Total Pelvic Exenteration for Primary and Recurrent Malignancies

Contains fulltext : 81087.pdf (publisher's version ) (Open Access)INTRODUCTION: Complete resection is the most important prognostic factor in surgery for pelvic tumors. In locally advanced and recurrent pelvic malignancies, radical margins are sometimes difficult to obtain because of close relation to or growth in adjacent organs/structures. Total pelvic exenteration (TPE) is an exenterative operation for these advanced tumors and involves en bloc resection of the rectum, bladder, and internal genital organs (prostate/seminal vesicles or uterus, ovaries and/or vagina). METHODS: Between 1994 and 2008, a TPE was performed in 69 patients with pelvic cancer; 48 with rectal cancer (32 primary and 16 recurrent), 14 with cervical cancer (1 primary and 13 recurrent), 5 with sarcoma (3 primary and 2 recurrent), 1 with primary vaginal, and 1 with recurrent endometrial carcinoma. Ten patients were treated with neoadjuvant chemotherapy and 66 patients with preoperative radiotherapy to induce down-staging. Eighteen patients received IORT because of an incomplete or marginal complete resection. RESULTS: The median follow-up was 43 (range, 1-196) months. Median duration of surgery was 448 (range, 300-670) minutes, median blood loss was 6,300 (range, 750-21,000) ml, and hospitalization was 17 (range, 4-65) days. Overall major and minor complication rates were 34% and 57%, respectively. The in-hospital mortality rate was 1%. A complete resection was possible in 75% of all patients, a microscopically incomplete resection (R1) in 16%, and a macroscopically incomplete resection (R2) in 9%. Five-year local control for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 89%, 38%, and 64%, respectively. Overall survival after 5 years for primary locally advanced rectal cancer, recurrent rectal cancer, and cervical cancer was 66%, 8%, and 45%. CONCLUSIONS: Total pelvic exenteration is accompanied with considerable morbidity, but good local control and acceptable overall survival justifies the use of this extensive surgical technique in most patients, especially patients with primary locally advanced rectal cancer and recurrent cervical cancer

The fate of soil organic carbon upon erosion, transport and deposition in agricultural landscapes - A review of different concepts

Erosion and deposition redistribute large quantities of sediment and soil organic carbon (SOC) in agricultural landscapes. In the perspective of global carbon cycling, the coupling between erosion processes and the fate of SOC is of particular interest. However, different concepts have been proposed to assess the impact of erosion-induced lateral and vertical carbon fluxes. On landscape scale, this resulted in contrasting conclusions if agricultural soils represent either a carbon sink or source. The large global area of arable soil and generally high erosion rates, make these insights important. In this review, we aim to give an overview of the different conceptual relations described governing C dynamics at sites of erosion, along the transport pathway and at depositional sites and the current state of knowledge on the fate of SOC upon erosion, transport and deposition in agricultural landscapes.The impact of erosion on SOC dynamics differs for sites of erosion, deposition and during transport, with further influences by agricultural practices (e.g. tillage and fertilisation). Controlling processes are the detachment of sediment and SOC, net primary production resulting in dynamic replacement and changes in mineralisation upon transport and deposition due to aggregate breakdown and deep burial, respectively. However, the exact magnitude and dominance of these processes are debated, resulting in a controversy whether arable land functions as a sink or source for atmospheric CO2. Global estimations range between a net sink strength of 0.06-1 versus a source of 0.27-1.14GtCyr-1 for agricultural soils.An eco-geomorphologic approach, which encompasses physical- and biological-driven factors (e.g. spatio-temporal variation in biological, geomorphological and biological processes, environmental conditions, mineralisation, and net primary production) is of importance to balance the carbon budget and ascertain sink or source formation at landscape scale. High spatio-temporal variability on process-scale imposes constrains, to measure and model the fate of SOC upon erosion, with limited quantitative data available. Prospective research across the landscape (eroding sites, transport pathway, and depositional sites) should include all relevant processes at broad temporal and spatial scales. Definitive resolution of the sink/source controversy lies in further eco-geomorphologic research on the fate of SOC, focussing on long-term and spatial extensive monitoring studies, combined with advanced measuring, modelling and extrapolation techniques to cover broad spatio-temporal SOC dynamics. Ascertainment of carbon dynamics in agricultural landscapes provides important insights to balance the carbon budget and finally holds the answer on sink/source formation

The fate of soil organic carbon upon erosion, transport and deposition in agricultural landscapes - A review of different concepts

Erosion and deposition redistribute large quantities of sediment and soil organic carbon (SOC) in agricultural landscapes. In the perspective of global carbon cycling, the coupling between erosion processes and the fate of SOC is of particular interest. However, different concepts have been proposed to assess the impact of erosion-induced lateral and vertical carbon fluxes. On landscape scale, this resulted in contrasting conclusions if agricultural soils represent either a carbon sink or source. The large global area of arable soil and generally high erosion rates, make these insights important. In this review, we aim to give an overview of the different conceptual relations described governing C dynamics at sites of erosion, along the transport pathway and at depositional sites and the current state of knowledge on the fate of SOC upon erosion, transport and deposition in agricultural landscapes.The impact of erosion on SOC dynamics differs for sites of erosion, deposition and during transport, with further influences by agricultural practices (e.g. tillage and fertilisation). Controlling processes are the detachment of sediment and SOC, net primary production resulting in dynamic replacement and changes in mineralisation upon transport and deposition due to aggregate breakdown and deep burial, respectively. However, the exact magnitude and dominance of these processes are debated, resulting in a controversy whether arable land functions as a sink or source for atmospheric CO2. Global estimations range between a net sink strength of 0.06-1 versus a source of 0.27-1.14GtCyr-1 for agricultural soils.An eco-geomorphologic approach, which encompasses physical- and biological-driven factors (e.g. spatio-temporal variation in biological, geomorphological and biological processes, environmental conditions, mineralisation, and net primary production) is of importance to balance the carbon budget and ascertain sink or source formation at landscape scale. High spatio-temporal variability on process-scale imposes constrains, to measure and model the fate of SOC upon erosion, with limited quantitative data available. Prospective research across the landscape (eroding sites, transport pathway, and depositional sites) should include all relevant processes at broad temporal and spatial scales. Definitive resolution of the sink/source controversy lies in further eco-geomorphologic research on the fate of SOC, focussing on long-term and spatial extensive monitoring studies, combined with advanced measuring, modelling and extrapolation techniques to cover broad spatio-temporal SOC dynamics. Ascertainment of carbon dynamics in agricultural landscapes provides important insights to balance the carbon budget and finally holds the answer on sink/source formation

A novel high-temperature combustion based system for stable isotope analysis of dissolved organic carbon in aqueous samples. : II optimization and assessment of analytical performance

RATIONALE: Dissolved organic carbon (DOC) plays an important role in carbon cycling, making precise and routine measurement of delta C-13 values and DOC concentration highly desirable. A new promising system has been developed for this purpose. However, broad-scale application of this new technique requires an in-depth assessment of analytical performance, and this is described here. METHODS: A high-temperature combustion Total Organic Carbon analyzer was interfaced with continuous flow isotope ratio mass spectrometry (TOC/IRMS) for the simultaneous analysis of the bulk DOC concentration and delta C-13 signature. The analytical performance (precision, memory effects, linearity, volume/concentration effects, accuracy) was thoroughly evaluated, including realistic and challenging conditions such as low DOC concentrations and natural DOC. RESULTS: High precision (standard deviation, SD predominantly ≤0.15 ‰) and accuracy (R2 = 0.9997) were achieved for the δ13C analysis of a broad diversity of DOC solutions. Simultaneously, good results were obtained for the measurement of DOC concentration. Assessment of natural abundance and slightly 13C-enriched DOC, a wide range of concentrations (~0.2–150 mgC/L) and injection volumes (0.05–3 mL), demonstrated minor/negligible memory effects, good linearity and flexible usage. Finally, TOC/IRMS was successfully applied to determine low DOC concentrations (<2 mgC/L) and DOC from diverse terrestrial, freshwater and marine environments (SD ≤0.23 ‰). CONCLUSIONS: TOC/IRMS enables fast and reliable measurement of DOC concentrations and delta C-13 values in aqueous samples, without pre-concentration and freeze-drying. Further investigations should focus on complex, saline matrices and very low DOC concentrations, to achieve a potential lower limit of 0.2 mgC/L. Thus, TOC/IRMS will give DOC research in terrestrial and aquatic environments a huge impulse with high-resolution, routine delta C-13 analysis. Copyright (C) 2014 John Wiley & Sons, Ltd

Thirty years of heart transplantation at the university medical centre Utrecht

Purpose To analyse patient demographics, indications, survival and donor characteristics for heart transplantation (HTx) during the past 30 years at the University Medical Centre Utrecht (UMCU). Methods Data have been prospectively collected for all patients who underwent HTx at the UMCU from 1985 until 2015. Patients who were included underwent ortho-topic HTx at an age >14 years. Results In total, 489 hearts have been transplanted since 1985; 120 patients (25%) had left ventricular assist device (LVAD) implantation prior to HTx. A shift from ischaemic heart disease to dilated cardiomyopathy has been seen as the leading indication for HTx since the year 2000. Median age at HTx was 49 years (range 16–68). Median waiting time and donor age have also increased from 40 to 513 days and from 27 to 44 years respectively (range 11–65). Donor cause of death is now primarily stroke, in contrast to head and brain injury in earlier years. Estimated median survival is 15.4 years (95% confidence interval 14.2–16.6) There is better survival throughout these years. Conclusion Over the past 30 years, patient and donor demographics and underlying diseases have shifted substantially. Furthermore, the increase in waiting time due to lack of available donor hearts has led to a rise in the use of LVADs as bridge to transplant. Importantly, an improvement in survival rates is found over time which could be explained by better immunosuppressive therapy and improvements in follow-up care

Mitral Annular Disjunction in Idiopathic Ventricular Fibrillation Patients: Just a Bystander or a Potential Cause?

Aims:Previously, we demonstrated that inferolateral mitral annular disjunction (MAD) is more prevalent in patients with idiopathic ventricular fibrillation (IVF) than in healthy controls. In the present study, we advanced the insights into the prevalence and ventricular arrhythmogenicity by inferolateral MAD in an even larger IVF cohort.Methods and results:This retrospective multicentre study included 185 IVF patients (median age 39 [27, 52] years, 40% female). Cardiac magnetic resonance images were analysed for mitral valve and annular abnormalities and late gadolinium enhancement. Clinical characteristics were compared between patients with and without MAD. MAD in any of the 4 locations was present in 112 (61%) IVF patients and inferolateral MAD was identified in 24 (13%) IVF patients. Mitral valve prolapse (MVP) was found in 13 (7%) IVF patients. MVP was more prevalent in patients with inferolateral MAD compared with patients without inferolateral MAD(42% vs. 2%, p &lt; 0.001). Proarrhythmic characteristics in terms of a high burden of premature ventricular complexes (PVC) and non-sustained ventricular tachycardia (VT) were more prevalent in patients with inferolateral MAD compared to patients without inferolateral MAD (67% vs. 23%, p &lt; 0.001 and 63% vs 41%, p = 0.046, respectively). Appropriate implantable cardioverter defibrillator therapy during follow-up was comparable for IVF patients with or without inferolateral MAD (13% vs. 18%, p = 0.579).Conclusion:A high prevalence of inferolateral MAD and MVP is a consistent finding in this large IVF cohort. The presence of inferolateral MAD is associated with a higher PVC burden and non-sustained VTs. Further research is needed to explain this potential interplay

A novel high-temperature combustion based system for stable isotope analysis of dissolved organic carbon in aqueous samples.: I development and validation

RATIONALE: Traditionally, dissolved organic carbon (DOC) stable isotope analysis (SIA) is performed using either offline sample preparation followed by elemental analyzer/isotope ratiomass spectrometry (EA/IRMS) or a wet chemical oxidation (WCO)-based device coupled to an isotope ratio mass spectrometer. The first method is time-consuming and laborious. The second involves the risks of underestimation of DOC concentration and isotopic fractionation due to incomplete oxidation. The development of an analytical method for accurate and sensitive DOC SIA is described in this study. METHODS: A high-temperature combustion (HTC) system improves upon traditional methods. A novel total organic carbon (TOC) system, specially designed for SIA, was coupled to an isotope ratio mass spectrometer. An integrated purge and trap technique (peak focusing), flexible injection volume (0.05-3 mL), favorable carrier gas flow, modified ash crucible, new design of combustion tube and optimized drying system were used to achieve the necessary performance. RESULTS: The system can reliably measure concentrations up to 1000 mgC/L. Compounds resistant to oxidation, such as barbituric acid, melamine and humic acid, were analyzed with recovery rates of 100 +/- 1% proving complete oxidation. In this initial testing, the delta C-13 values of these compounds were determined with precision and trueness of CONCLUSIONS: The novel HTC system coupled to an isotope ratio mass spectrometer resulted in significantly improved sensitivity. The system is suitable for salt-containing liquids and compounds that are resistant to oxidation, and it offers a large concentration range. A second paper (which follows this one in this issue) will present a more comprehensive assessment of the analytical performance with a broad set of solutions and real samples. This highly efficient TOC stable isotopic analyzer will probably open up new possibilities in biogeochemical carbon cycle research. Copyright (C) 2014 John Wiley & Sons, Ltd