Evaluation of PET and laparoscopy in STagIng advanced gastric cancer: a multicenter prospective study (PLASTIC-study).

BACKGROUND: Initial staging of gastric cancer consists of computed tomography (CT) and gastroscopy. In locally advanced (cT3-4) gastric cancer, fluorodeoxyglucose positron emission tomography with CT (FDG-PET/CT or PET) and staging laparoscopy (SL) may have a role in staging, but evidence is scarce. The aim of this study is to evaluate the impact and cost-effectiveness of PET and SL in addition to initial staging in patients with locally advanced gastric cancer. METHODS: This prospective observational cohort study will include all patients with a surgically resectable, advanced gastric adenocarcinoma (cT3-4b, N0-3, M0), that are scheduled for treatment with curative intent after initial staging with gastroscopy and CT. The modalities to be investigated in this study is the addition of PET and SL. The primary outcome of this study is the proportion of patients in whom the PET or SL lead to a change in treatment strategy. Secondary outcome parameters are: diagnostic performance, morbidity and mortality, quality of life, and cost-effectiveness of these additional diagnostic modalities. The study recently started in August 2017 with a duration of 36 months. At least 239 patients need to be included in this study to demonstrate that the diagnostic modalities are break-even. Based on the annual number of gastrectomies in the participating centers, it is estimated that approximately 543 patients are included in this study. DISCUSSION: In this study, it is hypothesized that performing PET and SL for locally advanced gastric adenocarcinomas results in a change of treatment strategy in 27% of patients and an annual cost-reduction in the Netherlands of €916.438 in this patient group by reducing futile treatment. The results of this study may be applicable to all countries with comparable treatment algorithms and health care systems. TRIAL REGISTRATION: NCT03208621 . This trial was registered prospectively on June 30, 2017.

Influence of BMI and smoking on IUI outcome with partner and donor sperm.

There is limited literature on the influence of smoking and BMI on success rates after intrauterine insemination (IUI). As a result of a prospective cohort study we could investigate data from 1401 IUI cycles with partner semen and 1264 IUI cycles with donor semen, primary outcome being clinical pregnancy rate (CPR). Univariate statistical analysis showed significant influence of female BMI on clinical pregnancy in the partner insemination group (CPR of 6,5%, 8%, 16,3% and 9,4% for a female BMI < 20, 20-24.9, 25-29.9 and 3 30, p=0.032), while in the donor group this in uence was not signi cant (CPR respectively 11.1% (BMI< 20), 18.5% (20-24.9), 18.0% (25-29.9) and 14.7% for BMI 3 30). Multivariate analysis through generalized estimating equations (GEE) could not confirm this significant influence of female BMI on fecundity in the partner semen group. For smoking, univariate statistical analysis revealed male smoking to be a negative influence for the clinical pregnancy rate in the partner insemination group (10.9% CPR in couples with male non-smokers versus 5.9% with male partners smoking 1-14 cig/day, p=0.017). After multivariate GEE analysis this result remained significant (p< 0,01). In the donor semen group female non-smoking or smoking less than 15 cigarettes a day turned out to be significantly associated with a higher CPR compared to women smoking more than 15 cigarettes daily (16.8% and 24.5% versus 5.6%, p=0,01). These results were also significant after multivariate GEE analysis (p= 0,047 and p= 0,02).

The prognostic value of perifollicular blood flow in the outcome after assisted reproduction: a systematic review.

BACKGROUND: The overall final outcome of assisted reproductive technologies (ART) is still more often a failure than a success. Assessing perifollicular blood flow (PFBF) is one technique to predict and possibly improve this outcome. The aim was to provide a structured review of studies concerning PFBF and its prognostic value in patients undergoing ART, including IUI (intrauterine insemination). METHODS: PUBMED, EMBASE and Cochrane Database of Systematic Reviews were searched for relevant studies published until December 2016. As key words 'Perifollicular blood flow', 'IUI', 'IVF' and 'ICSI' were used. RESULTS: A total of 14 articles were included in the current review. The results are very heterogeneous, though there is evidence that measuring PFBF could be a good prognostic marker for oocyte and embryo quality, but even more for pregnancy rate after IVF/ICSI. This finding is not observed in studies concerning IUI. CONCLUSIONS: Our results highlight an urgent need to investigate the role for PFBF assessment by Power Doppler in ART in randomised controlled trials.

Alterations in serotonin metabolism in the irritable bowel syndrome.

BACKGROUND: Alterations in serotonin (5-HT) metabolism have been postulated to play a role in the pathogenesis of irritable bowel syndrome (IBS). However, previous reports regarding 5-HT metabolism in IBS are contradicting. AIM: To compare platelet poor plasma (PPP) 5-HT and 5-hydroxyindole acetic acid (5-HIAA) levels and their ratio in a large cohort of IBS patients and healthy controls (HC), including IBS-subgroup analysis. METHODS: Irritable bowel syndrome patients and HC were evaluated for fasting PPP 5-HT and 5-HIAA levels. Furthermore, GI-symptom diary, GSRS, quality of life, anxiety and depression scores were assessed in the 2 weeks before blood sampling. RESULTS: One hundred and fifty four IBS patients and 137 HC were included. No differences were detected in plasma 5-HT between groups. The 5-HIAA concentrations and 5-HIAA/5-HT ratio were significantly lower in IBS compared to HC: 24.6 ± 21.9 vs. 39.0 ± 29.5 µg/L (P < 0.001) and 8.4 ± 12.2 vs. 13.5 ± 16.6 (P < 0.01), respectively. Subtype analysis for 5-HIAA showed all IBS subtypes to be significantly different from HC. The 5-HIAA/5-HT ratio was significantly lower in the IBS-M subtype vs. HC. Linear regression analysis points to an influence of gender but not of GI-symptoms, psychological scores or medication use. CONCLUSIONS: We demonstrated that fasting 5-HT plasma levels are not significantly different in IBS patients compared to controls. However, decreased 5-HIAA levels and 5-HIAA/5-HT ratio in IBS patients may reflect altered serotonin metabolism in IBS. Gender affects 5-HIAA levels in IBS patients, but no effects of drugs, such as SSRIs, or higher GI-symptom or psychological scores were found.

Polarization Engineering in Photonic Crystal Waveguides for Spin-Photon Entanglers.

By performing a full analysis of the projected local density of states (LDOS) in a photonic crystal waveguide, we show that phase plays a crucial role in the symmetry of the light-matter interaction. By considering a quantum dot (QD) spin coupled to a photonic crystal waveguide (PCW) mode, we demonstrate that the light-matter interaction can be asymmetric, leading to unidirectional emission and a deterministic entangled photon source. Further we show that understanding the phase associated with both the LDOS and the QD spin is essential for a range of devices that can be realized with a QD in a PCW. We also show how suppression of quantum interference prevents dipole induced reflection in the waveguide, and highlight a fundamental breakdown of the semiclassical dipole approximation for describing light-matter interactions in these spin dependent systems.

'Fertility Awareness-Based Methods' and subfertility: a systematic review.

Fertility awareness based methods (FABMs) can be used to ameliorate the likelihood to conceive. A literature search was performed to evaluate the relationship of cervical mucus monitoring (CMM) and the day-specific -pregnancy rate, in case of subfertility. A MEDLINE search revealed a total of 3331 articles. After excluding articles based on their relevance, 10 studies and were selected. The observed studies demonstrated that the cervical mucus monitoring (CMM) can identify the days with the highest pregnancy rate. According to the literature, the quality of the vaginal discharge correlates well with the cycle-specific probability of pregnancy in normally fertile couples but less in subfertile couples. The results indicate an urgent need for more prospective randomised trials and -prospective cohort studies on CMM in a subfertile population to evaluate the effectiveness of CMM in the subfertile couple.

Artificial insemination with donor sperm (AID): heterogeneity in sperm banking facilities in a single country (Belgium).

Due to the high inflow of foreign patients seeking cross-border reproductive care in Belgium and the increased number of lesbian couples and single women who call for artificial insemination with donor sperm (AID), Belgian sperm banks nowadays face a shortage in donor sperm. However, since there is no central registration system for sperm donors in Belgium, no figures are currently available supporting this statement. Therefore a study was performed to obtain a detailed overview of the sperm banking facilities in Belgium. Questionnaires were sent to all Belgian centres for assisted reproduction with laboratory facilities (n = 18) to report on their sperm banking methods. The results showed that 82% of the centres rely partially or completely on foreign donor sperm. Moreover, four of the thirteen centres that have their own sperm bank use imported donor sperm in > 95% AID cycles. Our results show that in 63% of the Belgian AID cycles imported Danish donor sperm is being used. Donor recruitment is mainly performed through the centre's website (61%) or by distributing flyers in the centre (46%) and 9 to 180 potential donors have been recruited per centre in 2013. Eventually, 15 to 50% of these candidate donors were accepted. Different criteria for donor acceptance are handled by the centres: donor age limits range from 18-25 to 36-46 years old, and thresholds for sperm normality differ considerably. We can conclude that a wide variation in methods associated with sperm banking is observed in Belgian centres.

Interfacing spins in an InGaAs quantum dot to a semiconductor waveguide circuit using emitted photons.

An in-plane spin-photon interface is essential for the integration of quantum dot spins with optical circuits. The optical dipole of a quantum dot lies in the plane and the spin is optically accessed via circularly polarized selection rules. Hence, a single waveguide, which can transport only one in-plane linear polarization component, cannot communicate the spin state between two points on a chip. To overcome this issue, we introduce a spin-photon interface based on two orthogonal waveguides, where the polarization emitted by a quantum dot is mapped to a path-encoded photon. We demonstrate operation by deducing the spin using the interference of in-plane photons. A second device directly maps right and left circular polarizations to antiparallel waveguides, surprising for a nonchiral structure but consistent with an off-center dot.

Mode structure of coupled L3 photonic crystal cavities.

We investigate the energy splitting, quality factor and polarization of the fundamental modes of coupled L3 photonic crystal cavities. Four different geometries are evaluated theoretically, before experimentally investigating coupling in a direction at 30◦ to the line of the cavities. In this geometry, a smooth variation of the energy splitting with the cavity separation is predicted and observed, together with significant differences between the polarizations of the bonding and anti-bonding states. The controlled splitting of the coupled states is potentially useful for applications that require simultaneous resonant enhancement of two transitions.

Transatlantic comparison of the competence of surgeons at the start of their professional career.

BACKGROUND: Although the objective in European Union and North American surgical residency programmes is similar-to train competent surgeons-residents' working hours are different. It was hypothesized that practice-ready surgeons with more working hours would perform significantly better than those being educated within shorter working week curricula. METHODS: At each test site, 21 practice-ready candidate surgeons were recruited. Twenty qualified Canadian and 19 qualified Dutch surgeons served as examiners. At both sites, three validated outcome instruments assessing multiple aspects of surgical competency were used. RESULTS: No significant differences were found in performance on the integrative and cognitive examination (Comprehensive Integrative Puzzle) or the technical skills test (Objective Structured Assessment of Technical Skill; OSATS). A significant difference in outcome was observed only on the Patient Assessment and Management Examination, which focuses on skills needed to manage patients with complex problems (P < 0.001). A significant interaction was observed between examiner and candidate origins for both task-specific OSATS checklist (P = 0.001) and OSATS global rating scale (P < 0.001) scores. CONCLUSION: Canadian residents, serving many more working hours, perform equivalently to Dutch residents when assessed on technical skills and cognitive knowledge, but outperformed Dutch residents in skills for patient management. Secondary analyses suggested that cultural differences influence the assessment process significantly.

A comparative study of metastatic renal cell carcinoma with correlation to subtype and primary tumor.

Clear cell (CRCC), papillary (PRCC) and chromophobe (CHRC) renal cell carcinoma (RCC) are the three most frequent subtypes of RCC. The rate and distribution of their metastatic lesions have not been well documented. We compared metastatic RCC according to subtype and primary tumor characteristics to better understand their behavior and to aid in the diagnosis of metastatic RCC. Pathology reports and clinical charts related to 283 CRCC, 48 PRCC and 13 CHRCC, including their respective sarcomatoid variants, were reviewed. A hundred and thirty-seven CRCC, 5 PRCC and 1 CHRCC with metastases were identified. CRCC and non-CRCC (PRCC and CHRCC) had different patterns of metastasis and primary tumor growth. CRCC metastases were predominantly distributed in lungs, bone, brain, lymph nodes, and adrenal glands. The associated primary CRCC measured 1.5 to 15 cm, were of all grades and stages, and were often associated with invasion of small or large veins. Three PRCC had regional lymph node metastases, 1 PRCC had both regional and mediastinal lymph node metastases. Bone metastasis was present in 1 case each of PRCC and CHRCC. One PRCC with metastasis solely to regional nodes measured 4 cm. The other 4 cases of PRCC with regional lymph node and/or distant metastases as well as the CHRCC with distant metastases were greater than 8 cm in diameter. In metastasizing and non-metastasizing non-CRCC, invasion of small veins was rare and invasion of renal veins was not seen. We cannot comment with any certainty on the metastatic behavior of CHRCC. In our experience, PRCC tend to loco-regional invasion with lymph node spread. They have a low potential for vascular invasion and distant metastases that likely occur only at late stages of the disease. CRCC has a propensity for vascular invasion and may be associated with distant metastasis at an early stage. Therefore, metastatic RCC at a distant location are most likely to be of CRCC origin than PRCC origin.

Fine needle aspiration biopsy of epithelioid angiomyolipoma. A case report.

BACKGROUND: Epithelioid angiomyolipoma (AMYL) is a variant of angiomyolipoma characterized by sheets of epithelioid cells that may mimic renal cell carcinoma. This is the first report describing the fine needle aspiration biopsy features of this lesion. CASE: A 47-year-old man with a history of epithelioid angiomyolipoma of the kidney treated with nephrectomy nine months previously presented with a recurrent retroperitoneal mass and multiple nodular liver lesions. Fine needle aspiration biopsy of one of the liver lesions showed fragments and sheets of noncohesive epithelioid cells with thin cytoplasm, markedly atypical nuclei, and scattered bizarre and multinucleated forms. The epithelioid cells focally expressed HMB-45 and were nonimmunoreactive, with epithelial markers. CONCLUSION: Epithelioid AMYL may pose differential diagnostic problems with high grade carcinoma, especially renal cell, hepatocellular and metastatic carcinoma. An awareness of this entity and its characteristic cytologic features and immunoreactivity with HMB-45 is helpful in its identification.

Long-term survival with malignant melanoma metastatic to the bladder.

Malignant melanoma metastatic to the bladder is a relatively common autopsy finding, but rarely manifests clinically as it is usually a late finding in the course of the disease. Herein is the report of a case of muscle invasive malignant melanoma at the dome of the urinary bladder treated by radical transurethral resection with no evidence of bladder recurrence four years later.

Calculus formation on migrant surgical staples in urinary undiversion.

Urinary undiversion and bladder reconstruction has led to some of the most ingenious uses of bowel by urologists and will improve the quality of life for patients. The use of the stapler has helped create intussuscepted nipple valves that are more likely to be effective and less likely to extussuscept. Calculi can form on surgical staples exposed to urine and measures to prevent this have been described. We report a case in which there was rapid development in multiple calculi, each having a single staple as a nidus, following urinary undiversion using an antireflux intussuscepted stapled nipple valve in which the distal-most staples were removed from the staple cartridge to its use.

Ureteral response to the placement of metallic stents: an animal model.

Metallic self-expanding mesh stents are increasingly used in the urinary tract. Little is known about the histological reactions that such prostheses have on the surrounding tissue. The effects of self-expanded metallic stents in the histologically normal ureter were examined in four dogs. Three-mm. Gianturco-Roubin coronary artery stents were introduced into the distal left ureter after dilatation. Follow-up excretory urography, retrograde pyelograms and autopsy were performed on 2 dogs at 1 month and on 2 dogs at 6 months. In all 4 dogs, the ureters remained patent. Histologic examination of the ureter showed that the stents had not become incorporated within the wall of the ureter. Reactive changes seen in the epithelium included penetration of both epithelium and submucosa between the wire struts and areas of fibrosis in the submucosal layer. The use of metallic stents in histologically normal ureters may be limited in the long term by this inflammatory response.

Experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma.

We describe our experience with the hemi-Kock ileocystoplasty with a continent abdominal stoma as an alternative to an indwelling catheter or supravesical diversion in 14 women and 4 men with various problems who could not perform intermittent urethral self-catheterization. The aim of management was also to provide, if possible, a competent urethra for additional access. Mean patient age was 37 years (range 22 to 75) and mean followup was 26 months (range 5 to 58). Preoperative management in the 11 wheelchair dependent women with neurological disease was an indwelling catheter in 7, urethral intermittent catheterization with the patient in the supine position in 3 and diapers in 1. Two women with a nonneurogenic bladder and a grossly incompetent urethra (1 after multiple incontinence and fistula repairs, and 1 after severe obstetrical trauma) wore diapers, while 1 with urinary retention and inability to perform self-catheterization had an indwelling catheter. The 4 men included 2 wheelchair dependent incontinent spinal cord injury patients who could not be managed with condom drainage, 1 with multiple anomalies who had trouble with self-catheterization, and 1 with an impassable postoperative stricture and a suprapubic tube. Surgery included anti-incontinence procedures in 10 patients and bladder neck closure in 3. A total of 15 patients required bladder augmentation in addition to the stoma and 3 had a stoma alone. Postoperative intervention was necessary in 4 women for stomal incontinence and in 2 of these bladder stones were removed simultaneously. One of these women was later treated for recurrent stones cystoscopically through the stoma. Overall, 17 of 18 patients are dry on intermittent stomal catheterization, with 1 lost to followup. We conclude that this procedure is a good alternative in patients with an end stage urethra or who cannot perform urethral catheterization because of physical disability. Establishing urethral continence and maintaining patency leaves a safety valve should the stoma fail. Since the bladder remains as a reservoir no ureteral surgery is necessary.

The value of immediate or early catheterization of the traumatized posterior urethra.

A total of 16 patients with posterior urethral ruptures was treated with the aim of reestablishing urethral continuity immediately or early after injury. Followup ranged from 13 to 83 months (average 27). In all patients an emergency retrograde urethrogram demonstrated extravasation from the posterior urethra. Of the patients 13 were treated with a urethral catheter either immediately or within 1 to 5 weeks after injury. Three patients were treated with a suprapubic catheter alone after unsuccessful attempts at reestablishing urethral continuity and all 3 subsequently required urethroplasty for an obliterative stricture. These 3 patients were also impotent after injury. Of the 13 patients treated with a urethral catheter 8 had the catheter inserted either retrograde (2) in the emergency room or antegrade (6) in the operating room just after the injury, and in 5 the catheter was inserted transurethrally at cystoscopy within a mean of 3 weeks after injury. A total of 7 patients (54%) treated with urethral catheterization had a stricture during followup: 4 responded well to internal urethrotomy and 3 required simple dilation. Of 12 patients 5 (42%) became impotent after injury, while 1 was impotent before injury. No patient became incontinent. We conclude that careful urethral catheter realignment either immediately or within 5 weeks after injury is safe and obviates total urethral closure. Impotence may result from the severity of the injury and not from management with catheterization.

Risk factors for upper tract deterioration in chronic spinal cord injury patients.

A total of 140 patients with neurogenic voiding dysfunction secondary to chronic spinal cord injuries was assessed initially at a tertiary care urodynamic center an average of 8 years after the acute injury. As a result of testing patients were divided into 2 functional urodynamic groups. Group 1 included 40 patients with an areflexic bladder, of whom 33 maintained normal upper tracts and 7 had significant upper tract deterioration. Group 2 included 100 patients with a hyperreflexic bladder, of whom 84 maintained normal upper tracts and 16 had documented upper tract deterioration. Maximum detrusor pressure during urine storage in group 1 with abnormal upper tracts was significantly higher than in those with normal kidneys (p less than 0.0001). Maximum detrusor contraction pressure during voiding in group 2 was significantly higher in those with abnormal upper tracts secondary to neurogenic outflow obstruction (p less than 0.0001). The most common outflow problem in this group was type 3 detrusor-sphincter dyssynergia. With guidelines thus developed for acceptable detrusor pressure in both types of bladder, silent upper tract damage can probably be prevented in most cases by proper and diligent followup and appropriate intervention, avoiding major morbidity and mortality in these high risk patients.

Effect of a metallic balloon-expanded stent on normal rabbit ureter.

Two-millimeter balloon-expanded Gianturco-Roubin coronary artery stents were placed in the 1-mm-diameter distal ureters of five normal rabbits. Retrograde pyelograms obtained immediately after stent placement showed no obstruction or extravasation of contrast material. Follow-up excretory urograms were obtained for each animal between 4 and 17 days, and autopsy was performed between 35 and 42 days. Findings at excretory urography and autopsy demonstrated severe obstruction at the level of the stent in each animal. Histologic examination of the resected ureter was performed. In four animals, the stent had penetrated into the wall of the ureter and a fibrous reaction had obliterated the lumen. In one animal, although the stent was still present within the lumen of the ureter, a fibrous reaction within the wall had destroyed the muscle layers and narrowed the lumen at the distal end of the stent. It is concluded that the 2-mm Gianturco-Roubin stent is unsuitable for placement in the 1-mm rabbit ureter.