A Self-Check Program Targeting Quality Improvement in a Hospital-Based Palliative Care Consultation Team, Japanese Society for Palliative Medicine: Issues Regarding Team Activities Identified through the Plan-Do-Check-Act Cycle

Background: The number of hospital-based palliative care consultation teams (PCCTs) has increased in Japan, and quality improvement (QI) of PCCTs is an issue. The Japanese Society for Palliative Medicine is building a framework for continuous QI of PCCT activities. Objective: The objective of this study was to develop a program to support QI for PCCTs, and to describe the initial experience with the program. Design: The report details the development of a self-check program, followed by a one-year follow-up observational survey. Methods: We developed a self-check program using the concept of the Plan-Do-Check-Act (PDCA) cycle and a multidisciplinary expert panel. A total of 114 PCCTs entered the program in the first year. Results: We developed three forms for the CHECK, ACT-PLAN, and DO phases aligned with the PDCA cycle. The forms consisted of 34 items across 8 domains. A total of 83 PCCTs (729 members) returned the CHECK, ACT-PLAN forms, and 41 PCCTs returned the DO forms after one year. Overall, 213 high priority issues were identified in the ACT phase. The issues of many PCCTs were "Sharing goals of care is inadequate within the PCCT (33%)" and "Sharing goals of care is inadequate between patient/family or primary team and the PCCT (28%)." Improvements in identified issues were: "achieved" 23% and "almost achieved" 48% after one year. Conclusions: We developed a self-check program to support QI efforts for hospital-based PCCTs. The priority issues among PCCTs and improvement goals with examples were identified. These results will support ongoing efforts to develop a continuous improvement model for QI of PCCTs.

[Medroxyprogesterone Acetate as Part of Palliative Care for Terminal-Stage Breast Cancer Patients--A Report of Two Cases]

Various effective strategies have recently been described in the treatment of breast cancer, including endocrine therapy, chemotherapy, and molecular-targeted therapy, providing long-term survival benefits even after cancer recurrence. However, terminal-stage patients experience side effects and worse quality of life (QOL), in addition to deterioration of their general condition caused by the progression of the disease itself. When providing the best supportive care, use of anti-cancer drugs is not taboo and can represent a good option as long as physical, social, psychological, and spiritual supports are provided to both the patients and their families. Medroxyprogesterone acetate (MPA) is an endocrine therapeutic drug. In Japan, MPA is used only as a late-line endocrine therapy for breast cancer recurrence because many other endocrine therapy drugs are much more effective and MPA increases the risk of thrombosis and obesity. Here, we report 2 patients with breast cancer who reached terminal stage more than 10 years after the first diagnosis. MPA was administered as the final-line treatment. During that time, their appetite and QOL improved and the patients became more active than when they had been undergoing aggressive anticancer treatment. Both patients spent quality time with their families until their death. MPA may be a good option as part of palliative care of breast cancer patients in terminal stage.

Successful treatment of γ-heavy-chain disease with rituximab and fludarabine

An 84-year-old Japanese man was admitted because of pancytopenia. The bone marrow was hypoplastic with a predominance of abnormal small lymphocytes and grape cells, which were positive for CD19 and CD20, and partially for the surface ĸ-light chain. Systemic CT scanning showed neither lymph node swelling nor hepatosplenomegaly. Serum immunoelectrophoresis and rocket immunoselection assays showed the presence of monoclonal IgG protein without a corresponding light chain and faint IgMĸ monoclonal protein. Histologic analysis of the clot preparation of the bone marrow aspirate facilitated a diagnosis of lymphoplasmacytic lymphoma (LPL). PCR analysis of the marrow cells demonstrated a clonal rearrangement of the immunoglobulin heavy-chain gene. From these results, we made a final diagnosis of γ-heavy-chain disease (γ-HCD) with underlying LPL localized in the bone marrow. We performed only a single course of immunochemotherapy (rituximab and fludarabine) in view of severely impaired hematopoiesis, which resulted in marked reduction of lymphoma cells and improvement of hematopoiesis. This report suggests the efficacy of rituximab plus fludarabine therapy for LPL-associated γ-HCD.

Permanent genetic resources added to Molecular Ecology Resources Database 1 December 2010-31 January 2011

This article documents the addition of 238 microsatellite marker loci to the Molecular Ecology Resources Database. Loci were developed for the following species: Alytes dickhilleni, Arapaima gigas, Austropotamobius italicus, Blumeria graminis f. sp. tritici, Cobitis lutheri, Dendroctonus ponderosae, Glossina morsitans morsitans, Haplophilus subterraneus, Kirengeshoma palmata, Lysimachia japonica, Macrolophus pygmaeus, Microtus cabrerae, Mytilus galloprovincialis, Pallisentis (Neosentis) celatus, Pulmonaria officinalis, Salminus franciscanus, Thais chocolata and Zootoca vivipara. These loci were cross-tested on the following species: Acanthina monodon, Alytes cisternasii, Alytes maurus, Alytes muletensis, Alytes obstetricans almogavarii, Alytes obstetricans boscai, Alytes obstetricans obstetricans, Alytes obstetricans pertinax, Cambarellus montezumae, Cambarellus zempoalensis, Chorus giganteus, Cobitis tetralineata, Glossina fuscipes fuscipes, Glossina pallidipes, Lysimachia japonica var. japonica, Lysimachia japonica var. minutissima, Orconectes virilis, Pacifastacus leniusculus, Procambarus clarkii, Salminus brasiliensis and Salminus hilarii.

[Amylase-producing multiple myeloma: a case report]

A 80-year-old man was admitted because of acute-onset thrombocytopenia and renal failure. He was diagnosed with Bence Jones (lambda) -type multiple myeloma associated with sepsis with methicillin-resistant Staphylococcus aureus. On admission, serum amylase activity was elevated to 1,814 IU/l (98% salivary type; S-amylase). Several days after admission, he developed bilateral myelomatous pleuritis. The activity of S-amylase in the effusion was 5,495 IU/l. Myeloma cells in the pleural effusion were positive for cytoplasmic amylase with an antibody against human amylase. High S-amylase activity was detected in the supernatant of cultured myeloma cells in the effusion. Furthermore, S-amylase gene expression was detected by RT-PCR. A diagnosis of amylase-producing multiple myeloma was made. The patient died of renal insufficiency complicated by severe DIC. We report a rare case of amylase-producing myeloma confirmed by immunocytochemistry, culture method, and gene expression.

[Two year investigation of glycosylation profiles in serum IgG from a patient with multiple myeloma]

Although abnormalities of glycosylation profile in serum IgG have been demonstrated in a variety of inflammatory autoimmune diseases such as rheumatoid arthritis, there are only a few reports describing long term monitoring of N-glycosylation profiles in such patients. Here we report the serial finding of N-glycosylation profiles of IgG-kappa M-protein in a patient with multiple myeloma monitored for two years. In this patient, serum formed a gel precipitation upon exposure to air. The HPLC mapping method demonstrated that IgG M-protein in the patient exhibited a significant decrease in the ratio of fucosyl to afucosyl N-glycans compared with that in a healthy control. With remission, the IgG M-protein showed an increase in this ratio, becoming closer to that in the healthy control. However, the gel-precipitation persisted. This finding suggested that this unique property of serum may not be related to the glycosylation profile of the M-protein.

In silico diagnosis of inherently inhibited gene expression focusing on initial codon combinations

The translation start site, immediately downstream from the start codon, is a dominant factor for gene expression in Escherichia coli. At present, no method exists to improve the expression level of cloned genes, since it remains difficult to find the best codon combination within the region. We determined the expression parameters that correspond to all sense codons within the first four codons using GFPuv which encodes a derivative of green fluorescent protein. Using a genetic algorithm (GA)-based computer program, these parameters were incorporated in a simple, static model for the prediction of translation efficiency, and optimized to the expression level for 137 randomly isolated GFPuv genes. The calculated initial translation index (ITI), also proven for the DsRed2 gene that encodes a red fluorescent protein, should provide a solution to overcome the gene expression problem in cloned genes whose expression is often inherently blocked at the translation process. The proposed method facilitates heterologous protein production in E. coli, the most commonly used host in biological and industrial fields.

[Simultaneous presence of macroamylase and macrolipase in a patient with celiac disease]

Celiac disease is a permanent intolerance to ingested gluten that results in immunologically mediated inflammatory damage of the small intestinal mucosa. Here we report the case of a patient with Celiac disease demonstrating simultaneous macroamylasemia and macrolipasemia. The patient showed persistently elevated levels of serum amylase and lipase. Amylase and lipase in normal serum were eluted from a Superdex-200 column after the 4S protein. These enzymes in the serum from this patient were eluted in the 19S protein. This finding indicated that these enzymes from this patient had a molecular weight greater than that of normal amylase and lipase. Immunoprecipitation assay showed that amylase was bound to polyclonal IgG and IgA, whereas lipase was bound to polyclonal IgA. To our knowledge, the simultaneous presence of macroamylase and macrolipase in the same patient has been previously reported in only four cases. Interestingly, two of those patients had Celiac disease. If macroamylase and macrolipase are present, the possibility of Celiac disease should be considered.

[Immunochemical properties of free mu-chain protein in a patient with mu-heavy chain disease]

We report a case of mu-heavy chain disease. A 56-year-old woman presented with anemia and hemorrhagic diathesis. The serum of the patient was found to have free mu-heavy chain. The patient also had a kappa type-Bence Jones protein in serum and urine. Immunoelectrophoresis showed an abnormal precipitin line in the alpha 2-globulin region which reacted with antiserum to mu-chain but not with antiserum for light chains. The molecular weight of the monomer of the patient's mu-heavy chain protein was approximately 67,000 daltons less than that of the normal mu-heavy chain protein.

[A case with multiple myeloma in which serum forms gel precipitation upon exposure to air]

We present the case of a 69-years-old man who was admitted to hospital with multiple myeloma. IgG-kappa type monoclonal protein was detected in the serum. When we separated the serum obtained from blood sample of the patient and the lid of the collecting tube was opened, the patient's serum became gelled immediately. When the lid of the collecting tube remained closed, the patient's serum did not become gelled even at 4 degrees C. Moreover, the gelled serum of the patient did not resolve at 56 degrees C. Taken together, these results indicated that gel formation of the patient's serum may not be due to cryoglobulin. It was found that the pH of the patient's serum elevated to pH 8.0 quickly after exposed to air. It was also found that the patient's serum, but not the sera of other IgG-kappa multiple myeloma patients, became gelled as soon as PBS of pH 8.0 was added. These results highly suggest that the patient's serum becomes gelled at pH 8.0. However, the isoelectric focusing of isolated precipitation in the patient showed fractions around the pH 8.5-8.7 zone, which was different from the pH at which the precipitation began to form. We think that this may be the first report of a multiple myeloma patient whose serum becomes gelled after exposed to air.

Relation between reactivity to the NS-4 region peptides of hepatitis C virus (HCV) and clinical features among patients infected with HCV genotype 1b

Nearly all patients infected with hepatitis C virus (HCV) genotype 1b have reactivity to the core (c22-3) or non-structural (NS)-3 region (c33c) protein in a second-generation recombinant immunoblot assay (RIBA-2). However, reactivities to the NS-4 region antigens (5-1-1, c100-3) vary among patients. To clarify whether differences in serological reactivities to the NS-4 antigens are associated with the clinical features or response to interferon (IFN) therapy of patients infected with hepatitis C virus (HCV) genotype 1b, we clinically investigated 115 such patients. Positive reactions to 5-1-1 and c100-3 were seen in 75.7 and 79.1%, respectively, of the patients. There were no differences between the patients with and those without antibodies to NS-4 region antigens (5-1-1, c100-3) with regard to age, duration of HCV infection, severity of liver disease and virus load. Fifty-one of the patients were treated with recombinant IFN-alpha, and 17 of the 51 patients showed sustained response to the therapy. The sustained response was more frequently seen in the patients positive for antibodies to both 5-1-1 and c100-3 as compared with those negative for either or both antibodies (41.0% vs. 8.3%, P<0.05).

[Simultaneous presence of macroamylase and macrolipase in a patient]

Here we report a case demonstrating simultaneous macroamylasemia and macrolipasemia. The patient showed persistently elevated serum amylase and lipase activities. On thin-layer gelfiltration, normal serum amylase migrated as a round spot behind albumin. However, serum amylase from this patient migrated slightly ahead of albumin. This finding indicated that serum amylase from this patient had a molecular weight greater than that of normal amylase. Lipase of normal serum was eluted from a Sephacryl S-300 column after the 4S protein. Lipase in the serum from this patient was eluted from the column slightly behind the 19S protein. This finding indicated that serum lipase from this patient also had a molecular weight greater than that of normal lipase. The conversion of macroamylase and macrolipase was observed when the normal serum was mixed with the patient's serum. To determine the isotypes of immunoglobulin (Ig) that was bound to amylase and lipase in the patient's serum, we investigated the effect of adding various anti-human Ig sera to the patient's serum. Amylase activity was precipitated only with anti-IgA lambda and lipase activity was precipitated both with anti-IgA lambda and anti-IgA kappa (anti-IgA kappa > anti-IgA lambda). Taken together, these data indicate that the material that enhanced amylase and lipase activities in the patient's serum was monoclonal IgA; IgA lambda for amylase and both IgA lambda and IgA kappa for lipase.

[Production and metabolism of prostaglandin D2 by cultured chick retinal pigment epithelial cells]

The production and metabolism of prostaglandin (PG) D2 in cultured chick retinal pigment epithelial (RPE) cells were studied. The production of PGD2 was evaluated using thin layer chromatography (TLC) after labeling the RPE cells with 1-14Carachidonic acid (AA) and radioimmunoassay (RIA). The metabolism was evaluated by measuring the activity of 15-hydroxyprostaglandin dehydrogenase. The conversion of AA to PGD2 was detected by TLC, and this conversion was inhibited with indomethacin (10(-5)M). In a steady state, 198 +/- 50 pg/6 x 10(5) cells/2 hours of PGD2 was detected by RIA. The amount of PGD2 was greater than that of both PGE2 and PGF2 alpha. The nicotinamide adenine dinucleotide phosphate (NADP)-linked 15-hydroxyprostaglandin dehydrogenase activity was detected in the 10,000 g supernatant of the RPE cells. These results demonstrated that cultured chick RPE cells produce and metabolize PGD2.

Production of Galacto-Oligosaccharide from Lactose by Sterigmatomyces elviae CBS8119

Volume 61, no. 11, p. 4022, column 2, line 10: "K(inf2)HSO(inf4)" and "KH(inf2)SO(inf4)" should read "K(inf2)HPO(inf4)" and "KH(inf2)PO(inf4)," respectively. Line 13: "K(inf2)HSO(inf4)" should read "K(inf2)HPO(inf4)." Line 14: "KH(inf2)SO(inf4)" and "0.2 g of CaCO(inf3)" should read "KH(inf2)PO(inf4)" and "1 g of CaCO(inf3)," respectively. [This corrects the article on p. 4022 in vol. 61.].

Production of galacto-oligosaccharide from lactose by Sterigmatomyces elviae CBS8119

Our stock cultures were screened for microorganisms that can produce galacto-oligosaccharide (Gal-OS) from lactose. Of the 574 strains of bacteria and yeasts tested, Sterigmatomyces elviae CBS8119, Rhodotorula minuta IFO879, and Sirobasidium magnum CBS6803 were found to be efficient producers of Gal-OS from lactose and S. elviae CBS8119 was selected as a representative, high-level producing strain. With toluene-treated resting S. elviae CBS8119 cells, 135 mg of Gal-OS per ml was produced from 360-mg/ml lactose. During this reaction, the by-product glucose was found to inhibit Gal-OS production. Therefore, in order to remove the glucose from the reaction mixture, a culture method in which cell growth followed the enzymatic reaction was devised, which increased the yield of Gal-OS considerably because of the consumption of glucose for cell growth. Under such conditions, 232 mg of Gal-OS per ml was produced from 360-mg/ml lactose after incubation at 30 degrees for 60 h. The structure of the major product was identified as O-beta-D-galactopyranosyl-(1-->4)-O-beta-D-galactopyranosyl-(1-->4)-D- glucopyranose (4'-galactosyl-lactose) by 13C nuclear magnetic resonance spectroscopy.

Seroepidemiological study of hepatitis delta virus infection in Okinawa, Japan

A seroepidemiological study on hepatitis delta virus (HDV) infection was conducted in the Okinawan islands, the area of Japan where hepatitis B virus infection is most prevalent. The subjects of this study included 116 asymptomatic hepatitis B surface antigen (HBsAg) carriers, 48 patients with chronic hepatitis (CH), 19 with liver cirrhosis (LC), and 11 with hepatocellular carcinoma (HCC). Among the 194 serum samples examined, a total of 10 (5.2%) were anti-HDV seropositive. Anti-HDV was detected in 2 (1.7%) of the 116 asymptomatic HBsAg carriers, in 3 (6.3%) of the 48 patients with CH, and in 5 (26.3%) of the 19 with LC. However, none of the patients with HCC had detectable anti-HDV. Eight of the 10 were born in the Miyako island group and the remaining 2 on the main island of Okinawa. Since the subjects included 34 individuals who were living and/or born in the Miyako islands, the positive rate of anti-HDV in the islands was 23.5%. This study demonstrates the existence of an endemic area of HDV infection in Japan.

[Studies on a serum factor inhibiting lactate dehydrogenase (LDH) activity in a patient's serum]

We found extremely low activity of serum lactate dehydrogenase (LDH, EC. 1.1.1.27) in a 70-year-old female patient. The decrease of LDH activity was observed when the normal serum was incubated with the patient's serum. Inhibition rate of LDH activity by the patient's serum was higher at 4 degrees C than at 37 degrees C. The patient's serum inhibited both subunits of LDH, and inhibited more strongly the M-subunit than the H-subunit LDH isoenzymes. IgG (lambda type) in the patient's serum was found to be responsible for the inhibition of LDH activity. The mechanism why IgG inhibiting LDH activity developed in the patient's serum remain undetermined.

Natural seroconversion from hepatitis Be antigen to antibody among hepatitis B virus carriers in Okinawa Islands

In the Okinawa Islands, the great majority of hepatitis B surface antigen (HBsAg) carriers have already acquired antibody to hepatitis Be antigen (anti-HBe) by the age of 30 years (preliminary cross-sectional data). To elucidate natural seroconversion from hepatitis Be antigen (HBeAg) to anti-HBe among HBsAg carriers found in the islands of Okinawa Prefecture, 34 HBeAg-positive HBsAg carriers were followed for 1-6 years with serial measurements of aminotransferase levels, HBeAg, and anti-HBe. The 34 subjects included 24 patients with chronic hepatitis (group 1) and ten asymptomatic HBsAg carriers (group 2). During the follow-up period, HBeAg disappeared from 14 subjects in group 1 with the cumulative clearance rate of HBeAg of 56.3% within the first 2 years and with 10 of the 14 subsequently developing anti-HBe. Moreover, the aminotransferases in 12 of the 14 spontaneously seroconverted fell into the normal range. The annual clearance rates of HBeAg among group 1 and group 2 were 25.6% and 9.3%, respectively. The tendency for early disappearance of HBeAg during a carrier's life time or in the course of chronic hepatitis may lead to the low death rate from hepatocellular carcinoma (HCC) particularly HCC associated with hepatitis B virus infection in this area.

[Comparison of efficacy of powder and tablet of mebendazole in the treatment of strongyloidiasis]

We previously treated 47 patients with 100 mg of mebendazole (MBZ) twice a day by oral use for 5 days and this treatment was repeated 1, 3 and 4 weeks later. Although the cure rate was 100%, liver injury was observed in 48.9% of the patients. On this study, we reduced the periods of administration of MBZ (powder; 100 mg twice a day) to 4 days, and repeated it once after 3 days interval, and this initial treatment was performed one more time after 10 days interval (group 1). As Strongyloides stercoralis is mainly located in upper digestive systems, we used the drug reduced to powder for the purpose of better contact with the parasites. We considered that the powder should be absorbed well and liver injury occurred in high incidence. As group 2, we used the tablet itself in the same schedules of group 1. The results obtained were as follows; 1) The eradication rates at 10 days after the initial treatment were 97.8% (44 of 45 patients) in group 1 (powder) and 93.0% (40/43) in group 2 (tablet). 2) At 3 days after the whole treatment, the eradication rates were 100.0% in group 1, and 97.7% (42/43) in group 2. 3) Slight side effects such as constipation (6.7% in the group 1), dizziness or vertigo (6.7% in the group 1) and itching (6.7% in the group 2) were observed. 4) Liver injury was observed at 11.1% (5/45) 10 days after the initial treatment in the group 1 and 13.3% (6/45) in the group 2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Early diagnosis of acute myocardial infarction by an immunoinhibition method for analysis of creatine kinase isoforms]

Conventional isoenzyme and enzyme values in serum usually are normal during the first few hours of acute myocardial infarction (AMI). Thus definitive diagnosis may be delayed. Measurement of serum creatine kinase (CK) isoform has begun to attract attention. In this study, we measured CK isoform with an immunoinhibition method in the first available samples from patients with AMI and from healthy subjects. In the 394 healthy subjects, the mean ratio of MM3 to MM1 of CK isoform was 0.494 +/- 0.1495 (SD). The upper limit of the reference values for this ratio was considered to be 0.793 (mean + 2 SD). In 40 of 48 patients, this ratio in the first available samples from patients with AMI was greater than 0.793. In 15 of 20 patients whose total CK activity was less than 260 IU/l, this ratio was greater than 0.793, while CK-MB activity measured with the immunoinhibition method was well within the reference range in all of these patients. Our results show that in the first available samples from patients with AMI, measurement of the ratio of MM3 to MM1 of CK isoform has the highest diagnostic efficiency. Thus, measurement of CK isoform with the immunoinhibition method can be applied for early diagnosis of AMI.