Assessment of off-label use of denosumab 60 mg injection during the early postmarketing period using health insurance claims data

Off-label use of denosumab 60 milligram (mg) injection was assessed within an administrative claims database. The completeness of claims to assess off-label use was investigated with medical record review. Potential denosumab 60 mg off-label use was observed based on claims, but many had evidence of on-label indications based on medical record review.

INTRODUCTION

Denosumab 60 mg injection is approved in the USA to treat patients at high fracture risk due to postmenopausal osteoporosis, male osteoporosis, and hormone therapy for the treatment of prostate and breast cancers. Its RANK ligand-inhibiting effect makes it a candidate for the off-label treatment of other conditions mediated by the rate of bone resorption by osteoclasts. To better understand its utilization patterns, we assessed off-label use of denosumab 60 mg within an administrative claims database.

METHODS

Definite, probable, and possible denosumab 60 mg users were identified during the early postmarketing period within a claims database of a US healthcare insurer. Medical record review confirmed a sample of these users. Off-label use among definite and probable users and all chart-confirmed users was classified using claims-derived age, dose interval, and diagnosis and treatment received relative to the administration date. Among chart-confirmed users classified as off-label, patient characteristics related to treatment indication were abstracted from medical records to investigate the completeness of claims to study off-label medication use.

RESULTS

Off-label use was identified based on claims in approximately 25 % of definite and probable denosumab 60 mg users and 35 % of chart-confirmed users. Medical record review identified evidence of on-label indications in 81 % of chart-confirmed users classified as off-label in claims.

CONCLUSIONS

Many of the off-label denosumab 60 mg users had diagnoses or treatment consistent with on-label indications based on medical record review, suggesting these are under-recorded in claims data. It is warranted to be cautious when using administrative databases to assess off-label medication use.

Risk of acute renal failure among breast cancer patients and chemotherapy treatment of breast cancer patients with a history of renal insufficiency in a commercially-insured population in the United States

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Background: Risk of acute renal failure (ARF) among breast cancer (BC) patients may increase with nephrotoxic chemotherapy and other exposures, but this risk is not well characterized. Furthermore, among patients who present with renal insufficiencies (RI) at cancer diagnosis, subsequent treatment patterns are not well described. Methods: We performed a retrospective cohort study using a large national commercial claims database. The cohort included all women diagnosed with BC from 2000 to 2007 who were 18–64 years at diagnosis with no history of cancer (n=13,296). We defined a diagnosis of BC as at least one inpatient or two outpatient claims more than 30 days apart with an ICD-9 code of 174. Among patients with no history of RI (n=13,150), we calculated the cumulative incidence (CI) of ARF_the proportion with at least one inpatient or two outpatient claims with an ICD-9 code of 584 or 586 in the first year following cancer diagnosis. Treatment for BC patients with a history of RI (n=146) was also assessed. Results: Among BC patients with no history of RI, 0.3% were diagnosed with ARF within a year after cancer diagnosis. The CI of ARF was higher in patients with metastases: 0.7% for any metastasis, 2.3% for bone metastasis, and 0.1% for no metastasis. The CI of ARF among patients undergoing radiation or mastectomy was similar to the overall rate (0.3%) but was higher in patients receiving nephrotoxic chemotherapy (1.0%) or intravenous bisphosphonates (IV BPs) (2.1%). The CI of ARF was higher in patients with congestive heart failure (1.4%), diabetes (0.9%), and/or hypertension (0.8%) at cancer diagnosis compared to patients without these comorbidities (0.2%). Among BC patients with a history of RI, 7.5% were administered nephrotoxic chemotherapy, 30.1% received potentially nephrotoxic chemotherapy, and 1.4% were given IV BPs. Conclusions: Breast cancer patients who present with comorbidities, develop metastases, or are given nephrotoxic chemotherapy or IV bisphosphonates are at higher risk of acute renal failure in the first year after breast cancer diagnosis. More research is warranted on the treatment of breast cancer patients with a history of renal insufficiency.

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HIV prevalence, previous HIV testing, and condom use with clients and regular partners among Senegalese commercial sex workers

OBJECTIVES

To assess HIV prevalence and risk factors for HIV infection, to investigate condom use among registered female commercial sex workers (CSWs) in Senegal, West Africa, and to examine the association between previous HIV testing, knowledge of HIV serostatus and condom use with both regular sex partners and clients within this population.

METHODS

A cross-sectional study was conducted at three sexually transmitted disease clinics among 1052 Senegalese registered CSWs between 2000 and 2004. Inperson interviews soliciting information concerning demographic characteristics, medical history, sexual behaviour with clients and regular partners, and previous HIV testing history were performed. Blood samples were collected for determination of HIV-1 and/or HIV-2 serostatus. Multivariable, Poisson and log-binomial models were used to calculate prevalence ratios.

RESULTS

The overall HIV prevalence was 19.8%. Over 95% of CSWs reported always using a condom with clients, but only 18% reported always using a condom with their regular partners. A history of previous HIV testing was not associated with condom use with clients (adjusted prevalence ratio (APR) = 0.98, 95% confidence intervals, CI: 0.90 to 1.06). However, prior HIV testing was associated with decreased condom use with their regular partners (APR = 0.44, 95% CI: 0.28 to 0.69), especially in women who tested HIV negative (APR = 0.17, 95% CI: 0.08 to 0.36).

CONCLUSIONS

CSWs in Senegal have a high HIV prevalence; therefore preventing HIV transmission from this population to the general population is important. Condom use with regular partners is low among registered CSWs in Senegal, and a prior HIV negative test is associated with even less condom use with regular partners. Intervention efforts to increase condom use with regular sexual partners are needed.

Comparison of human immunodeficiency virus (HIV)-specific T-cell responses in HIV-1- and HIV-2-infected individuals in Senegal

Human immunodeficiency virus type 2 (HIV-2) infection is typically less virulent than HIV-1 infection, which may permit the host to mount more effective, sustained T-cell immunity. We investigated antiviral gamma interferon-secreting T-cell responses by an ex vivo Elispot assay in 68 HIV-1- and 55 HIV-2-infected Senegalese patients to determine if differences relate to more efficient HIV-2 control. Homologous HIV-specific T cells were detected in similar frequencies (79% versus 76%, P = 0.7) and magnitude (3.12 versus 3.08 log(10) spot-forming cells/10(6) peripheral blood mononuclear cells) in HIV-1 and HIV-2 infection, respectively. Gag-specific responses predominated in both groups (>/=64%), and significantly higher Nef-specific responses occurred in HIV-1-infected (54%) than HIV-2-infected patients (22%) (P < 0.001). Heterologous responses were more frequent in HIV-1 than in HIV-2 infection (46% versus 27%, P = 0.04), but the mean magnitude was similar. Total frequencies of HIV-specific responses in both groups did not correlate with plasma viral load and CD4(+) T-cell count in multivariate regression analyses. However, the magnitude of HIV-2 Gag-specific responses was significantly associated with lower plasma viremia in HIV-1-infected patients (P = 0.04). CD4(+) T-helper responses, primarily recognizing HIV-2 Gag, were detected in 48% of HIV-2-infected compared to only 8% of HIV-1-infected patients. These findings indicate that improved control of HIV-2 infection may relate to the contribution of T-helper cell responses. By contrast, the superior control of HIV-1 replication associated with HIV-2 Gag responses suggests that these may represent cross-reactive, higher-avidity T cells targeting epitopes within Gag regions of functional importance in HIV replication.

Risk factors for diagnostic subgroups of painful temporomandibular disorders (TMD)

Temporomandibular Disorders (TMD) encompass several entities, which may have differing etiologies. To test this hypothesis, we investigated risk factors for three diagnostic subgroups of painful TMD. Ninety-seven subjects with myofascial pain only, 20 with arthralgia only, 157 with both myofascial pain and arthralgia, and 195 controls without TMD pain met criteria for study eligibility. Investigated risk factors included both physical and psychological variables. Adjusted odds ratios were calculated by multiple logistic regression analyses. Myofascial pain occurring alone was significantly associated with trauma (Odds Ratio [OR] = 2.0), clenching (OR = 4.8), third molar removal (OR = 3.2), somatization (OR = 3.7), and female gender (OR = 4.2). Myofascial pain with arthralgia was significantly associated with trauma (OR = 2.1), clenching (OR = 3.3), third molar removal (OR = 4.0), somatization (OR = 5.1), and female gender (OR = 4.7). No significant associations were found for the small-arthralgia-only group.

HLA class II DR-DQ and increased risk of cervical cancer among Senegalese women

To examine Senegalese women to confirm and extend associations between HLA class II types and cervical cancer previously observed among African-American, Caucasian, Hispanic, and Japanese ethnic populations, 55 Senegalese women with invasive cervical carcinoma were compared with age-matched (human papillomavirus) HPV-positive (n = 83) and HPV-negative (n = 107) control women. PCR-based HPV and HLA typing methods were used. Data were analyzed using a global randomization test and conditional logistic regression. Although this study failed to confirm a previously reported association between cervical cancer and DQB1*03 alleles, the DRB1*1101-DQB1*0301 haplotype was detected more frequently among cervical carcinoma cases than among controls (adjusted odds ratio, 2.6; 95% confidence interval, 1.0-7.1). Furthermore, as reported by others, we observed a negative association of borderline statistical significance between DRB1*13 and cervical carcinoma (adjusted odds ratio, 0.5; 95% confidence interval, 0.2-1.1). Observations from this study confirm earlier findings of a negative association between DRB1*13 and cervical cancer and suggest that specific DRB1-DQB1 haplotype combinations, rather than individual DQB1*03 alleles, increase the risk for cervical cancer.

Human papillomavirus and long-term oral contraceptive use increase the risk of adenocarcinoma in situ of the cervix

We examined United States Surveillance, Epidemiology, and End Results incidence data and conducted a population-based case-control study to examine the role of human papillomavirus (HPV) and oral contraceptive (OC) use in the etiology of adenocarcinoma in situ of the cervix (ACIS). One hundred and fifty women diagnosed with ACIS and 651 randomly selected control women completed in-person interviews. The presence of HPV DNA in archival ACIS specimens was determined by E6 and L1 consensus PCR. Serum samples from case and control subjects were collected at interview, and antibodies to HPV-16 L1 and HPV-18 L1 were detected by virus-like particle capture assays. The overall prevalence of HPV DNA was 86.6%, with 39.0% positive for HPV-16 DNA, 52.4% positive for HPV-18 DNA, and 13.4% positive for more than one HPV type. The age-adjusted relative risk of ACIS associated with HPV-18 seropositivity was 3.3 (95% confidence interval 2.2-4.9). No increased risk was associated with antibodies to HPV-16 L1. Among women born after 1945, the relative risk increased with duration of OC use, with the highest risk for 12 or more years of use (odds ratio, 5.5; 95% confidence interval, 2.1-14.6) relative to nonusers. The detection of HPV DNA in 86.6% of ACIS and the strong association of ACIS with HPV-18 L1 seropositivity underscore the importance of HPV, particularly HPV-18, in the etiology of ACIS. In addition, long-term OC use may contribute to the pathogenesis of these tumors in some women.

Maternal and neonatal outcomes after induction of labor without an identified indication

OBJECTIVE

This study was undertaken to examine associations between induction of labor and maternal and neonatal outcomes among women without an identified indication for induction.

STUDY DESIGN

This was a population-based cohort study of 2886 women with induced labor and 9648 women with spontaneous labor who were delivered at 37 to 41 weeks' gestation, all without identified medical and obstetric indications for induction.

RESULTS

Among nulliparous women 19% of women with induced labor versus 10% of those with spontaneous labor underwent cesarean delivery (adjusted relative risk, 1.77; 95% confidence interval, 1.50-2.08). No association was seen in multiparous women (relative risk, 1.07; 95% confidence interval, 0. 81-1.39). Among all women induction was associated with modest increases in instrumental delivery (19% vs 15%; relative risk, 1.20; 95% confidence interval, 1.09-1.32) and shoulder dystocia (3.0% vs 1. 7%; relative risk, 1.32; 95% confidence interval, 1.02-1.69).

CONCLUSION

Among women who lacked an identified indication for induction of labor, induction was associated with increased likelihood of cesarean delivery for nulliparous but not multiparous women and with modest increases in the risk of instrumental delivery and shoulder dystocia for all women.

Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men

OBJECTIVE

To determine whether combination antiretroviral therapy is associated with reduced detection of HIV-1 RNA and DNA in the anorectal mucosa of men who have sex with men (MSM).

DESIGN

Cross-sectional study of 233 MSM recruited from community and clinic sites in Seattle, Washington between July 1996 and December 1997.

METHODS

HIV-1 RNA and HIV-1 DNA were detected in anorectal swab specimens by polymerase chain reaction amplification assays.

RESULTS

HIV-1 RNA was detected significantly less often in anorectal specimens from users of combination antiretroviral therapies, whether a protease inhibitor was received (15/89; 17%) or not (16/53; 30%), than in men not receiving therapy (43/88; 49%) (P < 0.001, P = 0.03, respectively). In contrast, HIV-1 DNA was detected only slightly less frequently in anorectal specimens obtained from men receiving protease inhibitors (35/81; 43%) or reverse transcriptase inhibitors alone (22/48; 46%) than in specimens from men not receiving therapy (45/78; 58%) (P = 0.07, P = 0.20, respectively). Among men with < 50 copies HIV-1 RNA/ml plasma, detection of HIV-1 RNA in anorectal specimens was rare (1/54; 2%) but detection of HIV-1 DNA was common (14/50; 28%).

CONCLUSIONS

Combination antiretroviral therapy is associated with reductions in HIV-1 RNA, but HIV-1 DNA remains detectable in the anorectal canal of almost half of MSM receiving such therapy. Condom use during anal intercourse should be encouraged, regardless of plasma viral load response to potent antiretroviral therapy.

Secretor polymorphism and human immunodeficiency virus infection in Senegalese women

The FUT2 gene encodes the enzyme alpha (1,2) fucosyltransferase, which determines expression of blood-group antigens on mucosal epithelial cell surfaces and in secretions. Homozygotes for a specific stop mutation in FUT2 (nonsecretors) cannot produce this enzyme and thus are unable to express blood group antigens. Nonsecretor status is associated with a decreased risk of several respiratory viral infections. By use of molecular genotyping, 2 populations of Senegalese women were examined for polymorphisms of the FUT2 gene. Among Senegalese commercial sex workers, absence of FUT2 (nonsecretor genotype) was associated with reduced risk of human immunodeficiency virus (HIV) type 1 infection (odds ratio [OR] adjusted for cervical and vaginal infection, 0.18; 95% confidence interval [CI], 0.04-0.90) and HIV-2 infection (adjusted OR, 0.43; 95% CI, 0.13-1.39), although the latter was not statistically significant. Modification of cell surface carbohydrates at mucosal surfaces determined by the FUT2 gene may underlie the protective association against heterosexual HIV infection.

Risk factors for urinary tract infection in the postpartum period

OBJECTIVE

We sought to examine risk factors for urinary tract infection in postpartum women.

STUDY DESIGN

Subjects (n = 931) with maternal urinary tract infections and control subjects (n = 1862) were identified by using a linked Washington State birth certificate and Birth Events Records Database for the years 1987-1993; stratified analysis was performed by using Mantel-Haenszel procedures.

RESULTS

Increased risk for postpartum urinary tract infection was associated with black, Native American, or Hispanic race-ethnicity (odds ratio, 1.30; 95% confidence interval, 1.03-1.64) and unmarried status (odds ratio, 1.33; 95% confidence interval, 1.11-1.58). Cesarean delivery (odds ratio, 2.70; 95% confidence interval, 2.27-3.20) and tocolysis (odds ratio, 3.30; 95% confidence interval, 2.15-5.06) also contributed to maternal risk of acquiring a urinary tract infection. Maternal risk factors included renal disease (adjusted odds ratio, 3.89; 95% confidence interval, 1.80-8.41) and preeclampsia-eclampsia (adjusted odds ratio, 3.21; 95% confidence interval, 2.36-4.38). Among women undergoing vaginal delivery, renal disease (odds ratio, 5.47; 95% confidence interval, 2.04-14.64) and abruptio placentae (odds ratio, 5.02; 95% confidence interval, 1.84-13.64) were risk factors. Length of hospital stay was significantly associated with urinary tract infection.

CONCLUSION

Maternal medical conditions and procedures that predispose to urinary tract infections are those that also are associated with urethral catheterization. In addition, maternal urinary tract infections may contribute significantly to duration of postpartum hospital stay.

Characterization of ciliary activity in distal Fallopian tube biopsies of women with obstructive tubal infertility

Biopsy specimens were obtained from the distal end of the Fallopian tubes of 62 women with tubal infertility and examined by light and electron microscopy. Ciliary beat frequency (CBF) measurements were obtained using laser light spectroscopy. Neither demographic nor behavioural characteristics nor serological evidence of past chlamydial infection were associated with CBF measurements. In contrast, CBF were significantly lower (P < 0.05) in tissues with oedema compared to tissues without oedema (6.7 versus 12.9) and in tissues with erythema compared to tissues without erythema (9.2 versus 13.7). Furthermore, CBF measurements did vary by chlamydial serotype pattern, with lower values observed among the tissues of women with antibodies to serotype C or E (without D) as compared to the tissues of women with other serotypes (P < 0.04). However, these data must be interpreted with caution as the numbers of subjects with chlamydial antibodies to serotype C (n = 3) or E without D (n = 5) were few in number and serotyping of IgG antibodies in blood is not as accurate as it is in bacterial isolates. Confirmation of the suggested association between chlamydial serotype and risk of adverse sequelae could indicate potential new avenues for vaccine research.

Risk of anal carcinoma in situ in relation to human papillomavirus type 16 variants

Infection with human papillomavirus (HPV), especially HPV16, is central to the development of squamous anogenital cancers and their precursor lesions, termed "squamous intraepithelial neoplasias." Men who have sex with men, particularly those who are infected with HIV, are at a high risk for anal infection with HPV16 and for low-grade anal neoplasia; however, only a subset of these men develop anal invasive cancer or its immediate precursor lesion, anal carcinoma in situ (CIS). To examine the hypothesis that certain variants of HPV16 are most strongly associated with development of anal CIS, we followed 589 men who have sex with men whose initial anal cytological smears did not show anal CIS. Anoscopy, anal cytology, and PCR-based assays for detection and classification of HPV types were performed every 4-6 months, with HPV16 further classified by single-stranded conformation polymorphism analysis as being a prototype-like (PL) or non-prototype-like (NPL) variant. Anal CIS was histologically confirmed in 6 of 384 (1.6%) consistently HPV16-negative men, in 12 of 183 (6.6%) men with HPV16 PL variants, and in 4 of 22 (18.2%) men with HPV16 NPL variants. After adjustment for anal cytological diagnoses at study entry, HIV status and CD4 count, and detection of HPV types other than type 16, men with HPV16 NPL variants were 3.2 times (95% confidence interval, 1.0-10.3) more likely to develop anal CIS than were those with PL variants. Neither detection of HPV16 DNA at high levels nor detection of HPV16 DNA for a prolonged period, factors that we previously demonstrated to be associated with risk of high-grade anal squamous intraepithelial neoplasia, was significantly associated with HPV16 NPL variants. The biological mechanism relating to Ihis excess risk remains undetermined.

Effect of HIV infection on the natural history of anal human papillomavirus infection

OBJECTIVE

To identify risk factors for the detection of prevalent and incident anal human papillomavirus (HPV) infection, and HPV persistence among HIV-seropositive and seronegative homosexual men.

DESIGN

Longitudinal study of 287 HIV-seronegative and 322 HIV-seropositive men attending a community-based clinic.

METHODS

Subjects underwent an interview and examination; specimens were collected for HIV serology and assessment of anal HPV and HIV DNA.

RESULTS

Anal HPV DNA was detected at study entry in 91.6% of HIV-infected men, and 65.9% of men not infected with HIV. HPV detection was associated with lifetime number of sexual partners and recent receptive anal intercourse (HIV-seronegative men), decreased CD4+ lymphocyte count (HIV-seropositive men), and anal warts (all men). Among men negative for HPV at study entry, subsequent detection of HPV was associated with HIV, unprotected receptive anal intercourse, and any sexual contact since the last visit. Among men positive for HPV at study entry, subsequent detection of additional HPV types was more common among HIV-seropositive men. Becoming HPV negative during follow-up was less common among men with HIV or high HPV levels at study entry. Among those with HIV, HPV persistence was associated with presence of anal HIV DNA, but not with CD4+ lymphocyte count.

CONCLUSIONS

Risk of anal HPV infection appears to increase with sexual exposure, epithelial trauma, HIV infection and immune deficiency. Incident infection may result from recent sexual exposure or reactivation of latent infection. Further studies are needed to elucidate the mechanism by which HIV DNA in the anal canal increases the risk of HPV persistence.

Determinants of human immunodeficiency virus DNA and RNA shedding in the anal-rectal canal of homosexual men

To define the determinants of anal-rectal shedding of human immunodeficiency virus (HIV) DNA and RNA, 374 HIV-seropositive homosexual men were tested. Factors independently associated with detection of anal-rectal HIV DNA included anal-rectal inflammation and detection of anal human papillomavirus DNA; predictors of HIV RNA included detection of anal-rectal HIV DNA, anal-rectal inflammation, and high plasma HIV RNA levels. The latter (>10,000 copies/mL) was the main determinant of anal-rectal HIV RNA shedding when HIV DNA (e.g., HIV-infected cells) was not detected in the anal-rectal sample. The local presence of HIV-infected cells and local inflammation were the principal determinants of HIV RNA among those with low (<10,000 copies/mL) plasma HIV RNA load. Among those with anal-rectal HIV DNA present, increased HIV RNA plasma load did not increase the risk of shedding of HIV RNA into the anal-rectal canal.

The effect of health maintenance organization vs commercial insurance status on obstetrical management and outcome

OBJECTIVE

To compare obstetrical management and birth outcomes between patients with health maintenance organization (HMO) insurance and those with private commercial insurance.

DESIGN

Retrospective population-based cohort study.

SETTING

King County, Washington.

PATIENTS

Among newborns delivered in 1992 and 1993, a random sample of 4000 birth records listing HMO insurance for prenatal care was compared with a random sample of 4000 birth records listing private commercial insurance as the primary coverage.

MAIN OUTCOME MEASURES

Use of ultrasonography and amniocentesis; rate of primary cesarean section performed; adequacy of prenatal care; incidence of maternal medical complications, low birth weight, and congenital malformations; and length of hospital stay.

RESULTS

Women covered by HMO compared with commercial insurance were more likely to undergo ultrasonography (relative risk [RR], 1.4; 95% confidence interval [CI], 1.3-1.4). Inadequate prenatal care was less frequent among HMO-insured patients (RR, 0.6; 95% CI, 0.5-0.7), as was the incidence of birth weight below 2500 g (RR, 0.7; 95% CI, 0.6-0.9). No differences in rates of cesarean section and congenital anomalies were observed. Among women without obstetrical risk factors, HMO-insured mothers were at an increased risk of labor and delivery complications (RR, 1.4; 95% CI, 1.3-1.5); their infants were at an increased risk of infant distress (RR, 1.8; 95% CI, 1.5-2.2).

CONCLUSIONS

Patients with HMO insurance have improved access to prenatal care and screening when compared with privately insured patients. The reasons for increased risks of abnormal maternal and infant outcomes observed among a subset of HMO-insured patients are unclear. A study with more detailed prospective data collection is warranted.

Seroprevalence of human papillomavirus types 6 and 16 capsid antibodies in homosexual men

Human papillomavirus (HPV) has been implicated in the pathogenesis of anal carcinoma, which is increased in homosexual men. Little is known about the serologic response to HPV in normal or immunosuppressed men; therefore, HIV-infected and -uninfected homosexual men were screened for HPV-6 and -16 capsid antibodies. HIV-infected men had increased HPV DNA detection but did not significantly differ in the prevalence of serum HPV antibodies. HPV-6 DNA detection and the presence of anal warts were significantly correlated with serum antibody overall and in the HIV-infected subgroup. HPV-16 DNA detection was not significantly correlated with serum antibody overall or in either subgroup; however, HIV-infected men with high-grade anal squamous intraepithelial lesions were significantly more likely to have HPV-16 antibodies. HIV-infected men are able to generate an antibody response to HPV, and a lack of serum HPV antibodies cannot explain the increased HPV-associated disease seen in HIV-infected men.

Periodontal status of HIV-1 and HIV-2 seropositive and HIV seronegative female commercial sex workers in Senegal

Comprehensive studies of 92 commercial sex workers in Senegal, Africa included an oral examination in which we obtained measurements of decayed, missing, and filled (DMF) teeth; plaque index; gingival index; recession; probing depth (PD); clinical attachment loss (CAL); and the presence of HIV-associated periodontal lesions, under conditions wherein the examiner was unaware of the subject's HIV status. Twenty-seven subjects (29%) were HIV seropositive, 19 of whom were positive for HIV-1, 7 positive for HIV-2, and 1 positive for both. Most subjects were not taking any medications and previous dental care was limited. HIV-seronegative and HIV-seropositive subjects were similar in mean age, number of DMF teeth, percentage of sites with visible plaque, and number of sites with recession. However, the frequency of sites with gingival bleeding, with PD > or = 6 mm, and with CAL > or = 6 mm was significantly greater in seropositive than seronegative subjects. No differences were observed between HIV-1 and HIV-2 positive subjects. About 26% of HIV-seropositive subjects and about 5% of the seronegative subjects exhibited at least one site with concurrent PD > or = 6 mm and CAL > or = 6 mm. HIV-associated periodontal lesions were seen in 3 HIV-seropositive subjects (2 linear gingival erythema, 1 necrotizing periodontitis). One HIV-seronegative subject exhibited necrotizing gingivitis. In this population with multiple risks to oral health, both HIV-1 and HIV-2 infections were associated with a significantly increased prevalence of periodontal disease.

Detection of human immunodeficiency virus type 1 and type 2 in the female genital tract: implications for the understanding of virus transmission

Risk of perinatal or female to male sexual transmission of HIV is likely to be associated with whether, and at what concentration, the virus is present in the cervical and vaginal secretions of the HIV-infected woman. Examining correlates of cervical and vaginal HIV shedding is, therefore, essential for the development of strategies to interrupt HIV transmission. This article presents the rationale for using detection of HIV in the female genital tract as a marker of infectivity, and briefly describes methods for detecting HIV-1 and HIV-2 in cervical or vaginal fluids. Findings from studies incorporating the measurement of HIV in the female genital tract are reviewed, placing particular emphasis on issues relevant to epidemiological studies of HIV transmission.

HIV-1, HIV-2, human papillomavirus infection and cervical neoplasia in high-risk African women

OBJECTIVE

To determine the effect of HIV-1 and HIV-2 infection on the prevalence of cervical human papillomavirus (HPV) and squamous intraepithelial lesions (SIL) in a population of high-risk women in Senegal.

DESIGN AND PARTICIPANTS

Cross-sectional study among 759 female commercial sex workers, including 68 with HIV-1, 58 with HIV-2, 14 with HIV-1 and 2, and 619 without HIV infection.

RESULTS

Overall, HPV was detected in 43% of women by polymerase chain reaction (PCR), and in 7% by Southern transfer hybridization, with 7.4% of all women having SIL. The mean CD4 count was 820, 1205, and 727 x 10(6)/l for those with HIV-1, HIV-2, and dual HIV-1 and 2 infections, respectively, and 1447 x 10(6)/l for those without HIV infection. Both HIV-1 and HIV-2 were associated with HPV, as detected by PCR [HIV-1 odds ratio (OR), 2.9; 95% confidence interval (Cl), 1.7-4.9; HIV-2 OR, 1.7; 95% Cl, 1.0-2.9]. HIV-2 was also associated with cervical SIL, and although the association between HIV-1 and SIL did not attain statistical significance, a trend was apparent (HIV-1 OR, 1.8; 95% Cl, 0.7-4.7; HIV-2 OR, 2.9; 95% Cl, 1.2-7.2).

CONCLUSIONS

Despite less immunosuppression with HIV-2, both HIV-1 and HIV-2 were associated with detection of HPV. HIV-2 was also associated with SIL. Further studies are needed to examine the risks of high-grade SIL and invasive cervical cancer with HIV-1 versus HIV-2 infection.

Prospective study of high grade anal squamous intraepithelial neoplasia in a cohort of homosexual men: influence of HIV infection, immunosuppression and human papillomavirus infection

OBJECTIVE

To determine the risk of developing high grade anal squamous intraepithelial neoplasia (HG-AIN) in relation to HIV infection and immunosuppression, after controlling for the effects of human papillomavirus (HPV) infection.

DESIGN

Prospective cohort study of 158 HIV-seropositive and 147 HIV-seronegative homosexual men presenting to a community-based clinic with initially negative anal cytologic and colposcopic findings.

METHODS

Subjects completed self-administered questionnaires, underwent cytologic screening, and standardized unaided and colposcopic examination of the proximal anal canal for presence of abnormalities suggestive of AIN. Anal specimens were screened for HPV DNA.

RESULTS

HG-AIN developed in eight (5.4%) and 24 (15.2%) HIV-seronegative and -seropositive men, respectively. Risk of HG-AIN among HIV-seronegative men was associated with detection of anal HPV types 16 or 18 by Southern transfer hybridization (STH), detection of HPV 16 or 18 at the lower levels by polymerase chain reaction but not by STH, and with number of positive HPV tests; HG-AIN risk among HIV-seropositive men was associated with detection of HPV 16 or 18 only by STH, detection of HPV types other than 16 or 18, CD4 count < or = 500 x 10(6)/l, and number of positive HPV tests. HIV-induced immunosuppression remained an independent predictor of HG-AIN after adjusting for type and level of detection of HPV; HIV infection predicted HG-AIN risk after adjustment for number of positive HPV tests.

CONCLUSIONS

The association of HG-AIN with HIV, independent of HPV type, level of HPV detection and number of positive HPV tests, suggests that this increased risk cannot be entirely explained by an effect of HIV on HPV detection. Future studies focusing on factors more specific to the local microenvironment in the anal canal should help clarify these issues.

Determinants of cervical ectopia and of cervicitis: age, oral contraception, specific cervical infection, smoking, and douching

OBJECTIVE

Our purpose was to assess determinants of cervical ectopia and cervicitis, specifically after adjustment for cervical infection.

STUDY DESIGN

A cross-sectional study was conducted with colposcopic, cytologic, and microbiologic examination of 764 randomly selected women attending a sexually transmitted disease clinic and 819 consecutive college students undergoing routine annual examination.

RESULTS

After we controlled for potential confounders, cervical ectopia was positively associated with oral contraception and Chlamydia trachomatis infection and negatively associated with aging in both populations, with recent vaginal douching in patients with sexually transmitted diseases, and with current smoking in college students. Oral contraception wa also associated with the radius of ectopia, and among users of oral contraception ectopia was associated with duration of oral contraception. Cervicitis (evaluated by Gram stain, Papanicoloau smear, and colposcopy) was associated with cervical infection by C. trachomatis and cytomegalovirus (both populations) and with gonorrhea and cervical herpes simplex virus infection (patients with sexually transmitted diseases). Cervicitis was independently associated with ectopia but not with oral contraception after we adjusted for these four cervical infections. However, oral contraception was associated with edema and erythema of the zone of ectopia among women without cervical infection.

CONCLUSIONS

Oral contraception, aging, cervical infection, smoking, and douching have effects on cervical ectopia that may influence the acquisition, transmission, or effects of sexually transmitted agents. Ectopia is associated with young age, oral contraception, and cervical infection; cervicitis is associated with ectopia and cervical infection by C. trachomatis, Neisseria gonorrhoeae, herpes simplex virus, and cytomegalovirus. In women without cervical infection, edema and erythema of the zone of ectopia are associated with oral contraception.

Cerebrospinal fluid treponemal antibodies in untreated early syphilis

OBJECTIVE

Examine prevalence and diagnostic utility of cerebrospinal fluid (CSF) treponemal antibodies in early syphilis.

DESIGN

Comparison study.

SETTING

Sexually transmitted diseases clinic.

PATIENTS

Forty patients with untreated early syphilis who underwent lumbar puncture. Fifteen were human immunodeficiency virus seropositive.

MEASUREMENTS

Cerebrospinal fluid cell count, protein, VDRL test, and antibodies to Treponema pallidum by microhemagglutination test for T pallidum (MHA-TP) and fluorescent treponemal antibody absorption test (FTA-ABS); albumin ratio; and IgG index.

RESULTS

Cerebrospinal fluid cell count was not available for one sample, and this patient was excluded from analysis. Of 39 patients, eight (21%) had reactive CSF-VDRL (definite neurosyphilis). Eleven (28%) had mildly elevated cell count or protein concentration, but nonreactive CSF-VDRL (possible neurosyphilis). Twenty had normal cell count and protein concentration, and non-reactive CSF-VDRL (normal). Cerebrospinal fluid MHA-TP and CSF FTA-ABS were reactive in all eight with neurosyphilis. Cerebrospinal fluid MHA-TP was reactive in seven (70%) of 10 with possible neurosyphilis and in six (32%) of 19 with normal CSF. Cerebrospinal fluid FTA-ABS was reactive in four (36%) of 11 with possible neurosyphilis and in five (28%) of 18 with normal CSF. A reactive CSF treponemal test was associated with higher mean CSF cell count and reactive CSF-VDRL.

CONCLUSION

When criteria to define neurosyphilis depend on cell count or CSF-VDRL reactivity, the sensitivity of CSF treponemal antibodies is high. Nonreactive CSF treponemal tests may help to exclude a diagnosis of neurosyphilis in patients with early syphilis.

Cervical intraepithelial neoplasia and human papillomavirus infection among Senegalese women seropositive for HIV-1 or HIV-2 or seronegative for HIV

Studies in various regions of the world have shown that women infected with HIV-1 are at increased risk for cervical human papillomavirus (HPV) infection as well as for cervical cancer precursor lesions. HIV infection and cervical cancer are both widespread in West Africa, but little is known about the relationship between HPV and HIV-2, which is the predominant type of HIV in the general population of many West African countries. To address this issue, we collected cervical samples for cytology and HPV analysis from 93 women presenting to the University of Dakar Infectious Disease Service (18 women with HIV-1 infection, 17 with HIV-2 infection, and 58 HIV seronegative controls). Compared to those without HIV infection, HIV seropositive women were 13.1 (95% CI = 2.4, 128) and 11.0 (95% CI = 3.5, 35.8) times more likely to have HPV detected using Southern transfer hybridization (STH) and the polymerase chain reaction (PCR) respectively. Detection of high and intermediate risk HPV types were significantly associated with HIV-1 and HIV-2 infection. Among HPV positive women, those with, as compared to those without HIV infection were more likely to harbour high risk HPV types (OR = 9.2, 95% CI = 0.97, 433). HIV-1 and HIV-2 seropositive women were 23.3 (95% CI = 2.9, 209) and 9.3 (95% CI = 1.1, 79) times more likely to have cytological diagnosis of dysplasia, respectively, than were HIV seronegative women. Biopsy-proven CIN 3 was found in one woman with HIV-1 and invasive cancer was found in one woman with HIV-2.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors and infant outcomes associated with umbilical cord prolapse: a population-based case-control study among births in Washington State

OBJECTIVE

Our goal was to quantify the magnitude of risk associated with conditions resulting in umbilical cord prolapse and adverse infant outcome after cord prolapse.

STUDY DESIGN

This population-based case-control study used birth certificate data from 709 cases and 2407 randomly selected controls. Odds ratios were used as measures of association, with stratification performed to control for confounding.

RESULTS

Case infants were more likely to weigh < 2500 mg (odds ratio 4.8, 95% confidence interval 3.7 to 6.2) and to born prematurely (odds ratio 2.9, 95% confidence interval 2.2 to 3.7). Other risk factors were breech presentation (birth weight-adjusted odds ratio 2.5, 95% confidence interval 1.7 to 3.9) and being a second-born twin (odds ratio 5.0, 95% confidence interval 3.3 to 11.7). Subsequent adverse infant outcomes included an increased risk of mortality (relative risk 2.7, 95% confidence interval 1.9 to 4.0), with mortality being less likely to occur among cases delivered by cesarean section (relative risk 0.4, 95% confidence interval 0.2 to 0.6).

CONCLUSIONS

This study confirms previously suspected risk factors and supports clinical management of cord prolapse by cesarean section delivery.

Clinical manifestations of trichomoniasis in men

OBJECTIVE

To determine the prevalence and clinical manifestations of trichomoniasis among sexually active men.

DESIGN

Survey of two groups of men attending a sexually transmitted disease clinic. Subjects had a comprehensive sexual history and clinical examination plus cultures for Trichomonas vaginalis, Neisseria gonorrhoeae, and Chlamydia trachomatis.

PARTICIPANTS

The study included 147 sexual partners of women with trichomoniasis and 300 subjects selected randomly from heterosexual men coming to the same clinic for evaluation of new problems.

MAIN OUTCOME MEASURES

Isolation of T. vaginalis was compared with urogenital signs and symptoms.

RESULTS

The prevalence of T. vaginalis was 33 of 147 (22% [95% CI, 16% to 29%]) among sexual contacts of women with trichomoniasis and 17 of 300 (6% [CI, 3% to 9%]) among heterosexual men attending the same clinic. Men with trichomoniasis alone were more likely to complain of urethral discharge (P < 0.01), to have discharge on examination (P < 0.03), and to have inflammatory cells in their urethral secretions (P < 0.01) than were men who did not have T. vaginalis, N. gonorrhoeae, or C. trachomatis. Trichomonas vaginalis remained associated with nongonococcal nonchlamydial urethritis (adjusted odds ratio 3.8; CI, 1.1 to 11.2) after adjustment for race, age, number of sex partners in the previous 6 months, exposure to a partner with trichomoniasis, and history of trichomoniasis, urethritis, or gonorrhea.

CONCLUSIONS

Trichomoniasis was common among men at risk for sexually transmitted diseases and was associated with symptoms and signs of urethritis.

Comparison of dot filter hybridization, Southern transfer hybridization, and polymerase chain reaction amplification for diagnosis of anal human papillomavirus infection

The detection and classification of human papillomavirus (HPV) by a consensus primer polymerase chain reaction (PCR) technique were compared with detection and classification by dot filter hybridization (DFH) and Southern transfer hybridization (STH). PCR detected HPV in 87% of specimens; the detection rates for DFH and STH were 51% and 49%, respectively. The specific HPV types detected by STH were also detected by PCR in 90% of specimens. However, 75% of the samples positive for unclassified HPV by STH were typed by PCR. PCR results were reproducible, as assessed by repeat analysis (96% agreement), by analysis of paired same-day specimens (89% agreement), and by interlaboratory analysis (88% agreement). PCR is a sensitive, specific, and reproducible test for HPV detection and classification in clinical and epidemiologic studies.

Association of anal dysplasia and human papillomavirus with immunosuppression and HIV infection among homosexual men

OBJECTIVE

To examine and quantify the association between anal squamous intraepithelial lesions (ASIL), anal human papillomavirus (HPV) infection and immunosuppression among HIV-seropositive and HIV-seronegative homosexual men.

DESIGN

Cross-sectional study among homosexual men presenting at a community-based clinic for HIV serologic screening.

RESULTS

Anal HPV DNA was detected in 55 and 23% of 285 HIV-seropositive and 204 HIV-seronegative men, respectively, by Southern transfer hybridization (STH) [odds ratio (OR), 4.0; 95% confidence interval (CI), 2.7-6.2], and in 92 and 78% by polymerase chain reaction (PCR) (OR, 3.1; 95% CI, 1.6-5.8). ASIL was noted in 26% of HIV-seropositive men and in 8% of HIV-seronegative men (compared with men with negative cytologic findings: OR, 5.6; 95% CI, 3.0-10.5), with high-grade lesions noted in 4% of HIV-seropositive and in 0.5% of HIV-seronegative men. Among HIV-infected men, ASIL, detection of specific anal HPV types, and detection of high levels of anal HPV DNA (i.e., levels of HPV DNA detectable by both STH and PCR) were all associated with immunosuppression. Nevertheless, HIV-seropositive men with CD4 counts > 500 x 10(6)/l had a higher prevalence of both anal HPV and ASIL than men without HIV infection. Overall, detection of HPV at high levels was associated with ASIL. However, after adjustment for level of detectable HPV DNA, the risk of ASIL among HIV-seropositive men with CD4 counts < 500 x 10(6)/l was increased 2.9-fold (95% CI, 1.4-6.2) over that of HIV-seropositive men with CD4 counts > 500 x 10(6)/l.

CONCLUSION

Given the high rates of ASIL in HIV-seronegative and both immunosuppressed and non-immunosuppressed HIV-seropositive homosexual men, natural history studies are now needed to assist in the development of strategies for the detection and management of such lesions. The increased prevalence of ASIL seen among immunosuppressed HIV-seropositive men may be the result of both a non-specific increase in productive HPV infection and HIV-induced immune alterations of HIV-related neoplasia.

A cohort study of the risk of cervical intraepithelial neoplasia grade 2 or 3 in relation to papillomavirus infection

BACKGROUND

Human papillomavirus (HPV) has been associated with cervical intraepithelial neoplasia, but the temporal relation between the infection and the neoplasia remains unclear, as does the relative importance of the specific type of HPV, other sexually transmitted diseases, and other risk factors.

METHODS

We studied prospectively a cohort of 241 women who presented for evaluation of sexually transmitted disease and had negative cervical cytologic tests. The women were followed every four months with cytologic and colposcopic examinations of the uterine cervix and tests for HPV DNA and other sexually transmitted diseases.

RESULTS

Cervical intraepithelial neoplasia grade 2 or 3 was confirmed by biopsy in 28 women. On the basis of survival analysis, the cumulative incidence of cervical intraepithelial neoplasia at two years was 28 percent among women with a positive test for HPV and 3 percent among those without detectable HPV DNA: The risk was highest among those with HPV type 16 or 18 infection (adjusted relative risk as compared with that in women without HPV infection, 11; 95 percent confidence interval, 4.6 to 26; attributable risk, 52 percent). All 24 cases of cervical intraepithelial neoplasia grade 2 or 3 among HPV-positive women were detected within 24 months after the first positive test for HPV. After adjustment for the presence of HPV infection, the development of cervical intraepithelial neoplasia was also associated with younger age at first intercourse, the presence of serum antibodies to Chlamydia trachomatis, the presence of serum antibodies to cytomegalovirus, and cervical infection with Neisseria gonorrhoeae.

CONCLUSIONS

Cervical intraepithelial neoplasia is a common and apparently early manifestation of cervical infection by HPV, particularly types 16 and 18.

Association of human immunodeficiency virus and anal human papillomavirus infection among homosexual men

BACKGROUND

A previous study of men with proctitis, proctocolitis, or enteritis showed an association of anal human papillomavirus (HPV) infection with human immunodeficiency virus (HIV) infection. Because anorectal abnormalities may confound an observed association between anal HPV DNA and HIV seropositivity, the present study was undertaken among consecutive homosexual men seeking HIV serologic testing who were unselected for anorectal symptoms.

METHODS

Consecutive homosexual men underwent a standardized interview, physical examination, and collection of specimens for HIV serologic testing and detection of anal HPV DNA.

RESULTS

Anal HPV DNA was detected in eight (31%) of 26 HIV-seropositive men and in 10 (8%) of 119 HIV-seronegative men (odds ratio, 5.8; 95% confidence interval, 1.1 to 30.1, adjusted for history of sexually transmitted disease, current anorectal symptoms, and age). When men with anorectal symptoms were excluded from the analysis, anal HPV DNA was detected in 27% of seropositive men compared with 8% of seronegative men (odds ratio, 4.4; 95% confidence interval, 1.4 to 13.4). There was no difference between HIV-seropositive and HIV-seronegative men with respect to distribution of type of HPV DNA. Men with group II or III and group IV HIV disease were 4.1 and 10.9 times, respectively, more likely than HIV-seronegative men to have anal HPV DNA detected.

CONCLUSIONS

Because HIV-seropositive men appear to be at increased risk for the detection of anal HPV DNA, the natural course of anal HPV infection should be compared among HIV-seropositive and HIV-seronegative homosexual men.

Prevalence and cytologic manifestations of human papilloma virus (HPV) types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56 among 500 consecutive women

The prevalence and associated cytologic manifestations of cervical infection with human papillomavirus (HPV) types 6, 11, 16, 18, 31, 33, 35, 42, 43, 44, 45, 51, 52, and 56 were studied among 500 consecutive women attending the Harborview Medical Center Sexually Transmitted Diseases (STD) Clinic in Seattle, WA. Using radiolabeled-probes without prior amplification of DNA, HPV DNA was detected in cervical specimens from 120 (24%) of the women and was found to be more prevalent than Chlamydia trachomatis (13%), Neisseria gonorrhoeae (12%), or mucopurulent cervicitis (20%). High-risk HPV types 16 or 18 were present alone in 5% of the women; intermediate-risk types 31, 33, 35, 45, 51, 52, or 56 in 3%; and low-risk types 6, 11, 42, 43, and 44 in 5%. In an additional 8% HPV DNA was detected but could be characterized only as being type 6, 11, 16, 18, 31, 33, or 35. Each grouping of HPV types was equally associated with squamous intraepithelial lesions (SILs) of the cervix. In the absence of SIL and koilocytosis, the cytologic changes associated with HPV infection included frequent binucleation and variation in nuclear size and chromatin distribution. Parakeratosis and hyperkeratosis without nuclear atypia were not associated with HPV DNA. The natural history and clinical significance of these HPV-associated lesions remain to be defined.

Underdiagnosis of genital herpes by current clinical and viral-isolation procedures

BACKGROUND

The current clinical strategy for diagnosing genital herpes simplex virus (HSV) infection in women relies on clinical findings plus the selective use of viral culture. The effectiveness of this approach for identifying women with genital herpes is unknown.

METHODS

We performed physical examinations, colposcopy, Pap smears, viral cultures, and HSV type-specific serologic assays of 779 randomly selected women attending a sexually transmitted disease clinic.

RESULTS

Evidence of HSV type 2 infection was detected in 363 women (47 percent), and 9 others (1 percent) had positive cultures indicative of urogenital or anal infection with HSV type 1. Of these 372 women, only 82 (22 percent) had symptoms. Fourteen women (4 percent) had viral shedding without symptoms, 60 (16 percent) had formerly had symptomatic episodes, and 216 (58 percent) had antibodies to HSV-2 with neither viral shedding nor a history of clinical episodes. Characteristic ulcerations of the external genitalia were present in only two thirds of the 66 women with positive HSV cultures; the others had atypical genital lesions or asymptomatic viral shedding. Isolation of HSV from a genitourinary tract specimen was the most sensitive (77 percent) test for confirming a first episode of infection. The detection of HSV-2-specific antibodies was the most sensitive (97 percent) way to confirm symptomatic reactivations of HSV-2 infection. HSV-2 serologic testing also identified the 290 women with asymptomatic HSV-2 infections (37 percent), including 14 (5 percent) who were shedding virus asymptomatically on the day of the examination.

CONCLUSIONS

The current strategy for diagnosing genital HSV infection in women misses many cases. Newly developed type-specific serologic methods can identify women with recurrent genital HSV-2 infection, as well as those with unrecognized or subclinical infection.

Microbiological, epidemiological and clinical correlates of vaginal colonisation by Mobiluncus species

The microbiological and epidemiological correlates of vaginal colonisation by Mobiluncus species were examined among randomly selected women attending a sexually transmitted disease (STD) clinic. Women positive for Trichomonas vaginalis were excluded. Mobiluncus spp. were detected by Gram stained vaginal smear in 21% of 633 STD clinic patients, including 53% of those with and 4% of those without bacterial vaginosis (BV), as diagnosed by clinical criteria. Gardnerella vaginalis and Mycoplasma hominis detected by vaginal culture and Mobiluncus detected by vaginal Gram stain were each independently associated with BV after adjusting by logistic regression for the presence of sexually transmitted disease pathogens, gravidity, parity and number of lifetime sexual partners (p less than 0.001 for each organism). Bacterial vaginosis was negatively correlated with isolation of lactobacilli, yeast and herpes simplex virus. After adjusting for presence or absence of BV, women with Mobiluncus were more likely to harbour G vaginalis (odds ratio 5.6, 95% confidence interval 1.6-19.5), M hominis (OR 3.7, 95% CI 2.0-7.0) and Neisseria gonorrhoeae (OR 2.9, 95% CI 1.4-6.0) and less likely to harbour vaginal yeast (OR 0.4, 95% CI 0.2-1.0); were more likely to be black (OR 2.7, 95% CI 1.5-4.6), and to have been pregnant (OR 1.8, 95% CI 1.1-3.1); but after the adjustment for BV, vaginal colonisation by Mobiluncus was not associated with symptoms of odour, abdominal pain, menstrual irregularities, or with adnexal tenderness. In summary, Mobiluncus, Gardnerella vaginalis and Mycoplasma hominis were independently associated with a clinical diagnosis of bacterial vaginosis, and Mobiluncus was further associated with the presence of BV-associated microorganisms (M hominis and G vaginalis), N gonorrhoeae, black race, and gravidity.

Comparison of Southern transfer hybridization and dot filter hybridization for detection of cervical human papillomavirus infection with types 6, 11, 16, 18, 31, 33, and 35

A commercial dot filter hybridization kit (Virapap Kit) was compared with Southern transfer hybridization for the detection of seven types of human papillomavirus (HPV) in cervical specimens from 450 consecutive females attending a sexually transmitted diseases clinic. In comparison with Southern transfer hybridization, performed with the same probes used in the dot filter kit, the sensitivity, specificity, and positive and negative predictive values of dot filter hybridization were 90%, 94%, 74%, and 98%, respectively. Among patients with cervical cytologic dysplasia, HPV DNA was detected in 44% by dot filter hybridization and in 35% by Southern transfer hybridization. Although 26% of specimens positive by dot filter hybridization were not confirmed by Southern transfer hybridization, cervical dysplasia was detected in 5 (25%) of 20 with HPV DNA detected by dot filter hybridization alone, compared with 25 (8%) of those with no definitive evidence of HPV by either method (P = 0.009) and with 16 (30%) of 53 with HPV DNA detected by both methods (P = 0.7). The kappa statistic for interobserver and intraobserver reproducibility for interpretation of blots was similar for the two methods. The dot filter hybridization method evaluated appears to be a satisfactory alternative to Southern transfer hybridization for detection of HPV DNA.

Histopathology of endocervical infection caused by Chlamydia trachomatis, herpes simplex virus, Trichomonas vaginalis, and Neisseria gonorrhoeae

We determined the histologic correlates of clinically identified mucopurulent cervicitis, culture-proven cervical infection with Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex virus (HSV), and vaginal infection with Trichomonas vaginalis by examining cervical biopsies from 83 women. Clinical mucopurulent cervicitis and culture-documented infection with one or more of these pathogens correlated histologically with intraepithelial neutrophils, reactive endocervical cells, edema, luminal neutrophils, and with several deeper tissue changes such as extensive and dense subepithelial inflammation, granulation tissue, and necrotic ulceration. Focal loss of surface columnar cells and spongiosis were also correlated with culture-confirmed infection. Well-formed germinal centers were seen in biopsies from 14 of 21 patients (67%) with C trachomatis infection alone, but in none of 17 patients with infections other than C trachomatis (P less than 0.001). A predominantly plasmacytic infiltrate was also significantly associated with chlamydial infection. Necrotic ulcers overlying a predominantly lymphocytic infiltrate were seen in six of nine patients (67%) with HSV infection alone but in only two of 40 patients (5%) with other infections (P less than 0.001). Marked inflammatory changes were not seen in the patients infected with N gonorrhoeae. The organism T vaginalis was not associated with any endocervical pathology. If these results are confirmed by prospective studies, they suggest that pathologists should alert clinicians to the possibility of recent or current infection with C trachomatis or HSV when cervical biopsies show the above changes. The loss of surface columnar epithelium with HSV, chlamydial, and gonococcal infection offers a possible explanation for the reported association of these infections with increased risk of acquiring human immunodeficiency virus infection.

The frequency of unrecognized type 2 herpes simplex virus infection among women. Implications for the control of genital herpes

To evaluate the prevalence of symptomatic versus asymptomatic or unrecognized type 2 herpes simplex virus (HSV-2) infection, the authors performed physical examination, viral cultures, and type-specific serologic assays in 776 randomly selected women attending an STD clinic and 636 female university students. Forty-six percent of women attending the STD clinic compared with 8.8% of the university students had serologic evidence of HSV-2 infection. Clinical or historical evidence of genital herpes was present in only 34% of the HSV-2 seropositive women attending the STD clinic and in 29% of the HSV-2 seropositive women attending the university clinic. Among women attending the STD clinic, the prevalence of recognized genital infection was more common among those with HSV-2 antibodies only versus those with HSV-1 and -2 antibodies (odds ratio = 2.39; 95% confidence interval = 1.30-4.37), suggesting that HSV-1 infection reduces the likelihood of recognizing HSV-2 infection. In view of the high proportion of seropositive individuals with unrecognized HSV-2 infection in both high and low prevalence HSV-2 seropositive populations, newly developed HSV type-specific serologic methods should be evaluated for detecting carriers of HSV-2 infection and counseling these individuals about strategies for avoiding sexual and perinatal transmission of HSV-2.

Endometrial histopathology in patients with culture-proved upper genital tract infection and laparoscopically diagnosed acute salpingitis

To define and quantitate histologic changes in the endometrium that best correlate with documented upper genital tract infection (UGTI) and laparoscopically diagnosed acute salpingitis, we studied endometrial biopsy specimens from 69 consecutive patients with clinically suspected acute pelvic inflammatory disease (PID) who underwent microbiological evaluation for UGTI and laparoscopic examination for acute salpingitis. Both UGTI and acute laparoscopically confirmed salpingitis were present in 37 patients (54%), UGTI without salpingitis in 1 (1%), salpingitis without UGTI in 11 (16%), and neither UGTI nor salpingitis in 20 (29%). Chlamydia trachomatis or Neisseria gonorrhoeae UGTI was found in 34 women, Escherichia coli in two patients, Peptococcus magnus in one woman, and with Streptococcus agalactiae in one woman. The following features were correlated both with UGTI and with salpingitis: presence of any neutrophils in the endometrial surface epithelium; neutrophils within gland lumens; dense subepithelial stromal lymphocytic infiltration; any stromal plasma cells; and germinal centers containing transformed lymphocytes. The simultaneous presence of five or more neutrophils per X 400 field in endometrial surface epithelium, together with one or more plasma cell per X 120 field in endometrial stroma, was the best predictor of UGTI plus salpingitis. This combination had a sensitivity of 92% and a specificity of 87% for predicting the diagnosis of both UGTI and laparoscopically confirmable acute salpingitis. Prospective studies are needed to assess the usefulness of these criteria.

Significance of mild cervical cytologic atypia in a sexually transmitted disease clinic population

While the clinical management of patients with cytologic atypia consistent with cervical intraepithelial neoplasia (CIN) is well established, the management of so-called nondyskaryotic or benign atypias is controversial. The natural history of such atypias was prospectively studied in 124 patients attending a sexually transmitted disease clinic. The benign atypias were subdivided into different categories according to the cell type involved, and the patients were followed cytologically and colposcopically without cervical biopsy until they reached one of the study end points. Benign atypias often signified the presence of CIN: 17% of the patients had a smear consistent with CIN on the first study visit, and an additional 24% had such a smear by six months of follow-up. After 30 months of follow-up, the overall cumulative rate of biopsy-confirmed CIN 2 to CIN 3 was 13.5%; it was 12.5% among those with two consecutive smears showing benign atypias. Of the ten patients who reached biopsy-confirmed CIN 2 to CIN 3, a cytologic smear consistent with CIN was obtained in less than one year of follow-up in all but one case; however, colposcopic evidence of progression was seen in only half of the ten cases, suggesting a sampling error rather than true progression in many cases. Patients with metaplastic cell atypia had a higher progression rate to biopsy-confirmed CIN 2 to CIN 3 (21%) than did those with nonmetaplastic cell atypia (3%). This study provides direct evidence of the potential significance of metaplastic atypia as a marker of CIN. We conclude that patients with mild atypia are often found to have CIN and warrant further investigation by colposcopy and biopsy.

Prevalence of genital papillomavirus infection among women attending a college student health clinic or a sexually transmitted disease clinic

We examined 454 women randomly selected from a Sexually Transmitted Disease (STD) Clinic and 545 consecutive college women undergoing annual examination. Patients were examined for visible genital warts, koilocytes, and human papillomavirus (HPV) antigen on cervical smears and for cervical HPV DNA types 6, 11, 16, 18, and 31. Genital warts were found in 11% of STD Clinic patients and 2% of students (P less than .001). Among those women without genital warts, HPV DNA or antigen was detected in cervical specimens from 10.6% of STD Clinic patients and 11.4% of students (P = .73), with HPV type 16, 18, or 31 being 9.8 times more frequent than cervical HPV 6 or 11 among students and 5.8 times more frequent among STD Clinic patients. Dysplasia was present in 53% of those with HPV type 6 or 11 and in 41% of those with HPV type 16, 18, or 31 DNA.

Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment

STUDY OBJECTIVES

To determine the prevalence of Treponema pallidum in cerebrospinal fluid (CSF) of patients with syphilis, to determine the effect of concurrent HIV infection on central nervous system involvement by T. pallidum, and to examine the efficacy of conventional therapy for asymptomatic neurologic involvement.

PATIENTS

Fifty-eight patients with untreated syphilis who consented to lumbar puncture, representing approximately 10% of new cases of syphilis during the study period.

INTERVENTIONS

Lumbar puncture was done on all patients. Rabbit inoculation was used to test cerebrospinal fluid for viable T. pallidum. Patients with normal fluid received recommended benzathine penicillin therapy according to the stage of syphilis; patients with CSF abnormalities were offered 10-day therapy for neurosyphilis.

RESULTS

Treponema pallidum was isolated from the CSF of 12 (30%) of 40 patients (95% CI, 17 to 46) with untreated primary and secondary syphilis; isolation of T. pallidum was significantly associated (P = 0.008) with the presence of two or more abnormal laboratory variables (among leukocyte count, protein concentration, and CSF-Venereal Disease Research Laboratory [VDRL] test). Two (67%) of 3 early latent (CI, 13 to 100) and 3 (20%) of 15 late latent syphilis patients (CI, 5 to 47) also had reactive CSF-VDRL tests and elevated cell and protein levels, although T. pallidum was not isolated. Concurrent infection with the human immunodeficiency virus (HIV) was not associated with isolation of T. pallidum, increased number of CSF abnormalities, or reactive CSF serologic tests for syphilis, although CSF pleocytosis was commoner in subjects infected with HIV. Treatment with conventional benzathine penicillin G (2.4 mIU) failed to cure 3 of 4 patients with secondary syphilis from whom T. pallidum was isolated before therapy; all 3 patients in whom treatment failed were HIV seropositive when treated or seroconverted during follow-up.

CONCLUSIONS

Central nervous system invasion by T. pallidum is common in early syphilis, and is apparently independent of HIV infection. Examination of the CSF may be beneficial in patients with early syphilis, and therapy should be guided by knowledge of central nervous system involvement. Conventional benzathine penicillin G therapy may have reduced efficacy in patients with early syphilis who are also infected with HIV.

Colposcopic manifestations of cervical and vaginal infections

We analyzed the associations of colposcopic features with cervical and vaginal pathogens and with clinical diagnoses in randomly selected women attending a clinic for sexually transmitted diseases. Logistic regression models were used to adjust for coinfections. Significant associations (P less than 0.01) were found for endocervical mucopus with C. trachomatis, N. gonorrhoeae, and herpes simplex virus (HSV); ulcers/necrotic areas with HSV; "strawberry cervix" with T. vaginalis; increased surface vascularity with HSV; hypertropic cervicitis with C. trachomatis; and immature metaplasia with C. trachomatis and cytomegalovirus. Koilocytosis on cervical cytology was significantly associated with an atypical transformation zone on colposcopy, as well as with satellite lesions. The presence of leukoplakia and ectocervical asperities were also associated with koilocytosis. Awareness of these associations is important for colposcopists to identify patients who need specific microbiologic studies. Although colposcopy is generally used to evaluate patients selected because of abnormal cytology, our study suggests that colposcopic examination could be a useful adjunct to cytology in screening for a variety of cervical and vaginal infections.

Genital ulceration as a risk factor for human immunodeficiency virus infection

Among 115 heterosexual men who presented with genital ulcers to a sexually transmitted disease clinic in Nairobi, Kenya, the prevalence of serum antibody to HIV was 16.5%. A past history of genital ulcers was reported by 12 (63%) of 19 men with antibody to HIV versus 30 (31%) of 96 without antibody (P = 0.008). HIV infection was also positively associated with lack of circumcision, but was not associated with the etiology of the current genital ulcer. Logistic regression analysis (adjusted for age, number of recent sex partners, recent prostitute contact, circumcision, tribal ethnic identity, past history of urethritis, and current diagnoses) confirmed only the association between prior history of genital ulcer disease and HIV infection; (P = 0.04, odds ratio 2.35, 95% confidence limits, 1.01-5.47). The incidence of genital ulcers, particularly chancroid, is much higher in parts of Africa than in Europe or North America. This may contribute to the increased risk of heterosexual transmission of HIV in Africa. Aggressive control of chancroid and syphilis may offer one very feasible approach to reducing transmission of HIV in this region.

Effects on infants of a first episode of genital herpes during pregnancy

Although genital herpes simplex virus (HSV) infections occurring during pregnancy are known to be associated with neonatal and maternal complications, their frequency and contributing risk factors are not well understood. We prospectively followed 29 patients who acquired genital herpes during pregnancy, to evaluate the perinatal effects of the infection. The patients were classified on the basis of clinical or serologic criteria. Fifteen patients had a primary first episode of genital HSV Type 2 (HSV-2), and 14 had a nonprimary first episode. Although no patient had disseminated disease, 6 of the 15 with primary genital herpes but none of 14 with nonprimary first-episode infection had infants with serious perinatal morbidity (P less than 0.01). Four of the five infants whose mothers acquired primary HSV-2 in the third trimester had perinatal morbidity such as prematurity, intrauterine growth retardation, and neonatal infection with HSV-2. Perinatal complications occurred in one of five infants whose mothers acquired primary HSV-2 during the first trimester, as well as in one of five infants whose mothers had primary HSV-2 during the second trimester. Asymptomatic cervical shedding of HSV-2 was detected at 10.6 percent of weekly visits made after a primary first episode, as compared with 0.5 percent of visits after a nonprimary first episode (P less than 0.01). We conclude that infants born to women who acquire primary genital herpes during pregnancy are at high risk of exposure to HSV, either during premature labor at the time of the primary episode or subsequently because of asymptomatic cervical shedding of the virus. The 40 percent incidence of serious perinatal morbidity in such women suggests that studies of preventive measures such as the use of antiviral chemotherapy are warranted.

Etiology of cervical inflammation

We studied the relationships of selected microbial, clinical, demographic, and behavioral variables to mucopurulent cervicitis in two clinical settings, a sexually transmitted disease clinic and a student health clinic. From each clinic, we studied a group of women referred for suspected mucopurulent cervicitis and a representative sample of other women attending the clinic. After the women were stratified by patient group and summary odds ratios for all groups were obtained, mucopurulent cervicitis was most strongly associated with the isolation of Chlamydia trachomatis; other variables associated with mucopurulent cervicitis included the isolation of Ureaplasma urealyticum, Gardnerella vaginalis, and Trichomonas vaginalis, the presence of serum antibody to C. trachomatis, the clinical diagnosis of bacterial vaginosis, and oral contraceptive use (positive associations) or isolation of yeast (negative association). After adjustment for cervical culture results for C. trachomatis, mucopurulent cervicitis was positively associated with oral contraceptive use (p = 0.02) and isolation of U. urealyticum (p = 0.02) and negatively associated with isolation of yeast (p = 0.03). Among women with a positive cervical culture for C. trachomatis, isolation of U. urealyticum was significantly associated with mucopurulent cervicitis, while among the subgroup of women with a negative cervical culture for C. trachomatis and positive serum antibody to C. trachomatis, oral contraceptive use was strongly associated with mucopurulent cervicitis. These results confirm that in both clinical settings C. trachomatis is the major cause of mucopurulent cervicitis. The roles of U. urealyticum, T. vaginalis, G. vaginalis, bacterial vaginosis, and oral contraceptive use in the etiology of mucopurulent cervicitis deserve further study.

Genital herpes in pregnancy: risk factors associated with recurrences and asymptomatic viral shedding

One hundred forty-seven women with recurrent symptomatic genital herpes simplex virus acquired prior to the start of pregnancy (group 1) and 15 women whose first symptomatic episode of genital herpes was acquired during pregnancy (group 2) were followed weekly during the course of gestation. Among women with recurrent genital herpes antedating pregnancy, the mean number of recurrences per trimester increased from 0.97 to 1.26 to 1.63 in the first through third trimester, respectively (p less than 0.05 for comparison between each trimester). The median number of symptomatic recurrences of genital herpes during gestation was four in women in group 1 compared to one in women in group 2 (p less than 0.01). Asymptomatic viral excretion from the genital tract was, however, more common in women in group 2 (33%) than in women in group 1 (12.9%) (p less than 0.05). Herpes simplex virus was isolated at 5.5% of routine visits in group 2 women compared to 1% of routine visits among group 1 women. Logistic regression analysis indicated young age also was associated with more frequent asymptomatic viral shedding. Asymptomatic herpes simplex virus excretion was more common from the vulvar area than the cervix, and women in group 2 were more likely to shed virus from both sites simultaneously than women in group 1. Age and recent acquisition of genital herpes are risk factors for asymptomatic excretion of herpes simplex virus during pregnancy.

Sexually transmitted diseases in females in a juvenile detention center

Of 37 female adolescent prostitutes and 63 other females held in the King County, Washington, juvenile detention facility, 81 (81%) complained of vaginal discharge, and only eight (8%) had no genitourinary symptoms. The prevalence of genital infections among prostitutes and nonprostitutes was similar. Neisseria gonorrhoeae was found in 18 (18%) of 98 detainees tested, and Chlamydia trachomatis was found in 17 (20%) of 86 detainees tested; either organism was found in 27 (32%) of 85 tested for both organisms. Also, 38 (48%) of 80 tested had trichomoniasis. No detainees had syphilis. Sixty-seven (68%) of 98 responding detainees used no contraception. Such populations deserve the attention of public programs for control of sexually transmitted diseases and for family planning.

Cytologic manifestations of cervical and vaginal infections. I. Epithelial and inflammatory cellular changes

We used multiple logistic regression to analyze microbiological and clinical correlates of inflammatory and epithelial cell changes on Papanicolaou-stained cervical smears in patients from a sexually transmitted disease clinic. Among randomly selected patients, increased numbers of histiocytes and polymorphonuclear leukocytes and the presence of transformed lymphocytes were associated with Chlamydia trachomatis infection, while increased lymphocytes were associated with Trichomonas vaginalis infection; minimal squamous atypia was associated with yeast infection; and moderate squamous atypia and koilocytosis were associated with cervical condylomata visualized by colposcopy. Among patients referred for cervicitis, C trachomatis infection was also associated with reactive or atypical metaplastic cells. Distinct inclusions were seen by Papanicolaou smear in only 22% of C trachomatis infections. In randomly selected patients, however, the presence of transformed lymphocytes or increased histiocytes had a sensitivity of 95%, a specificity of 75%, and a positive predictive value of 50% in relation to isolation of C trachomatis, and could therefore be used for selection of patients for confirmatory testing for C trachomatis infection.