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行政院國家科學委員會專題研究計畫 成果報告

台灣地區登革病毒感染的分子流行病學與化學激素的角色

(2/2)

計畫類別: 個別型計畫

計畫編號: NSC91-2320-B-002-081-

執行期間: 91 年 08 月 01 日至 92 年 07 月 31 日

執行單位: 國立臺灣大學公共衛生學院流行病學研究所

計畫主持人: 金傳春

計畫參與人員: 沈倬光,王慧婷,趙黛瑜

報告類型: 完整報告

報告附件: 國外研究心得報告

處理方式: 本計畫可公開查詢

中 華 民 國 93 年 3 月 29 日

(2)

中文摘要

嚴重臨床症狀的登革出血熱與較為輕微症狀的登革熱之免疫致病機制差異

至今尚未被釐清。本研究目的是探討登革出血熱與登革熱病人致病過程中的 3

種人類化學激素(RANTES, Mig, MIP-1α chemokines)分泌變化是否有差異性存

在,且此差異是否與登革病患臨床狀的嚴重度有所關連。

研究群是以 2002 年月至 2003 年 3 月高屏地區通報登革熱病例為研究對

象,並經由台灣疾病管制局確認登革出血熱病例共 23 名與登革熱病例共 77

名,另取 46 名健康對照組作為比較,進行抽血,以流式細胞儀分析細胞表面人

類化學激素受體及酵素免疫試劑測人類化學激素分泌量,並請醫護人員進行問

卷訪談並追蹤症狀。

結果發現:(1)登革熱病患體內 CD4/CD3+T 細胞比值顯著低於健康對照組

(33.19±2.21 vs 40.13±15.94, p=0.03);(2)登革出血熱與登革熱確定病例

的人類化學激素如

RANTES(各為 13.69+3.46 ng/ml 與 19.56+2.74 ng/ml,

p=0.14)、Mig(各為 653.45+ 85.89 pg/ml 與 664.63+ 59.60 pg/ml, p=0.23)均

比健康人有顯著較高的分泌量,但此兩種登革病人的 MIP-1a 分泌量(各為

26.99+ 11.56pg/ml 與 38.59+ 9.86pg/ml)卻較健康人為低(92.47±13.55 pg/ml,

p<0.01)

(3)不同的化學激素在病程之動態分泌量有所不同,人類化學激素如

Mig 的分泌量在登革出血熱/登革熱病例急性期高於恢復期,相對地 RANTES

分泌量在登革出血熱/登革熱病例急性期卻低於恢復期。

本研究初步結果推論登革熱出血熱/登革熱病患其人類化學激素分泌變化

有差異性存在,登革出血熱病患體內人類化學激素

Mig 在發燒後頭三天(感

染急性期)有較高的分泌, 可能加速吸引帶有

CXCR3 之 T 細胞至受感染部

位,且因

RANTES 有持續性的分泌,由此三者的協同作用,會增進 CD8

+

T 細

胞中

CCR5 的表現量,進而引起相關的細胞受到傷害,結果造成病人的嚴重

出血。未來實有必要再更急性早期採集登革病人血液檢體,以整合病毒量.免

疫活化標誌與血液動態指標,以徹底明瞭登革出血熱病人的免疫致病機轉.

關鍵字: 登革熱、人類化學激素、人類化學激素受體、登革病毒免疫、免疫流行

病學

(3)

Abstract

Mechanism of immunopathogenesis in leading to dengue hemorrhagic fever (DHF)

versus mild form of dengue fever (DF) during the same epidemic has not been fully

understood. The specific aims of this study were to determine whether there are

differences in the levels of chemokines (RANTES, Mig and MIP-1a ) associated with

hemorrhage between DHF and DF patients or clinical complications.

A prospective cohort study recruited 23 DHF and 77 DF patients caused by dengue

virus serotype 2 plus 46 healthy donors from Aug. 2 to Mar. 31, 2003 in Kaohsiung

and Pingtung. Levels of RANTES, Mig, MIP-1a were measured in serum samples

collected at both the first visit and subsequent repeated visits. Mann-Whitney U and

Spearman correlation test were used to compare the relationship between above each

chemokine and clinical status of DF vs DHF or hemodynamic/ biochemical laboratory

results, and their kinetic changes at different time points after the onset of fever,

respectively.

Ratios of CD4/CD3+T cells in DF patients was lower significantly compared to

healthy controls (DF patients: 33.19+ 2.21 vs healthy controls: 40.13 + 15.94, P=0.03).

There were higher serum levels of RANTES ( DHF: 13.69+3.46 vs DF: 19.56+2.74,

P=0.14), Mig (DHF: 653.45+ 85.89 vs DF: 664.63+ 59.60, P=0.23) and lower levels

of MIP-1a (DHF: 26.99+ 11.56 vs DF: 38.59+ 9.86, P=0.56). However, serum levels

of RANTES, Mig were significantly higher than healthy controls (P<0.05), whereas

levels of MIP-1a in dengue patients were significantly lower than compared to healthy

controls (P<0.05). The serum levels of chemokine were also compared after fever

onset. Levels of Mig in DHF and DF patients after fever onset 7 days were higher

than that after fever onset >7 days. In contrast, levels of RANTES in DHF and DF

patients were lower after fever onset 7 days than that after fever onset >7 days.

.

In conclusion, the serum chemokine kinetic patterns of DHF were different from

DF patients. These effects may lead to infected cells damages and then cause

hemorrhage. A closer examination of the production of these chemokines and the

activation of dengue virus infected target cells in the early phase of dengue virus

infection is warranted to attain a better understanding of immunopathgenesis of DHF.

Keywords: Dengue hemorrhagic fever, Innate Immunity, Immunological Responses,

(4)

Introduction and Literature Review

Understanding on the pathogenesis of DHF/DSS provides more insights to prevent

severe dengue cases and decreasing case fatality rate. Exaggerated cellular immune

responses to dengue virus infection which are driven by cross-reactive memory T

lymphocytes may result in increasing disease severity and DHF【Rothman et al.,

1999】. Dysregulation of certain innate and bystander immune activation might play

an important role in exacerbating disease progression during dengue virus infection.

Chemokines are involved in the recruitment of leukocytes to sites of infection via

a cascade of coordinated events. Chemokines are synthesized and secreted by

macrophages/monocytes, endothelial cells, fibroblasts, epithelial cells, and

neutrophils during inflammation including RANTES, MIP-1α, IP-10, and Mig and

function to induce leukocytes adherence to vascular endothelium and extravasation

into tissues. Furthermore, chemokines might play an important role in the

pathogenesis of dengue virus infection, because levels of certain chemokines , such as

IL-8 and RANTES, were elevated during dengue virus infection in vitro or in vivo

【Lin et al., 2000; King et al., 2002】.

However, other chemokines in the immunopathogenesis of dengue virus infection

have not been explored. In our present study, we attempted to obtain an integrated

view of the chemokine-cehmokine receptors after dengue virus infection by obtaining

repeated measurements of blood samples from patients of dengue hemorrhagic fever

and dengue fever during the largest epidemic of DHF in Taiwan in 2002’ and

comparing the similarities and differences in quantitative kinetic changes between

these two groups of dengue patients with different clinical severity.

(5)

MATERIALS and METHODS

A. Study Areas

Study areas include past and present epidemic areas of dengue. Past

epidemic areas were (1) Kaohsiung County and City, and (2) Pingtung County

and City. Physicians/nurses working at the sentinel hospitals/clinics in these

study areas collected blood samples for this study.

B. Study Populations

The study subjects include confirmed DF, confirmed DHF/DSS cases, and the

healthy controls. The diagnosis of dengue infection was confirmed by the Center of

Disease Control (CDC), Taiwan. Both dengue-consensus and type-specific primers for

reverse-transcriptase polymerase chain reaction (RT-PCR). (>10 PFU is detectable)

and serologic tests (dengue-specific IgM seropositive or 4-fold serotiter rise but

Japanese-specific IgM seronegative) are used for confirming dengue virus will be

conducted mainly in our lab at National Taiwan University (NTU) to minimize false

results. Healthy donors chose people who lived in the area of Taipei City without

indigenous dengue cases reported.Patients with serotype one, three, and four

confirmed from laboratory tests (PCR and antibody tests) are analysis separately.

C. Clinical Diagnosis of Dengue Fever and Dengue Hemorrhagic Fever/Dengue

Shock Syndrome

Clinical diagnosis of dengue fever and dengue hemorrhagic fever/dengue

shock syndrome was defined according to the criteria of the World Health

Organization. All patient with dengue hemorrhagic fever had thrombocytopenia

(<100,000/mm

3

) and hemocencentration ( hematocrit > 20% of recovery value)

or > 1mm of pleural effusion detected on the right lateral chest radiograph.

D. Interview and Questionnaire

A personal interview based on standardized questionnaire will be conducted by

nosocomial infection control nurses who are well-trained on interview techniques and

questionnaire details in their hospitals. Questions are briefly listed as following:

1. Demographic Data: Gender, age, birth date and living areas

(6)

hepatitis, diabetes are included. In addition, History of dengue for case

and his/her family members, relatives, neighbors, coworkers and

classmates are recorded.

3. Date of Onset: Including the first date of fever, and other symptoms

and signs of dengue.

4. Clinical complication: To record patients who develop clinical

complications such as ascites, pleural effusion, or petechiae during their

hospital stay.

5. Clinical hematologic data: WBCs, lymphocyte, hematocrit, platelet,

ALT, AST

6. Risk Factors: Travel history to those dengue hyper-endemic or

epidemic areas during the incubation time.

E. Collection of Blood Samples

Two blood samples will be collected from confirmed dengue cases using

vacuum syringes with anti-coagulant (EDTA) for flow cytometry and without

anti-coagulant for chemokine tests. Serum collected through day 7 after fever

onset are referred to as acute-phase samples. Convalescent serum refer to

specimens collected 8 days or more after fever onset. The samples will be

immediately placed on ice and transported to our laboratory in the ice-filled

bottle/box by express service.

F. Laboratory Methods

1. Flow Cytometry

Using whole blood samples and stained with florescence conjugated with cell

surface CD molecule antibody right after those samples’ arrival to quantitate

subpopulations of T cells, including CD45RO, CD62L. CCR5 and CXCR3 stained to

detect chemokine receptor expression.

2. CD Masker Staining

Collect blood especially by venipuncture into a sterile K3 EDTA VACUTAINER

blood collection tube. Follow the collection tube manufacturer’s guidelines for the

minimun volume of blood to be collected. Store anticoagulated blood at room temp

(20

o

to 25

o

C) until ready for staining and lysing. Refer to the appropriate package

insert for storage restrictions prior to staining.

(7)

Analyze on the FACS brand flow cytometer. Mix samples thoroughly before

acquisition. Refer to the appropriate package insert for storage restrictions prior to

analysis.

3. Quantitation of Chmeokines

Serum levels of RANTES (cat.no.DRN00), IP-10 (cat.no.DIP100), Mig (cat.no.

DCX900), MIP-1α (cat.no. DMA00) were measured by use of commercial ELISA

kits (Quantikine, R&D System). As described by the manufacturer, lower detection

limits for the assays are 8 pg/ml for RANTES, 1.67 pg/ml for IP-10, 3.84 pg/ml for

Mig, 10 pg/ml for MIP-1α.

G. Statistical Data Analysis

All information was compiled with EXCELL software (Office 2000, Microsoft)

and analyzed by The Statistic Analysis Software 8.2 (SAS, Institute, Inc). Serum

chemokine levels were compared by use of the Kruskall-Wallis test, a nonparametric

analysis of variance. When the test revealed significant differences between the study

groups, 2-group comparisons were done with the Mann-Whitney U test. The

Wilcoxon signed rank test was used for comparison of paired samples from each

individual. Correlations between variables were evaluated with Spearman correlation

test. P < 0.05 was considered a statistically significance difference between groups.

(8)

Results

Serum samples from 138 individuals were selected for analysis and were

categorized into the following groups: 34 DHF patients , 90 DF patients , and 14

healthy controls (table 2). Between onset of fever and days of collecting serum

samples varied between the groups, but the differences were not statistically

significant (table 2). We can find that DHF patients were older(50.59±13.78), had

more underlying disease of diabetes(29.41%) and collected more earlier whole blood

samples at less than 7 days after onset of fever(58.82%) .

After fever onset ≦7 days represented the acute or early phase of illness, a time

when ongoing inflammatory responses were likely to be at a maximum. After fever

onset >7 days represented likely a late or convalescent phase of illness, a time when

inflammation would be expected to be resolving or be in a preterminal stage in those

who succumbed to disease.

A. Fundamental immunological markers in patients of DF versus DHF

There were differences in the ratios of CD4+T/CD3+T cells (DHF:36.34+ 5.18;

DF:33.19 + 2.21 ) and CD8+T/CD3+T cells (DHF: 27.34 + 3.60; DF: 30.20+ 1.89 ) in

DHF and DF patients compared with Healthy controls ( CD4+T/CD3+T cells: 40.13 +

2.35; CD8+T/CD3+T cells: 31.88 + 1.62; Table 3).

The significant differences only existed in the ratio of CD4+T/CD3+T cells in

DF patients compared with healthy controls (P=0.03). There were differences in the

CD3+ T cells absolute numbers in DHF (3140.6±907.8)and DF(3143.6±400.93)

patients compared to healthy controls(4567.4±482.85). The CD3+ T cells absolute

numbers were significant differences were present in DF and healthy controls

(p=0.02). There were differences in the CD4+ T cells and CD8+ T cells absolute

numbers in DHF (CD4+ T cells: 1959.9±431.09; CD8+T cells: 1933.2±457.2)and

DF(CD4+ T cells: 1869.8±157.16; CD8+T cells: 1899.3±226.93) patients compared

to healthy controls(CD4+ T cells: 2582.9±208.7; CD8+T cells: 2085.8±202.61).

Similar significant differences were observed in CD4+ T cells absolute numbers in

DF patients compared to healthy controls (p=0.01).

B. Kinetic changes of CD4/CD8 ratio in DHF vs DF patients

(9)

late phase. Only one Dengue Hemorrhagic Fever patients elevated slightly in first and

second time points (Figure 1). The decrease of CD4/CD8 ratio was not only found in

the Dengue Hemorrhagic Fever patients, but also in the Dengue Fever patients. The

eight of thirteen Dengue Fever patients declined the ratio of CD4/CD8 T cells

between early and late phase, whereas five Dengue Fever patients rised up gradually

at late phase.

C. The levels of chemokines (RANTES, MIP-1a, Mig) in DHF vs DF patients and

healthy donors

All the serum levels of three chemokines RANTES(DHF:13.69±3.46 ng/ml;

DF:19.56±2.74 ng/ml), and Mig(DHF:653.45±85.89 pg/ml; DF:664.63±59.60 pg/ml)

in dengue patients were significantly higher than healthy controls ( p<0.01)(Table 6;

Figure 2, 3)whereas the serum level of MIP-1α in dengue patients were significantly

(DHF:26.99±11.56 pg/ml; DF:38.59±9.86 pg/ml)lower than healthy controls(p<0.01)

(Table 6, Fig3)

D. Variation of the serum levels of chemokines at different days after onset of

fever in DHF vs DF patients.

The mean serum levels of Mig(DHF:763.83±118.43 pg/ml; DF:713.28±67.08

pg/ml) after fever onset ≤ 7 days were higher than those after fever onset>7 days in

both DHF(IP10: 2.74±0.98 ng/ml; Mig:487.88±102.3 pg/ml) and DF(Mig:580.96±

113.86 pg/ml) patients.. However, the serum levels of RANTES after fever onset ≤ 7

days(DHF:9.78±3.25 ng/ml; DF:11.82±2.10 ng/ml) was lower than that after fever

onset>7 days(DHF:19.57±6.94 ng/ml; DF:33.19±5.72 ng/ml). In addition, the levels

of RANTES, IP-10 and Mig at two different time periods after fever onset were

significantly higher than healthy controls(p<0.01) whereas the levels of MIP-1α at

two different time periods after fever onset were significantly lower than healthy

controls(p<0.01).

(10)
(11)
(12)

Table 2. The demographic characteristics and medical history of study subjects in chemokine studies in Taiwan, 2003 Characteristics DHF (n=34) DF (n=90) Healthy Controls (n=14) Age, years(Mean±SD) 50.59±13.78 44.34±14.83 28.78±7.08 <30 2 (5.88%) 17 (18.89%) 12 (85.71%) 30~44 7 (20.59%) 18 (20%) 1 (7.14%) 45~59 17 (50%) 46 (51.11%) 1 (7.14%) 60~74 8 (23.53%) 9 (10%) 0 Gender Males 18 (51.52%) 49 (54.44%) 9 (64.29%) Females 16 (48.48%) 41 (45.56%) 5 (35.71%) Clinical History DM 10 (29.41%) 13 (14.44%) Asthma 2 (5.88%) 0 Gout 0 2 (2.22%) HBsAg(+) 0 3 (3.33%) DM+Gout 2 (5.88%) 0 DM+HbsAg(+) 0 3 (3.33%) Samples Collected at Days after the Onset of

Fever

≦7 days 20 (58.82%) 59 (65.56%)

Table 3. Comparison of T cell subsets among DHF versus DF patients adjusted the medical history and healthy controls in Taiwan, 2003 * P values are Wilcoxon rank sum comparisons of data from the columns of Healthy controls.

NS = not significant (p >0.05)

DHF(n=10) DF(n=63) Healthy Control (n=46)

CD Markers and Chemokine Receptors

Mean±SE P value* Mean±SE P value* Mean±SE

CD4 (% of CD3) 36.34±5.18 NS 33.19±2.21 0.03 40.13±2.35 CD62L+CD45RO- (%of CD4) 7.96±5.32 NS# 9.44±2.10 NS 18.24±3.56 CD62L+CD45RO+ (%of CD4) 8.17±5.31 NS 10.11±2.02 NS 11.19±2.20 CD62L-CD45RO+ (%of CD4) 9.88±6.03 NS 12.61±2.53 NS 9.28±2.02 CCR5 (%of CD4) 5.12±1.71 NS 7.02±1.16 NS 4.20±0.82 CXCR3 (%of CD4) 19.76±5.99 NS 21.81±2.69 NS 21.53±2.85 CD8 (% of CD3) 27.34±3.60 NS 30.20±1.89 NS 31.88±1.62 CD62L+CD45RO- (%of CD8) 7.09±4.49 NS 7.07±1.79 NS 19.44±4.07 CD62L+CD45RO+(%of CD8) 4.66±2.59 NS 6.15±1.62 NS 3.09±0.71 CD62L-CD45RO+ (%of CD8) 9.91±5.18 NS 12.86±2.65 NS 12.02±2.39 CCR5 (%of CD8) 12.48±3.52 NS 13.93±2.02 NS 10.62±1.64 CXCR3 (%of CD8) 26.78±8.37 NS 23.75±2.87 0.001 43.39±4.40 CCR5+/CD62L+CD45RO-CD3+ 0.72±0.46 NS 0.48±0.17 NS 0.24±0.16 CCR5+/CD62L+CD45RO+ CD3+ 0.23±0.16 NS 0.57±0.32 NS 0.69±0.42 CCR5+/CD62L-CD45RO+ CD3+ 2.66±2.01 NS 1.99±0.87 NS 1.79±0.98 CXCR3+/ CD62L+CD45RO-CD3+ 6.59±3.40 NS 7.37±2.10 NS 7.03±2.07 CXCR3+/ CD62L+CD45RO+CD3+ 10.45±6.97 NS 4.80±1.83 NS 6.14±2.42 CXCR3+/ CD62L-CD45RO+CD3+ 9.58±6.39 NS 5.84±2.08 NS 7.25±2.84

(13)

Table 6. Levels of Chemokine in the serum samples of DHF versus DF patients adjusted medical history

DHF DF Healthy controls Chemokines n Mean±SE P value# n Mean±SE P value# n Mean±SE

RANTES (ng/ml) 20 13.69±3.46 <0.01 69 19.56±2.74 <0.001 14 2.21±0.78 IP-10 (ng/ml) 20 4.74±0.69 a <0.001 56 3.39±0.63 <0.001 9 0.15±0.03 Mig (pg/ml) 20 653.45±85.89 <0.001 69 664.63±59.60 <0.001 13 190.85±22.53 MIP-1α (pg/ml) 20 26.99±11.56 <0.001 69 38.59±9.86 <0.001 14 92.47±13.55

# P value compared to Healthy controls a.P <0.05, vs. DF patients

DISCUSSION

This research focuses on the study of possible roles of chemokines and chemokine

receptors from innate immunity to adaptive immunity in dengue patients manifested

different clinical severity. Several major findings have not been documented in

literature.

A. Differences in Dengue Patients versus Healthy Controls: Kinetic Changes of

CD4/CD8 ratio in DHF and DF Patients

Dengue patients are usually leukopenic for several days during the acute

infection. Our observation that Dengue patients, regardless DHF or DF had lower

expression of CD4+ T and CD8+ T cells than healthy donors.

The ratio of CD4/CD8 T cells in DHF patients declined at late phase(After fever

onset >7days).The 8 of 13 Dengue Fever patients declined the ratio of CD4/CD8 T

cells between early and late phase, too. The appearance of atypical lymphocytes may

be the T-cytotoxic/suppressor cells(CD3

+

/CD8

+

T cells)that contribute to the

imbalance between CD4 and CD8 T cells during dengue infection. The CD4/CD8

(14)

ratio changes was observed within two time points(≤ 7 days and >7 days after fever

onset). Frequent analysis of the immune parameters after dengue infection will help

to understand the interaction between dengue virus and the host.

B. Chemokines

After dengue virus infection, various chemokines were released with different

quantities, durations and kinetics. The levels of RANTES, and Mig were higher than

healthy controls. By contrast, the levels of MIP-1α was lower compared to healthy

controls, whereas the levels of MIP-1α had different magnitude and kinetics of

secretion in Dengue Hemorrhagic Fever and Dengue Fever patients. Secretion of

MIP-1α may have roles in the immunopathology and may contribute to fever and

bone marrow suppression observed in Dengue Fever and Dengue Hemorrhagic Fever

patients【

Spain- Santana et al., 2001

】. Paradoxically, the fact that MIP-1α recruit

monocytes to the site of infection might provide dengue virus infection. Dendritic

calls are potent antigen-presenting cells that can initiate immune responses by

presenting antigens to secondary lymphoid and prime naïve T cells there. It is found

that the ability of dengue virus to infect both human dendritic cells and skin

Langerhans cell【

Libraty et al., 2001

.Maturing DC are also an abundant and strategic

source of chemokines. It’s temping to speculate that these lower levels of MIP-1α

may affect dengue virus infected DC undergo maturation and transport dengue virus

antigen to lymphoids organs to initiate immunity. Other factors, such initial burst

chemokines of DC response to acute viremia may also play a role and there warrant

further study at this issue.

In addition, secretion of RANTES persisted at high levels long after fever onset

in Dengue Hemorrhagic Fever and Dengue Fever patients. This might result from

(15)

stability of this mediators or constant production.

C. Immunopathological Significanc

In our present study, we attempted to obtain an integrated view of the

chemokine-chemokine receptors of human dengue virus infection by using Dengue

Hemorrhagic Fever and Dengue Fever patients’ repeat serum samples and comparing

the production kinetics and dose responses.

The clinical symptoms of Dengue Fever and Dengue Hemorrhagic Fever present

the signs of local inflammation, which may result from extravasation of lymphocytes

to sites of infection. The onset and peak of chemokine and chemokine receptor

production by different dengue virus infected target cells indicated that these

molecules may play a role in early recruitment of different subsets of leukocytes and

participate in the early response to viral infection as well as tissue injury【

Okayama et

al., 2000

】. These may suggest that a possible cooperative interaction between these

target cells and lymphocyte trafficking by different production of chemokines

We found the serum levels of RANTES, IP-10 and Mig were higher in Dengue

Hemorrhagic Fever and Dengue Fever patients. RANTES, IP-10, and Mig were

shown to recruit and activate T lymphocytes with memory phenocyte【

Raghupathy et

al., 1998

】and then might b important for rapid T cell effector functions during

secondary dengue virus infection.

It’s known that MIP-1a, RANTES, and IP-10 can induce NK cells activation,

chemotaxis, adhesion and transendothelial migration. Therefore, regulation of NK

cells activity by these mediators may affect dengue virus infection and tissue injury.

(16)

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數據

Table 2. The demographic characteristics and medical history of study subjects in chemokine studies in Taiwan, 2003    Characteristics  DHF  (n=34)  DF  (n=90)  Healthy Controls (n=14)  Age, years(Mean±SD) 50.59±13.78 44.34±14.83 28.78±7.08  &lt;30  2  (5.
Table 6. Levels of Chemokine in the serum samples of DHF versus DF patients adjusted medical history

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