A Psychiatric Diagnostic System Integrating Probabilistic and Categorical Reasoning

We describe a diagnostic support system for clinical psychiatry and its evaluation results. The system has two inter-related components: a rule-based reasoning part associated with uncertainty, and a deterministic part, that uses heuristics to perform categorical reasoning. The system includes the 30 groups of psychiatric diagnoses which are classified under the categories 290 to 319 of the DSM-III-R and the ICD-9. There are, in fact, 1508 rules relating 208 clinical findings with 257 diagnoses. The reasoning strategy is based on selecting and differentiating diagnostic categories in a hierarchical classification tree. The system is intended to be used for education of medical students, and to help non-specialist clinicians, residents in psychiatry, or experts with few years of experience in decision making. We tested the diagnostic performance of the system using case reports extracted from a specialized journal. In 52.8% of the cases, the correct diagnosis was ranked as the first hypothesis using only the rule-based part. In combination with the deterministic strategy, the correct diagnosis could be made for 73.6% of the analyzed cases.

Building a Controlled Health Vocabulary in Japanese

Objectives: This study is aimed at developing a controlled clinical vocabulary for use in electronic patient record (EPR) systems.

Methods: In this paper, we propose a model for building the vocabulary. The model is composed of a Canonical Term Dictionary, an Atom Dictionary, a Composite Atom Dictionary, and an Index. Parsing and composing functions are included in this model. Canonical terms were extracted from reference terminologies. Atoms were extracted from the Canonical Term Dictionary and reduced to a set from which the Composite Atom Dictionary can be built. The index was built to link these two dictionaries. For testing the model, we compiled a sample vocabulary and applied the model to a SNOMED translation system (English to Japanese) and a term similarity estimation system.

Results: The sample vocabulary consisted of 15,600 atomic terms and 4,450 composite terms. 33,441 SNOMED terms were translated by the SNOMED translation system. The system gave adequate Japanese candidates in 56.3% of cases. The similarity estimation system found an average of 5.4 candidates when the equality ratio was over 50%.

Conclusions: The trial applications produced good results. The model seems promising for building a standard clinical vocabulary system. This system can be applied in certain other Asian countries, such as China and Korea.

Standard Method for Describing an Electronic Patient Record Template: Application of XML to Share Domain Knowledge

A Template Definition Language (TDL) was developed to share knowledge of how to construct an electronic patient record (EPR) template. Based on the extensible markup language XML, TDL has been designed to be independent of EPR platforms or databases. Our research of TDL was conducted through evaluation of the description of various templates in the currently available EPRs and through comparisons with some electronic clinical guidelines. We conclude that TDL is sufficient for the objective but still needs improvement of the algorithm for describing dynamic changes.

Duct-narrowing chronic pancreatitis without immunoserologic abnormality: comparison with duct-narrowing chronic pancreatitis with positive serological evidence and its clinical management

We reviewed the clinical features and clinical course of patients with duct-narrowing chronic pancreatitis who were negative for immunoserologic test results (n = 16) in comparison with the findings for serological test-positive patients (n = 20) in order to determine an adequate treatment for those who had typical morphology of autoimmune pancreatitis in the absence of immunoserologic abnormality. No significant differences were found between the two groups of patients in clinical profiles including associated autoimmune-related diseases, pancreatic histology, and response to steroid therapy. Of the seronegative patients, eight who showed an improvement in narrowing of the main pancreatic duct with steroid therapy and three who did no show an improvement or who relapsed after surgical resection without this therapy had stenosis of the common bile duct with increased levels of serum hepatobiliary enzymes, except for two patients with affected sites limited to the body or tail of the gland. For the remaining five patients, who showed an improvement in pancreatic duct changes or long-term remission after surgery without steroid administration, normal biochemistry test results for liver functions were obtained, with no abnormal cholangiographic findings in the three patients examined. Duct-narrowing chronic pancreatitis without immunoserologic abnormality overlaps in clinical features with that fulfilling the immunoserologic criteria for a diagnosis of autoimmune pancreatitis. In particular, the disease with bile duct involvement should be treated clinically as autoimmune pancreatitis, for which steroid therapy is recommended, even if an autoimmune mechanism is not demonstrated serologically.

Velocity pulse advances pressure pulse by close to 45 degrees in the rat pial arterioles

In order to clarify the phase relationship between velocity pulse and pressure pulse propagating along microvessels, the red cell velocity and intravascular pressure were simultaneously measured in the rat pial arterioles of 41-53 microm in diameter with a high temporal resolution by a laser-Doppler anemometer and a servo-null micropressure system. It was found that the velocity pulse preceded the pressure pulse in all the measured arterioles by 18.7-35.6 ms. The corresponding phase difference was 43.6+/-6.9 degrees (mean +/- SD), which is not statistically different from 45 degrees. The value is consistent with the phase difference predicted for the blood flow in microvessels with a small reflection coefficient at frequencies as low as the heart rate of the rats. The present results suggest that the upstream changes in blood flow are transmitted by the velocity pulse faster than by the pressure pulse in the microvasculature.

Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor-forming pancreatitis and pancreatic carcinoma

OBJECTIVES

Autoimmune pancreatitis (AIP) with a mass formation or swollen pancreas located in one or two segments of the gland (focal type AIP) has been reported. The aims of this study were to elucidate the relationship of the disease entity between this focal variant and so-called tumor-forming pancreatitis (TFP) and to describe the clinical and imaging features discriminating focal AIP from pancreatic carcinoma (Pca).

METHODS

The clinical, radiologic, and pathologic profiles of nine patients with focal AIP were reviewed retrospectively and compared with those of 11 patients with alcohol-induced TFP and 80 patients with Pca.

RESULTS

The patients with focal AIP were predominantly older (mean age 64.7 +/- 13.6 yr, range 28-78 yr), male, and presenting with obstructive jaundice or focal pancreatic enlargement accompanied by mild abdominal symptoms. In comparison, the patients with alcohol-induced TFP who were mostly middle-aged (mean age 50.1 +/- 7.95 yr, range 39-62 yr), male, and often had attacks of pancreatitis associated with findings of CT scans showing pseudocysts or peripancreatic effusion. Focal AIP usually demonstrated no abnormalities on pancreatograms downstream from the stricture or obstruction and often presented few contrast-filled side branches in the area of main pancreatic duct (MPD) stenosis. These characteristics were similar to the imaging features of Pca. Significant factors differentiating focal AIP from Pca were lower serum levels of CA19-9, homogeneous delayed enhancement evident in dynamic CT scans, and ERCP findings exhibiting a longer stenosed MPD and a thinner MPD upstream from the stricture.

CONCLUSIONS

Focal AIP is associated with clinical and radiologic features that are different from those of alcohol-induced TFP. In TFP there are two causative factors, namely, AIP and alcohol-induced chronic pancreatitis. Differential diagnosis of focal AIP from Pca seems to be possible in many cases by evaluating imaging findings such as dynamic CT and ERCP, although focal AIP sometimes shows clinical and radiologic features similar to those of Pca.

Clinical and imaging features of autoimmune pancreatitis with focal pancreatic swelling or mass formation: comparison with so-called tumor-forming pancreatitis and pancreatic carcinoma

OBJECTIVES

Autoimmune pancreatitis (AIP) with a mass formation or swollen pancreas located in one or two segments of the gland (focal type AIP) has been reported. The aims of this study were to elucidate the relationship of the disease entity between this focal variant and so-called tumor-forming pancreatitis (TFP) and to describe the clinical and imaging features discriminating focal AIP from pancreatic carcinoma (Pca).

METHODS

The clinical, radiologic, and pathologic profiles of nine patients with focal AIP were reviewed retrospectively and compared with those of 11 patients with alcohol-induced TFP and 80 patients with Pca.

RESULTS

The patients with focal AIP were predominantly older (mean age 64.7 +/- 13.6 yr, range 28-78 yr), male, and presenting with obstructive jaundice or focal pancreatic enlargement accompanied by mild abdominal symptoms. In comparison, the patients with alcohol-induced TFP who were mostly middle-aged (mean age 50.1 +/- 7.95 yr, range 39-62 yr), male, and often had attacks of pancreatitis associated with findings of CT scans showing pseudocysts or peripancreatic effusion. Focal AIP usually demonstrated no abnormalities on pancreatograms downstream from the stricture or obstruction and often presented few contrast-filled side branches in the area of main pancreatic duct (MPD) stenosis. These characteristics were similar to the imaging features of Pca. Significant factors differentiating focal AIP from Pca were lower serum levels of CA19-9, homogeneous delayed enhancement evident in dynamic CT scans, and ERCP findings exhibiting a longer stenosed MPD and a thinner MPD upstream from the stricture.

CONCLUSIONS

Focal AIP is associated with clinical and radiologic features that are different from those of alcohol-induced TFP. In TFP there are two causative factors, namely, AIP and alcohol-induced chronic pancreatitis. Differential diagnosis of focal AIP from Pca seems to be possible in many cases by evaluating imaging findings such as dynamic CT and ERCP, although focal AIP sometimes shows clinical and radiologic features similar to those of Pca.

Clinical study of chronic pancreatitis with focal irregular narrowing of the main pancreatic duct and mass formation: comparison with chronic pancreatitis showing diffuse irregular narrowing of the main pancreatic duct

INTRODUCTION

Main pancreatic duct (MPD)-narrowed chronic pancreatitis (CP) may be an autoimmune abnormality. It also has been called autoimmune pancreatitis and sclerosing pancreatitis. It is unclear whether cases with focal pancreatographic changes are part of the same clinical entity as cases with diffuse MPD changes.

AIM AND METHODOLOGY

We reviewed seven cases of chronic pancreatitis (CP) with focal narrowing of the main pancreatic duct (MPD), evidenced by endoscopic retrograde cholangiopancreatography (ERCP), and swelling of one or two segments of the pancreas, evidenced by ultrasonography (US) /computed tomography (CT), and indicated the clinicopathologic features of focal-type MPD-narrowed CP.

RESULTS

The patient group comprised six men and one woman, and their age range was 28-75 years, with a mean of 63.7 years. Affected sites were in the head in two patients, the body in one patient, the tail in one patient, and the body and tail in three patients; ERP showed narrowing in six patients and obstruction in one. Stricture of the lower portion of the common bile duct (CBD) that caused obstructive jaundice was shown by ERC in two cases in which the pancreas head was affected. In all six patients, a dynamic study by CT or MRI homogeneously showed delayed enhancement of involved segments of the pancreas. Serum levels of pancreatic enzyme were elevated in five patients, but only one subject had pancreatitis-like epigastric pain. Serological evidence suggestive of autoimmune abnormality was detected in only three patients with hypergammaglobulinemia (> or =2.0 g/dL) or positive titers of antinuclear antibody (ANA; > or =80). Histological assessment was available for five patients, who characteristically had dense lymphocytic or plasmocytic infiltration with severe fibrosis that caused luminal narrowing. The clinical, serologic, and histologic findings as described above were comparable to those for 12 CP patients with diffuse narrowing of the MPD, diagnosed during the same period. Surgical resection was performed in 5 patients, in 2 of whom a similar inflammatory process recurred in the remnant head of the pancreas, whereas pancreatitis no longer developed in the other 3 patients. One patient was initially treated with steroids, with clinical remission, although there was neither hypergammaglobulinemia nor positive ANA.

CONCLUSION

These results indicate that CP with focal narrowing of the MPD is part of the same clinical spectrum as CP with diffuse narrowing of the MPD, and whether the distribution is diffuse or focal seems to be related to the stage or the extent of the disease. It is therefore important to recognize the possible existence of this focal variant to avoid unnecessary surgery.

Building a controlled health vocabulary in Japanese

OBJECTIVES

This study is aimed at developing a controlled clinical vocabulary for use in electronic patient record (EPR) systems.

METHODS

In this paper, we propose a model for building the vocabulary. The model is composed of a Canonical Term Dictionary, an Atom Dictionary, a Composite Atom Dictionary, and an Index. Parsing and composing functions are included in this model. Canonical terms were extracted from reference terminologies. Atoms were extracted from the Canonical Term Dictionary and reduced to a set from which the Composite Atom Dictionary can be built. The index was built to link these two dictionaries. For testing the model, we compiled a sample vocabulary and applied the model to a SNOMED translation system (English to Japanese) and a term similarity estimation system.

RESULTS

The sample vocabulary consisted of 15,600 atomic terms and 4,450 composite terms. 33,441 SNOMED terms were translated by the SNOMED translation system. The system gave adequate Japanese candidates in 56.3% of cases. The similarity estimation system found an average of 5.4 candidates when the equality ratio was over 50%.

CONCLUSIONS

The trial applications produced good results. The model seems promising for building a standard clinical vocabulary system. This system can be applied in certain other Asian countries, such as China and Korea.

Clinical management of intraductal papillary mucinous tumors of the pancreas based on imaging findings

The aim of this study was to assess the imaging findings of pathologically proven intraductal papillary-mucinous tumors of the pancreas and the natural history of follow-up cases, and to optimize the therapeutic management of patients with these tumors according to their imaging findings. All nine patients with main duct type tumors were histologically diagnosed as having adenocarcinoma or adenoma, with no hyperplastic lesion. The images failed to discriminate between the two histologic types. In 26 patients with branch duct type tumors, all but one with intraductal mural nodules or tumors of > or = 30 mm had adenocarcinoma or adenoma, regardless of the caliber of the main duct. Of the nine patients with tumors < 30 mm and no mural nodules. three had adenoma, and six had hyperplasia. All of four patients had hyperplasia, with the additional caliber of the main duct being < 6 mm. In a series of 23 cases in which the patient was followed-up, no apparent progression was found in 17 patients who had no mural nodules and tumors of < 30 mm. Given these results, patients with main duct type tumors, and those with branch duct type tumors showing mural nodules or a tumor diameter of > or = 30 mm, are at high risk of developing neoplasms, including adenocarcinoma, for which surgical resection should be considered, whereas those patients with tumors < 30 mm and no mural nodules can be followed.

Apoptosis, cell proliferation and expression of oncogenes in gastric carcinomas induced by preoperative administration of 5-fluorouracil

The purpose of this study was to examine the correlations among enhancement of apoptosis, cell proliferation and expression of oncogenes in gastric carcinomas induced by preoperative oral administration of 5-fluorouracil (5-FU). The occurrence of spontaneous apoptotic cell death in 42 patients with gastric carcinoma was analyzed in the biopsy specimens preoperatively. p53 status was examined by polymerase chain reaction-single strand confirmation polymorphism and sequencing. Fourteen patients received oral administration of 5-FU at 300 mg/body/day for 7 days preoperatively. For detection of apoptotic cells, apoptotic incidences (AIs) were examined by the terminal deoxynucleotidyl transferase-mediated deoxy-uridine triphosphate biotin nick end labeling method, on gastric carcinoma lesions based on the endoscopic findings before administration in the biopsy and resected tissues. Expressions of p53, Bcl-2, Bax gene and proliferating cell nuclear antigen (PCNA) were also examined by immunohistochemical staining. On preoperative biopsy, p53 point mutation was observed in 14 of the 42 tumors. The immunohistochemical staining status and point mutation of p53 gene (positive or negative) were identical in 32 of the 42 tumors (76.2%). The average AIs of the biopsy specimens were 1.58+/-1.26% on p53-negative staining (n=19) and 1.14+/-1.02% on p53-positive staining (n=23), a significant association was not recognized between p53 expression and AI. In the preoperative administration group, the PCNA labeling index was significantly higher in the biopsy specimens than in the resected tissues (43. 6+/-12.8% vs. 35.3+/-8.8%, p<0.01). In addition, postoperatively, the rate of AI was significantly more accelerated in p53-negative staining (n=6) than in p53-positive staining (n=8) (0.89+/-0. 65%right curved arrow 4.18+/-3.26%, p<0.05 vs. 1.20+/-0.60%right curved arrow 2.60+/-2.60%, NS). There was no significant correlation between AI and Bcl-2 or Bax staining. Immunohistochemical analysis of p53 and PCNA stainings in biopsy specimens appears to be a well-characterized indicator of sensitivity of chemotherapy in gastric carcinomas.

Standard method for describing an electronic patient record template: application of XML to share domain knowledge

A Template Definition Language (TDL) was developed to share knowledge of how to construct an electronic patient record (EPR) template. Based on the extensible markup language XML, TDL has been designed to be independent of EPR platforms or databases. Our research of TDL was conducted through evaluation of the description of various templates in the currently available EPRs and through comparisons with some electronic clinical guidelines. We conclude that TDL is sufficient for the objective but still needs improvement of the algorithm for describing dynamic changes.

Computer-assisted instructions for patients with bronchial asthma

We produced computer-assisted instruction (CAI) software for bronchial asthma patients (asthma educational system with computer-assisted instruction; ASTCAI) to assist in self-management and avoid asthmatic attacks and death. ASTCAI is a question-and-answer program operating in a multimedia environment, and was evaluated from questionnaires which 33 patients were asked. Thirty-two patients could perform ASTCAI without any assistance. The responses of 31 patients (94%) indicated that they had no difficulty with manipulation, and 29 patients (88%) stated that the program was beneficial to control of their asthma. Elderly patients (over 65) required more time than younger adults. Emergency visits or admissions of at least 1 year after the first CAI trial decreased in eight out of 26 patients, while only two patients deteriorated compared to the previous year. Our results show that CAI is feasible for most patients, and through active self-learning CAI can improve motivation for self-management as well as supplement the physician's instructions.

Serum levels of pancreatitis-associated protein in digestive diseases with special reference to gastrointestinal cancers

The serum levels of pancreatitis-associated protein (PAP) were measured in 196 patients with digestive diseases and 15 healthy subjects by an enzyme-linked immunosorbent assay. The serum PAP levels were significantly elevated in the patients with gastric, colorectal, biliary tract, hepatocellular, or pancreatic cancers compared with the healthy subjects. After curative resection of the tumor, serum PAP levels were significantly decreased. The serum PAP levels were not related to clinicopathological factors except for the tumor size of pancreatic cancer. There were some cases of PAP-positive and carcinoembryonic antigen (CEA) or carbohydrate antigen (CA) 19-9 -negative gastric and colorectal cancers. The serum PAP levels were also significantly elevated in the patients with acute pancreatitis compared with those in not only the healthy subjects but also the patients with chronic pancreatitis. The peak PAP levels were significantly correlated with the severity of acute pancreatitis and reflected the clinical healing of the disease. The peak of serum PAP was significantly delayed compared with those of other pancreatic enzymes. These results suggest that the increase of serum PAP levels in patients with gastrointestinal cancers reflects an ectopic expression of PAP in cancer cells and that increased serum levels of PAP in acute pancreatitis are correlated with the disease severity and are prolonged than those of other pancreatic markers.

Standardizations of clinical laboratory examinations in Japan

In this paper we introduce Japanese activities concerning laboratory examinations by illustrating three major categories. The first is the contribution of JCCLS to ISO/TC212 clinical laboratory testing and in vitro diagnostic test systems, with NCCLS and CEN TC140. The second is the establishment and promotion of JLAC Classification and Coding for Clinical Laboratory Tests by The Japan Society of Clinical Pathology. The third is a clinical data exchange format between healthcare facilities using MML/MERIT-9 standard, started as a Ministry research project.

Urinary gonadotropin peptide in patients with cancer of digestive organs

Urinary gonadotropin peptide (UGP) has been measured in gynecological and urological cancers, but its usefulness in the diagnosis of cancers of digestive organs has not been investigated. In this report, UGP was measured by sandwich enzyme immunoassay in 311 patients, including 166 patients with cancers of digestive organs and 43 healthy controls. Positive rates of UGP in various cancers of digestive organs were as follows: biliary tract 61.5%, pancreas 61.5%, esophagus 50.0%, liver 38.7%, colon and rectum 24.2%, and stomach 23.9%. The positive rate of UGP in benign diseases was 8.1%, and most false-positive patients were postmenopausal females. Positive rates of UGP were increased at advanced stages of gastric cancers, and UGP was decreased after tumor resection. From these results, it is suggested that UGP can be used as a tumor marker for the cancers of digestive organs.

Detection of K-ras point mutations at codon 12 in pancreatic juice for the diagnosis of pancreatic cancer by hybridization protection assay: a simple method for the determination of the types of point mutation

The present study was undertaken to detect K-ras oncogene point mutations at codon 12 in pure pancreatic juice (PPJ) by the hybridization protection assay (HPA) method for the diagnosis of pancreatic cancer (PC). This assay can be carried out within 30 min and can determine not only the presence of a mutation, but also the mutational type of K-ras at codon 12. The minimal ratio of mutant DNA detectable by the HPA was 5-10% of the total DNA. PPJ was collected through a cannula under duodenal fiberscope control from 20 patients with PC and 20 patients with chronic pancreatitis (CP). Analysis of PPJ by the HPA revealed that the incidence of K-ras point mutations at codon 12 was 55% (11/20) in patients with PC and 0% (0/20) in those with CP. Mutational types of K-ras at codon 12 in PC were aspartic acid (Asp) in nine cases, both Asp and cysteine in one case, and arginine in one case. Analysis of K-ras point mutations at codon 12 in PPJ using the HPA method seems promising as a new genetic test for the diagnosis of PC, because the HPA method is simple, and can easily determine the mutational type.

Prospective assessment of donor blood screening for antibody to hepatitis C virus by first- and second-generation assays as a means of preventing posttransfusion hepatitis

In November 1989, the Japanese Red Cross began screening blood donors for the hepatitis C virus antibody (anti-HCV) by first-generation assay and high-titer hepatitis B virus core antigen antibody. A significant reduction in the incidence of acute posttransfusion hepatitis was reported; however, the incidence still ranged from 2 percent to 4 percent. The Red Cross changed to the second-generation assay in February 1992, the objective being the complete elimination of potential posttransfusion hepatitis. The aim was to elucidate the advantage of second-generation assay as a blood-donor screening test. The incidence of posttransfusion hepatitis after the introduction of second-generation assay was compared with that before the introduction of the first-generation assay and with that during its use. The incidence of posttransfusion hepatitis was 9.6 percent (216/2,240) before anti-HCV-s donor screening. It was 3.7 percent (24/655) and 0.9 percent (3/326) after the introductions of the first- and second-generation hepatitis C virus (HCV) assays, respectively (chi (2) = 50.0, P < .01). Blood-donor screening by second-generation anti-HCV provided a significant benefit compared with the first-generation assay.

Detection of K-ras point mutations at codon 12 in pure pancreatic juice for the diagnosis of pancreatic cancer by PCR-RFLP analysis

The present study was undertaken to detect K-ras point mutations at codon 12 in pure pancreatic juice (PPJ) for the diagnosis of pancreatic cancer (PC) using the polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method. PPJ was collected through a cannula under a duodenal fiberscope from 26 patients with PC and 32 patients with chronic pancreatitis (CP). DNA was extracted from PPJ and was used as the template for PCR. Analysis of PPJ by PCR-RFLP with BstNI revealed that the incidence of K-ras point mutations at codon 12 was 81% (21/26) in patients with PC and 6% (2/32) in those with CP. With reference to the location of PC, the incidence of K-ras mutations was 79% (11/14) in the head, 86% (6/7) in the body, and 80% (4/5) in the tail of the pancreas. The incidence of K-ras mutants was 50% (1/2) in tumor size 1 (TS1; < or = 2.0 cm in size), 71% (5/7) in TS2 (2.1 to < or = 4.0 cm), 89% (8/9) in TS3 (4.1 to < or = 6.0 cm), and 88% (7/8) in TS4 (> 6.1 cm). These results suggested that analysis of K-ras point mutations at codon 12 in PPJ using the PCR-RFLP method is a promising new genetic test for the diagnosis of PC.

Measurement of serum PSP/reg-protein concentration in various diseases with a newly developed enzyme-linked immunosorbent assay

An enzyme-linked immunosorbent assay, based on two monoclonal antibodies (Hreg1-1 and Hreg101-1) specific for pancreatic stone protein (PSP)/reg-protein, was developed to determine the concentration of this protein in serum from individuals with various diseases. The serum concentration of PSP/reg-protein was significantly higher in patients with various pancreatic diseases than in normal controls, and was also significantly higher in patients with acute pancreatitis or chronic relapsing pancreatitis than in patients with chronic pancreatitis. Furthermore, the serum PSP/reg-protein concentration was also significantly increased in liver cirrhosis, choledocholithiasis, and various cancers of the digestive system, and was extremely high in all patients tested with chronic renal failure. A significant correlation was apparent between the serum concentration of PSP/reg-protein and elastase-I in 68 patients with chronic pancreatitis or pancreatic cancer. Whereas only 7 of these patients showed a normal serum PSP/reg-protein concentration and a significantly increased elastase-I concentration, 15 of these patients showed a significantly increased serum PSP/reg-protein concentration and a normal serum elastase-I concentration. These results indicate that the serum PSP/reg-protein concentration may reflect pancreatic damage, especially in acute pancreatitis, and may be a sensitive a marker for such damage as elastase-1, although false positivity was apparent in renal failure and in some patients with hepatic dysfunction or digestive system malignancies.

A psychiatric diagnostic system integrating probabilistic and categorical reasoning

We describe a diagnostic support system for clinical psychiatry and its evaluation results. The system has two inter-related components: a rule-based reasoning part associated with uncertainty, and a deterministic part, that uses heuristics to perform categorical reasoning. The system includes the 30 groups of psychiatric diagnoses which are classified under the categories 290 to 319 of the DSM-III-R and the ICD-9. There are, in fact, 1508 rules relating 208 clinical findings with 257 diagnoses. The reasoning strategy is based on selecting and differentiating diagnostic categories in a hierarchical classification tree. The system is intended to be used for education of medical students, and to help non-specialist clinicians, residents in psychiatry, or experts with few years of experience in decision making. We tested the diagnostic performance of the system using case reports extracted from a specialized journal. In 52.8% of the cases, the correct diagnosis was ranked as the first hypothesis using only the rule-based part. In combination with the deterministic strategy, the correct diagnosis could be made for 73.6% of the analyzed cases.

The concept of "template" assisted electronic medical record

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

[A case of poorly differentiated hepatic cell carcinoma which showed 90% decrease in size after chemotherapy with intraarterial infusion of mitomycin C and oral administration of tegafur]

The patient was a 77-year-old man, admitted complaining of abdominal fullness and appetite loss. By ultrasonography and CT an 8 x 5 cm mass was discovered in S1 of the liver. Needle biopsy specimen from the lesion revealed poorly differentiated hepatic cell carcinoma. Because of his advanced age and the size of the tumor, surgical therapy was not used. Chemotherapy with intraarterial injection of mitomycin C 2 mg once a week and 800 mg of tegafur PO daily was given for 5 weeks until bone marrow suppression developed. After recovery of hematological data, tegafur 800 mg PO daily every other week was administered for a year. In the course of these therapies, the hepatic tumor became smaller, and the ultimate decrease rate was over 90% (PR). Thus far it seems that chemotherapy with tegafur might be tried in hepatic cell carcinoma cases in which surgery is not indicated.

Clinical features of hepatocellular carcinoma in the elderly: a study of 91 patients older than 70 years

In order to determine the clinical features of hepatocellular carcinoma in the elderly, a total of 622 patients with hepatocellular carcinoma, including 91 patients 70 years or older, were retrospectively analysed with reference to their ages at the time of diagnosis. The proportion of females increased and that of hepatitis B surface antigen-positive cases decreased as age increased. Tumour sizes at the time of diagnosis were somewhat smaller in the elderly than in younger patients, whereas clinical stage taking liver function into consideration was similar in the two age groups. The prognosis in the elderly patients was similar to that in the younger ones in a clinical stage-matched comparison. Furthermore, by a multivariate analysis using the Cox proportional hazards model with inclusion of age and other clinical parameters, age was not selected in the final model as an independent predictor for survival. These results indicate that elderly patients with hepatocellular carcinoma have certain clinical features different from those in younger patients and that their prognosis is not necessarily poorer than in the latter.

Effects of interferon beta on non-A, non-B acute hepatitis: a prospective, randomized, controlled-dose study. Japan Acute Hepatitis Cooperative Study Group

BACKGROUND/AIMS

Non-A, non-B acute hepatitis progresses to a higher incidence of chronicity and hepatocellular carcinoma. To avoid the development of chronic liver disease, resolution of acute hepatitis C might be most effective. The aim was to establish the effect of interferon in disturbing progression to chronicity and to determine the most appropriate treatment protocol.

METHODS

Ninety-seven acute non-A, non-B hepatitis cases were randomly assigned to six different protocols and treated with 8.4-336 MU of interferon; 90 cases were finally completely analyzed. Titers of hepatitis C virus (HCV) RNA and HCV genotypes were determined.

RESULTS

Seventy-four cases were positive for second-generation anti-HCV. Of these, 65 (89%) were positive for HCV RNA. In these 65 cases, the resolution rate was 32%, and this rate was dependent on the total treatment dosage. Only the group treated with 336 MU showed a high (83%; 10/12) resolution rate; the other five groups had 0%-38% resolution.

CONCLUSIONS

Interferon treatment for acute hepatitis C could be regarded as a "vaccinelike" therapy by preventing the development of the virus carrier state.

Structuring medical information into a language-independent database

We describe one approach for natural language processing and database representation of medical information. The method is based in the semantic analysis of the statements and in the identification of patterns. The processed information is indexed and structured into a frame format containing semantic slots into the database. We tested our method analysing sentences describing symptoms extracted from case reports presented in the volume 328 of the New England Journal of Medicine. The results are: 73.41% of the sentences were formatted; 81.05% of the analysed words were identified; and 95.33% of the medical terms were indexed. We conclude that this semantic approach is not only efficient for processing natural language texts, but it can also be used for the organization of medical information using a language-independent format. This interlingua that is set into the database can be applied to semantic data retrieval; serving as a basis to organize a problem-orientated medical record; displaying simultaneously the DB information into two or more languages; information interchanging among different human languages and computers; and automatic translation, among others.

Spinocerebellar degenerations in Japan: a nationwide epidemiological and clinical study

A nationwide survey of patients in Japan with spinocerebellar degenerations (SCD), including SDS and SND, was conducted from 1988 to 1989. The survey consisted of two parts. The first revealed that the estimated total number of patients with SCD in Japan was 5,050 (range: 4,100-6,000) with an estimated prevalence of 4.53 per 100,000 in 1987. The second part investigated the neurological and functional status of patients with SCD. The percentages of those belonging to each subtype of SCD were: OPCA; 34.4%, LCCA; 15.2%, MHCA; 12.6%, HHCA; 7.5%, SDS; 7.0%, HSP; 3.9%, DRPLA; 2.5%, FA; 2.4%, MJD; 2.0% and SND; 1.5%. Compared with European epidemiological studies Japan had a higher proportion of non-hereditary types of SCD. Various clinical features of SCD subtypes were compared grouped by pathological lesion and heredity. HHCA and LCCA: cerebellar ataxia predominated in all stages, and neurological signs other than cerebellar ataxia were rare. MHCA, DRPLA and MJD: in the early phase ataxia was the most common symptom in MHCA, the AC form of DRPLA and MJD, but ataxia was less common and chorea or epilepsy were often observed in ME and PH forms of DRPLA. Other frequently observed clinical features were parkinsonian rigidity in MHCA, abnormal movements and posture in DRPLA and MJD, and disturbances of eye movements in MHCA, the AC form of DRPLA and MJD. OPCA, SDS and SND: dominant clinical features were cerebellar ataxia in OPCA, autonomic disturbance in SDS, and parkinsonian rigidity in SND. FA and HSP: both were rare in Japan. Clinical features related to supra-supinal lesions were frequently observed in FA. Functional status of SCD: the severity of illness was significantly associated with the level of independence in each item of ADL. Activities not requiring dynamic balance were performed independently for a longer period than those requiring dynamic balance. Among SCD subtypes, functional prognosis was poorest in non-hereditary, multi-systemic types (OPCA, SDS and SND) followed by hereditary multi-systemic types (MHCA, DRPLA and MJD), and better in spinal types (FA and HSP) and cerebellar types (HHCA and LCCA).

Endoscopic ultrasonography in the diagnosis of extraluminal compressions mimicking gastric submucosal tumors

We evaluated the diagnostic usefulness of endoscopic ultrasonography (EUS) in 19 patients with extragastric compression. In these 19 cases, the causes of the compression were normal organs or structures in 16 cases (splenic artery 7, spleen 5, normal pancreas two, gall-bladder one, colon one) and extraluminal tumors in three cases (two hepatic hemangiomas, one neurogenic tumor of the omentum minor). In 12 of these 19 cases, the site of the submucosal compression was located in the upper part of the stomach. All three tumors were confirmed by other procedures, and in the remaining 16 patients with compression by normal organs or structures, negative follow-up results (mean: 14 months) supported the absence of a true submucosal tumor. EUS was 100% accurate in the differentiation of an extragastric compression from a submucosal tumor, and in the identification of the compressing organ. EUS was also far superior to other procedures, such as ultrasonography and CT. It significantly shortens the diagnostic procedure, especially in patients with compressions by normal extraluminal structures, making other diagnostic modalities unnecessary.

[Clinical usefulness of tumor markers associated with pancreatic cancer]

Most of the recently developed tumor antigens detected by monoclonal antibodies are sugar chains and frequently associated with blood group substance. By immunohistochemical studies, we evaluated mainly the clinical usefulness and significance of the serum assay of CA-50 classified as a type 1 sugar chain, sialyl SSEA-1 as a type 2 sugar chain, and ST-439 with an undetermined structure, as well as their clinicopathological significance. In addition, the value of measurement of CA19-9, ST-439, and SLX in pure pancreatic juice (PPJ) was investigated. Furthermore, the clinical usefulness of K-ras mutation at codon 12 (KRM) in PPJ was studied. The incidence of serum CA19-9 among tumor markers was highest in pancreatic cancer (81%), but relatively high in benign diseases. On the other hand, both serological and immunohistological studies showed that sialyl SSEA-1 and ST-439 were highly specific for the tumor, whereas they appeared in serum or tumor less frequently than CA19-9 or CA-50 carrying the type 1 sugar chain. The accuracy of the tumor markers (CA19-9, sialyl SSEA-1, and ST-439) for pancreatic cancer, was almost equal (77% to 80%) and higher than that of CEA (69%). However, a highly positive correlation between sialyl SSEA-1 and ST-439 was revealed as well as among type 1 sugar chains in malignant diseases. Therefore, we conclude that the combination assay with CA19-9 or a similar tumor marker, sialyl SSEA-1 or ST-439, and CEA would be appropriate for the screening of pancreatic cancer. When the cut off value was set as the M + 2SD of the controls, significantly elevated concentrations of CA19-9 in PPJ were found in the secretory phase in 90% of the patients with pancreatic cancer (PC) and 66% of the patients with chronic pancreatitis (CP). Although increased concentrations of CA19-9 in PPJ have no cancer specificity, measurement of CA19-9 in PPJ can be used as a sensitive marker for some pancreatic disorders. On the other hand, concentrations of ST-439 and SLX in PPJ were significantly increased only in PC, and their incidences were 50% and 40%, respectively. They have a high tumor-specificity, but their incidences were not as high as initially expected.(ABSTRACT TRUNCATED AT 400 WORDS)

Measurement of sialylated stage-specific embryonic antigen-1 in pure pancreatic juice for the diagnosis of pancreatic cancer

The diagnostic significance of measuring sialylated stage-specific embryonic antigen-1 (SLX) in pure pancreatic juice was evaluated in 20 patients with pancreatic cancer, 43 with chronic pancreatitis, 13 with cholecystolithiasis, and 15 control individuals. Four fractions of pure pancreatic juice were collected sequentially from the pancreatic duct by endoscopic cannulation. The SLX levels in all four fractions of pure pancreatic juice were significantly higher in patients with pancreatic cancer than in controls. On the other hand, patients with chronic pancreatitis or cholecystolithiasis did not have SLX levels that significantly differed from those of controls in any fraction. When the cut-off value was set as the mean concentration +2 times the standard deviation of the control values, the positive rates of SLX in the first fraction (washout phase) and the third fraction (secretory phase) of pure pancreatic juice from pancreatic cancer were 55% (11/20) and 40% (8/20), respectively. Although the false positive rates in the first fraction were high in chronic pancreatitis (30%) and cholecystolithiasis (31%), such high SLX levels in the third fraction were found only in one (2%) patient with chronic pancreatitis and in one (8%) with cholecystolithiasis. The specificities of the test for pancreatic cancer in the first fraction and the third fraction were 70% (39/56) and 96% (54/56), respectively. These results indicate that the measurement of SLX in the third fraction of pure pancreatic juice is useful as a specific marker for pancreatic cancer.

Prospective assessment of incidence of fulminant hepatitis in post-transfusion hepatitis: a study of 504 cases

The incidence of posttransfusion hepatitis and "fulminant" hepatitis was investigated by a plan devised at our hospital in December 1982. Of 2959 blood recipients between January 1982 and December 1988, 504 (22.5%) developed posttransfusion hepatitis, with a mean transfusion volume of 10.2 units. Of the 504 cases of posttransfusion hepatitis, "icteric" (T-Bil > 2.0 mg/dl) and "overt icteric" hepatitis (T-Bil > 5.0 mg-dl) developed in 111 cases (22.0%) and 28 cases (5.6%), respectively. Of the 28 overt icteric hepatitis cases, 13 (2.8%) were thought to be true overt icteric posttransfusion hepatitis because the icterus was caused by other reasons in the other 15 cases (seven neonatal jaundice, four hemolytic anemia, one radiation hepatitis, one halothane-induced hepatitis; two other cases were excluded because chronic liver disease was diagnosed by imaging procedures despite serum ALTs in the normal range before transfusion). The anti-HCV serostatus was investigated in five of the 13 true overt icteric posttransfusion hepatitis patients using blood specimens taken 180 days or more following the onset of posttransfusion hepatitis. Anti-HCV seroconversion occurred in three of the five cases (60%). HCV seroconversions were not seen in the cases in which the icterus was due to other reasons.

Biliary papillomatosis with the point mutation of K-ras gene arising in congenital choledochal cyst

Biliary papillomatosis is a rare entity. A case of biliary papillomatosis associated with congenital choledochal cyst and intrahepatic gallstones is reported here. Percutaneous transhepatic cholangioscopy revealed multiple papillary lesions of the right intrahepatic duct and the common bile duct. Microscopically, the papillary mucosal lesion showed papillary proliferations of bile duct epithelial cells with mild atypia. Furthermore, a point mutation at codon 12 of the K-ras oncogene was found in the papillary lesion. To the best of our knowledge, this is the first case of biliary papillomatosis arising in congenital choledochal cyst. Although the pathogenesis of biliary papillomatosis in our case was unclear, biliary irritation associated with choledochal cyst may be related to biliary papillomatosis with point mutation at codon 12 of K-ras gene.

A design for decision making: construction and connection of knowledge bases for a diagnostic system in medicine

We describe the process of organizing medical knowledge into knowledge bases and designing one architecture for a decision support system in clinical psychiatry. We define a set of knowledge bases that we regard as the necessary and sufficient structures to represent the medical knowledge to provide clinical consultations: disease profiles; frames with semantic relations to represent clinical findings; production rules with probabilities, to relate findings with diagnoses; a hierarchical classification tree, to represent disease categories; heuristic questions, to narrow the diagnostic hypotheses; and diagnostic criteria to conclude the clinical investigation. We propose one new architecture for a support system connecting these knowledge bases in a particular way to simulate medical clinical reasoning.

Identification of K-ras oncogene mutations in the pure pancreatic juice of patients with ductal pancreatic cancers

Pancreatic cancer is detected on the basis of morphological changes delineated by means of various image-diagnostic methods. However, differentiation between chronic pancreatitis and pancreatic cancer, especially at the early stage, is not always simple when based upon the morphological changes alone. Therefore, we attempted to elucidate K-ras mutations in the sediment of pure pancreatic juice (PPJ) containing exfoliated ductal pancreatic cancer cells. PPJ was collected endoscopically from 20 patients with pancreatic cancer (PC) and 18 patients with chronic pancreatitis (CP). Polymerase chain reaction and allele specific oligonucleotide dot blot hybridization for K-ras mutations were performed with the DNA extracted from these samples. A K-ras mutation at codon 12 was identified in the PPJ of 11/20 (55%) of the patients with PC. On the other hand, the same mutation was not identified in the PPJ of any patient with CP. Moreover, K-ras mutations at codons 13 and 61 were not recognized in the PPJ of any patient with either PC or CP. These findings suggested that the presence of a K-ras mutation at codon 12 in PPJ would be useful in confirming the diagnosis of PC.

Prospective assessment of donor blood screening for antibody to hepatitis C virus and high-titer antibody to HBcAg as a means of preventing posttransfusion hepatitis

Since December 1989, the Japan Red Cross Blood Bureau has screened blood donors for hepatitis C virus antibody on the basis of enzyme-linked immunosorbent assay and high titers of antibody to HBc antigen. To elucidate the effectiveness of the new screening tests in preventing posttransfusion hepatitis, the incidence of posttransfusion hepatitis after the introduction of the new tests (December 1989 to December 1990) was compared with the incidence before their introduction (January 1982 to December 1988). The incidence of posttransfusion hepatitis was 9.8% (219 of 2240), with a mean transfusion volume of 10.2 units, before the screening and 3.7% (12 of 326), with a mean transfusion volume of 14.7 units, after the introduction of the new tests. Statistical analysis revealed a significant decrease of incidence of posttransfusion non-A, non-B hepatitis after the introduction of the new tests (X2 = 10.9, p < 0.01). Posttransfusion hepatitis B occurred in 3 of 2,240 recipients (0.13%) before the introduction of HBc antibody testing. No cases of posttransfusion B viral hepatitis developed after the introduction of the new tests. Hepatitis C virus antibody status was investigated in 7 of 12 posttransfusion hepatitis patients who contracted the disease after the new screening tests were initiated. Hepatitis C virus antibody seroconversion occurred in three of the seven cases (43%), as detected on first- and second-generation hepatitis C virus antibody assays and reverse-transcription polymerase chain reaction.

Diagnostic significance of cancer-associated carbohydrate antigen (CA19-9) concentrations in pancreatic juice: analysis in pure pancreatic juice collected by endoscopic aspiration and immunohistochemical study in chronic pancreatitis

This study evaluated the diagnostic significance of concentrations of the cancer-associated carbohydrate antigen CA19-9 in pure pancreatic juice (PPJ) collected by endoscopic cannulation. We also attempted to elucidate the features and source of the increased CA19-9 concentration found in the pancreatic juice of patients with chronic pancreatitis (CP) by means of immunohistochemical staining. The mean output as well as the mean concentration of CA19-9 in each of the four fractions collected was highest in patients with pancreatic cancer (PC) and also was elevated significantly in patients with CP compared with controls. However, CA19-9 concentrations were not elevated in patients with cholecystolithiasis. When the cutoff value was set as the mean concentration + 2SD of the controls, significantly elevated concentrations of CA19-9 were found in the third fraction (secretory phase) in 90% of the patients with PC and 66% of the patients with CP. Immunohistochemical staining revealed that CA19-9 was expressed more widely in the ductal cells of CP tissues than in those of normal pancreatic (NP) tissues, with CP tissue showing more CA19-9-positive ductal cells per area than NP tissues. In NP tissue, CA19-9 was localized to the apical surface and supranuclear regions (apical type) in all the ductal cells stained by the antigen, while approximately 50% of cases with CP exhibited a cytoplasmic pattern showing a loss of polarity of the antigen expression. Moreover, this cellular localization pattern was more pronounced in the small ducts that had proliferated and aggregated following the destruction of lobules in CP.(ABSTRACT TRUNCATED AT 250 WORDS)

The immunohistochemical evaluation of PSP/reg-protein in normal and diseased human pancreatic tissues

In order to elucidate the characteristics of reg-protein, which is identical to pancreatic stone protein (PSP/reg-protein), and the relationship between the generation and evolution of chronic pancreatitis and the expression of PSP/reg-protein in the pancreas, we investigated the expression of PSP/reg-protein in normal and diseased human pancreatic tissues by immunohistochemistry. The PSP/reg-protein was expressed in all cases with normal pancreas or chronic pancreatitis, and in 70.6% of cases with pancreatic cancer. This protein was present in the cytoplasm of acinar cells and, in some cases, in the intraluminal contents of ductules in nonmalignant tissues. From the view of distribution and cellular localization, PSP/reg-protein was expressed more broadly and densely in chronic pancreatitis with mild to moderate injury than in the normal pancreas. However, the protein was less expressed in severely damaged chronic pancreatitis tissue, such as calcifying pancreatitis, than in the normal pancreas. These findings suggest that mild to moderate injury to pancreatic tissue may stimulate the synthesis of PSP/reg-protein, whereas more severe injury tends to depress it.

Simultaneous determination of retinol and tocopherols by high-performance liquid chromatography

A high-performance liquid chromatographic (HPLC) method to determine retinol and all four tocopherols (alpha-, beta-, gamma- and delta-) simultaneously was established using a reversed-phase column (YMC-PACK A-302 S-5 120A ODS). The HPLC conditions were mobile phase 65% isopropanol, sample solvent 99.5% methanol and temperature 30 degrees C. Retinol and tocopherols were measured in rat liver.

Automated diagnostic indexing by natural language processing

Developing tools for natural language understanding by computers represents an important and intense field of research. This paper describes a system developed for interpreting medical natural language in the domain of symptoms and diagnoses from complete discharge summaries and locating the correspondent category into the International Classification of Diseases, through indexing by the Systematized Nomenclature of Medicine. The indexing program makes use of the MEID dictionary and some auxiliary semantic databases for identifying adjectival forms, synonyms, hypernyms and other semantic relations while searching for the longest consistent match into SNOMED. A further subdivision of the SNOMED structure was also proposed in order to find the hierarchically superior representative of a conceptual class when this association is not assigned by the related SNOMED code number. The system can be used by any language that possesses a translation of SNOMED and ICD. The knowledge base was built using a conversion file that maps the terms of the nomenclature into the classification, which can be improved by learning from users.