E. Russell Alexander

Etiology manifestations and therapy of acute epididymitis: prospective study of 50 cases.

There were 50 patients with acute epididymitis who were evaluated prospectively by history, examination and microbiologic studies, including cultures for aerobes, anaerobes, Neisseria gonorrhoeae, Chlamydia trachomatis and Ureaplasma urealyticum. Escherichia coli was the predominant pathogen isolated from the urine of men more than 35 years old, while Chlamydia trachomatis and Neisseria gonorrhoeae were the predominant pathogens isolated from the urethra of men less than 35 years old. The etiologic role of Escherichia coli and Chlamydia trachomatis was confirmed by isolation from epididymal aspirates from a high proportion of men with positive urine or urethral cultures for these agents. Chlamydia trachomatis epididymitis accounted for two-thirds of idiopathic epididymitis in young men and often was associated with oligospermia. Of 9 female sexual partners of men with Chlamydia trachomatis infection 6 had antibody to Chlamydia trachomatis, of whom 2 had positive cervical cultures for this organism and 2 others had non-gonococcal pelvic inflammatory disease. Antibiotic therapy with tetracycline was effective for the treatment of men with Chlamydia trachomatis epididymitis and should be offered to the female sex partners.

A Case-Control Study of Necrotizing Fasciitis During Primary Varicella

Objective. An increase in the incidence of necrotizing fasciitis (NF) occurring in previously healthy children with primary varicella was noted in the Washington State area between December 1993 and June 1995. Our objective was to investigate ibuprofen use and other risk factors for NF in the setting of primary varicella. Methods. Case-control study. Demographic information, clinical parameters, and potential risk factors for NF were compared for cases and controls. Cases of NF were analyzed to identify potential determinants of NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome. Multivariate logistic regression was used to evaluate the association between ibuprofen use and NF. A case was defined as a child with NF hospitalized within 3 weeks of primary varicella (n = 19). Controls were children hospitalized with a soft tissue infection other than NF within 3 weeks of primary varicella (n = 29). Odds ratios (ORs) of ibuprofen, as well as other potential risk factors were evaluated. In addition, demographic and clinical data as well as other potential risk factors were compared between cases and controls. Results. After controlling for gender, age, and group A streptococcus isolation, cases were more likely than controls to have used ibuprofen before hospitalization (OR, 11.5; 95% confidence interval, 1.4 to 96.9). In most children, ibuprofen was initiated after the onset of symptoms of secondary infection. Children with NF complicated by renal insufficiency and/or streptococcal toxic shock syndrome were more likely than children with uncomplicated NF to have used ibuprofen (OR, 16.0; 95% confidence interval, 1.0 to 825.0). Children with complicated NF also had a higher mean maximum temperature (40.9°C vs 39.3°C), and a longer mean duration of secondary symptoms (1.7 days vs 0.6 days) before admission than children with uncomplicated NF. Conclusion. Ibuprofen use was associated with NF in the setting of primary varicella. Additional studies are needed to establish whether ibuprofen use has a causal role in the development of NF and its complications during varicella.

Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors

The association between needle exchange, change in drug use frequency and enrollment and retention in methadone drug treatment was studied in a cohort of Seattle injection drug users (IDUs). Participants included IDUs classified according to whether they had used a needle exchange by study enrollment and during the 12-month follow-up period. The relative risk (RR) and the adjusted RR (ARR) were estimated as measures of the association. It was found that IDUs who had formerly been exchange users were more likely than never-exchangers to report a substantial (> or= 75%) reduction in injection (ARR = 2.85, 95% confidence limit [CL] 1.47-5.51), to stop injecting altogether (ARR = 3.5, 95% CL 2.1-5.9), and to remain in drug treatment. New users of the exchange were five times more likely to enter drug treatment than never-exchangers. We conclude that reduced drug use and increased drug treatment enrollment associated with needle exchange participation may have many public health benefits, including prevention of blood-borne viral transmission.

Therapy for Nongonococcal Urethritis: Double-Blind Randomized Comparison of Two Doses and Two Durations of Minocycline

We treated 289 men who had nongonococcal urethritis with minocycline, 100 mg once or twice daily for 7 to 21 days. After 21 +/- 7 days, urethritis persisted or recurred in 31 (27%) of 114 given 7-day therapy and only nine (8%) of 110 given 21-day therapy (p = 0.0005). However, by 49 +/- 14 days, the cumulative percent rate of failure was 31% for 7-day and 30% for 21-day therapy. Thus, 21-day therapy only delayed recurrence. The higher daily dosage did not improve outcome. Urethritis persisted or recurred in 19% of men with initial Chlamydia trachomatis infection. Among men without C. trachomatis, urethritis persisted or recurred in 32% with and 52% without Ureaplasma urealyticum infection (p = 0.03). At follow-up, 79% of cases of persistent or recurrent urethritis were culture negative for C. trachomatis and U. urealyticum. The cause of C. trachomatis-negative, U. urealyticum-negative nongonococcal urethritis, which was least responsive to minocycline therapy, remains uncertain.

Risk of infection with hepatitis A, B or C, cytomegalovirus, varicella or measles among child care providers

BACKGROUND Employment as a child care provider has been suggested as an indication for hepatitis A virus (HAV) immunization; however, whether this occupational group is at increased risk of HAV infection is not well-defined. METHODS We obtained sera samples for testing for antibodies to hepatitis A, B and C, cytomegalovirus, varicella and measles from a sample of child care providers in King County, WA, and administered a questionnaire to assess employment characteristics and other potential risk factors for infection. We also compared the anti-HAV seroprevalence among providers with that of subjects in the Third National Health and Nutrition Survey, representative of the US general population. RESULTS Thirteen percent (48 of 360) of providers were anti-HAV-positive (46% (22 of 47) of foreign born vs. 8% (26 of 313) of US-born (P < 0.001)). In multivariate analysis anti-HAV seropositivity was associated with foreign birth, age, income and Hispanic ethnicity but was not associated with characteristics of employment. Seroprevalence among US-born providers tended to be lower than that among Third National Health and Nutrition Survey subjects of similar age, sex, race and income. Sixty-two percent of providers were seropositive to cytomegalovirus, which was associated with nonwhite race, changing diapers > or = 3 days/week while at work and having a child in the household. Antibody prevalence was 1.4% to hepatitis B core antigen, 0.6% to hepatitis C, 94% to measles and 98% to varicella. CONCLUSIONS The anti-HAV prevalence among US-born providers was low, and seropositivity was not associated with employment characteristics, indicating that occupational exposure to HAV is uncommon under non-outbreak circumstances.

VOLUNTEER BIAS IN NONRANDOMIZED EVALUATIONS OF THE EFFICACY OF NEEDLE-EXCHANGE PROGRAMS

ObjectiveNonrandomized comparisons of the incidence of HIV and hepatitis B and C between injection drug users (IDUs) who do and do not attend voluntary needle-exchange programs may be subject to bias. To explore possible sources of bias, we examined characteristics associated with voluntarily beginning or ceasing to participate in the Seattle needle exchange.MethodsIn a cohort of 2,879 IDUs, a standardized questionnaire measured characteristics present at enrollment. We examined the relation of these characteristics to the proportion of IDUs who began to use the program during the ensuing 12-month follow-up period and to the proportion of current exchangers who dropped out during that period of time.ResultsOf the 494 never-exchangers at baseline, 32% attended the exchange program during follow-up; those who reported sharing syringes or who were homeless at enrollment were more likely to become new exchange users (adjusted risk ratio [ARR] for becoming an exchange user = 1.8 for those who shared syringes, and ARR=2.2, for those who were homeless). Of 1,274 current exchangers, 16% stopped using the exchange during follow-up, with daily injectors (ARR=0.6) and those who reported backloading (ARR=0.6) being relatively less likely to drop out of the exchange.ConclusionsThe analysis suggests that IDUs participating in needle-exchange programs at a given point in time may include a particularly high proportion of those injectors whose pattern of drug use puts them at elevated risk of blood-borne viral infections.

Invasive Haemophilus influenzae Disease and Epiglottitis Among Swiss Children from 1980 to 1993: Evidence for Herd Immunity Among Older Age Groups

We analysed time trends in the incidence of invasive Haemophilus influenzae disease in Switzerland between 1980 and 1993 to investigate whether conjugated H. influenzae type b vaccines, licensed in Switzerland in May 1990, confer indirect protection to children in older, non-vaccinated age groups. Data were obtained from the records of 39 Swiss paediatric clinics for 2,857 children 0-16 years old with invasive H. influenzae disease. Incidence time trends were analysed by Poisson regression. The diseases incidence decreased by 80% among 0-4-year-old children (i.e. those eligible for vaccination) between 1990 and 1993. Among children aged 5-16 years, there also was an abrupt 50% fall in the incidence of H. influenzae meningitis after 1990. However, the incidence of epiglottitis in this age group had started to decline before conjugated vaccines became available, with no additional decline thereafter. While our results suggest some indirect protection conferred to older, non-vaccinated children through the administration of conjugated vaccines to younger children, they also argue that underlying time trends of invasive H. influenzae disease need not be considered when interpreting incidence rates in the vaccine era.

Circulatory and cellular immune responses to squamous cell carcinoma of the uterine cervix.

The sera from 176 patients with cervical cancer were examined by indirect immunofluorescence against cervical cancer cells (imprints of cervical cancer tissue). The mean serum titer in these patients was significantly higher than the titer in two control groups of identical size. These tumor-related antibodies were also higher in titer in sera from a small sample of nine husbands of cancer patients than in 18 control group patients. A cell-mediated immune response was studied with the use of leukocyte-migration inhibition from 39 blood specimens, including 23 patients with invasive epithelial carcinoma, five with intraepithelial carcinoma of the uterine cervix, six with other gynecologic diseases, and five without gynecologic disease. Migration inhibition was demonstrated for squamous cell carcinoma of the uterine cervix, suggesting a common specific cell-mediated response.

Factors Related to ST-Segment Depression after Exercise in Middle-Aged Chinese Men

Ninety-four or 7% of 1,346 healthy middle-aged Chinese men who underwent a graded treadmill test of maximal exercise showed post-exercise ST-segment depression. Stepwise linear discriminant function analysis showed that the major factors associated with this response were systolic blood pressures at maximal exercise, age, and certain resting ECG abnormalities, and to a lesser extent, systolic and diastolic pressure at rest, resting heart rate, and cigarette smoking. Hypertensive subjects showed at least a fourfold increase of post-exercise ST depression as compared with age-matched normotensive controls. Since coronary atherosclerosis is rare among Chinese, the study is of particular interest in demonstrating some factors related to ST depression after maximal exercise, particularly the effect of higher systemic pressure, in a group of middle-aged Chinese men.

Physical characteristics and exercise performance of pedicab and upper socioeconomic classes of middle-aged Chinese men. A comparative study of some risk factors for coronary heart disease.

Abstract 1. 1. A comparative study of physical characteristics and exercise performance of Chinese men of 40 to 59 years of age included 100 pedicabmen and 1,346 men from the upper socioeconomic class in Taipei, Taiwan. The daily arduous physical exertion and restricted diet imposed by meager earnings of the pedicabmen provided a group which approached the ultimate in minimizing risk factors for coronary heart disease. 2. 2. The pedicabmen were of comparable age and height, yet significantly lower mean body weight, skinfolds, circumferences of arm and waist, and serum concentrations of cholesterol and uric acid were characteristic of greater physical conditioning and prolonged dietary restrictions. Heart size was slightly larger, while greater exercise capacity, delayed acceleration of exertional heart rate, and more rapid postexertional deceleration of heart rate documented physical conditioning of the cardiovascular system. 3. 3. Whereas the usual trend for progressive increments in age-specific prevalence of S-T segment depression after maximal exertion was clearly demonstrated in men from the upper socioeconomic classes, the slight increase in a small number of older pedicabmen was not statistically significant. The protective role of dietary restrictions and/or enhanced physical activity imposed by a low socioeconomic status might be inferred from these observations.