Time trends in social contacts of individuals according to comorbidity and vaccination status, before and during the COVID-19 pandemic.

BACKGROUND: As we are confronted with more transmissible/severe variants with immune escape and the waning of vaccine efficacy, it is particularly relevant to understand how the social contacts of individuals at greater risk of COVID-19 complications evolved over time. We described time trends in social contacts of individuals according to comorbidity and vaccination status before and during the first three waves of the COVID-19 pandemic in Quebec, Canada. METHODS: We used data from CONNECT, a repeated cross-sectional population-based survey of social contacts conducted before (2018/2019) and during the pandemic (April 2020 to July 2021). We recruited non-institutionalized adults from Quebec, Canada, by random digit dialling. We used a self-administered web-based questionnaire to measure the number of social contacts of participants (two-way conversation at a distance ≤2 m or a physical contact, irrespective of masking). We compared the mean number of contacts/day according to the comorbidity status of participants (pre-existing medical conditions with symptoms/medication in the past 12 months) and 1-dose vaccination status during the third wave. All analyses were performed using weighted generalized linear models with a Poisson distribution and robust variance. RESULTS: A total of 1441 and 5185 participants with and without comorbidities, respectively, were included in the analyses. Contacts significantly decreased from a mean of 6.1 (95%CI 4.9-7.3) before the pandemic to 3.2 (95%CI 2.5-3.9) during the first wave among individuals with comorbidities and from 8.1 (95%CI 7.3-9.0) to 2.7 (95%CI 2.2-3.2) among individuals without comorbidities. Individuals with comorbidities maintained fewer contacts than those without comorbidities in the second wave, with a significant difference before the Christmas 2020/2021 holidays (2.9 (95%CI 2.5-3.2) vs 3.9 (95%CI 3.5-4.3); P<0.001). During the third wave, contacts were similar for individuals with (4.1, 95%CI 3.4-4.7) and without comorbidities (4.5, 95%CI 4.1-4.9; P=0.27). This could be partly explained by individuals with comorbidities vaccinated with their first dose who increased their contacts to the level of those without comorbidities. CONCLUSIONS: It will be important to closely monitor COVID-19-related outcomes and social contacts by comorbidity and vaccination status to inform targeted or population-based interventions (e.g., booster doses of the vaccine).

Time trends in social contacts before and during the COVID-19 pandemic: the CONNECT study.

BACKGROUND: Since the beginning of the COVID-19 pandemic, many countries, including Canada, have adopted unprecedented physical distancing measures such as closure of schools and non-essential businesses, and restrictions on gatherings and household visits. We described time trends in social contacts for the pre-pandemic and pandemic periods in Quebec, Canada. METHODS: CONNECT is a population-based study of social contacts conducted shortly before (2018/2019) and during the COVID-19 pandemic (April 2020 - February 2021), using the same methodology for both periods. We recruited participants by random digit dialing and collected data by self-administered web-based questionnaires. Questionnaires documented socio-demographic characteristics and social contacts for two assigned days. A contact was defined as a two-way conversation at a distance ≤ 2 m or as a physical contact, irrespective of masking. We used weighted generalized linear models with a Poisson distribution and robust variance (taking possible overdispersion into account) to compare the mean number of social contacts over time and by socio-demographic characteristics. RESULTS: A total of 1291 and 5516 Quebecers completed the study before and during the pandemic, respectively. Contacts significantly decreased from a mean of 8 contacts/day prior to the pandemic to 3 contacts/day during the spring 2020 lockdown. Contacts remained lower than the pre-COVID period thereafter (lowest = 3 contacts/day during the Christmas 2020/2021 holidays, highest = 5 in September 2020). Contacts at work, during leisure activities/in other locations, and at home with visitors showed the greatest decreases since the beginning of the pandemic. All sociodemographic subgroups showed significant decreases of contacts since the beginning of the pandemic. The mixing matrices illustrated the impact of public health measures (e.g. school closure, gathering restrictions) with fewer contacts between children/teenagers and fewer contacts outside of the three main diagonals of contacts between same-age partners/siblings and between children and their parents. CONCLUSION: Physical distancing measures in Quebec significantly decreased social contacts, which most likely mitigated the spread of COVID-19.

Adherence trajectories of adjuvant endocrine therapy in the five years after its initiation among women with non-metastatic breast cancer: a cohort study using administrative databases.

PURPOSE: Despite the benefits of adjuvant endocrine therapy (AET) for reducing recurrence and mortality risks after hormone-sensitive breast cancer, AET adherence is sub-optimal for a high proportion of women. However, little is known about long-term patterns of AET adherence over the minimally recommended 5 years. Our objectives were to: (1) identify 5-year AET adherence trajectory groups; (2) describe trajectory groups according to adherence measures traditionally used (i.e., Proportion of Days Covered); and (3) explore factors associated with trajectories. METHODS: We conducted a 5-year cohort study using data from a French national study that included AET dispensing data. Women diagnosed with first non-metastatic breast cancer and having at least 1 AET dispensing in the 12 months after diagnosis were included. Group-based trajectory modeling was used to identify adherence trajectory groups by clustering similar patterns of monthly AET dispensing. Multinomial logistic regressions were used to identify factors associated with trajectories. RESULTS: Among 674 women, five AET adherence trajectory groups were identified: (1) quick decline and stop (5.2% of women); (2) moderate decline and stop (6.4%); (3) slow decline (17.2%); (4) high adherence (30.0%); and (5) maintenance of very high adherence (41.2%). Mean 5-year Proportion of Days Covered varied from 10 to 97% according to trajectories. Women who did not receive chemotherapy or a personalized care plan were more likely to belong to trajectories where AET adherence declined and stopped. CONCLUSION: Our results provide information on the diversity of longitudinal AET adherence patterns, the timing of decline and discontinuation and associated factors that could inform healthcare professionals.

Acceptability of pre-exposure prophylaxis for HIV prevention: facilitators, barriers and impact on sexual risk behaviors among men who have sex with men in Benin.

BACKGROUND: In Benin, men who have sex with men (MSM) do not always use condoms during anal sex. Pre-exposure prophylaxis (PrEP) using Truvada® (tenofovir disoproxil fumarate / emtricitabine) may be a complementary HIV prevention measure for MSM. This study aimed at identifying the potential facilitators and barriers to the use of PrEP. METHODS: This was a cross-sectional study conducted in 2018 among male-born MSM aged 18 years or older who reported being HIV-negative or unaware of their HIV status. The participants were recruited by the RDS technique (respondent driven sampling) in six cities of Benin. Logistic regression analyses, adapted to RDS statistical requirements, were performed to identify the factors associated with PrEP acceptability. RESULTS: Mean age of the 400 MSM recruited was 26.2 ± 5.0 years. PrEP was known by 50.7% of respondents. The intention to use PrEP was expressed by 90% of MSM. If PrEP effectiveness were 90% or more, 87.8% of the respondents thought they would decrease condom use. In multivariate analysis, the facilitators associated with PrEP acceptability were: not having to pay for PrEP (odds ratio (OR) = 2.39, 95% CI: 1.50-4.46) and its accessibility within MSM networks (OR = 9.82, 95% CI: 3.50-27.52). Only one barrier was significant: the concern that taking PrEP be perceived as marker of adopting HIV risky behaviors (OR = 0.11, 95% CI: 0.04-0.30). CONCLUSION: In Benin, not all MSM know about PrEP. But once well informed, the majority seems willing to use it if made available. The free availability of the drug and its accessibility in the MSM networks are important facilitators. The possibility of decrease in condom use should not be a barrier to the prescription of PrEP if made available.

Canadians Adults Fail Their Dietary Quality Examination Twice.

For many years, dietary quality among Canadians has been assessed using an index that gives criticized scores and does not allow for comparison with Americans. In Canadians aged ≥19 years, we aimed to (1) determine the dietary quality by using a more widely used evidence-based index that has shown associations with health outcomes, the alternative Healthy Eating Index (aHEI-2010); (2) assess changes in aHEI-2010 score and its components between 2004 and 2015; and (3) identify factors associated with aHEI-2010 score. We relied on the Canadian Community Health Survey 2004 (n = 35,107) and 2015 (n = 20,487). We used adjusted linear models with a time effect to compare the total aHEI-2010 score and its components. The overall aHEI-2010 score increased from 36.5 (95%CI: 36.2-36.8) in 2004 to 39.0 (95%CI: 38.5-39.4) in 2015 (p < 0.0001). Participants with less than a high school diploma showed the lowest score and no improvement from 2004 to 2015 (34.8 vs. 35.3, p = 0.4864). In each period, higher scores were noted among immigrants than non-immigrants (38.3 vs. 35.9 in 2004, p < 0.0001; 40.5 vs. 38.5 in 2015 p < 0.0001), and lower scores were observed in current smokers (33.4 vs. 37.1 in 2004, p < 0.0001; 34.5 vs. 39.9 in 2015, p < 0.0001). The use of the aHEI-2010 tool suggests a lower score among Canadians than the previous index, more comparable to the score among Americans.

The Association Between Self-Reported Cigarette Smoking and Spinal Pain is Not Explained by Serum Cotinine Levels.

PURPOSE: The aim of this study was to check if self-reported smoking is still associated with back pain above and beyond its association with cotinine, to test the hypothesis that the association of self-reported cigarette smoking with back pain is due to residual confounding. METHODS: Secondary analyses of population-based cross-sectional data pertaining to 4470 adults were conducted. In multivariate analyses examining the associations of self-reported smoking with several spinal pain outcomes (neck pain, low back pain, low back pain with pain below knee, self-reported diagnosis of arthritis/rheumatism, and related limitations), further adjustment for serum cotinine concentrations was made. RESULTS: Self-reported cigarette smoking was associated with neck pain (adjusted Odds Ratio (aOR) Regular smokers vs. Non-smokers: 1.44; 95% Confidence Interval (CI): 1.14-1.82), low back pain (aOR: 1.48; 95% CI: 1.24-1.78), low back pain with pain below knee (aOR: 1.98; 95% CI: 1.42-2.76), as well as arthritis/rheumatism (aOR: 1.33; 95% CI: 1.03-1.71), and related functional limitations (P < .05). Further adjustment for serum cotinine concentrations brought about little change in the ORs or beta coefficients. CONCLUSIONS: These results do not support the hypothesis that serum cotinine concentrations explain the well-known relationship between cigarette smoking and spinal pain.

Epidemiology associated with the exposure to Toxoplasma gondii in Nunavik's Inuit population using the 2017 Qanuilirpitaa cross-sectional health survey.

Foci of high seroprevalence against Toxoplasma gondii are observed in Nunavik, the Inuit land of Northern Quebec (Canada). Considering the rare occurrence of felids in the region, exposure is suspected to be driven by water- and food-borne transmission routes. Hypotheses were that drinking untreated water from natural sources and eating country food mostly raw increased the risk of exposure to the parasite. Data from 1,300 Inuit participants of the 2017 Nunavik Health Survey were included in three weighted robust Poisson regression models. The effect of three types of exposure variables: (1) water treatment (yes/no) and if country food was mostly eaten raw (yes/no); (2) main source of drinking water (bottled/municipal/natural) and frequency of country food consumption (continuous) and (3) drinking water risk (low/intermediate/high) and frequency of a raw country food consumption (continuous), on the presence of Toxoplasma antibodies were estimated. Models were adjusted for age, sex and ecological region, with multiple sensitivity analyses being performed. Toxoplasma gondii seroprevalences were consistently correlated with age quadratically, sex (prevalence ratio = PRwoman/man ranged from 1.18 to 1.22), ecological region (PRHudsonBay/HudsonStrait ranged from 2.18 to 2.41; PRHudsonBay/UngavaBay ranged from 1.52 to 1.59) and consuming bivalve mollusc/urchin (PR varied from 1.02 to 1.21) across all three models. Each increase of two consumptions per month of beluga (PR ranged from 1.01 to 1.03), seal liver (PR ranged from 1.01 to 1.02) and goose (PR ranged from 1.01 to 1.02) were also associated with seropositivity, albeit more clearly in models 2 and 3, while drinking water mainly from natural (PR of 1.47) or municipal (PR = 1.42) sources compared to bottled water, was correlated with seroprevalence, although results were compatible with the null. Our results suggest that both the oocyst- (mollusc/urchin, drinking water) and cyst-borne (walrus, seal liver and goose) transmission pathways could be present in Nunavik.

Psychological distress and physical health in the year after diagnosis of DCIS or invasive breast cancer.

Ductal carcinoma in situ (DCIS) has an excellent prognosis, but its management can resemble that of early invasive breast cancer. We compared aspects of quality of life of women with DCIS to that of women with invasive disease during the first year after treatment initiation. Participants came from consecutive series of women with newly diagnosed, non-metastatic breast cancer treated in eight Quebec hospitals in 2003. Psychological distress and health-related quality of life were measured using the Psychiatric Symptom Index (PSI) and the SF-12 mental and physical component scales (MCS, PCS). Data were obtained 1, 6, and 12 months after the start of treatment. We used generalized linear models to compare mean scores and explored the possible clinical significance of between-group differences with effect size (ES). Participation and retention among eligible women were high, 86 and 97%, respectively. Among the 800 women who completed all interviews, 13.4% (n = 107) had DCIS and 86.6% (693) invasive disease. No statistically significant between-group differences were found at 1, 6, or 12 months in psychological state (PSI and MCS: P values from 0.065 to 0.904; ES from -0.01 to -0.21). Women with DCIS reported significantly higher levels of physical health, particularly when compared at 1 month to women with invasive disease who had chemotherapy (P value < 0.0001; ES = 0.82). Measured in symptoms of psychological distress, the better prognosis or less aggressive management of DCIS does not offset the general psychological effects of a cancer diagnosis to any great degree.

Vitamin C is not the Missing Link Between Cigarette Smoking and Spinal Pain.

STUDY DESIGN: A nationwide cross-sectional study. OBJECTIVES: To measure the associations between cigarette smoking (defined as serum cotinine concentration >15 ng/mL) and the 3-month prevalence of spinal pain (neck pain, low back pain, low back pain with pain below knee, and self-reported diagnosis of arthritis/rheumatism) and related limitations, and to verify whether these associations are mediated by serum concentrations of vitamin C. SUMMARY OF BACKGROUND DATA: Cigarette smoking has been consistently associated with back pain, but this association has never been explained. Because vitamin C has recently been reported to be associated with spinal pain and related functional limitations, and the metabolism of vitamin C differs between smokers and nonsmokers, we hypothesized that the prevalence of spinal pain and related limitations might be greater among smokers because they are more susceptible to be in a state of hypovitaminosis C. METHODS: We conducted secondary analyses of National Health and Nutrition Examination Survey (NHANES) 2003 to 2004 data on 4438 individuals aged ≥20 years. RESULTS: Serum concentrations of vitamin C and cotinine were strongly and inversely correlated (r = -0.35, P < 0.0001). Smoking was statistically associated with the prevalence of neck pain [adjusted odds ratio: aOR: 1.25; 95% confidence interval (95% CI): 1.06-1.47], low back pain (aOR: 1.20; 95% CI: 1.04-1.39), and low back pain with pain below knee (aOR: 1.58; 95% CI: 1.13-2.22) and related limitations, with a dose-response relationship (P < 0.05). However, the associations between smoking and spinal pain were not mediated by concentrations of vitamin C. CONCLUSION: These results confirm the relationship between smoking and spinal pain, but they do not support a mediating effect of vitamin C on this relationship. LEVEL OF EVIDENCE: 2.

Couples who get closer after breast cancer: frequency and predictors in a prospective investigation.

PURPOSE: Although some couples report an improved relationship since coping with breast cancer together, little quantitative information exists about this phenomenon. We assessed extent to which both couple members report that breast cancer brought them closer and characteristics that predicted this. PATIENTS AND METHODS: This prospective study was based on all women with newly diagnosed nonmetastatic disease first treated during recruitment in four Quebec hospitals, in addition to their spouses. Participation was 87% among eligible patients and 91% among spouses of participating patients. Both couple partners were interviewed individually about quality of life at 2 weeks and 3 and 12 months after treatment start. At 12 months, each was asked whether the disease had brought them closer, distanced them, or had no effect. RESULTS: Overall, 42% of the 282 couples said breast cancer brought them closer, 6% had one or other partner reporting feeling distanced, and less than 1% of couples had both partners reporting feeling distanced. Characteristics assessed explained 31% of variance in the proportion of couples getting closer (P < .0001). After taking into account partners' prediagnosis characteristics and the woman's treatment, the spouse reporting the patient as confidant (P = .003), getting advice from her in the first 2 weeks about coping with breast cancer (P = .03), accompanying her to surgery (P = .057), the patient's reporting more affection from her spouse at 3 months since diagnosis (P = .003) predicted both partners saying the disease brought them closer. CONCLUSION: Breast cancer can be a growth experience for couples under certain conditions. This information may help reassure patients and their spouses confronting this disease.

Serum vitamin C and spinal pain: a nationwide study.

Back pain brings about one of the heaviest burden of disease. Despite much research, this condition remains poorly understood, and effective treatments are frustratingly elusive. Thus, researchers in the field need to consider new hypotheses. Vitamin C (ascorbic acid) is an essential cofactor for collagen crosslinks, a key determinant of ligament, tendon, and bone quality. Recent studies have reported high frequency of hypovitaminosis C in the general population. We hypothesized that lack of vitamin C contributes to poor collagen properties and back pain. We conducted this study to examine the associations between serum concentration of vitamin C and the prevalence of spinal pain and related functional limitations in the adult general population. This study used nationwide cross-sectional data from the U.S. National Health and Nutrition Examination Survey (NHANES) 2003-2004. Data were available for 4742 individuals aged ≥20 years. Suboptimal serum vitamin C concentrations were associated with the prevalence of neck pain (adjusted odds ratio [aOR]: 1.5; 95% confidence interval [CI]: 1.2-2.0), low back pain (aOR: 1.3; 95% CI: 1.0-1.6), and low back pain with pain below knee (aOR: 1.3; 95% CI: 1.0-1.9) in the past 3 months, self-reported diagnosis of arthritis/rheumatism (aOR: 1.4; 95% CI: 1.2-1.7), and related functional limitations' score (adjusted difference of means [aB]: 0.03; 95% CI: 0.00-0.05). The prevalence of hypovitaminosis C in the general population is high. Our study shows associations between vitamin C and spinal pain that warrant further investigation to determine the possible importance of vitamin C in the treatment of back pain patients.

Work absence after breast cancer diagnosis: a population-based study.

BACKGROUND: Absence from work after breast cancer diagnosis may be part of the burden of disease for women with cancer, but little research has addressed this. We examined work absences of 4 weeks or more among women who had had breast cancer during the 3 years after diagnosis and compared their absences with those of women who had never had cancer. METHODS: Our 2 target study groups were women in Quebec 18-59 years of age who were working when they first received therapy for breast cancer between November 1996 and August 1997 and similarly aged women randomly selected from provincial health care files who had never had cancer and were working at the time of diagnosis in women who had cancer. We interviewed 646 women who had had breast cancer (73% of those eligible) and 890 women in the comparison group (51% of those eligible) by telephone 3 years after first diagnosis. RESULTS: One year after diagnosis, 85% (459/541) of breast cancer survivors who remained free of disease during the 3-year study period were absent from work for 4 weeks or more compared with 18% (156/881) of healthy women (geometric mean total duration 5.6 v. 1.7 months, p < 0.001). By the third year, disease-free women were not absent more than women in the comparison group; however, more women who had experienced any new cancer event continued to be absent from work and to be absent from work for longer periods of time. Receiving adjuvant chemotherapy prolonged absence duration (9.5 v. 5.4 months among women not receiving chemotherapy). Compared with survivors belonging to a union, those who did not belong to a union (multivariate relative risk [RR] 7.54, 95% confidence interval [CI] 3.02-18.83) and those who were self-employed (RR 13.95, 95% CI 5.53-35.21) were more likely to report no work absence. INTERPRETATION: Most of the women with breast cancer took time off work (almost 6 months on average) after receiving the diagnosis. Three years after diagnosis, breast cancer survivors who remained disease-free--a large proportion of women with nonmetastatic breast cancer--were not absent from work more often or for longer periods of time than other working women.

Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study.

BACKGROUND: This study was carried out to identify risk factors associated with urinary incontinence in women three months after giving birth. METHODS: Urinary incontinence before and during pregnancy was assessed at study enrolment early in the third trimester. Incontinence was re-assessed three months postpartum. Logistic regression analysis was used to assess the role of maternal and obstetric factors in causing postpartum urinary incontinence. This prospective cohort study in 949 pregnant women in Quebec, Canada was nested within a randomised controlled trial of prenatal perineal massage. RESULTS: Postpartum urinary incontinence was increased with prepregnancy incontinence (adjusted odds ratio [adj0R] 6.44, 95% CI 4.15, 9.98), incontinence beginning during pregnancy (adjOR 1.93, 95% CI 1.32, 2.83), and higher prepregnancy body mass index (adjOR 1.07/unit of BMI, 95% CI 1.03,1.11). Caesarean section was highly protective (adjOR 0.27, 95% CI 0.14, 0.50). While there was a trend towards increasing incontinence with forceps delivery (adjOR 1.73, 95% CI 0.96, 3.13) this was not statistically significant. The weight of the baby, episiotomy, the length of the second stage of labour, and epidural analgesia were not predictive of urinary incontinence. Nor was prenatal perineal massage, the randomised controlled trial intervention. When the analysis was limited to women having their first vaginal birth, the same risk factors were important, with similar adjusted odds ratios. CONCLUSIONS: Urinary incontinence during pregnancy is extremely common, affecting over half of pregnant women. Urinary incontinence beginning during pregnancy roughly doubles the likelihood of urinary incontinence at 3 months postpartum, regardless whether delivery is vaginal or by Caesarean section.

Immunization services offered in Québec (Canada) pharmacies.

Canadian Pharmacists are easy to reach. Although Québec pharmacists are not allowed to administer vaccines, they can: (1) promote vaccination, (2) counsel patients on vaccination, (3) sell vaccines and (4) provide vaccine administration by a nurse. Our objectives were to describe immunization services given in Québec pharmacies and assess the potential relation between, on one hand, pharmacy characteristics and difficulties perceived by pharmacists and, on the other hand, vaccine administration. In 2008-09, an anonymous questionnaire was mailed to all Québec pharmacy owners (n = 1663). Among the 1102 (66%) respondents, 90% stated that vaccines were sold, 27% that a nurse administered vaccines in their pharmacy and 44% were planning to offer vaccine administration in the next five years. Three out of four stated they were doing vaccine promotion and 65%, vaccine counselling. Half of respondents said they would be willing to administer vaccines themselves if legislative modifications were made. Recommendations for cold chain maintenance were followed in 23% of pharmacies selling vaccines. Presence of another health professional in the pharmacy, higher number of opening hours, not being located in the same building than a medical clinic and having an agreement to collaborate with a public health unit or a medical clinic for immunization were positively associated with vaccine administration in multivariate analysis. Higher perceived difficulties with lack of demand from patients were negatively associated with vaccine administration. Most pharmacists are willing to increase their involvement in immunization. Collaboration between public health professionals and pharmacists should be reinforced.

Out-of-pocket costs in the year after early breast cancer among Canadian women and spouses.

BACKGROUND: We lack comprehensive information about the extent of out-of-pocket costs after diagnosis of early breast cancer and their effects on the family's financial situation. METHODS: This longitudinal study assessed out-of-pocket costs and wage losses during the first year after diagnosis of early breast cancer among Canadian women and spouses. Out-of-pocket costs for treatments and follow-up, consultations with other practitioners, home help, clothing, and natural health products were estimated, with information collected from telephone interviews. Generalized linear models were used to identify women at risk of having higher costs and the effects of out-of-pocket costs on perceptions of the family's financial situation. RESULTS: Overall, 829 women (participation, 86.2%) and 391 spouses participated. Women's median net out-of-pocket costs during the year after diagnosis were $1002 (2003 Canadian dollars; mean = $1365; SD = $1238), and 74.4% of these costs resulted from treatments and follow-up. Spouses' median costs were $111 (mean = $234; SD = $320), or 9% of couples' total expenses. In multivariable analyses, the percentage of women with out-of-pocket costs of $1773 or more (upper quartile) was statistically significantly associated with higher education, working at diagnosis, living more than 50 km from the hospital where surgery was performed, and having two and three different types of adjuvant treatment (all 2-sided P values ≤ .01). However, when considered simultaneously with wage losses, out-of-pocket costs were not associated with perceived deterioration in the family's financial situation; rather, wage losses were the driving factor. CONCLUSIONS: Overall, out-of-pocket costs from breast cancer for the year after diagnosis are probably not unmanageable for most women. However, some women were at higher risk of experiencing financial burden resulting from these costs.

Anal incontinence after childbirth.

BACKGROUND: Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. METHODS: We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. RESULTS: Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01-2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40-3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4-282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2-28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0-50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9-28.5) but not with birth weight (adjusted RR for nirth weight 4000 g or more: 1.4, 95% CI 0.6-3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5-2.7). INTERPRETATION: Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour.

Effectiveness and complications associated with 2 vasectomy occlusion techniques.

PURPOSE: We compared the effectiveness and complications associated with 2 common vasectomy occlusion techniques, namely clipping and excision of a small vas segment and thermal cautery with fascial interposition and an open testicular end. MATERIALS AND METHODS: We retrospectively reviewed the computerized records of 3,761 men who underwent initial vasectomy at a single university hospital family planning clinic and at 2 private clinics in the Quebec City, Canada area, including concurrent and historical controls. All procedures were performed by 1 surgeon, who used the scalpel-free technique to expose the vas. RESULTS: The risk of vas occlusion failure in men with at least 1 semen analysis was much greater in the clipping and excision group than in the cautery, interposition and open testicular end group (126 of 1,453 or 8.7% versus 3 of 1,165 or 0.3%, OR 37, 95% CI 12 to 116). Medical consultations for hematoma or infection were more frequent in the cautery group (28 of 1,721 cases or 1.6% versus 10 of 2,040 or 0.5%, OR 3.4, 95% CI 1.6 to 6.9). Consultations for noninfectious pain were similar for the 2 techniques (71 of 1,721 cases or 4.1% versus 72 of 2,040 or 3.5%, OR 1.2, 95% CI 0.8 to 1.6). CONCLUSIONS: Cautery and interposition with an open testicular end are much more effective than clipping and excision. The effectiveness and morbidity associated with the components of the cautery, interposition and open testicular end technique need further evaluation.

The price of development: HIV infection in a semiurban community of Ghana.

OBJECTIVE: To describe the epidemiology of HIV infection in the Manya Krobo District, Ghana, and its potential link to the building of the Akosombo dam. METHODS: A questionnaire and a blood sample were collected among 1228 consecutive pregnant women seen at the prenatal clinics of the two major hospitals of the district. RESULTS: Overall, prevalence of HIV and of serologically confirmed syphilis were 14.9% and 0.7%, respectively. HIV infection was more prevalent among the Krobo ethnic group (137 of 742 [18.5%]) than among other ethnic groups (46 of 486 [9.5%]; p <.001). Two distinct patterns of HIV distribution were identified. Among the Krobos, HIV was common among all age groups, reached a plateau (21.9%) in the 30- to 34-year-old group and was associated strongly with having lived in Côte d'Ivoire and with having received only primary school education. Among the other ethnic groups, prevalence decreased with age, from 17.2% in the 13- to 19-year-old age group to 1.4% among women aged 35 years or older, and HIV infection was associated with having had first sexual intercourse before the age of 17 years. In logistic regression analysis, the independent risk factors for HIV infection were age, schooling, age at first sexual intercourse; having lived in Côte d'Ivoire; age and schooling showed significant interactions with ethnic group. CONCLUSIONS: The high HIV prevalence documented in this part of Ghana seems to be, to some extent, a consequence of construction of the Akosombo dam in the 1960s. The flooding of the land, the failures of the resettlement program and the ensuing poverty prompted economically driven migration, specially to Côte d'Ivoire, where many migrants became infected with HIV. Local transmission followed. This illustrates that HIV can disseminate widely in a society where most men are circumcised and where genital ulcerative diseases are uncommon and should be an indication for less complacency about HIV control in West Africa.