Second line chemotherapy for metastatic colorectal carcinoma

25 patients with metastatic colorectal carcinoma previously treated with 5-fluorouracil and folinic acid for advanced disease, were treated with mitomycin C 8 mg/m(2) i.v. bolus on day 1, adriamycin 40 mg/m(2) i.v. bolus on day 1, and lonidamine 150 mg per os t.i.d. starting one day before chemotherapy and stopping 2 days after the end of chemotherapy. Treatment was repeated every 4 weeks. All patients had previous surgery and systemic chemotherapy with 5-fluorouracil and folinic acid given as first line chemotherapy for metastatic tumor. Sites of disease included liver, lung, nodes, abdomen, and bone. All enrolled patients were evaluable for objective response. Only one patient, affected by rectal carcinoma, showed a partial response (4%) which lasted 5.8+ months. No complete response was seen. Stable disease was recorded in 4 cases (16%) with a mean duration of 4.6+ months. All remaining patients had progressive disease. Median overall survival was 8.7+ months. Toxicity was significant. Grade 3 thrombocytopenia was seen in 8 cases (32%), and grade 3 leukopenia in 5 cases (20%). Grade 3 vomiting was observed in 9 patients (36%). The combination of mitomycin C, adriamycin and lonidamine is not effective in the treatment of metastatic colorectal adenocarcinoma resistant to 5-fluorouracil-based chemotherapy. These data suggest that lonidamine is not able to potentiate antineoplastic activity of chemotherapeutic drugs in humans and its use in colorectal cancer should be avoided since it has no or little impact on response rate and survival.

Use of Chinese therapies among Chinese patients seeking emergency department care

We observed that many Chinese-Americans presenting to our emergency department use traditional Chinese therapies. We therefore conducted a survey using a convenience sample of first- and second-generation adult Chinese immigrants to characterize their use of traditional therapies. Seventy-six patients completed the survey; 43% had used Chinese therapy within 1 week of the ED visit. Use of Chinese therapies was common among first- and second-generation immigrants (44% and 42%, respectively). Patients claiming affiliation with a practitioner of Chinese medicine used Chinese therapies most frequently (60%). However, those lacking a traditional therapist and those associated with a Western physician also used traditional therapies frequently (38% and 41%, respectively). Many Chinese patients visit both a Western and a Chinese practitioner (17%). Emergency physicians treating Chinese-Americans should consider the possibility of concomitant use of traditional therapies. Physicians should be aware of the medical and social implications of alternative medical therapies.

Anticholinergic poisoning associated with herbal tea

An outbreak of cholinergic poisoning occurred in New York City during a 3-day period. Seven individuals from three families of South American origin were affected. Signs and symptoms of illness included dry skin, hyperthermia, tachycardia, dilated pupils, agitation, and hallucinations. Onset of illness in all cases was temporally associated with consumption of a tea that was labeled "Paraguay Tea" and was purchased from a grocery store specializing in South American foods. Paraguay tea, made from the leaves of the holly, Ilex paraguariensis, contains caffeine and theophylline and is a popular beverage in South America. Samples of the tea analyzed with gas chromatography contained belladonna alkaloids but neither caffeine nor theophylline. An investigation by the New York City Department of Health personnel determined that the tea was from a single lot, imported by one distributor, and sold at one grocery store. Unsold inventories of the tea were quarantined, and no further cases of anticholinergic poisoning were reported.

Endoscopic ultrasonography in the diagnosis of gastrointestinal amyloid deposits: clinical case report

A case of systemic amyloidosis of the digestive tract is described here, with particular attention to the endoscopic ultrasonography aspects, characterized by a wide-spread thickening of the stomach and rectum walls, with loss of the normal layer structure of the mucosa and submucosa. Endoscopic ultrasonography, especially in pseudotumoral forms, may contribute to the differential diagnosis from neoplastic lesions, in which the wall thickening appears to be localized and accompanied by parietal infiltration.

[Ultra-short and short surgical prophylaxis with pefloxacin]

A multicentre study has been done to evaluate the effectiveness and safety of pefloxacin, a new fluoroquinolone, when given intravenously for surgical prophylaxis. 440 patients (224 males, 216 females), mean age 51.7 +/- 27.3 (SD) years and mean weight 68.4 +/- 12.6 kg, were admitted to the study. The diagnoses for admission included several surgically treated specialties (obstetrics and gynecology, orthopedics and traumatology, oncology and general surgery). Pefloxacin was provided in 5 ml ampoules containing 400 mg of active principle to administer by slow intravenous perfusion (1 hour) diluted in 5% glucose solution. The multicentre study was open and non-comparative. The physician could choose between two different dosage schedules to use for surgical prophylaxis. The ultrashort schedule consisted of treatment with 2 ampoules (800 mg), given in the hour before the operation (followed for 217 cases). The short schedule consisted of 2 ampoules (800 mg) given in the hour before the operation, another 2 ampoules 12 hours after surgery and 2 ampoules 24 hours after the surgery (followed for 223 cases). The prophylaxis with pefloxacin was effective, with control of the temperature, the ESR and wound healing in the post-operative period. The surgical wounds of 11.4% of cases (50/440) were erythematous and infiltrated on the 2nd day, and of 14.8% of cases (65/440) on the 3rd day, and then became normal on the next few days. 24 patients had infections after the operation, in 15 cases involving the surgical field (3.4%) and in 9 cases being infections of the respiratory or urinary systems.(ABSTRACT TRUNCATED AT 250 WORDS)

Etoposide, doxorubicin (Adriamycin) and cisplatin regimen in advanced gastric adenocarcinoma: experience with a lower dose schedule

A phase II trial of etoposide (100 mg/m2) on days 4, 5, 6, doxorubicin (Adriamycin, 20 mg/m2) on days 1, 7, and cisplatin (30 mg/m2) on days 2, 8 (EAP) was carried out in order to reduce toxicity associated with a full-dose EAP regimen for advanced and/or metastatic gastric adenocarcinoma. Out of 21 evaluable patients, 2 (10%) had a complete response (CR), 7 (33%) had a partial response (PR), 4 (20%) showed no change and 8 progressed (38%). The mean duration of response (CR+PR) was 8.4+ months. Survival of the whole group was 7.5+ months. Treatment was quite well tolerated by most patients on an outpatient basis. Grade 3 vomiting and leukopenia were seen in 30% and 35% of cases respectively. One patient had grade 3 esophagitis, and 1 patient was hospitalized for severe grade 4 febrile leukopenia. Although the EAP regimen cannot be considered a standard therapy for gastric cancer, the EAP schedule employed in this study seems to be better tolerated than those reported by other authors, and can safely be given on an outpatient basis.

[Familial polyposis]

The F.A.P. is an hereditary disease autosomic dominant, characterized by the growth, from a minimum of 100 to several thousands, of adenoma of the large bowel that degenerate in carcinoma if not intervene surgically. The gene of the F.A.P. has been founded in the chromosome 5, region 5q 21-q22. The incidence is of one case above 6,850-30,000 inhabitants. The F.A.P. characterize it self besides the adenoma, of the large bowel also for the extracolic diseases (adenoma of the small bowel and of the stomach, epidermoid cysts, osteomas, dermoid tumors, congenital hypertrophy of the pigmentary epithelium of the retina). The Authors report their experience concerning a patient with F.A.P.: a man of 40 years old. The patient's genealogic tree was so composed: a brother, a sister and 2 children (a boy of 9 years old and a girl of 6 years old). They have been exposed to the following screening examinations: hemoccult test, rectal exploration, coloscopy and oculist visit). These investigations have given negative results. Because of the youth of the children it has been advised a yearly check-up. At last the Authors underline that each time a patient with F.A.P. is discovered (proband) it is necessary subject the 1 degree grade familiar to the screening above mentioned; because the life expectation in the secondary case (calls-up) discovered.

[Comparison of magnetic resonance (0,5 T), computed tomography, and endorectal ultrasonography in the preoperative staging of neoplasms of the rectum-sigma. Correlation with surgical and anatomopathologic findings]

Eighteen cases of rectal carcinoma were staged preoperatively with transrectal endosonography (EUS), CT and MRI (0.5 T). The results were compared with surgical specimens and histology to evaluate the accuracy of the imaging modalities in staging rectal carcinomas which had been quantified according to Astler-Coller's classification. All methods identified the lesion (100% sensitivity). EUS and MRI correctly staged 8 cases (44%) and CT 9 cases (50%). CT and MRI mistakes were relative to overstaging, whereas EUS understaged 4 cases (22%) and overstaged 6 cases (33%). In local tumor staging ("T" variable), CT and MRI understaged no lesions, thus exhibiting 100% sensitivity, which was higher than EUS sensitivity (92%). Conversely, CT and MRI more frequently overstaged the lesions, thus demonstrating lower sensitivity than EUS (55% and 50%, respectively, versus 76% for EUS). As for the "N" variable, EUS identified node metastases in one case only (25%) and misdiagnosed as positive 4 cases of negative node involvement. All the C-stage lesions were correctly diagnosed by CT and MRI (whose findings were in agreement) which also overstaged as C three cases with hyperplastic node enlargement. The diagnostic accuracy of EUS, which was highest for the A and B1 stages, progressively decreased for bigger lesions, clearly understaging node involvement. On the contrary, CT and MRI accuracy rates were lower in small tumors involving the rectal wall only, whereas they always identified tumor spread beyond the bowel wall into perirectal fat, and node metastases. Therefore, to conclude, EUS can be used first: in case of extraluminal tumor spread, CT is the method of choice, more accurate than MRI in identifying node involvement and equally effective in evaluating perirectal fat infiltration and pelvic structures involvement. Whenever the pelvic floor is involved, MRI is the best imaging method, thanks to its multiplanar capabilities, for better detailing of musculoskeletal involvement.

Nephrotoxicity of human Bence Jones protein in rats: proteinuria and enzymuria profile

The effect of intravenous administration of 80 mg purified human Bence Jones protein twice weekly for 5 weeks was investigated in male Wistar rats (N = 7; 2 months old). A state of immunological tolerance was demonstrated by the absence of a B-cell response (plaque-forming cells and hemagglutination titers) and by the absence of detectable antigen or antibody deposition in glomeruli, as indicated by light and electron microscopy. No rise in blood urea level was detected (33.9 +/- 4.3 vs 32.8 +/- 1.3 mg%). There was an increase in proteinuria (5.3 +/- 0.9 vs 32.8 +/- 4.0 mg/day), mainly due to Bence Jones protein excretion (0 vs 29.2 +/- 5.2 mg/day), with a slight but significant increase in albuminuria (0.2 +/- 0.1 vs 1.0 +/- 0.2 mg/day). There was a significant increase of lysosomal N-acetyl-beta-D-glucosaminidase in the urine (6.1 +/- 1.3 vs 72.7 +/- 18.8 mU/mg in creatinine). Lysosomal accumulation of Bence Jones protein in proximal tubular cells was evidenced by immunoelectronmicroscopy with protein A-gold. These results clearly showed proximal tubular dysfunction induced by chronic Bence Jones protein administration, without interference of autologous immune response as demonstrated by immunological state of tolerance.

Iron protein succynilate in the treatment of iron deficiency: potential interaction with H2-receptor antagonists

A prospective, open, multicenter clinical trial was set up to evaluate the potential interaction of ITF 282 with H2-receptor antagonists in patients affected with iron deficiency. Patients treated with H2 blockers and affected with iron deficiency or iron deficient anemia were given one tablet of ITF 282 (60 mg iron) twice daily for 60 days. A second group of iron deficient patients with no anti H2 concurrent treatment were admitted to the same iron treatment, lasting 60 days. To evaluate the outcome of the iron treatment, a comprehensive assessment of laboratory and clinical determinations was adopted in all the patients: special hematology, symptomatology, safety hematology and hematochemistry, urinalysis. Fifty-three patients with iron deficiency and 47 patients affected with overt iron deficient anemia entered the study. After treatment, a significant trend toward the normalization of the main hematologic parameters in both groups was detected. The general tolerability was apparently more favorable in the patients who had also the antiulcer (1 event of diarrhoea) than in those who had ITF 282 alone (2 heartburn, 3 constipation, 2 abdominal pain). There were no indications of subgroups of patients particularly at risk of adverse events, all of which resulted reversible without the need to reduce the dose of medication or to take other medical action. ITF 282 resulted, also when administered together with H2-receptor antagonists, in the expected therapeutic efficacy, with the expected clinical tolerability and biological safety, without signs of possible interaction, negative or positive.(ABSTRACT TRUNCATED AT 250 WORDS)

Natural history of hepatic haemangiomas: clinical and ultrasound study

Hepatic haemangiomas are the most common benign tumours of the liver and commonly present as incidental findings on sonographic examination of the abdomen. Since little is known of the natural course of these tumours, we performed a clinical and sonographic follow up of 123 haemangioma patients. Our prospective study investigated clinical and sonographic findings in 158 haemangiomas for periods of 12 to 60 months. Ninety nine haemangiomas measured less than 2 cm and had an echogenic pattern; 40 were between 2 cm and 5 cm with a mainly echogenic structure; 19 measured greater than 5 cm and showed a mixed echo pattern. At the first examination only eight patients, all with giant haemangiomas, presented symptoms which could be attributed to the tumour. During follow up only one haemangioma changed in shape and size. One patient who was symptom free at the first examination experienced right upper abdominal quadrant pain during follow up. No deterioration occurred in any of the patients with symptoms at the first examination, and all had a satisfactory quality of life. No complications arose during the follow up period. This study shows that in adults haemangiomas remain stable in size and echo patterns rarely change. Only haemangiomas greater than 5 cm may cause symptoms. Prolonged clinical and sonographic follow up of small and medium sized haemangiomas is not warranted.

[Echographic study of cryptorchidism]

The authors, after a nosologic review of cryptorchidism, illustrate their positive diagnostic experience with ultrasound. Limits as well as clinical advantages, in relation to the diagnosis and follow-up, are also described.

Laparoscopy compared with ultrasonography in the diagnosis of hepatocellular carcinoma

In recent years, various newer imaging procedures have superseded laparoscopy in the detection of many diseases. The role of laparoscopy in the diagnosis of hepatocellular carcinoma is still subject to debate. To assess the value of laparoscopy compared with that of ultrasonography, we compared data obtained from a series of 54 patients with hepatocellular carcinoma, all of whom had both procedures performed at nearly the same time. In our study, ultrasonography proved superior to laparoscopy in detecting the presence and extent of the hepatocellular carcinoma. Supplemental findings attributable to laparoscopy did not alter management, whereas additional information obtained by ultrasonography often did influence the choice of treatment. We conclude that ultrasonography is the primary diagnostic method of choice in the assessment of hepatocellular carcinoma and that laparoscopy should be reserved for only selected cases.

[Fowler-Stephens orchidopexy]

The authors, after a short report on intraabdominal cryptorchidism and its surgical problems, illustrate the Fowler-Stephens' technique with its advantages as they result from their experience, although limited. Some operative stages, considered essential, are emphasized.

[Endoscopic study in reflux esophagitis. Our experience]

One hundred twenty one cases of oesophagitis by gastroesophageal reflux were observed through a retrospective study of 1250 endoscopies of the upper digestive tract. The oesophagitis was staged according to Savary-Miller classification. The prevalence (93.3%) of cases were in I and II stage. The Authors found that the most frequent associated diseases with oesophagitis by gastroesophageal reflux were: hiatal hernia, gastric and duodenal peptic disorders, gastric resection according Billroth II and biliary disorders. In 86.7% of cases, endoscopic diagnosis was confirmed by histological findings. From these data and from those reported in literature the authors can ascertain that endoscopy, associated with histological findings has an important role in diagnosing oesophagitis and in monitoring medical and surgical treatment used.

Strength of scopolamine-induced amnesia as a function of time between training and testing

Variations in the strength of scopolamine-induced amnesia as a function of age of the habit were studied in Swiss Webster mice. Animals were trained in an active avoidance task to a criterion of 9/10 avoidances and immediately following training injected with scopolamine hydrochloride (1.0 mg/kg) or saline. Retention of the avoidance learning was evaluated by testing different groups of animals 1, 3, 7, 10, 14, and 28 days following training. The retention test consisted of five trials in which the CS but not the UCS was presented. Results indicated that saline-treated mice exhibited near-perfect retention up to 14 days post-training with forgetting beginning to be apparent at 28 days. Scopolamine treatment produced strong amnesia in animals tested 1 and 3 days post-training but normal retention in animals tested 7 and 10 days after learning. The amnesia abruptly reappeared at 14 days after which time it remained stable. The marked similarity of the scopolamine retention curve to changes in the strength of memory of discrimination learning in undertrained rats reported by Deutsch suggested that scopolamine resulted in the storage of a weak memory of the avoidance response. To explore this idea further we trained mice to a criterion (4/5) which would result in a weak avoidance response and tested different groups 1, 3, 10, 14, and 28 days following learning. Results showed that strength of the memory of avoidance learning increased up to 10 days and then decreased abruptly at 14 days thus replicating the general shape of the retention curve produced by injecting scopolamine following strong training. These data suggest that scopolamine disrupts processes essential for the formation of durable memories.

Alleviation of scopolamine amnesia by different retrieval enhancing treatments

Mice were trained in a one-way active avoidance task to a criterion of 9/10 avoidances. Immediately following training they were injected with scopolamine hydrochloride (1 mg/kg SC) or with saline. Retention was assessed 3 days after training by 5 test trials on which the UCS was not present. Thirty min prior to the test, groups were injected with different doses of arecoline, d-amphetamine sulphate or with saline. Other scopolamine-treated mice were exposed to the CS or the UCS 24 hr prior to the test. The scopolamine-induced amnesia was attenuated by both 0.5 and 1.0 mg/kg arecoline and by 2.0 mg/kg d-amphetamine. Retention was also improved by exposure to the CS and the UCS. These data show that scopolamine amnesia can be alleviated by treatments which activate retrieval processes.

Cancer of the gastric stump in Italy, 1979-1986

Sixteen thousand fiberoptic endoscopies were reviewed. Gastric stump cancer was found in 24 patients of 368 who had had gastric resection for benign peptic disease. A direct relation between the percentage of patients with cancer of the gastric stump and the postsurgical interval was observed. Patients with partial gastrectomy who are 15 to 20 years postoperative should have an endoscopy irrespective of presence or lack of symptoms. Multiple biopsies should be taken in view of the multicentric growth pattern of early carcinoma.

Attenuation of forgetting by pharmacological stimulation of aminergic neurotransmitter systems

Mice were trained in one-way active avoidance to a criterion of 3/4 avoidances and tested under extinction conditions one week later when substantial forgetting had occurred. Thirty min prior to testing animals were injected with either saline or different doses of drugs which activate the noradrenergic (phenylephrine, salbutamol, clonidine) dopaminergic (L-dopa(Sinemet) transdihydrolisuride, apomorphine) and serotonergic (fluoxetine, 5-methoxy DMT) neurotransmitter systems. Results showed that all agents alleviated forgetting in a dose dependent fashion. Untrained mice treated with the most effective dose of representative drugs from each class did not exhibit avoidance behavior at testing indicating that the improved performance of trained animals was probably not the result of increased activity or other non-memorial effects of the drugs. It was concluded that pharmacological agents which stimulate monoamine systems may improve memory retrieval by activating a non-specific neural system which controls arousal, attention and motor readiness.

Echo-guided fine-needle biopsy of pancreatic masses

Aim of this study was the evaluation of percutaneous echo-guided fine-needle biopsy in the diagnosis of focal lesions of the pancreas. In patients with masses of the pancreas 43 echo-guided fine-needle punctures have been performed. In 27 of the 30 cases of cancer, echo-guided puncture allowed aspiration of cells revealing malignancy. In the remaining three cases the histology was normal. Malignancy was not detected in the aspirate of any of the 13 cases of benign solid masses. In one of these patients we failed to obtain sufficient material for the purpose of diagnosis. The sensitivity of the method was 90%, the specificity 100%, and the diagnostic accuracy 92.8%. Positive and negative predictive values were 100 and 75%, respectively. No complications worthy of note occurred.

Demonstration of cytokeratins by immunoperoxidase staining in prostatic tissue

The presence and distribution of cytokeratins (CK) have been investigated using an epidermal keratin antiserum in various dilutions and the PaP (peroxidase-antiperoxidase) and avidin-biotin-peroxidase (ABC) immunohistochemical methods. A total of 44 samples of prostatic tissue were divided into alcohol-fixed (22 cases) and formaldehyde-fixed (22 cases). Each group included 12 non-malignant lesions (hyperplasias and prostatitis) and 10 adenocarcinomas. The best results were achieved with the ABC method in alcohol-fixed tissues, while formaldehyde-fixed tissues gave poor staining despite the use of different enzymes to unmask antigenic determinants. With similar dilutions of the specific antiserum the PaP method gave less intense staining. Cytokeratins were detected in basal and columnar cells, in areas of transitional and squamous metaplasia and in normal transitional epithelium. Columnar cells showed strong staining in the supranuclear portion. Adenocarcinomas gave positive staining for cytokeratins varying from weak to strong. The intensity of staining showed no correlation with the degree of differentiation of the tumor. Different degrees of intensity were frequently observed within the same tumor. High dilutions of the specific antiserum (greater than 1/400) failed to stain carcinomas or stained them poorly, whereas they still stained normal or hyperplastic tissues. Gland-forming tumors showed a highly polarized labelling with the strongest staining in the luminal portion of the cell. The conclusion is that all epithelial prostatic tissues, benign and malignant, express cytokeratins.

Indications for laparoscopy before and after the introduction of ultrasonography

We compared the outcome of laparoscopy performed from 1973 to 1974, prior to the introduction of routine ultrasound diagnostics, with that of examinations during the period 1980-1981 when ultrasound had become a well-established technique in the diagnosis of hepatic lesions. Our data reveal statistically significant changes in the use of laparoscopy in the diagnosis of cholestasis and tumors of the hepatic parenchyma. Laparoscopy now has fewer indications in the study of the jaundiced patient with suspected extrahepatic cholestasis which is easily identified at ultrasound. Given the high sensitivity and specificity of ultrasonography in detecting metastases, laparoscopy has become a secondary examination. However, there has been an increase in the use of laparoscopy to identify benign hepatic lesions, particularly hemangiomas.

[Endoscopy findings in gastroduodenal pathology in a group of welders]

Fourteen welders were examined with the purpose to evaluate the incidence and the type of pathologic changes of the gastrointestinal tract due to the exposure to welding fumes. The medical examination was followed by endoscopic and bioptic study of gastric and duodenal mucosa. The results show the presence of pathologic changes, mainly of flogistic type, in all the microscopic investigations, although the appearance of the mucosa was generally normal. Moreover, the results of this investigation suggest that pathologic changes of gastrointestinal tract could precede those of the respiratory tract.

The value of ultrasonography in the diagnosis of hepatic haemangiomas

The following ultrasonographic (U.S.) patterns were observed in 21 cases of proven hepatic haemangiomas: 1) Hyper-echoic (6 cases); 2) Hypo-echoic (4 cases); 3) Complex (11 cases). Several characteristic aspects of the echo structure (uneven appearance and fine internal parallel echoes) and the location of the lesion (para-caval or sub-diaphragmatic) may be useful for differential diagnosis with malignant neoplasia. The U.S. findings of a further 17 cases of hyperechoic focal lesion of the liver are reported. Although a definitive diagnosis was not possible in these subjects, the U.S. characteristics which remained unchanged for over 6 months, made the diagnosis of haemangioma highly likely.

Fetal electroencephalography. Relationship to neonatal and one-year developmental neurological examinations in high-risk infants

Sharp wave activity in fetal electroencephalograms was found to have a significant relation to neurological findings at 1 year of age but not to neurological findings obtained during the neonatal period. Neonatal neurological findings were significantly related to those at 1 year of age.