Objective: The purpose of this study was to clarify the importance of therapeutic drug monitoring (TDM) at acute care hospitals using Diagnosis Procedure Combination (DPC) data.
Methods: We used DPC data from about 3,500,000 inpatients at about 950 acute care hospitals.  The investigation period was from July 2010 to December 2010.  Patients were divided into 2 groups: TDM intervention (n=22,012); and non-TDM intervention (n=26,400).  We compared the clinical indicators (length of hospital stay, payment based on performance and drug costs) and use of antimicrobials.
Results: TDM intervention was carried out in 45.5% patients for whom an anti-MRSA agent was prescribed.  The duration of anti-MRSA agent administration was significantly longer in the TDM intervention group than in the non-TDM intervention group.  The total daily cost of anti-MRSA agents was significantly lower in the TDM intervention group than in the non-TDM intervention group.
Conclusion: Our results suggest that TDM intervention is often performed for seriously ill patients who require continuous treatment.  TDM intervention may prevent adverse reactions as a result of adjusting the dosage of the anti-MRSA agent.

When serious emergency patients come to a 3rd-level emergency hospital, they are able to obtain optimal medical treatment for their condition. However, the emergency room of general hospitals are extremely crowded with many kinds of patients, ranging from 1st-to 3rd-level emergencies. Thus, a good training program in triage is necessary for emergency medicine doctors because of the risk of inappropriate management of patients.
In this study, we examined the number of 2nd-and 3rd-level emergency patients who came to our emergency room initially as walk-in 1st-level emergency patients in 1991 and 1992. Our results indicate that the education for emergency medicine doctors needs to cover a wide range of medical fields dealing with 1st-to 3rd-level emergency patients, and that ideal training in emergency medicine must be organized in hospitals that accept 1st-to 3rd-level emergency patients.

BACKGROUND: Prior research indicates that patients with medically unexplained symptoms and doctorshopping behavior are more likely to have psychological distress. In patients with somatic symptoms, we hypothesized that high scores on COOP/WONCA Functional Assessment Charts, in addition to the presence of medically unexplained symptoms and doctor-shopping behavior, might have an important role in diagnosing psychological distress.
METHODS: Between November 2002 and March 2003, the patients who presented themselves to the hospital for the first time with somatic symptoms were enrolled in this study. In this study, we defined psychological distress as disease conditions, including Mood disorders, Anxiety disorders, Adjustment disorders, and Somatoform disorders, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth edition (DSM-IV) . Symptoms that, in the doctor's judgment, could not be medically explained were regarded as medically unexplained symptoms. Doctor shopping was defined as those patients with a complaint of sustained and unsolved symptoms for more than one month who had visited two or more medical facilities prior to visiting our hospital and arrived without any physician's referral.
RESULTS: One hundred and six patients out of 496 were diagnosed as having psychological distress. Among these 106 patients, 49 (46.2%) had doctorshopping behavior, 86 (81.1%) had medically unexplained symptoms, and 95 (89.6%) showed high scores on COOP/WONCA charts. Odds ratios and 95% confidence intervals of medically unexplained symptoms and doctor shopping were 24.12 (11.91-48.84) and 4.18 (2.16-8.07), respectively. High scores on COOP/WONCA charts 2, 3 and 6 were significantly associated with the presence of psychological distress, and the odds ratios (95% confidence intervals) of these three items were 1.41 (1.01-1.98), 1.41 (1.02-1.94), and 2.88 (1.68-4.95), respectively.
Positive and negative likelihood ratios for 4 items (i.e., age of not less than 45 years; duration of symptoms of not less than 6 months, ; doctorshopping behavior; and, medically unexplained symptoms) were 1.16 and 0.85; 1.43 and 0.55; 3.16 and 0.63; and, 3.96 and 0.24, respectively. Positive and negative likelihood ratios for high scores on COOP/WONCA charts were 1.42 and 0.28. Under ROC curves for the diagnosis of psychological distress, the information of COOP/WONCA charts, in addition to that of clinical data, medically unexplained symptoms, and doctor shopping behavior, increased the accuracy in diagnosing psychological distress.
CONCLUSIONS: In patients with somatic symptoms, COOP/WONCA charts increased diagnostic accuracy in predicting psychological distress when patients showed sustained symptoms for more than 6 month, doctor shopping, and medically unexplained symptoms.

Background: There has been debate over the indications for percutaneous endoscopic gastrostomy (PEG) in recent years in Japan. In addition, the level of satisfaction of patients and patient’s family after PEG remains unclear. The aim of this study was to investigate the current status of PEG and the level of satisfaction of patients and patients’ families after PEG in Japan.
Methods: We reviewed the existing data of all patients who underwent PEG tube insertion at Yuri Kumiai General Hospital (Akita, Japan) between February 2000 and December 2010. We examined the following points: underlying diseases requiring PEG, levels of consciousness, and performance status. We also sent a questionnaire to the patients and patient’s families to ask about their satisfaction with and thoughts about PEG.
Results: The data of 545 patients who underwent PEG were reviewed. There were 295 men and 250 women, with a mean age of 77.2 ± 11.4 years. PEG was indicated most frequently for cerebrovascular disorders (48.2%, 239/545). There were 515 (94.4%, 515/545) patients showing consciousness disturbance and 444 (81.5%, 444/545) bedridden patients. The questionnaire was answered by one patient himself and 316 patients’ families. When asked, “Was performing PEG a good decision?”, 57.5% (182/316) of the patients’ families answered yes. Meanwhile, when patients’ family members were asked if they would wish to undergo PEG if they were in the same condition as the patient, 28.4% (90/316) answered yes, whereas 55.3% (175/316) answered no.
Conclusions: Few patients were able to make their own decision about PEG tube placement because of consciousness disturbance. As a result, many family members of the patients did not want to experience PEG for themselves. Future studies should be performed to clarify the quality of life and ethical aspects associated with PEG.

Chylorrhea is a rare complication after cardiothoracic surgery, occurring in 0.5-2% of patients. It is extremely rare after coronary artery bypass grafting. The initial management of chylorrhea is conservative, but if it is unsuccessful, surgical intervention is indicated. Recently, some cases treated with octreotide have been reported. We report two cases of chylorrhea after internal thoracic artery harvest treated with octreotide.

Objective: Owing to the recent advances in genetic analysis technology, its application in drug development is expected to increase, although there are concerns regarding the leakage of personal information.  This study aimed to assess the attitudes of community citizens toward genetic analysis studies associated with clinical trials planned by the pharmaceutical industry.
Methods: A questionnaire survey was conducted after an educational seminar on drug development at a university campus festival.  Answers were obtained from 47 citizens (16 males and 31 females, ages ranging from teens to fifties).
Results: Attitudes toward providing genome samples were assessed using a 100-mm visual analogue scale, and the data revealed significant differences in the conditions of sample use (A, limited to specific genes during the trial, 89±14 mm; B, limited to genes related to the test drug or target disease, 81±23 mm; C, unlimited, 71±33 mm, p<0.01).  Twenty-seven citizens (57%) consistently expressed acceptance toward all three conditions.  The remaining 38% (n=18) expressed denial as the analysis targets widened.  Regarding the acceptable period for sample storage, 17 citizens (36%) allowed “indefinite storage” but 14 citizens (30%) requested “immediate disposal after analysis.”  A feedback on the accidental findings of abnormalities was requested by 43 citizens (91%).
Conclusion: The results demonstrated a wide variety of attitudes toward providing samples.  On the other hand, most citizens requested a feedback on the findings of abnormalities for disease-related genes.  These results suggest that it is necessary to improve the study protocol to reflect these fears and expectations.

Effects of hypothermia on corticoidogenesis (CG) were investigated in primary cultured bovine adrenocortical cells. In order to evoke CG, adrenocorticotropic hormone (ACTH), dibutyryl cyclic AMP (db-cAMP), and high K⁺ were used. In the presence of the above mentioned secretagogues, cells were incubated at 37°C, 27°C, and 20°C for 1 hour. Although there was no difference between the ACTH-induced CGs at 37°C and 27°C, CG was significantly lower at 20°C. Both db-cAMP and high K⁺-induced CGs were significantly lower at 27°C, and were not observed at 20°C.
These results indicate that CG is not affected by moderate hypothermia, and is not eliminated even by deep hypothermia. It is also suggested that ACTH influences not only adenylate cyclase and Ca²⁺ channels, but also various processes of glucocorticoid production and could evoke CG at 20°C in bovine adrenocortical cells.

Risk factors for stroke after coronary artery bypass grafting (CABG) were assessed. We retrospectively investigated 681 consecutive patients who underwent isolated, first-time CABG at our institute between 1987 and 1998. Ninety-eight patients (14%) had a history of preoperative stroke. They tended to be older and with a higher incidence of peripheral vascular disease (PVD) than those without preoperative stroke. In spite of several techniques for prevention of postoperative stroke, such as the aortic non-touch technique, 14 patients (2.0%) suffered postoperative stroke. Postoperative stroke was diagnosed soon after surgery in 7 patients (50%), and the causes of stroke in these patients seemed to be intraoperative manipulation of the ascending aorta in 5, and hypoperfusion during cardiopulmonary bypass in two. Stroke in the remaining 7 patients occurred after normal awakening from anesthesia, and the cause was unknown. We then compared the patients with postoperative stroke (n=14) to those without postoperative stroke (n=667). Statistical analysis demonstrated no significant difference between the two groups in variables such as history of preoperative stroke, duration of cardiopulmonary bypass, and prevalence of PVD. Four (29%) of the patients with postoperative stroke died, due mainly to aspiration pneumonia. The morbidity and mortality of the patients who suffered postoperative stroke were very high.

Tissue engineering and bone regeneration techniques using mesenchymal stem cells (MSCs) have started to be applied to the field of oral and maxillofacial surgery. Clinically, a shortened treatment time and improved efficiency are necessary because of the patients' needs and the running cost of cell culture. In the present study, the cultivation process for human MSCs (hMSCs) was examined by regulating the Wnt signaling pathway. We activated Wnt signaling with LiCl and inhibited Wnt signaling with sFRP-3 (secreted Frizzled-Related Protein-3). The proliferation of LiCl-treated hMSCs was examined by studying the cell growth rate and performing BrdU assays. Osteogenic differentiation of sFRP-3-treated hMSCs was examined by alizarin red staining, and osteogenic gene expression on days 7 and 14 after induction was examined by reverse-transcription polymerase chain reaction (RT-PCR) analysis and quantitative real-time RT-PCR analysis. LiCl-treated hMSCs showed increased cell numbers and BrdU-positive cells as compared to the untreated cells. Alizarin red staining showed early mineralization of hMSCs on day 7 of the sFRP-3 treatment. A high expression level of the alkaline phosphatase gene on days 7 and 14 of sFRP-3 treatment was also demonstrated. These results suggest that the regulation of the Wnt signaling pathway contributes to the increased cell numbers and the early osteogenic differentiation of hMSCs. This study supports the possibility that the regulation of the Wnt signaling pathway contributes to the development of effective and efficient bone regeneration techniques.

This study was performed to clarify the analgesic effect of ketamine injected into the first intercoccygeal (Co1-Co2) epidural space in standing cattle. Five adult cows were randomly received 3 treatments at least 1 week interval: 5, 10 and 20 mL of 5% ketamine. Sedation, analgesia, ataxia and other effects on cardiopulmonary and rumen functions were assessed before ketamine administration and until 120 min. The analgesia without sedation was shown at tail and perineum about 5 min after all three treatments. The duration of analgesia was significantly increased according to the volume of ketamine (p < 0.01). There was a similar tendency of ataxia with individual variation. There were minimal effects on cardiopulmonary and rumen functions. The present study showed that caudal epidural ketamine administration induced analgesia without sedation in cows, and the duration of analgesia was dose dependent with ataxia. However, the duration of analgesia after 5 and 10 mL ketamine administration is short for common surgical procedures and pain relief of perineum. Further studies are needed to prolong the duration of analgesia without side effects.
Analgesia, Epidural/*veterinary ; Analgesics/*administration & dosage ; Animals ; Blood Pressure/drug effects ; Body Temperature/drug effects ; Cattle/*physiology ; Female ; Heart Rate/drug effects ; Ketamine/*administration & dosage ; Respiration/drug effects ; Rumen/metabolism