Criminalisation of clients: reproducing vulnerabilities for violence and poor health among street-based sex workers in Canada-a qualitative study

OBJECTIVES

To explore how criminalisation and policing of sex buyers (clients) rather than sex workers shapes sex workers' working conditions and sexual transactions including risk of violence and HIV/sexually transmitted infections (STIs).

DESIGN

Qualitative and ethnographic study triangulated with sex work-related violence prevalence data and publicly available police statistics.

SETTING

Vancouver, Canada, provides a unique opportunity to evaluate the impact of policies that criminalise clients as the local police department adopted a sex work enforcement policy in January 2013 that prioritises sex workers' safety over arrest, while continuing to target clients.

PARTICIPANTS

26 cisgender and 5 transgender women who were street-based sex workers (n=31) participated in semistructured interviews about their working conditions. All had exchanged sex for money in the previous 30 days in Vancouver.

OUTCOME MEASURES

Thematic analysis of interview transcripts and ethnographic field notes focused on how police enforcement of clients shaped sex workers' working conditions and sexual transactions, including risk of violence and HIV/STIs, over an 11-month period postpolicy implementation (January-November 2013).

RESULTS

Sex workers' narratives and ethnographic observations indicated that while police sustained a high level of visibility, they eased charging or arresting sex workers and showed increased concern for their safety. However, participants' accounts and police statistics indicated continued police enforcement of clients. This profoundly impacted the safety strategies sex workers employed. Sex workers continued to mistrust police, had to rush screening clients and were displaced to outlying areas with increased risks of violence, including being forced to engage in unprotected sex.

CONCLUSIONS

These findings suggest that criminalisation and policing strategies that target clients reproduce the harms created by the criminalisation of sex work, in particular, vulnerability to violence and HIV/STIs. The current findings support decriminalisation of sex work to ensure work conditions that support the health and safety of sex workers in Canada and globally.

Glyco-engineered anti-EGFR mAb elicits ADCC by NK cells from colorectal cancer patients irrespective of chemotherapy

Background:

The epidermal growth factor receptor (EGFR) is overexpressed in colorectal cancer (CRC), and is correlated with poor prognosis, making it an attractive target for monoclonal antibody (mAb) therapy. A component of the therapeutic efficacy of IgG1 mAbs is their stimulation of antibody-dependent cellular cytotoxicity (ADCC) by natural killer (NK) cells bearing the CD16 receptor. As NK cells are functionally impaired in cancer patients and may be further compromised upon chemotherapy, it is crucial to assess whether immunotherapeutic strategies aimed at further enhancing ADCC are viable.

Methods:

CRC patients before, during and after chemotherapy were immunophenotyped by flow cytometry for major white blood cell populations. ADCC-independent NK cell functionality was assessed in cytotoxicity assays against K562 cells. ADCC-dependent killing of EGFR⁺ A431 cancer cells by NK cells was measured with a degranulation assay where ADCC was induced by GA201, an anti-EGFR mAb glyco-engineered to enhance ADCC.

Results:

Here, we confirm the observation that NK cells in cancer patients are dysfunctional. However, GA201 was able to induce robust NK cell-dependent cytotoxicity in CRC patient NK cells, effectively overcoming their impairment.

Conclusions:

These findings support the evaluation of the therapeutic potential of GA201 in combination with chemotherapy in CRC patients.

Lopinavir/ritonavir single agent therapy as a universal combination antiretroviral therapy stopping strategy: results from the STOP 1 and STOP 2 studies

OBJECTIVES

We designed two different studies to evaluate two different combination antiretroviral therapy (cART) stopping strategies namely a 'staggered stop' approach (STOP 1 study) and a 'protected stop' approach (STOP 2 study) to find the best 'universal stop' strategy.

PATIENTS AND METHODS

Patients who stopped cART for any reason were recruited. In STOP 1, 10 patients on efavirenz continued dual nucleos(t)ide reverse transcriptase inhibitors (NRTIs) for 1 week after discontinuing efavirenz. Efavirenz concentrations were measured weekly for up to 3 weeks. In STOP 2, 20 patients stopped their cART and replaced it with two tablets of lopinavir/ritonavir (Kaletra) (100/50 mg) twice daily for 4 weeks. Lopinavir, efavirenz, nevirapine and tenofovir concentrations were measured weekly for up to 4 weeks. Virological and resistance testing were performed.

RESULTS

In STOP 1 five patients still had efavirenz present (median t(1/2)=148.4 h) 3 weeks after stopping. In STOP 2, 15/20 patients had a viral load (VL) of <40 copies/mL and 3/20 patients had a reduction in VL by 4 weeks. Six patients opted not to stop lopinavir/ritonavir and still had <40 copies/mL at week 8. Week 1-4 median trough lopinavir concentrations were well above the EC(95). Six patients still had detectable concentrations of original cART persisting for >1 week after stopping. No patients developed new resistance mutations.

CONCLUSIONS

Plasma efavirenz concentrations can persist up to 3 weeks after patients stop efavirenz-containing regimens. This suggests a strategy of stopping efavirenz only 1 week before NRTIs may not be long enough for some individuals. The use of lopinavir/ritonavir monotherapy for a 4 week period may be an alternative pharmacologically and virologically effective universal stopping strategy which warrants further investigation.

Control of Culex quinquefasciatus in a storm drain system in Florida using attractive toxic sugar baits

Attractive toxic sugar baits (ATSBs) were used to control mosquitoes in the storm drains of a residential area on the outskirts of St Augustine, Florida. The drainage system was newly constructed and no mosquitoes were breeding inside it. The area covered by the storm drains was divided in half; 10 drains served as control drains and 16 drains served as experimental drains. The baits, which consisted of a mixture of brown sugar, fruit juice, green dye marker and boric acid, were presented at the entrances of the treated drains and exit traps were positioned over the drain openings and the connecting tubes leading to retention ponds. Similar baits with orange dye and without toxin were presented at the entrances of control drains. A total of 220 pupae of Culex quinquefasciatus (Diptera: Culicidae) were released in each control and toxin-treated drain, and the numbers of recovered mosquitoes were examined to determine the effectiveness of ATSBs in the storm drain system. An average of 178.2 mosquitoes exited each drain in the control area; 87.0% of these had fed on the baits and were stained orange, whereas 13.0% were unstained. In the toxin-treated drains, 83.7% of hatched females and 86.6% of hatched males were controlled by the baits.

A phase II trial of a neoadjuvant platinum-containing regimen for locally advanced breast cancer: Pathologic response, long-term follow-up, and correlation with biomarkers

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Background: To determine the response, tolerability, and long-term outcome of a neoadjuvant platinum-containing regimen for locally advanced breast cancer (LABC). To search for correlation between pathologic complete response (pCR) and predefined biomarkers in this cohort. Patients and Methods: Patients with LABC received eight cycles of either sequence A or B. Sequence A was doxorubicin 60 mg/m2 and paclitaxel 175 mg/m2 (AT) q3w X 4 followed by cisplatin (C) 60 mg/m2 and paclitaxel 90 mg/m2 (CT) q2w X 4. Sequence B was CT x 4 followed by AT x 4. In addition to estrogen receptor and HER2, immunohistochemistry (IHC) for MDR-1, MRP-1, topoisomerase IIα(topoIIα) and p53 was performed. Results: 88 patients were evaluable for response and toxicity. Median follow-up was 97 months. The overall pCR rate was 21.5%. For subgroups ER+/HER2-, HER2 +, and double negative (ER-/ HER2-) disease the pCR was 5.9%,23.3% and 35% respectively, p=0.006. Five year(y) overall survival for the entire cohort was 71.1%. Five y overall survival was 88.1% (CI 77.1%, 99.1%) for the ER positive HER2 negative group compared to 68.5% (CI 51.3%, 85.7%) and 49.5 (CI 27.4%, 71.6%) in the HER2 positive and “double negative” group respectively (p=0.0077). Over-expression of topo IIα was correlated with pCR (p<0.001). There were no toxic deaths. Conclusions: A platinum-containing neoadjuvant regimen was well tolerated and achieved a pCR rate which compares favorably to other recent studies of multi-agent chemotherapy. Further studies tailored for specific breast cancer subtypes are required.

No significant financial relationships to disclose.

Clinical, ethical and legal considerations in the treatment of newborns with non-ketotic hyperglycinaemia

Non-ketotic hyperglycinaemia (NKH) is a devastating neurometabolic disorder leading, in its classical form, to early death or severe disability and poor quality of life in survivors. Affected neonates may need ventilatory support during a short period of respiratory depression. The transient dependence on ventilation dictates urgency in decision-making regarding withdrawal of therapy. The occurrence of patients with apparent transient forms of the disease, albeit rare, adds uncertainty to the prediction of clinical outcome and dictates that the current practice of withholding or withdrawing therapy in these neonates be reviewed. Both bioethics and law take the view that treatment decisions should be based on the best interests of the patient. The medical-ethics approach is based on the principles of non-maleficence, beneficence, autonomy and justice. The law relating to withholding or withdrawing life-sustaining treatment is complex and varies between jurisdictions. Physicians treating newborns with NKH need to provide families with accurate and complete information regarding the disease and the relative probability of possible outcomes of the neonatal presentation and to explore the extent to which family members are willing to take part in the decision making process. Cultural and religious attitudes, which may potentially clash with bioethical and juridical principles, need to be considered.

Brevican and phosphacan expression and localization following transient middle cerebral artery occlusion in the rat

The ECM (extracellular matrix) is a complex molecular framework that provides physical support to cells and tissues, while also providing signals for cell growth, migration, differentiation and survival. The ECM of the CNS (central nervous system) is unusual in that it is rich in CSPGs (chondroitin sulfate proteoglycans), hyaluronan and tenascins. The CSPGs are widely expressed throughout the developing and adult CNS and have a role in guiding or limiting neurite outgrowth and cell migration. Alterations in the synthesis or breakdown of the ECM may contribute to disease processes. Here, we examine changes in the brain-specific CSPGs, brevican and phosphacan, following transient middle cerebral artery occlusion, a model of stroke in the rat. We have investigated their expression at various time points as well as their spatial relationship with ADAMTS-4 (adisintegrin and metalloprotease with thrombospondin motifs 4). The co-localization of ADAMTS or its activity may indicate a functional role for this matrix–protease pair in degeneration/regeneration processes that occur in stroke.

Phase II study of gemcitabine and oxaliplatin in patients with recurrent ovarian cancer: an Australian and New Zealand Gynaecological Oncology Group study

Gemcitabine and oxaliplatin have shown single-agent activity in relapsed ovarian cancer. This combination was used to determine response rates, time-to-event efficacy measures, and toxicity in patients with recurrent ovarian cancer. Patients with prior platinum-based chemotherapy who had measurable lesions and/or elevated CA-125 levels were identified as group A (platinum-refractory/platinum-resistant patients) and group B (platinum-sensitive patients). All patients received gemcitabine 1000 mg/m(2) on days 1 and 8 and oxaliplatin 130 mg/m(2) on day 8 every 21 days for up to eight cycles. Seventy-five patients (21 in group A and 54 in group B), with a median age of 58 years (range, 37-78), were enrolled. A median of six cycles (range, 1-8) was administered. By intent-to-treat analysis, 15 patients with measurable disease achieved partial response for an overall best response rate of 20.0% (9.5% in group A and 24.1% in group B). CA-125 response was observed in 48.4% patients (30.0% in group A and 57.1% in group B). Median time to progressive disease was 7.1 months (95% CI, 5.6-9.0 months) with 5.0 months in group A and 8.3 months in group B. Median overall survival was 17.8 months (95% CI, 12.9-21.3 months) with 9.2 months for group A and 20.0 months for group B. Major grade 3/4 toxicities were neutropenia (61.3%), leukopenia (24.0%), nausea (16.0%), and vomiting (22.7%). We conclude that the combination of oxaliplatin and gemcitabine is active in patients with recurrent ovarian cancer, but the regimen is unsatisfactory for further study due to modest response and relatively high toxicity.

Phase II study of carboplatin followed by sequential gemcitabine and paclitaxel as first-line treatment for advanced ovarian cancer

The aim of this exploratory phase II study was to evaluate sequential chemotherapy with carboplatin followed by gemcitabine-paclitaxel combination in chemonaive patients with advanced ovarian cancer. The primary objective was to evaluate time to progressive disease (TTPD); secondary objectives included the evaluation of 1- and 3-year survival, response rates, and toxicity. Following initial debulking surgery or biopsy, patients with FIGO stage IIC-IV disease received four cycles of carboplatin area under the curve (AUC) 6 (day 1) every 21 days, followed by four cycles of gemcitabine 1000 mg/m(2) (days 1 and 8) and paclitaxel 175 mg/m(2) (day 8) every 21 days. A total of 47 patients enrolled, 44 (93.6%) completed the initial four cycles, and 39 patients (82.9%) completed the planned eight cycles. The median and maximum lengths of follow-up were 31.2 and 43.7 months, respectively. Median TTPD was 13.8 months (95% CI, 11.6-21.0 months), and median survival time was 31.2 months (95% CI, 25.2-39.6 months). Survival at 1 and 3 years was 95.7% and 44.2%, respectively. Of the 43 evaluable patients, most (95.3%) of them achieved a CA-125 marker response based on Gynecologic Cancer Intergroup (GCIG) definition. The partial response rate in the seven patients with measurable disease was 46.4%. Myelosuppression was the major toxicity, with grade 3 and 4 neutropenia observed in 76.6% patients and thrombocytopenia in 12.8% patients. The sequential approach of carboplatin followed by gemcitabine-paclitaxel as first-line treatment for patients with ovarian cancer is feasible and well tolerated, and depending upon the findings from other major trials, it may merit further evaluation.

Initial safety results of an expanded access program (EAP) of erlotinib in non-small cell lung cancer (NSCLC)

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Background: Erlotinib is an orally active and selective inhibitor of HER1/EGFR tyrosine kinase. In the BR.21 phase III trial, erlotinib significantly prolonged survival, delayed symptom progression, and improved quality of life in NSCLC patients (pts) (Shepherd et al, NEJM, 2005;353:123). The EAP is an open label, non-randomized, multicentre phase IV trial. Methods: Eligibility criteria included stage III/IV NSCLC pts who failed or were unsuitable for chemotherapy. Pts were given oral erlotinib, 150 mg/d, for as long as treatment provided clinical benefit without unacceptable toxicity. Pts were monitored monthly. Results: In Dec 05, data were available for 1,140 pts from 25 countries, median age 64 y (range 25–91). Key base-line characteristics (% pts) were: males 58%; Caucasian/Oriental 82/15; non-smoker/former or current-smoker 26/73. The % pts with ECOG PS 0/1/2/3 were 20/52/20/8. Most pts (55%) had adenocarcinoma. The % pts receiving erlotinib as 1st/2nd/3rd-line treatment were 12/47/40. As expected, rash was a common adverse event (AE: any grade [gr]: 65%; gr 3/4: 9%). Full safety data were available for 581 pts. Unexpected erlotinib-related AEs were only seen in <2% pts. Erlotinib-related AEs leading to treatment discontinuation were GI disorders in 21 pts (12 pts had gr 3/4 AEs) and skin disorders in 14 pts (6 pts had gr 3/4 rash). Only 10% of pts had dose reductions, mainly due to rash (66%; gr 3 in 8 pts) and diarrhea (17%; gr 3 in 2 pts). The median daily dose of erlotinib was 150mg. Serious erlotinib-related AEs were GI disorders (19 AEs; 11 gr 3/4), mainly diarrhea (8 AEs, 5 were gr 3). Pt accrual and analyses of response, survival data and assessment of various predictive biomarkers are ongoing. Response and survival data will be presented. Conclusions: These interim safety results of erlotinib in the real-life clinical setting in a large number of unselected pts with advanced NSCLC confirm the good tolerability observed in clinical trials. To date, the trial demonstrates that erlotinib is well tolerated, thus, allowing full dose administration to most pts.

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A 3-year prospective study of the effects of adjuvant treatments on cognition in women with early stage breast cancer

The neuropsychological performance of 85 women with early stage breast cancer scheduled for chemotherapy, 43 women scheduled for endocrine therapy and/or radiotherapy and 49 healthy control subjects was assessed at baseline (T1), postchemotherapy (or 6 months) (T2) and at 18 months (T3). Repeated measures analysis found no significant interactions or main effect of group after controlling for age and intelligence. Using a calculation to examine performance at an individual level, reliable decline on multiple tasks was seen in 20% of chemotherapy patients, 26% of nonchemotherapy patients and 18% of controls at T2 (18%, 14 and 11%, respectively, at T3). Patients who had experienced a treatment-induced menopause were more likely to show reliable decline on multiple measures at T2 (OR=2.6, 95% confidence interval (CI) 0.823–8.266 P=0.086). Psychological distress, quality of life measures and self-reported cognitive failures did not impact on objective tests of cognitive function, but were significantly associated with each other. The results show that a few women experienced objective measurable change in their concentration and memory following standard adjuvant therapy, but the majority were either unaffected or even improve over time.

ADAMTS-1 and -4 are up-regulated following transient middle cerebral artery occlusion in the rat and their expression is modulated by TNF in cultured astrocytes

ADAMTS (a disintegrin and metalloproteinase with thrombospondin motifs) enzymes are a recently described group of metalloproteinases. The substrates degraded by ADAMTS-1, -4 and -5 suggest that they play a role in turnover of extracellular matrix in the central nervous system (CNS). ADAMTS-1 is also known to exhibit anti-angiogenic activity. Their main endogenous inhibitor is tissue inhibitor of metalloproteinases (TIMP)-3. The present study was designed to investigate ADAMTS-1, -4 and -5 and TIMP-3 expression after experimental cerebral ischaemia and to examine whether cytokines known to be up-regulated in stroke could alter their expression by astrocytes in vitro. Focal cerebral ischaemia was induced by transient middle cerebral artery occlusion in the rat using the filament method. Our results demonstrate a significant increase in expression of ADAMTS-1 and -4 in the occluded hemisphere but no significant change in TIMP-3. This was accompanied by an increase in mRNA levels for interleukin (IL)-1beta, IL-1 receptor antagonist (IL-1ra) and tumour necrosis factor (TNF). ADAMTS-4 mRNA and protein were up-regulated by TNF in primary human astrocyte cultures. The increased ADAMTS-1 and -4 in experimental stroke, together with no change in TIMP-3, may promote ECM breakdown after stroke, enabling infiltration of inflammatory cells and contributing to brain injury. In vitro studies suggest that the in vivo modulation of ADAMTS-1 and -4 may be controlled in part by TNF.

Relationship of anhedonia and anxiety to social rank, defeat and entrapment

There is good evidence to suggest that depression is highly correlated with perceptions of low rank and subordinate status (i.e. feeling inferior, low-self esteem, feeling that others look down on the self, and submissive behaviour). However, it is possible for people to feel inferior and anxious, and behave submissively but not necessarily be depressed. More recently two other processes, defeat and entrapment, have attracted attention as possible processes linked specifically to depression and anhedonia. This research explored the relationship of these variables (social rank variables and defeat and entrapment) to two measures of hedonic tone (low positive affectivity and anhedonia) and anxiety in both a clinical and student population. All variables were strongly associated with lowered hedonic tone and anxiety. However, partial correlations, and a structural equation model fitted to the data from combined groups, suggests that perceptions of defeat play a specifically important role in anhedonia as measured by low positive affect. Framed within an evolutionary model the data suggest that the mechanisms which evolved to help animals accommodate and respond to defeats may have important regulatory effects over positive affect, reducing exploration of and engagement with the environment.

A comparison of behaviour in two differing psychiatric long-stay rehabilitation environments

This study compares aspects of behaviour in two long-stay resident groups with residual psychiatric difficulties. One group was residing on traditional psychiatric hospital wards and the other group was based in a newly built bungalow complex set within the hospital grounds. This study compares behavioural profiles between these two resident groups. Results indicate that bungalow residents showed significantly lower levels of psychiatric difficulty than their 'ward-based' counterparts. To explore this result further we conducted an examination of possible selection bias at the time of initial assessment. Historical data on both groups were obtained from case notes and analysed to seek possible explanations for this result. These results are discussed with respect to the provision of mental health care in smaller retained hospital facilities and nursing practice, which emphasizes the provision of effective philosophies of care accentuating choice, a sense of autonomy and involvement in care.

Significance of a prenatally diagnosed del(10)(q23)

Structural chromosome mosaicism is rare. We report a case of prenatal mosaicism for a deletion of chromosome 10(q23). To our knowledge, there are only three reports of prenatally diagnosed cases of del(10)(q23). Two of these cases were due to an inherited fragile site. In the present case amniocentesis revealed 46,XY,del(10)(q23)[9]/46,XY[45]. Follow-up chromosome analysis of peripheral blood and placental tissue from a phenotypically normal liveborn male revealed the del(10)(q23) in only 3/100 blood cells grown in low-folate medium. It appears that prenatally diagnosed deleted (10q) mosaicism represents culture artifact and is not clinically significant.