Cutaneous lymphomas

This paper is a written presentation of a workshop held at the American Academy of Insurance Medicine 115th Annual Meeting held in October 2006 in San Antonio, Texas. Cutaneous lymphomas, though not common, are encountered several times per year in insurance medicine. Significant advances have been made in the diagnosis and classification of lymphomas. This paper serves as a general primer to help classify and assess mortality risk of various cutaneous lymphomas.

A case of cutaneous lymphoma

Cutaneous lymphomas are relatively rare neoplasms, yet they are occasionally encountered in underwriting. The classification of cutaneous lymphomas leaves many in a quandary. The following case represents an uncommon cutaneous lymphoma. It will be used as a springboard to present a classification of cutaneous lymphomas, the staging definitions, prognostic variables, and some mortality data.

Lone atrial fibrillation: more than meets the eye

Doxorubicin has been used as a chemotherapeutic agent for over 30 years. Its cardiac toxicity has been known for over 20 years. In recent years, delayed-onset cardiac toxicity has been described as yet another cardiac complication of doxorubicin and other anthracyclines. The following case is felt to represent such an example.

Renal effects of amlodipine in normotensive renal transplant recipients

Renal effects of amlodipine in normotensive renal transplant recipients. The use of cyclosporin A (CsA) has improved the success of renal transplantation, but is associated with hypertension and significant renal toxicity. Previous reports suggest that calcium channel blockers may be useful in opposing the adverse effects of CsA. We have evaluated the effects of amlodipine (5 mg, once daily for 8 weeks) on renal function in 27 normotensive renal transplant recipients with stable renal function, in a double-blind, placebo-controlled, multicentre, cross over study. Amlodipine significantly reduced serum creatinine concentration relative to placebo (mean+/-SD: 168+/-65 vs 177+/-66 micromol/l; P=0.002) and there was a strong trend towards an increase in effective renal plasma flow on amlodipine relative to placebo (238+/-92 vs 217+/-87 ml/min; P=0.055). Glomerular filtration rate and lithium clearance were unaffected. Trough CsA blood concentration was unaffected. Amlodipine was well tolerated, with a low incidence of adverse events, and did not affect blood pressure or heart rate. In conclusion, amlodipine reduced serum creatinine in normotensive renal transplant recipients after only 8 weeks treatment, and was well tolerated in concomitant administration with CsA.

Partner notification for sexually transmitted diseases: proposed practice guidelines

Using the results of an analysis of available scientific evidence and a survey of current practice in Canada, as well as expert opinion, these guidelines attempt to consider current partner notification practice in Canada and recommend an approach to determining practice which is flexible enough to address local circumstances. Priority areas for future research were also identified.

A survey of public health partner notification for sexually transmitted diseases in Canada

OBJECTIVE

To describe the range of practice for sexually transmitted disease (STD) contact tracing/partner notification (PN) by public health agencies in Canada.

METHODS

A two-level mailed survey, using two different questionnaires, was conducted from Aug. 1991 to Feb. 1992, directed to: 1) provincial and territorial epidemiologists/directors of STD control, asking about program organization; and 2) 154 local health units/provincially run PN programs, asking about practice patterns of STD partner notification.

CONCLUSIONS

In Canada, STD PN by public health agencies is routinely practised in most provinces. PN efforts vary by the STD; less PN effort goes to chlamydia despite a high burden of illness; HIV PN is frequently perceived to be within the responsibility of the physician. For STDs with higher PN effort, the preferred method is provider referral. Targeting is seldom utilized, and there are little available data at a local level monitoring even process measures of effectiveness.

Ongoing high-risk sexual behaviors in relation recreational drug use in sexual encounters. Analysis of 5 years of data from the Toronto Sexual Contact Study

The current study investigated the association between the use of recreational drugs at the time of sexual activity and high-risk sexual behavior in a Toronto cohort of 249 homosexual and bisexual men over a 5-year period commencing in 1984 to 1985 and concluding in 1989 to 1990. The main analysis was based on a total of 2536 visits. Univariate and multivariate Liang-Zeger regression models were used to relate the log of the sexual activity score (SARS) to the independent variables over the 20 follow-up visits while controlling for intercorrelations between variables from the same respondent. We found that there was a significant decline, over time, in the sexual activities that pose a higher risk of infection with human immunodeficiency virus. Recreational drugs still appear to be playing an important role in the continuation of higher-risk sexual activities. The use of poppers in conjunction with sex is a strong predictor of high-risk activity, as is use of alcohol and marijuana in conjunction with sex. Also, simultaneously strongly associated with higher-risk score is the Centers for Disease Control classification II. More emphasis needs to be placed on educating the population about the potential risks of combining reactional drugs with sexual activity.

Recurrent themes of concern in groups for health care professionals

This paper reports of recurrent themes of concern about AIDS expressed by health care professionals participating in small group sessions. Three dominant themes emerged: fear of contagion, homophobia, and attachment and loss. For each of these themes the possible meanings are explored. Fear of contagion was the dominant theme and is discussed as both a possible expression of displaced homophobia and a 'catastrophic' risk factor (extreme negative consequence). The need of health care professionals to see themselves as 'different' from the person with AIDS is also discussed. Professionals also discussed the emotional burden of caring for young patients often similar in age to themselves. It is suggested that hospital policy makers need to accept the reality of staff concerns and provide adequate forums for expression of concerns since without an opportunity for thoughtful discussion, health care professionals may espouse the 'correct' position and attitude, but believe and practise something else.

Varied potential risks of HIV infection among prostitutes

To date, most HIV prevention programs targeting North American prostitutes have focused on individual behaviour change, and in particular, the consistent use of condoms between prostitutes and their clients. The organizational and societal level issues which may influence high risk practices within the working and private spheres have received relatively little attention. In addition, most prevention efforts have been limited to targeting the sub-population of street prostitutes. We outline here three different types of prostitutes (street prostitutes, escorts, and prostitutes who work part time in the service sector, i.e. barmaids and erotic massage therapists) known to work in many North American centres. In doing so, we suggest that potential risks of infection vary according to the type of prostitution, and that prevention programs must recognize the diversity in potential risk practices. Differences in the organization of work and working conditions of varied types of prostitutes may, in particular, influence risk practices while working. Some of the individual, organizational and societal level issues which influence risk practices among different types of prostitutes are presented. Much of the research involving HIV and prostitutes has accessed prostitutes at sites where street prostitutes are over-represented. Other studies are based on potentially baised samples as they have recruited prostitutes from medical clinics. Methodologic problems that influence attempts to obtain a representative sample of the prostitute population are discussed.

An efficacy trial of a mammalian cell-derived recombinant DNA hepatitis B vaccine in infants born to mothers positive for HBsAg, in Shanghai, China

We conducted a randomized, double-blind clinical trial of an experimental mammalian cell-derived DNA hepatitis B vaccine (Betagen, Connaught Laboratories Ltd, Toronto, Canada) to determine its efficacy in infants born to mothers who were carriers of hepatitis B surface antigen (HBsAg). Four groups of 55 infants received injections as follows: (1) a licensed plasma-derived vaccine (Lanzhou, Lanzhou Institute for Biological Products, Lanzhou, People's Republic of China), 20 micrograms; (2) Betagen, 20 micrograms; (3) Betagen, 20 micrograms+hepatitis B immune globulin (HBIG); and (4) Betagen, 10 micrograms+HBIG. Vaccine injections were given at birth and at 1 and 6 months and HBIG was given at birth. The vaccines were compared to a historical placebo control group. The efficacy of Betagen alone was 82.6% compared to 51.0% for the Lanzhou. Efficacy of Betagen increased with the concomitant use of HBIG. No infants who were HBsAg negative at birth and/or were born to hepatitis B e antigen (HBeAg) negative mothers became carriers. The rate of HBsAg in infants receiving Betagen alone, and born to mothers who were HBeAg positive, decreased from 60% at birth to 20% by the ninth month, compared to 62.5% and 50% (respectively) for Lanzhou. The percentage of infants with protective levels of antiHBs was significantly higher for Betagen alone than for Lanzhou, but the geometric mean titre of antiHBs for responders was not significantly different. We have shown that Betagen alone is highly efficacious in preventing the development of hepatitis B in infants born to mothers who are carriers of HBsAg and is also highly effective in reducing the carriage of HBsAg in infants who are HBsAg positive at birth and/or born to HBeAg positive mothers.

A randomized trial of group interventions for hospital staff caring for persons with AIDS

The purpose of this study was to develop an educational package for health care providers. Findings from a survey conducted by investigators were used to direct intervention content. All subjects received a 1 hour educational package. Since this type of intervention was not expected to be sufficient to modify attitudes and concerns, 75% of the subjects received an additional 1 hour group discussion intervention (n = 118). In a subgroup of those receiving group interventions, the discussion was preceded by the presence of a person with AIDS (PWA) (in person or on video) discussing his personal experience with the illness and health care workers. It was demonstrated that in order to modify change attitudes, concerns, and affective response, groups were necessary. Furthermore, fear of risk of contagion and homophobia required the presence of a PWA (in person or on video) in order for change to occur.

Using serial observations to identify predictors of progression to AIDS in the Toronto Sexual Contact Study

The Toronto Sexual Contact Study comprises a cohort of 249 male sexual contacts of men with HIV disease which has been followed every 3 months for almost 5 years. On enrollment 143 were seropositive and 16 seroconverted during the follow-up period. By 31 December 1989, 41 of the 159 seropositive cohort members had developed AIDS. Using Cox relative risk regression models, we investigated the association of a number of laboratory and clinical variables and progression to AIDS. Fixed covariate models examined laboratory variables from the enrollment visit of cohort members, with time calculated from this date. In models assessing time dependent covariates, time was calculated from the estimated date of HIV infection. In the univariate models of either fixed or time dependent covariates, many variables were significantly associated with risk of progression to AIDS (T4 cell count, T4/T8 ratio, blastogenic responses to phytohemagglutinin, concanavalin A, and pokeweed mitogen, serum IgA, appearance of p24 antigen, and the development of oral hairy leukoplakia, thrush, or herpes zoster). Appearance of persistent generalized lymphadenopathy was not associated with increased risk of progression. In the multivariate model which evaluated fixed laboratory covariates, T4/T8 ratio, IgA level, and PHA response at enrollment were significantly associated with elevated risk.(ABSTRACT TRUNCATED AT 250 WORDS)

The probability of progression to AIDS in a cohort of male sexual contacts of men with HIV disease

In a cohort of 249 male sexual contacts of men with AIDS or an AIDS-related condition (ARC), 143 cohort members were seropositive on enrollment and 16 seroconverted during follow-up. A logistic Weibull mixture model was used to estimate the probability of progression to AIDS after HIV infection when infection was assumed to occur during the period of sexual contact with the primary case. Forty cohort members developed AIDS while under study. It appears that at least 50% of men with HIV disease will progress to AIDS and that the best estimate of this probability lies anywhere in the interval 70% to 100%.

The Ontario HIV seroprevalence study of childbearing women: results from the first year of testing

The Ontario HIV Seroprevalence Study of Childbearing Women is an unliked anonymous seroprevalence study designed according to the well-established ethical and legal guidelines for such studies. Commencing in November, 1989, randomly selected neonatal heelprick specimens were tested for the presence of HIV antibodies after all identifying information had been permanently and irrevocably unlinked from the specimens. During the first year of the study 94,119 (approximately 60% of all submitted specimens) were tested. Twenty-six specimens which were repeatedly reactive by EIA were confirmed as positive for an overall crude seroprevalence rate of 2.8 per 10,000 women having live births (95% CI: 1.8-4.1). Twenty-five of the 26 confirmed seropositive results came from babies born in hospitals in the Metropolitan Toronto, Ottawa-Carlton, or Hamilton-Peel-Halton regions.

Fear of contagion and AIDS: nurses' perception of risk

Nurses' fear of contagion when caring for persons with AIDS remains high despite increased levels of knowledge. This paper examines the multiple factors that contribute to nurses' perception of risk within the workplace. The authors suggests that constructs from theories such as decision making, psychoanalysis and cognitive psychology can provide insight into the assessment of risk. Findings from a recent survey of nurses are used to illustrate the complex nature of fear of contagion. Understanding this complexity may be an essential first step in order to provide opportunities for resolution of fears and modification of behaviors.

Needle sharing behaviour among injection drug users (IDUs) in treatment in Montreal and Toronto, 1988-1989

Injection drug users (IDUs) entering treatment programs in Montreal and Toronto were recruited for a study of drug using behaviour and risk of HIV infection. Only those who had injected within 6 months of entering their treatment program were eligible for participation. 183 subjects were recruited in Montreal and 167 in Toronto between November, 1988 and October, 1989. Each participant completed a standardized interviewer-administered questionnaire which focussed on, among other things, drug history and needle sharing behaviour. Approximately three-quarters of respondents in both cities reported sharing needles and syringes within the 6-month period prior to their entry into treatment. Our analysis, which focussed on variables associated with needle sharing revealed that having a sexual partner who injected, trouble obtaining sterile needles and syringes and cocaine injection were significantly and independently associated with needle sharing in a logistic regression model which also controlled for city of recruitment.

The knowledge, attitudes and concerns of hospital staff about AIDS

Staff from 3 Toronto hospitals were surveyed for knowledge, attitudes and concerns about AIDS. 70% of the 1,366 respondents had direct clinical experience with persons with AIDS. Data were analyzed according to hospital setting and professional group: physicians, nurses, technologists and supervisory staff. No setting difference was observed and although statistically significant differences (at the .001 level) were observed between professional groups, these differences are small and have little practical importance. In general, subjects answered 68% of the knowledge questions correctly. All attitudes and concerns were inversely associated to knowledge (Pearson r range was -.31 to -.20). Multivariate analysis demonstrated that knowledge and concern about contagion are important mediating variables (multiple r = .40) for other attitudes and concerns.

Sexual behaviour changes in a cohort of male sexual contacts of men with HIV disease: a three-year overview

We describe the sexual behaviour reported by 240 seronegative and seropositive homosexual men over a 3-year period. Sexual partners of men with HIV disease were recruited into a prospective study between July 1984 and July 1985 and were monitored every 3 months thereafter. Data on sexual activities were collected through interviewer-administered questionnaires. The cohort experienced a reduction in both the number of sexual partners and the volume of sexual activity. Reductions in the number of partners were early and dramatic. Changes in sexual activities were gradual and consistent in trend. The greatest reduction occurred in high risk activities (receptive and insertive anal intercourse). After 3 years of follow-up, only 10% of the men continue to be exposed to semen through unprotected receptive anal intercourse and 18% through unprotected receptive oral-genital sex. The proportion of men engaging in oral-genital contact and masturbation remained stable over the 3 years. Once informed of their serostatus, both seropositive and seronegative men reduced their high risk behaviour. The decline in rates of STDs and seroconversion confirmed that this cohort had indeed reduced their high risk behaviour.

Comparison of saliva and blood for human immunodeficiency virus prevalence testing

Testing saliva for the detection of human immunodeficiency virus (HIV) antibodies has many potential advantages for epidemiologic surveillance. A commercial ELISA kit and a standardized in-house immunoblot (IB) system were slightly modified to enhance antibody detection in saliva. Frozen saliva specimens from Toronto Sexual Contact Study participants (including sequential saliva specimens collected during seroconversion) were tested as were fresh saliva samples collected from a population of street-based intravenous drug users (IVDUs). HIV antibody results on saliva were compared with HIV serostatus determined by ELISA and IB on serum or dried blood spots. The overall sensitivity was 98.3% (117/119) for the kit and 99.2% (118/119) for IB; the specificity was 100% (429/429). In the IVDU population, compliance in the voluntary submission of specimens increased from 69% agreeing to provide blood samples to 89% agreeing to provide blood, saliva, or both. Saliva specimens can be easily collected under difficult field conditions with minimal training and provide a valuable alternative to testing blood for HIV-seroprevalence studies.

Changing trends of cirrhosis mortality in Ontario, Canada, 1911-1986

Cirrhosis mortality death rates in Ontario for ages 20 and over declined from a high of 9.3 per 100,000 in 1911 to a low of 5.6 per 100,000 in 1919 (p less than 0.001) and after a 17-year period of relative stability, rose steadily to a high of 19.7 per 100,000 in 1975 (p less than 0.0001) and then declined to 13.3 per 100,000 in 1986 (p less than 0.001). Rates were consistently higher for men than for women and the male to female ratio of the rates increased from a low of 1.3 in 1933 to a high of 2.5 in 1986. The rate of increase in the rates for both men and women, and the rate of decline after the mid 1970s was most noted in the younger ages. Differences in trend could not be related to changes in disease classification, method of recording deaths, changes in diagnostic habits such as introduction of needle liver biopsy or to method of standardizing the rates. There was a positive and significant correlation between per capita alcohol consumption and rates of cirrhosis in Ontario from 1932 to 1975. However, while cirrhosis rates declined markedly from 1976 to 1986, alcohol consumption remained stable from 1976 to 1980 and declined only slightly from 1981 to 1986. A possible explanation for lack of correlation between alcohol consumption and the cirrhosis rates from 1976 to 1986 could be that the balance of force favoured recovery i.e. those people who already had cirrhosis who decreased (or stopped) their consumption of alcohol, did not die. Correlations with lagged alcohol consumption could not explain all the changes in the cirrhosis rates. Although cirrhosis rates consistently increased with increasing age from 35 to 85, our results showed that succeeding generations were developing cirrhosis at successively younger ages after the age of 35. Possible explanations for this cohort effect are increased survival from infectious diseases in infancy and childhood, increase in hepatitis B infection, excessive drinking habits being established at younger ages or a change in the pathogenesis of the disease.

Cofactors of progression to acquired immunodeficiency syndrome in a cohort of male sexual contacts of men with human immunodeficiency virus disease

In a cohort of 249 male sexual contacts of men with acquired immunodeficiency syndrome (AIDS) or an AIDS-related condition in Toronto, Ontario, Canada, 143 cohort members were seropositive on enrollment and 16 seroconverted between initial recruitment in July 1984 to July 1985 and December 1988. Data on age, smoking and drinking status, recreational drug use, and history of sexually transmitted diseases and other diseases were obtained from interviews at induction and during follow-up on the cohort members every 3 months. Cox relative risk regression models, in which time was calculated from estimated date of human immunodeficiency virus (HIV) infection for seroprevalent cohort members and from 90 days prior to the first positive test for seroconverters, examined the potential effect of use of a variety of recreational drugs and the occurrence of selected infections on the risk of development of AIDS. Thirty-five cohort members developed AIDS while under study. No significant association with risk of progression to AIDS was noted for use of various recreational drugs (singly or in combination), history of specific infections, age at enrollment, or smoking and drinking status at enrollment. Only estimated duration of HIV infection appeared to be associated with increasing risk of development of AIDS.

A randomized double-blind clinical trial of a mammalian cell-derived recombinant DNA hepatitis B vaccine compared with a plasma-derived vaccine

Eight hundred volunteers from heath care and emergency fields participated in a randomized double-blind clinical trial of a new experimental mammalian cell-derived recombinant DNA hepatitis B vaccine (Betagen) compared with a licensed plasma-derived vaccine (Heptavax-B). Vaccine injections (20 micrograms) were administered intramuscularly at 0, 1, and 6 months, and sera were tested at 0, 1, 2, 3, 6, 7, and 12 months for hepatitis B surface antigen, antibody to hepatitis B surface antigen, and antibody to hepatitis B core antigen. Data from 745 vaccinees (93.1%), analyzed at the 7th month of follow-up, showed no significant difference in the seroconversion rates for Betagen (94.4%) vs Heptavax-B (97.3%), but the geometric mean titer of antibody was significantly higher for Heptavax-B (11 833 mIU/L) than for Betagen (4628 mIU/mL). The antibody response of Betagen was significantly and independently related to age and sex, while that of Heptavax-B was related to age only. Reported side effects from both vaccines were minor and mild, with approximately one fourth of all vaccinees reporting at least one side effect. Vaccinees, who had a protective level of antibody at the 7th month, were tested for antibodies at the 12th month. Of those in the Betagen-vaccinated group and those in the Heptavax-B-vaccinated group, 99.0% and 100%, respectively, were still protected. There was a proportionately larger decline in the geometric mean titers of antibody to hepatitis B surface antigen for Heptavax-B than for Betagen.

Underreporting of AIDS cases in Canada: a record linkage study

To estimate the rate of underreporting of AIDS (acquired immune deficiency syndrome) to the Federal Centre for AIDS (FCA), in 1988 the initials, date of birth and place of residence of 66 patients with AIDS known to the Toronto Sexual Contact Study (TSCS), 65 patients with AIDS known to the Vancouver Lymphadenopathy-AIDS Study (VLAS) and other participants in both studies who did not have AIDS were sent to the Bureau of Epidemiology and Surveillance, FCA. The FCA conducted a manual record linkage to link these data to the national registry of reported cases. The rate of underreporting was 12% (8/65) for the VLAS and 18% (12/66) for the TSCS. The specific diagnosis was not related to the rate of underreporting. For the TSCS the rate of underreporting had increased from 0% in 1983-84 to 44% in 1987-88 (p = 0.001). Differences in the observed rates of underreporting between the two studies are likely the result of differences in the reporting responsibilities of physicians involved in the studies.

Kaposi's sarcoma and AIDS: a variable spectrum

A cohort of 61 patients with Kaposi's sarcoma (KS) and AIDS was seen in the Oncology Unit of the Toronto General Hospital between 1982 and 1986. In an attempt to identify prognostic variables, laboratory and clinical parameters were examined using Kaplan-Meier estimates and the Cox Regression Model. All patients were male, median age 36 years (range 23-52). In 49 patients KS was diagnosed before any AIDS-associated opportunistic infection (OI). Three patients had concurrent KS and OI, and nine patients developed KS one or more months after an OI. Only 11 patients had stage I or II disease, 34 stage III, and 15 stage IV. Only 18 patients (30%) were asymptomatic. Twenty-six percent had fever, night sweats, or weight loss, 11% had minor opportunistic infections, and 33% had both symptom complexes. The median overall survival was 10.5 months. The survival of patients who received chemotherapy for their KS was not significantly different from the survival of non-treated patients (p = 0.7). Although significant differences in survival could not be seen between stages, patients with both systemic symptoms and minor opportunistic infections had significantly shorter survival (p = 0.03). Survival from the onset of KS was significantly shorter for patients who had experienced a previous OI, but their overall survival from the date of diagnosis of AIDS was not significantly different from those patients presenting with KS alone. When analyzed separately the laboratory parameters of hemoglobin (p less than 0.0001), absolute lymphocyte count (p = 0.03), platelet count (p = 0.04), and T4 level (p = 0.05) demonstrated a significant relationship with survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Mortality and hospital morbidity from cirrhosis of the liver in relation to per capita consumption of absolute alcohol, education and native status, Ontario; 1978 to 1982

Correlation and regression analyses have been carried out to test the hypothesis that areas experiencing high per capita consumption of absolute alcohol will also experience correspondingly higher annual rates of cirrhosis, in Ontario from 1978 to 1982. Adjustment was made for the influence of socio-demographic variables upon hospital morbidity and mortality rates. Areas experiencing higher per capita consumption of absolute alcohol were found to have higher hospital morbidity. The relationship between hospital morbidity and general mortality from cirrhosis, and per capita consumption of absolute alcohol appears to be growing weaker; no relationship could be demonstrated, however, between cirrhosis mortality and hospital morbidity and proportionate native population and education status.

Validity of sexual histories in a prospective study of male sexual contacts of men with AIDS or an AIDS-related condition

As part of a prospective study in Toronto, Canada of male sexual contacts of men with either acquired immunodeficiency syndrome (AIDS) or an AIDS-related condition (primary cases), separate interviews were conducted in 1984-1985 with primary cases and their corresponding sexual contacts. Seventy-five primary cases and their corresponding sexual contacts were asked details concerning the sexual activities involved in their sexual encounters. Spearman correlation coefficients were calculated for the responses regarding frequency of various sexual activities between the primary case and his corresponding contact. Comparison of responses revealed good to excellent correlations for the majority of the sexual activities. Regression analysis of responses (dependent variable = contact's response; independent variable = primary's response) revealed the tendency for primary cases to report greater numbers of various activities than sexual contacts, as illustrated by regression coefficients that were consistently less than unity. Agreement between primary responses and sexual contact responses appeared to be affected by the time lapsed from the last sexual encounter with the contact and the date of the primary case's interview. No effect on agreement was observed when primary case diagnosis and the total number of other sexual partners of primary cases were considered. The authors conclude that such data can be captured with sufficient reliability and validity for use in epidemiologic investigations to assess the risk of acquisition of human immunodeficiency virus for the more common forms of sexual activity. However, some caution may be necessary in interpreting the results for some activities (anal digit insertion, anilingus) since agreement is less satisfactory for these activities.

Risk factors for HIV infection in male sexual contacts of men with AIDS or an AIDS-related condition

A total of 246 healthy male sexual contacts of men with either acquired immunodeficiency syndrome (AIDS) or an AIDS-related condition were recruited into a prospective study in Toronto, Canada between July 1984 and July 1985. At induction, data were collected on the sexual relationship between the contact and his primary case, sexual activities with other men, history of sexually transmitted diseases and other diseases, and use of recreational drugs. At recruitment, 144 sexual contacts had antibodies to human immunodeficiency virus (HIV); 102 of the contacts were seronegative at induction and at three months following recruitment. No association between HIV seropositivity and total number of sexual partners could be demonstrated. In univariate and multivariate analyses, receptive and insertive anal intercourse with the primary cases, and activities which either indicated or potentially caused anorectal mucosal injury (rectal douching, perianal bleeding, receipt of objects in ano, and receptive fisting) were strongly associated with HIV seropositivity. In the final multiple logistic regression model, two significant interaction effects were observed: the interaction between receptive anal intercourse and insertive anal intercourse and that between receptive anal intercourse and the anorectal mucosal injury index. These two interaction terms had negative regression coefficients which suggested that change in one sexual activity would not decrementally reduce risk of HIV infection without a comparable modification in the other activity. No association could be demonstrated between oral-genital and oral-anal sexual contact and odds ratios for these sexual activities declined to levels below 1.0 when adjusted for frequency of receptive anal intercourse.

Relationship between liver cirrhosis death rate and nutritional factors in 38 countries

The relationship between liver cirrhosis death rates and certain nutritional factors was studied in 38 countries where mortality statistics were considered to be reliable. A partial correlation analysis showed that several food commodity consumption factors were independently and negatively (p less than 0.01) associated with liver cirrhosis death rates after adjustment for alcohol consumption. These factors were total calories, protein, fat, calcium, vitamin A and vitamin B2. The significant association of protein, vitamin A, vitamin B2 and calcium with the cirrhosis death rates is of importance since they were not intercorrelated with alcohol consumption. Further results showed that animal protein was more significantly related to cirrhosis death rates than vegetable protein. However, in view of certain limitations of this study, the findings do not necessarily reflect causal relationships but rather support the consideration by scientists that protein and vitamin deficiency may have certain effects on liver cirrhosis.

Relationship between hepatitis B surface antigen prevalence, per capita alcohol consumption and primary liver cancer death rate in 30 countries

The relationships between the prevalence of hepatitis B surface antigen (HBsAg), mean annual per capita alcohol consumption and primary liver cancer (PLC) death rates were explored in 30 countries. HBsAg prevalence was associated, significantly, with the logarithm of the primary liver cancer death rate (simple correlation coefficient = 0.44, p less than 0.05). This significant association increased following adjustment for a country's mean annual per capita alcohol consumption (partial correlation coefficient = 0.53, p less than 0.01). A logarithmic linear relationship was also found between per capita alcohol consumption and the primary liver cancer death rate after adjustment for the country's prevalence of HBsAg (partial correlation coefficient = 0.38, p less than 0.05). Results from both correlation and regression analyses showed that prevalence of HBsAg was more significantly associated with PLC death rates than was alcohol consumption. However, these two variables were independently related to the PLC death rate in a stepwise multiple regression model. We could not demonstrate an interaction between the two variables. These findings are consistent with the prevailing view that chronic hepatitis B infection is the major factor in the most common form of primary liver cell cancer, hepatocellular carcinoma. In addition, they support the notion that alcohol consumption contributes significantly and independently, although probably to a lesser extent than hepatitis B, to deaths from that disease.

Assessment of generalized lymphadenopathy in AIDS research: the degree of clinical agreement

The degree of clinical agreement amongst different physicians on the presence or absence of generalized lymphadenopathy was assessed in 32 randomly selected participants from a prospective study of male sexual contacts of men with AIDS or an AIDS-related condition (ARC). Three physicians completed the same standard examination that was developed for the main project and conducted the examination of the anatomic regions in the same order on each person, at approximately the same time, and in random order. One physician (Doctor A) was the physician responsible for conducting examinations on the main cohort from which these participants were selected. Intra-observer agreement was assessed by comparing Doctor A's examinations on these participants with those he had recently conducted within a one and a half month period in the main study. Acceptable levels of intra-observer agreement (kappa = 0.72) and interobserver agreement (kappa = 0.66) were demonstrated for the presence or absence of generalized lymphadenopathy for Doctor A and Doctor B, a physician who periodically replaced Doctor A in the main project. Agreement between Doctors A, B, and C, was less satisfactory (kappa of 0.45 and 0.39, respectively). Doctor C was the least experienced with the standardized examination. However, during the progress of this study, agreement between the three doctors improved (kappa values for the latter 16 participants ranged from 0.60 to 0.86) suggesting that experience with the criteria and the standardization of the examination may enhance agreement.(ABSTRACT TRUNCATED AT 250 WORDS)

A Critical Look at HIV-Antibody Tests: 2. Benefits, Risks and Clinical Use

Following their first article on HIV-antibody tests,(1) the authors, in this second article, on HIV-antibody testing focus on the benefits and risks that may result from use of the tests. The sequelae of testing, especially if the result is positive, often differ widely, depending on the person tested and on those around him/her. Significant social and psychiatric risks may outweigh any medical benefit of testing, especially for certain persons known to be at high risk of HIV infection. Accordingly, a detailed protocol is suggested for managing both patient requests and physician-perceived indications for HIV-antibody testing. The authors outline the preferred approach to obtaining informed consent, a prerequisite, in their opinion, for ordering the tests.

A Critical Look at HIV-Antibody Tests: 1. How Accurate Are They?

As the AIDS epidemic spreads, many patients are asking their primary-care physicians to perform AIDS (HIV-antibody) testing, and in some settings, clinical circumstances prompt physicians to consider ordering the test. As a result, thousands of HIV-antibody tests are being requested each month by Canadian family doctors, where none were available only two years ago. Yet particular characteristics of HIV infection make these tests very unlike most blood tests, since their use carries clear risks as well as benefits. The authors review these risks and benefits in two sequential articles. In this first paper, they review the quantitative aspects of test accuracy (validity). In a sequential paper, to be published in next month's issue, they will discuss the risks and benefits of performing the test in various clinical circumstances.

A method for estimating "persons" versus "cases" from hospital morbidity data in the absence of unique personal identifiers

The authors present a method for estimating the number of persons (as opposed to the number of admissions) admitted to hospital for a defined time period for specific diagnoses when unique personal identifiers are not available. A simple computer algorithm (algorithm 1), employing a family-based scrambled health insurance number in conjunction with diagnosis, sex, and age was used to estimate the rates of readmission to hospital specific diagnoses. A proportion of the hospital morbidity records used in the study did not contain a health insurance number; therefore, estimated readmission ratios for specific diagnoses, calculated from admissions with health insurance numbers, were applied to all admissions for those diagnoses to obtain the estimates of total persons admitted to hospital in the given time period. The validity of the methodology was tested for selected diagnoses for a specific year by 1) comparing estimates of persons obtained by applying algorithm 1 with manual counts of persons obtained through examination of printed lists of all Ontario admissions to hospital for the specific diagnoses, and 2) comparing actual counts of persons admitted to a specific hospital with computer estimates of persons admitted to that hospital. The conclusions drawn were that the method, using algorithm 1, is a valid one for obtaining estimates of the number of persons admitted to hospital in a given year with a specific diagnosis and that the information derived is potentially useful for conducting epidemiologic studies. Readmission ratios were also estimated through the use of a second algorithm (algorithm 2) which was not dependent on a scrambled health insurance number. Sensitivity and specificity of these ratios were found to be low when compared with ratios estimated by algorithm 1.

Elevated levels of interferon-induced 2'-5' oligoadenylate synthetase in generalized persistent lymphadenopathy and the acquired immunodeficiency syndrome

The levels of the 2'-5' oligoadenylate enzyme synthetase in extracts of peripheral blood mononuclear cells from individuals with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC) were measured and compared with synthetase levels in peripheral blood mononuclear cells (PBMs) from healthy heterosexual and homosexual controls. The mean basal synthetase level in heterosexual and homosexual controls was 14 +/- 13 and 12 +/- 9 pmol per hr/10(5) PBMs, respectively. Thirteen individuals with AIDS had a mean basal level of 129 +/- 75 pmol. Serial levels were persistently elevated in six of these individuals over a one- to 10-month period. Twelve of the 13 individuals had antibodies to human T cell lymphotrophic virus-III/lymphadenopathy-associated virus (HTLV-III/LAV). Thirty-three individuals with ARC had a mean basal synthetase level of 68 +/- 84 pmol. Thirty-two of the 33 had antibodies to HTLV-III/LAV. Eleven (33%) have had consistently normal synthetase levels (less than 2 SD above the mean for the homosexual controls, i.e., 30 pmol) over a three- to nine-month follow-up period. Fourteen (42%) had persistently elevated levels over the same period; four (29%) of these developed AIDS during the follow-up period. Eight have had fluctuating levels but have remained clinically well. These studies suggest that persistently elevated synthetase levels in individuals with ARC and antibodies to HTLV-III/LAV indicate progressive virus-induced disease activity. Elevated synthetase levels may be an important prognostic indicator of increased risk of progression to AIDS.

Alcohol consumption and blood pressure: analysis of data from the Canada Health Survey

Recent epidemiologic studies report a significant association between alcohol consumption and elevations in both systolic (SBP) and diastolic (DBP) blood pressures. To test this hypothesis, we conducted a multivariate analysis of physical examination and other data on 721 men and 697 women aged 20 or more collected during the Canada Health Survey in 1978-1979. SBP and DBP were considered as separate dependent variables in multiple regression models with the following independent variables: age, alcohol consumption (measured as a 7-day recall history and as an average frequency of consumption), serum cholesterol, plasma glucose, physical activity, Quetelet index, parental history of hypertension, cigarette consumption, income, education, and exogenous hormonal use in women. In both weighted and unweighted multiple regression analyses, we could not demonstrate for either sex, a significant association between alcohol consumption (as recorded and following quadratic and logarithmic transformations) and either SBP or DBP. For both sexes, only age and Quetelet index were highly significantly (P less than 0.0001) and consistently associated with both SBP and DBP. No other independent variables were consistently associated, for either sex, with SBP and DBP. Further, the dose-response patterns noted by other investigators suggesting either a positive and linear relationship or a curvilinear relationship were not found in either our univariate or multivariate analyses. Rather, the alcohol-blood pressure curves showed no consistent patterns of any kind in either sex. These findings do not support recent claims that alcohol consumption is a determinant of elevations in either SBP or DBP.

Hepatitis B vaccine requirements in at-risk hospital personnel: a survey of hospitals in Metropolitan Toronto

Approximately 50 000 individuals are employed in various hospital-based occupations in Metropolitan Toronto. To determine the proportion of this population that might be considered as first-priority recipients of the new hepatitis B vaccine, a questionnaire was sent to the executive directors of 45 hospitals in this region. The questionnaire requested data on the numbers of full- and part-time employees whose frequency of contact with blood and blood-related equipment was the greatest. The response rate was 89%. Of the 9545 individuals identified as being at risk of exposure to hepatitis B, 5443 (57%) were nonphysicians and 4102 (43%) were physicians. A highly significant (p less than 0.001) positive and linear relation was found between the numbers of personnel at highest risk of exposure and the total number of hospital personnel and type of hospital. Therefore, the potential exists for developing and validating a simple bivariate model that could predict the initial vaccine requirements for hospital-based personnel in Ontario and other provinces.