Emergency subtotal colectomy. A new trend for treatment of obstructing carcinoma of the left colon

During a 5-year period, 22 patients with obstructing carcinoma of the left colon were operated on in our department. All patients underwent emergency subtotal colectomy with primary ileocolonic or ileorectal anastomosis. The quality of life for patients undergoing subtotal colectomy is excellent. All patients enjoy an almost normal diet and those with an ileorectal anastomosis stabilize on two to three bowel movements per day. During a followup period of 65 months, four patients died from spread of their primary disease while two other patients died of unrelated causes. Sixteen patients are alive and free of disease. We consider subtotal colectomy the procedure of choice for patients with obstructing carcinoma of the left colon.

Sequential moderate-dose methotrexate and 5-fluorouracil in advanced gastric adenocarcinoma

A total of 23 patients with advanced gastric adenocarcinoma were treated with a combination of moderate-dose methotrexate (MDMTX), 250 mg/m2 i.v., with folinic acid rescue and 5-fluorouracil (5-FU) 600 mg/m2 i.v. Therapy was given every 7 days for 4 courses and then at 14-day intervals. All patients were evaluable for response. No complete responses occurred, but five patients (22%) had partial remissions (95% confidence limit, 5%-39%). The median duration of remission was 6 months, with a median survival of 11 months amongst responding patients. In all, six patients (26%) had stable disease for a median period of 5 months. The overall median survival was 6 months. Therapy was generally well tolerated, with principal toxicities consisting of neutropenia, nausea and vomiting, mucositis and diarrhoea. In terms of activity or survival in advanced gastric carcinoma, the combination of moderate-dose MTX and 5-FU does not appear to offer an advantage over single-agent therapy.

Thrombocytopenia associated with hypersensitivity to ranitidine: possible cross-reactivity with cimetidine

A rare case of thrombocytopenia associated with ranitidine is described. The thrombocytopenia was accompanied by eosinophilia and slightly elevated serum IgE. The platelet and eosinophilic counts returned to normal as soon as the drug was stopped. Cell-mediated immunity (CMI) determined in vitro by the leukocyte migration inhibition factor test was found against ranitidine and cimetidine. IgE antibody response against both drugs was also found by the mast cell degranulation test. These data suggest an association between the ranitidine-induced thrombocytopenia and both humoral antibody response and CMI. Cross-reactivity between the two H2-receptor antagonists is suggested, as well.

Brainstem auditory evoked responses in rats with experimental chronic renal failure

1. Chronic renal failure was induced in rats by five-sixths nephrectomy. Brainstem auditory evoked response (BAER) was recorded after 3 months. 2. In the uraemic rats latency of the first wave was delayed, while the interpeak I-V latency was similar to that of the controls. 3. These results suggest a delayed neural conduction along the acoustic nerve or cochlear changes in uraemic rats.

Enalapril attenuates glomerular hyperfiltration following a meat meal

It has been shown that the glomerular filtration rate increases after a meat meal. We examined in humans whether enalapril, which has been shown to decrease glomerular capillary pressure in rats with chronic renal failure, could attenuate the renal response to a meat meal. Twelve healthy volunteers were studied after an oral protein load, 1.5 g/kg body weight, as lean cooked beef meat, and on a separate day, after eating the same meal with prior oral intake of enalapril. On the control day, creatinine clearance increased from 114.3 +/- 4.7 before the meal to 137.1 +/- 4.7 ml/min/1.73 m2 after the meal (p less than 0.001). On the enalapril intake day, creatinine clearance increased from 113.7 +/- 5.6 before the meal to 128.3 +/- 5.8 ml/min/1.73 m2 after the meal (p less than 0.01). However, the mean increase in creatinine clearance was lower on the enalapril intake than on the control day (14.0 +/- 4.3 vs. 21.0 +/- 4.1%, p less than 0.05). Mean arterial pressure before the meal was lower on the enalapril intake day than on the control day (76.2 +/- 3.5 vs. 84.2 +/- 3.6, p less than 0.01). Likewise, postprandial mean arterial pressure was lower on the enalapril day compared with the control day (69.9 +/- 2.8 vs. 78.5 +/- 3.7, p less than 0.01). We conclude that enalapril blunts the hyperfiltration which follows a meat meal.

Brainstem auditory evoked responses in chronic renal failure and the effect of hemodialysis

Brainstem auditory evoked responses (BAER) were recorded in patients with chronic renal failure before commencement of chronic dialysis treatment, and in patients with end-stage renal failure on chronic hemodialysis for several years. Both groups of patients had delayed latencies of the third and fifth waves. The patients on hemodialysis revealed delayed latency of interpeak I-V as well. There was no correlation between wave latency, serum urea, creatinine, PTH or duration of chronic hemodialysis treatment. A hemodialysis session led to a slight shortening of the third wave. This study suggests that neural conduction along the brainstem in patients with chronic renal failure is delayed even before hemodialysis is started. Although 1 dialysis session may have some beneficial effect, long-term hemodialysis treatment does not seem to shorten the delay in neural conduction observed in patients with chronic renal failure.

Effect of prostaglandin on indomethacin-induced increased intestinal permeability in man

This study examines whether NSAID induced disruption of small intestinal integrity is preventable by concomitant prostaglandin administration, and whether prostaglandins themselves interfere with intestinal permeability and absorption. Twelve subjects underwent testing following treatment as indicated: baseline, no treatment rioprostil, 300 micrograms, at -9 and -1 h indomethacin, 75 mg and 50 mg, at -9 and -1 h respectively rioprostil plus indomethacin, regimen as above. At 0800 h (0 h) subjects drink a solution containing 51CrEDTA 100 microCi, L-rhamnose 0.5 g, D-xylose 0.5 g and 3-O-methyl-glucose 0.2 g; this is followed by a 5-h urine collection. The amount of test substance in the urine reflects non-mediated intercellular and transcellular permeability, and passive and active carrier mediated transport systems, respectively. Permeation of L-rhamnose, D-xylose and 3-O-methyl-glucose is unaffected by rioprostil and/or indomethacin. Indomethacin significantly increases intestinal permeability to 51CrEDTA; coadministration of rioprostil, however, significantly decreases this detrimental effect of indomethacin. These findings suggest that prostaglandins are essential for maintaining small intestinal integrity in man and lend further support to the suggestion that NSAIDs damage the small intestine by reducing mucosal prostaglandin synthesis.

Chemotherapy for non-small cell lung cancer: a randomized trial of cisplatin/vindesine v no chemotherapy

Separate but almost identical randomized trials testing the role of chemotherapy in non-small cell lung cancer (NSCLC) were started in Southampton, United Kingdom (UK) and in several centers in Australia. Between 1983 and 1987, 201 patients were assigned to either a chemotherapy arm: cisplatin 120 mg/m2 every 4 weeks and vindesine 3 mg/m2 weekly, or a no chemotherapy arm. Of 188 evaluable patients, 157 were randomized in Australia and 31 in Southampton. Objective responses after two cycles of cisplatin/vindesine were seen in 26 patients (28%). Median survival was 23 weeks for the treatment arm and 16 weeks in the no treatment arm (P = NS). Analysis of those patients with limited disease showed a median survival of 43 weeks for the chemotherapy arm and 26 weeks for the non-treatment arm (this difference approaches statistical significance). Toxicity was severe in the treatment arm, and all patients experienced subjective toxicity; 17 (18%) had WHO (World Health Organization) grade 3-4 myelotoxicity, 73% had grade 3-4 nausea and vomiting. There is a modest trend towards improved overall survival in patients with limited disease treated with chemotherapy. Because chemotherapy is palliative, future studies should have an appropriate control arm and should measure quality of life.

Establishing breast feeding in hospital

The experience and practice of the author is described in her appointment as a breast feeding advisor to the paediatric and obstetric units at University College Hospital with special responsibility for supervising infant feeding, especially breast feeding in the maternity unit. During 1980-5 there were 13,185 mothers whose babies fed. The feeding method of 12,842 mothers was recorded on discharge from the postnatal wards and 77% were breast feeding; only 3% of these mothers gave complement feeds of infant formula. The practices in the maternity wards to enable mothers to establish successful breast feeding and the methods of dealing with common problems of breast feeding are described.

A phase II trial of oral 4'demethoxydaunorubicin in advanced colorectal carcinoma

4'Demethoxydaunorubicin (DMDR), an orally active daunorubicin analogue, was administered to 22 patients with advanced colorectal carcinoma. Patients were stratified into good- and poor-risk categories and received doses of 45 mg/m2 and 40 mg/m2, respectively, at 28-day intervals. Twenty-one patients were evaluable for response. No tumour responses occurred, although six patients had stable disease. Therapy was well tolerated. Mild gastrointestinal toxicity occurred in 45% of patients. Marrow toxicity was common and usually mild. DMDR appears to have no useful activity in colorectal carcinoma.

A phase II trial of oral 4'demethoxydaunorubicin (DMDR) in inoperable non small cell lung cancer

4'Demethoxydaunorubicin, an orally active daunorubicin analogue, was administered to 22 patients with inoperable non small cell lung cancer (NSCLC). Patients were stratified into good and poor risk categories and received doses of 45 mg/m2 and 40 mg/m2 respectively at 28 day intervals. All 22 patients were evaluable for response: No tumour responses occurred. Therapy was well tolerated. Mild gastrointestinal toxicity occurred in 41% of patients. Leucopenia with a wcc less than 3 x 10(9)/L occurred in 33% of patients and thrombocytopenia less than 100 x 10(9)/L in 9%. Severe marrow toxicity was rare and there appeared to be no difference in terms of toxicity between the different dose levels. DMDR appears to have no useful clinical activity in NSCLC.

Surveillance for stage I non-seminomatous germ cell tumours of the testis: the optimal protocol has not yet been defined

Forty-six patients with clinical stage I testicular non-seminomatous germ cell tumours were followed up according to a protocol of active surveillance between 1979 and 1987. The median follow-up time was 40+ months. Thirteen patients (28%) relapsed, predominantly in retroperitoneum and/or lung. Ten of these relapses (76%) occurred within 8 months of orchiectomy. Relapses occurred in 7/35 T1 tumours and 5/10 T2 to T4 tumours. No correlation was detected between the histological type and relapse rate. Three late relapses were diagnosed at 23, 29 and 36 months. Eleven of the relapsed patients remain in prolonged complete remission after PVB chemotherapy +/- surgery; one patient, who initially refused treatment at the time of relapse, has died. Another relapsed with predominant elements of rhabdomyosarcoma intermingled with malignant teratoma in a bone metastasis. He had a partial response to PVB chemotherapy but subsequently died. Thirty-four patients (74%) did not undergo lymphography (LG) and had a higher relapse rate (11/34) than those who had LG (2/12); this was not a statistically significant difference in this small series. The policy of active surveillance is not yet the "state of the art" and should be under constant scrutiny with respect to safety and practice.

Myoglobinuric renal failure in a newborn after traumatic delivery

Fetal and neonatal asphyxia is the main cause of transient or acute renal failure (ARF) in neonates. Rhabdomyolysis and subsequent myoglobinuria have been rarely reported in neonates. We describe a case of ARF in a newborn infant in whom asphyxia, birth trauma and hypovolemic shock precipitated rhabdomyolysis which contributed to ARF.

Sialic acid and neuraminidase activity in rat kidneys 6 months after uninephrectomy

Sialic acid and neuraminidase activity were determined in the cortex of the remnant kidneys of six uninephrectomized rats. As controls served either the kidneys removed at operation or age-matched kidneys from eight sham operated rats. Six months after uninephrectomy the kidneys became hypertrophied and their mean weight was about 40% higher than age-matched kidneys. Blood urea and creatinine and protein levels in 24-hr urine collections were significantly higher in the experimental animals as compared to those of the same animals before nephrectomy and to sham operated rats, indicating a marked impairment of kidney function. The mean concentration of sialic acid in the cortex of hypertrophied kidneys was not statistically different from either that of the removed or that of the age-matched kidneys. Neuraminidase activity expressed as either per gram fresh tissue or per milligram protein, was not different in the removed and in the hypertrophied kidney. The activity, however, in the latter was significantly lower than in the age-matched kidneys. Whether this finding can be associated with the impairment of kidney function in rats 6 months after uninephrectomy remains to be studied.

Biochemical changes associated with the osmotic fragility of young and mature erythrocytes caused by parathyroid hormone in relation to the uremic syndrome

The effect of parathyroid hormone at concentrations found in uremic patients on erythrocytes (RBC) from newborn and adult rabbits was studied in relation to the fragility pattern in hypotonic salt solutions and the activities of Ca- and Mg-dependent ATPases. Median osmotic fragility of RBC from newborn rabbits was significantly lower than in mature rabbits. Parathyroid hormone (PTH) stimulated to a greater extent the mean osmotic fragility in RBC from newborn rabbits, than in those from adults. Similarly, the hormone stimulated to a much greater extent the Ca-ATPase but not the Mg-ATPase in RBC from the newborn rabbits, in comparison to those from adult rabbits. PTH, which is greatly elevated in the blood of patients with chronic renal failure, may be one cause of the anemia seen in these patients, and its effect, which is mediated by Ca-ATPase activity, is stronger on young RBC. There were significant morphological changes in the young RBC caused by PTH, as seen with scanning electron microscopy.

Phase I study of epirubicin given on a weekly schedule

Epirubicin was studied in a phase I setting to find the maximum tolerated dose when given weekly for 3 of 4 weeks. Forty-one evaluable patients were treated in groups at doses increasing from 20 to 45 mg/m2. The highest dose level produced the maximum degree of myelosuppression (lowest neutrophil count, 1.9 X 10(9)/L; range, 0-3.7) recorded on Day 22. This was well-tolerated in this group of mainly pretreated patients. Nonhematologic side effects were minimal. This dose schedule allows a greater dose per unit time to be administered than other recommended schedules for epirubicin.

Effect of parathyroid hormone on the fragility and enzyme activities of red blood cells from young and mature rabbits

The effect of parathyroid hormone on erythrocytes from newborn and adult rabbits was studied in relation to the fragility pattern in hypotonic salt solutions and the activities of Ca- and Mg-dependent ATPases. Median osmotic fragility of red blood cells from newborn rabbits was significantly higher than in red blood cells from mature rabbits. Parathyroid hormone increased the mean osmotic fragility of red blood cells from newborn and adult rabbits, but showed the greater effect on those from newborns. Similarly, the hormone stimulated to a much greater extent the Ca-ATPase, but not the Mg-ATPase in red blood cells from the newborn rabbits, in comparison with red blood cells from adult rabbits. Parathyroid hormone, which is greatly elevated in the blood of patients with chronic renal failure, may be one cause for the anaemia seen in these patients, and its effect, which is mediated by Ca-ATPase activity, is stronger on young red blood cells. Significant morphological changes in the young red blood cells, observed by scanning electron microscopy, were caused by parathyroid hormone.

Effect of verapamil on plasma parathyroid hormone

The effects of the Ca antagonist, verapamil, on the behaviour of parathyroid hormone was studied in normal and uraemic male Wistar rats. Parathyroidectomy was by cautery. Acute uraemia was induced by bilateral nephrectomy, and moderate uraemia by s.c. injection of gentamicin (200 mg/kg). Ethylendiamine tetracetic acid (50 mg/kg X d) was injected subcutaneously. Parathyroid hormone was determined by radioimmunoassay. The degree of uraemia was determined from plasma urea levels. Renal failure resulted in a significant increase in plasma parathyroid hormone (mean +/- SEM, ng/l) (84 +/- 6, n = 10, in the control; 277 +/- 39, n = 7, in the moderate uraemics and 667 +/- 128, n = 6, in the acute uraemics). Injection of verapamil significantly increased plasma levels of parathyroid hormone, ranging from 21% in the controls to 62% in the moderate uraemia group. In the acute uraemics, parathyroid hormone levels were very high and verapamil did not cause any further elevation of the hormone in the blood. Parathyroidectomy significantly lowered plasma parathyroid hormone, and verapamil resulted in a mean increase of 29%. EDTA caused an increase of 64%, compared with the control group.

Platelet count and thrombopoietic activity in patients with chronic renal failure

The frequency of thrombocytopenia in patients with chronic renal failure (CRF) is controversial. This study was undertaken to investigate the platelet count in 55 patients with end-stage renal disease on maintenance hemodialysis and in 19 patients with CRF before hemodialysis had begun. In both groups platelet counts were similar and significantly reduced, 175,000 +/- 6,500 and 181,000 +/- 10,800 compared to 253,000 +/- 3,700/mm3 in the control (p less than 0.0001). 31% of hemodialysis patients had thrombocytopenia (platelet count less than 150,000/mm3). The megakaryocyte number in their bone marrow aspirate was not reduced. Primary renal disease, androgen treatment or parathyroidectomy did not affect the platelet count. Thrombopoietic activity using 75Se-selenomethionine incorporation into platelets measured in 7 thrombocytopenic patients was found to be reduced, 6.77 +/- 0.29 vs. 9.06 +/- 0.27 (X 10(-2)%: p less than 0.001). This study shows that the platelet count is reduced and mild thrombocytopenia is frequent in patients with CRF. A possible cause for the platelet count reduction is insufficient thrombopoietic activity.