Clinical standards for the diagnosis, treatment and prevention of TB infection.

BACKGROUND: Tuberculosis (TB) preventive therapy (TPT) decreases the risk of developing TB disease and its associated morbidity and mortality. The aim of these clinical standards is to guide the assessment, management of TB infection (TBI) and implementation of TPT.METHODS: A panel of global experts in the field of TB care was identified; 41 participated in a Delphi process. A 5-point Likert scale was used to score the initial standards. After rounds of revision, the document was approved with 100% agreement.RESULTS: Eight clinical standards were defined: Standard 1, all individuals belonging to at-risk groups for TB should undergo testing for TBI; Standard 2, all individual candidates for TPT (including caregivers of children) should undergo a counselling/health education session; Standard 3, testing for TBI: timing and test of choice should be optimised; Standard 4, TB disease should be excluded prior to initiation of TPT; Standard 5, all candidates for TPT should undergo a set of baseline examinations; Standard 6, all individuals initiating TPT should receive one of the recommended regimens; Standard 7, all individuals who have started TPT should be monitored; Standard 8, a TBI screening and testing register should be kept to inform the cascade of care.CONCLUSION: This is the first consensus-based set of Clinical Standards for TBI. This document guides clinicians, programme managers and public health officers in planning and implementing adequate measures to assess and manage TBI.

HIV infection among non-injecting drug users entering drug treatment, United States, 1989-1992. Field Services Branch.

OBJECTIVE: To describe HIV seroprevalence among non-injecting drug users (non-IDU) entering sentinel drug treatment centers in the United States. DESIGN: Anonymous, blinded (unlinked) HIV seroprevalence surveys. SETTING: Sixty-eight sentinel drug treatment centers in 37 United States metropolitan areas. PARTICIPANTS: Consecutive sample of clients admitted to sentinel drug treatment centers from January 1989 through December 1992. Of 84,617 clients, 37,633 (44.5%) had used illicit drugs but reported no injecting drug use since 1978. MAIN OUTCOME MEASURES: Center-specific, metropolitan area-specific, and national median HIV seroprevalence rates. RESULTS: National median center-specific HIV seroprevalence among non-IDU was 3.2% (range, 0-15.2%). Rates varied widely by geographic area. Median rates were highest in the northeast (5.6%; range, 0-15.2%), intermediate in the south (3.4%; range, 0.6-8.0%), and generally lower throughout the rest of the country: midwest (1.3%; range, 0-3.1%) and west (1.8%; range, 0-14.5%). When stratified by treatment center, there were few statistically significant differences in seroprevalence among African Americans, Hispanics and whites. The median rate was 3.4% among men and 2.7% among women. Rates among non-IDU were lower than among IDU attending the same drug treatment centers, but consistently higher than among heterosexual patients attending sexually transmitted disease clinics in the same metropolitan areas. CONCLUSIONS: HIV seroprevalence among non-IDU entering drug treatment is high in many metropolitan areas. HIV prevention and education efforts in drug treatment centers should target sexual as well as drug-use risk reduction for all clients.

HIV infection among homeless adults and runaway youth, United States, 1989-1992. Field Services Branch.

OBJECTIVES: Homeless persons have an increased risk of HIV infection because of a high prevalence of HIV-related risk behaviors. These include drug use, sexual contact with persons at risk for HIV infection, and the exchange of sex for drugs. The objectives of this investigation were to describe HIV seroprevalence rates in homeless adults and runaway youth. METHODS: In 1989, the Centers for Disease Control and Prevention began collaboration with state and local health departments to conduct HIV seroprevalence surveys in homeless populations. Unlinked HIV seroprevalence surveys were conducted in 16 sites; 11 provided medical services primarily to homeless adults, and five to runaway youth aged < 25 years. RESULTS: From January 1989 through December 1992, annual surveys were conducted in 16 sites in 14 cities. Site-specific seroprevalence rates ranged from 0-21.1% (median, 3.3%). Among homeless adults in three sites, rates were higher among men who had sex with other men and those who injected drugs than among persons with other risk exposures (28.9 versus 5.3%). In general, rates were higher for heterosexual men than for women and higher among African Americans than whites. In sites providing services to homeless youth, HIV seroprevalence rates ranged from 0-7.3% (median, 2.3%). CONCLUSIONS: These data indicate that HIV infection among homeless adults and runaway youth is an important public health problem. HIV prevention and treatment should be integrated into comprehensive health and medical programs serving homeless populations.

Cell sorting using a universally applicable affinity chromatography matrix: solid-phase anti-fluorescein isothiocyanate antibody.

Procedures are described for fractionating cells utilizing a universally applicable cellular affinity chromatography matrix. The affinity matrix consists of immunoabsorption purified goat anti-fluorescein isothiocyanate antibody coupled to large derivatized polyacrylamide beads. This matrix may, in principle, be used to isolate any cell subpopulation provided it has a fluorescein-labeled ligand on its surface. In this report the matrix was used to isolate viable purified fractions of mouse surface Ig-positive cells, Lyt1 cells, and mouse lymphocytes that bind the lectin soybean agglutinin. A preliminary experiment using the anti-FITC beads suggested that this technique can provide a fraction of cells enriched in antigen binding cells. Cell populations isolated by this technique retain their ability to respond to in vitro mitogen stimulation, as well as their ability to be maintained in cell culture following fractionation. Additional experiments using a column consisting of goat anti-rabbit Ig antibody coupled to the same support material are also reported.

Emotional implications of primary familial hyperlipoproteinemia in childhood and adolescence.

To determine whether 43 patients and their 23 unaffected siblings were at increased risk for psychologic upset, 28 families of children being treated for primary familial hyperlipoproteinemia were studied. Nine fathers but no mothers had died of the disease. The families were interviewed for psychiatric assessment, and the parent(s) scored a questionnaire concerning eight behavioral factors. Male patients had significantly higher scores for impulsive hyperactive behavior than their male siblings. Fatherless female patients had the highest scores for perfectionism and the lowest scores for conduct problems and impulsive hyperactive behavior. Fatherless children scored lower for impulsive hyperactive behavior than children with fathers; fatherless male children were more anxious than fatherless female children. There were more significant differences in scores for children whose father was still alive vs those whose father had died than in scores for affected children vs unaffected siblings. Thus, the emotional impact of the premature death of an affected parent appears greater than that of having the disease. Therefore, one should be alert for changes in behavior in children with primary familial hyperlipoproteinemia when a parent dies of the disease and as the patients approach the age at which the parent died.

Readability of pediatric biomedical research informed consent forms.

Informed consent forms are used in biomedical research as a mechanism to convey study information to potential subjects so that they may arrive at a decision concerning their willingness to participate. Although the Department of Health and Human Services Regulations for the Protection of Human Subjects require the presentation of specific study information at a level that is easily understood, according to research concerning adult biomedical consent forms, the typical form is not readily comprehensible. Unfortunately, no data exist concerning the readability of informed consent forms that are used in the context of pediatric biomedical research. In the present study, readability analyses were conducted on a large sample (N = 238) of pediatric biomedical informed consent forms obtained during a 10-year period from a large midwestern children's hospital. For the entire sample, results derived from two readability estimates (Fry grade equivalent and Flesch Reading Ease methods) indicated that the consent forms were written at the college graduate level. Although there was a linear increase in the length of the consent document during the 10-year period evaluated, expanded length was not associated with improved readability. According to analyses, a differential pattern of reading difficulty was associated with specific sections of the informed consent document. Findings are highly consistent with those from studies of adult biomedical consent form and document that the purpose of the informed consent form is being compromised, in part, by a readability factor. Suggestions for solving this critical problem are advanced.

Behavioural risk factors and HIV infection of injection drug users at detoxification clinics in Puerto Rico.

BACKGROUND: The ethnic and geographical variations of AIDS prevalence among injection drug users (IDU) have highlighted the need to understand the role of the relevant risk factors in specific subpopulations of IDU. In this study we examine the factors related to seropositivity among IDU entering drug detoxification facilities in metropolitan San Juan, Puerto Rico. METHODS: From October 1990 until August 1991, 390 IDU were interviewed. Four groups of risk factors were examined: sexual practices, drug injection behaviours, risk behaviours while in US Mainland cities, and while incarcerated. A stepwise logistic regression model was used to simultaneously assess the independent effects of the behavioural risk factors on HIV seropositivity. RESULTS: Of the 342 IDU who were tested for HIV antibodies, 29.5% were seropositive. The behaviours found to be associated with seropositivity were: having sex with an IDU in the last 6 months; having injected drugs for over 5 years; and injecting with used needles while incarcerated. DISCUSSION: Public health programmes will need to establish more effective collaborative links with correctional institutions in order to reduce the spread of HIV among IDU in Puerto Rico.

PIP: In Puerto Rico between October, 1990 and August, 1991, 342 intravenous (IV) drug users at 3 detoxification clinics serving San Juan and its environs were interviewed, and blood samples were taken. Researchers wanted to determine the behavioral risk factors linked to HIV infection in a population of IV drug users in drug treatment. Most (84.9%) of the IV drug users were male. The HIV seropositivity rate was 29.5% (28.7% for males and 34% for females), which was lower than that for out-of- treatment IV drug users in metropolitan San Juan (47.5%). A stepwise logistic regression model revealed that having sexual intercourse with an IV drug user within the last 6 months (42.5% vs. 26%; adjusted odds ratio [AOR] = 1.9; p = .046), having used IV drugs for more than 5 years (32.4% for 6-10 years and 47.5% for 10 years vs. 8.8%; AOR = 4.69 and 9.64, respectively; p .001), and shooting up with used needles while imprisoned (56.8% vs. 26.2%; AOR = 3.59; p = .002) were significant behavioral risk factors of HIV infection. The significant risk factor of having sex with an IV drug user within the last 6 months suggests that sexual transmission of HIV among IV drug users in Puerto Rico is becoming as important an HIV-transmission mode as needle sharing. Since a considerable proportion of this IV drug use population in a treatment program (54.9%) has been incarcerated, and since needle sharing while in prison has an independent significant effect on HIV transmission, public health officials in Puerto Rico need to implement innovative and aggressive interventions in correctional institutions to induce risk reduction behaviors particular to IV drug inmates.

Sentinel surveillance of human immunodeficiency virus infection in women seeking reproductive health services in the United States, 1988-1989. The Field Services Branch.

Cases of AIDS among women of reproductive age have increased dramatically since 1981; nearly a third of all cases among females were reported in 1990 alone. Surveillance of human immunodeficiency virus (HIV) infection among women is essential for monitoring the spread of HIV over time and identifying specific populations and geographic areas in need of HIV counseling, testing, and prevention services. Blinded (unlinked) serologic surveys were conducted in the United States and Puerto Rico in sentinel clinics providing reproductive health services to women, including family planning, prenatal care, and abortion services. Seventy-eight of 94 clinics (83%) in 30 cities conducting surveys during 1988 and 1989 detected at least one HIV-positive woman. Clinic-specific prevalence ranged from 0-2.28% (median 0.22%), with rates over 1% occurring in clinics predominantly on the East Coast and in Puerto Rico. Seroprevalence varied by primary type of service, race-ethnicity, and age group. Median rates were higher in clinics offering prenatal services and lower in abortion and family planning clinics in the same cities. In general, women 25-29 years of age showed the highest median rate of infection (0.32%), and rates were higher among black women (median 0.34%) than among Hispanic (median 0.11%) and white women (median 0%). Our data indicate the need to educate women about recognizing and reducing their risk of HIV infection. Reproductive health clinics with high seroprevalence should implement voluntary HIV counseling and testing with appropriate follow-up clinical evaluation and referral for infected women. Clinics with low prevalence should seize the opportunity to enhance HIV education and prevention efforts.

Ultrastructural identification of synapses between mitral/tufted cell dendrites.

Asymmetrical, type 1 synapses between mitral and/or tufted (M/T) cell dendrites were observed in the glomerular layer (GL) and juxtaglomerular external plexiform layer (EPL) of salamander olfactory bulb sections. The dendrites had electron-lucent cytoplasm containing regularly-arrayed microtubules and spherical translucent vesicles. The vesicles were clustered against a thin pre-synaptic density that was aligned with a 17-20 nm-wide synaptic cleft and a thicker post-synaptic density. These dendrodendritic synapses could be a source of the delayed, prolonged excitation that originates from the GL/EPL. During spatiotemporal encoding of odor stimuli, they could amplify or synchronize M/T cell responses.

Calcitonin gene-related peptide and reperfusion injury.

Calcitonin gene-related peptide is a potent intrinsic vasodilator, can induce prostacyclin release, and may inhibit membrane lipid peroxidation. This study examines the effect of calcitonin gene-related peptide on vessel diameters, capillary perfusion, and contractile function of skeletal muscle after 4 or 5 hours of ischemia and during immediate reperfusion using the rat cremaster muscle model. Forty-two male rats were used; half of these received 0.2 ml of 10(-7) M calcitonin gene-related peptide after 0, 15, and 30 minutes of reperfusion, while the other half received normal saline as a control. By means of intravital videomicroscopy, the diameters of 10 vessels per muscle were measured prior to ischemia and during reperfusion. The fluorescein filling area was determined at 15, 30, and 60 minutes of reperfusion. After 1 hour of reperfusion, muscle function was examined in vitro by quantifying the contractile response to electric field stimulation of the muscles in an organ bath system. There was a significant increase in the diameter of the arterioles, but not the small arteries, at every time point from 10 to 60 minutes of reperfusion. The fluorescein filling area was increased in treated muscles at every time point. Contractile function was not significantly preserved. In light of the ability of calcitonin gene-related peptide to relieve vasospasm and improve capillary perfusion, it may be useful in reducing reperfusion injury in the future.

Disseminated Mycobacterium flavescens in a probable case of chronic granulomatous disease.

We report the case of a diabetic Chinese male with no previous history of recurrent infections. His course was at first notable for relapsing Salmonella blockley infections, following which he developed repeated soft-tissue infections and Cryptococcus neoformans pneumonia. He was diagnosed as having chronic granulomatous disease and was treated with gamma interferon. During the latter stages of his illness he developed Mycobacterium flavescens infection in soft tissues, joints, bones and lung. This is the first report of disseminated M. flavescens infection.

A 7-day course of ciprofloxacin for enteric fever.

A prospective, open and non-randomised clinical trial using a 7-day short course of oral ciprofloxacin 500 mg twice daily was conducted on 25 adult patients with bacteraemic enteric fever. Twenty-four patients (96%) were cured and there was one treatment failure. Two patients with typhoid fever relapsed 6 weeks after finishing treatment. Defervescence of fever was rapid (median: 4 days) and the duration of hospitalisation was short (median: 8 days). Both factors resulted in patient satisfaction. A short-course regime of ciprofloxacin for the treatment of enteric fever, is therefore, highly promising.

Regional differences in birth weight-specific infant mortality, United States, 1980.

To describe regional differences in birth weight-specific infant mortality in the United States, we used data from the National Infant Mortality Surveillance project. The infant mortality risk (IMR) for the nation was 11.0 deaths per 1,000 live births. The risk (with 95 percent confidence intervals [CI]) for the four U.S. Census regions were West 9.9 (9.7 to 10.1), Northeast 10.4 (10.1 to 10.6), North Central 10.8 (10.6 to 11.0), and South 12.1 (11.9 to 12.3). In all regions, the IMR for blacks was approximately twice that of whites. Seventy-two percent of the higher IMR in the South was due to a higher proportion of black births compared with the remainder of the nation, reflecting the higher mortality rates suffered by black infants, and 28 percent to higher mortality among southern whites. The IMR for whites in the South was significantly higher than in the remainder of the nation: 9.8 versus 9.1 (relative risk = 1.09, CI = 1.06 to 1.11). Thirty-six percent of this excess in IMR was due to a higher frequency of low birth weight (less than 2,500 grams), 18 percent was due to higher IMR in infants with birth weight less than 2,500 grams, and 46 percent due to higher IMR in infants with birth weights of 2,500 g or more. Black infants born in the West had a lower risk of death than black infants in the other regions. When compared with the Northeast and South, 36 percent of the lower risk in the West among black infants was due to a lower frequency of low birth weight, 38 percent due to lower IMR in infants w'ith birth weight less than 2,500 g, and 26 percent to lower IMR in infants with birth weight of 2,500 g or more.

HIV seroprevalence surveys in drug treatment centers.

Sharing of equipment used to inject illicit drugs intravenously is a risk factor for human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS). Systematic surveillance of HIV infection among intravenous drug users (IVDUs) in the United States is essential to monitor the HIV epidemic and to target and evaluate prevention programs for IVDUs and their partners. The most accessible segment of the largely covert population of IVDUs are those in drug treatment programs. In collaboration with State and local health departments and drug abuse treatment agencies, the Centers for Disease Control is conducting blinded (serologic test results not linked to identifiable persons) and nonblinded (in which clients voluntarily agree to participate) surveys of IVDUs entering drug treatment in 39 U.S. metropolitan areas. The same protocol is used in all participating drug treatment centers. Blinded surveys will be carried out annually to determine HIV seroprevalence rates in eligible IVDUs entering drug treatment and to monitor trends over time. Each year, nonblinded surveys of IVDUs entering drug treatment will assess self-reported drug use and sexual behaviors to help design educational interventions and to detect changes in behavior over time. This sentinel surveillance system, using a standardized methodology, will provide the best national and regional data available on the seroprevalence of HIV among IVDUs and the relationships of drug use, sexual behaviors, and HIV serologic status of IVDUs.

Determining HIV seroprevalence among women in women's health clinics.

Human immunodeficiency virus, type 1 (HIV), seroprevalence studies are needed to determine the level and trends of HIV infection among women attending family planning, abortion, and prenatal care clinics in the United States. A review of published and unpublished studies showed that HIV seroprevalence among women attending women's health clinics was 0 to 2.6 percent, although the studies were difficult to compare because of differences in methodology. The Centers for Disease Control, in association with State and local health departments, has developed a standardized protocol to determine HIV seroprevalence among women attending women's health clinics in selected metropolitan areas. Blinded HIV serosurveys (serologic test results not identified with a person) are being conducted annually in selected sentinel clinics in order to obtain estimates of HIV seroprevalence unbiased by self-selection, as well as to monitor trends in infection among clients attending these clinics. In areas with high HIV seroprevalence, nonblinded serosurveys (in which clients voluntarily agree to participate) will be used to assess behaviors that may place women at increased risk of exposure to HIV. Data from the surveys can be used in developing age-specific and culturally appropriate AIDS educational materials, assessing the amount and type of counseling activities required, and evaluating acquired immunodeficiency syndrome (AIDS) prevention activities. The information will provide epidemiologic data to complement the results of other surveys in characterizing the scope of HIV infection among women of childbearing age in the United States.

Effects of the transportation of beef cattle from the feedyard to the packing plant on prevalence levels of Escherichia coli O157 and Salmonella spp.

Two hundred steers and heifers from a large feedyard (65,000-head capacity) were used to determine the prevalence levels of enterohemorrhagic Escherichia coli O157 (EHEC O157) and Salmonella spp. prior to and after shipping to a commercial packing facility. Two samples, a ventral midline hide swab and a fecal sample, were aseptically collected from each animal 2 weeks prior to the date of transportation and at the packing plant immediately after exsanguination. Samples were collected from all trailers (n = 46) before animals were loaded for transport to the packing facility. The average prevalence levels of EHEC O157 on hides (18%) and in feces (9.5%) at the feedyard decreased (P > 0.05) at the packing plant to 4.5 and 5.5%, respectively. The average prevalence levels of Salmonella spp. on hides (6%) and in feces (18%) at the feedyard increased to 89 and 46%, respectively, upon arrival at the packing plant. Average prevalence levels for EHEC O157 and Salmonella spp. on the trailers were 5.43 and 59%, respectively. The results of this study demonstrate that transportation may be a potential stressor for cattle, as evidenced by the increased shedding of Salmonella spp.

Depressive characteristics of physically abused children.

Physically abused and nonabused children were compared on child-completed measures of depression, hopelessness, self-esteem, and locus of control. Results indicated that, in comparison with nonabused controls, abused children evidenced more depressive symptoms, heightened externality, lower self-esteem, and greater hopelessness about the future. Group differences in depressive symptomatology were not accounted for on the basis of differences in age, sex, race, gender, IQ, or socioeconomic status. Results replicate the results of Kazdin, Moser, Colbus, and Bell (1985) derived from a sample of physically abused psychiatric inpatients and extend the generality of these findings to abused children of nonpatient status. Implications of the findings for clinical interventions, theoretical models of child depression, and future research are discussed.

Utilization of beef from different cattle phenotypes to produce a guaranteed tender beef product.

Cattle (n = 303) were visually selected from four feed yards to represent six phenotypes (English [EN; n = 50], 3/4 English-1/4 Brahman [ENB; n = 52], 1/2 English-1/2 Exotic [ENEX; n = 56], 1/2 English-1/4 Exotic-1/4 Brahman [ENEXB; n = 47], 3/4 Exotic-1/4 Brahman [EXB; n = 49], and 1/2 Exotic-1/4 English-1/4 Brahman [EXENB; n = 49]). Carcasses were processed at a commercial beef packing facility, and strip loins were collected after 48-h chilling. Strip loins were aged for 14 d at 2 degrees C and frozen at -20 degrees C for 3 to 5 d before three 2.5-cm-thick steaks were cut for Warner-Bratzler shear force (WBSF) determinations and sensory evaluations. Phenotype EN had the highest (P < 0.05) adjusted fat thickness, and EXB had adjusted fat thickness that was lower (P < 0.05) than all other phenotypes except EXENB. Carcasses of EN and ENB had smaller (P < 0.05) longissimus muscle areas than phenotypes ENEX, EXB, and EXENB. Phenotype EN produced carcasses with the highest (P < 0.05) numerical yield grade, whereas carcasses originating from phenotype EXB had lower (P < 0.05) numerical yield grades than all other phenotypes except ENEX. No differences (P > 0.05) were found among phenotypes for mean WBSF values or sensory panel ratings for initial and sustained tenderness, initial and sustained juiciness, beef flavor characteristics, and overall mouthfeel. More than 90% of steaks from carcasses of all phenotypes had WBSF values less than 3.6 kg when cooked to an internal cooked temperature of 70 degrees C. Results from this study indicated that all phenotypes represented in this study could be managed to produce tender beef.

Effects of zeranol-implantation periods on palatability of longissimus steaks from young bulls and steers.

Fifty-five fall-born, Simmental-crossbred, male calves were allotted at birth to one of five treatments: bulls castrated at 5 mo and implanted from birth to slaughter (ST); bulls implanted from birth to slaughter (BI-BS); bulls implanted from birth to weaning (BI-BW); bulls implanted from weaning to slaughter (BI-WS) and non-implanted control bulls (CB). Implanted calves received 36 mg of zeranol at approximately 100-d intervals. Calves were fed a high-concentrate diet from 8.1 mo of age to an average slaughter age of 17 mo. Longissimus steaks (LS) were evaluated for palatability traits by both a trained sensory panel (TSP) and a take-home consumer panel (CP). Conclusions from both panels were similar. The TSP found LS from ST to be juicier (P less than .05) than LS from all bull groups, and to be more tender (P less than .05) than LS from BI-BW and BI-WS. The CP found LS from ST to be juicier, more tender and more acceptable (P less than .05) than LS from BI-BW, BI-WS and CB. Steaks from BI-BS were more tender (P less than .05) than LS from BI-WS and CB. Steaks from BI-BS and BI-BW had lower (P less than .05) shear values than LS from CB, but LS from ST had lower (P less than .05) shear values than LS from all bull groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Uptake of In-111 labeled leukocytes by lymphocele. A cause of false-positive vascular graft infection.

In-111 labeled leukocyte scintigraphy is a sensitive test for the diagnosis of prosthetic vascular graft infections. However, several causes of false-positive results have been reported. The authors describe a case of uninfected lymphocele around a synthetic vascular graft in a patient who showed an infected graft on In-111 labeled leukocyte scintigraphy.