Lactate dehydrogenase levels during MACOP-B chemotherapy for non-Hodgkin's lymphoma

Lactate dehydrogenase (LD) levels rose consistently during MACOP-B chemotherapy for intermediate and high-grade non-Hodgkin's lymphoma (NHL). Levels peaked at week nine and fell to normal within six weeks of completion of therapy. Isoenzyme patterns, studied prospectively in seven patients, showed a parallel rise in LD1 and LD2 suggesting a source other than tumour tissue for the rise in total LD. In the absence of evidence of myocardial or renal damage, haematopoietic tissue was the most likely source. With no evidence of haemolysis, normal serum levels of vitamin B12 and folate and normal red cell folate, dyserythropoiesis was considered to be the underlying mechanism. A rising mean corpuscular volume further reinforced this suggestion. Intensive use of methotrexate along with co-trimoxazole as prophylaxis against pneumoycystis carinii is considered the most likely cause of marrow dysfunction. Failure to recognise that rising LD levels during such therapy is treatment-related, rather than of tumour origin, may lead to inappropriate change or abandonment of therapy.

Impact of tissue plasminogen activator and heparin versus heparin alone on quantitative coronary angiographic findings in myocardial infarction. The Toronto Tissue Plasminogen Activator Trial Study Group

The influence of tissue plasminogen activator (t-PA) and heparin versus heparin alone on anatomic characteristics of patent infarct-related coronary arteries and the development of these angiographic descriptors in coronary arteries that remain patent during the hospital course was examined in 108 patients who participated in a placebo-controlled trial of recombinant tissue-type plasminogen activator in acute myocardial infarction. Coronary angiography was performed 18 +/- 6 hours after treatment in 47 patients (group A) and at 10 days in 61 patients (group B). Quantitative coronary angiography of the infarct-related lesion was performed, and luminal irregularity was quantitated with an ulceration index. Of the 47 patients in group A, 7 (29%) treated with placebo had Thrombolysis in Myocardial Infarction grade 2 or 3 perfusion, whereas 18 (78%) treated with t-PA had grade 2 or 3 (p < 0.001); there was no difference between patients who had grade 2 or 3 perfusion in group B (placebo 59% vs t-PA 75%). In group A, at 10 days, the luminal area of the infarct artery had increased from 0.59 +/- 0.11 to 0.9 +/- 0.24 mm2 and from 0.75 +/- 0.16 to 1.31 +/- 0.39 mm2 for placebo- and t-PA-treated patients, respectively (p < 0.04). There was no change in the ulcerative index over time in either placebo- or t-PA-treated patients. It is concluded that early after infarction, t-PA produces marked and rapid improvement in overall patency as compared with heparin, although this difference was attenuated at 10 days because of spontaneous recanalization in the placebo group.(ABSTRACT TRUNCATED AT 250 WORDS)

A circadian distribution to febrile episodes in neutropenic patients

Four-hourly temperature charts relating to 63 febrile neutropenic episodes in 32 patients were assessed for a circadian distribution to the onset of fever (> 37.5 degrees C) using the Edward's test. A highly significant distribution was found with the maximum incidence of febrile events between the hours of 5 p.m. and midnight (acrophase 9.30 p.m.). Patients were 5.53 times more likely to develop fever at 9.30 p.m. that 9.30 a.m.

Ephedrine, caffeine and aspirin: safety and efficacy for treatment of human obesity

The safety and efficacy of a mixture of ephedrine (75-150mg), caffeine (150mg) and aspirin (330mg), in divided premeal doses, were investigated in 24 obese humans (mean BMI 37.0) in a randomized double blind placebo-controlled trial. Energy intake was not restricted. Overall weight loss over 8 weeks was 2.2kg for ECA vs. 0.7 kg for placebo (p < 0.05). 8 of 13 placebo subjects returned 5 months later and received ECA in an unblinded crossover. After 8 weeks, mean weight loss with ECA was 3.2 kg vs 1.3 kg for placebo (p = 0.036). 6 subjects continued on ECA for 7 to 26 months. After 5 months on ECA, average weight loss in 5 of these was 5.2 kg compared to 0.03 kg gained during 5 months between studies with no intervention (p = 0.03). The sixth subject lost 66 kg over 13 months by self-imposed caloric restriction. In all studies, no significant changes in heart rate, blood pressure, blood glucose, insulin, and cholesterol levels, and no differences in the frequency of side effects were found. ECA in these doses is thus well tolerated in otherwise healthy obese subjects, and supports modest, sustained weight loss even without prescribed caloric restriction, and may be more effective in conjunction with restriction of energy intake.

Severe bleomycin lung toxicity: reversal with high dose corticosteroids

A 42 year old man, treated for testicular carcinoma with combination chemotherapy that included bleomycin, developed life threatening interstitial pneumonitis. He recovered successfully after treatment with very high doses of corticosteroids and azathioprine. This report suggests that bleomycin lung toxicity may be reversible if treated aggressively.

Breast cancer and pregnancy

Sixteen of 194 premenopausal woman with breast cancer developed the disease in association with pregnancy. Eight were pregnant as diagnosis and eight were post-partum. There were significant delays in referral for surgical opinion and treatment among both groups. Two of the eight pregnant patients were diagnosed during the first trimester and one during the second trimester. The rest were at or close to term. Standard surgical therapy without irradiation was employed for early stage disease. Adjuvant chemotherapy posed some problems. One of the patients in the first trimester declined all treatment while the other opted for surgery only until after delivery. There was a favourable obstetrical outcome in all cases and survival for this group of patients is similar to that reported in the medical literature. None of the group had a further pregnancy. The incidence of breast cancer related to pregnancy in this premenopausal group was 8% with 1% occurring in the first trimester. This would mean three or four such cases per annum in Ireland.

A multicentre survey of serum calcium levels in patients with malignant diseases

Serum calcium and albumin levels were measured in 255 patients with a confirmed diagnosis of malignant disease. The average serum calcium and albumin levels were similar to those reported in an earlier larger American survey. Only 6/255 patients were above the normal range of corrected serum calcium and one patient was sufficiently hypercalcaemic (corrected serum calcium at least 2.8 mmol/L) to be included in a trial of oral clodronate therapy. The incidence of hypercalcaemia in this survey is considerably lower than that reported in the published literature (5-10%). A much larger proportion of patients (21/255) were hypocalcaemic. Serum albumin was depressed in 25/255 cases and elevated in 2/255 cases.

Effect of cold exposure and nutrient intake on sympathetic nervous system activity in rat kidney

Renal sympathetic nervous system (SNS) responses to environmental temperature and diet were evaluated using [3H]norepinephrine ([3H]NE) turnover as the index of sympathetic activity. Pharmacological studies first demonstrated that renal NE was localized principally within storage granules of renal sympathetic nerves and regulated by central sympathetic outflow. Acute exposure to cold (4 degrees C), which increased cardiac SNS activity (P < 0.00005), had no effect on renal SNS. A 48-h fast suppressed renal [3H]NE turnover by 37% (P = 0.00024) and cardiac [3H]NE turnover by 48% (P = 0.00608). Dietary supplementation with sucrose did not affect [3H]NE turnover in kidney in either of two separate experiments, although it increased cardiac NE turnover in both. On the other hand, lard feeding significantly increased [3H]NE turnover in both kidney and heart, whereas dietary protein supplementation exerted no effect on either renal or cardiac [3H]NE turnover. These studies demonstrate a unique pattern of sympathetic regulation in kidney, one which is highly responsive to fasting and dietary fat, but not to cold exposure or dietary sucrose.

Phaeochromocytoma: diagnosis and management

The incidence, symptoms, signs and differential diagnosis of phaeochromocytoma have been discussed in detail. Current methods of biochemical diagnosis and anatomical localization of the tumour have been reviewed, the appropriate pharmacotherapy and other aspects of medical management have been outlined. Also detailed herein are anaesthetic management and surgical approach, the pitfalls of drug administration in known or suspected phaeochromocytoma, and particular considerations when phaeochromocytoma is malignant or when it coexists with pregnancy. Three decades ago, the diagnosis and management of phaeochromocytoma was succinctly summarized as follows: 'think of it, confirm it, find it and remove it' (Manger and Gifford, 1977; Ross, 1962). Despite the availability of sophisticated diagnostic tests and the significant progress in management, where phaeochromocytoma is concerned, a high index of suspicion ('thinking of it') remains the physician's most valuable tool.

Recycled heart valves from transplant patients

Forty heart transplantations were performed at the Toronto Western Hospital, University of Toronto, from October 1987 to December 1989. Each heart extracted from a recipient was examined with the view of using the aortic valve as a homograft for another patient requiring aortic valve replacement. Of the 40 explanted hearts, 26 had normal aortic valves that were potentially suitable for homografting, and 14 had aortic valves judged as unsuitable. Of the potentially suitable valves, four were preserved for ex vivo arrhythmia studies requiring aortic root perfusion and four were damaged during harvesting. The remaining 18 usable valves were sized at the time of explantation and stored in an antibiotic solution at 4 degrees C. Thirteen valves were transplanted within 10 days of harvesting, and five were discarded because no suitable recipients were available within this period. There were no operative deaths or valve-related complications in the 13 homograft valve recipients. Mean follow-up was 13 months (range, 3 to 27 months). One patient required replacement of the homograft with a mechanical prosthesis because of insufficiency and stenosis. All patients are alive, are New York Heart Association functional class status I, and have insignificant valve gradients based on Doppler echocardiography. Although hearts removed from transplant recipients are severely diseased, the aortic valves are frequently normal and should be considered for use as homografts for other patients requiring aortic valve replacement.

Coronary patency, infarct size and left ventricular function after thrombolytic therapy for acute myocardial infarction: results from the tissue plasminogen activator: Toronto (TPAT) placebo-controlled trial. TPAT Study Group

Infarct size, left ventricular function and infarct-related coronary artery patency were examined in 108 patients who took part in a previously reported placebo-controlled trial of recombinant tissue-type plasminogen activator (rt-PA) in acute myocardial infarction. Coronary angiography was performed 17 +/- 0.8 h after initiation of treatment in 47 patients (group A) or at 10 days in 61 patients (group B). Both groups underwent radionuclide ventriculography 3.8 +/- 0.8 h and again on day 9 after treatment and quantitative thallium scintigraphy on day 8. In group A, the infarct-related artery was patent in 53%; these patients had a smaller global (15.1 +/- 2.5% vs. 25.7 +/- 4.7%, p = 0.029) and regional (14.7 +/- 2.5% vs. 24.1 +/- 4.7%, p = 0.044) fixed thallium defect than did those with an occluded artery. Infarct regional ejection fraction improved by 10.1 +/- 2.1% between early and late studies when the infarct-related artery was patent and by 4.8 +/- 1.4% if it was occluded (p = 0.048); changes in global and noninfarct regional ejection fraction were similar irrespective of perfusion status. Infarct regional ejection fraction and fixed thallium defect were inversely related only when the infarct-related artery was occluded (r = -0.83, p less than 0.0001). In group B, 10 day patency of the infarct-related artery was 67%; there was no difference in patency by treatment assignment or in left ventricular function or infarct size between patients with and without infarct-related artery patency. There was no evidence of an effect of rt-PA therapy beyond that expressed through coronary patency alone in either group A or group B.

Hypertension in obesity and NIDDM. Role of insulin and sympathetic nervous system

An important link exists between obesity, noninsulin-dependent diabetes mellitus (NIDDM), and hypertension. Most patients with NIDDM are obese; the incidence of hypertension in obesity and NIDDM is substantial, approaching 50% in some studies. Furthermore, hypertension is known to contribute to the increased cardiovascular morbidity and mortality in patients with obesity and NIDDM. Despite the obvious clinical importance, the pathogenesis of hypertension in obesity and NIDDM remains poorly understood. Recent studies have identified hyperinsulinemia and insulin resistance as important threads that tie hypertension, obesity, and NIDDM together. The hypothesis is developed that insulin-mediated sympathetic stimulation contributes to blood pressure elevation in both obesity and NIDDM. Recruited as a mechanism to limit weight gain and restore energy balance, insulin resistance and sympathetic stimulation increase blood pressure by enhancing renal Na+ reabsorption and stimulating the cardiovascular system. In this article, we review the evidence on which this hypothesis is based.

Influence of aminoglutethimide on plasma levels of medroxyprogesterone acetate

To confirm that concomitant administration of aminoglutethimide (AG) reduces plasma levels of medroxyprogesterone acetate (MPA), MPA levels were assayed in six patients with advanced breast cancer receiving the two agents. Patients had disease resistant to AG and were studied during conversion to therapy with MPA. Hydrocortisone was discontinued at the commencement of study and MPA introduced and given at a constant dose of 800 mg daily while AG was reduced in dose from 250 mg b.d. to 125 mg b.d. and then discontinued. MPA levels were measured after two weeks at each dose of AG and after two weeks on MPA alone. Mean MPA levels showed a progressive and significant (P less than 0.01) rise as the AG dose was reduced--180 ng ml-1, 250 ng ml-1 and 740 ng ml-1 respectively. MPA levels were always in excess of the accepted therapeutic level of 100 ng ml-1 and plasma cortisol levels fell in parallel with the rise in MPA levels.

Myocardial catecholamines and the pathophysiology of heart failure

The sympathetic nervous system contributes importantly to the clinical expression and, perhaps, to the course of myocardial failure. The failing heart exhibits both anatomic and functional defects in its sympathetic innervation and adrenergic receptor function. The nature of these abnormalities is at least partially dependent on the etiology of the underlying myocardial injury. Both efferent cardiac sympathetic tone and circulating catecholamines are elevated during the later stages of most forms of heart failure. This increase is not merely a reflex compensatory response but is also a reflection of defects in parasympathetic function, baroreceptor afferent nerve traffic, and regulation of sympathetic tone within the central nervous system through a serotonergic pathway. Prolonged stimulation of the heart may exhaust myocardial stores of norepinephrine and may lead to the destruction of sympathetic nerve terminals. Importantly, these abnormalities of autonomic function are distributed nonuniformly across the myocardium. Such heterogeneity can have profound effects on the temporal coordination of myocardial contraction and relaxation as well as the duration and configuration of the cardiac action potential and, thus, may contribute to both the mechanical and electrophysiological derangements seen in the failing heart. Therapy that makes sympathetic responses more uniform may improve the temporal coordination of excitation and contraction between innervated and denervated segments. This hypothesis might explain why both sympathetic agonists and antagonists may improve cardiac function since both types of drugs can restore the uniformity of neural stimulation.

Nebulized amphotericin B as prophylaxis against invasive aspergillosis in granulocytopenic patients

The efficacy of inhaled amphotericin B in prevention of invasive aspergillosis in patients with granulocytopenia (granulocytes less than 0.5 X 10(9)/l for greater than 10 days) was investigated over a 12-month period. Amphotericin B prophylaxis was administered twice daily for the period of granulocytopenia to 34 patients who were at risk during 144 episodes of granulocytopenia. The cohort at risk was compared with historical controls. In the 2 years prior to institution of prophylaxis, 14 patients (11.4% of those at risk) developed invasive aspergillosis. All cases occurred whilst the patients were nursed on the open wards. Aspergillosis did not develop in 25 granulocytopenic patients nursed in single rooms with HEPA filtration. Since institution of prophylaxis, there have been no cases of invasive aspergillosis. These data suggest that nebulized amphotericin B may be useful in preventing invasive pulmonary aspergillosis in granulocytopenic patients, especially those nursed on the open wards, and warrants further investigation.

Attempted balloon catheter obstruction of pulmonary arterial flow in ventricular septal rupture

Leaving a standard balloon flotation catheter inflated in the main pulmonary artery has been recommended as a temporizing measure in patients with post-myocardial infarction ventricular septal rupture. Potential benefit has been ascribed to effective "banding" of the pulmonary artery as in congenital ventricular septal defects. We attempted this technique in five patients with post-infarction septal rupture and shock. In no patient was a significant hemodynamic benefit or reduction in shunt observed. Because of the lack of clearly documented efficacy, the inadequate size of standard pulmonary balloons to produce significant obstruction to pulmonary flow, and the inherent risks of this technique we recommend that it not be lightly attempted.

Relationship between preoperative pulmonary status and outcome after heart transplantation

To determine whether routine preoperative pulmonary function tests provide useful prognostic information in orthotopic heart transplant candidates, we evaluated the pulmonary status of 33 patients who subsequently underwent transplantation. There was one perioperative death and five other fatalities within 9 months after operation. Mean age of the six patients who died (mean +/- SD 51.8 +/- 5.0 years) was significantly different (p less than 0.05) from that of the survivors (44.6 +/- 11.1 years). Mean preoperative pulmonary vascular resistance was significantly different (p less than 0.05) between those patients who had a fatal outcome (mean, 4.4 +/- 2.0 mm Hg/L/min) and those who survived (2.7 +/- 1.0 mm Hg/L/min). By contrast, we found that measures of forced vital capacity, forced expired volume in 1 second, diffusion capacity for carbon monoxide, and arterial blood gases bore no apparent relationship to outcome. We conclude that standard noninvasive measures of pulmonary function may be useful in preoperative preparation of heart transplant candidates, but they do not appear to be helpful in predicting eventual outcome.

Progressive multifocal leukoencephalopathy-remission with cytarabine

A 51-year-old woman who was in complete remission from non-Hodgkin's lymphoma, developed a rapidly progressive dementia. Progressive multifocal leukoencephalopathy (PML) was diagnosed on the basis of a rising antibody titre to JC polyomavirus in cerebro-spinal fluid and serum and the presence of diffuse white matter changes on magnetic resonance imaging. She was treated initially with intravenous cytarabine and showed minimal improvement. Rapid improvement occurred when intrathecal cytarabine was added and the patient is in complete remission from both lymphoma and PML 20 months later.

Enterobacter cloacae in a haematology/oncology ward--first impressions

The observation that Enterobacter cloacae has emerged as a cause of infection in a haematology/oncology ward prompted a prospective study over an eight-month period. Sensitivity to antibiotics, plasmid screening and typing methods were used to describe the epidemiology of the organism which was isolated from 22 patients. There was evidence of a limited amount of cross infection. No common sources were found. A large number of distinct strains were identified. E. cloacae infection was associated with prolonged profound leucopenia and broad-spectrum antibiotic therapy.

Multiple lymphomatous polyposis of the gastrointestinal tract. A clinicopathologically distinctive form of non-Hodgkin's lymphoma of B-cell centrocytic type

Multiple lymphomatous polyposis of the gastrointestinal tract was initially described as mucosal lymphomatous involvement by any of a variety of Hodgkin's or non-Hodgkin's lymphomas that produced a polypoid appearance over long segments of the gastrointestinal tract. We studied four patients in whom histology revealed diffuse small cleaved cell lymphoma (one case), or intermediate lymphocytic lymphoma of diffuse type (one case), or mantle zone pattern (two cases). All four cases are classifiable as centrocytic lymphoma. Cell suspension and immunocytochemical studies demonstrated B-cells of IgMD or M type with light chain restriction (two kappa, two lambda) showing a B1+ HLA Dr+ LN2+ CD5+ CD10+. Although all four patients had a partial response to combination chemotherapy, three of them died within 3 years. Analysis of 24 cases reported since 1971 (including the present cases) suggests that MLP is a distinct clinicopathological entity that results from gastrointestinal involvement by a B-cell centrocytic lymphoma. It is distinct from the recently described clinicopathological forms of centrocytic lymphoma and intermediate lymphocytic lymphoma, which both show extensive peripheral lymphadenopathy and splenomegaly, but it is probably closely related to them. The differences are probably attributable to distinct cell tropism or homing properties rather than to cellular histogenesis or degree of maturation.

Tissue plasminogen activator: Toronto (TPAT) placebo-controlled randomized trial in acute myocardial infarction

The efficacy and safety of recombinant tissue plasminogen activator (rt-PA) administered on a dosing per weight basis was evaluated in a randomized, placebo-controlled, double-blind trial in 115 patients with acute myocardial infarction. The principal outcomes were global and regional left ventricular function in the distribution of the qualifying myocardial infarction, determined 9 days after the onset of symptoms. Global and regional ejection fraction values were significantly better for patients treated with rt-PA than for placebo-treated patients (the differences were 5.8 +/- 2.7% units [p = 0.017] and 7.1 +/- 3.1% units [p = 0.012], respectively). This benefit was also evident from visual assessment of left ventricular segmental wall motion. After adjustment for differences in important prognostic variables at baseline, the estimates of treatment effect were 4.0 +/- 2.4% units (p = 0.048) for global and 4.3 +/- 2.6% units (p = 0.047) for regional ejection fraction. Early patency of the infarct-related vessel was demonstrable in 7 (29%) of 24 placebo-treated patients and 18 (78%) of 23 rt-PA-treated patients, whereas 15 (56%) of 27 patients in the placebo group and 23 (72%) of 32 in the rt-PA group had a patent infarct-related vessel at hospital day 9. There was no significant difference in irreversible or reversible defect size as assessed by thallium scintigraphy on day 7.(ABSTRACT TRUNCATED AT 250 WORDS)

Systemic and coronary hemodynamic and neurohumoral effects of levodopa in chronic congestive heart failure

Systemic and neurohumoral effects of oral levodopa were evaluated in 17 patients with severe chronic heart failure. The maximum mean dopamine level achieved after 1.5 g of oral levodopa was 19.6 +/- 16.4 ng/ml. At peak dopamine level, cardiac index increased by 14% from baseline (1.95 +/- 0.55 to 2.27 +/- 0.45 liters/min/m2, p less than 0.05), stroke volume index increased by 14% (22.4 +/- 6.0 to 25.9 +/- 5.8 ml/min/m2, p less than 0.01). There was a trend toward reduced systemic vascular resistance of 13% (1,773 +/- 769 to 1,535 +/- 432 dynes.s.cm-5, p = 0.08). There was no significant change from baseline in heart rate, mean arterial pressure, right atrial pressure, pulmonary capillary wedge pressure, pulmonary vascular resistance and rate-pressure product. In addition, as the arterial dopamine level increased there was a concomitant decrease in plasma norepinephrine level that was sustained for the period of observation. In a subgroup of 8 patients, there was no change in coronary sinus blood flow, myocardial oxygen consumption, myocardial oxygen extraction, lactate extraction and transmyocardial release of catecholamines after levodopa. These findings suggest that oral levodopa, 1.5 g, can improve left ventricular function without adversely affecting myocardial energetics and catecholamine balance.

Value of surveillance cultures in the management of neutropenic patients

To assess whether bacteriological surveillance cultures can be used to predict infection in neutropenic patients, cultures were performed during the period of neutropenia of nose, throat and urine specimens collected once weekly and faeces specimens collected twice weekly. Seventy-six consecutively observed patients undergoing chemotherapy for haematological or non-haematological diseases were investigated. Severe infection including septicaemia, lower respiratory tract infection, anorectal lesion and urinary tract infection occurred in 32 patients. Enterobacter cloacae, Escherichia coli and Pseudomonas aeruginosa were the organisms most commonly involved. In the majority of cases of septicaemia the organisms were isolated from the faeces, often in pure culture, prior to the onset of septicaemia. Most of the isolates of Enterobacter cloacae were resistant to the empiric antibiotic therapy used in the unit and were able to colonise multiple sites, presumably increasing the risk of subsequent infection. Faecal culture is the most useful approach in bacteriological surveillance in neutropenic patients.

Hodgkin's disease with a granulomatous pulmonary presentation mimicking sarcoidosis

A prominent sarcoid like pulmonary granulomatous reaction to Hodgkin's disease was diagnosed six months before extrapulmonary Hodgkin's disease was confirmed histologically. It recurred with exacerbations of the lymphoma. The reaction is similar to that often seen at pathological staging of intra-abdominal organs not affected by Hodgkin's disease.

Unusual breast masses. The sequential development of mammary tuberculosis and Hodgkin's disease in a young woman

A left breast mass developed in association with pulmonary tuberculosis in a woman 26 years of age. Eight years later, rapidly fatal Hodgkin's Disease with chest wall erosion by involved mediastinal nodes simulating a breast lump developed. Subsequently, a discrete breast mass due to mammary Hodgkin's disease developed. Involvement of the breast by both tuberculosis and Hodgkin's disease, two diseases often associated with immune dysfunction, in a patient with dysmorphic features and a strong family history of tuberculosis, raises the possibility of an underlying genetic defect. This defect probably involves the immune system.

Relapsing large cell immunoblastic lymphoma complicating well-differentiated lymphocytic lymphoma: a report of two cases showing prolonged survival with therapy

Two patients presented with co-existing large cell immunoblastic and well-differentiated lymphocytic lymphomas. Prolonged remissions from the large cell lymphomas were achieved following intensive combination chemotherapy but both patients suffered relapses after many years. Previous reports have grouped such patients with those developing classical Richter's syndrome implying a uniformly poor prognosis. This report suggests that this is not the case. It was not possible with immunohistochemical stains to prove or disprove that these tumours had the same stem cell origins.

Potentiation of small cell lung cancer-related SIADH by trifluoperazine

The syndrome of inappropriate anti-diuretic hormone secretion (SIADH) is a feature of approximately 7% of cases of small cell lung cancer (SCLC). The elaboration of peptide hormones by this tumour is well recognised and cerebral oedema resulting from inappropriate ADH secretion may be a life-threatening complication of this illness, requiring prompt intervention. We report a patient with SCLC who presented with SIADH which worsened abruptly each time he was treated with trifluoperazine for a co-existing psychosis.

The simultaneous presentation of peripheral T-cell lymphoma and hairy cell leukemia

A patient who presented simultaneously with B hairy cell leukemia (HCL) and peripheral T-cell lymphoma (PTL) is described. The diagnoses of the two neoplasms were made by standard morphologic and cytochemical study and confirmed immunologically. There was no evidence of overlap in markers to suggest that they arose from a single clone of malignant cells. It is suggested that the simultaneous occurrence of the two neoplasms in the same patient reflects an underlying predisposition to the development of neoplasia in HCL.

Paraneoplastic papilloedema in neuroblastoma

We report a case of bilateral papilloedema in an adult male with neuroblastoma, in the absence of hypertension or detectable intracranial disease. This complication has not previously been described in the English-speaking literature. Possible mechanisms are discussed.

Survival in severe left ventricular failure treated with the new nonglycosidic, nonsympathomimetic oral inotropic agents

Survival in severe left ventricular failure is poor but has not been widely assessed since the introduction of several new nonglycosidic, nonsympathomimetic oral inotropic agents for long-term therapy. We examined retrospectively the survival of 82 patients with severe left heart failure during long-term treatment with oral milrinone (17 patients), posicor (12 patients), enoximone (47 patients), and piroximone (6 patients). Sixty-five patients were in New York Heart Association (NYHA) functional class 4, 15 patients were in class 3, and two patients were in class 2. There were 57 patients with ischemic and 25 patients were in class 2. There were 57 patients with ischemic and 25 patients with nonischemic etiology of left heart failure. Most patients were referred for inotropic therapy after failing to respond to conventional agents, including vasodilators. However, in almost all patients, marked hemodynamic and clinical improvement occurred initially. Overall survival was 36 percent at six months, the majority of deaths occurring during the first three months. Survival in relation to etiology of heart failure showed a trend toward increased mortality in patients associated with ischemic heart disease vs non-ischemic dilated cardiomyopathy. Sudden death mortality was also higher in the ischemic group (28 percent at six months vs 5 percent at six months; p less than 0.05). There was a trend toward reduced sudden death mortality in patients on antiarrhythmic agents during inotropic therapy (p = 0.06). We conclude that overall survival in symptomatic patients with severe left ventricular failure remains very low during long-term therapy with several new oral inotropic agents. Sudden death appears higher in patients with an ischemic etiology during therapy with these agents.

Enalaprilat, a new parenteral angiotensin-converting enzyme inhibitor: rapid changes in systemic and coronary hemodynamics and humoral profile in chronic heart failure

Systemic and coronary hemodynamic, metabolic and humoral effects of a new intravenous angiotensin-converting enzyme inhibitor, enalaprilat, were evaluated in 14 patients with chronic heart failure. Onset of hemodynamic action occurred within 15 minutes and persisted for 6 hours. At the time of peak effect, there was a significant reduction in mean arterial pressure (-21%) and pulmonary capillary wedge pressure (-33%). Systemic vascular resistance decreased by 32% and stroke volume index increased by 20%. These systemic hemodynamic changes indicate improved left ventricular function. There was a substantial sustained reduction in rate-pressure product initially without a change in coronary sinus blood flow or myocardial oxygen consumption. There was also reduced myocardial oxygen extraction and augmented coronary sinus oxygen saturation at 30 minutes and 1 hour. In three patients, abnormal myocardial lactate extraction, present before enalaprilat, changed to uptake after enalaprilat, indicating amelioration of myocardial ischemia that was not clinically manifest. Systemic catecholamine levels and myocardial catecholamine balance did not change. Plasma renin activity increased and plasma aldosterone decreased. These findings suggest that enalaprilat produces inhibition of the angiotensin-converting enzyme and consequent beneficial systemic hemodynamic changes in heart failure. In some patients with heart failure, silent myocardial ischemia at rest can occur and can be alleviated with enalaprilat. Decreased myocardial oxygen extraction, increased coronary sinus oxygen saturation and lack of expected decrease in coronary sinus blood flow despite reduced rate-pressure product suggest transient coronary vasodilation by enalaprilat.

Successful medical management of esophagopericardial fistula

Esophagopericardial fistula is a rare condition, usually presenting with cardiac tamponade, and is invariably fatal in the adult patient. In our patient the disorder resulted from fistulization secondary to a malignant tumor. Immediate decompression of resultant tense pneumopericardium can be accomplished safely through percutaneous pericardiocentesis without the need for surgery. Rarely, as in the present case, spontaneous closure of esophagopericardial fistula is encountered.

RO13-6438, a new inotrope-vasodilator: systemic and coronary hemodynamic effects in congestive heart failure

Systemic and coronary hemodynamics and transmyocardial norepinephrine release were determined before and after oral administration of RO13-6438, a new inotrope-vasodilator agent, in 12 patients with severe chronic heart failure unresponsive to conventional and vasodilator therapy. Improvement in left ventricular (LV) function was evident from a marked increase in cardiac index (from 2.09 +/- 0.45 to 3.30 +/- 0.73 liters/min/m2, p less than 0.01), stroke volume index (from 23 +/- 7 to 36 +/- 11 ml/m2, p less than 0.01), and stroke work index (from 23 +/- 11 to 36 +/- 14 g-m/m2, p less than 0.01), and concomitant fall in pulmonary capillary wedge pressure (from 26 +/- 7 to 16 +/- 8 mm Hg, p less than 0.01). Myocardial oxygen consumption did not change significantly (from 15.3 +/- 6.8 to 14.9 +/- 6.8 ml/min), but the ratio of minute work/myocardial oxygen consumption, an index of LV efficiency, increased significantly (p less than 0.05). Although average coronary sinus flow did not change, coronary sinus oxygen increased (from 3.2 +/- 0.8 to 4.2 +/- 1.5 vol%, p less than 0.05), and arterial-coronary sinus oxygen difference decreased (from 11.8 +/- 2.1 to 10.4 +/- 1.9 vol%, p less than 0.05), suggesting a primary vasodilating effect of RO13-6438 on the coronary vascular bed. Net transmyocardial norepinephrine release did not change despite the marked hemodynamic improvement. These findings suggest that RO13-6438 has the potential to cause marked improvement in LV function and LV efficiency in patients with severe, refractory congestive heart failure.

Alterations in left ventricular function, coronary hemodynamics and myocardial catecholamine balance with MDL 17043, a new inotropic vasodilator agent, in patients with severe heart failure

To evaluate changes in myocardial energetics and systemic and cardiac sympathetic activity associated with improved left ventricular function after MDL 17043, a new inotropic vasodilator agent, systemic and coronary hemodynamics and myocardial catecholamine balance were determined in 17 patients with severe heart failure. After the administration of MDL 17043, cardiac index increased by 67% and pulmonary capillary wedge pressure decreased (25 +/- 5 to 14 +/- 7 mm Hg, p less than 0.01), indicating improved left ventricular function. Coronary sinus blood flow (75 +/- 29 to 111 +/- 51 ml/min, p less than 0.01) and myocardial oxygen consumption (9.9 +/- 3.3 to 11.8 +/- 5.4 ml/min, p less than 0.05) increased despite decreased myocardial oxygen extraction (11.7 +/- 2 to 10.1 +/- 3.3 vol%, p less than 0.05) and a higher coronary sinus oxygen content. Although transmyocardial lactate extraction remained unchanged, increased myocardial oxygen consumption has potential deleterious effects on myocardial metabolic function. Arterial norepinephrine concentrations and transmyocardial norepinephrine release also remained unchanged. These findings suggest that MDL 17043 improves left ventricular pump function, but produces no detectable change in systemic and cardiac sympathetic activity. Improved left ventricular function is associated with increased myocardial oxygen consumption despite primary coronary vasodilation.

Multiple neoplasms in hairy cell leukaemia

A patient who presented simultaneously with typical hairy cell leukaemia (HCL) and multiple myeloma (MM) is described. He was treated with melphalan and irradiation and 18 months later presented with an adenocarcinoma. The occurrence of multiple neoplasms in this patient may reflect an underlying predisposition to neoplasia secondary to the immunological defects common in B cell lymphoproliferative diseases.

Alloimmunization prevents the migration of transfused indium-111-labeled granulocytes to sites of infection

111In-labeled granulocytes were used to study the effects of histocompatibility factors on the migration of transfused granulocytes to infected sites. Fourteen alloimmunized and 20 nonalloimmunized patients received approximately 10(8) 111In-labeled granulocytes from ABO-compatible, non-HLA-matched donors, and scans were performed over known infected sites. All 14 alloimmunized patients had lymphocytotoxic antibody (LCTAb) and required HLA-matched platelet transfusions. Of the nonalloimmunized patients, 20/20 had positive scans at sites of infection. None of the 20 had LCTAb, 0/17 had a positive lymphocytotoxic crossmatch (LCTXM) with the donor, and 3/18 had a positive leukoagglutinin crossmatch (LAXM). Thus, histocompatibility testing was not found to be important in nonalloimmunized patients. In contrast, only 3/14 alloimmunized patients had positive scans at sites of infection (p = 0.00001 compared to nonalloimmunized patients). One of 3 had a positive LCTXM and 2/3 had a positive LAXM. Of the alloimmunized patients, 10/11 with negative scans had a positive LCTXM and 8/11 had a positive LAXM. Labeled granulocytes failed to reach sites of infection in 11/14 (78%) alloimmunized patients, demonstrating that histocompatibility factors can be of major importance in affecting the outcome of granulocyte transfusions. Granulocytes from random donors are unlikely to be effective in alloimmunized patients. The lack of an adequate crossmatching technique is a major problem limiting the ability to provide granulocyte transfusions for alloimmunized patients.