Ventricular septal defect in the 9th decade

This case reports the oldest patient with a large, unoperated, isolated, congenital ventricular septal defect in the literature. Issues related to the natural history of the disease and its management are discussed.

A comparison of different depth ablations in the treatment of painful bullous keratopathy with phototherapeutic keratectomy

AIM

To study the efficacy of phototherapeutic keratectomy (PTK) for pain relief for patients with painful bullous keratopathy and poor visual potential.

METHODS

Patients with painful bullous keratopathy and poor visual potential were treated with superficial PTK (8-25 microm), intermediate (50-100 microm) or deep PTK (25% stromal thickness) using the Nidek EC5000 excimer laser after manual epithelial debridement. Follow up ranged from 1 to 24 months (mean 6.5 months). Outcome measures included symptomatic relief and need for further treatment.

RESULTS

In the superficial PTK group five of eight (62%) patients improved symptomatically after treatment. The three (38%) who did not improve went on to have penetrating keratoplasty for pain relief. In the intermediate depth group only two of five (40%) patients had symptom alleviation. The three others (60%) required further procedures. 20 of 24 (83%) patients treated with deep PTK had significant or total alleviation of symptoms. Of these, one developed acute anterior uveitis 9 months after PTK and two required botulinum ptosis for persistent corneal epithelial defects, one of whom had three consecutive episodes of microbial keratitis. Three of 24 suffered occasional discomfort and one patient required a penetrating keratoplasty for continued pain.

CONCLUSION

PTK can be a useful therapeutic measure in painful bullous keratopathy with poor visual potential. Deep PTK appears to be more successful in pain management than superficial treatment.

Incidence of primary opportunistic infections in two human immunodeficiency virus-infected French clinical cohorts

BACKGROUND

Clinical guidelines for the prevention of opportunistic infections in human immunodeficiency virus (HIV)-infected individuals have been developed on the basis of natural history data collected in the USA. The objective of this study was to estimate the incidence of primary opportunistic infections in HIV-infected individuals in geographically distinct cohorts in France.

METHODS

We conducted our study on 2664 HIV-infected patients from the Tourcoing AIDS Reference Centre and the hospital-based information system of the Groupe d'Epidémiologie Clinique du SIDA en Aquitaine enrolled from January 1987 to September 1995 and followed through December 1995. We estimated: (1) CD4-adjusted incidence rates of seven primary opportunistic infections in the absence of prophylaxis for that specific infection or any antiretroviral drugs other than zidovudine; and (2) CD4 lymphocyte count decline.

RESULTS

The highest incidence rates for all opportunistic infections studied occurred in patients with CD4 counts < 200/microl. With CD4 counts < 50/microl, the most common opportunistic infections were toxoplasmic encephalitis (12.6 per 100 person-years) and Pneumocystis carinii pneumonia (11.4 per 100 person-years). Mycobacterium tuberculosis was the least common opportunistic infection (< 5.0/100 person-years). Even with CD4 counts > 300/microl, cases of Pneumocystis carinii pneumonia and toxoplasmic encephalitis were reported. The mean CD4 lymphocyte decline per month was 4.6 cells/microl. There was a significant association between HIV risk behaviour and the incidence of cytomegalovirus infection, between calendar year and the incidence of Pneumocystis carinii pneumonia, toxoplasmic encephalitis and Candida esophagitis, and between geographical area and the incidence of Pneumocystis carinii pneumonia and cytomegalovirus infection.

CONCLUSIONS

Geographical differences exist in the incidence of HIV-related opportunistic infections. These results can be used to define local priorities for prophylaxis of opportunistic infections.

Favorable attitudes toward testing for chromosomal abnormalities via analysis of fetal cells in maternal blood

PURPOSE

The NICHD Fetal Cell Isolation Study (NIFTY) was a multicentered project to isolate fetal cells from maternal blood to detect fetal chromosomal abnormalities. The project included a psychosocial component, which is the basis of this article. We examined the attitudes of high-risk pregnant women toward the availability of a maternal blood test to identify fetal chromosomal abnormalities, how women would respond to hypothetical normal and abnormal maternal blood testing results, and the factors associated with a woman's preference to have an invasive procedure in response to a normal maternal blood test.

METHODS

High-risk pregnant women (N = 854) planning to have prenatal diagnostic invasive testing (amniocentesis or chorionic villus sampling) completed a survey.

RESULTS

The women highly favored maternal blood testing. Almost all women would seek invasive testing after an abnormal blood test. Only half of the women would seek invasive testing after a normal blood test; these women were older, more willing to terminate their pregnancy, and valued the increased accuracy of invasive testing more highly than women who would not have invasive testing after a normal maternal blood test.

CONCLUSIONS

Women having invasive diagnostic testing welcome a noninvasive procedure that uses fetal cells in maternal blood, and its availability would decrease invasive testing by approximately 50%. Research needs to examine the attitudes and anticipated responses of other risk groups as well as the effects of information about maternal blood test sensitivity and specificity on attitudes and responses.

Ubiquitous transgenic expression of the IL-23 subunit p19 induces multiorgan inflammation, runting, infertility, and premature death

p19, a molecule structurally related to IL-6, G-CSF, and the p35 subunit of IL-12, is a subunit of the recently discovered cytokine IL-23. Here we show that expression of p19 in multiple tissues of transgenic mice induced a striking phenotype characterized by runting, systemic inflammation, infertility, and death before 3 mo of age. Founder animals had infiltrates of lymphocytes and macrophages in skin, lung, liver, pancreas, and the digestive tract and were anemic. The serum concentrations of the proinflammatory cytokines TNF-alpha and IL-1 were elevated, and the number of circulating neutrophils was increased. In addition, ubiquitous expression of p19 resulted in constitutive expression of acute phase proteins in the liver. Surprisingly, liver-specific expression of p19 failed to reproduce any of these abnormalities, suggesting specific requirements for production of biologically active p19. Bone marrow transfer experiments showed that expression of p19 by hemopoietic cells alone recapitulated the phenotype induced by its widespread expression, pointing to hemopoietic cells as the source of biologically active p19. These findings indicate that p19 shares biological properties with IL-6, IL-12, and G-CSF and that cell-specific expression is required for its biological activity.

Improving participation in HIV clinical trials: impact of a brief intervention

PURPOSE

To determine if a brief intervention that provides information about AIDS clinical trials to HIV-infected patients at the initiation of primary care increases the participation of women, persons of color, and injection drug users (IDUs) in clinical trials.

METHOD

196 outpatients beginning HIV primary care at a municipal hospital were followed from September 1994 to April 1996. During the intake assessment, each patient met briefly with a research assistant who described the purpose, role, and availability of clinical trials. Contacts for further information about trials were given to patients who expressed interest. At the end of the 20-month period, enrollment rates of all patients, including women, persons of color, and IDUs, into clinical trials were compared with previously published enrollment rates of patients at the same hospital but prior to the development of this brief intervention.

RESULTS

The characteristics of the 196 HIV-infected patients were: 27% women; 47% IDUs; 14% gay/bisexual men; and 76% persons of color. Overall enrollment in AIDS clinical trials was 14.8% during the 20-month follow-up period. There was no significant difference in participation rates between males and females (p =.20), whites and persons of color (p =.71), and IDUs compared with non-IDUs (p =.90), whereas previously published data had shown significantly higher enrollment rates among males, whites, and non-IDUs.

CONCLUSION

Providing all HIV-infected patients with information about the meaning, role, and availability of AIDS clinical trials at the initiation of HIV primary care reduces differences in participation rates by gender, race, and history of drug use.

hprt mutant frequencies, nonpulmonary malignancies, and domestic radon exposure: "postmortem" analysis of an interesting hypothesis

The hypothesis that exposure to domestic radon raises the risk for leukemia and other nonpulmonary cancers has been proposed and tested in a number of epidemiologic studies over the past decade. During this period, interest in this hypothesis was heightened by evidence of increased frequencies of mutations at the hypoxanthine guanine phosphoribosyl transferase (hprt) gene in persons exposed to domestic radon (Bridges BA et al. [1991]: Lancet 337:1187-1189). An extension of this study (Cole J et al. [lsqb[1996]: Radiat Res 145:61-69) and two independent studies (Albering HJ et al. [1992[: Lancet 340:739; Albering HJ et al. [1994[: Lancet 344:750-751) found that hprt mutant frequency was not correlated with domestic radon exposure, and two well-designed epidemiologic studies showed no evidence of a relation between radon exposure and leukemia in children or adults. In this report, we present additional data from a study of Colorado high school students showing no correlation between domestic radon exposure and hprt mutant frequency. We use reanalyses of previous studies of radon and hprt mutant frequency to identify problems with this assay as a biomarker for domestic radon exposure and to illustrate difficulties in interpreting the statistical data. We also show with analyses of combined data sets that there is no support for the hypothesis that domestic radon exposure elevates hprt mutant frequency. Taken together, the scientific evidence provides a useful example of the problems associated with analyzing and interpreting data that link environmental exposures, biomarkers, and diseases in epidemiologic studies.

Leukocytes expressing green fluorescent protein as novel reagents for adoptive cell transfer and bone marrow transplantation studies

Transgenic mice expressing green fluorescent protein (GFP) were generated to provide a source of labeled leukocytes for cell transfer studies. The transgene comprises the GFP coding region under the transcriptional control of the chicken ss-actin promoter and human cytomegalovirus enhancer. Mice expressing this GFP transgene were generated in the B6D2 and in the 129SvEv backgrounds. Flow cytometric analysis of cells from the blood, spleen, and bone marrow of these transgenic mice revealed that most leukocytes, including dendritic cells and memory T cells, express GFP. In allogeneic cell transfers, donor GFP+ splenocytes were detected in the spleen and mesenteric lymph nodes of recipient mice within 2 hours after transfer and for at least 9 days thereafter. In syngeneic experiments using 129-derived GFP+ donor splenocytes, donor cells were detected in multiple tissues of 129 recipients from 2 hours to 3 weeks after transfer. In bone-marrow transplantation experiments using irradiated allogeneic recipients, the percent of GFP+ donor cells in recipients at 3 weeks was comparable to that seen in similar tissues of GFP+ donor mice. These data demonstrate that GFP+ transgenic mice provide a ready source of GFP-expressing primary cells that can be easily monitored after their transfer to recipient animals.

Efficacy of simulated epinephrine-containing epidural test dose after intravenous atropine during isoflurane anesthesia in children

BACKGROUND AND OBJECTIVES

A double-blind, randomized study was performed to investigate heart rate (HR) and blood pressure responses to 2 doses of intravenous (IV) epinephrine (0.5 and 0.75 microg/kg) in 61 children, ages 3 months to 12 years.

METHODS

Anesthesia was maintained with isoflurane (age-adjusted 1 minimal alveolar concentration [MAC]) in oxygen. All patients received IV atropine (10 microg/kg) and 5 minutes later were randomized to receive IV solutions (0.1 mL/kg) containing 1% lidocaine (n = 19, group I) with saline; lidocaine 1% with epinephrine 0.5 microg/kg (n = 21, group II); or lidocaine 1% with epinephrine 0.75 microg/kg (n = 21, group III). HR was recorded at 0, 15, 30, 45, 60, 90 seconds, and 2, 3, 4, and 5 minutes after test-dose injection. Systolic blood pressure (SBP), diastolic blood pressure, and end-tidal carbon dioxide were recorded at steady-state isoflurane anesthesia, after the injection of atropine, and at 45-second intervals after test-dose injections.

RESULTS

Median maximum increases in HR were similar in groups II and III at 19 and 22 beats per minute (beats/min), respectively. An HR increase of > or =10 beats/min was observed in 19 of 21 patients who received 0.5 microg/kg epinephrine and 21 of 21 patients receiving 0.75 microg/kg. None of the patients in group I developed HR increases > or =10 beats/min. SBP increased > or =15 mm Hg in 17 of 21 patients in group II and 19 of 21 in group III. No dysrhythmias or T-wave amplitude change was noted.

CONCLUSIONS

A simulated epidural test dose containing lidocaine 1 mg/kg with epinephrine 0.75 microg/kg, administered IV following atropine, may reliably increase HR to indicate unintentional injection into epidural vessels of children anesthetized with 1 MAC isoflurane.

Management of alkali burns : an 11-year retrospective review

OBJECTIVE

To review the spectrum of patients with alkali burns admitted over an 11-year period and to assess the clinical outcomes after the introduction of a standard alkali burn treatment protocol.

DESIGN

Retrospective nonrandomized comparative study.

PATIENTS AND INTERVENTIONS

A total of 121 patient records with alkali burns (n = 177 eyes) admitted to a tertiary hospital between 1987 and 1998 were reviewed. Eyes treated with a standard alkali burn treatment protocol, which included intensive topical steroids, ascorbate, citrate, and antibiotics, were compared with eyes treated by conservative management with antibiotics, and a short course of steroids.

MAIN OUTCOME MEASURES

Time to corneal reepithelialization, final best-corrected visual acuity, and time to visual recovery, length of hospital stay, and complications were analyzed.

RESULTS

The standard protocol tended to delay corneal reepithelialization by one day (P: = not significant) in eyes with grade 1 burns (n = 76) and by 2 days (P: = 0.04) in grade 2 burns (n = 52), with no difference in final visual outcome. There were 37 eyes with grade 3 burns. Those treated with the standard protocol showed a trend toward more rapid corneal reepithelialization. Twenty-seven of 29 (93%) eyes with grade 3 injuries achieved a final best-corrected visual acuity of 20/40 or better compared with 3 of 6 (50%) eyes not treated according to the standard protocol (P: = 0.02). Eyes with grade 4 burns (n = 12), whether treated with the standard protocol or not, required 10 to 12 weeks for corneal reepithelialization. There was no statistically significant difference in final visual acuity.

CONCLUSIONS

On the basis of our findings, a number of recommendations can be made for the management of alkali injuries. Patients with a grade 1 or 2 injury do not require routine admission and do not benefit from the use of intensive treatment with ascorbate and citrate. A trend toward more rapid healing and a better final visual outcome were apparent in grade 3 burns, but our standard protocol made no difference in grade 4 burns.

Physical and sexual abuse in women infected with the human immunodeficiency virus: increased illness and health care utilization

BACKGROUND

A history of physical or sexual abuse is associated with increased health care utilization and possibly an increase in illness based largely on self-reported data.

OBJECTIVE

To examine whether victimization experience is associated with increases in documented medical disease and health care utilization among women infected with the human immunodeficiency virus (HIV).

METHODS

We interviewed and reviewed medical record data of 50 women seeking initial primary care for HIV infection at 2 urban hospitals. Women with and without a history of physical and sexual abuse were compared. Using multiple regression analysis, 2 periods were examined: entire life before study entry and the subsequent 2 years. The characteristics examined included episodic disease, chronic disease, sexually transmitted disease, chronic pain syndrome, opportunistic infections, obstetrical history, and number of injuries, surgical procedures, hospitalizations, ambulatory care visits, and emergency department visits.

RESULTS

Evidence of physical or sexual abuse was found in 34 (68%) of the 50 women, of whom 16 (32%) did not disclose during the interview that they were abused. At entry, the rates of episodic disease, chronic pain syndrome, and sexually transmitted disease were greater among those women with histories of abuse. At 2 years, episodic disease, chronic disease, injuries, emergency department visits, and hospitalizations were all more likely in abused women.

CONCLUSION

Physical and sexual abuse are common and associated with increased medical disease and health care utilization among HIV-infected women.

Analysis of 'natural' and vaccine-induced haemophilus influenzae type B capsular polysaccharide serum antibodies for 3H1, a V3-23-associated idiotope

The variable (V-) region repertoire of antibodies (Abs) to Haemophilus influenzae capsular polysaccharide (Hib PS) has been extensively studied in individuals vaccinated against the microbe, but to a lesser extent in subjects who generated such Abs in response to a 'natural' encounter with this microbe or its antigenic mimics. To gain an insight into the repertoire of Hib PS-reactive Abs in vaccinated and non-vaccinated individuals, we used a monoclonal Ab, 3H1, which detects an idiotypic marker associated with an Ab V-region gene, V3-23. We show here that Hib PS-reactive Abs with detectable 3H1 idiotope can be quantified by an indirect inimunoezymatic assay in serum samples of non-vaccinated healthy adults as well as of recently vaccinated healthy infants. The percentage of Abs that was simultaneously Hib PS-reactive and 3H1-positive ranged widely (from 0 to 68%) among individual serum samples from both groups of subjects. No dramatic differences in the expression of 3H1 idiotope on Hib PS-reactive Abs were found between vaccinated and non-vaccinated individuals. Our results are consistent with the hypothesis that the utilization of V-region genes in Hib PS-reactive Abs that individuals generate after a 'natural' encounter with Hib PS or its mimics is similar to that in these Abs elicited by Hib PS conjugate vaccines.

Small cell carcinoma of the bladder: long term outcome with integrated chemoradiation

BACKGROUND

Small cell carcinoma of the bladder (SCCB) is an uncommon tumor with approximately 8% 5-year survival reported in the literature for patients with disease confined to the pelvis. It exhibits biologic behavior similar to that of small cell carcinoma of the lung (SCLC). The authors sought to determine whether etoposide and cisplatin chemotherapy integrated with local irradiation is associated with improved survival in SCCB, as has been shown in SCLC.

METHODS

The authors performed a retrospective analysis of stage, treatment, disease free survival (DFS), and overall survival (OS) among 14 British Columbia Cancer Agency (BCCA) patients treated between 1985 and 1996 for SCCB.

RESULTS

When multiagent chemotherapy was combined with local irradiation, the authors observed a 70% 2-year and 44% 5-year actuarial OS among 10 patients without contraindications to systemic chemotherapy. Actuarial DFS was 70% at 2 and 5 years. The mean survival was 47 months (95% confidence interval, 18.5-76.1 months) and the median survival was 41 months. Nine of these patients had disease confined to the pelvis, and one had metastases to retroperitoneal lymph nodes. Five patients were alive and disease free an average of 82 months following diagnosis. Two patients had died of other causes without evidence of disease at 34 and 48 months following diagnosis. The incidence of second primary transitional cell bladder neoplasms following successful treatment was 60% at 2 years (3 of 5 long term survivors).

CONCLUSIONS

Integrated chemoradiation for patients with limited stage SCCB generates a realistic expectation of long term survival. Prospective trials to confirm these findings are warranted.

Ultrasonography and fine needle aspirate cytology of the mesenteric lymph node in normal domestic ferrets (Mustela putorius furo)

The large mesenteric lymph node of 28 normal ferrets was imaged with ultrasound. The large node, located in the mid-abdomen at the root of the mesentery, was round to ovoid and uniformly hyperechoic. Mean ultrasonographic dimensions of the lymph node were 12.6 +/- 2.6 mm by 7.6 +/- 2.0 mm. Fine needle aspirates of 20 lymph nodes were obtained either using ultrasound guided free-hand techniques or at necropsy. The cytological descriptions were compared to histological descriptions of 13 lymph node core biopsies obtained during laparotomy or necropsy as well as 10 peripheral blood smear differentials. The large mesenteric lymph node of ferrets could be easily imaged and measured by ultrasound and evaluated by fine needle aspirate cytology. Normal lymph node cytology may include an eosinophilic infiltrate.

Patient satisfaction with Department of Veterans Affairs health care: do women differ from men?

This study compared the patient satisfaction of female and male veterans using Department of Veterans Affairs health care and examined the relationship between sociodemographic characteristics and satisfaction in men and women. Using data from the Department of Veterans Affairs Women's Health Project (N = 719) and the Veterans Health Study (N = 600), we examined women's and men's unadjusted and adjusted mean scores on three dimensions of satisfaction: location of health care facility, access to health care, and prescription services. Although the unadjusted results indicated that women were less satisfied with both location and access, there were no differences in satisfaction with prescription services. After adjusting for age and then for both age and a recent physician visit, women remained less satisfied with location but were more satisfied with prescription services; there were no differences on access ratings. In an exploratory analysis, we examined the relationships between sociodemographic, military experience, and health characteristics and satisfaction within each sample. Older age was the only characteristic consistently positively associated with each dimension of satisfaction among both women and men. General health perceptions were positively associated with all three dimensions of women's satisfaction but with only the location dimension for men. Although other characteristics were associated with satisfaction within each sample, these differed for women and men. The results suggest that although there were not consistent differences in mean satisfaction ratings by gender, the characteristics associated with satisfaction differed for men and women.

Regional sympathetic function in high spinal cord injury during mental stress and autonomic dysreflexia

Centrally mediated sympathetic stimulation of subjects who have suffered a spinal cord injury (SCI) does not activate the decentralized part of the body below the level of the lesion, whereas experimental data indicate an exaggerated response above the level of the lesion. SCI subjects may exhibit an autonomic dysreflexia reaction following afferent stimulation below the level of the lesion. In order to investigate the function of the sympathetic nervous system above and below the level of the lesion, regional noradrenaline spillover was measured by means of steady-state isotope dilution technique above (forearm) and below (leg) the level of the lesion at baseline, during mental stress and following bladder stimulation in nine SCI subjects (mean age 41 years; level of injury C7-T4; mean duration of injury 13.8 years). The results from the SCI subjects were also compared with those from 10 weight- and age-matched control subjects, both at rest and during mental stress. Body composition was determined by dual energy X-ray absorptiometry scanning and arm/leg blood flow by occlusion plethysmography. At baseline, total and regional noradrenaline spillover did not differ between the groups. Mental stress increased mean arterial pressure in both groups. Heart rate (76 versus 64 beats/min; P < 0.05) and arm noradrenaline spillover (2.73 versus 1.71 pmol/min/100 g; P < 0.05) increased more in spinal cord injury subjects than in control subjects, whereas total body (2826 versus 3783 pmol/min; P < 0.01) and leg noradrenaline spillover (0.23 versus 0.41 pmol/min/100 g; P < 0.05) increased only in the control group. During bladder stimulation, SCI subjects reacted with a marked increase in mean arterial pressure and leg noradrenaline spillover (from 0.06 to 0.91 pmol/min/100 g; P < 0.05) and their leg blood flow decreased. Regional and total noradrenaline clearance were similar in the two groups. In conclusion, peripheral afferent stimulation below the level of the lesion in spinal cord injury subjects gives rise to a marked noradrenaline spillover from the decentralized part of the sympathetic nervous system suggesting a remaining, but qualitatively altered, neuronal function. Centrally mediated stimulation induced an exaggerated response above the level of the lesion.

Butyrate analogue, isobutyramide, inhibits tumor growth and time to androgen-independent progression in the human prostate LNCaP tumor model

Progression to androgen independence remains the main obstacle to improving survival and quality of life in patients with advanced prostate cancer. Induction of differentiation may serve as a rational basis for prevention of progression to androgen independence by modulating gene expression activated by castration or upregulated during androgen-independent progression. The objectives of this study were to characterize the in vitro effects of sodium butyrate on human prostate cancer cell growth, PSA gene expression, and differentiation in the LNCaP tumor model and to determine whether tumor progression in vivo is delayed by isobutyramide, an orally bioavailable butyrate analogue with a longer half-life. The effects of isobutyramide on LNCaP tumor growth and serum PSA levels in both intact and castrate male mice were compared to controls. At concentrations >1 mM, butyrate induced dose-dependent changes towards a more differentiated phenotype, G1 cell cycle arrest, and an 80% decrease in LNCaP cell growth rates. PSA gene expression was increased threefold by butyrate, indicative of differentiation-enhanced gene expression. The half-life of isobutyramide in athymic mice was determined by gas chromatography to be 4 h. During a 4 week period in intact-placebo mice, tumor volume and serum PSA increased 4.1- and 6.6-fold, respectively, compared to twofold and 2.7-fold increases in tumor volume and serum PSA in intact-treated mice. During a 7 week period in castrate-placebo mice, tumor volume and serum PSA levels increased 2.4-fold and fourfold, respectively, compared to a 50% reduction in tumor volume and a twofold increase in serum PSA above nadir levels in castrate mice treated with adjuvant isobutyramide. Isobutyramide treatment induced pronounced morphological changes in LNCaP tumor cells, with loss of defined nucleoli and dispersion of chromatin distribution. LNCaP tumor PSA mRNA levels actually increased threefold, indicative of differentiation-enhanced gene expression. This study demonstrates that butyrate causes LNCaP cell cycle arrest and increased PSA gene expression, both indicative of differentiation. The combination of castration and adjuvant isobutyramide was synergistic in delaying tumor progression. Decreased tumor cell proliferation and increased PSA gene expression induced by isobutyramide results in disconcordant changes in serum PSA and tumor volume and reduces the utility of serum PSA as a marker of response to therapy.

Trillion virion delay: time from testing positive for HIV to presentation for primary care

BACKGROUND

Human immunodeficiency virus (HIV)-infected individuals' initial presentation to medical care frequently occurs at a point of advanced immunosuppression.

OBJECTIVES

To investigate the time between HIV testing and presentation to primary care. Also to examine factors associated with delayed presentation.

METHODS

One hundred eighty-nine consecutive outpatients without prior primary care for HIV infection were assessed at 2 urban hospitals: Boston City Hospital, Boston, Mass, and Rhode Island Hospital, Providence. Sociodemographics, alcohol and drug use, social support, sexual beliefs and practices, and HIV testing issues were examined in bivariate and multivariate analyses for association with delay in presentation to primary care after positive test results for HIV.

RESULTS

Of 189 patients, 74 (39%) delayed seeking primary care for more than 1 year, 61 (32%) delayed for more than 2 years, and 35 (18%) for more than 5 years after an initial positive HIV serologic evaluation. The median CD4+ cell count of subjects was 0.28 x 10(9)/L (range, 0.001-1.71 x 10(9)/L). In multiple linear regression analysis the following characteristics were found to be associated with delayed presentation to primary care after HIV testing: history of injection drug use (P<.001); not having a living mother (P=.01); not having a spouse or partner (P=.08); not being aware of HIV risk before testing (P<.001); and being notified of HIV status by mail or telephone (P=.002). An interaction effect between sex and screening for alcohol abuse was significant (P=.03) and suggested longer delays for men with positive screening test results (CAGE [an alcoholism screening questionnaire containing 4 structured questions], 2+) compared with men without positive screening test results or women.

CONCLUSIONS

Patients with positive HIV test results often delay for more than a year before establishing primary medical care. Information readily available at the time of HIV testing concerning substance abuse, social support, and awareness of personal HIV risk status is useful in identifying patients who are at high risk of not linking with primary care. Patients who were notified of their HIV status by mail or telephone delayed considerably longer than those notified in person. Efforts to ensure primary care linkage at the time of notification of positive HIV serostatus are necessary to maximize benefits for both individual and public health and should be an explicit task of posttest counseling.

Wing-beat frequency mutants and courtship behavior in Drosophila melanogaster males

Flightless mutations that affect wing-beat frequency (WBF) of Drosophila melanogaster were examined for their effect on male courtship. WBFs were measured using a fixed-wire tether that completely supports the fly in an attitude similar to hovering flight. The two spontaneous mutations, one of which reduces WBF to one-half normal and the other to zero, were placed on an isogenic background and were compared to an isogenic wildtype strain and to a genetically heterogeneous wildtype strain. Time to mating under noncompetitive conditions (single pair matings) was not significantly different among the four male types in one experiment. In a second experiment, although the time to mating varied significantly among the four male types, there was no association between the WBF that was characteristic of a male type and the length of time to mating. Time to mating was not significantly correlated with WBF, wing size, or body mass in either experiment. Genetically heterogeneous wild-type females were significantly more receptive (had shorter times to mating) than inbred wild-type females toward all four male types. During the time-to-mating tests, all four male types appeared to show typical courtship behaviors. Therefore, the male types were compared for possible differences in four components of the male courtship song: sine song frequency, interpulse interval, intrapulse frequency (= carrier frequency), and wing cycles per pulse. One or another of these components showed significant differences among the four male types (e.g., genetically heterogeneous, wild-type males showed a significantly higher sine song frequency and intrapulse frequency than males of the three isogenic types). However, the average values for all four male types were within reported wild-type ranges for each courtship song component. Although the two mutations drastically reduce WBF during tethered flight, they do not have any similar major effect on courtship. Apparently they affect muscles or neuronal control mechanisms that are not common elements shared by the wing movement of flight and male courtship song.