Long-Term Treatment With Extended-Release Methylphenidate Treatment in Children Aged 4 to <6 Years

OBJECTIVE

To investigate long-term (12-month) safety and symptom control of extended-release methylphenidate (MPH-MLR) in children aged 4 to <6 years after treatment optimization.

METHOD

A total of 90 children aged 4 to <6 years with attention-deficit/hyperactivity disorder (ADHD) were enrolled from 2 MPH-MLR studies. Treatment-emergent adverse events (TEAEs) and ADHD symptom control were assessed in the safety population (n = 89) and modeled with mixed model analyses.

RESULTS

Most TEAEs (89.9%) were rated by investigators as of mild or moderate severity. One serious AE was reported (unrelated to study drug). Ten children discontinued because of TEAEs. Two discontinued because of weight loss; no significant increase in the rate of underweight children from baseline to endpoint was observed. Overall, 18% lost weight and 18% reported decreased appetite. Weight and height z scores and obesity rates decreased significantly from baseline to endpoint. Insomnia was reported (9%); none of these children discontinued. Sleep quality did not change significantly. Hypertension was reported (6.7%); none of these children dropped out. Diastolic, but not systolic, blood pressure increased significantly during the follow-up. Control of ADHD symptoms was maintained throughout follow-up.

CONCLUSION

These data contribute to the understanding of the long-term safety of an extended-release stimulant in children 4 to <6 years of age. The observed risk of a TEAE-related discontinuation was ∼11%. TEAEs were not dose related, and most were of mild to moderate severity. Symptom control was maintained through the year-long study.

CLINICAL TRIAL REGISTRATION INFORMATION

A 12-Month Open Label Safety Study of Aptensio XR® in Children Ages 4-5 Years Diagnosed With ADHD (EF004); https://clinicaltrials.gov; NCT02677519.

Abstract 5282: Comparison of a public versus private hospital in New York City in delivering timely adjuvant chemotherapy among stage III colon cancer patients

Background: Although the optimal timing of adjuvant chemotherapy (AC) for stage III colon cancer patients has been debated, most studies recommend initiating AC within approximately 60 days of surgery. Significant disparities in timeliness of AC initiation in colon cancer have been reported in public versus private hospitals, with longer time to AC at public hospitals. We evaluated whether timeliness of AC differed between a public and a private hospital, both affiliated with the same major academic institution in New York City.

Methods: We conducted a retrospective cohort study of Stage III colon cancer patients who underwent surgery and received AC at the same institution from 2008-2015 at NYU Langone Medical Center’s affiliated public hospital (Bellevue) or its private hospital (Tisch). Patient data were obtained through review of hospital tumor registry and electronic medical records. Patient characteristics were compared by hospital. We defined timeliness as receipt of AC within 60 days postoperatively. Univariate and stepwise multivariable logistic regressions were used to identify factors associated with timely AC.

Results: Forty three patients at Bellevue Hospital and 79 patients at Tisch Hospital who underwent surgery and received AC at the same institution were included. Median number of days to AC was significantly greater among patients receiving care at Bellevue (53, range 31-231) compared to Tisch (43, range 25-105; p=0.002). However, the percentage of patients who received timely AC did not differ substantially at Bellevue and Tisch (74% vs 81%, p=0.40). Individual characteristics significantly associated with timely initiation of AC were non-Hispanic ethnicity (OR: 2.71, 95% CI: 1.06-6.95), married (OR: 2.89, 95%CI: 1.15-7.30), and laparoscopic (vs open) surgery (OR: 4.30, 95%CI: 1.64-11.25). The odds of receiving timely AC at Bellevue compared to Tisch was not significant (OR: 0.68, 95% CI: 0.28-1.65). When hospital and other factors were examined jointly, only age (OR: 0.95/year, 95% CI: 0.91-0.99) and laparoscopic (vs open) surgery (OR: 5.65, 95% CI: 1.92-16.62) remained as important factors associated with receiving timely AC (Likelihood Ratio Chi-Square=14.95, p=0.0019). When hospital was omitted from multivariable analysis, age and surgery type still remained the only significant factors associated with timely AC (OR’s unchanged, Likelihood Ratio Chi-Square=14.81, p-value=0.0006).

Conclusions: The proportion of patients receiving timely AC within 60 days of surgery was similar at both an affiliated public and private hospital at NYU Langone Medical Center. Age and type of surgery were significant predictors of timeliness in our population. Further research should be conducted to understand how system-level factors may promote timely receipt of care.

Citation Format: Daniel Lin, Benjamin Levinson, Judith D. Goldberg, Tsivia Hochman, Lawrence P. Leichman, Heather T. Gold. Comparison of a public versus private hospital in New York City in delivering timely adjuvant chemotherapy among stage III colon cancer patients [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2017; 2017 Apr 1-5; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2017;77(13 Suppl):Abstract nr 5282. doi:10.1158/1538-7445.AM2017-5282

Continuous-infusion topotecan and erlotinib: a study in topotecan-pretreated ovarian cancer assessing shed collagen epitopes as a marker of invasiveness

BACKGROUND

Continuous-infusion topotecan with erlotinib has the potential to reverse topotecan resistance due to drug efflux mechanisms. We assessed the activity of such a regimen in ovarian cancer patients previously failing bolus topotecan. Assay for shed collagen epitopes recognized by antibody HU177 during treatment explored its ability to reflect tumor invasion.

METHODS

Topotecan 0.4 mg/m(2) per day was administered by continuous infusion for 9-10 days every 3 weeks. Erlotinib, 150 mg orally, was administered on days 1-10 of each cycle. Cycles were repeated until progression or toxicity. Serum for shed HU177 collagen epitopes was collected weekly. This was a two-stage design to detect a CA-125 response rate of at least 20% in 30 patients after completing two treatment cycles. The trial would be terminated early if there were less than two CA-125 responses in 16 patients. Four or more CA-125 responses in 30 patients would justify further study of this regimen in prior topotecan treatment failures.

RESULTS

Six patients were enrolled, with four receiving three or more cycles and one achieving a partial response by cancer antigen 125 (CA-125) criteria. Shed epitope levels became undetectable on at least one measurement in all patients who received three or more cycles (Fig. 1A) and reappeared concomitantly with rises in CA-125 and clinical progression (Fig. 1B). After logistical delays, the trial was closed by the sponsor's decision to stop developing erlotinib in ovarian cancer. FIGURE 1: Monitoring of combination treatment. A, B, C, D, and F refer to patients. (A):: Topotecan and erlotinib. (B):: CA-125 in units/mL.

CONCLUSION

Continuous-infusion topotecan with erlotinib was found safe in six pretreated ovarian cancer patients; one met CA-125 criteria for partial response. Serial shed epitope levels to reflect invasiveness deserve further study.

Cisplatin with capecitabine: tolerance and activity in a phase I/II study preferentially enrolling patients with gastric cancer

BACKGROUND

Capecitabine is an oral prodrug of flurouracil with broad activity against various malignancies. We explored its tolerance and preliminary efficacy when given together with cisplatin in a phase I/II study preferentially enrolling gastric cancer patients.

PATIENTS AND METHODS

The study was a 3+3 dose escalation design and at the recommended phase II dose it included an expanded cohort of patients with upper gastrointestinal cancer. The dose of cisplatin was escalated from 40 to 50 mg/m(2) on day 1, and capecitabine of 2,500 mg/m(2)/day starting on day 2, was escalated from 5 days to 10 and then to 14 days, with the cycle repeated every 21 days. Prolonged maintenance with capecitabine was offered to selected patients completing three to six cycles.

RESULTS

A total of 34 patients were enrolled, and 27 patients were also evaluable for response. Dose limiting toxicities were palmar plantar erythrodyesthesia (PPE) and diarrhea; grade 3 and 4 neutropenia occurred in 8.8% and grade 3 PPE in 5.9%, while the most common grade 1-2 toxicities were anemia, neutropenia, fatigue and PPE (11.7% each). There were no treatment related deaths. With cisplatin at 40-50 mg/m(2) day 1 and capecitabine at 2,500 mg/m(2)/day for 5 -14 days every 21 days, 18 patients with gastric cancer were treated and 7 had partial responses.

CONCLUSION

A regimen of capecitabine and cisplatin at the doses and schedules explored was safe and active in patients with gastric cancer. Moreover, a 6-month administration of adjuvant capecitabine proved feasible, yielding favorable results after treatment completion and surgery, and should be investigated further.

Phase II study of sorafenib with gemcitabine and erlotinib (GES) in first-line advanced pancreatic cancer

266

Background: Addition of erlotinib (E) to gemcitabine (G) results in improved OS for patients (pts) with advanced pancreatic cancer. Many pancreatic tumors have constitutively activated ras/raf pathways and overexpress VEGF. Sorafenib (S), a multitargeted tyrosine kinase inhibitor, including VEGR 1-3, PDGFR-α and β and the RAF/MEK/ERK pathway, when combined with G and E may synergize, resulting in a more complete blockade of the signal transduction cascade in pancreatic cancer growth and progression, and improved outcome.

Methods: Pts with previously untreated, histologically confirmed, unresectable pancreatic adenocarcinoma, PS 0-1, and adequate organ function were eligible and received G 1,000 mg/m2 over 30 min qw x 3 every 4w. E 150 mg PO daily and S 400 mg PO bid were given continuously. CT scans were performed every 2 cycles (8w). Primary endpoint included PFS at 4 mos and secondary endpoints included safety and tolerability of the novel combination, RR, and OS.

Results: 45 pts enrolled, 44 evaluable for toxicity(1 not treated), and 30 evaluable for response. Median age was 64 (45-84), 32 males (71%), 43 (96%) had metastatic disease, PS was 0 in 26 (58%). Median number of cycles was 2 (0-10). Grade (gr) 3 toxicity included: thrombocytopenia 5; diarrhea 4; vomiting 4; HFS, hyperbilirubinemia, hyperglycemia and SOB each 3 pts; 1 bowel perforation and 1 epistaxis. Gr 4 toxicity included 1 each: bowel perforation, GI bleed, transaminitis, hyperglycemia and sepsis with hypotension. 2 patients only required dose reduction of S for HFS. There were 2 PR (7%), 13 SD (43%), overall RR of 7% and DCR of 50%. Median TTP 111 days (95% CI = 53-175) and median OS 195 days (144-290). PFS at 16 weeks was 49%, just reaching statistical significance.

Conclusions: The combination of G and E plus S in the treatment of advanced pancreatic cancer is a well tolerated regimen without significant increased toxicity as compared to G alone, except for very manageable cutaneous reactions. While the primary endpoint met our pre-determined criteria (compared with NCIC PA.3), this study does not suggest a major benefit for addition of S to G-E when compared to published data. Supported in part by grants from Bayer Healthcare Pharmaceuticals/Onyx and OSI.

No significant financial relationships to disclose.

Weekly paclitaxel with intermittent imatinib mesylate (Gleevec): tolerance and activity in recurrent epithelial ovarian cancer

OBJECTIVE

Imatinib mesylate (IM, Gleevec), a potent PDGF/PDGFR tyrosine kinase inhibitor, affects stroma and vascular endothelial cells. Our study sought to determine the safety and activity of paclitaxel with an intermittent schedule of IM.

MATERIALS AND METHODS

rEOC patients previously treated with platinum/paclitaxel and ≤2 regimens for recurrence were enrolled. Paclitaxel 80 mg/m2 was given on days 3, 10, 17 every 28 days and oral IM 300 mg bid on days 1-4, 8-11, and 13-18.

RESULTS

Between 2007-2009, 14 patients enrolled, 12 were evaluable. Nine patients were on study at 12 weeks. Objective responses (by RECIST and/or CA125) occurred in 4 patients. There were no grade 4, and only four grade 3 toxic events: diarrhea, edema and 2 cases of neutropenia. Early study closure was due to sufficient safety information with preliminary encouraging efficacy results.

CONCLUSION

This weekly paclitaxel regimen with intermittent IM is tolerable with anti-tumor activity, making it suitable as part of future studies.

Neurodegeneration associated with genetic defects in phospholipase A(2)

OBJECTIVE

Mutations in the gene encoding phospholipase A(2) group VI (PLA2G6) are associated with two childhood neurologic disorders: infantile neuroaxonal dystrophy (INAD) and idiopathic neurodegeneration with brain iron accumulation (NBIA). INAD is a severe progressive psychomotor disorder in which axonal spheroids are found in brain, spinal cord, and peripheral nerves. High globus pallidus iron is an inconsistent feature of INAD; however, it is a diagnostic criterion of NBIA, which describes a clinically and genetically heterogeneous group of disorders that share this hallmark feature. We sought to delineate the clinical, radiographic, pathologic, and genetic features of disease resulting from defective phospholipase A(2).

METHODS

We identified 56 patients clinically diagnosed with INAD and 23 with idiopathic NBIA and screened their DNA for PLA2G6 mutations.

RESULTS

Eighty percent of patients with INAD had mutations in PLA2G6, whereas mutations were found in only 20% of those with idiopathic NBIA. All patients with two null mutations had a more severe phenotype. On MRI, nearly all mutation-positive patients had cerebellar atrophy, and half showed brain iron accumulation. We observed Lewy bodies and neurofibrillary tangles in association with PLA2G6 mutations.

CONCLUSION

Defects in phospholipase A(2) lead to a range of phenotypes. PLA2G6 mutations are associated with nearly all cases of classic infantile neuroaxonal dystrophy but a minority of cases of idiopathic neurodegeneration with brain iron accumulation, and genotype correlates with phenotype. Cerebellar atrophy predicts which patients are likely to be mutation-positive. The neuropathologic changes that are caused by defective phospholipase A(2) suggest a shared pathogenesis with both Parkinson and Alzheimer diseases.

Phase I dose-escalating study of bi-weekly pemetrexed (MTA) with fixed dose rate gemcitabine (gem) in patients with advanced cancer

2049

Background: Fixed dose rate (FDR) gem may optimize the documented benefit of gem in pancreatic, NSCL, head and neck, and breast cancers. Preclinical data of the combination of MTA and gem indicate synergy. We studied a bi-weekly combination of MTA and FDR gem to improve tolerance over the previous “Day 1, 8” regimen. Methods: MTA followed by FDR gem infusion was given every 14 days in a dose-escalation design below. Dose-limiting toxicities (DLT) is defined as: grade 4 neutropenia ≥ 5 days, febrile neutropenia, grade 4 thrombocytopenia, or grade 3–4 non-hematological toxicities in 1st cycle. 27 patients were enrolled with median age 59 (range 41–82), males/females 18/9, and ECOG PS 0/1 (5/22). All received Vitamin B12 (1 mg IM prior to study & q9 weeks) and folic acid (350–1000 mcg po qd) supplementation 1–2 weeks prior and during study plus dexamethasone 4 mg po BID day before, of, and after chemotherapy. Results: Dose level 7 has been reached and is being expanded with DLT in 1 patient. Toxicities per patient during all cycles include grade 3–4 neutropenia (8/27 patients), grade 3 anemia (3), brief febrile neutropenia (6), grade 3 rash (1 patient), grade 3 low back pain (1), grade 3 renal failure (1), grade 5 perforated duodenal stent (1). In 19 patients evaluable for response, there were 11 stable disease and 8 progression of disease. Conclusion: Recommended phase II dose for bi-weekly MTA with FDR gem is likely to be 800 mg/m2 and 1,200 mg/m2 × 120 minutes. This regimen allows full doses and dose intensity of both drugs to be administered on a simple schedule with excellent tolerance. A phase II study in biliary cancer is planned. This study is supported in part by Eli Lilly.a This toxicity was at baseline, therefore not drug related.b, c These toxicities were in one patient and were not drug related, rather related to the individual patient’s status going into therapy.

[Table: see text]

[Table: see text]

Phase I study of bortezomib and oxaliplatin (BOX) in solid tumors: Improved neurotoxicity (NT) profile with lower bortezomib (B) dose

12007

Background: B inhibits proteasome function and may be synergistic in causing apoptotic death with platinum agents. We were interested in combining B with OX but concerned with dose limiting (DL) NT based on our prior B phase I study [Hamilton et al., JCO 2005]: therefore this Phase I dose-escalation study (alternating increases of B and OX) focusing on NT was planned. Methods: Patients (pts) with metastatic solid tumors, PS 0–2, platinum or taxane naive, no peripheral neuropathy and adequate organ function, received B (D1, 4, 15, 18) and OX (D1, 15) every 28 days in a dose escalation design (see table ). Baseline and monthly assessments were performed by an independent neurologist. Results: 27 (18 gastrointestinal, 3 melanoma, 3 ovarian, 3 others) were accrued; pt characteristics: 14 male/13 female; median age 55 years (range 35–75); 2 median cycles (range 1–10). NT was not DL because it did not occur within the first cycle. Late and limiting NT was observed in levels 2–5 after 2–9 cycles, but serial neurologic evaluations showed reversible NT. With an amended new dose level to lower B to 1.0 mg/m2 (level 6) to avoid late NT, NT was not observed. Of 22 evaluable pts, there were 3 partial responses (ampullary, GE junction, biliary), 6 stable disease, and 13 disease progression by RECIST criteria. Conclusions: biweekly BOX is tolerable at B 1.0 mg/m2 and OX 85 mg/m2 with no DL NT. Additional observations on late NT are ongoing. This suggests B is a major contributor to NT observed in dose levels 2–5 and may potentiate the effects of OX.

[Table: see text]

[Table: see text]

Azathioprine myelosuppression in multiple sclerosis: characterizing thiopurine methyltransferase polymorphisms

We describe two multiple sclerosis patients who developed pancytopenia following treatment with azathioprine. They were found to have the homozygous polymorphism for thiopurine methyltransferase deficiency and recovered after cessation of drug therapy. We review the literature concerning this molecular derangement and underscore the importance of performing surveillance testing for allelic characterization prior to treatment intervention with this agent for immune-mediated disorders.

Attenuation of the kaluretic properties of furosemide by triamterene (Dyrenium®) in healthy volunteers

OBJECTIVE

To examine if concomitant administration of furosemide, a loop diuretic, with the potassium- and magnesium-sparing diuretic triamterene would decrease loss of potassium and magnesium while improving diuresis.

METHODS

In this open-label, three-way crossover study, healthy subjects were randomized to receive treatment with 40 mg furosemide, with 150 mg triamterene, or treatment with 40 mg furosemide and 150 mg triamterene. Urine samples were collected 24 hours before dosing and between 0 - 1, 1 - 2, 2 - 3, 3 - 4, 4 - 6, 6 - 8, 8 - 12, and 12 - 24 hours post-dosing. Sodium and potassium levels were measured by an ion-selective electrode method. Magnesium was measured colorimetrically using a xylidyl blue reaction.

RESULTS

Co-administration of furosemide with triamterene resulted in enhanced diuresis, particularly in the first 0 - 12 hours post-dose, compared with either furosemide or triamterene alone. Compared to individual treatments, combination therapy significantly increased urinary sodium excretion (p = 0.0001) while significantly decreasing urinary potassium excretion (p = 0.0001); importantly, the magnesium-sparing characteristic of triamterene was retained with furosemide co-administration.

CONCLUSION

Triamterene, when used in combination with the loop diuretic, furosemide, preserves intracellular potassium and magnesium while enhancing the natriuretic effect of furosemide.

Neutral endopeptidase protein expression and prognosis in localized prostate cancer

PURPOSE

Neutral endopeptidase (NEP) is a cell-surface peptidase that inactivates neuropeptide growth factors implicated in prostate cancer progression. The clinical significance of decreased NEP expression observed in prostate cancer is unclear. We investigated whether decreased NEP expression in localized prostate cancers is associated with prostate-specific antigen (PSA) relapse after radical prostatectomy.

EXPERIMENTAL DESIGN

NEP expression patterns were examined by immunohistochemistry in 223 men, who underwent radical prostatectomy between 1990 and 2000 at the Veterans Administration Medical Center (New York, NY) with available representative tissues and adequate follow up. We also examined whether hypermethylation of the NEP promoter contributes to down-regulation of NEP protein expression in a subset of patients that showed decreased NEP expression (n = 22).

RESULTS

Three patterns of NEP expression were observed: (a) membranous expression similar to benign prostate epithelium (n = 82; 37%); (b) complete loss of NEP expression in prostate cancer compared with adjacent benign prostate glands (n = 105; 47%); and (c) heterogeneous NEP expression (n = 36; 16%). In a multivariate analysis, complete loss of NEP expression was associated with PSA relapse after controlling for grade, stage, pretreatment PSA, and race simultaneously (hazard ratio, 1.99; 95% confidence interval, 1.13-3.52; two-sided chi(2) P = 0.017). In addition, DNA hypermethylation of the NEP promoter was frequently (73%) identified in a subset of 22 of cases that showed decreased NEP expression.

CONCLUSION

Our data suggest that decreased NEP expression might contribute to progression of localized prostate cancer after surgery. Data also suggest that methylation is an important mechanism of NEP protein silencing. Larger prospective studies are required for confirmation.

13th National Congress of the South African Society of Psychiatrists, 20-23 September 2004

List of abstacts and authors:1. Integrating the art and science of psychiatryEugene Allers2. Chronic pain as a predictor of outcome in an inpatient Psychiatric populationEugene Allers and Gerhard Grundling3. Recent advances in social phobiaChrister Allgulander4. Clinical management of patients with anxiety disordersChrister Allgulander5. Do elephants suffer from Schizophrenia? (Or do the Schizophrenias represent a disorder of self consciousness?) A Southern African perspectiveSean Exner Baumann6. Long term maintenance treatment of Bipolar Disorder: Preventing relapseCharles L. Bowden7. Predictors of response to treatments for Bipolar DisorderCharles L. Bowden8. Aids/HIV knowledge and high risk behaviour: A Geo-graphical comparison in a schizophrenia populationP Buckley, S van Vuuren, L Koen, J E Muller, C Seller, H Lategan, D J H Niehaus9. Does Marijuana make you go mad?David J Castle10. Understanding and management of Treatment Resistant SchizophreniaDavid J Castle11. Workshop on research and publishingDavid J Castle12. From victim to victor: Without a self-help bookBeatrix Jacqueline Coetzee13. The evaluation of the Gender Dysphoric patientFranco Colin14. Dissociation: A South African modelA M Dikobe, C K Mataboge, L M Motlana, B F Sokudela, C Kruger15. Designated smoking rooms...and other "Secret sins" of psychiatry: Tobacco cessation approaches in the severely mentally illCharl Els16. Dual diagnosis: Implications for treatment and prognosisCharl Els17. Body weight, glucose metabolism and the new generation antipsychoticsRobin Emsley18. Neurological abnormalities in first episode Schizophrenia: Temporal stability and clinical and outcome correlatesRobin Emsley, H Jadri Turner, Piet P Oosthuizen, Jonathan Carr19. Mythology of depressive illnesses among AfricansSenathi Fisha20. Substance use and High school dropoutAlan J. Flisher, Lorraine Townsend, Perpetual Chikobvu, Carl Lombard, Gary King21. Psychosis and Psychotic disordersA E Gangat 22. Vulnerability of individuals in a family system to develop a psychiatric disorderGerhard Grundling and Eugene Allers23. What does it Uberhaupt mean to "Integrate"?Jürgen Harms24. Research issues in South African child and adolescent psychiatryS M Hawkridge25. New religious movements and psychiatry: The Good NewsV H Hitzeroth26. The pregnant heroin addict: Integrating theory and practice in the development and provision of a service for this client groupV H Hitzeroth, L Kramer27. Autism spectrum disorderErick Hollander28. Recent advances and management in treatment resistanceEric Hollander29. Bipolar mixed statesM. Leigh Janet30. Profile of acute psychiatric inpatients tested for HIV - Helen Jospeh Hospital, JohannesburgA B R Janse van Rensburg31. ADHD - Using the art of film-making as an education mediumShabeer Ahmed Jeeva32. Treatment of adult ADHD co-morbiditiesShabeer Ahmed Jeeva33. Needs and services at ward one, Valkenberg HospitalDr J. A. Joska, Prof. A.J. Flisher34. Unanswered questions in the adequate treatment of depressionModerator: Dr Andre F JoubertExpert: Prof. Tony Hale35. Unanswered questions in treatment resistant depressionModerator: Dr Andre F JoubertExpert: Prof. Sidney Kennedy36. Are mentally ill people dangerous?Sen Z Kaliski37. The child custody circusSean Z. Kaliski38. The appropriatenes of certification of patients to psychiatric hospitalsV. N. Khanyile39. HIV/Aids Psychosocial responses and ethical dilemmasFred Kigozi40. Sex and PsychiatryB Levinson41. Violence and abuse in psychiatric in-patient institutions: A South African perspectiveMarilyn Lucas, John Weinkoove, Dean Stevenson42. Public health sector expenditure for mental health - A baseline study for South AfricaE N Madela-Mntla43. HIV in South Africa: Depression and CD4 countM Y H Moosa, F Y Jeenah44. Clinical strategies in dealing with treatment resistant schizophreniaPiet Oosthuizen, Dana Niehaus, Liezl Koen45. Buprenorphine/Naloxone maintenance in office practice: 18 months and 170 patients after the American releaseTed Parran Jr, Chris Adelman46. Integration of Pharmacotherapy for Opioid dependence into general psychiatric practice: Naltrexone, Methadone and Buprenorphine/ NaloxoneTed Parran47. Our African understanding of individulalism and communitarianismWillie Pienaar48. Healthy ageing and the prevention of DementiaFelix Potocnik, Susan van Rensburg, Christianne Bouwens49. Indigenous plants and methods used by traditional African healers for treatinf psychiatric patients in the Soutpansberg Area (Research was done in 1998)Ramovha Muvhango Rachel50. Symptom pattern & associated psychiatric disorders in subjects with possible & confirmed 22Q11 deletional syndromeJ.L. Roos, H.W. Pretorius, M. Karayiorgou51. Duration of antidepressant treatment: How long is long enough? How long is too longSteven P Roose52. A comparison study of early non-psychotic deviant behaviour in the first ten years of life, in Afrikaner patients with Schizophrenia, Schizo-affective disorder and Bipolar disorderMartin Scholtz, Melissa Janse van Rensburg, J. Louw Roos53. Treatment, treatment issues, and prevention of PTSD in women: An updateSoraya Seedat54. Fron neural networks to clinical practiceM Spitzer55. Opening keynote presentation: The art and science of PsychiatryM Spitzer56. The future of Pharmacotherapy for anxiety disordersDan J. Stein57. Neuropsychological deficits pre and post Electro Convulsive Therapy (ECT) thrice a week: A report of four casesUgash Subramaney, Yusuf Moosa58. Prevalence of and risk factors for Tradive Dyskinesia in a Xhosa population in the Eastern CapeDave Singler, Betty D. Patterson, Sandi Willows59. Eating disorders: Addictive disorders?Christopher Paul Szabo60. Ethical challenges and dilemmas of research in third world countriesGodfrey B. Tangwa61. The interface between Neurology and Psychiatry with specific focus on Somatoform dissociative disordersMichael Trimble62. Prevalence and correlates of depression and anxiety in doctors and teachersH Van der Bijl, P Oosthuizen63. Ingrid Jonker: A psychological analysisL. M. van der Merwe64. The strange world we live in, and the nature of the human subjectVasi van Deventer65. Art in psychiatry: Appendix or brain stem?C W van Staden66. Medical students on what "Soft skills" are about before and after curriculum reformC W van Staden, P M Joubert, A-M Bergh, G E Pickworth, W J Schurink, R R du Preez, J L Roos, C Kruger, S V Grey, B G Lindeque67. Attention deficit hyperactivity disorder (ADHD) - Medical management. Methylphenidate (Ritalin) or Atomoxetine (Strattera)Andre Venter68. A comprehensive guide to the treatment of adults with ADHDW J C Verbeeck69. Treatment of Insomnia: Stasis of the Art?G C Verster70. Are prisoners vulnerable research participants?Merryll Vorster71. Psychiatric disorders in the gymMerryl Vorster72. Ciprales: Effects on anxiety symptoms in Major Depressive DisorderBruce Lydiard

Altered N-myc downstream-regulated gene 1 protein expression in African-American compared with caucasian prostate cancer patients

PURPOSE

The protein encoded by N-myc downstream-regulated gene 1 (NDRG1) is a recently discovered protein whose transcription is induced by androgens and hypoxia. We hypothesized that NDRG1 expression patterns might reveal a biological basis for the disparity of clinical outcome of prostate cancer patients with different ethnic backgrounds.

EXPERIMENTAL DESIGN

Patients who underwent radical prostatectomy between 1990 and 2000 at Veterans Administration Medical Center of New York were examined. We studied 223 cases, including 157 African Americans and 66 Caucasians (T2, n = 144; >/=T3, n = 79; Gleason <7, n = 122; >/=7, n = 101). Three patterns of NDRG1 expression were identified in prostate cancer: (a) intense, predominately membranous staining similar to benign prostatic epithelium; (b) intense, nucleocytoplasmic localization; and (c) low or undetectable expression. We then examined the correlations between patients' clinicopathological parameters and different NDRG1 expression patterns.

RESULTS

In this study of patients with equal access to care, African-American ethnic origin was an independent predictor of prostate-specific antigen recurrence (P < 0.05). We also observed a significant correlation between different patterns of NDRG1 expression and ethnic origin. Pattern 2 was less frequent in African Americans (21% versus 38%), whereas the reverse was observed for pattern 3 (60% in African Americans versus 44% in Caucasians; P = 0.03). This association remained significant after controlling for both grade and stage simultaneously (P = 0.02).

CONCLUSIONS

Our data suggest that different NDRG1 expression patterns reflect differences in the response of prostatic epithelium to hypoxia and androgens in African-American compared with Caucasian patients. Further studies are needed to determine the contribution of NDRG1 to the disparity in clinical outcome observed between the two groups.

Altered expression of p27 and Skp2 proteins in prostate cancer of African-American patients

PURPOSE

The purpose is to investigate the clinical relevance of altered patterns of p27 and Skp2 expression in African-American patients with localized prostate cancer. The abundance of p27, an inhibitor of cell proliferation, is controlled by Skp2-dependent proteolysis.

EXPERIMENTAL DESIGN

A well-characterized cohort of 162 African-Americans who underwent radical prostatectomy at the Veterans Affairs Medical Center of New York between 1990 and 2000 was studied. We analyzed p27 and Skp2 expression by immunohistochemistry. Altered expression of p27 (defined as <40% tumor cells expressing the protein) and Skp2 (defined as > or ==" BORDER="0">20% tumor cells expressing the protein) were correlated with clinicopathological parameters and time to prostate-specific antigen (PSA) recurrence.

RESULTS

Altered expression of p27 and Skp2 was observed in 112 of 162 (69.1%) and 93 of 162 (57.4%) cases, respectively. Inverse patterns of Skp2 and p27 protein expression were seen in 87 of 162 (53.7%) cases. A marginally significant association was found between Skp2 overexpression and extracapsular extension (P = 0.065). Moreover, patients with Skp2 overexpression had a 2.77 years decreased median time to PSA recurrence compared with patients with low Skp2 expression; however, the difference was not statistically significant. In multivariate analysis, only tumor grade and stage independently predicted PSA recurrence in this cohort.

CONCLUSIONS

Our data suggest a role for Skp2 overexpression in prostate cancer pathogenesis that might not be exclusively related to p27 degradation. More studies are needed to determine the mechanistic role of Skp2 in prostate cancer.

Concurrent interferon-alpha and radiation for head and neck melanoma

Melanoma cells are resistant to radiation in part due to their capacity to repair sublethal damage. A large fraction dose is therefore often utilized. However, if the tumour is located close to critical structures with modest tolerance, high fraction doses increase the risk for late complications compared with standard fractionation, but using the latter alone risks the desired outcome. Concurrent systemic biotherapy with standard radiation fractions may therefore represent an acceptable compromise. The outcome of concurrent systemic interferon-alpha (IFNalpha) and radiation in three patients with head and neck melanoma was evaluated. Standard radiation fractions were used because of the radiosensitizing properties of IFNalpha. Acute toxicity was significant and required treatment interruptions. However, all side effects subsided following treatment. All three patients achieved local control at follow-up periods of 24, 18 and 19 months, respectively. One patient developed widespread distant metastases. The combination of IFNalpha with radiation is considered feasible in terms of outcome and should be investigated with a larger cohort of patients. Toxicity is significant, and the addition of radioprotectors could be desirable.

A novel pantothenate kinase gene (PANK2) is defective in Hallervorden-Spatz syndrome

Hallervorden-Spatz syndrome (HSS) is an autosomal recessive neurodegenerative disorder associated with iron accumulation in the brain. Clinical features include extrapyramidal dysfunction, onset in childhood, and a relentlessly progressive course. Histologic study reveals iron deposits in the basal ganglia. In this respect, HSS may serve as a model for complex neurodegenerative diseases, such as Parkinson disease, Alzheimer disease, Huntington disease and human immunodeficiency virus (HIV) encephalopathy, in which pathologic accumulation of iron in the brain is also observed. Thus, understanding the biochemical defect in HSS may provide key insights into the regulation of iron metabolism and its perturbation in this and other neurodegenerative diseases. Here we show that HSS is caused by a defect in a novel pantothenate kinase gene and propose a mechanism for oxidative stress in the pathophysiology of the disease.

Regional dose response to pulmonary irradiation using a manual method

PURPOSE

To better understand the dose dependence of radiation therapy (RT)-induced changes in regional lung perfusion and tissue density, using a manual method to reduce inaccuracies that might be present in previously described automated methods.

MATERIALS AND METHODS

Patients who were to receive RT for tumors in and around the thorax, wherein portions of healthy lung would be incidentally irradiated, were prospectively studied. Changes in regional perfusion and tissue density were assessed by comparison of pre- and post-RT single photon emission computed tomography (SPECT), lung perfusion scans and computed tomography (CT) scans, respectively. The three-dimensional dose distribution was calculated on the pre-RT CT scan and correlated to the other scans via image registration. Study volumes were defined by hand and individually visualized on pre- and post-RT scans. The manually generated dose response data were compared to data generated using automated methods. The relationship between CT density and SPECT perfusion was also determined.

RESULTS

Thirteen patients with lung cancer were evaluated for changes in tissue density and 11 patients were evaluated for changes in regional perfusion at 12 months post-RT. In general, density increases with increasing regional dose, with marked changes at >60 Gy. Regional perfusion decreases with increasing regional dose. In the low dose regions, relative perfusion increases by 35% on average. Manually measured dose responses correlated well with those determined automatically. The relationship between regional perfusion and CT density indicates a wide range of perfusion over a narrow range of CT density, with markedly reduced perfusion at CT densities of > -600 and < -900 H.

CONCLUSIONS

The manually generated CT density dose response data broadly agree with data previously generated using automated methods. The manually generated perfusion dose response data are in fairly good agreement with automated data, lending credibility to the accuracy of the automated methods. Regional perfusion is markedly diminished where CT density is outside the range of normal lung tissue.

Mutation analysis and expression of the mottled gene in the macular mouse model of Menkes disease

The gene for Menkes disease, an X-linked disorder of copper transport, has recently been identified and shown to encode a copper-transporting P-type ATPase. The macular mutant mouse has been proposed as an animal model for Menkes disease. In the present study, we report the finding of a missense mutation in the mottled gene of the macular mouse. A single base change, T to C, at nucleotide position 4223, is predicted to result in an amino acid change from serine to proline at residue 1382 in the eighth transmembrane domain. This mutation differs from the 6-bp deletion we find in brindled cDNA. With validation of macular as an animal model of Menkes disease, we compared mottled gene expression in the intestine, kidney, and brain of macular and normal mice. In Northern analyses an 8.3-kb transcript was detected in the intestine, kidney, and brain of both normal and macular mice, with the level of transcript in macular approximately 80% that of normal. In situ hybridization studies revealed that the mottled gene was clearly expressed in intestinal epithelial cells, Paneth cells, and renal proximal tubular cells of both normal and macular mice. In normal brain, mottled gene expression was most intensely observed in the choroid plexus, in Ammon's born and the dentate gyrus in the hippocampus, in Purkinje cells, and the granular layer of the cerebellum. The intensity and localization of the signals in the brain of macular mice were similar to those of the controls. The distribution of expression of mottled is correlated with cells and tissues showing histopathology or abnormal copper sequestration in macular and other mutants.

A repeated element in the regulatory region of the MNK gene and its deletion in a patient with occipital horn syndrome

Occipital horn syndrome (OHS), an X-linked connective tissue disorder, has recently been shown to result from mutations in the Menkes disease gene (MNK), which encodes a copper-transporting ATPase. By Southern analysis we detected a small deletion in a region 5' to the MNK gene in one patient with OHS. Genomic clones from an unaffected individual were isolated and sequenced, revealing three tandem 98 bp repeats situated upstream of the reported transcription start site, and analysis of the patient's DNA showed a deletion of one of the repeats. The deletion is likely to be responsible for the disease in this patient, as it was not observed in 110 unaffected individuals analyzed, and no other mutation in the patient was detected by RT-PCR and chemical cleavage mismatch analysis or by cDNA sequence analysis. The deletion is associated with a dramatic decrease in expression of a chloramphenicol acetyltransferase reporter gene, implicating the repeat sequences in regulation of MNK expression, although a quantitative analysis of MNK mRNA from a cell line derived from the patient shows no detectable reduction. Other experiments revealed no effect on the site of transcription initiation, termination or on splicing.

Successful early copper therapy in Menkes disease associated with a mutant transcript containing a small In-frame deletion

Classical Menkes disease is a fatal X-linked neurodegenerative disorder caused by defects in a gene (MNK) that encodes a copper-transporting ATPase. Treatment with parenteral copper has been proposed for patients identified before symptoms develop. We recently described suboptimal outcomes despite early copper replacement in two classical Menkes patients whose mutation predicts little if any functional copper transporter. Here, we describe successful copper replacement therapy in a patient with Menkes disease with a splice acceptor site mutation (IVS8,AS,dup5) that causes exon-skipping and generates a mutant transcript with a small in-frame deletion in a noncritical region. The patient was diagnosed by analysis of neurochemical levels in cord blood, and parenteral copper replacement was begun at 8 days of life. Throughout infancy, he showed normal head growth, brain myelination, and age-appropriate neurodevelopment, including independent walking at 14 months of age. In contrast, his affected half-brother and first cousin with the same mutation, but who were not diagnosed and treated from an early age, showed arrested head growth, cerebral atrophy, delayed myelination, and abnormal neurodevelopment. We propose that the successful neurological outcome in this patient was related to early repletion of circulating copper levels, in combination with residual copper transport by a partially functional MNK ATPase containing the small deletion. We hypothesize that raising plasma copper concentrations in patients with Menkes disease with some residual functional gene product can increase the ligand: transporter ratio and thus alter favorably the kinetics of copper transport into and within the brain.

Subanesthetic concentrations of desflurane and propofol suppress recall of emotionally charged information

Whether anesthetized patients register emotionally charged information remains controversial. We tested this possibility using subanesthetic concentrations of propofol or desflurane. Twenty-two volunteers (selected for hypnosis susceptibility) received propofol and desflurane (on separate occasions, and in a random order) at a concentration 1.5-2 times each individual's minimum alveolar anesthetic concentration (MAC)-awake (or equivalent for propofol). We gave vecuronium, intubated the trachea of each volunteer, controlled ventilation, and then presented a neutral (control) drama or a "crisis" drama stating that the oxygen delivery system had failed, assigning crisis and control dramas in a blinded, randomized, and balanced manner. One day later, interviewers blinded to the assigned drama conducted a 2-h structured interview (including hypnosis) to determine whether the contents of the interviews after crisis and control dramas differed. In addition, messages permitting subsequent assessment of learning of matter-of-fact information (Trivial Pursuit-type question task and a behavior task) were presented at the anesthetic concentration just sufficient to prevent response to command in each volunteer. No analyses of the tasks involving matter-of-fact information revealed learning except one which correlated hypnosis susceptibility with behavior task performance. Both propofol and desflurane suppressed memory of the crisis. Consistent with previous findings for isoflurane and nitrous oxide, propofol and desflurane suppressed learning of matter-of-fact information at concentrations just above MAC-awake, except that volunteers' susceptibility to hypnosis correlated with performance of a behavior suggested during anesthesia. Propofol and desflurane suppressed learning of emotionally charged information at anesthetic concentrations 1.5-2 times MAC-awake (less than MAC), a different result from that previously reported for ether.

Similar splicing mutations of the Menkes/mottled copper-transporting ATPase gene in occipital horn syndrome and the blotchy mouse

The connective-tissue disorder occipital horn syndrome (OHS) is hypothesized to be allelic to Menkes disease. The two diseases have different clinical presentations but have a similar abnormality of copper transport. Mice hemizygous for the blotchy allele of the X-linked mottled locus have similar connective-tissue defects as OHS and may represent a mouse model of this disease. We have analyzed the Menkes/mottled copper-transporting ATPase in these two potentially homologous disorders and have identified similar splicing mutations in both. Some expression of normal mRNA was detectable by reverse transcription-PCR in the mutant tissues. These findings contrast with the more debilitating mutations observed in Menkes disease and suggest that low amounts of an otherwise normal protein product could result in the relatively mild phenotype of OHS and of the blotchy mouse.

Diverse mutations in patients with Menkes disease often lead to exon skipping

Fibroblast cultures from 12 unrelated patients with classical Menkes disease were analyzed for mutations in the MNK gene, by reverse transcription-PCR (RT-PCR) and chemical cleavage mismatch detection. Mutations were observed in 10 patients, and in each case a different mutation was present. All of the mutations would be predicted to have adverse effects on protein expression. Mutations that resulted in splicing abnormalities, detected by RT-PCR alone, were observed in six patients and included two splice-site changes, a nonsense mutation, a missense mutation, a small duplication, and a small deletion. Chemical cleavage analysis of the remaining six patients revealed the presence of one nonsense mutation, two adjacent 5-bp deletions, and one missense mutation. A valine/leucine polymorphism was also observed. These findings, combined with the prior observation of deletions in 15%-20% of Menkes patients, suggest that Southern blot hybridization and RT-PCR will identify mutations in the majority of patients.

The mottled gene is the mouse homologue of the Menkes disease gene

The mottled mouse has been proposed as an animal model for Menkes disease, an X-linked disorder of copper transport. The recent isolation of a copper-transporting ATPase gene responsible for Menkes disease has allowed us to test this hypothesis. Here we report the isolation and sequence of the mouse homologue of this gene. We show that two mottled (Mo) alleles, dappled (Modp) and blotchy (Moblo), have abnormalities in the murine mRNA and that Modp has a partial gene deletion. These studies prove that the mottled mouse is the murine model for Menkes disease, providing the basis for future biochemical and therapeutic studies.

Isolation of a candidate gene for Menkes disease and evidence that it encodes a copper-transporting ATPase

Menkes disease is an X-linked disorder of copper transport characterized by progressive neurological degeneration and death in early childhood. We have isolated a candidate gene (Mc1) for Menkes disease and find qualitative or quantitative abnormalities in the mRNA in sixteen of twenty-one Menkes patients. Four patients lacking Mc1RNA showed rearrangements of the Menkes gene. The gene codes for a 1,500 amino acid protein, predicted to be a P-type cation-transporting ATPase. The gene product is most similar to a bacterial copper-transporting ATPase and additionally contains six putative metal-binding motifs at the N-terminus. The gene is transcribed in all cell types tested except liver, consistent with the expression of the Menkes defect.

The rights of the unborn child seen through the eyes of a psychologist

There is a serious possibility that the developing foetus has become a sentient being long before his or her actual birth and that the most profound response patterns of our existence are already laid down in this early prenatal experience. Experiments over the last 50 to 60 years have shown that not alone is there life before birth, but that the quality of this life plays a determining role in the type of personality one may develop. Although for most of use, life in the womb remains a mysterious enigma, we can no longer afford to ignore the influences, both internal and external, which affect the growing child in its mother's womb. Often thought of as the ultimate haven--the refuge against all life's ills--it is perhaps disconcerting to have to consider that even here, one's first sanctuary, one may not be safe. The single parent is particularly at risk in this regard. Does the law offer sufficient protection for mother and child to ensure support for this critical process?

Evidence for a third transcript from the human factor VIII gene

Intron 22 of the human factor VIII gene was recently found to contain a gene, associated with a CpG island, which is transcribed in the direction opposite to factor VIII. We now report that another transcript emanates from the island and is transcribed in the same direction as factor VIII. The divergent transcripts originate within 122 bases of each other. The newly identified 5' exon in intron 22 potentially codes for eight amino acids and is spliced to exons 23-26, with the factor VIII reading frame maintained. The protein encoded by this transcript would include the factor VIII C2 domain, responsible for phospholipid binding and essential for coagulant activity.

Extension of the physical map in the region of the mouse X chromosome homologous to human Xq28 and identification of an exception to conserved linkage

We have extended our pulsed-field gel map of the region of the mouse X chromosome homologous to human Xq28 to include the loci Gdx (DXS254Eh), P3 (DXS253Eh), G6pd, Cf-8, and F8a. Gdx, P3, and G6pd are demonstrated to be physically linked to the X-linked visual pigment locus (Rsvp) within a maximal distance of 340 kb, while G6pd and Cf-8 are approximately 900 kb apart. These studies favor a gene order of cen-Rsvp-Gdx-P3-G6pd-(Cf-8)-tel and extend the physical map of this region to 5 million bp. In conjunction with previous physical mapping studies in both mouse and human, the results suggest conserved linkage for loci in this region of the mouse X chromosome and human Xq28. However, employing pulsed-field gel electrophoresis and genetic pedigree analysis of interspecific backcross progeny, we have found close linkage of a clone encoding a mouse homolog for human factor VIII-associated gene A (F8A) to DXPas8, thus revealing the first exception to conserved gene order between murine and human loci in the region.

Sequence of the human factor VIII-associated gene is conserved in mouse

cDNA and genomic clones corresponding to the human factor VIII-associated gene (F8A) were isolated from mouse cDNA and F8A-enriched genomic libraries. The sequences of these clones revealed an intronless gene coding for 380 amino acids, with 85% identity to the predicted human sequence. The single murine gene copy is genetically linked to factor VIII, but appears to lie outside the factor VIII gene by physical mapping. Like the human gene, the mouse F8A gene is highly expressed in a wide variety of tissues. This evolutionary comparison has helped to clarify the derived amino acid sequence in the human and strongly supports the hypothesis that the F8A gene encodes a protein.

Isolation and sequence of two genes associated with a CpG island 5' of the factor VIII gene

Many disease loci have been linked to the telomeric end of the long arm of the human X-chromosome, Xq28. We have isolated and sequenced cDNA sequences corresponding to two novel genes that map to Xq28. These genes, c6.1A and c6.1B, are transcribed in opposite directions from a CpG island that lies approximately 70 kilobases (kb) upstream (5') of the factor VIII locus. One of these genes, c6.1A, is highly conserved between species and expressed abundantly in many human and mouse tissues, whereas, c6.1B is moderately conserved and has a restricted tissue distribution of expression. The Xq28 gene c6.1A has an autosomal homologue that is transcriptionally inactive in B-cell lines. An open reading frame (ORF) predicting a peptide of 293 amino acids is observed for c6.1A but c6.1B does not possess a single long ORF. No striking homologies to existing genes could be found for either of the two new loci. Expressed sequences that are physically close to the factor VIII gene are candidates for disease loci that map to this region of Xq28. The relevance of these genes to disease loci was investigated using DNA and RNA from hemophilia A patients bearing deletions that extend in a 5' direction away from factor VIII. The results imply that neither of these genes are primarily responsible for the development Xq28-linked diseases. However, c6.1A and c6.1B define a region of Xq28 that is deleted in two brothers that suffer from mental handicap and dysmorphism as well as hemophilia A. Thus, this region is likely to contain loci that are important for physical and mental development.

Amino acid substitutions in conserved domains of factor VIII and related proteins: study of patients with mild and moderately severe hemophilia A

Mutations leading to hemophilia A by substitution of amino acids in coagulation factor VIII may provide important clues to the structure and function of this large and enigmatic protein. To efficiently find missense mutations, hemophiliacs with mild and moderately severe forms of the disease were surveyed. DNA samples from affected individuals were assayed for mutations by denaturing gradient gel electrophoresis following DNA amplification of target regions, which included all coding regions except for that of the dispensable B domain. Missense mutations were observed in 20 of the 34 patients examined, with identical mutations found in five pairs of patients. All mutations were found in the repetitive A and C domains. By aligning these domains in factor VIII with homologous domains in factor V, ceruloplasmin, and the mouse milk fat globule membrane protein, it was determined that most mutations change amino acids in areas of strong sequence conservation. Three additional mutations were detected, including a point mutation in an intron, a stop codon mutation, and a silent base change. Ten of the 18 different mutations discovered in this patient population are reported here for the first time.

A transcribed gene in an intron of the human factor VIII gene

We have identified a CpG island contained within the largest factor VIII intron. This island is associated with a 1.8-kb transcript and, unlike factor VIII, is produced abundantly in a wide variety of cell types. The nested gene is oriented in a direction opposite to that of factor VIII and contains no intervening sequences. A cDNA of 1739 bases was isolated from a human liver library and found to have a GC-rich, long open reading frame. Two computer-assisted methods (Fickett TESTCODE and Staden-McLachlan codon usage) predict that the gene codes for a protein. Two other copies of this gene are located within 1.1 Mb of the factor VIII gene. Northern blot analysis of RNA isolated from hemophilia patients deleted for factor VIII sequences has shown that both the intron gene and at least one other copy of the gene are transcribed. A homologous, transcribed sequence is also present in mice.