Effect of PM2.5 for hospitalization of cardiovascular diseases and medical expenses by age group: a nationwide study from the Japanese Registry Of All cardiac and vascular Diseases (JROAD)

Introduction

Although particulate matter with an aerodynamic diameter less than or equal to 2.5 μm (PM2.5) exposure influences cardiovascular events, there is limited knowledge how PM2.5 exposure is associated with cardiovascular hospitalization in Japan.

Purpose

We tested the hypothesis that PM2.5 exposure was related to the number of cardiovascular hospitalizations, hospitalization period, and medical expenses.

Methods

We included 835,405 subjects who were admitted to acute care hospitals in Japan. We classified PM2.5 exposure concentration into quintile groups (from low to high in the order of “PM-1” to “PM-5” group). Multilevel mixed-effects Poisson and linear regression analysis were used to estimate the association of PM2.5 exposure concentration with the cardiovascular hospitalization events, duration and medical expenses. We also analyzed those factors classified by age.

Results

PM-2, 3, 4, 5 group were positively related to the number of cardiovascular hospitalization events compared with PM-1 group (Table 1). PM-3, 4, 5 group were positively associated with a 0.018, 0.029, and 0.029 (all p<0.001) of the difference of log cardiovascular hospitalization period compared with PM-1 group (p for trend <0.001). These groups were also positively associated with a 0.016, 0.023, and 0.021 (all p<0.001) of the difference of log medical expenses compared with PM-1 group (p for trend <0.001). Analyzed by age group, hospitalization duration was longer (p<0.05) and medical expenses was lower (p<0.05) significantly in super-aging group (over 90 years old) than the group under 64 years old (Figure 1).

Conclusions

PM2.5 exposure concentration has harmful effect on not only cardiovascular events but cardiovascular hospitalization period and medical expenses due to big-data in Japan. Medical costs were kept low in comparison with their hospitalization period in subjects over 90 years old.

Figure 1

Funding Acknowledgement

Type of funding source: None

Prognostic relevance of exercise pulmonary hypertension for new-onset atrial fibrillation in primary mitral regurgitation

Background/Introduction

New-onset of atrial fibrillation (AF) portends poor prognosis in patients with primary mitral regurgitation (MR). However less is known about prognostic indicator for new-onset AF.

Purpose

The purpose of this study was to identify the prognostic relevance of exercise pulmonary hypertension for the new-onset AF in patients with primary MR.

Methods

Total of 114 consecutive patients with primary MR who underwent symptom-limited exercise echocardiography using supine-cycle ergometer were followed for new-onset AF over mean follow-up time of 3.6±2.6 years. Those with prevalent AF and pulmonary hypertension (estimated systolic pulmonary artery pressure ≥50mmHg) prior to exercise echocardiography were excluded from our analysis. We defined exercise-induced pulmonary hypertension (ExPHT) as those with peak estimated systolic pulmonary artery pressure (SPAP) ≥60mmHg or delta SPAP defined as differences between rest and peak SPAP ≥20mmHg.

Results

The mean age was 61±15 years old and 70 (61%) were male. Of those, 8 (7.8%) had mild MR, 32 (31.1%) had moderate MR, and 63 (61.2%) had severe MR. 60 (52.2%) patients had ExPHT. A total of 27 cases of new-onset AF were found during follow-up where the ExPHT group had higher prevalence of new-onset AF than the non-ExPHT group (35% vs. 11%, p=0.002). Those with ExPHT had significantly stronger association with shorter event-free survival time of new-onset AF (log-rank p<0.001, Figure). When adjusted for age, sex, body surface area, the American Society of Echocardiography MR grade, left atrial dimension, peak systolic blood pressure and heart rate, the multivariable Cox regression analysis showed that those with ExPHT had a hazard risk of 3.1 ([95% CI 1.1–9.1], p=0.039) for new-onset of AF.

Conclusions

Exercise-induced pulmonary hypertension predicted incident of new-onset AF in those with primary MR. Exercise echocardiography is expected to play an important role in decision making with regards to the optimal timing for surgical intervention in primary MR.

Figure 1

Funding Acknowledgement

Type of funding source: None

The Application of an Institutional Clinical Data Warehouse to the Assessment of Adverse Drug Reactions (ADRs)

Objectives: To apply an institutional clinical data warehouse (CDW) to the assessment of adverse drug reactions (ADRs) and demonstrate its utility through a specific example.

Methods: We modeled the process for assessing ADRs through retrospective cohort design by using CDW at the Osaka University Hospital as follows: 1) We defined a drug X, an adverse drug reaction (ADR) Y, and a laboratory measurement Z to assess Y during a given study period; 2) we excluded those whose Z value exceeded the defined criteria or were not available at the inception of the cohort; 3) we divided the patients into two groups based on exposure or non-exposure to X; 4) we matched the patient characteristics between the two groups through stratification and randomization; and 5) we compared the frequency of patients who presented Y during the study period between the two groups. Aminoglycoside and Cephalosporin associated nephrotoxicity in pediatric inpatients was used as an example to demonstrate the usefulness of this approach.

Results: Our evaluation indicates that there is an increased risk of nephrotoxicity for pediatric inpatients who were prescribed cephalosporin either alone or in combination with aminoglycoside; further, aminoglycoside tends to increase the cephalosporin-associated nephrotoxicity.

Conclusions: Our findings are consistent with those drawn from other studies, indicating thatthe method of a pplying an institutional CDW is useful for assessing ADRs.

Pleth variability index can predict spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery

BACKGROUND

Spinal anaesthesia carries a risk of hypotension. We hypothesized that pleth variability index and perfusion index would assess maternal volume status, and thus, allow identification of patients at higher risk of developing hypotension after spinal anaesthesia for caesarean delivery.

METHODS

Fifty patients undergoing elective caesarean delivery were enrolled. All patients received spinal anaesthesia with 0.5% hyperbaric bupivacaine (10 mg) and fentanyl (10 mcg). Blood pressure was measured every minute. Pleth variability index and perfusion index were automatically measured throughout the procedure using pulse oximetry on the index finger. In case of hypotension (systolic blood pressure below 90 mmHg or 80% of the baseline value), ephedrine 5 mg was administered. Receiver-operating characteristic and multivariate logistic regression analyses for spinal anaesthesia-induced hypotension were performed.

RESULTS

Hypotension occurred in 32 patients (64%). The areas under the receiver-operating characteristic curve were 0.751 (95% confidence interval: 0.597-0.904) for pleth variability index before anaesthesia, 0.793 (95% confidence interval: 0.655-0.930) for pleth variability index after anaesthesia and 0.731 (95% confidence interval: 0.570-0.892) for perfusion index change (percent change in perfusion index induced by spinal anaesthesia). The optimal threshold value of pleth variability index (after anaesthesia) for predicting hypotension was 18% (sensitivity: 78.1%, specificity: 83.3%). Pleth variability index after spinal anaesthesia was an independent factor for hypotension (odds ratio: 1.21, P = 0.041).

CONCLUSIONS

Pleth variability index after spinal anaesthesia was a good predictor of spinal anaesthesia-induced hypotension in patients undergoing caesarean delivery. In addition, perfusion index change after spinal anaesthesia has the potential to predict hypotension.

Usability Methods for Ensuring Health Information Technology Safety: Evidence-Based Approaches Contribution of the IMIA Working Group Health Informatics for Patient Safety

Objectives: Issues related to lack of system usability and potential safety hazards continue to be reported in the health information technology (HIT) literature. Usability engineering methods are increasingly used to ensure improved system usability and they are also beginning to be applied more widely for ensuring the safety of HIT applications. These methods are being used in the design and implementation of many HIT systems. In this paper we describe evidence- based approaches to applying usability engineering methods.

Methods: A multi-phased approach to ensuring system usability and safety in healthcare is described. Usability inspection methods are first described including the development of evidence-based safety heuristics for HIT. Laboratory-based usability testing is then conducted under artificial conditions to test if a system has any base level usability problems that need to be corrected. Usability problems that are detected are corrected and then a new phase is initiated where the system is tested under more realistic conditions using clinical simulations. This phase may involve testing the system with simulated patients. Finally, an additional phase may be conducted, involving a naturalistic study of system use under real-world clinical conditions.

Results: The methods described have been employed in the analysis of the usability and safety of a wide range of HIT applications, including electronic health record systems, decision support systems and consumer health applications. It has been found that at least usability inspection and usability testing should be applied prior to the widespread release of HIT. However, wherever possible, additional layers of testing involving clinical simulations and a naturalistic evaluation will likely detect usability and safety issues that may not otherwise be detected prior to widespread system release.

Conclusion: The framework presented in the paper can be applied in order to develop more usable and safer HIT, based on multiple layers of evidence.

A longitudinal study of the quantitative evaluation of patella cartilage after total knee replacement by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping at 3.0 T: preliminary results

OBJECTIVE

To characterize the quantitative changes of patella cartilage over time after total knee arthroplasty (TKA) by delayed gadolinium-enhanced magnetic resonance imaging of cartilage (dGEMRIC) and T2 mapping at 3.0 T.

METHOD

Twenty-six knees of 26 patients (23 women and three men, mean age, 75 years) with primary osteoarthritis and osteonecrosis of the knee underwent TKA with a zirconia ceramic implant in this prospective study. Twelve patients without patella resurfacing (NR group) and 14 patients with patella resurfacing (R group) had TKA with cemented fixation. The implant position was examined by radiograph, computed tomography (CT) and magnetic resonance imaging (MRI). The clinical scores were checked pre-operatively, 1 year post-operatively and at the final follow-up. Patella cartilage and its thickness were evaluated pre-operatively and 1 year after TKA by dGEMRIC and T2 mapping in the NR group only. Patella cartilage was divided into eight regions of interest: the deep and superficial layers of the outer lateral and medial half, and the inner lateral and medial half from the central ridge.

RESULTS

The implant position was appropriate in all cases and clinical scores were not significantly different between the two groups. The post-operative dGEMRIC value of the outer medial half superficial zone in the NR group was significantly decreased compared with the pre-operation value (P<0.05), whereas T2 mapping was not significantly changed in all zones. The cartilage thickness of the outer zone was significantly thinner post-operatively (P<0.05).

CONCLUSIONS

These findings indicate that osteoarthritic changes in the outer zone of patella cartilage occurred 1 year after TKA.

Usability Methods for Ensuring Health Information Technology Safety: Evidence-Based Approaches. Contribution of the IMIA Working Group Health Informatics for Patient Safety

OBJECTIVES

Issues related to lack of system usability and potential safety hazards continue to be reported in the health information technology (HIT) literature. Usability engineering methods are increasingly used to ensure improved system usability and they are also beginning to be applied more widely for ensuring the safety of HIT applications. These methods are being used in the design and implementation of many HIT systems. In this paper we describe evidence-based approaches to applying usability engineering methods.

METHODS

A multi-phased approach to ensuring system usability and safety in healthcare is described. Usability inspection methods are first described including the development of evidence-based safety heuristics for HIT. Laboratory-based usability testing is then conducted under artificial conditions to test if a system has any base level usability problems that need to be corrected. Usability problems that are detected are corrected and then a new phase is initiated where the system is tested under more realistic conditions using clinical simulations. This phase may involve testing the system with simulated patients. Finally, an additional phase may be conducted, involving a naturalistic study of system use under real-world clinical conditions.

RESULTS

The methods described have been employed in the analysis of the usability and safety of a wide range of HIT applications, including electronic health record systems, decision support systems and consumer health applications. It has been found that at least usability inspection and usability testing should be applied prior to the widespread release of HIT. However, wherever possible, additional layers of testing involving clinical simulations and a naturalistic evaluation will likely detect usability and safety issues that may not otherwise be detected prior to widespread system release.

CONCLUSION

The framework presented in the paper can be applied in order to develop more usable and safer HIT, based on multiple layers of evidence.

Peanut stunt virus 2b cistron plays a role in viral local and systemic accumulation and virulence in Nicotiana benthamiana

To analyze the role of the 2b protein (2bP) of Peanut stunt virus (PSV) in the viral infection cycle, we constructed PSV mutants that express either no 2bP or N-terminal-truncated 2bP. The accumulation of wild-type and mutant viruses in tobacco protoplasts indicated that the 2b cistron is not essential for viral replication. Viral accumulation in Nicotiana benthamiana plants suggested that the 2b cistron is responsible for viral accumulation in inoculated and upper leaves and has a role in virulence. The involvement of eight N-terminal amino acids of 2bP in these functions is discussed.

Improvement in respiratory function by percutaneous vertebroplasty

BACKGROUND

Percutaneous vertebroplasty (PVP) improves back pain and corrects spinal misalignment to some extent, and thus may improve respiratory function.

PURPOSE

To retrospectively investigate changes in respiratory function after PVP.

MATERIAL AND METHODS

41 patients (mean age 72.0 years, range 59-86 years; 39 women, two men) who had undergone PVP for vertebral compression fractures (37 thoracic vertebral bodies [Th6-Th12] and 50 lumbar vertebral bodies [L1-L5]) caused by osteoporosis visited our hospital for follow-up consultation between January and June 2005. At this follow-up consultation, respiratory function testing, including percent forced vital capacity (FVC%) and percent forced expiratory volume in 1 s (FEV(1)%), was performed. We retrospectively compared these values with those taken before PVP using a Wilcoxon signed-rank test.

RESULTS

FVC% was 85.2+/-30.3% before PVP and 91.5+/-16.8% at follow-up (mean 10 months after PVP), which represented a significant difference (P<0.003). No significant difference in FEV(1)% was detected. Regarding the number of treatment levels, that is, single vertebroplasty versus multiple vertebroplasty, no significant difference in improvement of FVC% was confirmed (P=0.1). FVC% was abnormally low (<or=79%) before PVP in 16 patients and improved to within normal range postoperatively in six of these patients (38%).

CONCLUSION

PVP improves preoperatively decreased lung function, but this improvement takes time.

Genetic contribution of the CD14 -159C/T dimorphism in the promoter region in Japanese RA

OBJECTIVE

To study the contribution of the CD14 gene to the pathogenesis of rheumatoid arthritis (RA) in Japanese patients.

METHODS

CD14 genotyping was carried out at the -159C/T dimorphic site in 97 RA patients and 104 normal subjects by the PCR-RFLP (restriction fragment length polymorphism)

METHOD

HLA-DRB1 genotyping was performed by the PCR-SSCP (sequence specific conformational polymorphism) method.

RESULTS

The -159C/T dimorphism is not associated with whole RA or with female RA, and the results were compatible with a previous report from Germany. The -159C/T dimorphism was not associated with rheumatoid factor (RF)-positive RA, although the -159T allele tended to be associated with RF in the German report. The -159C/T dimorphism showed no association even in RA patients with the RA-susceptibility HLA-DRB1*0405. The -159T allele was prevalent in Japanese controls.

CONCLUSION

The CD14 gene is very unlikely to be genetically involved in the pathogenesis of Japanese RA.

Using a low-cost simulation approach for assessing the impact of a medication administration system on workflow

This paper describes the analysis of the impact of a medication administration system on clinical workflow. The methodological framework employed was based on in-depth analysis of simulated user interactions with a medication administration system. The approach involved the collection of rich data consisting of audio and video recordings of interactions between 16 subjects (5 nurses and 11 physicians) as they interacted with a medication administration system. Methodological considerations and issues in conducting such studies are discussed. The study indicated that use of the system would have a significant impact on nurse and physician workflow and that this impact could be accurately identified using simulation approaches prior to widespread release of such systems in real clinical environments.

The application of an institutional clinical data warehouse to the assessment of adverse drug reactions (ADRs). Evaluation of aminoglycoside and cephalosporin associated nephrotoxicity

OBJECTIVES

To apply an institutional clinical data warehouse (CDW) to the assessment of adverse drug reactions (ADRs) and demonstrate its utility through a specific example.

METHODS

We modeled the process for assessing ADRs through retrospective cohort design by using CDW at the Osaka University Hospital as follows: 1) We defined a drug X, an adverse drug reaction (ADR) Y, and a laboratory measurement Z to assess Y during a given study period; 2) we excluded those whose Z value exceeded the defined criteria or were not available at the inception of the cohort; 3) we divided the patients into two groups based on exposure or non-exposure to X; 4) we matched the patient characteristics between the two groups through stratification and randomization; and 5) we compared the frequency of patients who presented Y during the study period between the two groups. Aminoglycoside and Cephalosporin associated nephrotoxicity in pediatric inpatients was used as an example to demonstrate the usefulness of this approach.

RESULTS

Our evaluation indicates that there is an increased risk of nephrotoxicity for pediatric inpatients who were prescribed cephalosporin either alone or in combination with aminoglycoside; further, aminoglycoside tends to increase the cephalosporin-associated nephrotoxicity.

CONCLUSIONS

Our findings are consistent with those drawn from other studies, indicating that the method of applying an institutional CDW is useful for assessing ADRs.

Genetic contribution of the tumour necrosis factor (TNF) B + 252*2/2 genotype, but not the TNFa,b microsatellite alleles, to systemic lupus erythematosus in Japanese patients

The contribution of the tumour necrosis factor (TNF) B + 252 (TNFB) dimorphism and microsatellite polymorphisms of TNFa and TNFb to the pathogenesis of systemic lupus erythematosus (SLE) was studied in Japanese patients. The TNFB dimorphism was determined using the restriction fragment length polymorphism (RFLP) method with NcoI digestion followed by specific polymerase chain reaction (PCR) amplification. TNFa and TNFb microsatellite polymorphisms were determined using the DNA sequencer and GeneScan program (Applera Corporation, Foster City, CA) followed by specific PCR amplification. HLA-DRB1*15 typing was carried out by the PCR-sequence specific conformational polymorphism (SSCP) method. In SLE, the allele frequency of TNFB*2 significantly increased (68.9%, P < 0.05) and the genotype frequency of TNFB*2/2 also increased (52.8%, P < 0.05). TNFB*2 showed no significant linkage disequilibrium with HLA-DRB1*1501. The prevalence of TNFa13 and TNFb4 showed very slight increases, but these increases were not significant. An association analysis indicated that TNFB*2/2 conferred greater, or at least equal, susceptibility to SLE in Japanese patients in comparison with HLA-DRB1*1501. The TNFB*2/2 genotype may contribute additively with DRB1*1501 to SLE in Japanese patients. No association was observed between auto-antibodies and TNF. TNFB*2 is a genetic marker for SLE in Japanese patients, while TNFa and TNFb microsatellites are not associated with SLE.

The genetic contribution of the TNFa11 microsatellite allele and the TNFb + 252*2 allele in Japanese RA

OBJECTIVES

The contribution of the microsatellite polymorphisms of TNFa and TNFb, and the TNFB + 252 (TNFB) dimorphism to the pathogenesis of rheumatoid arthritis (RA) was studied among Japanese patients.

METHODS

The TNFa and TNFb microsatellite polymorphisms, and the TNFB dimorphism were determined in Japanese RA patients and normal subjects using electrophoresis followed by specific PCR amplification. HLA-DRB1*04 typing was carried out by the PCR-SSCP method.

RESULTS

The allele frequency of TNFa11 showed a significant increase in RA with DRB1*0405 when compared to that in RA without DRB1*0405 (28.5% Vs 12.9%, respectively, p = 0.022). An association analysis indicated that TNFa11 was not primary, but secondary to the increase in HLA-DRB1*0405, because TNFa11 showed a strong positive association with HLA-DRB1*0405 in Japanese controls. The slight increase in the TNFb4 allele observed in RA with DRB1*0405 (50.0%) may be reflective of the increase in TNFa11 and DRB1*0405. In RA with DRB1*0405, the allele frequency of TNFB*2 significantly increased compared to that of normal controls (75.0% Vs 55.3%, respectively, p = 0.007) and compared to that of RA without DRB1*0405 (45.0%, p = 0.001). No significant positive association of TNFB*2 with HLA-DRB1*0405 or TNFa11 in Japanese controls might suggest that the increase in the TNFB*2 allele might not be secondary to the increase in DRB1*0405, and that TNFB*2 might contribute additively to DRB1*0405-positive RA in Japanese.

CONCLUSION

TNFB*2 may contribute additively to Japanese RA with HLA-DRB1*0405, while TNFa11 and TNFb4 are not independent genetic markers of RA among Japanese.

Molecular analysis of coat protein coding region of tobacco stunt virus shows that it is a strain of Lettuce big-vein virus in the genus Varicosavirus

To evaluate the relationship between tobacco stunt virus (TStV) and Lettuce big-vein virus (LBVV), we determined nucleotide sequences of the coat protein (CP) coding region of five TStV and three LBVV isolates and compared them with those of one Japanese and four Spanish isolates of LBVV. CP coding regions were identical in size and the nucleotide and amino acid sequence identities between TStV and LBVV were 95.6-96.5% and 97.2-98.7%, respectively. Phylogenetic analysis of nucleotide sequences indicated that TStV was very closely related to LBVV and a strain of LBVV rather than a distinct species.

Competition between wild-type virus and a reassortant from subgroups I and II of CMV and activation of antiviral responses in cowpea

To investigate the interactions between RNA3 and RNA4 from subgroups I and II in mixed infections, accumulation of CMV RNA were analyzed. In the mixed inoculation assays with CMV-LE (LE, subgroup I) and a reassortant LLm consisting of RNA1 and RNA2 from LE, and RNA3 from CMV-m2 (m2, subgroup II), LE RNA3 and RNA4 could systemically spread in the plants, whereas those of m2 could not. Furthermore, accumulation of virus short RNA and a cowpea-encoded RNA-directed RNA polymerase gene (VuRdRP1) mRNA were found in the plants, suggesting that VIGS and/or distinct antiviral responses (was) were activated by infection with CMV.

PACS linked to EPR

We developed a new PACS linked to Electronic Patient Record system (EPR). It was a hospital-wide PACS storing all the radiological examinations. The images and reports were linked on EPR. The concept of navigation servers and segment servers was introduced for prefetchig and quick displaying. After the start of operation, increasing retrieval indicated its effectiveness on practical work in spite of remaining delivery of radiographs.

Dynamic viewer of medical events in electronic medical record

Medical record should enable doctors to comprehend the patient's history and select suitable medical treatment. In paper based medical records, medical events (examination, treatment etc.) are recorded successively, and problem oriented recording is difficult to be applied to patients with much information and a long history. Consequently it is not easy to understand the patient's history from paper based medical records. In order to solve this problem, we developed the flow sheet system in our electronic medical record (EMR). To make a flow sheet, we analyzed the structure of the medical event data. In this paper we introduced the medical event information model for our EMR. Furthermore, we clarified the specification of the data presentation on the flow sheet. We developed the flow sheet on the basis of these analyses. Because there are 3 layers in the vertical axis of the flow sheet, many items of the medical event can be displayed on the screen. When user clicks the cell, the corresponding detail data including images are shown. This system functions to link medical event items with a problem, and shows the bundled items on the flow sheet when the user selects the problem. We implemented this system in Osaka University Hospital. The number of the types of medical events and those of detail events in inpatients are 5.0+1.7 (mean+SD) and 60+47, respectively. The medical doctors in Osaka University Hospital evaluated this system, and concludes that the flow sheet data presentation makes comprehension of the patient's history easier than paper based records. As to the function of bundling the items relevant to the problem, they feel it is especially useful for patients with chronic disease. Thus the flow sheet data presentation in EMR is useful for medical practice.

Cilnidipine more highly attenuates cold pressor stress-induced platelet activation in hypertension than does amlodipine

The clinical significance of N-type calcium channel blockade has not been fully examined. We here compared the effects of the N-type calcium channel blockers cilnidipine and amlodipine on the sympathetic nervous system and platelet function in hypertension under resting and stressed conditions. Thirty-two patients with hypertension (58+/-9 years) received cilnidipine or amlodipine for 4 weeks in this crossover study. On day 28 of each treatment, plasma levels of epinephrine (EP), norepinephrine (NEP), and beta-thromboglobulin (BTG), and EC50 of ADP-induced platelet aggregation (ADPE50) were determined at rest and after a cold pressor test. On day 29, the group receiving cilnidipine was switched to amlodipine treatment, and vice versa. At rest, the blood pressure, heart rates, EP, NEP, ADPEC50, and BTG, were similar in both treatments. After the cold pressor test, increases in EP (35+/-17 to 44+/-25 pg/ml; p<0.05) and BTG (40+/-13 to 49+/-22 ng/ml; p<0.01) and a decrease in ADPEC50 (32+/-26 to 27+/-24 micromol; p<0.05) were observed in the amlodipine treatment, but not in the cilnidipine treatment. In addition, the increase in NEP was significantly greater (p<0.05) in the amlodipine (276+/-78 to 318+/-87 pg/ml; p<0.01) than in the cilnidipine treatment (273+/-88 to 291+/-100 pg/ml; p<0.05). Cilnidipine more highly attenuates the activation of platelet function in response to cold pressor stress than does amlodipine. Attenuated activation of the sympathetic nervous system via N-type calcium channel blockade may contribute to this phenomenon.

Synthesis of TiRru2 heterobimetallic and TiRuM (M = Rh, Rr, Pd, Pt) heterotrimetallic sulfido clusters from a hydrosulfido-bridged titanium-ruthenium complex

Treatment of the hydrosulfido-bridged titanium-ruthenium heterobimetallic complex [Cp2Ti(mu2-SH)2RuCl(eta5-C5Me5)] (1; Cp = eta5-C5H5) with an excess of triethylamine followed by addition of [RuCl2(PPh3)3] and [[(cod)M]2(mu2-Cl)2] (M = Rh, Ir; cod = 1,5-cyclooctadiene) led to the formation of the TiRu2 and TiRuM mixed-metal sulfido clusters [(CpTi)[(eta5-C5Me5)Ru][Ru(PPh3)2](mu3-S)2(mu2-Cl)2] (3) and [(CpTi)[(eta5-C5Me5)Ru][M(cod)](mu3-S)2(mu2-Cl)] (M = Rh (4a), Ir (4b)), respectively. On the other hand, the reactions of 1 with [M(PPh3)4] (M = Pd, Pt) afforded the TiRuM trinuclear clusters [(CpTiCl)[(eta5-C5Me5)Ru][M(PPh3)2](mu3-S)(mu2-S)(mu2-H)] (M = Pd (5a), Pt (5b)) with an unprecedented M3(mu3-S)(mu2-S) core. The detailed structures of these triangular clusters 3-5 have been determined by X-ray crystallography. Crystal data: 3, triclinic, P1, a = 12.448(4) A, b = 12.773(4) A, c = 17.270(4) A, alpha = 100.16(2) degrees, beta = 99.93(2) degrees, gamma = 114.11(3) degrees, V = 2373(1) A(3), Z = 2; 4a, triclinic, P1, a = 7.714(2) A, b = 11.598(3) A, c = 14.802(4) A, alpha = 80.46(2) degrees, beta = 82.53(2) degrees, gamma = 71.47(2) degrees, V = 1234.0(6) A3, Z = 2; 4b, triclinic, P1, a = 7.729(1) A, b = 11.577(2) A, c = 14.766(3) A, alpha = 80.14(1) degrees, beta = 82.71(1) degrees, gamma = 71.55(1) degrees, V = 1231.1(4) A3, Z = 2; 5a, monoclinic, P2(1)/c, a = 11.259(4) A, b = 16.438(4) A, c = 26.092(5) A, beta = 102.23(3) degrees, V = 4719(2) A(3), Z = 4; 5b, monoclinic, P2(1)/n, a = 11.369(2) A, b = 16.207(3) A, c = 26.116(2) A, beta = 102.29(1) degrees, V = 4701(1) A3, Z = 4.

Architecture for networked electronic patient record systems

There have been two major approaches to the development of networked electronic patient record (EPR) architecture. One uses object-oriented methodologies for constructing the model, which include the GEHR project, Synapses, HL7 RIM and so on. The second approach uses document-oriented methodologies, as applied in examples of HL7 PRA. It is practically beneficial to take the advantages of both approaches and to add solution technologies for network security such as PKI. In recognition of the similarity with electronic commerce, a certificate authority as a trusted third party will be organised for establishing networked EPR system. This paper describes a Japanese functional model that has been developed, and proposes a document-object-oriented architecture, which is-compared with other existing models.

Papillon-Lefèvre syndrome: analysis of HLA antigens

OBJECTIVES

Papillon-Lefèvre syndrome (PLS) is a rare disease associated with prepubertal periodontitis. Our previous studies demonstrated that three unrelated patients with PLS showed the similar antigen-specific immune responses to Actinobacillus actinomycetemcomitans. The initiation of antigen-specific immune responses was involved with human leukocyte antigens (HLA) on antigen-presenting cells. The aim of this study was to examine HLA haplotypes in the three patients with PLS.

SUBJECTS AND METHODS

The three PLS patients, their mothers and the father of one patient participated in this study. HLA class I and class II antigens were determined serologically and DNA typing for DRB1 and DQB1 was performed using the restriction fragment length polymorphism-polymerase chain reaction method.

RESULTS

The distribution of serologic HLA haplotypes, in two of three patients, was found to be quite similar. The DNA typing revealed that DRB1*0406, DRB1*08032, DQB1*0302, DQB1*06011 genotypes were shared in the two patients. The probability of sharing these four DNA types in unrelated individuals was nearly 1:40,000 in the Japanese population.

CONCLUSION

Our results suggest that HLA antigen may be included as a possible host factor in the pathogenesis of PLS and that a genetically controlled immune response may account for an increased susceptibility to periodontal infection.

Close relationship of abnormal glucose tolerance with endothelial dysfunction in hypertension

Hypertension is frequently accompanied by left ventricular hypertrophy, endothelial dysfunction, and abnormal glucose metabolism. However, no study has examined the relative pathological significance of left ventricular hypertrophy and abnormal glucose metabolism on endothelial dysfunction in hypertension. This study was conducted to evaluate whether abnormal glucose tolerance assessed by 75-g oral glucose tolerance test or left ventricular hypertrophy is more closely associated with endothelial dysfunction in never-treated hypertensive patients without elevated fasting blood glucose. We studied 107 unmedicated hypertensive patients (mean age, 54+/-10 years) whose fasting blood glucose was <7.0 mmol/L. Endothelial function was assessed by change in brachial artery diameter in response to reactive hyperemia, and left ventricular mass index was determined by ultrasonography. Simple linear regression analysis demonstrated that endothelial function significantly correlated with left ventricular mass index and 2-hour blood glucose in 75-g oral glucose tolerance test, but not with fasting blood glucose. Multiple linear regression analysis revealed that endothelial function significantly correlated with 2-hour blood glucose (beta=-2.68, P<0.05) after we controlled for other clinical variables. Patients were divided into 3 groups according to 2-hour blood glucose levels. Endothelial function was more impaired in patients with diabetes (n=12; 4.7+/-1.8%) and in those with impaired glucose tolerance (n=31; 6.3+/-2.9%) than in those with normal glucose tolerance (n=64; 8.4+/-4.5%) (P<0.05), but left ventricular mass index was similar in these 3 groups. Abnormal glucose tolerance assessed by 75-g oral glucose tolerance test, rather than left ventricular hypertrophy, may have direct pathophysiological relevance to endothelial dysfunction in borderline to moderate hypertensive patients.

Differential expression of plastidic aldolase genes in Nicotiana plants under salt stress

Two homologous genes of plastidic fructose-1,6-bisphosphate aldolase (AldP) isozymes were isolated from green leaves of a salt stress-tolerant Nicotiana species, Nicotiana paniculata, by differential screening. The products of the corresponding genes, NpAldP1 and NpAldP2, were 91% identical to each other and 70-85% identical to the other known plant plastidic aldolases. Although these two genes showed similar organ-specific expression and daily cycles, their responses to salt stress differed: mRNA accumulation of NpAldP2 increased, but that of NpAldP1 slightly decreased. The mRNA accumulations of their counterparts of two other Nicotiana species, NeAldP1 and NeAldP2 (Nicotiana excelsior), and NaAldP1 and NaAldP2 (Nicotiana arentsii) were studied under the same stress condition. N. arentsii conserved accumulation profiles similar to N. paniculata, but N. excelsior did not. In N. excelsior, accumulation of NeAldP1 decreased to 50% of the control after stress and gradually recovered thereafter, whereas accumulation of NeAldP2 temporarily decreased and reached 250% of the control by the third day of stress. Southern blot analysis indicated that NpAldP1, NpAldP2, NaAldP1, and NaAldP2 include one or two closely related genes and NeAldP1 and NeAldP2 several.

Flower-predominant expression of a gene encoding a novel class I chitinase in rice (Oryza sativa L.)

A flower-predominant cDNA for a gene, termed OsChia 1;175, was isolated from a cDNA library of rice pistils. Northern blot and RT-PCR analyses revealed that the OsChia 1;175 gene is highly expressed in floral organs (pistils, stamens and lodicules at the heading stage) but not or at an extremely low level in vegetative organs. OsChia 1;175 encodes a protein that consists of 340 amino acid residues, and the putative mature protein shows 52% to 63% amino acid identity to class I chitinases of rice or other plants. The phylogenetic tree shows that the OsChia 1;175 protein is a new type of plant class I chitinase in rice. The expression of OsChia 1;175 in vegetative organs is not induced by several chemicals, UV, and wounding. The soluble putative mature OsChia 1;175 protein expressed in Escherichia coli exhibited chitinase activity in the assay with colloidal chitin as a substrate. Genomic Southern analysis revealed that the OsChia 1;175 gene was organized as a low-copy gene family. The rice genomic library was screened and a genome clone corresponding to OsChia 1;175 was isolated. The transcription start sites of the OsChia 1;175 gene were mapped by primer extension analysis. The 1.2 kb putative promoter region of the OsChia 1;175 gene was fused to the GUS (beta-glucuronidase) gene, and this chimeric gene was introduced to rice by Agrobacterium-mediated transformation. The flower-predominant gene expression was identified also in the transgenic rice plants. The high promoter activity was detected in the stigmas, styles, stamens and lodicules in transgenic plants. The possible functions of OsChia 1;175 are discussed.

Syntheses, structures, and reactivities of mono- and dinuclear iridium thiolato complexes containing nitrosyl ligands

Reactions of the iridium(III) nitrosyl complex [Ir(NO)Cl2(PPh3)2] (1) with hydrosulfide and arenethiolate anions afforded the square-pyramidal iridium(III) complex [Ir(NO)(SH)2(PPh3)2] (2) with a bent nitrosyl ligand and a series of the square-planar iridium(I) complexes [Ir(NO)(SAr)2(PPh3)] (3a, Ar = C6H2Me3-2,4,6 (Mes); 3b, Ar = C6H3Me2-2,6 (Xy); 3c, Ar = C6H2Pri3-2,4,6) containing a linear nitrosyl ligand, respectively. Complex 1 also reacted with alkanethiolate anions or alkanethiols to give the thiolato-bridged diiridium complexes [Ir(NO)(mu-SPri)(SPri)(PPh3)]2 (4) and [Ir(NO)(mu-SBut)(PPh3)]2 (5). Complex 4 contains two square-pyramidal iridium(III) centers with a bent nitrosyl ligand, whereas 5 contains two tetrahedral iridium(0) centers with a linear nitrosyl ligand and has an Ir-Ir bond. Upon treatment with benzoyl chloride, 3a and 3b were converted into the (diaryl disulfide)- and thiolato-bridged dichlorodiiridium(III) complexes [[IrCl(mu-SC6HnMe4-nCH2)(PPh3)]2(mu-ArSSAr)] (6a, Ar = Mes, n = 2; 6b, Ar = Xy, n = 3) accompanied by a loss of the nitrosyl ligands and cleavage of a C-H bond in an ortho methyl group of the thiolato ligands. Similar treatment of 4 gave the dichlorodiiridium complex [Ir(NO)(PPh3)(mu-SPri)3IrCl2(PPh3)] (7), which has an octahedral dichloroiridium(III) center and a distorted trigonal-bipyramidal Ir(I) atom with a linear nitrosyl ligand. The detailed structures of 3a, 4, 5, 6a, and 7 have been determined by X-ray crystallography.

Synthesis and reactivities of cubane-type sulfido clusters containing noble metals

Cubane-type sulfido clusters containing noble metals are newcomers compared with the corresponding clusters of the first transition series metals and molybdenum, which have been extensively studied in relation to metalloenzymes and industrial hydrodesulfurization catalysts. This Account reviews the recent progress in studies on the synthesis and reactivities of these noble metal cubane-type clusters. One of the goals in this new area lies in development of the unique catalysis of the noble metals embedded in the robust and redox-active cubane-type cores. Rational synthetic approaches indispensable to the preparation of such effective cluster catalysts are discussed to a significant extent.

Characteristics of cardiovascular morphology and function in the high-normal subset of hypertension defined by JNC-VI recommendations

A cross-sectional study was conducted to compare the morphological and functional characteristics of the cardiovascular system among subgroups of hypertension defined by the JNC-VI recommendations. One hundred and sixteen subjects (normotensives and unmedicated hypertensives: 49+/-10 yr) were classified into 4 groups based on the criteria of JNC-VI: normotensive (NOR: n = 38), high-normal blood pressure (HN: n = 16), stage 1 hypertensive (SI: n = 28), and stage 2 to 3 hypertensive (SII-III: n = 34). Ultrasonographic examinations of the heart and carotid artery were performed in all subjects, and the following parameters were obtained: left ventricular mass index (LVMI), relative wall thickness at end-diastole (RWTd), cardiac diastolic function (A/E), common carotid artery diameter (CAD), intimal media thickness of the common carotid artery (IMT), and distensibility of the common carotid artery (Distens). RWTd, A/E, and IMT in SI (RWTd, 0.41+/-0.07; A/E, 1.21+/-0.41; IMT, 0.69+/-0.17 mm) and SII-III patients (0.40+/-0.08, 1.38+/-0.33, 0.80+/-0.21 mm) were larger than those in NOR patients (0.33+/-0.03, 0.86+/-0.21, 0.56+/-0.10 mm) (p < .01). Furthermore, LVMI in SII-III (135.5+/-35.5 g/m2) patients was larger than that in NOR patients (99.4+/-17.5 g/m2) (p < .05). RWTd in HN patients (0.37+/-0.06) was significantly higher than that in NOR patients (p < .05). A/E tended to be larger in HN than in NOR patients (p < 0.1). In the normotensives, no significant difference in any of the parameters was detected between those with optimal (n = 19) and normal (n = 19) blood pressure. Thus, both morphological and functional changes were associated with elevation of blood pressure. Cardiac morphological adaptation and functional impairment were present even in subjects with high-normal blood pressure level, while there were no significant differences between the normal and optimal subsets.

Novel polymorphism in the promoter region of the tumor necrosis factor alpha gene: No association with narcolepsy

The striking evidence of almost 100% association of narcolepsy with human leukocyte antigens (HLA) DR2(DR15) antigen is an important clue to elucidate the molecular basis of this sleep disorder. The gene for tumor necrosis factor alpha (TNF alpha) is located in the HLA class II gene cluster. Recent studies have indicated that TNF alpha plays an important role in the regulation of normal human sleep, and regulation of this cytokine may be disturbed in narcolepsy. We searched for a mutation associated with narcolepsy in the promoter region of the TNF alpha gene by single-strand conformation polymorphism analysis. A novel polymorphism, C-850T, was found in narcoleptic patients. Genotype frequency was examined by restriction fragment length polymorphism method. No significant difference of genotype distribution was found between 92 patients with narcolepsy and 91 normal controls. These results do not support our hypothesis that genetic abnormality of TNF alpha production is pathogenetic for narcolepsy.

Polymorphisms of HLA-DM genes in Japanese patients with psoriasis vulgaris

We analysed the polymorphisms of HLA-DM genes in 85 unrelated Japanese patients with psoriasis vulgaris and 52 healthy controls using the polymerase chain reaction-restriction fragment length polymorphism method. The frequency of DMA*0101 was decreased (79% vs. 89%, P < 0.05) and that of DMA*0102 was increased (20% vs. 11%, P < 0.05) in the patients. However, neither of these remained significant after P-values were corrected for the number of comparisons made (Pc > 0.05). As we reported previously, HLA-C molecules are assumed to play a more important part than HLA-DM genes in the development of psoriasis vulgaris.

Devices for structured data entry in electronic patient record

Electronic patient record is expected to have edit, data analysis, and decision supporting functions. To realize these functions, the entered data should be structured. We made a template based data entry system with some devices. We defined a template for each describing unit, i.e., symptom, physical finding and examination report. Template is composed of several describing elements (a pair of property and value), which form tree structure in general. When a template is selected, the top layers of the elements are displayed at once allowing data entry. When the data qualified by other elements is entered then system presents the second layer about this data at once. This enables users to skip entering some unnecessary items. Users can constitute a form by combining some templates frequently used in a situation. Furthermore, at the second patient visit, the system can present the templates used in the former patient visit to check the different point. These templates and forms can be made easily by editing the master data using template master maintenance program. The entered patient data are presented in progress note and flow sheet. In progress note, the entered data are translated into natural language. In the flow sheet, representative data of each template are present in the cell of the matrix whose line indicates the describing unit and column indicates date. If the cell is clicked, then the details are presented. Using this system, we made templates and forms for cardiovascular field and entered the data about an actual patient with angina pectoris. The time taken by inputting data is shorter than that by handwriting and the content is enough for a patient record. This system is practical for structured data entry in electrical patient record.

Functional evaluation of telemedicine with super high definition images and B-ISDN

In order to determine whether a super high definition (SHD) image running at a series of 2048 resolution x 2048 line x 60 frame/sec was capable of telemedicine, we established a filing system for medical images and two experiments for transmission of high quality images were performed. All images of various types, produced from one case of ischemic heart disease were digitized and registered into the filing system. Images consisted of plain chest x-ray, electrocardiogram, ultrasound cardiogram, cardiac scintigram, coronary angiogram, left ventriculogram and so on. All images were animated and totaled a number of 243. We prepared a graphic user interface (GUI) for image retrieval based on the medical events and modalities. Twenty one cardiac specialists evaluated quality of the SHD images to be somewhat poor compared to the original pictures but sufficient for making diagnoses, and effective as a tool for teaching and case study purposes. The system capability of simultaneously displaying several animated images was especially deemed effective in grasping comprehension of diagnosis. Efficient input methods and creating capacity of filing all produced images are future issue. Using B-ISDN network, the SHD file was prefetched to the servers at Kyoto University Hospital and BBCC (Bradband ISDN Business chance & Culture Creation) laboratory as an telemedicine experiment. Simultaneous video conference system, the control of image retrieval and pointing function made the teleconference successful in terms of high quality of medical images, quick response time and interactive data exchange.

A search for a mutation in the tumour necrosis factor-alpha gene in narcolepsy

The discovery of almost 100% association of narcolepsy with human leukocyte antigens (HLA) DR2 antigen prompted molecular biological research of this disorder. In the HLA class II gene cluster, the gene for tumour necrosis factor-alpha (TNF-alpha), which plays a role in the regulation of normal human sleep, is located. The present study searched for a mutation in the TNF-alpha gene by single-strand conformation polymorphism analysis (SSCP) in patients with narcolepsy. No mutation was detected in exons and introns of the TNF-alpha gene by SSCP and sequencing.

Involvement of cucumber mosaic cucumovirus RNA2 and RNA3 in viral systemic spread in radish plant

The genetics of cucumber mosaic cucumovirus (CMV) and the pathogenicity of the virus for Raphanus sativus were analyzed using pseudorecombinants constructed from the infectious transcripts of two naturally occurring strains of cucumber mosaic cucumovirus (CMV-D8 and CMV-Y). CMV-D8, but not CMV-Y, could cause systemic infection of the plant. Viral accumulation and systemic movement in the plants was examined using immuno-tissue blot analysis, dot blot and Northern blot hybridization. Virus was equally distributed and CMV RNAs accumulated to similar levels in the inoculated cotyledons of radish irrespective of the pseudorecombinant, suggesting that there are no apparent differences in the ability of infection and viral accumulation between CMV-D8 and CMV-Y. We found, however, that both RNAs 2 and 3 of CMV-D8 are involved in determining the efficiency for the systemic infection of R. sativus. Co-operated interactions between genetic information of RNAs 2 and 3 would control the efficient translocation of virus from the inoculated leaves to the uninoculated upper leaves of radish plant.

Analysis of HLA class II and TAP alleles in Japanese patients with psoriasis vulgaris

We investigated HLA class II and transporter associated with antigen processing (TAP) alleles in eighty-five unrelated Japanese patients with psoriasis vulgaris and fifty-two healthy controls using the polymerase chain reaction-restriction fragment length polymorphism method. The frequencies of DRB1*1502 and DQB1*0601 were increased in the patient group (DRB1*1502; 21% vs 12%, p < 0.05, DQB1*0601; 35% vs. 21%, p < 0.05), while the frequencies of DRB1*0406 and TAP2*E were decreased in the patients (DRB1*0406; 2% vs 9%, p < 0.05, TAP2*E; 4% vs 11%, p < 0.05). However, none of these remained significant after p values were corrected for the number of comparisons made (pc > 0.05). We also analysed specific amino acids on HLA class II molecules, but no significant difference was found between the two groups. Our previous reports clarified that aspartate at residue 9 (48% vs 20%, p < 0.002) and alanine at residue 73 (81% vs 48%, p < 0.0001) on HLA-C molecules were strongly associated with Japanese patients with PsV. These specific amino acids on HLA-C molecules are supposed to play more important roles compared with HLA class II and TAP alleles in the development of psoriasis vulgaris.