A pilot study of isotretinoin in the treatment of juvenile chronic myelogenous leukemia

BACKGROUND

Juvenile chronic myelogenous leukemia (CML) is a rare myeloproliferative disease of infants and young children for which there is no effective therapy other than allogeneic bone marrow transplantation. In vitro, isotretinoin (13-cis-retinoic acid) attenuates both the spontaneous proliferation of leukemic peripheral-blood progenitor cells (granulocyte-macrophage colony-forming units) and their selective hypersensitivity to granulocyte-macrophage colony-stimulating factor (GM-CSF). We conducted a pilot study to evaluate the clinical efficacy of isotretinoin in juvenile CML.

METHODS

To be eligible the patients had to have newly diagnosed untreated disease, leukocytosis with monocytosis, marrow with less than 25 percent blasts, hepatosplenomegaly, no chromosomal abnormalities, and negative viral cultures and antibody titers. Isotretinoin was administered orally in single daily doses of 100 mg per square meter of body-surface area. When possible, patients subsequently underwent bone marrow transplantation.

RESULTS

Ten children (median age, 10 months) were enrolled in the study. In all 10 there was spontaneous colony formation of leukemic progenitor cells in vitro. In the eight patients tested there was hypersensitivity to GM-CSF. The only toxic effect of isotretinoin therapy was cheilitis in two patients. Four children had disease progression. Two children had complete responses to isotretinoin (normalization of the white-cell count and disappearance of organomegaly), three had partial responses (more than a 50 percent reduction in the white-cell count and degree of organomegaly), and one had a minimal response (more than a 50 percent reduction in the white-cell count, but a 26 to 50 percent reduction in the degree of organomegaly). The median duration of response was 37 months (range, 6 to 83). Three of the four children who had a complete or partial response and who did not undergo bone marrow transplantation were alive 36 to 83 months after the diagnosis of juvenile CML. The spontaneous colony formation in vitro was reduced in samples from the five patients in whom this factor was reassessed during treatment. There was also a reduction in the hypersensitivity of leukemic progenitor cells to GM-CSF in the two patients retested.

CONCLUSIONS

Isotretinoin can induce durable clinical and laboratory responses in patients with juvenile CML.

Drug-related behavior change for HIV transmission among American injection drug users

While high risk drug-related behaviors for human immunodeficiency virus (HIV) transmission among injection drug users (IDUs) are asserted to have declined over time in response to the AIDS epidemic, evidence from longitudinal cohorts has been sparse. In a cohort of 810 IDUs (442 seronegatives and 368 seropositives) in Baltimore, we identified drug-related risk behaviors at four consecutive semi-annual visits. Using robust methods for repeated measurements and multiple logistic regression, we estimated the probabilities of maintaining and reducing risk behaviors according to HIV serostatus and time in the study. Seropositive participants were more likely to maintain lower risk behaviors, and behavior maintenance increased with time in study for both seronegative and seropositive IDUs. Greater risk reduction (towards non-use and not sharing injection equipment) was seen among seropositive IDUs, with behavior change occurring soon after enrollment in the study. While behavior changes have been reported, many active IDUs, especially those still at risk for acquiring HIV infection, have not adequately reduced their risk. Continuing prevention programs and efforts in vaccine development are imperative to reduce the risk of HIV infection among IDUs.

Correlates of needle sharing among injection drug users

OBJECTIVES

The sharing of contaminated injection equipment is the primary mode of human immunodeficiency virus (HIV) transmission for injection drug users. This study examined demographic factors, life events, and drug use practices that are potential risk factors for sharing injection equipment.

METHODS

Between February 1988 and March 1989, 2921 active injection drug users were interviewed and questioned about their backgrounds, life-styles, and patterns of injection drug use.

RESULTS

Of 2524 participants who reported injecting drugs within the 6 months prior to study enrollment, 70.4% reported recent needle sharing. A multivariate analysis found needle sharing to be more frequent among those with a history of arrest and lower socioeconomic status, even after accounting for other demographic and drug use variables. In addition, recent needle sharing was higher in male homosexual or bisexual men than in their heterosexual counterparts.

CONCLUSIONS

These data suggest that injection drug users have an economic motive to share needles and that the availability of free and legal needles may reduce levels of needle sharing.

A pilot syringe exchange program in Washington, DC

The Washington, DC City Council authorized a pilot syringe exchange program to operate for only 60 days at a single drug abuse treatment facility in the District. Only adults on the waiting list for treatment were eligible (n = 467). Of the 33 who enrolled, median duration of drug injection was 18 years. Twenty-seven participants denied needle sharing. Of 209 needles distributed, 69% were returned. Low enrollment might have been due to restrictive entry criteria, inconvenient location, incorrect syringe size, and attitudes of treatment staff. For future efforts to have a public health impact, wider accessibility will be needed.

Comparison of clinical symptoms of human immunodeficiency virus disease between intravenous drug users and homosexual men

BACKGROUND

To compare the prevalence of human immunodeficiency virus (HIV)-related clinical symptoms among male intravenous drug users and homosexual men stratified by HIV serostatus and CD4 cell levels.

METHODS

A cross-sectional sample using concurrent longitudinal studies of the natural history of HIV-1 infection among intravenous drug users (N = 539) and homosexual men (N = 932) was recruited in Baltimore, Md. Participants were administered a risk behavior interview and physical examination, and had hematologic tests evaluated in a similar calendar period.

RESULTS

Both risk groups demonstrated an inverse relationship between frequency of symptoms and CD4 cell count. Fever, night sweats, and lymphadenopathy were not evaluated because pilot data suggested a confounding association with drug injection. Among those with mild to moderate immune suppression, intravenous drug users were significantly more likely than homosexual men to experience fatigue, weight loss, diarrhea, and shortness of breath; to have oral candidiasis, palpable spleen, and lower mean weight on physical examination; and abnormal hematocrit, platelets, and total lymphocyte counts. However, participants in either risk group with CD4 cell levels below 0.2 x 10(9)/L experienced similar frequency of all clinical symptoms. Self-reported oral candidiasis increased fourfold with HIV infection and was as likely in both groups at all CD4 cell levels. Duration and recency of intravenous drug use was not significantly associated with the higher frequency of most clinical symptoms.

CONCLUSION

Social factors are an important consideration in evaluating the association between clinical symptoms and HIV immunosuppression. Except for oral candidiasis, there are limitations for the use of clinical symptoms as intermediate outcome measures for HIV infection among intravenous drug users.

Differences in risk factors for human immunodeficiency virus type 1 seroconversion among male and female intravenous drug users

To examine sex-specific risk factors for human immunodeficiency virus (HIV) type 1 seroconversion among intravenous drug users, the authors conducted a nested case-control study in Baltimore, Maryland, from 1988 to 1992 comparing 146 seroconverters and 539 HIV seronegative controls. Controls were matched on sex, race, date of study entry, and duration of follow-up. Risk factor data were obtained from interviews conducted at the first seroconversion visit for the case and the closest visit for the corresponding seronegative control. Since test results were not available until several weeks after interview, both interviewers and participants were unaware of seroconversion status at the time of interview. When data were analyzed using conditional logistic regression techniques, the variables which were significantly associated with seroconversion among male intravenous drug users included age less than 35 years, a sexually transmitted disease within the past 6 months, lifetime history of syphilis, and current intravenous drug use with an abscess at the injection site. Among women, only a history of three or more sex partners was positively associated with seroconversion and having a biological child under age 18 years was inversely associated with HIV seroconversion. Although the small sample size may have limited the ability to ascertain differences in risks of seroconversion among males and females, these data suggest that sexual transmission contributes to HIV infection among intravenous drug users, especially women.

Hemodynamic effects of primary closure versus patch angioplasty of the carotid artery

This study evaluated the hemodynamic changes associated with patch angioplasty compared to primary closure of the canine carotid artery. A standard arteriotomy was closed either primarily, with a 5x28 mm expanded polytetrafluoroethylene (ePTFE) patch, or with a 10x28 mm ePTFE patch. Measurements for the primary closure group showed a systolic pressure gradient of 17 mmHg across the closure and a peak systolic velocity increase of 58% at mid-closure compared to proximal inflows. Flow turbulence increased at mid-closure in the 10 mm patch group, with the percent spectral window lowered from 0.50 to 0.36. These data show that primary vessel closure creates a mild local stenosis with flow acceleration but no flow turbulence. No significant hemodynamic disturbances are caused by a moderate sized patch; however, a large patch relative to native vessel dimensions creates marked flow disturbances throughout the cardiac cycle. As turbulence and flow separation are felt to contribute to restenosis, care should be taken in the selection of patch size when used following carotid endarterectomy.

Narcotic-induced suppression of natural killer cell activity in ventilated and nonventilated rats

Surgical stress and general anesthesia can suppress immune function and thus may increase postsurgical infections and tumor metastasis. We previously reported that two narcotics commonly used in high-dose opiate anesthesia (fentanyl and sufentanil) suppress natural killer (NK) cell activity in rats. Such doses of narcotics also cause respiratory depression accompanied by hypoxia, hypercarbia, and acidosis, which might account for the observed narcotic-induced NK suppression. In the present study, we compared the effects of fentanyl on NK activity in ventilated and non-ventilated rats. Fentanyl significantly suppressed NK cell activity to the same magnitude in the two groups, although the groups significantly differed in CO2 and O2 levels. The fact that high-dose fentanyl-induced NK suppression can be demonstrated in ventilated rats accentuates the relevance of these findings to clinical studies showing NK suppression in the immediate postoperative period. Such immunosuppression could be a risk factor for patients undergoing surgery, especially in cancer-related operations.

Needle-cleaning practices among intravenous drug users who share injection equipment in Baltimore, Maryland

In Baltimore, Maryland, between 1988 and 1989, 2,921 intravenous drug users were recruited into a study of drug injection practices and human immunodeficiency virus (HIV) infection. Sixty-three percent reported both current use and sharing of needles; almost all these (N = 1,757) reported using injection equipment immediately after it was used by another intravenous drug user. Of the 1,757, 62% said that they "typically" cleaned the used equipment with bleach or alcohol before injecting. These data suggest that information about disinfecting needles has disseminated into this population and identifies several groups to target for interventions.

Focal myocardial injury following blunt chest trauma: a comparison of indium-111 antimyosin scintigraphy with other noninvasive methods

The diagnosis of myocardial contusion is often difficult, as traditional methods such as serial electrocardiograms, cardiac enzyme (creatine kinase [CK-MB]) analysis, and echocardiography lack sensitivity and specificity. Recent reports have shown that 111In labelled antimyosin scanning has high sensitivity for detecting cardiac injury. However, no prior studies have been reported for antimyosin imaging with patients suspected of sustaining a cardiac contusion. Accordingly, 17 patients with severe multisystem trauma (intrathoracic vascular injury in eight patients, pneumothorax and pulmonary contusion in 13) underwent antimyosin scintigraphy, echocardiography, 12-lead electrocardiograms, and CK-MB determinations. Arrhythmias were noted in seven patients, four of whom died. All patients has elevated CK levels but CK-MB isoenzyme was greater than 4% in only three. Abnormal ST segments were noted in nine subjects, only one of whom had CK-MB elevation. Echocardiography revealed pericardial effusions in four patients but was technically suboptimal in 53% of the studies. Blinded interpretation of the antimyosin scans revealed only one with focal myocardial uptake; this same patient had the only discrete wall motion abnormality on the echocardiogram and also had ST depression with ectopy but normal CK-MB. Thus in patients with suspected myocardial contusion, echocardiography is frequently limited technically and the electrocardiogram and CK analysis appear to lack diagnostic accuracy. In contrast, monoclonal antimyosin imaging may be performed in patients with trauma without limitation and yields results that are concordant with echocardiograms. In patients with suspected myocardial contusion, focal antimyosin uptake is uncommon despite severe thoracic injury, which suggests that extensive myocardial necrosis is not the primary method of injury.

Changes in T-lymphocyte subsets in intravenous drug users with HIV-1 infection

OBJECTIVE

To evaluate changes in T-cell subsets in prevalent human immunodeficiency virus type 1 (HIV-1) seronegative and seropositive intravenous drug users (IVDUs) and in HIV-1 seropositive IVDUs with known time of seroconversion.

DESIGN

Cohort study with a median 18-month follow-up.

SETTING

Community-based clinic established to study the natural history of HIV infection in IVDUs.

SUBJECTS

Eight hundred fifty-nine self-referred IVDUs aged 18 through 49 years who injected drugs within the last 10 years and who did not have an AIDS (acquired immunodeficiency syndrome)--defining illness; 152 were seronegative for HIV-1, 621 were seropositive, and 86 seroconverted during the study.

OUTCOME MEASURES

Proportions and absolute numbers of lymphocytes and CD3, CD4, and CD8 T cells as determined at 6-month intervals by flow cytometry and complete blood cell counts with automated differential.

RESULTS

Median numbers of CD4 lymphocytes at enrollment were 1061/microL (1.06 x 10(9)/L) for seronegative IVDUs, 508/microL for seropositive IVDUs, and 733/microL for those who seroconverted (enrolled a median of 4.5 months after seroconversion); the corresponding figures for CD8 lymphocytes were 628, 894, and 889/microL, respectively. Median rates of decline in absolute numbers and percentages of CD4 lymphocytes per 6 months were 7.6/microL (0.0%) for seropositive IVDUs and 55.1/microL (1.9%) for IVDUs who seroconverted (median follow-up after seroconversion was 12 months). Multivariate regression analysis that incorporated the within-individual correlation of the CD4 lymphocyte counts showed no significant change in these cells over time and no change due to use of drugs.

CONCLUSION

Our data suggest that progression of HIV-1 infection in IVDUs, as reflected in decline of CD4 cell counts, is no more rapid than that reported for other risk groups.

Immune serum markers and CD4 cell counts in HIV-infected intravenous drug users

We examined the association of three serum immune markers with CD4 cell counts in a large cohort of i.v. drug users with and without human immunodeficiency virus (HIV) infection. Levels of beta 2-microglobulin and neopterin were significantly elevated in HIV-infected subjects and increased in association with decline in CD4 cell counts (all p less than 0.001). Serum IgA levels in HIV-seropositive individuals were significantly elevated only when the CD4 cell count was less than 200/microliters (p less than 0.001). After controlling for HIV status and CD4 count, recent history of hepatitis was associated with significantly higher beta 2-microglobulin (p = 0.028) and marginally higher neopterin (p = 0.052) levels. There was no association of race, gender, or drug use patterns with levels of serum immune markers after controlling for HIV status and CD4 count. These data indicate that immune activation is coupled with immunosuppression in HIV-infected i.v. drug users. In addition, beta 2-microglobulin and neopterin levels are elevated in persons with a recent history of hepatitis but not in those with recent non-AIDS-defining bacterial infections. Markers of immune activation do not vary by race, gender, or drug use patterns among i.v. drug users.

New evidence on intravenous cocaine use and the risk of infection with human immunodeficiency virus type 1

To examine whether recent intravenous use of cocaine might be associated with increased risk of human immunodeficiency virus type 1 (HIV) infection, the authors studied 2,597 active intravenous drug users: 2,399 with recent cocaine injection and 198 with recent injection of heroin or other drugs but not cocaine. These subjects were adult residents of Baltimore City and the surrounding Maryland counties, recruited via outreach into the community between February 1988 and March 1989. In contrast to the first report on the cocaine-HIV association, the present study sample was not recruited solely from drug treatment programs. In the present study, estimated HIV seroprevalence was 26.4% for recent cocaine injectors as compared with 10.6% among all other recent intravenous drug users; the relative odds estimate was 3.03. In the untreated segment of the sample, HIV seroprevalence was 26.0% for recent cocaine injectors as compared with 8.9% among others (relative odds (RO) = 3.61). The estimated degree of association did not change appreciably when multiple logistic regression was used to hold constant potentially confounding and/or mediating variables such as receptive anal intercourse, number of sex partners, and use of injection equipment obtained at shooting galleries (RO = 2.64). Augmenting these cross-sectional data, preliminary prospective data showed excess risk of HIV seroconversion among recent cocaine injectors (estimated relative risk = 2.11). While other research has examined the cocaine-HIV association, the present study differs in that it has allowed a test for whether the association was a spurious artifact of studying drug users recruited solely from drug treatment programs, a broad array of alternative determinants of HIV infection have been held constant, and the association has been examined with seroconversion data. The results lend support to the abiding concern about the risk of HIV infection among cocaine users.

Antibody to hepatitis C virus among cardiac surgery patients, homosexual men, and intravenous drug users in Baltimore, Maryland

In order to define the risk factors for infection with hepatitis C virus, the authors determined the prevalence and incidence of antibodies to hepatitis C in three cohorts in Baltimore, Maryland, enrolled in prospective studies of human immunodeficiency virus (HIV-1) infection. Among 500 multi-transfused patients who underwent cardiac surgery in 1985 and 1986, 12 (2.4%) were hepatitis C seropositive before surgery while 19 (3.9%) developed antibodies in the 8-12 months after surgery. The seroprevalence of hepatitis C virus among 225 intravenous drug users followed since 1988 was 85%, which did not vary by HIV-1 status. Longer duration of intravenous drug use was significantly associated with hepatitis C seropositivity. Among 926 homosexual/bisexual men followed since 1984, 15 (1.6%) were hepatitis C seropositive; only intravenous drug use and a history of hepatitis A were marginally associated with hepatitis C in this population. No association was found between hepatitis C virus and HIV-1 or sexual behavior variables in this population. These data suggest that hepatitis C is readily transmitted by blood exposure, but is transmitted inefficiently by sexual means.

HIV seroconversion and disinfection of injection equipment among intravenous drug users, Baltimore, Maryland

To examine the putative protective effect of disinfectant use on HIV seroconversion among intravenous drug users, we conducted a nested case-control study comparing 22 black heterosexual HIV seroconverters with 95 persistent seronegatives matched on gender, use of cocaine, date of study entry, and duration of follow-up. For intravenous drug users who reported using disinfectant all the time, the odds of seroconversion was 0.77 (95% CI: 0.25-2.38) compared with those who reported no use of disinfectants; for those who used disinfectants some of the time, the corresponding odds ratio was 0.91 (95% CI: 0.26-3.31). The odds ratio for use of disinfectant all the time was 0.63 (95% CI: 0.10-3.91) for those injecting at galleries and 1.08 (95% CI: 0.35-3.11) for those not injecting at galleries. These data suggest a limited protective effect of disinfectant use in the field which may be more beneficial to those injecting in shooting galleries.

Inherited propensity for neuropathic pain is mediated by sensitivity to injury discharge

We reported previously that injury discharge (ID), a burst of impulses fired following nerve injury, plays a role in triggering autotomy, a neuropathic pain-related behavior in rats. Here we affirm this link using two lines of rats, derived by selective breeding from the Sabra strain to express high (HA) or low (LA) levels of autotomy following hindpaw denervation. Blocking ID in HA rats before injury suppressed autotomy. Correspondingly, artificial prolongation of ID in LA rats just prior to neurectomy, increased autotomy. The autotomy in these HA and LA rats was like that of their Sabra ancestors. This suggests that the underlying basis for selection of these lines was differential sensitivity of the CNS to the effects of ID.

Human immunodeficiency virus infection in diabetic intravenous drug users

OBJECTIVE

--To evaluate the association between diabetes and human immunodeficiency virus (HIV) seroprevalence in a population of intravenous (IV) drug users.

DESIGN

--Cross-sectional survey in a cohort of IV drug users.

SETTING

--Community-based study clinic.

SUBJECTS

--The study included 2921 individuals with a history of IV drug use in the past 10 years; over 90% had injected drugs in the past year and 77% in the past month; only 15% were receiving drug treatment.

OUTCOME MEASURES

--The HIV seroprevalence among IV drug users with and without a history of diabetes.

RESULTS

--Those IV drug users with a history of diabetes had significantly lower HIV seroprevalence (9.8%) than nondiabetic IV drug users (24.3%; P = .03). Despite similar duration and intensity of drug use and sexual practices, diabetic IV drug users tended not to share injection paraphernalia and were less likely to attend shooting galleries than nondiabetic IV drug users.

CONCLUSION

--Our data suggest that the apparent protective effect of diabetes against HIV infection in IV drug users is most likely due to their safer injection practices afforded by their ready access to sterile injection equipment.

Risk factors for shooting gallery use and cessation among intravenous drug users

BACKGROUND

Shooting galleries, locations where intravenous drug users (IVDUs) can rent or borrow needles and syringes, are a high-risk environment for HIV-1 transmission. This study investigates risk factors for lifetime attendance at shooting galleries and differentiates characteristics of those who continue to frequent shooting galleries and those who have stopped.

METHODS

We interviewed 2615 active IVDUs in Baltimore in 1988 and 1989 and determined patterns of IV drug use, sociodemographics, and HIV-1 serostatus as related to persistence vs cessation of shooting gallery use.

RESULTS

Over half (52%) of active IVDUs reported ever using a shooting gallery, with 33% reporting use within the prior 3 months. In multivariate analysis, lifetime shooting gallery use was associated with male gender, homosexuality/bisexuality, low socioeconomic status, Black race, and heavier drug involvement. Persistent shooting gallery users were more frequently male, homosexual/bisexual, homeless, less educated, and started IV drug use more recently compared with those who ceased going to shooting galleries.

CONCLUSIONS

Shooting gallery attendance may be pragmatic from a sociological and economic perspective, but it carries with it a heightened risk of acquiring HIV-1 infection.

Sexually transmitted diseases in a population of intravenous drug users: association with seropositivity to the human immunodeficiency virus (HIV)

The association between human immunodeficiency virus (HIV) seropositivity and a history of sexually transmitted diseases (STDs), evidence of STDs on physical examination, and sexual and drug use practices was studied in a population of 2921 intravenous drug users (IVDUs) in Baltimore during 1988 and 1989. Overall, 24.1% were HIV-seropositive at baseline, and 60% reported a history of an STD. A significant association was found between HIV seropositivity and a history of syphilis (P = .04); both were more frequent among homosexual/bisexual men than among heterosexual IVDUs. In multivariate analysis, a history of syphilis was independently associated with HIV seroprevalence in homosexual/bisexual male IVDUs, of whom 90% reported a history of sexual intercourse with women. Cocaine injection was independently associated with HIV seropositivity but not a history of syphilis on multivariate analysis. STDs, indicative of unsafe sex practices, are common in this population; efforts are needed to prevent sexual transmission of HIV infection among IVDUs and their sex partners.

Smallest region of overlap in Wilms tumor deletions uniquely implicates an 11p13 zinc finger gene as the disease locus

The development of Wilms tumor (WT) has been associated with the inactivation of a "tumor suppressor" locus in human chromosome 11 band p13. Several WTs that exhibit homozygous deletions of an 11p13 candidate WT gene in its entirety have been reported. We report here a partial deletion of the candidate gene which, upon comparison with other documented homozygous deletions, permitted a precise definition of the critical genomic target in Wilms tumor. The smallest region of overlap between these deletions is a 16-kb segment of DNA encompassing the 5' exon(s) of an 11p13 gene coding for a zinc finger protein, together with an associated CpG island. This finding supports the notion that the candidate gene in question corresponds to the 11p13 WT1 Wilms tumor locus.

Association of drug injection patterns with antibody to human immunodeficiency virus type 1 among intravenous drug users in Baltimore, Maryland

During 1988 and 1989, intravenous drug users recruited through extensive community outreach efforts in Baltimore, Maryland, were interviewed about drug injection and sex practices in the prior 11 years, with screening for antibody to human immunodeficiency virus type 1 (HIV-1). Neither interviewers nor subjects were aware of HIV-1 serostatus until 2 weeks after the interview. Among 2,616 intravenous drug users who last injected drug within the same calendar year as screening, HIV-1 seroprevalence was 30.1% for those with any use of shooting galleries, 23.3% for those who shared needles but did not use shooting galleries, and 16.3% for drug users who denied both needle-sharing and gallery use between 1977 and 1987. Among 608 drug users who reported persistent use of shooting galleries since 1977 or subsequent initiation into drug use, there was a tendency for HIV-1 seroprevalence to increase with more recent onset of an injection career. Combined with a milder but similar tendency among 739 drug users who reported persistent sharing of needles, and a seroprevalence of 15.1% among participants who had just started injecting drugs in the 18 months prior to baseline, these data provide indirect evidence that a high risk for HIV-1 infection might occur early during a drug injection career.

Comparative immunogenicity of plasma and recombinant hepatitis B virus vaccines in homosexual men

A randomized, double-blind clinical trial of plasma-derived and DNA recombinant hepatitis B virus vaccines was conducted in 186 homosexual men. Nine months after the immunization series (three doses) began, the seroconversion rate in the plasma vaccine group was 88% (68/77); this was significantly higher than the 74% (60/81) response rate of the recombinant vaccine group. Men positive for antibody to the human immunodeficiency virus (HIV) had a considerably higher nonresponse rate to either vaccine than expected in non-HIV-infected homosexual men. The odds ratios of nonresponse to hepatitis B virus vaccine for HIV-seropositive vs HIV-seronegative subjects were 12.0 (95% confidence interval, 1.7 to 89.3) and 13.6 (95% confidence interval, 2.3 to 148.3) for the plasma and DNA recombinant vaccines, respectively.

Flow cytometric quantitation of T cell phenotypes in cerebrospinal fluid and peripheral blood of homosexual men with and without antibodies to human immunodeficiency virus, type I

Two-color flow cytometry was used to analyze T cell subsets (total (CD3), helper-inducer (CD4), and suppressor-cytotoxic (CD8] in paired specimens of cerebrospinal fluid (CSF) and peripheral blood of 66 homosexual men, including 62 with antibodies to human immunodeficiency virus, type 1 (HIV-1). With the exception of one traumatic specimen, all of the CSF specimens, 52 of which had less than or equal to 5 lymphocytes/mm3, were evaluated fully, with the number of lymphocytes counted for each antibody ranging from 200 to 2933 (mean = 1129). Proportions of CD3, CD4, and CD8 lymphocytes in CSF were very highly correlated with the proportions of these cells in the peripheral blood (r = 0.87, 0.96, and 0.94, respectively), as was the CD4/CD8 ratio (r = 0.98). These strong correlations were present in each of seven subgroups of study subjects defined on the basis of detailed neurologic examination, neuropsychological testing, and the presence or absence of antibodies to HIV-1. In the population studied, T cell phenotypes in CSF as analyzed by two-color flow cytometry were largely determined by the corresponding proportions in the peripheral blood.

The influence of human immunodeficiency virus (HIV) infection on antibody responses to influenza vaccines

STUDY OBJECTIVE

To ascertain whether subjects infected with human immunodeficiency virus (HIV) generally develop protective hemagglutination inhibition antibody responses to inactivated influenza vaccines.

DESIGN

Prospective study of 104 persons before and after immunization.

SETTING

Outpatient clinic and hospital ward.

PATIENTS

Persons with the acquired immunodeficiency syndrome (AIDS) (n = 25), AIDS-related complex (n = 14), and HIV-seropositive men with only lymphadenopathy or no symptoms (n = 27). Controls were HIV-seronegative homosexual men (n = 22) and HIV-seronegative heterosexuals (n = 16).

INTERVENTIONS

Subjects were immunized with inactivated vaccines containing 15 micrograms of each of the following influenza virus hemagglutinins: A/Taiwan/1/86 (HINI), A/Mississippi/1/85 (H3N2), A/Chile/1/83 (HINI), and B/Ann Arbor/1/86.

MEASUREMENTS AND MAIN RESULTS

Fourfold or greater antibody responses occurred less frequently in subjects with HIV infections than in HIV-seronegative controls. Protective levels (1:64 or greater) of hemagglutination inhibition antibodies were attained by 94% to 100% of HIV-seronegative controls, 52% to 89% of HIV-seropositive asymptomatic subjects, and 13% to 50% of subjects with AIDS or AIDS-related complex. No increase in the prevalence or level of serum HIV p24 antigen or clinical deterioration was detected among HIV-infected persons after influenza immunization.

CONCLUSIONS

Because of the poor antibody responses to influenza vaccines among HIV-infected subjects, even in many with no or minimal symptoms, alternative strategies for preventing influenza, such as booster doses of influenza vaccine, prophylaxis with amantidine, or both should be considered.

Left ventricular asynergy in acute myocarditis. Simulation of acute myocardial infarction

Recent studies have demonstrated the usefulness of two-dimensional echocardiography in the detection of regional wall abnormalities in acute myocardial infarction. We describe two patients with acute myocarditis who had acute chest pain simulating acute myocardial infarction. Two-dimensional echocardiography initially demonstrated regional wall motion abnormalities that disappeared within a few days. These two cases illustrate that regional wall motion abnormalities are not specific for acute myocardial infarction and that acute myocarditis may simulate acute myocardial infarction.

The erythrocyte sodium and potassium in patients treated with digoxin

1 Four healthy persons and ten patients with heart failure were studied for 5 to 20 days after they started taking digoxin. The sodium content of their erythrocytes increased and there was an equimolar decrease in potassium content. 2 The increase in erythrocyte sodium for a given increase in plasma digoxin during this acute digitalization was less on average and varied more in the patients than in the healthy persons, that is the patients' erythrocytes were less responsive to digoxin. 3 The average erythrocyte sodium was greater in 183 patients who had been taking digoxin for at least 2 months than in 100 healthy persons not taking digoxin but there was no significant correlation between the plasma digoxin concentrations and erythrocyte sodium concentration in the patients. Indeed, there was no apparent change in the erythrocyte sodium in many of the patients taking digoxin. 4 If the erythrocyte sodium concentration is a reliable guide to the tissue effects of digoxin then the results suggest that there is a wide variation in the response to digoxin between patients both during acute digitalization and during chronic treatment with digoxin.

Skeletal turnover and total body elemental composition during extended calcitonin treatment of Paget's disease

Twenty patients with generalized symptomatic Paget's disease had serial measurements of radiocalcium turnover and/or total body elemental composition by in vivo neutron activation analysis during long-term calcitonin therapy. Despite maintained clinical improvement, seven of 15 patients showed partial or total loss of the initial decelerating effect of calcitonin on skeletal turnover, whereas the remaining eight patients maintained the calcitonin-induced deceleration. The changes in skeletal turnover were roughly proportional to the induced changes in serum alkaline phosphatase and urinary hydroxyproline. However, disparities in the magnitude of the changes among the three parameters were not uncommon. Total body calcium was increased by a mean of 22% above predicted prior to calcitonin and decreased significantly by 4% during long-term calcitonin treatment. Total body phosphorus, nitrogen, and sodium also decreased. The phosphorus and sodium losses appeared to be mostly from the skeleton. These data confirm histologic evidence of the disappearance of pagetic bone, resumption of normal lamelar bone formation, and radiographic evidence of a decrease in bone volume during calcitonin treatment and incidate the relative magnitude of this effect. The action of calcitonin in this regard possibly represents a specific effect on Paget's disease beyond its general skeletal effect of reduce cellular activity.

PENETRATING WOUNDS OF THE CHEST

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