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The armor is familiar, but the man inside isn't who you'd expect! He's Arno Stark, the cold and hard-hitting Iron Man of the future - and Tony Stark's descendant has quite a legacy to live up to. Catch all the futuristic action as Arno battles Spider-Man and Blizzard in a time-traveling adventure to stop a nuclear terrorist; faces Machine Man at the behest of Tony's old foe Sunset Bain; and clashes with the original Death's Head, industrial saboteur Wellington Marcus and the high-flying Commodore Q! Can Arno overcome his foes - and himself - to become the hero he's modeled himself after?

Few Australasian studies have assessed persistent pain after breast cancer surgery. This study aims to evaluate the prevalence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand population. Retrospective cross-sectional study of patients who underwent breast cancer surgery between six and 48 months previously. Validated questionnaires were used to assess pain prevalence and impact, psychological distress, and upper limb function. Patients' clinical records were assessed for potential risk factors. Of the 375 patients who were sent questionnaires, 201 were included in the study. More than half of the patients (N = 111, 55%) reported breast surgery related-persistent pain, with 46 (23%) rating the pain as moderate to severe. Neuropathic pain was reported by 21 (46%) patients with moderate to severe pain. Pain interference, upper limb dysfunction, and psychological distress were significantly higher in patients with moderate to severe pain (P < 0.001). Non-European ethnicity (odds ratio [OR] = 5.02, 95% confidence interval [CI] = 2.05-12.25, P < 0.001), reconstruction surgery (OR = 4.10, 95% CI = 1.30-13.00, P = 0.02), and axillary node dissection (OR = 4.33, 95% CI = 1.19-15.73, P < 0.03) were identified as risk factors for moderate to severe pain by multivariate logistic regression analysis. Moderate to severe persistent pain after breast cancer surgery affects many New Zealand patients, and is associated with impaired daily life activities, physical disability, and psychological distress. Large numbers of patients undergo breast cancer surgery annually. This study emphasizes the importance of identification and management of these patients perioperatively.

Abstract Background Few Australasian studies have evaluated persistent pain after breast cancer surgery. Objective To evaluate the incidence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand cohort. Design Prospective cohort study Methods Consented patients were reviewed at 3 timepoints (preoperative, 2 weeks and 6 months postoperative). Pain incidence and interference, psychological distress and upper limb disability were assessed perioperatively. Clinical, demographic, psychological, cancer treatment-related variables, quantitative sensory testing, and patient genotype (COMT, OPRM1, GCH1, ESR1, and KCNJ6) were assessed as risk factors using multiple logistic regression. Results Of the 173 patients recruited, 140 completed the 6-month follow-up. Overall, 15.0% (n = 21, 95% CI: 9.5%—22.0%) of patients reported moderate to severe persistent pain after breast cancer surgery with 42.9% (n = 9, 95% CI: 21.9%—66.0%) reporting likely neuropathic pain. Pain interference, upper limb dysfunction and psychological distress were significantly higher in patients with moderate to severe pain (P < .004). Moderate to severe preoperative pain (OR= 3.60, 95% CI: 1.13–11.44, P = .03), COMT rs6269 GA genotype (OR = 5.03, 95% CI: 1.49—17.04, P = .009) and psychological distress at postoperative day 14 (OR= 1.08, 95% CI: 1.02—1.16, P = .02) were identified as risk factors. Total intravenous anesthesia (OR= 0.31, 95% CI: 0.10 – 0.99, P = .048) was identified as protective. Conclusion The incidence of moderate to severe persistent pain after breast cancer surgery is high with associated pain interference, physical disability, and psychological distress. Important modifiable risk factors were identified to reduce this important condition.

Background: Few Australasian studies have evaluated persistent pain after breast cancer surgery. Objective: To evaluate the incidence, impact, and risk factors of moderate to severe persistent pain after breast cancer surgery in a New Zealand cohort. Design: Prospective cohort study Methods: Consented patients were reviewed at 3 timepoints (preoperative, 2 weeks and 6months postoperative). Pain incidence and interference, psychological distress and upper limb disability were assessed perioperatively. Clinical, demographic, psychological, cancer treatmentrelated variables, quantitative sensory testing, and patient genotype (COMT, OPRM1, GCH1, ESR1, and KCNJ6) were assessed as risk factors using multiple logistic regression. Results: Of the 173 patients recruited, 140 completed the 6-month follow-up. Overall, 15.0% (n=21, 95% CI: 9.5%-22.0%) of patients reported moderate to severe persistent pain after breast cancer surgery with 42.9% (n= 9, 95% CI: 21.9%-66.0%) reporting likely neuropathic pain. Pain interference, upper limb dysfunction and psychological distress were significantly higher in patients with moderate to severe pain (P<.004). Moderate to severe preoperative pain (OR= 3.60, 95% CI: 1.13-11.44, P=.03), COMT rs6269 GA genotype (OR=5.03, 95% CI: 1.49-17.04, P=.009) and psychological distress at postoperative day 14 (OR= 1.08, 95% CI: 1.02-1.16, P=.02) were identified as risk factors. Total intravenous anesthesia (OR= 0.31, 95% CI: 0.10 - 0.99, P= .048) was identified as protective. Conclusion: The incidence of moderate to severe persistent pain after breast cancer surgery is high with associated pain interference, physical disability, and psychological distress. Important modifiable risk factors were identified to reduce this important condition. Keywords: persistent pain; breast cancer; surgery; risk factors; impact; postmastectomy pain

To describe the emergency department (ED) triage of anaphylaxis patients based on the Emergency Severity Index (ESI), assess the association between ESI triage level and ED epinephrine administration, and determine characteristics associated with lower acuity triage ESI assignment (levels 3 and 4). We conducted a cohort study of adult and pediatric anaphylaxis patients between September 2010 and September 2018 at an academic ED. Patient characteristics and management were compared between Emergency Severity Index (ESI) triage level 1 or 2 versus levels 3 or 4 using logistic regression analysis. We adhered to STROBE reporting guidelines. A total of 1090 patient visits were included. There were 26 (2%), 515 (47%), 489 (45%), and 60 (6%) visits that were assigned an ESI triage level of 1, 2, 3, and 4, respectively. Epinephrine was administered in the ED to 53% of patients triaged ESI level 1 or 2 and to 40% of patients triaged ESI level 3 or 4. Patients who were assigned a lower acuity ESI level of 3 or 4 had a longer median time from ED arrival to epinephrine administration compared to those with a higher acuity ESI level of 1 or 2 (28 min compared to 13 min, p < .001). A lower acuity ESI level was more likely to be assigned to visits with a chief concern of hives, rash, or pruritus (OR 2.33 [95% CI, 1.20–4.53]) and less likely to be assigned to visits among adults (OR, 0.43 [0.31–0.60]), patients who received epinephrine from emergency medical services (OR 0.56 [0.38–0.82]), presented with posterior pharyngeal or uvular angioedema (OR, 0.56 [0.38–0.82]), hypoxemia (OR, 0.34 [0.18–0.64]), or increased heart (OR 0.83 [0.73–0.95]) or respiratory (OR 0.70 [0.60–0.82]) rates. Patients triaged to lower acuity ESI levels experienced delays in ED epinephrine administration. Adult and pediatric patients with skin-related chief concerns were more likely to be to be assigned lower acuity ESI levels. Further studies are needed to identify interventions that will improve ED anaphylaxis triage. •51% of ED anaphylaxis patients were assigned a lower acuity ESI triage level.•Children were more likely to be assigned a lower acuity ESI triage level.•ED epinephrine administration was delayed in patients with lower acuity ESI levels.

Broad-spectrum β-lactam antibiotic resistance in Staphylococcus aureus is a global healthcare burden 1 , 2 . In clinical strains, resistance is largely controlled by BlaR1 3 , a receptor that senses β-lactams through the acylation of its sensor domain, inducing transmembrane signalling and activation of the cytoplasmic-facing metalloprotease domain 4 . The metalloprotease domain has a role in BlaI derepression, inducing blaZ (β-lactamase PC1) and mecA (β-lactam-resistant cell-wall transpeptidase PBP2a) expression 3 – 7 . Here, overcoming hurdles in isolation, we show that BlaR1 cleaves BlaI directly, as necessary for inactivation, with no requirement for additional components as suggested previously 8 . Cryo-electron microscopy structures of BlaR1—the wild type and an autocleavage-deficient F284A mutant, with or without β-lactam—reveal a domain-swapped dimer that we suggest is critical to the stabilization of the signalling loops within. BlaR1 undergoes spontaneous autocleavage in cis between Ser283 and Phe284 and we describe the catalytic mechanism and specificity underlying the self and BlaI cleavage. The structures suggest that allosteric signalling emanates from β-lactam-induced exclusion of the prominent extracellular loop bound competitively in the sensor-domain active site, driving subsequent dynamic motions, including a shift in the sensor towards the membrane and accompanying changes in the zinc metalloprotease domain. We propose that this enhances the expulsion of autocleaved products from the active site, shifting the equilibrium to a state that is permissive of efficient BlaI cleavage. Collectively, this study provides a structure of a two-component signalling receptor that mediates action—in this case, antibiotic resistance—through the direct cleavage of a repressor. Cryo-electron microscopy structures of Staphylococcus aureus BlaR1 reveal dynamic signalling states regulating broad spectrum β-lactam antibiotic resistance through cleavage of the transcriptional repressor BlaI and induced expression of the β-lactamase blaZ and the β-lactam-resistant cell-wall transpeptidase mecA .

Myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and fibromyalgia (FM) are debilitating disorders with overlapping symptoms such as chronic pain and fatigue. Dysregulation of the endogenous opioid system, particularly µ-opioid receptor function, may contribute to their pathophysiology. This study examined whether epigenetic modifications, specifically µ-opioid receptor 1 gene (OPRM1) promoter methylation, play a role in this dysfunction. Using a repeated-measures design, 28 ME/CFS/FM patients and 26 matched healthy controls visited the hospital twice within four days. Assessments included blood sampling for epigenetic analysis, a clinical questionnaire battery, and quantitative sensory testing (QST). Global DNA (hydroxy)methylation was quantified via liquid chromatography–tandem mass spectrometry, and targeted pyrosequencing was performed on promoter regions of OPRM1, COMT, and BDNF. ME/CFS/FM patients reported significantly worse symptom outcomes. No differences in global (hydroxy)methylation were found. Patients showed significantly higher OPRM1 promoter methylation, which remained after adjusting for symptom severity and QST findings. Across timepoints, OPRM1 methylation consistently correlated with BDNF Promoter I and Exon III methylation. This is, to the best of our knowledge, the first study examining OPRM1 methylation in ME/CFS/FM. Increased OPRM1 methylation in patients, independent of symptoms or pain sensitivity measures, supports the hypothesis of dysregulated opioidergic signaling in these conditions.

What is Christian worship all about? There are many divergent views toward this essential experience in Christian life. To many, worship is a time of praise and singing. To some, it is a message from the pulpit or it belongs to the legacy of a preacher. To many still, worship is a time for signs and wonders. Nevertheless, for me, worship is a time of meeting the risen Christ, a miracle on the road to Damascus. It is an opportunity and experience of salvation. All of these can become possible, as I firmly believe, only through the sacerdotal office of Christ for our sake. The study of this topic shall be done systematically according to the following: Chapter 1 shall look into statements and facts from Scriptures of Christ's call and His role as our High Priest, His taking our place for the sake of our eternal destiny, and Christ's decisive victory to bring about the once-and-for-all assurance for all who come to believe and trust in Him and His work. Chapter 2 will focus on the crucial factors of Christ's sacerdotal work to ensure our proper understanding of God's covenant made with His people, and the misuse of the law in our own hands as reflected in the history of His chosen people. The crucial importance of following the Scriptures for the proper use of the law in Christian life shall also be stressed in this chapter. Chapter 3 shall be a reflection on the blessings and promise of God made to those who come to rely on Christ's sacerdotal work. Such a turning point in life can be best described as an act of a human being, and yet it remains a work of God through the operation of the Holy Spirit. Chapter 4 is a theological research into characteristics of Christ's priestly office and work as compared to that of the Levitical order and the Melchizedek tradition presented by the author of the Epistle of Hebrews. Chapter 5 shall deal with the meaning and implication of Christ's sacerdotal work in relation to worship with the hope of deepening our earnest desire to be more intimately involved in the missiological task of reaching out with the saving message of Jesus Christ even in our worship time experience. Chapter 6 is a reflection on the faith and practice of the Christian Church (Disciple of Christ) in worship, its understanding of the person and works of Christ in terms of the means of grace in worship. Some changing trends in worship will also be included.

Ceramics matrix composites (CMC) combines the desirable characteristics of ceramics with good mechanical properties and are considered the most attractive material alternative for high temperature corrosive environments. Manufacturing CMC's is difficult due to the high melting temperature of the constitutive materials and the lack of material databases on these materials. Chemical vapor infiltration (CVI) is an attractive net-shape fabrication process for these materials and results in high quality composites. A new type of chemical vapor infiltration is explored in this work. The Alternating Flow Chemical Vapor Infiltration (AFCVI) uses an isothermal reactor and forced flow to introduce the reactant gases into the interior of the preform. The gas flow is alternatively introduced from opposite sides of the preform to densify the composite. Composites fabricated using this process show improvement over existing isothermal processes and results in a very short cycle time. AFCVI does not, however, produce as uniformly densified parts as the forced flow thermal gradient. Initial modeling of this process emphasized the need for more accurate kinetics to accurately capture the deposition profile in the preform. Kinetic parameters used in most CVI modeling are obtained from chemical vapor deposition (CVD) experiments. There are several fundamental differences between CVI and CVD that may affect the kinetics obtained and may limit the applicability of CVD kinetics in CVI. Namely the critical dimensions such as pore spacing and surface area to volume ratios are drastically different in these two systems. A new technique of determining the kinetic parameter specifically for CVI of SiC is developed and tested. This system consists of small 400 Um holes drilled in a solid graphite substrate. The results show excellent correlation at lower temperatures. Kinetic parameters obtained from CVD experiments severely over-predict the deposition thickness. The new parameters capture both the shape and absolute coating thickness in the CVI preform. The information obtained using this technique is unique to the kinetics preforms and gives CVI-specific knowledge.

This is an ethnographic study of the Paiwan, an Austronesian group of about 55,000 people living in the southern part of the island of Taiwan. The Paiwan subsists on swidden agriculture and hunting, supplemented by cash income generated from salary jobs. The people is renowned for their highly formalized social hierarchical system and a sophisticated artistic tradition in wood and slate carving, embroidery and beads work. The thesis follows an ethnohistorical point of view, and tries to present the process of structuration of Paiwan society. Two major social institutions are focused upon: house and social hierarchy. They are treated as loci in which practices of human agents are modeled as well as modeling the trajectory of history. Two Paiwan villages, Parilaiyan of the northwest region and Tjuabar of the east coast, provide the ethnographic material for discussion. In Chapter Three through Five, the Paiwan house is, first, presented as a focal idiom in ethnohistorical accounts, then, as a social unit with a corporate sole, and, finally, as a cultural institution that interplay with people in a dialectic process of mutual definition. In examining Paiwan social hierarchical system, I make the distinctions between two dyadic relationships, according to the material of Parilaiyan: the landlord-tenant dyad and the patron-client dyad. This is, then, compared to the supra-village chieftain system of Tjuabar. With this comparison, it is clear that economic privilege is not always an integral part of the status of Paiwan aristocrats; nor is their political power universally recognized. Only ritual privileges of the aristocrats are common and prominent. The last part of the thesis is a description of the most spectacular ritual practice of the Paiwan, now still thriving in Tjuabar village, the Five-year Rite (leve-leveq-an). The rite, based on the history of inland migration originated from the sacred mountain, and the belief of the returning of ancestral spirits from the sacred mountain to each village, is a superb illustration of the place of aristocrats in the embodiment of Paiwan ethnohistory.