Pharmacological blockage of the CXCR4-CXCL12 axis in endometriosis leads to contrasting effects in proliferation, migration, and invasion

High levels of inflammatory factors including chemokines have been reported in peritoneal fluid and blood of women with endometriosis. CXCL12 mediates its action by interaction with its specific receptor, CXCR4, reported to be elevated in human endometriosis lesions and in the rat model of endometriosis. Activation of the CXCR4-CXCL12 axis increases cell proliferation, migration, and invasion of cancer cells. To obtain insights into the CXCR4 expression profile in lesions and endometrium, as well as functionality of the CXCR4-CXCL12 axis in endometriosis, we analyzed the expression of CXCR4 in tissues on a human tissue array and studied CXCL12-mediated activation of proliferation, invasion, and migration in vitro. We observed differences in levels of nuclear CXCR4 expression among lesion types, being higher in ovarian lesions. Endometriotic cell lines (12Z) showed higher levels of CXCR4, proliferative and migratory potential, and AKT phosphorylation/kinase activity compared to untreated control cells (endometrial epithelial cells). CXCL12 and endometriotic stromal cell-enriched media increased proliferation of non-endometriotic epithelial cells. CXCL12 caused a significant increase in 12Z cell invasion but had no effect on migration; AMD3100, a CXCR4-specific inhibitor, significantly increased invasion of 12Z cells but decreased their migration. However, treatment with CXCL12 plus AMD3100 significantly decreased invasion and migration of 12Z cells. In conclusion, the CXCR4-CXCL12 axis is functional in endometriosis cells, but the expression of CXCR4 varies among lesions. CXCL12 promoted proliferation, migration, and invasion of endometriotic cells, while inducing AKT phosphorylation and activity, but pharmacologically blocking this axis in the absence of the ligand induced their invasiveness.

Stress During Development of Experimental Endometriosis Influences Nerve Growth and Disease Progression

PURPOSE

We have previously shown that stress prior to induction worsens clinical presentation and inflammatory parameters in a rat model of endometriosis. This study was designed to examine whether stress during the development of endometriosis can affect the growth of endometriotic implants through nerve growth and immune alterations.

METHODS

Endometriosis was surgically induced in female Sprague-Dawley rats by suturing uterine horn implants onto the small intestine mesentery. Two weeks later, one group of rats (endo-stress) was subjected to a 10-day swim stress protocol. Controls had no stress (endo-no stress) or sutures only and stress (sham-stress). On day 60, all rats were killed and examined for the presence of endometriotic vesicles. The size of each vesicle was measured. The uterus and colon were removed and assessed for damage, cell infiltration, and expression of nerve growth factor (NGF), its receptors (p75 and Tropomyosin receptor kinase A (Trk-A)/pTrk-A), and calcitonin gene-related peptide, a sensory fiber marker. A differential analysis of peritoneal fluid white blood cell count was performed.

RESULTS

Stress significantly increased endometriotic vesicle size but not colonic damage and increased infiltration of mast cells. Significantly increased expression of NGF and its receptors was found in the uterus of animals with endometriosis receiving stress.

CONCLUSIONS

Stress stimulates the development of ectopic endometrial vesicles in an animal model of endometriosis and increases inflammatory cell recruitment to the peritoneum. In addition, stress promotes nerve fiber growth in the uterus.

Abstract 3851: Low educational level is associated with a reduced DNA repair capacity and higher risk of breast cancer

BACKGROUND: Breast Cancer (BC) is the leading cause of cancer deaths among females in Puerto Rico. Educational level is well established as a modifier of cancer risk. We have undertaken a large population study and have shown that a low DNA Repair Capacity (DRC) is an important risk factor for BC. It is well established that DRC is regulated by genetic, epigenetic and environmental factors. We have investigated the relationship between educational level and DRC.

The purpose of this study was to evaluate the role of educational level as a modifier of the association between DRC and risk of BC in Puerto Rican women. METHODS: A total of 488 women with histopathologically confirmed BC and 607 controls were selected for the analysis. DRC was measured in lymphocytes using a host cell reactivation assay. Pathology reports were used to obtain tumor size. DRC levels were divided into low, medium and high using tertiles. Multiple logistic regression was used to assess the association among educational level and BC risk factors adjusted by DRC. For the analysis of tumor size and DRC, educational levels were divided into primary education, high school, and associate or more. Analysis of variance was performed using the Kruskal-Wallis test. RESULTS: Women with lower educational level (elementary education) had significantly higher risk of BC (OR: 5.9, 95%CI: 2.3, 14.9) followed by high school (OR: 1.4, 95%CI: 1.1, 2.1) and associate degree (OR: 1.4, 95%CI: 0.9, 2.2) using bachelor's degree as a referent. Women with low education had 8.9 times the odds of having low DRC (95%CI: 5.2, 15.2), while women with high educational level had 11.7 times the odds for a low DRC (95%CI: 7.7, 17.7). The association and tumor size (cm) and educational level showed that as educational level increased, women had smaller tumor sizes (Kruskal-Wallis test p = 0.031). CONCLUSIONS: This study showed that women with the lowest levels of education, in general, had a lower DRC and significantly higher risk of BC and of having larger breast tumors when compared to controls. This study provides new insights as to how educational level can influence BC risk. This association is controversial because some studies attribute a high educational level to high risk of BC while others present the opposite. Because our study uses a biological variable (DNA repair) to measure risk, it reduces ambiguity in terms of the criterion to estimate risk. Those with the highest levels of education had smaller tumors; therefore consequently better chances for early treatment and increased chances of survival. Because education is a modifiable lifestyle factor, this study provides data that can be utilized to identify women with a higher risk of developing BC in order to design more effective BC screening, and diagnosing BC an earlier stage. Supported by grants from the NCI Diversity Training Branch through the NIH-MBRS Program grants S06 GM008239-20, 9SC1CA182846-04 to PSMHS through JM and MBRS-RISE GM082406 through CO.

Citation Format: Luisa Morales, Manuel Bayona, Carmen Ortiz, Damian Adams, Carolina Alvarez-Garriga, Jaime L. Matta. Low educational level is associated with a reduced DNA repair capacity and higher risk of breast cancer. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 3851. doi:10.1158/1538-7445.AM2015-3851

Stress management affects outcomes in the pathophysiology of an endometriosis model

We have previously shown detrimental effects of stress in an animal model of endometriosis. We now investigated whether the ability to control stress can affect disease parameters. Endometriosis was surgically induced in female Sprague-Dawley rats before exposing animals to a controllable (submerged platform) or uncontrollable (no platform) swim stress protocol. Corticosterone levels and fecal pellet numbers were measured as an indicator of stress. Uncontrollable stress increased the number and size of the endometriotic cysts. Rats receiving uncontrollable stress had higher anxiety than those exposed to controllable stress or no stress and higher corticosterone levels. Uncontrollable stressed rats had more colonic damage and uterine cell infiltration compared to no stress, while controllable stress rats showed less of an effect. Uncontrollable stress also increased both colonic and uterine motility. In summary, the level of stress controllability appears to modulate the behavior and pathophysiology of endometriosis and offers evidence for evaluating therapeutic interventions.

Abstract 2394: The role of DNA repair in breast cancer risk and recurrence

BACKGROUND: Breast cancer (BC) is a complex disease that is caused by multiple factors. Deficits in DNA repair capacity (DRC) are known to cause certain familial BC, and dysregulation of DRC develops with progressive carcinogenesis. However, the effect of DRC on carcinogenesis of sporadic breast tumors has not been well characterized_and the factors associated with DRC variability are still poorly understood. DNA repair is integral to maintain genomic integrity, and carcinogenesis occurs when efficient, effective DNA repair is impaired. Our laboratory has just finished the recruitment of nearly 1,200 women in a seven-year molecular epidemiology study focused on the role of DRC as a risk factor for BC. OBJECTIVE: Our aim is to present key findings on the role of DRC as a risk factor for BC and its potential association with BC recurrence. METHODS: A personal interview was conducted for soliciting information on BC risk factors. Among the 493 BC cases and 683 controls the DRC was measured in lymphocytes using a host cell reactivation assay with a luciferase reporter gene. We stratified the women with BC using the median of the DRC level and selected 70 women with a low DRC level (<2.8%) who had been enrolled in the study for at least 5 years in order to assess the BC recurrence. RESULTS: Our 7 year study of DRC of female cohorts in Puerto Rico has shown that women with BC have a

DRC that, on average, is 51% lower than women without BC (P < 0.001, Mann Whitney U-test). Women with low DRC have 6.8 (95%CI 5.2, 9.0) times the odds for BC when compared with women with high DRC level. So far, the overall BC recurrence was 17% and the 5-year mortality was 10%. Recurrence was primarily in the lung, liver, bone, or occurred as generalized metastatic disease. CONCLUSIONS: Using a large sample size (n=1,183 participants), we show that women with BC had on an average a 51% lower DRC than controls (P<0.001). We also present the first data on the potential between a low DRC and risk of BC recurrence. With a larger sample size, we will test the hypothesis that low DRC can predict risk of BC recurrence. Supported by grants from the NCI Center to Reduce Health Disparities through the NIH-MBRS Program grants S06 GM008239-20, 9SC1CA182846-04 to PSMHS through JM and MBRS-RISE GM082406 through CO.

Citation Format: Jaime L. Matta, Erick Suarez, Wanda Vargas, Carmen Ortiz, Manuel Bayona, Luisa Morales. The role of DNA repair in breast cancer risk and recurrence. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 2394. doi:10.1158/1538-7445.AM2014-2394

Differential promoter methylation of kinesin family member 1a in plasma is associated with breast cancer and DNA repair capacity

Methylation alterations of CpG islands, CpG island shores and first exons are key events in the formation and progression of human cancer, and an increasing number of differentially methylated regions and genes have been identified in breast cancer. Recent studies of the breast cancer methylome using deep sequencing and microarray platforms are providing a novel insight on the different roles aberrant methylation plays in molecular subtypes of breast cancer. Accumulating evidence from a subset of studies suggests that promoter methylation of tumor-suppressor genes associated with breast cancer can be quantified in circulating DNA. However, there is a paucity of studies that examine the combined presence of genetic and epigenetic alterations associated with breast cancer using blood-based assays. Dysregulation of DNA repair capacity (DRC) is a genetic risk factor for breast cancer that has been measured in lymphocytes. We isolated plasma DNA from 340 participants in a breast cancer case control project to study promoter methylation levels of five genes previously shown to be associated with breast cancer in frozen tissue and in cell line DNA: MAL, KIF1A, FKBP4, VGF and OGDHL. Methylation of at least one gene was found in 49% of the cases compared to 20% of the controls. Three of the four genes had receiver characteristic operator curve values of ≥0.50: MAL (0.64), KIF1A (0.51) and OGDHL (0.53). KIF1A promoter methylation was associated with breast cancer and inversely associated with DRC. This is the first evidence of a significant association between genetic and epigenetic alterations in breast cancer using blood-based tests. The potential diagnostic utility of these biomarkers and their relevance for breast cancer risk prediction should be examined in larger cohorts.

Factors associated with breast cancer in Puerto Rican women

BACKGROUND

Breast cancer (BC) is the most common cancer afflicting Puerto Rican women and accounts for more cancer-related deaths in this population than any other cancer.

METHODS

Demographic, anthropometric, family history, and lifestyle data, as well as DNA repair capacity (DRC), were compared in 465 BC cases and 661 controls. Crude and multiple logistic regression-derived adjusted odds ratios were used as indicators of the associations between BC and the variables under study.

RESULTS

A low DRC level, aging (>61years), family history of BC, and low education level had statistically significant associations with increased BC risk. Endometriosis, full-term pregnancy at an earlier age, higher parity, hysterectomy before age 50, multivitamin and calcium intake, and longer duration of breastfeeding significantly decreased BC risk.

CONCLUSIONS

This study discusses the major risk factors for BC in Puerto Rico (PR). Because many of these findings represent modifiable risk factors, they can translate into public health initiatives to lower BC risk. In addition, the possibility of using DRC as a simple screening tool for BC risk is explored.

THE CONSUMPTION OF RED PUPUNHA (BACTRIS GASIPAES KUNTH) INCREASES HDL CHOLESTEROL AND REDUCES WEIGHT GAIN OF LACTATING AND POST-LACTATING WISTAR RATS

INTRODUCTION

The lactating and post-lactating periods are marked by large metabolic change. Production of milk is 60% lipid dependent. We reported in a recent scientific meeting that Red pupunha palm tree fruit increases HDL cholesterol in lactating rats. This study evaluated if consumption of Red Pupunha by adult female rats has a beneficial impact on the lipid metabolism of lacting and post-lacting adult rats.

OBJECTIVE

Evaluate if consumption of red pupunha has a beneficial effect in the lipid metabolism of lacting and post-lacting adult Wistar rats.

RESEARCH METHODS

Four groups including two for control; (1) control adult lactating rats, (2) control adults post-lactating rats; and two experimental groups; (3) pupunha adults lactating rats and (4) pupunha adult post-lactating rats were evaluated and compared regarding: weight gain, food consumption, plasma total protein, glucose, total lipid, triglycerides, total cholesterol and HDL-cholesterol levels. The mean difference and its 95% confidence intervals were used for group comparisons. Group comparisons were evaluated by using analysis of variance (one-way ANOVA). The statistical significance of the pairwise differences among groups was assessed by using the two-sided Tukey test.

RESULTS

There were no important differences in food consumption, plasma glucose, total lipids and triglycerides among groups. The red pupunha lactating group gain less weight showing lower body mass index (BMI) than controls (p < 0.05). Total cholesterol was lower in red pupunha lactating than in controls but not in the red pupunha post-lactating group as compared to controls. Triglycerides were lower in the post-lactating red pupunha group as compared to the control group (p = 0.039) but not for the lactating groups. Red pupunha lactating and post-lactating groups had higher HDL-cholesterol than their corresponding control groups (p ≤ 0.01).

CONCLUSION

Original findings include the beneficial effect of red pupunha in post-lactating rats increasing the HDL-cholesterol and lowering the BMI. Red pupunha was confirmed to increase HDL-cholesterol in lactating rats. These results suggest that red pupunha is a healthy fruit to be consumed during lactating and post-lactating periods as it is related to better lipid profile and less body weight gain.

Breast Cancer and DNA Repair Capacity: Association With Use of Multivitamin and Calcium Supplements

CONTEXT

Breast cancer (BC) is the most common cancer in women, with over 1 million new cases diagnosed every year worldwide. Over recent decades, considerable interest has emerged regarding whether vitamins and/or other supplements can lower the risk of BC. However, previous epidemiologic studies that investigated the association between intake of multivitamin and supplements of single vitamins and minerals and BC risk have reported conflicting results. Whether vitamins can actually reduce BC risk is still controversial.

OBJECTIVE

This study examined whether multivitamin and calcium use was associated with BC incidence and DNA repair capacity (DRC).

DESIGN

The research team designed an observational, case-control study.

SETTING

All work was performed at the Ponce School of Medicine and Health Sciences under the direct supervision of principal investigator Dr Jaime Matta.

PARTICIPANTS

Participants were 836 women recruited primarily from the private practices of oncologists, gynecologists, and surgeons in Puerto Rico.

INTERVENTIONS

A total of 312 individuals in the breast cancer (BC) group and 524 individuals in the control group were compared for their multivitamin and calcium intake, DRC levels, and other covariates.

OUTCOME MEASURES

Odds ratios (OR), adjusted using both crude analysis and multiple logistic regression, were used as measures of association between BC and DRC and other selected variables.

RESULTS

The BC group had 30% reduced odds of taking multivitamins and calcium as compared to controls: (1) OR = 0.7 (95% CI, 0.4-1.0; P = .073) for multivitamins and (2) OR = 0.7 (95% CI, 0.4-1.2; P = .167) for calcium. Women with low DRC had 50% lower odds of taking calcium and 30% lower odds of currently taking vitamins OR = 0.5 (95% CI, 0.4-0.7; P = .001) for calcium and (2) OR = 0.7 (95% CI, 0.5-0.9.1; P = .047) for vitamins.

CONCLUSIONS

Although this study is a case-control study in which the risk of BC could not be assessed, results suggest that vitamin supplementation could be an independent protective factor for BC. Calcium intake appears to affect DRC in a positive way, because it was associated with a high DRC level, which in turn is associated with low odds for BC.

The association of DNA Repair with breast cancer risk in women. A comparative observational study

Background

Previous studies have found a link between a low DNA repair capacity (DRC) level and increased cancer risk. Our aim was to assess the statistical association of DRC level and breast cancer (BC) using a case–control epidemiological study in a Hispanic community.

Methods

We conducted a comparative observational study to assess the validity of DRC in detecting BC in 824 women throughout Puerto Rico. Over a 6-year period, we compared 285 women newly diagnosed with BC to 539 without BC. DRC levels were measured in lymphocytes by means of a host-cell reactivation assay. We assessed the sensitivity, specificity, and association using the receiver operating characteristic curve analysis. Multiple logistic regression-adjusted odds ratios were estimated with 95% confidence level to measure the strength of the association of DRC and BC after adjusting for all confounders simultaneously.

Results

Compared to women without cancer, women with BC showed an average decrease of 60% in their DRC levels (p < 0.001). Validity of the association of DRC as a measure of BC risk showed a sensitivity of 83.2% and specificity of 77.6% (p < 0.0001).

Conclusions

Our results support the usefulness of DRC level as a measure of BC risk. Additional studies in other populations are needed to further verify its usefulness.

HDAC1 and HDAC2 are differentially expressed in endometriosis

Epigenetic mechanisms have been ascribed important roles in endometriosis. Covalent histone modifications at lysine residues have been shown to regulate gene expression and thus contribute to pathological states in many diseases. In endometriosis, histone deacetylase inhibition (HDACi) resulted in reactivation of E-cadherin, attenuation of invasion, decreased proliferation of endometriotic cells, and caused lesion regression in an animal model. This study was conducted to assess basal and hormone-regulated gene expression levels of HDAC1 and HDAC2 (HDAC1/2) in cell lines and protein expression levels in tissues. Basal and steroid hormone-regulated HDAC1/2 gene expression levels were determined by quantitative polymerase chain reaction in cell lines and tissues. Protein levels were measured by immunohistochemistry (IHC) in tissues on an endometriosis tissue microarray (TMA). Basal HDAC1/2 gene expression levels were significantly higher in endometriotic versus endometrial stromal cells, which was confirmed by Western blot analysis. Estradiol (E2) and progesterone (P4) significantly downregulated HDAC1 expression in endometrial epithelial cells. Levels of HDAC2 were upregulated by E2 and downregulated by E2 + P4 in endometrial stromal cells. Hormone modulation of HDAC1/2 gene expression was lost in the endometriotic cell line. Immunohistochemistry showed that HDAC1/2 proteins were expressed in a substantial proportion of lesions and endometrium from patients, and their expression levels varied according to lesion localization. The highest proportion of strong HDAC1 immunostaining was seen in ovarian, skin, and gastrointestinal lesions, and of HDAC2 in skin lesions and endometrium from patients with endometriosis. These studies suggest that endometriosis etiology may be partially explained by epigenetic regulation of gene expression due to dysregulations in the expression of HDACs.

Abstract A90: Nonmelanoma skin cancer epidemiology and DNA repair in Puerto Ricans

Introduction: Nonmelanoma skin cancers (NMSC) including basal cell and squamous cell carcinomas are the most common human cancers. DNA damage can be caused by exposure to solar UV light and other types of radiation, dietary factors, and ageing. The relationship between DNA damage and oncogenesis suggests that diminished DNA repair capacity (DRC) is involved in tumorigenesis.

Purpose: The purpose of this study was to identify and assess selected exposures and DRC as predictors for NMSC in Puerto Rico.

Methods: An incident-cases case-control study was conducted. A total of 477 NMSC cases and 365 controls were compared regarding DRC levels and other selected factors. Participants with low and high DRC levels were also compared regarding the same factors as in NMSC. DRC was measured using a host-cell reactivation assay with a luciferase reporter gene irradiated with UV light and transfected into human peripheral lymphocytes from participant's blood samples. A standardized epidemiological questionnaire was used to collect data from the participants. The crude and multiple logistic regression adjusted odds ratio was used to assess the associations between NMSC or DRC levels with selected factors after adjusting for age, gender, skin, hair, and eye color, and other potential confounders simultaneously.

Results: Exposures increasing the odds for NMSC were being male, aging, light skin, presence of freckles, light hair, light eye color, increased sun exposure, severe insolations, family history of NMSC, and low DRC (p &lt; 0.05). Protective factors found in the study included using sun block, taking aspirin regularly, and multivitamin supplements intake (p &lt; 0.05). Factors associated with low DRC level were aging, light skin, sun exposure, severe insolations and not using sun block regularly.

Discussion: The present study identified major epidemiologic factors for NMSC in Puerto Rico that are consistent with similar investigations elsewhere. Low DRC was strongly associated with NMSC (Matta et al, 2003). New unpublished data include the finding of the protective effect of multivitamin supplementation. Light skin, increased sun exposure, severe insolations and not using sun block regularly were associated with low DRC.

Conclusions: The protective effect of multivitamins deserves further consideration to confirm our findings. Persons with light skin, increased sun exposure and not using sun block regularly had low DRC levels and increased odds for NMSC. DRC measurements might be used to monitor the potential preventive impact of multivitamins and sun block when used as preventive therapy.

Citation Information: Cancer Epidemiol Biomarkers Prev 2010;19(10 Suppl):A90.

Abstract 976: Consumption of vitamins and calcium reduces breast cancer risk by their regulation of the DNA repair capacity

Background- Breast cancer (BC) is the most common cancer in women with over one million new cases diagnosed annually worldwide. The capacity of the DNA to repair itself (DRC) is a complex biological process involving over 200 proteins. This process involves at least five pathways and is critical in maintaining genomic stability. The objective of this study was to examine the association of DRC and BC risk in terms of consumption of vitamin and calcium supplements by means of a large scale case-control study.

Methods.- This was an incident-case case-control study design involving Puerto Rican women. The selection of potential predictors under study was based on previous published research in BC including information on vitamins, calcium, and variables that could provide an estimate of BC risk including age, BMI, family history, gynecological history, hormonal and environmental factors. The host reactivation assay with a luciferase reporter gene was used to measure the DRC in the lymphocytes from all participants. Cases were compared to controls, regarding diet supplement intake, DRC, and other selected covariates. The crude and multiple logistic regression adjusted Odds Ratio (OR) were used as measures of association and the 95% confidence interval of the OR was utilized to asses the precision of this estimate.

Results.- A total of 268 breast cancer cases and 457 controls were included in this analysis. Statistically significant associations were found between BC and ageing, low DRC levels, family history of BC, and no breastfeeding. Vitamins and calcium intake were found to be protective reducing 30% and 40% the odds of having BC respectively. Calcium reduced considerably its protective effect becoming negligibly and not statistically significant when DRC was included in the logistic regression model. This suggests that DRC explains this association. In contrast, vitamin's intake did not show an important change in the association with BC when adjusting for DRC. Calcium and vitamins’ intake were strongly associated with higher levels of DRC.

Discussion.- Vitamins and calcium intake are protective for breast cancer and are associated with higher DRC levels. Vitamins’ intake is an independent protective factor for BC while the protective effect of calcium may be explained by an increased DRC. DRC can be used to monitor the protective effect of calcium in terms of breast cancer risk. This study is supported by grants from the NCI Center to Reduce Health Disparities and NIH-MBRS Program grant #: S06 GM008239-23.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 976.

Single lesion as an indicator to monitor the leprosy trend to elimination in hyperendemic areas

INTRODUCTION: Prevalence and detection rates of leprosy are not sufficient to show the real magnitude of changes in epidemiological patterns. OBJECTIVES: Evaluate the feasibility and usefulness of the proportion of new leprosy patients with a single skin lesion (SSL) as a potential indicator of the elimination of leprosy. METHODS: We conducted a retrospective study based on secondary data analyzing newly reported cases of leprosy between 1997 and 2002, in the city of Palmas, Tocantins, Brazil. Patients with a single lesion were compared to remaining patients, and the odds ratio was used as measure of association. RESULTS: Out of the 1,303 new cases of leprosy, 481 (36.9%) had a SSL. An increasing time-trend was observed in the proportion of new cases detected with a single lesion, which grew from 20.3% in 1999 to 49.1% in 2002 (linear trend p<.001) while a reduction in the number of new cases was observed simultaneously after 1999. The proportion of patients with a single lesion was higher in women, young age, paucibacillary, tuberculoid and indeterminate clinical forms, residents of urban areas, those with negative baciloscopy, with macular lesions, without physical disabilities, and mainly detected in primary health care units. CONCLUSIONS: These findings confirm that the proportion of patients with a SSL can be used as a sensitive and feasible indicator to assess the progress of the elimination of leprosy in hyperendemic areas.

Risk factors for atopic dermatitis in southern Puerto Rico

BACKGROUND

Little is known about the risk factors and exposures to aeroallergens in subjects with atopic dermatitis (AD) in Southern Puerto Rico. The objective was to determine the prevalence of skin reactions to aeroallergens and to analyze self-reported risk factors in AD patients and a nonallergic control population.

METHODS

A cross-sectional study was conducted which included 726 AD patients and 313 nonallergic control subjects. Skin tests were conducted and a questionnaire was self-applied to all participants.

RESULTS

Seventy six percent of the AD patients showed at least one positive skin reactions to aeroallergens. Of these, half had positive skin reactions to dust mites, and one third to Periplaneta americana. A low prevalence of positive skin reactions to dog, cat, plant and fungal allergens was detected. Co-sensitivitity between mites and cockroaches was 30%. The maximum skin reactivity to mites was at 10-19 years of age declining thereafter while skin reactivity to dogs, and plants increased with age. No significant differences in the prevalence of skin reactions was observed between the male and female AD population. CONCLUSIONS. Of the aeroallergens tested, those derived from dust mites are the most frequent sensitizing agents in the AD patients. Data also showed that the mites B. tropicalis and E. maynei are also important sources of sensitization. Our study show that young patients specially those between the age of 10-19 age group are the most allergic. Being female, or having an asthmatic father are significant risk factors associated with allergen sensitivity in the AD population.

Transmission of Hansen's disease and unscreened household contacts

INTRODUCTION

Leprosy household contact investigation has been recommended as an epidemiological surveillance strategy for more than 50 years.

OBJECTIVE

The purpose of this study was to estimate the yield that could be achieved in case detection if four contacts could be examined for every case found.

METHODS

For the estimation of the number of cases not detected (lost) and yield per contact investigation in Mato Grosso, the incidence rates and yield calculations from a cohort study conducted in Rio de Janeiro by Matos et al (1999) were applied to data from the state of Mato Grosso. Also, to identify high-risk groups for leprosy, a cross-sectional study was conducted in which leprosy cases found as a result of a contact investigation were compared with index cases detected by other means.

RESULTS

The lost cases among household contacts were at least 4 per every 10 new cases detected. This is the result of insufficient contact investigations--it being 0.8 instead of 4 contact investigations per each case as recommended by the Brazilian Ministry of Health. Up to 60% of the incidence of leprosy could be explained by the high number of lost cases among household contacts not examined. Women and children are more likely to be contacts.

CONCLUSION

The lost cases due to insufficient contact investigation represent lost opportunities in early detection and treatment, thus losing the opportunity to reduce leprosy transmission.

Alfa 1 antitrypsin and protease levels in Puerto Rican asthmatics: a pilot study

A cross-sectional pilot study was conducted on a population of 119 asthmatics who had been recruited from the Emergency Room Department of a major hospital in Ponce, Puerto Rico. The purpose of the study was to determine the frequency of the MM, MS, and SS a-i-antiprotease variants. Also, we analyzed the serum levels of the alpha-1-antiprotease inhibitor, quantified the levels of serine proteases in homes of the asthmatic volunteers, and determined whether environmental levels of proteases, regardless of their sources, had any association with either asthma symptoms or alpha-1-antiprotease inhibitor phenotypes. Our results do not support the role of the alpha-1-antiprotease as a risk factor for asthma in the study population as previously reported. Patients who had visited the ED due to asthma on 3 or more occasions had significantly higher trypsin levels than those who had done so 2 or fewer times. Of those asthmatic patients who had daily symptoms, 40% had been exposed to high levels of elastase, and 33.3% to trypsin. Similarly, 52.9% of the patients with 2 or more hospitalizations a year had been exposed to high elastase levels, and 40.5% of asthma patients who had nocturnal asthma more than 3 times a week had been exposed to high levels of elastase.

Do acculturation and family cohesiveness influence severity of diabetes among Mexican Americans?

OBJECTIVE

The goal of the study was to evaluate the effect of family cohesiveness, acculturation, socioeconomic position, and cardiovascular risk factors on severity of diabetes among Mexican Americans.

DESIGN AND STUDY POPULATION

The cross-sectional study involved a consecutive sample of 275 Mexican Americans under treatment for type 2 diabetes recruited from two medical clinics on the north side of Fort Worth, Texas. Recruitment and data collection took place during a span of 24 months from December 2001 to December 2003.

MAIN OUTCOME MEASURES

Hemoglobin A1C levels, available from medical charts, were used to indicate diabetes severity. Cases were defined as individuals with poorly controlled or severe diabetes based upon abnormally high hemoglobin A1C (> or = 7.0). Controls were defined as individuals with well-controlled or mild-moderate diabetes as reflected in a normal hemoglobin A1C (< 7.0). A face-to-face questionnaire was administered to study participants to collect data on protective factors related to family cohesiveness and acculturation, demographic and socioeconomic variables, and cardiovascular risk factors.

RESULTS

The results suggest that several variables were associated with severity of diabetes, including, receipt of food stamps, having spent childhood in Mexico, and current smoking status. Other variables representing acculturation and family cohesiveness, separately or combined, approached statistical significance.

CONCLUSIONS

Even though acculturation and family cohesiveness as schemas were not statistically significant because of small sample size, they highlight the importance of building more sophisticated models for testing their association with severity of diabetes.

Tuberculosis: what is the yield of associate investigations in non-BCG-immunized children with positive tuberculin skin tests?

SETTING

Urban county health department in Tarrant County, Texas, USA.

OBJECTIVE

To determine the yield of associate investigations in non-bacille Calmette-Guerin (BCG) immunized children with positive tuberculin skin tests (TSTs).

DESIGN

We compared the results of associate investigations of the contacts of 38 TST-positive, non-BCG-immunized pre-school children with the results of contact investigations of 290 culture-confirmed persons with tuberculosis (TB).

RESULTS

Associate investigations were more likely than contact investigations to identify persons with culture-confirmed TB and positive TSTs. Contacts identified through associate investigation of non-BCG-immunized pre-school children were 9.4 (95%CI 4.2-22.5) times more likely to have culture-confirmed TB and 2.3 (95%CI 2.0-2.7) times more likely to have positive TSTs than contacts of persons with culture-confirmed TB.

CONCLUSION

While conducting associate investigations is labor intensive, these data indicate that associate investigation of pre-school non-BCG-immunized children should be assigned priority in TB control activities, at least equal to the importance of investigating the contacts of culture-proven TB.

Measuring asthma disparities in Hispanics: adherence to the national guidelines for asthma treatment in emergency departments in Puerto Rico

BACKGROUND

Puerto Rico has the highest prevalence of asthma in the United States. Currently, there are no data on actual care given to asthmatic patients.

OBJECTIVE

To determine the prevalence of documented adherence to the 1997 National Asthma Education Prevention Program guidelines regarding care given in emergency departments (EDs) in Ponce, Puerto Rico.

METHODS

A case series was conducted using 6,002 ED records with a physician-based diagnosis of asthma for 1999 through 2001.

RESULTS

A history of asthma attack was documented in 82.0% of the cases and in all age groups. In-home beta-agonist use was recorded in only 5.7% of the medical records. Documentation of previous admissions to the ED and the intensive care unit were found in 3.5% and 0.33% of the records, respectively. Nocturnal symptoms before the ED visit were found in only 6.4% of the records, and asthma treatment at home was found in 39.9%. Accessory muscle retraction was documented in 99.1% of the cases, and oxygen saturation was found in 23.2%. Treatment with nebulized beta-agonist was found in 72.1% of the records, and intravenous or oral corticosteroid use was found in 84.1%. Follow-up appointments were detected in 64.8% of the cases, and referrals to specialists were given in only 5.3%. Rate ratios between our data and those of other researchers indicate that there are geographical differences in compliance with the guidelines.

CONCLUSION

Of the variables tested, only one had acceptable levels of compliance, as evidenced in the patient's records, indicating that there are alarming differences in ED evaluation and treatment compared with the 1997 National Asthma Education Prevention Program guidelines.

Using GIS technology to identify areas of tuberculosis transmission and incidence

Background

Currently in the U.S. it is recommended that tuberculosis screening and treatment programs be targeted at high-risk populations. While a strategy of targeted testing and treatment of persons most likely to develop tuberculosis is attractive, it is uncertain how best to accomplish this goal. In this study we seek to identify geographical areas where on-going tuberculosis transmission is occurring by linking Geographic Information Systems (GIS) technology with molecular surveillance.

Methods

This cross-sectional analysis was performed on data collected on persons newly diagnosed with culture positive tuberculosis at the Tarrant County Health Department (TCHD) between January 1, 1993 and December 31, 2000. Clinical isolates were molecularly characterized using IS6110-based RFLP analysis and spoligotyping methods to identify patients infected with the same strain. Residential addresses at the time of diagnosis of tuberculosis were geocoded and mapped according to strain characterization. Generalized estimating equations (GEE) analysis models were used to identify risk factors involved in clustering.

Results

Evaluation of the spatial distribution of cases within zip-code boundaries identified distinct areas of geographical distribution of same strain disease. We identified these geographical areas as having increased likelihood of on-going transmission. Based on this evidence we plan to perform geographically based screening and treatment programs.

Conclusion

Using GIS analysis combined with molecular epidemiological surveillance may be an effective method for identifying instances of local transmission. These methods can be used to enhance targeted screening and control efforts, with the goal of interruption of disease transmission and ultimately incidence reduction.

Exposure levels of asthmatic children to allergens, endotoxins, and serine proteases in a tropical environment

A cross-sectional study was conducted in Bayamón, Puerto Rico, to identify and quantify indoor allergens, serine proteases, and bacterial endotoxin present in homes of asthmatic children. A total of 126 dust samples from houses were obtained from the entire mattress and bedside floor. Most of the patients had detectable levels of mite, cockroach, cat, and dog allergens. Mold allergens were found only in bedside floor dust samples. Mouse allergens were not detected. Forty-two percent, 36.5%, and 1.8% of the patients demonstrated exposures to sensitizing levels of mite, Bla g 1 and cat allergens, respectively. The percentage of patients exposed to high levels of allergens capable of triggering asthma symptoms was 33.3% and 26.4% for mite and Bla g 1 allergens. Only dog allergen, bacterial endotoxin, elastase, and trypsin were associated with asthma symptoms. Eighty-nine percent of the asthmatic children were exposed to endotoxin concentrations greater than 100 EU/mg dust, and more than half of the patients were exposed to high levels of serine proteases. Our study indicates that indoor concentrations of allergens traditionally associated with asthma symptoms and severity may not be applicable in tropical environments and highly ventilated households. In fact, in the study population, endotoxins, dog allergen, and serine proteases may play a dominant role in the induction of asthma symptoms.

Comparative prevalence of sensitization to common animal, plant and mould allergens in subjects with asthma, or atopic dermatitis and/or allergic rhinitis living in a tropical environment

BACKGROUND AND OBJECTIVES

Current information suggests that the expression of allergic diseases is determined by the exposure and nature of the allergen. The objectives of the present study were to determine if the nature of allergenic exposition to animal, plant or fungal allergens influenced the clinical manifestations of atopic dermatitis (AD), allergic rhinitis (AR) or asthma (AS) in patients living in a tropical environment. The prevalence and degree of sensitization to these allergens were analysed by age and gender.

SUBJECTS AND METHODS

A total of 1496 atopic cases, grouped according to the primary diagnosis of AD or AR or AS, were skin tested using a standardized allergen panel. Participants were categorized by age groups. The atopic index (AI) and mean weal diameter (MWD) as well as the prevalence of positive skin tests were determined for each of the patient groups and compared by age groups.

RESULTS

The prevalence of atopy as well as the AI and the MWD peaked at 6-15 years of age and declined thereafter. In all the patients tested, the prevalence of sensitization was, in decreasing order; dust mites 94.3%, cockroach 41.5%, pets 31.5%, plant allergens 31.1% and fungal 19.4%. Eight hundred and ninety-three atopic patients were exclusively sensitized only to animal allergens. Of these, 38.4% had AD, 31.3% had AR and 30.5% with AS.

CONCLUSION

These data demonstrate that for patients with AD, AR and AS living in a tropical environment, the prevalence of positive skin reactions to animal allergens is highest followed by plant and fungal allergens. We did not observe any association between the type of allergen and clinical manifestations. The index of atopy was similar for both sexes. The prevalence and degree of sensitization were shown to peak in young adults independent of the allergen in AD and AR patients.

Prognostic factors of severe asthma in Puerto Rico

Asthma in Puerto Rico is a serious Public Health Problem. This study extends our cross-sectional self-reported asthma prevalence survey of 3,000 volunteers. The purpose of the present study was to analyze the importance of known prognostic factors of asthma severity among 486 self-reported participants. Patients with more than one visit to the emergency room in the previous 12 months due to asthma exacerbations were classified as cases of "severe asthma", and those asthmatic patients who did not visit emergency rooms were classified as "non-severe asthmatic subjects". Severe cases and non-severe asthmatic subjects were compared regarding age, sex, family history of asthma, presence of household pets, and in the previous 12 months: history of hospitalization due to asthma, respiratory infections, tobacco smoking, exposure to passive smoking, and avoidance of passive smoking. Crude and logistic regression adjusted odds ratio was used as a measure of association between each prognostic factor, and the outcome namely severe asthma, while adjusting for all confounders simultaneously. The results clearly showed that previous hospitalizations due to asthma (OR = 7.3, p < 0.0001) and frequent of respiratory infection (OR = 2.5, p = 0.0003) were prognostic factors associated with increased asthma severity. A statistically significant, two percent less likelihood to have severe asthma for each year of age was found. Weak associations were found between asthma severity and male gender, family history of asthma, passive smoking, and presence of household pets. Avoidance of environmental tobacco exposure (passive smoking) was found to be an important and statistically significant protective factor associated with a 47% less likelihood for severe asthma. In conclusion, appropriate management of patients with history of hospitalization due to asthma is very important. The correct management of respiratory infection in asthmatic patients may result in a reduction of up to 60 percent of the odds of having asthma severe enough to require emergency treatment, and may reduced by 86.3 percent hospitalizations.

Age, gender and seasonal patterns of asthma in emergency departments of southern Puerto Rico

We report findings derived from 55,547 emergency department records of asthmatic patients in the city of Ponce, Puerto Rico over a period of six years. The analysis of the data revealed that mean age of the asthmatic cases were 18.7 +/- 17.8 years, with 45% percent of the patients in the 1-9 years age range, and proportionally decreasing with age. In children 1-9 years the percent of males was 1.5 times that of females, and in 10-19 year-old group, admissions to the emergency room for males and females was identical, and between 20-69 years of age, the female ratio ranged from 1.5-2.12. The data also demonstrated that there is a seasonal variation in the asthma attacks reaching its peak in December, and the lowest in June. In conclusion, in the city of Ponce, Puerto Rico, emergency department usage due to asthma attacks show a seasonal variation, and males are more affected by asthma at younger ages while females are more affected at older ages. These findings strongly suggest that emergency department usage due to asthma attacks is highly common and represents an important place where specialized health care delivery is needed. With the implementation of dedicated asthma centers, specialized health care delivery can be easily accomplished. In addition, our data supports the that asthma should be declared a public health problem and a reportable disease.

Laparoscopic diagnosis and repair of asymptomatic bilateral inguinal hernias

BACKGROUND

This study was designed to investigate age, sex, and side of hernia presentation at clinical examination as potential intrinsic risk factors for bilateral inguinal hernia (BIH), and to quantify the characteristics of clinical examination versus laparoscopy as a diagnostic tool for BIH.

METHODS

A cross-sectional study was utilized to analyze 99 consecutive patients undergoing laparoscopic inguinal hernia repair.

RESULTS

The incidence of BIH based on clinical examination alone was 49%, compared with 71% laparoscopically. Clinical examination of BIH resulted in 69% sensitivity, 100% specificity, 100% predictive value for bilateral diagnosis, and 57% predictive value for unilateral diagnosis. Left hernia presentation at clinical examination (prevalence rate ratio = 10.5, 95% confidence interval: 3.6 to 30.7) and male sex (prevalence rate ratio = 6.6, 95% confidence interval: 1.3 to 35.0) were found to be independent risk factors for BIH.

CONCLUSIONS

Laparoscopy yields detection of BIH that would be missed by clinical examination alone. Furthermore, left-sided hernia and male sex were associated with BIH.

Tolerance of nonsteroidal antiinflammatory drugs in patients with inflammatory bowel disease

OBJECTIVE

We sought to examine whether use of nonsteroidal antiinflammatory drugs (NSAIDs) in an outpatient inflammatory bowel disease (IBD) population is associated with an increased likelihood of active disease.

METHODS

We reviewed records of initial outpatient visits of IBD patients to the principal author from June 1995 to December 1997, with regard to use of aspirin and other NSAIDs and disease activity.

RESULTS

Of 40 Crohn's patients seen with active disease, three (7.5%) were using NSAIDs; 14 of 72 (19.4%) Crohn's patients seen with inactive disease were using NSAIDs. Fifty-eight ulcerative colitis patients were seen with active disease, with eight (13.7%) using NSAIDs. Among 21 UC patients initially seen while in remission, five (23.8%) were using NSAIDs.

CONCLUSIONS

Among this group of outpatients, NSAID use was not associated with a higher likelihood of active IBD. NSAID use in IBD deserves further study before recommending that patients refrain from their use under all circumstances.

The Onchocerciasis Elimination Program for the Americas: a history of partnership

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination of all morbidity from onchocerciasis from the Region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center. OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$ 2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico, and Venezuela, so as to take full advantage of the Merck donation. Now halfway into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999.

Prevalence of skin reactions to aeroallergens in asthmatics of Puerto Rico

In Puerto Rico, although a high prevalence of asthma has been reported, the sensitization rates to aeroallergens in these patients is unknown. The purpose of this study using a case control design, was to determine and compare the rates of sensitization to common aeroallergens in an asthmatic population of 576 asthmatics and 144 healthy controls. A skin prick test was conducted using standardized extracts of Dermatophagoides farinae (Df) and D. pteronyssinus (Dp), house dust (HD), cat hair and epithelium (CT), dog hair and dander (DG), grass pollen mix (PG), tree pollen mix (PT), weed pollen mix (PW), Aspergillus mix (AM), mold mixes A (MA) and B (MB), Periplaneta americana (PA) and Alternaria-Hormodendrum mix (AH). In addition, an extract from the domestic mite Blomia tropicalis (Bt) was also used. A wheal > or = 3 mm2 was considered a positive reaction. In addition, a standardized questionnaire was administered and a preliminary domestic mite identification survey was conducted. The analysis of the data showed that 85.8% of the asthmatics had at least one positive reaction and 61.6% of them had positive skin reactions to atleast one mite species. Asthmatics reacted to domestic mites 6.19 times more than the control group (p < 0.0001) and was the largest significant difference found in this study for any allergen tested. Preliminary identification of the acarologic fauna in southern Puerto Rico demonstrated that Blomia tropicalis, Dermatophagoides pteronyssinus, D. farinae and E. maynei are the dominant domestic mite species found in homes of asthmatic individuals. These results demonstrate that domestic mites are a very important source of sensitizing aeroallergens for asthmatic patients in Puerto Rico. Based upon the mite survey, Blomia tropicalis plays an important role in allergic sensitization, in addition to Dermatophagoides pteronyssinus and D. farinae. The skin prevalence to pollens and to molds may not reflect the true prevalence of sensitization to these allergens. Pollen identification and counts, and a survey of microflora of Puerto Rico are needed in order to identify and validate important allergens that eventually could be incorporated into a more appropriate panel for testing sensitization in susceptible individuals.

Identification of the domestic mite fauna of Puerto Rico

This study was conducted to identify the domestic mite fauna of Puerto Rico. A total of 57 dust samples were collected from mattresses in homes of 11 cities on the Island. The analysis of the samples revealed that 73.70% of the mattress samples had at least one mite species. The identified species include: Dermatophagoides pteronyssinus (45.6%), Blomia tropicalis (31.6%), Cheyletus sp. (19.3%), Dermatophagoides farinae (17.5%), Euroglyphus maynei (5.3%), Dermatophagoides sibonei (1.8%), Dermatophagoides sp. (1.8%), Suidasia melanensis (1.8%) and mite species that were not identified (5.3%). Differences in the geographical distribution of mites showed that only Blomia tropicalis is more frequently in the northern (43%) than in the southern region (19%) of Puerto Rico (OR 3.36, p, 0.046). This finding can be explained by the fact that in the northern region the relative humidity is significantly higher that in the southern region (p < 0.001). No significant differences were observed for other species or in the total mite counts between the northern and southern regions. The small sample size of this study may explain the lack significance for some of the differences found. Nevertheless, our results indicate that the domestic mite fauna is composed of several clinically important species, their numbers are high enough to be considered in the sensitizing levels, and the diversity of these species is comparable to other observations in the Caribbean areas, and in the southern states in the continental US. Based upon our results, we recommend that when performing the skin test in Puerto Rico, extracts from the identified local domestic mite species be included in the allergen panel. This may prove useful in the aid for the diagnosis and management of atopic conditions.

Prevalence of HIV1 in leprosy patients in Rio de Janeiro, Brazil

The purpose of this study was to learn if HIV1 infection was associated with leprosy in Rio de Janeiro, Brazil by comparing the prevalence rates of 1.016 leprosy patients tested on a voluntary basis and 78.482 blood donors. A cross-sectional survey of anti-HIV1 antibodies was conducted in Rio de Janeiro, from 1990 to 1992 for this purpose. HIV1 prevalence found among leprosy patients was (3 cases) 2.9 per 1000, and among blood donors was (282 cases) 3.8 per 1000. Such difference was not significant (OR = 0.79; p = 0.69). Since HIV1 cases were only found among male leprosy patients, further analysis excluded females. Male leprosy patients showed a slightly higher prevalence of HIV1 than blood donors before and after age adjustment. However, this result was not statistically significant (adjusted odds ratio = 1.38, 95% CI 0.35-4.5; p = 0.83). These data do not provide evidence that leprosy and HIV1 infection are associated in the State of Rio de Janeiro. This is consistent with similar investigations conducted elsewhere.

An estimate of the prevalence, severity and seasonality of asthma in visitors to a Ponce shopping center

To have an estimate of the prevalence of asthma in southern Puerto Rico, a cross-sectional study of a convenience sample of three thousand volunteers from southern Puerto Rico was conducted in a shopping center. Individuals were considered asthmatics when they indicated that had consulted their physicians during the previous 12 months for asthma, shortness of breath, accompanied wheezing, and medications had improved their condition. The crude point prevalence of asthma was 17.5 per 100 interviewees. The median age of the asthmatic population was 18 years while in the non-asthmatic it was 26 years of age (p < 0.0001). Males were 22 percent more likely to be asthmatics than females (p = 0.047). Twenty-six percent of the asthmatics reported hospitalizations at least one time, and 56 percent had received medical attention in emergency rooms due to asthma exacerbations. Analysis of the data strongly suggests that the asthma prevalence in southern Puerto Rico may be higher than in other parts of the United States and the rest of the world. This indicates that asthma probably is an important public health problem in the southern Puerto Rico and possibly, in the island.

Gender and ethnic differences in survival in a cohort of HIV positive clients

OBJECTIVES

The purpose of this study was to examine gender and ethnic differences in survival of persons receiving treatment for HIV infection to determine if differences existed, and if they did, to assess the possibility of explaining these differences by examining other factors, such as age, disease severity when beginning treatment, alcohol, illicit drugs, tobacco, educational level, living arrangements, antiretroviral treatment, PCP prophylaxis, sexually transmitted diseases, mode of transmission and opportunistic infections.

DESIGN

A retrospective cohort study of all clients receiving treatment at an HIV only clinic from its opening in early 1988 until the end of May 1993. Statistical methods used to examine the data included incidence density ratios, Kaplan-Meier survival curves, Breslow (generalized Wilcoxon) tests of equality of survival curves and Cox proportional hazards models both with and without time dependent covariates.

RESULTS

In the cohort (37% African American, 7% Hispanic American and 25% female), 220 deaths occurred during 1223 person years of follow-up. Compared to European American males, the following incidence density ratios were observed: European American females: 0.50, Hispanic American females: 0.70, Hispanic American males: 0.96, African American females: 1.28 and African American males: 2.38. The differences were noted above for gender/ethnicity groups were significant at the p < 0.0001 level. After adjusting for disease stage (as measured by laboratory testing of CD4 positive T-lymphocytes), educational level, and age, no differences in survival by gender or ethnicity remained. Disease stage and educational level had the greatest prognostic significance.

CONCLUSIONS

European Americans entered treatment at a much earlier disease stage (as measured by CD4 positive T-lymphocyte counts) and had higher educational levels (a surrogate for socioeconomic status) than African Americans. These factors may explain the longer survival in European Americans as compared to African Americans in this cohort.

Epidemiologic factors correlated with multiple sexual partners among women receiving prenatal care

A cross-sectional survey methodology was used to respond to the need of a local health department to identify correlates of high-risk behaviors related to human immunodeficiency virus (HIV) transmission among pregnant women attending prenatal care clinics. This study of 488 maternity patients was conducted at two public health clients in Tampa, Florida, in 1991. The prevalence of high-risk behaviors was assessed using a self-administered questionnaire. Out of 428 respondents, 25% reported having had intercourse with two or more male partners in the past year. Following multiple logistic regression analysis, four variables remained consistently and significantly associated (P < 0.05) with having two or more sexual partners: (1) annual household income of less than $10,000/y (prevalence odds ratio (POR) = 4.5; 95% confidence limits (CL): 1.5, 13.1); (2) history of prostitution (POR = 8.1; 95% CL: 1.5, 42.1); (3) history of rape or forcible intercourse (POR = 2.2; 95% CL: 1.0, 4.6); and (4) an expressed desire for confidentiality among women seeking further information about acquired immunodeficiency syndrome (AIDS) prevention (POR = 2.1; 95% CL: 1.1, 4.0). Assessment of these factors may lead to better direction of HIV education programs, as well as identification and counseling of specific individuals at high risk for engaging in behaviors that can lead to HIV infection. Short, self-administered questionnaires provide confidential, rapid, and inexpensive means of generating baseline data for further interventions.

Short course training in epidemiology and biostatistics for graduate and undergraduate public health professionals

The University of South Florida has developed short courses of 2 to 3 days in epidemiology and biostatistics geared to public health workers. A key focus is providing skills which will assist local and State public health units to assess their status and measure progress with respect to achieving their explicitly stated health objectives for the year 2000. The courses were developed after the identification of the training needs in health departments and other public health settings. The training objectives were (a) to enhance the biostatistics skills of professionals involved in the analysis of health data; (b) to reinforce basic knowledge of epidemiologic methods and its practical applications in public health settings, including measures of disease frequency and association, epidemic outbreak investigations, and the identification and use of surveillance data; and (c) to demonstrate the application of the risk factor approach to select the interventions needed to reach health objectives for year 2000 and how to evaluate such interventions. A total of 43 students have taken this course series. Professional staff in health departments cannot always enroll in formal training in epidemiology and biostatistics because of time limitations or a lack of a bachelor's degree. However, the need exists. An alternative to such training could be the short course program described in this paper.