Spinal anatomy and the use of epidurals

Epidurals can be used to provide analgesia or anaesthesia. Nurses should be aware of the main contraindications to epidurals and of the complications that may arise.

Self-reported levels of sleepiness among subjects with insomnia

Objectives: To determine the prevalence of sleepiness in a cohort of insomnia subjects. We evaluated if differential levels of subjective sleepiness predict systematic differences in the polysomnographic characteristics of these subjects.Background: Insomnia is prevalent among the adult population. While it has been speculated that sleepiness may be an important daytime consequence of insomnia, this has not been demonstrated.Methods: Sixty-two subjects with complaints of insomnia for at least 6 months were polysomnographically evaluated. Subjects were asked to self-report their level of sleepiness based on their experiences for the previous 7 days. Subjects were divided into three groups based on their level of sleepiness. Sleepiness was determined using the excessive daytime sleepiness scale of the Sleep/Wake Activity Inventory (SWAI-EDS).Results: Twenty-two percent of insomnia subjects were found to be sleepy on the EDS scale of the SWAI. The level of sleepiness was also found to predict difficulty initiating sleep both on the nocturnal scale of the SWAI, and on nocturnal polysomnography.Conclusions: This study established a base rate of sleepiness among a cohort of insomnia subjects. It also demonstrated a wide spectrum of sleepiness/alertness among subjects with insomnia. Differential levels of sleepiness were found to predict nocturnal sleep latencies.

Colonic CD8 and gamma delta T-cell infiltration with epithelial damage in children with autism

OBJECTIVES

We have reported colitis with ileal lymphoid nodular hyperplasia (LNH) in children with regressive autism. The aims of this study were to characterize this lesion and determine whether LNH is specific for autism.

METHODS

Ileo-colonoscopy was performed in 21 consecutively evaluated children with autistic spectrum disorders and bowel symptoms. Blinded comparison was made with 8 children with histologically normal ileum and colon, 10 developmentally normal children with ileal LNH, 15 with Crohn's disease, and 14 with ulcerative colitis. Immunohistochemistry was performed for cell lineage and functional markers, and histochemistry was performed for glycosaminoglycans and basement membrane thickness.

RESULTS

Histology demonstrated lymphocytic colitis in the autistic children, less severe than classical inflammatory bowel disease. However, basement membrane thickness and mucosal gamma delta cell density were significantly increased above those of all other groups including patients with inflammatory bowel disease. CD8(+) density and intraepithelial lymphocyte numbers were higher than those in the Crohn's disease, LNH, and normal control groups; and CD3 and plasma cell density and crypt proliferation were higher than those in normal and LNH control groups. Epithelial, but not lamina propria, glycosaminoglycans were disrupted. However, the epithelium was HLA-DR(-), suggesting a predominantly T(H)2 response.

INTERPRETATION

Immunohistochemistry confirms a distinct lymphocytic colitis in autistic spectrum disorders in which the epithelium appears particularly affected. This is consistent with increasing evidence for gut epithelial dysfunction in autism.

The effect of capsaicin on the thermal and metabolic responses of men exposed to 38 degrees C for 120 minutes

OBJECTIVE

To determine the thermoregulatory response of humans to heat following an ingestion of capsaicin.

METHODS

The thermoregulatory responses of 7 men (aged 22-28 years) to a 2-hour exposure to 38 degrees C (50% relative humidity) were compared following ingestion of either placebo or capsaicin. The capsaicin dose (2 mg x kg(-1)) was ingested 1 hour prior to the heat exposure, and all subjects were encouraged to overhydrate for 48 hours prior to each trial. Core temperature, mean skin temperature, cardiac output, and oxygen consumption were measured every 30 minutes. In addition, the changes (pre-exposure vs postexposure) in body mass and plasma volume were calculated.

RESULTS

As expected, core temperature, cardiac output, and oxygen consumption all increased significantly (P < .05) with exposure time. There were also significant decreases over time in body mass and plasma volume. These aforementioned changes, however, were not significantly different (P > .05) between the placebo and capsaicin trials, except for mean skin temperature. The treatment effect for mean skin temperature was significant (P = .013), with the capsaicin response (34.7 degrees C) registering lower than the placebo measurement (35.1 degrees C).

CONCLUSIONS

It appears that humans respond differently than animals to capsaicin ingestion. For humans, ingesting a 2-mg x kg(-1) dose of capsaicin 1 hour prior to heat exposure does not alter a person's ability to thermoregulate in the heat.

IDA-1, a Caenorhabditis elegans homolog of the diabetic autoantigens IA-2 and phogrin, is expressed in peptidergic neurons in the worm

The closely related mammalian proteins IA-2 and phogrin are protein tyrosine phosphatase-like receptor proteins spanning the membrane of dense core vesicles of neuroendocrine tissues. They are of interest as molecular components of the secretory machinery and as major targets of autoimmunity in type I diabetes mellitus. The Caenorhabditis elegans genome has a single copy of an IA-2/phogrin homolog ida-1 III (islet cell diabetic autoantigen), which encodes the ida-1 (B0244.2) gene product as a series of 12 exons over a 10-kb region of chromosome III. The full-length sequence of the ida-1 cDNA encoded a 767-amino acid type 1 transmembrane protein of 87 kDa. The PTP catalytic site consensus sequence of IDA-1, like IA-2 and phogrin, diverged and would not be active. Expression of green fluorescent protein (GFP) under the ida-1 gene promoter showed activity in a subset of around 30 neurons with sensory functions and the uv1 cells of the vulva in hermaphrodites. Males showed additional expression in male-specific neurons. In situ experiments in rat brain showing the distribution of IA-2 and phogrin suggested a complimentary and overlapping pattern compared with the proprotein convertases PC1 and PC2. In C. elegans, IDA-1-expressing cells comprised a subset of those expressing the PC2 homolog KPC-2 (C51E3. 7), consistent with IDA-1 being a component of neuropeptide-containing dense core vesicles. The results support the hypothesis that C. elegans IDA-1 is the functional homolog of IA-2 and phogrin in mammals. Analysis of the function of IDA-1 should contribute to our understanding of the function of these proteins in signal transduction, vesicle locomotion, and exocytosis.

Reduced heparan sulfate accumulation in enterocytes contributes to protein-losing enteropathy in a congenital disorder of glycosylation

Intestinal biopsy in a boy with gastroenteritis-induced protein-losing enteropathy (PLE) showed loss of heparan sulfate (HS) and syndecan-1 core protein from the basolateral surface of the enterocytes, which improved after PLE subsided. Isoelectric focusing analysis of serum transferrin indicated a congenital disorder of glycosylation (CDG) and subsequent analysis showed three point mutations in the ALG6 gene encoding an alpha1,3-glucosyltransferase needed for the addition of the first glucose to the dolichol-linked oligosaccharide. The maternal mutation, C998T, causing an A333V substitution, has been shown to cause CDG-Ic, whereas the two paternal mutations, T391C (Y131H) and C924A (S308R) have not previously been reported. The mutations were tested for their ability to rescue faulty N:-linked glycosylation of carboxypeptidase Y in an ALG6-deficient Saccharomyces cerevisiae strain. Normal human ALG6 rescues glycosylation and A333V partially rescues, whereas the combined paternal mutations (Y131H and S308R) are ineffective. Underglycosylation resulting from each of these mutations is much more severe in rapidly dividing yeast. Similarly, incomplete protein glycosylation in the patient is most severe in rapidly dividing enterocytes during gastroenteritis-induced stress. Incomplete N:-linked glycosylation of an HS core protein and/or other biosynthetic enzymes may explain the selective localized loss of HS and PLE.

Orofacial prosthesis design and fabrication using stereolithography

The use of stereolithography for the manufacture of implantable prostheses is relatively new. Until now, its use with regard to mandibular resection has been to produce pre-operative models that allow more sophisticated planning of the contour and better preparation of the metallic framework to be implanted. This framework rejoins the sections of the mandible, returning some function, but providing no soft tissue support. Hence, the aesthetic results are not optimal. The aim of this study was to investigate the accuracy with which a stereolithographic model could be made to completely reunite both surfaces of the resected mandible and restore full contour. The design and fabrication of a mandibular prosthesis utilizing CAD/CAM technology and stereolithography is still in the early stages, but initial results indicate that with further research and better tools this could provide a new approach to mandibular resections, providing better aesthetic results.

Comparison of upper gastrointestinal toxicity of rofecoxib and naproxen in patients with rheumatoid arthritis. VIGOR Study Group

BACKGROUND

Each year, clinical upper gastrointestinal events occur in 2 to 4 percent of patients who are taking nonselective nonsteroidal antiinflammatory drugs (NSAIDs). We assessed whether rofecoxib, a selective inhibitor of cyclooxygenase-2, would be associated with a lower incidence of clinically important upper gastrointestinal events than is the nonselective NSAID naproxen among patients with rheumatoid arthritis.

METHODS

We randomly assigned 8076 patients who were at least 50 years of age (or at least 40 years of age and receiving long-term glucocorticoid therapy) and who had rheumatoid arthritis to receive either 50 mg of rofecoxib daily or 500 mg of naproxen twice daily. The primary end point was confirmed clinical upper gastrointestinal events (gastroduodenal perforation or obstruction, upper gastrointestinal bleeding, and symptomatic gastroduodenal ulcers).

RESULTS

Rofecoxib and naproxen had similar efficacy against rheumatoid arthritis. During a median follow-up of 9.0 months, 2.1 confirmed gastrointestinal events per 100 patient-years occurred with rofecoxib, as compared with 4.5 per 100 patient-years with naproxen (relative risk, 0.5; 95 percent confidence interval, 0.3 to 0.6; P<0.001). The respective rates of complicated confirmed events (perforation, obstruction, and severe upper gastrointestinal bleeding) were 0.6 per 100 patient-years and 1.4 per 100 patient-years (relative risk, 0.4; 95 percent confidence interval, 0.2 to 0.8; P=0.005). The incidence of myocardial infarction was lower among patients in the naproxen group than among those in the rofecoxib group (0.1 percent vs. 0.4 percent; relative risk, 0.2; 95 percent confidence interval, 0.1 to 0.7); the overall mortality rate and the rate of death from cardiovascular causes were similar in the two groups.

CONCLUSIONS

In patients with rheumatoid arthritis, treatment with rofecoxib, a selective inhibitor of cyclooxygenase-2, is associated with significantly fewer clinically important upper gastrointestinal events than treatment with naproxen, a nonselective inhibitor.

Crosstalk between nervous and immune systems through the animal kingdom: focus on opioids

During the course of evolution invertebrates and vertebrates have maintained common signaling molecules, such as neuropeptides. For example, complete hormonal-enzymatic systems for the biosynthesis of opioid peptides have been found in both the CNS and immune systems of these animals. These signaling molecules have been found in the blood circulation and act as immunomodulators. In vertebrates, release of the signaling molecules occurs during stress (cognitive or pathogens), which triggers the hypothalamo-hypophysial-adrenal axis. Similarly, these neuropeptides are used as messengers to initiate and stimulate the innate immune response in invertebrates. Thus, the crosstalk between nervous and immune systems has an ancient evolutionary origin and the messengers used have been conserved during the course of evolution reflecting their vital importance.

Neuroinvasion by human respiratory coronaviruses

Human coronaviruses (HCoV) cause common colds but can also infect neural cell cultures. To provide definitive experimental evidence for the neurotropism and neuroinvasion of HCoV and its possible association with multiple sclerosis (MS), we have performed an extensive search and characterization of HCoV RNA in a large panel of human brain autopsy samples. Very stringent reverse transcription-PCR with two primer pairs for both viral strains (229E and OC43), combined with Southern hybridization, was performed on samples from 90 coded donors with various neurological diseases (39 with MS and 26 with other neurological diseases) or normal controls (25 patients). We report that 44% (40 of 90) of donors were positive for 229E and that 23% (21 of 90) were positive for OC43. A statistically significant higher prevalence of OC43 in MS patients (35.9%; 14 of 39) than in controls (13.7%; 7 of 51) was observed. Sequencing of nucleocapsid protein (N) gene amplicons revealed point mutations in OC43, some consistently found in three MS patient brains and one normal control but never observed in laboratory viruses. In situ hybridization confirmed the presence of viral RNA in brain parenchyma, outside blood vessels. The presence of HCoV in human brains is consistent with neuroinvasion by these respiratory pathogens. Further studies are needed to distinguish between opportunistic and disease-associated viral presence in human brains.

Efficacy of uvulopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea

OBJECTIVES

Uvulopalatopharyngoplasty (UPPP) is widely used as a first-step procedure for the surgical management of obstructive sleep apnea (OSA) syndrome but best manages obstruction occurring at the level of the oropharynx alone and not the hypopharynx. Previous publications have noted mediocre results with use of this procedure in unselected patients with OSA, but less clear is the effectiveness of this procedure in the unselected patient with mild OSA (respiratory event index [REI] 5-25). Using objective and subjective criteria, we retrospectively analyzed the results of UPPP in patients with mild OSA.

METHODS

We examined 37 patients with mild OSA (REI 13.5 +/- 5.1, range 5.6-23.1) who had been operated on during 1996 with UPPP with or without tonsillectomy and/or septoplasty. Follow-up polysomnography was obtained in 25 (68%) an average of 40.5 weeks after surgery and compared with findings before surgery. Subjective assessment of sleepiness was performed with the Sleep-Wake Activity Inventory.

RESULTS

Ten patients (40%) had a postoperative reduction in the REI of more than 50%, comparable with the improvements reported in those with more severe apnea. Those who did not have a reduction in REI after surgery actually saw an increase in average REI from 16.6 +/- 5 to 26.7 +/- 18.4. Similarly, subjective assessment of sleepiness with the Sleep-Wake Activity Inventory showed no statistically significant improvement after surgery.

CONCLUSION

Overall, these results indicate that UPPP alone in the unselected patient provides little benefit in the management of mild OSA, similar to findings for more severe OSA. Surgeons must use great care in discerning the level of obstruction in the patient with mild OSA to tailor the appropriate retropalatal and/or retrolingual procedures and thereby achieve excellent surgical outcomes.

Creatine supplementation alters the response to a graded cycle ergometer test

To determine the effects of creatine supplementation on cardiorespiratory responses during a graded exercise test (GXT) 36 trained adults (20 male, 16 female; 21-27 years old) performed two maximal GXTs on a cycle ergometer. The first GXT was done in a nonsupplemented condition, and the second GXT was done following 7 days of ingesting either 5 g creatine monohydrate, encased in gelatin capsules, four times daily (CS, 13 male, 6 female), or the same number of glucose capsules (PL, 7 male, 10 female). CS significantly (P<0.05) improved total test time [pre-CS = 1217 (240) s, mean (std. dev.) versus post-CS = 1289 (215) s], while PL administration had no effect (P>0.05) on total test time [pre-PL= 1037 (181) s. versus post-PL= 1047 (172) s]. In addition, both oxygen consumption (VO2) and heart rate at the end of each of the first five GXT stages were significantly lower after CS, but were unchanged after PL. Moreover, the ventilatory threshold occurred at a significantly greater VO2 for CS [pre-CS = 2.2 (0.4) l x min(-1) or 66% of peak VO2 versus post-CS = 2.6 (0.5) l x min(-1) or 78% of peak Vo2; pre-PL = 2.6 (0.9) l x min(-1) or 70% peak VO2 versus post-PL = 2.6 (1.1) l x min(-1) or 68% of peak Vo2]. Neither CS nor PL had an effect on peak Vo2 [pre-CS = 3.4 (0.7) l x min(-1) versus post-CS = 3.3 (0.7) l x min(-1); pre-PL = 3.7 (1.1) l x min(-1) versus post-PL = 3.7 (1.1) l x min(-1)]. Apparently, CS can alter the contributions of the different metabolic systems during the initial stages of a GXT. Thus, the body is able to perform the sub-maximal workloads at a lower oxygen cost with a concomitant reduction in the work performed by the cardiovascular system.

CPAP therapy in patients with mild OSA: implementation and treatment outcome

Objectives: To determine continuous positive airway pressure (CPAP) treatment compliance and reversal of excessive daytime sleepiness in patients with mild OSA.Background: CPAP therapy is the most widely accepted and used intervention in patients with a diagnosis of obstructive sleep apnea (OSA). There are, however, no widely accepted protocols to help guide the rational use of CPAP therapy. Patients with mild OSA (respiratory event index (REI) >5 or </=25) represent a subset of the OSA population where CPAP implementation needs to be evaluated.Methods: This is a retrospective study of 740 consecutive patients evaluated for sleep apnea in 1996. Mild OSA was documented in 241 patients, of whom, 41 opted for CPAP therapy. Implementation of CPAP treatment included an education session and an overnight clinical polysomnography (CPSG) for titration purposes. Patients returned for follow-ups after 1 week and 1 year of CPAP use. During each appointment, compliance and response to treatment were evaluated.Results: Of the initial 41 patients nine were lost to follow-up, 16 discontinued CPAP use during the first week, and 16 were still using CPAP after 1 year. For the 16 still using CPAP after one year, hours of use the first week was correlated to hours of use the first year (r=0.81). Patients using CPAP more than 4 h/night experienced a marked improvement in daytime sleepiness after 1 year (P<0.01).Conclusions: Patients with mild OSA showed a high rate of CPAP discontinuation. Those patients who manifested good compliance during the first week of treatment continued using CPAP for the entire first year. These patients experienced improved alertness during the day. A 1 week trial on CPAP therapy is warranted to identify patients who benefit from this form of therapy.

A randomized trial of the efficacy and tolerability of the COX-2 inhibitor rofecoxib vs ibuprofen in patients with osteoarthritis. Rofecoxib/Ibuprofen Comparator Study Group

BACKGROUND

Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit both cyclooxygenase-1 (COX-1) and cyclooxygenase-2 (COX-2). It is not known whether a specific inhibitor of COX-2 will provide efficacy in osteoarthritis (OA) comparable with NSAIDs. Therefore, we compared the efficacy and safety of the rofecoxib, which specifically inhibits COX-2, with those of the NSAID ibuprofen in patients with OA.

OBJECTIVE

To compare the clinical efficacy and tolerability of rofecoxib (12.5 and 25 mg once daily) with ibuprofen (800 mg 3 times daily).

METHODS

A randomized, double-blind trial of 809 adults with OA was conducted. Patients with OA in whom the knee or hip was the primary source of pain were randomized to 1 of 4 treatment groups on demonstration of disease activity: placebo; rofecoxib, 12.5 or 25 mg once daily; or ibuprofen, 800 mg 3 times daily. Clinical efficacy and safety were monitored during a 6-week treatment period.

RESULTS

Both doses of rofecoxib demonstrated efficacy clinically comparable with ibuprofen as assessed by 3 primary end points (pain walking on a flat surface [Western Ontario and McMaster Universities Osteoarthritis Index], patient global assessment of response to therapy, and investigator global assessment of disease status) according to predefined comparability criteria. Both rofecoxib doses and the ibuprofen dose provided significantly (P<.001) greater efficacy than placebo on all primary end points. Results from secondary end points were consistent with those of the primary end points. All treatments were well tolerated; the overall incidence rates of clinical adverse experiences were not significantly different (P>.05) among the treatment groups.

CONCLUSION

Rofecoxib was well tolerated and provided clinical efficacy comparable with a high dose of the NSAID ibuprofen.

Development of the Royal Marsden Hospital paediatric oncology quality of life questionnaire

Our objective was to develop a health-related quality of life measure for use in pediatric oncology. The development process followed the EORTC Quality of Life Study Group (QLSG) guidelines but utilized a parental proxy rating methodology developed within the framework of the EORTC QLSG. Data are reported on the preliminary stages of development, which include interviews in the target population, specialist review of questionnaire content and initial results on the psychometric structure of the measure. The questionnaire has been translated from English to Swedish and Dutch and is available for international field testing. Suggestions for further development of the new measure are described, including the need for parallel forms for use with children and adolescents as well as the parental proxy rating form described here.

High plasma growth hormone (GH) levels inhibit expression of GH secretagogue receptor messenger ribonucleic acid levels in the rat pituitary

Synthetic GH secretagogues (GHSs) act via a receptor (GHS-R) distinct from that of GH-releasing hormone. The GHS-R has been cloned from the pituitary and is expressed not only in the pituitary but also in specific areas of the brain, including the hypothalamus. Recent studies suggest that hypothalamic GHS-R expression is regulated by GH. This study was designed to investigate whether pituitary GHS-R expression is modulated by GH. Female Wistar-Furth rats were injected sc with either saline (control) or GC tumor cells (GC) that secrete rat GH. The tumors were allowed to develop for 1-4 weeks. At weeks 1-4, control (n = 4-8) and GC rats (n = 3-8) were killed. Pituitary GHS-R messenger RNA (mRNA) was measured by a quantitative competitive PCR assay. The endogenous GHS-R mRNA levels were measured by determining the amount of competitive template RNA required to produce equimolar amounts of native and competitive template PCR products. The mean log plasma GH levels were significantly greater in the GC rat group than in the control group at weeks 2, 3, and 4. At these times, the mean log pituitary GHS-R mRNA contents were significantly lower in the GC rat group than in the control group. No relationship could be established between log estradiol levels and GHS-R levels. These data indicate that pituitary GHS-R expression is modulated by GH.

Posttranslationally modified tubulins and microtubule organization in hemocytes of the brine shrimp, Artemia franciscana

Crustaceans possess blood cells (hemocytes) that mediate organismal defense and are analogous to vertebrate leukocytes. In order to more fully characterize these types of cells, hemocytes of the branchiopod crustacean, Artemia franciscana, were analyzed. The data indicate that Artemia have one type of hemocyte, ranging in morphology from compact and spherical to flat and spreading when examined in vitro. Electron microscopy revealed many cytoplasmic granules in the hemocytes and only a limited number of other membrane-bound organelles. Centrioles and microtubules were also visible in thin sections of chemically fixed samples. The cytoplasm of spherical hemocytes was completely labeled by general antitubulin antibodies, but in flattened hemocytes packing of cytoskeletal elements was less tight and individual microtubules were observed. Probing of Western blots disclosed acetylated, tyrosinated, and detyrosinated tubulin isoforms in hemocyte homogenates, the first characterization of posttranslationally modified tubulins in this cell type. Acetylated tubulin was restricted to a subset of microtubules, whereas tyrosinated microtubules were displayed more abundantly. Staining obtained with antibody to detyrosinated tubulin was unusual because it was limited to the perinuclear region of hemocytes. Incubation of blood cells with a monoclonal antibody to gamma-tubulin yielded fluorescent dots sometimes in pairs, a pattern characteristic of centrosomes. The findings support the conclusion that Artemia hemocytes undergo rapid morphogenesis in vitro accompanied by extensive rearrangement of their microtubules, the latter probably indicative of cytoskeletal changes that occur during cell movement and phagocytosis. Additionally, the hemocytes contain posttranslationally modified alpha-tubulins and centrosome-associated gamma-tubulin, both with the potential to influence microtubule organization and function.

Comparative characterization of two forms of recombinant human SPC1 secreted from Schneider 2 cells

SPC1 (furin/PACE), an enzyme belonging to the S8 group of serine endoproteases, is a type I integral membrane protein that catalyzes the processing of a multitude of precursor proteins. We report here the use of transfected Drosophila melanogaster Schneider 2 cells to produce milligram amounts of two forms of recombinant human SPC1. In order to investigate the role of the cysteine-rich region (CRR) of SPC1, we compared the biochemical and enzymatic properties of hSPC1/714 that has the C-terminal tail and transmembrane region of the native enzyme removed with that of hSPC1/585 which had, in addition, the CRR deleted. Two stable cell lines were established. The S2-hSPC1/714 line secreted a major form of apparent molecular weight of 83 kDa and a minor form of 80 kDa whereas the S2-hSPC1/585 line secreted a single 59-kDa protein. PNGase F treatment of the different forms demonstrated that the enzymes were glycosylated. Automated NH(2)-terminal sequencing revealed that all purified forms resulted from processing at the expected zymogen activation site. Removal of the CRR resulted in a broadening of the enzyme's pH range, a shift of K(0.5) for Ca(2+), and a shorter enzymatic half-life when compared to the longer form, which suggest that the CRR of hSPC1 may help in stabilizing the enzyme's proteolytic activity. The use of this high-level expression system will meet the demand for material necessary to perform biochemical and structural studies that are needed to further our understanding of this and other SPCs at the molecular level.

Evidence that anoreceptive intercourse with ejaculate exposure is associated with rapid CD4 cell loss

OBJECTIVE

To determine whether ejaculate exposure through anoreceptive intercourse is associated with rapid CD4 cell loss.

DESIGN

Self-reported behavioral, demographic data and blood samples were gathered longitudinally at ten semiannual visits from individuals participating in the Multicenter AIDS Cohort Study (MACS).

PATIENTS/PARTICIPANTS

A group of 937 HIV-seropositive men who were continuously followed for four to ten semiannual visits.

OUTCOME MEASURES

A loss of 10% or more in CD4 cells between the first two of any three consecutive semiannual visits that was followed by a 10% or greater loss between the second and third visits.

RESULTS

A period of rapid CD4 cell loss over three semiannual visits occurred in 389 of the 937 (42%) HIV-seropositive men studied. Men who reported one or more anoreceptive intercourse partners with whom they were exposed to ejaculate (RAI-E) during the 12 months immediately preceding their visits were more than twice as likely to show this rapid CD4 cell loss compared with men with no such partners.

CONCLUSIONS

The association between RAI-E partnerships and rapid CD4 cell loss suggests factors associated with ejaculate exposure (e.g., sexually transmitted diseases) may hasten the clinical progression of HIV disease. It is suggested that infectious diseases, which are known to be associated with ejaculate exposure, may be the causal factor underlying the association between RAI-E partnerships and rapid CD4 cell loss in these men, although the presence of these diseases was not ascertained in these data. HIV-infected individuals should be cautioned against unprotected anoreceptive intercourse.