Phase II study of short-time oxaliplatin, capecitabine and epirubicin (EXE) as first-line therapy in patients with non-resectable gastric cancer

Epirubicin, cisplatin and continuous infusion of 5-FU is a widely used palliative regimen in patients with gastric cancer. If cisplatin is substituted by oxaliplatin and 5-FU by capecitabine this regimen can be administered in the outpatient setting. Dose-limiting toxicity of oxaliplatin is peripheral sensory neuropathy and it is recommended to give oxaliplatin as a 120 min infusion. However, in patients with colorectal cancer a 30 min infusion of oxaliplatin can safely be administered without increasing neurotoxicity, standard infusion time is 30 min at our departments. In our phase I study the recommended doses of EXE was established (Dupont et al, 2006). Patients with non-resectable gastric adenocarcinoma were eligible. Patients received EXE (epirubicin 50 mg m(-2) day 1; capecitabine 1000 mg m(-2) day(-1) continuously and oxaliplatin 130 mg m(-2) day 1) as outpatient therapy every third week for a maximum of 8 cycles. From June 2004 to September 2005, we enroled 54 patients. Median age was 60 years (31-74 years) Median number of courses was 6 (1-8). Response rate was 45%. Median PFS was 6.8 (5.2-7.9) months and median survival was 10.1 (7.9-1.1) months. Most important grade 3 toxicities were as follows: nausea, vomiting, and diarrhoea (6%). Neurotoxicity grade 2 was seen in 36.5%. We therefore conclude, that EXE every third week is a convenient regimen that easily can be administrated in the outpatient setting but the regimen needs further evaluation in a phase III study.

Human immunodeficiency virus (HIV)-2-specific T lymphocyte proliferative responses in HIV-2-infected and in HIV-2-exposed but uninfected individuals in Guinea-Bissau

Human immunodeficiency virus (HIV)-2-specific T lymphocyte proliferative responses were determined in cultures of peripheral blood mononuclear cells from HIV-2-exposed uninfected individuals, HIV-2-infected individuals and HIV-negative controls in Guinea-Bissau. Increased HIV-2-specific T lymphocyte proliferative responses were detected in both groups compared to HIV-negative controls (healthy HIV-uninfected individuals without known exposure to an HIV-infected person); five out of 29 of the HIV-2-exposed uninfected and half (16 of 32) of the HIV-2-infected individuals had stimulation indexes >2, compared to one out of 49 of the HIV-negative controls (P = 0.003 and P < 0.0001, respectively). The exposed uninfected individuals had reactivity to a HIV-2 V3-peptide corresponding to amino acids 311-326 of the envelope glycoprotein, while the HIV-2-infected people reacted mainly to HIV-2 whole viral lysate. Thus, this study demonstrates a high degree of HIV-2-specific T helper cell activity, as measured by lymphocyte proliferation, in HIV-2-exposed uninfected individuals as well as in HIV-2-infected subjects. These immune responses could be important for resistance to the infection and for the control of established infection and, thus, play a role in the lower transmission and progression of HIV-2 compared to HIV-1.

[What does a hospital building tell?]

Hospital architecture may be seen as an artistic expression and interpreted as such. In general, architecture is more dependent than other form of art on external forces: The requested function of the building normally puts important constraints on the implementation of architectural ideas. In addition, buildings are often rebuilt and altered in ways that make a retrospective analysis of the basic ideas behind them difficult. Hospital buildings usually reflect the state of the art of medicine at the time of construction or reconstruction, and their architecture should be interpreted in the light of the medical setting of the time. Other elements and influences, such as general views on health and sickness, religion, economy, style etc. should also be taken into consideration. This article discusses examples that show some of the possible pitfalls when we attempt to give a cultural interpretation of hospital buildings. The conflict between charity and rationality seems to be a basic problem in modern hospitals, an example is given where this conflict is reflected in the architecture.

Prevalences of HTLV-1 infection and associated risk determinants in an urban population in Guinea-Bissau, West Africa

OBJECTIVE

To assess the prevalence and modes of transmission of HTLV-1 infection in an adult population in Bissau, and to evaluate possible interactions between the pattern of spread of HTLV-1 and HIV-1/HIV-2.

DESIGN AND METHODS

Univariate and multivariate analyses were used to evaluate gender-and age-specific HTLV-1 prevalences as well as associated risk determinants in an adult population based on a serosurvey comprising 2127 individuals from 304 randomly selected houses in Bissau.

RESULTS

Using stringent Western blot criteria, the overall seroprevalence of HTLV-1 was 3.6%, 2.2% among men and 4.7% among women, respectively. One individual was seropositive to HTLV-2. The prevalence of HTLV-1, which increased with age in both genders, however more markedly among women, was >4 times higher (9.4%) among older individuals (>44 years of age) than among younger individuals (2.4%). Blood transfusion and HIV-2 seropositivity were independently associated with HTLV-1 seropositivity in men. Among women, both HIV-2 seropositivity and HIV-1 seropositivity were significant risk determinants. Having had sexual partners was associated with a fivefold increased risk among women but did not reach significance.

CONCLUSION

The adult population of Guinea-Bissau has a higher prevalence of HTLV-1 than reported from most other countries in West Africa. The gender-and age-specific pattern of spread of HTLV-1 closely resembles that observed for HIV-2, another retrovirus prevalent to the region. The close correlation between HTLV-1 and HIV-2 most likely reflects the shared risk factors related to sexual behavior. The implication of the high percentage of double infections in this population needs to be determined.

[Professional cooperation and overview of the health status. Two important initiatives from Christian August Egeberg in 1838 and 1855]

Christian August Egeberg (1809-74) was a Norwegian military surgeon who practised surgery and family medicine in the capital city of Christiania and in neighbouring rural Baerum. He saw the medical profession's need for establishing a scientific community, for information-seeking and knowledge updates. He was among the founders of the Norwegian Medical Society in 1833 and in 1838 initiated a series of Scandinavian scientific conferences which lasted until 1929. In 1855 he established a notification system for contagious diseases with reports submitted every month from practising physician. The system was intended to provide a basis for surveillance of the so-called epidemic constitution, so that appropriate measures might be taken against prevailing diseases.

[What shapes people's notions of health and illness?]

Lay conceptions of health are shaped by a variety of demographic, social, and personal factors. Research has focused on psychological and sociological perspectives, and three core models have dominated the field: the cognitive developmental model, the health locus of control model, and the so-called health belief model. Societal factors have been less studied. On the basis of a meta model we discuss how changes in prevalence of disease and disease panorama, social network, the experience of uncertainty, and the medical focus on risk may have impact on lay conceptions of health and disease. The joint effect of the medical focus on risk and disintegrating social networks seems to be the central force behind medicalization.

[Health, medicine and population development in Norway]

If health, medicine and medical services in Norway throughout the millennium are seen through a demographer's eyes, it is obvious that the health situation and the preconditions for medical work have changed profoundly, especially in the last two centuries. A relatively stable, young, and geographically dispersed population, living with, and probably to a large extent accepting high morbidity and high mortality, has gradually been transformed into a more middleaged, urbanized population where absence of disease and untimely death is perceived as a normal situation, which it is the goal of the health services to achieve. The population growth was especially accelerated during the 19th century, when mortality rates declined rapidly before a corresponding decrease took place in the birth rates. The demographic effects of medicine in Norway in the 19th century should mostly be ascribed to efforts in preventive and social medicine. The life saving and life prolonging effects of curative medicine belong to the the 20th century, a period when specific treatment of infections had become available. However, further achievements in demographic effects of medicine have to take into account the demands set by the perceptions of health and welfare in the population, and the ever increasing social and economic constraints.

Increased prevalence of retrovirus infections among older women in Africa

Recent studies of HIV-2 have suggested an increased incidence and prevalence among women older than 45 y compared with younger women. We therefore examined whether this phenomenon applied generally to all 3 major retroviruses, HIV-1, HIV-2 and HTLV-I, among women in Africa. We conducted a MedLine search from 1987 to 1997, using the keywords Africa and HIV-1, HIV-2 or HTLV, respectively. Community studies, national surveys and studies on professional cohorts were selected. Age groups > 45/50 y were compared with the age group with the lowest female/male prevalence ratio between 20 and 44 y of age. Thirty-one studies had sufficient data to be included. The female/male odds ratio (OR) for seropositivity was calculated for the old and the young age groups, respectively, providing the ratio of odds ratios: OR (old)/OR (young). Summary ratios for studies of all 3 retroviruses were estimated. In general we found a higher female/male prevalence ratio in the age group over 45/50 y than in the younger age group. For HIV-1 the odds ratio was 1.82 times [95% confidence interval (CI) 1.19-2.79] higher in the old age group than in the young group. For HIV-2 it was 1.97 [95% CI 0.95-4.08], and for HTLV-I it was 2.02 [95% CI 0.99-4.14] times higher. For all 3 viruses combined, the ratio was 1.88 [95% CI 1.36-2.61]. The few incidence studies of HIV-1 and HIV-2 indicated a similar tendency. Since differential mortality is unlikely to explain the pattern, the increase in the HIV-1, HIV-2 and HTLV-I female/male prevalence ratio suggests that older women may have increased exposure or susceptibility to all 3 retrovirus infections.

Learning medical history in Oslo: training for medical practice

The teaching in medical history at the University of Oslo, Norway, is given as an integrated part of the student training for practical work in health care and community health. I summarize here the underlying argumentation and the teaching experiences, concluding that this is felt as an effective way to convey relevant medical historical knowledge and skills to the future doctors.

Presence and dehydration of ikaite, calcium carbonate hexahydrate, in frozen shrimp shell

Ikaite, calcium carbonate hexahydrate, has by means of X-ray diffraction analyses of frozen samples been identified as the mineral component of the white spots formed in the shell of frozen shrimp during storage. When the shrimp thaw and the shell material is dried and kept at room temperature, ikaite rapidly transforms into a mixture of anhydrous calcium carbonate forms. X-ray diffraction analyses and Raman spectra of synthetic ikaite as well as the dehydration product confirm the assignments, and the rate constant for dehydration is approximately 7 x 10(-)(4) s(-)(1) at ambient temperature. Differential scanning calorimetry showed that dehydration of synthetic ikaite is an entropy-driven, athermal process and confirms that a single first-order reaction is rate-determining. Ikaite is found to be stable in aqueous solution at temperatures below 5 degrees C and in the shell of frozen shrimps but decomposes on thawing to form anhydrous calcium carbonates.

Dissimilatory sulfite reductase from Archaeoglobus profundus and Desulfotomaculum thermocisternum: phylogenetic and structural implications from gene sequences

The genes encoding the alpha- and beta-subunits of dissimilatory sulfite reductase, dsrAB, from the hyperthermophilic archaeon Archaeoglobus profundus and the thermophilic gram-positive bacterium Desulfotomaculum thermocisternum were cloned and sequenced. The dsrAB genes are contiguous, and most probably comprise an operon also including a dsrD homolog, a conserved gene of unknown function located downstream of dsrAB in all four sulfate reducers so far sequenced. Sequence comparison confirms that dissimilatory sulfite reductase, Dsr, is a highly conserved enzyme. A phylogenetic analysis using the available Dsr sequences, including Dsr-like proteins from nonsulfate reducers, suggests a paralogous origin of the alpha- and beta-subunits. Furthermore, the Dsr from sulfate reducers forms a separate cluster, with Dsr from the bacterial sulfate reducers Desulfotomaculum thermocisternum and Desulfovibrio vulgaris branching together, next to Dsr from Archaeoglobus profundus and Archaeoglobus fulgidus. Based on an alignment with the assimilatory sulfite reductase from Escherichia coli, the amino acid residues involved in binding of sulfite, siroheme, and [Fe4S4]-clusters have been tentatively identified, which is consistent with the binding of two sirohemes and four [Fe4S4]-clusters per alpha2beta2 structure. The evolution of Dsr and the structural basis for the binding of substrate and cofactors are discussed.

[Heinrich von Kleist and the true nature of man]

In short-stories, novels and plays, the artist's interpretation of human nature may render the reader valuable insights into the basics of human behaviour. This article is a discussion of a short-story about a fictitious earthquake in Chile, written in 1807 by Heinrich von Kleist (1777-1811). The writer shows how feelings of warmth, friendliness and solidarity come out when a catastrophe reduces the relative importance of man-made rules and regulations. But more sombre sides of human nature also come to the surface in the wake of the disaster, and the writer indicates that even the apparently virtuous Christian morality contains severe traits of cruelty and repressiveness.

Declining HIV-2 prevalence and incidence among men in a community study from Guinea-Bissau

OBJECTIVE

To assess the present level of HIV-2 infection in an adult population in Bissau and to evaluate sex and age-specific changes in HIV-2 prevalence and incidence between 1987 and 1996.

DESIGN AND METHODS

Sex and age-specific changes in HIV-2 prevalence were evaluated comparing a survey from 1987 in a sample of 100 houses with a survey performed in 1996 in an independent sample of 212 houses from the same study area. HIV-2 incidence rates were examined in an adult population (age > or = 15 years) from 100 randomly selected houses followed with four consecutive HIV serosurveys from 1987 to 1996.

RESULTS

The HIV-2 prevalence in 1996 was 6.8% (men, 4.7%; women, 8.4%). Compared with the 1987 survey there was a significant decrease in prevalence among men [age-adjusted relative risk (RR), 0.50; 95% confidence interval (CI), 0.31-0.83], whereas it remained unchanged in women (RR, 1.00; 95% CI, 0.67-1.48). The male-to-female RR decreased from 0.99 (95% CI, 0.61-1.61) in 1987 to 0.51 (95% CI, 0.34-0.76) in 1996. The overall annual incidence rate was 0.54 per 100 person-years of observation (PYO), being higher in women (0.72 per 100 PYO) than in men (0.31 per 100 PYO). With the observation time divided into an early and a late period, there was a decrease in incidence with time among men (0.66 to 0.00 per 100 PYO), but no major change among women (0.59 to 0.85 per 100 PYO). The two trends differed significantly (P = 0.03). We observed a higher annual incidence rate amongst older women aged > 44 years (1.77 per 100 PYO) than among younger women (0.55 per 100 PYO; P = 0.05).

CONCLUSION

There are no signs of an epidemic spread of HIV-2 in Bissau even though the HIV-1 prevalence is increasing rapidly. A significant reduction in the male HIV-2 prevalence and incidence rates has resulted in a major shift in the pattern of spread of HIV-2, from being equally distributed to being predominantly a female infection. Currently, older women in particular seem to have a high risk of getting infected.

HTLV-1 infection in a population-based cohort of older persons in Guinea-Bissau, West Africa: risk factors and impact on survival

In 1989, a population-based cohort of persons aged > or = 50 years was established in an urban area of Guinea-Bissau, West Africa. Overall, 346 persons were interviewed in detail about risk behaviors and had capillary blood drawn. Among women, 12.4% were HTLV-1 seropositive, compared with 4.6% in men. No HTLV-2 was found. Seropositivity varied considerably according to place of birth and ethnic group. In women, but not in men, HTLV-1 seropositivity was strongly associated with early sexual debut (10-14 yrs, 33.3%; 15-17 yrs, 26.0%; 18-20 yrs, 6.5%; 21+ yrs, 0%; ptrend = 0.001), lifetime number of male partners (ptrend = 0.006), and the male partner's number of co-wives (ptrend = 0.006). There was also a 3.1-fold increased risk of being HTLV-1 seropositive if the woman was also HIV-2 seropositive. In a multivariate-risk-factor analysis, the strongest association with HTLV-1 was a history of having been bitten by a monkey (n = 11; combined OR adjusted = 10.1; 95% CI 2.3-44.4). Ornamental scarification was associated with a 3.3-fold increased risk. Ethnic affiliation also significantly influenced the risk of being HTLV-1 seropositive. Follow-up performed in January 1996 revealed no difference in survival between HTLV-1-seropositive and -seronegative individuals over 6 years (rate ratio = 1.4, 95% CI 0.7-2.8). In conclusion, this population, which has very high HIV-2 seroprevalence, is also highly endemic for HTLV-1. Whereas sexual behaviors are clearly important for HTLV-1 spread in women, non-sexual risk factors were the only ones of potential importance in men. HTLV-1 had no impact on survival in this older population.

HIV-2 genetic variation and DNA load in asymptomatic carriers and AIDS cases in Guinea-Bissau

The purpose of this study was to document which genetic subtypes of HIV-2 are present in Guinea-Bissau and to investigate whether asymptomatic HIV-2 carriers and AIDS patients carry distinct genetic variants. A secondary aim was to correlate proviral DNA load to clinical and immunologic status of the patients. Thirty-eight asymptomatic HIV-2 carriers and 11 AIDS patients from Bissau, Guinea-Bissau were included in a cross-sectional study in which HIV-2 env V3 sequences, HIV-2 DNA load, and CD4-positive (CD4+) lymphocyte counts were determined. Phylogenetic analyses showed that all investigated subjects carried subtype A HIV-2 variants and that the sequences from AIDS patients and asymptomatic carriers did not form distinct subclusters in the tree. As expected, patients with AIDS had significantly higher median HIV-2 DNA load than did asymptomatic carriers (4.6 vs. 2.0 log10 HIV-2 DNA copies/10(6) CD4+ lymphocytes). Our study indicates that the HIV-2 epidemic in Guinea-Bissau is almost exclusively caused by subtype A HIV-2 variants and that the HIV-2 infections among the asymptomatic carriers and AIDS cases included in the study do not have distinct epidemiologic histories.

9-year HIV-2-associated mortality in an urban community in Bissau, west Africa

BACKGROUND

Community studies with 1-3 years of follow-up have reported four to five times higher mortality in HIV-2-infected than in uninfected adults. In a cohort study of HIV-1, an increasing difference in mortality rates of HIV-1-infected and uninfected individuals is expected over time, because of rising mortality with advancing HIV-1 infection. We therefore investigated long-term survival of HIV-2-infected adults.

METHODS

Adults enrolled in 1987 in a community study of HIV-2 infection in Guinea-Bissau were followed up with serological surveys in 1989 and 1992. Survival was assessed in 1995, 9 years after enrollment.

FINDINGS

The annual incidence of HIV-2 was 0.7% for adults and tended to be higher for older individuals than for participants aged 15-44 years (relative risk 3.21 [95% CI 0.91-11.37]). With control for age, HIV-2-infected adults had twice as high mortality as uninfected individuals (mortality ratio 2.32 [1.18-4.57]); the mortality ratio was highest in the first year of the study (4.50 [1.31-15.43]). The difference between infected and uninfected individuals was stronger for adults under 45 years of age (mortality ratio 4.72 [1.86-11.97]) than for older people (1.35 [0.51-3.56]). HIV-2-infected individuals living with an infected spouse had significantly higher mortality than HIV-2-infected individuals living with an uninfected spouse (p = 0.027).

INTERPRETATION

HIV-2-associated mortality is not increasing with length of follow-up. Mortality in HIV-2-infected adults is only twice as high as that in uninfected individuals. In the majority of adults, HIV-2 has no effect on survival.

Age of wife as a major determinant of male-to-female transmission of HIV-2 infection: a community study from rural West Africa

OBJECTIVE

To examine whether proviral load is important for transmission between spouses, since we have previously found that the proviral load of HIV-2 predicts the severity of infection.

DESIGN

Proviral load was examined in 121 HIV-2-infected adults in a rural area of Guinea-Bissau. For the 68 subjects who had a spouse of known HIV status the risk of the spouse being infected was examined.

METHODS

Statistical methods for dependent data were used, because several couples were polygamous.

RESULTS

Twenty-seven HIV-2-infected men had 52 current wives of whom 17 (33%) were HIV-2-seropositive. Forty-one HIV-2-infected women had 36 current husbands of known HIV serostatus; nine (25%) were HIV-2-positive. In univariate analyses, concordance of female partners of HIV-2-infected men increased with a previous history of prostitution, age of wife, lack of age difference between the spouses, number of previous husbands, number of wives of the man, and the proviral load. The only significant predictor of concordance in multivariate analyses when wives with a history of prostitution were excluded was an age of 45 years or older [odds ratio (OR), 8.68; 95% confidence interval (CI), 2.34-32.22]. This tendency was not explained by the length of current marriage. Although husbands with a high proviral load were more likely to have concordant spouses than those with a low proviral load (< 20 copies/10(5) CD4 cells), this association was not statistically significant (OR, 2.59; 95% CI, 0.90-7.46). Among spouses of HIV-2-infected women, none of the examined factors, including previous prostitution or proviral load in the woman, predicted whether the husband was HIV-2-infected.

CONCLUSIONS

Women appear to be more susceptible to HIV-2 infection after 40-45 years of age. The apparent change in susceptibility may be a major reason for the distinctive age pattern of HIV-2 infection observed in West Africa.

[Planning of a museum of medical history--thoughts about why and how]

Plans are being made for a new, national museum of medical history. The need for a central institution to take care of the dimension of time in the development of medical and health science has become more and more obvious in recent years. A new museum should meet the visitors by means of modern exhibition and teaching techniques, but should also serve as a center of competence for historical research on health-related topics. The building of a new University Hospital in Oslo has opened up possibilities of converting one of the old buildings into a museum.

Family risk factors of alcoholism and drinking patterns among non alcoholic women: an inverse relationship? An exploratory study of female employees

95 non alcoholic female employees were personally interviewed and divided into three drinking pattern groups with an increasing level of alcohol consumption: the traditional feminine drinking group (TF) (n = 28), the new feminine drinking group (NF) (n = 37), and the masculine drinking group (M) (n = 30). The groups were compared on family variables which may be regarded as risk factors of alcoholism. The results show an inverse relationship between family risk factors and consumption level, the TF-group having significantly more risk factors than the other two groups. The TF-women more often came from families where the mother and her parents were abstainers, while the father and his parents were more often alcohol abusers or not abstainers. The TF-women were more often attached to their alcoholic fathers as children, while the M-women were more often attached to their mothers. The choice of drinking pattern may be inversely related to the frequency of family risk factors among non alcoholic women.

Depression and alcohol consumption in non alcoholic and alcoholic women. A clinical study

The relationship between level of depression and alcohol consumption was studied in 64 alcoholic women, 80 non alcoholic female psychiatric patients and 72 healthy women, using a clinical, semistructured interview, SADS, SSP and HSCL-58. Among DSM-III depressive women, the alcohol consumption was bimodally distributed. Among healthy women, there was an inverse relationship between depressive symptoms and alcohol consumption. Among non alcoholic women dysthymic patients consumed significantly more than major depressive, subclinically depressed and psychotic non depressive patients, and significantly less than healthy, non depressive women. Among alcoholic women, there was no difference in consumption between major depressives, dysthymics and the other diagnostic groups. The results show that there was no general dose-response relationship between level of depression and alcohol consumption. Anxiety level and personality disorder may be more influential on the alcohol consumption than the level of depression among depressive women.

Dating of late Archaean crustal mobilisation north of Qugssuk, Godthåbsfjord, southern West Greenland

The Taserssuaq tonalite, which is slightly younger than or coeval with the common grey gneisses north of Godthåbsfjord, has yielded a zircon U-Pb age of 2982 ± 7 Ma, and an apparent Rb-Sr whole-rock age of 2882 ± 36 Ma (MSWD = 1.57, initial 87Sr/86Sr = 0.7017). The minerals were isotopicaIly equilibrated at 2500 Ma, and finally biotite was reset at 1700 Ma. The Qugssuk granite, an adjacent granitic mobilisate, has yielded a Rb-Sr age of 2969 ± 32 Ma (MSWD = 1.09, initial 87Sr/86Sr = 0.7020). The intrusion of the Taserssuaq tonalite is probably dated by its zircon age, which broadly correlates it with the Nilk gneisses. Field relations and microtextures strongly suggest that the Qugssuk granite is younger than the Taserssuaq tonalite and post-dates granulite facies metamorphism in the area, and its formation may be related to the extensive retrogression of the Taserssuaq tonalite. Isotopic data may support this interpretation in spite of the apparent inconsistencies in the age values.