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Low-fat diet impedes the development of actinic keratosis
46
Notes
We report a 23 year-old man with Crohn’s disease of the colon and renal insufficiency. Renal biopsy showed chronic interstitial nephritis with local periglomerulo fibrosis and granuloma formation. There was no evidence of any other disease which could be implicated in the granuloma formation. A protocolectomy was performed. Four years, later, renal insufficiency was remarkably improved; a new renal biopsy showed mesangial prominence, loss, and atrophy of renal tubules and local interstitial fibrosis; no granulomas were found. Granulomas in the kidneys are generally uncommon. In the presented case, no other cause of granuloma formation could be documented. In addition, the beneficial effect of procytocolectomy on renal function and the disappearance of granuloma provide further evidence that kidney granulomas were a manifestation of Crohn’s diseases. AJ Archimandritis (3) University of Athens, Athens I I5 27, Greece
(3)
Br Med .I
like relationship to the risk of perinatal transmission. Independent of clinical stage, higher maternal antibody titers to peptides corresponding to the V3 region of gp120 and the immunodominant domain of gp41 were correlated with a higher risk of perinatal transmission. In a logistic regression model, the predicted risk of perinatal transmission for asymptomatic women whose antibody titers to V3 and gp41 were lowest was 0.02, while it was 0.88 for symptomatic women whose antibody titers to V3 and TMSPl8 were highest (see table). Although the actual timing of perinatal transmission and factors that influence it are not well understood, drug and immune therapy trials to interrupt transmission are underway. While the association we have observed may give new insight to our understanding of the actual mechanisms of perinatal transmission, measurement of the antibody response in infected women with or without clinical symptoms may also provide a powerful tool for identifying women who would most benefit from such interventions. M Lallemant (4) Harvard school of Public Health, Boston. MA 02115, USA
1993;307:540-1 (4)
Perinatal transmission of HIV-l men
in African wo-
Perinatal transmission of HIV-1 is the primary source of pediatric AIDS. At present, about two-thirds of all HIV-l-infected women live in Africa. From 1987 to 1991, a prospective study was conducted in Brazzaville, Congo, to evaluate the overall risk of perinatal transmission of HIV-1 and determine the factors involved. Enrolled in the study were 118 infants born, to HIVl-positive mothers and 208 control infants born to HIVl-negative mothers. The overall transmission rate was 40.4% (95% CI: 30.7-50.1%), considered as HIV-infected infants who met the criteria of HIV-attributable death and those who were seropositive at 15 months. Women showing symptoms during pregnancy had an increased risk of transmitting the virus to their infant. Moreover, maternal antibody titers to peptides corresponding to the third variable domain of envelope glycoprotein 120 (V3) and antibody titers to the immunodominant domain of gp41 had a dose response-
Maternal -. Klsk bactor
Titers to V3 Titers to gp41 Symptoms
by
Values each
Lancrt 1994;343:1001-5
taken variable
I l:lOO-1:500-l:lOOO-I:2000 5 1:10-l :50-l: loo-1:500 O-l
Low-fat diet impedes the development of actinit keratosis Actinic keratoses are sun-induced pre-malignant lesions which occur with great frequency in persons 60 years of age and older. If left untreated, these lesions can eventually turn malignant. Due to its precancerous nature and great frequency, actinic keratosis may be considered the most important manifestation of sun-induced skin damage. Animal studies have shown that a high-fat intake increased the likelihood of skin cancer after exposure to ultraviolet radiation. In addition, changing to a low-fat diet after exposure reduced the incidence of skin cancer. However, little was known about the effect of diet on tumors. including actinic keratosis, in humans. This issue was examined in a study in which 76 middle-aged patients with nonmelanoma skin cancer were randomly assigned to one of two groups: a control group whose
Adjusted OR
1.89 2.08 6.00
95% Cl
1.12-3.19 1.10-4.10 1.48-24.65
P value
0.021 0.038 0.015
47
Notes
diets were not changed, or a dietary intervention group which was instructed to alter their diets so that no more than 20% of their total caloric intake was consumed as fat. The control group consumed 36-40% of their caloric intake as fat during the 24-month study. All patients were examined at 4-month intervals by their dermatologists, who were unaware of their dietary regimen, for the occurrence of new actinic keratoses. On average, patients in the control group were diagnosed with new keratoses four times as often as those in the low-fat group. The mean cumulative number of new actinic keratoses per patient in the control group for the 24-month period was three times that of the low-fat diet intervention group. Overall, patients in the control group (high fat) where estimated to be at 4.7 times greater risk of having one or more actinic keratoses during the 24-month period than similar patients in the low-fat diet group. Based on these findings, reduced incidence of actinic keratosis may now be seen as another important health benefit attributed to a low-fat diet. HS Black (5) Veterans
Affairs
Medical
(5) N Engl J Med
Prediction
Center and Baylor College of Medicine, Houston, Texas 77030, USA
1994:330:1271-5
of diabetes
Identifying patients who will subsequently develop diabetes is the first step towards disease prevention. Antibodies and T-lymphocyte changes in the peripheral blood are found in patients with insulin-dependent diabetes and can be detected in twins of patients before they develop diabetes, though their predictive value in the general population is low. To define the pattern of cellular and humoral changes in the period before the onset of insulin-dependent diabetes, a prospective study was performed of nondiabetic identical twins of patients with the disease. The percentage of activated T-lymphocytes expressing the HLA DR antigen and the presence of antibodies to islet cells and insulin were measured in 25 nondiabetic twins. By the end of 10 years, a combination of cellular and humoral immune changes was detected in all 10 of the prediabetic twins but in only one of the 15 nondiabetic twins. Furthermore in the prediabetic twins, this combination of changes persisted and was found in most samples, while in the twins who did not develop diabetes, the changes did not persist. Thus, a combination of activated T-lymphocytes and either islet cell or insulin auto-antibodies predicts diabetes. This suggests a strategy for more accurately identifying patients in the general population
who will subsequently develop diabetes. Moreover, it suggests that the immune changes are programmed at an early state following exposure to some environmental event and are not the consequence of intermittent environmental exposures during the prediabetic period. RDG Leslie (6) St Bartholomew’s
(6)
Br
Med
Hospital,
London
ECIA
7BE,
UK
J 1994;308:1063-8
Apolipoproteins
and ischaemic heart disease
This prospective study of 21,520 British men aged 35 64 years examined the relationship between mortality from ischaemic heart disease (IHD) and serum concentrations of apolipoproteins and lipids together with other risk factors. Serum apo B (the protein component of low density lipoprotein [LDL] cholesterol) was the apolipoprotein most strongly associated with IHD risk. A decrease in apo B level of 10% was associated with an estimated 22% lower risk of IHD (95% confidence interval 17-27%, p < O.OOl), emphasizing the benefits of lowering LDL cholesterol in preventing IHD. As a screening test, however, measurement of apo B alone detected only 17% of all IHD deaths at the cost of a 5% false-positive rate. The performance of screening for IHD by measuring apo B alone or in conjunction with apo AI and apo (a) is too poor to discriminate usefully between individuals in recommending drug therapy or life-style change for some and not others. We conclude that it is not advisable to screen for IHD by measuring any combination of cholesterol, apo B, apo AI, apo (a) and the other risk factors considered. The primary prevention of IHD through low-ering the distributions of these risk factors in the population should be the priority. Wolfson
(7) Lancet
Institute
of Preventive London ECIM
N Wald (7) Medicine, 6BQ, UK
1994;343:75-9
Coinfection with hepatitis C virus and hepatitis B virus The longitudinally collected data and stored sera from the Transfusion-transmitted Viruses Study in the 1970s have been reevaluated by presently available laboratory methods for acute hepatitis B and C virus infections. Despite routine HBsAg donor screening, 15 (1%) of 1533 recipients became HBV-infected following trans-
Notes
We report a 23 year-old man with Crohn’s disease of the colon and renal insufficiency. Renal biopsy showed chronic interstitial nephritis with local periglomerulo fibrosis and granuloma formation. There was no evidence of any other disease which could be implicated in the granuloma formation. A protocolectomy was performed. Four years, later, renal insufficiency was remarkably improved; a new renal biopsy showed mesangial prominence, loss, and atrophy of renal tubules and local interstitial fibrosis; no granulomas were found. Granulomas in the kidneys are generally uncommon. In the presented case, no other cause of granuloma formation could be documented. In addition, the beneficial effect of procytocolectomy on renal function and the disappearance of granuloma provide further evidence that kidney granulomas were a manifestation of Crohn’s diseases. AJ Archimandritis (3) University of Athens, Athens I I5 27, Greece
(3)
Br Med .I
like relationship to the risk of perinatal transmission. Independent of clinical stage, higher maternal antibody titers to peptides corresponding to the V3 region of gp120 and the immunodominant domain of gp41 were correlated with a higher risk of perinatal transmission. In a logistic regression model, the predicted risk of perinatal transmission for asymptomatic women whose antibody titers to V3 and gp41 were lowest was 0.02, while it was 0.88 for symptomatic women whose antibody titers to V3 and TMSPl8 were highest (see table). Although the actual timing of perinatal transmission and factors that influence it are not well understood, drug and immune therapy trials to interrupt transmission are underway. While the association we have observed may give new insight to our understanding of the actual mechanisms of perinatal transmission, measurement of the antibody response in infected women with or without clinical symptoms may also provide a powerful tool for identifying women who would most benefit from such interventions. M Lallemant (4) Harvard school of Public Health, Boston. MA 02115, USA
1993;307:540-1 (4)
Perinatal transmission of HIV-l men
in African wo-
Perinatal transmission of HIV-1 is the primary source of pediatric AIDS. At present, about two-thirds of all HIV-l-infected women live in Africa. From 1987 to 1991, a prospective study was conducted in Brazzaville, Congo, to evaluate the overall risk of perinatal transmission of HIV-1 and determine the factors involved. Enrolled in the study were 118 infants born, to HIVl-positive mothers and 208 control infants born to HIVl-negative mothers. The overall transmission rate was 40.4% (95% CI: 30.7-50.1%), considered as HIV-infected infants who met the criteria of HIV-attributable death and those who were seropositive at 15 months. Women showing symptoms during pregnancy had an increased risk of transmitting the virus to their infant. Moreover, maternal antibody titers to peptides corresponding to the third variable domain of envelope glycoprotein 120 (V3) and antibody titers to the immunodominant domain of gp41 had a dose response-
Maternal -. Klsk bactor
Titers to V3 Titers to gp41 Symptoms
by
Values each
Lancrt 1994;343:1001-5
taken variable
I l:lOO-1:500-l:lOOO-I:2000 5 1:10-l :50-l: loo-1:500 O-l
Low-fat diet impedes the development of actinit keratosis Actinic keratoses are sun-induced pre-malignant lesions which occur with great frequency in persons 60 years of age and older. If left untreated, these lesions can eventually turn malignant. Due to its precancerous nature and great frequency, actinic keratosis may be considered the most important manifestation of sun-induced skin damage. Animal studies have shown that a high-fat intake increased the likelihood of skin cancer after exposure to ultraviolet radiation. In addition, changing to a low-fat diet after exposure reduced the incidence of skin cancer. However, little was known about the effect of diet on tumors. including actinic keratosis, in humans. This issue was examined in a study in which 76 middle-aged patients with nonmelanoma skin cancer were randomly assigned to one of two groups: a control group whose
Adjusted OR
1.89 2.08 6.00
95% Cl
1.12-3.19 1.10-4.10 1.48-24.65
P value
0.021 0.038 0.015
47
Notes
diets were not changed, or a dietary intervention group which was instructed to alter their diets so that no more than 20% of their total caloric intake was consumed as fat. The control group consumed 36-40% of their caloric intake as fat during the 24-month study. All patients were examined at 4-month intervals by their dermatologists, who were unaware of their dietary regimen, for the occurrence of new actinic keratoses. On average, patients in the control group were diagnosed with new keratoses four times as often as those in the low-fat group. The mean cumulative number of new actinic keratoses per patient in the control group for the 24-month period was three times that of the low-fat diet intervention group. Overall, patients in the control group (high fat) where estimated to be at 4.7 times greater risk of having one or more actinic keratoses during the 24-month period than similar patients in the low-fat diet group. Based on these findings, reduced incidence of actinic keratosis may now be seen as another important health benefit attributed to a low-fat diet. HS Black (5) Veterans
Affairs
Medical
(5) N Engl J Med
Prediction
Center and Baylor College of Medicine, Houston, Texas 77030, USA
1994:330:1271-5
of diabetes
Identifying patients who will subsequently develop diabetes is the first step towards disease prevention. Antibodies and T-lymphocyte changes in the peripheral blood are found in patients with insulin-dependent diabetes and can be detected in twins of patients before they develop diabetes, though their predictive value in the general population is low. To define the pattern of cellular and humoral changes in the period before the onset of insulin-dependent diabetes, a prospective study was performed of nondiabetic identical twins of patients with the disease. The percentage of activated T-lymphocytes expressing the HLA DR antigen and the presence of antibodies to islet cells and insulin were measured in 25 nondiabetic twins. By the end of 10 years, a combination of cellular and humoral immune changes was detected in all 10 of the prediabetic twins but in only one of the 15 nondiabetic twins. Furthermore in the prediabetic twins, this combination of changes persisted and was found in most samples, while in the twins who did not develop diabetes, the changes did not persist. Thus, a combination of activated T-lymphocytes and either islet cell or insulin auto-antibodies predicts diabetes. This suggests a strategy for more accurately identifying patients in the general population
who will subsequently develop diabetes. Moreover, it suggests that the immune changes are programmed at an early state following exposure to some environmental event and are not the consequence of intermittent environmental exposures during the prediabetic period. RDG Leslie (6) St Bartholomew’s
(6)
Br
Med
Hospital,
London
ECIA
7BE,
UK
J 1994;308:1063-8
Apolipoproteins
and ischaemic heart disease
This prospective study of 21,520 British men aged 35 64 years examined the relationship between mortality from ischaemic heart disease (IHD) and serum concentrations of apolipoproteins and lipids together with other risk factors. Serum apo B (the protein component of low density lipoprotein [LDL] cholesterol) was the apolipoprotein most strongly associated with IHD risk. A decrease in apo B level of 10% was associated with an estimated 22% lower risk of IHD (95% confidence interval 17-27%, p < O.OOl), emphasizing the benefits of lowering LDL cholesterol in preventing IHD. As a screening test, however, measurement of apo B alone detected only 17% of all IHD deaths at the cost of a 5% false-positive rate. The performance of screening for IHD by measuring apo B alone or in conjunction with apo AI and apo (a) is too poor to discriminate usefully between individuals in recommending drug therapy or life-style change for some and not others. We conclude that it is not advisable to screen for IHD by measuring any combination of cholesterol, apo B, apo AI, apo (a) and the other risk factors considered. The primary prevention of IHD through low-ering the distributions of these risk factors in the population should be the priority. Wolfson
(7) Lancet
Institute
of Preventive London ECIM
N Wald (7) Medicine, 6BQ, UK
1994;343:75-9
Coinfection with hepatitis C virus and hepatitis B virus The longitudinally collected data and stored sera from the Transfusion-transmitted Viruses Study in the 1970s have been reevaluated by presently available laboratory methods for acute hepatitis B and C virus infections. Despite routine HBsAg donor screening, 15 (1%) of 1533 recipients became HBV-infected following trans-