Acute changes in blood-CSF barrier permselectivity to serum proteins after intrathecal methotrexate and CNS irradiation

Effect of a preoperative single-dose steroid on pulmonary function and postoperative symptoms after modified radical mastectomy: results of a randomized clinical trial

Background

Evidence suggests that a preoperative single-dose steroid improves lung function and decreases the incidence of postoperative symptoms; however, this has not been sufficiently proved in modified radical mastectomy for cancer. This study aimed to evaluate the efficacy of preoperative single-dose steroid administration for postoperative lung function and postoperative symptoms in women undergoing modified radical mastectomy for breast cancer.

Methods

In this controlled clinical trial, conducted between June 2014 and October 2018, we examined 81 patients. Patients received a preoperative single dose of 8 mg dexamethasone (n=41; treatment group) or placebo (sterile injectable water; n=40; control group). We obtained data on postoperative nausea and vomiting and pain intensity and performed spirometry 1 h before and 1, 6, 12, and 24 h after surgery. The use of additional analgesic or antiemetic drugs was recorded. We followed up patients 30 days after discharge and recorded any surgical or medical complications.

Results

The age distribution and anthropometric variables of the two groups were similar. Almost 50% of the patients in each group also underwent breast reconstruction. In the treatment group, pain intensity was always lower, the incidence of postoperative nausea and vomiting was lower at 6, 12, and 24 h, and additional analgesics or antiemetics were required less frequently (P<0.05 for all). Both treatment and control groups demonstrated a restrictive ventilatory pattern immediately after surgery, which in the treatment group was reversed after 24 h. However, the reconstructed patients had a more intense and prolonged restrictive pattern (P<0.05). Surgical morbidity included one seroma observed in the control group. No infections occurred at the surgical site or at any other level, and no patient developed any metabolic disorder. No mortality was observed in either group.

Conclusions

This study establishes that a single preoperative dose of dexamethasone markedly decreased the incidence of postoperative nausea and vomiting and pain, improved respiratory parameters, and decreased the need for additional postoperative analgesic or antiemetic drugs.

Clinical Trial Registration

ClinicalTrials.gov (ID NCT02305173).

Effects of preoperative dexamethasone on postoperative pain, nausea, vomiting and respiratory function in women undergoing conservative breast surgery for cancer: Results of a controlled clinical trial

The objective was to evaluate whether preoperative administration of dexamethasone improved postoperative nausea and vomiting (PONV), pain and respiratory function tests in women undergoing conservative surgery for breast cancer. This was a controlled clinical trial conducted between June 2013 and October 2014. Eighty patients were evaluated. Patients received a preoperative dose of 8 mg of dexamethasone (n = 40) or placebo (n = 40). The data on PONV and pain intensity was obtained and forced spirometry tests were performed, 1 hr before and at 1, 6, 12 and 24 hr after surgery. Any use of additional analgesic/antiemetic drugs was recorded. Patients were followed until 30 days after surgery for any surgical or medical complications. The pain intensity was lower in the treatment group for all periods; PONV was lower at 6, 12 and 24 hr; Additional analgesics/antiemetics were required less frequently (all p < .05). Both groups exhibited a restrictive ventilatory pattern immediately after surgery, which was reversed in the following hours. However, spirometric values were higher in the dexamethasone group. There were no pulmonary or metabolic complications after surgery. Our conclusions were that dexamethasone significantly reduced the incidences of PONV, pain and improved respiratory parameters, and reduced the need for additional postoperative analgesic and antiemetic drugs.

Efficacy of dexamethasone for reducing postoperative nausea and vomiting and analgesic requirements after thyroidectomy

Objective

To evaluate the efficacy of dexamethasone for reducing postoperative nausea and vomiting (PONV) and analgesic requirements after thyroidectomy.

Study Design and Setting

In a prospective, randomized, double-blind, placebo-controlled study, 75 patients, 20 men and 55 women, received intravenously placebo or dexamethasone at 2 different doses (4 and 8 mg) (n = 25 of each) at the end of surgery. A standard general anesthetic technique was used. PONV and analgesic requirements were evaluated.

Results

The rate of patients experiencing PONV during the first 24 hours after anesthesia was 64% with dexamethasone 4 mg ( P = 0.269) and 28% with dexamethasone 8 mg ( P = 0.001), compared with placebo (76%). The need of indomethacin for intolerable pain was less in patients who had received dexamethasone 8 mg than in those who had received placebo ( P = 0.009).

Conclusion

Dexamethasone 8 mg effectively decreases PONV and analgesic requirements after thyroidectomy.

[Blood-brain barrier permeability in healthy rats and rats with experimental C6 glioma after fractionated radiotherapy of the brain]

OBJECTIVE

To evaluate the effect of fractionated radiotherapy on permeability of the blood-brain barrier in healthy rats and rats with C6 glioma in vivo.

MATERIAL AND METHODS

An increase in BBB permeability in C6 glioma was assessed by dynamic MRI monitoring (glioma size before and after radiation therapy in combination with immunotherapy, n=30) and confocal microscopy (fluorescence imaging of tumor invasion boundaries in a dose-dependent experiment for the amount of injected antibodies). In healthy rats, BBB permeability to macromolecular substances (MMS) was assessed by ELISA (n=23, 192 plasma samples) and confocal microscopy (n=7).

RESULTS

It was shown that BBB permeability to biological macromolecules in blood-brain and brain-blood directions was increased after fractionated radiotherapy.

CONCLUSION

Drug delivery to the brain can be improved using therapeutic doses of radiation treatment that affects the BBB and minimizes the risk of serious side effects that are often associated with the drug dose.

Is infusion of subhypnotic propofol as effective as dexamethasone in prevention of postoperative nausea and vomiting related to laparoscopic cholecystectomy? A randomized controlled trial

Background. Postoperative nausea and vomiting (PONV) is one of common complications in patients undergoing laparoscopic cholecystectomy (LC). Aim of this study was to compare the efficacy of subhypnotic (1 mg/kg/h) infusion of propofol with dexamethasone on PONV in patients undergoing LC. Methods. A total of 120 patients were included in this randomized, double-blind, placebo-controlled study. Patients were randomly assigned to 3 groups; patients of group dexamethasone (group D) were administrated 8 mg dexamethasone before induction of anesthesia, patients of group propofol (group P) were infused to subhypnotic (1 mg/kg/h) propofol during operation and patients of group control (group C) were applied infusion of 10% intralipid. The incidence of PONV and needs for rescue analgesic and antiemetic were recorded in the first 24 h postoperatively. Results. In the 0–24 h, the incidence of PONV was significantly lower in the group D and group P compared with the group C (37.5%, 40%, and 72.5%, resp.). There was no significant difference in the incidence of PONV and use of antiemetics and analgesic between group D and group P. Conclusion. We concluded that infusion of propofol 1 mg/kg/h is as effective as dexamethasone for the prevention of PONV during the first 24 hours after anesthesia in patients undergoing LC.

Effects of ramosetron and dexamethasone on postoperative nausea, vomiting, pain, and shivering in female patients undergoing thyroid surgery

PURPOSE

Some antiemetics are effective in the treatment of postoperative pain and shivering, as well as for postoperative nausea and vomiting (PONV). The aim of this study was to investigate the effects of ramosetron and dexamethasone on PONV, pain, and shivering and to determine the correlations between nausea, pain, and shivering.

METHODS

For this study, 123 patients scheduled for thyroid surgery were randomly allocated to one of three groups: the control group (group C, n = 41), dexamethasone group (group D, n = 41), or the ramosetron group (group R, n = 41). The patients were treated intravenously with 2 mL of 0.9 % NaCl, 2 mL of 5 mg/mL dexamethasone, or 2 mL of 0.15 mg/mL ramosetron immediately after anesthesia.

RESULTS

The overall incidence and severity of postoperative nausea and the level of antiemetic consumption were significantly lower in group R compared with group D, and these parameters were significantly lower in groups R and D than in group C. There were significant differences in the incidence and severity of shivering, severity of pain, and analgesic consumption between group C and group R or D, but the incidence of shivering, pain severity, and analgesic consumption did not differ between groups R and D. The severity of shivering was significantly lower in group R than in group D. The correlation coefficients for shivering and pain, shivering and nausea, and pain and nausea were 0.210 (P = 0.010), 0.106 (P = 0.198), and 0.190 (P = 0.035), respectively, in group C.

CONCLUSIONS

Two antiemetic drugs, ramosetron and dexamethasone, significantly reduced the incidence and severity of postoperative nausea and the need for administration of rescue antiemetic drugs. Furthermore, both drugs effectively decreased the severity of pain and shivering. Ramosetron was superior to dexamethasone for reducing nausea, antiemetic consumption, and the severity of nausea, but not for reducing the incidence of shivering. Further studies are required to elucidate the correlations between postoperative nausea, pain, and shivering, as a statistically significant but weak correlation was shown in the present study.

Preoperative dexamethasone reduces postoperative pain, nausea and vomiting following mastectomy for breast cancer

Background

Dexamethasone has been reported to reduce postoperative symptoms after different surgical procedures. We evaluated the efficacy of preoperative dexamethasone in ameliorating postoperative nausea and vomiting (PONV), and pain after mastectomy.

Methods

In this prospective, double-blind, placebo-controlled study, 70 patients scheduled for mastectomy with axillary lymph node dissection were analyzed after randomization to treatment with 8 mg intravenous dexamethasone (n = 35) or placebo (n = 35). All patients underwent standardized procedures for general anesthesia and surgery. Episodes of PONV and pain score were recorded on a visual analogue scale. Analgesic and antiemetic requirements were also recorded.

Results

Demographic and medical variables were similar between groups. The incidence of PONV was lower in the dexamethasone group at the early postoperative evaluation (28.6% vs. 60%; p = 0.02) and at 6 h (17.2% vs. 45.8%; p = 0.03). More patients in the placebo group required additional antiemetic medication (21 vs. 8; p = 0.01). Dexamethasone treatment significantly reduced postoperative pain just after surgery (VAS score, 4.54 ± 1.55 vs. 5.83 ± 2.00; p = 0.004), at 6 h (3.03 ± 1.20 vs. 4.17 ± 1.24; p < 0.0005) and at 12 h (2.09 ± 0.85 vs. 2.54 ± 0.98; p = 0.04). Analgesics were required in more patients of the control group (21 vs. 10; p = 0.008). There were no adverse events, morbidity or mortality.

Conclusions

Preoperative intravenous dexamethasone (8 mg) can significantly reduce the incidence of PONV and pain in patients undergoing mastectomy with axillary dissection for breast cancer.

Trial registration number

NCT01116713

RETRACTED: Dexamethasone for reduction of nausea, vomiting and analgesic use after gynecological laparoscopic surgery

OBJECTIVE

To evaluate the prophylactic use of dexamethasone for reducing postoperative nausea and vomiting (PONV) and analgesic use after gynecological laparoscopic surgery.

METHODS

In a prospective randomized, double-blind, placebo-controlled trial, 90 women received either intravenous placebo, 4 mg dexamethasone or 8 mg dexamethasone at the end of surgery. PONV and analgesic requirements were evaluated.

RESULTS

The rate of patients experiencing PONV within 24 h after anesthesia was 53% in the 4 mg dexamethasone group (P=0.3) and 20% in the 8 mg dexamethasone group (P=0.001), compared with the placebo group (63%). Requests for indomethacin to relieve intolerable pain were less in patients in the 8 mg dexamethasone group compared with the 4 mg dexamethasone (P=0.047) or placebo (P=0.029) groups.

CONCLUSION

Prophylactic use of 8 mg dexamethasone is effective for reducing PONV and analgesic requirements after gynecological laparoscopic surgery.

Effects of dexamethasone in preventing postoperative emetic symptoms after total knee replacement surgery: a prospective, randomized, double-blind, vehicle-controlled trial in adult Japanese patients

BACKGROUND

Postoperative emetic symptoms (nausea, retching, and vomiting) are common following total joint replacement, with an incidence as high as 83% when no prophylactic antiemetic is provided. However, most antiemetics currently used in Japan, such as antihistamines (eg, hydroxyzine), butyrophenones (eg, droperidol), and dopamine receptor antagonists (eg, metoclopramide), have been associated with adverse effects (AEs), such as excessive sedation, hypotension, dry mouth, dysphoria, hallucinations, and extrapyramidal symptoms.

OBJECTIVE

The aim of this study was to assess the efficacy and tolerability of 3 doses of intravenous dexamethasone monotherapy versus vehicle in preventing emetic symptoms after total knee replacement performed under combined general and epidural anesthesia.

METHODS

This prospective, randomized, double-blind, vehicle-controlled trial was conducted at the Department of Anesthesiology, University of Tsukuba Institute of Clinical Medicine, Tsukuba, Japan. Adult Japanese patients scheduled to undergo total knee replacement were eligible. Patients were randomly assigned to 1 of 4 treatment groups: dexamethasone 4, 8, or 16 mg, or vehicle (control). Patients received combination anesthesia with sevoflurane and nitrous oxide in pure oxygen (general) and lidocaine (epidural). Study drugs were administered intravenously after the completion of surgery. An investigator blinded to treatment assignment monitored patients for emetic symptoms for 24 hours after the patient awoke. Patients rated their satisfaction with the study drug using a linear, 11-point scale (0 = complete satisfaction to 10 = complete dissatisfaction). Tolerability was assessed by the study investigator using spontaneous reporting and patient interview.

RESULTS

A total of 80 patients were enrolled (58 women, 22 men; mean [SD] age, 59 [10] years; mean [SD] height, 154 [7] cm; mean [SD] body weight, 55 [7] kg; 20 patients per treatment group). The demographic, clinical, and surgical data were comparable between the 4 treatment groups. The rates of emesis-free patients were 35% (7 patients), 70% (14), and 75% (15) with dexamethasone 4, 8, and 16 mg, respectively, compared with 30% (6) with vehicle (P = NS, 0.013, and 0.005, respectively). Median (range) patient satisfaction scores were significantly higher in the groups receiving dexamethasone 8 and 16 mg (both, 0.0 [0-9]) compared with controls (6.0 [0-10]) (P = 0.013 and 0.008, respectively). This effect was not found with the 4-mg dose. No clinically serious AEs attributed to the study drug were observed in any of the 4 treatment groups.

CONCLUSIONS

In this study of a small, select group of adult Japanese patients undergoing total knee replacement, the rates of emesis-free patients were higher with dexamethasone 8 and 16 mg compared with vehicle 24 hours after anesthesia induction. This effect was not found with the 4-mg dose. All treatments were well tolerated.

RETRACTED: Reduction of postoperative emetic episodes and analgesic requirements with dexamethasone in patients scheduled for dental surgery

STUDY OBJECTIVE

To evaluate the antiemetic and analgesic effects of dexamethasone for the first 24 hours postoperatively in patients scheduled for dental surgery.

DESIGN

Prospective, randomized, double-blind, placebo-controlled study.

SETTING

University hospital.

PATIENTS

One hundred twenty ASA physical status I and II patients (45 men, 75 women; aged 17-48 years) undergoing general anesthesia for dental surgery.

INTERVENTIONS

Patients received intravenously placebo or dexamethasone at 3 different doses (4, 8, or 16 mg) at the end of the surgical procedure. A standard general anesthetic technique, including sevoflurane and nitrous oxide in oxygen, was used.

MEASUREMENT AND MAIN RESULTS

Emetic episodes and analgesic requirements were evaluated. The rate of patients who were emesis free (no nausea, retching, or vomiting) during 0 to 24 hours after anesthesia was 63% with dexamethasone 4 mg (P = NS), 83% with dexamethasone 8 mg (P < .05), and 90% with dexamethasone 16 mg (P < .05), compared to placebo (60%). The need for diclofenac sodium for intolerable pain was less in patients who had received dexamethasone 8 mg or dexamethasone 16 mg than in those who had received placebo or dexamethasone 4 mg (P < .05). No clinically important adverse events were observed in any group.

CONCLUSIONS

Prophylactic dexamethasone 8 mg is effective for the prevention of nausea and vomiting after dental surgery and in the management of postoperative pain. Increasing the dose to 16 mg provides no further benefit.

The effect of dexamethasone on postoperative pain and emesis after intrathecal neostigmine

We evaluated the effect of a single dose of dexamethasone on the incidence and severity of postoperative nausea and vomiting (PONV) after intrathecal injection of tetracaine plus neostigmine. Sixty ASA physical status I patients scheduled for inguinal herniorrhaphy were studied with a randomized, double-blinded, placebo-controlled protocol. The dexamethasone group (Group D) received 10 mg of dexamethasone IV before performance of spinal anesthesia, whereas the placebo group (Group P) received saline. Spinal anesthesia was performed with intrathecal injection of 15 mg tetracaine plus neostigmine 100 microg in both groups. Pain, PONV, and other side effects were evaluated 24 h after surgery. The duration and severity of analgesia and the incidence of PONV were not significantly different between the two groups. Our results demonstrate that a single dose of dexamethasone (10 mg) did not potentiate the analgesic effect or reduce the incidence of PONV after intrathecal injection of tetracaine and neostigmine.

IMPLICATIONS

The results of our evaluation of the effect of IV dexamethasone versus saline control on analgesia and nausea and vomiting after intrathecal neostigmine and tetracaine suggest that IV dexamethasone did not enhance the analgesic effect of neostigmine or reduce the incidence of emesis after intrathecal administration.

Delayed craniospinal irradiation for a first isolated central nervous relapse of acute lymphoblastic leukemia: report on 14 cases

BACKGROUND

Children developing an isolated central nervous system (CNS) relapse as first recurrence of their acute lymphoblastic leukemia (ALL) are considered to have a systemic relapse as well. They are mostly treated with intensive chemotherapy and craniospinal irradiation. In most treatment schedules, irradiation is given early after induction treatment. Because craniospinal irradiation affects a large portion of hematopoietic bone marrow systemically, treatment is often delayed owing to aplasias. Also, dose reductions are frequently needed. Children receiving simultaneously irradiation and chemotherapy are prone to (often severe) neurotoxicity. This study reports on children with a first isolated CNS relapse of their ALL receiving chemotherapy for 40 weeks. Treatment ends with the administration of irradiation given after cessation of chemotherapy.

PROCEDURE

Fourteen children, with blasts and >5 cells/mm(3) in two consecutive samples of cerebrospinal fluid and a blast percentage <5% in their bone marrow were treated according to an intensive systemic and site-specific chemotherapy. Craniospinal irradiation was administered after cessation chemotherapy.

RESULTS

Event-free-survival was 57% (confidence interval 35-89%), freedom from relapse was 61.5%; follow-up ranges from 2.0 to 15.1 years (median 11.7 years). One child died from septicemia during induction. Five children experienced a second relapse and died from their malignancy. Two children [with a t(9;22) or a rearranged MLL gene] relapsed prior to radiotherapy. Outcome was related to duration of first remission, age at relapse, and identification as a high-risk patient at initial diagnosis. No neurologic complications were noted during and after treatment.

CONCLUSIONS

Delayed irradiation for isolated CNS relapse in children with ALL gives favorable survival rates, without significant toxicity. Neurotoxicity was absent.

Role of dexamethasone dosage in combination with 5-HT3 antagonists for prophylaxis of acute chemotherapy-induced nausea and vomiting

Dexamethasone (20 mg) or its equivalent in combination with 5-HT3 antagonists appears to be the gold-standard dose for antiemetic prophylaxis. Additional to concerns about the use of corticosteroids with respect to enhanced tumour growth or impaired killing of the tumour cells, there is evidence that high-dosage dexamethasone impairs the control of delayed nausea and emesis, whereas lower doses appear more beneficial. To come closer to the most adequate dose, we started a prospective, single-blind, randomized trial investigating additional dosage of 8 or 20 mg dexamethasone to tropisetron (Navoban), a 5-HT3 receptor antagonist, in cis-platinum-containing chemotherapy. After an interim analysis of 121 courses of chemotherapy in 69 patients, we have been unable to detect major differences between both treatment alternatives. High-dose dexamethasone (20 mg) had no advantage over medium-dose dexamethasone with respect to objective and subjective parameters of acute and delayed nausea and vomiting. In relation to concerns about the use of corticosteroids in non-haematological cancer chemotherapy, we suggest that 8 mg or its equivalent should be used in combination with 5-HT3 antagonists until further research proves otherwise.

5-Hydroxyindoleacetic acid (5-HIAA) and cortisol excretion as predictors of chemotherapy-induced emesis

This study evaluated the relationship between prechemotherapy cortisol and 5-hydroxyindoleacetic acid (5-HIAA) excretion and chemotherapy-induced emesis. The urinary excretion of cortisol and the serotonin metabolite 5-HIAA in the night before chemotherapy administration were measured in 28 and 49 female patients receiving > 300 mg m-2 carboplatin. Vomiting and nausea were documented over a 3 day observation period. Lower basal cortisol excretion was significantly correlated with vomiting with or without nausea occurring within the observation period. 5-HIAA showed only a weak correlation with emesis on days 1-3, but low 5-HIAA excretion was correlated with a higher proportion of patients vomiting on days 2-3 following chemotherapy. Low basal cortisol excretion might be useful as a predictor for chemotherapy-induced emesis and therefore should be evaluated prospectively in future studies.

Cisplatin acutely reduces 5-hydroxytryptamine-induced vagal depolarization in the rat: protective action of dexamethasone

The effect of the anti-cancer cytotoxic drug cisplatin on KCl and 5-hydroxytryptamine (5-HT)-induced depolarization in the rat isolated cervical vagus nerve was investigated using the 'grease gap' extracellular recording technique. KCl (10 mM) perfused onto the isolated nerve previously incubated for 2 h in 10 microM cisplatin initiated a d.c. potential of 1.06 +/- 0.09 mV compared to a potential of 1.29 +/- 0.13 mV in control nerves. Perfusion with 5 microM 5-HT produced a markedly reduced depolarization (0.23 +/- 0.02 mV) in cisplatin-treated nerves compared with control nerves (0.42 +/- 0.04 mV, P = 0.005). This effect was enhanced when 5-HT was reapplied 30 min later (0.19 +/- 0.02 mV in cisplatin-treated compared with 0.42 +/- 0.03 mV in controls, P < 0.0001). The inhibitory effect of cisplatin on 5-HT-induced depolarization was found to be significantly (P = 0.004) reduced by the addition of dexamethasone (10 microM) to the incubation buffer (0.34 +/- 0.04 mV). These results are discussed in the light of the emetic and neurotoxic effects of cisplatin and the protective effects of dexamethasone.

Antiemetic therapy in adults with terminal disease: a brief review

Although nausea and vomiting (NV) are common complaints among individuals with terminal illness, there are few studies evaluating the magnitude of this disabling syndrome. Most research has emphasized chemotherapy-induced emesis, however, Reuben and Mor analyzed National Hospice Study data and noted NV in 62 percent of patients with advanced malignancy during the last two months of life. In addition, NV was observed more frequently in women, persons younger than 65 years of age, and patients with stomach and breast cancer. Lamentably, physicians were less likely to prescribe antiemetics in the elderly and in patients with an impaired level of awareness. With such a paucity of studies on NV in terminally-ill patients, there is frequent confusion regarding the etiology of emesis and the selection of appropriate antiemetics. This article will review the syndrome of NV, and discuss available drug regimens.

Control of chemotherapy-induced emesis

The development of antiemetic drugs has been one of the most rewarding areas of oncologic research, since therapeutic advances in this area can result in immediate improvement in the quality of life for patients undergoing chemotherapy. Antiemetic therapy has progressed dramatically during the past decade and a half. Fifteen years ago, patients receiving cisplatin for the first time had a median of 12 vomiting episodes within the first 24 hours, whereas now more than 50 percent of such patients have no vomiting episodes at all. Theoretical and clinical challenges remain, however, in the effort to control chemotherapy-induced emesis. The mechanisms of anticipatory vomiting and delayed vomiting are still not understood, and consistently effective therapeutic approaches to these problems have yet to be developed.

Endogenous cortisol exerts antiemetic effect similar to that of exogenous corticosteroids

Lower pre-chemotherapy night time cortisol excretion predicted more severe cisplatin induced nausea and vomiting in 42 ovarian cancer patients receiving ondansetron as a single antiemetic agent. Dexamethasone administration added to the antiemetic effect of ondansetron principally in patients who had low excretion of cortisol.

Brain lesions following combined treatment with methotrexate and craniospinal irradiation

Eight patients with meningeal seeding by carcinoma or lymphomas were treated with intravenous (i.v.) and/or intrathecal (i.th.) Methotrexate (MTX). Seven patients received additional craniospinal irradiation and in all seven a fatal encephalopathy developed. On the bases of clinical and morphological findings we identified an acute and a delayed form of encephalopathy and concluded that the concurrent administration of Methotrexate and of craniospinal irradiation increases considerably the risk of brain damage.

Controlling emesis related to cancer therapy

Combinations of dopamine antagonists or high-dose metoclopramide with steroids can provide complete control of chemotherapy-related nausea and vomiting in up to 60-70% of patients undergoing high-dose cisplatin-based chemotherapy. High-dose metoclopramide probably acts as a 5-HT3 receptor antagonist, but because of its dopamine-receptor antagonism it is the cause of extrapyramidal side-effects. These compounds, and the agents used in combination with them, tend to cause sedation, an undesirable effect in the outpatient setting. Specific 5-HT3 receptor antagonists (ondansetron, granisetron, tropisetron) give a similar control of chemotherapy related nausea and vomiting, with minimum side-effects. These drugs can cause headaches and constipation and some have been related to transient liver enzyme abnormalities in cancer patients; however, disease and chemotherapy might also be the cause of the enzyme anomalies. Combinations of 5-HT3 receptor antagonists with steroids may provide a very high degree of protection.

Electrolytes, amino acids and proteins in lumbar CSF during the treatment of acute leukemia in childhood

We performed analyses of electrolytes, amino acids, albumin, alpha 2-macroglobulin, gamma-globulin and LDH in the lumbar cerebrospinal fluid of children undergoing treatment for acute lymphoblastic leukemia, non-Hodgkin-lymphoma or acute myeloid leukemia. At the time of diagnosis signs of a disturbance of the blood-brain barrier were found in some patients. During induction treatment with L-asparaginase a rise of glutamic acid and a decrease of glutamine occurred. This finding correlated with slowing of the EEG. Treatment with vincristine was associated with a slight drop of sodium and chloride concentration in serum, but not in the cerebrospinal fluid. Central nervous system prophylaxis with cranial irradiation, and to a lesser degree with intravenous medium-dose methotrexate, gave rise to a further deterioration of the blood-brain barrier function as indicated by an increase in albumin, alpha 2-macroglobulin and LDH levels. During radiotherapy the concentration of several amino acids rose, probably due to a disturbance of active carrier mechanisms. Patients with elevated albumin at the end of radiotherapy more often suffered an early leukemia relapse while still on treatment. No other clinical or electroencephalographic correlations of altered barrier function could be found.

Dexamethasone can potentiate the anti-emetic action of a 5HT3 receptor antagonist on cyclophosphamide induced vomiting in the ferret

A new group of selective 5HT3 antagonists are proving to be effective anti-emetics for cytotoxic and radiation induced vomiting in both animal models and man. Current anti-emetic regimens often benefit from combination therapy, in particular the efficacy of metoclopramide (which can be a weak 5HT3 antagonist), can be improved by combination with dexamethasone, another anti-emetic. Hence it was of interest to evaluate whether a 5HT3 receptor antagonist GR38032F could be improved by combination with dexamethasone. Vomiting induced by cyclophosphamide in the ferret was observed after pre-treatment with dexamethasone alone or in combination with GR38032F. Animals were also observed for signs of 'nausea'. Dexamethasone alone proved a weak anti-emetic in this system but did have significant effects on 'nausea'. GR38032F has previously been shown to be capable of totally controlling emesis due to cyclophosphamide in the ferret. Here a dose of GR38032F that is not 100% effective was employed; this was shown to have effects on 'nausea' but most interestingly its anti-emetic action was increased by combination with dexamethasone. This may be important for the minority of patients whose vomiting is not completely controlled by GR38032F alone.

Correlation between protein data in normal lumbar CSF and morphological findings of choroid plexus epithelium: a biochemical corroboration of barrier transport via tight junction pores

Specific "reference areas" were derived from relationships between the proteins prealbumin, albumin, alpha 1-acid glycoprotein, alpha 2-macroglobulin, total transferrin, IgG, IgA, IgM, and the corresponding total protein in normal lumbar CSF samples. The procedure for calculating the boundary lines of these reference areas was carried out on the basis of double standard deviations in subgroups with total protein differences of 50 ml/l within the whole range of 150-400 ml/l CSF. The resulting biochemical data, hydrodynamic radii of the individual proteins investigated, and van Deurs' and Koehler's morphological findings on the existence of pores in the barrier-forming tight junctions of the choroid plexus epithelium could be surprisingly well correlated with one another, although these morphological findings were obtained in choroid plexus of the rat brain. The correlation allowed the conclusion that proteins undergo ultrafiltration via a pattern of tight junction pores with various diameters. However, the molecular mechanism seems to include an additional facilitating component.