Better documentation in electronic medical records would lead to an increased use of lower extremity venous ultrasound in the inpatient setting: a retrospective study.

Aim: We hypothesized that the quality of the assessment of abnormal laboratory data in the emergency department (ED) could affect the hospital-attending physicians' decision-making after a patient's hospitalization. To test this hypothesis, we investigated how patients with a positive D-dimer result were reported by ED physicians in electronic medical records, and measured whether lower extremity venous ultrasonography examination was undertaken during hospitalization by the hospital-attending physicians. Methods: In an urban tertiary acute care general hospital in Japan, between January 2012 and December 2013, we included patients hospitalized after a positive D-dimer measurement (≥1.0 µg/mL) that was taken in the emergency department. We retrospectively measured the quality of ED physician assessments. Then we examined whether that affected the decisions of attending physicians to order lower extremity venous ultrasonography examinations during hospitalization. The exposure variable was the quality of the ED physicians' assessment of patients with positive D-dimer results. The outcome was whether a lower extremity venous ultrasonography examination was ordered by the attending physician during hospitalization. Results: When assessments were described by ED physicians for patients with positive D-dimer results, the attending physicians frequently ordered lower extremity venous ultrasonography (odds ratio, 10.74; 95% confidence interval, 5.92-19.50), even if the assessments only contained "copied and pasted" laboratory data (odds ratio, 1.68; 95% confidence interval, 2.10-2.40). Conclusions: Better documentation by ED physicians, regarding patients with positive D-dimer results, strongly affected the decisions made by attending physicians to order lower extremity venous ultrasonography examination.

[How to Interpret Routine Laboratory Data? Challenge Faced by Inexperienced Certified Clinical Laboratory Physicians -Practical Advice from Experienced Certified Clinical Laboratory Physicians -].

At the annual meeting of the Japanese Society of Laboratory Medicine in Kobe in 2016, a joint symposium was held in cooperation between the Japanese Society of Laboratory Medicine and Japanese Association of Clinical Laboratory Physicians. We presented and discussed 5 cases at the Reversed Clinico-pathological Conference. Each case was analyzed by 5 new members of the Japanese Association of Clinical Laboratory Physicians, who had passed the examination for Certified Clinical Laboratory Physicians in 2015. After the presentation of their interpretation for basic laboratory tests, the correct diagnosis and useful practical advice were given by experienced Certified Clinical Laboratory Physicians. The first case involved hemolytic anemia due to valve replacement and multiple myeloma with the BJP type. The second case involved primary aldos- teronism with hypokalemia. The third case involved cold agglutination with a high value of MCHC. The fourth case involved pneumonia due to influenza virus. The last case involved diabetic ketoacidosis. All 5 cases were common rather than rare, and any members of the clinical laboratories may encounter them in routine work. A systemic analysis of routine laboratory data can sometimes directly lead to the correct diag- nosis using laboratory data alone and give doctors valuable clinical information on patients. Continuous daily efforts in systemic analysis will ensure that the evaluation skills of inexperienced Certified Clinical Laboratory Physicians in their hospitals will increase. Certified Clinical Laboratory Physicians in clinical laboratories are gatekeepers in every hospital from the viewpoints of both "medical audit" and "risk management".

[Clinical Research Ethics in Seirei General Hospital -Introduction to the Actual Environment in Clinical Research Ethics in a Private Community Hospital-].

Seirei General Hospital is a community hospital with 744 beds located in Hamamatsu City, one of the ordi- nance-designated cities. Since the introduction of the mandatory residency program, marked changes have occurred in the medical field. Most young residents have chosen to stay for training in community hospitals even after the initial mandatory program, not moving to university hospitals. Considering the changes in medical situations, the role of community hospitals has to change. Nowadays, different from the previous situation, even a community hospital has to concentrate on and devote efforts for the education of young staff and clinical research. To perform clinical research with ethics is essential for education of young staff and progress in clinical medicine. Our hospital is private and has a strict code of clinical ethics. To start clinical research in our hospital, we should maintain ethics in clinical research. We have to obey the Helsinki Decla- ration and ethics guidance put forward by the government. In addition, all researchers have to'take a series of lectures on clinical ethics. Using a specimens for clinical research, we need a general rule on how to treat and use such specimens. The general rule should not be decided by government bureaucrats, but by the staff of clinical laboratories. Active performance of clinical research with ethics in a community hospital may contribute to progress in clinical medicine. It will definitely promote the interest of medical students and young staff in community hospitals. Community hospitals will be highly evaluated. [Review].

[An Accurate Diagnosis is Possible with a Systematic Analysis of Routine Laboratory Data].

Routine laboratory tests are ordered for almost all in- and outpatients. A systematic analysis of routine laboratory data can give doctors valuable clinical information about patients. In some cases, a correct diag- nosis can be made using laboratory data alone. In our laboratory, we use five processes to evaluate routine laboratory data. Firstly, we estimate the patient's general condition based on A/G, Hb, TP, Alb, ChE, and platelet (PLT) levels. Secondly, we look for inflammation and malignancy based on WBC, CRP, PLT, fibrinogen, and ESR levels and the protein electrophoresis pattern. Thirdly, we examine the major organs, especially the liver and kidney. We check the liver for hepatocyte damage, obstruction, hepatic synthetic function, infection, and malignancy. We estimate GFR and check the kidney for any localized damage. We then check the chemistry, hematology, and immunology. Finally, we form a conclusion after a comprehensive interpretation of the above four processes. With this systematic approach, any members of the laboratory unit can easily estimate the exact pathological status of the patient. In this case study, marked change of TP indicated non-selective loss from the skin; namely a burn. Tissue injury and infections due to different focuses were the most likely causes of severe inflammation. Neither the liver nor kidney was severely damaged. Continual bleeding and hemolysis through the clinical course probably caused anemia. Hypooxygenic respiratory failure and metabolic alkalosis were confirmed by blood gasses. Multiple organ failure was suggested.

[Essential role of specialists in laboratory medicine--introduction to a novel logistic support system in our hospital].

In cooperation with the clinical laboratory, our Department of Laboratory Medicine has established a novel logistic support system. The goal of this system is to improve the efficacy of laboratory medicine for both the clinician and patient through a new advisory service. Any abnormal patient laboratory data are detected by computer, printed and then checked and analyzed by medical technologists. The resulting comprehensive interpretation report is checked and confirmed by a clinical pathologist. After the results are analyzed, the clinical pathologist sends relevant clinical comments to a clinician via electric medical records. Additional comments are provided if further tests are needed. In serious cases, the clinical pathologist contacts the clinician directly by mobile phone. This system can benefit the clinician and patient in regards to both risk management and medical audit. In addition, other medical staff may become more aware of the role of the clinical laboratory and the Department of Laboratory Medicine. In a community hospital, specialists in laboratory medicine are gatekeepers for risk management and medical audits through advisory services. The day when the necessity and importance of specialists in laboratory medicine are properly recognized will surely come in the future.

[Reversed clinicopathological conference (R-CPC)--interpreting laboratory data in the same way as physical findings].

Routine laboratory data are discussed by time series analysis in reversed clinicopathological conferences (R-CPC) at Shinshu University School of Medicine. We can identify fine changes in the laboratory data and the importance of negative data (without any changes) using time series analysis. Routine laboratory tests can be performed repeatedly and relatively cheaply, and time series analysis can be performed. The examination process of routine laboratory data in the R-CPC is almost the same as the process of taking physical findings. Firstly, general findings are checked and then the state of each organ is examined. Although routine laboratory data are cheap, we can obtain much more information about a patient's state than from physical examinations. In this R-CPC, several specialists in the various fields of laboratory medicine discussed the routine laboratory data of a patient, and we tried to understand the detailed state of the patient. R-CPC is an educational method to examine laboratory data and we, reconfirmed the usefulness of R-CPC to elucidate the clinical state of the patient.

Glycopeptide profiling of beta-2-glycoprotein I by mass spectrometry reveals attenuated sialylation in patients with antiphospholipid syndrome.

Beta2-glycoprotein I (beta2GPI) is a five-domain protein associated with the antiphospholipid syndrome (APS), however, its normal biological function is yet to be defined. beta2GPI is N-glycosylated at several asparagine residues and the glycan moiety conjugated to residue 143 has been proposed to interact with the Gly40-Arg43 motif of beta2GPI. The Gly40-Arg43 motif has also been proposed to serve as the epitope for the anti-beta2GPI autoantibody associated with APS. We hypothesized that the structure or composition of the glycan at Asn-143 might be associated with the APS symptom by shielding or exposing the Gly40-Arg43 motif towards the anti-beta2GPI autoantibody. To test this hypothesis we used mass spectrometry (MS) for comparative glycopeptide profiling of human beta2GPI obtained from blood serum from four healthy test subjects and six APS patients. It revealed significant differences in the extent of sialylation and branching of glycans at Asn-143. Biantennary glycans were more abundant than triantennary glycans at Asn-143 in both healthy subjects and patients. In APS patient samples we observed a decrease in sialylated triantennary glycans and an increase in sialylated biantennary glycan structures, as compared to controls. These data indicate that some APS patients have beta2GPI molecules with a reduced number of negatively charged sialic acid units in the glycan structure at Asn-143. This alteration of the electrostatic properties of the glycan moiety may attenuate the intramolecular interactions with the positively charged Gly40-Arg43 motif of beta2GPI and, in turn, leads to conformational instability and exposure of the disease-related linear epitope Gly40-Arg43 to the circulating autoantibody. Thus, our study suggests a link between site-specific glycan profiles of beta2GPI and the pathology of antiphospholipid syndrome.

Eccentric dosing of nitrates does not increase cardiac events in patients with healed myocardial infarction.

This study was performed to investigate the risk of cardiac events by eccentric or continuous dosing of nitrates in patients with healed myocardial infarction. A total of 573 patients with healed myocardial infarction were assigned to one of two groups: a nitrate-treatment (n =239) and a nontreatment (n =334) group. The nitrate-treatment group was further subdivided into a group receiving eccentric dosing of nitrates (n =153) and a group receiving continuous dosing of nitrates (n =86). The mean observation period was 11.2+/-8.2 months. The cardiac events investigated were nonfatal and fatal recurrent myocardial infarction, death from congestive heart failure, sudden death, worsening angina and rebound angina. Baseline characteristics were also compared among the three groups to determine any effects on outcome. Among the patients receiving eccentric or continuous dosing of nitrates, the rates of cardiac events were 12.7/1,000 person.year and 67.4/1,000 person.year, respectively, whereas the rate was 19.7/1,000 person.year in the nontreated patients. The incidence of cardiac events was significantly greater in patients receiving continuous dosing of nitrates than in the nontreated patients (p <0.05). Continuous dosing of nitrates thus increases cardiac events, and while eccentric dosing of nitrates does not increase them, it is also not effective at preventing them in patients with healed myocardial infarction.

The diagnostic value of serum concentrations of 2-(alpha-mannopyranosyl)-L-tryptophan for normal renal function.

BACKGROUND: We have previously reported that the serum concentration of 2-(alpha-mannopyranosyl)-L-tryptophan (MPT), tryptophan glycoconjugate, is a more accurate measure of renal function than that of serum creatinine concentration. The aim of the present study was to compare the diagnostic value of serum concentrations of MPT and creatinine as a measure of normal renal function. METHODS: A total of 156 subjects with serum creatinine concentration < or =1.60 mg/dL aged 0 to 88 years were recruited. Serum concentrations of MPT and creatinine, and creatinine clearance calculated by Cockcroft-Galt formula were determined. A diagnostic accuracy of serum concentrations of MPT and creatinine for normal renal function was analyzed by using receiver-operating characteristics (ROC) curves. In 82 subjects with normal renal function defined as calculated creatinine clearance > or =80 mL/min (aged 6 to 68 years), the correlations between age and/or urinary creatinine excretion, which is related to muscle mass, and serum concentrations of MPT or creatinine, were determined. RESULTS: In the ROC curve, the area under the curve (AUC) in serum MPT concentration was significantly greater than that of creatinine (0.855 versus 0.800, respectively, P < 0.001) and the cut-off levels associated with the greatest diagnostic accuracy were 90 ng/mL for serum MPT concentration and 0.70 mg/dL for serum creatinine concentration. The sensitivity, specificity, and positive and negative predictive values were 69.5%, 85.1%, 83.8%, and 71.6% for serum MPT concentration, and 53.7%, 81.1%, 75.9%, and 61.2% for serum creatinine concentration. A close correlation existed between serum creatinine concentration and age (r= 0.798, P < 0.0001) in 23 subjects aged 20 years or younger. Conversely, serum MPT concentration remained unchanged regardless of age (r=-0.135, P= 0.228). Furthermore, a close correlation existed between serum creatinine concentration and urinary creatinine excretion (r= 0.817, P < 0.0001), but not between serum MPT concentration and urinary creatinine excretion (r= 0.082, P= 0.461). CONCLUSION: The concentration of serum MPT is a more reliable diagnostic parameter than that of serum creatinine as a measure of normal renal function, and renal function can be compared in subjects independently of age and muscle mass when serum MPT concentration is measured.

Severe neutropenia with gelatinous bone marrow transformation in anorexia nervosa: a case report.

A 28-year-old woman with a history of anorexia nervosa was admitted with excessive weight loss, edema, and amenorrhea. She had lost 34% of her previous body weight within 2 years, and her body mass index was 12.3 kg/m(2). The leukocyte count on admission was 2150/microl and gradually decreased to 980/microl (neutrophils; 276/microl). Bone marrow biopsy disclosed gelatinous transformation with hypocellularity. After the patient was treated with intravenous nutritional support, the severe neutropenia improved to the level on admission. Hematological abnormalities seem to be common in anorexia nervosa, but severe neutropenia with gelatinous bone marrow transformation has rarely been reported.