Based on our own 35 cases treated with kobokushichimotsuto as well as our predecessors' experience and their opinions, we investigated the drug's mechanism of action and its background indications. Our predecessors' opinions seem to be divided into two groups. Group A : An external pattern/syndrome (a keishito indication) of external contraction, followed by an interior heat pattern/syndrome (a kobokusammotsuto indication) appear. Mechanism of disease wise, this means that both external and internal patterns/syndromes exist at the same time. Because an internal pattern/syndrome is heavier than an external one, both patterns/syndromes are simultaneously treated, by making both medicinals bound together. Group B : Internal heat due to yang exuberance with yin debilitation is the mechanism of disease here. In group A, cause of disease is classed as a true heat pattern/syndrome. In group B, depending whether the internal heat belongs to either true heat or false type, deficiency and excess of pulse/abdominal patterns/syndromes change, and appetite differs. In either group, no peony is used to cope with the chest pattern/syndrome induced by the progression of gastric heat into the chest. Our cases consisted of upper respiratory illnesses with appetite loss, gastrointestinal diseases with chest oppression, respiratory diseases and intestinal obstructions. Kobokushichimotsuto, however, can be applied to neuroses, mental disorders and low back pains.

The administration of Bukuryo-shigyaku-to has been effective in five cases of chronic headache. All five patients visited our department because of unsatisfactory results using Western medicine. They suffered from severe migraines with restlessness, and they were treated effectively with Bukuryo-shigyaku-to. In four of all cases (cases 1-4), symptoms and signs related to coldness were obvious, and especially cases 1 and 3 complained about undesirable coldness on their backs. It is suggested that Bukuryo-shigyaku-to can be useful against severe migraine with restlessness caused by exposure to strong coldness. Case 5 was initially thought to have a status of heat and excess, but the effect of Bukuryo-shigyaku-to revealed the existence of cold and deficiency. Case 5 emphasizes the importance of being aware of the possibility of hidden coldness and deficiency, and that Bukuryo-shigyaku-to can be useful in such a case.

We treated one rheumatoid arthritis (RA) patient with Toki-shakuyaku-san-ka-bushi. A 51-year-old woman was diagnosed as RA in another hospital and was treated with salazosulfapyridine (SASP) and methotrexate (MTX). She was living a restricted daily life while taking MTX. She had to lie down for almost 48 hours after taking MTX once a week because of general fatigue. She was also suffering from depression. After the administration of Toki-shakuyaku-san-ka-bushi, her malaise after taking MTX and her depressive-mood disappeared. Her quality of life improved measurably.

We successfully treated two chronic hepatitis B patients with Hochuekkito-go-Keishibukuryogan. Case 1 was a 27-year-old male diagnosed with chronic hepatitis B in 1998, who had received interferon (IFN) therapy. Liver function tests did not improve with this therapy. He visited the department of Japanese Oriental Medicine at Yukiguni-Yamato Hospital, complaining of fatigue, on **********. We initiated treatment with Hochuekkito-go-Keishibukuryogan. At two months of treatment, marked improvement in liver function tests was noted, with normalization of ALT, seroconversion (SC) and negative HBV-DNA. Case 2 was a 26-year-old male diagnosed with chronic hepatitis B in 2001 who had received IFN therapy. Seven months after termination of this therapy, on **********, he visited our department for a flare-up of hepatitis. Treatment with Hochuekkito-go-Keishibukuryogan was begun. Almost immediately, marked improvements were observed in the form of ALT and SC normalizations, and only slightly positive HBV-DNA.

This report presents our experience in using a dual-lumen catheter with a Dacron cuff as longterm vascular access for homodialysis in an elderly patient. The female patient who at first treated with continuous ambulatory peritoneal dialysis for chronic renal failure, but the treatment could not be continued because she developed inveterate peritonitis. Thereafter, hemodialysis was performed. However, a lot of blood access troubles occurred and consequently peripheral access was exhausted. Therefore, we placed the catheter into a right internal jugular vein. This procedure made it possible to secure enough and stable blood flow during the hemodialysis session. Thus, the clearence ratios of blood urea nitrogen and serum creatinine and the value of KT/V increased. No complications have been observed since then. We further examined whether the placement of the catheter would affect hemodynamics in brain and upper extremities, using transcranial Doppler ultrasound and plethysmography. No remarkable difference in blood flow between right and left ophthalmic arteries and decrease in arterial blood flow of right finger tips were observed. Furthermore, venous dilatation, swelling in neck and right upper extremities, and facial edema were not found. The catheter, therefore, represents a significant advance, providing immediate, durable and relatively safe access for hemodialysis after repeated blood access troubles and exhausted peripheral access.

Six (1.2%) of 501 patients sustained phrenic nerve injury during operation for congenital heart disease at our institutions between 1992 and 1998. The diagnosis was confirmed by percutaneous stimulation of the phrenic nerve. All but 1 patient were less than 9 months old, and the average weight was 3.6kg. All 6 patients underwent diaphragmatic plication and were extubated by 7 days after operation. Percutaneous stimulation of the phrenic nerve allowed direct assessment of phrenic nerve function which was difficult to detect by clinical and radiological evidence. This method can be non-invasively used at the bedside to facilitate early and accurate diagnosis of phrenic nerve palsy.

We report a rare case with infection of a stent-graft. A 82-year-old man, who had undergone endovascular stent grafting to repair the descending aortic aneurysm 2 years previously, was admitted with high-grade fever. The blood culture detected methicillin-resistant Staphylococcus aureus (MRSA). Endoleak due to stent-graft infection was diagnosed and operation for synthetic graft replacement was performed. The synthetic graft was infiltrated in Rifampicin prior to the graft replacement to prevent re-infection. Additionally, the graft was covered with the greater omentum. He was discharged on the 45th day after surgery without any problems. One year follow-up showed no sign of re-infection of the graft.

OBJECTIVES: The objective is to introduce 'clinical archetype' which is a formal and agreed way of representing clinical information to ensure interoperability across and within Electronic Health Records (EHRs). The paper also aims at presenting the challenges building quality labeled clinical archetypes and the challenges towards achieving semantic interoperability between EHRs. METHODS: Twenty years of international research, various European healthcare informatics projects and the pioneering work of the openEHR Foundation have led to the following results. RESULTS: The requirements for EHR information architectures have been consolidated within ISO 18308 and adopted within the ISO 13606 EHR interoperability standard. However, a generic EHR architecture cannot ensure that the clinical meaning of information from heterogeneous sources can be reliably interpreted by receiving systems and services. Therefore, clinical models called 'clinical archetypes' are required to formalize the representation of clinical information within the EHR. Part 2 of ISO 13606 defines how archetypes should be formally represented. The current challenge is to grow clinical communities to build a library of clinical archetypes and to identify how evidence of best practice and multi-professional clinical consensus should best be combined to define archetypes at the optimal level of granularity and specificity and quality label them for wide adoption. Standardizing clinical terms within EHRs using clinical terminology like Systematized Nomenclature of Medicine Clinical Terms is also a challenge. CONCLUSIONS: Clinical archetypes would play an important role in achieving semantic interoperability within EHRs. Attempts are being made in exploring the design and adoption challenges for clinical archetypes.
Consensus ; Delivery of Health Care ; Electronic Health Records ; Health Information Management ; Informatics ; Practice Guidelines as Topic ; Semantics* ; Sensitivity and Specificity ; Systematized Nomenclature of Medicine

OBJECTIVES: This article describes the Web application framework for Electronic Health Records (EHRs) we have developed to reduce construction costs for EHR sytems. METHODS: The openEHR project has developed clinical model driven architecture for future-proof interoperable EHR systems. This project provides the specifications to standardize clinical domain model implementations, upon which the ISO/CEN 13606 standards are based. The reference implementation has been formally described in Eiffel. Moreover C# and Java implementations have been developed as reference. While scripting languages had been more popular because of their higher efficiency and faster development in recent years, they had not been involved in the openEHR implementations. From 2007, we have used the Ruby language and Ruby on Rails (RoR) as an agile development platform to implement EHR systems, which is in conformity with the openEHR specifications. RESULTS: We implemented almost all of the specifications, the Archetype Definition Language parser, and RoR scaffold generator from archetype. Although some problems have emerged, most of them have been resolved. CONCLUSIONS: We have provided an agile EHR Web framework, which can build up Web systems from archetype models using RoR. The feasibility of the archetype model to provide semantic interoperability of EHRs has been demonstrated and we have verified that that it is suitable for the construction of EHR systems.
Automatic Data Processing ; Computing Methodologies ; Electronic Health Records ; Indonesia ; Internet ; Semantics