Economic evaluation of a preemptive treatment strategy for invasive fungal infection in neutropenic patients with hematological diseases.

We compared the expected medical costs of empirical and preemptive treatment strategies for invasive fungal infection in neutropenic patients with hematological diseases. Based on the results of two clinical trials with different backgrounds reported by Oshima et al. [J Antimicrob Chemother 60(2):350-355; Oshima study] and Cordonnier et al. [Clin Infect Dis 48(8):1042-1051; PREVERT study], we developed a decision tree model that represented the outcomes of empirical and preemptive treatment strategies, and estimated the expected medical costs of medications and examinations in the two strategies. We assumed that micafungin was started in the empirical group at 5 days after fever had developed, while voriconazole was started in the preemptive group only when certain criteria, such as positive test results of imaging studies and/or serum markers, were fulfilled. When we used an incidence of positive test results of 6.7 % based on the Oshima study, the expected medical costs of the empirical and preemptive groups were 288,198 and 150,280 yen, respectively. Even in the case of the PREVERT study, in which the incidence of positive test results was 32.9 %, the expected medical costs in the empirical and preemptive groups were 291,871 and 284,944 yen, respectively. A sensitivity analysis indicated that the expected medical costs in the preemptive group would exceed those in the empirical group when the incidence of positive test results in the former was over 34.4 %. These results suggest that a preemptive treatment strategy can be expected to reduce medical costs compared with empirical therapy in most clinical settings.

The new assessment of left atrial plication for giant left atrium.

AIM: Left atrial plication is occasionally performed to reduce the size of the left atrium. We present our new method of evaluating the effect of plication on giant left atrium. METHODS: Respiratory and cardiac function were evaluated before and after left atrial plication in 8 patients with giant left atrium. At the same time, the postoperative changes in the ratio of left atrial volume to left ventricular end-diastolic volume and left atrial volume to stroke volume were examined. These values were also compared with those of 5 patients who underwent individual mitral surgery and of 9 patients with normal cardiac function. RESULTS: No significant change was seen in vital capacity, percent of one second forced expiratory volume, ejection fraction, pulmonary capillary wedge pressure and left ventricular end-diastolic volume index, while left atrial dimension and left atrial volume decreased significantly. Both the ratio of left atrial volume to left ventricular end-diastolic volume and the ratio of left atrial volume to stroke volume decreased after surgery; the significant difference disappeared compared to the normal values. CONCLUSION: Left atrial plication is a useful method for patients with giant left atrium, since it corrects the disproportion between atrial and the ventricular volumes, which may decrease the left ventricular preload and increase the flow velocity passing through the mitral valve. The ratio of left atrial volume to left ventricular end-diastolic volume and to stroke volume are helpful for evaluating the efficacy of plication.

Strategy for reduction of stroke incidence in coronary bypass patients with cerebral lesions. Early results and mid-term morbidity using pulsatile perfusion.

OBJECTIVES: Cerebral complication is an important factor affecting the outcome after coronary artery bypass surgery under cardiopulmonary bypass. One of the causes for cerebral complication is preoperative cerebrovascular stenotic lesion. Here, we have studied the effect of pulsatile perfusion on the rate of cerebral complication due to a cerebrovascular lesion in patients undergoing coronary arterial bypass graft under cardiopulmonary bypass. METHODS: 261 consecutive elective patients underwent operation using cardiopulmonary bypass for management of the atherosclerotic ascending aorta. Group 1 consisted of 62 patients with a cerebrovascular stenotic lesion (> or = 75%) identified on a magnetic resonance angiogram or multiple cerebral infarction diagnosed using a computer tomogram. Group 2 consisted of 199 patients diagnosed with no significant cerebral lesion. In Group 1, the systolic blood pressure during cardiopulmonary bypass was maintained at a level of 80 mmHg by means of pulsatile flow. In Group 2, non-pulsatile perfusion was used as usual. RESULTS: The overall hospital mortality was 1.5%, and no mortality was caused by a cerebral event. Only one patient in Group 1 suffered from temporary hemiparalysis. A cerebral complication occurred in only 1.6% in Group 1, and 0.4% overall. The actuarial freedom from cerebrovascular accident after 54 months was 84.4% in Group 1, and 96.2% in Group 2 (p = 0.0011). CONCLUSIONS: Management of the atherosclerotic ascending aorta and the use of pulsatile perfusion were helpful in preventing cerebral injury during CABG.

Assessment of the normal adult right ventricular diastolic function using M-mode echocardiographic measurement of tricuspid ring motion.

Right ventricular function can be evaluated echocardiographically by assessing the longitudinal motion of the tricuspid ring recorded in the apical four chamber view. In this study, we applied this technique to assess the right ventricular diastolic function in 10 healthy Japanese men (mean age: 28 +/- 6 years; age range: 20-43 years). Echocardiographic studies were performed with a phased-array imaging system using a 2.5 MHz probe. Tricuspid ring motion was measured by two-dimensional echo guided M-mode echocardiogram of the right lateral tricuspid ring. The excursion of the tricuspid ring during early diastole (DS; mm) and the peak rate of change of the excursion (dS/dt; mm/sec) were measured. We also assessed the right ventricular function by cine magnetic resonance imaging (MRI). Cine gradient echo images were obtained along the short axis of the right ventricle. The right ventricular volume at each phase of the cardiac cycle was calculated by Simpson's method and time-volume curves were constructed. The peak filling rate (dV/dt; ml/s) was determined from these time-volume curves. The dS was 12.8 +/- 2.5 mm, dS/dt was 132 +/- 27 mm/sec and dV/dt was 269 +/- 66 ml/s. There were significant positive correlations between dS and dV/dt (r = 0.80, P < 0.01), and between dS/dt and dV/dt (r = 0.45, P < 0.05). Based on our results, M-mode echocardiographic measurements of tricuspid ring motion may be used to assess the right ventricular diastolic function.

Dental students' understanding of titanium.

The understanding of titanium by students in the dental faculty of Tokyo Medical and Dental University was surveyed from 1990 to 1996. A seven-item questionnaire was used in the survey conducted during the first lecture of the dental materials and science course. The students' basic understanding of titanium was not very good and did not improve with time. However, their understanding improved significantly after the lecture and laboratory instructions.

[Assessment of fetal lung maturity using newly developed immunological measurement of fetal pulmonary surfactant apoprotein-A in amniotic fluid].

The level of immunoreactive lung surfactant apoprotein A (SP-A) was determined with a newly developed one-step ELISA kit (TDR-20) in 217 samples obtained by transabdominal or transvaginal amniocentesis from 217 pregnant women with high risk pregnancy. The lecithin/sphingomyelin ratio (L/S ratio) by two-dimensional thin layer chromatography, disaturated phosphatidylcholine (DSPC) values, shake test and the stable microbubble method were done simultaneously to compare diagnostic reliability in estimating fetal lung maturity. Amniotic fluid SP-A levels increased with advancing gestational age and correlated well with the values obtained by the other methods. When the cut-off SP-A value for the assessment of lung maturity was set at 1,700ng/ml in the amniotic fluid obtained within 24h before delivery, the true-negative rate for RDS was 71% and the true-positive rate for non-RDS was 83%. The sensitivity, specificity and accuracy were 100%, 83% and 88%, respectively. These results are comparable with those for the L/S ratio, DSPC determination and the stable microbubble method, and were slightly better than those for the shake test. In conclusion, this newly developed ELISA kit for the measurement of amniotic fluid SP-A is more effective than other methods currently available for the evaluation of fetal lung maturity, when it is considered that it requires only 0.2ml of amniotic fluid and provides results in only 2h without technical difficulties.

The immunosuppressive effect of hepatocytes in rats--assessment by heart allograft survival and delayed-type-hypersensitivity reactions.

The immunosuppressive effect of hepatocytes was examined experimentally by heart allograft and delayed-type-hypersensitivity (DTH) reactions. The hepatocyte inoculation (1 X 10(7) of BDE (of the major histocompatibility complex haplotype RT1u), LEW (RT1l), and DA (RT1a) into the spleens of LEW rats significantly prolonged the survival of BDE heart allografts to 14.3 +/- 2.7 (mean +/- SD), 9.2 +/- 0.8, and 10.8 +/- 2.3 days respectively, compared with 6.7 +/- 0.8 days in controls (p less than 0.01). Moreover, the BDE hepatocytes had a significantly prolonged survival compared to the LEW (p less than 0.01) and DA (0.02 less than p less than 0.05) groups. BDE hepatocyte (donor specific) inoculation 4 and 7 days before priming with the spleen cells reduced DTH responses in the LEW rats to 44.6 +/- 4.8 per cent, and 74.2 +/- 8.0 per cent, respectively. DA hepatocyte inoculation (third party) 4 and 7 days prior to priming reduced DTH responses to 72.5 +/- 11.5 per cent, and 76.5 +/- 11.9 per cent, respectively. All DTH responses were significantly suppressed after hepatocyte inoculation compared to 100 per cent in the controls (p less than 0.01). Moreover, the inoculation of BDE hepatocytes (donor specific) 4 days prior to the priming significantly reduced DTH responses compared to the group primed 7 days before (p less than 0.01). From these results we concluded that hepatocytes produced not only non-specific but also donor specific immunosuppressive effects through T cell immune reaction. Moreover, donor specific immunosuppressive effects were induced at least 4 to 7 days after hepatocyte inoculation.

A 2-year assessment of a microcomputer based local-area network system for managing perinatal medical information.

Based on a 2-year experience using a perinatal information system and a microcomputer-based local area network (LAN), we assessed the LAN system to see how it provided positive feedback in daily perinatal practice. Discussed herein are the results pertaining to the compatibility between data on conventional patient's charts and that input into the computer system, along with a review of the data-base acquired, containing a large quantity of perinatal medical information.

Assessment of local area network based on the microcomputer system for data processing of perinatal medical information.

In order to control perinatal medical information, we developed a microcomputer-based local area network. This system has been in practical operation since June, 1986. We have assessed this system with regard to both patient-machine and doctor-machine interfaces. Consequently, although input operation took 20-30% longer per individual patient than before, it was more feasible for medical staff to access and retrieve the data in a real-time manner. When tested in a ten month period, this system was found to be a prototype applicable for further extending the management of the entire scope of perinatal medical information.

An application of the Markov process for quantitative prediction of labor progress.

To quantitatively predict the progress of labor, we devised a mathematical model suitable for the Markov process. Included were 625 primiparas who went into spontaneous labor between 37 and 41 weeks of gestation with a cephalic presentation. When applying the Markov process, the sequence of labor was divided into eight categories from 4 cm cervical dilatation to delivery of the baby. Based on all data collected, a transition matrix was calculated, using a microcomputer system, in which the value in each element showed the percent of probability of progression in labor from one given state to another over a 30-minute period. This matrix was found to be available for evaluating the course of labor in clinical practise with a good predictive value and therefore the Markov process could be confirmed to be actually applicable as an analytical model.

A new antitumor antibiotic FR66973: clonogenic in vitro assessment of activity against human non-small cell lung carcinoma.

We have utilized a human tumor clonogenic assay (HTCA), as a disease-oriented drug screening model of new antitumor drugs, to test the antitumor activity of FR66973 and compared the activity with that of its analogous compound, mitomycin C. The overall in vitro response rate (defined as less than 50% survival of tumor colony forming units) for FR66973 against fresh tumor cells obtained from patients with non-small cell lung carcinoma (NSCLC) was 32%, 50% and 89% at 0.1, 1 and 10 micrograms/ml, respectively, which was superior to that of mitomycin C at the corresponding concentration. Our data suggest that FR66973 is a promising new drug against NSCLC. If phase I toxicities are not prohibitive, FR66973 may also have good activity against NSCLC in clinical phase II trial.

Modified Blalock-Taussig shunt operation without cardiac catheterization: two-dimensional echocardiographic preoperative assessment in cyanotic infants.

Between May 1981 and December 1983, 25 infants with cyanotic congenital heart defects underwent 26 Blalock-Taussig shunt operations without cardiac catheterization and angiocardiography. In these infants, the diagnosis was established by 2-dimensional echocardiography (2-D echo) supplemented with clinical findings, chest x-ray and electrocardiography. The right and left pulmonary artery measurements, a prerequisite for a shunt operation, determined by 2-D echo were compared with those at surgery and had an excellent correlation (r = 0.94). No infant died as a consequence of an early shunt failure, and only 1 died of postoperative pyothorax. In conclusion, 2-D echo may eliminate the need for invasive investigation in selected patients undergoing the Blalock-Taussig anastomosis.

Assessment of dystocia pelvis by ultrasound pelvimetry.

Following successful preceding studies, a quantitative analysis of the female pelvic cavity was made using contact compound scanning procedures. The subjects were seventy-seven, 3 day postpartum women and ultrasonic tomograms were obtained concerning the five pelvic transections in each individual. For the quantitative analysis, variables of binary digits were used. Such were based on the standard of "normopelvis" in the polar coordinate system plus the external criteria, normal progress of labor, protraction and arrest disorders. Characteristics of the dystocia pelvis included an abnormal side wall of the small pelvis as well as an increased resistance of the muscles of the pelvic floor. The efficiency of the discrimination was greatest when those variables were adopted from each transection (78.3%). Arrest disorders could be clearly distinguished from the normal cases, however, cases of protraction disorder presented more difficulty as the distribution was wide between normal and the arrest disorder. Here, the pelvic floor muscles contribute significantly. The newly developed numerical system should make feasible an early prediction of dystocia, assist in screening processes and pave the way for accurate assessments of the interaction of anatomical factors related to the mechanics and processes of labor.