Medical emergency education using a robot patient in a dental setting.

INTRODUCTION: In an ageing society, the frequency of medical emergencies in a dental setting appears to be increasing because of a growing number of medically compromised patients. However, we currently have no dental-specific simulation environment with advanced reproducibility for medical emergencies. Therefore, we used the robot patient in objective structured clinical examinations (OSCEs) for testing student competence in emergency management. This study aimed to evaluate student responses to medical emergencies in the dental setting. MATERIAL AND METHODS: We used 98 fifth-grade dental students at Showa University as subjects and implemented the OSCE task entitled 'Management of medical emergency using a robot patient'. Candidates were asked to manage an emergency situation immediately after local anaesthesia, with one robot patient configured to develop vasovagal syncope and the other to experience adrenaline hypersensitivity. A questionnaire on the educational value of the robot patient was completed after the examination. RESULTS: Thirty-two per cent of students could not accurately count her pulse because of an inappropriate method. Moreover, 78% could not correctly attach either the tonometer or pulse oximetry to the patient. Accurate diagnoses were given by only 22% of students, with vasovagal syncope diagnosed by 33% and adrenaline hypersensitivity by 8%. From a questionnaire, 78% of students recognised the usefulness of the robot patient in medical emergency training. CONCLUSION: We found that student responses to the emergency situation were poor. The robot patient is useful in dental education for medical emergency training and assessment not only for situation management but also for differential diagnosis.

Analysis of bone volume using computer simulation system for secondary bone graft in alveolar cleft.

The purpose of this study was to measure the bone volume necessary for secondary bone grafting in the alveolar cleft using surgical simulation software based on three-dimensional computed tomography (CT) scan data, to compare this measurement with the actual volume of the bone graft, and to evaluate consistency. The subjects were 13 patients with cleft lip and palate who underwent CT using a cone-beam CT unit (CB-CT) 1 month before surgery, followed by bone grafting with particulate cancellous bone and marrow (PCBM) to close the cleft. The bone volume necessary for grafting was measured based on the CB-CT scan data. Correlation analysis, a test of the population mean between two samples, and Wilcoxon's signed rank test were conducted between these measurements and the actual bone volume (PCBM volume) used for grafting. SPSS was used for statistical analysis, and the level of significance was set below the 5% level. The results showed a significant correlation, with no significant differences between the two in all tests. These results suggest that measuring and preoperatively calculating the bone volume necessary for bone grafting with surgical simulation software using CB-CT scan data is beneficial.

The effects of hydraulic pressure on atrial natriuretic peptide during rehabilitative head-out water immersion.

To study the hydraulic effects of subtotal immersion as a rehabilitative hydrotherapy, we examined the change in serum levels of atrial natriuretic peptide, catecholamine, cortisol and interleukins in 12 healthy volunteers. The subjects soaked in 42 degrees C water of 70 cm depth up to chin level in the upright seated position for 10 min. The serum level of atrial natriuretic peptide increased significantly 15 min after the start of subtotal immersion, though that of brain natriuretic peptide did not change. The serum dopamine level increased significantly 15 min after immersion, though neither the serum epinephrine nor norepinephrine levels did. In addition, 30 min after the start of immersion, the serum levels of atrial natriuretic peptide and dopamine decreased to those before immersion. The serum level of adrenocorticotropic hormone increased 15 min after immersion, though those of cortisol, interleukin-1beta and 6, and tumor necrotic factor-alpha did not change. It is suggested that 10-min head-out water immersion increased atrial natriuretic peptide partly due to increased venous return or right atrial load by hydraulic pressure.

Endosseous titanium implants as anchors for mesiodistal tooth movement in the beagle dog.

The purpose of this study was to determine the anchorage potential of titanium implants (Branemark; 3.75 x 7 mm) with the use of a sectional arch wire technique for orthodontic mesiodistal tooth movement, as assessed by the osseointegration of implants and tooth movement. Two implants were surgically placed in healed mandibular extraction sites of the second and third premolars on each side in 4 adult male beagle dogs. The implants were surgically uncovered 18 weeks later, and second-stage abutments with soldered edgewise tubes were attached. Segmented edgewise rectangular archwires (0.017 x 0. 025 inch) with a T-loop or an L-loop were placed between the implants and the fourth premolars on both sides as the anchorage unit. One segment in each dog served as a loaded side, and the archwire was calibrated to produce 200 g of lateral force on the fourth premolar. The contralateral segment served as an unloaded side and was not subjected to orthodontic force. Sectional wires were activated biweekly 24, 28, 28, and 32 weeks, respectively, depending on the magnitude and the appearance of mesial tipping movement of the fourth premolar. After mandibular impressions were taken to measure the distance between the first molar and the fourth premolar, the animals were euthanized and dissected mandibles were prepared. The specimens were then embedded in polyester resin and cut to take backscattered electron images. On the basis of these images, the percentage of peri-implant bone volume was calculated and defined as an index of osseointegration. The differences between the initial and final fourth premolar to first molar distances varied (7.40, 8.85, 10.50, and 3.30 mm) on the loaded side, whereas the unloaded side showed no movement. Not only was there no statistical difference in the percent of peri-implant bone volume between the loaded and unloaded sides, but there was also no statistical difference between the compression and tension sides in both loaded and unloaded implants, which suggests that the implants maintained rigid osseointegration. In conclusion, the present study demonstrated that endosseous titanium implants can function as anchors for long-term orthodontic mesiodistal movement.

Possible existence of platelet activation before the onset of cerebral infarction.

To study the existence of platelet activation before the onset of cerebral infarction, the ultrastructural features of platelets (7-day survival) and coagulation-fibrinolytic markers (70-100-min life span) were measured 2-12 h (acute phase), 7 days (subacute phase) and 6 months (chronic phase) after onset in 18 patients with cerebral infarction. Seven patients with atherosclerosis but without cerebral infarction and eight healthy subjects were studied as controls. Ultrastructural study included folds, pseudopods, vacuoles and centralization in addition to immunochemical staining such as platelet peroxidase and fibrinogen. Furthermore, beta-thromboglobulin, platelet factor-4, thrombin antithrombin complex and alpha(2)-plasmin inhibitor plasmin complex were examined as coagulation-fibrinolytic markers. Ultrastructural study of circulating platelets demonstrated no difference between acute and chronic phases and little difference between cerebral infarction and atherosclerosis, although plasma coagulation-fibrinolytic markers showed an increase in cerebral infarction at the acute phase but no difference among the chronic phase of cerebral infarction, atherosclerosis and normal healthy subjects. It is considered that shape change in circulating platelets was caused by pre-existed atherosclerosis rather than the thrombotic event itself though coagulation-fibrinolytic markers were derived from the thrombotic event.

Breathing out into water during subtotal immersion: a therapy for chronic pulmonary emphysema.

OBJECTIVE: To determine the importance of a breathing out into water exercise during subtotal immersion for emphysematous patients. DESIGN: Results of a respiratory function test and arterial blood gas analysis were examined to compare the programs of breathing exercise with and without the breathing out into water exercise. The breathing exercises in a pool filled with 38 degrees C water were performed 30 min/day, 5 days/wk, for 2 mo in 17 patients with stable chronic emphysema. Patients were randomly assigned to breathing exercise programs including subtotal water immersion with the nose and mouth either immersed (9 patients) or out of the water (8 patients) during exhalation. RESULTS: The ratio of %forced expired volume in 1 sec to forced vital capacity and %forced vital capacity at rest were significantly increased in the program with the breathing out into water exercise, but they did not change in the program without the breathing out into water exercise. A significant increase in peak flow was observed in the former program, although it did not change in the latter program. The maximal expiratory flow at 25% did not change in either program. Pao2 was significantly increased and Paco2 was significantly decreased in the former program, although a trend for a decrease in Paco2 was observed in the latter program. CONCLUSIONS: These results suggest that the breathing out into water exercise enhances the effects of a breathing exercise during immersion and is useful in rehabilitation for chronic pulmonary emphysema.

Effects of physical therapy on cytokines and two color analysis-lymphocyte subsets in patients with cerebrovascular diseases.

The effects of physical therapy on immunological parameters were evaluated in 12 patients (8 males and 4 females, 69.2 +/- 9.0 years) with cerebrovascular diseases in a stable situation two to three months after the onset of stroke who entered in our hospital between 1994 and 1997. After a two-month physical therapy program, the proportions of helper-inducer T (Thi) cells and suppressor-inducer T (Tsi) cells were increased significantly and that of cytotoxic T (Tc) cells was decreased, although those of HLA-DR+, suppressor T (Ts) and activated T (Tac) cells were not changed. The antibody dependent cellular cytotoxicity (ADCC) was significantly increased, although natural killer (NK) cell activity was not changed. The serum levels of interleukin-2 receptor was significantly increased but those of interleukin-2, interleukin-6 and interleukin-12 were not changed. The serum levels of interleukin-10, interleukin-12 and tumor necrosis factor-alpha were not detectable, while interleukin-1beta was decreased in 2 patients and interleukin-10 was increased in 2 patients. These findings suggest that daily physical exercise may activate the immune system possibly through the cytokine network in patients with cerebrovascular diseases (CVD).

Clinical analysis of breathing exercise during immersion in 38 degrees C water for obstructive and constrictive pulmonary diseases.

Breathing exercises during immersion in 38 degrees C water were performed in 22 patients with bronchial asthma, pulmonary emphysema and constrictive pulmonary diseases. The patients entered a pool filled with 38 degrees C water to shoulder level. While standing, they breathed in deeply and breathed out slowly through the mouth into water while sinking the nose below the water level. This breathing method was repeated for 20 min. with a 5-min. rest out of water and this cycle was performed twice a day for two months. Respiratory function test and arterial blood gas analysis were examined before and after the two-month exercise program. FEV1.0% was significantly increased in patients with asthma and emphysema (p = 0.042 and 0.032, respectively) but did not change in patients with constrictive pulmonary diseases. %FVC, PF and Vmf25 did not change in any of the diseases. PaO2 was significantly increased in emphysematous patients (p = 0.0002) and PaCO2 was significantly decreased in asthmatic and emphysematous patients (p = 0.034 and 0.046, respectively). These results suggest that our breathing exercise by immersion is useful in patients with asthma and emphysema but is less effective in patients with constrictive pulmonary diseases.

Prognostic value of morphological classifications and clinical variables in elderly and young patients with multiple myeloma.

The prognostic value of morphological classifications and clinical variables was compared between 31 elderly (> or = 65 years) and 43 young (< 65 years) patients with myeloma. Prognostic factors were divided into three groups: factors useful in elderly patients, e.g., calcium, albumin; factors useful in young patients, e.g., platelet, creatinine, light-chain type; and factors useful in both patients, e.g., clinical stage, hemoglobin, LDH, CRP, bone marrow plasma cell and plasmablast percentages, light- and electron-microscopic classifications. The 5-year survival rates of elderly patients with calcium < 12 and > or = 12 mg/dl were 66.2 and < 11.1%, respectively (p<0.01). Those of the young patients were 64.1 and 33.3%, respectively. The 5-year survival rates of elderly patients with platelets > or = 200 x 10(9)/l and < 100 x 10(9)/l were 59.7 and 50.0%, respectively. Those of the young patients were 68.9 and 33.3%, respectively (p<0.05). The 5-year survival rates of elderly patients with few and numerous electron-microscopic abnormalities were 90 and 0%, respectively (p<0.01), those of young patients were 92.9 and < 14.3%, respectively (p<0.01). These findings suggest that individual clinical variables may differ in prognostic importance in elderly and young patients.

[The role of protein kinases and phosphatases in erythroid colony formation of elderly].

Using H-7, HA1001, FK506, cyclosporin A (CsA) and okadaic acid (OA), which are protein kinase and phosphatase inhibitors, we examined qualitative changes in hematopoietic precursor cells due to aging from the viewpoint of the role of protein kinases and phosphatases. Though H-7 and OA suppressed erythroid colony formation both in the elderly (age: 72-92, median: 86) and the young (age: 22-39, median: 29), no change due to aging was noted. HA1001 did not affect erythroid colony formation either in the elderly or the young. Erythroid colony formation was enhanced by FK506 and CsA in the young, however, erythroid colony formation was suppressed in the elderly. Similar examinations using cell fractions of non-T, non-macrophage, non-T + T, and CD34 positive cells were performed in both groups. Enhancement of erythroid colony formation in the young and suppression in the elderly by FK506 using unseparated MNC disappeared after removal of T cells. Enhancement of colony formation in the young and suppression of colony formation in the elderly were recovered when T cells were added again. The effects of FK506 and CsA on erythroid colony formation were thought to be the results of T cell inactivation, and the different sensitivity to FK506 and CsA in the elderly and young seemed to be the result of changes in the control mechanisms of hematopoiesis, such as the regulation of cytokine production by T cells, caused by aging.

Improvement in ejection fraction by hydrotherapy as rehabilitation in patients with chronic pulmonary emphysema.

BACKGROUND AND PURPOSE: It has been reported that breathing exercise by immersion in combination with expiring into water improved pulmonary function and blood-gas exchange in patients with chronic obstructive pulmonary disease (COPD). This effect may result from respiratory muscle exercise against hydraulic pressure and decreased dead space by increased sub-abdominal pressure. Increased cardiac function by bathing is suggested to contribute to the effect. To clarify the effect of the breathing exercise by immersion on cardiac function, a study was made of cardiac function during the exercise in patients with emphysema. METHOD: Echocardiography, respiratory function test and arterial blood gas analysis were performed during a two-month breathing exercise programme in a pool filled with 38 degrees C water for 12 patients (aged 70.9 +/- 9.1 years) with stable chronic pulmonary emphysema who were treated at our hospital between 1993 and 1996. The patients breathed in whilst standing in a pool and breathed out through the mouth while sinking the nose under water. This exercise was repeated for 30 min per day and continued for six days a week for two months. RESULTS: The ejection fraction increased significantly after each 30-minute exercise (N = 12; p < 0.01) as well as after the two-month exercise programme (N = 12, p < 0.05). Left ventricular end-diastolic and systolic dimensions at rest decreased significantly after the two-month exercise programme (N = 12, p < 0.01). The ratio of forced expired volume in one second to forced vital capacity (FEV1:FVC) increased and PaCO2 decreased following this programme (N = 12, p < 0.05). CONCLUSIONS: These results suggest that the breathing exercise by immersion is useful not only in treating emphysema but also in improving cardiac function.

Acute idiopathic thrombocytopenic purpura presenting a high serum level of immunoglobulin E and eosinophilia in an elderly patient.

An 80-year-old Japanese woman having acute idiopathic thrombocytopenic purpura presented with an increased serum level of IgE and eosinophilia. No evidence for allergic, parasitic, collagen or malignant diseases was observed. The disease subsided with prednisolone therapy and she has been in remission for three years. Our case is one of the oldest ITP patients with increased IgE and eosinophilia.

[Relationship between ultrastructure of myeloma cells and clinical features in elderly patients with multiple myeloma].

The relationship between the ultrastructure of plasma cells and clinical features was analyzed in 54 patients with multiple myeloma: 20 elderly patients (9,8 and 3 cases of IgG, IgA and BJP types, respectively; 5,3 and 12 cases in clinical stage I, II and III, respectively) and 34 young patients (16, 10, 1 and 7 cases of IgG, IgA, IgD and BJP types, respectively; 5, 10 and 19 cases in clinical stage I, II and III, respectively). Five-year survival rates of the elderly and young groups were 41.5 and 60.5%, respectively, though the difference of both survival curves was not significant. Response rates of initial therapy in the elderly and young groups were 55 and 56%, respectively (not significant). The number of patients presenting disarrangement of organelles was significantly larger in the elderly group, but those presenting other abnormal structures were equal between both groups. The ratios of dense body, intramitochondrial granules and multilamellar body in bone marrow plasma cells were significantly higher in nonresponders than in responders of the elderly group. The ratios of disarrangement of organelles, single sac loop-like structure and intramitochondrial granules in bone marrow plasma cells were significantly higher in nonresponders than in responders of the young group. It is suggested that the ultrastructure of plasma cells in multiple myeloma differs between elderly and young patients and is useful in predicting the respective clinical features, although drug responses and survival curves do not show a significant difference.

Comparison of three protocols for breathing exercises during immersion in 38 degrees C water for chronic obstructive pulmonary disease.

Respiratory function test, arterial blood gas analysis, and ejection fraction were used to compare three protocols of breathing exercises during immersion in 38 degrees C water. Therapy was given for 2 mo to patients with stable chronic obstructive pulmonary disease. Protocol A consisted of a total exercise period of 20 min/wk (10 min/day, 2 days/wk) and was performed by 7 patients (5 cases of asthma and 2 cases of emphysema). Protocol B consisted of a total exercise period of 120 min/wk (20 min x 2 per day at 10:00 am and 3:00 pm, 3 days/wk) and was performed by 9 patients (6 asthmas and 3 emphysemas). Protocol C consisted of a total exercise period of 120 min/wk (20 min/day, 6 days/wk) and was performed by 8 patients (4 asthmas and 4 emphysemas). The ratio of forced expired volume in one second to forced vital capacity (FEV1.0%) was significantly increased in protocols B and C (P < 0.01). The ratio of forced vital capacity to the predicted normal value (%FVC) was not changed in any of the three protocols. A significant increase in peak flow was observed in protocols B and C (P < 0.05). The maximal expiratory flow at 25% (V25) was not changed in any of the three protocols. PaO2 was significantly increased and PacO2 was significantly decreased in protocol B (P < 0.01 and P < 0.05, respectively), whereas only PaCO2 was significantly decreased in protocol C (P < 0.05). Ejection fraction was increased in protocols B and C. These results suggest that exercise for a total period of 120 min/wk is preferable to that of 20 min/wk in COPD.

Clinical analysis of the prognostic value of ultrastructural abnormalities of plasma cells in patients with multiple myeloma.

The prognostic value of ultrastructural abnormalities of plasma, cells was analyzed in 61 patients with multiple myeloma treated in our hospitals from 1985 to 1996. The survival curves demonstrated significant differences by stratification of ultrastructural abnormalities, such as irregular contour of the nuclear membrane, nuclear body, budding, disarrangement of organelles, fibrillar formation, intramitochondrial granules, multilamellar body, single-sac loop-like structure, and vacuole. However, categorizing by nuclear inclusion body, cytoplasmic inclusion body and dense body showed no significant difference in survival curves. Abnormalities, as well as maturity, may be useful in predicting the prognosis of myeloma patients.

Treatment of refractory cases of atopic dermatitis with acidic hot-spring bathing.

The incidence of refractory atopic dermatitis has increased in teenagers and young adults. The purpose of this study was to control the skin symptoms of such patients in daily life. Seventy patients repeatedly took a 10-min 42 degrees C acidic hot-spring bath twice daily. The skin symptoms were improved in 76% of cases. In 30 of 42 responders examined Staphylococcus aureus, detected on the skin surface, disappeared or decreased through balneotherapy. In contrast, S. aureus remained unchanged in 8 of 10 non-responders examined. Thus, the balneotherapy using acidic hot-spring water may be useful for controlling the skin symptoms of acute flares of refractory cases of atopic dermatitis.

Effects of hyperthermal stress on the ultrastructure of platelets with reference to the localization of platelet peroxidase and fibrinogen in vivo.

Ultrastructure of platelets with the localization of platelet peroxidase and fibrinogen through 3-min 47 degrees C hot-spring bathing was investigated in eight healthy volunteers. The mean sublingual temperature rose about 1.8 degrees C 5 min after the start of bathing. The frequencies of fold, pseudopods, vacuoles, and centralization were increased after bathing. Platelet peroxidase activity was decreased after bathing. Furthermore, fibrinogen was decreased in alpha-granules after bathing. Thus, hyperthermal stress in vivo may activate platelets, resulting in consumption of platelet peroxidase and fibrinogen.

Ultrastructure of myeloma cells producing parathyroid hormone-related peptide.

We examined the ultrastructure of myeloma cells producing parathyroid hormone-related peptide. The nucleus was mature and the cytoplasm was well-developed, being classified into the mature type with slight nucleo-cytoplasmic asynchrony. Although various nuclear and cytoplasmic abnormalities commonly observed in myeloma cells were recognized, a multilamellar body-like structure which has not been reported previously in myeloma cells was characteristically observed. Numerous nuclear and cytoplasmic abnormalities observed in the myeloma cells of this case were considered to have resulted from increased and aberrant proliferation of myeloma cells. We reported previously that the immature nucleus and various nuclear and cytoplasmic abnormalities are related to poor prognosis. Thus, the ultrastructural findings of myeloma cells in this case is not inconsistent with the short survival time.

Effective physical therapy for chronic obstructive pulmonary disease. Pilot study of exercise in hot spring water.

Respiratory function and arterial blood gas were examined before and after a two-month exercise program performed in a pool filled with hot spring water in 22 patients (70.9 +/- 9.1 years of age) with stable chronic obstructive pulmonary disease (12 cases of bronchial asthma and 10 cases of pulmonary emphysema) treated at our hospital between 1991 and 1994. The ratio of forced expired volume in one second to forced vital capacity (FEV1%) was significantly increased after the exercise program (P < 0.05), whereas the ratio of forced vital capacity to predicted normal value (%FVC) did not change. In addition, a tendency toward an increase in peak flow without an increase in maximum expiratory flow at 25 and 50% (V25 and V50) was observed. Although PaO2 was not increased, PaCO2 was selectively decreased by the exercise program (P < 0.05). The changes in respiratory function and arterial blood gas were considered attributable to respiratory muscle training and small airway clearance. Exercise in a pool filled with hot spring water may be useful in treating chronic obstructive pulmonary disease.