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This page provides many useful links and documents related to advice, policies, procedures, and norms that apply broadly to members of the MIT and DUSP community.
These links and documents are not comprehensive and constitute a living instrument that is subject to change.
Faculty, staff and students are advised to consult the latest version for the DUSP Handbook and MIT Policies page for most updated information.

subset: commoncrawl


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A new mysterious and deadly virus has in just three weeks spread to five countries including the U.S. as it has infected hundreds of people and killed several.
What's reported as a mysterious outbreak in Wuhan, China, caused dozens of people to fall sick there with pneumonia, which is a serious respiratory infection. And what sets this outbreak apart is that its caused by a yet-to-be-identified pathogen.
But the outbreak has been linked to a food market, where vendors peddle seafood and animals, such as birds and rabbits.
Fast forward from three weeks ago to now, and the virus has leaped to 300 people in at least five other countries with it spreading from person to person. Which this could mean a new disease has made the leap across species, from animals to humans.
The details are so far reminiscent of the SARS scare in the early 2000s.
When SARS, a deadly respiratory virus, was first discovered in China in 2003, when it jumped from civet cats to humans. It then spread to two dozen countries and eventually killed 774 people and infected more than 8,000.
This new unknown virus has spread to several countries now including the US.
Where a 30-something year old man, a resident of Washington state, tested positive for the virus after being hospitalized with pneumonia according to the Center for Disease Control and Prevention.
The patient had recently traveled to Wuhan, China — the epicenter of the outbreak — and returned to Seattle. He showed no signs of sickness when re-entering the US.
The president of EcoHealth Alliance, a US global health research organization working in China, described the appearance of an infected person in the US to mean this disease is on the cusp of becoming a pandemic, just like SARS in 2003.
And that the risk is that infected people might not get noticed at the border before they get sick, and then spread the virus to others, seeding further outbreaks.
It's unusual to get health care worker infections in outbreaks, but at least 15 health care workers have been infected thus far, which is a sign of alarm.
For when that happens it indicates that the virus may be easily transmitted and this is a very serious outbreak with the potential for widespread transmission.
The Centers for Disease Control and Prevention have implemented screening of passengers arriving from Wuhan, China, in airports at Los Angeles International, San Francisco International, New York JFK, Atlanta's Hartsfield-Jackson International, and Chicago's O'Hare International Airport.
The Biblical prophecies (Matthew 24, Luke 21, Revelation 6) foretell that pestilence will be a sign of the Last Days indicating the coming end of this age of grace.
These events and conditions happening now are signs pointing to the nearing fulfillment of the Last Days prophecies at the end of this age revealing it's time to prepare for the nearing appearance of Jesus Christ for His Church by being born again spiritually into the Kingdom of God as Jesus said we must (John 3) and His Apostles who were authorized (Matthew 16:19) described how (Acts 2).
Preparing those Biblically born again into the Kingdom of God to be ready to escape all the things that will come to pass, in the wrath of the tribulation of Revelation prophecy, that comes upon the world of disobedience. As the born again Church is not appointed unto wrath (1 Thessalonians 1:10) but instead to salvation through the Lord Jesus Christ.
The prophecy has come true, the perilous times are here. The need is greater than ever before. Help us continue declaring the signs of the Biblical prophecies to the world. Please support this ministry. If each of our viewers would give a donation, no matter the amount, as a tax-deductible offering, you will help ensure the signs of Biblical prophecy continue to be shared here with the world. Please Give Here any amount, no matter the size, to help continue sharing more signs of Biblical prophecy.
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A small group of Year 10s visited the Purley Food Hub on Friday 28th February. It was a fantastic trip; the girls delivered our food and then were taken on a tour of the shop.
They now understand how food banks operate and how necessary they are where families are falling into absolute poverty. The girls were mature and asked thoughtful questions. They are now preparing an assembly to present to the rest of their year group.
Mrs A Mcdonald


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If you are into day trading, or are considering day trading as a source of income, a stock trading computer may be able to help you increase your success. Most normal desktop computers that you can get at an ordinary store work fine for normal applications, but keeping up with the many different global stock exchanges in real time can go beyond their abilities. If the numbers you are seeing displayed on your computer are behind the actual current prices, you could end up losing money with your out of date price data. Stock trading computers designed specifically for this situation can help to prevent problems like this.
The most commonly traded things are stocks, futures, and currencies. The prices of all these are constantly changing, so you Read More


text: Annals of Oncology Advance Access published August 8, 2016 1 FERTILITY-SPARING SURGERY IN EPITHELIAL OVARIAN CANCER: A SYSTEMATIC REVIEW OF ONCOLOGICAL ISSUES E. Bentivegna1, S. Gouy1, A. Maulard1, P. Pautier2, A. Leary2,3, N. Colombo4, P. Morice1,5,6 of Gynecologic Surgery, Gustave Roussy, Villejuif France 2Department of Medical Oncology, Gustave Roussy, Villejuif France 3Unit INSERM U981, Villejuif, France 4Department of surgery and interdisciplinary Medicine, Milano,University Milano- Bicocca Italy 5Unit INSERM U10-30, Villejuif France 6University Paris Sud, Le Kremlin Bicêtre France Corresponding author: Prof. Philippe Morice, Gustave Roussy, 114 rue EdouardVaillant, 94805 Villejuif. France. E mail: [email protected], Phone: 188.8.131.52.44.39. Fax: 22.214.171.124.52.13. © The Author 2016. Published by Oxford University Press on behalf of the European Society for Medical Oncology. All rights reserved. For permissions, please email: [email protected] Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 1Department 2 Abstract Since the last two decades, the feasibility of fertility-sparing surgery (FSS) in early-stage epithelial ovarian cancer has been explored by several teams and is reconsidered in this systematic review undertaken using the PRISMA guidelines. Borderline ovarian tumours and non-epithelial ovarian cancers were excluded. This review comprises 1150 patients and 139 relapsing patients reported by 21 teams. This conservative treatment can be safely performed for stage IA and IC grade 1 and 2 disease and stage IC1 according to the new FIGO staging system. Nevertheless confirm whether FSS is safe in this subgroup. For patients with "less favourable" prognostic factors (grade 3 or stage IC3 disease), the safety of FSS could not be confirmed but patients should be informed that radical treatment probably may not necessarily improve their oncological outcome, because the poorest survival observed could be related to the natural history of the disease itself and not specifically to the use of conservative therapy. FSS could probably be considered in stage I clear-cell tumours but should remain contraindicated for stage II/III disease (whatever the histologic subtype). As the disease stage and the histologic data (tumour type and grade) are crucial to patient selection for this treatment, this implies careful and mandatory complete surgical staging surgery in this context and a pathologic analysis (or review) of the tumour by an expert pathologist. Key words: Fertility-sparing surgery, conservative treatment, epithelial ovarian cancer, early stage, recurrence, survival. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 the number of patients reported with grade 2 disease is too small to definitively 3 Key message: Conservative treatment to preserve fertility in ovarian cancer can be safely performed for stage IA and IC grade 1 and 2 disease and stage IC1 according to the new FIGO staging system. For patients with "less favourable" prognostic factors (grade 3, stage IC3 disease, clear cell tumour), the safety of FSS could not be confirmed but patients should be informed that radical treatment probably may not necessarily improve their oncological outcome. FSS should remain contraindicated for stage II/III disease (whatever the histologic subtype). Fertility-sparing surgery (FSS) of epithelial ovarian cancer (EOC) is based on unilateral (salpingo-)oophorectomy and complete surgical staging. This empirical treatment option had initially been proposed to young women presenting with an early-stage invasive tumour and a low risk of recurrence [1]. The first large series specifically devoted to this management was published nearly 5 decades ago (mixing different subtypes of ovarian tumours)[2]. Different publications, initially mixing different subtypes (EOC and borderline tumours and/or epithelial and non-epithelial cancers) and more recently specifically dedicated to EOC, have been reported [3-6]. Five years ago, international recommendations were finalized concerning the indications and modalities for FSS in EOC [7]. Nevertheless, many questions continue to fuel debate and remain unclear concerning this management. These questions concern oncological outcomes and fertility issues. The fertility issues will not be covered in the present review most debatable and strategic (and finally philosophical) questions concern the oncological issues. We know that the outcomes (recurrence rate and survival) of patients Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Introduction 4 undergoing FSS seem to be similar to those following conventional treatment, at least in patients with stage IA (grade 1 and 2) and stage IC (grade 1) disease [3-6]. However, the current hot topics on oncological issues can be summarized in 4 main points: 1. The impact of the tumour grade on the risk of recurrence; 2. The oncological results in the most controversial subgroup of stage IC disease in the light of the new FIGO staging system, modified in 2014 and now incorporating 3 different substages of IC disease [8]; 3. The oncological results in stage > I and 4. The oncological results in "high risk" histologic subtypes, particularly clear-cell ovarian undertaking a systematic review of the literature and conducting an objective analysis of our findings. Data collection Search Strategy and selection criteria The design of this systematic review of the literature was in accordance with the PRISMA guidelines. Data were identified from searches of MEDLINE, Current Contents, PubMed and from references in relevant articles from 1988 to April 1, 2016, using the following search terms: "early-stage ovarian cancer", "conservative surgery", "conservative treatment", "fertility-sparing surgery", "ovarian cancer" and "ovary". Only articles published in English were included. For repeated publications by the same team on a similar topic, the series comprising the largest number of patients (or the most complete data) was retained. Case reports reporting fewer than 5 cases were not retained (except if they reported stage > I and/or clear cell tumours). In cases of series reporting mixed histologic subtypes (borderline tumours Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 tumours. The aim of this paper was to try to address these 4 questions by 5 and EOC or epithelial and non-epithelial cancers or 3 groups of tumours), we retained papers that reported analysable results specifically in the subgroup of EOC. Series reporting patients without oncological outcomes were not retained. The flowchart in Figure I in the supplementary material shows the criteria used for including and excluding studies. Finally, 39 series were retained and analysed [9-47]. Data extraction and analysis topics. The analysis comprises patient characteristics (stage, tumour, histologic subtype) and oncological issues (characteristics of relapsing patients and postrecurrence outcomes). In cases of stage IC disease, when the data were available, the cases were reclassified according to the 2014 FIGO staging system (IC1, IC2 and IC3) to determine the recurrence rate in each subgroup. The grading system (and histologic subtypes) reported in Table 1 and in the paper were those reported at the time of the publication and not reconverted in the light of the lastly updated classification for histologic subtypes or of the recommendations for the grading system [48]. Similarly, concerning clear-cell tumours, series published before 2010 included these lesions among grade 3 tumours (Table 1). In the different recent series published later, as these tumours were not deemed histologically gradable (even though clinicians considered them as "high-grade" lesions), they were not included in the subcolumns, stage IA or IC/grade 3 disease, in Table 1, as in previous series [35,38]. As the surgical approach (laparotomy or laparoscopy) had no impact on the oncological issues, the results were not specifically studied according to this Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 The corresponding author and the first author extracted all the series on these 6 factor. Nevertheless, all the series reporting pure laparoscopic surgery were included in the review [40,41,42]. Findings A total of 32 papers written by 21 teams and 7 multicentre studies were retained (39 articles) and analysed summarizing 1150 patients who had undergone 125 (because of 1 ambiguous stage) in stage I disease and 14 or 15 in stage II or III disease (Tables 1-4). The impact of stage IA/IC and the tumour grade on the recurrence rate in stage I disease (Table 1) A total of 1110 stage I lesions were included in Tables 1 and 3. The impact of the histologic and clear-cell subtype will be examined specifically later. Among the series detailing the clinical substage of the disease, 633 stage IA and 411 stage IC cases were reported. More marginally, 15 stage IB disease cases were reported. Among the series that provided details about the disease stage in relapsing patients, 55 (10%) recurrences had occurred among 560 patients with stage IA disease and 58 (16%) recurrences had occurred among 358 patients with stage IC disease (p= .002). Among the series that reported details concerning the initial characteristics of patients and of relapsing patients (substage I and tumour grade), data were available Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 FSS (Table 1). One hundred and thirty-nine (12%) recurrences had occurred: 124 or 7 for 385 cases of stage IA disease (285 stage IA grade 1, 72 stage IA grade 2 and 28 stage IA grade 3). Among these lesions, 35 recurrences had occurred: 19 (7%) stage IA grade 1, 8 (11%) stage IA grade 2 and 8 (29%) stage IA grade 3 (p=.0004). Likewise, data were available for 247 cases of stage IC disease (170 stage IC grade 1, 47 stage IC grade 2 and 30 stage IC grade 3). Among these lesions, 30 recurrences had occurred: 18 (11%) stage IC grade 1, 5 (11%) stage IC grade 2 and 7 (23%) stage IC grade 3 disease (Grade 1+2 vs Grade 3; p= 0.02). As mentioned above, several series published after 2010, involving 34 cases and 6 relapsing relapsing patients were not included in the above calculation concerning stage IA or IC grade 3 disease in Table 1. Among 91 relapsing patients with data concerning the location of the recurrence, 34 (37%) were an isolated ovarian tumour and 57 (63%) other sites of recurrence +/- involvement of the remaining ovary (Table 1). At the time of the publication 72 patients had died of the disease or were alive with persistent disease (Tables 1 & 3). Results according to the new FIGO staging system (for stage IC disease)(Table 2) The 2014 FIGO staging system modified stage IC into 3 new clinically (and prognostically) more relevant subgroups in the stage I disease category [8]. We collected 10 different papers, involving 214 patients with stage IC that provided precise data on the initial subgroups of patients with stage IC (IC1, IC2 and IC3) Thirty-one recurrences (14%) had occurred in this disease category (Table 2). Among these 31 recurrences, the substage of the disease was not reported in 2 series (comprising jointly 32 patients with stage IC disease) [28,35]. In one of these 2 Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 patients considered clear-cell tumours as ungradable [35,38]. Consequently, these 6 8 series, the team had mixed stage IC2+3 disease [31,34]. Finally, among the series that had provided all the data required to perform the calculation, respectively 13 and 17 recurrences had occurred among 108 (12%) and 74 (19%) patients with stage IC1 and IC2+3 disease (p=0.02). Stage II and III disease – Results (Table 3) Forty cases of stage II or III disease were collected. In a majority of these stage II or III disease after (re)staging surgery. Thirteen cases were stage IIA (3), IIB (6), IIC (3) and undetermined stage II in 1. Twenty-seven cases of stage III disease were reported: IIIA (7), IIIB (2) and IIIC (18). In this latter subgroup, at least 5 cases were upstaged to IIIC due to nodal spread without peritoneal spread (stage IIIA1 of the 2014 FIGO staging system). Among these 40 cases, 15 (38%) recurrences had occurred. Eleven patients had died or were alive with persistent disease (Table 3). Clear-cell tumours – Results (Table 4) The histologic subtypes of the tumours collected in Table 1 (among 1116 cases with available data) were: mucinous n=588 (53%); serous n=203 (18%), endometrioid n=190 (17%) and clear cell n=97 (9%). Thirty-eight other/mixed/unknown subtypes (3%) should be added (Table 1). Among the series which reported complete data on the histologic subtypes in initially treated patients and in relapsing patients, 49 recurrences had occurred among 513 mucinous Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 patients the tumour was initially confined to the ovary but was finally modified to 9 tumours (10%), 25 among 165 serous (15%), 23 among 174 endometrioid (13%) and 19 among 88 (22%) clear-cell tumours (p=.007). A total of 116 clear-cell tumours had been reported (98 are also presented in Table 1, but 18 were added in the updated version of one previously published paper [27,44])(Table 4). All but 1 of these tumours were stage I (but the stage is uncertain for 27 clear-cell tumours). Among these 115 cases with specific data on the followup, 19 (17%) recurrences had occurred (Table 4). Among these 19 relapsing had metastatic (extra-ovarian disease)(87%) and 2 had an ovarian (13%) recurrence (this rate is statistically significant compared to the rate of ovarian/extra-ovarian recurrences in the overall population; p< 0.0003). Eleven patients had died of the disease or were alive with persistent disease. Discussion The results of this systematic review raised the main question of the selection criteria for FSS in EOC. These criteria were strongly and firstly related to the prognostic factors for recurrences in this context (a possible higher recurrence rate due to the use of a conservative treatment compared to conventional treatment [radical surgery]). No phase II randomized or phase III study comparing both treatment modalities has been conducted to demonstrate that survival is totally similar for early-stage EOC. Several of the previously published retrospective series compared conservative and radical treatment but found no significant differences in survival [16,32,33,39,44]. Yet such comparisons are sometimes unreliable from a statistical and methodological point of view because firstly, in series comparing Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 patients, the location of the recurrent disease was available in 15. Thirteen patients 10 conservative and conventional treatment, patients selected for FSS tend to have a better prognosis than patients treated according to the standard of care. Comparing recurrence and survival rates between these two groups would therefore lead to a potential bias. Secondly, the number of patients evaluated for FSS may be too small to detect a difference in the prognosis of patients with similar oncological prognostic factors (substage I, histologic type and tumour grade). If the two treatment modalities are compared in a retrospective analysis, the number of patients required to confirm the reliability of this calculation is critical. The analysis of the SEER (Surveillance, IA or IC disease had no impact on survival [49]. But as stated by the authors, "to detect a 20% difference in survival for patients with stage IC disease, a cohort of 1282 patients with 52 deaths is required". Nevertheless, even if this number of patients had never been reached in any of the previous series, the current systematic review gathered more than 1,000 cases of FSS published and thus seems to confirm the safety of this modality (meaning the absence of an increased rate of recurrence specifically due to the use of a conservative surgical procedure), at least in patients with stage I A/C and grade 1/2 disease. The recurrence rates reported in these subgroups were 7% in stage IA grade 1 and 11% in stages IA grade 2 and IC grade 1/2 disease, so very close, or similar, to the rates observed after radical surgery. This review confirms the safety and the validity of FSS in young patients eligible for fertility-sparing management. Nevertheless, the number of patients with IA and IC grade 2 disease (respectively 72 and 47) is too small to definitively confirm whether FSS is safe in this subgroup. Can this management be safely extended to stage I (A or C) grade 3 disease? Our review confirms that the risk of recurrence is increased in such cases compared Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Epidemiology and End Results) database reported that ovarian preservation in stage 11 to patients with grade 1 or 2 disease. Nevertheless, in these patients, the risk of an ovarian recurrence in currently "debatable" indications for FSS is lower compared to extra-ovarian recurrences that occur more frequently and are less amenable to surgical cure when they arise whereas in stage IA disease (a good indication for FSS), isolated ovarian recurrences are more common and are also more curable [21,22]. In the case of grade 3 tumours, 95% of the recurrences were extra-ovarian (and only 22% of them were rendered disease free) [22]. If the potential recurrences are less curable this could challenge the validity of these "debatable" indications. is thus one of the limits of the oncological indication [4,5,20,22]. On the other hand, if the recurrences are more frequently extra-ovarian, this could signify that the preservation of one ovary is not necessarily the cause of the recurrence. Extraovarian relapses could then be related to the natural history of the disease and to the presence of "intermediate" or the "poorest" prognostic factors (grade 3) or to ovarian preservation itself. Thus, from this standpoint, some teams consider that the use of a conservative approach would not be questioned even in these cases [12-15]. A similar attitude could be considered concerning the second question of the use of FSS in patients with stage IC disease and the new FIGO staging system. Our study confirms that the recurrence rate is acceptable (and seems to be similar to that observed with conventional treatment) for preoperatively ruptured stage IC1 tumours (half of these recurrences were isolated on the remaining ovary) (Table 3). However, the recurrence rates are higher (23%) in stages IC2 + IC3 disease. As mentioned above concerning grade 3 disease, it is unclear whether such recurrences are related to the natural history of the disease (grade 3 and/or stage IC grade 2 and/or stage Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 That is why, some teams consider that FSS is unsafe in stage I grade 3 disease and 12 IC3 disease) or to the use of fertility-sparing surgery itself. We cannot solve these endless and inextricable discussions in this paper. In theory, a randomised trial should be performed to compare FSS and radical surgery in patients with "high-risk" early-stage EOC in order to validate this practice. However, it would not be ethical to propose radical treatment to young patients of childbearing age because many studies have reported that FSS is safe in selected cases. Furthermore, EOC is a rare disease and a randomised trial is technically unachievable because it would be necessary to accrue a large number of patients in used in such a trial). Nevertheless, a prospective non-randomized trial (JCOG1203; UMIN00013380) is currently on-going in Japan in "high risk" disease (stage IC and/or stage IA clear-cell disease) and will probably provide us with more robust data in the future [12-15]. While awaiting these results, we have two options: to use "the precautionary principle" in these "uncertain" indications (stage IA grade 3 or stage IC3 disease) and remove both ovaries (but leave the uterus in place for a subsequent potential pregnancy using an ovum donation) or to "respond" to the enquiry of the patient/couple and to use FSS with a "wait and see" policy. Nevertheless, in these "debated oncological indications", the age of the patient, and the ovarian reserve (which should then be evaluated) need to be taken into account because pragmatically, we do not need to take a "potential" risk of recurrence using FSS in this context in a patient aged 37/38 or 39 years with a poor ovarian reserve (and thus a very limited likelihood of spontaneous fertility). As we know since a decade that the fallopian tubes are in fact the initial site of "ovarian" tumours, particularly in high-grade serous carcinoma, another potential theoretical option, akin to FSS, could be a bilateral salpingectomy but leaving both Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 order to observe a statistical difference in survival (even if a non-inferiority design is 13 ovaries in place that could potentially be used later for In Vitro Fertilization. Nevertheless, this interesting concept could not be used in epithelial cancer because ovarian hyperstimulation remains contraindicated in patients treated conservatively for a previous malignant epithelial tumour. Our review included the study of patients with stage II and III disease. Among 40 cases reported, the rate of recurrence was 38% (15/40). As mentioned earlier, we contend that this recurrence rate seems to be close to that observed after conventional management of stage II/III disease. Yet, a majority of patients among than other stage III lesions. In our opinion, it is unsafe to use FSS in stage II and III EOC. As the disease stage is critical for selecting patients for FSS, complete staging surgery (including lymphadenectomy except for mucinous tumours) would be imperatively included during the initial staging work-up or the restaging procedure [51]. The last question raised is the impact of the histologic subtype on the recurrence rate. The mucinous subtype was the most common (53%) reported. That is logical because these tumours frequently arise in young patients and with a high rate of disease confined to the ovary (stage I disease) explaining a higher rate of such cases in patients eligible for FSS. This also explains a trend towards a lower rate of recurrence in mucinous tumours compared to other subtypes. Recently, mucinous tumours were divided into 2 separate subtypes: expansile (the most common) and infiltrative (exhibiting a higher rate of nodal spread and the poorest prognosis)[48]. This new classification should be used systematically in the case of "mucinous carcinoma". Nevertheless, we found no data in the current review (or other series) on the results of conservative treatment in both subtypes (expansile and Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 these 40 cases had stage IIA/B, IIIA2 or stage IIIA1 disease with a better prognosis 14 infiltrative mucinous tumours). Anyway, as the histologic subtype (and the tumour grade) is a key issue in the selection of patients for FSS, a pathologic review of the slide by an expert pathologist should be done before validating this management. The centralization and/or review of the pathologic slides of the tumour is also a quality assurance measure of the reliability of the interpretation of the series on the conservative approach in epithelial tumours, in order to be certain that borderline tumours or non-epithelial cancers will not be mixed in studies "officially" focused on EOC, since the overall prognosis of these 2 latter subgroups is better than that of FSS spanning a long time period, because such management is not so widespread, the criteria for selecting patients distinguishing borderline tumours from true EOC could have varied over time given the evolution of selection criteria and the histological classifications of EOC. That is why, from our point of view, a pathologic review of the slides (even in the case of patients treated in the same institution and sometimes with the same pathologist) is a quality criterion. Table 1 summarizes this pathologic review (centralized or not in multicentre studies) and about 21 teams reported their results, eleven clearly stating this quality indicator (Table 1). In fact, the hottest topic in terms of histologic subtypes for FSS is the case of clear-cell tumours. Historically, these tumours had been considered as high-grade lesions and thus ineligible for FSS. Yet, when we reviewed the different series published, 116 FSS procedures for clear-cell tumours had been reported (in a majority of cases for stage I disease). The recurrence rate was 17% (19 cases). This rate seems as to be "oncologically" acceptable and so we can probably accept to extend FSS even for stage I clear-cell tumours. Two series compared the survival of patients with a clear-cell tumour according to the type of surgical treatment Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 epithelial cancer. Furthermore, in the same team in retrospective series dedicated to 15 (conservative/radical) without demonstrating any difference in disease-free and overall survival [44,46]. Nevertheless, as mentioned above, such analyses should be interpreted with caution because the number of patients studied could be too small to detect a possible statistically significant difference between the two treatments. Anyway, more than 100 cases of conservative treatment had been reported in this context with a "similar", or very close recurrence rate to that observed after conventional management. Among 19 relapsing patients, information was available on the use (or not) of adjuvant chemotherapy during the initial management of the recommendations initially made by several teams, FSS seems to be potentially considered in patients with a stage I A/C clear-cell tumour, we should integrate two key pieces of information about the time to recurrence. Among 19 relapsing patients, the time to the 1st recurrence was reported in 16 cases: 2 patients had relapsed within the 6 months after FSS, 6 between 6 and 12 months, 7 between 12 and 24 months and only 1 after 24 months. This means that relapsing patients in this subgroup of clear-cell tumours had developed a recurrence very early, within the first 2 years after the initial treatment. The other key piece of information is the location and prognosis of relapsing patients. This information was available for 15/19 relapsing patients. Among them, 13 had an extra-ovarian recurrence and 11 patients had died or were alive with disease. This means that these patients have a high risk of an extra-ovarian and lethal relapse. These 2 facts had a pragmatic impact on the management of patients. Although this will not render doubtful the potential validity of conservative management, as a recurrence may arise shortly and will then have a poor prognosis, we should not "authorize" the patient/couple to attempt a potential pregnancy before 2 years after FSS in clear-cell disease if we do not want to be Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 clear-cell tumour in 16 cases and all but 3 received it. Even if, contrary to the 16 faced with the diagnosis of a metastatic recurrence in a pregnant patient. Finally, having discussed all these potential criteria for selecting patients with EOC for FSS, how many patients could be involved ? Huber et al. focused recently on this question and showed that in a local registry (Geneva) comprising 888 EOC, only 1.2% would be potentially eligible for FSS [52]. A similar study had been undertaken a decade ago by Sonoda et al. for cervical cancer. They estimated with hindsight that nearly half of the patients below 40 years of age who had undergone a radical hysterectomy would have been eligible for FSS [53]. Even if this rate depends this conservative approach, these studies show that this discussion concerns a minority of patients affected by EOC. This strategy is also an emblem of the progress achieved in surgical treatment allowing this selected subgroup involving few patients to have access to fertility preservation. Conclusions The management of patients with early EOC eligible for FSS should be multidisciplinary. The histological review of the ovarian tumour and surgical staging should be done by experienced teams. This conservative treatment can be safely performed in stage IA and IC grade 1 and 2 disease and stage IC1 according to the 2014 FIGO staging system. Nevertheless the number of patients reported with grade 2 disease is too small to definitively confirm whether FSS is safe in this subgroup. For patients with "less favourable" prognostic factors (grade 3 or stage IC3 disease), the safety of FSS could not be confirmed. However, patients should be informed that radical surgery may not necessarily improve their oncological outcome, because the Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 on the local recruitment of cases and the criteria finally retained to select patients for 17 poorest survival observed is related to the natural history of the disease and not specifically to the use of a conservative treatment. FSS could probably be considered for stage I clear-cell tumours but should remain contraindicated in stage II/III disease (whatever the histologic subtype). Acknowledgments The authors wish to thank Ms. Lorna Saint Ange for editing. None declared. Conflict of interest The authors declare no conflict of interest related to this study. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Funding 18 REFERENCES 1. DiSaia PJ. Conservative management of the patient with early gynecologic cancer. CA Cancer J Clin 1989; 39: 135-154. 2. Munnell EW. Is conservative therapy ever justified in stage I (IA) cancer of the ovary ? Am J Obstet Gynecol 1969; 103: 641-650. Zapardiel I, Diestro MD, Aletti G. Conservative treatment of early stage ovarian cancer: oncological and fertility outcomes. EJSO 2014; 40: 387-393. 4. Du Bois A, Heitz F, Harter P. Fertility-sparing surgery in ovarian cancer: a systematic review. Onkologie 2013; 36: 436-443. 5. Fotopoulou C, Braicu I, Sehouli J. Fertility-Sparing Surgery in Early Epithelial Ovarian Cancer: A Viable Option? Obstet Gynecol Int 2012 ;2012: e238061. 6. Bentivegna E, Morice P, Uzan C, Gouy S. Fertility-sparing surgery in epithelial ovarian cancer. Future Oncol 2016; 12: 389-398. 7. Morice P, Denschlag D, Rodolakis A, Reed N, Schneider A, Kesic V, et al. Recommendations of the Fertility Task Force of the European Society of Gynecologic Oncology about the conservative management of ovarian malignant tumors. Int J Gynecol Cancer 2011; 21: 951-963. 8. Prat J. FIGO Committee on Gynecologic Oncology. Staging classification for cancer of the ovary, fallopian tube, and peritoneum. Int J Gynaecol Obstet 2014; 124: 1-5. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 3. 19 9. Miyazaki T, Tomoda Y, Ohta M et al. Preservation of ovarian function and reproductive ability in patients with malignant ovarian tumors. Gynecol Oncol 1988; 30: 329-341. 10. Colombo N, Chiari S, Maggioni A et al. Controversial issues in the management of early epithelial ovarian cancer: conservative surgery and role of adjuvant therapy. Gynecol Oncol 1994; 55(3 Pt 2): S47-51. 11. Zanetta G, Chiari S, Rota S et al. Conservative surgery for stage I ovarian 12. Colombo N, Parma G, Lapresa MT, Maggi F, Piantanida P, Maggioni A. Role of conservative surgery in ovarian cancer: the European experience. Int J Gynecol Cancer 2005; 15 Suppl 3: 206-211. 13. Fruscio R, Corso S, Ceppi L, Garavaglia D, Garbi A, Floriani I, et al. Conservative management of early-stage epithelial ovarian cancer: results of a large retrospective series. Ann Oncol 2013; 24: 138-44. 14. Raspagliesi F, Fontanelli R, Paladini D, di Re EM. Conservative surgery in highrisk epithelial ovarian carcinoma. J Am Coll Surg 1997; 185: 457-460. 15. Ditto A, Martinelli F, Lorusso D et al. Fertility sparing surgery in early stage epithelial ovarian cancer. J Gynecol Oncol 2014; 25: 320-327. 16. Ditto A, Martinelli F, Bogani G et al. Long-term safety of fertility sparing surgery in early stage ovarian cancer: Comparison to standard radical surgical procedures. Gynecol Oncol 2015;138: 78-82. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 carcinoma in women of childbearing age. BJOG 1997; 104: 1030-1035. 20 17. Gonzalez-Lira G, Escudero-De Los Ríos P, Salazar-Martínez E, LazcanoPonce EC. Conservative surgery for ovarian cancer and effect on fertility. Int J Gynaecol Obstet. 1997; 56: 155-162. 18. Jobo T, Yonaha H, Iwaya H, Kanai T, Kuramoto H. Conservative surgery for malignant ovarian tumor in women of childbearing age. Int J Clin Oncol. 2000; 5: 4147. epithelial ovarian carcinoma. Cancer 2001; 92: 2412-2418. 20. Morice P, Leblanc E, Rey A, Baron M, Querleu D, Blanchot J, et al. Conservative treatment in epithelial ovarian cancer: results of a multicentre study of the GCCLCC and SFOG. Hum Reprod 2005; 20: 1379-85. 21. Marpeau O, Schilder J, Zafrani Y et al. Prognosis of patients who relapse after fertility-sparing surgery in epithelial ovarian cancer. Ann Surg Oncol 2008; 15: 47883. 22. Bentivegna E, Fruscio R, Roussin S et al. Long-term follow-up of patients with an isolated ovarian recurrence after conservative treatment of epithelial ovarian cancer: review of the results of an international multicenter study comprising 545 patients. Fertil Steril 2015; 104: 1319-1324. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 19. Morice P, Wicart-Poque F, Rey A et al. Results of conservative treatment in 21 23. Schilder JM, Thompson AM, DePriest PD et al. Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertilitysparing therapy. Gynecol Oncol 2002; 87: 1-7. 24. Sardi JE, Anchezar P, Bermudez A. Favorable clinical behavior in young ovarian carcinoma patients: a rationale for conservative surgery? Int J Gynecol Cancer 2005; 15: 762-769. surgery in patients with epithelial ovarian cancer. J Surg Oncol 2009; 100: 55-58 26. Borgfeldt C, Iosif C, Måsbäck A. Fertility-sparing surgery and outcome in fertile women with ovarian borderline tumors and epithelial invasive ovarian cancer. Eur J Obstet Gynecol Reprod Biol 2007; 134: 110-114. 27. Park J-Y, Kim D-Y, Suh D-S et al. Outcomes of fertility-sparing surgery for invasive epithelial ovarian cancer: oncologic safety and reproductive outcomes. Gynecol Oncol 2008; 110: 345-353. 28. Kwon Y-S, Hahn H-S, Kim T-Jet al. Fertility preservation in patients with early epithelial ovarian cancer. J Gynecol Oncol 2009; 20: 44-47. 29. Muzii L, Palaia I, Sansone M et al. Laparoscopic fertility-sparing staging in unexpected early stage ovarian malignancies. Fertil Steril 2009; 91: 2632-2637. 30. Schlaerth AC, Chi DS, Poynor EA, Barakat RR, Brown CL. Long-term survival after fertility-sparing surgery for epithelial ovarian cancer. Int J Gynecol Cancer 2009; 19: 1199-1204. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 25. Anchezar JP, Sardi J, Soderini A. Long-term follow-up results of fertility sparing 22 31. Kajiyama H, Shibata K, Suzuki S, Ino K, Nawa A, Kawai M, et al. Fertilitysparing surgery in young women with invasive epithelial ovarian cancer. EJSO 2010; 36: 404-408. 32. Kajiyama H, Shibata K, Mizuno M et al. Long-term survival of young women receiving fertility-sparing surgery for ovarian cancer in comparison with those undergoing radical surgery. Br J Cancer 2011; 105: 1288-1294. Fertility-sparing surgery in young women with mucinous adenocarcinoma of the ovary. Gynecol Oncol 2011; 122: 334-338. 34. Kajiyama H, Mizuno M, Shibata K et al. Recurrence-predicting prognostic factors for patients with early-stage epithelial ovarian cancer undergoing fertilitysparing surgery: a multi-institutional study. Eur J Obstet Gynecol Reprod Biol 2014; 175: 97-102. 35. Satoh T, Hatae M, Watanabe Y et al. Outcomes of fertility-sparing surgery for stage I epithelial ovarian cancer: a proposal for patient selection. J Clin Oncol 2010; 28: 1727-1732. 36. Hu J, Zhu LR, Liang ZQ et al. Clinical outcomes of fertility-sparing treatments in young patients with epithelial ovarian carcinoma. J Zhejiang Univ Sci B 2011; 12: 787-795. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 33. Kajiyama H, Shibata K, Mizuno M, Nawa A, Mizuno K, Matsuzawa K, et al. 23 37. Cheng X, Cheng B, Wan X, Lu W, Xie X. Outcomes of conservative surgery in early epithelial ovarian carcinoma. Eur J Gynaecol Oncol 2012; 33: 93-5. 38. Kashima K, Yahata T, Fujita K, Tanaka K. Outcomes of fertility-sparing surgery for women of reproductive age with FIGO stage IC epithelial ovarian cancer. Int J Gynaecol Obstet 2013; 121: 53-55. 39. Lee JY, Jo YR, Kim TH et al. Safety of fertility-sparing surgery in primary 40. Cromi A, Bogani G, Uccella S, Casarin J, Serati M, Ghezzi F. Laparoscopic fertility-sparing surgery for early stage ovarian cancer: a single-centre case series and systematic literature review. J Ovarian Res 2014; 7: 59. 41. Ghezzi F, Cromi A, Fanfani F et al. Laparoscopic fertility-sparing surgery for early ovarian epithelial cancer: A multi-institutional experience. Gynecol Oncol 2016 Apr 13. pii: S0090-8258(16)30086-5. 42. Park JY, Heo EJ, Lee JW et al. Outcomes of laparoscopic fertility-sparing surgery in clinically early-stage epithelial ovarian cancer. J Gynecol Oncol. 2016; 27: e20. 43. Petrillo M, Legge F, Ferrandina G, Monterisi A, Pedone Anchora L, Scambia G. Fertility-sparing surgery in ovarian cancer extended beyond the ovaries: a case report and review of the literature. Gynecol Obstet Invest 2014; 77: 1-5. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 mucinous carcinoma of the ovary. Cancer Res Treat 2015; 47: 290-297. 24 44. Park JY, Suh DS, Kim JH et al. Outcomes of fertility-sparing surgery among young women with FIGO stage I clear cell carcinoma of the ovary. Int J Gynaecol Obstet. 2016 Mar 11. pii: S0020-7292(16)30006-6. 45. Kajiyama H, Shibata K, Suzuki S et al. Is there any possibility of fertility-sparing surgery in patients with clear-cell carcinoma of the ovary? Gynecol Oncol 2008; 111: 523-526. Fertility-sparing surgery in patients with clear-cell carcinoma of the ovary: Is it possible? Hum Reprod 2011; 26: 3297-302. 47. Kajiyama H, Mizuno M, Shibata K et al. A recurrence-predicting prognostic factor for patients with ovarian clear-cell adenocarcinoma at reproductive age. Int J Clin Oncol 2014; 19: 921-927. 48. Kurman RJ, Carcangiu ML, Herrington CS, Young RH. WHO Classification of Tumours, Volume 6. IARC WHO Classification of Tumours, No 6. 2014. 49. Wright JD, Shah M, Mathew L, Burke WM, Culhane J, Goldman N, et al. Fertility preservation in young women with epithelial ovarian cancer. Cancer 2009; 115: 41184126. 50. Satoh T, Tsuda H, Kanato K et al; Gynecologic Cancer Study Group of the Japan Clinical Oncology Group. A non-randomized confirmatory study regarding Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 46. Kajiyama H, Shibata K, Mizuno M, Hosono S, Kawai M, Nagasaka T, et al. 25 selection of fertility-sparing surgery for patients with epithelial ovarian cancer: Japan Clinical Oncology Group Study (JCOG1203). Jpn J Clin Oncol 2015; 45: 595-599. 51. Kajiyama H. Fertility sparing surgery in patients with early stage epithelial ovarian cancer: implication of survival analysis and lymphadenectomy. J Gynecol Oncol 2014; 25: 270-271. 52. Huber D, Cimorelli V, Usel M, Bouchardy C, Rapiti E, Petignat P. How man Reprod Biol 2013; 170: 270-274. 53. Sonoda Y, Abu-Rustum NR, Gemignani ML et al. A fertility-sparing alternative to radical hysterectomy: how many patients may be eligible? Gynecol Oncol 2004; 95: 534Y538. Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 ovarian cancer patients are eligible for fertility-sparing surgery? Eur J Obstet Gynecol Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Table 1. Literature review of patient characteristics and oncological outcomes after Fertility-Sparing Surgery in stage I Epithelial Ovarian Cancer (series including > 5 cases). Authors-Years 9 Miyazaki 1988 n pts Stage n pts Pathology review Grade n pts Histology* n pts Staging n** Recurrence (n) Stage, histology in relapsing pts Stage IA G1 n rec, n tot Stage IA G2 n rec, n tot Stage IA G3 n rec, n tot Stage IC Grade 1 n rec, n tot Stage IC G2 n rec, n tot. Stage IC G3 n rec, n tot Location recurrence Isolated ovary/Other Outcomes Follow up (months) 18 I No NS S4 M 12 E1 CC 1 NS 2 (1 IB, 1 IC NS NS NS NS NS NS NS 2 DOD NS G1 141*** G2 70 G3 29 S 62*** M 99 E 60 CC 17 Unk 2 112 7/84 2/31 5/15 6/54 4/37 2/14 12/14 14 NED, 1 AWD, 11 DOD FU 108 mths G1 36*** G2 24 G3 9 Unk 1 S 18*** M 36 E8 CC at least 1 Other 7 All 2/? 0/? 1? 0/? 1/? 0/? 2/2 3 NED, 1 AWD FU 76 mths NS NS NS NA NA Colombo 1994, 2005 Zanetta 1997 10-13 Fuscio 2010 237 Raspagliesi 1997, 14-16 Ditto 2014, 2015 63 17 IA 130 IB 2 IC 105 Yes IA 46 IB 2 IC 15 No 1 S, 1 M) 26 (14 IA, 12 IC 10 S, 8 M, 6 E, 2 CC) At least 4**** (3 IA, 1 IC 1 M, 2 E, 1 CC) 10 NS No NS S6 M2 E1 Other 1 NS 0 NS NS NS 18 11 IA 6 IC 5 No NS S2 M8 E1 NS 3 (3 IC M) 0 0 0 3 0 0 2/1 3 DOD FU 51 mths Morice 2001, 2005 Marpeau 2008 19-22 Bentivegna 2015 33 IA 30 IC 3 Yes G1 15 G2 14 G3 4 S3 M 21 E2 Other 3 All 10**** (7 IA, 3 IC 2 S, 5 M, 1 E, 1 CC, 1 Mixed) 2/13 4/14 1/3 2/2 0 1/1 5/6 4 NED, 2 AWD, 3 DOD, 1 Unknown FU 47 mths 52 IA 42 IC3 10 Yes G1 38 G2 9 G3 5 S 10 M 25 E 10 CC 5 Other 2 All 5 (4 IA, 1 IC 2/33 2/6 0/3 0/5 1/3 0/2 3/2 3 NED, 2 DOD FU 68 mths S1 M8 E5 CC 2 All 2/11 0/0 0/0 0/3 0/1 0/1 0/2 1 NED, 1 DOD FU 96 mths Gonzalez-Lira 1997 Jobo 2000 Schilder 2002 23 Sardi 2005 24,25 Anchezar 2009 16 IA 11 IC 5 Yes G1 14 G2 1 G3 1 1 S, 2 M, 1 E, 1 Mixed) 2 (2 IA, 1 S, 1 E) Park 2008 27 11 IA 10 IC 1 Yes G1 9 G2 1 G3 1 S2 M8 E1 In 7 1 (IC M) 0/9 0/1 0/0 59 IA 36 IB 2 IC 21 Yes G1 48*** G2 5 G3 9 S 7*** M 41 E8 CC 4 Other 2 All 9 (5 IA, 4 IC 1/29 0/3 4/4 5 M, 1 E, 2 CC, 1 Mixed) Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 26 Borgfeld 2007 0/0 0/0 1/1 0/1 1 DOD FU 92 mths 1/15 1/2 2/4 1/8 2 NED, 3 AWD, 4 DOD FU 56 mths NS NS NS NS NS FU 43 mths NS NS NS NS 1 AWD FU 20 mths NS 2NS NS 3/0 3 DOD FU 122 mths NS NS NS NS 11 DOD FU 66 mths 28 Kwon 2009 21 IA 17 IC 4 No G1 16 G2 3 G3 2 S1 M 16 E2 CC 3 In 14 1 (IC G1) NS NS NS 29 Muzii 2009 9 NS Yes NS S4 M3 E2 CC 2 All 1 (IC) NS NS NS 20 IA 11 IC 9 Yes G1 14 G2 5 G3 1 S1 M 11 E6 CC 1 Unk 1 In 18 3 (2 IC & 1 IA) & 1 uterine cancer**** NS NS NS 94 IA 43 IC 51 Yes G1 59 G2 14 G3 4 (CC 17) S3 M 52 CC 17 E 21 Other 1 In 14 14 (5 IA & 9 IC, NS NS NS G1 95 G2 13 G3 3 (CC 30) S 27 M 126 E 27 CC 30 Other 1 In 86 (omentectomy) 5/95 0/13 2/3****** 5/65 0/2 1/3****** 5/13 8 NED, 5 AWD, 5 DOD FU 78 mths Schlaerth 2009 30 Kajiyama 2010, 2011a, 31-34 2011b, 2014 35 Satoh 2010 36 Hu 2011 Cheng 2011 37 38 Kashima 2013 211 IA 126 IC 85 Yes 3 S, 4 M, 4 E, 3 CC) 18 (7 IA, 11 IC 3 S, 6 M, 4 E, 5 CC)****** 82 IA 46 IB 8 IC 28 Yes ? G1 57 G2 10 G3 1 Unk/CC 14 S 31 M 32 E5 CC 3 Other 11 94 1 in stage I NS NS NS NS NS NS NS 0 in stage I FU 132 mths 16 IA 10 IC 6 Yes G1 4 G2 2 S 1*** M 13 E1 Other 2 All 1 (IC Mixed) 0/9 0/1 0/0 1/5 0/1 0/0 0/1 0 FU 61 mths 18 IC 18 No G1 14 CC 4 S2 M9 E3 CC 4 In 15 5 (1 S, 3 M, 1 CC) 0/0 0/0 0/0 4/14 0/0 0/0****** 1/4 1 NED, 4 DOD FU 78 mths 34 IA 21 IC 13 No G1 27*** G2 5 G3 1 Unk. 2 All M In 12 (omentectomy) 5 or 6 (1 stage II?) NS NS NS Cromi 2014, 61 IA 42 IB 1 IC 18 No G1 38*** G3 19 G3 8 S 15 *** M 25 E 21 CC 3 Other 1 All 10 (7 IA, 1 IB, 2 IC 3 S, 4 M, 3 E) NS NS NS 16 IA 6 IC 12 (2 IIIA1) No G1 9 G2 4 G3 5 S3 M7 E5 CC 3 11 (omentectomy) 0 in stage I 0/2 0/3 0/0 40,41 Ghezzi 2015 Park 2016 Total 42 1092******* 121 or 122 (11%) (1 st. > I?) 19/285 (7%) *: S: Serous; M: Mucinous; E: Endometrioid; CC: Clear Cell; Unk: Unknown; 8/72 (11%) 8/28 (29%) Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 39 Lee 2015 NS NS NS 1/ 4 or 5 NS FU 104 mths NS NS NS NS 1 DOD FU 38 mths 0/7 0/1 0/4 NS 0 FU 47 mths 18/170 (11%) 5/47 (11%) **: Complete staging definition varied in different series. In cases of incomplete data, patients having at least an omentectomy were considered as having "staging" surgery ***: Data incomplete stage > I disease; ****: The characteristics of relapsing patients were detailed in the 2nd publication involving 18 conservative procedures; ****: 1 patient had a recurrence in the form of borderline disease *****: 1 patient had a recurrence in the form of a secondary uterine cancer. She is not included in the results ******: Clear- cell recurrence(s) was/were not included because these lesions were not graded in this series *******: 18 CC tumours reported by Park et al. separately in a specific updated paper and 40 stage II/ III , should be added to these 1092 stage I cases, resulting in a total of 1150 patients NS: Not Stated; NED: No Evidence of Disease; DOD: Died of Disease; AWD: Alive with Persistent Disease; mths: months 7/30 (23%) Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Table 2. Literature review of oncological outcomes after Fertility-Sparing Surgery in stage IC Epithelial Ovarian Cancer according to the FIGO 2014 staging system. Authors-Years n pts Recurrence (n) Stage IC1 n rec, n tot Stage IC2 n rec, n tot. Stage IC3 n rec, n tot Location recurrence DOD & AWD (n) 5 3 0/0 3/5 0/0 2 ovary, 1 lung 3 DOD 23 10 1 0/0 0/0 1/10 ovary 26 Borgfeld 2007 1 1 0/0 0/0 1/1 Peritoneum 28 Kwon 2009 4 1 ?/3 0/0 ?/1 NS 51 9 3/31 35 Satoh 2010 85 11 7/55 2/18 2/12 3 ovary, 8 peritoneum and/or nodes and/or liver 3 NED, 4 AWD, 4 DOD 36 Hu 2011 28 ? ?/9 ?/6 ?/13 NS NS 38 Kashima 2013 18 5 3/11 1/3 1/4 1 ovary, 2 nodes, 1 peritoneum, 1 brain 4 DOD, 1 NED 12 0 0/11 0/1 0/0 NA NA 214 31 (14%) 13/108 (12%) Jobo 2000 18 Schilder 2002 Kajiyama 2010, 2014 Park 2016 Total 42 31,34 6/20 6/27 (22%) NS NED DOD NS NS 5/27 (19%) IC2+3= 17/74 (23%) NS: Not Stated; NA: Not Applicable; NED: No Evidence of Disease; AWD, Alive with Persistent Disease; DOD: Died of Disease; mths: months Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Table 3. Literature review of patient characteristics and oncological outcomes after Fertility-Sparing Surgery in stage II and II disease. Authors-Years n pts Stage (FIGO 1987) Histology Grade Recurrence Time to recurrence months Location recurrence Outcomes Colombo 1994, 2005 10,12,13 Fuscio 2010 3 I IIA, 2 IIB At least 1 serous At least 1 G1 1 recurrence 151 Ovary NED Raspagliesi 1997, 14-16 Ditto 2015 7 1 IIA, 1 IIC, 5 IIIC At least 4 serous 2 mucinous At least 3 G1, 2 G2 No recurrence for 6 pts NA NA NA 19 Morice 2001 2 1 IIA, I IIB At least 1 mixed in 1 At least 1 G 2 1 recurrence 5 Ovary & peritoneum DOD 16 mths 3 1 IIB, 1 IIIA, 1 IIIC At least 2 mucinous At least 1 G1, 1 G3 2 8, 10 1 ovary & perit. 1 nodes & lung 2 DOD 10, 16 mths 25 Anchezar 2009 2 2 IIIB 1 serous, 1 mucinous 1 G1, 1 G2 1 14 Ovary NED 38 mths 29 Muzii 2009 2 1 IIB, I IIIA NS NS No recurrence NA NA NA 36 Hu 2011 12 1 II, 4 IIIA, 7 IIIC 3 serous, 2 mucinous, 4 endometrioid, 1 clear-cell, 1 mixed 7 G1, 3 G2, 2 unknown 8 7, 22, 24, 24, 26 Unknown for 3 1 ovary, 4 peritoneum, 3 unknown 4 DOD, 3 AWD 1 IIIA NS NS No recurrence NA NA NA 43 Petrillio 2013 1 IIC Endometrioid G2 No recurrence NA NA NA 39 Lee 2015 1 1 IIC NS NS 1 Recurrence ? NS NS NS Cromi 2014, 4 1 IIB, 3 IIIC (IIIC due to nodal spread) NA NA No recurrence NA NA NA 2 2 IIIC (due to nodal spread) 2 serous 1 G2, 1 G3 1 NA Peritoneum, liver & nodes AWD 44 mths Park 2008 27 Cheng 2011 37 40,41 Ghezzi 2015 Park 2016 Total 42 40 15 (38%) NS: Not Stated; NA: Not Applicable; NED: No Evidence of Disease; AWD: Alive with Persistent Disease; DOD: Died of Disease; mths: months Downloaded from http://annonc.oxfordjournals.org/ by guest on September 4, 2016 Table 4. Literature review of patients undergoing Fertility-Sparing Surgery for Clear-Cell ovarian tumours. Authors-Years n pts Stage (n) Pathology review Recurrence (n) Location recurrence Outcomes 7 Miyazaki 1988 1 I No No recurrence NA NA Colombo 1994 Zanetta 1997, 10,11,13 Fuscio 2010 17 All stage I? Yes 2 2 Peritoneum 1 NED, 1 DOD 1 IA No 1 Ovary NED 1 IA Yes 1 Metastatic AWD 5 NS Yes No recurrence NA NA 2 IA 1, IC 1 Yes No recurrence NA NA 22 IA 12, IC 10 No 5 (3 IA & 2 IC) All metastatic +/- ovary 2 NED, 1 AWD, 2 DOD 28 Kwon 2009 3 I No No recurrence NA NA 29 Muzii 2009 2 NS Yes No recurrence NA NA 1 I Yes NS NS NS 17 IA 7* IC 9 Yes 3 NS NS 35 Satoh 2010 30 I Yes 5 (all stage IC) 1 ovary, 4 peritoneum, nodes or liver 1 NED, 3 AWD, 1 DOD 36 Hu 2011 4 3 I, 1 IIIA Yes ? At least 1 NS At least 1 DOD 38 Kashima 2013 4 All IC No 1 Nodes DOD 41 Ghezzi 2015 3 NS No No recurrence NA NA 3 3 IC No No recurrence NA NA Raspagliesi 1997, Ditto 2014 14,15 19,20 Morice 2001, 2005 Schilder 2002 23 24,25 Sardi 2005 Anchezar 2009 Park 2008, Park 2016 Schlaerth 2009 27,44 30 Kajiyama 2010, 2011a, 31,32,34,45-47 2011b, 2011 c, 2014a, 2014b Park 2016 Total 42 116 19/115 (17%) *: Results given in the series published in 2011 including 16 cases NS: Not Stated; NA: Not Applicable; NED: No Evidence of Disease; AWD: Alive with Persistent Disease; DOD: Died of Disease; mths: months


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Welcome to the Eastlake
Police Department's website
City of Eastlake Police Department - 35150 Lakeshore Boulevard, Eastlake, OH 44095
Emergency: Dial 9-1-1 - Business Phone: 440-951-1400 - Fax: 440-951-7781
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The Eastlake Police Department will be accepting applications and resumes for the position of full-time patrolman – lateral transfer. All candidates entering into the process for a lateral transfer to the position of full-time patrolman for the City of Eastlake must currently be a "Full-time employee" employed as a law enforcement officer, as defined by the Ohio Revised Code, with a minimum of 2 years of service, and whose regular hours of duty total eighty hours in a pay period in a department whose appointment is not for a limited period of time, as promulgated in Ohio Revised Code 124.382.
An application fee of $25 will be required at time of submission. Only the first 50 completed applications will be considered.
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History of the Eastlake Police Department
The first police chief for the Village of Eastlake was Richard Taylor. He started as chief in 1949, working for no pay and using his own car to patrol the village streets.
The village officially became a city in 1955. Chief Taylor and his part-time policemen worked out of the first police station, a small building at the intersections of Roberts Road, Beachpark, and Lakeshore Boulevard. The police station consisted of a small room that contained a desk, two chairs, and two file cabinets. The rest of the building was the city hall and clerk's office. The building later became Steve's Barbershop.
The second police station was a little larger room in a concrete building that also was used as the city hall and clerk's office. This station had its first prison holding cell, a steel cage constructed in a section of the Hinkle service garage. The location of this building was known as the Hinkle Block and it is located across from the Subway shop on Lakeshore Boulevard.
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To serve and protect persons and property in Eastlake in accordance with federal, state and local laws and ordinances; To be responsive to the citizens of Eastlake and its government; To cooperate with various governmental agencies, not restricted to Eastlake, when such cooperation is desirable and/or necessary.
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Watch every episode of DIY Sci with Steve Spangler + experiment guides for several episodes.
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The Green Line bus line and the Tourist Kit initiative were launched in 2009 to encourage locals and tourists to use the bus more often. Since its launch the project has been running at full speed with new updates and improvements. The public transport operator continues to lobby more hotels to participate in the scheme, instead of running their own courtesy buses to the city centre.
Background & Objectives
Studies conducted by the tourism regional authority have outlined that traffic nuisance is one of the things that tourists dislike the most in Madeira. Actively contributing to raise traffic levels are the 21 courtesy bus services that used to circulate in the Green Line catchment area.
Green Line and its supportive action Tourist Kit were launched within the European Mobility Week of 2009. The main objectives were:
- to persuade the hotels to stop their courtesy bus services and to sign a cooperative agreement with Public Transport (PT) company,
- to reorganize the public transport services in the target area and improve the overall image of public transport in the urban area with new communication tools.
Along with the new high-quality PT line, called Green Line, run by Euro V buses, improvements at the corridor's bus stops were carried out. New multimedia kiosks were installed along the corridor to inform tourists of the way through the bus stops. A Tourist kit package was provided at the hotels receptions to convince tourists to use public transport to get around the city.
The main obstacles encountered were the limitations to the expansion of Tourist Kit: some hotels do not sell public transport tickets due to their links with local taxis that give strong commissions to hotel receptionists in order to persuade tourists to choose them over the PT service.>In addition to this, some hotels cannot stop running their courtesy bus as they have commercial agreements with tourism operators. Other problems registered was that the project received low suport from those hotels that believe PT is less "exclusive" than a special shuttle service.
This measure had the financial support of CIVITAS MIMOSA project with a co-financing for staff costs and the multimedia kiosks. Also, another project – under the European Regional Development Fund (ERDF) - co-financed 85% the tourist kit materials and the new "green line" layout for busses and bus stops.
- In less than 3 years, 34% of all the hotel units located along the target corridor have converted to the Tourist Kit and have started selling PT tickets at their reception desks.
- Reduction of pollutant levels in a range of 13% (CO2eq) to 43% (PM10) due to the allocation of Euro V busses to this area and reduction of shortcoming courtesy services.
- A cost-benefit analysis carried out has shown that the benefits of the project were surprisingly high. Basically, the overall Net Present Value, evaluated against a Business-as-Usual 2015 scenario, summed up to nearly 7.000.000€.
- Financial balance was achieved and revenues increased by 10 percent
All in all, this initiative is proving to be an efficient way of encouraging new sustainable and responsible mobility habits and it is sending out a clear message to tourists that Madeira is a high quality and environmentally friendly destination. Future developments include promoting the Tourist Kit for special events, as well as partnerships with museums to clearly distinguish the Tourist Kit and make it even more appealing.


text: Is is possible to publish a password protected WMS service using ArcGIS Server 10.5.1? My windows server 2012 system uses LDAP for its internal user accounts. I want to publish WMS Services which are password protected due to lizenzing restrictions attatched to the data. What possibilities do I have to implement this?


text:
Men, women equally benefit from endovascular treatment for stroke
Endovascular treatment (EVT) for ischaemic stroke produces improvements in functional outcome and other clinical, imaging and safety outcome measures. The treatment effect is similar between men and women, with the latter even having more years of healthy life, as shown in the results of two recent studies.
The first study used data from seven randomized controlled trials on EVT within the HERMES* collaboration and included 1,762 patients (47 percent women). Compared with men, women were older (median, 70 vs 66 years; p<0.001), were smoking less often (30 percent vs 44 percent; p<0.001) and had higher collateral grades (grade 3: 46 percent vs 35 percent; p<0.001).
Functional independence (modified Rankin Scale [mRS] score, 0–2) at 90 days, the primary outcome, did not differ significantly by sex (39 percent of men vs 39 percent of women). On ordinal logistic regression, EVT exerted a similar effect in women (adjusted common odds ratio [acOR], 2.13, 95 percent confidence interval [CI], 1.47–3.07) and men (acOR, 2.16, 95 percent CI, 1.59–2.96; p-interaction=0.926). [Stroke 2019;50:2413-2419]
Other outcomes were also comparable between women and men, as follows: mortality at 90 days (15 percent vs 16 percent, respectively), symptomatic intracranial haemorrhage (3.7 percent vs 3.6 percent) and successful reperfusion (75 percent vs 76 percent).
In light of the findings, lead investigator Dr Vicky Chalos from the Erasmus MC University Medical Center at Rotterdam, the Netherlands, pointed out that "sex does not influence clinical outcome after EVT for ischaemic stroke," and that EVT benefits women as much as men.
"Sex should, therefore, not be a consideration in the selection of patients for EVT," Chalos added.
Post-EVT optimal life advantage for women
In the second study, researchers went further by examining the effect of EVT on lifelong disability outcomes. "[B]ecause of differences in age of onset and poststroke mortality between the sexes, 90-day outcomes may be insufficient to characterize the differences in endovascular stroke thrombectomy outcome on poststroke disability, as they do not account for poststroke lifetime disability, which could be substantially different between males and females," said principal researcher Dr Sunil Shet from the McGovern School of Medicine, University of Texas Health Science Center at Houston, Texas, US.
Shet and colleagues looked at 389 patients (55 percent female; median National Institutes of Health Stroke Scale [NIHSS], 17) treated with the Solitaire stent retriever in the combined SWIFT**, STAR+ and SWIFT PRIME++ cohorts.
There were no sex-specific differences observed in terms of deficit severity (p=0.21), occlusion location (p=0.62), infarct extent (p=0.24), rate of substantial reperfusion (p=0.37) and onset to reperfusion time (p=0.46). Functional independence at 90 days was also similar between men and women (OR, 1.0, 95 percent CI, 0.6–1.6), even with the latter being older (69 vs 64 years; p<0.001) and having a higher rate of atrial fibrillation (45 percent vs 30 percent; p=0.002). [Stroke 2019;50:2420-2427]
However, results for disability-adjusted life year (DALY) outcomes, defined as DALYs gained to represent life expectancy and adjusted for age at presentation and stroke severity, were significantly different between the sexes. Women had about 2 more years of optimal life after EVT compared with men (10.6 vs 8.5 years; p<0.001).
"[F]emales treated with endovascular stroke thrombectomy … enjoyed a DALY advantage over males up to the age of late 80s," Shet said.
Role of selection bias
In a linked commentary, Drs Bharti Manwani and Louise McCullough from the McGovern Medical School, University of Texas Health Science Center at Houston, Texas, US, pointed out that while EVT indeed yields higher DALYs in women than men, selection bias is likely a factor. [Stroke 2019;50:2285-2287]
"Women have worse premorbid function which seems to account for much of the higher mortality and poorer outcomes seen after stroke… The women in the Chalos et al article had a lower stroke severity than men, which may be because of selection of healthier women and underscores the importance of capturing prestroke mRS as a potential confounder to effect size," Manwani and McCullough wrote.
"Certainly, it is clear that sex should not be considered a factor in determining eligibility for acute stroke intervention. However, elderly women may be excluded from some of our most efficacious interventions solely based on their poor prestroke functional status," they added.
*Highly Effective Reperfusion Using Multiple Endovascular Devices
**Solitaire FR With the Intention for Thrombectomy
+Solitaire FR Thrombectomy for Acute Revascularization
++Solitaire FR With the Intention for Thrombectomy as Primary Endovascular Treatment


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Alabama rocket builder ULA prepares for scheduled February Solar Orbiter launch
A powerful Atlas V rocket built at United Launch Alliance's (ULA) world-class Decatur facility is assembled and set for yet another Alabama-powered historic launch.
The Atlas V rocket has now been stacked to launch Solar Orbiter, an international spacecraft bound for the inner solar system to gain unparalleled insights into the lifestyle of the sun, according to a release from ULA this week.
The Alabama rocket maker detailed a busy – and productive – week of operations at ULA's Vertical Integration Facility (VIF) at Cape Canaveral Air Force Station.
ULA first kicked off the new year by bringing together the Atlas V rocket's first stage, single solid rocket motor and Centaur upper stage aboard the Mobile Launch Platform (MLP).
Engineers then gave approval for the pre-launch milestone known as LVOS, or Launch Vehicle on Stand, during a readiness review last Friday. That authorized the first stage to be hauled from the Atlas Spaceflight Operations Center (ASOC) to the VIF on the following Monday morning. Cranes lifted the 107-foot-long stage from its ground transportation equipment and rotated it vertically for maneuvering through the VIF doorway and alignment on the MLP.
The next day, the 100,000-pound strap-on solid rocket booster was brought to the VIF, pulled from its erector device and secured to the north-facing side Atlas V first stage.
Then, Wednesday saw the basic build-up of the rocket completed as the pre-integrated assembly known as OVI, or Off-site Vertical Integration, arrived at the VIF for hoisting atop the first stage. The OVI is comprised for the interstage, Centaur upper stage and base of the payload fairing.
In the coming days, the launch vehicle will be powered up, its flight controls tested and engine nozzles gimbaled. Then, a simulated launch sequence will be conducted before the MLP transports the rocket to the pad for a Wet Dress Rehearsal (WDR).
That WDR will be conducted to mitigate any issues before the interplanetary launch window opens. Once the WDR is accomplished and the rocket is returned to the VIF from the pad, crews will mount Solar Orbiter atop the rocket. The spacecraft is undergoing final preparations at the Astrotech payload processing facility in Titusville, FL, which is where the satellite will be fueled and then encapsulated in the rocket's four-meter-diameter payload fairing.
The Atlas V has a three-week period to launch Solar Orbiter while Earth and Venus are properly aligned to carry out the mission plan. Launch of Solar Orbiter is currently scheduled for February 5.
The spacecraft's highly elliptical orbit will periodically swing by Venus and Earth to receive gravity-assists in order to refine the orbit around the sun and change the viewing angle to see the poles.
The first encounter with the sun should occur this June.
Solar Orbiter is an international cooperative mission between the European Space Agency (ESA) and NASA. ULA is conducting the launch under contract to NASA's Launch Services Program.
This launch would follow ULA's perfect launch of Boeing's CST-100 Starliner and NASA selecting the ULA Atlas V rocket to power the Geostationary Operational Environmental Satellite-T (GOES-T) into space last month.
ULA's Alabama built rockets boast an incredible 100% mission success rate, delivering more than 130 satellites to orbit that provide Earth observation capabilities, enable global communications, strengthens the United States' national security, unlock the mysteries of the solar system and support life-saving technology.
The Atlas V rocket, manufactured at ULA's 1.6 million square foot facility in Decatur, has "more than 15 years of 100% mission success founded on a heritage of more than 600 Atlas program launches," according to the company.
Sean Ross is the editor of Yellowhammer News. You can follow him on Twitter @sean_yhn


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Short Subjects
Kalla A. Gervasio, BA; Albert Y. Wu, MD, PhD
A 4-year-old boy presented with a 6-day history of severe non-limbic–sparing conjunctivitis. Atypical Stevens–Johnson syndrome with a possible cause of Mycoplasma pneumoniae was suspected as the precipitant of the clinical symptoms. The patient recovered with amniotic membrane transplantation and intravenous immunoglobulin therapy despite an initial delay in diagnosis. [J Pediatr Ophthalmol Strabismus. 2015;52:e41–e44.]
From Icahn School of Medicine at Mount Sinai, New York, New York (KAG); and the Department of Ophthalmology, Icahn School of Medicine at Mount Sinai, New York, New York (AYW).
The authors have no financial or proprietary interest in the materials presented herein.
The authors thank the Department of Medical Education at the Icahn School of Medicine at Mount Sinai for support in the copyediting of this case report.
Correspondence: Kalla A. Gervasio, BA, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1183, New York, NY 10029. E-mail:
Mycoplasma pneumoniae is considered the most common infectious cause of Stevens–Johnson syndrome (SJS), particularly in children.1 It can cause an atypical presentation limited to ocular, oral, and genitourinary mucous membranes that spares the skin. It has been suggested that M. pneumoniae-associated mucositis be considered its own distinct clinical entity.2 Up to 25% of people with M. pneumoniae infections experience extrapulmonary symptoms before, during, or after onset of pulmonary signs or in the complete absence of respiratory symptoms.3
There have been reports of M. pneumoniae-associated SJS in patients who all exhibited preceding pulmonary symptoms such as cough, congestion, and pharyngitis.4 We report a case of severe ocular involvement in atypical SJS with a possible cause of M. pneumoniae in a previously healthy boy lacking respiratory symptoms.
A 4-year-old boy with no medical history experienced 3 days of self-limiting night fevers, without cough, pharyngitis, or respiratory symptoms (Table 1). Four days after his fevers resolved without medication, he presented to the emergency department with purulent bilateral conjunctivitis and one oral tongue ulcer. He was discharged with a prescription of cefdinir and ofloxacin drops. His condition worsened despite antibiotics for 5 days, with more oral ulcers and periorbital edema. He subsequently presented to the emergency department a second time and was discharged with Magic Mouthwash (CutisPharma, Inc., Wilmington, MA) for suspected Coxsackievirus. Two days later, he was admitted to the pediatric intensive care unit for 11 days with odynophagia and inability to open his eyes, and was given empiric intravenous acyclovir.
Table 1:
Disease Time Course and Events Before and After Hospital Admission
Laboratory results showed a high white blood cell count, C-reactive protein level, and erythrocyte sedimentation rate. Throat herpes-simplex virus cultures and direct fluorescent antibody test, throat varicella-zoster virus direct fluorescent antibody, throat enterovirus culture, and blood and urine cultures were negative. M. pneumoniae IgM titer was positive on serology and immunofluorescent antibody test and IgG was positive on serology. Polymerase chain reaction test for M. pneumoniae IgM and paired sera for IgM and IgG were not performed. Lip and buccal mucosa biopsies stained negative for organisms on periodic acid-Schiff stain and showed necrotic tissue with acute and chronic inflammation and no viable epidermis, consistent with SJS.
Ophthalmology consultation on the first hospital day was significant for bilateral symblepharon and severe non-limbic–sparing conjunctivitis. At this time, culture and direct fluorescent antibody results were not available, and the diagnosis considered was herpes-simplex virus gingivostomatitis with conjunctivitis. For this reason, conservative management was initiated with artificial tears, Lacri-Lube (Allergan, Dublin, Ireland), prednisolone acetate, and tobramycin-dexamethasone drops, with eyelid hygiene for symblepharon.
Symptoms did not improve. Dilated funduscopic examination and amniotic membrane transplantation were performed on the third hospital day. No intraocular disease, herpetic lesions, or ulcers were found. Fluorescein stain demonstrated bilateral inferior linear corneal epithelial defects, likely due to exposure. The fornices were swept with muscle hooks and symblepharon and eyelid adhesions were lysed. Cryopreserved amniotic membranes (Ambio 5; Okto Ophtho, Costa Mesa, CA) were grafted within all fornices using two 6-0 polyglactin 910 mattress sutures on the medial and lateral sides of each fornix (Figure 1B). Symblepharon rings (FCI Ophthalmics, Pembroke, MA) were then placed to maintain the fornix.
Figure 1.
(A) Clinical appearance of a patient with atypical Stevens–Johnson syndrome during the acute phase, after symblepharon lysis and immediately before bilateral amniotic membrane transplantation on day 3 of the hospital course. Symblepharons are not pictured. (B) The right superior and inferior fornices immediately after bilateral amniotic membrane transplantation. (C) The patient 6 weeks after amniotic membrane transplantation with bilateral white and quiet eyes. Symblepharon rings are still in place.
Postoperative management included a 3-day course of 1 g/kg/d intravenous immunoglobulin, as well as an ophthalmic regimen including artificial tears, Lacri-Lube, 0.05% cyclosporine, 0.5% moxifloxacin, and 0.1% dexamethasone. The patient recovered fully with intravenous immunoglobulin and amniotic membrane transplantation. Additional antibiotic therapy was not given because the patient's symptoms improved with intravenous immunoglobulin and no pulmonary manifestations were present.
This case demonstrates the ongoing challenges in the early diagnosis of atypical SJS. Delays in diagnosis and ophthalmologic management can potentially result in end-stage corneal blindness if not caught during the acute phase.5 Pediatric ophthalmologists should be aware that atypical SJS with a possible cause of M. pneumoniae could occur in a child without any pulmonary manifestations.
Typically, in children younger than 5 years, M. pneumoniae infections manifest as coryza and wheezing, and uncommonly progress to pneumonia.6 Initial pharyngitis, cough, sore throat, hoarseness, and fever also tend to occur. Because children may carry M. pneumoniae without respiratory symptoms before manifestation of a more severe condition, the timely correct diagnosis of SJS is particularly important. Initially, this patient was suspected of having either a bacterial or viral infection and treated accordingly. With no skin rash present, SJS was not considered at the onset. Neither antibiotics nor Magic Mouthwash improved the patient's conjunctivitis or oral lesions, delaying SJS diagnosis for approximately 9 days after initial ocular symptoms.
SJS may be drug-induced, idiopathic, or secondary to infection. In this case, ophthalmology, dermatology, and infectious disease teams postulated a possible cause of M. pneumoniae given single positive IgM and IgG titers. It is possible that SJS had a different cause, because additional confirmatory polymerase chain reaction and paired serology tests for IgM and IgG were not performed. IgM may persist for weeks to months after M. pneumoniae infection, making the timing of infection difficult to deduce from a single IgM titer. The ofloxacin and cefdinir drops the patient took are another potential cause. However, he presented with simultaneous conjunctivitis and oral ulcers before initiating antibiotics and had not taken any prior medications. Previous research also suggests that ocular involvement is more common in M. pneumoniae-associated SJS than drug-induced SJS.7,8
Mild forms of SJS can improve with conservative treatment and not all patients develop serious ocular sequelae. However, amniotic membrane transplantation has been recommended in patients with more severe conjunctival inflammation at higher risk for long-term complications.9 In such patients, it is most ideal to initiate amniotic membrane transplantation in the hyperacute (< 72 hours) or the acute (72 hours to 4 weeks) phase.10 Amniotic membrane promotes epithelialization, possessing anti-inflammatory and anti-fibrotic effects.11 In this case, amniotic membrane transplantation was prudently initiated during the acute phase and proved effective. This confirms reports that amniotic membrane transplantation is a successful treatment for ocular involvement in severe SJS when applied early.12 Two weeks after amniotic membrane transplantation, the patient's cornea and conjunctiva completely healed with no irritation present and remained so at 6 weeks (Figure 1C).
This case demonstrates that SJS limited to ocular and oral mucous membranes may still be missed clinically at the onset. In children with a mucositis-type presentation, pediatric ophthalmologists should consider atypical SJS with a possible cause of M. pneumoniae from the start, even in the absence of respiratory symptoms. Although amniotic membrane transplantation is now regarded as an effective ocular treatment in severe SJS, further investigations are needed to elucidate how specific delays in amniotic membrane transplantation initiation, as in this case, affect visual outcomes. Knowing the exact time periods within the acute phase of SJS during which amniotic membrane transplantation initiation will still have positive effects would improve ocular management guidelines.
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Tour of Flanders bike route: yellow loop
"Well, don't underestimate the Blue Loop. You might think that it's ok because it's only 78km. But it has the Kwaremont, the Paterberg and the Koppenberg all within a very short distance. You don't want to do that. And we really wouldn't advise you to go on the Red one. It takes you all the way to Geraardsbergen, where you have to climb the famous Wall. Did you bring your mountain gear? What you really want do is go out and try the Yellow Loop. Sure it's 103 km, but it's generally flat with just a few cobblestone sections in between."
That is the advise we give our visitors when we notice that they are not the well trained 300km a week riding bike enthusiasts. However, the final word is up to them. All three signposted cycling loops start and end at the front door of the Tour of Flanders Centre.
Yellow loop a piece of cake?
So in these Corona times my colleague Sander (Marketing) and myself decided to go out and test the theory. Is the Yellow Loop really the piece of cake we make it out to be? Or is there something more to it? Sander is the type of cycling addict most of us are. He goes out on his bike a few times a week and I would describe him as a Flandrien. It is a state of mind. He doesn't give up. He keeps on hitting those pedals to make his bike fly over any surface nature is throwing at him. As for myself, I recently bought a Specialized gravel bike and love cycling the same way I loved my granny. Sincere, but from a certain distance.
Now, the three loops were created by the province of East-Flanders. They made the maps, the made the signposts and they maintain everything. And let us say: they are doing a fantastic job at it. The thing is, you can not put every single climb or every single cobblestone on a map.
Climbs and cobblestones all the way
That is something we discovered after only a few kilometers. A nasty small climb called the
𝙋𝙚𝙩𝙚𝙜𝙚𝙢𝙗𝙚𝙧𝙜 (530m length, avg. 7,6%, max. 11%) was our first challenge on this so called piece of cake. As it came as a total surprise, it made us wonder what else would come our way. It was there that I decided never ever again to sell this loop as an easy one.
The first real climb was 𝙉𝙤𝙠𝙚𝙧𝙚𝙗𝙚𝙧𝙜 (350m length, avg. 6%, max. 7%). This short cobblestoned climb is the main scene for the UCI ProSeries race Nokere Koerse. We found it to be fairly easy, but after checking section times on Strava, we weren't too convinced that everyone was staying on the cobblestones. So for those of you who like to cut corners, there is fairly large pavement that you can use to conquer this climb. Who are we to judge.
Next on the list are 𝙃𝙪𝙞𝙨𝙚𝙥𝙤𝙣𝙩𝙬𝙚𝙜, 𝙇𝙚𝙙𝙚𝙬𝙚𝙜 and 𝘿𝙤𝙤𝙧𝙣. A combined 3.2km of different cobblestone sections. None of them are really challenging, but we saw it as a good
taste of what was to come. And you can see them as a practice track. Because there have been entire books written about riding on cobblestones, but the essential thing is that you have to let the bike do the work. All that you heard is true. Don't sink your fingers into the steering wheel. Just gently let your hands rest on it in any way you feel most comfortable with. A bit like I would hug my granny.
A practice track, you said? Yes. Because after 𝘿𝙚𝙣 𝘼𝙨𝙩 (450m length, avg. 5%, max. 11%) we got to ride the famous 𝙋𝙖𝙙𝙙𝙚𝙨𝙩𝙧𝙖𝙖𝙩. This 2.4km long cobblestone section is renowned for its yearly appearances in the Tour of Flanders. It will hardly decide who is going to win, but it will separate boys from men. When we rode it, the street was in fairly good condition and although being quite challenging, we found it to be doable. In hindsight. Because people warned us that we should save a little something for the last 20km of the loop. More on that to come.
Did I mention that the Yellow Loop is sometimes unforgiving? There are hardly 300m between the end of the Paddestraat and the beginning of the 𝙇𝙞𝙥𝙥𝙚𝙣𝙝𝙤𝙫𝙚𝙨𝙩𝙧𝙖𝙖𝙩. A further 1.3km of cobblestones. With the first part slightly climbing. But after this, it's a straightforward ride to the town of Zottegem, which is just over halfway. Mind you that there will be a dangerous crossing between Buke and the N462. Other than that, this loop is a very safe ride.
Next on the menu are the 𝙑𝙡𝙖𝙢𝙢𝙚 (700m length downhill, avg. 5%, max. 10%) and the 𝙃𝙤𝙨𝙩𝙚𝙡𝙡𝙚𝙧𝙞𝙚 (1.2km length downhill, avg. 3%, max. 10%) so if you want to up your average speed on Strava, these two downhill sections are a welcome change of scenery. Were it not that I conveniently forgot to mention the appearance of the 𝙆𝙤𝙧𝙩𝙚𝙣𝙙𝙧𝙞𝙚𝙨 in between. This 2.2km climb has a comfortable average of 3% but a steepest point of 10%. Luckily all those 3 sections have not a single cobblestone in them. But still, if you're as badly trained as I am every muscle starts to hurt.
Afraid of the Molenberg
And then came the 𝙈𝙤𝙡𝙚𝙣𝙗𝙚𝙧𝙜 (460m length, avg. 7%, max. 14%). Well, this was the first and only section of the Yellow Loop where Sander and I decided to each go our own way. Here's the deal. He's a marketing guy. They get to blow things out of proportion. He warned me. I was afraid. Even more afraid than when my granny wanted to kiss the 6 year old version of myself with her hairy mustache.
Ho ho holy cobblestones…
So while he was jumping up the cobblestoned back of this famous little monster, I took an early turn to the right and went up the 𝘾𝙖𝙞𝙡𝙙𝙚𝙣𝙗𝙚𝙧𝙜 (800m length, avg. 4%, max. 7%) instead. Because of the lack of cobblestones. Still a little challenge, but what my dear colleague failed to tell me was that the Caildenberg crosses with the Molenberg, so I still had to do about 150m of cobblestone climbing. Apart from this treacherous lying, we make a great team!
This was later followed by the 𝙅𝙖𝙜𝙚𝙧𝙞𝙟, a 1km long cobblestoned street. A fair section, but nothing compared with what was about to follow. 𝙆𝙚𝙧𝙠𝙜𝙖𝙩𝙚. 2.5km of cobblestones of which the start is
devious, to say the least. The first 500m are easy pavé compared with what is to come. It is pure suffering. The street is degrading at an unforgiving rate. Torture all the way. You can feel all 206 bones in your body shaking and screaming. Agony. And just when you think a T-section is the end of all your suffering, you get to turn right to the worst piece of road in the Yellow Loop. It was there that I made a promise to myself. Starting from today I will track down whoever designed this loop and I will make him swallow a cobblestone. Or a Kwaremont beer if he turns out to be a decent guy.
Muscles thrown to the wolves on the Wolvenberg
After this horror, came the downhill cobblestone section of 𝙑𝙤𝙡𝙠𝙚𝙜𝙚𝙢𝙗𝙚𝙧𝙜 (1km length, avg. 5%, max. 12%). A straight, yet challenging descent. Still it was fun to throw yourself downhill.
And the final climb of the day was the 𝙒𝙤𝙡𝙫𝙚𝙣𝙗𝙚𝙧𝙜 (800m length, avg. 4%, max. 17%). This asphalt road was, in combination with Kerkgate, what we were warned about. "Save a little something for the last 20km". A steepest section of 17% after 90km of shaking on cobblestones is painful. We all know that feeling when you think your muscles are going to explode. Well mine did. I lost them there. If anyone finds them, please return them to Markt 43 in 9700 Oudenaarde. A finders fee will be rewarded.
But what we knew was that after this hideous little climb, all that was left to do were two cobblestone sections. De 𝙍𝙪𝙞𝙩𝙚𝙧𝙨𝙩𝙧𝙖𝙖𝙩 with a length of 800m was painful and going downhill on the 𝙆𝙖𝙩𝙩𝙚𝙣𝙗𝙚𝙧𝙜 (600 m length, avg. 6%, max. 8%) was in a masochistic way somewhat rewarding.
After 5 hours, we were pleased to see the beautiful gothic town hall of 𝙊𝙪𝙙𝙚𝙣𝙖𝙖𝙧𝙙𝙚. Bathing in the shimmering light of the evening sun. It is a sight my colleague and I see every day. But never before did it look that beautiful.
The final verdict
Now for the verdict. Is this Yellow Loop the flat and easy one? Is it the piece of cake we make it out to be? No. Most definitely not. We must confess that it is equally hard as its Red and Blue brother and sister. But in its own way. Sure, it doesn't have the Muur or the Paterberg. You won't be able to brag that you survived the Koppenberg. No, this Yellow Loop is hard because it gives you another taste of the Flemish Ardennes. It is the succession of different types of sections that makes it a real challenge.
Enjoy the ride and stay safe,


text:
J-Stars Victory Vs (ジェイスターズ ビクトリーバーサス Jei Sutāzu Bikutorī Bāsasu?) is an upcoming fighting video game that combines the universes of several Weekly Shōnen Jump manga series, including former series and some that have been transferred to other magazines. It is set to be released by Namco Bandai Games on March 19, 2014 for the PlayStation 3 and PlayStation Vita.
|J-Stars Victory Vs preview
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text:
Sam Field Center
*Update – Sunday, March 15th, 2020*
Dear Commonpoint Queens Community Member,
Like the rest of our city, we have been working around the clock for the last several days thinking about the best ways to service our community.
With today's announcement that all New York City schools will be closed, effective immediately, we want to inform you that we will also be suspending our in-person programs and services – and closing our buildings – for the immediate future, effective Monday, March 16th.
To elaborate, this includes all infant and toddler, early childhood, after school, youth sports, health and wellness (including our indoor pool and fitness center) and older adult programs. As this message is being sent we are working on the logistics to ensure that our seniors will still have access to meals, our food pantry will be able to provide groceries, and that mental health services are still available through our CAPE programs.
Our staff will continue to work diligently and thoughtfully to plan programming and services to offer to our community, and we will provide updates for virtual learning and engagement opportunities ASAP.
Your well-being is of the utmost importance to us, and we will be doing everything in our power to continue to be a resource for you all, in many new and different ways. In the meantime, we are here for you, if you need our assistance/services please feel free to reach out to us at [email protected] and we will do our best to connect you with the services you need.
Continue to check our website for further updates. We will also be posting updates and interactive content to to our Facebook, Instagram and Twitter pages.
Encouraging everyone to stay safe and remain in good health,
Commonpoint Queens
Contact Details
58-20 Little Neck Parkway
Little Neck, NY 11362
Sunday: 8:00 AM – 2:00 PM
Monday – Thursday: 8:00 AM – 8:00 PM
Friday: 8:00 AM – 6:00 PM
Programs Include
- Early Childhood Center with day care for children ages 2-4 as well as (free) Pre-K For All.
- After school program that picks up from schools in District 26 and offers pick-up until 6:30 PM.
- Youth sports classes and clinics as well as 9 FUN birthday party options!
- Kidz Fit Gym with equipment, classes and trainers specific for children ages 6 to 14.
- Summer Day Camp that goes out to the Henry Kaufmann Campgrounds in Huntington, as well as a Summer Day Camp that stays in Little Neck and focuses more on academics.
- After school program and summer camp for children with developmental disabilities.
- Volleyball, Pickleball, Open Gym Basketball (gym rentals) and so much more in our huge – air conditioned – gymnasium.
- Neighborhood Senior Center with socialization groups, card games, daily lunch, exercise classes and so much more!
- Outpatient Mental Health Clinic (CAPE) that offers individual, group and family therapy, psychiatric evaluations and medication monitoring for both clinic and homebound older adults.
- Dementia Care programs including social adult day care family respite and early stage memory care.
- Access to Naturally Occurring Retirement Communities in Deepdale, Whitestone and the Floral Park/Glen Oaks/Bellerose/New Hyde Park area.
- Access to Tanenbaum Family Pool Club in Little Neck and Bay Terrace Pool and Athletic Center in Bayside.


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