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Enhanced Recovery After Surgery (ERAS) ist ein multiprofessionelles Modell zur Verbesserung der Versorgungsqualität von Patientinnen nach gynäkologisch-chirurgischem Eingriff. Standardisierte ERAS-Protokolle spielen in der gynäkologischen Onkologie eine entscheidende Rolle hinsichtlich einer Reduktion der Morbidität. Die Einführung erfordert eine Planung im interdisziplinären Team und bedarf neben einer leitliniengerechten Therapie stets der Anpassung an die individuellen Bedürfnisse der Patientinnen. Bei älteren Tumorpatientinnen treten Fragilität und Vulnerabilität in Bezug auf externe Stressoren gehäuft auf. Diese Patientinnen haben eine verlängerte Rekonvaleszenz nach ausgedehnten operativen Verfahren und ein deutlich erhöhtes Risiko für einen komplikationsreichen postoperativen Verlauf, auch verbunden mit höheren Gesundheitskosten. Der holistische Ansatz zur Betreuung fragiler Patientinnen mit gynäkoonkologischen Grunderkrankungen im interprofessionellen Team sollte die perioperative Versorgung standardisieren.

Germline data have become widely available in paediatric oncology since the introduction of paired tumour-germline sequencing. To guide best practice in cancer predisposition syndrome (CPS) diagnostics, we aimed to assess the diagnostic yield of extensive germline analysis compared with clinical selection-based genetic testing among all children with cancer.

Mesenteric artery stenting with a bare-metal stent is the current treatment for atherosclerotic chronic mesenteric ischaemia. Long-term patency of bare-metal stents is unsatisfactory due to in-stent intimal hyperplasia. Use of covered stents might improve long-term patency. We aimed to compare the patency of covered stents and bare-metal stents in patients with chronic mesenteric ischaemia.

Molecular cavities that mimic natural metalloenzymes have shown the potential to trap elusive reaction intermediates. Here, we demonstrate the formation of a rare yet stable Fe(IV)-superoxo intermediate at room temperature subsequent to dioxygen binding at the Fe(III) site of a (Et4N)2[FeIII(Cl)(bTAML)] complex confined inside the hydrophobic interior of a water-soluble Pd6L412+nanocage. Using a combination of electron paramagnetic resonance, Mössbauer, Raman/IR vibrational, X-ray absorption, and emission spectroscopies, we demonstrate that the cage-encapsulated complex has a Fe(IV) oxidation state characterized by a stable S = 1/2 spin state and a short Fe–O bond distance of ∼1.70 Å. We find that the O2reaction in confinement is reversible, while the formed Fe(IV)-superoxo complex readily reacts when presented with substrates having weak C–H bonds, highlighting the lability of the O–O bond. We envision that such optimally trapped high-valent superoxos can show new classes of reactivities catalyzing both oxygen atom transfer and C–H bond activation reactions.

Climate change increases the need to understand the effect of predicted future temperature and nutrient scenarios on marine phytoplankton. However, experimental studies addressing the effects of both drivers use a variety of design approaches regarding their temperature change rate and nutrient supply regimes. This study combines a systematic literature map to identify the existing bias in the experimental design of studies evaluating the phytoplankton response to temperature change, with a laboratory experiment. The experiment was designed to quantify how different temperature levels (6°C, 12°C, and 18°C), temperature regimes (abrupt vs. gradual increase), timings of nutrient addition (before or after the temperature change) and nutrient regimes (limiting vs. balanced) alter the growth and stoichiometry of a natural marine phytoplankton community. The systematic map revealed three key biases in marine global change experiments: (1) 66% of the studies do not explicitly describe the experimental temperature change or nutrient regime, (2) 84% applied an abrupt temperature exposure, and (3) only 15% experimentally manipulated the nutrient regime. Our experiment demonstrated that the identified biases in experimental design toward abrupt temperature exposure induced a short‐term growth overshoot compared to gradually increasing temperatures. Additionally, the timing of nutrient availability strongly modulated the direction of the temperature effect and strength of growth enhancement along balanced N : P supply ratios. Our study stresses that the rate of temperature change, the timing of nutrient addition and the N : P supply ratio should be considered in experimental planning to produce ecologically relevant results as different setups lead to contrasting directions of outcome.

Herein, we show that the reaction of a mononuclear FeIII(OH) complex (1) with N-tosyliminobenzyliodinane (PhINTs) resulted in the formation of a FeIV(OH) species (3). The obtained complex 3was characterized by an array of spectroscopic techniques and represented a rare example of a synthetic FeIV(OH) complex. The reaction of 1with the one-electron oxidizing agent was reported to form a ligand-oxidized FeIII(OH) complex (2). 3revealed a one-electron reduction potential of −0.22 V vs Fc+/Fc at −15 °C, which was 150 mV anodically shifted than 2(Ered= −0.37 V vs Fc+/Fc at −15 °C), inferring 3to be more oxidizing than 2. 3reacted spontaneously with (4-OMe-C6H4)3C•to form (4-OMe-C6H4)3C(OH) through rebound of the OH group and displayed significantly faster reactivity than 2. Further, activation of the hydrocarbon C–H and the phenolic O–H bond by 2and 3was compared and showed that 3is a stronger oxidant than 2. A detailed kinetic study established the occurrence of a concerted proton–electron transfer/hydrogen atom transfer reaction of 3. Studying one-electron reduction of 2and 3using decamethylferrocene (Fc*) revealed a higher ketof 3than 2. The study established that the primary coordination sphere around Fe and the redox state of the metal center is very crucial in controlling the reactivity of high-valent Fe–OH complexes. Further, a FeIII(OMe) complex (4) was synthesized and thoroughly characterized, including X-ray structure determination. The reaction of 4with PhINTs resulted in the formation of a FeIV(OMe) species (5), revealing the presence of two FeIVspecies with isomer shifts of −0.11 mm/s and = 0.17 mm/s in the Mössbauer spectrum and showed FeIV/FeIIIpotential at −0.36 V vs Fc+/Fc couple in acetonitrile at −15 °C. The reactivity studies of 5were investigated and compared with the FeIV(OH) complex (3).

The European Union (EU) and the United States (US) determine municipal solid waste (MSW) statistics differently. The EU applies a site-specific methodology that directly measures waste whereas the US employs a materials flow methodology that estimates MSW statistics indirectly based on production and recovery data from industries. This study dissects the materials flow methodology and presents quantitative materials flow Sankey diagrams for the primary MSW materials to highlight data gaps that can be addressed to improve the methodology’s accuracy. Private industry plastics data were applied to the materials flow methodology, and the results were within 10% of the plastics statistics reported by the US Environmental Protection Agency (US EPA). Drawbacks to the methodologies include EU measurement inaccuracies due to double-counting and not accounting for residual waste in the US. The latter may partially explain why landfilling tonnages reported by the US EPA were approximately 60% less than the tonnages reported by the Waste to Energy Research and Technology Council (WTERT) in its national MSW survey that applied the EU methodology in the US. Unlike the EU, there is no US national policy that requires states to measure and report state-level waste data to the US EPA. Future improvements in US MSW statistics rely heavily on the implementation of national policies to homogenize the measurement and collection of waste data from states.

Transcriptional activation of target genes is essential for TP53-mediated tumour suppression, though the roles of the diverse TP53-activated target genes in tumour suppression remains poorly understood. Knockdown of ZMAT3, an RNA-binding zinc-finger protein involved in regulating alternative splicing, in haematopoietic cells by shRNA caused leukaemia only with the concomitant absence of the PUMA and p21, the critical effectors of TRP53-mediated apoptosis and cell cycle arrest respectively. We were interested to further investigate the role of ZMAT3 in tumour suppression beyond the haematopoietic system. Therefore, we generated Zmat3knockout and compound gene knockout mice, lacking Zmat3and p21, Zmat3and Pumaor all three genes. Puma−/−p21−/−Zmat3−/−triple knockout mice developed tumours at a significantly higher frequency compared to wild-type, Puma−/−Zmat3−/−or p21−/−Zmat3−/−deficient mice. Interestingly, we observed that the triple knockout and Puma−/−Zmat3−/−double deficient animals succumbed to lymphoma, while p21−/−Zmat3−/−animals developed mainly solid cancers. This analysis suggests that in addition to ZMAT3 loss, additional TRP53-regulated processes must be disabled simultaneously for TRP53-mediated tumour suppression to fail. Our findings reveal that the absence of different TRP53 regulated tumour suppressive processes changes the tumour spectrum, indicating that different TRP53 tumour suppressive pathways are more critical in different tissues.

We propose nonparametric methods to obtain the Probability Density Function (PDF) to assess the properties of the underlying data generating process (DGP) without imposing any assumptions on the DGP, using neural networks (NNs). The proposed NN has advantages compared to well-known parametric and nonparametric density estimators. Our approach builds on literature on cumulative distribution function (CDF) estimation using NN. We extend this literature by providing analytical derivatives of this obtained CDF. Our approach hence removes the numerical approximation error in differentiating the CDF output, leading to more accurate PDF estimates. The proposed solution applies to any NN model, i.e., for any number of hidden layers or hidden neurons in the multilayer perceptron (MLP) structure. The proposed solution applies the PDF estimation by NN to continuous distributions as well as discrete distributions. We also show that the proposed solution to obtain the PDF leads to good approximations when applied to correlated variables in a multivariate setting. We test the performance of our method in a large Monte Carlo simulation using various complex distributions. Subsequently, we apply our method to estimate the density of the number of vehicle counts per minute measured with road sensors for a time window of 24 h.

Pancreatic cancer (PC) is one of the most lethal cancer types. Despite advancements that have led to some modest improvements in survival rates over the past decade, PC still has a dismal prognosis. Patients diagnosed with early-stage disease have higher survival rates. Unfortunately, PC seldom manifests itself early, and symptoms prompting diagnostic investigations usually develop when the disease is already advanced. PC screening may lead to better patient outcomes through detection of asymptomatic early-stage cancers and precursor lesions. Population-based screening is deemed unfeasible because of the low incidence of PC. However, screening of individuals with an inherited lifetime risk of ≥5%-10% for developing PC may prove beneficial. In the context of high-risk individuals, screening is referred to as surveillance. Yet, critical aspects such as suitable candidates for surveillance, the ideal time to initiate and discontinue surveillance, as well as the most effective surveillance method, preferred surveillance modalities, and optimal surveillance interval remain unclear. Herein, we summarize the current state of knowledge regarding PC surveillance by reviewing current expert consensus statements and guidelines. In addition, we review the management of identified lesions, the yield in different cohorts, and future directions to improve the outcomes of individuals at high-risk of developing PC.

Severe glomerulonephritis followed one to five weekly i.p. injections in TLFM mice of rabbit antimouse lymphocyte γ-globulin (ALG). Glomerulonephritis did not occur in C57BL mice subjected to the same regimen. Administration of normal rabbit γ-globulin (NRG) to RFM mice also caused renal glomerular changes, but no obvious clinical illness or death. Electron microscopy revealed severe alterations in renal glomerular basement membranes after ALG treatment, including subepithelial deposition of electron-dense material and fusion of epithelial foot processes. Subepithelial and subendothelial deposits were seen after NRG treatment. Immunofluorescence microscopy revealed the presence of both rabbit and mouse y-globulins in damaged glomeruli after administration of ALG and NRG. These changes, together with the clinical signs, indicated that an immune complex scrum sickness nephritis followed ALG treatment in RFM mice. A mild form of the disease occurred after treatment with NRG. These results show that, dangerous hypersensitivity reactions may follow administration of highly purified ALG. The selective toxicity of ALG in RFM, but not in C57BL, mice may be related to preexisting renal or autoimmune disease in the RFM strain. The results imply a need for caution in using ALG in patients with coexisting renal disease or autoimmune disease.

•Low frequency of emergency department thoracotomy (EDT) limits residents' training, thus creating a learning gap.•Use of simulation in general surgery training has been proven effective.•Low-cost EDT trainer allows deliberate practice of EDT procedure for residents.

Thrombopoietin (Tpo), which binds to its specific receptor, the Mpl protein, is the major cytokine regulator of megakaryopoiesis and circulating platelet number. Tpo binding to Mpl triggers activation of Janus kinase 2 (Jak2) and phosphorylation of the receptor, as well as activation of several intracellular signalling cascades that mediate cellular responses. Three tyrosine (Y) residues in the C-terminal region of the Mpl intracellular domain have been implicated as sites of phosphorylation required for regulation of major Tpo-stimulated signalling pathways: Mpl-Y565, Mpl-Y599 and Mpl-Y604. Here, we have introduced mutations in the mouse germline and report a consistent physiological requirement for Mpl-Y599, mutation of which resulted in thrombocytopenia, deficient megakaryopoiesis, low hematopoietic stem cell (HSC) number and function, and attenuated responses to myelosuppression. We further show that in models of myeloproliferative neoplasms (MPN), where Mpl is required for pathogenesis, thrombocytosis was dependent on intact Mpl-Y599. In contrast, Mpl-Y565 was required for negative regulation of Tpo responses; mutation of this residue resulted in excess megakaryopoiesis at steady-state and in response to myelosuppression, and exacerbated thrombocytosis associated with MPN.

Defining minimal standards for data collection is key to creating interoperative, searchable genomic and clinical databases. We highlight here the 1+Million Genomes Minimal Dataset for Cancer, encompassing 140 items in 8 domains to foster the collection of cancer data, inform transnational cooperation and advance precision cancer medicine.

ObjectiveContaminated duodenoscopes caused several hospital outbreaks. Despite efforts to reduce contamination rates, 15% of patient-ready duodenoscopes are still contaminated with gastrointestinal microorganisms. This study aimed to provide an overview of duodenoscope contamination over time, identify risk factors and study the effects of implemented interventions.DesignDuodenoscope culture sets between March 2015 and June 2022 at a Dutch tertiary care centre were analysed. Contamination was defined as (1) the presence of microorganisms of oral or gastrointestinal origin (MGO) or (2) any other microorganism with ≥20 colony-forming units/20 mL (AM20). A logistic mixed effects model was used to identify risk factors and assess the effect of interventions, such as using duodenoscopes with disposable caps, replacing automated endoscope reprocessors (AER) and conducting audits in the endoscopy department.ResultsA total of 404 culture sets were analysed. The yearly contamination rate with MGO showed great variation, ranging from 14.3% to 47.5%. Contamination with AM20 increased up to 94.7% by 2022. For both MGO and AM20, the biopsy and suction channels were the most frequently contaminated duodenoscope components. The studied interventions, including audits, AER replacement and implementation of duodenoscopes with disposable caps, did not show a clear association with contamination rates.ConclusionDuodenoscope contamination remains a significant problem, with high contamination rates despite several interventions. Reprocessing the biopsy and suction channels is especially challenging. Changes in the design of reusable duodenoscopes, such as enabling sterilisation or easily replaceable channels, are necessary to facilitate effective duodenoscope reprocessing and to eliminate the risk of duodenoscope-associated infections.

Clarithromycin resistance of Helicobacter pylori(H. pylori) represents a major challenge in eradication therapy. In this study, we assessed if non‐invasive stool tests can be used to verify successful H. pylorieradication and determine clarithromycin resistance. In this prospective study, patients undergoing urea breath testing (UBT) for confirmation of H. pylorieradication were asked to collect the stool as both a dry fecal sample and fecal immunochemical test (FIT). Stool H. pyloriantigen testing (SAT) was performed on these samples and assessed for its accuracy in eradication verification. Type and duration of antibiotic treatment were retrospectively collected from patient records and compared with clarithromycin resistance determined by PCR of stool samples. H. pylorieradication information was available for a total of 145 patients (42.7% male, median age: 51.2). Successful eradication was achieved in 68.1% of patients. SAT on FIT samples had similar accuracy for eradication assessment compared to dry fecal samples, 72.1% [95% CI 61.4–81.2] versus 72.2% [95% CI 60.9–81.7]. Clarithromycin resistance rate was 13.4%. H. pyloriantigen testing on FIT stool samples to verify H. pylorieradication is feasible and has similar accuracy as H. pyloriantigen testing on dry stool samples. Dry stool, but not FIT, was suitable for non‐invasive identification of H. pyloriclarithromycin resistance by rt‐PCR personalizing antibiotic treatment strategies without the need for invasive diagnostics is desirable, as the cure rate of first‐line empirical H. pyloritreatment remains low.

The root cause for biliary pancreatitis is a transient impediment of the outflow of secretion from the pancreatic duct due to gallstones and sludge obstructing the ampulla of Vater. Based on meta-analyses and recent studies, clear recommendations can be formulated when and when not to perform an ERC in patients with biliary pancreatitis. ERC is indicated urgently in patients with biliary pancreatitis and concomitant cholangitis. Urgent ERC is not indicated in patients with predicted mild or severe biliary pancreatitis without cholangitis, even when stones or sludge are proven on EUS imaging.

Surveillance of pancreatic cysts focuses on the detection of (mostly morphologic) features warranting surgery. European guidelines consider elevated CA19.9 as a relative indication for surgery. We aimed to evaluate the role of CA19.9 monitoring for early detection and management in a cyst surveillance population. The PACYFIC‐registry is a prospective collaboration that investigates the yield of pancreatic cyst surveillance performed at the discretion of the treating physician. We included participants for whom at least one serum CA19.9 value was determined by a minimum follow‐up of 12 months. Of 1865 PACYFIC participants, 685 met the inclusion criteria for this study (mean age 67 years, SD 10; 61% female). During a median follow‐up of 25 months (IQR 24, 1966 visits), 29 participants developed high‐grade dysplasia (HGD) or pancreatic cancer. At baseline, CA19.9 ranged from 1 to 591 kU/L (median 10 kU/L [IQR 14]), and was elevated (≥37 kU/L) in 64 participants (9%). During 191 of 1966 visits (10%), an elevated CA19.9 was detected, and these visits more often led to an intensified follow‐up (42%) than those without an elevated CA19.9 (27%; p< 0.001). An elevated CA19.9 was the sole reason for surgery in five participants with benign disease (10%). The baseline CA19.9 value was (as continuous or dichotomous variable at the 37 kU/L threshold) not independently associated with HGD or pancreatic cancer development, whilst a CA19.9 of ≥ 133 kU/L was (HR 3.8, 95% CI 1.1–13, p= 0.03). In this pancreatic cyst surveillance cohort, CA19.9 monitoring caused substantial harm by shortening surveillance intervals (and performance of unnecessary surgery). The current CA19.9 cutoff was not predictive of HGD and pancreatic cancer, whereas a higher cutoff may decrease false‐positive values. The role of CA19.9 monitoring should be critically appraised prior to implementation in surveillance programs and guidelines.

Introduction: Bacterial meningitis in infants is an infrequent but life-threatening condition. Empiric therapy should begin as soon as meningitis is thought likely. Consequently, the causative microorganisms may not always be detected using culturing techniques, as cerebrospinal fluid (CSF) cultures are influenced by antibiotics. Nucleic acid amplification tests, such as polymerase chain reaction (PCR) (multiplex panels), may overcome this limitation but require a priori knowledge of the likely pathogen present within the sample. With this in mind, we investigated to what extent a culture-free, broad-range 16S rRNA gene next-generation sequencing (NGS) platform (MYcrobiota) could add to the microbiological diagnosis of meningitis. Methods: Retrospective cohort study at level III neonatal intensive care unit. Included were all infants with suspected meningitis admitted between 10 November 2017 and 31 December 2020. A comparison was made of the bacterial pathogen detection rate between MYcrobiota and conventional bacterial culture. Results: In a 3-year period, 37 CSF samples (diagnostic and follow-up) from 35 infants with proven or possible meningitis were available for MYcrobiota testing. MYcrobiota detected the presence of bacterial pathogens in 11 samples (30%), in contrast with the conventional CSF culture, which detected bacteria in 2 of 36 samples (5.6%). Conclusion: Addition of 16S rRNA sequencing to conventional culturing greatly improved the identification of the aetiology of bacterial meningitis compared to culturing of CSF samples alone.

A clinical diagnosis of multiple endocrine neoplasia type 1 (MEN1) syndrome is usually confirmed with genetic testing in the germline. It is expected that menin protein expression is lost in MEN1-related tumors. Therefore, we investigated the potential of menin immunohistochemistry in parathyroid adenomas as an additional tool in the recognition and genetic diagnosis of MEN1 syndrome. Local pathology archives were searched for parathyroid tumors from patients with MEN1 syndrome and without MEN1, including sporadic, patients with multiple endocrine neoplasia type 2A and hyperparathyroidism-jaw parathyroid tumors. Menin immunohistochemistry was performed and its use to identify MEN1-related tumors was assessed. Twenty-nine parathyroid tumors from 16 patients with MEN1 and 61 patients with parathyroid tumors from 32 non-MEN1 were evaluated. Immunohistochemical nuclear menin loss in one or more tumors was found in 100% of patients with MEN1 and 9% of patients with non-MEN1. In patients with multiple tumors, menin loss in at least one tumor was seen in 100% of 8 patients with MEN1 and 21% of patients with 14 non-MEN1. Using a cutoff of at least 2 tumors showing menin loss per patient, the positive and negative predictive values for the diagnosis MEN1 were both 100%. The practical and additional value of menin immunohistochemistry in clinical genetic MEN1 diagnosis is further illustrated by menin immunohistochemistry in 2 cases with a germline variant of unknown significance in the MEN1gene. Menin immunohistochemistry is useful in the recognition of MEN1syndrome as well as in the clinical genetic analysis of patients with inconclusive MEN1germline testing.

Immunocompromised populations, such as organ transplant recipients and patients with inflammatory bowel disease (IBD) receiving immunosuppressive/immunomodulatory medications, may be more susceptible to coronavirus infections. However, little is known about how immunosuppressants affect coronavirus replication and their combinational effects with antiviral drugs. This study aims to profile the effects of immunosuppressants and the combination of immunosuppressants with oral antiviral drugs molnupiravir and nirmatrelvir on pan‐coronavirus infection in cell and human airway organoids (hAOs) culture models. Different coronaviruses (including wild type, delta and omicron variants of SARS‐CoV‐2, and NL63, 229E and OC43 seasonal coronaviruses) were used in lung cell lines and hAOs models. The effects of immunosuppressants were tested. Dexamethasone and 5‐aminosalicylic acid moderately stimulated the replication of different coronaviruses. Mycophenolic acid (MPA), 6‐thioguanine (6‐TG), tofacitinib and filgotinib treatment dose‐dependently inhibited viral replication of all tested coronaviruses in both cell lines and hAOs. The half maximum effective concentration (EC50) of tofacitinib against SARS‐CoV‐2 was 0.62 μM and the half maximum cytotoxic concentration (CC50) was above 30 μM, which resulted in a selective index (SI) of about 50. The anti‐coronavirus effect of the JAK inhibitors tofacitinib and filgotinib is dependent on the inhibition of STAT3 phosphorylation. Combinations of MPA, 6‐TG, tofacitinib, and filgotinib with the oral antiviral drugs molnupiravir or nirmatrelvir exerted an additive or synergistic antiviral activity. Different immunosuppressants have distinct effects on coronavirus replication, with 6‐TG, MPA, tofacitinib and filgotinib possessing pan‐coronavirus antiviral activity. The combinations of MPA, 6‐TG, tofacitinib and filgotinib with antiviral drugs exerted an additive or synergistic antiviral activity. Thus, these findings provide an important reference for optimal management of immunocompromised patients infected with coronaviruses.

Various volumes of bowel preparation are used in clinical practice. There is conflicting data on the effectiveness of individual regimens. This study aims to evaluate the efficacy and compliance of currently used bowel preparations with the European Society of Gastrointestinal Endoscopy (ESGE) performance measures using data of the Dutch nationwide colorectal cancer screening (CRC) program. In a prospective, multicenter endoscopy database, we identified all CRC screening colonoscopies performed in 15 Dutch endoscopy centers from 2016 to 2020. We excluded procedures without documented bowel preparation or the Boston Bowel Preparation Scale (BBPS) score. Bowel preparation regimens were categorized into three groups, that is, 4‐L (polyethylene glycol (PEG)), 2‐L (2‐L PEG with ascorbic acid) and ≤1‐L volumes (sodium picosulfate with magnesium citrate, 1L‐PEG with sodium sulfate and ascorbic acid or oral sulfate solution). European Society of Gastrointestinal Endoscopy performance measures included adequate BBPS score (≥6) (>90%), cecal intubation rate (CIR, >90%), adenoma detection rate (ADR, >25%) and polyp detection rate (PDR, >40%). Logistic regression was performed to identify predictive factors for adequate BBPS and patient discomfort. A total of 39,042 CRC screening colonoscopies were included. Boston Bowel Preparation Scale scores, CIR, ADR and PDR for 4L, 2L and ≤1L regimens all met the minimum ESGE performance measures standards. However, an adequate BBPS score was more frequently seen with 2L regimens (98.0%) as compared to 4L (97.1%) and ≤1L regimens (97.0%) (p< 0.001), respectively. In addition, CIR was higher for ≤1L (98.4%) versus 4L (97.7%) and 2L (97.9%) regimens (p= 0.001), ADR higher for lower volume (≤1L (60.0%) and 2L (61.2)) versus higher volume (4L (58.6%)) regimens (p< 0.001), and PDR higher for ≤1L (70.0%) and 2L (70.8%) versus 4L (67.2%) regimens (p< 0.001). Boston Bowel Preparation Scale for ≤1L regimens was higher when combined with bisacodyl (97.3%) than without (95.6%) (p< 0.001). Overall, bisacodyl use was independently associated with higher patient discomfort (odds ratios = 1.47, confidence intervals = 1.26–1.72). Despite variations in bowel preparation volumes, all regimens meet the minimum ESGE performance measures for bowel preparation and other quality parameters. Boston Bowel Preparation Scale can be further improved if ultra low volume regimens are combined with bisacodyl. The choice for either bowel preparation volume can therefore be based on volume‐tolerance and patient preference.

Many lymphoid malignancies arise from deregulated c-MYC expression in cooperation with additional genetic lesions. While many of these cooperative genetic lesions have been discovered and their functions characterised, DNA sequence data of primary patient samples suggest that many more do exist. However, the nature of their contributions to c-MYC driven lymphomagenesis have not yet been investigated. We identified TFAP4 as a potent suppressor of c-MYC driven lymphoma development in a previous genome-wide CRISPR knockout screen in primary cells in vivo [1]. CRISPR deletion of TFAP4 in Eµ-MYCtransgenic haematopoietic stem and progenitor cells (HSPCs) and transplantation of these manipulated HSPCs into lethally irradiated animals significantly accelerated c-MYC-driven lymphoma development. Interestingly, TFAP4 deficient Eµ-MYClymphomas all arose at the pre-B cell stage of B cell development. This observation prompted us to characterise the transcriptional profile of pre-B cells from pre-leukaemic mice transplanted with Eµ-MYC/Cas9HSPCs that had been transduced with sgRNAs targeting TFAP4. This analysis revealed that TFAP4 deletion reduced expression of several master regulators of B cell differentiation, such as Spi1, SpiBand Pax5, which are direct target genes of both TFAP4 and MYC. We therefore conclude that loss of TFAP4 leads to a block in differentiation during early B cell development, thereby accelerating c-MYC-driven lymphoma development.

Langerhans cell histiocytosis (LCH) is a rare neoplastic disorder caused by somatic genetic alterations in hematopoietic precursor cells differentiating into CD1a+/CD207+ histiocytes. LCH clinical manifestation is highly heterogeneous. BRAF and MAP2K1 mutations account for ∼80% of genetic driver alterations in neoplastic LCH cells. However, their clinical associations remain incompletely understood. Here, we present an international clinicogenomic study of childhood LCH, investigating 377 patients genotyped for at least BRAFV600E. MAPK pathway gene alterations were detected in 300 (79.6%) patients, including 191 (50.7%) with BRAFV600E, 54 with MAP2K1 mutations, 39 with BRAF exon 12 mutations, 13 with rare BRAF alterations, and 3 with ARAF or KRAS mutations. Our results confirm that BRAFV600E associates with lower age at diagnosis and higher prevalence of multisystem LCH, high-risk disease, and skin involvement. Furthermore, BRAFV600E appeared to correlate with a higher prevalence of central nervous system (CNS)–risk bone lesions. In contrast, MAP2K1 mutations associated with a higher prevalence of single-system (SS)-bone LCH, and BRAF exon 12 deletions seemed to correlate with more lung involvement. Although BRAFV600E correlated with reduced event-free survival in the overall cohort, neither BRAF nor MAP2K1 mutations associated with event-free survival when patients were stratified by disease extent. Thus, the correlation of BRAFV600E with inferior clinical outcome is (primarily) driven by its association with disease extents known for high rates of progression or relapse, including multisystem LCH. These findings advance our understanding of factors underlying the remarkable clinical heterogeneity of LCH but also question the independent prognostic value of lesional BRAFV600E status.

Graphical abstract:

Graphical Abstract: Exploring the limits of Fe3+solid solution in calcium hexaluminate.

Randomized trials in acute myeloid leukemia (AML) have demonstrated improved survival by the BCL-2 inhibitor venetoclax combined with azacitidine in older patients, and clinical trials are actively exploring the role of venetoclax in combination with intensive chemotherapy in fitter patients with AML. As most patients still develop recurrent disease, improved understanding of relapse mechanisms is needed. We find that 17% of patients relapsing after venetoclax-based therapy for AML have acquired inactivating missense or frameshift/nonsense mutations in the apoptosis effector gene BAX. In contrast, such variants were rare after genotoxic chemotherapy. BAX variants arose within either leukemic or preleukemic compartments, with multiple mutations observed in some patients. In vitro, AML cells with mutated BAX were competitively selected during prolonged exposure to BCL-2 antagonists. In model systems, AML cells rendered deficient for BAX, but not its close relative BAK, displayed resistance to BCL-2 targeting, whereas sensitivity to conventional chemotherapy was variable. Acquired mutations in BAX during venetoclax-based therapy represent a novel mechanism of resistance to BH3-mimetics and a potential barrier to the long-term efficacy of drugs targeting BCL-2 in AML.

Many therapeutic interventions in psychiatry can be viewed as attempts to influence the brain’s large-scale, dynamic network state transitions. Building on connectome-based graph analysis and control theory, Network Control Theory is emerging as a powerful tool to quantify network controllability—i.e., the influence of one brain region over others regarding dynamic network state transitions. If and how network controllability is related to mental health remains elusive. Here, from Diffusion Tensor Imaging data, we inferred structural connectivity and inferred calculated network controllability parameters to investigate their association with genetic and familial risk in patients diagnosed with major depressive disorder (MDD, n= 692) and healthy controls (n= 820). First, we establish that controllability measures differ between healthy controls and MDD patients while not varying with current symptom severity or remission status. Second, we show that controllability in MDD patients is associated with polygenic scores for MDD and psychiatric cross-disorder risk. Finally, we provide evidence that controllability varies with familial risk of MDD and bipolar disorder as well as with body mass index. In summary, we show that network controllability is related to genetic, individual, and familial risk in MDD patients. We discuss how these insights into individual variation of network controllability may inform mechanistic models of treatment response prediction and personalized intervention-design in mental health.

ObjectiveRoutine urgent endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (ES) does not improve outcome in patients with predicted severe acute biliary pancreatitis. Improved patient selection for ERCP by means of endoscopic ultrasonography (EUS) for stone/sludge detection may challenge these findings.DesignA multicentre, prospective cohort study included patients with predicted severe acute biliary pancreatitis without cholangitis. Patients underwent urgent EUS, followed by ERCP with ES in case of common bile duct stones/sludge, within 24 hours after hospital presentation and within 72 hours after symptom onset. The primary endpoint was a composite of major complications or mortality within 6 months after inclusion. The historical control group was the conservative treatment arm (n=113) of the randomised APEC trial (Acute biliary Pancreatitis: urgent ERCP with sphincterotomy versus conservative treatment, patient inclusion 2013–2017) applying the same study design.ResultsOverall, 83 patients underwent urgent EUS at a median of 21 hours (IQR 17–23) after hospital presentation and at a median of 29 hours (IQR 23–41) after start of symptoms. Gallstones/sludge in the bile ducts were detected by EUS in 48/83 patients (58%), all of whom underwent immediate ERCP with ES. The primary endpoint occurred in 34/83 patients (41%) in the urgent EUS-guided ERCP group. This was not different from the 44% rate (50/113 patients) in the historical conservative treatment group (risk ratio (RR) 0.93, 95% CI 0.67 to 1.29; p=0.65). Sensitivity analysis to correct for baseline differences using a logistic regression model also showed no significant beneficial effect of the intervention on the primary outcome (adjusted OR 1.03, 95% CI 0.56 to 1.90, p=0.92).ConclusionIn patients with predicted severe acute biliary pancreatitis without cholangitis, urgent EUS-guided ERCP with ES did not reduce the composite endpoint of major complications or mortality, as compared with conservative treatment in a historical control group.Trial registration numberISRCTN15545919.

ObjectiveLumen-apposing metal stents (LAMS) are believed to clinically improve endoscopic transluminal drainage of infected necrosis when compared with double-pigtail plastic stents. However, comparative data from prospective studies are very limited.DesignPatients with infected necrotising pancreatitis, who underwent an endoscopic step-up approach with LAMS within a multicentre prospective cohort study were compared with the data of 51 patients in the randomised TENSION trial who had been assigned to the endoscopic step-up approach with double-pigtail plastic stents. The clinical study protocol was otherwise identical for both groups. Primary end point was the need for endoscopic transluminal necrosectomy. Secondary end points included mortality, major complications, hospital stay and healthcare costs.ResultsA total of 53 patients were treated with LAMS in 16 hospitals during 27 months. The need for endoscopic transluminal necrosectomy was 64% (n=34) and was not different from the previous trial using plastic stents (53%, n=27)), also after correction for baseline characteristics (OR 1.21 (95% CI 0.45 to 3.23)). Secondary end points did not differ between groups either, which also included bleeding requiring intervention—5 patients (9%) after LAMS placement vs 11 patients (22%) after placement of plastic stents (relative risk 0.44; 95% CI 0.16 to 1.17). Total healthcare costs were also comparable (mean difference −€6348, bias-corrected and accelerated 95% CI −€26 386 to €10 121).ConclusionOur comparison of two patient groups from two multicentre prospective studies with a similar design suggests that LAMS do not reduce the need for endoscopic transluminal necrosectomy when compared with double-pigtail plastic stents in patients with infected necrotising pancreatitis. Also, the rate of bleeding complications was comparable.

Whole-genome screens using CRISPR technologies are powerful tools to identify novel tumour suppressors as well as factors that impact responses of malignant cells to anti-cancer agents. Applying this methodology to lymphoma cells, we conducted a genome-wide screen to identify novel inhibitors of tumour expansion that are induced by the tumour suppressor TRP53. We discovered that the absence of Arrestin domain containing 3 (ARRDC3) increases the survival and long-term competitiveness of MYC-driven lymphoma cells when treated with anti-cancer agents that activate TRP53. Deleting Arrdc3in mice caused perinatal lethality due to various developmental abnormalities, including cardiac defects. Notably, the absence of ARRDC3 markedly accelerated MYC-driven lymphoma development. Thus, ARRDC3 is a new mediator of TRP53-mediated suppression of tumour expansion, and this discovery may open new avenues to harness this process for cancer therapy.

Battery thermal management systems are critical for high-performance electric vehicles, where the ability to remove heat and homogenize temperature distributions in single cells and packs are key considerations. Immersion cooling, which immerses the battery in a dielectric fluid, can improve cooling efficiency compared to air cooling. However, stringent instrumentation standards make in-situ monitoring under immersion cooling a difficult challenge. This study proposes a novel cell instrumentation method based on the integrated combination of three O-rings, which for the first time achieves in-situ temperature sensing of batteries under oil-immersed cooling conditions. Reliability of the sealing system and instrumentation methodology is ensured by leakage tests and oil corrosion assessment. Data such as cell impedance and discharge capacity also support the success and reliability of the instrumentation process without affecting the battery performance. Compared with natural air cooling, immersion cooling can reduce the temperature rise during battery operation by >10 °C under high C-rate discharge conditions. However, this is accompanied by an increase in radial temperature gradient. The temperature gradient of the cell with oil immersed reaches a maximum of >7 °C, while the temperature gradient under natural cooling under the same test conditions is only 3 to 4 °C. This leads to intensified temperature inhomogeneity of the cell, which may accelerate the local ageing and degradation. Our instrumentation approach contributes to a deeper understanding of the thermal behaviour of batteries under direct immersion cooling, aiding the development of more advanced cooling strategies and associated battery thermal management models.

IMPORTANCE: Glucose control in patients after total pancreatectomy is problematic because of the complete absence of α- and β-cells, leading to impaired quality of life. A novel, bihormonal artificial pancreas (BIHAP), using both insulin and glucagon, may improve glucose control, but studies in this setting are lacking. OBJECTIVE: To assess the efficacy and safety of the BIHAP in patients after total pancreatectomy. DESIGN, SETTING, AND PARTICIPANTS: This randomized crossover clinical trial compared the fully closed-loop BIHAP with current diabetes care (ie, insulin pump or pen therapy) in 12 adult outpatients after total pancreatectomy. Patients were recruited between August 21 and November 16, 2020. This first-in-patient study began with a feasibility phase in 2 patients. Subsequently, 12 patients were randomly assigned to 7-day treatment with the BIHAP (preceded by a 5-day training period) followed by 7-day treatment with current diabetes care, or the same treatments in reverse order. Statistical analysis was by Wilcoxon signed rank and Mann-Whitney U tests, with significance set at a 2-sided P &lt; .05. MAIN OUTCOMES AND MEASURES: The primary outcome was the percentage of time spent in euglycemia (70-180 mg/dL [3.9-10 mmol/L]) as assessed by continuous glucose monitoring. RESULTS: In total, 12 patients (7 men and 3 women; median [IQR] age, 62.5 [43.1-74.0] years) were randomly assigned, of whom 3 did not complete the BIHAP phase and 1 was replaced. The time spent in euglycemia was significantly higher during treatment with the BIHAP (median, 78.30%; IQR, 71.05%-82.61%) than current diabetes care (median, 57.38%; IQR, 52.38%-81.35%; P = .03). In addition, the time spent in hypoglycemia (&lt;70 mg/dL [3.9 mmol/L]) was lower with the BIHAP (median, 0.00% [IQR, 0.00%-0.07%] vs 1.61% [IQR, 0.80%-3.81%]; P = .004). No serious adverse events occurred. CONCLUSIONS AND RELEVANCE: Patients using the BIHAP after total pancreatectomy experienced an increased percentage of time in euglycemia and a reduced percentage of time in hypoglycemia compared with current diabetes care, without apparent safety risks. Larger randomized trials, including longer periods of treatment and an assessment of quality of life, should confirm these findings. TRIAL REGISTRATION: trialregister.nl Identifier: NL8871

The effect of coating parameters of NMC622 cathodes and graphite anodes on their physical structure and half-cell electrochemical performance is evaluated by design of experiments. Coating parameters include the coater comma bar gap, coating ratio and web speed. The electrochemical properties studied are gravimetric and volumetric capacity, rate performance, areal specific impedance (ASI) and C-rate. Differences in the manufacturing effects on the electrode physical structure and electrochemical performance are observed between the electrodes and are modelled by linear regression. The effect of cell coating weight and porosity on half-coin cell electrochemical performance is also evaluated by linear regression. The cathode performance at high gravimetric and volumetric C-rates is mainly influenced by coating weight, whereas porosity is the only explanatory variable for volumetric C-rates of 1C and below. For anode, correlations are only found for the C/20 and 5C gravimetric and volumetric capacities and are related to coating weight. An inverse relationship between ASI and coating weight is observed for cathode, but in general the cell physical characteristics cannot completely explain the observed ASI for both electrodes. The obtained models are useful for the design and robust manufacturing of electrodes since present a quantitative relationship between the coating parameters, cell characteristics and final cell electrochemical performance.

Due to requirements of the ongoing Global War on Terrorism, the United States military must continue to learn as much as possible about the nature of combat leadership. The Civil [...]

Studies on genetic variation in model organisms, namely, zebrafish, can clarify rate and composition as well as distribution and organization of polymorphic loci in the genome and analysis reveal very high nucleotide diversity between zebrafish isolates. It is stated that the levels and organisation of genetic variation between and within commonly used zebrafish strains are markedly different from other laboratory model organisms.

After finishing the basic infantry officer course at Fort Benning, I looked forward to a career of what I thought would be distinctly infantry experiences such as maneuvering M2 Bradley [...]

The United States Army is committed to a comprehensive program of change that it calls Transformation. The challenges associated with force downsizing since the 1991 Gulf War, a new age [...]

•Water disparities in Kabul arise from geographic, socio-economic, environmental, and political (geosocial) factors.•Disproportionate water prices in Kabul, trucked costs 33 times piped water.•Drought, contamination, & electricity issues amplify water insecurity.•Emphasizes collaboration with gatekeepers for sustainable water interventions.•Calls for a geosocial approach, integrating both quantitative and qualitative research to measure water (in)security at the sub-basin level.

Complex biomolecular technologies revolutionise scientific research. Fully embedding scientific advances in the community requires innovative ways to educate learners on the molecular foundations upon which these technologies are based. In this case study, we present the conception and design of Walter and Eliza Hall Institute of Medical Research (WEHI’s) inaugural wholly online learning course focussed on explaining the revolutionary genome-editing technology, clustered regulatory interspaced palindromic repeats (CRISPR). Utilising WEHI’s strength in bringing science educators and world-leading CRISPR scientists together, we designed a multimodal online resource that introduces learners, without an extensive background in either science or genome editing, to the fundamental concepts of CRISPR technology. Using the online course creation tool, Articulate 360, we guided learners through three modules containing targeted lessons designed to focus on specific learning outcomes. Integrated videos, research articles, interviews, and other resources, allowed for self-paced learning that met various learning style needs. The extensive resources provided opportunities to delve deeper into the content for advanced learners. The effectiveness of the course, evaluated with survey responses collected upon completion of the course, highlighted the ease of use and functionality of the course, and an increased understanding of CRISPR technology after course completion. We anticipate future online learning course development to showcase complex molecular technology that will be valuable for tertiary education, as well as for those in the wider community interested in understanding important advances in biomedicine.

Drug-resistant pathogens pose a global challenge to public health as they cause diseases that are extremely difficult to cure. Metallo-β-lactamases (MBLs) are a diverse set of zinc-containing enzymes that catalyze the hydrolysis of β-lactam drugs, including carbapenems, which are considered as the last resort to fight severe infections. To restore the activity of current β-lactam antibiotics and to offer an orthogonal strategy to the discovery of new antibiotics, we have identified a series of polar N-aryl mercaptopropionamide derivatives as potent inhibitors of several class B1 MBLs. We have identified a hit structure with high selectivity restoring the effect of imipenem and reducing minimum inhibitory concentration (MIC) values up to 256-fold in resistant isolates from Escherichia coli. Furthermore, the combination of imipenem with our inhibitor showed in vivoefficacy in a Galleria mellonellamodel, increasing the survival rate of infected larvae by up to 31%.

Identifying branch‐duct intraductal papillary mucinous neoplasms (BD‐IPMNs) at lowest risk of progression may allow for a reduced intensity of surveillance. We aimed to externally validate the previously developed Dutch‐American Risk stratification Tool (DART‐1; https://rtools.mayo.edu/DART/), which identifies cysts at low risk of developing worrisome features (WFs) or high‐risk stigmata (HRS). Three prospective cohorts of individuals under surveillance for BD‐IPMNs were combined, independent from the original development cohort. We assessed the performance (discrimination and calibration) of DART‐1, a multivariable Cox‐proportional logistic regression model with five predictors for the development of WFs or HRS. Of 832 individuals (mean age 77 years, SD 11.5) under surveillance for a median of 40 months (IQR 44), 163 (20%) developed WFs or HRS. DART‐1's discriminative ability (C‐statistic 0.68) was similar to that in the development cohort (0.64–0.72) and showed moderate calibration. DART‐1 adequately estimated the risk for patients in the middle risk quintile, and slightly underestimated it in the lowest quintiles. Their range of predicted versus observed 3‐year risk was 0%–0% versus 0%–3.7% for Q1; 0.3%–0.4% versus 3%–11% for Q2; and 2.6%–3% versus 2.4%–9.8% for Q3. The development of WFs or HRS was associated with pancreatic cancer (p< 0.001). Vice versa, in absence of WFs or HRS, the risk of malignancy was low (0.3%). The performance of DART‐1 to predict the development of WFs or HRS in BD‐IPMN was validated in an external international cohort, with a discriminative ability equal as in the development cohort. Risk estimations were most accurate for patients with BD‐IPMNs in the middle risk quintile and slightly underestimated in the lowest quintiles.

ObjectiveWe aimed to determine the long-term yield of pancreatic cancer surveillance in hereditary predisposed high-risk individuals.DesignFrom 2006 to 2019, we prospectively enrolled asymptomatic individuals with an estimated 10% or greater lifetime risk of pancreatic ductal adenocarcinoma (PDAC) after obligatory evaluation by a clinical geneticist and genetic testing, and subjected them to annual surveillance with both endoscopic ultrasonography (EUS) and MRI/cholangiopancreatography (MRI/MRCP) at each visit.Results366 individuals (201 mutation-negative familial pancreatic cancer (FPC) kindreds and 165 PDAC susceptibility gene mutation carriers; mean age 54 years, SD 9.9) were followed for 63 months on average (SD 43.2). Ten individuals developed PDAC, of which four presented with a symptomatic interval carcinoma and six underwent resection. The cumulative PDAC incidence was 9.3% in the mutation carriers and 0% in the FPC kindreds (p<0.001). Median PDAC survival was 18 months (range 1–32). Surgery was performed in 17 individuals (4.6%), whose pathology revealed 6 PDACs (3 T1N0M0), 7 low-grade precursor lesions, 2 neuroendocrine tumours <2 cm, 1 autoimmune pancreatitis and in 1 individual no abnormality. There was no surgery-related mortality. EUS detected more solid lesions than MRI/MRCP (100% vs 22%, p<0.001), but less cystic lesions (42% vs 83%, p<0.001).ConclusionThe diagnostic yield of PDAC was substantial in established high-risk mutation carriers, but non-existent in the mutation-negative proven FPC kindreds. Nevertheless, timely identification of resectable lesions proved challenging despite the concurrent use of two imaging modalities, with EUS outperforming MRI/MRCP. Overall, surveillance by imaging yields suboptimal results with a clear need for more sensitive diagnostic markers, including biomarkers.

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