Accelerated hyperfractionated radiotherapy combined with induction and concomitant chemotherapy for inoperable non-small-cell lung cancer--impact of total treatment time

Tumour cell proliferation during conventionally fractionated radiotherapy (RT) can negatively influence the treatment outcome in patients with unresectable non-small-cell lung cancer (NSCLC). Accelerated and hyperfractionated RT may therefore have an advantage over conventional RT. Moreover, earlier studies have suggested improved survival with addition of cisplatin-based chemotherapy (CT). We present here the results of combined treatment with induction and concomitant CT and accelerated hyperfractionated RT in a retrospective series of patients with advanced NSCLC. Between August 1990 and August 1995, 90 consecutive patients, aged 42-77 years (median 63 years), with locally advanced unresectable or medically inoperable NSCLC and good performance status were referred for treatment: stage: I 23%, IIIa 37%, IIIb 40%. Patient histologies included: squamous cell carcinoma 52%, adenocarcinoma 34% and large cell carcinoma 13%. The treatment consisted of two courses of CT (cisplatin 100 mg/m2 day 1 and etoposide 100 mg/m2 day 1-3 i.v.), the second course given concomitantly with RT. The total RT dose was 61.2-64.6 Gy, with two daily fractions of 1.7 Gy. A one-week interval was introduced after 40.8 Gy to reduce acute toxicity, making the total treatment time 4.5 weeks. Concerning toxicity, 33 patients had febrile neutropenia, 10 patients suffered from grade III oesophagitis and 7 patients had grade III pneumonitis. There were two possible treatment-related deaths, one due to myocardial infarction and the other due to a pneumocystis carinii infection. The 1-, 2- and 3-year overall survival rates were 72%, 46% and 34%, respectively; median survival was 21.3 months. Fifty-nine patients had progressive disease: 21 failed locoregionally, 29 had distant metastases and 9 patients had a combination of these. Pretreatment weight loss was the only prognostic factor found, except for stage. However, the results for stage IIIb were no different from those for stage IIIa. We conclude that the survival results compare favourably with those of most other studies with a manageable toxicity.

The presence and expression of hetR in the non-heterocystous cyanobacterium Symploca PCC 8002

The filamentous cyanobacteria Symploca PCC 8002 (Symploca) and Trichodesmium spp. fix nitrogen aerobically in the light in a light/dark cycle, without forming specialized thick-walled cells (heterocysts). Even though they do not form heterocysts, we amplified and sequenced a segment of a key regulatory gene in heterocyst differentiation, the hetR gene, from Symploca, Trichodesmium erythraeum and Leptolyngbya PCC 73110 (which fixes nitrogen anaerobically) using degenerate oligonucleotides. The transcriptional level of hetR in Symploca PCC 8002 was examined in relation to nifH expression during nitrogen step-down. The expression pattern of hetR suggests that it was not induced during removal of combined nitrogen, as is the case with the heterocystous cyanobacteria. This is the first report of sequences corresponding to a portion of hetR from within the group of non-heterocystous cyanobacteria.

Gender, marital status and ethnicity. A Swedish retrospective study of criminality, morbidity and mortality among victims of non-fatal firearm injuries

OBJECTIVE

To study gender and ethnic aspects in a population consisting of patients treated for non-fatal firearm injuries at public hospitals in Stockholm, Sweden, during a period of 21 years.

DESIGN

Retrospective study. Ethnicity was defined as being a foreign-born individual or a native Swede. The morbidity and criminality data were analysed with unconditional logistic regression and the mortality data were analysed by a proportional hazard model.

RESULTS

Females and foreign-born persons were more often victims of attempted murder than males or native Swedes. Attempted suicide was more common among native Swedes. Male patients, single persons and Finnish immigrants treated for a firearm injury all showed an increased risk of being registered for criminality or committing a violent crime. There was no difference between native Swedes and foreign-born persons concerning the number of hospitalisations during the follow-up period. Living alone and being of male gender were associated with an increased risk of hospitalisation. Firearm victims, independently of ethnicity, had an increased mortality rate compared to a Swedish population; the standardised mortality ratio (SMR) for males was almost 3 and for females almost 8 compared to the SMR of 1 for the whole Swedish population.

CONCLUSION

Firearm victims constitute a population at risk from social, psychological as well as from medical points of view. The present study shows an association between gender, ethnicity, criminality, and morbidity among firearm victims underlining the importance of ethnic- and gender-specific violence prevention strategies.

The significance of alcohol for violence and accidents

For almost all types of accidents and violence, there is a causal relationship with alcohol intoxication or alcohol abuse. Alcohol may have significance as a risk factor for the perpetrator (culprit, car driver, etc.), as well as for the victim. This is especially clear in cases of violence and assault. Younger males are overrepresented in much of the data that shows causal relationships. A clear dose-response association can be seen in many accident cases concerning both accident risk and severity. The correlation is not as clear in cases of violence. However, the causal relationships between alcohol and accidents or violence may be difficult to evaluate. Factors such as the abuse of other drugs, unemployment, and other sociodemographic factors must be taken into account. The populations studied are often selected, e.g., from emergency departments, pathology units (postmortem data), or related to those epidemiological studies based on interviews. There is often a lack of relevant control data.

Immigration, moving house and psychiatric admissions

This study was designed to elucidate psychiatric admission rates for native Swedes and foreign-born individuals during the period 1991-1994, when Sweden had a great influx of refugees. During the same period, and even earlier, psychiatric in-patient care had been reduced. Tests of differences between Swedes and foreign-born individuals in first psychiatric admission rates were performed using Poisson regressions, and the risk of a readmission was assessed using a proportional hazard model. Foreign-born individuals and native Swedes, both males and females, showed a similar admission pattern with regard to the number of admissions. Foreign-born males under 55 years of age and foreign-born females under 35 years of age had significantly higher admission rates than native Swedes. In total, native Swedes, both males and females, were hospitalized for a significantly longer period than the foreign-born subjects. About 43% of the patients were readmitted. The risk of a readmission was significantly increased among those with a high rate of internal migration. The high admission rates for young foreign-born individuals might be explained by a high incidence of mental illness owing to the trauma of being violently forced to migrate, acculturation difficulties, or unsatisfactory social circumstances such as high unemployment. The shorter hospitalization time could be due to undertreatment or less serious mental illness.

Outcome of combination chemotherapy in extensive stage small-cell lung cancer: any treatment related progress?

During the past two decades many different treatment regimens of combination chemotherapy have been applied in extensive stage small-cell lung cancer (SCLC). This study was carried out to identify whether these modifications have resulted in an improved overall survival for extensive stage during the past two decades. In total, 1111 patients with extensive stage SCLC were included in six consecutive randomised trials in our setting from 1973 until 1992. Of these, 526 patients treated in the early period (1973-1981) were compared with 585 patients treated in the late period (1981-1992) with respect to pretreatment prognostic factors, staging, treatment and outcome. No change in the distribution of prognostic factors was detected and the frequency of patients with extensive stage was equal in the two periods, and no difference in overall response rates and survival was observed (P = 0.49). Median survival in the two periods was 208 days and 215 days, respectively. No stage migration or treatment-related improved outcome was observed in extensive disease. We suggest restricting aggressive treatment to patients with favorable prognosis and long-term survival as a realistic aim.

Quality of life and survival in patients with advanced non-small cell lung cancer receiving supportive care plus chemotherapy with carboplatin and etoposide or supportive care only. A multicentre randomised phase III trial. Joint Lung Cancer Study Group

The aim of the present trial was to evaluate the effects of chemotherapy on the quality of life and survival of patients with advanced non-small cell lung cancer (NSCLC) (stage IIIB or IV). In a controlled multicentre trial, patients were randomised to receive supportive care only or supportive care plus chemotherapy. Chemotherapy consisted of intravenous (i.v.) carboplatin 300 mg/m2 on day 1 and etoposide 120 mg/m2 orally on days 1-5 every 4 weeks for a maximum of eight courses. Quality of life was measured at randomisation and prior to each treatment course and at corresponding 4-week intervals in the control arm, using the EORTC QLQ-C30 + LC13 questionnaire. 48 patients were randomised (supportive care 26, chemotherapy 22), being eligible for comparative analyses. Another 102 patients, 97 of which received chemotherapy, were subsequently included in the study on an individual treatment preference basis. Data from these patients were used for confirmative purposes. Patients in the chemotherapy group reported better overall physical functioning and symptom control compared with the supportive care group. Group differences were smaller within the psychosocial domain, although trends were seen in favour of the chemotherapy group. No significant differences were seen in favour of the supportive care group, except for hair loss. Median survival times were 29 weeks in the chemotherapy group versus 11 weeks in the supportive care group, and 1-year survival rates were 28% versus 8%. Quality of life and survival outcomes were similar in the randomised and non-randomised patients receiving chemotherapy. No treatment-related deaths occurred. In conclusion, treatment with carboplatin and etoposide can improve both the quality of life and the survival of patients with advanced NSCLC.

A 9-year longitudinal study of reported oral problems and dental and periodontal status in 70- and 79-year-old city cohorts in northern Sweden

Before 1981 no representative studies of oral health in an elderly population in northern Sweden had been presented, and longitudinal studies of oral health in the aging person were in general rare. Thus the aim of this study was to investigate longitudinal changes in oral health in a representative sample of an elderly city population in northern Sweden. Reported oral problems and treatment needs were noted, and dental and periodontal status was registered in clinical examinations. The frequency of reported annual dental visits and of being called by the dentist increased in the younger but not in the older cohort during the 9-year period. In 1990 all the 79- and 88-year-olds with annual visits reported that they were recalled by the dentist. The clinical investigation showed an increasing amount of tooth loss, root caries, and periodontal disease with increasing age. Among dentulous persons 1.7 teeth per subject were lost from 1981 to 1990 in the younger cohort, compared with 2.6 teeth per subject in the older cohort. The number of sound teeth decreased very little in the younger cohort (from 3.44 to 3.34) but more evidently in the older cohort (from 3.47 to 2.65) during the 9-year period. The frequency of surfaces with attachment level > 3 mm increased statistically significantly from 1981 to 1990 in the older cohort. Subjects with annual visits had in general fewer oral problems.

Perforation of continent urinary reservoirs. Scandinavian experience

In a questionnaire survey of urological departments in Sweden, Denmark, Finland and Norway, 20 episodes of perforation of continent urinary pouches were found to have occurred in 18 patients, representing an incidence of 1.5%. This complication occurred with ileal as well as colonic segments, without predilection. In one case there was perforation of an appendiceal outlet. Noticeable findings were (a) a long delay (median 10h) to treatment and (b) that investigational procedures such as enterocystography and enterocystoscopy were not commonly employed. Treatment of this potentially lethal complication was by oversewing the perforation, and there were no subsequent major complications. This complication should be strongly suspected if a patient with continent urinary reconstruction presents with acute abdominal pain.

Somatic morbidity in schizophrenia--a case control study

Several studies have stated that rates of premature mortality of schizophrenic patients are increased. Morbidity, however, is less often examined. In the present study we have compared the number of hospitalizations due to different somatic diseases in 775 schizophrenic patients with their sex- and age-matched controls. The total number of patients hospitalized due to somatic diseases was significantly greater among the schizophrenics than among the controls. In the former group, 523 out of 775 and in the latter 373 out of 775 had been admitted at least once during a 15 y period. If the schizophrenic patients who also had been diagnosed as substance abusers at least once were excluded from the analysis there was still a significant difference between the remaining patients and their controls. The patients exhibited an over-morbidity in almost all diagnostic groups, the most prominent excess morbidity appeared in the groups of injuries and symptoms, signs and ill-defined conditions, when compared with the controls. Even if there are confounding factors which should be taken into consideration when interpreting morbidity data, the pattern of excess morbidity among schizophrenic patients found in this study is so definite that it cannot be considered merely coincidental.

Evidence for redox regulation of the transcription factor NtcA, acting both as an activator and a repressor, in the cyanobacterium Anabaena PCC 7120

NtcA has been identified as a nitrogen-responsive regulatory protein required for nitrogen assimilation and heterocyst differentiation in cyanobacteria. It is proposed that NtcA functions through the formation of DNA-protein complexes with its specific target sequence within the promoter regions of the regulated genes. In vitro, NtcA of Anabaena PCC 7120 binds to upstream regions of the genes whose products are involved in nitrogen assimilation, but also to the upstream region of rbcLS (carbon-fixation gene), xisA (encoding a site-specific recombinase expressed during heterocyst differentiation) and ntcA (encoding NtcA itself). However, the mechanism by which NtcA serves as a critical regulator for such diverse processes is not understood. With the use of electrophoretic mobility shift assays, NtcA from Anabaena PCC 7120 was here shown to interact with the promoter sequence of the gor gene, encoding glutathione reductase, thereby providing a novel example of NtcA's acting as a repressor, previously found only for the rbcLS gene. Furthermore we demonstrate that the binding of DNA by NtcA is regulated in vitro by a redox-dependent mechanism involving cysteine residues of the NtcA protein. These findings suggest that NtcA is a transcriptional regulator that responds not only to the nitrogen status but also to the cellular redox status, a function that might be particularly significant during heterocyst differentiation.

Sex hormones during alcohol withdrawal: a longitudinal study of 29 male alcoholics during detoxification

It is a well-known fact that alcohol affects sex hormone levels in males. Even in the absence of liver dysfunction, there is still a direct toxic effect of ethanol on testosterone synthesis resulting in acutely decreased values. This study is based on 29 male alcoholics without severe signs of liver disease treated on the alcohol detoxification ward at Huddinge hospital in Stockholm, Sweden during 1995. The aim was to study levels of sex hormones in male alcoholics during detoxification with benzodiazepines and after 3 weeks of sobriety. Blood samples were taken three times: one day after admission (day 2) when the patient was sober, at discharge (day 5) and after 3 weeks of sobriety (day 21). Levels of testosterone and sex hormone-binding globulin (SHBG) showed the same pattern during detoxification and follow-up. They were both low, but generally within normal limits, on days 2 and 5, but raised after 3 weeks of sobriety. Follicle stimulating hormone (FSH) and luteinizing hormone (LH) were initially high, but were substantially depressed during detoxification. Levels of FSH recovered after 3 weeks, whereas LH remained at the same level. Most patients exhibited generally low levels of both FSH and LH, however. Levels of oestrone decreased steadily. There were no correlations between levels of sex hormones and the number of milligrams of oxazepam administered to the patients during detoxification either at admission, at discharge or at follow-up. In summary, the endocrinological response to alcohol intake is complex. This study suggests that the duration of endocrinological recovery after drinking is a quite long-lasting process, that different hormones need different times to recover and that the normal glandular-pituitary feed-back processes may be partly put out of order.

Responsibility for crime and injury when drunk

The aim of this paper is to highlight the complexity in the connection between alcohol intoxication and responsibility for crime from a multidisciplinary approach comprising medical, legal and criminological perspectives. There is no doubt that there is a connection between violent behaviour and alcohol intoxication. However, several investigations show that alcohol heightens aggressiveness only when the drunken person is provoked. A case which may serve as a model when discussing legal responsibility for acts carried out when drunk is outlined. Ethical considerations are discussed and exemplified concerning the motive, as well as the principles, of punishing an intoxicated perpetrator. However, there are no definite solutions concerning what is right or wrong, and each reader will have his own opinion, which may well differ from that of the author.

Accidental firearm injury in childhood--a predictor of social and medical outcome?

This paper reports register data on a consecutive series of 141 children and teenagers hospitalized due to firearm injuries during a 21-year period in a community with restrictive firearm laws. Most of the injuries were minor and hospitalization was short. Shot by an air gun resulting in an eye injury was the most frequent reason for hospitalization. The patients hospitalized due to firearm injuries were compared with a control group composed of 141 individuals matched pair-wise for sex and age. The total morbidity during the follow-up period of on average 10 years was higher among patients compared with controls concerning both somatic diseases and injuries. All cases of severe psychopathology were found in the patient group. Criminality was higher among patients compared with controls and the former were younger at the time of the first crime compared with the latter. This study indicates that, irrespective of firearm laws, young people suffering from firearm injuries, even if the injury is classified as accidental, run a higher risk of becoming psychosocially disadvantaged and criminal as adults. This makes preventative measures highly necessary not only from a societal point of view, but also to avoid individual suffering in this high-risk group of youngsters.

A randomized study of gemcitabine monotherapy versus etoposide/cisplatin in the treatment of locally advanced or metastatic non-small cell lung cancer

This randomized, multinational, multicenter study was designed to determine the response rate of gemcitabine monotherapy and cisplatin/etoposide combination therapy in chemotherapy-naive patients with advanced, recurrent, and/or metastatic non-small cell lung cancer (stage IIIA [if inoperable], IIIB, or IV). One group of patients received gemcitabine 1,000 mg/m2 intravenously once a week for 3 weeks (days 1, 8, and 15) followed by a 1-week rest period. The second group received cisplatin 100 mg/m2 intravenously on day 1 of each 28-day cycle in combination with etoposide 100 mg/m2, administered on days 1, 2, and 3 following the cisplatin infusion. Each patient was allowed to remain on study up to a maximum of six cycles. The planned interim analysis was based on the 117 patients in the study, 116 of whom were randomized up until November 20, 1995. The efficacy analysis was performed on the 107 patients who had data from a minimum of two cycles, whereas the safety analysis was based on data from all 116 randomized patients. In the gemcitabine arm there were 10 of 52 (19%) partial responders; in the cisplatin/etoposide arm there were four (7%) of 54 partial responders. There was a statistically significant difference in the response rates between the two arms, with a 95% confidence interval of 0.6% to 32.1% (P = .040). The median time to progressive disease was 4.2 months for gemcitabine patients and 3.7 months for cisplatin/etoposide patients. There was significantly more alopecia and nausea and vomiting in the cisplatin/etoposide arm compared with the gemcitabine arm, as well as two cases of neutropenic sepsis in the cisplatin/etoposide arm. These data indicate that single-agent gemcitabine is at least as effective as the combination of cisplatin/etoposide in the treatment of advanced non-small cell lung cancer and has an improved safety profile.

Single-agent gemcitabine versus cisplatin-etoposide: early results of a randomised phase II study in locally advanced or metastatic non-small-cell lung cancer

BACKGROUND

This randomised study was designed to determine the response rate survival and toxicity of single-agent gemcitabine and cisplatin-etoposide in chemo-naïve patients with locally advanced or metastatic non-small-cell lung cancer.

PATIENTS AND METHODS

Gemcitabine 1,000 mg/m2 was given as a 30 min intravenous infusion on days 1, 8, 15 of a 28-day cycle, cisplatin 100 mg/m2 on day 1, and etoposide 100 mg/m2 on days 1 (following cisplatin), 2 and 3. Major eligibility criteria included histologically confirmed non-small-cell lung cancer, measurable disease, Zubrod PS 0-2; no prior chemotherapy, no prior radiation of the measured lesion, and no CNS metastases.

RESULTS

146 patients were enrolled, 71 patients on gemcitabine and 75 patients on cisplatin-etoposide. Patient characteristics were well matched across both arms. Sixty-six gemcitabine patients and 72 cisplatin-etoposide patients were evaluable. Partial responses were seen in 12 gemcitabine patients (18.2%; 95% CI: 9.8-30) and 11 cisplatin-etoposide patients (15.3%; 95% CI: 7.9-25.7). Early indications show no statistical differences between the two treatments with respect to time to disease progression or survival. Haematological and laboratory toxicity were moderate and manageable. However, hospitalisation because of neutropenic fever was required for 6 (8%) cisplatin-etoposide patients but not for any gemcitabine patients. Non-haematological toxicity was more pronounced with significant differences in nausea and vomiting (grade 3 and 4: 11% gemcitabine vs. 29% cisplatin-etoposide; despite the allowance for 5-HT3 antiemetics during the first cycle of cisplatin-etoposide), and alopecia (grade 3 and 4:3% gemcitabine vs. 62% cisplatin-etoposide).

CONCLUSIONS

In this randomised study, single-agent gemcitabine was at least as active but better tolerated than the combination cisplatin-etoposide.

Theft behaviour and its consequences among kleptomaniacs and shoplifters--a comparative study

This study is based on interviews with 37 persons fulfilling the DSM-IV criteria for kleptomania recruited through newspaper advertisements, and on 50 shoplifters interviewed directly after apprehension. Our hypothesis was that there are no absolute borders between 'pure' kleptomania according to DSM-IV and other forms of shoplifting. When asked about the latest case of shoplifting, one fifth of the shoplifters reported not having stolen the item for personal use and had later discarded it. A quarter of the kleptomaniacs reported ambivalence when asked if they needed the item in question. The degree of reported impulsivity and a feeling of not being oneself at the time of the theft was the same in the two groups. The two groups also estimated their degree of impulsivity, planning, thrill, relief, vengeance, need, pleasure on a Visual Analogue Scale (VAS) as well as the degree of psychiatric imbalance on the latest theft occasion. These estimates showed that there were no differences between the groups concerning the degree of planning, psychological imbalance and the need for the stolen item in question. The kleptomaniacs rated a feeling of inner tension before the theft higher than the shoplifters. The same was true concerning a feeling of relief during the theft and impulsivity. However, the shoplifters also rated high on all these items. Altogether, these findings support our hypothesis that many shoplifters, even if they do not fulfill all DSM criteria for kleptomania, may constitute a significant medical problem and should be offered support and treatment. Anti-depressants as well as the educational programmes developed by the Shoplifters Alternatives may be effective not only in cases of kleptomania but also for more unselected groups of non-professional shoplifters.

The influence of ethnicity and social and demographic factors on Swedish suicide rates. A four year follow-up study

The aim of this follow-up study, based on individual data, was to analyse the influence of ethnicity and other demographic and social factors on suicide rates between 1986 and 1989 for the Swedish population according to the 1985 census. The data were analysed by sex and age using a Poisson regression model. During the study period there were 8,310 cases of suicide and undetermined death. The main finding in this study was that ethnicity, defined as being foreign-born, was a significant risk factor for suicide in both sexes and in all age groups except for males aged 30 to 49 years. Not being married was a significant risk factor in all age groups for both males and females. Form of tenure, i.e. living in rented flats, was a significant risk factor for suicide in middle-aged males and females, while over-crowding was a risk factor for middle-aged males and for the over 50's of both sexes. As ethnicity, defined as foreign-born, was an important variable related to suicide, the association between different ethnic groups and suicide will be evaluated in forthcoming studies.

Ethnicity, social factors, illness and suicide: a follow-up study of a random sample of the Swedish population

The aim of this longitudinal study was to determine the influence of ethnicity, social factors and self-reported long-term somatic and psychiatric illness on suicide in a random sample of the Swedish population. The study is based on face-to-face interviews conducted between 1979 and 1985 with a random sample of the Swedish population consisting of 47,762 Swedish-born subjects and 4407 individuals born elsewhere. The sample has been followed via register data concerning cases of suicide (suicides and undetermined deaths) until 31 December 1993. In total, 102 males and 46 females committed suicide prior to this date. Living alone and self-reported somatic illness with impaired health status were very strong risk factors for suicide, with risk ratios of 2.15 (CI, 1.51-3.05) and 1.80 (1.19-2.72), respectively. Ethnicity, defined as being born outside Sweden, had a risk ratio of 1.87 (1.18-2.97) in a model controlled for sex and age. However, this risk decreased with increasing age in the final model. Furthermore, an increased risk of suicide was found among female subjects living in rented flats and among male subjects irrespective of form of tenure, as well as among residents of large urban areas. Respondents with a self-reported long-term psychiatric illness with impaired health status also had a high risk of suicide, which decreased with increasing age. The main finding of this study is that somatic diseases and psychiatric disorders, which are known risk factors for suicide, may be revealed in surveys conducted by interviewers without medical training. Thus self-reported psychiatric and somatic illness appear to have a good potential for predicting suicide, even if the prevalence of psychiatric disorders is to some extent underestimated.