The role of human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in the detection of cervical intraepithelial neoplasia among human immunodeficiency virus-infected women. Cervical Disease Study Group of the American Foundation for AIDS Research Community Based Clinical Trials Network.

OBJECTIVES: We sought to measure the characteristics of a quantitative human papillomavirus deoxyribonucleic acid assay and repeated cervical cytologic examination in screening for cervical intraepithelial neoplasia among human immunodeficiency virus-infected women. STUDY DESIGN: Human immunodeficiency virus-infected women with screening CD4+ lymphocyte counts of < or = 500 cells/mm3 (n = 103) were examined by quantitative human papillomavirus deoxyribonucleic acid assay and serial cervical cytologic examination and by colposcopy with biopsy and endocervical curettage during the course of 1 year. RESULTS: Quantitative measures of total human papillomavirus deoxyribonucleic acid and high-risk human papillomavirus deoxyribonucleic acid were strongly associated with any cervical intraepithelial neoplasia (P = .005) and high-grade cervical intraepithelial neoplasia (P = .0006), but they improved the sensitivity and negative predictive value of baseline screening only slightly when combined with cervical cytologic examination. Incident cervical intraepithelial neoplasia occurred frequently (20%) during 1 year of follow-up and was more common among human papillomavirus-infected women. Repeated cytologic examination identified 60% of women with new cervical intraepithelial neoplasia. CONCLUSION: Human immunodeficiency virus-infected women with at least mild immunosuppression have a high incidence of cervical intraepithelial neoplasia, which warrants close follow-up. Those with high baseline human papillomavirus deoxyribonucleic acid levels may be at the highest risk for incident cervical intraepithelial neoplasia.

Population surveillance for physical violence among adult men and women, Montana 1998.

BACKGROUND: Few epidemiologic studies of physical violence or intimate partner violence provide population-based surveillance data. OBJECTIVES: To estimate the prevalence and describe the characteristics associated with physical violence among adult men and women in the past year. METHODS: A random sample of Montana households was contacted via the Behavioral Risk Factor Surveillance System telephone survey in 1998 (N=1804). RESULTS: Five percent of men (39/787) and 3% of women (33/1017) reported experiencing physical violence in the past year. Among respondents reporting physical violence in the past year, women were more likely than men to report that the perpetrator was a current/former partner (58% vs 10%, p/=0.05). Men who reported experiencing physical violence in the past year were more likely to be younger and not to be living with a current partner. Women who reported experiencing physical violence in the past year were more likely to be younger, not currently living with a partner, have no health insurance, and have more days with mental health problems in the past month. CONCLUSIONS: Recent physical violence is common for both men and women; however, the perpetrators, locations, and demographic characteristics differ. Further study is needed to better understand the factors associated with physical violence among men and women in the context of designing and implementing appropriate interventions to reduce violence.

Evaluation of the surgical treatment of vulvar vestibulitis.

OBJECTIVE: To assess the efficacy of perineoplasty in the management of vulvar vestibulitis. STUDY DESIGN: Forty-two women who had undergone operative perineoplasty for the treatment of vulvar vestibulitis completed a questionnaire, a mean of 4.8 years postoperatively. RESULTS: Vulvodynia was constant or daily in 29 (69%) before surgery and in eight (19%) of respondents after surgery. In all, 27 (80%) of 34 women who had preoperative vulvar discomfort reported that the discomfort was much better or absent following surgery. Before surgery, 26 (70%) of 37 women who were not celibate for reasons other than vulvar vestibulitis, were celibate because of vulvar vestibulitis or always had pain during coitus and sometimes had to discontinue coitus because of pain. In contrast, only two (5.7%) of 35 women had this degree of dyspareunia following surgery. Similarly, 28 (85%) of 33 sexually active women who had dyspareunia before surgery reported that intercourse was much less painful or pain-free following surgery. CONCLUSION: Perineoplasty has a role in the management of vulvar vestibulitis for women who do not achieve satisfactory relief of vulvodynia and/or dyspareunia with nonoperative treatments.

Pediatric primary care provider's knowledge of HIV/AIDS care.

To respond to the difficulties that community-based providers face in keeping abreast of the rapid changes in HIV-related care, an intensive pediatric HIV mentoring program (Pediatric HIV Miniresidency [MR]) was developed, linking a regional AIDS Education and Training Center (AETC) with an urban children's hospital HIV outpatient care site. The purpose of this study was to evaluate HIV-related knowledge and perceived skills, abilities, and willingness of community-based primary care pediatric providers and providers completing the MR. A convenience sample of community-based primary pediatric practitioners and those participants in the MR program completed a three-part mailed survey. The survey assessed practice characteristics, knowledge of pediatric HIV clinical care, and perceived skills, ability, and willingness (PSAW) to provide HIV-related care. The main outcome measures were overall knowledge and PSAW scores. One hundred nineteen community-based practitioners (NMRs), 20% of those surveyed, completed the instrument, as did 19 of 20 MR participants. NMRs exhibited low knowledge scores in key areas relating to the identification and evaluation of HIV-exposed children. Fewer than half of these respondents correctly answered questions related to HIV antibody incidence in HIV-exposed newborns and recommended diagnostic testing of such infants. Providers completing the MR scored significantly higher on the knowledge survey (15.2 vs. 8.8, p < 0.001), and had higher PSAW scores (45.8 vs. 33.9, p < 0.001). Although the generalizability of our study is limited by the low response rate, community-based physicians completing the survey demonstrated a lack of knowledge we believe necessary to provide pediatric HIV-related care (as defined by Public Health Service practice guidelines). Physicians completing the MR program had substantial HIV-related knowledge and expressed a willingness to provide care to HIV-exposed/infected children. An effective MR program provides a mechanism for developing a network of dedicated community-based physicians who are willing and capable of providing care to HIV-infected or exposed infants and children.

The minimum single oral metronidazole dose for treating trichomoniasis: a randomized, blinded study.

OBJECTIVE: To identify the minimum effective single oral dose of metronidazole for trichomoniasis. METHODS: Women attending an inner-city sexually transmitted disease clinic who had Trichomonas vaginalis vaginitis diagnosed by microscopy were recruited for this randomized, double-blind study. Subjects were given a 0.5-, 1-, 1.5-, or 2-g single oral dose of metronidazole, taken under direct observation. Demographic information, symptoms, and clinical findings were collected from patient interviews, and physical examinations were conducted at the time of enrollment and at the follow-up visit. The primary outcome measure was treatment success at the follow-up visit, established by negative culture and microscopy. RESULTS: Three (1.8%) of the 167 women enrolled were excluded because of vomiting after taking metronidazole, and 66 (40%) of the 164 remaining subjects did not return for the follow-up visit. No associations were found between the proportion of subjects lost to follow-up and the characteristics of these subjects across assignment groups. The treatment success ratio was highest in subjects who received the 1.5-g dose (23, 85%), followed by the 2-g (16, 84%), 1-g (18, 62%), and the 0.5-g dose (8, 35%). CONCLUSION: A single 1.5-g dose of metronidazole has efficacy equivalent to a single 2-g dose for the treatment of T vaginalis vaginitis.

Multicenter comparison of clotrimazole vaginal tablets, oral metronidazole, and vaginal suppositories containing sulfanilamide, aminacrine hydrochloride, and allantoin in the treatment of symptomatic trichomoniasis.

BACKGROUND AND OBJECTIVES: Trichomonas vaginalis is a common vaginal pathogen. Oral metronidazole is the drug of choice for the treatment of trichomoniasis. Oral metronidazole, however, may cause unpleasant side effects and is contraindicated during the first trimester of pregnancy. In vitro studies and preliminary clinical data have suggested that intravaginal clotrimazole may be effective against this pathogen. GOALS: To compare the efficacy of clotrimazole vaginal tablets, oral metronidazole, and vaginal suppositories containing sulfanilamide, aminacrine, and allantoin (AVC suppositories) in the treatment of women with symptomatic trichomoniasis. STUDY DESIGN: In a multicenter, open-label trial conducted in 1982 and 1983, 168 symptomatic women with microscopically evident vaginal trichomoniasis were randomized to receive any of 2 g of metronidazole as a single oral dose, two 100-mg clotrimazole vaginal tablets once a day for 7 days, or vaginal suppositories containing 1.05 g of sulfanilamide, 14 mg of aminacrine hydrochloride, and 140 mg of allantoin (AVC suppositories) twice a day for 7 days. Wet mounts and cultures were repated at 1 to 2 and 4 to 6 weeks after completion of treatment. RESULTS: The number of patients who had positive cultures after treatment were 40/45 (88.9%) in the clotrimazole group, 35/43 (81.4%) in the AVC suppository group, and 9/45 (20%) in the metronidazole group (P < 0.001). All treatments were associated with a reduction in reported symptoms. Oral metrohidazole was more effective in reducing symptoms than either of the topical preparations. Adverse events, mostly mild or moderate in severity, were reported by 7 (14.6%) of 48 patients who had received oral metronidazole and 4 (7.8%) of 51 women who used AVC suppositories. There were no adverse events reported by the 50 women who used clotrimazole vaginal tablets. CONCLUSIONS: Oral metronidazole was more effective in eradicating T. vaginalis than clotrimazole vaginal tablets or AVC vaginal suppositories. All three regimens reduced symptoms; oral metronidazole was more effective in reducing symptoms than either topical preparation.

Substance use in an inner-city family planning population.

OBJECTIVE: To determine the prevalence of drug and alcohol use in an inner-city family planning population and to identify variables associated with a positive urine screen. STUDY DESIGN: We conducted blind urine drug and alcohol screening in 309 women attending an inner-city hospital family planning clinic. RESULTS: The prevalence of a positive urine drug and/or alcohol screen was 15.5% (48/309). Specific substance positivity rates were: marijuana 9.4%, cocaine 4.9%, alcohol 1.3%, benzodiazepines 1.0%, opiates 1.0% and amphetamines 0.3%. After controlling for other independent variables, increased age was the only predictor of having a positive drug and/or alcohol screen, while increased age and a history of a sexually transmitted disease predicted the use of drugs other than marijuana or alcohol alone. CONCLUSIONS: Our findings support the concept that substance use histories and urine drug screening should be considered in patients seeking family planning services. This strategy can lead to counseling and treatment for a population seeking preventive care that might otherwise not be identified.

PIP: During February-June 1992, in Pennsylvania, health workers collected urine specimens from 309 women attending an inner city hospital family planning clinic in Philadelphia so researchers could determine the prevalence of drug and alcohol use in this population and to identify the variables associated with a positive urine screen for drugs and/or alcohol. 48 (15.5%) tested positive for at least one drug metabolite or alcohol. Six (2%) tested positive for at least two substances. The most frequent substances included marijuana (9.4%) and cocaine (4.9%). Other prevalence rates were 1.3% for alcohol, 1% for benzodiazepines and opiates, and 0.3% for amphetamines. The logistic regression revealed that increasing age was the only variable that predicted women having a positive urine drug and/or alcohol screen (odds ratio [OR] = 1.09). Women older than 29 years old had the highest prevalence of recent drug or alcohol use (25.4%). Increased age and history of a sexually transmitted disease (STD) were predictors of use of drugs other than marijuana or alcohol alone (OR = 1.17 and 2.18, respectively). Overall condom use stood at only 24%. Women who screened positive for drugs other than marijuana and alcohol alone had the lowest rates of current condom use (5% vs. 29%) and the highest rate of a history of an STD (70% vs. 29%). These findings indicate a need for family planning providers to screen for drugs and alcohol and to take substance use histories to identify the population at risk. Thus they will be able to provide counseling and treatment referrals, when appropriate, for a population seeking preventive care that might otherwise not be identified.

HIV infections in women.

Women constitute the most rapidly growing group of individuals in the USA diagnosed with AIDS. Additionally, 35% of these individuals acquired their infection through heterosexual contact. In view of this and the many gender-specific problems that are encountered in immunocompromised women it is critical that our knowledge in this area is kept up-to-date. In this presentation current information regarding the epidemiology, diagnoses and management of HIV disease in women is addressed.

Increased encapsulation and virulence of Francisella tularensis live vaccine strain (LVS) by subculturing on synthetic medium.

Francisella tularensis live vaccine strain (LVS), taken directly from lyophilized vials, did not appear to have a capsule and had low virulence for Balb/c mice. When this strain was subcultured on Chamberlain's synthetic medium (pH 6.5), it became extensively capsulated (1-5 micron in diameter) and its virulence for Balb/c mice increased about 1000-fold. We conclude that the virulence of the attenuated vaccine strain, F. tularensis LVS, may still be influenced by growth conditions.

Development of new-onset seizures in the peripartum period. Should human immunodeficiency virus infection be considered a cause?

The case histories of two women who developed new-onset seizures in the peripartum period of their pregnancies are presented. These two women had divergent medical histories and prenatal courses. Both women developed grand mal seizures that could be attributed to several established etiologies, yet no specific diagnoses were made. Although their risk factors for developing human immunodeficiency virus (HIV) infection were quite different, both women subsequently were confirmed as HIV positive. Since new-onset seizures have been described as a presenting symptom of HIV infection in other studies, the seizures experienced by these two women could be the presenting symptom of their HIV infection. The authors suggest that HIV testing should be considered for any pregnant woman who develops new-onset seizures during the course of her pregnancy, regardless of her risk factor assessment for HIV infection.

The relationship between recent cocaine use and pregnancy outcome.

We conducted urine screening for cocaine metabolite in 500 consecutive women admitted to a labor and delivery unit. The pregnancy outcome of 411 of the women was determined at that admission. The prevalence of cocaine-positive urines was 15.3% (95% confidence interval 11.8-18.8%). A subset of this population that had not received prenatal care had a prevalence of 62% (95% confidence interval 47.2-76.6%). Women with positive urines were almost four times more likely to have preterm labor and over twice as likely to deliver a premature infant or one with a 1-minute Apgar score of 6 or lower. Our findings support the concept that urine drug screening for cocaine and/or other drugs of abuse should be considered in patients who present with no prenatal care, premature labor, premature delivery, and delivery of an infant with a 1-minute Apgar score of 6 or less. This strategy may enable us to identify and bring to therapy a population of women that could potentially go unrecognized.

Seroprevalence of human immunodeficiency virus type I (HIV-1) antibodies in a family-planning population.

Blind testing of 743 women who attended an inner-city hospital family-planning clinic showed 8 (1.1%) patients to have serum antibodies to human immunodeficiency virus type I (HIV-1). A retrospective chart survey did not show an association between HIV-1 antibody seropositivity and ethnicity, marital status, education, history of sexually transmitted diseases, drug and/or alcohol use, and contraceptive method. This failure to establish previously reported correlation may be a function of methods, sample size, or reflect a different population. Nonetheless, the seroprevalence the authors found shows that all patients in a family-planning clinic setting should be offered HIV-1 antibody testing.

PIP: Researchers conducted a retrospective blind study of 743 women attending the family planning clinic at Hahnemann University Hospital in Philadelphia, Pennsylvania to determine HIV-1 prevalence in a family planning population. HIV-1 seroprevalence stood at 1.1% (8 patients). The researchers were confident that the population size was large enough to accurately reflect HIV-1 prevalence in a family planning population. Since around 90,000 women used family planning services in Philadelphia, they estimated that 1600 women were actually HIV-1 seropositive in Philadelphia. HIV-1 seropositive patients were older than seronegative patients, but the difference was not significant (26.9% vs. 23.6%). 57.1% of seropositive patients and 48.7% of seronegative patients used oral contraceptives. HIV-1 seropositive clients used them. None of the HIV-1 seropositive patients had a sexually transmitted disease (STD) which alters the epithelium (condyloma, herpes, and syphilis) while 4.9% for the seronegative patients had such an STD. IN fact, 66.7% of the HIV-1 seropositive patients had no STD at all compared to 50% of seronegative patients. No association existed between HIV-1 seropositivity and illicit drug abuse. In conclusion, no association was found between HIV-1 seropositivity and ethnicity, marital status, education, history of STDs, drug and/or alcohol use, and contraceptive method. The researchers suggested that the inability to establish relationships may be due to a function of methods, sample size, or a reflection of a different population. Nevertheless they believed that the family planning clinic should offer HIV testing to women.

Pelvic inflammatory disease in the adolescent.

We studied 171 women, 106 young adults, and 65 adolescents, with a clinical diagnosis of pelvic inflammatory disease (PID) to determine whether differences existed in the presentation in these two groups. The study population was an age-stratified, random sample obtained from 1162 women with this condition. Demographic characteristics, sexual history, physical findings, severity of illness, and laboratory findings were compared between the two groups. The most significant findings were that the adolescents sought health care later in the course of the illness (7.8 vs. 5.6 days; p less than 0.02) and were more commonly infected with the gonococcus (42% vs. 28%; p less than 0.05). No statistically significant differences were found in the other parameters evaluated. Implications of these findings regarding the health care for sexually transmitted diseases (STDs) and the education of adolescents are discussed.

Hepatitis B: perceptions, knowledge and vaccine acceptance among registered nurses in high-risk occupations in a university hospital.

We employed a questionnaire to survey 334 registered nurses regarding their knowledge, perceptions and vaccine acceptance for Hepatitis B virus (HBV) infections. The study population was those persons working in areas considered at high-risk for contracting HBV. The nurses were asked to provide information regarding blood and body fluid exposures and the reporting of these exposures. The questionnaire was completed by 169 nurses (50.6%). Less than half of the respondents (42%) had been vaccinated. We found that 13 of 14 black nurses, compared to 85 of 154 nonblack nurses, had not been vaccinated (p less than .01). No other demographic differences between recipients and nonrecipients were noted. Partially or totally incorrect answers regarding transmittal knowledge were given by 108 of 160 (68%) respondents. Reasons for failure to be vaccinated were varied. Fear of side effects of the vaccine, contracting AIDS or hepatitis from the vaccine, or doubt of efficacy of the vaccine were cited by 50 of 88 (58%) respondents as reasons for not being vaccinated. Inability to schedule an appointment or unawareness of the vaccine's availability were expressed by 23% and 17% of the individuals, respectively. Our data allow us to conclude that to improve vaccination compliance, the vaccine must be made more readily available, possibly through workplace on-site administration. Additionally, a concerted effort to educate our staff regarding HBV with particular emphasis on minorities is needed.

Epidemiology of sexually transmitted diseases.

The epidemiology of STDs is a vast topic. It includes examining not only the frequency of disease but also those factors that influence the frequency. It requires taking into account not only the characteristics of the infected persons and their risk factors but also the characteristics of the causative organisms. There is a commonality between various STDs that results in people frequently harboring one or more agent. In view of this, efforts should be made to evaluate patients for inapparent disease. Another important aspect is recognizing that patients do not acquire their infection except through sexual contact, indicating that another person is involved. Therefore, for control purposes, treatment of all sexual contacts also must be addressed.

Pelvic inflammatory disease.

Pelvic inflammatory disease (PID) is a genital tract infection that affects a predominantly young and sexually active population. While its exact pathogenesis has yet to be determined, it appears to be caused by several micro-organisms that develop in response to one or more of the following: foreign bodies, such as intrauterine contraceptive devices, retained tampons and douching solutions, and surgery, such as endometrial biopsy and hysterosalpingography. The most common risk factor for PID is multiple sexual partners. The disease is associated with infertility, sterility and adverse pregnancy outcomes. Management calls for aggressive antibiotic therapy and the temporary suspension of sexual activity.

Monoclonal-antibody-based enzyme-linked immunosorbent assay for Trichomonas vaginalis.

Trichomonas vaginalis is estimated to infect 4 million women per year in the United States. The diagnosis of trichomoniasis is predominantly achieved by direct microscopic examination of vaginal exudates. This subjective diagnostic procedure is reported to be 75% sensitive under ideal circumstances. We have developed an enzyme-linked immunosorbent assay (ELISA) for the detection of T. vaginalis directly from vaginal exudates. The ELISA employs a monoclonal antibody specific for a 65-kilodalton surface polypeptide of T. vaginalis as the capture antibody in a sandwich format. A polyclonal rabbit anti-T. vaginalis antibody labeled with horseradish peroxidase serves as the probe. An evaluation of vaginal specimens from women attending clinics revealed a sensitivity and specificity of the ELISA of 89 and 97%, respectively, versus the culture technique. These results indicate the usefulness of this ELISA as an alternative to microscopic and culture methods for the detection of T. vaginalis in vaginal exudates.