Circulating tumor DNA as a potential marker of adjuvant chemotherapy benefit following surgery for localized pancreatic cancer.

BACKGROUND: In early-stage pancreatic cancer, there are currently no biomarkers to guide selection of therapeutic options. This prospective biomarker trial evaluated the feasibility and potential clinical utility of circulating tumor DNA (ctDNA) analysis to inform adjuvant therapy decision making. MATERIALS AND METHODS: Patients considered by the multidisciplinary team to have resectable pancreatic adenocarcinoma were enrolled. Pre- and post-operative samples for ctDNA analysis were collected. PCR-based-SafeSeqS assays were used to identify mutations at codon 12, 13 and 61 of KRAS in the primary pancreatic tumor and to detect ctDNA. Results of ctDNA analysis were correlated with CA19-9, recurrence-free and overall survival (OS). Patient management was per standard of care, blinded to ctDNA data. RESULTS: Of 112 patients consented pre-operatively, 81 (72%) underwent resection. KRAS mutations were identified in 91% (38/42) of available tumor samples. Of available plasma samples (N = 42), KRAS mutated ctDNA was detected in 62% (23/37) pre-operative and 37% (13/35) post-operative cases. At a median follow-up of 38.4 months, ctDNA detection in the pre-operative setting was associated with inferior recurrence-free survival (RFS) [hazard ratio (HR) 4.1; P = 0.002)] and OS (HR 4.1; P = 0.015). Detectable ctDNA following curative intent resection was associated with inferior RFS (HR 5.4; P < 0.0001) and OS (HR 4.0; P = 0.003). Recurrence occurred in 13/13 (100%) patients with detectable ctDNA post-operatively, including in seven that received gemcitabine-based adjuvant chemotherapy. CONCLUSION: ctDNA studies in localized pancreatic cancer are challenging, with a substantial number of patients not able to undergo resection, not having sufficient tumor tissue for analysis or not completing per protocol sample collection. ctDNA analysis, pre- and/or post-surgery, is a promising prognostic marker. Studies of ctDNA guided therapy are justified, including of treatment intensification strategies for patients with detectable ctDNA post-operatively who appear at very high risk of recurrence despite gemcitabine-based adjuvant therapy.

Serous cystic neoplasm of the pancreas: a multinational study of 2622 patients under the auspices of the International Association of Pancreatology and European Pancreatic Club (European Study Group on Cystic Tumors of the Pancreas).

OBJECTIVES: Serous cystic neoplasm (SCN) is a cystic neoplasm of the pancreas whose natural history is poorly known. The purpose of the study was to attempt to describe the natural history of SCN, including the specific mortality. DESIGN: Retrospective multinational study including SCN diagnosed between 1990 and 2014. RESULTS: 2622 patients were included. Seventy-four per cent were women, and median age at diagnosis was 58 years (16-99). Patients presented with non-specific abdominal pain (27%), pancreaticobiliary symptoms (9%), diabetes mellitus (5%), other symptoms (4%) and/or were asymptomatic (61%). Fifty-two per cent of patients were operated on during the first year after diagnosis (median size: 40 mm (2-200)), 9% had resection beyond 1 year of follow-up (3 years (1-20), size at diagnosis: 25 mm (4-140)) and 39% had no surgery (3.6 years (1-23), 25.5 mm (1-200)). Surgical indications were (not exclusive) uncertain diagnosis (60%), symptoms (23%), size increase (12%), large size (6%) and adjacent organ compression (5%). In patients followed beyond 1 year (n=1271), size increased in 37% (growth rate: 4 mm/year), was stable in 57% and decreased in 6%. Three serous cystadenocarcinomas were recorded. Postoperative mortality was 0.6% (n=10), and SCN's related mortality was 0.1% (n=1). CONCLUSIONS: After a 3-year follow-up, clinical relevant symptoms occurred in a very small proportion of patients and size slowly increased in less than half. Surgical treatment should be proposed only for diagnosis remaining uncertain after complete workup, significant and related symptoms or exceptionally when exists concern with malignancy. This study supports an initial conservative management in the majority of patients with SCN. TRIAL REGISTRATION NUMBER: IRB 00006477.

Systematic review with network meta-analysis: pharmacological prophylaxis against post-ERCP pancreatitis.

BACKGROUND: The efficacy of many pharmacological agents for preventing post-ERCP pancreatitis (PEP) has been evaluated in randomised controlled trials (RCTs), but it is unclear which agent(s) should be used in clinical practice. Network meta-analyses of RCTs are used to simultaneously compare several agents to determine their relative efficacy and identify priority agents for comparison in future RCTs. AIM: To evaluate pharmacological agents for the prevention of PEP by conducting a network meta-analysis of RCTs. METHODS: We searched MEDLINE, EMBASE and Cochrane Library databases for RCTs that evaluated the efficacy of agents for preventing PEP. RCTs were simultaneously analysed using random-effects network meta-analysis under the Bayesian framework to identify the best agents. The efficacy of agents was ordered according to the probability of being ranked as any of the top three best performing agents. RESULTS: The network meta-analysis included 99 RCTs evaluating 16 agents in 25 313 patients. Topical epinephrine (adrenaline) was the most efficacious agent with 85.9% probability of ranking among the top three agents, followed by nafamostat (51.4%), antibiotics (44.5%) and NSAIDs (42.8%). However, in a sensitivity analysis including only rectal NSAIDs, NSAIDs moved from fourth rank to second (58.1%). Patients receiving topical epinephrine, compared with placebo, had a 75% reduced risk of PEP (OR 0.25, 95% probability interval 0.06-0.66). CONCLUSIONS: Topical epinephrine and rectal NSAIDs are the most efficacious agents for preventing post-ERCP pancreatitis, based on existing RCTs. Combinations of these agents, which act on different steps in the pathogenesis of post-ERCP pancreatitis, should be evaluated in future trials.

Verification and implementation of a modified split Hopkinson pressure bar technique for characterizing biological tissue and soft biosimulant materials under dynamic shear loading.

Modeling human body response to dynamic loading events and developing biofidelic human surrogate systems require accurate material properties over a range of loading rates for various human organ tissues. This work describes a technique for measuring the shear properties of soft biomaterials at high rates of strain (100-1000 s(-1)) using a modified split Hopkinson pressure bar (SHPB). Establishing a uniform state of stress in the sample is a fundamental requirement for this type of high-rate testing. Input pulse shaping was utilized to tailor and control the ramping of the incident loading pulse such that a uniform stress state could be maintained within the specimen from the start of the test. Direct experimental verification of the stress uniformity in the sample was obtained via comparison of the force measured by piezoelectric quartz force gages on both the input and the output sides of the shear specimen. The technique was demonstrated for shear loading of silicone gel biosimulant materials and porcine brain tissue. Finite element simulations were utilized to further investigate the effect of pulse shaping on the loading rate and rise time. Simulations also provided a means for visualization of the degree of shear stress and strain uniformity in the specimen during an experiment. The presented technique can be applied to verify stress uniformity and ensure high quality data when measuring the dynamic shear modulus of soft biological simulants and tissue.

Performance of cold-set binding agents in re-formed beef steaks.

Four cold-setting gel-forming binding agents were compared in preparation of re-formed steaks from strips of each of two muscles, M. triceps brachii-caput longum (TB) from the shoulder, and M. pectoralis profundus (PP) from the brisket, of steer forequarter. The binding agents, which were commercial preparations, were Activa, containing transglutaminase enzyme as active ingredient, Fibrimex, containing the blood plasma fractions fibrinogen and thrombin, Textor, containing a modified starch, and alginate, containing sodium alginate and Ca(++). Binding of the cooked steaks and of slices therefrom, was satisfactory for the first three of the above but relatively weak for the alginate agent. Colour of steaks was affected by binder, in that Activa and Textor treatments gave lighter, redder and yellower (higher L*, a*, b* values) steaks than did the other two. Overall acceptability ratings by taste panels corresponded with those for flavour in the case of TB steaks, with Activa and Fibrimex samples scoring highest (P<0.05). For the less tender PP steaks, the highest acceptability score was for the Textor samples, reflecting their scoring best for tenderness. Warner-Bratzler shear force values corresponded with tenderness ratings in that Textor samples had lowest shear values for both muscles, but the differences were not significant. The overall conclusion, considering cohesion, appearance, cooking yield and sensory quality of the products, was that the Activa binder performed best and would facilitate the production of good-quality chilled re-formed beef steaks from various low-value beef muscles, and without addition of sodium chloride if so desired.

Mechanical tenderisation of beef muscles for use in re-formed joints made with a cold-set binder.

Three treatments, blade tenderisation (BT), needle tenderisation (NT) and enhancement by brine injection+vacuum-pulsing (VP), were applied to each of two muscles from beef forequarter, M. pectoralis profundus and M. supraspinatus, and two from the round of the hindquarter, M. semimembranosus and M. vastus lateralis. The tenderised muscles and non-treated controls were re-formed into joints using a cold-set bonding agent and tested as steaks cut from the joints. NT and VP gave a similar degree of tenderisation, as indicated by W-B shear force and taste panel, while BT had a lesser but still significant effect. Cook loss from steaks was increased by BT and NT treatments for the, tougher, forequarter but not the hindquarter muscles. The overall conclusion was that NT and VP treatments are more effective than BT but that the 3 methods are satisfactory for tenderisation of beef for production of re-formed steaks. Reduced redness and higher bacterial numbers arising from VP could render this treatment more suitable for re-formed steaks for catering than for retail sale. A supplementary trial showed that slices from roasted VP-treated re-formed joints (as distinct from grill-cooked steaks tested in the main trial) were better in sliceability and equal to or better in sensory quality than those from commercial whole-muscle round roasts purchased in a supermarket.

Endoscopic ultrasound in cancer staging.

BACKGROUND: Endoscopic ultrasound (EUS) represents one of the most significant developments in endoscopy over the past 20 years. It allows highly detailed assessment of the gastrointestinal wall layers as well as to visualize extraluminal structures such as the mediastium and retroperitoneum. METHODS: The literature was reviewed to assess the role of EUS in cancer staging. RESULTS: EUS is an integral part of the staging of many upper gastrointestinal cancers as well as rectal and lung cancer and has been shown to be cost-effective. It can be used to confirm malignancy in suspicious lesions as well as to identify and confirm nodal or metastatic spread. It has been used to re-stage cancers following chemoradiotherapy, but results are disappointing. Future developments are discussed, which may include using EUS-guided delivery of anti-tumour agents directly into tumours.

Smear layer and surface state affect dentin fluoride uptake.

OBJECTIVES: Polishing generates a smear layer (SL) on in vitro dentin samples that may influence fluoride uptake. We tested two hypotheses: SL increases fluoride uptake in superficial dentin (H1) and decreases fluoride uptake in deeper layers (H2) irrespectively of the amount of fluoride administered. METHODS: Polished bovine dentin with SL present and removed by four methods (5% tannic acid, 20s [TA]; 17% EDTA, 120 s; 38% phosphoric acid, 60s [PA]; and 10s air polishing) was fluoridated with 1200 or 12000 ppm F (NaF) solution (pH 4.0). RESULTS: Scanning electron microscopy (SEM) revealed that aggressiveness of SL removal varied by method from leaving SL patches behind (TA) to collagen exposure (PA). SL increased KOH-soluble and structurally bound fluoride uptake into superficial and deeper layers compared to SL free surfaces (except PA) following 1200 ppm, but not 12000 ppm fluoridation. CONCLUSION: Presence of SL and surface conditions influence dentin fluoride uptake depending on fluoride concentration administered.

Deposition of fluoride on enamel surfaces released from varnishes is limited to vicinity of fluoridation site.

The aim of the in-situ study was to determine fluoride uptake in non-fluoridated, demineralized enamel after application of fluoride varnishes on enamel samples located at various distances from the non-fluoridated samples. All enamel samples used were demineralized with acidic hydroxyethylcellulose before the experiment. Intra-oral appliances were worn by ten volunteers in three series: (1, Mirafluorid, 0.15% F; 2, Duraphat, 2.3% F and 3, unfluoridated controls) of 6 days each. Each two enamel samples were prepared from 30 bovine incisors. One sample was used for the determination of baseline fluoride content (BFC); the other was treated according to the respective series and fixed in the intra-oral appliance for 6 days. Additionally, from 120 incisors, each four enamel samples were prepared (one for BFC). Three samples (a-c) were placed into each appliance at different sites: (a) directly neighboured to the fluoridated specimen (=next), (b) at 1-cm distance (=1 cm) and (c) in the opposite buccal aspect of the appliance (=opposite). At these sites, new unfluoridated samples were placed at days 1, 3 and 5, which were left in place for 1 day. The volunteers brushed their teeth and the samples with fluoridated toothpaste twice per day. Both the KOH-soluble and structurally bound fluoride were determined in all samples to determine fluoride uptake and were statistically analyzed. One day, after fluoridation with Duraphat, KOH-soluble fluoride uptake in specimen a (=next) was significantly higher compared to the corresponding samples of both the control and Mirafluorid series, which in turn were not significantly different from each other. At all other sites and time points, fluoride uptake in the enamel samples were not different from controls for both fluoride varnishes. Within the first day after application, intra-oral-fluoride release from the tested fluoride varnish Duraphat leads to KOH-soluble fluoride uptake only in enamel samples located in close vicinity to the fluoridation site.

Mechanical properties of soft human tissues under dynamic loading.

The dynamic response of soft human tissues in hydrostatic compression and simple shear is studied using the Kolsky bar technique. We have made modifications to the technique that allow loading of a soft tissue specimen in hydrostatic compression or simple shear. The dynamic response of human tissues (from stomach, heart, liver, and lung of cadavers) is obtained, and analyzed to provide measures of dynamic bulk modulus and shear response for each tissue type. The dynamic bulk response of these tissues is easily described by a linear fit for the bulk modulus in this pressure range, whereas the dynamic shearing response of these tissues is strongly non-linear, showing a near exponential growth of the shear stress.

Prevention of erosion and abrasion by a high fluoride concentration gel applied at high frequencies.

The aim of this study was to determine maximum attainable protection of enamel from erosion and erosion abrasion using a highly fluoridated gel with and without additional fluoride from toothpaste. Thirty-six bovine enamel specimens were subjected to six erosive attacks per day (1% citric acid with pH 2.3 for 30 s), while the rest of the day the specimens were in artificial saliva. There were four treatment groups (9 specimens in each group): fluoride-free toothpaste/saliva slurry twice daily (group T0), fluoride-containing toothpaste/saliva slurry twice daily using 1,250 ppm F toothpaste (group TF), fluoride-containing toothpaste/saliva slurry twice per day plus application of a highly fluoridated gel (12,500 ppm F) twice a day for 120 s (group 2F) and a group with gel application 8 times a day (group 8F). Additionally, half of each specimen in all groups was subjected to brushing abrasion during application of the toothpaste/saliva slurry. Brushing abrasion alone led to no observable enamel loss measured with profilometry. After 14 days of cycling of erosion without toothbrushing abrasion, high-fluoride gel application 2 or 8 times daily showed significantly less enamel loss (median 24/19 microm) than with toothpaste with or without fluoride (41/45 microm). After 14 days of cycling of erosion and toothbrushing abrasion, gel application 2 or 8 times daily (33/29 microm) showed significantly less enamel loss than toothpaste with or without fluoride (57/62 microm). We conclude that a highly fluoridated acidic gel is able to protect enamel from erosion and toothbrushing abrasion while fluoridated tooth paste provides little protection.

Effect of a casein/calcium phosphate-containing tooth cream and fluoride on enamel erosion in vitro.

The aim of this study was to determine whether a tooth cream containing casein/calcium phosphate (CasCP) protects enamel against erosion. Sixty bovine enamel specimens were prepared for profilometry and distributed into five groups. Specimens were rinsed with artificial saliva interrupted by 1% citric acid (pH 2.3) for 30 s 6 times daily for 14 days. Group 1 (n=12) was not treated (control); in group 2 (n=12) CasCP was applied for 120 s twice daily; in group 3 (n=12) 250 ppm fluoride as NaF was applied for 120 s twice daily; in group 4 (n=12) CasCP was applied for 120 s, then 250 ppm fluoride for 120 s twice daily, and in group 5 (n=12) amine fluoride (AmF) gel (12,500 ppm fluoride) was applied for 120 s twice daily. Differences between groups with respect to erosive enamel loss (profilometrically determined depth after 7 and 14 days) were tested by the Mann-Whitney test (alpha=0.05). After 7/14 days' erosive cycling, specimens treated with AmF gel showed significantly less enamel loss (18.5/35.5 microm; medians) than those treated with CasCP (25.5/46.9 microm), 250 ppm fluoride (25.0/ 40.9 microm), CasCP and 250 ppm fluoride (23.9/47.4 microm) or with no treatment (26.3/49.8 microm). It is concluded that highly fluoridated acidic AmF gel can protect enamel against erosion while CasCP, 250 ppm fluoride or a combination of CasCP and 250 ppm fluoride provide little protection.

The ability of selected oral microorganisms to emit red fluorescence.

Some novel caries detection and excavation devices rely on the ability of bacteria to produce red fluorescing compounds. The aim of this study was to examine the ability of selected oral microorganisms to emit red fluorescence. Streptococcus mutans, S. oralis, S. salivarius, S. sobrinus, Lactobacillus fermentans, L. casei, L. rhamnosus, Actinomyces naeslundi, A. israelii, Prevotella intermedia, and Fusobacterium nucleatum were inoculated onto Columbia agar with haemin and vitamin K and incubated anaerobically for up to 7 days in the dark. The resulting bacterial colonies were excited using filtered xenon light (405 +/- 20 nm) and digitally photographed through a 530-nm high-pass filter. The red and green portions of the colony fluorescence were analyzed using a computer program and the red/green ratio was calculated. All colonies emitted both red and green fluorescence. The green outweighed the red portion for the following species (in descending order) S. oralis, S. salivarius, S. mutans, F. nucleatum and S. sobrinus. The red portion was higher for the following species (in descending order) P. intermedia, A. naeslundi, A. israelii, L. fermentans, L. rhamnosus and L. casei. With all the bacteria examined, one color portion generally outweighed the other, giving the visual impression of either red or green fluorescence. We conclude that red fluorescence is well suited to detection of the bacteria which cause dentin caries but it is not suitable as an indicator of the presence and activity of the streptococci involved in initial caries.

Effects of enhancement procedures on whole and re-formed beef forequarter muscles.

Beef Supraspinatus and Triceps brachii muscles were subjected to three enhancement and/or re-forming treatments: (i) injected whole @ 15%w/w with salt-phosphate solution; (ii) injected and re-formed; (iii) injected with added flavouring and re-formed. The treated muscles were compared to whole uninjected controls. All injection treatments reduced shear force values of cooked samples and in most cases these reductions were reflected in sensory panel tenderness and chewiness ratings. For example, shear values for Supraspinatus were 83N/g in control samples and 50 in whole injected samples, while corresponding sensory panel tenderness ratings were 3.6 and 5.2. Enhanced samples did not differ from controls in sliceability or in colour and binding ratings, indicating that enhancement combined with re-forming can give an acceptable roast beef product. There were no differences in drip loss and very few differences in colour L*, a* and b* values for raw samples between any of the treatments. Addition of beef stock did not result in higher flavour ratings by sensory panels. Whole injected samples scored higher for flavour than both control (p<0.01) and injected+re-formed (p<0.05) samples.

Fluorescence spectroscopy of dental calculus.

BACKGROUND: Correct diagnosis of the presence and extent of subgingival calculus is important for periodontal treatment planning and reassessment after periodontal therapy. Traditional tactile methods often lack sensitivity. The present investigation shall contribute to understanding the fundamental fluorescence properties that may be useful for optical detection of both supra- and subgingival calculus. OBJECTIVES: The aim of this study was to investigate emission spectra from supra- and subgingival calculus under a wide range of excitation wavelengths. METHODS AND RESULTS: Extracted human molars with either supragingival or subgingival calculus deposits on the root surface were selected (n = 3 each). Emission spectra were recorded from the calculus of each tooth and corresponding areas of clean root surfaces using a fluorescence spectrophotometer at excitation wavelengths from 360 nm up to 580 nm in steps of 20 nm. The spectra were corrected for the wavelength dependent instrument sensitivity and normalized to peak intensity (the highest peak was set at 1.0). Emission spectra of calculus exhibited distinct fluorescence bands between 570 and 730 nm not present in clean root surfaces. This fluorescence emission was strongest for excitation wavelengths from 400 to 420 nm. No differences were observed between supra- and subgingival calculus. CONCLUSIONS: Human dental calculus can clearly be differentiated from clean root surfaces by emission spectrophotometry. The characteristic fluorescence emission of supra- and subgingival calculus may be due to a variety of porphyrin derivatives and may provide the basis for future diagnostic procedures.

Systemic versus topical fluoride.

The actual mechanism of fluoride action is still a subject of debate. A dogma has existed for many decades, that fluoride has to be ingested and acts mainly pre-eruptively. However, recent studies concerning the systemic effect of fluoride supplementation concluded that the caries-preventive effect of fluoride is almost exclusively posteruptive. Moreover, epidemiologists have cast doubt on the validity of the 'old' studies dealing with fluoride use. The concept of the posteruptive fluoride effect is supported by in vitro and in situ investigations demonstrating that the mode of action of fluoride can be attributed mainly to its influence on de- and remineralization kinetics of dental hard tissues. Therefore, topical fluoride application (e.g. in the form of fluoridated dentifrices) should be encouraged. There are still important questions open that need to be answered despite existing knowledge about the caries-preventive effect of fluoride.