Unprotected intercourse for extra money among commercial sex workers in Kinshasa, Democratic Republic of Congo.

This study assessed the extent and correlates of the practice of engaging in unprotected intercourse for extra money among commercial sex workers (CSWs) in Kinshasa, Democratic Republic of the Congo. We conducted a cross-sectional survey using a structured, interviewer-administered questionnaire among a convenience sample of 136 CSWs. More than one-quarter of CSWs (26.5%) engaged in unprotected intercourse for extra money. These CSWs charged about 3.5 times more for unprotected intercourse than for protected intercourse. Multivariate logistic regression showed that CSWs who engaged in unprotected intercourse for extra money were significantly more likely to live or work in non-downtown (lower socioeconomic) areas of Kinshasa (odds ratio [OR] = 3.07), to have at least one child less than six years of age (OR = 2.95), and to know other CSWs who engaged in the same practice (OR = 9.38). We hypothesize that desperate socioeconomic conditions combined with peer/social norms drive the practice of engaging in unprotected intercourse for extra money. Additional circumstances under which Kinshasa CSWs engaged in unprotected intercourse included intercourse with clients who tore their condoms to increase sexual pleasure (58.8% of CSWs), episodes of condom failure (56.8% of CSWs), and unprotected intercourse with regular noncommercial partners (only 5.3% of CSWs with noncommercial partners always used condoms with these partners).

Population-based sentinel lymph node biopsy in early invasive breast cancer.

INTRODUCTION: Sentinel lymph node biopsy (SLNB) has been proposed as a reliable method for staging of early invasive breast cancer (EIBC). In the present study we analyse the impact of this procedure when systematically applied to all unselected women of a community-based Breast Cancer Unit (BCU). METHODS: All consecutive women with unifocal cT1-2 (

Sentinel node biopsy in the surgical management of breast cancer: experience in a general hospital with a dedicated surgical team.

The aims of this study were to analyse the feasibility and accuracy of the sentinel lymph node biopsy (SLNB) procedure as performed in a general hospital compared with the literature results; to report on the organizational aspects of planning surgical time with higher accuracy of pathological analysis; and to verify that there is a real advantage of SLNB in the surgical management of breast cancer. From October 1999 to September 2000, 371 consecutive patients with T1-2N0 breast lesions underwent SLNB. The immunoscintigraphic method of sentinel node identification was the main one used, the blue dye method being used only when the lymphoscintigraphic method was unsuccessful in identifying sentinel nodes. SLNB was done under either general or local anaesthesia, depending on how the surgical procedure was organized and clinically planned. SLNB was successful in 99% of these T1-2N0 breast cancer cases, and in 71% no metastases were found in the sentinel node. In 47% of cases with axillary metastasis only the sentinel node was involved. Nodal involvement was not present in any case of microinvasive or in situ carcinoma. In T1 cancers nodal involvement was present in 21%; in T2 cases the corresponding rate reached 51%. The results obtained with the SLNB procedure at Bergamo Hospital are similar to the literature data. When a dedicated surgical team, the nuclear medicine department and the pathology department work together, a general hospital can provide breast cancer patients with appropriate surgical treatment.

Effectiveness of HIV prevention interventions in developing countries.

OBJECTIVE: To review the effectiveness of projects and programs in developing countries that aim to reduce sexual transmission of HIV infection or transmission related to injection drug use. DESIGN: We identified 34 published studies undertaken in 18 developing countries that met rigorous inclusion criteria. These criteria included the length of follow-up, use of statistical analysis, the inclusion of a comparison group, and type of outcomes measured. RESULTS: We found that behavioral change interventions are effective when targeted to populations at high risk, particularly female sex workers and their clients. Few studies have evaluated harm reduction interventions in injecting drug users (IDUs). Evidence on the effectiveness of voluntary counseling and testing programs was promising, and VCT was most effective when directed at discordant couples. Treatment of sexually transmitted diseases (STD) appears highly effective in reducing HIV/STD transmission, particularly in the earlier stages of the epidemic. CONCLUSIONS: This review demonstrates that HIV prevention interventions can be effective in changing risk behaviors and preventing transmission in low and middle-income countries. When the appropriate mix of interventions is applied, they can lead to significant reductions in the prevalence of HIV at the national level. Additional research is needed to identify effective interventions, particularly in men who have sex with men, youth, IDUs and HIV-infected persons. Structural and environmental interventions show great promise, although more evaluation is needed.

Structural interventions in public health.

OBJECTIVE: To review structural interventions in public health, identify distinct approaches to structural interventions, and assess their implications for HIV-prevention interventions. METHOD: The MEDLINE, HealthStar, PsychInfo and Sociofile databases were searched on specific health issues, types of public health interventions, and conceptual topics (e.g. empowerment, social structure, and inequality) to compile a list of public health interventions in the United States. We excluded interventions focused on testing and surveillance unless they specifically facilitated prevention, and educational or media campaigns focused on increasing individuals' level of knowledge about a particular health problem. RESULTS: The term 'structural' is used to refer to interventions that work by altering the context within which health is produced or reproduced. Structural interventions locate the source of public-health problems in factors in the social, economic and political environments that shape and constrain individual, community, and societal health outcomes. We identified two dimensions along which structural interventions can vary. They may locate the source of health problems in factors relating to availability, acceptability, or accessibility; and they may be targeted at the individual, organizational, or environmental levels. All together, this framework suggests nine kinds of structural interventions, and it is possible to identify examples of each kind of intervention across a range of public health issues. CONCLUSIONS: The relevance of this framework for developing HIV prevention interventions is considered.

Global dimensions of the AIDS epidemic: implications for prevention and care.

The appropriate balance of HIV prevention and care activities depends on the specific epidemiology of HIV, including the stage of the epidemic; information about the cost-effectiveness of specific prevention interventions and treatment regimens; and the level of public resources available. In all countries, it is far less costly to prevent HIV than to treat people with AIDS. Once prevention needs are met, governments facing a severe epidemic who have additional resources should consider cost-effective treatment for people living with AIDS. The epidemiology of HIV provides two clear messages for prevention. First, it is imperative to act early in the epidemic, when HIV spreads exponentially. Viral load is highest during the first few months of infection, so that early in the epidemic a large proportion of those infected may be highly infectious. Second, it is crucial to target interventions initially to those with the highest-risk behavior. This will have the greatest impact on the number of new HIV infections prevented, as individuals with large numbers of sexual and needle-sharing partners who do not use condoms or clean injecting equipment are those most likely to become infected and then spread HIV. Changing the behavior of these individuals, even if only a relatively few members of society, is essential to curbing the epidemic.

Electropotential measurements as a new diagnostic modality for breast cancer.

BACKGROUND: Proliferative changes in breast epithelium are an intrinsic aspect in the development of breast cancer, and result in regions of epithelial electrical depolarisation within the breast parenchyma, which can extend to the skin surface. Diagnostic information might be obtained from a non-imaging and non-invasive test based on skin-surface electropotentials. METHODS: In 661 women, scheduled for open biopsy at eight European centres, we studied whether measurements of breast electrical activity with surface sensors could distinguish benign from malignant breast disease. A depolarisation index was developed. RESULTS: We found a highly significant trend of progressive electrical changes according to the proliferative characteristics of the biopsied tissue. Discriminatory information was obtained in both premenopausal and postmenopausal women, and the index was not related to age. The best test performances were for women with palpable lesions. The median index was 0.398 for non-proliferative benign lesions, 0.531 for proliferative benign lesions, and 0.644 for cancer (ductal carcinoma-in-situ and invasive). A specificity of 55% was obtained at 90% sensitivity for women with palpable lesions when a discriminant based on age and the depolarisation index was used. INTERPRETATION: This new modality may have diagnostic value, especially in reducing the number of unnecessary diagnostic tests among women with inconclusive findings on physical examination. Understanding and control of the biological variability of these electrical phenomena will be important in the improvement of this test. Studies in populations with a lower cancer prevalence are needed to assess further the diagnostic value of this approach.

Enhancing awareness of hospice through physician assisted living: public health perspectives.

The provision, management, and financing of care for patients with irreversible diseases has become increasingly complex in this era of advanced medical technology. With enhanced capabilities of medicine to prolong life, clinical practice has taken on legal and ethical dimensions that reach beyond the traditional scope of medicine. This paper demonstrates that hospice represents a major area of public health practice and research. It argues for enhanced involvement of public health practitioners and academics in the design and evaluation of efforts to encourage appropriate use of hospice for patients with irreversible diseases. The physician assisted living intervention in Connecticut represents one such effort. However, ongoing educational efforts targeted at both the public and health care providers are needed to ensure that all those with irreversible diseases fully understand and have access to hospice care at the end of life.

[Therapeutic alternatives in the treatment of class T1N0 squamous cell carcinoma of the penis: indications and limitations]. / Alternative terapeutiche nel trattamento del carcinoma spinocellulare del pene di categoria T1N0: indicazioni e limiti.

At INT of Milan between 1964 and 1990, 204 consecutive native patients suffering from penile cancer have been treated. 101 (59%) patients out of 171 with invasive cancer (23 affected with Tis were excluded) have been classified T1N0M0. 74 patients have been treated with penis conserving methods, such as circumcision, radiotherapy, laser excision and primary chemotherapy + conserving surgery. Overall local failure and/or nodal relapses occurred in 27% (20/74). Relapses are significantly related with grading but there isn't any relationship with macroscopical aspect or size of the tumor. The conservative treatment had been possible in 80% of patients. In our experience T1N0 clinical stage conservative therapy does not worsen the prognosis.

Results of a breast-cancer-surgery trial compared with observational data from routine practice.

BACKGROUND: The strength of randomised controlled trials (RCTs) is that they allow investigators to draw reliable inferences about treatment differences; physicians can then make a choice between different options. Their weakness is that they are conducted on a set of patients who cannot be regarded as a random sample from the population that will be treated outside the trial. Observational data collected in a prospective clinical database may provide more realistic estimates. METHODS: At the Istituto Nazionale de Tumori of Milan an RCT was started in 1973 (MI1) in which Halsted mastectomy was compared with quadrantectomy plus axillary dissection and radiotherapy (QUART), a breast conserving treatment, for "early-stage" primary breast cancer. In addition, a prospective clinical database was established to collect, in standard format, information on all women undergoing breast conservation thereafter and followed up at the Institute. 1760 women were treated with QUART, 350 of them being accrued in the years 1973-80 in the context of the MI1 trial. The remaining 1408 received QUART after the MI1 trial, up to December, 1984. RESULTS: In the years after the trial, the criteria for use of QUART became more liberal. However, after adjustment for baseline characteristics, out-trial patients fared no worse than trial patients in terms of survival or distant metastasis. Out-trial patients did have a slightly higher rate of local recurrence, probably because of subtle and multiple changes in the surgical procedures since the time of the trial. INTERPRETATION: The results of QUART in out-trial patients resembled those reported from research settings. In this instance, the results of clinical trials did not exaggerate the benefits obtainable in routine practice.

Local recurrences and distant metastases after conservative breast cancer treatments: partly independent events.

BACKGROUND: Local disease recurrences are a concern in conservative breast cancer surgery, and many studies have attempted to identify risk factors for these events. It is important to distinguish local recurrences linked to increased risk of distant spread from those due to inadequate local treatment. PURPOSE: We evaluated the incidence of local and distant recurrences according to demographic, biological, and pathologic variables in a large series of women who were conservatively and uniformly treated for breast cancer, with the aim of identifying women in whom local failure is predictive for distant metastases and who are therefore candidates for aggressive systemic treatment. METHODS: Medical records of 2233 women who had been hospitalized at the Milan Cancer Institute from 1970 to 1987 were analyzed. All women received quadrantectomy and axillary lymph node dissection followed by radiotherapy for the breast. Quadrantectomy is breast-conserving removal of most of the affected quadrant by a radial incision that includes part of the skin. The end points considered were local failures (including local recurrences and new ipsilateral carcinomas) and distant metastases. Statistical analysis employed the competing risks and multiple failures approaches. RESULTS: There were 119 local recurrences, 32 new ipsilateral carcinomas, and 414 distant metastases as first events. The timing of local failures and distant metastases differed: The yearly probability for local failures was approximately 1% up to the 10th year and for distant metastases was 5% in the 2nd year and decreased progressively until the 8th year. Young age was an important risk factor, with peritumoral lymphatic invasion also predictive for local and distant recurrences. Tumor size and axillary lymph node involvement were not related to local recurrence but were important predictors of distant metastases. Extensive intraductal component was only a risk factor for local recurrence. Early (< 2 years) local failure predicted for distant metastases compared with later failure. In local failure patients, the 5-year survival rate was 69% from failure. CONCLUSIONS: Local recurrences and distant metastases are partially independent events that occur at different times; several predicting factors also differ. However, women with local recurrences have increased risk of distant metastases. In particular, women 35 years old or younger at first diagnosis who had initial peritumoral lymphatic invasion and local recurrence within 2 years are at high risk for distant spread. For recurrence in cases with an extensive intraductal component or where initial local surgery was possibly inadequate, women are at lower risk.