- Email: [email protected]
ARTIFICIAL SURFACTANT THERAPY
252 SYMPTOMS RECORDED AFTER INGESTION OF MSG OR PLACEBO IN WATER
complained of the classic triad of symptoms associated with the Chinese restaurant syndrome. Although reactions to MSG were significant, the symptoms recorded were not those of the Chinese restaurant syndrome.3 There was no dose-related effect of MSG, and the women were not more susceptible than men to MSG, as has been suggested.7 We feel that if the Chinese restaurant syndrome exists it is due not solely to the ingestion of MSG but either to a combination of MSG with another as yet unrecognised substance or to the ingestion of something entirely different.
no-one
Rayne Institute, University College Hospital Medical School, London WC1E 6JJ
effective in the presence of advanced tumour. An increasing number of patients with small-cell lung cancer can achieve complete clinical remission with minimal toxicity on chemotherapy alone. This pattern of chemotherapy response has preceded the curative therapy of a number of tumours and offers much future promise. It would be unfortunate if, despite encouraging developments in the therapy of this tumour, clinicians were dissuaded by your editorial from
using chemotherapy. C.R.C. Medical Oncology Unit, Southampton General Hospital, Southampton SO9 4XY
MARTIN E. GORE P. R. SALMON
SiR,-It would be unfortunate if the general reader were to uncritically the views expressed in your Jan. 12 editor-
accept ial.
Although surgery may be the therapy of choice for peripheral lesions’ (some 12% of the total2), in most carefully staged patients the disease is central and commonly widespread,2·3 a fact attested to by an incidence of CNS disease approaching 80% at two years in one study/ 33 of the 52 "curative" resections done in the Liverpool study were on peripheral tumours, appropriately representing a grossly biased series. You cast scorn on the conclusions of Greco and Oldham, without corroborative data, though general experience would support the points made by these workers. We suggest that the "gruelling" nature of the chemotherapy used in the M.R.C. study is predominantly due to the combination of radiotherapy with chemotherapy; especially when the chemotherapy is given immediately after the irradiation as used in the early months of this study. The role of radiotherapy in this condition is not clearly defined, but in a disseminated disease, chemotherapy is the treatment of choice, and in our experience effective combinations are well tolerated when given as primary therapy.
7. Reif-Lehrer L. Possible significance of adverse reactions to glutamate in humans. Fed Proc 1976; 35: 2205-12. 1. Higgins GA, Shields TW, Keehn RJ. The solitary pulmonary nodule. Ten year follow-up of Veterans Administration-Armed Forces Co-operative
Group. Archs Surg 1975; 110: 570. 2. Mountain CR. Clinical biology of small-cell carcinoma: relation to surgical therapy. Sem Oncol 1979; 5: 272. 3. Hansen HH, Dombernowsky P, Hirsch FR. Staging procedures and prognostic features in small-cell anaplastic bronchogenic carcinoma. Sem Oncol
Ihde DC, Cohen MH, Gazdar A, Minna JD. CNS metastases in small-cell bronchogenic carcinoma: Increasing frequency and changing pattern with lengthening survival. Cancer 1979; 44: 885.
G. M. MEAD A. M. ARNOLD J. A. GREEN C. J. WILLIAMS J. M. A. WHITEHOUSE
ARTIFICIAL SURFACTANT THERAPY
SiR,—All who
care for premature babies would be delighted non-toxic artificial surfactant with which to treat the respiratory-distress syndrome (RDS). We fear that many of them may have had their hopes prematurely raised by the paper by Dr Fujiwara and colleagues (Jan. 12, p. 55). It has been known for eight years’ that in newborn animals natural surfactant obtained from lung washes will improve the compliance of surfactant deficient lungs before hyaline membranes have formed. Almost certainly this would be effective in babies: however, natural surfactant is always contaminated by protein and may contain infective agents from the animal or human source, -and it is this that has prevented its use. Fujiwara’s "artificial surfactant"2 is not really artificial because over half of the material is from an extract of minced bovine lung. This is mainly lipid (not entirely surface active lipid) but also contains 2% of bovine protein. There is obviously a potential risk in giving such material to human babies. Another problem with this technique is the large volume of fluid used. About 10 ml is said to have been instilled into the lungs of babies with severe RDS. The total lung volume per kg is about 25 ml with a tidal volume of 6 ml, in babies with RDS:3 10 ml therefore represents a very large liquid load and we would surmise that it could make babies temporarily hypoxic; indeed one is not surprised that they had to be revived by "bagging" with 100% oxygen. Fujiwara shows us some impressive improvements in the ventilatory status of the treated babies. Could these have been the result not just of extra surfactant but also of the resuscitation by bagging with 100% oxygen (or even of the instillation of saline). Some controlled evidence to allay such reservations would be useful.
to
SMALL-CELL LUNG CANCER
1979; 5: 280. 4. Nugent JL, Bunn PA, Matthews MJ,
You refer to the first Oxford trial in a group of patients with lung cancer of multiple histological types. Few would deny the inadequacy of chemotherapy for non-small-cell cancer, so the conclusions you draw from this study are entirely invalid since only 18% of these cases had small-cell cancer. To suggest that therapy should await symptoms (and therefore advancement of disease) seems inappropriate in a tumour in which response to therapy and survival are so closely related to the stage of the tumour.5 Many patients will eventually be treated and such therapy will be much less well tolerated and certainly less
have
a
Department of Pædiatrics, University of Cambridge Clinical School, Addenbrooke’s Hospital,
Cambridge CB2 2QQ
COLIN J. MORLEY
JOHN A. DAVIS
5. Greco FA, Einhorn LH, Richardson RL, Oldham RK. Small-cell lung cancer: progress and perspectives. Sem Oncol 5: 323. 1. Enhorning G, Robertson B. Lung expansion in the premature rabbit fetus after tracheal deposition of surfactant. Pediatrics 1972; 50: 58-66. 2. Fujiwara T, Tanaka Y, Takei T. Surface properties of artificial surfactant in comparison with natural and synthetic surfactant lipids. IRCS Med Sci
1979; 11: 178-82. 3.
LB. Neonatal respiration: Physical and clinical studies. Oxford Blackwell Scientific Publications, 1977.
Strang
complained of the classic triad of symptoms associated with the Chinese restaurant syndrome. Although reactions to MSG were significant, the symptoms recorded were not those of the Chinese restaurant syndrome.3 There was no dose-related effect of MSG, and the women were not more susceptible than men to MSG, as has been suggested.7 We feel that if the Chinese restaurant syndrome exists it is due not solely to the ingestion of MSG but either to a combination of MSG with another as yet unrecognised substance or to the ingestion of something entirely different.
no-one
Rayne Institute, University College Hospital Medical School, London WC1E 6JJ
effective in the presence of advanced tumour. An increasing number of patients with small-cell lung cancer can achieve complete clinical remission with minimal toxicity on chemotherapy alone. This pattern of chemotherapy response has preceded the curative therapy of a number of tumours and offers much future promise. It would be unfortunate if, despite encouraging developments in the therapy of this tumour, clinicians were dissuaded by your editorial from
using chemotherapy. C.R.C. Medical Oncology Unit, Southampton General Hospital, Southampton SO9 4XY
MARTIN E. GORE P. R. SALMON
SiR,-It would be unfortunate if the general reader were to uncritically the views expressed in your Jan. 12 editor-
accept ial.
Although surgery may be the therapy of choice for peripheral lesions’ (some 12% of the total2), in most carefully staged patients the disease is central and commonly widespread,2·3 a fact attested to by an incidence of CNS disease approaching 80% at two years in one study/ 33 of the 52 "curative" resections done in the Liverpool study were on peripheral tumours, appropriately representing a grossly biased series. You cast scorn on the conclusions of Greco and Oldham, without corroborative data, though general experience would support the points made by these workers. We suggest that the "gruelling" nature of the chemotherapy used in the M.R.C. study is predominantly due to the combination of radiotherapy with chemotherapy; especially when the chemotherapy is given immediately after the irradiation as used in the early months of this study. The role of radiotherapy in this condition is not clearly defined, but in a disseminated disease, chemotherapy is the treatment of choice, and in our experience effective combinations are well tolerated when given as primary therapy.
7. Reif-Lehrer L. Possible significance of adverse reactions to glutamate in humans. Fed Proc 1976; 35: 2205-12. 1. Higgins GA, Shields TW, Keehn RJ. The solitary pulmonary nodule. Ten year follow-up of Veterans Administration-Armed Forces Co-operative
Group. Archs Surg 1975; 110: 570. 2. Mountain CR. Clinical biology of small-cell carcinoma: relation to surgical therapy. Sem Oncol 1979; 5: 272. 3. Hansen HH, Dombernowsky P, Hirsch FR. Staging procedures and prognostic features in small-cell anaplastic bronchogenic carcinoma. Sem Oncol
Ihde DC, Cohen MH, Gazdar A, Minna JD. CNS metastases in small-cell bronchogenic carcinoma: Increasing frequency and changing pattern with lengthening survival. Cancer 1979; 44: 885.
G. M. MEAD A. M. ARNOLD J. A. GREEN C. J. WILLIAMS J. M. A. WHITEHOUSE
ARTIFICIAL SURFACTANT THERAPY
SiR,—All who
care for premature babies would be delighted non-toxic artificial surfactant with which to treat the respiratory-distress syndrome (RDS). We fear that many of them may have had their hopes prematurely raised by the paper by Dr Fujiwara and colleagues (Jan. 12, p. 55). It has been known for eight years’ that in newborn animals natural surfactant obtained from lung washes will improve the compliance of surfactant deficient lungs before hyaline membranes have formed. Almost certainly this would be effective in babies: however, natural surfactant is always contaminated by protein and may contain infective agents from the animal or human source, -and it is this that has prevented its use. Fujiwara’s "artificial surfactant"2 is not really artificial because over half of the material is from an extract of minced bovine lung. This is mainly lipid (not entirely surface active lipid) but also contains 2% of bovine protein. There is obviously a potential risk in giving such material to human babies. Another problem with this technique is the large volume of fluid used. About 10 ml is said to have been instilled into the lungs of babies with severe RDS. The total lung volume per kg is about 25 ml with a tidal volume of 6 ml, in babies with RDS:3 10 ml therefore represents a very large liquid load and we would surmise that it could make babies temporarily hypoxic; indeed one is not surprised that they had to be revived by "bagging" with 100% oxygen. Fujiwara shows us some impressive improvements in the ventilatory status of the treated babies. Could these have been the result not just of extra surfactant but also of the resuscitation by bagging with 100% oxygen (or even of the instillation of saline). Some controlled evidence to allay such reservations would be useful.
to
SMALL-CELL LUNG CANCER
1979; 5: 280. 4. Nugent JL, Bunn PA, Matthews MJ,
You refer to the first Oxford trial in a group of patients with lung cancer of multiple histological types. Few would deny the inadequacy of chemotherapy for non-small-cell cancer, so the conclusions you draw from this study are entirely invalid since only 18% of these cases had small-cell cancer. To suggest that therapy should await symptoms (and therefore advancement of disease) seems inappropriate in a tumour in which response to therapy and survival are so closely related to the stage of the tumour.5 Many patients will eventually be treated and such therapy will be much less well tolerated and certainly less
have
a
Department of Pædiatrics, University of Cambridge Clinical School, Addenbrooke’s Hospital,
Cambridge CB2 2QQ
COLIN J. MORLEY
JOHN A. DAVIS
5. Greco FA, Einhorn LH, Richardson RL, Oldham RK. Small-cell lung cancer: progress and perspectives. Sem Oncol 5: 323. 1. Enhorning G, Robertson B. Lung expansion in the premature rabbit fetus after tracheal deposition of surfactant. Pediatrics 1972; 50: 58-66. 2. Fujiwara T, Tanaka Y, Takei T. Surface properties of artificial surfactant in comparison with natural and synthetic surfactant lipids. IRCS Med Sci
1979; 11: 178-82. 3.
LB. Neonatal respiration: Physical and clinical studies. Oxford Blackwell Scientific Publications, 1977.
Strang