[Alternative combination chemotherapy with mitomycin C, vincristine, methotrexate, 5-fluorouracil, cis-platinum and adriamycin for adenocarcinoma of the lung]

Efficacy of an alternative combination chemotherapy with MMC, VCR, MTX, 5-FU, CDDP and ADM for adenocarcinoma of the lung is reported. Forty-one advanced cases (stage III: 9; IV: 32) were chosen for the chemotherapy. Two combination chemotherapies MMC + VCR + MTX + 5-FU + CDDP: MVMFP; MMC + VCR + MTX + 5-FU + ADM: MVMFA were repeated alternatively for 8 consecutive weeks with 2 interposed rest weeks, and this regimen was completed in 34 cases. All 41 cases were evaluable. Three and 26 cases achieved complete and partial responses, respectively. The response rate was 70.7%, and the median survival time was 13 months. The adverse effects of the chemotherapy observed were tolerable: alopecia (63.4%), gastrointestinal symptoms (14.5%), bone marrow toxicity (12.2%) and liver dysfunction (4.8%). These results indicate that our MVMFP/MVMFA alternative chemotherapy is quite effective for adenocarcinoma of the lung, comparable or superior to conventional chemotherapies.

[Detection of myocardial damage in patients with dilated cardiomyopathy using ultrafast CT]

The myocardial characteristics of DCM patients were investigated by ultrafast CT (UFCT), left ventriculography (LVG) and T1 myocardial scintigraphy (SCINTI). Late enhancement, focal wall thinning and intramyocardial fatty components were detected as focal abnormal findings by UFCT. The regions of asynergy detected by LVG and perfusion defect detected by SCINTI were well correlated with those of focal abnormal findings detected by UFCT. There were significant differences between patients with and without focal abnormal findings, in ejection fraction and end-diastolic pressure of left ventricle and the incidence of ventricular arrhythmia. It is possible that these focal abnormal findings represented focal ischemic myocardial damage in DCM patients. DCM patients were divided into two different functional groups by UFCT findings.

Poisoning caused by the combined ingestion of nifedipine and metoprolol

Poisonings due to ingestion of a calcium channel or beta-adrenergic blocker have been the subject of several previous reports, but reports of poisoning due to combined ingestion of these drugs are infrequent. This is a report of suicidal ingestion of nifedipine 600 mg, metoprolol 200 mg, and etizolam 20 mg. Intravenous dopamine, norepinephrine, and calcium chloride had little effect but the administration of methylprednisolone and glucagon were associated with an increase in systolic blood pressure above 100 mm Hg.

A pitfall in ultrafast CT scanning for the detection of left atrial thrombi

We studied 41 patients with mitral stenosis by ultrafast CT (UFCT) and transesophageal echocardiography to detect left atrial thrombi. Cardiac UFCT was performed twice after contrast medium injection to obtain early (during injection lasting 40-60 s) and late (approximately 5 min after beginning injection) phase images. There were 10 patients (24%) in whom a filling defect detected in the early phase disappeared in the late phase. The site of filling defects was the left atrial appendage in nine patients and the left atrium in one patient. All of the filling defects were in the ventral side of the left atrium. Furthermore, all of those patients had chronic atrial fibrillation. Transesophageal echocardiography revealed no thrombus in the area of the filling defect in the early phase. We believe that blood stasis existed in those patients. This finding leads to a false-positive result when only early phase images are obtained. The diagnosis of thrombi should be made only when a filling defect is observed in both phases. Late phase scanning is necessary in the diagnosis of left atrial thrombi.

Plasma lidocaine concentrations during epidural blockade with isoflurane or halothane anesthesia

Because isoflurane maintains hepatic blood flow at higher flows than halothane, we proposed that the elimination of lidocaine would be different between these two volatile anesthetics. The plasma lidocaine concentrations were determined in 14 female patients undergoing epidural blockade plus isoflurane anesthesia and compared with those obtained during halothane anesthesia for lower abdominal surgery. General anesthesia was maintained with isoflurane (0.46% +/- 0.04% [mean +/- SE] inspired, n = 7) or halothane (0.48% +/- 0.05% inspired, n = 7) and 67% nitrous oxide in oxygen. All patients received 2% lidocaine solution, 10 mL as a bolus dose and continuous administration at a rate of 10 mL/h, through the epidural catheter. The plasma lidocaine concentrations over 180 min after the epidural injection in patients receiving isoflurane were similar to those in patients receiving halothane. The results suggest that low inspired concentrations of isoflurane do not reduce plasma lidocaine concentrations in patients during epidural blockade, compared with halothane.

Long-term results of pylorus-preserving gastrectomy for gastric ulcer

The postoperative results of pylorus-preserving gastrectomy (PPG) for gastric ulcer performed in 134 patients during the past 25 years (mean postoperative period, 16.6 years) were studied. The incidence of postoperative complications was low. Dumping syndrome occurred in only 4.4% and 0% of cases as assessed by questionnaire and interview, respectively. Four (5.4%) of 74 patients available for this study had ulcer recurrence. In one of these four patients concurrent gastroduodenal ulcer was suspected from preoperative gastric analysis. The site of recurrence was found in all cases to be the remnant antral gland area along the greater curvature between the proper gastric gland area and the duodenum. Basal and maximal acid outputs at the time of relapse were significantly higher in patients with recurrence than in patients without recurrence. The fasting and postprandial serum gastrin levels were high in one patient with recurrence, whose antrum was preserved as long as 3 cm proximal to the pyloric ring; this was longer than that described in our original method of PPG. In two other recurrent cases the serum gastrin levels were not different from those in nonrecurrent cases. Immunohistochemical examination of the residual antrum showed no increase in the G-cell density in patients either with or without recurrence. These results suggest that the long-term quality of life of patients treated with PPG remains favorable. Recurrence rate can be further reduced if PPG is strictly indicated for gastric ulcer only and carried out by meticulous surgical techniques. In the pathogenesis of the ulcer recurrence the role of gastrin release from the residual antral mucosa seems to be limited.

[Successful treatment with combination of methylprednisolone, antilymphocyte globulin and cyclosporine in two cases of aplastic anemia]

Two children with severe and moderate aplastic anemia received combination treatment with methylprednisolone, antilymphocyte globulin and cyclosporine. One child (severe type) was given 2 courses of high dose methylprednisolone during the last 4 weeks without improvement prior to this combination therapy. The other child (moderate type) was not previously treated. Both patients showed complete response within 3 months following this therapy. Serious side effects were not observed. Combination therapy of these three drugs may be beneficial for patients with aplastic anemia.

Histomorphological characteristics of cholangiocellular carcinomas in northeast Thailand, where a region infection with the liver fluke, Opisthorchis viverrini is endemic

Northeast Thailand has a very high incidence rate of intrahepatic biliary tumors which is believed to closely related to infestation with the liver fluke, Opisthorchis viverrini. This study was conducted to ascertain whether there are any phenotypic differences in such tumors between northeast Thailand and Japan, a country free of liver flukes. Forty one intrahepatic cholangiocarcinomas from patients in northeast Thailand were histopathologically compared with 39 lesions collected in Japan. The proportions of each type of adenocarcinoma in the Thailand cases were similar to those of the Japanese cases except that medullary type poorly differentiated tubular adenocarcinoma was only found in the series from Thailand. Whether the presence of medullary lesions only in the cases from the area of endemic fluke infection implies differences in etiology remains in question. The similarity in the majority of histological types, the inflammatory reactions observed in the bile ducts and the earlier development of tumors in association with parasites suggests that tumor promotion resulting from liver fluke infection rather than quantitative or qualitative differences in genetic alterations is responsible for the high frequency of cholangiocellular carcinomas in northeast Thailand.

Aortic aneurysms: growth rates measured with CT

Because of a lack of information about the rates of growth of aortic aneurysms, such rates in thoracic and abdominal aortic aneurysms were determined. One hundred seventy-one patients with atherosclerotic aortic aneurysm managed nonoperatively were followed up for more than 6 months with sequential computed tomography (CT). There were 211 aneurysms (thoracic aortic, 82; abdominal aortic, 129). The growth rates of thoracic and abdominal aortic aneurysms were 0.42 and 0.28 cm/y, respectively. Aneurysms at the aortic arch (n = 34) grew at a faster average rate (0.56 cm/y) than aneurysms arising at other levels, even when the rate was corrected for the initial diameter. It is recommended that thoracic aortic aneurysms, especially aortic arch aneurysms, be followed frequently with CT examination of size.

Arteriovenous differences of blood alcohol concentrations after celiac plexus block

After a celiac plexus block with ethyl alcohol, patients sometimes complain of symptoms of alcohol intoxication. We studied the consecutive changes of arterial and venous blood alcohol concentrations in 11 patients and investigated whether an arteriovenous difference exists. We performed a celiac plexus block with 10 ml absolute ethyl alcohol. The sampling sites were radial artery and internal jugular vein. Blood samples were collected at 0, 5, 10, 15, 30, 60, 120, 240 and 480 minutes after the block. The maximum level was reached 15 minutes after injection in both arterial and venous blood, 29.9 +/- 19.4 and 27.7 +/- 21.8 mg/dl (means +/- SD), respectively. Arteriovenous differences were observed 5 and 10 minutes after ethyl alcohol injection (p less than 0.01). There was a significant negative correlation between the ratio of arteriovenous differences to venous sampling and the time elapsed after the block (r = 0.41, p less than 0.01).

An experimental study on the gastric acid and gut hormone secretion after pylorus preserving duodenectomy in dogs

To clarify changes in gastric acid and gut hormone secretion after pylorus-preserving pancreaticoduodenectomy (PPPD), an experimental study was performed using a model of pylorus-preserving duodenectomy in dogs previously provided with Heidenhain pouch (HP). The duodenectomy involves resection of the duodenum and 10 cm of the proximal jejunum preserving 2 cm of juxtapyloric duodenum and round-shaped duodenal wall around pancreatic papilla. Reconstruction was done by anastomosing the rho-shaped jejunal loop to gallbladder, juxtapyloric duodenum and peripapillar round-shaped duodenal wall with ligation of the common bile duct. For these dogs, intravenous glucose tolerance test (IVGTT), oral glucose tolerance test (OGTT), meal ingestion test (TM) and histological studies of pancreatic specimen obtained at autopsy were performed investigating pancreatic, gastric acid and gut hormone secretion. Preservation of endocrine and exocrine pancreatic secretion after operation demonstrated our experimental model to be adequate for evaluation of the factor of duodenectomy in PPPD on gastric acid and gut hormone secretion avoiding the influences of changes in pancreatic secretion. Postprandial gastric acid secretion from HP did not change significantly after operation. Postprandial secretion of gastrin, glucagon, GIP and enteroglucagon did not alter significantly after operation. These results indicated that in the clinical PPPD procedure, preservation of more than 2 cm of duodenum from the pylorus produced neither postprandial gastric acid hypersecretion, which might be cause of postoperative stomal ulcer, nor any change of related gut hormone secretion.

Cytogenetic characteristics of childhood non-Hodgkin lymphoma

Cytogenetic studies were performed successfully on 24 patients with non-Hodgkin lymphoma (NHL) who were younger than 15 years of age. Of these, 22 patients (92%) had abnormal clones. With respect to histologic findings, 3 (25%) of the 12 patients with lymphoblastic lymphoma had 14q11 translocations and 2 (17%) had t(9;17) (q34;q23). Four (80%) of the five patients with small non-cleaved cell lymphoma had t(8;14)(q24;q32). With respect to immunologic findings, four (44%) of the nine patients with T-cell lymphoma had abnormalities consisting of 14q11 and 7q36 translocations, in which the T-cell receptor genes resided. Three (33%) of the patients with T-cell lymphoma had t(9;17)(q34;q23). However, three (43%) of the seven patients with B-cell lymphoma had t(8;14) (q23;q32), and two (29%) of the patients with B-cell lymphoma had an extra i(11q) chromosome with a resultant 11q tetrasomy. Non-T-cell non-B-cell lymphomas, which occurred in 21% of all patients, showed various chromosomal abnormalities. This study demonstrated that, in childhood NHL, karyotype correlates closely with immunophenotype, clinical features, and histologic findings.

Lack of carcinogenicity of tragacanth gum in B6C3F1 mice

Tragacanth gum was administered at dietary levels of 0 (control), 1.25 and 5.0% to groups of 50 male and 50 female B6C3F1 mice for 96 wk after which all animals were maintained on a basal diet without tragacanth gum for a further 10 wk. Mean body weights of females in the 5.0% and 1.25% groups were lower than those of the controls after 11 and 16 wk, respectively. However, there were no treatment-related clinical signs or adverse effects on survival rate, urinalysis, haematology, blood biochemistry and organ weight. While detailed histopathology revealed the development of squamous cell hyperplasias, papillomas and one carcinoma in the forestomach, there was no significant treatment-related increase in the incidence of any preneoplastic or neoplastic lesion. Thus, under the experimental conditions used, tragacanth gum was not carcinogenic in B6C3F1 mice of either sex.

Dose dependence of N-hydroxy-3,2'-dimethyl-4-aminobiphenyl-induced rat prostate carcinogenesis

Groups of F344 rats were administered biweekly intraperitoneal injections of N-hydroxy-3,2'-dimethyl-4-aminobiphenyl (N-OH-DMAB) at a dose of 5, 10 or 20 mg/kg body weight or DMAB, the parent compound, at a dose of 25 mg/kg body weight, for a total of 10 times. Prostate carcinomas in the ventral lobe developed in a N-OH-DMAB dose-dependent manner (0, 17.6 and 66.7%, respectively) with limited tumor yields in other organs. Although intraperitoneal administration of DMAB was similarly found to induce prostate tumors, it also caused severe chemical peritonitis, which resulted in a high mortality. The present data confirmed that intraperitoneal administration of N-OH-DMAB provides a relatively specific induction method for models of prostate carcinogenesis.

Evaluation of myocardium in ischemic heart disease by ultrafast computed tomography

In this study we evaluated quantitatively the contrast enhancement of the myocardium of 27 patients with infarction and ischemia by ultrafast CT (Imatron C-100) with a scan time of 100 msec. We defined three parameters from the CT numbers of the myocardium and the ventricle in both the early and the late phase (about 4 min) after the injection of non-ionic contrast material; the difference of the CT numbers of myocardium between the early and the late phase (delta CT#), and the ratios of the CT numbers of the myocardium and the ventricular lumen (M/L) in both the early phase and the late phase. The delta CT# for myocardial infarction and severe ischemia were -20 +/- 10HU and -8 +/- 10HU, respectively. These values were significantly lower than the mild ischemic myocardium and normal myocardium (p less than 0.001). The average M/L values for myocardial infarction and ischemia in the early phase were 19 +/- 8% and 16 +/- 6%, respectively. These values were significantly lower than those in normal myocardium (p less than 0.001). The average M/L values for infarction and severe ischemia in the late phase were 90 +/- 18% and 63 +/- 20%, respectively. These M/L were significantly dissociated (p less than 0.001). Our results indicate that with contrast UFCT it is feasible to detect quantitatively the myocardial characteristics of ischemia and infarction.

Analysis of 13 postmortem examinations with regard to the effect of chemotherapy on neuroblastoma patients

Thirteen postmortem examinations on neuroblastoma patients were reviewed clinicopathologically. Commonly found metastatic sites were bone, liver and lung. The introduction of massive doses of cyclophosphamide and cisplatinum into chemotherapy protocol markedly reduced the tumor burden: no tumor focus in liver or lung, small tumor burden in bone. Lymph node metastasis remained, however, and was refractory to the chemotherapy. The intensive chemotherapy caused severe side effects: interstitial or bacterial pneumonia and intrathecal bleeding, which sometimes proved fatal. Such side effects must, therefore, be carefully controlled in order to maximize the survival rate.

Quantitative assessment of myocardial enhancement with iodinated contrast medium in patients with ischemic heart disease by using ultrafast x-ray computed tomography

BACKGROUND AND RATIONALE

The authors report the quantitation of myocardial enhancement using iodinated contrast medium in patients with ischemic heart disease. Twenty-eight patients with chronic ischemic heart disease and 11 controls were examined by ultrafast computed tomography (CT) using 100-msecond scans.

METHODS

The authors analyzed M/L (ratio of post-contrast incremental increases in the left ventricular myocardial and luminal CT number) in early and late phases after contrast injection.

RESULTS

In controls, mean values of early and late M/L were 30% and 51%, respectively. In infarcted or severely ischemic segments, early M/Ls (19%, 16%) were significantly small (P less than .001), whereas late M/Ls (90%, 63%) were higher (P less than .001, .01) than controls. Segments with infarction or severe ischemia were differentiated from mild or nonsignificant ischemia by using this parameter (sensitivity, 99%; specificity, 88%).

CONCLUSIONS

M/L is useful for detection of the ischemic myocardium.

[Growth rate of abdominal aortic aneurysms as measured by Computerized tomography]

To evaluate the growth rate of abdominal aortic aneurysms, sequential computed tomography (CT) examinations were performed on 125 nonoperated patients (M/F 101/24, mean age 67 +/- 8 years, 129 lesions) at intervals of at least 6 months. Growth rates of aneurysms were obtained by subtracting the first from the last diameter and adjusting for examination interval. Mean growth rate was 0.28 +/- 0.26 cm/year. Aneurysms with an initial diameter exceeding 4 or 5 cm showed significantly faster growth than smaller aneurysms. There was no significant correlation between growth rate and atherosclerogenic factors, but systolic blood pressure was significantly higher in patients whose aneurysms ruptured. Our study showed quantitatively that aneurysms with a large diameter have a rapid growth rate, the growth rate of infrarenal aneurysms is significantly faster than that of suprarenal aneurysms, and blood pressure control is important to prevent rupture.

Type A aortic dissection: evaluation with ultrafast CT

The authors examined 17 patients with type A aortic dissection with ultrafast computed tomography (CT). Forty sections with 1-cm intervals, from the aortic arch to the aortic bifurcation, were scanned serially without breath holding within only 74 seconds. Except for two thrombosed dissections, all intimal flaps in the ascending aorta were demonstrated, and 14 (93%) of the 15 surgically proved intimal tears were depicted. An intimal tear in the aortic arch was missed. Since conventional scanning tends not to depict type A aortic dissection, millisecond-order ultrafast CT scanning has the potential to become the modality of choice for imaging of aortic dissection.

[Anaphylactic shock with ventricular fibrillation induced by chlorhexidine]

We experienced a case in which a 66 year-old male patient developed anaphylactic shock followed by ventricular fibrillation, possibly due to intravenous aspiration of chlorhexidine used for topical application when right internal jugular vein was punctured. He was successfully resuscitated without any sequelae. Although lymphocyte transformation test failed to identify the specific allergen, IgE antibodies against chlorhexidine in the patient's serum were detected by radioallergosorbent technique. Chlorhexidine is an extensively used antiseptic, but there have been many reports regarding severe adverse reactions associated with its use. Chlorhexidine does not seem to be a safe antiseptic.

[The relation between upper respiratory tract infection and mild hypoxemia during general anesthesia in children]

Anesthesiologists often face the problem of a child with symptoms of an acute upper respiratory infection (URI) presenting for surgery. Anesthesia in the presence of uncomplicated URI may not be contraindicated. However, we experienced three cases of such children in which lung atelectasis developed after the induction of general anesthesia. Because continuous monitoring of arterial oxygen saturation by pulse oximetry (SpO2) was useful for detecting mild hypoxemia in these patients, we retrospectively examined the possible association between URI symptoms and SpO2 in 63 children. Patients with symptoms of URI showed a significantly high incidence of decreased SpO2 to below 95% for 5 minutes. Our results suggest that, with URI symptoms even uncomplicated, symptomatic patients have increased risks for the development of mild hypoxemia during anesthesia.

[The effect of deliberate hypotensive anesthesia on the prognosis of patients who underwent early surgeries for ruptured cerebral aneurysm]

The effects of deliberate hypotensive anesthesia (DHA) on prognosis were analysed retrospectively in 112 patients who underwent early surgeries for ruptured cerebral aneurysms. Eighty-five patients received DHA (DHA group) and 27 patients were allocated to the control group. No difference was found in preoperative Hunt's grading, the time elapsed from subarachnoid hemorrhage to operation, arterial pressure before DHA. In the DHA group systolic arterial pressure was reduced to 80-90 mmHg for 87 +/- 6 min (M +/- SE) during operation. DHA had no effect on postoperative Glasgow Coma Scale, the incidence of post-operative complication, the period of hospitalization, and outcome (I: discharge with ability to walk, II: discharge with disability of walk, III: death). But DHA failed to reduce the incidence of intraoperative re-rupture, the prevention of which is the primary object of DHA. The mortality rate in the groups of Hunt's grade IV-V accompanied with the rate pressure product greater than 12,000 mmHg.min-1 was 55-80%. This suggests that in severely ill patients with ruptured cerebral aneurysm, the excitation of sympathetic efferents caused by the neural damage of hypothalamus might increase intracranial pressure and aggravate prognosis.

[Alveolar rhabdomyosarcoma with massive bone marrow involvement and 2;13 chromosome translocation]

We report a 9-year-old girl who had massive bone marrow infiltration of tumor cells at the onset of alveolar rhabdomyosarcoma. She was admitted to a surgical hospital because of abdominal pain and tumor in the buttock. Computerized tomographic scans of the pelvis revealed an abnormal mass. She was referred to our department. Hematological examination showed pancytopenia. Blood chemistry revealed hypercalcemia and hyperuricemia. Bone marrow was occupied with 100% tumor cells. Chromosome analysis of tumor cells in bone marrow revealed a specific translocation, t(2;13) (q37;q14). This finding enabled the diagnosis of a disseminated alveolar rhabdomyosarcoma to be established. She was treated with vincristine, cyclophosphamide and epirubicin, achieved a complete remission, but died of relapse 3 months after diagnosis.