The feasible maintenance dose of corticosteroid in Takayasu arteritis in the era of biologic therapy.

Objective: Although biologic agents are used in Takayasu arteritis (TAK), corticosteroids are still the mainstay of treatment. This study aimed to investigate the feasible maintenance dose of prednisolone (PSL) in the biologic therapy era.Method: We enrolled 93 patients with TAK who satisfied the criteria of the American College of Rheumatology and visited our department from 2008 to 2018. The clinical characteristics and PSL dose of the patients were retrospectively evaluated.Results: The mean ± sd maintenance dose of PSL was 5.0 ± 3.0 mg/day. In patients having TAK for > 20 years, PSL discontinuation and drug-free status were achieved in 27.2% and 18%, respectively. Although tapering the PSL dose to 10 mg/day was achieved within 12 months, tapering to 5 mg/day required 10 years. Relapse significantly interfered with the PSL dose reduction. The clinical characteristics of patients with relapse included a lower rate of combination therapy using immunosuppressants. Moreover, biologics were used in > 60% of patients with relapse. Tapering of PSL was significantly possible in patients receiving biologics and additional relapse was observed in 6.3% and 50% of patients with and without biologics, respectively. Such PSL-sparing effect enabled the reduction of the median PSL dose from 10 to 5 mg/day. Steroid discontinuation was achieved in some patients.Conclusions: The use of biologics significantly reduced the PSL dose in relapsed patients. A PSL dose of ≤ 5 mg/day is a feasible target for TAK, especially when biologic agents are used. Nevertheless, corticosteroid discontinuation may also be the target in some patients.

Four distinct clinical phenotypes of vasculitis affecting medium-sized arteries.

Objective: Within the spectrum of polyarteritis nodosa (PAN), cutaneous PAN (cPAN) is further classified into mild cPAN and severe cPAN which presents with ulcers, necrosis, or neuritis. As distinguishing between severe cPAN and systemic PAN can be difficult, this study evaluated the clinical characteristics of patients with necrotizing arteritis of medium-sized arteries. Methods: Forty-one patients diagnosed with necrotizing arteritis of medium-sized arteries between 2008 and 2017 at our institution were enrolled in this study. Clinical background, laboratory findings, treatments, and rates of relapse and death were evaluated. Results: Thirty-six patients were classified as having cPAN (mild, 15; ulcer, nine; neuritis, eight; both, four), and five cases manifested systemic vasculitis. Clinical characteristics of mild cPAN included female predominance (84.6%) and younger age (median 31 years); those of systemic PAN included older age (median 71 years) and higher levels of inflammatory markers. Severe cPAN manifested with intermediate phenotypes. The median doses of prednisolone used to treat mild cPAN, severe cPAN, and systemic PAN were 20.0, 40.0, and 40.0 mg/day, respectively. Immunosuppressants were used in 20.0% of mild cPAN, 90.5% of severe cPAN, and 80.0% of systemic PAN patients. Although the mortality rates were indistinguishable, the relapse rates of severe cPAN (ulcer type) were significantly higher than those of other types (88.9%). Conclusion: The clinical characteristics of mild cPAN, severe cPAN (ulcer type), severe cPAN (neuritis type), and systemic PAN were distinct from each other. In particular, patients with severe cPAN (ulcer type) had higher relapse rates, indicating the importance of combination therapy.

Identification of patterns of factors preceding severe or life-threatening asthma exacerbations in a nationwide study.

BACKGROUND: Reducing near-fatal asthma exacerbations is a critical problem in asthma management. OBJECTIVES: To determine patterns of factors preceding asthma exacerbations in a real-world setting. METHODS: In a nationwide prospective study of 190 patients who had experienced near-fatal asthma exacerbation, cluster analysis was performed using asthma symptoms over the 2-week period before admission. RESULTS: Three distinct clusters of symptoms were defined employing the self-reporting of a visual analogue scale. Cluster A (42.1%): rapid worsening within 7.4 hours from moderate attack to admission, young to middle-aged patients with low Body mass index and tendency to depression who had stopped anti-asthma medications, smoked, and hypersensitive to environmental triggers and furred pets. Cluster B (40.0%): fairly rapid worsening within 48 hours, mostly middle-aged and older, relatively good inhaled corticosteroid (ICS) or ICS/long-acting beta-agonist (LABA) compliance, and low perception of dyspnea. Cluster C (17.9%): slow worsening over 10 days before admission, high perception of dyspnea, smokers, and chronic daily mild-moderate symptoms. There were no differences in overuse of short-acting beta-agonists, baseline asthma severity, or outcomes after admission for patients in these 3 clusters. CONCLUSION: To reduce severe or life-threatening asthma exacerbation, personalized asthma management plans should be considered for each cluster. Improvement of ICS and ICS/LABA compliance and cessation of smoking are important in cluster A. To compensate for low perception of dyspnea, asthma monitoring of peak expiratory flow rate and/or exhaled nitric oxide would be useful for patients in cluster B. Avoidance of environmental triggers, increase usual therapy, or new anti-type 2 response-targeted therapies should be considered for cluster C.

A clustering approach to identify and characterize the asthma and chronic obstructive pulmonary disease overlap phenotype.

BACKGROUND: Asthma and chronic obstructive pulmonary disease (COPD) are heterogeneous diseases. The phenotypes that have clinical features of both asthma and COPD are still incompletely understood. OBJECTIVE: To clarify the best discriminators of the asthma-COPD overlap phenotype from asthma and COPD subgroups using a clustering approach. METHODS: This study assessed pathophysiological parameters, including mRNA expression levels of T helper cell-related transcription factors, namely TBX21 (Th1), GATA3 (Th2), RORC (Th17) and FOXP3 (Treg), in peripheral blood mononuclear cells in asthma patients (n=152) and in COPD patients (n=50). Clusters were determined using k-means clustering. Exacerbations of asthma and COPD were recorded during the 1-year follow-up period. RESULTS: The cluster analysis revealed four biological clusters: cluster 1, predominantly patients with COPD; cluster 2, patients with an asthma-COPD overlap phenotype; cluster 3, patients with non-atopic and late-onset asthma; and cluster 4, patients with early-onset atopic asthma. Hazard ratios for exacerbation were 2.5 (95% confidence interval [CI], 1.1-5.6) in cluster 1 and 2.3 (95% CI, 1.0-5.0) in cluster 2 compared with patients in other clusters. Cluster 2 was discriminated from other clusters by total serum IgE level ≥310 IU/mL, blood eosinophil counts ≥280 cells/µL, a higher ratio of TBX21/GATA3, FEV1 /FVC ratio <0.67 and smoking ≥10 pack-years with an area under the curve of 0.94 (95% CI, 0.90-0.98) in the receiver operating characteristic analysis. CONCLUSIONS AND CLINICAL RELEVANCE: The asthma-COPD overlap phenotype was characterized by peripheral blood eosinophilia and higher levels of IgE despite the Th2-low endotype.

A decadal inversion of CO2 using the Global Eulerian-Lagrangian Coupled Atmospheric model (GELCA): sensitivity to the ground-based observation network.

We present an assimilation system for atmospheric carbon dioxide (CO2) using a Global Eulerian-Lagrangian Coupled Atmospheric model (GELCA), and demonstrate its capability to capture the observed atmospheric CO2 mixing ratios and to estimate CO2 fluxes. With the efficient data handling scheme in GELCA, our system assimilates non-smoothed CO2 data from observational data products such as the Observation Package (ObsPack) data products as constraints on surface fluxes. We conducted sensitivity tests to examine the impact of the site selections and the prior uncertainty settings of observation on the inversion results. For these sensitivity tests, we made five different site/data selections from the ObsPack product. In all cases, the time series of the global net CO2 flux to the atmosphere stayed close to values calculated from the growth rate of the observed global mean atmospheric CO2 mixing ratio. At regional scales, estimated seasonal CO2 fluxes were altered, depending on the CO2 data selected for assimilation. Uncertainty reductions (URs) were determined at the regional scale and compared among cases. As measures of the model-data mismatch, we used the model-data bias, root-mean-square error, and the linear correlation. For most observation sites, the model-data mismatch was reasonably small. Regarding regional flux estimates, tropical Asia was one of the regions that showed a significant impact from the observation network settings. We found that the surface fluxes in tropical Asia were the most sensitive to the use of aircraft measurements over the Pacific, and the seasonal cycle agreed better with the results of bottom-up studies when the aircraft measurements were assimilated. These results confirm the importance of these aircraft observations, especially for constraining surface fluxes in the tropics.

Severe or life-threatening asthma exacerbation: patient heterogeneity identified by cluster analysis.

BACKGROUND: Severe or life-threatening asthma exacerbation is one of the worst outcomes of asthma because of the risk of death. To date, few studies have explored the potential heterogeneity of this condition. OBJECTIVES: To examine the clinical characteristics and heterogeneity of patients with severe or life-threatening asthma exacerbation. METHODS: This was a multicentre, prospective study of patients with severe or life-threatening asthma exacerbation and pulse oxygen saturation < 90% who were admitted to 17 institutions across Japan. Cluster analysis was performed using variables from patient- and physician-orientated structured questionnaires. RESULTS: Analysis of data from 175 patients with severe or life-threatening asthma exacerbation revealed five distinct clusters. Cluster 1 (n = 27) was younger-onset asthma with severe symptoms at baseline, including limitation of activities, a higher frequency of treatment with oral corticosteroids and short-acting beta-agonists, and a higher frequency of asthma hospitalizations in the past year. Cluster 2 (n = 35) was predominantly composed of elderly females, with the highest frequency of comorbid, chronic hyperplastic rhinosinusitis/nasal polyposis, and a long disease duration. Cluster 3 (n = 40) was allergic asthma without inhaled corticosteroid use at baseline. Patients in this cluster had a higher frequency of atopy, including allergic rhinitis and furred pet hypersensitivity, and a better prognosis during hospitalization compared with the other clusters. Cluster 4 (n = 34) was characterized by elderly males with concomitant chronic obstructive pulmonary disease (COPD). Although cluster 5 (n = 39) had very mild symptoms at baseline according to the patient questionnaires, 41% had previously been hospitalized for asthma. CONCLUSIONS & CLINICAL RELEVANCE: This study demonstrated that significant heterogeneity exists among patients with severe or life-threatening asthma exacerbation. Differences were observed in the severity of asthma symptoms and use of inhaled corticosteroids at baseline, and the presence of comorbid COPD. These findings may contribute to a deeper understanding and better management of this patient population.

Improved optical properties of silica/UV-cured polymer composite films made of hollow silica nanoparticles with a hierarchical structure for light diffuser film applications.

This study successfully improved the optical properties of silica/UV-cured polymer composite films made of hollow silica nanoparticles having a hierarchical structure. The particles were synthesized by an inorganic particle method, which involves two steps of sol-gel silica coating around the template and acid dissolution removal of the template. The pH of the acid was varied to achieve different hierarchical structures of the particles. The morphologies and surface properties of the obtained particles were characterized before dispersing in a UV-curable acrylate monomer solution to prepare dispersions for fabricating light diffuser films. The optical properties and the light diffusing ability of the fabricated films were studied. The results revealed that the increased pH of the acid provides the particles with a thinner shell, a larger hollow interior and a higher specific surface area. Moreover, the films with these particles exhibit a better light diffusing ability and a higher diffuse transmittance value when compared to those without particles. Therefore, the composite films can be used as light diffuser films, which is an essential part of optical diffusers in the back-light unit of LCDs. In addition, utilizing the hierarchical particles probably reduces the number of back-light units in the LCDs leading to energy-savings and subsequently lightweight LCDs.

Transduction of Oct6 or Oct9 gene concomitant with Myc family gene induced osteoblast-like phenotypic conversion in normal human fibroblasts.

INTRODUCTION: Osteoblasts play essential roles in bone formation and regeneration, while they have low proliferation potential. Recently we established a procedure to directly convert human fibroblasts into osteoblasts (dOBs). Transduction of Runx2 (R), Osterix (X), Oct3/4 (O) and L-myc (L) genes followed by culturing under osteogenic conditions induced normal human fibroblasts to express osteoblast-specific genes and produce calcified bone matrix both in vitro and in vivo Intriguingly, a combination of only two factors, Oct3/4 and L-myc, significantly induced osteoblast-like phenotype in fibroblasts, but the mechanisms underlying the direct conversion remains to be unveiled. MATERIALS AND METHODS: We examined which Oct family genes and Myc family genes are capable of inducing osteoblast-like phenotypic conversion. RESULTS: As result Oct3/4, Oct6 and Oct9, among other Oct family members, had the capability, while N-myc was the most effective Myc family gene. The Oct9 plus N-myc was the best combination to induce direct conversion of human fibroblasts into osteoblast-like cells. DISCUSSION: The present findings may greatly contribute to the elucidation of the roles of the Oct and Myc proteins in osteoblast direct reprogramming. The results may also lead to establishment of novel regenerative therapy for various bone resorption diseases.

Role of Quantum and Surface-State Effects in the Bulk Fermi-Level Position of Ultrathin Bi Films.

We performed high-resolution photon-energy and polarization-dependent ARPES measurements on ultrathin Bi(111) films [6-180 bilayers (BL), 2.5-70 nm thick] formed on Si(111). In addition to the extensively studied surface states (SSs), the edge of the bulk valence band was clearly measured by using S-polarized light. We found direct evidence that this valence band edge, which forms a hole pocket in the bulk Bi crystal, does not cross the Fermi level for the 180 BL thick film. This is consistent with the predicted semimetal-to-semiconductor transition due to the quantum-size effect [V.B. Sandomirskii, Sov. Phys. JETP 25, 101 (1967)]. However, it became metallic again when the film thickness was decreased (below 30 BL). A plausible explanation for this phenomenon is the modification of the charge neutrality condition due to the size effect of the SSs.

Surgical treatment for pyogenic vertebral osteomyelitis using iodine-supported spinal instruments: initial case series of 14 patients.

Reports have detailed the increasing use of spinal instrumentation in the treatment of pyogenic vertebral osteomyelitis, with the aims of achieving a lower pseudoarthrosis rate and restoring spinal alignment. However, controversy remains over the use of instrumentation in the presence of active infection because of concerns about increased bacterial adherence and biofilm formation on the metallic implant surface. Fourteen consecutive patients were followed who were diagnosed as having pyogenic vertebral osteomyelitis and underwent surgery with spinal instrumentation with iodine-containing surfaces that could be directly supported to existing titanium implants. Bone-cage interfaces and implant-related complications after surgery were evaluated. The white blood cell (WBC) count and C-reactive protein (CRP) level were analyzed during the follow-up period. To confirm the influence of iodine release from the implant, thyroid-stimulating hormone (TSH), free triiodothyronine (FT3), and free thyroxine (FT4) were also examined. The infection subsided in all 14 patients. Both WBC counts and CRP levels returned to normal ranges by the final follow-up. One patient showed a lucent area around the screw and two patients showed lucencies inside the cage. However, no cage dislocations, cage migrations, or screw pull-outs were noted, and all patients' FT3, FT4, and TSH levels were within normal ranges during the follow-up period. We demonstrated the efficacy of iodine-supported titanium implants in the management of pyogenic vertebral osteomyelitis. No cytotoxicity or adverse effects were noted in this series.

Respiratory mechanics and peripheral airway inflammation and dysfunction in asthma.

BACKGROUND: Clinical application of the forced oscillation technique (FOT) has progressed with the spread of commercially available FOT devices. The correlation between respiratory impedance and spirometry has been reported; however, the association with airway inflammation and pulmonary function, in the lung periphery in particular, is unclear. OBJECTIVE: To assess whether respiratory impedance is associated with peripheral airway inflammation and dysfunction in asthma. METHODS: Subjects included 78 patients with overall controlled asthma. We measured whole-breath or within-breath respiratory system resistance (Rrs) and reactance (Xrs) using a commercially available multi-frequency FOT device (MostGraph-01), and assessed the correlation with the fraction of exhaled nitric oxide (FeNO), alveolar nitric oxide concentration (CANO), maximal NO flux in the conductive airways (J'awNO), and the N2 phase III slope of single breath N2 washout (delta N2 ). RESULTS: The differences between inspiratory and expiratory phases of Xrs at 5 Hz (X5), resonant frequency (Fres), and a low-frequency reactance area (ALX) were significantly correlated with CANO; however, there was no correlation between respiratory impedance and FeNO or J'awNO. The delta N2 values were significantly correlated with whole-breath, inspiratory, and expiratory Rrs and Xrs, except for R20. CONCLUSIONS AND CLINICAL RELEVANCE: We conclude that respiratory impedance reflects peripheral airway inflammation and ventilation inhomogeneity.

Fabrication of unique hollow silicate nanoparticles with hierarchically micro/mesoporous shell structure by a simple double template approach.

An innovative type of hollow silicate nanoparticle with a micro/mesoporous shell wall (NSHPMS) was synthesized at room temperature via an eco-friendly double template approach, followed by simple acid reflux. TEM observations of NSHPMSs showed hollow interior nanoparticles (<100 nm) with a wormhole-like shell structure. The nitrogen gas (N(2)) adsorption/desorption isotherm exhibited a unique two-step pattern: the first step (0.2 < P/P(o) < 0.35) signifies the presence of the micro/mesoporous shell wall while the second step (0.85 < P/P(o) < 0.99) represents the void space in between the NSHPMSs. This resulted to an improved specific surface area up to ~2055.5 m(2) g(-1) and a total pore volume as high as ~6.59 cm(3) g(-1) which is better compared with the usual reported data for hollow particles with a mesoporous shell wall. The stable wormhole mesoporous shell wall provided sufficient spaces that contribute to high adsorption capacities and faster adsorption rates. One can envision that larger quantities of framework composition can be obtained using our NSHPMSs.

Molecular cloning and characterization of Th1 and Th2 cytokines of African buffalo (Syncerus caffer).

The African buffalo (Syncerus caffer) has been implicated as the reservoir of several bovine infectious agents. However, there is insufficient information on the protective immune responses in the African buffalo, particularly in infected animals. In this study, we analysed Th1 cytokines IL-2 and IFN-γ, and Th2 cytokines IL-4 and IL-10. The cloned cDNA of IL-2, IL-4, IL-10 and IFN-γ contained an open reading frame of 468, 501, 408 and 540 nucleotides, encoding polypeptides of 155, 166, 135 and 179 amino acids, respectively. Nucleotide sequence homology of IL-2, IFN-γ and IL-4 was more than 98% between the African buffalo and cattle, which resulted in identical polypeptides. Meanwhile, IL-10 gene of African buffalo and cattle had 95% homology in nucleotide sequence, corresponding to thirteen amino acid residues substitution. Cysteine residues and potential glycosylation sites were conserved within the family Bovinae. Phylogenetic analyses including cytokines of the African buffalo placed them within a cluster comprised mainly of species belonging to the order Artiodactyla, including cattle, water buffalo, sheep, goat, pig and artiodactyl wildlife. A deeper understanding of the structure of these cytokines will shed light on their protective role in the disease-resistant African buffalo in comparison with other closely related species.

Evaluation of the efficacy and safety of the combination of gemcitabine and nedaplatin for elderly patients with advanced non-small-cell lung cancer.

OBJECTIVE: The aim of the present study was to retrospectively assess the safety and efficacy of the combination of gemcitabine and nedaplatin in elderly patients with advanced non-small-cell lung cancer (NSCLC). METHODS: Patients ≥75 years with previously untreated NSCLC who underwent chemotherapy consisting of gemcitabine (800 mg/m(2) on days 1 and 8) and nedaplatin (80 mg/m(2) on day 1) every 3 weeks were retrospectively analyzed. RESULTS: Of the 35 patients, 28 were men and 7 were women, with a mean age of 78 years (range 75-87); 10 patients had stage IIIB disease and 25 patients had stage IV disease. The overall response rate was 45.7% (95% confidence interval 28.8-63.4). The median survival time was 14 months (range 3-44). Grade 3-4 toxicities included neutropenia in 74.3%, thrombocytopenia in 48.6%, anemia in 34.3%, hepatic dysfunction in 11.4%, and infection in 2.9%. There were no treatment-related deaths. There were no differences in response rate and survival between patients aged 75-79 years and patients ≥80 years, although grade 3-4 thrombocytopenia and anemia were significantly more frequent in patients ≥80 years. CONCLUSION: Our results suggest that the combination of gemcitabine and nedaplatin is effective and well tolerated for selected elderly patients with advanced NSCLC.

Enhancing effect of H-2-linked NZW gene(s) on the autoimmune traits of (NZB X NZW)F1 mice.

To investigate the possible enhancing effect of the H-2z haplotype of the New Zealand White (NZW) strain on the production of autoantibodies and renal disease observed in B/W F1 mice, we developed the ZWD/8 strain, a NZW congenic line carrying the H-2d haplotype, produced (NZB X ZWD/8)F1 (B/WD8 F1) mice, and examined the difference in several immunological abnormalities between the B/W F1 (H-2d/H-2z) and the B/WD8 F1 (H-2d/H-2d) mice. In comparison with B/W F1 mice, the B/WD8 F1 mice showed markedly lower serum levels of the anti-DNA antibodies and the gp70 ICs, and a later onset and a lower incidence of proteinuria with a lower mortality. In contrast, there was no significant difference in the incidences and the amounts of both natural thymocytotoxic autoantibody and anti-erythrocyte autoantibody between these two hybrid strains. Further, the serum levels of IgG and IgM in B/WD8 F1 mice were as high as those in B/W F1 mice. These findings indicate that the gene(s) that is within or closely linked to the H-2 complex of NZW strain specifically acts to intensify the levels of anti-DNA antibodies and gp70 ICs, and to promote the severity of renal disease in B/W F1 mice. This gene may play a role in the class conversion of anti-dsDNA antibodies from IgM to IgG.

Wild-type Gross leukemia virus and the pathogenesis of the glomerulonephritis of New Zealand mice.

The pathogenesis of the spontaneous glomerulonephritis of NZB and (NZB x NZW) F(1) hybrid mice is related at least in part to the formation of natural antibody against antigens of the G (Gross) system, and apparently to the deposition in the glomeruli of immune complexes of G natural antibody with G soluble antigen (GSA), type-specific antigen specified by wild-type Gross leukemia virus. G natural antibody and GSA are detectable in the acid-buffer eluate of the kidneys of NZB mice during the course of the glomerulonephritis. (NZB x NZW) F(1) hybrid mice develop glomerulonephritis and produce GSA and free G natural antibody earlier in life than do NZB mice. The proteinuria manifestation of the gomerulonephritis of (NZB x NZW) F(1) hybrid mice becomes increasingly prevalent as GSA undergoes immune elimination from the circulation. Gross leukemia virus-specified antigens together with bound immunoglobulins are located in the glomerular lesions of (NZB x NZW) F(1) hybrid mice, both in the mesangium as observed in NZB mice and also in the wall of the peripheral capillary loops of the glomeruli.

Aberrant high expression of B lymphocyte chemokine (BLC/CXCL13) by C11b+CD11c+ dendritic cells in murine lupus and preferential chemotaxis of B1 cells towards BLC.

We observed here that the expression of B lymphocyte chemokine (BLC/CXCL13) was markedly enhanced in the thymus and kidney in aged (NZB x NZW)F1 (BWF1) mice developing lupus nephritis, but not in similarly aged NZB and NZW mice. BLC-positive cells were present in the cellular infiltrates in the target organs with a reticular pattern of staining. CD11b+CD11c+ dendritic cells were increased in the thymus and spleen in aged BWF1 mice and identified as the major cell source for BLC. CD4+ T cells as well as B cells were dramatically increased in the thymus in aged BWF1 mice, whereas no increase was observed in aged NZB and NZW mice. B1/B2 ratio in the thymus was significantly higher than those in the spleen and peripheral blood in aged BWF1 mice. Interestingly, BLC showed preferential chemotactic activity for B1 cells derived from several mouse strains, including nonautoimmune mice. Cell surface CXCR5 expression on B1 cells was significantly higher than that on B2 cells. Thus, aberrant high expression of BLC by myeloid dendritic cells in the target organs in aged BWF1 mice may play a pivotal role in breaking immune tolerance in the thymus and in recruiting autoantibody-producing B cells in the development of murine lupus.

Risk-adjusted assessment of incidence and quantity of blood use in acute-care hospitals in Japan: an analysis using administrative data.

BACKGROUND AND OBJECTIVES: Continuous monitoring of blood use and feedback on transfusions are effective in decreasing inappropriate blood transfusions. However, traditional methods of monitoring have practical challenges, such as the limited availability of experts and funding. Administrative data including a patient classification system may be employed for risk-adjusted assessment of hospital-wide blood use. MATERIALS AND METHODS: We conducted an audit of blood use at two hospitals and determined proportions of appropriate blood use at each hospital. We then used administrative data of 587,045 cases provided by 73 hospitals to develop two mathematical models to calculate risk-adjusted use of blood products. The first model is a logistic regression model to predict the percentage of transfused patients. Patient demographics, surgery and diagnostic groups were utilized as predictors of transfusion. The second model is a case-mix adjusted model which predicts hospital-wide use of units of blood products from the distribution of diagnosis-related groups. For each model, the observed to expected (O/E) ratio of blood use in each hospital was calculated. We compared resultant ratios with proportions of appropriate blood use in two of the hospitals studied. RESULTS: Both models showed good prediction abilities. O/E ratios calculated using the two models were relevant to proportions of appropriate transfusions. CONCLUSIONS: Risk-adjusted assessments of blood product use based on administrative data allow hospital-wide evaluation of transfusion use. Comparing blood use between different hospitals contributes toward establishing appropriate transfusion practices.

[Papillary fibroelastoma of the tricuspid valve with mitral regurgitation].

We report a 64-year-old male patient with papillary fibroelastoma of the tricuspid valve associated with moderate mitral regurgitation. Echocardiography had revealed a 10 x 10 mm tumor attaching to the anterior tricuspid leaflet 3 years before. Because the tumor was enlarged to 19 x 15 mm, we excised it with a part of the anterior tricuspid leaflet, and performed tricuspid and mitral valvoplasty. The histological findings suggested papillary fibroelastoma. The postoperative course was uneventful.