How Can We Identify Extraprostatic Extension (EPE) Before Surgery? The Use of a Preoperative Prostate MRI EPE Scoring System to Assess Postprostatectomy Locally Advanced Prostate Cancer

Background: Distinguishing between organ-confined disease and extraprostatic extension (EPE) is crucial for the treatment of patients with prostate cancer. EPE is associated with an increased risk of biochemical recurrence, positive surgical margins, and metastatic disease. An MRI-based EPE scoring system was developed by Mehralivand in 2019; however, it has not been adopted in the Urology community. The purpose of this study is to evaluate the association of MRI-based EPE scoring with the pathologic EPE (pEPE) after radical prostatectomy. Methods: We conducted a retrospective review on a prospectively collected database of male patients who underwent a prostate MRI with EPE scoring by a trained genitourinary radiologist and subsequent robotic radical prostatectomy at our institution from September 2020 to December 2022. The associations between MRI EPE (mEPE) score and the presence of EPE on surgical pathology (pEPE) were examined using multivariable logistic regression. Results: A total of 194 patients met inclusion criteria with a median age of 63 years and prostate specific antigen (PSA) 7 ng/mL. Among those with mEPE score 3, 96% had pEPE. Those patients with an mEPE score ≥2 had an increased risk of pEPE compared with those with mEPE score 0 (odds ratio 3.79; 95% confidence interval 1.28-11.3) Furthermore, those with an mEPE score 3 were significantly more likely to have pEPE compared with those with mEPE score 0, 1 and 2 independently. Conclusion: MRI EPE is a straightforward tool that strongly correlates with the presence of pEPE. If validated prospectively, this scoring system could assist in counseling patients regarding nerve-sparing approach.

Safety and Efficacy of Inpatient Infliximab Rescue Therapy for Acute Crohn's Disease Flares

PURPOSE

Describe the safety, complications, and need for urgent surgery in patients requiring inpatient rescue infliximab for acute Crohn's disease (CD) flare.

BACKGROUND

Infliximab is increasingly used for patients hospitalized with acute severe ulcerative colitis as rescue therapy; however, optimal management for patients hospitalized for CD flares remains unclear.

METHODS

A single-institution retrospective study of patients aged 18+ admitted from 2008 to 2020 with acute Crohn's flare requiring induction of rescue infliximab therapy. Outcomes included postoperative and medication-related complications and need for urgent surgery.

RESULTS

52 patients were included in analysis; 8% required surgery on index admission, and 19% required surgery within 90 days of infliximab. Postoperative complications included 1 anastomotic leak, 3 superficial wound infections, 3 prolonged ileus, and 1 urinary infection. There were no adverse reactions to infliximab infusion, and medical complication rates were low. Patients with penetrating disease were more likely to undergo surgery within 90 days of infliximab (43% vs 8%; P = .01). Mean LOS was longer for patients undergoing surgery within 90 days of therapy compared to those who did not (13.4 vs 8.3 days, P = .04).

CONCLUSION

Inpatient rescue infliximab is safe for treating acute Crohn's disease flare in addition to standard steroid therapy. The majority of patients hospitalized with Crohn's flare requiring rescue infliximab avoided surgery with low postoperative and medication-related complications. More research is needed to clarify the optimal rescue infliximab therapy dosage.

Preoperative Workup of Patients With Excessive Central Airway Collapse: Does Stent Evaluation Serve a Role?

BACKGROUND

Tracheobronchoplasty (TBP) is a definitive anatomic intervention for patients with severe symptomatic expiratory central airway collapse. Although stent evaluations have been described for surgical workup, current literature does not address if improvement during stent evaluation is sustained after TBP. We compared health-related quality of life (HRQOL) and functional status responses after airway stenting to those post-TBP.

METHODS

A retrospective review was performed in patients with severe expiratory central airway collapse who underwent stent evaluation followed by TBP from January 2004 to December 2019. Baseline, poststent, 3- and 12-month postoperative HRQOL scores, and functional status were analyzed with statistical tests as appropriate.

RESULTS

One hundred twenty patients underwent a stent evaluation and TBP. Baseline and stent evaluation measurements were compared with statistically and clinically significant differences in the Cough Quality-of-life Questionnaire (CQLQ) (55 vs. 68, P <0.01), Modified Medical Research Council (mMRC) 0 to 2 (90% vs. 47%, P <0.01), 6-minute walk test (6MWT) (1301 ft vs. 1138 ft, P <0.01). Improvements in the HRQOL and functional status were maintained from stent evaluation to 3 months postoperatively [CQLQ 55 vs. 54, P =0.63; mMRC 0 to 2 (87% vs. 84%), P =0.39; 6MWT 1350 ft vs. 1314 ft, P =0.33], and 12 months postoperatively [CQLQ 54 vs. 54, P =0.91; mMRC 0 to 2 (95% vs. 86%), P =0.74; 6MWT 1409 ft vs. 1328 ft, P =0.13]. The magnitude of change between the data was not significantly different between the stent evaluation, 3-, and 12 months postoperative. Predicted forced expiratory volume in 1-second measurements at baseline, after stent placement, 3 months, and 12 months post-TBP were 74%, 79%, 73%, and 73%, respectively, and not clinically significant.

CONCLUSIONS

Improvement after stent evaluation and the magnitude of improvement may be predictive of postoperative outcomes up to 1 year after surgery.

The Association of a Peritoneal Interposition Flap With Lymphocele Formation After Pelvic Lymph Node Dissection During Robotic-assisted Laparoscopic Radical Prostatectomy: A Systematic Review and Meta-analysis

OBJECTIVE

To conduct a systematic review and meta-analysis to evaluate the association of a peritoneal interposition flap (PIF) with lymphocele formation following robotic-assisted laparoscopic radical prostatectomy (RALP) with pelvic lymph node dissection.

METHODS

We conducted a systematic search of MEDLINE, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials through August 30, 2023, to identify randomized and nonrandomized studies comparing RALP with pelvic lymph node dissection with and without PIF. A random effects meta-analysis was then performed to evaluate the associations of PIF with 90-day postoperative outcomes.

RESULTS

Five randomized controlled trials (RCTs) and four observational studies, including a total of 2941 patients, were included. The use of PIF was associated with a reduced risk of 90-day symptomatic lymphocele formation after RALP when examining only RCTs (pooled odds ratios [OR] 0.44, 95% CI 0.28-0.69; I2 =3%) and both RCTs and observational studies (OR 0.35, 95% CI 0.22-0.56; I2 =17%). Similarly, use of PIF was associated with a reduced risk of 90-day any lymphocele formation (OR 0.40, 95% CI 0.28-0.56, I2 =39%). There were no statistically significant differences in postoperative complications between the two groups (OR 0.89; 95% CI 0.69-1.14; I2 =20%).

CONCLUSION

Use of the PIF is associated with an approximately 50% reduced risk of symptomatic and any lymphocele formation within 90-days of surgery, and it is not associated with an increase in postoperative complications.

The association of patient and disease characteristics with the overtreatment of low-risk prostate cancer from 2010 to 2016

BACKGROUND

Although active surveillance is the preferred management for low-risk prostate cancer (PCa), some men remain at risk of overtreatment with definitive local therapy. We hypothesized that baseline characteristics may be associated with overtreatment and represent a potential source of health disparities. We therefore examined the associations of patient and disease characteristics with the surgical overtreatment of low-risk PCa.

METHODS

We identified men aged 45-75 years with cT1 cN0 cM0 prostate adenocarcinoma with biopsy Gleason score 6 and PSA < 10 ng/ml from 2010-2016 in the National Cancer Database (NCDB) and who underwent radical prostatectomy (RP). We evaluated the associations of baseline characteristics with clinically insignificant PCa (iPCa) at RP (i.e., "overtreatment"), defined as organ-confined (i.e., pT2) Gleason 3 + 3 disease, using multivariable logistic regression.

RESULTS

We identified 36,088 men with low-risk PCa who underwent RP. The unadjusted rate of iPCa decreased during the study period, from 54.7% in 2010 to 40.0% in 2016. In multivariable analyses adjusting for baseline characteristics, older age (OR 0.98, 95% CI 0.97-0.98), later year of diagnosis (OR 0.62, 95% CI 0.57-0.67 for 2016 vs. 2010), Black race (OR 0.85, 95% CI 0.79-0.91), treatment at an academic/research program (OR 0.82, 95% CI 0.73-0.91), higher PSA (OR 0.91, 95% CI 0.90-0.92), and higher number of positive biopsy cores (OR 0.87, 95% CI 0.86-0.88) were independently associated with a lower risk of overtreatment (iPCa) at RP. Conversely, a greater number of biopsy cores sampled (OR 1.01, 95% CI 1.01-1.02) was independently associated with an increased risk of overtreatment (iPCa) at RP.

CONCLUSIONS

We observed an ~27% reduction in rates of overtreatment of men with low-risk PCa over the study period. Several patient, disease, and structural characteristics are associated with detection of iPCa at RP and can inform the management of men with low-risk PCa to reduce potential overtreatment.

Immediate radiotherapy versus observation in patients with node-positive prostate cancer after radical prostatectomy

BACKGROUND

The optimal management of node-positive (pN1) prostate cancer following radical prostatectomy (RP) remains uncertain. Despite randomized evidence, utilization of immediate, life-long androgen deprivation therapy (ADT) remains poor, and recent trials of early salvage radiotherapy included only a minority of pN1 patients. We therefore emulated a hypothetical pragmatic trial of adjuvant radiotherapy versus observation in men with pN1 prostate cancer.

METHODS

Using the RADICALS-RT trial to inform the design of a hypothetical trial, we identified men aged 50-69 years with pT2-3 Rany pN1 M0, pre-treatment PSA < 50 ng/mL prostate cancer in the NCDB from 2006 to 2015 treated with 60-72 Gy of adjuvant RT (aRT) ± ADT within 26 weeks of RP or observation. After estimating a propensity score for receipt of aRT, we estimated absolute and relative treatment effects using stabilized inverse probability of treatment (sIPW) re-weighting.

RESULTS

In total, 3510 patients were included in the study, of whom 587 (17%) received aRT (73% with concurrent ADT). Median follow-up was 40.0 -months, during which 333 deaths occurred. After sIPW re-weighting, baseline characteristics were well-balanced. Adjusted overall survival (OS) was 93% versus 89% at 5-years and 82% versus 79% at 7-years for aRT versus observation (p = 0.11). In IPW-reweighted Cox regression, aRT was associated with a lower risk of all-cause mortality (ACM) than observation, but this did not reach statistical significance (HR 0.70 p = 0.06). In analyses examining heterogeneity of treatment effects, aRT was associated with improved ACM only for men with Gleason 8-10 disease (HR 0.59, p = 0.01), ≥2 positive LNs (HR 0.49, p = 0.04 for 2 positive LNs; HR 0.42, p = 0.01 for ≥3 positive LNs), or negative surgical margins (HR 0.50, p = 0.02).

CONCLUSIONS

In observational analyses designed to emulate a hypothetical target trial of aRT versus observation in pN1 prostate cancer, aRT was associated with improved OS only for men with Gleason 8-10 disease, ≥2 positive LNs, or negative surgical margins.

Insights into microRNA-mediated interaction and regulation of metabolites in tomato

microRNAs direct regulation of various metabolic pathways in plants and animals. miRNAs may be useful in developing novel/elite genotypes, with enhanced metabolites and disease resistance. We examined miRNAs in tomato. In tomato, miRNAs in the carotenoid pathway have not been fully elucidated. We examined the potential role of miRNAs in biosynthesis of carotenoids, transcript profiling of miRNAs and their possible targets (genes and transcription factors) at different development stages of tomato using stem-loop PCR and RT-qPCR. We also identified miRNAs targeting key flavonoid genes, such as chalcone isomerase (CHI), and dihydroflavonol-4-reductase (DFR). Distinct expression profiles of miRNAs and their targets were found in fruits of three tomato accessions, suggesting carotenoid regulation by miRNAs at various stages of fruit development. This was also confirmed using HPLC of the carotenoids. The present study may help in understanding possible regulation of carotenoid biosynthesis. The identified miRNAs can be exploited to enhance biosynthesis of different carotenoids in plants.

Liposuction Complications in the Outpatient Setting: A National Analysis of 246,119 Cases in Accredited Ambulatory Surgery Facilities

Background

Suction lipectomy (liposuction) is a popular cosmetic surgical procedure performed in the United States, but little has been documented regarding perioperative complications due to its outpatient nature.

Objectives

This cross-sectional study aims to analyze the most common complications that accompany liposuction-related procedures and importantly estimate the total complication rate occurring at ambulatory surgical facilities.

Methods

Adult patients who experienced liposuction-related complications from 2019 to 2021 were identified in the reporting database of the global surgery accreditation authority, the American Association for Accreditation of Ambulatory Surgery Facilities (QUAD A). Patients were then divided by complication type and procedure location. Demographics and facility-specific variables were analyzed. Descriptive statistics were performed.

Results

Overall, 984 patients were included, with a mean age of 44 years (interquartile range [IQR] 37-53) and a median BMI of 28.7 kg/m2 (IQR 25.7-32.2). The overall confirmed complication rate was found to be 0.40% (984/246,119). Unplanned emergency department presentation was the most common complication overall (24%). Wound disruption was associated with the longest median procedure length (261 min), and venous thromboembolism was associated with the highest median BMI (30.1 kg/m2). The Southeast had the most complications (431), which accounted for 13/21 deaths (61.9%). Out of all complications, death was associated with the highest average annual case volume (241).

Conclusions

Procedures that involve liposuction are associated with a variety of medical and surgical complications. Given the high frequency and variability in how liposuction is performed, a thorough assessment of complications is critical to improve the safety of this procedure.

Level of Evidence 3

Magnetic resonance imaging accuracy in staging early and locally advanced rectal cancer

INTRODUCTION

Magnetic Resonance Imaging (MRI) is the standard pretreatment staging in patients with rectal cancer. Accurate tumor staging is paramount to determining the appropriate treatment course for patients diagnosed with rectal cancer. The current study aims to re-evaluate the accuracy of pre-operative MRI in staging of both early and locally advanced rectal cancer following completion of neoadjuvant therapy (NAT) compared to the pathologic stage.

METHODS

A retrospective review of patients treated for rectal cancer between 2015 and 2020 at a single academic institution. All patients underwent rectal cancer protocol MRIs before surgical resection. Analysis was carried out in two groups: early rectal cancer: T1/2 N0 tumors with upfront surgical resection (N = 40); and locally advanced disease: T3 or greater or N+ disease receiving NAT, with restaging MRI following NAT (n = 63).

RESULTS

103 patients were included in analysis. MRI accuracy in early tumors was 35% ICC = 0.52 (95% CI 0.25-0.71) T stage and 66% ICC = 0 (95% CI -0.24, 0.29) for 29 patients with nodal data for N stage. There was 28% understaging of T2 tumors and 34% understaging of N0 stage by MRI. Post NAT MRI had 44% accuracy ICC = 0.57 (95% CI -0.15-0.20) T stage and 60% accuracy ICC = 0.32 (95% CI 0.08-0.52) N stage. Tumor invasion was overstaged on MRI: 40% T2, 29% T3, 90% T4. Nodal inaccuracy was due to overstaging, 61% N1, 90% N2.

CONCLUSIONS

In locally advanced rectal cancer MRI overstaged tumors, this could be due to the continued effect of NAT from MRI to resection. This overstaging is of little clinical significance as it doesn't alter the treatment plan, except in cases of complete clinical response. In early rectal cancer, MRI had limited accuracy compared to pathology, understaging a quarter of patients who would benefit from NAT before surgery. Other adjunct imaging modalities should be considered to improve accuracy in staging early rectal cancer and consideration of complete response and enrollment in watch and wait protocols.

Conditional survival following radical cystectomy for urothelial carcinoma of the bladder

INTRODUCTION

Traditional surveillance protocols do not adequately account for the decreasing risk of mortality over time in aggressive malignancies, such as bladder cancer. Rather, the risk of death depends on both the baseline risk of mortality and the time survived since treatment. We therefore evaluated the conditional survival of patients diagnosed with urothelial carcinoma of the bladder (UCB) following radical cystectomy (RC).

PATIENTS AND METHODS

We identified patients aged 18 to 75 with Charlson 0-1 and pTany pN0-3 cM0 UCB diagnosed from 2006 to 2015 in the National Cancer Database and treated with RC. The 2- and 5-year conditional overall survival (COS)-i.e., the probability of surviving an additional 2- or 5-years given a specified time survived since treatment-was estimated using the Kaplan-Meier method. Multivariable Cox regression models with landmark time analysis were used to evaluate the associations of baseline characteristics with OS over time.

RESULTS

A total of 15,594 patients were included in the study. Median follow-up was 27.8 months. The 2- and 5-year COS for the overall cohort increased through 36 months follow-up and then plateaued. When stratified by pT and pN stage, the COS gain increased with higher pT and pN stage, demonstrating the greatest increase over time for patients with pTany N1-3 disease (5-year COS of 23% at baseline, 58% at 36-months, and 71% at 60-months). In multivariable Cox regression modeling, pT and pN stage were significantly associated with higher all-cause mortality at baseline (HR 3.27 for pT4, HR 2.57 for pT3 vs. ≤pT2; HR 2.26 for pN2-3, HR 1.77 for pN1 vs. pN0), but these associations were attenuated in magnitude with increasing landmark times of 36- and 60-months (HR 1.63 for pT4, HR 1.35 for pT3 vs. ≤pT2; HR 1.34 for pN2-3, HR 1.27 for pN1 vs. pN0). Our study is limited by the retrospective design and the lack of cancer-specific survival data.

CONCLUSIONS

Risk of death after RC varies with time elapsed since treatment and disease stage. Accordingly, stage-specific COS may be used to improve prognostication and surveillance protocols.

Delay in Surgery and Papillary Thyroid Cancer Survival in the United States: A SEER-Medicare Analysis

INTRODUCTION

Delays in surgery and their impact on survival in papillary thyroid cancer (PTC) is unclear. We sought to investigate the association between time to surgery and survival in patients with PTC.

METHODS

A total of 8170 Medicare beneficiaries with PTC who underwent thyroidectomy were identified within the Surveillance, Epidemiology, and End Results-Medicare linked data files between 1999 and 2018. Disease-specific survival (DSS) and overall survival (OS) were estimated using Kaplan-Meir analysis, and Cox proportional hazards models were specified to estimate the association between time to surgery and survival.

RESULTS

Among 8170 patients with PTC, mean age 69.3 (SD+/- 11.4), 89.8% had surgery within the first 90 days, 7.8% had surgery 91 to 180 days from diagnosis, and 2.4% had surgery after 180 days. Increasing time to surgery was associated with increased mortality for OS in the >180-day group [adjusted hazard ratio (aHR) 1.24; 95% CI, 1.01-1.53]. Moreover, on stratification by summary stage, those with localized disease in the 91- to 180-day group increased risk by 25% (aHR 1.25; 95%CI, 1.05-1.51), and delaying over 180 days increased risk by 61% (aHR 1.61; 95%CI, 1.19-2.18) in OS. Those with localized disease in the >180-day group had almost 4 times the estimated rate of DSS mortality (aHR3.51; 95%CI, 1.68-7.32). When stratified by T stage, those with T2 disease in the >180 days group had double the estimated rate of all-cause mortality (aHR 2.0; 95% CI, 1.1-3.3) and almost triple the estimated rate of disease-specific mortality (aHR 2.7; 95% CI, 1.05-6.8).

CONCLUSIONS

Delays in surgery for PTC may impact OS and DSS in localized disease, prior to nodal metastasis.

Evaluation of the Effects of an Extubation Protocol With Neostigmine on Duration of Mechanical Ventilation After Cardiac Surgery

OBJECTIVES

Residual neuromuscular blockade is associated with increased postoperative pulmonary complications. This study aimed to evaluate the effect of an extubation protocol incorporating neuromuscular blockade reversal (NMBR) by train-of-four monitoring on "fast-track" cardiac surgery outcomes.

DESIGN

A retrospective cohort study.

SETTING

At a university hospital.

PARTICIPANTS

Out of 1,843 cardiac surgery patients, from February 2, 2015, to March 31, 2017, 957 (52%) underwent cardiac surgery on or after February 29, 2016.

INTERVENTIONS

An extubation protocol, comprised of weaning from mechanical ventilation and NMBR guidelines, was implemented on February 29, 2016.

MEASUREMENTS AND MAIN RESULTS

The associations of baseline characteristics with the postoperative duration of mechanical ventilation (primary outcome) and respiratory and/or adverse complications (secondary outcomes) were evaluated using regression and interrupted- time series models. The implementation of an extubation protocol was associated with an 18% decrease in the duration of mechanical ventilation (incident rate ratio [IRR] 0.82, 95% CI 0.72-0.94; p < 0.01), statistically insignificant 26% increase in patients extubated ≤6 hours (odds ratio [OR] 1.26, 95% CI 0.97-1.65; p = 0.09), and 13% shorter intensive care unit length of stay (LOS) (IRR 0.87, 95% CI 0.79-0.97; p < 0.01). Patients undergoing isolated coronary artery bypass graft or isolated valve procedures, on or after February 29, 2016, had decreased extubation times (IRR 0.82, p < 0.01 and IRR 0.80, p = 0.02). The protocol did not have a statistically significant association with hospital LOS (IRR 0.98, p = 0.57) or readmission (OR 1.22, p = 0.33), and differences in the occurrence of pulmonary complications and adverse outcomes between the pre- and postprotocol groups were clinically insignificant.

CONCLUSIONS

The application of an extubation protocol incorporating NMBR based on neuromuscular monitoring was associated with a decrease in postoperative duration of mechanical ventilation and facilitated more patients meeting the early extubation benchmark without an increased risk of respiratory complications or adverse outcomes.

Comparative Effectiveness of Magnetic Resonance Imaging-Ultrasound Fusion Versus In-bore Magnetic Resonance Imaging-targeted Prostate Biopsy

OBJECTIVE

To examine the comparative effectiveness of magnetic resonance imaging-ultrasound (MRI-U/S) fusion biopsy and in-bore MRI-targeted biopsy.

METHODS

We identified men aged 18-89 with a diagnosis of elevated prostate specific antigen (PSA) or Gleason 6 prostate cancer on active surveillance who underwent MRI-U/S fusion prostate biopsy (12-core + targeted) in the office or in-bore MRI-targeted biopsy (MRI-IB; targeted only). The cancer detection rate (CDR; Gleason 6-10) and clinically significant CDR (csCDR; Gleason 7-10) were compared across biopsy techniques, adjusted for patient and radiographic features.

RESULTS

A total of 280 patients (346 lesions) were included, of whom 23.9% were on active surveillance for Gleason 6 prostate cancer. In the per-patient analyses, there was no statistically significant difference in adjusted overall CDR (64.1% vs 54.2%; P = .24) or csCDR (36.5% vs 37.9%; P = .85) between MRI-U/S and MRI-IB biopsy. In the per-lesion analyses, there was no statistically significant difference in adjusted overall CDR (45.7% vs 50.1%; P = .49) between MRI-U/S and MRI-IB biopsy, but MRI-IB biopsy was associated with a higher csCDR than MRI-U/S biopsy (32.8% vs 21.4%; P = .02).

CONCLUSION

We observed no statistically significant differences in cancer detection rates between MRI-U/S fusion biopsy and MRI-IB biopsy in per-patient analyses. However, MRI-IB biopsy was associated with higher csCDR when considering targeted biopsy cores only. These results suggest that systematic cores should be obtained when performing MRI-U/S fusion biopsy.

Disparities in the prevalence and management of high-risk non-muscle invasive bladder cancer

OBJECTIVE

To evaluate the associations of socioeconomic characteristics with the management of non-muscle invasive bladder cancer (NMIBC).

METHODS

We identified adult patients aged 18 to 89 years with Ta, T1, or Tis NMIBC in the NCDB. We then examined the associations of patient and socioeconomic characteristics with the guidelines-based management of high-risk NMIBC using multivariable logistic regression.

RESULTS

163,949 patients were included in the study cohort, including 64% with Ta, 32% with T1, and 4% with Tis disease. Among those diagnosed with bladder cancer, male (OR 1.24, 95%CI 1.21-1.27), uninsured (OR 1.10, 95%CI 1.01-1.19 vs. private), and non-White (OR 1.34, 95%CI 1.28-1.41 for Black; OR 1.10; 95%CI 1.03-1.18 for Other vs. White) patients were more likely to be diagnosed with high-risk disease, as well as patients from lower education level areas. Among those with high-risk NMIBC, patients who were older, non-White, Hispanic, uninsured or insured with Medicaid were less likely to receive guideline recommended intravesical BCG, while those residing in rural and higher education level areas were more likely to receive BCG. When examining non-guidelines based use of radiotherapy for HGT1 disease, older age (OR 1.06; 95% CI 1.04-1.07) and VA/Military insurance (OR 2.73; 95%CI 1.07, 6.98 vs. private) were associated with radiotherapy use.

CONCLUSION

There are strong disparities in the prevalence and management of high-risk NMIBC. These observations highlight important targets for future strategies to reduce such healthcare disparities and provide more equitable bladder cancer treatment to patients.

P-054 STANDARDIZATION OF HERNIA REGISTRY IN A HIGH-VOLUME LOW-COMPLEXITY CENTRE

Introduction

Our surgical department performs an average of 350 cases per year, performed by general surgeons of various seniority. These are predominantly in a post-pandemic period, where a backlog of patients are awaiting surgery in the NHS. It is not always possible for the same professional to provide continuity of care. An easy and reproducible classification of hernias is necessary to facilitate universal communication among surgeons.

Methods

We implemented a surgical proforma for the pre-assessment and operation note, based on the European Hernia Society (EHS) for inguinal and ventral hernias. The pre-assessment and operation note proforma were trialled on an elective basis on a week designated for hernia surgery. The proforma was then rolled out to both elective and emergency hernia repair surgery with the collaboration of all surgeons from our department.

Results

The use of designated hernia week was beneficial to learning and led to acceptance of the new proforma amongst all our surgeons. Hence, the reproducibility in non-dedicated elective lists and emergency cases could be achieved.

Conclusion

The adoption of a single classification accepted internationally, as proposed by the EHS, improves the continuity of patients’ care from pre-assessment to post-operative follow-up. The registry will benefit from better planning of theatre lists, improved productivity, understanding of recurrence rates, types of complications, and lead to improved quality of life. Long-term data collection and further studies can be uniformly compared inside the surgical department, and in collaboration with multinational studies with this initiative.

Adjuvant chemotherapy plus radiotherapy versus chemotherapy alone for locally advanced bladder cancer after radical cystectomy

BACKGROUND: Survival with locally advanced bladder cancer (LABC) following radical cystectomy (RC) remains poor. Although adjuvant chemotherapy (AC) is standard of care, one small, randomized trial has suggested a potential survival benefit when combined with post-operative radiotherapy (PORT). OBJECTIVE: We examined the association of AC + PORT with overall survival (OS) in patients with LABC after RC. METHODS: Using a prior phase 2 trial to inform design, we conducted observational analyses to emulate a hypothetical target trial of patients aged 18–79 years with pT3-4 Nany M0 or pTany N1-3 M0 urothelial bladder carcinoma following RC who were treated with AC (multiagent chemotherapy within 3 months of RC) with or without PORT (≥45 Gy to the pelvis) from 2006–2015 in the NCDB. Patients who received preoperative chemotherapy or radiotherapy were excluded. The associations of treatment with OS were evaluated using multivariable Cox regression. RESULTS: 1,684 patients were included, with 66 receiving AC + PORT and 1,618 AC alone. Compared to patients treated with AC alone, those treated with AC + PORT were more likely to have pT4 disease (52% vs 26% ; p <  0.01), positive surgical margins (44% vs 17% ; p <  0.01), and be treated at a non-academic facility (75% vs 53% ; p <  0.01). Crude 5-year OS was 19% for AC + PORT versus 36% for AC alone (p = 0.01). Adjusted 5-year OS was 33% for AC + PORT versus 36% for AC alone (p = 0.49). After adjusting for baseline characteristics including pathologic features, AC + PORT was not associated with improved OS compared to AC alone (HR 1.11; 95% CI 0.82–1.51). CONCLUSIONS: Although infrequently utilized, the addition of radiotherapy to AC is not associated with improved OS in LABC. These results highlight the need for prospective trials to better define the potential benefits from PORT with regard to symptomatic progression and oncologic outcomes.

Radical cystectomy versus trimodality therapy for muscle-invasive urothelial carcinoma of the bladder

BACKGROUND

The comparative effectiveness of radical cystectomy (RC) and trimodality therapy (TMT) for muscle-invasive bladder cancer remains uncertain, as no randomized data exist. A phase 3 trial (SPARE) was attempted in the UK, however, was deemed infeasible and closed.

OBJECTIVE

To emulate the SPARE trial using observational data.

DESIGN, SETTING, AND PARTICIPANTS

We identified patients aged 40 to 79 with cT2-3cN0cM0 urothelial carcinoma of the bladder diagnosed from 2006 to 2015 who were treated with multiagent neoadjuvant chemotherapy + RC with lymphadenectomy (RC arm) or multiagent chemotherapy + 3D conformal radiotherapy to the bladder (TMT arm) in the National Cancer Database.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The primary outcome was overall survival (OS). We fit a flexible logistic regression model for treatment to estimate the propensity score, and then used inverse probability of treatment weights to evaluate the associations of treatment group with OS.

RESULTS AND LIMITATIONS

A total of 2,048 patients were included, of whom 1,812 underwent RC and 236 underwent TMT. Median follow-up was 29.0 months. After propensity score adjustment, compared to TMT, RC was not associated with a statistically significant difference in OS (HR 0.87; 95% CI 0.64-1.19; P = 0.40). When examining heterogeneity of treatment effects, RC appeared to be associated with improved OS only for patients with cT3 disease. Similar results were observed in sensitivity analyses. Our study is limited by the retrospective design and the lack of cancer-specific survival data.

CONCLUSIONS

In observational analyses designed to emulate the SPARE trial, there was no statistically significant difference in OS between RC and TMT. Heterogeneity of treatment effects suggested improved survival with RC only for cT3 disease.

48 Consenting Surgical Patients for the Risk Associated with Contracting COVID-19 During Their Stay at the Hospital

Aim

Literature is suggesting significant perioperative mortality and morbidity associated with COVID-19. Therefore, the Royal College of Surgeons (RCS) has produced guidance detailing additional considerations in consenting for surgery whilst COVID-19 is prevalent within society. Section 3A of this document emphasizes the need to discuss the risk of contracting COVID-19 while patients are in hospital. We conducted a multi-cycle closed-loop audit to examine the adherence to this guidance.

Method

We completed four audit cycles, each comprising data collection and educational intervention to disseminate the guidance. Data was obtained from consent forms for patients who had consented to both emergency and elective surgery over a two-month period at a large NHS Trust in London. The intervention consisted of teaching sessions, regular emails to the general surgical department, and posters displayed in common areas.

Results

Consent forms from 139 patients were reviewed over the four cycles (n = 38, 41, 28, and 32). The proportion of patients consented for the risk of contracting COVID-19 during the perioperative period rose serially between the cycles (37%, 61%, 71%, and 85% respectively), and was significantly increased between the first and last cycle (p < 0.01, two-sided Z-test). The interventions proved most effective for senior house officers who improved from consenting 8% initially to 100% on completion of the audit.

Conclusions

We demonstrate the marked effectiveness of simple interventions combined with serial auditing to disseminate this message. The same practice may help improve consenting practice at other centres whilst COVID-19 is prevalent in society.

Fully automated left ventricular ejection fraction and global longitudinal strain predicts obstructive coronary artery disease in patients undergoing stress echocardiography: a multi-centre study

Background

Assessment of LVEF and myocardial deformation with GLS has shown promise in predicting CAD, which may add prognostic information for patients undergoing SE. However, selection bias precludes an accurate assessment of routine clinical SE workflow due to the exclusion of poor image quality and contrast enhanced studies. We hypothesise that an artificial intelligence (AI) pipeline capable of fully automated contouring of the left ventricle and GLS analysis of both non-contrast and contrast SE images is feasible and can predict CAD.

Purpose

The aim of this study was to evaluate the prediction of obstructive coronary artery disease (CAD) from fully automated left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS) measures in a large multicentre population of patients undergoing stress echocardiography (SE).

Methods

500 patients from five medical centres undergoing SE for the clinical evaluation of ischaemic heart disease were included in this study. LVEF and GLS was automatically calculated using AI in non-contrast and contrast images at rest and peak stress. The primary endpoint was CAD assessed using invasive coronary angiography.

Results

Patients with significant CAD demonstrated significantly reduced LVEF and GLS at rest and peak stress (all p&lt;0.001) compared to those without CAD. Of the 130 patients who exhibited myocardial ischaemia at peak stress, patients without significant CAD (37%) had significantly reduced LVEF and GLS when compared to those who did. Multivariate analysis demonstrated that a peak LVEF (0.93; 95% CI 0.9–0.96) and peak GLS (1.15; 95% CI 1.07–1.24) were significant independent predictors of CAD. The addition of automated LVEF and GLS to basic models significantly improved the C statistic from 0.78 to 0.83 and 0.85 (both p&lt;0.001), respectively.

Conclusions

Fully automated LVEF and GLS in non-contrast and contrast SE images is feasible and independently augment the prediction of obstructive CAD above and beyond traditional SE indexes.

Funding Acknowledgement

Type of funding sources: None.

Is the Management of Rectal Cancer Using a Watch and Wait Approach Feasible, Safe and Effective in a Publicly Funded General Hospital?

AIMS

Although there is emerging evidence to suggest equivalent oncological outcomes using a watch and wait approach compared with primary total mesorectal excision surgery, there is a paucity of evidence about the safety and efficacy of this approach in routine clinical practice. Here we report the long-term outcomes and quality of life from patients managed with watch and wait following a clinical complete response (cCR) to neoadjuvant therapy.

MATERIALS AND METHODS

Patients with adenocarcinoma of the rectum with cCR following neoadjuvant therapy managed using watch and wait were retrospectively identified. Demographic data, performance status, pretreatment staging information, oncological and surgical outcomes were obtained from routinely collected clinical data. Quality of life was measured by trained clinicians during telephone interviews.

RESULTS

Over a 7-year period, 506 patients were treated for rectal cancer, 276 had neoadjuvant therapy and 72 had a cCR (26.1%). Sixty-three were managed with watch and wait. Thirteen patients had mucosal regrowth. There was no significant difference in the incidence of metastatic disease between the surgical and watch and wait cohorts (P = 0.38). The 13 patients with mucosal regrowth underwent salvage surgery. Eleven of the patients who underwent surgical resection had R0 resections. There was also a statistically and clinically significant improvement in the Functional Assessment of Cancer Therapy - Colorectal (FACT-C) trial outcome index (P = 0.022).

CONCLUSION

This study shows that watch and wait is safe and effective outside of tertiary referral centres. It suggests that an opportunistic cCR is durable and when mucosal regrowth occurs it can be salvaged. Finally, we have shown that quality of life is probably improved if a watch and wait approach is adopted.

Allergen Immunotherapy (AIT) in children: a vulnerable population with its own rights and legislation - summary of EMA-initiated multi-stakeholder meeting on Allergen Immunotherapy (AIT) for children, held at Paul-Ehrlich-Institut, Langen, Germany, 16.1.2019

Concerning development of medicinal products, children belong to a so-called "special population" for which additional legislation applies: Regulation (EC) No 1901/2006 on medicinal products for paediatric use sets up a system of requirements, rewards and incentives to ensure that medicinal products are researched, developed and authorized to meet the therapeutic needs of children. Allergen Immunotherapy (AIT) is believed to contain a strong potential for immunomodulatory effects inducing sustained clinical efficacy after cessation of treatment (disease modifying effect) and thereby may prevent the progression of the atopic march towards asthma manifestation. However, to this day only few data on long-term effects in general exist and even fewer in children. These are predominantly data from open studies, which are strongly influenced in their validity by the known placebo effect of AIT. Furthermore, there are no studies allowing for the conclusion that efficacy in adults are mirrored by a similar efficacy in children and thus, up to now, it is not possible to extrapolate data from adults to children. The Paediatric Committee (PDCO)-European Medicines Agency's (EMA) scientific committee responsible for activities on medicines for children-initiated a Multi-Stakeholder Meeting on AIT for Children held at the Paul-Ehrlich-Institut in Langen, Germany, to provide a platform for discussion and exchange of thoughts to this topic between allergy experts from academia, regulators and AIT-manufacturers. The consented meeting minutes, conclusions and participants are presented.

Identification of novel translocation between short arm of chromosome 4 and long arm of chromosome 6 in an infertile man using Interphase Chromosome Profiling (ICP)

Conventional cytogenetics has always been a favourite to detect chromosomal aberrations. Carriers of chromosomal translocation are often phenotypically normal but are infertile. Couples are often advised to go for karyotyping, but culture failure or improper metaphase spread with poor banding often makes the analysis difficult. We report here a novel translocation between short arm of chromosome 4 and long arm of chromosome 6 in an infertile man using an advanced molecular cytogenetic technique of Interphase Chromosome Profiling (ICP).

Effects of work-family conflict and job insecurity on psychological distress

Background

Work-family conflict (WFC) and job insecurity are important determinants of workers' mental health.

Aims

To examine the relationship between WFC and psychological distress, and the co-occurring effects of WFC and job insecurity on distress in US working adults.

Methods

This study used cross-sectional data from the 2010 National Health Interview Survey (NHIS) for adults aged 18-64 years. The 2010 NHIS included occupational data from the National Institute for Occupational Safety and Health (NIOSH) sponsored Occupational Health Supplement. Logistic regression models were used to examine the independent and co-occurring effects of WFC and job insecurity on distress.

Results

The study group consisted of 12059 participants. In the model fully adjusted for relevant occupational, behavioural, sociodemographic and health covariates, WFC and job insecurity were independently significantly associated with increased odds of psychological distress. Relative to participants reporting WFC only, participants reporting no WFC and no job insecurity had lower odds of moderate and severe distress. Co-occurring WFC and job insecurity was associated with significantly higher odds of both moderate [odds ratio (OR) = 1.55; 95% confidence interval (CI) 1.25-1.9] and severe (OR = 3.57; 95% CI 2.66-4.79) distress.

Conclusions

Rates of WFC and job insecurity were influenced by differing factors in working adults; however, both significantly increased risk of adverse mental health outcomes, particularly when experienced jointly. Future studies should explore the temporal association between co-occurring WFC and job insecurity and psychological distress.

Family-led rehabilitation after stroke in India (ATTEND): a randomised controlled trial

BACKGROUND

Most people with stroke in India have no access to organised rehabilitation services. The effectiveness of training family members to provide stroke rehabilitation is uncertain. Our primary objective was to determine whether family-led stroke rehabilitation, initiated in hospital and continued at home, would be superior to usual care in a low-resource setting.

METHODS

The Family-led Rehabilitation after Stroke in India (ATTEND) trial was a prospectively randomised open trial with blinded endpoint done across 14 hospitals in India. Patients aged 18 years or older who had had a stroke within the past month, had residual disability and reasonable expectation of survival, and who had an informal family-nominated caregiver were randomly assigned to intervention or usual care by site coordinators using a secure web-based system with minimisation by site and stroke severity. The family members of participants in the intervention group received additional structured rehabilitation training-including information provision, joint goal setting, carer training, and task-specific training-that was started in hospital and continued at home for up to 2 months. The primary outcome was death or dependency at 6 months, defined by scores 3-6 on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) as assessed by masked observers. Analyses were by intention to treat. This trial is registered with Clinical Trials Registry-India (CTRI/2013/04/003557), Australian New Zealand Clinical Trials Registry (ACTRN12613000078752), and Universal Trial Number (U1111-1138-6707).

FINDINGS

Between Jan 13, 2014, and Feb 12, 2016, 1250 patients were randomly assigned to intervention (n=623) or control (n=627) groups. 33 patients were lost to follow-up (14 intervention, 19 control) and five patients withdrew (two intervention, three control). At 6 months, 285 (47%) of 607 patients in the intervention group and 287 (47%) of 605 controls were dead or dependent (odds ratio 0·98, 95% CI 0·78-1·23, p=0·87). 72 (12%) patients in the intervention group and 86 (14%) in the control group died (p=0·27), and we observed no difference in rehospitalisation (89 [14%]patients in the intervention group vs 82 [13%] in the control group; p=0·56). We also found no difference in total non-fatal events (112 events in 82 [13%] intervention patients vs 110 events in 79 [13%] control patients; p=0·80).

INTERPRETATION

Although task shifting is an attractive solution for health-care sustainability, our results do not support investment in new stroke rehabilitation services that shift tasks to family caregivers, unless new evidence emerges. A future avenue of research should be to investigate the effects of task shifting to health-care assistants or team-based community care.

FUNDING

The National Health and Medical Research Council of Australia.

Allergen exposure chambers: harmonizing current concepts and projecting the needs for the future - an EAACI Position Paper

BACKGROUND

Allergen exposure chambers (AECs) are clinical facilities allowing for controlled exposure of subjects to allergens in an enclosed environment. AECs have contributed towards characterizing the pathophysiology of respiratory allergic diseases and the pharmacological properties of new therapies. In addition, they are complementary to and offer some advantages over traditional multicentre field trials for evaluation of novel therapeutics. To date, AEC studies conducted have been monocentric and have followed protocols unique to each centre. Because there are technical differences among AECs, it may be necessary to define parameters to standardize the AECs so that studies may be extrapolated for driving basic immunological research and for marketing authorization purposes by regulatory authorities.

METHODS

For this task force initiative of the European Academy of Allergy and Clinical Immunology (EAACI), experts from academia and regulatory agencies met with chamber operators to list technical, clinical and regulatory unmet needs as well as the prerequisites for clinical validation.

RESULTS

The latter covered the validation process, standardization of challenges and outcomes, intra- and interchamber variability and reproducibility, in addition to comparability with field trials and specifics of paediatric trials and regulatory issues.

CONCLUSION

This EAACI Position Paper aims to harmonize current concepts in AECs and to project unmet needs with the intent to enhance progress towards use of these facilities in determining safety and efficacy of new therapeutics in the future.

Minor allergen patterns in birch pollen allergen products-A question of pollen?

BACKGROUND

Contrary to the scientific differentiation between major and minor allergens, the regulatory framework controlling allergen products in the EU distinguishes relevant and non-relevant allergens. Given the lack of knowledge on their clinical relevance, minor allergens are usually not controlled by allergen product specifications. Especially, in birch pollen (BP) allergen products, minor allergens are commonly disregarded.

OBJECTIVES

To quantify three minor allergens in BP allergen products from different manufacturers and to assess the influence of the utilized BP on minor allergen patterns.

METHODS

Apart from common quality parameters such as Bet v 1 content, Bet v 4, Bet v 6 and Bet v 7 were quantified in 70 BP allergen product batches from six manufacturers, using ELISA systems developed in-house. Batch-to-batch variability was checked for agreement with a variability margin of 50%-200% from mean of the given batches for individual allergen content. Subsequently, minor allergen patterns were generated via multidimensional scaling and related to information on the pollen lots used in production of the respective product batches.

RESULTS

Like the already established Bet v 4 ELISA, the ELISA systems for quantification of Bet v 6 and Bet v 7 were successfully validated. Differences in minor allergen content between products and batch-to-batch consistency were observed. Correlations between minor and major allergen content were low to moderate. About 20% of batches exceeded the variability margin for at least one minor allergen. Interestingly, these fluctuations could not in all cases be linked to the use of certain BP lots.

CONCLUSIONS AND CLINICAL RELEVANCE

The impact of the observed minor allergen variability on safety and efficacy of BP allergen products can currently not be estimated. As the described differences could only in few cases be related to the used pollen lots, it is evident that additional factors influence minor allergens in BP allergen products.

Epidemiological and survival analysis of triple-negative breast cancer cases in a retrospective multicenter study

INTRODUCTION

This is a retrospective study with data collected from breast cancer cases from five major Apollo Hospitals across India, as part of a biobanking process. One aspect of our study focused specifically on data from triple-negative breast cancer (TNBC) cases. The aim of this study was to analyze epidemiology, treatment options, and survival of the patients with TNBC. Our goal was to draw conclusions on the preponderance of the disease and also to understand the outcomes using the existing therapy options.

MATERIALS AND METHODS

Data were collected after due ethical clearances and were coded with regard to patient identifiers to protect patient privacy. Data were not only from the various departments of the respective hospitals and the treating physicians but also from the follow-up made by hospital staff and social workers.

RESULTS

About 20% of all cases of breast cancer comprised TNBC. Although the disease is generally thought to be an early onset disease, there was no major difference in the median age of diagnosis of TNBC compared to other breast cancer cases. More than 85% of the TNBC cases were of early stage disease with <4% of the cases of metastatic cancer. Data on follow-up were somewhat sporadic as a good number of cases were lost to follow-up, but from the available data, recurrence rate was about 11%. Death, when it occurred, was mostly in the early periods of treatment with 35% of the events occurring before 3 years. The overall survival rates beyond 3 years were more than 86%.

CONCLUSIONS

Data and sample collection are an ongoing process, so we expect this data set to be enriched with more cases and longer duration of follow-up in a year. Preliminary analysis sheds light on the potential of such a collection both for understanding the epidemiology of the disease and also for conducting future studies with an eye toward improving treatment outcomes.

Validation of ELISA methods for quantification of the major birch allergen Bet v 1 (BSP090)

To date, the potency of allergen products in Europe is expressed in manufacturer-specific units relative to a product-specific in-house reference. Consequently, cross-product comparability of allergen products from different manufacturers with respect to strength and efficacy is impossible. The Biological Standardisation Programme (BSP) project BSP090 addresses this issue via the establishment of reference standards in conjunction with ELISA methods for the quantification of major allergens in allergen products. Since the initiation of BSP090, the recombinant major allergen Bet v 1 has been adopted by the European Pharmacopoeia Commission as a Chemical Reference Substance (CRS). In parallel, two sandwich ELISA systems for quantification of Bet v 1 were found suitable in preliminary phases of BSP090 to be validated in a large collaborative study. In this study, the candidate ELISA systems were compared with respect to accuracy, precision and variability. Thirteen participating laboratories tested model samples containing the CRS as well as spiked and unspiked birch pollen extracts. Both in pre-testing and in the collaborative study, the 2 candidate ELISA systems confirmed their suitability to quantify recombinant and native Bet v 1. As no clear-cut decision for one of the ELISA systems could be made based on the results of the collaborative study, a post-study testing was performed. Bet v 1 content of 30 birch pollen allergen products was determined in parallel in both ELISA systems. Consequently, 1 candidate ELISA system was selected to be proposed as the future European Pharmacopoeia standard method for Bet v 1 quantification.

Standardization of allergen products: 3. Validation of candidate European Pharmacopoeia standard methods for quantification of major birch allergen Bet v 1

BACKGROUND

The BSP090 project aims at establishing European Pharmacopoeia Reference Substances in combination with the corresponding ELISA methods for the quantification of major allergens in allergen products. Two sandwich ELISAs proved suitable for quantification of Bet v 1, the major birch pollen allergen, in preceding phases of BSP090.

METHODS

Two Bet v 1-specific ELISA systems were compared with respect to accuracy and precision in a ring trial including 13 laboratories. Model samples containing recombinant rBet v 1.0101 as well as native birch pollen extracts were measured independently at least three times in each facility. The assessment was completed with a comparative quantification of Bet v 1 in 30 marketed birch allergen products in one laboratory, simulating the future use as reference method.

RESULTS

In the collaborative study, both candidate ELISAs confirmed their suitability to quantify recombinant and native Bet v 1. ELISA-A showed higher precision and lower interlaboratory variability, yet ELISA-B exhibited slightly higher accuracy. Subsequent parallel measurement of Bet v 1 in a panel of 'real-life' birch allergen products indicated better repeatability of ELISA-B. Both systems detected substantial differences in Bet v 1 content between allergen products, but the effect was more pronounced using ELISA-B due to persistently higher values compared to ELISA-A.

CONCLUSIONS

In the collaborative study, no deciding differences were observed between the two candidate ELISAs. Further comparison under conditions simulating the intended use combined with the criterion of long-term availability enabled the selection of one Bet v 1-specific ELISA for proposal as European Pharmacopoeia standard method.

Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from East Java and Papua, Indonesia, in 2004 – implications for treatment

We examined gonococci isolated in 2004, in East Java and Papua, Indonesia, to review the suitability of ciprofloxacin-based and other treatment regimens. Gonococci from the two provinces were tested in Sydney for susceptibility to penicillin, tetracycline, spectinomycin, ceftriaxone, ciprofloxacin, gentamicin, azithromycin and rifampicin. Of 163 gonococcal isolates from East Java (91) and Papua (72), 120 (74%) of gonococci, 62 (68%) and 58 (80%) from East Java and Papua, respectively, were penicillinase-producing gonococci and 162 displayed high-level tetracycline resistance. Eighty-seven isolates (53%) were ciprofloxacin resistant, 44 (48%) from East Java and 43 (60%) from Papua. All isolates were sensitive to cefixime/ceftriaxone, spectinomycin and azithromycin. Minimum inhibitory concentrations of gentamicin were in the range 0.05–8 mg/L. Sixty-nine gonococci (42%) showed combined resistance, to penicillin, tetracycline and quinolones. Quinolone resistance has now reached unacceptable levels, and their use for the treatment of gonorrhoea in Indonesia should be reconsidered.

Identification of the predicted 5s-4f level crossing optical lines with applications to metrology and searches for the variation of fundamental constants

We measure optical spectra of Nd-like W, Re, Os, Ir, and Pt ions of particular interest for studies of a possibly varying fine-structure constant. Exploiting characteristic energy scalings we identify the strongest lines, confirm the predicted 5s-4f level crossing, and benchmark advanced calculations. We infer two possible values for optical M2/E3 and E1 transitions in Ir^{17+} that have the highest predicted sensitivity to a variation of the fine-structure constant among stable atomic systems. Furthermore, we determine the energies of proposed frequency standards in Hf^{12+} and W^{14+}.