Prevalence of Toxoplasma infection in a cohort of homosexual men at risk of AIDS and toxoplasmic encephalitis

The purpose of this study was to characterize the epidemiologic, clinical, and laboratory parameters of a cohort of men at risk of AIDS-associated toxoplasmic encephalitis. One hundred seventeen (11%) of the 1,073 participants at the time of enrollment into the Chicago Multicenter AIDS Cohort Study (MACS) were seropositive for Toxoplasma antibodies. Significant differences in prevalence of antibodies between African-American, Hispanic, or white men were not observed (p = 0.49). One hundred one (86%) of the 117 antibody-positive participants had at least one follow-up serology performed and 6 (6%) of the 101 had a significant rise in IgG antibody titer on subsequent visits. Five of six participants with a significant rise in titer were also seropositive for HIV-1 at entry or seroconverted during the study. A trend toward higher IgG Toxoplasma titers and prevalence of IgM antibodies in participants seropositive for HIV-1 was observed, but the differences did not reach statistical significance. There was no evidence that the presence of Toxoplasma infection predisposed to development of CD4+ depletion or AIDS. None of the 183 individuals in the cohort who developed AIDS and who were seronegative for Toxoplasma antibodies developed toxoplasmic encephalitis. In contrast, of the 13 persons who developed AIDS and who were positive for Toxoplasma antibodies, 5 (38%) developed toxoplasmic encephalitis. Prevalence of Toxoplasma antibodies in the MACS population was independent of HIV-1 serostatus. Toxoplasma infection does not appear to predispose to progression of HIV-1 infection. The risk of development of toxoplasmic encephalitis in persons with AIDS and chronic Toxoplasma infection may have been underestimated by previous retrospective studies.

National survey of ovarian carcinoma. I. A patient care evaluation study of the American College of Surgeons

BACKGROUND

The Commission on Cancer of the American College of Surgeons recently finished a national survey of patients with ovarian cancer patients. The goal was to compare the patterns of care over a 5-year period.

METHODS

Data were collected from 25 consecutive patients whose disease was diagnosed first at 904 hospitals with cancer programs in 1983 and 1988.

RESULTS

There was a total of 12,316 patients, of whom 80% were 45-85 years old. Contrary to popular belief, only 8.2% of patients were nulliparous; 85% of patients had one to five children. Of significance, 18.2% of patients with ovarian cancer had undergone a previous hysterectomy with ovarian preservation. Primary surgical treatment was used in 94.9% of patients and consisted of: oophorectomy, 81.9%; hysterectomy, 55.1%; and omentectomy, 59.0%. However, only 12-25% of patients had biopsies of the diaphragm, paracolic gutters, colon, small bowel, pelvic and paraaortic lymph nodes, and cul-de-sac to permit adequate surgical staging. The primary surgeons were: gynecologic oncologists, 21%; obstetrician-gynecologists, 45%; general surgeons, 21%; and others, 13%.

CONCLUSIONS

These data indicate that additional resources are needed to improve the care of patients with ovarian cancer.

Primary renal sarcoma in adults. A natural history and management study by the American Cancer Society, Illinois Division

BACKGROUND

Primary renal sarcomas in adults are rare and unusual neoplasms. This study was performed to better define the natural history and current management of these sarcomas in a typical medical setting in the United States.

METHODS

The hospital records of 4018 adult patients with renal neoplasms treated in the state of Illinois from 1975 to 1985 were examined by American Cancer Society professional volunteers.

RESULTS

A primary renal sarcoma occurred in 34 patients (0.8% incidence). Eleven adult patients had Wilms tumor, 21 had primary renal sarcoma (47% leiomyosarcoma), and 2 were not found to have sarcoma on review. The median age of the patients with Wilms tumor was 30 years, whereas that of the patients with non-Wilms sarcoma was 65 years. Four of the patients with Wilms tumor (36%) are long-term survivors and all received adjuvant chemotherapy after radical nephrectomy. Six of the patients with non-Wilms sarcoma (29%) are long-term survivors after radical nephrectomy alone.

CONCLUSIONS

Primary renal sarcomas, when treated with radical nephrectomy and, in the case of Wilms tumor, adjuvant chemotherapy, appear to be curable in 29-36% of cases. Histologic review of patients younger than 40 years of age with renal neoplasia is recommended.

A method to test for a recent increase in HIV-1 seroconversion incidence: results from the Multicenter AIDS Cohort Study (MACS)

We have formulated the problem of determining whether there has been an upturn in HIV-1 seroconversion incidence over the first five years of follow-up in the Multicenter AIDS Cohort Study (MACS) as that of locating the minimum of a quadratic regression or examination of two-knot piecewise spline models. Under a quadratic model, we propose a method to obtain a direct estimate and a bootstrap estimate for the location of the temporal turning point (local minimum) for HIV-1 seroconversion incidence and three methods to estimate confidence intervals for the location of the turning point for HIV seroconversion incidence: (1) Wald confidence interval estimate with or without log transformation assuming the asymptotic normality and applying the Delta method; (2) asymmetric confidence intervals using Fieller's Theorem and its modification; and (3) bootstrapping confidence intervals. Inferences for the temporal turning point based on Wald tests for a single regression term in a non-linear regression model were not reliable compared to inferences based on confidence intervals placed on calendar time. We present results using these different methods applied to the MACS data and we obtain power estimates to illustrate the performances of different methods.

Recreational drugs and sexual behavior in the Chicago MACS/CCS cohort of homosexually active men. Chicago Multicenter AIDS Cohort Study (MACS)/Coping and Change Study

Since initial reports emerged of an association between recreational drug use and high-risk sexual behaviors in gay men, there has been interest in studying this relationship for its relevance to behavioral interventions. Reported here are the longitudinal patterns of alcohol and recreational drug use in the Chicago Multicenter AIDS Cohort Study (MACS)/Coping and Change Study (CCS) of gay men. A pattern of decreasing drug use over 6 years was observed that paralleled a decline in high-risk sexual behavior (i.e., unprotected anal intercourse). In contrast, alcohol consumption tended to be more stable over time, and to show no relationship to sexual behavior change. Men who combined volatile nitrite (popper) use with other recreational drugs were at highest risk both behaviorally and in terms of human immunodeficiency virus-1 (HIV) seroconversion throughout the study. Popper use also was associated independently with lapse from safer sexual behaviors (failure to use a condom during receptive anal sex). Use of other recreational substances showed no relationship to sexual behavior change patterns, and stopping popper use was unrelated to improvement in safer sexual behavior. When popper use and lapse from safer sex were reanalyzed, controlling for primary relationship status, popper use was associated with failure to use condoms during receptive anal sex among nonmonogamous men only. These findings suggest an association between popper use and high-risk sexual behavior among members of the Chicago MACS/CCS cohort that has relevance to HIV prevention intervention efforts.

Association of Antibody to Human Immunodeficiency Virus Type 1 Core Protein (p24), CD4 Lymphocyte Number, and AIDS-Free Time

Serum antibody to p24 (anti-p24) and p24 antigen, alone and in combination with CD4+ lymphocyte number, were evaluated as predictors of progression of human immunodeficiency virus type 1 (HIV-1) infection. Two hundred six HIV-1-prevalent seropositive men in the Multi-center AIDS Cohort Study since 1984-1985 were studied cross-sectionally and 84 seroconverters were evaluated longitudinally. Cross-sectional analyses revealed significant associations among titer of anti-p24, CD4+ cell count, disease status (Centers for Disease Control class), and progression to AIDS. A high titer of anti-p24 was associated with lack of p24 antigenemia. Longitudinal studies of seroconverters demonstrated that a low titer of anti-p24, low CD4+ cell count, and detection of HIV-1 p24 antigen are individually strong predictors of AIDS, but only low CD4+ cell count retains its independent predictive value in multivariate analysis of the three markers during the period immediately after infection with HIV-1.

Patient characteristics, methods of diagnosis and treatment of melanoma in the United States

The American College of Surgeons performed a patient care and evaluation study of melanoma for 1981 and 1987 to determine the presenting symptoms, methods of evaluation, clinical management and resulting outcome. Melanomas of the skin, eye, mucous membrane, metastases with unknown primary site and miscellaneous sites were included. Details concerning 5,004 patients from 681 hospitals in the study in 1981 and 6,900 patients from 844 hospitals in the study in 1987 were obtained--most melanomas were located in the skin; a decline in symptoms occurred at initial diagnosis; an increase in age at first diagnosis was reported; most melanomas were in Caucasian patients; slightly more melanomas occurred in men than women; more melanomas occurred in men on the head and neck and trunk, and more in the lower extremity in women; most tumors were not large in diameter; a significant shift was reported to lower levels of Clark's invasion, and a significant amount of unknowns existed in the Breslow's thickness of invasion. The large number of unknowns makes analysis difficult, but there seems to be some shift toward thinner levels of Breslow's in tumors in which it was known, from 1981 to 1987. Only a small proportion of patients in the current series was known to have node involvement or known distant metastases. An overall decline in diagnostic studies occurred between 1981 and 1987.

Estimation of time since exposure for a prevalent cohort

In natural history studies of human immunodeficiency virus type 1 (HIV-1) infection a substantial proportion of participants are seropositive at time of enrollment in the study. These participants form a prevalent subcohort. Estimation of the unknown times since exposure to HIV-1 in the prevalent subcohort is of primary importance for estimation of the incubation time of AIDS. The subset of the cohort that tested negative for antibody to HIV-1 at study entry and was observed to seroconvert forms the incident subcohort that provides longitudinal data on markers of maturity (that is, duration) of infection. We use parametric life table regression models incorporating truncation to describe the conditional distribution (imputing model) of the times since seroconversion given a vector of the markers of maturity. Using the fitted model and the values of the markers of maturity of infection provided by the seroprevalent subcohort at entry into the study, we can impute the unknown times since seroconversion for the prevalent subcohort. We implement multiple imputation based on a model-robust estimate of the covariance matrix of parameters of the imputing model to provide confidence intervals for the geometric mean of the time since seroconversion in the prevalent subcohort, and to compare maturity of infection of cohorts recruited in different cities. The accuracy of imputation is further validated by comparisons of imputation-based estimates of AIDS incubation distribution in the seroprevalent subcohort with more direct estimates obtained from the seroincident subcohort.

Hospital variables associated with quality of care for breast cancer patients

OBJECTIVE

To determine the degree of compliance with clinical standards among hospitals for care of breast cancer patients and account for variations in compliance.

DESIGN

Analysis of cancer registry data submitted to the American Cancer Society, Illinois Division, Chicago, for a concurrent prospective descriptive study of breast cancer, supplemented by other hospital data from public sources.

SETTING

Ninety-nine Illinois hospitals evenly distributed among rural counties, counties with small cities outside the Chicago metropolitan area, exurban counties in the Chicago metropolitan area, suburban Cook County, and urban Chicago.

PATIENTS

A total of 5766 newly diagnosed patients with histologically confirmed breast cancer in 1988, representing 84% of the estimated 6900 new cases in the state for that year.

MAIN OUTCOME MEASURES

Descriptive statistics and multiple linear regression analyses of five dependent quality variables from clinical indicators related to early diagnosis, hormone receptor determination, adjuvant therapy, radiation therapy, and axillary lymph node dissection.

RESULTS

At the hospitals studied, (1) late stage (IIb through IV) at diagnosis was associated with urban location, higher proportion of poorly insured patients, fewer breast cancer cases treated, and lower oncology charges (proportion of variance explained, R2 = .50, P less than .00001); (2) omission of hormone receptor test for stages II through IV was associated with urban location and higher proportion of poorly insured patients (R2 = .18, P less than .00003); and (3) omission of indicated radiation therapy was associated with urban location and fewer breast cancer cases (R2 = .21, P less than .00001). Omission of adjuvant therapy and omission of axillary lymph node dissection were not significantly associated with any of the hospital variables examined.

CONCLUSIONS

The findings suggest that there is a group of urban hospitals, generally small and marginally reimbursed, where comprehensive diagnosis and treatment of breast cancer are not obtained.

The unseen sample in cohort studies: estimation of its size and effect. Multicenter AIDS Cohort Study

Recruitment of disease-free subjects into cohort studies and measurement of their time from exposure/infection to disease selectively excludes individuals (the unseen sample) who had earlier exposure and who have shorter times to disease. The unseen and observed samples may differ in other characteristics in addition to incubation period and exposure/infection time. For data with known truncation times, we develop non-parametric maximum likelihood estimates of the size, exposure/infection dates and distribution of incubation time in the unseen sample. We provide procedures to estimate and compensate for the biasing effects due to exclusion of the unseen sample in descriptive and survival analysis. We give consistency properties of these estimates and assess variability using bootstrap methods. One can use imputation to derive the above estimates from data with unknown truncation times that have been estimated parametrically. Application is made to an AIDS cohort study of over 5000 homosexual men. Important estimates obtained from this application are the annual seroconversion rates from 1978 to 1983, not otherwise obtainable in this study population.

Estimating the 1978-1990 and future spread of human immunodeficiency virus type 1 in subgroups of homosexual men

The authors studied the historical spread of human immunodeficiency virus type 1 (HIV-1) infection in homosexual/bisexual men and projected its future spread in these men using data from an AIDS-free cohort recruited during late 1984 in Baltimore, Maryland; Chicago, Illinois; Los Angeles, California; and Pittsburgh, Pennsylvania. Dates of preentry seroconversion in HIV-1 seroprevalent men were estimated using study entry values of hematologic variables influenced by HIV-1 infection. The authors used survival methods incorporating truncation to determine numbers/dates of seroconversion for men with a pre-1984 AIDS diagnosis who were selectively excluded by design from the 1984 AIDS-free cohort. Overall, the annual seroconversion hazard rose progressively from 0.4% in 1978 to 13.8% in 1983, dropped to 4.6% in 1985, and remained relatively stable at 1.1-2.2% from 1986 to 1990. By January 1990, almost 46% of men who were seronegative in 1978 had seroconverted. The authors estimated historical rates of spread by city, age, education, and ethnicity to examine the effects of these factors in the early and continuing stages of the HIV-1 epidemic. There were striking differences among cities with respect to pre-1985 seroconversion rates but not with respect to post-1985 seroconversion rates. Age, education, and ethnicity were all associated with 1978-1990 seroconversion rates. Future seroconversion among homosexual men was predicted assuming that the "stabilized" 1986-1990 hazards (stratified by age) observed here will be representative of future rates. Truncated Kaplan-Meier methods gave the probability of a seronegative 20-year-old man's remaining seronegative in subsequent years. Such a man has a 20.2% chance of seroconverting before reaching the age of 25 years (a 4.4% yearly hazard). The annual hazard drops to 2.5% between 25 and 30 years, to about 1.5% between 30 and 45 years, and to 1.0% between 45 and 55 years. The overall probability of seroconversion prior to age 55 years is about 50%, with seroconversion still continuing at and after age 55. Given that this cohort consists of volunteers receiving extensive anti-HIV-1 transmission education, the future seroconversion rates of the general homosexual population may be even higher than those observed here.

Pancreatic cancer in Illinois. A report by 88 hospitals on 2,401 patients diagnosed 1978-84

A retrospective study of survival results for pancreatic cancer was performed. The study had two objectives: 1) to relate the extent of disease and management to survival, and 2) to determine whether newer treatment combinations have altered prognosis. Cancer registrars from 88 Illinois hospitals reviewed original medical records and submitted standardized report forms on 2,401 patients diagnosed between 1978-84. Three-year survival time was longer after laparotomy/bypass plus radiation/chemotherapy than for laparotomy/bypass alone (P less than .02). But the difference in survival between resection versus resection, radiation, and chemotherapy was not significant (P = .16). After resection, the median survival for 78 Stage I patients was 12.5 months, whereas for 181 Stage I patients after laparotomy/bypass it was 6.8 months (P less than .00001). For patients without metastases, 3-year survival was significantly better for 249 patients in whom cancer was resected versus 568 unresected patients (P less than .001). Survival was longer for 568 unresected patients without gross metastases than for 954 patients with metastatic disease found at laparotomy (P less than .05). From this study the authors concluded that: 1) since 3-year survival results were higher than expected after resection for localized cancers, resection is still desirable when it can be done with acceptable complication risks, and 2) the use of multiple treatment modalities for pancreatic cancer warrants further study in organized trials.

Prognostic implications of proliferative activity and DNA aneuploidy in Astler-Coller Dukes stage C colonic adenocarcinomas

Paraffin-embedded surgical specimens from 69 patients who underwent resections of otherwise untreated Dukes stage C adenocarcinoma of the colon were examined for proliferative activity, DNA aneuploidy, DNA index, and proportion of aneuploid cells by flow cytometry. Results were correlated to clinical characteristics of the patients and to overall survival times. DNA aneuploid tumors were identified in 60 cases (87%), diploid tumors in 9 cases (13%). The mean S-phase fraction for all cases was 17.6%, with a standard deviation (SD) of 7.8. In univariate statistical analysis, younger patient age, lower tumor proliferative activity, DNA index less than or equal to 1.2, and presence of only 1-4 lymph nodes with tumor involvement were found to be significant predictors of improved patient survival. In multivariate Cox regression analysis, low tumor proliferative activity, younger patient age, and location of the tumor in the right or transverse colon were found to be significant independent predictors of increased patient survival. When tumor proliferative activity was stratified into statistically defined subgroups, patients with tumors of low proliferative activity (S-phase less than mean - 0.5 SD) had significantly longer survival than patients with tumors of moderate proliferative activity (S-phase value greater than mean - 0.5 SD and less than mean +0.5 SD) or high proliferative activity (S-phase greater than mean +0.5 SD). These results suggest that tumor proliferative activity in Dukes C colon carcinoma may be an important biological factor in determining patient prognosis.

Predicting progression to AIDS: combined usefulness of CD4 lymphocyte counts and p24 antigenemia

PURPOSE

To investigate the combined usefulness of CD4 lymphocyte counts and human immunodeficiency virus type 1 (HIV-1) p24 antigen in predicting progression to the acquired immunodeficiency syndrome (AIDS).

PATIENTS AND METHODS

CD4 lymphocyte counts and HIV-1 p24 antigen status were evaluated over a 4-year period in 518 HIV-1-seropositive men enrolled in the Multicenter AIDS Cohort Study in Chicago.

RESULTS

Twenty-six percent (134 of 518) of the HIV-1-seropositive cohort had detectable p24 antigen during the study period. Men with p24 antigenemia experienced a more rapid decline in CD4 lymphocyte counts than men who were persistently p24 antigen-negative (p less than 0.01). Mean CD4 lymphocyte counts at first detection of p24 antigen were 406 and 455 cells/microL for men with incident and prevalent antigenemia, respectively. Antigen was detected in 61% (63 of 103) of the men who progressed to AIDS and in only 17% (71 of 415) of the men who did not (p less than 0.0001). The 4-year estimated cumulative AIDS incidence was 86%, 63%, and 21% for men with entry CD4 counts less than 200, 200 to 399, and 400 or more cells/microL, respectively. Presence of p24 antigenemia was strongly associated with more rapid disease progression within each of these CD4 groupings (p less than 0.0001).

CONCLUSION

Our data indicate that p24 antigenemia can first be detected with moderate CD4 cell depletion, is associated with a more rapid decline in the CD4 lymphocyte population, and combined with CD4 lymphocyte counts is useful in identifying individuals at significantly greater risk of disease progression. Our findings provide important information for assessing HIV-1 disease prognosis over a 4-year period.

Prevention of thromboembolism after spinal cord injury using low-molecular-weight heparin

OBJECTIVE

To examine the safety and effectiveness of a low-molecular-weight heparin in the prevention of thromboembolism in patients with recent spinal cord injury and complete motor paralysis.

DESIGN

Randomized evaluation of two heparin regimens in 41 consecutive patients meeting eligibility requirements for anticoagulant prophylaxis. Daily bedside examinations were supplemented by serial venous flow studies; suspicious or positive tests were confirmed by venography.

INTERVENTION

Standard heparin, 5000 units subcutaneously three times a day; low-molecular-weight heparin 3500 anti-Xa units subcutaneously once daily.

MEASUREMENTS AND MAIN RESULTS

Five patients in the standard heparin group had thrombotic events, including two patients with fatal pulmonary embolism; two other patients had bleeding severe enough to necessitate withdrawing the heparin. The cumulative event rate was 34.7% (95% CI, 13.7% to 55.2%). None of the patients treated with low-molecular-weight heparin had thrombosis or bleeding (CI, 0% to 14%). The difference between the two groups was significant (P = 0.006, log-rank test).

CONCLUSIONS

Low-molecular-weight heparin is safe and effective in the prevention of thromboembolism in selected patients with spinal cord injury and complete motor paralysis, and is superior to standard heparin in fixed doses of 5000 units three times a day.

Survival discriminants for differentiated thyroid cancer

Since 1975, the American Cancer Society, Illinois Division, has published end results of major cancer sites drawn from patient data contributed voluntarily by hospital cancer registries throughout the state. The current study was undertaken, in part, to apprehend information regarding contested areas in the management of patients having differentiated (papillary/follicular) thyroid cancer. A total of 2,282 patients with either papillary or follicular carcinoma of the thyroid from 76 different Illinois hospitals and providing 10 years of follow-up information (life-table analysis) were retrospectively analyzed for demographic, disease, and treatment-related predictors of survival. Multivariate analysis using the Cox proportional hazards method was made for stage, age, race, sex, morphology, history of radiation exposure, presence of positive lymph nodes, initial surgical treatment, postoperative iodine 131 therapy, and replacement/suppressive thyroid hormone treatment. Statistically significant (p less than or equal to 0.05) predictors of favorable survival after thyroid cancer were low stage (I and II), young age (less than 50 years), white race, female sex, and the administration, postoperatively, of either thyroid hormone or radioactive iodine. Factors that had no influence on survival were lymph node status, choice of initial surgical treatment, and a history of prior irradiation. We suggest that where a prospective clinical trial is impracticable, a retrospective analysis of a large and detailed database, such as that available from cooperating hospital-based tumor registries, may yet provide useful insights to solutions of cancer management problems.

Two quick estimates of the HIV prevalence in homosexual men in Los Angeles, New York and San Francisco. The Multicenter AIDS Cohort Study

Two rough methods are given to estimate the combined HIV prevalence in Los Angeles, New York and San Francisco in homosexual men. Both methods are related to the back calculation technique, and use AIDS surveillance data and information obtained from the Multicenter AIDS Cohort Study. Both methods suggest that the combined HIV prevalence is approximately 100,000, with a possible range of 80,000-140,000.

Estimating the distribution of times from HIV seroconversion to AIDS using multiple imputation. Multicentre AIDS Cohort Study

Multiple imputation is a model based technique for handling missing data problems. In this application we use the technique to estimate the distribution of times from HIV seroconversion to AIDS diagnosis with data from a cohort study of 4954 homosexual men with 4 years of follow-up. In this example the missing data are the dates of diagnosis with AIDS. The imputation procedure is performed in two stages. In the first stage, we estimate the residual AIDS-free time distribution as a function of covariates measured on the study participants with data provided by the participants who were seropositive at study entry. Specifically, we assume the residual AIDS-free times follow a log-normal regression model that depends on the covariates measured at enrolment on the seropositive participants. In the second stage we impute the date of AIDS diagnosis for the participants who seroconverted during the course of the study and are AIDS-free with use of the log-normal distribution estimated in the first stage and the covariates from each seroconverter's latest visit. The estimated proportions developing AIDS within 4 and within 7 years of seroconversion are 15 and 36 per cent respectively, with associated 95 per cent confidence intervals of (10, 21) and (26, 47) per cent. We discuss the Bayesian foundations of the multiple imputation technique and the statistical and scientific assumptions.

Non-androgenic role of testis in enhancing ventral prostate growth in rats

This study was conducted to investigate whether the testis, aside from its ability to secrete androgen, is able to promote prostatic growth in rats. Increasing quantities of silastic capsules filled with crystalline dihydrotestosterone (DHT) were implanted subcutaneously into adult Sprague-Dawley rats at the time of bilateral epididymo-orchiectomy or sham operation on the testes. Control animals received empty capsules. Twenty-eight days later, the growth of the ventral prostate as measured by wet weight, DNA, and protein content per prostate was significantly greater in rats with intact testes than in orchiectomized rats. An overall increased growth was noted at all doses of exogenous DHT administered. Serum levels of luteinizing hormone in animals treated with DHT were undetectable. Serum levels of testosterone in intact rats treated with DHT were not significantly different from those in castrated rats. These observations suggest a non-androgenic role for the testis and, perhaps, epididymis in promoting prostatic growth in rats, and are consistent with the concept that a non-androgenic substance, produced from the testis and/or epididymis, is able to enhance prostate growth induced by androgen stimulation. The possibility that this phenomenon may play a role in the benign growth of the prostate observed in aging human males with decreased blood levels of androgen warrants consideration.

Low prevalence of neurological and neuropsychological abnormalities in otherwise healthy HIV-1-infected individuals: results from the multicenter AIDS Cohort Study

Accurate description of the prevalence of neurological impairment in healthy individuals who are infected with human immunodeficiency virus type 1 (HIV-1) has relevance for public health policy, for employment issues, and for planning future health needs. Within the Multicenter AIDS Cohort Study, we determined the cross-sectional prevalence of neurological abnormalities in 270 HIV-1 seropositive homosexual and bisexual men in Centers for Disease Control Groups II and III, using a control group of 193 HIV-1 seronegative homosexual men. Utilizing a neurological and neuropsychological screening battery, we found no differences in the prevalence of neuropsychiatric symptoms or in neuropsychological performance. One hundred nineteen subjects with abnormalities on screening tests completed additional neuropsychological testing and had neurological examinations. The majority had normal results and the frequency of neurological abnormalities and impaired neuropsychological performance was not significantly increased among HIV-1 seropositive subjects. Most of the abnormalities could be attributed to causes other than HIV-1. One subject had mild HIV-1-related dementia, yielding a prevalence of 3.7:1,000 (95% confidence interval: 0.19-23.7:1,000). Magnetic resonance imaging demonstrated sulcal prominence and focal areas of high signal intensity in white matter in 63% of HIV-1 seropositive subjects and 48% of uninfected control subjects. Abnormalities in cerebrospinal fluid were noted in 23 (85%) of 27 HIV-1-infected individuals. Our studies indicate that the prevalence of dementia and other HIV-1-related neurological disorders is very low among healthy HIV-1 seropositive homosexual men. The confounding effects of factors such as substance abuse or preexisting medical conditions must be considered in the neurological evaluation of such patients.

Acquired immunodeficiency syndrome (AIDS)-free time after human immunodeficiency virus type 1 (HIV-1) seroconversion in homosexual men. Multicenter AIDS Cohort Study Group

To estimate the time interval between human immunodeficiency virus type 1 (HIV-1) seroconversion and acquired immunodeficiency syndrome (AIDS) diagnosis in homosexual men, prospective incident cohorts are difficult to obtain and, if assembled, provide few events owing to the long incubation time. Although seroprevalent cohorts are numerous in size and events, the information is limited due to the unknown times since seroconversion. To combine the information provided by 1,628 seroprevalent men (304 AIDS cases) and 233 seroconverters (12 AIDS cases) being followed in a multicenter study since 1984, the postseroconversion changes in hematologic variables occurring in the incident cohort were used to develop a model that allowed for the imputation of the unknown times since seroconversion for the seroprevalent cohort. Nonparametric life table methods incorporating truncation and censoring were applied for the estimation of the probability distribution of the AIDS-free time after seroconversion. The precision of the estimates was evaluated using bootstrap methods. The analysis suggested that AIDS is unlikely (less than 0.5%) in the first year; 78% of seropositive homosexual men remain AIDS-free 60 months after seroconversion; and the AIDS incidence increases for months 12-36 and levels off at 38 per 1,000 person-semesters for months 42-60. The nonparametric estimate of the incidence rate suggests a median AIDS-free time of 11 years, which is longer than previous estimates based on parametric models.

Prognostic significance of positive peritoneal cytology in clinical stage I adenocarcinoma of the endometrium

One hundred fifty-seven consecutive patients with clinical stage I endometrial adenocarcinoma who underwent primary surgical therapy between July 1979 and January 1986 were evaluated prospectively for malignant peritoneal cytology. No treatment was directed specifically for positive peritoneal cytology. Thirty patients (19%) had malignant peritoneal cytology. In univariate statistical analysis, positive cytology was significantly associated with depth of myometrial invasion (P = .02) and histopathology (P less than .025), but not with disease recurrence (P = .33). Recurrence developed in five (17%) of 30 patients with positive cytology and 11 (9%) of 127 patients with negative cytology. Using multivariate analysis, the presence of extrauterine disease spread other than lymph node metastasis was the only variable significantly associated with time to recurrence (P = .009). When patients with poor prognostic factors (grade 3 tumors, deep myometrial invasion, tumors larger than 2 cm, positive lymph nodes, and other extrauterine disease spread) were excluded from analysis, malignant peritoneal cytology still had no influence on time to recurrence. Of the five patients with positive peritoneal cytology who had disease recurrence, only one recurrence arose within the peritoneal cavity. The presence of positive peritoneal cytology in clinical stage I endometrial adenocarcinoma does not appear to have independent prognostic significance and probably should not influence treatment decisions in the absence of other poor prognostic factors.

Effects of HIV infection, perceived health and clinical status on a cohort at risk for AIDS

Data from a general population sample of 621 healthy homosexual men are used to evaluate the social and emotional effects of HIV antibody status, clinical signs detected by medical examination, and subjectively perceived symptoms. Participants are unaware of their serologic status at the time of data collection, thus allowing the effects of the virus to be separated from reactions to the knowledge of serologic status. The data show that seropositivity for HIV is not associated with elevated levels of social or emotional impairment. Clinical signs lead to impairment in baseline data, but these effects do not persist at a second wave. This weakening suggests that the effects are mediated by psychological pathways rather than biologic ones. This suspicion is confirmed in further analyses, which show that the effects of clinical signs are mediated by subjectively perceived symptoms. These results show that neither social nor emotional impairment is likely to be a prodromal sign of HIV infection in otherwise healthy homosexual men. The substantial levels of distress found among these men is more directly influenced by psychological determinants than biologic ones. This suggests that physicians should be aware of the psychological toll imposed on gay men who develop health problems in the current atmosphere of uncertainty regarding risk of AIDS.

Prevalence of antibody to hepatitis B virus in foreign-born hospital employees

Hepatitis B surface and core antibodies were measured in 512 community hospital employees at increased risk for developing infection with hepatitis B virus. Antibody was detected in 140 (27 percent) participants. Multivariate logistic regression analysis indicated that seropositivity was strongly associated with the prevalence of hepatitis B in an employee's country of birth and with age. These results suggest that reported differences among hospitals in hepatitis B seropositivity may in part be a reflection of the national origin of its employees. These data also indicate that each hospital should assess its own risk for hepatitis B infection and that prevaccination serologic testing is particularly worthwhile in hospitals having large numbers of foreign-born employees.

An immunosorbent assay for blood group I antigens in breast carcinoma

Tumor cells elaborate and release into the circulation a variety of glycoproteins. An enzyme-linked immunosorbent assay (ELISA) was developed to monitor carbohydrate structures secreted into the circulation. Among these antigens are the structures specific for the blood group I antigens, which are incompletely converted to ABH antigens on the membranes of tumor cells. The I antigens in the sera of 67 women with breast carcinoma (BCa), 58 with benign breast disease (BBD), and 47 controls were measured by the ELISA. In this assay, I antigen from ovarian cyst mucin was bound to the wells of polystyrene microtiter plates. The monoclonal human anti-I antibody (Hy) was added to the wells along with perchloric acid extracts of patient and control sera at five different dilutions. The anti-I binding to the solid-phase I antigen was determined after incubation steps with peroxidase-labeled anti-human IgM and substrate. The amount of sera extracts giving 50% inhibition of anti-I (Hy) binding was determined from the inhibition curves which were corrected by integrating the slope values into that of the standard curve obtained with extracts of normal sera. The I antigens were significantly higher in pathologic stage (PS) IV sera (P less than 0.001), and comparable in PS I, PS II, and PS III and BBD sera to those in control sera. The anti-I (Hy) binds strongly Gal 1,4 GlcNAc 1,6 Gal (alpha GalNAc); Gal 1,4 GlcNAc 1,6 (Gal 1,4 GlcNAc 1,3) Gal; and to a lesser extent Gal 1,4 GlcNAc 1,3 Gal 1,4 GlcNAc (0.06, 0.09, and 0.35 mM, giving 50% inhibition, respectively). It was concluded that similar or related structures may be expressed on the membrane of metastatic BCa cells.

Factors associated with prevalent human immunodeficiency virus (HIV) infection in the Multicenter AIDS Cohort Study

Interviews regarding medical history, life-style, specific drug taking and sexual activities, and physical examinations were administered to 4,955 homosexual men who volunteered for the Multicenter AIDS Cohort Study in Baltimore, Chicago, Los Angeles, and Pittsburgh. Overall, the prevalence of antibodies to human immunodeficiency virus (HIV) in these men was 38.0%. The factor most strongly associated with prevalent HIV infection according to a multiple logistic regression model was rectal trauma, a composite variable which included receptive anal fisting, enemas before sex, reporting of blood around the rectum, and the observation of scarring, fissures or fistulas on rectal examination. Receptive anal intercourse also was strongly associated with HIV infection in the model. The multivariate relative odds for HIV antibody positivity was 7.72 for the highest level of rectal trauma and 3.04 for receptive anal intercourse. Symptoms reported to occur in some persons who subsequently develop acquired immunodeficiency syndrome (AIDS) were frequent among HIV seropositive men (12.9%) but were reported in 8.4% of seronegative men as well. Generalized lymphadenopathy was observed significantly more often in seropositive men (48.8%) compared with seronegative men (11.4%). The prevalence of HIV antibodies was inversely related to the number of T-helper cells and directly related (to a lesser extent) to the number of T-suppressor cells. The results suggest that disruption of the rectal mucosa provides access by HIV to the blood stream and to specific immunologic cells. Since symptoms and generalized lymphadenopathy were often reported among seronegative men, they probably also occur among some seropositive men not currently progressing to AIDS.

Prognostic implications of proliferative activity and DNA aneuploidy in colonic adenocarcinomas

Paraffin-embedded surgical specimens from 120 patients who underwent resections for primary untreated colonic adenocarcinoma were examined for proliferative activity, DNA aneuploidy, DNA index, and the proportion of aneuploid cells by flow cytometry. The results were correlated with survival times and clinical characteristics of the patients. The presence of metastases, both distant and restricted to local lymph nodes, was found to be a more potent adverse prognostic indicator than any DNA flow cytometry-derived parameter. Additional analyses were performed following stratification of patients into two groups on the basis of presence or absence of metastases. Analysis of 60 patients without metastatic involvement revealed a significant correlation between high proliferative activity, defined as more than 20% of cells in S-phase, and DNA aneuploidy. In fact, high proliferative activity was shown to be a more powerful adverse prognostic indicator in relation to survival than DNA aneuploidy in these cases after multivariate analysis. These results suggest that differences in proliferative activity may be an important biologic factor operative in the variable prognosis seen in colonic adenocarcinoma. In addition, they re-emphasize the importance of stratifying patients into groups based on metastatic involvement when evaluating other possible prognostic features in this disease.

Tumor size in endometrial cancer: a prognostic factor for lymph node metastasis

The association of tumor size and lymph node metastasis in endometrial cancer clinically confined to the uterus was evaluated in 91 patients. Other factors possibly associated with lymph node metastasis were also analyzed. Tumor size was independently associated with lymph node metastasis when analyzed by multivariate analysis (P = .022). Patients with tumors less than or equal to 2 cm in diameter had only a 5.7% incidence of lymphatic metastases. When tumors exceeded 2 cm in diameter or involved the entire endometrial surface, metastases occurred in 21.7 and 40.0% of patients, respectively. Measuring tumor size at surgery, or possibly preoperatively by hysteroscopy, will help predict which patients are at increased risk for lymph node metastasis. There were no lymph node metastases in patients with tumors less than or equal to 2 cm in diameter and invasion of less than half of the myometrium. For these patients, extended surgical staging with pelvic and aortic lymph node biopsies may not be indicated.

Nonresponse to hepatitis B vaccine in homosexual men

Of 479 homosexual men immunized with three 20-microgram doses of the hepatitis B vaccine, approximately 15% failed to develop protective titers of antibody to the surface antigen of hepatitis B virus (greater than 10 sample ratio units [SRU]). We revaccinated 34 nonresponders with an additional three doses of vaccine and compared their immunologic status with that of 14 control men who had responded to initial vaccination. Most men (15 of 19) who had measurable antibody to hepatitis B surface antigen (SRU, 2.1-9.9) after initial vaccination responded to revaccination, whereas ten of the remaining 15 nonresponders (SRU, less than 2.1) did not. No single immunologic measure distinguished ultimate responders from nonresponders; however, the initial responders differed from delayed responders and nonresponders by having higher numbers of total lymphocytes, B, T, and T helper and suppressor cells.

Antibody to human lymphotropic virus type III: immunologic status of homosexual contacts of patients with the acquired immunodeficiency syndrome and the acquired immunodeficiency-related complex

Twenty homosexual men who reported having sexual contact with homosexual men who had the acquired immunodeficiency syndrome (AIDS) or the AIDS-related complex were examined to determine their clinical status, immunologic profiles, and the presence of antibody to the human T-cell lymphotropic virus type III (HTLV-III). Of the 20, eight men had one or more signs or symptoms of the AIDS-related complex and 12 were asymptomatic. Antibodies to HTLV-III were present in 14 (70%) of 20 of the sexual contacts as compared with four (10%) of 40 healthy homosexuals without known contact with a patient who had AIDS (P less than .0001). Seropositive contacts had significantly higher mean counts of suppressor lymphocytes and lower helper: suppressor ratios (P less than .05 and .005, respectively) and higher serum levels of IgG than seronegative contacts (P less than .05). It was not possible to determine significant differences in sexual practices, drug use, length of relationship, or numbers of different sexual partners between symptomatic and asymptomatic contacts or between seropositive and seronegative contacts in this study.

Dosimetry study of Nd:YAG laser damage to canine renal cortex

A dosimetry study of factors affecting the extent of tissue damage inflicted upon the canine renal cortex by the Neodymium:Yttrium Aluminum Garnet (Nd:YAG) laser was undertaken. Laser parameters and renal tissue conditions were varied independently in duplicate in the following manner: (1) power - 5, 10, 20, 50, 75, 100 watts with a spot size of 1.2 mm; (2) exposure duration - 1, 2, and 4 seconds; (3) kidney perfusion and temperature--renal artery unclamped (perfused) without cooling; renal artery clamped (non-perfused) without cooling; and renal artery clamped with cooling. Five days following application of the laser, the animals were sacrificed and serial sections of the renal cortex were examined for maximum depth and width of tissue damage and ablation. Multiple linear regression analysis of the data indicated a direct linear relationship between the joules (watts X seconds) of energy delivered to the renal cortex and the depth and width of tissue damage and ablation (p less than 0.001 for joule regression coefficient for each variable). Seconds and/or watts alone were not major predictors of the outcome after accounting for joules. Clamping the main renal artery significantly reduced the depth and width of laser damage when compared to the perfused kidney (p less than 0.001 for each variable). The depth of damage was similar in the cooled and the non-cooled non-perfused kidney. These data suggest that increased laser energy and kidney perfusion significantly increase renal cortical laser induced damage. Adjustment of these parameters may permit controlled tumor ablation or tissue incision with minimal damage to adjacent normal tissue.

Sequential clinical and immunologic abnormalities in hemophiliacs

We examined 35 patients with hemophilia to determine if there was an association between impaired cell-mediated immunity and the amount of factor concentrate use. There was a significant negative relationship between the logarithm of the helper-suppressor ratio and the logarithm of concentrate use determined over the previous one year, five years, and total lifetime. Similarly, the presence of splenomegaly was significantly associated with the logarithm of concentrate use for each time interval. Hypergammaglobulinemia, anergy, and lymphadenopathy were present in a high proportion of patients. Repeated study of 30 of these patients at eight to 14 months showed no significant changes in their T-cell subsets. At follow-up, 16 patients had lymphadenopathy with or without splenomegaly and four had splenomegaly alone. No significant associations between concentrate use during the study period and changes in T-cell subsets or clinical condition were found.

Serum cold agglutinin and IgM levels in breast carcinoma

Breast carcinoma (BCa) cells produce I antigen or I antigen-like substances that may influence serum anti-I. We determined cold hemagglutinins in 170 BCa patients, 97 women with benign breast disease, and 37 female controls of comparable ages to the patients. The results were expressed as an anti-I score. Serum IgM was measured by radial immunodiffusion. The data for the BCa patients were analyzed by pathologic stage (PS) and histologic category. The anti-I score for PS III (28.1 +/- 13.0; mean +/- S.D.) was higher (p less than 0.02), and that for PS IV (11.4 +/- 7.4) lower (p less than 0.02) than the control value (17.7 +/- 10.2). IgM concentrations of the BCa patients as a group or by PS were similar to those of the controls. The mean anti-I scores were higher in mucinous (31.1 +/- 14.9, p less than 0.001) and apocrine BCa (28.6 +/- 16.2, p less than 0.02) compared to the control value. IgM concentrations were elevated in mucinous (218.1 +/- 85.8 mg/dl, p less than 0.01) and apocrine BCa (241.9 +/- 99.0, p less than 0.005) compared to the control value (157.1 +/- 66.9). The results suggest an association of anti-I scores and PS of BCa and suggest an antigenic difference of mucinous and apocrine from infiltrative ductal BCa.

Adjuvant doxorubicin hydrochloride and radiation in stage D bladder cancer: a preliminary report

The prognosis of patients with stage D bladder cancer is dismal. This report expands the results of our efforts to modify the clinical course of such patients by administration of doxorubicin hydrochloride sandwiched around pelvic radiation. Pathologic stage D bladder cancer was recognized in 19 patients by evaluation of tissue obtained by radical cystectomy and pelvic lymphadenectomy (8), pelvic lymph node dissection (5) or biopsies (3), ileal conduit and pelvic lymph node biopsy (1), or transurethral biopsy of the bladder and prostate (2). Treatment of these patients with doxorubicin hydrochloride before and after radiation was initiated 3 to 4 weeks postoperatively. The treatment regimen consisted of 1) 60 mg. per M.2 doxorubicin intravenously every 3 weeks for 3 cycles, 2) 5,000 rad external radiation to the entire pelvis in 5 to 6 weeks and 3) doxorubicin for 5 cycles. The observed survival rates were 37 per cent at 3 years and 28 per cent at 5 years. The median survival time was 16 months. Five patients had no evidence of disease 13 to 63 months postoperatively. One patient underwent salvage cystectomy for recurrent bladder carcinoma at 33 months and had no evidence of disease at 74 months. One patient was alive with recurrent disease at 13 months. Three patients who died did not complete the protocol owing to metastatic disease, 8 lived 6 to 52 months without recognized disease and died of metastases, and 1 died of a second primary. The extent of surgical excision was not associated significantly with survival. Of 8 patients treated with radical cystectomy 7 suffered a significant obstruction of the small bowel that required decompression or bypass surgery and all 7 recovered completely. These preliminary observations indicate encouraging results with a high but manageable morbidity for this regimen.

Mannose-sensitive adherence of Escherichia coli to epithelial cells from women with recurrent urinary tract infections

The effect of D-mannose on adherence of 73 Escherichia coli strains to vaginal and buccal epithelial cells from women with recurrent urinary tract infections, and on agglutination of human and guinea pig erythrocytes was tested. Urinary, vaginal or anal isolates from women with such infections were used. Of the strains 66 (90 per cent) demonstrated adherence to epithelial cells. D-mannose inhibited completely the adherence of 25 strains (42 per cent) that adhered to vaginal cells and inhibited an additional 11 strains (18 per cent) by at least 50 per cent. Similar results were obtained with buccal cells. The inhibitory effect of D-mannose was similar regardless of the origin of the strains. Hemagglutination frequently was inhibited by D-mannose but no consistent association between hemagglutination, and epithelial cell adherence and the effect of D-mannose was observed. The results suggest that mannose-sensitive as well as mannose-resistant adhesins frequently mediate Escherichia coli adherence to vaginal epithelial cells, and may contribute to vaginal colonization and cystitis.

The advantages of the 30-cm flexible sigmoidoscope over the 60-cm flexible sigmoidoscope

To determine the optimal length of the flexible fiberoptic sigmoidoscope we performed a randomized, blinded comparison study of the standard 60-cm instrument with a prototype 30-cm instrument with identical design features. Ninety-six male patients referred for symptom evaluation underwent examination with both instruments in random order by different examiners; positive examinations were followed by colonoscopy or surgery. Performance of the 30-cm sigmoidoscope compared with the 60-cm instrument revealed that the former was significantly more likely to yield a complete examination (74 vs. 32 examinations, p less than 0.002), took less time to perform (6.4 vs. 9.8 min, p less than 0.0001), and was more acceptable to patients and physicians. The 30-cm instrument was not significantly less effective than the 60-cm instrument in detecting polyps (21 vs. 25), adenocarcinoma (six for each), and inflammatory lesions. For these reasons, we conclude that the 30-cm flexible sigmoidoscope has a role in the evaluation of colorectal complaints.

The spectrum of immunologic abnormalities and clinical findings in homosexually active men

Clinical and laboratory evaluations of 181 men were performed; the population studied included 131 homosexual or bisexual men (who were stratified into one of three groups on the basis of symptomatology and abnormal findings on physical examination), 39 heterosexual men (who served as controls), and 11 men with acquired immunodeficiency syndrome (AIDS). The presence of specific symptoms and/or lymphadenopathy in homosexual men was associated with perturbation of immunoregulation. A large percentage of asymptomatic, homosexually active men had abnormalities in lymphocyte numbers, subpopulations, and subclasses. Symptomatic individuals had clinical findings, immunologic alterations, and abnormalities of hematopoiesis similar to those found in patients with AIDS. These data suggest that clinical evaluation in conjunction with laboratory studies may serve to identify individuals at increased risk of developing AIDS.

Human leukocyte antigens in women with recurrent urinary tract infections

The HLAs of the major histocompatibility complex in humans have been associated statistically with many diseases [1]. The possibility that recurrent UTIs in women are controlled in part by genotypic traits was suggested by the observation that adherence of Escherichia coli in vitro to both vaginal and buccal cells was greater for patients with such infections than for healthy control subjects and that there was a strong correlation between vaginal cell and buccal cell receptivity [2]. A3 antigen was identified in 12 (34%) of the patients. This frequency was significantly higher in patients than in healthy control subjects, but it was not significantly different from the frequency observed in the reference population. After correction for the number of comparisons made, there was no statistically significant difference between patients and control subjects with any other antigen. These data suggest that HLA A3 may be associated with increased risk of recurrent UTIs.

An epidemiologic study on carcinoma of the breast following irradiation for benign conditions in infancy and childhood

To investigate the relationship of irradiation during infancy and childhood to the subsequent development of carcinoma of the breast, 996 eligible patients were studied at Evanston Hospital, Evanston, Illinois, and Northwestern Memorial Hospital, Chicago. This was a case-control study, with those in the control group being selected from concurrent hospital admissions for nonmalignant surgical conditions. A second group consisting of those with benign biopsy results was also studied. The Mantel-Haenszel method of analysis, controlling for age and race, was used to estimate the approximate relative risk of carcinoma of the breast in the irradiated group compared with that for the nonirradiated group. The type of radiation history included radiotherapy for mastitis or enlarged thymus (nine patients), irradiation of the head and neck (69 patients), diagnostic fluoroscopies (ten patients) and miscellaneous irradiation (52 patients) for bursitis, eczema or keloid. Based upon the data obtained from the results of this study and its analysis, we conclude that there is little evidence of increased risk of carcinoma of the breast after irradiation about the head, neck and chest areas for benign conditions in the population being studied herein. Such a risk, if indeed it exists at all for this population, is estimated to be about 10 per cent.

Effect of D-mannose and D-glucose on Escherichia coli bacteriuria in rats

The effect of D-mannose and D-glucose on bacteriuria due to Escherichia coli with mannose-sensitive adhesins was investigated in adult male Sprague-Dawley rats undergoing diuresis. Inocula of 10(5), 10(7), or 10(8) bacteria in 0.1 ml of normal saline or 2.5% or 10% D-mannose or D-glucose were injected intravesically and urine was cultured 1, 3, 5, 7 and 9 days later. The levels of bacteriuria on days 1 and 5 were significantly lower in rats inoculated with 10(5) E coli and 10% D-mannose than in controls (p less than 0.05 and 0.01 respectively) and the percentages of rats with less than 100 bacteria/ml were higher on days 1 and 3 (p = 0.05 and 0.02 respectively). Bacteriuria was significantly lower in rats inoculated with 10(7) bacteria and 10% D-mannose than in controls on days 5 and 7 (p less than 0.01 for each day) and the percentage of rats with less than 100 bacteria/ml was higher on day 7 (p = 0.01). D-glucose reduced bacteriuria significantly only with a concentration of 10% after instillation of 10(5) E. coli (p less than 0.05, day 1). The results indicate that D-mannose and D-glucose can significantly reduce bacteriuria within 1 day and that their efficacy is dependent upon the concentration of both saccharide and bacteria.

Variable adherence of uropathogenic Escherichia coli to epithelial cells from women with recurrent urinary tract infection

The adherence of 74 Escherichia coli strains to vaginal and buccal epithelial cells from women with recurrent urinary tract infections was studied. The strains were isolated from the urine, vaginal introitus or anal mucosa of women with recurrent bacteriuria. Vaginal and anal isolates were judged to be associated with urinary tract infection if they had the same biotype and serotype as the strain isolated subsequently from the urine. Adherence levels of urinary and anal isolates, and vaginal isolates associated with urinary tract infection were similar for vaginal and buccal cells. Adherence of vaginal isolates not associated with urinary tract infection was significantly lower than adherence of urinary isolates for vaginal (p less than 0.001) and buccal (p less than 0.005) epithelial cells. A positive nonlinear correlation between vaginal and buccal adherence was observed for urinary (r equals 0.87, p less than 0.0001), vaginal (r equals 0.70, p less than 0.0005) and anal (r equals 0.32, p equals 0.047) isolates. Strains of O-serogroups commonly and less commonly associated with bacteriuria had similar adherence. The results suggest that adherence of vaginal isolates is associated with the ability to cause urinary tract infections. The strong correlation between vaginal and buccal cell receptivity suggests that susceptibility to such infections may be controlled by genotypic traits.

Bone studies in patients on prolonged systemic corticosteroid therapy for asthma

Cortical thickness of the second metacarpal bone and lumbar spine fractures were determined radiographically in twenty-one caucasian corticosteroid-dependent asthmatics (mean age, 61.2 years; range 47-73 years). The mean number of prednisone years per patient of continuous corticosteroid treatment averages 9.7 (range 5.0-21.5 years), and the mean accumulated dose of prednisone was 46.7 g (range 10.7-160 g). Thirteen of twenty-one (61.9%) patients had cortical thickness between 1 and 2 standard deviations (s.d.) below the age- and sex-specific mean for normals, but only four (19%) patients fell below 2 s.d. Although the study indicated decreased cortical thickness in the prednisone-treated group, in only one (4.8%) patient were vertebral fractures present, an incidence not unexpected in this group. In serious chronic asthma, concern for bone structure should not prohibit the cautious use of appropriate corticosteroid regimens at the lowest possible maintenance dose.

Adhesion of uropathogenic Escherichia coli to epithelial cells from women with recurrent urinary tract infection

Adherence of Escherichia coli to human uroepithelial cells obtained from the midstream urine of healthy women, nd to vaginal and buccal cells obtained from 11 healthy women and 24 patients who had had at least three urinary tract infections in the preceding year was studied. Bacteria labeled with [3H] uridine were used, and unattached organisms were separated from the epithelial cells by vacuum filtration through a polycarbonate membrane filter (5-micrometers-pore-size). A day-to-day variation in the receptivity of uroepithelial cells was noted. The range and rapidity of change in adherence to both vaginal and buccal cells were greater in patients than in controls. Adherence to vaginal cells was greater in patients than in controls (10.1 +/- 0.92 vs. 3.8 +/- 0.47 bacteria per cell [mean +/- S. E.], P less than 0.001), as was adherence to buccal cells (1.7 +/- 1.29 vs. 7.1 +/- 0.49, P = 0.002). There was a very strong, positive non-linear correlation between vaginal and buccal cell receptivity (R = 0.87, P less than 0.0001). The data suggest that susceptibility in women to urinary-tract infections is associated with widespread, fluctuating changes in the adhesive characteristics of epithelial cells.