Immunotherapy of recurrent genital herpes with recombinant herpes simplex virus type 2 glycoproteins D and B: results of a placebo-controlled vaccine trial

To determine the safety, immunogenicity, and efficacy of a recombinant herpes simplex virus type 2 glycoprotein D and B vaccine in the treatment of recurrent genital herpes, a randomized, placebo-controlled trial was held at two referral centers. Healthy patients with 4-14 recurrences per year received injections of both glycoproteins in MF59 adjuvant or of MF59 alone at 0, 2, 12, and 14 months. For 18 study months, the rate and number of recurrences, the duration and severity of the first confirmed recurrence, vaccine immunogenicity, and rates of local and systemic reactions were determined. The monthly rate of recurrences was not significantly improved, but the duration and severity of the first study outbreak was reduced significantly by vaccination. Glycoprotein-specific and neutralizing antibodies were boosted by vaccination for the duration of the study. This vaccine is safe and immunogenic and ameliorated an observed first postvaccination genital recurrence, but it does not reduce recurrence frequency.

Colonic and anorectal function in constipated patients with anorexia nervosa

OBJECTIVES

Many patients with eating disorders complain of severe constipation. Previous studies have suggested that constipation in patients with anorexia nervosa may be associated with slow colonic transit. However, it is unclear whether a refeeding program will alter colonic transit in these patients. The aim of this study was to investigate colorectal function by measuring colonic transit and anorectal function in anorexic patients with constipation during treatment with a refeeding program.

METHODS

We prospectively studied 13 female patients with anorexia nervosa who were admitted to an inpatient treatment unit and compared them to 20 previously studied, age-matched, healthy female control subjects. Patients underwent colonic transit studies using a radiopaque marker technique and anorectal manometry measuring anal sphincter function, rectal sensation, expulsion dynamics, and rectal compliance. Patients were studied both early (< 3 wk) and late (> 3 wk) in their admission. We restudied two patients who had slow colonic transit. All patients also underwent structured interviews.

RESULTS

Four of six patients studied within the first 3 wk of their admission had slow colonic transit, defined as > 70 h (108.0 +/- 17.0 h, mean +/- SEM), on initial evaluation. In contrast, none of the seven patients studied later than 3 wk into their admission had slow colonic transit. Two of the four patients with slow transit were restudied later in their admission and were found to have normal transit times. Rectal sensation, internal anal sphincter relaxation threshold, rectal compliance, sphincter pressures, and expulsion pattern were normal in all subjects.

CONCLUSIONS

Despite complaints of severe constipation, colonic transit is normal or returns to normal in the majority of patients with anorexia nervosa once they are consuming a balanced weight gain or weight maintenance diet for at least 3 wk.

Effective communication and supervision in the biomedical engineering department

It is important for biomedical engineering supervisors to master the art of effective communication. Supervisors who have effective communication skills can successfully initiate creative programs and generate a harmonious working atmosphere. Using effective communication, they can promote good working conditions, such as high morale, worker initiative and loyalty to the department, which are almost impossible to measure but imperative for a successful department. However, effective communication tends to be neglected by supervisors who are either functional specialists or managerial generalists. This paper presents several cases of what effective communication truly is and discusses some potential factors that may lead to ineffective communication.

Fecal incontinence: three steps to successful management

Fecal incontinence is a socially disruptive problem that occurs with increased frequency in older individuals. The causes of incontinence in this age group include abnormalities of rectal storage capacity, fecal impaction with overflow incontinence and disorders of rectosphincteric continence mechanisms. Evaluation consists of a careful history and physical examination, followed by studies of anorectal structure and function in selected patients. Therapeutic approaches include disimpaction and colonic cleansing, dietary modifications, pharmacologic agents, biofeedback techniques, and surgery. Most patients can be treated successfully with nonsurgical measures, with improvement in their quality of life.

Epidemiology of Aspergillus infections in a large cohort of patients undergoing bone marrow transplantation

To investigate the incidence, risk factors, and outcome of Aspergillus infections among marrow transplant recipients, records from 2496 patients were reviewed, and 214 patients had Aspergillus organisms identified. Of these, 158 had invasive aspergillosis, 44 were colonized, and 12 had contaminated cultures. The incidence of invasive aspergillosis increased from 5.7% to 11.2% during the study. The onset of infection was bimodal, peaking 16 and 96 days after transplant. For patients within 40 days after transplant, underlying disease, donor type, season, and transplant outside of laminar air flow rooms were associated with significant risk for invasive aspergillosis. For patients >40 days after transplant, age, underlying disease, donor type, graft-versus-host disease, neutropenia, and corticosteroid use were associated with increased risk of aspergillosis. Only 31% of infected patients were neutropenic at the time of diagnosis. The risk factors for aspergillosis depend on the time after marrow transplant and include both host and environmental characteristics.

Evaluation of a quantitative competitive PCR assay for measuring herpes simplex virus DNA content in genital tract secretions

Previous studies have shown an association between the approximate titer of herpes simplex virus (HSV) DNA in clinical specimens and the ability to isolate HSV from genital secretions. To control for variance in amplification conditions, we developed a competitive quantitative PCR (QC PCR) for the detection of HSV DNA. The assay accurately measured from 10 to 10(6) copies of HSV DNA. We compared the QC PCR with our previous semiquantitative detection method and found concordance for 61 of 63 positive specimens. We also evaluated the HSV DNA content from individual swabs of genital secretions obtained from individual sites of the genital tract (cervix, vulva, and rectum) with that from one swab with secretions from all three sites. The concordance for detecting HSV DNA was 91%; for only 4 of 143 collection days was there a > 1 log difference between the two collection methods. A single swab with secretions from all three genital sites and evaluated in a QC PCR format can accurately measure the frequency of subclinical and clinical shedding of HSV and the titer of HSV shed from the genital region. Such an approach should be very useful in the evaluation of antiviral chemotherapy for HSV.

Anal sphincter structure and function in homosexual males engaging in anoreceptive intercourse

OBJECTIVES

To evaluate the structure and function of the internal (IAS) and external (EAS) anal sphincters in anoreceptive homosexual men and to determine whether anoreceptive intercourse (ARI) is associated with a higher risk of incontinence in this population.

METHODS

We studied 14 anoreceptive homosexual males and 10 age-matched non-anoreceptive heterosexual males in a controlled, prospective cohort study. Subjects underwent evaluation of resting and maximum squeeze anal canal pressures (maximum squeeze pressure obtained over resting pressure) by station pull-through technique, using a manometric perfusion catheter followed by endoanal ultrasonography to evaluate the structure of the IAS and EAS. Manometry also was performed in age-matched male controls. All subjects completed a questionnaire that assessed sexual practices and bowel habits, including fecal incontinence.

RESULTS

Resting pressures were significantly lower in subjects engaging in ARI (70.7 +/- 3.2 mm Hg vs. 91.4 +/- 5.2 mm Hg; mean +/- SEM, p < 0.003), whereas there was no significant difference in the mean maximum squeeze pressures, compared with controls (177.1 +/- 14.1 mm Hg vs. 151.8 +/- 19.6 mm Hg; mean +/- SEM, p = 0.32). No disruptions of the IAS or EAS were identified in either the anoreceptive or control group. Anoreceptive men tended to have thinner anal sphincters than controls, but the difference was not statistically significant. Furthermore, there were no complaints of fecal incontinence by the study subjects.

CONCLUSIONS

Passive ARI is associated with decreased resting anal canal pressures, but total pressures are normal. There were no IAS or EAS defects, as well as no fecal incontinence, in our subjects. Better relaxation of the ARI subjects during anal canal manometry may explain the lower resting pressures.

Genital herpes in a primary care clinic. Demographic and sexual correlates of herpes simplex type 2 infections

BACKGROUND AND OBJECTIVES

Genital herpes remains one of the most prevalent sexually transmitted diseases (STDs). The sexual behavioral correlates of herpes simplex virus type 2 (HSV-2) infection in the general population have not been well characterized.

GOALS

To assess demographic and sexual behavioral correlates of symptomatic and subclinical HSV-2 infection.

STUDY DESIGN

Cross-sectional survey of 922 randomly chosen patients and 78 of their partners (1,000 total) in a family practice. Sexual behavior information was collected in 492 people.

RESULTS

Two hundred twenty-five (23%) heterosexual people had HSV-2 infection, but only 59 (26%) reported a history of genital herpes. HSV-2 seroprevalence was 63% in African-American women, 27% in white women, 40% in African-American men, and 12% in white men. In multivariate analyses of risk factors for HSV-2 infection among men, 10 or more sexual partners and a prior STD were statistically significantly associated with HSV-2 infection. Among white women, number of sexual partners, a prior STD, marriage or cohabitation, and less than a college education were predictive of HSV-2 infection. A history of oral sex was the only statistically significant predictor of HSV-2 infection in African-American women.

CONCLUSIONS

Risk factors for HSV-2 infection differ by gender and ethnic group. Traditionally recognized behavioral correlates of STD acquisition may not identify people in communities with high prevalence of HSV-2 infection.

Frequent genital herpes simplex virus 2 shedding in immunocompetent women. Effect of acyclovir treatment

Reactivation of herpes simplex virus type 2 (HSV-2) occurs intermittently as perceived clinically and by viral culture. We performed a series of studies to evaluate the frequency and pattern of HSV-2 reactivation using both viral isolation and HSV PCR assay. Daily samples of genital secretions were obtained from 27 HSV-2 seropositive women; a subset of subjects obtained samples while receiving oral acyclovir 400 mg PO twice a day. HSV DNA was detected in genital swab specimens on 28% of 1,410 d compared with 8.1% of days by viral isolation. 11 of 20 women had HSV DNA detected on > 20% of days, 4 on > 50%, and 2 on > 75% of days; in contrast, none of the women shed on > 21% of days by viral isolation. The daily administration of oral acyclovir promptly reduced the frequency of HSV DNA detection by a median of 80%. Within 3-4 d of discontinuing daily acyclovir, HSV DNA again appeared in the genital area. HSV-2 shedding in the genital mucosa occurs much more frequently than previously appreciated. This frequent reactivation likely plays a role in the epidemic spread of genital herpes worldwide.

Suppression of subclinical shedding of herpes simplex virus type 2 with acyclovir

OBJECTIVE

To assess the effect of the antiviral drug acyclovir on the frequency of subclinical shedding of herpes simplex virus (HSV) in the genital tract.

DESIGN

A double-blind, placebo-controlled, crossover clinical trial.

SETTING

A university-based virology research clinic.

PATIENTS

34 women with herpes simplex virus type 2 (HSV-2) antibody only and genital herpes of less than 2 years' duration.

INTERVENTION

Participants were randomly assigned to receive either acyclovir, 400 mg twice daily for 70 days, followed by a 14-day washout period, and then placebo for 70 days, or the study medications in the reverse order.

MEASUREMENTS

Women collected daily genital swabs of the vulvar, cervicovaginal, and perianal areas for HSV culture, maintained a diary of genital lesions, and were examined at the time of recurrences.

RESULTS

In an intent-to-treat analysis of the initial treatment period, 15 of the 17 women who received placebo and 3 of the 17 women who received acyclovir had at least 1 day of subclinical shedding (P < 0.001). Among the participants who received placebo, subclinical shedding occurred on 64 of 928 (6.9%) days compared with 3 of 1057 (0.3%) days among the participants who received acyclovir (P < 0.001). The relative risk for subclinical shedding was 0.09 (95% CI, 0.03 to 0.35) for the women who received acyclovir compared with the women who received placebo. In a paired analysis of 26 women who completed both arms of the study, acyclovir therapy was associated with a decrease in the frequency of subclinical shedding; subclinical shedding occurred on 83 of 1439 (5.8%) days with placebo, and on 6 of 1611 (0.37%) days with acyclovir (P < 0.001)--a 94% reduction. The frequency of subclinical shedding was reduced at all anatomic sites and in all patients.

CONCLUSIONS

Daily therapy with oral acyclovir suppresses subclinical shedding of HSV-2 in the genital tract, suggesting that studies to evaluate the use of acyclovir in preventing HSV-2 transmission are warranted.

Measuring health-related quality of life in persons with genital herpes

A disease-specific measure was needed for use in an international clinical trial to evaluate an investigational drug for genital herpes. A new measure was developed initially in the UK and translated and adapted for use in France, Italy, Germany, Denmark, Spain and the USA. This paper describes the translation and adaptation of the USA measure. It also describes the assessment of internal consistency, reproducibility, content validity, and construct validity (convergent and discriminant) of the measure. Two outcome measures of the final genital herpes-specific measure were developed: (1) a 21-item symptoms subscale; and (2) a 20-item HRQOL subscale. Each measure was scored and analyzed separately; the psychometric testing discussed in this paper refers to the HRQOL subscale only. The internal consistency of the HRQOL subscale is high (r = 0.93), as is the reproducibility measured with a two week interval (r = 0.85). Convergent validity is moderate to high. (Fleming Self-Regard subscale, r = 0.48; SF-36 Social Functioning dimension r = 0.59; SF-36 Mental Health dimension r = 0.50). The number of herpes outbreaks in the past year was a significant predictor of scores on the HRQOL subscale (0-1 outbreaks, mean = 82.1; 2+ outbreaks, mean = 72.1, p = 0.058) suggesting discriminant validity. The measure is currently in a phase III clinical trial including anti-viral therapy where the question of responsiveness can be addressed.

Virologic characteristics of subclinical and symptomatic genital herpes infections

BACKGROUND

The frequency, pattern, and anatomical sites of subclinical shedding of herpes simplex virus (HSV) in the genital tract, along with factors that predict such shedding, have not been well characterized.

METHODS

We studied prospectively the clinical and virologic course of genital herpes in 110 women. The women kept symptom diaries and provided daily samples from the vulva, cervix, and rectum for viral culture.

RESULTS

During a median follow-up of 105 days, subclinical shedding of virus was identified in 36 of 65 women (55 percent) with HSV type 2 (HSV-2), in 16 of 31 women (52 percent) with HSV type 1 (HSV-1) and HSV-2, and in 4 of 14 women (29 percent) with only HSV-1. Among women with genital HSV-2 infection, subclinical shedding occurred on a mean of 2 percent of the days. The mean duration of viral shedding during subclinical episodes was 1.5 days, as compared with 1.8 days during symptomatic episodes. HSV was isolated from several sites in the genital tract and rectum in 17 percent of subclinical episodes and 22 percent of symptomatic episodes. Half the episodes of subclinical shedding of HSV occurred within seven days of a symptomatic recurrence. The risk of subclinical shedding increased with the frequency of symptomatic recurrences. Subclinical shedding was more frequent among women with more than 12 recurrences per year than among those with no symptomatic recurrences (odds ratio, 3.3; 95 percent confidence interval, 1.4 to 7.9); it was also more frequent among women who had recently acquired genital herpes (odds ratio for women with HSV acquired in the past year as compared with those who had had the infection for a year or more, 1.85; 95 percent confidence interval, 1.1 to 3.1).

CONCLUSIONS

Among women with a history of genital herpes infection, subclinical shedding of HSV is common and accounts for nearly one third of the total days of reactivation of HSV infection in the genital tract. Women with frequent symptomatic recurrences also have frequent subclinical shedding and may be at high risk for transmitting HSV.

Intraoperative data acquisition for the study of cerebral dysfunction following cardiopulmonary bypass

As a first step in our study to document postoperative cerebral dysfunction, and to determine whether global cerebral blood flow can be implicated in the etiology of this postoperative change, we have assembled a flexible data acquisition system to acquire and record data from four independent sources, three in digital form and one analog. Each of the monitors that we use has a different requirement: One has eight channels of analog output; the other three have RS-232 digital outputs, each with a data stream with different characteristics. The central element of our data collection is a personal computer running the data acquisition and analysis program, LabVIEW for Windows (National Instruments, Austin, TX). All data are processed through separate LabVIEW global variables; the data strings are concatenated and stored on the hard disk in a spreadsheet format for further analysis. We illustrate an intraoperative recording made during cardiopulmonary bypass (CPB) by showing a graph of the mean arterial pressure (MAP), mixed venous oxyhemoglobin saturation recorded from the jugular bulb (JVO2Sat), and temperature measured from the nasopharynx. A decrease in the MAP after unclamping the aorta is accompanied by a decrease in JVO2Sat.

Incontinence and anorectal dysfunction in patients with diabetes mellitus

The elucidation of the pathogenesis of faecal incontinence in patients with advanced diabetes mellitus has progressed during the last 15 years. In contrast to earlier concepts which promoted the concept that high stool volumes overwhelm normal continence mechanisms, recent studies indicate that the vast majority of diabetic patients with faecal incontinence have normal or only moderately increased daily stool volumes, but also exhibit multiple abnormalities of anorectal sensory and motor functions. These changes are not observed in continent diabetic patients. Treatment consists of pharmacologic and dietary interventions to modulate diarrhoea, and biofeedback techniques to improve rectal sensory thresholds and striated muscle responsiveness of continence mechanisms. This dual approach is often successful and is free of risks.

Seroprevalence of herpes simplex virus infections in a family medicine clinic

OBJECTIVES

To determine the prevalence of herpes simplex virus (HSV) antibody in a general medical practice setting and to assess the frequency of subclinical infection.

DESIGN

Prevalence study.

SETTING

A family practice clinic at the University of Washington Medical Center, Seattle.

PARTICIPANTS

Five hundred randomly selected patients between the ages of 18 and 45 years.

MAIN OUTCOME MEASURES

Serum samples were tested by Western blot assay to detect the presence of antibody to HSV type 1 (HSV-1) and HSV-2. Demographic information and clinical history of oral and genital herpes were obtained.

RESULTS

One hundred fourteen patients (23%) were seropositive for HSV-2 antibody, 277 patients (56%) were seropositive for HSV-1 antibody, 59 patients (12%) were seropositive for both HSV-2 and HSV-1 antibodies, and 163 patients (33%) were seronegative for both. Women were almost twice as likely as men to be seropositive for HSV-2 antibody (28% vs 15%, P < .001). Blacks had the highest rates of HSV-2 antibody seropositivity (60%) compared with whites (20%) and Asians (6%) (P < .001). Other demographic correlates of seropositivity included being older, having fewer years of education, and having public insurance. The specificity of a clinical history of genital herpes or sores for HSV-2 infection was high (99%), but the sensitivity was low (27%).

CONCLUSIONS

Herpes simplex virus infection is common among patients seeking primary care. Women, blacks, and patients of lower socioeconomic status are most likely to be seropositive for HSV-2 antibody. The high frequency of unrecognized HSV infection has implications for primary care physicians in counseling patients regarding HSV infection and transmission.

Clinical and epidemiologic features of infection with Mycobacterium genavense. Swiss HIV Cohort Study

OBJECTIVES

To characterize clinical and epidemiologic features of infections with Mycobacterium genavense.

DESIGN

Case series and case-control studies. Patients with M genavense were compared with two control groups: CD4 controls were matched on the basis of CD4 counts, and Mycobacterium avium-intracellulare complex controls had disseminated infection with M avium-intracellulare complex.

RESULTS

Fifty-four patients with disseminated infections caused by M genavense were found, from Europe (37), North America (15), and Australia (two). All were infected with human immunodeficiency virus. The median CD4 count was 0.016 x 10(9)/L (16/mm3) (range, 0.001 to 0.082 x 10(9)/L). Eighty-seven percent had fever and weight loss, 44% had diarrhea, 43% had splenomegaly, 39% had hepatomegaly, and 72% had anemia. In Swiss university hospitals, M genavense was responsible for 12.8% of nontuberculous disseminated mycobacterial infections in patients with human immunodeficiency virus from 1990 to 1992. The median survival was 190 days after the first isolation of M genavense. Among the patients who had been treated with at least two antimycobacterial drugs for 1 month or more, median survival was 263 days (95% confidence interval, 144 to 382 days), compared with 81 days (95% confidence interval, 73 to 89 days) for those not treated (P = .0009). Survival in patients with M genavense was similar to the survival of M avium-intracellulare complex controls. However, patients with similar CD4 counts (CD4 controls) survived longer (median, 342 days; 95% confidence interval, 269 to 415 days; P < .0003).

CONCLUSIONS

Infection with M genavense may be responsible for more than 10% of disseminated nontuberculous mycobacterial infections in patients with human immunodeficiency virus infection. Its clinical presentation and response to treatment are similar to those of infection with M avium-intracellulare complex.