A case of nivolumab-induced acute-onset type 1 diabetes mellitus in melanoma

Nivolumab, an anti-PD-1 antibody, is now considered an important therapeutic agent in several advanced malignancies. However, immune-related adverse events such as endocrinopathies have been reported with its use. Thyroid disorder and isolated adrenocorticotropic hormone deficiency have frequently been reported as nivolumab-induced immune-related adverse events. Another endocrinopathy is nivolumab-induced type 1 diabetes mellitus (t1dm), described as diabetes mellitus with rapid onset and complete insulin insufficiency, at times leading to fulminant t1dm. We report the case of a 68-year-old woman who developed pancreatic islet-related autoantibody-negative t1dm, possibly induced by nivolumab, under continuous glucocorticoid administration. She was treated with nivolumab for advanced malignant melanoma, concomitant with 10 mg prednisolone daily for thrombophlebitis tapered to 5 mg after 13 courses of nivolumab therapy. At approximately the 27th course of nivolumab therapy, she showed elevated plasma glucose levels despite preserved insulin secretion. A month later, she developed diabetic ketoacidosis. Her insulin secretion decreased and finally was exhausted. She was diagnosed with acute-onset rather than fulminant t1dm because of a rapidly progressive course to diabetic ketoacidosis during just more than 1 week. She is currently receiving insulin replacement. There has been no recurrence of the melanoma. Thus, nivolumab might induce autoimmune diabetes mellitus, with patients having t1dm-sensitive human leucocyte antigen being more susceptible even when receiving glucocorticoids. Physicians should be aware that nivolumab could potentially induce t1dm as a critical immune-related adverse event.

Using a WWW-based Mail User Agent for Secure Electronic Mail Service for Health Care Users

WWW-based user interface is presented for secure electronic mail service for healthcare users. Using this method, communications between an electronic mail (WWW) server and users (WWW browsers) can be performed securely using Secure Socket Layer protocol-based Hypertext Transfer Protocol (SSL-HTIP). The mail can be encrypted, signed, and sent to the recipients and vice versa on the remote WWW server. The merit of this method is that many healthcare users can use a secure electronic mail system easily and immediately, because SSL-compatible WWW browsers are widely used and this system can be made available simply by installing a WWW-based mail user agent on a mail server. We implemented a WWWbased mail user agent which is compatible with PEM-based secure mail and made it available to about 16,000 healthcare users. We believe this approach is effective in facilitating secure network-based information exchange among medical professionals.

Object-oriented Analysis and Design of an ECG Storage and Retrieval System Integrated with an HIS

For a hospital information system, object-oriented methodology plays an increasingly important role, especially for the management of digitized data, e.g., the electrocardiogram, electroencephalogram, electromyogram, spirogram, X-ray, CT and histopathological images, which are not yet computerized in most hospitals. As a first step in an object-oriented approach to hospital information management and storing medical data in an object-oriented database, we connected electrocardiographs to a hospital network and established the integration of ECG storage and retrieval systems with a hospital information system. In this paper, the object-oriented analysis and design of the ECG storage and retrieval systems is reported.

A CORBA-Based Object Framework with Patient Identification Translation and Dynamic Linking

Exchanging and integration of patient data across heterogeneous databases and institutional boundaries offers many problems. We focused on two issues: (1) how to identify identical patients between different systems and institutions while lacking universal patient identifiers; and (2) how to link patient data across heterogeneous databases and institutional boundaries. To solve these problems, we created a patient identification (ID) translation model and a dynamic linking method in the Common Object Request Broker Architecture (CORBA) environment. The algorithm for the patient ID translation is based on patient attribute matching plus computer-based human checking; the method for dynamic linking is temporal mapping. By implementing these methods into computer systems with help of the distributed object computing technology, we built a prototype of a CORBA-based object framework in which the patient ID translation and dynamic linking methods were embedded. Our experiments with a Web-based user interface using the object framework and dynamic linking through the object framework were successful. These methods are important for exchanging and integrating patient data across heterogeneous databases and institutional boundaries.

An Ontology-based Mediator of Clinical Information for Decision Support Systems

Objective: We have been developing a decision support system that uses electronic clinical data and provides alerts to clinicians. However, the inference rules for such a system are difficult to write in terms of representing domain concepts and temporal reasoning. To address this problem, we have developed an ontologybased mediator of clinical information for the decision support system.

Methods: Our approach consists of three steps: 1) development of an ontology-based mediator that represents domain concepts and temporal information; 2) mapping of clinical data to corresponding concepts in the mediator; 3) temporal abstraction that creates high-level, interval-based concepts from time-stamped clinical data. As a result, we can write a concept-based rule expression that is available for use in domain concepts and interval-based temporal information. The proposed approach was applied to a prototype of clinical alert system, and the rules for adverse drug events were executed on data gathered over a 3-month period.

Results: The system generated 615 alerts. 346 cases (56%) were considered appropriate and 269 cases (44%) were inappropriate. Of the false alerts, 192 cases were due to data inaccuracy and 77 cases were due to insufficiency of the temporal abstraction.

Conclusion: Our approach enabled to represent a concept-based rule expression that was available for the prototype of a clinical alert system. We believe our approach will contribute to narrow the gaps of information model between domain concepts and clinical data repositories.

A smartphone-based medication self-management system with realtime medication monitoring

BACKGROUND

Most patients cannot remember their entire medication regimen and occasionally forget to take their medication.

OBJECTIVES

The objective of the study was to design, develop, and demonstrate the feasibility of a new type of medication self-management system using smartphones with real-time medication monitoring.

METHODS

We designed and developed a smartphone-based medication self-management system (SMSS) based on interviews of 116 patients. The system offered patients two main functions by means of smartphones: (1) storage and provision of an accurate, portable medication history and medication-taking records of patients; and (2) provision of a reminder to take medication only when the patient has forgotten to take his/her medication. These functions were realized by two data input methods: (a) reading of prescription data represented in two-dimensional barcodes using the smartphone camera and getting the photographic images of the pills; and (b) real-time medication monitoring by novel user-friendly wireless pillboxes.

RESULTS

Interviews suggested that a pocket-sized pillbox was demanded to support patient's medication-taking outside the home and pillboxes for home use should be adaptable to the different means of pillbox storage. In accordance with the result, we designed and developed SMSS. Ten patients participated in the feasibility study. In 17 out of 47 cases (36.2%), patients took their medication upon being presented with reminders by the system. Correct medication-taking occurrence was improved using this system.

CONCLUSIONS

The SMSS is acceptable to patients and has the advantage of supporting ubiquitous medication self-management using a smartphone. We believe that the proposed system is feasible and provides an innovative solution to encourage medication self-management.

An easily implemented method for abbreviation expansion for the medical domain in Japanese text. A preliminary study

BACKGROUND

One of the barriers for the effective use of computerized health-care related text is the ambiguity of abbreviations. To date, the task of disambiguating abbreviations has been treated as a classification task based on surrounding words. Application of this framework for languages that have no word boundaries requires pre-processing to segment a sentence into separate word sequences. While the segmentation processing is often a source of problem, it is unknown whether word information is really requisite for abbreviation expansion.

OBJECTIVES

The present study examined and compared abbreviation expansion methods with and without the incorporation of word information as a preliminary study.

METHODS

We implemented two abbreviation expansion methods: 1) a morpheme-based method that relied on word information and therefore required pre-processing, and 2) a character-based method that relied on simple character information. We compared the expansion accuracies for these two methods using eight medical abbreviations. Experimental data were automatically built as a pseudo-annotated corpus using the Internet.

RESULTS

As a result of the experiment, accuracies for the character-based method were from 0.890 to 0.942 while accuracies for the morpheme-based method were from 0.796 to 0.932. The character-based method significantly outperformed the morpheme-based method for three of the eight abbreviations (p < 0.05). For the remaining five abbreviations, no significant differences were found between the two methods.

CONCLUSIONS

Character information may be a good alternative in terms of simplicity to morphological information for abbreviation expansion in English medical abbreviations appeared in Japanese texts on the Internet.

Wireless LAN security management with location detection capability in hospitals

OBJECTIVES

In medical institutions, unauthorized access points and terminals obstruct the stable operation of a large-scale wireless local area network (LAN) system. By establishing a real-time monitoring method to detect such unauthorized wireless devices, we can improve the efficiency of security management.

METHODS

We detected unauthorized wireless devices by using a centralized wireless LAN system and a location detection system at 370 access points at the University of Tokyo Hospital. By storing the detected radio signal strength and location information in a database, we evaluated the risk level from the detection history. We also evaluated the location detection performance in our hospital ward using Wi-Fi tags.

RESULTS

The presence of electric waves outside the hospital and those emitted from portable game machines with wireless communication capability was confirmed from the detection result. The location detection performance showed an error margin of approximately 4 m in detection accuracy and approximately 5% in false detection. Therefore, it was effective to consider the radio signal strength as both an index of likelihood at the detection location and an index for the level of risk.

CONCLUSIONS

We determined the location of wireless devices with high accuracy by filtering the detection results on the basis of radio signal strength and detection history. Results of this study showed that it would be effective to use the developed location database containing radio signal strength and detection history for security management of wireless LAN systems and more general-purpose location detection applications.

Genogrouping of Vaccine Breakdown Strains (VBS) of Feline Calicivirus in Japan

Although prevention of feline calcivirus (FCV) infection by vaccination has been attempted, and isolation of FCV, development of the disease, and a few fatal cases in vaccinated cats have been reported. Fifteen FCV strains isolated from cats that had been vaccinated with commercially available FCV vaccines (F9, FCV-255, and FC-7) were genogrouped. Molecular analysis of viral genomes involved the construction of a phylogenetic tree of capsid genes using the NJ method. Cat anti-F9 serum and rabbit anti-FCV-255 serum were used for virus neutralization tests. Molecular phylogenetic analysis of the amino acid sequences of 15 virus isolates and those of the previously published and GenBank-deposited 9 global and 14 Japanese strains showed that 8 (53%) of the 15 virus isolates as well as the vaccine strains F9 and FCV-255 belonged to genogroup I (G(A)I), and 7 (47%) belonged to genogroup II (G(A)II). Of the 8 G(A)I strains, 2 were isolated from cats that had been vaccinated with an F9 strain live vaccine, 5 from cats vaccinated with an FCV-255-derived vaccine, and 1 from a cat vaccinated with an FC-7-derived vaccine. Of the 7 GAll strains, 5 were isolated from cats that had been vaccinated with the F9 strain live vaccine, 1 from a cat vaccinated with the FCV-255-derived vaccine, and 1 from a cat vaccinated with the FC-7-derived vaccine. These results indicate that more vaccine breakdown strains isolated from the cats vaccinated with the F9 strain-derived vaccine belong to G(A)II than to G(A)I, whereas more vaccine breakdown strains isolated from the cats vaccinated with the FCV-255 strain-derived vaccine belong to G(A)I than to G(A)II, and that when the FC-7 strain-derived vaccine is used, the vaccine breakdown strains belong almost equally to G(A)I and G(A)II. Thus, the genogroups of virus isolates varied with the vaccine strain used (p < 0.05). On the other hand, the neutralizing titres of feline anti-F9 serum and rabbit anti-FCV-255 serum against the 15 isolates were very low, showing no relationships between neutralizing antibody titres and genogroups. The DNA sequence identities between the virus isolates and the vaccine strains were low, at 70.6-82.9%, and no strains were found to have sequences derived from the vaccine strains. Alignment of amino acid sequences showed that the G(A)I or G(A)II virus isolates from the F9-vaccinated cats differed at position 428 of the 5' hypervariable region (HVR) of capsid region of the F9 strain, whereas those from the FCV-255-vaccinated cats differed at positions 438, 453, and 460 of the 5'HVR of capsid region E of the F9 strain. We speculate that these differences influence genogrouping. The amino acid changes within the F9 linear epitopes common to G(A)I and G(A)II were noted at positions 450, 451, 457 of 5'HVR of the capsid region E in the isolates from F9-derived vaccine-treated cats, and 449, 450, and 451 of 5'HVR of capsid region E in the isolates from FCV-255-derived vaccine-treated cats, suggesting that these amino acid changes are involved in escapes. These results suggest that alternate vaccination with the F9 and FCV-255 strains or the use of a polyvalent vaccine containing GAll strains serves to inhibit development.

Accuracy of economic studies on surgical site infection

Estimating the cost of hospital infection has become a matter of increasing interest in terms of health economics. This study aimed to assess the accuracy of economic studies on hospital infections, using surgical site infection (SSI) as an example. A search was performed for original articles reporting the cost of SSI, published in the English language between 1996 and 2005. For the critical review, the period of cost tracking, classification of costs and cost counting methods were noted. Fifteen articles met the inclusion criteria. The costs of SSI vary according to surgical procedures, country, publication year, study design and accounting method. Only two studies estimated the additional cost of SSI after discharge. All 15 studies included healthcare costs and none measured patient/family resources. In 10 studies, the costs were calculated based on accounting. Three studies used estimated costs from the ratio of costs to charges and two studies used charge data in place of cost data. It will become increasingly important for future studies to perform multi-centre prospective surveys, establish a standard method for cost accounting, include the cost of healthcare services following hospitalization and consider the morbidity cost to patients themselves from a societal perspective.

Detection of Feline calicivirus (FCV) from Vaccinated Cats and Phylogenetic Analysis of its Capsid Genes

We analysed genogroups of four feline calcivirus (FCV) isolates (FCV-S, H10, Ao198-1 and ML89) obtained from cats that experienced FCV infection after having been vaccinated against FCV. New PCR primer sets (8F/8R, Ao-S/Ao-A, cp-S/cp-A) were also designed, since the conventional Seal primer failed to amplify the target sequences in two samples. The genogroups of the four isolates as well as eight global and 17 domestic strains were determined by phylogenetic analysis of their amino acid sequences. One out of the four strains (25%) isolated in this study, H10, was grouped into genogroup I, along with the vaccine strains F9 and FCV-255. The other three isolates (75%) belonged to genogroup II. Thus, there were more isolates in genogroup II than in genogroup I. However, the antibody values of the four isolates against cat anti-F9 antisera were significantly decreased. There may be no relationship between the neutralizing antibody titre and genogroup. Amino acid sequence alignment of the four isolates showed that only a single amino acid in region C, which is involved in neutralization epitopes, was different in ML89 strain from that of F9. The other three strains, H10, Ao198-1 and FCV-B, shared the same amino acid sequence with F9. Alignment of amino acids for linear epitopes in the F9 strain, which are located at regions D and E, showed variations in 5' hypervariable region (HVR) of E, whereas D and conE had only synonymous substitutions i.e. no change in the amino acid sequence. This mutation in 5' HVR of region E suggested a vaccine breakdown, as the region is known to be essential for antigenicity. The genogroup II FCV is likely to be the cause of the FCV infection in this study, while the vaccine strains belong to genogroup I. Thus, the existing vaccine may need reevaluation for its effectiveness.

Capsid protein genetic analysis and viral spread to the spinal cord in cats experimentally infected with feline calicivirus (FCV)

We investigated primitively the molecular basis of the neural spread of a feline calcivirus isolate (FCV-S) from the spinal cord of a cat that died after manifesting excitation. Experimental infections of cats with three clones from parent virus isolate FCV-S, isolated based on plaque size, were performed, and virus recovery from the spinal cord and the nucleotide and predicted amino acid sequences of the viral capsid protein region (ORF2) were compared. In the experimental infection with the one-time cloned virus (C1L1) isolated from a large plaque, the C1L1 was recovered from the spinal cord. In contrast, seven-times cloned C6L7 (from large plaque) and five-times cloned C5S2 (isolated from small plaque) were not recovered from the spinal cord. Genetic analysis of the capsid protein gene of the three viral clones revealed that four bases were different and two amino acids were different at positions 34 (Val in C6L7 and Ala in C1L1 and C5S2) and 46 (Leu in C6L7 and Pro in C1L1 and C5S2) between C6L7 (with large plaque) and C5S2 (with small plaque). The amino acid at position 434 of C1L1 was different from those of C6L7 and C5S2 (Gly in C1L1, D (Asp) in C6L7 and C5S2). From these results, the plaque size seemed not to be related to the spread of virus to the spinal cord. Clone C1L1, which spread to the spinal cord, had a difference of one amino acid from the other two clones, which may be related to the ability to spread to the spinal cord.

Properties of a calicivirus isolated from cats dying in an agitated state

In June 1993, two of five pet cats kept in Yokohama city in Japan suddenly became agitated and died. Feline calicivirus (FCV) was isolated from them. One strain (FCV-S) was isolated from the spinal cord, lung and tonsil of cat 1, another (FCV-B) from the ileum, medulla oblongata and cervical spinal cord of cat 2, and a third (FCV-SAKURA) from the oral cavity of one of the three surviving cats which showed no clinical signs. These three strains were equally resistant to pH 3.0 and serologically similar to each other, but distinct from strain F9. A genetic analysis, using a 208 base pair fragment from region E of the capsid, showed that FCV-Ari had a 70.4 per cent nucleotide and 77.3 per cent amino acid homology and FCV-F9 had a 68.6 per cent nucleotide and 73.9 per cent amino acid homology with the three strains, indicating that these two strains were genetically distinct from the three new isolates. Unvaccinated cats and cats which had been vaccinated against FCV-F9 developed watery diarrhoea but did not become agitated after the administration of FCV-S. The FCV-S strain did not induce signs of excitability after it was administered orally to specific pathogen-free cats.

Detection of canine distemper virus antigen in canine serum and its application to diagnosis

Canine distemper virus (CDV) antigen was detected in the serum of dogs by an ELISA and the results of this assay were compared with an anti-CDV immunoglobulin M (IgM) antibody test. In paired sera from 26 naturally infected dogs, the antigen-positive rate was 26.9 per cent at the first examination and 11.5 per cent at the second examination two to three weeks later. The antigen was detected in three of the 10 dogs which were negative for anti-CDV IgM antibody at the first examination. It could also be detected in the serum of between eight and two of 40 specific pathogen-free dogs vaccinated against CDV, for up to four weeks after they were vaccinated.

Right Ventricle of Patients Undergoing Congenital Cardiac Surgery Differentially Expresses Haem Oxygenase-1 and Heat Shock Protein 70 Genes

Reactive oxygen species are implicated in the pathogenesis of cardiac hypertrophy. Haem oxygenase-1 (HO-1), the rate-limiting enzyme in haem catabolism, is induced by oxidative stress and confers protection against oxidative tissue injuries. We used Northern blotting to examine expression of HO-1 and heat shock protein 70 (HSP70) in the hypertrophic cardiac muscle of eight patients (one infant and seven children) who underwent surgery for congenital heart disease. Levels of HO-1 and HSP70 mRNA were significantly increased in all specimens, but the orders of magnitude of the increases were different, suggesting that the genes expressing HO-1 and HSP70 are regulated separately.

Phylogenetic analysis of field isolates of feline calcivirus (FCV) in Japan by sequencing part of its capsid gene

The molecular epidemiology of the infectious disease caused by feline calcivirus (FCV) in Japan was investigated by analysing the phylogenetic relationship among 21 Japanese field isolates, including the F4 strain, and 30 global isolates. Parts of the capsid gene (B-F) of the isolates were amplified by RT-PCR, and the amino acid sequences were compared with those from the global isolates. Thirty-seven and 14 out of a total of 51 isolates were clustered into two distinct genogroups, I and II respectively, by UPGMA and NJ analysis. Seven of the 21 Japanese isolates (33%) fell into group I together with 30 global isolates, while the other 14 Japanese isolates (67%) belonged to group II. The bootstrap repetition analysis of groups I and II formed by the NJ method gave a value of 99.00%. The 14 latter Japanese isolates were clearly separated from the isolates in group I, and they were different from any previously known FCV, forming a new genogroup, which implies that this lineage has been confined to Japan. Comparing the amino acid sequences shared by groups I and II, the amino acid at position 377 in B region was asparagine (Asn or Asp (NH2)) in group I, while it was lysine (Lys) in all the strains in group II. Similarly, the amino acid at position 539 in the F region was alanine (Ala) or proline (Pro) in group I, while it was valine (Val) in group II; glycine (Gly) at position 557 in group I was serine (Ser) in Group II; and phenylalanine (Phe) or leucine (Leu) at position 566 in genogroup I was tyrosine (Tyr) in group II.

UMIN--key information infrastructure for the Japanese medical community

University hospital Medical Information Network (UMIN) was established in 1989 as a collaborative project of national university hospitals in Japan funded by the Ministry of Education, Science, Sports, and Culture, and it started its Internet-based service for medical professionals in 1995. Since then, many services including those for academic societies and research groups have been added. Currently, due to batch registration of the members of large academic societies, the number of registered users and Web accesses are rapidly increasing (about 87,000 registered users and 4,500,000 page views in November, 2000). More than one hundred homepages of academic societies and research groups (including forty- two member-only ones) and one thousand mailing lists are operated. More than one hundred thirty academic societies collect abstracts using the UMIN server. All the Internet-based clinical and epidemiological research projects in Japan are now under way using UMIN. The characteristics of UMIN are its large variety of services and large number of user accounts of medical professionals, which are beneficial to both users and information service providers. UMIN is now important for some medical specialties and will be so for further ones in the future. UMIN is, in fact, evolving into a collaborative project of the Japanese medical community and is considered as its key information infrastructure.

Oxidative transformation of tert-cyclobutanols by palladium catalysis under oxygen atmosphere

Palladium(II)-catalyzed oxidative reaction of tert-cyclobutanols involving the cleavage of a C-C bond via beta-carbon elimination under atmospheric pressure of oxygen is described. An alkylpalladium intermediate produced by beta-carbon elimination from a Pd(II) alcoholate gives a variety of products, depending on the substituents on the cyclobutane ring, in which reactions such as dehydrogenative ring opening, ring expansion and ring contraction are involved. For some substrates, the addition of a catalytic amount of ethyl acrylate dramatically accelerates the reaction. In all cases, the dehydrogenative products are obtained and the Pd(II)-hydride species produced at the final stage can be converted again to active Pd(II) species by molecular oxygen.

Orphan receptor DAX-1 is a shuttling RNA binding protein associated with polyribosomes via mRNA

The DAX-1 (NR0B1) gene encodes an unusual member of the nuclear hormone receptor superfamily which acts as a transcriptional repressor. Mutations in the human DAX-1 gene cause X-linked adrenal hypoplasia congenita (AHC) associated with hypogonadotropic hypogonadism (HHG). We have studied the intracellular localization of the DAX-1 protein in human adrenal cortex and mouse Leydig tumor cells and found it to be both nuclear and cytoplasmic. A significant proportion of DAX-1 is associated with polyribosomes and is found complexed with polyadenylated RNA. DAX-1 directly binds to RNA, two domains within the protein being responsible for cooperative binding activity and specificity. Mutations in DAX-1 found in AHC-HHG patients significantly impair RNA binding. These findings reveal that DAX-1 plays multiple regulatory roles at the transcriptional and posttranscriptional levels.

Catalytic diastereoselective sulfimidation of diaryl sulfides and application of chiral sulfimides to asymmetric allylic alkylation

The copper-catalyzed diastereoselective imidation of diaryl sulfides bearing a chiral oxazolinyl moiety at the ortho-position with [N-(p-toluenesulfonyl) imino]phenyliodinane (TsN=IPh) or Chloramine-T trihydrate [TsN(Cl)Na.3H2O] was successfully carried out to give the corresponding optically active N-tosylsulfimides in good yields. For example, the imidation of diphenyl sulfide bearing a methoxymethyl moiety at the 4-position of the oxazoline ring with TsN(Cl)Na.3H2O in acetonitrile in the presence of 10 mol% Cu(OTf)2 at 25 degrees C for 24 h affords the corresponding optically active N-tosylsulfimide in 52% isolated yield with a high diastereoselectivity of 99%. Hydrolysis of the optically active N-p-tosylsulfimides converts them into the corresponding optically active sulfimides in high yields without loss of diastereoselectivity. These novel optically active sulfimides and N-tosylsulfimides work as efficient chiral ligands for palladium(II)-catalyzed allylic alkylation of 1, 3-diphenyl-3-acetoxy-1-propene with dimethyl malonate to give the corresponding alkylation product quantitatively and with a high stereoselectivity (up to 90% ee).

Computerized reminders to monitor liver function to improve the use of etretinate

OBJECTIVE

to determine whether computerized reminders during the process of prescribing can improve the use of drugs requiring prior laboratory testing according to the indications listed in the Drug Package Insert.

MEASURES

Change in proportion of appropriate prescribing and frequency of severe hepatotoxicity between pre- and post-intervention.

METHODS

etretinate, a medication indicated for psoriasis, was selected as a monitored drug because it was the most prescribed of all the identified drugs that require specific prior laboratory tests. Computerized reminders are designed to alert a physician who is about to prescribe etretinate either without the alanine aminotransferase (ALT) test or the aspartate aminotransferase (AST) test within 3 months or despite abnormality in ALT or AST. Data on alerts were gathered by using electronic mail whenever alerts occurred.

RESULTS

prescriptions of etretinate with normal ALT or AST results within the previous three months increased suddenly from 25.9% (127/491) in the pre-intervention period to 66.2% (353/533) in the post-intervention period (P < 0.0001). Moreover, three patients who used etretinate had markedly abnormal tests in the pre-intervention period, but none of the patients were classified in this way in the post-intervention period.

CONCLUSIONS

the computerized reminders appear to improve physicians' use of a drug requiring specific prior laboratory tests.

Plasma endothelin-1 elevation associated with alcohol-induced variant angina

Vasospastic angina as a result of alcohol ingestion has been reported, but the mechanism of alcohol-induced coronary artery spasm is presently unknown. This report presents 2 cases of alcohol-induced variant angina (VA) with elevated levels of plasma endothelin-1 after alcohol ingestion. In case 1, the plasma endothelin-1 concentration was 3.15 pg/ml before drinking (normal <2.30 pg/ml) and increased to 4.09 pg/ml when measured 5 h after alcohol ingestion. After 2 months of abstinence, the plasma endothelin-1 concentration was 2.88 pg/ml and 6 months after abstinence, it decreased to 2.03 pg/ml (normal range). In case 2, the plasma endothelin-1 concentration was 2.44 pg/ml before drinking and increased to 4.36 pg/ml when measured 5 h after alcohol ingestion. After 2 months of abstinence, the plasma endothelin-1 concentration was 3.04 pg/ml and 6 months after abstinence, it decreased to 2.09 pg/ml (normal range). These 2 cases suggest that a relationship may exist between alcohol-induced VA and elevation in the plasma endothelin-1 concentration after alcohol ingestion.

Patient information exchange guideline MERIT-9 using medical markup language MML

To realize clinical data exchange between healthcare providers, there must be many standards in many layers. Terms and codes should be standardized, syntax to wrap the data must be mutually parsable, then transfer protocol or exchange media should be agreed. Among many standards for the syntax, HL7 and DICOM are most successful. However, everything could not be handled by HL7 solely. DICOM is good for radiology images, but, other clinical images are already handled by other "lighter" data formats like JPEG, TIFF. So, it is not realistic to use only one standard for every area of clinical information. For description of medical records, especially for narrative information, we created SGML DTD for medical information, called MML (Medical Markup Language). It is already implemented in more than 10 healthcare providers in Japan. As it is a hierarchical description of information, it is easily used as a basis of object request brokering. It is again not realistic to use MML solely for clinical information in various level of detail. Therefore, we proposed a guide-line for use of available medical standards to facilitate clinical information exchange between healthcare providers. It is called MERIT-9 (MEdical Records, Images, Texts,--Information eXchange). A typical use is HL7 files, DICOM files, referred from an MML file in a patient record, as external entities. Both MML and MERIT-9 are research projects of Japanese Ministry of Health and Welfare, and the purpose is to facilitate clinical data exchanges. They are becoming to be used in technical specifications for new hospital information systems in Japan.

University medical information network--past, present, and future

The University Medical Information Network (UMIN), established in 1989, is a network service organization for national university hospitals in Japan. It has provided various medical information services to medical professionals, including database, electronic mail, and news services. Although its initial network was constructed as a closed network using N1 protocol, it now adopts TCP/IP protocol and is open to other medical professionals via the Internet. The next UMIN network system is planned to be constructed as a secure virtual closed network on the Internet, using cipher technology, and to provide secure information services to national university hospitals via the closed network, and to other medical professional via the Internet. User friendly interface and flexible system development were made possible by adopting TCP/IP, and the number of users dramatically increased accordingly. However, the database, software design, and human organizations developed in the N1 era have now proven to be of great value, and contribute to todayís flourishing state of the UMIN.

A hospital information system based on Common Object Request Broker Architecture (CORBA) for exchanging distributed medical objects--an approach to future environment of sharing healthcare information

Tightly related subsystems in a HIS have to exchange medical data flexibly by the data object rather than by the battery of the data. We developed a CPR subsystem based on Common Object Request Broker Architecture (CORBA) that retrieves and stores clinical information in the object-oriented database via Internet Intra-ORB Protocol (IIOP). The system is hybridized with the legacy HIS applications on the client terminals. We believe that our solution and the experiences will contribute to the future CORBA-based environment in which computerized patient information is shared among hospitals, clinics, and tightly related systems.

SGML-based construction and automatic organization of comprehensive medical textbook on the Internet

The amount of knowledge required in practical medicine is large and ever increasing. Medical staff must select and use appropriate pieces of the knowledge from this flood of medical information. Recent Internet technology may be solving these problems because it makes information open to the public immediately after it is created and enables many people to share it. Medical resources on the Internet are however currently not always well organized, because these are often voluntarily provided by the experts of a particular field. We therefore decided to create a comprehensive medical database on the Internet, which is well organized, and of a high quality for practical medical use. In order to make full use of the benefits provided by electronic media, we created a new structured data set of information. We then commissioned authors to write manuscripts from which we created Standard General Mark-up Language (SGML) documents. We then wrote a translation program that took the SGML and automatically created a fully inter-linked HyperText Mark-up Language (HTML) document. The translation program generated 4,814 HTML files created from 1,373 number of SGML documents. The total data size including pictures was about 640 MB. 205,775 related links were created. We then published our electronic medical textbook described in HTML publicly on the Internet. Using SGML-based structured data, we constructed a complex electronic medical textbook created organically from simple SGML instances. Our electronic medical textbook is systematic and comprehensive, and has a homogeneous structure. We believe that this is the first comprehensive medical textbook available on the Internet. Furthermore, it was found that our approach to the electronic medical textbook has two major advantages. One is automatic generation of inter-links among documents, and another is easy to maintain documents. In addition, once we construct the electronic textbase in SGML format, the data can be utilized to various application programs on different platforms. Making use of this feature, we are now planning to develop a new style of electronic textbook, which is closely integrated with a Hospital Information System (HIS). The plan would provide medical staff with on-demand access to the electronic medical textbook while using HIS terminals.

Nicotinamide potentiates TSHR and MHC class II promoter activity in FRTL-5 cells

Here we show that nicotinamide modulates the promoter activity of rat thyrotropin (TSHR) and major histocompatibility complex (MHC) class II genes in rat FRTL-5 thyroid cells, and have identified a novel mechanism for its action. TSHR and MHC class II, are potentiated through reduced expression of a common repressor of these two genes, TSEP-1 (TSHR suppressor element binding protein-1)/YB-1. Thus we show that TSHR mRNA is increased and TSHR promoter activity was concentration-dependently activated from 0 to 40 mM nicotinamide. The promoter lengths of TSHR and MHC class II containing TSEP/YB-1 binding sites were enhanced by 40 mM nicotinamide, but not the ones deleted of these binding sites. TSEP-1/YB-1 binding to the recognition sites in both TSHR and MHC class II promoters was reduced in nicotinamide-treated FRTL-5 nuclear extracts. Nicotinamide reduced the expression of TSEP-1/YB-1 mRNA and TSEP-1/YB-1 protein in the nucleus.

A CORBA-based object framework with patient identification translation and dynamic linking. Methods for exchanging patient data

Exchanging and integration of patient data across heterogeneous databases and institutional boundaries offers many problems. We focused on two issues: (1) how to identify identical patients between different systems and institutions while lacking universal patient identifiers; and (2) how to link patient data across heterogeneous databases and institutional boundaries. To solve these problems, we created a patient identification (ID) translation model and a dynamic linking method in the Common Object Request Broker Architecture (CORBA) environment. The algorithm for the patient ID translation is based on patient attribute matching plus computer-based human checking; the method for dynamic linking is temporal mapping. By implementing these methods into computer systems with help of the distributed object computing technology, we built a prototype of a CORBA-based object framework in which the patient ID translation and dynamic linking methods were embedded. Our experiments with a Web-based user interface using the object framework and dynamic linking-through the object framework were successful. These methods are important for exchanging and integrating patient data across heterogeneous databases and institutional boundaries.

Retinal complications and plasma C5a levels during interferon alpha therapy for chronic hepatitis C

OBJECTIVE

The pathogenesis of retinal complications, such as retinal hemorrhage and cotton-wool spots formation, during interferon (IFN) therapy is unclear. We studied the relationship between the presence of retinal complications and levels of plasma-activated complement 5 (C5a), a known potent intravascular aggregator of granulocytes, during IFN-alpha therapy.

METHODS

Forty-five patients with chronic hepatitis C but without diabetes mellitus and hypertension were studied. IFN-alpha was used 10 MU per day for 2 wk and 3 times weekly for an additional 22 wk. In 25 patients with IFN therapy, the optic fundi were examined before therapy began, every 4 wk thereafter, and whenever patients complained of visual symptoms. C5a levels were measured before, and during the 4th, 8th, 12th, and 24th wk, and at any time that a retinal complication was discovered. Twenty patients served as IFN-untreated controls. They had six optic fundi examinations, each 4 wk apart. C5a levels were measured three times, 4 wk apart, in 10 controls.

RESULTS

No retinal hemorrhage or cotton-wool spots were detected before IFN-alpha therapy or in any of the controls. However, retinal hemorrhage occurred in six patients (24%) during IFN-alpha therapy. Five of six episodes occurred within the first 8 wk. Only three patients with retinal hemorrhage had visual symptoms. Cotton-wool spots developed in four patients with retinal hemorrhage. Retinal hemorrhage and cotton-wool spots resolved gradually despite continuous administration of IFN-alpha. Before IFN therapy and in controls, all C5a levels were <7 ng/ml. When retinal hemorrhage occurred, C5a was significantly increased (27.3+/-15.6 ng/ml,p < 0.01) relative to levels from the same patients before and after the hemorrhage (5.7+/-1.1 ng/ml), and also relative to levels in IFN-a-treated patients without retinal hemorrhage (5.7+/-1.1 ng/ml) and compared with levels in IFN-untreated controls (5.4+/-0.7 ng/ml).

CONCLUSIONS

Retinal hemorrhage or cotton-wool spots often occur during IFN-alpha therapy for chronic hepatitis C. This study suggests that a high C5a level may be an important step in the pathogenesis of retinal capillary infarction, hemorrhage, and cotton-wool spots formation.

Low level of glucocorticoid receptor messenger ribonucleic acid in pituitary adenomas manifesting Cushing's disease with resistance to a high dose-dexamethasone suppression test

OBJECTIVES

The overnight 8-mg dexamethasone suppression test is often used to differentiate Cushing's disease, due to an oversecretion of ACTH from the pituitary gland, from other kinds of Cushing's syndrome. However, a few patients with ACTH-producing pituitary adenoma show no suppression of plasma cortisol after the administration of 8 mg of dexamethasone. To clarify the relationship between the level of glucocorticoid receptor (GR) in the pituitary adenoma and the sensitivity to dexamethasone in Cushing's disease, we thus examined the levels of GR alpha and GR beta mRNAs in the pituitary adenomas in six patients who were proven at surgery to have pituitary ACTH-producing adenomas.

MATERIALS

Total RNA was extracted from six pituitary adenomas and pituitary tissue adjacent to one of the adenomas, and the mRNA levels of GR alpha, GR beta, pro-opiomelanocortin (POMC) and beta-actin in these samples were sampled by quantitative RT-PCR.

RESULTS

The GR alpha mRNA levels in the adenomas from the two patients who showed no response to the 8-mg dexamethasone suppression test were significantly lower than those in the adenomas of four patients who showed suppression. The GR beta mRNA level was much lower than that of GR alpha mRNA but not significantly different among the six adenomas.

CONCLUSIONS

These results suggest strongly that decreased expression of GR alpha in pituitary adenomas may be the major reason for the marked insensitivity to the 8-mg dexamethasone suppression test observed in two patients with Cushing's disease.

Using a WWW-based mail user agent for secure electronic mail service for health care users

WWW-based user interface is presented for secure electronic mail service for healthcare users. Using this method, communications between an electronic mail (WWW) server and users (WWW browsers) can be performed securely using Secure Socket Layer protocol-based Hypertext Transfer Protocol (SSL-HTTP). The mail can be encrypted, signed, and sent to the recipients and vice versa on the remote WWW server. The merit of this method is that many healthcare users can use a secure electronic mail system easily and immediately, because SSL-compatible WWW browsers are widely used and this system can be made available simply by installing a WWW-based mail user agent on a mail server. We implemented a WWW-based mail user agent which is compatible with PEM-based secure mail and made it available to about 16,000 healthcare users. We believe this approach is effective in facilitating secure network-based information exchange among medical professionals.

[The evaluation of the pre-operative interviews using information sheets]

This investigation deals with patients of more than 15 years of age and family members of children younger than 12 years of age to evaluate the pre-operative interviews using information sheets. The information sheets describe the anesthetic management and complications in a simple style. Sixty% of the patients and 75% of the children's family felt anxiety about the anesthesia and/or the operation (P < 0.05). More than a half of the patients did not want to receive informations about the anesthetic management and the risk of anesthesia. On the other hand, 9% of children's family did not want to know informations about the risk (P < 0.05). More than 80% of patients read the information sheets after the pre-operative interviews and about a half of patients answered that their anxiety before the surgery decreased. In this investigation, the children's family wanted to have information about the anesthesia or the operation more than patients themselves. The pre-anesthetic interviews using information sheets is useful to give information about anesthesia and to relieve anxiety of the patients and the children's family.

MERIT-9: a patient information exchange guideline using MML, HL7 and DICOM

To realize clinical data exchange between healthcare providers, there must be many standards in many layers. Terms and codes should be standardized, syntax to wrap the data must be mutually parsable, then transfer protocol or exchange media should be agreed. Among many standards for the syntax, HL7 and DICOM are most successful. However, everything could not be handled by HL7 solely. DICOM is good for radiology images, but, other clinical images are already handled by other 'lighter' data formats like JPEG, TIFF. So, it is not realistic to use only one standard for every area of clinical information. For description of medical records, especially for narrative information, an standard generalized mark-up language, document type definition (SGML DTD) for medical information, called MML (medical markup language) had been created in Japan. It is already implemented in more than ten healthcare providers. However, it is again not realistic to use MML solely for clinical information in various level of detail. Therefore, we proposed a guideline for use of available medical standards to facilitate clinical information exchange between healthcare providers. It is called MERIT-9 (Medical Records, Images, Texts, -Information Exchange). A typical use is HL7 messages, DICOM files, referred from an MML file in a patient record, as external entities. Both MML and MERIT-9 have been research projects of Japanese Ministry of Health and Welfare and the purpose is to facilitate clinical data exchanges. They are becoming to be used in technical specifications for new hospital information systems in Japan.

Expression of an orphan nuclear receptor DAX-1 in human pituitary adenomas

OBJECTIVES

An orphan nuclear receptor, DAX-1, is known to be involved in the development and differentiation of anterior pituitary cells. The present study aimed to examine 1) whether DAX-1 is expressed in human pituitary adenomas, and 2) if it is expressed, what types of adenoma express the factor.

MATERIALS AND METHODS

Adenoma tissues examined included 18 clinically non-functioning adenomas, 14 GH-secreting adenomas and 7 PRL-secreting adenomas. The expression of the following genes were tested by reverse transcription-polymerase chain reaction (RT-PCR): DAX-1, Adrenal-4-binding protein/steroidogenic factor-1 (Ad4BP/SF-1), Pit-1, LH beta, FSH beta, gonadotrophin-releasing hormone receptor (GnRH-R), GH, PRL, and TSH beta, as well as beta-actin as a control.

RESULTS

Eleven clinically non-functioning adenomas expressed DAX-1, 10 of which also expressed Ad4BP/SF-1. Nine out of the 11 DAX-1 expressing adenomas also expressed LH beta, FSH beta and GnRH-R as well, indicating that these adenomas possessed gonadotrophic properties. Nine clinically non-functioning adenomas expressed Pit-1 as well as GH, PRL and/or TSH beta, thus having somatomammotrophic or thyrotrophic properties, 3 of which overlapped with the above DAX-1-expressing adenomas. One non-functioning adenoma expressed Ad4BP/SF1 and FSH beta but not DAX-1, and another one expressed DAX-1 and Ad4BP/SF-1 with PRL. On the other hand, all GH-secreting and PRL-secreting adenomas expressed Pit-1 and GH and/or PRL, but neither DAX-1 nor Ad4BP/SF-1.

CONCLUSIONS

The results shown here indicate that DAX-1 is expressed in the majority of human pituitary adenomas of gonadotrophic origin in parallel with Adrenal-4-binding protein/steroidogenic factor-1.

Development and trial operation of a World Wide Web-based data entry system for the collection of statistical data on the management of the national university hospitals in Japan

A WWW-based, on-line, data-entry system for the collection of statistical data on the management of Japanese national university hospitals has been developed. Trial operation of the system showed that it can reduce the labour and budgetary costs of data collection and also demonstrated that an on-line, data-entry system is feasible in Japan. In April 1997, we began production use of the system, and we are to develop another WWW-based data-entry system that can deal with all other statistics on hospital management.

Hepatic actinomycosis: case report and review of the literature in Japan

Hepatic actinomycosis is rare. We report an 86-year-old Japanese man with a 3-day history of high fever and anorexia who had an actinomycotic liver abscess complicated by disseminated intravascular coagulation (DIC). A definitive diagnosis was made when an Actinomyces species was cultured from aspirated pus. The clinical course was satisfactory. Treatment included prompt percutaneous drainage coupled with long-term intravenous administration of high-dose minocycline and piperacillin, combined with therapy for DIC. We reviewed 11 cases in Japan of Actinomyces involving the liver, including the case reported here. In most patients, there were no predisposing factors. Common symptoms and laboratory findings included fever, abdominal pain, leukocytosis, and elevated C-reactive protein. In 6 of the 11 patients a partial hepatectomy was performed because hepatic tumor was suspected. Five patients presented with a liver abscess. Hepatic actinomycosis should be considered in the differential diagnoses of pyogenic liver abscess and space-occupying lesions of the liver.

Cloning and characterization of the 4.2 kb region of the rat thyrotropin receptor promoter

We previously identified an approximately 200 bp "minimal promoter" of the rat TSH receptor (TSHR) gene which is essential for the promoter activity. In the present study, we have cloned and characterized an upstream region of the TSHR promoter to disclose additional functional element(s). We screened a rat genomic library and obtained a DNA fragment which contained a 4.2 kb 5'-flanking region. This fragment was 2.5 kb longer than that we previously studied (1.7 kb). To assess the promoter activity, chimeric plasmids containing the 4.2 kb promoter and its 5'-deletions ligated to a chloramphenicol acetyltransferase gene were transfected into thyroid and non-thyroid cells. These plasmids expressed significant promoter activity in FRTL-5 and FRT thyroid cells, but not in BRL liver cells. The strongest promoter activity was expressed by the -199 bp promoter, and the longer promoter expressed rather decreased activity. Co-expression of thyroid transcription factor-1 (TTF-1) increased the activity of the promoter region from -3187 to -199 bp, which encompassed one or two TTF-1 binding sites we previously identified, but not the -4206 bp promoter. In addition, FRTL-5 stable transfectants each having a chimeric construct were cultured in the presence or absence of TSH. All transfectants expressed higher promoter activity in the absence of TSH than in the presence of TSH, in particular, the -3187 bp plasmid expressed significantly higher activity by comparison to the -2617 and -4206 bp constructs. This result indicates that the region between -3187 and -2617 bp may contribute to TSH/cAMP-induced suppression and also suggests that the region between -4206 and -3187 bp involves the element(s) for constitutive suppression of the promoter activity. These results not only suggest that the 4.2 kb upstream region of the TSHR gene possibly contains some elements for the regulation of the gene expression, but also emphasize the importance of the minimal promoter region which we previously identified for the efficient expression of the gene.

Dynamic link between ECG and clinical data by a CORBA-based query engine and temporal mapping

It is important to create a dynamic link method to link distributed patient data across multiple hospitals on an "as needed" basis because the pre-defined links (an item of data has a character or group of characters that indicates the storage of another item of data) are difficult to be managed, or can only be established in part, or are not necessary to be pre-defined in many cases, especially in linking the descriptive data such as history data with the corresponding examination data across multiple hospitals. A method of linking electrocardiogram (ECG) with clinical data dynamically in a Common Object Request Broker Architecture (CORBA) environment has been achieved and verified in a real computing environment to approach to this goal. By this method, distributed patient data can be linked dynamically by a CORBA-based query engine and temporal mapping no matter where they are located on the Internet. The necessary temporal information is provided by either computing or human being. Since multiple time-axes for different databases are involved in, some temporal reasoning methods (such as mapping occurrences across temporal contexts and determining bounds for absolute occurrences, etc.) are applied to this study, and a series of temporal mappings including the first mapping, the secondary mapping, the contextual mapping, the extended mapping, the previous mapping and the next mapping are created. In comparison with the pre-defined link, the major strengths of this method are the dynamic link on an "as needed" basis, no limitation of institutional boundaries, easy creation, simplifying the data storage, and the high flexibility, etc.

Follicle stimulating hormone-beta subunit gene is expressed in parallel with a transcription factor Ad4BP/SF-1 in human pituitary adenomas

OBJECTIVES

A transcription factor Ad4BP/SF-1 is implicated in the differentiation of gonadotrophs in the pituitary gland, but it is not known whether human pituitary cells express this factor. The present study aimed to disclose (1) whether human pituitary adenomas express Ad4BP/SF-1, and (2) if this is the case, what kinds of adenoma express the factor.

MATERIAL

Total RNA was extracted from 23 pituitary adenomas obtained by transsphenoidal surgery, and subjected to Northern blot analyses using cDNAs of bovine Ad4BP/SF-1, porcine FSH-beta, LH-beta and glycoprotein hormone-alpha (GPH-alpha) subunts as radiolabelled probes. These adenomas included 13 clinically non-functioning adenomas, 1 GH/PRL-producing adenoma, 6 GH-producing adenomas, 2 PRL-producing adenomas and 1 ACTH-producing adenoma.

RESULTS

The expression of Ad4BP/SF-1 exactly coincided with the expression of FSH-beta. Thus 5 out of 13 clinically non-functioning adenomas expressed Ad4BP/SF-1 and only these 5 adenomas expressed FSH-beta. Interestingly, only one of the GH-producing adenomas also expressed Ad4BP/SF-1 as well as FSH-beta. GPH-alpha was expressed in 4 non-functioning adenomas and 2 hormonally functioning adenomas, but did not necessarily coincide with Ad4BP/SF-1 expression. None of the 23 adenomas we tested expressed LH-beta, probably because LH-beta-producing adenomas are rather rare.

CONCLUSIONS

The expression of FSH-beta was parallel with Ad4BP/SF-1 expression, indicating that the expression of Ad4BP/SF-1 is restricted to cells derived from gonadotroph lineages in human pituitary adenomas.

Implementation of HL7 to client-server hospital information system (HIS) in the University of Tokyo Hospital

In developing a large-scale Hospital Information System (HIS), a client-server architecture has been gaining in popularity. It is important to introduce a standard message protocol that is independent both on the database structure and on the vender's proprietary platform. We introduced Health Level Seven (HL7) to our hospital information system. From our experiences, although we had to modify the original HL7 specifications in order to introduce the protocol to a client-server HIS especially in the area of order entry and record-oriented query, it was found that HL7 can be adopted in a client-server HIS.

Interferon-gamma suppresses thyrotropin receptor promoter activity by reducing thyroid transcription factor-1 (TTF-1) binding to its recognition site

Interferon-gamma (IFN gamma) is known to suppress the expression of thyroid-specific genes, such as thyroglobulin, thyroid peroxidase, and the TSH receptor (TSHR). In the present study, we show that this reflects, in part, a transcriptional action mediated by thyroid transcription factor-1 (TTF-1). Thus, transfected into rat FRTL-5 cells, the activity of reporter plasmids, containing rat TSHR promoter ligated to a chloramphenicol acetyltransferase gene, was significantly suppressed in the presence of rat IFN gamma. A -199-bp promoter construct showed the greatest suppression by IFN gamma whereas a -177-bp construct, in which the TTF-1 binding site was deleted, showed less suppressibility. The suppressive effect was rat IFN gamma-specific, since human IFN alpha, -beta, and -gamma exhibited no significant effects. The effect was concentration-dependent from 3-50 U/ml. In FRT rat thyroid cells that do not express TTF-1, IFN gamma-induced suppression on the promoter activity was not observed. In addition, when the TTF-1 binding site was mutated so that TTF-1 can not bind, IFN gamma-induced suppression was significantly reduced. In gel mobility shift analyses, a protein-DNA complex formed by TTF-1 was reduced when the nuclear extract prepared from IFN gamma-treated FRTL-5 cells was used; however, expression of TTF-1 mRNA and TTF-1 protein, which were assessed by Northern blot analysis and Western blot analysis, respectively, were not affected by IFN gamma treatment of FRTL-5 cells. Instead, reduction of DNA-binding affinity of TTF-1 was evident when competition analysis was performed in gel mobility shift analysis. From these results, we conclude that IFN gamma suppresses TSHR promoter activity, in part, by reducing TTF-1 binding to its recognition site. We also raise the possibility that the suppressive effect of IFN gamma on promoter activity is mediated by additional element(s) and factor(s) downstream of the TTF-1 site.

Object-oriented analysis and design of an ECG storage and retrieval system integrated with an HIS

For a hospital information system, object-oriented methodology plays an increasingly important role, especially for the management of digitized data, e.g., the electrocardiogram, electroencephalogram, electromyogram, spirogram, X-ray, CT and histopathological images, which are not yet computerized in most hospitals. As a first step in an object-oriented approach to hospital information management and storing medical data in an object-oriented database, we connected electrocardiographs to a hospital network and established the integration of ECG storage and retrieval systems with a hospital information system. In this paper, the object-oriented analysis and design of the ECG storage and retrieval systems is reported.

An ECG storage and retrieval system embedded in client server HIS utilizing object-oriented DB

In the University of Tokyo Hospital, the improved client server HIS has been applied to clinical practice and physicians can order prescription, laboratory examination, ECG examination and radiographic examination, etc. directly by themselves and read results of these examinations, except medical signal waves, schema and image, on UNIX workstations. Recently, we designed and developed an ECG storage and retrieval system embedded in the client server HIS utilizing object-oriented database to take the first step in dealing with digitized signal, schema and image data and show waves, graphics, and images directly to physicians by the client server HIS. The system was developed based on object-oriented analysis and design, and implemented with object-oriented database management system (OODMS) and C++ programming language. In this paper, we describe the ECG data model, functions of the storage and retrieval system, features of user interface and the result of its implementation in the HIS.

New mutations of DAX-1 genes in two Japanese patients with X-linked congenital adrenal hypoplasia and hypogonadotropic hypogonadism

Congenital adrenal hypoplasia, an X-linked disorder, is characterized by primary adrenal insufficiency and frequent association with hypogonadotropic hypogonadism. The X-chromosome gene DAX-1 has been most recently identified and shown to be responsible for this disorder. We analyzed the DAX-1 genes of two unrelated Japanese patients with congenital adrenal hypoplasia and hypogonadotropic hypogonadism by using PCR amplification of genomic DNA and its complete exonic sequencing. In a family containing several affected individuals, the proband male patient had a stop codon (TGA) in place of tryptophan (TGG) at amino acid position 171. As expected, his mother was a heterozygous carrier for the mutation, whereas his father and unaffected brother did not carry this mutation. In another male patient with noncontributory family history, sequencing revealed a 1-bp (T) deletion at amino acid position 280, leading to a frame shift and, subsequently a premature stop codon at amino acid position 371. The presence of this mutation in the patients' genome was further confirmed by digestion of genomic PCR product with MspI created by this mutation. Family studies using MspI digestion of genomic PCR products revealed that neither parent of this individual carried the mutation. These results clearly indicate that congenital adrenal hypoplasia and hypogonadotropic hypogonadism result from not only inherited but also de novo mutation in the DAX-1 gene.