Adjuvant endocrine therapy with tamoxifen in young women with breast cancer: determinants of interruptions vary over time.

BACKGROUND: In premenopausal women with hormone receptor-positive breast cancer (BC), 5 years of tamoxifen is recommended. Little is known about reasons for interruption in this population. The aim was to estimate the incidence of tamoxifen interruption and its correlates among younger women. PATIENTS AND METHODS: Using a prospective cohort Elippse 40 of women with BC aged ≤ 40 diagnosed between 2005 and 2008, we studied 196 women. Tamoxifen interruption was defined as two or more consecutive months without dispensed prescription of tamoxifen, based on pharmacy refill database. Two periods were studied: between tamoxifen initiation and 16 months after BC diagnosis, and between 16 and 28 months. RESULTS: Among women treated with tamoxifen, 42% interrupted within the first 2 years of treatment. During the first period, treatment interruptions were associated with a lack of understandable information about endocrine treatment and insufficient social support. During the second period, another set of factors were associated with interruption: treatment side-effects, no longer fearing cancer relapse, lack of social support, no opportunity to ask questions at the time of diagnosis, and fewer treatment modalities. CONCLUSIONS: Improving information and patient-provider relationship might prevent interruption. Particular attention should be paid to women with little social support.

Immunosuppression and cancer: A comparison of risks in recipients of organ transplants and in HIV-positive individuals.

The comparison of cancers occurring excessively among HIV-infected and transplanted individuals may help to elucidate the relationship between immune surveillance, viral infections, and cancer. A longitudinal study was conducted on 2002 HIV-infected Italian subjects, 6072 HIV-infected French individuals, and 2878 Italian recipients of solid organ transplants. Standardized incidence ratios (SIR) and 95% confidence intervals (CI) were computed to quantify the risk for cancer, compared with the French and Italian general populations. The SIRs for all cancers were 9.8 (95% CI: 9.0-10.6) for HIV-infected individuals versus 2.2 (95% CI: 1.9-2.5) for transplant recipients. In both groups, most of the excess risk was attributable to virus-related cancers, such as Kaposi's sarcoma (KS; SIR = 451 in HIV-positive individuals, 125 in transplant recipients), non-Hodgkin's lymphoma (NHL; SIR = 62.1 and 11.1, respectively), and liver cancer (SIR = 9.4 and 4.1, respectively). Significantly increased SIRs for anal cancer and Hodgkin's lymphoma were found only among HIV-positive individuals. Among women younger than 40 years of age, a more than 10-fold increase in cervical cancer risk was found in both groups. Among HIV-infected individuals treatment with highly active antiretroviral therapies drastically reduced SIRs for KS and NHL only. These results show that HIV-infected individuals and transplant recipients share a similar pattern of cancer risk, largely due to virus-related cancers.

Idiopathic chronic fatigue and chronic fatigue syndrome: a comparison of two case-definitions.

The aim of the study was to compare the signs and symptoms of individuals meeting two different definitions of chronic fatigue syndrome (CFS). Ninety-four patients fitting the eligibility criteria for idiopathic fatigue were enrolled into the study. Of the 94 patients, 48 met the 1988 definition of CFS, 20 the 1994 (but not the 1988) definition of CFS, and 26 met neither definition. The 1994 defined cases were more likely than 1988 defined cases, and non-syndromal individuals to be male, married, and high school educated. The 1994 cases were less likely than 1988 cases to present acute onset, self reported sore throat, mild fever lymphadenopathy, pharyngitis. In conclusion, the 1994 criteria increased the number of patients classified as CFS; however, those who fit only the 1994 criteria were less likely to have an acute symptomatic onset and signs and symptoms suggestive of an infectious process.

A case-control study on risk factors for Peyronie's disease.

The aim of this study was to investigate the relationship between history of selected diseases, genital traumas, and Peyronie's disease. A hospital-based case-control study was conducted at the Andrologic and Surgical Outpatient Units of the Policlinico Gemelli, Rome, where 134 men with Peyronie's disease and 134 male controls were interviewed. The association between Peyronie's disease and selected characteristics was estimated by means of odds ratios (OR) and 95% confidence intervals (CI). Patients who underwent invasive procedures on the penis (i.e., urethral catheterization, cystoscopy, and transurethral prostatectomy) had a 16-fold increased risk for Peyronie's disease (OR = 16.1, 95% CI: 1.8-142), while a nearly three-fold increase was observed among patients who had genital and/or perineal traumatisms (95% CI: 1.0-7.1). A history of urethritis, uricacidemia, and lipoma was also significantly associated with an increased risk for Peyronie's disease. Twenty-one percent of the cases and none of the controls were affected by Dupuytren's contracture, and 4% of cases and none of the controls reported familial history for Peyronie's disease. The frequency of inflammatory or fibromatous lesions of the genital tract of the partner was significantly higher in men with Peyronie's disease than among controls. These results were consistent when performing a stratified analysis according to the type of controls (i.e., controls affected by urologic or by digestive conditions) to rule out the potential effect of recall bias. The findings of the study lend support to clinical reports stressing the importance of genital traumatisms and genetic conditions in the development of Peyronie's disease.

Mandatory prenatal screening for the human immunodeficiency virus: the experience in south-eastern France of a national policy, 1992-1994.

OBJECTIVE: To evaluate the impact of the 1993 French National Policy which made it mandatory to offer screening for the presence of human immunodeficiency virus (HIV) to all pregnant women who planned to give birth, although women remained free to refuse the test. DESIGN: Successive surveys in April 1992 and May 1994 in south-eastern France. Logistic regressions were performed to identify factors which affected access to HIV testing for women who gave birth and those who terminated their pregnancy, and for each year of study. MAIN OUTCOME MEASURES: Attitudes and access to HIV testing among pregnant women, irrespective of pregnancy outcome. SETTING: All obstetrics and gynaecology departments and abortion clinics in the region. POPULATION: 3497 women in 1992 (2775 who were delivered and 722 who chose termination) and 3407 in 1994 (2701 who were delivered and 766 who chose termination). The response rates were 82% and 88%, respectively. RESULTS: In 1994 of women who were delivered, 73% had an HIV test, compared with 63% in 1992 (P < 0.001); however of women who terminated their pregnancy, only 28% had an HIV test, compared with 24.5% in 1992 (P not significant), although they were more at risk for HIV infection. Socioeconomic differences affecting access to testing were reduced between 1992 and 1994, but only among women who gave birth. CONCLUSION: Introduction of a policy which makes it mandatory to offer HIV screening to all women who intended to have their baby improved access to screening but did not improve the rate of preventative counselling. A mandatory requirement to offer HIV screening should be extended to women who request termination of pregnancy.

HIV screening for pregnant women in south eastern France: evolution 1992-1994-1996.

OBJECTIVES: To assess the evolution of the HIV screening practices towards pregnant women between 1992 and 1996, in relation with the 1993 French mandatory obligation to offer prenatal HIV testing and recent therapeutic possibilities to reduce HIV vertical transmission. STUDY DESIGN: Three successive surveys (January 1992, May 1994 and May 1996) about HIV screening policies among medical chiefs of all prenatal care and abortion departments of South Eastern France. Sixty-seven of the 74 departments concerned agreed to participate in the three surveys. RESULTS: The proportion of departments practising routine prenatal HIV screening had not increased since 1992 (89%) but systematic women's consent is more often requested (65.5 vs. 38.2%, P < 0.01). In the context of abortion, HIV testing is more often routinely offered (38.1 vs. 16.4%, P < 0.05) but selective screening remains a frequent practice (29.1%). CONCLUSION: Mandatory proposal of HIV testing to women who terminate could improve access to test but is not sufficient to guarantee adequate preventive counselling.

[The effect of changing some patient care practices on the incidence of surgical wound infections following "clean" interventions. PRINOS group of study]. / Impatto del cambiamento di alcune pratiche assistenziali sull'incidenza di infezioni della ferita chirurgica in seguito a interventi puliti. Gruppo di Studio PRINOS.

OBJECTIVES: To evaluate the changes in patient care practices following an intervention program in general surgery and their impact on surgical wound infections (SWI) associated with clean operations. STUDY DESIGN: A "before-after" study design was used. Active surveillance was implemented in each ward; the intervention consisted of an educational program, whose effectiveness was evaluated comparing SWI rates before and after its implementation. RESULTS: A total of 799 patients undergoing clean operations from three general surgical wards were included in the study: 606 before and 193 after the intervention program. The observed reduction in the SWI incidence was 79.2%; the most striking change in patient care practices observed after the intervention was the substitution of open surgical drains with closed drains. High risk operations (RR 8.4), length of operation greater than 2 hours (RR 11.2), and open surgical drains lasting more than three days (RR 5.1) significantly increased the risk of SWIs in the preintervention phase, according to the logistic regression analysis. Of the observed pre-intervention SWIs, 46.2% was attributable to exposure to open drains. CONCLUSIONS: Many postoperative infections can be prevented in environments where patient care practices fall well below the accepted standards. More efforts should be placed on the prevention of the risk associated with modifiable risk factors, such as open surgical drains.

Risk factors for surgical wound infections in clean surgery: a multicenter study. Italian PRINOS Study Group.

OBJECTIVE: To investigate potential risk factors for surgical wound infections in clean surgery. STUDY DESIGN: Multicenter prospective study in eight general surgical wards and one thoracic surgical ward. METHODS: All patients undergoing clean operations in the nine wards were included in the study. The following data were collected for each study participant: demographic characteristics, underlying disease, predisposing factors, type of surgery, length of operation, preoperative shaving, type and duration of surgical drains, and length of hospital stay. After surgery, patients were visited daily by an intern surgeon in order to detect infections. Infections occurring after discharge were not actively surveyed. A multiple logistic regression was performed to obtain an adjusted estimate of the odds ratios and to identify which factors were independently associated with surgical infection. RESULTS: 2,262 patients were included in the study: eighty three patients (3.7%) developed a surgical infection. The highest infection rates were observed following vascular surgery, thoracic surgery and herniorraphy. Seven factors appeared to be significantly and independently associated with an increased risk of SWIs in a logistic regression model; age greater than 85 years, obesity, patients undergoing high risk operations or more than one operation during stay, length of operation greater than 120, preoperative shaving, open surgical drains lasting more than three days. CONCLUSIONS: The high incidence of infection observed in our study population indicates potential problems in quality of care. In order to prevent SWIs in patients undergoing clean operations, more efforts should be placed on the prevention of the risk associated with two modifiable risk factors, that is preoperative shaving and use of open surgical drains.

Bone aluminum content in predialysis chronic renal failure and its relation with secondary hyperparathyroidism and 1,25(OH)2D3 treatment.

32 patients with slowly evolving predialysis chronic renal failure, who were not exposed to aluminum-containing antacids, were studied. A low aluminum intake was considered a useful condition to examine the bone deposition of the element as dependent variable, not interfering with PTH secretion and bone metabolism. Iliac bone biopsies for bone aluminum content and histomorphometric and histodynamic evaluations were taken. Serum aluminum, creatinine, calcium, phosphate, iPTH, osteocalcin (BGP), alkaline phosphatase (AP), 25-OHD3 and 1,25(OH)2D3 were also measured. 16 of the patients were on long-term treatment with 1,25(OH)2D3 (0.25 micrograms daily) for prevention and treatment of secondary hyperparathyroidism. Bone aluminum content of all patients showed a strong positive correlation with BGP and iPTH (p less than 0.001) while the correlation with serum creatinine was not significant. Multiregression analysis has singled out BGP as the most predictive variable of bone aluminum content (r2 = 0.419). The patients receiving 1,25(OH)2D3 had lower iPTH (p less than 0.01), lower bone aluminum content (p less than 0.05) and increased mineral apposition rate (p less than 0.05) compared to the untreated group. The results suggest that treatment with 1,25(OH)2D3 for long-term suppression of secondary hyperparathyroidism does not enhance aluminum accumulation in bone. The finding of lower bone aluminum together with increased mineral apposition rate, seems to indicate that 1,25(OH)2D3 is able to induce an osteoid mineralization process more selective against aluminum incorporation in bone than in case of more severe hyperparathyroidism and 1,25(OH)2D3 deficiency. At least in the present condition of low aluminum intake, 1,25(OH)2D3 may be considered to have protective effects on bone from aluminum deposition.

Lead exposure: assessment of the risk for the general Italian population.

According to the regulations contained in the presidential decree DPR 496/82 certain Italian regions have carried out investigations--based on the blood lead level measurement--for the biological surveillance of the general population against the risk of saturnism. A work-group from the Istituto Superiore di Sanità (Italian National Institute of Health) coordinated the activity of the various centers and organized an appropriate quality control program to guarantee the quality of the analytical data collected. A total of 8635 subjects (4864 females and 3771 males) have been examined, 1968 of which (1058 females and 910 males) were under 14 years of age. The median values of the observed blood lead levels were, for the adults, 153 micrograms/l in males and 100 micrograms/l in females; and, for the children, 94 micrograms/l in males and 86 micrograms/l in females. The reference limit decreed by law for the 98th percentile is exceeded by the adult-males group, while both limits, at the 90th and 98th percentiles are exceeded by the population residing in the Portoscuso (CA) municipality. Our investigation confirms the correlation between blood lead levels, alcohol consumption, and cigarette smoking; in both sexes and in all age groups (except for females 15-25 years of age) a positive correlation of blood lead levels with alcohol consumption and cigarette smoking is clearly evident. The association of blood lead levels with alcohol seems to be stronger than that with cigarette smoking. The comparison with the results of previous investigations shows a 25% reduction of blood lead levels in the general Italian population during the 1979-1985 period.