Adjuvant Use of PlasmaJet Device During Cytoreductive Surgery for Advanced-Stage Ovarian Cancer: Results of the PlaComOv-study, a Randomized Controlled Trial in The Netherlands

Objective

Standard surgical treatment of advanced-stage ovarian carcinoma with electrosurgery cannot always result in complete cytoreductive surgery (CRS), especially when many small metastases are found on the mesentery and intestinal surface. We investigated whether adjuvant use of a neutral argon plasma device can help increase the complete cytoreduction rate.

Patients and Methods

327 patients with FIGO stage IIIB–IV epithelial ovarian cancer (EOC) who underwent primary or interval CRS were randomized to either surgery with neutral argon plasma (PlasmaJet) (intervention) or without PlasmaJet (control group). The primary outcome was the percentage of complete CRS. The secondary outcomes were duration of surgery, blood loss, number of bowel resections and colostomies, hospitalization, 30-day morbidity, and quality of life (QoL).

Results

Complete CRS was achieved in 119 patients (75.8%) in the intervention group and 115 patients (67.6%) in the control group (risk difference (RD) 8.2%, 95% confidence interval (CI) –0.021 to 0.181; P = 0.131). In a per-protocol analysis excluding patients with unresectable disease, complete CRS was obtained in 85.6% in the intervention group and 71.5% in the control group (RD 14.1%, 95% CI 0.042 to 0.235; P = 0.005). Patient-reported QoL at 6 months after surgery differed between groups in favor of PlasmaJet surgery (95% CI 0.455–8.350; P = 0.029). Other secondary outcomes did not differ significantly.

Conclusions

Adjuvant use of PlasmaJet during CRS for advanced-stage ovarian cancer resulted in a significantly higher proportion of complete CRS in patients with resectable disease and higher QoL at 6 months after surgery. (Funded by ZonMw, Trial Register NL62035.078.17.)

Trial Registration

Approved by the Medical Ethics Review Board of the Erasmus University Medical Center Rotterdam, the Netherlands, NL62035.078.17 on 20-11-2017. Recruitment started on 30-1-2018.

Supplementary Information

The online version contains supplementary material available at 10.1245/s10434-022-11763-2.

Evaluation of effectiveness of the PlasmaJet surgical device in the treatment of advanced stage ovarian cancer (PlaComOv-study): study protocol of a randomized controlled trial in the Netherlands

BACKGROUND

The most important goal for survival benefit of advanced stage ovarian cancer is to surgically remove all visible tumour, because complete cytoreductive surgery (CCS) has been shown to be associated with prolonged survival. In a remarkable number of women, CCS is very challenging. Especially in women with many small metastases on the peritoneum and intestinal surface, conventional CCS with electrosurgery is not able to be "complete" in removing safely all visible tumour. In this randomized controlled trail (RCT) we investigate whether the use of the PlasmaJet Surgical Device increases the rate of CCS, and whether this indeed leads to a longer progression free and overall survival. The main research question is: does the use of the PlasmaJet Surgical Device in surgery for advanced stage ovarian cancer result in an increased number of complete cytoreductive surgeries when compared with conventional surgical techniques. Secondary study objectives are: 30-day morbidity, duration of surgery, blood loss, length of hospitalisation, Quality of Life, disease-free survival, overall survival, percentage colostomy, cost-effectiveness.

METHODS

The study design is a multicentre single-blinded superiority RCT in two university and nine non-university hospitals in The Netherlands. Three hundred and thirty women undergoing cytoreductive surgery for advanced stage ovarian carcinoma (FIGO Stage IIIB-IV) will be randomized into two arms: use of the PlasmaJet (intervention group) versus the use of standard surgical instruments combined with electrocoagulation (control group). The primary outcome is the rate of complete cytoreductive surgery in both groups. Secondary study objectives are: 30-day morbidity, duration of surgery, blood loss, length of hospitalisation, Quality of Life, disease-free survival, overall survival, percentage colostomy, cost-effectiveness. Quality of life will be evaluated using validated questionnaires at baseline, at 1 and 6 months after surgery and at 1, 2, 3 and 4 years after surgery.

DISCUSSION

We hypothesize the additional value of the use of the PlasmaJet in CCS for advanced stage epithelial ovarian cancer. More knowledge about efficacy, side effects, recurrence rates, cost effectiveness and pathology findings after using the PlasmaJet Device is advocated. This RCT may aid in this void.

TRIAL REGISTRATION

Dutch Trial Register NTR6624 . Registered 18 August 2017. Medical Ethical Committee approval number: NL62035.078.17 (Medical Ethical Committee Erasmus Medical Centre Rotterdam).

Improved search for Muon-neutrino to electron-neutrino oscillations in MINOS

We report the results of a search for ν(e) appearance in a ν(μ) beam in the MINOS long-baseline neutrino experiment. With an improved analysis and an increased exposure of 8.2 × 10(20) protons on the NuMI target at Fermilab, we find that 2 sin(2) (θ(23))sin(2)(2θ(13))<0.12(0.20) at 90% confidence level for δ = 0 and the normal (inverted) neutrino mass hierarchy, with a best-fit of 2sin(2) (θ(23))sin(2)(2θ(13)) = 0.041(-0.031)(+0.047) (0.079(-0.053) (+0.071)). The θ(13) = 0 hypothesis is disfavored by the MINOS data at the 89% confidence level.

First direct observation of muon antineutrino disappearance

This Letter reports the first direct observation of muon antineutrino disappearance. The MINOS experiment has taken data with an accelerator beam optimized for ν(μ) production, accumulating an exposure of 1.71 × 10²⁰ protons on target. In the Far Detector, 97 charged current ν(μ) events are observed. The no-oscillation hypothesis predicts 156 events and is excluded at 6.3σ. The best fit to oscillation yields |Δm²| = [3.36(-0.40)(+0.46)(stat) ± 0.06(syst)] × 10⁻³ eV², sin²(2θ) = 0.86(-0.12)(+0.11)(stat) ± 0.01(syst). The MINOS ν(μ) and ν(μ) measurements are consistent at the 2.0% confidence level, assuming identical underlying oscillation parameters.

Active to sterile neutrino mixing limits from neutral-current interactions in MINOS

Results are reported from a search for active to sterile neutrino oscillations in the MINOS long-baseline experiment, based on the observation of neutral-current neutrino interactions, from an exposure to the NuMI neutrino beam of 7.07×10(20) protons on target. A total of 802 neutral-current event candidates is observed in the Far Detector, compared to an expected number of 754 ± 28(stat) ± 37(syst) for oscillations among three active flavors. The fraction f(s) of disappearing ν(μ) that may transition to ν(s) is found to be less than 22% at the 90% C.L.

Measurement of the neutrino mass splitting and flavor mixing by MINOS

Measurements of neutrino oscillations using the disappearance of muon neutrinos from the Fermilab NuMI neutrino beam as observed by the two MINOS detectors are reported. New analysis methods have been applied to an enlarged data sample from an exposure of 7.25×10(20) protons on target. A fit to neutrino oscillations yields values of |Δm(2)|=(2.32(-0.08)(+0.12))×10(-3) eV(2) for the atmospheric mass splitting and sin(2)(2θ)>0.90 (90% C.L.) for the mixing angle. Pure neutrino decay and quantum decoherence hypotheses are excluded at 7 and 9 standard deviations, respectively.

The Genetic Production of Synthetic Crystalline Protein Polymers

Genetic and protein engineering are components of a new polymer chemistry which provide the tools for producing macromolecular polyamide copolymers of diversity and precision far beyond the current capabilities of synthetic polymer chemistry. The genetic machinery allows molecular control of chemical and physical chain properties. Nature utilizes this control to formulate protein polymers into materials with extraordinary mechanical properties such as the strength and toughness of silk and the elasticity and resilience of mammalian elastin. The protein chains which make up these fibers consist of extensive repeating oligopeptide sequences. By producing synthetically designed protein chains containing many tandem repeats of only one repetitive sequence block (homoblock polymers), we are able to evaluate the inherent contribution of each repeat to the overall material properties. Using biotechnology, we produced homoblock protein polymers consisting exclusively of silklike crystalline blocks in quantities sufficient for material evaluation studies (10–100 grams). Silk-like homoblock polymers, as produced by microbial fermentation, exhibited measurable crystallinity both in solution and in solid state. The chain properties of the homoblock polymer were changed by adding blocks of amino acids designed to contribute different structural or functional properties. We produced alternating copolymers of various amounts of silk-like and elastin-like blocks ranging from a ratio of 1:4 to 2:1, respectively. The crystallinity of each copolymer varied with the extent of crystalline block interruption. The substitution of the elastin block with one containing the amino acids from human fibronectin responsible for mammalian cell attachment, produced a highly active silk-like copolymer with biological activity. The ability to specifically engineer the mechanical and functional properties of a fiber material is a potential outcome of this technology.

Search for Lorentz invariance and CPT violation with the MINOS far detector

We searched for a sidereal modulation in the MINOS far detector neutrino rate. Such a signal would be a consequence of Lorentz and CPT violation as described by the standard-model extension framework. It also would be the first detection of a perturbative effect to conventional neutrino mass oscillations. We found no evidence for this sidereal signature, and the upper limits placed on the magnitudes of the Lorentz and CPT violating coefficients describing the theory are an improvement by factors of 20-510 over the current best limits found by using the MINOS near detector.

Search for muon-neutrino to electron-neutrino transitions in MINOS

This Letter reports on a search for nu(mu) --> nu(e) transitions by the MINOS experiment based on a 3.14x10(20) protons-on-target exposure in the Fermilab NuMI beam. We observe 35 events in the Far Detector with a background of 27+/-5(stat)+/-2(syst) events predicted by the measurements in the Near Detector. If interpreted in terms of nu(mu) --> nu(e) oscillations, this 1.5sigma excess of events is consistent with sin2(2theta(13)) comparable to the CHOOZ limit when |Delta m2|=2.43x10(-3) eV2 and sin2(2theta(23))=1.0 are assumed.

Search for active neutrino disappearance using neutral-current interactions in the MINOS long-baseline experiment

We report the first detailed comparisons of the rates and spectra of neutral-current neutrino interactions at two widely separated locations. A depletion in the rate at the far site would indicate mixing between nu(mu) and a sterile particle. No anomalous depletion in the reconstructed energy spectrum is observed. Assuming oscillations occur at a single mass-squared splitting, a fit to the neutral- and charged-current energy spectra limits the fraction of nu(mu) oscillating to a sterile neutrino to be below 0.68 at 90% confidence level. A less stringent limit due to a possible contribution to the measured neutral-current event rate at the far site from nu(e) appearance at the current experimental limit is also presented.

Testing Lorentz invariance and CPT conservation with NuMI neutrinos in the MINOS near detector

A search for a sidereal modulation in the MINOS near detector neutrino data was performed. If present, this signature could be a consequence of Lorentz and CPT violation as predicted by the effective field theory called the standard-model extension. No evidence for a sidereal signal in the data set was found, implying that there is no significant change in neutrino propagation that depends on the direction of the neutrino beam in a sun-centered inertial frame. Upper limits on the magnitudes of the Lorentz and CPT violating terms in the standard-model extension lie between 10(-4) and 10(-2) of the maximum expected, assuming a suppression of these signatures by a factor of 10(-17).

Measurement of neutrino oscillations with the MINOS detectors in the NuMI beam

This Letter reports new results from the MINOS experiment based on a two-year exposure to muon neutrinos from the Fermilab NuMI beam. Our data are consistent with quantum-mechanical oscillations of neutrino flavor with mass splitting |Deltam2| = (2.43+/-0.13) x 10(-3) eV2 (68% C.L.) and mixing angle sin2(2theta) > 0.90 (90% C.L.). Our data disfavor two alternative explanations for the disappearance of neutrinos in flight: namely, neutrino decays into lighter particles and quantum decoherence of neutrinos, at the 3.7 and 5.7 standard-deviation levels, respectively.

Observation of muon neutrino disappearance with the MINOS detectors in the NuMI neutrino beam

This Letter reports results from the MINOS experiment based on its initial exposure to neutrinos from the Fermilab NuMI beam. The rates and energy spectra of charged current nu(mu) interactions are compared in two detectors located along the beam axis at distances of 1 and 735 km. With 1.27 x 10(20) 120 GeV protons incident on the NuMI target, 215 events with energies below 30 GeV are observed at the Far Detector, compared to an expectation of 336+/-14 events. The data are consistent with nu(mu) disappearance via oscillations with |Delta(m)2/32|=2.74 +0.44/-0.26 x10(-3)eV(2) and sin(2)(2theta(23))>0.87 (68% C.L.).

Ectopic salivary gland tissue in the anterior mandible: a case report

Ectopic salivary gland inclusions in the mandible are a rare phenomenon. Classically as described by Stafne they have been found in the posterior mandibular region. Cases affecting the anterior mandible are even more unusual. We report a case of ectopic salivary gland tissue in the anterior mandible. In our discussion we emphasise the need for a thorough history, examination and relevant investigations. Mandibular radiolucencies can prove a pitfall for the unwary.

Speech recognition by normal-hearing and cochlear implant listeners as a function of intensity resolution

The importance of intensity resolution in terms of the number of intensity steps needed for speech recognition was assessed for normal-hearing and cochlear implant listeners. In experiment 1, the channel amplitudes extracted from a six-channel continuous interleaved sampling (CIS) processor were quantized into 2, 4, 8, 16, or 32 steps. Consonant recognition was assessed for five cochlear implant listeners, using the Med-El/CIS-link device, as a function of the number of steps in the electrical dynamic range. Results showed that eight steps within the dynamic range are sufficient for reaching asymptotic performance in consonant recognition. These results suggest that amplitude resolution is not a major factor in determining consonant identification. In experiment 2, the relationship between spectral resolution (number of channels) and intensity resolution (number of steps) in normal-hearing listeners was investigated. Speech was filtered through 4-20 frequency bands, synthesized as a linear combination of sine waves with amplitudes extracted from the envelopes of the bandpassed waveforms, and then quantized into 2-32 levels to produce stimuli with varying degrees of intensity resolution. Results showed that the number of steps needed to achieve asymptotic performance was a function of the number of channels and the speech material used. For vowels, asymptotic performance was obtained with four steps, while for consonants, eight steps were needed for most channel conditions, consistent with our findings in experiment 1. For sentences processed though 4 channels, 16 steps were needed to reach asymptotic performance, while for sentences processed through 16 channels, 4 steps were needed. The results with normal-hearing listeners on sentence recognition point to an inverse relationship between spectral resolution and intensity resolution. When spectral resolution is poor (i.e., a small number of channels is available) a relatively fine intensity resolution is needed to achieve high levels of understanding. Conversely, when the intensity resolution is poor, a high degree of spectral resolution is needed to achieve asymptotic performance. The results of this study, taken together with previous findings on the effect of reduced dynamic range, suggest that the performance of cochlear implant subjects is primarily limited by the small number (four to six) of channels received, and not by the small number of intensity steps or reduced dynamic range.

The effect of parametric variations of cochlear implant processors on speech understanding

This study investigated the effect of five speech processing parameters, currently employed in cochlear implant processors, on speech understanding. Experiment 1 examined speech recognition as a function of stimulation rate in six Med-E1/CIS-Link cochlear implant listeners. Results showed that higher stimulation rates (2100 pulses/s) produced a significantly higher performance on word and consonant recognition than lower stimulation rates (<800 pulses/s). The effect of stimulation rate on consonant recognition was highly dependent on the vowel context. The largest benefit was noted for consonants in the /uCu/ and /iCi/ contexts, while the smallest benefit was noted for consonants in the /aCa/ context. This finding suggests that the /aCa/ consonant test, which is widely used today, is not sensitive enough to parametric variations of implant processors. Experiment 2 examined vowel and consonant recognition as a function of pulse width for low-rate (400 and 800 pps) implementations of the CIS strategy. For the 400-pps condition, wider pulse widths (208 micros/phase) produced significantly higher performance on consonant recognition than shorter pulse widths (40 micros/phase). Experiments 3-5 examined vowel and consonant recognition as a function of the filter overlap in the analysis filters, shape of the amplitude mapping function, and signal bandwidth. Results showed that the amount of filter overlap (ranging from -20 to -60 dB/oct) and the signal bandwidth (ranging from 6.7 to 9.9 kHz) had no effect on phoneme recognition. The shape of the amplitude mapping functions (ranging from strongly compressive to weakly compressive) had only a minor effect on performance, with the lowest performance obtained for nearly linear mapping functions. Of the five speech processing parameters examined in this study, the pulse rate and the pulse width had the largest (positive) effect on speech recognition. For a fixed pulse width, higher rates (2100 pps) of stimulation provided a significantly better performance on word recognition than lower rates (<800 pps) of stimulation. High performance was also achieved by jointly varying the pulse rate and pulse width. The above results indicate that audiologists can optimize the implant listener's performance either by increasing the pulse rate or by jointly varying the pulse rate and pulse width.

The effect of reduced dynamic range on speech understanding: implications for patients with cochlear implants

OBJECTIVE

To determine the effect of reduced dynamic range on speech understanding when the speech signals are processed in a manner similar to a 6-channel cochlear implant speech processor.

DESIGN

Signals were processed in a manner similar to a 6-channel cochlear implant processor and output as a sum of sine waves with frequencies equal to the center frequencies of the analysis filters. The amplitudes of the sine waves were compressed in a systematic fashion to simulate the effect of reduced dynamic range. The compressed signals were presented to 10 normal-hearing listeners for identification.

RESULTS

There was a significant effect of compression for all test materials. The effect of the compression on speech understanding was different for the three test materials (vowels, consonants, and sentences). Vowel recognition was affected the most by the compression, and consonant recognition was affected the least by the compression. Feature analysis indicated that the reception of place information was affected the most. Sentence recognition was moderately affected by the compression.

CONCLUSIONS

Dynamic range should affect the speech perception abilities of cochlear implant users. Our results suggest that a relatively wide dynamic range is needed for a high level of vowel recognition and a relatively small dynamic range is sufficient to maintain consonant recognition. We infer from this outcome that, if other factors were held equal, an implant patient with a small dynamic range could achieve moderately high scores on tests of consonant recognition but poor performance on vowel recognition, and that it is more likely for an implant patient with a large dynamic range to obtain high scores on vowel recognition than for an implant patient with a small dynamic range.

Palmoplantar keratoderma (Voerner) with composite keratohyalin granules: studies on keratinization parameters and ultrastructures

A case of the Voerner type palmoplantar keratoderma was studied for abnormalities of keratinization parameters. An enzyme and materials used to build the marginal band or cellular envelope of the cornified cell were all abnormally expressed; i.e. transglutaminase I (TGK), loricrin, and involucrin were abnormally immunostained. In the normal controls, their expression was limited to the upper epidermis, mainly in the granular layer. In the lesional skin, they were detected from the suprabasal layer to the lower horny layer. Filaggrin, the protein of the keratohyalin granule, was also expressed more widely than in controls. Ultrastructural abnormalities included a significantly higher frequency of composite keratohyalin granules than controls, early formation of a marginal band in the midepidermis, and, most remarkably, the clumping of tonofilaments causing vacuolization of the cytoplasm of affected keratinocytes.

On the number of channels needed to understand speech

Recent studies have shown that high levels of speech understanding could be achieved when the speech spectrum was divided into four channels and then reconstructed as a sum of four noise bands or sine waves with frequencies equal to the center frequencies of the channels. In these studies speech understanding was assessed using sentences produced by a single male talker. The aim of experiment 1 was to assess the number of channels necessary for a high level of speech understanding when sentences were produced by multiple talkers. In experiment 1, sentences produced by 135 different talkers were processed through n (2 < or = n < or = 16) number of channels, synthesized as a sum of n sine waves with frequencies equal to the center frequencies of the filters, and presented to normal-hearing listeners for identification. A minimum of five channels was needed to achieve a high level (90%) of speech understanding. Asymptotic performance was achieved with eight channels, at least for the speech material used in this study. The outcome of experiment 1 demonstrated that the number of channels needed to reach asymptotic performance varies as a function of the recognition task and/or need for listeners to attend to fine phonetic detail. In experiment 2, sentences were processed through 6 and 16 channels and quantized into a small number of steps. The purpose of this experiment was to investigate whether listeners use across-channel differences in amplitude to code frequency information, particularly when speech is processed through a small number of channels. For sentences processed through six channels there was a significant reduction in speech understanding when the spectral amplitudes were quantized into a small number (< 8) of steps. High levels (92%) of speech understanding were maintained for sentences processed through 16 channels and quantized into only 2 steps. The findings of experiment 2 suggest an inverse relationship between the importance of spectral amplitude resolution (number of steps) and spectral resolution (number of channels).

Automatic recognition of syllable-final nasals preceded by /epsilon/

In this paper, it is shown how an automatic recognition algorithm, based on hidden Markov models (HMM), can benefit by properly utilizing findings from perceptual experiments on nasals. Perceptual studies on nasal consonants have shown that both nasal murmurs and formant transitions are important in the identification of place of articulation. Thus both acoustic segments bordering the nasal release were incorporated into this HMM-based system. A 7% improvement in alveolar recognition was obtained by explicitly modeling the vowel-nasal transition segments. Further overall improvement (6%) was realized by making the HMM recognizer "focus" more on the vowel-nasal transition segments bordering the nasal release, and less on the nasal murmur and vowel portion of the /epsilon m/ and /epsilon n/ syllables. An overall average [m]-[n] recognition of 95% was obtained when testing this technique on 60 speakers outside the training set.

Genetic engineering of structural protein polymers

Genetic and protein engineering are components of a new polymer chemistry that provide the tools for producing macromolecular polyamide copolymers of diversity and precision far beyond the current capabilities of synthetic polymer chemistry. The genetic machinery allows molecular control of chemical and physical chain properties. Nature utilizes this control to formulate protein polymers into materials with extraordinary mechanical properties, such as the strength and toughness of silk and the elasticity and resilience of mammalian elastin. The properties of these materials have been attributed to the presence of short repeating oligopeptide sequences contained in the proteins, fibroin, and elastin. We have produced homoblock protein polymers consisting exclusively of silk-like crystalline blocks and elastin-like flexible blocks. We have demonstrated that each homoblock polymer as produced by microbial fermentation exhibits measurable properties of crystallinity and elasticity. Additionally, we have produced alternating block copolymers of various amounts of silk-like and elastin-like blocks, ranging from a ratio of 1:4 to 2:1, respectively. The crystallinity of each copolymer varies with the amount of crystalline block interruptions. The production of fiber materials with custom-engineered mechanical properties is a potential outcome of this technology.

Consonant recognition as a function of the number of channels of stimulation by patients who use the Symbion cochlear implant

The intelligibility of a 16-item consonant set was assessed for 10 patients who use the Symbion four-channel cochlear implant. The patients were selected on the basis of "good" speech recognition scores. For each patient, consonant intelligibility was assessed when his/her processor was configured to pass from one to four channels of information. The results suggest, most generally, that two channels, one low frequency and one high frequency, provide most of the information about consonant identity.

Assessing the family environment of schizophrenic patients with multiple hospital admissions

The authors compared the responses on the Family Environment Scale of 12 schizophrenic inpatients who had been hospitalized more than three times in the previous 12 months and a control group of 12 similarly diagnosed inpatients who had been admitted less frequently. Responses of the patients' families were also computed. Patients who were admitted more often reported greater family conflict and less freedom to express emotions. Family responses revealed significantly more incongruity among family members of the more frequently hospitalized patients than among those of the control group. The authors suggest that studies be conducted to determine if the data obtained by the scale are analogous to data on expressed emotion obtained by the more complex Camberwell Family Interview; if so, the Family Environment Scale could be an alternative to the Camberwell Family Interview in studies of schizophrenic patients and their families.

Children's perception of sibilants: the relation between articulation and perceptual development

When synthetic fricative noises from an [s] continuum are followed by [a] and [u], adult listeners perceive fewer instances of in the context of the rounded vowel [u] (Mann & Repp, 1980). This perceptual context effect presumably reflects adjustment for certain coarticulatory effects and implies tacit knowledge of coarticulation and its consequences. To clarify the role of articulatory experience in the ontogeny of such knowledge and the consequent perceptual adjustment, the present study examined the effect of rounded and unrounded vowels on the perception of [s] and by adults, 5-, and 7-year-old children who produce and [s] and 7-year-old children who misarticulate these phonemes. All three groups of children showed a context effect equivalent to that of adults and independent of age and articulation ability. Therefore, productive mastery of [s] and is not critically responsible for perception of the [s] distinction, nor for perceptual sensitivity to the consequences of sibilant-vowel coarticulation.