[Targeted newborn screening for sickle-cell anemia: Sickling test (Emmel test) boundaries in the prenatal assessment in West African area]. / Dépistage néonatal ciblé de la drépanocytose : limites du test de falciformation (test d'Emmel) dans le bilan prénatal en zone ouest africaine.

BACKGROUND: Newborn screening for sickle cell anemia is necessary in Africa where the disease is more frequent. Hemoglobin electrophoresis is used for screening, but is limited by a high cost and difficult access. Sickling test (Emmel test), which is more affordable and technically more accessible, is often requested for prenatal assessment of pregnant women in West African areas to reserve screening for newborns from mothers in whom the positive sickling test attests the presence of hemoglobin S. This study aims to evaluate the number of undetected sickle cell anemia newborns by a screening policy targeting only newborns from mothers in whom a sickling test would have been positive. METHODS: From 2010 to 2012, in Bamako, Mali, West Africa, 2489 newborns were routinely screened for sickle cell anemia at the umbilical cord or heel by isoelectrofocusing and, if necessary, by high-performance liquid chromatography. These newborns were born from 2420 mothers whose hemoglobin was studied by isoelectrofocusing. The data was recorded and processed using Excel software version 14.0.0. We calculated the frequency of the sickle cell gene in mothers and newborns as well as the number of SCA newborns from heterozygous or C homozygous mothers. RESULTS: Of the 2489 newborns, 16 had sickle cell anemia (6 SS and 10 SC); 198 had the sickle cell trait; 139 were AC and 1 was CC. Of the 10 newborns with SC profile, 3 were born from mothers not carrying the S gene but the C gene of hemoglobin and in which an Emmel test would have been negative. CONCLUSION: Targeted newborn screening, based on the results of sickling test in pregnant women, would misdiagnose more than one of six sickle cell anemia newborns who would not benefit from early care. Cost-effectiveness studies of routine newborn screening for sickle cell anemia should lead to a better screening strategy in contexts where hemoglobin S and other hemoglobin defect genes coexist.

[Screening of cerebral vasculopathy in sickle cell anemia children using transcranial Doppler]. / Dépistage de la vasculopathie cérébrale drépanocytaire par doppler transcrânien au Mali.

Cerebral vasculopathy exposes patients to a high risk of stroke, a major complication of sickle cell disease (SCD) associated with a high risk of death and disability. Transcranial doppler (TCD) ultrasonography used to identify SCD patients at risk of stroke may contribute to significantly reducing morbidity and mortality in these patients by indicating appropriate treatment. From March 2008 to February 2013, we conducted systematic screening for cerebral vasculopathy using TCD in 572 SCD patients (including 375 SS, 144 SC, 26 S/ß(0), and 27 S/ß(+) thalassemia patients) aged 1-17 years in a comprehensive center for follow-up and research on sickle cell disease in Bamako, Mali. After exclusion of 30 inadequate results and one case of abnormal TCD observed in a multiple organ failure patient, we found an abnormal or conditional TCD in 18% of 541 children examined in a steady state. The highest prevalence of abnormal cases concerned homozygous SS patients (8.1%). No case of abnormal or conditional TCD was observed in children with S/ß(+) thalassemia. Hemoglobin concentrations were significantly lower in patients with conditional or abnormal TCD (P<0.01). In a subgroup of 68 patients with conditional TCD, nine (13%) converted to abnormal TCD over 1 year. In this subgroup of 68 conditional TCD patients, a decrease or increase in baseline hemoglobin concentration was predictive of conditional or abnormal TCD at the follow-up visit. Progression towards conditional TCD was observed in four patients (0.9%) who initially had normal TCD. Children with abnormal TCD had, whenever possible, a monthly exchange transfusion program. One case of transient stroke in the context of P. falciparum malaria with low hemoglobin concentration and one death were observed. These findings highlight the need for systematic TCD in sickle cell disease monitoring and implementing regular blood transfusion programs in the context of limited access to regular and secure blood transfusions.

Associations between intimate partner violence and posttraumatic stress symptom severity in a multiethnic sample of men with histories of childhood sexual abuse.

OBJECTIVE: Little research exists identifying risk factors for posttraumatic stress symptoms (PTSS) among men with histories of childhood sexual abuse (CSA) who have been exposed to intimate partner violence (IPV). METHODS: One hundred and fifty African American, Latino and non-Latino White men with histories of CSA participated in this study. RESULTS: An ordinary least squares regression model with race/ethnicity, HIV serostatus, and CSA severity treated as cofounders and with IPV as the predictor was fitted to predict level of PTSS. Higher levels of IPV were significantly associated with higher PTSS, as were higher levels of chronic stress, and being African American. CONCLUSIONS: Mental health service providers should routinely screen for IPV in men who report histories of CSA and PTSS.

Validation of a next-generation sequencing assay for clinical molecular oncology.

Currently, oncology testing includes molecular studies and cytogenetic analysis to detect genetic aberrations of clinical significance. Next-generation sequencing (NGS) allows rapid analysis of multiple genes for clinically actionable somatic variants. The WUCaMP assay uses targeted capture for NGS analysis of 25 cancer-associated genes to detect mutations at actionable loci. We present clinical validation of the assay and a detailed framework for design and validation of similar clinical assays. Deep sequencing of 78 tumor specimens (≥ 1000× average unique coverage across the capture region) achieved high sensitivity for detecting somatic variants at low allele fraction (AF). Validation revealed sensitivities and specificities of 100% for detection of single-nucleotide variants (SNVs) within coding regions, compared with SNP array sequence data (95% CI = 83.4-100.0 for sensitivity and 94.2-100.0 for specificity) or whole-genome sequencing (95% CI = 89.1-100.0 for sensitivity and 99.9-100.0 for specificity) of HapMap samples. Sensitivity for detecting variants at an observed 10% AF was 100% (95% CI = 93.2-100.0) in HapMap mixes. Analysis of 15 masked specimens harboring clinically reported variants yielded concordant calls for 13/13 variants at AF of ≥ 15%. The WUCaMP assay is a robust and sensitive method to detect somatic variants of clinical significance in molecular oncology laboratories, with reduced time and cost of genetic analysis allowing for strategic patient management.

[Sickle cell anemia and transfusion safety in Bamako, Mali. Seroprevalence of HIV, HBV and HCV infections and alloimmunization belonged to Rh and Kell systems in sickle cell anemia patients]. / Sécurité transfusionnelle et drépanocytose à Bamako, Mali. Séroprévalence des infections à VIH, VHB, VHC et allo-immunisation anti-Rh et Kell chez les drépanocytaires.

Red cell transfusion is one of the main treatments in sickle cell disease. However there are potential risks of blood transfusions. In order to propose strategies to improve blood safety in sickle cell disease in Mali, we conducted a prospective study of 133 patients with sickle cell anemia recruited at the sickle cell disease research and control center of Bamako, November 2010 to October 2011. The study aimed to determine the prevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections by serum screening and the frequency of red cell alloimmunization before and after blood transfusion. The diagnosis of sickle cell syndrome was made by HPLC, the detection of markers of viral infection was performed by ELISA, and the diagnosis of alloimmunization was conducted by the Indirect Coombs test. Prevalence of viral infections observed at the time of enrolment of patients in the study was 1%, 3% and 1% respectively for HIV, HBV and HCV. Three cases of seroconversion after blood transfusion were detected, including one for HIV, one for HBV and one another for HCV in sickle cell anemia patients. All these patients had received blood from occasional donors. The red cell alloimmunization was observed in 4.4% of patients. All antibodies belonged to Rh system only. Blood transfusion safety in sickle cell anemia patients in Mali should be improved by the introduction of at least the technique for detecting the viral genome in the panel of screening tests and a policy of transfusions of blood units only from regular blood donors.

A sexual risk and stress reduction intervention designed for HIV-positive bisexual African American men with childhood sexual abuse histories.

OBJECTIVES: HIV transmission risk is high among men who have sex with men and women (MSMW), and it is further heightened by a history of childhood sexual abuse (CSA) and current traumatic stress or depression. Yet, traumatic stress is rarely addressed in HIV interventions. We tested a stress-focused sexual risk reduction intervention for African American MSMW with CSA histories. METHODS: This randomized controlled trial compared a stress-focused sexual risk reduction intervention with a general health promotion intervention. Sexual risk behaviors, psychological symptoms, stress biomarkers (urinary cortisol and catecholamines), and neopterin (an indicator of HIV progression) were assessed at baseline and at 3- and 6-month follow-ups. RESULTS: Both interventions decreased and sustained reductions in sexual risk and psychological symptoms. The stress-focused intervention was more efficacious than the general health promotion intervention in decreasing unprotected anal insertive sex and reducing depression symptoms. Despite randomization, baseline group differences in CSA severity, psychological symptoms, and biomarkers were found and linked to subsequent intervention outcomes. CONCLUSIONS: Although interventions designed specifically for HIV-positive African American MSMW can lead to improvements in health outcomes, future research is needed to examine factors that influence intervention effects.

Using novel methods to examine stress among HIV-positive African American men who have sex with men and women.

Biomarker composites (BCs) that objectively quantify psychosocial stress independent of self report could help to identify those at greatest risk for negative health outcomes and elucidate mechanisms of stress-related processes. Here, BCs are examined in the context of existing disease progression among HIV-positive African American men who have sex with men and women (MSMW) with high stress histories, including childhood sexual abuse. Participants (N = 99) collected 12-h overnight and morning urine samples for assay of cortisol and catecholamines (primary BC) and neopterin (an indicator of HIV disease progression). Data on cumulative psychosocial trauma history (severity, types, frequency, age at first incident), posttraumatic stress disorder (PTSD) symptoms, sexual risk behaviors, and a secondary BC consisting of routine health indicators (heart rate, blood pressure, body mass index, waist-to-hip ratio) were also collected. Lifetime trauma exposure was highly pervasive and significantly greater among those meeting a standard cutoff for PTSD caseness (24 %). After controlling for HIV factors (neopterin levels and years with disease), PTSD was a significant (p < .05) predictor of the primary, but not secondary BC. Those with PTSD also had significantly more sexual partners, sex without a condom, and exchange sex for money or drugs than those without PTSD. Specific trauma characteristics predicted PTSD severity and caseness independently and uniquely in regression models (p's < .05-.001). A primary BC appears sensitive to cumulative trauma burden and PTSD in HIV-positive African American MSMW, providing support for the use of BCs to quantify psychosocial stress and inform novel methods for examining mechanisms of stress influenced health behaviors and disease outcomes in at-risk populations.

CNTO 530 increases expression of HbA and HbF in murine models of ß-thalassemia and sickle cell anemia.

CNTO 530 is an erythropoietin receptor agonist MIMETIBODYTM construct. CNTO 530 has been shown to be active in a number of rodent models of acquired anemia (e.g. renal insufficiency and chemotherapy induced anemia). We investigated the efficacy of CNTO 530 in murine models of ß-thalassemia and sickle cell anemia (Berkeley mice). ß- thalassemic mice are deficient in expression of α-globin chain and heterozygous mice are characterized by a clinical syndrome similar to the human ß-thalassemia intermedia. Berkeley mice are knocked out for murine alpha and beta globin and are transgenic for human alpha, beta (sickle) and gamma globin genes. Berkeley mice thus express human sickle hemoglobin A (HbS) and can also express human fetal hemoglobin. These mice express a severe compensated hypochromic microcytic anemia and display the sickle cell phenotype. To test the effectiveness of CNTO 530, mice from both genotypes received a single subcutaneous (s.c.) dose of CNTO 530 or darbepoetin-α (as a comparator) at 10,000 U/kg, a dose shown to cause a similar increase in reticulocytes and hemoglobin in normal mice. Hematologic parameters were evaluated over time. CNTO 530, but not darbepoetin-α, increased reticulocytes, red blood cells and total hemoglobin in ß- thalassemic mice. In Berkeley mice CNTO 530 showed an increase in reticulocytes, red blood cells, F-cells, total hemoglobin and fetal hemoglobin. In conclusion, CNTO 530 is effective in murine models of ß-thalassemia and sickle cell anemia. These data suggest that CNTO 530 may have beneficial effects in patients with genetically mediated hemoglobinopathies.

Treatment-influenced associations of PML-RARα mutations, FLT3 mutations, and additional chromosome abnormalities in relapsed acute promyelocytic leukemia.

Mutations in the all-trans retinoic acid (ATRA)-targeted ligand binding domain of PML-RARα (PRα/LBD+) have been implicated in the passive selection of ATRA-resistant acute promyelocytic leukemia clones leading to disease relapse. Among 45 relapse patients from the ATRA/chemotherapy arm of intergroup protocol C9710, 18 patients harbored PRα/LBD+ (40%), 7 of whom (39%) relapsed Off-ATRA selection pressure, suggesting a possible active role of PRα/LBD+. Of 41 relapse patients coanalyzed, 15 (37%) had FMS-related tyrosine kinase 3 internal tandem duplication mutations (FLT3-ITD+), which were differentially associated with PRα/LBD+ depending on ATRA treatment status at relapse: positively, On-ATRA; negatively, Off-ATRA. Thirteen of 21 patients (62%) had additional chromosome abnormalities (ACAs); all coanalyzed PRα/LBD mutant patients who relapsed off-ATRA (n = 5) had associated ACA. After relapse Off-ATRA, ACA and FLT3-ITD+ were negatively associated and were oppositely associated with presenting white blood count and PML-RARα type: ACA, low, L-isoform; FLT3-ITD+, high, S-isoform. These exploratory results suggest that differing PRα/LBD+ activities may interact with FLT3-ITD+ or ACA, that FLT3-ITD+ and ACA are associated with different intrinsic disease progression pathways manifest at relapse Off-ATRA, and that these different pathways may be short-circuited by ATRA-selectable defects at relapse On-ATRA. ACA and certain PRα/LBD+ were also associated with reduced postrelapse survival.

Predictors of unsuccessful magnetic resonance imaging scanning in older generalized anxiety disorder patients and controls.

A thorough understanding of the neurobiology of late life anxiety is likely to depend on the use of brain imaging techniques such as magnetic resonance imaging (MRI). Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders in older adults, and is thus a focus for neurobiological studies using MRI. This study tested 1-3 weeks predictors of unsuccessful scan outcomes (i.e., scan trials in which the participant moved excessively or prematurely terminated the scan) in older adults with GAD (n = 39) and age- and sex-matched nonanxious controls (n = 21). It was hypothesized that successful completion of a prior MRI scan, clinical status (GAD versus control), and scores on the Anxiety Sensitivity Index (ASI; Peterson et al. 1986), a measure tapping psychological aspects of medical interventions, would predict scan outcome when current diagnoses of claustrophobia were controlled. In logistic regression analyses, unsuccessful scan outcome was predicted by prior MRI completion and ASI Mental Concerns subscale scores, but not clinical status. This model correctly classified 91% of successful and 71% of unsuccessful scans. An alternative model that included a single ASI item rather than Mental Concerns subscale scores showed similar performance, and a model including categorical anxiety sensitivity groups was also effective but slightly less accurate. Implications for improving the success rates of MRI with older adults are discussed.

[Human parvovirus B19 infection in sickle cell anemia patient in Mali: a case-control study]. / L'infection par l'érythrovirus B19 chez le drépanocytaire au Mali : une étude cas-témoins.

Human parvovirus B19 (HP-19) is the only Parvoviridae known to be pathogenic in human. Studies of HP-19 infection and its associated life-threatening complications in sickle cell anemia patients have been reported in Europe and the US. These results justify the development of HP-B19 prevention and strategies to reduce the incidence of severe and life-threatening complications associated with the infection in patients with sickle cell anemia, particularly in sub-Saharan Africa where the sickle cell anemia burden is high. In light of these considerations, we conducted a case-control study including 163 patients with sickle cell anemia and 163 controls. HP-B19 diagnosis was based on the detection of IgG and IgM antibodies specific for HP-B19 using commercially available enzyme immunoassays. Anti-human parvovirus B19 IgG antibodies were found in 105 of 193 (64.8%) patients vs 79 of 193 controls (48.4%). IgM antibodies were found at a higher frequency in sickle cell anemia patients than in controls. This higher frequency was found to be age-dependent. However, the reticulocyte count showed no significant decrease in Malian patients with sickle cell anemia. Further studies are needed to better characterize the implication of HP-B19 infection in sickle cell anemia mortality and morbidity and to develop preventive strategies and efficient management of the resulting complications.

A novel EPO receptor agonist improves glucose tolerance via glucose uptake in skeletal muscle in a mouse model of diabetes.

Patients treated with recombinant human Epo demonstrate an improvement in insulin sensitivity. We aimed to investigate whether CNTO 530, a novel Epo receptor agonist, could affect glucose tolerance and insulin sensitivity. A single administration of CNTO 530 significantly and dose-dependently reduced the area under the curve in a glucose tolerance test in diet-induced obese and diabetic mice after 14, 21, and 28 days. HOMA analysis suggested an improvement in insulin sensitivity, and this effect was confirmed by a hyperinsulinemic-euglycemic clamp. Uptake of (14)C-2-deoxy-D-glucose indicated that animals dosed with CNTO 530 transported more glucose into skeletal muscle and heart relative to control animals. In conclusion, CNTO530 has a profound effect on glucose tolerance in insulin-resistant rodents likely because of improving peripheral insulin sensitivity. This effect was observed with epoetin-α and darbepoetin-α, suggesting this is a class effect, but the effect with these compounds relative to CNTO530 was decreased in duration and magnitude.

Development of a human whole blood assay for prediction of cytokine release similar to anti-CD28 superagonists using multiplex cytokine and hierarchical cluster analysis.

Anti-CD28 superagonist (SA) mediated cytokine release syndrome (CRS), an adverse event resulting in systemic release of cytokines, is an emergent issue in drug development. CRS is of potential concern for all monoclonal antibodies (mAbs) particularly those directed against cell surface targets on lymphocytes. Concern regarding patient safety requires development of novel methods to predict these adverse reactions. Due to the inability of animal studies to predict CRS, we have developed a whole blood in vitro screen to support First in Human studies and assess the potential for mAbs to cause anti-CD28 SA-like CRS. For this purpose we have immobilized marketed mAbs, whose potential for causing CRS and milder infusion reactions is known, on Protein A beads and used these beads to stimulate cytokine release. After culture, supernatants are harvested and frozen for later multiplex analysis of cytokines using Searchlight™ technology. We have employed hierarchicalluster analysis (HCA) to allow comparison of 12 different cytokine levels across numerous donors, treatments, and experiments. Results conclusively distinguish test mAb responses from an anti-CD28 superagonist mAb response. As part of a global analysis of preclinical data, the results of this assay can facilitate entry into First in Human clinical trials, help with selection of starting doses and may allow more rapid dose escalation using smaller cohorts.

The feasibility of ambulatory biosensor measurement of salivary alpha amylase: Relationships with self-reported and naturalistic psychological stress.

Recent developments in biosensor technology allow point-of-use reporting of salivary alpha amylase (sAA) levels while approaching the precision and accuracy of conventional laboratory-based testing. We deployed a portable prototype sAA biosensor in 54 healthy, male dental students during a low stress baseline and during final exams. At baseline, participants completed the Brief Symptom Inventory (BSI). At baseline and the exam week, participants provided saliva samples at 10 AM, 1 PM, and 5 PM, and rated concurrent subjective distress. Although subjective distress was higher during exams compared to baseline, sAA levels did not differ between baseline and exams. Higher sAA levels were related to higher concurrent subjective distress, and higher depressive and social isolation symptoms on the BSI were related to lower sAA during exams. Results from this study, in combination with previous validation data, suggest that the sAA biosensor is a promising tool for point-of-use measures of exposure to stress.

Childhood sexual abuse severity and disclosure predict posttraumatic stress symptoms and biomarkers in ethnic minority women.

OBJECTIVE: Adult posttraumatic stress symptoms and a biomarker index of current health risk in childhood sexual abuse (CSA) survivors were investigated in relation to CSA severity, disclosure, and other peri- and post-trauma factors. METHOD: A community sample of 94 African American and Latina female CSA survivors was assessed. RESULTS: Severe CSA predicted posttraumatic stress symptoms overall, avoidance/numbing symptoms, and greater biomarker risk and was not mediated by post-trauma variables. Moderate CSA severity was mediated by post-trauma disclosure, predicted reexperiencing symptoms, but was unrelated to biomarker risk. No overall ethnic differences were found. CONCLUSION: Results suggest targets for interventions to improve the well-being of minority women CSA survivors.

Stress biomarkers as outcomes for HIV+ prevention: participation, feasibility and findings among HIV+ Latina and African American mothers.

Mothers living with HIV (MLH) are at high risk for acute and chronic stress, given challenges related to their HIV status, ethnicity, economic and urban living conditions. Biomarkers combined into a composite index show promise in quantifying psychosocial stress in healthy people, but have not yet been examined among MLH. According, we examined potential biomarker correlates of stress [cortisol and catecholamines from home-collected urine and basic health indicators (blood pressure, height and weight, waist-to-hip ratio) measured during an interview] among 100 poor African American and Latina mothers MLH and demographic-matched control mothers without HIV (n = 50). Participants had been enrolled in a randomized controlled trial about 18 months earlier and had either received (MLH-I) or were awaiting (MLH-W) the psychosocial intervention. Participation was high, biomarkers were correctly collected for 93% of cases, and a complete composite biomarker index (CBI) calculated for 133 mothers (mean age = 42). As predicted, MLH had a significantly higher CBI than controls, but there was no CBI difference across ethnicity or intervention group. CBI predicted CD4 counts independently after controlling for age, years since diagnosis, prior CD4 counts, medication adherence, and depression symptoms. The study demonstrates acceptability, feasibility and potential utility of community-based biomarker collections in evaluating individual differences in psychosocial stress.

Peripheral biomarker composite associated with smaller hippocampal volume.

Animal and human studies demonstrate an association between smaller hippocampal volume and stress. A composite index of peripheral biomarkers used to objectively quantify human psychosocial stress has demonstrated utility, but has not yet been linked to hippocampal volume in putative 'high stress' groups. Structural magnetic resonance imaging exams and a composite of biomarkers representing cardiovascular, atherosclerosis, hypothylamic-pituitary-adrenal axis, glucose metabolism, and sympathetic nervous system activity were assessed in 30 healthy women with histories of stress precipitated by their child's diagnosis of a life-threatening illness. Hippocampal volume was significantly predicted by age, time since stressor onset, and the composite. An objective biomarker index may improve temporal tracking of brain changes in relation to stress-related psychological symptoms, with implications for basic and clinical research.

Myelodysplasia and anemia of chronic disease in human tumor necrosis factor-alpha transgenic mice.

TNF-alpha is a pleitropic cytokine that expresses both pro- and anti-inflammatory activity and transgenic mice expressing human tumor necrosis factor-alpha (TNF-alpha) exhibit a progressive polyarthritis that models rheumatoid arthritis (RA). One of the common comorbidities of RA is anemia of chronic disease (ACD). The purpose of these experiments was to study the changes in the bone marrow and peripheral blood that accompany polyarthritis in TNF-alpha transgenic mice in an effort to better understand the pathogenesis of myelodysplasia and ACD. Polychromatic cytometry, hematology and serum cytokine analysis were used to study the pathogenesis of ACD in human TNF-alpha transgenic mice. Our hematological evaluation revealed a mild, compensated, microcytic hypochromic anemia, and monocytosis. In the bone marrow, we observed alterations in cell kinetics, decreased relative expression of transferrin receptor and increased apoptosis and cell death in several late precursor cell populations. Although significant levels of human TNF-alpha were found in the serum, neither change in serum murine erythropoietin nor any significant difference observed in serum levels of murine IL-beta, IL-5, IL-6, IL-10, IL-12(p70), IL-17, TNF-alpha, IFNgamma, GM-CSF, MIP-1alphaJE, MCP-5 was observed. Tg197 mice develop a compensated, microcytic, hypochromic anemia, and a functional iron deficiency by 9 weeks of age. Changes in peripheral blood are reflected in alterations in cell kinetics, transferrin receptor expression and markedly increased apoptosis and cell death in the bone marrow indicating that TNF-alpha may contribute to myelodysplasia in ACD. Moreover, since human TNF-alpha can interact only with murine TNFR1, our data suggest that TNFR1 may play an important role in the development of ACD.

Temporal sequence of swallow events during the oropharyngeal swallow.

PURPOSE: To (a) identify and characterize the temporal relation of selected structural movements during the oropharyngeal swallow across participants, (b) determine whether patterns of movement could be identified, and (c) determine whether the temporal relations were affected by aging and bolus characteristics. METHOD: Retrospective analysis of videofluoroscopic swallows of 100 normal participants (age range=22-92 years) was conducted. Two swallows each of 3-ml and 10-ml liquids and a 1-3-ml paste bolus were analyzed. The onset of a number of structural movements and bolus arrival points were compared against a single reference event: onset of upper esophageal sphincter (UES) opening. RESULTS: Normal participants demonstrated predominant sequences in pharyngeal movement patterns with some variability. The use of voluntary swallow maneuvers by these normal participants accounted for some degree of this variability. Volume, consistency, and age all affected the temporal relation between onset of specific motor events relative to the onset of UES opening. Increasing bolus volume was associated with a shorter temporal difference between UES opening and onset of other pharyngeal movements. In contrast, a thicker bolus was associated with longer temporal differences. Younger participants generally demonstrated shorter temporal differences between events than did older participants. CONCLUSION: Temporal relations between structural movements are not fixed but can be systematically affected by bolus characteristics and age.