Real-world data on efficacy/safety and economic impact of nivolumab administered every 2 and 4 weeks among Japanese patients

AIM

A new treatment interval for nivolumab administration at 480 mg every 4 weeks, in addition to 240 mg every 2 weeks, was approved in Japan in 2020. Using model-based evaluation, it was speculated that the effects or safety of nivolumab do not differ between the two treatment intervals; however, real-world data on nivolumab efficacy, safety, and economic impact are lacking. Accordingly, we aimed to examine the effects of nivolumab treatment intervals (2 weeks vs. 4 weeks) in terms of efficacy, safety, and economic impact in Japanese patients with cancer.

METHODS

We retrospectively analyzed 126 patients treated with nivolumab. The patients were divided into two groups depending on whether they received nivolumab at 240 mg every 2 weeks (2-week group) or 480 mg every 4 weeks (4-week group).

RESULTS

Efficacy results found no significant difference between the 4- and 2-week groups considering median overall survival (p = 0.70) and median progression-free survival (p = 0.57). The incidence of any grade and ≥  grade 3 immune-related adverse events did not differ between the 4-week and 2-week groups (any grade, p = 0.13; ≥  grade 3, p = 0.36). Excluding drug costs, the 4-week group had significantly lower medical costs than the 2-week group (2-week vs. 4-week: mean, 94,659 JPY [679.0 USD] vs. 58,737 JPY [421.3 USD]; p < 0.05).

CONCLUSION

Collectively, our findings suggest that nivolumab 480 mg every 4 weeks may be more effective than nivolumab 240 mg every 2 weeks in terms of economic impact.

Eosinophil may be a predictor of immune-related adverse events induced by different immune checkpoint inhibitor types: A retrospective multidisciplinary study

BACKGROUND

Immune checkpoint inhibitors (ICIs) can cause severe immune-related adverse events (irAEs). However, biomarkers for irAEs common to different types of ICIs and cancers have not been reported. This study examined whether eosinophils can be used as a predictor of irAEs.

METHODS

Six hundred fourteen patients with cancer (esophageal, gastric, head and neck, lung, melanoma, renal cell, urothelial, and other cancer) received anti-PD-1, anti-PD-L1, or anti-CTLA-4 plus anti-PD-1 therapy. The patients were divided into two groups depending on whether they experienced irAEs (irAE group) or not (non-irAE group). Eosinophils were examined before the two-course treatment.

RESULTS

Patients in the irAE group who received anti-PD-1 or anti-CTLA-4 plus anti-PD-1 therapy had higher eosinophils before the two-course treatment than those in the non-irAE group (p < 0.05). The eosinophils in the anti-PD-L1 therapy group tended to increase in the irAE group. Furthermore, eosinophils in gastric, head and neck, lung, melanoma, renal, and urothelial cancers were significantly higher in the irAE group than in the non-irAE group (p < 0.05). The optimal cutoff value for eosinophils against irAEs was 3.0% (area under the curve = 0.668). In multivariate analyses, eosinophils of ≥3.0% were an independent factor for irAEs (odds ratio: 2.57, 95% CI: 1.79-3.67).

CONCLUSION

An increased eosinophil before the two-course treatment may be a predictor of irAEs in various cancers treated with different ICIs.

Hemoglobin and neutrophil levels stratified according to International Metastatic Renal Cell Carcinoma Database Consortium risk predict the effectiveness of ipilimumab plus nivolumab in patients with advanced metastatic renal cell carcinoma

OBJECTIVE

To identify biomarkers associated with the effectiveness of ipilimumab plus nivolumab against advanced metastatic renal cell carcinoma.

METHODS

We retrospectively analyzed the data of 75 patients treated with ipilimumab plus nivolumab at seven hospitals between August 2018 and April 2021. Prognostic biomarkers were assessed prior to initiating treatment with ipilimumab plus nivolumab. Median overall survival and progression-free survival were examined using the Kaplan-Meier method. Univariate and multivariate analyses were performed to identify predictors of disease progression. The International Metastatic Renal Cell Carcinoma Database Consortium (IMDC) risk factors most important for predicting disease progression were determined using classification and regression tree analysis.

RESULTS

Median overall survival and progression-free survival were longer in the intermediate IMDC risk group than in the poor IMDC risk group (overall: not reached vs. 18.3 months; progression-free: not reached vs. 13.5 months). The multivariate analysis identified poor IMDC risk as a risk factor for disease progression (hazard ratio 2.61, 95% confidence interval: 1.05-6.51). Based on the results of the classification and regression tree analysis, the cohort was divided into non-anemia, anemia + neutro-Low, and anemia + neutro-High groups. Median overall survival and progression-free survival were longer in the non-anemia and anemia + neutro-Low groups than in the anemia + neutro-High group (overall: not reached vs. 29.3 months vs. 4.3 months: progression-free: not reached vs. 29.0 months vs. 3.9 months).

CONCLUSION

Hemoglobin and neutrophil levels may represent crucial biomarkers for predicting the effectiveness of ipilimumab plus nivolumab therapy in patients with renal cell carcinoma.

GNRI sustainability during one cycle of first-line chemotherapy as a prognostic indicator in patients with metastatic urothelial carcinoma

INTRODUCTION

This study evaluated the prognostic value of a sustained high geriatric nutritional risk index (GNRI) during first-line chemotherapy for patients with metastatic urothelial carcinoma (mUC).

METHODS

Between January 2018 and February 2022, 123 patients received platinum-based chemotherapy at Nagoya City University Hospital and affiliated institutions. Of these, 118 eligible patients that showed an Eastern Cooperative Oncology Group performance status (ECOG-PS) between 0 and 2 were retrospectively examined. Based on body mass index and serum albumin levels, GNRI was calculated immediately before and after the first primary chemotherapy cycle. Patients were divided into two groups based on GNRI: GNRI sustained  92 in sustainable (n=63), and GNRI < 92 in unsustainable (n=55) groups, respectively. Clinical outcomes were compared.

RESULTS

No significant differences were noted between the two groups including for age, gender, cycle of first-line treatment, and type of series of sequential treatments after failure of first-line therapy. Median overall survival from the start of first-line chemotherapy was 30.2 months (95% confidence interval [CI]: 20.9-NA) for sustainable and 12.6 months (95% CI: 9.0-21.2) for unsustainable groups, respectively (p < 0.05). Multivariate analysis identified ECOG-PS:2 and fatigue, an adverse event, as independent predictors of unsustainable GNRI transition (95% CI: 1.29-90.6, odds ratio [OR]: 10.8; 95% CI: 1.06-26.9, OR: 5.34, respectively). Conclusion/Conclusion: Sustaining a high level of GNRI was an important prognostic indicator in patients with mUC receiving first-line chemotherapy. Appropriate intervention for controlling adverse events, including fatigue, may enhance physical strength during cancer treatment.

Simultaneous LC-MS analysis of plasma concentrations of sildenafil, tadalafil, bosentan, ambrisentan, and macitentan in patients with pulmonary arterial hypertension

Phosphodiesterase-5 (PDE-5) inhibitors and endothelin receptor antagonists (ERAs) are standard therapies for pulmonary arterial hypertension (PAH). The inter-individual variability of these pharmacokinetics is reported remarkably large, and therapeutic drug monitoring (TDM) can be useful to improve the likelihood of the desired therapeutic and safety outcomes. This study aimed to develop a LC-MS method to determine the concentrations of five PAH drugs (PDE-5 inhibitors: sildenafil and tadalafil, ERAs: bosentan, macitentan, and ambrisentan) from plasma samples using a simple process followed by a single mass spectrometric run, and to validate this approach through pharmacokinetic analyses in patients. A solid extraction method was used for sample preparation of the drugs from human plasma. The total run time for a single injection was within 10 min. The calibration curves for all drugs were linear, and the lower limits of quantitation were 1 (sildenafil), 2 (tadalafil), 5 (ambrisentan), and 10 ng/mL (bosentan, macitentan). The accuracy and precision values suggested that the assay had high accuracy and reliability. To prove the utility of this method, the plasma concentrations of the five PAH drugs were determined after their oral administration to nine PAH patients.

Pharmacokinetic and Pharmacodynamic Comparison of Sildenafil-Bosentan and Sildenafil-Ambrisentan Combination Therapies for Pulmonary Hypertension

To elucidate whether the pharmacokinetics (PK) and pharmacodynamics (PD) of sildenafil are influenced differently when it is coadministered with bosentan (S+B) or with ambrisentan (S+A), we evaluated the PK and PD profiles of sildenafil before and after 4–5 weeks of S+A or S+B treatment in patients with pulmonary arterial hypertension. The area under the plasma concentration–time curve of sildenafil was significantly higher in S+A treatment than in S+B treatment (165.8 ng•h/mL vs. 396.8 ng•h/mL, P = 0.018) and the oral clearance of sildenafil was significantly lower after S+A treatment than after S+B treatment (120.6 L/h/kg vs. 50.4 L/h/kg, P = 0.018). In the PD study, incremental shuttle walking distance was superior during treatment with S+A than during treatment with S+B (S+B; 280 m vs. S+A; 340 m, P = 0.042). There were no concerns about safety with either combination therapy regime.

Detection of Salmonella in Spent Hens and Eggs Associated with Foodborne Infections

About 16,000 spent hens from 23 farms in the northern area of Japan were purchased in 1996, 1997, 1998, and 1999 to isolate Salmonella in two poultry processing plants. Salmonella was detected in 12 of 23 farms (52.2%). In particular, the serotypes Enteritidis and Infantis were detected in four and three farms, respectively. The prevalence rates in the hens' ceca, immature eggs, and the yolk of mature eggs in oviducts were 14%, 7.2%, and 6.8%, respectively. A total of 23 serotypes were detected. The major serotypes of the strains were Enteritidis, Corvallis, Typhimurium, and Infantis, but most of the strains were untypable. In the same area during 1992 to 1996, Salmonella was detected in eggs associated with four outbreaks of Salmonella Enteritidis infection and one outbreak of Salmonella Infantis infection. The ratio of contamination was approximately 1%, and the level was estimated to be 93 MPN(most probable number)/100 g in one outbreak. In farms that produced the eggs associated with all of the five outbreaks of Salmonella, the serotype Enteritidis or Infantis was isolated from hens. Farms where Salmonella was not detected were not related to any of the outbreaks.

Umbilical cord pseudocyst in a fetus with trisomy 18

An umbilical cord pseudocyst was detected in the 28th week of gestation in a fetus complicated with growth restriction and polyhydramnios. The combination of cord pseudocysts, growth restriction, and polyhydramnios prompted us to perform a detailed ultrasonographic examination (gray scale and three-dimensional), which revealed the presence of micrognathia, overlapping fingers, and congenital heart defects, features characteristic of trisomy 18. Karyotyping confirmed a diagnosis of trisomy 18. After spontaneous labor onset, the infant was delivered at 31 weeks of gestation, and died soon after delivery. An umbilical cord pseudocyst is a good marker for the prenatal detection of trisomy 18.

Immunohistochemical detection of apolipoprotein E within prion-associated lesions in squirrel monkey brains

The interaction of various amyloid precursors and apolipoprotein E (apoE) is important for Congophilic amyloid formation. As for cerebral amyloidoses, although the correlation between amyloid beta protein (Abeta) and apoE in Alzheimer's disease (AD) has been clarified, the interaction of prion protein isoform (PrPsc) and apoE in several types of prion diseases (PDs) has not been examined in detail. ApoE colocalization has been confirmed in Congophilic PrPsc plaques, but to clarify the participation of apoE in the early stage of PDs, apoE deposition in immature lesions without Congophilic amyloid in PDs needs to be examined. In the present study two squirrel monkeys were inoculated with mouse PrPsc derived from sheep scrapie, and showed signs of severe spongiform degeneration. These lesions were immunohistochemically characterized as patchy perivacuolar and diffuse synaptic lesions without Congophilic amyloid. The central portion of the assemblies involving a few patchy perivacuolar lesions was detected by methenamine silver staining and appeared as a plaque-like lesion. ApoE was colocalized in all the plaque-like lesions and in half of the patchy perivacuolar lesions, but not in any diffuse synaptic lesions. These immunohistochemical characteristics indicated that apoE colocalization occurred in moderate mature lesions in PDs, and apoE might play an important role in the aggregation of PrPsc after a conformational change from cellular PrP isoform to PrPsc.

Exercise myocardial perfusion scintigraphy is useful for evaluating myocardial ischemia even in the elderly

Pharmacologic stress testing is recommended to elderly patients as a valuable alternative to exercise testing. We examined whether exercise testing is as useful for evaluating myocardial ischemia in the elderly as in the young. The consecutive 1,508 patients who underwent exercise 201Tl single-photon emission computed tomography (SPECT) were divided into six age groups: 6-29 years (n = 56), 30-44 (n = 143), 45-54 (n = 311), 55-64 (n = 498), 65-74 (n = 402), and 75-88 (n = 98). Both heart rate and rate-pressure product at peak exercise were significantly lower in patients aged 75-88 than in the other five groups. The frequency of ischemic ST depression was higher in patients aged 75-88 than in those aged 6-74, although the difference was not significant. Moreover, the frequency of 201Tl transient defect was significantly higher in patients aged 75-88 than in those aged 6-74. On the other hand, the sensitivity of ischemic ST depression for 201Tl transient defect was similar among the six groups, but the specificity was significantly lower in patients aged 75-88 than in those aged 6-74. In conclusion, exercise 201Tl SPECT is useful for evaluating myocardial ischemia even in the elderly, but exercise electrocardiography has limitations such as lower specificity in the elderly than 201Tl SPECT.

Egg-eating behaviour in laboratory squirrel monkeys (Saimiri scuireus)

The present study aimed to clarify an individual character of squirrel monkey by analysing a complicated behaviour, the egg-eating behaviour series (ES), of laboratory-reared squirrel monkeys. Eight types of unit movements were observed in the ES: the initial taking of the egg by hand; rolling it between the fingers; sniffing it in its shell; biting it in its shell; pressing or rubbing it against a surface of the cage; opening or peeling it; eating it; or putting it down without eating. In the first experiment, the behaviour of 72 monkeys was recorded by direct observation or by a video camera, following which the sequences of the movement from a total of 378 ES were analysed. Three statistically significant ES were detected (Ta-Bi-Op/Pe-Ea, Ta-Ro-Bi-Op/Pe-Ea and Ta-Pr/Ru-Bi-Op/Pe-Ea). In the second experiment, eight squirrel monkeys were selected at random from the same group and 31 to 36 ES for each monkey were observed and analysed. These monkeys were classified into a pressing/rubbing (Pr/Ru) group and a no-Pr/Ru group. Pr/Ru appeared to have no relationship to the monkey's age or sex. Furthermore, the Pr/Ru group monkeys contained individuals always exhibiting Pr/Ru in their ES and others sometimes lacking Pr/Pu in their ES. In short, the monkeys could be divided into two groups (i.e., Pr/Ru and no-Pr/Ru) and they displayed their own individual characteristic ES. We concluded that the ES observed in this experiment suggest that the squirrel monkeys acquired individual characteristics in their ES in the laboratory environment.

Evaluation of small internal mammary lymph node metastases in breast cancer by MRI

PURPOSE

In breast cancer, diagnosis of a small internal mammary lymph node (IMLN) metastasis of less than 10 mm in size has been difficult. Our purpose was to retrospectively evaluate MRI findings of small IMLN metastases in comparison with dissected IMLNs.

METHODS

We studied 43 dissected IMLNs (range 2-12 mm, mean 4.512+/-2.763 mm) in 16 women with breast cancer (15 primary, and 1 recurrent). MRI examinations were performed using a 1.5 Tesla scanner (200FX; Toshiba, Tokyo, Japan) to obtain noncontrast T1-weighted SE images (TR/TE; 500/15 or 400/15ms), with a slice thickness of 5 mm on coronal images, 10 mm or 7 mm on sagittal images, FOV 15x15 cm, matrix 256x256, using a surface coil with patients in the supine position. MR images were evaluated regarding the major diameter and shape and margin of each node.

RESULTS

Regarding the presence of IMLN metastases, there was a significant difference between nodes with a major diameter of 5 mm or more and those of less than 5 mm (p<0.05). Using the size-based criterion (defining< or =5 mm as positive), MRI had 90.7% accuracy, 93.3% sensitivity, and 89.3% specificity. There were no significant differences in the shape-or margin-based criterion.

CONCLUSIONS

MRI was useful in diagnosing small IMLN metastases, using a size-based criterion.

[Balloon-occluded arterial infusion chemotherapy in treatment of the patients with locally recurrent carcinoma of the cervix who previously received radiation therapy]

Nine patients with locally recurrent carcinoma of the cervix were treated with balloon-occluded arterial infusion chemotherapy (BOAI) in order to secure high concentrations of antitumor agents. All the patients had previously received radiation therapy for squamous cell carcinoma of the cervix. Recurrence was diagnosed by cytology and/or biopsy, or CT. Either cisplatin 100 mg/body and doxorubicin hydrochloride 40 mg/body or cisplatin 50-100 mg/body and pirarubicin 40-60 mg/body were infused after the bilateral internal iliac arteries had been occluded using balloon catheters. As the largest diameter of the tumors on CT increased, the mean survival after BOAI decreased. The mean survival of 4 patients with no detectable masses on CT was 45 +/- 30.7 months. In 5 patients, neurological complications, subcutaneous and/ or skin reactions of the buttock, or necrosis of the uterus developed. The neurological complications were damage to the sciatic nerve at the level of S1 or S2. Our study suggests that BOAI therapy may lead to a high complication rate in patients with locally recurrent carcinoma of the cervix who previously received radiation therapy, although long-term survival can be expected in patients with no detectable masses on CT.

Computed radiography excretory urography: can the system sensitivity value be used as an image quality indicator?

The purpose of this study is to determine whether the computed radiography system sensitivity value can be used as an image quality indicator for computed radiography excretory urography with radiation dose reduction. One hundred and twenty-four patients with gynecological malignancies were studied prospectively. Five-minute and 10-minute computed radiographic images of excretory urography were obtained in each patient with different radiation doses (ie, a standard dose image required with screen-film method and a reduced dose one). The images were subjectivity scored by three radiologists without knowledge of the exposure factors or the system sensitivity values. The quality scores of the reduced-dose images used in the five steps were compared with those of the standard dose images (the system sensitivity value was 80 to 120). The images with reduced exposures were arbitrarily divided into five steps according to the system sensitivity value (ie, 150 to 250, 260-400, 410-600, 610-1000, and 1010-1500). There was a gradual degradation of the image quality as the system sensitivity value was increased. In terms of visualization of the bones, the images taken with the system sensitivity values of 150-250 (40%-67% of the standard dose system) showed no statistically significant difference from the standard dose images. As for visualization of the renal pelvic margins, the images taken with the system sensitivity values of 260 to 400 (2%-38% of the standard dose system) showed no statistically significant difference. We conclude that system sensitivity value can be used as a practical though approximate indicator of the image quality.

Analysis of sexual behavior in rams (Ovis aries)

In this study, a matured ram was paired with an estrus ewe and sexual behavior was investigated. All the behavior was recorded by a time-lapse video tape recorder from the start of pairing. The series of unit movements comprising the sexual behavior, the mounting series (MS), was extracted from the record and analyzed quantitatively (n = 774). The MS starts from ram's approaching or following a ewe and ends by ram's mounting on a ewe. The sexual behavior was consisted of the following eight unit movements, following or approaching (F/A), chin resting (CR), flehmen (Fl), mounting (Mo), nosing (No), nudging (Nu), pushing (Pu) and twisting (Tw). Analysis of a frequency of any combinations of two unit movements consisted of preceding and succeeding ones, observed in the MS was conducted by cell-by-cell test using the transitional matrix to make a flow-diagram of the ram's sexual behavior. As a result, the pattern of unit movements, F/A-Tw-Nu-CR-Mo, formed a main route of the MS, whereas the repertoire of a sequential pattern increased by diverging. Though Fl and No didn't lead to mounting directly, these movements associated with olfactory perception also belonged to sexual behavior and may have independent function from other six unit movements that constitute the MS.

Portal vein aneurysm in the liver associated with multiple vascular malformations

Portal vein aneurysm (PVA) includes focal dilatation of the portal vein, and was formerly thought to be a rare disease. We report a 46-year-old man with chronic aggressive hepatitis and intrahepatic portal vein aneurysm communicating with the hepatic vein. Hemangiomas in the liver and intracranial arteriovenous malformation (AVM) were also found. To our knowledge, this is the first report of a case of PVA in a patient with congenital intracranial AVM. As the PVA in this patient communicated with the hepatic vein, and as hemangiomas in the liver and intracranial AVM were also present, the pathogenesis in this patient seems to have been congenital anomaly of the vasculature.

Mechanical properties of artificial teeth

In selecting the teeth for fabrication of complete or partial dentures, each patient's anatomic and physiologic requirements and the properties of the artificial teeth themselves should be taken into consideration. The purpose of this study was to evaluate the mechanical properties of the artificial teeth by the static compression test and the impact test. Specimens were the lower first molar porcelain and resin teeth (Livdent FB-20 teeth by G. C. Co., Tokyo, Japan). All were of the same shape. In the static compression test, the fracture load and deformation of the artificial teeth were measured with an Instron-type universal testing machine at a cross-head speed of 1.0 mm/min. Elastic modulus, ultimate strength and absorbed energy were calculated. In the impact test, the acceleration of a falling impactor was measured with a drop impact apparatus. The load applied to the specimen was equivalent to 300N. Absorbed energy and deformation were calculated. The resin teeth showed a lower elastic modulus, higher fracture toughness and shock-absorbing ability than the porcelain teeth. Resin teeth should be selected when the first requisite is high shock-absorbing ability, and porcelain teeth should be selected when the first requisite is high masticating efficiency.

[Local compressibility of denture foundation--evaluation of denture foundation in relation to impression pressure]

The viscoelastic character of the denture foundation is different in each individual or site. The character of the mucosa and the appropriate impression procedure should be examined. However, few investigations concerning the relation between the compressibility of the denture foundation and the impression pressure have been reported. The purpose of this study was to discuss the objective evaluation of the denture foundation in relation to the impression pressure. In this report, the local compressibility of the denture foundation of 20 upper edentulous patients was measured with the 20 MHz B-Mode ultrasonic diagnostic equipment. The Compressible Index was defined to analyze the compressibility of the denture foundation quantitatively as against the impression pressure. The main results were as follows: 1. The compressible amount of the denture foundation against 100 gw/cm2 pressurization was an average of 0.32-0.61 mm. 2. The compressible rate of the denture foundation against 100 gw/cm2 pressurization was an average of 13.5-20.7%. 3. The Compressible Index was confirmed to represent the compressibility of the denture foundation accurately as against the impression pressure. 4. It was suggested that the Compressible Index was useful for the clinical simple evaluation of the denture foundation.

Clinical evaluation of a teleradiology system utilizing personal computers and public telephone line

Practical usefulness of a teleradiology system using CCD camera, personal computer and telephone line was evaluated in a daily clinical practice. Image quality of this system is diagnostic for the majority of abnormalities on radiological images including plain radiographs. Radiological consultation between hospitals in the same city as well as between distant cities using this moderately priced system was thought to be useful in 90% of cases. Teleradiology using compact systems like ours is expected to be useful in the urban clinical environment as well as in distant areas.

[Studies on the flow properties of autopolymerizing hard-setting resins used as direct relining materials for denture bases]

Autopolymerizing hard-setting direct relining resin is currently being used in dentistry to attain denture bases that conform to the supporting tissues with a high degree of accuracy. The purpose of this study is to investigate the flow of six commercial hard-setting direct relining resins (Denture Liner, Kooliner, New Truliner, Rebaron, Swift, Tokuso Rebase) and several types of impression materials (zinc oxide-eugenol, polysulfide rubber, silicone rubber) using the parallel plate viscometer. The viscometer is used to measure the spread radius of samples (a volume of 0.5 cm3) between two parallel flat plates when a load of 750-gram weight is applied at 1, 10, 60, 100 seconds after loading has begun. In this experiment, the load was applied at 120, 150, 180, 210, 240, 300 seconds after mixing had begun. All the samples were mixed according to the manufacturer's recommendations. The findings were as follows; 1. The flow of the six commercial hard-setting direct relining resins could be compared with one another by the spread radius at 1 second after loading (r1) with no relation to time lapse after initiation of the mix. 2. Denture Liner, Kooliner, Rebaron and Swift had the same flow characteristic when r1 was the same. 3. Polysulfide rubber impression materials had similar flow characteristic to hard-setting direct relining resins.

[Clinical application of FCR (Fuji Computed Radiography) for portable chest radiographs in the ICU]

The diagnostic value of the portable chest radiography obtained with Fuji computed radiography (FCR) was evaluated in comparison with conventional images in 23 patients who were admitted to ICU in Yokohama City University Hospital. On the whole, FCR produced more excellent images than conventional screen-film radiographs. Especially the evaluation for the demonstration of the catheters, the endotracheal tubes and the tracheal shadows obtained high score. We discuss the clinically utility of FCR for the portable chest radiographs in ICU.

Use of computed radiography in respiratory distress syndrome in the neonatal nursery

A study was performed to establish the value of a computed radiography (CR) system in neonatal respiratory distress syndrome (RDS). CR images obtained with various X-ray doses were compared with the images of a standard film-screen system. The image quality of CR taken with about one half radiation exposure, was comparable to that of the standard high speed film-screen combination. The use of CR could lead to a significant reduction in radiation in the neonatal I.C.U.

Chest x-ray findings in the acute phase of Kawasaki disease

We reviewed the chest x-ray (CXR) findings and clinical courses of 129 patients with Kawasaki disease and found abnormal CXR findings in 14.7% of the patients. Reticulogranular pattern was the most frequent abnormality (89.5%), while peribronchial cuffing (21.1%), pleural effusion (15.8%), atelectasis (10.5%) and air trapping (5.3%) were also seen. In each of these patients, CXR abnormalities appeared within 10 days after the onset of illness. In the group with abnormal CXR findings, a statistically significant increase was noted in duration of fever, incidence of adventitious sounds, serum CRP levels and incidence of coronary arterial lesions and pericardial effusion, as compared with the group having normal CXR findings. The pathological basis of these CXR changes is not clear, since no biopsy or autopsy specimen was obtained from these patients, none of these patients showed definite heart failure, it is difficult to consider that abnormal CXR findings were due to heart failure. On the other hand, physical signs and previous pathological reports suggested that the causes of abnormal CXR findings were lower respiratory tract inflammation and/or pulmonary arteritis.

Plastic bronchitis: large, branching, mucoid bronchial casts in children

Expectoration of large, branching, bronchial casts, termed plastic bronchitis, is an uncommon condition in children. Asthma or allergy often is the cause of cast production, but in some instances no etiology is found. Five children produced large, obstructing bronchial casts that either were expectorated or were extracted at bronchoscopy. Four of the children had asthma or allergies and the fifth had congenital tricuspid atresia and chronic pericardial and pleural effusions. In two patients, expectorated casts initially were thought to be aspirated food material. Radiographic findings during periods of cast formation included atelectasis, obstructive emphysema, bronchiectasis, pleural effusion, and pneumomediastinum. Cast formation may be self-limited but generally ceases with appropriate treatment of the causative disorder. Bronchoscopic extraction of casts may benefit some patients.

The bulbous bowel segment: a sign of congenital small bowel obstruction

A study of 29 neonates with intestinal obstruction has shown that a massively dilated, bulbous terminal segment of bowel is characteristic of neonatal infestinal obstruction of congenital origin. The sign is an important diagnostic indicator but its absence does not exclude intestinal atresia.