[Report template from the German Society of Urology and the German Radiological Society for standardized, structured reporting of native computed tomography scans in the diagnosis of urinary stones]

Standardized structured radiological reporting (SSRB) has been promoted in recent years. The aims of SSRB include that reports be complete, clear, understandable, and stringent. Repetitions or superfluous content should be avoided. In addition, there are advantages in the presentation of chronological sequences, tracking and correlations with structured findings from other disciplines and also the use of artificial intelligence (AI)-based methods. The development of the presented template for SSRB of native computed tomography for urinary stones followed the "process for the creation of quality-assured and consensus-based report templates as well as subsequent continuous quality control and updating" proposed by the German Radiological Society (DRG). This includes several stages of drafts, consensus meetings and further developments. The final version was published on the DRG website ( www.befundung.drg.de ). The template will be checked annually by the steering group and adjusted as necessary. The template contains 6 organ domains (e.g., right kidney) for which entries can be made for a total of 21 different items, mostly with selection windows. If "no evidence of stones" is selected for an organ in the first query, the query automatically jumps to the next organ, so that the processing can be processed very quickly despite the potentially high total number of individual queries for all organs. The German, European, and North American Radiological Societies perceive the establishment of a standardized structured diagnosis of tomographic imaging methods not only in oncological radiology as one of the current central tasks. With the present template for the description of computed tomographic findings for urinary stone diagnostics, we are presenting the first version of a urological template. Further templates for urological diseases are to follow.

Impact of primary resistance to front-line targeted therapy in metastatic renal cell carcinoma on subsequent immune-checkpoint-inhibition

INTRODUCTION

Synergistic effects have been discussed for tyrosine kinase (TKI) and immune checkpoint inhibitors (ICI). Primary resistance to TKI might disturb subsequent ICI effectiveness. The objective was to investigate, if primary resistance to 1st line TKI monotherapy predicts response to ICI in subsequent therapy lines and impacts overall survival (OS) in advanced renal cell carcinoma (aRCC).

MATERIALS AND METHODS

Retrospectively, aRCC patients which received front-line TKI from 2016 to 2019 were analyzed for the outcomes primary resistance (1LR), response to sequential ICI therapy, progression free survival (PFS) and overall survival (OS). Kaplan-Meier-estimates, Cox proportional hazards and logistic regression were used.

RESULTS

Primary resistance to front-line TKI was observed in 27 (53%) of 51 patients. Groups with disease control (DC) and 1st line TKI resistance (1LR) were not different at baseline with regard to clinicopathological features. Median duration on 1st line therapy was significantly shorter in the 1LR (5.1 months) than in the DC (14.7 months) group (p = 0.01). Sequential therapy was started in 21 (75%) and 12 (52%) patients of 1LR and DC groups using nivolumab in 16 (76%) vs. 11 (92%) cases (p > 0.05). Logistic regression revealed that 1LR status, neutrophil-to-lymphocyte ratio < 3, IMDC favorable prognosis and clear cell histology had no significant impact on responsiveness to ICI in subsequent therapy lines. Cox proportional hazards demonstrated no significant association of 1LR status with PFS and OS in patients who received subsequent ICI treatment.

CONCLUSION

Primary TKI resistance of aRCC was neither significantly associated with responsiveness to ICI during sequential therapy nor with PFS and OS. This adds the evidence for ICI based sequential therapy in primary TKI resistant aRCC.

First Comparison of Retroperitoneal Versus Transperitoneal Robot-Assisted Nephroureterectomy with Bladder Cuff: A Single Center Study

INTRODUCTION

After recent presentation of the first complete robot-assisted retroperitoneal nephroureterectomy with bladder cuff (RRNU) for patients with upper tract urothelial cancer (UTUC), we aimed to compare this new surgical technique with robot-assisted transperitoneal nephroureterectomy (TRNU) representing the current standard of care.

METHODS

Robot-assisted nephroureterectomies (NUs) were retrospectively analyzed and compared based on two groups: transperitoneal versus retroperitoneal approach. Baseline data were collected for patient demographics, tumor characteristics, intra- (EAUiaiC) and postoperative (Clavien-Dindo) complications, and perioperative variables. Tumor characteristics included grade of malignancy, clinical stage, and surgical margin status. Short-term follow-up data including 30-day readmission rates were collected. Statistical analyses were performed assuming a significant p-value of < 0.05.

RESULTS

The analysis includes perioperative patient data after proven UTUC of 24 TRNU versus 12 RRNU (mean age: 70 versus 71 years; BMI: 25.9 versus 26.1 kg/m²; CCI score ≥ 4: 83% versus 75%; ASA score ≥ 3: 37% vs 33%). Intraoperative (16.4% vs 0%, p = 0.35) and postoperative (25% vs 12.5%, p = 0.64) complications demonstrated no significant discrepancy. Notably, RRNU demonstrated significantly shorter surgery time (p < 0.05) and length of stay (p < 0.05). There was no significant difference in histopathological tumor characteristics, whereas significantly more lymph nodes were removed through RRNU (11.0±3.3 vs. 6.4±5.1, p < 0.05). Finally, no statistical difference was shown in short-term follow-up.

CONCLUSION

We report the first head-to-head comparison between RRNU and TRNU. RRNU proves to be a safe and feasible approach which appears to be non-inferior to TRNU. RRNU expands the spectrum of minimally invasive treatment options, particularly for patients with major previous abdominal surgery.

Assessment of a novel smartglass-based point-of-care fusion approach for mixed reality-assisted targeted prostate biopsy: A pilot proof-of-concept study

Purpose

While several biopsy techniques and platforms for magnetic resonance imaging (MRI)-guided targeted biopsy of the prostate have been established, none of them has proven definite superiority. Augmented and virtual reality (mixed reality) smartglasses have emerged as an innovative technology to support image-guidance and optimize accuracy during medical interventions. We aimed to investigate the benefits of smartglasses for MRI-guided mixed reality-assisted cognitive targeted biopsy of the prostate.

Methods

For prospectively collected patients with suspect prostate PIRADS lesions, multiparametric MRI was uploaded to a smartglass (Microsoft® Hololens I), and smartglass-assisted targeted biopsy (SMART TB) of the prostate was executed by generation of a cognitive fusion technology at the point-of-care. Detection rates of prostate cancer (PCA) were compared between SMART TB and 12-core systematic biopsy. Assessment of SMART-TB was executed by the two performing surgeons based on 10 domains on a 10-point scale ranging from bad (1) to excellent (10).

Results

SMART TB and systematic biopsy of the prostate were performed for 10 patients with a total of 17 suspect PIRADS lesions (PIRADS 3, n = 6; PIRADS 4, n = 6; PIRADS 5, n = 5). PCA detection rate per core was significant (p < 0.05) higher for SMART TB (47%) than for systematic biopsy (19%). Likelihood for PCA according to each core of a PIRADS lesion (17%, PIRADS 3; 58%, PIRADS 4; 67%, PIRADS 5) demonstrated convenient accuracy. Feasibility scores for SMART TB were high for practicality (10), multitasking (10), execution speed (9), comfort (8), improvement of surgery (8) and image quality (8), medium for physical stress (6) and device handling (6) and low for device weight (5) and battery autonomy (4).

Conclusion

SMART TB has the potential to increase accuracy for PCA detection and might enhance cognitive MRI-guided targeted prostate biopsy in the future.

First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique

Introduction

While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach.

Methods

Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.

Results

The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m²; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9–6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100–250). No patient experienced postoperative complications exceeding Clavien–Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission.

Conclusion

We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00345-021-03920-1.

The IL23-IL17 Immune Axis in the Treatment of Ulcerative Colitis: Successes, Defeats, and Ongoing Challenges

Ulcerative colitis (UC) is a chronic relapsing disorder of the colonic tract, characterized by a dysregulated innate and adaptive immune response to gut microbiota that contributes to the perpetuation of intestinal inflammatory processes. The Interleukin (IL) 23/IL17 axis has been reported to play a key role in UC pathogenesis promoting Th17 cells and cytokines-related immune response. Recently, the blockade of IL23/IL17 pathways has been raised enormous interest in the treatment o several chronic inflammatory disorders. In this review, we summarize the emerging results from clinical trials that evoked both promise and discouragement in IL23/IL17 axis in the treatment of UC. Targeting IL23 p40 through Ustekinumab results safe and effective to induce and maintain clinical remission, low inflammatory indexes, mucosal healing, and a better quality of life. Studies targeting IL23 p19 through Mirikizumab, Risankizumab, Brazikumab and Guselkumab are still ongoing. To date, no clinical studies targeting IL17 pathway are ongoing in UC. IL-17 targeting is thought to have a context-dependent biological effect, based on whether cytokine is selectively targeted or if its function is dampened by the upstream block of IL23.

Fibrotic Strictures in Crohn's Disease: Mechanisms and Predictive Factors

Fibrotic strictures are one of the most severe complications of Crohn's Disease (CD). They occur in about 50% of patients at five years and in 70% at ten years of the diagnosis. The only treatment available for symptomatic fibrotic strictures is surgical resection and endoscopic dilation. Both strategies are associated with a high rate of recurrence, and with multiple surgical resections, which pose the threat of surgical morbidity and short bowel syndrome. Therefore, it is crucial to identify, early, the patients more prone to develop intestinal fibrosis to intensify follow-ups, switch to more aggressive treatments, and suggest lifestyle modifications. Scarce data are available concerning biomarkers and genetic determinants to predict which patient will develop intestinal fibrosis. Biologic or clinical markers would be useful to determine this subgroup of CD patients and to predict the onset of intestinal fibrosis and, ideally, its severity. Furthermore, the identification of environmental risk factors may suggest lifestyle changes aimed at modifying the natural course, thus decreasing the risk of complicated CD. In this review, we will critically revise clinical, environmental, genetic, and serologic factors that have been associated with a complicated CD course with a particular focus on the fibrostenosing phenotype and their possible implications as predictive factors of intestinal fibrosis.

Streptococci and the complement system: interplay during infection, inflammation and autoimmunity

Streptococci are a broad group of Gram-positive bacteria. This genus includes various human pathogens causing significant morbidity and mortality. Two of the most important human pathogens are Streptococcus pneumoniae (pneumococcus) and Streptococcus pyogenes (group A streptococcus or GAS). Streptococcal pathogens have evolved to express virulence factors that enable them to evade complement-mediated attack. These include factor H-binding M (S. pyogenes) and pneumococcal surface protein C (PspC) (S. pneumoniae) proteins. In addition, S. pyogenes and S. pneumoniae express cytolysins (streptolysin and pneumolysin), which are able to destroy host cells. Sometimes, the interplay between streptococci, the complement, and antistreptococcal immunity may lead to an excessive inflammatory response or autoimmune disease. Understanding the fundamental role of the complement system in microbial clearance and the bacterial escape mechanisms is of paramount importance for understanding microbial virulence, in general, and, the conversion of commensals to pathogens, more specifically. Such insights may help to identify novel antibiotic and vaccine targets in bacterial pathogens to counter their growing resistance to commonly used antibiotics.

Immunostimulants in respiratory diseases: focus on Pidotimod

Usefulness of Pidotimod and its role as immunostimulant, has been discussed, we know, for several decades. Nevertheless, there is still much to know. Understanding its mechanisms and its potential usefulness in airway infections and its prevention, asthma both Th2 and non Th2 type, bronchiectasis, as adjuvant in vaccination and in allergen immunotherapy still remains to clearly unveil. The aim of this paper was to provide a useful updated review of the role of the main available immunostimulants, giving particular focus on Pidotimod use and its potentials utility in respiratory diseases. Pidotimod showed its usefulness in reducing need for antibiotics in airway infections, increasing the level of immunoglobulins (IgA, IgM, IgG) and T-lymphocyte subsets (CD3+, CD4+) endowed with immunomodulatory activity that affect both innate and adaptive immune responses. Higher expression of TLR2 and of HLA-DR molecules, induction of dendritic cell maturation and release of pro-inflammatory molecules, stimulation of T lymphocyte proliferation and differentiation toward a Th1 phenotype, as well as an increase of the phagocytosis have been demonstrated to be associated with Pidotimod in in vitro studies. All these activities are potentially useful for several respiratory conditions such as asthma, COPD, and recurrent respiratory tract infections.

Immunostimulants in respiratory diseases: focus on Pidotimod

Usefulness of Pidotimod and its role as immunostimulant, has been discussed, we know, for several decades. Nevertheless, there is still much to know. Understanding its mechanisms and its potential usefulness in airway infections and its prevention, asthma both Th2 and non Th2 type, bronchiectasis, as adjuvant in vaccination and in allergen immunotherapy still remains to clearly unveil. The aim of this paper was to provide a useful updated review of the role of the main available immunostimulants, giving particular focus on Pidotimod use and its potentials utility in respiratory diseases. Pidotimod showed its usefulness in reducing need for antibiotics in airway infections, increasing the level of immunoglobulins (IgA, IgM, IgG) and T-lymphocyte subsets (CD3+, CD4+) endowed with immunomodulatory activity that affect both innate and adaptive immune responses. Higher expression of TLR2 and of HLA-DR molecules, induction of dendritic cell maturation and release of pro-inflammatory molecules, stimulation of T lymphocyte proliferation and differentiation toward a Th1 phenotype, as well as an increase of the phagocytosis have been demonstrated to be associated with Pidotimod in in vitro studies. All these activities are potentially useful for several respiratory conditions such as asthma, COPD, and recurrent respiratory tract infections.

[Standard surgery for small renal masses (<4 cm)]

BACKGROUND

Several new treatment strategies have emerged in the treatment of small renal masses (<4 cm in diameter). Active surveillance and ablative techniques have been introduced but it remains unclear which patients will benefit the most from these new treatment options. A surgical approach remains standard of care. In recent decades, radical nephrectomy has been replaced by nephron-sparing surgery for the management of small renal masses.

RESULTS

In addition to the open partial nephrectomy, which is considered the standard approach, the number of surgeries performed using minimally invasive techniques is increasing. Recent data show that there might be some benefits such as less blood loss. The disadvantages shown by laparoscopic partial nephrectomy such as prolonged warm ischemia, longer operation times, and postoperative renal impairment might be negligible for the robotic approach. Therefore, current guidelines allow these approaches in addition to open partial nephrectomy if sufficient surgical expertise is given.

OECI TuBaFrost Tumor Biobanking

OECI TuBaFrost harbors a complete infrastructure for the exchange of frozen tumor samples between European countries. OECI TuBaFrost consists of: • A code of conduct on how to exchange human residual samples in Europe • A central database application accessible over the Internet ( www.tubafrost.org ) where data can be uploaded and searched from samples that can be selected and ordered • Access rules with incentives for collectors • Standardization needed to enable the analysis of high quality samples derived from different centers • Virtual Microscopy to support sample selection with difficult pathology

The entire infrastructure was, after completion, which was entirely financed by the European Commission, implemented in the OECI. But so far it has not been used to its capacity. A recent survey held amongst the OECI members shed light on the causes. The main conclusion is that all responders see OECI TuBaFrost as a good platform for exchange of samples, however, the biggest bottleneck found was that potential users are too unfamiliar with the communication between their own biobank tracking system and the TuBaFrost central database application. Therefore, new future plans are drawn. In addition, new infrastructure plans have been developed and the first preparatory steps have been set. For biobanks the BBMRI project has started aiming for Pan-European Biobanking and Biomolecular Resources Research Infrastructure.

OLEOGEL-S10 TO ACCELERATE HEALING OF DONOR SITES: MONOCENTRIC RESULTS OF PHASE III CLINICAL TRIAL

MATERIAL AND METHODS

Oleogel-S10, an ointment containing betulin-rich triterpene dry extract from birch bark was tested in an open, blindly evaluated, prospective, controlled, randomized multicentre study to improve wound healing in donor sites. The primary endpoint was time to wound closure, and secondary endpoints were scar related measurements at the time of wound closure, and 3 and 12 months after wound closure (POSAS, laser speckle contrast analysis, viscoelastic analysis).

RESULTS

We report the results from a single centre (Department of Burns and Reconstructive Surgery, University Hospital Brno) of this phase III clinical trial. A total of 32 patients (25 men and 7 women) were included with the mean patient age of 41.8 years (SD, ±11.66). The mean extent of patients donor sites in the study was 56.77cm2 (SD, ±20.39). Median healing time of the verum group (Oleogel-S10) was 7 days (95% Confidence Interval 7-8 days) and for controls 8 days (95% CI 7-10 days). Comparison of POSAS data from the verum group revealed significantly lower values at all three time points as compared to the controls. Perfusion of scars of the verum group reached on average of 115 perfusion units at the end of treatment; the average was 69.8 perfusion units at the 3-month follow-up and 50.2 perfusion units at the 12-month follow-up. Control sites displayed significantly higher values at all time points (122.2 perfusion units, 73.9 perfusion units, 52.2 perfusion units). Significant differences were detected in the skins viscoelastic properties, with sites treated with Oleogel-S10 displaying more favourable values.

CONCLUSION

In our results, we demonstrate the significant effectiveness of Oleogel-S10 in donor sites healingKeywords: Donor site, Triterpenes, Oleogel-S10, wound closure.

From novice to expert: analyzing the learning curve for MRI-transrectal ultrasonography fusion-guided transrectal prostate biopsy

PURPOSE

To investigate the learning curve of a novice in MRI/TRUS software fusion biopsy and to compare his results with the expert standard at our institution.

METHODS

Overall 126 MRI/TRUS fusion-guided transrectal biopsies were performed using an electromagnetic tracking ultrasonography platform. The learning progress of the novice was evaluated comparing his initial 42 procedures (group A) with his following 42 (group B). The institution's expert standard (group C), which was compared to the novice's groups, was defined by the expert's experience of 42 MRI/TRUS fusion biopsies. Primary learning curve parameters were targeted biopsy detection quotient and biopsy time.

RESULTS

Overall detection of prostate cancer was 64% (27/42), 62% (26/42) and 62% (26/42) in groups A, B and C, respectively. The median target biopsy detection quotient significantly increased (p = 0.04) in group B (0.75, interquartile range (IQR) 0.25-1.0) compared to group A. (0.33, IQR 0.2-0.5). Group C revealed a median detection quotient of 0.5 (IQR 0.25-0.76) that did not differ significantly from the novice's groups (p = 0.2). Median biopsy time was significantly higher in group A (45 min, IQR 33-50 min) compared to groups B (25 min, IQR 23-29 min) and C (24 min, IQR 16-46 min) (p < 0.01).

CONCLUSIONS

The present study revealed the individual learning curve of a novice in MRI/TRUS fusion biopsy and demonstrated significant learning progress regarding targeted biopsy detection quotient and biopsy time.

A liquid jet setup for x-ray scattering experiments on complex liquids at free-electron laser sources

In this paper we describe a setup for x-ray scattering experiments on complex fluids using a liquid jet. The setup supports Small and Wide Angle X-ray Scattering (SAXS/WAXS) geometries. The jet is formed by a gas-dynamic virtual nozzle (GDVN) allowing for diameters ranging between 1 μm and 20 μm at a jet length of several hundred μm. To control jet properties such as jet length, diameter, or flow rate, the instrument is equipped with several diagnostic tools. Three microscopes are installed to quantify jet dimensions and stability in situ. The setup has been used at several beamlines performing both SAXS and WAXS experiments. As a typical example we show an experiment on a colloidal dispersion in a liquid jet at the X-ray Correlation Spectroscopy instrument at the Linac Coherent Light Source free-electron laser.

[Therapy of overactive bladder (OAB)]

Overactive bladder (OAB) is a symptom complex which is present in approximately 17% of the European population. It is observed in the presence or absence of incontinence (wet or dry) and is associated with a high degree of psychological stress as well as high costs for the healthcare system. Myogenic, urothelial and neurogenic factors lead to frequently unknown changes of muscular, neural and connective tissue. For the definition, etiology and diagnostics of the disease the previous continuing medical education (CME) article "Diagnosis of overactive bladder (OAB)" should be consulted. In recent years some improvements have been made in OAB-related research, in terms of pathophysiological models and new pharmacological approaches with the development of new therapeutic agents. Besides classical substances, recently approved agents are increasingly being used for the therapy of OAB. Furthermore, non-pharmaceutical approaches and surgical techniques still play an important role in the therapy of OAB.

Use of Xe-Derma(®), a novel biological cover, in a female patient with toxic epidermal necrolysis

Toxic epidermal necrolysis is a rare condition involving the skin at the dermoepidermal junction, with possible inclusion of mucous membranes. The condition is associated with systemic toxicity and high mortality rates. Successful treatment requires optimization of local as well as systemic therapy. We report the case of a young woman who developed toxic epidermal necrolysis, possibly resulting from lamotrigine therapy. Local therapy included a combination of a biological cover and alginate together with a synthetic cover (Aquacel Ag®).

[Tract sealing techniques in percutaneous nephrolitholapaxy]

Since the introduction of the percutanous nephrolitholapaxy (PNL), the instruments as well as the technique have experienced a tremendous modification. The miniaturisation of the instruments has led to a decreased hospital stay, reduced analgetic use as well as an extension of the indication for PNL. A nephrostomy tube was normally inserted to prevent urinoma and to provoke renal haemostasis. In 1997, the necessity for the regular use of a nephrostomy tube was first questioned. In a prospective study, the nephrostomy tube was successfully omitted in 50 selected patients. Since then, increasingly, the nephrostomy tube is omitted. Alternatively, different haemostatic substances are used for renal tract closure. The necessity for the use of these agents is still unclear.

[Prevention of postprostatectomy incontinence: etiology and risk factors]

The prevention of postprostatectomy incontinence has always been a challenge for urologists. Improved understanding of male continence and changes in pelvic anatomy after radical prostatectomy and the implementation of new surgical techniques raised hope of reduced incontinence rates. Despite using the full potential of continence-sparing techniques and atraumatic robot-assisted surgery, postprostatectomy incontinence still occurs in 5-20 % of cases. Recently published data showed a trend of improved early return to continence using anterior suspension or posterior reconstruction in robot-assisted prostatectomy. Postprostatectomy incontinence has a negative impact on quality of life and causes high costs of treatment. Therefore, further research in the amelioration of postoperative continence is mandatory.

Unsuccessful therapy of combined mycotic infection in a severely burned patient: a case study

Patients with burn trauma are always in danger of contracting an infection. Although invasive mycotic infections are not as frequent as bacterial infections, high mortality and in many cases difficult diagnostics pose a serious threat not only for neutropenic patients. In more extensive burns the status is further complicated by specifically compromised immunity. The most frequent species of micromycetes isolated in burn patients are Candida spp. and Aspergillus spp. Zygomycetes represents a relatively uncommon isolation worldwide (up to 2% of all fungi. We present a case study of a young patient with 82% TBSA (total body surface area) burns, where we isolated simultaneously 3 different types of micromycetes (Aspergillus fumigatus, Fusarium sp., Absidia sp.). Mycotic infection is understood primarily as a complication in neutropenic patients and, after prophylactic antibiotic and antimycotic administration, in extensive burn trauma patients. The case ended with the death of the patient due to severe sepsis caused by the multiresistant strain Pseudomonas aeruginosa.

TuBaFrost: European virtual tumor tissue banking

TuBaFrost is a consortium responsible for the task to create a virtual European human frozen tumor tissue bank, composed of high quality frozen tumor tissue collections with corresponding accurate diagnosis stored in European cancer centers and universities, searchable on the Internet, providing rules for access and use and a code of conduct to comply with the various legal and ethical regulations in European countries. Such infrastructure would enlarge tissue availability and accessibility in large amounts of specified or even rare tumor samples. Design of an infrastructure for European residual tissue banking with the described characteristics, clear focus points emerge that can be broken down in dedicated subjects: (1) standardization and quality assurance (QA) to avoid inter-institute quality variation; (2) law and ethics enabling exchange of tissue samples possible between institutes in the different European countries, where law and ethics are characterized by a strong variability; (3) rules for access, with sufficient incentives for collectors; (4) central database application containing innovations on search and selection procedures; (5) support when needed with histology images; and (6) Internet access to search and upload, with in addition a solid website giving proper information on the procedures, intentions and activities not only to the scientific community, but also to the general public. One consortium decision, part of the incentives for collectors, had major impact on the infrastructure; custodianship over the tissues as well as the tissues stay with the collector institute. Resulting in specimens that are not given to an organization, taking decisions on participation of requests, but instead the local collected tissues stay very easy to access by the collector and allows autonomous negotiation between collector and requestor on cooperation, coauthorship in publication or compensation in costs. Thereby, improving availability of large amounts of high quality samples of a highly specified or rare tumor types and contact opportunities for cooperation with other institutes.

TuBaFrost 6: Virtual microscopy in virtual tumour banking

Many systems have already been designed and successfully used for sharing histology images over large distances, without transfer of the original glass slides. Rapid evolution was seen when digital images could be transferred over the Internet. Nowadays, sophisticated Virtual Microscope systems can be acquired, with the capability to quickly scan large batches of glass slides at high magnification and compress and store the large images on disc, which subsequently can be consulted through the Internet. The images are stored on an image server, which can give simple, easy to transfer pictures to the user specifying a certain magnification on any position in the scan. This offers new opportunities in histology review, overcoming the necessity of the dynamic telepathology systems to have compatible software systems and microscopes and in addition, an adequate connection of sufficient bandwidth. Consulting the images now only requires an Internet connection and a computer with a high quality monitor. A system of complete pathology review supporting bio-repositories is described, based on the implementation of this technique in the European Human Frozen Tumor Tissue Bank (TuBaFrost).

TuBaFrost 5: multifunctional central database application for a European tumor bank

Developing a tissue bank database has become more than just logically arranging data in tables combined with a search engine. Current demand for high quality samples and data, and the ever-changing legal and ethical regulations mean that the application must reflect TuBaFrost rules and protocols for the collection, exchange and use of tissue. To ensure continuation and extension of the TuBaFrost European tissue bank, the custodianship of the samples, and hence the decision over whether to issue samples to requestors, remains with the local collecting centre. The database application described in this article has been developed to facilitate this open structure virtual tissue bank model serving a large group. It encompasses many key tasks, without the requirement for personnel, hence minimising operational costs. The Internet-accessible database application enables search, selection and request submission for requestors, whereas collectors can upload and edit their collection. Communication between requestor and involved collectors is started with automatically generated e-mails.

TuBaFrost 1: Uniting local frozen tumour banks into a European network: an overview

TuBaFrost is the consortium responsible for the creation of a virtual European human frozen tumour tissue bank: a collection of high quality frozen residual, accurately classified tumour tissue samples, which are stored in European cancer centres and universities. This virtual tissue bank, searchable on the internet, has rules for access and use, and a code of conduct to comply with the various legal and ethical regulations in European countries. The easy accessibility and the European scale of the bank will result in the availability of a large number of samples even of rarer tumour types. Standardisation of collection, storage and quality control throughout the network is achieved minimising inter-institutional variability. A website providing access to upload, search and request samples is a key tool of the tissue bank. The search engine makes use of virtual microscopy. An overview of the development of the European virtual frozen tissue bank infrastructure is described in this paper. The various key aspects are described in more detail in a series of articles to appear in this Journal.

TuBaFrost 4: access rules and incentives for a European tumour bank

When designing infrastructure for a networked virtual tumour bank (samples remain at the collector institutes and sample data are collected in a searchable central database), it is apparent that this can only function properly after developing an adequate set of rules for use and access. These rules must include sufficient incentives for the tissue sample collectors to remain active within the network and maintain sufficient sample levels in the local bank. These requirements resulted in a key TuBaFrost rule, stating that the custodianship of the samples remains under the authority of the local collector. As a consequence, the samples and the decision to issue the samples to a requestor are not transferred to a large organisation but instead remain with the collector, thus allowing autonomous negotiation between collector and requestor, potential co-authorship in publications or compensation for collection and processing costs. Furthermore, it realises a streamlined cost effective network, ensuring tissue visibility and accessibility thereby improving the availability of large amounts of samples of highly specific or rare tumour types as well as providing contact opportunities for collaboration between scientists with cutting edge technology and tissue collectors. With this general purpose in mind, the rules and responsibilities for collectors, requestors and central office were generated.

TuBaFrost 2: Standardising tissue collection and quality control procedures for a European virtual frozen tissue bank network

Tumour Bank Networking presents a great challenge for oncological research as in order to carry out large-scale, multi-centre studies with minimal intrinsic bias, each tumour bank in the network must have some fundamental similarities and be using the same standardised and validated procedures. The European Human Frozen Tumour Tissue Bank (TuBaFrost) has responded to this need by the promotion of an integrated platform of tumour banks in Europe. The operational framework for TuBaFrost has drawn upon the best practice of standard workflows and operating procedures employed by members of the TuBaFrost project and key initiatives worldwide.

[How does the brain react to conflict and error?]

In der Informationsverarbeitung des menschlichen Gehirns besteht eine wesentliche adaptive Funktion darin, aktuelle Kognitionen und Geschehnisse zu erfassen und in der Folge das Verhalten so anzupassen, dass das Individuum möglichst zielgerichtet handeln kann und keinen Schaden erleidet. In den letzten Jahren konnten über verschiedene experimentelle Zugänge vorwiegend präfrontale Strukturen als Kandidaten für eine solche Supervisionstätigkeit identifiziert werden. Zum einen führen konflikthafte oder widersprüchliche Informationen zu einer Aktivierung dieser Strukturen, zum anderen wird eine Aktivierung bevorzugt dann gesehen, wenn eine Erwartung durch die eintretende Realität widerlegt wird (Irrtum). Diese Supervisionszentren üben neben der Detektion von Konflikt und Irrtum eine Kontrollfunktion aus. Dabei nehmen sie Einfluss auf laufende Kognitionen und leiten notwendige Handlungsveränderungen ein, um effizienter agieren zu können. Diese Prozesse laufen zum Teil unbewusst ab, sodass die Forschung hier heute einen Zugang zu «vor- bzw. unbewussten» Kognitionen hat. Dieser Zugang wird zunehmend zur Erforschung psychiatrischer und neurologischer Erkrankungen genutzt.

Virtual Microscopy in Virtual Tumor Banking

Many systems have already been designed and successfully used for sharing histology images over large distances, without transfer of the original glass slides. Rapid evolution was seen when digital images could be transferred over the Internet. Nowadays, sophisticated virtual microscope systems can be acquired, with the capability to quickly scan large batches of glass slides at high magnification and compress and store the large images on disc, which subsequently can be consulted through the Internet. The images are stored on an image server, which can give simple, easy to transfer pictures to the user specifying a certain magnification on any position in the scan. This offers new opportunities in histology review, overcoming the necessity of the dynamic telepathology systems to have compatible software systems and microscopes and in addition, an adequate connection of sufficient bandwidth. Consulting the images now only requires an Internet connection and a computer with a high quality monitor. A system of complete pathology review supporting biorepositories is described, based on the implementation of this technique in the European Human Frozen Tumor Tissue Bank (TuBaFrost).

Modification of virtual reality combined with a mental task stimulates cortisol in volunteers

Immersive, stereoscopic virtual reality (VR) systems provide a powerful multimedia tool for a laboratory simulation of distinct scenarios including stressful situations close to reality. Thus far, cortisol secretion as a neuroendocrine parameter of stress has not been evaluated within a VR paradigm. Ninety-four healthy subjects were subjected to a VR paradigm and a cognitive stress task. It was tested (a) if the modification of reality induced by dynamic VR as opposed to static VR can be regarded as a stressor and (b) if it can modify an additional cognitive stress response. In addition, the impact of gender on cortisol responses was assessed. A significant cortisol increase was observed only after the combined application of both conditions, but not after the dynamic VR or the cognitive stress alone. Cortisol reactivity was greater for men than for women. We conclude that dynamic VR does not affect cortisol secretion per se, but increases cortisol responses in a dual task paradigm. This provides the basis for the application of VR in neuroscientific research, which includes the assessment of hypothalamus-pituitary-adrenal axis regulation.

Auditory distraction in young and middle-aged adults: a behavioural and event-related potential study

Cognitive tasks involving distraction are associated with an early age-related decline in performance. Involuntary shifts in attention to irrelevant stimulus features and subsequent reorientation were studied in young and middle-aged subjects focussing on behavioural and event-related potential (ERP) measures. Subjects were asked to discriminate between equiprobable short and long auditory stimuli. Irrelevant rare frequency deviations prolonged reaction times (RT's), while an age-related effect on RT's was not observed. In contrast, notably after short deviant tones the error rate was considerably increased in the middle-aged subjects. ERP measures after deviant stimuli elicited a sequence of mismatch negativity (MMN), P3a and reorienting negativity (RON). The latency and amplitude of the MMN did not differ between age groups indicating an unchanged deviance detection. However, the consecutive process of attention orientation (P3a) was delayed and the subsequent reorienting (RON) to the primary task was strongly attenuated in the middle-aged subjects. After short deviants the RON was virtually absent in the middle-aged subjects, which might account for the observed decline of accuracy.

[Treatment of acrophobia in a virtual environment]

Specific phobias are one of the most frequent mental health problems and can lead to years of personal suffering. The most effective treatment is exposure therapy. Our aim was to proof the feasibility and efficacy of virtual environments in treating acrophobia patients using a manually guided exposure therapy. Our pilot study was designed as a crossover intervention with a waiting list condition as a control group. After treatment, our results show that exposure in virtual environments is a feasible technique, can provoke anxiety, and leads to a therapeutic effect.

Successful treatment of a critically burned patient (case report)

The objective of this study was to document that treatment of a critically burned patient could be, although with some problems, ultimately very successful. The commonplace of such successful therapy is certainly not only current, up-to-date and most intensive care, but also good teamwork and professionalism of the whole team in the specialized workplace--Burn and Reconstructive Surgery Departments of the Faculty Hospital in Brno.

Reconstructive surgeries after extensive burns in children

The authors' aim is to summarize and generalize the knowledge acquired in the course of the last eight years of work with children with extensive burns. Reconstructive surgeries show a certain specific feature consisting in the considerable extent of the scarred area often exceeding 50% of the body surface, and with the gradual increase in number of operations they are gaining importance.

Real-time monitoring of brain activity in patients with specific phobia during exposure therapy, employing a stereoscopic virtual environment

Exposure therapy is a behavioral technique that is reported to be the most effective, long-lasting treatment for patients suffering from specific phobia. During the performance in enclosed spaces, the patients show a strong psychophysiological response to the phobic stimulus that is normally avoided. This psychophysiological response changes characteristically during the course of exposure. We implemented an electroencephalographic monitoring focusing on event-related potentials to resolve the modulation of preattentive information processing by the anxiety state of the subject. Therefore, mismatch-negativity (MMN) was chosen as parameter using a passive auditory oddball paradigm that does not interfere with performance in the virtual environment. The results of this neurophysiological monitoring are demonstrated in one patient suffering from claustrophobia.

Immersive virtual environments in cue exposure

Cue reactivity to drug-related stimuli is a frequently observed phenomenon in drug addiction. Cue reactivity refers to a classical conditioned response pattern that occurs when an addicted subject is exposed to drug-related stimuli. This response consists of physiological and cognitive reactions. Craving, a subjective desire to use the drug of choice, is believed to play an important role in the occurrence of relapse in the natural setting. Besides craving, other subjective cue-elicited reactions have been reported, including withdrawal symptoms, drug-agonistic effects, and mood swings. Physiological reactions that have been investigated include skin conductance, heart rate, salivation, and body temperature. Conditioned reactivity to cues is an important factor in addiction to alcohol, nicotine, opiates, and cocaine. Cue exposure treatment (CET) refers to a manualized, repeated exposure to drug-related cues, aimed at the reduction of cue reactivity by extinction. In CET, different stimuli are presented, for example, slides, video tapes, pictures, or paraphernalia in nonrealistic, experimental settings. Most often assessments consist in subjective ratings by craving scales. Our pilot study will show that immersive virtual reality (IVR) is as good or even better in eliciting subjective and physiological craving symptoms as classical devices.

GTP- and GDP-analogues modulate an inwardly rectifying chloride channel in cultured hippocampal neurons

Three different GABA-insensitive Cl- channels could be resolved in cultured hippocampal neurons using the inside-out patch clamp configuration. The most commonly observed channel revealed an inward rectification with a chord conductance of 40 pS in symmetrical Cl- solutions at a membrane potential of -50 mV and had voltage sensitive gating kinetics. Channel openings were not observed in cell-attached patch, and after excision, several minutes of perfusion of the cytoplasmic side were required before detecting the first openings. The open state probability was increased by guanosine 5'-O-(3-thiotriphosphate) (GTP-gamma-S 10(-4) M) and reduced by guanosine 5'-O-(2-thiophosphate) (GDP-beta-S 10(-4) M) suggesting its regulation by G proteins. This new identified chloride channel may account for the previously described voltage-sensitive, inward-rectifying whole cell Cl- current which was enhanced by adenosine in a pertussis toxin-sensitive manner.