Nancy Mueller’s research while affiliated with Massachusetts Department of Public Health and other places

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Publications (130)


Elevated Serum Levels of sCD30 and IL6 and Detectable IL10 Precede Classical Hodgkin Lymphoma Diagnosis
  • Article

March 2017

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24 Reads

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25 Citations

Cancer Epidemiology Biomarkers & Prevention

Lynn I. Levin

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Brenda M. Birmann

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Background: We investigated whether an immune system environment characterized by elevated serum levels of B-cell activation molecules was associated with the subsequent development of classical Hodgkin lymphoma (cHL). Methods: We measured serum levels of B cell stimulatory cytokines, interleukin (IL)-6 and IL-10, soluble CD30 (sCD30) and total IgE prior to cHL diagnosis in 103 cases and 206 matched controls with archived specimens in the DoD Department of Defense Serum Repository. Results: Pre-diagnosis serum sCD30 and IL-6 levels had strong positive associations with risk of a cHL diagnosis 0-1 year prior to diagnosis (sCD30 odds ratio [OR] =5.5, 95% confidence interval [CI] = 3.4-9.0; IL-6 OR = 4.6, 95% CI = 2.9-7.5) and >1 year to 2 years pre-cHL diagnosis (sCD30 OR =3.3, 95% CI = 1.6-6.7; IL-6 OR = 2.9, 95% CI = 1.3-6.5). We observed similar, albeit not consistently significant positive associations, over four or more years preceding diagnosis. We did not observe a clear association with IgE levels. Of note, detectable IL-10 levels were significantly associated with Epstein-Barr virus (EBV)-positive cHL cases compared with EBV-negative cases. Conclusions: In this prospective analysis, elevated sCD30 and IL-6 levels and detectable IL-10 preceded cHL diagnosis. Impact: The associations of these cytokines with cHL risk may reflect the production of these molecules by proliferating nascent cHL tumor cells, or by immune cells responding to their presence, prior to clinical detection. The stable elevation in cHL risk, four or more years pre-diagnosis, also suggests that a B cell-stimulatory immune system milieu precedes, and may promote, lymphomagenesis.


Dietary Pattern and Risk of Hodgkin Lymphoma in a Population-Based Case-Control Study

July 2015

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45 Reads

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20 Citations

American Journal of Epidemiology

Classic Hodgkin lymphoma (cHL) has few known modifiable risk factors, and the relationship between diet and cHL risk is unclear. We performed the first investigation of an association between dietary pattern and cHL risk in 435 cHL cases and 563 population-based controls from Massachusetts and Connecticut (1997-2000) who completed baseline diet questionnaires. We identified 4 major dietary patterns ("vegetable," "high meat," "fruit/low-fat dairy," "desserts/sweets") using principal components analysis. We computed multivariable odds ratios and 95% confidence intervals for associations of dietary pattern score (quartiles) with younger-adult (age <50 years), older-adult (age ≥50 years), and overall cHL risk. Secondary analyses examined associations by histological subtype and tumor Epstein-Barr virus (EBV) status. A diet high in desserts/sweets was associated with younger-adult (odds ratio(quartile 4 vs. quartile 1) = 1.60, 95% confidence interval: 1.05, 2.45; Ptrend = 0.008) and EBV-negative, younger-adult (odds ratio = 2.11, 95% confidence interval: 1.31, 3.41; Ptrend = 0.007) cHL risk. A high meat diet was associated with older-adult (odds ratio = 3.34, 95% confidence interval: 1.02, 10.91; Ptrend = 0.04) and EBV-negative, older-adult (odds ratio = 4.64, 95% confidence interval: 1.03, 20.86; Ptrend = 0.04) cHL risk. Other dietary patterns were not clearly associated with cHL. We report the first evidence for a role of dietary pattern in cHL etiology. Diets featuring high intake of meat or desserts and sweets may increase cHL risk. Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2015. This work is written by (a) US Government employee(s) and is in the public domain in the US.


Serum IgA to Epstein-Barr virus Early Antigen-Diffuse identifies Hodgkin's Lymphoma

September 2014

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35 Reads

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4 Citations

Journal of Medical Virology

Hodgkin's lymphoma is associated with immune dysregulation. Immune impairment often results in aberrant immune responses and lytic reactivation of ubiquitous Herpesviruses, such as Epstein-Barr virus (EBV) in mucosal tissues. Accordingly, the specificity of IgA to EBV early lytic antigens, which are important for reactivation, was evaluated to determine Hodgkin's lymphoma-specific sero-reactive patterns. Sera from 42 patients with Hodgkin's lymphoma were compared to sera from 17 patients with infectious mononucleosis (IM), another EBV-related condition that often presents in a similar manner; and to sera from 15 healthy EBV-seropositive subjects. Flow cytometry analysis demonstrated that like IM sera, most Hodgkin's lymphoma sera contained IgA that labeled cells expressing EBV early lytic antigens whereas healthy EBV-seropositive sera did not. Further evaluation to distinguish Hodgkin's lymphoma from IM showed that IgA in most Hodgkin's lymphoma, irrespective of the presence of EBV in primary tumors, detected only modified forms of EBV lytic Early Antigen-Diffuse (EA-D) while IM sera detected the un-modified form as well, further supporting the presence of immune dysregulation in Hodgkin's lymphoma patients. This IgA pattern distinguished Hodgkin's lymphoma from IM sera with a sensitivity of 92.9%, specificity 100%, positive predictive value 100%, and negative predictive value 85%. Our findings lay the groundwork for additional scientific and clinical investigation, particularly into the potential for developing Hodgkin's lymphoma-associated diagnostic and prognostic biomarkers. J. Med. Virol. © 2013 Wiley Periodicals, Inc.


Table 1. Selected characteristics of EBV + Hodgkin lymphoma cases, EBV -Hodgkin 
Table 3 . Association of elevated EBV antibody titer and low antibody ratio of EBNA-1/EBNA-2 with Hodgkin lymphoma risk overall and EBV + and EBV -Hodgkin lymphoma
Table 4 . Multivariate analyses of elevated EBV antibody titer and low ratio of EBNA-1/EBNA-2 and risk of EBV + vs EBV -Hodgkin
Atypical prediagnosis Epstein-Barr virus serology restricted to EBV-positive Hodgkin lymphoma
  • Article
  • Full-text available

September 2012

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146 Reads

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56 Citations

Blood

An altered anti-Epstein-Barr virus (EBV) serologic profile preceding diagnosis is associated with an increased risk of Hodgkin lymphoma. It is unknown whether this atypical pattern predicts Hodgkin lymphoma risk further subdivided by determination of EBV in tumor cells. A nested case-control study of 128 incident Hodgkin lymphoma cases and 368 matched controls from active-duty military personnel with archived serum in the US Department of Defense Serum Repository was conducted to determine whether a panel of anti-EBV antibody titers differed in EBV(+) and EBV(-) Hodgkin lymphoma. Among 40 EBV(+) Hodgkin lymphoma cases and matched controls, statistically significant increased risks were associated with elevated anti-EBV VCA IgG antibody titers, (relative risk [RR] = 3.1; 95% confidence interval [CI], 1.1-8.7), and an anti-EBNA-1/anti-EBNA-2 antibody ratio ≤ 1.0 versus > 1.0 (RR = 4.7; 95% CI, 1.6-13.8). In contrast, no significant associations were found among 88 EBV(-) Hodgkin lymphoma cases relative to their matched controls. In case-case analysis, EBV-positive disease was significantly associated with a low anti-EBNA-1/anti-EBNA-2 antibody ratio. This distinctive serologic response to EBV latent antigens, indicative of immune dysfunction in other clinical settings, is associated with an increased risk of developing EBV(+) but not EBV(-) Hodgkin lymphoma.

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Antibody titers against EBNA1 and EBNA2 in relation to Hodgkin lymphoma and history of infectious mononucleosis

June 2012

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47 Reads

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22 Citations

A role for Epstein Barr virus (EBV) in Hodgkin lymphoma (HL) pathogenesis is supported by the detection of EBV genome in about one-third of HL cases, but is not well defined. We previously reported that an elevated prediagnosis antibody titer against EBV nuclear antigens (EBNA) was the strongest serologic predictor of subsequent HL. For the present analysis, we measured antibody levels against EBNA components EBNA1 and EBNA2 and computed their titer ratio (anti-EBNA1:2) in serum samples from HL cases and healthy siblings. We undertook this analysis to examine whether titer patterns atypical of well-resolved EBV infection, such as an anti-EBNA1:2 ratio ≤ 1.0, simply reflect history of infectious mononucleosis (IM), an HL risk factor, or independently predict HL risk. Participants were selected from a previous population-based case-control study according to their history of IM. We identified 55 EBV-seropositive persons with a history of IM (IM+; 33 HL cases, 22 siblings) and frequency-matched a comparison series of 173 IM history-negative, EBV-seropositive subjects on HL status, gender, age and year of blood draw (IM-; 105 cases, 58 siblings). In multivariate logistic regression models, an anti-EBNA1:2 ratio ≤ 1.0 was significantly more prevalent in HL cases than siblings (odds ratio, 95% confidence interval = 2.43, 1.05-5.65); similar associations were apparent within the IM+ and IM- groups. EBNA antibodies were not significantly associated with IM history in HL cases or siblings. These associations suggest that chronic or more severe EBV infection is a risk factor for HL, independent of IM history.


Nutrients and Genetic Variation Involved in One-Carbon Metabolism and Hodgkin Lymphoma Risk: A Population-based Case-Control Study

August 2011

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59 Reads

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13 Citations

American Journal of Epidemiology

Nutritional and genetic determinants of the one-carbon metabolism pathway have been related to risk of malignant lymphomas, but little is known about their associations with Hodgkin lymphoma risk specifically. The authors examined nutrient intake (folate, vitamin B(2), vitamin B(6), vitamin B(12), methionine) and multivitamin use among 497 Hodgkin lymphoma patients and 638 population-based controls (Massachusetts and Connecticut, 1997-2000), and genetic variation (MTHFR 677C>T, MTHFR 1298A>C, MTR 2756A>G, SHMT1 1420C>T, TYMS 1494del6) and gene-diet interactions in a subset. Unconditional logistic regression was used to calculate multivariable odds ratios and 95% confidence intervals. Hodgkin lymphoma risk was not associated with total nutrient intake or intake from food alone (excluding supplements). Multivitamin use (odds ratio (OR) = 1.46, 95% CI: 1.09, 1.96), total vitamin B(6) (OR(quartile 4 vs. 1) = 1.62) (P(trend) = 0.03), and total vitamin B(12) (OR(quartile 4 vs. 1) = 1.75) (P(trend) = 0.02) intakes were positively associated with risk of Epstein-Barr virus-negative, but not -positive, disease. The 5 genetic variants were not significantly associated with Hodgkin lymphoma risk; no significant gene-diet interactions were observed after Bonferroni correction. Study findings do not support a strong role for nutrients and genetic variation in the one-carbon metabolism pathway in susceptibility to Hodgkin lymphoma. Associations between diet and risk of Epstein-Barr virus-negative disease require confirmation in other populations.


Polymorphic Variation in NFKB1 and Other Aspirin-Related Genes and Risk of Hodgkin Lymphoma

March 2009

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30 Reads

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35 Citations

Cancer Epidemiology Biomarkers & Prevention

We found that regular use of aspirin may reduce the risk of Hodgkin lymphoma (HL), a common cancer of adolescents and young adults in the United States. To explore possible biological mechanisms underlying this association, we investigated whether polymorphic variation in genes involved in nuclear factor-kappaB (NF-kappaB) activation and inhibition, other inflammatory pathways, and aspirin metabolism influences HL risk. Twenty single nucleotide polymorphisms (SNP) in seven genes were genotyped in DNA from 473 classical HL cases and 373 controls enrolled between 1997 and 2000 in a population-based case-control study in the Boston, Massachusetts, metropolitan area and the state of Connecticut. We selected target genes and SNPs primarily using a candidate-SNP approach and estimated haplotypes using the expectation-maximization algorithm. We used multivariable logistic regression to estimate odds ratios (OR) for associations with HL risk. HL risk was significantly associated with rs1585215 in NFKB1 (AG versus AA: OR, 2.1; 95% confidence interval, 1.5-2.9; GG versus AA: OR, 3.5; 95% confidence interval, 2.2-5.7, Ptrend=1.7x10(-8)) and with NFKB1 haplotypes (Pglobal=6.0x10(-21)). Similar associations were apparent across categories of age, sex, tumor EBV status, tumor histology, and regular aspirin use, although statistical power was limited for stratified analyses. Nominally significant associations with HL risk were detected for SNPs in NFKBIA and CYP2C9. HL risk was not associated with SNPs in IKKA/CHUK, PTGS2/COX2, UDP1A6, or LTC4S. In conclusion, genetic variation in the NF-kappaB pathway seems to influence risk of HL. Pooled studies are needed to detect any heterogeneity in the association with NF-kappaB across HL subgroups, including aspirin users and nonusers.


Population differences in immune marker profiles associated with human T-lymphotropic virus type I infection in Japan and Jamaica

February 2009

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27 Reads

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24 Citations

The natural history of human T-lymphotropic virus type I (HTLV-I) has been shown to differ markedly by geographic area. The differences include contrasting patterns of risk of adult T-cell lymphoma (ATL) and HTLV-I-associated myelopathy/tropical spastic paraparesis (HAM/TSP), which may be due in part to differences in host immune response to infection. To characterize variations in host immunity across populations, we compared serologic immune marker patterns in HTLV-I-endemic populations in Japan and Jamaica. We matched 204 participants with archived blood from the Miyazaki Cohort Study (Japan) and the Food Handlers Study (Jamaica)-i.e., 51 HTLV-I-positive ("carriers") and 51 HTLV-I-negative individuals ("noncarriers") from each population-by age, sex and blood collection year. We compared plasma concentrations of markers of T-cell-mediated (antigen-specific) and nonspecific immunity using regression models and correlation coefficients. Compared to Jamaican HTLV-I noncarriers, Japanese noncarriers had higher covariate-adjusted mean levels of T-cell activation markers, including antibody to Epstein-Barr virus nuclear antigen-1 (reciprocal titer 27 vs. 71, respectively, p=0.005), soluble interleukin-2 receptor-alpha (477 vs. 623 pg/mL, p=0.0008) and soluble CD30 (34 vs. 46 U/mL, p=0.0001) and lower levels of C-reactive protein (1.1 vs. 0.43 microg/mL, p=0.0004). HTLV-I infection was associated with activated T-cell immunity in Jamaicans but with diminished T-cell immunity in Japanese persons. The observed population differences in background and HTLV-I-related host immunity correspond closely to the divergent natural histories of infection observed among HTLV-I carriers in Japan and Jamaica and corroborate a role for host immune status in the contrasting patterns of ATL and HAM/TSP risk.


Infectious Agents

January 2009

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16 Reads

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13 Citations

Journal of Cancer Epidemiology and Prevention

The third edition of this book reviews the global burden of cancer, causes of cancer, and current priorities and future directions in cancer epidemiology and prevention research. The book maintains the structure of previous editions with seventy-two chapters organized into five major sections: Basic Concepts; The Magnitude of Cancer; The Causes of Cancer; Cancer by Tissue of Origin, and Cancer Prevention and Control. The introductory chapters under Basic Concepts highlight the advances in genomic and molecular biology that have applications in morphologic classification of malignant tumors, and in the elucidation of critical genetic events that result in malignant transformation and tumor invasion. The section on the Magnitude of Cancer reviews global patterns of cancer incidence and mortality in relation to country of residence, age, gender, race and ethnicity, and socioeconomic status. The section on The Causes of Cancer reviews the spectrum of environmental, lifestyle and genetic risk factors that are associated with the origin of human cancers. Chapters on Cancer by Tissue of Origin review systematically the demographic, environmental, and host factors that impact the origin and progression of cell-and organ-specific neoplasms. The concluding section, Cancer Prevention and Control, addresses methods and applications for translating epidemiologic, laboratory, and clinical research observations into preventive interventions. Special emphasis is provided on measuring the impact of behavioral interventions on health-promoting practices, as well as governmental policies that regulate environmental carcinogens.


Host Immune Status and Incidence of Hepatocellular Carcinoma among Subjects Infected with Hepatitis C Virus: A Nested Case-Control Study in Japan

January 2007

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38 Reads

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24 Citations

Cancer Epidemiology Biomarkers & Prevention

A nested case-control study was conducted to examine the association between host immune status, as characterized by serum immune marker levels, and the development of hepatocellular carcinoma (HCC) up to 8 years later in persons with chronic hepatitis C virus (HCV) infection. Cases (n = 39) and matched controls (n = 117) were selected from participants of the Town C HCV Study in Japan between 1996 and 2004 and matched on age at first available sample (+/-1 year), gender, and length of follow-up. Separate analyses were done for each of three serum immune markers: soluble tumor necrosis factor-receptor II (sTNF-R2) and soluble intercellular adhesion molecule-1 (sICAM-1), as indicators of type 1, cell-mediated immune response, and soluble CD30 (sCD30), as an indicator of type 2, humoral immune response. The median concentrations of sTNF-R2, sICAM-1, and sCD30 among controls were 3,170 pg/mL, 305 ng/mL, and 3.0 units/mL, respectively, and were higher among cases (3,870 pg/mL, 372 ng/mL, and 3.3 units/mL, respectively). The risk of developing HCC among subjects with immune marker concentrations above the median levels of the controls was >2-fold greater than among subjects with lower concentrations for all three markers [sTNF-R2: odds ratio (OR), 6.9; 95% confidence interval (95% CI), 2.4-20.5; sICAM-1: OR, 2.0; 95% CI, 0.9-4.1; and sCD30: OR, 2.1; 95% CI, 1.0-4.7]. Simultaneous adjustment for all three markers revealed only sTNF-R2 to be associated with HCC risk (OR, 6.4; 95% CI, 2.0-20.6). Adjustment for alcohol consumption and HCV serotype did not materially alter these associations. Results from this prospective, community-based study suggest that a dysregulation in both type 1-related and type 2-related host immunity contributes to the development of HCV-associated HCC.


Citations (72)


... High HTLV-1 proviral load in asymptomatic carriers is recognized as a risk factor for the development of both ATL and HAM/TSP [16,17]. Thus, factors that contribute to alterations in proviral load are of significant importance to HTLV-1 pathogenesis. ...

Reference:

HTLV-1 CTCF-binding site is dispensable for in vitro immortalization and persistent infection in vivo
Risk Factors for Adult T-Cell Leukemia Among Carriers of Human T-Lymphotropic Virus Type I
  • Citing Article
  • November 1998

Blood

... Additionally, genetic predispositions specific to certain populations may play a role, as hereditary mutations associated with RB could be more prevalent in East Asia [33]. Environmental influences, such as increased pollution and changing lifestyle factors, may also be linked to rising cancer rates [34,35]. Furthermore, disparities in healthcare access, particularly between urban and rural areas, may have historically led to underreporting, with recent improvements in access resulting in more cases being diagnosed. ...

Fruit and Vegetable Intake during Pregnancy and Risk for Development of Sporadic Retinoblastoma

Cancer Epidemiology Biomarkers & Prevention

... Similar to ctDNA, cytokines can be identified in blood samples from cancer patients through minimally invasive approaches [82]. Their presence has been demonstrated to correlate with the risk of developing specific types of cancer [83][84][85] as well as being associated with the tumor stage [86] and prognosis [87] or influencing treatment efficacy [88]. Indeed, certain studies have conducted a combined analysis to detect both ctDNA and cytokines as potential non-invasive biomarkers [89,90]. ...

Elevated Serum Levels of sCD30 and IL6 and Detectable IL10 Precede Classical Hodgkin Lymphoma Diagnosis
  • Citing Article
  • March 2017

Cancer Epidemiology Biomarkers & Prevention

... Regarding the immunological aspects of HTLV/TB co-infection (Table 3), four out of six studies were conducted in Japan and involved patients from the cohort of Myazaki. Three studies (37)(38)(39) evaluated the response to the PPD skin test, indicating a reduced response in patients co-infected by HTLV-1/TB, compared to uninfected controls. Another study reported a reduced response to PPD in vitro in individuals infected with HTLV -1 vaccinated with BCG and TST-. ...

Gender Difference in Skin Reactivity to Purified Protein Derivative Among Carriers of HTLV-I in Japan
  • Citing Article
  • November 1999

JAIDS Journal of Acquired Immune Deficiency Syndromes

... 4 The apparent effects of these public health measures were observed in a group of 157 Mexican patients with TAHI who were studied between 1980 and 1996. 5 The case frequency of TAHI by year of transfu- sion was 1 (0.6%) in 1980 and in 1981, 7 (4.5%) in 1984, 34 (22.4%) in 1985, 85 (54.5%) in 1986, 16 (10.3%) in 1987, 1 (0.6%) in 1988, 3 (1.9%) in 1989 and in 1990, 2 (1.3%) in 1993, and 1 (0.6%) in 1994 and in 1996. ...

Transfusion-Associated HIV Infection in Mexico Related to Paid Blood Donors; HIV Epidemic
  • Citing Article
  • May 2004

International Journal of STD & AIDS

... A limitation of this study is the accuracy of available epidemiologic data pertaining to HIV and HCV infections in CDC-IRD groups. Such data are derived from high-risk Donors at Increased Risk for HIV or HCV population surveys, which may be biased by self-selection, mobility and nonparticipation of persons with marginal lifestyles and influenced by coincidence of multiple risk factors, misclassification of risk behaviors and geographic variations (26). However, for the individual patient or surgeon who is trying to decide whether to proceed with a kidney transplant from a particular CDC-IRD, it is probably sufficient to offer an estimate of the infectivity risk, as outlined in Table 3. ...

Retroviruses—Human Immunodeficiency Virus
  • Citing Chapter
  • January 1997

... Other disorders associated with HTLV-I infection HTLV-I has been known to be associated with not only HAM/TSP and ATL but also uveitis, alveolitis, myositis, arthritis, dermatitis, mononeuropathy, inclusion body myositis , Sjogren syndrome, Behcet disease, pseudohypoparathyroidism , and SLE (Leite et al. 2004; Morgan et al. 1989; Higuchi et al. 1992; Sugimoto et al. 1987; Vernant et al. 1988; Nakao et al. 1991; Nishioka et al. 1989; LaGrenade et al. 1990; Vernant et al. 1990; Cupler et al. 1996; Engel et al. 1997; Ozden et al. 2001; Matsuura et al. 2008; Yoshida et al. 2002). Although HAM/TSP patients with HCV hepatitis are sometimes seen, there is no significant epidemiological link (Taylor et al. 1999; Ijichi et al. 1993; Maruyama et al. 1995). Retrospective statistical studies show stronger associations of HTLV-I with HAM/ TSP, uveitis, myositis, and peripheral neuropathy (Gessain et al. 1985; Morgan et al. 1989; Higuchi et al. 1992; Nakao et al. 1991; Gilbert et al. 2001; Leite et al. 2003), but less clear associations are for alveolitis, arthritis, and the other suggested diseases. ...

HUMAN T-CELL LYMPHOTROPIC VIRUS-I COINFECTION IN PATIENTS WITH CHRONIC HEPATITIS AND HEPATOCELLULAR-CARCINOMA ASSOCIATED WITH HEPATITIS-C VIRUS
  • Citing Article
  • October 1995

Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology

... For samples with detectable anti-EA-restricted and anti-EA-diffuse IgGs, the higher value was taken to be the titer against EA, as in other studies. 24 IgG antibodies against EBNA-1 and EBNA-2 were determined by enzyme-linked immunosorbent assay. Antibody titers are reported as the reciprocal of the highest of serial 2-fold dilutions to yield a positive reading on immunofluorescence. ...

Epstein—Barr Virus and Malignant Lymphomas
  • Citing Chapter
  • January 1997

... It most commonly occurs in the lumbar spine in patients typically younger than those affected by ATL. 71 Transfusion with HTLV-1-contaminated blood has been associated with a more rapid onset of development of HAM/TSP versus ATL. 23,88 The pathogenesis of HAM/TSP is thought to involve both molecular mimicry and autoantigens. ...

Retroviruses—Human T-Cell Lymphotropic Virus
  • Citing Chapter
  • January 1997

... Hepatocellular carcinoma (HCC) is the most frequent histologic type of primary liver cancer (Stuver and Trichopoulos, 2008), accounting for up to 85% of cases. The predominant role of chronic infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) in the aetiology of HCC is well documented (Llovet et al, 2003;London and McGlynn, 2006;Mueller et al, 2006). Advanced age, male gender, heavy alcohol drinking, tobacco smoking and cirrhosis are other important recognised HCC risk factors (Llovet et al, 2003;London & McGlynn, 2006;Mueller et al, 2006). ...

Infectious Agents
  • Citing Article
  • January 2009

Journal of Cancer Epidemiology and Prevention