[Phase II study of a continuous five-day intravenous infusion of cisplatin and etoposide with concurrent chest radiation therapy in limited stage small cell lung cancer]

The efficacy of continuous five-day intravenous infusion of cisplatin (CDDP) and etoposide with concurrent chest radiation therapy was evaluated in patients with limited stage small cell lung cancer. The first group of patients registered from February 1989 to September 1990 received three courses of chemotherapy (CDDP 20 mg/m2/day x 5 days, etoposide 40 mg/m2/day x 5 days) and concurrent chest radiation therapy on the third course with dose reduction of etoposide. The second group of patients registered after February 1991 received four courses of chemotherapy (CDDP 20 mg/m2/day x 5 days, etoposide 50 mg/m2/day x 5 days) and concurrent chest radiation therapy on the first and second courses with dose reduction of etoposide. The response rates were 91.7% and 93.3%, respectively. The median duration of survival was 32.0 months and 20.1 months, respectively. Major toxicity was leukocytopenia and 64% and 80% of patients encountered leukocytopenia of Grade 3 or 4. In conclusion, these regimens show remarkable efficacy with acceptable toxicity.

Clonidine decreases the dose of thiamylal required to induce anesthesia in children

Clonidine is a useful drug to give preoperatively because it produces anxiolysis, sedation, and hemodynamic stability, and reduces intravenous and volatile anesthetic requirements. Several premedicants, including midazolam and diazepam, have been shown to reduce the induction dose of intravenous anesthetics, such as thiopental, ketamine, or propofol. A randomized, double-blind controlled study was conducted to evaluate the effect of premedication with oral clonidine on thiamylal requirement for the induction of anesthesia and on associated hemodynamic changes in children. Sixty children (ASA grades I-II, 7-12 yr old) were assigned randomly to receive one of three treatments (n = 20, for each group): placebo (control), clonidine 2 micrograms/kg, or clonidine 4 micrograms/kg 105 min before the induction of anesthesia. Thiamylal was injected at a dose of 1 mg/kg every 15 s until loss of the eyelash reflex and the dose was recorded. Blood pressure (BP), heart rate (HR), and arterial oxygen saturation were recorded every minute from the beginning of injection of thiamylal for 5 min. Significant decreases in thiamylal dose were observed in patients receiving clonidine. The induction dose of thiamylal (mean +/- SD) was 5.4 +/- 0.9, 4.5 +/- 1.1, and 3.4 +/- 0.9 mg/kg for patients receiving placebo, clonidine 2 micrograms/kg, and clonidine 4 micrograms/kg, respectively (P < 0.05). Systolic BP decreased by 6.8%, 5.6%, and 6.6% and HR increased by 5.7%, 4.8%, and 4.1% after administration of thiamylal in the control (placebo) group and the clonidine 2 micrograms/kg and clonidine 4 micrograms/kg groups, respectively (P > 0.05). Premedication with oral clonidine reduced the dose of intravenous thiamylal required for the induction of anesthesia in children.

Acceleration of phagocytosis in human neutrophils incubated with gabexate mesilate

It has recently been shown that gabexate mesilate inhibited human neutrophil functions including chemotaxis and reactive oxygen species production. In the present study, the effects of gabexate mesilate on phagocytosis by human neutrophils in vitro were investigated. Gabexate mesilate significantly enhanced neutrophil phagocytosis in a dose-dependent manner. This characteristic of gabexate mesilate may facilitate protection against infecting micro-organisms, although the inhibition of reactive oxygen species production by neutrophils may be a disadvantage for host-defense against infection.

Inhibitory effect of gabexate mesilate on human neutrophil function

Neutrophils accumulated in the lung are thought to play a key role in the pathogenesis of adult respiratory distress syndrome and interstitial pneumonia following bone-marrow transplantation. The effects of gabexate mesilate on several aspects of human neutrophil function have been investigated. Gabexate mesilate significantly decreased both the generation of reactive oxygen species (O2-, H2O2, OH.) by neutrophils and neutrophil chemotaxis. In contrast, the drug did not affect the levels of reactive oxygen species generated by a cell-free reactive-oxygen-species generating system. Intracellular calcium concentrations in neutrophils stimulated by f-Met-Leu-Phe were decreased in the presence of gabexate mesilate. These data suggest that the reduction in reactive-oxygen-species production and neutrophil chemotaxis by gabexate mesilate may contribute to the effectiveness of the drug in adult respiratory distress syndrome and interstitial pneumonia after bone-marrow transplantation. The suppression of the increase in intracellular calcium concentration may at least be responsible for the inhibition of these neutrophil functions by gabexate mesilate.

[Surgery of bilateral pulmonary aspergilloma]

A 60-year-old man with cough and fever was admitted to our hospital. Chest radiography revealed multiple bullae and fungus balls in both lungs. He was treated with MCZ and FCZ for about 2 months, but the chest radiograph shadows did not improve and the fever continued. A two-stage operation was performed. The bullae were incised and the fungus balls were removed, then a muscle flap plombage was made with a pectoralis major muscle, a latissimus dorsi muscle and an intercostal muscle. The postoperative course was uneventful and respiratory function was preserved.

Effect of lidocaine pretreatment on endotoxin-induced lung injury in rabbits

BACKGROUND

It is well known that endotoxin causes acute lung injury resulting in adult respiratory distress syndrome. Numerous cellular and humoral factors such as macrophages, neutrophils, platelets, and inflammatory mediators (e.g., activated complements, cytokines, and arachidonic acid metabolites) are thought to play a pivotal role in the pathogenesis of endotoxin-induced lung injury. Furthermore, pulmonary edema in acute lung injury is associated with an increase in vascular permeability that may arise from a perturbation of the endothelial cell surface membrane. Lidocaine has been shown to inhibit function of these cells and stabilize cell membranes. The aim of the current study was to determine whether pretreatment with intravenous lidocaine could attenuate acute lung injury induced by endotoxin in rabbits.

METHODS

Twenty-seven anesthetized male rabbits were randomly assigned to receive one of three treatments (n = 9 for each group); infusion of saline (as a control), infusion of Escherichia coli endotoxin (30 micrograms kg-1 over a 60-min period) without treatment with lidocaine, and infusion of endotoxin with treatment with lidocaine. A single dose of intravenous lidocaine 2 mg.kg-1 was administered 10 min before infusion of endotoxin and thereafter infused at a rate of 2 mg.kg-1.h-1 until 6 h after the start of endotoxin administration, when the animals were killed. The lungs of the rabbits were ventilated with 40% oxygen. Hemodynamics, peripheral leukocytes counts, and arterial oxygen tension were recorded during the ventilation period. After the observation, lung mechanics, cell fraction of bronchoalveolar lavage fluid (BALF), activated complements, cytokines, and arachidonic acid metabolites concentrations in BALF were measured and analyzed. The lung wet-to-dry-weight ratio and albumin concentrations in BALF were analyzed as an indices of pulmonary edema. The cypridina luciferin analog-dependent chemiluminescence (representing superoxide production) by neutrophils isolated from the pulmonary artery and light microscopic findings were compared among the three groups.

RESULTS

Endotoxin caused decreases in peripheral leukocyte counts, lung compliance, and arterial oxygen tension, and increases in the lung wet-to dry-weight ratio, polymorphonuclear cell counts in BALF, and albumin, C3a, C5a, tumor necrosis factor alpha, interleukin-1 beta, and thromboxane B2 concentrations in BALF. Lidocaine pretreatment attenuated these changes. The cypridina luciferin analog--dependent chemiluminescence was greater in rabbits receiving endotoxin than in the control. Lidocaine pretreatment attenuated the increase in chemiluminescence. Endotoxin caused extensive morphologic lung damage, which was lessened by lidocaine.

CONCLUSIONS

These results suggest that intravenous lidocaine pretreatment has a prophylactic effect on endotoxin-induced lung injury in rabbits. However, further studies are required to investigate the therapeutic (as an early posttreatment) effect of the drug given after lung injury because rabbits in the current study received lidocaine before endotoxemia.

[A case of advanced gastric cancer with multiple liver metastases showing marked response to new combination chemotherapy using 5-FU, THP and MMC (FTM)]

A 67-year-old man with advanced gastric cancer with multiple liver metastases was treated by a new combination chemotherapy using 5-FU, THP and MMC (FTM). After the first course of FTM, both abnormal liver function and the elevated level of serum CA 19-9 were restored. After the second course of FTM, the primary lesion became a small ulcer around cardia. A partial response was recognized both in the primary lesion and in the liver metastases. No serious side effect was observed except for leukocytopenia, which was controlled by G-CSFS. This new combination chemotherapy (FTM) was suggested to be useful even for far advanced gastric cancer.

Partial attenuation of the cardiovascular responses to tracheal intubation with oral manidipine

We conducted a placebo-controlled, randomized, and double-blinded study to evaluate the efficacy of manidipine given orally in attenuating the cardiovascular responses to laryngoscopy and tracheal intubation. Thirty normotensive patients (ASA physical status 1) undergoing elective surgery were allocated to one of three groups (n = 10 for each); placebo, 5 mg manidipine, and 10 mg manidipine groups. These tablets were orally administered 3 h before induction of anaesthesia. Anaesthesia was induced with thiopentone 5 mg.kg-1 iv, and tracheal intubation was facilitated with vecuronium 0.2 mg.kg-1. Laryngoscopy lasting 30 sec was attempted 2 min after induction of anaesthesia. Patients receiving placebo showed a significant increase in systolic and diastolic blood pressure associated with tracheal intubation. These increases following tracheal intubation were significantly reduced in patients receiving manidipine 10 mg compared with patients receiving placebo or manidipine 5 mg (P < 0.05). Oral administration of manidipine 10 mg before induction of anaesthesia is a simple and effective method for attenuating pressor response to laryngoscopy and tracheal intubation. We stressed that the potential beneficial effect of a reduced haemodynamic reaction to intubation might be obtained at the expense of hypotension later on.

Effect of superoxide dismutase on endothelium-dependent relaxation of aorta from endotoxin-treated rabbits

To assess the protective effect of superoxide dismutase (SOD) on the endothelium of aorta in endotoxaemia, we investigated the production of endothelium-derived relaxing factor in aorta obtained from endotoxin-treated rabbits concomitantly receiving SOD or not. Thirty-two male Japanese white rabbits were randomly divided into four groups (n = 8 for each group): one group receiving saline as a placebo, a second receiving 5 mg/kg endotoxin intravenously, a third receiving 5 mg/kg endotoxin intravenously plus SOD, and a fourth receiving SOD alone. SOD was injected intravenously at a dose of 10,000 U/kg before the endotoxin and was infused continuously at a rate of 15,000 units/kg/h throughout the experiment. The tension of the aorta was recorded in vitro 6 h after the start of in vivo treatment with endotoxin or saline. In the aorta of rabbits receiving endotoxin alone, acetylcholine-induced relaxation was reduced by 50%. The SOD fully restored the reduction of acetylcholine-induced relaxation by endotoxin. Histological studies using photomicroscopy revealed endothelial damage in the endotoxin-treated aorta, which was attenuated in the SOD-treated group. These data suggest that intravenous SOD may be an effective treatment for unstable haemodynamics in endotoxaemia.

Improvement of gas exchange following endobronchial instillation of an exogenous surfactant in an infant with respiratory failure by postoperative pulmonary haemorrhage

We administered surfactant to a 5-month-old infant with respiratory failure due to right pulmonary haemorrhage accompanied by oedema following abdominal surgery. These pathological conditions were probably precipitated by disseminated intravascular coagulation and intra-operative excessive administration of fluids, respectively. Endobronchial instillation of the exogenous surfactant (120 mg) after selective intubation of the right bronchus produced a dramatic improvement of gas exchange 30 min after treatment and of chest X-ray findings at 6 h post-treatment. This case on an infant indicates that administration of surfactant may be one of promising therapeutic approaches to respiratory failure due to pulmonary haemorrhage.

Perioperative changes in superoxide production in neonates and infants

We conducted a prospective study to investigate perioperative changes in the production of superoxide anion (O2-) by neutrophils isolated from ten neonates between the ages of five and 16 days (N group) and ten infants ranging in age from one to ten months (I group). They underwent abdominal surgery under general anaesthesia with halothane and nitrous oxide in oxygen. The O2- production (speed and amount) was measured perioperatively using the cytochrome c reduction method. Both groups showed a decrease in the speed and amount of O2- production during and after surgery. The decrease in O2- production reached its lowest level three hours postoperatively or at the end of surgery in both groups. The O2- production in the I group returned to the basal value 48 hr postoperatively. In contrast, the O2- production in the N group was still lower 48 hr after surgery than before anaesthesia. Although the total amount of O2- production by neutrophils in one mL of peripheral blood remained unchanged in the I group, the total amount of O2- production in the N group decreased at the end of surgery and thereafter. These data indicate that even relatively minor abdominal surgery with halothane anaesthesia may be associated with perioperative neutrophil impairment in both neonates and infants. This impairment of neutrophil function in infants but not in neonates may be compensated by an increase in neutrophil numbers. It is possible that perioperative susceptibility of neonates to bacterial infections is attributable, at least in part, to the inhibition of O2- production in neutrophils by surgery and general anaesthesia.

Efficacy of oral clonidine premedication in children

BACKGROUND

Clonidine, an alpha 2-adrenoceptor agonist, has been shown to be effective as a preanesthetic medication in adults. The current study was designed to investigate the efficacy of two doses of oral clonidine as a premedicant preceding oral atropine in children.

METHODS

In a prospective, randomized, double-blind, controlled clinical trial, 105 children, aged 4-12 yr, undergoing elective ophthalmologic surgery received 0.4 mg/kg diazepam, 2 micrograms/kg clonidine, or 4 micrograms/kg clonidine orally. These agents mixed with apple juice were administered 105 min before the estimated time of induction of anesthesia, and were followed by treatment with 0.03 mg/kg oral atropine 60 min before anesthesia. A blinded observer noted the children's level of sedation, quality of separation from parents, and degree of acceptance of mask application during inhalation of nitrous oxide used for establishment of venous access. Anesthesia was induced with 5 mg/kg thiamylal, and tracheal intubation was facilitated with 0.2 mg/kg vecuronium. Hemodynamic changes after tracheal intubation were compared among the three groups.

RESULTS

Clonidine produced significant sedation, and the effect was dose related. Clonidine, 4 micrograms/kg, provided better quality of separation and acceptance of mask than the two other regimens. This dose of clonidine attenuated the increases in blood pressure and heart rate after tracheal intubation. No clinically significant perioperative hypotension or bradycardia was observed.

CONCLUSIONS

These data indicate that, even in pediatric surgery, the combination of 4 micrograms/kg and 0.03 mg/kg oral clonidine is an effective premedication. However, the safety and optimal dose of clonidine in this setting remain to be determined.

Selective intrabronchial instillation of surfactant in a patient with pneumonia: a preliminary report

The efficacy of treatment with exogenous surfactant has been reported in children with respiratory failure due to severe pneumonia. Its effect in adults with similar features has not been established. We therefore administered 240 mg of surfactant to a 71 year old man, who had developed right lower lobe pneumonia and hypoxaemia following abdominal aortic surgery. After this treatment, the patient's oxygenation, evaluated by arterial oxygen tension/fraction of inspired oxygen (PaO2/FIO2) ratio during artificial ventilation, gradually improved, and ventilator settings could be reduced whilst maintaining PaO2 at the appropriate level. Although the precise mechanism by which surfactant improves respiratory failure due to pneumonia is unclear, administration of the drug may have overcome a quantitative deficiency of endogenous surfactant attributable to the antagonistic effect of pulmonary exudates and reduced production following damage to type II pneumocytes. The present case provides an indirect suggestion of a possible causal relationship between the improvement of oxygenation and administration of surfactant in adult respiratory failure caused by pneumonia.

Detection of human T-cell lymphotropic virus type-1 proviral DNA in the saliva of an adult T-cell leukaemia/lymphoma patient using the polymerase chain reaction

We report a case of adult T-cell leukaemia/lymphoma (ATLL), in whom the polymerase chain reaction (PCR) on genomic DNA from saliva demonstrated the monoclonal integration of human T-cell lymphotropic virus type-1 (HTLV-1) proviral DNA in lymphocytes in the saliva. These results provided evidence of the possibility of saliva-borne transmission of HTLV-1.

Selective intrabronchial instillation of surfactant in a patient with pneumonia: a preliminary report

The efficacy of treatment with exogenous surfactant has been reported in children with respiratory failure due to severe pneumonia. Its effect in adults with similar features has not been established. We therefore administered 240 mg of surfactant to a 71 year old man, who had developed right lower lobe pneumonia and hypoxaemia following abdominal aortic surgery. After this treatment, the patient's oxygenation, evaluated by arterial oxygen tension/fraction of inspired oxygen (PaO2/FIO2) ratio during artificial ventilation, gradually improved, and ventilator settings could be reduced whilst maintaining PaO2 at the appropriate level. Although the precise mechanism by which surfactant improves respiratory failure due to pneumonia is unclear, administration of the drug may have overcome a quantitative deficiency of endogenous surfactant attributable to the antagonistic effect of pulmonary exudates and reduced production following damage to type II pneumocytes. The present case provides an indirect suggestion of a possible causal relationship between the improvement of oxygenation and administration of surfactant in adult respiratory failure caused by pneumonia.

Effects of 2-, 4- and 12-hour fasting intervals on preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis in children

We evaluated 105 randomly-selected unpremedicated children aged 1-14 years to determine the effects of a 2-, 4- and 12-h preoperative fasting interval on the preoperative gastric fluid pH and volume, and plasma glucose and lipid homeostasis. Each child undergoing elective surgery ingested a large volume (approximately 10 ml/kg b.w.) of apple juice and then fasted for 2, 4 or 12 h before the estimated induction of anaesthesia. After induction of anaesthesia, gastric fluid was aspirated through a large-bore, multiorifice orogastric tube. Plasma concentrations of glucose, total ketone bodies, non-esterified fatty acid (NEFA), triglycerides, and cortisol were measured at the time of induction to evaluate the fasting interval effects on preoperative plasma glucose and lipid homeostasis. There were no significant differences between the three groups in either gastric fluid volume or pH. In addition, there were no significant differences between the groups with respect to the proportion with a pH < 2.5 and volume > 0.4 ml/kg b.w. Neither plasma concentrations of glucose, triglycerides, nor cortisol at the time of anaesthetic induction differed between the three groups. Both 4 and 12 h nil per os (NPO) caused an increase in lipolysis, which was presumably a compensatory mechanism to maintain normoglycaemia. The plasma NEFA and total ketone bodies concentrations were therefore significantly higher in these two fasting intervals than in 2 h NPO. These data suggest that a 2-h NPO, after a large volume of ingested apple juice, may offer additional benefits by preventing an increase in lipolysis during the fasting interval without either increasing the volume of gastric fluid or decreasing the gastric pH.(ABSTRACT TRUNCATED AT 250 WORDS)

Enhancement of Fc epsilon RII/CD23 expression on U937 cells with opsonized zymosan: the requirement of a Fc gamma RI/CD64 mediated signal associated phagocytosis

The kinetics of surface Fc epsilon RII/CD23 was tested on monocytic cell line U937 stimulated with opsonized zymosan. Zymosan opsonized with human serum enhanced not only the expression of surface Fc epsilon RII/CD23 but also Fc epsilon RII/CD23 mRNA detected by Northern blot and in situ hybridization techniques. This stimulation showed a marked synergism with IL-4 in the induction of Fc epsilon RII/CD23. Heat-inactivation of serum did not affect the inducibility of Fc epsilon RII/CD23 by opsonized zymosan, suggesting the involvement of serum substances other than complement. Zymosan treated with human gamma-globulin also induced Fc epsilon RII/CD23, indicating the possible involvement of Fc gamma receptors. The Fc epsilon RII/CD23 inducing effect of opsonized zymosan was partially blocked by pretreatment with heat-aggregated human gamma-globulin or an anti-Fc gamma RI monoclonal antibody but not by the anti-Fc gamma RII or Fc gamma RIII antibody. Our results showed the involvement of signals from Fc gamma receptor associated phagocytosis in the induction of Fc epsilon RII/CD23.

Attenuation of the pressor response to tracheal intubation with oral nitrendipine

The effect of nitrendipine on the cardiovascular responses to tracheal intubation was studied in a placebo-controlled, randomised, double-blind trial. Thirty patients (ASA physical status 1) undergoing elective surgery received either 5 or 10 mg nitrendipine, or a placebo orally 3 h before induction of anaesthesia (n = 10 for each group). Anaesthesia was induced with sodium thiopentone 5 mg/kg i.v. and tracheal intubation was facilitated with vecuronium 0.2 mg/kg i.v. Patients receiving the placebo showed a significant increase in the mean arterial pressure and the rate-pressure product in response to tracheal intubation. These increases following intubation were reduced in nitrendipine-treated patients compared with the placebo group (P < 0.05). Oral administration of nitrendipine (5 or 10 mg, 3 h before induction of anaesthesia) was able to attenuate the hypertensive response to tracheal intubation in ASA 1 patients under light anaesthesia. We propose this pharmacological technique with supplementary doses of opioids and/or benzodiazepines for the management of patients with hypertension or coronary artery disease.

[Case of diffuse esophageal spasm treated by long myotomy]

Diffuse esophageal spasm is a rare condition, which has generally been treated conservatively in Japan. A case of this disorder treated successfully by long myotomy is reported with a knowledge of prolonged pressure monitoring of the esophagus. A 56-year-old woman was admitted to our hospital with dysphagia. Barium swallow and esophagoscopy showed contraction of the esophagus, and manometry showed normal peristalsis, so the diagnosis of achalasia was ruled out. Prolonged pressure monitoring of the esophagus showed spastic contractions with the pressure over 130 mmHg that continued for 25 sec during meals, which led us to the diagnosis of diffuse esophageal spasm. Extramucosal long myotomy of the esophagus and a modified Belsey Mark IV operation were performed. The postoperative course was satisfactory and esophageal functional tests showed no spasms. The patient regained weight without dysphagia.

Effects of colchicine on the induction of ornithine decarboxylase and its gene expression by the phorbol ester tumour promoter

The activity and gene expression of ornithine decarboxylase (ODC, an indicator of tumour promotion) were induced by the phorbol ester tumour promoter, 12-O-tetradecanoylphorbol-13-acetate (TPA), in mouse skin. In the present study, the effect of colchicine, a microtubule-disrupting agent, on ODC activity and its gene expression were investigated. On administration of colchicine (100 micrograms) intraperitoneally 1.5 h before TPA treatment, ODC activity and ODC mRNA levels stimulated by TPA were suppressed to about 52 and 64%, respectively. These results suggest the involvement of a microtubule or colchicine-sensitive substrate in the signal transduction system for gene expression.

Use of prostaglandin E1 to treat peri-anaesthetic pulmonary hypertension associated with mitral valve disease

Severe pulmonary hypertension (PH) can be a critical problem during and after cardiac surgery, since it increases right ventricular afterload resulting in decreased cardiac output. A case of pulmonary hypertension associated with mitral valve disease and resistant to glyceryl trinitrate therapy during surgery is reported. The case was treated successfully with prostaglandin E1 (PGE1), indicating that PGE1 can be used peri-operatively in a patient with refractory PH resistant to glyceryl trinitrate treatment.