Neural activity during attentional conflict predicts reduction in tinnitus perception following rTMS.

BACKGROUND: Subjective idiopathic tinnitus is an intrusive, distracting, and potentially disabling disorder characterized by phantom perception of sounds. Although tinnitus has no approved pharmacologic treatment, recent evidence supports the use of repetitive transcranial magnetic stimulation (rTMS) to alleviate tinnitus symptoms. OBJECTIVE/HYPOTHESIS: Repetitive TMS delivered over the middle superior temporal gyrus (STG) may alter ratings of tinnitus awareness and annoyance more than loudness due to change in attentional processing. STG has reciprocal connections to regions of the prefrontal cortex that mediate attention. To probe the hypothesized influence of STG stimulation on attention, a subset of patients with tinnitus enrolled in an rTMS clinical trial [n = 12, 9 male, mean (sd) age = 49 (15) years] underwent an attentional conflict task before and after rTMS treatment in a repeated-measures functional magnetic resonance imaging (fMRI) study. METHODS: The Multi-Source Interference Task (MSIT), a Stroop-based visual attentional conflict fMRI task, was used to map participants' neural processing of attentional conflict prior to rTMS intervention (Baseline) and after three rTMS intervention arms: Sham, 1 Hz, and 10 Hz (four sessions per arm, 1800 pulses per session, delivered @110% of the motor threshold over the posterior superior temporal gyrus). RESULTS: All measures of tinnitus severity (awareness, loudness, and annoyance) improved with 1 Hz rTMS intervention; however, the greatest and most robust changes were observed for ratings of tinnitus awareness (mean 16% reduction in severity from Baseline, p < 0.01). The MSIT elicited a similar pattern of neural activation among tinnitus participants at Baseline compared to an independent sample of 43 healthy comparison adults (r = 0.801, p = 0.001). Linear regression with bootstrap resampling showed that greater recruitment of bilateral prefrontal and bilateral parietal regions by MSIT at Baseline corresponded with poorer treatment response. Individual regions' activities explained 37-67% variance in participant treatment response, with left dorsolateral prefrontal cortex's MSIT activity at Baseline explaining the greatest reduction in tinnitus awareness following 1 Hz stimulation. Although left dorsolateral prefrontal cortex activity at Baseline also predicted reduction in tinnitus loudness and annoyance (∼50% variance explained), these symptoms were more strongly predicted by right middle occipital cortex (∼70% variance explained) - suggesting that the neural predictors of symptom-specific treatment outcomes may be dissociable. CONCLUSION: These candidate neural reactivity markers of treatment response have potential clinical value in identifying tinnitus sufferers who would or would not therapeutically benefit from rTMS intervention.

Pneumothorax necessitans presenting as a presternal pneumothoracocele.

A 31-year-old woman who is an intravenous drug abuser developed sternoclavicular joint infection with mediastinal and subcutaneous tissue abscesses that communicated through an erosion in the manubrium caused by osteomyelitis. Air entrapment from a subsequent apical pneumothorax formed a localized anterior "pneumothoracocele." We referred to this condition as "pneumothorax necessitans," and we suggest including it in the differential diagnosis of anterior chest wall masses.

Immune-deficient bronchiectasis associated with X-linked lymphoproliferative disease.

Bronchiectasis may occur with various congenital and acquired immunodeficiency diseases. The association of bronchiectasis and the X-linked lymphoproliferative disease (XLP), also known as Duncan's disease is unknown. We describe the case of a 39-year-old man with XLP, the oldest surviving, who developed chronic bronchiectasis with hemoptysis and required a pneumonectomy to control his symptoms.

Advantage of dimeric peptide antigens in serodiagnosis of HIV-1 infection.

The reactivity of antibodies with dimeric and monomeric peptide antigens was compared by ELISA. A panel of highly purified synthetic peptides of HIV-1 representing defined regions, 598-609 and 524-533 (fusion domain) of gp41 and 306-320 of gp120, were used as antigens in the ELISA. These peptides were selected and synthesized taking into account the level of sequence conservation of various strains and hydrophilicity. The analysis included sera from 52 HIV-1 infected individuals and 53 HIV-1 negative controls. Both peptides from gp41 were found to be particularly immunoreactive with sera from HIV-1 infected individuals. The frequency of reactivity to the selected peptide from gp120 (V3 loop) in infected individuals was 82%. An interesting observation was that the dimeric peptide antigens had a detection rate more than 4-fold higher than the monomeric antigens. We found that lower levels of antibodies could be detected with dimeric antigens. The peptides reacted with few sera other than HIV-1 positive sera. These results implicate the potential dimeric peptide antigens to be utilized in the serodiagnosis of HIV-1 infection.

Thrombosis of tibial arteries in a patient receiving tamoxifen therapy.

BACKGROUND: Tamoxifen has been used extensively as adjuvant therapy in the treatment of pre- and post-menopausal patients with breast cancer. One of its known complications is venous thromboembolism. However, arterial thrombosis has been reported rarely. METHODS: A 49-year-old patient with breast cancer had had a total mastectomy 3 years earlier. She was receiving tamoxifen therapy when she developed a sudden onset of pain and numbness of the left foot and calf. An arteriogram showed thrombosis of her tibial arteries. RESULTS: This thrombosis was lysed successfully with urokinase therapy, and tamoxifen therapy was discontinued. At follow-up 4 months later, the patient had normal circulation to both legs. CONCLUSIONS: Patients receiving tamoxifen should be monitored closely for the development of venous or arterial thromboembolism.

Impact of an intervention on HIV, sexually transmitted diseases, and condom use among sex workers in Bombay, India.

OBJECTIVE: To develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay. SUBJECTS AND METHODS: In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use and knowledge of HIV was collected by interviewer-administered questionnaire. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year. RESULTS: The baseline level of knowledge about HIV and experience with condoms was extremely low among both sex workers and madams. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (P = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the two groups (all P < 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, women reported increased levels of condom use, and some (41%) said they were willing to refuse clients who wouldn't use them. However, both the sex workers and the madams were concerned about losing business if condom use was insisted upon. CONCLUSIONS: Both HIV prevalence and incidence are alarmingly high among female sex workers in Bombay. Successful interventions can be developed for these women, and even a partial increase in condom use may decrease the transmission of HIV and sexually transmitted diseases. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed at multiple sites in red-light areas.

PIP: The objective was to develop and test an HIV intervention targeting sex workers and madams in the brothels of Bombay. In a controlled intervention trial, with measurements before and after the intervention, 334 sex workers and 20 madams were recruited from an intervention site, and 207 and 17, respectively, from a similar control site, both in red-light areas of Bombay. All sex workers were tested for antibodies to HIV and syphilis, and for hepatitis B surface antigen. Information on sexual practices, condom use, and knowledge of HIV was collected by questionnaires. All subjects in the intervention group underwent a 6-month program of educational videos, small group discussions and pictorial educational materials; free condoms were also distributed. The blood tests and the questionnaire were readministered to all subjects at both sites immediately after the intervention. Both groups were followed for approximately 1 year. The baseline prevalence of HIV antibodies was 47% in the intervention group and 41% in the control group (p = 0.17). The incidence densities for HIV and sexually transmitted diseases were significantly different in the 2 groups (all p 0.005): 0.05 and 0.16 per person-year of follow-up for HIV, 0.08 and 0.22 per person-year for antibodies to syphilis, and 0.04 and 0.12 per person-year for hepatitis B surface antigen in the intervention and control women, respectively. Following the intervention, there was a significant increase in knowledge of modes of HIV transmission in the intervention group (n = 334) compared to the control group (n = 190) (60% vs. 99% compared to 56% vs. 26%, p 0.001). In addition, women reported increased levels of condom use and some (41%) said they were willing to refuse clients who would not use them. However, both the sex workers and 100% of the madams were concerned about losing business if condom use was insisted upon. Intervention programs of longer duration that target madams and clients and make condoms easily available are urgently needed.