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Within the BUSTER trial, we analyzed the surgeon’s amount of experience and other parameters associated with URS procedures regarding the stone-free rate, complication rate, and operative time. Patient characteristics and surgical details on 307 URS procedures were prospectively documented according to a standardized study protocol at 14 German centers 01–04/2015. Surgeon’s experience was correlated to clinical characteristics, and its impact on the stone-free rate, complication rate, and operative time subjected to multivariate analysis. 76 (25%), 66 (21%) and 165 (54%) of 307 URS procedures were carried out by residents, young specialists, and experienced specialists (> 5 years after board certification), respectively. Median stone size was 6 mm, median operative time 35 min. A ureteral stent was placed at the end of 82% of procedures. Stone-free rate and stone-free rate including minimal residual stone fragments (adequate for spontaneous clearance) following URS were 69 and 91%, respectively. No complications were documented during the hospital stays of 89% of patients (Clavien–Dindo grade 0). According to multivariate analysis, experienced specialists achieved a 2.2-fold higher stone-free rate compared to residents (p = 0.038), but used post-URS stenting 2.6-fold more frequently (p = 0.023). Surgeon’s experience had no significant impact on the complication rate. We observed no differences in this study’s main endpoints, namely the stone-free and complication rates, between residents and young specialists, but experienced specialists’ stone-free rate was significantly higher. During this cross-sectional study, 75% of URS procedures were performed by specialists. The experienced specialists’ more than two-fold higher stone-free rate compared to residents’ justifies ongoing efforts to establish structured URS training programs.

SummaryBackgroundDespite the high utilisation of ureterorenoscopy (URS) in interventional stone treatment, there is little evidence of any link between annual hospital volume and outcome.MethodsFrom January to April 2015, data from 307 URS patients were prospectively recorded in the multicentre observational BUSTER-Trial (Benchmarks of ureterorenoscopic stone treatment-results in terms of complications, quality of life, and stone-free rates). The best threshold value for annual hospital volume with an independent effect on the outcome (measured on stone-free and complication rates) of our study group was established with logistic regression.ResultsIn 38.4% of cases of renal and 61.6% of ureteral stones, median stone size was 6 mm with an interquartile range (IQR) of 4–8 mm. The annual URS rate in the 14 participating hospitals ranged from 77 to 333 (median 144; IQR 109–208). The binary endpoint as a combination of completely stone-free or residual fragments small enough to pass spontaneously and a maximum complication severity of Clavien–Dindo grade 1 was attained in 234/252 (92.9%) cases with a hospital volume of ≥ 99 URS compared with 43/55 (78.2%) in < 99 URS (p = 0.002). Adjusted for patient-, stone- and physician-related factors, an annual hospital URS volume of ≥ 99 increases the chance of an optimum outcome (OR = 3.92; 95% CI 1.46–10.51; p = 0.007).ConclusionsAn independent effect of URS hospital volume on outcome quality in the 14 participating hospitals was demonstrated. Threshold values for annual case numbers should be scientifically established irrespective of the considered procedure.

Necrotizing fasciitis is a synergistic aerobical-anaerobical infection that rapidly spreads from its origin leading to foudroyant increasing soft tissue gangrene and systemic sepsis. In the perineal, perianal and genital regions it is referred to as Fournier's gangrene constituting a clinical entity with the gangrene of the abdominal wall. After a short presentation of the own experience with 17 patients the surgical approach to the life-threatening disease is presented reviewing the former and the recent literature. There is a worldwide consensus that immediate radical excision of the gangrene should be accompanied by intensive care measures. Functional and cosmetic defects are to be reconstructed in a second stage. However, morbidity and mortality remain high in spite of consequent treatment due to often associated significant co-morbidity of affected patients.

HintergrundDie „Post-Ureteroscopic Lesion Scale“ (PULS) wurde als eine Klassifikation zur Standardisierung der iatrogenen Harnleiterläsionen während der Ureterorenoskopie (URS) vorgestellt. Mit der vorliegenden Studie sollen die praktische Anwendung und der mögliche klinische Nutzen des PULS-Scores an einem repräsentativen Patientenkollektiv überprüft werden.Material und MethodeIm Rahmen der prospektiven BUSTER-Studie (Bewertung der ureterorenoskopischen Steintherapie – Ergebnisse hinsichtlich Komplikationen, Lebensqualität und Steinfreiheitsrate) konnten Daten von 307 Patienten aus 14 deutschen Kliniken aufgezeichnet werden. Für die hier vorgestellte Arbeit wurden drei Studienhypothesen (H) überprüft: Es besteht eine hohe Übereinstimmung der unabhängig zu einander erfolgten PULS-Graduierungen von Operateur und Pflegeassistenzpersonal (H1), es gibt eine positive Korrelation der PULS-Grade mit der postoperativen Komplikationsdichte während des stationären Aufenthalts (H2), es liegt eine signifikante Übereinstimmung des postinterventionellen Harnleiterstentings mit den verursachten PULS-Graden vor (H3).ErgebnisseDas mediane Alter der Studienpatienten lag bei 54,4 („interquartile range“ [IQR] 44,4–65,84) Jahren; 65,5 % der Patienten waren männlichen Geschlechts. Die mediane Steingröße des Indexkonkrements betrug 6 (IQR, 4–8) mm, wobei 117 (38,4 %) und 188 (61,6 %) der Indexkonkremente in der Niere bzw. im Harnleiter lagen. 70 und 82,4 % erhielten ein präoperatives bzw. postoperatives Harnleiterstenting. 68,7 % der Studienpatienten waren nach einer URS komplett steinfrei, die Komplikationsrate betrug 10,8 % (dominant Grad 1 oder 2 nach Clavien-Dindo). Die PULS-Grade 0, 1, 2 und 3 nach Einschätzung des Operateurs lagen bei 40 %, 52,1 %, 6,9 % bzw. 1 %. Es bestand eine hohe Interobserver-Übereinstimmung der erfolgten Pulsgraduierungen zwischen Operateur und Pflegeassistenzpersonal (κ = 0,883, p < 0,001; H1+). Eine signifikante Korrelation zwischen dem PULS-Grad und den aufgezeichneten Komplikationen konnte nicht gefunden werden (ρ = 0,09, p = 0,881; H2−). Es bestand hingegen eine signifikante positive Korrelation zwischen dem PULS-Grad und der postoperativen Einlage eines Harnleiterstents (ρ = 0,287, p < 0,001; H3+), wobei hier beispielsweise ein PULS-Grad 1 (im Vergleich zu PULS-Grad 0) die Wahrscheinlichkeit um den Faktor 3,24 erhöhte (95 %-Konfidenzintervall 1,43–7,34, p = 0,005).SchlussfolgerungDie URS ist in der täglichen Routine ein sicheres und effektives Verfahren zur Behandlung von Konkrementen des oberen Harntrakts. Die vorliegenden „Real-world-Daten“ bestätigen die hohe Interrater-Reliabilität des PULS-Scores und dessen potentiellen Anwendernutzen hinsichtlich der Indikationsstellung zur postoperativen Harnleiterschienung. Auf der Basis des PULS-Scores sollte jetzt eine prospektiv-randomisierte Studie prüfen, inwieweit die Standardisierung einer postoperativen Harnleiterstenteinlage erfolgen kann.

We present particle optical properties of stratospheric smoke layers observed with multiwavelength polarization Raman lidar over Punta Arenas (53.2∘ S, 70.9∘ W), Chile, at the southernmost tip of South America in January 2020. The smoke originated from the record-breaking bushfires in Australia. The stratospheric aerosol optical thickness reached values up to 0.85 at 532 nm in mid-January 2020. The main goal of this rapid communication letter is to provide first stratospheric measurements of smoke extinction-to-backscatter ratios (lidar ratios) and particle linear depolarization ratios at 355 and 532 nm wavelengths. These aerosol parameters are important input parameters in the analysis of spaceborne CALIPSO and Aeolus lidar observations of the Australian smoke spreading over large parts of the Southern Hemisphere in January and February 2020 up to heights of around 30 km. Lidar and depolarization ratios, simultaneously measured at 355 and 532 nm, are of key importance regarding the homogenization of the overall Aeolus (355 nm wavelength) and CALIPSO (532 nm wavelength) lidar data sets documenting the spread of the smoke and the decay of the stratospheric perturbation, which will be observable over the entire year of 2020. We found typical values and spectral dependencies of the lidar ratio and linear depolarization ratio for aged stratospheric smoke. At 355 nm, the lidar ratio and depolarization ratio ranged from 53 to 97 sr (mean 71 sr) and 0.2 to 0.26 (mean 0.23), respectively. At 532 nm, the lidar ratios were higher (75–112 sr, mean 97 sr) and the depolarization ratios were lower with values of 0.14–0.22 (mean 0.18). The determined depolarization ratios for aged Australian smoke are in very good agreement with respective ones for aged Canadian smoke, observed with lidar in stratospheric smoke layers over central Europe in the summer of 2017. The much higher 532 nm lidar ratios, however, indicate stronger absorption by the Australian smoke particles.

The virulence of intracellular pathogens such as Leishmania major (L. major) relies largely on their ability to undergo cycles of replication within phagocytes, release, and uptake into new host cells. While all these steps are critical for successful establishment of infection, neither the cellular niche of efficient proliferation, nor the spread to new host cells have been characterized in vivo. Here, using a biosensor for measuring pathogen proliferation in the living tissue, we found that monocyte-derived Ly6C+CCR2+ phagocytes expressing CD11c constituted the main cell type harboring rapidly proliferating L. major in the ongoing infection. Synchronization of host cell recruitment and intravital 2-photon imaging showed that these high proliferating parasites preferentially underwent cell-to-cell spread. However, newly recruited host cells were infected irrespectively of their cell type or maturation state. We propose that among these cells, CD11c-expressing monocytes are most permissive for pathogen proliferation, and thus mainly fuel the cycle of intracellular proliferation and cell-to-cell transfer during the acute infection. Thus, besides the well-described function for priming and activating T cell effector functions against L. major, CD11c-expressing monocyte-derived cells provide a reservoir for rapidly proliferating parasites that disseminate at the site of infection.

An advanced multiwavelength polarization Raman lidar was operated aboard the icebreaker Polarstern during the MOSAiC (Multidisciplinary drifting Observatory for the Study of Arctic Climate) expedition to continuously monitor aerosol and cloud layers in the central Arctic up to 30 km height. The expedition lasted from September 2019 to October 2020 and measurements were mostly taken between 85 and 88.5∘ N. The lidar was integrated into a complex remote-sensing infrastructure aboard the Polarstern. In this article, novel lidar techniques, innovative concepts to study aerosol–cloud interaction in the Arctic, and unique MOSAiC findings will be presented. The highlight of the lidar measurements was the detection of a 10 km deep wildfire smoke layer over the North Pole region between 7–8 km and 17–18 km height with an aerosol optical thickness (AOT) at 532 nm of around 0.1 (in October–November 2019) and 0.05 from December to March. The dual-wavelength Raman lidar technique allowed us to unambiguously identify smoke as the dominating aerosol type in the aerosol layer in the upper troposphere and lower stratosphere (UTLS). An additional contribution to the 532 nm AOT by volcanic sulfate aerosol (Raikoke eruption) was estimated to always be lower than 15 %. The optical and microphysical properties of the UTLS smoke layer are presented in an accompanying paper (Ohneiser et al., 2021). This smoke event offered the unique opportunity to study the influence of organic aerosol particles (serving as ice-nucleating particles, INPs) on cirrus formation in the upper troposphere. An example of a closure study is presented to explain our concept of investigating aerosol–cloud interaction in this field. The smoke particles were obviously able to control the evolution of the cirrus system and caused low ice crystal number concentration. After the discussion of two typical Arctic haze events, we present a case study of the evolution of a long-lasting mixed-phase cloud layer embedded in Arctic haze in the free troposphere. The recently introduced dual-field-of-view polarization lidar technique was applied, for the first time, to mixed-phase cloud observations in order to determine the microphysical properties of the water droplets. The mixed-phase cloud closure experiment (based on combined lidar and radar observations) indicated that the observed aerosol levels controlled the number concentrations of nucleated droplets and ice crystals.

The multi-wavelength Raman lidar PollyXT has been regularly operated aboard the research vessel Polarstern on expeditions across the Atlantic Ocean from north to south and vice versa. The lidar measurements of the RV Polarstern cruises PS95 from Bremerhaven, Germany, to Cape Town, Republic of South Africa (November 2015), and PS98 from Punta Arenas, Chile, to Bremerhaven, Germany (April/May 2016), are presented and analysed in detail. The latest set-up of PollyXT allows improved coverage of the marine boundary layer (MBL) due to an additional near-range receiver. Three case studies provide an overview of the aerosol detected over the Atlantic Ocean. In the first case, marine conditions were observed near South Africa on the autumn cruise PS95. Values of optical properties (depolarisation ratios close to zero, lidar ratios of 23 sr at 355 and 532 nm) within the MBL indicate pure marine aerosol. A layer of dried marine aerosol, indicated by an increase of the particle depolarisation ratio to about 10 % at 355 nm (9 % at 532 nm) and thus confirming the non-sphericity of these particles, could be detected on top of the MBL. On the same cruise, an almost pure Saharan dust plume was observed near the Canary Islands, presented in the second case. The third case deals with several layers of Saharan dust partly mixed with biomass-burning smoke measured on PS98 near the Cabo Verde islands. While the MBL was partly mixed with dust in the pure Saharan dust case, an almost marine MBL was observed in the third case. A statistical analysis showed latitudinal differences in the optical properties within the MBL, caused by the down-mixing of dust in the tropics and anthropogenic influences in the northern latitudes, whereas the optical properties of the MBL in the Southern Hemisphere correlate with typical marine values. The particle depolarisation ratio of dried marine layers ranged between 4 and 9 % at 532 nm. Night measurements from PS95 and PS98 were used to illustrate the potential of aerosol classification using lidar ratio, particle depolarisation ratio at 355 and 532 nm, and Ångström exponent. Lidar ratio and particle depolarisation ratio have been found to be the main indicator for particle type, whereas the Ångström exponent is rather variable.

We present retrievals of tropospheric and stratospheric height profiles of particle mass, volume, surface area, and number concentrations in the case of wildfire smoke layers as well as estimates of smoke-related cloud condensation nuclei (CCN) and ice-nucleating particle (INP) concentrations from backscatter lidar measurements on the ground and in space. Conversion factors used to convert the optical measurements into microphysical properties play a central role in the data analysis, in addition to estimates of the smoke extinction-to-backscatter ratios required to obtain smoke extinction coefficients. The set of needed conversion parameters for wildfire smoke is derived from AERONET observations of major smoke events, e.g., in western Canada in August 2017, California in September 2020, and southeastern Australia in January–February 2020 as well as from AERONET long-term observations of smoke in the Amazon region, southern Africa, and Southeast Asia. The new smoke analysis scheme is applied to CALIPSO observations of tropospheric smoke plumes over the United States in September 2020 and to ground-based lidar observation in Punta Arenas, in southern Chile, in aged Australian smoke layers in the stratosphere in January 2020. These case studies show the potential of spaceborne and ground-based lidars to document large-scale and long-lasting wildfire smoke events in detail and thus to provide valuable information for climate, cloud, and air chemistry modeling efforts performed to investigate the role of wildfire smoke in the atmospheric system.

In the framework of the Multidisciplinary drifting Observatory for the Study of Arctic Climate Polarstern expedition, the Leibniz Institute for Tropospheric Research, Leipzig, Germany, operated the shipborne OCEANET-Atmosphere facility for cloud and aerosol observations throughout the whole year. OCEANET-Atmosphere comprises, amongst others, a multiwavelength Raman lidar, a microwave radiometer, and an optical disdrometer. A cloud radar was operated aboard Polarstern by the US Atmospheric Radiation Measurement program. These measurements were processed by applying the so-called Cloudnet methodology to derive cloud properties. To gain a comprehensive view of the clouds, lidar and cloud radar capabilities for low- and high-altitude observations were combined. Cloudnet offers a variety of products with a spatiotemporal resolution of 30 s and 30 m, such as the target classification, and liquid and ice microphysical properties. Additionally, a lidar-based low-level stratus retrieval was applied for cloud detection below the lowest range gate of the cloud radar. Based on the presented dataset, e.g., studies on cloud formation processes and their radiative impact, and model evaluation studies can be conducted.