Adverse Event Signal Detection Using Patients' Concerns in Pharmaceutical Care Records: Evaluation of Deep Learning Models

BACKGROUND

Early detection of adverse events and their management are crucial to improving anticancer treatment outcomes, and listening to patients' subjective opinions (patients' voices) can make a major contribution to improving safety management. Recent progress in deep learning technologies has enabled various new approaches for the evaluation of safety-related events based on patient-generated text data, but few studies have focused on the improvement of real-time safety monitoring for individual patients. In addition, no study has yet been performed to validate deep learning models for screening patients' narratives for clinically important adverse event signals that require medical intervention. In our previous work, novel deep learning models have been developed to detect adverse event signals for hand-foot syndrome or adverse events limiting patients' daily lives from the authored narratives of patients with cancer, aiming ultimately to use them as safety monitoring support tools for individual patients.

OBJECTIVE

This study was designed to evaluate whether our deep learning models can screen clinically important adverse event signals that require intervention by health care professionals. The applicability of our deep learning models to data on patients' concerns at pharmacies was also assessed.

METHODS

Pharmaceutical care records at community pharmacies were used for the evaluation of our deep learning models. The records followed the SOAP format, consisting of subjective (S), objective (O), assessment (A), and plan (P) columns. Because of the unique combination of patients' concerns in the S column and the professional records of the pharmacists, this was considered a suitable data for the present purpose. Our deep learning models were applied to the S records of patients with cancer, and the extracted adverse event signals were assessed in relation to medical actions and prescribed drugs.

RESULTS

From 30,784 S records of 2479 patients with at least 1 prescription of anticancer drugs, our deep learning models extracted true adverse event signals with more than 80% accuracy for both hand-foot syndrome (n=152, 91%) and adverse events limiting patients' daily lives (n=157, 80.1%). The deep learning models were also able to screen adverse event signals that require medical intervention by health care providers. The extracted adverse event signals could reflect the side effects of anticancer drugs used by the patients based on analysis of prescribed anticancer drugs. "Pain or numbness" (n=57, 36.3%), "fever" (n=46, 29.3%), and "nausea" (n=40, 25.5%) were common symptoms out of the true adverse event signals identified by the model for adverse events limiting patients' daily lives.

CONCLUSIONS

Our deep learning models were able to screen clinically important adverse event signals that require intervention for symptoms. It was also confirmed that these deep learning models could be applied to patients' subjective information recorded in pharmaceutical care records accumulated during pharmacists' daily work.

P1650Clinical significance of uNGAL, uKIM-1, and uL-FABP in patients with acute pulmonary edema

Introduction

Novel urinary biomarkers such as urinary neutrophil gelatinase-associated lipocalin (u-NGAL),urinary kidney injury molecule-1 (u-KIM-1), and urinary liver-type fatty acid-binding protein (uL-FABP) are proposed to be reliable markers for acute heart failure (AHF). Acute pulmonary edema (APE) is one of the vascular phenotypes of AHF, such as `vascular failure”, often with high blood pressure at admission. We aimed to investigate the differences in the clinical impact and prognostic utility of urinary biomarkers in AHF patients with and without APE.

Methods and results

This prospective observational study included 203 AHF patients (mean age: 77 years, 52% male). uL-FABP, u-NGAL, and u-KIM-1 were measured at admission and before discharge, with correction for urinary creatinine. APE was defined as acute-onset dyspnea and radiographic alveolar edema requiring non-invasive positive pressure ventilation. The primary outcome was a composite of all-cause death and AHF rehospitalization for 1 year. The median uL-FABP levels at admission were higher in APE (n=42) than in non-APE patients (n=161; 10.8 [4.5–23.7] vs. 20.7 [5.9–63.5] μg/gCr, p=0.017), whereas u-KIM-1, u-NGAL, and serum creatinine did not significantly differ between AHF patients with and without APE. The primary outcome did not differ between patients with and without APE. However, among patients with APE, Kaplan–Meier analysis showed that higher uL-FABP (≥median: 20.7 μg/gCr) was associated with adverse events (log-rank: p=0.019). After adjusting for age, sex, serum creatinine, and brain natriuretic peptide, multivariable Cox hazard analysis showed that higher uL-FABP is an independent predictor of adverse events (HR: 4.0 [1.2–18.2], p=0.023).

Conclusion

Unlike u-NGAL and u-KIM-1, uL-FABP was higher in APE patients than in non-APE patients. Further, among patients with APE, higher uL-FABP was predictive for poor prognosis.

Acknowledgement/Funding

None

[The Usefulness of a Pamphlet for Preventing Exposure to Antineoplastic Agents at Cancer Patients' Homes and an Awareness Survey for Pharmacists about Providing Information to Cancer Patients about Exposure to Antineoplastic Agents]

As the number of patients undergoing outpatient chemotherapy has increased, there is concern that cancer patients' family members are unknowingly exposed to antineoplastic agents at home through cancer patients' excrement or other secreted materials. In this study, we created a pamphlet that introduces several methods to prevent exposure to antineoplastic agents at home and conducted a questionnaire survey to assess the usefulness of the pamphlet. The results indicated that more than 90% of patients believed that the pamphlet was "useful" or "very useful" for ensuring safety with respect to antineoplastic agents at home. Further, most patients responded that the pamphlet decreased their anxieties about their disease and/or treatment. In order to examine pharmacists' involvement in providing information to cancer patients about exposure to antineoplastic agents, we conducted another questionnaire survey, with pharmacists working at Sapporo-Higashi Tokushukai Hospital and Sapporo Tokushukai Hospital. The results indicated that 41 out of 46 pharmacists practiced medication counseling; however, 39 pharmacists did not provide patients with instructions on ways to prevent exposure to antineoplastic agents at home. Their primary reason was a lack of adequate information to do so. Accordingly, the pamphlet prepared in our study would be an effective way to provide guidance for preventing exposure to antineoplastic agents at home.

Movement Patterns as an Output Variable in Reaction Time

Effects of two experimental variables, movement pattern and signal selection, on EMG-reaction time (RT) of the biceps brachii were investigated in 17 subjects. Analysis showed that (a) interaction of two variables was not significant in the analysis of variance, (b) RT-difference between the movement patterns was not affected by the signal selection, and (c) the degree of EMG-RT slowing due to the process of signal selection did not vary with movement patterns. The movement pattern was regarded as an output variable.

A case of ovarian small cell carcinoma of the pulmonary type that was observed as it developed

INTRODUCTION

In the case reported here, the authors observed ovarian small cell carcinoma of the pulmonary type as it developed.

CASE

The patient was a 48-year-old woman who underwent a hysterectomy for CIN3 in 2007. A year later, the woman underwent screening for ovarian cancer. A gradually growing ovarian mass was noted. This mass was found to be a mixed tumor. This mixed tumor grew to 36 mm in size, and six months later it had enlarged to 119 mm. After surgery, the tumor was pathologically diagnosed as an ovarian small cell carcinoma of the pulmonary type with a neuroendocrine nature that was positive for CD56 and synaptophysin. Postoperatively, the patient received six courses of combined therapy with irinotecan and cisplatin (CPT-P therapy), and the patient has survived disease- free for over two years.

CONCLUSION

Findings suggested that ovarian small cell carcinoma of the pulmonary type is a type I ovarian malignancy that develops through an adenoma-carcinoma sequence.

Fate of the asymptomatic contralateral limb after initial intervention for ipsilateral critical limb ischemia

AIM

In Trans-Atlantic Inter-Society Concensus (TASC) II, patients at risk for critical limb ischemia (CLI) without symptoms are termed "chronic subclinical ische mia," but research are still lacking. The objective was to find out whether clinically asymptomatic contralateral limbs at the time of treatment for ipsilateral CLI could be regarded as "chronic subclinical ischemia".

METHODS

Ninety-six patients with CLI who had no symptoms in the contralateral limb were retrospectively reviewed. The symptoms of the contralateral limb after initial intervention for the ipsilateral limb were surveyed. Risk factors for developing CLI and tissue loss were then analyzed.

RESULTS

Five patients (5.2%) became claudicants, 37 patients (38.5%) had symptoms of CLI, and 14 (14.6%) experienced tissue loss during the follow-up period. The overall CLI-free rates at 12, 36, and 60 months were 79.2%, 55.2%, and 45.8%, respectively, while the tissue loss-free rates at 12, 36, and 60 months were 91.3%, 78.8%, and 78.8%, respectively. Risk factor for developing CLI on the contralateral limb was having skin perfusion pressure (SPP) <40 mmHg at the surgery for ipsilateral limb. The presence of SPP <40 mmHg and end stage renal failure with hemodialysis resulted in a significantly high probability of tissue loss.

CONCLUSION

Patients with CLI with an asymptomatic contralateral limb with an SPP value <40 mmHg are at a high risk of developing CLI and tissue loss during the follow-up period. Information on the contralateral limb at initial surgery may help to speculate the fate of the asymptomatic contralateral limb.

A case of granulosa cell tumor of the ovary detected from metastatic foci

The authors report a case of granulosa cell tumor of the ovary that followed a rare clinical course, where the primary focus did not appear as a mass, and disseminated foci grew in the abdominal cavity. In 2008, a 70-year-old patient, gravida 6 and para 3, was diagnosed with a perihepatic mass, peritoneal dissemination, and an abdominal wall mass as confirmed by computed tomography (CT) scanning. There was no mass lesion in the pelvis. The pathological diagnosis based on the resected mass in the abdominal wall was malignant mesothelioma. During follow-up, abdominal bloating developed from April 2009. CT scans indicated growth of the intraperitoneal lesions. Therefore, the patient received two cycles of combination therapy with cisplatin and pemetrexed. The treatment was discontinued due to lack of efficacy. The intraperitoneal lesions grew but the clinical course was slow and inconsistent with that of malignant mesothelioma. Central pathological review was requested in April 2011, and a granulosa cell tumor was diagnosed. The patient was referred to the department for detailed examination and treatment. The patient underwent incision of the intraperitoneal tumors, simple total hysterectomy, bilateral salpingo-oophorectomy, and omentectomy. The final pathological diagnosis was normal-size adult-type granulosa cell tumor originating from the left ovary. It was a case of granulosa cell tumor without ovarian enlargement where growth of the metastatic foci was the major observation. As complete surgical resection was achieved and no additional therapy was given, the subject was followed on an outpatient basis and no recurrence was identified.

Infectivity of HBV DNA positive donations identified in look-back studies in Hyogo-Prefecture, Japan

AIMS/OBJECTIVES

To clarify transfusion incidence of hepatitis B virus (HBV) infected blood negative for mini pool-nucleic acid amplification testing (MP-NAT).

BACKGROUND

Japanese Red Cross (JRC) blood centres screen donated blood to avoid contamination with HBV. However, a low copy number of HBV may be overlooked.

METHODS/MATERIALS

In Hyogo-Prefecture, JRC blood centres screened 787 695 donations for HBV from April 2005 to March 2009. Of these, 685 844 were donations from the repeat donors. To detect the donors with HBV, serological tests, MP-NAT and/or individual donation (ID)-NAT were performed. To detect the recipients with transfusion-transmitted HBV infection (TTHBI), serological analysis and/or ID-NAT were performed.

RESULTS

In this study, 265 of the 685 844 repeat donations were serologically and/or MP-NAT positive for HBV. Their repository samples from the previous donation were examined in a look-back study; 13 of the 265 repository samples proved ID-NAT positive. Twelve recipients were transfused with HBV-infected blood components derived from 10 of the 13 HBV-infected donors. Only 1 of the 12 recipients was identified as TTHBI case. Seven of the 12 recipients escaped from our follow-up study and 4 recipients were negative for HBV during the observation period.

CONCLUSION

On the basis of the look-back study among the repeat donors in Hyogo-Prefecture, Japan, donations with HBV-infected blood negative for MP-NAT occurred with a frequency of 13 in 685 844 donations (∼1/53 000 donations). However, more than half of the recipients transfused with HBV-infected blood negative for MP-NAT could not be followed up. It is necessary to establish a more cautious follow-up system.

[Prediction of gemcitabine treatment discontinuation based on platelet count before first administration]

Decrease in white blood cell (WBC), neutrophil or platelet (PLT) count due to treatment with gemcitabine (GEM) is a dose-limited factor (DLF). Even for cases that satisfy the standard criteria for initiation of GEM therapy, the scheduled therapy is reportedly occasionally discontinued because of decreased PLT or WBC count. Here, a retrospective study was made to predict the factor causing discontinuation of GEM treatment before its first administration. The results showed that PLT count immediately before the first administration was significantly less in the unfinished administration group than in the finished group. It was also demonstrated that a PLT count less than 16×10/4 mL before the first administration of GEM was the significant risk factor leading to discontinuation of GEM treatment. Thus, it was suggested that this result would be available as the dose reduction standard to determine the first dose of GEM treatment.

Hypercholesterolemia accelerates bone loss in postmenopausal women

OBJECTIVES

To clarify the effect of lipid profiles on postmenopausal bone loss using a longitudinal method and to determine whether cytokines are involved in bone loss.

METHODS

The subjects were Japanese residents participating in the Iwaki Health Promotion Projects. Women with one or more of the following factors were excluded: a history of surgical menopause, current or past users of bisphosphonates or current user of other drugs known to influence bone and lipid metabolism, and current medication for diabetes or hypertension. Consequently, 99 postmenopausal women (61.2 ± 7.7 years old) and 85 premenopausal women (41.2 ± 8.6 years old) were selected for this study. The osteo-sono-assessment index (OSI) of the left calcaneal bone was obtained twice at 1-year intervals and the annual percentage change in OSI was calculated. Serum total cholesterol, high and low density lipoprotein cholesterol, triglycerides, homocysteine and cytokines such as adipocytokines, interleukins and tumor necrosis factor-α were measured. Postmenopausal women were grouped into three groups according to their basal cholesterol level, and the relationship between basal cholesterol level and annual change in OSI was studied.

RESULTS

The annual percentage change in OSI in postmenopausal women with a serum total cholesterol level ≥240 mg/dl was significantly higher compared to those with a normal total cholesterol level, suggesting that hypercholesterolemia accelerates postmenopausal bone loss. No significant differences were seen in any of the cytokines that presumably cause bone resorption.

CONCLUSION

These results showed that hypercholesterolemia has an inverse effect on bone loss independent of cytokines presumed to mediate bone loss.

[Investigation of factors associated with time change in breath alcohol concentration after paclitaxel administration]

Paclitaxel (PTX) injection is presently used for various types of cancer therapy. Because PTX is an insoluble medicine, alcohol is included. Therefore, after PTX administration, the breath alcohol concentration (BAC) detected is reported. We measured BAC after PTX administration and conducted an investigation into change over time. We also investigated factors associated with BAC. As a result, the BAC rate of detection just after the PTX administration was 52%. BAC was confirmed 3 hours after the administration. Therefore, sufficient rest periods were necessary after PTX administration and the need to avoid driving was proved. From comparison of the BAC detected and undetected groups, no significant sex differences were found in the BAC detected group in age, dosage, or body surface area. However, about a dosage per the time, many other things were significant in the BAC detected group in terms of dosage per time. From these results, it was suggested that the BAC detection rate rose with the dosage per time. However, one cannot predict BAC detection by the usual medical examination. Thus, when receiving PTX treatment on an outpatient basis, the patient should be warned not to drive to and from the clinic.

Serial circulating concentrations of C-reactive protein, interleukin (IL)-4, and IL-6 in patients with acute left heart decompensation

BACKGROUND

Interleukin (IL)-6 has recently been shown to have negative inotropic effects, and several studies have reported increases in circulating concentrations of this cytokine in patients with depressed left ventricular ejection fraction and chronic left heart failure. However, most previous clinical studies have measured cytokines in compensated chronic heart failure.

HYPOTHESIS

The purpose of this study was to examine the temporal evolution of circulating concentrations of C-reactive protein (CRP) and cytokines in patients with cardiomyopathy and acute cardiac decompensation, free of infection and unstable angina.

METHODS

The time course of circulating concentrations of CRP, an anti-inflammatory cytokine interleukin (IL)-4, and a proinflammatory cytokine IL-6 were studied in eight patients with cardiomyopathy and acute cardiac decompensation in the absence of infection or unstable angina. Control samples were obtained from eight age-matched asymptomatic subjects.

RESULTS

Increased circulating concentrations of CRP (2.6 +/- 0.8 mg/dl), IL-4 (164.6 + 36.5 pg/ml), and IL-6 (17.1 +/- 5.1 pg/ml) were found in all eight patients during acute cardiac decompensation; these values decreased significantly with the resolution of symptoms of cardiac decompensation (0.5 +/- 0.1 mg/dl, 77.8 +/- 23.6 pg/ml, 2.3 +/- 0.1 pg/ml, respectively, p < 0.05 for both). There was a significant correlation between peak CRP and peak IL-6 (p < 0.05).

CONCLUSIONS

In patients with acute left heart decompensation in the absence of infection or coronary events, CRP, IL-4, and IL-6 increased and returned toward normal levels as the symptoms of heart failure resolved. Since the changes in concentrations of CRP, IL-4, and IL-6 in patients with heart failure are dynamic, the distinction between compensated and decompensated state is important when discussing the significance of acute reactive proteins or cytokines in the pathogenesis of heart failure.

Alterations in cognitive function in prepubertal mice with protein malnutrition: Relationship to changes in choline acetyltransferase

We have found that protein malnutrition (PM) causes a significant impairment of memory-related behavior on the 15th and 20th day after the start of PM (5% casein) feeding in prepubertal mice but not in postpubertal mice, as measured by a passive-avoidance task. This impairment was almost completely reversed by merely switching to a standard protein (20% casein) diet on the 10th day after the start of PM. However, the reversal was not observed when the switching to a standard protein regimen was done on the 15th day of the PM diet. Interestingly, the impairment of memory-related behavior on the 20th day was improved by the chronic administration of physostigmine (0.1 mg/kg/day x last 10 days, i.p.), a cholinesterase inhibitor. To correlate brain cholinergic neuron function with the memory-related behavior impairment induced by PM, microphotometry was used to determine the histological distribution of the imunofluorescence intensity for choline acetyltransferase (ChAT), a functional marker of presynapse in cholinergic neurons. The change in the intensity of fluorescence indicated that ChAT protein was decreased in the hippocampus (CA1, CA3 and dentate gyrus) on the 20th day after PM feeding in comparison with controls. These results suggest the possibility that the memory-related behavior deficits observed in prepubertal mice with PM are caused by a dysfunction of the cholinergic neurons in the hippocampus.

A trial of quantitative estimation of Al-corrosion detected by neutron radiography

Comparing the hydrogen content in aluminum hydroxides, one of the main components of Al-corrosion, with that in polyethylene sheets, corroded degree of practical Al-corrosions were estimated quantitatively by neutron radiography.

Effect of kami-untan-to on the impairment of learning and memory induced by thiamine-deficient feeding in mice

We have recently reported that thiamine deficient (TD) mice show an impairment of learning and memory on the 20th day after start of TD feeding. Interestingly, it has been reported that the kampo medicine, "kami-untan-to" (KUT) may be useful as a potential therapeutic agent in diseases associated with cholinergic deficit such as Alzheimer's disease. In the present study, we investigated the effects of KUT on the impairment of memory-related behavior concomitant with psychoneuronal symptoms after TD feeding in mice. Oral administration of KUT had no effect on the food intake, body weight or locomotor activity in TD mice, but the mortality rate in the KUT-treated TD group was significantly lower compared with that in the non-treated TD group. Daily administration of KUT from the 1st day of TD feeding protected against the impairment of memory-related behavior induced by TD. The intensity of the choline acetyltransferase fluorescence decreased in the field of CA1 and dentate gyrus in the hippocampus in TD mice compared with pair-fed mice as the control group, and KUT treatment inhibited this decrease. These results suggest that the effect of KUT on the impairment of memory-related behavior induced by TD feeding may be closely related to the activation of cholinergic neurons in the hippocampus.

Characteristics of depressive behavior induced by feeding thiamine-deficient diet in mice

We produced thiamine-deficient (TD) mice by TD diet treatment. The growth curve of mice on TD feeding was sharply increased until on the 10th day and subsequently the body weight gradually decreased. The mortality rate in mice was about 67% on the 30th day after the start of TD feeding. We performed the forced swimming test on the 10th and 20th day after the start of TD feeding. The duration of immobility in the forced swimming test was increased on the 20th day of TD feeding. Locomotor activity and motor co-ordination between the pair-fed control group and TD group on the 20th day of TD feeding were not significantly changed. Only a single injection of thiamine HCI (50 mg/kg, s.c.) on the 10th day after the start of a TD diet shortened the increased duration of immobility in the forced swimming test on the 20th day after the start of TD feeding. Whereas these reversal effects of thiamine treatment on the 20th day were not found when the treatment was given on the 19th day after the start of a TD diet. On the 20th day after the start of TD feeding, the increased duration of immobility time induced by TD was shortened by chronic administration of the tricyclic antidepressant imipramine (10 mg/kg, i.p.). These results suggested that behavioral changes in the forced swimming test might be involved in the degeneration of serotonergic and noradrenergic neurons.

Antinociceptive effect following dietary-induced thiamine deficiency in mice: involvement of substance P and somatostatin

We produced thiamine deficiency by treating mice with a thiamine deficient (TD) diet, but not with pyrithiamine, a thiamine antagonist. Twenty days after TD feeding, a significant antinociceptive effect was observed in the formalin test. A single injection of thiamine HCl (50 mg/kg, s.c.) on the 19th day after TD feeding (on the late TD stage) failed to reverse the antinociceptive effect, the muricide effect, and impairment of avoidance learning induced by TD feeding, as compared to pair-fed controls. These results indicate the possibility that the TD-induced antinociceptive effect may result from irreversible changes in the spinal and/or brain neurons. To clarify the involvement of substance P (SP) and somatostatin (SST) systems in the spinal cord, we examined the effect of intrathecal (i.t.) injections of these agonists on TD feeding-inducd elevation of pain threshold. I.t. injection of SP and SST elicited a behavioral response consisting of reciprocal hindlimb scratching, biting and/or licking of hindpaws. There was no significant difference in the behavioral response to SP between TD mice and PF mice on the 5th day after feeding. However, on the 10th and 20th day after TD feeding the response to SP was significantly increased compared with PF mice. This phenomenon was also observed with SST on the 20th day after TD feeding. These results indicate the possibility that TD feeding may produce an increased behavioral response to SP and SST through an enhanced sensitivity of neurokinin-1 and SST receptors in the spinal cord. Taken together, the antinociceptive effect following TD feeding may result from a decrease in spinal SP and SST contents.

Distribution of various calcium channel alpha(1) subunits in murine DRG neurons and antinociceptive effect of omega-conotoxin SVIB in mice

Immunohistological study revealed the differential localization of subtypes of voltage-dependent calcium channels in the dorsal root ganglion neurons. Intrathecal injection of omega-conotoxin SVIB, an analogue of omega-conotoxin GVIA, which acts on N-type voltage-dependent calcium channels, significantly shortened the licking time in the late phase of a formalin test.

Antinociceptive action of amlodipine blocking N-type Ca2+ channels at the primary afferent neurons in mice

We investigated the antinociceptive action of amlodipine, a dihydropyridine derivative, which acts on both L- and N-type voltage-dependent Ca2+ channels (VDCCs), in mice. Intrathecal injection of amlodipine (300 nmol/kg) significantly shortened the licking time in the late phase of a formalin test, while no effect was found with another dihydropyridine derivative, nicardipine (300 nmol/kg). Cilnidipine and omega-conotoxin GVIA also showed marked analgesic effects under the same experimental conditions. Transcripts of alpha1A, alpha1B, alpha1E, alpha1F, alpha1H, beta3, and beta4 subunits were detected by polymerase-chain reaction (PCR) in the dorsal root ganglion, suggesting the existence of a variety of voltage-dependent Ca2+ channels. Electrophysiological experiments showed that amlodipine and cilnidipine inhibit N-type currents in the dorsal root ganglion cells. These results suggest that amlodipine, cilnidipine, and omega-conotoxin GVIA exert their antinociceptive actions by blocking N-type Ca2+ channels in the primary nociceptive afferent fibers. Blocking of the Ca2+ channels results in attenuation of synaptic transmission of nociceptive neurons. Furthermore, it is suggested that some N-type Ca2+ channel blockers might have therapeutic potential as analgesics when applied directly into the subarachnoidal space.

[Survey of consciousness of community residents regarding the community life of disabled persons with service dogs]

PURPOSE

Service dogs have received much attention as effective choices for promoting participation in society of disabled persons. The purpose of this study was to obtain the fundamental data to prepare guidelines regarding service dogs use in community life, by making clear the problems in terms of public health and community welfare through a survey of attitudes towards service dogs in community residents.

METHODS

Study 1 was conducted as follows. The subjects were 423 community residents between their teens and seventies who participated in health and welfare lectures in 4 metropolitan areas. A questionnaire survey was conducted just after watching a promotion video about service dogs, including several items on aspects not accept, were anxious about or were unpleasant in the case of community life of a disabled person and a service dog. Study 2 was as follows. A questionnaire survey was conducted inside a supermarket in the central part of Tokyo. One group of subjects were 103 shopping customers who witnessed a shopping scene featuring a disabled person with her service dog, and the other subjects were 84 customers who were not witnessed to the scene. The same survey was simultaneously performed for impression about the shopping scene.

RESULTS

Study 1 showed that 31.8% of all the respondents replied that they had some knowledge of service dogs before watching the video. A total of 20.4% (32.5% of the elderly) replied that there were places where service dogs should not enter. Concretely speaking, these included restaurants for 7.3-22.5% and medical institutions for 8.5-12.5% of the respondents. A third of all the respondents (51.3% of older persons) replied they could not endure some actions by service dogs, concretely "carrying food in the mouth" was highly pointed out by 27.3%. Zoonosis (15.3-19.0%), hair scattering (9.5-21.3%), injuries (4.4-7.4%) were also pointed out as main sources of anxiety or uncomfortable feelings. Such negative opinions were especially apparent among those aged 60 years and older. Also, 44.1% knew some disabled person. Cross tabulation showed those who had experience of taking care of a dog were significant less anxious about "vague anxiety or discomfort," and "zoonosis" than those who had not (P < 0.01). On the other hand, most of both witness (79.6%), and non-witness groups (81.0%) replied that it was heartwarming that the service dog assisted with shopping. None expressed discomfort about the presence of "service dog" inside the supermarket. In terms of carrying a commodity in the mouth, 92.2% and 89.1% in both groups replied that they don't mind, especially if safety was guaranteed for public health, and 91.3% and 95.2% in both groups replied that they had no other problems. Moreover, none of them would not entering stores. Significant differences were seldom in replies between the witness and non-witness groups.

CONCLUSION

Although the respondents were extremely affirmative regarding the image of service dogs, it became clear that anxiety about public health aspects such as "zoonosis" or "utilization of medical institutions" was persisting. On the whole, negative opinions were more apparent in the elderly.

Kinetic analysis of cytokine gene expression in patients with GVHD after donor lymphocyte infusion

Patients who receive a donor lymphocyte infusion (DLI) for the treatment of relapsed leukemia after allogeneic BMT (alloBMT) often developed GVHD. To determine whether cytokines might have a role in GVHD, an intensive kinetic analysis of in vivo cytokine gene expression was performed on PBMC from three such patients. Expression of IL-1beta, IL-2, IFN-gamma, IL-4, IL-5, IL-8, IL-10, IL-12, TNF-alpha, and IL-2Ralpha was examined using a sensitive semi-quantitative reverse transcription (RT)-PCR assay system. Six normal controls were also analyzed for comparison. Expression of type 1 T helper (Th1) cytokines, IL-2 and IFN-gamma was greatly increased in all three patients. In particular, the changes in IL-2 gene expression correlated well with disease progression, suggesting that IL-2 has a critical role in the development of GVHD. Although the pattern of type 2 T helper (Th2) cytokine gene expression differed in each patient, the expression of IL-4 was inversely related to expression of Th1 cytokines. These results suggest that Th1 dominates in the development of human clinical GVHD.

Persistently increased serum concentrations of cardiac troponin t in patients with idiopathic dilated cardiomyopathy are predictive of adverse outcomes

BACKGROUND

The measurement of serum concentrations of cardiac troponin T (TnT) is a simple, useful method to detect myocyte injury that may be repeated multiple times to follow patients without interobserver variability.

METHODS AND RESULTS

Multiple measurements of TnT with a second-generation assay were performed in 60 patients with dilated cardiomyopathy confirmed by coronary angiography and endomyocardial biopsy between April 1996 and December 1999. Three evolutionary patterns of TnT concentrations were identified. Thirty-three patients had concentrations of TnT <0.02 ng/mL throughout the follow-up period (group 1). The remaining 27 patients had high initial serum concentrations of TnT (>/=0.02 ng/mL). In 10 of these 27 patients, TnT decreased to <0.02 ng/mL during follow-up (group 2), whereas 17 had persistently high serum TnT concentrations despite being conventionally treated for chronic congestive heart failure (group 3). Although the initial echocardiographic left ventricular diastolic dimension (LVDd) and left ventricular ejection fraction (LVEF) were not significantly different among the 3 groups, follow-up echocardiography showed significantly decreased LVDd and increased LVEF in group 1 (each P:<0.01) and group 2 (each P:<0.05) compared with increased LVDd and decreased LVEF in group 3 (each P:<0.05). The cardiac event-free rate was significantly lower in group 3 than in groups 1 and 2 (each P:<0.001), and the survival rate was lower in group 3 than in group 1 (P:<0.05).

CONCLUSIONS

Persistently increased TnT concentrations in dilated cardiomyopathy suggest ongoing subclinical myocyte degeneration associated with deterioration of the patients' clinical status.

Antinociceptive effect of cilnidipine, a novel N-type calcium channel antagonist

We investigated the antinociceptic effects of cilnidipine, a dihydropyridine derivative which acts on both L- and N-type voltage-dependent calcium channels, in mice. Intrathecally injected cilnidipine showed significant analgesic effect in formalin test. Cilnidipine significantly suppressed N-type currents in dorsal root ganglion (DRG) cells. Our findings apparently support the idea that cilnidipine attenuates synaptic neurotransmission by inhibiting N-type calcium channels in DRG neurons.

Quantitation of minimal residual disease in t(8;21)-positive acute myelogenous leukemia patients using real-time quantitative RT-PCR

t(8;21) is one of the common chromosomal translocations in acute myelogenous leukemia (AML). Using a recently developed real-time quantitative polymerase chain reaction (PCR) system, we analyzed the minimal residual disease (MRD) in bone marrow samples from seven AML patients with t(8;21) at different time points during the clinical courses of their disease. Four of these patients received chemotherapy and allogenic bone marrow transplantation (allo-BMT), and the other three were treated with chemotherapy alone. Two of the patients that received allo-BMT suffered a relapse. In these patients, the levels of AML1-MTG8 mRNA expression were shown to quantitatively increase. After re-induction chemotherapy and donor lymphocyte infusion therapy, AML went into remission and the expression levels decreased. In the other two patients receiving allo-BMT, the disease went into remission and the level of AML1-MTG8 mRNA expression remained under the detectable range. The other three patients received several courses of chemotherapy, without allo-BMT, and all of them clinically reached the hematological and cytogenetic remission state. However, there were low but detectable levels of MRD in their bone marrow samples. These results suggest that the real-time quantitative PCR assay is very useful for the monitoring of MRD and detecting an early relapse. This assay may also be useful in determining the quantitative difference in myelo-ablative activity between the chemotherapy alone and chemotherapy in conjunction with allo-BMT.

Sli2 (Ypk1), a homologue of mammalian protein kinase SGK, is a downstream kinase in the sphingolipid-mediated signaling pathway of yeast

ISP-1 is a new type of immunosuppressant, the structure of which is homologous to that of sphingosine. In a previous study, ISP-1 was found to inhibit mammalian serine palmitoyltransferase, the primary enzyme involved in sphingolipid biosynthesis, and to reduce the intracellular pool of sphingolipids. ISP-1 induces the apoptosis of cytotoxic T cells, which is triggered by decreases in the intracellular levels of sphingolipids. In this study, the inhibition of yeast (Saccharomyces cerevisiae) proliferation by ISP-1 was observed. This ISP-1-induced growth inhibition was also triggered by decreases in the intracellular levels of sphingolipids. In addition, DNA duplication without cytokinesis was detected in ISP-1-treated yeast cells on flow cytometry analysis. We have cloned multicopy suppressor genes of yeast which overcome the lethal sphingolipid depletion induced by ISP-1. One of these genes, SLI2, is synonymous with YPK1, which encodes a serine/threonine kinase. Kinase-dead mutants of YPK1 did not show any resistance to ISP-1, leading us to predict that the kinase activity of the Ypk1 protein should be essential for this resistance to ISP-1. Ypk1 protein overexpression had no effect on sphingolipid biosynthesis by the yeast. Furthermore, both the phosphorylation and intracellular localization of the Ypk1 protein were regulated by the intracellular sphingolipid levels. These data suggest that the Ypk1 protein is a downstream kinase in the sphingolipid-mediated signaling pathway of yeast. The Ypk1 protein was reported to be a functional homologue of the mammalian protein kinase SGK, which is a downstream kinase of 3-phosphoinositide-dependent kinase 1 (PDK1). PDK1 phosphotidylinositol (PI) is regulated by PI-3,4,5-triphosphate and PI-3,4-bisphosphate through the pleckstrin homology (PH) domain. Overexpression of mammalian SGK also overcomes the sphingolipid depletion in yeast. Taking both the inability to produce PI-3,4, 5-triphosphate and PI-3,4-bisphosphate and the lack of a PH domain in the yeast homologue of PDK1, the Pkh1 protein, into account, these findings further suggest that yeast may use sphingolipids instead of inositol phospholipids as lipid mediators.

Interferon treatment for dilated cardiomyopathy and striated myopathy associated with hepatitis C virus infection based on serial measurements of serum concentrations of cardiac troponin T

The present authors recently suggested, on the basis of studies using polymerase chain reaction (PCR), that hepatitis C virus (HCV) infection is involved in the etiology or pathogenesis of cardiomyopathic disorders. They have also reported that the serum concentration of cardiac troponin T is an indicator of ongoing myocyte degeneration in patients with dilated cardiomyopathy (DCM) and hypothesized that its serial measurement may be a marker of therapeutic efficacy. This is the first case report of DCM and striated myopathy, associated with HCV infection, treated with interferon therapy guided by monitoring of serial serum concentrations of cardiac troponin T. Positive-plus strands of HCV RNA were found in the patient's myocardium, as well as plus and minus strands in the quadriceps muscle specimens. Serum levels of creatine kinase (CK), CK-MB and cardiac troponin T fell as serum HCV titers decreased during treatment with interferon, whereas conventional treatment of heart failure had no effect. Monitoring of serial serum concentrations of cardiac troponin T may allow the earlier diagnosis and treatment of patients with HCV-associated cardiomyopathy and improve their clinical course.

Trophoblastic cells expressing human chorionic gonadotropin genes in peripheral blood of patients with trophoblastic disease

We attempted to identify the cells expressing alpha and beta subunits of human chorionic gonadotropin (hCG) in the peripheral blood of patients with trophoblastic disease and normal pregnant women by using reverse transcriptase polymerase chain reaction (RT-PCR) and Southern blot. By this method, the mRNAs of hCG alpha and hCG beta were detected in the peripheral blood mononulear cells (PBMNC) from 3 of 7 hydatidiform mole (mole) and 1 of 4 choriocarcinoma patients as well as from normal pregnant women during the first trimester. None of the mRNAs of hCG subunits was detected in the PBMNC from healthy male and nonpregnant healthy women examined. The expression of hCG alpha and hCG beta in patients with trophoblastic disease and normal pregnant women almost correlated with their plasma levels of intact hCG. The present study indicates that the cells expressing hCG alpha and hCG beta, which virtually represent trophoblasts, are circulating in the peripheral blood of patients with trophoblastic disease as well as of normal pregnant women.

Identification of a new variable sequence in the P1 cytadhesin gene of Mycoplasma pneumoniae: evidence for the generation of antigenic variation by DNA recombination between repetitive sequences

A Mycoplasma pneumoniae cytadhesin P1 gene with novel nucleotide sequence variation has been identified. Four clinical strains of M. pneumoniae were found to carry this type of P1 gene. This new P1 gene is similar to the known group II P1 genes but possesses novel sequence variation of approximately 300 bp in the RepMP2/3 region. The position of the new variable region is distant from the previously reported variable regions known to differ between group I and II P1 genes. Two sequences closely homologous to this new variable region were found within the repetitive sequences outside the P1 gene of the M. pneumoniae M129 genome. This suggests that the new P1 gene was generated by DNA recombination between repetitive sequences and the P1 gene locus. The finding of this new type of P1 gene supports the hypothesis that the repetitive sequences of the M. pneumoniae genome serve as a reservoir to generate antigenic variation of the cytadhesin P1 gene.

A case of aldosterone-producing adenoma with severe postoperative hyperkalemia

It is known that some patients with primary aldosteronism show postoperative hyperkalemia, which is due to inability of the adrenal gland to secrete sufficient amounts of aldosterone. However, hyperkalemia is generally neither severe nor prolonged, in which replacement therapy with mineralocorticoid is seldom necessary. We report a case of a 46-year-old woman with an aldosterone-producing adenoma associated with severe postoperative hyperkalemia. After unilateral adrenalectomy, the patient showed episodes of severe hyperkalemia for four months, which required not only cation-exchange resin, but also mineralocorticoid replacement. Plasma aldosterone concentration (PAC) was low, although PAC was increased after rapid ACTH test. Histological examination indicated the presence of adrenocortical tumor and paradoxical hyperplasia of zona glomerulosa in the adjacent adrenal. Immunohistochemistry demonstrated that the enzymes involved in aldosterone synthesis, such as cholesterol side chain cleavage (P-450scc), 3beta-hydroxysteroid dehydrogenase (3beta-HSD), and 21-hydroxylase (P-450c21), or the enzyme involved in glucocorticoid synthesis, 11beta-hydroxylase (P-450c11beta), were expressed in the tumor, but they were completely absent in zona glomerulosa of the adjacent adrenal. These findings were consistent with the patterns of primary aldosteronism. Serum potassium level was gradually decreased with concomitant increase in PAC. These results suggest that severe postoperative hyperkalemia of the present case was attributable to severe suppression of aldosterone synthesis in the adjacent and contralateral adrenal, which resulted in slow recovery of aldosterone secretion. It is plausible that aldosterone synthesis of adjacent and contralateral adrenal glands is severely impaired in some cases with primary aldosteronism, as glucocorticoid synthesis in Cushing syndrome.

Molecular heterogeneity of hCGbeta--related glycoproteins and the clinical relevance in trophoblastic and non-trophoblastic tumors

We analyzed immunoreactive hCG/hCGbeta (IR-beta) in the sera and urine of patients with trophoblastic diseases and non-trophoblastic tumors by using enzyme immunoassays (EIAs) specific for intact hCG, free hCG beta, and beta-core fragment of hCG (beta-CF). In trophoblastic diseases, while intact hCG and free hCGbeta were contained in both serum and urine, the beta-CF could be detected only in the urine of the patients. The relative contribution of the beta-CF to the total urinary IR-beta accounted for about 30-50% in normal early pregnancy and hydatidiform mole, and more than 60% in choriocarcinoma. We conclude that intact hCG should be measured in the serum rather than in the urine as a tumor marker for trophoblastic diseases, and suggested that the ratios of intact hCG, free hCGbeta, and beta-CF to each other may be useful indices in the differential diagnosis of trophoblastic diseases. Ectopic IR-beta was also investigated in the sera and urine of the patients with cervical, endometrial, ovarian, lung, and bladder carcinomas. We found that even when IR-beta could not be detected in the serum, the urine of the same patients with cancer often contained the significant amounts of IR-beta. The chromatographic study indicated that these urinary IR-beta were essentially attributed to beta-CF, leading to the evaluation of urinary beta-CF as a tumor marker. The positive rated of urinary beta-CF were 48% for cervical, 38% for endometrial, and 84% for ovarian, 40% for lung, and 42% for bladder carcinomas. We conclude that ectopic production of hCG beta by non-trophoblastic tumors is not a rare phenomenon and it can be recognized as a tumor marker when beta -CF is measured in urine of the patients.

Expression of alpha and beta genes of human chorionic gonadotropin in lung cancer

To confirm the ectopic production of human chorionic gonadotropin (hCG) in lung cancer, we attempted to detect the presence of mRNA transcripts of the alpha and beta genes for hCG in lung cancer tissues obtained from surgical operations. Although we were able to show the presence of hCG beta mRNA transcripts in lung cancer tissue by Northern blot, the sensitivity of the assay was too low for a precise analysis of hCG beta mRNA transcripts in most lung cancers. Using reverse transcription PCR (RT-PCR) and Southern blot analysis, however, various amounts of mRNA transcripts of hCG beta genes 3, 5, 7 and 8 were demonstrated in 9 of the 14 lung cancer tissues examined, while no mRNA transcripts were detectable in 12 normal lung tissues from the same patients. Our results are consistent with a clear difference in serum and urinary hCG beta levels observed between normal subjects and lung cancer patients. The expression of the hCG alpha gene, however, was detected in normal lung tissues more frequently than in lung cancer tissues using RT-PCR Southern blot. Our results strongly suggest the production of hCG beta as being part of the phenotype of malignantly transformed lung cells and further strengthen its superior specificity over intact hCG or hCG alpha as a tumor marker for lung cancers.

Cloning of the cDNA encoding rat Presenilin-1

We isolated rat presenilin-1 (PS-1; also called S182 previously) cDNA from total brain RNA by using a reverse transcription-polymerase chain reaction (RT-PCR) technique with primers homologous to the conserved sequences of human and mouse PS-1. Rat PS-1 cDNA encoded 468 amino acids (aa) and the deduced aa sequence was highly homologous to those of the human (88.4%) and mouse (92.7%). Northern blot analysis of the rat PS-1 cDNA revealed two mRNA species in rat neurotypic pheochromocytoma and glioma cell lines (PC-12 and C6, respectively) that migrated at rates corresponding to approximately 3.0 and 7.5 kb.

Influence of oocyte aging on developmental ability of reconstituted embryos produced from oocyte cytoplast and single blastomeres of two-cell stage embryos

The present study was conducted to investigate the influence of aging of recipient oocyte on the developmental ability of reconstituted mouse embryos produced from the cytoplast of oocytes and single blastomeres of early or late 2-cell stage embryos by electrofusion. Oocytes were obtained at 14 (newly ovulated oocytes), 18, 22 (oocyte that time passed after ovulation; aged oocyte) hr after hCG injection and oocyte cytoplast was produced by manual enucleation using a fine glass needle under the dissecting microscope. The aging of the oocytes significantly influenced on the fusion rate of the reconstituted embryos (14 hr: 42.7-47.2% vs. 22 hr: 75.3-77.6%). Similarly, the cleavage rate of reconstituted embryos increased with aging of the oocytes (14 hr: 50.8-56.3% vs. 22 hr: 82.2-90.7%). The percentage of reconstituted embryos produced from cytoplast of aged oocytes (22 hr post hCG) and single blastomeres of late 2-cell stage embryos developing to the blastocyst (20.8%) was significantly higher than that of reconstituted embryos produced by other combinations (2.0-8.2%: P < 0.01). Although cell cycle stage of donor nuclei influenced to developmental ability of reconstituted embryos, these results are probably related to the aging of the oocytes since aged oocytes can be activated more easily by electrical stimulation than newly ovulated oocytes.

Pharmacy benefit management companies

The principal services offered by pharmacy benefit management companies (PBMs) are described. A PBM contracts with employers, insurers, and others to provide accessible and cost-effective benefits to those groups' members. PBMs vary in their organization and services because they originate from different types of businesses. Many PBMs have been formed by publicly traded companies that have combined traditional ways of controlling cost and use, such as formularies, with new elements to form organizations whose primary function is managing the pharmacy benefit. Often, the PBM is paid a fixed amount for which it must provide all contracted services. PBMs may provide pharmacy services themselves (e.g., mail order prescription service is offered by Medco, one of the largest PBMs); more often, they subcontract with others to provide certain services. Full-service PBMs have the following functions: establishing networks of pharmacies for use by plan members; processing claims electronically at the time a prescription is filled and thus maintaining a database on drug use and cost; using these data to generate various reports; encouraging the use of generic products; managing existing formularies, helping to establish customized formularies, or providing a national formulary; providing information to support formulary guidelines (counter-detailing); offering programs in which prescriptions for maintenance medications are filled less frequently with larger amounts, often by mail order; negotiating volume-based rebates from manufacturers; performing drug-use review; developing disease management programs based on clinical practice guidelines and measurements of patient outcome; and evaluating outcomes by combining data on drug therapy with information about other parts of the patient's care.(ABSTRACT TRUNCATED AT 250 WORDS)

Headaches in dementia

We investigated 288 elderly subjects with various degree of dementia, focusing on headaches. Seventy-three of 288 elderly subjects (25.3%) complained of some headaches. The most common type was the tension-type headache, from which 43 of the 73 subjects with headaches (58.9%) suffered. The degree of cognitive disturbances, evaluated by Hasegawa's intelligence scale, significantly correlated to the prevalence of headaches, and indicated that patients with dementia appeared to have less headaches. The methodological issues and views on headache research in dementia were assessed, and it is concluded that the field is a difficult one, with potential for error.