A global map of travel time to cities to assess inequalities in accessibility in 2015.

The economic and man-made resources that sustain human wellbeing are not distributed evenly across the world, but are instead heavily concentrated in cities. Poor access to opportunities and services offered by urban centres (a function of distance, transport infrastructure, and the spatial distribution of cities) is a major barrier to improved livelihoods and overall development. Advancing accessibility worldwide underpins the equity agenda of 'leaving no one behind' established by the Sustainable Development Goals of the United Nations. This has renewed international efforts to accurately measure accessibility and generate a metric that can inform the design and implementation of development policies. The only previous attempt to reliably map accessibility worldwide, which was published nearly a decade ago, predated the baseline for the Sustainable Development Goals and excluded the recent expansion in infrastructure networks, particularly in lower-resource settings. In parallel, new data sources provided by Open Street Map and Google now capture transportation networks with unprecedented detail and precision. Here we develop and validate a map that quantifies travel time to cities for 2015 at a spatial resolution of approximately one by one kilometre by integrating ten global-scale surfaces that characterize factors affecting human movement rates and 13,840 high-density urban centres within an established geospatial-modelling framework. Our results highlight disparities in accessibility relative to wealth as 50.9% of individuals living in low-income settings (concentrated in sub-Saharan Africa) reside within an hour of a city compared to 90.7% of individuals in high-income settings. By further triangulating this map against socioeconomic datasets, we demonstrate how access to urban centres stratifies the economic, educational, and health status of humanity.

Concept and evaluation of the German War Surgery Course - Einsatzchirurgie-Kurs der Bundeswehr.

INTRODUCTION: Military surgeons must be prepared to care for severe and complex life-threatening injuries rarely seen in the civilian setting. Typical civilian training and practice do not provide adequate exposure to the broad set of surgical skills required. The German Bundeswehr Medical Service has developed and refined the War Surgery Course (WSC) to meet this training gap. This article describes the recent experience with this readiness curriculum. METHODS: Run annually since 1998, WSC consists nowadays of 5 days with 20 theoretical modules. Four sessions with standardised practical skills training use a live tissue porcine model, and the recently added cadaver-based Advanced Surgical Skills for Exposure in Trauma course. Sixteen military surgeons who participated in the WSC in January 2016 completed a survey of their self-rated readiness for 114 predefined emergency skills before and after completion, and provided an overall evaluation of the course. RESULTS: Self-assessed readiness improved significantly over baseline for all areas covered in both the practical skills and theoretical knowledge portions of the WSC curriculum. Additionally, all participants rated the course as important and universally recommended it to other military surgeons preparing for missions. CONCLUSIONS: The WSC course format was well received and perceived by learners as a valuable readiness platform. Ongoing evaluation of this course will enable data-driven evolution to ensure a maximum learning benefit for participants. With the increasing multinational nature of modern military missions, surgeons' training should follow international standards. Continuing evolution of military surgical training courses should further encourage the sharing and adoption of best educational practices.

[Near-infrared spectroscopy for the detection of traumatic intracranial hemorrhage: Feasibility study in a German army field hospital in Afghanistan]. / Nahinfrarotspektroskopie zur Detektion intrakranieller traumatischer Hirnblutungen: Praktikabilitätsstudie in einem Bundeswehrrettungszentrum in Afghanistan.

Traumatic brain injury (TBI) is one of the most common causes of death in ordinary accidents, natural disasters, or warfare. The gold standard for diagnosis of TBI is the CT scan; a delay of diagnostics or medical care is the strongest independent predictor of mortality of TBI patients--particularly in the case of a surgically treatable intracranial hematoma. The proper classification of these patients is of major importance in situations where a CT is not accessible. A portable screening device that uses near-infrared spectroscopy (NIRS) technology allows a preliminary estimate of an intracranial hematoma. This study assessing practicability shows that the use of the device in a military medical rescue center (Kunduz, Afghanistan) is easy to learn and can be repeatedly used even under emergency room conditions. The technique can be applied in penetrating and blunt TBIs in the absence of an immediately available CT scan in rural areas, preclinically, under mass casualty conditions (e.g., in disaster situations) as well as in humanitarian crises or war zones. Nevertheless, further studies to assess the validity of this device are necessary.

Chromatin structure of two genomic sites for targeted transgene integration in induced pluripotent stem cells and hematopoietic stem cells.

Achieving transgene integration into preselected genomic sites is currently one of the central tasks in stem cell gene therapy. A strategy to mediate such targeted integration involves site-specific endonucleases. Two genomic sites within the MBS85 and chemokine (C-C motif) receptor 5 (CCR5) genes (AAVS1 and CCR5 zinc-finger nuclease (CCR5-ZFN) sites, respectively) have recently been suggested as potential target regions for integration as their disruption has no functional consequence. We hypothesized that efficient transgene integration maybe affected by DNA accessibility of endonucleases and therefore studied the transcriptional and chromatin status of the AAVS1 and CCR5 sites in eight human induced pluripotent stem (iPS) cell lines and pooled CD34+ hematopoietic stem cells (HSCs). Matrix chromatin immunoprecipitation (ChIP) assays demonstrated that the CCR5 site and surrounding regions possessed a predominantly closed chromatin configuration consistent with its transcriptional inactivity in these cell types. In contrast, the AAVS1 site was located within a transcriptionally active region and exhibited an open chromatin configuration in both iPS cells and HSCs. To show that the AAVS1 site is readily amendable to genome modification, we expressed Rep78, an AAV2-derived protein with AAVS1-specific endonuclease activity, in iPS cells after adenoviral gene transfer. We showed that Rep78 efficiently associated with the AAVS1 site and triggered genome modifications within this site. On the other hand, binding to and modification of the CCR5-ZFN site by a ZFN was relatively inefficient. Our data suggest a critical influence of chromatin structure on efficacy of site-specific endonucleases used for genome editing.

Tumor-specific gene expression in hepatic metastases by a replication-activated adenovirus vector.

Clinical applications of tumor gene therapy require tumor-specific delivery or expression of therapeutic genes in order to maximize the oncolytic index and minimize side effects. This study demonstrates activation of transgene expression exclusively in hepatic metastases after systemic application of a modified first-generation (E1A/E1B-deleted) adenovirus vector (AdE1-) in mouse tumor models. The discrimination between tumors and normal liver tissue is based on selective DNA replication of AdE1- vectors in tumor cells. This new AdE1- based vector system uses homologous recombination between inverted repeats to mediate precise rearrangements within the viral genome. As a result of these rearrangements, a promoter is brought into conjunction with a reporter gene creating a functional expression cassette. Genomic rearrangements are dependent upon viral DNA replication, which in turn occurs specifically in tumor cells. In a mouse tumor model with liver metastases derived from human tumor cells, a single systemic administration of replication activated AdE1- vectors achieved transgene expression in every metastasis, whereas no extra-tumoral transgene induction was observed. Here we provide a new concept for tumor-specific gene expression that is also applicable for other conditionally replicating adenovirus vectors.

[Patterns and causes of injuries in a contemporary combat environment]. / Verletzungsmuster und -ursachen in modernen Kriegen.

Epidemiological analyses of injury patterns and mechanisms help to identify the expertise military surgeons need in a combat setting and accordingly help to adjust infrastructure and training requirements. Therefore, a MEDLINE search (1949-2009), World Wide Web search (keywords "combat, casualties, war, military, wounded and neurosurgery") and an analysis of deaths among allied war casualties in Afghanistan and Iraq were performed. Up to 10th December 2009 there had been 4,688 allied military deaths in Iraq and 1,538 in Afghanistan. Of these 22% died in non-hostile action, 33% in direct combat situations and the majority of 45% in indirect combat actions. The leading causes of injury were explosive devices (70%) and gunshot wounds. Chest or abdominal injuries (40%) and traumatic brain injuries (35%) were the main causes of death for soldiers killed in action. The case fatality rate in Iraq is approximately half that of the Vietnam War, whereas the killed-in-action rate in Afghanistan (18.7%) is similar to the Vietnam War (20%); however, the amputation rate is twice as high in modern conflicts. Approximately 8-15% of the fatal injuries seem to be potentially survivable.Military surgeons must have an excellent expertise in a wide variety of surgical specialties. Life saving emergency care, especially in the fields of thoracic, visceral and vascular surgery as well as practical skills in the fields of neurosurgery and oral and maxillofacial surgery are required. Additionally, it is of vital importance to ensure the availability of sufficient tactical and strategic medical evacuation capabilities for the wounded.

[The educational program for modern military surgeons]. / Weiterbildung zum modernen Militärchirurgen.

Casualties in military conflict produce patterns of injuries that are not seen in routine surgical practice at home. In an era of increasing surgical sub-specialization the deployed surgeon needs to acquire and maintain a wide range of skills from a variety of surgical specialties. Improvised explosive devices (IEDs) have become the modus operandi for terrorists and in the current global security situation these tactics can be equally employed against civilian targets. Therefore, knowledge and training in the management of these injuries are relevant to both military and civilian surgeons. To create this kind of military surgeon the so-called "DUO-plus" model for the training of surgical officers (specialization general surgery plus a second specialization either in visceral surgery or orthopedics/trauma surgery) has been developed in the Joint Medical Service of the German Bundeswehr. Other relevant skills, such as emergency neurotraumatology, battlefield surgery with integrated oral and craniomaxillofacial surgery and emergency gynecology, are integrated into this concept and will be taught in courses. Log books will be kept in accordance with the training curricula. On successful completion of the program medical officers will be officially appointed as Medical Officer "Einsatzchirurg" by their commanding officers for a maximum of 5 years and it will be necessary to renew it after this period. These refresher programs will require participation in visiting physicians programs in the complementary surgical disciplines in order to retain the essential specific skills.

[Spectrum of surgical procedures performed in German rescue centers and the field hospital in Afghanistan in 2008]. / Spektrum der Operationen in deutschen Sanitätseinrichtungen in Afghanistan im Jahr 2008.

From the military perspective detailed knowledge about the spectrum of operations undertaken abroad is of particular interest to provide indications of the skills that will be required by the surgeons. Therefore, all surgical reports produced in 2008 in the operation theatres of Mazar-e-Sharif, Feyzabad and Kunduz were reviewed. The overview shows that a total of 799 operations were performed equivalent to 0.4-1.6 operations/day. Most of the patients who underwent surgery were local civilians and most of these operations involved osteosynthesis, débridement and soft tissue procedures. Of the surgical procedures 11% involved patients who were German service personnel of which 85% were urgent or emergency procedures and 25% of these involved treatment of combat injuries. When civilian patients with life-threatening injuries or diseases are referred to the medical facilities there is little opportunity to make decisions with regard to acceptance. Often it may be necessary for surgeons to perform procedures which are outside their field of specialization. In order to ensure a favorable outcome in acute situations surgeons mainly required skills in emergency surgery of the body cavities (visceral and thoracic surgery).

Global maps of travel time to healthcare facilities.

Access to healthcare is a requirement for human well-being that is constrained, in part, by the allocation of healthcare resources relative to the geographically dispersed human population1-3. Quantifying access to care globally is challenging due to the absence of a comprehensive database of healthcare facilities. We harness major data collection efforts underway by OpenStreetMap, Google Maps and academic researchers to compile the most complete collection of facility locations to date. Leveraging the geographically variable strengths of our facility datasets, we use an established methodology4 to characterize travel time to healthcare facilities in unprecedented detail. We produce maps of travel time with and without access to motorized transport, thus characterizing travel time to healthcare for populations distributed across the wealth spectrum. We find that just 8.9% of the global population (646 million people) cannot reach healthcare within one hour if they have access to motorized transport, and that 43.3% (3.16 billion people) cannot reach a healthcare facility by foot within one hour. Our maps highlight an additional vulnerability faced by poorer individuals in remote areas and can help to estimate whether individuals will seek healthcare when it is needed, as well as providing an evidence base for efficiently distributing limited healthcare and transportation resources to underserved populations both now and in the future.

Selection of efficient cleavage sites in target RNAs by using a ribozyme expression library.

Inactivation of gene expression by antisense mechanisms in general and by ribozymes in particular is a powerful technique for studying the function of a gene product. We have designed a strategy for expression of ribozymes, for selection of accessible cleavage sites in target RNAs, and for isolation of ribozymes from a library of random sequences flanking the unique sequence of a hammerhead. The expression cassette for ribozyme genes is based on adenovirus-associated RNA. Alternatively, we used polymerase III or the T7 phage transcription machinery. The ribozyme sequences are positioned in the center of a stable stem-loop structure, allowing for a correctly folded ribozyme region within the expressed RNA. A library of ribozyme genes with random sequences of 13 nucleotides on both sides of the hammerhead was generated. As an example, ribozymes which are specific for seven sites within the mRNA or nuclear RNA of human growth hormone were selected and identified. Sequencing of ribozyme genes reamplified from the library confirmed not only the predicted cleavage sites but also the presence of different ribozyme variants in the library. In a test of the ribozyme variants for repression of growth hormone synthesis in a cellular assay, the strongest effect (more than 99% inhibition) was found for the variant with the shortest stretch of complementarity (7 and 8 nucleotides on either side) to the target RNA. This basic strategy seems to be applicable to the selection of suitable target sites and to the isolation of corresponding ribozymes for any mRNA of interest.

Adenoviral preterminal protein stabilizes mini-adenoviral genomes in vitro and in vivo.

In the absence of host immunity, nonintegrating, first-generation adenoviral vectors remain stable in the nucleus of quiescent transduced cells in mice. A mini-adenoviral genome (9 kb) deleted for viral E1, E2, E3, and late genes, but containing the viral inverted terminal repeats (ITRs), transgene expression cassette (human alpha 1-antitrypsin), and the viral E4 genes was equally efficient at transducing cells in vitro or in vivo as first generation, E1-deleted vectors. In contrast to a first generation vector, gene expression as well as vector DNA was short-lived in cells transduced with the deleted adenoviral genome. We demonstrate that coexpression of the adenoviral E2-preterminal protein from the vector or in trans stabilizes the mini-genome in vitro and in vivo without evidence of cellular toxicity.

Evaluation of adenovirus vectors containing serotype 35 fibers for tumor targeting.

There is growing evidence from in vitro studies that subgroup B adenoviruses (Ad) can overcome the limitations in safety and tumor transduction efficiency seen with commonly used subgroup C serotype 5-based vectors. In this study, we confirm that the expression level of the B-group Ad receptor, CD46, correlates with the grade of malignancy of cervical cancer in situ. We also demonstrate the in vivo properties of Ad5-based vectors that contain the B-group Ad serotype 35 fiber (Ad5/35) in transgenic mice that express CD46 in a pattern and at a level similar to humans. Upon intravenous and intraperitoneal injection, an Ad5/35 vector did not efficiently transduce normal tissue, but was able to target metastatic or intraperitoneal tumors that express CD46 at levels comparable to human tumors. When an oncolytic Ad5/35-based vector was employed, in both tumor models antitumor effects were observed. Furthermore, injection of Ad5/35 vectors into CD46 transgenic mice caused less innate toxicity than Ad5 vectors. Our data demonstrate that Ad vectors that target CD46 offer advantages over Ad5-based vectors for treatment of cancer.

[The value of thoracoscopy in thorax trauma]. / Hat die Thorakoskopie beim Thoraxtrauma einen Platz?

A hemodynamically stable patient presenting with persistent bleeding through his chest tube (ICD) is a classic indication for early thoracoscopic intervention in trauma. The source of bleeding and air leaks can be identified and often treated: bleeding and perforated pulmonary segments can be resected, and chest wall bleeding may be coagulated or sutured. Injuries to the diaphragm are difficult to diagnose, as they might not be seen in conventional trauma imaging without gross herniation of intra-abdominal contents into the thoracic cavity. Identifying the site of diaphragm perforation can give useful hints in thoracoabdominal trauma, identifying injured cavities and localizing the bullet or stab tract. Most often, diaphragmatic defects may be closed during diagnostic thoracoscopy as well. Non- or partially drainable hemothorax is another indication for thoracoscopy. Coagulated blood can be mechanically mobilised, and aspirated or primary bleeding may be stopped. Effective lavage and a high-performance suction device are required. Correct placement of the drainage is part of optimized therapy, along with inspection of all intrathoracic organs and surfaces. Furthermore, surgical and anaesthesiological teamwork and experience are prerequisites for the fast, professional application of a minimally invasive thoracoscopic approach in chest trauma patients. Diagnostically and theurapeutically, thoracoscopy plays an important role in the trauma setting--in the case of hemodynamically stable patients.

[Procedures of temporary wall closure in abdominal trauma and sepsis]. / Verfahren zum temporären Bauchdeckenverschluss bei Trauma und Sepsis.

Temporary abdominal closure methods differ mainly between vacuum-assisted and conventional approaches. Each method has its indications. Vacuum-assisted methods seem to be superior especially for trauma indications--in terms of lethality, the possibility of secondary closure during primary hospital stay, and frequency of enterocutaneous fistulas. Skin-only closure might be used as a short-term application (e.g. when damage control closure is needed), and the Bogota bag silo gives space to protruding bowels in pending or manifest abdominal compartment syndrome. Temporary fascial mesh closure enables repetitive laparotomies through the mesh, thus sparing the fascia. For that reason it is to be preferred, especially for its good practicability in clinical situations and on mission abroad.

[A tamponade complicating an acute eosinophilic pericarditis due to a myeloproliferative/myelodysplastic syndrome]. / Une tamponnade compliquant une péricardite à éosinophiles au cours d'un syndrome myéloprolifératif/myélodysplasique.

Cardiac involvement in eosinophilia is potentially fatal and requires early diagnosis and prompt treatment. We report here the case of a 71-year-old female patient with eosinophilia>10,000/mm(3) for 2 months due to a myeloproliferative/myelodysplastic syndrome, with a rapidly progressive exertional dyspnea explained by an important circumferential eosinophilic pericarditis. Due to a rapid evolution to a tamponade, an emergent surgical drainage was performed. Subsequent medical treatment combined high-dose corticosteroids (1mg/kg/day) with hydroxyurea and imatinib. The outcome was favourable with regression of the effusion, of the volume overload symptoms and decrease in eosinophilia.

Stimulation of cell division and fibroblast focus formation by antisense repression of retinoblastoma protein synthesis.

Circumstantial evidence supports a role for the retinoblastoma susceptibility gene, Rb-1, in the maintenance of normal cell growth, in that loss of its function results in abnormal growth and malignancy. Here we report that a high rate of mitosis and efficient dense focus formation in human embryonic lung fibroblasts (HEL cells) is induced by antisense oligonucleotide-directed inhibition of synthesis of p105-Rb, the product of the Rb-1 gene. mRNA specific for p105-Rb is truncated at the site of base pairing with the antisense oligonucleotide, and no synthesis of p105-Rb is observed. The rate of mitosis is considerably increased and the frequency of dense focus formation is extremely high in treated cells. However, although phosphothioate oligodeoxyribonucleotides taken up by the cells remain stable for at least 4 weeks, the recipient cells do not become immortal; nor are they able to induce tumor formation in nude mice. Thus, loss of Rb-1 function is not sufficient per se to allow malignant transformation.

[German education for treatment of penetrating gut traumata in army service]. / Penetrierendes Bauchtrauma aus der Sicht der Bundeswehr.

On military missions abroad, surgical care for penetrating abdominal injuries differentiates from that given at home. The different conditions in the field usually include a single general surgeon with no further specialists or hospitals to rely upon. Thus a mismatch between treatment capacity and needs can be experienced in mass casualty situations. Therefore the focus is on damage control surgery, getting patients fit for evacuation, and transport home under intensive care if needed. Knowledge of ballistics and explosive devices are adjunct fields of interest, as they improve the understanding and treatment of military injuries. Although these aspects add up to additional training requirements to be met by our surgeons, we are convinced that the new German education standards will allow successful training of future military surgeons.

DNA replication of first-generation adenovirus vectors in tumor cells.

A major role of the early gene 1A and 1B products (E1A and E1B) in adenovirus infection is to create a cellular environment appropriate for viral DNA replication. This is, in part, achieved by inactivation of tumor suppressor gene products such as pRb or p53. The functions of these same cellular proteins are also frequently lost in tumor cells. Therefore, we hypothesized that tumor cell lines with deregulated p53 and/or pRb pathways might support replication of E1A/E1B-deleted, first-generation adenovirus vectors (AdE1(-)). Here, we analyzed the impact of virus uptake, cell cycling, and the status of cell cycle regulators on AdE1(-) DNA synthesis. Cellular internalization of AdE1(-) vectors varied significantly among different tumor cell lines, whereas nuclear import of incoming viral DNA appeared to be less variable. Replication assays performed under equalized infection conditions demonstrated that all analyzed tumor cell lines supported AdE1(-) synthesis to varying degrees. There was no obvious correlation between the efficiency of viral DNA replication and the status of p53, pRb, and p16. However, the amount of virus attached and internalized changed with the cell cycle, affecting the intracellular concentration of viral DNA and thereby the replication efficacy. Furthermore, infection with AdE1 - vectors caused a partial G(2)/M arrest or delay in cell cycle progression, which became more pronounced in consecutive cell cycles. Correspondingly, vector DNA replication was found to be enhanced in cells artificially arrested in G(2)/M. Our findings suggest that cell cycling and thus passing through G(2)/M supports AdE1(-) DNA replication in the absence of E1A/E1B. This has potential implications for the use of first-generation adenovirus vectors in tumor gene therapy.

Induced apoptosis supports spread of adenovirus vectors in tumors.

Selectively replicating viruses hold promise as anticancer agents. To eliminate the tumor, these viruses must efficiently spread throughout the tumor and induce oncolysis. We hypothesized that viral release and spread could be supported by apoptosis induced after assembly of de novo-produced virions in tumor cells. As a model to test this, we employed an adenovirus vector that replicated in human tumor cell lines. Expression of a dominant-negative I-kappaB from this vector sensitized tumor cells to recombinant human tumor necrosis factor alpha (TNF-alpha)-mediated apoptosis. We found that apoptosis induced during viral DNA replication compromised virus production, whereas apoptosis induced after virion assembly enhanced viral release from infected cells and dissemination. Electron microscopy demonstrated that viral particles were associated with or included in apoptotic bodies whose phagocytosis by neighboring cells provides a potential means for viral spread. Apoptosis induced after viral replication also supported spread in vivo, in subcutaneous tumors or liver metastases, resulting in a delay of tumor growth. Our findings could be applicable to other selectively replicating viruses or antitumor strategies that involve application of proapoptotic or cytolytic agents.

Adenovirus-mediated transfer of the amphotropic retrovirus receptor cDNA increases retroviral transduction in cultured cells.

The presence of functional amphotropic receptors on the cell surface is necessary for amphotropic retrovirus-mediated gene transfer. A recombinant adenoviral vector that expresses the receptor for amphotropic retrovirus (RAM) was constructed and used to express the receptor cDNA in different cell types in culture. Transfer of the RAM cDNA increased amphotropic retroviral-mediated transfer from 0 to 60% in Chinese hamster ovary cells. RAM expression increased retroviral transduction four- to eight-fold from 2-4% to 18%-35% in HeLa, Namalva, and X63 cells, but had no effect on 208F and HepG2 cells which have high baseline retroviral transduction rates of about 50%. For the purpose of application to ex vivo gene therapy, primary mouse hepatocytes were studied in a similar manner. Hepatocytes had a baseline transduction efficiency of about 40% and did not have increased rates of retroviral-mediated gene transfer with expression of recombinant RAM. This recombinant adenoviral vector conferred infection of amphotropic retrovirus into cells that were relatively resistant to infection, thus offering a rapid and easy method to stably introduce genes into these cell lines.