Assessment of Cesarean hysterotomy scar in non-pregnant women: reliability of transvaginal sonography with and without contrast enhancement.

OBJECTIVES: To determine intra- and interobserver reliability of evaluating the appearance and measurement of Cesarean hysterotomy scars using transvaginal ultrasound (TVS), with and without saline contrast sonohysterography (SCSH), in non-pregnant women. METHODS: Fifty-six women with one previous Cesarean delivery were examined by TVS, with and without contrast enhancement, 6-9 months after the Cesarean delivery. Two observers, blinded to their own and each other's measurements, evaluated the appearance of the hysterotomy scar and measured the myometrial thickness adjacent to the scar or scar defect (MTS). If a scar defect was noted, the remaining myometrial thickness over the defect (RMT) was measured. A scar defect was defined as large if RMT was ≤ 2.2 mm on conventional TVS and ≤ 2.5 mm when SCSH was performed. Intra- and interobserver reliability of conventional TVS and SCSH were assessed. RESULTS: Intraobserver reliability was good, with intraclass correlation coefficients (ICCs) of ≥ 0.97 for measurements of MTS and RMT on conventional TVS and SCSH. Interobserver ICCs for measurements obtained on SCSH were 0.85 (95% CI, 0.76-0.91) for MTS and 0.96 (95% CI, 0.93-0.98) for RMT, compared with 0.82 (95% CI, 0.72-0.89) for MTS and 0.87 (95% CI, 0.68-0.95) for RMT measured on conventional TVS. The kappa coefficient for measurements obtained on SCSH was 0.92, compared with 0.85 for conventional TVS. Intermethod ICC was 0.86 (95% CI, 0.78-0.92) for measurement of MTS and 0.89 (95% CI, 0.78-0.95) for measurement of RMT, with a kappa coefficient of 0.57. CONCLUSIONS: Measurement of RMT using SCSH is a reliable method for assessing Cesarean hysterotomy scars in non-pregnant women and can be used in clinical practice. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

More rapid shift to a benthic niche in larger Gadus morhua juveniles.

Trophic use by Atlantic cod Gadus morhua juveniles was examined early and late in the shift from pelagic to benthic habitats. Changes in the proportion of pelagic copepods, estimates of benthic prey indicated by isotope mixing models and stable-isotope values between sample periods suggested a gradual shift towards a benthic niche. Values of the trophic proxies, however, changed most markedly in the largest juvenile group, suggesting a more rapid trophic niche shift, and in turn competitive advantage, of larger juveniles.

Permanent Genetic Resources added to the Molecular Ecology Resources Database 1 February 2010-31 March 2010.

This article documents the addition of 228 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Anser cygnoides, Apodemus flavicollis, Athene noctua, Cercis canadensis, Glis glis, Gubernatrix cristata, Haliotis tuberculata, Helianthus maximiliani, Laricobius nigrinus, Laricobius rubidus, Neoheligmonella granjoni, Nephrops norvegicus, Oenanthe javanica, Paramuricea clavata, Pyrrhura orcesi and Samanea saman. These loci were cross-tested on the following species: Apodemus sylvaticus, Laricobius laticollis and Laricobius osakensis (a proposed new species currently being described).

Continuous ST-segment monitoring of patients with left bundle branch block and suspicion of acute myocardial infarction.

OBJECTIVES: Patients with left bundle branch block comprise 5-9% of all patients with acute myocardial infarction. Limited data exist on the usefulness of continuous electrocardiographic monitoring of these patients. We have investigated prospectively the usefulness of real-time continuous vectorcardiography for monitoring patients with left bundle branch block and suspicion of acute myocardial infarction. DESIGN: A prospective multi-centre study. SETTING: Fourteen Swedish coronary care units. SUBJECTS: Patients with left bundle branch block and suspicion of acute myocardial infarction with <6-h symptom duration were included. MAIN OUTCOME MEASURES: All patients were monitored with continuous vectorcardiography for 12-24 h. RESULTS: One hundred thirty-three patients were included, 47% had acute myocardial infarction. Patients with acute myocardial infarction showed a marked relative decrease in ST-vector than those without (P = 0.0002). These changes were most marked in the first 90 min. When comparing patients with acute myocardial infarction receiving thrombolytic therapy or not, those treated with thrombolytics showed more marked decline in ST-vector magnitude (P < 0.0001) and in shorter time (P = 0.0017). All patients showed STC-vector magnitude changes that were more marked in patients with acute myocardial infarction (P = 0.0002). An STC-vector magnitude cut-off value of 65 microV after 90 min of monitoring gave 54% sensitivity and 72% specificity for diagnosis of acute myocardial infarction. CONCLUSION: Real-time continuous vectorcardiographic monitoring of patients with left bundle branch and suspicion of acute myocardial infarction shows significant differences between those with and without acute myocardial infarction and could be of use for early diagnosis and subsequent monitoring.

Blood redistribution in the fetal brain during chronic hypoxia.

BACKGROUND: Studies on blood flow velocity in the fetal middle cerebral artery have revealed signs of brain sparing in chronic hypoxia. These signs of brain sparing can disappear in the terminal case, but whether this applies to the whole brain or only parts of it is unknown. METHODS: Velocity waveforms of the middle cerebral, anterior cerebral and posterior cerebral arteries were recorded in 221 pregnancies complicated by pregnancy-induced hypertension. The presence of brain sparing (pulsatility index < 2 standard deviations) was noted and correlated to outcome of pregnancy, including emergency operative intervention and/or neonatal distress. RESULTS: Signs of brain sparing in the anterior cerebral artery were found in 90 fetuses, and in the middle cerebral and posterior cerebral arteries in 52 and 65, respectively. Signs of brain sparing in the anterior cerebral artery showed the strongest relationship to adverse perinatal outcome. The anterior cerebral artery was the only vessel in which signs of brain sparing were predictive of perinatal mortality. CONCLUSIONS: Velocimetry of the anterior cerebral artery appears to be superior to that of the middle cerebral and posterior cerebral arteries as a means to predict adverse perinatal outcome. Anterior cerebral artery brain sparing may therefore be less transitory than sparing in the middle cerebral and posterior cerebral arteries, possibly suggesting that the frontal lobes are spared longer than the lateral and occipital regions of the fetal brain.

Septic arthritis caused by Chryseobacterium meningosepticum in an immunocompetent male.

This is the first report of septic arthritis of the knee caused by Chryseobacterium meningosepticum. The infection was associated with a penetrating injury to the joint. The patient was cured by flushing of the joint and antibiotic treatment.

Sinusitis due to Stenotrophomonas maltophilia.

This is the first report of a patient diagnosed with sinusitis due to Stenotrophomonas maltophilia. Despite the organism being resistant to trimethoprim-sulfamethoxazole, the infection was cured by drainage and treatment with intravenous piperacillin, followed by oral ciprofloxacin.

ECG criteria in diagnosis of acute myocardial infarction in the presence of left bundle branch block.

BACKGROUND: The diagnosis of acute myocardial infarction in the presence of left bundle branch block is difficult. Recently a diagnostic ECG scoring system was suggested, showing good diagnostic abilities. This scoring system has never been tested in a prospective manner; we have done so and investigated if it might bear prognostic information. METHODS: A prospective multi-centre study. Consecutive patients with left bundle branch block and suspicion of acute myocardial infarction, admitted to 14 Swedish coronary care units. Recruitment from March 1996 to December 1997. ECG registered on admission and after 12-24 h. RESULTS: One hundred and fifty-eight patients were included, mean age 74.9 years. Seventy-six patients (48%) had an acute myocardial infarction. The proposed cut-off total score of > or = 3 of the ECG scoring system for the diagnosis of acute myocardial infarction had a sensitivity of 17.1% (95% CI 8.6-25.6%) and specificity of 94.0% (95% CI 88.9-99.1%). Clinical judgement of acute myocardial infarction resulted in a sensitivity of 15.8% (95% CI 7.6-24%) and specificity of 96.0% (CI 92.3-100%). No difference was seen in 3-month or 1-year survival between those with total ECG score > or = 3 versus total score < 3. CONCLUSION: The diagnostic abilities of the proposed ECG criteria are low and not better than the clinical judgement. The criteria are therefore not suitable for screening patients with suspicion of acute myocardial infarction in the presence of left bundle branch block, nor do they seem to identify high risk patients.

[Brachytherapy with palladium-103--a new way to deliver radiation therapy for localized prostatic cancer]. / Brakyterapi med palladium-103--nytt sätt att strålbehandla lokaliserad prostatacancer.

The incidence of prostate cancer is increasing and, due to the use of PSA, more and more patients are diagnosed with localized disease. These patients may be offered treatment with the intent to cure. Traditionally, this has been either by radical prostatectomy or some form of radiation therapy. This article describes the minimally invasive method with permanent seed implantation. The procedure, indications, contraindications, side effects and results from the literature 28 patients have been treated so far with acceptable proximate side effects and reductions in serum-PSA as expected.

Dissociation and unfolding of cold-active alkaline phosphatase from atlantic cod in the presence of guanidinium chloride.

Cold-adaptation of enzymes involves improvements in catalytic efficiency. This paper describes studies on the conformational stability of a cold-active alkaline phosphatase (AP) from Atlantic cod, with the aim of understanding more clearly its structural stability in terms of subunit dissociation and unfolding of monomers. AP is a homodimeric enzyme that is only active in the dimeric state. Tryptophan fluorescence, size-exclusion chromatography and enzyme activity were used to monitor alterations in conformational state induced by guanidinium chloride or urea. In cod AP, a clear distinction could be made between dissociation of dimers into monomers and subsequent unfolding of monomers (fits a three-state model). In contrast, dimer dissociation of calf AP coincided with the monophasic unfolding curve observed by tryptophan fluorescence (fits a two-state model). The DeltaG for dimer dissociation of cod AP was 8.3 kcal.mol-1, and the monomer stabilization free energy was 2.2 kcal.mol-1, giving a total of 12.7 kcal.mol-1, whereas the total free energy of calf intestinal AP was 17.3 kcal.mol-1. Thus, dimer formation provided a major contribution to the overall stability of the cod enzyme. Phosphate, the reaction product, had the effect of promoting dimer dissociation and stabilizing the monomers. Cod AP has reduced affinity for inorganic phosphate, the release of which is the rate-limiting step of the reaction mechanism. More flexible links at the interface between the dimer subunits may ease structural rearrangements that facilitate more rapid release of phosphate, and thus catalytic turnover.

A method to evaluate the in vivo behaviour of lumbar spine implants.

The aim of the study was to design a method for evaluating the stabilizing effect of different lumbar spine implants in vivo, and to apply this method to a comparison of plates versus rods in lumbar spine posterolateral fusion using transpedicular screw fixation. Fourteen patients, seven operated on with transpedicular plates and screws (VSP), and seven operated on with rods and screws (Diapason), matched according to number of levels fused, had tantalum markers inserted in the vertebrae at surgery, enabling roentgen stereophotogrammetric analysis (RSA). Mean patient age was 45 (range 33-56) years. In each group, two patients underwent fusion between L4 and L5, three between L5 and S1, and two from L4 to S1. In three patients, concomitant nerve root decompression was performed using a facet joint preserving technique. RSA was performed 4 weeks after surgery. This interval was chosen to allow enough time for soft tissue healing, but not fusion healing, to occur. RSA was performed in supine and standing position without any mobility provocation, in line with the postoperative regimen given. Movements between the outermost vertebrae of the fusion were calculated along the transverse, vertical and sagittal axes. The method of measurement along these three axes has previously been determined to be accurate to 0.3, 0.6 and 0.7 mm, respectively. One patient stabilized with rods and screws between L5 and S1 displayed a sagittal translation of 1.01 mm but no mobility along the transverse or vertical axes. In the remaining 13 patients, positional change from supine to standing did not provoke any intervertebral mobility above the RSA accuracy along any of the axes. With the limited provocation described, in line with the postoperative regimen for lumbar fusion patients, plates with transpedicular screws and rods with transpedicular screws both seem to give adequate intervertebral stability in posterolateral lumbar fusions.

Genomic, transcriptional and mutational analysis of the mouse microphthalmia locus.

Mouse microphthalmia transcription factor (Mitf) mutations affect the development of four cell types: melanocytes, mast cells, osteoclasts, and pigmented epithelial cells of the eye. The mutations are phenotypically diverse and can be arranged in an allelic series. In humans, MITF mutations cause Waardenburg syndrome type 2A (WS2A) and Tietz syndrome, autosomal dominant disorders resulting in deafness and hypopigmentation. Mitf mice thus represent an important model system for the study of human disease. Here we report the complete exon/intron structure of the mouse Mitf gene and show it to be similar to the human gene. We also found that the mouse gene is transcriptionally complex and is capable of generating at least 13 different Mitf isoforms. Some of these isoforms are missing important functional domains of the protein, suggesting that they might play an inhibitory role in Mitf function and signal transduction. In addition, we determined the molecular basis for six microphthalmia mutations. Two of the mutations are reported for the first time here (Mitf(mi-enu198) and Mitf(mi-x39)), while the others (Mitf(mi-ws), Mitf(mi-bws), Mitf(mi-ew), and Mitf(mi-di)) have been described but the molecular basis for the mutation not determined. When analyzed in terms of the genomic and transcriptional data presented here, it is apparent that these mutations result from RNA processing or transcriptional defects. Interestingly, three of the mutations (Mitf(mi-x39), Mitf(mi-bws), and Mitf(mi-ws)) produce proteins that are missing important functional domains of the protein identified in in vitro studies, further confirming a biological role for these domains in the whole animal.

Bundle branch block and acute myocardial infarction. Treatment and outcome.

OBJECTIVE: To study early diagnosis, treatment and outcome in patients with bundle branch block and clinically suspected acute myocardial infarction. DESIGN: A prospective multicenter study including 14 Swedish coronary care units. The study included 257 consecutive patients with bundle branch block and clinical suspicion of acute myocardial infarction. RESULTS: Left bundle branch block was present in 62% of patients and right bundle branch block in 38%. Thrombolytic treatment of acute myocardial infarction in the left and right bundle branch block was 16% and 36%, respectively. Of those undergoing thrombolytic therapy, 20% of patients with left and 13% with right bundle branch block did not develop an acute myocardial infarction. Patients with left bundle branch block had higher mortality rates than those with right bundle branch block. After one year there was no difference in mortality rates between patients with and those without acute myocardial infarction on admission. CONCLUSION: Patients with bundle branch block and suspected acute myocardial infarction receive suboptimal treatment. Thus better diagnostic regimes are needed to identify those patients with bundle branch block and acute myocardial infarction who are suitable for thrombolytic treatment.

Venous Doppler velocimetry in relationship to central venous pressure and heart rate during hypoxia in the ovine fetus.

OBJECTIVE: Characteristic changes in ductus venosus (DV) blood velocity and pulsations in the umbilical vein (UV) have been described during imminent fetal asphyxia. The aim of this study was to examine fetal venous blood velocity in relationship to pressure gradient across the DV during hypoxia in a fetal lamb preparation. METHODS: In general anesthesia, a cesarean section was performed on seven pregnant ewes, the fetus was exteriorized and put into a heated waterbath with uninterrupted umbilical circulation. Pressure measurements in the UV and inferior vena cava (IVC) were performed with the catheter tips on both sides of the DV. Fetal hypoxemia was induced by giving the ewe 12% oxygen in inhaling air. Pressure across the DV and Doppler velocimetry were repeatedly measured during hypoxemia. Blood velocity was recorded in the DV and UV by Doppler ultrasound. RESULTS: Before hypoxia the median pressure gradient across the DV was in systole 1 mmHg and 0.31 mmHg in end-diastole and during hypoxemia 1.5 mmHg and zero, respectively. The pressure difference across the DV was constant during hypoxemia irrespective of the presence of umbilical venous pulsations or heart rate. IVC-pressure was greatly influenced by fetal heart rate (FHR). A small but linear fall in systolic IVC pressure was seen with increasing FHR. In end-diastole the IVC pressure changed in a parabolic fashion, with increasing pressure during brady- and tachycardia. Pulsations in the UV also showed a parabolic relationship to FHR and central venous pressure. DV end-systolic and end-diastolic blood velocity changed during hypoxemia in direct relationship to FHR and central venous pressure, but without direct relationship to fetal blood gases. CONCLUSION: The pressure gradient across the DV is constant during hypoxemia. Changes in central and umbilical venous pressure are directly related to FHR. Umbilical venous and DV blood velocity changed in direct relationship to FHR and central venous pressure.

Stability of lumbar fusion with transpedicular fixation determined by roentgen stereophotogrammetric analysis.

STUDY DESIGN: An evaluation of the intervertebral stability of transpedicular instrumentation in posterolateral lumbar fusions by roentgen stereophotogrammetric analysis. OBJECTIVES: To determine the in vivo intervertebral stability of posterolateral lumbar fusions augmented with transpedicular screws and plates. SUMMARY OF BACKGROUND DATA: Transpedicular bone screw systems have been found to be as safe and clinically effective as other types of devices in stabilizing surgery of the spine. Many experimental studies have yielded basic data on the stabilizing implant effect in vitro, but the exact in vivo stabilizing effect on human lumbar vertebrae has not been presented previously. METHODS: In 12 patients, the intervertebral stability of posterolateral fusion in the lower lumbar spine augmented with transpedicular screws and plates was evaluated by serial roentgen stereophotogrammetric analysis with the patients in supine and erect positions 1 year after surgery. RESULTS: Screws in each fused vertebra yielded stable fixation or permitted sagittal intervertebral translations smaller than 1 mm induced by the positional change. A widely decompressed and destabilized vertebra without screw fixation yielded persisting intervertebral translations. CONCLUSIONS: The current study demonstrated the adequacy of in vivo stability of lumbar fusions augmented with transpedicular screws and plates. Sagittal translation seems easier to elicit than movements along the other three-dimensional axes. A widely decompressed and destabilized vertebra without screw fixation increases the risk for persisting intervertebral translations. The roentgen stereophotogrammetric analysis technique described seems to be a good way of comparing the in vivo behavior of different implant systems.

Diagnosis of acute myocardial infarction in patients with chronic left bundle-branch block. Standard 12-lead ECG compared to dynamic vectorcardiography.

Standard 12-lead electrocardiogram (ECG) criteria were evaluated and compared with dynamic vectorcardiography for diagnosing acute myocardial infarction in 33 patients with chronic left bundle-branch block. In 14 patients a clinical diagnosis of acute myocardial infarction was made, but it was found that none of the seven most promising ECG criteria suggested in the literature could alone or in combination diagnose acute myocardial infarction. QRS vector difference evolution showed the same kind of pattern as that for patients with narrow QRS-complex. By using a predefined specific pattern, a diagnostic accuracy of 79% was achieved. The results indicate that dynamic vectorcardiography is a better tool for diagnosing and monitoring acute myocardial infarction in patients with left bundle-branch block than standard 12-lead ECGs taken on admission and after 12-24 h.

[Herpes simplex esophagitis in immunocompetent individuals.].

OBJECTIVE: Infections by herpes simplex viruses (HSV) are common but esophageal involvement is relatively rare. It is most frequently diagnosed in immunocompromized patients. We describe four healthy, young men with HSV esophagitis and review the literature on the subject. MATERIAL AND METHODS: The diagnosis of HSV esophagitis was considered likely if three out of four of our criteria were met but definite if all four were fulfilled. IgM and IgG against HSV was measured with two different ELISAs. Viral culture was done in Vero and A-549 cells. Virus typing was done with ELISA. Histopathological exam was performed. A MEDLINE search of HSV esophagitis among otherwise healthy individuals was performed and the literature reviewed. RESULTS: Four young, healthy men were diagnosed with HSV esophagitis in 1997. Diagnosis was likely in two cases and definite in two. One patient was initially suspected of heart disease and another of gallbladder disease. All four patients were proven to have primary infection, were hospitalized, given intravenous hydration and treated with acyclovir. A MEDLINE search revealed 12 other cases of HSV esopha notgitis in otherwise healthy individuals. Including all 16 cases, the age ranged from 18 to 50 years (mean age 26 years). There were two women and 14 men. The most frequent symptom was odynophagia (69%). Eight patients (50%) had fever but only six (37.5%)had lesions in skin and/or mucosa on examination. Esophageal ulcers or inflammation were detected in all patients. The changes were in the distal esophagus (13/16), in the middle (2/16) or the entire organ (1/16). HSV-1 was cultured from 10 patients. Viral inclusions were seen in esophageal samples from eight patients. HSV antibodies were measured in 10 patients, six of which were proven to have primary infection. CONCLUSIONS: HSV esophagitis is rare in otherwise healthy individuals but probably underdiagnosed. Most cases are young men. Clues to the diagnosis such as visible lesions in skin or mucosae are frequently not present. Vigilance and endoscopy with biopsies and culture is needed for an accurate diagnosis.

Diagnosis of acute myocardial infarction in patients with chronic right bundle-branch block using standard 12-lead electrocardiogram compared with dynamic vector cardiography.

The aim of the study was to evaluate standard 12-lead electrocardiogram (ECG) criteria and to compare them with dynamic vector cardiography in patients with chronic right bundle-branch block for diagnosing acute myocardial infarction. We used standard 12-lead ECGs recorded on admission and after 12-24 h and compared them with dynamic vector cardiography with trend analysis during the first 12 h. In patients with right bundle-branch block, ST segment changes occurred in the same way as for patients with narrow QRS complexes. By adding 4 h of continuous vector cardiographic monitoring we were able to identify patients with acute myocardial infarction with a high diagnostic accuracy.

Cerebral Doppler blood flow velocimetry and central hemodynamics in the ovine fetus during hypoxemia-acidemia.

The purpose of this study was to assess the effects of hypocapnic hypoxia, acidemia and the combination of hypoxia/acidemia on blood flow velocity variables in the fetal cerebral circulation. Chronically instrumented fetal sheep were used and the ewes were induced to breathe a hypoxic gas mixture for about 90 min. This caused an initial period of hypoxemia followed by a period of mixed hypoxemia/acidemia. When the ewe was reoxygenated, the fetus experienced a period of normoxic acidemia. The fetal cerebral circulation was assessed by recording Doppler blood flow velocity waveform variables in a cerebral vessel and the umbilical artery, using standard ultrasound equipment. External carotid artery blood flow was maintained during hypoxic and hypoxic/acidotic periods despite a fall in cardiac output. In the cerebral vessel, mean maximum velocity (time-averaged maximum velocity), minimum diastolic velocity and maximum systolic velocity manifested increases during hypoxic and hypoxic-acidotic periods, but pulsatility index did not change due to the effect of reduced heart rate on pulsatility index. Umbilical artery pulsatility index increased in the hypoxic and hypoxic-acidotic periods, despite unchanged mean maximum velocity, minimum diastolic velocity and maximum systolic velocity. With acute hemodynamic changes, the measurement of pulsatility index can yield misleading results. For clinical and experimental research on the fetal cerebral circulation, more attention should be paid to the individual Doppler variables, especially to the mean maximum velocity, than to the pulsatility index alone. Changes in mean maximum velocity recorded from the cerebral artery seem to reflect changes in the cerebral arterial flow.

[Analysis of antibiotic utilization review at Landspitalinn, the University Hospital in Iceland.].

OBJECTIVE: To describe the application of and analyze the cost effects of antibiotic utilization review at Landspitalinn, the National University Hospital in Iceland, and review the use of prophylactic antibiotics in a general surgical ward. MATERIAL AND METHODS: The study was undertaken during a two month period in 1996. Patients in wards 11-A and 11-B (general medical floors), ward 12-G (general surgery service) and 11-E (hematology service) were enrolled. A specialist in infectious diseases and a clinical pharmacist reviewed the antibiotic treatment daily. If felt appropriate a recommendation to change treatment was forwarded. The number of patients treated with antibiotics, recommendations, recommendations accepted, and types of suggestions were recorded. Minimal savings per day were calculated by subtracting the cost of the antibiotic treatment after recommended modifications from the cost of the previous treatment. Prophylactic surgical treatment was examined in ward 12-G during an additional month. RESULTS: One hundred and fifty patients were treated with antibiotics during January and February 1996. The percentage of cases where changes in antibiotic treatment was recommended was 74% in 12-G, 65% in 11-E but 33% and 32% in 11-A and 11-B respectively. In ward 11-E, 80% of the recommendations were accepted and appropriate changes made, corresponding figures for the other wards were 93-100%. The most frequently recommended changes were stopping antibiotics (33%), reducing doses (31%) and switching to oral agents (19%). The minimum savings were estimated at ISK 210 000 per month if the effects of recommendations that were accepted were presumed to have lasted three days. Four percent of prescribed prophylactic surgical treatment was according to approved standards. CONCLUSIONS: The results confirm the need to optimize the use of antibiotics at The National University Hospital. The antibiotic utilization review was well received and acceptance of recommendations was high. The application of antibiotic utilization review to the entire hospital could reduce antibiotic cost by as much as 30-36%.