The Effect of Leucotomy on Creative Ability

Treatment by prefrontal leucotomy, though undoubtedly of value, still rests upon an insufficiently scientific basis. Its anatomical and physiological effects are being increasingly discovered, but many of its psychological effects are still unpredictable and obscure. Its effect on intelligence, on immediate memory, and on simple learning ability are now well known, but with these we are not concerned. Rather, we have attempted to assess the effect of leucotomy on “creative ability.” By this phrase we shall refer to that ability by which the ideational content of past experience is utilized in a situation to provide concepts and actions not directly evoked by the new situation, but elaborated by the patient's more complex cerebral reactions to the situation; The ability is worthy of examination, since the more intellectual the work the more is it evident. The architect, for instance, needs more creative ability than the bricklayer, the novelist more than the amanuensis, and the Royal Academician more than the house painter.

African American race to predict for earlier failure of active surveillance: Results from the Duke Prostate Center

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Background: As concerns mount regarding overtreatment and over-diagnosis of prostate cancer (CaP), active surveillance (AS) is increasingly utilized in low risk patients. While African-American (AA) race is associated with adverse outcomes after prostatectomy, its effect on patients managed with AS is not known. Methods: A retrospective review identified 222 patients managed with AS at the Duke Prostate Center from January 2005 to September 2011. All men had CaP diagnosed on biopsy performed at our center, and elected AS over treatment. Failure was defined as progression to treatment. In men who failed AS, the reasons for failure, follow-up PSA and biopsy characteristics were analyzed. The primary outcome - time from diagnosis to failure of AS for a reason other than patient choice - was analyzed with univariable and multivariable Cox proportional hazards models. Results: In our AS cohort, 73% are Caucasian and 23% AA. Median follow-up is 25.4 months. Age, household income, BMI, PSA, clinical stage, family history, prostate volume, number of cores with cancer, and Gleason grade on initial biopsy did not differ by race. The number of biopsies and PSA tests performed on AS did not differ by race. A higher proportion of AA men tended to fail from biopsy progression (72.7% vs. 63.8%) while a lower proportion failed by choice (9.1% vs. 14.9%) compared to Caucasians (p = 0.114). AA men had a significantly shorter time to failure (HR 1.74, p = 0.045) compared to Caucasians. There was a trend toward increased Gleason grade 8 or higher cancer on follow-up biopsy in AA compared to Caucasian men (10% vs. 2.5%, p = 0.08). AA race remained a predictor (HR 1.76, p = 0.058) of failure on multivariable analysis, as did initial PSA (HR 1.90, p = 0.031) and number of cores with cancer on initial biopsy (HR 1.29, p = 0.013). Conclusions: AA race was associated with higher risk for failure of AS. There was a trend toward AA men failing due to biopsy progression and with higher grade cancer. Additional follow-up is necessary to determine how this affects the long term outcomes of these men.

Routine versus clinically driven laboratory monitoring of HIV antiretroviral therapy in Africa (DART): a randomised non-inferiority trial

BACKGROUND

HIV antiretroviral therapy (ART) is often managed without routine laboratory monitoring in Africa; however, the effect of this approach is unknown. This trial investigated whether routine toxicity and efficacy monitoring of HIV-infected patients receiving ART had an important long-term effect on clinical outcomes in Africa.

METHODS

In this open, non-inferiority trial in three centres in Uganda and one in Zimbabwe, 3321 symptomatic, ART-naive, HIV-infected adults with CD4 counts less than 200 cells per microL starting ART were randomly assigned to laboratory and clinical monitoring (LCM; n=1659) or clinically driven monitoring (CDM; n=1662) by a computer-generated list. Haematology, biochemistry, and CD4-cell counts were done every 12 weeks. In the LCM group, results were available to clinicians; in the CDM group, results (apart from CD4-cell count) could be requested if clinically indicated and grade 4 toxicities were available. Participants switched to second-line ART after new or recurrent WHO stage 4 events in both groups, or CD4 count less than 100 cells per microL (LCM only). Co-primary endpoints were new WHO stage 4 HIV events or death, and serious adverse events. Non-inferiority was defined as the upper 95% confidence limit for the hazard ratio (HR) for new WHO stage 4 events or death being no greater than 1.18. Analyses were by intention to treat. This study is registered, number ISRCTN13968779.

FINDINGS

Two participants assigned to CDM and three to LCM were excluded from analyses. 5-year survival was 87% (95% CI 85-88) in the CDM group and 90% (88-91) in the LCM group, and 122 (7%) and 112 (7%) participants, respectively, were lost to follow-up over median 4.9 years' follow-up. 459 (28%) participants receiving CDM versus 356 (21%) LCM had a new WHO stage 4 event or died (6.94 [95% CI 6.33-7.60] vs 5.24 [4.72-5.81] per 100 person-years; absolute difference 1.70 per 100 person-years [0.87-2.54]; HR 1.31 [1.14-1.51]; p=0.0001). Differences in disease progression occurred from the third year on ART, whereas higher rates of switch to second-line treatment occurred in LCM from the second year. 283 (17%) participants receiving CDM versus 260 (16%) LCM had a new serious adverse event (HR 1.12 [0.94-1.32]; p=0.19), with anaemia the most common (76 vs 61 cases).

INTERPRETATION

ART can be delivered safely without routine laboratory monitoring for toxic effects, but differences in disease progression suggest a role for monitoring of CD4-cell count from the second year of ART to guide the switch to second-line treatment.

FUNDING

UK Medical Research Council, the UK Department for International Development, the Rockefeller Foundation, GlaxoSmithKline, Gilead Sciences, Boehringer-Ingelheim, and Abbott Laboratories.

Nearly Constant Loss in Lithium and LiCl-doped Borate Glasses

Measurements of the complex dielectric permittivity in (Li2O)x(B2O3)100-x and halide-doped (Li2O)x (LiCl)y(B2O3)100-x-y glasses conducted in the nearly constant loss (NCL) regime at low temperatures are reported. Scaling properties reveal that the NCL in (Li2O)x(B2O3)100-x is largely ionic in origin for these materials and increases in proportion to the Li2O content. However, at low Li2O content, the NCL becomes dominated by a non-ionic loss arising from the borate network or other impurity polarizations. Halide doping is seen to produce an additional enhancement of the NCL that is consistent with its known enhancement of the bulk conduction.

Evaluation of perceived usefulness of activity scheduling in an inpatient depression group

Recent studies have documented that inpatient care on acute psychiatric wards is ineffective. Government directives suggest that wards should initiate and provide a choice of therapeutic and recreational activities. Priority should be given to effective treatments, such as cognitive behavioural therapy. Homework tasks, such as activity scheduling (AS), form an important part of cognitive behavioural therapy for depression. To address inactivity on the wards and use more evidence-based interventions, a quality improvement project was carried out that implemented AS in an inpatient depression group programme. Both inpatients' and staff's perception of its usefulness was evaluated. Sixteen inpatients completed the Beck Depression Inventory-II, and a questionnaire, which was specifically designed to assess the perceived usefulness of AS. In addition, 14 nursing staff completed a similar questionnaire. Both quantitative and qualitative analyses were carried out. Results showed that all participants found AS useful. Eight inpatients had not engaged in any activity prior to being involved in AS. Most inpatients reported gaining some pleasure and satisfaction out of doing AS and experienced a positive effect on their mood and recovery. While 12 staff expressed interest in learning more about AS, 10 needed more information before carrying it out themselves, and only four had the time to do so. The perceived usefulness of AS will be discussed within the context of a psychiatric inpatient setting.

Assessing health impact assessment: multidisciplinary and international perspectives

Health impact assessment (HIA) seeks to expand evaluation of policy and programmes in all sectors, both private and public, to include their impact on population health. While the idea that the public's health is affected by a broad array of social and economic policies is not new and dates back well over two centuries, what is new is the notion-increasingly adopted by major health institutions, such as the World Health Organisation (WHO) and the United Kingdom National Health Services (NHS)-that health should be an explicit consideration when evaluating all public policies. In this article, it is argued that while HIA has the potential to enhance recognition of societal determinants of health and of intersectoral responsibility for health, its pitfalls warrant critical attention. Greater clarity is required regarding criteria for initiating, conducting, and completing HIA, including rules pertaining to decision making, enforcement, compliance, plus paying for their conduct. Critical debate over the promise, process, and pitfalls of HIA needs to be informed by multiple disciplines and perspectives from diverse people and regions of the world.

Pituitary homeobox factor 1, a novel transcription factor in the adrenal regulating steroid 11beta-hydroxylase

Pituitary homeobox 1 (Ptx1/Pitx1) is a homeodomain-containing transcription factor present throughout pituitary development. Ptx1/Pitx1 interacts with steroidogenic factor 1 (SF-1) in the regulation of pituitary gene expression. SF-1 also plays a critical role in the transcription of enzymes involved in adrenal steroidogenesis. Therefore, we analyzed the presence and role of Ptx1/Pitx1 in human adrenal cortex. Both Ptx1/Pitx1 and SF-1 mRNA were expressed in the human adrenal gland, and immuno-electron microscopy demonstrated the presence of Ptx1/Pitx1 protein in the nucleus of adrenocortical cells. Computer analysis revealed the presence of Ptx1/Pitx1 signal sequences within the promoter region of human 11beta hydroxylase ( hCYP11B1). To examine the role of Ptx1/Pitx1 in the regulation of the genes, we prepared reporter constructs using the 5'-flanking DNA of the hCYP11B1 gene and transfected them into Y-1 mouse adrenocortical cells, HeLa and CV-1 cells. Ptx1/Pitx1 stimulation of hCYP11B1 reporter activity (3-fold over basal) in Y-1 cells was equal to that observed with SF-1. The hCYP11B1 promoter activity in Y-1 cells was not synergistically increased by co-transfection with both Ptx1/Pitx1 and SF-1. Both basal and ACTH-stimulated hCYP11B1 reporter activities in Y-1 cells were increased by co-transfection with either Ptx1/Pitx1 or SF-1 expression vectors. In contrast, co-transfection with both Ptx1/Pitx1 and SF-1 synergistically increased hCYP11B1 promoter activity in HeLa and CV-1 cells (5-fold and 20-fold over basal, respectively). In conclusion, this study represents the first demonstration for a role of Ptx1/Pitx1 in the regulation of transcription of enzymes involved in adrenal steroidogenesis.

Acceptance of neonatal genetic screening for hereditary hemochromatosis by informed parents

The aim of this study was to assess attitudes to neonatal genetic screening for hereditary hemochromatosis. A total of 135 consecutive, pregnant women and their partners attending a hospital antenatal clinic in the Australian Capital Territory were given detailed written and verbal information about potential risks and benefits of neonatal genetic screening. Issues such as uncertainty of disease expression, confidentiality, genetic discrimination, and storage of genetic data were addressed. Attitudes were assessed by interview and questionnaire. There was a high level of acceptance for neonatal genetic screening in general (99%) and for hemochromatosis in particular (91.5%). There was no association of prior knowledge of hemochromatosis, family history of hemochromatosis, ethnicity, age, education, or occupation class with nonacceptance. Of the subjects, 39.5% reported feeling "a little anxious" about the prospect of screening their infants, although only 5.4% reported feeling "very anxious." Reasons given for nonacceptance of screening included inability of the child to give informed consent, insufficient evidence that diagnosis of hemochromatosis in childhood is beneficial, risk of discrimination on genetic grounds, lack of agreement between partners, and privacy issues. These data suggest that an Australian neonatal genetic screening program for hemochromatosis is likely to be accepted by this and similar groups of subjects, but there should be an opportunity for parents who object to screening to opt out of any such program.

Liver receptor homologue-1 is expressed in the adrenal and can regulate transcription of 11 beta-hydroxylase

Liver receptor homologue-1 (LRH-1, designated NR5A2) is a mammalian homologue of Drosophila fushi tarazu factor (dFTZ-F1) and structurally belongs to the orphan nuclear receptor superfamily. LRH-1 can recognize the DNA sequence 5'-AAGGTCA-3', the canonical recognition motif for steroidogenic factor 1 (SF-1). Herein, we hypothesized that LRH-1 might play a role in the regulation of human adrenal expression of steroidogenic enzymes. To test this hypothesis, LRH-1 expression in human adult and fetal adrenal glands was examined by RT-PCR analysis. The fetal and adult adrenal glands, as well as liver and pancreas, were observed to express LRH-1 mRNA using RT-PCR. The ability of LRH-1 to enhance transcription of the gene encoding human 11 beta- hydroxylase (hCYP11B1) was then examined using the H295R adrenal cell line. LRH-1 co-transfection with hCYP11B1 luciferase promoter constructs caused a 25-fold induction of luciferase activity. Furthermore, co-transfection of a hCYP11B1 reporter construct containing a mutation in the SF-1 binding cis-element abolished the stimulatory effect of both SF-1 and LRH-1. Electrophoretic mobility shift assay (EMSA) demonstrated that LRH-1 could bind to the SF-1 response element. Taken together, our data suggested that LRH-1 is expressed in the adrenal, and can substitute for SF-1 to enhance transcription of genes encoding certain of the steroid-metabolizing enzymes. A role for LRH-1 in the regulation of adrenal or gonadal steroid hormone production should be further studied.

Prostate carcinoma knowledge, attitudes, and screening behavior among African-American men in Central Harlem, New York City

BACKGROUND

Although the benefits of prostate carcinoma screening in reducing mortality rates have not been proven or shown to be cost-effective, screening, particularly using prostate specific antigen (PSA) tests, is widespread. A better understanding of screening behavior, knowledge of prostate carcinoma risk, and attitudes toward screening among men at high risk, such as African-American men, would be valuable.

METHODS

A prevalence survey was conducted using 2 samples of African-American men, aged 50-74 years: a clinic sample drawn from all clinics in Central Harlem (n = 404) and a random-digit dial sample from the same geographic region (n = 319). The prevalence of self-reported PSA screening was estimated using a cognitive survey methodology based on the internal consistency of answers to four different questions. Prevalence estimates were adjusted to take into account the high proportion of nontelephone residences.

RESULTS

The clinic sample, representing a poorer, more ill population (as determined by MOS Physical Function Scores, was less likely to report PSA screening than the community sample (11.1% in clinic sample vs. 25.5% in community). The prevalence of PSA testing in Central Harlem overall in this age group by using two different techniques was estimated to be 24%. In multiple logistic models, self-reported PSA screening was associated with age, education, favorable attitudes toward screening, and knowing someone who had prostate carcinoma. However, the association between these factors and the likelihood of self-reported PSA screening differed between clinic and community samples.

CONCLUSIONS

The prevalence of self-reported PSA screening in Central Harlem was lower than that reported for other populations. These findings may be useful in the design of health education campaigns and for counseling innercity, low-income African-American patients appropriately about the disease.

The application of high density microarray for analysis of mitogenic signaling and cell-cycle in the adrenal

Angiotensin II (AII) binds to specific G-protein coupled receptors and is mitogenic in adrenal, liver epithelial, and vascular smooth muscle cells. The H295R human adrenocortical cell line, which expresses AII receptors predominantly of the AT1 subclass, proliferates in response to treatment with AII. The induction and maintenance of cellular proliferation involves a precisely coordinated induction of a variety of genes. As the human genome sequencing projects near completion a variety of high throughput technologies have been developed in order to create dynamic displays of genomic responses. One high throughput method, the gridded cDNA microarray has been developed in which immobilised DNA samples are hybridized on glass slides for the identification of global genomic responses. For this purpose high precision robotic microarrayers have been developed at AECOM. The cyclin D1 gene, which encodes the regulatory subunit of the cyclin D1-dependent kinase (CD1K) required for phosphorylation of the retinoblastoma protein (pRB), was induced by AII in H295R cells. Abundance of the cyclin D1 gene is rate-limiting in G1 phase progression of the cell-cycle in a variety of cell types. AII induced cyclin D1 promoter activity through a c-Fos and c-Jun binding sequence at -954 bp. Theabundance of c-Fos within this complex was increased by AII treatment. Analysis of AII signaling in adrenal cells by cDNA microarray demonstrated an induction of the human homologue of Xenopus XPMC2 (HXPMC2). The cDNA for XPMC2 was previously shown to rescue mitotic catastrophe in mutant S. Pombe defective in cdc2 kinase function. Further studies are required to determine the requirement for cyclin D1 and XPMC2H in AII-induced cell-cycle progression and cellular proliferation in the adrenal.

Transcriptional regulation of human 11beta-hydroxylase (hCYP11B1)

Steroid 11beta-hydroxylase is a mitochondrial enzyme that catalyzes the conversion of deoxycortisol to cortisol. The gene encoding human 11beta-hydroxylase (hCYP11B1) is expressed in the adrenal cortex under the control of circulating levels of ACTH. The current study was undertaken to define the cis-regulatory elements and transacting factors that regulate hCYP11B1 transcription. The hCYP11B1 5'-flanking DNA was studied using transient transfection of luciferase reporter constructs in NCI-H295R human adrenocortical cells. A cAMP analogue ((Bu)2cAMP) increased expression of a construct containing -1102 bp of hCYP11B1 5'-flanking DNA (pB1-1102). An element at position -71/-64 (TGACGTGA, previously termed Ad1) resembling a consensus cAMP response element (CRE) was required for maximal induction by cAMP. The Ad1 element bound several transcriptional factors in electrophoretic mobility shift assays, including CRE-binding protein, activating transcription factor-1 (ATF-1), and ATF-2, but only the ATF-2 complex migrated similarly to a complex seen using H295R nuclear extract. In addition, Western analysis of H295R and adrenal lysates demonstrated expression of high levels of ATF-2 and ATF-1. CRE-binding protein levels varied among the strains of H295R cells tested. Transcription of CYP11B1 also appeared to be regulated by steroidogenic factor-1 (SF-1). Luciferase reporter gene activity was increased after cotransfection with expression vectors containing SF-1. An element in hCYP11B1 at positions 242/-234 (CCAAGGCTC), previously termed Ad4, was required for maximal induction by SF-1 and was found to bind SF-1 in electrophoretic mobility shift assays. The key role for SF-1 in hCYP11B1 transcription is in contrast to its lack of an effect on expression of the hCYP11B2 (aldosterone synthase) isozyme. The differential effects of SF-1 on transcription of hCYP11B1 and hCYP11B2 may be one of the mechanisms controlling differential expression of these isozymes within the zonae fasciculata and glomerulosa of the human adrenal cortex.

Proximal shift of colorectal cancer in the Australian Capital Territory over 20 years

BACKGROUND

Several studies in other countries have demonstrated a change in subsite distribution of colorectal cancer, with increasing proximal cancers. Confirmation of such a change in Australia would have implications for screening and diagnosis of colorectal cancer.

AIMS

To determine whether there has been an increase in the proportion of proximal colorectal cancers in Australia, and whether there have been changes in other clinical and pathological aspects of colorectal cancer.

METHODS

A study of the hospital files of patients with colorectal cancer diagnosed and treated at all hospitals in the Australian Capital Territory (ACT) between 1989 and 1995 was compared with data from a published study of patients diagnosed between 1969 and 1976.

RESULTS

There was a proximal shift of cancers with a significant increase in the proportion of tumours in the hepatic flexure, ascending colon and caecum, more marked for females than males. There was a corresponding reduction in distal colorectal cancers. Time from onset of symptoms to diagnosis decreased, risk factors for colorectal cancer were noted more frequently, and endoscopy replaced barium enema X-ray as the main diagnostic modality. The resectability of cancers increased, stay in hospital and 30 day mortality declined. Despite apparent earlier presentation and improved surgical resectability, the proportion of patients with localised disease (Dukes' stage A and B) had not changed significantly.

CONCLUSIONS

We have detected a number of changes in clinical and pathological aspects of colorectal cancer over a 20 year period in the ACT, including a proximal shift in the subsite distribution of colorectal cancer. These changes suggest that proximal and distal colorectal cancers may have a different aetio-pathogenesis, and have implications for the investigation of patients with suspected colorectal cancer and in screening high-risk groups.

Syphilis serology and HIV infection in Harare, Zimbabwe

OBJECTIVE

To determine the reliability of serological tests in detecting syphilis in a factory worker cohort and examine the impact of concurrent HIV infection on serological tests for syphilis.

METHOD

Reactions to non-treponemal and treponemal antigens were tested using sera from a cohort of 3401 factory workers in Harare, Zimbabwe. The participants consented to regular testing for syphilis, by VDRL, and HIV using two ELISAs. All sera from men who were VDRL positive, and a random sample of VDRL negative sera, were tested by RPR, TPHA, and where appropriate FTA-Abs. From the results, men were defined as having no syphilis, active syphilis, incident syphilis, historic syphilis, or giving biological false positive reactions.

RESULTS

709 sera were examined from 580 men. There were 78 cases of active syphilis in the cohort, giving a prevalence of 2.3%, and the seroincidence was 0.25 per 100 person years of follow up. The prevalence of HIV in the cohort was 19.8%. There was a strong association between syphilis, whether active, incident or historic, and HIV seropositivity. With both HIV positive and negative sera the negative predictive values of VDRL and RPR were > 99.9% while the positive predictive value for VDRL (30%) was lower than for RPR (39%). Biological false positive reactions were detected in 0.5% of the cohort, with in most cases a transient rise in VDRL titres up to < 1/16. Higher false positive titres occurred in five men, each of whom was HIV positive.

CONCLUSIONS

The VDRL is reliable in detecting possible cases of syphilis even in a community with a high prevalence of heterosexually transmitted HIV. There is need, however, for confirmatory tests. The prevalence of syphilis in this cohort is very low in comparison with other countries in southern Africa, but is consistent with recent data from Harare. Despite a strong association between syphilis and HIV it was clear that syphilis could not be counted as a major factor fueling the HIV epidemic in Zimbabwe.

Influence of coping style and precolonoscopy information on pain and anxiety of colonoscopy

BACKGROUND

This study assessed the relationship between patient coping style, precolonoscopy information, and anxiety and pain associated with colonoscopy.

METHODS

Eighty consecutive adult patients undergoing initial colonoscopy were classified into two groups on the basis of coping style: information seekers or information avoiders. All were given standardized information about colonoscopy. Half of each group was randomly assigned to receive additional sensory information describing what they could expect to feel. Self-report, physiologic, and behavioral indices of anxiety and pain were measured.

RESULTS

Patients given information congruent with coping style experienced significantly less self-report anxiety immediately after the information intervention and spent less time in recovery. In contrast, patients given information not congruent with coping style maintained their pre-intervention anxiety level. Patients given information congruent with coping style scored lower on behavioral indices of pain, but there were no differences with respect to patient perception of pain or the dosage of sedative drugs. Most patients reported that the bowel preparation was the most distressing part of the colonoscopy.

CONCLUSIONS

Assessment of coping style and provision of congruent information reduces anxiety, recovery time, and observed behavioral indices of pain of colonoscopy but has no effect on sedation dose or patient perception of pain.

Biologically erodable microspheres as potential oral drug delivery systems

Biologically adhesive delivery systems offer important advantages over conventional drug delivery systems. Here we show that engineered polymer microspheres made of biologically erodable polymers, which display strong adhesive interactions with gastrointestinal mucus and cellular linings, can traverse both the mucosal absorptive epithelium and the follicle-associated epithelium covering the lymphoid tissue of Peyer's patches. The polymers maintain contact with intestinal epithelium for extended periods of time and actually penetrate it, through and between cells. Thus, once loaded with compounds of pharmacological interest, the microspheres could be developed as delivery systems to transfer biologically active molecules to the circulation. We show that these microspheres increase the absorption of three model substances of widely different molecular size: dicumarol, insulin and plasmid DNA.

HIV seroincidence and correlates of seroconversion in a cohort of male factory workers in Harare, Zimbabwe

OBJECTIVES

Given that health promotion messages on transmission of HIV and other sexually transmitted diseases (STD) have been widely publicized in Zimbabwe and elsewhere in the late 1980s, it is vital to analyse which risk events still expose individuals to infection. A cohort was established with the objectives of estimating HIV seroincidence, behavioural and biological determinants of infection, and ultimately, evaluating the impact of AIDS prevention interventions in the workplace.

METHODS

HIV seroincidence was estimated in a prospectively followed cohort of male factory workers recruited in Harare, Zimbabwe during the period prior to a workplace AIDS prevention intervention. Correlates of HIV seroconversion were identified using Cox regression analysis.

RESULTS

There were 51 seroconversions among 1607 HIV-negative participants following 1738 person-years (PY) of observation [seroincidence, 2.93 per 100 PY; 95% confidence interval (CI), 2.18-3.86]. The prevalence of HIV in the cohort was 19.1%. HIV seroincidence was significantly increased among men who were younger [hazard ratio (HR) per year, 0.96; 95% CI, 0.93-0.99], were single (HR, 3.29; 95% CI, 1.56-6.96), were married but resided separately from their wives (HR, 2.18; 95% CI, 0.99-4.80), reported having any STD (HR, 3.00; 95% CI, 1.53-5.86), reported having a genital ulcer (HR, 4.87; 95% CI, 2.18-10.91), and reported paying for sex (HR, 2.01; 95% CI, 1.06-3.77). Seroincidence also increased with the number of sex partners reported in the year preceding enrolment (HR per partner, 1.10; 95% CI, 1.01-1.21). In multiple Cox regression analysis, three independent associations with HIV seroconversion were reporting a genital ulcer (adjusted HR, 3.55; 95% CI, 1.52-8.29), number of sex partners (adjusted HR, 1.10; 95% CI, 1.01-1.21), and being married but residing separately from one's wife (adjusted HR, 2.21; 95% CI, 1.00-4.89).

CONCLUSIONS

Innovative and sustained workplace-based interventions are needed to address the high risk of HIV infection in this economically productive population. The predictors of HIV seroconversion described in this study underscore the need for public health efforts to simultaneously address the biological, socioeconomic and behavioural factors that continue to place individuals at risk of HIV in general populations of Africa.

Condom use and the risk of HIV infection: who is being protected?

Descriptive baseline data at enrollment into a cohort of male factory workers who were tested for HIV serology and monitored for sero-conversion over time, were analysed for condom use. At recruitment, the 1,146 men were asked about their sexual behaviour, history of sexually transmitted diseases (STDs), condom use and circumstances under which condoms were used. HIV seroprevalence in the cohort was 18.2 pc. Self reported use of condoms was low, with only 5 pc of the men reporting using them all the time. Forty four pc reported that they had never used a condom, 11.5 pc tried a condom only once, and 30.5 pc used condoms less than half the time. HIV positive men were more likely (Odds Ratio [OR] = 2.2 95 pc CI: 1.3-3.3) to use condoms than those who tested negative. Men using a condom more than once were younger and had more education (p values < 0.0005). Univariate analysis showed that men with self reported risk factors for HIV infection were more likely to use condoms. Significantly more condom users reported paying for sex, multiple sex partners or (for married men) a girlfriend (p < 0.005). Condom users also more often had a history of genital ulcers, urethral discharge or other STDs. Few married men (24 pc) reported using a condom with their wives. Condom use was more commonly reported with commercial sex workers (44 pc) or other extramarital partners (36 pc). Some risk factors for HIV infection were also present amongst men who reported that they did not use condoms.(ABSTRACT TRUNCATED AT 250 WORDS)

Reduced semen quality and risk behaviour amongst men consulting a referral STD clinic

Sexually transmitted diseases (STDs) and infertility are public health challenges that continue to represent a high demand and costly adult medical care conditions in most developing countries. Few studies address strategies for prevention of infertility secondary to STDs through behavioural change and early and prompt STD treatment. A prospective cohort design was used to study the effects of urogenital infection on semen quality in consenting consecutive subjects that presented with chronic or recurrent sexually transmitted diseases. Health seeking behavioural correlates and socio-economic variables were compared between index subjects at a genito-urinary referral clinic and those that presented with non-STD conditions at a referral polyclinic.

The association of tuberculosis and HIV infection in Harare, Zimbabwe

SETTING

The tuberculosis (TB) service responsible for all TB treatment in Harare, Zimbabwe.

OBJECTIVES

(1) To determine HIV seroprevalence among TB patients and controls. (2) To compare clinical and demographic characteristics of HIV-infected and uninfected TB patients.

DESIGN

Cohort study. Entry criterion: TB diagnosed during the 18 month study period. Assessment included HIV serology. Matched community controls were HIV serotested.

RESULTS

In 1434 TB patients tested, HIV seroprevalence was 48% in men and 44% in women, peaked in the 25-34 year age group and was higher than in controls (relative risk [RR] = 3.1, 95% confidence interval [CI] = 2.6-3.7). In adults, seroprevalence was 34%, 49% and 58% in successive 6 month periods. A history of entry of prior TB treatment was less common in the HIV-seropositive (RR = 0.57, CI = 0.37-0.88). In adults, tuberculin negativity, TB at 2 sites, lymph node, pericardial and miliary TB, hilar adenopathy and pleural effusion were significantly more common in HIV-seropositive patients; cavitation and upper lobe involvement were significantly less frequent. Pulmonary TB and sputum smear positivity had similar frequencies in the 2 groups.

CONCLUSION

HIV was strongly and increasingly associated with TB in Harare and altered the clinical and radiologic features of TB. Failed standard TB treatment in HIV-infected individuals contributed minimally to new cases of TB.

Could it be gallstones, doctor?

Gallstones may be asymptomatic, in which case they require no treatment. The author discusses symptomatic gallstones and the complications of gallstone disease. The type of presentation, appropriate investigations and treatment options are discussed.

A Model for HCO(3) Accumulation and Photosynthesis in the Cyanobacterium Synechococcus sp: Theoretical Predictions and Experimental Observations

A simple model based on HCO(3) (-) transport has been developed to relate photosynthesis and inorganic carbon fluxes for the marine cyanobacterium, Synechococcus sp. Nägeli (strain RRIMP N1). Predicted relationships between inorganic carbon transport, CO(2) fixation, internal carbonic anhydrase activity, and leakage of CO(2) out of the cell, allow comparisons to be made with experimentally obtained data. Measurements of inorganic carbon fluxes and internal inorganic carbon pool sizes in these cells were made by monitoring time-courses of CO(2) changes (using a mass spectrometer) during light/dark transients. At just saturating CO(2) conditions, total inorganic carbon transport did not exceed net CO(2) fixation by more than 30%. This indicates CO(2) leakage similar to that estimated for C(4) plants.For this leakage rate, the model predicts the cell would need a conductance to CO(2) of around 10(-5) centimeters per second. This is similar to estimates made for the same cells using inorganic carbon pool sizes and CO(2) efflux measurements. The model predicts that carbonic anhydrase is necessary internally to allow a sufficiently fast rate of CO(2) production to prevent a large accumulation of HCO(3) (-). Intact cells show light stimulated carbonic anhydrase activity when assayed using (18)O-labeled CO(2) techniques. This is also supported by low but detectable levels of carbonic anhydrase activity in cell extracts, sufficient to meet the requirements of the model.

Papillary carcinoma of the thyroid occurring as multiple vascular tumors

A case of advanced papillary carcinoma in a 16-year-old boy is presented. While this case is typical of the indolent and locally invasive character of papillary carcinoma, it is remarkable for the extent of tumor involvement appearing as reactive lymphadenopathy. The pronounced tumor vascularity and the similarity of the needle biopsy specimen to chemodectoma both conflicted with the initial diagnostic impression. The correct diagnosis was confirmed only with definitive surgical therapy.

Knowledge and attitudes of gastroenterologists in colorectal cancer

A group of 73 gastroenterological specialists (36 physicians, 25 surgeons, 12 trainees) completed a detailed questionnaire on their knowledge of and attitudes to colorectal cancer. A surprising unawareness of recent developments in colorectal cancer was apparent. Although responses to individual questions varied throughout the three groups, overall knowledge and attitudes on colorectal cancer were not related to age and years since graduation, and were not different in the three groups. This study suggests failure of traditional methods of continuing medical education, and has practical implications for any screening programme designed to detect early colorectal cancer.