PSA-Based Screening Outcomes, Dietary Heterocyclic Amine Exposure, and Prostate Cancer Risk in African Americans: Annual Report (Year 1 of 3)

Prostate cancer (PC) is the second leading cause of male U.S. cancer deaths, with African-Americans having the highest rate of PC mortality worldwide, as well as more abnormal results from screening tests that correlate with current or eventual PC. A 3-year prospective clinic-based study is studying the performance of current (PSA and DRE) vs. (% free PSA) clinical biomarkers of PC risk in 400 African-American men 50 to 70 years of age who undergo PC screening in Oakland, CA (East Bay San Francisco area), as well as possible association of PC screening results for these men with their dietary exposures to the cancer-causing heterocyclic amine, 2-amino-1-methyl-6-phenylimidazo[4,5-b]pyridine (PhIP) that forms when meat is cooked. This study expands an ongoing NIH-funded study (by the same research team) to add a new %-free-PSA test, results of which will be compared with PSA/DRE results and PhIP exposures estimated by dietary interviews. For 392 men studied under the NIH protocol, an odds ratio (95% CL) of 32 (3.2, 720) for highly elevated PSA ({ge}20 ng/mL) was observed in the highest 15% vs. the lower 50% of estimated daily PhIP intakes. Approximately 100 additional men have completed participation in the expanded NIH/DOD-supported study. This study will help define the potential value of improved screening and dietary/behavioral intervention to reduce PC risk, namely, prevention of PhIP intake by avoiding overcooked meats

Risk Analysis for Environmental Health Triage

The Homeland Security Act mandates development of a national, risk-based system to support planning for, response to and recovery from emergency situations involving large-scale toxic exposures. To prepare for and manage consequences effectively, planners and responders need not only to identify zones of potentially elevated individual risk, but also to predict expected casualties. Emergency response support systems now define ''consequences'' by mapping areas in which toxic chemical concentrations do or may exceed Acute Exposure Guideline Levels (AEGLs) or similar guidelines. However, because AEGLs do not estimate expected risks, current unqualified claims that such maps support consequence management are misleading. Intentionally protective, AEGLs incorporate various safety/uncertainty factors depending on scope and quality of chemical-specific toxicity data. Some of these factors are irrelevant, and others need to be modified, whenever resource constraints or exposure-scenario complexities require responders to make critical trade-off (triage) decisions in order to minimize expected casualties. AEGL-exceedance zones cannot consistently be aggregated, compared, or used to calculate expected casualties, and so may seriously misguide emergency response triage decisions. Methods and tools well established and readily available to support environmental health protection are not yet developed for chemically related environmental health triage. Effective triage decisions involving chemical risks require a new assessment approach that focuses on best estimates of likely casualties, rather than on upper plausible bounds of individual risk. If risk-based consequence management is to become a reality, federal agencies tasked with supporting emergency response must actively coordinate to foster new methods that can support effective environmental health triage

Comment on "Steady State Solutions to PBPK Models and their Applications to Risk Assessment I: Route to Route Extrapolation of Volatile Chemicals," by Chiu and White in Risk Analysis, 26(3), 769-780

Steady-state analyses of generic PBPK models for volatile organic chemical (VOC) exposure and risk assessment have been undertaken and applied for nearly two decades now. Chiu and White's paper on this subject adds little new to this earlier work. Their dismissive claim that ''Similar analyses have been done for specific chemicals and for inhalation'' is misleading, because some of this earlier work did indeed focus on ''generic'' PBPK models generally applicable to VOC exposure by multiple routes. In particular, the earliest of these previous studies developed steady-state solutions for generic PBPK models including respiratory and 1-compartment oral routes of exposure, and further specified how to add injection and dermal exposure routes. Chiu and White included a 2-compartment oral pathway and a lung compartment in an otherwise identical generic PBPK model, but did not consider other exposure pathways such as dermal uptake. Each of the earlier studies first presented a steady-state solution to a generic, multiroute PBPK model, and only then applied the generic solution to a problem or illustration involving a specific compound--i.e., the same approach used later by Chiu and White. For example, the earlier study included a simple, intuitive expression for low-dose metabolized fraction f*{sub m} of any applied multiroute dose, allowing route-to-route extrapolation regardless of compound in low-dose contexts that typically are of interest in environmental VOC risk assessment. Section 2.2 of Chiu and White's paper (''Generalization to Time-Varying Exposures'') concludes that, under conditions of virtually linear metabolism, PBPK system ''solutions to steady-state exposures are directly applicable to intermittent exposures''--i.e., under such conditions, all steady-state system solutions (or output states) become valid when each dynamic input is replaced by its corresponding time-weighted average value. This conclusion, a well known axiom of linear systems theory, was stated explicitly to apply to f*{sub m} in an earlier study. A subsequent study addressed how generic steady-state PBPK solutions can be modified to estimate transient peak target-tissue concentrations at dynamic equilibrium, for dynamic exposure scenarios that involve exposure to a regular (e.g., daily) series of brief inputs by multiple pathways--an issue that may be importance for endpoints that have a cytotoxic mechanism of action

Mode-of-Action Uncertainty for Dual-Mode Carcinogens:Lower Bounds for Naphthalene-Induced Nasal Tumors in Rats Implied byPBPK and 2-Stage Stochastic Cancer Risk Models

As reflected in the 2005 USEPA Guidelines for Cancer Risk Assessment, some chemical carcinogens may have a site-specific mode of action (MOA) that is dual, involving mutation in addition to cell-killing induced hyperplasia. Although genotoxicity may contribute to increased risk at all doses, the Guidelines imply that for dual MOA (DMOA) carcinogens, judgment be used to compare and assess results obtained using separate ''linear'' (genotoxic) vs. ''nonlinear'' (nongenotoxic) approaches to low-level risk extrapolation. However, the Guidelines allow the latter approach to be used only when evidence is sufficient to parameterize a biologically based model that reliably extrapolates risk to low levels of concern. The Guidelines thus effectively prevent MOA uncertainty from being characterized and addressed when data are insufficient to parameterize such a model, but otherwise clearly support a DMOA. A bounding factor approach--similar to that used in reference dose procedures for classic toxicity endpoints--can address MOA uncertainty in a way that avoids explicit modeling of low-dose risk as a function of administered or internal dose. Even when a ''nonlinear'' toxicokinetic model cannot be fully validated, implications of DMOA uncertainty on low-dose risk may be bounded with reasonable confidence when target tumor types happen to be extremely rare. This concept was illustrated for the rodent carcinogen naphthalene. Bioassay data, supplemental toxicokinetic data, and related physiologically based pharmacokinetic and 2-stage stochastic carcinogenesis modeling results all clearly indicate that naphthalene is a DMOA carcinogen. Plausibility bounds on rat-tumor-type specific DMOA-related uncertainty were obtained using a 2-stage model adapted to reflect the empirical link between genotoxic and cytotoxic effects of the most potent identified genotoxic naphthalene metabolites, 1,2- and 1,4-naphthoquinone. Resulting bounds each provided the basis for a corresponding ''uncertainty'' factor <1 appropriate to apply to estimates of naphthalene risk obtained by linear extrapolation under a default genotoxic MOA assumption. This procedure is proposed as scientifically credible method to address MOA uncertainty for DMOA carcinogens

Mode-of-Action Uncertainty for Dual-Mode Carcinogens: A Bounding Approach for Naphthalene-Induced Nasal Tumors in Rats Based on PBPK and 2-Stage Stochastic Cancer Risk Models

A relatively simple, quantitative approach is proposed to address a specific, important gap in the appr approach recommended by the USEPA Guidelines for Cancer Risk Assessment to oach address uncertainty in carcinogenic mode of action of certain chemicals when risk is extrapolated from bioassay data. These Guidelines recognize that some chemical carcinogens may have a site-specific mode of action (MOA) that is dual, involving mutation in addition to cell-killing induced hyperplasia. Although genotoxicity may contribute to increased risk at all doses, the Guidelines imply that for dual MOA (DMOA) carcinogens, judgment be used to compare and assess results obtained using separate 'linear' (genotoxic) vs. 'nonlinear' (nongenotoxic) approaches to low low-level risk extrapolation. However, the Guidelines allow the latter approach to be used only when evidence is sufficient t to parameterize a biologically based model that reliably o extrapolates risk to low levels of concern. The Guidelines thus effectively prevent MOA uncertainty from being characterized and addressed when data are insufficient to parameterize such a model, but otherwise clearly support a DMOA. A bounding factor approach - similar to that used in reference dose procedures for classic toxicity endpoints - can address MOA uncertainty in a way that avoids explicit modeling of low low-dose risk as a function of administere administered or internal dose. Even when a 'nonlinear' toxicokinetic model cannot be fully validated, implications of DMOA uncertainty on low low-dose risk may be bounded with reasonable confidence when target tumor types happen to be extremely rare. This concept was i illustrated llustrated for a likely DMOA rodent carcinogen naphthalene, specifically to the issue of risk extrapolation from bioassay data on naphthalene naphthalene-induced nasal tumors in rats. Bioassay data, supplemental toxicokinetic data, and related physiologically based p pharmacokinetic and 2 harmacokinetic 2-stage stochastic carcinogenesis modeling results all clearly indicate that naphthalene is a DMOA carcinogen. Plausibility bounds on rat rat-tumor tumor-type specific DMOA DMOA-related uncertainty were obtained using a 2-stage model adapted to reflec reflect the empirical link between genotoxic and cytotoxic effects of t the most potent identified genotoxic naphthalene metabolites, 1,2 1,2- and 1,4 1,4-naphthoquinone. Bound Bound-specific 'adjustment' factors were then used to reduce naphthalene risk estimated by linear ex extrapolation (under the default genotoxic MOA assumption), to account for the DMOA trapolation exhibited by this compound

Extended family caring for children orphaned by AIDS: balancing essential work and caregiving in a high HIV prevalence nations.

While over 90 per cent of the 15 million children who have been orphaned by HIV/AIDS are cared for by family members, there is little information about whether adults can meet orphans' essential caregiving needs while working to economically survive. Using a survey we conducted in Botswana of 1033 working adults, we analyse the experience of adults who are caring for orphans. Over one-third of working adults were caring for orphans and many with few financial resources: 82% were living on household incomes below US$10 purchasing power parity adjusted per person per day. Because of their caregiving responsibilities, they were less able to supplement income with overtime, weekend, evening, or night work. At the same time caregiving responsibilities meant orphan caregivers spent fewer hours caring for their own children and other family members. Nearly half of orphan caregivers had difficulties meeting their children's needs, and nearly 75% weren't able to meet with children's teachers. Pay loss at work compounded the problems: One-quarter of orphan caregivers reported having to take unpaid leave to meet sick childcare needs and nearly half reported being absent from work for children's routine health care. This paper makes clear that if families are to provide adequate care for orphans while economically surviving there needs to be increases in social supports and improvements in working conditions

Validation of a novel device to objectively measure adherence to long-term oxygen therapy

Sun-Kai V Lin1, Daniel K Bogen1, Samuel T Kuna2,31Department of Bioengineering; 2Department of Medicine, Pulmonary, Allergy and Critical Care Division, and Center for Sleep and Respiratory Neurobiology, University of Pennsylvania, Pennsylvania, USA; 3Department of Medicine, Philadelphia Veterans Affairs Medical Center Philadelphia, Pennsylvania, USARationale: We have developed a novel oxygen adherence monitor that objectively measures patient use of long-term oxygen therapy. The monitor attaches to the oxygen source and detects whether or not the patient is wearing the nasal cannula.Objective: The study’s purpose was to validate the monitor’s performance in patients with chronic obstructive pulmonary disease during wakefulness and sleep.Methods: Ten adult males with stable chronic obstructive pulmonary disease (mean ± SD FEV1 37.7 ± 14.9% of predicted) on long-term continuous oxygen therapy were tested in a sleep laboratory over a 12–13 hour period that included an overnight polysomnogram.Measurements: The monitor’s measurements were obtained at 4-minute intervals and compared to actual oxygen use determined by review of time-synchronized video recordings.Main results: The monitor made 1504/1888 (79.7%) correct detections (unprocessed data) across all participants: 957/1,118 (85.6%) correct detections during wakefulness and 546/770 (70.9%) during sleep. All errors were false negatives, ie, the monitor failed to detect that the participant was actually wearing the cannula. Application of a majority-vote filter to the raw data improved overall detection accuracy to 84.9%.Conclusions: The results demonstrate the monitor’s ability to objectively measure whether or not men with chronic obstructive pulmonary disease are receiving their oxygen treatment. The ability to objectively measure oxygen delivery, rather than oxygen expended, may help improve the management of patients on long-term oxygen therapy.Keywords: chronic obstructive pulmonary diseas

Risks of Mortality and Morbidity from Worldwide Terrorism: 1968-2004

Worldwide data on terrorist incidents between 1968 and 2004 gathered by the RAND corporation and the Oklahoma City National Memorial Institute for the Prevention of Terrorism (MIPT) were assessed for patterns and trends in morbidity/mortality. Adjusted data analyzed involve a total of 19,828 events, 7,401 ''adverse'' events (each causing {ge}1 victim), and 86,568 ''casualties'' (injuries) of which 25,408 were fatal. Most terror-related adverse events, casualties and deaths involved bombs and guns. Weapon-specific patterns and terror-related risk levels in Israel (IS) have differed markedly from those of all other regions combined (OR). IS had a fatal fraction of casualties about half that of OR, but has experienced relatively constant lifetime terror-related casualty risks on the order of 0.5%--a level 2 to 3 orders of magnitude more than those experienced in OR that increased {approx}100-fold over the same period. Individual event fatality has increased steadily, the median increasing from 14 to 50%. Lorenz curves obtained indicate substantial dispersion among victim/event rates: about half of all victims were caused by the top 2.5% (or 10%) of harm-ranked events in OR (or IS). Extreme values of victim/event rates were approximated fairly well by generalized Pareto models (typically used to fit to data on forest fires, sea levels, earthquakes, etc.). These results were in turn used to forecast maximum OR- and IS-specific victims/event rates through 2080, illustrating empirically based methods that could be applied to improve strategies to assess, prevent and manage terror-related risks and consequences

Understanding the barriers to accessing symptom-specific cognitive behavior therapy (CBT) for distressing voices: reflecting on and extending the lessons learnt from the CBT for psychosis literature

The experience of hearing voices ('auditory hallucinations') can cause significant distress and disruption to quality of life for people with a psychosis diagnosis. Psychological therapy in the form of Cognitive Behavior Therapy for psychosis is recommended for the treatment of positive symptoms, including distressing voices, but is rarely available to patients in the UK. Cognitive Behavior Therapy for psychosis has recently evolved with the development of symptom-specific therapies that focus upon only one symptom of psychosis at a time. Preliminary findings from randomized controlled trials suggest that these symptom-specific therapies can be more effective for distressing voices than the use of broad CBT protocols, and have the potential to target voices trans-diagnostically. Whilst this literature is evolving, consideration must be given to the potential for a symptom-specific approach to overcome some of the barriers to delivery of evidence-based psychological therapies within clinical services. These barriers are discussed in relation to the UK mental health services, and we offer suggestions for future research to enhance our understanding of these barriers