First nationwide attitude survey of Japanese physicians on the use of traditional Japanese medicine (kampo) in cancer treatment.

The aim of this nationwide survey was to investigate the use of Kampo medicine by Japanese physicians who worked in the core cancer treatment hospitals which were designated by Ministry of Health, Labour and Welfare. Among the 900 physicians surveyed, 92.4% reported having prescribed Kampo medications, of whom 73.5% reported having prescribed them for cancer patients. Despite this high percentage and the finding that only 9.7% of the physicians reported that they considered Kampo medications to be harmful, only 23.1% of the physicians expressed high expectations of the efficacy of Kampo medicine in tumor suppression and the exertion of immunostimulatory action. In contrast, many cancer patients have expressed the belief that Kampo medications can suppress tumor growth, and several studies have reported that they exert immunostimulatory action. To resolve this discrepancy in patient and physician expectations and to clarify the research findings, further research into the effectiveness and harmfulness of Kampo medicine in cancer treatment is warranted.

T-cell insulitis found in anti-GAD65+ diabetes with residual beta-cell function. A case report.

CASE HISTORY: We recently encountered a 65-year-old anti-GAD+ diabetic woman with residual beta-cell function who was proved to have T-cell insulitis. The proportion of CD4+ and CD8+ cells varied among individual islets, although CD4+ cells tended to be the predominant T-cell type in the islets examined. All of the islets examined still contained insulin, suggesting that beta-cell mass may have been preserved. DISCUSSION: It is well known that lymphocytic infiltration of pancreatic islets, a condition referred to as "insulitis," is seen in acute-onset type 1 diabetes at autopsy and in biopsy specimens. However, there have been no proven cases of insulitis in type 1 diabetes with residual beta-cell function. We believe that this is the first type 1 diabetic patient with residual beta-cell function who was proven to have T-cell insulitis. This novel evidence will contribute to the proper classification and treatment of diabetes and to a better understanding of the pathophysiology of type 1 diabetes.

Double stenting for esophageal and tracheobronchial stenoses.

BACKGROUND: We examined the complications and outcomes of placing stents for both esophageal and tracheobronchial stenoses. METHODS: We placed stents for both esophageal and tracheobronchial stenoses in 8 patients (7 with esophageal cancer and 1 with lung cancer). Covered or noncovered metallic stents were used for the esophageal stenoses, except in 1 patient treated with a silicone stent. Silicone stents were used for the tracheobronchial stenoses. The grades of esophageal and tracheobronchial stenoses were scored. RESULTS: All patients experienced improvement of grades of both dysphagia and respiratory symptoms after stent therapy. The complications were: (1) 2 patients suffered respiratory distress after placement of the esophageal stent because of compression of the trachea by the stent; and (2) 3 patients developed new esophago-tracheobronchial fistulae, and 2 patients had recurring fistula symptoms because of growth of preexisting fistulae after the stent placement, which were caused by pressure from the 2 stents. Despite the fistulae, the 5 patients treated with covered metallic stents did not complain of fistula symptoms, but 2 patients treated with noncovered metallic or silicone stents did complain. CONCLUSIONS: For patients with both esophageal and tracheobronchial stenoses, a stent should be introduced into the tracheobronchus first. Because placement of stents in both the esophagus and tracheobronchus has a high risk of enlargement of the fistula, a covered metallic stent is preferable for esophageal cancer involving the tracheobronchus.

Pneumococcal psoas abscess.

A 47-year-old woman was admitted to our hospital because of severe low back pain. A computed tomography (CT) scan revealed a left sided psoas muscle abscess. On the first hospital day, US-guided drainage was performed. Streptococcus pneumoniae was isolated from the pus. Thereafter, the open drainage of the abscess and antibiotic treatment were given with subsequent clinical improvement. Only 10 cases of pneumococcal psoas abscess have been previously reported in the world literature.

Effect of long-term storage on monoamine metabolite levels in human cerebrospinal fluid.

Concentrations of homovanillic acid (HVA) and 5-hydroxyindoleacetic acid (5-HIAA) were measured in human cerebrospinal fluid (CSF) following long-term storage at -20 degrees C for intervals of three to 60 months. No significant changes in HVA levels were detected in CSF stored for up to 60 months. On the other hand, 5-HIAA concentrations remained stable for up to 6 months, but decreased significantly in the specimens stored for longer time intervals. The results indicate that 5-HIAA should be determined within 6 months after CSF collection, while HVA determinations may be delayed.

[Effect of controlled hypotension on cerebral oxygen delivery].

The margin of safety for controlled hypotension is still unclear especially in the central nervous system (CNS) which is one of the most sensitive organs to hypoxia and ischemia. Recently, cerebral optical spectroscopy in the infrared light range was developed as a useful tool which makes it possible to monitor cerebral oxygenation (rSO2) non-invasively and continuously during anesthesia. Resulting rSO2 mainly reflects oxygen extracts by cerebral tissue and then indicates cerebral oxygen delivery. We examined the limitation of controlled hypotension in the brain in 12 patients by monitoring rSO2 during anesthesia. rSO2 under room air breathing (control value as normal physiological condition) was 67 +/- 3% (mean +/- SEM). It significantly increased by 5.6 +/- 0.8% under 100% oxygen breathing, but decreased near to the control value under sevoflurane anesthesia (FIO2 1.0). During moderate controlled hypotension (70% of normal blood pressure) by prostaglandin E1 under sevoflurane anesthesia (FIO2 1.0). rSO2 remained at control value, indicating that cerebral oxygen delivery was still sufficiently maintained. However rSO2 decreased significantly by 9.0 +/- 1.1% in same controlled hypotension condition under FIO2 0.4. This decrease in rSO2 could be potentially harmful for CNS although any post-operative neurological disorder was not observed in our cases. We conclude that cerebral oxygen delivery may be insufficient even in the moderate controlled hypotension, and thus higher FIO2 is recommended in such procedures.

[A case of pheochromocytoma incorrectly diagnosed before and during surgery].

In a patient with an adrenal tumor, although norepinephrine levels in the blood and urine were abnormally high, findings in CT and 131 I-MIBG scintigraphy denied pheochromocytoma. The preoperative diagnosis was metastatic adrenal tumor. The surgical manipulation of the tumor increased the blood pressure from 110/60 to 210/110 mmHg. However, intraoperative microscopic examination in frozen section excluded again possibility of pheochromocytoma. Later, findings in the permanent specimen confirmed that the tumor was pheochromocytoma. The problem of this case was that each specialist made judgment only on the subject of his own interest without considering of the patient's status as a whole. Anesthesiologist should have the ability to make preoperative assessment of a patient by using all available information with his unbiased mind.

Differences in effects of sultopride and sulpiride on dopamine turnover in rat brain.

Sultopride and sulpiride are both chemically similar benzamide derivatives and selective antagonists of dopamine D2 receptors. However, these drugs differ in clinical properties. We compared the effects of sultopride and sulpiride on dopamine turnover in rats following the administration of these drugs alone or in combination with apomorphine. The administration of sultopride or sulpiride markedly accelerated dopamine turnover in the rat brain. The increase in the level of dopamine metabolites in the striatum was more marked in the sultopride-treated rats. Sulpiride affected the limbic dopamine receptors preferentially, whereas sultopride affected the striatal and the limbic dopamine receptors equally. A low dose of apomorphine induced a reduction in the concentration of dopamine metabolites in the striatum and the nucleus accumbens by approximately 55%, but not in the medial prefrontal cortex. Sultopride was more effective in preventing an apomorphine-induced reduction in dopamine metabolite levels. These results from rat experiments would model the pharmacological differences observed between sultopride and sulpiride in clinical use.

Comparative study of sulpiride and haloperidol on dopamine turnover in the rat brain.

The effects of the neuroleptics, sulpiride and haloperidol, on dopamine (DA) turnover were compared following the acute and chronic administration of these drugs alone or in combination with levodopa or apomorphine. In the acute treatment, the increase in DA metabolites in the striatum and nucleus accumbens was more marked in the haloperidol-treated rats than in the sulpiride-treated rats. Following the additional administration of levodopa, however, the potency of the neuroleptics in elevating DA metabolites was reversed. A low dose of apomorphine induced a marked reduction in the striatal DA metabolite levels by approximately 50%. When rats were pretreated with the neuroleptics, haloperidol was more effective in preventing an apomorphine-induced reduction in DA metabolites. On repeated administration of the neuroleptics, a tolerance occurred in the striatum and nucleus accumbens, but not in the prefrontal cortex. This differential development of tolerance was observed in the different brain regions and with the different drugs administered. These results suggest that the pharmacological mechanism of sulpiride on DA turnover differs from that of haloperidol.

Enhanced motility of the vagotomized canine stomach by electrical stimulation.

Functional impairment of the vagotomized stomach used as a substitute oesophagus seriously deteriorates the quality of life of patients following oesophageal cancer surgery. We speculated that if the enteric neurons of the reconstructed gastric tube survived functionally, the motility of the gastric tube could be facilitated and the recovery process after operation would improve as a consequence. In the present study we investigated whether direct electrical stimulation was effective for facilitating the motility of the canine vagotomized stomach. Dogs underwent truncal vagotomy by transabdominal approach and, in some cases, arteries to the upper stomach and the oesophagus were also ligated and resected to resemble the blood supply and surgical invasion of the reconstructed gastric tube. Electrical stimulation, a few minutes of positive rectangular current pulses, amplitude 20 V (or 15 mA), duration 0.5 ms and frequency between 0.2 and 7 Hz, was delivered on the greater curvature of the mid corpus. Changes in mechanical contractions were recorded using strain gauge force transducers. Electrical stimulation successfully enhanced the mechanical force of the phasic ring contractions of the vagotomized stomach in a frequency dependent manner. Aboral propagation and periodicity of the contractions, impaired by surgical procedures, were restored during stimulation. These excitatory effects were inhibited by atropine, hexamethonium and tetrodotoxin, suggesting that electrical stimulation acts on intramural cholinergic nerves that have survived functionally. These results suggest that electrical stimulation could be an effective method for improving the motility of the vagotomized stomach.

De-epithelialization for esophageal cyst by video-assisted thoracoscopic surgery monitored by esophagoscopy.

In a 26-year-old male a congenital esophageal cyst was de-epithelialized using electro-cauterization via video-assisted thoracoscopic surgery (VATS) together with esophagoscopy. As the cyst adhered firmly to the esophageal muscle layer and mucosa, partial excision of the cyst and burning up of the cystic mucosa by electro-cauterization was performed to prevent esophageal mucosal perforation and postoperative esophageal dysmotility. Intraoperative video esophagoscopic monitoring enabled esophageal mucosal perforation to be avoided. Postoperative barium esophagography revealed good esophageal motility, and the patient showed no symptoms of esophageal dysmotility. We conclude that de-epithelialization for congenital esophageal cysts using VATS together with esophagoscopy is a minimally damaging and reasonable curative procedure without postoperative complications.