Prognostic significance of time trends in treatment of head and neck squamous cell carcinoma

PURPOSE

To analyze the impact of demographic, clinical, and management variables on time to treatment initiation (TTI) and overall survival (OS).

STUDY DESIGN

Retrospective chart review.

MATERIALS AND METHODS

Medical records of patients diagnosed with head and neck cancer from 2018 to 2020 were reviewed. Univariate linear and Cox-regressions identified predictors of TTI and OS. Kaplan Meier (KM) curves assessed the difference in survival by diagnostic year and TTI.

RESULTS

381 patients met eligibility criteria. Median TTI was 35.0 days (IQR: 25.0-49.0). Only 10.8 % of all patients reported any treatment delay, with TTI exceeding 90 days found in 3.7 % of patients. TTI increased with African American race (p = 0.02), ED referrals (p = 0.02), and direct admission status (p = 0.01). When compared to treatment with surgery alone, TTI was shorter in patients undergoing surgery with adjuvant radiation (p = 0.02), adjuvant chemoradiation (p = 0.04), and salvage surgery (p = 0.04). Univariate Cox-regressions found smoking (p = 0.01), direct admission status (p = 0.02), increased duration of symptoms (p = 0.02), placement of PEG tubes (p < 0.01) and tracheostomies (p < 0.01), combination treatment (p < 0.01), and surgery with adjuvant chemoradiation treatment (p = 0.01) to increase mortality risk. Disease characteristics, including tumor size (p < 0.01), presence of nodal disease (p = 0.02), and late-stage disease (p < 0.01), increased mortality risk. TTI and diagnostic year did not impact survival.

CONCLUSIONS

Our analysis determined several demographic, referral, and treatment factors impacted TTI. However, increased TTI did not impact survival. Characteristics consistent with advanced disease worsened OS. Despite the pandemic burden, patients diagnosed in 2020 showed no difference in short-term survival compared to prior years.

Associations of cannabis use with motor vehicle crashes and traffic stops among older drivers: AAA LongROAD study

BACKGROUND

Acute cannabis use is associated with a higher risk of motor vehicle crashes (MVC). This study aimed to determine if self-reported past-year cannabis use is associated with MVC or traffic stops among older drivers.

METHODS

This cross-sectional analysis used data from a multi-center study enrolling active drivers aged 65-79 years. Data regarding cannabis use, MVC, and traffic stops (i.e., being pulled over by police, whether ticketed or not) within the previous 12 months were collected through participant interviews. Log-binomial regression models examined associations of past-year cannabis use with MVC and traffic stops, adjusting for site and sociodemographic and mental health characteristics.

RESULTS

Of 2,095 participating older drivers, 186 (8.88%) used cannabis in the past year but only 10 (<0.5%) within an hour before driving in the last 30 days; 11.41% reported an MVC and 9.45% reported a traffic stop. Past-year cannabis users had a higher prevalence of MVC (adjusted prevalence ratio [aPR] = 1.38; 95%CI: 0.96, 2.00; p = 0.086) and traffic stops (aPR = 1.58; 1.06, 2.35; p = 0.024).

CONCLUSIONS

Past-year cannabis use was associated with increased traffic stops, which are correlated modestly with increased MVC in past studies and may indicate impaired driving performance. We did not find a statistically significant association of past-year cannabis use with MVC, which may indicate limited sustained effects on driving performance from periodic use among older adults, who report rarely driving immediately after use.

Treatment failure patterns are similar between p16− and p16+ oropharyngeal squamous cell carcinomas

Background

The incidence of p16+ oropharyngeal squamous cell carcinoma (OPSCC) has been increasing. The notion that p16+ OPSCC has a propensity for atypical and disseminating metastasis has gained traction. We compared treatment failure patterns in p16+ and p16− OPSCC and evaluated survival impact.

Methods

Retrospective analysis of patients with recurrent/metastatic OPSCC disease between 1/2009 and 12/2019.

Results

Thirty‐eight p16+ and 36 p16− patients were identified. Three distinct failure patterns (distant vs. locoregional, atypical vs. typical, and disseminating vs. non‐disseminating) were studied. No significant differences were found between p16+ and p16− patients. Multivariate analysis showed p16 status was an independent prognostic biomarker; p16+ patients have a favorable overall survival compared to p16− patients (HR 0.34, 95% CI 0.16–0.77; P = .005).

Conclusions

We challenge the view that p16+ OPSCC exhibits a distinctive treatment failure pattern and showed that p16 status impacts patient survival independent of disease progression.

Impact of p16 Status and Anatomical Site in Anti-PD-1 Immunotherapy-Treated Recurrent/Metastatic Head and Neck Squamous Cell Carcinoma Patients

In head and neck squamous cell carcinoma (HNSCC), anti-PD-1 inhibitors are approved for recurrent/metastatic (R/M) disease and anticipated to expand to other indications. The impact of p16 status and anatomical site on overall survival (OS) in immunotherapy-treated HNSCC patients remains unresolved. We performed a retrospective analysis of R/M HNSCC patients receiving anti-PD-1 immunotherapy at our academic medical center with an extensive community satellite network. Fifty-three R/M HNSCC patients were treated with anti-PD-1 immunotherapy and had a median OS of 6 months. Anatomical site was associated with distinct OS; oropharynx and larynx patients have superior OS compared to oral cavity patients. Analysis of the OPSCC subset showed p16+ status as a favorable, independent prognostic biomarker (HR 7.67 (1.23-47.8); p = 0.029). Further studies to assess the link between anatomical site, p16 status, and anti-PD-1 treatment outcomes in large cohorts of R/M HNSCC patients managed in real-world clinical practices and clinical trials should be prioritized.

Permanent Interstitial Cesium-131 Brachytherapy in Treating High-Risk Recurrent Head and Neck Cancer: A Prospective Pilot Study

Purpose/Objectives

To establish the feasibility and safety of intraoperative placement of cesium-131 (Cs-131) seeds for re-irradiation in recurrent head and neck cancer (HNC).

Methods

Patients with resectable recurrent HNC who were deemed to have a high risk of second recurrence were eligible. Immediately after tumor extirpation, seeds were implanted in the surgical bed based on the preoperative treatment plan with intraoperative adjustment. The surgical bed and the seeds were covered with a regional flap or microvascular free flap. A CT of the neck was obtained on postoperative day 1 for evaluation of the postoperative dose distribution. Patients were followed 1 and 3 months after surgery, then every 3 months in the first 2 years.

Results

From November 2016 to September 2018, 15 patients were recruited and 12 patients received treatment per protocol. For the patients who had implants, the sites of initial recurrence included 10 neck alone, 1 neck and larynx, and 1 neck/peristomal. The median follow-up was 21.4 months. After surgery, patients remained hospitalized for a median of 6 days. There were no high-grade toxicities except two patients with wound complications requiring wound care. Eight patients had recurrences, three locoregional alone, three distant alone, and two with both locoregional and distant recurrences. Only one patient had an in-field failure. Five patients died, with 1- and 2-year overall survival of 75 and 58%.

Conclusions

Cs-131 implant after surgical resection in recurrent HNC is feasible and safe. There were no unexpected severe toxicities. Most failures were out-of-field or distant.

Clinical Trial Registration

ClinicalTrials.gov, identifier NCT02794675.

Cancellous Tibial Bone Graft for Malunion after Mandibular Reconstruction in Head and Neck Cancer

OBJECTIVES/HYPOTHESIS

While nonunion after mandibular reconstruction for head and neck surgery is rare, literature exploring management is scarce. Our primary objective was to determine success rates of tibial bone graft (TBG) in achieving mandibular union. Secondary objectives include determining factors that contribute to failure of TBG.

STUDY DESIGN

Retrospective Chart Review.

METHODS

Retrospective chart review between January 1, 2008 and December 31, 2018. Patients who underwent a mandibulotomy or mandibulectomy with osteocutaneous free flap reconstruction were identified. Patients who were pursuing dental rehabilitation, subsequently diagnosed with mandibular nonunion and received a cancellous TBG were assessed.

RESULTS

The 15 patients meeting inclusion criteria were mostly male (67%), white (87%), and nonsmokers (67%) with a median age of 64 (IQR = 60-73). Successful union occurred in 13 of 18 (72%) TBGs and the majority (63%) had a partial union documented at the time of surgery. Five patients (83%) who initially had a mandibulotomy achieved union compared to 78% of those with osteocutaneous reconstruction (P = 1.0). Postoperative radiation did not affect rates of union: 80% for both (P = 1.0). Patients with osteoradionecrosis (ORN) achieved union in 67% of cases compared to 75% of cases who did not have ORN (P = .86). There were similar rates of union for those who required perioperative antibiotics for infection and those without infection (67% vs. 75%, P = .86). Dental rehabilitation was achieved in 55% of patients, most commonly dentures.

CONCLUSIONS

This study shows that TBG can be used to achieve union for patients with malunion after head and neck cancer reconstruction. We show its successful use within the reconstructive algorithm for patients regardless of postoperative radiation for very small defects.

LEVEL OF EVIDENCE

3 Laryngoscope, 131:1291-1296, 2021.

Abdominal Aortic Aneurysm: A Case Report and Literature Review

INTRODUCTION

Abdominal aortic aneurysms (AAA) more commonly affect men than women and are estimated to affect 4% to 8% of men older that age 60 years. Mortality because of a ruptured AAA is high, but elective repair is an effective and relatively safe intervention.

CASE PRESENTATION

A 79-year-old man came to the Emergency Department because of worsening back pain. Workup revealed a previously unknown, 10-cm aneurysm that had ruptured. Unfortunately, the patient died during emergency surgery.

DISCUSSION

A literature review of proper screening, referral timeframe, the most common surgical techniques, potential complications, and postoperative surveillance was conducted. Early detection, referral to vascular surgery, and possible open or endovascular repair are key to limiting the morbidity and mortality associated with AAA.

Predictive value of the ACS NSQIP calculator for head and neck reconstruction free tissue transfer

BACKGROUND

Predictive models to forecast the likelihood of specific outcomes after surgical intervention allow informed shared decision-making by surgeons and patients. Previous studies have suggested that existing general surgical risk calculators poorly forecast head and neck surgical outcomes. However, no large study has addressed this question while subdividing subjects by surgery performed.

OBJECTIVES

To determine the accuracy of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Surgical Risk Calculator in estimating length of hospital stay and risk of postoperative complications after free tissue transfer surgery.

STUDY DESIGN

A retrospective chart review of patients at one institution was performed using Current Procedural Terminology codes for anterolateral thigh (ALT) flap, fibula free flap (FFF), and radial forearm free flap (RFFF) reconstruction. Output data from the ACS NSQIP surgical risk calculator were compared with the observed rates in our patients.

METHODS

Incidences of cardiac complications, pneumonia, venous thromboembolism, return to the operating room, and discharge to skilled nursing facility (SNF) were compared to predicted incidences. Length of stay was also compared to the predicted length of stay.

RESULTS

Three hundred thirty-six free flap reconstructions with 197 ALT flaps, 85 RFFFs, and 54 FFFFs were included. Brier scores were calculated using ACS NSQIP forecast and actual incidences. No Brier score was <0.01 for the entire sample or any subgroup, which indicates that the NSQIP risk calculator does not accurately forecast outcomes after free tissue reconstruction.

CONCLUSION

The ACS NSQIP failed to accurately forecast postoperative outcomes after head and neck free flap reconstruction for the entire sample or subgroup analyses.

LEVEL OF EVIDENCE

4 Laryngoscope, 130:679-684, 2020.

Grappling With Complex Food Systems to Reduce Obesity: A US Public Health Challenge

Despite 2 decades of effort by the public health community to combat obesity, obesity rates in the United States continue to rise. This lack of progress raises fundamental questions about the adequacy of our current approaches. Although the causes of population-wide obesity are multifactorial, attention to food systems as potential drivers of obesity has been prominent. However, the relationships between broader food systems and obesity are not always well understood. Our efforts to address obesity can be advanced and improved by the use of systems approaches that consider outcomes of the interconnected global food system, including undernutrition, climate change, the environmental sustainability of agriculture, and other social and economic concerns. By implementing innovative local and state programs, taking new approaches to overcome political obstacles to effect policy, and reconceptualizing research needs, we can improve obesity prevention efforts that target the food systems, maximize positive outcomes, and minimize adverse consequences. We recommend strengthening innovative local policies and programs, particularly those that involve community members in identifying problems and potential solutions and that embrace a broad set of goals beyond making eating patterns healthier. We also recommend undertaking interdisciplinary research projects that go beyond testing targeted interventions in specific populations and aim to build an understanding of the broader social, political, and economic context.

Performance of Cold Chains for Chesapeake Bay Farmed Oysters and Modeled Growth of Vibrio parahaemolyticus

Temperature-controlled supply chains (cold chains) require an unbroken chain of refrigeration to maintain product quality and safety. This study investigated cold chains for farmed oysters raised in the Chesapeake Bay, one of the largest shellfish-growing regions in the United States, and sold live to the half-shell market in surrounding states. Temperature sensors were used in boxes of oysters from February to September 2017, which generated 5,250 h of temperature data. Thirty-nine businesses participated in the temperature sensor study, and 26 of those businesses participated in interviews to further understand how cold chains function. Internal oyster temperatures were measured above 50°F (10°C) for over 1 h in 19% (7 of 36) of shipments, which is a temperature that exceeds National Shellfish Sanitation Program criteria. The highest internal oyster temperature recorded in any shipment was 54.5°F (12.5°C). Some parts of the cold chain had difficulty maintaining storage temperatures below 45°F (7.2°C) in warmer months when Vibrio control plans were in effect. We modeled the effects of temperature on Vibrio parahaemolyticus. The model predicted moderate bacterial growth before oysters were under temperature control, but cold chains prevented further bacterial growth and provided a moderate drop-off in V. parahaemolyticus abundance.

Perioperative cardiac complications in patients undergoing head and neck free flap reconstruction

BACKGROUND

Limited data exists on cardiac complications following head and neck free flaps.

DESIGN

A retrospective review was performed on patients that underwent free flap reconstruction from 2012 to 2015.

RESULTS

368 flaps were performed. 12.5% of patients experienced a cardiac event. Hypertension, coronary artery disease, heart failure, venous thromboembolism, and anticoagulation were associated with cardiac complications. ASA class was not predictive of cardiac events. 7.6% of patients required anticoagulation, which exhibited a strong association with surgical site hematoma. Cardiac complications led to a significantly increased length of stay.

CONCLUSIONS

There is a significant rate of cardiac events in this cohort. When estimating risk, a patient's total burden of comorbidities is more important than any one factor. ASA Class fails to demonstrate utility in this setting. Cardiac events have implications for quality-related metrics including length of stay and hematoma rate.

The impact of a head and neck microvascular fellowship program on otolaryngology resident training

OBJECTIVE

To assess the impact of a microvascular head and neck (H&N) fellowship on senior residents' surgical experience.

STUDY DESIGN

Retrospective review of Accreditation Council for Graduate Medical Education-generated operative case log reports, retrospective chart review, and electronic survey.

METHODS

A retrospective review of one institution's residents' H&N operative case logs and free flap operative reports was performed to determine changes in key indicator cases (KICs) after the addition of a H&N fellowship. An electronic survey was distributed to senior residents at all U.S. otolaryngology residency programs to determine residents' perceptions of a H&N fellow's impact on their surgical experience. An electronic survey was distributed to senior medical students applying to surgical residencies to explore the perceived impact that a fellowship has on the desirability of a residency program.

RESULTS

The average number of each postgraduate year (PGY)5's H&N KIC before and after the addition of the fellowship were: parotidectomy, 19 versus 17.8; neck dissection, 33.2 versus 40.6; oral cavity resection, 15.3 versus 12.6; thyroid/parathyroid, 45.5 versus 45.6; and flaps/grafts, 56.7 versus 42. PGY5 participation as first assistant in free flaps dropped from 78% to 17%; however, residents still participated in some aspect of 45% of the cases. Seventy percent of senior residents reported a positive perception of the H&N fellow on their H&N operative experience. Eighty-nine percent of senior medical student respondents reported a nonnegative perception of a fellowship in their applied field.

CONCLUSION

The addition of a H&N fellowship did not decrease senior residents' H&N KIC, and most senior residents at programs with fellowships report that the fellow has a positive impact on their H&N operative experience.

LEVEL OF EVIDENCE

4. Laryngoscope, 128:52-56, 2018.

The use of the submental island flap in reconstructing palatal and facial defects in a surgical camp in East Africa

BACKGROUND

The goals of successful reconstructive surgery are to restore function and cosmesis; however, limitation of resources can become an important consideration in low-middle income countries.

METHODS

We describe our experience using the submental island flap in two cases during a short-term surgical camp in East Africa.

RESULTS

The submental island flap was utilized as an excellent alternative to a free flap to reconstruct a subtotal maxillectomy and a parotidectomy defect in two patients.

CONCLUSIONS

We demonstrate the successful use of this flap and describe some necessary modifications to achieve optimal results in a resource limited setting.

Thermodynamic signature of DNA damage: characterization of DNA with a 5-hydroxy-2'-deoxycytidine·2'-deoxyguanosine base pair

Oxidation of DNA due to exposure to reactive oxygen species is a major source of DNA damage. One of the oxidation lesions formed, 5-hydroxy-2'-deoxycytidine, has been shown to miscode by some replicative DNA polymerases but not by error prone polymerases capable of translesion synthesis. The 5-hydroxy-2'-deoxycytidine lesion is repaired by DNA glycosylases that require the 5-hydroxycytidine base to be extrahelical so it can enter into the enzyme's active site where it is excised off the DNA backbone to afford an abasic site. The thermodynamic and nuclear magnetic resonance results presented here describe the effect of a 5-hydroxy-2'-deoxycytidine·2'-deoxyguanosine base pair on the stability of two different DNA duplexes. The results demonstrate that the lesion is highly destabilizing and that the energy barrier for the unstacking of 5-hydroxy-2'-deoxycytidine from the DNA duplex may be low. This could provide a thermodynamic mode of adduct identification by DNA glycosylases that requires the lesion to be extrahelical.

Randomised clinical trial: a 'nudge' strategy to modify endoscopic sedation practice

BACKGROUND

In behavioural economics, a 'nudge' describes configuration of a choice to encourage a certain action without taking away freedom of choice.

AIM

To determine the impact of a 'nudge' strategy - prefilling either 3mL or 5mL syringes with midazolam - on endoscopic sedation practice.

METHODS

Consecutive patients undergoing sedation for EGD or colonoscopy were enrolled. On alternate weeks, midazolam was prefilled in either 3mL or 5mL syringes. Preprocedure sedation was administered by the endoscopist to achieve moderate conscious sedation; dosages were at the discretion of the endoscopist. Meperidine was not prefilled.

RESULTS

Overall, 120 patients received sedation for EGD [59 (5mL), 61 (3mL)] and 86 patients were sedated for colonoscopy [38 (5mL), 48 (3mL)]. For EGDs, average midazolam dose was significantly higher in the 5-mL group (5.2mg) vs. 3-mL group (3.3mg), (P<0.0001); for colonoscopies, average midazolam dose was also significantly higher in the 5-mL group (5.1mg) vs. 3-mL group (3.3mg), (P<0.0001). There was no significant difference in mean meperidine dose (42.1mg vs. 42.8mg, P=0.9) administered to both colonoscopy groups. No adverse sedation-related events occurred; no patient required reversal of sedation.

CONCLUSIONS

These findings demonstrate that 'nudge' strategies may hold promise in modifying endoscopic sedation practice. Further research is required to explore the utility of 'nudges' in impacting other aspects of endoscopic practice.

Assessing the functional performance of post-call hospital doctors using a Nintendo Wii

Sleep deprivation is an established part of the working life for Non-Consultant Hospital Doctors (NCHDs) in Ireland. Concern exists about the effect of extended NCHD work hours. We utilised a Nintendo Wii to evaluate motor function of NCHDs both prior to their on-call shift and the day afterwards. Data was exported to SPSS ver. 15 for statistical analysis with p < 0.05 considered significant. A total of 72 NCHDs were invited to participate in this study. There was a 62.5% (45) rate of follow-up. Overall 27 (60%) NCHDs were on medical call, with 18 (40%) on surgical call. There was no statistically significant difference between NCHDs pre-and post-call motor assessment scores. The majority of study participants (75.5%, n = 34) had four or more hours sleep. On-call duty allows for a greater than anticipated amount of sleep per on-call shift and therefore has a negligible effect on the motor skills of medical staff.

A new betaA1-crystallin splice junction mutation in autosomal dominant cataract

PURPOSE

To map the locus for autosomal dominant cataracts (ADCs) in a Brazilian family using candidate gene linkage analyses, describe the clinical variability, and identify potential mutations in the human betaA1-crystallin gene (CRYBA1), a candidate gene identified through linkage studies demonstrating cosegregation with markers on chromosome 17.

METHODS

Members of a Brazilian family with ADC were studied. Clinical examinations and linkage analyses with polymerase chain reaction (PCR) polymorphisms of 22 anonymous markers and 2 within the neurofibromatosis type 1 gene were performed; two-point lod scores were calculated. DNA sequences of all 6 exons and 12 exon-intron boundaries of the betaA1-crystallin gene, a proximal candidate gene mapped to 17q11.1-q12 in one unaffected and two affected individuals, were screened and new variants assessed for cosegregation with the disease.

RESULTS

Affected individuals exhibited variable expressivity of pulverulent opacities in the embryonal nucleus and sutures; star-shaped, shieldlike, or radial opacities in the posterior embryonal nucleus; and/or midcortical opacities. All known loci for ADC in this family on chromosomes 1 and 13 were excluded. A positive lod score on chromosome 17 was calculated. This ADC locus was mapped to two potential regions on the long arm with an intervening recombination. The only known candidate gene in these regions was betaA1-crystallin. Three previously unreported single nucleotide variants were found in this gene, one in the donor splice junction site of intron C. This variant was found in all affected members and is presumed to be the causative mutation.

CONCLUSIONS

An ADC locus was mapped in a Brazilian family with variable expressivity to either 17q23.1-23.2 or 17q11.1-12 based on linkage analyses. Analyses of DNA sequences of the betaA1-crystallin gene in this family revealed three new variants, one of which is within a donor splice junction and cosegregates with affected members.

Criteria for gene identification and features of genome organization: analysis of 6.5 Mb of DNA sequence from human chromosome 21

To establish criteria for and the limitations of novel gene identification, to identify novel genes of potential relevance to Down Syndrome and to investigate features of genome organization, 6. 550kb. In total, 41 novel gene models were predicted, and for a subset of these, RT-PCR experiments helped to verify and refine the models, and were used to assess expression in early development and in adult brain regions of potential relevance to Down syndrome. Results suggest generally low and/or restricted patterns of expression, and also reveal examples of complex alternative processing, especially in brain, that may have important implications for regulation of protein function. Analysis of complete gene structures of the known genes identified a number of very large introns, a number of very short intergenic distances, and at least one potentially bi-directional promoter. At least 3/4 of known genes and 1/2 of predicted genes are associated with CpG islands. For novel genes, three cases of overlapping genes are predicted. Results of these analyses illustrate some of the complexities inherent in mammalian genome organization and some of the limitations of current sequence analysis technologies. They also doubled the number of potential genes within the region.

Structures, sequence characteristics, and synteny relationships of the transcription factor E4TF1, the splicing factor U2AF35 and the cystathionine beta synthetase genes from Fugu rubripes

A cosmid containing the beta-amyloid precursor protein (APP) from Fugu rubripes has been completely sequenced. In addition to APP, the cosmid contains the E4TF1-60 transcription factor, the U2AF35 pre-mRNA splicing factor, and the cystathionine beta synthetase (CBS) gene. The human homologues of all four genes map to human chromosome 21 but are not clustered; APP and E4TF1-60 map within 21q21, whereas U2AF35 and CBS map approximately 20Mb distal in 21q22. 3. The protein sequences of the Fugu genes vary in their overall level of similarity to their mammalian homologues, but several regions of functional importance are almost identical. As expected, the intron/exon structures of the homologous pairs of genes are highly conserved, but there are significant differences in the compaction ratios. The introns of APP and E4TF1-60 are 49- and 24-fold smaller in Fugu than in human, and the intergenic distance is compressed at least 100-fold. For U2AF35 and CBS, the introns are compressed only five- to eightfold. These size differences were compared with those for a number of previously reported Fugu genes; in general, levels of compaction of Fugu genes are consistent with the isochore locations of the human homologues.

Analysis of pufferfish homologues of the AT-rich human APP gene

Mutations in the beta-amyloid precursor protein (APP) gene are associated with some forms of Familial Alzheimer's Disease. The human APP gene is large, the 19 exons span approximately 300 kb, and AT-rich, at 40% GC. We have examined the genomic structure and cDNA sequence of the APP gene in the pufferfish Fugu rubripes and Tetraodon fluviatilis, respectively. In contrast to human, the Fugu APP gene spans less than 10 kb of DNA, with the introns compacted 48-fold on average. Two axons, alternatively processed in humans, are absent in both pufferfish. APP is the largest, most AT-rich gene examined in Fugu and is also the most highly compressed. The genomic sequences spanning the human and the Fugu APP genes were analysed with a set of exon and gene prediction programs. Results show that these are highly reliable for the Fugu gene with lower false positive and false negative rates than are seen in the analysis of the human gene. Comparative analysis of Fugu sequences homologous to very AT-rich regions in the human genome may, therefore, be advantageous in gene-finding efforts, both for their highly reduced sizes and their reliable gene predictions.

Reading and metaphonological outcomes in late talkers

Children with a history of slow expressive language development (SELD) were followed to second grade, at which point outcomes in terms of speech, language, cognitive skills, reading achievement, and metaphonological performance were evaluated. Although there were some statistically significant differences between groups, children with a history of SELD generally performed within the normal range on the measures collected. Relations among speech, reading, and metaphonology in the SELD cohort appeared to operate in a manner similar to that seen in groups with typical language development. The implications of these findings for understanding the nature of specific language impairments and for treating early circumscribed language delays are discussed.

Are neurovegetative symptoms stable in relapsing or recurrent atypical depressive episodes?

Few data exist that assess the presence of reversed and positive neurovegetative symptoms through successive depressive episodes. To assess the stability of depressive symptoms across episodes, we studied 74 outpatients with atypical unipolar major depression, diagnosed by the Structured Clinical Interview for DSM-III-R, before response to fluoxetine treatment and again after relapse on either fluoxetine or placebo. Patients were assessed at baseline with the Atypical Depression Diagnosis Scale and at baseline and during follow-up with the 17-item Hamilton Rating Scale for Depression. Thirty-two (43%) of responders had a relapse or recurrence, 21 (66%) of whom had a predominance of reversed of positive neurovegetative symptoms at baseline. Nine of 10 (90%) patients with reversed symptoms at baseline had the same symptoms when they relapsed; seven of 11 (64%) of those with positive symptoms at baseline had positive symptoms again (kappa 0.557). Overall, five of 21 (24%) had changes in their disturbances in sleep, appetite, or weight when they relapsed. This study supports the relative stability of neurovegetative symptoms in atypical depression across episodes.

Natural variants of the human papillomavirus type 16 E6 protein differ in their abilities to alter keratinocyte differentiation and to induce p53 degradation

Three naturally occurring variant human papillomavirus type 16 (HPV-16) E6 proteins, which contained amino acid substitutions predominantly near the N terminus, exhibited significant differences in their abilities to abrogate keratinocyte differentiation in response to serum and calcium and to induce the degradation of p53 in vitro. One variant surpassed the reference E6 protein in its ability to abrogate keratinocyte differentiation responses, whereas another showed a reduction in this activity. Interestingly, the biological activities of the HPV-16 E6 proteins and their abilities to induce p53 degradation in vitro were directly correlated. These results demonstrate that naturally occurring variants of HPV-16 differ in biological and biochemical properties which might result in differences in pathogenicity.

Accumulation of fluoxetine and norfluoxetine in human brain during therapeutic administration

In vivo 19fluorine nuclear magnetic resonance spectroscopy was used to measure the brain concentration of fluoxetine and norfluoxetine in five patients with obsessive-compulsive disorder and three with major depression. The mean brain:plasma ratio of the parent drug plus the metabolite was significantly elevated to 2.6 (SD = 1.0) (95% confidence interval = 1.9-3.3). This accumulation may have implications for understanding both the therapeutic and the toxic effects of fluoxetine.

High-dose fluoxetine in the treatment of depressed patients not responsive to a standard dose of fluoxetine

In a four-week, open label study of major depression, 15 patients who had failed to respond to a trial of fluoxetine 20 mg/day of 8-12 weeks duration were then treated with fluoxetine 40 mg/day for one week and then, if tolerated, with either 60 or 80 mg/day. The mean HAM-D-17 and CGIS scores of these 15 patients decreased significantly at the end of 4 weeks on a higher dosage of fluoxetine (60 or 80 mg/day) with respect to the beginning of the four-week study. No significant side-effects were noted.