The challenge of improving boiling: lessons learned from a randomized controlled trial of water pasteurization and safe storage in Peru.

Boiling is the most common method of household water treatment in developing countries; however, it is not always effectively practised. We conducted a randomized controlled trial among 210 households to assess the effectiveness of water pasteurization and safe-storage interventions in reducing Escherichia coli contamination of household drinking water in a water-boiling population in rural Peru. Households were randomized to receive either a safe-storage container or a safe-storage container plus water pasteurization indicator or to a control group. During a 13-week follow-up period, households that received a safe-storage container and water pasteurization indicator did not have a significantly different prevalence of stored drinking-water contamination relative to the control group [prevalence ratio (PR) 1·18, 95% confidence interval (CI) 0·92-1·52]. Similarly, receipt of a safe-storage container alone had no effect on prevalence of contamination (PR 1·02, 95% CI 0·79-1·31). Although use of water pasteurization indicators and locally available storage containers did not increase the safety of household drinking water in this study, future research could illuminate factors that facilitate the effective use of these interventions to improve water quality and reduce the risk of waterborne disease in populations that boil drinking water.

Factors associated with CD4 lymphocyte counts in HIV-negative Senegalese individuals.

CD4+ lymphocytes are a primary target of the human immunodeficiency virus (HIV), and CD4 counts are one of the factors used to measure disease progression in HIV-positive individuals. CD4 counts vary in uninfected individuals and across populations due to a variety of demographic, environmental, immunological and genetic factors that probably persist throughout the course of HIV infection. This study sought to determine reference levels and identify factors that influence lymphocyte counts in 681 HIV-uninfected adults in Senegal, where residents are exposed to a variety of infectious diseases and other conditions that may affect CD4 counts. Lymphocyte counts were assessed in commercial sex workers, symptomatic men and women presenting to the University of Dakar infectious disease clinic for out-patient care and women seeking family planning services. CD4 and CD3 lymphocyte counts differed between the four study groups (P < 0.01). Men had the lowest mean CD4 count (711.6 cells/microl), while commercial sex workers had the highest levels (966.0 cells/microl). After adjustment for age and other behavioural and clinical factors, the difference in CD4 counts between the three groups of women did not remain. However, both gender and smoking were associated independently with CD4 counts, as men maintained lower mean CD4 counts (beta = -156.4 cells/microl, P < 0.01) and smokers had higher mean CD4 counts (beta = 124.0 cells/microl, P < 0.01) than non-smokers in multivariable analyses. This study is the first to explore factors that may influence CD4 levels in Senegal and to estimate baseline CD4 levels among HIV-negatives, information that may guide clinicians in interpreting CD4 counts.

HIV prevalence, previous HIV testing, and condom use with clients and regular partners among Senegalese commercial sex workers.

OBJECTIVES: To assess HIV prevalence and risk factors for HIV infection, to investigate condom use among registered female commercial sex workers (CSWs) in Senegal, West Africa, and to examine the association between previous HIV testing, knowledge of HIV serostatus and condom use with both regular sex partners and clients within this population. METHODS: A cross-sectional study was conducted at three sexually transmitted disease clinics among 1052 Senegalese registered CSWs between 2000 and 2004. Inperson interviews soliciting information concerning demographic characteristics, medical history, sexual behaviour with clients and regular partners, and previous HIV testing history were performed. Blood samples were collected for determination of HIV-1 and/or HIV-2 serostatus. Multivariable, Poisson and log-binomial models were used to calculate prevalence ratios. RESULTS: The overall HIV prevalence was 19.8%. Over 95% of CSWs reported always using a condom with clients, but only 18% reported always using a condom with their regular partners. A history of previous HIV testing was not associated with condom use with clients (adjusted prevalence ratio (APR) = 0.98, 95% confidence intervals, CI: 0.90 to 1.06). However, prior HIV testing was associated with decreased condom use with their regular partners (APR = 0.44, 95% CI: 0.28 to 0.69), especially in women who tested HIV negative (APR = 0.17, 95% CI: 0.08 to 0.36). CONCLUSIONS: CSWs in Senegal have a high HIV prevalence; therefore preventing HIV transmission from this population to the general population is important. Condom use with regular partners is low among registered CSWs in Senegal, and a prior HIV negative test is associated with even less condom use with regular partners. Intervention efforts to increase condom use with regular sexual partners are needed.

Neonatal abstinence syndrome and early childhood morbidity and mortality in Washington state: a retrospective cohort study.

OBJECTIVE: The objective of the study was to evaluate the association between neonatal abstinence syndrome (NAS) and long-term childhood morbidity and infant mortality. STUDY DESIGN: We conducted a cohort study of infants born in Washington State during 1990 to 2008 who were diagnosed with NAS (n=1900) or were unexposed (n=12,283, frequency matched by birth year). 5-year hospital readmissions and infant mortality were ascertained. RESULTS: Children with history of NAS had increased risk of readmission during the first 5 years of life relative to unexposed children; this remained statistically significant after adjustment for maternal age, maternal education, gestational age and intrapartum smoking status (readmission rates: NAS=21.3%, unexposed=12.7%, adjusted relative risk (aRR) 1.54, 95% confidence interval (CI) 1.37 to 1.73). NAS was associated with increased unadjusted infant mortality risk, but this did not persist after adjustment (aRR 1.94, 95% CI 0.99 to 3.80). CONCLUSION: The observed increased risk for childhood hospital readmission following NAS diagnosis argues for development of early childhood interventions to prevent morbidity.Journal of Perinatology advance online publication,.

Risk of anal carcinoma in situ in relation to human papillomavirus type 16 variants.

Infection with human papillomavirus (HPV), especially HPV16, is central to the development of squamous anogenital cancers and their precursor lesions, termed "squamous intraepithelial neoplasias." Men who have sex with men, particularly those who are infected with HIV, are at a high risk for anal infection with HPV16 and for low-grade anal neoplasia; however, only a subset of these men develop anal invasive cancer or its immediate precursor lesion, anal carcinoma in situ (CIS). To examine the hypothesis that certain variants of HPV16 are most strongly associated with development of anal CIS, we followed 589 men who have sex with men whose initial anal cytological smears did not show anal CIS. Anoscopy, anal cytology, and PCR-based assays for detection and classification of HPV types were performed every 4-6 months, with HPV16 further classified by single-stranded conformation polymorphism analysis as being a prototype-like (PL) or non-prototype-like (NPL) variant. Anal CIS was histologically confirmed in 6 of 384 (1.6%) consistently HPV16-negative men, in 12 of 183 (6.6%) men with HPV16 PL variants, and in 4 of 22 (18.2%) men with HPV16 NPL variants. After adjustment for anal cytological diagnoses at study entry, HIV status and CD4 count, and detection of HPV types other than type 16, men with HPV16 NPL variants were 3.2 times (95% confidence interval, 1.0-10.3) more likely to develop anal CIS than were those with PL variants. Neither detection of HPV16 DNA at high levels nor detection of HPV16 DNA for a prolonged period, factors that we previously demonstrated to be associated with risk of high-grade anal squamous intraepithelial neoplasia, was significantly associated with HPV16 NPL variants. The biological mechanism relating to Ihis excess risk remains undetermined.

Prospective study of high grade anal squamous intraepithelial neoplasia in a cohort of homosexual men: influence of HIV infection, immunosuppression and human papillomavirus infection.

OBJECTIVE: To determine the risk of developing high grade anal squamous intraepithelial neoplasia (HG-AIN) in relation to HIV infection and immunosuppression, after controlling for the effects of human papillomavirus (HPV) infection. DESIGN: Prospective cohort study of 158 HIV-seropositive and 147 HIV-seronegative homosexual men presenting to a community-based clinic with initially negative anal cytologic and colposcopic findings. METHODS: Subjects completed self-administered questionnaires, underwent cytologic screening, and standardized unaided and colposcopic examination of the proximal anal canal for presence of abnormalities suggestive of AIN. Anal specimens were screened for HPV DNA. RESULTS: HG-AIN developed in eight (5.4%) and 24 (15.2%) HIV-seronegative and -seropositive men, respectively. Risk of HG-AIN among HIV-seronegative men was associated with detection of anal HPV types 16 or 18 by Southern transfer hybridization (STH), detection of HPV 16 or 18 at the lower levels by polymerase chain reaction but not by STH, and with number of positive HPV tests; HG-AIN risk among HIV-seropositive men was associated with detection of HPV 16 or 18 only by STH, detection of HPV types other than 16 or 18, CD4 count < or = 500 x 10(6)/l, and number of positive HPV tests. HIV-induced immunosuppression remained an independent predictor of HG-AIN after adjusting for type and level of detection of HPV; HIV infection predicted HG-AIN risk after adjustment for number of positive HPV tests. CONCLUSIONS: The association of HG-AIN with HIV, independent of HPV type, level of HPV detection and number of positive HPV tests, suggests that this increased risk cannot be entirely explained by an effect of HIV on HPV detection. Future studies focusing on factors more specific to the local microenvironment in the anal canal should help clarify these issues.

Effect of HIV infection on the natural history of anal human papillomavirus infection.

OBJECTIVE: To identify risk factors for the detection of prevalent and incident anal human papillomavirus (HPV) infection, and HPV persistence among HIV-seropositive and seronegative homosexual men. DESIGN: Longitudinal study of 287 HIV-seronegative and 322 HIV-seropositive men attending a community-based clinic. METHODS: Subjects underwent an interview and examination; specimens were collected for HIV serology and assessment of anal HPV and HIV DNA. RESULTS: Anal HPV DNA was detected at study entry in 91.6% of HIV-infected men, and 65.9% of men not infected with HIV. HPV detection was associated with lifetime number of sexual partners and recent receptive anal intercourse (HIV-seronegative men), decreased CD4+ lymphocyte count (HIV-seropositive men), and anal warts (all men). Among men negative for HPV at study entry, subsequent detection of HPV was associated with HIV, unprotected receptive anal intercourse, and any sexual contact since the last visit. Among men positive for HPV at study entry, subsequent detection of additional HPV types was more common among HIV-seropositive men. Becoming HPV negative during follow-up was less common among men with HIV or high HPV levels at study entry. Among those with HIV, HPV persistence was associated with presence of anal HIV DNA, but not with CD4+ lymphocyte count. CONCLUSIONS: Risk of anal HPV infection appears to increase with sexual exposure, epithelial trauma, HIV infection and immune deficiency. Incident infection may result from recent sexual exposure or reactivation of latent infection. Further studies are needed to elucidate the mechanism by which HIV DNA in the anal canal increases the risk of HPV persistence.

Migration, ethnicity and environment: HIV risk factors for women on the sugar cane plantations of the Dominican Republic.

OBJECTIVE: To determine risk factors for HIV infection among women living in the sugar cane plantation communities (bateyes) of a large private sugar cane company in the Dominican Republic. DESIGN: Cross-sectional study of sexually active female volunteers living in the bateyes. METHODS: Of 98 bateyes, 23 were randomly selected and visited by a mobile medical unit, to interview, examine and test volunteers for seroreactivity to HIV and syphilis. RESULTS: The 490 subjects ranged in age from 16 to 72 years (median, 37 years); 53% were born in Haiti, 36% in Dominican Republic bateyes, and 12% elsewhere in the Dominican Republic; 58% had no formal education; and 87% had no income. HIV seropositivity was found in 28 women (5.7%), including 8.8% of those aged < 35 years. By logistic regression analysis, HIV infection was independently associated with age < 35 years [odds ratio (OR), 4.5; P < 0.01), being single with children (OR, 4.3; P < 0.01), more than one lifetime sex partners (OR, 3.4; P = 0.06), engaging in sex during menses (OR, 3.2; P = 0.02), and self-description as a prostitute (OR, 4.4; P = 0.05)1. For Haitian women, those coming to the Dominican Republic alone were more likely to have HIV infection than those coming with a male partner. Less than 4% of women reported condom use at last intercourse. CONCLUSIONS: Women in the bateyes have a much higher rate of HIV infection than that estimated for women in the general population of Dominican Republic and a rate comparable to that of female sex workers in the Dominican Republic. AIDS prevention in the bateyes should address condom education and distribution as well as employment opportunities and education for women.

Association of antiretroviral therapy with detection of HIV-1 RNA and DNA in the anorectal mucosa of homosexual men.

OBJECTIVE: To determine whether combination antiretroviral therapy is associated with reduced detection of HIV-1 RNA and DNA in the anorectal mucosa of men who have sex with men (MSM). DESIGN: Cross-sectional study of 233 MSM recruited from community and clinic sites in Seattle, Washington between July 1996 and December 1997. METHODS: HIV-1 RNA and HIV-1 DNA were detected in anorectal swab specimens by polymerase chain reaction amplification assays. RESULTS: HIV-1 RNA was detected significantly less often in anorectal specimens from users of combination antiretroviral therapies, whether a protease inhibitor was received (15/89; 17%) or not (16/53; 30%), than in men not receiving therapy (43/88; 49%) (P < 0.001, P = 0.03, respectively). In contrast, HIV-1 DNA was detected only slightly less frequently in anorectal specimens obtained from men receiving protease inhibitors (35/81; 43%) or reverse transcriptase inhibitors alone (22/48; 46%) than in specimens from men not receiving therapy (45/78; 58%) (P = 0.07, P = 0.20, respectively). Among men with < 50 copies HIV-1 RNA/ml plasma, detection of HIV-1 RNA in anorectal specimens was rare (1/54; 2%) but detection of HIV-1 DNA was common (14/50; 28%). CONCLUSIONS: Combination antiretroviral therapy is associated with reductions in HIV-1 RNA, but HIV-1 DNA remains detectable in the anorectal canal of almost half of MSM receiving such therapy. Condom use during anal intercourse should be encouraged, regardless of plasma viral load response to potent antiretroviral therapy.

HLA class II DR-DQ and increased risk of cervical cancer among Senegalese women.

To examine Senegalese women to confirm and extend associations between HLA class II types and cervical cancer previously observed among African-American, Caucasian, Hispanic, and Japanese ethnic populations, 55 Senegalese women with invasive cervical carcinoma were compared with age-matched (human papillomavirus) HPV-positive (n = 83) and HPV-negative (n = 107) control women. PCR-based HPV and HLA typing methods were used. Data were analyzed using a global randomization test and conditional logistic regression. Although this study failed to confirm a previously reported association between cervical cancer and DQB1*03 alleles, the DRB1*1101-DQB1*0301 haplotype was detected more frequently among cervical carcinoma cases than among controls (adjusted odds ratio, 2.6; 95% confidence interval, 1.0-7.1). Furthermore, as reported by others, we observed a negative association of borderline statistical significance between DRB1*13 and cervical carcinoma (adjusted odds ratio, 0.5; 95% confidence interval, 0.2-1.1). Observations from this study confirm earlier findings of a negative association between DRB1*13 and cervical cancer and suggest that specific DRB1-DQB1 haplotype combinations, rather than individual DQB1*03 alleles, increase the risk for cervical cancer.

Acute pelvic inflammatory disease: associations of clinical and laboratory findings with laparoscopic findings.

OBJECTIVE: To assess the relation of clinical variables and laboratory data to pelvic laparoscopic observations of tubal occlusion, adnexal adhesions, and peritoneal exudate in women with acute salpingitis. METHODS: Clinical and laboratory evaluations were performed systematically before laparoscopy in 155 women with suspected acute pelvic inflammatory disease (PID), 82% of whom proved to have acute salpingitis confirmed with laparoscopy. Laparoscopic findings were scored in three categories (tubal patency, adhesions, and exudate.) RESULTS: Two general categories of laparoscopic findings were present: 1) tubal occlusion and moderate to severe adhesions in 30 women, and 2) pelvic-abdominal exudate in 27 women. In the remaining 16 women, these laparoscopic findings occurred alone or in other combinations. Among women with acute salpingitis, tubal occlusion was associated positively with older age, palpable adnexal mass, and moderate to severe pelvic adhesions; negative associations were found with abdominal rebound tenderness, mean abdominal-pelvic tenderness score, pelvic-abdominal exudate, and isolation of either Neisseria gonorrhoeae or Chlamydia trachomatis. Moderate or severe pelvic adhesions were associated positively with increased duration of abdominal pain (5 versus 3 days) compared with limited or no pelvic adhesions, but they were associated negatively with mean abdominal-pelvic tenderness score and with pelvic-abdominal exudate (47% versus 73%). Free exudate in the pelvis or abdomen as compared with limited or no exudate was associated positively with abdominal rebound tenderness (86% versus 65%), abdominal-pelvic tenderness score, elevated white blood cell count (83% versus 52%), and recovery of N gonorrhoeae (79% versus 57%). Free exudate was associated negatively with the median duration of pain (3 versus 6 days), oral contraceptive use (4% versus 26%), and palpable adnexal mass (7% versus 25%). Analyses limited to women without a history of PID gave similar results. CONCLUSIONS: Although clinical and laboratory criteria traditionally used to judge the clinical severity of acute PID partially predict the degree of tubal or other pelvic abnormalities among women with acute salpingitis and tend to distinguish those with tubal occlusion or moderate to severe adhesions from those with peritonitis, these criteria have low predictive value and are not reliable in the individual patient.

Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm.

OBJECTIVE: To correlate symptoms, signs, and risk factors with positive wet mounts or cultures for Candida albicans and to develop an algorithm to diagnose vulvovaginal candidiasis. METHODS: This cross-sectional study of 774 randomly selected women from an urban sexually transmitted disease (STD) clinic evaluated symptoms, signs, and risk factors associated with C albicans, detected by wet mount and culture, and constructed an algorithm. RESULTS: C albicans, recovered from 186 (24%) of the 774 women, was associated with chief complaints of vulvar pruritus or burning. Elicited symptoms were vulvar pruritus, pain or burning, and external dysuria; signs were vulvar erythema, edema, fissures, vaginal erythema, and thick, curdy vaginal discharge. Among 545 women with symptoms of either increased vaginal discharge or vulvar pruritus or burning, only 155 (28%) had positive C albicans cultures, whereas bacterial vaginosis or other sexually transmitted infections were found in 288 (53%). In multivariate analysis, risk factors for positive C albicans culture included condom use, presentation after the 14th menstrual cycle day, sexual intercourse more than four times per month, recent antibiotic use, young age, past gonococcal infection, and absence of current gonorrhea or bacterial vaginosis. A clinical algorithm based on symptoms, signs, and selective use of wet mounts and cultures would have provided prompt treatment to 150 of 167 (90%) women with vulvovaginal candidiasis while minimizing the number of cultures performed. CONCLUSION: A simple algorithm using symptoms, signs, wet mounts, and selective cultures can identify 90% of women with vulvovaginal candidiasis. In this STD clinic, vulvovaginal symptoms also require assessment for bacterial vaginosis, trichomoniasis, and cervical infection.

Influence of HIV-1 and/or HIV-2 infection and CD4 count on cervical HPV DNA detection in women from Senegal, West Africa.

BACKGROUND: HIV infection is associated with greater risk of precancerous lesions and cervical cancer in women. However, several factors remain unclarified regarding the association between HIV infection and HPV detection, especially among those with HIV type 2 versus type 1 infection and severely immunocompromised persons. OBJECTIVES: To evaluate HPV overall and type-specific detection among HIV-infected and uninfected women in Senegal. STUDY DESIGN: Detection of HPV DNA for 38 genotypes in cervical swabs using PCR-based methods was evaluated in HIV-positive (n=467) and HIV-negative (n=2139) women participating in studies in Senegal. Among HIV-1 and/or HIV-2 positive women, CD4 counts were assessed. Adjusted multivariable prevalence ratios (PR) were calculated. RESULTS: The prevalence of any HPV DNA and multiple HPV types was greater among HIV-infected individuals (78.2% and 62.3%, respectively) compared with HIV-negative women (27.1% and 11.6%). This trend was also seen for HPV types 16 and 18 (13.1% and 10.9%) compared to HIV-negative women (2.2% and 1.7%). HIV-infected women with CD4 cell counts less than 200 cells/µl had a higher likelihood of any HPV detection (PRa 1.30; 95% CI 1.07-1.59), multiple HPV types (PRa 1.52; 95% CI 1.14-2.01), and HPV-16 (PRa 9.00; 95% CI 1.66-48.67), but not HPV-18 (PRa 1.20, 95% CI 0.45-3.24) compared to those with CD4 counts 500 cells/µl or above. CONCLUSION: HIV-infected women, especially those most severely immunocompromised, are more likely to harbor HPV. Measures to prevent initial HPV infection and subsequent development of cervical cancer through focused screening efforts should be implemented in these high risk populations.

Trends of HIV-1, HIV-2 and dual infection in women attending outpatient clinics in Senegal, 1990-2009.

We assessed trends in the relative prevalences of HIV-1, HIV-2 and dual HIV-1/HIV-2 infection in 10,321 women attending outpatient clinics in Senegal between 1990 and 2009. The relative prevalence of HIV-1 (defined as the proportion of seropositive subjects having HIV-1) rose sharply from 38% in 1990 until 1993 (P < 0.001), whereupon it continued to rise, but at a slower rate, reaching 72% of HIV infections in 2009. As compared with HIV-1, the relative prevalence of HIV-2 decreased sharply from 54% in 1990 until 1993 (P < 0.001) and continued to decrease at a slower rate through 2009. The relative prevalence of dual infection, as compared with HIV-1, was stable from 1990 to 1993, but decreased slightly thereafter (P < 0.001). These study findings indicate that during the early 1990s, the relative prevalence of HIV-1 increased markedly, while the relative prevalence of HIV-2 decreased and the relative prevalence of dual infection remained stable in Senegal. From 1993 to 2009, the relative prevalence of HIV-1 increased at a slower rate, while the relative prevalences of HIV-2 and dual infection decreased. These results confirm trends in HIV prevalence observed in other West African populations and provide a critical update on HIV transmission risk among women in Senegal.

The identification of vaginal Lactobacillus species and the demographic and microbiologic characteristics of women colonized by these species.

Lactobacillus acidophilus has been reported to be the predominant vaginal species. Vaginal lactobacilli isolated from 215 sexually active women were identified using whole-chromosomal DNA probes to 20 American Type Culture Collection Lactobacillus strains. Most women were colonized by L. crispatus (32%), followed by L. jensenii (23%), a previously undescribed species designated L. 1086V (15%), L. gasseri (5%), L. fermentum (0.3%), L. oris (0.3%), L. reuteri (0.3%), L. ruminis (0.3%), and L. vaginalis (0.3%). H2O2 was produced by 95% of L. crispatus and 94% of L. jensenii isolates, compared with only 9% of L. 1086V. Colonization by L. crispatus or L. jensenii was positively associated with being white (P<.001), age >/=20 years (P=.05), barrier contraceptive usage (P=.008), and lower frequency of bacterial vaginosis (P<.001) and gonorrhea (P=.03). L. crispatus and L. jensenii, not L. acidophilus, are the most common species of vaginal lactobacilli.

Quantitative Chlamydia trachomatis cultures: correlation of chlamydial inclusion-forming units with serovar, age, sex, and race.

The number of inclusion-forming units (IFUs) observed in quantitative chlamydial cultures may be a surrogate for infectivity or transmissibility. Therefore, we conducted a cross-sectional study of 11,034 patients with Chlamydia trachomatis infection who presented to the Seattle-King County public health department clinics between 1988 and 1996, to determine relationships between the number of IFUs observed in culture and sex, age, race, and serovar class. Of the 11,034 cases of infection we studied, 6801 (62%) were cervical infections in women, and 4233 (38%) were urethral infections in men. The median count was 450 IFU for women and 72 IFU for men (P<.001). Overall, both men and women infected with B-class serovars had significantly higher IFU counts than did those infected with C-class serovars (P<.001). The median IFU count fell consistently with increasing age for both women (625 IFU for those <16 years old to 185 IFU for those >30 years old; P<.001) and men (210 IFU for those <16 years old to 40.5 IFU for those >30 years old; P<.001). We found, by use of multiple regression analysis, that sex, age, race, and serovar class remained independently related to IFU count, with counts being highest among young white women infected with B-class serovars.

Factors associated with acquisition of, or persistent colonization by, vaginal lactobacilli: role of hydrogen peroxide production.

To identify factors that predict sustained colonization by vaginal lactobacilli, microbiologic, behavioral, and demographic data were obtained from 101 nonpregnant women at baseline and at 4 and 8 months. A total of 272 isolates of lactobacilli were identified to the species level by use of whole chromosomal DNA homology to type strains. The predominant lactobacilli were the species Lactobacillus crispatus (38%) and L. jensenii (41%). Of 57 women initially colonized by H(2)O(2)-producing L. crispatus or L. jensenii, 23 (40%) remained colonized over 8 months, compared with 1 (5%) of 21 women colonized by other H(2)O(2)-producing species or by H(2)O(2)-negative strains (P=.01). Frequency of sexual intercourse (> or =1 sex act per week) was associated with loss of colonization with H(2)O(2)-producing lactobacilli (P=.018), as was antibiotic use (P< or =.0001). Other behavioral and demographic characteristics did not predict sustained colonization. The production of H(2)O(2) is closely linked with species and is a predictor for sustained long-term colonization of the vagina.

Infertility following pelvic inflammatory disease.

OBJECTIVE: To assess the frequency of infertility after pelvic inflammatory disease (PID) and factors important in postinfectious tubal damage in an urban population at high risk for sexually transmitted diseases. METHODS: From a cohort of 213 women with PID documented by laparoscopy and/or endometrial biopsy, 58 women (27% of the initial cohort) were interviewed by phone 2 to 9 years after an index episode of PID. Data regarding the initial history, physical examination, microbiology, laparoscopic, and serologic findings, and data concerning interval contraception, subsequent pregnancy, subsequent infection, and chronic pelvic pain were compared among those with and without infertility at follow up. RESULTS: Nineteen (40%) of the 48 women not using contraception were involuntarily infertile after the index episode of PID. Compared with those who had an interval pregnancy, infertile women were older (P = 0.02), more likely to have a history of infertility prior to the index episode of PID (P = 0.001), and were more likely to have occluded or partially occluded fallopian tubes (P = 0.03), peritubal adhesions (P = 0.007), or perihepatic adhesions (P = 0.02) seen by laparoscopy performed during the index episode. Surprisingly, recovery of Chlamydia trachomatis was negatively related to infertility (P = 0.001), although a similar proportion of both groups had chlamydia immunoglobulin M antibody (40% vs. 31%). Chlamydia heat shock protein was weakly related to infertility (P = 0.08). The isolation of Neisseria gonorrhoeae was not significantly different between groups (53% vs. 57%). CONCLUSIONS: The high rate of postinfection infertility found was probably related to a combination of tubal damage before and during the index episode of PID. Prevention of recurrent PID and better understanding of the pathophysiology of postinfection tubal damage (which may differ between chlamydia and gonorrhea) is needed to develop more effective strategies to reduce permanent tubal damage.

Neoplasms of the ampulla of vater with concurrent pancreatic intraductal neoplasia: a histological and molecular study.

Adenoma and adenocarcinoma of the ampulla of Vater are uncommon neoplasms of the gastrointestinal tract. Only one report has analyzed the relationship between ampullary adenocarcinoma and pancreatic intraductal neoplasia (PanIN), the precursor lesion of pancreatic adenocarcinoma. An association between PanIN and ampullary adenoma has not been reported previously. Case reports have documented the progression of PanIN to invasive pancreatic adenocarcinoma. We reviewed five resected ampullary adenoma and 17 ampullary adenocarcinoma cases and evaluated the pancreas for PanIN. Pancreatic sections from 35 autopsies were reviewed as a control group. Immunohistochemistry for overexpression of p53 and COX-2 proteins was performed in selected cases, as was PCR analysis for K-ras mutations. Follow-up clinical data were obtained. All 22 ampullary neoplasms were associated with PanIN, which was high grade in two (40%) adenoma cases and seven (41%) adenocarcinoma cases. In 16 (73%) evaluable cases, PanIN extended to the pancreatic resection margin; two of which had high grade PanIN. Among the autopsy controls eight (23%) had low-grade PanIN. Seven of the 22 ampullary cases but none of the autopsy controls had coexistent pancreatitis. A smoking history was present in two of four autopsy cases in which this history was available. Overexpression of the p53 and COX-2 proteins was present in only one case of high-grade PanIN. K-ras mutations were present in four of four of the PanIN lesions evaluated, including one autopsy case. Clinical follow-up revealed no progression of PanIN to invasive carcinoma in the remnant pancreas, although the follow-up period was too short to adequately assess that risk (an average of 3.8 y for adenoma cases and 2.5 y for adenocarcinoma cases). We conclude that adenomas and carcinomas of the ampulla are associated with PanIN, and often high-grade PanIN. Although its malignant potential has not been fully established, PanIN is underreported and often unrecognized. PanIN may be analogous to colorectal adenoma in that both are prevalent in the older adult population, but few progress to carcinoma.

Seroprevalence of human papillomavirus types 6 and 16 capsid antibodies in homosexual men.

Human papillomavirus (HPV) has been implicated in the pathogenesis of anal carcinoma, which is increased in homosexual men. Little is known about the serologic response to HPV in normal or immunosuppressed men; therefore, HIV-infected and -uninfected homosexual men were screened for HPV-6 and -16 capsid antibodies. HIV-infected men had increased HPV DNA detection but did not significantly differ in the prevalence of serum HPV antibodies. HPV-6 DNA detection and the presence of anal warts were significantly correlated with serum antibody overall and in the HIV-infected subgroup. HPV-16 DNA detection was not significantly correlated with serum antibody overall or in either subgroup; however, HIV-infected men with high-grade anal squamous intraepithelial lesions were significantly more likely to have HPV-16 antibodies. HIV-infected men are able to generate an antibody response to HPV, and a lack of serum HPV antibodies cannot explain the increased HPV-associated disease seen in HIV-infected men.