Human papillomavirus (HPV) DNA methylation changes in HPV-associated head and neck cancer

Despite the rising incidence, currently, there are no early detection methods for HPV-driven HNC (HPV-HNC). Cervical cancer studies suggest that HPV DNA methylation changes can be used as a biomarker to discriminate cancer patients from HPV-infected individuals. As such, this study was designed to establish a protocol to evaluate DNA methylation changes in HPV late genes and long control region (LCR) in saliva samples of HPV-HNC patients and HPV-positive controls. Higher methylation levels were detected in HPV late genes (L1 and L2) in both tumour and saliva samples of HPV-HNC patients compared with HPV-positive controls. Moreover, methylation patterns between tumours and corresponding saliva samples were observed to have a strong correlation (Passing-Bablok regression analysis; τ = 0.7483, P < 0.0001). Considering the differences between HNC and controls in methylation levels in late genes, and considering primer amplification efficiencies, 13 CpG sites located at L1 and L2 genes were selected for further evaluation. A total of 18 HNC saliva samples and 10 control saliva samples were assessed for the methylation levels in the selected sites. From the CpG sites evaluated statistically significant differences were identified for CpG sites at L2-CpG 6 (P = 0.0004), L1-CpG 3 (P = 0.0144), L1-CpG 2 (P = 0.0395) and L2-CpG 19 (P = 0.0455). Our pilot data indicate that higher levels of DNA methylation in HPV late genes are indicative of HPV-HNC risk, and it is a potential supplementary biomarker for salivary HPV detection-based HPV-HNC screening.

Artificial intelligence in medical referrals triage based on Clinical Prioritization Criteria

The clinical prioritisation criteria (CPC) are a clinical decision support tool that ensures patients referred for public specialist outpatient services to Queensland Health are assessed according to their clinical urgency. Medical referrals are manually triaged and prioritised into three categories by the associated health service before appointments are booked. We have developed a method using artificial intelligence to automate the process of categorizing medical referrals based on clinical prioritization criteria (CPC) guidelines. Using machine learning techniques, we have created a tool that can assist clinicians in sorting through the substantial number of referrals they receive each year, leading to more efficient use of clinical specialists' time and improved access to healthcare for patients. Our research included analyzing 17,378 ENT referrals from two hospitals in Queensland between 2019 and 2022. Our results show a level of agreement between referral categories and generated predictions of 53.8%.

Benign paroxysmal positional vertigo in a young child

A girl in her early childhood presented to a regional otolaryngology outpatient clinic with classic signs of benign paroxysmal positional vertigo (BPPV). She reported episodic dizziness when rolling in a supine position. She did not convey any other associated audiovestibular symptoms. A bedside Dix-Hallpike test confirmed geotropic rotational nystagmus indicative of lateral canal BPPV. Due to her young age, limited communicative abilities and concerns for more sinister underlying pathology, a complete neurological examination, MRI and pure tone audiometry were performed. After two sessions of Epley's manoeuvre, she was symptom-free. At her 3-month follow-up, the patient denied any recurrent episodes of vertigo.

Inter-rater agreement between 13 otolaryngologists to diagnose otitis media in Aboriginal and Torres Strait Islander children using a telehealth approach

INTRODUCTION

Telehealth programs are important to deliver otolaryngology services for Aboriginal and Torres Strait Islander children living in rural and remote areas, where distance and access to specialists is a critical factor.

OBJECTIVE

To evaluate the inter-rater agreement and value of increasing levels of clinical data (otoscopy with or without audiometry and in-field nurse impressions) to diagnose otitis media using a telehealth approach.

DESIGN

Blinded, inter-rater reliability study.

SETTING

Ear health and hearing assessments collected from a statewide telehealth program for Indigenous children living in rural and remote areas of Queensland, Australia.

PARTICIPANTS

Thirteen board-certified otolaryngologists independently reviewed 80 telehealth assessments from 65 Indigenous children (mean age 5.7 ± 3.1 years, 33.8% female).

INTERVENTIONS

Raters were provided increasing tiers of clinical data to assess concordance to the reference standard diagnosis: Tier A) otoscopic images alone, Tier B) otoscopic images plus tympanometry and category of hearing loss, and Tier C) as B plus static compliance, canal volume, pure-tone audiometry, and nurse impressions (otoscopic findings and presumed diagnosis). For each tier, raters were asked to determine which of the four diagnostic categories applied: normal aerated ear, acute otitis media (AOM), otitis media with effusion (OME), and chronic otitis media (COM).

MAIN OUTCOME MEASURES

Proportion of agreement to the reference standard, prevalence-and-bias adjusted κ coefficients, mean difference in accuracy estimates between each tier of clinical data.

RESULTS

Accuracy between raters and the reference standard increased with increased provision of clinical data (Tier A: 65% (95%CI: 63-68%), κ = 0.53 (95%CI: 0.48-0.57); Tier B: 77% (95%CI: 74-79%), 0.68 (95%CI: 0.65-0.72); C: 85% (95%CI: 82-87%), 0.79 (95%CI: 0.76-0.82)). Classification accuracy significantly improved between Tier A to B (mean difference:12%, p < 0.001) and between Tier B to C (mean difference: 8%, p < 0.001). The largest improvement in classification accuracy was observed between Tier A and C (mean difference: 20%, p < 0.001). Inter-rater agreement similarly improved with increasing provision of clinical data.

CONCLUSIONS

There is substantial agreement between otolaryngologists to diagnose ear disease using electronically stored clinical data collected from telehealth assessments. The addition of audiometry, tympanometry and nurse impressions significantly improved expert accuracy and inter-rater agreement, compared to reviewing otoscopic images alone.

Implementation of an extended scope of practice speech-language pathology allied health practitioner service: An evaluation of service impacts and outcomes

PURPOSE

Extended scope of practice roles can address health service challenges and enhance patient services; however there has been limited research of extended scope roles in the discipline of speech-language pathology (SLP). The aim of this study was to examine the clinical outcomes and service impacts of a Speech-Language Pathology Allied Health Practitioner (SLP AHP) led dysphagia and dysphonia service within an Integrated Specialist Ear Nose and Throat (ENT) Service.

METHOD

Low risk referrals were triaged by ENT from the waiting list into the SLP AHP dysphagia and dysphonia clinic. Outcomes from an initial 6-month pilot phase (n = 43) and 6-month implementation phase (n = 158) were evaluated.

RESULT

Approximately 70% of patients managed in the SLP AHP clinic in both phases were discharged without requiring separate ENT appointments. There were no adverse events. In the pilot phase, only 4.3% of medium priority and 10% of low priority referrals were seen within clinically recommended time frames. This improved to 90% in the final three months of the implementation phase.

CONCLUSION

With appropriate governance and risk management, an extended scope SLP AHP service for low risk dysphagia and dysphonia can achieve safe, effective and beneficial changes to ENT service delivery.

A Collective Route to Head and Neck Cancer Metastasis

Distant metastasis (DM) from head and neck cancers (HNC) portends a poor patient prognosis. Despite its important biological role, little is known about the cells which seed these DM. Circulating tumour cells (CTCs) represent a transient cancer cell population, which circulate in HNC patients’ peripheral blood and seed at distant sites. Capture and analysis of CTCs offers insights into tumour metastasis and can facilitate treatment strategies. Whilst the data on singular CTCs have shown clinical significance, the role of CTC clusters in metastasis remains limited. In this pilot study, we assessed 60 treatment naïve HNC patients for CTCs with disease ranging from early to advanced stages, for CTC clusters utilizing spiral CTC enrichment technology. Single CTCs were isolated in 18/60–30% (Ranging from Stage I-IV), CTC clusters in 15/60–25% (exclusively Stage IV) with 3/15–20% of CTC clusters also containing leukocytes. The presence of CTC clusters associated with the development of distant metastatic disease(P = 0.0313). This study demonstrates that CTC clusters are found in locally advanced patients, and this may be an important prognostic marker. In vivo and in vitro studies are warranted to determine the role of these CTC clusters, in particular, whether leukocyte involvement in CTC clusters has clinical relevance.

Diagnosis and management of hearing loss in elderly patients

BACKGROUND

Hearing loss is the most common sensory deficit in elderly patients, and is often under-recognised and poorly managed. It is essential for all clinicians to have awareness and knowledge in this field to enable the institution of early and appropriate care.

OBJECTIVE

The goal of this article is to review the causes, diagnosis and management of hearing loss as it applies to elderly patients. The review describes a useful approach that clinicians can apply to daily practice.

DISCUSSION

For elderly patients presenting with hearing loss, the basic assessment should include history, physical examination and pure tone audiometry. Management depends on the cause and type of hearing loss, and options include medical therapy, surgery and amplification. In the absence of a simple and correctable cause, consider referring patients to an otolaryngologist for further assessment.

Missed obturator hip dislocation in a 19-year-old man

Traumatic obturator hip dislocations are rare injuries that are typically diagnosed and managed acutely. We encountered a patient who presented with a painful hip 2 months after sustaining an undiagnosed traumatic obturator hip dislocation. After failed closed treatment, the hip was reduced with open reduction, utilizing a Kocher approach and a trochanteric osteotomy. At 15 months postoperatively, the patient maintained a functional range of motion without clinical or radiographic signs of posttraumatic arthritis or avascular necrosis.

Non-host-reactive donor CD8+ T cells of Tc2 phenotype potently inhibit marrow graft rejection

Donor CD8+ T cells capable of host reactivity inhibit marrow graft rejection, but also generate graft-versus-host disease (GVHD). To evaluate whether the Tc1- and Tc2-type subsets of CD8 cells might inhibit rejection without host reactivity, we established an F1 into-parent murine bone marrow transplant model. Donor Tc1 and Tc2 cells were generated that preferentially secreted type I or type II cytokines; both subsets possessed potent cytolytic function, and clonally deleted host-type allospecific precursor CTL in vitro. B6 hosts receiving 950 cGy irradiation did not reject the donor marrow (F1 chimerism of 78.6%; n = 10), whereas hosts receiving 650 cGy rejected the donor marrow (3.8% chimerism; n = 8). At 650 cGy irradiation, the addition of Tc2 cells to the F1 marrow resulted in extensive F1 chimerism (70.8%) in 8 of 8 recipients; in contrast, alloengraftment was not consistently observed in mice receiving Tc1 cells or unmanipulated CD8 cells. Furthermore, when the preparative regimen was further reduced to 600 cGy, only hosts receiving the Tc2-type cells did not reject the F1 marrow. We conclude that Tc2 cells potently inhibit marrow graft rejection without inducing an alloaggressive response and that non-host-reactive Tc2 cells therefore facilitate engraftment across genetic barriers with reduced GVHD.

Current status of bioassays in genetic toxicology--the dominant lethal assay. A report of the U.S. Environmental Protection Agency Gene-Tox Program

The term dominant lethal may be defined as death of the heterozygote arising through multiple chromosomal breaks. The assay is generally conducted by treating male animals, usually mice or rats, acutely (1 dose), subacutely (5 doses), or over the entire period of spermatogenesis. Animals treated acutely or subacutely are mated at weekly intervals to females for a sufficient number of weeks to cover the period of spermatogenesis. Those treated for the entire spermatogenic cycle are mated for 1 or 2 successive weeks at the termination of treatment. Females usually are killed at 14 days of pregnancy and examined for the number of total implantations in the uterus, the number of implantations classified as early deaths, and, in some cases, the number of corpora lutea. The category of early death is the most significant index of dominant lethality. A total of 249 papers were reviewed and 140 chemicals were evaluated. Of the 140 chemicals, 65 were positive by the criteria used by the Work Group in evaluating each publication. The category of "positive" includes those responses of a borderline nature. 99 chemicals were declared negative. There is considerable overlap of chemicals in both categories, which accounts for the incongruity in the total number of chemicals tested and the number considered positive and negative. A total of 44 animal carcinogens have been tested in the dominant lethal assay, 26 of which were positive and 18 negative for a correlation of 59%. The role of the assay should be that of confirming positive results from lower tier chromosomal aberration-detecting systems (confirming in the sense of indicating the ability of the chemical to penetrate gonadal tissue and to produce cytogenetic damage). The dominant lethal assay should not be used as a risk assessment method.

Sister-chromatid exchanges: a report of the GENE-TOX program

The effects of a number of chemicals on sister-chromatid exchange (SCE) frequencies in in vivo and in vitro systems are reviewed. Standardized protocols for future SCE testing in important systems, as well as for evaluation of test results, are presented. Data reported thus far suggest that SCE analysis may prove useful, especially at a secondary level, as a test of mutagenic carcinogens. Strengths and limitations of SCE analysis are summarized as a guide for future evaluation and use of this procedure.