The intracellular visualization of exogenous DNA in fluorescence microscopy

In the development of non-viral gene delivery vectors, it is essential to reliably localize and quantify transfected DNA inside the cell. To track DNA, fluorescence microscopy methods are commonly applied. These mostly rely on fluorescently labeled DNA, DNA binding proteins fused to a fluorescent protein, or fluorescence in situ hybridization (FISH). In addition, co-stainings are often used to determine the colocalization of the DNA in specific cellular compartments, such as the endolysosomes or the nucleus. We provide an overview of these DNA tracking methods, advice on how they should be combined, and indicate which co-stainings or additional methods are required to draw precise conclusions from a DNA tracking experiment. Some emphasis is given to the localization of exogenous DNA inside the nucleus, which is the last step of DNA delivery. We argue that suitable tools which allow for the nuclear detection of faint signals are still missing, hampering the rational development of more efficient non-viral transfection systems.

Quantification of skin wound tension using a newly designed wound tensiometer

OBJECTIVE

To (i) quantitatively measure wound tension in experimental skin wounds using a newly developed wound tensiometer and (ii) establish reference values for primary skin wound closure in medium- and large-breed dogs.

STUDY DESIGN

Experimental cadaveric study.

ANIMAL POPULATION

Nineteen dogs of medium to large breeds (BW 20 to 40 kg).

METHODS

Elliptical skin wounds of different sizes were created on the chest and abdomen. The wounds were gradually enlarged. Experienced surgeons (ECVS diplomates or professors of small animal surgery) and inexperienced surgeons (1st year after graduation) independently assessed wound tension through manual manipulation and determined whether the wound could be closed without tension-relieving measures. In addition, wound tension was objectively quantified using a newly developed wound tensiometer.

RESULTS

The upper threshold for wound tension at which direct appositional wound closure was recommended by the experienced surgeons was 5.4 N, and the median minimal tension without recommendations for closure was 6.0 N. The data also demonstrate that wound tension and wound size do not necessarily correlate, and inexperienced surgeons need to develop a feel for wound tension.

CONCLUSION

The intraoperative use of the wound tensiometer, in combination with established cut-off values, might facilitate decision-making regarding primary wound closure.

CLINICAL RELEVANCE

The findings of this study provide evidence for the applicability of a wound tensiometer in guiding inexperienced surgeons in their choice of the skin wound closure method.

Molecular Determinants of Calcitriol Signaling and Sensitivity in Glioma Stem-like Cells

Glioblastoma is the most common primary brain cancer in adults and represents one of the worst cancer diagnoses for patients. Suffering from a poor prognosis and limited treatment options, tumor recurrences are virtually inevitable. Additionally, treatment resistance is very common for this disease and worsens the prognosis. These and other factors are hypothesized to be largely due to the fact that glioblastoma cells are known to be able to obtain stem-like traits, thereby driving these phenotypes. Recently, we have shown that the in vitro and ex vivo treatment of glioblastoma stem-like cells with the hormonally active form of vitamin D3, calcitriol (1α,25(OH)2-vitamin D3) can block stemness in a subset of cell lines and reduce tumor growth. Here, we expanded our cell panel to over 40 different cultures and can show that, while half of the tested cell lines are sensitive, a quarter can be classified as high responders. Using genetic and proteomic analysis, we further determined that treatment success can be partially explained by specific polymorphism of the vitamin D3 receptor and that high responders display a proteome suggestive of blockade of stemness, as well as migratory potential.

A dedicated cytoplasmic container collects extrachromosomal DNA away from the mammalian nucleus

Expression from transfected plasmid DNA is generally transient, but it is unclear what process terminates it. We show that DNA entering mammalian cells is rapidly surrounded by a double membrane in the cytoplasm, in some cases after leaving the nucleus. This cytoplasmic container, termed exclusome, frequently also contains extrachromosomal telomeric DNA, and is maintained by the cell over several division cycles. The exclusome envelope contains endoplasmic reticulum proteins and the inner-nuclear membrane proteins Lap2β and Emerin, but differs from the nuclear envelope by its fenestrations and the absence of the Lamin B Receptor and nuclear pore complexes. Reduction of exclusome frequency upon overexpressing Emerin's LEM-domain suggests a role for Emerin in plasmid DNA compartmentalization. Thus, cells distinguish extrachromosomal DNA and chromosomes and wrap them into similar yet distinct envelopes keeping the former in the exclusome but the latter in the nucleus, where transcription occurs.

Get out or die trying: Peptide- and protein-based endosomal escape of RNA therapeutics

RNA therapeutics offer great potential to transform the biomedical landscape, encompassing the treatment of hereditary conditions and the development of better vaccines. However, the delivery of RNAs into the cell is hampered, among others, by poor endosomal escape. This major hurdle is often tackled using special lipids, polymers, or protein-based delivery vectors. In this review, we will focus on the most prominent peptide- and protein-based endosomal escape strategies with focus on RNA drugs. We discuss cell penetrating peptides, which are still incorporated into novel transfection systems today to promote endosomal escape. However, direct evidence for enhanced endosomal escape by the action of such peptides is missing and their transfection efficiency, even in permissive cell culture conditions, is rather low. Endosomal escape by the help of pore forming proteins or phospholipases, on the other hand, allowed to generate more efficient transfection systems. These are, however, often hampered by considerable toxicity and immunogenicity. We conclude that the perfect enhancer of endosomal escape has yet to be devised. To increase the chances of success, any new transfection system should be tested under relevant conditions and guided by assays that allow direct quantification of endosomal escape.

Emission characteristics of bulk aerosols excited by externally focused femtosecond filaments

The bulk aerosol emissions excited by externally focused femtosecond laser filaments are characterized using time-resolved plasma imaging and spectroscopy. Images of N₂ and N2+ plasma fluorescence are used to characterize the filament dimensions. Emission profiles from bulk Sr aerosols are studied, showing that several localized emission regions in the filament begin to develop for lower repetition rates and higher pulse energies. Plasma temperature and electron density profiles are determined using particle emissions along the length of short- and long-focused filaments, and results are compared for on-axis and side-collected spectra. The use of on-axis collection enables the sampling of light emitted over the entire length of the filament; however, the necessary back-propagation of light makes on-axis collection susceptible to self-absorption as the optical path is extended through the filament plasma column formed in bulk aerosols.

Generation of multiple obstruction-free channels for free space optical communication

Multi-filament structures produced by vortical high-power femtosecond pulses propagating through clouds and fog can simultaneously clear two channels with cylindrical and annular profile. We present a method to achieve Free Space Optical (FSO) communications through such highly scattering media by propagating appropriately shaped laser modes through these channels. As a proof of concept, we implemented a Laguerre-Gaussian beam as information signal carrier to demonstrate transmission of 543-nm CW laser beam through a 1-m long cloud chamber using both channels. The low power of the information signal in this experiment allows considering applications in Earth-satellite FSO communication.

PL02.1.A EO2401, a novel microbiome-derived therapeutic vaccine for patients with recurrent glioblastoma: ROSALIE study

Background

EO2401 (EO) was designed to activate existing commensal memory T-cells cross-reacting with tumor associated antigens (TAAs). EO includes microbial-derived, synthetically produced peptides corresponding to HLA-A2 restricted epitopes with molecular mimicry to three TAAs upregulated in glioblastoma (GB), IL13Rα2, BIRC5 and FOXM1, with the CD4 helper peptide UCP2 and the adjuvant Montanide. Pre-clinically EO generated strong immune responses and cross-reactive CD8 cells recognizing the targeted TAAs.

Methods

This ongoing Ph 1/2 trial (NCT04116658) investigates the safety and tolerability (primary) of EO (300 µg/peptide, SC Q2W X 4, then Q4W), EO with nivolumab (3 mg/kg Q2W; EN), and EN with bevacizumab (10 mg/kg Q2W; ENB) among four Cohorts (Cs) of pts with GB at first progression/recurrence after radiotherapy/temozolomide. Treatment was delivered until progression, or 24 months. After the Ph 1 of EO followed by EN (C1), C2 investigated EN without (C2a) or with (C2b) surgery while C3 investigated ENB (population as C2a).

Results

Among 40 treated pts (C1 n=3, C2a n=23, C2b n=3, C3 n=11), median age was 60 years, 53% were male, 40% had KPS 90-100%, 35% had O6-methylguanine DNA-methyltransferase promotor hypermethylated tumors, and 5% isocitrate dehydrogenase 1 mutated tumors. All evaluable pts demonstrated strong CD8 T-cell ELISPOT responses against the 3 vaccine peptides; response was shown with tetramer staining of specific CD8 in 24/25 investigated pts after in vitro stimulation and in 19/20 pts directly ex vivo. Cross-reactivity against targeted TAAs was confirmed in 20/21 pts. Majority of response were detected by week 4 after 1st dose and as early as 2 weeks in some pts. EO, EN, and ENB were well tolerated (max exposure EN 86 wks, ENB 47 wks) with EO associated toxicity limited to local administration site reactions (48%; all grade 1-2). The frequency and severity of nivolumab- or bevacizumab-associated AEs was consistent with historical single-agent profiles. With a median follow-up of 13.6 months, median progression-free survival (mPFS), and median survival for EN (C1+C2a+C2b) were 1.8 months (2 ongoing at 7.3, and 18.5 months), and 11.0 months (survival at 12 months 42%), respectively. With a median follow-up of 7.3 months (range, 3.0-10.5), pts on ENB (C3) have mPFS and survival at 6 months of 5.5 months (3 ongoing at 5.6, 7.3 and 9.1 months), and 82% (9/11 alive), respectively. ORR/DCR (ORR+SD) for EN and ENB were 10%/34% and 55%/82%, respectively.

Conclusion

EO2401 generated strong systemic immune responses and was well tolerated in combination with nivolumab ± bevacizumab. Preliminary ORR/DCR and mPFS for ENB, and survival for EN seem encouraging. Updated results from the current 40 patients and results from additional 35 patients who already started treatment with EN with the option for low-dose bevacizumab edema treatment at neurological symptoms will be presented.

Iterative wavefront optimization of ultrafast laser beams carrying orbital angular momentum

Structured intense laser beams offer degrees of freedom that are highly attractive for high-field science applications. However, the performance of high-power laser beams in these applications is often hindered by deviations from the desired spatiotemporal profile. This study reports the wavefront optimization of ultrafast Laguerre-Gaussian beams through the synergy of adaptive optics and genetic algorithm-guided feedback. The results indicate that the intensity fluctuations along the perimeter of the target ring-shaped profile can be reduced up to ∼15%. Furthermore, the radius of the ring beam profile can be tailored to a certain extent by establishing threshold fitting criteria. The versatility of this approach is experimentally demonstrated in conjunction with different focusing geometries.

Ultra-broadband long-wave-infrared pulse production using a chirped-pulse difference-frequency generation

We present a broadband light source based on near-infrared chirped-pulse difference-frequency mixing that is suitable for seeding long-wave-infrared (LWIR) optical parametric chirped-pulse amplification (OPCPA). A nitrocellulose pellicle is used in a Ti:sapphire regenerative amplifier to generate dual-frequency output pulses, which are subsequently mixed in a 0.4-mm thick AgGaS₂ crystal. LWIR pulses with ∼1 µm full width at half maximum (FWHM) bandwidth centered at 10.5 µm are generated by mixing transform-limited pulses. Assisted by genetic algorithm optimization, the bandwidth is broadened to ∼3 µm FWHM within the 8-12 µm atmospheric transmission window. The seed source paves the path towards tabletop ultrafast terawatt-class passively carrier-envelope-phase stabilized OPCPA in the LWIR region.

Activity-Based Approach for Selective Molecular CO2 Sensing

Carbon dioxide (CO₂) impacts every aspect of life, and numerous sensing technologies have been established to detect and monitor this ubiquitous molecule. However, its selective sensing at the molecular level remains an unmet challenge, despite the tremendous potential of such an approach for understanding this molecule's role in complex environments. In this work, we introduce a unique class of selective fluorescent carbon dioxide molecular sensors (CarboSen) that addresses these existing challenges through an activity-based approach. Besides the design, synthesis, and evaluation of these small molecules as CO₂ sensors, we demonstrate their utility by tailoring their reactivity and optical properties, allowing their use in a broad spectrum of multidisciplinary applications, including atmospheric sensing, chemical reaction monitoring, enzymology, and live-cell imaging. Collectively, these results showcase the potential of CarboSen sensors as broadly applicable tools to monitor and visualize carbon dioxide across multiple disciplines.

The TFAMoplex-Conversion of the Mitochondrial Transcription Factor A into a DNA Transfection Agent

Non-viral gene delivery agents, such as cationic lipids, polymers, and peptides, mainly rely on charge-based and hydrophobic interactions for the condensation of DNA molecules into nanoparticles. The human protein mitochondrial transcription factor A (TFAM), on the other hand, has evolved to form nanoparticles with DNA through highly specific protein-protein and protein-DNA interactions. Here, the properties of TFAM are repurposed to create a DNA transfection agent by means of protein engineering. TFAM is covalently fused to Listeria monocytogenes phospholipase C (PLC), an enzyme that lyses lipid membranes under acidic conditions, to enable endosomal escape and human vaccinia-related kinase 1 (VRK1), which is intended to protect the DNA from cytoplasmic defense mechanisms. The TFAM/DNA complexes (TFAMoplexes) are stabilized by cysteine point mutations introduced rationally in the TFAM homodimerization site, resulting in particles, which show maximal activity when formed in 80% serum and transfect HeLa cells in vitro after 30 min of incubation under challenging cell culture conditions. The herein developed TFAM-based DNA scaffolds combine interesting characteristics in an easy-to-use system and can be readily expanded with further protein factors. This makes the TFAMoplex a promising tool in protein-based gene delivery.

The mechanical testing of a novel interlocking forearm nail

BACKGROUND: Mechanical testing of newly designed implants provides valuable insight into their mechanical properties. This provides surgeons with information about implant choice for the treatment of fractures and the effect of the implant's mechanical properties on fracture healing METHODS: A novel interlocking forearm nail was subjected to standardised mechanical testing according to the Standard Specification and Test Methods for Intramedullary Fixation Devices (ATSM 126416), using static and dynamic four-point bending and static torsion (ASTM STP 588). Three nails were used for the static bending and torsion and nine for the dynamic bending tests. All nails were catalogued, numbered and photographed before testing RESULTS: The mechanical testing results showed a mean force yield (Fy) of 566 ± 20 N, a moment of yield (My) 10.75 ± 0.37 Nm, a stiffness of 67.10 ± 2 N/mm and structural stiffness of 1.53 ± 0.50 m2. The torsional stiffness of the nail was 0.088 ± 0.002 Nm/°. The four-point dynamic bending test showed a fatigue strength of 5.23 Nm. This value was determined using the semi-log moment/ number of cycles (M-N) diagram and showed a 50% failure at a million cycles. If the moment were reduced to 4.4 Nm, mathematically, the survival rate would improve to 90% CONCLUSION: The results from this mechanical testing show that this novel intramedullary forearm nail can resist mechanical forces experienced during fracture healing and could potentially be used in future clinical studies Level of evidence: Level 4

Single-shot, double-pulse determination of the detonation energy in nanosecond-laser ablation using the blast model

We demonstrate a novel single-shot method to determine the detonation energy of laser-induced plasma and investigate its performance. This approach can be used in cases where there are significant shot-to-shot variations in ablation conditions, such as laser fluctuations, target inhomogeneity, or multiple filamentation with ultrashort pulses. The Sedov blast model is used to fit two time-delayed shadowgrams measured with a double-pulse laser. We find that the reconstruction of detonation parameters is insensitive to the choice of interpulse delay in double-pulse shadowgraphy. In contrast, the initial assumption of expansion dimensionality has a large impact on the reconstructed detonation energy. The method allows for a reduction in the uncertainties of blast wave energy measurements as a diagnostic technique employed in various laser ablation applications.

The reliability of physical examination in diagnosing arterial injury in penetrating trauma to extremities: A first look at different anatomical regions and injury mechanisms

BACKGROUND

The accuracy of physical examination to exclude arterial injury in penetrating trauma to extremities has been well established.

OBJECTIVES

To determine whether the accuracy of physical examination to exclude arterial injury is similar to that of a computed tomography arteriogram (CTA) for different anatomical regions and mechanisms of injury, and in patients with concomitant fractures compared with those without.

METHODS

A retrospective review was conducted on all patients who underwent CTA for penetrating injuries to an extremity between 1 June 2016 and 30 June 2017. The presence of arterial injuries was noted, and these were grouped into anatomical areas. Clinical notes were reviewed for the presence of hard signs of arterial injury at initial examination.

RESULTS

A total of 220 lower limb and 133 upper limb CTAs were included. The mean patient age was 28.9 years (range 11 - 68). The overall sensitivity of physical examination in detecting a CTA-confirmed arterial injury was 95.3% (95% confidence interval (CI) 88.4 - 98.7), with a specificity of 93.9% (95% CI 90.2 - 96.4). Physical examination of the thigh had the highest specificity of 96.4% (95% CI 91.8 - 98.8), followed by the lower leg at 94.4% (95% CI 81.3 - 99.3), the upper arm at 89.6% (95% CI 79.7 - 95.7) and the forearm at 77.8% (95% CI 40.0 - 97.2). For gunshot wounds the specificity was 96.1% (95% CI 92.4 - 98.3), while for stab wounds it was 86.8% (95% CI 74.7 - 94.5).

CONCLUSIONS

This study agrees with current literature indicating that physical examination has high specificity in detecting arterial injury in the setting of penetrating trauma to an extremity. However, it shows that the specificity is not equal for all anatomical regions or mechanisms of injury.

Abstract NG01: Synthetic lethal interaction between the ESCRT paralog enzymes VPS4A and VPS4B in cancers harboring loss of chromosome 18q or 16q

Background: Discovery of new biomarker-linked cancer therapeutic targets may enable novel drug development and ultimately lead to advances in clinical care. Somatic copy number alterations (CNAs) leading to loss of tumor suppressor gene function constitute important driver events in tumorigenesis. Unfortunately, there are few existing therapeutic options to target the oncogenic processes evoked by tumor suppressor inactivation. However, developing drugs that target tractable synthetic lethal interactions with common somatic CNAs represents a promising approach to attain cancer-selective therapeutics. Synthetic lethality refers to the observation that for certain gene pairs, inactivation of either gene is tolerated but combined loss-of-function of both genes results in decreased cell viability. Synthetic lethal relationships in cancer have been defined in several different contexts, including among paralog genes for which dependency on one paralog is conferred by loss of a second functionally redundant paralog gene. Since targeting synthetic lethal relationships in cancer may yield a wide therapeutic window of efficacy between tumor and normal cells, identification of pharmacologically tractable synthetic lethal targets remains a priority for oncology drug development programs. Results and Discussion: To systematically define synthetic lethal vulnerabilities associated with genomic loss of established tumor suppressor genes, we analyzed genome-scale CRISPR-SpCas9 and RNA interference loss-of-function screening data from over 600 cancer cell lines. We identified and prioritized 193 synthetic lethal interactions with genomic loss of one or more of 51 common tumor suppressor genes. In particular, we discovered that the paralog genes encoding vacuolar protein sorting 4 homolog A and B (VPS4A and VPS4B) are selective genetic vulnerabilities for tumors harboring genomic copy loss of SMAD4 or CDH1 due to co-deletion of VPS4B or VPS4A, respectively. VPS4B is located on the long arm (q) of chromosome 18, 12.3 Mb away from SMAD4, while VPS4A is located 0.476 Mb downstream of CDH1 (encoding E-cadherin) on chromosome 16q. Thus, cancer cells with genomic loss of VPS4B selectively depend on expression of VPS4A for survival, and tumors with loss of VPS4A depend on VPS4B expression. Co-deletion of SMAD4 and VPS4B is commonly observed in approximately 33% of human cancer, with particularly high rates of loss in pancreatic cancers (68%), colorectal (71%) and renal cell carcinomas (17%) and to a lesser extent in cancers of the bile duct, lung, prostate, esophagus, uterus, cervix and ovary. Meanwhile, loss of CDH1 and VPS4A occurs frequently in cancers of the stomach, breast, skin, colon and prostate. VPS4A and B function as AAA ATPases which are critical for the regulation of endosomal sorting complex required for transport (ESCRT), a multimeric protein complex essential for inverse membrane remodeling. The ESCRT machinery is involved in a range of cellular processes, including cytokinesis, membrane repair, autophagy and endosomal processing. VPS4A/B are believed to form asymmetric hexameric complexes that are recruited to ESCRT-III filaments to drive ESCRT-mediated membrane fission and sealing. Here, we demonstrate that suppression of VPS4A in cancer cells with reduced copy number of VPS4B leads to accumulation of CHMP4B-containing ESCRT-III filaments, cytokinesis defects, nuclear membrane abnormalities and micronucleation, ultimately resulting in G2/M cell cycle arrest and apoptosis. We also observed that VPS4 suppression leads to defects in endosomal and endoplasmic reticulum structure. Furthermore, upon VPS4A suppression, we observed potent in vivo tumor regressions, which led to markedly prolonged survival in mouse xenograft models of pancreatic cancer and rhabdomyosarcoma harboring genomic loss of VPS4B. To understand regulators of VPS4A dependency, we performed a CRISPR-SpCas9 genome-scale screen in a pancreatic cancer cell line in the context of VPS4A suppression. We identified multiple genes that promote or suppress VPS4A dependency. Cancer cell sensitivity to VPS4A suppression was potently enhanced by disruption of regulators of the abscission checkpoint, including genes encoding the ULK3 kinase and the ESCRT-III proteins CHMP1A and CHMP1B. The abscission checkpoint is a genome protection mechanism that relies on Aurora B kinase (AURKB) and ESCRT-III subunits to delay abscission in response to chromosome mis-segregation to avoid DNA damage and aneuploidy. These findings suggest that inhibition of the ESCRT pathway and blockade of the abscission checkpoint could provide strategies to further enhance sensitivity of cancer cells to VPS4A suppression. Moreover, through CRISPR-SpCas9 screening and integrative transcriptomic and proteomic analysis, we also identified a strong correlation between baseline interferon response gene expression and VPS4A dependency. Indeed, when we treated VPS4B-deficient cells with interferon-β and interferon-γ to induce interferon signaling, we observed a pronounced sensitization of these cells to VPS4A depletion, thus suggesting that immune signals from the tumor microenvironment may influence VPS4 dependency. These data collectively suggest potential future therapeutic strategies for combination with VPS4A inhibition. Finally, we demonstrate through mutant rescue experiments that the ATPase domain is critical for the function of VPS4A in mediating survival of cells with partial copy loss of VPS4B. Furthermore, we provide data that elucidate the degree to which VPS4A and VPS4B cooperate and form functional complexes in human cancer cells. Although VPS4A and B demonstrate 80.5% homology, the development of small molecules that differentially target VPS4A in cells with VPS4B loss or VPS4B in cells with VPS4A loss remains a tractable possibility due to small structural differences near the ATP-binding pocket. Moreover, combined inhibition of VPS4A and VPS4B may also prove effective and clinically tolerable given a potential therapeutic window arising from gene dosage alterations and differences in total VPS4A/B levels in tumor versus normal cells.

Citation Format: Jasper E. Neggers, Brenton Paolella, Adhana Asfaw, Michael V. Rothberg, Tom A. Skipper, Radha Kalekar, Michael Burger, Neekesh Dharia, Guillaume Kugener, Jeremie Kalfon, Nancy Dumont, Yvonne Li, Liam Spurr, Annan Yang, Wenbo Wu, AndrewAdam Durbin, Brian M. Wolpin, David E. Root, Jesse Boehm, Andrew D. Cherniack, Aviad Tsherniak, Andrew L. Hong, William C. Hahn, Kimberly Stegmaier, Todd Golub, Francisca Vazquez, Andrew J. Aguirre. Synthetic lethal interaction between the ESCRT paralog enzymes VPS4A and VPS4B in cancers harboring loss of chromosome 18q or 16q [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2021; 2021 Apr 10-15 and May 17-21. Philadelphia (PA): AACR; Cancer Res 2021;81(13_Suppl):Abstract nr NG01.

The HELENA study: Hexvix®-TURB vs. white-light TURB followed by intravesical adjuvant chemotherapy-a prospective randomized controlled open-label multicenter non-inferiority study

Purpose

Photodynamic diagnosis and white-light TURB with adjuvant intravesical chemotherapy (ICT) is widely used in treatment of bladder cancer. This non-inferiority trial is designed to demonstrate non-inferiority regarding recurrence-free survival (RFS) of Hexvix^® TURB followed by immediate instillation compared to white-light TURB with immediate instillation followed by maintenance ICT.

Methods

Between 07/2010 and 12/2016, 129 patients with EORTC intermediate risk non-muscle invasive bladder cancer treated with TURB were included in this multicentre phase III study. Patients were randomized and received either white-light TURB with immediate ICT followed by maintenance ICT (n = 62, 20 mg Mitomycin weekly for 6 weeks as induction phase, afterwards 20 mg/month for 6 months) or Hexvix^® TURB with immediate ICT only (n = 67, 40 mg Mitomycin). Primary study endpoint was RFS after 12 months. Hexvix^® TURB was counted as non-inferior to white light alone if the upper limit of the one-sided 95% confidence interval of hazard ratio was lower than 1.676. Due to the non-inferiority design, the per-protocol population was used as the primary analysis population (n = 113)

Results

Median follow-up was 1.81 years. Hexvix^® group showed more events (recurrence or death) than white-light group (19 vs. 10) resulting in a HR of 1.29 (upper limit of one-sided 95%-CI = 2.45; p_{non-inferiority} = 0.249). The ITT population yielded similar results (HR = 1.67); 3.18], p_{non-inferiority} = 0.493). There was no significant difference in overall survival between both groups (p = 0.257).

Conclusion

Non-inferiority of Hexvix^® TURB relative to white-light TURB with maintenance Mitomycin instillation in intermediate risk urothelial carcinoma of the bladder was not proven. Hence a higher effect of maintenance ICT is to assume compared to a Hexvix^®-improved TURB only, confirming its important role in patient treatment.

[Quality assessment of radical cystectomy-opportunities, risks, challenges]

Radical cystectomy (RC) is the standard treatment for nonmetastatic muscle-invasive urothelial carcinoma of the urinary bladder. It is associated with relevant morbidity and mortality. After RC, the 5‑year overall survival rate is approximately 60%. In the context of the present work, quality parameters of RC divided into oncological/functional criteria and freedom from complications are identified and summarized. A PubMed search was performed. In addition to early criteria such as negative surgical margins, performance of pelvic lymphadenectomy, creation of a continent urinary diversion or preservation of sexual function, long-term criteria were identified such as the absence of higher-grade postoperative complications, recurrence-free survival and the preservation of health-related quality of life. The early criteria are suitable for individualized therapy planning, whereas the long-term criteria can be used for quality monitoring.

Filament-induced breakdown spectroscopy with structured beams

Filament-induced ablation represents an attractive scheme for long-range material identification via optical spectroscopy. However, the delivery of laser energy to the target can be severely hindered by the stochastic nature of multiple-filamentation, ionization of ambient gas, and atmospheric turbulence. In order to mitigate some of these adverse effects, we examine the utility of beam shaping for femtosecond filament-induced breakdown spectroscopy with Gaussian and structured (Laguerre-Gaussian, Airy, and Bessel-Gaussian) beams in the nonlinear regime. Interaction of filaments with copper, zinc, and brass targets was studied by recording axially-resolved broadband emission from the filament-induced plasma. The laser-solid coupling efficacy was assessed by inferring thermodynamic parameters such as excitation temperature and electron density. While under our experimental conditions the ablation rate with Gaussian- and Laguerre-Gaussian beams is found to be similar, the Airy and Bessel-Gaussian beams offer the advantage of longitudinally extended working zones. These results provide insights into potential benefits of structuring ultrafast laser beams for standoff sensing applications.

A national Health and Work Strategy: a search for evidence

BACKGROUND

The Health and Safety Executive's new Health and Work Strategy is based on an up-to-date assessment of workplace health priorities. Rather than replicating traditional prioritization approaches, a broader assessment of health and work priorities was carried out using a range of stakeholders.

AIMS

To develop a set of health priorities for further research and intervention activity.

METHODS

Four exercises were carried out, including internal prioritization, two external web-hosted questionnaire studies of younger workers and occupational health professionals, focus groups and tele-depth interviews with workplace health and safety professionals.

RESULTS

The highest rated internal priorities (weighted priority scores) were identified as mesothelioma (70), lung cancer (69.25), chronic obstructive pulmonary disease (COPD; 69), musculoskeletal disorders (MSDs; 66.25), hearing loss (65.75), stress (65.5), asthma (64.5) and hand-arm vibration syndrome (61.5). Using the three highest ranked criteria developed by occupational health professionals ((i) the preventability of the condition, (ii) the impact of the condition and (iii) the number of workers affected), mesothelioma, lung cancer, COPD, MSDs, hearing loss, stress and asthma were identified as the top seven priorities. Generic issues identified included ageing and work, obesity, newer technologies, and ethnicity and cultures of workforces. Apprentices identified stress, depression, anxiety, musculoskeletal and respiratory disorders, fatigue and workload as important workplace health considerations.

CONCLUSIONS

This process identified a number of expected and new areas of health research interest. We believe the findings reflect the real world requirements of work as assessed by occupational health and safety practitioners and workers.

[Is the discipline associated with self-confidence in handling rational antibiotic prescription? : Results from the MR2 study in German hospitals]

BACKGROUND

Besides public awareness and specialist knowledge and training of physicians, their self-confidence plays a key role for clinical decision-making in the respective area.

OBJECTIVE

This exploratory study investigated the influence of the discipline on differences in self-confidence in dealing with antibiotics and in the self-rated knowledge.

METHODS

In 2015 the multi-institutional reconnaissance of practice with multiresistant bacteria (MR2) questionnaire containing items on antibiotic prescription and multiresistant pathogens was sent out to 1061 physicians working in departments for internal medicine, general surgery, gynecology and obstetrics and urology. In 2017 a similar MR2 survey was sent to 1268 specialist and assistant physicians in anesthesiology in Germany. Besides demographic data 4 items on self-confidence in the use of antibiotic treatment and 11 items concerning self-rated knowledge about rational antibiotic therapy and multiresistant pathogens were included in the present analysis. Logistic regression analysis, the χ²-test and the Kruskal-Wallis test were used for statistical analysis of the influence of the discipline on these items.

RESULTS

The response rates were 43% (456 out of 1061) from the non-anesthetists and 56% (705 out of 1268) from the anesthetists. Of the non-anesthetists 44% and 57% of the anesthetists had had no advanced training on antibiotic stewardship during the year before the study. In the overall analysis anesthetists (mean±SD: 2.53±0.54) were significantly less self-confident about antibiotics than colleagues from other departments (internal medicine: 3.10±0.50, general surgery: 2.97±0.44, gynecology and obstetrics: 3.12±0.42 and urology: 3.15±0.44) in the unadjusted (all p<0.001) and adjusted comparison. The analysis of self-rated knowledge about rational antibiotic prescription showed similar results. Senior consultant status and advanced training in infectiology were significantly associated with self-confidence and self-rated knowledge about antibiotics.

CONCLUSION

Anesthetists showed significantly less self-confidence in dealing with antibiotics than colleagues from other disciplines. Advanced training on a rational prescription of antibiotics was associated with a greater self-confidence, so that the implementation of compulsory courses on rational antibiotic stewardship in the respective residency curriculum needs to be considered.

Fixation of femoral neck fractures in patients younger than 65 years: a retrospective descriptive study at a high-volume trauma centre

ABSTRACT BACKGROUND: The management of femoral neck fractures in the younger patient remains contentious, with high failure rates being reported in the literature. Patient age usually plays a major role during decision-making with regard to head-sparing versus head-sacrificing surgical strategies. The aim of this study was to review the outcomes of fixation of femoral neck fractures in patients younger than 65 years in an attempt to identify factors that might predict fixation failure. METHODS: A retrospective study, evaluating the outcome of fixation of femoral neck fractures in patients younger than 65 years of age was conducted. Factors affecting the outcome of treatment were explored in an attempt to identify variables that might predict fixation failure. RESULTS: The final cohort comprised 51 men (76%) and 16 women (24%) with a mean age of 43.9±12.2 years (95% CI 41.0-46.8; range 23-64) and a median follow-up of 8.7 months (IQR 6.2-17.4). Thirteen patients (19%) presented with undisplaced (Garden I and II) fractures while 54 (81%) presented with displaced (Garden III and IV) fractures. Twenty-four patients (36%) met the definition of failure. These included 15 cases (22%) of non-union, seven cases (10%) of femoral neck collapse and two cases (3%) of avascular necrosis. Sixteen patients (24%) underwent conversion to total hip arthroplasty. All cases of failure occurred in patients who presented with Garden III and IV displaced fractures. Factors associated with failure included the presence of fracture comminution (p<0.001) and the increased vertical orientation of the fracture line according to the Pauwels classification (p<0.001). Neither patient age (p=0.117), time from injury to surgery (p=0.204), mechanism of injury (p=0.136), smoking (p>0.999) nor alcohol abuse (p=0.528) was associated with failure CONCLUSION: The incidence of fixation failure following surgical management of femoral neck fractures in patients younger than 65 years of age remains high. While undisplaced fractures heal readily regardless of time from injury to surgery, mechanism of injury or fixation method, displaced fractures remain a difficult problem to solve. In our series, fixation failure was observed in one in three patients, while one in four required revision to total hip arthroplasty. Level of evidence: Level 4. Keywords: femoral neck fracture, fixation, failure, non-union, avascular necrosis

Adherence to the EAU guideline recommendations for systemic chemotherapy in penile cancer: results of the E-PROPS study group survey

OBJECTIVES

To validate the adherence of urologists to chemotherapy recommendations given in the EAU guidelines on PeCa. The European Association of Urology (EAU) guidelines on penile cancer (PeCa) are predominantly based on retrospective studies with low level of evidence.

MATERIALS AND METHODS

A 14-item-survey addressing general issues of PeCa treatment was developed and sent to 45 European hospitals. 557 urologists participated in the survey of which 43.5%, 19.3%, and 37.2% were in-training, certified, and in leading positions, respectively. Median response rate among participating departments was 85.7% (IQR 75-94%). Three of 14 questions addressed clinical decisions on neoadjuvant, adjuvant, and palliative chemotherapy. Survey results were analyzed by bootstrap-adjusted multivariate logistic-regression-analysis to identify predictors for chemotherapy recommendations consistent with the guidelines.

RESULTS

Neoadjuvant, adjuvant, and palliative chemotherapy was recommended according to EAU guidelines in 21%, 26%, and 48%, respectively. For neoadjuvant chemotherapy, urologists holding leading positions or performing chemotherapy were more likely to recommend guideline-consistent treatment (OR 1.85 and 1.92 with p_(bootstrap) = 0.007 and 0.003, respectively). Supporting resources (i.e., guidelines, textbooks) were used by 23% of survey participants and significantly improved consistency between treatment recommendations and Guideline recommendations in all chemotherapy settings (p_(bootstrap) = 0.010-0.001). Department size and university center status were no significant predictors for all three endpoints.

CONCLUSIONS

In this study, we found a very low rate of adherence to the EAU guidelines on systemic treatment for PeCa. Further investigations are needed to clarify whether this missing adherence is a consequence of limited individual knowledge level or of the low grade of guideline recommendations.

Ergonomic Principles as an Adjunct to the Profession of Biokinetics

Work-related injuries date back to antiquity. Attempts to resolve these work-related challenges have, inter alia, led to the establishment of the professions of Ergonomics, Occupational Therapy, Physiotherapy, Occupational Hygiene, and Biokinetics. The objective of this article is to illustrate the value of Ergonomic principles as an adjunct to the profession of Biokinetics. Insofar as Ergonomics addresses the physical and environmental risks which predispose and precipitate injuries, the profession of Ergonomics is primarily concerned with the practice of eradicating work-related challenges that impede human-machine interfacing, and which adversely influence work productivity and employee health. While Occupational Therapy and Biokinetics, by rehabilitating work-related injuries, assist in improving working conditions, little is known about the exact interface between the professions of Ergonomics and Biokinetics. The Google Scholar database was consulted in order to determine the relationship between Ergonomics and Biokinetics. The key words used were ergonomics and biokinetics and lead to the identification of 545 records, none of which pertained to the aforementioned subject. A subsequent search was conducted using the key words work-related musculoskeletal injuries and biokinetics. This search identified 925 records, the number of which were reduced to 42 (4.76%) after the exclusion of patents (n = 24), citations (n = 3), and nonbiokinetic work-related injury research (n = 856). Given that many work-related injuries are managed through the use of biokinetic rehabilitation, knowledge of the physical ergonomic risk factors at play will afford biokineticists an enhanced understanding of the etiology of work-related injuries, thereby helping to improve the vigor of the rehabilitation.

EAU-ESMO consensus statements on the management of advanced and variant bladder cancer-an international collaborative multi-stakeholder effort: under the auspices of the EAU and ESMO Guidelines Committees†

BACKGROUND

Although guidelines exist for advanced and variant bladder cancer management, evidence is limited/conflicting in some areas and the optimal approach remains controversial.

OBJECTIVE

To bring together a large multidisciplinary group of experts to develop consensus statements on controversial topics in bladder cancer management.

DESIGN

A steering committee compiled proposed statements regarding advanced and variant bladder cancer management which were assessed by 113 experts in a Delphi survey. Statements not reaching consensus were reviewed; those prioritised were revised by a panel of 45 experts before voting during a consensus conference.

SETTING

Online Delphi survey and consensus conference.

PARTICIPANTS

The European Association of Urology (EAU), the European Society for Medical Oncology (ESMO), experts in bladder cancer management.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Statements were ranked by experts according to their level of agreement: 1-3 (disagree), 4-6 (equivocal), 7-9 (agree). A priori (level 1) consensus was defined as ≥70% agreement and ≤15% disagreement, or vice versa. In the Delphi survey, a second analysis was restricted to stakeholder group(s) considered to have adequate expertise relating to each statement (to achieve level 2 consensus).

RESULTS AND LIMITATIONS

Overall, 116 statements were included in the Delphi survey. Of these, 33 (28%) statements achieved level 1 consensus and 49 (42%) statements achieved level 1 or 2 consensus. At the consensus conference, 22 of 27 (81%) statements achieved consensus. These consensus statements provide further guidance across a broad range of topics, including the management of variant histologies, the role/limitations of prognostic biomarkers in clinical decision making, bladder preservation strategies, modern radiotherapy techniques, the management of oligometastatic disease and the evolving role of checkpoint inhibitor therapy in metastatic disease.

CONCLUSIONS

These consensus statements provide further guidance on controversial topics in advanced and variant bladder cancer management until a time where further evidence is available to guide our approach.

[Interrater reliability and clinical impact of the Post-Ureteroscopic Lesion Scale (PULS) grading system for ureteral lesions after ureteroscopy : Results of the German prospective multicenter BUSTER project]

BACKGROUND

The Post-ureteroscopic Lesion Scale (PULS) was designed as a standardized classification system for ureteral lesions after uretero(reno)scopy (URS). This study evaluates its routine use and a possible clinical impact based on a representative patient cohort.

MATERIALS AND METHODS

Data of 307 patients in 14 German centers within the BUSTER project were used to test 3 hypotheses (H): PULS score shows a high interrater reliability (IRR) after independent assessment by urologic surgeon and assistance personnel (H1); PULS score is correlated with the frequency of postoperative complications during hospital stay (H2); post-URS stenting of the ureter is associated with higher PULS scores (H3).

RESULTS

Median age of patients was 54.4 years (interquartile range [IQR] 44.4-65.8; 65.5% male). Median diameter of index stones was 6 mm (IQR 4-8) with 117 (38.4%) pyelo-caliceal and 188 (61.6%) ureteral stones. Overall, 70 and 82.4% of patients had pre-stenting and post-URS stenting, respectively. Stone-free status was achieved in 68.7% after one URS procedure with a complication rate of 10.8% (mostly grade 1-2 according to Clavien-Dindo). PULS scores 0, 1, 2 and 3 were assessed in 40%, 52.1%, 6.9% and 1% of patients, respectively, when estimated by urologic surgeons. PULS score showed a high IRR between the urologic surgeon and assistance personnel (κ = 0.883, p < 0.001), but was not significantly correlated with complications (ρ = 0.09, p = 0.881). In contrast, a significant positive correlation was found between PULS score and post-URS stenting (ρ = 0.287, p < 0.001). A PULS score of 1 multiplied the likelihood of post-URS stenting by 3.24 (95% confidence interval 1.43-7.34; p = 0.005) as opposed to PULS score 0.

CONCLUSIONS

Removal of upper urinary tract stones using URS is safe and efficacious. Real-world data provided by this study confirm a high IRR of the PULS score and its clinical impact on the indication for post-URS stenting. A future prospective randomized trial should evaluate a possible standardization of post-URS stenting based on PULS score assessment.

Physical conditions for UO formation in laser-produced uranium plumes

We investigate the oxidation of uranium (U) species, the physical conditions leading to uranium monoxide (UO) formation and the interplay between plume hydrodynamics and plasma chemistry in a laser-produced U plasma. Plasmas are produced by ablation of metallic U using nanosecond laser pulses. An ambient gas environment with varying oxygen partial pressures in 100 Torr inert Ar gas is used for controlling the plasma oxidation chemistry. Optical emission spectroscopic analysis of U atomic and monoxide species shows a reduction in the emission intensity and persistence with increasing oxygen partial pressure. Spectral modelling is used for identifying the physical conditions in the plasma that favor UO formation. The optimal temperature for UO formation is found to be in the temperature range of ∼1500-5000 K. The spectrally integrated and spectrally filtered (monochromatic) imaging of U atomic and molecular species reveals the evolutionary paths of various species in the plasma. Our results also highlight that oxidation in U plasmas predominantly occurs at the cooler periphery and is delayed with respect to plasma formation, and the dissipation of molecular species strongly depends on oxygen partial pressure.

[Sacral neuromodulation in under- and overactive detrusor-quo vadis? : Principles and developments]

BACKGROUND

Sacral neuromodulation (SNM) has been used in the treatment of refractory overactive bladder syndrome, nonobstructive urinary retention and faecal incontinence for almost 40 years now. It is not to be confused with the sacral anterior root stimulation which is exclusively used for bladder dysfunction due to spinal paraplegia.

MECHANISM OF ACTION

The principles of SNM are yet to be fully understood. Nevertheless, there is proof of modulating the activity of several micturition-associated, afferent neurons in the spine, brainstem and cerebrum. Thus, premature detrusor contractions are suppressed, the desire to void is delayed and detrusor-sphincter coordination improves.

TECHNIQUES OF IMPLANTATION AND STIMULATION

Motor reactions are an important indicator of correct electrode placement. The implantation procedure consists of two stages with an initial trial phase to determine the best possible treatment response through an external generator before implanting the whole stimulating device. Yearly check-up examinations are recommended; wireless adjustments allow for long-lasting symptom reduction.

INDICATION AND OUTCOME

Success rates in the treatment of the refractory overactive bladder syndrome and the non-obstructive urinary retention lie above 70% and can still be perceived as sufficient after 5 years of ongoing SNM therapy. There is also profound evidence of SNM being an effective option for patients with faecal incontinence or chronic obstipation.

CONTRAINDICATIONS AND RISKS

Children, pregnant women and patients in need of frequent MRI examinations are usually not eligible for SNM therapy. Infection of the implant, technical failure (including lead displacement and battery depletion) and pain in the implantation site are important adverse effects which might require surgical revision.

CONCLUSIONS

The indications for SNM in the German health care system can be expected to be expanded upon the chronic pelvic pain syndrome, erectile dysfunction and additional gastrointestinal conditions. Technical progress will continue to improve the risk-benefit ratio of SNM.