Retrorectus mesh reinforcement of ileostomy site fascial closure: stoma closure and reinforcement (SCAR) trial phase I/II results.

PURPOSE: Loop ileostomy (LI) is commonly employed during colorectal surgeries to reduce the consequences of anastomotic leak. Unfortunately, LI is associated with a 10-30% incisional hernia (IH) rate after closure. We hypothesized that prophylactic mesh reinforcement during LI takedown would safely prevent subsequent IH formation. METHODS: This single-center, phase I/II prospective study evaluated adult patients undergoing LI closure after left-sided colorectal cancer procedures. After LI closure, the posterior rectus sheath was mobilized and reapproximated with absorbable suture. A reduced-weight, macroporous, polypropylene mesh (Softmesh, BD) was placed in the retrorectus position to allow 3 cm of overlap and secured with fibrin sealant. The anterior fascia was closed with slowly absorbable suture. CT images obtained for cancer surveillance were reviewed by a radiologist blinded to the study intervention to evaluate for evidence of hernia or surgical site occurrence (SSO). RESULTS: Twenty patients were included with mean defect and mesh sizes of 11.2 cm2 and 64.2 cm2, respectively. Mean operative time for LI takedown and mesh augmented closure was 84 min with mesh implantation time being 16.4 min. Two patients were readmitted within 30 days for ileus, no patient required procedural intervention. Over a mean follow-up period of 20 ± 7 months, no SSO or hernias were observed clinically or on CT imaging. CONCLUSION: In our small series, retromuscular mesh reinforcement of LI closure appears feasible, safe and effective. This mesh reinforcement approach should be further investigated to evaluate its long-term effectiveness.

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.

Observer variation in the detection of acetabular bone deficiencies.

To determine observer variation in the detection of acetabular bone deficiencies, 42 pairs of frontal (AP) and lateral hip radiographs and CT studies for total hip arthroplasty patients obtained within an average of 4 weeks of each other were reviewed separately by five radiologists and one orthopedic surgeon. Interobserver variations were calculated for each individual reading the films using kappa values. The individual film readings were then compared with a consensus reading of the CT data. When separate observers were analyzed, agreement on plain film readings was slight to fair (av. kappa = 0.1440 +/- 0.1047). The individual observers were not able to give readings which were very consistent with the CT consensus reading, resulting in a low sensitivity (65%) and specificity (74%) for acetabular defect classification with plain radiographs. The identification of acetabular bone defects from the AP and lateral views of the hip is highly subjective and variable from observer to observer.

Ligand-mediated conformational changes in Trp repressor protein of Escherichia coli probed through limited proteolysis and the use of specific antibodies.

Trp repressor of Escherichia coli K-12 is a dimeric protein (monomer size, 108 amino acids) that acquires high affinity for certain operator targets in double-stranded DNA upon interaction with L-tryptophan. High titer antiserum directed against E. coli Trp repressor protein, elicited in rabbits, was monospecific toward native or denatured Trp repressor. Using an enzyme-linked immunosorbent assay to measure antigen-antibody reaction, we found that the binding of L-tryptophan to Trp repressor was associated with a marked decrease in antibody reactivity that presumably accompanied a conformational change in this protein to a state with strong affinity for trp operator-bearing DNA. We analyzed the pattern of cleavage of Trp repressor by chymotrypsin and trypsin and the effect of L-tryptophan on such hydrolytic cleavages. Chymotrypsin cleaved Trp repressor mainly between residues 71 and 72. In the presence of L-tryptophan this cleavage was slowed. The first-order rate constants for chymotryptic digestion of Trp repressor were 7.6 X 10(-2) and 4.6 X 10(-2) min-1 in the absence and presence of L-tryptophan, respectively. Tryptic digestion was more complex. Initial cleavage of Trp repressor occurred with approximately equal facility between residues 69-70 or 84-85. Subsequent tryptic hydrolyses led eventually to a major core fragment containing the first 54 amino acids of Trp repressor plus four other fragments from the carboxyl-terminal half of the protein. In the presence of L-tryptophan, cleavage by trypsin between residues 54-55 and 84-85 was retarded, even when a previous hydrolytic event elsewhere in the protein had occurred. Tryptophan had essentially no effect on the tryptic hydrolysis of peptide bond 97-98, but accelerated cleavage at peptide bond 69-70. The first-order rate constants for the first tryptic cleavage of Trp receptor were 1.55 X 10(-1) and 1.33 X 10(-1) min-1 in the absence and presence of ligand, respectively. Our results are compatible with a structural model wherein certain amino acid side chains and peptide bonds of Trp repressor (specifically, those of residues 69-85) lie on or near the surface of the protein. This region of Trp repressor has been predicted to contain the operator recognition site. The susceptibility to proteolytic attack of at least four peptide bonds in this area changes when the protein interacts with L-tryptophan.

Chromium(VI)-induced DNA lesions and chromium distribution in rat kidney, liver, and lung.

DNA lesions were detected in rat organ nuclei following an i.p. injection of sodium dichromate. Kidney, liver, and lung nuclei were examined for DNA interstrand cross-links, strand breaks, and DNA-protein cross-links using the alkaline elution technique. The time course for formation of cross-links in kidney nuclei revealed the presence of DNA interstrand and DNA-protein cross-links 1 hr after injection of sodium dichromate. By 40 hr in kidney, DNA interstrand cross-links had been repaired, but DNA-protein cross-links persisted. In liver nuclei, the time course for formation of cross-links after injection of dichromate showed a maximum in DNA-protein cross-linking at 4 hr and a maximum in DNA interstrand cross-linking at 2 hr. By 36 hr, in the liver, both types of lesions had been repaired. In lung nuclei, both DNA interstrand and DNA-protein cross-links were observed 1 hr after dichromate injection; however, by 36 hr, only DNA-protein cross-links persisted. No DNA lesions were detectable in kidney 1 hr after an i.p. injection of chromium(III) chloride. Chromium distribution in rat kidney, liver, and lung was measured and is discussed with respect to the observed DNA lesions. The lung and kidney may be more sensitive than liver to chromium-induced DNA damage, an observation which correlates with the reported toxicity and carcinogenicity data for chromium(VI) in both animals and humans.

The interaction of chromium with nucleic acids.

Native and denatured calf thymus DNA, and homopolyribonucleotides were compared with respect to chromium and protein binding after an in vitro incubation with rat liver microsomes, NADPH, and chromium (VI) or chromium (III). A significant amount of chromium bound to DNA when chromium (VI) was incubated with the native or the denatured form of DNA in the presence of microsomes and NADPH. For both native and denatured DNA the amount of protein bound to DNA increased with the amount of chromium bound to DNA. Denatured DNA had much higher amounts of chromium and protein bound than native DNA. There was no interaction between chromium(VI) and either form of DNA in the absence of the complete microsomal reducing system. The binding of chromium(III) to native or denatured DNA was small and relatively unaffected by the presence of microsomes and NADPH. The binding of chromium and protein to polyriboadenylic acid (poly(A], polyribocytidylic acid (poly(C], polyriboguanylic acid (poly(G] and polyribouridylic acid (poly(U] was determined after incubation with chromium(VI) in the presence of microsomes and NADPH. The magnitude of chromium and protein binding to the ribopolymers was found to be poly(G) much greater than poly(A) approximately equal to poly(C) approximately equal to poly(U). These results suggest that the metabolism of chromium(VI) is necessary in order for chromium to interact significantly with nucleic acids. The metabolically-produced chromium preferentially binds to the base guanine and results in DNA-protein cross-links. These findings are discussed with respect to the proposed scheme for the carcinogenicity of chromium(VI).

The carcinogen chromate causes DNA damage and inhibits drug-mediated induction of porphyrin accumulation and glucuronidation in chick embryo hepatocytes.

DNA damage by chromate in chick embryo hepatocytes has been correlated with the effect of chromate on inducible cell functions. Treatment of chick embryo hepatocytes with chromium(VI) in the form of sodium chromate resulted in the rapid uptake of chromate and the induction of DNA lesions in a time- and concentration-dependent manner. DNA interstrand cross-links, strand breaks and DNA-protein crosslinks, as measured by the alkaline elution technique, were observed after treatment of the hepatocytes with chromate concentrations (2.5- 0 microM) which did not affect cell viability. The effect of chromate on inducible cell functions was measured by assaying propylisopropylacetamide-induced accumulation of porphyrin and glucuronidation of phenol red by intact cells. Chromate inhibited propylisopropylacetamide-induction of porphyrin accumulation and phenol red glucuronidation in a time- and concentration-dependent manner which paralleled DNA damage. DNA damage was removed and inducibility of porphyrin accumulation by propylisopropylacetamide plus deferoxamine methanesulfonate was restored 21 h following a 2 h pretreatment with chromate. Chromium(III) in the form of chromic nitrate at concentrations up to 25 times those used with chromate had no effect on DNA damage or the induction of porphyrin accumulation and phenol red glucuronidation by propylisopropylacetamide in the cultured chick hepatocytes.

The carcinogen chromate induces DNA cross-links in rat liver and kidney.

DNA cross-links were found in nuclei isolated from the liver and kidney of rats treated with chromate. A dose-dependent relationship between chromate exposure and total DNA cross-links was determined using the alkaline elution technique. DNA cross-links in kidney were mainly DNA-protein in nature. Chromate also induced a small amount of interstrand DNA cross-links in kidney. Liver nuclei contained protein-associated DNA single strand breaks in addition to DNA-protein cross-links. The organotropic DNA damage induced by chromate is discussed in relation to the carcinogenicity and toxicity of chromium(VI) compounds.