A rare case of Lemierre`s syndrome caused by Porphyromonas asaccharolytica.

Lemierre's syndrome is only very rarely caused by Porphyromonas asaccharolytica. Here, we report the case of a 35-year-old man who developed a left peritonsillar abscess, thrombophlebitis of the left internal jugular vein, and septic embolization of both lungs. Anaerobic P. asaccharolytica was isolated in the blood cultures, and we subsequently confirmed the diagnosis as Lemierre's syndrome. Our case indicates that although P. asaccharolytica is not commonly found in oral cavities, this organism may still cause Lemierre's syndrome. Consequently, when it is detected in blood cultures, the treating physician should perform the medical examination while keeping in mind the possibility that the patient could have Lemierre's syndrome.

Large scale replication analysis of loci associated with lipid concentrations in a Japanese population.

BACKGROUND: Recent genome wide association studies discovered seven novel loci that influence plasma concentrations of triglycerides, high density lipoprotein (HDL) and low density lipoprotein (LDL) cholesterol in Europeans. To date, large scale replication studies using populations with known differences in genome-wide linkage disequilibrium (LD) pattern have not been undertaken. METHODS: To address this issue, we tested associations between single nucleotide polymorphisms (SNPs) within the seven novel loci and plasma lipid profiles in 21 010 Japanese individuals. RESULTS: Multiple linear regression analyses showed that the rs3812316 in MLXIPL was strongly associated with triglyceride concentrations (p approximately 3.0x10(-11), 7.1 mg/dl decrease per minor C allele) and that rs599839 in CELSR2/PSRC1/SORT1 was strongly associated with LDL cholesterol concentrations (p approximately 3.1x10(-11), 4.7 mg/dl decrease per minor G allele) in the Japanese population. SNPs near ANGPTL3, TRIB1 and GALNT2 showed evidence for associations with triglyceride concentrations (3.6x10(-6)

The RHD gene is highly detectable in RhD-negative Japanese donors.

Recent molecular studies on the Rh blood group system have shown that the Rh locus of each haploid RhD-positive chromosome is composed of two structural genes: RHD and RHCE, whereas the locus is made of a single gene (RHCE) on each haploid RhD-negative chromosome. We analyzed the presence or absence of the RHD gene in 130 Japanese RhD-negative donors using the PCR method. The RhD-negative phenotypes consisted of 34 ccEe, 27 ccee, 17 ccEE, 26 Ccee, 19 CcEe, 1 CcEE, and 6 CCee. Among them, 36 (27.7%) donors demonstrated the presence of the RHD gene. Others showed gross or partial deletions of the RHD gene. These results were confirmed by Southern blot analysis. Additionally, the RHD gene detected in the RhD-negative donors seemed to be intact through sequencing of the RhD polypeptide cDNA and the promoter region of RHD gene. The phenotypes of these donors with the RHD gene were CC or Cc, but not cc. It suggested that there is some relationship between the RHD gene and the RhC phenotypes in RhD-negative individuals. In Caucasian RhD-negative individuals, the RHD gene has not been found outside of the report of Hyland et al. (Hyland, C.A., L.C. Wolter, and A. Saul. 1994. Blood. 84:321-324). The discrepant data on the RHD gene in RhD-negative donors between Japanese and Caucasians appear to be derived from the difference of the frequency of RhD-negative and RhC-positive phenotypes. Careful attention is necessary for clinicians in applying RhD genotyping to clinical medicine.

Identification of the truncated Duffy mRNAs in erythroid cells.

Chaudhruri et al. reported the Duffy glycoprotein cDNA (Fy71-81) (Proc Natl Acad Sci USA 1990; 90; 10793), and we cloned a novel Duffy cDNA named Fy0.1 (Blood 1996; 87: 378). Reverse transcription-polymerase chain reaction analysis revealed the presence of the four truncated mRNAs associated with both transcripts. The truncated Duffy mRNAs is predominantly present in reticulocytes but is not detected in the erythroblasts. The sequencing data indicated that the truncated Duffy mRNAs were processed by splicing. Further study is needed to clarify the biological role of the truncated Duffy mRNA in reticulocytes.

Direct antiglobulin test negative autoimmune hemolytic anemia associated with autoimmune hepatitis.

A case of direct antiglobulin test(DAT)-negative autoimmune hemolytic anemia (AIHA) associated with autoimmune hepatitis (AIH) is presented. A 54-year-old female was admitted with liver dysfunction and anemia. AIH was diagnosed based on the diagnostic criteria of the International Autoimmune Hepatitis Group. The patient was DAT-negative, and exhibited all the clinical features of warm type AIHA and elevated levels of red blood cell-associated IgG. Marked improvement of subjective symptoms, the return to normal of hematological and liver test values, and a decrease in the level of RBC-associated IgG were observed after the start of corticosteroid therapy. Although an association of AIH and AIHA is rarely reported, the measurement of RBC-associated IgG is recommended in cases of AIH with DAT-negative anemia, as both disorders are autoimmune in nature.

A patient with Tn syndrome associated with myelodysplastic syndrome showed abnormal glycophorin B.

A Japanese male patient with myelodysplastic syndrome (MDS) was shown to have associated Tn syndrome; the first report of Tn syndrome with MDS. The Tn expression was demonstrated on erythrocytes, granulocytes, monocytes, platelets, and lymphocytes by flow cytometric analysis using a lectin and an antibody. Electrophoresis of erythrocyte membrane proteins revealed slower mobility of glycophorin B from the patient than that from normal individuals, suggesting a glycophorin B molecular abnormality.

Expression analysis of human Rhesus blood group antigens by gene transduction into erythroid and non-erythroid cells.

Rh blood group antigens are associated with non-glycosylated human erythrocyte membrane proteins encoded by two closely related genes, RHCE and RHD, and with a glycoprotein, a critical co-expressing factor encoded by the RH50 gene. The sequence analysis of RHCE transcripts has revealed that RhE/e and C/c serological phenotypes are associated with a nucleotide substitution in exon 5 and six substitutions in exons 1 and 2 of RHCE gene, respectively. Smythe et al. have shown that the full length transcript of RhcE gene expressed c and E antigens and the transcript of RhD gene expressed D and G antigens, using retroviral-mediated gene transduction into K562 cells. We performed an epitope analysis of Rh antigen by constructing retroviral gene coding six RH cDNAs, which contain RhcE, ce, CE and D cDNAs, and CE-D, D-CE chimera cDNAs. The cDNAs were introduced into KU812E cells and the expressed antigens were analyzed by flow cytometry. These studies revealed that the C/c and E/e associated substitutions actually participated in respective polymorphic epitopes. However, the C antigen was not detected on the KU812E cells introduced with CE cDNA, despite E antigen being expressed. The study with the chimera gene between CE and D cDNAs also indicated that the Rh epitopes were not constructed with short polymorphic exofacial peptide loops only but also with other peptide fragments and membrane components. Co-expression studies of Rh50 and RhD or cE gene in non-erythroid cells, 293, and expression studies of Rh50 in another erythroid cell, HEL, did not show any Rh antigens on the transduced cells, despite the Northern blot study showing both transcripts in the cells. It was suggested that at least a second co-expressing factor was needed to express RhCE or D antigens on the plasma membrane.

Hypertension control and medication increase in primary care.

Over half of treated patients with hypertension are not well controlled. However, little is known about physicians' prescribing behaviour for these patients. Our objective was to clarify whether physicians increase antihypertensive medication in patients with poorly controlled hypertension and what characteristics are predictors of medication increase. This was a retrospective cohort study by surveying medical records in primary care clinics in Tochigi, Japan. Twenty-nine of 79 randomly selected physicians agreed to select 20 consecutive hypertensive patients. This resulted in 547 patients (women 60%; mean (s.d.) age, 68 (12) years) who had blood pressure measurements taken in 1998 and prescription of antihypertensive medication in 1998 and 1999. Mean (s.d.) systolic/diastolic blood pressure was 142 (12)/81 (9) mm Hg and the percentage of patients in good control (<140/90 mm Hg), fair (140-159/90-94) and poor (> or =160/95) were 42%, 47%, and 11%, respectively. Physicians increased medication in 28% of poorly controlled patients (95% confidence interval (CI), 17-41%), which was more than those in fair (12%, 95%CI 8-16%) or good control (7%, 95%CI 4-12%). Multivariate logistic regression analysis showed that systolic and diastolic blood pressures were positively, and the number of kinds of antihypertensive medications and the age of the physician were negatively, associated with an increase in medication. In conclusion, primary care physicians did not increase antihypertensive medication adequately for patients with uncontrolled hypertension. Attempts to understand and to change physicians' prescription behaviour could reduce the burden of uncontrolled hypertension among treated hypertensive patients.

Alterations of blood group antigens in angio-immunoblastic lymphadenopathy with dysproteinemia.

Antigen analysis of the red cell membrane in a patient with angio-immunoblastic lymphadenopathy with dysproteinemia (AILD) with red cell autoantibody revealed that four blood group antigens had been acquired. These four antigens consisted of S of MNSs blood group, Lua of Lutheran blood group, and K and Kpa of Kell-Cellano blood group. These antigens disappeared and the Coombs' test became negative after complete remission induced by combination chemotherapy. Free amino acid analysis after Dispase treatment of red cell membrane suggested that the antigenic modifications were associated with abnormal composition of amino acids.

Molecular genetic basis of red cell markers and its forensic application.

(1) The polymerase chain reaction (PCR) was used to amplify Rh-related cDNAs from erythroid cells cultured by the selective two-phase liquid culture system for human erythroid progenitors in peripheral blood. Two Rh polypeptide cDNAs have been isolated from the PCR products and tentatively designated RhPI cDNA and RhPII cDNA. Both cDNA clones have an open reading frame composed of 1251 nucleotides. The RhPI cDNA clone shows a single nucleotide substitution with no amino acid substitution compared with the published sequence. The RhPII cDNA clone differs from the above by 41 nucleotide substitutions in the open reading frame, resulting in 31 amino acid substitutions. Besides these cDNA clones, eleven and five truncated isoforms of the RhPI and RhPII cDNAs, have been isolated, respectively. (2) The promoter region of the Duffy gene was cloned by IPCR of 1.1 kb SacI fragment and the 3' flanking sequence was cloned by IPCR of 1.9 kb EcoRI fragment. The IPCR products contained the known Duffy cDNA sequence without introns. By comparing the coding area of the Duffy gene in 28 Duffy positive individuals, we elucidated that one base change that results in an amino acid substitution (GAT(Asp44)-->GGT(Gly)) is in accordance with the Fya/Fyb polymorphism. This fact proves that the Duffy cDNA and its gene encode the Duffy blood group system. (3) Two common alleles in Esterase D (EsD) polymorphism, EsD1 and EsD2 were characterized by the substitution of one amino acid (Gly-Glu) caused by the point mutation of one nucleotide (G-A). The point mutation between cDNAs of EsD1 and EsD2 alleles was detectable as restriction fragment length polymorphism (RFLP) using Ssp1. The RFLP makes it possible to determine the EsD phenotypes using DNA samples from forensic materials without EsD enzymatic activity. (4) The authors report studies on 19 pairs of donors and recipients in bone marrow transplantation. A broad range of genetic markers at 42 gene loci, including one DNA marker 11 red blood cell markers, five human lymphocyte antigen types, 12 serum protein markers, five red cell enzyme markers, and eight salivary markers was evaluated before and after BMT over about 2 months. As a result, 11 out of 42 gene loci of genetic markers in recipients were transformed into the donor type.

Further evidence for phenotypes and gene frequencies of nine salivary polymorphisms in Japanese population.

Nine salivary polymorphic systems (Pa, Pb, Pr, Db, PmF, PIF, Ph, Amy1 and s-AcP) were examined using parotid and whole saliva from random Japanese individuals. The gene frequencies obtained were: Pa+ = 0.221, Pb1 = 1.000 Pr1 = 0.741, Db+ = 0.033, PIF+ = 0.715, Ph+ = 0.029, Amyv1 = 0.013 and s-AcPA = 0.217, respectively.

Complementary medicine education in Japanese medical schools: a survey.

OBJECTIVES: To evaluate the present state of complementary medicine (CM) education in Japanese medical schools. DESIGN: This investigation consisted of two studies: (1) a telephone survey to curricular office workers in September 1998; and (2) a self-completed questionnaire to representatives of sponsoring departments in July 1999. SETTINGS: All 80 medical schools for Western medicine. MAIN OUTCOME MEASURES: Presence of a CM course and sponsoring department. Titles of courses and teaching methods. RESULTS: The response rate to the telephone survey and self-completed questionnaire was 100 and 95%, respectively. Of 80 medical schools, CM was officially taught in 16 schools (20%). Of these 16 schools, there were 19 CM courses and the anesthesia department sponsored the most courses (six courses). All courses had oriental medicine titles such as acupuncture and Kampo except for one course. CONCLUSION: Twenty per cent of Japanese Medical Schools taught CM with predominantly oriental medicine themes.

Genotyping of TF*Dchi allele in human transferrin polymorphism.

Transferrin (TF) polymorphism, one of the most useful genetic markers, have been studied extensively. TF*Dchi allele is widely distributed both among east Asian populations and American Indian populations. The TFDchi peptide was characterized by replacement of His by Arg at position 300 by amino acid sequencing. In the present study, one base substitution at the 956th nucleotide from the first nucleotide in the starting codon that induced His300Arg exchange was confirmed by direct DNA sequencing. The genotyping method used to detect the TF*Dchi allele involved the use of PCR-RFLP and restriction enzyme Acc II. Analysis of the 1765th nucleotide, which determines the common TF alleles, TF*C1 and TF*C2, in TF*Dchi cDNA indicated that the TF*Dchi allele is derived from the TF*C1 allele.

RHC/c genotyping based on polymorphism in the promoter region of the RHCE gene.

Designing of PCR tests for the RHC allele is difficult because of the high DNA sequence homology between RHC and RHD genes, which differ by only a one-nucleotide substitution at position 48 in exon 1 of the RHCE gene. We sequenced the promoter region of the RHCE gene, and compared our results with the reported sequence. Genomic DNA was prepared from blood samples collected from 656 Japanese donors. The DNA segment encompassing the promoter region and exon 1 of the RHCE gene from 30 donors was amplified by PCR and analyzed by DNA sequencing. Four nucleotide differences between RHC/c and RHD were found at positions -468, -304, -58, and -46. On the basis of the nucleotide differences at positions -468 (RHCE vs. RHD) and -292 (RHC vs. RHc), we then developed a novel polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) method for RHC/c genotyping. Analysis of the genomic DNA from the 656 donors revealed that this method could discriminate RHC from RHc, irrespective of the RHD genotype, with only a few exceptions. The combination of our system and the intron 2-based PCR-RFLP method previously reported may prove to be more accurate than either of the methods alone, and therefore, useful and valuable for RHC/c genotyping.

Behavior of genetic markers in recipients after bone marrow transplantation and problems in forensic medicine.

The authors report studies on four pairs of donors and recipients in bone marrow transplantation (BMT). A broad range of gene markers at 41 gene loci, including 11 red blood cell markers, 5 human lymphocyte antigen (HLA) types, 12 serum protein markers, 5 red cell enzyme markers, and 8 salivary markers were evaluated before and after BMT over 2 months. As a result, 9 out of 41 gene loci of genetic markers in recipients were transformed into the donor type. BMT between family members may lead to transformation of gene markers, but within a pattern compatible with family inheritance patterns, and no genetic paradox will be found in later surveys of familial genetic relationships. However, in a personal identification system in forensic medicine using genetic markers as an index, the appearance of a phenotype incompatible with a blood relationship is possible after BMT with a non-blood-relative donor. This result is similar to the inheritance pattern observed after artificial insemination by a donor's semen (AID), a more complete out-of-family cross.

[Blood pressure measurement by primary care physicians: comparison with the standard method].

OBJECT: To examine the usual methods of blood pressure (BP) measurement by primary care physicians and to compare them with the standard methods. DESIGN: Cross-sectional survey by self-administered questionnaire. SUBJECTS: Primary care physicians who graduated from Jichi Medical School and were working at clinics. Each standard method for 20 items was defined as the one that was most frequently recommended by 6 guidelines (USA 3, UK 1, Canada 1, Japan 1) and a recent comprehensive review about BP measurement. RESULTS: Of 333 physicians, 190 (58%) responded (median age 33, range 26 to 45 years). Standard methods and percentages of physicians who follow them are: [BP measurement, 17 items] supported arm 96%; measurement to 2 mmHg 91%; sitting position 86%; mercury sphygmomanometer 83%; waiting > or = 1 minute between readings 58%; palpation to assess systolic BP before auscultation 57%; check accuracy of home BP monitor 56%; Korotkoff Phase V for diastolic BP 51%; bilateral measurements on initial visit 44%; small cuff available 41%; > or = 2 readings in patients with atrial fibrillation 38%; > or = 2 readings on one visit 20%; cuff deflation rate of 2 mmHg/pulse 14%; large cuff available 13%; check accuracy of monitor used for home visit 8%; waiting time > or = 5 minute 3%; readings from the arm with the higher BP 1%. [Knowledge about BP monitor, 2 items] appropriate size bladder: length 11%; width 11%. [Check of sphygmomanometer for leakage, inflate to 200 mmHg then close valve for 1 minute] leakage < 2 mmHg 6%; median 10 (range 0-200) mmHg. Average percentage of all 20 items was 39%. Number of methods physicians follow as standard: median 8 (range 4 to 15) and this number did not correlate with any background characteristics of the physicians. Furthermore, we also obtained information on methods not compared with the standard. Fifty-four percentage of physicians used more standard methods in deciding the start or change of treatment than in measuring BP of patients with good control. About 80% of physicians use home BP readings in diagnosis or treatment of hypertension, but about half of physicians with ambulatory BP monitors use their measured readings. CONCLUSION: Primary care physicians used various techniques for routine BP measurement and no physician completely followed the standard. Such measurements may affect the diagnosis and treatment of hypertension, but measuring all BPs solely by the standard is not practical. We need to have a practical and efficient method of BP measurement for routine practice in the primary care setting.

[Prevalence, awareness, treatment, and control of hypertension in Japanese rural communities].

BACKGROUND: In Japan, a national survey indicated that only 7% of hypertensive patients had a blood pressure less than 140/90 mmHg. There have been no reports of studies investigating all of the prevalence of hypertension, the percentage of subjects who are aware of hypertension, the percentage being treated, and the percentage that are well-controlled (awareness, treatment and control, respectively) among hypertensives in the Japanese general population. OBJECTIVE: To investigate the prevalence of hypertension, and awareness, treatment and control of hypertension among hypertensives in a Japanese rural population. DESIGN: A cross-sectional analysis of base-line data of the Jichi Medical School Cohort Study. SETTING: Twelve rural communities is 8 prefectures in Japan. PARTICIPANTS: Community-dwelling people who participated in the health examination program in 1992-1995. MAIN OUTCOME MEASURES: Blood pressure (BP) measured once in the sitting position after a 5-minute rest using oscillometric automatic BP monitors (BP203RV-II; Nippon Colin, Japan), and history of hypertension assessed using a self-administered questionnaire. RESULTS: We analyzed data from 11,302 subjects (4,415 men and 6,887 women). The mean (standard deviation) age was 55(12) years for men and 55(11) years for women. Mean systolic BP and diastolic BP levels were, respectively, 131(21) mmHg and 79(12) mmHg for men and 128(21) mmHg and 76(12) mmHg for women. Prevalence of hypertension (systolic BP > or = 140 mmHg or diastolic BP > or = 90 mmHg or on antihypertensive medication) was 37% for men and 33% for women. Percentages for awareness (on medication or present past history), treatment and control (both systolic BP < 140 mmHg and diastolic BP < 90 mmHg) were, respectively, 39%, 27% and 10% for men and 46%, 38% and 13% for women. CONCLUSIONS: About one third of the study popUlation were hypertensive, and awareness, treatment and control of hypertension among the hypertensives were 43%, 34% and 12%, respectively. Less than half of the hypertensives were well-controlled even when measurement bias was considered. In the rural Japanese population, improvements are required with regard to awareness, treatment and control of hypertension.

[Blood group genes].

Blood group antigens are surface markers on the red blood cell membrane. Biochemical analysis of blood group antigens has shown that these antigens divide into two types of proteins and carbohydrates attached to lipids or proteins. Protein determinants are directly coded on blood group genes, while carbohydrate determinants are controlled through the expression of glycosyltransferase enzymes. For the past ten years, considerable information has been gained from molecular studies of many blood group systems, thereby clarifying several aspects of these genes, genetic backgrounds of variants, and molecular evolution. Additionally, it has become possible to genotype blood groups and to genetically engineer the expression of protein antigens and the activity and specificity of enzymes. ABO system on the carbohydrate and Rh system on the protein are the most important systems in transfusion medicine. In this paper, we will review recent progress in the field of blood grouping; mainly ABO and Rh.

[Macrophages and erythrocytes].

The mechanism by which senescent red blood cells (SRBCs) are eliminated from circulation by the reticuloendothelial system was investigated using the newly developed phagocytosis assay. Phagocytosis of SRBCs and Vibrio cholera neuraminidase (VCN) treated RBCs by autologous macrophages were significantly higher than that of unfractionated RBCs. The phagocytosis of VCN-treated RBCs was enhanced by pre-treatment of RBCs with freshly prepared autologous serum, but not with heat inactivated serum. These results suggest that the erythrophagocytosis is mediated by lectin-like receptors and complement receptors which are present on the surface of macrophages. We also studied the erythrophagocytic capacity of macrophages in the presence of tumor necrosis factor (TNF) as a model of the anemia due to acute inflammation. The phagocytosis of VCN-treated RBCs was enhanced with the addition of a small amount of TNF (1 U/ml). This result suggests that TNF enhances the destruction of damaged RBCs by activating the reticuloendothelial system.

[A new approach for diagnosis of autoimmune hemolytic anemia].

Sixty four cases of autoimmune hemolytic anemia (AIHA) referred to our laboratory from 1985 to 1993 consisted of 51 warm type AIHA, 9 cold agglutinin disease (CAD), one paroxysmal cold hemoglobinuria, and 3 mixed type AIHA. There were 5 patients who had all clinical features of AIHA except for a positive direct-antiglobulin test (DAT). These patients were diagnosed as DAT-negative AIHA because of the elevation of red blood cell-associated IgG (RBC-IgG). The mean RBC-IgG of 100 healthy individuals was 33 +/- 13 (SD) molecules per one RBC. On the other hand, the RBC-IgG of patients with DAT-positive and with DAT-negative warm type AIHA were ranged from 257 to 12,421 and from 126 to 256 molecules per one RBC, respectively. One of 9 patients with CAD had a hemolytic anemia associated with only a cold agglutinin titer of 32 using saline-suspended RBCs, but a titer of 4,096 in the presence of bovine albumin. This case was diagnosed as low titer CAD. All of patients with DAT-negative AIHA or low titer CAD showed a good response to corticosteroid treatment.