African American men are disproportionately affected by, not only HIV/AIDS, but also chronic non-communicable diseases. Despite the known benefits of physical activity for reducing chronic non-communicable diseases, scant research has identified factors that may influence physical activity in this population. A growing literature centers on the syndemic theory, the notion that multiple adverse conditions interact synergistically, contributing to excess morbidity. This secondary data analysis examined two primary questions: whether syndemic conditions prospectively predicted physical activity, and whether, consistent with the syndemic theory, syndemic conditions interacted to predict physical activity. Participants were 595 African American men who have sex with men (MSM), a population underrepresented in health research, enrolled in a health-promotion intervention trial from 2008–2011. We used generalized-estimating-equations models to test the associations of syndemic conditions and resilience factors measured pre-intervention to self-reported physical activity 6 and 12 months post-intervention. As hypothesized, reporting more syndemic conditions pre-intervention predicted reporting less physical activity 6 and 12 months post-intervention, adjusting for the intervention. However, contrary to the syndemic theory, we did not find evidence for the interaction effects of syndemic conditions in predicting physical activity. Receiving high school education and having greater social network diversity predicted more physical activity whereas older age predicted less physical activity. To our knowledge, this is the first study to examine the syndemic theory in relation to physical activity. Although reporting a greater number of syndemic conditions was related to reduced physical activity, there was no evidence for synergy among syndemic conditions. After decades of efforts to reduce health disparities, African American men continue to have the highest mortality rate among all racial/ethnic and gender groups in the United States –3. AfricAfrican American men who have sex with men (MSM), the group accounting for the largest number of African Americans with HIV/AIDS , has recDespite the well-established benefits of physical activity for a range of NCDs, it is estimated that only 28% of African American men meet the 2008 federal guidelines  for aeroA growing literature centers on the syndemic theory, the notion that multiple adverse conditions interact synergistically, contributing to excess morbidity within a population , 31. ConA key premise of the syndemic theory is that syndemic conditions interact synergistically to affect health. Although a growing literature documents the relation of a greater number of syndemic conditions to health-related outcomes, recently Tsai and colleagues , 44 haveBeyond examining the relation of syndemic conditions to physical activity, the question of whether there are resilience factors that can potentially contribute to African American MSM’s physical health is also important and has received little empirical attention. Resilience factors have been studied in the context of HIV risks. Previous studies provide evidence suggesting that internal homophobia management, optimism, religiosity, cultural identity, social network support, and connection to a sexual minority community as potential sources of resilience –49. In oBuilding on previous studies, this secondary data analysis examined the relations of syndemic conditions and resilience factors to physical activity among African American MSM, participants in a 12-month health-promotion intervention trial , 54. We This article reports findings from a longitudinal survey collected as a part of a behavioral intervention, “Project Being Responsible for Ourselves” (BRO), designed to reduce health risks including cardiovascular diseases, cancers, and STIs, including HIV for African American MSM. The trial randomized 595 African American MSM to either a physical-activity intervention or a HIV/STI risk-reduction intervention and assessed a variety of health outcomes including physical activity 6- and 12-months post-intervention. Details of the trial’s methods are reported elsewhere , 54. InsParticipants were enrolled between April 2008 and March 2011, with all data collection completed by May 2012. Participants completed pre-intervention, post-intervention, and 6 and 12 months post-intervention questionnaires. The intervention and data-collection sessions were implemented at a university research center. The original trial involved 595 African American MSM: 295 in the HIV/STI risk-reduction and 300 in the physical-activity intervention. Among the 595, 168 said they were HIV-positive at the pre-intervention assessment.The participants completed confidential questionnaires via audio computer-assisted self-interviewing (ACASI) technology, providing audio and video presentation of the questions and response options on a laptop. ACASI has been shown to increase reports of socially undesirable behaviors compared with face-to-face interviews and self-administered surveys, possibly reflecting more accurate responding . Psychosand engaging in strength-building activity on 2 or more days, in the past 7 days. Accordingly, the weighted average was calculated as a sum of the weighted days, as follows: (days of vigorous activity/4 + days of moderate activity/5 + days of strength building activity/2) / (1/4 + 1/5 + 1/2). This formula differed from the original formula used in the main intervention trial [r = .97 for the two baseline physical activity measurements, p < .0001).Physical activity was assessed with 3 items the Centers for Disease Control and Prevention developed concerning the number of days on which people did vigorous-intensity aerobic activities for at least 20 min, moderate-intensity aerobic activities for at least 30 min, and strength-building activities in the past 7 days . The outon trial , but theParticipants reported their education level by answering the question “What is the highest grade of school you have completed?” We created a binary variable of having received at least a high school diploma (or GED) versus having received less than a high school education.Participants reported their monthly income in seven categories that ranged from “less than $400” to “1651 and above.” We created a categorical variable with 3 categories: “Less than $400,” “$400 - $850,” and “$851 or more.”Syndemic condition is a composite variable summing 6 binary syndemic factors including depression , childhoResilience factors include the following measures.Participants responded “yes” or “no” to the question, “Do you consider yourself to be a member of the gay community?” as used in previous research .Participants reported the frequency with which they engage in specific religious activities, on a scale from 1 (never) to 5 (twice a week or more), as used in previous research . Questioa = 0.82).Black pride was assessed with a 7-item Likert scale validated in previous research . ResponsThis was assessed with Cantril’s Self-Anchoring Ladder scale , 67, whiSocial network diversity was assessed with a 10-item scale validated in previous research , asking Descriptive statistics, including percentages, means, and standard deviations were used to describe the sociodemographic characteristics of the sample. T-test was conducted to examine the difference on physical activity between HIV positive and negative men. The bivariate relation of each baseline predictor  to physical activity was tested using generalized-estimating-equations (GEE) models , 70, adjIn addition to the bivariate relations, we tested one complete GEE model (model 1) that included the demographic predictors, syndemic conditions, and all resilient factors. The model included 9 baseline predictors, follow-up time (2 categories representing 6- and 12-month follow-up), and the intervention condition. Lastly, we tested an alternative complete GEE model (model 2) that included the demographic predictors, all 6 individual syndemic factors, and all resilient factors. We used robust standard errors and specified an independent working correlation matrix for all the GEE models. We report regression coefficients and their corresponding 95% confidence intervals.To test whether individual syndemic factors had synergistic effects on predicting physical activity, we conducted explorative tests to identify all potential interaction effects among the 6 syndemic factors. Specifically, we tested 15 GEE models for all 2-way interactions, 20 models for all 3-way interactions, 15 models for 4-way interactions, 6 models for 5-way interactions, and 1 model for the 6-way interaction. These models included only the interested syndemic factors and their interactions, adjusting for time and intervention condition. We applied Bonferroni correction for each set of interaction tests and adjusted the significance criteria for the 2-way, 3-way, 4-way, 5-way, and 6-way interactions to be .003, .0025, .003, .008, and .05. After we identified a significant interaction effect, we then compared the R-squared values of the interaction model with its corresponding baseline model without the interaction terms to determine whether adding the interactions improved the model fit in predicting physical activity. All analyses were performed using SAS V9.3.The participants were 595 African American MSM. Participants’ age ranged from 18 to 69 years . As shown in Regarding prospective predictors, as shown in We did not find any evidence of a moderating role of any resilience factor on the relations between syndemic conditions and physical activity. In other words, the negative relation of syndemic conditions to physical activity did not differ for different levels of gay community connection (p = 0.123), religiosity (p = 0.885), black pride (p = 0.417), optimism (p = 0.993), or social network diversity (p = 0.411).Using the adjusted significance criteria for all tested interaction models, we did not find any significant interaction effect of the syndemic conditions in predicting physical activity.To our knowledge, this is the first study to provide empirical data on the relations of syndemic conditions and levels of physical activity and the psychosocial predictors among African American MSM. The results contribute to the limited research on physical activity among MSM in general, and among African American MSM specifically. The sample of 595 African American MSM experienced a composite of social and economic disadvantages. Less than one-third were employed, one-third were living with HIV, and one-half had spent time in jail or prison. The majority had experienced at least one of the syndemic conditions.Previous research documented that people living with HIV engaged in less physical activity than most other populations with chronic diseases , 73. HowAs we hypothesized, this research identified a negative association of syndemic conditions to physical activity. Our longitudinal survey data showed robust evidence that the number of syndemic conditions reported at baseline directly predicted lower levels of physical activity during the following year, indicating a potential additive influence of the negative psychosocial experiences of depression, childhood sexual abuse, alcohol problems, problems with drug use, intimate partner violence, and unemployment. The more conditions participants experienced, the less physical activity they engaged in the following year. Although previous research documented interactions of some of these factors in impacting HIV risks , we did On resilience factors, we found social network diversity prospectively predicted higher levels of physical activity. This finding corroborated one survey study which concluded higher network diversity was associated with an increased likelihood of physical activity . This fiThere are limitations to this study that should be considered when interpreting results. The data are from African American men who lived in Philadelphia, Pennsylvania; therefore, the results may not be representative of other African American MSM populations. The physical activity behaviors were self-reported, therefore subjective to recall bias. Notwithstanding these limitations this is the first study to provide information on physical activity among African American HIV-positive and HIV-negative MSM, a minority group within a minority population characterized by disproportional health problems. The prospective design is an additional strength, which allows for establishing temporal precedence in investigating the relations between psychosocial factors and physical activity. However, it is important to note that the predictive relations do not indicate causality. While factors such as depression and substance abuse can cause negative health outcomes, we cannot rule out the possibility that a lack of physical activity may also contribute to depression and substance abuse.The findings from this study suggest important directions for developing physical activity promotion interventions for this population. The same types of interventions can be used to promote physical activity among African American MSM regardless of their HIV status. Intervention contents should address the syndemic conditions experienced by African American MSM. For instance, interventions can consider addressing depression, alcohol and drug use, and sexual violence alongside improving physical activity. Lastly, given the significant association of social network diversity to physical activity, social network-level interventions that involve building and expanding supportive networks of African American MSM should receive more attention and empirical test in the future to enhance the general physical health of this population.


There is growing evidence that history of allergic or autoimmune disease is associated with reduced risk of glioma, but few prospective studies have explored the biological basis. To assess associations with immune conditions and levels of 14 cytokines in serial prediagnostic serum samples, we conducted a study of glioma/brain cancer nested in a cohort of active component military personnel.A total of 457 case-control sets were ascertained from the Department of Defense (DoD) Automated Central Tumour Registry, Defense Medical Surveillance System (DMSS) database, and DoD Serum Repository. These were individually matched on sex, race/ethnicity, birth year, number of serum samples , and date(s) of sample collection. We obtained diagnoses of pre-existing immune-related conditions from the DMSS database and measured cytokines using Meso Scale Discovery assays. Statistical analyses included conditional logistic regression.Ptrend = 0.002 and Ptrend = 0.001); both associations were more pronounced in individuals with prior immune conditions (Pheterogeneity = 0.0009 and Pheterogeneity = 0.031).Overall association between glioma and prior immune-related conditions was null. Higher levels of IL-15 and IL-16 were independently associated with lower glioma risks (Associations with pre-diagnostic levels of IL-15 and IL-16 and their modification by diagnosis of immune-related conditions support the importance of immune alterations in glioma aetiology years before diagnosis. While allergies and autoimmune diseases differ in underlying immune alterations, both result from an inappropriate immune response to otherwise innocuous foreign substances. How chronic antigenic stimulation accompanying allergic or autoimmune diseases may be protective against glioma remains largely unknown, but changes in cellular/humoral immunity and levels of associated cytokines may be involved.16 In addition, there is intriguing recent evidence that selected growth factors, a subset of cytokines governing organogenesis, are also altered in allergy and autoimmune disease and may drive glioma stem cell proliferation and invasion; the latter has been shown in mouse models and in vitro studies,17 but human data are limited.There is accumulating evidence that prior history of allergy and, to a lesser extent, autoimmune disease is associated with reduced risk of glioma,19 Furthermore, due to the aggressive and rapidly progressive nature of adult gliomas, patients may die or become incapacitated before they provide their medical history. Studies with serum samples and validated information on medical history collected prior to glioma diagnosis are less prone to bias but are limited. Several case-control studies nested in prospective cohorts reported an inverse association between elevated levels of total IgE in pre-diagnostic serum samples and glioma risk.22 Also, a recent case-control study nested in the Janus Serum Bank Cohort (JSBC) in Norway assessed 277 cytokines and identified five  independently related to glioma risk in one of five periods prior to glioma diagnosis based on a single pre-diagnostic sample.24 These findings remain unconfirmed.Due to the rarity of glioma, case-control studies generally have been the preferred study design and have provided initial clues about the role of immune-related conditions in the aetiology of glioma; however, most case-control studies of glioma in relation to immune markers suffer from the limitations of having to rely on serum samples collected after cancer diagnosis, and possibly after initiation of treatment.25 Defense Medical Surveillance System (DMSS) database and DoD Serum Repository (DoDSR),27 we conducted a nested case-control study to assess associations of risk of adult glioma/brain cancer with pre-diagnostic serum levels of 14 a priori selected cytokines and growth factors and a personal history of immune-related conditions. At the time of selection and measurements of these cytokines, the JSBC study results were unknown. We used multiple, prospectively collected serum samples and accurate medical diagnoses for active component U.S. military personnel. The availability of serial serum samples allowed us to evaluate whether cytokine associations vary by time leading up to the diagnosis of glioma/brain cancer.Using the Department of Defense (DoD) Automated Central Tumour Registry (ACTUR),27 These samples are collected as part of a universal, mandatory screening for human immunodeficiency virus (HIV-1) implemented by the DOD. The first archived serum sample of each service member is typically obtained during a pre-induction medical examination or shortly after military service commences. Follow-up samples generally consist of serum that remains after routine, periodic HIV-1 antibody testing or required pre- and post-deployment samples, carried out on average every two years for a given individual. At the time of the study, the DoDSR policy allowed use of up to three serum samples per individual for research purposes.The current case-control study of brain cancer is nested within a population of more than 10 million U.S. military applicants, active component personnel, and reserve service members who had serum samples collected since 1988 and stored in the DoDSR.N = 162 cases; median age at diagnosis, 29 years), or a first primary brain cancer  supported by relevant diagnostic procedure codes  in the DMSS database  and at least one serum sample in the DoDSR collected at least 12 months prior to diagnosis of glioma or brain cancer. During selection, we made certain that no duplicate cases from both ACTUR and DMSS were included in the study. Ninty four percent of cases identified through ACTUR had ICD-O-3 codes consistent with astrocytoma or other glioma. Of these, low-grade astrocytoma, oligodendroglioma, and mixed oligoastrocytoma accounted for 80%. We lack tumour morphology codes for the primary brain cancer cases ascertained through DMSS but, based on comparability of median ages at diagnosis for ACTUR and DMSS cases and age-specific and tumour histology-specific distribution of cases in ACTUR and Central Brain Tumour Registry of the United States (CBTRUS) databases,4 we presume that most DMSS cases were low-grade glioma. For purposes of the present analysis, the term “brain cancer” is nearly interchangeable with “glioma”.We selected eligible cases from active component military personnel with a diagnosis of a first primary brain glioma  between 1988 and 2006 in the ACTUR database (Eligible controls were active component military personnel free of brain cancer or other neoplasm in the DMSS database (ICD-9 codes outside the range 140–239) with at least one serum sample in the DoDSR database. Controls were randomly selected from the pool of eligible subjects and individually matched to cases in a 1:1 ratio on sex, year of birth (+/− 1 year), race/ethnicity , number of serum samples , and date of each serum sample collection (+/− 30 days). We defined a reference date for the case and matched control as the date of brain cancer diagnosis. For individuals with more than three serum samples collected ≥12 months before the reference date, we requested the earliest and latest samples and an intermediate sample spaced evenly between the earliest and latest samples wherever possible.The study protocol was reviewed and approved by the Institutional Review Boards of the Uniformed Services University and Armed Forces Institute of Pathology, and the Office of Human Subjects Research Protections of the National Cancer Institute.6After the case-control sets were identified, data on diagnoses of immune-related conditions and diseases were extracted from in-patient and out-patient medical records stored in the DMSS database. A complete list of requested ICD-9 codes is presented in Supplemental Table a priori selected cytokines and growth factors in 2305 unique samples. The assays were conducted at the SAIC-Frederick laboratory using a combination of four sensitive custom V-PLEX Meso Scale Discovery kits  including human Proinflammatory Panel 1 , Cytokine Panel 1 , Chemokine Panel 1 , and Angiogenesis Panel 1 . We also used standard MSD kits to measure human HGF and TGFβ individually. MSD platforms use an electro-chemiluminescence detection system that is designed to minimise nonspecific reactions and background noise. All assays were performed according to manufacturer instructions.All serum samples (0.5 ml) were continuously frozen at approximately –30 °C until cytokine testing. In total, we measured 14 To measure study samples including quality control (QC) samples, 33 × 96-well plates were necessary. Case-control sets were selected for plating at random. All serum samples for a given set were plated on the same plate in random order in adjacent wells. QC samples included three external pooled serum samples that were measured in duplicate on all plates (3 × 2 × 33 = 198 measurements) and 110 internal study samples of which 55 were measured in duplicate on the same plate (110 measurements) and 55 were measured on different plates (110 measurements). The coefficients of variation ranged from 5.4 to 14.3 and the intraclass correlation coefficients ranged from 95% to 99%. Fourteen percent of the IL-8 measurements and 15% of the IL-10 measurements were below detection limits, while, for the remaining 12 cytokines, <2% of values were below detection limits.Conditional logistic regression models were used to estimate hazard ratios (HR) and calculate 95% confidence intervals (95% CI) for associations between brain cancer and concentration of each cytokine, as well as history of immune-related conditions. We conditioned on the matched sets, and also on sample number, and thus compared levels of the first, second or third cytokine measurement in a case with those in the matched control. To account for correlations among multiple measurements from the same matched set, we computed robust sandwich variance estimates. The conditioning was used to accommodate the matched design. Cytokine measurements were analysed as categorical , and age at brain cancer diagnosis (reference date). The effect modifiers were evaluated individually and then simultaneously, i.e., mutually adjusting for each other. We also conducted separate analyses for brain cancer cases ascertained through ACTUR and DMSS databases.28All tests of statistical significance were two-sided with type-I error of 0.05. Analyses were carried out in SAS version 9.3.P < 0.001). ACTUR and DMSS cases were comparable with respect to many sociodemographic characteristics except year of birth and type of military service. Specifically, DMSS cases tended to be born in later calendar years than ACTUR cases and had a lower proportion of Army personnel. Sixty-seven percent of all cases and controls had three pre-diagnostic serum samples, 18% had two, and 15% had one serum sample. The proportion of cases with three serum samples was higher in DMSS than ACTUR cases . Overall, nearly 50% of samples were taken at least 3.6 years prior to cancer diagnosis (up to 22 years); with the respective proportions in DMSS and ACTUR cases being 49% and 55%, respectively.Descriptive characteristics of the 457 cases  and 457 controls are presented in Table We found no evidence that a history of individual or grouped immune-related conditions diagnosed ≥12 months Table  prior toThe intra-class correlation coefficients (ICCs) for cytokine concentrations in controls with repeated samples varied widely Table . The ICCP = 0.002 and P = 0.001, respectively) or a log-linear trend  (Table P = 0.033) and log-linear trend for TGFβ (P = 0.049). When included in the same model, the associations with IL-15 and IL-16 persisted, while the associations with IL-10 and TGFβ became attenuated and were no longer significant (data not shown). There was no indication that the associations with cytokine levels differed meaningfully between ACTUR and DMSS cases  Table . The asses Table . When anes Table .Table 3AP = 0.0009, P = 0.031, P = 0.045, respectively; Table The associations with IL-15, IL-16 and PLGF based on a quartile trend varied significantly by history of immune-related conditions . The inverse association with IL-15 was strongest >7.1 years prior to brain cancer diagnosis  and within 1.8–1.0 years of diagnosis , as well as in individuals ≥35 years old at cancer diagnosis .The analyses of heterogeneity of cytokine associations by time interval from date of sample collection to date of cancer diagnosis, or age at cancer diagnosis , while the modifying effect of immune-related condition with adjustment for time or age largely persisted .However, when evaluating effect modification of IL-15 by time or age and simultaneously allowing for modification by a history of diagnosis of immune-related condition, we found that the modifying effect of time and age was no longer significant , the JSBC investigators used a single pre-diagnostic serum sample to measure 277 cytokines.24 They found five cytokines  to be significantly associated with risk of glioma at different time periods prior to glioma diagnosis, i.e., discovery rate within the false positive range; the associations with IL-15 and IL-16 in that study were null.24Our study provides new evidence concerning the possible importance of IL-15 and IL-16 in the aetiology of brain cancer with young and middle age onset. Our approach to studying the role of cytokines was to measure a limited number of candidates with strong prior evidence and well-performing assays in serially collected pre-diagnostic serum samples among active component military personnel. Due to the rarity of glioma, it is challenging to obtain sufficient numbers of pre-diagnostic samples for epidemiologic studies. Only one other study of glioma, conducted in Norway (JSBC study), assessed pre-diagnostic cytokine levels.24 It is possible that the associations with different cytokines observed in the two studies reflect etiologic heterogeneity of histologically/genetically distinct glial tumours.29 However, alternative explanations include variable characteristics of assays used to measure cytokines, as well as chance.There are several possible reasons for the discrepancy of our findings and those of the JSBC study, including different methodological approaches and population characteristics. Our study was conducted among active component military personnel who are younger, fitter, and disproportionately male relative to the general population. As would be expected given the young age at diagnosis , 80% of cases with known histology in the current study (ACTUR cases) had low-grade astrocytoma, oligodendroglioma, or mixed oligoastrocytoma, while the remaining 20% had high-grade anaplastic oligodendroglioma or glioblastoma. By comparison, 65% of cases in the JSBC study  were glioblastoma.6 including a hospital discharge records study of 4.5 million U.S. male veterans,6 we anticipated finding an inverse association between prior diagnosis of immune conditions and risk of brain cancer and thought that cytokine levels might be at least partially responsible for this association. Instead, we found no associations with immune-related conditions diagnosed either ≥12 months or ≥24 months prior; these results were unaffected by adjustment for cytokine levels. In addition to young age and preponderance of low grade neuroepithelial cancers discussed above, this might be due to a lower prevalence and lesser severity of allergies and autoimmune diseases in active duty military personnel related to medical selection and disqualification from service30 and thus low power. The lack of a main effect of immune-related conditions in our study does not preclude a role for these conditions in the aetiology of glioma insofar as a prior diagnosis of an immune-related condition significantly modified the associations of glioma risk with IL-15 and IL-16. Both cytokine associations were stronger in individuals with a positive than negative medical history, particularly for IL-15. The modifying effect of immune-related conditions on the IL-15 association persisted in analyses allowing for independent effect modification by lag-time interval before cancer diagnosis or age at cancer diagnosis, but neither effect modification by lag-time nor age remained significant. We do not know what factors associated with presence of allergy or autoimmune disease would contribute to a modifying effect, but unmeasured cytokines, genetic susceptibility, reactivity of immune cells, or chance could be involved.Another important finding in our study is that IL-15 and IL-16 associations varied significantly by history of diagnosis of immune-related condition available from in-patient or out-patient medical records of military personnel. Based on results of previous epidemiologic studies33 IL-15 in the brain originates either from the periphery, through limited penetration of the blood-brain-barrier, or from production within the brain by glial and neural cells; the IL-15 receptors are expressed throughout the brain.32 Intraperitoneal injection of ALT-803 (a complex of an IL-15 super-agonist and a dimeric IL-15 receptor) to glioblastoma-bearing mice was recently found to inhibit tumour growth, prolong survival, and eradicate tumour in 20% of surviving animals.34 Clinical trials of ALT-803 complex to treat patients with metastatic melanoma, kidney and bladder cancer have been promising;33 however, there have been no reports concerning glioma in humans thus far. Compared with IL-15, collective evidence for relevance of IL-16 to glioma aetiology is limited. IL-16 mainly functions as chemoattractant of immune cells expressing CD4 molecule. Higher levels of this cytokine were found in patients with multiple sclerosis, rheumatoid arthritis, and Crohn’s disease.35 Interestingly, allergic sensitivity to atopic dermatitis was positively correlated with serum levels of IL-16, as well as total IgE,37 although the correlation with IL-16 was weaker than the correlation with IgE levels. In addition, one study reported increased proportion of IL-16 expressing macrophages and microglial cells in human astrocytic tumours that correlated with tumour’s grade,38 while another study found increased risk of glioma with SNPs in IL-16 gene.39An inverse relationship between pre-diagnostic levels of serum IL-15 and brain cancer risk is plausible biologically. One of the main effects of IL-15 is the induction of proliferation and differentiation of natural killer and CD8 memory cells and, thus, enhanced immune-surveillance against cancer.Our study has several strengths and limitations. It is nested in a cohort of active component military personnel, a well-defined population with standardised access to medical care and level of care. Another important strength of our study is that 67% of cases and controls had three serially collected pre-diagnostic serum samples allowing us to assess within subject temporal stability of cytokine concentration (as measured by ICCs) and lag-time variation in risk. Of 14 cytokines, half exhibited fair or adequate ICCs and another half exhibited poor ICCs. While the reasons for these differences are unclear, the main effect of low ICCs is reduced statistical power and thus an increased possibility of false negative findings. We used electronic records from two established medical registries (ACTUR and DMSS) to identify brain cancer cases and controls and to obtain in- and out-patient diagnoses of immune-related conditions (DMSS). We think that combined use of in- and out-patient records assured comprehensive ascertainment of serious immune-related conditions, although we cannot exclude a possibility of under-ascertainment of milder conditions, particularly those occurring prior to enrolment. Low prevalence of these conditions among military personnel discussed above and a relatively small number of informative case-control pairs among individuals with immune conditions might have limited our power to detect additional modifications of cytokine associations by immune status. Most cases identified through ACTUR had ICD-O-3 codes consistent with low grade astrocytoma, oligodendroglioma, or mixed oligoastrocytoma; however, only ICD-9 and CPT codes were available for cases identified through DMSS. We found no evidence that this may have introduced bias, as cytokine associations for DMSS and ACTUR cases were not meaningfully different. Nonetheless, the lack of detailed morphology codes for the DMSS cases restricted our ability to evaluate etiologic heterogeneity for histologically distinct primary brain cancers. To reduce assay-related variability, we plated all samples for a case-control set on the same plate in adjacent wells. The review of quality control indicators of cytokine assay performance confirmed that these performed well. We did not adjust for multiple testing because we assessed a limited number of cytokines that were selected based on prior hypotheses.In conclusion, novel associations with pre-diagnostic serum levels of IL-15 and IL-16 and their modification by history of diagnosis of immune-related conditions support the importance of immune alterations in the aetiology of young- and middle-age-at-onset brain glioma years before diagnosis. Large studies of brain glioma including a broad range of histologic and molecular subtypes in independent populations are needed to validate and extend our findings.The contents of this publication are the sole responsibility of the authors and do not necessarily reflect the views, assertions, opinions or policies of the Uniformed Services University of the Health Sciences (USUHS) or the Department of Defense (DoD).Supplemental Materials and Data


Currently in Vietnam contact tracing for multidrug-resistant tuberculosis (MDR-TB) entails passive case finding among symptomatic household contacts who present themselves for diagnosis. Close contacts of MDR-TB cases are therefore not identified adequately. We assessed the added value of active contact tracing within and beyond households using social network questionnaires to identify close contacts of MDR-TB patients in Vietnam.We conducted a cohort study using social network questionnaires in which contacts were identified by MDR-TB patients, including contacts from ‘high risk’ places like work. Contacts of MDR-TB patients were followed up and screened over a period of at least 6 months. This included two active screenings and any unscheduled passive screening of self-referred contacts during the study period.Four hundred seventeen contacts of 99 index cases were recruited, 325 (77.9%) and 160/417 (38.4%) contacts participated in the first and second screenings, respectively. The first screening detected one TB case but the bacteria were not MDR. From passive screening, a household contact was diagnosed with TB meningitis but not through our active approach.Social network analysis showed that only 1/17 (5.9%) high-risk places agreed to cooperate and were included in the screening, and no MDR-TB cases were detected. There were two pairs of index cases (identified separately) who were found to be contacts of each other and who had been diagnosed before the study started.No new MDR-TB cases were detected using social network analysis of nearly 100 MDR-TB index cases, likely due to a relatively short follow up time, and loss to follow up .The online version of this article (10.1186/s12889-019-6573-z) contains supplementary material, which is available to authorized users. The emergence of resistance to anti-tuberculosis drugs, and particularly of multidrug-resistant tuberculosis (MDR-TB) is a serious public health threat and an obstacle to effective global TB control . It is cContact screening of MDR-TB patients is highly recommended by the World Health Organization (WHO) . HoweverAlthough screening of close contacts of MDR-TB patients is recommended by the National Tuberculosis Control Programme (NTP) of Vietnam  among contacts of MDR-TB patients in Vietnam.A cohort study was conducted to analyze the added value of an active screening using SNQ, the questionnaire revealed the patient’s contacts through their social network including the frequently met people and visited places. Contacts were either named by patients or identified from eligible places. Close contacts of MDR-TB patients were enrolled and followed up over a period of at least 6 months and screened for TB and MDR-TB. Contacts were screened at enrolment, followed by an appointment on completion of the first screening and a reminder at 6 months by telephone for the second screening. During the study period, study participants were asked to make an unscheduled visit to district TB units and contact with the district health coordinators if they had any symptom suggestive of TB. The screening consisted of (i) standardized clinical assessment, (ii) chest X-ray among those who were not presumed to have TB by clinical assessment, and (iii) microbiological testing by Gene Xpert MTB/RIF  for patients with a history or chest X-ray suggestive of TB.The study involved patients with rifampicin resistant TB and their eligible contacts , who were named by index patients or identified from eligible places as defined below. The minimum sample size was estimated at 100 patients  who were living in Hanoi and started MDR-TB treatment between October 2013 and April 2015. Their defined contacts  during the 3 months preceding MDR-TB diagnosis were eligible for enrolment as contacts. Eligible high-risk places were physically enclosed spaces where the MDR-TB index case spent an average of at least 4 h a day for at least 14 days, or a cumulative total average duration of at least 8 h per week for at least 8 weeks in 3 months prior MDR-TB diagnosis. For children who were less than 18 years old, information was obtained from their parents or responsible family members.Eligible for enrolment were all patients diagnosed with rifampicin-resistant TB or MDR-TB diagnosed by Xpert or by Genotype MTBDR We modified and contextualized a published case report form (CRF) , which wEligible contacts were registered at district TB units to be followed up by the study team. Eligible places were visited by provincial or district coordinators to obtain informed consent from the place’s legal representative, followed by public announcement to call frequent visitors to come for screening to identify additional contacts. Completed contact CRFs were entered in the central database.Social network analysis was applied to identify links among MDR-TB index cases, contacts, and places. In the network illustrated by the link among patients, contacts and places, contacts or index cases linked to more than one patient were considered as the source of transmission, hence the centers of the network. The centrality degree of the contacts was measured by the number of patients attached with each contact. In order to determine if the contacts or places were mutual (i.e. named by at least 2 confirmed MDR-TB patients), demographics and information such as address and telephone number of the places and contacts were collected and compared. Mutual contacts or places were identified when identical information was obtained between pairs of contacts or pairs of places named by different patients. The Social network analysis also looked at the density illustrated by how closely contacts and patients are connected. The number of contacts per patient was used to rank the closeness level between patient and contacts .P-values (2-sided) below 0.05 were considered significant.Data were entered in MS Access software  and then transferred to SPSS 16.0 for statistical analysis. Descriptive statistics, including frequency, median, interquartile range (IQR), proportion and 95% confidence intervals (95% CIs), were performed where appropriate. The comparisons were tested statistically using Chi-Square test to compare proportions. Of 112 eligible patients, 99 were enrolled into the study as MDR-TB index cases. All patients were adult, 51(51%) were 35–54 years old and 77 (78%) were male. Four patients were HIV positive  had a smear- positive result. Thirty-two patients (32%) had X-ray signs of cavitation, all of whom were smear-positive. Seventy patients (71%) had been previously treated with first-line anti-TB drugs. These included patients detected as MDR-TB when starting retreatment or detected later when found to be smear-positive (non-converters) after two months of retreatment. Fourteen patients (14%) had received no or less than one month of TB treatment previously. The remaining 15 patients (15%) included 11 non-converters during their first treatment course and 4 patients previously treated in the private sector with unknown outcome.We identified 496 contacts and 17 high risk places based on information provided in the SNQ: 481 contacts were named by patients and 17 high risk places were approached by visiting for informed consent. Of which 1 place agreed to cooperate and subsequently an additional 15 contacts were identified.n = 16) and/or had not been in direct contact with the index patient during the 3 months before diagnosis (n = 69)  and 33/125 , respectively. The participation of female contacts in the first screening was higher than for males, 186/223 (83.4%) versus 135/189   participated in the first screening  contacts interviewed were clinically diagnosed as presumed TB. Chest X-rays were performed for 299 contacts, including 10 with clinically presumed TB, of whom an additional 12 (4.0%) had an abnormal chest X-ray suggestive for TB  had presumptive TB by interview and/or chest X-ray. Xpert MTB/RIF testing detected no TB case. From passive screening, a two-year old child, whose father was an index patient, was diagnosed with TB meningitis but not as part of our study Fig. . This chThe median number of eligible contacts per index patient was 3 (IQR: 3–6). These median numbers were 3 (IQR: 2–4) among household contacts and 2 IQR: 1–4) among non-household contacts. Index patients named 35 places, of which 17 were identified as high-risk places including 3 workplaces , 3 internet café’s, 2 hair salons and 9 restaurants. Only 1/17 (5.9%) high-risk place  agreed to cooperate. One presumed MDR-TB case was identified based on clinical diagnosis among 15 people screened who frequented this high-risk place  MDR-TB meningitis was missed by our study. Links between MDR-TB cases were found in two instances but did not lead to the detection of new cases. Only one of seventeen high-risk places agreed to participate in the screening, resulting in one additional presumed MDR-TB case identified.The likely reasons why we did not detect additional MDR-TB cases was limited participation of contacts in TB screening. Participation was reasonable (~ 80%) in the first screening, but dropped considerably to ~ 40% at the second screening. Observation from discussions with staff suggest that participation may have been poor due to the following elements:1) perceived stigma among patients, contacts and high risk places and reluctance to cooperate and to reveal correct contact information, 2) low awareness about TB and its transmission, especially among contacts with low levels of education or contacts belonging to vulnerable groups such as drug users, and 3) participation in the second screening may not have been perceived as in their interest if they were busy and not diagnosed with TB from the first screening.Furthermore, the relatively short follow-up period in our study of 6 months may be another reason. Studies have shown that active TB usually develops within five years after initial infection –15, and The pick-up rate for MDR-TB cases may also increase by improving the sensitivity of our diagnostic approach. Future diagnostic approaches should consider: (i) to ensure the quality of sputum and chest X-ray, (ii) expanding TB clinical assessment criteria to any cough and other tuberculosis-related symptoms like chest pain, weight loss, lack of appetite, weakness or fatigue, chills, fever and night sweats (iii) including MTB culture with higher sensitivity  as an adA limitation of our study using Xpert MTB/RIF is that only TB and rifampicin resistance is diagnosed as an indicator for MDR-TB . In VietThere is a need to develop a system to identify and manage contacts of MDR-TB cases better, including providing of adequate instructions, and possibly screening. We recommend to use a simpler questionnaire rather than a comprehensive social network approach. This is a more efficient and likely more cost-effective means for MDR-TB case detection in Vietnam and other low and middle-income countries. Information about household contacts and those who have the most frequent contact with patients such as close friends and colleagues should be collected. Depending on available resources, screening may start with a clinical assessment to determine if the person has TB-related symptoms, followed by chest X-ray and Gene Xpert MTB/RIF. This should be combined with health education, i.e. inform contacts with what symptoms they need to come for TB screening.Health education about TB, MDR-TB and its transmission among the general population should be more focused, and results of this study may help in prioritizing risk groups. It is needed to enhance awareness among contacts of MDR-TB and their compliance with screening programmes. Particular attention should be paid to enhance screening of non-household contacts as some studies show the incidence of TB among these contacts to be higher compared with household contacts –7. FurthCurrently, about 50% of the estimated MDR-TB cases in Vietnam have not been previously treated, reflecting significant transmission of MDR-TB among contacts –24. HoweWhile MDR-TB can be cured, social barriers to MDR-TB treatment could be an important factor that needs to be taken into account when designing and implementing a contact tracing program . Home viEven though we did not find any new MDR-TB case directly through our social network analysis, this approach may still be worth consideration if the key limitations of our study are addressed. The screening process should be simplified, well organized, to increase the participation of contacts, extend the time of follow-up of contacts, and improve diagnostic screening strategy. Given that the low participation rate in our study may have limited case detection, it is recommended to expand health education on transmission of TB and MDR-TB among contacts, reduce stigma attached to TB, improve communication skills of health staff, and increase staff resources to trace contacts and get them involved in the screening.In this study of nearly 100 MDR-TB index cases we were not able to find new MDR-TB cases using household contact screening and social network analysis within a follow-up period of 6 months. Screening of identified contacts was complicated by refusals. More staff resources may be needed and better communication skills and community awareness, collaboration of non NTP health facilities is needed to enhance participation and improve MDR-TB case detection.Additional file 1:Policy and performance of the National TB Control Programme of Viet Nam. Notification and enrollment for treatment of MDR-TB from 2009 to 2014. Policy recommended by the NTP Guidelines for detection of MDR-TB. (DOCX 39 kb)Additional file 2:Additional information for Methods and Results Sections. Sample size calculation. Modification description of questionnaire and the completeness of responses. Operational definitions and definition of patient category. Screening among contacts by gender, age and contact type. (DOCX 49 kb)


The effect of lifestyle, anthropometry and cardiovascular risk factors on cardiovascular disease in men with prostate cancer (PCa) remains unclear.Using a population-based cohort of 25,436 Danish, cancer-free men aged 50–64 years, we obtained information on self-reported pre-cancer lifestyle, objectively measured anthropometry and cardiovascular risk factors, and linked them to national health registers for information on major cardiovascular outcomes. We assessed hazard ratios (HRs) of incident acute myocardial infarction (MI), ischaemic stroke (IS) and heart failure (HF) among 1546 men diagnosed with PCa treated with first-line active surveillance, watchful waiting, intended curative or palliative treatment compared with PCa-free men during 18 years of follow-up.Men who received first-line palliative treatment had higher rates of IS and HF with adjusted HRs of 2.09 (95% CI 1.49–2.93) and 2.05 (95% CI 1.43–2.94), respectively, compared with PCa-free men. The risks were increased from start of treatment. We did not find the same relation for men in any other treatment group. No differences between men treated for PCa and cancer-free controls were observed for MI after adjustment for lifestyle, anthropometry, and cardiovascular risk factors.Pre-diagnosis lifestyle, anthropometry or cardiovascular risk factors did not explain the risk of IS and HF in PCa patients receiving palliative treatment. The results emphasise the need for balancing disease management and monitoring of cardiovascular health in this patient group. Further, few studies have compared the risk of CV outcomes for PCa patients with that of PCa-free men and with different results.15 Armenian et al.14 found a lower CV risk (incidence rate ratio (IRR), 0.89; 95 % confidence interval (CI) 0.84 – 0.95) compared with cancer-free men, whereas O’Farrell et al.15 found an increased risk, hazard ratio (HR) 1.21 (95 % CI 1.18–1.25).A well-investigated late effect of PCa treatment is cardiovascular (CV) disease. The suggested biological mechanisms include a direct cardio-toxic effect of hormone manipulation or an indirect CV effect through metabolic mechanisms.16 Smoking, high-risk drinking and a sedentary lifestyle are factors associated with the risk of CV disease, as are a high body mass index (BMI) and waist circumference, as well as hypertension, hypercholesterolaemia and diabetes.20When investigating the risk of CV events after diagnosis, it is paramount to address pre-diagnostic lifestyle and pre-existing CV risk to elucidate the complex relationship between existing risk factors at time of diagnosis and initiation of anti-cancer treatment and treatment-induced morbidity.We aimed to investigate risk differences of major ischaemic disease outcomes—acute myocardial infarction (MI), ischaemic stroke (IS) and heart failure (HF)—for men with PCa in either active surveillance, watchful waiting, intended curative or palliative first-line treatment compared with men without a PCa diagnosis. Analyses were adjusted for pre-diagnosis lifestyle, anthropometry, blood pressure, serum cholesterol and diabetes, as well as CV precursor disease.21 The Diet, Cancer and Health study was approved by the regional ethical committees in Copenhagen and Aarhus ((KF)11–037/01), and the present study by the Danish Data Protection Agency (2013–41–4232).Our study was based on data from the Danish prospective Diet, Cancer and Health cohort. Briefly, 80,996 men aged 50 – 64 years without previous cancer diagnoses were invited and 27,179 (34%) participated. Baseline information was collected between December 1993 and May 1997, where all participants completed questionnaires concerning diet, lifestyle- and health-related issues, and trained staff obtained blood samples and anthropometric measurements. A detailed description of the cohort is provided elsewhere.23 We identified 1838 men from the cohort diagnosed with incident PCa (ICD-10: C619) between study enrolment and 31 December 2013. By thoroughly reviewing hospital records, we obtained clinical information on stage, Prostate Specific Antigen (PSA) level, Gleason score and first-line treatment for all men diagnosed with PCa from 1993 to 2013. Stage was reported by the TNM classification system in the hospital records and was supplemented with information from the Danish Cancer Registry when missing in the record. To include stage of disease recorded before the introduction of TNM in 2003, we merged TNM with the previously used classification system, resulting in ‘localised disease’ and ‘non-localised disease’ . Gleason score and PSA level at baseline were categorised and included solely for descriptive purposes. First-line treatment was coded as follows: ‘active surveillance’ (surveillance with a curative intent in case of progression), ‘watchful waiting’ , ‘intended curative’  or ‘palliative treatment’ (hormone therapy (received by 94 % in this group), chemotherapy, surgery or radiotherapy) for all PCa diagnosed from 1993 to 2013. Detailed description of the clinical information was previously reported.24We used the unique personal identification number provided to all Danish residents to link the cohort to the Danish Cancer Registry with records of all cancers diagnosed in Denmark.25 (NPR) including all in-patient hospital admissions since 1977 and outpatient contacts since 1995. We supplemented information on CV events with information from the Danish Cause of Death Registry dating back to 1970, to include fatal first-time CV events.26The outcomes were incident acute MI, IS or HF. Date of each incident CV event was obtained from the Danish National Patient Registry30 or obese (>30), whiereas waist circumference in centimetre was grouped in quartiles. Diastolic and systolic blood pressure (mmHg) and serum cholesterol (mMol/L) measured at enrolment were included as continuous covariates. Blood pressure was measured at the right arm using automatic devices: TAKEDA UA 751 and UA 743 in lying position after a minimum of 5 min rest. Non-fasting total cholesterol (mMol/L) was determined in whole blood using a Lipotrend® C device with Lipotrend test strips (Boehringer Mannheim).From self-reported questionnaires, we categorised education as ‘short’ , ‘medium’  or ‘long’ . Smoking was included as ‘never’, ‘former’ or ‘current’. Alcohol intake (g/day) was included as a continuous covariate. To measure physical activity, we calculated metabolic equivalent of task (MET) from an average of summer and winter physical activity multiplied by number of hours per week. MET-score was grouped in quartiles. From the anthropometric measures obtained by the staff at enrolment, the BMI was grouped as normal (<25), overweightInformation on diabetes and precursor CV disease was obtained from the NPR at baseline. Diabetes was included as a yes/no covariate. The three CV precursor diseases, angina pectoris, transitional cerebral ischaemia  and men who changed personal identification number during follow-up  or had missing values on any of the covariates of interest  were excluded, leaving 25,436 men available for analysis  or a censoring event ), whichever occurred first. First-line treatment was included as a time-varying exposure and was analysed using Cox proportional hazards models with stepwise adjustment for confounding variables, i.e., lifestyle, anthropometry and CV risk factors. Model 1 was adjusted for year of study entry. In Model 2, we added education, smoking, alcohol intake and physical activity. Model 3 further included anthropometry (BMI and waist circumference) and Model 4 included systolic and diastolic blood pressure, serum cholesterol and diabetes. In each analysis, the two other CV events were included as competing events together with death from other causes.We estimated the cause-specific HR of each CV event stratified by first-line treatment among men with PCa compared with men without PCa adjusted for lifestyle, anthropometry and CV risk factors. We analysed temporal variation in HRs by splitting the time scale into three intervals according to time since diagnosis. As a sensitivity analysis, we adjusted for CV precursor diseases in Model 4 to see whetherpre-existing CV comorbidity confounded any association between PCa and CV events. We analysed the sub-distribution hazards for each CV event without the two other events as competing events to see whether the direction of the association remained the same.p-values and plots of each covariate in all models based on scaled Schoenfeld residuals. We stratified all analyses by smoking status, due to continuous violation of the proportional hazards assumption. For the covariates BMI and MET, the proportionality assumption was violated in some of the models. These models were extended by including separate baseline hazards for each level of these confounders. However, the estimates for the exposures did not change after doing this and to be consistent throughout the analyses we used the original specification of the models with one baseline hazard. Cumulative incidences were calculated for each CV outcome and death from other causes (competing event) for each category of first-line treatment. The analyses were done in R version 3.3.3 with packages ‘survival’, ‘ggplot2 and ‘etm’.29We tested the proportional hazards assumption in all analyses by inspecting Of the 25,436 men participating in the Diet, Cancer and Health study, 1838 (7%) were diagnosed with PCa during the median 18.5 years of follow-up accruing 387,032 person-years at risk. Only 342 (1%) men were lost to follow-up due to migration. We observed 3% of the incident 1948 MI, 4% of the 2144 IS and 4% of the 1547 HF among men diagnosed with PCa  among men who received GnRH agonists and 1.12 (95% CI 1.04–1.21) among men who underwent surgical orchiectomy at time of diagnosis, but 0.83 (95% CI 0.71–0.97) among those receiving AA, when adjusting for history of CV disease, education, stage and statin use. This study used PCa-free men as reference group; however, this did not exclude men with pre-existing CV disease and they did not include lifestyle factors in the analyses.15 Regarding IS, we found a twofold increased rate among men managed on palliative care compared with PCa-free men, and to our knowledge the risk of IS in PCa patients has never been compared with the risk in men without PCa. One Danish cohort study including >30,000 men diagnosed with PCa observed an increased, although much lower adjusted HR for stroke of 1.19 (95% CI 1.06–1.35) among men managed on endocrine therapy  but not in those undergoing orchiectomy compared with non-users of Androgen Deprivation Therapy (ADT).16 A US study of 22,310 men with non-metastatic PCa reported an increased risk of stroke or transient ischaemic attack (TIA) in men undergoing bilateral orchiectomy (Relative risk (RR) 1.77, 95% CI 1.25–2.39) compared with non-ADT users, with patients age >65 years at diagnoses having an increased risk for stroke/TIA compared with the younger patients.31 We did not find an increased risk of MI in any treatment group when comparing with PCa-free men, which contrasts to large PCa cohort studies from United States and the United Kingdom including a minimum of 30,000 PCa patients and reporting risk estimates in the range of 1.09 to 1.40 (95% CI 1.01–1.49).33 To our knowledge, only one study has compared the risk of ischaemic heart disease, stroke and cardiomyopathy/HF between PCa patients and cancer-free men.14 The study found that among 10,932 PCa patients who survived diagnosis by 2 years, those with American Joint Committee on Cancer (AJCC) stage I/II and III had a lower CV risk  compared with cancer-free men. The risk did not differ between PCa patients with stage IV and cancer-free men .14 However, the study lacked information on pre-diagnosis lifestyle, comorbidity and PCa treatment, and the study population was selected based on participants in an intensive screening programme through insurance coverage, which might have introduced selection bias as well as a high percentage of advanced tumours.The increased rate for HF in men receiving first-line palliative treatment for PCa compared with cancer-free men has also been observed in a population-based Swedish study. In this study, men with incident PCa undergoing endocrine treatment , orchiectomy, gonadotropin-releasing hormone (GnRH) agonists or combined AA/GnRH agonist treatment) had an increased standardised incidence rate of 1.66 (95% CI 1.57–1.76) for HF compared with that expected based on the Swedish male background population without pre-existing circulatory disease.23 and The NPR include information on both in- and outpatient contacts for CV events, which has been validated for research use.35 Further information on first-line treatment of PCa cases was obtained independently of the outcome of interest. We included all cancer stages in our analyses, thus providing a comprehensive perspective on how PCa treatment is associated with the risk of CV outcomes. Furthermore, our study had several methodological strengths. We made the comparison of men with PCa with a cohort of cancer-free men to disentangle the role of shared risk factors for PCa and CV disease. To the best of our knowledge, we are the first to include prospectively collected high-quality information on pre-cancer lifestyle, objectively measured body composition, CV risk factors and precursor heart disease in the same study. We include both competing risk analysis and sub-distribution hazards to account for the significant competing events present in this study population. In our study, the results from sub-distribution hazard analyses aligned with the cause-specific hazards, which strengthens our interpretation that the estimated rates are likely to reflect a direct effect of PCa and treatment on the studied CV events.36 Our study has some limitations regarding information on outcomes of interest, treatment and selection into the study. Most cases of MI and IS will cause admission or other hospital contact. However, we acknowledge that our study results may still be prone to surveillance bias, i.e., that men diagnosed with PCa may have a higher probability of being diagnosed with particularly HF. When diagnosed with PCa, assessment of their stage of disease, symptom burden and severe comorbidity may result in confounding by indication. We excluded all men with pre-existing events, but still saw indications, albeit statistically nonsignificant of higher risk of MI among conservatively treated men and lower risk of MI among curatively treated men. No first-line treatments were associated with changes in risk over time after diagnosis. Among palliative treated men, the risk for both IS and HF was increased throughout the full follow-up period, despite a high non-CVD mortality, indicating that an effect of palliative first-line treatment on these CV outcomes may present from beginning of treatment and pointing to a need for early and targeted surveillance among these men. PCa patients initially managed on either active surveillance or watchful waiting may later have changed treatment strategy, and likewise men undergoing curatively intended therapy may subsequently have progressed during follow-up, potentially underestimating the difference between men who receive first-line palliative treatment and those who receive other first-line treatments. Watchful waiting is in general associated with older age, more comorbidity and shorter life expectancy than other treatments. This may explain the persistent findings among the conservatively treated men in watchful waiting of an increased, albeit statistically nonsignificant, risk of MI, whereas the risk for IS and HF tended to be very close to null or even reduced. As we excluded men with pre-existing CV events, this may have introduced more selection in terms of health in the group of patients allocated to watchful waiting than in the other treatment groups.The strengths of our study include the use of high-quality registers. The Danish Cancer Registry holds accurate and almost complete recording of incident cancers37 however, we were not able to discriminate between subtypes of hormone therapy in the available data. This could efface within-group differences in the palliative group due to an underestimation for those receiving GnRH agonists and an overestimation among those who underwent bilateral orchiectomy. Contrary to expectations, the stepwise adjustment for lifestyle, anthropometry and CV risk factors did not affect the effect estimates markedly indicating that men with PCa in this cohort do not differ from the comparable men in terms of these CV risk factors. This may be because the men in the Diet, Cancer and Health cohort are somewhat healthier than the general population, thus resulting in less variation in risk factors, which is a well-known phenomenon in large-scale population-based cohorts.40Some studies suggest that the risk of subsequent CV events correlates to the type of hormone therapy;41 and addition of abiraterone to standard hormone therapy42 can improve survival in men with newly diagnosed metastatic PCa. The patients included in the present study were diagnosed through December 2013 and in the present period only few patients had chemotherapy in combination with first-line endocrine treatment. Abiraterone and second-generation AAs, i.e., enzalutamide and apalutamide, have not yet been approved in Denmark in combination with standard endocrine therapy in men with newly diagnosed metastatic disease. Thus, our data cannot provide information on the role of these therapies that would be both relevant and interesting to investigate in future studies, in PCa populations in relation to CV events. We encourage interpretation of the results to other settings with this in mind.We are aware that the results from this study population may not be generalisable to populations that have different baseline CV risks than Danish men and in settings with new chemo- and endocrine regiments available. Recent studies have demonstrated that combined chemo- and endocrine therapy,In summary, we found an increased risk of IS and HF among men who received first-line palliative treatment compared with men without cancer after adjusting for pre-cancer lifestyle, anthropometry and CV risk factors. As many of these men live with their PCa for a long time, it remains necessary to balance symptom relief and disease control with monitoring CV health in this patient group from the upstart treatment, in order to prevent or secure early management of CV events potentially affecting overall morbidity, health-related quality of life and ultimately mortality.Supplementary information


The University of Arizona Integrative Health Center (UAIHC) was an innovative membership-supported integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC delivered healthcare using an integrative medicine model that combined conventional and complementary medical treatments, including nutrition, mind-body medicine, acupuncture, manual medicine, health coaching, educational classes, and groups. Results from pre-post evaluation of patient-reported outcomes on several standardized measures are presented here. Short-Form Health Survey , Perceived Stress Scale (PSS4), Work Productivity and Activity Impairment Questionnaire (WPAI), World Health Organization Well-Being Index (WHO-5), Pain Visual Analog Scale (VAS), Fatigue Severity Scale , Generalized Anxiety Disorder Scale (GAD2), Patient Health Questionnaire for depression (PHQ2), Pittsburgh Sleep Quality Index (PSQI) global rating of sleep quality, and the Behavioral Risk Factor Surveillance System . Overall differences between time points were assessed for statistical significance. Patient demographics are also described. UAIHC patients completed surveys at baseline and after 12 months of continuous integrative primary care. Patients reported on perceived changes in health outcomes as measured byp <.05) on all but perceived stress (PSS-4) and work absenteeism (WPAI). Clinical impact and/or practical effects are reported as percent change or standardized effect sizes whenever possible. Other demographic and descriptive information is summarized. 177 patients completed baseline and follow-up outcome measures. Patients were predominantly white, female, college-educated, and employed. Baseline to one-year follow-up results indicate statistically significant improvements ( Following one year of IM primary care at UAIHC, patient-reported outcomes indicated positive impacts in several areas of patients' lives: mental, physical, and overall health; work productivity; sleep quality; pain; fatigue; overall well-being; and physical activity. This paper addresses the second IMPACT study question on whether the care received at UAIHC impacted patients' health and well-being. These results derive from a pre-post comparison of patient-reported outcomes on multiple standardized measures.The University of Arizona Integrative Health Center (UAIHC) was an innovative membership-supported integrative medicine (IM) adult primary care clinic in Phoenix, Arizona. UAIHC used a hybrid payment model to deliver comprehensive holistic healthcare combining conventional and complementary medical treatments. The Integrative Medicine Primary Care Trial (IMPACT) evaluates the impact of integrative primary care on patients' health using the model of care delivered at the UAIHC. The IMPACT study design is described elsewhere –3, but s integrates conventional medical approaches with evidence-supported complementary medicine (CM) modalities [Integrative medicine (IM) is patient-centered, whole person care that emphasizes the body's innate healing capacity and the importance of lifestyle to enhance health , 5. IM idalities , 7.The University of Arizona Integrative Health Center (UAIHC), in Phoenix, Arizona, was an innovative clinic that delivered integrative primary care via a patient-centered, team-based model , 3. UAIHGroups and classes were available to patients on topics such as nutrition, stress reduction, optimal weight and lifestyle, in addition to yoga and Tai Chi. During almost 4 years of operation, 1,700 patients received care at the clinic.Since the integrative primary care model was the intervention, it was important to first establish its fidelity, . As meaFollowing approval by the University of Arizona institutional review board, the UAIHC invited all patients to complete baseline questionnaires after their first visit and again after 12-months of continuous enrollment. Upon enrollment in the study, participants received a hyperlink to access the baseline questionnaire on a secure system. Patients received another hyperlink to a follow-up questionnaire just prior to 12 months of continual enrollment. For each of these questionnaires, the system automatically generated secure email reminders to nonresponders at 3, 5, and 10 days following the initial contact for each of these questionnaires. Although this process was automated, the study coordinator would follow up with nonresponders to encourage them to complete the questionnaire. This study was designed as a real-world observational study of daily clinical practice, with visits scheduled per clinicians' best clinical judgment; hence patients did not necessarily have scheduled follow-up visits at specific time intervals. In accordance with the protocol [Patients reported on health outcomes using several brief, published, standardized, and some norm-referenced measures summarized in Data used for analyses contained no direct identifying patient information and were stored on secured servers at the University of Arizona. Random, unique patient identification codes were used to link and merge the separate baseline and follow-up data sets. Data were examined for missing, illogical, or out-of-range values.Patients who completed baseline and 12-month assessments for at least one outcome measure were included in the analyses. Scoring required complete data for each measure on each time point, resulting in different sample sizes for the various outcomes. Publicly available algorithms were used to score the measures. t-test or—when parametric test assumptions were not met—using the nonparametric alternative Wilcoxon Signed Rank test. All two-tailed p-values less than .05 were considered statistically significant. Confidence intervals of differences for t-tests and effect sizes for both tests are also reported [Study participants served as their own control; baseline values were compared to those measured after 12 months. Overall differences between time points were assessed using the paired (dependent)reported . Medians n = 159).A total of 253 patients completed 12 months in the study. Of these, 76 were excluded due to missing either baseline or month 12 outcomes measures, resulting in a 70% participation rate. N = 177) completed follow-up questionnaires at 12.7 months on average (SD = 0.9) from baseline. Results of the published standardized measures are summarized in  PSS-4).Patients , the Physical Component Summary scores, , and the Mental Component Summary scores .At 12 months the PSS-4 (0 to 16) was not statistically significant (p = .08). However, an additional two-item measure (Stress Response and Amount) indicated statistically significant improvement in participants' amount of stress in life over the past year and their ability to handle stress .The improvement in overall perceived stress scores on the WPAI, the percent of time missed at work (absenteeism) did not differ from baseline (Mdn < 0.01%) to 12 months . However, there was a significant decrease in the percent of time impaired while working (presenteeism) from baseline (Mdn = 15%) to 12 months . Overall work impairment due to health  was significantly lower at 12-months (Mdn = 10%) than at baseline . For all respondents, employed and unemployed, overall activity impairment due to health over the past seven days was significantly lower at 12 months (Mdn = 10%) than at baseline .For employed patients (62% of respondents) reporting on the past seven days using the WHO-5 from baseline to 12 months . A statistically significant decrease in average GAD-2 anxiety summary scores was also observed (p < .001), representing a moderate effect (r = 0.27). In addition, the PHQ-2 depression summary scores indicated a statistically significant improvement (p = .002), representing a modest effect (r = 0.24).On average, patients reported a significant improvement in overall well-being on thep < .001) as measured on the PSQI. Patients were more likely to rate good quality sleep  at 12 months (74%) than at baseline (60%).Global ratings of sleep quality significantly improved , but no difference in fruits consumed. Patients also reported a significant increase in the average number of times per week engaged in their primary physical activity . The number of times per week patients engaged in muscle strengthening activities also increased significantly (p < .05).The BRFSS indicated increased consumption of vegetables (p < .001), representing a moderate effect (r = 0.48).Among 65 respondents who initially reported that pain was a frequent problem, a statistically significant decrease in pain ratings on the Pain Visual Analog Scale was found (p < .001), representing a large effect (r = 0.66). This subgroup of patients also completed the Fatigue Severity Scale (FSS) showing a statistically significant improvement (p < .001). The 26% decrease in average FSS scores represents a large effect (r = 0.59).Likewise, among 94 patients who initially reported that fatigue or tiredness were frequent problems, a statistically significant decrease in fatigue ratings on the Fatigue Visual Analog Scale was also observed  for physical and mental functioning . Based oOther studies assessing IM approaches have shown similar improvements with the SF-12. A 6-month, randomized, prospective study of an IM approach to asthma management  found a statistically significant improvement in the physical and mental summary scores when compared to a control group .Another IM clinic studied patient reported outcomes following 6 months of treatment for patients with a variety of conditions . The SF-The SF-12 was also completed by 145 patients with chronic pain, participating in a 6-month evaluation of an IM treatment approach . ResultsAnother outcome measure assessing mental functioning found similar results. Patients' psychological well-being improved 12% as measured by the WHO-5, which exceeds the 10% considered to be a clinically meaningful improvement , 29. TheThe predictive validity of the WHO-5 has been investigated in a study in which patients with cardiac disease were followed over a period of 6 years . PatientAnxiety and depression scales were another indicator of mental health. Patients experienced a 29% significant improvement in both anxiety (GAD-2) and depression (PHQ-2) measures despite baseline scores well below the threshold indicating need for further evaluation , 18. PSS-4 was the only mental health measure that did not show a significant difference, with only 8% improvement. This four-item measure is an abbreviated form of the original ten-item version (PSS-10). The shorter version may not be as sensitive to detect changes, as indicated by a study of a four-week mindfulness-based stress reduction class given to 23 inner-city patients; despite their 26% improvement in PSS-4 scores, the change was not statistically different [Patients' perceived stress rated over the past month on theifferent . HoweverSimilar to the improvement seen in the SF-12 physical summary score, other measures related to physical domains also improved. Pain scores improved 37% which exceeds the 33% standard generally considered a meaningful change from a patient's perspective .Patients in this study did not experience considerable fatigue, but still reported significant improvement with UAIHC. When used as a screening tool, scores of 5 or greater on the Fatigue VAS indicate need for further evaluation . Thus, tAlthough it is widely recognized that improvements in diet and exercise are linked with multiple positive impacts on health, we found no similar studies with which to compare our improved BRFSS diet and activity scores.Perhaps spanning both mental and physical health, there was a 21% statistical improvement in global sleep quality as measured by the PSQI. Findings were similar to results from a 10-week yoga program to reduce menopausal symptoms, which also demonstrated a significant improvement in the global rating of sleep quality .The improvements in both physical and mental well-being for patients receiving IM primary care appear to carry over to the workplace. The WPAI showed improvement in presenteeism (productivity while at work), work impairment, and activity impairment. Although the 38% decrease in absenteeism was not statistically significant, change is difficult to detect given the floor effect observed in this sample . Despite the lack of statistical significance, the improvement may have been clinically important to these patients. Studies using the WPAI have found that a 7% improvement in scores led to a meaningful change in patients with Crohn's disease (Sandborn 2007) and a 20% improvement in work productivity or activity impairment represented a clinically meaningful change in patients with psoriasis (Wu 2019).The lack of statistically significant improvement on the WPAI in our study is not unexpected as many studies have similar results, even in populations where absenteeism would be expected to improve. Patients with depression have substantial work impairment, missing an average 27 days per year due to absenteeism and presenteeism . A studyOther IM modalities have demonstrated improvement in the WPAI as well. A prospective, nonrandomized, open-label observational study evaluated an integrative approach to managing chronic pain . The WPA underestimate the improvements on some measures that are most relevant to subgroups by conditions or treatment areas. IM primary care clinics comprised of less healthy patients than our study population would be expected to see even greater improvements in these outcomes measures.These results must be considered in light of study limitations. First, outcomes were assessed for the patient population as a whole, which included any patients with available information on any measures at both time points irrespective of presenting problems or consequent treatments. As indicated by the baseline SF-12 and WHO-5, the patients in this study were considered relatively healthy. Thus, results mayAlthough participants served as their own controls between baseline and follow-up, real-world observational studies  cannot exclude possible confounding and selection bias. Further research is needed to clearly delineate the impact of IM primary care on patient-reported outcomes.The relationship between intensity of care and improvement in patient-reported outcomes was not evaluated. Further research is needed to determine whether numbers of visits or specific provider types contribute to measured outcomes.Several analyses outlined in our protocol could not be completed due to smaller than anticipated sample size. For example, we planned subgroup analyses for patients with the following five conditions: low back pain, fibromyalgia, other musculoskeletal conditions, metabolic syndrome and diabetes, and cardiovascular disease, assuming IM primary care would have the greatest impact on outcomes in these patients. Similarly, subgroup analyses by intervention or provider types were not feasible. Future research is also needed to explore predictive modeling to identify demographic or health-related conditions at baseline that predict who would benefit most from IM primary care. Examining correlations among various outcomes such as depression and stress would be another future topic to explore with a larger number of patients. Finally, survey measures that ask patients to reflect on the past  potentially introduce an inherent risk of recall bias.Following one year of integrative primary care at UAIHC, patient-reported outcomes indicated positive impacts in patients' mental, physical, and overall health; work productivity and activity; and overall well-being. These findings are consistent with other integrative medicine studies that demonstrated enhanced patient well-being. Having focused our analysis on a relatively healthy patient population, we potentially underestimated improvements on some measures that are more clinically relevant to certain patient subgroups. These results are encouraging at a time when there is agreement about the need for more patient-centered models of health care delivery and speaks to the importance and timeliness of the IMPACT study and its contribution to the literature on IM outcomes.Real-world research is certainly messy. In this study, there was no rigidly defined intervention. Instead, each patient's care and treatment plan was based not only on their clinical history, but also on their personal goals, beliefs and values. In addition, these patients were encouraged to become actively involved in the design of their treatment plan. This principle is at the heart of integrative medicine.The UAIHC model was designed in the spirit of patient-centeredness, and patient-reported standardized measures were used to evaluate the model's impact. We encourage other researchers to continue assessing the impact of IM on patients as there is both real need and opportunity.


Pseudomonas fluorescens SG-1 and Bacillus megaterium Mes11) exposure to pesticides. VOC determination was based on solid-phase microextraction (SPME) coupled with gas chromatography-mass spectrometry (GC-MS). Accordingly, we highlighted a set of bacterial VOCs modulated in each strains according to the nature of the pesticide used. Three out these VOCs were specifically modulated in P. fluorescens SG-1 when exposed with two pyrethroid pesticides (deltamethrine and cypermethrine): 2-hexanone; 1,3-ditertbutylbenzene and malonic acid, hexyl 3-methylbutyl ester. Our results thus suggest the possible existence of generic VOC markers of pyrethroids in this strain. Of particular interest, two out of these three VOCs, the 1,3-ditertbutylbenzene and the malonic acid, hexyl 3-methylbutyl ester were found also in B. megaterium Mes11 when exposed with cypermethrine. This result highlighted the possible existence of interspecific VOC markers of pyrethroid in these two bacteria. Altogether, our work underlined the relevance of volatolomic to detect signatures of pesticides exposure in microorganisms and more generally to microbial ecotoxicology. Based on these first results, considerations of volatolomics for the chemical risk assessment in environment such as soils can be indirectly explored in longer terms.Volatile organic compounds (VOC) produced by microorganisms in response to chemical stressor showed recently increasing attention, because of possible environmental applications. In this work, we aimed to bring the first proof of concept that volatolomic  can be used to determine candidate VOC markers of two soil bacteria strains ( Accordingly, many VOCs are pointed out as markers of the gut microbiota exposure to benzo[a]pyrene, enlarging the potential applications of volatolomics in microbial ecotoxicology studies. To date, the use of volatolomic in microbial and/or bacterial ecotoxicology was restricted to community levels . We choose to work with nditions . Based onditions , we assuP. fluorescens SG-1 . For experiments, strains were grown in 30 mL of medium growth solution  maintained in dark condition at 28°C under orbital agitation (200 rpm). To ensure enough bacterial biomass for further experiments, medium inoculation consist about 2 × 10e4 cells/ml and 2.5 × 10e6 cells/ml for B. megaterium Mes11 and P. fluorescens SG-1, respectively. Pseudomonas fluorescens SG-1 was pre-cultivated under these conditions overnight 12 h, whereas B. megaterium Mes11 was pre-cultivated for 48 h.Two edaphic bacterial strains isolated from soils from enrichment culture, ens SG-1  and B. m®, analytical standard). DMSO was used at a final concentration of 0.5% to enhance solubility of the three pesticides. The effective concentration that decrease the generation time of 10 % (EC10) was determined for each pesticide in both strains. Indeed, to guarantee a situation where deviation of the metabolome is linked to the presence of toxicant with phenotypic trait  method coupled with gas chromatography-mass spectrometry (GC-MS) adapted from ®-624Sil MS fused silica column  according to previously established settings (Volatile organic compounds (VOCs) of both settings . By usinPeak areas of VOCs were determined using a mass fragment selected for its specificity and free from co-elution with an automatic algorithm developed in our laboratory under Matlab R2017 by Finally, the three pesticide solutions  used to expose the bacteria were also analyzed at EC10 concentration by similar protocol as described for samples in order to verify if candidate VOCs markers of pesticide exposure had an exogenous origin.R 3.1.1 statistical software  was performed based on discriminant VOCs selected by the ANOVAs to visualize the data structuration . Accordingly, eight, six and three of them were over- or under-expressed following exposure to deltamethrine, cypermethrine and sulcotrione, respectively, meaning that pesticides are associated with a volatolome deviation in strains.The analytical pipeline identified a total of 134 VOCs in P. fluorescens SG-1. Potential markers of P. fluorescens SG-1 exposure to pesticide were thus found among the most contributing VOCs to PC1.Based on these discriminant VOCs, PCAs were performed for each pesticide to visualize the structure of data and which compounds were over- and/or down-expressed in treated specimens Figure . The firWhen exposed to deltamethrine, PC1 separation was mainly due to the increase expression of carbonyl sulfide, two branched-alkanes , malonic acid, hexyl 3-methylbutyl ester, and one aromatic compound , and to the decrease expression of ketone (2-hexanone) and two others unidentified VOCs despite the high-resolution mass spectrum assay , one alcohol (2-methyl-2-butanol), one acid , one ester (hexyl 3-methylbutyl ester) and one aromatic compound , whereas no VOC reduction was observed . Out of 150 VOCs which were identified in B. megaterium Mes11 volatolome, 15 were over or under-expressed following cypermethrine exposure. All of them seem to be endogenous to B. megaterium Mes11 (no one were identified in the cypermethrine specific volatolome).As shown in Figure The clear case-control separation exhibited by PC1 (79.4%) was explained by the increase expression of five branched-alkanes , one alkane diol , one branched-alkene , one acid , one ester (hexyl 3-methylbutyl ester), one alcohol (2-hexyl-1-octanol), one aromatic compound  and five unidentified VOCs  modulated in P. fluorescens SG-1 when exposed with pyrethroid pesticides (deltamethrine and cypermethrine), suggesting the existence of candidate generic VOC markers of pyrethroids in this strain. Interestingly, two out of these three VOCs were found in B. megaterium Mes11 when exposed with cypermethrine too, suggesting the existence of interspecific markers of pyrethroid in these bacteria. Altogether, our results underlined the relevance of volatolomics to detect signatures of pesticide exposure in microorganisms.The present work aimed at identifying metabolic VOC markers of exposure to three different pesticides used at low concentration (EC10) in two edaphic bacteria strains, P. fluorescens SG-1. Bacteria modulated a set of strain-specific VOCs following exposure to deltamethrine, cypermethrine or sulcotrione. Accordingly, when they were exposed to deltamethrine, P. fluorescens SG-1 showed higher levels in carbonyl sulfide and two branched-alkanes . The increased levels of these three VOCs should be the results of distinct metabolic responses displayed by the strain to challenge the impacts of deltamethrine in cells. According to previous works, the release of carbonyl sulfide could be linked with an increase of metabolic rate and respiration in plants and some soil microorganisms  to counteract the impacts of deltamethrine at cell levels. Indeed, there is many evidence that species over-produce such an energetic substrate when they are exposed to environmental stressful conditions , one branched-alkene , and one primary alcohol (2-hexyl-1-octanol). Exposure to pyrethroids induced many modifications at cellular levels, including lipid peroxidation of fatty acids that form part of the cell membranes, and the synthesis of polyunsaturated fatty acids (PUFAs). In response, organisms display number of metabolites from oxidation reactions catalyzed by enzyme systems associated with cytochrome p450 and alcohol dehydrogenases (ADH). These metabolites include alkanes (C3-C11), branched-alkanes and -alkenes, alcohols and also aldehydes and carboxylic acids as end metabolites of the reaction  and thus physiological modulations in organisms, including volatolome adjustments. Corroborating this hypothesis, our approach has detected modulated expression of three VOCS  in channels , the act results . FurtherP. fluorescens SG-1 under pyrethroid (deltamethrine and cypermethrine) exposure, and in B. megaterium Mes11 under cypermethrine exposure. Although we have no data about how deltamethrine influences the volatolome of B. megaterium, the two VOCs seem to be interspecific markers of cypermethrine contamination in the two strains. Based on the detection of such generic and interspecific markers of cypermethrine exposure, we could further envisage risk assessment investigations in more complex ecosystemic fields like soil mesocosms. However, more studies are still required in order to comfort an interpretative marker of these two compounds. Investigating physiological incidences of these two VOCs on bacteria may help to clarify the origin of these compounds as candidate markers of many mammal diseases related to lipid peroxidation processes , an increase was observed in rocesses .B. megaterium Mes11 whether they were exposed to the sulcotrione or not. B. megaterium Mes11 was characterized as an efficient mesotrione-degrading strain (B. megaterium Mes11 isolated from soils was able to completely and very rapidly (about 1 h at 30 mg/L) biotransform the mesotrione into 2-amino-4methylsulfonylbenzoic acid (AMBA) and 4-methylsufonyl-2-nitrobenzoic acid (MNBA) in its culture growth (Tetrahymena pyriformis and Vibrio fischeri were shown to be able to degrade both sulcotrione and mesotrione herbicides. Although we cannot rule out the hypothesis that the vehicle (DMSO 0.5%) might hide the effects of sulcotrione on the strain volatolome, we can first supposed that B. megaterium Mes11 should rapidly degrade the sulcotrione. However, such a sulcotrione-degrading activity of B. megaterium Mes11 have to be further investigated by measuring the sulcotrione and its residues directly in strain cells and growth medium along the experiment duration.The PCA analysis did not reveal significant volatolome difference in g strain , a selece growth  by nitroB. megaterium Mes11 could induce a 10% decline of their generation time because of a genotoxic effect on cells (impacting cellular division) rather than detoxification processes at the metabolic scale. Similar conclusions had been made in the protist Paramecium in which exposure to sulcotrione influences the transcription of genes involved in cell division whereas exposure to deltamethrine influences the transcription of detoxifying genes .Second, triketone pesticides can have genotoxic effects on cells, as already demonstrated in plants . TherefoBacillus can turned to resistance form by encapsulation when they were exposed to chemical stress. The decline of generation time measured with 327.33 mg/L of sulcotrione could also be the consequence of such a protective encapsulation state of the strain rather than a consequence of stress detoxification.Third, Conventional analyses used to detect and quantify the presence of xenobiotics in the environment provide an efficient way to improve risk assessments, but do not estimate how they influence biological systems inhabiting these ecosystems. It is in this context that ecotoxicogenomics, a set of analytical tools that combines high throughput DNA technologies with bioinformatics, had emerged . Thus, rIn our knowledge, no previous work had already used volatolomics to investigate indirect markers related to the exposure of soil bacterial strains to different pesticides. We thus optimized a volatolomic pipeline from previous works devoted to livestock and microbial communities  and adapThis work was driven by EE and PB. EE, PB, and KH designed and wrote the manuscript. KH conducted all experiments. FM and JR helped KH in adapting the volatolomic assay for single bacteria. BG conducted the HR-MS analysis to validate VOC identification.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.