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On December 5, 2022, an indirect drive fusion implosion on the National Ignition Facility (NIF) achieved a target gain G_{target} of 1.5. This is the first laboratory demonstration of exceeding "scientific breakeven" (or G_{target}>1) where 2.05 MJ of 351 nm laser light produced 3.1 MJ of total fusion yield, a result which significantly exceeds the Lawson criterion for fusion ignition as reported in a previous NIF implosion [H. Abu-Shawareb et al. (Indirect Drive ICF Collaboration), Phys. Rev. Lett. 129, 075001 (2022)PRLTAO0031-900710.1103/PhysRevLett.129.075001]. This achievement is the culmination of more than five decades of research and gives proof that laboratory fusion, based on fundamental physics principles, is possible. This Letter reports on the target, laser, design, and experimental advancements that led to this result.

Objectives: In children, radiography is performed to diagnose vertebral fractures and dual energy x-ray absorptiometry (DXA) to assess bone density. In adults, DXA assesses both. We aimed to establish whether DXA can replace spine radiographs in assessment of paediatric vertebral fractures., Methods: Prospectively, lateral spine radiographs and lateral spine DXA of 250 children performed on the same day were independently scored by three radiologists using the simplified algorithm-based qualitative technique and blinded to results of the other modality. Consensus radiograph read and second read of 100 random images were performed. Diagnostic accuracy, inter/intraobserver and intermodality agreements, patient/carer experience and radiation dose were assessed., Results: Average sensitivity and specificity (95 % confidence interval) in diagnosing one or more vertebral fractures requiring treatment was 70 % (58-82 %) and 97 % (94-100 %) respectively for DXA and 74 % (55-93 %) and 96 % (95-98 %) for radiographs. Fleiss' kappa for interobserver and average kappa for intraobserver reliability were 0.371 and 0.631 respectively for DXA and 0.418 and 0.621 for radiographs. Average effective dose was 41.9 μSv for DXA and 232.7 μSv for radiographs. Image quality was similar., Conclusion: Given comparable image quality and non-inferior diagnostic accuracy, lateral spine DXA should replace conventional radiographs for assessment of vertebral fractures in children., Key Points: • Vertebral fracture diagnostic accuracy of lateral spine DXA is non-inferior to radiographs. • The rate of unreadable vertebrae for DXA is lower than for radiographs. • Effective dose of DXA is significantly lower than radiographs. • Children prefer DXA to radiographs. • Given the above, DXA should replace radiographs for paediatric vertebral fracture assessment.

Background: The Abdominal Aortic Aneurysm (AAA) Screening Programme was introduced by the National Health Service (NHS) in England to reduce the rate of death from ruptured AAA in men. The programme commenced in 2009 and was implemented completely across the country in April 2013. The aim was to review the first 5 years of the programme, looking specifically at compliance and early outcome., Methods: Men aged 65 years were invited for a single abdominal ultrasound scan. Data were entered into a bespoke database (AAA SMaRT). This was a planned analysis after the first 5 years of the programme., Results: The summation analysis involved the first 700 000 men screened, and the first 1000 men with a large AAA referred for possible treatment. The prevalence of AAA (aortic diameter larger than 2·9 cm) in 65-year-old men was 1·34 per cent. Mean uptake was 78·1 per cent, but varied from 61·7 to 85·8 per cent across the country. Based on the Index of Multiple Deprivation, uptake was 65·1 per cent in the most deprived versus 84·1 per cent in the least deprived areas. Of the first 1000 men referred for possible treatment of a large AAA (greater than 5·4 cm), the false-positive rate was 3·2 per cent. Some 870 men underwent a planned AAA intervention (non-intervention rate 9·2 per cent), with seven deaths (perioperative mortality rate 0·8 per cent)., Conclusion: The processes in the NHS AAA Screening Programme are effective in detecting and treating men with AAA., (© 2016 BJS Society Ltd Published by John Wiley & Sons Ltd.)

Background: Identification of osteoporotic vertebral fractures allows treatment opportunity reducing future risk. There is no agreed standardised method for diagnosing paediatric vertebral fractures., Objective: To evaluate the precision of a modified adult algorithm-based qualitative (ABQ) technique, applicable to children with primary or secondary osteoporosis., Materials and Methods: Three radiologists independently assessed lateral spine radiographs of 50 children with suspected reduction in bone mineral density using a modified ABQ scoring system and following simplification to include only clinically relevant parameters, a simplified ABQ score. A final consensus of all observers using simplified ABQ was performed as a reference standard for fracture characterisation. Kappa was calculated for interobserver agreement of the components of both scoring systems and intraobserver agreement of simplified ABQ based on a second read of 29 randomly selected images., Results: Interobserver Kappa for modified ABQ scoring for fracture detection, severity and shape ranged from 0.34 to 0.49 Kappa for abnormal endplate and position assessment was 0.27 to 0.38. Inter- and intraobserver Kappa for simplified ABQ scoring for fracture detection and grade ranged from 0.37 to 0.46 and 0.45 to 0.56, respectively. Inter- and intraobserver Kappa for affected endplate ranged from 0.31 to 0.41 and 0.45 to 0.51, respectively. Subjectively, observers' felt simplified ABQ was easier and less time-consuming., Conclusion: Observer reliability of modified and simplified ABQ was similar, with slight to moderate agreement for fracture detection and grade/severity. Due to subjective preference for simplified ABQ, we suggest its use as a semi-objective measure of diagnosing paediatric vertebral fractures.

Background and Purpose: Inflammation is associated with oxidative stress and local generation of lipid peroxidation-derived aldehydes, such as 4-hydroxy-trans-2-nonenal (HNE). In most tissues, HNE is readily conjugated with glutathione and presently it is unknown whether glutathionyl-HNE (GS-HNE) plays a functional role in inflammation. Here, we sought to determine whether GS-HNE is a mediator of oxidative stress-initiated inflammation and if its actions can be regulated by the anti-inflammatory and pro-resolving lipid mediator, resolvin D1 (RvD1)., Experimental Approach: GS-HNE was administered intraperitoneally to mice and peritoneal lavages were assessed for leukocyte infiltration and lipid mediators were targeted by mediator-lipidomics. RvD1 was administered to mice treated with GS-HNE and leukocyte infiltration was assessed in the peritoneum. Superoxide production and CD11b modulation were measured in isolated human polymorphonuclear leukocytes incubated with GS-HNE., Key Results: GS-HNE (1-10 microg) evoked infiltration of Gr-1(+) leukocytes into the peritoneum to form an inflammatory exudate. With isolated human polymorphonuclear leukocytes, GS-HNE stimulated both superoxide generation and CD11b expression. Among the lipid mediators, both cyclooxygenase- and lipoxygenase-derived pro-inflammatory eicosanoids, including prostaglandin E(2), leukotriene B(4) and cysteinyl leukotrienes, were generated in exudates of mice injected intraperitoneally with GS-HNE. RvD1, given i.v. in doses as low as 0.01-10.0 ng, sharply reduced GS-HNE-stimulated leukocyte infiltration ( approximately 30-70%)., Conclusions and Implications: Glutathione conjugates of HNE, derived during oxidative stress, are pro-inflammatory in vivo. RvD1 protects against this oxidative stress-initiated inflammation.

As the oldest professional midwifery organization in the United States, The American College of Nurse Midwives (ACNM) represents the profession of midwifery in the United States and sets standards for education, certification, and practice. The ACNM has generated and revised several critical documents that provide guidance for the scope of midwifery practice, individually and collectively. This article reviews essential ACNM documents and their role in supporting professional midwifery.

Recent studies have shown that conjugated linoleic acid (CLA) can inhibit the initiation and thus, incidence of mammary tumors in rodents. The concentration of CLA required for these effects was as low as 0.1% of the diet, with no increased effects above 1%. To date, there is little evidence that CLA has any effect on growth or metastasis of mammary tumors. In this report, we demonstrate that CLA, at the concentrations used in previous studies, had a significant effect on the latency, metastasis, and pulmonary tumor burden of transplantable murine mammary tumors grown in mice fed 20% fat diets. The latency of tumors from mice fed CLA was significantly increased when compared with the 0% CLA control diet. The volume of pulmonary tumor burden, as a result of spontaneous metastasis, decreased proportionately with increasing concentrations of dietary CLA. With 0.5 and 1% CLA, pulmonary tumor burden was significantly decreased compared to mice treated with the eicosanoid inhibitor, indomethacin and fed diets containing no CLA. Tumors of mice fed as little as 0.1% CLA and as much as 1% had significantly decreased numbers of pulmonary nodules when compared with diets containing no CLA. The decrease in the number of pulmonary nodules by CLA was nearly as effective as indomethacin, a known suppressor of tumor growth and metastasis in this malignant model. These data suggest that effects of CLA on mammary tumorigenesis may go beyond the reported alterations in tumor incidence and effect later stages, especially metastasis.

The CD1 molecules have been shown to present non-protein antigens, such as complex lipids to Mycobacteria, and may be important in presenting glycolipids which are involved in inflammatory neuropathies. To study the expression of CD1 molecules in peripheral nerve, we examined nerve biopsies from two patients with acute inflammatory demyelinating polyradiculoneuropathy (AIDP), five with acute axonal neuropathy, six with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), nine with chronic axonal neuropathy, six with vasculitic neuropathy and three with no histological abnormality. Immunocytochemical studies showed strong labelling of CD1b on endoneurial macrophages (CD68+) and on myelinated nerve fibres in both AIDP patients, but it was rarely observed in the other patients. Weaker staining was seen on endoneurial macrophages and/or other endoneurial cells in some of the patients with other peripheral neuropathies, but none of the control nerves. CD1a had a weaker, but similar pattern. There was endoneurial infiltration of CD4+ and CD8+ T cells in the AIDP and CIDP nerves and sometimes in the other peripheral neuropathy nerves, but not in the normal nerves. Most T cells had alpha beta+ T cell receptors (TCR), but gamma delta+ TCR T cells were found in the nerves of both AIDP patients and sometimes in the nerves of other patients with peripheral neuropathy. Staining for mannose receptor was almost universal, being more intense in AIDP, chronic axonal neuropathy and vasculitis patients. We conclude that CD1 molecule expression is upregulated in peripheral neuropathy, especially in association with inflammation.

Nurse-midwives have participated informally in the education of medical students and residents for many years, yet little is known about their formal involvement in medical education. A two-part survey was conducted to investigate the extent and characteristics of nurse-midwifery participation in medical education in the United States. The initial questionnaire was sent to every department of obstetrics and gynecology chair listed in the directory of the Association of Professors of Gynecology and Obstetrics and addressed the use of certified nurse-midwives (CNMs) as educators within their respective departments. A subsequent questionnaire was distributed to CNMs participating in medical education and addressed their demographic characteristics, roles within the medical school faculty, and attitudes regarding work in medical education. More than one half (54%) of U.S. allopathic medical schools are formally using CNMs as educators, with the strongest involvement reported in the West and Northeast. Nearly as many CNM respondents are participating in the education of family medicine residents (57%) as in obstetrics and gynecology (59%). Most CNMs (93%) involved in medical education are also involved in nurse-midwifery education. Eighty percent of CNM respondents perceived congruency between educating student physicians and their philosophy of nurse-midwifery practice.

Much has recently been learned about the processes involved in postprandial triacylglycerol clearance. As discussed previously, important differences in the metabolism of chylomicrons and VLDL have become apparent. The ASP pathway has also been recognized and appears to play a critical role in chylomicron metabolism. The ASP pathway is activated in order to trap the fatty acids released from chylomicrons by the action of LPL and there is now unequivocal in vivo evidence in human subjects that ASP is generated by adipocytes in the postprandial period. These findings match the in vitro data showing that chylomicrons, but not the other plasma lipoproteins or fatty acids, activate the generation of ASP by cultured human adipocytes. An inverse relationship appears to exist between the proportion of fatty acids taken up by adipocytes and that released into the general circulation. Too great a release into the general circulation because of diminished trapping of fatty acids released from chylomicrons appears to be critical in the pathogenesis of the dyslipoproteinaemias associated with hyperapo B or FCHL and omental obesity. Evidence has been presented that dysfunction of the ASP pathway may be one of the causes of this disorder. Put differently, the ASP pathway is essential for the normal clearance and disposition of dietary fatty acids. Binding of chylomicrons to capillary endothelium followed by lipolysis by LPL results in the sudden liberation of fatty acids, and in the marked generation of ASP by adipocytes. The ASP that is generated is essential if LPL is to continue to form fatty acids at a normal rate. It is essential also if the fatty acids which are formed are to enter the adipocyte rather than exit into the general circulation. The transport vehicle, the chylomicron, therefore stimulates the formation of the peptide, ASP, which is responsible for its successful metabolism. Thus, the ASP pathway provides the metabolic coordination between the chylomicron and the adipocyte, which we describe as microenvironmental metabolic regulation and which we believe is essential for the normal clearance of dietary triacylglycerol from plasma.

Objectives: (1) To describe contemporary birth centers in terms of the population served, organizational and financial characteristics, services provided, mission and philosophy, and planning and marketing techniques. (2) To compare hospital-sponsored and nonhospital models with regard to the above characteristics., Method: Data from the National Survey of Women's Health Centers conducted in 1994 are analyzed using t-tests and chi-square tests., Results: Contemporary birth centers serve a diverse population of women and provide a range of clinical and nonclinical services. Birth centers are both hospital-sponsored and nonhospital, with the former growing at a faster rate. Compared to hospital-sponsored centers, nonhospital centers serve a larger proportion of uninsured women, provide a broader range of clinical services, and are more committed to women-centered care. Centers utilize different marketing methods and are involved in a number of organizational changes to better position themselves in the changing health care environment., Conclusions: Birth centers offer an attractive option to consumers and are a viable model for delivering women-centered care. Given that all "birth center" facilities do not share the same philosophy and service mix, women need to have some assurance of what a "birth center" will, and will not, provide.

The overall rate of induction of labor in the United States in 1993 was 134 per 1,000 live births, or over 527,000 of the four million births that occur annually in the United States. Indications for labor induction include postdate pregnancy, premature rupture of membranes (PROM), and maternal medical complications, such as diabetes mellitus and pregnancy-induced hypertension. This article briefly reviews common indications for induction of labor and the importance of cervical ripening. It then addresses methods used to hasten cervical ripening and to induce labor, ranging from the more "natural" and noninvasive methods, such as nipple stimulation, to the newest commercially available formulation of prostaglandin. Methods well documented in the scientific literature, as well as those commonly used but less well studied, are included. Although one may argue about the "invasive" nature of these methods, they are addressed, in general, from the most natural methods to the latest pharmacologic methods, and they include the following: sexual intercourse, nipple/breast stimulation, herbal preparations, homeopathic solutions, castor oil, enemas, acupuncture, membrane sweeping or stripping, mechanical dilation (balloon catheters, laminaria, and synthetic osmotic dilators), amniotomy, and pharmacologic hormonal preparations (prostaglandin E2, oxytocin, misoprostol, mifepristone, and relaxin).

This article reviews the essential neuroanatomy and neurophysiology, and summarizes the components of the health history, physical exam, and laboratory tests required for an assessment of the neurologic system within the primary care setting. Brief case studies illustrate the wide range of symptoms associated with neurologic disorders in women and the manner in which the pattern of symptoms can be used to locate the site of pathology and indicate the need for referral and follow-up.

Three needleless systems were compared for general usability and cost. A closed, one-piece, nonmechanical unit was chosen as it proved safe in both peripheral and central lines, required minimal inservicing and yielded significant cost savings.

In 1990, the United States Public Health Service published Healthy People 2000: National Health Promotion and Disease Prevention Objectives. One of the objectives included in the family planning priority area and repeated in the maternal and infant health priority area is the following: "Increase to at least 60 percent the proportion of primary care providers who provide age-appropriate preconception care and counseling." Drawing on the guidelines proposed by the Public Health Service Expert Panel on the Content of Prenatal Care, this article describes the components of preconception care: 1) appropriate and ongoing risk assessment, 2) health promotion, and 3) medical and psychological interventions and follow-up. The organization of this article is based on a preconception class outline developed by the authors; recommendations included in the article are consistent with those of the Expert Panel. After discussing opportunities for providing preconception care, this article addresses: 1) helping women evaluate their psychological readiness; 2) evaluating physical readiness; 3) the examination and concerns of the father; 4) evaluating the need for genetic counseling; 5) creating a positive environment for conception; 6) discontinuing family planning methods and timing conception; and 7) choosing a provider and birth place.

Nurse-midwives at the Johns Hopkins Hospital, in conjunction with their colleagues in obstetrics, pediatrics, and infectious disease, are participating in a demonstration project designed to provide continuity of care for women with HIV disease in pregnancy. In the past 19 months, 73 women have been enrolled in the project. This article describes how the midwifery model of care has been integrated into the existing system of routine obstetric care and specialized HIV-related care at the institution. This project could serve as a model for others who are redesigning health care delivery systems to include more nurse-midwives, especially those who are trying to adapt to an ever-increasing number of women experiencing some phase of HIV disease during their pregnancy. A companion article explains the midwifery and medical protocols used in the project and discusses other clinically relevant issues.

Primary care for women with human immunodeficiency virus (HIV) disease is appropriately provided by nurse-midwives within a well-coordinated system of medical consultation and referral. The issues of access to care, partner notification, reproductive choice, and breast-feeding are discussed. The nature of the collaborative management of HIV in pregnancy is explained. Management issues include the effects of HIV infection and pregnancy upon each other, perinatal transmission risks and postpartum needs, family planning, and gynecologic needs. Clinical care guidelines are included.

In a retrospective single-case study of a patient (L.S., the first author), who suffers from recurrent depression, we compared the onsets of his depression with meteorological data on light intensity, independently obtained, for the years 1975-1988. During those years there were 24 onsets or worsening of an existing depressive episode. Eleven of these occurred in the months September-December. Seven of these 11 autumn/winter onsets and 12 of the remaining 13 non-autumn/winter onsets coincided with a period of unusually low natural light intensity. Thus, 19 of 24 onsets (79%) were associated with falling light intensity, regardless of season. Some episodes that were not related to falling light intensity were associated with life events. For the years prior to the patient's use of light therapy, there was a statistically significant relationship between falling light and onset of depression. This supports the suggestion that depressive episodes (in certain individuals) may be triggered by unusually dull weather, regardless of season.

In 1971, the Board of Directors of the American College of Nurse-Midwives approved a statement that prohibited certified nurse-midwives (CNMs) from performing abortions. In 1990, the statement was superseded by a second "Statement on Abortion," which essentially reworded the 1971 statement with no substantive change. In 1991, 20 years after the first statement was adopted, a resolution was approved at the Annual Meeting recommending that the Board of Directors rescind the statement, thereby allowing individual CNMs to utilize the guidelines for the incorporation of new procedures into nurse-midwifery practice if she/he decides to provide abortions. This article describes the historical basis for the initial 1971 statement in the hope that an understanding of that history will assist nurse-midwives as they reconsider the statement.

To determine the effect of coadministration of lipiodol on the pharmacokinetics and systemic toxicity of intraarterial Adriamycin in patients with hepatocellular carcinoma, nine patients were studied in detail. Each received two courses of a bolus injection of Adriamycin (60 mg/m2), in one of which the Adriamycin was mixed with 10 ml of lipiodol. Analysis of the paired data, and additional 'non-paired' data from a further seven patients, showed that there was no significant difference in the area under the concentration-time curve for Adriamycin or adriamycinol or, in the case of Adriamycin, the terminal half-life. Likewise the fall in haemoglobin concentration, white cell count and platelet count following treatment, and the degree of nausea and vomiting were not significantly different. Comparison with a series of 12 patients receiving intravenous Adriamycin, in the same dose schedule, revealed no difference in terms of pharmacokinetic parameters or toxicity with intraarterial administration of Adriamycin, with or without lipiodol.

Ascaris lumbricoides is the most common helminth to infect humans. Infection occurs when contaminated soil containing mature eggs is swallowed. Clinically, infection ranges from the asymptomatic carrier state to life-threatening pulmonary disease or intestinal obstruction. Diagnosis is most frequently established by identification of the eggs in stool specimens. Treatment with antiparasitic drugs is effective in preventing serious complications and eradicating the parasite from all members of the household.

Crystals of the non-collagenous C-terminal region (NC1) of type IV collagen have been obtained from human placenta. These crystals diffract to 2.0 A, and belong to space group P22(1)2(1), with cell dimensions a = 81 A, b = 158 A, c = 138 A, alpha = beta = gamma = 90 degrees. The crystals contain one hexamer in the asymmetric unit; they are very stable with respect to X-rays.

Although patients with advanced breast cancer usually die of their disease, the clinical course is highly variable. Numerous investigators have examined potential prognostic factors predicting time to recurrence for primary (localized) breast cancer. Less attention has been paid to evaluating prognostic factors in patients presenting with metastatic disease. A group of 86 women with metastatic breast cancer diagnosed between 1974 and 1984 was studied to determine the effect of certain prognostic factors on survival. Univariate analysis of these factors indicates that specific sites of recurrence, estrogen receptor (ER) status, size of the primary tumor at original diagnosis, and tumor histology; i.e., tumor differentiation, were significantly associated with predicting survival in patients presenting with metastatic disease. Poor survival, i.e., less than, or equal to, 22 months from initial presentation, is associated with a primary tumor greater than five cm., ER level less than 10 fmol/mg. of protein, lung and bone marrow recurrence, and poorly differentiated histology. Menstrual status, age, bone or lymph node site of metastases, and elapsed time between patient knowledge of symptoms and subsequent initial medical evaluation were not significant predictors of survival in patients presenting with metastatic disease.

Methods of pre-operative assessment of impacted lower third molar teeth are discussed and the main diagnostic features are stressed in order to ensure that the pracitioner fully comprehends the nature and difficulty of the procedure.

The Gram-negative bacterium Myxococcus xanthus has a complex life cycle during which large amounts of a protein of relative molecular mass (Mr) 19,000, known as protein S, are assembled into a spore surface coat by a process that specifically requires calcium ions. The gene for protein S has been cloned and the DNA sequence shows that the gene product is composed of four internally repeated homologous sequences, each 40 amino acids long. Although protein S resembles calmodulin both in its internally duplicated structure and its ability to bind calcium, it apparently has a beta-sheet secondary structure rather than the helix-loop-helix motifs that characterize the calmodulin family. We now show that protein S has a striking homology with the beta- and gamma-crystallins of the vertebrate eye lens which are beta-sheet proteins with internally duplicated structures. This implies that the beta- and gamma-crystallins evolved from already existing proteins, whose ancestors occurred in the prokaryotes. The biological function of protein S, as a closely packed, stable protein in a relatively dehydrated environment, has implications for the functions of crystallins, which are found closely packed in the lens fibre cells, where their stability is essential for maintenance of transparency.

Knowledge of the three-dimensional structure of bovine gamma II-crystallin has provided the basis for building molecular models using computer graphics of two human gamma-crystallins, the sequences of which have recently been determined. The tertiary structures of these gamma-crystallins are predicted to be highly conserved. They have extensive networks of interacting charges on their surfaces, which may contribute to their thermodynamic stability and partially define the degree of water retention in the lens. The human crystallins appear to be more hydrophobic than the bovine molecule. All have arrangements of cysteine thiols which may be important as electron sinks and reserve redox potential in the normal lens but which may contribute to protein aggregation in cataract.

Multivariate flow cytometric analysis and sorting of mouse bone marrow cells viably stained with Hoechst 33342 (HO) was utilized to obtain a subpopulation enriched at least 30- to 60-fold for clonogenic megakaryocyte precursors (CFU-Meg). HO fluorescence intensity, forward light scatter, and perpendicular light scatter were measured on each HO-stained bone marrow cell as it passed through a dual beam flow cytometer. Cells were sorted on the basis of their light scattering and HO fluorescence intensity properties. The sorting region which included cells with high forward light scatter, low perpendicular light scatter, and low (0.1-0.65 times the modal channel) HO fluorescence intensity contained approximately 0.6% CFU-Meg. Of all CFU-Meg, 75% were contained in the light scatter gate, and 56% of all CFU-Meg were in the low HO-sorting region. This technique offers a simple, one-step procedure to obtain preparations enriched in murine clonogenic megakaryocyte precursors.

Two cases of false ankylosis of the temporo-mandibular joint following elective neurosurgery are described. The possible causation of this condition is discussed.

Two cases of recurrent desmoplastic fibroma are reported and the relevant literature reviewed. In both cases the original lesion was incompletely removed more than 10 years previously and the slow but aggressive spread of the recurrences is documented. Desmoplastic fibromas are locally invasive tumors and primary surgical excision should be accomplished together with a margin of normal tissue. The second case also presented with an associated amputation neuroma and this topic is briefly discussed.

The removal of fractured teeth and retained tooth roots is described in a systematic fashion, with emphasis being placed on such procedures being carried out in general practice. The discussion is aimed at producing sound treatment planning and sequential action in order to achieve best results for patient and surgeon.