Cerebral edema associated with diabetic ketoacidosis: Two case reports

Background

Diabetic ketoacidosis (DKA) is associated with a high mortality rate, especially if cerebral edema develops during the disease course. It is rarer and more severe in adults than in children. We present cases of two patients with cerebral edema-related DKA.

Case presentation

The first patient was a 38-year-old man with diabetes mellitus who presented with DKA-related disturbed consciousness. Although glycemic correction was performed slowly, he showed pupil dilation 11 h later. He underwent emergency ventricular drainage, but died of cerebral herniation. The second patient was a 25-year-old woman who presented with impaired consciousness secondary to DKA. Head computed tomography showed subarachnoid hemorrhage and cerebral edema. No related intraoperative findings were observed; it was concluded that the first computed tomography scan revealed pseudo-subarachnoid hemorrhage.

Conclusion

Diabetic ketoacidosis-related cerebral edema develops despite treatment according to guidelines and is difficult to predict. Therefore, adult patients should be treated cautiously during DKA management.

A false-positive pneumococcal rapid urinary antigen test in Streptococcus intermedius infection

An 83-year-old woman was admitted with empyema. Pneumococcal rapid urinary antigen testing on admission showed a positive result, but culture of pleural effusion yielded only Streptococcus intermedius. S. intermedius is a member of the anginosus group and a component of the regular flora of the oral cavity and gastrointestinal tract. As a human pathogen, this species has gained notoriety for abscess formation in the liver and brain but has also been reported recently as a major agent causing pulmonary abscesses or empyema, and the number of affected patients is increasing with the aging of society. We present the first case of a false-positive pneumococcal rapid urinary antigen test in empyema caused by S. intermedius.

Evidence for intermolecular interaction between sulfonium and sulfide sulfur atoms and its application to synthesis of cyclic bis(disulfide) dimer

On the basis of the remote Pummerer reaction of p-bis(alkylthio)-aromatic S-oxides, the intermolecular interaction between the sulfonium and sulfide sulfur atoms is described. (1) In marked contrast to the Pummerer reaction of 1b-d(3) with (CF(3)CO)(2)O (J. Org. Chem. 1999, 64, 3190-3195), the reaction of 3,3',5,5'-tetramesityl-4-(trideuteriomethylsulfinyl)-4'-(methylthio)biphenyl (1a-d(3)) as a sterically hindered analogue of 1b gave only 2a-d(2). (2) Both reactions of the two unsymmetrical regioisomers of 1-(ethylthio)-4-(methylthio)benzene S-oxide (5a and 5b) with (CF(3)CO)(2)O afforded a mixture of the mono-Pummerer products 6a and 6b, the bis-Pummerer product 7, and the bis-sulfide 8 in a similar ratio. The quenching at the initial stage of both reactions produced 5a, 5b, 8, and the bis-sulfoxide 10 in a similar ratio. These results indicate the equilibrium in the intermolecular interaction between the sulfur atoms. (3) The reaction of the p-bis(benzylthio)-aromatic S-oxide 16 with (CF(3)SO(2))(2)O gave the cyclic bis(disulfide) dimer 17 for the diphenyl sulfide and diphenylmethane spacers or the cyclic tetrakis(disulfide) tetramer 19 for the benzene and biphenyl spacers via the debenzylation of an intermolecular dithia dication. The cyclic bis(dithia dication) dimer A resulting from the intermolecular interaction between the sulfonium and sulfide sulfur atoms is proposed as an intermediate throughout the present reactions.

A multi-institutional prospective study of lentinan in advanced gastric cancer patients with unresectable and recurrent diseases: effect on prolongation of survival and improvement of quality of life. Kanagawa Lentinan Research Group

BACKGROUND/AIMS

Lentinan is one of the host-mediated anti-cancer drugs which has been shown to affect host defense immune systems. Although the mechanisms involved in the antitumor effects of lentinan have been reported experimentally, the clinical outcome on prolongation of survival and improvement of quality of life in gastric cancer patients with unresectable or recurrent diseases has yet to be clarified. The aim of the present study was to investigate whether administration of lentinan prolonged survival or improved quality of life in these patients.

METHODOLOGY

A multi-institutional randomized prospective protocol, consisting of patients administered tegafur and cisplatin (control group), and patients administered lentinan, tegafur and cisplatin (lentinan group), was performed. Quality of life was investigated using a questionnaire survey.

RESULTS

Median survival was significantly longer in the lentinan group than in the control group (297 days vs. 199 days, p = 0.028). One-year survival rate was greater in the lentinan group than in the control group (49.1% vs. 0%). Total QOL score, especially appetite and sleep quality, was significantly improved with the administration of lentinan.

CONCLUSIONS

Lentinan is considered to prolong survival and improved quality of life when gastric cancer patients with unresectable or recurrent diseases are treated in combination with other chemotherapeutic agents.

Histopathological response to preoperative chemotherapy including 5-fluorouracil additionally assessed by immunocytochemical and pharmacologic parameters in patients with advanced gastric cancer

To investigate quantitative methods for assessing the response to preoperative downstaging chemotherapy (PDC), the immunocytochemical expression of proliferating cell nuclear antigen (PCNA) and bromodeoxyuridine (BrdU) as well as a pharmacologic study of the rate of thymidylate synthetase inhibition (TSIR) were studied in resected specimens obtained from patients with advanced gastric cancer. Fifty-one patients with advanced gastric cancer who received PDC (30 with 5-fluorouracil peroral administration and the other 21 with intravenous administration of 5-fluorouracil and cisplatin) were studied. The labeling index of PCNA (PCNA-LI) and BrdU were measured. The PCNA suppression (PCNA-S), which was measured by both the values of prechemotherapeutic PCNA-LI in endoscopically biopsied specimens and postchemotherapeutic PCNA-LI in resected specimens, was also examined. TSIR was measured by a protein-bound radiochemical method. We compared the above-mentioned parameters with the histopathological response to PDC according to the General Rules for Gastric Cancer Study. In the patients with peroral 5-flurorouracil, a stepwise regression analysis showed that TSIR is a significantly effective for determining the histopathological response to PDC. In the patients with 5-fluorouracil and cisplatin, PCNA-S was the most effective indicator of the histopathological response to PDC, as shown by a stepwise regression analysis. The present study thus showed that both TSIR and PCNA-S were effective additional indicators of the histopathological response to PDC.

Prognostic evaluation of curatively resected locally advanced gastric cancer patients with preoperative downstaging chemotherapy assessed by histochemical and pharmacologic means

The aim of the present study was to investigate whether the rate of thymidylate synthetase inhibition (TSIR) and the rate of proliferating cell nuclear antigen expression (PCNA-R) in gastric cancer tissues, which can be obtained within a short period after surgery, were predictive and quantitative prognostic factors for locally advanced gastric cancer patients with preoperative down-staging chemotherapy. Curatively resected 30 locally advanced gastric cancer patients with preoperative chemotherapies were studied. Three-year survival analysis showed that the higher TSIR and the lower PCNA-R significantly predicted better prognosis (p < 0.01 and p < 0.05, respectively). Multiple regression test showed that the TSIR was a significantly predictive variable for 1-year survival (p < 0.05). The TSIR and PCNA-R could be predictive and quantitative prognostic factors in advanced gastric cancer patients who received preoperative downstaging chemotherapy.

Efficacy of intraportal injection of anti-ICAM-1 monoclonal antibody against liver cell injury following warm ischemia in the rat

BACKGROUND

Increased expression of intercellular adhesion molecule-1 (ICAM-1) and lymphocyte-function-associated antigen-1 (LFA-1) has been reported to play a major role in reperfusion injury after ischemia. In the present study we tested the effects of anti-rat-ICAM-1 monoclonal antibody (1A29) on partial-liver warm ischemia in rats.

METHODS

Histological changes and expression of ICAM-1 and LFA-1 were investigated in rat partial-liver warm ischemia, performed by clamping hepatic hilar vessels distributing to the right lateral lobe for 30, 45, and 60 minutes. In a second study, the effects of intraportal 1A29 injection after 60 minutes of warm ischemia in the rat were examined histologically. In both studies, the liver tissue was removed for analysis 48 hours after clamping.

RESULTS

Reperfusion after 60 minutes of warm ischemia induced histological liver injury and strong expression of ICAM-1 and LFA-1, although 30 and 45 minutes of ischemia did not provoke either histological damages or the expression of ICAM-1 and LFA-1. Intraportal injection of 1A29 after 60 minutes of warm ischemia clearly suppressed liver cell injury histologically.

CONCLUSION

Intraportal injection of 1A29 prevented the histological inflammation of an ischemic liver and may be useful in liver surgery or liver transplantation, because high concentrations can reach the target organ and nonspecific immunosuppression in other tissues and organs can be decreased.

[The evaluation of cellular proliferating activity in gastric carcinoma with the proliferating cell nuclear antigen (PCNA) expressive rate: its fundamental examination of the immunohistochemical procedures and its clinical applications]

PCNA is known as a cell cycle-related nuclear antigen. We stained PCNA immunohistochemically, and examined whether or not PCNA expressive rate could be applied clinically for a biological parameter of the histopathological effects in preoperative chemotherapy. PCNA was stained in proliferating cell by measuring nuclear DNA simultaneously. The most suitable fixation time in PCNA expression was 24 hours. On the examination of fixation fluid, ethanol was considered to be more suitable than buffer formaldehyde because PCNA expressive rate in ethanol correlated to BrdU labeling index with statistical significance. We examined PCNA expressive rate in gastric carcinomas. In the group whose histopathological effects of preoperative chemotherapy was recognized to be positive, PCNA expressive rate was significantly lower than in the group of negative effect. We measured thymidylate synthetase inhibition rate (TSIR) in the cases of preoperative oral administration of 5-FU, and the significantly negative correlation was seen between TSIR and PCNA expressive rate in the cases of differentiated adenocarcinoma (p < 0.05). The proliferating activity was recognized to be lower in the cases of higher inhibitional effect for DNA synthesis. PCNA expressive rate was considered to be a more effective and objective biological parameter on the evaluation of malignant potential in gastric carcinoma.

[The comparison of absorptive routes of intraperitoneal infusion with cisplatin in dogs]

Dogs weighing between 10 and 15 kg were used, and cisplatin was given at a dose of 2 mg/kg. The dogs were infused ip with either 100 ml (A groups) or 200 ml (B groups) of physiological salt solution containing cisplatin. The cisplatin concentrations in serum (peripheral and portal blood), and liver tissues were measured with limited filtration using MPS of AMICON (free-CDDP). The total CDDP concentration was also determined. Blood was collected at 30 minutes, and 1, 2, 3, 4, 5 and 6 hours after ip administration. The following results were obtained: 1) A high concentration of free-CDDP (AUC) was observed in the portal blood of A groups. 2) Peripheral serum level (total-CDDP) was increased in the B groups. 3) Total CDDP level within the liver tissues was higher in the A groups. It is concluded that ip cisplatin therapy with moderate volume solution may be effective for liver metastasis of gastric cancer for delivery to the liver tissue.

[Combination therapy with 5-FU, etoposide and CDDP (FEP regimen) in advanced primary and recurrent gastric cancer]

Surgery is still the treatment of choice in gastric cancer. However, despite the availability of extended surgical procedures, the majority of patients with stage IV gastric cancer have a poor prognosis. Therefore, other treatment modalities, especially systemic chemotherapy, have been investigated intensively. The recent successes achieved with combination chemotherapy regimens, such as EAP, strongly indicated that gastric cancer is chemosensitive. We also treated previously untreated patients with advanced and recurrent gastric cancer. Chemotherapy of CDDP 30 mg/m2 was given intravenously (i.v.) on day 1; etoposide 70 mg/m2 (i.v.) on days 2 to 4; and 5-FU 500 mg/m2 (i.v.) on days 2 to 5. The courses were repeated every 3 weeks. FEP induced an overall response rate of 25%, including 25% PR (primary tumor) and 25% PR (liver-metastasis). The median survival rate for all patients was 7.3 months and partial responses were seen in three patients with a median response duration of 13.1 months. In 2 patients with PR of primary tumor, one patient underwent a second-look operation and one patient refused an operation. Therefore, ten of 12 patients entered have died, and 2 patients remain alive. We concluded that FEP regimen can be useful in the treatment of advanced and recurrent gastric cancer. Moreover, the preoperative use of effective regimens seems to improve prognosis.

[Pharmacokinetics following intraperitoneal infusion of cisplatinum with and without sodium thiosulfate rescue in carcinomatous peritonitis in advanced gastric cancers]

The pharmacokinetics of ip cisplatinum (100 mg/body) was studied in 10 patients with advanced gastric cancer. Five patients were administered ip-cisplatinum with STS and another 5 patients were given the same without STS. As a result, 1) the level of free-CDDP in ascites fluid was significantly elevated after administration, showing that free-CDDP possessing anti-tumor activity persisted in the ascites fluid for a long time and reached the peak concentration 30 minutes after administration. 2) The free-CDDP transferred into the blood after administration also persisted for a long time in parallel with changes in the free-CDDP level in the ascites fluid. 3) The AUC, MRT and VRT of the free-CDDP concentration in the peritoneal cavity after ip administration of CDDP were high, clearly indicating the direct effect on peritoneal concentration. 4) The AUC, MRT and VRT of free-CDDP in the venous phase after ip administration of CDDP were higher than after its iv administration, suggesting that effects equivalent to or greater than those of the iv route drug can be expected in the venous phase. 5) The frequency of side effects induced by the combination of STS was lower than that of side effects induced by the administration without combined STS. Much larger doses of CDDP may be given ip by combining with STS.

[Evaluation of pre-operative 5-fluorouracil treatment of the patients with gastric cancer--alteration of the inhibition rate of thymidilate synthetase by dose difference]

5-fluorouracil (5-FU) was orally administered before surgical operation to two groups of patients, one treated at 300 mg for 7 days and the other treated at 400 mg for 5 days, to examine the change of TSIR in gastric patients. Tumor tissue, lymph node and normal lesions were collected from removed specimens immediately frozen. As a result, there were no differences in FdUMP volumes of various tissues between 300 mg and 400 mg groups. TSIR tended to be higher in the order of normal tissue, lymph node and tumor lesions. TSIR was significantly higher in 400 mg group than 300 mg group. We believe that further studies on TSIR will provide a useful information as to various studies, including efficacy reinforcement by combination therapy, problems in resistance, histological efficacy and sensitivity tests.

[A study of CDDP in the treatment of patients with gastric and esophageal cancers, with special reference to the evaluation of renal functions before and after CDDP administration]

Although CDDP has been widely used for cancer chemotherapy in recent years, the problem is that it causes a renal dysfunction as a side effect. As briefly reported here, we have currently used this drug for the treatment of stomach esophageal cancers as a part of multidepartmental therapy, and obtained a finding on the therapeutic usefulness, particularly for monitoring the renal function before and after administration. The subjects were 6 patients with stomach and 11 with esophageal cancer given CDDP at the dose of 50 mg 2 courses, in principle, a single course per week. Blood transfusion was carried out in an amount of 1,000 ml before administration, 2,500 ml on the day of treatment and 1,000 ml for 3 days after administration. When the effects of CDDP on urinary BUN, Na, K, Cl, Mg, NAG, beta 2 microglobulin, Ccr and FENa levels were measured for the determination of renal functions before and after administration, NAG and beta 2 microglobulin levels were conceivably found to be useful indices.

[Clinical evaluation of endoscopic therapy for early gastric cancer by diathermic polypectomy, Nd; YAG laser irradiation and heater probe]

Forty early gastric cancers (37 cases) were treated endoscopically by diathermic polypectomy and Nd; YAG laser irradiation. In 23 cases of protruded early gastric cancer, 16 cases were treated by diathermic polypectomy only, 2 cases by Nd; YAG laser only and 5 cases underwent combination therapy with both procedures. Endoscopic treatment was successful in 20 cases, but surgery was performed in two cases with cancerous invasion or lymph vessel infiltration at their cut ends after polypectomy. Local recurrence occurred in a case of submucosal involvement 6 months after combination therapy. In excavated early gastric cancers, 17 lesions of 14 cases were treated by Nd; YAG laser irradiation. Although 13 lesions disappeared successfully after laser treatment, cancers remained in 3 lesions with submucosal involvement after several irradiations. Local recurrence was experienced in a lesion of poorly differentiated adenocarcinoma three months after treatment. In addition, a heat probe unit for hemostasis was applied for endoscopic treatment of early gastric cancer and found to be effective for cancer of the mucosal layer. Among other early gastric cancers, endoscopic treatment is indicated for differentiated adenocarcinomas which are less than 2 cm in size and confined within the mucosal layer.

[A clinicopathological study of five cases of adenosquamous carcinoma of the stomach]

Five cases of adenosquamous carcinoma with resected stomach were subjected to this study, and the clinicopathological characteristics of this condition were described. The five patients represented 0.8% of 589 cases of resected stomach. There were two men and three women ranging in age from 40 to 70 (average, 62.8). Macroscopically, the adenosquamous carcinomas were all advanced gastric cancer situated in the lower body along the lesser curvature of the stomach, averaging 7.6 cm in size. The characteristic finding was the histologically differentiated type, invading to the serosa. Lymph node metastasis was most prominent.

[By-pass surgery with infusion therapy for non-resectable esophageal cancer]

In principle, the following three steps are considered for by-pass surgery; I. A gastric tube is moved up to the retro-sternal or to the ante-thoracic position. A T-tube is the inserted in the mid position of the gastric tube for decompression and drainage. 2. A retention vinyl tube is inserted in to the excluded esophagus for the purpose of post infusion therapy and for evaluation of the therapy. 3. A Roux-Y anastomotic internal fistula is placed at the distal site of the excluded esophagus. As a plan for combined therapy, PANa-Oil bleomycin (oil bleomycin 30 mg, PANa 0.5 g) is the infused into the isolated esophagus after the by-pass operation and the clinical effect is evaluated by introducing a radiopaque medium into the excluded esophagus via an inserted vinyl tube. Such infusion therapy after by-pass surgery was given to 3 patients and in 1 patient it was very effective. This suggested a positive effect on survival in cases of non-resectable esophageal cancer without side effects.

[Effect of intravenous administration of FT-207 for gastric cancer]

FT-207, 800mg per day, was administered intravenously 2 hours per day for 6 days to 15 patients with gastric cancer. By chemical assay, FT-207 and 5-FU concentrations in the blood and tissues were determined. The FT-207 levels in cancerous tissue, metastatic lymph nodes and normal gastric mucosa were almost equal. The mean 5-FU level in cancerous lesions was 0.110 +/- 0.075mcg/g, and was 0.124 +/- 0.080mcg/g in lymph nodes, and 0.043 +/- 0.021mcg/g in normal mucosa. This showed that 5-FU levels were significantly higher in tumors and lymph nodes than in normal mucosa. (p less than 0.05, p less than 0.01 respectively). The mean blood level of 5-FU was low at 4 hours after FT-207 infusion. In conclusion, intravenous drip administration of FT-207 was considered to be effective for gastric cancer because of the high tumor affinity of 5-FU.

[Clinical evaluation of cefoxitin in surgery]

Cefoxitin (CFX) was administered to 13 patients who were admitted to the surgical ward of the hospital. The results of the study as follows; Disc susceptibility tests of the 11 strains isolated from the patients to antibiotic were performed and 10 strains showed good susceptibility to CFX. The clinical response was good in all 4 patients with surgical infections. It is noted that 1 patient with mixed infection caused by E. coli, Clostridium sp. and Bacteroides sp. showed good response to CFX. Out of 9 patients treated with CFX for prophylaxis of postoperative infections, 8 patients responded effectively to CFX, and clinical efficacy rate was 88.9%. No side effects were noted due to CFX. It is considered from these results of the study that CFX is a highly effective and safe drug for treatment of infections and for the prevention of postoperative infections in surgery.