Induction therapy with ipilimumab and nivolumab followed by consolidative chemoradiation as organ-sparing treatment in urothelial bladder cancer: study protocol of the INDIBLADE trial.

Introduction: Studies that assessed the efficacy of pre-operative immune checkpoint blockade (ICB) in locally advanced urothelial cancer of the bladder showed encouraging pathological complete response rates, suggesting that a bladder-sparing approach may be a viable option in a subset of patients. Chemoradiation is an alternative for radical cystectomy with similar oncological outcomes, but is still mainly used in selected patients with organ-confined tumors or patients ineligible to undergo radical cystectomy. We propose to sequentially administer ICB and chemoradiation to patients with (locally advanced) muscle-invasive bladder cancer. Methods: The INDIBLADE trial is an investigator-initiated, single-arm, multicenter phase 2 trial. Fifty patients with cT2-4aN0-2M0 urothelial bladder cancer will be treated with ipilimumab 3 mg/kg on day 1, ipilimumab 3 mg/kg plus nivolumab 1 mg/kg on day 22, and nivolumab 3 mg/kg on day 43 followed by chemoradiation. The primary endpoint is the bladder-intact event-free survival (BI-EFS). Events include: local or distant recurrence, salvage cystectomy, death and switch to platinum-based chemotherapy. We will also evaluate the potential of multiparametric magnetic resonance imaging of the bladder to identify non-responders, and we will assess the clearance of circulating tumor DNA as a biomarker for ICB treatment response. Discussion: This is the first trial in which the efficacy of induction combination ICB followed by chemoradiation is being evaluated to provide bladder-preservation in patients with (locally advanced) urothelial bladder cancer. Clinical Trial Registration: The INDIBLADE trial was registered on clinicaltrials.gov on January 21, 2022 (NCT05200988).

Outcome of penetrating chest injuries in an urban level I trauma center in the Netherlands.

INTRODUCTION: Most patients with penetrating chest injuries benefit from early treatment with chest tube drainage or surgery. Although penetrating chest injury is not uncommon, few descriptive studies are published, especially in Europe. The aim of this study was to review our experience and further improve our management of penetrating chest injuries in a level I trauma center in the Netherlands. METHODS: All patients with penetrating chest injury between August 2004 and December 2012 were included. Demographics, mechanism of injury, physiological parameters, Injury Severity Scores (ISS), surgical and non-surgical treatment, length of intensive care unit (ICU) stay, length of hospital stay (LOS), complications and rate of mortality were collected. RESULTS: A total of 159 patients were analyzed. Patients included 116 (73 %) stab wounds and 34 (21 %) gunshot wounds. In 27 patients (17 %), cardiac injury was seen. The mean ISS was 12. Almost half of all patients (49 %) were treated with only chest tube drainage. Alternatively, surgical treatment was performed in 24 % of all cases. Anterolateral incision was most frequently used to gain access to the thoracic cavity. The mean LOS was 9 days. Among all patients, 17 % were admitted to the ICU with a mean stay of 3 days. In 18 (11 %) patients, one or more complications occurred. The 30-day mortality was 7.5 %. CONCLUSION: Patients presenting with penetrating chest injury are not uncommon in the Netherlands and can mostly be treated conservatively. In one-fourth of the patients, surgical treatment is performed. A structural and vigorous approach is needed for good clinical outcome.

Plastic-to-elastic transition in aggregated emulsion networks, studied with atomic force microscopy-confocal scanning laser microscopy microrheology.

In this paper, we demonstrate how the simultaneous application of atomic force microscopy (AFM) and confocal scanning laser microscopy (CSLM) can be used to characterize the (local) rheological properties of soft condensed matter at micrometer length scales. Measurement of AFM force curves as a function of the indentation amplitude and speed (magnitude and direction) can produce a "mechanical fingerprint" that contains information about material stiffness, hysteretic losses, and time scales for stress relaxation and/or network recovery. The simultaneous CSLM visualization of changes in the material's structure provides complementary information about how the material accommodates the indentation load. Since these experiments are done on areas of O(100 microm2) on materials having a surface of O(1 cm2), the measurements can be repeated on "fresh" material many times, contrary to traditional rheometers where the whole sample is loaded at once. As a particular example, we consider the case of a network of aggregated water-in-oil (W/O) emulsion droplets, in which the mechanical behavior changes drastically over time. Whereas the freshly prepared material shows a soft plastic behavior, after a time lapse of several weeks, the very same sample shows a much stiffer and elastic response. This drastic change in behavior is clearly reflected both in the signature of the AFM force curves and in (the reversibility of) the structural deformations observed with CSLM. The fact that these drastic mechanical changes take place without significant changes in the structure of the material (before loading) indicates that the stiffening of the droplet network is caused by an increase in the strength of the bonds between droplets. A remarkable finding for the elastic droplet network is that, while the structure recovers completely after the indenter is taken out, there is still an appreciable hysteresis in the force curves, indicating that dissipation also occurs. This hysteresis was not found to depend on the indentation speed.

Microrheology of aggregated emulsion droplet networks, studied with AFM-CSLM.

We studied the mechanical behavior of densely packed (up to approximately 30% v/v), sedimented layers of (1 microm) water-in-oil W/O emulsion droplets, upon indentation with a (10 microm) large spherical probe. In the presence of attractive forces, the droplets form solid like networks which can resist deformation. Adding a polymer to the oil phase was used to control droplet attraction. The droplet layers were assembled via normal gravity settling. Considering that both the network structure and the droplet interactions play a key role, we used a combination of atomic force microscopy (AFM) and confocal scanning laser microscopy (CSLM) to characterize the mechanical behavior. Here the AFM was used both as indentation tool and as force sensor. Indentation experiments were performed via a protocol consisting of approach, waiting, and retract stages. CSLM was used to observe the network structure at micron resolution in real time. Use of refractive index matched fluorescent droplets allowed the visualization of the entire layer. Upon compression with the probe, a markedly nonhomogeneous deformation occurred, evidenced by the formation of a dense corona (containing practically all of the displaced droplets) in the direct vicinity of the probe, as well as more subtle deformations of force-chains at larger distances. Upon decompression, both the imprint of the indenter and the corona remained, even long after the load was released. The force-distance curves recorded with the AFM correspond well to these observations. For each deformation cycle performed on fresh material, the retract curve was much steeper than the approach curve, thus corroborating the occurrence of irreversible compaction. Contrary to classic linear viscoelastic materials, this hysteresis did not show any dependence on the deformation speed. Our force-indentation approach curves were seen to scale roughly as F approximately delta(3/2). The pre-factor was found to increase with the polymer concentration and with the density of the network. These findings suggest that this new AFM-CSLM method could be used for rheological characterization of small volumes of "granular networks" in liquid. Our hypothesis that the mechanical resistance of the networks originates from interdroplet friction forces, which in turn are set by the interdroplet potential forces, is supported by the predictions from a new mechanical model in which the interdroplet bonds are represented by stick-slip elements.

Coalescence in semiconcentrated emulsions in simple shear flow.

The coalescence frequency in emulsions containing droplets with a low viscosity (viscosity ratio approximately 0.005) in simple shear flow has been investigated experimentally at several volume fractions of the dispersed phase (2%-14%) and several values of the shear rate (0.1-10 s(-1)). The evolution of the size distribution was monitored to determine the average coalescence probability from the decay of the total number of droplets. Theoretically models for two-droplet coalescence are considered, where the probability is given by P(c)=exp(-tau(dr)tau(int)). Since the drainage time tau(dr) depends on the size of the two colliding droplets, and the collision time tau(int) depends on the initial orientation of the colliding droplets, the calculated coalescence probability was averaged over the initial orientation distribution and the experimental size distribution. This averaged probability was compared to the experimentally obtained coalescence frequency. The experimental results indicate that (1) to predict the average coalescence probability one has to take into account the full size distribution of the droplets; (2) the coalescence process is best described by the "partially mobile deformable interface" model or the "fully immobile deformable interface" model of Chesters [A. K. Chesters, Chem. Eng. Res. Des. 69, 259 (1991)]; and (3) independent of the models used it was concluded that the ratio tau(dr)tau(int) scales with the coalescence radius to a power (2+/-1) and with the rate of shear to a power (1.5+/-1). The critical coalescence radius R(o), above which hardly any coalescence occurs is about 10 microm.

Influence of bulk elasticity and interfacial tension on the deformation of gelled water-in-oil emulsion droplets: an AFM study.

We used atomic force microscopy (AFM) to study the deformation and wetting behavior of large (50-250 microm) emulsion droplets upon mechanical loading with a colloidal glass probe. Our droplets were obtained from water-in-oil emulsions. By adding gelatin to the water prior to emulsification, also droplets with a bulk elasticity were prepared. Systematic variations of surfactant and gelatin concentrations were made, to investigate their effect on the deformation and wetting behavior of the droplets and to identify the contributions of interfacial tension, bulk elasticity, and expelled water. The AFM experiments were performed in force--distance mode and showed on approach a repulsive regime which in many cases was terminated by a jump-in of the probe. In the case of pure water (i.e. gelatin-free) droplets, the repulsive part of the curve showed a good linearity, thus allowing the extraction of an effective droplet spring constant. This quantity was found to decrease on raising the surfactant concentration from below the critical micelle concentration (cmc) to well above the cmc, and its numerical values were found to correspond remarkably well to literature values for the interfacial tension. Our findings indicate that, on gelatin increase inside the droplets, the bulk elasticity gradually becomes dominant and the droplets' stiffness does not depend anymore on surfactant concentration. Also the stability of the droplet interface against wetting, as measured by the force at which the jump-in instability occurs, was enhanced by gelatin. For gelatin concentrations of > or =15 wt %, the droplets were found to behave like purely elastic bodies. Both gelatin and surfactant contribute positively to the stability against interface breakup.

Flow electrification in nonaqueous colloidal suspensions, studied with video microscopy.

Flow electrification in nonaqueous suspensions has been scarcely reported in the literature but can significantly affect colloidal stability and (phase) behavior, perhaps even without being recognized. We have observed it in shear flow experiments on concentrated binary suspensions of hydrophobized silica particles in chloroform. In this low-polarity solvent, electrical charges on the large-particles' surfaces manifest themselves via long-ranged forces, because hardly any screening can take place through counterions. By shearing the suspension for a prolonged time, we could demonstrate that the effective interactions between the large particles change from weakly attractive (due to the small particles) to strongly repulsive (due to acquired Coulomb interactions). One of the conditions required for flow electrification was the presence of a glass surface in the shear cell. A spectacular manifestation of the phenomenon was observed with confocal video microscopy. First, the formation of large-particle aggregates was seen, while subsequently (over a long shearing time) the aggregates disintegrated into small entities, mostly primary particles. The spatial distribution of these entities in the quiescent state after stopping the flow showed evidence for acquired long-range repulsion. The occurrence of flow electrification was further corroborated by control experiments, where no flow was imposed, antistatic agent was added, or the glass bottom was coated with a conducting (indium tin oxide, ITO) layer: here, the aggregates kept growing until they became very large. To further diagnose the phenomenon, we have also done experiments in which an external electric field was applied (via the ITO layer) to an aggregated suspension. When the lower electrode was given the lowest potential, the aggregates were found to move away from the bottom and disintegrate. The qualitative similarity hereof with the flow electrification experiment suggests that in the latter, the glass acquired negative charges. After prolonged application of an external electric field, we observed segregation into regions enriched in large particles and regions completely depleted of them. In the quiescent fluid these regions exist as isolated units, but in shear flow they merge into bands, a behavior which resembles shear banding.

Hierarchical networks of casein proteins: an elasticity study based on atomic force microscopy.

2D- and 3D-atomic force microscopy (AFM) experiments were performed on single casein micelles (CM) in native state, submerged in liquid, using a home-built AFM instrument. The micelles were immobilized via carbodiimide chemistry to a self-assembled monolayer supported on gold-coated slides. Off-line data analysis allowed the extraction of both surface topography and elastic properties. Relative Young moduli (E*) were derived from force-vs-indentation curves, using the Hertz theory. The obtained E* values were found to increase with CM diameter, following a straight line dependence. The data showed that temperature, via its influence on both the protein-protein interactions and the composition of the micelle, has a clear effect on the mechanical properties of the CMs: higher temperatures and lower serum casein concentrations result in stiffer micelles. For pH < or = 5.6, effecting calcium phosphate release from the micelles by decreasing the pH does not have a large effect on CM stiffness. On decrease of the pH below 5.0, particulate gels and multilayers were obtained. Their measured elasticity (expressed by an equivalent G'AFM) agrees remarkably well with the storage moduli as measured with a conventional rheometer. Compared to single micelles, gels from nonheated CM suspensions are about 3 orders of magnitude softer. The "softness" of these gels (measured under compression or shear) therefore must come from the microscopic and/or mesoscopic links rather than the micelles themselves.

Aggregation and breakup of colloidal particle aggregates in shear flow, studied with video microscopy.

We used video microscopy to study the behavior of aggregating suspensions in shear flow. Suspensions consisted of 920 nm diameter silica spheres, dispersed in a methanol/bromoform solvent, to which poly(ethylene glycol) (M = 35.000 g) was added to effect weak particle aggregation. With our solvent mixture, the refractive index of the particles could be closely matched, to allow microscopic observations up to 80 microm deep into the suspension. Also the mass density is nearly equal to that of the particles, thus allowing long observation times without problems due to aggregate sedimentation. Particles were visualized via fluorescent molecules incorporated into their cores. Using a fast confocal scanning laser microscope made it possible to characterize the (flowing) aggregates via their contour-area distributions as observed in the focal plane. The aggregation process was monitored from the initial state (just after adding the polymer), until a steady state was reached. The particle volume fraction was chosen at 0.001, to obtain a characteristic aggregation time of a few hundred seconds. On variation of polymer concentration, cP (2.2-12.0 g/L), and shear rate, gamma (3-6/s), it was observed that the volume-averaged size, Dv, in the steady state became larger with polymer concentration and smaller with shear rate. This demonstrates that the aggregate size is set by a competition between cohesive forces caused by the polymer and rupture forces caused by the flow. Also aggregate size distributions were be measured (semiquantitatively). Together with a description for the internal aggregate structure they allowed a modeling of the complete aggregation curve, from t = 0 up to the steady state. A satisfactory description could be obtained by describing the aggregates as fractal objects, with Df = 2.0, as measured from CSLM images after stopping the flow. In this modeling, the fitted characteristic breakup time was found to increase with cP.

Measuring shear-induced self-diffusion in a counterrotating geometry.

The novel correlation method to measure shear-induced self-diffusion in concentrated suspensions of noncolloidal hard spheres which we developed recently [J. Fluid Mech. 375, 297 (1998)] has been applied in a dedicated counterrotating geometry. The counterrotating nature of the setup enables experiments over a wider range of well-controlled dimensionless time (gamma;Deltat in the range 0.03-3.5, compared to 0.05-0.6 in previous experiments; here gamma; denotes the shear rate and Deltat the correlation time). The accessible range of timescales made it possible to study the nature of the particle motion in a more detailed way. The wide radius geometry provides a well-defined flow field and was designed such that there is optical access from different directions. As a result, shear-induced self-diffusion coefficients could be determined as a function of particle volume fraction straight phi (0.20-0.50) in both the vorticity and velocity gradient direction. A transition could be observed to occur for gamma;Deltat of O(1), above which the particle motion is diffusive. The corresponding self-diffusion coefficients do not increase monotonically with particle volume fraction, as has been suggested by numerical calculations and theoretical modeling of Brady and Morris [J. Fluid Mech. 348, 103 (1997)]. After an exponential growth up to straight phi=0.35, the diffusion coefficients level off. The experiments even suggest the existence of a maximum around straight phi=0.40. The results are in good agreement with experimental literature data of Phan and Leighton [J. Fluid Mech. (submitted)], although these measurements were performed for much larger values of the dimensionless time gamma;Deltat.

Linear viscoelasticity of an inverse ferrofluid.

A magnetorheological fluid consisting of colloidal silica spheres suspended in an organic ferrofluid is described. Its linear viscoelastic behavior as a function of frequency, magnetic field strength, and silica volume fraction was investigated with a specially designed magnetorheometer. The storage modulus G' is at least an order of magnitude larger than the loss modulus G" at all magnetic field strengths investigated. G' does depend only weakly on frequency, and linearly on volume fraction. A model is presented for the high frequency limit of the storage modulus G'(infinity). In the model our system is treated as a collection of single noninteracting chains of particles. Assuming a dipolar magnetic interaction, theory and experiment show reasonable agreement at high frequencies.

Severe paroxysmal sinus bradycardia associated with high-frequency oscillatory ventilation.

OBJECTIVE: To determine the incidence of and risk factors for unexplained paroxysmal bradycardia in children treated with high-frequency oscillatory ventilation (HFOV). DESIGN: A nested case-control study. SETTING: A university-affiliated children's hospital. SUBJECTS: All children treated with HFOV for at least 3 days during a 2-year period and a randomly chosen comparison group of 50 children treated with only conventional mechanical ventilation (CMV) for at least 3 days during the same time period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Unexplained paroxysmal sinus bradycardia occurred in six children (12%) receiving HFOV, and was significantly more common than in children treated with CMV (0%). The bradycardic events occurred after the lung disease started to improve, and the mean airway pressure (mPaw) at the time of the bradycardias was significantly decreased from the child's maximal mPaw. The bradycardic events were effectively treated acutely with manual ventilation or atropine sulfate, and resolved completely after the patient was changed to a regimen of CMV. CONCLUSION: Unexplained paroxysmal bradycardia associated with HFOV in children is not uncommon. It completely resolves with conversion to CMV and may be related to overdistention of alveoli as compliance improves.

High-frequency oscillatory ventilation with partial liquid ventilation in a model of acute respiratory failure.

OBJECTIVE: To determine whether there is an improvement in oxygenation when partial liquid ventilation and high-frequency oscillatory ventilation are combined in the treatment of acute lung injury, compared with high-frequency oscillatory ventilation alone. DESIGN: Controlled animal trial. SETTING: Research laboratory in a university setting. SUBJECTS: Ten 3-kg piglets. INTERVENTIONS: Anesthetized piglets underwent high-frequency oscillatory ventilation, with mean airway pressure of 20 cm H2O, before induction of acute lung injury with repeated saline lavage. When PaO2 values were < 100 torr (< 13.3 kPa), five animals were randomized to receive escalating doses (3, 15, and 30 mL/kg) of perflubron at 60-min intervals. The other five animals remained on high-frequency oscillatory ventilation only. Sham dosing was performed at 60-min intervals in these animals. Arterial blood gases were obtained in both groups at baseline, after injury, and after perflubron and sham doses. MEASUREMENTS AND MAIN RESULTS: Statistically significant improvements in oxygenation were demonstrated in animals that received 3 mL/kg of perflubron with high-frequency oscillatory ventilation compared with animals receiving high-frequency oscillatory ventilation alone (253 +/- 161 vs. 90 +/- 30 torr [33.65 +/- 21.46 vs. 12.0 +/- 4.0 kPa], p < .05). Improvements in oxygenation with additional administration of perflubron were not greater than the improvements seen in the high-frequency oscillatory ventilation-only group. PaCO2 and pH were similar in both groups at all times. No hemodynamic compromise occurred in either group of animals. CONCLUSIONS: The combination of low-dose perflubron with high-frequency oscillatory ventilation leads to more rapid improvement in arterial oxygenation than high-frequency oscillatory ventilation alone, in a piglet model of acute lung injury. Although the group receiving high-frequency oscillatory ventilation alone eventually achieved PaO2 values that were equivalent to the group receiving high-frequency ventilation and perflubron, the combination of perflubron with high-frequency oscillatory ventilation may permit effective oxygenation and ventilation at lower mean airway pressures by facilitating alveolar expansion and decreasing intrapulmonary shunt.

Use of cardiopulmonary bypass during bronchoscopy following sand aspiration. A case report.

A 6-year-old boy with massive sand aspiration was effectively treated with femoral vein to femoral artery cardiopulmonary bypass (CPB), saline bronchial lavage, and exogenous surfactant. The patient was discharged the 9th hospital day without apparent sequelae. CPB should be considered for cases of sand or gravel aspiration when gas exchange is compromised.