Many reagents and techniques have been used for delayed-type hypersensitivity (DTH) skin testing in the evaluation of HIV-infected patients, resulting in varied interpretation of the utility of DTH skin testing in this population. We report the development of a simple algorithm for selection of DTH antigens and the clinical relevance of DTH skin testing in HIV disease. Antigens and concentrations for testing were first evaluated in a demographically matched, HIV-negative, immunologically healthy population. The testing scheme was then applied to the HIV population of interest for 5 years at several clinical sites. The antigens and concentrations selected resulted in 100% reactivity to two or more antigens in the HIV-negative cohort. Anergy is thus a distinct immunologic abnormality. Although some correlation (r2 = 0.6) of skin test reactivity and CD4 cell count was found in a cohort of HIV-infected individuals, anergy was found to be independently predictive of the development of symptomatic late-stage disease (Walter Reed Stage 6), AIDS, or death. This stepwise evaluation of skin testing and reagents has led to the modification of the skin testing protocol by defining the minimum number of antigens required and establishing the independent prognostic role of DTH skin testing in the evaluation of HIV-infected patients. The addition of mumps (40 CFU/ml), tetanus (1:10), and candida (1:10) to the purified protein derivative (PPD) skin test provides the critical controls to evaluate the status of PPD skin test in HIV-infected individuals as well as to provide a useful and prognostic clinical immunology evaluation.

Many reagents and techniques have been used for delayed-type hypersensitivity (DTH) skin testing in the evaluation of HIV-infected patients, resulting in varied interpretation of the utility of DTH skin testing in this population. We report the development of a simple algorithm for selection of DTH antigens and the clinical relevance of DTH skin testing in HIV disease. Antigens and concentrations for testing were first evaluated in a demographically matched, HIV-negative, immunologically healthy population. The testing scheme was then applied to the HIV population of interest for 5 years at several clinical sites. The antigens and concentrations selected resulted in 100% reactivity to two or more antigens in the HIV-negative cohort. Anergy is thus a distinct immunologic abnormality. Although some correlation (r2 = 0.6) of skin test reactivity and CD4 cell count was found in a cohort of HIV-infected individuals, anergy was found to be independently predictive of the development of symptomatic late-stage disease (Walter Reed Stage 6), AIDS, or death. This stepwise evaluation of skin testing and reagents has led to the modification of the skin testing protocol by defining the minimum number of antigens required and establishing the independent prognostic role of DTH skin testing in the evaluation of HIV-infected patients. The addition of mumps (40 CFU/ml), tetanus (1:10), and candida (1:10) to the purified protein derivative (PPD) skin test provides the critical controls to evaluate the status of PPD skin test in HIV-infected individuals as well as to provide a useful and prognostic clinical immunology evaluation.

PURPOSE:The purpose of this study was to examine the relationship between psychiatric depression and ventricular arrhythmias in patients with coronary artery disease (CAD). The hypothesis was that depressed patients with CAD would have a higher prevalence of ventricular tachycardia (VT) than nondepressed patients with CAD.PATIENTS AND METHODS:One hundred three patients who were found to have significant CAD by elective diagnostic cardiac catheterization were administered a standardized psychiatric interview and underwent 24-hour Holter monitoring.RESULTS:Twenty-one patients (20%) met the criteria for either major or minor depression. There were no significant differences between depressed and nondepressed patients with CAD in severity of CAD or in ventricular function. Five (23.8%) of the depressed patients and three (3.7%) of the nondepressed patients exhibited episodes of VT during 24 hours of Holter monitoring (p < 0.008). This difference remained significant even after controlling for relevant covariates.CONCLUSIONS:We conclude that there is a higher prevalence of VT among patients with CAD and depression than among those CAD patients without depression. This may help to explain the increased risk for cardiac mortality in depressed patients with CAD.

The psychosocial functioning of patients arriving at the emergency department with an acute myocardial infarction early enough to be candidates for treatment with thrombolytic agents was compared with that of those arriving later. Patients who arrived within 3 hours were significantly more anxious when assessed 1 week after admission and had a consistently worse pattern of psychosocial adjustment 3 months after hospital discharge than did those who arrived later. The implications of these findings for efforts to improve early arrival at the emergency department, as well as for medical and psychosocial outcomes after acute myocardial infarction, were considered.

CLINICAL IMMUNOLOGY, with great interest.However, there are certain comments regarding the discussion by Dr. Cassidy which are worth mentioning.The sequence for the development of lymphocyte surface receptors appears to be surface immunoglobulin --, receptors for IgG Fc + receptors for CB, rather than the one suggested by Dr. Cassidy.Our study on human fetal liver clearly demonstrates that receptors for C3 develop later than surface Ig and receptors for IgG Fe.'This sequence appears to be analogous to that seen in the mouse.'The sequence suggested by Dr. Cassidy is probably based on previous indirect evidence that patients with x-linked aggammag,lobulinemia lack lymphoid cells with surface Ig but possess cells with receptors for IgG Fc and C,.With the definition of "third population cells," which carry high avidity IgG Fc receptors and occasionally C3 receptors, but lack surface Ig and T cell characteristics,3 it became apparent that the cells with receptors for IgG Fc and C3 present in patients with x-linked agammaglobulinemia belong to this "third population."The "third population cells" as detected by Ripley rosette test are present in normal proportions in patients with x-linked agammaglobu1inemia.lThey participate in antibody-dependent cytotoxicity, which is reported to be normal in these patients.j Rowe and co-workers" suggested that IgD is probably the earliest Ig to appear on the surface of human lymphocytes as evidenced by a higher proportion of surface IgD-bearing cells than those with surface IgM in human cord blood.However, our recent study' of ontogeny of human lymphocyte receptors in fetal liver has clearly demonstrated that IgM is the first immunoglobulin to appear on the lymphocyte surface at a time when no other surface Ig including IgD is present.Vitetta and co-workers7 also demonstrated that in mice an "IgD-like" molecule follows the appearance of IgM on the lymphocyte surface.Gathings and coworker?also confirmed our observations and demonstrated further that the cytoplasmic IgM appears even earlier than surface IgM.Therefore, the role of IgD as the primordial antigen receptor for the B lymphocyte remains speculative.