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Genetically encoded visible fluorescent proteins (VFPs) are a key tool used to visualize cellular processes. However, compared to synthetic fluorophores, VFPs are photophysically complex. This photophysical complexity includes the presence of non-emitting, dark proteins within the ensemble of VFPs. Quantitative fluorescence microcopy approaches that rely on VFPs to obtain molecular insights are hampered by the presence of these dark proteins. To account for the presence of dark proteins, it is necessary to know the fraction of dark proteins (ƒdark) in the ensemble. To date, ƒdark has rarely been quantified, and different methods to determine fdark have not been compared. Here, we use and compare two different methods to determine the fdark of four commonly used VFPs: EGFP, SYFP2, mStrawberry, and mRFP1. In the first, direct method, we make use of VFP tandems and single-molecule two-color coincidence detection (TCCD). The second method relies on comparing the bright state fluorescence quantum yield obtained by photonic manipulation to the ensemble-averaged fluorescence quantum yield of the VFP. Our results show that, although very different in nature, both methods are suitable to obtain fdark. Both methods show that all four VFPs contain a considerable fraction of dark proteins. We determine ƒdark values between 30 and 60% for the different VFPs. The high values for ƒdark of these commonly used VFPs highlight that fdark has to be accounted for in quantitative microscopy and spectroscopy.

Purpose: Accuracy of image-guided liver surgery is challenged by deformation of the liver during the procedure. This study aims at improving navigation accuracy by using intraoperative deep learning segmentation and nonrigid registration of hepatic vasculature from ultrasound (US) images to compensate for changes in liver position and deformation. Methods: This was a single-center prospective study of patients with liver metastases from any origin. Electromagnetic tracking was used to follow US and liver movement. A preoperative 3D model of the liver, including liver lesions, and hepatic and portal vasculature, was registered with the intraoperative organ position. Hepatic vasculature was segmented using a reduced 3D U-Net and registered to preoperative imaging after initial alignment followed by nonrigid registration. Accuracy was assessed as Euclidean distance between the tumor center imaged in the intraoperative US and the registered preoperative image. Results: Median target registration error (TRE) after initial alignment was 11.6 mm in 25 procedures and improved to 6.9 mm after nonrigid registration (p = 0.0076). The number of TREs above 10 mm halved from 16 to 8 after nonrigid registration. In 9 cases, registration was performed twice after failure of the first attempt. The first registration cycle was completed in median 11 min (8:00–18:45 min) and a second in 5 min (2:30–10:20 min). Conclusion: This novel registration workflow using automatic vascular detection and nonrigid registration allows to accurately localize liver lesions. Further automation in the workflow is required in initial alignment and classification accuracy.

Purpose: Surgical navigation techniques can guide surgeons in localizing pelvic–abdominal malignancies. For abdominal navigation, accurate patient registration is crucial and is generally performed using an intra-operative cone-beam CT (CBCT). However, this method causes 15-min surgical preparation workflow interruption and radiation exposure, and more importantly, it cannot be repeated during surgery to compensate for large patient movement. As an alternative, the accuracy and feasibility of tracked ultrasound (US) registration are assessed in this patient study. Methods: Patients scheduled for surgical navigation during laparotomy of pelvic–abdominal malignancies were prospectively included. In the operating room, two percutaneous tracked US scans of the pelvic bone were acquired: one in supine and one in Trendelenburg patient position. Postoperatively, the bone surface was semiautomatically segmented from US images and registered to the bone surface on the preoperative CT scan. The US registration accuracy was computed using the CBCT registration as a reference and acquisition times were compared. Additionally, both US measurements were compared to quantify the registration error caused by patient movement into Trendelenburg. Results: In total, 18 patients were included and analyzed. US registration resulted in a mean surface registration error of 1.2 ± 0.2 mm and a mean target registration error of 3.3 ± 1.4 mm. US acquisitions were 4 × faster than the CBCT scans (two-sample t-test P < 0.05) and could even be performed during standard patient preparation before skin incision. Patient repositioning in Trendelenburg caused a mean target registration error of 7.7 ± 3.3 mm, mainly in cranial direction. Conclusion: US registration based on the pelvic bone is accurate, fast and feasible for surgical navigation. Further optimization of the bone segmentation algorithm will allow for real-time registration in the clinical workflow. In the end, this would allow intra-operative US registration to correct for large patient movement. Trial registration: This study is registered in ClinicalTrials.gov (NCT05637359).

In vivo tissue imaging is an essential tool for medical diagnosis, surgical guidance, and treatment. However, specular reflections caused by glossy tissue surfaces can significantly degrade image quality and hinder the accuracy of imaging systems. In this work, we further the miniaturisation of specular reflection reduction techniques using micro cameras, which have the potential to act as intra-operative supportive tools for clinicians. In order to remove these specular reflections, two small form factor camera probes, handheld at 10 mm footprint and miniaturisable to 2.3 mm, are developed using different modalities, with line-of-sight to further miniaturisation. (1) The sample is illuminated via multi-flash technique from four different positions, causing a shift in reflections which are then filtered out in a post-processing image reconstruction step. (2) The cross-polarisation technique integrates orthogonal polarisers onto the tip of the illumination fibres and camera, respectively, to filter out the polarisation maintaining reflections. These form part of a portable imaging system that is capable of rapid image acquisition using different illumination wavelengths, and employs techniques that lend themselves well to further footprint reduction. We demonstrate the efficacy of the proposed system with validating experiments on tissue-mimicking phantoms with high surface reflection, as well as on excised human breast tissue. We show that both methods can provide clear and detailed images of tissue structures along with the effective removal of distortion or artefacts caused by specular reflections. Our results suggest that the proposed system can improve the image quality of miniature in vivo tissue imaging systems and reveal underlying feature information at depth, for both human and machine observers, leading to better diagnosis and treatment outcomes.

Amyloid fibrils of the protein α-synuclein (αS) have recently been identified as a biomarker for Parkinson’s disease (PD). To detect the presence of these amyloid fibrils, seed amplification assays (SAAs) have been developed. SAAs allow for the detection of αS amyloid fibrils in biomatrices such as cerebral spinal fluid and are promising for PD diagnosis by providing a dichotomous (yes/no) response. The additional quantification of the number of αS amyloid fibrils may enable clinicians to evaluate and follow the disease progression and severity. Developing quantitative SAAs has been shown to be challenging. Here, we report on a proof-of-principle study on the quantification of αS fibrils in fibril-spiked model solutions of increasing compositional complexity including blood serum. We show that parameters derived from standard SAAs can be used for fibril quantification in these solutions. However, interactions between the monomeric αS reactant that is used for amplification and biomatrix components such as human serum albumin have to be taken into account. We demonstrate that quantification of fibrils is possible even down to the single fibril level in a model sample consisting of fibril-spiked diluted blood serum.

There is an unmet clinical need for an accurate, rapid and reliable tool for margin assessment during breast-conserving surgeries. Ultrasound offers the potential for a rapid, reproducible, and non-invasive method to assess margins. However, it is challenged by certain drawbacks, including a low signal-to-noise ratio, artifacts, and the need for experience with the acquirement and interpretation of images. A possible solution might be computer-aided ultrasound evaluation. In this study, we have developed new ensemble approaches for automated breast tumor segmentation. The ensemble approaches to predict positive and close margins (distance from tumor to margin ≤ 2.0 mm) in the ultrasound images were based on 8 pre-trained deep neural networks. The best optimum ensemble approach for segmentation attained a median Dice score of 0.88 on our data set. Furthermore, utilizing the segmentation results we were able to achieve a sensitivity of 96% and a specificity of 76% for predicting a close margin when compared to histology results. The promising results demonstrate the capability of AI-based ultrasound imaging as an intraoperative surgical margin assessment tool during breast-conserving surgery.

Introduction: Anastomotic leakage after gastrointestinal surgery has a high impact on patient's quality of life and its origin is associated with inadequate perfusion. Imaging photoplethysmography (iPPG) is a noninvasive imaging technique that measures blood-volume changes in the microvascular tissue bed and detects changes in tissue perfusion. Materials and methods: Intraoperative iPPG imaging was performed in 29 patients undergoing an open segment resection of the small intestine or colon. During each surgery, imaging was performed on fully perfused (true positives) and ischemic intestines (true negatives) and the anastomosis (unknowns). Imaging consisted of a 30-s video from which perfusion maps were extracted, providing detailed information about blood flow within the intestine microvasculature. To detect the predictive capabilities of iPPG, true positive and true negative perfusion conditions were used to develop two different perfusion classification methods. Results: iPPG-derived perfusion parameters were highly correlated with perfusion—perfused or ischemic—in intestinal tissues. A perfusion confidence map distinguished perfused and ischemic intestinal tissues with 96% sensitivity and 86% specificity. Anastomosis images were scored as adequately perfused in 86% of cases and 14% inconclusive. The cubic-Support Vector Machine achieved 90.9% accuracy and an area under the curve of 96%. No anastomosis-related postoperative complications were encountered in this study. Conclusions: This study shows that noninvasive intraoperative iPPG is suitable for the objective assessment of small intestine and colon anastomotic perfusion. In addition, two perfusion classification methods were developed, providing the first step in an intestinal perfusion prediction model.

Background There is a transition from wire-guided localization (WGL) of non-palpable breast cancer to other localization techniques. Multiple prospective studies have sought to establish superior clinical outcomes for radioactive-seed localization (RSL), but consistent and congruent evidence is missing. Methods In this study, female patients with breast cancer operated with breast-conserving surgery after tumour localization of a non-palpable breast cancer or ductal carcinoma in situ (DCIS) were included. The cohort was identified from the nationwide Netherlands Breast Cancer Audit conducted between 2013 and 2018. Trends in localization techniques were analysed. Univariable and multivariable analyses were performed to assess the association between the localization technique and the probability of a reoperation. Results A total of 28 370 patients were included in the study cohort. The use of RSL increased from 15.7 to 61.1 per cent during the study years, while WGL decreased from 75.4 to 31.6 per cent. The localization technique used (RSL versus WGL) was not significantly associated with the odds of a reoperation, regardless of whether the lesion was DCIS (odds ratio 0.96 (95 per cent c.i. 0.89 to 1.03; P = 0.281)) or invasive breast cancer (OR 1.02 (95 per cent c.i. 0.96 to 1.10; P = 0.518)). Conclusion RSL is rapidly replacing WGL as the preoperative localization technique in breast surgery. This large nationwide registry study found no association between the type of localization technique and the odds of having a reoperation, thus confirming the results of previous prospective cohort studies.

The standard treatment for rectal cancer is surgical resection of the entire rectum with its surrounding fat. Despite this radical procedure, local recurrence may still occur in up to 10% of patients and is often due to incomplete resection of the tumor area. To better assess tumor borders, image-guided navigation (IGN) can be used. A common form of IGN is where the surgeon uses tracked surgical tools that are visualized on a screen in real-time, relative to a 3D anatomical model created from preoperative imaging. To maintain sufficient navigation accuracy, when operating on the non-rigid rectum, the 3D model should be updated upon tumor motion. It was investigated if including real-time tumor tracking, using electromagnetic (EM) trackers placed close or inside the tumor, can facilitate this. Using an IGN system with wired EM tumor tracking, surgeons assessed proximal rectal tumor borders with a low median error of 3mm. Tumor tracker placement and linking it to the 3D model, however, took 30 minutes of intraoperative time. With implantable wireless trackers these steps can be done preoperatively. It was investigated if a commercially available system for wireless EM tumor tracking in radiotherapy (WL-EMTS) can also be used for IGN surgery. An IGN system was developed using the WL-EMTS for tumor tracking and an optical tracking system for tool tracking. With this IGN system it was possible to reduce incomplete resections of non-palpable breast phantom tumors by a factor of 3, compared to a clinically used wireless localization technique. The IGN system was upgraded using only the WL-EMTS for tumor ánd tool tracking. Accurate navigated resections were possible on virtual lesions in ex vivo liver specimens, where surgeons cut with 0.1±2.3mm accuracy along a planned resection margin. Ideally, the 3D model is projected onto the actual anatomy, such that the navigation screen can be omitted, improving usability. In laparoscopic surgeries this requires laparoscope camera calibration. With oblique-viewing laparoscopes, often used in rectal surgery, camera calibration parameters change when rotating their telescope. Therefore, a camera model was developed modeling these changes, resulting in reprojection accuracies of about 4 pixels (0.4mm) independent on telescope rotation.

Item does not contain fulltext BACKGROUND AND AIMS: Screening for colorectal cancer (CRC) aims to decrease CRC incidence and mortality. Biennial fecal immunochemical test screening started in the Netherlands in 2014 for individuals 55-75 years of age. This study investigated the effect of screening on stage-specific incidence, with focus on stage III and IV CRC. METHODS: Inhabitants diagnosed with CRC in 2009-2018 were included. CRC incidence per stage, year, and detection method (ie, screen-detected vs clinically detected) was evaluated. Patient, tumor, and treatment characteristics, and survival of patients with stage III and IV CRC, were compared according to the detection method. RESULTS: Included were 140,649 CRCs in 136,882 patients. An initial peak of stage I-III CRC diagnoses after initiation of screening was followed by a continuous decrease within screening-eligible ages. Total CRC incidence remained higher than before screening, although stage II and IV CRC incidence decreased below prescreening levels. Screen-detected CRCs were significantly more frequently located in the left-sided colon (stage III; 43.7% vs 30.9%; stage IV: 45.1% vs 36.1%), and the primary tumor resection rate was higher (stage III colon: 99.8% vs 99.0%, rectum: 97.3% vs 89.7%; stage IV colon: 65.4% vs 56.6%, rectum: 47.3% vs 33.5%). Patients with screen-detected stage IV CRC had significantly more often single-organ metastases (74.5% vs 57.0%; P < .001) and more frequently received treatment with curative intent (colon: 41.3% vs 27.4%; rectum: 33.8% vs 24.6%). Overall survival significantly improved for patients with screen-detected CRCs (stage III: P < .001; stage IV: P < .001). CONCLUSIONS: Five years after the start of a nationwide CRC screening program, a decrease in stage II and IV CRC incidence was observed. Patients with screen-detected stage III and stage IV CRC had less extensive disease and improved survival compared with those with clinically detected CRC.

Monitoring the performance of polymer-functionalized surfaces that aim at removing and inactivating viruses is typically labor-intensive and time-consuming. This hampers the development and optimization of such surfaces. Here we present experiments of low complexity that can be used to characterize and quantify the antiviral properties of polymer-functionalized surfaces. We showcase our approach on polyethylenimine (PEI)-coated poly(ether sulfone) (PES) microfiltration membranes. We use a fluorescently labeled model virus to quantify both virus removal and inactivation. We directly quantify the log removal of intact viruses by this membrane using single particle counting. Additionally, we exploit the change in photophysical properties upon disassembly of the virus to show that viruses are inactivated by the PEI coating. Although only a small fraction of intact viruses can pass the membrane, a considerable fraction of inactivated, disassembled viruses are found in the filtrate. Fluorescence microscopy experiments show that most of the viruses left behind on the microfiltration membrane are in the inactivated, disassembled state. Combined, our fluorescence microscopy and spectroscopy experiments show that not only does the model virus adsorb to the PEI coating on the membrane but also the interaction with PEI results in the disassembly of the virus capsid.

In mandibular surgery, three-dimensionally printed patient-specific cutting guides are used to translate the preoperative virtually planned resection planes to the operating room. This study was performed to determine whether cutting guides are positioned according to the virtual plan and to compare the intraoperative position of the cutting guide with the resection performed. Nine patients were included. The exact positions of the resection planes were planned virtually and a patient-specific cutting guide was designed and printed. After surgical placement of the cutting guide, intraoperative cone beam computed tomography (CBCT) was performed. Postoperative CT was used to obtain the final resection planes. Distances and yaw and pitch angles between the preoperative, intraoperative, and postoperative resection planes were calculated. Cutting guides were positioned on the mandible with millimetre accuracy. Anterior osteotomies were performed more accurately than posterior osteotomies (intraoperatively positioned and final resection planes differed by 1.2 ± 1.0 mm, 4.9 ± 6.6°, and 1.8 ± 1.5°, respectively, and by 2.2 ± 0.9 mm, 9.3 ± 9°, and 8.3 ± 6.5° respectively). Differences between intraoperatively planned and final resection planes imply a directional freedom of the saw through the saw slots. Since cutting guides are positioned with millimetre accuracy compared to the virtual plan, the design of the saw slots in the cutting guides needs improvement to allow more accurate resections.

(1) Background: Assessing the resection margins during breast-conserving surgery is an important clinical need to minimize the risk of recurrent breast cancer. However, currently there is no technique that can provide real-time feedback to aid surgeons in the margin assessment. Hyperspectral imaging has the potential to overcome this problem. To classify resection margins with this technique, a tissue discrimination model should be developed, which requires a dataset with accurate ground-truth labels. However, establishing such a dataset for resection specimens is difficult. (2) Methods: In this study, we therefore propose a novel approach based on hyperspectral unmixing to determine which pixels within hyperspectral images should be assigned to the ground-truth labels from histopathology. Subsequently, we use this hyperspectral-unmixing-based approach to develop a tissue discrimination model on the presence of tumor tissue within the resection margins of ex vivo breast lumpectomy specimens. (3) Results: In total, 372 measured locations were included on the lumpectomy resection surface of 189 patients. We achieved a sensitivity of 0.94, specificity of 0.85, accuracy of 0.87, Matthew’s correlation coefficient of 0.71, and area under the curve of 0.92. (4) Conclusion: Using this hyperspectral-unmixing-based approach, we demonstrated that the measured locations with hyperspectral imaging on the resection surface of lumpectomy specimens could be classified with excellent performance.

Alpha-synuclein (αS) is an intrinsically disordered protein (IDP) that is abundantly present in the brain and is associated with Parkinson's disease (PD). In spite of its abundance and its contribution to PD pathogenesis, the exact cellular function of αS remains largely unknown. The ability of αS to remodel phospholipid model membranes combined with biochemical and cellular studies suggests that αS is involved in endocytosis. To unravel with which route(s) and stage(s) of the endocytic pathway αS is associated, we quantified the colocalization between αS and endocytic marker proteins in differentiated SH-SY5Y neuronal cells, using an object based colocalization analysis. Comparison with randomized data allowed us to discriminate between structural and coincidental colocalizations. A large fraction of the αS positive vesicles colocalizes with caveolin positive vesicles, a smaller fraction colocalizes with EEA1 and Rab7. We find no structural colocalization between αS and clathrin and Rab11 positive vesicles. We conclude that in a physiological context, αS is structurally associated with caveolin dependent membrane vesiculation and is found further along the endocytic pathway, in decreasing amounts, on early and late endosomes. Our results not only shed new light on the function of αS, they also provide a possible link between αS function and vesicle trafficking malfunction in PD.

Various solvents such as ionic liquids, deep eutectic solvents, and aqueous two phase systems have been suggested as greener alternatives to existing extraction processes. We propose to add macroscopic complex coacervates to this list. Complex coacervates are liquid-like forms of polyion condensates and consist of a complex of oppositely charged polyions and water. Previous research focussing on the biological significance of these polyion-rich phases has shown that polyion condensates have the ability to extract certain solutes from water and back-extract them by changing parameters such as ionic strength and pH. In this study, we present the distribution coefficients of five commonly used industrial chemicals, namely lactic acid, butanol, and three types of lipase enzymes in poly(ethylenimine)/poly(acrylic acid) complex coacervates. It was found that the distribution coefficients can vary strongly upon variation of tunable parameters such as polyion ratio, ionic strength, polyion and compound concentrations, and temperature. Distribution coefficients ranged from approximately 2 to 50 depending on the tuning of the system parameters. It was also demonstrated that a temperature-swing extraction is possible, with back-extraction of butanol from complex coacervates with a recovery of 21.1%, demonstrating their potential as extraction media., Macroscopic complex coacervates can be used to extract compounds from aqueous supernatants. Compound partitioning depends on the ionic strength, complex composition, and temperature. These findings show their potential as aqueous extraction media.

Background A first pilot study showed that an image-guided navigation system could improve resection margin rates in locally advanced (LARC) and locally recurrent rectal cancer (LRRC) patients. Incremental surgical innovation is often implemented without reimbursement consequences, health economic aspects should however also be taken into account. This study evaluates the early cost-effectiveness of navigated surgery compared to standard surgery in LARC and LRRC. Methods A Markov decision model was constructed to estimate the expected costs and outcomes for navigated and standard surgery. The input parameters were based on pilot data from a prospective (navigation cohort n = 33) and retrospective (control group n = 142) data. Utility values were measured in a comparable group (n = 63) through the EQ5D-5L. Additionally, sensitivity and value of information analyses were performed. Results Based on this early evaluation, navigated surgery showed incremental costs of €3141 and €2896 in LARC and LRRC. In LARC, navigated surgery resulted in 2.05 Quality-Adjusted Life Years (QALYs) vs 2.02 QALYs for standard surgery. For LRRC, we found 1.73 vs 1.67 QALYs respectively. This showed an Incremental Cost-Effectiveness Ratio (ICER) of €136.604 for LARC and €52.510 for LRRC per QALY gained. In scenario analyses, optimal utilization rates of the navigation technology lowered the ICER to €61.817 and €21.334 for LARC and LRRC. The ICERs of both indications were most sensitive to uncertainty surrounding the risk of progression in the first year after surgery, the risk of having a positive surgical margin, and the costs of the navigation system. Conclusion Adding navigation system use is expected to be cost-effective in LRRC and has the potential to become cost-effective in LARC. To increase the probability of being cost-effective, it is crucial to optimize efficient use of both the hybrid OR and the navigation system and identify subgroups where navigation is expected to show higher effectiveness.

Achieving an adequate resection margin during breast-conserving surgery remains challenging due to the lack of intraoperative feedback. Here, we evaluated the use of hyperspectral imaging to discriminate healthy tissue from tumor tissue in lumpectomy specimens. We first used a dataset obtained on tissue slices to develop and evaluate three convolutional neural networks. Second, we fine-tuned the networks with lumpectomy data to predict the tissue percentages of the lumpectomy resection surface. A MCC of 0.92 was achieved on the tissue slices and an RMSE of 9% on the lumpectomy resection surface. This shows the potential of hyperspectral imaging to classify the resection margins of lumpectomy specimens.

Biomolecular condensates present in cells can fundamentally affect the aggregation of amyloidogenic proteins and play a role in the regulation of this process. While liquid-liquid phase separation of amyloidogenic proteins by themselves can act as an alternative nucleation pathway, interaction of partly disordered aggregation-prone proteins with pre-existing condensates that act as localization centers could be a far more general mechanism of altering their aggregation behavior. Here, we show that so-called host biomolecular condensates can both accelerate and slow down amyloid formation. We study the amyloidogenic protein α-synuclein and two truncated α-synuclein variants in the presence of three types of condensates composed of non-aggregating peptides, RNA or ATP. Our results demonstrate that condensates can dramatically speed up amyloid formation when proteins localize to their interface. However, condensates can also significantly suppress aggregation by sequestering and stabilizing amyloidogenic proteins, thereby providing living cells with a possible protection mechanism against amyloid formation.

Background Accurate and up-to-date assessment of demographic metrics is crucial for understanding a wide range of social, economic, and public health issues that affect populations worldwide. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019 produced updated and comprehensive demographic assessments of the key indicators of fertility, mortality, migration, and population for 204 countries and territories and selected subnational locations from 1950 to 2019. Methods 8078 country-years of vital registration and sample registration data, 938 surveys, 349 censuses, and 238 other sources were identified and used to estimate age-specific fertility. Spatiotemporal Gaussian process regression (ST-GPR) was used to generate age-specific fertility rates for 5-year age groups between ages 15 and 49 years. With extensions to age groups 10-14 and 50-54 years, the total fertility rate (TFR) was then aggregated using the estimated age-specific fertility between ages 10 and 54 years. 7417 sources were used for under-5 mortality estimation and 7355 for adult mortality. ST-GPR was used to synthesise data sources after correction for known biases. Adult mortality was measured as the probability of death between ages 15 and 60 years based on vital registration, sample registration, and sibling histories, and was also estimated using ST-GPR. HIV-free life tables were then estimated using estimates of under-5 and adult mortality rates using a relational model life table system created for GBD, which closely tracks observed age-specific mortality rates from complete vital registration when available. Independent estimates of HIV-specific mortality generated by an epidemiological analysis of HIV prevalence surveys and antenatal clinic serosurveillance and other sources were incorporated into the estimates in countries with large epidemics. Annual and single-year age estimates of net migration and population for each country and territory were generated using a Bayesian hierarchical cohort component model that analysed estimated age-specific fertility and mortality rates along with 1250 censuses and 747 population registry years. We classified location-years into seven categories on the basis of the natural rate of increase in population (calculated by subtracting the crude death rate from the crude birth rate) and the net migration rate. We computed healthy life expectancy (HALE) using years lived with disability (YLDs) per capita, life tables, and standard demographic methods. Uncertainty was propagated throughout the demographic estimation process, including fertility, mortality, and population, with 1000 draw-level estimates produced for each metric. Findings The global TFR decreased from 2.72 (95% uncertainty interval [UI] 2.66-2.79) in 2000 to 2.31 (2.17-2.46) in 2019. Global annual livebirths increased from 134.5 million (131.5-137.8) in 2000 to a peak of 139.6 million (133.0-146.9) in 2016. Global livebirths then declined to 135.3 million (127.2-144.1) in 2019. Of the 204 countries and territories included in this study, in 2019, 102 had a TFR lower than 2.1, which is considered a good approximation of replacement-level fertility. All countries in sub-Saharan Africa had TFRs above replacement level in 2019 and accounted for 27.1% (95% UI 26.4-27.8) of global livebirths. Global life expectancy at birth increased from 67.2 years (95% UI 66.8-67.6) in 2000 to 73.5 years (72.8-74.3) in 2019. The total number of deaths increased from 50.7 million (49.5-51.9) in 2000 to 56.5 million (53.7-59.2) in 2019. Under-5 deaths declined from 9.6 million (9.1-10.3) in 2000 to 5.0 million (4.3-6.0) in 2019. Global population increased by 25.7%, from 6.2 billion (6.0-6.3) in 2000 to 7.7 billion (7.5-8.0) in 2019. In 2019, 34 countries had negative natural rates of increase; in 17 of these, the population declined because immigration was not sufficient to counteract the negative rate of decline. Globally, HALE increased from 58.6 years (56.1-60.8) in 2000 to 63.5 years (60.8-66.1) in 2019. HALE increased in 202 of 204 countries and territories between 2000 and 2019. Interpretation Over the past 20 years, fertility rates have been dropping steadily and life expectancy has been increasing, with few exceptions. Much of this change follows historical patterns linking social and economic determinants, such as those captured by the GBD Socio-demographic Index, with demographic outcomes. More recently, several countries have experienced a combination of low fertility and stagnating improvement in mortality rates, pushing more populations into the late stages of the demographic transition. Tracking demographic change and the emergence of new patterns will be essential for global health monitoring. Copyright (C) 2020 The Author(s). Published by Elsevier Ltd.

Background and Objectives: In patients with rectal cancer who received neoadjuvant (chemo)radiotherapy, fibrosis is induced in and around the tumor area. As tumors and fibrosis have similar visual and tactile feedback, they are hard to distinguish during surgery. To prevent positive resection margins during surgery and spare healthy tissue, it would be of great benefit to have a real-time tissue classification technology that can be used in vivo. Study Design/Materials and Methods: In this study diffuse reflectance spectroscopy (DRS) was evaluated for real-time tissue classification of tumor and fibrosis. DRS spectra of fibrosis and tumor were obtained on excised rectal specimens. After normalization using the area under the curve, a support vector machine was trained using a 10-fold cross-validation. Results: Using spectra of pure tumor tissue and pure fibrosis tissue, we obtained a mean accuracy of 0.88. This decreased to a mean accuracy of 0.61 when tumor measurements were used in which a layer of healthy tissue, mainly fibrosis, was present between the tumor and the measurement surface. Conclusion: It is possible to distinguish pure fibrosis from pure tumor. However, when the measurements on tumor also involve fibrotic tissue, the classification accuracy decreases. Lasers Surg. Med.

Accurate assessment of 3D models of patient-specific anatomy of the liver, including underlying hepatic and biliary tree, is critical for preparation and safe execution of complex liver resections, especially due to high variability of biliary and hepatic artery anatomies. Dynamic MRI with hepatospecific contrast agents is currently the only type of diagnostic imaging that provides all anatomical information required for generation of such a model, yet there is no information in the literature on how the complete 3D model can be generated automatically. In this work, a new automated segmentation workflow for extraction of patient-specific 3D model of the liver, hepatovascular and biliary anatomy from a single multiphase MRI acquisition is developed and quantitatively evaluated. The workflow incorporates course 4D k-means clustering estimation and geodesic active contour refinement of the liver boundary, based on organ's characteristic uptake of gadolinium contrast agents overtime. Subsequently, hepatic vasculature and biliary ducts segmentations are performed using multiscale vesselness filters. The algorithm was evaluated using 15 test datasets of patients with liver malignancies of various histopathological types. It showed good correlation with expert manual segmentation, resulting in an average of 1.76 ± 2.44 mm Hausdorff distance for the liver boundary, and 0.58 ± 0.72 and 1.16 ± 1.98 mm between centrelines of biliary ducts and liver veins, respectively. A workflow for automatic segmentation of the liver, hepatic vasculature and biliary anatomy from a single diagnostic MRI acquisition was developed. This enables automated extraction of 3D models of patient-specific liver anatomy, and may facilitating better perception of organ's anatomy during preparation and execution of liver surgeries. Additionally, it may help to reduce the incidence of intraoperative biliary duct damage due to an unanticipated variation in the anatomy.

We wanted to find out whether ultrasound (US) can be used to assess the deep resection margins after excision of squamous cell carcinoma (SCC) of the tongue, as intraoperative feedback on their condition might help to prevent them being too close. Resected specimens of cancers of the tongue from 31 patients with SCC of the tongue were suspended in US gel and scanned with a small 5-10 MHz US probe. The tumour was readily visible and US could differentiate it from muscle tissue. The margin of normal tongue musculature surrounding the tumour was measured on the US images, and the minimal resection margin was noted and compared with that reported by the histopathologist. The mean (SD) deep resection margins measured on the US images differed by 1.1 (0.9) mm from those reported by the histopathologist (Pearson's correlation coefficient: 0.79, p < 0.01). The US measurements took a maximum of five minutes. It is feasible to use US to assess resection specimens of SCC of the tongue as an adjunct to existing strategies (such as frozen section analysis) to help achieve the desired deep surgical margins. The method is easy to incorporate into surgical routine as it does not take long.

The fluorescence quantum yield of four representative red fluorescent proteins mCherry, mKate2, mRuby2, and the recently introduced mScarlet was investigated. The excited state lifetimes were measured as a function of the distance to a gold mirror in order to control the local density of optical states (LDOS). By analyzing the total emission rates as a function of the LDOS, we obtain separately the emission rate and the nonradiative rate of the bright states. We thus obtain for the first time the bright state quantum yield of the proteins without interference from dark, nonemitting states. The bright state quantum yields are considerably higher than previously reported quantum yields that average over both bright and dark states. We determine that mCherry, mKate2, and mRuby2 have a considerable fraction of dark chromophores up to 45%, which explains both the low measured quantum yields of red emitting proteins reported in the literature and the difficulties in developing high quantum yield variants of such proteins. For the recently developed bright mScarlet, we find a much smaller dark fraction of 14%, accompanied by a very high quantum yield of the bright state of 81%. The presence of a considerable fraction of dark chromophores has implications for numerous applications of fluorescent proteins, ranging from quantitative fluorescence microscopy to FRET studies to monitoring protein expression levels. We recommend that future optimization of red fluorescent proteins should pay more attention to minimizing the fraction of dark proteins.

Accurate hepatic vessel segmentation and registration using ultrasound (US) can contribute to beneficial navigation during hepatic surgery. However, it is challenging due to noise and speckle in US imaging and liver deformation. Therefore, a workflow is developed using a reduced 3D U-Net for segmentation, followed by non-rigid coherent point drift (CPD) registration. By means of electromagnetically tracked US, 61 3D volumes were acquired during surgery. Dice scores of 0.77, 0.65 and 0.66 were achieved for segmentation of all vasculature, hepatic vein and portal vein respectively. This compares to inter-observer variabilities of 0.85, 0.88 and 0.74 respectively. Target registration error at a tumor lesion of interest was lower (7.1 mm) when registration is performed either on the hepatic or the portal vein, compared to using all vasculature (8.9 mm). Using clinical data, we developed a workflow consisting of multi-class segmentation combined with selective non-rigid registration that leads to sufficient accuracy for integration in computer assisted liver surgery.

During oncological surgery, it can be challenging to identify the tumor and establish adequate resection margins. This study proposes a new two-layer approach in which diffuse reflectance spectroscopy (DRS) is used to predict the top layer thickness and classify the layers in two-layered phantom and animal tissue. Using wavelet-based and peak-based DRS spectral features, the proposed method could predict the top layer thickness with an accuracy of up to 0.35 mm. In addition, the tissue types of the first and second layers were classified with an accuracy of 0.95 and 0.99. Distinguishing multiple tissue layers during spectral analyses results in a better understanding of more complex tissue structures encountered in surgical practice.

First cases that point at a correlation between SARS-CoV-2 infections and the development of Parkinson’s disease have been reported. Currently it is unclear if there also is a direct causal link between these diseases. To obtain first insights into a possible molecular relation between viral infections and the aggregation of α-synuclein protein into amyloid fibrils characteristic for Parkinson’s disease, we investigated the effect of the presence of SARS-CoV-2 proteins on α-synuclein aggregation. We show, in test tube experiments, that SARS-CoV-2 S-protein has no effect on α-synuclein aggregation while SARS-CoV-2 N-protein considerably speeds up the aggregation process. We observe the formation of multi-protein complexes, and eventually amyloid fibrils. Microinjection of N-protein in SHSY-5Y cells disturbed the α-synuclein proteostasis and increased cell death. Our results point toward direct interactions between the N-protein of SARS-CoV-2 and α-synuclein as molecular basis for the observed coincidence between SARS-CoV-2 infections and Parkinsonism.

Background Although the incidence of positive resection margins in breast-conserving surgery has decreased, both incomplete resection and unnecessary large resections still occur. This is especially the case in the surgical treatment of ductal carcinoma in situ (DCIS). Diffuse reflectance spectroscopy (DRS), an optical technology based on light tissue interactions, can potentially characterize tissue during surgery thereby guiding the surgeon intraoperatively. DRS has shown to be able to discriminate pure healthy breast tissue from pure invasive carcinoma (IC) but limited research has been done on (1) the actual optical characteristics of DCIS and (2) the ability of DRS to characterize measurements that are a mixture of tissue types. Methods In this study, DRS spectra were acquired from 107 breast specimens from 107 patients with proven IC and/or DCIS (1488 measurement locations). With a generalized estimating equation model, the differences between the DRS spectra of locations with DCIS and IC and only healthy tissue were compared to see if there were significant differences between these spectra. Subsequently, different classification models were developed to be able to predict if the DRS spectrum of a measurement location represented a measurement location with “healthy” or “malignant” tissue. In the development and testing of the models, different definitions for “healthy” and “malignant” were used. This allowed varying the level of homogeneity in the train and test data. Results It was found that the optical characteristics of IC and DCIS were similar. Regarding the classification of tissue with a mixture of tissue types, it was found that using mixed measurement locations in the development of the classification models did not tremendously improve the accuracy of the classification of other measurement locations with a mixture of tissue types. The evaluated classification models were able to classify measurement locations with > 5% malignant cells with a Matthews correlation coefficient of 0.41 or 0.40. Some models showed better sensitivity whereas others had better specificity. Conclusion The results suggest that DRS has the potential to detect malignant tissue, including DCIS, in healthy breast tissue and could thus be helpful for surgical guidance.

Background: This study assessed whether electromagnetic navigation can be of added value during resection of recurrent or post-therapy intra-abdominal/pelvic soft tissue sarcomas (STS) in challenging locations. Materials and Methods: Patients were included in a prospective navigation study. A pre-operatively 3D roadmap was made and tracked using electromagnetic reference markers. During the operation, an electromagnetic pointer was used for the localization of the tumor/critical anatomical structures. The primary endpoint was feasibility, secondary outcomes were safety and usability. Results: Nine patients with a total of 12 tumors were included, 7 patients with locally recurrent sarcoma. Three patients received neoadjuvant radiotherapy and three other patients received neoadjuvant systemic treatment. The median tumor size was 4.6 cm (2.4–10.4). The majority of distances from tumor to critical anatomical structures was

Optical technologies are widely used for tissue sensing purposes. However, maneuvering conventional probe designs with flat-tipped fibers in narrow spaces can be challenging, for instance during pelvic colorectal cancer surgery. In this study, a compact side-firing fiber probe was developed for tissue discrimination during colorectal cancer surgery using diffuse reflectance spectroscopy. The optical behavior was compared to flat-tipped fibers using both Monte Carlo simulations and experimental phantom measurements. The tissue classification performance was examined using freshly excised colorectal cancer specimens. Using the developed probe and classification algorithm, an accuracy of 0.92 was achieved for discriminating tumor tissue from healthy tissue.

Polyelectrolytes are polymers with potentially charged monomer units. Under the right conditions, oppositely charged polyelectrolytes in solution can interact and form polyelectrolyte complexes (PECs). These PECs have peculiar emergent properties. One of these properties is the ability to accumulate certain molecules in very high concentrations. A comparison can be made between PECs and membraneless-organelles (MLOs), which are droplet-like liquid-in-liquid phases present in our cells that aid the cell in organising its interior milieu through selective partitioning of specific molecules. Similar to PECs, MLOs are also composed op oppositely charged polyelectrolytes. In the case of MLOs, these are typically negatively charged RNA molecules and positively charged intrinsically disordered proteins. Taking inspiration from nature, in this dissertation we present the use of PECs for the partitioning of molecules. We investigated whether it was possible to use PECs to selectively extract a protein from a mixture. Followed by whether a PEC containing a protein could be used as a biocatalytic membrane. In chapters 2 – 4 we investigate various extraction procedures of small molecules and proteins using PECs. We find that various system parameters influence the degree of partitioning of these compounds. This culminates in chapter 4, where we were able to selectively extract lysozyme from lyophilised egg white by choosing a specific PEC composition as determined by the polycation:polyanion ratio. After extraction of lysozyme into the PEC phase and release back into a new aqueous phase, the lysozyme remained enzymatically active. In chapter 5 we produced a PEC membrane containing lysozyme via aqueous phase separation (APS). The resulting biocatalytic membrane gained the enzymatic activity of lysozyme without compromising on membrane properties. The membrane remained biocatalytically active for at least one week.

Supramolecular protein complexes are the corner stone of biological processes, they are essential for many biological functions. Unraveling the interactions responsible for the (dis)assembly of these complexes is required to understand nature and to exploit such systems in future applications. Virus capsids are well-defined assemblies of hundreds of proteins and form the outer shell of non-enveloped viruses. Due to their potential as a drug carriers or nano-reactors and the need for virus inactivation strategies, assessing the intactness of virus capsids is of great interest. Current methods to evaluate the (dis)assembly of these protein assemblies are experimentally demanding in terms of instrumentation, expertise and time. Here we investigate a new strategy to monitor the disassembly of fluorescently labeled virus capsids. To monitor surfactant-induced capsid disassembly, we exploit the complex photophysical interplay between multiple fluorophores conjugated to capsid proteins. The disassembly of the capsid changes the photophysical interactions between the fluorophores, and this can be spectrally monitored. The presented data show that this low complexity method can be used to study and monitor the disassembly of supramolecular protein complexes like virus capsids. However, the range of labeling densities that is suitable for this assay is surprisingly narrow.

Hydrogels of amyloid fibrils are a versatile biomaterial for tissue engineering and other biomedical applications. Their suitability for these applications has been partly ascribed to their excellent and potentially engineerable rheological properties. However, while in biomedical applications the gels have to function in compositionally complex physiological solutions, their rheological behavior is typically only characterized in simple buffers. Here we show that the viscoelastic response of networks of amyloid fibrils of the protein lysozyme in biologically relevant solutions substantially differs from the response in simple buffers. We observe enhanced energy dissipation in both cell culture medium and synovial fluid. We attribute this energy dissipation to interactions of the amyloid fibrils with other molecules in these solutions and especially to the adsorption of the abundantly present protein serum albumin. This finding provides the basis for a better understanding of the performance of amyloid hydrogels in biomedical applications.

Introduction In the 8th edition of the AJCC/UICC cancer staging system (AJCC8), the depth of invasion (DOI) of the oral cavity tumor is the discriminative factor in tumor staging over the previously used greatest dimension (GD). In order to obtain a complete representation of how accurate we stage oral cavity cancer clinically, we evaluated the accuracy of measurements of the tumor dimensions on ultrasound (US) and magnetic resonance (MR) imaging by comparing this with the histopathology as the “golden standard”. Secondly, we compared the pathological tumor staging of these tumors according to the AJCC7 and AJCC8, to evaluate the effect of the incorporation of the DOI in the AJCC8. Materials and methods In a retrospective analysis, including 85 oral cavity tumors, the GD and tumor thickness (TT) measured on US and MR, were compared to histopathology with a Pearson correlation coefficient (R) and a Bland-Altman plot. The tumors were staged according to both the AJCC7 and AJCC8. Results TT was more reliably measured with US (R = 0.67, limits of agreement = 10.7 mm), whereas GD was more reliably measured with MR (R = 0.69, limits of agreement = 25.7 mm). The AJCC8 staging resulted into a higher tumor stage in 21% of the cases, compared to the AJCC7. Conclusion For preoperative tumor staging, the TT is best estimated by the use of US. The incorporation of DOI in the AJCC8 can result in a higher tumor stage in more than twenty percent of the patients, with an associated worse prognosis for the patient.

Complete tumor removal during breast-conserving surgery remains challenging due to the lack of optimal intraoperative margin assessment techniques. Here, we use hyperspectral imaging for tumor detection in fresh breast tissue. We evaluated different wavelength ranges and two classification algorithms; a pixel-wise classification algorithm and a convolutional neural network that combines spectral and spatial information. The highest classification performance was obtained using the full wavelength range (450-1650nm). Adding spatial information mainly improved the differentiation of tissue classes within the malignant and healthy classes. High sensitivity and specificity were accomplished, which offers potential for hyperspectral imaging as a margin assessment technique to improve surgical outcome. (C) 2019 Optical Society of America under the terms of the OSA Open Access Publishing Agreement

Apolipoprotein E (APOE) genotype determines Alzheimer's disease (AD) susceptibility, with the APOE ε4 allele being an established risk factor for late‐onset AD. The ApoE lipidation status has been reported to impact amyloid‐beta (Aβ) peptide metabolism. The details of how lipidation affects ApoE behavior remain to be elucidated. In this study, we prepared lipid‐free and lipid‐bound ApoE particles, mimicking the high‐density lipoprotein particles found in vivo, for all three isoforms (ApoE2, ApoE3, and ApoE4) and biophysically characterized them. We find that lipid‐free ApoE in solution has the tendency to aggregate in vitro in an isoform‐dependent manner under near‐physiological conditions and that aggregation is impeded by lipidation of ApoE.

This pilot study explored the value of localized index node removal after neoadjuvant immunotherapy in patients with stage III melanoma, for use as a response indicator to guide the extent of completion lymph node dissection. Promising technology.

The plasma membrane of cells has a complex architecture based on the bidimensional liquid-crystalline bilayer arrangement of phospho- and sphingolipids, which in turn embeds several proteins and is connected to the cytoskeleton. Several studies highlight the spatial membrane organization into more ordered (L o or lipid raft) and more disordered (L d ) domains. We here report on a fluorescent analog of the green fluorescent protein chromophore that, when conjugated to a phospholipid, enables the quantification of the L o and L d domains in living cells on account of its large fluorescence lifetime variation in the two phases. The domain composition is straightforwardly obtained by the phasor approach to confocal fluorescence lifetime imaging, a graphical method that does not require global fitting of the fluorescence decay in every spatial position of the sample. Our imaging strategy was applied to recover the domain composition in human oligodendrocytes at rest and under treatment with galactosylsphingosine (psychosine). Exogenous psychosine administration recapitulates many of the molecular fingerprints of a severe neurological disease, globoid cell leukodystrophy, better known as Krabbe disease. We found out that psychosine progressively destabilizes plasma membrane, as witnessed by a shrinking of the L o fraction. The unchanged levels of galactosyl ceramidase, i.e., the enzyme lacking in Krabbe disease, upon psychosine treatment suggest that psychosine alters the plasma membrane structure by direct physical effect, as also recently demonstrated in model membranes.

For the validation of optical diagnostic technologies, experimental results need to be benchmarked against the gold standard. Currently, the gold standard for tissue characterization is assessment of hematoxylin and eosin (H&E)-stained sections by a pathologist. When processing tissue into H&E sections, the shape of the tissue deforms with respect to the initial shape when it was optically measured. We demonstrate the importance of accounting for these tissue deformations when correlating optical measurement with routinely acquired histopathology. We propose a method to register the tissue in the H&E sections to the optical measurements, which corrects for these tissue deformations. We compare the registered H&E sections to H&E sections that were registered with an algorithm that does not account for tissue deformations by evaluating both the shape and the composition of the tissue and using microcomputer tomography data as an independent measure. The proposed method, which did account for tissue deformations, was more accurate than the method that did not account for tissue deformations. These results emphasize the need for a registration method that accounts for tissue deformations, such as the method presented in this study, which can aid in validating optical techniques for clinical use. (C) The Authors. Published by SPIE under a Creative Commons Attribution 4.0 Unported License.

Wire-guided localization (WGL) is the standard of care in the surgical treatment of nonpalpable breast tumors. In this study, we compare the use of a new magnetic marker localization (MaMaLoc) technique to WGL in the treatment of early-stage breast cancer patients. Open-label, single-center, randomized controlled trial comparing MaMaLoc (intervention) to WGL (control) in women with early-stage breast cancer. Primary outcome was surgical usability measured using the System Usability Scale (SUS, 0-100 score). Secondary outcomes were patient reported, clinical, and pathological outcomes such as retrieval rate, operative time, resected specimen weight, margin status, and reoperation rate. Thirty-two patients were analyzed in the MaMaLoc group and 35 in the WGL group. Patient and tumor characteristics were comparable between groups. No in situ complications occurred. Retrieval rate was 100% in both groups. Surgical usability was higher for MaMaLoc: 70.2 ± 8.9 vs. 58.1 ± 9.1, p < 0.001. Patients reported higher overall satisfaction with MaMaLoc (median score 5/5) versus WGL (score 4/5), p < 0.001. The use of magnetic marker localization (MaMaLoc) for early-stage breast cancer is effective and has higher surgical usability than standard WGL.

Cutting-edge technology has the potential to provide guidance during oncological oral surgery. Guidance could be considered in two ways: to evaluate the cutting edge of the resected specimen after the resection (resection margin assessment) or to indicate where to cut during the resection (surgical guidance). To determine whether the tumor is completely excised during surgery, there is a need for technologies that provide intra-operative feedback on the status of the resection margin. In this thesis, the status of the resection margin of fresh surgical specimens from patients with oral cavity cancer was evaluated with ultrasound, diffuse reflectance spectroscopy (DRS) and hyperspectral imaging (HSI). Ultrasound works fast, reaches a sampling depth of several centimetres and is widely available. However, it is user dependent and cannot detect microscopic tumor infiltrations. DRS is suitable for microscopic tumor detection at specific suspicious locations build into a surgical instrument, whereas HSI could be used for evaluation of the whole resection surface in one view. However, these optical technologies require more research to increase the robustness. Surgical guidance is relevant in patients undergoing surgery for malignant disease invading the mandible, where osteotomies (i.e., the resection through bone) of the involved part of the mandible must be determined accurately to ensure clear resection margins, but also to allow precise placement of bone segments for reconstruction. At the moment, these surgeries are prepared virtually, and patient-specific cutting guides are used to translate the position of the osteotomies from the virtual surgical plan to the clinical situation in the operating room. It is hypothesised that the use of surgical navigation could expedite the preparation of the procedure and improve the accuracy. The accuracy of the surgical navigation system was evaluated with a patient study and inaccuracies of 2.6 ± 1.5 mm were achieved. A dental splint was designed to improve the accuracy further (inaccuracy of 0.83 mm). Furthermore, to achieve both guidance in localization of the osteotomy as well as guidance during sawing, a navigated cutting guide was developed.

Purpose: Registration of pre- and intraoperative images is a crucial step of surgical liver navigation, where rigid registration of vessel centerlines is currently commonly used. When using 3D ultrasound (US), accuracy during navigation might be influenced by the size of the intraoperative US volume, yet the relationship between registration accuracy and US volume size is understudied. In this study, we specify an optimal 3D US volume size for registration using varying volumes of liver vasculature. While previous studies measured accuracy at registered fiducials, in this work, accuracy is determined at the target lesion which is clinically the most relevant structure. Methods: Three-dimensional US volumes were acquired in 14 patients after laparotomy and liver mobilization. Manual segmentation of vasculature and centerline extraction was performed. Intraoperative and preoperative vasculature centerlines were registered with coherent point drift, using different sub-volumes (sphere with radius r = 30, 40, …, 120 mm). Accuracy was measured by fiducial registration error (FRE) between vessel centerlines and target registration error (TRE) at the center of the target lesion. Results: The lowest FRE for vessel registration was reached with r = 50 mm (6.5 ± 2.5 mm), the highest with r = 120 mm (7.1 ± 2.1 mm). Clinical accuracy at the target lesion, resulted most accurate (TRE = 8.8 ± 5.0 mm) in sub-volumes with a radius of 50 mm. Smaller US sub-volumes resulted in lower average TREs when compared to larger US sub-volumes (Pearson's correlation coefficient R = 0.91, p

Purpose The surgical navigation system that provides guidance throughout the surgery can facilitate safer and more radical liver resections, but such a system should also be able to handle organ motion. This work investigates the accuracy of intraoperative surgical guidance during open liver resection, with a semi-rigid organ approximation and electromagnetic tracking of the target area. Methods The suggested navigation technique incorporates a preoperative 3D liver model based on diagnostic 4D MRI scan, intraoperative contrast-enhanced CBCT imaging and electromagnetic (EM) tracking of the liver surface, as well as surgical instruments, by means of six degrees-of-freedom micro-EM sensors. Results The system was evaluated during surgeries with 35 patients and resulted in an accurate and intuitive real-time visualization of liver anatomy and tumor's location, confirmed by intraoperative checks on visible anatomical landmarks. Based on accuracy measurements verified by intraoperative CBCT, the system's average accuracy was 4.0 ± 3.0 mm, while the total surgical delay due to navigation stayed below 20 min. Conclusions The electromagnetic navigation system for open liver surgery developed in this work allows for accurate localization of liver lesions and critical anatomical structures surrounding the resection area, even when the liver was manipulated. However, further clinically integrating the method requires shortening the guidance-related surgical delay, which can be achieved by shifting to faster intraoperative imaging like ultrasound. Our approach is adaptable to navigation on other mobile and deformable organs, and therefore may benefit various clinical applications.

Funder: Lindemann Trust Fellowship, English-Speaking Union, Knowledge of the mechanisms of assembly of amyloid proteins into aggregates is of central importance in building an understanding of neurodegenerative disease. Given that oligomeric intermediates formed during the aggregation reaction are believed to be the major toxic species, methods to track such intermediates are clearly needed. Here we present a method, electron paramagnetic resonance (EPR), by which the amount of intermediates can be measured over the course of the aggregation, directly in the reacting solution, without the need for separation. We use this approach to investigate the aggregation of α-synuclein (αS), a synaptic protein implicated in Parkinson’s disease and find a large population of oligomeric species. Our results show that these are primary oligomers, formed directly from monomeric species, rather than oligomers formed by secondary nucleation processes, and that they are short-lived, the majority of them dissociates rather than converts to fibrils. As demonstrated here, EPR offers the means to detect such short-lived intermediate species directly in situ. As it relies only on the change in size of the detected species, it will be applicable to a wide range of self-assembling systems, making accessible the kinetics of intermediates and thus allowing the determination of their rates of formation and conversion, key processes in the self-assembly reaction.

The purpose of this study was to evaluate the feasibility of electromagnetic (EM) navigation for guidance on osteotomies in patients undergoing oncologic mandibular surgery. Preoperatively, a 3D rendered model of the mandible was constructed from diagnostic computed tomography (CT) images. Cutting guides and patient specific reconstruction plates were designed and printed for intraoperative use. Intraoperative patient registration was performed using a cone beam CT scan (CBCT). The location of the mandible was tracked with an EM sensor fixated to the mandible. The real-time location of both the mandible and a pointer were displayed on the navigation system. Accuracy measurements were performed by pinpointing four anatomical landmarks and four landmarks on the cutting guide using the pointer on the patient and comparing these locations to the corresponding locations on the CBCT. Differences between actual and virtual locations were expressed as target registration error (TRE). The procedure was performed in eleven patients. TREs were 3.2 ± 1.1 mm and 2.6 ± 1.5 mm using anatomical landmarks and landmarks on the cutting guide, respectively. The navigation procedure added on average half an hour to the duration of the surgery. This is the first study that reports on the accuracy of EM navigation in patients undergoing mandibular surgery.

Surgical excision is the golden standard for treatment of intestinal tumors. In this surgical procedure, inadequate perfusion of the anastomosis can lead to postoperative complications, such as anastomotic leakages. Imaging photoplethysmography (iPPG) can potentially provide objective and real-time feedback of the perfusion status of tissues. This feasibility study aims to evaluate an iPPG acquisition system during intestinal surgeries to detect the perfusion levels of the microvasculature tissue bed in different perfusion conditions. This feasibility study assesses three patients that underwent resection of a portion of the small intestine. Data was acquired from fully perfused, non-perfused and anastomosis parts of the intestine during different phases of the surgical procedure. Strategies for limiting motion and noise during acquisition were implemented. iPPG perfusion maps were successfully extracted from the intestine microvasculature, demonstrating that iPPG can be successfully used for detecting perturbations and perfusion changes in intestinal tissues during surgery. This study provides proof of concept for iPPG to detect changes in organ perfusion levels.

Complete tumor removal during breast-conserving surgery remains challenging due to the lack of optimal intraoperative margin assessment techniques. This thesis investigates the potential of hyperspectral imaging to assess the resection margin during surgery. Hyperspectral imaging is a non-invasive, optical imaging technique that measures differences in the optical properties of tissue. These differences in optical properties are measured in the form of diffuse reflectance spectra and can be used to differentiate tumor from healthy tissue. By imaging and analyzing the resection margin of a specimen during surgery, direct feedback can be given to the surgeon. We started our research with imaging breast tissue slices, that were obtained after gross-sectioning lumpectomy specimen. We developed a registration method to obtain a high correlation of these optical measurements with histopathology and, thereby, created an extensive hyperspectral database that was used to research the maximum capability of hyperspectral imaging to differentiate tissue types. The highest classification results were obtained using both the visual and near-infrared wavelength range. On hyperspectral signals, representing a single tissue type, we report a sensitivity and specificity above 98%, which indicates that the optical differences in tissue composition and morphology can be used to distinguish tumor from healthy breast tissue. On hyperspectral signals, representing a mixture of tissue classes, the sensitivity and specificity decrease to 80% and 93%, respectively. This is related to the percentage of a specific tissue class in the measured volume. The next step was to image lumpectomy specimen during surgery to verify the feasibility of using hyperspectral imaging during surgery. Hyperspectral imaging was fast and could provide feedback over the entire resection surface of one side of the specimen in 3 minutes. In combination with the classification performance on the tissue slices, these findings support that hyperspectral imaging can become a powerful tool for margin assessment during breast-conserving surgery. Original promotion date: April 24, 2020 (COVID-19)

Significance: In breast-preserving tumor surgery, the inspection of the excised tissue boundaries for tumor residue is too slow to provide feedback during the surgery. The discovery of positive margins requires a new surgery which is difficult and associated with low success. If the re-excision could be done immediately this is believed to improve the success rate considerably. Aim: Our aim is for a fast microscopic analysis that can be done directly on the excised tissue in or near the operating theatre. Approach: We demonstrate the combination of three nonlinear imaging techniques at selected wavelengths to delineate tumor boundaries. We use hyperspectral coherent anti-Stokes Raman scattering (CARS), second harmonic generation (SHG), and two-photon excited fluorescence (TPF) on excised patient tissue. Results: We show the discriminatory power of each of the signals and demonstrate a sensitivity of 0.87 and a specificity of 0.95 using four CARS wavelengths in combination with SHG and TPF. We verify that the information is independent of sample treatment. Conclusions: Nonlinear multispectral imaging can be used to accurately determine tumor boundaries. This demonstration using microscopy in the epi-direction directly on thick tissue slices brings this technology one step closer to clinical implementation.