The cytotoxic activity of carfilzomib together with nelfinavir is superior to the bortezomib/nelfinavir combination in non-small cell lung carcinoma

Chemotherapy resistance is still a major problem in the treatment of patients with non-small-cell-lung carcinoma (NSCLC), and novel concepts for the induction of cytotoxicity in NSCLC are highly warranted. Proteotoxicity, the induction of cytotoxicity by targeting the ubiquitin proteasome system, represents an appealing innovative strategy. The combination of the proteasome inhibitor bortezomib (BTZ) and the proteotoxic stress-inducing HIV drug nelfinavir (NFV) synergistically induces proteotoxicity and shows encouraging preclinical efficacy in NSCLC. The second-generation proteasome inhibitor carfilzomib (CFZ) is superior to BTZ and overcomes BTZ resistance in multiple myeloma patients. Here, we show that CFZ together with NFV is superior to the BTZ + NFV combination in inducing endoplasmic reticulum stress and proteotoxicity through the accumulation of excess proteasomal substrate protein in NSCLC in vitro and ex vivo. Interestingly, NFV increases the intracellular availability of CFZ through inhibition of CFZ export from NSCLC cells that express multidrug resistance (MDR) protein. Combining CFZ with NFV may therefore represent a future treatment option for NSCLC, which warrants further investigation.

Health care effects and medical benefits of a smartphone-based diabetes self-management application: study protocol for a randomized controlled trial

Background

Diabetes self-management is a mainstay of diabetes care, but the implementation of self-management regimens into daily life is complex and often results in discouragement and distress. Modern approaches such as smartphone-based self-management applications are therefore needed to support people with diabetes. Since reimbursability would increase the availability of such digital applications to people with diabetes, we designed a study that meets all scientific and methodological requirements set by the German Digital Healthcare Act to allow reimbursement for a specific application (mySugr PRO). Here, we report the protocol of this study that aims at evaluating the efficacy of the digital self-management application with regard to patient-reported outcomes and medical benefits.

Methods/design

This multicenter, open-label, randomized, parallel-group, controlled trial will evaluate the health care effects and medical benefits of mySugr PRO. A total of 466 people with diabetes will be randomly allocated (2:1 randomization) to the interventional group (n = 311) that will use the digital self-management application during the 12-week study period or the control group (n = 155; no usage of the application). Baseline and follow-up examinations will assess diabetes distress as the primary endpoint as well as empowerment, HbA1c, blood glucose data, self-management, general well-being, and treatment satisfaction as secondary endpoints. Statistical analyses will use an intention-to-treat procedure (using multiple imputation for missing values) as well as a per-protocol approach for sensitivity analysis.

Discussion

To the best of our knowledge, this study will be one of the largest diabetes-specific evaluations of a digital health application supporting people with diabetes in their diabetes self-management that follow the requirements of the German Digital Healthcare Act.

Trial registration

German Clinical Trial Register DRKS00022923. Registered on 22 October 2020.

Influence of denosumab on bone mineral density in a severe case of pregnancy-associated osteoporosis

Pregnancy and lactation-associated osteoporosis (PLO) with predominantly subsequent vertebral fracture is a rare but severe disease with an estimated incidence of 0.4 in 100,000. In the past, patients with PLO have been predominantly treated with oral and i.v. bisphosphonates to reduce subsequent fracture risk. Hereby, the use of bisphosphonates in premenopausal women is controversial, as bisphosphonates know to persist in bone for many years and can be exposed and circulate in maternal serum and subsequently pass the placenta barrier and may have a detrimental effect on fetal bone health. Here we report the effects of denosumab on the bone mineral density (BMD) and subsequent fracture risk in PLO. In this case presentation, denosumab was administered postpartum with 3000 IE vitamin D and 1000 mg of calcium daily in a patient with PLO and vertebral fracture of L1 and L4. After 18 months of treatment with denosumab, we could demonstrate a clinical significant increase of BMD at the lumbar spine, femoral neck, and total hip of 32.2%, 13.0%, and 11.5% respectively with no further subsequent fractures. As the patient had regular menstrual cycles and considered a further pregnancy, denosumab treatment was terminated and soon a second pregnancy occurred. After the second pregnancy, BMD decreased at the lumbar spine, femur neck, and total hip by -8.8%, -6.9%, and -7.0% respectively compared to the maximum values during treatment with denosumab, but was still significantly higher compared to baseline levels with no further fractures.

[Decision support for patient admission in case of suspicion of COVID-19]

During a pandemic situation, patients with suspected coronavirus disease (COVID-19) are also treated by emergency medical services (EMS). In order to establish an adequate procedure, a decision aid for the allocation of patients in case of suspicion of COVID-19 has been prepared for the ambulance staff as well as for the emergency physician in the Bavarian EMS. The decision-making aid includes the current guidelines and recommendations on COVID-19. A flowchart in A4 format was chosen for the presentation of the decision aid, which is structured according to the ABCDE scheme (A-Airway, B-Breathing, C-Circulation, D-Disability, E-Environment/Exposure) established in EMS. The flowchart allows patients to be categorized in three stages, based on (vital) parameters and criteria such as risk factors and specific framework conditions. The aim is to provide emergency physicians and ambulance staff with guidance for the assessment of patients and the resulting transport decision with a suitable target clinic if necessary.

Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

The Impact of Immersion on Cluster Identification Tasks

Recent developments in technology encourage the use of head-mounted displays (HMDs) as a medium to explore visualizations in virtual realities (VRs). VR environments (VREs) enable new, more immersive visualization design spaces compared to traditional computer screens. Previous studies in different domains, such as medicine, psychology, and geology, report a positive effect of immersion, e.g., on learning performance or phobia treatment effectiveness. Our work presented in this paper assesses the applicability of those findings to a common task from the information visualization (InfoVis) domain. We conducted a quantitative user study to investigate the impact of immersion on cluster identification tasks in scatterplot visualizations. The main experiment was carried out with 18 participants in a within-subjects setting using four different visualizations, (1) a 2D scatterplot matrix on a screen, (2) a 3D scatterplot on a screen, (3) a 3D scatterplot miniature in a VRE and (4) a fully immersive 3D scatterplot in a VRE. The four visualization design spaces vary in their level of immersion, as shown in a supplementary study. The results of our main study indicate that task performance differs between the investigated visualization design spaces in terms of accuracy, efficiency, memorability, sense of orientation, and user preference. In particular, the 2D visualization on the screen performed worse compared to the 3D visualizations with regard to the measured variables. The study shows that an increased level of immersion can be a substantial benefit in the context of 3D data and cluster detection.

Improved Upper Limit on the Neutrino Mass from a Direct Kinematic Method by KATRIN

We report on the neutrino mass measurement result from the first four-week science run of the Karlsruhe Tritium Neutrino experiment KATRIN in spring 2019. Beta-decay electrons from a high-purity gaseous molecular tritium source are energy analyzed by a high-resolution MAC-E filter. A fit of the integrated electron spectrum over a narrow interval around the kinematic end point at 18.57 keV gives an effective neutrino mass square value of (-1.0_{-1.1}^{+0.9})  eV^{2}. From this, we derive an upper limit of 1.1 eV (90% confidence level) on the absolute mass scale of neutrinos. This value coincides with the KATRIN sensitivity. It improves upon previous mass limits from kinematic measurements by almost a factor of 2 and provides model-independent input to cosmological studies of structure formation.

Nelfinavir and lenalidomide/dexamethasone in patients with lenalidomide-refractory multiple myeloma. A phase I/II Trial (SAKK 39/10)

The antiretroviral agent nelfinavir has antimyeloma activity and can overcome resistance to bortezomib. Our phase I/II trial investigated whether adding nelfinavir to lenalidomide-dexamethasone can overcome lenalidomide resistance in lenalidomide-refractory multiple myeloma (MM). Twenty-nine patients were included (high-risk cytogenetic aberrations 31%; ≥2 prior therapy lines 93%; lenalidomide-bortezomib double-refractory 34%). Twenty-four patients (83%) had prior bortezomib and 10 (34%) were lenalidomide-bortezomib double-refractory. They received four cycles of nelfinavir 2500 mg/day with standard-dose lenalidomide (25 mg days 1-21) and dexamethasone (40/20 mg days 1, 8, 15, 22). Minor response or better was achieved in 16 patients (55%; 95% CI 36-74%), including 40% of those who were lenalidomide-bortezomib double-refractory, and partial response or better in nine patients (31%; 95% CI 15-51%). Median progression-free survival was 3.4 (95% CI 2.0-4.9) months and median overall survival 21.6 (13.0-50.1) months. Lenalidomide-related pneumonitis, pneumonia, and neutropenic fever occurred, but there were no unexpected adverse events. Peripheral blood mononuclear cells showed a 45% (95% CI 40-51%) reduction in total proteasome activity from baseline and significant induction of unfolded protein response and autophagy. Thus, nelfinavir-lenalidomide-dexamethasone is an active oral combination in lenalidomide-refractory MM.

[Advanced medical post within hospitals as possible tactical instrument for handling mass casualty incidents]

BACKGROUND

An important instrument for handling mass casualty incidents in preclinical settings is the use of an advanced medical post. In certain circumstances, however, the establishment of such an advanced medical post on or close to the incident site is impossible. Terrorist attacks are a prime example for this. The highest priority for hospitals during mass casualty incidents is to adjust the treatment capacity to the acute rise in demand and to sustain its functionality throughout the duration of the incident. By establishing an advanced medical post within hospitals during certain types of mass casualty incidents these aims could potentially be accomplished.

AIMS

The aims of this pilot study were to test the practicability of the establishment of an advanced medical post within a university hospital and to identify potential problems. The results provide the foundation of a generalized concept, which will then be integrated into the hospital emergency plans.

METHODS

After the formation of a multiprofessional expert committee, different areas within the hospital were evaluated based on spatial and tactical considerations. Predefined questions were assessed and harmonized with respect to organization, vehicle management, communication, leadership and patient transport through the means of a practice run.

RESULTS

The establishment and operation of an advanced medical post within the hospital were easily possible. The consequent deployment of section leaders enabled the smooth coordination of transport and an unobstructed simulated patient flow. The management of the treatment area by a senior emergency physician and a senior emergency medical service officer in close cooperation with the operational hospital lead proved to be a useful concept. Technical problems with communication within the hospital were resolved by using wireless phones and the installation of a digital radio repeater.

DISCUSSION

During acute scenarios with only short prior notice, the authors prefer concepts that supplement the normal hospital operation through additional staff and material. In circumstances with prior notice of more than 60 min an advanced intrahospital advanced medical post, staffed by civil protection units, could be a concept that enables the absorption of the first patient arrivals within the first hour of a mass casualty incident without disturbing the functionality of hospitals to any great extent. Further practice runs are, however, necessary to further develop and adjust this concept to real-life circumstances.

Novel cell line models to study mechanisms and overcoming strategies of proteasome inhibitor resistance in multiple myeloma

Experimental data on resistance mechanisms of multiple myeloma (MM) to ixazomib (IXA), a second-generation proteasome inhibitor (PI), are currently lacking. We generated MM cell lines with a 10-fold higher resistance to IXA as their sensitive counterparts, and observed cross-resistance towards the PIs carfilzomib (CFZ) and bortezomib (BTZ). Analyses of the IXA-binding proteasome subunits PSMB5 and PSMB1 show increased PSMB5 expression and activity in all IXA-resistant MM cells, and upregulated PSMB1 expression in IXA-resistant AMO1 cells. In addition, sequence analysis of PSMB5 revealed a p.Thr21Ala mutation in IXA-resistant MM1.S cells, and a p.Ala50Val mutation in IXA-resistant L363 cells, whereas IXA-resistant AMO1 cells lack PSMB5 mutations. IXA-resistant cells retain their sensitivity to therapeutic agents that mediate cytotoxic effects via induction of proteotoxic stress. Induction of ER stress and apoptosis by the p97 inhibitor CB-5083 was strongly enhanced in combination with the PI3Kα inhibitor BYL-719 or the HDAC inhibitor panobinostat suggesting potential therapeutic strategies to circumvent IXA resistance in MM. Taken together, our newly established IXA-resistant cell lines provide first insights into resistance mechanisms and overcoming treatment strategies, and represent suitable models to further study IXA resistance in MM.

Structured analysis, evaluation and report of the emergency response to a terrorist attack in Wuerzburg, Germany using a new template of standardised quality indicators

Background

Until now there has been a reported lack of systematic reports and scientific evaluations of rescue missions during terror attacks. This however is urgently required in order to improve the performance of emergency medical services and to be able to compare different missions with each other. Aim of the presented work was to report the systematic evaluation and the lessons learned from the response to a terror attack that happened in Wuerzburg, Germany in 2016.

Methods

A team of 14 experts developed a template of quality indicators and operational characteristics, which allow for the description, assessment and comparison of civil emergency rescue missions during mass killing incidents. The entire systematic evaluation process consisted of three main steps. The first step was the systematic data collection according to the quality indicators and operational characteristics. Second was the systematic stratification and assessment of the data. The last step was the prioritisation of the identified weaknesses and the definition of the lessons learned.

Results

Five important “lessons learned” have been defined. First of all, a comprehensive concept for rescue missions during terror attacks is essential. Furthermore, the establishment of a defined high priority communication infrastructure between the different dispatch centres (“red phone”) is vital. The goal is to secure the continuity of information between a few well-defined individuals. Thirdly, the organization of the incident scene needs to be commonly decided and communicated between police, medical services and fire services during the mission. A successful mission tactic requires continuous flux of reports to the on-site command post. Therefore, a predefined and common communication infrastructure for all operational forces is a crucial point. Finally, all strategies need to be extensively trained before the real life scenario hits.

Conclusion

According to a systematic evaluation, we defined the lessons learned from a terror attack in 2016. Further systematic reports and academic work surrounding life threatening rescue missions and mass killing incidents are needed in order to ultimately improve such mission outcomes. In the future, a close international collaboration might help to find the best database to report and evaluate major incidents but also mass killing events.

Multimessenger observations of a flaring blazar coincident with high-energy neutrino IceCube-170922A

Previous detections of individual astrophysical sources of neutrinos are limited to the Sun and the supernova 1987A, whereas the origins of the diffuse flux of high-energy cosmic neutrinos remain unidentified. On 22 September 2017, we detected a high-energy neutrino, IceCube-170922A, with an energy of ~290 tera–electron volts. Its arrival direction was consistent with the location of a known γ-ray blazar, TXS 0506+056, observed to be in a flaring state. An extensive multiwavelength campaign followed, ranging from radio frequencies to γ-rays. These observations characterize the variability and energetics of the blazar and include the detection of TXS 0506+056 in very-high-energy γ-rays. This observation of a neutrino in spatial coincidence with a γ-ray–emitting blazar during an active phase suggests that blazars may be a source of high-energy neutrinos.

Correction to: Radiation exposure for intraoperative 3D scans in a hybrid operating room: how to reduce radiation exposure for the surgical team

The original version of this article unfortunately contained a mistake. In abstract, results section should read.

Search for γ-Ray Line Signals from Dark Matter Annihilations in the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

Spectral lines are among the most powerful signatures for dark matter (DM) annihilation searches in very-high-energy γ rays. The central region of the Milky Way halo is one of the most promising targets given its large amount of DM and proximity to Earth. We report on a search for a monoenergetic spectral line from self-annihilations of DM particles in the energy range from 300 GeV to 70 TeV using a two-dimensional maximum likelihood method taking advantage of both the spectral and spatial features of the signal versus background. The analysis makes use of Galactic center observations accumulated over ten years (2004-2014) with the H.E.S.S. array of ground-based Cherenkov telescopes. No significant γ-ray excess above the background is found. We derive upper limits on the annihilation cross section ⟨σv⟩ for monoenergetic DM lines at the level of 4×10^{-28}  cm^{3} s^{-1} at 1 TeV, assuming an Einasto DM profile for the Milky Way halo. For a DM mass of 1 TeV, they improve over the previous ones by a factor of 6. The present constraints are the strongest obtained so far for DM particles in the mass range 300 GeV-70 TeV. Ground-based γ-ray observations have reached sufficient sensitivity to explore relevant velocity-averaged cross sections for DM annihilation into two γ-ray photons at the level expected from the thermal relic density for TeV DM particles.

Conjunctivalization of Meibomian Glands following Cryosurgery for Basal Cell Carcinoma of the Eyelid

Cryosurgery on the eyelids destroys the cellular elements in the frozen region, but preserves the collagenous supporting structures. Cells from the neighborhood colonize this framework during wound healing. The Authors describe a peculiar change in the Meibomian glands, which obviously developed by this mechanism in a lid treated by cryotherapy for a basal cell carcinoma. The collagenous lodges of the Meibomian glands, denuded of their sebaceous cells by the therapy, were epithelialized by ingrown conjunctival epithelium. This situation seems to promote the spread of and maintain acute and chronic exogenous inflammation in the tarsal plate.

Improving the efficacy of proteasome inhibitors in the treatment of renal cell carcinoma by combination with the human immunodeficiency virus (HIV)-protease inhibitors lopinavir or nelfinavir

OBJECTIVES

To assess the potential of second-generation proteasome inhibition by carfilzomib and its combination with the human immunodeficiency virus (HIV) protease inhibitors (HIV-PIs) lopinavir and nelfinavir in vitro for improved treatment of clear cell renal cell cancer (ccRCC).

MATERIALS AND METHODS

Cytotoxicity, reactive oxygen species (ROS) production, and unfolded protein response (UPR) activation of proteasome inhibitors, HIV-PIs, and their combination were assessed in three cell lines and primary cells derived from three ccRCC tumours by MTS assay, flow cytometry, quantitative reverse transcriptase-polymerase chain reaction and western blot, respectively. Proteasome activity was determined by activity based probes. Flow cytometry was used to assess apoptosis by annexin V/propidium iodide assay and ATP-binding cassette sub-family B member 1 (ABCB1) activity by MitoTracker™ Green FM efflux assay (Thermo Fisher Scientific, MA, USA).

RESULTS

Lopinavir and nelfinavir significantly increased the cytotoxic effect of carfilzomib in all cell lines and primary cells. ABCB1 efflux pump inhibition, induction of ROS production, and UPR pre-activation by lopinavir were identified as underlying mechanisms of this strong synergistic effect. Combined treatment led to unresolved protein stress, increased activation of pro-apoptotic UPR pathway, and a significant increase in apoptosis.

CONCLUSION

The combination of the proteasome inhibitor carfilzomib and the HIV-PIs lopinavir and nelfinavir has a strong synergistic cytotoxic activity against ccRCCin vitro at therapeutically relevant drug concentrations. This effect is most likely explained by synergistic UPR triggering and ABCB1-modulation caused by HIV-PIs. Our findings suggest that combined treatment of second-generation proteasome inhibitors and HIV-PIs should be investigated in patients with metastatic RCC within a clinical trial.

Alcohol-abuse drug disulfiram targets cancer via p97 segregase adaptor NPL4

Cancer incidence is rising and this global challenge is further exacerbated by tumour resistance to available medicines. A promising approach to such unmet need for improved cancer treatment is drug repurposing. Here we highlight the potential for repurposing disulfiram (Antabuse), an old alcohol-aversion drug effective against diverse cancer types in preclinical studies. Our nationwide epidemiological study reveals that patients who continuously used disulfiram have a lower risk of death from cancer compared to those who stopped using the drug at their diagnosis. Moreover, we identify ditiocarb-copper complex as the metabolite of disulfiram responsible for anticancer effects, and provide methods to detect its preferential accumulation in tumours and candidate biomarkers for impact in cells and tissues. Finally, our functional and biophysical analyses reveal the long-sought molecular target of disulfiram’s tumour suppressing effects as NPL4, an adapter of p97/VCP segregase essential for protein turnover involved in multiple regulatory and stress-response cellular pathways.

The p97 Inhibitor CB-5083 Is a Unique Disrupter of Protein Homeostasis in Models of Multiple Myeloma

Inhibition of the AAA ATPase, p97, was recently shown to be a novel method for targeting the ubiquitin proteasome system, and CB-5083, a first-in-class inhibitor of p97, has demonstrated broad antitumor activity in a range of both hematologic and solid tumor models. Here, we show that CB-5083 has robust activity against multiple myeloma cell lines and a number of in vivo multiple myeloma models. Treatment with CB-5083 is associated with accumulation of ubiquitinated proteins, induction of the unfolded protein response, and apoptosis. CB-5083 decreases viability in multiple myeloma cell lines and patient-derived multiple myeloma cells, including those with background proteasome inhibitor (PI) resistance. CB-5083 has a unique mechanism of action that combines well with PIs, which is likely owing to the p97-dependent retro-translocation of the transcription factor, Nrf1, which transcribes proteasome subunit genes following exposure to a PI. In vivo studies using clinically relevant multiple myeloma models demonstrate that single-agent CB-5083 inhibits tumor growth and combines well with multiple myeloma standard-of-care agents. Our preclinical data demonstrate the efficacy of CB-5083 in several multiple myeloma disease models and provide the rationale for clinical evaluation as monotherapy and in combination in multiple myeloma. Mol Cancer Ther; 16(11); 2375-86. ©2017 AACR.

Carfilzomib resistance due to ABCB1/MDR1 overexpression is overcome by nelfinavir and lopinavir in multiple myeloma

Proteasome inhibitor (PI) carfilzomib (CFZ) has activity superior to bortezomib (BTZ) and is increasingly incorporated in multiple myeloma (MM) frontline therapy and relapsed settings. Most MM patients ultimately experience PI-refractory disease, an unmet medical need with poorly understood biology and dismal outcome. Pharmacologic targeting of ABCB1 improved patient outcomes, including MM, but suffered from adverse drug effects and insufficient plasma concentrations. Proteomics analysis identified ABCB1 overexpression as the most significant change in CFZ-resistant MM cells. We addressed the functional role of ABCB1 overexpression in MM and observed significantly upregulated ABCB1 in peripheral blood malignant plasma cells (PCs) vs untreated patients' bone marrow PC. ABCB1 overexpression reduces the proteasome-inhibiting activity of CFZ due to drug efflux, in contrast to BTZ. Likewise, the cytotoxicity of established anti-MM drugs was significantly reduced in ABCB1-expressing MM cells. In search for potential drugs targeting ABCB1 in clinical trials, we identified the HIV protease inhibitors nelfinavir (NFV) and lopinavir (LPV) as potent functional modulators of ABCB1-mediated drug export, most likely via modulation of mitochondria permeability transition pore. NFV and LPV restored CFZ activity at therapeutically relevant drug levels and thus represent ready-to-use drugs to be tested in clinical trials to target ABCB1 and to re-sensitize PC to established myeloma drugs, in particular CFZ.

[Quality indicators for rescue operations in terrorist attacks or other threats : A pilot study after the Würzburg terrorist attack of July 2016]

BACKGROUND

Terrorist attacks have become reality in Germany. The aim of this work was, after the Würzburg terrorist attack, to define quality indicators and application characteristics for rescue missions in life-threatening situations. The results can be used to record data from future missions using this template in order to make them comparable with each other.

METHODS

After approval of the local ethic committee, the first step was to designate a group of experts in order to define the template in a consensus process. The next step was to perform the consensus process by defining the template. An independent expert for emergency medicine and disaster management reviewed and approved the results afterwards.

RESULTS

The expert group defined 13 categories and 158 parameters that will further serve the systematic evaluation of the rescue mission of the Würzburg terror attack. Preliminary results of this evaluation process are given in this paper; the full evaluation has not yet been completed.

DISCUSSION

In this study we first describe quality indicators and parameters suitable for the German rescue system in order to evaluate rescue operations for violence caused mass casualties. There is similar international documentation, but it does not specifically focus on life-threatening operations and are not adapted to the German context.

CONCLUSION

There is an important need to systematically evaluate rescue missions after mass killing incidents. In this study we report a template of parameters and quality indicators in order to systematically evaluate mass violence events. The presented template is the result of an expert consensus process and may serve as a basis for further development and research.

Feasibility of laser-guided percutaneous pedicle screw placement in the lumbar spine using a hybrid-OR

PURPOSE

Innovations in intraoperative imaging lead to major changes in orthopaedic surgery. In our setting, a 3D flat-panel c-arm (Artis zeego) is mounted on a robotic arm offering an integrated aiming tool (Syngo iGuide). Our aim was to investigate the feasibility of Syngo iGuide for pedicle screw placement in comparison with fluoroscopic screw implantation.

METHODS

In 10 lumbar models, 100 screws were implanted. In 5 models, a standard fluoroscopic technique was used. Syngo iGuide was used in all other models. Afterwards, CT-scans were performed and screw accuracy was investigated.

RESULTS

The procedure time for the new technique was significantly longer in comparison with the standard technique. The post-operative CT showed the same accuracy in both groups.

CONCLUSIONS

Syngo iGuide proofed feasible for percutaneous implantation of pedicle screws in anatomic models. Syngo iGuide can be a help for screw implantation in difficult anatomic regions without the need of an additional navigation system.

Synthesis of the rare disaccharide nigerose by structure-based design of a phosphorylase mutant with altered regioselectivity

In the absence of the natural acceptor inorganic phosphate wild-type sucrose phosphorylase from Bifidobacterium adolescentis (BaSP) produces maltose (4-O-α-d-glucopyranosyl-d-glucose) and kojibiose (2-O-α-d-glucopyranosyl-d-glucose) as sole transfer products. A Q345F exchange switches the enzyme's regioselectivity from 2 to 3 exclusively, yielding the rare sugar nigerose (3-O-α-d-glucopyranosyl-d-glucose, sakebiose).

Nanostructured Stealth Surfaces for Visible and Near-Infrared Light

So far, all previous attempts to apply nanostructures for perfect transmission have not achieved maximum transmittance beyond 99.5% due to the limited regularity of the nanoscale surface geometry: too low for many high-end applications. Here we demonstrate a nanostructured stealth surface, with minimal reflectance (<0.02%) and maximal transmittance (>99.8%) for a wavelength range, covering visible and near-infrared. Compared to multilayer thin film coatings for near-infrared applications our antireflective surfaces operate within a much broader wavelength range, are mechanical stable to resist human touch or contamination, show a 44% higher laser-induced damage threshold, and are suitable for bended interfaces such as microlenses as well.

H.E.S.S. Limits on Linelike Dark Matter Signatures in the 100 GeV to 2 TeV Energy Range Close to the Galactic Center

A search for dark matter linelike signals iss performed in the vicinity of the Galactic Center by the H.E.S.S. experiment on observational data taken in 2014. An unbinned likelihood analysis iss developed to improve the sensitivity to linelike signals. The upgraded analysis along with newer data extend the energy coverage of the previous measurement down to 100 GeV. The 18 h of data collected with the H.E.S.S. array allow one to rule out at 95% C.L. the presence of a 130 GeV line (at l=-1.5°, b=0° and for a dark matter profile centered at this location) previously reported in Fermi-LAT data. This new analysis overlaps significantly in energy with previous Fermi-LAT and H.E.S.S.

RESULTS

No significant excess associated with dark matter annihilations was found in the energy range of 100 GeV to 2 TeV and upper limits on the gamma-ray flux and the velocity weighted annihilation cross section are derived adopting an Einasto dark matter halo profile. Expected limits for present and future large statistics H.E.S.S. observations are also given.

Search for Dark Matter Annihilations towards the Inner Galactic Halo from 10 Years of Observations with H.E.S.S

The inner region of the Milky Way halo harbors a large amount of dark matter (DM). Given its proximity, it is one of the most promising targets to look for DM. We report on a search for the annihilations of DM particles using γ-ray observations towards the inner 300 pc of the Milky Way, with the H.E.S.S. array of ground-based Cherenkov telescopes. The analysis is based on a 2D maximum likelihood method using Galactic Center (GC) data accumulated by H.E.S.S. over the last 10 years (2004-2014), and does not show any significant γ-ray signal above background. Assuming Einasto and Navarro-Frenk-White DM density profiles at the GC, we derive upper limits on the annihilation cross section ⟨σv⟩. These constraints are the strongest obtained so far in the TeV DM mass range and improve upon previous limits by a factor 5. For the Einasto profile, the constraints reach ⟨σv⟩ values of 6×10^{-26}  cm^{3} s^{-1} in the W^{+}W^{-} channel for a DM particle mass of 1.5 TeV, and 2×10^{-26}  cm^{3} s^{-1} in the τ^{+}τ^{-} channel for a 1 TeV mass. For the first time, ground-based γ-ray observations have reached sufficient sensitivity to probe ⟨σv⟩ values expected from the thermal relic density for TeV DM particles.

Abstract 1243: Inside of multiple mechanism of adaption towards the proteasome inhibitors in multiple myeloma

Malignant plasma cells drive massive overproduction of monoclonal immunoglobulin in multiple myeloma (MM). Hence MM cells critically rely on a proper balance between protein biosynthesis and folding, and degradation of unfolded/ misfolded protein orchestrated by the unfolded protein response (UPR). Inhibitors of the proteasome, the terminal protease along the UPR pathway, are highly effective against MM. Adaptive resistance to current proteasome inhibitors (PI) (Bortezomib-Btz, Carfilzomib-Cfz) is a major cause of treatment failure. Btz is a peptide boronate-type reversible inhibitor, whereas Cfz is of epoxyketone-type and binds irreversibly to the same proteasomal B5 active site target. Next generation PI are likewise B5-directed and either of the peptide boronate (ixazomib, dalanzomib), or the epoxyketone type (oprozomib). PI resistance is currently understood via two alternative concepts, the load/capacity concept characterized by proteasome upregulation in conjunction with downregulation of the UPR via reduced IRE/XBP-1 signaling, and the mutation concept basing on B5 active site mutations that prevent PI binding. Only IRE1/XBP1 downregulation have been confirmed in patient-derived material. We generated an in vitro model where AMO-1 myeloma cells (IC50: 3.1nM for Btz, 4.9nM Cfz) were adapted to Btz (AMOaBtz; IC50: 298.7nM Btz, 43.2nM Cfz) or to Cfz, (AMOaCfz; IC50: 27.9nM Btz, 411.5nM Cfz). AMOaBtz cells showed preferential resistance against ixazomib and dalanzomib, while AMOaCfz cells were preferentially resistant to oprozomib and other epoxyketone-type experimental inhibitors. AMOaBtz and AMOaCfz likewise downregulated IRE/XBP-1, but only AMOaBtz contained an acquired proteasome mutation (A310G in PSMB5), however this had only a modest influence on Btz binding and proteasome inhibition. Global gene expression analysis revealed 1430 differentially expressed genes in AMOaBtz/ AMOaCfz (FC&gt;2, p&lt;0.05). Analysis of uniquely upregulated genes in AMOaCfz identified the multi-drug resistance gene ABCB1 (MDR1) that was found 120-fold upregulated by qPCR. Inhibition of ABCB1 with Verapamil or Reserpin strongly increased Cfz sensitivity, confirming functional significance. Genes responsible for immunoglobulin production were selectively downregulated in AMOaBtz, and paraprotein production (IgA) was abolished as measured by ELISA. In conclusion, AMOaCfz is the first model combining the key features found in PI-resistant patient cells (lack of PSMB5 mutation and low IRE1/XBP1 activity). The comparison of AMOaCfz and AMOaBtz suggests the presence of class-preferential adaptation mechanisms, which may be overcome by using alternative type proteasome inhibitors or mMDR1 inhibitors.

Citation Format: Andrej Besse, Lenka Besse, Marianne Kraus, Jurgen Bader, Mario Novkovic, Fedor Kryukov, Pavel Nemec, Tobias Silzle, Christoph Driessen. Inside of multiple mechanism of adaption towards the proteasome inhibitors in multiple myeloma. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr 1243.

The relationship between negative symptom subdomains and cognition

BACKGROUND

Negative symptoms and cognitive deficits in schizophrenia are partially overlapping. However, the nature of the relationship between negative symptoms and cognition remains equivocal. Recent reviews have demonstrated the presence of two negative symptom subdomains, diminished emotional expression (DEE) and avolition. In view of this, we sought to clarify the relationship between negative symptoms and cognitive domains.

METHOD

A total of 687 participants with schizophrenia were assessed on measures of psychopathology and cognition. Three cognitive factors, namely executive function, fluency/memory and speed/vigilance were computed from the cognitive tests. Confirmatory factor analysis was utilized to examine if a one-factor or two-factor negative model was applicable to our sample. Subsequently, the relationships between negative symptoms and cognition were examined using structural equation modeling.

RESULTS

Results demonstrated that the two-factor model fitted the data well. While negative symptoms were mildly to moderately associated with cognition, we found that DEE had unique associations with cognition compared to social avolition, contributing to the validity of the constructs and suggesting the possibility of common underlying substrates in negative symptoms and cognition.

CONCLUSIONS

Our study highlighted the need to classify DEE and social avolition separately as both are necessary in refining the complex relationship between negative symptoms and cognition as well as potentially guiding treatment and management of schizophrenia.

Top Quark Pair Production in Association with a Jet with Next-to-Leading-Order QCD Off-Shell Effects at the Large Hadron Collider

We present a complete description of top quark pair production in association with a jet in the dilepton channel. Our calculation is accurate to next-to-leading order (NLO) in QCD and includes all nonresonant diagrams, interferences, and off-shell effects of the top quark. Moreover, nonresonant and off-shell effects due to the finite W gauge boson width are taken into account. This calculation constitutes the first fully realistic NLO computation for top quark pair production with a final state jet in hadronic collisions. Numerical results for differential distributions as well as total cross sections are presented for the Large Hadron Collider at 8 TeV. With our inclusive cuts, NLO predictions reduce the unphysical scale dependence by more than a factor of 3 and lower the total rate by about 13% compared to leading-order QCD predictions. In addition, the size of the top quark off-shell effects is estimated to be below 2%.

Treatment with the HIV protease inhibitor nelfinavir triggers the unfolded protein response and may overcome proteasome inhibitor resistance of multiple myeloma in combination with bortezomib: a phase I trial (SAKK 65/08)

Downregulation of the unfolded protein response mediates proteasome inhibitor resistance in multiple myeloma. The Human Immunodeficieny Virus protease inhibitor nelfinavir activates the unfolded protein response in vitro. We determined dose-limiting toxicity and recommended dose for phase II of nelfinavir in combination with the proteasome inhibitor bortezomib. Twelve patients with advanced hematologic malignancies were treated with nelfinavir (2500-5000 mg/day p.o., days 1-14, 3+3 dose escalation) and bortezomib (1.3 mg/m(2), days 1, 4, 8, 11; 21-day cycles). A run in phase with nelfinavir monotherapy allowed pharmakokinetic/pharmakodynamic assessment of nelfinavir in the presence or absence of concomittant bortezomib. End points included dose-limiting toxicity, activation of the unfolded protein response, proteasome activity, toxicity and response to trial treatment. Nelfinavir 2×2500 mg was the recommended phase II dose identified. Nelfinavir alone significantly up-regulated expression of proteins related to the unfolded protein response in peripheral blood mononuclear cells and inhibited proteasome activity. Of 10 evaluable patients in the dose escalation cohort, 3 achieved a partial response, 4 stable disease for 2 cycles or more, while 3 had progressive disease as best response. In an exploratory extension cohort with 6 relapsed, bortezomib-refractory, lenalidomide-resistant myeloma patients treated at the recommended phase II dose, 3 reached a partial response, 2 a minor response, and one progressive disease. The combination of nelfinavir with bortezomib is safe and shows promising activity in advanced, bortezomib-refractory multiple myeloma. Induction of the unfolded protein response by nelfinavir may overcome the biological features of proteasome inhibitor resistance. (clinicaltrials.gov identifier: 01164709).

A Set of Activity-Based Probes to Visualize Human (Immuno)proteasome Activities

Proteasomes are therapeutic targets for various cancers and autoimmune diseases. Constitutively expressed proteasomes have three active sites, β1c, β2c, and β5c. Lymphoid tissues also express the immunoproteasome subunits β1i, β2i, and β5i. Rapid and simultaneous measurement of the activity of these catalytic subunits would assist in the discovery of new inhibitors, improve analysis of proteasome inhibitors in clinical trials, and simplify analysis of subunit expression. In this work, we present a cocktail of activity-based probes that enables simultaneous gel-based detection of all six catalytic human proteasome subunits. We used this cocktail to develop specific inhibitors for β1c, β2c, β5c, and β2i, to compare the active-site specificity of clinical proteasome inhibitors, and to demonstrate that many hematologic malignancies predominantly express immunoproteasomes. Furthermore, we show that selective and complete inhibition of β5i and β1i is cytotoxic to primary cells from acute lymphocytic leukemia (ALL) patients.

The novel β2-selective proteasome inhibitor LU-102 synergizes with bortezomib and carfilzomib to overcome proteasome inhibitor resistance of myeloma cells

Proteasome inhibitor resistance is a challenge for myeloma therapy. Bortezomib targets the β5 and β1 activity, but not the β2 activity of the proteasome. Bortezomib-resistant myeloma cells down-regulate the activation status of the unfolded protein response, and up-regulate β2 proteasome activity. To improve proteasome inhibition in bortezomib-resistant myeloma and to achieve more efficient UPR activation, we have developed LU-102, a selective inhibitor of the β2 proteasome activity. LU-102 inhibited the β2 activity in intact myeloma cells at low micromolar concentrations without relevant co-inhibition of β1 and β5 proteasome subunits. In proteasome inhibitor-resistant myeloma cells, significantly more potent proteasome inhibition was achieved by bortezomib or carfilzomib in combination with LU-102, compared to bortezomib/carfilzomib alone, resulting in highly synergistic cytotoxic activity of the drug combination via endoplasmatic reticulum stress-induced apoptosis. Combining bortezomib/carfilzomib with LU-102 significantly prolonged proteasome inhibition and increased activation of the unfolded protein response and IRE1-a activity. IRE1-α has recently been shown to control myeloma cell differentiation and bortezomib sensitivity (Leung-Hagesteijn, Cancer Cell 24:3, 289-304). Thus, β2-selective proteasome inhibition by LU-102 in combination with bortezomib or carfilzomib results in synergistic proteasome inhibition, activation of the unfolded protein response, and cytotoxicity, and overcomes bortezomib/carfilzomib resistance in myeloma cells in vitro.

[Weightings and sequences in magnetic resonance imaging in orthopedic surgery]

Magnetic resonance imaging (MRI) plays a very important role in the diagnosis of musculoskeletal conditions; its importance in orthopedic trauma continues to grow. To ensure optimal imaging and to be able to answer all clinically relevant questions, some prerequisites must be taken into account. Of uttermost importance is a functioning communication between surgeons and radiologists. To adapt the best sequences, the radiologist needs to know all suspected injuries and the mechanism of trauma. Second, the surgeon must have basic knowledge regarding this technology to optimally use all its possibilities. The aim of this article is to familiarize the reader with basic MRI in traumatology focusing on weightings and sequences.

Refining the latent structure of neuropsychological performance in schizophrenia

BACKGROUND

Elucidating the cognitive architecture of schizophrenia promises to advance understanding of the clinical and biological substrates of the illness. Traditional cross-sectional neuropsychological approaches differentiate impaired from normal cognitive abilities but are limited in their ability to determine latent substructure. The current study examined the latent architecture of abnormal cognition in schizophrenia via a systematic approach.

METHOD

Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were carried out on a large neuropsychological dataset including the Brief Assessment of Cognition in Schizophrenia, Continuous Performance Test, Wisconsin Card Sorting Test, Benton Judgment of Line Orientation Test, and Wechsler Abbreviated Scale of Intelligence matrix reasoning derived from 1012 English-speaking ethnic Chinese healthy controls and 707 schizophrenia cases recruited from in- and out-patient clinics.

RESULTS

An initial six-factor model fit cognitive data in healthy and schizophrenia subjects. Further modeling, which accounted for methodological variance between tests, resulted in a three-factor model of executive functioning, vigilance/speed of processing and memory that appeared to best discriminate schizophrenia cases from controls. Factor analytic-derived g estimands and conventionally calculated g showed similar case-control discrimination. However, agreement analysis suggested systematic differences between both g indices.

CONCLUSIONS

Factor structures derived in the current study were broadly similar to those reported previously. However, factor structures between schizophrenia subjects and healthy controls were different. Roles of factor analytic-derived g estimands and conventional composite score g were further discussed. Cognitive structures underlying cognitive deficits in schizophrenia may prove useful for interrogating biological substrates and enriching effect sizes for subsequent work.

[The utilization of MRI by orthopaedic surgeons: requirements and limitations]

BACKGROUND

The tendency in surgical fields to subspecialize continues. Diagnostic possibilities and surgical indications are becoming more and more sophisticated. As a consequence, surgeons in Germany have the possibility to acquire qualifications in magnetic resonance imaging (MRI) and are allowed to employ MRI scanners without consulting radiologists.

AIMS

This article aims to describe the requirements to achieve this special qualification and to give a summary on the legal issues in this matter.