Evaluation of the Availability of Nursing Quality Indicators in German FHIR Implementations

Standardized nursing data sets facilitate data analysis and help to improve nursing research and quality management in Germany. Recently, governmental standardization approaches have favored the FHIR standard and helped to define it as the state of the art for healthcare interoperability and data exchange. In this study, we identify common data elements used for nursing quality research purposes by analyzing nursing quality data sets and databases. We then compare the results with current FHIR implementations in Germany to find most relevant data fields and overlaps. Our results show that most of the patient focused information has already been modelled in national standardization efforts and FHIR implementations. However, representation of data fields describing nursing staff related information, such as experience, workload or satisfaction, is missing or lacking.

Speech and Nonspeech Parameters in the Clinical Assessment of Dysarthria: A Dimensional Analysis

Nonspeech (or paraspeech) parameters are widely used in clinical assessment of speech impairment in persons with dysarthria (PWD). Virtually every standard clinical instrument used in dysarthria diagnostics includes nonspeech parameters, often in considerable numbers. While theoretical considerations have challenged the validity of these measures as markers of speech impairment, only a few studies have directly examined their relationship to speech parameters on a broader scale. This study was designed to investigate how nonspeech parameters commonly used in clinical dysarthria assessment relate to speech characteristics of dysarthria in individuals with movement disorders. Maximum syllable repetition rates, accuracies, and rates of isolated and repetitive nonspeech oral-facial movements and maximum phonation times were compared with auditory-perceptual and acoustic speech parameters. Overall, 23 diagnostic parameters were assessed in a sample of 130 patients with movement disorders of six etiologies. Each variable was standardized for its distribution and for age and sex effects in 130 neurotypical speakers. Exploratory Graph Analysis (EGA) and Confirmatory Factor Analysis (CFA) were used to examine the factor structure underlying the diagnostic parameters. In the first analysis, we tested the hypothesis that nonspeech parameters combine with speech parameters within diagnostic dimensions representing domain-general motor control principles. In a second analysis, we tested the more specific hypotheses that diagnostic parameters split along effector (lip vs. tongue) or functional (speed vs. accuracy) rather than task boundaries. Our findings contradict the view that nonspeech parameters currently used in dysarthria diagnostics are congruent with diagnostic measures of speech characteristics in PWD.

Comparison of Human Surrogate Responses in Underbody Blast Loading Conditions

Impact biomechanics research in occupant safety predominantly focuses on the effects of loads applied to human subjects during automotive collisions. Characterization of the biomechanical response under such loading conditions is an active and important area of investigation. However, critical knowledge gaps remain in our understanding of human biomechanical response and injury tolerance under vertically accelerated loading conditions experienced due to underbody blast (UBB) events. This knowledge gap is reflected in anthropomorphic test devices (ATDs) used to assess occupant safety. Experiments are needed to characterize biomechanical response under UBB relevant loading conditions. Matched pair experiments in which an existing ATD is evaluated in the same conditions as a post mortem human subject (PMHS) may be utilized to evaluate biofidelity and injury prediction capabilities, as well as ATD durability, under vertical loading. To characterize whole body response in the vertical direction, six whole body PMHS tests were completed under two vertical loading conditions. A series of 50th percentile hybrid III ATD tests were completed under the same conditions. Ability of the hybrid III to represent the PMHS response was evaluated using a standard evaluation metric. Tibial accelerations were comparable in both response shape and magnitude, while other sensor locations had large variations in response. Posttest inspection of the hybrid III revealed damage to the pelvis foam and skin, which resulted in large variations in pelvis response. This work provides an initial characterization of the response of the seated hybrid III ATD and PMHS under high rate vertical accelerative loading.

Dynamics of the Buckling Transition in Double-Stranded DNA and RNA

DNA under torsional strain undergoes a buckling transition that is the fundamental step in plectoneme nucleation and supercoil dynamics, which are critical for the processing of genomic information. Despite its importance, quantitative models of the buckling transition, in particular to also explain the surprising two-orders-of-magnitude difference between the buckling times for RNA and DNA revealed by single-molecule tweezers experiments, are currently lacking. Additionally, little is known about the configurations of the DNA during the buckling transition because they are not directly observable experimentally. Here, we use a discrete worm-like chain model and Brownian dynamics to simulate the DNA/RNA buckling transition. Our simulations are in good agreement with experimentally determined parameters of the buckling transition. The simulations show that the buckling time strongly and exponentially depends on the bending stiffness, which accounts for more than half the measured difference between DNA and RNA. Analyzing the microscopic conformations of the chain revealed by our simulations, we find clear evidence for a solenoid-shaped transition state and a curl intermediate. The curl intermediate features a single loop and becomes increasingly populated at low forces. Taken together, the simulations suggest that the worm-like chain model can account semiquantitatively for the buckling dynamics of both DNA and RNA.

Optical absorption of composition-tunable InGaAs nanowire arrays

InGaAs nanowire (NW) arrays have emerged as important active materials in future photovoltaic and photodetector applications, due to their excellent electronic properties and tunable band gap. Here, we report a systematic investigation of the optical absorption characteristics of composition-tunable vertical InGaAs NW arrays. Using finite-difference time-domain simulations we first study the effect of variable composition (Ga-molar fraction) and NW array geometry (NW diameter, period, fill factor) on the optical generation rate. NWs with typical diameters in the range of ∼100-250 nm lead to generation rates higher than the equivalent bulk case for moderate fill factors (NW period of ∼0.3-0.8 μm), while slightly smaller fill factors and increased diameters are required to maintain high generation rates at increased Ga-molar fraction. The optical absorption was further measured using spectrally resolved ultraviolet-visible-near-infrared (UV-vis-NIR) spectroscopy on NW arrays transferred to transparent substrates. Interestingly, large variations in Ga-molar fraction (0 < x(Ga) < 0.5) have a negligible influence, while minute changes in NW diameter of less than ±20 nm affect the absorption spectra very strongly, leading to pronounced shifts in the peak absorption energies by more than ∼700 meV. These results clearly highlight the much larger sensitivity of the optical absorption behavior to geometric parameters rather than to variations in the electronic band gap of the underlying NW array.

Quantum Optomechanics in a Liquid

We measure the quantum fluctuations of a single acoustic mode in a volume of superfluid He that is coupled to an optical cavity. Specifically, we monitor the Stokes and anti-Stokes light scattered by a standing acoustic wave that is confined by the cavity mirrors. The intensity of these signals (and their cross-correlation) exhibits the characteristic features of the acoustic wave's zero-point motion and the quantum backaction of the intracavity light. While these features are also observed in the vibrations of solid objects and ultracold atomic gases, their observation in superfluid He opens the possibility of exploiting the remarkable properties of this material to access new regimes of quantum optomechanics.

A novel pretherapeutic gene expression-based risk score for treatment guidance in gastric cancer

Background

Perioperative chemotherapy is an established treatment of advanced gastric cancer patients. Treatment selection is based on clinical staging (cT). We aimed to establish and validate a prognostic score including clinical and molecular factors, to optimize treatment decisions for these patients.

Patients and methods

We analyzed 626 carcinomas of the stomach and of the gastro-esophageal junction from two academic centers including primarily resected and pre-/perioperatively treated patients. Patients were divided into a training (N = 269) and validation (N = 357) set. Expression of 11 target genes was measured by quantitative PCR in resected tumors. A risk score to predict overall survival (OS) was generated and validated. Intra-tumoral heterogeneity was assessed by analyzing 50 tumor areas from 10 patients.

Results

A risk score including the expression of CCL5, CTNNB1, EXOSC3 and LZTR1 and the clinical parameters cT, tumor localization and histopathologic type suggested two groups with a significant difference in OS [hazard ratio (HR) 0.30; 95% confidence interval (CI) 0.17-0.52]. The risk score was successfully validated in an independent cohort (HR 0.32; 95% CI 0.21-0.51; P < 0.001) as well as in subgroups of primarily resected (HR 0.30; 95% CI 0.17-0.54; P < 0.001) and pre-/perioperatively treated patients (HR 0.37; 95% CI 0.17-0.81; P = 0.009). A significant difference in OS of high- and low-risk patients was also found in primarily resected patients with intestinal (HR 0.45; 95% CI 0.23-0.90; P = 0.020) and nonintestinal-type carcinomas (HR 0.1; 95% CI 0.02-0.42; P < 0.001). Intra-tumor heterogeneity analysis indicated a classification reliability of 95% for a supposed analysis of three biopsies.

Conclusion

The identified risk score could substantially contribute to an improved management of gastric cancer patients in the context of perioperative chemotherapy.

Assessing the population relevance of endocrine-disrupting effects for nontarget vertebrates exposed to plant protection products

The European Commission intends to protect vertebrate wildlife populations by regulating plant protection product (PPP) active substances that have endocrine-disrupting properties with a hazard-based approach. In this paper we consider how the Commission's hazard-based regulation and accompanying guidance can be operationalized to ensure that a technically robust process is used to distinguish between substances with adverse population-level effects and those for which it can be demonstrated that adverse effects observed (typically in the laboratory) do not translate into adverse effects at the population level. Our approach is to use population models within the adverse outcome pathway framework to link the nonlinear relationship between adverse effects at the individual and population levels in the following way: (1) use specific protection goals for focal wildlife populations within an ecosystem services framework; (2) model the effects of changes in population-related inputs on focal species populations with individual-based population models to determine thresholds between negligible and nonnegligible (i.e., adverse) population-level effects; (3) compare these thresholds with the relevant endpoints from laboratory toxicity tests to determine whether they are likely to be exceeded at hazard-based limits or the maximum tolerated dose/concentration from the experimental studies. If the population threshold is not exceeded, then the substance should not be classified as an endocrine disruptor with population-relevant adversity unless there are other lines of evidence within a weight-of-evidence approach to challenge this. We believe this approach is scientifically robust and still addresses the political and legal requirement for a hazard-based assessment. Integr Environ Assess Manag 2019;15:278-291. © 2018 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

[Gastric stump carcinoma: frequency, treatment, complications and prognosis]

BACKGROUND

Gastric stump carcinoma develops in the gastric remnant after partial gastrectomy. While the frequency of gastric cancer is declining, the incidence of gastric stump carcinoma has remained stable due to the long latency period. As the surgical treatment of gastric ulcers by partial gastrectomy has become much less important, more and more gastric stump carcinomas develop after oncological resection.

AIM

This study compared the surgical therapy of gastric stump carcinoma with the therapy of primary gastric cancer.

MATERIAL AND METHODS

From 2001 to 2014 a total of 24 patients were surgically treated for gastric stump carcinoma in the University Hospital of Heidelberg. In the same time 428 patients underwent resection due to primary gastric cancer. Both groups were analyzed and compared with a focus on preoperative therapy, intraoperative differences, complications and overall survival.

RESULTS

Patients with gastric stump carcinoma were older at disease onset (68 years vs. 62 years, p = 0.003). Compared with primary gastric cancer, patients with gastric stump carcinoma were more often suspected of having lymph node (cN+) involvement (51.4 % vs. 41.7 %, p < 0.001) but neoadjuvant therapy was applied less often (48.7 % vs. 14.3 %, p < 0.01). For resection of gastric stump carcinoma, extended resections were more often necessary (54.5 % vs. 28.2 %, p < 0.001). There were no significant differences in mean overall survival between the two patient groups (64.4 months vs. 45.8 months, p = 0.34) CONCLUSION: Despite the differences described, the treatment of gastric stump carcinoma does not essentially differ from that of primary gastric cancer. Carcinomas of the gastric stump are more often locally advanced and in our opinion a neoadjuvant therapy should be applied analogue to gastric cancer even if evidence-based data on this point are limited.

FDG PET and CT in locally advanced adenocarcinomas of the distal oesophagus

Aim: The incidence of adenocarcinomas of the distal oesophagus (ADE) has dramatically increased in Western countries. The clinical importance of a FDG PET finding discordant with CT was determined in patients with locally advanced ADE. In addition, tumour standardized uptake values (SUV) were correlated with patient survival. Patients, methods: 40 consecutive patients were analyzed retrospectively. All patients underwent an attenuation corrected FDG PET scan (neck, chest, abdomen) and contrast enhanced helical CT of the chest and abdomen. PET and CT scans were reviewed independently and concomitantly with respect to metastases in predefined lymph node sites and organs. Any discordance between PET and CT was assessed for clinical relevance. Clinical relevance was defined as a change in the overall therapeutic concept (curative vs. palliative). Follow-up imaging and histological evaluation served as the gold standard. Mean tumour SUVs were determined by 1.5 cm regions of interest placed over the tumour’s maximum. Results: When read independently from the CT scan FDG PET indicated a clinically relevant change in tumour stage in 9/40 patients (23%) and a non-relevant change in 11/40 patients (28%). PET was correct in 5/9 patients (56%) with clinically relevant discordances. In 4/9 patients PET was incorrect (3 false positive due to suspicion of M1-lymph nodes or lung metastases, 1 false negative in disseminated liver metastases). With concomitant reading, PET indicated a clinically relevant change in tumour stage in 6/40 patients (15%) and a non-relevant change in 5/40 patients (13%). PET was correct in 5/6 patients (83%) with clinically relevant discordances. The patient with disseminated liver disease remained the single false negative. Overall, the benefit from PET was based on its higher diagnostic accuracy at organ sites. Tumour SUV did not correlate with patient survival. Conclusion: About half of discordances between FDG PET and CT are clinically relevant. Concomitant reading of PET and CT is advisable as it reduces the overall rate of discordances and enhances the accuracy of PET in clinical relevant discordances (from 56% to 83%).

[Pacemaker, defibrillator and co : Perioperative handling of cardiac implantable electronic devices]

The number of patients treated with cardiac implantable electronic devices (CIED) is continously increasing. Knowledge of the medical indications and technical mode of functioning of these devices is a basic prerequisite for the safe perioperative care of this patient cohort. The CIEDs are subjected to a multitude of disturbing influences in the perioperative setting. This can result in potentially dangerous complications, such as exit block and oversensing. The safe performance of interventions is possible as long as some basic rules are followed. An interdisciplinary approach involving all participating disciplines is necessary in order to adequately deal with the high demands placed on the logistics.

Non-animal models of epithelial barriers (skin, intestine and lung) in research, industrial applications and regulatory toxicology

Models of the outer epithelia of the human body - namely the skin, the intestine and the lung - have found valid applications in both research and industrial settings as attractive alternatives to animal testing. A variety of approaches to model these barriers are currently employed in such fields, ranging from the utilization of ex vivo tissue to reconstructed in vitro models, and further to chip-based technologies, synthetic membrane systems and, of increasing current interest, in silico modeling approaches. An international group of experts in the field of epithelial barriers was convened from academia, industry and regulatory bodies to present both the current state of the art of non-animal models of the skin, intestinal and pulmonary barriers in their various fields of application, and to discuss research-based, industry-driven and regulatory-relevant future directions for both the development of new models and the refinement of existing test methods. Issues of model relevance and preference, validation and standardization, acceptance, and the need for simplicity versus complexity were focal themes of the discussions. The outcomes of workshop presentations and discussions, in relation to both current status and future directions in the utilization and development of epithelial barrier models, are presented by the attending experts in the current report.

Abstract P6-10-17: Rates of prophylactic surgeries among BRCA 1 or 2 mutation carriers: A single institution experience

Background

Women with identified BRCA1/2 mutation have a substantially increased risk of developing several types of cancer, mainly breast and ovarian, during their lifetime. Management options included close surveillance, chemoprevention and prophylactic surgeries. The aim of this study is to assess the rate of prophylactic surgeries among BRCA1/2 carriers counseled and screened at a single institution in the last 2 decades.

Methods

We retrospectively captured all women with a BRCA1/2 mutation that were identified in our genetic clinic between 2000 and 2015. The incidence of breast and ovarian cancer among all BRCA carriers was reported. The rates of prophylactic surgeries were calculated and analyzed in all identified carriers.

Results

Six hundred and eighty four women were identified to carry a deleterious BRCA mutation, among them 364 BRCA1 (53%) and 320 BRCA2 (47%). Three hundred and twenty seven (48%) were diagnosed with breast cancer and 80 (12%) had either ovarian or fallopian tumor. Forty percent (N=271) of the women assessed were healthy carriers. Prophylactic bilateral salpingo-oophorectomies (BSO) were performed in 342 women (50%) and prophylactic mastectomies (PM) (bilateral or unilateral) in 190 (28%). Furthermore, 154 women (23%) had both BSO and PM. Of note, 79 women (12%) were less than 35 years old and 122 were less than 40 years old (18%), the majority of those were waiting to have BSO later on. If we remove the young women from the analysis, 57 and 61% of the women would have had BSO (less than 35 and 40 years excluded respectively). If we only analyze the women who had a recent follow up in our clinic (2014-2015), 422 women would be eligible. Among those, 58 and 84 were less than 35 and 40 years old (y) respectively. For this cohort, the rates of BSO would be 61% (257/422)(whole cohort), 71% (excluding women less than 35y) and 76% (excluding women less than 40y).

Conclusion

A promising rate of BSO was reported in our cohort of BRCA carriers as compared to the literature. This rate was even higher (from 50 to over 70%) when we only analyzed patients with recent follow up in clinic and when we excluded young women waiting to have BSO. More efforts are needed to determine why the rates of PM are lower, for example limited breast reconstruction resources, in order to reduce the incidence of subsequent invasive breast cancer in this high-risk population.

Citation Format: Raphael J, Hewitt P, Graham T, Ott K, Mancuso T, Lorentz J, Emmerson M, Eisen A. Rates of prophylactic surgeries among BRCA 1 or 2 mutation carriers: A single institution experience. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P6-10-17.

[Are There Gender-Specific Differences in Complications Following Abdominal Surgery?]

Studies in mice indicate gender-specific differences in surgical complications with a distinct advantage for females. In patient care, however, gender has been an underrated aspect of complication management in abdominal surgery as far. Proven differences between the sexes regarding anatomy, hormonal regulation, constitutional polymorphisms, immune response and psychology suggest different types and incidence of complications and seem to justify studies on the topic. This review aims to compare a selection of current original articles reporting on complications following abdominal surgery separately for the genders. However, data in the literature are sparse and in part very heterogeneous. With data on colorectal carcinoma being most comprehensive, for stomach, oesophagus and finally pancreas fewer data can be found. Summing up all organ systems, the following cautious conclusions can be drawn. Men tend to suffer from postoperative complications more frequently. Men have more cases of anastomotic leakage, whereas women suffer from anastomotic stenosis more often. Currently, however, existing data do not justify any adaptation of patient management. Thus, taking gender aspects into account in designing new trials is paramount in order to obtain robust gender-specific data on incidence and types of complications.

[Gender Aspects in Gastrointestinal Tumours and Their Prognosis in Regard to Multimodal Treatment Concepts]

Systematic analyses of gender effects in gastrointestinal malignancies are currently lacking, partly because sex and gender have not been used as stratification criteria in major studies on the topic. It is, however, indisputable that gastrointestinal tumours differ in risk factors, incidence and prognosis between the genders. This review summarises the most important findings on differences related to biological sex and sociocultural gender and discusses anatomic specifics with immediate significance for surgical interventions. Epidemiological differences in upper gastrointestinal malignancies are most prominent in regard to histological subtypes, directly affecting diagnostics, therapy, and prognosis. Women have a better prognosis in many of these tumour subtypes. For colorectal carcinoma, sex hormones, specifically oestrogens, appear to play a distinct role in tumourigenesis. Histopathological analysis of the expression of oestrogen receptor beta (ERβ) in the tumour tissue has attracted interest since it was shown that women with low ERβ expression have a better prognosis than men with comparable ERβ status. Data on the higher incidence of right-sided colon carcinoma and non-polypoid neoplasms in women could lead to improved screening programmes. Men and women cite differing reasons for avoidance of screening colonoscopies, thus gender specific approaches could improve colon cancer prevention programmes. Data on differing bioavailability of 5-fluorouracil between the genders are useful to minimise adverse effects of chemotherapy and should be accounted for in dosage. Further systematic analysis of gender effects on gastrointestinal tumours is warranted and would be a substantial step towards personalised oncological surgery.

How Does GPi-DBS Affect Speech in Primary Dystonia?

BACKGROUND

Globus pallidus internus deep brain stimulation (GPi-DBS) can be an effective treatment for primary dystonia. However, speech disorders have previously been reported as a common possible side effect of the treatment.

OBJECTIVES

To study possible deterioration of speech after GPi-DBS and describe this in different dimensions.

METHODS

Speech was systematically evaluated in 15 patients with predominant torticollis and GPi-DBS. Each patient was tested twice within one day in two stimulation conditions: ON-DBS vs. OFF-DBS. Speech analyses comprised both function-oriented (perceptual scales, acoustic analyses) and communication-related measures (intelligibility, naturalness). A control sample of 15 healthy speakers underwent the same speech assessment.

RESULTS

On the group level, patients with dystonia showed mild but significant impairment on the overall dysarthria scale, the intelligibility score, and the naturalness ratings in both stimulation conditions (Mann-Whitney, P < .05). No stimulation-induced deterioration was found. A slight increase in articulation rate was measured in the ON condition. On the single-case level, effects of GPi-DBS on speech were heterogenous. In one patient we observed a deterioration of speech (dysarthria), in a second patient with a history of childhood stuttering we found an aggravation of dysfluency. Impressive benefits could be documented in another patient who also suffered from spasmodic dysphonia.

CONCLUSIONS

The study provides evidence that speech impairment is not a necessary side-effect of GPi-DBS in primary dystonia. Both, recurring of stuttering and a worsening of dysarthria may be seen in individual patients. The positive effects of GPi-DBS on the symptoms of spasmodic dysphonia merits further research as DBS is not commonly applied in this population.

[Salvage surgery in esophageal cancer : Feasibility in patients after definitive radiochemotherapy (> 50 Gy)]

BACKGROUND

Salvage surgery as an additional therapy option is currently discussed for an increasing number of patients with esophageal cancer after definitive radio(chemo)therapy after tumor progression, recurrence or on explicit request of the patient.

OBJECTIVES

The objective of this study was an analysis of the surgical option of salvage esophagectomy after definitive radiation in patients with esophageal cancer. Additionally the current literature on this topic was evaluated.

MATERIAL AND METHODS

A total of 92 patients with esophageal cancer from a prospective database were included in this study who underwent esophagectomy either after neoadjuvant radio(chemo)therapy (< 50 Gy) or definitive radio(chemo)therapy (> 50 Gy) between 2002 and 2012. The analysis was performed retrospectively.

RESULTS

The median survival of the two groups of patients was not significantly different after initial diagnosis with 24.2 months (95 % CI 0.0-51.93) for patients undergoing definitive radio(chemo)therapy and 30.7 months (95 % CI 9.3-52.2) for patients after neoadjuvant therapy (p = 0.96). Both patient groups showed no differences in pretherapeutic characteristics and response to radio(chemo)therapy. Postoperative complications and perioperative mortality were not different.

DISCUSSION

Salvage esophagectomy is now an additional treatment option after definitive radio(chemo)therapy in patients with esophageal cancer. In preselected patients with tumor recurrence, progression or with a strong wish for surgical therapy, salvage surgery should be discussed in interdisciplinary tumor boards after exclusion of distant metastases.

[Importance of PET in surgery of esophageal cancer]

Perioperative or preoperative radiochemotherapy (RCTx) is nowadays standard for locally advanced esophageal cancer in Europe, as randomized studies have shown a significant survival benefit for patients with multimodal treatment. As responders and nonresponders have a significantly different prognosis, a response-based tailored preoperative treatment would be of utmost interest. An established method is a metabolic response evaluation by 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). The level of metabolic response is known to be dependent on the localization, tumor entity and type of preoperative treatment. Association of FDG-PET with later response and prognosis was shown for absolute standardized uptake values (SUV) or a decrease of SUV levels before and after therapy but there are also contradictory findings in the literature and no prospective validation. However, neither time points nor cut-off for metabolic response evaluation have been defined so far. The most interesting approach seems to be early response monitoring during preoperative chemotherapy, which has shown promising results in prospective single center trials (MUNICON I/II) during chemotherapy of adenocarcinoma of the esophagogastric junction (AEG), but needs to be validated in prospective multicenter trails.

Prognostic value of histopathological regression in 850 neoadjuvantly treated oesophagogastric adenocarcinomas

Background:

Recently, histopathological tumour regression, prevalence of signet ring cells, and localisation were reported as prognostic factors in neoadjuvantly treated oesophagogastric (junctional and gastric) cancer. This exploratory retrospective study analyses independent prognostic factors within a large patient cohort after preoperative chemotherapy including clinical and histopathological factors.

Methods:

In all, 850 patients presenting with oesophagogastric cancer staged cT3/4 Nany cM0/x were treated with neoadjuvant chemotherapy followed by resection in two academic centres. Patient data were documented in a prospective database and retrospectively analysed.

Results:

Of all factors prognostic on univariate analysis, only clinical response, complications, ypTNM stage, and R category were independently prognostic (P<0.01) on multivariate analysis. Tumour localisation and signet ring cells were independently prognostic only when investigator-dependent clinical response evaluation was excluded from the multivariate model. Histopathological tumour regression correlates with tumour grading, Laurén classification, clinical response, ypT, ypN, and R categories but was not identified as an independent prognostic factor. Within R0-resected patients only surgical complications and ypTNM stage were independent prognostic factors.

Conclusions:

Only established prognostic factors like ypTNM stage, R category, and complications were identified as independent prognostic factors in resected patients after neoadjuvant chemotherapy. In contrast, histopathological tumour regression was not found as an independent prognostic marker.

Dead-time effects of neutron detectors due to pulsed radiation

Electron storage rings of synchrotron light sources are typically filled only for several minutes day(-1). During these injections, the dose rates outside the shielding walls can be quite high even if the annual dose personal dose equivalent is below 1 mSv a(-1), which is the case at most synchrotron light sources. During the injection process, there is a time structure of short pulses (often defined by the convolution time of the synchrotron) having a pulse length of several 100 ns and a repetition rate between 1 and 10 Hz, which is defined by the acceleration processes in synchrotrons or linacs. Under these conditions, high measurement errors are possible, especially for neutron monitors that are based on proportional counters, which is the case for most commercially available neutron detectors. In this article, the authors' investigations of different neutron monitors are presented and how these results depend on the beam parameters, neutron fields and detector properties is shown. The experiments were conducted at the synchrotron light sources BESSYII and Metrology Light Source with pulsed electron beams of 1.7 GeV and 100 MeV, respectively. Other experiments were conducted at the HZB cyclotron with a 68-MeV pulsed proton beam that hits a spallation target. Fluka calculations of dose rates and neutron spectra were performed for the experiments. Correction formulas that are valid even in the saturation range were derived.

Preoperative therapy of esophagogastric cancer: the problem of nonresponding patients

INTRODUCTION

Preoperative treatment is nowadays standard for locally advanced esophagogastric cancer in Europe. Surprisingly, little attention has been paid to nonresponders so far. The aim of our retrospective exploratory study was the comparison of responder, nonresponder, and primary resected patients in respect of outcome considering the tumor entity.

PATIENTS AND METHODS

From 2001-2011, 607 patients with locally advanced esophagogastric carcinoma (adenocarcinoma of the esophagogastric junction (AEG), n = 293; squamous cell cancer (SCC), n = 111; gastric cancer, n = 203) after preoperative treatment (n = 281) or primary resection (n = 326) were included. Histopathological response evaluation (Becker criteria) was available for 263.

RESULTS

A total of 76/263 (28.9 %) were responders (<10 % residual tumor). There was an association of response with increased R0 resections (p < 0.001) but also with a higher complication rate (p = 0.008) compared to nonresponse and primary surgery. Mortality was not influenced. Increased R0 resections after response were confirmed in every tumor entity (AEG, p = 0.010; SCC, p = 0.023; gastric cancer, p = 0.006). Median survival was best for responders with 43.5 months [95 % confidence interval (CI), 27.9-59.1], followed by nonresponders with 24.3 months (95 % CI, 21.6-27.0) and primary resected patients with 20.8 months (95 % CI, 17.7-23.9; p = 0.002). AEG (p = 0.012) and gastric cancer (p = 0.017) revealed identical results, but in the subgroup of SCC, the survival of nonresponders (median, 11.6 months; 95 % CI, 6.9-16.3) was even worse than for primary resected patients (median, 23.8 months; 95 % CI, 1.7-46.0; p = 0.012).

CONCLUSION

The histopathological response rate was low. Generally, nonresponding patients with AEG or gastric cancer seem not to have a disadvantage compared to primary resected patients, but nonresponders with SCC have a worse prognosis, which strengthens the demand for a critical patient selection in surgery for this tumor entity.

Controlling fast transport of cold trapped ions

We realize fast transport of ions in a segmented microstructured Paul trap. The ion is shuttled over a distance of more than 10(4) times its ground state wave function size during only five motional cycles of the trap (280 μm in 3.6 μs). Starting from a ground-state-cooled ion, we find an optimized transport such that the energy increase is as low as 0.10±0.01 motional quanta. In addition, we demonstrate that quantum information stored in a spin-motion entangled state is preserved throughout the transport. Shuttling operations are concatenated, as a proof-of-principle for the shuttling-based architecture to scalable ion trap quantum computing.

[Gastric cancer and adenocarcinoma of the esophagogastric junction: principles of neoadjuvant therapy]

According to the current European and German S3 guidelines, neoadjuvant chemotherapy is now an integral part of the treatment of locally advanced gastric cancer and adenocarcinoma of the esophagogastric junction. Neoadjuvant therapy seeks to achieve downsizing of the primary tumor, lowering of the T and N categories and eradication of micrometastases. As the indications for neoadjuvant treatment are based on pretherapeutic information alone, a sophisticated clinical staging plays a central role. Despite all progress made in the field of diagnostic work-up, clinical staging often fails. Despite this fact, controlled randomized trials showed that neoadjuvant chemotherapy enhances the rate of curative (R0) resections and reduces the likelihood of systemic relapse. Overall, survival can be improved by neoadjuvant chemotherapy. The current research is focused on the molecular prediction of response and early response monitoring with functional imaging. New targeted drugs are being integrated into the peri-operative treatment.

New trends for staging and therapy for localized gastroesophageal cancer: the role of PET

Treatment options for localized gastroesophageal cancers reach from limited resection to multimodality treatment. Accurate clinical assessment, prognostic and predictive information are needed to select the most appropriate treatment approach. Positron emission tomography (PET) in combination with computed tomography (CT) in a hybrid imaging modality PET-CT may refine the staging accuracy and add prognostic information. Moreover, experiences from diverse centers indicate that PET also might improve significantly the assessment of response to preoperative chemotherapy and chemoradiotherapy. This article outlines the current value of PET in the staging and multidisciplinary care of gastroesophageal cancer. At this stage, it remains unclear whether the prognosis of patients can be improved by implementing PET in the management of localized disease. Prospective multicenter studies have to be carried out to validate metabolic cut-off values and to prove the benefit of PET-guided treatment decisions.

[Neoadjuvant therapy in the upper gastro-intestinal tract. Gastric cancer from a surgical viewpoint]

The prognosis of locally advanced gastric cancer remains poor. It has been shown that multimodal treatment can improve the outcome in comparison to surgery alone. Two randomized studies that have been performed in Europe have shown that peri-operative chemotherapy significantly improves the survival of patients with adenocarcinoma of the stomach and of the gastro-esophageal junction. These results have a profound effect on the treatment of patients presenting with stage II or stage III disease. For more than 10 years it has been accepted that responding patients have a significantly improved prognosis compared to non-responding patients. Therefore, (early) response evaluation or response prediction is of utmost importance. After neoadjuvant chemotherapy patients should undergo a D-2 lymphadenectomy due to the high probability of lymph node metastasis. Neither mortality nor complication rate are increased after neoadjuvant chemotherapy for gastric cancer. Patients with locally advanced gastric cancer should always be referred to experienced high volume centers, where the findings are discussed in a multidisciplinary tumor board.

Isolation rooms for highly infectious diseases: an inventory of capabilities in European countries

Isolation of patients with highly infectious diseases (HIDs) in hospital rooms with adequate technical facilities is essential to reduce the risk of spreading disease. The European Network for Infectious Diseases (EUNID), a project co-funded by European Commission and involving 16 European Union member states, performed an inventory of high level isolation rooms (HIRs, hospital rooms with negative pressure and anteroom). In participating countries, HIRs are available in at least 211 hospitals, with at least 1789 hospital beds. The adequacy of this number is not known and will depend on prevailing circumstances. Sporadic HID cases can be managed in the available HIRs. HIRs could also have a role in the initial phases of an influenza pandemic. However, large outbreaks due to natural or to bioterrorist events will need management strategies involving healthcare facilities other than HIRs.

Limited resection and free jejunal graft interposition for squamous cell carcinoma of the cervical oesophagus

BACKGROUND

Therapeutic strategies for cervical oesophageal squamous cell carcinoma (SCC) are controversial. Treatment options range from definitive radiotherapy to multimodal treatment. Outcome after limited resection and reconstruction with a free jejunal graft interposition was evaluated retrospectively.

METHODS

Patients with clinical T1-4 Nx M0 tumours treated between 1986 and 2006 were included.

RESULTS

Of 109 patients, 94 underwent preoperative chemoradiotherapy and 15 had a primary resection. Complete or partial preservation of the larynx was achieved in 93 patients (85.3 per cent). Minor and major complications occurred in 74.3 per cent, with 44.0 per cent of all patients having more than one complication. Reoperation was necessary in 29.4 per cent. The 30-day mortality rate was 1.8 per cent, and the in-hospital mortality rate 2.8 per cent. The complete R0 resection rate was 72.5 per cent. Median overall survival was 34.3 months; 1-, 3- and 5-year survival rates were 83.8, 47.0 and 47.0 per cent respectively. Survival was not influenced by complications (P = 0.401) or reoperation (P = 0.428).

CONCLUSION

Despite high complication and reoperation rates, the mortality rate was low, even after preoperative chemoradiation. This complex surgical strategy is a treatment option for cervical SCC in oncological centres with an infrastructure providing multidisciplinary management.

Neoadjuvant continuous infusion of weekly 5-fluorouracil and escalating doses of oxaliplatin plus concurrent radiation in locally advanced oesophageal squamous cell carcinoma: results of a phase I/II trial

Oxaliplatin and 5-fluorouracil have a significant activity in locally advanced oesophageal squamous cell cancer (OSCC). However, their optimal dosage and efficacy when combined with concurrent radiotherapy as neoadjuvant treatment are unknown. This non-randomised, phase I/II study aimed to define the maximum tolerated dose (MTD) and assessed the histopathological tumour response rate to neoadjuvant oxaliplatin in weekly escalating doses (40, 45, 50 mg m⁻²) and continuous infusional 5-fluorouracil (CI-5FU; 225 mg m⁻²) plus concurrent radiotherapy. Patients had resectable OSCC. Resection was scheduled for 4–6 weeks after chemoradiotherapy. During phase I (dose escalation; n=19), weekly oxaliplatin 45 mg m⁻² plus CI-5FU 225 mg m⁻² was established as the MTD and was the recommended dosage for phase II. Oesophageal mucositis was the dose-limiting toxicity at higher doses. During phase II, histopathological responses (<10% residual tumour cells within the specimen) were observed in 10 of 16 patients (63%; 95% confidence interval: 39–82%). Overall, 16 of the 25 patients (64%) who underwent resection had a histopathological response; tumour-free resection (R0) was achieved in 80%. Neoadjuvant weekly oxaliplatin 45 mg m⁻² plus CI-5FU 225 mg m⁻² with concurrent radiotherapy provides promising histological response rates and R0 resection rates in locally advanced OSCC.

Predictors of response and survival for neoadjuvant treated patients with esophageal adenocarcinoma

Mainly patients with advanced esophageal adenocarcinoma who respond to neoadjuvant chemotherapy show a significant survival benefit after resection. Therefore, prediction of response before treatment is desirable. The aim of this study was to assess genetic predictors of response and survival for patients with esophageal adenocarcinoma prior to neoadjuvant therapy. Thirty-two patients with advanced esophageal adenocarcinoma who underwent neoadjuvant therapy with resection of their tumor were analyzed for thymidylate synthase (TS), excision repair cross complementing (ERCC1) and Gluthatione S-transferase (GSTP-1) mRNA levels prior to the treatment. These results were analyzed in regards of response and survival. In total, 18 patients responded to this protocol. Seventeen of those did show a gene expression level at or below the respective median of at least one gene. This had a profound impact on survival, demonstrating an increase in survival for patients who have TS, ERCC1, or GSTP-1 mRNA level at or below the median. These results demonstrate a potential predictive value of a gene expression profile available prior to therapy. These data have to be confirmed by a larger prospective trial.

Visualisation of metastatic oesophageal and gastric cancer and prediction of clinical response to palliative chemotherapy using 18FDG PET

AIM

This study assessed the value of (18)F-deoxyglucose positron emission tomography (FDG-PET) for visualisation and early metabolic response assessment in metastatic gastro-oesophageal cancer.

PATIENTS, METHODS

Twenty-six patients who were treated for metastatic disease (20 adenocarcinomas, 6 squamous cell cancers) underwent FDG-PET before and two weeks after the onset of palliative chemotherapy with either oxaliplatin + 5-FU/LV or with docetaxel + capecitabine. PET results were validated according to clinical response based on RECIST criteria.

RESULTS

Twenty-four tumours (92%) could be visualised by FDG-PET and were also assessable by a second PET scan at 2 weeks. The 2 tumours that were not detectable by PET were both gastric cancers belonging to the non-intestinal subtype according to Lauren. Median time to progression and overall survival were not significantly different for metabolic responders and non-responders (6.3 vs 5.3 months and 14.1 vs 12.5 months, respectively).

CONCLUSION

In this heterogeneous study population, FDG-PET had a limited accuracy in predicting clinical response. However, the metabolic response prediction was particularly good in the subgroup of patients with oesophageal squamous cell cancer. Therefore, FDG-PET and assessment of cancer therapy clearly merits further investigation in circumscribed patient populations with metastatic disease.

[Lymphadenectomy with tumors of the upper gastrointestinal tract]

In surgical therapy for upper gastrointestinal cancer, adequate lymphadenectomy together with R0 resection of the primary tumour is one of the most important prognostic factors which can be influenced by the surgeon. Recommendations for localization- and stage-adapted lymphadenectomy can be made according to histopathologic and anatomic investigations of the patient collectives of large centres. After neoadjuvant radiochemotherapy in cancer of the cervical oesophagus, the absence of lymph nodes on the resected specimen seems to be of less prognostic value. In squamous cell cancer of the suprabifurcal oesophagus, radical lymphadenectomy is recommended. Despite significant morbidity, in specialized centres this procedure yields good results with low mortality. For infrabifurcal oesophageal cancer, two-field lymphadenectomy during the so-called Ivor-Lewis operation is the method of choice. Locally advanced Barrett carcinoma is also an indication for classic two-field lymphadenectomy together with abdominothoracic oesophagectomy and creation of a stomach tube with intrathoracic anastomosis. The lymphadenectomy should however include the area of retroperitoneal lymphatic drainage at the pedicle of the left kidney. Submucosal cancer in this area can be treated with luminal limited resection of the oesophagogastric junction with adequate lymphadenectomy. Adenocarcinoma of the cardia and subcardial gastric cancer including the cardia both require lymphadenectomy analogous to that performed in gastric cancer, with special attention paid to the retroperitoneal lymphatic drainage towards the left kidney pedicle. For therapy of gastric cancer, a systematic D2 lymphadenectomy should always be performed.

R1-Resektion in der Chirurgie des oberen Gastrointestinaltrakts

Microscopically involved tumor margins are an important problem in the surgery of locally advanced esophageal and gastric carcinomas. We conducted a systematic review of the literature and a specific analysis of our own patient database. This article summarizes current knowledge of the incidence and prognosis of R1 resections in upper gastrointestinal cancers. Preoperative strategies for reducing the rate of R1 resections are presented, and the surgical options in case of R1 resection are discussed.