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Objectives: This survey was undertaken to learn how Traditional Chinese Medicine acupuncturists' diagnose and treat patients with chronic low back pain in order to develop a standardized treatment for a clinical trial of that condition., Design: We surveyed a randomly selected group of 56 acupuncturists in Washington State, USA about styles of acupuncture they used for treating chronic low back pain, diagnoses made, and key features of treatment for this condition., Results: While substantial variability existed among practitioners, there was agreement on several broad features of treatment including: the use of local and distal acupuncture points (86% of practitioners), the use of acupuncture points on the meridians traversing the back (especially the UB meridian, 90%) the use of acupoints determined by palpation (82%), the importance of eliciting de qi (60%), and of providing up to eight treatments for achieving therapeutic results (79%)., Conclusion: The use of practitioner surveys can enhance the systematic development of acupuncture treatment protocols and should be part of this process in future clinical trials of common conditions.

Background: There is increasing need to examine the effectiveness of acupuncture and other alternative therapies for common conditions. However, little attention has focused on the variability in acupuncturists' assessment, diagnosis, and treatment patterns., Methods: Seven office-based acupuncturists practicing Traditional Chinese Medicine evaluated the same patient with chronic low back pain and provided data regarding principal assessment techniques, diagnoses, and therapeutic recommendations., Results: A high diagnostic agreement existed among 5 of 7 acupuncturists. However, recommended treatments included varying numbers and locations of acupuncture points. Recommendations varied between 5 and 14 points requiring 7 to 26 needles, since many points were intended for bilateral application. Of 28 acupuncture points selected, only 4 (14%) were prescribed by two or more acupuncturists. Most recommended various forms of adjuvant heat., Conclusions: Seven acupuncturists agreed considerably in the diagnoses for the same patient with chronic low back pain, but treatment recommendations varied substantially. Clinicians and researchers must recognize treatment recommendation variations and the challenges they present for study design and interpretation.

Background: Condylomata acuminata is one of the most common sexually transmitted diseases (STDs) diagnosed in the United States, yet relatively little research has been conducted on the determinants of this disease in well-defined populations., Goal: To determine the exposures that predispose a woman to the development of condylomata acuminata or genital warts., Study Design: A population-based case-control study was conducted among enrollees of Group Health Cooperative of Puget Sound. Patients (94 women with incident and 55 women with recurrent condyloma) were diagnosed between April 1, 1987 and September 30, 1991. Control subjects were 133 women without a history of genital warts. An in-person interview was conducted to collect information on subject characteristics, exposures, and on all episodes of genital warts., Results: Women with five or more partners within the 5 years before reference date were over seven times more likely to have incident condyloma (relative risk [RR], 7.5; 95% confidence interval [CI], 3.1-18.1) and over 12 times more likely to have recurrent condyloma (RR, 12.8; 95% CI, 4.2-38.9) compared with women with only one sexual partner during this time period. An increased risk of incident condyloma was also associated with a history of any STD (RR, 2.6; 95% CI, 1.1-5.8), a history of oral herpes (RR, 2.2; 95% CI, 1.1-4.4), and a history of allergies (RR, 2.0 95% CI, 1.0-3.8). Our data did not support a strong association between risk of condyloma and smoking or recent use of oral contraceptives., Conclusion: Our results suggest that risk of condyloma is primarily related to sexual behavior. We did not observe a strong association between risk of condyloma and many of the exposures considered to be potential cofactors for anogenital cancers associated with other types of human papillomaviruses.

Background and Objectives: The rapid increase in the number of physician office visits for condylomata acuminata and the association of human papillomavirus and cancer has prompted renewed interest in the epidemiology of this sexually-transmitted disease. Few epidemiologic studies have examined what risk factors are associated with condylomata acuminata in men., Goal: To determine what factors may predispose a man to the occurrence of condylomata acuminata., Study Design: A population-based case-control study was conducted among male members of a health maintenance organization. Patients were men 18 years or older who were seen for condyloma at one of four primary care clinics of Group Health Cooperative of Puget Sound between April 1, 1987 and September 30, 1991. Control subjects were frequency matched to the patients on clinic site, race, and age. In-person interviews were used to ascertain exposure histories from both patients and control subjects., Results: Recurrent condyloma was reported by about one third of our patients. Patients with multiple partners were strongly associated with developing the disease. Several factors were either more strongly or only associated with recurrent disease. Other behavioral measures, such as recreational drug use, were also related the occurrence of condyloma., Conclusion: These results confirm the sexual-transmitted mechanism of condyloma in men. Exposure to multiple partners was associated with elevated risk of both recurrent and incident disease. Other cofactors may be involved in the etiology of condyloma.

Background: Epidemiological evidence suggests lack of neonatal circumcision as the strongest risk factor for penile cancer, but the role of sexually transmitted diseases in the etiology of penile cancer has remained unclear., Purpose: To further clarify risk factors for penile cancer, we examined the role of circumcision, personal characteristics and habits (such as smoking), sexually transmitted diseases, past sexual activity, and medical conditions of the penis., Methods: A population-based, case-control study was conducted in western Washington state and in the province of British Columbia. We interviewed 110 men with penile cancer diagnosed from January 1979 to July 1990 and 355 control subjects from the general population, frequency matched to case subjects on age and date of diagnosis. Tumor tissue from 67 case subjects was tested for human papillomavirus (HPV) DNA by polymerase chain reaction. Results of blood tests from 69 case subjects and 208 control subjects were available for study. STATISTICALLY SIGNIFICANT RESULTS: Relative to men circumcised at birth, the risk for penile cancer was 3.2 times greater among men who were never circumcised and 3.0 times greater among men who were circumcised after the neonatal period. For current smokers, the risk was 2.8 times that of men who never smoked. The risk among men reporting a history of genital warts was 5.9 times that of men reporting no such history. Of 67 tumors tested for HPV DNA, 49% were positive; the majority of these positive tumors (70%) were type 16, which has been associated with anogenital carcinoma. Relative risks (RRs) associated with a reported history of penile rash or penile tear were 9.4 and 3.9, respectively. Among men not circumcised at birth, RRs associated with presence of smegma and difficulty in retracting the foreskin were 2.1 and 3.5, respectively. Twenty-eight percent of case subjects, compared with only 10% of control subjects, reported 30 or more sexual partners, and men with HPV-positive tumors were more likely to report a greater number of sexual partners., Conclusions: These results suggest that the absence of neonatal circumcision and potential resulting complications are associated with penile cancer. Additionally, medical conditions of the penis, sexual activity, infection with HPV, and smoking may increase the risk for penile cancer., Implications: A larger study would allow examination of interrelationships of circumcision, infection with HPV, and smoking as risk factors.

A population-based case-control study was conducted in western Washington state to examine the relations between infection with human papilloma viruses (HPV), herpes simplex viruses (HSV), and risk of oral squamous cell cancer in men. Interviews were completed on 131 oral cancer cases diagnosed between January 1985 and December 1989 and 136 controls frequency matched to cases on age and date of diagnosis who were obtained by random digit dialing. The risk for oral cancer among men with 30 or more sexual partners was 2.4 times that of men with four or fewer partners (95% confidence interval (CI) 1.0-5.9). Men who ever practiced oral sex had lower risk for oral cancer relative to men who never practiced oral sex (relative risk (RR) = 0.4, 95% CI 0.2-0.8). Analyses of exfoliated oral cavity cells for the presence of HPV-6 DNA with polymerase chain reaction revealed that men with an oral HPV-6 infection had 2.9 times the risk for oral cancer of noninfected men (95% CI 1.1-7.3), whereas men with an oral HPV-16 infection had 6.2 times the risk for oral cancer of noninfected men (crude RR = 6.2, 95% CI 0.7-52.2). Relative risks associated with serologically detected HSV-1 and HSV-2 infections were 0.8 (95% CI 0.3-1.7) and 1.8 (95% CI 0.7-4.6), respectively. The authors conclude that HPV-6 is associated with oral cancer. Although men infected with HPV-16 and HSV-2 were at elevated risk, these associations may have been due to chance. The role of specific sexual practices in the transmission of viruses to the oral cavity remains unclear.

The association between cigarette smoking and cervical cancer has been demonstrated in numerous prior studies. As part of population-based case-control studies of cancers of the vulva, vagina, cervix, anus, and penis in relation to infection with human papillomavirus, conducted in western Washington State and the province of British Columbia from the mid 1980s until the present time, the authors have collected detailed information on smoking history. The proportion of subjects who were current smokers of cigarettes ranged from slightly over 40% among incident cases of vaginal and cervical cancer to 60% among cases of vulvar and anal cancer. In contrast, only about 25% of controls were current smokers. The adjusted odds ratios (OR) associated with current smoking were substantially elevated (OR = 1.9-14.6) for all cancer sites except cancer of the vagina (OR = 1.3). The risks tended to increase in proportion to the number of cigarettes smoked. For most cancer sites, the odds ratios associated with former smoking were substantially less than those associated with current smoking and diminished with increasing time since cessation of smoking. The authors' data and those of other investigators suggest that cigarette smoking plays a role in the etiology of anogenital cancers and that smoking has a late-stage or promotional effect.

To determine whether specific sexually transmitted diseases were associated with an increased risk of vulvar cancer, we conducted a case-control study among residents of three countries in western Washington. We identified, interviewed, and obtained blood samples from women with in situ (n = 180) and invasive (n = 53) vulvar cancer, 18-79 years of age, who were first diagnosed with these diseases during 1980-1988. We compared their responses with those of 466 women from the general population who were identified by means of random digit dialing. On average, women with vulvar cancer reported a greater number of prior sexual partners than did controls. The risk of vulvar cancer was elevated among women who reported a prior history of condyloma (for in situ cancer, RR = 15.8; for invasive disease, RR = 17.3) or gonorrhea (for in situ cancer, RR = 2.2; for invasive disease, RR = 5.0). Women who were seropositive to herpes simplex virus type 2 (HSV-2) were at higher risk for carcinoma in situ than were controls (RR = 2.0). A history of nonspecific vaginitis, trichomoniasis, syphilis, or seropositivity to cytomegalovirus was not related to case-control status. These results indicate that only a subset of sexually transmitted diseases, particularly human papillomavirus, may play a role in the development of vulvar cancers.