Racial/ethnic differences in health-related quality of life among female breast cancer survivors: cross-sectional findings from the Medical Expenditure Panel Survey.

OBJECTIVES: Breast cancer survivors have reported worse health-related quality of life (HRQoL) outcomes on some subscales when compared with members of the general population. However, the increased attention to breast cancer survivorship should have improved the HRQoL of these survivors. Our aim was to examine whether physical and mental component scores (PCS-12 and MCS-12) using the Short Form (SF-12) questionnaire were different for racial/ethnic minorities, specifically for Black and Hispanic women relative to White women. Furthermore, we stratified the data by age group to evaluate these racial/ethnic differences in HRQoL of breast cancer survivors. STUDY DESIGN: Cross-sectional study. METHODS: Pooled cross-sectional analyses using data from the Medical Expenditure Panel Survey between 2008 and 2016 were conducted. Pooled ordinary least squares (OLS) regression was used to examine the racial/ethnic differences in PCS-12 and MCS-12 scores of breast cancer survivors. Furthermore, stratified analyses by age group were conducted to evaluate racial/ethnic differences in HRQoL by the age of breast cancer survivors. RESULTS: After adjusting for confounders, there was no association between race/ethnicity and PCS-12 scores. However, Hispanic breast cancer survivors had statistically significantly lower MCS-12 scores (by 1.9 points [95% confidence interval {CI}: -3.53 to -0.37]) when compared with White breast cancer survivors. For PCS-12, after stratifying by age, the adjusted analyses showed no significant differences in PCS-12 scores when White female breast cancer survivors were compared with the other racial/ethnic categories. On the other hand, Black female survivors aged <50 years had 4.3 points (95% CI: 0.46-8.13) higher MCS-12 scores when compared with their White counterparts, while Hispanic breast cancer survivors aged <50 years had 3.1 points (95% CI: -0.40-6.69) higher MCS-12 scores relative to White women. Furthermore, among female breast cancer survivors aged ≥50 years, Hispanic women had 3.2 points (95% CI: -4.98 to -1.40) lower MCS-12 scores than White women. CONCLUSION: Our study generated findings showing the racial/ethnic differences in HRQoL of breast cancer survivors and presented results stratified by age group. These findings provide the much-needed rationale for targeted and racial/ethnic-specific HRQoL improvement strategies among breast cancer survivors.

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.

Improving the diagnosis of pulmonary tuberculosis in HIV-infected individuals in Ho Chi Minh City, Viet Nam.

SETTING: District 6, An Hoa Clinic in Ho Chi Minh City (HCMC), Viet Nam. OBJECTIVE: To evaluate the performance of various algorithms in tuberculosis (TB) screening and diagnosis in a human immunodeficiency virus (HIV) infected population in HCMC, Viet Nam. DESIGN: A cross-sectional study of 397 consecutive HIV-infected patients seeking care at the An Hoa Clinic from August 2009 to June 2010. Data on participant demographics, clinical status, chest radiography (CXR) and laboratory results were collected. A multiple logistic regression model was developed to assess the association of covariates and pulmonary TB (PTB). RESULTS: The prevalence of sputum culture-confirmed PTB, acid-fast bacilli (AFB) positive TB, and multidrugresistant TB among the 397 HIV-infected patients was respectively 7%, 2%, and 0.3%. Adjusted odds ratios for low CD4+ cell count, positive sputum smear, and CXR to positive sputum culture were respectively 3.17, 32.04 and 4.28. Clinical findings alone had poor sensitivity, but combining CD4+ cell count, AFB sputum smear and CXR had a more accurate diagnostic performance. CONCLUSION: Results suggest that symptom screening had poor clinical performance, and support the routine use of sputum culture to improve the detection of TB disease in HIV-infected individuals in Viet Nam. However, when routine sputum culture is not available, an algorithm combining CD4+ cell count, AFB sputum smear and CXR is recommended for diagnosing PTB.

Interrupted time series analysis of vancomycin compared to cefuroxime for surgical prophylaxis in patients undergoing cardiac surgery.

The increased incidence of methicillin-resistant Staphylococcus aureus (MRSA), the emergence of community-acquired MRSA, and the continued high incidence of methicillin-resistant Staphylococcus epidermidis have required that certain institutions choose vancomycin for surgical prophylaxis. However, the data supporting the use of vancomycin for surgical prophylaxis are controversial. The purpose of this project was to assess the effect of the change from cefuroxime to vancomycin for surgical site infection (SSI) rates in patients undergoing coronary artery bypass graft (CABG) surgery. The monthly rates of SSIs from 2001 to 2005 were analyzed before and after a change from cefuroxime to vancomycin antibiotic prophylaxis in patients undergoing CABG by using an interrupted time series analysis. Patients who underwent cardiac valve replacement surgery and who had received vancomycin during the entire study period were used as a comparator group. A total of 6,465 patients underwent CABG surgery (n = 4,239) or valve replacement surgery (n = 2,226) during the study period. On average, the monthly SSI incidence rate in patients undergoing CABG surgery decreased by 2.1 cases per 100 surgeries after the switch from cefuroxime to vancomycin (P = 0.042) when patients undergoing valve replacement were used as a comparator group. The change in SSI rates was associated with a decrease in the incidence of infections caused by coagulase-negative Staphylococcus and MRSA isolates, with little change in the incidence of SSIs due to other gram-positive organisms or gram-negative organisms. In institutions with a high incidence of methicillin-resistant Staphylococcus species, this study provides evidence for the clinical efficacy of vancomycin prophylaxis for the prevention of postoperative SSIs in patients undergoing CABG surgery.

Tuberculosis infection in drug users: interferon-gamma release assay performance.

SETTING: An inner city neighborhood in Houston, Texas, known for a high rate of drug use. OBJECTIVE: To determine the prevalence of latent tuberculosis infection (LTBI) using the QuantiFERON-TB Gold (QFT-G) test, the TSPOT.TB test and the tuberculin skin test (TST) in drug users and to evaluate the performance of the QFT-G and TSPOT.TB tests vs. the TST. DESIGN: Cross-sectional study. Bivariate and multivariate logistic regression analyses were used to determine risks associated with each test outcome. RESULTS: The prevalence of LTBI in 119 drug users studied was 28% by TST and 34% by QFT-G and T-SPOT.TB. Kappa statistics indicated fair to moderate concordance between QFT-G and TSPOT.TB vs. TST. About one-fifth of the population that tested negative with TST was positive with either QFT-G or T-SPOT.TB. On multivariate analysis, the likelihood of testing QFT-positive or T-SPOT.TB-positive increased by 8% and 6%, respectively, for every year of age; TST positivity was associated with smoking crack at home; being Caucasian or having a history of alcohol use was positively associated with a positive T-SPOT.TB test. CONCLUSION: Interferon-gamma release assays (IGRAs) are superior to the TST in drug users with a higher prevalence of LTBI. Future studies need to assess the predictive value of IGRAs on the progression from LTBI to active TB in high-risk populations.

Significance of anti-hbc in the absence of other hepatitis B markers in a college-aged population.

A study of 291 college students in the Houston (Tex., USA) area was performed to determine the relationship between alanine aminotransferase (ALT) level and antibodies to the hepatitis B virus (HBV) core antigen (anti-HBc) in the absence of other HBV markers (referred to as isolated anti-HBc). Participants were drawn from three groups: those positive only for anti-HBc (cases), those positive for hepatitis B surface antigen, a marker of acute/chronic HBV infection (control group 1), and those with no previous exposure to the HBV (control group 2). There were no significant differences between the groups in percentages of subjects with an elevated ALT level. The mean ALT level from active HBV infections was highest with HBV-negative controls having the lowest mean ALT concentration (p = 0.06), but no significant differences were found between ALT levels of those with isolated anti-HBc and either control group. This study may further aid in determining the presence of any liver damage when testing positive only for the antibodies to HBc.

Epidemiology and molecular characterization of co-circulating influenza A/H3N2 virus variants in children: Houston, Texas, 1997-8.

Co-circulating variants of influenza A/H3N2 viruses in children were studied in Houston, Texas between October 1997 and March 1998 to assess the effects of a new variant strain on the severity of clinical illness. Influenza A virus was isolated from the nasal wash or nasal aspirate specimens collected from children at two tertiary care hospitals, and 271 isolates were available for variant-specific subtyping using RT-PCR and restriction fragment length polymorphism (RFLP) analysis. We classified 124 (46%) influenza viruses as A/H3N2/Wuhan/359/95-like and 137 (50%) as A/H3N2/Sydney/05/97-like. Ten (4%) virus isolates could not be classified. Ill contacts in the household were reported more frequently in patients infected with A/Sydney-like viruses than in those infected with A/Wuhan-like viruses (85% vs. 71%, respectively, P=0.02). There were no differences in other demographic variables among children infected with these strains. This study found no increase in illness severity in children infected with a newly emerging strain.

Acceptance of syphilis screening among residents of high-STD-risk Houston communities.

The purpose of this study was to assess the rate of acceptance of street-intercept syphilis screening and to identify barriers to screening among residents of 2 Houston communities with high rates of syphilis. Each of 691 people who participated in a street-intercept survey about syphilis was offered a free syphilis test immediately after completion of the survey. Acceptors of screening had blood drawn at the site of the interview, and blood samples were tested by rapid plasma reagin (RPR) and a confirmatory microhaemagglutination-Treponema pallidum (MHA-TP) for those with a positive antibody reaction on the RPR. On-street syphilis screening was accepted by 26% of the sample. The most common reason for refusal was not wanting to have blood drawn (19.5%). Among those screened for syphilis (n=148), seroprevalence was 19%, with 33% of women testing positive and 10% of men. The results of this study point to a need for increased case-finding, standard screening recommendations, and interventions targeting specific barriers to syphilis screening.

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.

Erythema elevatum diutinum mimicking extensive keloids; quiz 386.

GOAL: To describe a case of erythema elevatum diutinum (EED) that clinically mimicked extensive keloids. OBJECTIVES: Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Describe the clinical presentation and lesion appearance in EED. 2. Discuss the electron microscopic and laboratory findings of EED. 3. Outline treatment options for EED. CME: This article has been peer reviewed and approved by Michael Fisher, MD, Professor of Medicine, Albert Einstein College of Medicine. REVIEW DATE: April 2001. This activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education through the joint sponsorship of Albert Einstein College of Medicine and Quadrant HealthCom, Inc. The Albert Einstein College of Medicine is accredited by the ACCME to provide continuing medical education for physicians. Albert Einstein College of Medicine designates this educational activity for a maximum of 1.0 hour in category 1 credit toward the AMA Physician's Recognition Award. Each physician should claim only those hours of credit that he/she actually spent in the educational activity. This activity has been planned and produced in accordance with ACCME Essentials.

Functional regulation of immunoproteasomes and transporter associated with antigen processing.

The central event in the cellular immune response to invading pathogens is the presentation of non-self antigenic peptides by major histocompatibility complex (MHC) class I molecules to cytotoxic T lymphocytes (CTLs). As peptide binding and transport proteins, MHC class I molecules have evolved distinct biochemical and cellular strategies for acquiring antigenic peptides, providing CTLs an extracellular representation of the intracellular antigen content. Whereas efficient generation of MHC class I binding peptides depends on the intracellular, immunoproteasome-mediated proteolysis machinery, translocation of peptides into the lumen of the endoplasmic reticulum requires the endoplasmic reticulum-resident, adenosine 5'-triphosphate (ATP) binding cassette transporter associated with antigen processing (TAP). Here we show, for the first time, that immunoproteasomes, TAP complexes, and MHC class I molecules are physically associated, providing an effective means of transporting MHC class I binding peptides from their sites of generation into the lumen of the endoplasmic reticulum for loading onto MHC class I molecules. In this review, we assess the current understanding of the functional regulation of immunoproteasomes and transporter associated with antigen processing.

Prevalence of sexually transmitted infections and associated risk factors among populations of drug abusers.

A cross-sectional survey was conducted of sexually transmitted diseases (STDs) and risky behaviors among 407 drug abusers in treatment facilities in 1998. Infections with human immunodeficiency virus (HIV), hepatitis B virus (HBV), hepatitis C virus (HCV), herpes simplex virus type 2 (HSV-2), and syphilis were detected by testing serum antibody levels; chlamydia and gonorrhea were detected by testing nucleic acid levels in urine. Logistic regression analysis was performed to measure associations. Prevalences of antibodies were as follows: to HSV-2, 44.4%; to HCV, 35.1%; to HBV, 29.5%; to HIV, 2.7%. The prevalence of syphilis was 3.4%; of chlamydia, 3.7%; and of gonorrhea, 1.7%. Of the 407 subjects, approximately 62% had markers for 1 of the STDs. HIV infection was associated with African American race, use of smokable freebase (crack) cocaine, and STD history. HBV infection was associated with age >30 years, injecting drugs, needle sharing, a history of treatment for drug abuse, and African American race. HCV infection was associated with an age >30 years, injecting drugs, and needle sharing, and HSV-2 infection with an age >30 years, female sex, and African American race. Syphilis was associated with a history of STDs. High prevalences of STDs among drug abusers indicate the need for integration of STD screening and treatment into drug treatment programs.

A direct interaction between EXT proteins and glycosyltransferases is defective in hereditary multiple exostoses.

Hereditary multiple exostoses (HME) is an autosomal dominant condition in which bony outgrowths occur from the juxtaepiphyseal regions of the long bones. In a few percent of cases these exostoses undergo malignant transformation to chondrosarcomas. HME results from mutations in one of two homologous genes, EXT1 and EXT2. These are members of a new gene family that is conserved from Caenorhabditis elegans to higher vertebrates. In humans this family comprises five genes which are most conserved at their C-termini, but they do not contain any discernible functional motifs and their function(s) is unclear. Indirect evidence suggests that EXT proteins are involved in glycosaminoglycan synthesis, act as tumor suppressors and affect hedgehog signaling. One recent study has also reported that these proteins co-purify with glycosyltransferase (GlcA and GlcNAc transferase) activity and on that basis it has been postulated that they are themselves glycosyl-transferases. We performed two-hybrid screens with a fragment of EXT2 from the region that is most highly conserved in the gene family and identified two interacting proteins: the tumor necrosis factor type 1 associated protein and a novel UDP-GalNAc:poly-peptide N -acetylgalactosaminyltransferase. Significantly, both these interactions were abrogated by a disease-causing EXT mutation, indicating that they are important in the etiology of HME. The EXT2-GalNAc-T5 interaction provides the first direct physical link between EXT proteins and known components of glycosamino-glycan synthesis.

Prevalence of antibody to Trypanosoma cruzi in pregnant Hispanic women in Houston.

We assessed the seroprevalence of antibodies to Trypanosoma cruzi among pregnant Hispanic women in Houston. Sera from 2,107 Hispanic and 1,658 non-Hispanic subjects were tested by ELISA for the presence of antibodies to T. cruzi. Twenty-two (0.6%) of 3,765 subjects had sera that were reactive. Seroreactivity was confirmed by hemagglutination assay. Eleven subjects had reactive sera, giving a confirmed seroprevalence of 0.3% (95% CI, 0-1%). Nine sera from Hispanic and two from non-Hispanic women were positive by hemagglutination assay, for a prevalence of 0.4% and 0.1%, respectively, during pregnancy. On the basis of these seroreactivity data, transplacental transmission of T. cruzi could occur in the continental United States. Screening for antibodies to T. cruzi during pregnancy would provide the potential for early intervention in congenital Chagas' disease.

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.

The epidemiology of syphilis in the waning years of an epidemic: Houston, Texas, 1991-1997.

BACKGROUND: National and local syphilis rates have fallen since 1990. Accurate epidemiologic information about the distribution of syphilis during the waning years of an epidemic are important to health care organizations so that they can specifically target screening and intervention programs. GOALS: To describe the epidemiology of syphilis in Houston, Texas, from 1991 through 1997. STUDY DESIGN: Descriptive evaluation of morbidity surveillance data from the Houston Department of Health and Human Services. RESULTS: Between 1991 and 1997, rates for syphilis fell 61%. Rates for primary and secondary syphilis fell 90% among men and women in all race/ethnicity groups; early latent rates fell 81% among blacks, 57% among Hispanics, and 50% among whites. Late latent rates were stable among blacks and whites and increased among Hispanics. The proportion of total cases identified as late latent disease increased from 16% in 1991 to 63% in 1997. Congenital syphilis rates have remained at approximately 2 per 1,000 live births since 1993. CONCLUSION: Syphilis continues to be a problem in Houston. The medical community and HIV/STD prevention programs need to be vigilant in actively screening high-risk individuals to identify syphilis at earlier stages of the disease and to prevent congenital syphilis.

Sexual behaviour, STDs and drug use in a crack house population.

We aimed to investigate the prevalence of ulcerative sexually transmissible diseases (STDs) and hepatitis in crack users. We interviewed 435 crack users on site in crack houses in Houston, Texas and took blood for laboratory analysis. There was evidence of syphilis infection in 13%, herpes simplex virus-2 (HSV-2) in 61%, HIV in 12%, hepatitis B in 52%, and hepatitis C in 41% of cases. On DSM-III-R criteria, 12% were crack abusers and 84% crack dependent: over half reported previous treatment. Forty per cent reported also injecting. Sexual behaviour indicated a mean of 2.4 partners in the past month for men, 3.7 for women. Sexual behaviour was largely vaginal, although women also reported more than twice the level of oral sex of men. Significant multivariate predictors for HIV and hepatitis B and C were previous reported STD and injecting drug use (including sharing needles), while female gender for syphilis and HSV-2, and additionally condom use for HSV-2, were significant risks. These data confirm high rates of STDs in a crack house population as inferred from previous clinic-based and community studies, and the link between STDs, injecting and HIV. The high rates of STDs found should lead to considering STDs and substance abuse to be dual diagnoses in crack users and the integration of STD diagnosis and treatment into crack outreach and treatment programmes.

HIV-related malignancies: community-based study using linkage of cancer registry and HIV registry data.

For people immunosuppressed by human immunodeficiency virus (HIV), we expect an increase in cancer incidence similar to that documented in transplant patients. We examined the cancer spectrum in an HIV-infected cohort, specifically malignancies not currently associated with acquired immunodeficiency syndrome (AIDS), in relation to the general population. Cancer incidence data for residents of Harris County, Texas, diagnosed between 1975 and 1994, were linked to HIV/AIDS registry data by Soundex code and date of birth to identify malignancies in an HIV-infected cohort of 14,986 persons. Incidence of cancer in this cohort was compared to the general population by standardized incidence ratio (SIR) analysis. From the HIV-infected cohort, 2289 persons (15%) were identified as having one or more malignancies, with 97% occurring in males. The linkage alone identified 29.5% of the malignancies, of which only 28.7% were diagnosed in males. Adjusting for age, HIV-infected men and women had incidences of cancer that were 16.7 [95% confidence interval (CI) 16.1-17.3] and 2.9 (95% CI 2.3-3.7) times that expected for the general population of Harris County, Texas. Besides Kaposi's sarcoma, non-Hodgkin's lymphoma, cervix cancer and brain lymphoma, non-AIDS related malignancies of Hodgkin's lymphoma, non-melanotic skin cancer in males and colon cancer in females, exhibited significant SIRs of 5.6 (95% CI 3.6-8.4), 6.9 (95% CI 4.8-9.5) and 4.0 (95% CI 1.1-10.2). Increased incidences of lung, prostate and breast malignancies were not seen in this HIV cohort. Persons infected with HIV appear to be at increased risk for the non-AIDS related malignancies, Hodgkin's lymphoma, non-melanotic skin cancer in males and colon cancer in females.

Conservation of function and primary structure in the BRCA1-associated RING domain (BARD1) protein.

The BRCA1 gene encodes a tumor suppressor that has been implicated in hereditary forms of breast and ovarian cancer. During S phase of the cell cycle, BRCA1 polypeptides are found in discrete nuclear bodies ('BRCA1 nuclear dots') together with HsRad51, a human homolog of the E. coli recA protein, and BARD1, a protein that interacts with BRCA1 to form a stable heterodimer. BARD1 is structurally similar to BRCA1 in that both molecules harbor an amino-terminal RING domain and two carboxy-terminal BRCT domains. Here we describe the amino acid sequence and expression pattern of murine Bard1. A comparison of the mouse and human sequences reveals that the recognizable protein motifs of BARD1 are well conserved, including the RING domain, the three tandem ankyrin repeats, and, to a lesser extent, the two BRCT domains. However, the remaining sequences of BARD1 display a markedly lower degree of phylogenetic conservation, comparable to those reported for BRCA1 and BRCA2. Moreover, murine Bard1 retains the ability to associate in vivo with BRCA1, and its expression pattern in adult mice mirrors that of Brca1, with elevated levels of RNA transcripts found in the testes and spleen. These data suggest that BRCA1 and BARD1 have co-evolved to participate in a common pathway of tumor suppression.