Human papillomavirus detection and comorbidity: critical issues in selection of patients with oropharyngeal cancer for treatment De-escalation trials

BACKGROUND

The presence of human papillomavirus (HPV)-infection in oropharyngeal squamous cell carcinoma (OPSCC) is a major determinant in prognostic risk modeling. However, most risk models are based on clinical trials which only include a selected patient population. The clinical significance of HPV and other prognostic factors in patients with OPSCC remains to be evaluated in a large, unselected cohort, which also includes patients with stage I/II disease and patients with severe comorbidity.

PATIENTS AND METHODS

All patients diagnosed with OPSCC in 2000-2006 in two Dutch university hospitals were included. The presence of an oncogenic HPV infection was determined by p16-immunostaining, followed by a high-risk HPV general primer 5+/6+ DNA PCR on the p16-positive cases. Cox regression analysis was carried out to compare survival rates between HPV-positive and HPV-negative patients and a prognostic model was generated by recursive partitioning.

RESULTS

In total, 163 of 841 (19.4%) tumors were HPV-positive. Patients with HPV-positive OPSCC had a more favorable overall survival [73.5% versus 40.9% after 5 years; P < 0.001; hazard ratio = 0.34, 95% confidence interval (CI) 0.25-0.48] compared with patients with HPV-negative OPSCC. Patients with p16-positive but HPV DNA-negative tumors showed a significantly less favorable survival than patients with p16-positive and HPV DNA-positive tumors (P < 0.001). A prognostic model was developed in which patients were classified into three risk groups according to HPV status, nodal stage and comorbidity. [Harrell's concordance index of 0.68 (95% CI 0.65-0.71)].

CONCLUSIONS

Tumor HPV status is a strong and independent prognostic factor for survival among patients with OPSCC. A prognostic risk model was proposed, based on our large, unselected cohort of patients with HPV status, comorbidity and nodal stage being the important prognostic factors. In addition, this study emphasizes the importance of performing an HPV DNA-specific test besides p16-immunostaining.

Thrombogenicity of beta 2-glycoprotein I-dependent antiphospholipid antibodies in a photochemically induced thrombosis model in the hamster

We previously showed that beta(2)-glycoprotein I (beta(2)GPI)-dependent lupus anticoagulants (LAs) form bivalent antigen-antibody complexes with high affinity for phospholipids; these complexes are responsible for their in vitro anticoagulant effect. We now studied the role of these bivalent complexes in arterial thrombosis in the hamster. Three monoclonal antibodies (mAbs) raised against human beta(2)GPI were selected on the basis of their cross-reactivity with hamster beta(2)GPI. Two of these, one with LA activity, 5H2, and one with only anticardiolipin properties, 11E8, were infused at 0 to 10 mg/kg prior to photochemically induced vessel damage. 5H2 promoted thrombus formation dose dependently, raising the thrombus size from 6.0 arbitrary units (AU) in controls (n = 9) to 65.0 AU in the high-dose group (10 mg/kg, n = 6, P =.007). The LA(-) mAb 11E8 and mAb 27A8, reactive with human beta(2)GPI exclusively, did not significantly promote thrombus formation. In a second set of experiments, intact mAb 5H2 was compared to its fragments. Intact mAb 5H2 at 3.3 mg/kg and the equimolar dose of F(ab')(2) fragments (2.2 mg/kg) promoted thrombus formation equally well (55.8 AU, n = 8 and 62.5 AU, n = 7, respectively); mAb 5H2-derived Fab' fragments were inactive. Immunohistochemical analysis showed platelet-rich thrombi, with 5H2 or its F(ab')(2) fragments mainly bound to individual platelets. Our results indicate that bivalent immune complex formation plays an important role in the genesis of arterial thrombosis by certain antiphospholipid antibodies. Cellular activation via the Fc portion of these immune complexes, however, is not essential, because F(ab')(2) fragments of 5H2 still promote thrombus formation.

Pyrokinin neuropeptides in a crustacean. Isolation and identification in the white shrimp Penaeus vannamei

Identification of substances able to elicit physiological or behavioural processes that are related to reproduction would greatly contribute to the domestication of commercially important crustaceans that do not reproduce easily in captivity. Crustaceans are thought to release urine signals used for chemical communication involved in courtship behaviour. In contrast to insects, very little is known about the endocrinological processes underlying this phenomenon. Therefore, an extract of 3500 central nervous systems of female white shrimp Penaeus vannamei was screened for myotropic activity in order to purify pyrokinin-like peptides that belong to the pyrokinin/PBAN neuropeptide family. Members of this family regulate reproductive processes in insects, including pheromone biosynthesis. Purification of these pyrokinins was achieved by a combination of reversed-phase and normal-phase chromatography. Subsequent characterization by mass spectrometry, Edman degradation and peptide synthesis resulted in the elucidation of two novel peptides. Pev-PK 1 has the primary sequence DFAFSPRL-NH(2) and a second peptide (Pev-PK 2) is characterized as the nonapeptide ADFAFNPRL-NH(2). Pev-PK 1 contains the typical FXPRL-NH(2) (X = G, S, T or V) C-terminal sequence that characterizes members of the versatile pyrokinin/PBAN family. Pev-PK 2 displays an Asn residue at the variable X position of the core pyrokinin sequence. These crustacean pyrokinins are the first to be found in a noninsect. The synthetic peptides display myotropic activity on the Leucophaea maderae as well as on the Astacus leptodactylus hindgut.

The kinin peptide family in invertebrates

Kinins comprise a family of peptides that were first found in the central nervous system of insects and recently also in mollusks and crustaceans. After the isolation of the first members of the kinin family, the leukokinins from Leucophaea maderae, leukokinin-related peptides were found in the cricket Acheta domesticus and the locust Locusta migratoria, all through their ability to induce Leucophaea maderae hindgut contraction. Subsequently, kinins were found in the mosquitoes Culex salinarius and Aedes aegypti and in the earworm Helicoverpa zea. The first noninsect member of this family was isolated from a mollusk, the pond snail Lymnaea stagnalis. Most recently our group has isolated the first kinins from crustaceans. Six kinins were isolated from the white shrimp Penaeus vannamei. To date, 35 members of this family have been isolated. The first relatively small family of insect kinins has grown into an expanding and rather large family with members in insects, crustaceans, and mollusks. In this paper we discuss the kinin family in terms of method of isolation, structure, in vitro and in vivo activity, distribution, receptors, and signal transduction. We will compare the crustacean and insect members of the kinin family, using the data available on crustacea.

An evaluation of the GlideScope®, a new video laryngoscope for difficult airways

BACKGROUND AND OBJECTIVES

The GlideScope is a new video laryngoscope. The aim of our study was to assess its use compared to a Macintosh blade in airway scenarios on the Airman airway simulator. The scenarios were: 'normal' or resting state of the manikin, pharyngeal obstruction, cervical rigidity and tongue oedema.

METHODS

Thirty anaesthetists from the Christchurch Anaesthetic Department attempted to pass a bougie or stylet through the vocal cords of the manikin with a size 3 Macintosh blade, then the GlideScope. View at laryngoscopy, ease of 'intubation' and whether they thought the GlideScope would be useful in clinical practice were recorded.

RESULTS

Forty three percent (P = 0.02) found an improved view with the GlideScope in the pharyngeal obstruction scenario. In the other scenarios there was no significant difference in view. Reportage of ease of intubation showed no statistical difference in any scenarios. However, 93% of anaesthetists considered having the GlideScope would be useful if faced clinically with one or more of the studied scenarios.

CONCLUSIONS

The GlideScope improved the view in one of three difficult airway situations when used by anaesthetists with no formal training in its use. No single airway device offers a solution to all scenarios, however, we consider that the GlideScope is a useful addition to the range of difficult airway devices available.

Chronic Eosinophilic Dermatitis Associated with Persistent Feline Herpes Virus Infection in Cheetahs (Acinonyx jubatus)

A chronic ulcerative and eosinophilic dermatitis occurred in 20 captive cheetahs ( Acinonyx jubatus) with persistent feline herpes virus 1 (FHV1) infection. Affected animals had erythematous, ulcerated plaques primarily on the face and forelegs in sites of contact with lachrymal and salivary secretions. The dermatitis was characterized by dense infiltrates of eosinophils and plasma cells and pseudoepitheliomatous hyperplasia. Rare keratinocytes within the lesions had nuclei with marginated chromatin and small eosinophilic inclusions composed of herpes virus nucleocapsids. Virus isolated from lesions was confirmed to be FHV1. Lesions persisted and progressed unless removed by cryoexcision. The occurrence of this unusual reaction to FHV1 in approximately 5% of captive North American cheetahs suggests a species propensity for a Th2-dominant response to herpes virus infection. This atypical immune reaction may indicate a heritable trait or modulation of the immune response by other factors such as chronic stress.

Silent ischaemia and hypertension

For many years now, silent ischaemia has been recognized as a distinct clinical entity, and its relevance in different patient groups has been established. However, a number of basic questions have not been answered. In explaining the pathophysiology of silent ischaemia, factors affecting both the demand and the supply side are now being recognized. With the exception of certain well-defined groups, it is not clear why some patients are mostly symptomatic, while other patients are predominantly asymptomatic. There appear to be many factors influencing the ischaemic pain threshold. Studies investigating the prevalence of silent ischaemia show a remarkably high prevalence of silent ischaemia in different patient groups. Patients with hypertension but without coronary artery disease form a specific and vulnerable high-risk population that is particularly prone to silent ischaemia. Since changes at the macrovascular level are not responsible, various factors negatively influencing either cardiac supply or demand have been investigated. A reduced coronary reserve is central in explaining the increased prevalence of silent ischaemia in hypertensives. Left ventricular hypertrophy renders meaningful detection of ST segment changes difficult, but a possible solution dealing with this problem is offered by applying more stringent criteria in terms of minimal ST depression in the definition of ischaemia. The treatment of silent ischaemia is largely the same as for angina pectoris, but whether therapy should be directed at elimination of all ischaemic episodes or only of symptomatic episodes depends on further prospective work addressing this question.

A randomised double-blind study of interpleural analgesia after cholecystectomy

Continuous interpleural analgesia provided by 4 hourly injections of 20 ml bupivacaine 0.5% with adrenaline 5 micrograms/ml was compared with placebo in a randomised, double-blind study after cholecystectomy. All patients self-administered intravenous morphine using a patient-controlled analgesia device. There was a highly significant difference in mean morphine consumption between the groups (72 mg as compared with 22 mg). Visual analogue pain scores tended to be lower in the bupivacaine group throughout and this was significant at 2 hours. Respiratory function measurements were not significantly different between the groups. The mean peak venous plasma bupivacaine concentration after the sixth dose was 3.03 micrograms/ml and no symptoms suggestive of local anaesthetic toxicity occurred. It is concluded that this regimen can provide effective and continuous analgesia after cholecystectomy and that combined administration of interpleural bupivacaine and systemic morphine is more effective than morphine alone in the immediate postoperative period. The doses of bupivacaine required for optimal use of the technique lead to significant total plasma bupivacaine concentrations within 24 hours.

What should doctors wear in the accident and emergency department? Patients' perception

In many accident and emergency (A&E) departments doctors still wear white coats or their ordinary clothes, rather than a type of uniform, which, should it become contaminated, can be changed easily for a clean uniform. Before a change of clothing to a uniform could be considered in an inner-city A&E department, a study was carried out to assess the public's perception towards different styles of dress. Three hundred and twenty-nine questionnaires were returned by minor injury patients requiring a radiograph. The study was carried out over 3 weeks in January 1993. Each week a different style of dress was worn: week 1--white coats, week 2--normal clothing and week 3--theatre greens. The majority of patients thought that style of dress was important but did not alter their attitude towards the A&E medical staff. Therefore, there is no reason why doctors should not wear a more appropriate uniform that can be changed easily when contaminated.

Structure-activity studies on narcotic antagonists. 2. N-substituted ethyl 3-(m- or p-hydroxyphenyl) nipecotates

A number of N-substituted ethyl 3-(n- or p-hydroxyphenyl)nipecotates were synthesized to evaluate the role of a m- or p-hydroxy substituted beta-phenethylamine moiety in narcotic antagonist action. Ethyl m- or p-methoxy-phenylcyanoacetate was alkylated with 1-bromo-3-chloropropane. The resultant chloronitriles were hydrogenated (Raney Ni) to amines and cyclized to yield the N-substituted ethyl 3-(m- or p-methoxyphenyl)nipecotates. These were N-benzylated, O-demethylated using BBr3, N-debenzylated, and then N-alkylated. The following N-substituted derivatives were prepared: methyl, allyl, cyclopropylmethyl, and n-propyl. No significant morphine-like analgesic activity was found in mice by the tail-flick method. The acetic writhing assay showed several compounds to possess analgesic activity. N-n-Propyl and N-(cyclopropylmethyl) m-hydroxy derivatives were marginally active antagonists by the mouse tail-flick method. Surprisingly, the N-methyl m-hydroxy derivative, 11m, was found to be an antagonist.

Diversity of hepatitis C virus infection among HIV-infected people who inject drugs in India

The availability of generic direct acting antivirals (DAAs) for hepatitis C virus (HCV) treatment has prompted many low-and-middle-income countries to launch HCV elimination programs. Because the efficacy of some of these generic DAAs varies by HCV viral subtype, information on subtype distribution can contribute important information to these elimination programs. We conducted a cross-sectional serosurvey to characterize HCV subtype diversity among HIV positive people who inject drugs (PWID) across 14 cities in India. Of 801 HIV positive PWID sampled, 639 tested HCV antibody positive (78.9%). Among 105 samples sequenced, genotype 3 (58.1%) was the most commonly observed followed by genotype 1 (36.2%) and genotype 6 (5.7%). Of the genotype 3 infections, 65% were subtype 3a and 35% were subtype 3b. Of the genotype 1 infections, 94% were subtype 1a and 6% were subtype 1b. All genotype 6 samples were subtype 6n. There was some variability in genotype diversity depending on geographic region and PWID epidemic stage with greater diversity observed in older PWID epidemics. One sequence, HY018, did not cluster with any known reference sequences in phylogenetic analysis. Nearly 80% of HIV infected PWID across India are co-infected with HCV, and subtype prevalence and genetic diversity varied by region and PWID epidemic stage. HCV elimination programs in India will need to consider HCV subtype.

Acute effects of peritoneal dialysis on hemodynamics

OBJECTIVES

To investigate the acute hemodynamic effects of peritoneal dialysis (PD) using the noninvasive Portapres technique [TNO Biomedical Instrumentation (TNO BMI); Amsterdam, The Netherlands].

DESIGN AND METHODS

Blood pressure was measured in 21 consecutive patients on continuous ambulatory PD during a standard peritoneal permeability analysis (SPA). Blood pressure, stroke volume, cardiac output, and total peripheral resistance were recorded and calculated using continuous finger pressure recordings with Portapres and Modelflow software (TNO BMI). The SPA consists of four phases: (1) drainage of night dwell dialysate, (2) instillation of a rinsing solution (1.36% glucose), (3) drainage of rinsing solution, and (4) instillation of the test solution (3.86% glucose to which dextran 70 has been added).

RESULTS

Both systolic blood pressure (SBP) (7 +/- 9 mmHg, p < 0.005) and diastolic blood pressure (DBP) (5 +/- 6 mmHg, p < 0.01) increased during phase 2. Systolic BP and DBP increased further during phase 4 (SBP 8 +/- 14 mmHg, p < 0.05; DBP 6 +/- 8 mmHg, p < 0.005). These BP increases were caused by a rise in total peripheral resistance of 10% +/- 18% (p< 0.05) during phase 1, and 15% +/- 21% (p < 0.005) during phase 2.

CONCLUSIONS

Instillation and dwell of a dialysis solution during PD causes a rise in blood pressure. This is caused by an increase in total peripheral resistance. Factors influencing total peripheral resistance could be a direct mechanical effect of dialysate on mesenteric resistance vessels or a temperature-related effect.