Generation of liver metastases in a mouse model using ultrasound-guided intravenous injection

Here, we present a protocol to generate a murine model of liver metastasis by directly injecting tumor cells into the portal vein under ultrasound guidance. We describe steps for animal and cell preparation and two techniques for injecting tumor cells. One technique is freehand, while the other technique is device-assisted using a 3D-printed prototype device. Finally, we describe tumor surveillance with bioluminescent imaging.

The Majority of Patients with Resectable Incidental Lung Cancers are Ineligible for Lung Cancer Screening

Objective

The study objective was to determine what proportion of asymptomatic patients had resectable lung cancer detected through lung cancer screening versus incidentally.

Methods

We performed a retrospective study of patients who underwent resection for lung cancer between January 2015 and December 2020. We then assessed whether asymptomatic patients with incidentally found lung cancers were eligible for lung cancer screening using the National Comprehensive Cancer Network, United States Preventive Services Task Force, Centers for Medicare & Medicaid Services, American College of Chest Physicians, American Cancer Society, and American Society of Clinical Oncology guidelines.

Results

Of 539 patients who underwent resection for primary lung cancer, 437 (81%) were asymptomatic and 355 (66%) of these patients had lung cancer found discovered incidentally. Of the 355 patients with incidentally detected lung cancer, 10 were excluded for insufficient data. Of the remaining 345 patients, 110 (32%) would have been eligible for screening using National Comprehensive Cancer Network guidelines, 65 (19%) using 2021 United States Preventive Services Task Force guidelines, 53 (15%) using 2013 United States Preventive Services Task Force guidelines, 64 (19%) using 2022 Centers for Medicare & Medicaid Services guidelines, 52 (15%) using 2015 Centers for Medicare & Medicaid Services/American College of Chest Physicians guidelines, and 45 (13%) using American Cancer Society/American Society of Clinical Oncology guidelines. Of the 280 patients who were screen ineligible by 2021 United States Preventive Services Task Force criteria, 143 patients (51%) never smoked, 112 patients (40%) quit smoking more than 15 years ago, 89 patients (32%) did not smoke at least 20 pack-years, and 44 patients (16%) were ineligible due to age.

Conclusions

The majority of asymptomatic patients with resectable lung cancers had lung cancer identified incidentally and not through lung cancer screening. Most of these patients were not eligible for screening under current guidelines. This study suggests a need for improved lung cancer screening implementation and further investigation in the identification and assessment of risk factors for lung cancer.

Surface conjugation of antibodies improves nanoparticle uptake in bronchial epithelial cells

BACKGROUND

Advances in Molecular Therapy have made gene editing through systemic or topical administration of reagents a feasible strategy to treat genetic diseases in a rational manner. Encapsulation of therapeutic agents in nanoparticles can improve intracellular delivery of therapeutic agents, provided that the nanoparticles are efficiently taken up within the target cells. In prior work we had established proof-of-principle that nanoparticles carrying gene editing reagents can mediate site-specific gene editing in fetal and adult animals in vivo that results in functional disease improvement in rodent models of β-thalassemia and cystic fibrosis. Modification of the surface of nanoparticles to include targeting molecules (e.g. antibodies) holds the promise of improving cellular uptake and specific cellular binding.

METHODS AND FINDINGS

To improve particle uptake for diseases of the airway, like cystic fibrosis, our group tested the impact of nanoparticle surface modification with cell surface marker antibodies on uptake in human bronchial epithelial cells in vitro. Binding kinetics of antibodies (Podoplanin, Muc 1, Surfactant Protein C, and Intracellular Adhesion Molecule-1 (ICAM)) were determined to select appropriate antibodies for cellular targeting. The best target-specific antibody among those screened was ICAM antibody. Surface conjugation of nanoparticles with antibodies against ICAM improved cellular uptake in bronchial epithelial cells up to 24-fold.

CONCLUSIONS

This is a first demonstration of improved nanoparticle uptake in epithelial cells using conjugation of target specific antibodies. Improved binding, uptake or specificity of particles delivered systemically or to the luminal surface of the airway would potentially improve efficacy, reduce the necessary dose and thus safety of administered therapeutic agents. Incremental improvement in the efficacy and safety of particle-based therapeutic strategies may allow genetic diseases such as cystic fibrosis to be cured on a fundamental genetic level before birth or shortly after birth.

Fully Automated Surveillance of Healthcare-Associated Infections with MONI-ICU: A Breakthrough in Clinical Infection Surveillance

OBJECTIVE

Expert surveillance of healthcare-associated infections (HCAIs) is a key parameter for good clinical practice, especially in intensive care medicine. Assessment of clinical entities such as HCAIs is a time-consuming task for highly trained experts. Such are neither available nor affordable in sufficient numbers for continuous surveillance services. Intelligent information technology (IT) tools are in urgent demand.

METHODS

MONI-ICU (monitoring of nosocomial infections in intensive care units (ICUs)) has been developed methodologically and practically in a stepwise manner and is a reliable surveillance IT tool for clinical experts. It uses information from the patient data management systems in the ICUs, the laboratory information system, and the administrative hospital information system of the Vienna General Hospital as well as medical expert knowledge on infection criteria applied in a multilevel approach which includes fuzzy logic rules.

RESULTS

We describe the use of this system in clinical routine and compare the results generated automatically by MONI-ICU with those generated in parallel by trained surveillance staff using patient chart reviews and other available information ("gold standard"). A total of 99 ICU patient admissions representing 1007 patient days were analyzed. MONI-ICU identified correctly the presence of an HCAI condition in 28/31 cases (sensitivity, 90.3%) and their absence in 68/68 of the non-HCAI cases (specificity, 100%), the latter meaning that MONI-ICU produced no "false alarms". The 3 missed cases were due to correctable technical errors. The time taken for conventional surveillance at the 52 ward visits was 82.5 hours. MONI-ICU analysis of the same patient cases, including careful review of the generated results, required only 12.5 hours (15.2%).

CONCLUSION

Provided structured and sufficient information on clinical findings is online available, MONI-ICU provides an almost real-time view of clinical indicators for HCAI - at the cost of almost no additional time on the part of surveillance staff or clinicians.

Learning from Worked-Out Examples: The Effects of Example Variability and Elicited Self-Explanations

It was investigated to what extent example variability and the elicitation of sophisticated self-explanations foster the acquisition of transferable knowledge by learning from worked-out examples. In addition, it was asked whether the effects of these factors are moderated by the learners' levels of prior topic knowledge. To this end, we had 56 apprentices from a bank learn calculation of compound interest and real interest. They were randomly assigned to the four conditions of a 2 x 2-factorial design (factor 1: uniform vs. multiple examples; factor 2: spontaneous vs. elicited self-explanations). The learning results were measured by a post-test comprising near-transfer problems and far-transfer problems. It was found that the acquisition of transferable knowledge can be supported by eliciting self-explanations. In the case of near transfer, especially learners with low levels of prior topic knowledge profited from the elicitation procedure. On the whole, the findings underline the "causal" relevance of the quality of self-explanations for knowledge acquisition by learning from worked-out examples. The assumption that multiple examples foster transfer performance, at least when sophisticated self-explanations are elicited, was not supported. Copyright 1998 Academic Press.

[CASUS model trial. A computer-assisted author system for problem-oriented learning in medicine]

The CASUS-project, a three year publicly funded effort to improve the quality of continuing medical education in Germany, has one major goal: The development and evaluation of an easy-to-handle author-system for problem-oriented learning in medicine. On the theoretical basis of the cognitive apprenticeship-approach, the concept of a teaching and learning database as a hypermedia system was built. The student should learn to manage authentical problems in the form of authentical clinical cases. The step-by-step learning process is expert-guided by the clinical authors of each case. The creation of various differential diagnoses by the learner is strongly supported in the process. The structure of the program can also be used for case-based examinations. In parallel to the technical development, a case-selection process for medical students students in internal medicine was initiated. About 120 relevant diseases were identified to be represented in the CASUS-case library. Prevalence, transferability of knowledge, treatability, urgence of treatment and preventive aspects were used as selection criteria. The system will be evaluated during the implementation of test cases and will then be available to be used by authors and students on a routine basis in 1997.

[Clinical and electroneurographic results following surgical treatment of the ulnar nerve sulcus syndrome]

The sulcus of the elbow-joint represents a bottleneck which may cause compression of the ulnar nerve. We studied clinical and electroneurographical results in 26 patients after operation of the sulcus ulnaris-syndrome. The influence of the duration of compression as well as additional illnesses was evaluated on the postoperative result. The surgical treatment was an anterior transposition of the nerve in a subcutaneous layer combined with external neurolysis. Due to the symptoms and the electroneurographical results after operation the patients were divided into three groups. The best results were obtained in cases with a short period of preoperative complaints (below 1 year). Although heavy work had a positive effect on the manifestation of a sulcus ulnaris-syndrome, it had no adverse effect if started again after operation. Anterior subcutaneous transposition is the operative procedure of choice in cases of sulcus ulnaris-syndrome.

[Late results following surgical correction of syndactyly and symbrachydactyly]

Growth and the type of surgical treatment of the hand play an important role in the results of surgery in children. 29 patients have been operated on because of syndactyly and symbrachydactyly and were controlled. The following parameters were assessed: kind of incision and skin graft, functional results, x-ray to examine the skeleton and the depth of the commissure, colour of the skin graft and use of the hand. After operation of syndactyly all patients were able to use their hands normally, although full extend of flexion and extension was achieved only in 20 of 22 hands. In 5 divided pairs of fingers there was recurrence of syndactyly. In all cases except one, a split thickness skin graft has been used. After operative treatment of symbrachydactyly and complex syndactyly, full extent of flexion was achieved in 13 of 19 hands, in 6 hands the range of flexion was incomplete because of skeleton abnormalities. Recurrence occurred in 9 divided pairs of fingers; in 7 cases, a split thickness skin graft had been used. Despite this, all patients were able to use their hands normally. The use of split thickness skin grafts resulted in a 60% recurrence rate, whereas the use of full thickness skin graft led merely to 7.5% recurrence rate. Our results show the advantage of the full thickness skin graft. As a consequence, full thickness skin graft should be used in all cases. Furthermore, the operation should be performed at an early age, if fingers of unequal length have to be separated. Zig-zag incision should be used in all cases.

[Reconstruction of deformities of the external ear]

Microtia is a rare malformation. Reconstruction of microtia is not a routine operation because of its rarity of occurrence and the complex deformity. In this paper the indication for surgical treatment, technique, results and complications are discussed. Two different operation methods were used in our patients. A multiple-stage and a single-stage reconstruction procedure. We used autogenous rib cartilage. Five of the seven treated patients came to the follow-up examination. Reconstruction was performed 2 years ago in two cases and between 4 and 12 years ago in three cases. Our patients were content with the result in so far as they would be prepared to undergo treatment again. Carefully built rib framework is an essential prerequisite for a successful postoperative result. Microtia represents a greater psychological problem than a cosmetically imperfect result after reconstruction.

Inadequacy of conventional computerized tomography scans for treatment planning of tangential breast (chest wall) fields

The use of transverse tomography treatment-planning scans, which have to be taken in the exact treatment position of the patients, is essential for precision radiotherapy of breast cancer. Transverse tomography scans give all necessary informations for an optimal isodose distribution within the target volume for the individual patient, and maximal sparing of normal tissues (e.g. lung) is achieved. The exact topography of internal mammary nodes may also be incorporated in the planning scan with the help of lymphoscintigraphy. Conventional computerized tomography (CT) scanners have too small gantry openings (50-70 cm) to allow for proper positioning of the patients under treatment conditions. Using such treatment-planning scans for patients in the actual treatment position would cause an underdosage in excess of 5% within the target volume, when 60Co fields are used. Also, a much larger volume of normal tissues (mainly lung) would unnecessarily be irradiated. Treatment-planning scans obtained by TAT (transverse analog tomography) do not have the crucial positioning problems of conventional CT scanners and enable the precise transformation of a valid isodose distribution to each patient. In addition, positioning wedges (with adjustable wedge angles) may be placed under the patient to achieve the optimal treatment position. A useful alternative of TAT scanning for precise treatment planning of patients with breast cancer would be a CT scanner with a wide enough gantry opening to allow for any patient positioning under actual treatment conditions.

[Comparative study of primary and secondary management of flexor tendon injuries]

In 1974 a replantation service started at the authors' department. Before that time the treatment of flexor tendon injuries was mainly performed secondarily. Therefore, the authors had the opportunity to compare patients after primary and secondary surgery. In 52 primarily and 22 secondarily treated patients the technique of Kleinert was used. Following issues were investigated: functional results, decrease of grip strength, influence of early mobilization on sensibility restoration in cases of nerve injury, relation between sensitivity to cold and vessel and nerve injuries, duration of physiotherapy and disability. The damage of only one finger might lead to decrease of grip strength. Primary surgery was superior to secondary surgery. Early mobilization in cases of additional nerve injuries did not affect sensibility restoration. Poor sensibility increased the chance of cold sensitivity. The duration of physiotherapy and of disability depended on the need for second procedures such as tenolysis which was more common in the group of secondarily treated patients.

[Determination of the integral dose in computer tomography of the neurocranium]

The amount of exposure of the cranium is calculated on the basis of the measured dose distribution in craniocaudal direction and on the axial planes of the Alderson phantom. The integral dose of the cranium and the local dose at sensitive organs are used as a measure of radiation exposure.

[Reconstruction of grip function in cases of a fingerless or missing hand]

In two cases a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient all fingers of the left hand were amputated at the metacarpo-phalangeal joint level. The second and the third finger were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. The distal and middle phalanx of the transplanted third toe had to be re-amputated because of mummification two weeks after the transplantation and was covered with a groin flap. Good function of the newly formed grip could be demonstrated. The second patient was a 21-year old man with amputation of both hands. Grip reconstruction in the right lower arm was performed by transplantation of the second toe of each foot together with a metatarsal bone and a dorsalis pedis flap. One year after the operation the follow-up study demonstrated good function of the newly formed hand. The patient is able to use his two new fingers during daily life mainly to hold small objects. The sensation and the range of movement of the newly formed right hand are demonstrated and discussed.

[Percutaneous measurement of oxygen partial pressure as an evaluation method of free flaps]

Transcutaneous, polarographic pO2-measurement can be used to estimate and monitor the circulation in free tissue transfers. Our experience in this field using a modified Clark's electrode is reported by presenting some examples. Its value in intraoperative and postoperative monitoring and for the early diagnosis of a critical reduction of blood flow in free flaps with microvascular anastomoses is assessed in the light of our early experience with this technique.

Grip reconstruction by double-toe transplantation in cases of a fingerless hand and a handless arm

In two cases, a grip reconstruction by double toe-to-hand transfer is demonstrated. In the first patient, all fingers of the left hand were amputated at the metacarpophalangeal joint level. The second and third fingers were reconstructed by transplantation of the second toe from the left foot and the third toe from the right foot. Although the distal and the middle phalanx of the transplanted third toe had to be amputated because of mummification 2 weeks after the transplantation and was covered with a groin flap, good function of the newly formed grip can be demonstrated. The second patient is a 21-year-old man with amputation of both hands at the wrist. A grip formation on the right lower arm was performed by transplantation of the second toe of each foot together with the metatarsal bone and a dorsalis pedis flap. Both metatarsal bones were fixed to the ulna and radius with metal plates, and tendons and nerves, together with a vascular supply, were reconstructed. One year after the operation, a follow-up study demonstrates good function of the newly formed "hand." The patient is able to use his two new "fingers" during daily life, mainly to hold small objects. A myoelectric prosthesis has been placed on the patient's left arm, and the patient uses this to hold bigger objects. Restoration of sensation and the range of movement of the newly formed right "hand" are demonstrated and discussed.

[Microsurgical reconstruction of lymphatic system defects]

In a group of eighteen dogs (1977-79) artificially interrupted lymphatics have been bridged by suitable small vein grafts. Patency was controlled by different methods: by clinical microscopical control, by microlymphangiography and by histological examinations. The patency rate in this group was 61.1 per cent. So for the first time it could be shown experimentally that it is possible to restore interrupted lymphatics by grafting. This might be the basis for a causal therapy of secondary lymphedema by reconstruction of interrupted or occluded lymphatics. In a further group of fifteen dogs different autologous grafts have been compared. Each five lymphatic, venous and arterial grafts have been interposed in lymph collectors of 0.3 to 0.6 mm in diameter by the same surgeon applying the same microsurgical and atraumatic technique. The grafts varied from 8 to 25 mm in length. While all the lymphatic grafts remained patent, one of the five venous and all arterial grafts were occluded. There could not be found any correlation of patency rate to length of the grafts. Light microscopical and electron microscopical examinations of the harvested vessels showed heavy pathological findings of the arterial walls. In the venous grafts the intima was thickened to different extent. This could be explained by the lack of blood supply from the lumen. Very likely the occlusion of all arterial grafts seems to be explained by the disturbance of the vessel wall blood supply. The lymphatic grafts histologically showed nearly no pathological damage. There was complete reendothelialization at the suture line of all patent grafts. From these experimental results it is concluded that arteries are not suitable for interposition in order to restore lymph drainage. It could be shown that veins and lymphatics are equally usable for this purpose. Therefore these two structures have been used clinically in cases of therapy resisting lymphedemas for reconstruction of the destroyed lymph paths.

[Plastic surgery after extensive tumor surgery of the scalp]

Extensive resections of tumors of the scalp penetrating into the bone and the brain often require the use of free flaps for coverage as the only possibility. Four cases are reported and the specific problems of these microsurgical operations in this region are discussed.

[Surgical specialties in replantation surgery]

Special operative techniques developed by the advances in the replantation surgery are the subject of a review. The replantation of an amputated finger in a more important position is demonstrated by a clinical case. Defects can be replaced by parts of non-replanted fingers or with the aid of transplanted structures, such as skin, vessels, bone and local flaps. Clinical examples are given of the primary transplantation of bone from the iliac crest and of enhancement of circulation from the healthy, neighbouring finger.

[Functional outcome after reimplantations in the hand and finger region]

Successful replantation of total amputated parts of the hand having been performed during a period of five years were investigated as a homogenous group. Long-term function of replanted parts was evaluated by objective criteria, as signs of use, trophique, vascularisation, mobility, sensibility and the integration of replants into general function of the hand, and on the other side by subjective criteria as usefulness in professional and private life, retrospective personal attitude to replantation and subjective complaints.

[Reconstruction of the breast after surgery for cancer (author's transl)]

The tendency towards less radical, stage-dependent procedures in the surgical management of breast cancer has opened the way to improvement in the reconstructive measures available. Reconstruction of the female breast can be undertaken with greater or lesser success and facility according to whether the initial procedure was subcutaneous mastectomy, modified radical mastectomy or the Rotter--Halstedt radical operation. The different plastic reconstructive methods developed over the past years are discussed and illustrated by cases treated under our care.

Replantation and revascularization of amputated parts of extremities: a three-year report from the Viennese replantation team

A Replantation Team was instituted in Vienna 3 years ago. This team is the oldest in Europe. One hundred and eighty-one complete and incomplete amputated parts of 118 patients were replanted during this period. A survival rate of 86% and a useful functional result ("integrated parts") in 78% of the cases was obtained. Appropriate preparation of the amputated parts, the right timing, a 24 hour service and a clear indication with intensive postoperative physicotherapeutical treatment are the fundamental points for this result.

[Multiple-stage treatment of malignant melanoma (author's transl)]

The paper reports on 11 patients with very advanced melanoma, who were treated with a modified version of multiple-stage cancer therapy. No improvement in the course of the illness resulted, but survival may have been slightly prolonged.

[Muscular neurotisation in traumatic abducens paresis (A new method of operative treatment) (author's transl)]

Traumatic abducens pareses occur quite often. The methods of operation known until now often achieved no good functional result. Therefore the authors experimentally tried to reinnervate by means of "musculr neurotisation" in 10 rabbits an extraocular muscle previously denervated. After 6 months the histological examination revealed the presence of newly germinated medullated nerve fibers and motor end plates. This was the proof that eye muscles may be reinnervated. Consequently in 5 patients with traumatic abducens paresis an implantation of the inferior oblique muscle was done. The functional improvement secured by this method of operation which for the first time has been applied on the human eye was good, in some cases even extremely good, depending on the time elapsed between lesion and operation.

[The electrophysiological behavior of normal and glaucomatous human eyes with short term intraocular pressure elevation (author's transl)]

An electrophysiological study has been done on glaucomatous and normal eyes with briefly elevated intraocular pressure. There was no significant difference between the ERGs, but the changes in the VERs of glaucomatous eyes differed widely from those of normal eyes. This seems to be due to the high sensitivity to pressure of the prelaminary part of the optic nerve in glaucomatous eyes. Obviously this could be a method for the objective measurement of the sensitivity of the papillary vessels to raised intraocular pressure.