Caty Blanchette

EPIDURAL CORTICOSTEROID INJECTIONS FOR SCIATICA DUE TO HERNIATED NUCLEUS PULPOSUS

BACKGROUND Although epidural corticosteroid injections are commonly used for sciatica, their efficacy has not been established. METHODS In a randomized, double-blind trial, we administered up to three epidural injections of methylprednisolone acetate (80 mg in 8 ml of isotonic saline) or isotonic saline (1 ml) to 158 patients with sciatica due to a herniated nucleus pulposus. All patients had Oswestry disability scores higher than 20 (on a scale of 1 to 100, with scores of 20 or less indicating minimal disability, and higher scores greater disability). RESULTS At three weeks, the Oswestry score had improved by a mean of -8.0 in the methylprednisolone group and -5.5 in the placebo group (95 percent confidence interval for the difference, -7.1 to 2.2). Differences in improvements between the groups were not significant, except for improvements in the finger-to-floor distance (P=0.006) and sensory deficits (P=0.03), which were greater in the methylprednisolone group. After six weeks, the only significant difference was the improvement in leg pain, which was greater in the methylprednisolone group (P=0.03). After three months, there were no significant differences between the groups. The Oswestry score had improved by a mean of -17.3 in the methylprednisolone group and -15.4 in the placebo group (95 percent confidence interval for the difference, -9.3 to 5.4). At 12 months, the cumulative probability of back surgery was 25.8 percent in the methylprednisolone group and 24.8 percent in the placebo group (P=0.90). CONCLUSIONS Although epidural injections of methylprednisolone may afford short-term improvement in leg pain and sensory deficits in patients with sciatica due to a herniated nucleus pulposus, this treatment offers no significant functional benefit, nor does it reduce the need for surgery.

Compliance with consensus recommendations for the treatment of early stage breast carcinoma in elderly women

The goal of this study was to assess variations with age in the management of breast carcinoma and to identify determinants of care received.

Reliability and validity of the French version of the 18-item Karasek job content questionnaire

Abstract Previous studies have shown that job strain, a combination of high psychological demands and low decision latitude, may be involved in the development of cardiovascular diseases and other health outcomes. In 1985, Karasek recommended a standard questionnaire to measure psychological demands (nine items) and job decision latitude (nine items). The internal consistency, factorial validity, discriminant validity, and 1-year stability of the French version of this instrument were evaluated in a population of 8263 white collar workers. Participants filled out the questionnaire during working hours in the context of a larger cardiovascular study. A subgroup of the study population completed the questionnaire again 1 year later (n = 953). Internal consistency was adequate: .74 for men and .73 for women for psychological demands and .83 for men and .81 for women for decision latitude. The results of the factor analysis were consistent with the two dimensions expected from the theory, although some items ...

Effects of Job Strain on Blood Pressure: A Prospective Study of Male and Female White-Collar Workers

OBJECTIVES We evaluated whether cumulative exposure to job strain increases blood pressure. METHODS A prospective study of 8395 white-collar workers was initiated during 1991 to 1993. At follow-up, 7.5 years later, 84% of the participants were reassessed to estimate cumulative exposure to job strain. RESULTS Compared with men who had never been exposed, men with cumulative exposure and those who became exposed during follow-up showed significant systolic blood pressure increments of 1.8 mm Hg (95% confidence interval [CI]=0.1, 3.5) and 1.5 mm Hg (95% CI=0.2, 2.8), respectively, and relative risks of blood pressure increases in the highest quintile group of 1.33 (95% CI = 1.01, 1.76) and 1.40 (95% CI = 1.14, 1.73). Effect magnitudes were smaller among women. Effects tended to be more pronounced among men and women with low levels of social support at work. CONCLUSIONS Among these white-collar workers, exposure to cumulative job strain had a modest but significant effect on systolic blood pressure among men. The risk was of comparable magnitude to that observed for age and sedentary behavior. Men and women with low levels of social support at work appeared to be at higher risk for increases in blood pressure.

The influence of MMP-14, TIMP-2 and MMP-2 expression on breast cancer prognosis

IntroductionMatrix metalloproteinase (MMP)-2 is very active at degrading extracellular matrix. It is under the influence of an activator, membrane type 1 MMP (MMP-14), and the tissue inhibitor of metalloproteases (TIMP)-2. We hypothesized that the individual expression of these three markers or their balance may help to predict breast cancer prognosis.MethodsMMP-2, MMP-14 and TIMP-2 expression has been evaluated by 35S mRNA in situ hybridization on paraffin material of 539 breast cancers without distant metastasis at diagnosis and with a median follow-up of 9.2 years.ResultsMMP-2 and MMP-14 mRNA was detected primarily in reactive stromal cells whereas TIMP-2 mRNA was expressed by both stromal and cancer cells. Of the three molecules, an adjusted Cox model revealed that high MMP-14 mRNA (≥ 10% cells) alone predicted a significantly shorter overall survival (p = 0.031) when adjusted for clinical factors (tumor size and number of involved lymph nodes). Prognostic significance was lost when further adjusted for Her-2/neu and urokinase-type plasminogen activator (p = 0.284). Furthermore, when all three components were analyzed together, the survival was worst for patients with high MMP-2/high MMP-14/low TIMP-2 (5 year survival = 60%) and best with low MMP-2/low MMP-14/high TIMP-2 (5 year survival = 74%), but the difference did not reach statistical significance (p = 0.3285).ConclusionOf the MMP-14/TIMP-2/MMP-2 complex, MMP-14 was the factor most significantly associated with the outcome of breast cancer and was an independent factor of poor overall survival when adjusted for clinical prognostic factors, but not for certain ancillary markers.

Repeated exposure to effort-reward imbalance, increased blood pressure, and hypertension incidence among white-collar workers: effort-reward imbalance and blood pressure.

OBJECTIVES To determine whether men and women with repeated ERI exposure have increased BP means or higher hypertension incidence over a 3-year follow-up. To examine the potential modifying effect of age and overcommitment. METHODS The study cohort was composed of 1,595 white-collar workers (629 men and 966 women) assessed at baseline and 3-year follow-up. Ambulatory BP measures were taken every 15 min during a working day. ERI at work was self-reported using validated scales. BP means at follow-up and cumulative incidence of hypertension were respectively modeled with analyses of covariance (ANCOVA) and log-binomial regression. RESULTS Among men, no association was observed between repeated ERI exposure and BP. Among women, age had a modifying effect. Women <45 years old exposed to ERI at both times had significantly higher BP means at follow-up (122.2/78.9 mmHg) than those unexposed (120.4/77.4 mmHg). In women ≥45 years old, the cumulative incidence of hypertension was 2.78 (95% CI: 1.26-6.10) times higher among those exposed to ERI at both times. Men and women in the higher tertile of overcommitment had higher BP means (men: 128.9/82.2 mmHg, women: 121.9/78.0 mmHg) than those in the lower tertile (men: 127.2/81.3 mmHg, women: 120.6/77.0 mmHg). CONCLUSION This prospective study showed that, among women, repeated ERI exposure led to a significant age-specific increase in BP means and a major age-specific increase in hypertension incidence. These results suggest that primary intervention aimed at reducing ERI may contribute to lower BP and prevent hypertension in women.

Time trends in systemic adjuvant treatment for node-negative breast cancer.

PURPOSE We conducted a population-based study in Quebec, Canada, to assess longitudinal changes in systemic adjuvant therapy for node-negative breast cancer. MATERIALS AND METHODS A stratified random sample was selected among women with newly diagnosed node-negative breast cancer in 1988, 1991, and 1993. Information on the patient, her tumor, source of care, and treatment was abstracted from medical charts. Patients were classified as being at minimal, moderate, or high risk of recurrence on the basis of criteria proposed at the 4th International Conference on Adjuvant Therapy of Primary Breast Cancer (St. Gallen, Switzerland, 1992), and systemic adjuvant treatment received was dichotomized as being consistent or not consistent with consensus recommendations. RESULTS Overall, 1,578 cases of invasive breast carcinoma were reviewed. The proportion of patients who were given hormonal or cytotoxic treatment increased from 51.7% to 73.1% from 1988 to 1993. Virtually all women at minimal risk were treated in 1991 and 1993 according to the consensus statement. The proportions of women so treated were 75.0% and 65.4% in the moderate- and high-risk categories, respectively, in 1991. In 1993, these proportions were 71.4% and 67.0%, respectively. Omission of chemotherapy, especially in high-risk women with estrogen receptor-negative tumors who were 50 to 69 years of age, was the most frequent inconsistency with guidelines. CONCLUSION Systemic adjuvant therapy for node-negative breast cancer has gained acceptance. Better understanding of the decision-making process, of the perception of the risks and benefits involved, and of the impact of alternative strategies for the dissemination of consensus recommendations are needed to promote the use of chemotherapy in specific categories of women who are at high risk of recurrence.

Human papillomaviruses and vulvar vestibulitis

Objective To assess the relationship between human papillomavirus (HPV) infection and vulvar vestibulitis syndrome. Methods From November 1995 to December 1997, 135 women with vulvar vestibulitis were compared with 322 controls who had no evidence of vulvar vestibulitis. Human papillomavirus DNA was amplified by polymerase chain reaction and detected with liquid-capture molecular assay. Results Human papillomavirus DNA was found in 29.6% of cases and in 23.9% of controls (relative risk [RR] 1.4; 95% confidence interval [CI] .8, 2.2). The prevalence of HPV tended to decrease with increasing duration of pain among cases. Thus, prevalences were 37.5%, 29.6%, and 22.0% for pain durations of 3–6 months, 7–12 months, and 13–24 months, respectively (P = .14). Prevalence of HPV also tended to increase with pain intensity among cases, but that association was not statistically significant (P = .57). Prevalence percentages for women with low, moderate, or severe pain were 27.5%, 28.8%, and 34.4%, respectively. Prevalence of HPV was slightly higher in cases with the most severe pain (34.4%) than in controls (23.9%) (RR 1.8; 95% CI .8, 4.0). In cases with the most pain in the shortest time (3–6 months), prevalence of HPV was double that of controls (50% versus 23.9%) (RR 3.5; 95% CI 1.0, 12.7; P = .054). Conclusion There was little support for the idea that HPV might be related to vulvar vestibulitis.

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

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

Temporal changes in risk factors associated with Hiv seroconversion among injection drug users in eastern central Canada

Objectives:To investigate temporal trends in HIV incidence rates and to assess changes over time in associated risk factors. Methods:Since 1995, the SurvUDI network has conducted surveillance among IDUs recruited in harm reduction programmes in eastern central Canada. Among the 11 731 participants, 2903 repeaters were initially HIV-negative. HIV incidence was calculated and compared for two time periods (1995–2002 vs. 2003–2009). Multivariate Cox proportional hazard models with time-dependent covariates were used to assess risk factors associated with HIV seroconversion. Interactions between covariates and time periods were examined. Results:The overall HIV incidence rate was 2.7 per 100 person-years [95% confidence interval (CI) 2.4–3.1]. It significantly decreased from 3.1 per 100 person-years in 1995–2002 to 2.2 person-years in 2003–2009. Sex, needle borrowing, and cocaine as most often injected drug were independent and stable determinants of HIV seroconversion. Age, daily injection, sex work and being recruited in an urban area showed significant interactions with time. Being aged 25 years and older, injecting daily and being recruited in an urban area predicted HIV incidence in 1995–2002 but were no longer risk factors in 2003–2009. HIV incidence increased significantly among younger IDUs and sex work emerged as a new determinant of HIV incidence in 2003–2009. Conclusion:HIV incidence has decreased over time but remains high among IDUs in eastern central Canada. Associations between risk factors and HIV incidence have changed. Further research is needed to better understand HIV transmission among younger IDUs and IDU sex workers.