Laryngeal widening and adequate ventilation by expiratory pressure load training improve aerobic capacity in COPD: a randomised controlled trial

RATIONALE

Despite strategies acting on peripheral airway obstruction in chronic obstructive pulmonary disease (COPD), exercise intolerance remains inadequately improved. We hypothesised that laryngeal narrowing is a potential treatment target of expiratory pressure load training (EPT) to improve exercise intolerance in COPD.

METHODS

The effect of 3-month EPT was assessed in 47 patients with COPD divided into Global Initiative for Chronic Obstructive Lung Disease (GOLD) mild-to-moderate (I-II) and severe-to-very severe (III-IV), randomly allocating 1:1 to EPT or control groups. The primary outcome was endurance time in the constant work rate exercise test in GOLD III-IV patients.

RESULTS

Compared with controls, EPT increased: (1) endurance time, with estimated treatment effect: +703 (95% CI: 379 to 1031) s, p=0.0008 (GOLD I-II); +390 (95% CI: 205 to 574) s, p=0.0006 (GOLD III-IV); (2) peak oxygen uptake (p=0.0086 in GOLD I-II; p=0.0004 in GOLD III-IV); (3) glottic dilatation ratio at maximum collapse on laryngoscopy in the submaximal exercise (p=0.0062 in GOLD I-II; p=0.0001 in GOLD III-IV); and (4) the inflection point of expiratory tidal volume relative to minute ventilation during the incremental exercise (p=0.0015 in GOLD I-II; p=0.0075 in GOLD III-IV). Across GOLD grades, the responses of glottic dilatation ratio at maximum collapse and the expiratory tidal volume at the inflection point were selected as more influential variables correlating with the improvement in peak oxygen uptake and endurance time, respectively.

CONCLUSION

These results show that EPT improved aerobic capacity and endurance time with larger laryngeal widening and adequate ventilation despite advanced COPD.

TRIAL REGISTRATION NUMBER

UMIN000041250.

Diagnosis and Management of Drug-Induced Interstitial Lung Disease Associated with Amikacin Liposome Inhalation Suspension in Refractory Mycobacterium Avium Complex Pulmonary Disease: A Case Report

Amikacin liposome inhalation suspension (ALIS) is a key drug for the treatment of refractory Mycobacterium avium complex pulmonary disease (MAC-PD). Although cases of drug-induced interstitial lung disease (DIILD) by ALIS have been reported, its diagnosis is challenging due to overlapping existing pulmonary shadows, airway bleeding, exacerbation of underlying conditions, and the potential for various concurrent infections. A 72-year-old woman started treatment with ALIS for refractory MAC-PD. Three weeks later, she had a fever, cough, and appetite loss. She was hospitalized because multiple infiltrative opacities were observed on chest X-ray and chest computed tomography. Because the opacities worsened after empiric antibiotic therapy with broad-spectrum antibiotics, we initiated corticosteroid therapy, suspecting DIILD caused by ALIS, although drug lymphocyte stimulation tests for ALIS and amikacin were negative. Three days later, we found signs of improvement and quickly tapered the corticosteroids. After obtaining informed consent, we performed a drug provocation test of ALIS. Seven days later, she exhibited fever, an increased peripheral white blood cell count, and elevated serum C-reactive protein level, all of which returned to baseline 4 days after stopping ALIS, leading to a diagnosis of DIILD caused by ALIS in this patient. DIILD caused by ALIS is rare but should be carefully diagnosed to ensure that patients with refractory MAC-PD do not miss the opportunity to receive ALIS treatment.

Regulation of aromatase activity in bone-derived cells: possible role of mitogen-activated protein kinase

Fetal human osteoblast-like cells and the THP-1 cell line that differentiates into macrophage/osteoblast-like cells in the presence of Vitamin D3 and which possesses high aromatase activity, constitute a useful model with which to study the regulation of aromatase in bone. We showed that dexamethasone (DEX)-induced aromatase activity in the THP-1 cell line is completely suppressed by forskolin and by dibutyryl cAMP. We therefore investigated the contribution of mitogen-activated protein kinase (MAPK) to the regulation of aromatase, because cAMP inhibits MAPK in many cells. We examined the role of MAPK on aromatase activity using PD98059, a selective inhibitor of MEK-1. PD98059 (100 microM) reduced DEX+interleukin (IL)-1beta-induced aromatase activity in human osteoblast-like cells by more than 90%, whereas 50% of the aromatase mRNA concentration was retained compared with the control incubated with DEX+IL-1beta. PD98059 (50 microM) reduced the activity of aromatase in THP-1 cells by 80% without significantly affecting the mRNA level. These results indicated that MAPK plays an important role in aromatase activation at the post-transcriptional level.

Inhibition of in situ expression of aromatase P450 in leiomyoma of the uterus by leuprorelin acetate

We have shown that in situ estrogen synthesized in leiomyoma of the uterus plays a possible role in the promotion of leiomyoma cell growth via an autocrine/paracrine mechanism. In the present study, we demonstrated that leuprorelin acetate, a GnRH agonist widely used for treatment of uterine leiomyoma by down-regulation of pituitary-ovarian function, suppressed the expression of aromatase P450 (an estrogen synthetase) in leiomyoma cells. Given the role of in situ estrogen in leiomyoma cell growth, the inhibition of in situ estrogen synthesis may play a role in GnRH agonist-induced rapid regression of leiomyomas. Quantitative RT-PCR revealed that in women receiving no medication uterine leiomyomas express aromatase P450 mRNA at levels 20 times higher than that in the surrounding myometrium. Leuprorelin acetate treatment (1.88 mg every 4 wk, sc injection) for 12-24 wk reduced the expression of aromatase P450 mRNA in leiomyoma tissue as well as in the myometrium, to approximately one tenth of that in the myometrium of untreated women. Suppression of aromatase P450 expression was also demonstrated by Western blot analysis and aromatase activity assay of microsomal fractions prepared from leiomyomas. On the other hand, no differences in the levels of activity and mRNA of aromatase P450 were observed between leiomyoma cells obtained from women treated with and without leuprorelin acetate injections when cells were cultured ex vivo and stimulated by various combinations of stimulants such as dexamethasone + IL-1beta. The addition of various concentrations of E2 did not affect the aromatase activity of leiomyoma cells, suggesting that deprivation of circulating (ovarian) estrogen is not a cause of decreased expression of aromatase during leuprorelin acetate therapy. On the other hand, 8-d treatment with leuprorelin acetate (100 nmol/liter) reduced dexamethasone + IL-1beta-induced activity and a mRNA level of aromatase by 28% and 42%, respectively. These results indicated that leuprorelin acetate inhibits the expression of aromatase P450 in leiomyoma cells, which contributes to the rapid regression of leiomyoma during leuprorelin acetate therapy.

Modifications to the modified Shirodkar operation

In cases of cervical incompetence, the Shirodkar procedure is occasionally necessary when the McDonald procedure cannot be used due to poor cervical anatomic conditions. We have further facilitated a modified Shirodkar procedure with some modifications. A transverse incision over the anterior lip of the cervix is made and the bladder is separated from the cervix. One end of an atraumatic forceps is introduced deeply into the space between the bladder and the cervix, and the other end is pushed against the posterior fornix to grasp paracervical tissues, so that a needle is easily passed through at the tip of the forceps. The knot is placed anteriorly and a silk thread is passed around the tape in the posterior fornix to facilitate removal of the tape. This procedure resulted in no complications and greatly facilitated removal of the tape, resulting in a cervical cerclage which was comparatively easily carried out.

Leak-proof puncture of ovarian cysts: instant mounting of plastic bag using cyanoacrylate adhesive

BACKGROUND

Reliable leak-proof aspiration of cyst contents is required for treatment of large ovarian cysts by minilaparotomy.

TECHNIQUE

Through a small abdominal wound a transparent plastic bag was instantly mounted onto the cyst surface using an ethyl-2-cyanoacrylate adhesive. A 1-2-cm-wide cut was made in the consolidated cyst wall through the inside of the bag and the contents directly aspirated. The fluid was trapped inside the bag without leaking into the abdominal cavity. This method can also be applied to relatively small cysts by holding the cyst just beneath the wound.

EXPERIENCE

We used this method in 30 patients with unilateral ovarian cysts and in one patient with an ovarian cyst associated with an ipsilateral paraovarian cyst. All patients were successfully treated without spillage, although in one case a large mucinous ovarian cyst ruptured before surgery.

CONCLUSION

Minilaparotomy using the instant adhesive is cost-effective, safe, reliable, and easily implemented. This procedure is also applicable to relatively small cysts and is a viable alternative to laparoscopic surgery for treatment of dermoid cysts showing considerable calcification.

In situ estrogen synthesized by aromatase P450 in uterine leiomyoma cells promotes cell growth probably via an autocrine/intracrine mechanism

In the present study we characterized in detail the expression of aromatase P450 in leiomyomas to determine the role of in situ estrogen in the growth advantage of leiomyomas. The levels of aromatase P450 transcripts were determined by quantitative RT-PCR to be significantly higher in leiomyomas than in corresponding myometrium. The overexpression of aromatase P450 in leiomyomas was also confirmed by Western blot analysis. The estimated size of immunoreactive aromatase was 58 kDa, similar to that in placenta. To identify a cell type that express aromatase P450 in leiomyomas, histological specimens were stained for aromatase P450 using a polyclonal antibody. Strong immunoreactivity was detected in the cytoplasm of leiomyoma cells, whereas surrounding normal myometrium displayed weak or negative staining. Smooth muscle-like cells in culture obtained from leiomyomas, positive for actin D fiber, possessed immunoreactive granules of aromatase in the cytoplasm. Conversion of androgen to estrogen was effectively stimulated by phorbol myristate acetate and dexamethasone plus interleukin-1beta and was completely abolished by selective inhibitors of aromatase P450 (fadrozole and TZA-2209), but not by inhibitors of 5alpha-reductase (finasteride and flutamide). The apparent Km of androstenedione was 3 nM in the presence of dexamethasone and interleukin-1beta, corresponding to the plasma concentration of androstenedione in women of reproductive age. To determine whether endogenous aromatase P450 plays a role in the growth promotion of leiomyoma cells, we evaluated the cell growth of smooth muscle-like cells treated with various concentrations of estrogen and androgen using a WST-1 assay. Treatment with testosterone (10(-8) and 10(-7) M) and androstenedione (10(-8) and 10(-7) M) stimulated the growth of smooth muscle-like cells obtained from leiomyomas to the same extent as estradiol (10(-10)-10(-7) M), whereas dihydrotestosterone (10(-11)-10(-8) M) did not. The stimulatory effect of testosterone on cell growth was again abolished by cotreatment with fadrozole. The level of estradiol in the medium of testosterone (10(-8) M)-treated smooth muscle-like cells was 10(-11) M, which was 1 order lower than the minimum concentration of estradiol necessary to promote cell growth (10(-10) M). This indicates that estradiol synthesized in leiomyomas promotes their growth via an autocrine/intracrine mechanism. We conclude that myometrial cells of leiomyomas overexpress aromatase P450 and are able to synthesize sufficient estrogen to accelerate their own cell growth. Overexpression of aromatase P450 may play a role in the growth advantage of leiomyoma tissue over surrounding myometrium via an autocrine/intracrine mechanism.

[Long-term follow-up of the Le Duc-Camey antireflux technique]

BACKGROUND

An effective ureteroileal reimplantation without reflux and obstruction is indispensable for lower urinary reconstruction or diversion using an ileal segment. Based on our earlier experience of afferent nipple valve malfunction of the Kock pouch, we performed Le Duc-Camey antireflux ureteroileal implantation. In the present study, we evaluated the long-term outcome of the Le Duc-Camey technique on the upper urinary tract in patients with a postoperative observation period of 2 years or more.

PATIENTS AND METHODS

From 1989 to 1994, 39 patients (73 ureters) underwent Le Duc-Camey technique for prevention of reflux of a Kock pouch. In 28 patients the ileal reservoir was connected to the skin for cutaneous urinary diversion, and in 11 it was connected to the urethra for lower urinary reconstruction. The ureters were implanted into the reservoir through the anterior wall window of the reservoir. In most patients, excretory urography (DIP) was performed once a year after the first year. Retrograde cystography or voiding cystourethrography was performed within 12 months postoperatively. After the first year, retrograde study was performed once during the follow-up period in the majority of the patients. The mean follow-up period was 44.8 months (range 24-71 months).

RESULTS

There was no urinary tract dilatation in 68 renal units (93.1%), while slight dilatation was noted in 3 (4.1%), moderate dilatation in 1 (1.4%), and marked dilatation due to stenosis of ureteroileal anastomosis in 1 (1.4%). Retrograde studies revealed absence of reflux in all patients. Another complication that related to this procedure was not observed in any patients.

CONCLUSION

We conclude that Le Duc-Camey technique is effective in reflux prevention and protection of the upper urinary tract, and recommend it for use with detubularized ileal reservoir.

Myocardial infarction as a complication of pheochromocytoma in a pregnant woman

Pheochromocytoma is an unusual cause of hypertension during pregnancy. We present a 40-year-old woman who had a myocardial infarction during pregnancy in whom pheochromocytoma was subsequently diagnosed. This disorder carries a high risk of maternal and perinatal mortality, if undiagnosed prior to delivery. Therefore, the diagnosis of pheochromocytoma should be considered in pregnant patients who exhibit a marked fluctuation in hypertension. Urinary concentrations of catecholamines and their metabolites should be measured in such cases.

[Efficacy of granisetron rescue therapy for nausea and vomiting induced by cancer chemotherapies in urogenital malignant tumor]

In this study, the usefulness of granisetron rescue therapy for nausea and vomiting induced by cancer chemotherapies, including CDDP, was examined. Granisetron was given to twenty patients with urogenital malignant tumor by iv infusion for thirty minutes after the onset of nausea or vomiting. Nausea disappeared in 15 out of 20 patients (75%), 8 of whom (40%) experienced its disappearance while the granisetron was being administered. Vomiting was perfectly controlled in 5 out of 20 patients (25%) for 24 hours after the granisetron administration. No adverse event seemingly due to granisetron was observed. The result of this study confirmed the speedy effect granisetron on nausea induced by cancer chemotherapy including CDDP, but it stopped short of demonstrating sufficient efficacy for vomiting. Prophylactic use, therefore, seems more desirable in view of the patient's QOL, when a highly emetogenic anti-tumor drug, such as CDDP, is used.

Carboplatin-based chemotherapy in patients undergoing hemodialysis

In the present study, we investigated the pharmacology of carboplatin in two patients with chronic renal failure undergoing hemodialysis. In Case 1, squamous cell carcinoma of the epipharynx was treated with 265 mg/m2 of carboplatin alone. In Case 2, adenocarcinoma of the lung was treated with 300 mg/m2 of carboplatin in combination with 50 mg/m2 of etoposide. All agents were injected intravenously. Hemodialysis was initiated 30 minutes after carboplatin administration. Most platinum was excluded by hemodialysis in a pattern similar to that in patients with normal renal function. These observations suggest that carboplatin-based chemotherapy can be considered as a treatment modality for malignant neoplasia in patients with chronic renal failure undergoing hemodialysis.

[Combination chemotherapy with carboplatin and etoposide against lung adenocarcinoma in a patient undergoing hemodialysis: a case report]

A 60-year-old male with chronic renal failure undergoing hemodialysis was treated with combination chemotherapy with carboplatin and etoposide against stage IV adenocarcinoma of the lung. Three hundred mg/m2 of carboplatin on day 1, and 50 mg/m2 of etoposide on days 1 and 3 were injected intravenously before hemodialysis. Pharmacokinetic results revealed that carboplatin was dialyzed. No severe side effects were observed. These observations suggest that combination chemotherapy with carboplatin and etoposide seemed to be applicable to the patients with chronic renal failure undergoing hemodialysis.

Inductively coupled plasma atomic emission spectrometric determination of tin in canned food

Various canned foods were digested sequentially with HNO3 and HCl, diluted to 100 mL, and filtered, and then tin was determined by inductively coupled plasma atomic emission spectrometry (ICP/AES). Samples of canned Satsuma mandarin, peach, apricot, pineapple, apple juice, mushroom, asparagus, evaporated milk, short-necked clam, spinach, whole tomato, meat, and salmon were evaluated. Sample preparations did not require time-consuming dilutions, because ICP/AES has wide dynamic range. The standard addition method was used to determine tin concentration. Accuracy of the method was tested by analyzing analytical standards containing tin at 2 levels (50 and 250 micrograms/g). The amounts of tin found for the 50 and 250 micrograms/g levels were 50.5 and 256 micrograms/g, respectively, and the repeatability coefficients of variation were 4.0 and 3.8%, respectively. Recovery of tin from 13 canned foods spiked at 2 levels (50 and 250 micrograms/g) ranged from 93.9 to 109.4%, with a mean of 99.2%. The quantitation limit for tin standard solution was about 0.5 microgram/g.

[Endoscopic findings of nipple fixation in Kock pouch]

Fixing the nipple to the pouch wall is indispensable to reduce the incidence of late complications of the Kock pouch. We performed endoscopy of the Kock pouch in 28 patients to evaluate the nipple valve fixation. We carried out submucosal fixation of nipple in 17 patients, fixation using staples in 2 patients and full layer fixation in last 9 patients. On endoscopy, both efferent and afferent nipples were poorly fixed or completely detached in 8 of the 17 patients who underwent submucosal fixation. On the other hand, there were no patients in whom the nipple was poorly fixed or completely detached among the other 11 patients. We experienced nipple malfunction in only one of the last 9 patients. Based on endoscopic findings and clinical results, we concluded that full layer fixation was reliable and useful to reduce the incidence of nipple valve complications.

A new system for real-time synthetic aperture ultrasonic imaging

The authors devised a way to generate in real time a cross-sectional image of an object with uniformly high resolution based on the synthetic aperture focusing technique (SAFT). A computer simulation was conducted to study the effects of essential parameters on the resulting images. An imaging system was built that produces a cross-sectional image composed of an assembly of line images of depth direction, i.e. processed A-scan images, and displays a scroll picture on a CRT (cathode ray tube) with no interruption regardless of the object size. It takes only 3 ms from the start of transmission of the ultrasonic wave to the completion of a line image reconstruction, and the framed image on a CRT is updated at the TV rate of 1/30 s. Imaging experiments were conducted using the system, and its expected performance was demonstrated.