Biomedical subjects
Publications and source records attributed to F N Judson.
An evaluation of a tuberculosis screening program for food handlers revealed an unexpectedly low cost ($45) per identifiable candidate for preventive treatment (324 of 6,090 individuals screened). Four new active cases of tuberculosis were identified, and a risk/benefit analysis projected a potential reduction of 19.4 new active cases over the subsequent ten-year period.
Of 3,816 homosexual men examined in five sexually transmitted disease clinics in the United States, 6.1% had hepatitis B surface antigen, 52.4% had antibody to hepatitis B surface antigen, and 3.0% of the men who had no other indicator of infection with hepatitis B virus (HBV) had antibody to hepatitis B core antigen. The rate of seropositivity for HBV indicated by the presence of one or more of these serologic markers was 61.5%; seropositivity was significantly related to the duration of regular homosexual activity and to the number of nonsteady male sexual contacts in the four months before the patients were interviewed. Anal-genital intercourse, oral-anal intercourse, and rectal douching were significantly related to evidence of HBV infection, but oral-oral contact and oral-genital contact were not. Trauma to the rectal mucosa is a feature common to the practices that were significantly related to seropositivity for HBV.
To ascertain why active and passive oral-anal and genital anal intercourse correlate strongly with hepatitis B virus (HBV) infection in homosexual men, we studied 22 men with HBV infection for the presence of hepatitis B surface antigen (HBsAg) in gingival and anorectal mucosa, feces, and semen. Thirteen of 22 (59%) patients had asymptomatic rectal mucosal lesions consisting of punctate bleeding points. Seventy-seven percent of swabbed specimens from lesions, 62% from feces, 59% from rectal mucosa, and 50% from anal canal mucosa contained HBsAg. Sera diluted serially and tested for HBsAg by radioimmunoassay showed that men with serum titers of 105 or greater were more likely to have HBsAg in specimens from lesions (p = 0.034), feces (p = 0.032), and normal mucosa (p = 0.001) than men with titers under 10 5. Asymptomatic rectal bleeding is frequent in homosexual men with persistent HBV infection. Rectal mucosa, feces, and anal canal mucosa become contaminated with HBsAg, creating a setting for de facto parenteral transmission when there is contact with oral or urethral mucosa.
A randomized, double-blind, vaccine/placebo trial of the Merck 20-micrograms hepatitis B virus (HBV) vaccine was done among 1402 homosexual men attending venereal disease clinics in five American cities. Vaccination was followed by only minimal side effects. Two doses of vaccine induced antibody in 80% of vaccine recipients. A booster dose 6 months after the first dose induced antibody in 85% of recipients and markedly increased the proportion of recipients who produced high antibody titers. The incidence of HBV events was markedly less in the vaccine recipients compared to that in the placebo recipients (p = 0.0004). Between month 3 and 15 after the first dose, 56 more significant HBV events (hepatitis, or hepatitis B surface antigen positive, or both) occurred in the placebo group while only 11 occurred in the vaccine group. Ten of the 11 HBV events in the vaccine recipients occurred in hypo- or nonresponders to the vaccine. This vaccine appears to be safe, immunogenic, and efficacious in preventing infection with hepatitis B virus.
In a randomized, double-blind, dose-ranging study, single oral doses of rosoxacin were used to treat 126 patients with uncomplicated genital or anorectal gonorrhea. Neisseria gonorrhoeae was eradicated from 5 (28%) of 18 men treated with 100 mg, compared with 101 (94%) of 108 men and women treated with 200 mg, 300 mg, or 400 mg (P less than 0.001). Susceptibility to rosoxacin was determined for 6 pretreatment gonococcal isolates from these patients and for 194 stored clinical isolates; 296 (98.7%) of these 300 isolates, including 10 strains of penicillinase-producing N. gonorrhaeae, required a minimal inhibitory concentration of less than or equal to 0.062 microgram/ml. Urethral or cervical infection with Chlamydia trachomatis coexisted with gonococcal infection in 14 (22%) of 63 patients and persisted in 7 of 10 patients treated with rosoxacin. Postgonococcal urethritis developed in 11 (34%) of 32 men who were monitored for 12 to 30 days. Sixty-four subjects (51%) developed transient dizziness, drowsiness, altered visual perceptions, or other symptoms suggestive of central nervous system dysfunction after treatment with rosoxacin, but these symptoms were not clearly dose related. Rosoxacin in doses of greater than or equal to 200 mg appears to be effective for single-dose treatment of uncomplicated gonorrhea, but further studies of its possible central nervous system toxicity are indicated.
This study compared prevalence rates of most common sexually transmitted diseases (STD) in heterosexual and homosexual men who made respectively 12,201 and 5324 visits to an STD clinic over 18 months. Overall, homosexual men were significantly (p < 0.001) more likely than heterosexual men to have gonorrhea (30.31% vs. 19.83%), early syphilis (1.08% vs. 0.34%) and anal warts (2.90% vs. 0.26%) but less likely to have nongonococcal urethritis (NGU) (14.63% vs. 36.40%, p < 0.001), herpes genitalis (0.93% vs. 3.65%, p < 0.001), pediculosis pubis (4.30% vs. 5.35%, p < 0.005), scabies (0.42% vs. 0.76%, p < 0.02), and genital warts (1.68% vs. 6.69%, p < 0.001). In most cases the differences in rates remained significant (p < 0.05) when corrected for age and race. It is speculated that higher rates of gonorrhea and syphilis result from a larger mean number of sexual contacts, more potential sites of infection, and more hidden and asymptomatic disease, while the lower rates of the other STD result from a lesser susceptibility of anal mucosa to the causative agent(s) of NGU, herpes genitalis, and venereal warts or from a lack of pubic apposition (pediculosis pubis).
To reduce the cost of detecting gonorrhea, we studied the effect on diagnostic sensitivity of combining two culture specimens on the same plate of modified Thayer-Martin medium, using specimens from 7,787 women seen consecutively in the clinic. There was no significant difference (P greater than 0.05) between one cervical and one anal-canal specimen placed on separate plates (C,A) and these two specimens combined but spaced apart on a single plate (C/A), or between two cervical specimens combined but spaced apart on the same plate (C/C) and C/A. Therefore, C/C, C/A, and C,A have equivalent diagnostic sensitivities. C/A detected 5.68% more women with gonorrhea than did a single cervical culture (C) (P less than 0.001). If C/A were to replace C,A for culture specimens from women seen in venereal disease clinics and C for specimens taken and cultured outside of venereal disease, gonorrhea control programs in the United States could realize savings in excess of $2.5 million per year.
Urban air pollution, when sufficiently severe, can cause death in humans; these deaths occur preponderantly among those with increased susceptibility. Pollution--carbon monoxide and oxidants in particular--is capable of aggravating preexisting chronic heart and lung diseases. Pollution and tobacco (especially cigarette) smoke act synergistically in a causative role in chronic bronchitis and in an aggravating role in emphysema. Susceptibility to the effects of urban air pollution varies widely, with the most susceptible being fetuses, the newborn, the elderly, the infirm, those with chronic heart and lung diseases, and those who smoke. The carbon monoxide standards for sea level are probably too lenient for an altitude of 1,500 m and above. Using a broad definition of health, which takes into account concepts such as quality of life and social and mental well-being, few metropolitan residents would deny that their health is compromised by air that is malodorous, that irritates mucous membranes, and that obscures beautiful scenery.
A one-year epidemiologic study of penile venereal edema in a clinic for sexually transmitted diseases identified 25 cases, a rate of 1.7 per 1,000 male visits. Twenty-four patients had coexisting urethritis (36%), infected penile lesions (36%), or both (24%). Men with penile edema were significantly more likely to have gonococcal urethritis (40%), genital scabies (12%), genital herpes (12%), and inguinal adenopathy (52%) than men without penile edema. Penile edema is self-limited and seems to resolve along with the underlying penile disease. Lymphatic involvement may be the final common factor.
In a study of women with anogenital gonorrhoea who had undergone hysterectomy, the sensitivities of urethral, vaginal, and anal canal cultures were 88.9, 55.7, and 40.7% respectively in specimens from 27 woemn. To obtain the greatest sensitivity, however, we recommend that specimens from all three sites should be cultured routinely. After the raising effects of trichomoniasis and menstrual blood on the pH values have been allowed for, the vaginal pH of 74 women in the study group and of 137 healthy controls was similar.
To evaluate the cost-effectiveness of a routine rescreening (RS) culture several weeks after treatment for gonorrhea, as well as the specific efforts to ensure return visits, we followed 438 consecutive patients, 347 men and 91 women. Return visit compliance rates were 70 per cent for a test-of-cure culture, 27 per cent for a six-week RS, and 15 per cent at 12 weeks. The program detected seven cases of gonorrhea at $796 per case. In our clinic, RS is not a cost-effective way go control gonorrhea.
For men with urethral discharge, a simple gram stained smear is 98% sensitive and over 99% specific in detecting gonococcal infection when compared to a single Thayer-Martin culture. The smear is less than 50% sensitive in asymptomatic urethritis. Neither Fluorescent antibody nor various serologic tests offer any diagnostic advantages over smears and/or cultures and they are not cost-effective. Treatment of gonococcal urethritis may be successfully accomplished with a variety of antibiotic regimens. Tetracycline hydrochloride (500 mg four times a day for 5 days) is highly effective, inexpensive, and is active against Chlamydia trachomatis; post gonococcal urethritis (PGU) is therefore uncommon. Aqueous Procaine Penicillin G (4.8 million units IM with 1 g of probenecid) has become the standard in the United States but suffers from higher cost, the need for refrigeration, occasional alarming toxic procaine reactions, and a high incidence of PGU. Spectinomycin 2 g IM remains expensive but is the regimen of choice for treatment failures and for Neisseria gonorrhoeae that produce penicillinase (PPNG). Other antibiotics active against PPNG are cotrimoxozole, cefoxitin, and cefuroxime. PNNG have now been reported from 27 countries throughout the world, but have attained significant prevalence in only a few areas of East Asia and West Africa. Because gonococcal patterns of antibiotic resistance are constantly changing, each region of the world needs to monitor treatment results and maintain some surveillance over sensitivity to antibiotics.
Three cases of an unusual Pseudomonas skin infection acquired from a health spa whirlpool were reported, and an epidemiologic survey showed 17 additional cases. This dermatosis is characterized by the abrupt onset of urticarial papules and superficial and deep papulopustules that spare only the head and neck and occur eight to 48 hours after using the whirlpool. Cultures from one patient's pustules and from the spa whirlpool environment were positive for P aeruginosa, serotype O-11. The condition cleared in all but one patient, without treatment, within seven to ten days. This patient continues to have recurrent follicular pustules three months after exposure. Samples from whirlpools at six other selected establishments were also positive for P aeruginosa.
Among monosexual men anal infection with Neisseria meningitidis was more prevalent (15 of 731 men) than expected and significantly more prevalent than urethral infection with N. meningitidis (three of 669 men, P less than 0.01). Anal infection was also significantly more prevalent among homosexual men than among heterosexual women (two of 1,197 women, P less than 0.001). These differences in rates of prevalence may be best explained by a preference of meningococci for anal mucosa and by the common homosexual practice of oral-anal sexual contact. Serogrouping of the 17 anal and three urethral isolates revealed a broad representation of serogroups often found in meningococcal pharyngeal carriage in the community. Of 14 patients who returned for a test-of-cure culture within seven days of treatment with an antibiotic regimen recommended for anogenital gonococcal infection, each was culture-negative for N. meningitidis. Minor and symptoms in three men and profuse urethral discharges in two men resolved with treatment.
In the United States statistics on sexually transmitted diseases (STDs), other than gonorrhoea and syphilis, are meagre. In this study the relative and seasonal incidences of most STDs in an American clinic where 34,938 patient visits were recorded over a two-year period (1975-76) are assessed. Gonorrhoea was the most common STD in male and female patients combined (18%), while nongonococcal urethritis (NGU) was most common in men (23%), and vaginitis (trichomonal 7.5%, yeast 7.1%, and non-specific 7.1%) was the most common in women. A significantly higher incidence of NGU occurred in Caucasian (63%) than in black (42%) men (P less than 0.005). No other STD was diagnosed in more than 5% of patients, and 31% had normal findings on clinical examination and investigation, and could be described as the 'worried well'. Two or more STDs co-existed in 4.2% of patients. In 1976 the incidence of genital herpes and scabies decreased in contrast to other STDs and total patient visits, which increased. A seasonal peak in late summer and early autumn was observed for most STDs. These observations indicate the importance of a comprehensive approach when attempting to compile accurate statistics on selected epidemiological aspects of sexually transmitted diseases.
The fluorescent treponemal antibody absorption (FTA-ABS) test, an excellent confirmatory treponemal test, has been used increasingly for syphilis screening and case detection. To evaluate its performance as an initial test, we did Venereal Disease Research Laboratory (VDRL) slide and FTA-ABS tests on 1,043 patients suspected of having syphilis. When retested in both a local and a reference laboratory, sera from 226 patients with borderline or reactive results demonstrated interlaboratory consistency for the VDRL but not the FTA-ABS. Borderline FTA-ABS results correlated poorly with the diagnosis of syphilis in both laboratories; a reactive FTA-ABS test correlated well only in the reference laboratory. Performance of the test appeared to be diminished by its use in a low-prevalence population and by seemingly minor alterations in the test procedure at the local laboratory.
In 202 men with urethral gonorrhoea (176 symptomatic and 26 asymptomatic) who had modified Thayer-Martin cultures taken before and within five minutes after micturition there was complete agreement between results of the two cultures. Micturition did, however, temporarily eliminate the discharge in 100 (56.8%) and make interpretation of Gram-stained smears more laborious.
During 33 screening sessions in Denver gay steambaths, 48 of 419 (11.5 per cent) men were found to have asymptomatic gonorrhea and six (1.4 per cent) had early latent syphilis. Questionnaires were administered to 160 men who reported a mean of 7.9 different male sex contacts per month. Female sex contacts were also reported by 30 per cent. The respondents used the baths an average of 2.2 times per month, having an average of 2.7 different sex contacts per visit, 84 per cent of whom were not previously known to the respondent. Gay steambaths are productive locations for detecting asymptomatic gonorrhea and syphilis.