Novant Health Forsyth Medical Center

// Reza Bayat Mokhtari 1,2,4 , Tina S. Homayouni 1 , Narges Baluch 3 , Evgeniya Morgatskaya 1 , Sushil Kumar 1 , Bikul Das 4 and Herman Yeger 1,2 1 Developmental and Stem Cell Biology, The Hospital for Sick Children, Toronto, Ontario, Canada 2 Department of Paediatric Laboratory Medicine, The Hospital for Sick Children and Institute of Medical Science, University of Toronto, Toronto, Ontario, Canada 3 Department of Pathology and Molecular Medicine, Queen’s University, Kingston, Ontario, Canada 4 Department of Immunology and Infectious Diseases, The Forsyth Institute, Cambridge, Massachusetts, USA Correspondence to: Herman Yeger, email: // Reza Bayat Mokhtari, email: // Keywords : Nrf2-Keap1, HIF-1alpha, carbonic anhydrase 9 (CAIX), histone deacetylase inhibitor (HDACi), carbonic anhydrase inhibitor (CAI) Received : October 19, 2016 Accepted : February 27, 2017 Published : March 30, 2017 Abstract Combination therapy, a treatment modality that combines two or more therapeutic agents, is a cornerstone of cancer therapy. The amalgamation of anti-cancer drugs enhances efficacy compared to the mono-therapy approach because it targets key pathways in a characteristically synergistic or an additive manner. This approach potentially reduces drug resistance, while simultaneously providing therapeutic anti-cancer benefits, such as reducing tumour growth and metastatic potential, arresting mitotically active cells, reducing cancer stem cell populations, and inducing apoptosis. The 5-year survival rates for most metastatic cancers are still quite low, and the process of developing a new anti-cancer drug is costly and extremely time-consuming. Therefore, new strategies that target the survival pathways that provide efficient and effective results at an affordable cost are being considered. One such approach incorporates repurposing therapeutic agents initially used for the treatment of different diseases other than cancer. This approach is effective primarily when the FDA-approved agent targets similar pathways found in cancer. Because one of the drugs used in combination therapy is already FDA-approved, overall costs of combination therapy research are reduced. This increases cost efficiency of therapy, thereby benefiting the “medically underserved”. In addition, an approach that combines repurposed pharmaceutical agents with other therapeutics has shown promising results in mitigating tumour burden. In this systematic review, we discuss important pathways commonly targeted in cancer therapy. Furthermore, we also review important repurposed or primary anti-cancer agents that have gained popularity in clinical trials and research since 2012.

IMPORTANCE: Whole brain radiotherapy (WBRT) significantly improves tumor control in the brain after stereotactic radiosurgery (SRS), yet because of its association with cognitive decline, its role in the treatment of patients with brain metastases remains controversial. OBJECTIVE: To determine whether there is less cognitive deterioration at 3 months after SRS alone vs SRS plus WBRT. DESIGN, SETTING, AND PARTICIPANTS: At 34 institutions in North America, patients with 1 to 3 brain metastases were randomized to receive SRS or SRS plus WBRT between February 2002 and December 2013. INTERVENTIONS: The WBRT dose schedule was 30 Gy in 12 fractions; the SRS dose was 18 to 22 Gy in the SRS plus WBRT group and 20 to 24 Gy for SRS alone. MAIN OUTCOMES AND MEASURES: The primary end point was cognitive deterioration (decline >1 SD from baseline on at least 1 cognitive test at 3 months) in participants who completed the baseline and 3-month assessments. Secondary end points included time to intracranial failure, quality of life, functional independence, long-term cognitive status, and overall survival. RESULTS: There were 213 randomized participants (SRS alone, n = 111; SRS plus WBRT, n = 102) with a mean age of 60.6 years (SD, 10.5 years); 103 (48%) were women. There was less cognitive deterioration at 3 months after SRS alone (40/63 patients [63.5%]) than when combined with WBRT (44/48 patients [91.7%]; difference, -28.2%; 90% CI, -41.9% to -14.4%; P < .001). Quality of life was higher at 3 months with SRS alone, including overall quality of life (mean change from baseline, -0.1 vs -12.0 points; mean difference, 11.9; 95% CI, 4.8-19.0 points; P = .001). Time to intracranial failure was significantly shorter for SRS alone compared with SRS plus WBRT (hazard ratio, 3.6; 95% CI, 2.2-5.9; P < .001). There was no significant difference in functional independence at 3 months between the treatment groups (mean change from baseline, -1.5 points for SRS alone vs -4.2 points for SRS plus WBRT; mean difference, 2.7 points; 95% CI, -2.0 to 7.4 points; P = .26). Median overall survival was 10.4 months for SRS alone and 7.4 months for SRS plus WBRT (hazard ratio, 1.02; 95% CI, 0.75-1.38; P = .92). For long-term survivors, the incidence of cognitive deterioration was less after SRS alone at 3 months (5/11 [45.5%] vs 16/17 [94.1%]; difference, -48.7%; 95% CI, -87.6% to -9.7%; P = .007) and at 12 months (6/10 [60%] vs 17/18 [94.4%]; difference, -34.4%; 95% CI, -74.4% to 5.5%; P = .04). CONCLUSIONS AND RELEVANCE: Among patients with 1 to 3 brain metastases, the use of SRS alone, compared with SRS combined with WBRT, resulted in less cognitive deterioration at 3 months. In the absence of a difference in overall survival, these findings suggest that for patients with 1 to 3 brain metastases amenable to radiosurgery, SRS alone may be a preferred strategy. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00377156.

BACKGROUND: Alternative therapies for Staphylococcus aureus bacteremia and endocarditis are needed. METHODS: We randomly assigned 124 patients with S. aureus bacteremia with or without endocarditis to receive 6 mg of daptomycin intravenously per kilogram of body weight daily and 122 to receive initial low-dose gentamicin plus either an antistaphylococcal penicillin or vancomycin. The primary efficacy end point was treatment success 42 days after the end of therapy. RESULTS: Forty-two days after the end of therapy in the modified intention-to-treat analysis, a successful outcome was documented for 53 of 120 patients who received daptomycin as compared with 48 of 115 patients who received standard therapy (44.2 percent vs. 41.7 percent; absolute difference, 2.4 percent; 95 percent confidence interval, -10.2 to 15.1 percent). Our results met prespecified criteria for the noninferiority of daptomycin. The success rates were similar in subgroups of patients with complicated bacteremia, right-sided endocarditis, and methicillin-resistant S. aureus. Daptomycin therapy was associated with a higher rate of microbiologic failure than was standard therapy (19 vs. 11 patients, P=0.17). In 6 of the 19 patients with microbiologic failure in the daptomycin group, isolates with reduced susceptibility to daptomycin emerged; similarly, a reduced susceptibility to vancomycin was noted in isolates from patients treated with vancomycin. As compared with daptomycin therapy, standard therapy was associated with a nonsignificantly higher rate of adverse events that led to treatment failure due to the discontinuation of therapy (17 vs. 8, P=0.06). Clinically significant renal dysfunction occurred in 11.0 percent of patients who received daptomycin and in 26.3 percent of patients who received standard therapy (P=0.004). CONCLUSIONS: Daptomycin (6 mg per kilogram daily) is not inferior to standard therapy for S. aureus bacteremia and right-sided endocarditis. (ClinicalTrials.gov number, NCT00093067 [ClinicalTrials.gov].).

OBJECTIVE: Decades-old, common ICU practices including deep sedation, immobilization, and limited family access are being challenged. We endeavoured to evaluate the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. DESIGN: Prospective, multicenter, cohort study from a national quality improvement collaborative. SETTING: 68 academic, community, and federal ICUs collected data during a 20-month period. PATIENTS: 15,226 adults with at least one ICU day. INTERVENTIONS: We defined ABCDEF bundle performance (our main exposure) in two ways: 1) complete performance (patient received every eligible bundle element on any given day) and 2) proportional performance (percentage of eligible bundle elements performed on any given day). We explored the association between complete and proportional ABCDEF bundle performance and three sets of outcomes: patient-related (mortality, ICU and hospital discharge), symptom-related (mechanical ventilation, coma, delirium, pain, restraint use), and system-related (ICU readmission, discharge destination). All models were adjusted for a minimum of 18 a priori determined potential confounders. MEASUREMENTS AND RESULTS: Complete ABCDEF bundle performance was associated with lower likelihood of seven outcomes: hospital death within 7 days (adjusted hazard ratio, 0.32; CI, 0.17-0.62), next-day mechanical ventilation (adjusted odds ratio [AOR], 0.28; CI, 0.22-0.36), coma (AOR, 0.35; CI, 0.22-0.56), delirium (AOR, 0.60; CI, 0.49-0.72), physical restraint use (AOR, 0.37; CI, 0.30-0.46), ICU readmission (AOR, 0.54; CI, 0.37-0.79), and discharge to a facility other than home (AOR, 0.64; CI, 0.51-0.80). There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001). CONCLUSIONS: ABCDEF bundle performance showed significant and clinically meaningful improvements in outcomes including survival, mechanical ventilation use, coma, delirium, restraint-free care, ICU readmissions, and post-ICU discharge disposition.

The most common forms of destructive periodontal disease have been thought to slowly and continuously progress until treatment or tooth loss. Recently, data have become available which are inconsistent with this "continuous disease" hypothesis. Data from longitudinal monitoring of periodontal attachment levels and alveolar bone in humans and in animals suggest that periodontal disease progresses by recurrent acute episodes. In addition, rates of attachment loss have been measured in individual sites which are faster than those consistent with the continuous disease hypothesis or slower than those expected from estimates of prior loss rates. To account for these observations, a model of destructive periodontal disease is described in which bursts of activity occur for short periods of time in individual sites. These bursts appear to occur randomly at periodontal sites throughout the mouth. Some sites demonstrate a brief active burst of destructive periodontal disease (which could take a few days to a few months) before going into a period of remission. Other sites appear to be free of destructive periodontal disease throughout the individual's life. The sites which demonstrate destructive periodontal activity may show no further activity or could be subject to one or more bursts of activity at later time periods. Comparison of monitored loss rates for a year with mean loss rates prior to monitoring suggested that there may be relatively short periods in an individual's life in which many sites undergo periodontal destruction followed by periods of extended remission. An extension of the random disease model is also suggested in which bursts of destructive periodontal disease activity occur with higher frequency during certain periods of an individual's life.

Subgingival plaque samples were taken from active and inactive lesions in 33 subjects exhibiting active destructive periodontal diseases. Active diseased sites were those which showed a significant loss of attachment within a 2-month interval as computed by the "tolerance method". The predominant cultivable species from 100 active sites were compared with those found in 150 inactive sites of comparable pocket depth and attachment level loss. Among the 33 subjects, W. recta, B. intermedius, F. nucleatum, B. gingivalis and B. forsythus were elevated more often in active sites; whereas, S. mitis, C. ochracea, S. sanguis II, V. parvula and an unnamed Actinomyces sp. were elevated in inactive sites. The likelihood of a site being active was increased if B. forsythus, B. gingivalis, P. micros, A. actinomycetemcomitans, W. recta, or B. intermedius were detected in that site, and decreased if S. sanguis II, the Actinomyces sp., or C. ochracea were detected.

The microbial etiology of dental caries is discussed in terms of the dynamic relationship among the dental plaque microbiota, dietary carbohydrate, saliva, and the pH-lowering and cariogenic potential of dental plaque. The evidence supports a concept of caries as a dietary carbohydrate-modified bacterial infectious disease. Its key feature is a dietary carbohydrate-induced enrichment of the plaque microbiota with organisms such as the mutans streptococci and lactobacilli which causes an increase of plaque's pH-lowering and cariogenic potential. The shift in the plaque proportions of these organisms appears to be related to their relatively high acid tolerance. A large body of evidence also supports a major effect of saliva on caries development. Integration of salivary effects with the concept of caries as a dietary carbohydrate-modified bacterial infectious disease suggests a broader concept which includes a major role of saliva in the regulation of the exposure of tooth surfaces to carbohydrate and of plaque acidity and, hence, the microbial composition and the pH-lowering and cariogenic potential of dental plaque. It is proposed that caries occurs preferentially in dentition sites characterized by a relatively high exposure to carbohydrate and diminished salivary effects. Some implications of this concept are discussed.

The "altered Schaedler flora" (ASF) was developed for colonizing germfree rodents with a standardized microbiota. The purpose of this study was to identify each of the eight ASF strains by 16S rRNA sequence analysis. Three strains were previously identified as Lactobacillus acidophilus (strain ASF 360), Lactobacillus salivarius (strain ASF 361), and Bacteroides distasonis (strain ASF 519) based on phenotypic criteria. 16S rRNA analysis indicated that each of the strains differed from its presumptive identity. The 16S rRNA sequence of strain ASF 361 is essentially identical to the 16S rRNA sequences of the type strains of Lactobacillus murinis and Lactobacillus animalis (both isolated from mice), and all of these strains probably belong to a single species. Strain ASF 360 is a novel lactobacillus that clusters with L. acidophilus and Lactobacillus lactis. Strain ASF 519 falls into an unnamed genus containing [Bacteroides] distasonis, [Bacteroides] merdae, [Bacteroides] forsythus, and CDC group DF-3. This unnamed genus is in the Cytophaga-Flavobacterium-Bacteroides phylum and is most closely related to the genus Porphyromonas. The spiral-shaped strain, strain ASF 457, is in the Flexistipes phylum and exhibits sequence identity with rodent isolates of Robertson. The remaining four ASF strains, which are extremely oxygen-sensitive fusiform bacteria, group phylogenetically with the low-G+C-content gram-positive bacteria (Firmicutes, Bacillus-Clostridium group). ASF 356, ASF 492, and ASF 502 fall into Clostridium cluster XIV of Collins et al. Morphologically, ASF 492 resembles members of this cluster, Roseburia cecicola, and Eubacterium plexicaudatum. The 16S rRNA sequence of ASF 492 is identical to that of E. plexicaudatum. Since the type strain and other viable original isolates of E. plexicaudatum have been lost, strain ASF 492 is a candidate for a neotype strain. Strain ASF 500 branches deeply in the low-G+C-content gram-positive phylogenetic tree but is not closely related to any organisms whose 16S rRNA sequences are currently in the GenBank database. The 16S rRNA sequence information determined in the present study should allow rapid identification of ASF strains and should permit detailed analysis of the interactions of ASF organisms during development of intestinal disease in mice that are coinfected with a variety of pathogenic microorganisms.

The possible relationship between the ability of Streptococcus species to adhere to oral epithelial cells and their natural distribution on epithelial surfaces within the mouth was studied. Strains of S. salivarius and S. sanguis, which are present in significant proportions on oral epithelial surfaces, were found to possess a definite capacity to adhere to epithelial cells obtained from cheek scrapings of humans, hamsters, and germ-free rats. In contrast, strains of S. mutans, which are found in only minor proportions, if at all, on oral epithelial surfaces exhibited feeble or no adherence to oral epithelial cells. S. salivarius cells attached well to human cheek cells over the range of pH 5 to 8. Its adherence was not found to be markedly influenced by saliva or by growth in sucrose broth. Several other types of bacteria were examined which also exhibited widely different abilities to attach to human cheek cells. Mixtures of streptomycin-labeled strains were introduced into the mouths of volunteers for study of the adherence of Streptococcus species to oral epithelial surfaces in vivo. Labeled S. salivarius and S. sanguis were recovered in high proportions from cheek and tongue surfaces, whereas the proportions of labeled S. mutans recovered from these surfaces were low in comparison to the original mixture. These data indicate that a correlation exists between the relative adherence of various Streptococcus species and their proportional distribution found naturally on oral epithelial surfaces. The ability of bacteria to adhere to surfaces is proposed as a critical ecological determinant affecting their colonization in environments with open surfaces exposed to bathing fluids.

This investigation examined the ability of cells of Bacteroides melaninogenicus subsp. asaccharolyticus 381 to adhere to surfaces that might be important for its initial colonization of the mouth and its subsequent colonization in periodontal pockets. Of 48 asaccharolytic strains of B. melaninogenicus , 47 agglutinated human erythrocytes, whereas none of 20 fermentative strains, which included reference cultures of the subspecies intermedius and melaninogenicus , were active. Electron microscopy indicated that both asaccharolytic and fermentative strains possessed pili; hence, the presence of pili did not correlate with the hemagglutinating activities of B. melaninogenicus strains. Both asaccharolytic and fermentative B. melaninogenicus strains suspended in phosphate-buffered saline adhered in high numbers to buccal epithelial cells and to the surfaces of several gram-positive bacteria tested, including Actinomyces viscosus, A. naeslundii, A. israelii, Streptococcus sanguis , and S. mitis. B. melaninogenicus subsp. asaccharolyticus 381 also attached, but in comparatively low numbers, to untreated and to saliva-treated hydroxyapatite. Addition of clarified whole saliva to suspensions of strain 381 almost completely eliminated adherence to buccal epithelial cells and to hydroxyapatite surfaces, but saliva had no detectable effect on attachment to gram-positive plaque bacteria. Both fermentative and nonfermentative strains of B. melaninogenicus also attached in high numbers to crevicular epithelial cells derived from human periodontal pockets, but normal human serum strongly inhibited attachment. Serum also inhibited attachment of strain 381 to saliva- and serum-treated hydroxyapatite, but it had little effect upon attachment to gram-positive bacteria. These observations suggested that salivary and serum components would strongly inhibit the attachment of B. melaninogenicus cells to several oral surfaces, but not to the surfaces of certain gram-positive bacteria commonly present in human dental plaque. This was confirmed by an in vivo experiment in which streptomycin-labeled cells of B. melaninogenicus 381-R were introduced into the mouths of two volunteers. After 10 min, several hundred-fold higher numbers of the organism were recovered from preformed bacterial plaque present on teeth than from clean tooth surfaces or from the buccal mucosa and tongue dorsum. High numbers of B. melaninogenicus cells were also recovered from preformed plaque after 150 min, but virtually no cells of the organism were recovered from the other surfaces studied. These data suggest that the presence of dental plaque containing Actinomyces and other gram-positive bacteria may be essential for the attachment and colonization of B. melaninogenicus cells after their initial introduction into the mouth. Similarly, the presence of subgingival plaque containing gram-positive bacteria may be necessary for its secondary colonization in periodontal pockets.

This investigation compared the site prevalence of 40 subgingival species in 30 periodontally healthy (mean age 36+/-9 years), 35 elders with a well-maintained periodontium (mean age 77+/-5) and 138 adult periodontitis subjects (mean age 46+/-11). Subgingival plaque samples were taken from the mesial aspect of each tooth (up to 28 samples) in the 203 subjects at baseline. The presence and levels of 40 subgingival taxa were determined in 5003 plaque samples using whole genomic DNA probes and checkerboard DNA-DNA hybridization. Clinical assessments including dichotomous measures of gingival redness, bleeding on probing, plaque accumulation and suppuration, as well as duplicate measures of pocket depth and attachment level, were made at 6 sites per tooth. The % of sites colonized by each species (prevalence) was computed for each subject. Differences in prevalence and levels among groups were sought using the Kruskal-Wallis test. Commonly detected species, such as Actinomyces naeslundii genospecies 2, Streptococcus sanguis and Streptococcus oralis did not differ significantly among subject groups. After adjusting for multiple comparisons, 4 species were significantly elevated and at greater prevalence in the periodontitis group. Mean % of sites (+/-SEM) colonized by Bacteroides forsythus was 10+/-3, 12+/-2 and 40+/-2 (p<0.001) for healthy, elder and periodontitis groups respectively. The odds ratio was 14.4:1 that a subject had periodontitis when B. forsythus was detected at > or = 5% of sampled sites. Mean prevalence for Porphyromonas gingivalis in healthy, elder and periodontitis subjects was 4+/-2, 5+/-2 and 23+/-2 respectively (p<0.001); for Treponema denticola 12+/-4, 10+/-3 and 30+/-2 (p<0.001) and for Selenomonas noxia 6+/-2, 7+/-2 and 19+/-2 (p<0.01). Similar differences among subject groups were observed when only sites with PD 0-4 mm were analyzed. The data suggest an etiologic role for B. forsythus, P. gingivalis, T. denticola and S. noxia in adult periodontitis.

Abstract Interleukin Iβ is a potent bone resorptive cytokine which also mediates soft tissue destruction through the stimulation of prostaglandin production, and the induction of collagenase and other proteases. This constellation of activities suggests a role for IL‐1β in the pathogenesis of human periodontitis. Levels of IL‐1β were therefore determined in tissue obtained from (1) diseased, active (2) diseased, inactive, and (3) healthy sites from 12 patients with destructive adult periodontitis. Disease activity was defined as attachment loss of ≥2.5 mm, as determined by sequential probing and the tolerance method. IL‐1β was extracted from homogenates of tissue biopsies taken at surgery, and levels were quantified by ELISA. IL‐1β was found to be present in most patient tissue samples, with levels ranging from 0–82 ng/ml. Disease active sites had higher IL‐1β levels ( p &lt; 0.05) than inactive and healthy sites. Diseased inactive sites were divided into 2 groups, those losing small amounts of attachment (0.5–2.0 mm, worsening sites) and those which showed no change or attachment gain (stable sites). Stable diseased sites had IL‐1β levels which were comparable to those found in healthy sites, and which were significantly different from active sites ( p &lt; 0.02). Worsening sites had IL‐1β levels intermediate between the levels in stable and active sites. Detection of disease activity occurred more frequently at sites with IL‐1β levels &gt;25 ng/ml ( p &lt; 0.01). Thus, IL‐1β levels were positively related to changes in attachment level, but were inversely related to the presence of supragingival plaque or redness, and were unrelated to bleeding on probing or suppuration, indicating a dissociation between the presence of inflammation and IL‐1β levels. These data indicate that IL‐1β may have utility for the detection of sites of periodontal disease activity, and suggest that IL‐1β may be an important mediator of attachment loss in human periodontitis.

The 16S rRNA sequences were determined for species of Spirochaeta, Treponema, Borrelia, Leptospira, Leptonema, and Serpula, using a modified Sanger method of direct RNA sequencing. Analysis of aligned 16S rRNA sequences indicated that the spirochetes form a coherent taxon composed of six major clusters or groups. The first group, termed the treponemes, was divided into two subgroups. The first treponeme subgroup consisted of Treponema pallidum, Treponema phagedenis, Treponema denticola, a thermophilic spirochete strain, and two species of Spirochaeta, Spirochaeta zuelzerae and Spirochaeta stenostrepta, with an average interspecies similarity of 89.9%. The second treponeme subgroup contained Treponema bryantii, Treponema pectinovorum, Treponema saccharophilum, Treponema succinifaciens, and rumen strain CA, with an average interspecies similarity of 86.2%. The average interspecies similarity between the two treponeme subgroups was 84.2%. The division of the treponemes into two subgroups was verified by single-base signature analysis. The second spirochete group contained Spirochaeta aurantia, Spirochaeta halophila, Spirochaeta bajacaliforniensis, Spirochaeta litoralis, and Spirochaeta isovalerica, with an average similarity of 87.4%. The Spirochaeta group was related to the treponeme group, with an average similarity of 81.9%. The third spirochete group contained borrelias, including Borrelia burgdorferi, Borrelia anserina, Borrelia hermsii, and a rabbit tick strain. The borrelias formed a tight phylogenetic cluster, with average similarity of 97%. THe borrelia group shared a common branch with the Spirochaeta group and was closer to this group than to the treponemes. A single spirochete strain isolated fromt the shew constituted the fourth group. The fifth group was composed of strains of Serpula (Treponema) hyodysenteriae and Serpula (Treponema) innocens. The two species of this group were closely related, with a similarity of greater than 99%. Leptonema illini, Leptospira biflexa, and Leptospira interrogans formed the sixth and most deeply branching group. The average similarity within this group was 83.2%. This study represents the first demonstration that pathogenic and saprophytic Leptospira species are phylogenetically related. The division of the spirochetes into six major phylogenetic clusters was defined also by sequence signature elements. These signature analyses supported the conclusion that the spirochetes represent a monophylectic bacterial phylum.

BACKGROUND: National Surgical Adjuvant Breast and Bowel Project R-04 was designed to determine whether the oral fluoropyrimidine capecitabine could be substituted for continuous infusion 5-FU in the curative setting of stage II/III rectal cancer during neoadjuvant radiation therapy and whether the addition of oxaliplatin could further enhance the activity of fluoropyrimidine-sensitized radiation. METHODS: Patients with clinical stage II or III rectal cancer undergoing preoperative radiation were randomly assigned to one of four chemotherapy regimens in a 2x2 design: CVI 5-FU or oral capecitabine with or without oxaliplatin. The primary endpoint was local-regional tumor control. Time-to-event endpoint distributions were estimated using the Kaplan-Meier method. Hazard ratios were estimated from Cox proportional hazard models. All statistical tests were two-sided. RESULTS: Among 1608 randomized patients there were no statistically significant differences between regimens using 5-FU vs capecitabine in three-year local-regional tumor event rates (11.2% vs 11.8%), 5-year DFS (66.4% vs 67.7%), or 5-year OS (79.9% vs 80.8%); or for oxaliplatin vs no oxaliplatin for the three endpoints of local-regional events, DFS, and OS (11.2% vs 12.1%, 69.2% vs 64.2%, and 81.3% vs 79.0%). The addition of oxaliplatin was associated with statistically significantly more overall and grade 3-4 diarrhea (P < .0001). Three-year rates of local-regional recurrence among patients who underwent R0 resection ranged from 3.1 to 5.1% depending on the study arm. CONCLUSIONS: Continuous infusion 5-FU produced outcomes for local-regional control, DFS, and OS similar to those obtained with oral capecitabine combined with radiation. This study establishes capecitabine as a standard of care in the pre-operative rectal setting. Oxaliplatin did not improve the local-regional failure rate, DFS, or OS for any patient risk group but did add considerable toxicity.

The adsorption of strains of prominent oral bacteria to hydroxyapatite (HA) surfaces was studied by use of an adsorption model based on the Langmuir adsorption isotherm; this permitted comparative estimates of the number of adsorption sites and the strength of the adsorption bonds on untreated and salivatreated HA surfaces for strain of Streptococcus mutans, S. salivarius, S. sanguis, S. mitis, Actinomyces viscosus, and A. naeslundii. The experimental data closely followed the adsorption model as judged by the high correlation coefficients obtained for all strains studied. Adsorption to untreated HA was similar for strains of the six species studied, suggesting that a common adsorption mechanism, possibly Ca(2+) bridging, may exist for attachment to HA. More complex interactions appeared to be involved in bacterial adsorption to saliva-treated HA since adsorption of the strains tested at unsaturating cell concentrations varied more than 30-fold. This indicates that adsorbed salivary components on HA surfaces impart a higher order of specificity for subsequent bacterial adsorption. Fewer cells of strains of S. mutans, S. salivarius, and A. naeslundii adsorbed to saliva-treated HA than to untreated HA because adsorbed salivary components presented fewer adsorption sites. Substantially higher numbers of cells of strains of S. sanguis, S. mitis, and A. viscosus adsorbed to saliva-treated HA because the film of adsorbed salivary components increased the number of adsorption sites for these strains. The affinity constants for all but one strain studied were lower on saliva-treated HA than on untreated HA. The number of bacterial cells which adsorbed to saliva-treated HA more closely related to the number of available binding sites than to the strength of their adsorption bonds when tested at an initial concentration of 2 x 10(7) organisms/ml. Although some differences were observed in the adsorption of strains of S. mutans representative of five serological groups, the numbers which attached to saliva-treated HA did not vary widely; this suggests that factors other than their ability to attach to a pellicle-covered HA surface may be responsible for their varying geographic distribution in human populations.

The quadriceps femoris angle ("Q angle") has been implicated as a source of several knee disorders, but values for normal knees have not been adequately documented in the literature. This study was designed to provide clinicians with normal values and information regarding the relationships between Q angle, gender, and selected anatomical measurements. The Q angles of 100 individuals (50 men, 50 women), who had no history of knee disorders, were measured goniometrically. The hip widths and femur lengths of all subjects were measured with calipers. The mean Q angle for women was 15.8 +/- 4.5 degrees and for men was 11.2 +/- 3.0 degrees. Using a point biserial correlation, we found a relationship between gender and Q angle (r = -.517) that remained significant (p less than .01) when the effects of femur length and hip width were controlled. The relationships identified between Q angle and the anatomical measurements were no longer significant when the effect of gender was eliminated. The results substantiate the belief that women have larger Q angles than men, but they fail to provide clinicians with an anatomical explanation or new predictor of Q angle.

Recent studies of the cellular mechanisms involved in chronic inflammatory periodontal disease (CIPD) have contributed significantly to our understanding of the pathogenesis of the disease process. Functional studies have demonstrated polymorphonuclear neutrophil (PMN) chemotactic defects in some 70% of subjects with localized juvenile periodontitis while chemiluminescence data have suggested that periphertal blood PMNs from young subjects with adult periodontitis (AP) may be in a metabolically active state. Further studies have shown that stimulation of PMNs with a number of periodontopathic bacteria resulted in the production of an IL‐1 inhibitor suggesting a possible regulatory role for PMNs in CIPD in addition to their established protective role. Most work on the immunoregulation of CIPD has, however, concentrated on T‐cells. Recent limit dilution analysis has demonstrated the presence of periodontopathic bacteria‐specific T cells in peripheral blood and the involvement and homing of these cells to the local lesions of CIPD is currently the focus of many studies. In animal studies, Actinobacillus actinomycetemcomitans (Aa) ‐specific T‐cell clones home to the gingival tissues where they may exert a protective role. Homing and retention of lymphocytes to and in specific sites is dependent upon the expression of adhesion molecules. Recent data indicate however, that while there are increasing levels of ICAM‐1, LECAM‐1 and PECAM‐1 expression with increasing degrees of inflammation, there are no differences between gingivitis and periodontitis lesions. Cytokine profiles may be related to the role of T‐cell clones homing to the gingiva in CIPD. In subjects susceptible to periodontal breakdown there may be an increase in the type 2 IL‐4 producing T‐cells whereas in non‐susceptible subjects, type 1 IL‐2/IFN‐γ producing T‐cells may preferentially home to the gingiva. This hypothesis is generally supported by recent data obtained from human studies but data obtained from animal studies is only partly supportive and may suggest the opposite. Nevertheless, it is now possible to construct a testable framework or model of CIPD based on these cellular and molecular mechanisms.

Glucose-grown washed cells of streptococci similar to Streptococcus mutans, which contain cell-bound dextransucrase, have been observed to agglutinate upon the addition of high molecular weight dextran. Low molecular weight dextran or unrelated polysaccharides were ineffective. Agglutination also occurred upon addition of sucrose, which can be converted into dextran, but not with other mono- and disaccharides. Other bacteria, including species capable of synthesizing dextrans, were not observed to exhibit this phenomenon. Cells of S. mutans agglutinated upon addition of dextran over a wide pH range, but maximal sensitivity to dextran occurred at pH 8.5. At this pH, such cells can be used for a simple, specific, and exquisitely sensitive qualitative assay for high molecular weight dextran, for addition of 6 ng of dextran with a molecular weight of 2 x 10(6) (i.e., approximately three molecules per cell) caused detectable agglutination. High concentrations of glucose, levan, and dextran of molecular weight of 2 x 10(4) inhibited the reaction. Fluorescein-labeled cells of S. mutans were observed to adhere to dextran-containing plaques and dextran-treated teeth, suggesting that this phenomenon may be of importance in the formation of streptococcal dental plaques. The mechanism responsible for dextraninduced agglutination appears to involve the affinity of a receptor site, possibly dextransucrase, on the surface of several cells for common dextran molecules.

Anaerobes differ in their sensitivity to oxygen, as two patterns were recognizable in the organisms included in this study. Strict anaerobes were species incapable of agar surface growth at pO(2) levels greater than 0.5%. Species that were found to be strict anaerobes were Treponema macrodentium, Treponema denticola, Treponema oralis n. sp., Clostridium haemolyticum, Selenomonas ruminatium, Butyrivibrio fibrisolvens, Succinivibrio dextrinosolvens, and Lachnospira multiparus. Moderate anaerobes would include those species capable of growth in the presence of oxygen levels as high as 2 to 8%. The moderate anaerobes could be exposed to room atmosphere for 60 to 90 min without appreciable loss of viability. Species considered as moderate anaerobes were Bacteroides fragilis, B. melaninogenicus, B. oralis, Fusobacteria nucleatum, Clostridium novyi type A, and Peptostreptococcus elsdenii. The recognition of at least two general types of anaerobes would seem to have practical import in regard to the primary isolation of anaerobes from source material.

We compared 46 strains of gram-negative, asaccharolytic, rod-shaped bacteria which were isolated from humans with gingivitis, periodontal pockets, and lesions in alveolar bone with 10 reference strains of Eikenella corrodens, Vibrio succinogenes, Bacteroides ureolyticus, and species of Campylobacter. We divided these 56 strains into seven groups based on the guanine-plus-cytosine contents of their deoxyribonucleic acids, their deoxyribonucleic acid homologies, and cluster analyses of their phenotypic features. A total of 23 of the fresh isolates showed more than 90% similarity (Jaccard coefficient) with E. corrodens. Growth of the remaining 23 isolates was enhanced in. broth cultures by formate and fumarate. These isolates were not members of B. ureolyticus, V. succinogenes, or previously described species of Campylobacter, they constituted three distinct new species. We propose Bacteroides gracilis sp. nov. (type strain, ATCC 33236) as the name for seven isolates of slender, gram-negative, nonmotile, anaerobic, rod-shaped bacteria that corroded agar and had deoxyribonucleic acid guanine-plus-cytosine contents of 44 to 46 mol%. All of the remaining isolates were motile by means of a single polar flagellum. Ten anaerobic strains were similar to V. succinogenes in phenotypic characteristics and guanine-plus-cytosine contents. However, these strains were distinct from V. succinogenes on the basis of deoxyribonucleic acid homology results. We propose Wolinella as the name of a new genus to include anaerobic, asaccharolytic, rod-shaped bacteria with single polar flagella and deoxyribonucleic acid guanine-plus-cytosine contents of 42 to 49 mol%. Wolinella succinogenes (Wolin et al.) comb. nov. is designated the type species of the genus, and ATCC 29543 is the type strain of W. succinogenes. We propose Wolinella recta sp. nov. (type strain, ATCC 33238) as the name for nine of the strains that formed a related but distinct group. We propose Campylobacter concisus sp. nov. (type strain, ATCC 33237) as the name for the six isolates of noncorroding, microaerophilic, gram-negative, rod-shaped bacteria that have predominantly curved cells and deoxyribonucleic acid guanine-plus-cytosine contents of 34 to 38 mol%. The description of the genus Campylobacter is amended to include species with deoxyribonucleic acid guanine-plus-cytosine contents of 30 to 38 mol%.