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Materials Research (58)
MRS Online Proceedings Library Archive (50)
Materials Research Society Internet Journal of Nitride Semiconductor Research (1)
Prehospital and Disaster Medicine (1)
Materials Research Society (59)
World Association for Disaster and Emergency Medicine (1)
Amorphization of nanocrystalline 3C-SiC irradiated with Si+ ions
W. Jiang, H. Wang, I. Kim, Y. Zhang, W.J. Weber
Journal: Journal of Materials Research / Volume 25 / Issue 12 / December 2010
Irradiation-induced amorphization in nanocrystalline and single-crystal 3C-SiC has been studied using 1 MeV Si+ ions under identical irradiation conditions at room temperature and 400 K. The disordering behavior has been characterized using in situ ion channeling and ex situ x-ray diffraction methods. The results show that, compared with single-crystal 3C-SiC, full amorphization of small 3C-SiC grains (˜3.8 nm in size) at room temperature occurs at a slightly lower dose. Grain size decreases with increasing dose until a fully amorphized state is attained. The amorphization dose increases at 400 K relative to room temperature. However, at 400 K, the amorphization dose for 2.0 nm grains is about a factor of 4 and 8 smaller than for 3.0 nm grains and bulk single-crystal 3C-SiC, respectively. The behavior is attributed to the preferential amorphization at the interface.
First-principles calculation of structural and energetic properties for A2Ti2O7 (A = Lu, Er, Y, Gd, Sm, Nd, La)
Z.L. Zhang, H.Y. Xiao, X.T. Zu, Fei Gao, W.J. Weber
Journal: Journal of Materials Research / Volume 24 / Issue 4 / April 2009
A first-principles method was used to investigate the structural and energetic properties for A2Ti2O7 (A = Lu, Er, Y, Gd, Sm, Nd, La), including the formation energies of the cation antisite-pair, the anion Frenkel pair that defines anion-disorder, and the coupled cation antisite-pair/anion-Frenkel. It is proposed that the 〈A–O48f〉 interaction may have more significant influence on the radiation resistance behavior of titanate pyrochlores, although the 〈Ti–O48f〉 interactions are relatively stronger than the 〈A–O48f〉 interactions. It was found that the defect formation energies are not simple functions of the A-site cation radii. The formation energy of the cation antisite-pair increases continuously as the A-site cation varies from Lu to Gd, and then decreases continuously with the variation of the A-site cation from Gd to La, in excellent agreement with the radiation-resistance trend of the titanate pyrochlores. The band gaps in these pyrochlores were also measured, and the band gap widths changed continuously with cation radius.
Radiation detector materials: An overview
B.D. Milbrath, A.J. Peurrung, M. Bliss, W.J. Weber
Journal: Journal of Materials Research / Volume 23 / Issue 10 / October 2008
Due to events of the past two decades, there has been new and increased usage of radiation-detection technologies for applications in homeland security, nonproliferation, and national defense. As a result, there has been renewed realization of the materials limitations of these technologies and greater demand for the development of next-generation radiation-detection materials. This review describes the current state of radiation-detection material science, with particular emphasis on national security needs and the goal of identifying the challenges and opportunities that this area represents for the materials-science community. Radiation-detector materials physics is reviewed, which sets the stage for performance metrics that determine the relative merit of existing and new materials. Semiconductors and scintillators represent the two primary classes of radiation detector materials that are of interest. The state-of-the-art and limitations for each of these materials classes are presented, along with possible avenues of research. Novel materials that could overcome the need for single crystals will also be discussed. Finally, new methods of material discovery and development are put forward, the goal being to provide more predictive guidance and faster screening of candidate materials and thus, ultimately, the faster development of superior radiation-detection materials.
Responding to Biological and Radiological Events: Pediatric Simulation Using the US Strategic National Stockpile Ventilators for Resuscitation
E.K. Weber, W.J. Eppich, L. Chlebanowski, M. Adler
Journal: Prehospital and Disaster Medicine / Volume 22 / Issue S1 / April 2007
Published online by Cambridge University Press: 17 February 2017, p. S94
Atomic-level simulation of epitaxial recrystallization and phase transformation in SiC
F. Gao, R. Devanathan, Y. Zhang, M. Posselt, W.J. Weber
Published online by Cambridge University Press: 01 June 2006, pp. 1420-1426
A nano-sized amorphous layer embedded in an atomic simulation cell was used to study the amorphous-to-crystalline (a-c) transition and subsequent phase transformation by molecular-dynamics computer simulations in 3C–SiC. The recovery of bond defects at the interfaces is an important process driving the initial epitaxial recrystallization of the amorphous layer, which is hindered by the nucleation of a polycrystalline 2H–SiC phase. The kink sites and triple junctions formed at the interfaces between 2H– and 3C–SiC provide low-energy paths for 2H–SiC atoms to transform to 3C–SiC atoms. The spectrum of activation energies associated with these processes ranges from below 0.8 eV to about 1.9 eV.
Hydrogen behavior in Mg+-implanted graphite
W. Jiang, V. Shutthanandan, Y. Zhang, S. Thevuthasan, W.J. Weber, G.J. Exarhos
A graphite wafer has been implanted with Mg+ to produce a uniform Mg concentration. Subsequent H+ implantation covered the Mg+-implanted and -unimplanted regions. Ion-beam analysis shows a higher H retention in graphite embedded with Mg than in regions without Mg. A small amount of H diffuses out of the H+-implanted graphite during thermal annealing at temperatures up to 300 °C. However, significant H release from the region implanted with Mg+ and H+ ions occurs at 150 °C; further release is also observed at 300 °C. The results suggest that there are efficient H trapping centers and fast pathways for H diffusion in the Mg+-implanted graphite, which may prove highly desirable for reversible H storage.
Ion-Beam Enhanced Stress-Relaxation of SiGe on SiO2
Masanori Tanaka, Taizoh Sadoh, Masaharu Ninomiya, Masahiko Nakamae, Toyotsugu Enokida, Masanobu Miyao
Published online by Cambridge University Press: 26 February 2011, 0908-OO05-21
The Ge condensation by oxidation of SiGe/Si-on-insulator (SOI) structures enabled highly stress relaxed SGOI. However, the relaxation rate obtained in the SiGe layers on insulator (SGOI) abruptly decreased with decreasing SiGe thickness below 50 nm. In order to enhance the relaxation rate in ultra-thin SGOI, the technique combined with H+ irradiation with medium dose (5×1015 cm-2) and post-annealing (1200°C) has been developed. It was demonstrated that highly relaxed (70 %) ultra-thin SGOI with low defect density (<106 cm-2) has been realized by this technique.
Layer-by-Layer Sputtering and Ultrathin Ion Implantation by Low-Energy Grazing Ion Bombardment
Abdurauf Dzhurakhalov, Sirojiddin Rahmatov, Nigorakhon Teshabaeva, Maqsud Yusupov
The ion sputtering and implantation into GaAs(001) surface at 1-5 keV Se+ grazing ion bombardment have been investigated by computer simulation.The azimuth angular dependencies of sputtering and penetration yield at grazing incidence have been calculated. It was observed that these dependencies correlate the crystal orientation. The depth distributions of 1-5 keV Se ions implanted into GaAs(001) for several azimuth angles of incidence have been presented.
Characterization of Plasma Immersion Deposited Multilayer Coatings by Ion Beam Techniques Combined with Energy Filtered Transmission Electron Microscopy
Florian Schwarz, Joerg K. N. Lindner, Maik Häeberlen, Goetz Thorwarth, Claus Hammerl, Walter Assmann, Marcus Kuhn, Bernd Stritzker
Multilayered and nanostructured coatings of amorphous carbon (DLC), silicon composite multilayers and nanocluster containing films today have great potential for applications as hard coatings, wear reduction layers and as diffusion barriers in biomaterials. Plasma immersion ion implantation and deposition (PIII&D) is a powerful technique to synthesize such films. The quantitative nanoscale analysis of the elemental distribution in such multielemental films and thin film stacks however is demanding.
In this paper it is shown how the high spatial resolution capabilities of energy filtered trans-mission electron microscopy (EFTEM) chemical analysis can be combined with accurate and standard-less concentration determination of ion beam analysis (IBA) techniques like Rutherford Backscattering Spectroscopy (RBS) and Elastic Recoil Detection Analysis (ERDA) to achieve absolute and accurate multielement concentration profiles in complicated nanomaterials.
Enhanced Biocompatibility of GPC by Ion Implantation and Deposition
Robert Lee Zimmerman, Ismet Gürhan, Claudiu I. Muntele, Daryush Ila, Feyzan Özdal-Kurt, B. H. Sen
Biocompatible Glassy Polymeric Carbon (GPC) is used for artificial heart valves and in other biomedical applications. Although it is ideally suited for implants in the blood stream, tissue that normally forms around the moving parts of a GPC heart valve sometimes loses adhesion and creates embolisms downstream. Here we compare silver ion implantation and silver deposition, each of which strongly inhibits cell attachment on GPC. Inhibition of cell adhesion is a desirable improvement to current GPC cardiac implants. In vitro biocompatibility tests have been carried out with model cell lines to demonstrate that traces of silver can favorably influence the surface of GPC for biomedical applications.
A short review and Present Status of ZnO Nanoparticle Formation by Ion Implantation Combined with Thermal Oxidation
Hiroshi Amekura, Oleg A Plaksin, Naoki Umeda, Yoshihiko Takeda, Naoki Kishimoto, Christoph Buchal
Recently many groups have started studies of formation of zinc-oxide (ZnO) nanoparticle (NP) in transparent insulators, such as silica glass, sapphire, etc, using ion implantation techniques. In the early half of this article, we shortly review recent activities of ZnO NP formation using ion implantation combined with thermal oxidation. Some groups succeeded but the others did not. Even if they succeeded in the formation of ZnO nanostructures, one reported that they were in the shape of thin film and another reported the NP form. Based on our recent experimental results, we point out the importance of the oxidation temperature and the peculiar shapes and depth profiles of ZnO formed.
Positron Annihilation Investigation in Ion-implanted Yttria-stabilized Zirconia
Robert Grynszpan, G. Brauer, W. Anwand
Implantation with a variety of sub-MeV ions (He, Ar, Xe, O, and I) were performed on cubic single crystals of yttria-stabilized zirconia in order to assess the capability of such material to withstand high fluences as a confinement matrix for nuclear waste. In this work, we confronted the results of both Doppler Broadening using slow positron implantation spectroscopy (DB-SPIS) and the Rutherford Backscattering/Channeling spectroscopy (RBS-C) which are sensitive to lattice defects almost opposite in nature. In spite of their difference in defect specific sensitivity, and except for a precursory damage production stage almost exclusively exhibited by SPIS for very low doses (< 0.1 dpa), either techniques show a similar fluence dependence, which exhibits 3 stages starting respectively around 0.1, 2 and 3 dpa, regardless of the damaging ion. However, owing to the stage I plateau displayed in the variation of the DB-SPIS lineshape parameter, we were able to estimate an ion-mass dependence of the critical size of open-volume defects reached before the production of new predominant defects.
Chemical Behavior and Corrosion Resistance of Medical Grade Titanium after Surface Modification by Means of Ion Implantation Techniques
Frank Schrempel, Gerhard Hildebrand, Marion Frant, Werner Wesch, Klaus Liefeith
This work presents data on topographical structure, chemical surface composition, physicochemical properties and corrosion resistance of medical grade titanium after ion implantation. Pure commercial titanium has been implanted with 30 keV Na-, Ca- and P-ions at fluences of 2.0 × 1017 cm-2 and 1.5 × 1017 cm-2, respectively. Some of the samples were heat treated at 600 °C for 40 min. Atomic force microscopy (AFM) was used for surface analysis. The chemical composition was investigated using Rutherford backscattering spectrometry (RBS). Physicochemical investigations were carried out using contact angle measurements to determine the polarity of the modified titanium surfaces. Moreover, the electrokinetic zeta potentials on a physiological pH value have been determined. Finally, the corrosion resistance was examined in simulated body fluid (SBF) containing 4 g/l bovine serum albumin (BSA) using cyclic voltametry.
Considering the P-implantations, the measured depth distribution of phosphorus agrees well with calculations. For the implantation of Na and Ca, the concentration of implanted atoms in the maximum of the depth distribution is noticeably lower and the distribution extends to larger depths compared to the predictions. This finding is associated with a strong incorporation of oxygen over the whole penetration depth of the implanted ions. According to topographical and chemical changes different contact angles as well as zeta potentials have been detected for the ion implanted surfaces compared to pure titanium. The electrochemical examinations indicate that the implantation has no negative influence on the corrosion resistance in comparison to unmodified medical grade titanium. The results show that ion implantation using certain ions can be used to design tailor-made titanium surfaces from a physicochemical point of view.
Redistribution of Mn upon Annealing in Ferromagnetic Mn-implanted Si
Martin Bolduc, Chaffra Awo-Affouda, Frank Ramos, Vincent P LaBella
The redistribution of implanted Mn ions in Si after thermal annealing is studied. P-type Si wafers were implanted with 300-keV Mn+ ions at 350°C to a dose of 1×1015 cm-2, and then annealed at 800 °C for 5 min. Ferromagnetic hysteresis loops were obtained at 10 K using a SQUID magnetometer both before and after annealing. The saturation magnetization increases by ∼2 × after the post-implant annealing, while the Mn redistributes with sharp peaks in concentration. The calculated point-defect profile created during the implantation process peaks around the Mn-depleted region, suggesting that the residual implant damage may play a role in the ferromagnetic behavior of Mn-implanted Si.
Investigation of effects of ion beam irradiation on properties of magnesium oxide films
Yasuhiko Morimoto, Yoshikazu Tanaka, Ari Ide-Ektessabi
Magnesium oxide (MgO) film is commonly used as protecting layer for alternative current plasma display panels (AC-PDPs). Low energy ion induced secondary electron emission coefficient (γ) is one of the important factors to improve performance of AC-PDPs. The aim of this study is to prepare MgO films with high γ using ion beam assisted deposition (IBAD). The film composition, density, and crystal orientation were also investigated. The results suggest that MgO films with high γ can be obtained using IBAD. On the other hand, as the assisted ion beam energy increased to more than 500eV during deposition, (200)-oriented film with low γ grew preferentially and then the γ decreased.
High Aspect Ratio Microstructures in LiNbO3 Produced by Ion Beam Enhanced Etching
Frank Schrempel, Thomas Gischkat, Holger Hartung, Ernst Bernhard Kley, Werner Wesch, Andreas Tünnermann
This work presents data on damage evolution, volume expansion and etching behavior of LiNbO3 irradiated with Ar+-ions as a function of irradiation and etching conditions. Single crystals of x- and z-cut LiNbO3 were irradiated at room temperature and 15 K using Ar-ions with energies between 60 and 600 keV and ion fluences between 5 × 1012 and 1 × 1015 cm-2. The damage formation investigated with RBS channeling analysis depends on the crystal cut as well as on the irradiation temperature. Irradiation of z-cut material at 300 K causes complete amorphization at 0.4 dpa (displacements per target atom). In contrast 0.27 dpa are sufficient to amorphize the x-cut LiNbO3. Irradiation at 15 K reduces the number of displacements per atom necessary for amorphization to 0.18 dpa. To study the etching behavior ∼500 nm thick amorphous layers were generated via multiple irradiations with Ar+-ions. Etching was performed in HF-solution of different concentration and at different temperatures. The influence of the irradiation and etching conditions on damage formation and etching of LiNbO3 is discussed. In conclusion, negligible etching of the perfect crystal, high etching rates and high contrast of Ion Beam Enhanced Etching (IBEE) allow the realization of high aspect ratio microstructures in LiNbO3.
Nano-Sized Zirconium Carbides: Synthesis, Characterisation and Irradiation
Mickaël Dollé, Dominique Gosset, Christine Bogicevic, Guido Baldinozzi, Fabienne Karolak, David Simeone
The projects of a new generation of nuclear plants with improved yield and drastical reduction of waste production make necessary the development of materials able to withstand high temperature (1000-1200°C) in normal conditions. New materials such as the refractory transition metal carbides are then considered. These materials have a ceramic-like, brittle behaviour. Their mechanical properties might be improved by decreasing the particles size at a nanometer level. The behaviour under irradiation of such nano-sized materials have then to be compared with classical micro-sized ones. High density, nano-sized materials have been obtained by two different sintering techniques. In order to simulate neutron irradiation, the samples were irradiated with low energy heavy ions. Consequently, the damaged material has a low thickness (100-200 nm), requiring surface analysis methods. Here, the grazing incidence X-ray diffraction method is used. From a Rietveld analysis of the diffraction patterns, the micro-sized materials show a linear volume swelling in the range 20-40 dpa in the Zr sublattice. Nano- and micro-sized materials both show high internal distortions.
Ion irradiation-induced welding of a carbon nanotube to a Si (100) surface
Jani Kotakoski, Kai Nordlund
Carbon nanotubes (CNTs) are one of the possible building blocks for electronic devices in the transition phase from traditional silicon-based microelectronics towards the few-nanometer regime. Remaining problems in integrating CNTs to the existing technology is the low reactivity of the CNT walls which leads to low conductance between CNTs and the other components. Because recent studies have shown that ion irradiation can be used to modify both the electrical and structural properties of CNTs, we propose that it could also be possible to use ion irradiation with low energies to enhance the conductance of these connections. We have used classical molecular dynamics simulations with empirically fitted potentials to examine this possibility by irradiating a single-walled carbon nanotube (SWCNT) on a silicon substrate at room temperature. The nanotube was deposited over a trench created to the silicon substrate so that the nanotube was partly suspended. Low irradiation doses and low energies (0.2 keV − 1.2 keV) were used to ensure that the irradiated CNT will not be destroyed. The simulations were carried out for silicon, carbon and neon ions. Our simulations indicate that ion irradiation will increase the number of covalent bonds between the CNT and the Si substrate. When the irradiation dose and energies are low, the damage caused to the SWCNT atomic network can be tolerable when compared to the improvement in the conductance of the contact regions. Furthermore, as the CNTs have high ability to heal the irradiation-induced damage, it is possible that the irradiation will not have a significant negative effect to the conductivity of the CNT in a system of this type.
Ion beam modification of polyimides with linear ion source
Tetsuro Yamaguchi, Shih Hsiu Hsiao, Yoshikazu Tanaka, Ari Ide Ektessabi
Polyimide films are widely used in various industrial fields. Some typical products are flexible printed circuits (FPCs), flexible displays, and electronic papers. Good adhesion between metal thin films and polyimide films is required for their long lifetime. Ion beam irradiation to the polyimide films modifies the chemical compositions, the chemical states, and the surface nanomorphology. These modifications are potential techniques to improve the adhesion. In this study, the authors employed a linear ion source, which is able to irradiate ion beam on large surfaces homogeneously. The linear ion source is desirable for industrial usage because of its high productivity. The aim of this work was to investigate the effect of modification using the linear ion source. The chemical states of the interface were characterized using x-ray photoelectron spectroscopy (XPS). The surface nanomorphology was investigated by atomic force microscopy (AFM). The performance of the modification system will be discussed, and the characteristics of the modified polyimide will be investigated in detail.
Formation and characterization of swelled nano-porous structures on ion-irradiated Ge surfaces
Junichi Yanagisawa, Keiji Ogushi, Kentaro Takarabe, Kenji Gamo, Yoichi Akasaka
Single crystal germanium (Ge) surfaces were irradiated with 100 keV Ga ions at room temperature at doses up to 3×1017 cm-2 and were observed by a scanning electron microscope (SEM) and an atomic force microscope (AFM). It is found that the Ga-irradiated regions swelled and nano-porous structures were formed on the surface after the Ga irradiation up to a dose of about 2×1017 cm-2, but the region was etched by the Ga irradiation for larger doses. The atomic composition of the swelled and etched surfaces was investigated by an Auger electron spectroscopy (AES), but no Ga signal was observed, indicating that the precipitation of Ga did not influence on these characteristics of the Ga-irradiated Ge surfaces. To investigate the water resistance of such nano-porous structures, the sample was dipped in water up to 10 hours, and the surface was observed using SEM and AFM. It is found that the swelled structures were maintained, but the etched region formed by larger-dose irradiation was partially peeled off. This indicates that the nano-porous structures can be used under water environments as a functional surface, such as filters, and deep etching can be performed by larger dose irradiations and dipping the sample in water.


Azad Jammu and Kashmir (AJK) Prime Minister Raja Farooq Haider reached London on Sunday evening to lead the scheduled April 18 mass anti-India protest rally to mark Kashmiris' everlasting hatred against India on the arrival of Indian Prime Minister Narendra Modi in the United Kingdom (UK).
Leadership of the main political parties of AJK is also already present in UK to join the scheduled protest against India and its PM Modi as he was the culprit of the massive human rights violation in Indian Occupied Kashmir (IOK).
Leader of opposition in AJK Legislative Assembly Choudhary Muhammad Yasin, former AJK prime minister and PTI AJK Chapter President Barrister Sultan Mahmood Chaudhry and former Jamat-e-Islami AJK Chapter Chief Abdul Rasheed Turabi are actively engaged in UK to ensure maximum participation of the overseas Kashmiris in the scheduled anti-India rally.
AJK PM Haider had been invited by House of Lords member Nazir Ahmed to lead the protest during his visit to AJK last week.


Southwestern Community Services (SCS) is pleased to announce that the Northeast Delta Dental Foundation has granted $25,000 in support of the WIC Dental Project. The mission of the project is to improve the oral health of women and children enrolled in NH WIC and to demonstrate that paying for preventative dental care is less expensive and more effective than dental care after problems have occurred and been identified.
The project is a collaborative effort to make dental care more accessible for low-income women and children through a partnership with the State of NH Division of Public Health Services, NH Medicaid and the WIC (Women, Infants and Children) Program. WIC is the nation's most successful and cost-effective public health nutrition program. WIC provides wholesome food, nutrition education and community support for income eligible women who are pregnant, new moms, infants and children up to five years old.
Since 2014, the HNH Foundation, the Jessie B. Cox Foundation, the New Hampshire Charitable Foundation, and the Northeast Delta Dental Foundation have funded the WIC "Pay for Prevention Project". This is a partnership between the New Hampshire DPHS Oral Health Program, public health dental hygienists, and WIC staff in Concord and Keene. The project provides on-site preventive dental services to WIC enrolled pregnant women and children.
Other funding has also been provided by the Monadnock United Way and the Keene Kiwanis Club's Success By Six committee. Since 2014, over 2400 women, infants and children have received an oral health screening at a WIC site. On-site preventive oral health services have included oral health screening, risk assessments, oral health education, application of fluoride varnish, silver diamine fluoride (SDF), sealants and interim therapeutic restorations (ITR). Referrals are made to local dentists to treat urgent and other restorative needs as well as to establish a "dental home".
About Southwestern Community Services, Inc.: Founded in 1965, Southwestern Community Services (SCS) is a Community Action Program providing social services to the residents of Cheshire and Sullivan Counties in New Hampshire. SCS' Mission Statement is as follows: SCS strives to empower low-income people and families. With dignity and respect, SCS will provide direct assistance, reduce stressors, and advocate for such persons and families as they lift themselves toward self-sufficiency.


Our palates went on a Mexican holiday at the American Bounty Restaurant at The Culinary Institute of America in Hyde Park, New York, during the Encountering the Flavors of Tamaulipas, Mexico gala as part of the State of Tamaulipas Mexico and The Culinary Institute of America Cultural Culinary Exchange. Celebrating the cuisine from the state of Tamaulipas, was Chef Hugo Urtaza Alvarez, Tampico, Tamaulipas, Mexico, Chef Ángel García, Tampico, Tamaulipas, Mexico, Brian Kaywork Chef-Instructor, American Bounty Restaurant, Charles Garibaldi, CHE, Maître d'hôtel Instructor, Michael Zebrowski, Pastry Chef-Instructor, and the American Bounty Restaurant Class of 2018-2019.
Wine, food, and fun flowed during the 2018 Greenwich WINE + FOOD Festival presented by Serendipity. It was a beautiful blue sky, last day of summer, on Saturday, September 22, 2018 and Roger Sherman Baldwin Park in Greenwich, Connecticut was buzzing with energy and excitement over the eighth year of the Greenwich WINE + Food Festival, and Luxury Experience was there to help celebrate!
I had the opportunity to watch Adam Richman in action at the stove during the 2018 Greenwich WINE + FOOD Festival presented by Serendipity located at Roger Sherman Baldwin Park in Greenwich, Connecticut. Always irreverent, and downright funny, Adam Richman, whom many in the audience knew from his former television show, Man vs. Food, created Garlic Shrimp and Honeydew Siracha Salsa Tacos while delivering one-liners with breakneck speed, providing restaurant and travel tips, and answering questions from the audience. Adam Richman is definitely a funny man who knows how to cook!
Celebrity chef and top culinary talent Alex Guarnaschelli engaged and entertained audience members with her chef demo during the 2018 Greenwich WINE + FOOD Festival presented by Serendipity held in Roger Sherman Baldwin Park in Greenwich, Connecticut where she made Clams in a Puttanesca Sauce. Easy to make and very tasty, what more could you ask for?
Love to eat seafood but are afraid of cooking it at home? Joe Knows Fish - Taking The Intimidation Out of Cooking Seafood by Joe Gurrera is the perfect cookbook to guide you from purchasing, prepping, and preparing. Passionate about seafood, Joe Gurrera, owner of Citarella Fine Foods shares his knowledge in an approachable, humorous style with recipes that include step-by-step instructions and before and after inspiring photos that will have you cooking seafood with confidence and ease. Joe Gurerra graciously shares two recipes from Joe Knows Fish - Taking The Intimidation Out of Cooking Seafood to tempt your palate, Spaghetti Vongole and Fried Flounder. Bon Appetit!
The 2017 Greenwich WINE + FOOD Festival presented by Serendipity in Greenwich, Connecticut was truly a Luxury Experience! Imagine an all-day festival dedicated to wine, spirits, and food, with Greenwich's own Kathie Lee Gifford pouring her wines for attendees, cooking demos by Mario Batali, Adam Richman, Mary Giuliani, Samantha Benjamin, Alex Guarnaschelli, Kevin Des Chenes, Lindsay Perkins, Scott Conant, and Julia Deane, and more food and drink than you could possible consume, even in only small bites. The platinum-selling Pop band, TRAIN, was the grand finale, and as the icing on the cake, the festival benefitted the Mario Batali Foundation, The Friends of James Beard Benefits and the Town of Greenwich Parks and Recreation Foundation.
Sea Robins, Triggerfish & Other Overlooked Seafood - The Complete Guide To Preparing And Serving Bycatch by Chef Matthew Pietsch and James O. Fraioli deftly combines the culinary talents of Chef Matthew Pietsch, chef and restauranteur, with James Beard Award-Winning Author, James O. Fraioli. The esteemed Fabien Cousteau contributes an outstanding foreward. The result is an irresistible combination that showcases the need to consider, and enjoy, alternative fish and seafood, taking bycatch and making it commercially and culinarily desirable with inspired, delectable recipes.
Love fish but have no idea how to cook it? Simply Fish - 75 Modern and Delicious Recipes for Sustainable Seafood by Matthew Dolan is a well-crafted, easy to follow cookbook that guides readers on the full fish experience from the water to the table providing information on what to look for, what to ask for, step-by-step recipes, suggestions for beverage pairings, and even has a dessert or two to provide you with the "tools" to create many wonderful (seafood sustainable) meals. Happy cooking!
It was another amazing year at the 2016 Greenwich WINE + FOOD Festival presented by Serendipity in Greenwich, Connecticut benefitting The Hole in The Wall Gang Camp, Wholesome Wave, and the Greenwich Department of Parks and Recreation. Great wines and spirits, delicious food from area restaurants along with celebrities Kathie Lee Gifford, Michel Nischan, Adam Richman, Marcus Samuelsson, Marc Murphy, Alex Guarnaschelli, and more, with music by Grammy award winners Ziggy Marley and the Old Crow Medicine Show made it an event to remember.
For culinary enthusiasts as well as professional chefs, the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and The International Culinary Center) was once again a memorable weekend of baking, cooking, and celebrating with top industry professionals. Over the course of 2 days during the New York Culinary Experience 2016 we took bread classes, culinary classes, had chocolate and cocktail demos, and took a dessert class with top industry professionals where we learned professional techniques, tips, and delicious recipes.
Chef Alain Sailhac, Dean Emeritus of The International Culinary Center (The ICC) in New York City, taught me how to make the classic French recipes, Bouillabaisse and Raspberry Crème Brûlée during the during the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and The International Culinary Center). Chef Alain Sailhac graciously shares his recipe for Raspberry Crême Brulée. Bon Appétit!
François Hiegel, Executive Head Baker of the prestigious Thomas Keller Restaurant Group shared the art of making Classic New York Pretzels during The International Culinary Center (The ICC) in New York City, during the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and The International Culinary Center). Is there anything better than eating homemade pretzels hot from the oven?
For an oyster fan, Oysters A - Z with Chef Kerry Heffernan during the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and The International Culinary Center (ICC) in New York City was a fantasy of a cooking class. During the class I shucked my fair share of oysters to make East and West Raw Oysters with Two Mignonettes, Fried Oysters with Cornichon, Tangerine and Coriander Crema, and Oyster Pan Roast, with Oysteroot (Salsify) Celeriac, Bacon and Kale, and although all of the recipes were delicious, alas there were no pearls in any of my oysters. Chef Kerry Heffernan graciously shares his recipes for East and West Raw Oysters with Two Mignonettes, and Fried Oysters with Cornichon, Tangerine and Coriander Crema.
Learning the art of making authentic Fish and Chips with Chef Paul Liebrandt during the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and The International Culinary Center (ICC) brought back many fond memories of time spent in England. Chef Paul Liebrandt graciously shares his recipe for Fish and Chips with Lime Pickle Aioli.
Chef Zachary Golper, owner of Bien Cuit in Brooklyn, New York returned to the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and the The International Culinary Center (ICC) in New York City for the 4th year as an instructor. As someone who loves making bread, when I saw the list of participating chefs for the NYCE 2016, I knew that I wanted to take Chef Golper's bread class where I learned to make Madawaska Bread, Pugliese Bread, and Potato Focaccia, for which he graciously shares his recipe.
Attention chocoholics! Pastry Chef Miroslav Uskokovic of Gramercy Tavern in New York City, brought the art of making decadent chocolate desserts at home to the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and The International Culinary Center (ICC). The class menu: Hot Fudge Cake and Chocolate Pudding with Pecan Dragée, Pecan Praline, Prunes and Chocolate Covered Puffed Rice. Pastry Chef Miro Uskokovic graciously shares his pudding recipe below, which is fabulously delicious, need I say more?
I took an exciting Modern Hawaiian Techniques and Cuisine class with Chef Chung Chow of Noreetuh in New York City, New York during the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and the The International Culinary Center (ICC). As a scuba diver, I have spent substantial time in the Hawaiian Islands, and wanted to learn new techniques and flavor profiles to create Hawaiian cuisine at home. Under Chef Chung Chow's guidance, the class created Mochi-Crusted Black Bass with Green Beans in a Fermented Black Bean Sauce, and Big-Eye Tuna Poke with Macadamia Nuts, Seaweed, and Soy-Pickled Jalapenos. It felt great to be back in Hawaii, if even only by my palate!
What I especially enjoyed about the class, Breads Vaucluse Style with Head Baker Ellie Pegler at the New York Culinary Experience (NYCE) 2016 hosted by New York magazine and the The International Culinary Center (ICC) in New York City, was the opportunity to learn new bread techniques. Ellie Pegler, the head baker at Chef Michael White's restaurant, Vaucluse, deftly guided the class through the art of making croissants and baguettes, which were oh so delicious!
Chili and Cornbread are perfect winter comfort food, so we set off to North Conway Village, New Hampshire to experience the 13th Annual Chilly Chili Cook-Off presented by the Mt Washington Valley Chamber of Commerce. For those not familiar with chili, Merriam-Webster dictionary defines it as "Chili con carne, a spiced stew of ground beef and minced chiles or chili powder usually with beans," and cornbread as "a bread or cake made with cornmeal." These broad definitions provided plenty of opportunity for chefs to let their creativity flow for this very tasty competition.
Calling all cooking enthusiasts, foodies, aspiring chefs, and industry professionals! The New York Culinary Experience (NYCE) 2016 hosted by New York magazine and the The International Culinary Center in New York City on April 16- 17, 2016 is a "must-attend" gastronomic cooking event. If you love to cook and watching cooking shows is your idea of fun, imagine the possibility of cooking with 30 renowned chefs including: Allesandra Altieri, Einat Admony, Dan Barber, Jonathan Benno and Richard Capizzi, Chung Chow, Cesare Casella, Suzanne Cupps, Amanda Freitag, Jose Garces, Zachary Golper, Kerry Heffernan, François Hiegel, Judy Joo, Gabriel Kreuther, Paul Liebrandt, Michael Lomonaco, Ivan Orkin, Ellie Pegler, Missy Robbins, Daniel Rose, Alain Sailhac, Taku Sato and Ricky Estrellado, Bryce Shuman, Justin Smillie, Miroslav Uskokovic, Bill Yosses, and many more.
The fifth annual Greenwich 2015 WINE + FOOD Festival presented by Serendipity was a celebration of delectable wine and spirits, delicious food, celebrities, fun, and live music by Grammy and CMA Award Winners, Little Big Town, to benefit the charity founded by Paul Newman, The Hole in The Wall Gang Camp for children coping with serious illnesses, and the Greenwich Parks & Recreation Scholarship Fund.
Mangia Bene! We ate our way through Boston's famous Italian North End on Michele Topor's Boston Food Tour in Boston, Massachusetts. During the 3-hour "original, award winning North End Market Tour" we learned about the history of the area that measures a mere 0.36 square miles (0.93 km), about the culture, and most importantly on a food tour, we tasted our way through the neighborhood and picked up a few great culinary tips and recipes, too!
The New York Culinary Experience 2015 hosted by New York magazine culinary editor Gillian Duffy and The International Culinary Center, CEO and founder Dorothy Cann Hamilton, at the International Culinary Center in New York City was the perfect blend of meeting and cooking with top chefs of the world, culinary influential guest-speaker lunches, cocktail receptions, and meeting new friends.
Stunning accommodations at the luxurious 90-room Saybrook Point Inn & Spa in Old Saybrook, Connecticut was part of A Taste of New England Food Lover's Package with cooking classes with Executive Chef Leslie Tripp featuring lobster rolls, chowders, oysters, and New England Pot Roast, and making new friendships, made for a memorable weekend experience.
Try Swedish - A Taste of West Sweden, part of the North - Nordic Food Festival New York '14 in New York City inspired guests to visit Sweden with delicious menus created by visiting chefs, Frida Ronge and Fredrik Andersson from Gothenburg, Sweden, and a panel discussion to inspire travel to the region.
The Greenwich 2014 Wine + Food Festival presented by Serendipity brought out the crowds to experience excellent wine and beer, delicious food by top area restaurants and celebrity chefs, inspired cocktails by talented mixologists, and music by the Ian Murray Band, The Bacon Brothers, and Alabama to benefit the charity founded by Paul Newman, The Hole in The Wall Gang Camp for children coping with serious illnesses.
We took a great cooking class at El Arrayan while we were in Puerto Vallarta, Jalisco, Mexico where we learned to make traditional Mexican dishes. Destination cooking classes are extremely popular as they provide an opportunity to learn about local flavors, techniques, and culture while on vacation, and to recreate the recipes when you return home as an extension of your trip. We cannot wait to create the recipes at home to share the experience with our family and friends.
Love to cook? Join Luxury Experience on April 5-6, 2014 at the New York Culinary Experience 2014 - "A Fantasy Camp for Foodies" hosted by New York magazine and the International Culinary Center in New York City cooking alongside top toques. Begin each day with breakfast, take a morning class cooking with one of your favorite chefs, have lunch, followed by an afternoon cooking class. At the end of each day, join fellow NYCE students and chefs at a reception. The opportunity to take your class work home with you at the end of each day is another great perk. Classes are held at the prestigious International Culinary Center, located at 462 Broadway, New York, New York.
Spaghetti al Pomodoro, a glorious celebration of tomatoes, olive oil, basil, spaghetti, and Grana Padano cheese at the International Culinary Center in New York City to celebrate the Feast of Saint Anthony the Abbot. Presented by Chef Cesare Casella, Dean of the Italian Studies of the International Culinary Center, it was a day of learning and tastings.
We attended The New York Culinary Experience 2013 hosted by New York magazine and The International Culinary Center in New York for the second year, and what an experience it was! Imagine what a great opportunity it was to cook alongside such culinary "stars" as Mindy Segal, Peter Endriss, Laurie Jon Moran, Masaharu Morimoto, Seamus Mullen, Paul Liebrandt, David Bouley, Dan Barber, Jonathan Benno, Michael Anthony, Cesare Casella, Gerard Craft, Richard Capizzi, Jeffrey Elliot, Michael Lomanaco, Marc Forgione, Marc Murphy, Dominique Ansel, Ron Ben-Israel, Jacques Torres, Elizabeth Karmel, Christopher Hache, Shaun Hergatt, Zachary Golper, Christina Tosi, Jean-Georges Vongerichten, André Soltner, Jesse Schenker, Alain Sailhac, Daniel Rose, Michael Psilakis, April Bloomfield, Naomi Pomeroy, and Harold Moore.
The art of making chocolate truffles with award-winning Danish Master Chocolatier Fritz Knipschildt of Chocopologie by House of Knipschildt at The Clarke Culinary Center in South Norwalk, Connecticut was a most delicious experience. For chocolate lovers, biting into a sinfully rich chocolate truffle with its decadent creaminess is one of life's little pleasures. Taking its name from the shape of a fungus that is the culinary equivalent of gold the chocolate truffle is every bit as precious as its earthy namesake.


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Adaptations to the current ECCO/ESPGHAN guidelines on the management of paediatric acute severe colitis in the context of the COVID-19 pandemic: a RAND appropriateness panel
http://orcid.org/0000-0002-3944-6646Richard Hansen1,
http://orcid.org/0000-0002-8283-6148Susanna Meade2,
http://orcid.org/0000-0003-4721-0577R Mark Beattie3,
http://orcid.org/0000-0002-9381-6994Marcus KH Auth4,
http://orcid.org/0000-0002-1519-6435Nick Croft5,6,
http://orcid.org/0000-0001-7487-5115Philip Davies7,
http://orcid.org/0000-0003-3376-3795David Devadason8,
Conor Doherty9,
http://orcid.org/0000-0003-1380-465XJenny Epstein10,
http://orcid.org/0000-0002-6963-8745Lucy Howarth11,
http://orcid.org/0000-0003-1545-8893Fevronia Kiparissi12,
http://orcid.org/0000-0001-6107-8109Rafeeq Muhammed13,
http://orcid.org/0000-0003-2174-3439Vinay Shivamurthy14,
http://orcid.org/0000-0002-2885-9156Christine Spray15,
http://orcid.org/0000-0003-1130-9778Michael P Stanton16,
http://orcid.org/0000-0003-0060-5141Franco Torrente17,
http://orcid.org/0000-0002-8776-565XArun Urs18,
http://orcid.org/0000-0003-0879-1129David Wilson19,20,
http://orcid.org/0000-0003-0972-8148Peter M Irving2,
http://orcid.org/0000-0002-4057-9200Mark Samaan2,
http://orcid.org/0000-0002-6046-8727Jochen Kammermeier21
1 Department of Paediatric Gastroenterology, Royal Hospital for Children, Glasgow, UK
2 Department of Gastroenterology, Guy's and Saint Thomas' NHS Foundation Trust, London, UK
3 Department of Paediatric Gastroenterology, Southampton Children's Hospital, Southampton, UK
4 Department of Paediatric Gastroenterology, Alder Hey Children's NHS Foundation Trust, Liverpool, Merseyside, UK
5 Blizard Institute, Queen Mary's University of London, Barts and the London School of Medicine, London, UK
6 Department of Paediatric Gastroenterology, Royal London Children's Hospital, Barts Health NHS Trust, London, UK
7 Department of Paediatric Respiratory Medicine, Royal Hospital for Children, Glasgow, UK
8 Department of Paediatric Gastroenterology, Queen's Medical Centre Nottingham University Hospital NHS Trust, Nottingham, UK
9 Department of Paediatric Infectious Diseases and Immunology, Royal Hospital for Children, Glasgow, UK
10 Department of Paediatric Gastroenterology, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
11 Department of Paediatric Gastroenterology, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
12 Department of Paediatric Gastroenterology, Great Ormond Street Hospital for Children, London, UK
13 Department of Paediatric Gastroenterology, Birmingham Children's Hospital, Birmingham, West Midlands, UK
14 Department of Paediatric Rheumatology, Evelina London Children's Hospital, London, UK
15 Department of Paediatric Gastroenterology, Hepatology & Nutrition, Bristol Royal Hospital for Children, Bristol, UK
16 Department of Paediatric Surgery, University Hospital Southampton NHS Foundation Trust, Southampton, Hampshire, UK
17 Department of Paediatric Gastroenterology, Addenbrookes Hospital, Cambridge, UK
18 Department of Paediatric Gastroenterology, Sheffield Children's Hospital NHS Foundation Trust, Sheffield, UK
19 Child Life and Health, University of Edinburgh, Edinburgh, UK
20 Department of Paediatric Gastroenterology and Nutrition, Royal Hospital for Sick Children, Edinburgh, UK
21 Department of Paediatric Gastroenterology, Evelina London Children's Hospital, London, UK
Correspondence to Dr Jochen Kammermeier, Paediatric Gastroenterology, Evelina London Children's Hospital, London, London, UK; jochen.kammermeier{at}gstt.nhs.uk
Objective Paediatric acute severe colitis (ASC) management during the novel SARS-CoV-2/COVID-19 pandemic is challenging due to reliance on immunosuppression and the potential for surgery. We aimed to provide COVID-19-specific guidance using the European Crohn's and Colitis Organisation/European Society for Paediatric Gastroenterology, Hepatology and Nutrition guidelines for comparison.
Design We convened a RAND appropriateness panel comprising 14 paediatric gastroenterologists and paediatric experts in surgery, rheumatology, respiratory and infectious diseases. Panellists rated the appropriateness of interventions for ASC in the context of the COVID-19 pandemic. Results were discussed at a moderated meeting prior to a second survey.
Results Panellists recommended patients with ASC have a SARS-CoV-2 swab and expedited biological screening on admission and should be isolated. A positive swab should trigger discussion with a COVID-19 specialist. Sigmoidoscopy was recommended prior to escalation to second-line therapy or colectomy. Methylprednisolone was considered appropriate first-line management in all, including those with symptomatic COVID-19. Thromboprophylaxis was also recommended in all. In patients requiring second-line therapy, infliximab was considered appropriate irrespective of SARS-CoV-2 status. Delaying colectomy due to SARS-CoV-2 infection was considered inappropriate. Corticosteroid tapering over 8–10 weeks was deemed appropriate for all. After successful corticosteroid rescue, thiopurine maintenance was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive swab but uncertain in symptomatic COVID-19.
Conclusion Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab, irrespective of SARS-CoV-2 status. Consideration of routine prophylactic anticoagulation was recommended.
This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.
https://bmj.com/coronavirus/usage
Significance of this study
What is already known on this subject?
Paediatric acute severe colitis management has been standardised by evidence-based guidelines from European Crohn's and Colitis Organisation and European Society for Paediatric Gastroenterology, Hepatology and Nutrition.
The management of acute severe UC during the COVID-19 pandemic in adults has been supported by specific new guidance generated through RAND panel methodology based on the British Society of Gastroenterology IBD guidelines.
The management of acute severe colitis relies heavily on immunosuppressive therapy, posing specific concerns during the current COVID-19 pandemic.
What are the new findings?
This RAND panel process has supported existing practice in the context of paediatric acute severe colitis, particularly the use of intravenous corticosteroids and second-line infliximab.
Delaying colectomy was considered inappropriate in those who require this, irrespective of COVID-19 status.
The RAND panel considered anticoagulation appropriate in all paediatric patients admitted with acute severe colitis, irrespective of COVID-19 status.
How might it impact on clinical practice in the foreseeable future?
This process enabled rapid review of existing guidance with specific reference to the risk:benefit of established acute severe colitis management in the context of an emerging pandemic.
Our recommendations have the potential to increase clinician confidence and may be of considerable benefit as new challenges occur during the continued pandemic.
All aspects of healthcare have been impacted in recent months by the novel SARS-CoV-2 pandemic, with rapid and fundamental shifts occurring in clinical services as a result. While infection has been seen to cause variable phenotypes of clinical disease, from asymptomatic carriage to fatal acute respiratory distress syndrome with resultant hyperinflammation and cytokine storm syndrome,1 children have been relatively unaffected with low rates of morbidity or mortality. Encouragingly, paediatric IBD and its treatment does not appear to confer significant additional risk to children infected with SARS-CoV-2. A small case series of eight children with IBD and SARS-CoV-2 infection revealed that they had mild symptoms, even with concurrent immunosuppressant treatment.2 In addition, of the 85 patients younger than 20 years of age reported to date on the Surveillance Epidemiology of Coronavirus Under Research Exclusion (SECURE)-IBD database, none resulted in death and only one required admission for ventilation.3 4
While data are still emerging on the true impact of SARS-CoV-2, practitioners are more cautious about the risks of general anaesthetics, surgery and the use of immunosuppressants. The potential risks of these interventions however, need to be considered in the context of the likely increase of secondary morbidity from suboptimal assessment and treatment of IBD. Similarly, COVID-19 has generated an impetus for innovation within healthcare.
For these reasons, members of the British Society of Gastroenterology reviewed their own guidelines for managing acute severe UC (ASUC) by applying RAND appropriateness methodology to offer expert commentary and guidance on how management might need adaptation in light of SARS-CoV-2.5 Subsequently and independently, we convened a RAND panel for the management of paediatric ASC using the current European Crohn's and Colitis Organisation (ECCO)/European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) guidance6 as a reference point against which to highlight any changes to proposed current management.
While the ECCO/ESPGHAN guideline focuses on patients younger than 18 years of age, the adult RAND publication applies to patients 16 years of age or older presenting to an adult department. We acknowledge that, between different countries, there is significant variation of practice. Although our guidance is mainly aimed to young persons under the age of 16 and aligned with the adult RAND panel publication, we acknowledge that many patients between the ages 16 and 17 years are appropriately managed in an adult setting. The paediatric acute severe colitis (ASC) guideline differs from the adult version, for example, by recommending the paediatric ulcerative colitis activity index (PUCAI)7 as a marker of disease severity, mandating sigmoidoscopy on day 3 rather than day 1 and second-line therapy escalation on day 5 instead of day 3.6 Both paediatric and adult guidelines agree on initial management of ASC with first-line intravenous corticosteroids followed by second-line immunosuppressant therapy prior to colectomy unless surgical intervention is required as an emergency.
Significant variations were proposed in the recently published adaptation of management in adult ASUC in the context of COVID-19.5 We therefore convened a RAND appropriateness panel to provide clarity on the management of ASC in children and adolescents, as defined by PUCAI,6 in the context of the COVID-19 pandemic. RAND appropriateness methodology is a widely used, iterative, evidence-based process that combines the best available evidence with expert opinion. It is ideally suited to providing greater clarity in circumstances where genuine uncertainty and clinical equipoise exist.7 8
RAND/University of California, Los Angeles methodology was used to assess the appropriateness of following the standard ECCO/ESPGHAN guidelines for the management of ASC during the COVID-19 pandemic.6 It follows a modified Delphi panel approach which combines expert opinion with the best evidence to determine the appropriateness of interventions in specific clinical scenarios.7 8 We assembled a 14-person panel of British Society of Paediatric Gastroenterology, Hepatology and Nutrition IBD experts comprising consultants from the IBD working group and medium-sized to large-sized paediatric gastroenterology departments across the UK to ensure a geographically balanced representation (online supplementary table 1). The chosen number of panellists was based on RAND recommendations stating that panels should ideally include no more than 15 participants.8
[gutjnl-2020-322449supp001.pdf]
An online survey was created, iteratively improved and subsequently sent to all panellists to complete before the moderated online meeting. Panellists were provided with the current ECCO/ESPGHAN guidelines on the management of ASC6 as well as a list of relevant publications on COVID-19 in general and specifically in relation to paediatric±IBD (PIBD) ahead of the meeting. Of particular relevance to paediatric COVID-19 infection were articles relating to the paediatric inflammatory multisystem syndrome—temporally associated with SARS-CoV-2 (PIMS-TS).9 Some of the scenarios and interventions considered were not part of current guidelines but were proposed to aid comparison to the adult RAND panel (eg, timing of sigmoidoscopy) or proposed based on evidence from the literature review, to assess the appropriateness of immunosuppressant-sparing intervention (metronidazole, amoxicillin, doxycycline, vancomycin (MADoV also known as the Jerusalem cocktail) and use of thromboprophylaxis which may be of particular relevance during the pandemic.10–12
Panellists rated the appropriateness of specific interventions at various time points during a patient's admission with ASC (admission, first-line therapy, rescue therapy, continued medical therapy on discharge and surgery) in the context of their SARS-CoV-2 swab status and the presence or absence of symptoms or signs of COVID-19 infection. The appropriateness of each intervention was graded on a scale of 1–9, where 1–3 is inappropriate, 4–6 is uncertain and 7–9 is appropriate. The anonymised results were presented at a virtual meeting in June 2020. This enabled the moderators to ensure a common understanding of the questions and also enabled focused discussion on areas of disagreement, without trying to force consensus. Also present at the meeting were non-voting specialists who provided expert opinion with regard to IBD surgery (MS), rheumatology (VS), respiratory medicine (PD) and infectious diseases (CD). In practice, several specialists may provide expert opinion on COVID-19 management, including intensivists, respiratory physicians and infectious disease physicians. We used the encompassing term 'COVID-19 specialist' to represent this group. The moderators (MS, PMI) are experts in the management of IBD and RAND panel methodology but neither gave opinions during the meeting nor took part in either survey. Following the panel meeting, minor adjustments were made to the initial questionnaire and a second online survey of 113 questions was re-distributed for completion.
A number of assumptions were made to add clarity to the clinical scenarios. Patients were assumed to have a diagnosis of ASC, as defined by a PUCAI ≥65, with GI infection having been excluded. It was assumed patients had received optimised 5-aminosalicylic acid therapy prior to admission (except when admission was an index presentation). Where calcineurin inhibitors were proposed patients were assumed to be thiopurine-naïve. When discussing corticosteroid weaning or cessation, it was assumed that patients could discontinue corticosteroids without the risk of Addisonian crisis. Management decisions not discussed in the survey were presumed to be in line with ECCO/ESPGHAN guidance.6 Particular to rescue therapy, patients were assumed to have ongoing ASC despite 5 days of intravenous corticosteroid therapy and had reached standard criteria for rescue therapy.6 When discussing medical therapy after discharge, patients were assumed to have responded to intravenous corticosteroids, to have been successfully switched to oral prednisolone and were medically fit for discharge. Finally, RAND methodology mandates that decisions with regard to the appropriateness of interventions should not take into account treatment availability, practicalities or cost.
Median scores were calculated for each clinical question. A score of <3.5 was considered inappropriate, ≥3.5 but<6.5 uncertain and ≥6.5 appropriate. We used the validated RAND disagreement index (DI) to define disagreement among panellists using the equation outlined below.8 A DI ≥1 denotes disagreement. Where disagreement was present for any scenario, the final outcome for that scenario was uncertain irrespective of the median score.
All 14 panellists completed the prepanel and postpanel meeting questionnaires. Of the 113 clinical scenarios, panellists rated 30 as appropriate, 22 as uncertain and 61 as inappropriate. After the second round of voting, agreement was present for all scenarios (DI<1) except two, both relating to SARS-CoV-2-positive patients with symptoms or signs of infection; the use of ciclosporin with corticosteroids as rescue therapy and the use of prophylactic anticoagulation after discharge A detailed list of all scenarios, complete with median score, appropriateness rating and DI is shown in online supplementary table 2. The key findings are summarised in this chapter (overall results) and their relationship to current ECCO/ESPGHAN guidance is highlighted in figure 1.
Variations to the current ECCO/ESPGHAN guidance as proposed by the RAND appropriateness panel. 5-ASA, 5-aminosalicylic acid; CMV, cytomegalovirus; ECCO, European Crohn's and Colitis Organisation; ESPGHAN, European Society for Paediatric Gastroenterology, Hepatology and Nutrition; PUCAI, paediatric ulcerative colitis activity index.
Indications for investigations, inpatient isolation and specialist referral
It was rated appropriate that all patients admitted to hospital with ASC should have a SARS-CoV-2 swab performed on admission. If the result was negative it was felt appropriate to repeat the swab at the point of requiring rescue therapy and/or surgery. It was also considered appropriate to isolate all patients throughout their admission, irrespective of their SARS-CoV-2 status. It was considered inappropriate to expedite flexible sigmoidoscopy within 24 hours of admission from the current guideline recommendation of day 3. It was, however, considered appropriate that a flexible sigmoidoscopy should be performed prior to rescue therapy or colectomy had it not occurred already. Repeating this test during a single admission (eg, prior to rescue therapy and again prior to colectomy) was considered inappropriate (table 1).
Appropriateness of patient isolation and investigation in paediatric patients admitted with acute severe colitis in the context of the COVID-19 pandemic
The appropriateness of a routine chest X-ray in all patients admitted with ASC was rated as uncertain but this was considered appropriate as a preoperative investigation in all patients who require colectomy. It was deemed inappropriate to delay colectomy, if required, in all patients. Expedited biological screening on admission was considered appropriate. In patients who had received broad-spectrum antibiotics (in the context of COVID-19), it was considered appropriate to repeat Clostridium difficile testing at day 5 if patients were failing first-line therapy.
The appropriateness of referral to a COVID-19 specialist at various time points during admission was considered. In patients with a negative swab and no symptoms or signs of COVID-19 infection, this was deemed inappropriate if receiving first-line therapy but uncertain in patients requiring rescue therapy. It was however considered appropriate in all patients with a positive swab, irrespective of the presence of symptoms or signs of COVID-19 infection.
Initial treatment of ASC
As per ECCO/ESPGHAN guidance, inpatient intravenous methylprednisolone was rated appropriate as the initial management of patients presenting with ASC irrespective of SARS-CoV-2 infection or its sequelae. It was the only first-line treatment deemed appropriate; all other agents (infliximab, ciclosporin and tacrolimus) were deemed inappropriate irrespective of SARS-CoV-2 status. Outpatient treatment with intravenous methylprednisolone or inpatient treatment with poorly absorbed bioavailable steroids (budesonide multimatrix (MMX) or beclometasone) were also deemed inappropriate in all scenarios. The use of MADoV antibiotic combination11 (metronidazole, amoxicillin, doxycycline, vancomycin or equivalent) concurrently with corticosteroids was deemed inappropriate in SARS-CoV-2-negative patients but uncertain in patients with a positive swab. MADoV therapy alone was considered inappropriate in all scenarios. It was considered appropriate to prescribe prophylactic anticoagulation in all patients with ASC, irrespective of their SARS-CoV-2 status (table 2).
Appropriateness of treatment options in acute severe colitis in the context of the COVID-19 pandemic: first-line medical therapy
Rescue therapy
In patients with a PUCAI 35–65 at day 5 of first-line therapy it was deemed appropriate, irrespective of SARS-CoV-2 status, to continue intravenous corticosteroids for a further 2–5 days (as per ECCO/ESPGHAN guidelines). Expediting second-line therapy at this juncture was considered uncertain in all scenarios. Conversely, in patients with a PUCAI >65 it was considered inappropriate to continue monotherapy with intravenous corticosteroids, irrespective of SARS-CoV-2 status. Instead, the panellists deemed that following standard ECCO/ESPGHAN guidance by initiating infliximab and continuing corticosteroids was appropriate. ECCO/ESPGHAN guidelines also recommend ciclosporin or tacrolimus as alternatives to infliximab. Despite this, treatment with ciclosporin concurrently with corticosteroids was deemed uncertain (irrespective of SARS-CoV-2 status) and the use of tacrolimus was deemed inappropriate irrespective of swab status or concurrent corticosteroid use. Commencing any second-line immunosuppressive therapy (infliximab, ciclosporin or tacrolimus) with simultaneous discontinuation of intravenous corticosteroid therapy was deemed inappropriate irrespective of SARS-CoV-2 status. In all scenarios, the appropriateness of MADoV alongside immunosuppressive therapy was considered uncertain, whereas MADoV alone was deemed inappropriate. Management by colectomy after failed first-line therapy was considered inappropriate in all patients with ASC irrespective of SARS-CoV-2 status (excluding cases where complications indicating the need for surgery were present such as toxic megacolon, perforation or severe haemorrhage) (table 3).
Appropriateness of treatment options in acute severe colitis in the context of the COVID-19 pandemic
Continuing medical therapy
On discharge from hospital, irrespective of SARS-CoV-2 status, it was deemed appropriate to use a standard corticosteroid taper as per ECCO/ESPGHAN guidance.6 An accelerated corticosteroid taper over 4–8 weeks was considered inappropriate in patients with a negative SARS-CoV-2 swab but uncertain in patients with a positive swab. It was considered inappropriate in all scenarios to use poorly bioavailable oral steroids as an alternative to prednisolone. Initiation of additional maintenance therapy during corticosteroid weaning to prevent disease relapse, was also considered. Following ECCO/ESPGHAN guidance by initiating a thiopurine was rated appropriate in patients with negative SARS-CoV-2 swab and asymptomatic patients with positive SARS-CoV-2 swab but uncertain in symptomatic patients with a positive swab (table 4).
Appropriateness of treatment options in acute severe colitis in the context of the COVID-19 pandemic: continuing medical therapy
Use of antitumour necrosis factor (anti-TNF) maintenance was considered uncertain irrespective of SARS-CoV-2 swab status. The use of vedolizumab was considered uncertain in asymptomatic patients with positive SARS-CoV-2 swab and inappropriate in symptomatic patients with positive swab and patients with negative swab.
Lastly, the appropriateness of the use of prophylactic anticoagulation for a period after discharge was considered. This was deemed inappropriate in patients who had a negative SARS-CoV-2 swab and uncertain in patients with a positive swab regardless of whether they had displayed signs or symptoms of COVID-19 infection.
Our COVID-19-specific adaptations to paediatric ASC guidelines using a RAND panel generally support existing recommendations, particularly the use of corticosteroids and escalation to infliximab.
The role of corticosteroids as first-line therapy
The use of intravenous corticosteroids constitutes the mainstay therapy for children with ASC. More than 70% respond to daily methylprednisolone according to the 'Outcome of Steroid therapy in Colitis Individuals' study published by Turner et al in 2010.13 We considered it appropriate to follow the current ECCO/ESPGHAN ASC guideline6 and initiate therapy with intravenous methylprednisolone irrespective of the SARS-CoV-2 screening result and without delay. Despite initial concerns regarding the safety profile of corticosteroids in the context of COVID-19 in adult patients, emerging evidence for the use of dexamethasone suggest that it is safe and might positively influence the disease course. Preliminary results from the RECOVERY trial revealed that dexamethasone treatment led to a significant reduction of mortality in hospitalised patients requiring respiratory support.14 In addition, patients with PIMS-TS have been regularly treated with corticosteroids.9 15 Doubts regarding the safety of immunosuppressant medications including corticosteroids during the COVID-19 pandemic persist, particularly in light of preliminary data published from SECURE-IBD which suggested corticosteroids were associated with worse disease outcomes.4 However, the median age was 41 years, 59.4% of patients had Crohn's disease and none of the reported 29 paediatric SARS-CoV-2 cases was classified as severe. The obvious confounder with regard to corticosteroid use is underlying moderate-to-severely active UC, which in itself has been associated with the risk of viral infection and worse outcomes in SARS-CoV-2 infection.16 17 Reassuringly, international paediatric studies consistently report a milder disease phenotype in children particularly in terms of respiratory complications.15 In addition, it has become evident that a delay in initiating therapy is likely to have a detrimental effect on paediatric patients with IBD.2
The role of infliximab as rescue therapy
We also concluded that infliximab in combination with corticosteroids was an appropriate therapy, ciclosporin in combination with corticosteroids was considered uncertain and tacrolimus was deemed inappropriate regardless of SARS-CoV-2 status. None of these treatments was considered appropriate as monotherapy. Infliximab and ciclosporin are equally effective in achieving clinical remission in paediatric patients with ASC.6 Infliximab has, however, emerged as the preferred option due to its favourable risk:benefit profile, demonstrating the importance of safety considerations over efficacy alone in therapy selection.13 Ciclosporin use in adult patients with ASUC and COVID-19 has been considered inappropriate due to the combined risk of drug toxicity and COVID-19-related kidney injury.18 The risk for COVID-19-related kidney injury is significantly smaller in children; approximately 20% of children with PIMS-TS develop acute kidney injury.9 The risk of infliximab therapy in adult and paediatric patients with ASC and COVID-19 remains unknown. There is some evidence, however, that biologics, including infliximab, may have a beneficial effect by counteracting the hyperinflammatory response seen in COVID-19.19 20 Biologics including anakinra and infliximab may also be beneficial in the management of PIMS-TS.9
Maintenance therapy
The ECCO/ESPGHAN guideline6 recommends tapering corticosteroids over 8–10 weeks which was deemed appropriate by our RAND panel in all three clinical scenarios with uncertainty regarding an accelerated taper over 4–6 weeks in SARS-CoV-2-positive patients. ECCO/ESPGHAN guidance suggests to initiate azathioprine maintenance therapy in combination with mesalazine for the majority of patients following ASC to decrease the likelihood of relapse.6 21 The RAND panel considered it appropriate to initiate azathioprine except in patients with signs of COVID-19 infection when it was deemed uncertain. This is in contrast to the adult RAND panel outcome5 in which azathioprine treatment was more likely to be considered inappropriate. Reasons for concerns were possible side effects such as pancreatitis which might require hospital admission and lymphopenia potentially mimicking acute SARS-CoV-2 infection as well as the need for regular blood monitoring.22 This is likely to become less of a concern as services start to resume and areas and systems to manage patients without COVID-19 are put in place. The paediatric RAND panel considered azathioprine appropriate which might be explained by the rapidly evolving experience with COVID-19 confirming an overall favourable disease course in the general paediatric population15 as well as in children with IBD on immunosuppressant therapy.2 As per current guidance, patients who underwent rescue therapy with infliximab are recommended to continue this treatment as maintenance. Initiating an anti-TNF as maintenance treatment was considered uncertain in first-line (corticosteroid) responders regardless of SARS-CoV-2 status, which perhaps suggests a desire to avoid escalation to anti-TNF purely for the purposes of maintenance in those who have not required it as a rescue.
MADoV therapy
Although MADoV is only mentioned as a side note in the ECCO/ESPHAGN guidelines, it was deemed feasible that at the onset of the pandemic immunosuppressant-sparing approaches may be relevant or preferable. Although data are limited,11 12 we felt it important to explore the use of MADoV in this context. MADoV was considered inappropriate as a single agent in all contexts and uncertain as an adjunct in SARS-CoV-2-positive patients. This demonstrates that conventional therapy with agents known to be efficacious in preventing morbidity and mortality were considered more appropriate despite the potential risks of immunosuppression.
One of the most interesting and compelling findings of this RAND panel was that prophylactic anticoagulation was deemed appropriate in all patients, irrespective of COVID-19 status. This is distinct from the current ECCO/ESPGHAN guideline which recommends anticoagulation with low molecular weight heparin (LMWH) in adolescents with one or more risk factors for venous thromboembolic events (VTE).2 Notably, the median score was highest for SARS-CoV-2-positive patients with signs of COVID-19 infection and all panellists scored this scenario as appropriate. For SARS-CoV-2-positive patients without signs of COVID-19 infection and SARS-CoV-2-negative patients, the DI remained <1 but not all panellists voted anticoagulation as appropriate likely reflecting the need to weigh up thrombotic risk in individual patients. Adult guidelines advise thromboprophylaxis in all inpatients with ASUC,23 whereas this is not currently the case in paediatric ASC. The adult RAND panel therefore explored prophylactic anticoagulation postdischarge and recommended this in patients with a positive SARS-CoV-2 swab.5 While we considered routine thromboprophylaxis at presentation appropriate in all paediatric patients, there was uncertainty about continued therapy on discharge in SARS-CoV-2-positive patients and it was considered inappropriate in patients with negative swab. One limitation of our survey with regard to anticoagulation was that our clinical scenarios did not take into consideration specific patient factors such as age or thrombotic risk profile. It is likely that more nuanced guidance would emerge if clinical scenarios were more refined. Data from the safety registry in the PIBD-SETQuality (Safety, Efficacy, Treatment and Quality Improvement of Care) project suggest that VTEs are rare in PIBD but are 10 times more likely to occur compared with the general paediatric population. Most reported cases were seen in the context of UC or IBD-unclassified and during acute relapse.10 The cumulative incidence of thrombotic complications in critically ill adult patients with COVID-19 is nearly 50%.24 Even in critically ill adult patients with COVID-19 on standard prophylactic regimen, thromboembolic events were reported in 20%–30% of cases.25 This has led to the implementation of more intensive anticoagulation strategies.23 Despite the paucity of literature to support anticoagulation in paediatric patients with COVID-19, the favourable side-effect profile of LMWH26 and the clear prothrombotic effect of COVID-19 in adults27 suggest to adopt a low threshold to use anticoagulation in paediatric COVID-19.
Further comparisons with adult RAND panel data
Several comparisons can be made between our results and those from the recent adult RAND panel.5 There was agreement that all patients should be isolated, tested for SARS-CoV-2 on admission and subsequently re-swabbed prior to rescue therapy or colectomy. Results were also similar with regard to the decision to refer to a COVID-19 specialist in all SARS-CoV-2-positive patients. These findings are perhaps unsurprising given the risk of nosocomial infection, particularly in a population being treated with immunosuppressive therapy. Similar to the adult RAND panel, it was considered appropriate to perform a flexible sigmoidoscopy at the point advised in the respective guidelines (day 1 for adults, day 3 for paediatrics) and it was not deemed necessary to repeat this test prior to treatment escalation or colectomy. Although SARS-CoV-2 can present with GI symptoms,28 it was considered that expediting endoscopy would not alter management but was required at the advised time point to confirm the diagnosis and, in particular, to exclude cytomegalovirus infection ahead of colectomy. Practical issues are not considered in the RAND process, but unlike in adult practice, most endoscopies in paediatrics are performed under general anaesthetic.
In the adult RAND panel, panellists were asked whether all patients should undergo a CT chest on admission and prior to colectomy which were deemed uncertain and appropriate respectively. The majority of adult patients undergo a routine chest X-ray on admission to hospital. However, there have been reports of improved sensitivity of CT chest compared with SARS-CoV-2 PCR for the diagnosis of COVID-19 infection.29 The inclusion of questions regarding CT chest scanning were generally considered inappropriate in paediatric patients due to the irradiation exposure and the additional requirement for a general anaesthetic to obtain adequate studies in some patients. The appropriateness of a routine chest-X-ray was posed instead and deemed appropriate prior to colectomy but only considered appropriate on a case-by-case basis on admission, leading to an outcome of uncertain.
The panel did not believe that SARS-CoV-2 status affected their decision to arrange an abdominal X-ray and therefore this question included in the first survey was removed from the second. The appropriateness of ustekinumab and tofacitinib use were considered during the adult RAND panel. Although discussed during the paediatric panel meeting, both therapies are not licensed in paediatrics at present and are not mentioned in the ECCO/ESPGHAN guideline. Although it was appreciated that these therapies may be considered in individual paediatric cases, the focus of the RAND panel was to explore how practice might change when compared with standard practice. In both panels, there was a clear message that, if indicated, colectomy should not be delayed due to SARS-CoV-2 positivity.
With regard to the use of intravenous corticosteroids first-line and infliximab monotherapy as first-line or rescue therapy, there was less uncertainty in our results compared with the adult RAND panel. This likely reflects evolving decision-making processes during a period of rapidly emerging evidence and the fact that children have been relatively spared of severe sequelae from COVID-19 when compared with adults.3 In the adult panel, there were only six questions (6%) where all panellists voted the same appropriateness category as the final outcome category compared with 42 scenarios in our results (37%), whereas the number of scenarios reaching disagreement were similar 0/92 and 2/113, respectively.
Strengths and limitations
Our study has several strengths. We assembled a panel of IBD experts from multiple UK centres, evenly distributed across the country. We used RAND methodology, a validated and evidence-based technique to aid decision making, in an area with significant clinical uncertainty. We invited non-gastroenterology specialists with experience in managing children with COVID-19 and PIMS-TS to enable informed discussions during the panel meeting and provide specialist insight where uncertainty or disagreement existed, particularly with regard to the risks and benefits of immunosuppression. Although the aforementioned adult RAND panel has recently been published, our data provide new guidance on the management of ASC specific to children. Furthermore, by comparing our RAND panel with the adult version we have demonstrated how, despite the short time interval, decision making can change as data emerges, highlighting the need for us to be prepared to perpetually adapt our clinical practice. To our knowledge, this is the first study in paediatric IBD applying RAND appropriateness methodology to provide guidance in an area of clinical uncertainty. Given its successful application and positive feedback from panellists and experts within the field, this approach should be considered more often in the future.
Our study also has limitations. We made a number of assumptions with regard to the clinical scenarios considered and nuances in clinical decision making in specific clinical circumstances could not be brought to the fore. We broadly reviewed the use of individual agents to demonstrate themes with regard to the risks and benefits of therapy. We did not, for example, discuss continuing medical therapy in patients who required rescue with infliximab, in whom the potential risk of concomitant therapy needs to be weighed-up with the risks of immunogenicity if omitted. Rather, the outcomes discussed should serve as a guide and as an adjunct to clinical judgement and multidisciplinary decision making. It is possible that treatment-related considerations may change as new data come to light.
This process was undertaken during a period of great uncertainty with a rapidly emerging evidence base. The process enabled rapid review of existing guidance with specific reference to the risk:benefit of established ASC management in the context of an emerging pandemic. Our recommendations have the potential to increase clinician confidence and may be of considerable benefit as new challenges occur during the continued pandemic. The process also raised new issues for consideration including the timing of investigations, specifics of therapy and use of anticoagulation.
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RH and SM are joint first authors.
MS and JK are joint senior authors.
Twitter @SamaanMark
Correction notice This articel has been corrected since it published Online First. The author's name Conor Doherty has been corrected and ORCID IDs have been added for all authors.
Contributors All authors approved the final version. Study concept and design: RH, SM, RMB, MS, PMI and JK. Development of questionnaire: RH, RMB, SM, MS, PMI and JK. Data analysis: SM, MS and PMI. Interpretation of data and drafting of manuscript: RH, RMB, SM, MS, PMI and JK. Panellists, experts and moderators: all authors. Contributions to literature review and critical revision of the manuscript for important intellectual content: all authors.
Funding RH is supported by an NHS Research Scotland Career Researcher Fellowship.
Competing interests Competing interests listed in online supplementary table 1.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information. This is not a clinical trial, hence no patient identifiable data generated. Any other data generated in this study is included in the article.
© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ. This article is made freely available for use in accordance with BMJ's website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.https://bmj.com/coronavirus/usage

redpajama_set_name: RedPajamaCommonCrawl


If I attach Obi Force Ghost to Han Solo Rebel General and then switch him out for a different Han, what happens to the force ghost?
Well here's my take on it. Since they both occur at the start of the scirmish, you should be able to choose which order.
If you switch out Han first then there is no issue. The issue arrises when you attach obi first. And with that I see 2 options.
Either you lose the ghost unless the other Han has a force point, or obi would get to hop on someone else with a force rating. Personally, I would want the 1st option to take precedence as the whole thing was avoidable. I think that if you made the mistake of attaching the ghost first, then you should also pay the price if your new Han doesn't have a force rating. It was a good question and await the official answer from Scott.
The problem is that Versatility occurs after set-up so I have already had to choose (during set-up) who the ghost goes onto.
The next part of the question is if I swap Han, can the new Han take mettle as it is an SA he now has from the force ghost or is versatility limited to strictly the abilities on the card.
My assumption would be that you would lose the force ghost no matter what happened as the character he is haunting (han general) is no longer in play, but I wanted to see what others thought.
From what you just described, I'm pretty sure Scott's answer will be that ObiGhost is banished. Your opponent gains 8pts, and you end up feeling like a noob.
Seriously, while Versatility is a very powerful and flexible ability in most situations, it actually hinders your choices if you want to take a force ghost.
A technicality perhaps, but swapping Han does not "defeat" the previous one.
Based on that, I would think the ghost remains, but is useless (unless it is Yoda or Anakin, who have CEs).
And this is why I brought up the question so we can think about it.
As far as I'm aware, Sever Force does not remove a Light Spirit. So the loss of a Force Rating would not create him to be ineligible after a Light Spirit was assigned. The only difference, is that Han would still be able to benefit from Force Renewal (see Sidogram).
Does this mean that you could swap and say give han smuggler force renewal?
I guess it means the real question is the "new" han the same as the "old" han in game terms?
Well the ghost says "start of scirmish", while Versitility says "start of scirmish, after set up"
It seems to me that Versitility is limited as to when but the ghost is not. What's to say, you can't attach the ghost after set up. In which case you would still get to choose order.
Regardless the real question in play is if you do attach first, then swap. I don't want to see Han Smuggler be able to get FR. Maybe I'm wrong, as I don't know who thought of Versitility, but that doesn't seem the intent. Could just be that they overlooked the situation with a ghost. IMO, I think the ghost should die and your oppontent gets free pnts to start the match. In other words, don't attach the ghost to Han. That sounds the more simple route to me.
The glossary entry for Light Spirit specifies "During setup", so it would have to happen before Versatility, because that specifies "after setup".
If Sever Force doesn't remove a Light Spirit, then I don't see why Versatility would. Han Rebel General isn't defeated by Versatility, he's just replaced, so it doesn't make any sense for the Light Spirit to be defeated. I don't know of any good reason for it to be re-assigned to a different character or anything like that, so leaving it on the new Han seems to make the most sense to me.
Doing this to give Force Renewal to Han Smuggler would be dumb, though. Really it's dumb to ever replace Han Rebel General for Han Smuggler; you keep the CE so you don't get to count as a follower, but otherwise you just lose a bunch of SAs and stats and don't gain anything.
Han of Hoth just keeps getting better!
It's not like he could've gotten much worse.
Maybe it's just me, but I don't understand the comparison between Versitility and Sever Force. They are different in so many ways. No Sever Force does not defeat a character, (just like Versitility doesn't) but that's about the only similarities between the 2.
Han Rebel General might not be defeated but he is removed from play.
If the ghost isn't defeated then he would just be hanging around doing nothing, creating a game error, as the ghost can't be hanging around if not attached to anyone.
I don't see why it would switch to the new Han. You attached it to Rebel General and then took Rebel General out of play.
Does the new Han count as the old Han.
IMO I don't think it should, but that's not for me to decide.
The same question could apply to Leia too. If for example after you see your opponets set up you decide you need Force Sense.
I really don't understand why it's even a question.
No you cannot just arbitrarily attach a ghost to a new version.
I think Jake nailed it.
I can't wait to face a Rebel squad with the new Han and Leia in it, along with multiple Force ghosts, and maybe Tyber and Lobot, too. Setting up is fun! Oooh, and maybe I'll be playing a Yammosk!
Lol. If not a Yammosk, then maybe Pellaeon.
You know this does bring up a good point about how its's even more important to allow sufficient and equal set-up time.
Ruling: If a character a Light Spirit, Dark Spirit, or Eternal Sith Spirit is assigned to is replaced via an ability such as Camaderie or a CE such as Pelleon's, the Spirit remains on the board. The assigned character that was brought in does not benefit from Spirit, even if they are considered to be the same personae.
As for my reasoning. The replacement is not defeat. Plain and simple. Camraderie does not work if it did. Pelleaon had set a LOT of the precedents for how Camraderie works, and I'm not interested in changing them. So, they are not defeated, and the effects of one character do not transfer over. And since the conditions of removal are defeat, you are sort of stuck with the Spirits.
Thanks Scott, that will help keep things simple(r) in the future.