The PRO-ACTIVE trial protocol: a randomized study comparing the effectiveness of PROphylACTic swallow InterVEntion for patients receiving radiotherapy for head and neck cancer.

BACKGROUND: Swallowing therapy is commonly provided as a treatment to lessen the risk or severity of dysphagia secondary to radiotherapy (RT) for head and neck cancer (HNC); however, best practice is not yet established. This trial will compare the effectiveness of prophylactic (high and low intensity) versus reactive interventions for swallowing in patients with HNC undergoing RT. METHODS: This multi-site, international randomized clinical trial (RCT) will include 952 adult patients receiving radiotherapy for HNC and who are at high risk for post-RT dysphagia. Participants will be randomized to receive one of three interventions for swallowing during RT: RE-ACTIVE, started promptly if/when dysphagia is identified; PRO-ACTIVE EAT, low intensity prophylactic intervention started before RT commences; or, PRO-ACTIVE EAT+EXERCISE, high intensity prophylactic intervention also started before RT commences. We hypothesize that the PRO-ACTIVE therapies are more effective than late RE-ACTIVE therapy; and, that the more intensive PRO-ACTIVE (EAT + EXERCISE) is superior to the low intensive PRO-ACTIVE (EAT). The primary endpoint of effectiveness is duration of feeding tube dependency one year post radiation therapy, selected as a pragmatic outcome valued equally by diverse stakeholders (e.g., patients, caregivers and clinicians). Secondary outcomes will include objective measures of swallow physiology and function, pneumonia and weight loss, along with various patient-reported swallowing-related outcomes, such as quality of life, symptom burden, and self-efficacy. DISCUSSION: Dysphagia is a common and potentially life-threatening chronic toxicity of radiotherapy, and a priority issue for HNC survivors. Yet, the optimal timing and intensity of swallowing therapy provided by a speech-language pathologist is not known. With no clearly preferred strategy, current practice is fraught with substantial variation. The pragmatic PRO-ACTIVE trial aims to specifically address the decisional dilemma of when swallowing therapy should begin (i.e., before or after a swallowing problem develops). The critical impact of this dilemma is heightened by the growing number of young HNC patients in healthcare systems that need to allocate resources most effectively. The results of the PRO-ACTIVE trial will address the global uncertainty regarding best practice for dysphagia management in HNC patients receiving radiotherapy. TRIAL REGISTRATION: The protocol is registered with the US Patient Centered Outcomes Research Institute, and the PRO-ACTIVE trial was prospectively registered at ClinicalTrials.gov , under the identifier NCT03455608 ; First posted: Mar 6, 2018; Last verified: Jun 17, 2021. Protocol Version: 1.3 (January 27, 2020).

Age-Related Changes in Pharyngeal Lumen Size: A Retrospective MRI Analysis.

Age-related loss of muscle bulk and strength (sarcopenia) is often cited as a potential mechanism underlying age-related changes in swallowing. Our goal was to explore this phenomenon in the pharynx, specifically, by measuring pharyngeal wall thickness and pharyngeal lumen area in a sample of young versus older women. MRI scans of the neck were retrospectively reviewed from 60 women equally stratified into three age groups (20s, 60s, 70+). Four de-identified slices were extracted per scan for randomized, blinded analysis: one mid-sagittal and three axial slices were selected at the anterior inferior border of C2 and C3, and at the pit of the vallecula. Pixel-based measures of pharyngeal wall thickness and pharyngeal lumen area were completed using ImageJ and then converted to metric units. Measures of pharyngeal wall thickness and pharyngeal lumen area were compared between age groups with one-way ANOVAs using Sidak adjustments for post-hoc pairwise comparisons. A significant main effect for age was observed across all variables whereby pharyngeal wall thickness decreased and pharyngeal lumen area increased with advancing age. Pairwise comparisons revealed significant differences between 20s versus 70+ for all variables and 20s versus 60s for all variables except those measured at C2. Effect sizes ranged from 0.54 to 1.34. Consistent with existing sacropenia literature, the pharyngeal muscles appear to atrophy with age and consequently, the size of the pharyngeal lumen increases.

Temporal and Physiologic Measurements of Deglutition in the Upright and Supine Position with Videofluoroscopy (VFS) in Healthy Subjects.

Cross-sectional imaging has long been employed to examine swallowing in both the sagittal and axial planes. However, data regarding temporal swallow measures in the upright and supine positions are sparse, and none have employed the MBS impairment profile (MBSImP). We report temporal swallow measures, physiologic variables, and swallow safety of upright and supine swallowing in healthy subjects using videofluoroscopy (VFS). Twenty healthy subjects ages 21-40 underwent VFS study upright and supine. Subjects were viewed in the sagittal plane and swallowed 5 mL liquid and pudding barium. Oral transit time, pharyngeal delay time, pharyngeal response time, pharyngeal transit time, and total swallow duration were measured. Penetration/aspiration scores and 14 MBSImP variables were analyzed in both positions. All subjects completed swallows supine, although one aspirated on one liquid bolus. Temporal measures of swallowing were similar for pudding upright and supine. Pharyngeal phase swallow measures were longer for liquids in supine. MBSImP physiologic measures revealed a pharyngeal delay in both positions. Although Pen/Asp range was higher supine, more subjects penetrated upright. Temporal measures were increased for liquids in supine. Although Pen/Asp range was higher in supine, more subjects penetrated upright. These results provide support for cross-sectional supine imaging of swallowing for pudding, but perhaps not thin liquids for dysphagic patients. Slightly thicker liquids might prove reliable in supine without compromising swallow safety. Future research should examine swallow physiology in both positions in dysphagic and older healthy subjects.

Reconstructing fungal natural product biosynthetic pathways.

Large scale fungal genome sequencing has revealed a multitude of potential natural product biosynthetic pathways that remain uncharted. Here we describe some of the methods that have been used to explore them via heterologous gene expression. We focus on filamentous fungal hosts and discuss the technological challenges and successes behind the reconstruction of fungal natural product pathways. Optimised, efficient heterologous expression of reconstructed biosynthetic pathways promises progress in the discovery of novel compounds that could be utilised by the pharmaceutical and agrochemical industries.

Development of a new lingual range-of-motion assessment scale: normative data in surgically treated oral cancer patients.

Surgical resection in oral cancer patients can result in altered speech, swallowing, and patient perception of quality of life (QOL). Oral surgery can result in reduced lingual range of motion (ROM). However, few studies have quantified the degree of lingual restriction after surgery. This pilot study describes a new measurement system to define tongue ROM in surgically treated tongue cancer patients. This measurement system was validated by comparing results in these treated surgical patients versus healthy individuals. This scale was further validated by correlating ROM with performance status, oral outcomes, and patient-rated QOL. Thirty-six patients who underwent oral tongue surgery and 31 healthy individuals were included. Tongue ROM was assessed using a novel ROM assessment system. This novel system was examined in these patients versus healthy subjects. This measurement tool was further validated by correlating tongue ROM in treated patients with performance status, oral outcomes, and patient-rated QOL. Tongue ROM was found to be significantly lower in the surgically treated patients than in the healthy individuals (p = 0.0001). Tongue ROM correlated with performance status, oral outcomes, and all QOL measures. This new tongue ROM measurement system defined tongue deficits in surgically treated oral cancer patients. This tool was validated by comparing results to those in healthy individuals, as well as by correlating tongue ROM to performance status, oral outcomes, and QOL. This measurement tool can be used to define baseline and postsurgery tongue ROM in oral cancer patients, as well as track change over time with recovery and therapy. Future studies should examine use of this measurement tool with other populations demonstrating tongue deficits.

Functional outcomes and quality of life after chemoradiotherapy: baseline and 3 and 6 months post-treatment.

Concomitant chemoradiotherapy provides organ preservation for those patients with head and neck cancer. We report the results of a prospective study that examined functional outcomes and quality of life (QOL) after chemoradiotherapy over the first 6 months post-treatment (tx). Twenty-nine patients with head and neck cancer were treated with chemoradiotherapy. All were seen baseline and 3 and 6 months post-tx. Assessments included the performance status scale (PSS), Karnofsky performance status scale, tongue strength, jaw opening, and saliva weight. QOL was patient-rated using the eating assessment tool (EAT-10), MD Anderson dysphagia inventory, speech handicap index (SHI), and the EORTC H&N35 scale. Repeated-measures ANOVAs were used, with significance at p < 0.05. PSS scores were significantly different across time points. Tongue strength, jaw range of motion (ROM), and saliva weight were significantly lower at 3 and 6 months than at baseline. QOL was significantly worse after tx, although it improved by 6 months as rated with the EAT-10 and the SHI scores were significantly worse at 3 and 6 months. EORTC domains of swallowing, senses, speech, dry mouth, and sticky saliva were significantly worse at 3 and 6 months. Concomitant chemoradiotherapy for treatment of head and neck tumors can result in impaired performance outcomes and QOL over the first 6 months post-tx. However, performance status, tongue strength, jaw ROM, and eating QOL were only mildly impaired by 6 months post-tx. Saliva production and speech QOL remained significantly impaired at 6 months post-treatment. Current studies are examining outcomes at 12 and 24 months post-treatment to better predict outcomes over time in this population.

Developing a disease prevention strategy in the Caribbean: the importance of assessing animal health-related risks at regional level.

In 2009 CaribVET conducted a survey among Caribbean national Veterinary Services to assess perceptions of risk assessment and to identify the principal exotic diseases of concern in the region and their means of introduction. The results showed that the introduction of live animals was considered the most likely route of introduction of exotic animal pathogens, followed by the uncontrolled introduction of animal products by boat passengers. The results were used to define a regional strategy for assessing animal health risks that highlights the importance of within-region exchanges.

Laparoscopically inserted button colostomy as a venting stoma and access port for the administration of antegrade enemas in African degenerative leiomyopathy.

African degenerative leiomyopathy (ADL) is a rare incurable disorder seen in African children, predominantly in southern and south-eastern Africa. ADL presents as chronic intestinal pseudo-obstruction. Management is traditionally conservative, with surgery restricted to the management of complications. We have placed Malone antegrade continence enema (MACE) stomas in the grossly dilated colon to vent accumulated gas and administer antegrade bowel enemas. This is done mainly for relief of gaseous distension and constipation in an attempt to provide symptomatic relief and improve quality of life. In this article, we present our preliminary results of laparoscopically assisted technique to insert a Mic-Key gastrostomy device as a 'button colostomy' in 8 patients over the past 6½ years.

Identification of genes encoding squalestatin S1 biosynthesis and in vitro production of new squalestatin analogues.

A gene cluster responsible for the biosynthesis of squalestatin S1 (SQS1, 1) was identified by full genome sequencing of two SQS1-producing ascomycetes: Phoma sp. C2932 and unidentified fungus MF5453. A transformation protocol was established and a subsequent knockout of one PKS gene from the cluster led to loss of SQS1 production and enhanced concentration of an SQS1 precursor. An acyltransferase gene from the cluster was expressed in E. coli and the expressed protein MfM4 shown to be responsible for loading acyl groups from CoA onto the squalestatin core as the final step of biosynthesis. MfM4 appears to have a broad substrate selectivity for its acyl CoA substrate, allowing the in vitro synthesis of novel squalestatins.

Design and utility of oligonucleotide gene probes for fungal polyketide synthases.

BACKGROUND: Recent advances in the molecular biology of polyketide biosynthesis have allowed the engineering of polyketide synthases and the biological ('combinatorial') synthesis of novel polyketides. Additional structural diversity in these compounds could be expected if more diverse polyketide synthases (PKS) could be utilised. Fungal polyketides are highly variable in structure, reflecting a potentially wide range of differences in the structure and function of fungal PKS complexes. Relatively few fungal synthases have been investigated, perhaps because of a lack of suitable genetic techniques available for the isolation and manipulation of gene clusters from diverse hosts. We set out to devise a general method for the detection of specific PKS genes from fungi. RESULTS: We examined sequence data from known fungal and bacterial polyketide synthases as well as sequence data from bacterial, fungal and vertebrate fatty acid synthases in order to determine regions of high sequence conservation. Using individual domains such as beta-ketoacylsynthases (KS), beta-ketoreductases (KR) and methyltransferases (MeT) we determined specific short (ca 7 amino acid) sequences showing high conservation for particular functional domains (e.g. fungal KR domains involved in producing partially reduced metabolites; fungal KS domains involved in the production of highly reduced metabolites etc.). Degenerate PCR primers were designed matching these regions of specific homology and the primers were used in PCR reactions with fungal genomic DNA from a number of known polyketide producing species. Products obtained from these reactions were sequenced and shown to be fragments from as-yet undiscovered PKS gene clusters. The fragments could be used in blotting experiments with either homologous or heterologous fungal genomic DNA. CONCLUSIONS: A number of sequences are presented which have high utility for the discovery of novel fungal PKS gene clusters. The sequences appear to be specific for particular types of fungal polyketide (i.e. non-reduced, partially reduced or highly reduced KS domains). We have also developed primers suitable for amplifying segments of fungal genes encoding polyketide C-methyltransferase domains. Genomic fragments amplified using these specific primer sequences can be used in blotting experiments and have high potential as aids for the eventual cloning of new fungal PKS gene clusters.

Osteoradionecrosis of the subaxial cervical spine following treatment for head and neck carcinomas.

OBJECTIVE: To study MRI and positron emission tomography (PET)/CT imaging of osteoradionecrosis (ORN) of the subaxial cervical spine, a serious long-term complication of radiation therapy (RT) for head and neck cancers that can lead to pain, vertebral instability, myelopathy and cord compression. METHODS: This is a single-institution retrospective review of patients diagnosed and treated for ORN of the subaxial cervical spine following surgery and radiation for head and neck cancer. RESULTS: We report PET/CT imaging and MRI for four patients, each with extensive treatment for recurrent head and neck cancer. Osteomyelitis (OM) and discitis are the end-stage manifestations of ORN of the subaxial spine. CONCLUSION: ORN of the subaxial spine has variable imaging appearance and needs to be differentiated from recurrent or metastatic disease. Surgical violation of the posterior pharyngeal wall on top of the compromised vasculature in patients treated heavily with RT may pre-dispose the subaxial cervical vertebrae to ORN, with possible resultant OM and discitis. MRI and PET/CT imaging are complimentary in this setting. PET/CT images may be misinterpreted in view of the history of head and neck cancer. MRI should be utilized for definitive diagnosis of OM and discitis in view of its imaging specificity. ADVANCES IN KNOWLEDGE: We identify the end-stage manifestation of ORN in the sub-axial spine on PET/CT and MRI to facilitate its correct diagnosis.

Synthesis and secretion of wheat alpha-amylase in Saccharomyces cerevisiae.

A wheat alpha-amylase cDNA clone has been fused to the phosphoglycerate kinase initiator methionine to enable synthesis in the yeast Saccharomyces cerevisiae of an alpha-amylase enzyme that is identical in size to the wild-type alpha-amylase. The alpha-amylase is synthesized with an N-terminal plant signal peptide which is recognized in the yeast host, leading to efficient processing and secretion into the medium. The secretion of alpha-amylase into the medium is quite efficient in rich medium, but barely detectable in a minimal medium.

Functional identification of a fatty acid delta5 desaturase gene from Caenorhabditis elegans.

We have identified a cDNA from the nematode worm Caenorhabditis elegans that encodes a fatty acid delta5 desaturase. Saccharomyces cerevisiae expressing the full-length cDNA was able to convert di-homo-gamma-linolenic acid to arachidonic acid, thus confirming delta5 desaturation. The 1341 bp delta5 desaturase sequence contained an N-terminal cytochrome b5 domain and was located within a kilobase of the C. elegans delta6 desaturase on chromosome IV. With an amino acid identity of 45% it is possible that one of these genes arose from the other by gene duplication. This is the first example of a delta5 desaturase gene isolated from an animal.

Stable expression of maize auxin-binding protein in insect cell lines.

To achieve continuous expression of the major maize auxin-binding protein (ABP1) in insect cells, the ABP1 gene coding region was placed under control of a baculovirus immediate-early gene promoter and transfected into Spodoptera frugiperda Sf9 cells. The ABP1 gene was detected in twelve cell lines, one of which was selected for detailed analysis. Immunolocalisation demonstrated that ABP1 was targeted to and retained in the endoplasmic reticulum (ER), in accordance with its signal peptide and carboxy-terminal KDEL ER-retention signal. We discuss the advantages of stable-transformation over transient expression systems for characterising proteins targeted to the secretory system of insect cells.

Antagonism by piperidine of levodopa effects in Parkinson disease.

The nicotinic cholinergic amine piperidine diminished both the dyskinesia and the symptomatic control in some patients with Parkinson disease receiving levodopa. Since the piperdine configuration is contained in the molecules of the apomorphine and N-propylnoraporphine, it might be responsible for the antagonism of these drugs to some effects of levodopa in Parkinson disease and for the palliation by apomorphine of some dopamine-mediated symptoms in other extrapyramidal disorders.

Immunohistochemical and neurochemical correlates of learning deficits in aged rats.

This study examined whether cholinergic and monoaminergic dysfunctions in the brain could be related to spatial learning capabilities in 26-month-old, as compared to three-month-old, Long-Evans female rats. Performances were evaluated in the water maze task and used to constitute subgroups with a cluster analysis statistical procedure. In the first experiment (histological approach), the first cluster contained young rats and aged unimpaired rats, the second one aged rats with moderate impairment and the third one aged rats with severe impairment. Aged rats showed a reduced number of choline acetyltransferase- and p75(NTR)-positive neurons in the nucleus basalis magnocellularis, and choline acetyltransferase-positive neurons in the striatum. In the second experiment (neurochemical approach), the three clusters comprised young rats, aged rats with moderate impairment and aged rats with severe impairment. Alterations related to aging consisted of reduced concentration of acetylcholine, norepinephrine and serotonin in the striatum, serotonin in the occipital cortex, dopamine and norepinephrine in the dorsal hippocampus, and norepinephrine in the ventral hippocampus. In the first experiment, there were significant correlations between water maze performance and the number of; (i) choline acetyltransferase- and p75(NTR)-positive neurons in the nucleus basalis magnocellularis; (ii) choline acetyltransferase-positive neurons in the striatum and; (iii) p75(NTR)-positive neurons in the medial septum. In the second experiment, water maze performance was correlated with the concentration of; (i) acetylcholine and serotonin in the striatum; (ii) serotonin and norepinephrine in the dorsal hippocampus; (iii) norepinephrine in the frontoparietal cortex and; (iv) with other functional markers such as the 5-hydroxyindoleacetic acid/serotonin ratio in the striatum, 3,4-dihydroxyphenylacetic acid/dopamine ratio in the dorsal hippocampus, 5-hydroxyindoleacetic acid/serotonin and homovanillic acid/dopamine ratios in the frontoparietal cortex, and 3,4-dihydroxyphenylacetic acid/dopamine ratio in the occipital cortex. The results indicate that cognitive deficits related to aging might involve concomitant alterations of various neurochemical systems in several brain regions such as the striatum, the hippocampus or the cortex. It also seems that these alterations occur in a complex way which, in addition to the loss of cholinergic neurons in the basal forebrain, affects dopaminergic, noradrenergic and serotonergic processes.

Grafts of fetal septal cells after cholinergic immunotoxic denervation of the hippocampus: a functional dissociation between dorsal and ventral implantation sites.

Three-month-old Long-Evans rats were subjected to intraseptal infusions of 0.8 microg of 192 IgG-saporin followed, 2 weeks later, by intrahippocampal suspension grafts containing fetal cells from the medial septum and the diagonal band of Broca. The suspensions were implanted in the dorsal or the ventral hippocampus. Sham-operated and lesion-only rats were used as controls. Between 18 and 32 weeks after grafting, all rats were tested in a water maze (using protocols placing emphasis on reference memory or on working memory) and an eight-arm radial maze. The lesion produced extensive cholinergic denervation of the hippocampus, as evidenced by reduced acetylcholinesterase-positivity and acetylcholine content. Depending upon their implantation site, the grafts restored an acetylcholinesterase-positive reinnervation pattern in either the dorsal or the ventral hippocampus. Nevertheless, the grafts failed to normalize the concentration of acetylcholine in either region. The cholinergic lesion impaired working memory performance in both the water maze and the radial maze. To a limited degree, reference memory was also altered. Grafts placed in the ventral hippocampus had no significant behavioral effect, whereas those placed in the dorsal hippocampus normalized working memory performance in the water maze. Our data show that infusion of 192 IgG-saporin into the septal region deprived the hippocampus of its cholinergic innervation and altered spatial working memory more consistently than spatial reference memory. Although the cholinergic nature of the graft-induced reinnervation remains to be established more clearly, these results further support the idea of a functional dissociation between the dorsal and the ventral hippocampus, the former being preferentially involved in spatial memory.

Hippocampal amino acid concentrations after raphe and/or septal cell suspension grafts in rats with fimbria-fornix lesions.

Two weeks after infracallosal electrolytic fimbria-fornix lesions, Long-Evans female rats received intrahippocampal suspension grafts of either fetal septal or mesencephalic raphe tissue, or a mixture of both. Ten months after lesion surgery, the concentrations of alanine, aspartate, GABA, glutamate, glutamine, glycine, serine and taurine were determined in a dorsal, a "middle" and a ventral region of the hippocampus. We found neither the lesions nor the grafts to have significantly modified the concentration of these amino acids which, in all groups, presented a regional heterogeneity in their hippocampal distribution. GABA, glutamate and glutamine were highest in the ventral hippocampus, whereas the other amino acids were highest in the dorsal region. Our results (i) show that fimbria-fornix lesions do not result in lasting effects on hippocampal concentrations of the assessed amino acids, (ii) confirm the regional heterogeneity in the distribution of these amino acids in the hippocampus and (iii) demonstrate that cell suspension grafts of fetal septal or mesencephalic raphe tissue, as well as grafts of a mixture of both of these tissues, do not exert a non-specific effect on either of the amino acid concentrations measured. These data complete those of the preceeding paper [Kiss et al. (1990) Neuroscience 36, 61-72] concerning the effects of the same grafts on hippocampal cholinergic, serotonergic and noradrenergic markers, as well as on several behavioural variables.

Pentavalent [99mTc]DMSA, [131I]MIBG, and [99mTc]MDP--an evaluation of three imaging techniques in patients with medullary carcinoma of the thyroid.

Nine patients with histologically proven medullary carcinoma of the thyroid (MCT) were imaged using pentavalent [99mTc]dimercaptosuccinic acid [(V)DMSA], [131I] metaiodobenzylguanidine (MIBG) and [99mTc]methylene diphosphonate (MDP). Technetium-99m (V)DMSA demonstrated most of the tumor sites in eight patients with proven metastases, with an overall sensitivity of 95% in lesion detection. Iodine-131 MIBG showed definite uptake in some of the tumor sites in three of the nine patients imaged, with equivocal uptake seen in a further one patient, with sensitivity of only 11% for lesion detection. Technetium-99m MDP demonstrated bony metastases only, in four of the patients imaged yielding a sensitivity of 61%. Technetium-99m (V)DMSA has been demonstrated in this study to be a useful imaging agent in patients with MCT, showing uptake in significantly more lesions and with better imaging qualities than [131I]MIBG, and with the ability to detect soft tissue as well as bony metastases.