Universal hepatitis C screening in genitourinary medicine

Our genitourinary (GU) medicine service currently offers all attendees hepatitis C testing, regardless of risk factors. We carried out a retrospective case-note review of all cases of hepatitis C diagnosed in 2008 to determine whether a significant number of these cases would have been missed if screening was targeted at high-risk groups. Twenty-three cases of hepatitis C were diagnosed from approximately 30,000 screening tests, of which 19 were available for study. In all, 53% (10/19) were polymerase chain reaction-negative resolved infection and 47% (9/19) were chronic active hepatitis. All cases of infection had identifiable risk factors for infection with hepatitis C. We are now changing our guidelines to screen only those with identifiable risk factors.

The Interaction Between Gaze and Facial Expression in the Amygdala and Extended Amygdala is Modulated by Anxiety

Behavioral evidence indicates that angry faces are seen as more threatening, and elicit greater anxiety, when directed at the observer, whereas the influence of gaze on the processing of fearful faces is less consistent. Recent research has also found inconsistent effects of expression and gaze direction on the amygdala response to facial signals of threat. However, such studies have failed to consider the important influence of anxiety on the response to signals of threat; an influence that is well established in behavioral research and recent neuroimaging studies. Here, we investigated the way in which individual differences in anxiety would influence the interactive effect of gaze and expression on the response to angry and fearful faces in the human extended amygdala. Participants viewed images of fearful, angry and neutral faces, either displaying an averted or direct gaze. We found that state anxiety predicted an increased response in the dorsal amygdala/substantia innominata (SI) to angry faces when gazing at, relative to away from the observer. By contrast, high state anxious individuals showed an increased amygdala response to fearful faces that was less dependent on gaze. In addition, the relationship between state anxiety and gaze on emotional intensity ratings mirrored the relationship between anxiety and the amygdala/SI response. These results have implications for understanding the functional role of the amygdala and extended amygdala in processing signals of threat, and are consistent with the proposed role of this region in coding the relevance or significance of a stimulus to the observer.

Do TETRA (Airwave) base station signals have a short-term impact on health and well-being? A randomized double-blind provocation study

BACKGROUND

"Airwave" is the new communication system currently being rolled out across the United Kingdom for the police and emergency services, based on the Terrestrial Trunked Radio Telecommunications System (TETRA). Some police officers have complained about skin rashes, nausea, headaches, and depression as a consequence of using their Airwave handsets. In addition, a small subgroup in the population self-report being sensitive to electromagnetic fields (EMFs) in general.

OBJECTIVES

We conducted a randomized double-blind provocation study to establish whether short-term exposure to a TETRA base station signal has an impact on the health and well-being of individuals with self-reported "electrosensitivity" and of participants who served as controls.

METHODS

Fifty-one individuals with self-reported electrosensitivity and 132 age- and sex-matched controls participated in an open provocation test; 48 sensitive and 132 control participants went on to complete double-blind tests in a fully screened semianechoic chamber. Heart rate, skin conductance, and blood pressure readings provided objective indices of short-term physiological response. Visual analog scales and symptom scales provided subjective indices of well-being.

RESULTS

We found no differences on any measure between TETRA and sham (no signal) under double-blind conditions for either controls or electrosensitive participants, and neither group could detect the presence of a TETRA signal at rates greater than chance (50%). When conditions were not double blind, however, the self-reported electrosensitive individuals did report feeling worse and experienced more severe symptoms during TETRA compared with sham.

CONCLUSIONS

Our findings suggest that the adverse symptoms experienced by electrosensitive individuals are due to the belief of harm from TETRA base stations rather than to the low-level EMF exposure itself.

Preconscious processing biases predict emotional reactivity to stress

BACKGROUND

Anxiety vulnerability is associated with biases in attention: a tendency to selectively process negative relative to neutral or positive information. It is not clear whether this bias is: 1) related to the physiological response to stressful events, and 2) causally related to the development of anxiety disorders.

METHODS

We tested the predictive value of both preconscious and conscious attention biases in a prospective study of stress reactivity in a nonclinical sample. One hundred four male participants were assessed at baseline and then again 4 months (n = 82) and 8 months later (n = 70). Salivary cortisol and self-report measures were obtained at the baseline testing session in addition to measures of biased attention. Subsequent emotional reactivity was assessed by means of salivary cortisol and self-reported state-anxiety responses during a laboratory-based stressor (4 months later) as well as during a real-life stressor 8 months later (i.e., examination period).

RESULTS

Regression analyses indicated that a preconscious negative processing bias was the best predictor of the cortisol response to stressful events. Importantly, a measure of selective processing provided a better indicator of subsequent emotional reactivity than self-report measures of neuroticism, trait-anxiety, and extraversion.

CONCLUSIONS

These results suggest that preconscious biases toward negative material play a causal role in heightened anxiety vulnerability. Our results illustrate the potential utility of preconscious biases in attention in providing an early marker of anxiety vulnerability and a potential target for treatment intervention.

Comparing visual and auditory presentation for the modification of interpretation bias

This experiment compares the effects of visual vs. auditory presentation of cognitive bias modification (CBM) training scenarios upon interpretation style and emotional vulnerability. For both modalities, negative, but not positive interpretation biases were successfully induced relative to a baseline. Mood declined for the auditory but not the visual group throughout the CBM procedure, irrespective of the valence of the CBM condition. This deterioration in mood raises an important methodological issue and indicates that the increased testing time brought about by auditory compared to visual presentation needs to be addressed. The CBM procedures did not influence emotional vulnerability as assessed by behavioural measures, but counter-to-prediction, CBM procedures did increase self-reported depression vulnerability for the positive but not negative CBM condition.

Characteristics of children enrolled in treatment trials for NF1-related plexiform neurofibromas

OBJECTIVE

To describe the characteristics of children enrolled in treatment trials for neurofibromatosis type 1 (NF1)-related plexiform neurofibroma (PN), PN tumor burden, PN-related complications, and treatment outcomes and to highlight the differences between characteristics of children with NF1 vs children with cancers entered on early phase drug trials.

METHODS

Pre-enrollment characteristics and complications of PN were retrospectively analyzed in a cohort of 59 children with NF1-related PN treated on 1 of 7 clinical trials at the NIH between 1996 and 2007. Outcome was analyzed in a subset of 19 patients enrolled in phase I trials. Comparisons to children with cancer were made from a similar analysis performed recently.

RESULTS

The median age at enrollment was 8 years. The median PN volume was 555 mL. Most patients had no prior chemotherapy or radiation, but nearly half had previous surgery for PN. PN-associated complications and NF1 manifestations were common, including pain (53%), other tumors (18%), and hypertension (8%). Investigational drug therapy was well tolerated. A median of 10 treatment cycles was administered. Patients with NF1-related PN were younger, had better performance score, had less prior therapy, and remained on study longer than cancer patients.

CONCLUSIONS

Children with NF1-related plexiform neurofibroma (PN) enrolled in clinical trials had large tumors with substantial morbidity. Clinical trials in these children provide information about drug tolerance, cumulative toxicity, and pharmacokinetics in a younger population than early phase pediatric cancer trials. This report may aid in the evaluation of the applicability of traditional pediatric cancer trial designs and endpoints for NF1-related PN.

Introduction to the special section on cognitive bias modification in emotional disorders

Cognitive models of anxiety disorders and unipolar depression have postulated that selective information processing plays an important role in the development and maintenance of emotional psychopathology. Cognitive bias modification (CBM) procedures have recently been developed to test this theoretical claim. The purpose of this special section is to introduce the central ideas underlying CBM and to bring together the research that exemplifies the theoretical and clinical potential of the CBM approach.

Phase I/II trial of vandetanib in children and adolescents with hereditary medullary thyroid carcinoma

10014

Background: Mutations in the RET protooncogenecause hereditary medullary thyroid carcinoma (MTC) including Multiple Endocrine Neoplasia (MEN) Type 2A, Type 2B and familial MTC. Vandetanib inhibits VEGFR, EGFR, and RET tyrosine kinases and is active in adults with hereditary MTC. Methods: We are conducting a trial of vandetanib in children and adolescents with RET mutations and MTC. Safety is evaluated at each dose level in adolescents (13–18 years) prior to enrolling children (5–12 years). In the absence of dose limiting toxicity (DLT), intrapatient dose escalation is permitted after cycle 2. To assess bone toxicity, growth plate volume is measured using MRI. Response is monitored using tumor measurements (RECIST), serum biomarkers, calcitonin (CTN), and carcinoembryonic antigen (CEA). Results: Five adolescents and 2 children were enrolled at the 100 mg/m2 dose level, 3 adolescents were dose escalated to 150 mg/m2. Six have MEN2B (M918T RET mutation). Median (range) baseline CTN was 12,200 pg/mL (2,300–67,000) and CEA was 104 mcg/L (5–325). Dose limiting diarrhea was observed in 1/5 adolescents at the 100 mg/m2 and 1/3 adolescents escalated to 150 mg/m2. No DLTs were observed in children receiving 100 mg/m2. Non-DLT included elevated TSH (n = 6), rash (n = 5), anorexia (n = 3), diarrhea (n = 2), hypertension (n = 1), and fatigue (n = 1). Median (range) percent change in growth plate volume during therapy was -18% (-44% to + 50%). All patients had linear growth during therapy. Serum CTN and CEA decreased by ≥ 50% in 6/7 and 2/7 patients, respectively. Tumor size decreased in 6/6 patients with M918T RET mutations; 2 achieved RECIST partial response after 6 and 12 cycles. Conclusions: Preliminary results suggest that vandetanib has activity in children and adolescents with MEN2B associated MTC. Vandetanib 100 mg/m2 was well tolerated. Linear growth was not impaired.

[Table: see text]

Phase I study of sorafenib in children with refractory solid tumors: A Children's Oncology Group Phase I Consortium trial

10012

Background: Sorafenib, an oral multitargeted kinase inhibitor, is indicated for treatment of adults with refractory renal cell or hepatocelluar carcinoma. We performed a phase I trial to determine the toxicities, maximum tolerated dose (MTD), pharmacokinetics (PK), and pharmacodynamics (PD) of sorafenib in children with refractory solid tumors. Methods: Sorafenib was administered q12h for 28 consecutive day cycles. Cohorts of 3–12 patients were enrolled at 105, 130, 150, 200, and 250 mg/m2/dose dose levels. Results: 34 eligible pts [16M, median age 14.6 yrs, (range, 5–21)] with osteosarcoma (n = 8), rhabdomyosarcoma (n = 3), other sarcomas (n = 13), hepatoblastoma (n = 3), or other solid tumors (n = 7) received 1–22 cycles (median 2). Grade 3 dose-limiting toxicity (DLT) occurred in 4/6 pts at the starting dose (150 mg/m2) and included hypertension (n = 1), rash/urticaria (n = 1), back pain (n = 1), thrombocytopenia (n = 1) and ALT/AST (n = 1). No DLTs were observed at 105 (n = 6) or 130 (n = 3) mg/m2, and the dose was re-escalated to 150 mg/m2 with modified eligibility criteria (normal ALT) and revised guidelines for grading and management of hypertension. Gr 3 DLTs occurred in 1/6 pts (lipase) at 150 mg/m2 and 2/2 pts (hyponatremia, hand-foot syndrome) at 250 mg/m2. At 200 mg/m2 only 1/6 pts experienced DLT (gr 3 ALT). No objective responses were observed, but 2 pts had tumor shrinkage. Sorafenib AUC did not increase proportionally with dose - the mean AUC0–24h was similar at 150 mg/m2 (28±24 μg · h/mL, n = 9) and 200 mg/m2 (28±17 μg · h/mL, n = 4). Tmax was prolonged and variable (10±11 h, n = 19). Plasma VEGFR (n = 13) decreased from 9.9±1.6 ng/mL at baseline to 8.3±1.7 ng/mL by d 28 (p < 0.001). Conclusions: The MTD of sorafenib in children with solid tumors is 200 mg/m2, similar to the adult recommended dose (400 mg).

No significant financial relationships to disclose.

Looking on the bright side: biased attention and the human serotonin transporter gene

Humans differ in terms of biased attention for emotional stimuli and these biases can confer differential resilience and vulnerability to emotional disorders. Selective processing of positive emotional information, for example, is associated with enhanced sociability and well-being while a bias for negative material is associated with neuroticism and anxiety. A tendency to selectively avoid negative material might also be associated with mental health and well-being. The neurobiological mechanisms underlying these cognitive phenotypes are currently unknown. Here we show for the first time that allelic variation in the promotor region of the serotonin transporter gene (5-HTTLPR) is associated with differential biases for positive and negative affective pictures. Individuals homozygous for the long allele (LL) showed a marked bias to selectively process positive affective material alongside selective avoidance of negative affective material. This potentially protective pattern was absent among individuals carrying the short allele (S or SL). Thus, allelic variation on a common genetic polymorphism was associated with the tendency to selectively process positive or negative information. The current study is important in demonstrating a genotype-related alteration in a well-established processing bias, which is a known risk factor in determining both resilience and vulnerability to emotional disorders.

Domestic violence in a genitourinary medicine setting – an anonymous prevalence study in women

Domestic violence (DV) affects around one in four women in the UK. This study aimed to determine the prevalence of DV and the associations with sociodemographic and sexual behaviour variables in female attendees of an inner-city genitourinary (GU) medicine clinic. In this cross-sectional survey, 177 of 380 women (46.6%) disclosed a history of abuse and 17.4% reported DV in the preceding 12 months. Women with a history of a sexually transmitted infection (STI) were more likely to have experienced DV at some point in their lives (odds ratio [OR] = 2.39; 95% confidence interval [CI]: 1.58–3.63). Logistic regression analysis revealed that being black compared with white, (OR = 1.7; 95% CI: 2.4–12.5) current cohabitation with a partner (OR = 2.24; 95% CI: 1.06–4.75), increasing number of sexual partners in the last year (OR = 1.24; 95% CI: 1.01–1.5) and consumption of illicit drugs (OR = 2.05; 95% CI: 1.02–4.11) were significantly associated with DV in the last 12 months but age, current occupation, history of STIs, age of coitarche and condom use were not. DV was common in this GU medicine clinic population and associated with STIs. We recommend that health practitioners undergo training to increase awareness of the links between partner violence and sexual health problems.

Black and minority ethnic men who have sex with men: a London genitourinary medicine clinic experience

Summary:

The aim was to examine sexual behaviour and rates of sexually transmitted infections (STIs) in black and minority ethnic (BME) men who have sex with men (MSM) attending a London genitourinary medicine clinic. A case-note review of BME MSM (n = 203) attending our service between 1 April 2005 and 31 March 2006 was carried out. BME MSM were those who self-identified as being of Black (Caribbean, African or Other), South Asian (Indian, Pakistani, Bangladeshi or Sri Lankan) and Chinese/South-East Asian (Malaysian, Thai, Filipino, Japanese) ethnicities. Consecutively attending self-identified white British (WB) MSM (n = 203) were used as a comparative group. BME MSM were significantly more likely to report unprotected anal intercourse with casual male partners in the preceding three months (P = 0.0016) and were more likely to report female sexual partners (P = 0.0018). Rectal gonorrhoea was more common in WB MSM (P = 0.02). Numbers of other bacterial STIs and HIV infection were similar in both groups.

The higher reported rates of risk behaviour in BME MSM are of concern and support the need for focussed sexual health promotion.

Molecular analysis of DNA rearrangements in leukemias and non-Hodgkin's lymphomas

Genetic markers for leukemias and lymphomas include chromosomal translocations and antigen-receptor gene rearrangements. Clonal rearrangements of immunoglobulin or T cell receptor (TCR) genes reflect clonal proliferations of lymphocytes, a characteristic feature of lymphoid neoplasia. These rearrangements can be detected as described in this unit by Southern blot hybridization or, in many instances, the polymerase chain reaction (PCR). Specific chromosomal translocations can also serve as markers for clonality, for malignant transformation, and for various defined subtypes of hematopoietic cancers. PCR protocols are described for detection of the two most commonly assayed translocations, t(9;22) of chronic myelogenous leukemia or acute lymphoblastic leukemia, and t(14;18) of follicular lymphomas.

Growth arrest-specific gene 6 expression in human breast cancer

Growth arrest-specific gene 6 (Gas6), identified in 1995, acts as the ligand to the Axl/Tyro3 family of tyrosine kinase receptors and exerts mitogenic activity when bound to these receptors. Overexpression of the Axl/Tyro3 receptor family has been found in breast, ovarian and lung tumours. Gas6 is upregulated 23-fold by progesterone acting through the progesterone receptor B (PRB). Recently, Gas6 has been shown to be a target for overexpression and amplification in breast cancer. Quantitative real-time PCR analysis was used to determine the levels of Gas6 mRNA expression in 49 primary breast carcinomas. Expression of PRB protein was evaluated immunohistochemically with a commercially available PRB antibody. The results showed a positive association between PRB protein and Gas6 mRNA levels (P=0.04). Gas6 correlated positively with a number of favourable prognostic variables including lymph node negativity (P=0.0002), younger age at diagnosis (P=0.04), smaller size of tumours (P=0.02), low Nottingham prognostic index scores (P=0.03) and low nuclear morphology (P=0.03). This study verifies for the first time the association between PRB and Gas6 in breast cancer tissue.

Does short-term exposure to mobile phone base station signals increase symptoms in individuals who report sensitivity to electromagnetic fields? A double-blind randomized provocation study

BACKGROUND

Individuals with idiopathic environmental illness with attribution to electromagnetic fields (IEI-EMF) believe they suffer negative health effects when exposed to electromagnetic fields from everyday objects such as mobile phone base stations.

OBJECTIVES

This study used both open provocation and double-blind tests to determine if sensitive and control individuals experience more negative health effects when exposed to base station-like signals compared with sham.

METHODS

Fifty-six self-reported sensitive and 120 control participants were tested in an open provocation test. Of these, 12 sensitive and 6 controls withdrew after the first session. The remainder completed a series of double-blind tests. Subjective measures of well-being and symptoms as well as physiological measures of blood volume pulse, heart rate, and skin conductance were obtained.

RESULTS

During the open provocation, sensitive individuals reported lower levels of well-being in both the global system for mobile communication (GSM) and universal mobile telecommunications system (UMTS) compared with sham exposure, whereas controls reported more symptoms during the UMTS exposure. During double-blind tests the GSM signal did not have any effect on either group. Sensitive participants did report elevated levels of arousal during the UMTS condition, whereas the number or severity of symptoms experienced did not increase. Physiological measures did not differ across the three exposure conditions for either group.

CONCLUSIONS

Short-term exposure to a typical GSM base station-like signal did not affect well-being or physiological functions in sensitive or control individuals. Sensitive individuals reported elevated levels of arousal when exposed to a UMTS signal. Further analysis, however, indicated that this difference was likely to be due to the effect of order of exposure rather than the exposure itself.

The detection of fear-relevant stimuli: are guns noticed as quickly as snakes?

Potentially dangerous stimuli are important contenders for the capture of visual-spatial attention, and it has been suggested that an evolved fear module is preferentially activated by stimuli that are fear relevant in a phylogenetic sense (e.g., snakes, spiders, angry faces). In this study, a visual search task was used to test this hypothesis by directly contrasting phylogenetically (snakes) and ontogenetically (guns) fear-relevant stimuli. Results showed that the modern threat was detected as efficiently as the more ancient threat. Thus, both guns and snakes attracted attention more effectively than neutral stimuli (flowers, mushrooms, and toasters). These results support a threat superiority effect but not one that is preferentially accessed by threat-related stimuli of phylogenetic origin. The results are consistent with the view that faster detection of threat in visual search tasks may be more accurately characterized as relevance superiority effects rather than as threat superiority effects.

Anxiety and sensitivity to gaze direction in emotionally expressive faces

This study investigated the role of neutral, happy, fearful, and angry facial expressions in enhancing orienting to the direction of eye gaze. Photographs of faces with either direct or averted gaze were presented. A target letter (T or L) appeared unpredictably to the left or the right of the face, either 300 ms or 700 ms after gaze direction changed. Response times were faster in congruent conditions (i.e., when the eyes gazed toward the target) relative to incongruent conditions (when the eyes gazed away from the target letter). Facial expression did influence reaction times, but these effects were qualified by individual differences in self-reported anxiety. High trait-anxious participants showed an enhanced orienting to the eye gaze of faces with fearful expressions relative to all other expressions. In contrast, when the eyes stared straight ahead, trait anxiety was associated with slower responding when the facial expressions depicted anger. Thus, in anxiety-prone people attention is more likely to be held by an expression of anger, whereas attention is guided more potently by fearful facial expressions.

Congenital oesophageal stricture in a Japanese shiba inu

An 11-week-old, female, Japanese shiba inu, weighing 1.3 kg, was presented with a history of intermittent regurgitation since birth. An oesophagram showed a partial obstruction of the caudal cervical oesophagus associated with a narrow, transverse tissue band. Following surgical resection, the regurgitation resolved and the dog attained a normal bodyweight. Histological examination revealed focally hyperplastic epithelium with dense fibrous underlying connective tissue forming the band. The diagnosis was a congenital oesophageal stricture.