Blood-borne and sexual transmission of human herpesvirus 8 in women with or at risk for human immunodeficiency virus infection

BACKGROUND: Human herpesvirus 8 (HHV-8), the causal agent of Kaposi's sarcoma, is transmitted sexually among homosexual men, but little is known of its transmission among women. Although HHV-8 has been detected in blood, there has been no clear evidence of blood-borne transmission. METHODS: We identified risk factors for HHV-8 infection in 1295 women in Baltimore, Detroit, New York, and Providence, Rhode Island, who reported high-risk sexual behavior or drug use. HHV-8 serologic studies were performed with two enzyme-linked immunosorbent assays. RESULTS: In univariate analyses, HHV-8 was associated with black race, Hispanic ethnic background, a lower level of education, and infection with syphilis, the human immunodeficiency virus (HIV), hepatitis B virus (HBV), or hepatitis C virus (HCV). The risk of seropositivity for HHV-8 increased with the frequency of injection-drug use (P<0.001); HHV-8 seroprevalence among the women who used drugs daily was three times that among women who never injected drugs. Among the women with a low risk of sexual transmission, HHV-8 seroprevalence was 0 percent in those who had never injected drugs and 36 percent in those who had injected drugs (P<0.001). However, injection-drug use was linked less strongly to HHV-8 infection than to infection with HBV or HCV. In a multivariate analysis, independent predictors of HHV-8 seropositivity included HIV infection (odds ratio, 1.6; 95 percent confidence interval, 1.1 to 2.2), syphilis infection (odds ratio, 1.8; 95 percent confidence interval, 1.1 to 2.8), and daily injection-drug use (odds ratio, 3.2; 95 percent confidence interval, 1.4 to 7.6). CONCLUSIONS: Both injection-drug use and correlates of sexual activity were risk factors for HHV-8 infection in the women studied. The independent association of HHV-8 infection with injection-drug use suggests that HHV-8 is transmitted through needle sharing, albeit less efficiently than HBV, HCV, or HIV.     

Adverse outcomes and lack of health insurance among newborns in an eight-county area of California, 1982 to 1986

In this study of hospital discharge data on births to residents of an eight-county region of California, we found an increasing lack of health insurance that was associated with an elevated and increasing risk of adverse outcomes in newborns. Between 1982 and 1986, the percentage of newborns without health insurance increased overall by 45 percent (from 5.5 to 8.0 percent; P less than 0.001); the increases were larger among Asians (by 54 percent [from 7.8 to 12.0 percent]; P less than 0.001) and Latinos (by 140 percent [from 8.2 to 19.7 percent]; P less than 0.001). By 1986, the odds ratio for an adverse hospital outcome (defined as a prolonged hospital stay, transfer of the newborn to another institution, or death) was 1.31 (95 percent confidence interval, 1.17 to 1.46) in uninsured as compared with privately insured newborns, with control for race or ethnic group. There was a significant increase in risk over time (P less than 0.03); the comparable odds ratios in 1982 and 1984 were 1.11 (95 percent confidence interval, 0.93 to 1.33) and 1.19 (1.05 to 1.35), respectively. In 1986 the risks were especially elevated for uninsured as compared with privately insured blacks and Latinos (odds ratios, 2.24 [95 percent confidence interval, 1.60 to 3.13] and 1.56 [1.26 to 1.94], respectively); the increases in risk over time were the most marked in these groups. We believe that the elevated and increasing risks for uninsured newborns are explained at least in part by inadequate and diminishing access to care and that this burden is borne disproportionately by blacks and Latinos.     

Heterosexually transmitted human immunodeficiency virus infection among pregnant women in a rural Florida community.

BACKGROUND. In the United States, an increasing proportion of women infected with the human immunodeficiency virus (HIV) live in nonmetropolitan areas. Little is known, however, about the risk factors for HIV transmission in women outside large cities. METHODS. We interviewed and tested 1082 (99.8 percent) of 1084 consecutive pregnant women who registered for prenatal care at a public health clinic in western Palm Beach County, Florida. This rural agricultural area of about 36,000 people is known to have a high prevalence of HIV infection. RESULTS. The seroprevalence of HIV was 5.1 percent (52 of 1011 women). Black women who were neither Haitian nor Hispanic had the highest rate of infection (8.3 percent [48 of 575]). Only 4 of 1009 women (0.4 percent) reported ever injecting drugs, and the 4 were HIV-seronegative; however, 14 of 43 users of "crack" cocaine (33 percent) had HIV infection. At prenatal registration, 131 of 983 women (13 percent) tested positive for gonorrhea, chlamydial infection, or syphilis. By multivariate logistic-regression analysis, HIV infection was found to be independently associated with having used crack cocaine (odds ratio, 3.3; P < 0.001), having had more than two sexual partners (odds ratio, 4.6; P < 0.001), being black but neither Hispanic nor Haitian (odds ratio, 11; P < 0.001), having had sexual intercourse with a high-risk partner (odds ratio, 5.6; P < 0.001), and testing positive for syphilis (odds ratio, 3.1; P = 0.015). Nevertheless, 11 of the 52 HIV-infected women (21 percent) reported a total of only two to five sexual partners and no known high-risk partners, had never used crack cocaine, and had no positive tests for sexually transmitted disease. CONCLUSIONS. In the rural community we studied, most of the women with HIV infection acquired it through heterosexual contact. The increasing seroprevalence of HIV and the increasing incidence of syphilis and use of crack cocaine mean that other women may be at similar risk of acquiring heterosexually transmitted HIV infection.     

Seroprevalence of HTLV-1 and HTLV-2 among intravenous drug users and persons in clinics for sexually transmitted diseases.

Background. The human T-cell lymphotropic virus Type I (HTLV-I) is associated with adult T-cell leukemia and myelopathy, whereas HTLV-II infection has uncertain clinical consequences. We assessed the seroprevalence of these retroviruses among intravenous drug users and among patients seen at clinics for sexually transmitted diseases (STD clinics). METHODS. We used serum samples that were collected in eight cities in 1988 and 1989 during surveys of human immunodeficiency virus infection among intravenous drug users entering treatment and persons seen in STD clinics. The serum samples were tested for antibodies to HTLV, and positive specimens were tested further by a synthetic peptide-based enzyme-linked immunosorbent assay to differentiate between HTLV-I and HTLV-II. RESULTS. Among 3217 intravenous drug users in 29-drug-treatment centers, the median seroprevalence rates of HTLV varied widely according to city (range, 0.4 percent in Atlanta to 17.6 percent in Los Angeles). Seroprevalence increased sharply with age, to 32 percent in persons over 44 years of age. HTLV infection was more common among blacks (15.5 percent) and Hispanics (10.7 percent) than among whites (4.1 percent), and it was strongly associated with a history of heroin injection (P less than or equal to 0.001). Among 5264 patients in 24 STD clinics, the median rates of HTLV infection were much lower (range, 0.1 percent in Atlanta and Newark to 2.0 percent in Los Angeles). Again, this infection was more common among intravenous drug users (7.6 percent) than among non-drug users (0.7 percent). Eighty-four percent of the seropositive samples from drug-treatment centers and 69 percent of those from STD clinics were due to HTLV-II infection (P = 0.03). CONCLUSIONS. HTLV infections are common among intravenous drug users and are primarily caused by HTLV-II. Among patients seen at STD clinics, HTLV is strongly associated with intravenous drug use, but the retrovirus is also prevalent among non-drug users.     

The prevalence of ulcerated plaques in the aortic arch in patients with stroke.

BACKGROUND AND METHODS. The cause of cerebral infarction is obscure in up to 40 percent of patients with this disorder who are studied prospectively. In this investigation, we determined the frequency of ulcerated plaques in the aortic arch and explored the part they may play in the formation of cerebral emboli. Using an autopsy data bank, we studied the prevalence of ulcerated plaques in the aortic arch in 500 consecutive patients with cerebrovascular and other neurologic diseases who were studied at autopsy. RESULTS. Ulcerated plaques were present in 26 percent of the 239 patients with cerebrovascular disease but in only 5 percent of the 261 patients with other neurologic diseases (P less than 0.001). After we controlled for age and heart weight, the adjusted rates were 16.9 percent and 5.1 percent, respectively (adjusted odds ratio, 4.0; 95 percent confidence interval, 2.1 to 7.8; P less than 0.001). Among the patients with cerebrovascular disease, the prevalence of ulcerated plaques in the aortic arch was 28 percent in the 183 patients with cerebral infarcts and 20 percent in the 56 patients with brain hemorrhage. The prevalence of ulcerated plaques was 61 percent among the 28 patients with no known cause of cerebral infarction, as compared with 22 percent among the 155 patients with a known cause of cerebral infarction (P less than 0.001). After adjustment for covariates, the prevalence was 57.8 percent among patients with no known cause of cerebral infarction and 20.2 percent among those with a known cause (adjusted odds ratio, 5.7; 95 percent confidence interval, 2.4 to 13.6; P less than 0.001). The presence of ulcerated plaques in the aortic arch was not correlated with the presence of extracranial internal-carotid artery stenosis, suggesting that these were two independent risk factors for stroke. CONCLUSIONS. Ulcerated plaques in the aortic arch may play a part in causing cerebral infarction, especially in patients in whom cerebral infarction has no known cause.     

Use of the automatic external defibrillator in the management of out-of-hospital cardiac arrest

The automatic external defibrillator is a simple device that can be used by nonprofessional rescuers to treat cardiac arrest. In 1287 consecutive patients with out-of-hospital cardiac arrest, we assessed the results of initial treatment with this device by firefighters who arrived first at the scene, as compared with the results of standard defibrillation administered by paramedics who arrived slightly after the firefighters. Of 276 patients who were initially treated by firefighters using the automatic defibrillator, 84 (30 percent) survived to hospital discharge (expected rate according to a logistic model, 17 percent; P less than 0.001), as compared with 44 (19 percent) of 228 patients when fire-fighters delivered only basic cardiopulmonary resuscitation and the first defibrillation was performed after the arrival of the paramedic team. Few patients with conditions other than ventricular fibrillation survived. In a multivariate analysis of characteristics that influenced survival after ventricular fibrillation, a better survival rate was related to a witnessed collapse (odds ratio, 3.9; 95 percent confidence interval, 2.0 to 7.6), younger age (odds ratio, 1.2; 95 percent confidence interval, 1.0 to 1.4), the presence of "coarse" (higher-amplitude) fibrillation (odds ratio, 4.2; 95 percent confidence interval, 1.6 to 11.0), a shorter response time for paramedics (odds ratio, 1.4; 95 percent confidence interval, 1.0 to 2.1), and initial treatment by firefighters using an automatic external defibrillator (odds ratio, 1.8; 95 percent confidence interval, 1.1 to 2.9). These findings support the widespread use of the automatic external defibrillator as an important part of the treatment of out-of-hospital cardiac arrest, although the overall impact of the use of this device on community survival rates is still uncertain.     

Racial disparities in HIV incidence among young men who have sex with men: the Baltimore Young Men's Survey

Recent reports have demonstrated racial disparities in the prevalence of HIV infection among men who have sex with men (MSM). The objectives of this study are to investigate whether racial disparities exist in HIV incidence among young MSM in Baltimore, MD and to examine potential explanations for differences. Data were collected by the Baltimore Young Men's Survey, a cross-sectional venue-based survey (1996 to 2000) enrolling MSM aged 15 to 29 years. HIV incidence was ascertained using the serologic testing algorithm for recent HIV seroconversion. HIV incidence was 4.2% per year (95% confidence interval [CI]: 1.2 to 10.5) among 843 participants. There were substantial racial differences in HIV incidence, ranging from 0 among Hispanics to 11.0% per year (95% CI: 5.5 to 19.7) among non-Hispanic blacks. In multivariate analysis, among MSM at risk for HIV acquisition, race was not associated with unprotected anal intercourse. Independent risks included having more than 4 recent male sexual partners (adjusted odds ratio [AOR] = 1.6, 95% CI: 1.0 to 2.4) and being under the influence of drugs while having sex (AOR = 1.6, 95% CI: 1.1 to 2.3). Non-Hispanic blacks were no more likely than non-Hispanic whites to report these risk behaviors. Possible alternative explanations for the observed racial disparities in HIV incidence and implications for prevention are explored.     

Perinatal HIV counseling and rapid testing in Tijuana, Baja California, Mexico: seroprevalence and correlates of HIV infection

OBJECTIVE: To evaluate the acceptance of counseling and rapid HIV testing and to determine the associated risk factors for HIV infection in pregnant women in Baja California, Mexico. METHODS: Pregnant women attending Tijuana General Hospital who consented to participate in the study had blood drawn for a rapid HIV test (Determine HIV-1/2; Abbott Diagnostics, North Chicago, IL). A confirmatory enzyme immunoassay and Western blot were performed and demographic and risk factor data were obtained. RESULTS: From March to November 2003, 1529 (92.5%) of 1653 women who sought prenatal care and 1068 (95.2%) of 1122 women in labor consented to participate. HIV seroprevalence was significantly higher among women screened during labor (12/1068, 1.12%) compared with those seeking prenatal care (5/1529, 0.33%). HIV-infected women were significantly more likely to use injection drugs (12% vs. 1%, P = 0.02), "other" drugs, including methamphetamine, marijuana, and cocaine (65% vs. 6%, P < 0.001), to have more sex partners (3.6 vs. 2.6, P = 0.0002), to not have received prenatal care (41% vs. 13%, P = 0.03), and to have a spouse/partner who used injection drugs (36% vs. 4%, P < 0.001) or "other" drugs (73% vs. 23%, P < 0.001). In multivariate regression analysis, use of methamphetamine (adjusted odds ratio, 17.8, 95% CI, 5.6-56) was independently associated with the risk of HIV infection. CONCLUSIONS: These findings indicate a wide acceptance of HIV counseling and testing and document a higher HIV seroprevalence among pregnant women delivering at Tijuana General Hospital than current established estimates in Mexico.     

Use of complementary and alternative medical therapies among racial and ethnic minority adults: results from the 2002 National Health Interview Survey

PURPOSE: Complementary and alternative medicine (CAM) use among ethnic minority populations is poorly understood. We sought to examine CAM use in Hispanics, non-Hispanic blacks and non-Hispanic whites. METHODS: We analyzed data from the Alternative Health Supplement to the 2002 National Health Interview Survey (NHIS), including information on 19 different CAM therapies used in the past 12 months. RESULTS: An estimated 34% of Hispanic, non-Hispanic black and non-Hispanic white adults in the United States used at least one CAM therapy (excluding prayer) during the prior 12 months (2002). CAM use was highest for non-Hispanic whites (36%), followed by Hispanics (27%) and non-Hispanic blacks (26%). Non-Hispanic whites were more likely to use herbal medicine, relaxation techniques and chiropractic more frequently than Hispanics and non-Hispanic blacks. After controlling for other sociodemographic factors, Hispanic and non-Hispanic black races/ethnicities were associated with less CAM use, with adjusted odds ratios (95% confidence intervals) of 0.78 (0.70, 0.87) and 0.71 (0.65, 0.78), respectively. Hispanics cited using CAM because conventional medical treatments were too expensive more frequently than non-Hispanic blacks or whites. Hispanics had the highest provider nondisclosure rates (68.5%), followed by non-Hispanic blacks (65.1%) and non-Hispanic whites (58.1%). CONCLUSIONS: Excluding prayer, Hispanics and non-Hispanic blacks used CAM less frequently than non-Hispanic whites and were less likely to disclose their use to their healthcare provider. Further research is needed to improve our understanding of the disparities in CAM use.     

Psychotropic drug use and the risk of hip fracture

To assess the risk of hip fracture associated with the use of four classes of psychotropic drugs, we performed a case-control study of 1021 patients with hip fractures and 5606 controls among elderly Medicaid enrollees. Persons treated with hypnotics-anxiolytics having short (less than or equal to 24 hours) elimination half-lives had no increased risk of hip fracture. By contrast, a significantly increased risk was associated with current use of hypnotics-anxiolytics having long (greater than 24 hours) elimination half-lives (odds ratio, 1.8; 95 percent confidence interval, 1.3 to 2.4), tricyclic antidepressants (odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8), and antipsychotics (odds ratio, 2.0; 95 percent confidence interval, 1.6 to 2.6). The risk increased in relation to the doses of drugs in these three classes. An analysis for possible confounding by dementia did not alter the results. Previous but noncurrent use of drugs in these classes conferred no increase in risk. Although a cause-and-effect relation was not proved, these data support the hypothesis that the sedative and autonomic effects of psychotropic drugs increase the risk of falling and fractures in elderly persons. The results suggest the need for studies of this association in other populations and for evaluation of newer psychotropic drugs with fewer undesirable sedative and autonomic effects.     

A comparison of lorazepam, diazepam, and placebo for the treatment of out-of-hospital status epilepticus

BACKGROUND: It is uncertain whether the administration of benzodiazepines by paramedics is an effective and safe treatment for out-of-hospital status epilepticus. METHODS: We conducted a randomized, double-blind trial to evaluate intravenous benzodiazepines administered by paramedics for the treatment of out-of-hospital status epilepticus. Adults with prolonged (lasting five minutes or more) or repetitive generalized convulsive seizures received intravenous diazepam (5 mg), lorazepam (2 mg), or placebo. An identical second injection was given if needed. RESULTS: Of the 205 patients enrolled, 66 received lorazepam, 68 received diazepam, and 71 received placebo. Status epilepticus had been terminated on arrival at the emergency department in more patients treated with lorazepam (59.1 percent) or diazepam (42.6 percent) than patients given placebo (21.1 percent) (P=0.001). After adjustment for covariates, the odds ratio for termination of status epilepticus by the time of arrival in the lorazepam group as compared with the placebo group was 4.8 (95 percent confidence interval, 1.9 to 13.0). The odds ratio was 1.9 (95 percent confidence interval, 0.8 to 4.4) in the lorazepam group as compared with the diazepam group and 2.3 (95 percent confidence interval, 1.0 to 5.9) in the diazepam group as compared with the placebo group. The rates of respiratory or circulatory complications (indicated by bag valve-mask ventilation or an attempt at intubation, hypotension, or cardiac dysrhythmia) after the study treatment was administered were 10.6 percent for the lorazepam group, 10.3 percent for the diazepam group, and 22.5 percent for the placebo group (P=0.08). CONCLUSIONS: Benzodiazepines are safe and effective when administered by paramedics for out-of-hospital status epilepticus in adults. Lorazepam is likely to be a better therapy than diazepam.     

Stroke following coronary-artery bypass surgery. A case-control estimate of the risk from carotid bruits

The causes of stroke following coronary-artery bypass surgery are largely unknown. To determine whether carotid bruits increase the risk of these events, we compared 54 patients with postoperative stroke or transient ischemic attacks with 54 randomly selected control patients. Both groups were drawn from 5915 consecutive patients who had coronary bypass surgery at our hospital from 1970 to 1984. Carotid bruits were noted preoperatively in 13 patients with postoperative stroke and in 4 control patients. Case-control analysis showed that the presence of carotid bruits increased the risk of stroke or transient ischemic attacks by 3.9-fold (95 percent confidence interval, 1.2 to 12.8; P less than 0.05). This increased risk remained essentially unchanged after adjustment for potentially confounding variables in a multiple logistic regression analysis. Other factors associated with a significantly increased risk (P less than 0.05) of these neurologic deficits were a history of stroke or transient ischemic attack (odds ratio, 6.0; 95 percent confidence interval, 1.6 to 22.1), a history of congestive heart failure (odds ratio, 5.3; confidence interval, 1.6 to 17.0), mitral regurgitation (odds ratio, 4.3; confidence interval, 1.4 to 12.9), postoperative atrial fibrillation (odds ratio, 3.0; confidence interval, 1.4 to 6.7), a cardiopulmonary-bypass pump time of more than two hours (odds ratio, 2.7; confidence interval, 1.1 to 6.7), and a previous myocardial infarction (odds ratio, 2.3; confidence interval, 1.1 to 5.1). We conclude that the presence of carotid bruits increases the risk of stroke after coronary-artery bypass surgery. However, the absolute magnitude of this risk, 2.9 percent, is small and comparable to the reported risk of stroke from carotid endarterectomy.     

Underlying causes and long-term survival in patients with initially unexplained cardiomyopathy

BACKGROUND: Previous studies of the prognosis of patients with heart failure due to cardiomyopathy categorized patients according to whether they had ischemic or nonischemic disease. The prognostic value of identifying more specific underlying causes of cardiomyopathy is unknown. METHODS: We evaluated the outcomes of 1230 patients with cardiomyopathy. The patients were grouped into the following categories according to underlying cause: idiopathic cardiomyopathy (616 patients), peripartum cardiomyopathy (51); and cardiomyopathy due to myocarditis (111), ischemic heart disease (91), infiltrative myocardial disease (59), hypertension (49), human immunodeficiency virus (HIV) infection (45), connective-tissue disease (39), substance abuse (37), therapy with doxorubicin (15), and other causes (117). Cox proportional-hazards analysis was used to assess the association between the underlying cause of cardiomyopathy and survival. RESULTS: During a mean follow-up of 4.4 years, 417 patients died and 57 underwent cardiac transplantation. As compared with the patients with idiopathic cardiomyopathy, the patients with peripartum cardiomyopathy had better survival (adjusted hazard ratio for death, 0.31; 95 percent confidence interval, 0.09 to 0.98), and survival was significantly worse among the patients with cardiomyopathy due to infiltrative myocardial disease (adjusted hazard ratio, 4.40; 95 percent confidence interval, 3.04 to 6.39), HIV infection (adjusted hazard ratio, 5.86; 95 percent confidence interval, 3.92 to 8.77), therapy with doxorubicin (adjusted hazard ratio, 3.46; 95 percent confidence interval, 1.67 to 7.18), and ischemic heart disease (adjusted hazard ratio, 1.52; 95 percent confidence interval, 1.07 to 2.17). CONCLUSIONS: The underlying cause of heart failure has prognostic value in patients with unexplained cardiomyopathy. Patients with peripartum cardiomyopathy appear to have a better prognosis than those with other forms of cardiomyopathy. Patients with cardiomyopathy due to infiltrative myocardial diseases, HIV infection, or doxorubicin therapy have an especially poor prognosis.     

Do the results of randomized clinical trials of cardiovascular drugs influence medical practice? The SAVE Investigators.

BACKGROUND. Medical practice patterns change in response to a variety of stimuli, one of which may be the publication of the results of randomized clinical trials. We assessed the temporal association between the publication of clinical trials on myocardial infarction and changes in treatment practices for this disorder. METHODS. We analyzed the use of aspirin before and after myocardial infarction and that of calcium antagonists after myocardial infarction in 2231 survivors of myocardial infarction enrolled in the Survival and Ventricular Enlargement (SAVE) study over a three-year period (from January 1987 through January 1990). The proportion of patients using these treatments was analyzed before and after the publication dates of three clinical trials: the Physicians' Health Study, published in January 1988, which supported the use of aspirin to prevent a first myocardial infarction; the Second International Study of Infarct Survival (ISIS-2), published in August 1988, which supported the use of aspirin after myocardial infarction; and the Multicenter Diltiazem Postinfarction Trial, published in August 1988, which reported a deleterious effect of diltiazem in some patients after myocardial infarction. RESULTS. The use of aspirin before myocardial infarction increased from 16.2 percent to 23.9 percent between January 1987 and January 1990 (P less than 0.001). Enrollment in the study after the publication of the Physicians' Health Study independently predicted aspirin use before myocardial infarction (odds ratio, 1.43; 95 percent confidence interval, 1.11 to 1.85). The use of aspirin after myocardial infarction increased from 38.8 percent to 71.9 percent (P less than 0.001) during the three-year study period. Enrollment in the study after the publication of ISIS-2 independently predicted the use of aspirin after myocardial infarction (odds ratio, 2.28; 95 percent confidence interval, 1.89 to 2.76). The use of calcium antagonists after myocardial infarction decreased from 57.1 percent to 33.1 percent (P less than 0.001) during the study period. Enrollment in the study after the publication of the Multicenter Diltiazem Postinfarction Trial independently predicted the use of calcium antagonists after myocardial infarction (odds ratio, 0.47; 95 percent confidence interval, 0.39 to 0.57). CONCLUSIONS. These observations suggest that randomized clinical trials have a measurable influence on medical practice patterns.     

Prevalence of human immunodeficiency virus and its association with hepatitis B,C, and D virus infections among incarcerated male substance abusers in Taiwan

Taiwan has been facing a rising epidemic of human immunodeficiency virus (HIV) infection since 2004. Injection drug users comprised 38.5% of accumulated HIV cases by 2007. This cross‐sectional study investigated the seroprevalence of hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), and HIV infection in 753 male substance users who were detained in a detoxification center in Taoyuan, Taiwan. The subjects were enrolled into the study consecutively between February and October, 2005. The seroprevalence rates of HIV antibodies, HCV antibodies, and HBV surface antigens among all subjects, and HDV antibodies among HBV carriers were 6.9% (95% confidence interval [CI]: 5.19–8.95), 30.5% (95% CI: 27.23–33.93), 16.9% (95% CI: 14.24–19.71) and 13.7% (95% CI: 8.19–21.04), respectively. Subjects in the heroin injection group had significantly higher rates of HIV infection, HCV infection and HDV superinfection (25.5%, 89.6%, and 38.7%) than those in the heroin non‐injection group (0.9%, 24.5%, and 6.25%), the methamphetamine group (0.3%, 8.1%, and 6.7%), and the club drug group (1%, 3%, and 0%; P < 0.001). The odds of HCV, HIV, or HDV infection were 74.7, 63.8, and 11.1 higher, respectively, for heroin injection drug users than for non‐injection drug users (P < 0.0001). Compared to HIV‐negative individuals, the odds of being a heroin injector and the odds of HCV co‐infections were 64‐fold and 149‐fold higher, respectively, in HIV‐positive individuals. The impact of HBV, HCV, and HDV infection on the HIV epidemic in Taiwan should be monitored closely. J. Med. Virol. 81:973–978, 2009. © 2009 Wiley‐Liss, Inc.     

Nitrovasodilators, low-dose aspirin, other nonsteroidal antiinflammatory drugs, and the risk of upper gastrointestinal bleeding

BACKGROUND The relation between medications that release nitric oxide, such as nitroglycerin and other nitrovasodilators, and upper gastrointestinal bleeding is uncertain. In animals, these medications reduce the gastric damage induced by nonsteroidal antiinflammatory drugs. Nitric oxide, however, inhibits platelet aggregation and may contribute to bleeding from an ulcer. METHODS: We performed a case-control study to determine the risk of bleeding in patients taking nitrovasodilators, low-dose aspirin, or other nonsteroidal antiinflammatory drugs. The case group was made up of 1122 consecutive patients admitted to one of four hospitals with bleeding from a peptic lesion. The 2231 control subjects were 1109 patients hospitalized for other reasons and 1122 outpatients from the same geographic area. RESULTS: In the week before admission, 520 (46.3 percent) of the patients with bleeding had taken a nonsteroidal antiinflammatory drug other than low-dose aspirin, 120 (10.7 percent) had taken low-dose aspirin (< or = 300 mg per day), 60 (5.3 percent) a nitrovasodilator, and 135 (12.0 percent) an antisecretory agent such as a histamine H2-receptor antagonist or a proton-pump inhibitor. In multivariate models that adjusted for age, sex, and clinical risk factors, the use of a nonsteroidal antiinflammatory drug other than low-dose aspirin was independently associated with an increased risk of bleeding from a peptic ulcer (odds ratio, 7.4; 95 percent confidence interval, 4.5 to 12.0), as was the use of low-dose aspirin alone (odds ratio, 2.4; 95 percent confidence interval, 1.8 to 3.3). The use of a nitrovasodilator was associated with a decreased risk of bleeding (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 0.9), as was antisecretory therapy (odds ratio, 0.6; 95 percent confidence interval, 0.4 to 0.8). In patients taking any type of nonsteroidai antiinflammatory drug, the use of a nitrovasodilator or antisecretory therapy was independently associated with a decreased risk of bleeding. CONCLUSIONS: The use of nitrovasodilator drugs is independently associated with a decreased risk of upper gastrointestinal bleeding.     

Requiring help injecting independently predicts incident HIV infection among injection drug users

BACKGROUND: Requiring help injecting has been associated with syringe sharing among injection drug users (IDUs). No prospective study has fully examined this risk factor and its relation to rates of HIV infection. We investigated whether requiring help injecting illicit drugs was a predictor of HIV infection among a prospective cohort of IDUs. METHODS: The Vancouver Injection Drug User Study is a prospective study of more than 1500 IDUs who have been recruited from the Downtown Eastside of Vancouver since May 1996. At baseline and semiannually, subjects provided blood samples and completed an interviewer-administered questionnaire. The questionnaire elicits demographic data as well as information about drug use, HIV risk behavior, and drug treatment. HIV incidence rates were calculated using Kaplan-Meier methods, and Cox regression determined independent predictors of seroconversion. RESULTS: A total of 1013 baseline HIV-negative participants were eligible for this study. Within this population, 418 (41.3%) participants had required help injecting during the last 6 months at baseline. Participants requiring help injecting were more likely to be female (odds ratio = 2.3, 95% confidence interval [CI]: 1.8-3.0; P < 0.001), were slightly younger (33.5 vs. 34.9 years of age; P = 0.014), and had fewer years of experience injecting drugs (7 vs. 11 years; P < or = 0.001). Among participants who required help injecting at baseline, cumulative HIV incidence at 36 months was 16.1% compared with 8.8% among participants who did not require help injecting (log-rank, P < 0.001). In an adjusted model controlling for potential confounding variables, being aboriginal (relative hazard [RH] = 1.68, 95% CI: 1.15-2.48), injecting cocaine daily (RH = 2.71, 95% CI: 1.87-3.95), and requiring help injecting (RH = 1.79, 95% CI: 1.23-2.62) remained independent predictors of HIV seroconversion. CONCLUSIONS: These data demonstrate the need for interventions to reduce the risk of HIV infection among IDUs who require help injecting.     

An investigation of the cause of the eosinophilia-myalgia syndrome associated with tryptophan use

BACKGROUND. The eosinophilia-myalgia syndrome is a newly recognized illness that has been associated with the consumption of tryptophan products. It is not known whether the cause is related to the tryptophan itself or to chemical constituents introduced by the manufacturing process. METHODS. To describe the epidemiology of the eosinophilia-myalgia syndrome further and elucidate a possible association with the manufacturing process, we conducted surveillance for the syndrome in Minnesota, a community survey of tryptophan use in Minneapolis-St. Paul, and a case-control study to assess potential risk factors, including the use of tryptophan from different manufacturers. We performed high-performance liquid chromatography on tryptophan samples to identify other chemical constituents. RESULTS. The prevalence of tryptophan use increased from 1980 to 1989 and was highest among women. Among the subjects for whom the source of the tryptophan was known, 29 of 30 case patients (97 percent) and 21 of 35 controls (60 percent) had consumed tryptophan manufactured by a single company (odds ratio, 19.3; 95 percent confidence interval, 2.5 to 844.9; P less than 0.001). This company used a fermentation process involving Bacillus amyloliquefaciens to manufacture tryptophan. Analysis of the manufacturing conditions according to the retail lot demonstrated an association between lots used by case patients and the use of reduced quantities of powdered carbon in a purification step (odds ratio, 9.0; 95 percent confidence interval, 1.1 to 84.6; P = 0.014), as well as the use of a new strain of B. amyloliquefaciens (Strain V) (odds ratio, 6.0; 95 percent confidence interval, 0.8 to 51.8; P = 0.04). There was a significant correlation (r = 0.78, P less than 0.001) between the reduced amount of powdered carbon used during manufacturing and the use of the new bacterial strain. High-performance liquid chromatography of this company's tryptophan demonstrated one absorbance peak (peak E) that was present in 9 of the 12 retail lots (75 percent) used by patients and 3 of 11 lots (27 percent) used by controls (odds ratio, 8.0; 95 percent confidence interval, 0.9 to 76.6; P = 0.022). CONCLUSIONS. The outbreak of the eosinophilia-myalgia syndrome in 1989 resulted from the ingestion of a chemical constituent that was associated with specific tryptophan-manufacturing conditions at one company. The chemical constituent represented by peak E may contribute to the pathogenesis of the eosinophilia-myalgia syndrome, or it may be a surrogate for another chemical that induces the syndrome.     

Risk factors for falls as a cause of hip fracture in women. The Northeast Hip Fracture Study Group

BACKGROUND. Although even in the elderly most falls are not associated with fractures, over 90 percent of hip fractures are the result of a fall. Few studies have assessed whether the risk factors for falls are also important risk factors for hip fracture. METHODS. To examine the importance of risk factors for falls in the epidemiology of hip fracture, we performed a case-control study of 174 women (median age, 80 years) admitted with a first hip fracture to 1 of 30 hospitals in New York and Philadelphia. Controls, matched to the case patients according to age and hospital, were selected from general surgical and orthopedic surgical hospital services. Information was obtained by direct interview. RESULTS. As measured by the odds ratio, increased risks for hip fracture were associated with lower-limb dysfunction (odds ratio = 1.7; 95 percent confidence interval, 1.1 to 2.8), visual impairment (odds ratio = 5.1; 95 percent confidence interval, 1.9 to 13.9), previous stroke (odds ratio = 2.0; 95 percent confidence interval, 1.0 to 4.0), Parkinson's disease (odds ratio = 9.4; 95 percent confidence interval, 1.2 to 76.1), and use of long-acting barbiturates (odds ratio = 5.2; 95 percent confidence interval, 0.6 to 45.0). Of the controls, 44 (25 percent) had had a recent fall. The case patients were more likely than these controls to have fallen from a standing height or higher (odds ratio = 2.4; 95 percent confidence interval, 1.0 to 5.7). Of those with hip fracture the younger patients (less than 75 years old) were more likely than the older ones (greater than or equal to 75 years old) to have fallen on a hard surface (odds ratio = 1.9; 95 percent confidence interval, 1.04 to 3.7). CONCLUSIONS. A number of factors that have been identified as risk factors for falls are also associated with hip fracture, including lower-limb dysfunction, neurologic conditions, barbiturate use, and visual impairment. Given the prevalence of these problems among the elderly, who are at highest risk, programs to prevent hip fracture should include measures to prevent falls in addition to measures to slow bone loss.