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This observational case–control study evaluated the anterior ocular segment parameters of patients with celiac disease with a Scheimpflug imaging system and compared them with those of a healthy controls group, highlighting potential differences related to the underlying pathogenetic mechanisms of the disease. Seventy celiac patients and 70 healthy subjects were assessed with a comprehensive ophthalmological evaluation, including clinical history, Snellen best-corrected visual acuity, axial length (AL) measurements with IOLMaster, and anterior segment tomographic evaluation with Pentacam HR. The measurements of all keratometry values, astigmatism, steep axis, anterior and posterior Q value (asphericity), pupil diameter, pupil center, corneal apex, the thinnest point, corneal volume, anterior chamber depth from the epithelium, anterior chamber depth from endothelium, anterior chamber volume, and iridocorneal angle were also appraised. The two study groups were comparable and similar for gender, age, and AL, with no statistically significant differences regarding all analyzed tomographic parameters. Thus, ocular anterior segment parameters of celiac patients are not significantly different from those of healthy subjects, suggesting no underlying pathogenetic implications of celiac disease affecting the assessed structures. Nevertheless, a routine ophthalmological examination for all celiac patients should be recommended throughout their lifetimes due to the potential ocular manifestations of the disease.

Endoscopic sphincterotomy (ES) is commonly performed during endoscopic retrograde cholangiopancreatography, and bleeding is a severe adverse event. PuraStat is a peptide developed as a hemostatic agent for endoscopy. We report its use as a hemostatic strategy in post-ES bleeding refractory to combined hemostasis. A patient with choledocholithiasis underwent endoscopic retrograde cholangiopancreatography for stone removal. After the ES, severe bleeding refractory to the injection of diluted epinephrine around the bleeding source and metal stent placement occurred. Hemostasis was achieved with the application of the hemostatic gel. We reported the use of novel self-assembling hemostatic gel as an effective therapeutic tool for post-ES refractory bleeding.

Psychological stress and anxiety, such those generated by forced quarantine, affect gastrointestinal symptoms course in patients with functional gastrointestinal disorders. Thus, our aim was to assess, in a cohort of patients regularly followed up in a devoted outpatient clinic of Southern Italy, the association between their gastrointestinal symptoms changes, stress, and anxiety reported during the Italian lockdown.We recruited patients from the outpatient clinic of the University of Salerno, devoted to functional gastrointestinal disorders, selecting only patients for whom an evaluation was available in the last 6 months before the lockdown. Gastrointestinal symptoms were evaluated at each visit through standardized questionnaire and pooled in a database. On 45th days from the beginning of the lockdown, patients were re-assessed by phone with the same questionnaire. Anxiety and stress levels were assessed through a self-administered online questionnaire based on Generalized Anxiety Disorder 7 test and Perceived Stress Scale 10 test.The intensity-frequency scores of several upper gastrointestinal symptoms improved (Wilcoxon test0.05). Higher anxiety levels had a higher risk of worsening chest pain (OR 1.3 [1.1-1.7]), waterbrash (OR 1.3 [1.0-1.7]), epigastric burning (OR 1.3 [1.0-1.6]), and abdominal pain (OR 1.6 [1.0-2.3]). When compared to the interval preceding the outbreak, half of the patients declared their symptoms remained unchanged, 13.6% worsened, and 36.4% improved.During the COVID-19 quarantine, there was an improvement of the majority of upper gastrointestinal symptoms in our patients, and anxiety seems an important risk of worsening few of them.

The ITER project is under construction in Cadarache, France, to assemble and operate an experimental nuclear fusion facility. The aim of this paper is the description of the implementation of the French Order of February 7, 2012, concerning Basic Nuclear Installation (also called “INB” Order) [1] within the European Union Domestic Agency (EU-DA), specifically on the Electron Cyclotron Upper Launcher (EC UL). The EC UL will be used for the control and heating of the ITER plasma. The launcher includes the port plug and related in-vessel items (nuclear shielding, blanket module, and optics) and the ex-vessel first confinement items (diamond window, isolation valve, waveguides, miterbends, tapers and port plug back end).

ITER will be equipped with four EC (Electron Cyclotron) Upper Launchers (UL) of 8 MW microwave power each with the aim to counteract plasma instabilities during operation. These launcher antennas will be installed into four upper ports of the ITER vacuum vessel. Beside their functional purpose the port plugs which are the structural system of the launchers, have to provide as much shielding as possible in order to protect adjacent components from neutrons and photons and to minimize the shutdown dose rate in the port interspace and the port cell, being located further back in the ITER Tokamak building. Thus appropriate shielding blocks shall be installed at proper positions inside the plug. In addition several structural components will be dressed up geometrically in order to provide maximum shielding capability. This paper presents the general design of the shielding elements and their technical integration into the EC Upper Launcher.

The ITER torus diamond window unit is part of the electron cyclotron (EC) upper launcher (UL) used to direct high power microwave beams generated by the gyrotrons into the plasma for heating and current drive (H&CD) applications. The UL consists of an assembly of ex-vessel waveguides (WGs) and an in-vessel port plug (PP). The diamond window units form vacuum and confinement boundaries between the torus volume and the transmission lines (TLs) which guide beams between 1 and 1.5 MW at 170 GHz from the gyrotrons to the launcher. There are eight window units attached to the assembly of the WGs, one unit for each WG. The design strategy of the unit is to have a very rigid outer frame able to withstand the potential external loads acting on the unit while thin copper cuffs brazed to the diamond disk allow indirect cooling of the disk to remove the EC power absorption during the beam transmission. The load combination given by the stringent ITER seismic level 2 (SL-2) event occurring during baking of the torus vessel is the design driver for the outer frame of the unit. In fact, the assembly of the WGs is connected from one side to the ceiling of the ITER port cell area by a support frame and to the UL PP from the other side. Movements of the torus vessel due to baking, seismic and plasma disruption events, result in forces and moments acting on the units. Furthermore, during a seismic event, the unit is subject to additional loads induced by the oscillation of the support frame attached to the ceiling. An outer frame surrounding the window unit is thus required to ensure the structural integrity and the confinement function of the unit. This paper shows how the design of the window unit was assessed and optimized by finite element method (FEM) analyses. A specific methodology was developed to carry out the analyses with respect to the seismic and baking loads. At Karlsruhe Institute of Technology (KIT), FABRY-PEROT resonators measure the loss tangent of the diamond disk and it is then used as input to the computational fluid dynamics and FEM analyses aiming to assess the design. The impact of the FEM analyses on the design of the window unit is discussed also together with the manufacturing aspects of the unit.

A 49-years-old woman with a recent history of tenesmus, constipation, abdominal and rectal pain referred to our Unit. There was no previous history of rectal bleeding or a family history of gastrointestinal diseases. Laboratory tests showed haemoglobin 10.9 g/dl, MCV 72fl, ferritin 18 U/l. Physical examination was normal. The patient underwent a colonoscopy which identified a single ulcer of 2.5 cm of diameter without bleeding signs in the distal rectum, 4 cm from the anal margin. Histopathological examination revealed shallow ulceration with fibrosis in lamina propria. We decided to treat the ulcer with one application of Purastat. Four weeks later, a follow-up colonoscopy revealed a complete mucosal healing with only mild residual mucosal erythema. Solitary Rectal Ulcer Syndrome (SRUS) is an uncommon benign proctologic disease usually affecting young adults with a prevalence of 1:100.000 per year, equally affecting women and men with a slight predominance in young women. SRUS is characterized by chronic rectal pain and bleeding, constipation, incomplete evacuation, tenesmus and mucous discharge impairing the patients’ quality of life. In past years several topical agents have been used reporting clinical improvements, also if none of them has been evaluated in prospective controlled trials. Purastat (3D-Matrix Europe SAS, France) is a novel self-assembling peptide developed as a haemostatic agent for endoscopic and surgical procedures. In addition to the known haemostatic effect, it has been hypothesized that the activated Purastat nanostructure favors the cell and tissue proliferative process since the similarity of the activated Purastat 3-D nanostructure with the natural extracellular matrix (ECM-SM) scaffold material would result in an adequate adherence of cells and regenerative tissues, achieving more effective healing of the mucosa. Based on this hypothetical re-epithelizing property of Purastat, we decided to use it in this patient, achieving mucosal healing and symptoms improvement.

Background Psychological stress and anxiety, such those generated by forced quarantine, affect gastrointestinal symptoms course in patients with functional gastrointestinal disorders. Thus, our aim was to assess, in a cohort of patients regularly followed up in a devoted outpatient clinic of Southern Italy, the association between their gastrointestinal symptoms changes, stress, and anxiety reported during the Italian lockdown. Methods We recruited patients from the outpatient clinic of the University of Salerno, devoted to functional gastrointestinal disorders, selecting only patients for whom an evaluation was available in the last 6 months before the lockdown. Gastrointestinal symptoms were evaluated at each visit through standardized questionnaire and pooled in a database. On 45th days from the beginning of the lockdown, patients were re‐assessed by phone with the same questionnaire. Anxiety and stress levels were assessed through a self‐administered online questionnaire based on Generalized Anxiety Disorder 7 test and Perceived Stress Scale 10 test. Key Results The intensity‐frequency scores of several upper gastrointestinal symptoms improved (Wilcoxon test

Background: Coronavirus disease 2019 (COVID-19) causes not only severe illness but also detrimental effects associated with the lockdown measures. The present study aimed to evaluate reported lifestyle changes in a cohort of adults in Italy, including physical exercise, food choices, and psychological wellbeing, after two months of lockdown. Methods: A web survey on social media (Facebook and LinkedIn) of 32 multiple-choice questions aiming to evaluate the impact of the national COVID-19 lockdown in a sample of Italian adults. Results: We received 1378 complete responses (women 68.3%, mean age 39.5 ± 12.5 years). The percentage of participants reporting regular exercise decreased during lockdown (52 vs. 56.5%). The vast majority of people continued to consume the three traditional meals per day, but the consumption of meat, fish, and eggs significantly decreased. Women reported more frequent anxiety, sadness, fear, and feelings of insecurity than men. The factors predicting the worst outcome during the lockdown were being a woman, low education and income, gastrointestinal diseases. Conclusion: The lockdown has had a limited impact on food choices and physical exercise in Italian adults of our series, since most of them made an effort to improve their lifestyle. However, women with gastrointestinal diseases reported more frequent negative feelings and poor adaptation to the lockdown.

Carolina Ciacci,1 Mario Gagliardi,1 Monica Siniscalchi,1 Monica Ruotolo,1 Antonella Santonicola,1 Najla Hajji,1 Fabiana Zingone2 1Celiac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Salerno, Italy; 2Gastroenterology Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, ItalyCorrespondence: Carolina CiacciCeliac Center at Department of Medicine, Surgery, and Dentistry, Scuola Medica Salernitana, University of Salerno, Baronissi, Salerno, 84081, ItalyEmail cciacci@unisa.itIntroduction: Celiac disease (CeD) diagnosis has worldwide shared protocols. Conversely, follow-up of patients is still an object of study. Gluten immunogenic peptide detection in the urine (GIP) appears to be a new and efficient method for dietary gluten control of patients. The present study aims to assess the clinical usefulness of the GIP point-of-care urine test in the follow-up of symptomatic and asymptomatic patients with CeD before and during the COVID-19 lockdown in Italy.Methods: Thirty adult CeD patients on a gluten-free diet (GFD) were enrolled before and during the COVID-19 lockdown through follow-up visits or remote consultation. Patients underwent anthropometrical evaluation, dietetic interview, and State-Trait Anxiety Inventory (STAI). Then, two groups were formed: symptomatic and worried about gluten contamination. Each patient received 5 GIP point-of-care tests to perform a maximum of 5 times in the following 5 weeks in case of symptoms or anxiety state due to hypothesized gluten contamination.Results: Sixteen symptomatic patients and 14 patients with concerns related to gluten contamination were included. There were no differences in age, BMI, compliance to GFD and GIP positive tests between the two groups. Worried group showed a borderline higher level of anxiety than symptomatic group (p = 0.06), with a significant minor percentage of patients reporting “no or low anxiety” (14.3% vs 50% p = 0.03). The symptomatic patients showed a higher rate of diarrhea than worried group (25% vs 0%, p = 0.04). Gluten in urine samples was globally found in 8 out of 30 cases (26.6%).Conclusion: The GIP test is a tool that can be used as a point of care test to assess adequate compliance with GFD and reassure symptomatic CeD patients from the feeling of anxiety for gluten contamination, especially during the COVID-19 pandemic.Keywords: GIP, POCT gluten contamination, GFD, anxiety, burden, celiac disease

Bariatric surgery (BS) is a pillar for the treatment of morbid obesity and its related comorbidities. However, it might be associated with long-term deficiencies and absorption issues. Adherence to micronutrient supplementation is a crucial aspect in the management of these patients.The aim of the present survey was to evaluate the adherence to micronutrient supplementation in a cohort of Italian patients submitted to BS (BS patients) and to identify predictors of adherence using a self-administered, anonymous, internet-based instrument.Patients who underwent BS over the last decade in a single center were invited to participate to a self-administered, anonymous, internet-based survey consisting of a 23 items structured questionnaire evaluating: a. demographic information b. Bariatric procedures performed; c. Indication to BS; d. Lapse of time since last BS, e. Frequency of follow up visits post-surgery, f. Perception of well-being post BS; g. Adherence to micronutrient supplementation; h. Changes in their quality of life and self-esteem.We received an automatic notification of delivery from 1100 out of 1600 BS patients and 290 (81.4% female, mean age 39.5 ± 10.1 years) completed the questionnaire. The main reported bariatric procedures were: Sleeve Gastrectomy (59%), Roux-en-Y Gastric Bypass (31%) and Adjustable Gastric Banding (7.2%). Only 33.1% of the sample acknowledged to have taken all recommended medication regularly. BS patients who underwent malabsorptive procedures and had their last follow up visit more than 5 years earlier, had a higher risk of being nonadherent to micronutrient supplementation. Conversely, BS patients in their forties seemed more likely to adhere to treatment recommendations. Losing more weight was the only independent risk factors for nonadherence to micronutrient supplementation, independently from patient's perception of wellbeing.After BS, several clinical and psychosocial factors might predict nonadherence to micronutrient supplementation.

Patient: Male, 77-year-old Final Diagnosis: Enterocolic fistula Symptoms: Diarrhea • pain and guarding of the abdomen • weight loss Medication:— Clinical Procedure: Colonoscopy with colon biopsy Specialty: Gastroenterology and Hepatology Objective: Unusual clinical course Background: Endoscopic full-thickness resection represents an innovative procedure, used in selected patients that allows lesions en-bloc resection with an integral wall specimen available for histopathological definition. Bleeding and perforation are known to be the most frequent procedure-related adverse events. We report a case of enterocolonic fistula as complication of an endoscopic full-thickness resection. Case Report: A 77-year-old male, with a personal history of right-hemicolectomy for a colonic adenocarcinoma presented to our department for a routine colonoscopy that showed the presence of a 25 mm lateral spreading tumor localized at about 50 cm from the anal margin. A full-thickness resection of the lateral spreading tumor using the over-the-scope clip device was performed. After 4 weeks, because of abdominal pain, weight loss, diarrhea, and signs of malnutrition, the patient underwent a new colonoscopy showing hyperemic mucosa with ulcerations in all colonic segments and, at the site of the previous endoscopic full-thickness resection, an orifice of an entero-colonic fistula. The histological definition was suggestive for ulcerative proctocolitis and confirmed the presence of small bowel mucosa at fistula orifice. An intussusception at the level of fistula with consequent intestinal obstruction caused a worsening of clinical conditions and finally the patient death for a septic peritonitis. Conclusions: Full thickness resection represents an innovative tool for en-bloc resection of gastrointestinal tumoral lesion, but procedural complications and limitations must be considered before performing this procedure.

Background Obese patients (Ob) with a binge eating disorders (BED) behavior pattern have a higher prevalence of postprandial distress syndrome (PDS) compared to Ob without a BED behavior pattern, while an increase of PDS has been described in Ob after sleeve gastrectomy (SG). Hedonic response to a meal is dissociable from satiation in healthy subjects. Anhedonia is the lowered ability to experience pleasure. There are no studies investigating the presence of anhedonia in Ob with and without SG and its relationship to PDS symptoms. Aim To assess the relationship among anhedonia, BED and upper gastrointestinal symptoms in two group of morbidly Ob with and without SG. Methods Eighty-one Ob without SG, 45 Ob with SG and 55 healthy controls (HC) were studied. All subjects fulfilled the binge eating scale (BES) to investigate BED, the validated 14 items Snaith-Hamilton pleasure scale (SHAPS) to assess Anhedonia as well as the Beck Depression Inventory-II (BDI II) and State Trait Anxiety Inventory (STAI) questionnaires to screen for depression and anxiety. All patients underwent a standardized questionnaire investigating the intensity-frequency scores (0-6) of upper gastrointestinal symptoms and were diagnosed for the presence of functional dyspepsia (FD) and its subtypes according to ROME IV criteria. Results Ob without SG who were positive for BED had a 4.7 higher risk of FD compared to Ob without SG who were negative for BED (OR: 4.7; 95.0%CI 1.23-18.24; P = 0.02). STAI-Y2 scores were significantly higher in Ob without SG positive for BED (42.2 ± 1.5 vs Ob negative for BED: 39.6 ± 1 .0, P = 0.04), while SHAPS scores and BDI II did not differ in the two groups (1.16 ± 1.30 vs 0.89 ± 1.02, P = 0.49). A lower prevalence of BED (BES > 17: 11.4% vs 40.7%, P = 0.001) and BDI-II (6.8 ± 1.2 vs 13.8 ± 1.9, P = 0.005) was reported in Ob with SG than Ob without SG, on the contrary total mean scores of STAI-Y1 and STAI-Y2 were significantly higher in Ob with SG than Ob without SG. Thirty-five percent of Ob with SG fulfilled the diagnosis of FD. SHAPS mean scores and the prevalence of anhedonia did not differ among the two groups (18.2 vs 8.1%, P = 0.2). Fifty-four percent of Ob with SG achieved surgical success excess weight loss > 50%. Excess weight loss was negatively related to SHAPS total mean scores [adjusted B: -7. 099 (95%CI: -13.91 to -0.29), P = 0.04]. Conclusion Ob without SG showed a higher prevalence of PDS, mood disorders and anxiety when positive for BE behavior compared to those negative for BE behavior, whereas no differences were found in SHAPS score. Ob with SG showed a higher prevalence of PDS compared to Ob without SG. Concerning psychological aspect, BED and depression are less frequent in the Ob with SG, while both state and trait anxiety are significantly higher. Moreover, the more an Ob with SG is anhedonic, less surgical success was achieved.

The Mirror one Lower (LM1) is part of the in-vessel quasi-optical beam propagation system for the ITER Electro Cyclotron (EC) Upper Launcher (UL), where eight beams are reflected through four mirrors during its passage to the plasma. The mirrors are grouped into two rows of four beams each and the mirror LM1 refers to a four mirror set. High power millimeter (mm) waves are generated by the gyrotrons and delivered to the in-vessel components via corrugated wave-guides. The design of the LM1 shall guarantee the optimal propagation of the beams during their transmission through the optical system taking into consideration 1) the shape of the reflecting surfaces, 2) loads coming from the beams themselves, the plasma and nuclear reactions as well as off-normal events and 3) the port plug space restrictions. This paper reports the Ohmic loss assessment at LM1 as function of frequency, surface roughness and resistivity using the most suitable material and the power input (1.31 MW at 170 GHz). It describes the design investigation of the cooling solutions for the normal scenario via computational fluid dynamic analyses, based on the ITER Primary Heat Transfer System (PHTS) cooling boundary conditions, needed to remove ∼20 kW of power deposition on the mirror surface. Finite element analyses are performed to guide the design choices in an effort to minimize the maximum mirror surface temperature and thus diminishing the deformation of the reflecting surfaces. The conclusion of this study will provide a feasible design solution for the LM1 and Upper Mirror 1 (UM1).

The Electron Cyclotron Upper Launcher is an eight beamline ITER antenna whose main goal is to drive current locally, inside magnetic islands that may form on the q = 3/2 or 2 rational magnetic flux surfaces, in order to stabilize neoclassical tearing modes (NTMs). The primary vacuum boundary at the port plug extends into the port cell region through the ex-vessel mm-wave waveguide components, defining the so-called First Confinement System (FCS). Thermal expansion, seismic events and plasma disruption events result in displacements of the vacuum vessel, relative to the tokamak building, that are transferred to the FCS at its interfaces with the port plug. In absence of suitable inline waveguide bellows, the adaptation to such imposed displacements is provided by bending compliance of the straight waveguide sections. An analysis methodology for the ex-vessel components was developed which covers a preliminary set of applicable load combinations throughout the system life-cycle. This methodology describes the FCS numerical model developed to assess the system against independent events as well as the load combination strategy followed to combine the results. Some simplifications like the simulation of the Vertical Displacement Events (VDEs) by a static approach are considered in order to develop this methodology. The analysis of the results shows that the miter bends and the pieces of waveguides rigidly attached to the port cell ceiling are the most demanded components for most of the considered load combinations.

The ITER ECRH system consists of 24 gyrotrons with up to 24 MW installed millimeter wave heating power at 170 GHz, power supplies, control system, transmission lines, one Equatorial and the four Upper Launchers. With its high frequency and small beam focus the ECRH has the unique capability of driving locally current. While the Equatorial Launcher mainly acts for central heating and current profile shaping, the Upper Launchers aim on suppressing MHD instabilities, especially neoclassical tearing modes (NTM) triggering plasma disruptions. The Upper Launchers inject millimeter waves through a quasi-optical section consisting of three fixed and the front steering mirror set. The eight overlapping beams have focal points optimized for suppression of the q = 3/2 and q = 2/1 NTMs., Several project change requests required the redesign of the Upper Launchers and the connected ex-vessel system. This redesign includes a new boundary geometry of the launchers as well as a newly designed cooling system for the Blanket Shield Module (BSM), a modified flange of the BSM to the structural main frame and a refined optical design. Additionally shield blocks with integrated in-vessel waveguides were added and the closure plate with waveguide and supply line feedthroughs was adapted. Further changes, not all caused by PCRs, include newly designed ex-vessel waveguide components with a reduced aperture and redesigned ultra low-loss CVD diamond windows. Finally several components originally foreseen as off-the-shelf components have become part of the design scope. The new launcher design status is presented with selected results on numerical design validation.

The ITER Electron Cyclotron Heating (ECH) system will be used to counteract magneto-hydrodynamic plasma instabilities by aiming up to 20 MW of mm-wave power at 170 GHz. The primary vacuum boundary at the Electron Cyclotron Upper Launcher (EC UL) extends into the port cell region through eight beamlines, defining the so-called First Confinement System (FCS). Each beamline, designed for the transmission of 1.31 MW, is delimited by the closure plate at the port plug back-end and by a diamond window in the port cell. The FCS essentially consists of a Z-shaped set of straight corrugated waveguides (WG) connected by Mitre Bends (MB) with a nominal inner diameter of 50 mm. Due to the space restrictions, the eight MBs at the last FCS section are grouped into two monoblocks. Each Monoblock Mitre Bend (MBMB) consists of a body with corrugated feedthroughs defining a specific angle for each beamline and four mirrors attached by bolted connection to reflect the mm-wave power. The thermal expansion arising from the ohmic losses, the cooling pressure, the bolt pre-tension and the imposed displacements coming from the connection with the transmission lines are the primary design loads for the MBMBs. The fluid-dynamic analyses performed for both upper and lower MBMBs show that highest temperature takes place in the MB mirrors, reaching a maximum value of 203 °C at the beam center. The thermo-mechanical analyses demonstrate that the peak stress also occurs at this location with a maximum value of 324 MPa. These stresses are categorized and compared with the allowable limits defined in the ASME code, what probes that the current design of both upper and lower MBMBs are able to withstand the loads taking place during the mm-wave normal operation.

The ITER Electron Cyclotron Upper Launcher (ECUL) port plug is undergoing final design evolutions towards manufacturing, which include engineering efforts to ascertain and manage the radiation conditions during operation and maintenance. Two important aspects of these efforts are discussed here. First, design and analysis activities undertaken to ameliorate the residual radiation field (shut-down dose rate, SDDR), present during maintenance due to activation of components by plasma neutrons, are presented. Several shielding options were proposed and analysed. It was concluded that very significant improvement is achieved by those located within the port plug itself, and that further necessary reductions are only possible by considering changes in the surrounding environment. Second, the nuclear heating profile in the critical blanket shield module (BSM) component was computed. For this part of the work, a pioneering application of the novel MCNP conformal unstructured mesh capability (UM) for both geometry description and results tallying was made, in addition to the conventional approach of MCNP native geometry plus superimposed structured mesh. Different aspects of the results and functionality of both approaches were compared in a variety of conditions. It is concluded that, whilst the UM succeeds in accelerating geometry preparation and post-processing and in removing unphysical results inherent to the conventional approach, the latter still provides a more computationally efficient representation leading to uniform precision. These may be limiting factors for large analysis models such as those needed for ITER systems.

International audience; The safety classification of Structures, Systems and Components (SSCs) used in nuclear power plants provided in various IAEA guides and other international standards is mostly aimed at the fission applications. For fusion the main safety functions are related to the confinement of radioactive materials and the limitation of personnel radiation exposure and not with heat removal or reactivity control. Similarly, various plant states and events with their severity levels specific to a fusion plant are different. Ranking SSCs according to their significance to safety helps to determine the design, quality and manufacturing requirements to be applied to individual SSCs. Classification is a top down process that begins with a basic understanding of the plant design, its safety analysis and how the main safety functions will be achieved. On the basis of the classification, a complete set of engineering rules must be specified which then dictate the codes and standards that are used by the designers. Guidelines for identification and classification of SSCs that are important to safety for Fusion applications have been provided considering the current practice and highlight the differences in the approaches used to identify and classify SSCs that are important to safety. © 2018

The torus window unit is a very particular component of the ITER EC HC this structure is then integrated into a metallic housing by welding. The compliance with the requirements shall be assured by applying the ASME Section III – Subsection NC code and a dedicated experimental qualification program. This paper reports the way in which the design of the unit, already optimized by FEM analyses against the ITER loading conditions, was further improved by the application of the ASME III-NC code, leading to a more feasible and simpler manufacturing and assembling sequence. In addition, the impact of the ITER project decision to change the inner diameter of the waveguide from 63.5 to 50 mm, to improve the beams’ mode purity, was assessed and it is also discussed. Different materials for the metallic housing and in particular for the millimeter-wave inserts of the unit were compared using appropriate engineering criteria to mitigate the significant increase of the millimeter-wave thermal loads on the waveguides when the diameter is decreased.

Four EC H&CD (Electron Cyclotron Heating and Current Drive) launchers will be installed into the upper ports #12, #13, #15 and #16 in ITER. Beside plasma heating their main purpose is to counteract plasma instabilities by injecting up to 20 MW of microwave power at a frequency of 170 GHz at dedicated positions into the plasma. The microwave power is generated in 24 Gyrotrons outside the Tokamak and transmitted into the dedicated ports by 8 waveguide lines per launcher. After passing a CVD (Chemical Vapor Deposition) diamond window and another section of circular waveguides, the microwaves are quasi-optically guided into the plasma by an adjusted set of mirrors. These mirrors and also the foremost segments of the waveguides are mounted into the Upper Port Plug, which is a massive steel structure capable to dissipate up to 800 kW heat and to withstand heavy mechanical loads induced mainly from plasma disruptions. This paper presents the most recent status of the design of the EC H&CD Upper Port Plug (UPP), featuring the construction of the supporting structure and the BSM (Blanket Shield Module) with its plasma facing First Wall, the PHTS (Primary Heat Transfer System) water cooling layout, the shielding components engineering, the microwave system integration and comprehensive manufacturing strategies. Also correlated computational analyses to prove the final design of the launcheŕs structural system are given.

The diamond window is part of the ex-vessel waveguide system of the ITER ECRH Upper Launcher and consists of an ultra-low loss CVD diamond disk mounted in a system of metallic parts. On the one hand the window has to fulfil adequate transmission capability for high power mm-waves and on the other hand it serves, together with an isolation valve, as primary vacuum boundary of the ITER vacuum vessel, and has the function of tritium confinement. Therefore it is classified as Protection Important Component and high requirements for quality and safety apply. The window assembly cannot be entirely covered by codes and standards and thus an ad-hoc qualification program is required, including prototyping activities. The mm-wave transmission capability of the window, which is mainly defined by the dielectric loss of the diamond disk, has to be demonstrated as well as its structural integrity. For previous and current window prototypes, diamond disks with low dielectric losses have been chosen with a diameter of 80 mm and a thickness of 1.11 mm. This thickness satisfies the resonance condition (d = n*λeff/2) for the 170 GHz beam, ensuring a high transmission, but it also needs to be validated with respect to the mechanical loads, especially the expected pressure loads. Investigations on the flexural strength of diamond disks (D = 30 mm, d = 1.11 mm) have been performed using a ring-on-ring set-up and the results lead to an estimation of the failure behavior. In addition, pressure tests of a mock-up consisting of a diamond disk (D = 80 mm, d = 1.11 mm) brazed to a copper cuff are under examination. The dedicated test program includes cyclic tests at lower pressures and high pressure tests (up to 2 bar) allowing a simulation of the expected events. This paper will give an overview on the qualification activities for the ITER torus window with a focus on the qualification of the diamond disk and with respect to its mechanical properties. Respective parts of the test program, which need F4E and IO review and approval, will be described and first results will be presented.

Eating disorders (ED) are frequently associated with a wide range of psychiatric or somatic comorbidities. The most relevant ED are anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorders (BED). Patients with ED exhibit both upper and lower gastrointestinal (GI) symptoms. Evidence of alterations throughout the GI tract in ED will be analyzed given the role of the GI tract in food intake and its regulation. It remains a matter of debate whether GI disorders are inherent manifestations of ED or the results of malnutrition occurring from ED. Moreover, recent clinical studies have highlighted the growing role of intestinal microbiota in the pathogenesis of ED, making it possible to hypothesize a modulation of intestinal microbiota as a co-adjuvant to standard therapy. The aim of this review is to analyze the link between ED and GI diseases and to present, where known, the potential key factors underlying these conditions. Conclusions: The presence of GI disorders should be investigated in patients with ED. Screening for ED should also be encouraged in individuals seeking treatment for unexplained GI complaints to better address therapeutic issues that surround these difficult medical conditions.

Mitigating edge localized modes (ELMs) with resonant magnetic perturbations (RMPs) can increase energetic particle losses and resulting wall loads, which have previously been studied in the vacuum approximation. This paper presents recent results of fusion alpha and NBI ion losses in the ITER baseline scenario modelled with the Monte Carlo orbit following code ASCOT in a realistic magnetic field including the effect of the plasma response. The response was found to reduce alpha particle losses but increase NBI losses, with up to 4.2% of the injected power being lost. Additionally, some of the load in the divertor was found to be shifted away from the target plates toward the divertor dome.

The diamond window is part of the electron cyclotron heating upper launcher system for ITER. Together with the isolation valve it constitutes the primary vacuum boundary and it also acts as first tritium barrier. Therefore the window is classified as Safety/Protection Important Component (SIC/PIC) with the nuclear safety function “confinement”. As the diamond window unit is not entirely covered by standard codes, an ad-hoc qualification program needs to be defined, including analysis, prototyping and testing. In the framework of a contract with F4E, the test program for a diamond window prototype is being developed with the aim to prove its operability for normal, accidental and incidental conditions as identified in the ITER load specifications. Tests range from dielectric loss measurements for the bare Chemical Vapour Deposition (CVD) diamond disk up to mechanical and vacuum tests for the complete window assembly. Finally mm-wave properties have to be characterized for the complete window. A clear definition of the testing requirements and of the acceptance criteria is necessary as well as a complete documentation of the process. This paper will present the development of the test plan for a window prototype, which is currently under manufacturing. First tests are directed to the characterization of the bare diamond disk with a focus on its dielectric properties.

The electron cyclotron (EC) heating and current drive (H&CD) system developed for the ITER is made of 12 sets of high-voltage power supplies feeding 24 gyrotrons connected through 24 transmission lines (TL), to five launchers, four located in upper ports and one at the equatorial level. Nearly all procurements are in-kind, following general ITER philosophy, and will come from Europe, India, Japan, Russia and the USA. The full system is designed to couple to the plasma 20 MW among the 24 MW generated power, at the frequency of 170 GHz, for various physics applications such as plasma start-up, central H&CD and magnetohydrodynamic (MHD) activity control. The design takes present day technology and extends toward high-power continuous operation, which represents a large step forward as compared to the present state of the art. The ITER EC system will be a stepping stone to future EC systems for DEMO and beyond. The development of the EC system is facing significant challenges, which includes not only an advanced microwave system but also compliance with stringent requirements associated with nuclear safety as ITER became the first fusion device licensed as basic nuclear installations as of 9 November 2012. Since the conceptual design of the EC system was established in 2007, the EC system has progressed to a preliminary design stage in 2012 and is now moving forward toward a final design.

We assess the effect of the European design of the pebble-bed helium-cooled test blanket modules (TBM) on fast ion power loads on ITER material surfaces. For this purpose, the effect of not only the TBMs but also the ferritic inserts (FI), used for mitigating the toroidal field ripple, were included in unprecedented detail in the reconstruction of the 3-dimensional magnetic field. This is important because, due to their low collisionality, fast ions follow the magnetic geometry much more faithfully than the thermal plasma. The Monte Carlo orbit-following code ASCOT was used to simulate all the foreseen operating scenarios of ITER: the baseline 15 MA standard H-mode operation, the 12.5 MA hybrid scenario, the 9 MA advanced scenario, and the half-field scenario with helium plasma that will be ITER’s initial operating scenario. The effect of TBMs was assessed by carrying out the simulations in pairs: one including only the effect of ferritic inserts, and the other including also the perturbation due to TBMs. Both thermonuclear fusion alphas and NBI ions from ITER heating beams were addressed. The TBMs are found to increase the power loads, but the absolute values remain small. Neither do they produce any additional hot spots.

Objectives: The diagnosis of vestibular neurolabyrinthitis is based on the sudden appearance of vertigo that lasts for hours or days without associated cochlear or central nervous system signs or symptoms. The advent of the video head impulse test, cervical vestibular evoked myogenic potential testing, and ocular vestibular evoked myogenic potential testing has provided interesting clinical evidence for evaluating and monitoring the damage to specific compartments of the vestibular apparatus. These various methods of testing individual end-organ functions may have a clinical impact on the vestibular workup of neurolabyrinthitis. Methods: This report describes 3 patients with acute vestibular neurolabyrinthitis in whom caloric tests, cervical vestibular evoked myogenic potentials, ocular vestibular evoked myogenic potentials, and the video head impulse test led to a suspicion of peripheral vestibular deficits of the lateral or superior semicircular canal ampulla or ampullary nerves. Results: In our patients, the examination results (normal hearing, absence of responses on caloric testing, and bilateral preservation of cervical and ocular vestibular evoked myogenic potentials) disclosed an acute partial superior vestibular neurolabyrinthitis. Conclusions: To our knowledge, these are the first reported cases in which selective damage to the lateral and superior semicircular canals and their nerves caused by neurolabyrinthitis was demonstrated clinically. Our clinical results indicate that the damage can be selective for specific vestibular end organs.

In this comparison of Western and Asian perspectives, Mario Gagliardi analyzes differences in each culture's understanding of uniqueness, copying, the integration of external influences, and the inclusion of consumer perceptions within the design process. Insights such as these become important as corporations try to create products and brands that have meaning—functional, cultural, mythical, symbolic, and ethical meaning—around the world.

The magnetic perturbation due to the ferromagnetic test blanket modules (TBMs) may deteriorate fast ion confinement in ITER. This effect must be quantified by numerical studies in 3D. We have implemented a combined finite element method (FEM) -- Biot-Savart law integrator method (BSLIM) to calculate the ITER 3D magnetic field and vector potential in detail. Unavoidable geometry simplifications changed the mass of the TBMs and ferritic inserts (FIs) up to 26%. This has been compensated for by modifying the nonlinear ferromagnetic material properties accordingly. Despite the simplifications, the computation geometry and the calculated fields are highly detailed. The combination of careful FEM mesh design and using BSLIM enables the use of the fields unsmoothed for particle orbit-following simulations. The magnetic field was found to agree with earlier calculations and revealed finer details. The vector potential is intended to serve as input for plasma shielding calculations., In proceedings of the 28th Symposium on Fusion Technology

A 24 MW Electron Cyclotron (EC) system operating at 170 GHz and 3600 s pulse length is to be installed on ITER. The EC plant shall deliver 20 MW of this power to the plasma for Heating and Current Drive (H&CD) applications. The EC system is designed for plasma initiation, central heating, current drive, current profile tailoring, and Magneto-hydrodynamic control (in particular, sawteeth and Neo-classical Tearing Mode) in the flat-top phase of the plasma. A preliminary design review was performed in 2012, which identified a need for extended application of the EC system to the plasma ramp-up, flattop, and ramp down phases of ITER plasma pulse. The various functionalities are prioritized based on those applications, which can be uniquely addressed with the EC system in contrast to other H&CD systems. An initial attempt has been developed at prioritizing the allocated H&CD applications for the three scenarios envisioned: ELMy H-mode (15 MA), Hybrid (similar to 12 MA), and Advanced (similar to 9 MA) scenarios. This leads to the finalization of the design requirements for the EC sub-systems.

This paper addresses the confinement of thermonuclear alpha particles and neutral beam injected deuterons in the 15 MA Q = 10 inductive scenario in the presence of the magnetic perturbation caused by the helium cooled pebble bed test blanket module using the vacuum approximation. Both the flat top phase and plasma ramp-up are studied. The transport of fast ions is calculated using the Monte Carlo guiding center orbit-following code ASCOT. A detailed three-dimensional wall, derived from the ITER blanket module CAD data, is used for evaluating the fast ion wall loads. The effect of the test blanket module is studied for both overall confinement and possible hot spots. The study indicates that the test blanket modules do not significantly deteriorate the fast ion confinement.

An electron cyclotron system is one of the four auxiliary plasma heating systems to be installed on the ITER tokamak. The ITER EC system consists of 24 gyrotrons with associated 12 high voltage power supplies, a set of evacuated transmission lines and two types of launchers. The whole system is designed to inject 20 MW of microwave power at 170 GHz into the plasma. The primary functions of the system include plasma start-up, central heating and current drive, and magneto-hydrodynamic instabilities control. The design takes present day technology and extends towards high power CW operation, which represents a large step forward as compared to the present state of the art. The ITER EC system will be a stepping stone to future EC systems for DEMO and beyond. The EC system is faced with significant challenges, which not only includes an advanced microwave system for plasma heating and current drive applications but also has to comply with stringent requirements associated with nuclear safety as ITER became the first fusion device licensed as basic nuclear installations as of 9 November 2012. Since conceptual design of the EC system established in 2007, the EC system has progressed to a preliminary design stage in 2012, and is now moving forward towards a final design. The majority of the subsystems have completed the detailed design and now advancing towards the final design completion. (C) 2014 Elsevier B.V. All rights reserved.

The ITER electron cyclotron upper launcher (EC UL) is used to direct high power microwave beams generated by the gyrotrons into the plasma for magneto-hydrodynamic (MHD) control and heating and current drive (H&CD) applications. The UL consists of an assembly of ex-vessel waveguides (WGs) and an in-vessel port plug. The diamond window units form vacuum and tritium confinement boundaries between the torus volume and the transmission lines (TLs) which guide beams between 1 and 2 MW from the gyrotrons to the launcher.

The aim of the study was to present a case report demonstrating that vestibular evoked myogenic potentials originate from the saccular nerve.Retrospective case review.Tertiary referral center.Vestibular evoked myogenic potentials are shown before and after operation in a patient with a surgically confirmed superior vestibular schwannoma (1.3 cm).Preoperative and postoperative audiometry, auditory brainstem response, caloric test, vestibular evoked myogenic potentials, and magnetic resonance imaging outcomes. RESULTS On preoperative audiometry, slight sensorineural hearing loss with normal auditory brainstem response could be detected. Caloric tests showed a reduced response of the right labyrinth. Vestibular evoked myogenic potentials were normal. The tumor was removed via a combined retrosigmoid and partial labyrinthectomy approach with the removal of the posterior semicircular canal. The facial, auditory, and inferior semicircular nerves were anatomically preserved. Postoperative audiometry revealed preservation of hearing and vestibular evoked myogenic potentials; caloric responses were now absent.The combined retrosigmoid and partial labyrinthectomy approach represents an ideal condition to study the influence of the saccular nerve on the origin of the vestibular evoked myogenic potentials. The maintenance of the vestibular evoked myogenic potential responses in our patient supports the concept that the vestibular evoked myogenic potential originates in the saccule and is transmitted in the saccular nerve.

The fusion alpha and beam ion with steady-state power loads in all four main operating scenarios of ITER have been evaluated by the ASCOT code. For this purpose, high-fidelity magnetic backgrounds were reconstructed, taking into account even the internal structure of the ferritic inserts and tritium breeding modules (TBM). The beam ions were found to be almost perfectly confined in all scenarios, and only the so-called hybrid scenario featured alpha loads reaching 0.5 MW due to its more triangular plasma. The TBMs were not found to jeopardize the alpha confinement, nor cause any hot spots. Including plasma response did not bring dramatic changes to the load. The ELM control coils (ECC) were simulated in the baseline scenario and found to seriously deteriorate even the beam confinement. However, the edge perturbation in this case is so large that the sources have to be re-evaluated with plasma profiles that take into account the ECC perturbation.

Objectives: We analyzed the behavior of preoperative and postoperative vestibular evoked myogenic potentials (VEMPs) and vestibular evoked periocular potentials (VEPPs) in 3 patients who had vestibular schwannoma and underwent modified translabyrinthine surgery. Methods: We compared VEMPs and VEPPs, measured with both air-conducted (AC) and bone-conducted (BC) stimulations. Vestibular evoked potentials were measured both in the immediate postoperative period and some months later. Results: At the immediate postoperative examination, VEPPs were preserved in all 3 patients with both AC and BC stimulations. The VEMPs showed stable or improved parameters in 2 of our patients and were absent in the third patient. At the follow-up examination, VEMPs did not show any significant change with respect to the previous evaluation. In contrast, VEPPs were absent in 2 of our patients with AC stimulation and in 1 patient with BC stimulation. Conclusions: Our results seem to indicate a greater stability and reproducibility of VEMPs compared with VEPPs. In 1 patient, who had a schwannoma of the inferior vestibular nerve, the preservation of VEPPs and the absence of VEMPs in the immediate postoperative period confirm that the saccule represents the origin of VEMPs. Furthermore, these results suggest that not only the saccule, but also the utriculus, could be implicated in the origin of VEPPs.

The object of this paper was to evaluate the binaural hearing in 20 patients suffering from unilateral otosclerosis. Binaural performance was assessed at a test frequency of 500 Hz using masking level difference (MLD) before and after surgery. The postsurgical results showed abnormal MLDs in patients in whom stapedotomy had successfully corrected the threshold asymmetry. Three possible hypotheses regarding this phenomenon were investigated: (1) cochlear damage, (2) auditory deprivation and (3) a mechanical middle ear anomaly due to the surgical prosthesis or healing processes. The analyses suggest that the conductive hearing loss may effect central auditory processing resulting in poor binaural hearing (auditory deprivation theory).

estibular evoked myogenic potentials (VEMPs) represent a relatively recent subject Vestibular evoked myogenic potentials (VEMPs) represent a relatively recent subject of investigation in regard to diagnosing specific vestibular disorders. Numerous experimental animal models 1-3 and clinical studies 4-9 suggest that VEMPs are a vestibularcolic reflex, the afferent branch of which originates in the acoustic cells of the saccule, conducting signals through the inferior vestibular nerve. These studies have proposed hypotheses based on the possibility of VEMPs originating in the saccule but have provided no definitive proof to that effect.