Community pharmacy-level factors associated with medical and nursing home facility collaboration in Japan.

The aim of this study was to clarify the community pharmacy-level factors related to experiences of and attitudes toward collaboration with medical and nursing home care facilities. We conducted a postal questionnaire survey of all pharmacies in Gifu, Japan, assessing the experiences and attitudes of supervising pharmacists regarding the following activities related to collaboration between medical facilities and nursing home care facilities: regional care meetings/service adjustment meetings, case discussion conferences, joint workshops/continuing education conferences, community service, information sharing through medical cooperation networks, and pharmacists accompanying physicians on home care visits. The factors significantly related to inter-professional collaboration were the family pharmacist guidance fee and the number of patients offered pharmaceutical care through cooperation with other medical facilities. Items on attitudes toward collaborating with other medical facilities showed similar results. Overall, policies that support inter-professional collaboration to create a foundation, establish mechanisms to facilitate collaboration, and identify collaborative activities that can be carried out at each pharmacy should be developed.

Comparison of dynamic contrast-enhanced MRI parameters of breast lesions at 1.5 and 3.0 T: a pilot study.

OBJECTIVE: To compare dynamic contrast-enhanced (DCE) MRI parameters from scans of breast lesions at 1.5 and 3.0 T. METHODS: 11 patients underwent paired MRI examinations in both Philips 1.5 and 3.0 T systems (Best, Netherlands) using a standard clinical fat-suppressed, T1 weighted DCE-MRI protocol, with 70-76 s temporal resolution. Signal intensity vs time curves were fit with an empirical mathematical model to obtain semi-quantitative measures of uptake and washout rates as well as time-to-peak enhancement (TTP). Maximum percent enhancement and signal enhancement ratio (SER) were also measured for each lesion. Percent differences between parameters measured at the two field strengths were compared. RESULTS: TTP and SER parameters measured at 1.5 and 3.0 T were similar; with mean absolute differences of 19% and 22%, respectively. Maximum percent signal enhancement was significantly higher at 3 T than at 1.5 T (p = 0.006). Qualitative assessment showed that image quality was significantly higher at 3 T (p = 0.005). CONCLUSION: Our results suggest that TTP and SER are more robust to field strength change than other measured kinetic parameters, and therefore measurements of these parameters can be more easily standardized than measurements of other parameters derived from DCE-MRI. Semi-quantitative measures of overall kinetic curve shape showed higher reproducibility than do discrete classification of kinetic curve early and delayed phases in a majority of the cases studied. ADVANCES IN KNOWLEDGE: Qualitative measures of curve shape are not consistent across field strength even when acquisition parameters are standardized. Quantitative measures of overall kinetic curve shape, by contrast, have higher reproducibility.

Pressure overload per se rather than cardiac angiotensin converting enzyme activity may be important in the development of rat cardiac hypertrophy.

OBJECTIVE: To investigate the roles of the renin-angiotensin system and blood pressure in cardiac hypertrophy caused by a pressure overload. METHODS: Cardiac hypertrophy was induced by constricting the abdominal aorta above the renal arteries. After they had been banded, the rats were treated with the lower (1 mg/kg per day) or the higher (10 mg/kg per day) dose of quinapril [an angiotensin converting enzyme (ACE) inhibitor], or the lower (1 mg/kg per day) or the higher (10 mg/kg per day) dose of TCV-116 [an angiotensin II (AngII) AT1 receptor antagonist], for 4 weeks. Then, we measured the mean blood pressure (MBP), body weight, left ventricular weight (LVW), and serum and cardiac ACE activities. RESULTS: The higher dose of quinapril and that of TCV-116 prevented left ventricular hypertrophy and MBP elevation. Both the higher and the lower doses of quinapril reduced the serum and cardiac ACE activities significantly, whereas the higher dose of TCV-116 reduced the cardiac ACE activity and increased the serum ACE activity. The lower dose of quinapril, however, exerted no significant effect on MBP and the LVW:body weight ratio, although it reduced the cardiac and serum ACE activities significantly. There was a significant positive correlation between the MBP and the LVW:body weight ratio regardless of the cardiac ACE activity in data from all groups (r = 0.676, P < 0.0001). CONCLUSIONS: Our data indicate the importance of the blood pressure as a determinant of cardiac hypertrophy because inhibition of cardiac ACE activity alone without lowering of the blood pressure is insufficient to prevent cardiac hypertrophy. Our results suggest the presence of other pathways for AngII production not mediated by ACE, or growth factors other than AngII in pressure-overload cardiac hypertrophy.

Insulin increases distinct species of 1,2-diacylglycerol in isolated perfused rat heart.

Insulin and glucose increase the synthesis of 1,2-diacylglycerol (1,2-DAG), the physiological activator of protein kinase C (PKC) in a variety of tissues and cells. The effects of insulin and glucose on the abundance and fatty acid composition of 1,2-DAG were investigated in isolated perfused rat hearts with the use of capillary gas chromatography and 1,2-dipentadecanoin as an internal standard. A high concentration of insulin (25 mU/ mL) significantly increased cardiac contractility and reduced coronary flow. In addition, perfusion with 25 mU/mL insulin induced significant increases of 18.2% and 26.4% in 1,2-DAG mass after 5 and 30 minutes, respectively, in the presence of 8.6 mmol/L glucose, whereas there was no increase in 1,2-DAG with 2.5 mU/mL insulin. Analysis of the fatty acid composition of 1,2-DAG showed that only species containing specific fatty acids (16:0, 18:1, and 18:2) were increased in response to insulin. In contrast, an increase in glucose concentration in the perfusion medium from 3 to 17 mmol/L had no effect on the total mass or fatty acid composition of 1,2-DAG, cardiac contractility, or coronary flow. Addition of a high insulin concentration to the high-glucose medium increased the abundance of 1,2-DAG containing 16:0, 18:1, and 18:2 fatty acids, as well as cardiac contractility. It is concluded that the effect of insulin on cardiac contractility may be related to the associated increase in 1,2-DAG abundance.

Short-term treatment with prostaglandin E1 analogue has long-term preventive effects on intimal thickening in balloon-injured rat carotid arteries.

We examined effects of a prostaglandin E1 analogue alprostadil on intimal thickening and arterial remodeling in balloon-injured rat carotid arteries. Right common carotid arteries were balloon-injured, and their left counterparts were sham-operated (uninjured). Rats were given alprostadil (0.3 microgram/kg/min, continuous subcutaneous (s.c.) infusion) or vehicle for 1 week after the injury and sacrificed at 4 weeks or 8 weeks. Segments of common carotid arteries corresponding to balloon-injured and uninjured sites were excised and subjected to elastica van Gieson staining. Cross-sectional areas were measured by computed planimetry. Alprostadil prevented intimal thickening at both 4 and 8 weeks. In addition, alprostadil prevented the increase in intimal area/area surrounded by external elastic lamina at both 4 and 8 weeks. Alprostadil had no effects on body weight, heart rate, or systolic blood pressure. Our study demonstrated that alprostadil administered only for the initial 1 week had long-term (up to 8 weeks) preventive effects on intimal thickening. Alprostadil may be useful to prevent restenosis after balloon angioplasty.

[Clinical study of continuous local arterial-infusion chemotherapy for severely advanced hepatocellular carcinoma (HCC) using reservoir].

We attempted continuous local arterial-infusion chemotherapy using reservoir for patients with severely advanced hepatocellular carcinoma (HCC), with no indications for operation, PEIT or TAE because of the advanced clinical stage, Vp-factor, and so on. Twenty-two HCC patients were given continuous arterial-infusion of 5-FU + CDDP and were observed for 36-443 days from June, 1991 to December, 1992. Until the end of 1992, we had 3 partial response (PR) cases and 3 progressive disease (PD) cases, and the other cases showed no change (NC). Except for a case in which therapy was stopped because of renal failure, no patients were disturbed by side effects, and 68.2% of the patients completed all of their therapy as outpatients. Because CDDP can amplify the effect of 5-FU in addition to its own effect as a biochemical modulator, and because continuous infusion can strengthen the effect of 5-FU and reduce the side effects of CDDP, we consider continuous local arterial-infusion of 5-FU and CDDP to be an effective therapy for severely advanced HCC. This treatment does not cure the carcinoma but helps to slow its progress and assure good QOL.

[A case of a patient with sternocostoclavicular hyperostosis complaining of severe chest pain, which must be distinguished from cardiovascular disease].

We report a case of a patient complaining of severe chest pain which required a differential diagnosis between cardiovascular disease and sternocostoclavicular hyperostosis. The patient was a 61-year old male who began experiencing pain across both scapulas at the end of September, 1990. He was admitted to our hospital when the pain extended to the back and anterior chest areas. Examination on admission revealed inflammation with a white blood cell count at 11,800/mm3, an erythrocyte sedimentation rate of 136 mm/hr, and CRP at 14.2 mg/dl. Angina pectoris was suspected based on findings from coronary arteriography which showed 60% stenosis at Seg 6. A Ga-scintigram conducted to determine the cause of the chest pain revealed accumulations in the upper mediastinum. CT and MRI both showed hyperostosis of the sternum, and bone scintigram confirmed marked accumulations in the same area. Palmoplantar pustulosis (PPP) was also clearly noted on the palms and soles of the feet. Sternocostoclavicular hyperostosis was diagnosed based on these findings. Sternocostoclavicular hyperostosis was suspected in this case based on the clinical findings, inflammatory state, and accumulations revealed by bone scintigraphy. However, the diagnosis could have been more conclusive if non-suppurative hyperosteostic osteomyelitis were observed by bone biopsy. A differential diagnosis for unknown sources of chest pain should be considered in cases such as this.

Characterizing early contrast uptake of ductal carcinoma in situ with high temporal resolution dynamic contrast-enhanced MRI of the breast: a pilot study.

Improvements in the reliable diagnosis of preinvasive ductal carcinoma in situ (DCIS) by dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) are needed. In this study, we present a new characterization of early contrast kinetics of DCIS using high temporal resolution (HiT) DCE-MRI and compare it with other breast lesions and normal parenchyma. Forty patients with mammographic calcifications suspicious for DCIS were selected for HiT imaging using T(1)-weighted DCE-MRI with ∼7 s temporal resolution for 90 s post-contrast injection. Pixel-based and whole-lesion kinetic curves were fit to an empirical mathematical model (EMM) and several secondary kinetic parameters derived. Using the EMM parameterized and fitted concentration time curve for subsequent analysis allowed for calculation of kinetic parameters that were less susceptible to fluctuations due to noise. The parameters' initial area under the curve (iAUC) and contrast concentration at 1 min (C(1 min)) provided the highest diagnostic accuracy in the task of distinguishing pathologically proven DCIS from normal tissue. There was a trend for DCIS lesions with solid architectural pattern to exhibit a negative slope at 1 min (i.e. increased washout rate) compared to those with a cribriform pattern (p < 0.04). This pilot study demonstrates the feasibility of quantitative analysis of early contrast kinetics at high temporal resolution and points to the potential for such an analysis to improve the characterization of DCIS.

Japanese healthcare system: in vitro diagnostic tests and reimbursements.

In 1961, a new and mandatory National Health Insurance plan was enacted in Japan. This healthcare system has succeeded in providing universal coverage while also containing the growth of national medical expenditures (NME) to the rate of growth of the gross national product (GNP), namely, approximately 4-5% annually, for several decades. All Japanese medical procedures, including dental procedures, prescription drugs, and diagnostic tests, are reimbursed by a fee schedule set by the Ministry of Health and Welfare. The combination of strict fee control and low administration costs has kept the Japanese NME growth below that of the GNP. In 1990, NME was 20.6 trillion yen ($187 billion), total diagnostic testing expenditures (DTE) were 2.3 trillion yen, representing 11.2% of national medical expenditures (NME). Of this amount, in vitro diagnostic testing accounted for 1.4 trillion yen, representing 61% of DTE and 6.8% of NME. Annually, 1.8 billion in vitro diagnostic tests are performed.

[A case report of epithelioid hemangioendothelioma of the lung].

A 15-year-old woman presented with an abnormal chest X-ray taken at a medical check up. Her chest X-ray disclosed multiple nodular shadows in bilateral lung fields. A transbronchial biopsy was non-diagnostic and an open biopsy was performed. The tumor was histologically diagnosed as epithelioid hemangioendothelioma on the basis of associated with immunoreactivity to factor-VIII related antigen by immunohistochemistry and the presence of Weibel-Pallade bodies on electron microscopy. She has been followed-up in her home town without significant change.

Clinical significance of no-reflow phenomenon observed on angiography after successful treatment of acute myocardial infarction with percutaneous transluminal coronary angioplasty.

The clinical significance of the angiographic no-reflow phenomenon was evaluated in 93 patients with acute myocardial infarction treated by percutaneous transluminal coronary angioplasty (PTCA). On the basis of the post-PTCA angiograms, patients were divided into three groups: normal angiogram (group 1, n = 65), slight no-reflow (group 2, n = 13), and severe no-reflow (group 3, n = 15). Regional wall motion in the chronic phase was depressed in groups 2 and 3 compared with group 1. The proportion of the area of the transmural infarction to that of the total infarction determined by scintigraphy was higher in groups 2 and 3 than in group 1. A significantly higher incidence of myocardial rupture and of death resulting from cardiac causes was observed in group 3 compared with group 1. The severity of this phenomenon immediately after an emergency PTCA correlated well with the severity of myocardial damage, with patients having severe no-reflow showing the poorest prognosis.

Characteristics of prehospital cardiac arrest patients in Japan and determinant factors for survival.

Two hundred forty-seven consecutive patients who had prehospital cardiac arrest and were transferred to a municipal hospital were studied to elucidate the characteristics of these patients and to investigate factors for improving the survival rate among prehospital cardiac arrest patients. Detailed information on 130 patients with cardiac etiology was analyzed: 110 were confirmed dead in the emergency department (group A); 14 survived less than 1 week (group B); 6 survived longer than 1 week (group C). Only one patient received cardiopulmonary resuscitation (CPR) from a bystander, and none received electrical defibrillation before arriving at hospital because, at the time, emergency personnel were not allowed to perform advanced life support (ALS) in Japan. The three characteristics for better prognosis after prehospital cardiac arrest were found to be as follows: being witnessed on collapse, receiving prompt ALS, and ventricular fibrillation on arrival at hospital. The survival rate would have been higher if more lay people could have performed CPR and if emergency unit personnel had been allowed to perform ALS.