Keratin 17 modulates the immune topography of pancreatic cancer

BACKGROUND

The immune microenvironment impacts tumor growth, invasion, metastasis, and patient survival and may provide opportunities for therapeutic intervention in pancreatic ductal adenocarcinoma (PDAC). Although never studied as a potential modulator of the immune response in most cancers, Keratin 17 (K17), a biomarker of the most aggressive (basal) molecular subtype of PDAC, is intimately involved in the histogenesis of the immune response in psoriasis, basal cell carcinoma, and cervical squamous cell carcinoma. Thus, we hypothesized that K17 expression could also impact the immune cell response in PDAC, and that uncovering this relationship could provide insight to guide the development of immunotherapeutic opportunities to extend patient survival.

METHODS

Multiplex immunohistochemistry (mIHC) and automated image analysis based on novel computational imaging technology were used to decipher the abundance and spatial distribution of T cells, macrophages, and tumor cells, relative to K17 expression in 235 PDACs.

RESULTS

K17 expression had profound effects on the exclusion of intratumoral CD8+ T cells and was also associated with decreased numbers of peritumoral CD8+ T cells, CD16+ macrophages, and CD163+ macrophages (p < 0.0001). The differences in the intratumor and peritumoral CD8+ T cell abundance were not impacted by neoadjuvant therapy, tumor stage, grade, lymph node status, histologic subtype, nor KRAS, p53, SMAD4, or CDKN2A mutations.

CONCLUSIONS

Thus, K17 expression correlates with major differences in the immune microenvironment that are independent of any tested clinicopathologic or tumor intrinsic variables, suggesting that targeting K17-mediated immune effects on the immune system could restore the innate immunologic response to PDAC and might provide novel opportunities to restore immunotherapeutic approaches for this most deadly form of cancer.

Assembly and Repair of Photosystem II in Chlamydomonas reinhardtii

Oxygenic photosynthetic organisms use Photosystem II (PSII) to oxidize water and reduce plastoquinone. Here, we review the mechanisms by which PSII is assembled and turned over in the model green alga Chlamydomonas reinhardtii. This species has been used to make key discoveries in PSII research due to its metabolic flexibility and amenability to genetic approaches. PSII subunits originate from both nuclear and chloroplastic gene products in Chlamydomonas. Nuclear-encoded PSII subunits are transported into the chloroplast and chloroplast-encoded PSII subunits are translated by a coordinated mechanism. Active PSII dimers are built from discrete reaction center complexes in a process facilitated by assembly factors. The phosphorylation of core subunits affects supercomplex formation and localization within the thylakoid network. Proteolysis primarily targets the D1 subunit, which when replaced, allows PSII to be reactivated and completes a repair cycle. While PSII has been extensively studied using Chlamydomonas as a model species, important questions remain about its assembly and repair which are presented here.

The Disproportionate Rise in Pancreatic Cancer in Younger Women Is Due to a Rise in Adenocarcinoma and Not Neuroendocrine Tumors: A Nationwide Time-Trend Analysis Using 2001-2018 United States Cancer Statistics Databases

In previous studies, a significant increase in the incidence of pancreatic cancer among younger women compared to men in the United States was noted. However, the specific histopathologic characteristics were not delineated. This population-based study aimed to assess whether this disproportionate rise in pancreatic cancer in younger women was contributed by pancreatic ductal adenocarcinoma (PDAC) or pancreatic neuroendocrine tumors (PanNET). The United States Cancer Statistics (USCS) database was used to identify patients with pancreatic cancer between 2001 and 2018. The results showed that, in younger adults, the incidence of PDAC has increased in women [average annual percentage change (AAPC) = 0.62%], while it has remained stable in men (AAPC = -0.09%). The PDAC incidence rate among women increased at a greater rate compared to men with a statistically significant difference in AAPC (p < 0.001), with neither identical nor parallel trends. In contrast, cases of PanNET did not demonstrate a statistically significant sex-specific AAPC difference. In conclusion, this study demonstrated that the dramatic increase in the incidence rate of PDAC explains the disproportionate rise in pancreatic cancer incidence in younger women. This prompts further prospective studies to investigate the underlying reasons for these sex-specific disparities in PDAC.

Keratin 17 modulates the immune topography of pancreatic cancer

Background

The immune microenvironment impacts tumor growth, invasion, metastasis, and patient survival and may provide opportunities for therapeutic intervention in pancreatic ductal adenocarcinoma (PDAC). Although never studied as a potential modulator of the immune response in most cancers, Keratin 17 (K17), a biomarker of the most aggressive (basal) molecular subtype of PDAC, is intimately involved in the histogenesis of the immune response in psoriasis, basal cell carcinoma, and cervical squamous cell carcinoma. Thus, we hypothesized that K17 expression could also impact the immune cell response in PDAC, and that uncovering this relationship could provide insight to guide the development of immunotherapeutic opportunities to extend patient survival.

Methods

Multiplex immunohistochemistry (mIHC) and automated image analysis based on novel computational imaging technology were used to decipher the abundance and spatial distribution of T cells, macrophages, and tumor cells, relative to K17 expression in 235 PDACs.

Results

K17 expression had profound effects on the exclusion of intratumoral CD8 + T cells and was also associated with decreased numbers of peritumoral CD8 + T cells, CD16 + macrophages, and CD163 + macrophages (p < 0.0001). The differences in the intratumor and peritumoral CD8 + T cell abundance were not impacted by neoadjuvant therapy, tumor stage, grade, lymph node status, histologic subtype, nor KRAS, p53, SMAD4, or CDKN2A mutations.

Conclusions

Thus, K17 expression correlates with major differences in the immune microenvironment that are independent of any tested clinicopathologic or tumor intrinsic variables, suggesting that targeting K17-mediated immune effects on the immune system could restore the innate immunologic response to PDAC and might provide novel opportunities to restore immunotherapeutic approaches for this most deadly form of cancer.

Impacts of Wildfire Events on California Radiation Oncology Clinics and Patients

PURPOSE/OBJECTIVE(S)

The impact of climate-related disasters such as wildfires on healthcare delivery and cancer care is a growing concern. Patients undergoing radiotherapy are particularly vulnerable to treatment interruptions which are known to have a direct impact on survival outcomes. We report results of the first pilot study characterizing the impact of wildfires on radiation oncology clinics and their patients.

MATERIALS/METHODS

A survey was sent to 415 California radiation oncologists representing 144 clinics identified using the ASTRO member directory to gather information about clinic and radiation oncologist demographics, wildfires' impacts on the clinic (physical/operational), physicians, staff, and patients between 2017 and 2022, as well as clinics' disaster preparedness efforts.

RESULTS

A total of 51 radiation oncologists completed the survey, representing 43 clinics (30% of clinics) in 24 (41%) of California counties. 35 (69%) of respondents self-identified as male, 27 (53%) worked at hospital-affiliated centers, 19 (37%) worked in academic centers, with 49 (96%) practicing in metropolitan areas. A total of 31 clinics were impacted by a wildfire between 2017 and 2020. The two rural clinics (100%) and 29 (59%) of metro practices reported being impacted by wildfires in the last 5 years, with 9 (18%) reporting a clinic closure and 15 (29%) reporting staffing shortages. 28 (55%) of respondents reported impacts on patients including having to evacuate, 27 (53%) having to cancel or reschedule treatments, and 23 (45%) experiencing physical, mental, or financial hardship due to the wildfires. Among the 25 clinics impacted by wildfires, 12 (24%) reported physical/operational impacts including being forced to evacuate patients to another treatment center, transportation interruptions (19, 37%), community and regional evacuations (18, 35%), school closures (18, 35%), and physical/mental health impacts (14, 27%) on staff due to the wildfires. Small clinics (25 staff or less) that experienced a wildfire were twice as likely to experience closures (6 of 16 clinics, 38%) but equally likely to experience staffing shortages (8 of 16, 50 %) as compared to larger practices (7 of 15, 47%). Nearly half of respondents 25 (47%) reported their workplace had a wildfire emergency preparedness plan.

CONCLUSION

The results of this study demonstrate the significant impact wildfires have on patient care in both rural and metropolitan areas. The findings emphasize the importance of emergency preparedness planning to minimize the consequences of such disasters and underscores the need for further research to explore risk factors associated with patient and community vulnerability to climate-related crises. Such research will be essential to informing and developing future emergency preparedness plans.

Assessment of artificial intelligence-based remote monitoring of clear aligner therapy: A prospective study

INTRODUCTION

Artificial intelligence remote monitoring of clear aligner therapy has recently gained popularity. It uses deep learning algorithms on a patient's mobile smartphone to determine readiness to progress to the next aligner (ie, GO vs NO-GO) and identify areas in which the teeth are not tracking with the clear aligners. This study aimed to assess the repeatability of the Go or No-Go instructions provided by the application and to determine the 3-dimensional discrepancies that constitute an unseat.

METHODS

Thirty patients in treatment with clear aligners at an academic clinic were scanned twice using a remote monitoring application on a smartphone, and the results were compared. Gauge repeatability and reproducibility analysis were performed. Intraoral and remote monitoring scans were obtained on the same day from 24 additional clear aligner patients that completed treatment using their final aligners. The intraoral scan after using the final aligner and the stereolithography file of the planned position at the final aligner was compared with measure the maximum discrepancies between the actual and planned position of the teeth.

RESULTS

Gauge compatibility of 44.7% was noted. In total 83.3% of patient instructions agreed between Scan 1 and 2, but 0% agreed completely on which and/or how many teeth had tracking issues. Patients who received GO instruction had mean greatest discrepancies of 1.997 mm, 1.901 mm, 0.530 mm, 8.911°, 7.827°, and 7.049° in mesiodistal, buccolingual, occlusogingival, tip, torque, and rotational dimensions, respectively. These discrepancies were not significantly different from patients receiving NO-GO instruction (1.771 mm, 1.808 mm, 0.606 mm, 8.673°, 8.134°, and 6.719° for the corresponding categories).

CONCLUSIONS

Despite the study's limitations, these findings suggest concerns with the consistency of remote monitoring instructions because of gauge compatibility over the industry standard. Similarly, large discrepancies in tooth position for patients receiving GO and NO-GO instruction suggest that artificial intelligence decisions were inconsistent with quantitative findings.

Abstract C071: Keratin 17 excludes CD8-positive T cells and recruits CD163-positive macrophages in pancreatic ductal adenocarcinoma

Background: Keratin 17 (K17) is a negative prognostic biomarker, overexpressed in the biologically most aggressive forms of pancreatic ductal adenocarcinoma (PDAC). In other anatomic sites and disease processes, K17 expression also correlates with immune cell infiltrates and could block T-cell infiltration. Thus, we hypothesized that K17 expression correlates with the inflammatory microenvironment in PDAC. In this study, we aimed to determine the relationship between the stromal immune cell infiltrates and K17 expression, using multiplexed immunohistochemistry (mIHC) and our suite of deep learning tools to quantitatively evaluate the expression of four biomarkers of T-cells and macrophages in PDAC. Methods: mIHC was performed on representative sections of 201 primary PDACs from Stony Brook University Hospital, Thomas Jefferson University Hospital, Cedars Sinai Medical Center, and from a national cohort (KYT, Pancreatic Cancer Action Network, and Perthera). Antibodies for CD4 (helper T-cells), CD8 (cytotoxic T-cells), CD16 (pan-macrophage), CD163 (M2 macrophages), pancytokeratin, and K17 were provided by Roche Diagnostics Corporation through a sponsored research agreement. mIHC was performed on a Discovery Ultra Autostainer (Roche), using horseradish peroxidase (HRP) and alkaline phosphatase (AP)-based protocols with multiple chromogens (Red: CD4, Purple: CD8, Yellow: CD16, Green: CD163, Teal: pancytokeratin, and Brown: K17) to enable multispectral imaging of diverse immune cell populations within the cancer microenvironment. A deep learning analysis workflow was used to detect and classify stromal inflammatory cells, in whole slide images (WSIs), generated using an Olympus VS120 digital microscope (Olympus, Tokyo, Japan). Pixel-wise predictions from a color auto-encoder (ColorAE) union UNET anchor UNET model were combined to create multi-class masks that were further analyzed to perform detection and classification. Results: The analysis of the inflammatory microenvironment focused on defining immune cell infiltrates located within 25 microns of the closest K17-positive versus K17-negative tumor cell in each representative section. Across the sum of K17-positive and negative zones/section, CD4 cell counts ranged from 0-10,617 (mean 2,709), CD8 cell counts ranged from 63-28,596 (mean 6,745), CD16 cell counts ranged from 4-7,797 (mean 3,024), and CD163 cell counts ranged from 35-34,696 (mean 14,968). CD4 T-helper cells, CD8 cytotoxic T cells, and CD16 macrophages were more numerous (respectively, p=0.0012; p=&lt;0.0001; p=&lt;0.0001) in K17-negative tumor zones compared to K17-positive zones. By contrast, the number of CD163 (M2) tumor-promoting macrophages was greater in K17 positive zones (p=0.0019). Conclusion: K17 expression by tumor cells impacts the chronic inflammatory microenvironment, shielding tumor cells from immune cell mediated cytotoxic responses, while recruiting tumor-promoting M2 macrophages, indicating that K17 impacts the immune response as a fundamental hallmark of aggression in PDAC.

Citation Format: Lyanne Oblein, Michael Horowitz, Mahmudul Hasan, Sruthi Babu, Mariana Torrente-Goncalves, Lucia Roa, Jaymie Oentoro, Jason Harper, Xin Yao Zheng, Wei Jiang, Andrew Hendifar, Natalie Moshayedi, Brent Larson, Veronica Placencio-Hickok, Edik Blais, Emmanuel Petricoin, Joel Saltz, Natalia D. Marchenko, Luisa F. Escobar-Hoyos, Kenneth Shroyer. Keratin 17 excludes CD8-positive T cells and recruits CD163-positive macrophages in pancreatic ductal adenocarcinoma [abstract]. In: Proceedings of the AACR Special Conference on Pancreatic Cancer; 2022 Sep 13-16; Boston, MA. Philadelphia (PA): AACR; Cancer Res 2022;82(22 Suppl):Abstract nr C071.

Anti-EGFR Therapy Induces EGF Secretion by Cancer-Associated Fibroblasts to Confer Colorectal Cancer Chemoresistance

Targeted agents have improved the efficacy of chemotherapy for cancer patients, however, there remains a lack of understanding of how these therapies affect the unsuspecting bystanders of the stromal microenvironment. Cetuximab, a monoclonal antibody therapy targeting the epidermal growth factor receptor (EGFR), is given in combination with chemotherapy as the standard of care for a subset of metastatic colorectal cancer patients. The overall response to this treatment is underwhelming and, while genetic mutations that confer resistance have been identified, it is still not known why this drug is ineffective for some patients. We discovered that cancer-associated fibroblasts (CAFs), a major cellular subset of the tumor stroma, can provide a source of cancer cell resistance. Specifically, we observed that upon treatment with cetuximab, CAFs increased their secretion of EGF, which was sufficient to render neighboring cancer cells resistant to cetuximab treatment through sustained mitogen-activated protein kinases (MAPK) signaling. Furthermore, we show the cetuximab-induced EGF secretion to be specific to CAFs and not to cancer cells or normal fibroblasts. Altogether, this work emphasizes the importance of the tumor microenvironment and considering the potential unintended consequences of therapeutically targeting cancer-driving proteins on non-tumorigenic cell types.

Determination of Methylcellulose and Hydroxypropyl Methylcellulose Food Gums in Food and Food Products: Collaborative Study

A collaborative study was performed to determine the reproducibility of a method for the determination of methylcellulose (MC) and hydroxypropyl methylcellulose (HPMC) in food. These widely used food gums possess unusual solubility characteristics and cannot accurately be determined by existing dietary fiber methods. The new method uses the enzyme-digestion procedure of AOAC Official Method 991.43. Digestate solutions must be refrigerated to fully hydrate MC or HPMC. The chilled solutions are filtered and analyzed by size-exclusion liquid chromatography. Collaborating laboratories received 28 samples containing MC or HPMC in the range of 0100%. The sample set included blind duplicates of 5 food matrixes (bread, milk, fish, potato, and powdered juice drink). Cochran and Grubbs tests were used to eliminate outliers. For food samples containing MC, values for within-laboratory precision, repeatability relative standard deviation (RSDr), ranged from 4.2 to 16%, and values for among-laboratories precision, reproducibility relative standard deviation (RSDR), ranged from 11 to 20%. For HPMC samples, RSDr values ranged from 6.4 to 27%, and RSDR values ranged from 17 to 39%. Recoveries of MC and HPMC from the food matrixes ranged from 78 to 101%. These results show acceptable precision and reproducibility for the determination of MC and HPMC, for which no Official AOAC Methods exist. It is recommended that this method be adopted as AOAC Official First Action.

First Reported Case of a Well-Differentiated Neuroendocrine Tumor (WDNET) Arising Within Diffuse Ganglioneuromatosis (DGN) in a Patient With Neurofibromatosis Type 1 (NF-1)

Case Report

A 51-year-old female with NF-1 underwent flexible sigmoidoscopy, which revealed a 1.8-cm mass in the upper rectum. The noncircumferential mass was located predominantly at the posterior rectal wall and was suspicious for a neurofibroma. The biopsy revealed a WDNET arising in a ganglioneuroma that extended to the edges of the biopsy tissue. The patient underwent a segmental resection, and sections revealed residual grade 1 WDNET intimately admixed with DGN. The area of DGN also showed multifocal microscopic clusters of neuroendocrine cells limited to the lamina propria.

Discussion

NF-1 involves the gastrointestinal tract in 10% to 25% of affected individuals. DGN is a poorly circumscribed, frequently transmural gastrointestinal lesion composed of spindled and ganglion cells that may be seen in PTEN hamartomatous tumor syndrome, multiple endocrine neoplasia syndrome type 2B, and (less commonly) NF-1. Though malignant transformation of neurofibromas to malignant peripheral nerve sheath tumors is well documented in NF-1, malignant transformation of DGN is extremely rare. To our knowledge, this is the first reported case of a WDNET arising in DGN.

In addition to being the first reported case of WDNET in this setting, this is the first case to describe microscopic neuroendocrine cell nests in DGN. Similar proliferations have been described in the setting of inflammatory bowel disease, termed microcarcinoid or neuroendocrine cell micronests, which are not thought to have malignant potential. However, given the presence of these microscopic neuroendocrine cell nests within the larger DGN lesions and adjacent to the WDNET, we hypothesize that in the setting of NF-1, microscopic neuroendocrine cell clusters may serve as a precursor of WDNET. While this is a rare situation, these novel findings should prompt careful examination for WDNET and microscopic neuroendocrine cell nests in future cases of DGN.

Three-dimensional treatment outcomes in Class II patients with different vertical facial patterns treated with the Herbst appliance

INTRODUCTION

The aims of this study were to evaluate, using 3-dimensional superimposition techniques, the skeletal changes in Class II subjects with different vertical facial patterns treated with the Herbst appliance and to compare these skeletal changes to those of Class II controls treated with elastics.

METHODS

Sixteen Herbst patients who met the inclusion criteria were divided into 2 equal groups based on vertical facial pattern as determined by the Frankfort mandibular plane angle (brachyfacial, ≤22°; mesofacial, 23°-29°) and had cone-beam computed tomographs taken before treatment, 8 weeks after Herbst appliance removal, and after subsequent fixed appliance treatment. Eleven Class II control patients treated with fixed appliances and elastics had cone-beam computed tomographs taken before and after treatment. Three-dimensional models were generated from the cone-beam computed tomography images, registered on the anterior cranial bases, and analyzed using color maps and point-to-point measurements.

RESULTS

There were minimal differences in treatment response between the 2 Herbst groups across all skeletal parameters measured. The Herbst subjects showed a greater inferior displacement of anterior nasal spine compared with the Class II controls (Herbst brachyfacial, -1.44 mm; Herbst mesofacial, -1.95 mm) with other maxillary changes being clinically insignificant. The Herbst subjects showed greater inferior displacement of B-point compared with the Class II controls (Herbst brachyfacial, -2.59 mm; Herbst mesofacial, -2.75 mm). There were no statistically significant differences in mean linear mandibular measurements. All groups showed a trend toward posterior displacement of the condyles and glenoid fossae from the start to the end of treatment, with no significant differences across the 3 groups. There were minimal differences in the changes in gonial angle and Frankfort mandibular plane angle across all groups.

CONCLUSION

Approximately 2 years after Herbst treatment, the Herbst subjects with different vertical facial patterns showed similar patterns of skeletal change compared with the Class II controls treated with elastics.

Cadherin-11 Is a Cell Surface Marker Up-Regulated in Activated Pancreatic Stellate Cells and Is Involved in Pancreatic Cancer Cell Migration

Chronic pancreatitis is a prominent risk factor for the development of pancreatic ductal adenocarcinoma. In both conditions, the activation of myofibroblast-like pancreatic stellate cells (PSCs) plays a predominant role in the formation of desmoplastic reaction through the synthesis of connective tissue and extracellular matrix, inducing local pancreatic fibrosis and an inflammatory response. Yet the signaling events involved in chronic pancreatitis and pancreatic cancer progression and metastasis remain poorly defined. Cadherin-11 (Cad-11, also known as OB cadherin or CDH11) is a cell-to-cell adhesion molecule implicated in many biological functions, including tissue morphogenesis and architecture, extracellular matrix-mediated tissue remodeling, cytoskeletal organization, epithelial-to-mesenchymal transition, and cellular migration. In this study, we show that, in human chronic pancreatitis and pancreatic cancer tissues, Cad-11 expression was significantly increased in PSCs and pancreatic cancer cells. In particular, an increased expression of Cad-11 can be detected on the plasma membrane of activated PSCs isolated from chronic pancreatitis tissues and in pancreatic cancer cells metastasized to the liver. Moreover, knockdown of Cad-11 in cancer cells reduced pancreatic cancer cell migration. Taken together, our data underline the potential role of Cad-11 in PSC activation and pancreatic cancer metastasis.

Infective Endovascular Fibrin Sheath Vegetations—A New Cause of Bacteremia Detected by Transesophageal Echocardiogram

BACKGROUND/PURPOSE

A fibrin sheath is a circumferential sleeve of endothelium that forms around the surface of implanted central venous catheters and frequently remains intact within the lumen of the vein after removal of the catheters. We describe a new entity of infective endovascular fibrin sheath vegetations.

METHODS

Records of patients hospitalized and found to have echocardiographically identified infective endovascular fibrin sheath vegetations at our institution, Cedars Sinai Medical Center, from 2010 to 2014 were reviewed for clinical variables of interest. Collected data included medical history, physical examination findings, laboratory, microbiology, imaging, a prior history of presence of a central venous catheter, treatment, and outcomes.

RESULTS

Eleven patients (20-77 years old; 6 women, 5 men) were found by transesophageal echocardiogram to have fibrin sheaths. All of the infective endovascular fibrin sheath vegetations were identified by transesophageal echocardiography, while none were seen with transthoracic echocardiography. Eight of 11 patients were critically ill, septic, and admitted to the Intensive Care Unit. Six patients were intubated and required vasopressor therapy. All cases were treated with long-term antibiotics, 5 were treated with anticoagulation, and 2 were treated with mechanical thrombectomy. Mortality was 36%, with death ranging from 44 to 251 days after diagnosis. The 90-day hospital readmission rate was 55%.

CONCLUSION

Infective endovascular fibrin sheath vegetations are not seen with transthoracic echocardiogram. They may be overlooked and not seen by transesophageal echocardiogram unless the vena cava is adequately imaged. Moreover, fibrin sheath vegetations are associated with a high morbidity and mortality. They should be treated as a serious endovascular infection and managed with aggressive medical or interventional therapies, or both.

Fulminant clostridium difficile colitis: comparing computed tomography with histopathology: are they concordant?

A Total abdominal colectomy (TAC) is recommended for fulminant Clostridium difficile colitis (FCDC) because intraoperative assessment of diseased segments is inaccurate. To determine whether computerized tomography (CT) provides an accurate assessment of disease, we examined the concordance between CT and histopathologic colitis distribution in patients undergoing TAC for FCDC. The ileocolon was divided into seven distinct segments. Of 20 patients meeting criteria, the median interval between preoperative CT and TAC was 1.5 days (range, 0 to 23 days), and mortality was 65 per cent. The CT distribution of colitis was pancolitis in 12 patients and segmental in eight. Nine of the 12 patients with CT pancolitis had histologic pancolitis (75% concordance). Four of the eight patients with CT-diagnosed segmental disease had histologic segmental disease (50% concordance). For patients with FCDC, the distribution of colitis on CT agrees with the histopathologic extent of disease in the majority of patients. However, discordance between CT and histologic extent of disease was present in 25 to 50 per cent of patients. Therefore, the recommendation for TAC rather than segmental resection for FCDC remains justified.

Fulminant Clostridium difficile Colitis: Comparing Computed Tomography with Histopathology: Are They Concordant?

A Total abdominal colectomy (TAC) is recommended for fulminant Clostridium difficile colitis (FCDC) because intraoperative assessment of diseased segments is inaccurate. To determine whether computerized tomography (CT) provides an accurate assessment of disease, we examined the concordance between CT and histopathologic colitis distribution in patients undergoing TAC for FCDC. The ileocolon was divided into seven distinct segments. Of 20 patients meeting criteria, the median interval between preoperative CT and TAC was 1.5 days (range, 0 to 23 days), and mortality was 65 per cent. The CT distribution of colitis was pancolitis in 12 patients and segmental in eight. Nine of the 12 patients with CT pancolitis had histologic pancolitis (75% concordance). Four of the eight patients with CT-diagnosed segmental disease had histologic segmental disease (50% concordance). For patients with FCDC, the distribution of colitis on CT agrees with the histopathologic extent of disease in the majority of patients. However, discordance between CT and histologic extent of disease was present in 25 to 50 per cent of patients. Therefore, the recommendation for TAC rather than segmental resection for FCDC remains justified.

Detection of skin cancer margins in Mohs excisions with high-speed strip mosaicing confocal microscopy: a feasibility study

BACKGROUND

Fluorescence confocal mosaicing microscopy is an emerging technology for rapid imaging of nuclear and morphological detail directly in excised tissue, without the need for frozen or fixed section processing. Basal cell carcinomas (BCCs) can be detected with high sensitivity and specificity in Mohs excisions with this approach. For translation to clinical trials and towards potentially routine implementation, a new and faster approach called strip mosaicing confocal microscopy was recently developed.

OBJECTIVES

To perform a preliminary assessment of fluorescence strip mosaicing confocal microscopy for detecting skin cancer margins in Mohs excisions.

METHODS

Tissue samples from 17 Mohs cases were imaged in the form of strip mosaics. Each mosaic was divided into two halves (submosaics) and graded by a Mohs surgeon and a dermatologist who were blinded to the pathology. The 34 submosaics were compared with the corresponding Mohs pathology.

RESULTS

The overall image quality was excellent for resolution, contrast and stitching in the 34 submosaics. Components of normal skin including the epidermis, dermis, dermal appendages and subcutaneous tissue were easily visualized. The preliminary measures of sensitivity and specificity were both 94% for detecting skin cancer margins.

CONCLUSIONS

The new strip mosaicing approach represents another advance in confocal microscopy for imaging of large areas of excised tissue. Strip mosaicing may enable rapid assessment of BCC margins in fresh excisions during Mohs surgery and may serve as an adjunct to frozen pathology.

Three-dimensional treatment outcomes in Class II patients treated with the Herbst appliance: a pilot study

INTRODUCTION

The aims of this study were to analyze 3-dimensional skeletal changes in subjects with Class II malocclusion treated with the Herbst appliance and to compare these changes with treated Class II controls using 3-dimensional superimposition techniques.

METHODS

Seven consecutive Herbst patients and 7 Class II controls treated with Class II elastics who met the inclusion criteria had cone-beam computed tomographs taken before treatment, and either after Herbst removal or at posttreatment for the control subjects. Three-dimensional models were generated from the cone-beam computed tomography images, registered on the anterior cranial bases, and analyzed using color maps and point-to-point measurements.

RESULTS

The Herbst patients demonstrated anterior translation of the glenoid fossae and condyles (right anterior fossa, 1.69 ± 0.62 mm; left anterior fossa, 1.43 ± 0.71 mm; right anterior condyle, 1.20 ± 0.41 mm; left anterior condyle, 1.29 ± 0.57 mm), whereas posterior displacement predominated in the controls (right anterior fossa, -1.51 ± 0.68 mm; left anterior fossa, -1.31 ± 0.61 mm; right anterior condyle, -1.20 ± 0.41 mm; left anterior condyle, -1.29 ± 0.57 mm; P <0.001). There was more anterior projection of B-point in the Herbst patients (2.62 ± 1.08 mm vs 1.49 ± 0.79 mm; P <0.05). Anterior displacement of A-point was more predominant in the controls when compared with the Herbst patients (1.20 ± 0.53 mm vs -1.22 ± 0.43 mm; P <0.001).

CONCLUSIONS

Class II patients treated with the Herbst appliance demonstrated anterior displacement of the condyles and glenoid fossae along with maxillary restraint when compared with the treated Class II controls; this might result in more anterior mandibular projection.

Abstract P2-03-03: Feasibility of evaluation of breast tissue using confocal microscopy with strip mosaicing

Background: Confocal microscopic strip mosaicing (CSM) provides noninvasive optical sectioning and high resolution, which allows for imaging of nuclear and morphological detail in freshly excised tissue. CSM can image large areas of tissue at micron-level resolution in minutes, which may offer an advantage over standard histology that requires days. We have conducted a preliminary investigation of the feasibility of this technology for the evaluation of breast tissue from surgical excision specimens.

Design: In a prospective study, 80 fresh human breast tissue samples from surgical excision specimens of 24 patients were imaged using a prototype confocal strip scanner. Fresh tissue specimens were immersed in Acridine Orange (AO) for 45 seconds to stain the nuclei, then pressed against the glass imaging window and imaged with a 30X, 0.75 numerical aperture (measured) objective lens and a 488 nm laser. Images were acquired in two modes of contrast: in fluorescence (with AO), showing nuclear morphology, and in reflectance (endogenous), showing stroma. The use of fluorescence for nuclear staining mimics the use of hematoxylin in pathology, and the use of reflectance eosin. Use of two contrast modes allows the fluorescence image to be colorized purple and the reflectance image pink, producing confocal strip mosaics that mimic H&E histology in appearance. Specimens were subsequently fixed in formalin and routinely processed to obtain H&E stained sections. H&E and confocal images were compared by the study pathologist (M.M.)

Results: Freshly excised breast tissue samples as large as 2 cm x 2 cm were imaged in less than five minutes, with 1-micron resolution and measured optical sectioning of 6 microns. We compared the CSM images against standard histopathology images. In our series we evaluated the following histologies: 12 invasive carcinoma (11 ductal, 1 lobular), 3 ductal carcinoma in-situ, 3 lobular carcinoma in situ, 1 atypical lobular hyperplasia, 1 atypical ductal hyperplasia and various benign lesions such as fat necrosis, fibrocystic changes, and ductal hyperplasia. In confocal images invasive and in situ carcinoma as well as benign ducts and lobules were distinguished from surrounding stromal tissue. Limitations that are typically encountered in standard histology, such as distinguishing low grade ductal carcinoma in situ (DCIS) from lobular carcinoma in situ (LCIS) or atypical proliferations were encountered in the grayscale confocal images as well.

Conclusion: In this initial feasibility study, CSM produced images that could be diagnosed as benign or neoplastic by the study pathologist. Further study is needed to build an image library of breast histology and compare reproducibility of histologic diagnoses between CSM (grayscale and colorized images) and traditional optical microscopy, and assess interobserver reproducibility in diagnosis. CSM potentially provides rapid and noninvasive evaluation of breast parenchyma, and has a potential application for intraoperative margin assessment of resected breast specimens.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P2-03-03.

Producer survey of bird-livestock interactions in commercial dairies

The objective of this producer survey was to identify and estimate damage caused by bird-livestock interactions in commercial dairies. The interactions between birds and livestock have previously been implicated in causing economic damage while contributing to the environmental dissemination of microorganisms pathogenic to livestock and humans. Very little research exists to help producers understand what bird species use dairies, why they use dairies, or the scope and nature of damage created as a result of bird-livestock interactions. To better characterize these interactions, we surveyed dairy operators within Pennsylvania, New York, and Wisconsin. Survey results suggest that the most common and destructive bird species found on commercial dairies are invasive to North America, and their use of dairies is associated with the loss of cattle feed, increased operating costs, and an increase in dairies self-reporting Salmonella spp. and Mycobacterium avium ssp. paratuberculosis. Cattle feed loss estimates generated from this survey were used to parameterize an input-output (IO) economic model using data from 10 counties in the state of Pennsylvania (Bedford, Berks, Blair, Bradford, Chester, Cumberland, Franklin, Lancaster, Lebanon, and Somerset). This IO model allowed us to estimate direct, indirect, and induced economic effects of feed loss from bird damage to dairies within these counties. The IO model output suggests that feed loss costs Pennsylvania between $4.11 and $12.08 million (mean $10.6 million) in total economic damage, with approximately 43 to 128 jobs (mean 112) forgone statewide in 2009.

Early prediction of 30-day mortality after Q-wave myocardial infarction by echocardiographic assessment of left ventricular function--a pilot investigation

BACKGROUND

The GUSTO angiographic substudy demonstrated that left ventricular function measured 90 min after thrombolytic therapy was given had important prognostic implications at 30 days in patients with an acute myocardial infarction (MI).

HYPOTHESIS

Thirty-day prognosis after Q-wave MI can be determined by early echocardiographic assessment of left ventricular function.

METHODS

Using transthoracic echocardiography, semiquantitative ejection fraction and wall motion score index was assessed prospectively in 201 consecutive patients within 24 h following Q-wave MI. Independent experts blinded to the patient's status performed the echocardiographic assessment. All patients received standard medical care as dictated by the attending cardiologist.

RESULTS

Of the 201 patients, 24 (11.9%) died within 30 days, with 70% of the deaths occurring within 10 days after the infarction. Three deaths occurred in the 120 patients with an ejection fraction > or = 45% (2.5% mortality rate). In contrast, 21 deaths occurred among the 81 patients with an ejection fraction <45% (25.9% mortality rate) p = 0.0003. Two of the three patients who died in the high ejection fraction group died as a result of intracerebral hemorrhage from thrombolytic therapy. Ejection fraction was lower in nonsurvivors (32.3+/-10.3 vs. 46.3+/-13%) than in survivors, p < 0.0002. Wall motion score index (WMSI) of < 1.4 was associated with a 2.9% 30-day mortality (two deaths in 76 patients); WMSI of > or = 1.4 was associated with a 17.6% 30-day mortality (22 deaths in 125 patients), p = 0.0007. Average WMSI was higher in the nonsurvivors (1.95+/-0.5) than in survivors (1.52+/-0.45), p = 0.00001.

CONCLUSIONS

Echocardiographic assessment of left ventricular function during the first 24 h after an acute Q-wave MI can be performed in all patients regardless of stability. High-risk patients are identified early in the hospital course, with relative ease, at no risk and at an acceptable cost. An ejection fraction < 45% or WMSI > or = 1.4 identifies patients who are at a high risk of dying within 30 days. These are the patients who may benefit most from aggressive medical therapy and early angiography to assess coronary pathology.

Influence of physical activity on urinary leakage in primiparous women

The impact of physical activity on urinary leakage (UL) has previously been considered, but not in relation to first pregnancy and delivery. The aim of this study was to describe physical activity and urinary leakage before, during and after the first childbirth. The subjects who were invited to participate in the study were taken consecutively from nine maternity clinics in the northwest part of Stockholm County, and the study group included 665 primiparous women. The mean age of the women was 28 (range 17-43) years. The women answered one questionnaire during the 36th gestation week and another 1 year post partum. Physical activity/exercises were classified according to their impact on the pelvic floor, and the women were divided into three groups: high-impact exercise (n=327), low-impact exercise (n=84) and the inactive group (n=254). The results showed a high intensity and frequency of physical activity in the participating primiparous women. Risk factors for UL were symptoms of a dysfunctional pelvic floor and connective tissue disorders and high-impact physical activity before pregnancy, while low-impact activity seemed to promote continence. If urinary leakage was present before pregnancy, it persisted in most women during pregnancy and 1 year post partum.

Quantitative analyses of GFRα-1 and GFRα-2 mRNAs and tyrosine hydroxylase protein in the nigrostriatal system reveal bilateral compensatory changes following unilateral 6-OHDA lesions in the rat

Copy numbers of mRNAs for GFRalpha-1 and GFRalpha-2, the preferred receptors for glial cell line-derived neurotrophic factor (GDNF) and neurturin (NTN) were determined by real-time quantitative RT-PCR (QRT-PCR). Receptor expression was assessed in striatum (ST) and substantia nigra (SN) of normal rats and rats acutely or progressively lesioned by 6-OHDA injected into the medial forebrain bundle or ST, respectively. GFRalpha-1 mRNA was clearly detected in normal ST. In normal SN, significantly higher expression of both receptors was observed. At 4 weeks after acute lesion, GFRalpha-2 mRNA was markedly decreased in SN bilaterally, whereas GFRalpha-1 mRNA in SN and ST was not affected. A progressive lesion resulted in a progressive decrease of GFRalpha1 mRNA in ST bilaterally. In SN, levels of GFRalpha-1 mRNA were not significantly affected by a progressive lesion, whereas GFRalpha-2 mRNA was markedly decreased bilaterally. Quantitative western blotting standardized against tyrosine hydroxylase (TH) protein from PC12 cells revealed the expected decrease in TH protein in lesioned SN, but also significant increases in TH protein in contralateral, unlesioned SNs at 4 weeks after both acute and progressive lesions. These data suggest that previously unrecognized compensatory changes in the nigrostriatal system occur in response to unilateral dopamine depletion. Since the changes observed in receptor expression did not always parallel loss of dopamine neurons, cells in addition to the nigral dopamine neurons appear to be affected by a 6-OHDA insult and are potential targets for the neurotrophic factors, GDNF and NTN.

Prevalence of urinary leakage in nulliparous women with respect to physical activity and micturition habits

In order to survey the influence of physical activity and micturition habits on urinary leakage (UL) in women before their first pregnancy, a study including 725 women attending nine maternity clinics in the northwest area of Stockholm was performed. During the 36th gestational week the women answered a questionnaire regarding the pre-pregnancy situation regarding UL, micturition habits and physical activity. Thirty-nine percent of the women, mean age of 28 (range 17-43) years, had experienced occasional UL. Of these, the majority (79%) had symptoms of stress urinary leakage and 21% had urge symptoms. Two percent were incontinent according to the definition of the International Continence Society (ICS). In a multivariate analysis age, inability to interrupt the urine flow and high-impact physical activity turned out to be independent risk factors for UL and thus should be observed together with traditional factors concerning UL in nulliparous women.

Preoperative treatment of anemic women with epoetin beta

AIM

To compare the effects of preoperative treatment with recombinant human erythropoietin (EPO) and iron with iron only on hemoglobin levels (Hb) in anemic women prior to hysterectomy.

METHODS

The study was an open-labelled randomized parallel study. Fifteen women scheduled for hysterectomy due to uterine myoma were given oral iron and EPO (NeoRecormon) 4 weeks prior to surgery (group I) and 16 women were given oral iron only (group II).

RESULTS

Group I showed a significantly greater increase in mean Hb during the pre-surgery study period compared with group II (p=0.007). Two weeks postoperatively, however, there was no significant difference in mean Hb between the two groups.

CONCLUSION

We found that a significantly greater increase in Hb was achieved with iron in combination with EPO, although in most cases iron only seemed to be as efficacious as iron+EPO in correcting anemia in myoma patients pre-operatively.

Preoperative treatment of anemic women with epoetin beta

AIM

To compare the effects of preoperative treatment with recombinant human erythropoietin (EPO) and iron with iron only on hemoglobin levels (Hb) in anemic women prior to hysterectomy.

METHODS

The study was an open-labelled randomized parallel study. Fifteen women scheduled for hysterectomy due to uterine myoma were given oral iron and EPO (NeoRecormon) 4 weeks prior to surgery (group I) and 16 women were given oral iron only (group II).

RESULTS

Group I showed a significantly greater increase in mean Hb during the pre-surgery study period compared with group II (p=0.007). Two weeks postoperatively, however, there was no significant difference in mean Hb between the two groups.

CONCLUSION

We found that a significantly greater increase in Hb was achieved with iron in combination with EPO, although in most cases iron only seemed to be as efficacious as iron+EPO in correcting anemia in myoma patients pre-operatively.

Quantitative analysis of transgene protein, mRNA, and vector DNA following injection of an adenoviral vector harboring glial cell line-derived neurotrophic factor into the primate caudate nucleus

Gene therapy for neurodegenerative diseases relies on stable expression of a vector-mediated transgene in the human central nervous system (CNS). In nonhuman primate CNS, transgene expression has been primarily assessed using descriptive histological methods. Here, we quantified the expression of a human glial cell line-derived neurotrophic factor (hGDNF) transgene using an ELISA specific for hGDNF protein and real-time quantitative RT-PCR and PCR for hGDNF mRNA and vector DNA, respectively. Transgene expression was assessed 1 week after injection of an E1-, E3-deleted adenovirus harboring hGDNF into the caudate nucleus of St. Kitts green monkey. We found that 57-147 million and 116-771 million copies of hGDNF mRNA and vector DNA, respectively, were present per 10,000 copies of the beta-actin gene. In the same sites, 40-152 pg of hGDNF protein per milligram of tissue was measured. Comparisons of these measures among monkeys demonstrated variable vector DNA and protein levels, but consistent mRNA levels at one-third of the level of vector DNA. This suggests that local responses to the vector play a role in the level of transgene expression and that high levels of vector DNA do not necessarily predict a high level of transgene protein. However, the results of this study do show that neuroprotective levels of GDNF transgene expression can be achieved following injection of an adenoviral vector into nonhuman primate caudate. Moreover, these assays provide quantitative methods for evaluating and comparing viral vectors in primate CNS.

Reasons that orthodontic faculty teach and consider leaving teaching

To assess reasons why orthodontic faculty consider leaving academia, a pretested questionnaire was mailed to 200 full-time (FT) and 200 part-time (PT) faculty randomly selected from the United States and Canada. A total of 144 (72 percent) of FT and 120 (60 percent) PT responded. About 38 percent FT and 25 percent PT were currently considering leaving academia. The average age of each group was about fifty years. Although significant differences were found in fifteen factors affecting the decision to leave, three factors ranked as most important (means> or =3.4) for FTs: salary support, financial support of department, and control over work or destiny. The three factors most important (means>3. 1) for PTs were: challenge of private practice, family commitments, and personal. FT and PT were similar in the most important and least important factors influencing their initial reasons to teach and satisfaction in teaching. However, the reasons why FT considered leaving were work related, while the PT's reasons were more personal. With the current shortage of FT orthodontic faculty becoming imminently greater, it appears that work-related issues could be addressed directly by administration.

Primary reconstructive surgery with a sliding flap for carcinoma of the Bartholin gland

Bartholin gland tumours are rare and therefore recommendations concerning management have been based on small series. Although there is a tendency today to perform less radical surgery, meaning hemivulvectomy or a wide local excision, the anatomical position of these tumours often leads to a large postoperative defect. The objective of this report is to present data on three patients but mainly to describe our surgical technique where a sliding flap obtained from the gluteal region is used for primary closure. This surgical procedure offers a functional and cosmetically acceptable vulva which is of importance considering the relative young age of patients with Bartholin gland tumours.

Autonomic nervous influence of the female guinea-pig urinary bladder during the oestrus cycle

The mammalian urinary bladder receives dual innervation. The excitatory innervation is considered to be partly cholinergic and partly mediated via NANC-receptors. Several (co-)transmitters have been suggested. The adrenergic inhibitory innervation is mediated via alpha- and beta-receptors. Female sex hormones could change autonomic influence of urogenital organs. It was considered to be of interest to characterize the spontaneous and nerve stimulation-induced muscular activity in the urinary bladder of the female guinea-pig during the oestrus cycle. Both the spontaneous activity and nerve-induced activity varied according to the hormonal status of the animal. An alpha-adrenergic inhibitory influence was identified. It was further confirmed that the excitatory innervation could not be blocked by the cholinergic antagonist scopolamine, while alpha-beta-methylene ATP partly inhibited nerve stimulation-induced smooth muscle response, most prominent at cycle day 6. Indomethacin did not impair spontaneous activity or nerve stimulation-induced activity. Nitric oxide reduced nerve stimulation-induced responses on cycle day 12. Imperative urinary bladder contractions are reported to diminish after oestrogen use and in the female a hormonal effect of the nervous influence on the urinary bladder smooth muscle is suggested.

Urogenital and vasomotor symptoms in relation to menopausal status and the use of hormone replacement therapy (HRT) in healthy women during transition to menopause

OBJECTIVE

To investigate the relationship between climacteric status, hormonal levels, vasomotor symptoms, vaginal dryness and urinary incontinence in a cohort of healthy women during transition to menopause, and further to evaluate the effects of hormone replacement therapy on these symptoms.

METHODS

A total of 147 women were followed for 4 years during transition to menopause. They were all 49 years old when entering the study. Each annual visit included a general health screening, gynecological examination and blood sampling. The subjects were questioned about sociodemographic background, obstetric and gynecological history and they kept bleeding diary cards.

RESULTS

Urinary incontinence was reported by 57% at the first visit and decreased to 34% at the last visit. No correlation to hormonal levels or to the use of HRT (hormone replacement therapy) was seen, but parity was significantly (P = 0.05) correlated to urinary incontinence. Vaginal dryness occurred in 37% at the first visit. Vaginal dryness was experienced by 1/3 of the premenopausal women. Vasomotor symptoms were reported by 56% at the first visit and were associated with high levels of FSH and LH (P < 0.001 and P = 0.002, respectively). One third of premenopausal women reported on vasomotor symptoms. Hormone replacement therapy did not relieve hot flushes in these women.

CONCLUSIONS

Urogenital and vasomotor symptoms experienced by premenopausal women do not seem to be relieved by hormone replacement therapy.