Laser-guided real-time automatic target identification for endoscopic stone lithotripsy: a two-arm in vivo porcine comparison study.

INTRODUCTION AND OBJECTIVE: Thermal injuries associated with Holmium laser lithotripsy of the urinary tract are an underestimated problem in stone therapy. Surgical precision relies exclusively on visual target identification when applying laser energy for stone disintegration. This study evaluates a laser system that enables target identification automatically during bladder stone lithotripsy, URS, and PCNL in a porcine animal model. METHODS: Holmium laser lithotripsy was performed on two domestic pigs by an experienced endourology surgeon in vivo. Human stone fragments (4-6 mm) were inserted in both ureters, renal pelvises, and bladders. Ho:YAG laser lithotripsy was conducted as a two-arm comparison study, evaluating the target identification system against common lithotripsy. We assessed the ureters' lesions according to PULS and the other locations descriptively. Post-mortem nephroureterectomy and cystectomy specimens were examined by a pathologist. RESULTS: The sufficient disintegration of stone samples was achieved in both setups. Endoscopic examination revealed numerous lesions in the urinary tract after the commercial Holmium laser system. The extent of lesions with the feedback system was semi-quantitatively and qualitatively lower. The energy applied was significantly less, with a mean reduction of more than 30% (URS 27.1%, PCNL 52.2%, bladder stone lithotripsy 17.1%). Pathology examination revealed only superficial lesions in both animals. There was no evidence of organ perforation in either study arm. CONCLUSIONS: Our study provides proof-of-concept for a laser system enabling automatic real-time target identification during lithotripsy on human urinary stones. Further studies in humans are necessary, and to objectively quantify this new system's advantages, investigations involving a large number of cases are mandatory.

[Sovereignty and Responsibility in a Multilevel System: Subsidiarity as the Guiding Principle?] / Souveränität und Verantwortung im Mehrebenensystem: Subsidiarität als Leitmotiv?

In the German political debate, the principle of subsidiarity plays an important role in the acceptance of the European multilevel system. In such a system, there is a collision of historically diverging, systematically inconsistent and qualitatively different needs. This combination demands an "active subsidiarity" and a "subsidiarity routine" in order to dynamically shape the heterogeneous EU. This way, we may find a balance between the needs of the citizens (acceptancy), the EU institutions (efficiency) as well as of the different levels of decision making and acting (reason for being). Above all, subsidiarity must start at home, it can be strengthened in the EU if it does not erode in the member states. This challenge has been regularly neglected til now.

Risk Factors for Complicated Lymphadenitis Caused by Nontuberculous Mycobacteria in Children.

Nontuberculous mycobacteria (NTM) are an emerging cause of infections, including chronic lymphadenitis in children. To identify risk factors for NTM lymphadenitis, particularly complicated disease, we collected epidemiologic, clinical, and microbiological data on 138 cases of NTM lymphadenitis in children across 13 centers in Germany and Austria. We assessed lifestyle factors but did not identify specific risk behaviors. We noted that more cases of NTM lymphadenitis occurred during cold months than during warm months. Moreover, we noted female sex and age <5.5 years as potential risk factors. Complete extirpation of the affected lymph node appeared to be the best therapeutic measure. We integrated the study data to develop a simple risk score to predict unfavorable clinical outcomes for NTM lymphadenitis.

A Novel Laser Lithotripsy System with Automatic Real-Time Urinary Stone Recognition: Computer Controlled Ex Vivo Lithotripsy is Feasible and Reproducible in Endoscopic Stone Fragmentation.

PURPOSE: Urinary stone treatment has been strongly influenced by advances in technology. Nevertheless, the photonic characteristics of stones as the treatment target have been neglected. Monitoring fluorescence spectra is sufficient for automatic target differentiation and laser feedback control as previously described. We investigated the characteristics of fluorescence signals and the clinical practicability of real-time laser feedback control during lithotripsy. MATERIALS AND METHODS: Fluorescence excitation light was superimposed on a holmium laser beam into the treatment fiber. Spectra were recorded and signal amplitude changes were analyzed during increases in distance between the fiber tip and the stone to identify the optimal threshold level for stone recognition. Ho:YAG lithotripsy was performed under in vitro surgical conditions in porcine tissue while our feedback system autonomously controlled the laser impulse release during lithotripsy. The tissue was then endoscopically and macroscopically examined for laser induced lesions. RESULTS: Mean ± SD autofluorescence signal amplitudes from urinary stone samples varied between 142 ± 29 and 1,521 ± 152 ADU while tissue and endoscope coating emission was negligible. Signal amplitude decreased rapidly at distances larger than 1 to 2 mm. Clinically reliable threshold values for target recognition could be set to prevent laser pulse emission if the stone was out of range or urothelial tissue might be harmed by laser irradiation. We observed no incorrectly released laser pulse or injury to tissue during autonomously controlled holmium laser lithotripsy. CONCLUSIONS: Our laboratory study strengthens the evidence that tracking real-time autofluorescence spectra during endoscopic stone surgery via automatic feedback control of the laser impulse release may become a potentially useful clinical tool for surgeons who navigate in the upper urinary tract.

An N-terminal acidic region of Sgs1 interacts with Rpa70 and recruits Rad53 kinase to stalled forks.

DNA replication fork stalling poses a major threat to genome stability. This is counteracted in part by the intra-S phase checkpoint, which stabilizes arrested replication machinery, prevents cell-cycle progression and promotes DNA repair. The checkpoint kinase Mec1/ATR and RecQ helicase Sgs1/BLM contribute synergistically to fork maintenance on hydroxyurea (HU). Both enzymes interact with replication protein A (RPA). We identified and deleted the major interaction sites on Sgs1 for Rpa70, generating a mutant called sgs1-r1. In contrast to a helicase-dead mutant of Sgs1, sgs1-r1 did not significantly reduce recovery of DNA polymerase α at HU-arrested replication forks. However, the Sgs1 R1 domain is a target of Mec1 kinase, deletion of which compromises Rad53 activation on HU. Full activation of Rad53 is achieved through phosphorylation of the Sgs1 R1 domain by Mec1, which promotes Sgs1 binding to the FHA1 domain of Rad53 with high affinity. We propose that the recruitment of Rad53 by phosphorylated Sgs1 promotes the replication checkpoint response on HU. Loss of the R1 domain increases lethality selectively in cells lacking Mus81, Slx4, Slx5 or Slx8.

Homozygous HOXB1 loss-of-function mutation in a large family with hereditary congenital facial paresis.

Hereditary congenital facial paresis (HCFP) belongs to the congenital cranial dysinnervation disorders. HCFP is characterized by the isolated dysfunction of the seventh cranial nerve and can be associated with hearing loss, strabismus, and orofacial anomalies. Möbius syndrome shares facial palsy with HCFP, but is additionally characterized by limited abduction of the eye(s). Genetic heterogeneity has been documented for HCFP as one locus mapped to chromosome 3q21-q22 (HCFP1) and a second to 10q21.3-q22.1 (HCFP2). The only known causative gene for HCFP is HOXB1 (17q21; HCFP3), encoding a homeodomain-containing transcription factor of the HOX gene family, which are master regulators of early developmental processes. The previously reported HOXB1 mutations change arginine 207 to another residue in the homeodomain and alter binding capacity of HOXB1 for transcriptional co-regulators and DNA. We performed whole exome sequencing in HCFP-affected individuals of a large consanguineous Moroccan family. The homozygous nonsense variant c.66C>G/p.(Tyr22*) in HOXB1 was identified in the four patients with HCFP and ear malformations, while healthy family members carried the mutation in the heterozygous state. This is the first disease-associated HOXB1 mutation with a likely loss-of-function effect suggesting that all HOXB1 variants reported so far also have severe impact on activity of this transcriptional regulator. © 2016 Wiley Periodicals, Inc.

Analysis of Documentation Speed Using Web-Based Medical Speech Recognition Technology: Randomized Controlled Trial.

BACKGROUND: Clinical documentation has undergone a change due to the usage of electronic health records. The core element is to capture clinical findings and document therapy electronically. Health care personnel spend a significant portion of their time on the computer. Alternatives to self-typing, such as speech recognition, are currently believed to increase documentation efficiency and quality, as well as satisfaction of health professionals while accomplishing clinical documentation, but few studies in this area have been published to date. OBJECTIVE: This study describes the effects of using a Web-based medical speech recognition system for clinical documentation in a university hospital on (1) documentation speed, (2) document length, and (3) physician satisfaction. METHODS: Reports of 28 physicians were randomized to be created with (intervention) or without (control) the assistance of a Web-based system of medical automatic speech recognition (ASR) in the German language. The documentation was entered into a browser's text area and the time to complete the documentation including all necessary corrections, correction effort, number of characters, and mood of participant were stored in a database. The underlying time comprised text entering, text correction, and finalization of the documentation event. Participants self-assessed their moods on a scale of 1-3 (1=good, 2=moderate, 3=bad). Statistical analysis was done using permutation tests. RESULTS: The number of clinical reports eligible for further analysis stood at 1455. Out of 1455 reports, 718 (49.35%) were assisted by ASR and 737 (50.65%) were not assisted by ASR. Average documentation speed without ASR was 173 (SD 101) characters per minute, while it was 217 (SD 120) characters per minute using ASR. The overall increase in documentation speed through Web-based ASR assistance was 26% (P=.04). Participants documented an average of 356 (SD 388) characters per report when not assisted by ASR and 649 (SD 561) characters per report when assisted by ASR. Participants' average mood rating was 1.3 (SD 0.6) using ASR assistance compared to 1.6 (SD 0.7) without ASR assistance (P<.001). CONCLUSIONS: We conclude that medical documentation with the assistance of Web-based speech recognition leads to an increase in documentation speed, document length, and participant mood when compared to self-typing. Speech recognition is a meaningful and effective tool for the clinical documentation process.

The safety and use of perioperative dexamethasone in the perioperative management of primary sporadic supratentorial meningiomas.

Objective: Despite the lack of prospective evidence for the perioperative use of dexamethasone in meningioma surgery, its use is well established in the daily routine of several centers. The present study evaluates the effect of dexamethasone on postoperative complications, peritumoral T2/FLAIR hyperintensity, and progression-free survival in patients with supratentorial meningiomas undergoing resection. Methods: A total of 148 patients who underwent resection of a primary sporadic supratentorial meningioma at the authors' institution between 2018 and 2020 were included in this retrospective cohort. Safety criteria were side effects of dexamethasone (e.g. hyperglycemia), surgical morbidities, length of stay, and mortality. The individual Karnofsky Performance Scales (KPS) were evaluated regarding the individual development and the delta of KPS at 3- and 12-months compared to baseline KPS was calculated. Longitudinal assessment of the peritumoral T2-/FLAIR hyperintensity changes was performed. Results: The use of both pre- and postoperative dexamethasone did not influence the incidence rates of wound infections, infarctions, postoperative seizures, pulmonary embolism, postoperative hemorrhage, mortality, length of stay, new-onset hyperglycemia and new neurological deficits. Perioperative Dexamethasone use was associated with an improved Karnofsky performance development at 3- (delta of KPS 3.3 vs. -1.9, p=0.001) and 12-months (delta of KPS 3.8 vs. -1.1, p=0.008) compared to the preoperative Karnofsky performance status. Multivariable analysis revealed that perioperative dexamethasone use enhances the KPS improvement (OR: 3.65, 95% CI: 1.01-13.18, p=0.048). Persistent peritumoral T2/FLAIR hyperintensity changes were observed in 35 cases of 70 patients with available follow-up images and a baseline edema (50.0%). Perioperative dexamethasone use enhanced the reduction of the preoperative peritumoral T2-/FLAIR hyperintensity changes (mean reduction of maximum diameter: 1.8 cm vs. 1.1 cm, p=0.023). Perioperative dexamethasone use was independently associated with a lower risk for persistent peritumoral T2-/FLAIR hyperintensity changes (OR: 3.77, 95% CI: 1.05-13.54, p=0.042) The perioperative use of dexamethasone did not influence the progression-free survival time in Simpson grade I or II resected WHO grade 1 meningiomas (log-rank test: p=0.27). Conclusion: Perioperative dexamethasone use seems to be safe in surgery for primary supratentorial meningiomas. Dexamethasone use might enhance the functionality by reducing postoperative peritumoral T2-/FLAIR hyperintensities. These findings highlight the need for prospective data.

Analyzing and supporting mental representations and strategies in solving Bayesian problems.

Solving Bayesian problems poses many challenges, such as identifying relevant numerical information, classifying, and translating it into mathematical formula language, and forming a mental representation. This triggers research on how to support the solving of Bayesian problems. The facilitating effect of using numerical data in frequency format instead of probabilities is well documented, as is the facilitating effect of given visualizations of statistical data. The present study not only compares the visualizations of the 2 × 2 table and the unit square, but also focuses on the results obtained from the self-creation of these visualizations by the participants. Since it has not yet been investigated whether the better correspondence between external and internal visualization also has an effect on cognitive load when solving Bayesian tasks, passive and active cognitive load are additionally measured. Due to the analog character and the proportional representation of the numerical information by the unit square, it is assumed that the passive cognitive load is lower when using the unit square as visualization than when using the 2 × 2 table. The opposite is true for active cognitive load.

Measuring people's covariational reasoning in Bayesian situations.

Previous research on Bayesian reasoning has typically investigated people's ability to assess a posterior probability (i.e., a positive predictive value) based on prior knowledge (i.e., base rate, true-positive rate, and false-positive rate). In this article, we systematically examine the extent to which people understand the effects of changes in the three input probabilities on the positive predictive value, that is, covariational reasoning. In this regard, two different operationalizations for measuring covariational reasoning (i.e., by single-choice vs. slider format) are investigated in an empirical study with N = 229 university students. In addition, we aim to answer the question wheter a skill in "conventional" Bayesian reasoning is a prerequisite for covariational reasoning.

A CRISPR Screen Reveals Resistance Mechanisms to CD3-Bispecific Antibody Therapy.

CD3-bispecific antibodies represent an important therapeutic strategy in oncology. These molecules work by redirecting cytotoxic T cells to antigen-bearing tumor cells. Although CD3-bispecific antibodies have been developed for several clinical indications, cases of cancer-derived resistance are an emerging limitation to the more generalized application of these molecules. Here, we devised whole-genome CRISPR screens to identify cancer resistance mechanisms to CD3-bispecific antibodies across multiple targets and cancer types. By validating the screen hits, we found that deficiency in IFNγ signaling has a prominent role in cancer resistance. IFNγ functioned by stimulating the expression of T-cell killing-related molecules in a cell type-specific manner. By assessing resistance to the clinical CD3-bispecific antibody flotetuzumab, we identified core fucosylation as a critical pathway to regulate flotetuzumab binding to the CD123 antigen. Disruption of this pathway resulted in significant resistance to flotetuzumab treatment. Proper fucosylation of CD123 was required for its normal biological functions. In order to treat the resistance associated with fucosylation loss, flotetuzumab in combination with an alternative targeting CD3-bispecific antibody demonstrated superior efficacy. Together, our study reveals multiple mechanisms that can be targeted to enhance the clinical potential of current and future T-cell-engaging CD3-bispecific antibody therapies.

Palivizumab-resistant human respiratory syncytial virus infection in infancy.

Palivizumab-resistant respiratory syncytial virus was isolated from an infant treated with palivizumab. A stable mutation at codon 276 led to a nearly complete resistance to palivizumab. Additional studies revealed a second mutation at codon 272. Further passage of the virus led to a complete loss of binding of palivizumab.

Vaginal carcinoma in a female-to-male transsexual.

INTRODUCTION: Sex reassignment surgery (SRS) can be considered a reasonable and secure treatment for transsexualism, today. Because the population of patients who have received SRS is growing steadily, it can be expected that the number of patients who present with diseases specific to their original gender will increase as well. AIM: In female-to-male transsexuals, vaginal cancer has not been reported so far. This article reports, to our knowledge, the first case of a female-to-male transsexual who developed vaginal cancer. METHODS: Eighteen years after receiving female-to-male SRS, the patient presented with vaginal cancer, which infiltrated rectum and bladder and also showed involvement of inguinal lymph nodes. Surgery consisted of an anterior and posterior pelvic demolition and extended lymphadenectomy with preservation of the penoid and reconstruction of the pelvic defect with multiple flaps. RESULTS: The tumor was removed completely (R0), and 2 years after surgery, the patient has no signs or symptoms of tumor recurrence and enjoys good quality of life. CONCLUSIONS: In SRS patients, diseases of their original gender should always be considered and patients should be encouraged to participate in screening programs. When choosing the surgical approach for SRS, the risks for developing cancer from remaining structures of the genetic gender should be considered. Of course, removal of e.g., ovaries, cervix and vagina, will prevent cancer of these structures. When it comes to surgery in SRS patients with malignancies, an interdisciplinary approach should be chosen.

Different Visualizations Cause Different Strategies When Dealing With Bayesian Situations.

People often struggle with Bayesian reasoning. However, previous research showed that people's performance (and rationality) can be supported by the way the statistical information is represented. First, research showed that using natural frequencies instead of probabilities as the format of statistical information significantly increases people's performance in Bayesian situations. Second, research also revealed that people's performance increases through using visualization. We have built our paper on existing research in this field. Our main aim was to analyze people's strategies in Bayesian situations that are erroneous even though statistical information is represented as natural frequencies and visualizations. In particular, we compared two pairs of visualization with similar numerical information (tree diagram vs. unit square, and double-tree diagram vs. 2 × 2-table) concerning their impact on people's erroneous strategies in Bayesian situations. For this aim, we conducted an experiment with 540 university students. The students were randomly assigned to four conditions defined by the four different visualizations of statistical information. The students were asked to indicate a fraction in response to four Bayesian situations. We documented the numerator and denominator of the students' responses representing a basic set and a subset in a Bayesian situation. Our results showed that people's erroneous strategies are highly dependent on visualization. A central finding was that the visualization's characteristic of making the nested-sets structure of a Bayesian situation transparent has a facilitating effect on people's Bayesian reasoning. For example, compared to the unit square, a tree diagram does not explicitly visualize the set-subset relations that are relevant in a Bayesian situation. Accordingly, compared to a unit square, a tree diagram partly hinders people in finding the correct denominator in a Bayesian situation, and, in particular, triggers selecting a wrong numerator. By analyzing people's erroneous strategies in Bayesian situations, we contribute to investigating approaches to facilitate Bayesian reasoning and to further develop the teaching of Bayesian reasoning.

Streptococcus agalactiae invasion of human brain microvascular endothelial cells is promoted by the laminin-binding protein Lmb.

Streptococcus agalactiae (S. agalactiae) can cause severe pneumonia, sepsis and meningitis in neonates and remains one of the most prevalent causes of invasive neonatal infections. During the course of infection, S. agalactiae colonizes and invades a number of host compartments, thereby interacting with different host tissues. Deletion of the scpB-lmb region, coding for the C5a peptidase and the laminin-binding protein Lmb, respectively, resulted in a 64% decreased invasion of S. agalactiae into human brain microvascular endothelial cells (HBMEC). Decreased invasion was also seen in lmb mutant strains lmb-k1 and lmb-k2 (74% and 69% reduction, respectively). Finally, host cell invasion was significantly reduced in competition experiments with either purified recombinant laminin-binding protein by 46% or a polyclonal antibody directed against the laminin-binding protein of S. agalactiae by 45%. The S. agalactiae scpB-lmb mutant induced an equal amount of the neutrophil chemoattractant interleukin (IL)-8 release in comparison to the wild-type. Taken together, our studies support the conclusion that Lmb promotes invasion of S. agalactiae into HBMEC but does not play a role in IL-8 release from HBMEC.

Toc12, a novel subunit of the intermembrane space preprotein translocon of chloroplasts.

Translocation of proteins across membranes is essential for the biogenesis of each cell and is achieved by proteinaceous complexes. We analyzed the translocation complex of the intermembrane space from chloroplasts and identified a 12-kDa protein associated with the Toc machinery. Toc12 is an outer envelope protein exposing a soluble domain into the intermembrane space. Toc12 contains a J-domain and stimulates the ATPase activity of DnaK. The conformational stability and the ability to stimulate Hsp70 are dependent on a disulfide bridge within the loop region of the J-domain, suggesting a redox-regulated activation of the chaperone. Toc12 is associated with Toc64 and Tic22. Its J-domain recruits the Hsp70 of outer envelope membrane to the intermembrane space translocon and facilitates its interaction to the preprotein.

Case report: recurrent abdominal symptoms in a child with panhypopituitarism - there is always a differential.

BACKGROUND: We report the case of a 6 year old boy suffering from adenohypophysis aplasia as well as ectopic neurohypophysis and delayed diagnosis of familial Mediterranean fever (FMF). CASE PRESENTATION: The boy was diagnosed with panhypopituitarism during the neonatal period and suffered from recurrent episodes during the following years suggesting infections. He also showed signs of adrenal insufficiency. Finally, at the age of 6 years, an additional diagnosis of familial Mediterranean fever (FMF) was clinically suspected and later confirmed by molecular analysis. CONCLUSION: The clinical pictures of panhypopituitarism and FMF can be overlapping. It is imperative to take a detailed and accurate history in order to find the right diagnosis, particularly a precise family history. In conditions like FMF an early diagnosis is crucial, as initiation of treatment with colchicine is important to prevent long-term complications due to amyloid fibril deposition.

What We Have Learned from the Influenza A pH1N1 2009/10 Pandemic: High Clinical Impact of Human Metapneumovirus and Respiratory Syncytial Virus in Hospitalized Pediatric Patients.

The influenza pandemic in 2009/2010 shifted public awareness to respiratory tract infections caused by the influenza virus. A prospective study was conducted during the influenza pandemic from November 2009 through April 2010 to determine the causative pathogens and clinical symptoms present in all children and adolescents admitted to the University Children's Hospital, Duesseldorf, Germany, with signs and symptoms of respiratory tract infection. A total of 272 children and adolescents were admitted with symptoms of acute respiratory tract infection (ARI) or influenza-like illness. Viral pathogens were detected in 80% (218/272). However, influenza A pH1N1 infection was only detected in 11% (30/272) of children. Human metapneumovirus (HMPV) and respiratory syncytial virus (RSV) were the predominant identified pathogens that led to the admission of young tachypneic children with pneumonia in the post pandemic phase and the requirement for more intense treatment. During the pandemic and early post-pandemic phase the clinical impact of other respiratory viruses, such as HMPV and RSV, led to a higher clinical disease burden than pH1N1. Consequently, HMPV testing should be performed as routinely as RSV testing in patients hospitalized for ARI. Even while preparing for pandemics, the awareness of other respiratory viruses must be maintained.

Pathways of allosteric regulation in Hsp70 chaperones.

Central to the protein folding activity of Hsp70 chaperones is their ability to interact with protein substrates in an ATP-controlled manner, which relies on allosteric regulation between their nucleotide-binding (NBD) and substrate-binding domains (SBD). Here we dissect this mechanism by analysing mutant variants of the Escherichia coli Hsp70 DnaK blocked at distinct steps of allosteric communication. We show that the SBD inhibits ATPase activity by interacting with the NBD through a highly conserved hydrogen bond network, and define the signal transduction pathway that allows bound substrates to trigger ATP hydrolysis. We identify variants deficient in only one direction of allosteric control and demonstrate that ATP-induced substrate release is more important for chaperone activity than substrate-stimulated ATP hydrolysis. These findings provide evidence of an unexpected dichotomic allostery mechanism in Hsp70 chaperones and provide the basis for a comprehensive mechanical model of allostery in Hsp70s.