Antibiotic selection patterns in acutely febrile new outpatients with or without immediate testing for C reactive protein and leucocyte count.

BACKGROUND: Excessive use of broad spectrum antibiotics is related to the spread of drug resistant bacterial strains in the community. AIM/METHODS: The effects of immediate testing for C reactive protein (CRP) and white blood cell count (WBC) on physicians' choices of antibiotic was investigated in patients with acute infection. Acutely febrile new outpatients were randomised into two groups: group 1 (147 patients) underwent CRP and WBC testing before initial consultation (advance testing). Prescriptions were compared with those in group 2 (no advance testing; 154 patients). RESULTS: In non-pneumonic acute respiratory tract infections, 61 (58%) and 122 (91%) of group 1 and 2 patients were prescribed antibiotics, respectively. Cefcapene pivoxil (third generation cephalosporin) and amoxicillin were the most frequently chosen drugs for group 1 and 2, respectively. Total prescriptions of newer, extended spectrum antibiotics (cefcapene pivoxil and clarithromycin (advanced macrolide)) were reduced by 25% in group 1, although they increased in rate (41 (67%) v 55 (45%) prescriptions) because of the decreased prescription of amoxicillin. In group 1, cefcapene pivoxil was preferentially selected when WBC values were greater than 9 x 10(9)/litre. Prescription shifted to macrolides (mainly clarithromycin) in patients without leucocytosis. Patient treatment outcome did not significantly differ between the two groups. CONCLUSIONS: The availability of CRP and WBC data during initial consultation greatly reduced prescription of amoxicillin, but had a lesser effect on newer, potent, broad spectrum antibiotics.

Type 1 diabetes mellitus caused by treatment with interferon-beta.

A 57-year-old man was referred to our outpatient clinic after interferon-beta (IFN-beta) treatment for 7 weeks. While IFN-beta therapy was continued in our outpatient clinic, his blood glucose level increased gradually, and he was admitted to our hospital for hyperglycemia. The patient was prescribed a 1,600-kcal diet and intensive insulin therapy was performed. GAD antibody became positive 15 months after the start of IFN therapy, and disappeared 27 months after the start of IFN therapy. Insulin secretion was depleted and the patient had HLA-DR4, B54, and DRB1*0405. This appears to be a case of type 1 diabetes mellitus induced by administration of IFN-beta alone.

[Experimental study on intraperitoneal and intravenous administration of anti-tumor agents for liver metastasis].

Intraperitoneal chemotherapy has been the treatment for peritoneal seedings. Most of the anti-tumor agent administered intraperitoneally is absorbed from visceral peritoneum, gets into the portal vein system and reaches the liver. Theoretically, intraperitoneal administration of anti-tumor agents must show equivalent effects on the liver metastasis to portal vein infusion. We compared the efficacy of intraperitoneal and intravenous administration of 5-FU, CDDP and CPT-11, using colon 26 mouse liver metastasis model. Intraperitoneal administration of 5-FU or CPT-11 was statistically superior to intravenous administration to diminish the liver metastatic deposits. CDDP experiment did not show a statistical difference, but the superiority intraperitoneal administration was recognized. Intraperitoneal administration of anti-tumor agents is more effective for not only peritoneal seedings but also liver metastases than intravenous administration. Intraperitoneal chemotherapy might be an effective adjuvant chemotherapy for gastrointestinal malignancies.

Scanning tunneling microscopic study of osmium-impregnated collagen.

The vapor-phase osmium impregnation method was applied to increase the conductivity of the collagen specimens used in scanning tunneling microscopy (STM), since the application of STM to biological materials has been limited by the poor conductivity, irregular sample geometry, and instability of these materials. The impregnation method was applied to collagen fibrils attached to highly oriented pyrolytic graphite, and the STM images obtained were compared with those of routinely processed uncoated specimens. The osmium-impregnated collagen fibrils showed a periodicity of about 67 nm, which was also observed on the negative-stained specimens by transmission electron microscopy. In addition, the periodicity of 3.1 nm, which corresponded to the helical cycle of the 3 alpha-chains within collagen, was clearly demonstrated by STM. Moreover, the comparative observations of collagen specimens without osmium impregnation disclosed the left-handed helical structure with a periodicity of 3.1 nm in a single collagen filament.

Clinical outcome of intraoperative pelvic hyperthermochemotherapy for patients with Dukes' C rectal cancer.

In attempts to prevent local recurrence after curative resection for rectal cancer, intraoperative pelvic hyperthermochemotherapy (IOPHC) was prescribed for 27 patients with Dukes' C cancer. The procedures used were as follows: immediately after amputation or resection of the rectum with extended lymphadenectomy, the pelvic cavity was filled with physiological saline containing 40 micrograms/ml mitomycin C, which was warmed at 45 degrees C for 90 min with an apparatus devised for IOPHC. Thirty-five patients who underwent surgery alone for Dukes' C rectal cancer within the same period served as controls. There was a local recurrence in three patients in the IOPHC group (11.1%), and in 13 in the control group (37.1%). With regard to hepatic or pulmonary metastasis, there was no difference between the two groups. There was no morbidity in the IOPHC treatment except for a large volume of exudate from the pelvic cavity. Thus, IOPHC can be considered as one option for limiting local recurrence after surgical resection of an advanced rectal cancer.

Comparative clinicopathologic features of early gastric cancer in young and older patients.

BACKGROUND: The clinicopathologic features of advanced gastric cancer have been analyzed in young or older patients; however, with regard to early gastric cancer, it remains unknown whether the features differ between young and older patients. Reported here is an analysis of clinicopathologic characteristics in young and in older patients. METHODS: This study is based on a retrospective review of 25 patients less than 40 years of age with early gastric cancer and of 64 patients more than 70 years of age with early gastric cancer. These patients were treated from 1977 through 1991. RESULTS: Because in the older group there were early double cancers in three patients and quadruple cancers in one, 70 early cancers were present in these 64 patients. Although the young group included a larger percentage of women, the ratio of mucosal cancer to submucosal and the incidence of nodal metastasis did not differ between the groups. Poorly differentiated adenocarcinoma was detected in 13 (52%) of the 25 younger patients, whereas in the older group it was present in 6 cancers (8.6%) alone. The number of metastatic nodes and extent of nodal metastasis were more severe in the young group, but survival rates did not differ between the groups. The depressed type of lesion was present in all patients in the young group, whereas it was only 41 of 70 cancers in the older group. CONCLUSIONS: These findings suggest that early gastric cancer in young adults has aggressive features as based on the histologic pattern, in particular with cancer invasion into the submucosal layer. For these patients nodal extirpation and postoperative adjuvant chemotherapy should be performed in an attempt to prevent lymphatic or hematogenic metastases.

A new method for palliation of malignant obstructive jaundice utilizing a peritoneo-venous shunt pump.

A new simple palliative method for use in malignant obstructive jaundice is presented. This method is particularly effective in the prevention of ascending infections. The method consists of interposing a one-way flow shunt pump (peritoneo-venous shunt pump) between a bile catheter and a jejunal catheter. Four patients were treated with this new method. Jaundice improved significantly in all patients. They had a much better quality of life with no serious complications during the terminal course. This less invasive and safe procedure is preferred for patients who have extrahepatic biliary obstruction due to incurable malignant tumors.

Relation between clinical and histologic outcome of intraperitoneal hyperthermic perfusion for patients with gastric cancer and peritoneal metastasis.

In 15 patients with refractory gastric cancer and peritoneal metastasis, the relationship among histologic outcome of intraperitoneal hyperthermic perfusion (IPHP), extent of peritoneal metastasis, and cause of death was studied. The IPHP treatment did not kill all the gastric cancer cells which had penetrated deeply into subperitoneal layers. In contrast, gastric cancer cells in the abdominal effusion and/or lavage vanished. Three patients with peritoneal metastasis, deeply invaded and spread all over the peritoneum, died of peritoneal recurrence and 1 died of pericardial metastasis. In the remaining 11 patients with a lesser extent of peritoneal metastasis, 5 are living without recurrence and among the other 6, 4 died of recurrence of the disease and 1 died of other causes.

Combined treatment of pelvic exenterative surgery and intra-operative pelvic hyperthermochemotherapy for locally advanced rectosigmoid cancer: report of a case.

A huge rectosigmoidal cancer which extended into the urinary bladder in a 64-year-old man is herein described. The tumor occupied the pelvic and lower abdominal cavities, while the rectosigmoid was totally obstructed. No hepatic or pulmonary metastasis was evident. The ventral and flank sides of the peritoneum in the right lower abdomen, right common iliac vessels, bilateral ureters, terminal ileum, cecum, ascending colon, and urinary bladder were all directly invaded by the tumor, but the aorta, sacrum, and lower rectum were free of cancer. Consequently, an anterior pelvic exenteration was carried out along with an ileal conduit and a right hemicolectomy. Immediately after the exenteration, intra-pelvic hyperthermochemotherapy was performed using a 46-47 degrees C perfusate containing 40 micrograms/ml of mitomycin C (MMC) and 200 micrograms/ml of cisplatin (CDDP), for 90 min, in an attempt to prevent any further local recurrence. A right hemicolectomy and a permanent colostomy were done simultaneously with the hyperthermia treatment. After an uneventful postoperative course, the patient was prescribed adjuvant chemotherapy, i.e., two administrations of 17 mg/m2 and 21 mg/m2 of MMC, and ten doses of 710 mg/m2 of 5-fluorouracil (5-FU) followed by five doses of 535 mg/m2 of 5-FU. At the time of this writing, the patient is still alive without recurrence at 21 months after surgery.

Cytohistologic assessment of antitumor effects of intraperitoneal hyperthermic perfusion with mitomycin C for patients with gastric cancer with peritoneal metastasis.

For 15 patients with refractory gastric cancer and peritoneal metastasis, intraperitoneal hyperthermic perfusion (IPHP) using mitomycin C combined with extensive surgery was prescribed. The antitumor effects were assessed cytohistologically in pre-IPHP and post-IPHP specimens of the abdominal effusion and peritoneal tissue. Gastric cancer cells in the abdominal effusion and/or lavage vanished from post-IPHP peritoneal exudate obtained from the pouch of Douglas. Peritoneal tissues from nine patients were harvested just after the IPHP treatment. All the nuclei of cancer cells were pyknotic in three of nine patients, and two of these three patients are alive with no local recurrence; one patient died of hepatic metastasis. In the remaining six patients, four with preoperative ascitic effusion and positive post-IPHP histologic findings died of peritoneal, intraabdominal, and pericardial metastases. The other two had some residual microscopic foci in the subperitoneal deep layer; one patient died of pleural recurrence, and the other is alive with no evidence of recurrence 42 months after the IPHP. Among the other six patients, whose post-IPHP peritoneal tissues were not available because of disappearance of disseminating foci as a result of the IPHP, two are living with no recurrence and, of the remaining four patients, three died of hepatic and intraabdominal metastases and the other one died of other causes. The histologic findings are suggestive of the following: (1) uniform heat and drug distribution in the abdominal cavity with IPHP treatment, except for an area adjacent to the inflow point of the perfusate; and (2) limited penetration of heat and drug through the subperitoneal layer. Thus, IPHP treatment results in complete destruction of cancer cells in the abdominal effusion and on and just beneath the peritoneum.

[Cell-mediated immune responses of patients with gastro-intestinal cancer to allogenic tumor-associated antigens].

Soluble tumor extract was prepared from cancer tissue of 172 patients with gastrointestinal cancer by the methods of hypertonic salt extraction (HSE) and 3M-KCL salt extraction (3M-KCL). Lymphocyte proliferative (LP) response and skin test was assessed with these tumor extracts. The LP response of cancer patients could be induced on 4 day-incubation in 10 micrograms.protein/ml of the extracts. The allogenic tumor extract induced the LP response with a close correlation to an autologous extract (p less than 0.001). Both HSE and 3M-KCL extracts induced a positive LP response as well as delayed hypersensitivity of the skin in 20 to 30% with a good correlation (p less than 0.001). The clinical stage related closely to a responsibility of LP response and of skin test to the tumor extracts except in stage IV. Gel filtration with Sephadex G-200 revealed the 5th graduated fraction (M.W. less than 10,000) responsible for the activity of LP test. The LP cancer could be demonstrated by LP response and skin test with the tumor extract prepared by HSE and 3M-KCL methods. Thus, it was concluded that the LP response and skin test is a useful parameter of tumor-specific immune response.

[Complete remission in a case of concurrent breast and thyroid cancers with metastatic spinal paralysis].

UNLABELLED: A case of right breast and thyroid cancer is reported in which, despite metastasis to the spinal cord occurring 1 year after mastectomy, satisfactory therapeutic results were obtained. At the time of her first examination the patient had spastic paresis involving all segmental levels below Th7. Bone scintigraphy disclosed multiple hot areas in the spinal column, centering around Th5 6. On myelography, complete block was noted above the lower margins of the vertebral body of Th5. The paresis progressed to result in a complete loss of touch and pain sensations with flaccid paralysis of both lower extremities. Laminectomy of Th4-6 was therefore performed on the 20th day of hospitalization. Biopsy at that time demonstrated the metastasis to be from the breast cancer. Radiotherapy (Linac, 600 rad/w) was started at the 20th postoperative day, a total dose of 3,000 rad being given. Physicotherapy was instituted simultaneously. As drug therapy, OK-432 and FT-207 suppositories (750 mg) were used in addition to diethylstilbestrol, 300 mg/day. RESULTS: After 6 months of these combined therapeutic regimens the patient became capable of moving along the edge of the bed with the aid of a good hand and leg. After 7 months she underwent radical surgery for the thyroid cancer and 3 months later she was discharged asymptomatic.

[Immunological study of the actions of auxiliary antitumor agents--effects on lymphocyte transformation reaction and natural cytotoxicity activity in nude mice].

P-aminobenzoic acid-N-xyloside (K-247) and dimethyl-2- (tetrahydro-2-furanyl) ethylsulfonium-p-toluene sulfonate (GT-101) were tested their in vivo effects on both mitogen-induced lymphoproliferative reactions and natural cell-mediated cytotoxicities in BALB/c nude mice (homozygous and heterozygous) spleen lymphocytes. The animals were injected i.p. either 400 mg/kg of K-247 or 5 mg/kg of GT-101 (for 7 days consecutively). GT-101 caused a positive increase in lymphoproliferations by PHA and SPA, while the administration of K-247 had no effect on PHA-and SPA-induced lymphoproliferations. Furthermore, in a 12-hour 51Cr release assay, both drugs had no effect on the natural cell-mediated cytotoxicity against YAC-1 cells.

[Immunologic studies on the patients with gastrointestinal cancer--with particular reference to correlation between T lymphocyte and macrophage].

Correlation of monocyte with T lymphocyte or IgG-FcR+ T lymphocyte was studied in 57 gastrointestinal cancer patients and 24 healthy volunteers as control. In 24 volunteers, no correlation was found between them. Forty gastrointestinal cancer patients with curative tumor showed pre-and postoperatively a close correlation between monocyte and T lymphocyte, but there was little correlation, both pre-and postoperatively, between monocyte and IgG-FcR+ T lymphocyte. Seventeen patients with recurrent and/or inoperable gastrointestinal cancer, had a reverse correlation of monocyte with IgG-Fc R+T lymphocyte. It was suggested from these data that mononuclear phagocyte system (monocyte), which fulfils its function as an antigen presentation, has an intimate relationship, both directly and indirectly, to T lymphocyte.