The concept of "template" assisted electronic medical record

A new design for an electronic medical record with flexible template generation was developed. The "template" in this paper refers to one of the tools that calls a user's attention to entering the data items for each problem or to ordering tests when they are due. The template shows the patient's previous data and guides physicians to record the consistent description. Two kinds of medical data dictionaries are prepared. Data representations of signs, symptoms, laboratory tests, and other examinations are defined in the check items dictionary. The problem dictionary contains the possible patient problems with relation to check items and other kinds of related subjects. This system provides Problem Oriented Medical Record (POMR) and the graphical presentation of various patient data. The system was designed to establish a constant and integrated medical record.

C-terminal proteolytic degradation of recombinant desulfato-hirudin and its mutants in the yeast Saccharomyces cerevisiae

The potent thrombin inhibitor hirudin variant 1, originally isolated from the leech Hirudo medicinalis, was expressed in Saccharomyces cerevisiae under the control of a truncated glyceraldehyde-3-phosphate dehydrogenase (GAP) promoter fragment. Fusion of the yeast acid phosphatase (PHO5) signal sequence to the hirudin gene led to quantitative secretion of recombinant desulfato-hirudin variant 1 (r-hirudin) into the extracellular medium in a growth-dependent manner. In comparison to the genuine molecule, r-hirudin lacks the sulfate group at the Tyr in position 63. Besides the full-length protein of 65 amino acids (hir65), chemical analysis revealed the presence mainly of two derivatives lacking the last amino acid Gln (hir64) or the penultimate Leu (hir63) in addition. When expressing r-hirudin in mutant strains defective in all but one of the three major known carboxypeptidases, it turned out that the vacuolar carboxypeptidase yscY as well as the alpha-factor precursor-processing carboxypeptidase, ysc alpha, participate in the C-terminal degradation of r-hirudin. Direct involvement of yscY and ysc alpha was confirmed by sequential disruption of their structural genes PRC1 and KEX1, respectively. Disruption of PRA1, coding for the yscY-processing proteinase yscA, also abolished yscY-mediated C-terminal r-hirudin degradation, but clearly reduced the overall expression yield. Since ysc alpha is described to be highly specific for basic amino acids which are not present at the C-terminus of r-hirudin, a series of r-hirudin mutants with changes in the C-terminal amino acids were constructed and analysed for ysc alpha-mediated and yscY-mediated degradation. Chromatographic analysis of the expression products confirmed the preference of ysc alpha for basic amino acids, although Tyr, Leu and Gln were also hydrolysed. It could further be concluded that ysc alpha might also be responsible for the C-terminal degradation of recombinant atrial natriuretic factor and epidermal growth factor expressed in yeast.

[Thrombotic thrombocytopenic purpura (TTP) observed in a patient with primary antiphospholipid antibody syndrome]

Thrombotic thrombocytopenic purpura (TTP) is a rare syndrome of unknown etiology and has a high mortality rate. TTP is characterized by a pentad of clinical findings, including microangiopathic hemolytic anemia, thrombocytopenia, renal abnormalities, neurologic signs and fever. The pathological feature of TTP consists of disseminated microvascular platelet thrombi. We describe a case of TTP with primary anti-phospholipid syndrome. A 27-year-old woman developed TTP in her second trimester of pregnancy. She presented with classical symptoms of TTP with compatible renal biopsy findings. Although four articles of SLE criteria (1982 ARA) were fulfilled, three of them were considered to be derived from multiple thrombosis except for a positive antinuclear antibody. Positive antiphospholipid antibodies (lupus anticoagulant and anticardiolipin antibody) with SLE-like findings suggested the diagnosis of antiphospholipid antibody syndrome rather than SLE. Although TTP has been described in patients with SLE and they can share common clinical and pathological features, the relationship between these two diseases is controversial. Many theories have been proposed to explain the nature and cause of intravascular platelet aggregation in TTP. But the pathogenesis of TTP is still unclear. This case suggests an important causal relationship between antiphospholipid antibodies and TTP during pregnancy. In TTP patients who also have SLE or SLE-like features, the antiphospholipid antibodies may have a role in the development of multiple microthrombosis.

[Hemophagocytic syndrome observed in a patient with systemic lupus erythematosus]

A 52-year-old woman was admitted to our hospital because of a skin rash, high fever and myalgia. She had been diagnosed ten years ago by a dermatologist as having MCTD (mixed connective tissue disease). At the time of admission a diagnosis of active SLE was made by fulfilling four of the 1982 ARA criteria together with increasing levels of anti-DNA antibody and low levels of complements. Prednisolone (PSL) given orally in an initial dosage of 60 mg/day was effective during the first 6 weeks. Then a high fever, skin rash and pancytopenia appeared without active findings of SLE. Infection caused by bacteria, fungus or virus was suspected, but no infectious agent was present in cultures derived from blood or other sources. Antimicrobic drugs used were not effective at all. The clinical picture was suggestive of a drug allergy, but no causative drug was found. A diagnosis of hemophagocytic syndrome (HPS) was made because of the increased number of unusual hemophagocytic cells in the bone marrow. High levels of serum ferritin and neopterin, which are known to reflect macrophage activation, supported the diagnosis of HPS. HPS is characterized by activated phagocytosis presumably induced by hypersecretion of cytokines. Malignant lymphoma and infection are the two representative diseases which may cause HPS. Recently, an acute lupus HPS was reported in patients with active SLE. Here we reported a case of reactive HPS observed in a patient with SLE who had been receiving high dose PSL. Symptoms and findings of the patient gradually disappeared in several weeks after rapid reduction of the PSL dose.(ABSTRACT TRUNCATED AT 250 WORDS)

[Differences in inpatient medical costs for the aged within one prefecture]

The rapid increase in the proportion of the elderly population has made the problem of medical costs increasingly important. This problem, however, is not uniform over all regions in Japan. In order to determine what factors are associated with per capita medical care expenditure of inpatients aged 70 years and over, in fiscal 1991, correlation analyses were performed using several indices of medical services, socioeconomic factors and medical supplies among 208 municipalities in one prefecture. Data from a survey in 1992 conducted by the Ministry of Health and Welfare was used in the analysis. Requests were sent to all 218 municipalities in one prefecture, and 208 responses were received a response rate of 95.4%. The main findings were as follows: 1) There were large differences in per capita medical care expenditure for those aged 70 years and over among the secondary medical areas in the prefecture. 2) Both the inpatient expenditures per person per year and bed-days in hospitals per person per year were positively correlated with number of hospital beds per 1,000, the aging population rate and death rate of those aged 70 years and over; but correlated negatively with the primary industry population rate for both sexes. 3) Inpatient expenditure per person per day was negatively correlated with the aging population rate, especially for men. 4) Three major factors that correlated significantly and positively with per capita medical care expenditure for those aged 70 years and over were bed days of inpatients per receipt, the total receipts per inpatient per year, and the number of the admission days of inpatients per year. These three major factors were negatively correlated but not significantly, with the per capita medical care expenditure per day. 5) Multiple regression analyses indicate that the aging population rate, the number of hospital beds per 1,000 of those aged 70 years and over, and death rate of those aged 70 years and over were independently correlated with the inpatient expenditure per person per year for both sexes. 6) Results of this analysis indicate that data from secondary medical regions within the prefecture rather than the municipalities yield a stronger possibility of clarifying those factors contributing to differences in per capita medical care expenditure.

[Personnel requirements for health examination of infants under 5 months in municipalities in Japan]

Municipalities offer health education, health counseling, health examinations, and home visitation service for infants and their mothers. In order to determine what the personnel staffing requirements were for health examination of infants under 5 months for municipalities in Japan in 1989, a questionnaire survey was conducted in 1990. Questionnaires were sent to all municipalities and 3,198 responses were received for a response rate of 97.9%. Responses from 912 municipalities were considered invalid, leaving a total of 2,286 responses that were analysed. Results showed that 79.2% of the 2,286 municipalities were able to perform health examinations for infants under 5 months independently, while in 6.5% of the municipalities these examinations were performed by the clinical hospitals. Analysis by size of municipalities showed that 85.7% of the cities with populations of 500,000 or more were able to perform health examinations independently. In the large cities designated by the Government, the health personnel system adequately supported these health examinations. However in rural towns and villages with small populations, it was necessary for public health nurses to be assisted by other staff, most of whom were public health nurses from prefectural health centers. For example, in areas with populations of less than 3,000, about 60% of the total volume of the work required to be performed by public health nurses during the health examinations had to be covered by assistance from prefectural public health nurses.

A continuous spectrophotometric assay for glycosyltransferases

This paper describes a continuous spectrophotometric assay for glycosyltransferases. In this assay, a nucleotide diphosphate is coupled to NADH oxidation via pyruvate kinase and lactate dehydrogenase. The nucleotide diphosphate is produced either directly during the glycosyltransferase mediated reaction, or indirectly by the production of a nucleotide monophosphate during the glycosyltransferase mediated reaction, and subsequent conversion of the nucleotide monophosphate to nucleotide diphosphate using nucleoside monophosphate kinase. Using this assay, kinetic parameters for fucosyl-, sialyl-, and N-acetylglucosaminyltransferases were determined. The assay not only allows continual monitoring of the enzymatic reaction, but is rapid and allows the processing of 96 samples at once since it is performed in 96-well microtiter plates. In addition, the procedure provides a means of monitoring the activity of these enzymes using sugar-nucleotide donor analogs, where radiochemical procedures cannot be used.

HLA-DR alleles in patients with Sjögren's syndrome over-representing V beta 2 and V beta 13 genes in the labial salivary glands

To identify genetic factors that play a role in the pathogenesis of patients with SS over-representing V beta 2 and V beta 13 genes in the lips, HLA-DR and -DQ alleles of 10 primary SS patients with predominant expression of V beta 2 and V beta 13 genes in the lips were analysed, using the polymerase chain reaction (PCR) and sequence specific oligonucleotide probes. The CDR3 amino acid sequences of cDNA clones encoding V beta 2 and V beta 13 genes were also determined by PCR. The results showed that the DRB4*0101 allele was significantly increased (80%) and that the frequency of DRB3 allele was decreased (0%) when compared to findings in healthy subjects (35.6 and 26%, respectively). Sequencing analyses demonstrated that 75% of V beta 2 cDNA clones and 87% of V beta 13 cDNA clones had a glutamine residue at position 106, in the CDR13 region. Moreover, the conserved sequences (Y*TLRNEQ) in the CDR3 of V beta 13-positive T cell were detected in two different clones (27%) from the two individual SS patients. These findings suggest that the decreased DRB3 and increased DRB4*0101 alleles may be associated with the antigens recognized by V beta 2- and V beta 13-positive T cells.

Deletions of the cyclin-dependent kinase-4 inhibitor gene in multiple human cancers

Cytogenetic abnormalities of chromosome 9p21 are characteristic of malignant melanomas, gliomas, lung cancers and leukaemias. From a panel of 46 human malignant cell lines, we localized by positional cloning the most frequently deleted region on 9p21. Sequence analysis of the isolated fragment reveals two open reading frames identical to the recently described complementary DNA for the inhibitor of cyclin-dependent kinase 4 (CDK4). Polymerase chain reaction and Southern blot analysis confirmed the frequent deletion or rearrangement of the CDK4-inhibitor gene in melanomas, gliomas, lung cancers and leukaemias, and the absence of detectable gene transcripts. One carcinoma had a deletion entirely within the CDK4-inhibitor gene. The CDK4-inhibitor gene from a patient with dysplastic nevus syndrome had a germ-line nonsense mutation. The CDK4 inhibitor is thought to be a physiological suppressor of proliferation. Cells unable to produce the inhibitor may be prone to neoplastic transformation.

[A survey of goals and the utilization of numerical goals in the health planning of 47 prefectures]

Health plans of 47 prefectural governments based on the Medical Law of 1985, were evaluated regarding four health planning factors: final goal, implementation plan, development of resources, and evaluation planning. Results of the evaluation showed that 8.5% of the 47 prefectures had defined future level of health based on numerical goals. On the other hand, all of the prefectures had developed numerical goals specifying the number of hospital beds in each medical district. A major component of health planning is improvement in the accomplishment of the implementation plan. There were 14 prefectures which had numerical goals for the upgrading of facilities and for manpower development to meet future health care activities. The following factors are required in the health planning to meet the needs for improving the health status of the population. 1) Including in the future health goals, in addition to the number of medical bed in regional areas, objective levels of health that should be attained. 2) Development of practical plans for evaluation of effectiveness of health planning.

[Health personnel staffing requirements for health examination for three year old children in municipalities in Japan]

Based on the Maternal and Child Health Law, municipalities offer health education, health counseling, health examination, and home visitation service for three year old children and for their mothers. In order to determine personnel staffing requirements for the health examination of three year old children for municipalities in Japan for 1989, data from a questionnaire survey in 1990 conducted by the Ministry of Health, was analyzed. Questionnaires were sent to all municipalities and there were 3,198 responses for a response rate of 97.9%. Results showed that in 1989, only 7% of the 3,198 municipalities were able to perform health examinations for three year old children independently. However 83% of the cities which had populations 500,000 or more were able to perform the health examinations independently. In both the large cities designated by the Government and those cities which have Health Centers, the health personnel system adequately supported these health examinations. Due to the lack of health personnel, rural towns and villages with small populations required public health nurses to be assisted by other staff, most often public health nurses from prefectural Health Centers. For example, in those areas with populations less than 3,000, 43% of the total volume of the work required to be performed by public health nurses during the health examinations had to be covered by assistance for prefectural public health nurses.

The crystal structure of specific granules in human eosinophils studied by thin sectioning and deep-etching with the aid of Fourier transformation

The crystal structures of specific granules in human eosinophils were studied by thin sectioning and deep-etching with the aid of Fourier transformation. The crystal, thought to be a simple cubic by previous studies by thin sectioning, was demonstrated as the body-centered cubic (the cesium chloride type) consisting of two kinds of particles. The crystal parameters obtained by deep-etching were slightly larger (a = b = c = 4.1-4.4 nm) than by thin sectioning (4.0 nm). By deep-etching, the crystal also showed the stacking folds suggesting the piled-up plates. Although it is known that the patients with hypereosinophilic syndrome have more hypodense eosinophils compared with normal persons, no morphological differences could be detected in the crystals between these eosinophils.

[The ultrastructure of human eosinophils studied by thin sectioning, rapid-freezing and deep-etching technique]

The crystalline structure of mature human eosinophils were observed, both by an ultrathin sectioning, rapid-freezing and deep-etching (RF-DE) technique. The crystals obtained with thin sectioning show parallel bands or square lattice structure with a periodicity of about 4 nm. By the RF-DE technique, most crystals show a staircase appearance and in the crystal parallel bands are observed with a spacing of about 4.4 nm. A square lattice structure is observed in a few granules. Since biochemical studies have revealed that the major basic protein (MBP) was localized in the crystal, the crystals can be considered to be crystalized MBP. Although it is known that the patients with hypereosinophilic syndrome have more hypodense eosinophils compared with the normal volunteer, no morphological differences was found in the crystals, between these two eosinophils.

Protein losing enteropathy associated with collagen diseases

Four patients with collagen diseases are described, who developed protein losing enteropathy in the course of their disease. Their protein losing enteropathies subsided after treatment with 60 mg/day oral prednisolone. Immunohistological studies of the small intestine showed deposits of C3 in the capillary walls of villi in two patients. Increased capillary permeability due to autoimmune phenomena may have a role in the pathogenesis of protein losing enteropathy associated with collagen diseases.

The immunosuppressant FK-506 prevents progression of diabetes in nonobese diabetic mice

A novel immunosuppressive compound, FK-506, isolated from Streptomyces has potent immunosuppressive activities. To investigate the effect of FK-506 on the course of diabetes in nonobese diabetic (NOD) mice, we gave this drug to these animals, from the age of 8 weeks, intraperitoneally, in doses of 0.1 mg (2.5 mg/kg/day) or 0.01 mg (0.25 mg/kg/day) three times a week. Overt diabetes were observed in 75.5% of control mice by the age of 20 weeks. In contrast, no diabetes occurred in mice given 0.1 mg of FK-506. Sixteen percent of mice treated with 0.01 mg of the drug became diabetic. Administration of this drug prevented the progression of insulitis in NOD mice. The mice given 0.1 mg of FK-506 lost weight, but this was reversible.

[Bone marrow re-transplantation following a busulfan and cyclophosphamide regimen]

A 36-year-old man was diagnosed as having RAEB in 1986, and required blood transfusion regularly because of severe anemia. He received the first bone marrow transplantation following total-body irradiation and etoposide infusion in October 1987. He was found to be relapsed into RAEB on 106th day after BMT. And the second BMT was planned. According to the conditioning regimen of Tutschka, et al, we administrated busulfan and cyclophosphamide before re-transplantation. On 26th day after BMT, the WBC count exceeded 1,000/microliters and anemia was improved, while thrombocytopenia persisted until 50th day. Normal hematopoiesis in the bone marrow was confirmed on the 29th day. No severe side effect except for a little fevering and bleeding was found during the clinical course. Unfortunately he died of pneumonia following graft versus host disease on the 166th day after re-BMT. This new conditioning regimen is considered to be a choice for the high risk patients on re-transplantation.

IgG class anti-cardiolipin antibody as a possible marker for evaluating fetal risk in patients with systemic lupus erythematosus

To identify the correlation between incidence of anti-phospholipid antibodies and fetal prognosis in pregnant SLE patients, we measured the amount of anti-cardiolipin antibody in their sera, using solid-phase enzyme immunoassay (EIA) methods. Findings in the group having poor obstetric results (fetal loss group) and in those with a history of full-term births (live birth group) were compared with regard to other anti-phospholipid antibodies. The incidence of IgG class anti-cardiolipin antibody was 60% in the fetal loss group and 19% in the live birth group, (P less than 0.05). The incidence of the other anti-phospholipid antibodies, including lupus anticoagulant and biological false-positive serological test for syphilis (BFP-STS), did not differ significantly between the two groups. Therefore, the presence of IgG class anti-cardiolipin antibody may prove to be a useful marker for evaluating fetal risk in SLE patients.

Effect of FK-506, a novel immunosuppressive drug on murine systemic lupus erythematosus

A novel immunosuppressive compound extracted from the fermentation broth of Streptomyces tsukubaensis belongs to the macrolide family. We gave this drug (FK-506) to MRL/lpr and NZB X NZW F1 (B/W F1) mice, an animal model of human systemic lupus erythematosus (SLE), to investigate its effect on the course of the disease. This drug showed potential to prolong the lifespan, to reduce proteinuria, and to prevent the progression of nephropathy. Appreciable differences in the levels of anti-dsDNA antibodies between treated and control animals were nil.

Rat mammary gland fatty acid synthase: localization of the constituent domains and two functional polyadenylation/termination signals in the cDNA

The rat fatty acid synthase (FAS) is active only as a dimer, although the eight component functions are contained in a single polypeptide chain. Using mRNA from lactating rat mammary glands a cDNA expression library was established. With the overlapping immunologically positive clones we have an 8.9kb cDNA sequence for rat FAS. In the 3'-nontranslated region of the rat FAS cDNA we find a prototype polyadenylation/termination signal and 779 nucleotides upstream, a mutated one. Both of these polyadenylation/termination signals are used and give rise to two equally abundant mRNA species which are coordinately regulated. In the derived amino acid sequence we could locate six of the eight component functions; their order is NH2- beta-ketoacyl synthase - acetyl/malonyl transferases -enoyl reductase - acyl carrier protein - thioesterase -COOH. Comparison of FAS from different sources shows that the primary sequence is conserved only for the active residues and the amino acids in their immediate vicinity.

Immunohistochemical identification of infiltrating mononuclear cells in tubulointerstitial nephritis associated with Sjögren's syndrome

Using monoclonal antibodies, immunoperoxidase analysis was performed on eight renal biopsy samples obtained from patients with Sjögren's syndrome-associated tubulointerstitial nephritis. In all cases the interstitial infiltrates were predominantly CD5-positive T-cells (mean 66%), whereas both B-cell (CD19-positive) and monocyte (CD15-positive) populations participated to a lesser degree. CD16-positive NK/K cells were rarely encountered. The CD4/CD8 ratio was consistently higher than 1.0 (mean 2.08). The lymphocytes which invaded the tubular epithelial cells to present a feature of tubulitis were CD8-positive, suggesting that they were cytotoxic T-cells. These results were in general accord with those obtained in the salivary glands of patients with Sjögren's syndrome. It was thus concluded that the same immunological process was probably operative in the renal tubulointerstitial tissue as in the salivary glands to induce the characteristic tissue changes of Sjögren's syndrome.

IgG subclass distribution of anticardiolipin antibody in patients with systemic lupus erythematosus

IgG subclass distributions of anticardiolipin (aCL), anti-ssDNA, and anti-dsDNA antibodies in sera of patients with systemic lupus erythematosus were determined by an enzyme linked immunoassay (ELISA) method, using mouse monoclonal antihuman IgG subclass antibodies. IgG aCL activity consisted mainly of the IgG1 subclass, and to some extent, the IgG3 subclass. Definite amounts of aCL activity were also detected in IgG2 in sera from 25% of the patients. Anti-ssDNA antibody activity was relatively equally distributed among IgG1, IgG2 and IgG3, but was poorly distributed in IgG4. In contrast, anti-dsDNA antibody activity consisted mainly of IgG1 and IgG3.

Antibody to activated lymphocytes in patients with systemic lupus erythematosus

IgG antilymphocyte antibodies preferentially reacting with phytohemagglutinin (PHA) activated peripheral blood lymphocytes (PBL) and an adult T cell leukemia cell line were detected in 70.6% sera from patients with systemic lupus erythematosus (SLE), using a fluorescence activated cell sorter (FACS). In the sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) analysis, 2 major peaks with an apparent molecular weight 60,000 to 65,000 Da and about 40,000 Da were observed in the membrane glycoprotein fractions of both PHA activated PBL and an adult T cell leukemia cell line. From the result of sequential coprecipitation analysis of SDS-PAGE between SLE serum, antiinterleukin-2 (IL-2) receptor antibody (anti-Tac antibody) and anti-Ia antibody, the reactive antigen on the activated PBL and an adult T cell leukemia cell line proved to be an identical molecule of the IL-2 receptor on these cells. The role of this autoantibody in the modulation of T cell mediated immunity in patients with SLE is discussed.

Cytotoxic anti-lymphocyte antibody in schizophrenics

An IgM antibody cytotoxic to normal human lymphocytes was found in 46.2% (male: 61.5%; female: 30.8%) of sera from chronic schizophrenics by means of a complement-dependent cytotoxicity test. The relationship between this antibody and the immunological manifestations of schizophrenia is discussed.