IMPORTANCE: Previous retrospective studies have shown that surgical quality affects local control in rectal cancer.. OBJECTIVE: In this secondary end point analysis, we evaluated the prognostic ...effect of the total mesorectal excision (TME) plane in the CAO/ARO/AIO-04 phase 3 randomized clinical trial. DESIGN, SETTING, AND PARTICIPANTS: The CAO/ARO/AIO-04 trial enrolled 1236 patients with cT3-4 and/or node-positive rectal adenocarcinoma from 88 centers in Germany between July 25, 2006, and February 26, 2010. INTERVENTIONS: Patients were randomized to receive treatment with standard fluorouracil-based preoperative chemoradiotherapy (CRT) alone (control arm) or oxaliplatin (experimental arm) followed by TME and adjuvant chemotherapy. MAIN OUTCOMES AND MEASURES: The TME quality (mesorectal, intramesorectal, and muscularis propria plane) was prospectively assessed in 1152 operation specimens. An assessment was performed independently by pathologists and surgeons. The results were correlated with clinicopathologic data and the clinical outcome was tested, including multivariable analysis with the Cox regression model. RESULTS: Of 1152 German Caucasian participants, 332 (28.8) were women and the mean age was 63 years. The plane of TME was mesorectal in 930 patients (80.7%), intramesorectal in 169 (14.7%), and muscularis propria in 53 (4.6%). In a univariable analysis, the TME plane was significantly associated with 3-year disease-free survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 73.1-78.8 vs 61.6-76.0 vs 55.6-81.3, respectively; P = .01), cumulative incidence of local and distant recurrences (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 2.0-4.5 vs 1.2-8.1 vs 2.5-20.5, respectively; P < .001; and mesorectal vs intramesorectal vs muscularis propria, 95% CI, 17.0-22.4 vs 18.3-32.0 vs 14.2-39.0, respectively; P = .03, respectively), and overall survival (mesorectal vs intramesorectal vs muscularis propria, 95% CI, 88.3-92.3 vs 79.7-91.0 vs 81.6-98.7, respectively; P = .02). In contrast to the pathologist-based evaluation, the assessment of TME plane by the operating surgeon failed to demonstrate prognostic significance for any of these clinical end points. In a multivariable analysis, the plane of surgery (mesorectal vs muscularis propria TME) constituted an independent factor for local recurrence (P = .002). CONCLUSIONS AND RELEVANCE: This phase 3 randomized clinical trial confirms the long-term clinical effect of TME plane quality on local recurrence, as initially reported in the MRC CR07 study. The data highlight the key role of pathologists and surgeons in the multidisciplinary management of rectal cancer. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00349076.
Postoperative disease recurrence in Crohn's disease represents a relevant issue despite recent advancements in surgical and medical therapies. Additional criteria are necessary to improve the ...identification of patients at risk and to enable selective therapeutic approaches. The role of resection margins on disease recurrence remains unclear and general recommendations are lacking. A single-center retrospective analysis was performed including all patients who received ileocecal resection due to Crohn's disease. Resection margins were analyzed by two independent pathologists and defined by histopathological criteria based on previous consensus reports. 158 patients were included for analysis with a median follow up of 35 months. While postoperative morbidity was not affected, positive resection margins resulted in significantly increased rates of severe endoscopic recurrence at 6 months (2.0% versus 15.6%, p = 0.02) and overall (4.2% versus 19.6%, p = 0.001), which resulted in significantly increased numbers of surgical recurrence (0% versus 4.5%, p = 0.04). Additionally, positive margins were identified as independent risk factor for severe endoscopic disease recurrence in a multivariate analysis. Based on that, positive margins represent an independent risk factor for postoperative endoscopic and surgical disease recurrence. Prospective studies are required to determine whether extended resection or postoperative medical prophylaxis is beneficial for patients with positive resection margins.
Abstract
In the atmospheric boundary layer, phenomena exist with challenging properties such as spatial heterogeneity, particularly during stable weak wind situations. Studying spatially ...heterogeneous features requires spatially distributed measurements on fine spatial and temporal scales. Fiber-Optic Distributed Sensing (FODS) can provide spatially distributed measurements, simultaneously offering a spatial resolution on the order of decimeters and a temporal resolution on the order of seconds. While FODS has already been deployed to study various variables, FODS wind direction sensing has only been demonstrated in idealized wind tunnel experiments. We present the first distributed observations of FODS wind directions from field data. The wind direction sensing is accomplished by using pairs of actively heated fiber optic cables with cone-shaped microstructures attached to them. Here we present three different methods of calculating wind directions from the FODS measurements, two based on using combined wind speed and direction information and one deriving wind direction independently from FODS wind speed. For each approach, the effective temporal and spatial resolution is quantified using spectral coherence. With each method of calculating wind directions, temporal resolutions on the order of tens of seconds can be achieved. The accuracy of FODS wind directions was evaluated against a sonic anemometer, showing deviations of less than 15° most of the time. The applicability of FODS for wind direction measurements in different environmental conditions is tested by analysing the dependence of FODS wind direction accuracy and observable scales on environmental factors. Finally, we demonstrate the potential of this technique by presenting a period that displays spatial and temporal structures in the wind direction.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
The suitability of a fibre-optic distributed temperature sensing (DTS) technique for observing atmospheric mixing profiles within and above a forest was quantified, and these profiles were analysed. ...The spatially continuous observations were made at a 125 m tall mast in a boreal pine forest. Airflows near forest canopies diverge from typical boundary layer flows due to the influence of roughness elements (i.e. trees) on the flow. Ideally, these complex flows should be studied with spatially continuous measurements, yet such measurements are not feasible with conventional micrometeorological measurements with, for example, sonic anemometers. Hence, the suitability of DTS measurements for studying canopy flows was assessed.
Background
In the surgical treatment of adrenocortical carcinoma (ACC), lymphadenectomy may improve oncologic outcome. However, patterns of metastatic lymphatic spread in ACC are unknown.
Methods
...Clinical data of patients included in the European Network for the Study of Adrenal Tumors (ENSAT) registry were retrospectively reviewed. Inclusion criteria were: nonmetastatic ACC, complete resection of the primary tumor, a disease-free time of > 3 months, and lymph node metastases as the first disease relapse. The retroperitoneal lymphatic drainage area was evaluated by using follow-up imaging.
Results
Of 971 patients from the ENSAT registry, 56 patients were included. In left-sided ACC (
n
= 36), lymphatic recurrence was detected in the left renal hilum (50%), in the perirenal fat tissue cranial to the renal hilum (ventral, 47%; dorsal, 55%), para-aortic (47%), interaorto-caval (22%), and/or in the perirenal fat tissue caudal to the renal hilum (ventral, 20%; dorsal, 17%). In right-sided ACC (
n
= 20), lymph node metastases were detected in the perirenal fat tissue cranial to the renal hilum (dorsal, 55%; ventral, 45%), interaorto-caval (35%), in the area of the right renal artery (10%), and/or paracaval (15%). Patients with right-sided ACC showed left-paraaortic lymph node recurrences in 10% of cases.
Conclusion
Metastatic lymphatic spread appears to be more extensive than previously thought. The distribution pattern of lymph node metastases described in our study could be used as a guide for a more extended lymph node dissection.
Background
Colorectal cancer incidence increases with patient age. The aim of this study was to assess, at the nationwide level, in‐hospital mortality, and failure to rescue in geriatric patients (≥ ...80 years old) with colorectal cancer arising from postoperative complications.
Methods
All patients receiving surgery for colorectal cancer in Germany between 2012 and 2018 were identified in a nationwide database. Association between age and in‐hospital mortality following surgery and failure to rescue, defined as death after complication, were determined in univariate and multivariate analyses.
Results
Three lakh twenty‐eight thousands two hundred and ninety patients with colorectal cancer were included of whom 77,287 were 80 years or older. With increasing age, a significant relative increase in right hemicolectomy was observed. In general, these patients had more comorbid conditions and higher frailty. In‐hospital mortality following colorectal cancer surgery was 4.9% but geriatric patients displayed a significantly higher postoperative in‐hospital mortality of 10.6%. The overall postoperative complication rate as well as failure to rescue increased with age. In contrast, surgical site infection (SSI) and anastomotic leakage (AL) did not increase in geriatric patients, whereas the associated mortality increased disproportionately (13.3% for SSI and 29.9% mortality for patients with AI, both p < 0.001). Logistic regression analysis adjusting for confounders showed that geriatric patients had almost five‐times higher odds for death after surgery than the baseline age group below 60 (OR 4.86; 95%CI 4.45–5.53, p < 0.001).
Conclusion
Geriatric patients have higher mortality after colorectal cancer surgery. This may be partly due to higher frailty and disproportionately higher rates of failure to rescue arising from postoperative complications.
Patients above the age of 80 years show a disproportional high mortality and failure to rescue after resection of colorectal cancer.
To compare and combine dual-energy based and iterative metal artefact reduction on hip prosthesis and dental implants in CT.
A total of 46 patients (women:50%,mean age:63±15years) with dental ...implants or hip prostheses (n = 30/20) were included and examined with a second-generation Dual Source Scanner. 120kV equivalent mixed-images were derived from reconstructions of the 100/Sn140kV source images using no metal artefact reduction (NOMAR) and iterative metal artefact reduction (IMAR). We then generated monoenergetic extrapolations at 130keV from source images without IMAR (DEMAR) or from source images with IMAR, (IMAR+DEMAR). The degree of metal artefact was quantified for NOMAR, IMAR, DEMAR and IMAR+DEMAR using a Fourier-based method and subjectively rated on a five point Likert scale by two independent readers.
In subjects with hip prosthesis, DEMAR and IMAR resulted in significantly reduced artefacts compared to standard reconstructions (33% vs. 56%; for DEMAR and IMAR; respectively, p<0.005), but the degree of artefact reduction was significantly higher for IMAR (all p<0.005). In contrast, in subjects with dental implants only IMAR showed a significant reduction of artefacts whereas DEMAR did not (71%, vs. 8% p<0.01 and p = 0.1; respectively). Furthermore, the combination of IMAR with DEMAR resulted in additionally reduced artefacts (Hip prosthesis: 47%, dental implants 18%; both p<0.0001).
IMAR allows for significantly higher reduction of metal artefacts caused by hip prostheses and dental implants, compared to a dual energy based method. The combination of DE-source images with IMAR and subsequent monoenergetic extrapolation provides an incremental benefit compared to both single methods.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The flux contribution of coherent structures to the total exchange of energy and matter is investigated in a spruce canopy of moderate density in heterogeneous, complex terrain. The study deploys two ...methods of analysis to estimate the coherent exchange: conditional averages in combination with wavelet analysis, and quadrant analysis. The data were obtained by high-frequency single-point measurements using sonic anemometers and gas analysers at five observation heights above and within the canopy and subcanopy, and represent a period of up to 2.5 months. The study mainly addresses the momentum transfer and exchange of sensible heat throughout the roughness sublayer, while results are provided for the exchange of carbon dioxide and water vapour above the canopy. The magnitude of the flux contribution of coherent structures largely depends on the method of analysis, and it is demonstrated that these differences are attributed to differences in the sampling strategy between the two methods. Despite the differences, relational properties such as sweep and ejection ratios and the variation of the flux contribution with height were in agreement for both methods. The sweep phase of coherent structures is the dominant process close to and within the canopy, whereas the ejections gain importance with increasing distance to the canopy. The efficiency of the coherent exchange in transporting scalars exceeds that for momentum by a factor of two. The occurrence of coherent structures results in a flux error less than 4% for the eddy-covariance method. Based on the physical processes identified from the analysis of the ejection and sweep phases along the vertical profile in the roughness sublayer, a classification scheme for the identification of exchange regimes is developed. This scheme allows one to estimate the region of the canopy participating in the exchange of energy and matter with the above-canopy air under varying environmental conditions.
Adaptive immunity vitally depends on major histocompatibility complex class I (MHC I) molecules loaded with peptides. Selective loading of peptides onto MHC I, referred to as peptide editing, is ...catalyzed by tapasin and the tapasin-related TAPBPR. An important catalytic role has been ascribed to a structural feature in TAPBPR called the scoop loop, but the exact function of the scoop loop remains elusive. Here, using a reconstituted system of defined peptide-exchange components including human TAPBPR variants, we uncover a substantial contribution of the scoop loop to the stability of the MHC I-chaperone complex and to peptide editing. We reveal that the scoop loop of TAPBPR functions as an internal peptide surrogate in peptide-depleted environments stabilizing empty MHC I and impeding peptide rebinding. The scoop loop thereby acts as an additional selectivity filter in shaping the repertoire of presented peptide epitopes and the formation of a hierarchical immune response.
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