Trends and outcomes of hospitalized patients with priapism in Germany: results from the GRAND study

We aimed to provide evidence on the trends and in-hospital outcomes of patients with low- and high-flow priapism through the largest study in the field. We used the GeRmAn Nationwide inpatient Data (GRAND), provided by the Research Data Center of the Federal Bureau of Statistics (2008-2021), and performed multiple patient-level analyses. We included 6,588 men with low-flow and 729 with high-flow priapism. Among patients with low-flow priapism, 156 (2.4%) suffered from sickle cell disease, and 1,477 (22.4%) patients required shunt surgery. Of them, only 37 (2.5%) received a concomitant penile prosthesis implantation (30 inflatable and 7 semi-rigid prosthesis). In Germany, the total number of patients with low-flow priapism requiring hospital stay has steadily increased, while the number of patients with high-flow priapism requiring hospital stay has decreased in the last years. Among patients with high-flow priapism, 136 (18.7%) required selective artery embolization. In men with low-flow priapism, sickle cell disease was associated with high rates of exchange transfusion (OR: 21, 95% CI: 14-31, p < 0.001). The length of hospital stay (p = 0.06) and the intensive care unit admissions (p = 0.9) did not differ between patients with low-flow priapism due to sickle cell disease versus other causes of low-flow priapism. Accordingly, in men with high-flow priapism, embolization was not associated with worse outcomes in terms of length of hospital stay (p > 0.9), transfusion (p = 0.8), and intensive care unit admission (p = 0.5). Low-flow priapism is an absolute emergency that requires shunt surgery in more than one-fifth of all patients requiring hospital stay. On the contrary, high-flow priapism is still managed, in most cases, conservatively.

[68Ga]Ga-FAPI-46 PET/CT for penile cancer - a feasibility study

PURPOSE

Penile cancer is a rare entity and has a good prognosis in localized stage. Delayed surgical treatment of lymphatic disease is associated with poor overall survival but conventional imaging cannot detect occult lymph node metastasis sufficiently. Imaging cancer related fibroblasts has shown promising results as non-invasive staging tool in various tumor entities but has not yet been evaluated in penile cancer.

METHODS

In this single-center pilot study, patients planned for surgical treatment for penile cancer underwent preoperatively [68Ga]Ga-FAPI-46 PET/CT. Post-operative histopathology was compared to [68Ga]Ga-FAPI-46 PET/CT results.

RESULTS

From January 2022 to June 2022, a total number 11 patients with histopathologically proven penile cancer underwent surgery and received [68Ga]Ga-FAPI-46 PET/CT prior therapy. 8 primary tumor sites and 4 lymph node regions were analyzed. FAPI uptake was increased on primary tumor site (SUVmax 16.2 (9.1 - 25.8)). Histopathological proven lymph node regions showed highly increased FAPI uptakes (SUVmax 17.9 (16.4 - 23.5) on [68Ga]Ga-FAPI-46 PET/CT.

CONCLUSION

In this first pilot cohort, there were no false-positive FAPI uptake which might allow the detection of occult lymph node metastasis by [68Ga]Ga-FAPI-46 PET/CT and might consequently lead to omitting lymph node regions during surgery that had no increased FAPI uptake pre-operatively.

Added value of randomised biopsy to multiparametric magnetic resonance imaging-targeted biopsy of the prostate in a contemporary cohort

OBJECTIVE

To assess the added value of concurrent systematic randomised ultrasonography-guided biopsy (SBx) to multiparametric magnetic resonance imaging (mpMRI)-targeted biopsy and the additional rate of overdiagnosis of clinically insignificant prostate cancer (ciPCa) by SBx in a large contemporary, real-world cohort.

PATIENTS AND METHODS

A total of 1552 patients with positive mpMRI and consecutive mpMRI-targeted biopsy and SBx were enrolled. Added value and the rate of overdiagnosis by SBx was evaluated.

PRIMARY OUTCOME

added value of SBx, defined as detection rate of clinically significant PCa (csPCa; International Society of Urological Pathology [ISUP] Grade ≥2) by SBx, while mpMRI-targeted biopsy was negative or showed ciPCa (ISUP Grade 1).

SECONDARY OUTCOME

rate of overdiagnosis by SBx, defined as detection of ciPCa in patients with negative mpMRI-targeted biopsy and PSA level of <10 ng/mL.

RESULTS

Detection rate of csPCa by mpMRI-targeted biopsy and/or SBx was 753/1552 (49%). Added value of SBx was 145/944 (15%). Rate of overdiagnosis by SBx was 146/656 (22%). Added value of SBx did not change when comparing patients with previous prostate biopsy and biopsy naïve patients. In multivariable analysis, a Prostate Imaging-Reporting and Data System (PI-RADS) 4 index lesion (odds ratio [OR] 3.19, 95% confidence interval [CI] 1.66-6.78; P = 0.001), a PI-RADS 5 index lesion (OR 2.89, 95% CI 1.39-6.46; P = 0.006) and age (OR 1.05, 95% CI 1.03-1.08; P < 0.001) were independently associated with added value of SBx.

CONCLUSIONS

In our real-world analysis, we saw a significant impact on added value and added rate of overdiagnosis by SBx. Subgroup analysis showed no significant decrease of added value in any evaluated risk group. Therefore, we do not endorse omitting concurrent SBx to mpMRI-guided biopsy of the prostate.

mpMRI-targeted biopsy of the prostate in men ≥ 75 years. 7-year report from a high-volume referral center

OBJECTIVE

Multiparametric magnetic resonance imaging (mpMRI) -Ultrasound- fusion guided biopsy of the prostate (FBx) is the new gold standard for the detection of prostate cancer. Hallmark studies showing superior detection rates of FBx over randomized biopsies routinely excluded patients≥75 years and information on outcome of FBx on this patient cohort is sparse. As a large referral center, we have performed FBx on a substantial number of patients this age. By evaluating outcome of FBx of patients over the age of 75 years we wanted to close the gap of knowledge on this patient cohort.

MATERIALS AND METHODS

Between 2015 -2022, 1577 patients underwent FBx at our department and were considered for analysis. Clinical and histopathological parameters were recorded. Clinical data comprised age at FBx, serum level of Prostate-specific antigen (PSA), prostate volume, PSA-density, history of previous biopsies of the prostate, result of the digital rectal examination (DRE) and assessment of the indexlesion of mpMRI according to the Prostate Imaging and Reporting Data System (PI-RADS). Univariate analysis and multivariable logistic regression was used to identify age barrier of 75 years as a potential risk factor of detection of clinically significant prostate cancer by FBx.

RESULTS

379/1577 patients (24%) were≥75 years and 1198/1577 (76%) patients were < 75 years, respectively. Preoperative PSA was significantly higher in patients≥75 years compared to patients < 75 years (9.54 vs. 7.8, p < 0.001). Patients≥75 years presented significantly more often with mpMRI target lesions classified as PI-RADS 5 compared to patients < 75 years (45% vs. 29%, p < 0.001). Detection rate of clinically significant prostate cancer was significantly higher in patients≥75 years compared to patients < 75 years (63% vs. 43%, p < 0.001). Aggressive prostate cancer grade ISUP 5 was significantly more often detected in patients≥75 years compared to patients < 75 years (13% vs. 8%, p = 0.03). On multivariable logistic regression model adjusted for PSA and PI-RADS score, age barrier of 75 years was identified as a significant risk factor for the detection of clinically significant prostate cancer by FBx (OR: 1.77, 95% CI: 1.36 -2.31, p < 0.001).

CONCLUSION

After evaluation of a large patient cohort, we show that age≥75 years represents a significant risk factor for the detection of clinically significant prostate cancer. Further studies on mid- and long term outcome are necessary to draw conclusions for clinical decision making in this patient cohort.

Perioperative outcomes of penile prosthesis implantation in Germany: results from the GRAND study

We aimed to assess the recommended annual hospital volume for inflatable penile prosthesis implantation (PPI) and to provide evidence on perioperative outcomes of semi-rigid and inflatable PPI in Germany. We used the GeRmAn Nationwide inpatient Data (GRAND) from 2005 to 2021 and report the largest study to date with 7,222 patients. 6,818 (94.4%) patients underwent inflatable and 404 (5.6%) semi-rigid PPI. Inflatable PPI was significantly associated with shorter length of hospital stay (difference of 2.2 days, 95%CI: 1.6-2.7, p < 0.001), lower odds of perioperative urinary tract infections (5.5% versus 9.2%; OR: 0.58, 95%CI: 0.41-0.84, p = 0.003) and surgical wound infections (1% versus 2.5%; OR: 0.42, 95%CI: 0.22-0.88, p = 0.012) compared to semi-rigid PPI. Overall, 4255 (62.4%) inflatable PPIs were undertaken in low- ( < 20 PPI/year) and 2563 (37.6%) in high-volume ( ≥ 20 PPI/year) centers. High-volume centers were significantly associated with shorter length of hospital stay (difference of 1.4 days, 95%CI: 1.2-1.7, p < 0.001) compared to low-volume centers. Our findings suggest that inflatable PPI leads to a shorter length of hospital stay and lower rates of perioperative urinary tract and surgical wound infections compared to semi-rigid PPI. Patients undergoing surgery in high-volume centers for inflatable PPI are discharged earlier from the hospital.

Specific T-cell receptor beta-rearrangements of gluten-triggered CD8+ T-cells are enriched in celiac disease patients' duodenal mucosa

Celiac disease (CeD) is an autoimmune disorder affecting the small intestine with gluten as disease trigger. Infections including Influenza A, increase the CeD risk. While gluten-specific CD4+ T-cells, recognizing HLA-DQ2/DQ8 presented gluten-peptides, initiate and sustain the celiac immune response, CD8+ α/β intraepithelial T-cells elicit mucosal damage. Here, we subjected TCRs from a cohort of 56 CeD patients and 22 controls to an analysis employing 749 published CeD-related TCRβ-rearrangements derived from gluten-specific CD4+ T-cells and gluten-triggered peripheral blood CD8+ T-cells. We show, that in addition to TCRs from gluten-specific CD4+ T-cells, TCRs of gluten-triggered CD8+ T-cells are significantly enriched in CeD duodenal tissue samples. TCRβ-rearrangements of gluten-triggered CD8+ T-cells were even more expanded in patients than TCRs from gluten-specific CD4+ T-cells (p < 0.0002) and highest in refractory CeD. Sequence alignments with TCR-antigen databases suggest that a subgroup of these most likely indirectly gluten-triggered TCRs recognize microbial, viral, and autoantigens.

The Impact of Prostate Volume on the Prostate Imaging and Reporting Data System (PI-RADS) in a Real-World Setting

Multiparametric magnetic resonance imaging (mpMRI) has emerged as a new cornerstone in the diagnostic pathway of prostate cancer. However, mpMRI is not devoid of factors influencing its detection rate of clinically significant prostate cancer (csPCa). Amongst others, prostate volume has been demonstrated to influence the detection rates of csPCa. Particularly, increasing volume has been linked to a reduced cancer detection rate. However, information about the linkage between PI-RADS, prostate volume and detection rate is relatively sparse. Therefore, the current study aims to assess the association between prostate volume, PI-RADS score and detection rate of csP-Ca, representing daily practice and contemporary mpMRI expertise. Thus, 1039 consecutive patients with 1151 PI-RADS targets, who underwent mpMRI-guided prostate biopsy at our tertiary referral center, were included. Prior mpMRI had been assessed by a plethora of 111 radiology offices, including academic centers and private practices. mpMRI was not secondarily reviewed in house before biopsy. mpMRI-targeted biopsy was performed by a small group of a total of ten urologists, who had performed at least 100 previous biopsies. Using ROC analysis, we defined cut-off values of prostate volume for each PI-RADS score, where the detection rate drops significantly. For PI-RADS 4 lesions, we found a volume > 61.5 ccm significantly reduced the cancer detection rate (OR 0.24; 95% CI 0.16-0.38; p < 0.001). For PI-RADS 5 lesions, we found a volume > 51.5 ccm to significantly reduce the cancer detection rate (OR 0.39; 95% CI 0.25-0.62; p < 0.001). For PI-RADS 3 lesions, none of the evaluated clinical parameters had a significant impact on the detection rate of csPCa. In conclusion, we show that enlarged prostate volume represents a major limitation in the daily practice of mpMRI-targeted biopsy. This study is the first to define exact cut-off values of prostate volume to significantly impair the validity of PI-RADS assessed in a real-world setting. Therefore, the results of mpMRI-targeted biopsy should be interpreted carefully, especially in patients with prostate volumes above our defined thresholds.

Local and Nonlocal Transport Spectroscopy in Planar Josephson Junctions

We report simultaneously acquired local and nonlocal transport spectroscopy in a phase-biased planar Josephson junction based on an epitaxial InAs-Al hybrid two-dimensional heterostructure. Quantum point contacts at the junction ends allow measurement of the 2×2 matrix of local and nonlocal tunneling conductances as a function of magnetic field along the junction, phase difference across the junction, and carrier density. A closing and reopening of a gap was observed in both the local and nonlocal tunneling spectra as a function of magnetic field. For particular tunings of junction density, gap reopenings were accompanied by zero-bias conductance peaks (ZBCPs) in local conductances. End-to-end correlation of gap reopening was strong, while correlation of local ZBCPs was weak. A model of the device, with disorder treated phenomenologically, shows comparable conductance matrix behavior associated with a topological phase transition. Phase dependence helps distinguish possible origins of the ZBCPs.

Additional cycles of docetaxel in combination with androgen deprivation therapy (D-ADT) in metastatic hormone-sensitive prostate cancer (mHSPC): Efficacy and feasibility analysis

185

Background: Several phase III trials have assessed efficacy and safety of 6 cycles of docetaxel combined to androgen deprivation therapy (ADT). This is the current standard of care for a subgroup of patients. We aimed to assess whether treatment beyond 6 cycles of docetaxel prove to be more effective than the standard of care. Methods: We retrospectively analyzed patients with histologically confirmed adenocarcinoma of the prostate and radiologically proven metastatic disease from a large tertiary care center. All patients with mHSPC were treated in first line with ADT in combination with docetaxel (75 mg/m2) (D-ADT) intravenously on the first day of each 21-day cycle. A subset of patients was treated beyond the standard of 6 cycles. Clinical and pathological variables were analyzed, progression free survival on D-ADT (PFS1), progression free survival on subsequent therapy (PFS2) and overall survival (OS) were the endpoints analyzed by log- rank test. Results: Between 2018-2022 a total of 74 mHSPC patients were followed-up for a median time of 13.7 months. Mean age was 66.2 years (range 50.1-82.4), and 79.7% had GS≥8, 73% a CHAARTED high-volume and 76% LATITUDE high risk disease. 43 pts. were treated with ≤ 6 cycles (D-ADTstand) (2.4 % 1-2 cycles; 97.6 % ≥3 cycles; mean 5.3 cycles) and 31 were treated with >6 cycles docetaxel (D-ADTadd) (25.8 % 7-8 cycles; 74.2% ≥9-10 cycles, mean 9.2 cycles). No significant differences were observed in median PFS1 (12.4 vs. 13.7 mos.) and PFS2 (5.4 vs. 9.6 mos.). Median OS in the D-ADTstand group was 39.8 mos., median OS in the D-ADTadd group was not yet reached. Conclusions: While more than 6 cycles of D-ADT in mHSPC proved to be feasible without significant additional toxicity, efficacy is not superior compared to the standard of 6 cycles. Overall survival data is not mature yet, but the benefit of more chemotherapy upfront is debatable and leverages further studies in light of the upcoming triplet combinations in mHSPC, that presumably will render D-ADT obsolete in future. [Table: see text]

Prognostic impact of activin subunit inhibin beta A in gastric and esophageal adenocarcinomas

PURPOSE

Adenocarcinomas of the esophagus (AEG) and stomach (AS) are among the most common cancers worldwide. Novel markers for risk stratification and guiding treatment are strongly needed. Activin is a multi-functional cytokine with context specific pro- and anti-tumorigenic effects. We aimed to investigate the prognostic role of activin tumor protein expression in AEG/ASs.

METHODS

Tissue from a retrospective cohort of 277 patients with AEG/AS treated primarily by surgery at the Charité - Universitätsmedizin Berlin was collected and analyzed by immunohistochemistry using a specific antibody to the activin homodimer inhibin beta A. Additionally, we evaluated T-cell infiltration and PD1 expression as well as expression of PD-L1 by immunohistochemistry as possible confounding factors. Clinico-pathologic data were collected and correlated with activin protein expression.

RESULTS

Out of 277 tumor samples, 72 (26.0%) exhibited high activin subunit inhibin beta A protein expression. Higher expression was correlated with lower Union for International Cancer Control (UICC) stage and longer overall survival. Interestingly, activin subunit expression correlated with CD4+ T-cell infiltration, and the correlation with higher overall survival was exclusively seen in tumors with high CD4+ T-cell infiltration, pointing towards a role of activin in the tumor immune response in AEG/ASs.

CONCLUSION

In our cohort of AEG/AS, higher activin subunit levels were correlated with longer overall survival, an effect exclusively seen in tumors with high CD4+ cell infiltration. Further mechanistic research is warranted discerning the exact effect of this context specific cytokine.

Asymptomatic bacteriospermia and infertility-what is the connection?

OBJECTIVE

To determine the impact of asymptomatic bacteriospermia on semen quality in subfertile men.

METHODS

We conducted a retrospective, single-centre cohort study in 1300 subfertile men. In those diagnosed with asymptomatic bacteriospermia we performed univariate and multivariate logistic regression models to evaluate the strain-specific association with semen parameters.

RESULTS

Asymptomatic bacteriospermia was diagnosed in 3.2% of patients. The microbiological semen analysis revealed a poly-microbial result in 60%. The most common bacterial species were coagulase-negative Staphylococci species (71.4%), Streptococcus viridans (50.0%) and Enterococcus faecalis (26.2%). Sexually transmitted pathogens were identified in 11.9% of semen samples. The detection of Streptococcus viridians or Haemophilus parainfluenzae correlated with impaired sperm morphology (p < 0.05). The presence of coagulase-negative Staphylococci species or Enterococcus faecalis was associated with pathological low counts of live spermatozoa (p < 0.05). In multivariate analysis only Enterococcus faecalis showed a significant impact on sperm concentration (OR 4.48; 95% CI 1.06-22.10; p = 0.041).

CONCLUSIONS

Asymptomatic bacteriospermia has always been a subject of great controversy. There is still an ongoing debate whether to treat or not to treat. Here, we demonstrate that asymptomatic bacteriospermia is clearly associated with impaired semen quality. Our findings speak in favour of strain-specific interactions with semen parameters. Especially Enterococcus faecalis seriously affects sperm concentration.

Pre-diagnosis urine exosomal RNA (ExoDx EPI score) is associated with post-prostatectomy pathology outcome

PURPOSE

ExoDx Prostate IntelliScore (EPI) is a non-invasive urine exosome RNA-based test for risk assessment of high-grade prostate cancer. We evaluated the association of pre-biopsy test results with post-radical prostatectomy (RP) outcomes to understand the potential utility of EPI to inform invasive treatment vs active surveillance (AS) decisions.

METHODS

Urine samples were collected from 2066 men scheduled for initial biopsy with PSA between 2 and 10 ng/mL, no history of prostate cancer, and ≥ 50 years across multiple clinical studies. 310 men proceeded to RP, of which 111 patients had Gleason group grade 1 (GG1) at biopsy and would have been potential candidates for AS. We compared pre-biopsy urine scores with ERSPC and PCPT multivariate risk calculator scores for men with GG1 at biopsy to post-RP pathology.

RESULTS

Urine EPI scores were significantly lower in men with GG1 at biopsy than in men with > GG1 (p = 0.04), while there were no differences in multivariate risk scores used in standard clinical practice (p > 0.05). Further, EPI scores were significantly lower in men with GG1 at biopsy who remained GG1 post-RP compared to men upgraded to ≥ GG3 post-RP (p < 0.001). In contrast, none of the multiparametric risk calculators showed significant differences (p > 0.05). Men with GG1 at biopsy and EPI score < 15.6 had zero rate of upgrading to ≥ GG3 post-RP compared to 16.0% for EPI scores ≥ 15.6.

CONCLUSIONS

The EPI urine biomarker outperformed the multivariate risk calculators in a homogenous risk group of pre-biopsy men. The EPI score was associated with low-risk pathology post-RP, with potential implications on informing AS decisions.

TRIAL REGISTRATION

NCT02702856, NCT03031418, NCT03235687, NCT04720599.

The Effect of COVID-19 Infection on Transplant Function and Development of CLAD in Lung Transplant Patients: A Multicenter Experience

Purpose

Concerns have been raised on the impact of the coronavirus disease (COVID-19) on lung transplant (LTx) patients. The aim of this study was to evaluate the effect on the clinical course and transplant function pre- and post-COVID-19 infection in LTx patients.

Methods

Data were retrospectively collected from adult LTx patients with a proven COVID-19 infection from three Dutch transplant centres, between February 2020 and September 2021. Spirometry results were collected pre-COVID-19 infection and within 3 and 6 months post-COVID-19 infection.

Results

A total of 59 LTx patients had been tested positive for COVID-19. The median age was 58 years (IQR 49-66), 64% was male and median time since transplantation was 5 years (IQR 2-11). Thirty-three patients (56%) were hospitalized, 30 (51%) were in need for supplemental oxygen therapy, 17 (29%) were admitted to the intensive care unit (ICU) and 13 (22%) required invasive mechanical ventilation. Thirteen patients died (22%), 10 in ICU (77%), 3 (23%) on general wards. Post-COVID-19 spirometry results were available in 45 (76%) patients within three months post-infection and in 34 (58%) 6 months post-infection. Spirometry results and the prevalence of chronic lung allograft dysfunction (CLAD) are shown in Table 1. CLAD pre-COVID-19 was not associated with higher mortality (12% vs 10%, p = 0.162).

Conclusion

In LTx patients COVID-19 infection results in high hospitalization and mortality rate. FVC and FEV1 was declined three months after infection and gradually improved at 6 months post-COVID-19 infection. However, FVC remained significantly lower after 6 months, demonstrating a more restrictive pattern. The prevalence of CLAD did not change after COVID-19 infection. Further follow-up is required to obtain more detailed information about CLAD.

Lead-free MCP to improve coincidence time resolution and reduce MCP direct interactions

Achieving direct imaging of the annihilation position of a positron on an event-by-event basis using an ultrafast detector would have a great impact on the field of nuclear medicine. Cherenkov emission is the most attractive physical phenomenon for realizing such an ultrafast timing performance. Moreover, a microchannel-plate photomultiplier tube (MCP-PMT) is one of the most promising photodetectors for fully exploiting the fast timing properties of Cherenkov emission owing to its excellent single photon time resolution of 25 ps full width at half maximum (FWHM). However, as the MCP structure generally contains a lead compound, the gamma rays frequently and directly interact with the MCP, resulting in the degradation of its timing performance and generation of undesirable side peaks in its coincidence timing histogram. To overcome this problem, we have developed a new MCP-PMT based on an MCP consisting of borosilicate glass, thus drastically reducing the probability of the photoelectric effect occurring in the MCP. To evaluate its insensitivity to gamma rays and its timing performance, a coincidence experiment was performed and showed that the probability of direct interactions was reduced by a factor of 3.4. Moreover, a coincidence time resolution of 35.4 ± 0.4 ps FWHM, which is equivalent to a position resolution of 5.31 mm, was obtained without any pulse height/area cut, improving to 28.7 ± 3.0 ps when selecting on the highest amplitude events by careful optimization of the voltage divider circuit of the new MCP-PMT. The timing performance of this new MCP-PMT presents an important step toward making direct imaging possible.

Better prognosis of gastric cancer patients with high levels of tumor infiltrating lymphocytes is counteracted by PD-1 expression

The prognostic potential of anti-tumor immune responses is becoming increasingly important in adenocarcinoma of the gastroesophageal junction and stomach (AGE/S) especially regarding the use of immune checkpoint inhibitors. This study analyzes for the first time the prognostic impact of tumor-infiltrating lymphocytes (TILs) and checkpoint inhibitors in a large Caucasian cohort in patients with AGE/S. We screened tissue samples from 438 therapy-naïve patients with AGE/S undergoing surgery between 1992 and 2005, examined in a tissue microarray (TMA) and stained against human CD3, CD4, CD8, PD-1, and PD-L1. Out of 438 tissue samples, 210 were eligible for multivariate analysis. This revealed that high infiltration with CD3+, CD4+, or CD8+ TILs was associated with an increased overall survival in AGE/S patients, which could only be confirmed in multivariate analysis for CD3 (HR: 0.326; p = .023). Independent improved survival was limited to gastric cancer patients and to early tumor stages as long as TILs did not express PD-1 (HR: 1.522; p = .021). Subgroup analyses indicate that TIL-dependent anti-tumor immune response is only effective in gastric cancer patients in early stages of disease in PD-1 negative TILs. Combined analysis of PD-1 and CD3 could serve as a prognostic marker for the clinical outcome of gastric cancer patients and could also be of interest for immunotherapy.

Evidence for a role of RUNX1 as recombinase cofactor for TCRβ rearrangements and pathological deletions in ETV6-RUNX1 ALL

T-cell receptor gene beta (TCRβ) gene rearrangement represents a complex, tightly regulated molecular mechanism involving excision, deletion and recombination of DNA during T-cell development. RUNX1, a well-known transcription factor for T-cell differentiation, has recently been described to act in addition as a recombinase cofactor for TCRδ gene rearrangements. In this work we employed a RUNX1 knock-out mouse model and demonstrate by deep TCRβ sequencing, immunostaining and chromatin immunoprecipitation that RUNX1 binds to the initiation site of TCRβ rearrangement and its homozygous inactivation induces severe structural changes of the rearranged TCRβ gene, whereas heterozygous inactivation has almost no impact. To compare the mouse model results to the situation in Acute Lymphoblastic Leukemia (ALL) we analyzed TCRβ gene rearrangements in T-ALL samples harboring heterozygous Runx1 mutations. Comparable to the Runx1+/- mouse model, heterozygous Runx1 mutations in T-ALL patients displayed no detectable impact on TCRβ rearrangements. Furthermore, we reanalyzed published sequence data from recurrent deletion borders of ALL patients carrying an ETV6-RUNX1 translocation. RUNX1 motifs were significantly overrepresented at the deletion ends arguing for a role of RUNX1 in the deletion mechanism. Collectively, our data imply a role of RUNX1 as recombinase cofactor for both physiological and aberrant deletions.

Cascade of phase transitions and Dirac revivals in magic-angle graphene

Twisted bilayer graphene near the magic angle^1-4 exhibits rich electron-correlation physics, displaying insulating^3-6, magnetic^7,8 and superconducting phases^4-6. The electronic bands of this system were predicted^1,2 to narrow markedly^9,10 near the magic angle, leading to a variety of possible symmetry-breaking ground states^11-17. Here, using measurements of the local electronic compressibility, we show that these correlated phases originate from a high-energy state with an unusual sequence of band population. As carriers are added to the system, the four electronic 'flavours', which correspond to the spin and valley degrees of freedom, are not filled equally. Rather, they are populated through a sequence of sharp phase transitions, which appear as strong asymmetric jumps of the electronic compressibility near integer fillings of the moiré lattice. At each transition, a single spin/valley flavour takes all the carriers from its partially filled peers, 'resetting' them to the vicinity of the charge neutrality point. As a result, the Dirac-like character observed near charge neutrality reappears after each integer filling. Measurement of the in-plane magnetic field dependence of the chemical potential near filling factor one reveals a large spontaneous magnetization, further substantiating this picture of a cascade of symmetry breaking. The sequence of phase transitions and Dirac revivals is observed at temperatures well above the onset of the superconducting and correlated insulating states. This indicates that the state that we report here, with its strongly broken electronic flavour symmetry and revived Dirac-like electronic character, is important in the physics of magic-angle graphene, forming the parent state out of which the more fragile superconducting and correlated insulating ground states emerge.

Operative results, sexual function and quality of life after gracilis muscle transposition in complex rectovaginal fistulas

AIM

Successful treatment of complex rectovaginal fistulas (RVFs) continues to be a surgical challenge. Interposition of well-perfused tissue, such as gracilis muscle, is one treatment option. The aim of this study was to investigate the operative results, sexual function and quality of life after gracilis muscle transposition (GMT) in the authors' own group of patients.

METHOD

The study included 19 women with RVF (mean age 48 years). The postoperative outcome was evaluated by a questionnaire and clinical examination.

RESULTS

The postoperative follow-up period was 7 months to 3.5 years (mean 23 months). GMT led to primary healing of RVF in 10 (53%) patients. Recurrences were observed in nine (47%) patients with RVF, in four (44%) of whom healing was achieved as a result of further interventions. Following GMT, two complications (abscess formation) requiring revision occurred. Although 42% of the patients reported certain limitations following muscle removal, GMT is a procedure that has a positive influence on the healing rate (74%), quality of life, continence and patient satisfaction.

CONCLUSION

GMT is a procedure that allows healing in the majority of patients with RVFs, and it should be considered especially in patients with recurrent fistulas, in whom a correlation between decreasing healing rates and the number of previous operations has been demonstrated.

Obstetric outcomes in patients with primary thrombotic and obstetric antiphospholipid syndrome and its relation to the antiphospholipid antibody profile

Introduction: Previous studies suggested different obstetric outcomes between patients with thrombotic or obstetric antiphospholipid syndrome, but the data are inconclusive. Aims: To investigate obstetric outcomes and their relation to the antiphospholipid antibody profile in primary thrombotic or obstetric antiphospholipid syndrome patients and compare those to a control population. Materials and methods: A retrospective single-centre study on a cohort of 30 pregnant women with primary antiphospholipid syndrome treated at Karolinska University Hospital Solna, Sweden between 2000 and 2016. The pregnancy outcomes were compared to the outcomes of all pregnancies in Stockholm County during the same period. Results: Preeclampsia ( p < 0.001), low birth weight at delivery ( p = 0.001), Apgar < 7 at 5 minutes ( p < 0.001) and small infants ( p < 0.001) were more common in antiphospholipid syndrome patients compared to controls. Obstetric antiphospholipid syndrome patients had a higher incidence of small infants ( p = 0.023), lower birth weight ( p = 0.013) and infants born with complications ( p=0.004) compared to thrombotic antiphospholipid syndrome. Mothers with triple antibody positivity had a higher incidence of preeclampsia ( p = 0.03), preterm delivery ( p = 0.011), small infants ( p=0.002) and infants born with complications ( p = 0.012). Conclusions: Patients with primary antiphospholipid syndrome, especially those with obstetric antiphospholipid syndrome and triple antibody positivity, are at higher risk for adverse pregnancy outcomes, even under antithrombotic treatment. More frequent antenatal controls in high-risk patients can further improve outcomes.

Elevated seminal plasma estradiol and epigenetic inactivation of ESR1 and ESR2 is associated with CP/CPPS

Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is associated with urinary tract symptoms and hormonal imbalances amongst others. The heterogeneous clinical presentation, unexplored molecular background and lack of prostate biopsies complicate therapy. Here, using liquid biopsies, we performed a comprehensive translational study on men diagnosed with CP/CPPS type III (n= 50; median age 39.8, range 23-65) and age-matched controls (n= 61; median age 36.8, range 20-69), considering biochemical parameters of blood and ejaculates, and epigenetic regulation of the estrogen receptor genes (ESR1 and ESR2) in leukocytes isolated from blood (systemic regulation) and in somatic cells isolated from ejaculates (local regulation). We found elevated 17β-estradiol (E2) levels in seminal plasma, but not in blood plasma, that was significantly associated with CP/CPPS and impaired urinary tract symptoms. In ejaculated somatic cells of CP/CPPS patients we found that ESR1 and ESR2 were both significantly higher methylated in CpG-promoters and expressionally down-regulated in comparison to controls. Mast cells are reported to contribute to CP/CPPS and are estrogen responsive. Consistent with this, we found that E2 -treatment of human mast cell lines (HMC-1 and LAD2) resulted in altered cytokine and chemokine expression. Interestingly, in HMC-1 cells, possessing epigenetically inactivated ESR1 and ESR2, E2 -treatment led to a reduced transcription of a number of inflammatory genes. Overall, these data suggest that elevated local E2 levels associate with an epigenetic down-regulation of the estrogen receptors and have a prominent role in CP/CPPS. Investigating E2 levels in semen could therefore serve as a promising biomarker to select patients for estrogen targeted therapy.

Measurement of a Novel Biomarker, Secretory Phospholipase A2 Group IIA as a Marker of Sepsis: A Pilot Study

Introduction:

Early identification of sepsis is critical as early treatment improves outcomes. We sought to identify threshold values of secretory phospholipase A2 (sPLA2)-IIA that predict sepsis and bacterial infection compared to nonseptic controls in an emergency department (ED) population.

Materials and Methods:

This is a prospective cohort of consenting adult patients who met two or more systemic inflammatory response syndrome (SIRS) criteria with clinical diagnosis of infectious source likely (septic patients). Controls were nonseptic consenting adults undergoing blood draw for other ED indications. Both groups had blood drawn, blind-coded, and sent to an outside laboratory for quantitative analysis of sPLA2-IIA levels. The study investigators reviewed patients’ inpatient medical record for laboratory, imaging, and microbiology results, as well as clinical course.

Results:

sPLA2-IIA levels were significantly lower in control patients as compared to septic patients (median = 0 ng/ml [interquartile range (IQR): 0–6.5] versus median = 123 ng/ml [IQR 44–507.75]; P < 0.0001). SPLA2-IIA levels were higher in patients with confirmed source (n = 28 patients, median = 186 ng/ml, 95% confidence interval = 115.1–516.8) as compared to those with no source identified or a viral source (n = 17, median = 68 ng/ml, 95% confidence interval = 38.1–122.7; P = 0.04). Using a cutoff value of 25 ng/ml, sPLA2-IIA had a sensitivity of 86.7% (confidence interval 72.5–94.5) and a specificity of 91.1% (confidence interval 77.9–97.1) in detecting sepsis.

Conclusions:

sPLA2-IIA shows potential as a biomarker distinguishing sepsis from other disease entities. Further study is warranted to identify predictive value of trends in sPLA-IIA during disease course in septic patients.

Automatic data collection for cardiopulmonary bypass

An open software system for automatic data collection during cardiopulmonary bypass is presented. The software is run on a microprocessor with permanent memory, a general purpose interface board capable of analogue-to-digital conversion and five serial communication ports for data collection.

Analogue data signals for blood flow, gas flow, patient temperatures and pressures are automatically recorded and referenced to real time. Continuous inline blood gas and temperature parameters are passed to the microprocessor for storage in a database. Results from a blood analyser and an electrolyte analyser, placed in the next room, are automatically passed to the computer and presented on the screen.

This system provides the perfusionist with automatic preoperative calculations of all parameters necessary for setting up the perfusion. During bypass, data are automatically collected, presented for evaluation and used in calculated transformations. A maximum of 36 real time curves are traced and stored as trend curves. In critical situations they may also be stored as real time curves. These curves can be recalled or plotted for further analysis. At the end of bypass a perfusion report is printed out.

The records of the patients are permanently stored on disk and the files can be transferred to other software systems for further statistical analysis.

Enhancement of superconductivity near a nematic quantum critical point

We consider a low T_{c} metallic superconductor weakly coupled to the soft fluctuations associated with proximity to a nematic quantum critical point (NQCP). We show that (1) a BCS-Eliashberg treatment remains valid outside of a parametrically narrow interval about the NQCP, (2) the symmetry of the superconducting state (d wave, s wave, p wave) is typically determined by the noncritical interactions, but T_{c} is enhanced by the nematic fluctuations in all channels, and (3) in 2D, this enhancement grows upon approach to criticality up to the point at which the weak coupling approach breaks down, but in 3D, the enhancement is much weaker.

[Practical Implementation of the "Four-column Concept" in the Situation-Adjusted Therapy for Haemorrhoidal Disease in the Daily Routine of a Proctology Department]

INTRODUCTION

In addition to the stage, several factors influence the treatment of haemorrhoids. The aim of this study was the elaboration of an individual therapy concept which is situation-adjusted. In this context, our own experience and approaches are presented.

MATERIALS AND METHODS

In the Department of Coloproctology of the Prosper-Hospital Recklinghausen, from January 2009 to August 2012, 903 haemorrhoidectomies (2nd to 4th degree) have been performed. We report our results on the practical implementation of a situation-adjusted treatment of haemorrhoidal disease. In this context we present an overview of effective modifications of surgical techniques. Retrospectively the perioperative course and postoperative outcome were evaluated.

RESULTS

Even in a collective with a large number of high-risk patients (26 %) respecting the "four columns" that constitute the fundament of a situation-adjusted treatment of haemorrhoids, high patient satisfaction and good outcome with low complication (7 %) and recurrence (0 %) rates could be attained.

CONCLUSION

The "four columns" (findings of examination, therapeutic options, physician and patient) form the fundament of an effective treatment of haemorrhoidal disease without many complications and guarantee an individually tailored therapy for each patient.

[Situation-adjusted Treatment of Haemorrhoidal Disease]

In addition to the stage several factors influence the treatment of haemorrhoids. The adequate treatment of haemorrhoids is not solely dependent on the stage, thus a situation-adapted therapy should be preferred. Advantages, disadvantages and specific characteristics of different therapy strategies in addition to potential complication risks have to be evaluated in order to obtain an effective and low-risk course. Also requests and personal living conditions of the patient as well as the expertise and experience of the physician have to be considered. A review of the current literature has been performed and a "four columns concept" has been developed that constitutes the fundament of a situation-adjusted treatment of haemorrhoids. The "four columns" that should be considered when therapy strategies are determined are composed of the following key factors: diagnostic findings, treatment alternatives, physician, and patient.

[Anal sphincter repair in the treatment of anal incontinence - when and how to do it?]

Anal incontinence is a disease of high prevalence. For many patients the disease causes severe stress and often results in social isolation. Whenever a sphincter lesion has been diagnosed by digital rectal examination and endosonographic access, anal sphincter reconstruction can be performed with the same results either in overlapping or in end-to-end suture technique. sing these procedures, in more than 60 % of patients the continence can be initially improved. However, benefit decreases after 5 years down to 40-50 %. The prognosis gets worse with increasing age and supplementary descending pelvic floor. Anal repair with reconstruction of internal and external sphincters is performed in neurogenic incontinence. This can be achieved by posterior or anterior anal repair (total pelvic floor repair). Nowadays these procedures are not common, due to unsuccessfulness. Instead, sacral nerve stimulation as a more expensive but less invasive method has displaced the anal repair on this indication. Interpretation of the published results remains delicate because of heterogenous evaluation criteria of postoperative outcome: subjective amelioration, postoperative satisfaction and quality of life, improvement of incontinence score or achievement of complete anal continence. However, it is proven that after immediate reconstruction of traumatic sphincter lesions the postoperative outcome is better than a two-step operation with primary ostomy.