Neoadjuvant cetuximab, twice-weekly gemcitabine, and intensity-modulated radiotherapy (IMRT) in patients with pancreatic adenocarcinoma.

BACKGROUND: Neoadjuvant therapy has been investigated for localized and locally advanced pancreatic ductal adenocarcinoma (PDAC) but no standard of care exists. Combination cetuximab/gemcitabine/radiotherapy demonstrates encouraging preclinical activity in PDAC. We investigated cetuximab with twice-weekly gemcitabine and intensity-modulated radiotherapy (IMRT) as neoadjuvant therapy in patients with localized or locally advanced PDAC. EXPERIMENTAL DESIGN: Treatment consisted of cetuximab load at 400 mg/m(2) followed by cetuximab 250 mg/m(2) weekly and gemcitabine 50 mg/m(2) twice-weekly given concurrently with IMRT to 54 Gy. Following therapy, patients were considered for resection. RESULTS: Thirty-seven patients were enrolled with 33 assessable for response. Ten patients (30%) manifested partial response and 20 (61%) manifested stable disease by RECIST. Twenty-five patients (76%) underwent resection, including 18/23 previously borderline and 3/6 previously unresectable tumors. Twenty-three (92%) of these had negative surgical margins. Pathology revealed that 24% of resected tumors had grade III/IV tumor kill, including two pathological complete responses (8%). Median survival was 24.3 months in resected patients. Outcome did not vary by epidermal growth factor receptor status. CONCLUSIONS: Neoadjuvant therapy with cetuximab/gemcitabine/IMRT is tolerable and active in PDAC. Margin-negative resection rates are high and some locally advanced tumors can be downstaged to allow for complete resection with encouraging survival. Pathological complete responses can occur. This combination warrants further investigation.

Differentiation between Tuberculous and Pyogenic Spondylodiscitis: The Role of the Anterior Meningovertebral Ligament in Patients with Anterior Epidural Abscess.

BACKGROUND AND PURPOSE: Differentiation between tuberculous and pyogenic spondylodiscitis is a diagnostic challenge because imaging often does not reliably distinguish the 2 entities and percutaneous biopsies are often culture-negative. The purpose of this study was to determine whether violation of the anterior meningovertebral ligament in the setting of anterior epidural abscess discriminates between these entities. MATERIALS AND METHODS: This was a retrospective cohort study of all patients with acid-fast bacillus testing and anterior epidural abscess diagnosed on spinal MR imaging between May 2014 and September 2019, with a final diagnosis of tuberculous or pyogenic spondylodiscitis. Six cases of tuberculous spondylodiscitis (mean age, 45.5 years; 80% male) and 35 cases of pyogenic spondylodiscitis were evaluated (mean age, 56.6 years; 49% male). Demographic characteristics were recorded. Cases were assessed for anterior meningovertebral ligament destruction on MR imaging, as demonstrated by the shape of the epidural collection. Segmental location of the infection was also assessed. Independent 2-sample t tests and χ2 tests of independence were performed to evaluate the significance of the difference between the groups. RESULTS: Five of 6 (83.3%) cases of tuberculous epidural abscess had an intact anterior meningovertebral ligament, and 0/35 cases of pyogenic epidural abscess demonstrated an intact ligament (P < .001). The presence of an intact anterior meningovertebral ligament had 83.3% sensitivity and 100% specificity for tuberculous spondylodiscitis, a 100% positive predictive value, and a 97.2% negative predictive value. CONCLUSIONS: The presence of an intact anterior meningovertebral ligament has high sensitivity and specificity for tuberculous spondylodiscitis-associated epidural abscess, though these results should be validated in a larger sample.

Somatomedin C: restoration in vivo of cycle traverse in G0/G1 blocked cells of hypophysectomized animals.

DNA synthesis and mitosis in frog lens epithelium are abolished by hypophysectomy and restored by somatomedin C. Both growth hormone and triiodothyronine also restore lens cell proliferation in vivo but not in vitro. Somatomedin-like activity in frog serum is diminished by hypophysectomy and is restored by growth hormone and triiodothyronine.

Investigations on circumferential microfilament bundles in rat retinal pigment epithelium.

The presence of contractile proteins in normal rat retinal pigment epithelium has been studied using fluorescence and electron microscopy. Investigations using the F-actin binding toxin, phallacidin, coupled to the fluorochrome nitrobenzoxadiazole, revealed a band of fluorescence at or near the cell membrane. Immunofluorescent observations with anti-myosin and anti-alpha-actinin antisera gave similar results. Electron microscopy employing glutaraldehyde-8% tannic acid fixation revealed the presence of a circumferential microfilament band beneath the pigment epithelial apical surface that is closely associated with the plasma membrane and junctional complexes. Freeze-fracture studies confirmed the relationship of this band to the junctional complexes. The microfilament band measures approximately 0.5 micron +/- 0.2 micron in width and is composed of numerous 6 to 7 nm filaments. Some microtubules are seen in regions around the band, but no organelles appear to be associated with this structure. In en face sections through the zonula adherens, the circumferential microfilament band is associated with 30-nm electron-dense particles that are bound to the internal side of the membrane. Morphological evidence suggests that these may serve in anchoring the band to the membrane and assist in aligning the microfilament bands of adjoining cells. In the subapical cytoplasm, a microfilament bundle network was detected that interfaced with the circumferential microfilament band. In some cases, pigment epithelium was incubated in media-199 containing 25 to 50 ng/ml phallacidin prior to fixation. Circumferential microfilament bands of tissues treated in this manner exhibited a striated appearance.

Studies on corneal endothelial growth and repair. IV. Changes in the surface during cell division as revealed by scanning electron microscopy.

Changes in the surface morphology of regenerating rabbit, rat and frog corneal endothelial cells in vivo have been investigated by scanning electron microscopy. In adult tissue these cells do not normally divide unless given a stimulus, such as injury. Surfaces of quiescent rabbit and rat cells are devoid of microvilli but display globular projections and surface pits up to 300 nm in diameter. However, regenerating endothelia are characterized by the appearance of microvilli which attain their greatest length when the cells are rounded. At this stage, cells also possess filopodia and broad processes. In cytokinesis, the microvilli have shortened and blebs and ruffles appear for the first time. In contrast to rabbits and rats, frog endothelial cells of noninjured tissue are covered by microvilli and smaller surface pits of 60-70 nm diameters. During regeneration, these cells have reduced numbers of microvilli and extensive foldings of the membrane. Neither blebs nor filopodia occur during the mitotic cycle and ruffles are not detected until cytokinesis.

Thrombospondin: biosynthesis, distribution, and changes associated with wound repair in corneal endothelium.

Thrombospondin is a cell adhesion molecule which interacts via specific domains with a wide array of extracellular matrix components, including fibrinogen, fibrin, fibronectin, collagen, and heparan sulfate proteoglycan. Although this protein has been localized in several human tissues, its presence in corneal tissues had not been previously established. In the present study, we have demonstrated that cultured bovine corneal endothelial cells synthesize thrombospondin and incorporate it into their extracellular matrix. We have also shown immunofluorescently the presence and distribution of thrombospondin in these cultured cells and in the noninjured and injured corneal endothelium in situ. Ultrastructural immunoperoxidase cytochemistry revealed that thrombospondin could be displaced from the cell surface by heparin, but not by keratan sulfate. Confluent cultures of corneal endothelium synthesize and secrete the three cell adhesion proteins laminin, thrombospondin, and fibronectin in the ratios 1:8.2:51.8. Only the laminin B chains were detected in immunoprecipitates. Immunofluorescent studies of these cultured cells, using a polyclonal antiserum raised against purified thrombospondin, revealed a low level of fluorescence associated with the cell layer but a punctate fluorescent pattern at the level of the extracellular matrix. Noninjured corneal endothelium in situ also demonstrated a low level of fluorescence throughout the cell layer. However, this dramatically changed after a circular freeze injury to the tissue. By 24 h after wounding, cells surrounding the injury zone displayed a prominent fluorescence that was still observed at 48 h post-injury. In addition to its increased intracellular fluorescence, thrombospondin was also localized as migration tracks, oriented in the direction of cellular migration into the wound site. Thus, in corneal endothelium, thrombospondin appears to play a major role in injury-induced cell migration in situ along a natural basement membrane.

Cytological and immunocytochemical approaches to the study of corneal endothelial wound repair.

The vertebrate corneal endothelium represents a unique model system for investigating many cellular aspects of wound repair within an organized tissue in situ. The tissue exists as a cell monolayer that resides upon its own natural basement membrane that can be prepared as a flat mount to observe the entire cell population. Thus, it readily avails itself to many cytological and immunocytochemical methods at both the light microscopic and ultrastructural levels. In addition, the tissue is easily explanted into organ culture where further investigations can be carried out. These techniques have enabled investigators to use many approaches to explore function and changes in response to injury. In vivo, the endothelium acts as a transport tissue to actively pump Na+ and bicarbonate ions from the corneal stroma into the aqueous humor to control corneal transparency. Physiological findings indicate that fluid diffuses back into the stroma, across the endothelium, and thus hydration is said to be controlled by a pump-leak mechanism. Ultrastructural investigations, some employing horseradish peroxidase and lanthanum, have established the morphological basis for this mechanism as apical focal junctions that are not the classical tight junctions and do not constitute a complete zona occludens. Along with these apical focal junctions are gap junctions that appear identical to their counterparts in other cell types. Cytochemical studies localized both Na+K(+)-ATPase and carbonic anhydrase, the main pump enzymes associated with corneal hydration, to the lateral plasma membranes. Corneal endothelial cells of noninjured tissue do not traverse the cell cycle and are considered to be in the "Go" phase of the cell cycle as determined by microfluorometric analysis with DNA binding dyes such as auramin O and pararosaniline-Feulgen. However, injury can initiate cell cycle transverse and histochemical and cytological methods have been used to understand the tissue's response. Classical histochemical studies revealed that increased staining was observed for metabolic (NADase and NADPase) and lysosomal enzymes in cells bordering the wound area. The use of radiolabelled agents has further lead to an understanding of the endothelial wound response. Autoradiographic analyses of 3H-actinomycin D incorporation indicated that injury initiates changes in chromatin leading to increased binding levels of the drug in cells surrounding the wound. This change suggests that those cells undergo heightened macromolecular synthesis and this was confirmed by examining 3H-uridine and 3H-thymidine incorporation. The major mechanism involved in corneal endothelial repair is cell migration. Cytochemical and immunocytochemical investigations have allowed investigators an opportunity to gain some insight into changes that occur during this cellular process.(ABSTRACT TRUNCATED AT 400 WORDS)

Changes in distribution of extracellular matrix proteins during wound repair in corneal endothelium.

The distribution of fibronectin (FN) and laminin (LM) in non-injured and injured rat corneal endothelium in vivo was investigated by light microscopy using immunoperoxidase cytochemistry. In non-injured tissues, both FN and LM have distinct pericellular staining patterns and exhibit some diffuse cytoplasmic staining. After a circular freeze injury, cells migrating into the wound area at 24 hr lack the characteristic pericellular staining observed in non-injured cells but show cytoplasmic staining for both extracellular matrix glycoproteins. Endothelial cells on the periphery of such preparations do not partake in wound repair and retain their pericellular staining patterns. Forty-eight hours after injury, cells have filled in the wound area but are disorganized. They display intracellular FN and LM staining but do not demonstrate any pericellular staining. When observed 10 days after injury, a uniform monolayer has formed but neither FN nor LM is detected pericellularly. By 14 days post injury, endothelial cells in the wound area display pericellular FN patterns but not LM patterns. This may reflect differences in the function of each glycoprotein in maintaining the attachment of the endothelium to Descemet's membrane.

Use of selected excitation filters for enhancement of diaminobenzidine photomicroscopy.

Enhancement of the diaminobenzidine (DAB) reaction product for light photomicroscopy was investigated using commercially available glass interference filters FITC-495, BG38, and BG12. The oxidized DAB transmission curve between 400-700 nm revealed a broad peak extending mostly through the yellow to red portions of the visible light spectrum, indicating that no single color predominates. Absorption spectra from the interference filters showed that FITC-495 gave total absorbance from 495-650 nm, with a smaller peak at 675 nm; BG38 transmitted at least a percentage of every wavelength up to 700 nm, whereas BG12 absorbed all light above 490 nm. To determine whether these filters could photographically increase DAB reaction product contrast, photographs were taken of corneal endothelial cells 24 hr after freeze injury. At this time, these cells demonstrate increased levels of laminin, as revealed by immunoperoxidase cytochemistry. When photography was performed using either no filter or a standard green filter, DAB contrast relative to background was minimal. However, when photographs were made using either the FITC-495 or the BG12 filter, DAB contrast increased sharply, although background density increased in the former case and decreased greatly in the latter. BG38 by itself did not increase DAB contrast. However, when used in combination with FITC-495 good DAB contrast was achieved and background density was lower than that seen using FITC-495 alone. Therefore, selective interference filters can photographically increase DAB contrast for studies using immunoperoxidase cytochemistry.

Changes in extracellular matrix proteins and actin during corneal endothelial growth.

Basement membranes influence growth, shape and differentiation of cells and tissues. However, the role and influence of Descemet's membrane during corneal development is not understood. To address this question, the relationships between cell growth and fibronectin, laminin and actin distribution in the developing rat corneal endothelium in vivo has been examined. During fetal development, rat corneal endothelial cells undergo DNA synthesis and mitosis. However, at day 14 of gestation both processes begin to decline and neither can be detected in endothelium of 1-month-old animals. By this time cell number has increased to approximately 100,000 and tissue area has increased 25-fold. However, as the tissue area increased, cell density decreased, indicating that cell spreading occurred in order to maintain tissue integrity. Changes in endothelial growth were accompanied by changes in the distribution of laminin, fibronectin and actin. Laminin and fibronectin were diffusely localized within endothelial cells in newborn animals. By 4 weeks of age, no proliferation was demonstrated and both extracellular matrix proteins were localized in pericellular patterns. Actin, on the other hand, which appeared diffuse at 16 days in utero, was distributed at or near the cell membrane by 19 days in utero. Thus, the reorganization of extracellular matrix glycoproteins and actin may indicate important roles for these components in regulating the growth and formation of the corneal endothelium in vivo.

Oral assessment of the edentulous elderly patient.

While the need for regular oral examinations increases in the aged, edentulous elderly persons generally see their dentists rarely, while most see their physicians relatively frequently. If these patients cannot be convinced to see a dentist, the physician should perform regular oral screening examinations. A technique is described for accomplishing this.

Oral assessment of the dentulous elderly patient.

The percentage of elderly persons retaining natural teeth is increasing. Although many of these individuals cannot be convinced to see a dentist regularly, they are generally seen by a physician or nurse relatively frequently. The physician or nurse can provide a vital service for these patients by performing oral screening examinations. A technique is described for accomplishing this.

Relationship in very elderly veterans of nutritional status, self-perceived chewing ability, dental status, and social isolation.

The relationship of nutritional status, self-perceived chewing ability, dental status, and social isolation was examined. Seventy-three ambulatory, elderly (means = 86 years) veterans were studied. Parameters of nutritional status included intakes of protein, carbohydrate, fat, and total calories, and hemoglobin, serum albumin, total lymphocyte count, and height/weight ratio were determined. Dental status was measured, and self-perceived chewing problems and social isolation were assessed by interview. Results showed a significant correlation between perceived chewing problems and diminished protein and total caloric intake and increased carbohydrate intake. No association was found between measured dental status and nutritional status. Social isolation was weakly correlated with greater protein and calorie intake. These results support the contention that the presence of self-perceived chewing problems are more reliable than the quality of the dentition itself as an indicator of altered nutritional status.

Demonstration of microfibrils in Bruch's membrane of the eye.

The cationic dyes ruthenium red and alcian blue were used to visualize a population of microfibrils in Bruch's membrane, a compound basement membrane located in the uveal tract of the eye between the retinal pigment epithelium and choriocapillaris. Microfibrils were tubular structures, 10-12 nm in diameter, that showed a characteristic beaded pattern. The majority of microfibrils appeared as a dense mantle around the layer of amorphous elastin. Microfibrils and collagen fibers were also present as a loosely organized meshwork in the collagenous zone of the membrane. Microfibrils were also seen along the basal surface of the retinal pigment epithelium where they appeared to insert into the substance of the basal lamina. Ruthenium red staining of microfibrils was not abolished by prior exposure of tissue to several kinds of degradative enzymes. The findings suggest that the elastic properties of Bruch's membrane may depend on both the elastin and microfibrillar components.

Studies on corneal endothelial growth and repair. II. increased transcription as detected by incorporation of 3H-uridine and 3H-actinomycin D.

Endothelial cells from injured frog corneas undergo increased 3H-uridine and 3H-actinomycin D (3H-AMD) incorporation as judged by autoradiography. The increase in 3H-AMD binding occurs when living endothelium is labeled in vitro or when fixed preparations are exposed to the drug. The changes in 3H-AMD incorporation detected by the two methods are comparable (55 and 62% for living and pre-fixed tissue respectively). However, when fixed endothelium is also de-histonized with 2 N HCl, differential binding of 3H-AMD is eliminated. This result suggests that the enhanced incorporation of 3H-AMD into nuclei is at least partly due to a modification in the association of chromosomal proteins with DNA and not entirely to cell permeability changes that may accompany wound repair. This contrasts with observations of cells that are killed outright by the injury. Such cells bind very large amounts of 3H-AMD compared with their living neighbors. Here the difference in incorporation is eliminated by prefixation. Thus, in the dead cells increased binding may be due to a reduction of cell surface permeability barriers which accompanies cell morbidity.

Fixed prosthodontics in the elderly population. Life expectancy of fixed restorations, failures, and retreatment methods.

The restorative needs of older dental patients challenge the ingenuity, anatomic knowledge, artistic skills, occlusal philosophies, and material knowledge of the clinician. Achieving the most secure foundation while simultaneously eliminating imperfections and incorporating a design that promotes good oral hygiene and a natural and attractive appearance are significant contributors to a patient's welfare. The treatment decision regarding fixed prosthodontics for elderly patients requires the balancing of two opposing arguments: 1. In patients who are older, and who are perhaps medically or physically compromised, and, in addition, who may be on a limited budget (or perceived limited budget), it is important to fabricate dental prostheses that are as good as possible to minimize the likelihood that the prosthesis will need to be remade in the future when the patient is likely to be even more compromised financially, medically, or physically, and also to minimize the stress on the patient of accommodating to something that is less than an optimal dental solution. 2. Patients in this age group often anticipate financial strain in the future, perhaps realistically in view of the increasing percent of older adults who are institutionalized (5% of persons 65 years old or older, 20% of persons 80 years old or older). Also, many are reluctant to invest large amounts of money in their teeth when they are already quite elderly and realize they may not live long enough to make the investment "worthwhile." Educating the patient regarding average life expectancy is sometimes helpful, but the experience of many clinical dentists is that many elderly persons either do not believe the numbers, require greater certainty in their "investments," or do not place as high a value on their dental health as they do other aspects of their lives (in a context in which there are more needs than resources to pay for them). Finally, many older adults, contrary to the popular bumper sticker, are trying to preserve as many resources for their children and grandchildren as possible. The final decision should be made with sensitivity to the overall needs of the patient, and with the assistance of a well-informed patient or other responsible party.

Treatment planning in dental schools.

Treatment planning is a complex process that is difficult to teach and evaluate. Various frameworks have been used to organize the decision-making process. While many have merit, the transition from ideal to realistic plan is rarely described in detail adequate for teaching purposes. None of the research recommends an objective method to measure students' treatment planning skills. A treatment planning model is described that would follow presentation of the "ideal" treatment plan in the curriculum. The model focuses specifically on the sequence of decisions necessary to formulate appropriate treatment plans for adult dental patients who present with compromising factors. Also, a method is suggested for objective evaluation of dental students' mastery of dental treatment planning at each of several intermediate steps, as well as at the final result.

Dental needs related to primary cause for institutionalization.

One hundred and forty-seven dentate residents of a long-term care facility were examined to determine oral status and need for treatment. The assessment included dental caries (NIDR criteria), oral hygiene index-simplified, and missing teeth. Caries was further divided into "restorable" and "nonrestorable." Also, the primary cause for institutionalization was determined.