Rimming - Is it safe?

[Guest JH]

Good advice Rick. You also need to have antibody levels checked afterwards to ensure that the immunisation has been effective. Some people don't produce antibodies after the first course and may need a booster.

[Guest TruthTeller]

>I think you recently went through the same bullshit with Reg

>when you and he were discussing the effects of ecstasy,

>didn't you?

 

I believe that was you, actually - not Reg. But who knows; on some issues, you two are so alike that it's hard to distinguish.

 

>To support his position he cited a specific

>study by a distinguished scientist, whom he named, and to

>support yours you cited absolutely nothing except your own

>prejudice in favor of taking drugs. Seems to be a pattern

>with you.

 

As for this issue, others have posted scientific support against your position, including those means identified by the CDC for transmission of HVC. Why do you keep ignoring that?

 

Also, according to JT - whose excellent analysis of the NEJM study you are studiously ignoring - made clear why that study does not support your assertion that rimming transmits HCV. That was just a fabrication by you. So you don't have any scientist - distinguished or otherwise - supporting your view.

 

Finally, as to the ecstacy point and "proof" generally, one of the lowest, most primitive forms of thinking is credentialing: "X says Y and X has Z credentials. Therefore, what X says is true." I don't engage in it, and you should stop doing so. It's pathetic.

 

If someone asserts a conclusion, and states his reasoning for it, I won't accept the conclusion unless the reasoning is persuasive to me - regardless of the person's title. If the reasoning is flawed, I will say why and then reject the conclusion. The fact that you're in awe of the person's title shouldn't affect that process, and it shouldn't make you cede your capacity and duty of reason to them.

 

>If the reputations of medical practitioners mean nothing to

>you then I assume the next time you become ill you will seek

>out a witch doctor and ask him to drive the evil spirits out

>of your body by shaking his rattle and chanting.

 

In general, I think that medical doctors are the most qualified to treat diseases. Contrary to what they believe (and what you apparently believe), they are not infallible, and are often wrong. Therefore, I would not submit blindly to what they dictate. I would demand to know their reasoning for their recommendations, seek out other recommendations, research, and decide what course of action is best using my own judgment.

 

There are people besides you who -- due to laziness or intimidation or an inability to think critically -- submit blindly to the dictates of doctors because of their title, and don't use their own critical faculties to make decisions about their own body and their own life. Until discussing this topic with you, I never met anyone who thought that was a preferable approach.

[Guest regulation]

>>I think you recently went through the same bullshit with Reg

>>when you and he were discussing the effects of ecstasy,

>>didn't you?

>

>I believe that was you, actually - not Reg. But who knows;

>on some issues, you two are so alike that it's hard to

>distinguish.

 

Nope, it was me. How well I remember! I cited a study on X by a distinguished professor at Johns Hopkins. You responded by saying that this man, whom you had never heard of, must have been bribed to falsify his results by a nefarious anti-drug conspiracy in the government. Very convincing!

 

>As for this issue, others have posted scientific support

>against your position, including those means identified by

>the CDC for transmission of HVC. Why do you keep ignoring

>that?

 

I think he's ignoring it because it's a lie. As P said, the CDC Fact Sheet on HCV does indeed say that there is a risk of sexual transmission, as JT confirmed below. Donnie simply lied about that. But you wouldn't know that because you didn't bother to read it.

 

>Also, according to JT - whose excellent analysis of the NEJM

>study you are studiously ignoring - made clear why that

>study does not support your assertion that rimming transmits

>HCV. That was just a fabrication by you. So you don't have

>any scientist - distinguished or otherwise - supporting your

>view.

 

I'm the one who first brought up the study, and neither P nor I have fabricated anything. JT has not come up with any facts to cast doubt on those reported by the study, he has simply tried to come up with a different interpretation of the facts the study presents -- all this without actually having read the study we are all discussing. You haven't read it either, so how the fuck would you know how "excellent" his analysis is? :-)

 

>Finally, as to the ecstacy point and "proof" generally, one

>of the lowest, most primitive forms of thinking is

>credentialing: "X says Y and X has Z credentials.

>Therefore, what X says is true." I don't engage in it, and

>you should stop doing so. It's pathetic.

 

 

You're lying again. In this case and in the earlier one as well, you are arguing that studies whose methods and conclusions you haven't even read are wrong. It's on those methods and conclusions, of which you are almost completely ignorant, that P and I are basing our argument. You know nothing about them, you merely throw shit at them because you hate to be proved wrong.

 

 

>If someone asserts a conclusion, and states his reasoning

>for it, I won't accept the conclusion unless the reasoning

>is persuasive to me - regardless of the person's title. If

>the reasoning is flawed, I will say why and then reject the

>conclusion.

 

But in this case and in the earlier one you haven't even taken the trouble to examine the reasoning of the researchers we are talking about. You are simply announcing they are wrong because they've reached conclusions you don't like. How childish. :-(

 

>>If the reputations of medical practitioners mean nothing to

>>you then I assume the next time you become ill you will seek

>>out a witch doctor and ask him to drive the evil spirits out

>>of your body by shaking his rattle and chanting.

 

I rather liked this image. :-)

 

>In general, I think that medical doctors are the most

>qualified to treat diseases. Contrary to what they believe

>(and what you apparently believe), they are not infallible,

>and are often wrong. Therefore, I would not submit blindly

>to what they dictate. I would demand to know their

>reasoning for their recommendations, seek out other

>recommendations, research, and decide what course of action

>is best using my own judgment.

 

But that is not what you are doing here. As I pointed out, you haven't taken the trouble to examine the reasoning of the studies you are trashing. You're just trashing them because they say it's not a good idea to do things that you want to do.

[Guest regulation]

>>As Reg said, the Worman study in NEJC concludes that

>>tranmission occurred anally. I neither said nor implied

>>anything else.

 

Correct.

 

 

>This is the inevitable time when Pickwick starts denying

>that he ever intended to argue exactly that which has been

>the only implication possible of everything he's said for

>the last 10 posts.

 

This is the inevitable time when TT falls into his pattern of altering what another poster has said because it's so much easier to argue against that than against what the poster REALLY said. :-)

 

>If you weren't trying to imply that HCV was transmissible

>through rimming:

 

I think P did not IMPLY but plainly STATED that the Worman study indicates a risk of transmission through anal contact. And it certainly does. Only someone with hash for brains and fried eggs for eyes would fail to see that. :-)

 

>>>However, he didn't specify what kinds of sexual activity

>>>were identified in the report and then jumped to the

>>>conclusion that they must include rimming.

>>

>>Sorry, but I stated no such conclusion. The Italian study,

>>among others, refutes the statements of several posters on

>>this board that sexual contact is not one of the risk

>>factors for HCV. Those statements are plainly wrong, as you

>>know.

>

>What bullshit - see above.

 

No bullshit here. Your statement that HCV is not sexually transmissible IS plainly wrong. As the CDC Fact Sheet explicitly

states. P did not say that the Italian study has anything to do with rimming or anal transmission. He cites it merely to refute your absurd denial that HCV can be transmitted sexually, which it does. You really shouldn't use this message board to spread disinformation.

 

>HEY PICKWICK -- DO YOU OR DO YOU NOT THINK THAT RIMMING

>ENTAILS A RISK OF HVC TRANSMISSION??

 

He'll have to answer that. My question would be, is there anything a colonoscope can do (other than visually) that your mouth can't?

[Traveller]

>Only someone with hash for brains

>and fried eggs for eyes would fail to see that.

 

Hoo,

 

Reg is making fun of me again. Make him stop. This food talk is turning my stomach. Doesn't he know the weekend began 2 hours ago.

 

Later.

[Guest TruthTeller]

>You're just trashing them

>because they say it's not a good idea to do things that you

>want to do.

 

Let's learn a little lesson before beginning. The fact that one advocates freedom to do X does not mean that one wants to engage in X. I think people should be free to gamble, even though I hate gambling.

 

Similarly, the fact that one denies that X causes Y -- or points out that there is no proof establishing a causal link between the two -- does not mean that one wants to engage in X. I do think that AZT causes AIDS (as some have argued), but I do not have a desire to take AZT.

 

Therefore, to assert, as you have done, that I want to take ecstacy or that I want to rim - based on NOTHING other than the fact that I have pointed out the lack of evidence linking those activities to the parade of horribles you hysterically assert is casued by them - is simply stupid.

 

>Nope, it was me. How well I remember! I cited a study on X

>by a distinguished professor at Johns Hopkins. You

>responded by saying that this man, whom you had never heard

>of, must have been bribed to falsify his results by a

>nefarious anti-drug conspiracy in the government. Very

>convincing!

 

All scientists funded by the NIH or other federal government programs are not permitted to reach any conclusions with respect to drugs other than to conclude that they are all unspeakably destructive and lethal. Therefore, any researcher who is funded by the NIH is inherently suspect, due to the constraints on their objectivity.

 

>I think he's ignoring it because it's a lie. As P said, the

>CDC Fact Sheet on HCV does indeed say that there is a risk

>of sexual transmission, as JT confirmed below.

 

In post #27, pshaw pointed out (to you) that the American Liver Foundation does NOT list any sexual activity on its list of activities "Known to transmit infection" of HCV. You ignored him. Why did you do that?

 

>JT has not come up with any

>facts to cast doubt on those reported by the study, he has

>simply tried to come up with a different interpretation of

>the facts the study presents -- all this without actually

>having read the study we are all discussing. You haven't

>read it either, so how the fuck would you know how

>"excellent" his analysis is?

 

JT assumed that what you represented about the findings of the study was true (a precarious assumption, but one that he generously made). From that assumption, he proceeded to identify numerous logical reasons why the findings of the study do NOT support the conclusion that you suggested was proven by it. You ignored those reasons. Why?

 

>You're lying again. In this case and in the earlier one as

>well, you are arguing that studies whose methods and

>conclusions you haven't even read are wrong. It's on those

>methods and conclusions, of which you are almost completely

>ignorant, that P and I are basing our argument.

 

Again, we accepted what you said about the study as true. From that premise, we pointed out why - even if the study said what you claimed - it does not establish any causal connection between HCV transmission and rimming. Those are arguments for which you have no answer (except to say that "the top liver man" says that rimming is caused by HCV - even though he didn't say that - so it's good enough for you).

 

 

>>>If the reputations of medical practitioners mean nothing to

>>>you then I assume the next time you become ill you will seek

>>>out a witch doctor and ask him to drive the evil spirits out

>>>of your body by shaking his rattle and chanting.

>

>I rather liked this image. :-)

 

I think it's healthy for you to compliment yourself now and then when you feel impressed with what you've written. After all, if you don't - who will?

[Guest TruthTeller]

>I think P did not IMPLY but plainly STATED that the Worman

>study indicates a risk of transmission through anal contact.

 

This is unintelligible. What do you mean by "transmission through anal contact?" Oral-anal contact? Fucking somoene in the ass? Sticking metallic instruments into their assholes and piercing it and causing transmission in the ways JT described which do not occur in rimming?

 

"Transmission through anal contact" is a vague, meaningless phrase which you're using to cover up the fact that your original claim - that rimming risks transmission of HCV - was baseless.

 

HEY REG - DO YOU OR DO YOU NOT THINK THAT RIMMING ENTAILS A RISK OF HCV TRANSMISSION??

 

>My question would be, is there

>anything a colonoscope can do (other than visually) that

>your mouth can't?

 

YES - serve as a means of transmission of HCV.

[Guest TruthTeller]

>I do think that AZT causes AIDS (as some have argued),

 

This should be "I do not think"

[Guest JT]

Reg,

 

>>>As Reg said, the Worman study in NEJC concludes that

>>>tranmission occurred anally. I neither said nor implied

>>>anything else.

>

>Correct.

 

Really? So why did both Pickwick and you bring up HCV transmission in a discussion thread about rimming? Worman study just reported a case of HCV transmission via a breach in medical asepsis (thru' a contaminated colonoscope). If Pickwick and you insist that fecal-oral transmission (via rimming) is the same as parenteral transmission, then perhaps it is pointless for further discussion since both of you fail to understand the basis of human physiology, host defense mechanisms and modes of transmission of infectious agents.

 

 

>>This is the inevitable time when Pickwick starts denying

>>that he ever intended to argue exactly that which has been

>>the only implication possible of everything he's said for

>>the last 10 posts.

 

Despite your denial, both Pickwick and you have quoted the Worman study to support the argument that HCV transmission can occur via rimming. So, would you please provide a specific quote from the Worman paper that could address my following question which remains unanswered?

 

Did the Worman study state that HCV can be transmitted via the fecal-oral route and/or rimming?

 

 

>I think P did not IMPLY but plainly STATED that the Worman

>study indicates a risk of transmission through anal contact.

 

Please see the question above.

 

 

> And it certainly does. Only someone with hash for brains

>and fried eggs for eyes would fail to see that. :-)

 

Sorry, why are you so certain? Do you know what happens to the HCV when it's ingested? Can and do they survive the host's physical and chemical barriers in the gastrointestinal tract as well as the immune response?

 

 

>>>>However, he didn't specify what kinds of sexual activity

>>>>were identified in the report and then jumped to the

>>>>conclusion that they must include rimming.

>>>

>>>Sorry, but I stated no such conclusion. The Italian study,

>>>among others, refutes the statements of several posters on

>>>this board that sexual contact is not one of the risk

>>>factors for HCV. Those statements are plainly wrong, as you

>>>know.

>>

>>What bullshit - see above.

>

>No bullshit here. Your statement that HCV is not sexually

>transmissible IS plainly wrong. As the CDC Fact Sheet

>explicitly

>states. >P did not say that the Italian study has anything

>to do with rimming or anal transmission. He cites it merely

>to refute your absurd denial that HCV can be transmitted

>sexually, which it does.

 

Please don't try to deny that Pickwick brought up the Italian study in an attempt to convince people that HCV can be transmitted by rimming. He did not specify the kinds of sexual activities that were actually reported to be the risk factors for HCV transmission by confusing people to think that those unspecified sexual activities must include rimming.

 

 

>You really shouldn't use this

>message board to spread disinformation.

 

I'd kindly remind you to do the same.

 

 

>He'll have to answer that. My question would be, is there

>anything a colonoscope can do (other than visually) that

>your mouth can't?

 

Well, for starter, a mouth (under normal circumstances) would NOT be able to bypass the physical and chemical barriers (e.g. stomach acids and digestive enzymes) AND introduce HCV DIRECTLY into damaged intestinal mucosa and bloodstream. A colonoscope CAN!

 

HCV is not known to be able to survive those physical and chemical barriers. Hence, the virus would have been killed before they can spread to the bloodstream and the hepatocytes where they multiply and cause damage.

 

 

JT

[Guest JT]

>'Fraid you're out on a limb here. A recent paper by Dr.

>Howard Worman in the New England Journal of Medicine reports

>a case of HCV transmission between two colonoscopy patients

>who "shared" the same equipment. That seems to put the

>kibosh on the idea that the disease can't be transmitted

>anally. Sorry to be such a killjoy. :-(

 

Reg,

 

Would you please provide the speific issue and page number(s) of the Worman's study in the NEJM since both Pcikwick and you have read it? I've searched the NEJM website database (from Jan 1975 to Jan. 2002) and there was nothing on Worman, H! Others are welcomed to try, the following is the address for the NEJM site:

 

http://content.nejm.org/search.dtl

 

Waiting...

 

JT

[Guest JT]

>I'm the one who first brought up the study, and neither P

>nor I have fabricated anything. JT has not come up with any

>facts to cast doubt on those reported by the study, he has

>simply tried to come up with a different interpretation of

>the facts the study presents -- all this without actually

>having read the study we are all discussing.

 

I haven't come up with any facts? Well, the ones I mentioned are pretty well-established facts:

 

1) The weakness of case report as conclusive proof for causation between an exposure and disease is well-established in the medical/scientific communites.

 

2) The scenarios I've proposed are compatible with the "reported" observation that HCV transmission can occur via a contaminated colonoscope. Parenteral HCV transmission is a KNOWN fact well recognized by the CDC, NIH, WHO, APHA, AMA, etc.

 

3) The explanation I provided is compatible with known facts about the properties of HCV, human anatomy and physiology, and host defense mechanisms.

 

If you'd kindly provide the the issue and page numbers of the Worman study, then everyone who is interested in this topic can read it and find out on his own whether the study actually states that "HCV can be transmitted via the fecal-oral route and/or rimming"!

 

JT

[Guest TruthTeller]

>Would you please provide the speific issue and page

>number(s) of the Worman's study in the NEJM since both

>Pcikwick and you have read it? I've searched the NEJM

>website database (from Jan 1975 to Jan. 2002) and there was

>nothing on Worman, H! Others are welcomed to try, the

>following is the address for the NEJM site:

>

>http://content.nejm.org/search.dtl

 

I tried exactly the same thing. There are several short articles which appear to discuss a reported case of transmission of HCV through a colonoscopy (whcih I'm downloading and will send to you if you want), but nothing by Worman.

[Boston Guy]

JT:

 

HCV aside, what would you say are the normally-accepted medical risks associated with rimming?

 

BG

[Guest showme43]

>

>a case of HCV transmission between two colonoscopy patients

>who "shared" the same equipment. <

 

jeez couldn't they get a couple dildos like nornal people???

 

Rick

[DaninWA]

TT,

 

Why do you think AZT causes Aids? This is the first time I've heard that suggestion.

 

Dan

[Guest TruthTeller]

>Why do you think AZT causes Aids? This is the first time

>I've heard that suggestion.

 

That was a typo - I meant to say that I believe that AZT does NOT cause AIDS. I corrected it in the subsequent post.

 

There were (and likely still are) a small but vocal contingent of AIDS activists (and even some doctors) who, in the early 1990s, argued that what was killing people was not HIV - which they claimed was a relatively harmless virus - but instead, the AZT which they were taking. They claimed that the AZT was toxic and destroyed the immune system and was responsible for the onset of AIDS symptoms. This claim has been almost universally rejected.

 

Regulation accused me of wanting to take ecstacy and wanting to rim -- based on nothing other than the fact that I denied that there was any causal link between those activities and the harms he was claiming come from them.

 

To illustrate the stupidity of Regulation's accusation, I explained that one can deny that harmful effects are caused by a certain activity without wanting to engage in that activity. The example that I chose was that I deny that AZT causes AIDS, but this does not mean that I want to take AZT.

[Guest 7Zach]

One other thing, some of the materials I've read mention the chance of getting Chron's disease from oral exposure to fecal matter, which I assume, in my limited understanding of medicine, to be that of eating shit.

But seriously, there's no cure, and can kill you. Don't know the truth of this one.

[Guest 7Zach]

Because of the heightened interest in this page, just want to be clear that Chron's kills you...as far as rimming, an awful lot of people around..

[Guest JT]

>JT:

>

>HCV aside, what would you say are the normally-accepted

>medical risks associated with rimming?

>

>BG

 

BG,

 

I'm not sure what do you mean by the "normally-accepted medical risks"? However, we do recognize rimming is a risk factor for transmission of certain infectious agents. The risk could depend on various factors, e.g. the nature of infectious agents (e.g. bacteria, viruses, protozoa or multicellular parasites including their stages of development such as ova), the amount of the infectious agents ingested (i.e. does it constitute the infectious dose?), as well as the immune and health status of the rimmer.

 

It is possible that the rimmee does not exhibit any signs and symptoms associated with the infection and yet, he is contagious. As many have said, it's important for each individual to be informed of the risks associated with rimming, or for that matter, any sexual or non-sexual activities so that they can make their own informed decision (i.e. how much risk they're willing to take). I guess the key word here is "informed".

 

JT

[Guest JT]

>I would be obliged if you could cite your source for the

>latter statement. I have never seen it in the literature.

 

Sigh! Well, there are too many of them to be listed here. Please go to visit the PubMed site (the online equivalent to the MedLine database for medical literature found in most university libraries). Once you're there, type "hepatitis C transmission" or do similar search.

 

JT

[Guest JT]

>>I tried exactly the same thing. There are several short

>articles which appear to discuss a reported case of

>transmission of HCV through a colonoscopy (whcih I'm

>downloading and will send to you if you want), but nothing

>by Worman.

 

Well, well, well...I now know why Reg and Pickwick would not and cannot provide us any specific quote from the "Worman" study in the NEJM. Why? Because there is no such study!!!

 

Howard Worman DID include a paper by Bronowicki et. al. on his website (HepNet http://www.hepnet.com/hepc/worman197b.html). The paper was published in 1997 in the NEJM but it was NOT a study conducted by Worman!

 

TT, thanks for forwarding the paper to me. I've taken the liberty to post the paper here. So here we go folks, read it yourself and see whether the so called "Worman" paper said anything remotely about HCV transmission via the fecal-oral route and/or rimming! It seems that both Reg and Pickwick themselves have not read the paper written by Worman, one of the top liver experts in the US! The "Worman" study that they have been using to defend their baseless arguments after all DOES NOT EXIST!

 

So much for criticizing me for not reading the "Worman" study and not having any facts to support my arguments, Reg! Did you read it and where are your facts?

 

 

JT

 

_______________________

Volume 337:237-240 July 24, 1997 Number 4

 

Patient-to-Patient Transmission of Hepatitis C Virus during Colonoscopy

 

Jean-Pierre Bronowicki, M.D., Véronique Venard, Pharm.D., Christine Botté, M.D., Nathalie Monhoven, Ph.D., Isabelle Gastin, M.D., Laurence Choné, M.D., Hervé Hudziak, M.D., Bertrand Rhin, M.D., Christophe Delanoë, M.D., Alain LeFaou, M.D., Marc-André Bigard, M.D., and Pierre Gaucher, M.D.

 

Invasive diagnostic or therapeutic procedures may be a route for the transmission of the hepatitis C virus (HCV).1,2,3,4,5 In a study of patients in a gastrointestinal-disease unit, endoscopic biopsies were found to be an independent risk factor for HCV infection.6 We report the transmission of HCV during colonoscopy from a person known to have HCV infection to two other patients. The patient-to-patient transmission was ascertained by sequencing the nucleotides in the various HCV isolates.

 

Case Report

 

A 55-year-old man (Patient 1) and his 54-year-old wife (Patient 2) were referred in October 1995. In June 1995, both had had hepatitis-like illnesses, with nausea, abdominal pain, and conjunctival icterus. They had elevated serum alanine aminotransferase levels and tested positive for HCV antibodies by third-generation assays (Ortho Diagnostic Systems, Roissy en France, France, and Pasteur Diagnostique, Marnes-la-Coquette, France). Both had been regular blood donors for 20 years; they had had normal liver-enzyme levels and negative HCV serologic tests at the time of their most recent blood donations, in January 1995. They had not had blood transfusions, and there was no evidence of intravenous drug use. However, both patients had family histories of colon cancer, and both had undergone colonoscopy on March 16, 1995. Their serum alanine aminotransferase levels one week earlier were normal. Neither patient had previously undergone endoscopy in the same unit.

 

Liver biopsies were performed in both patients in November 1995, and the histologic activity was measured by the Knodell score.7 The biopsies revealed chronic hepatitis, minimal in Patient 2 and moderate in Patient 1 (Knodell scores, 3 and 9, respectively). No fibrosis was found in either biopsy specimen. The results of serologic tests for HCV were confirmed by third-generation enzyme immunoassays (Ortho Diagnostic Systems and Abbott Diagnostic Division, Rungis, France). Both patients tested negative for hepatitis B virus (HBV) and human immunodeficiency virus (HIV) types 1 and 2.

 

Methods

 

The temporal relation between HCV positivity and colonoscopy in the two patients led us to suspect a nosocomial infection (Figure 1). We investigated whether any HCV-positive patients had undergone colonoscopy in the clinic on the same day as our patients and whether any staff member performing endoscopy was HCV-positive. By genotyping and nucleotide sequencing of the HCV genome, we compared the virus isolated from our patients with that isolated from a patient known to be HCV-positive. We studied the procedures used for anesthesia and colonoscopy, in particular the techniques used in cleaning and disinfecting the endoscopes, to try to determine a possible route of infection.

 

All the staff members involved in performing endoscopy (one gastroenterologist, one anesthetist, one nurse, and one nurse's aide) tested negative for HCV serology by third-generation assays. Only three colonoscopies were performed on March 16, 1995. The first involved a 42-year-old woman (Patient 3) with a history of polypectomy. She was known to have been HCV-positive for one year, but she had not been treated because she had chronic depression. In November 1995, her serum alanine aminotransferase level was 43 IU per liter (normal level, <40). Serologic tests were positive for HCV and negative for HBV and HIV.

Detection and Titration of HCV RNA

 

Serum samples from Patients 1 and 2 collected in January 1995 at the time of blood donation and frozen at -80°C and serum samples obtained from Patients 1, 2, and 3 in October and November 1995 were tested for HCV RNA by a reverse-transcription polymerase chain reaction (PCR) with primers from the highly conserved 5' noncoding region of the HCV genome (Table 1). Briefly, RNA was extracted from 100 µl of serum with use of the method described by Chomczynski and Sacchi.9 RNA samples were heated for 10 minutes at 70°C and then incubated for 60 minutes at 37°C in a reaction mixture containing reverse-transcription buffer, 10 mM dithiothreitol, 1 mM of each deoxynucleotide triphosphate, 10 U of RNAsin (Life Technologies, Cergy Pontoise, France), 200 U of reverse transcriptase of Moloney murine leukemia virus (Life Technologies), and 0.4 mM outer antisense primer. The samples were then heated to 100°C for 10 minutes. Distilled water, extraction buffer, and HCV-negative serum samples were used as negative controls. Serum positive for HCV RNA served as a positive control. The complementary DNA (cDNA) was amplified by a nested PCR.10 The first PCR was performed in a 50-µl reaction mixture containing Taq polymerase buffer, 1 mM of each deoxynucleotide triphosphate, 1.5 mM magnesium chloride, 1 mM of each outer primer, 1 U of Taq polymerase (Life Technologies), and 5 µl of cDNA. There were 35 PCR cycles consisting of denaturation at 95°C for one minute, annealing at 55°C for one minute, and extension at 72°C for one minute.

 

 

The second PCR reaction was performed as described above for 25 cycles, with 5 µl of the first PCR product and the inner primers. The PCR products were subjected to electrophoresis in 2 percent agarose gels, stained with ethidium bromide, and visualized under ultraviolet light. The expected size of the amplification product was 190 bp.

HCV RNA was measured in serum by a branched-chain DNA assay (Quantiplex bDNA 2.00, Chiron Diagnostics Europe, Cergy Pontoise, France) in accordance with the instructions of the manufacturer.

 

HCV Genotyping and Nucleotide Sequencing

 

HCV genotyping was performed by a line-probe assay according to the instructions of the manufacturer (Innogenetics, Antwerp, Belgium). This assay is based on variations in the 5' untranslated regions of the various HCV genotypes. In the line-probe assay, type-specific probes are tagged with poly(T) tails by terminal deoxynucleotidyl transferase and attached to nitrocellulose membranes. Amplified products labeled with biotin are hybridized in reverse to the probes on the nitrocellulose strip. The biotin group is incorporated by using a 5'-biotinylated primer during the amplification. The labeled product obtained from the 5' untranslated region hybridizes with the probe that has a perfect match of sequences. After hybridization, streptavidin labeled with alkaline phosphatase is added and bound to any biotinylated hybrid formed. This technique allows the six major types of HCV and their most common subtypes to be detected.

 

To study the HCV sequences in the three patients, we performed a nested reverse-transcription PCR in nonstructural region 3 (NS3) with the patients' serum samples (using the primers described in Table 1). The NS3 region probably codes for a protease and helicase. Serum positive for HCV genotype 1b was used as a positive control, and serum negative for HCV RNA was used as a negative control. The NS3 region was chosen for the analysis of sequencing because the 5' noncoding and core regions appear to be quite conserved among the various types of HCV, whereas the putative envelope regions are highly variable even among examples of the same HCV subtype.11

 

To check the size of the amplification products, the PCR products were subjected to electrophoresis in 2 percent agarose gels and visualized with ethidium bromide staining (expected size, 186 bp). Each sample was tested in triplicate. The PCR products were gently separated from the agarose gel, purified by separation with a minicolumn (Wizard A7170, Promega, Madison, Wis.), and eluted in 50 µl of distilled water. The total yield of DNA was determined by spectrophotometry; 100 ng of purified DNA product was used in the cycle-sequencing reactions (Prism 401388, Applied Biosystems, Foster City, Calif.), which were performed according to the instructions of the manufacturer. The sequencing products were analyzed with a DNA-sequencing system (Model 373 A, Applied Biosystems). At least two sequencing reactions were performed with each sample, with the appropriate sense and antisense primers (Table 1). The sequences were aligned with use of the Clustal V program, which is widely employed to study the alignment of multiple sequences.12 This software is marketed under various names by various manufacturers. We used Assemblylign (Kodak International Biotechnologies, New Haven, Conn.). The nucleotide alignments were compared among the three patients, the control serum positive for HCV genotype 1b, and the published sequence of HCV genotype 1b.8,13

 

Results

 

Detection and Quantitation of HCV RNA

 

The serum samples collected from Patients 1 and 2 in January 1995 tested negative for HCV RNA, whereas those obtained in October and November 1995 tested positive. The level of viremia of Patient 3 in November 1995 was 3.5 million genome equivalents per milliliter.

 

Genotyping and Sequencing of HCV

 

All three patients were infected with HCV genotype 1b. Nucleotide sequencing of the NS3 region showed that the three patients were all infected with the same isolate, because there was 100 percent nucleotide homology among the three clones. The degree of homology between the nucleotides in the NS3 region, the control serum positive for HCV genotype 1b, and the published sequences of HCV-BK8 and HCV-J13 genotype 1b isolates ranged from 86.9 percent to 89 percent. The degree of homology in the amino acid sequences deduced from the nucleotide sequences ranged from 89.6 to 96 percent (Figure 2).

 

 

 

View larger version (6K):

 

 

Figure 2. Nucleotide Sequence of the HCV NS3 Gene Region in the Three Patients Who Underwent Colonoscopy on March 16, 1995, as Compared with the Sequence in Control Serum Positive for HCV Genotype 1b and Two Published Sequences of That Genotype.

There was 100 percent homology among the three patients with respect to the nucleotides sequenced. The dashes in the control and published sequences denote nucleotides identical to those sequenced in the patients; only divergent nucleotides are shown. Underscoring denotes a change in the amino acid sequence expected on the basis of the coding information. Amino acid sequences were not determined. Shading has been added to facilitate the comparison of the sequences.

 

 

 

 

Procedures Used for Colonoscopy, Disinfection, and Anesthesia

Patient 3 underwent colonoscopy from 10:10 to 10:30 a.m., and Patient 2 underwent the procedure from 11:00 to 11:30 a.m. Multiple biopsy specimens were obtained from both patients, because micropolyps were found. Patient 1 had a polypectomy between noon and 12:30 p.m. in which a diathermic loop was used. The same colonoscope (Olympus, Tokyo, Japan) was used throughout all three procedures. The biopsy specimens from Patients 2 and 3 were obtained with the same forceps.

 

After each procedure, the colonoscope was immediately immersed for 10 minutes in water containing detergent and washed on the outside with disposable swabs. The air, water, and biopsy-suction channels were washed with the same detergent as the colonoscope, with an all-channel irrigator (Olympus). After being rinsed with water, the endoscope and all the internal channels were soaked for five minutes in 2 percent glutaraldehyde. Rinsing in water and drying with compressed air followed.

 

During the procedures, the biopsy-suction channel was never thoroughly cleaned with an appropriate brush. A consensus report on endoscope disinfection14 has emphasized that the brush used in cleaning should be appropriate for the instrument and channel size. This mechanical cleaning is used to remove residual tissue, the presence of which may contribute to the failure of the cleaning and disinfection procedures. In interviews, nurses stated that this cleaning step was never performed in the clinic. After each procedure, the biopsy forceps and the diathermic loop were cleaned mechanically in detergent and in glutaraldehyde, but they were not autoclaved.

 

The same procedure for anesthesia was used in each patient. An intravenous line was inserted, and anesthesia was induced by injecting fentanyl and midazolam directly into the line. Anesthesia was maintained by injecting propofol continuously into the intravenous line with an electric syringe. The intravenous tubing was changed after each patient's procedure. Because Patient 3 was known to be HCV-positive, the intravenous line and the syringes used to inject the fentanyl, midazolam, and propofol were thrown away after that patient's procedure, which was the first of the three. During the interval between the procedures in Patient 2 and Patient 1, the intravenous lines and the needles were changed, but the same syringes of fentanyl, midazolam, and propofol were used.

 

Discussion

 

The timing of the events and the molecular characterization of the various HCV isolates provide evidence that HCV was transmitted during colonoscopy. There are few documented cases of viral transmission during endoscopy.15 One case of transmission of HBV in this manner has been reported.16 Acute hepatitis C was reported in a patient 10 weeks after the patient underwent retrograde cholangiography with sphincterotomy; no genotyping or nucleotide sequencing was performed, and HCV could not be proved to have been transmitted during the endoscopy.17 In both these cases, the disinfection procedure used was considered inadequate.

 

We suggest that during the disinfection of the colonoscope after the procedures in the patients we describe, two recommendations on endoscopic disinfection made by the American Society for Gastrointestinal Endoscopy14 and the British Society of Gastroenterology18 and the working party of the World Congresses of Gastroenterology19 were not followed. From our investigation it appeared that the biopsy-suction channel was never cleaned with a brush and that the accessories that breach the mucosa, such as the biopsy forceps and the diathermic loop, were not autoclaved after each use. Recently, the effectiveness of manual cleaning and disinfection in preventing the transmission of HCV was assessed by testing the effluent from the endoscope biopsy channel by reverse-transcription PCR for the presence of HCV RNA.20 That study involved 39 patients with chronic hepatitis C who underwent gastroscopy with biopsy. Sterile water was flushed through the biopsy channel immediately after the removal of the endoscope, after cleaning with a detergent solution, and after a final disinfection with glutaraldehyde. HCV RNA was found in two cases before the cleaning with a detergent, but in every case the water flushed through the biopsy channel after the cleaning step and after the disinfection with glutaraldehyde was negative for HCV RNA.20 These findings confirm that the disinfection procedure is effective when all the recommendations are followed.

 

Other studies assessing the degree of adherence to guidelines for the cleaning and disinfection of gastrointestinal endoscopes have pointed out the high rate of inadequate disinfection procedures (30 to 100 percent).14 Failure to follow the recommended procedures can have an important role in the endoscopic transmission of microorganisms.

 

The possibility that HCV was transmitted because of inadequate procedures in the use of anesthesia should also be considered. We believe this route of transmission is less likely, because the intravenous tubing and all the syringes containing the anesthetic drugs were changed after the first colonoscopy, in which the patient evaluated was known to be HCV-positive. However, inadequate procedures were followed during the other two procedures. Only the intravenous tubing and the needles were changed between the endoscopies of Patients 2 and 1. The anesthetist stated that he discarded syringes only after they were used in a patient known to be infected. To justify this approach, he said that he systematically used a check valve to avoid the backflow of blood into the syringe. However, other studies have shown that the rate at which blood contaminates the intravenous tubing used for anesthesia is substantial (0.3 to 3.3 percent of cases).21,22,23 The presence of a check valve and the changing of the needle do not affect the rate at which intravenous lines and syringes become contaminated — a point that should be emphasized, because multidose vials are very commonly used in anesthesia.21,22,23 Moreover, because the assessment of risk factors is not a reliable predictor of which patients have chronic viral infection, the practice of following strict procedures for anesthesia only in patients with known infections has little rationale and should be abandoned. The standard of care should be to use equipment and ampules only once.

 

 

We are indebted to Dr. M.P. Mahoney for his help in preparing this article.

 

 

Source Information

 

From the Service d'Hépato-Gastroentérologie (J.-P.B., L.C., H.H., C.D., M.-A.B., P.G.), the Laboratoire de Microbiologie (V.V., B.R., A.L.), the Etablissement de Transfusion Sanguine (C.B.), the Laboratoire Commun de Biologie Moléculaire (N.M.), and the Laboratoire de Pathologie Cellulaire et Moléculaire en Nutrition (J.-P.B., I.G., M.-A.B., P.G.), Faculté de Médecine et Centre Hospitalier Universitaire de Nancy, Vandoeuvre, France.

 

Address reprint requests to Dr. Bronowicki at the Service d'Hépato-Gastroentérologie, CHU de Nancy, 54500 Vandoeuvre, France.

 

References

 

 

Conry-Cantilena C, VanRaden M, Gibble J, et al. Routes of infection, viremia, and liver disease in blood donors found to have hepatitis C virus infection. N Engl J Med 1996;334:1691-1696.

Kiyosawa K, Tanaka E, Sodeyama T, et al. Transmission of hepatitis C in an isolated area in Japan: community-acquired infection. Gastroenterology 1994;106:1596-1602.

Allander T, Gruber A, Naghavi M, et al. Frequent patient-to-patient transmission of hepatitis C virus in a haematology ward. Lancet 1995;345:603-607.

Allander T, Medin C, Jacobson SH, Grillner L, Persson MAA. Hepatitis C transmission in a hemodialysis unit: molecular evidence for spread of virus among patients not sharing equipment. J Med Virol 1994;43:415-419.

Esteban JI, Gómez J, Martell M, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med 1996;334:555-560.

Andrieu J, Barny S, Colardelle P, et al. Prévalence et facteurs de risque de l'infection par le virus de l'hépatite C dans une population hospitalisée en Gastroentérologie: rôle des biopsies per-endoscopiques. Gastroenterol Clin Biol 1995;19:340-345.

Knodell RG, Ishak KG, Black WC, et al. Formulation and application of a numerical scoring system for assessing histological activity in asymptomatic chronic active hepatitis. Hepatology 1981;1:431-435.

Takamizawa A, Mori C, Fuke I, et al. Structure and organization of the hepatitis C virus genome isolated from human carriers. J Virol 1991;65:1105-1113.

Chomczynski P, Sacchi N. Single-step method of RNA isolation by acid guanidinium thiocyanate-phenol-chloroform extraction. Anal Biochem 1987;162:156-159.

Paterlini P, Driss F, Nalpas B, et al. Persistence of hepatitis B and hepatitis C viral genomes in primary liver cancers from HBsAg-negative patients: a study of a low-endemic area. Hepatology 1993;17:20-29.

Simmonds P. Variability of hepatitis C virus. Hepatology 1995;21:570-583.

Higgens DG, Bleasby AJ, Fuchs R. CLUSTAL V: improved software for multiple sequence alignments. Comput Appl Biosci 1992;8:189-191.

Kato N, Hijikata M, Ootsuyama Y, et al. Molecular cloning of the human hepatitis C virus genome from Japanese patients with non-A, non-B hepatitis. Proc Natl Acad Sci U S A 1990;87524-9528.

Infection control during gastrointestinal endoscopy: guidelines for clinical application. Gastrointest Endosc 1988;34:Suppl:37S-40S.

Spach DH, Silverstein FE, Stamm WE. Transmission of infection by gastrointestinal endoscopy and bronchoscopy. Ann Intern Med 1993;118:117-128.

Birnie GG, Quigley EM, Clements GB, Follett EA, Watkinson G. Endoscopic transmission of hepatitis B virus. Gut 1983;24:171-174.

Tennenbaum R, Colardelle P, Chochon M, Maisonneuve P, Jean F, Andrieu J. Hépatite C après cholangiographie rétrograde. Gastroenterol Clin Biol 1993;1763-764.

Cleaning and disinfection of equipment for gastrointestinal flexible endoscopy: interim recommendations of a Working Party of the British Society of Gastroenterology. Gut 1988;29:1134-1151.

Axon AT. Disinfection and endoscopy: summary and recommendations: working party report to the World Congresses of Gastroenterology, Sydney 1990. J Gastroenterol Hepatol 1991;6:23-24.

Rey J-F, Halfon P, Feryn J-M, Khiri H, Masseyeff M-F, Ouzan D. Risque de transmission du virus de l'hépatite C par l'endoscopie digestive. Gastroenterol Clin Biol 1995;19:346-349.

Trépanier CA, Lessard MR, Brochu JG, Denault PH. Risk of cross-infection related to the multiple use of disposable syringes. Can J Anaesth 1990;37:156-159.

Parlow JL. Blood contamination of drug syringes used in anaesthesia. Can J Anaesth 1989;36:Suppl:S61-S62.

Kempen PM. Contamination of syringes. Can J Anaesth 1990;3730-731.

[Boston Guy]

JT:

 

Thanks for the info. I was simply looking for what you thought would be routine medical advice today concerning the risks associated with rimming.

 

For years, I've seen rimming listed as "unsafe" in HIV literature, which usually lists it below unprotected anal intercourse but above many other types of sexual activity. It's been my general impression that it carries multiple risks, even when the person being rimmed looks "clean."

 

That's why I asked. Thanks for responding.

 

BG

[Guest 7Zach]

How do u get several bouts of hep? Isn't it just one type or the other, and either u have it or don't, but it is not that sort of disease where you get hep A twice or Hep B twice, is it?

[Guest JT]

BG,

 

>Thanks for the info.

 

You're welcomed. I was not too sure what you meant by "normally-medically accepted risks" because often, we use that term to refer to medical and surgical procedures and treatments but not in the context of rimming.

 

 

>I was simply looking for what you

>thought would be routine medical advice today concerning the

>risks associated with rimming.

 

Most doctors today would probably advise against rimming because there are a host of infectious diseases that can be spread via the anal-oral or fecal-oral route, e.g. herpes simplex 1 and 2, hepatitis A, as well as some enteric bacteria and protozoa. Some of these can be serious, life-threatening while others are self-limited infections.

 

 

>It's been my general impression that it carries multiple

>risks, even when the person being rimmed looks "clean."

 

You're right. Looking clean often does not tell the whole story when it comes to infectious diseases. And as I mentioned previously, an asymptomatic rimmee could potentially spread the infection to his partner, the rimmer! Therefore, there is no doubt that rimming does carry with its risks.

 

However, just because something can be spread via a particular route/mode DOES NOT mean it will always result in an infection! And even when an infection occurs, it DOES NOT always lead to disease! For example, many HAV infections are asymptomatic and many are mild and without jaundice. Whether infection and/or disease occur(s) would depend on some or all of the factors I listed in my previous post.

 

Many of us LOVES kissing but kissing also carries with its own risks too! So once again, it all depends on how much risks one is willing to take when it comes to any type of sexual activities.

 

My advice: get informed, get the necessary precautions (e.g. vaccinations), get realistic, get into a hottie's pants and get down and "dirty"! :9

 

Hope this helps.

 

 

JT

[Donnie]

RE: Listening to pickwick and regulation - Is it safe?

 

>Well, well, well...I now know why Reg and Pickwick would not

>and cannot provide us any specific quote from the "Worman"

>study in the NEJM. Why? Because there is no such study!!!

 

LOL!!!! Don't expect either pickwick or regulation to come back with anything resembling an apology for their intentional misinformation. Someone needs to shove a contaminated colonoscope up both of their asses. TT, you do one and I'll do the other.