Internet-Based Access to Sexual and Reproductive Health Services Among Colombian Youth: A Cross-Sectional Study

Introduction: Sexual and reproductive health (SRH) is a sensitive subject, and young people may be unfamiliar with how to access SRH services. In this cross-sectional study, we examined young people's internet use to understand how they accessed SRH clinics in Colombia. This study also explored Colombian youth's interest in online material teaching how to access SRH services. Methods: During August 2019-February 2020, patients aged 10-24 years old presenting at two SRH clinics in Colombia were invited to answer a survey. Chi-square tests were performed to assess possible differences in how participants inquired how to access the clinic according to sociodemographic characteristics. Results: Among the 812 patients who participated, 91.4% were female and the median age was 19 years. To inquire how to access the SRH clinic, 30.7% of participants asked their parent(s) and 24.0% used the internet. Participants aged 20-24 years old were more likely to use the internet compared to younger participants (p < .001). Most respondents (81.5%) were interested in the availability of online material explaining how to access SRH services. Conclusions: While Colombian youth learned about how to access SRH clinics from several different sources, the vast majority indicated their interest in having access to online materials explaining how to access SRH services.

A Mixed-Methods Study Exploring Colombian Adolescents' Access to Sexual and Reproductive Health Services: The Need for a Relational Autonomy Approach

This study's objective was to understand Colombian adolescents' experiences and preferences regarding access to sexual and reproductive health services (SRHS), either alone or accompanied. A mixed-method approach was used, involving a survey of 812 participants aged eleven to twenty-four years old and forty-five semi-structured interviews with participants aged fourteen to twenty-three. Previous research shows that adolescents prefer privacy when accessing SRHS and often do not want their parents involved. Such findings align with the longstanding tendency to frame the ethical principle of autonomy as based on independence in decision-making. However, the present study shows that such a conceptualization and application of autonomy does not adequately explain Colombian adolescent participants' preferences regarding access to SRHS. Participants shared a variety of preferences to access SRHS, with the majority of participants attaching great importance to having their parents involved, to varying degrees. What emerges is a more complex and non-homogenous conceptualization of autonomy that is not inherently grounded in independence from parental involvement in access to care. We thus argue that when developing policies involving adolescents, policymakers and health professionals should adopt a nuanced "relational autonomy" approach to better respect the myriad of preferences that Colombian (and other) adolescents may have regarding their access to SRHS.

Empowering the next generation: integrating adolescents into the Reproductive Justice movement

This article explores the ethical implications of mandatory parental consent requirements for adolescents seeking sexual and reproductive health services (SRHS). Using a Reproductive Justice framework, which identifies systemic barriers to accessing healthcare services, we examine ageism as a potential factor restricting adolescents' access to SRHS. While the Reproductive Justice framework has addressed systemic issues like racism and ableism in healthcare, ageism involving adolescents has been less explored. The article challenges the pertinence of mandatory parental consent requirements-as a potential barrier-for adolescents' access to SRHS. We argue that in the specific context of SRHS (contraceptives, abortion, testing and treatment of sexually transmitted infections), adolescents' autonomy (self-determination) should be respected if they request to access those services independently. From a global health perspective, adolescents have a low prevalence and uneven access to SRHS. To address the issue, we propose the integration of adolescence into the Reproductive Justice movement to empower them through education on how to access the SRHS they need.

Period poverty and mental health in times of covid-19 in France

We investigate the relationship between period poverty and anxiety and depression in women aged from 18 to 50 years in the context of the first French covid19 lockdown. 890 participants completed an online survey. Anxiety was assessed with the General Anxiety Disorder scale, depression with the Major Depression Inventory. 9.6% of participants experienced difficulties accessing period protection during the first lockdown. Among the women experiencing period poverty, 49.4% showed depressive symptoms compared to 28.6% of the women who had not experienced menstrual poverty, 40% showed anxious symptoms (vs 24.1%). The relationships between period poverty, depression and are significant even in adjusted models controlled by sociodemographics variables (depression: AOR = 2.191 [1.372 - 3.499]; anxiety: AOR = 1.793, [1.110 - 2.897]). As clinicians, psychologists or social workers, it seems interesting to go beyond the first symptoms of depression and anxiety and question the patients' access to menstrual health products.

Ravez L. Introduction à l’éthique de la santé publique (2020)

Ce compte rendu examine le livre de Laurent Ravez, Introduction à l’éthique de la santé publique et souligne l’importance d’être familier avec l’éthique en santé publique, autant pour les gens oeuvrant en bioéthique que celles et ceux qui travaillent en santé publique.

A Critique of O'Byrne's Understanding of Ethnography and the Politics of Public Health Research

Patrick O'Byrne criticizes the use of ethnography in public health research focused on cultural groups. His main argument is that ethnography disciplines marginalized populations that do not respect the imperative of health. In this article, I argue that O'Byrne has an erroneous understanding of ethnography and the politics of scientific research. My main argument is that a methodology itself cannot discipline individuals. I argue that if data are used as a basis to develop problematic public health policies, the issue is the policies themselves and not the methodology used to collect the data. While O'Byrne discourages researchers from conducting health research like ethnography focused on cultural groups, I argue the exact opposite. This has to do with justice and equity for marginalized communities and the obligation to tailor health services for their specific needs, which may not be the same as those of the general population.

Towards an Integration of PrEP into a Safe Sex Ethics Framework for Men Who Have Sex with Men

The ethics of safe sex in the gay community has, for many years, been focused on debates surrounding the responsibility (or lack thereof) regarding the use of condoms to prevent HIV transmission, once the only tool available. With the development of Truvada as a pre-exposure prophylaxis (PrEP) for HIV, for the first time in the history of the HIV/AIDS epidemic there is the potential to significantly reduce the risk of HIV transmission during sex without the use of condoms (without taking into consideration 'treatment as prevention' with HIV-positive people). The introduction of PrEP necessitates a renewed discussion about the politics and ethics of safe sex for men who have sex with men (MSM). We present the arguments of authors who hold radically opposite positions with regard to the ethics of condom use by gay men, but who currently both criticize the use of PrEP. We offer a critique of their arguments and advance the position that the use of PrEP, even without condoms, can be acceptable and part of a safe sex ethics framework for MSM.

Reflections on the history of bareback sex through ethnography: the works of subjectivity and PrEP

Throughout the history of bareback sex (condomless sex between men), 'subjects' have been created, particularly through scientific literature, to characterise the men who engage in the sexual practice. For example, a gay man who does not use a condom may be framed as a pathologised subject. This paper first presents this history. Afterwards, by relying upon ethnographic data such as interviews collected from fieldwork research done in Toronto in 2014 with young gay men who have bareback sex, it shows exactly how these young gay men related themselves to those subjects. Then, it focuses on the pre-exposure prophylaxis (PrEP) Truvada as a new HIV prevention technology. Although PrEP can allow condomless sex to occur while diminishing the risk of HIV transmission, at the time of the research, none of the young gay men were interested in using this tool despite being the subjects for whom the drug is tailored. This paper argues that PrEP and subjectivity are coproduced and can have conflicting meanings. This contradiction of meanings is a result of the various representations and symbols of bareback sex and the men who engage in the practice that have been produced throughout the history of bareback sex.

Science, technology, power and sex: PrEP and HIV-positive gay men in Paris

The pre-exposure prophylaxis (PrEP) drug Truvada is a new HIV prevention technology that is predominantly promoted as relevant to HIV-negative gay men. This paper explores what PrEP represents for HIV-positive gay men living in Paris, based upon data collected through interviews and ethnographic research. While HIV-positive gay men do not directly consume Truvada through PrEP, they nonetheless hold opinions and understandings of this drug, specifically as it relates to their own sexuality. This paper expands the representations and meanings of this new technology in a different light through the voices of gay men living with HIV in Paris. The main argument of this article is that PrEP as an additional HIV prevention tool blurs the lines between science, technologies and human sexuality.

Ethical public health issues for the use of informal PrEP

This article presents the phenomenon of the use of informal pre-exposure prophylaxis (PrEP), also known colloquially as 'wild PrEP'. The related ethical public health issues of the use of informal PrEP are discussed. From the approach of an ethical framework of risk reduction in public health, the main objective of this article is to encourage health-related practices and policies that do not stop the informal access to PrEP, but rather promote the wellbeing of users by providing them with the necessary knowledge and resources related to PrEP and HIV prevention (i.e. getting regularly tested for HIV if one is to take PrEP). As each country has its own policies with respect to PrEP and access to healthcare services, this article does not explore specific locations but rather highlights different global ethical key points on how to approach the use of informal PrEP with the goal of promoting HIV prevention among individuals at high risk for HIV infection.

Treatment of a mixed wood preservative leachate by a hybrid constructed wetland and a willow planted filter

The performance and removal mechanisms of a hybrid constructed wetland (HCW) followed by a willow planted filter (WPF) were evaluated for the treatment of a leachate contaminated by wood pole preservatives (pentachlorophenol (PCP) and chromated copper arsenate) to reach the storm sewer discharge limits. The HCW aimed to dechlorinate the PCP and polychlorodibenzo-p-dioxins/polychlorodibenzofuran (PCDD/F) and to remove metals by adsorption and precipitation. The HCW was efficient in removing PCP (>98.6%), oil, arsenic (99.4%), chromium (>99.2%), copper (>99.6%%) and iron (29%) to under their discharge limits, but it was unable to reach those of Mn and PCDD/F, with residual concentrations of 0.11 mg Mn/L and 0.32 pg TEQ/L. Iron and manganese could be removed but were subsequently released by the HCW due to low redox conditions. No dechlorination of PCDD/F was observed since its chlorination profile remained the same in the different sections of the HCW. Adsorption was the most probable removal mechanism of PCDD/F. The WPF was able to remove some residual contamination, but it released Mn at a gradually decreasing rate. Total evapotranspiration of the leachate by a larger fertilized WPF and the construction of an underground retention basin are proposed to prevent any discharge of PCDD/F traces in the environment.

Audit feedback on reading performance of screening mammograms: An international comparison

Objective

Providing feedback to mammography radiologists and facilities may improve interpretive performance. We conducted a web-based survey to investigate how and why such feedback is undertaken and used in mammographic screening programmes.

Methods

The survey was sent to representatives in 30 International Cancer Screening Network member countries where mammographic screening is offered.

Results

Seventeen programmes in 14 countries responded to the survey. Audit feedback was aimed at readers in 14 programmes, and facilities in 12 programmes. Monitoring quality assurance was the most common purpose of audit feedback. Screening volume, recall rate, and rate of screen-detected cancers were typically reported performance measures. Audit reports were commonly provided annually, but more frequently when target guidelines were not reached.

Conclusion

The purpose, target audience, performance measures included, form and frequency of the audit feedback varied amongst mammographic screening programmes. These variations may provide a basis for those developing and improving such programmes.

Characteristics affecting survival after locally advanced colorectal cancer in Quebec

BACKGROUND

We estimated the relations of sociodemographic, organizational, disease, and treatment variables with the risk of death from colorectal cancer (crc) in a Quebec population-based sample of patients with locally advanced crc (lacrc) who underwent tumour resection with curative intent.

METHODS

Information from medical records and administrative databases was obtained for a random sample of 633 patients surgically treated for stages ii-iii rectal and stage iii colon cancer and declared to the Quebec cancer registry in 1998 and 2003. We measured personal, disease, and clinical management characteristics, relative survival, and through multivariate modelling, relative excess rate (rer) of death.

RESULTS

The relative 5- and 10-year survivals in this cohort were 67.7% [95% confidence interval (ci): 65.8% to 69.6%] and 61.2% (95% ci: 58.3% to 64.0%) respectively. Stage T4, stage N2, and emergency rather than elective surgery affected 18%, 24% and 10% of patients respectively. Those disease progression characteristics each independently increased the rer of death by factors of 2 to almost 5. Grade, vascular invasion, and tumour location were also significantly associated with the rer for death. Receiving guideline-adherent treatment was associated with a 60% reduction in the rer for death (0.41; 95% ci: 0.28 to 0.61), an effect that was consistent across age groups. Clear margins (proximal-distal, radial) and clinical trial enrolment were each associated with a nonsignificant 50% reduction in the rer. Of patients less than 70 years of age and 70 years of age and older, 81.3% and 42.0% respectively received guideline-adherent treatment.

CONCLUSIONS

This study is the first Quebec population-based examination of patients with lacrc and their management, outcomes, and outcome determinants. The results can help in planning crc control strategies at a population level.

Using the Cancer Risk Management Model to evaluate colorectal cancer screening options for Canada

BACKGROUND

Several screening methods for colorectal cancer (crc) are available, and some have been shown by randomized trials to be effective. In the present study, we used a well-developed population health simulation model to compare the risks and benefits of a variety of screening scenarios. Tests considered were the fecal occult blood test (fobt), the fecal immunochemical test (fit), flexible sigmoidoscopy, and colonoscopy. Outcomes considered included years of life gained, crc cases and deaths prevented, and direct health system costs.

METHODS

A natural history model of crc was implemented and calibrated to specified targets within the framework of the Cancer Risk Management Model (crmm) from the Canadian Partnership Against Cancer. The crmm-crc permits users to enter their own parameter values or to use program-specified base values. For each of 23 screening scenarios, we used the crmm-crc to run 10 million replicate simulations.

RESULTS

Using base parameter values and some user-specified values in the crmm-crc, and comparing our screening scenarios with no screening, all screening scenarios were found to reduce the incidence of and mortality from crc. The fobt was the least effective test; it was not associated with lower net cost. Colonoscopy screening was the most effective test; it had net costs comparable to those for several other strategies considered, but required more than 3 times the colonoscopy resources needed by other approaches. After colonoscopy, strategies based on the fit were predicted to be the most effective. In sensitivity analyses performed for the fobt and fit screening strategies, fobt parameter values associated with high-sensitivity formulations were associated with a substantial increase in test effectiveness. The fit was more cost-effective at the 50 ng/mL threshold than at the 100 ng/mL threshold.

CONCLUSIONS

The crmm-crc provides a sophisticated and flexible environment in which to evaluate crc control options. All screening scenarios considered in this study effectively reduced crc mortality, although sensitivity analyses demonstrated some uncertainty in the magnitude of the improvements. Where possible, local data should be used to reduce uncertainty in the parameters.

No effect of scalp cooling on survival among women with breast cancer

Scalp cooling can prevent chemotherapy-induced alopecia in some cancer patients. It is not used in all countries. No data are available regarding its impact, if any, on survival. The aim of this study was to compare overall survival according to whether or not scalp cooling was used during neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer. We conducted a retrospective cohort study of 1,370 women with non-metastatic invasive breast carcinoma who received chemotherapy in the neoadjuvant or adjuvant setting. A total of 553 women who used scalp cooling came from a tertiary breast cancer clinic in Quebec City (diagnosed between 1998 and 2002) and 817 were treated in other hospitals in the province of Quebec (between 1998 and 2003) where scalp cooling was not routinely available. Overall survival of women who used scalp cooling and those who did not was compared using Cox proportional hazards models. Median follow-up for the scalp-cooled and the non-scalp-cooled groups was 6.3 years and 8.0 years, respectively. Overall mortality was no different (adjusted hazard ratio 0.89, 95 % confidence interval: 0.68-1.17, p = 0.40) among scalp-cooled women, compared to those not getting scalp cooling. Among women getting neoadjuvant or adjuvant chemotherapy for non-metastatic breast cancer, scalp cooling used to prevent chemotherapy-induced alopecia had no negative effect on survival. To our knowledge, this is the first study to compare survival of women who used scalp cooling to that of women who did not.

Maximizing pollutant removal in constructed wetlands: should we pay more attention to macrophyte species selection?

While the positive role of macrophytes on removal efficiency in constructed wetlands has been well established, possible differences in performance between plants species of comparable life forms and sizes are much harder to demonstrate. We reviewed 35 experimental studies published in peer-reviewed journals and proceedings on the effect of macrophyte species selection on pollutant removal in SSFCW. The studies cover a wide range of macrophyte species, experimental approaches (from well-replicated microcosm experiments to comparison between full full-size constructed wetlands), climatic conditions (from tropical to cold-temperate) and types of effluent (domestic, industrial, etc.). Frequent methodological limitations in these studies compel caution in the interpretation of their results. Yet, the fact that the majority found some (occasionally large) differences in efficiency between plant species for one or more type of pollutant suggests that macrophyte species selection does matter. However, there is little generalization to be made that could help guide species selection for SSFCW, except for the exact conditions in which the experiments were done. For example, the same pair of species that was tested in different studies occasionally gave opposite results in terms of which one performs best. Also, most studies provided few insights on the mechanisms or plant properties that could explain the observed differences in plant species efficiency. Finally, we discuss other relevant research questions and approaches that could help better guide macrophyte species selection for CW.

Financial burden from wage losses after early breast cancer: Extent and determinants among Canadian women

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Background: Wage losses after breast cancer may result in considerable financial burden. More women now participate in the workforce and breast cancer is managed using multiple treatment modalities that could lead to long work absences. We evaluated the burden from wage losses and determinants among Canadian women in the first 12 months after newly diagnosed non-metastatic breast cancer. Methods: This prospective cohort study was conducted among 800 women from 8 hospitals (participation 83%) of whom 459 were working at diagnosis. For these latter women, information on potential determinants of wage losses, work absences, compensation received and perception of financial situation was collected by 3 telephone interviews over the year. Information on medical characteristics came from medical files. The main outcome was the relative loss, namely wages lost divided by annual wages the woman would have earned had she not been absent from work. ANOVA was used to identify determinants. Results: The median relative loss in the first year after diagnosis for the 403 women reporting an absence or reduced work hours was 19% or $5,502 (Can dollars). Multivariate analysis showed that the mean relative loss was 13% for women who reported that breast cancer was not at all costly compared to 22%, 33% and 38% among women who said that breast cancer was a bit, quite or very costly, respectively (ptrend<0.0001). A higher relative loss was significantly associated with a lower level of education (difference between lowest and highest levels = 8 %, ptrend=0.0016), living =50 km from the surgery hospital (diff = 6%, p=0.0697), lower social support (diff = 8%, p=0.0119), invasive disease (diff = 6%, p=0.0861), chemotherapy (diff = 17%, p<0.0001), self-employment (diff= 17%, p<0.0001), shorter tenure in the job (diff between lowest and highest levels = 12%, ptrend<0.0001) and part-time work (diff = 10%, p=0.0003). Conclusions: Financial effects of wage losses could add to the overall burden of breast cancer. Clinicians and policy makers should be sensitized further to the fact that financial burden may be important for working women having more aggressive treatment and precarious work situations.

No significant financial relationships to disclose.

Influence of macrophyte species on microbial density and activity in constructed wetlands

It is often assumed that planted wastewater treatment systems outperform unplanted ones, mainly because plants stimulate belowground microbial population. Yet, fundamental interactions between plants and associated microorganisms remain only partly understood. The aim of our project was to evaluate microbial density and activity associated to the rhizosphere of three plant species. Experimental set-up, in six replicates, consisted of four 1.8-L microcosms respectively planted in monoculture of Typha angustifolia, Phragmites australis, Phalaris arundinacea and unplanted control. Plants were grown for two months with 25 L m(-2) d(-1) of secondary effluent (in g m(-2) d(-1): 1.3 TSS, 7.5 COD, 1.0 TKN). Sampling of substrate, roots and interstitial water was made according to depth (0-10, 10-20 cm). Biofilm was extracted with 500 mL of a buffer solution. Microbial density was directly estimated by flow cytometry and indirectly by protein measurements. Biological activity was determined using respirometry assays, dehydrogenase and enzymatic activity measurements. Our results show that microbial density and activity are higher in the presence of plants, with significantly higher values associated with Phalaris arundinacea. Greater density of aerobic or facultative bacteria was present in planted microcosm, particularly on root surface, suggesting root oxygen release. Microbes were present on substrate and roots as an attached biofilm and abundance was correlated to root surface throughout depth. Plant species root morphology and development seem to be a key factor influencing microbial-plant interaction.

Effect of loading rate on performance of constructed wetlands treating an anaerobic supernatant

The effect of organic loading, season and plant species on the treatment of fish farm effluent was tested using three-year old mesocosm wetland systems. During one year, nine 1 m2 mesocosms (horizontal subsurface flow), located in a controlled greenhouse environment, were fed with a reconstituted fish farm effluent containing a high fraction of soluble components (1,600 microS/cm and in mg/L: 230 +/- 80 COD, 179 +/- 60 sCOD, 100 +/- 40 TSS, 37 +/- 7 TKN, 14 +/- 2 TP). Combinations of three hydraulic loading rates (30, 60 and 90 L.m(-2) d(-1)) and two plant species (Phragmites australis, Typha angustifolia) and an unplanted control were tested for treatment performance and hydraulic behaviour. Loadings higher than 15 g COD m(-2) d(-1) resulted in a net decrease of hydraulic performances (generation of short circuiting) coupled with low TKN removal. Maximal TKN removal rates (summer: 1.2, winter: 0.6 g.m(-2) d(-1)) were reached in planted units. In all mesocosms, phosphorus was removed during summer (maximal removal rate: 0.3 g TP m(-2) d(-1)) and was released in winter (release rate = approximately half of summer removal rate). This study confirmed that constructed wetlands are susceptible to clogging when treating anaerobic storage tank supernatant rich in highly biodegradable compounds. Contributions of plants to hydraulic efficiency were mainly observed in summer, associated with high evapotranspiration rates. Both plant species gave a similar removal efficiency for all pollutants.

Slag columns for upgrading phosphorus removal from constructed wetland effluents

The current best option to upgrade constructed wetlands (CWs) for phosphorus (P) retention, in terms of efficiency, cost and simplicity, consists in using media having a strong P affinity. The media can be used either in the planted beds or in a filtration system downstream of the beds. The use of slag filters was shown to be efficient for removing P from wastewater as it represented a slow release source of calcium and hydroxide, favouring the formation of hydroxyapatite. Our study aimed at maximising the P retention capacity of slag filters located at the outlet of CWs since electric arc furnace slag has been shown to inhibit the growth of macrophytes when used in the filtration matrix. Bench-scale columns (Vtot = 6.2 L) filled with various combinations of filter media (slag, granite, limestone) of different sizes (2-5, 5-10, 10-20 mm) were fed on-site during four months with a CW effluent (in mg/L: 30 COD, 30 TSS, 10 Pt). Results showed that the best media combination enabling the maximum o-PO4 retention (more than 80% removal without clogging) consisted in a series of a ternary mix column (slag 5-10 mm, granite 2-5 mm, limestone 5-10 mm) followed by a slag column (slag 5-10 mm). Pilot scale columns (Vtot = 300 L), filled with the best media combination, were installed at the outlet of a 28 m2 CW. These columns showed more than 75% removal efficiency during one year and were designed to be easily replaced each year.

The benefit of participating to clinical research

We assessed the impact of participating to clinical research among 1727 women with localized breast cancer. Using as referent individuals not treated according to guidelines for systemic therapy, the adjusted hazard ratio of death was 0.70 (95% confidence interval (CI): 0.54,0.90, p-value: 0.006) in those treated according to current guidelines and 0.45 (95% CI: 0.27,0.73, p-value: 0.001) in participants to research. Participation to clinical trials results in a substantial gain in survival.

Contribution of clinical breast examination to mammography screening in the early detection of breast cancer

OBJECTIVES

As the benefit of clinical breast examination (CBE) over that of screening mammography alone in reducing breast cancer mortality is uncertain, it is informative to monitor its contribution to interim measures of effectiveness of a screening programme. Here, the contribution of CBE to screening mammography in the early detection of breast cancer was evaluated.

SETTING

Four Canadian organised breast cancer screening programmes.

METHODS

Women aged 50-69 receiving dual screening (CBE and mammography) (n = 300,303) between 1996 and 1998 were followed up between screen and diagnosis. Outcomes assessed by mode of detection (CBE alone, mammography alone, or both CBE and mammography) included referral rate, positive predictive value, pathological features of tumours (size, nodal status, morphology), and cancer detection rates overall and for small cancers (< or = 10 mm or node-negative). Heterogeneity in findings across programmes was also assessed.

RESULTS

On first versus subsequent screen, CBE alone resulted in 28.5-36.7% of referrals, and 4.6-5.9% of cancers compared with 52.6-60.1% of referrals and 60.0-64.3% of cancers for mammography alone. Among cancers detected by CBE, 83.6-88.6% were also detected by mammography, whereas for mammographically detected cancers only 31.7-37.2% were also detected by CBE. On average, CBE increased the rate of detection of small invasive cancers by 2-6% over rates if mammography was the sole detection method. Without CBE, programmes would be missing three cancers for every 10,000 screens and 3-10 small invasive cancers in every 100,000 screens.

CONCLUSIONS

Inclusion of CBE in an organised programme contributes minimally to early detection.

Delay in adjuvant radiation treatment and outcomes of breast cancer--a review

Recent meta-analyses have shown the importance of locoregional control as a long-term determinant of breast cancer survival. Whether factors related to the delivery of radiotherapy, such as delay, dose, fractionation or irradiated volume, are associated with outcome remains unclear. We performed a critical review of the literature on delay to radiation using a computerized search of papers published between 1985 and 2000. Periods of accrual, details of radiotherapy, surgical and systemic treatment, and information on prognostic factors were noted. Studies on sequencing of adjuvant therapy were compared to studies on delay to radiation, classified according to whether or not patients also received chemotherapy. Comparisons of patients receiving systemic therapy to individuals spared this option were considered uninformative since the impact of delaying radiation is then highly confounded by systemic treatment received. The single published experimental study on sequencing suggests that delay to radiation may compromise local control, and this is consistent with a few retrospective reports on delay to radiotherapy among patients receiving chemotherapy. However, indirect evidence from two randomized clinical trials of chemotherapy, and the majority of observational studies on delay to radiotherapy, suggest that it has no impact on either local, distant control or survival. Factors, methodological, and others, that could explain these inconsistencies are discussed. No study restricted to patients at low risk of recurrence suggested an impact of delaying radiation. Short chemotherapy regimens are likely to represent a safe option with respect to outcome of radiation treatment.

Expression of cathepsin D, stromelysin-3, and urokinase by reactive stromal cells on breast carcinoma prognosis

BACKGROUND

Current literature suggests that several proteases act in a cascade to mediate remodeling of the extracellular matrix and favor cancer progression. Others and the authors of this study recently identified cathepsin D, stromelysin-3, and urokinase plasminogen activator (uPA) expression by reactive stromal cells as significant factors of poor prognosis in breast carcinoma. The authors evaluated the joint effect of protease expression on cancer aggressiveness.

METHODS

Protease expression was analyzed by immunohistochemistry (cathepsin D) and in situ hybridization (stromelysin-3 and uPA) on formalin fixed paraffin embedded specimens from 557 breast carcinomas without distant metastasis at diagnosis and with an average of 10 years of follow-up.

RESULTS

Of the 557 breast carcinomas, 80 (14.3%) expressed all 3 proteases, and 134 (24%) expressed none of them. An adjusted Cox model revealed significantly worse distant metastasis free survival (DMFS) with expression of all three proteases (P < 0.0001). The DMFS of patients whose tumor lacked at least one of the three proteases was similar to that of patients without any protease expression, irrespective of the type or number of proteases missing.

CONCLUSIONS

This study suggests that proteases expressed by reactive stromal cells are interdependent and that a breach in the protease pathway may impair breast carcinoma progression.

Short polyglutamine tracts in the androgen receptor are protective against breast cancer in the general population

We studied the association of breast cancer with the polymorphic polyglutamine repeat of the androgen receptor (AR) in 255 incident cases of breast cancer and 461 matched controls from the Quebec City metropolitan area. Women for whom the sum of both of the AR (CAG)n-repeats alleles is 39 or less (short-allele AR genotypes) have one-half the risk of breast cancer compared with women for whom the sum of AR (CAG)n-repeats is 40 or more [odds ratio (OR), 0.5; 95% confidence interval (CI), 0.3-0.83; P = 0.007]. This association is stronger in postmenopausal women (180 cases, 297 controls; OR, 0.36; 95% CI, 0.19-0.7; P = 0.003). We also observed an interaction between the type of menopause (natural versus surgical) and the AR genotype on breast cancer risk. Alternately, when subjects were grouped according to their (CAG)n-repeat genotype [homozygous for short alleles (CAG)n < or = 20; other genotypes ("long allele")], results were similar (OR. 0.5; 95% CI, 0.27-0.82; P = 0.007). Thus, women with short-alleles AR genotypes appear to be protected against breast cancer. Short-alleles AR genotypes were observed in 16% of the general population as represented by the control group. Short polyglutamine repeats in the AR protein have been reported to be associated with an increase in the capacity of the receptor to activate transcription of reporter genes in vitro. Furthermore, androgens have been previously shown to inhibit in vitro the growth of breast cancer cell lines. This suggests that differences in the number of polyglutamines in the AR protein may influence individual risk of breast cancer, especially in postmenopausal women, and that this apparent protection could be the consequence of an increased response/sensitivity to androgens.

Disrupting evolutionary processes: the effect of habitat fragmentation on collared lizards in the Missouri Ozarks

Humans affect biodiversity at the genetic, species, community, and ecosystem levels. This impact on genetic diversity is critical, because genetic diversity is the raw material of evolutionary change, including adaptation and speciation. Two forces affecting genetic variation are genetic drift (which decreases genetic variation within but increases genetic differentiation among local populations) and gene flow (which increases variation within but decreases differentiation among local populations). Humans activities often augment drift and diminish gene flow for many species, which reduces genetic variation in local populations and prevents the spread of adaptive complexes outside their population of origin, thereby disrupting adaptive processes both locally and globally within a species. These impacts are illustrated with collared lizards (Crotaphytus collaris) in the Missouri Ozarks. Forest fire suppression has reduced habitat and disrupted gene flow in this lizard, thereby altering the balance toward drift and away from gene flow. This balance can be restored by managed landscape burns. Some have argued that, although human-induced fragmentation disrupts adaptation, it will also ultimately produce new species through founder effects. However, population genetic theory and experiments predict that most fragmentation events caused by human activities will facilitate not speciation, but local extinction. Founder events have played an important role in the macroevolution of certain groups, but only when ecological opportunities are expanding rather than contracting. The general impact of human activities on genetic diversity disrupts or diminishes the capacity for adaptation, speciation, and macroevolutionary change. This impact will ultimately diminish biodiversity at all levels.

Stressful life events and survival after breast cancer

OBJECTIVE

This study assessed the relation of stressful life events with survival after breast cancer.

METHODS

This study was based on women with histologically confirmed, newly diagnosed, localized or regional stage breast cancer first treated in 1 of 11 Quebec City (Canada) hospitals from 1982 through 1984. Among 765 eligible patients, 673 (88%) were interviewed 3 to 6 months after diagnosis about the number and perceived impact of stressful events in the 5 years before diagnosis. Three scores were calculated: number of events; number weighted by reported impact; and for almost 80% of events, number weighted by community-derived values reflecting adjustment required by the event. Scores were divided into quartiles to assess possible dose-response relationships. Survival was assessed in 1993. Hazard ratios and 95% confidence intervals (CIs) comparing all-cause and breast cancer-specific mortality were calculated with adjustment for age, presence of invaded axillary nodes, adjuvant radiotherapy, and systemic therapy (ie, chemotherapy and hormone therapy).

RESULTS

When quartiles 2, 3, and 4 were compared with the appropriate lowest quartile, adjusted hazard ratios for all-cause mortality were 0.99 (CI = 0.70-1.38), 0.97 (CI = 0.73-1.31), and 1.04 (CI = 0.78-1.40) for number, number weighted by impact, and number weighted by community-derived values, respectively. Results were essentially similar for the relation between stressful life events limited to those occurring within the 12 months before diagnosis and overall mortality and between stressful life events in the 5 years before diagnosis and breast cancer-specific mortality.

CONCLUSIONS

Stress was conceptualized as life events presumed to be negative, undesirable, or to require adjustment by the person confronting them. We found no evidence indicating that this kind of stress during the 5 years before diagnosis negatively affected survival among women with nonmetastatic breast cancer. Evidence from this study and others on the lack of effect of this type of stress on survival may be reassuring for women living with breast cancer.

Phosphorus removal from trout farm effluents by constructed wetlands

Freshwater trout farms need a high and continuous clean water flow to keep fish exposed to a non-toxic ammonium concentration. As a result, the concentration of effluents from these farms are even below standard effluent criteria for municipal wastewater effluent for solids, nitrogen and phosphorus. Nevertheless, the mass of pollutants discharged, originating mostly from excreta and undigested fish food, must be reduced by simple and economical treatment processes. We designed and operated a three-stage system aimed at retaining solids by a 60 pm nylon rotating microscreen followed by treatment with a phosphorus-retaining constructed wetland system. Washwater from the microscreen was pumped to a series of two horizontal flow beds of 100 m3 each (0.6 m deep). Coarse (2 mm) and finer (< 2 mm) crushed limestone were used in each bed, respectively, with the first one being planted with reeds (Phragmites australis) and the second one designed to remove even more phosphorus by adsorption and precipitation. Preliminary results indicated that the microscreen captured about 60% of the suspended solids and that greater than 95% of the suspended solids and greater than 80% of the total phosphorus mass loads were retained by the beds. The potential of constructed wetlands as an ecologically attractive and economical method for treating fish farm effluents to reduce solids and phosphorus discharge appears promising.

Rectal cancer and occupational risk factors: a hypothesis-generating, exposure-based case-control study

In 1979, a hypothesis-generating, population-based case-control study was undertaken in Montreal, Canada, to explore the association between occupational exposure to 294 substances, 130 occupations and industries, and various cancers. Interviews were carried out with 3, 630 histologically confirmed cancer cases, of whom 257 had rectal cancer, and with 533 population controls, to obtain detailed job history and data on potential confounders. The job history of each subject was evaluated by a team of chemists and hygienists and translated into occupational exposures. Logistic regression analyses adjusted for age, education, cigarette smoking, beer consumption, body mass index, and respondent status were performed using population controls and cancer controls, e.g., 1,295 subjects with cancers at sites other than the rectum, lung, colon, rectosigmoid junction, small intestine, and peritoneum. We present here the results based on cancer controls. The following substances showed some association with rectal cancer: rubber dust, rubber pyrolysis products, cotton dust, wool fibers, rayon fibers, a group of solvents (carbon tetrachloride, methylene chloride, trichloroethylene, acetone, aliphatic ketones, aliphatic esters, toluene, styrene), polychloroprene, glass fibers, formaldehyde, extenders, and ionizing radiation. The independent effect of many of these substances could not be disentangled as many were highly correlated with each other.

Tamoxifen and mammographic breast densities

The extent of breast tissue density on mammograms is one of the strongest risk factors for breast cancer. The aim of this analysis was to evaluate whether tamoxifen can affect mammographic breast density. Subjects were participants in the National Surgical Adjuvant Breast Project Breast Cancer Prevention Trial (BCPT), recruited and followed at the Breast Center of Saint-Sacrement Hospital in Quebec City, Canada. The Breast Cancer Prevention Trial is a double-blind trial in which women at high risk of breast cancer were randomized to receive either 20 mg tamoxifen per day or placebo. Mammograms were taken before treatment began and yearly thereafter. For the purpose of this analysis, Wolfe's parenchymal pattern and the percentage of the breast showing tissue densities were assessed by review of pre- and posttreatment mammograms without knowledge of treatment assignment. Among the 69 women included in this analysis, 36 received tamoxifen and 33 received placebo for an average of 3.3 and 3.5 years, respectively. Among women receiving tamoxifen, 16 of 36 (44.4%) changed to a parenchymal pattern of lower density compared with 5 of 33 (15.2%) women receiving placebo (P = 0.010). Moreover, in the tamoxifen-treated group, the difference in the percentage of the breast showing tissue densities between the pre- and posttreatment mammograms reached -9.4% on average compared with a reduction of -3.6% in the placebo group (P = 0.010). Our data show that tamoxifen can reduce high-risk mammographic features. Breast densities should be evaluated as possible early markers of the preventive effect of selective estrogen receptor modulators.

Structure of the Bordetella pertussis 1414 endotoxin

The endotoxin (lipopolysaccharide) of Bordetella pertussis, the agent of whooping cough, consists of a lipid A linked to a highly branched dodecasaccharide containing several acid and amino sugars. The elucidation of the polysaccharide structure was accomplished by first analyzing the structures of fragments obtained by hydrolysis and nitrous deamination and then piecing the fragments together. The fine structure of the antigenic distal pentasaccharide, presented here, was determined by chemical analyses as well as by high-resolution nuclear magnetic resonance and mass spectrometry. The complete structure was reconstituted and confirmed by matrix-assisted laser desorption/ionization mass spectrometry. The following structure was derived from the combined experimental data:The detailed structure combined with previously reported serological data now allows the synthesis of its epitopes for potential vaccines.

Human papillomaviruses and vulvar vestibulitis

OBJECTIVE

To assess the relationship between human papillomavirus (HPV) infection and vulvar vestibulitis syndrome.

METHODS

From November 1995 to December 1997, 135 women with vulvar vestibulitis were compared with 322 controls who had no evidence of vulvar vestibulitis. Human papillomavirus DNA was amplified by polymerase chain reaction and detected with liquid-capture molecular assay.

RESULTS

Human papillomavirus DNA was found in 29.6% of cases and in 23.9% of controls (relative risk [RR] 1.4; 95% confidence interval [CI].8, 2.2). The prevalence of HPV tended to decrease with increasing duration of pain among cases. Thus, prevalences were 37. 5%, 29.6%, and 22.0% for pain durations of 3-6 months, 7-12 months, and 13-24 months, respectively (P =.14). Prevalence of HPV also tended to increase with pain intensity among cases, but that association was not statistically significant (P =.57). Prevalence percentages for women with low, moderate, or severe pain were 27.5%, 28.8%, and 34.4%, respectively. Prevalence of HPV was slightly higher in cases with the most severe pain (34.4%) than in controls (23.9%) (RR 1.8; 95% CI.8, 4.0). In cases with the most pain in the shortest time (3-6 months), prevalence of HPV was double that of controls (50% versus 23.9%) (RR 3.5; 95% CI 1.0, 12.7; P =.054).

CONCLUSION

There was little support for the idea that HPV might be related to vulvar vestibulitis.

Effect of multiple cilostazol doses on single dose lovastatin pharmacokinetics in healthy volunteers

OBJECTIVE

To assess the effects of cilostazol on lovastatin pharmacokinetics.

DESIGN

This was a single-centre, open-label, multiple dose, sequential treatment study. Participants received single oral doses of lovastatin 80 mg on days 1, 7 and 9, as well as oral cilostazol 100 mg twice daily on days 2 to 8, followed by a single oral 150 mg cilostazol dose on day 9.

STUDY PARTICIPANTS

15 healthy, nonsmoking male or female volunteers (aged 18 to 60 years) were enrolled, and 12 completed the study.

MAIN OUTCOME MEASURES

Pharmacokinetic parameters were calculated using plasma concentrations of lovastatin and its beta-hydroxy metabolite and of cilostazol and its metabolites. Differences in the pharmacokinetics of each drug when given alone or in combination were assessed by analysis of variance.

RESULTS

The maximum observed plasma concentration (Cmax) of lovastatin or its metabolite did not differ significantly when lovastatin was given alone and when it was given with 100 mg of cilostazol. The mean ratios of the area under the plasma concentration-time curve from zero to the time of the last measurable concentration (AUCt) for lovastatin coadministered with 100 mg of cilostazol to that with lovastatin given alone were 1.6 for lovastatin and 1.7 for its metabolite. With 150 mg of cilostazol, lovastatin Cmax did not change, whereas Cmax of the metabolite increased 2.2-fold. The mean AUCt ratios for lovastatin given with 150 mg cilostazol/lovastatin given alone were 1.6 and 2.0 for lovastatin and its metabolite, respectively. All increases in lovastatin and metabolite AUC were statistically significant, except for the 1.6-fold increase in lovastatin AUC with 150 mg of cilostazol. Maximum steady-state plasma drug concentration (Cssmax) and AUC during a dosage interval (AUC tau) for cilostazol 100 mg twice daily decreased 14 and 15%, respectively, upon lovastatin coadministration.

CONCLUSIONS

Lovastatin and metabolite exposure is increased only by up to 2-fold when cilostazol is coadministered, which is considerably less than that observed for potent CYP3A inhibitors such as itraconazole and grapefruit juice. Absorption of cilostazol decreased approximately 15% when it was given with lovastatin. No dosage adjustments are necessary for cilostazol when coadministered with lovastatin, whereas lovastatin dose reductions may be needed when the 2 drugs are given together.

Risk and aggressiveness of breast cancer in relation to plasma organochlorine concentrations

Several organochlorines identified as "hormone mimics" were proposed as possible risk factors for breast cancer. We conducted a case-control study to assess breast cancer risk and disease aggressiveness in relation to plasma concentrations of several organochlorine compounds. Plasma lipid concentrations of 11 chlorinated pesticides and 14 polychlorinated biphenyl congeners were measured in 315 women newly diagnosed with breast cancer, 219 hospital-based controls, and 307 population controls from the Quebec City area (Canada). Concentrations of hormonally active organochlorines or their surrogates were compared between cases and controls as well as between groups of cases defined according to tumor size and axillary-lymph-node involvement. We found similar levels of organochlorines in cases and controls and no relationship between the relative risk of breast cancer and organochlorine exposure. However, the probability of lymph-node invasion among cases increased with exposure to 1,1-dichloro-2,2-bis(4-chlorophenyl)ethylene [p,p'-DDE; odds ratio, 2.54; 95% confidence interval (CI), 1.20-5.35; between the highest and the lowest tertiles]. Furthermore, p,p'-DDE exposure was associated with a dose-related increased relative risk of exhibiting both lymph-node involvement and a large tumor. Indeed odds ratio raised to 2.33 (95% CI, 0.94-5.77) for the second tertile relative to the first tertile and reached 3.51 (95% CI, 1.41-8.73) for the third tertile relative to the first tertile. Similar associations were noted with beta-hexachlorocyclohexane, oxychlordane, and transnonachlor. We conclude that exposure to persistent, hormonally active organochlorines during adulthood is not associated with breast cancer risk. The possibility that some organochlorines and especially p,p'-DDE may increase breast cancer aggressiveness deserves further attention.

Variations in the treatment of early-stage breast cancer in Quebec between 1988 and 1994

BACKGROUND

The influence of organizational factors on the process and outcomes of the treatment of breast cancer has been extensively investigated. Although the quality of care is presumed to be better in larger centres, evidence is inconsistent. This study was conducted to determine whether therapies for patients with breast cancer varied according to hospital caseload.

METHODS

Women newly diagnosed between 1988 and 1994 with early-stage node-negative primary breast cancer were randomly selected from the Quebec tumour registry and the Quebec hospital discharge database. Data were collected from medical charts, and only women having undergone dissection of the axilla were included in the analyses. Logistic regression analysis was used to adjust for case mix and organizational variables.

RESULTS

The final sample included 1259 patients with node-negative stage I or II primary breast cancer. The proportion of women who underwent breast-conserving surgery increased significantly with hospital caseload (from 78.0% in hospitals admitting fewer than 25 new cases each year to 88.0% in those admitting 100 patients or more; p for trend < 0.001). This trend remained significant even after statistical adjustment for case mix and organizational factors (p for trend = 0.001). Of the 1039 women who underwent breast-conserving surgery 965 (92.9%) received radiotherapy. Use of systemic adjuvant therapy (tamoxifen or chemotherapy, or both) increased with the number of patients treated in a given centre (from 60.1% to 68.5%), but this trend disappeared after adjustment for case mix and other factors. The proportion of patients receiving systemic adjuvant therapy consistent with published consensus guidelines tended to increase with caseload for those treated in hospitals participating in multicentre clinical trials but decrease with caseload for patients in hospitals not involved in clinical research.

INTERPRETATION

The care of patients in Quebec with early-stage breast cancer is characterized by a high prevalence of both breast-conserving surgery and systemic adjuvant therapy. Large centres, especially those actively involved in clinical research, rapidly adopt innovative therapeutic modalities.

Conservation and accessibility of an inner core lipopolysaccharide epitope of Neisseria meningitidis

We investigated the conservation and antibody accessibility of inner core epitopes of Neisseria meningitidis lipopolysaccharide (LPS) because of their potential as vaccine candidates. An immunoglobulin G3 murine monoclonal antibody (MAb), designated MAb B5, was obtained by immunizing mice with a galE mutant of N. meningitidis H44/76 (B. 15.P1.7,16 immunotype L3). We have shown that MAb B5 can bind to the core LPS of wild-type encapsulated MC58 (B.15.P1.7,16 immunotype L3) organisms in vitro and ex vivo. An inner core structure recognized by MAb B5 is conserved and accessible in 26 of 34 (76%) of group B and 78 of 112 (70%) of groups A, C, W, X, Y, and Z strains. N. meningitidis strains which possess this epitope are immunotypes in which phosphoethanolamine (PEtn) is linked to the 3-position of the beta-chain heptose (HepII) of the inner core. In contrast, N. meningitidis strains lacking reactivity with MAb B5 have an alternative core structure in which PEtn is linked to an exocyclic position (i.e., position 6 or 7) of HepII (immunotypes L2, L4, and L6) or is absent (immunotype L5). We conclude that MAb B5 defines one or more of the major inner core glycoforms of N. meningitidis LPS. These findings support the possibility that immunogens capable of eliciting functional antibodies specific to inner core structures could be the basis of a vaccine against invasive infections caused by N. meningitidis.

A structural comparison of the total polar lipids from the human archaea Methanobrevibacter smithii and Methanosphaera stadtmanae and its relevance to the adjuvant activities of their liposomes

Mice were immunized with bovine serum albumin (BSA) entrapped within archaeosomes (i.e. liposomes) composed of the total polar lipids (TPL) from the two methanogenic archaea common to the human digestive tract. Methanobrevibacter smithii archaeosomes boosted serum anti-BSA antibody to titers comparable to those achieved with Freund's adjuvant, whereas Methanosphaera stadtmanae archaeosomes were relatively poor adjuvants. An explanation for this difference was sought by analysis of the polar lipid composition of each archaeobacterium. Fast atom bombardment mass spectrometry and NMR analyses of the purified lipids revealed a remarkable similarity in the ether lipid structures present in each TPL extract. However, the relative amounts of each lipid species varied dramatically. The phospholipid fraction in M. stadtmanae TPL was dominated by archaetidylinositol (50 mol% of TPL) and the glycolipid fraction by beta-Glcp-(1,6)-beta-Glcp-(1,1)-archaeol (36 mol%), whereas in M. smithii extracts, both caldarchaeol and archaeol lipids containing a phosphoserine head group were relatively abundant. Liposomes prepared from purified archaetidylinositol and from M. stadtmanae TPL supplemented with increasing amounts of phosphatidylserine elicited poor humoral responses to encapsulated BSA. A dramatic loss in the adjuvanticity of M. smithii archaeosomes was seen upon incorporation of 36 mol% of the uncharged lipid diglucosyl archaeol and, to a lesser extent, of 50 mol% of archaetidylinositol. Interestingly, the relative rates of uptake of M. smithii and M. stadtmanae archaeosomes by phagocytic cultures in vitro were similar. Thus, the lipid composition may influence archaeosome adjuvanticity, particularly a high diglucosyl archaeol and/or archaetidyl inositol content, resulting in a low adjuvant activity.

Cathepsin D expression by cancer and stromal cells in breast cancer: an immunohistochemical study of 1348 cases

This study was aimed at investigating the influence of cathepsin D (CD) expression by cancer cells and stromal cells on breast cancer prognosis. This is a study of 1348 node-positive (NPBC) and node-negative (NNBC) breast cancers diagnosed between 1980 and 1986 and with a minimum follow-up of 5.2 years. CD expression was assessed by immunohistochemistry on archival material using a polyclonal antibody. The expression by cancer and stromal cells was assessed separately and correlated with distant metastasis free (DMFS) and overall survival (OS). Cancer cells expressed CD (more than 10% cells expressing CD) in 38.9% of cases and reactive stromal cells in 43.6%. CD expression by reactive stromal cells, and not cancer cells, correlated with several factors of poor prognosis by cancer cells. A strong association was also found with expression of other proteases (stromelysin-3, gelatinase A, and urokinase Plasminogen Activator) by these same reactive stromal cells. CD expression by cancer cells did not predict DMFS or OS but, by univariate analysis, CD expression by reactive stromal cells was associated with earlier recurrence and shorter survival in NNBC (p = 0.0425) and NPBC patients submitted to adjuvant chemotherapy (p = 0.0234). However, CD expression by reactive stromal cells remained a significant predictor of recurrence by multivariate analyses only in a subgroup of NPBC submitted to adjuvant chemotherapy. Overall, those data support the concept that proteases produced by reactive stromal cells are under cancer cell stimulation and that CD by stromal cells, and not cancer cells, influences the prognosis, but only in a subgroup of patients with breast cancer.