Behavioural and serological human immunodeficiency virus risk factors among female commercial sex workers in Cambodia.

BACKGROUND: The spread of human immunodeficiency virus (HIV) in Cambodia is mainly caused by sexual transmission and the high-risk group in this country are female commercial sex workers (CSW). There are two types of CSW, direct CSW (DCSW) and indirect CSW (IDCSW), who are different from each other in sexual activities. This study was conducted in order to describe the risk factors on HIV for each type of CSW, and to establish effective preventive strategies against the HIV epidemic among CSW. METHODS: The participants, 143 DCSW and 94 IDCSW, were interviewed using a questionnaire to determine their demographic characteristics and behaviour. Blood samples were taken for serological tests on HIV, Chlamydia trachomatis and syphilis. The association between their behavioural pattern and their serological results was analysed. RESULTS: The questionnaire study showed that IDCSW had a riskier behavioural pattern than DCSW. The HIV seroprevalence rates of the DCSW and the IDCSW were 52.4% and 22.3%, respectively. Univariate logistic analyses showed a significant association between HIV antibody (HIV-Ab) and current age, age at commencement of commercial sex work, duration of commercial sex work, and the seropositivity of Chlamydia trachomatis-IgG antibody (CT-IgG-Ab) among the DCSW. The analyses also showed a significant relationship between HIV-Ab and CT-IgG-Ab among the IDCSW. CONCLUSIONS: Improving condom use rate is very important in order to prevent an HIV epidemic among the two types of CSW. This study also suggests it is important to prevent sexually transmitted disease (STD) such as Chlamydia trachomatis infection. The STD control programme could be efficient for HIV prevention, especially among DCSW.

Hepatic veno-occlusive disease in a patient with lupus anticoagulant after allogeneic bone marrow transplantation.

A 37-year-old man with acute myeloblastic leukemia (FAB M2) in first remission underwent a bone marrow transplant (BMT) following conditioning with high-dose cytarabine and total body irradiation. The donor was an HLA-identical brother. Graft rejection occurred and a second BMT was performed from the same donor following conditioning with cyclophosphamide. Engraftment was achieved, but the patient developed severe jaundice and died of respiratory failure on day +46 after the second BMT. Liver biopsy revealed luminal narrowing of the central veins and a diagnosis of hepatic veno-occlusive disease (VOD) was made. The coagulation studies showed a prolonged kaolin clotting time which was not corrected by 1:1 mixture with normal plasma, and the platelet neutralization test was positive. Dilute tissue thromboplastin time and dilute Russell viper venom time were also prolonged. These results fulfilled the criteria for lupus anticoagulant, which may have contributed to VOD in this patient.

Three year follow up study of national influenza vaccination practices in Japan.

STUDY OBJECTIVE: To evaluate new national influenza vaccination practices which were started in 1987 under a revised law in Japan. DESIGN: This was a three year, nonrandomised cohort study with information collected by questionnaire between 1989 and 1991. SETTING: Eight primary schools in the city of Yonago, Tottori, Japan. These schools were selected from 23 schools in the city. PARTICIPANTS: Altogether 4251 pupils (1355 boys and 2896 girls) in years 1-4 of the eight primary schools were included in this study, and followed up. Three years later, data for 1619 pupils (768 boys and 851 girls) were obtained and analysed. MAIN RESULTS: The one-winter seasonal incidence rates of influenza-like disease were 13.4%, 29.9%, and 10.3% in 1989, 1990, and 1991 respectively. The incidence rate of influenza-like disease in fully vaccinated pupils was significantly lower than that in unvaccinated pupils in 1990, but not in 1989 or 1991. Stepwise multiple regression analysis showed that the incidence of influenza-like disease had a statistical relationship with the frequency of vaccination and the school year (R2 was 0.0148). Standardised parameters of the frequency of vaccination and the school frequency of vaccination and the school year were -0.089 and -0.080 respectively. CONCLUSIONS: The preventive effects of influenza vaccine are not strong. There must be some unknown factors that affect the incidence of influenza. This vaccine is useful for pupils in the early school years who seem to have less resistance. All pupils should not be inoculated with the vaccine to reduce influenza transmission in the community or school.

Effect of oleoresin capsicum (OC) and ortho-chlorobenzylidene malononitrile (CS) on ciliary beat frequency.

Tear gases are largely used to control civil unrest. Their incapacitating effects involve the eyes, skin, and respiratory tract. We aimed to evaluate the effects of ortho-chlorobenzylidene malononitrile (CS) and oleoresin capsicum (OC) on ciliary beat frequency (CBF) of mouse tracheal rings. Addition of 0.05% OC or 0.01% CS induced a progressive decrease in CBF, from 11.5+/-0.5 to 4+/-0.1 Hz (P<0.05) and from 12.5+/-0.5 to 2.5+/-0.1 Hz (P<0.05), respectively, 30 min after exposure to the tear gas. Addition of exogenous ATP inhibited the effect of OC, suggesting that ATP could be used to counteract these adverse effects on CBF. However, ATP was inefficient against CS. Methylene blue and H7 inhibited the effects of OC, whereas indomethacin had no effect. None of these drugs affected the inhibitory action of CS. These results suggest that the inhibitory effect of OC is mediated through the guanylate cyclase-dependent pathway or protein kinase C-dependent phosphorylation. Another mechanism is probably involved in CS-induced inhibitory effect. Histological analysis of the trachea revealed an increase in mucus secretion after exposure to OC, and cytoplasmic vacuoles in epithelial cells after exposure to CS.

Association between angiotensin converting enzyme gene polymorphism and clinical features in autosomal dominant polycystic kidney disease.

We investigated the association between angiotensin converting enzyme (ACE) gene polymorphism and clinical manifestations in 47 patients with autosomal dominant polycystic kidney disease (ADPKD). One-hundred, age- and sex-matched subjects with non-ADPKD served as the controls. ACE gene polymorphism was analysed using a GeneAnp kit. Renal size was determined by abdominal CT scan, by adding the longitudinal axis of each kidney. Incidence of extrarenal complication was also examined. Out of 47 patients, 24 patients (51%) were II, 18 (38%) ID and 5 (11%) DD type. The frequencies of the I and D alleles as well as the distributions of ACE genotypes in ADPKD did not differ from those in controls. The number of patients undertaking renal replacement therapy was 11 in II (46%), 6 (33%) in ID and 2 (40%) in DD genotype, respectively, that was not significantly different among the groups. The mean age of the initiation of renal replacement therapy did not vary among the three genotypes. The slopes of 1/serum creatinine did not differ between II and ID genotypes, whose initial serum creatinine levels ranged from 1.5 to 2.5 mg/dl. Renal size, blood pressure, and extrarenal complications including liver cysts and cardiac valvular disease were unrelated to the ACE genotypes. The present data suggested the irrelevance of ACE gene polymorphism in clinical manifestations in patients with ADPKD.

An expert system for early detection of cancer of the breast.

In order to study the relevancy of exploring complex expert systems for use by the lay public, an expert system for the early detection of cancer of the breast has been developed. The system consists of a conversion between a microcomputer and a woman who is anxious about breast cancer. The conversation is divided into two parts: one is listening to the woman's symptoms regarding the breast then giving advice, the other is an explanation of breast cancer and how to detect it in its early stages. After listening to the woman's symptoms, the computer presents its conclusion and suggests courses of action the woman should take. The system is written in Prolog. It was tried by women in a small town at a festival for health, by female patients who visit our hospital, and received a positive reaction.

[Systems analytical investigation of the effect of countermeasures against the AIDS epidemic among homosexuals].

In Japan, the AIDS (Acquired Immunodeficiency Syndrome) epidemic among haemophiliacs has been the most urgent issue, because of the large number of haemophiliacs with AIDS. However, after governmental approval of the production of heated coagulating agents in 1985 and 1986, the prime object of prevention against the AIDS epidemic shifted from transmission through coagulation agents to that through sexual contacts. In order to investigate the most appropriate countermeasures against the AIDS epidemic among homosexuals in Japan, the numbers of HIV (Human Immunodeficiency Virus)-infected cases and AIDS cases in the future were estimated, and changes of the future numbers of HIV-infected persons and AIDS cases by behavior of homosexuals were compared using a systems analytical method. The methods of estimation and comparison are similar to those of R. M. Anderson and others, using numerical analysis of a mathematical model consisting of differential equations. They assumed a closed homosexual group whose members seldom have contact with members of other homosexual groups, but we assumed an open homosexual group whose members are being infected by other groups, because this assumption was more appropriate to the situation of homosexual society in Japan. The results showed that the prevalence number of HIV-infected cases would be about 1,800, that the prevalence number of AIDS cases would be about 100 among 100,000 homosexuals at 20 years after the beginning of the AIDS epidemic, and that the most effective countermeasure was reducing the frequency of sexual contacts among members or taking prophylactic measures during sexual contacts. These prevalence numbers of HIV-infected cases and AIDS cases would be reduced to between 1/4 and 1/2 of the above-mentioned calculated values by promotion of that countermeasure.

[Follow-up study of obese pupils and their life styles in the lower grades of primary schools].

Physical examinations and a questionnaire survey of life style were carried out on all pupils (105 boys and 110 girls) at the first grade of primary school in Saigo town, Fuse village, Goka village, and Tsuma village of Shimane prefecture in 1992. In 1994, physical examinations and a questionnaire survey were again performed along with a newly-added blood examination on the same cohort. Parents of the pupils answered the questionnaire. The pupils who were included in both the first (in 1992) and the second (in 1994) examinations and surveys (89 boys and 101 girls, but 71 boys and 77 girls for blood examination) were subjects in this study to analyse the relationship between obesity and life style. The results showed (a) the proportional rates of obese boys and girls increased during the two years; (b) the obesity index of boys and girls in the third grades correlated with the obesity index of their mothers; (c) obese boys ate snacks frequently, had a higher speed in eating, and disliked physical exercise; and (d) the obesity index of boys and girls correlated with serum total cholesterol. These findings indicate that obesity occurs as early as the lower grades of primary schools and that it continues for at least two years.

[Participation of regional inhabitants in cancer screening].

As part of the strategic planning for increasing participation by community residents in cancer screening, a survey about life style and attitudes toward cancer screening was carried out in Samukawa town, Kanagawa Prefecture. Subjects were males 40 years old or over, and females 30 years old or over selected by random sampling from residents. Number of subjects was 1,916 (822 males, 1,094 females). Self administered anonymous questionnaires were sent and returned by mail. The response rate was 73%. The results were as follows: (1) The reported participation rates for cancer screening under "the Health and Medical Services Law for the Aged" did not reflect the actual participation rate of residents. (2) The major reason for not participation in screening was lack of interest in cancer prevention. (3) Socio-economic status of regular participants in screening was different from persons who did not participate. (4) Persons who did not participate in screening were more passive with regard to obtaining knowledge of cancer than regular participants. (5) Results of this study show that cancer prevention education at various levels such as by clinical offices, TV and radio programs, and newspapers may be effective. In order to increase participation in screening programs, health education that considers the life style characteristics of persons who do not participate in the screening programs is vitally important.

[Prediction of future trends of HIV infection and AIDS in Japan].

Current status and future trends of HIV infection and AIDS in Japan were estimated based on AIDS surveillance data up until 1992, excluding HIV infection from blood products and blood-borne transmission. The coverage rate of reports of HIV infection was estimated as the proportion of the reported AIDS cases who are also included in reports of HIV infection. Current numbers of HIV infected persons were then estimated to be the reported numbers divided by the coverage rate. Future numbers of HIV infected persons were predicted by extrapolation. Future numbers of AIDS cases were predicted based on the predicted numbers of HIV infected persons and the incubation distribution. The results were as follows: 1) The coverage rate of the reports of HIV infection was estimated to be 11.5%. 2) The numbers of HIV infected persons were estimated to be 2,900 in Japanese and 4,500 in foreigners by the end of 1992, and are predicted to be 7,700 in Japanese and 15,500 in foreigners by the end of 1997. 3) The numbers of AIDS cases were reported to be 125 in Japanese and 52 in foreigners by the end of 1992, and are predicted to be 1,100 in Japanese and 1,600 in foreigners (including AIDS cases developed after return to home country) by the end of 1997.

[The HIV/AIDS Epidemic in Cambodia].

In December 1995 and March 1996, we visited institutes which were conducting epidemiological studied of HIV/AIDS in Cambodia, and obtained data for further collaborative study between Japan and Cambodia. Data included information on AIDS patients and HIV infected persons, and behavioral epidemiology of CSWs (Commercial Sex Workers). The cumulative reported number of AIDS patients and HIV infected persons in Cambodia was 86 and 2,536 cases respectively in 1995. The cause of infection was mostly heterosexual contact with very few cases from injecting drug use (IDU) and other causes. The seroprevalence rate of HIV antibody among donated blood rapidly increased from 0.08% in 1991 to 4.47% in 1995, and those among CSWs and pregnant women were 37.9% and 2.6%, respectively, in 1995. The average rate of condom use among CSWs was 66%, but the rate of usual usage was only 14%. These results indicate that the HIV/AIDS epidemic had spread rapidly through CSWs, that it had been spread among peoples in communities, and that usage of condoms among CSWs was insufficient in Cambodia. Without strong countermeasures against HIV/AIDS in this country, HIV/AIDS epidemic may spread significantly to not only peoples in this country but also those in neighbouring countries in the future.

[Epidemiological study on HIV/AIDS in Cambodia seroprevalence of HIV/STD among commercial sex workers].

OBJECTIVE: To describe epidemiological features of HIV prevalence among female commercial sex workers (CSWs) in Cambodia, a cross-sectional study using a questionnaire study and serological tests was carried out from December 1997 to January 1998. We report the main results of the analyses of serological tests in this article. METHODS: Two hundred ninety six CSWs working in Sisophon and Poi Pet, located in northwest Cambodia, Bantey Mean Chey province, were recruited for interview based on a questionnaire on sexual behavior, and serological tests. The blood samples were examined for HIV antibody, Chlamydia trachomatis IgG antibody, TPHA, Hepatitis B surface antigen, and Hepatitis B surface antibody. The relationship between HIV and the other STD's was analyzed by using logistic regression analysis. RESULTS: The HIV seroprevalence rate was 43.9% (130 out of 296). The seropositive rate of Chlamydia trachomatis IgG antibody (C.T.-IgG-Ab) was 73.3% (217 out of 296). Logistic regression analysis showed a significant association between C.T.-IgG-Ab positive and HIV prevalence. (Odds Ratio: 5.33; 95% Confidence Interval, 2.82-10.07). CONCLUSIONS: This study suggests that the existence of Chlamydia trachomatis is closely related with HIV prevalence among CSWs in Cambodia. Other STDs may also increase susceptibility to male-to-female sexual transmission of HIV. This suggests that appropriate prevention against STDs will be needed for the control of HIV prevalence in Cambodia.

[Cyclosporine-induced graft-versus-host disease in a syngeneic bone marrow transplantation].

A 33-year-old woman with AML (M4) resistant to chemotherapy received syngeneic marrow graft from her identical twin following high dose busulfan and etoposide. However, the relapse was confirmed on the 60th day after the procedure. Since she failed to achieve remission despite intensive chemotherapy, a second BMT from the same donor was performed following total body irradiation and high dose etoposide on the 126th day after the initial BMT. At this time, cyclosporine (1 mg/kg/day) was administered to induce graft-versus-host disease (GVHD). Skin rash appeared on the 18th day after the 2nd BMT, and biopsy from the rash on the 23rd day showed a typical picture of cutaneous GVHD (grade 2) and there was no evidence of viral infection. On the 36th day after the 2nd BMT, the patient died of veno-occlusive disease. Although graft-versus-leukemia effect in this patient could not be evaluated because of early death, the induction of GVHD with cyclosporine might be effective to reduce the relapse rate after syngeneic or autologous BMT. Further studies are required to confirm this effect.

[Prostaglandin E1 bladder instillations for a patient with severe hemorrhagic cystitis after allogeneic bone marrow transplantation].

A 39-year-old female with AML (M2) underwent allogeneic bone marrow transplantation (BMT) on July 8th, 1991. The post transplantation course had been going well until day 85 post BMT, when severe hemorrhagic cystitis with right hydronephrosis and ureter stenosis developed. Adenovirus type 11 was isolated from the urine. She received instillations of prostaglandin E1 (PGE1) directly into the bladder after the appearance of clots in the urine. Complete resolution of hematuria was obtained by two courses of this treatment. PGE1 bladder instillations seem to be effective for the control of hematuria caused by severe hemorrhagic cystitis after BMT.

[Transient B lymphocytosis associated to hepatitis B after allogeneic bone marrow transplantation].

A 42-year-old male suffered from AML (M2) and achieved remission with chemotherapy. After that, he was successfully treated with allogeneic bone marrow transplantation. About eight months later, jaundice and general malaise developed and diagnosis of acute hepatitis B type was made based on laboratory findings. After 3 months of a conservative therapy, he recovered from the disease. During the clinical course of the hepatitis, B lymphocytes were increased to about 70% of peripheral blood lymphocytes (PBLs) transiently, and furthermore CD5 positive B lymphocytes occupied 12% of the PBLs at that time. This B lymphocytosis disappeared gradually along with the improvement of the hepatitis. The remarkable increase of B lymphocytes in PBLs was considered to be an abnormal reaction induced by HB virus infection, when his immune system was in the recovering phase after bone marrow transplantation.

[A trial use of prostaglandin E1 for prevention of hepatic veno-occlusive disease after allogeneic bone marrow transplantation].

We performed retrospective analysis of hepatic veno-occlusive disease (VOD) in 57 cases with leukemia after allogeneic bone marrow transplantation (BMT). Prostaglandin E1 (PGE1) was used to prevent VOD in 8 cases at a dose of 0.3 micrograms/kg/hr from day -8 to day 30. No VOD was noted in the PGE1 group, while the incidence of VOD was 8/49 (16.3%) in the non PGE1 group. In twelve patients with pretransplant liver dysfunction, VOD was noted in 0/3 in the PGE1 group and 4/9 (44.4%) in the non PGE1 group, respectively. However, prophylactic effects of PGE1 on VOD is not significant in this study, so further studies are needed to determine the efficacy of PGE1. One of 8 patients with PGE1 prophylaxis had edema and erythema on extremities, however, severe toxicity was not experienced.

[Prophylactic use of DDAVP in a patient with von Willebrand disease during labor: a case report and a review].

A Case of delivery in a 23-year-old woman after a prophylactic infusion of DDAVP is described. She had a life-long history of easy bruising and frequent epistaxis, with the diagnosis of vWD being made when she was 14 years old. A hemostatic examination showed a prolonged bleeding time, a moderate reduction in the factor VIII level (VIII: C) and von Willebrand Factor Antigen (vWF: Ag), decreased platelet aggregation by ristocetin, and depletion of platelet retention. In April, 1988, in the 34th week of pregnancy, she was admitted to our clinic in order to avoid abnormal bleeding during labor. On admission, the level of factor VIII, ristocetin aggregation, and platelet retention were normal, but the bleeding time remained prolonged. The diagnosis of vWD type I was made on the normal multimeric structure. The DDAVP infusion test revealed a shortening of the bleeding time and an increase in the vWF: Ag. In the 41st week of pregnancy, labor was induced, accompanied by infusion of DDAVP, she gave birth to an infant without any abnormal bleeding. Since conventional treatments with human plasma derivatives may cause complicating viral infections, we propose the infusion of DDAVP is one of the treatments to prevent the abnormal bleeding of the patient with vWD during labor.

[Multiple liver abscesses due to Candida albicans in a patient with acute promyelocytic leukemia: percutaneous transhepatic intraportal administration of amphotericin B].

A 36-year-old male with acute promyelocytic leukemia in second relapse was admitted to receive reinduction therapy in June, 1985, and entered into third complete remission, but he developed spiky fever after chemotherapy. Ultrasonic tomography revealed multiple liver abscesses and culture of the aspirates demonstrated Candida albicans in the abscesses. He was treated with intravenous administration of amphotericin B (AMPH-B) but the effect on the liver abscesses was unsatisfactory and consolidation therapy was difficult to start. AMPH-B (30 mg/day) was administered by percutaneous transhepatic intraportal administration (PTIA). About two months later, multiple liver abscesses disappeared. No remarkable complications such as severe fever, chill and renal dysfunction were recognized during PTIA of AMPH-B. So PTIA of AMPH-B is considered to be useful and safe for the management of fungal liver abscesses.

[Multiple myeloma in a patient in remission from malignant lymphoma].

A 71-year-old man was admitted because of right cervical lymph node swelling in February 1986. Lymph node biopsy revealed that he suffered from diffuse, large cell malignant lymphoma. Immunological staining showed lymphoma characterized by B cell markers, IgG, kappa type. Bone marrow aspiration, revealed no evidence of lymphoma and 0.2% plasma cells. The clinical stage was IIA. The patient was treated with the CHOP regimen (doxorubicin, cyclophosphamide, vincristine and prednisolone), which achieved complete remission. In October 1988, he was re-admitted because of a subcutaneous abscess, and biopsy of the inguinal lymph node showed reactive lymphadenitis. Although he improved with antibiotic therapy, laboratory date on admission showed monoclonal gammopathy. Serum immunoelectrophoresis demonstrated a monoclonal bow of IgA kappa type, and bone marrow aspiration revealed hypercellularity with an increased number of plasma cells (76.8%). The patient was diagnosed as having multiple myeloma, and combination chemotherapy was begun. He now attends the out-patient department at our hospital. The development of multiple myeloma has not been reported previously during a course of malignant lymphoma. Although the association of these two B cell neoplasias was unknown, in this case both showed the characteristic of kappa type light chains. This case may provide information concerning tumor cell origin.

[The combination therapy with vinca-alkaloid slow infusion and cholchicine was effective to refractory idiopathic thrombocytopenic purpura. The patient could receive femoral head replacement in safety].

A 46-year-old man with idiopathic thrombocytopenic purpura (ITP) refractory to corticosteroid, splenectomy and other drugs was admitted to our hospital in August, 1994, because of aseptic necrosis of the right femoral head. Although high-dose intravenous gamma-globulin was ineffective, the platelet count was increased within two weeks by the combination therapy that consisted of 0.02 mg/kg vincristine alternating with 0.1 mg/kg vinblastine by slow infusion at a 1-week interval, and oral 1.5 mg/day colchicine. He subsequently underwent the femoral head replacement. This combination therapy seems to be useful for refractory ITP in preparation for surgery.