Age of onset and the characteristics of asthma

OBJECTIVE

The aim of this study was to evaluate the characteristics of asthma in patients with different ages of disease onset.

METHODOLOGY

Five hundred and four asthmatic patients (303 males and 201 females) were divided into five groups based on age of onset (group I, age of onset < 15 years old; group II, 15-24 years old; group III, 25-44 years old; group IV, 45-64 years old; and group V, > 64 years old). The relationship between age of onset and the characteristics of asthma, including lung function, reversibility, atopic status and the incidence of coexistent allergic rhinitis was assessed. Multivariate analysis, adjusted for the duration of disease, gender, educational level, smoking status, and degree of previous inhaled corticosteroid treatment, was performed.

RESULTS

Thirty per cent of the patients developed asthma before they were 14 years old (group I), and the percentages of those developing asthma at other ages of onset were: group II, 12%; group III, 29%; group IV, 21% and group V, 8%. In all, 57.6% of the asthmatic patients had coexistent allergic rhinitis; younger patients tended to have this comorbidity. The pulmonary function of older onset asthma patients was worse than that of early onset patients. The multivariate analysis showed that there was a positive correlation between the reduction of pulmonary function and duration of the disease (P < 0.001), but there was no relationship between pulmonary function and gender (P = 0.502), educational level (P = 0.734), smoking pack-years (P = 0.902), or degree of use of inhaled corticosteroid treatment (P = 0.586).

CONCLUSION

Asthma is a heterogeneous disease with a wide variety of presentations. This study provides information about the disease characteristics and their relationship with age of onset. Further study is necessary to determine why these differences exist.

The diagnosis of pneumonia in renal transplant recipients using invasive and noninvasive procedures

STUDY OBJECTIVES

We used invasive and noninvasive procedures to determine the causes of pneumonia in renal transplant recipients.

SUBJECTS AND METHODS

We retrospectively surveyed 565 renal transplant recipients (transplants received March 1984 to August 2001) to find those with pneumonia. Noninvasive diagnostic methods included serologic testing, and blood and sputum cultures with stains. Invasive procedures included fiberoptic bronchoscopy and percutaneous transthoracic procedures.

RESULTS

A total of 92 patients were enrolled. Of these, 71 patients had a definite etiologic diagnosis of pneumonia. The major infectious pathogens were bacterial (n = 21) and mixed bacterial infection (n = 10), Mycobacterium tuberculosis (TB) [n = 18], and fungi (n = 8). Noninvasive and invasive procedures led to the diagnosis of pneumonia in 31.5% (n = 29) and 45.6% (n = 42) of patients, respectively. Bronchoscopy was used in 64 patients, with a diagnostic yield of 38 cases (59.3%). Patients were 3.62 times more likely to contract pneumonia within 12 months of renal transplantation than they were > or =12 months thereafter (95% confidence interval, 1.33 to 9.84). Twenty-seven of the 92 patients (29.3%) died. The pneumonia mortality rate has dropped significantly since 1996 (41.8% vs 10.8%, p = 0.002).

CONCLUSION

Both invasive and noninvasive procedures are useful in the diagnosis of pneumonia, with declining mortality, in renal transplant recipients. Bacterial and mixed bacterial infection, TB, and fungal infection are the most common pathogens; cases are most likely to occur within 1 year after renal transplantation.

Features of severe pneumonia in patients with undiagnosed pulmonary tuberculosis in an intensive care unit

BACKGROUND AND PURPOSE

Early antituberculosis (anti-TB) therapy in hospitalized, severely ill patients with pulmonary tuberculosis (PTB) diminishes the mortality and morbidity rate and also reduces nosocomial transmission. However, delayed diagnosis of PTB is common in the respiratory intensive care unit (RICU), especially in patients with respiratory failure. This retrospective study evaluated the clinical features of RICU patients with severe pneumonia and undiagnosed active PTB, in order to determine which specific features might help in the screening of these patients.

METHODS

Patients with severe pneumonia with undiagnosed active PTB and those without active PTB on admission to the RICU, from March 1, 2000 to August 31, 2002, were compared. The 2 groups of patients were matched for age, gender, and Acute Physiology and Chronic Health Evaluation (APACHE) II score prior to the analysis. Data on clinical course, chest radiographic patterns, and laboratory findings were collected.

RESULTS

Thirty five patients in the case group were matched with 35 controls who were similar with regard to age, gender, smoking history, acute lung injury score, and the presence of underlying disease. The duration of symptoms before admission was significantly longer in the case group than in the control group (15.1 +/- 13.9 vs 7.8 +/- 7.6 days, p = 0.012). The mean interval from admission to the RICU to the initiation of anti-TB therapy was 10.0 +/- 9.8 days. Small nodular lesions (p = 0.044) and cavitary lesions (p = 0.013) predominated on the chest radiograph in the case group. The mortality rates at discharge were not significantly different between the case group and the control group.

CONCLUSIONS

These data suggest that when a patient developing severe pneumonia has a history of a sub-acute or chronic illness longer than 2 weeks in duration, and predominant small nodular or cavitary patterns on chest radiograph, active PTB should be considered.

Successful treatment of multifocal bronchioloalveolar cell carcinoma with ZD1839 (Iressa) in two patients

Multifocal bronchioloalveolar cell carcinoma (BAC) is a rare condition that often presents as bilateral lung infiltrates unsuitable for surgical and radiological treatment, with poor response to conventional chemotherapies. Epidermal growth factor receptor (EGFR) pathways are closely related to the proliferation and metastasis of cancer cells. ZD1839 (Iressa) is a quinazoline-derived, orally active, selective inhibitor of the EGFR tyrosine kinase that shows promising effects in the treatment of non-small cell lung cancer. We report 2 cases of multifocal BAC successfully treated with ZD1839. Both patients had advanced disease, and had productive cough for more than 1 year. After the diagnosis of BAC, the first patient received chemotherapy, but was unresponsive. Within 2 weeks of starting treatment with ZD1839 250 mg per day, the amount of bronchorrhea decreased. Two months after the start of ZD1839 treatment, image study showed a marked decrease of lung infiltrates. The second patient developed respiratory failure after an operation on the spine. He received ZD1839 250 mg daily via nasogastric tube. Two weeks after the start of treatment, his dyspnea had improved and he was weaned from the mechanical ventilator. The side effects of ZD1839 treatment in these 2 patients consisted only of dry skin and acne over the face, trunk, and periungual areas. Although the precise mechanisms of the antitumor effects of ZD1839 remain unclear, these results suggest a role for the agent in the management of patients with advanced multifocal BAC.

Serial-measured versus estimated creatinine clearance in patients with non-small cell lung cancer receiving cisplatin-based chemotherapy

BACKGROUND AND PURPOSE

Cisplatin-based chemotherapy is the main therapy for patients with advanced stage non-small cell lung cancer (NSCLC). The dose of cisplatin is adjusted according to the patient's renal function. Calculation of creatinine clearance (CCr) by 24-hour urine collection is the most common method for estimating the glomerular filtration rate but is time-consuming and inconvenient. Estimation of CCr using the Cockcroft-Gault formula has been suggested to be accurate, reproducible, and less costly. This study compared CCr values obtained by measured and estimated methods during cisplatin-based chemotherapy in NSCLC patients in Taiwan.

METHODS

A total of 92 patients (58 men, 34 women) with advanced NSCLC who completed 6 cycles of chemotherapy participated in the study. The dose of cisplatin per cycle was 80 mg/m(2) every 28 days, reduced to 50 mg/m(2) if CCr was 30 to 60 mL/min by the measured method. When urine collection was finished, serum and urine creatinine levels were measured simultaneously. Estimated values were calculated before each cycle of chemotherapy.

RESULTS

The mean measured CCr was 85.2 mL/min, 25.7 mL/min higher than the mean estimated value. CCr values obtained by both methods were significantly reduced during the 6 cycles of chemotherapy. There was no significant difference in CCr values between patients aged < 65 years or >/= 65 years (-19.9 vs -15.1 mL/min, p = 0.15). Using a cut-off of measured CCr >/= 60 or < 60 mL/min, agreement on the dosage for both methods was 51% for all patients, 77.7% for patients < 65 years, and 26.7% for patients >/= 65 years.

CONCLUSIONS

The Cockcroft-Gault formula underestimated measured CCr by about 25 mL/min in this study. Cisplatin-based chemotherapy reduced CCr, with no significant difference between older and younger patients. Use of the estimated method would result in significant under-dosing, especially for patients >/= 65 years old.

Bronchoalveolar interleukin-1 beta: a marker of bacterial burden in mechanically ventilated patients with community-acquired pneumonia

OBJECTIVE

To assess the relationship between concentrations of bronchoalveolar cytokines and bacterial burden (quantitative bacterial count) in intubated patients with a presumptive diagnosis of community-acquired pneumonia.

DESIGN

A cross-sectional and clinical investigation. SETTING Medical/surgical and respiratory intensive care unit of a tertiary 1,200-bed medical center.

PATIENTS

According to the time course of community-acquired pneumonia at the time of study with bronchoalveolar lavage, 69 mechanically ventilated patients were divided into three subgroups: primary (n = 11), referral (n = 23), and treated (n = 35) community-acquired pneumonia.

INTERVENTIONS

Bronchoalveolar lavage was performed in the most abnormal area on chest radiograph by fiberoptic bronchoscope. Bronchoalveolar lavage fluid was processed for quantitative bacterial culture. The concentrations of bronchoalveolar lavage cytokines (tumor necrosis factor-alpha, interleukin-1 beta, interleukin-6, interleukin-8, and interleukin-10) also were measured.

MEASUREMENTS AND MAIN RESULTS

Thirty-two patients had a positive bacterial culture (bronchoalveolar lavage > or = 10 colony-forming units/mL)., and made up 76% of pathogens recovered at high concentrations. The concentrations of bronchoalveolar lavage interleukin-1 beta were 199.1 +/- 32.1 and 54.9 +/- 13.0 pg/mL (mean +/- se) in the patients with positive and negative bacterial culture, respectively (p < .001). Bronchoalveolar lavage interleukin- 1 beta was significantly higher in the patients with a high bacterial burden (p < .001), with mixed bacterial infection (p < .001), and with pneumonia (p < .001), compared with values in patients without these features. The relationship between bacterial load and concentrations of bronchoalveolar lavage interleukin-1 beta was very strong in the patients with primary and referral community-acquired pneumonia but was borderline in treated community-acquired pneumonia.

CONCLUSIONS

The common pathogens were similar to the core pathogens of hospital-acquired pneumonia, probably due to antibiotic effects, delayed sampling, and superimposed nosocomial infection. Since the concentration of bronchoalveolar lavage interleukin-1 beta was correlated with bacterial burden in the alveoli, it may be a marker for progressive and ongoing inflammation in patients who have not responded to pneumonia therapy and who have persistence of bacteria in the lung.

Clinical patterns among invasive pulmonary aspergillosis patients with and without recent intensive immunosuppressive therapy

BACKGROUND AND PURPOSE

Invasive pulmonary aspergillosis (IPA) is usually an acute life-threatening infection in cancer patients receiving chemotherapy and in organ transplant recipients receiving immunosuppressive therapy. In some immunocompetent patients, IPA has a chronic and indolent clinical course. We compared the clinical patterns among IPA patients who had received recent intensive immunosuppressive therapy (RIIT) and those who had not (N-RIIT).

METHODS

We reviewed the medical records of patients with a diagnosis of IPA made between 1992 and 1999. RIIT was defined as chemotherapy or high-dose corticosteroid therapy (at least 500 mg/d methylprednisolone, or equivalent, for at least 3 d) within 2 weeks before the onset of symptoms. RIIT patients were divided into those with and without malignancy. We compared clinical characteristics including age, sex, chest image patterns, diagnostic methods, culture results, treatment conditions, mortality, and recurrence rate in IPA patients: RIIT versus N-RIIT, and RIIT with and without malignancy.

RESULTS

A total of 24 patients with IPA, 17 patients who had received RIIT and seven patients who had not (N-RIIT), were included. In the RIIT group, 11 patients had malignancy and six did not. No significant differences in gender, chest image patterns, diagnostic methods, and culture results were found between the RIIT and N-RIIT groups. The N-RIIT group was older and was treated significantly later after the onset of symptoms than the RIIT group (mean +/- standard deviation, SD, 89.43 +/- 129.47 vs 9.70 +/- 9.33 d, p = 0.018). Only one of the seven N-RIIT patients died, while nine of the 17 RIIT patients died (p = 0.08). Among the RIIT patients, five of the six without malignancy died, while four of the 11 patients with malignancy died. IPA recurred in seven of the eight RIIT patients, all of whom had malignancy, but in none of the six N-RIIT patients during a similar follow-up period (mean +/- SD, 16.3 +/- 18.9 vs 27.0 +/- 54.5 mo, p = 0.505).

CONCLUSIONS

No differences were noted in image and culture studies between RIIT and N-RIIT IPA patients. RIIT IPA patients had acute and fulminant clinical courses, especially patients without malignancy, even though they received treatment with a mean duration of about 10 days starting from the onset of symptoms. All patients with malignancy undergoing further chemotherapy had recurrence of IPA. N-RIIT IPA patients had chronic clinical courses, a trend of lower mortality rate even with delayed diagnosis, and no recurrence.

Increased soluble Fas ligand concentration in tuberculous pleural effusion

BACKGROUND AND PURPOSE

Tuberculous (TB) pleurisy results from a delayed hypersensitivity reaction involving macrophages, T-cells, and many cytokines (including tumor necrosis factor, interferon-gamma, and interleukin 1 and 2). Infection by Mycobacterium tuberculosis induces apoptosis in gamma/delta T-cells and macrophages. Fas ligand (FasL) is a type II membrane protein that plays an important role in the regulation of apoptosis and has an intimate relation with these cells and cytokines. A soluble form of FasL (sFasL) exists in a variety of human body fluids, including serum, pleural effusion, cerebral spinal fluid, and ocular fluid. Therefore, we hypothesized that Fas activity is elevated in TB pleurisy. This study investigated the concentration of sFasL in TB pleural effusions and compared it with expression of sFasL in various other pleural effusions.

METHODS

Using an enzyme-linked immunosorbent assay, we investigated the sFasL concentrations of 80 pleural effusions from patients with various diagnoses.

RESULTS

The median sFasL concentration in the TB pleural effusion group was 104.91 pg/mL (n = 32). This was significantly higher than values in the transudate group (median value, 20.02 pg/mL, n = 9, p < 0.001) and patients with malignant effusion associated with adenocarcinoma of the lung (median value, 23.29 pg/mL, n = 14, p < 0.001). Lymphoproliferative disease could not be distinguished from TB based on sFasL concentrations in pleural effusion.

CONCLUSIONS

The sFasL concentration in TB pleural effusions is significantly higher than that in adenocarcinomatous pleural effusions, which are the most common malignant pleural effusions. This difference may serve as a diagnostic tool to differentiate these two most commonly encountered unexplained pleural effusions. Determination of the cellular source and the actual role of the abundant sFasL in TB pleurisy will require further investigation.

Establishment and characterization of a paclitaxel-resistant human non-small cell lung cancer cell line

We have established a paclitaxel-resistant mutant cell line called H460/TAX which was derived from human non-small cell lung cancer (NSCLC) H460. A 64-fold greater resistant was shown in our assay as compared with the parental cells. High specificity of drug resistance was also observed since this mutant was not cross-resistant to several other anticancer drugs. Drug accumulation in H460/TAX was significantly less than that in H460. Many endogenous protein profiles were intact, including the expression level of P-glycoprotein, multidrug resistance-associated protein, the 70 kDa heat shock proteins as well as the phosphorylation of Bcl-2 in H460/TAX cells, except that the total amount of alpha- and beta- tubulins was higher in H460/TAX than in H460 cells. Higher drug concentration and longer treatment for paclitaxel were required in H460/TAX to exert the phosphorylation of keratin 19 which was then accompanied by reorganization of the intermediate filament and the microtubule networks. Since all of the aforementioned factors involved in paclitaxel-resistance in other systems were not found to be significantly altered in H460/TAX, there must be other paclitaxel-resistance mechanisms(s) which remains to be identified in human lung cancers.

Novel cystic fibrosis mutation (2215insG) in two adolescent Taiwanese siblings

Cystic fibrosis (CF) is an autosomal recessive disorder that is rarely found in Asians. Only four cases of CF from four different families have been reported in Taiwan. We report two cases of CF involving two teenage siblings. Both presented with repeated airway infections, poor weight gain, clubbing of the fingers, hypoxemia, and obstructive ventilatory impairment. Multiple focal bronchiectases and emphysema were demonstrated on high-resolution computed tomography. Sweat chloride concentrations, as measured using the modified sweat chloride test in a closed space with a heater, were 327 mmol/L and 276 mmol/L, respectively. To confirm the CF diagnosis, DNA mutation analysis was performed. All 27 exons of the CF transmembrane conductance regulator (TR) gene and their flanking intron sequences were screened for nucleotide sequence alterations, and the mutations were then identified by direct DNA sequence analysis. Both siblings carried 1898 + 5G-->T; a mutation previously identified in Taiwan. In addition, the mutation analysis identified a new single-base-insertion mutation in exon 13 on the second CFTR allele of these patients. This mutation, named 2215insG, is expected to cause a significant disruption of CFTR function. The 1898 + 5G-->T/2215insG genotype is thus consistent with the CF diagnosis. A new missense mutation, S895N, in exon 15 of the CFTR gene, which cosegregated with 2215insG, was also identified in both of these patients.

Indolent cutaneous mucormycosis with pulmonary dissemination in an asthmatic patient: survival after local debridement and amphotericin B therapy

We describe a 68-year-old asthmatic female patient with multiple pulmonary cavities. A preexisting ecthyma on the left lower leg became erythematous and swollen during exacerbation of her asthma which was under treatment with high-dose steroids. Nonseptate broad hyphae were found in her sputum, pus from the wound, and debrided skin tissue. Hematogenous spread of septic emboli from indolent cutaneous mucormycosis to both lungs was the suspected mechanism of dissemination. High-dose steroid therapy may have been the major contributory factor. The patient was successfully treated with local surgical debridement of the wound and intravenous amphotericin B.

Effects of cytoskeletal inhibitors on the accumulation of vincristine in a resistant human lung cancer cell line with high level of polymerized tubulin

We have previously established a vincristine resistant human lung cancer cell line (PC-9/VCR) by a stepwise exposure of parental line PC-9 to vincristine. In this study the resistant cells showed enhanced vincristine cytotoxicity in the presence of cytochalasin B and D. The increase in cytotoxicity was associated with an enhanced accumulation and a reduced efflux of vincristine. Colchicine and taxol had no effects on vincristine accumulation. Several cytoplasmic proteins were overexpressed in the resistant cells. The two major ones, with molecular weights of 58.8 kDa and 83.2 kDa, were shown by western blotting to be beta-tubulin and actin, respectively. The polymerized tubulin level in the resistant cells was significantly (p < 0.05) higher than that in the parental cells. These results suggest that the cellular cytoskeletons might play an important role in VCR resistance in the PC-9/VCR human lung cancer cell line.

Preliminary result of phase II study of paclitaxel and cisplatin chemotherapy for advanced non-small-cell lung cancer in Chinese patients

This phase II study was designed to assess the response rate and toxicity of paclitaxel and cisplatin chemotherapy in Chinese patients with untreated advanced non-small-cell lung cancer (NSCLC). Eligibility requirements included histologically confirmed stage IIIb-IV NSCLC, Eastern Cooperative Oncology Group performance status less than 2, no previous chemotherapy, and adequate bone marrow, renal, and hepatic function. From April 1996 through March 1997, 32 patients were treated. The dose of paclitaxel was 135 mg/m2 as a 3-hour infusion on day 1 and cisplatin 75 mg/m2 on day 2. The regimen was repeated every 3 to 4 weeks for up to 6 to 8 cycles unless there was evidence of tumor progression. The median age was 57 years (range, 31-77 years). Sixty-five percent were men. Sixty-nine percent had adenocarcinoma, and 75% had stage IV disease. One hundred seventy-two cycles were administrated; 18 patients (56%) completed all six cycles. Peripheral neuropathy and myelosuppression were the principle toxicities. Neurotoxicity appeared to be dose limiting and manifested primarily as paresthesia. Grade 2 neurotoxicity was observed in 5% of courses, which was slowly reversible. However, the severity of myelosuppression was generally mild to moderate. No episode of neutropenic fever was noted. Thrombocytopenia remained infrequent throughout the study. Other nonhematologic toxicities were also generally mild. The objective response rate was 50%. In conclusion, this combination of paclitaxel and cisplatin is active in Chinese patients with advanced NSCLC. It merits further investigation in phase III trials.

Color Doppler ultrasound pulsatile flow signals of thoracic lesions: comparison of lung cancers and benign lesions

Color Doppler ultrasound (US) was performed in 153 patients (including 102 with lung cancer and 51 with benign lesions) to assess pulsatile flow signals in thoracic lesions. The values of resistive index (RI) and pulsatility index (PI) of color Doppler US pulsatile flow signals in lung cancers and benign lesions were measured, analyzed, and compared. In the enrolled 153 patients with thoracic lesions, 61 lung cancers and 34 benign lesions had detectable color Doppler US pulsatile flow signals, and lung cancers had lower RI and PI values than benign lesions (RI: 0.70+/-0.03 vs. 0.79+/-0.04, p < 0.05; PI: 1.61+/-0.15 vs. 2.44+/-0.25, p < 0.005). However, overlapping RI and PI values in lung cancers and benign lesions somewhat limited color Doppler US pulsatile flow signals to differentiate lung cancers from benign lesions. Further analysis of RI and PI values in subgroups of lung cancers [squamous cell carcinoma (SCC, n = 34), adenocarcinoma (AC, n = 18), and small-cell lung cancer (SCLC, n = 6)] and benign lesions [cavitary benign lesions (CBL, n = 8), and noncavitary benign lesions (NCBL, n = 26)] revealed that all different cell types of lung cancers (SCC, AC, and SCLC), indeed, had lower RI and PI values than NCBL (for RI, all p < 0.01; for PI, all p< or =0.001). Moreover, the mean RI and PI values showed a significant incremental decrease from NCBL (mean RI, PI = 0.88, 2.94) toward SCC and AC (for SCC, mean RI, PI = 0.71, 1.68; for AC, mean RI, PI = 0.68, 1.67) and, finally, to SCLC (mean RI, PI = 0.62, 1.05). In contrast, CBL had relatively lower RI and PI values than AC and SCLC (for CBL, mean RI, PI = 0.53, 0.80; both p > 0.05 for RI and PI), and even a significant difference from SCC (p < 0.05 for RI and PI). We conclude that color Doppler US pulsatile flow signal is somewhat limited to differentiate lung cancers from benign lesions, but provides a noninvasive in vivo model to assess the neovascularity intensity of lung cancers.

Synthesis, DNA cleavage and cytotoxicity of some novel cyclic peptide-2,6-dimethoxyhydroquinone-3-mercaptoacetic acid conjugates containing D-amino acids

This paper reports an ongoing study of the use of small-ring-size cyclic peptides as carriers of a potential antitumor agent: 2,6-dimethoxyhydroquinone-3-mercaptoacetic acid (DMQ-MA). Three new cyclic tripeptide-DMQ-MA conjugates--cyclo[D-Val-Lys(DMQ-MA)-gamma-aminobutyric acid (GABA)-], cyclo[Val-Lys(DMQ-MA)-GABA-] and cyclo[D-Val-D-Lys(DMQ-MA)-GABA-]--were synthesized. The isomeric cyclic tripeptide-DMQ-MA conjugates were designed and synthesized to study the effect of stereoisomerism of the conjugates on cytotoxicity. The cyclic peptides were synthesized by coupling protected amino acids in solution and the final cyclization performed by the pentafluorophenyl ester method as described previously. After removing the lysyl-Z protecting group of the cyclic peptides the conjugation was achieved by reacting with the pentafluorophenyl ester of DMQ-MA. Electron spin resonance (ESR) studies of these three cyclic tripeptide-DMQ-MA conjugates showed that hydroxyl radicals were generated as a non-linear function of L-ascorbic acid (AH2) concentration. The IC50 of the cyclic tripeptide-DMQ-MA conjugates against a human pulmonary carcinoma cell line (PC-9 cells) under the synergistic activation of AH2 ranges from 0.4 to 1.6 microM, which is significantly lower than the parent compound DMQ-MA (6.1 microM). Agarose gel electrophoresis showed that DMQ-MA and these cyclic peptide-DMQ-MA conjugates are capable of cleaving supercoiled plasmid DNA to open circular and linear forms, even in the absence of AH2. The effects of enantiomeric and diastereomeric variations of these cyclic tripeptide-DMQ-MA conjugates on the cytotoxicity against PC-9 cells were discussed.

Taxol induces concomitant hyperphosphorylation and reorganization of vimentin intermediate filaments in 9L rat brain tumor cells

Taxol, a microtubule stabilizing agent, has been extensively investigated for its antitumor activity. The cytotoxic effect of taxol is generally attributed to its antimicrotubule activity and is believed to be cell cycle dependent. Herein, we report that taxol induces hyperphosphorylation and reorganization of the vimentin intermediate filament in 9L rat brain tumor cells, in concentration- and time-dependent manner. Phosphorylation of vimentin was maximum at 10(-6) M of taxol treatment for 8 h and diminished at higher (10(-5) M) concentration. Enhanced phosphorylation of vimentin was detectable at 2 h treatment with 10(-6) M taxol and was maximum after 12 h of treatment. Taxol-induced phosphorylation of vimentin was largely abolished in cells pretreated with staurosporine and bisindolymaleimide but was unaffected by H-89, KT-5926, SB203580, genistein, and olomoucine. Thus, protein kinase C may be involved in this process. Hyperphosphorylation of vimentin was accompanied by rounding up of cells as revealed by scanning electron microscopy. Moreover, there was a concomitant reorganization of the vimentin intermediate filament in the taxol-treated cells, whereas the microtubules and the actin microfilaments were less affected. Taken together, our data demonstrate that taxol induces hyperphosphorylation of vimentin with concomitant reorganization of the vimentin intermediate filament and that this process may be mediated via a protein kinase C signaling pathway.

Ultrasound-guided fine needle aspiration biopsy in the diagnosis of pulmonary cryptococcosis

The purpose of this study was to assess the safety and reliability of ultrasound-guided fine needle aspiration biopsy (US-guided FNAB) combined with modified Papanicolaou's staining in the diagnosis of pulmonary cryptococcosis. The study included 10 patients (9 men, 1 woman, 28-70 yr). Percutaneous US-guided FNAB was performed through a puncture probe with central channel guidance (n = 8) or in a 'free-hand' manner (2), depending on the size of the lesion and the experience of the operator. Sonography disclosed homogeneously hypoechoic lesions with air bronchograms over the peripheral or central portion in nine patients, and occasional heterogeneous echogenicity with necrotic tissue without air bronchogram in one. Thirteen lesions were found on the chest radiographs of the 10 patients; these could be divided into three patterns: infiltrates (2), nodules or masses (7), and consolidation (4). Using US-guided FNAB and immediate modified Papanicolaou's stain, a diagnosis of pulmonary cryptococcosis was confirmed in nine of the 10 patients. The remaining case was proven by surgical resection. No major complications developed after US-guided FNAB. We conclude that this technique, combined with modified Papanicolaou's staining, provides a safe, rapid, and reliable method for diagnosing pulmonary cryptococcosis.

Ultrasound-guided small-bore Elecath tube insertion for the rapid sclerotherapy of malignant pleural effusion

BACKGROUND

Traditional pleurodesis for malignant pleural effusion is performed by large-bore chest tube insertion with the instillation of sclerosing agents after the compressed lung re-expansion and pleural fluid drainage of 100-150 ml/day. This study was carried out to evaluate the possibility of rapid sclerotherapy for malignant pleural effusions by insertion of a small-bore Elecath tube (12-French) under ultrasound guidance and intrapleural injection of bleomycin 60 IU.

METHODS

Twenty-six patients, with 28 cytopathologically proven malignant pleural effusions (two patients had bilateral pleural effusions) and receiving the insertion of the Elecath tube for drainage, were included in our series. This rapid and short-term sclerosing method was performed and completed by intrapleural injection of bleomycin when the pleural effusion had been clearly drained by the small-bore Elecath tube and the compressed lung had fully re-expanded on follow-up chest radiographs.

RESULTS

Twenty patients with 22 pleural effusions underwent the intrapleural injection of bleomycin, with the results of pleurodesis being complete response 41% (9/22), partial response 36% (8/22) and failure 23% (5/22). Interestingly, among the 17 successful procedures of pleurodesis (complete response and partial response), 71% (12) procedures could be completed within 2 days (seven within one day and five within 2 days). The remaining unsuccessful procedures carried out on six patients without the injection of bleomycin were due to a non-re-expanded lung (n = 3) and inadequate drainage (n = 3); of these, four patients also received the large-bore chest tube insertion after the removal of the Elecath tube, but the compressed lung still could not re-expand. The complications of the bleomycin injection were fever [77% (17/22)], vomiting [14% (3/22)] and hiccup [5% (1/22)].

CONCLUSION

The method of rapid sclerotherapy for malignant pleural effusions by small-bore Elecath tube is promising, with a success rate achieving 77%, usually within 2 days.

The effect of large-dose prednisolone on patients with obstructive lung disease associated with consuming sauropus androgynus

BACKGROUND

In 1995, the consumption of the vegetable Sauropus androgynus in order to reduce weight led to an outbreak of patients with obstructive ventilatory impairment. The pathologic findings showed bronchiolitis obliterans with or without organized pneumonia. Steroid therapy was used in an attempt to reverse the pulmonary dysfunction even though the pathogenesis was unknown.

METHODS

In this retrospective study, we reviewed the response of seven non-smoking female patients who were consuming Sauropus androgynus to large-dose prednisolone therapy (prednisolone > 0.5 mg/kg/day, > 30 days). Conventional pulmonary function testing (PFT) was used to assess patient lung function.

RESULTS

All patients had greatly reduced forced expiratory volume in one second (FEV1) before and after steroid treatment. There was no significant change in the parameters of PFT, such as FEV1, forced vital capacity (FVC), FEV1/FVC, and carbon monoxide diffusion capacity (DLco) after prednisolone therapy.

CONCLUSIONS

Large-dose steroid therapy was unable to relieve the obstructive ventilatory impairment present in patients after consuming Sauropus androgynus.

Ultrasound-guided fine needle aspiration biopsy in the diagnosis of chronic pulmonary infection

Fourteen patients, with abnormalities on their chest radiographs found over a period of > or = 4 weeks and diagnosed as chronic pulmonary infections in the follow-up, underwent ultrasound-guided fine-needle aspiration biopsy (US-guided FNAB). Six patients also underwent color Doppler ultrasound examination before needle aspiration biopsy. Nine patients had a confirmed diagnosis [tuberculosis (n = 1), cryptococcosis (n = 3), actinomycosis (n = 2), and aspergillosis (n = 1)] or a suggestive diagnosis [caseating granulomatous inflammation (n = 1) and caseous necrosis (n = 1)] made after US-guided FNAB. The remaining 5 patients were finally diagnosed by US-guided large-bore cutting biopsy (n = 1, tuberculosis) and surgical resection [aspergillosis and organized pneumonia (n = 1), mucormycosis and organized pneumonia (n = 1), penicillium infection and organized pneumonia (n = 1), and cryptococcosis (n = 1)]. In 8 patients receiving gray scale US examination only, complications developed in 2 patients after US-guided FNAB [minimal pneumothorax (n = 1) and hemoptysis (n = 1)]. Of the 6 patients who also underwent color Doppler US examination, 4 had detectable blood vessels within the lesion. Thus, the site for US-guided FNAB was changed in 2 patients to prevent injury to prominent blood vessels. There were no complications observed following color Doppler US examination. We conclude that US-guided FNAB is useful for diagnosing chronic pulmonary infections, and color Doppler US is valuable for preventing injury to blood vessels.

Importance of sputum differential cell counting in the diagnosis of airway diseases

We examined the sputum of 114 subjects by noninvasive methods (voluntary coughing or induced cough with hypertonic saline) to determine whether sputum examination could be used to separate patients with episodic wheezing, dyspnea or cough of unknown origin into different diagnostic categories. An increased percentage of sputum eosinophils was seen in 92% (48/52) of asthmatics, 36% (9/25) of patients with chronic obstructive pulmonary disease (COPD) and 28% (7/25) of chronic coughers, but not in any of the 12 patients with congestive heart failure (CHF). Eight patients with combined symptoms of COPD and asthma (mixed COPD subgroup) showed above average diurnal peak expiratory flow variation (10.3 +/- 2.1% vs 2.5 +/- 1.4%, p < 0.05) and an above average percentage of sputum eosinophils (19.8 +/- 9.1 vs 2.1 +/- 3.2, p < 0.01) than those in the pure COPD group. After therapeutic corticosteroid trial, all of the mixed COPD patients and six of the 17 pure COPD patients were steroid responders. Seven of the 25 chronic coughers had sputum eosinophilia, but no asthmatic symptoms. The cough symptoms subsided in five of these seven patients after steroid treatment but not in the other 18 chronic coughers. Further study is indicated to determine if simple eosinophilic bronchitis is an early stage of asthma. In conclusion, sputum differential cell counting is a useful noninvasive diagnostic tool in differentiating diseases with episodic wheezing or chronic cough.

Value of ultrasonically guided needle biopsy of pleural masses: an under-utilized technique

Thirty-six patients with pleural masses underwent ultrasonically guided needle biopsy (UGNB), including ultrasonically guided aspiration biopsy (UGAB) in all 36 patients and ultrasonically guided cutting biopsy (UGCB) in 13 patients. Using UGAB alone, the diagnostic rate for pleural masses was 64% (23/36); carcinomatous pleural masses were more easily diagnosed than non-carcinomatous pleural masses (87% vs 23%, p < 0.01). If both UGAB and UGCB were used, the diagnostic rate was 89% (32/36); thus, selective UGCB was valuable in improving the diagnostic rate of non-carcinomatous pleural masses (from 23% to 69%). In patients with pleural effusions (n = 19), 11 underwent cytologic examinations of the pleural effusion (3 also undergoing pleural biopsy) without conclusive diagnosis; however, the diagnosis was made from pleural masses by UGAB (n = 7) or UGCB (n = 4). In patients without pleural effusions (n = 17), 12 had only pleural masses (3 also having multiple peripheral pulmonary nodules and 4 having mediastinal tumors) and could not be diagnosed by conventional bronchoscopic and sputum examinations. However, the diagnosis was rapidly confirmed by UGAB (n = 5) or UGCB (n = 3) from the pleural masses in 8 patients. We conclude that UGNB is a useful and valuable diagnostic tool, not only detecting the pleural masses hidden by pleural effusions but also for rapidly diagnosing the pleural masses.

Lung injury related to consuming Sauropus androgynus vegetable

BACKGROUND

Taking Sauropus androgynus, a Malaysian food, to reduce weight began as a fad in Taiwan in 1994. Some advocates of this fad developed pulmonary dysfunction. The aim of this study is to report the lung injury in patients taking Sauropus androgynus.

METHODS

From July 1995 to November 1995, we investigated 104 nonsmoking patients (one male and 103 females) with chest roentgenography, pulmonary function, test, and Technetium 99m-labeled diethylene triamine penta-acetate (Tc-99m DTPA) radioaerosol inhalation lung scintigraphy.

RESULTS

Among the 90 patients receiving Tc-99m DTPA inhalation lung scan, 46 (51.1%) patients had increased clearance of Tc-99m DTPA from lung and 20 (22.2%) patients had inhomogeneous deposition of the submicronic radioaerosol. Eighteen (18/100) patients had obstructive ventilatory impairment in pulmonary function test. Analyzing the results, we found that the patients with respiratory symptoms (n = 42) took more vegetables (p = 0.016), had increased clearance of Tc-99m DTPA (p = 0.010) and had lower FEV1 (p = 0.001), FEV1/FVC (p < 0.001), FEF25-75 (p = 0.001), VC (p = 0.002) and DLCO (p = 0.009) than the patients without respiratory symptoms (n = 62). FEV1 and FEV1/FVC were significantly reduced in patients with severe impairment of alveolar permeability. The cumulative dosage and duration of exposure were significantly associated with the reduction of FEV1 and FEV1/FVC.

CONCLUSION

The lung injury after taking Sauropus androgynus involves alveoli and/or small airways and is manifest as obstructive ventilatory impairment with inhomogeneous aerosol distribution and increased lung epithelial permeability.

Increased NM23: MTS1 ratio inversely correlated with metastasis behaviour in human lung squamous cell carcinoma

The nm23 and mts1 genes have been the focus of attention as regards the association of their expression with metastatic behaviour. The level of nm23 and mts1 gene products has been demonstrated to correlate with metastatic potential in some tumors, but not in all. Here we show that these two genes might be coregulated and the ratio of their expression correlated with metastatic behaviour. Western blot analysis showed that the expression of both NM23 and MTS1 proteins was reduced in human lung cancer CH27 cells by retinoic acid treatment, but the ratio of NM23: MTS1 increased in a dose-dependent manner. Results also exhibited that retinoic acid altered the microtubule assembly of CH27 cells and reduced the metastatic ability of the cells in vitro. These data suggest that the metastatic potential of CH27 cells may be related to the relative expression of these two genes, and that their pathway in regulating metastatsis might be linked.

A case report of novel roentgenographic finding in pulmonary zygomycosis: thickening of the posterior tracheal band

Zygomycosis (Mucormycosis) has been reported to involve most of the organ systems in man, although pulmonary zygomycosis with mediastinum invasion in rare and only few cases were reported in the literature previously. The roentgenographic findings of pulmonary zygomycosis have been well-discussed. However, the lateral view of chest radiograph has never been described. We report a patient with diabetes mellitus who had pulmonary zygomycosis with mediastinal involvement, presenting as thickening of posterior tracheal band (PTB, 6mm in width). Amphotericin B therapy effectively reduced it to return to normal width.

Color Doppler ultrasound signals of thoracic lesions. Correlation with resected histologic specimens

Sixty-eight patients with thoracic lesions (48 with lung cancer and 20 with benign lesions) underwent color Doppler ultrasound (US) examinations. Of those, 21 patients (13 with lung cancer and eight with benign lesions) also received resections, and the correlation between color Doppler US signals and resected histologic specimens was evaluated. Our results showed that three patterns of color Doppler US signals could be detected and confirmed: pulsatile flow (artery), constant flow, and triphasic flow (pulmonary vein). Among the 48 patients with lung cancer, pulsatile flow, constant flow, and/or triphasic flow were detected in 34 (71%), 24 (50%), and 14 (29%), respectively. Among the 20 patients with benign lesions, only pulsatile flow and/or triphasic flow were detected in nine (45%) and eight (40%), respectively. From the correlation between color Doppler US signals and histologic specimens, constant flow was representative of the true neovascularity of lung cancers, and it was valuable for differentiating lung cancers from benign lesions (p = 0.00008, sensitivity = 0.50, and specificity = 1.0). Although color Doppler US still had some limitations in detecting blood vessels in thoracic lesions, the correlation between the vascularity represented by color Doppler US signals and histologic specimens was excellent. We conclude that color Doppler US is a valuable method for assessing blood flow in thoracic lesions and differentiating lung cancers from intrapulmonary benign lesions.

Ultrasound-guided fine-needle aspiration biopsy of lung cancers

One hundred eighty-eight patients with 191 lung cancers were collected retrospectively to evaluate the diagnostic results and to determine the accuracy of cytologic diagnoses obtained from ultrasound-guided fine-needle aspiration biopsy (US-guided FNAB), and to discuss the necessity of large-bore tissue core needle biopsy. All 188 patients underwent US-guided FNAB, and 20 patients with 21 lung tumors also underwent US-guided tissue-core needle biopsy. Using US-guided FNAB alone, the positive cytologic results and correct cytologic diagnoses were 91% (174 of 191) and 71% (37 of 52). If both US-guided FNAB and selected US-guided tissue core needle biopsy (n = 21) were evaluated, the positive cytologic or histologic results and correct cytologic or histologic diagnoses were 94% (180 of 191) and 80% (45 of 57), respectively. Analyzing the disagreement between the cytologic results and histologic diagnoses (n = 15), we found that the disagreement usually occurred in the specimens with poorly differentiated carcinomas (nonspecific cell type) (53% [8 of 15]); of these, two patients (13% [2 of 15], small cell carcinoma) would have a change in treatment. The complications of US-guided FNAB were pneumothorax (n = 3), hemoptysis (n = 1), hemothorax (n = 1), and suspected tract metastasis (n = 1). We conclude that US-guided FNAB has a high diagnostic yield in lung cancers, and US-guided tissue core needle biopsy is only necessary in patients whose cytologic results are negative or who have poorly differentiated carcinomas.

Ultrasound-guided fine needle aspiration biopsy of small pulmonary nodules abutting to the chest wall

BACKGROUND

Ultrasound (US)-guided needle biopsies in peripheral pulmonary lesions are widely applied. Most pulmonary lesions had a large size. We report our results in evaluating the availability of US-guided fine needle aspiration biopsy (US-guided FNAB) in diagnosing small pulmonary nodules abutting to the chest wall.

METHODS

Forty patients, whose chest radiographs showed peripheral pulmonary nodules of diameter smaller than 3.0cm, received chest sonographic examination and US-guided FNAB. Of those, six patients had no definite diagnoses; the remaining 34 patients with pulmonary nodules, we divided into three groups. There were four tiny nodules of diameters smaller than 1.0cm, 11 nodules between 1.1 and 2.0cm, and 19 nodules between 2.1 and 3.0cm. We evaluated the diagnostic yields and rates of complication in relation to the size or nature of the nodule.

RESULTS

In the enrolled 40 patients, six were lost to surveillance and had indeterminate diagnoses. Of the remaining 34 patients with proven pathological diagnoses and compatible clinical conditions, the diagnostic yields of US-guided FNAB achieved 88% (30/34) which include 96% (26/27) in malignancies and 57% (4/7) in benign nodules. According to the nodular size, the diagnostic rate achieved 100% (4/4) in tiny nodules, 91% (10/11) in nodules between 1.1 and 2.0cm, and 84% (16/19) in nodules between 2.1 and 3.0cm. Only one patient with a 2.5-cm nodule developed pneumothorax after the US-guided FNAB procedure.

CONCLUSIONS

US-guided FNAB is a useful and safe diagnostic tool for small pulmonary nodules abutting to the chest wall. The nodular nature, but not size, affects the diagnostic yields and rates of complication.

Ultrasound-guided fine-needle aspiration biopsy of solitary pulmonary nodules

Ultrasound-guided fine-needle aspiration biopsy (US-guided FNAB) was performed in 40 patients with solitary pulmonary nodules (SPNs) for evaluation of diagnostic results and complication rates. The final diagnoses of the 40 patients included 30 malignancies and 10 benign lesions. Using US-guided FNAB, the diagnostic yields were 97% (29/30) in malignancies and 60% (6/10) in benign lesions. Of the 29 patients with cytologically proven malignancies, 12 underwent surgical resection. The correlation between cytological results and histologic diagnoses in these 12 was excellent (100%). The size of the nodule did not affect the diagnostic rate or complication rate. Only two patients (5%) developed minimal pneumothorax after US-guided FNAB. We conclude that US-guided FNAB is a useful, safe, and convenient diagnostic tool for SPN, and that malignant pulmonary nodules are more easily diagnosed than benign nodules.

Superior vena cava syndrome in lung cancer: an analysis of 54 cases

Traditionally, superior vena cava syndrome (SVCS) has been recognized as an oncologic emergency, and with clinical suspicion of the syndrome, tissue diagnosis was often delayed due to possible complications in diagnostic procedures and immediately threatening of life. Previously, local radiotherapy was regarded as the best immediate strategy for management of the condition. We have analyzed 54 lung cancer patients with SVCS in the past 6 years. Our results show that dyspnea (34 cases, 63%) and facial swelling (29 cases, 54%) are the two most common symptoms. The most frequent physical finding was venous distension of the neck (35 cases, 65%). The chest X-ray findings also showed a large ratio of superior mediastinal widening (26 cases, 48%). Fine needle aspiration of palpable lymph node (20 cases, 37%) and trans-thoracic needle aspiration guided by ultrasound (US) (8 cases, 14%) made diagnosis of at least half of the cases possible (28 cases, 51%). Both of these procedures are safer and easier than other invasive methods of examination. Of the 54 patients, small cell carcinoma constituted the majority of the cases (23 cases, 43%) and, with combination chemotherapy, there was a good response rate and a longer survival time (7.4 months) as compared to that of non-small cell carcinoma (3.7 months) treated by radiotherapy. We conclude that lung cancer with SVCS could be quickly and safely diagnosed by needle aspiration of the palpable lymph node or trans-thoracic needle aspiration guided by US, and that with combination chemotherapy the SVCS in small cell carcinoma can be effectively relieved.

Ultrasonically guided needle biopsy of anterior mediastinal masses: comparison of carcinomatous and non-carcinomatous masses

Thirty-three patients with anterior mediastinal masses underwent percutaneous ultrasonically guided needle biopsy (UGNB), including ultrasonically guided aspiration biopsy (UGAB) in all 33 patients and ultrasonically guided cutting biopsy (UGCB) in 13 patients. Using UGAB alone, the diagnostic rate of anterior mediastinal masses was 52% (17/33); if both the UGAB and UGCB methods were used, the diagnostic rate could achieve 79% (26/33). If the anterior mediastinal masses were divided into carcinomatous (n = 15) and non-carcinomatous (n = 18) groups, we found that the carcinomatous group was more easily diagnosed by UGAB than the non-carcinomatous group (87% vs 22%, p < 0.01) and UGCB was more valuable and helpful than UGAB in the diagnosis of non-carcinomatous mediastinal masses (75% vs 22%). One episode of injury to the aortic wall occurred after a UGCB. Our results show that carcinomatous mediastinal masses can be easily diagnosed by UGAB, and UGCB is often necessary in the diagnosis of non-carcinomatous mediastinal masses.

Ultrasonic detection of persistent small unilateral hematocolpos in two girls

Two girls with unilateral hematocolpos are reported. In both cases, a small amount of blood which had accumulated in the partially obstructed hemivagina was detected by real-time high resolution ultrasonography, and was confirmed by magnetic resonance imaging. Both patients were asymptomatic, and were regularly followed up at an outpatient clinic. To date, the hematocolpos persists but continues to be small.

Existence of a well-defined pulmonary lesion on plain chest film predicts poor response of chemotherapy in small cell lung cancer

BACKGROUND

Plain chest film is the most convenient and common tool used to evaluate the response of lung cancer to chemotherapy. Many authors tried to evaluate the use of plain chest films to predict chemotherapy response. This study investigated a new factor which could be used to predict the chemotherapy response of small cell lung cancer (SCLC).

METHODS

Sixty-two patients with cytopathologically proven small cell lung cancer receiving at least two courses of chemotherapy were included in this study. Among these patients, thirty-nine patients received six courses of chemotherapy. The regimens of chemotherapy are Etoposide (100 mg/m2) and Cisplatin (25 mg/m2). We divided these patients into two groups according to whether a well-defined pulmonary lesion excluding hilar and mediastinal lymphoadenopathy, could be identified on plain chest X-ray (CXR). Group I consisted of 31 patients with identified lesions on the CXR; group II consisted of 31 patients with unidentifiable lung lesions. CXRs were taken each time before chemotherapy and were collected and compared to evaluate the chemotherapy response. The 39 patients receiving six course of chemotherapy, were further divided into group I (n = 19) and group II (n = 20) to evaluate the chemotherapy response.

RESULTS

After two courses of chemotherapy, we found 23 patients [74.2% (23/31)] in group I had partial response(PR) as compared to 12 patients [38.7% (12/31)] in group II (P < 0.05). For the 39 patients receiving six courses of chemotherapy, we could find only five patients [16.1% (5/19)] in group I who had a complete response (CR) as compared to 17 patients [85% (17/20)] in group II (P < 0.001).

CONCLUSION

For patients with SCLC, a well-defined lung lesion on a CXR could be an important new factor to predict the chemotherapy response. It could predict less responsiveness to chemotherapy.

Potentiation of growth inhibition due to vincristine by ascorbic acid in a resistant human non-small cell lung cancer cell line

A human cell subline (PC-9/VCR) resistant to vincristine was established from non-small cell lung cancer PC-9 cells by incremental exposure of the cells to vincristine. The resistant cells showed phenotypic resistance to vincristine (10-fold), colchicine (6.9-fold) and cisplatin (1.4-fold) but they showed sensitivity to other chemotherapeutic agents including melphalan and etoposide VP-16. The characteristics of the vincristine resistance was partially inhibited (5-7-fold) by co-treatment of PC-9/VCR cells with a nontoxic concentration of L-ascorbic acid (25 micrograms/ml). Co-treatment or 96 h pre-treatment with ascorbic acid resulted in potentiation of the vincristine effect on the resistant, but not on the sensitive, cell line. The growth inhibition due to vincristine treatment after 24 or 96 h growth in ascorbic acid-free medium was decreased in the resistant as well as in the sensitive cell line. In both cell lines, enhanced growth rate has been shown after ascorbic acid treatment. Similarly, cross-resistance of PC-9/VCR cells to colchicine could also be blocked by ascorbic acid. In addition, a nontoxic concentration of verapamil, a known multidrug resistance inhibitor, did not affect the resistant phenotype of PC-9/VCR cells. These findings suggest that an ascorbic acid-sensitive mechanism may be involved in drug resistance per se in the human lung cancer cells, which differs from the classical phosphoglycoprotein-mediated or previously reported non-phosphoglycoprotein-mediated multidrug resistance.

Alveolar integrity in pulmonary emphysema using technetium-99m-DTPA and technetium-99m-HMPAO radioaerosol inhalation lung scintigraphy

The alveolar integrity (AI) in 17 male patients with pulmonary emphysema (EMPH) diagnosed by chest x-ray was measured by 99mTc-DTPA and 99mTc-HMPAO radioaerosol inhalation lung scintigraphy.

METHODS

The patients were divided into two groups: (A) nine patients with pulmonary emphysema and normal carbon monoxide diffusion capacity (DLCO) and (B) eight patients with pulmonary emphysema and abnormal DLCO. The degree of AI damage in EMPH was presented as the slope of the time-activity curves from the dynamic left lung imagings in DTPA and HMPAO. The AI of EMPH patients were compared with the AI of 16 normal controls.

RESULTS

The results show that: (1) the slope of DTPA is larger than that of HMPAO in each of the portions of the left lung for any of the study groups; (2) statistical differences were found between the normal controls and EMPH patients in HMPAO but not in DTPA; and (3) the correlation was not good between DLCO and DTPA/HMPAO in EMPH patients.

CONCLUSION

Our results suggest that: (1) at least two different mechanisms in the lungs were at work; (2) the AI damage in EMPH developed mainly in the lipophilic part of the alveoli; and (3) the AI damage presented as slopes of DTPA/HMPAO in our study was different from the traditional pulmonary function such as DLCO.

Ultrasound-guided biopsy of thoracic masses

BACKGROUND

Fine needle aspiration cytologic examination may be sufficient for managing patients with primary lung cancer. However, the procedure is not reliable for benign lesions and metastatic lung cancers. An attempt was made to find the influence of cell type on the results of fine needle aspiration and cutting biopsy.

METHODS

One hundred and sixteen patients with thoracic nodules or masses underwent chest ultrasound examination and percutaneous ultrasound-guided needle biopsy. All patients underwent ultrasound-guided fine needle aspiration biopsy (UGAB) and thirty-eight of them also underwent ultrasound-guided cutting biopsy (UGCB). Thoracic lesions were divided into seven groups.

RESULTS

Using UGAB alone, the diagnostic rate varied from 56% (mediastinal tumor) to 91% (lung mass). When both methods of UGAB and UGCB were evaluated, the diagnostic rate varied from 67% (pulmonary nodule) to 100% (collapsed lung with mass and pancoast tumor). When thoracic lesions were divided into carcinomatous neoplasms (n = 88) and noncarcinomatous lesions (n = 21), a higher diagnostic rate was found in the carcinomatous group than in the noncarcinomatous group (92% versus 53%, p < 0.001). Correct histologic results between both groups had no statistical significance (64% versus 56%, p > 0.05).

CONCLUSIONS

Ultrasound-guided needle biopsy has a high diagnostic yield of thoracic tumors, and carcinomatous masses can be easily diagnosed by UGCB. Noncarcinomatous masses and benign tumors frequently need UGAB to obtain a histologic diagnosis.

Ascorbic acid increases drug accumulation and reverses vincristine resistance of human non-small-cell lung-cancer cells

A human lung-cancer PC-9 subline with acquired resistance to vincristine (VCR), a chemotherapeutic agent, was established with incremental increases of the drug. The resistant PC-9 subline (PC-9/VCR) shows a 12-fold increase in resistance to VCR and a unique cross-resistance pattern: high cross-resistance to the potent VCR analogue colchicine (6.9-fold) and vinblastine (2.5-fold); lower cross-resistance to actinomycin D (1.8-fold), cisplatin (1.2-fold) and adriamycin (1.3-fold) and a sensitivity to melphalan and VP-16 which is similar to that of the parental cell line. A reduced accumulation of VCR in the resistant cells was demonstrated. Interestingly, the VCR resistance of the PC-9/VCR cell line was partially reversed by ascorbic acid, and the drug uptake was enhanced. In contrast, ascorbic acid had no effect on drug tolerance and drug accumulation was not observed in either PC-9 parental cells or known multidrug-resistant (MDR) cells, suggesting that VCR resistance in PC-9/VCR cells results essentially from reduced drug accumulation. It is worth noting that, whereas reduced drug accumulation in the PC-9/VCR cells was susceptible to modulation by ascorbic acid, the increased efflux rate characteristic of the resistant cells was not. Further, there was a higher efflux rate in resistant cells than in parental cells. DNA Southern- and RNA Northern-blot hybridization analyses indicate that PC-9/VCR cells do not contain amplified mdr genes or overexpress P-glycoprotein. In addition, the calcium-channel blocker verapamil, which acts as a competitive inhibitor of drug binding and efflux, did not affect the resistant phenotype of PC-9/VCR cells. These findings suggest an ascorbic acid-sensitive drug uptake mechanism which is important in mediating VCR resistance per se in human lung-cancer cells; this differs from the P-glycoprotein-mediated MDR mechanism.

[The effects of exercise on the arterial potassium and ventilatory response under hyperoxic, normoxic, and hypoxic conditions]

BACKGROUND

Exercise leads to an increase in plasma potassium, the animal experiments showed that potassium infusion stimulated ventilation and abolished by peripheral chemodenervation and also showed that combined effects of potassium and hypoxia were greater than the sum of the individual effects. This study proposed to investigate plasma potassium and its correlation with exercise, and to investigate the effects of hypoxia and hyperoxia on potassium and ventilation during steady state exercise.

METHODS

Ten male subjects exercised on a cycle ergometer. Each performed (1) incremental exercise test; (2) steady state exercise test with a work rate of about 75% of anaerobic threshold under hyperoxic (FiO2 100%), normoxic (FiO2 21%) and hypoxic (FiO2 12%) conditions, respectively.

RESULTS

Arterial plasma potassium concentration rose from a pre-exercise level of 3.97 +/- 0.40 mEq/L to the post-exercise level of 5.11 +/- 0.49 mEq/L. The increase in plasma potassium during exercise correlated well with the increase in lactate (r = 0.72, p < 0.05) and the decrease in pH (r = 0.69, p < 0.05). During the steady state exercise test, switching the subject from room air to hypoxic (12% O2) conditions led to a significant rise in both plasma potassium (p < 0.05) and ventilation (p < 0.05) with good correlation between the potassium increase and the increase in ventilation (r = 0.85, p < 0.05). Switching the subject from room air to hyperoxic (100% O2) condition resulted in a significant decrease in ventilation (p < 0.05) without significant change in plasma potassium (p > 0.01).

CONCLUSIONS

It was concluded that (1) exercise can lead to an increase in arterial potassium, hydrogen ion, lactate in men; (2) hypoxia can stimulate the peripheral chemoreceptor and increase plasma potassium level. Potassium may, therefore, be an important factor by which the magnitude of the peripheral chemoreflex response is augmented during exercise.

Detection of specific antibody to mycobacterial antigen 60 in tuberculous pleural effusion

BACKGROUND

With the development of the enzyme-linked immunosorbent assay (ELISA) method, serodiagnosis of tuberculosis has been studied by many investigators. Only a few studies have been performed in pleural fluid. This study was designed to evaluate the IgG antibody levels to mycobacterial antigen 60 (Ag60) in pleural fluid, and evaluate its role in the diagnosis of tuberculous pleurisy.

METHODS

Eighteen patients with tuberculous pleural effusions and 18 patients with malignant pleural effusions were studied. The levels of IgG antibodies to Ag60 in pleural fluids were measured by ELISA method.

RESULTS

The mean titers of IgG against Ag60 in pleural fluids of tuberculous patients (508.3 +/- 382.7 EU) were significantly higher than those of the mean value of the malignant group (131.2 +/- 83.2 EU). In the TB pleurisy group, patients with positive M. tuberculosis cultures from pleural fluids had significantly higher titers than those with negative cultures (796.5 +/- 394.7 vs 277.8 +/- 150.2 EU); patients with impaired immune function had significantly lower titers than those without (138.4 +/- 28.9 vs 650.6 +/- 358.1 EU). Using 250 EU as a cutoff value for a positive test, the sensitivity was 72.2% and the specificity, 94.4%.

CONCLUSIONS

ELISA method using Ag60 is a rapid test with an acceptable sensitivity and excellent specificity for differentiation between tuberculous and malignant pleural effusion.

Neopterin, soluble interleukin-2 receptor and adenosine deaminase levels in pleural effusions

We evaluated soluble interleukin-2 receptors (sIL-2R), neopterin and adenosine deaminase (ADA) in pleural effusions from 93 patients with tuberculosis, malignancies, uremia, pneumonia and other kinds of pleurisy. There were significantly elevated ADA (102.7 +/- 47 U/l) and sIL-2R (8,238 +/- 4,117 U/ml) values in tuberculous (TB) pleural fluids as compared with other non-TB pleural fluids (p < 0.005). The neopterin levels in pleural fluid were significantly lower in the cancer group (17.3 +/- 7.8 nmol/l; p < 0.005) and most strikingly elevated (309.4 +/- 112.2 nmol/l; p < 0.0001) in patients with uremic pleural effusions. Using cut-off values of 60 U/l in ADA and 5,000 U/l in sIL-2R, 92.0 and 86.9% of pleural effusions were TB in origin. Eighty-four percent of patients with malignant pleural effusions had neopterin levels less than 25 nmol/l.

[Detection of Mycobacterium tuberculosis in sputum by polymerase chain reaction]

A method based on DNA amplification (PCR) and hybridization for the detection of M. tuberculosis was used to test 86 sputum specimens from 52 patients in whom tuberculosis was suspected. M. tuberculosis was detected in 35 specimens, with 1 false positive. The finding was negative in 51 specimens, of which 4 were false negative. Thirty-two specimens were positive by standard microbiological criteria (acid-fast stain and culture), and 54 specimens were negative (including 6 false negative). Of 38 specimens with definite diagnosis of tuberculosis, 89.5% (34/38) were positive by DNA amplification and 84.2% (32/38) by acid-fast stain and/or culture. The difference is not statistically significant (P > 0.05). The specificity was 97.9% (47/48) and 100% (48/48) by DNA amplification and acid-fast stain and/or culture, specificity was 97.9% (47/48) and 100% (48/48) by DNA amplification and acid-fast stain and/or culture, individually, and difference is also not statistically significant (P > 0.05). However, PCR combined with specific DNA probe is more sensitive than the acid-fast stain method and faster than the culture method. Therefore it is useful for early detection of pulmonary mycobacterial infection.

Apical malignancies diagnosed by ultrasound-guided fine needle aspiration biopsy

Sixteen patients with apical malignancies, including 12 with Pancoast tumors and four with metastatic apical pleural masses, underwent chest ultrasound (US) examinations and direct percutaneous fine needle aspiration biopsy (FNAB). Of those, 15 patients were proven to have malignancies by FNAB and the remaining patient (only revealing necrosis by FNAB) was also proven to have a Pancoast tumor after surgical intervention. Percutaneous FNAB was performed through the supraclavicular approach (n = 10) or through the upper back (n = 6). The sonographic appearances of the apical malignancies were homogeneous hypoechoic (n = 8), homogeneous isoechoic (n = 3) or heterogeneous (n = 5). No complications occurred after the FNAB. Our limited experience showed that a convex probe was convenient and useful in the detection of apical malignancies. Apical malignancies, diagnosed previously by percutaneous needle aspiration under fluoroscopy or surgical intervention, can be easily diagnosed by percutaneous FNAB, especially when the FNAB is performed using the supraclavicular approach.

Diagnostic value of pleural adenosine deaminase in tuberculous effusions of immunocompromised hosts

To investigate the diagnostic value of adenosine deaminase (ADA) in immunocompromised hosts with tuberculous pleural effusions, we collected and checked 60 pleural effusion specimens from admitted patients. These patients were divided into three groups: group I (n = 20), immunocompetent hosts with tuberculous pleural effusions; group II (n = 10), immunocompromised hosts with tuberculous pleural effusions; and group III (n = 30), patients with malignant pleural effusions. Using statistical analysis to compare the ADA value in each group, the p value was found to be significant between groups I and II (p < 0.01), groups I and III (p < 0.001) and groups I+II and III (p < 0.001); however, the p value was not significant between groups II and III. If the lowest ADA value for the tuberculous pleural effusion was designed as 80 U/L, the sensitivity/specificity was 1.0/0.90 (group I), 0.40/0.90 (group II), and 0.80/0.90 (group I+II), respectively. We conclude that the diagnostic value of ADA in immunocompromised hosts with tuberculous pleural effusions is not as significant as in immunocompetent hosts.

[The efflux of intracellular vincristine in drug-resistant human lung cancer cells is not mediated by P-glycoprotein]

A subline (PC-9/VCR) of the human lung adenocarcinoma cell line (PC-9), derived by in vitro exposure to vincristine (VCR), exhibited a 10-12-fold resistance to VCR by MTT and HTCA assay. Compared to the parental cell line (PC-9), PC-9/VCR-resistant cells displayed a reduced accumulation of VCR. The rate of VCR efflux was shown to be enhanced by PC-9/VCR. Unlike multidrug resistance, this efflux was independent of P-glycoprotein overexpression as determined by the Northern blotting method. In addition, PC-9/VCR showed no collateral sensitivity to verapamil. This resistant subline only showed 6.9-fold and 2.5-fold cross resistance to colchicine and vinblastine, respectively. This preliminary result indicates that defective drug accumulation in PC-9/VCR is due to other mechanisms possibly involving the microtubule assembly.

Synthesis and cytotoxicity studies of novel cyclic peptide-2,6-dimethoxyhydroquinone-3-mercaptoacetic acid conjugates

In an effort to investigate the use of small-ring-size cyclic peptides as carriers of new antitumor agents, we synthesized three cyclic tripeptide-cytotoxic agent conjugates. The cytotoxic agent conjugated to the epsilon-amino group of the lysyl residue of the cyclic peptides is 2,6-dimethoxyhydroquinone-3-mercaptoacetic acid (DMQ-MA), (Sheh et al., 1992). The cyclic peptides were synthesized by coupling protected amino acid residues in solution and the subsequent cyclization performed by the pentafluorophenyl ester method as described previously (Sheh et al., 1985, 1987, 1990). After deblocking the lysyl-Z group of the peptides, the conjugation was achieved by reaction with the pentafluorophenyl ester of DMQ-MA. The three cyclic peptides exhibited potent cytotoxicity against two solid tumor cell lines (KB and PC-9) under the synergistic activation of L-ascorbic acid. Electron spin resonance (ESR) studies of DMQ-MA and two conjugates showed that massive hydroxyl radicals were generated as a non-linear function of L-ascorbic acid concentration. These studies indicate that the hydroxyl radical is a possible mediator of cytotoxicity for these conjugates and that small-ring-size cyclic peptides are potentially useful carriers of cytotoxic agents.

[Blood lactate changes during incremental exercise in chronic obstructive pulmonary disease]

In order to evaluate whether the lactic acidosis is developed during incremental exercise test in COPD. 12 untrained subjects with COPD performed incremental maximal cycle ergometer tests. Ventilation (VE); O2 uptake (VO2), CO2 output (VCO2); and end-tidal CO2 fraction (FETCO2) were measured. Arterial lactate concentration and blood gas analysis were measured at rest, maximal exercise and recovery of exercise from an indwelling arterial catheter. of the degree of airway obstruction. (2) T40 and BEecf correlated well with lactate change (r = 0.83; 0.84, P < 0.05). (3) The change of VE, and RQ correlated with the lactate change (r = 0.81; 0.83, 0.72, P < 0.05), but not the VE/VO2, VE/VCO2, nor FETCO2, (r = 0.24; 0.06; 0.46, P > 0.05). We concluded that the blood lactate increased markedly in patients of COPD during increment exercise, and it was well corrected with the change of VE, VCO2 and RQ. The increased lactate could be indicated by the concomitant change of T40 and BEecf.

Diffuse panbronchiolitis: report of a case

A 33-year-old male presented with a productive cough of yellowish sputum which he had had for several years and progressive dyspnea on exertion that had been present for one year. Physical examination on admission disclosed clubbing of the fingers, diffuse inspiratory crackles and some rhonchi on auscultation. Plain chest film showed diffuse fine nodular lesions in both lungs. Pulmonary function tests demonstrated obstructive ventilatory impairment with a positive bronchodilator response. A CT scan of the chest showed diffuse fine nodular infiltrations in both lung fields. Arterial blood gas analysis of the patient, while breathing room air, revealed mild hypoxemia. The histologic findings of an open lung biopsy specimen were compatible with a diagnosis of diffuse panbronchiolitis. The patient was treated with erythromycin and a bronchodilator, and was regularly followed at the outpatient department. In this report, clinical manifestations, diagnostic criteria and recent advances in the treatment of diffuse panbronchiolitis are discussed.