The polychoric dual-component wealth index as an alternative to the DHS index: Addressing the urban bias.

BACKGROUND: The DHS wealth index - based on a statistical technique known as principal component analysis - is used extensively in mainstream surveys and epidemiological studies to assign individuals to wealth categories from information collected on common assets and household characteristics. Since its development in the late nineties, the index has established itself as a standard and, due to its ease of use, has led to a large and welcome increase in the analysis of inequalities. The index is, however, known to present some serious limitations, one being a bias towards patterns of urban wealth: the so-called "urban bias". METHODS: We use 10 data sets - 5 MICS (Multiple Indicator Cluster Survey), 4 DHS (Demographic and Health Survey) and one HBS (Household Budget Survey) - to demonstrate that urban bias continues to be a prominent and worrying feature of the wealth index, even after several methodological changes implemented in recent years to try to reduce it. We then propose and investigate an approach to improve the performance of the index and reduce the urban bias. This approach involves the use of ordinal rather than dummy variables, of a polychoric instead of a product-moment correlation matrix, and the use of two principal components rather than one. These approaches are used jointly to produce the polychoric dual-component wealth index (P2C). RESULTS: The P2C index enables a larger proportion of the variance of the asset variables to be accounted for, results in all assets contributing positively to the wealth score, exploits added analytical power from ordinal variables, and incorporates the extra dimension of wealth expressed by the second principal component. It results in a better representation of typically rural characteristics of wealth and leads to the identification of more plausible distributions of both the urban and rural populations across wealth quintiles, which are closer to expenditure quintiles than the standard DHS index. CONCLUSIONS: The P2C wealth index can be easily applied to mainstream surveys, such as the MICS and DHS, and to epidemiological studies; it yields more credible distributions of rural and urban subpopulations across wealth quintiles. It is proposed as an alternative to the DHS wealth index.

The Relationship between Organic Loading and Effects on Fish Reproduction for Pulp Mill Effluents across Canada.

This study builds upon the work of a multiagency consortium tasked with determining cost-effective solutions for the effects of pulp mill effluents on fish reproduction. A laboratory fathead minnow egg production test and chemical characterization tools were used to benchmark 81 effluents from 20 mills across Canada, representing the major pulping, bleaching, and effluent treatment technologies. For Kraft and mechanical pulp mills, effluents containing less than 20 mg/L BOD5 were found to have the greatest probability of having no effects. Organic loading, expressed as the total detected solvent-extractable components by gas chromatography/mass spectrometry (GC/MS), also correlated with decreased egg laying. Exceptions were found for specific Kraft, mechanical, and sulfite mills, suggesting yet unidentified causative agents are involved. Recycled fiber mill effluents, tested for the first time, were found to have little potential for reproductive effects despite large variations in BOD5 and GC/MS profiles. Effluent treatment systems across all production types were generally efficient, achieving a combined 82-98% BOD5 removal. Further reductions of final effluent organic loadings toward the target of less than 20 mg/L are recommended and can be realized through biotreatment optimization, the reduction of organic losses associated with production upsets and selecting best available technologies that reduce organic loadings to biotreatment.

Ovulation but not milt production is inhibited in fathead minnows (Pimephales promelas) exposed to a reproductively inhibitory pulp mill effluent.

BACKGROUND: A 5-day fathead minnow (FHM) spawning assay is used by industry to monitor pulp mill effluent quality, with some mill effluents capable of completely inhibiting spawning. The purpose of this report is to characterize the effect of an inhibitory effluent on egg and milt production in FHM. METHODS: Eight tanks were treated with an inhibitory effluent while eight were kept with clean water. Each tank contained two males and four females as per the 5-day FHM spawning assay used by industry. Females were stripped of ovulated eggs and males of milt in four effluent-exposed and four control tanks. Eggs oviposited in every tank were also counted and checked for fertilization and data analyzed with 2-way ANOVA. RESULTS: We show that female, but not male, fathead minnow reproductive function is impaired in the 5-day fathead minnow spawning assay used by industry to evaluate pulp mill effluent quality in Canada. Milt production was not changed in the control or exposed males mid-way and at the end of the five day exposure (p > 0.05; n = 8). Total egg production (stripped + oviposited) was impaired (p < 0.05) in fathead minnows exposed to effluent (288 eggs/tank, n = 4 tanks) compared to those in control tanks (753 eggs/tank, n = 4 tanks). CONCLUSIONS: Our results indicate that males are able to detect female signals and prepare appropriately for spawning while in females inhibition of ovulation is occurring somewhere along the hypothalamus-pituitary-gonad reproductive axis. These results suggest female-specific neuroendocrine disruption and provide mechanistic insight into an assay used by industry to assess pulp mill effluent quality.

A survey of Canadian mechanical pulp and paper mill effluents: insights concerning the potential to affect fish reproduction.

Building on breakthroughs recently made at kraft mills, a survey of mechanical pulp and paper mill effluents was undertaken to gain insights concerning potential effects on fish reproduction. Effluents from seven Canadian mills were characterized chemically for conventional parameters such as biochemical oxygen demand (BOD) and total suspended solids (TSS). Each sample was further subjected to solvent extraction followed by gas chromatographic separation for the determination of resin/fatty acids and for the estimation of a gas chromatography (GC) profile index. Each mill effluent was assessed for the potential to affect fish reproduction in the laboratory using a five day adult fathead minnow (Pimephales promelas) egg production bioassay with exposures to 100% effluent. The seven effluents were found to have substantial variation both in terms of chemical characterization and effects on fish reproduction. Temporal variations were also noted in effluent quality at mills sampled on different occasions. Similar to what has been observed for kraft mills, a general trend of greater reductions in egg production caused by effluents with greater BOD concentrations and GC profile indices was noted. Effluents with BOD > 25 mg/L and GC Profile indices >5.0 caused a complete cessation of egg production. At the same time, about half of the total effluents sampled had BOD < 25 mg/L and GC profile indices <5.0 and caused no significant effects on egg production, suggesting these values may be useful as effluent quality targets for mechanical pulp and paper mills. However, 3 out of 14 effluents sampled had BOD < 25 mg/L and GC profile indices <5.0 and caused significant reductions in egg production. The reason(s) for reproductive effects caused by such effluents is presently unclear. The effluent quality parameters considered in this study may require further refinement to address their utility in predicting the adverse reproductive effects induced by effluents from mechanical pulp and paper mills.

Effluent monitoring at a bleached kraft mill: directions for best management practices for eliminating effects on fish reproduction.

A long-term monitoring study was conducted on effluents from a bleached kraft pulp and paper mill located in Eastern Canada. The study was designed to gain insights into temporal effluent variability with respect to fish reproduction as it related to production upsets, mill restarts and conditions affecting biological treatment performance. Final effluent quality was monitored between February 2007 and May 2009 using biochemical and chemical oxygen demand, total suspended solids, resin and fatty acids, a gas chromatographic profiling index, and the presence of methyl substituted 2-cyclopentenones. Selected effluent samples were evaluated for effects on fish reproduction (egg production) using a shortened version of the adult fathead minnow reproductive test. The events relating to negative effects on fish reproduction were upsets of the pulping liquor recovery system resulting in black liquor losses, operational upsets of the hardwood line resulting in the loss of oxygen delignification filtrates, and conditions that reduced the performance of biological treatment (e.g., mill shutdown and low ambient temperatures). The reductions in egg production observed in fathead minnow were associated with biochemical oxygen demand values > 20 mg/L, GC profiling indices > 1.2 and the presence of methyl-substituted 2-cyclopentenones at concentrations > 100 µg/L. This study demonstrated the importance of both in-plant measures for controlling the loss of organics as well as the optimum operation of biological effluent treatment for eliminating effluent-related effects on fish reproduction (egg production) in the laboratory.

Kraft mill effluent survey: progress toward best management practices for reducing effects on fish reproduction.

Pulp and paper mill effluents have been linked to effects on fish reproduction for more than 25 years. To date, the causes of these effects and remedial strategies have eluded investigators. Recent work has shown that the degree of reproductive effect caused by a mill effluent is related to the overall organic content. If verified, this could lead to breakthroughs for best management practices (BMPs). For this study, the effluents from seven kraft mills were assessed for their ability to reduce egg production in fathead minnow (Pimephales promelas) in the laboratory. At the same time, the effluents were analyzed for three parameters thought to be good indicators of organic losses: biochemical oxygen demand (BOD), methyl-substituted 2-cyclopentenones (cellulose degradation products), and a gas chromatographic (GC) profile index, which integrates the total area of the chromatographic peaks of solvent-extracted effluents using low-resolution mass spectrometry. The results showed that the degree to which the effluents reduced egg production increased with increased organic losses as characterized by BOD and the GC profile index. Therefore, these parameters could be used to guide BMPs at kraft mills according to specific targets: BOD < 20 mg/L and GC profile index equivalent to effluent with BOD of 20 mg/L. Such targets should be achievable by good in-plant control of organic losses and optimized effluent biotreatment systems.

An ecotoxicological characterization of nanocrystalline cellulose (NCC).

The pulp and paper industry in Canada is developing technology for the production and use of nanocrystalline cellulose (NCC). A key component of the developmental work is an assessment of potential environmental risks. Towards this goal, NCC samples as well as carboxyl methyl cellulose (CMC), a surrogate of the parent cellulosic material, were subjected to an ecotoxicological evaluation. This involved toxicity tests with rainbow trout hepatocytes and nine aquatic species. The hepatocytes were most sensitive (EC20s between 10 and 200 mg/l) to NCC, although neither NCC nor CMC caused genotoxicity. In tests with the nine species, NCC affected the reproduction of the fathead minnow at (IC25) 0.29 g/l, but no other effects on endpoints such as survival and growth occurred in the other species at concentrations below 1 g/l, which was comparable to CMC. Based on this ecotoxicological characterization, NCC was found to have low toxicity potential and environmental risk.

Gene expression profiling of the fathead minnow (Pimephales promelas) neuroendocrine brain in response to pulp and paper mill effluents.

The toxicity of pulp and paper mill effluents (PPMEs) has been greatly decreased, yet some continue to negatively affect fish reproduction. We hypothesized that PPMEs are affecting the brain resulting in decreased reproductive performance. Our goal was to use gene expression profiling to test the hypothesis that PPMEs are having an effect on neural systems in the fathead minnow (FHM; Pimephales promelas) in vivo. Sexually mature male and female FHM were exposed to 100% final biotreated PPMEs from 5 different sources for 5 days. Using an oligo-array (15K genes) we examined the effect of PPMEs on gene expression in the hypothalamus of female fish. We validated selected genes (cholecystokinin, RevErbbeta2, and urotensin I) that were identified by microarray analysis using real-time reverse-transcriptase polymerase chain reaction (RT-PCR). We compared the FHM microarray dataset to multiple microarray datasets from experiments conducted with goldfish injected with different dopaminergic pharmaceuticals to examine whether PPMEs could be affecting the dopamine system. Exposure of FHM to PPMEs resulted in varying degrees of spawning inhibition. Microarray analysis revealed surprisingly few genes in the brain that were commonly affected by the different PPMEs. Real-time RT-PCR confirmed the changes in expression for cholecystokinin, RevErbbeta2, and urotensin I. Comparison of the FHM and goldfish microarray datasets suggest that some PPMEs may be acting on the dopamine system. We show that PPMEs are neuroactive in fish and may be acting through some of the pathways in a manner similar to dopamine.

Modified posterior pelvic exenteration for ovarian cancer.

INTRODUCTION: A modified posterior pelvic exenteration (MPE) might be needed to reach an optimal tumoral reduction. The issue of this study is to relate a multicentric experience of this kind of resection. MATERIALS: Three hundred five patients who needed an MPE were analyzed from 9 French cancer centers. One hundred sixty-eight MPEs were performed during initial surgery (55.1%), 69 during interval surgery (22.6%), 36 after chemotherapy (11.8%), and 32 for recurrences (10.5%). RESULTS: Three hundred two colorectal anastomoses were realized with a protective stoma in 59 (19.5%) of cases and a stoma closure in 76.5% (51). The rate of functional anastomosis was 96% (290/302). Complications occurred in 26.9% (82/305) of the patients, with a fistula in 25 (8.2%). The reintervention rate was 8.8% (27/305). The median length of hospitalization was 15 days. The absence of a macroscopic residual disease was obtained in 58% (173/303) of cases. A residual disease that was 1 cm or smaller was observed in 73 cases (24%) and 2 cm or smaller observed in 36 (11.9%). Postoperative chemotherapy was started with a median time of 32 days.Postoperative death occurred in 1 patient (0.33%). The survival rates were 62.7% and 27.6% at 2 and 5 years, respectively. With a multivariate analysis, the 2 significant prognostic factors were residual disease and time of surgery (P < 0.0001). CONCLUSIONS: A rectal invasion should not be an obstacle to reach the aim to obtain a macroscopic minimal residual disease or, if possible, the absence of one. An MPE is useful in those cases to reach optimal cytoreduction, with comparable results whatever the patient's age is. A temporary protective stoma should be considered only exceptionally.

[Critical study of our initial experience of 993 sentinel node biopsies for breast surgery]. / La procédure du ganglion sentinelle en routine : intérêts et limites à propos d'une série de 993 cas.

OBJECTIVE: Identification of sentinel node (SN) involvement predictive factors, non-sentinel node involvement predictive factors, selective prognosis of each group of patients by study of breast surgery cases with sentinel node sampling. METHODS: Prospective monocentric registering of 993 sentinel node samples routinely taken between January 2001 and October 2005, covering technical aspects of detection (colorimetric and radio-isotope), pathological results (serial sections 5 Mmicro thick prior to staining hematoxylin-eosine-saffron and if necessary, by immune histochemistry cytokeratine high molecular weight), therapeutics and follow-up (average period: 32 months (3-69). RESULTS: Seven hundred and sixteen patients (72.1%) were free of sentinel node involvement. Among positive sentinel node patients (27.9%), 14.5% presented macrometastasis, 11% micrometastasis and 2.4% isolated tumor cells (CTI). Sentinel node involvement risk factors included: related to clinical features, age (2 years younger in the micrometastatic group compared to the macrometastatic group); related to tumor caracteristics, size (12.15 mm for the negative SN group, 15.4 mm for the micrometastatic group and 16.25 mm for the macrometastatic group), grading (a majority of grade I encountered with micrometastasis versus macrometastasis) and multifocality (macrometastasis SN associated with multilocular tumor in 77.8% cases, micro metastasis SN in 22.2% cases and negative SN in 6.7% cases). Predictive factors do not differ for micro- or macrometastasic involvement. Among features concerning secondary axillary dissection, 47.1% (66/140) were positive with a macrometastatic SN, 12.1% (13/107) with micrometastic SN. Predictive factors of positive secondary axillary dissection were tumor size, grading, micrometastasis size and micrometastasis multifocality. With a 32 months mean follow-up, the positive micrometastasis sub-group (with or without positive secondary axillary dissection) expressed one only metastatic recurrence (0.9%); on the contrary, three patients (2.1%) issued from the macrometastatic SN group, expressed metastatic recurrence. One only local axillary recurrence (0.14%) occurred among negative SN (717 cases); no axillary recurrence occurred among the 30 patients without secondary axillary dissection (CTI [22 cases], micrometastatic SN group [5 cases] and macrometastatc group [3 cases]). CONCLUSION: First, 72.1% of T0 or T1 tumors, avoid adverse axillary dissection effects. Second, micrometastatic involvement predictive factors do not differ from macrometastatic ones and those of positive secondary axillary dissection among micrometastatic SN do not appear clearly : the risk of axillary recurrence is low: at the very most, it seems possible to propose a safe guideline, avoiding secondary axillary dissection only for selected group of lower risk patients: tumoral size < 10 mm, grade I, monocentric SN involvement. Third, it is not possible to differentiate a selective prognosis between negative, CTI, micrometastatic and macrometastatic SN subgroups probably because of a short follow-up. Fourth, teaching through companionship is fully valided by the secondary minimal rate of axillary recurrence.

Altered reproduction in fish exposed to pulp and paper mill effluents: roles of individual compounds and mill operating conditions.

For the last 20 years, studies conducted in North America, Scandinavia, and New Zealand have shown that pulp and paper mill effluents affect fish reproduction. Despite the level of effort applied, few leads are available regarding the factors responsible. Effluents affect reproduction in multiple fish species, as evidenced by decreased gonad size, decreased circulating and gonadal production of reproductive steroids, altered expression of secondary sex characteristics, and decreased egg production. Several studies also have shown that effluent constituents are capable of accumulating in fish and binding to sex steroid receptors/ binding proteins. Studies aimed at isolating biologically active substances within the pulping and papermaking process have provided clues about their source, and work has progressed in identifying opportunities for in-mill treatment technologies. Following comparisons of manufacturing processes and fish responses before and after process changes, it can be concluded that effluent from all types of mill processes are capable of affecting fish reproduction and that any improvements could not be attributed to a specific process modification (because mills normally performed multiple modifications simultaneously). Improved reproductive performance in fish generally was associated with reduced use of molecular chlorine, improved condensate handling, and liquor spill control. Effluent biotreatment has been effective in reducing some effects, but biotreated effluents also have shown no difference or an exacerbation of effects. The role of biotreatment in relation to effects on fish reproduction remains unclear and needs to be resolved.

[Laparoscopic surgery and gynaecological cancers]. / Coeliochirurgie des cancers gynécologiques.

The use of laparoscopic staging and/or surgery in the field of gynaecological oncology was pioneered in the late 80's and the first reports were published in the early 90's. The issue has been initially most controversial, and is still debated, with some justification considering the possible adverse consequences of surgical mismanagement of gynaecologic malignancy. Since then, a number of papers have confirmed the absence of significant adverse effects on survival after laparoscopic diagnosis or surgery in gynaecological cancers. New developments cover virtually all the basic techniques in cancer surgery, including major exenterative surgery. The use of extraperitoneal technique for aortic dissections is emerging as a new tool. New indications, such as radical vaginal trachelectomy (Dargent operation), radical parametrectomy, pelvic sentinel node identification, decisional laparoscopy in adnexal malignancies, or the use of pretherapeutic surgical staging of uterine cancers, have been developed in direct relation with the use of laparoscopic techniques. Worldwide interest clearly demonstrates that laparoscopic techniques must now be part of the armamentarium of the gynaecologic oncologist. Postoperative morbidity and recurrence risk do not seem to be affected. Cost-efficiency of laparoscopic procedures is based on the reduction of hospital stay and recovery time, particularly in obese patients. Combined training in gynaecologic oncology and in laparoscopic and/or vaginal surgery is more than ever mandatory to reduce the operating time, which is becoming similar to laparotomy in experiences hands, and avoid the risk of inadequate staging or management of pelvic malignancies.

Prospective multicentric randomized study comparing periareolar and peritumoral injection of radiotracer and blue dye for the detection of sentinel lymph node in breast sparing procedures: FRANSENODE trial.

PURPOSE: To determine the optimal injection path for blue dye and radiocolloid for sentinel lymph node (SLN) biopsy in early breast cancer. PATIENTS AND METHODS: A prospective randomized multicentric study was initiated to compare the peritumoral (PT) injection site to the periareolar (PA) site in 449 patients. RESULTS: The detection rate of axillary SLN by lymphoscintigraphy was significantly higher (P = .03) in the PA group (85.2%) than in the PT group (73.2%). Intraoperative detection rate by blue dye and/or gamma probe was similar (99.11%) in both groups. The rate of SLN detection was somewhat higher in the PA group than in the PT group: 95.6% versus 93.8% with blue dye (P = .24) and 98.2% versus 96.0% by probe (P = .16), respectively. The number of SLNs detected by lymphoscintigraphy and by probe was significantly higher in the PA group than in the PT group, 1.5 versus 1.2 (P = .001) and 1.9 versus 1.7 (P = .02). The blue and hot concordance was 95.6% in the PA group and 91.5% in the PT group (P = .08). The mean ex vivo count of the SLN was significantly higher in the PA group than in the PT group (P < .0001). CONCLUSION: This study strongly validates the PA injection technique given the high detection rate (99.1%) of SLN and the high concordance (95.6%) between blue dye and the radiotracer, as well as higher significant ex and in vivo counts, improving SLN probe detection.

Combined laparoscopically harvested omental flap with meshed skin grafts and vacuum-assisted closure for reconstruction of complex chest wall defects.

BACKGROUND: Chest wall reconstruction after radiation damage is a challenge in oncologic and plastic surgery. The defect can be reconstructed with laparoscopically harvested omental flap and meshed skin grafts. Our aim was to evaluate the use of vacuum-assisted closure (V.A.C.) in combination with laparoscopically harvested omental flap and meshed skin graft for treating these complex wounds. METHODS: Between October 2003 and December 2004, 11 patients underwent a chest wall reconstruction with laparoscopic omentoplasty and V.A.C. treatment of severe chest wall radionecrosis after breast cancer treatment (n = 10) or for locally advanced breast cancer treated first by irradiation (n = 1). RESULTS: Laparoscopic harvesting was uneventful in 10 cases. One patient had a laparoscopic transverse colic resection because of a middle colic artery injury. Mean time of the laparoscopic procedure was 53 minutes (range: 35-120). Wound surface area averaged 360 cm (range: 80-750). The mean duration of V.A.C. treatment was 9.3 days (range: 6-16). Nine patients showed primary wound healing without adverse events. Complications occurred in 3 patients. One developed a pulmonary infection and died after healing during the postoperative course. One presented a partial flap loss, leading to delayed healing after 45 days. One patient with severe radiation damage and a complete brachial plexus paralysis required a shoulder amputation after an extensive necrosis. All but 1 patient are alive and resumed their normal daily activities. CONCLUSIONS: Combination of laparoscopic omentoplasty and V.A.C. can successfully be used for reconstruction of complex chest wall radiation damage.

Audit of preoperative and early complications of laparoscopic lymph node dissection in 1000 gynecologic cancer patients.

OBJECTIVE: Establish the reliability and safety of minimal invasive surgery in gynecologic oncology in a large-scale study. Estimate the complication rate on a large sample size. STUDY DESIGN: From December 1998 to November 2004, 1000 gynecologic cancer patients underwent pelvic and/or aortic lymphadenectomies by laparoscopy. A total of 1192 pelvic and aortic lymphadenectomies have been performed: 777 pelvic (757 transperitoneal, 20 extraperitoneal) and 415 aortic lymphadenectomies (155 transperitoneal, 260 extraperitoneal). Main indications for laparoscopic lymph node dissection were: early cervical carcinoma (n = 456), advanced cervical carcinoma (n = 219), vaginal carcinoma (n = 4), endometrial carcinoma (n = 182), and ovarian carcinoma (n = 139). Surgical laparoscopic management via laparoscopy was achieved during the same operative session in 372 patients. RESULTS: No lethality occurred. Thirteen open surgeries (1.3%) were required as a result of failure to complete a satisfactory laparoscopic procedure. Intraoperative, early postoperative complication rate, and lymphocyst formation rate were 2.0%, 2.9%, and 7.1%, respectively. A laparotomy was required for complication in seven patients (7 per 1000), including five returns to operating room. Eleven significant intraoperative vascular injuries occurred, but none required a laparotomy. The most frequently encountered visceral complications were bowel complications (n = 7), urinary tract complications (n = 5), and nerve injuries (n = 5). CONCLUSION: Evidence is given on a large series that laparoscopic lymph node dissection is safe. Laparoscopic surgery may be considered as the gold standard of assessment of the status of regional lymph nodes in gynecologic malignancies.

Laparoscopy-assisted vaginal pelvic exenteration.

OBJECTIVE: The aim of this study was to evaluate the feasibility, morbidity and survival outcome of laparoscopy-assisted vaginal pelvic exenteration. METHODS: Since 2000, we have performed 5 cases of en-bloc pelvic exenteration combining a vaginal or perineal approach and laparoscopic approach. All patients had received previous pelvic irradiation. One patient underwent a total type II exenteration with ileal-loop diversion, an omental flap and a temporary colostomy. Two patients underwent a middle and posterior exenteration: one was a type III exenteration with perineal rectal resection and a gracilis myocutaneous flap; the second one was a type II exenteration with a colorectal anastomosis and a vaginal reconstruction using a gluteal thigh flap. Two patients underwent a type I anterior and middle exenteration with continent Miami pouch and vaginal reconstruction by omental cylinder. RESULTS: Mean time of the procedure was 6 h (range: 4.5-9). Peroperative bleeding was less than 500 cm3. Two patients presented minor complications: a perineal abscess after perineal rectal resection and an abdominal wound abscess. Mean length of hospital stay was 27 days. Three patients are free of disease. Two patients presented groin metastasis. One patient died of disease after 8 months. CONCLUSION: Laparoscopic or laparoscopy-assisted vaginal pelvic exenteration followed by reconstruction is feasible with curative intent in selected patients.

Low-dose intraoperative brachytherapy in soft tissue sarcomas involving neurovascular structure.

BACKGROUND AND PURPOSE: To evaluate intraoperative brachytherapy in the management of soft tissue sarcomas involving neurovascular structures, its impact on local control and complications. PATIENTS AND METHODS: Between 01/1989 and 12/2002, 98 patients received an intraoperative implant in conjunction with conservative surgery. Brachytherapy was part of the initial treatment (79 cases) or performed in recurrent disease (19 cases). We studied primary sarcomas involving neurovascular structures treated with conservative surgery and intraoperative brachytherapy (n = 6) or intraoperative brachytherapy and external irradiation (n = 73). Conservative surgery was performed as first treatment (51 cases), after chemotherapy (21 cases) and after primary external radiation (seven cases). Brachytherapy was performed according to Paris system rules. Patients were loaded with Iridium 192 (64 cases) or connected to a Microselectron PDR (15 cases). Mean dose given by brachytherapy was 20 Gy. Mean dose given of external radiotherapy was 46 Gy. RESULTS: With a median follow-up of 58 months, 5-year actuarial survival was 69% and local free disease at 5 years was 90%. Acute side-effects occurred in 22/79 requiring surgical repair in 10 patients. Late side-effects occurred in 35/79. No patient required amputation for complications. Prognostic factors were studied for the occurrence of acute and late side-effects and local control. CONCLUSIONS: Intraoperative brachytherapy is efficient with excellent local control rates in soft tissue sarcomas presenting with neurovascular involvement and offers an acceptable conservative option.

Further insights into the potential of pulp and paper mill effluents to affect fish reproduction.

As part of a continuing survey, effluents from five mills in Canada were tested in the laboratory for their potential to affect fish reproduction. The study included effluents from two thermomechanical pulp (TMP) mills, two kraft pulp mills, and one mill that used both chemical and mechanical pulping. The laboratory test used adult fathead minnows and involved a 21-day exposure to each effluent. All the effluents were tested at 2 and 20% concentration. The effluent from 1 of the kraft mills was also tested at 40% concentration. The endpoints of the test included, egg production, gonad size, sex steroids, secondary sexual characteristics, and vitellogenin concentration in males, considered to be an indicator of estrogenicity. The results of this study were similar to the results of our previous survey. None of the effluents produced noteworthy changes at 2% concentration. At 20% concentration, only the effluent from the multiprocess mill produced a significant reduction in eggs, which was considered to be the most important indicator of reproductive performance. Some effluents did produce an increase and/or a decrease in a variety of endpoints other than egg production, but the most consistent response was an induction of vitellogenin in males exposed to three of the five effluents tested. In summary, these results indicate that most mill effluents up to 20 or 40% concentration do not affect the overall reproductive capacity of minnows in the laboratory. However, the mill effluents do seem to contain substances that cause vitellogenin induction.

AIDS, drought, and child malnutrition in southern Africa.

OBJECTIVE: To investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3. DESIGN: Epidemiological analysis of sub-national and national surveys with related data. SETTING: Data from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices. SUBJECTS: Secondary data: children 0-5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance. RESULTS: Child nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997-2002), 17 to 32% in Copperbelt (Zambia, 1999-2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999-2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas--with greater reliance on trade and wage employment--have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status. CONCLUSIONS: First, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.

Management of soft tissue sarcomas (STS) in first isolated local recurrence: a retrospective study of 83 cases.

PURPOSE: To analyze the management and clinical outcome of patients treated for a first isolated local recurrence of soft tissue sarcomas (trunk or extremities) and to identify prognosis factors. METHODS AND MATERIAL: Between 1980 and 1999, 83 adult patients were included in the study. Mean age was 61 years. Mean tumor size was 6 cm. Most sarcomas were located in extremities (n=74), were deep (n=60), and proximal (n=53); 30 involved nerves or vessels. Histologic subtypes were mainly grade 2 (42%) or 3 (36%) histiocytofibrosarcomas (49%) and liposarcomas (20%). Surgical treatment of recurrences consisted in wide excision (29 cases), marginal resection (43 cases), 5 patients requiring amputation. Final results were R0 (n=33), R1 (n=47) or R2 (n=3) resection. Besides surgery, 6 patients received neo-adjuvant and 7 others adjuvant chemotherapy. Twenty three patients received post-operative external beam radiotherapy (EBRT) (mean dose 55 Gy) and 26 interstitial 192Ir low dose rate brachytherapy (BCT) (mean dose 45 Gy for BCT alone, 22 Gy when associated with EBRT), 19 patients being re-irradiated. RESULTS: Mean follow up was 13 years. Thirty-seven (45%) patients relapsed, 62% of whom presenting an isolated local recurrence. Nineteen patients developed distant metastases. Multivariate analysis showed only tumor depth (P=0.05) and re-resection for primary R1 resection (P=0.018) being independent prognosis factors for tumor control, radiotherapy (EBRT and/or BCT) being significant in univariate analysis (P=0.05). Overall survival rate was 73%, 54%, and 47% at, respectively, 3.5 and 10 years, and was 65%, 35% and 32% after a further local recurrence. Multivariate analysis showed trunk (P=0.0001) or inferior extremity locations (P=0.023), symptomatic (P=0.001), high grade (P=0.01), deep (P=0.01) tumors, and the occurrence of a further local failure (P=0.004) as unfavorable characteristics for overall survival. CONCLUSIONS: A first isolated local recurrence of STS increases mainly the risk of a subsequent local relapse. Quality of local treatment is decisive. When a conservative treatment is feasible, it should combine surgical resection and radiotherapy, BCT being the best suited in previously irradiated patients. Efforts have to be pursued to increase quality of the treatment of primary tumors, at best performed in centers that have expertise in this field.