capsule endoscopy . For exaChing HL  reportedIn our previous studies , 14, secThis pilot study was a prospective, single-centered, blinded self-controlled study. The study protocol was approved by the Institutional Review Board of Changhai Hospital  and registered at ClinicalTrials.gov. with registration number NCT04329468. All enrolled subjects signed the informed consents according to the Helsinki Declaration.Helicobacter pylori infection status were recorded. Patients with the following criteria were excluded: (1) those with suspected or known gastrointestinal stenosis, obstruction, fistula, or other risk factors for capsule retention; (2) metallic or electronic medical devices implanted; (3) those were pregnant or suspected of pregnancy; (4) unable to cooperate with the examination such as psychotics or in poor general condition of hemodynamic instability; and (5) those with any other contraindications to MCE or EGD procedure determined by endoscopists.Patients aged from 18 to 80 years old and willing to undergo both UMGI capsule and EGD examination with or without gastrointestinal complaints were prospectively recruited in Changhai Hospital from March to August 2020, in which the asymptomatic subjects were healthy volunteers. Examination of UGI tract with/without small bowel were confirmed according to their clinical manifestations and requirements. Basic characteristics, gastrointestinal complaints, and Each participant underwent UMGI capsule endoscopy followed by EGD within one week, and all endoscopy examinations were conducted before treatment of GI diseases. UMGI capsule was carried out by an endoscopist with an experience of more than 1000 cases of MCE procedures and a physician assisting in the control of detachable string. Standardized EGD examination with xylocaine spray for pharyngeal local anesthesia was performed by another well-trained endoscopist, who was blinded to the capsule findings. The final diagnosis was made by combining the results of both modalities. During these procedures, a designated researcher collected the relative data about all evaluation parameters.UMGI capsule endoscopy system  consists of a detachable string attached to the capsule and an upgraded MCE  with an After a standardized preparation regimen  Bowel p.Fig. 1ExThe primary study outcome was technical success of UMGI capsule endoscopy, defined as successful repeated observation of esophagus, stomach, and duodenum and detachment of capsule from string after duodenal examination. Secondary outcomes included the visualization of UMGI tract, examination time, diagnostic yield, discomfort and adverse events associated with the procedure.Visualization of esophagus was indicated by the detection of Z-line defined as at least one image of Z-line was obtained and circumferential viewing of Z-line  . VisualiAs a pilot study to evaluate the clinical utility of the UMGI capsule, sample size was not calculated. Quantitative data were presented as mean ± standard deviation (SD) or median and interquartile range (IQR), where appropriate, and categorical data were described as frequency (percentage). Statistical analyses were performed using SPSS software version 25.0 .Helicobacter pylori infection, 8 subjects received UGI tract examination and 22 participants received UGI tract and small bowel examination. The mean interval between UMGI capsule and EGD procedure is 3.63 days (range 1–7 days).A total of 30 subjects  were enrolled and analyzed, which consisted of 12 asymptomatic volunteers and 18 patients with gastrointestinal complaints including abdominal pain, distention, acid reflux and nausea or vomiting. 4 subjects had a history of Successful repeated observation in esophagus, stomach and duodenum was achieved in all patients, with detachment of capsule from string failed in one patient, and technical success rate was 96.7% (29/30). Among 22 patients demanding small bowel inspection, 21 (95.5%) achieved complete examination with cecal images and the other one failed caused by ileal ulcer with stenosis. No adverse events including anaphylaxis and capsule retention were reported.UMGI capsule endoscopy provided satisfactory visualization of UGI tract mucosa Table . In gastMost patients felt no or mild discomfort during UMGI capsule endoscopy procedure Table . Mean diThe median capsule swallowing time and esophageal examination time were 9.5 s  and 2.42 min , respectively. The mean gastric examination time and duodenal examination time were 6.24 ± 0.98 min and 12.06 ± 4.71 min (range 4.48–23.95 min), respectively. The median pyloric transit time and mean small bowel transit time were 44.50 min  and 297.04 ± 68.86 min, respectively.As described in Table This is the first study that assessed the feasibility and safety of a novel UMGI capsule endoscopy. Our results confirmed that the UMGI capsule could successfully repeat the examination and had sufficient observation of UGI tract in all patients, and realized complete and consecutive UMGI examination within one capsule. This study optimized clinical application of MCE and further benefited patients who require whole UMGI tract examination, including those with definite or suspected GI bleeding, and taking antithrombotic or non-steroidal anti-inflammatory drugs with gastrointestinal complaints .Our study highlighted the role of UMGI capsule in duodenal visualization. The major duodenal papilla presented a good surrogate maker of lesions in proximal small bowel for capsule examination, its identification was still unsatisfactory although improvement of technical parameters might promote the visualization –19. In tUMGI capsule also presented a satisfactory visualization in esophagus and stomach with controllable movement and real-time viewing, merging the advantages of string capsule and MCE. The detection rate of Z-line was 100% with a complete circumferential viewing of 66.7%, similar to that of string capsule , 24 and Helicobacter pylori infection and precancerous lesions, and unable to wash gastric mucosa during inspection require a good gastric preparation and multiple body position changes. Our results showed an excellent capability of UMGI capsule in detecting duodenal lesions, and more mucosal lesions were detected such as erosion and ulcer, 2 of which were located in the reverse side of pylorus. Of note, one submucosal mass suspected as a cyst in the second part of duodenum was missed under capsule, possibly hindered by the folds and loop angulations despite of water ingestion and position changes, indicating that sufficient distention of intestine still needs investigation.This study confirmed the diagnostic ability of UMGI capsule in esophageal diseases with a high consistency with EGD, showing a promising utility in detecting gastroesophageal varices in patients with liver cirrhosis , 27. ForThe detachable string helped effective control of the capsule, contributed to a successful consecutive inspection of the UMGI tract, and avoided the discomfort caused by pulling the capsule out . The majThere are limitations in this trial. First, excellent diagnostic ability of UMGI capsule endoscopy with a small sample size in the pilot study merits validation in large-scale trials. Second, the longer operation time for the UGI tract under UMGI capsule endoscopy than that of EGD, especially during pyloric transit of the capsule, promotes further innovations.Our study provided a safe and feasible modality for complete and consecutive visualization of UMGI tract with high tolerance and diagnostic yield, and UMGI capsule might be indicated in cases of suspected upper and small bowel GI bleeding, possibly associated with or due to the use of anticoagulant/antiplatelet or non-steroidal anti-inflammatory therapy, especially in those who are unwilling and unable to undergo traditional endoscopy. The study provided a basis for innovation of a real “mouth to anus” screening tool in the future.


In the group of water-soluble carvedilol release modifying excipients, which produced relatively fast carvedilol release profiles, POLYOXᵀᴹ WSR N-80 and Polyglykol® 8000 P demonstrated the best carvedilol release control, and in the group of water-insoluble carvedilol release modifying excipients, which produced relatively slow carvedilol release profiles, AVICEL® PH-102 and AVICEL® PH-200 performed best.Solid dosage forms based on hypromellose (HPMC) with prolonged/extended drug release are very important from the research and industrial viewpoint. In the present research, the influence of selected excipients on carvedilol release performance from HPMC-based matrix tablets was studied. A comprehensive group of selected excipients was used within the same experimental setup, including different grades of excipients. Compression mixtures were directly compressed using constant compression speed and main compression force. LOESS modelling was used for a detailed comparison of carvedilol release profiles via estimating burst release, lag time, and times at which a certain % of carvedilol was released from the tablets. The overall similarity between obtained carvedilol release profiles was estimated using the bootstrapped similarity factor (f Hypromellose (HPMC) based hydrophilic matrix tablets are a therapeutically important and widely used controlled-release (CR) dosage form for achieving prolonged/extended drug release. They are designed to hydrate on swallowing, swell and form a ‘gel’ layer of the hydrated HPMC at the tablet surface. The formation of this ‘gel’ layer is responsible for controlling the drug release rate during the passage of the matrix tablet through the gastrointestinal tract (GIT). HPMC is a popular matrix-forming polymer due to its physicochemical characteristics, safety, global compliance, and availability. The 2208 substitution type of HPMC is the most used and has been reported to produce slower drug release profiles than other HPMC types of similar molecular weight. HPMC is available in several viscosity grades, which enables formulators to design matrices with different drug-release mechanisms, i.e., predominantly diffusion, erosion, or mixed diffusion/erosion mechanisms. Direct compression is a simple, low-cost, and suitable method of HPMC matrix tablet manufacture, making it a preferred choice ,4,5,6,7.Several known factors influence the performance of drug release from HPMC matrix tablets. The most important formulation factors are the HPMC substitution type, viscosity grade, and content in tablets, as well as the choice of other excipients  included in the tablets. HPMC batch-to-batch consistency is also important because variations in the molecular weight, degree of substitution, and variations in HPMC particle size can influence the drug release performance. Physicochemical characteristics of the drug play an important role in drug release performance, especially drug solubility. On the manufacturing side, the main compression force is recognized as an important factor as well as the size and shape of the tablets .The focus of our research is investigating the influence of selected excipients, which can be used in a high content as filers within the tablets, on the performance of drug release from HPMC matrix tablets. From the literature review, it is apparent that fillers were the most studied excipients in HPMC matrix dosage forms, where, generally, soluble fillers produced faster drug release profiles than insoluble ones. There are some exceptions to this rule found in the literature, where HPMC matrix failure occurred with insoluble fillers, leading to fast drug release. The majority of research was performed using soluble fillers lactose and mannitol and insoluble fillers dibasic calcium phosphate (DCP), microcrystalline cellulose (MCC), and pregelatinised starch ,27,28,29The main deficiency in the literature regarding the published studies of fillers/excipients’ influence on HPMC matrix performance in general is that a comprehensive selection of excipients was never tested within the same experimental system. There are differences among individual studies in the HPMC substitution type, viscosity grade and content used, differences in the drug used, differences in the tablet shape and size, and differences in the manufacturing procedure and process parameters used, such as the main compression force. The amount of the drug used in the research is not always within the therapeutic range, which makes sense for a once-daily treatment using the chosen drug. Usually, only one representative grade of a filler or excipient is used for each chemical entity of the filler/excipient, and several filler/excipient grades are not researched within the same experimental system. The focus of research found in the literature is mainly on average drug release, whereas the influence of excipient choice on tablet-to-tablet variation is not well covered. In addition, there is no emphasis put on the occurrence of burst release (the uncontrolled and rapid dissolution and release of the drug from the tablets’ surface at the beginning of the drug release profile) or lag time (the delay of the onset of drug release) using different excipients in HPMC dosage forms. Both can have implications for the quality of HPMC tablets as both can lead to unwanted drug release testing results and, in severe cases, failure to meet the drug release specification criteria. Failure to achieve a targeted in vitro drug release profile can result in failure to achieve a targeted in vivo plasma drug release profile, which can have important implications for the safety and efficacy of the dosage form.2) is used for a robust and reliable overall determination of significant differences among experimentally obtained drug release profiles. However, f2 is a single number estimate and does not provide detailed information regarding where in the drug release profiles differences among different formulations occur, nor does it provide any information regarding the occurrence of burst release or lag time. To compare the obtained drug release profiles in detail, it is useful to calculate the times at which a certain % of the drug is released from the tablets. This information is useful in targeting a desired drug release profile and, at the same time, provides an estimate of burst release or lag time. For this purpose, mathematical modelling of drug release profiles is usually applied using established mathematical drug release models such as Higuchi, Korsmeyer–Peppas, etc. Local (Weighted) Regression (LOESS or LOWESS), a general modelling and signal smoothing method, has never been used as an alternative drug release profile modelling and analysis method, although it can model a broad range of different nonlinear shapes.The bootstrapped similarity factor , a lower viscosity grade of polyethene oxide (PEO)—lower than that used in CR formulations or combinations with HPMC ,31—and p® extended-release capsules 80 mg, which is designed for once-daily dosing of carvedilol and is therapeutically equivalent to twice-daily dosing of an immediate-release (IR) carvedilol formulation containing 25 mg of carvedilol (free base) per dose [Formulation parameters, such as the amount of HPMC, drug, selected excipients/drug release modifiers, and other formulation ingredients, were kept constant , along with the target tablet weight, target main compression force, and the manufacturing equipment used in the experiments. The same type, viscosity grade, and batch of HPMC  were used for all experiments. Carvedilol (free base) was used as a model drug substance in a 64.8 mg dose per tablet. This is equivalent to 80 mg of carvedilol phosphate per tablet used in the highest strength of the marketed product Coreg CRper dose ,34. SincThe main research goal is to investigate the influence of a comprehensive selection of excipients on drug release from an HPMC matrix tablet within the same experimental setup and compare the obtained drug release profiles in a detailed way.Carvedilol (free base) was supplied by Krka, d.d., Novo Mesto, Slovenia. Refer to Hypromellose (HPMC) of the 2208 substitution type (HPMC 2208) and nominal viscosity of 15,000 mPa·s (cP), METHOCELᵀᴹ K15M Premium, was obtained from DOW, Specialty Electronic Materials Switzerland GmbH, Luzern, Switzerland. The same batch of HPMC was used in all of the experiments. The certificate of analysis (CoA) stated values of the main functionality-related characteristics (FRCs) for the HPMC batch used, which are summarised in ® 200 Pharma, was obtained from Evonik Operations GmbH, Germany. Refer to Silica, Colloidal Anhydrous (Ph. Eur), i.e., Colloidal Silicon Dioxide (USP), AEROSILMagnesium stearate, Magnesium stearate EUR PHAR Vegetable, was obtained from FACI S.p.A., Carasco, Italy. Refer to In our experiments, different selected excipients as water-soluble and water-insoluble carvedilol release modifiers were used. The information on the used selected excipients is compiled in Tablet composition and summary of used selected excipients as carvedilol release modifiers are presented in The compression mixtures were prepared on a laboratory scale in 1 kg batch sizes using a 6 L biconical mixer at 32 rpm mixing speed. The volume fill % was between 1/3 and 2/3 of the available blender volume, dependent on the bulk volume of prepared compression mixtures. Homogenisation of the ingredients before the addition of lubricant (magnesium stearate) was performed for 8 min, and additional homogenisation after the addition of lubricant was performed for 2 min. The homogenization conditions were chosen based on preliminary experiments.Tablets were prepared via direct compression of compression mixtures using the Killian Pressima rotary tablet press and round, slightly concave (R = 30 mm) punches with a 12 mm diameter and bevelled edges. The same compression speed of 7200 tbl/h, the same fill-o-matic speed of 10 rpm, and the same main compression force of 20 kN (with no pre-compression) were used in all of the performed experiments. The main compression force of 20 kN was chosen based on preliminary experiments to achieve satisfactory friability results of tablets. The targeted average weight of tablets was 648 mg. Individual tablet weight variation was low, with maximal observed relative standard deviation % (RSD %) of 1.5% and an average observed RSD % of just 0.6%.The carvedilol release profiles were obtained using a method previously described by Košir et al. , which p0,LOESS, was used as a burst release indicator/estimator to identify the presence and estimate the extent of burst release  and as a lag time indicator to estimate the presence of lag time . Furthermore, the use of LOESS VBA code and Microsoft Excel’s Solver was combined to iteratively estimate times at which 0% , 5% , 10% … and 90%  of carvedilol was released from the tested tablets. The LOESS-estimated T0%,LOESS i.e., Tlag,LOESS was used to estimate carvedilol release lag time and was iteratively calculated only if F0,LOESS was significantly <0%. All of these LOESS calculations were performed for each of the four tested tablets per experiment, so the necessary statistics to present results, i.e., average ± standard deviation (SD), could be calculated. The relevant results using LOESS are presented in X%,LOESS data), and Figure 2 and LOESS (or LOWESS) is a modern modelling method that is primarily used for smoothing data or signals. It uses local regression, also known as moving regression. For each X value where a Y value is to be calculated, the LOESS technique performs a regression on points in a moving range around the X value, where the values in the moving range are weighted according to their distance from this X value ,37. Micr2) was calculated and the lower bound of the bootstrapped 90% confidence interval for the similarity factor  was estimated; n = 5000 was used in bootstrapping. The results are presented in 2 calculations were performed using DDSolver [2 and the 5th percentile of bootstrapped f2 values were ≥50.0 [2 was ≥50.0 and the 5th percentile of bootstrapped f2 values was not, the two carvedilol release profiles were considered as ‘partially similar’. In the latter case, the mean carvedilol release profiles are similar enough to result in observed f2 ≥50.0; however, a significant portion (>5%) of bootstrapped profiles fail to meet the f2 similarity criteria. In the ‘Results and Discussion’ chapter, the similarity of two carvedilol release profiles is frequently commented as ‘similar’ or ‘partially similar’, where herein established criteria for ‘similarity’ or ‘partial similarity’ of every two compared carvedilol release profiles are strictly adhered to.For each combination of two carvedilol release profiles, the observed similarity factor ). Colloidal silicon dioxide was not measured since this material was not suited for particle size analysis using the mentioned method. The particle size distribution measurement results are presented in The particle size distribution of the materials used in experiments was determined with the laser diffraction method using a Malvern Mastersizer 2000 . A wet dispersion method was used for carvedilol and a dry dispersion method for all other excipients. The results of particle size distribution were given based on the volume-weight diameter (D2), was performed. Calculation of times at which a certain % of the drug was released was utilized, as well as obtaining estimates of F0, a burst release estimator, and Tlag, a lag time estimator. At first, the employment of classical and established mathematical models was tried for this type of analysis using DDSolver, but several problems occurred. Firstly, a suitable mathematical model, which produced a reasonably good fit for all the tested tablets per formulation, could not always be found. This made the estimated drug release data between experimentally determined data points and model-dependent re-estimations of experimentally determined data points unreliable. Consequently, the model-dependent estimations of times at which a certain % of the drug was released were also not accurate enough. Secondly, not every mathematical model available in DDSolver had an option of estimating F0 and/or Tlag, which was intended to be employed in the comparison of drug release performance for tested formulations. To solve these issues, an experimental new application of LOESS was tried. LOESS was utilized for modelling of drug release profiles, estimation of F0,LOESS and Tlag,LOESS (referred to simply as F0 and Tlag in the further text), and in the calculation of times at which a certain % of the drug was released, i.e., TX%,LOESS  as well as among different grades of selected excipients within the same group. In contrast, differences in carvedilol release from formulations using selected insoluble excipients are less significant. A more detailed comment on f2 results is provided in the later text, where individual groups of selected excipients are discussed.The observed files see . The obsX%,LOESS results can be confidently utilized for a detailed comparison of obtained carvedilol release profiles , the viscosity of solution (POLYOXᵀᴹ WSR N-80 > Polyglykol® 8000 P > Polyglykol® 4000 P), and the number of ether groups (-O- groups) per single molecule of PEG/PEO (POLYOXᵀᴹ WSR N-80 > Polyglykol® 8000 P > Polyglykol® 4000 P), which are hydrogen bond (H-bond) acceptors and can interact with hydroxyl groups (-OH groups) of HPMC (hydrogens in -OH groups of HPMC acts as H-bond donors). A larger molecular weight of PEG/PEO results in a higher viscosity of solution [In the PEG/PEO group of formulations, formulations with both PEGs, PolyglykolN-80 see a. Accordtion see . However one see . The car one see . The lat one see . All thesolution ,44 and a® 25 and KOLLIDON® 90 F are not similar according to the f2 metric , the viscosity of solution (KOLLIDON® 90 F > KOLLIDON® 25) [® 25 formulation is only partially similar to both PEG formulations due to the high variability of carvedilol release in the KOLLIDON® 25 formulation  , and posDON® 25) ,44,45, aDON® 25) , which ation see . The carions see , and manMannitol® M 100 and Parteck® M 200, demonstrate faster carvedilol release than crystalline mannitol formulations, C*Pharm Mannidex 16700 and PEARLITOL® 160C   [lag is observed in the mannitol group in comparison to some grades of lactose (the lactose group will be discussed later), and at the same time, fast carvedilol release profiles and high carvedilol release profile variability  see . With thte (IDR) . This hite (IDR) . On the te (IDR) . Furtherte (IDR) ,44,45,49lity see .® M 100 formulation is similar to both PEG formulations, whereas the Parteck® M 200 formulation exhibits only partial similarity according to the f2 metric , SuperTab® 11SD (a spray-dried form of lactose), and Tablettose® 70 (an agglomerated form of lactose). The second cluster consists of Lactochem® Fine Powder  and FlowLac® 100 (a spray-dried form of lactose with a similar particle size as SuperTab® 11SD). Lactose grades in the first cluster demonstrate faster carvedilol release profiles than grades in the second cluster and a significantly greater burst effect, although the burst effect in the second cluster is also clearly present  and Granulated sugar N°1 600  demonstrate the slowest carvedilol release out of all tested formulations using selected water-soluble excipients in tested carvedilol formulations (see 2 metric and do not exhibit significant burst effect nor Tlag (see ® 19 formulation did demonstrate some increase in carvedilol release variability after t = 480 min (8 h) in comparison to the Granulated sugar N°1 600 one. However, variability was still generally low and acceptable , whereas the GLUCIDEX® 19 formulation and the FlowLac® 100 formulation exhibit similar carvedilol release profiles according to the f2 metric. In addition, the carvedilol release profile of the GLUCIDEX® 19 formulation is partially similar to that of the Lactochem® Fine Powder formulation  can be identified as good soluble excipient choices for use in HPMC matrix tablets for obtaining a fairly fast carvedilol prolonged release profile. Specifically, Polyglykol2) is an established and useful tool for the determination of the overall similarity of any two drug release profiles. In addition, the utilization and usefulness of LOESS as a general drug release profile modelling technique was demonstrated, which is a novel application of this technique. It facilitates detailed analysis of differences among the drug release profiles as well as the identification and estimation of burst release and lag time without the need to search for a suitable mathematical drug release model for each different formulation, i.e., drug release profile, which produces a sufficient fit with the experimental data to be practically useful in drug release profile analysis. LOESS modelling can be successfully applied to a wide variety of drug release profiles and utilized in the analysis of drug release if enough experimentally measured data points are available to facilitate good local regression fitting.The similarity factor (f


Thirty to 50% of differentiated thyroid carcinomas include papillary thyroid microcarcinomas (mPTC). Most of these tumors remain clinically silent, have a bright prognosis and a disease-specific mortality <1%. Surgery has been recommended as first line-treatment by current guidelines, the standard treatment being lobectomy. However, surgery has some drawbacks, including potential recurrent laryngeal nerve paralysis, hypothyroidism, hypoparathyroidism, in -patient basis hospital stay, lifelong medication, scarring of the neck, and general anesthesia related risks. Moreover, elderly patients who present severe comorbidities, could be ineligible for surgery, and others may refuse invasive surgery. Another option supported by the American Thyroid Association is active surveillance. This option can be considered as unattractive and difficult to accept by European patients, as there is a 2–6% risk of disease progression. Percutaneous image-guided thermal ablation has been successfully applied in the treatment of liver and lung tumors in the 1990s and 2000s; and has recently been proposed as an alternative to surgery in patients presenting with thyroid diseases. This minimally invasive treatment has similar efficacy, fewer complications, better quality of life and cosmetic outcomes than surgery. We report herein two cases of radiofrequency ablation of mPTC and T2 PTC in elderly patients who were ineligible for surgery. Papillary thyroid carcinoma (PTC) is the most frequent thyroid malignancy. Its increased incidence over the last few decades is attributable to the following factors; the extensive use and continual improvement of high frequency ultrasonography (US) of the neck since the 1990s  and Eu-TWe present herein two cases of incidental evolving PTC in elderly patients who were not eligible for/or who refused surgery. Percutaneous radiofrequency ablation (RFA) was performed as there was no evidence of gross extrathyroidal extension and metastatic neck lymph nodes on pre operative US assessment.A 80 years old female patient, body mass index BMI of 31.5, with no particular medical or surgical history presented with a central left 7 mm evolving (+50% volume increase within three months) thyroid nodule Eu-TIRADS5, Bethesda B6, that was incidentally depicted during a systematic Doppler arterial US examination in 2022 January. There was no suspicious lymph node, and the patient refused both surgery and active surveillance.Multidisciplinary decision was taken to treat this evolving T1a N0M0 mPTC in 2022 May by using percutaneous RFA thermal ablation and US follow-up at 3, 6, 9 and 13 months .A 18 G single VIVA internally cooled electrode needle with 5 mm active tip  was used to deliver thermal ablation. Global delivered energy was 1171.5 Joules representing approximately 2240 J/mL of the treated nodule. Mean procedure pain assessed by numerical rating scale was 0.5/10 and post procedure related pain was nil , mean age, 45.4 years  with 1822 tumors treated with RFA. Fourty-nine patients out of 1822 (=2.7%) underwent one additional RFA session and 1 tumor underwent 2 additional RFA sessions . The pooIn our present cases, patients were informed about advantages and limitations of percutaneous RFA in comparison with the other management options. RFA decision was made in accordance with the patient, by referent physicians at a multidisciplinary council, taking into account the tumor progression of incidentally diagnosed PTC, the refusal for surgery and willingness to undergo safe quick efficient curative treatment with preservation of the thyroid gland in case 1, the ineligibility of surgery with strong tumor progression in severe comorbidity patient in case 2 after one year of active surveillance ,36. As aCase 2 was more debatable as there is currently no guidelines, which may formally valid RFA in larger T2 thyroid tumors, even if RFA indication of mPTC T1a may extend to T1b thyroid tumors. Interestingly Zhao et al. reported the complication rate  of RFA to be related to the size and malignant cause of the thyroid nodule as follows: 2.9% in benign thyroid nodules, and 6.3% in PTC, 5% in T1a PTC, 10.7% in T1b PTC; and 28.6% in T2 PTC patients, as in case 2 . In the Interestingly, it is worthy to note that as RLN is anatomically running more vertical on the left side of the TEG compared to the right side, the RFA retreatment procedure appears to be a little less risky than that on the right side. Moreover, there was still a 2.2 mm non tumoral thyroid tissue between the TEG and the left PTC medial regrowth on last US scanning of the neck A, thus gIt is also important to keep in mind that the RLN palsy incidence after RFA among 1004 RFA treated patients was 6.3%, to be compared to the 6.0% rate reported in 11,370 surgery patients in Gunn et al.’s study .As parathyroid gland preservation is also a main thyroid surgery issue, we would therefore point out that neck US may frequently identify even normal sized parathyroid glands at the posterior aspect of the lower thyroid B, whose The results of our preliminary experience show that image-guided thermal ablation can be safely applied in the treatment of small indolent PTC, offering a potentially curative, minimally invasive treatment to patients in alternative to surgical resection or active surveillance . This hiThese two case reports including (us) T1a and (us) T2 PTC in the elderly were technically successfully treated with percutaneous RFA with no related complications. They illustrate the actual situation where indolent T1 PTC may benefit from active surveillance and/or RFA treatment. They support the evolving leading position of neck high frequency ultrasound in the decision making algorithm and treatment of small low risk papillary thyroid carcinomas, namely in the elderly. RFA provides an alternative and intermediate solution between lobectomy  and active surveillance (AS) and could be considered in the near future as a step-up minimally invasive treatment of local PTC growth under active surveillance or as an initial treatment in PTC patients being anxious about AS and/or refusing or being not eligible for surgery. Further prospective studies are nevertheless needed to validate the role of RFA in (us) T2 N0 PTC patients who are ineligible or contraindicated for thyroid surgery.