Yield of chest radiograph in tuberculosis screening for HIV-infected persons at a district-level HIV clinic

SETTING

An Hoa Clinic, a district-level human immunodeficiency virus (HIV) clinic in Ho Chi Minh City, Viet Nam.

OBJECTIVE

To assess the performance of chest radiograph (CXR) in screening for pulmonary tuberculosis (PTB) among HIV-infected individuals and identify misdiagnosed opportunities.

DESIGN

This cross-sectional study was conducted in 397 HIV-infected patients consecutively enrolled at the An Hoa Clinic in Ho Chi Minh City, Viet Nam, from August 2009 to June 2010. The performance of CXR in TB screening was assessed based on its sensitivity, specificity, positive likelihood ratio and negative likelihood ratio.

RESULTS

Symptom screening alone missed 50% of PTB cases. The combination of CXR and symptom screening yielded an additional 28.6% (8/28) in PTB screening as compared with symptom screening alone, and should be applied routinely, especially in high TB prevalent settings.

CONCLUSION

CXR is a good predictor for PTB even in HIV-infected individuals. The combination of CXR and screening for common TB symptoms considerably improved the sensitivity of detecting active PTB in people living with HIV. If available, routine sputum culture and the World Health Organization-endorsed Xpert(®) MTB/RIF assay should be implemented to achieve a more accurate diagnosis.

Association between smoking and size of anal warts in HIV-infected women

While the association between smoking and human papillomavirus infection, cervical cancer, and anal cancer has been well studied, evidence on the association between cigarette smoking and anal warts is limited. The purpose of this study was to investigate if cigarette smoking status influences the size of anal warts over time in HIV-infected women in a sample of 976 HIV-infected women from the Women's Interagency HIV Study (WIHS). A linear mixed model was used to determine the effect of smoking on anal wart size. Even though women who were currently smokers had larger anal warts at baseline and slower growth rate of anal wart size after each visit than women who were not current smokers, there was no association between size of anal wart and current smoking status over time. Further studies on the role of smoking and interaction between smoking and other risk factors, however, should be explored.

The role of hepatitis C in hepatocellular carcinoma: a case control study among Egyptian patients

BACKGROUND

Egypt has one of the highest prevalence rates of hepatitis C virus (HCV) infection in the world; however, the risk and attribution related to HCV in Egyptian patients with hepatocellular carcinoma (HCC) remains unknown.

GOALS

The current study was undertaken to estimate the risk of HCC in relation to HCV in Egypt.

STUDY

Thirty-three patients with HCC and 35 healthy controls who had a similar socioeconomic status were prospectively enrolled at the University of Cairo National Cancer Institute.

RESULTS

Anti-HCV antibodies were present in 75.8% of the patients and in 42.9% of the controls (p = 0.01); hepatitis B surface antigen (HBsAg) was present in 15.2% of the patients and in 2.9% of the controls (p = 0.03). In addition, the sex-and age-adjusted odds ratio (OR) for anti-HCV antibodies was 5.1 (95% CI = 1.5-17.4) and for HBsAg was 13.2 (95% CI = 1.2-148.2). Concurrent Schistosoma mansoni and anti-HCV was associated with an OR of 10.3 (95% CI = 1.3-79.8), which was higher than that for anti-HCV (6.5; 95% CI = 1.6-26.6) and S. mansoni infection (0.2; 95% CI = 0.1-6.2) alone. Finally, we estimated the attributable fraction of HCC to HCV to be 64% in this study population and 48% in the general Egyptian population.

CONCLUSIONS

Both HCV and hepatitis B virus infection increase the risk of HCC in Egyptian patients, whereas isolated Schistosoma infection does not. Because of the very high prevalence rate of HCV in the general Egyptian population, it accounts for most HCC cases in Egypt.

Hepatitis B vaccination in high-risk infants: 10-year follow-up

The long-term efficacy of hepatitis B vaccination among high-risk infants was determined in 805 vaccine responders, immunized at birth in Taiwan during 1981-1984 and followed to age 10 years, via life table survival and Cox multivariate analyses. At 10 years, cumulative persistence of antibody to hepatitis B surface antigen (anti-HBs) was 85%, and cumulative incidence of hepatitis B virus (HBV) infection was 15%. Three children became carriers. Twelve-month anti-HBs titer was the strongest predictor of efficacy. The higher the initial titer, the lower the risk of anti-HBs loss (relative risk [RR], 0.26 for titer of 100-999 mIU/mL; RR, 0.08 for titer >1000 mIU/mL; P<.001) and HBV infection (RR, 0.55 and 0.27; P<.05). Maternal hepatitis B e antigen positivity but not hepatitis B immunoglobulin dose or gender predicted greater antibody persistence to age 10 years. Because the level of antibody persistence remained high and few became carriers, booster revaccination within 10 years seems unnecessary.

Familial aggregation of colorectal cancer in Egypt

We have investigated the familial aggregation of colorectal cancer and hereditary nonpolyposis colorectal cancer (HNPCC) in Egypt because of the high incidence of colorectal cancer in Egyptian children and young adults and the prevalence of consanguinity there. In a pilot study, we conducted detailed interviews with 111 Egyptian colorectal cancer patients and 111 healthy Egyptian controls about their family histories of colorectal cancer, and other cancers, consanguinity, age at diagnosis, symptoms and recurrence. Eight patients (7.2%) had one or more first- or second-degree relatives under age 40 with colorectal cancer, suggestive of HNPCC by the Amsterdam criteria. One of these families had a typical history of HNPCC, with 4 relatives having colorectal cancer in 3 generations; 3 of these relatives were younger than age 45 at colon cancer diagnosis, and other relatives had extracolonic tumors. Another 14 patients (12.6%) had a first- or second-degree relative with a family history of other neoplasms such as endometrial, urinary and hepatobiliary cancers that could also be related to HNPCC. Four patients with early-onset colon cancer and a family history of other HNPCC-related cancers reported that their parents were first-degree cousins.

Mutagen sensitivity as a susceptibility marker for human hepatocellular carcinoma

Although the pathogenesis of hepatocellular carcinoma (HCC) remains poorly understood, hepatitis B virus and dietary aflatoxin exposures are established etiological factors for this disease. We conducted a pilot study of 28 patients with HCC and 110 healthy controls matched for age, sex, and ethnicity to determine whether constitutional genetic instability, based on the quantification of mutagen-induced chromatid breaks in cultured lymphocytes, modifies an individual's risk of HCC development. The mean numbers of bleomycin-induced breaks per cell for cases and controls were 0.92 and 0.55, respectively (P < 0.0001). For benzo(a)pyrene diol epoxide (BPDE) sensitivity, the values were 0.90 for cases and 0.46 for controls (P < 0.0001). Nearly 68% of the cases but only 27% of the controls exhibited bleomycin sensitivity (i.e., had > or = 0.68 breaks per cell). Eighty % of the case group but only 22% of the control group exhibited BPDE sensitivity (i.e., had > or = 0.58 breaks per cell). On multivariate analyses, both bleomycin sensitivity and BPDE sensitivity were associated with significantly elevated risks for HCC, with odds ratios (95% confidence intervals) of 5.63 (2.30, 13.81) and 14.13 (3.52, 56.68), respectively. For individuals who were sensitive to both assays, the risk was 35.88. A synergistic interaction between the bleomycin sensitivity and BPDE sensitivity in HCC risk was suggested. These preliminary findings suggest that differences in host factors related to the predisposition to chromosome breakage, the capacity for DNA repair, or both may be involved in HCC development by influencing the predisposition of hepatitis B virus integration into human DNA or that the carcinogens induced DNA damage susceptibility. A larger study is needed to confirm these intriguing results.

Reduced expression of mismatch repair genes in colorectal cancer patients in Egypt

An Egyptian hospital-based pilot case-control study was conducted to investigate the relationship between the expression level of mismatch repair (MMR) genes and the risk of colorectal cancer. The relative expression of five known MMR genes, i.e., hMSH2, hMLH1, hPMS1, hPMS2, and GTBP/hMSH6, was measured by a multiplex reverse transcriptase (RT)-polymerase chain reaction (PCR) in peripheral blood lymphocytes from 31 colorectal cancer patients and 47 age- and-sex matched controls. The expression of hMSH2, GTBP/hMSH6, hPMS1 and hPMS2 tended to be lower in patients than controls, but only the difference in hPMS2 expression was statistically significant (p<0. 01). Although 50% of the cases had chemotherapy or radiotherapy within the last six months before the blood was drawn, their gene expression was not statistically different from those who had not undergone such therapies. After adjustment for age and sex, the odds ratios (OR) calculated from a logistical regression model, using the median levels of gene expression of controls as cut-off values, indicated that increased risk was associated with reduced expressions of both hPMS1 (OR = 3.97, 95% confidence interval (CI) = 1.04 to 7.65) and hPMS2 (OR = 2.86, 95% CI = 1.05 to 7.76). Although the results of this study were inconclusive because of the small sample size and use of prevalent cases, it is biologically plausible that patients with colorectal cancers may have a lower expression of MMR genes than healthy controls because malfunction of these genes has been shown in hereditary nonpolyposis colon cancer. The involvement of low hPMS2 expression in colon cancer risk seems to be unique in the Egyptian population. Further studies with newly diagnosed patients before they begin therapy will provide more convincing data about the role of MMR gene expression in the etiology of colorectal cancers in Egypt.

Colorectal cancer in Egyptian patients under 40 years of age

Although colorectal cancer is not a common cancer in Egypt, the age distribution of the disease shows that a high proportion occurs in children and adults under 40 years of age. We reviewed the records of 1,608 colorectal cancer patients treated in 4 cancer hospitals in Egypt during a period of 3 to 10 years. The hospitals in which about 85% of all colorectal cancer cases in Egypt were seen included Egypt's 2 major cancer centers, The National Cancer Institute (NCI) in Cairo and Tanta Cancer Center (TCC) in the mid-Nile Delta region, and 2 major university hospitals, Assiut University in South Egypt and Ain Shams University in Cairo. Our review showed that patients younger than 40 years represented 35.6% of all patients in the 4 cancer hospitals, and that these rates were similar among the hospitals and for the years reviewed. The male-to-female ratio increased from 1.0 to 1.7 for the age groups ranging from 0-9 and 30-39 years, and increased from 1.0 to 1.5 for the age groups ranging from 40-49 to over 60 years. More than half of all the patients had rectal tumors, and about 90% of the cancers were adenocarcinomas; 30.6% of patients younger than 40 years, compared with 13.8% of older patients, had mucin-producing tumors. This study confirmed the occurrence of a high colorectal cancer rate in young Egyptians, and it opens the door to future epidemiologic studies to identify causes and risk factors of this disease pattern in Egypt.

Outcome of perinatal hepatitis B virus exposure is dependent on maternal virus load

To evaluate the role of maternal hepatitis B virus (HBV) DNA levels in perinatal infection, two nested case-control studies were done within a cohort of 773 hepatitis B surface antigen (HBsAg)-positive Taiwanese women and their infants. As serum HBV DNA levels increased from < 0.005 to > or = 1.4 ng/mL among the hepatitis B e antigen (HBeAg)-positive mothers, the odds ratio (OR) for having a persistently infected infant increased from 1.0 to 147.0 (P for trend < .001). Among HBeAg-negative mothers, the OR for having a persistently infected infant was 19.2 (95% confidence interval, 2.3-176.6) in mothers with high versus low levels of serum HBV DNA. A logistic regression analysis identified maternal HBV DNA to be a stronger independent predictor of persistent infection than HBeAg status. Thus, perinatal exposure to high levels of maternal HBV DNA is the most important determinant of infection outcome in the infant.

Antibody to Epstein-Barr virus-specific DNase as a marker for field survey of patients with nasopharyngeal carcinoma in Taiwan

A serological survey using antibody to Epstein-Barr virus (EBV)-specific DNase activity as a marker for the identification of patients with nasopharyngeal carcinoma (NPC) has been carried out on healthy subjects who visited Government Employees' Clinic Center (GECC) for routine health examination and on individuals residing in NPC high-risk areas (HRA) in Taiwan. During a 3-year prospective study, 22,596 and 9,869 sera were collected from the GECC and HRA groups, respectively. Taking neutralization of 2 or more units of EBV DNase activity as a positive response, the positivity rates in the GECC and HRA groups were 5.4% and 11.92%, respectively. Among the antibody-positive individuals, three cases of NPC were found in the GECC group (detection rate 0.63%) and 11 in the HRA group (detection rate 1.32%). A further patient at stage III of the disease was found in the first year of following up of 1,005 antibody-positive individuals. Among the 12 NPC patients in the HRA, five were newly diagnosed as having stage II (three patients) and stage III (two patients) NPC. These results support the hypothesis that antibody against EBV-specific DNase activity may be a useful marker for detection of patients with NPC, and they imply that individuals having high levels of antibody to EBV DNase activity may have an increased risk of development of NPC.

Human immunodeficiency virus seroprevalence among blood product recipients in San Francisco before transfusion

To determine the incidence of transfusion-associated human immunodeficiency virus (HIV) infection after routine screening of donated blood, a pilot study estimated the pretransfusion prevalence of HIV infection among blood product recipients in San Francisco. Among the 911 nonduplicate pretransfusion specimens from recipients without a clinical history of acquired immune deficiency syndrome (AIDS) or AIDS-related complex (ARC), the overall prevalence of antibody to HIV was 2.9 percent (5.2% among males and 0.6% among females; p = 0.00002). If recipients in specifically defined or possible high-risk groups (n = 348) were excluded, a seropositivity rate of 1.8 percent (10/563) was detected, with all the positives occurring in men (10/242, 4.1%) and none in women (0/321, 0%). This demonstrated prevalence of HIV infection among blood product recipients in San Francisco before transfusion was substantially higher than the known 0.02 to 0.04 percent prevalence in the donor population. Therefore, the population of women without known risk for AIDS is the best in which to assess the risk of HIV infection in patients who are currently receiving seronegative blood transfusions.

Epidemiology of hepatitis B virus infection in South African Chinese

The authors determined the age-specific prevalence of hepatitis B virus markers in 1,408 Chinese who resided in South Africa in 1983-1985. The small South African Chinese community consists of original Chinese settlers, almost all of whom migrated from the hepatitis B virus endemic mainland China province of Guangdong, and their South African-born descendants. The Chinese live among the white South African community, which has a very low hepatitis B virus carrier rate. The overall hepatitis B virus carrier rate was 5.3%, and the carrier rate was highest in age group 30-39 years (11.9%) and significantly lower in children aged 1-9 and 10-19 years (2.4% and 2.0%, respectively). Overall infection rates increased progressively with increasing age, starting at about 10% in the children aged 1-19 years and reaching 50% in adults aged 60-69 years. Among carrier children, 89% had carrier mothers, and all of the latter were also hepatitis e antigen (HBeAg)-positive. The prevalence of hepatitis B virus carriers in South African Chinese women of child-bearing age was 6.1%, and 41.9% of these carriers were HBeAg-positive. The age-specific prevalence of hepatitis B virus markers among South African Chinese is appreciably lower than that of Chinese in southeastern China, who have carrier rates of 15-20% with a peak in childhood. The prevalence of hepatitis B virus infection appears to be decreasing in South African Chinese, probably because improved hygienic and socioeconomic circumstances, in comparison with those in Guangdong, have resulted in less horizontal transmission of the virus. A diminishing pool of carriers is maintained by perinatal maternal-infant infection.

Prospective study of asymptomatic HBsAg carrier children infected in the perinatal period: clinical and liver histologic studies

Liver histologic findings were studied in 18 children who were 4 to 9 years old, and who had been HBsAg carriers since having been infected by their mothers in the perinatal period. All were born to HBeAg-HBsAg carrier mothers; the children were followed periodically from birth. Throughout their entire course, none developed symptoms or signs suggestive of liver disease. All of the 18 children showed mild but definite liver histologic changes: 15 had nonspecific histologic changes, and three had chronic persistent hepatitis. In 13 of 18 children, follow-up aminotransferase activities were abnormal, but none exceeded 100 KU. At the time of biopsy, ALTs on four children were above the upper limit of normal. All children were HBeAg-positive in early infancy, but five lost this antigen and developed antibody during follow-up. The histologic findings in HBeAg-positive children did not differ from those in children with antibody. Perinatal hepatitis B virus infection has been thought to play an important role in chronic liver disease, including hepatocellular carcinoma. This study indicates that some pathologic changes following perinatal infection begin very early.

Prognostic significance of histologic findings in resected small hepatocellular carcinoma

Fifty-one patients with histologically proven small (less than 5 cm) hepatocellular carcinoma underwent hepatic resection. In ten cases (group A) the cancer cells were confined within the tumor capsule, in ten (group B) there was extracapsular extension of growth, in 23 (group C) there was also invasion of the portal vein from the main tumor or from satellite nodules, or both, and in eight cases (group D) the findings were the same as in group C but there was no tumor capsule. The mean follow-up period was 54 +/- 12 months, minimum 37 months. The estimated 7-year survival rates in groups A-D were, respectively 100, 47.5, 47.5 and 37.5%. The classification of gross tumor appearance as typical or atypical was fairly well correlated to the histologic pattern in groups A, C and D, but not in group B. Although safety margin at resection did not emerge as a prognostic factor, the group A patients with a good margin were free from tumour recurrence.

Anti-HBc IgM in cases of hepatocellular carcinoma and cirrhosis in Taiwan

The sera of apparently healthy carriers of hepatitis B virus surface antigen enrolled in the Taiwan Prospective Study were tested retrospectively for anti-HBc IgM, to determine whether this test would be useful in predicting the development of hepatocellular carcinoma (HCC) and/or cirrhosis. In comparison with men who did not develop HCC or cirrhosis, the relative risk of those with anti-HBc IgM elevations was 3.4 and 5.6, respectively. Each of these factors was highly statistically significant, although the difference between them was not. Demonstration of anti-HBc IgM titers of greater than 1:1000 in serum probably reflects ongoing low level viral replication but not recent infection. Anti-HBc IgM appears to be a useful prognostic indicator for the future development of HCC and/or cirrhosis.

Detection of alpha-foetoprotein messenger RNA in human hepatocellular carcinoma and hepatoblastoma tissue

Alpha-foetoprotein (AFP) synthesis, although repressed in normal adults, is increased in the majority of patients with hepatocellular carcinoma (HCC). We have investigated whether active transcription of the AFP gene may explain raised serum AFP concentrations in patients with HCC and hepatoblastoma by assaying human tumour and non-neoplastic tissue by molecular hybridization for the presence of mRNA encoding AFP. Ten operative HCC and six autopsy HCC specimens, two HCC cell lines, and one hepatoblastoma specimen were examined. Total cellular RNA and poly-(A)+ RNA were extracted and AFP mRNA sequences sought by dot-blot and Northern blot hybridisation to a human cDNA AFP probe. Cellular AFP was localised by avidin-biotin staining. AFP mRNA was detected in 8/10 operative specimens, as well as PLC/PRF/5 nude mouse tumours. Weaker hybridization was detected in 4/6 autopsy specimens. Signals of comparable intensity to that in operative tumours were detected in non-neoplastic tissue of 6 patients. AFP mRNA from nude mouse tumours migrated as a 20S discrete band on agarose gel electrophoresis, whereas a more complex hybridization pattern was evident in human tumours. Positive cytoplasmic immuno-staining for AFP was observed in 4 tumours and 2 corresponding non-neoplastic specimens and in a HCC cell line. In non-neoplastic liver, AFP was localised in cells that appeared dysplastic. Thus steady-state levels of AFP mRNA are detectable in human HCC tissue and surrounding non-neoplastic liver. These findings may prove pertinent to an understanding of the genetic expression of AFP in malignant hepatocytes, and the sequence of events leading to uncontrolled cellular proliferation.

Iron-binding proteins and risk of cancer in Taiwan

The relationship of serum ferritin and transferrin levels to risk of cancer was examined in a population of 21,513 Chinese male government workers in Taiwan who have been followed prospectively since 1975. On the basis of a previous study in the Solomon Islands, increased ferritin and decreased transferrin levels were predicted for those men who developed cancer. The results were consistent with the prediction. The mean serum ferritin was higher at the start of the study in 192 men who had died of cancer or who had developed primary hepatocellular carcinoma (PHC) as of July 1983, as compared to their controls. The mean serum transferrin level was lower in men who had died of cancers other than PHC. The estimate of relative risk of cancer death for a man with 200 ng ferritin/ml and 200 mg transferrin/dl, as compared to a man with levels of 20 ng/ml and 400 mg/dl, respectively, is 2.9. These serum iron-binding protein levels are at the extremes of the "normal" range. Men who subsequently died of cancer had lower hemoglobin, lower hematocrit, lower albumin, and higher globulin levels at the start of the study than did the controls. These results are consistent with the hypothesis that increased iron stores increase the risk of cancer. However, direct assessment of iron stores prior to disease was not possible, and the same constellation of findings may be consistent with other explanations.

Surgical treatment of 109 patients with symptomatic and asymptomatic hepatocellular carcinoma

A total of 109 patients with histologically proved hepatocellular carcinoma (HCC) have undergone hepatic resection during the 56-month period from October 1978 to May 1983. There were two sources of patients: those with symptomatic HCC (n = 47) and those with asymptomatic HCC (n = 62). A family tendency of HCC was noted in 11% of the patients studied. The percent of positive hepatitis B surface antigen (HBsAg) was 87%, and the serum alpha-fetoprotein was less than 20 ng/ml in 30% in the group with symptoms. The operative mortality rate was 3% and the hospital mortality rate was also 3%. The postoperative course was complicated with pleural effusion in 10%, bile leakage in 4%, subphrenic abscess in 4%, and upper gastrointestinal bleeding caused by gastritis in 1% of the patients. The actual survival rate for the 103 cases was 84% for 350 days and 28% for 1400 days. However, in the group with asymptomatic HCC with an average tumor size of 3.35 +/- 1.49 cm in diameter, the rate was 92% for 350 days and 44% for 1400 days. In the group with symptomatic HCC with an average tumor size of 10.6 +/- 5.1 cm in diameter, the rate was 76% for 350 days and 8% for 1400 days. The survival rate of the group with asymptomatic HCC was far better than that of the group with symptoms (p less than 0.05). In analysis of factors that might affect the patient's survival, only second or third operations (p less than 0.05), typical gross findings of tumor appearance (p less than 0.05), and an adequate margin were closely related (p less than 0.001). Neither the tumor size, the status of accompanying liver cirrhosis, the tumor location, nor the patient's sex and age affected the patient's survival (all p greater than 0.05).

HBsAG and HBeAG markers among pregnant women in Manila, Philippines

The sera of 5,684 pregnant women were tested for HBsAG and 432 (7.6%) were found positive. Positive HBsAG sera were then tested for the e antigen and of 413 tested, 115 or 27.8% were positive. The over-all prevalence rate of e antigen was 2.03%. All women were asymptomatic. Six of 13 HBsAG-HBeAg-positive mothers delivered infants who became HBsAg-positive within two years of age for a rate of 46%. The findings support earlier studies on the importance of the e antigen as an index of perinatal transmission. Also, they support evidence of unusually high rates of transmission among Asian ethnic groups.

Prognostic histologic features of resected small hepatocellular carcinoma (HCC) in Taiwan. A comparison with resected large HCC

The morphologic features and their prognostic significance were analyzed in 83 surgically resected hepatocellular carcinomas (HCC): 44 of them were of less than or equal to 5 cm in diameter and 39 were larger. This study demonstrated a high prevalence of tumor capsule in both small and large HCCs, 86.4% and 84.6%, respectively. In small HCC, the capsule formation was significantly higher in the liver with cirrhosis (96.9%, or 31/32) than without (58.3%, or 7/12) (P less than 0.003). In both small and large HCCs, the most important histologic parameter influencing the tumor recurrence was the liver invasion. In the small but not in the large HCC, the invasion through the capsule also correlated well with recurrence (P less than 0.05). None of the 19 patients whose HCC were confined by a tumor capsule and did not invade the liver, had a recurrence during the 10 months or longer follow-up period. The significantly more favorable outcome of smaller HCC was related to the lower frequencies of liver invasion (P less than 0.001), portal vein involvement (P less than 0.01), and satellite formation (P less than 0.01). Tumor recurrence did not correlate with the tumor grading, presence of clear cells, liver cell dysplasia, or host inflammatory response. The HBsAg positivity in tumor cells was significantly higher in small (40.9%, or 18/44) than in large HCC (10.3%, or 4/39), suggestive of a gradual loss of the cytoplasmic expression of HBsAg in the tumor cells during the growth of HCC.

Prognostic histologic features of resected small hepatocellular carcinoma (HCC) in Taiwan. A comparison with resected large HCC

The morphologic features and their prognostic significance were analyzed in 83 surgically resected hepatocellular carcinomas (HCC): 44 of them were of less than or equal to 5 cm in diameter and 39 were larger. This study demonstrated a high prevalence of tumor capsule in both small and large HCCs, 86.4% and 84.6%, respectively. In small HCC, the capsule formation was significantly higher in the liver with cirrhosis (96.9%, or 31/32) than without (58.3%, or 7/12) (P less than 0.003). In both small and large HCCs, the most important histologic parameter influencing the tumor recurrence was the liver invasion. In the small but not in the large HCC, the invasion through the capsule also correlated well with recurrence (P less than 0.05). None of the 19 patients whose HCC were confined by a tumor capsule and did not invade the liver, had a recurrence during the 10 months or longer follow-up period. The significantly more favorable outcome of smaller HCC was related to the lower frequencies of liver invasion (P less than 0.001), portal vein involvement (P less than 0.01), and satellite formation (P less than 0.01). Tumor recurrence did not correlate with the tumor grading, presence of clear cells, liver cell dysplasia, or host inflammatory response. The HBsAg positivity in tumor cells was significantly higher in small (40.9%, or 18/44) than in large HCC (10.3%, or 4/39), suggestive of a gradual loss of the cytoplasmic expression of HBsAg in the tumor cells during the growth of HCC.

Antibody response to Epstein-Barr-virus-specific DNase in 13 patients with nasopharyngeal carcinoma in Taiwan: a retrospective study

Serum samples obtained from 13 individuals who were found to have a previous history of or to be suffering from nasopharyngeal carcinoma (NPC) were examined for the presence of antibody to Epstein-Barr virus (EBV) DNase activity. Significant to high levels of antibody to EBV DNase activity were detected in most serum samples obtained from four patients prior to the diagnosis of NPC. The samples from the other nine patients showed variable levels of antibody. The majority of the samples collected at the remission stage of the disease, especially those from long-term survivors, contained little or no antibody to the DNase activity. Data presented here suggest that antibody to EBV DNase activity may be a useful marker for the early diagnosis as well as the prognosis of NPC.

Perinatal transmission of hepatitis B virus: role of maternal HBeAg and anti-HBc IgM

The development of hepatitis B surface antigen (HBsAg) carrier states in newborns of HBsAg-positive mothers was correlated to the presence of anti-HBc IgM and HBeAg in the mothers. There was a positive correlation between infection of the newborn and the presence of HBeAg, as shown previously, but no correlation with anti-HBc IgM.

Immunogenicity of hepatitis B virus vaccine (Heptavax-B)--response of healthy adults

We vaccinated 30 healthy adults who were susceptible to hepatitis B virus with 20 mug of Merck Sharp & Dohme vaccine at zero, one and six months and measured their antibody (anti-HBs) response weekly for four weeks and monthly for at least seven months. A month following the first dose 40% had antibodies and 90% were positive for anti-HBs a month following the second dose. The third dose raised the response rate to 93.3% but its major effect was to substantially raise the titer of virtually all of the vaccinees. Two persons had no antibody response to vaccination and four others were hyporesponders. No complications or significant side effects were observed.

Immunogenicity of HBV vaccine in healthy Chinese children

The immunogenic response of healthy Chinese children to three different doses of hepatitis B virus (HBV) vaccine was compared. One hundred susceptible children received two doses of 10, 20 or 40 micrograms a month apart. A month following the first dose 33% of all the children had antibodies. The response rate rose to 78% a month later and 99% four months later. Ninety percent of the 100 children still had antibody at 12 months after vaccination was initiated. The response rate, antibody levels and persistence of antibody were directly related to the dose of vaccine and inversely to the age of children. No adverse reactions were observed.

Prevention of perinatally transmitted hepatitis B virus infections with hepatitis B immune globulin and hepatitis B vaccine

A randomised blind controlled trial of hepatitis B immune globulin (HBIG) plus hepatitis B vaccine for the prevention of the perinatally transmitted HBsAg carrier state was conducted in Taipei. Infants of e-antigen-positive HBsAg carrier mothers were given HBIG immediately after birth, and then one of three schedules of vaccination. There was no difference in efficacy between the three schedules; the combined efficacy was 94%, compared with that of HBIG alone (71%) or of vaccination alone (75%). Persistent HBs antigenaemia developed in only 9 (6%) of the 159 infants receiving prophylaxis, but in 88% of the controls. Antibodies developed in all those who did not become antigenaemic and presumably will provide long-term protection from hepatitis B virus infection. HBIG should be given as soon as possible after birth and need not be given again if the infant is subsequently vaccinated. With HBIG coverage from birth, the timing of the start of vaccination does not seem to be of importance within the first month of life, but to maximise compliance and minimise costs hepatitis B vaccination should be initiated during the confinement.

Low prevalence of rheumatoid arthritis in Chinese. Prevalence survey in a rural community

A prevalence survey for arthritis among the general adult population of a rural island off the coast of China revealed a prevalence of rheumatoid arthritis (RA) of no more than 0.3% compared with 1.0% among Americans in the National Health Examination Survey (NHES). The frequency of clinical ankylosing spondylitis (AS) (0.2%) appears to be higher than expected, although limited data are available for comparison. No clinically unusual features of these diseases were recognized.

Monitoring of T lymphocytes before and after surgical removal of hepatic tumors

Monitoring of peripheral T lymphocyte level after surgical removal of hepatic tumors has been periodically carried out in thirty patients to observe the relation between T lymphocytes suppression and presence of tumor. Rosette formation with neuraminidase treated sheep erythrocytes has been considered as T lymphocytes. Twenty-two cases were considered as free from residual hepatic tumor after operation and eight cases were diagnosed as residual or recurrent hepatic tumor postoperatively. The result indicated that significant difference in T lymphocyte level has been observed between preoperative level (59.3 +/- 14.0%) and postoperative 4th week level (69.4 +/- 5.5%) 5th week level (69.5 +/- 8.3%) (both p less than 0.01) in group of complete removal of hepatic tumor. While in group of residual or recurrent hepatic tumor, the average T lymphocytes stayed at rather low level throughout the postoperative course. From another point of view, when we compare the T lymphocyte level between the two groups, significant difference has been observed either at postoperative 4th week (69.4 +/- 5.5% vs 57.8 +/- 12.7%) or at postoperative 5th week (69.5 +/- 8.3% vs 53.8 +/- 11.6%) (both p less than 0.01). Accordingly we believed that there is a close relation between depressed T lymphocyte level and presence of hepatic tumor.

Immunogenicity of hepatitis B virus vaccine in healthy Chinese neonates

The immunogenicity of hepatitis B virus vaccine was studied in 38 Chinese neonates, 23 of whom were healthy and susceptible and 15 of whom had passive serum antibody to hepatitis B surface antigen (anti-HBs). Initially, each infant received two 20-micrograms doses of vaccine by the intramuscular route, with a one-month interval between doses. No adverse reactions occurred, and all susceptible neonates had a brisk antibody response that was comparable to that in older infants and children and superior to that in adults. The first dose of vaccine stimulated the production of anti-HBs within one month in 48% of the neonates. Anti-HBs was detectable in the serum of 91% of the vaccinees at the age of three months--that is, two months after the second dose. By the age of six months, 96% of vaccinees had detectable anti-HBs in their serum. All vaccinees developed anti-HBs after a third dose was administered at the age of seven months. High levels of anti-HBs were sustained after vaccination in infants who initially had passive antibodies.

Efficacy of hepatitis B immune globulin for prevention of perinatal transmission of the hepatitis B virus carrier state: final report of a randomized double-blind, placebo-controlled trial

A randomized double-blind, placebo-controlled efficacy trial of hepatitis B immune globulin (HBIG) for prevention of the mother-to-infant transmitted HBsAg carrier state was conducted in Taiwan where the carrier rate in the general population is 15 to 20%. HBIG was given immediately after birth to infants of e antigen positive HBsAg carrier mothers, and all infants were followed for at least 15 months. Among 61 placebo recipients, the carrier rate was 92%; compared with 26% among 57 infants who received 0.5 ml HBIG at birth, 3 months, and 6 months, and 54% among 67 infants who received a single 1.0 ml dose of HBIG at birth only. Efficacy was 71 and 42%, respectively, for the two treatment schedules. The most common response of HBIG-treated infants was passive-active immunization which was 27% in the single-dose group and 61% in the three-dose group. Some of the infants who became carriers were probably infected as HBIG protection waned, and we expect that higher efficacy can be achieved by hepatitis B vaccine in conjunction with HBIG.

Incidence of hepatitis among students at a university in Taiwan

The incidence of hepatitis in a general open population of Asian adults was estimated for the first time in this study. A group of 2445 students were first tested when they enrolled at National Taiwan University in 1977; approximately one third were susceptible to hepatitis A and another third to hepatitis B. Most of these students (92%) were retested shortly before their graduation in 1981 to determine the frequency of serologic conversions and clinical hepatitis which had occurred in the 3 1/2 years since they had entered the university. Among 704 susceptible to hepatitis A, 12 (1.7%) had undergone serologic conversions, 33% of which were associated with clinical illness diagnosed as hepatitis. Among 738 susceptible to hepatitis B, 39 (5.3%) had undergone serologic conversions, 12.8% of which were associated with clinical hepatitis. The annual incidence of new infections was 0.5% for hepatitis A and 1.5% for hepatitis B. An additional eight students among the 17 who had clinical hepatitis had no associated conversion of hepatitis A or hepatitis B markers, and were considered to have non-A, non-B hepatitis. No factors could be identified which were predictive of hepatitis risk. No difference in incidence was observed according to sex, type of residence, place of food consumption, or receipt of acupuncture or blood transfusion. Among the 39 students who experienced hepatitis B infections while at the university, there were 2.7% who became hepatitis B surface antigen (HBsAg) carriers. Thus the carrier frequency following hepatitis B infection among Chinese adults is the same or lower than that among Caucasian adults.

Postnatal infectivity of hepatitis B surface antigen-carrier mothers

The incidence of hepatitis B virus (HBV) infections during the second and third year of life was determined for 105 children whose mothers were carriers of hepatitis B surface antigen. Children were given hepatitis B immune globulin (HBIG) at birth and in some instances three and six months later to protect against HBV infection. Passive antibodies from the dose of HBIG disappeared in three to four months. Infants negative for HBV markers at 12 months were selected and subsequent infections were analyzed in relation to the e system markers in the mother. Over an average of 17.5 months of follow-up, 38.1% of the infants became infected, an annual incidence rate of 26.0%. The rate was highest for children whose mothers were positive for hepatitis B e antigen (HBeAg) (57.1%), moderate for those whose mothers were negative for both HBeAg and antibody to HBeAg (anti-HBe) (20.4%), and lowest for those whose mothers were positive for anti-HBe (11.3%).

Incidence of hepatitis A virus infection in children in Taipei, Taiwan

To understand the prevalence and incidence of hepatitis A virus (HAV) infection in Chinese children in Taiwan, we determined the age-specific prevalence of hepatitis A antibodies (anti-HAV) in 823 children, ranging from birth (cord blood) to 19 years of age. The frequency of anti-HAV rose with increasing age with three different slopes, probably reflecting different age-specific incidences: lowest under 4 years of age, intermediate between 4 and 10 years, and highest above 10 years. We obtained follow-up specimens on 618 of the preschool children under 6 years of age. 11 (1.9%) of the 573 without antibodies had seroconversions after an average of 1.9 years of follow-up. The annual incidence was 1.0% and increased with advancing age of the children after infancy. None of the 11 seroconversions had clinical hepatitis. Among the 28 children 1-24 months of age who had antibodies, only 1 was positive on follow-up, reflecting loss of passively acquired maternal antibody in most children.

Geographic distribution of HBsAg carriers in China

We tested by radioimmunoassay the sera of 22,707 male Chinese government employees in Taiwan for HBsAg and found 15.2% to be positive. Almost all were confirmed as carriers by follow-up testing 1 year later. This paper presents HBsAg positivity rates of these men according to the province of China from which they originated, and compares the rates with published provincial mortality rates for primary hepatocellular carcinoma. Moderate variation in carrier rates between provinces was observed with high prevalence in men from provinces south of the Yangtze River. There was positive correlation between HBsAg prevalence and primary hepatocellular carcinoma incidence giving further support to the possibility of a causal relationship.

Incidence of hepatitis B virus infections in preschool children in Taiwan

To determine the incidence of infections with hepatitis B virus (HBV) among Chinese preschool children, 1,510 children (mean age, 29 months) were tested for HBV markers; 15.9% were infected with HBV (7.8% positive for hepatitis B surface antigen [HBsAg] and 8.1% positive for antibody to HBsAg) and 84.1% were susceptible when the children were enrolled in the study. The average length of follow-up was 2.1 years among 1,110 children. Among the 924 susceptible children who were followed up, 10.6% had seroconversions for HBV markers, none of which was associated with clinical illness; the annual incidence of HBV infections was 5.0%. Among the 98 children who experienced HBV infections during the study, 23% became HBsAg carriers, and HBsAg persistence was age-related, with most carriers being among the youngest children infected. In contrast, among the children with HBV markers at the time of enrollment, 118 (49.2%) were HBsAg-positive and 86% were still positive on follow-up. The incidence of HBV infections was significantly associated with the frequency of previous injections.

HBeAg and anti-HBe detection by radioimmunoassay: correlation with vertical transmission of hepatitis B virus in Taiwan

A sensitive radioimmunoassay technique was used to detect hepatitis B e antigen (HBeAg). A strong correlation was found between HBeAg positivity of the serum of hepatitis B surface antigen (HBsAg) carrier women in Taiwan and the subsequent development of surface antigenemia in their babies. All babies who became chronic HBsAg carriers were born to HBeAg positive women, maternal HBeAg positivity being a better prior indication of chronic antigenemia developing in the baby than the HBsAg titer in the mother's serum.

Excess mortality and influenza surveillance in Taiwan

Excess mortality has proven to be a useful epidemiologic tool for influenza surveillance in the temperate zone. A retrospective analysis of the epidemiology of influenza in Taiwan was undertaken to explore the usefulness of this technique in the tropical--subtropical zone. Excess mortality similar to that observed during influenza epidemics in the temperate zone was noted during periods of previously recognized influenza epidemics in Taiwan. For the very young and the elderly excess mortality was observed to be even higher than in the temperate zone. Virus isolations, increased school absenteeism, and high clinical attack rates were also noted during influenza epidemics. Use of these epidemiologic techniques in Taiwan proved to be a useful approach to describe the impact of influenza.