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Real-world outcomes of ipilimumab plus nivolumab in esophageal squamous cell carcinoma: a multi-institutional large cohort study.

BACKGROUND: Combination immune checkpoint inhibition with ipilimumab plus nivolumab (NIVO + IPI) has shown promising efficacy in advanced esophageal squamous cell carcinoma (ESCC) in the CheckMate648 trial. However, real-world evidence regarding its safety, efficacy as first-line therapy, and host-related biomarkers relevant to immunotherapy remains limited. METHODS: This multicenter retrospective study evaluated a large cohort of 111 patients with unresectable advanced or recurrent ESCC who received first-line NIVO + IPI therapy. Treatment response, treatment-related adverse events, and prognostic factors were analyzed. RESULTS: The objective response and disease control rates in cases with target lesions were 44.0% and 70.7%, respectively. Treatment-related adverse events ≥ Grade 2 occurred in 58 (52.3%) patients, including one Grade 4 event (type 1 diabetes) and two Grade 5 events (biliary infection and myocarditis). The median overall survival (OS) and progression-free survival were 22 months (95% confidence interval [CI]: 13-not reached) and 5 months (95% CI 3-8), respectively. OS was significantly affected by lymph node metastasis in unresectable advanced disease and by liver metastasis in recurrent disease. Multivariate analysis of OS identified the C-reactive protein-to-albumin ratio (CAR), a marker of host immune-inflammatory status, as the only independent prognostic parameter (hazard ratio = 2.99, 95% CI 1.35-6.63, P = 0.0071). CONCLUSIONS: In this large real-world cohort, first-line NIVO + IPI therapy demonstrated meaningful clinical activity and an acceptable safety profile in advanced ESCC. Treatment outcomes varied according to metastatic patterns, suggesting an influence of organ-specific immune microenvironments, and CAR emerged as a simple and robust prognostic biomarker. These findings support the real-world applicability of dual immune checkpoint blockade and highlight the importance of host immune context in patient selection.

Humans↗

Maribor General Hospital from its foundation until World War II.

The author describes the history of Maribor General Hospital from its foundation in 1799 until the beginning of World War II. In 1799 the magistrate of the town of Maribor issued a memorandum regarding the establishment of a town hospital in the renovated building of the town hospice, providing space for 24 patients. The work of the hospital was carried out in the former hospice building until 1855. In the period between its establishment and eventual relocation 26 beds were added. The last two decades of the hospital's operation at the original location were marked by the assiduous work of the town's physicist, Dr. Anton Kuker. In the first half of the 19th century, the population of Maribor grew rapidly as a consequence of the construction of the Southern Railway. The town authorities therefore purchased the Prosenjak family villa in the Magdalena suburbs and relocated the hospital to it in 1855, providing 28 rooms for 110 patients. For a whole century, the care of patients was taken over by the Daughters of Charity of Saint Vincent de Paul. The hospital was soon admitting over 1000 patients a year, the most common complaints being pulmonary catarrh, gastritis and fever. In 1872, when the Master of Surgery Feliks Ferk joined the hospital, the internal "medical" and the "external" surgical departments were formed. Although medical studies were not easily accessible, there were a number of Slovene physicians working in the hospital and the town in that period. In the last decades of the 19th century, the hospital was often renovated and enlarged. The infrastructure (telephone, water supply system, heating, lighting) had also been modernized before World War I. In 1914, the first X-ray apparatus was purchased. Between the wars, the hospital's development was boosted by recruitment of the Slovene physicians Ivan Matko, Mirko Cernic, Janko Dernovsek and Hugon Robic. The initial external and medical departments split into several departments: internal medicine, surgery, dermatovenereology, gynecology and obstetrics, infectious diseases, X-ray institute, autopsy department, and pulmonary department. A department of otology and ophthalmology was also founded. After the disintegration of the Austro-Hungarian Empire, Maribor Hospital was no longer overshadowed by the formerly dominant regional hospital in Graz in present-day Austria. A greater number of patients entailed more rapid professional development. At the beginning of World War II, the hospital comprised six departments, two institutes and a dispensary, and had an elaborate administrative structure with numerous support services.

Delivery of Health Care↗

Convention on psychotropic substances, 1971. The role and responsibilities of the World Health Organization.

1. The world community has realized as early as the beginning of this century that collective action between nations is to be more effective in controlling drugs of abuse. A number of international drug control treaties including the Single Convention on Narcotic Drugs, 1961, controls drugs primarily obtained from plant material (opium, coca leaves and cannabis) and synthetic analogues of morphine. The Convention on Psychotropic Substances, 1971, is aimed at controlling psychotropic substances and was formulated in Vienna in 1971. 2. The Convention on Psychotropic Substances, 1971, lays a great responsibility on the World Health Organization to recommend to the United Nations Commission on Narcotic Drugs notifications initiated by the World Health Organization, or by a party to the Convention, regarding international control.

International Cooperation↗

Waking up to shell shock: psychiatry in the US military during World War II.

During World War I, military officers encountered a new and puzzling phenomenon: soldiers emerged from the trenches stuttering, crying, trembling and at times were even paralysed and blind. Those in charge were convinced these soldiers were cowards or malingerers who deserved stern discipline or to be court-martialled. A number of physicians, by contrast, initially assumed that these alarming symptoms resulted from close exposure to explosions and called it shell shock. Later, they realized that it was a psychological reaction and came up with psychotherapeutic treatments. But it was only in World War II that military psychiatrists, particularly those in the USA, began to implement treatment methods for this phenomenon in a systematic way. Their thinking and the treatments they devised had significant consequences for the future of American psychiatry, which in turn influenced the development of psychiatry and military psychiatry world-wide.

Combat Disorders↗

Neurology training programs worldwide: a world federation of neurology survey.

This World Federation of Neurology (WFN) project was aimed at collecting data about the number and nature of neurology residency programs in different countries. A survey was sent to delegates from the neurology societies belonging to the World Federation of Neurology. Over 6200 physicians graduating from neurology training programs each year were identified. Many regions of the world, including those with the highest prevalence of disorders of the nervous system, have few or no post-graduate neurology training programs. Adequate teaching in psychiatry, neuroradiology, and neuropathology is lacking in many programs. Training in a large number of countries is hampered by inadequate access to books, journals, and the internet. The global distribution of postgraduate neurology training programs is unrelated equally to the burden of neurological diseases or to the need for their treatment and prevention.

Data Collection↗

Thymoma: a clinicopathologic study based on the new World Health Organization classification.

OBJECTIVE: This study explored the relationship between the histologic subtype of thymoma according to the new World Health Organization histologic classification and the clinical findings, as well as the prognostic significance of the classification. METHODS: A total of 130 patients with thymoma, who underwent resection at the National Cancer Center Hospital, Tokyo, from 1962 to 2000, were studied retrospectively. The histologic subtype of thymoma was determined according to the new World Health Organization histologic classification. The stage was also determined according to a modified Masaoka's classification as stage I, II, III, IVa, or IVb. To determine the factors that may affect the prognosis of thymoma, a multivariate analysis with Cox's proportional hazards regression model was performed. RESULTS: The distribution of histologic subtype was type A (n = 18), type AB (n = 56), type B1 (n = 15), type B2 (n = 29), and type B3 (n = 12). A close correlation was seen between the histologic subtype and stage (P =.000). The overall survivals at 5 and 10 years were 92% and 91%, respectively. The 5- and 10-year survivals according to stage were 100% and 100% (stage I, n = 40; stage II, n = 54), 81% and 76% (stage III, n = 25), and 47% and 47% (stage IV, n = 11), respectively. The difference in survival between stage III and stage IV was significant (P =.000). Patients with type A or AB thymoma demonstrated a 100% survival at both 5 and 10 years. Recurrences were seen in 12 patients with complete resection. According to a multivariate analysis, tumor size (P =.001), completeness of resection (P =.002), histologic subtype (P =.011), and stage (P =.00) were significant prognostic factors. CONCLUSION: The World Health Organization histologic classification significantly correlated with the clinical stage. Tumor size, completeness of resection, histologic subtype, and stage predicted the prognosis of thymoma.

Adult↗

The world report on violence and health.

In 1996, the World Health Assembly declared violence a major public health issue. To follow up on this resolution, on Oct 3 this year, WHO released the first World Report on Violence and Health. The report analyses different types of violence including child abuse and neglect, youth violence, intimate partner violence, sexual violence, elder abuse, self-directed violence, and collective violence. For all these types of violence, the report explores the magnitude of the health and social effects, the risk and protective factors, and the types of prevention efforts that have been initiated. The launch of the report will be followed by a 1-year Global Campaign on Violence Prevention, focusing on implementation of the recommendations. This article summarises some of the main points of the world report.

Global Health↗

[The World Health Organization Report 2000: a politically incorrect computer game].

The World Health Organization Report 2000 is aimed at supporting an evidence-based development of health care systems in the world. The report has brought about a significant political and academic debate. This article reviews the contribution of the WHO Report to current health care policy, as well as analyzes and comments the main published critiques. Through a commented compilation of the health care reforms implemented over the last fifteen years in the world, WHO shifts radically its traditional position supporting now universal access to health care and a strong government's conduction role, but within a financial risk sharing environment, public and private co-operation and deregulation of the public management of health care institutions. WHO ranks in this report the 191 countries according to their health care systems' goal attainment and performance using a very weak, obscure and artificial methodology which has been opposed internationally. WHO is, however, committed to continue this initiative without apparently any major changes in the general and methodological approach.

Annual Reports as Topic↗

Sixty years later: post-traumatic stress symptoms and current psychopathology in former German children of World War II.

BACKGROUND: The aim of the study was to determine the amount of trauma impact, post-traumatic stress symptoms and current psychopathological distress in a sample of former German children of World War II. METHODS: 93 participants were recruited through the local press, and assessed using the modified Post-traumatic Diagnostic Scale (PDS) and the Symptom Checklist (SCL-90-R). RESULTS: Subjects reported a high qualitative and quantitative degree of trauma exposure. 13.8% reported PTSD-related symptoms after the war, and 10.8% reported current symptoms. PTSD symptoms after World War II were significantly correlated with current psychopathological distress. CONCLUSIONS: In line with other studies, our data document a high degree of trauma exposure during warchildhood. In comparison with other studies on PTSD in warchildren, there is a persisting high prevalence of war-associated PTSD symptoms in this sample. Despite some methodological limitations, our data underline the urgent need for further studies on the ageing group of former children of World War II.

Age Factors↗

The World Oral Health Report 2003: continuous improvement of oral health in the 21st century--the approach of the WHO Global Oral Health Programme.

Chronic diseases and injuries are the leading health problems in all but a few parts of the world. The rapidly changing disease patterns throughout the world are closely linked to changing lifestyles, which include diets rich in sugars, widespread use of tobacco, and increased consumption of alcohol. In addition to socio-environmental determinants, oral disease is highly related to these lifestyle factors, which are risks to most chronic diseases as well as protective factors such as appropriate exposure to fluoride and good oral hygiene. Oral diseases qualify as major public health problems owing to their high prevalence and incidence in all regions of the world, and as for all diseases, the greatest burden of oral diseases is on disadvantaged and socially marginalized populations. The severe impact in terms of pain and suffering, impairment of function and effect on quality of life must also be considered. Traditional treatment of oral diseases is extremely costly in several industrialized countries, and not feasible in most low-income and middle-income countries. The WHO Global Strategy for Prevention and Control of Noncommunicable Diseases, added to the common risk factor approach is a new strategy for managing prevention and control of oral diseases. The WHO Oral Health Programme has also strengthened its work for improved oral health globally through links with other technical programmes within the Department for Noncommunicable Disease Prevention and Health Promotion. The current oral health situation and development trends at global level are described and WHO strategies and approaches for better oral health in the 21st century are outlined.

Adolescent↗

The World Federation of Hemophilia: 40 years of improving haemophilia care worldwide.

In 2003, the World Federation of Hemophilia marks its 40th anniversary. Established in 1963 by Frank Schnabel, a person with hemophilia from Montreal, Canada, the WFH has grown into its role as an independent, not-for-profit representative of the global haemophilia community. Since then, its biannual world congresses have provided an opportunity to exchange information on research and treatment. Today, more than 3,000 delegates attend these congresses. Until the early 1990s, the WFH's other major function was the International Hemophilia Training Centre programme, offering training fellowships and workshops to medical and paramedical staff from developing countries. In 1982, AIDS was reported in people with haemophilia who had received tainted blood products. The WFH developed task forces and committees to monitor safety and supply issues and set up the Global Forum on the Safety and Supply of Treatment Products. In the mid-1990s, twinning programmes were established for treatment centres and national haemophilia organizations. Twinning facilitates the exchange of training, coaching, and expertise. In the late 1990s, the WFH expanded and began working with local organizations and health authorities in a number of countries to improve the diagnosis and care of persons with hemophilia. The federation currently has ongoing projects in 25 developing countries. On World Hemophilia Day, April 17, 2003, the WFH launched the Global Alliance for Progress (GAP) in haemophilia which aims to double the number of people with haemophilia diagnosed and receiving treatment in up to 40 developing countries over a 10-year period.

Acquired Immunodeficiency Syndrome↗

The state of the world's pharmacy: a portrait of the pharmacy profession.

Pharmacy is the health profession that has the responsibility for ensuring the safe, effective and rational use of medicines. As such it plays a vital part in the delivery of health care world-wide. However, there remain wide variations in the practice of pharmacy, not only between countries but also within countries. Nevertheless, in recent years there has been significant convergence, driven by a number of key factors. These include World Health Organization declarations concerning the role of pharmacists, changes in the political climate of many countries, and the pursuit by pharmacists themselves of the goals of medicines management and pharmaceutical care. This paper considers the main activities undertaken by pharmacists, describes their education and regulation, and explores the current state of pharmacy around the world.

Developing Countries↗

The Expanded Programme on Immunization of the World Health Organization.

In the developing world today, less than 20% of children are immunized against diphtheria, pertussis, tetanus, tuberculosis, measles, and poliomyelitis. Consequently, these diseases kill 10 children and disable 10 more each minute. To address this problem, the World Health Organization created the Expanded Programme on Immunization (EPI), with the goal of reducing morbidity and mortality by making immunization services available for all children of the world by 1990. This goal will be difficult to achieve. Information systems and immunization services themselves need to be strengthened. This goal will require commitments by the developing countries of human resources and commitments by developing and developed countries of financial support. Commitment is also needed by parents, who need to be informed that death and disability from these diseases can disappear if their children are immunized. Can these commitments be obtained? There is no choice but to try, for few appeals can be made as powerfully. The EPI cannot be permitted to fail.

Community Health Services↗

Psychiatry and race during World War II.

Although the American literature on "war neuroses" expanded during World War II, psychiatrists remained more interested in dramatic instances of "combat fatigue" than in the problems of soldiers who broke down far from the field of battle. This bias in the medical literature shaped both diagnosis and treatment. It had an especially powerful effect on African American soldiers who, in the "Jim Crow" army of World War II, were assigned in disproportionate numbers to service units. When military neuropsychiatrists did write about troubled young African Americans, many revealed a racial conservatism that was surprising given the liberal environmentalist paradigm of the day. (Here, a particularly useful source is the two-volume history of Neuropsychiatry in World War II, produced by the Medical Department of the U.S. Army.) The major challenge to such views came from the National Medical Association (NMA). Despite its many criticisms of military medicine, the NMA argued that African American soldiers and veterans needed more, not fewer, psychiatric services. NMA members also joined their white counterparts in the campaign to diminish the stigma of mental illness, especially among the families of soldiers returning home. We need more investigation of the subsequent history of race and psychiatry, especially within the Veterans Administration.

Black or African American↗

Reclassification of cystic bronchioloalveolar carcinomas to adenocarcinomas based on the revised World Health Organization Classification of Lung and Pleural Tumours.

The objective of this study was to evaluate the radiologic-pathologic correlation of cystic change in cases of bronchioloalveolar carcinoma (BAC) using the 1999 revised World Health Organization Classification of Lung and Pleural Tumours. A total of 304 cases diagnosed as BAC before 1999 were reviewed retrospectively for radiologic findings of cystic change (n = 31). Of these, 20 had adequate clinical, pathologic, and radiologic material available for review. Patient demographics and history; the method, location, and size of specimen biopsy; and pathology reports were evaluated. A pulmonary pathologist reviewed the microscopic findings to confirm the diagnosis based on the 1999 World Health Organization criteria. Chest radiographs (n = 20) and computed tomographic scans (n = 11) were analyzed for location, size, and multiplicity of pulmonary nodules, masses, consolidations, or characterization of cystic change. Associated findings of lymphadenopathy, pleural effusion, atelectasis, and underlying lung disease were noted. There were 10 men and 10 women (mean age, 49.3 years) who participated in the study. Eleven were symptomatic. Pathologic review, based on the revised World Health Organization classification, yielded the diagnosis of adenocarcinoma (n = 14); adenocarcinoma, possible BAC (n = 4); and BAC (n = 2). Radiologically, adenocarcinoma (n = 14) manifested as a solitary pulmonary nodule/mass (n = 5) or consolidation (n = 6) and as multifocal mixed disease (n = 3) with solitary (n = 8) or multicystic (n = 6) change. Adenocarcinoma, possible BAC (n = 4) manifested as multifocal and multicystic consolidations (n = 2) or mixed disease (n = 1) and as a solitary cystic mass (n = 1). BAC (n = 2) manifested as a cystic mass (n = 1) and as multifocal multicystic mixed disease (n = 1). Most cases of BAC with radiologic cystic change were reclassified as adenocarcinoma. The radiologic features of BAC may need to be redefined in light of the current diagnostic criteria to help identify patients with limited and potentially curable disease.

Adenocarcinoma↗

Medical education in the light of the World Health Organization Health for All strategy and the European Union.

Most governments and health professionals clearly recognize that the education of professionals must be adapted to practice in order to meet the needs of the population and of health systems. The role of medical schools, in a world where specialization is becoming a requirement to practice and is highly regulated, needs to be redefined. Medical schools need to transform their specialist training into a community-oriented, generalist education. In this light, the article analyses the European Union directives on medical education, and the recommendations of the World Health Organization (to meet the challenges of the Health for All Policy) and the World Federation for Medical Education. All are designed to reorient medical education to meet the health needs of the population, to reduce health costs, to ensure quality and to permit the free movement of sufficiently qualified health professionals.

Curriculum↗

Epilepsy Care in the World: results of an ILAE/IBE/WHO Global Campaign Against Epilepsy survey.

PURPOSE: Information about existing resources available within the countries to tackle the huge medical, social, and economic burden caused by epilepsy is lacking. To fill this information gap, a survey of country resources available for epilepsy care was conducted within the framework of the ILAE/IBE/WHO Global Campaign Against Epilepsy. METHODS: The study represents a major collaborative effort involving the World Health Organization (WHO), the International League Against Epilepsy (ILAE) and the International Bureau for Epilepsy (IBE). RESULTS: Data were collected from 160 countries representing 97.5% of the world population. The information included availability, role, and involvement of professional and patient associations for epilepsy, epilepsy treatment and services including antiepileptic drugs, human resources involved in epilepsy care, teaching in epileptology, disability benefits, and problems encountered by people with epilepsy and health professionals involved in epilepsy care. The data confirm that epilepsy care is grossly inadequate compared with the needs in most countries. In addition, large inequities exist across regions and income groups of countries, with low-income countries having extremely meager resources. Complete results of this survey can be found in the Atlas: Epilepsy Care in the World. CONCLUSIONS: The data reinforce the need for urgent, substantial, and systematic action to enhance resources for epilepsy care, especially in low-income countries.

Cross-Cultural Comparison↗

The World Health Organization International Consortium in Psychiatric Epidemiology (ICPE): initial work and future directions -- the NAPE Lecture 1998. Nordic Association for Psychiatric Epidemiology.

OBJECTIVE: To provide an overview of the World Health Organization (WHO) International Consortium in Psychiatric Epidemiology (ICPE), to introduce the World Mental Health 2000 (WMH2000) Initiative and to discuss methodological issues that the ICPE is grappling with in planning the WMH2000 Initiative. METHOD: We review the history, mission and organization of the ICPE and the rationale behind the WMH2000 Initiative. We review methodological research underlying major design and implementation decisions regarding the WMH2000 surveys. RESULTS: The ICPE is an international consortium created to facilitate cross-national comparative epidemiological research using the WHO Composite International Diagnostic Interview (CIDI). The first-phase core ICPE surveys, which we are currently analysing, include over 33 000 interviews in seven countries, with an additional set of over 30 000 interviews in seven countries ready to be added to the master file within the next year. The WMH2000 Initiative will include a third series of CIDI surveys that include an anticipated 100000 additional interviews in 10 countries. A series of complex methodological challenges confront us in designing and implementing the WMH2000 surveys. These include issues in the conceptualization and measurement of impairment and disablement, the implementation of standardized quality control procedures across countries, and the blending of epidemiological and clinical interviewing methods to obtain a valid cross-national characterization of disorder prevalences. Our current plans regarding these issues are discussed. CONCLUSION: Valid and representative general population epidemiological data on patterns, predictors and adverse consequences of psychiatric disorders are needed as a foundation for public health initiatives. The efforts of the ICPE promise to provide data of this sort for many regions in the world. Formidable methodological and logistical challenges arise in implementing this agenda, but we are confident that these challenges can be met by building on the firm foundation already established in the ongoing ICPE collaboration.

Data Collection↗