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Alternative splicing is an important mechanism that links to transcription and contributes to protein diversity. Disturbed alternative splicing is frequently observed in cancers, but its precise mechanism remains largely unknown. FUSE-binding protein (FBP) -interacting repressor (FIR) is a transcriptional repressor of the c-myc gene. Previous studies indicated that a splice variant of FIR, FIRΔexon2, that lacks exon2 in the transcriptional repressor domain, was increased in colorectal cancers, hepatocellular carcinomas, and leukemia cells. Furthermore, FIRΔexon2 activated c-myc transcription by disabling wild-type FIR as a dominant-negative form of FIR. Recently, somatic mutations of the SF3B1 (SAP155) gene, a subunit of the SF3B spliceosome complex, were found in myelodysplastic leukemia. In this study, FIR heterozygous knockout (FIR(+/-)) was established as a dominant-negative model of FIR in the C57BL/6 mouse. FIR(+/-) mice showed an increased c-myc mRNA expression level, particularly in peripheral blood, although FIR(+/-) mice had no apparent pathogenic phenotype. Therefore, an increased c-myc mRNA expression level alone is not enough for leukemogenesis. Nevertheless, FIR(+/-)TP53(-/-) mice generated acute T-cell lymphoblastic leukemia (T-ALL) with increased organ and/or bone marrow invasion. In conclusion, alternative splicing of FIR, generating FIRΔexon2, contributes to not only colorectal carcinogenesis but also leukemogenesis independent of the c-Myc activation pathway. Finally, we will discuss our hypothesis that FIRΔexon2 interferes with FBW7, that FIRΔexon2 inhibits PP1 in the EGFR pathway, and that FIR haploinsufficiency is potentially associated with protein expression through transcriptional and post-transcriptional mechanisms.

In the field of laboratory medicine, sex differences are found in many clinical tests. Human sex-determination system is at least doubly driven: by sex-chromosomes and by sex-hormones. Karyogram and sex-hormones are typical clinical tests that show sexual dimorphism. Cases of Androgen-Insensitive Syndromes imply sex hormones exert great influences on sex differences found in clinical tests. While childhood, sex steroids secretions from sex-specific organs are inhibited in both sexes. After puberty onset, differences in sex steroids enlarge. In case of females, estrogen secretion decreases in postmenopausal periods. In some of clinical tests, sex differences enlarge after puberty onset, and decrease in postmenopausal periods. Some clinical tests in the field of bone metabolism and lipid metabolism show this kind of sex difference, which seem to be influenced by estrogen.

Vitamin D is pro-hormone that has important roles in calcium metabolism in the intestine, kidneys, and bone. Many studies have indicated that vitamin D deficiency causes not only rickets and osteomalacia, but also increases the risk of various diseases such as cancer and autoimmune disease. Of the many vitamin D metabolites, 25-hydroxyvitamin D[25OH-D], 1α,25-dihydroxyvitamin D[1,25(OH)2-D], and 24,25-dihydroxyvitamin D [24,25 (OH) 2-D] are important for assessing vitamin D metabolism. They are circulating, biologically active, and major inactive forms of vitamin D metabolite, respectively. Immunoassays are widely used for the measurement of serum/plasma vitamin D metabolites. With such an assay, however, the accurate quantification of these metabolites is difficult because of cross-reactivity. Liquid chromatography-tandem mass spectrometry [LC-MS/MS] is the gold standard method for analyzing these metabolites due to its high sensitivity and selectivity. Derivatization with a Cookson-type reagent is a key technique for robust and sensitive analysis by LC-MS/MS. A Cookson-type reagent rapidly and quantitatively reacts with the s-cis-diene structure of vitamin D metabolites, and markedly enhances the ionization efficiency. Using a recently developed Cookson-type reagent (DAPTAD), we successfully established an LC-MS/MS-based method for analyzing serum vitamin D metabolites including 250H-D, 1,25 (OH) 2-D, and 24,25 (OH) 2-D. Thus, LC-MS/MS can be a powerful tool for the accurate determination of vitamin D metabolism. In this review, we describe the advantages of LC-MS/MS for the determination of vitamin D metabolites.

During the past 15 years, various approaches have been adopted for medical personnel training in the Division of Laboratory Medicine, Chiba University Hospital. Medical personnel have been encouraged to enter the Graduate School of Medicine, Chiba University. At present, 14 of them have successfully completed the Ph.D. program and 16 have been awarded a master's degree. In our unit, clinical proteomics is a principal research subject, and we have identified a number of biomarker candidates in collaboration with clinical units. In Chiba University Hospital, all clinical laboratory physicians are certified as medical geneticists and are in charge of the Division of Clinical Genetics as well. We have treated a total of 1,009 patients, including those with hereditary neuromuscular diseases, familial cancers, and prenatal diagnoses. We have also encouraged medical technologists to become certified as genetic counselors, which may be a promising subspecialty for medical technologists. Mass spectrometry (MS) is a powerful analytical tool used in an increasing number of clinical laboratories around the world. Liquid chromatography (LC) coupled with tandem mass spectrometry (MS/MS) has been used for newborn screening, toxicology, therapeutic drug monitoring endocrinology, and, more recently, for the measurement of targeted proteins and peptides. Matrix-assisted laser desorption ionization-time of flight (MALDI-TOF) has proven to be a rapid and reliable tool for identifying microorganisms. The Japanese Society for Medical Mass Spectrometry has started to certify medical mass spectrometrists, which could be another promising subspecialty for medical technologists.

Alternative splicing is a fundamental process of gene regulation that contributes to protein diversity, a common phenomenon in the mammalian genome. Alternative splicing events not only happen in the normal gene regulation process, but are also closely related to certain diseases, including cancer. In this review, we briefly demonstrate the proof of concept (POC) of the relationship between alternative splicing and DNA damage, and describe the associations among alternative splicing and cancer pathogenesis, DNA damage, and gastrointestinal cancers. We discuss whether alternative splicing leads to genetic instability, which is considered to be a driving force for tumorigenesis. FUSE-binding protein (FBP) -interacting repressor (FIR) is a c-myc transcriptional suppressor. A splice variant of FIR that lacks exon 2 in the transcriptional repressor domain (FIRΔexon2), upregulates c-myc transcription by inactivating wild-type FIR. FIR+/- mice exhibited marked c-myc mRNA upregulation, particularly in the peripheral blood (PB), without any significant pathogenic phenotype. Because the single knockout of TP53 generates thymic lymphoma, FIR+/-TP53-/- mice developed T-cell type acute lymphocytic/lymphoblastic leukemia (T-ALL) with increased organ or bone marrow invasion and showed a poor prognosis. After describing the POC of alternative splicing of FIR in DNA damage and carcinogenesis, clinical application for cancer diagnosis and treatment by FIR/FIRΔexon2 was briefly summarized. Chiba University has prepared a biobank to support studies to develop biomarker detection, molecular diagnosis, and "Omics" research. In conclusion, alternative splicing of FIR, generating FIRΔexon2, potentially contributes to not only colorectal carcinogenesis, but also leukemogenesis, and a better understanding of the role and mechanism of alternative splicing in tumorigenesis may reveal new directions for cancer biomarker detection.

Personalized medicine has been expected to be utilized in daily practice since the international human genome project completed sequencing of the entire genome in 2003. The aim of personalized medicine is to treat patients effectively and safely based on the genome characteristics of each patient, or to choose the right drug for the right patient at the right time and at the right dose. Regulatory agencies such as the United States Food and Drug Administration(FDA) and Pharmaceuticals and Medical Devices Agency (PMDA), Japan implemented guidance to facilitate the co-development of drugs and companion diagnostics. For the practice of personalized medicine, companion diagnostic tests are essential, although their availability is limited.

The nationwide surveillance of antibacterial susceptibility to meropenem (MEPM) and other parenteral antibiotics against clinical isolates during 2012 in Japan was conducted. A total of 2985 strains including 955 strains of Gram-positive bacteria, 1782 strains of Gram-negative bacteria, and 248 strains of anaerobic bacteria obtained from 31 medical institutions were examined. The results were as follows; 1. MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA). 2. Of all species tested, there were no species, which MIC90 of MEPM was more than 4-fold higher than those in our previous studies in 2009 or 2006. Therefore, the tendency to increase in antimicrobial resistance rates was not observed. 3. MEPM resistance against Pseudomonas aeruginosa was 17.8% (56/315 strains). Compared to our previous results, it was the lowest than that in 2006 and 2009. 4. Carbapenem-resistant Klebsiella pneumoniae, and multi-drug-resistant Acinetobacter species, which emerged in worldwide, were not observed. 5. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 6.2% (59/951 strains) in enterobacteriaceae, which increased compared with that of our previous studies in 2009 or before. Whereas, the proportion of metallo-beta-lactamase strains was 1.6% (5/315 strains) in P. aeruginosa, which was stable. In conclusion, the results from this surveillance suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem for serious infections treatment at present, 17 years passed after available for commercial use in Japan.

Mass spectrometry has been recently used in clinical diagnostics, especially drug screening, newborn screening, and bacterial identification; therefore, the current developments in mass spectrometry platforms (i. e. GC-MS, LC-MS/MS) and applications for clinical diagnosis will be discussed. Technological advances in drug analyses and bacterial identification using mass spectrometry during recent years have provided an effective tool for the clinical laboratory. This symposium provides a comprehensive future overview of the latest technologies to quantify metabolites, drugs, and identify bacterial proteins using mass spectrometry, proposed for potential new biomarker development.

Serum cystatin C (sCysC) is valuable to evaluate the renal functions in various clinically studies. Since the reagents to detect sCysC are different among institutes or hospitals, the accidental error due to the difference of reagents is not negligible. That is why sCysC is sometimes difficult to use or interpret for patient as estimated Glomerular filtration rate (eGFR) that is one of the most popular factors to evaluate renal function. Recently, the international reference standard is gradually accepted as standardization of chemical measurement of sCysC in Japan. Japan Society of Clinical Chemistry has reported the utilities for sCysC measurement standardization in 2010. In this study, we examined the usefulness of the standardization of sCysC reagent in Chiba University Hospital. Our study indicated that the clinical usefulness of eGFR calculated by sCysC. As results, eGFR from serum creatinine (sCr) was relatively high in patients with reduced muscle mass, such as old-age patients with wheelchair and prolonged hospitalization. On the other hand, eGFR from sCysC was high in patients with hypothyroidism. Together, eGFR calculated by sCysC is clinically available for the patients with reduced muscle mass could be underestimated. Further studies are required to evaluate the validity of standardization of sCysC measurement and find the dissociation among eGFR, sCysC and sCr depending in the renal disease or pathogenesis.

In a clinical diagnostic microbiology laboratory, the current method of identifying bacterial isolates is based mainly on phenotypic characteristics, such as the growth pattern on different media, colony morphology, Gram stain, and various biochemical reactions. These techniques collectively allow high-level accuracy in identifying most bacterial isolates, but they are costly and time-consuming. In our clinical microbiology laboratory, we prospectively assessed the ability of matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) to identify bacterial strains that were routinely isolated from clinical samples. Bacterial colonies obtained from a total of 468 strains of 92 bacterial species isolated at the Department of Clinical Laboratory at Chiba University were directly placed on target MALDI plates, followed by the addition of CHCA matrix solution. The plates were then subjected to MALDI-TOF MS measurement, and the microorganisms were identified by pattern matching by the libraries in the BioTyper 2.0 software. The identification rates at species and genus levels were 91.7% (429/468) and 97.0% (454/468), respectively. MALDI-TOF MS is a rapid, simple, and high-throughput proteomic technique for the identification of a variety of bacterial species. Since colony to colony differences and the effects of culture duration on the results are minimal, it can be implemented in a conventional laboratory setting. Although for some pathogens, the preanalytic processes should be refined and current database should be improved to obtain more accurate results, the MALDI-TOF MS-based method generally performs as well as the conventional methods and is a promising technology in clinical laboratories.

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 2655 strains including 810 strains of Gram-positive bacteria, 1635 strains of Gram-negative bacteria, and 210 strains of anaerobic bacteria obtained from 30 medical institutions during 2009 was examined. The results were as follows; (1) MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multidrug resistant strains including methicillin-resistant Staphylococcus aureus (MRSA). (2) MEPM maintained potent and stable antibacterial activity against Pseudomonas aeruginosa. The proportion of MEPM-resistant strains to ciprofloxacin-resistant strains or imipenem-resistant strains were 53.1% and 58.0% respectively. (3) The proportion of extended-spectrum beta-lactamase (ESBL) strains was 3.1% (26 strains) in enterobacteriaceae. And the proportion of metallo-beta-lactamase strains was 2.0% (6 strains) in P. aeruginosa. (4) Of all species tested, there were no species except for Bacteroides fragilis group, which MIC90 of MEPM was more than 4-fold higher than those in our previous study. Therefore, there is almost no significant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem for serious infections treatment at present, 14 years passed after available for commercial use in Japan.

In this study, clinical utility of various renal function markers (Cystatin C, Creatinine, beta2-microglobulin, Urea nitrogen) including serum Cystatin C was evaluated by the latex turbidimetric immunoassay based on the Chronic Kidney Disease (CKD) stage classification. Serum creatinine was most correlated with estimated Glomerular Filtration Rate (eGFR), followed by serum Cystatin C. However, the level of serum Cystatin C increased significantly earlier than other renal function markers in the group of mild renal dysfunction based on the CKD stage classification. Cystatin C also had the most distinctive ability of the renal dysfunction by Receiver Operating Characteristic (ROC) and distinction characteristic analysis. Thus, it is useful to measure serum Cystatin C and serum creatinine at the same time to improve diagnostic sensitivity and specificity, eGFR was 6% higher than Ccr on stage III-V, though Ccr was 30% higher than eGFR on stage I-II by CKD stage classifications. Since eGFR and Ccr showed different results in early and severe CKD groups, it was suggested that Ccr and eGFR need to be evaluated as different renal function markers.

Development of useful biomarkers is pivotal for prediction of micro-metastasis, recurrence probability and/or prognosis of the patients. Recent studies have revealed that cancer-specific alternative splicing can be valuable for cancer cell detection. Among them, FUSE-binding protein-interacting repressor, FIR, has been reported to repress c-myc transcription and its exon2-spliced variant, FIRDelta(exon)2, is unable to repress c-myc by competing with authentic FIR in vivo and in vitro. Moreover FIRDelta(exon)2 was frequently discovered in human primary colorectal cancers, but not in the adjacent normal tissues, indicating its cancer-related expression. Thus, the expression level of FIRDelta(exon)2 mRNA in the colorectal cancer tissues as tumor marker candidates is examined. Further, to determine the interacting proteins, FIR-flag or FIRDelta(exon)2-flag stably expressing HeLa cells have been established by G418 selection and nuclear proteins were co immunoprecipitated with flag-conjugated magnetic beads. Those co-immunoprecipitated proteins with FIR or FIRDelta(exon)2 are candidates of tumor makers. In addition, substances that interfers FIR mRNA splicing should be anti-cancer drugs. Together, FIR splicing variant, FIRDelta(exon)2 mRNA or proteins and its interacting proteins are applicable for novel screening tumor markers in colorectal cancer detection.

It is well-known that there are significant "sex differences" in many laboratory tests. After puberty onset, sex-specific organs are well developed and clinical tests concerning their functions show obvious sex differences. On the other hand, sex differences are minimal or negligible in other test items representing functions of organs common in the both sexes. But, there are some exceptions. While in childhood, sex steroids secretions from sex-specific organs are inhibited in both sexes, after puberty onset, differences in the amount of secretion of sex steroids increase, resulting, either in a direct or indirect ways, in sex differences of the blood levels of many laboratory tests. The mechanisms of sex differences are not clear in many test items. Indeed, sex difference in height is not necessarily completely unraveled. Further studies on mechanisms of sex differences in laboratory tests will reveal mysterious differences between men and women.

Since the completion of the human genome project, there is growing interest in the clinical application of genome sciences. For this purpose, particular attention toward identifying at-risk individuals and understanding the complexities of the testing process are essential. In this article, I describe the importance of clinical genetics and genetic counseling, and explain how and why the division of laboratory medicine is involved in these tasks in Chiba University Hospital. Our genetic counseling team consists of a clinical laboratory physician qualified as a clinical geneticist, medical technologist qualified as a genetic counselor, clinical psychologists, and a medical social worker. We treat more than 100 cases including late-onset, incurable neurological diseases, hereditary tumors, prenatal diagnosis, and chromosomal abnormalities. The sequencing of the human genome has paved the way for comprehensive transcriptome and proteome analyses. Since the detailed understanding of biological processes, both in healthy and pathological states, requires the direct study of relevant proteins, proteomics bridges the gap between the information coded in the genome sequence and cellular behavior. Therefore, proteomics is among the most promising technologies for the development of novel diagnostic tools. Recent advances in sophisticated technologies in proteomics should identify promising ways to discover novel markers in various fields of clinical medicine. In this presentation, I will give a definition of the proteome, and outline the basic methodologies for proteome analyses. I will also present our experiences in identifying novel biomarker candidates in hepatobiliary diseases, and discuss future perspectives of clinical proteomics in laboratory medicine.

Hepatitis C virus (HCV) is a major cause of chronic liver disease worldwide. The severity of disease varies widely from mild illness to cirrhosis and hepatocellular carcinoma. The routine diagnostic test for HCV infection is performed using anti-HCV antibodies and an enzyme immunoassay (EIA) for serologic identification and HCV-RNA assay employing the polymerase chain reaction(PCR) for genetic identification. This study assessed the sensitivity and specificity of HCV-RNA diagnostic tests on analysis of the literature. A literature search was performed using the criteria from The standards for Reporting of Diagnostic Accuracy (STARD) steering committee for the assessment of diagnostic tests. The selected studies were searched for identifying publications on the appropriate conducting and reporting of diagnostic studies, and we extracted potential items to generate an extensive list. Out of 409 studies, 38 were selected. Further studies are necessary to accurately access HCV-RNA in various populations compared with reference tests.

The track records of the use of anti-methicillin-resistant Staphylococcus aureus agents (anti-MRSA agents) in a 5-year period (2001.4-2006.3) were collected, and cases in which anti-MRSA agents were used for >4 days were selected. In each case, the results of laboratory data and bacterial examination before and after administering the anti-MRSA agents were investigated retrospectively. In addition, it was also investigated in each case whether therapeutic drug monitoring (TDM) was carried out. It was observed that the number of patients treated with anti-MRSA agents and the total dose of anti-MRSA agents used tended to increase over time, except for arbekacin sulfate. It was, however, shown that treatment with anti-MRSA agents resulted in significant decreases in body temperature, C-reactive protein, and white blood cell counts. Bacterial examination was conducted in 75.6% of the patients treated with anti-MRSA agents, with MRSA being detected in 72.4% of the cases examined. On the other hand, TDM was also conducted in 60% of the cases, but this was at a lower percentage than that of the other examinations. Quantitative bacterial examination after treatment with anti-MRSA agents indicates that TDM can be considered important for the appropriate use of anti-MRSA agents.

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 876 strains of Gram-positive bacteria, 1764 strains of Gram-negative bacteria, and 198 strains of anaerobic bacteria obtained from 30 medical institutions during 2006 was measured. The results were as follows; 1. MEPM was more active than the other carbapenem antibiotics tested against Gram-negative bacteria, especially against enterobacteriaceae and Haemophilus influenzae. MEPM was also active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus. 2. As for Pseudomonas aeruginosa, all of the MEPM-resistant strains were resistant to imipenem (IPM). MEPM showed low cross-resistant rate both againt IPM-resistant P. aeruginosa (41.8%) and ciprofloxacin-resistant P. aeruginosa (33.3%). 3. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 4.3% (6 strains) in Escherichia coli, 1.1% (1 strain) in Citrobacter freundii, 21.7% (5 strains) in Citrobacter koseri, 3.1% (4 strains) in Klebsiella pneumoniae, 3.3% (3 strains) in Enterobacter cloacae, 0.8% (1 strain) in Serratia marcescens, and 4.9% (2 strains) in Providencia spp. The proportion of metallo-beta-lactamase strains was 3.1% (10 strains) in P. aeruginosa. 4. Of all species tested, there were no species, which MIC90 of MEPM was more than 4-fold higher than those in our previous study. Therefore, there is almost no significant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem at present, 11 years after available for commercial use.

Serum tartrate resistant acid phosphatase 5b (TRACP 5b) is an isozyme of osteoclast origin. Indeed, measurement of TRACP 5b activity is used as an index of osteoclast activity. However, the precise mechanism of TRACP 5b maturation is unclear. This study aimed to clarify the mechanism of generation of TRACP 5b. We used a highly sensitive fiber-type DNA chip to investigate the mechanism of generation of TRACP 5b at the genetic level. Genes derived from three related cell types (monocytes, macrophages and osteoclasts) were compared. In addition, at the protein level, posttranscriptional modification was tested by Western blotting using an antiserum specific for the flexible loop region of TRACP 5. Our DNA chip study shows that genes implicated in oligosaccharide construction do not show significant differences in expression levels between the cell types under investigation. Strongly expressed Cathepsin K was observed in osteoclasts. Western blotting demonstrated that TRACP undergoes unique partial degradation during bone resorption, such that serum TRACP 5b lacks the flexible loop found in TRACP 5a. In conclusion, TRACP 5b generated by a specific posttranscriptional modification pathway undergoes partial digestion in resorption lacunae or inside osteoclasts. Serum TRACP 5b lacking the flexible loop differs from TRACP 5a in terms of optimum pH, isoelectric point, sugar chain and antigenicity. The measurement of TRACP 5b could therefore be of great use for monitoring of osteoporosis, rheumatoid arthritis and bone metastasis.

Cancer has been the disease with the highest cause of death for a decade. This is partly due to the lack of ideal tumor markers for early diagnosis, which causes cancer found at the advanced stage where no curative treatment is available. Therefore, development of tumor markers with higher sensitivity and specificity is waiting to emerge. The ideal source for the tumor markers are serum, plasma or urine samples that are routinely used as clinical laboratory test. They contain a number of proteins that could be useful for cancer diagnosis. Recent advances in proteomic technology made it possible to identify the low abundant proteins in the clinical samples and thus extensive efforts are now attempted to search for the tumor markers across the country. There are two prominent types of proteomic approaches, 2D gel-based (2DE) and MS/MS based approach. 2DE is favorable to analyze relatively high moleculer weight proteins (MW > 20kD) and MS is superior to detect low molecular proteins or peptides. In this article, we introduce our recent studies on tumor marker discovery using various proteomic approaches and will discuss future application for cancer

It is important "to obtain cooperation of a patient" and "to practice efficiently" in paramedic intubation practice. In our hospital, we distribute a pamphlet at the time of informed consent acquisition and we present a letter of thanks after the practice. Moreover, paramedics come to the hospital everyday throughout the practice period. By the time 5 paramedics have completed the practice period, the average time is 36.4 days, the rate of patient consent is 94% and the successful rate of intubation is 99%. The paramedic intubation practice is implemented relatively smoothly.

During the past few years, the emphasis on genomics has shifted via transcriptomics to proteomics, the science of understanding how the whole set of proteins are expressed and function at the cellular level. Recent progress in clinical proteomics is mostly thanks to sophisticated new methodologies for proteome analyses. In search for novel biomarkers for cancers and other disorders, we have taken advantage of the surface-enhanced laser/desorption ionization time-of-flight mass spectrometry (SELDI-TOF MS) and the MALDI-TOF/TOF. Since personal and verbal reporting of alcohol use is not necessarily accurate, objective markers to assess alcohol consumption are required. We used the ProteinChip SELDI technology to generate comparative protein profiles of the consecutive serum samples obtained during abstinence and found that a 5.9kD peptide detected and identified by this technology could be a novel marker of heavy alcohol consumption. Recent advances in two-dimensional electrophoresis (2-DE) such as fluorescent 2-D differential gel electrophoresis (2-D DIGE) has made it possible to detect and quantitate the critical changes involved in disease pathogenesis. We could identify novel proteins with altered expression in primary esophageal cancer using the powerful method of agarose 2-DE and agarose 2-D DIGE. A number of proteins with altered expression between cancer and adjacent non-cancer tissues were identified. Among them, a 195-kDa protein, periplakin, was significantly downregulated in esophageal cancer, which was confirmed by immunoblotting and immunohistochemistry. Clinical proteomics consists of the discovery proteomics and the measurement proteomics. Although we still stand at the discovery proteomics, undoubtedly, the clinical proteomics will be a major contributor in laboratory medicine in the near future.

The antibacterial activity of meropenem (MEPM) and other parenteral antibiotics against clinical isolates of 907 strains of Gram-positive bacteria, 1790 strains of Gram-negative bacteria, and 192 strains of anaerobic bacteria obtained from 30 medical institutions during 2004 was measured. The results were as follows; 1. MIC90 of MEPM for almost all of enterobacteriaceae and Haemophilus influenzae were 4-fold to 32-fold lower than those of other carbapenems. MEPM was more active than other carbapenem antibiotics against Gram-negative bacteria, especially against enterobacteriaceae and H. influenzae. MEPM were active against most of the species tested in Gram-positive and anaerobic bacteria, except for multi-drug resistant strains including methicillin-resistant Staphylococcus aureus. 2. As for Pseudomonas aeruginosa, imipenem (IPM) showed high cross-resistant rate againt meropenem-resistant P. aeruginosa (87.9%). MEPM showed low cross-resistant rate both againt IPM-resistant P. aeruginosa (49.2%) and ciprofloxacin-resistant P. aeruginosa (38.0%). 3. The proportion of extended-spectrum beta-lactamase (ESBL) strains was 3.1% (4 strains) in Escherichia coli, 8.0% (2 strains) in Citrobacter koseri, 2.5% (3 strains) in Klebsiella pneumoniae, 2.5% (2 strains) in Enterobacter cloacae, 0.9% (1 strains) in Serratia marcescens, and 2.2% (2 strains) in Proteus mirabilis. The proportion of metallo-beta-lactamase strains was 1.6% (5 strains) in P. aeruginosa. 4. Of all species tested, Peptostreptococcus spp. was the only species, which MIC90 of MEPM was more than 4-fold higher than that in our previous study using clinical isolates during 2002 (0.25 microg/ml --> 1 microg/ml). Therefore, there is almost no siginificant decrease in susceptibility of clinical isolates to meropenem. In conclusion, the results from this surveillance study suggest that MEPM retains its potent and broad antibacterial activity and therefore is a clinically useful carbapenem at present, 9 years after available for commercial use.

Compulsory postgraduate clinical training in laboratory medicine will start on a national basis in April 2004. It remains to be discussed how departments of laboratory medicine and/or divisions of clinical laboratory should contribute to the training program. I here summarize what we are planning to do in Chiba University Hospital together with my personal views on this topic. Two points are of note in our program. First, one-week training in the division of clinical laboratory is essential as a part of the 6-month training of internal medicine. The items in the program include Gram staining, white blood cell differential counting, urinary sediment study, and representative point-of-care testing. A program to follow the entire flow of laboratory tests(from withdrawal of blood to reporting of the test results) is also included to highlight a variety of pre-analytical errors. Furthermore, trainees are encouraged to learn how to work and co-operate with co-medical personnel. Second, our program aims at training postgraduate medical students to be clinical geneticists competent at genetic counseling. Genetic counseling is the process by which patients or relatives at risk of a disorder that may be hereditary are advised of the consequences of the disorder, the probability of developing or transmitting it and of the ways to test them. Thus, our final goal is to foster genetically oriented experts in laboratory medicine and clinical geneticists with a wide knowledge of laboratory medicine.

Detection of virus genomes and their mutants by molecular technology is essential in clinical practice for patients with hepatitis B virus(HBV) and hepatitis C virus(HCV) related liver diseases. We here briefly summarize genome structures of HBV-DNA and HCV-RNA. Also, we describe representative methods to detect and quantify HBV-DNA and HCV-RNA.

A retrospective case-control study was performed with TB patients who were admitted to our hospital over the two years from Jan. 1997 to Dec. 1998 and healthy men who underwent a health screening in April 2000 in the same hospital. Thirty-two non-homeless TB patients (the first control group) and 32 healthy men (the second control group) were matched with 32 homeless TB patients according to age. All 3 groups were male. Total protein, albumin, cholesterol, cholinesterase, hemoglobin level and lymphocyte count on admission were significantly lower in the homeless patients than in the non-homeless patients and healthy men. Albumin, cholesterol, cholinesterase, hemoglobin level, white blood cell count and lymphocyte count on admission were significantly lower in non-homeless patients than healthy men. Height, weight and body mass index were significantly lower in the homeless patients than in the healthy men. However, there were no significant differences in these body characteristics between the homeless and non-homeless patients. Twenty-five percent of homeless patients died during hospitalization, compared with 6.3 percent of non-homeless patients. Lymphocyte counts among homeless patients who died during hospitalization were significantly lower than among those who survived during hospitalization. Total protein, albumin, cholesterol, cholinesterase, hemoglobin level and weight were lower in patients who died than in those who survived, although the differences were statistically not significant.

Cytochrome P450-2E1 (CYP2E1) is a major component of the microsomal ethanol-oxidizing system (MEOS) and is also involved in the metabolism of a variety of foreign compounds including carcinogens. It has been shown that there is an interindividual variation in the expression of human hepatic CYP2E1. Gene-environmental interactions have been suggested to account for the difference. In this study, we screened nine exons of the human CYP2E1 gene for detecting allelic variants in genomic DNA samples obtained from 115 Japanese controls, 96 Japanese alcoholics and 124 American control subjects. A novel missense mutation in exon 2 (V72L) was found in Japanese controls, and another missense mutation in exon 8 (D394G) was detected in American Caucasians. In addition, two novel silent mutations in exon 6 (T303T) and exon 8 (F420F) were found in Japanese controls and alcoholics. Especially the silent mutation in exon 8 was highly polymorphic among three population groups. The mutation in exon 2 (V72L) was detected only in Japanese controls, but not in alcoholics although it shows no significant difference. Gene frequency of the silent mutation in exon 8 was significantly higher in Japanese than American Caucasians (34.8% vs 21.0%, p < 0.02). Our data indicated that nucleotide replacement in the open reading frame is no major factor responsible for alcoholism. However, functional significance of the two novel missense mutations remains to be detailed.

Three assays for measuring hepatitis C virus(HCV) were compared with regard to sensitivity and correlations. The methods included were the Roche Amplicor HCV Monitor test(PCR), the branched DNA signal amplification assay(b-probe), and the serum concentration of HCV core protein measured by the sandwich FEIA (Core-Ag). Also, HCV serotypes were determined by the enzyme-linked immunosorbent assay. Testing 105 consecutive HCV-RNA positive samples showed that the PCR was the most sensitive assay(100% quantifiable), followed by the Core-Ag(82.4%) and the b-probe(75.3%). The values obtained by each method correlated well in serotype 1, whereas some discordance was noted in serotype 2 cases. Also, serotype 2 samples were less quantifiable particularly by b-probe assay than serotype 1 samples. These points have to be considered in quantification of serum HCV levels by currently available these three methods.

Current EIA for PIVKA-II is not sensitive enough to detect small Hepatocellular Carcinoma (HCC). In an attempt to increase the diagnostic threshold, the current EIA was modified in two different ways: 1) immunoreaction of PIVKA-II in the sample with its monoclonal antibody was carried out overnight at 5 degrees C instead of for two hours at room temperature (the overnight method), 2) Avidin-Biotin technique was used for the second reaction(the ABC method);and their diagnostic values were determined as compared with the current EIA(2hr method) in a total of 138 patients including 36 patients with HCC. In 27 patients with HCC(< 3 cm in diameter), the rates of abnormal values obtained by the 2hr-, the overnight- and the ABC method were 14.8, 25.9 and 29.6% respectively. False positive rates of these three methods in 69 patients with liver cirrhosis were 1.4, 8.6 and 22.9% respectively. Thus, these two modifications improved the sensitivity of the current EIA and the overnight method appears to be superior to the ABC method in terms of specificity and simplicity. This conclusion was confirmed by ROC analysis.

Pheochromocytomas synthesize and release catecholamines, which subsequently are related to various clinical manifestations of the disease. However, pheochromocytomas are not innervated and the catecholamine release and synthesis are not initiated by neural impulses. It is still unknown how catecholamine synthesis is regulated in pheochromocytomas. As a first step toward understanding the molecular mechanisms by which catecholamine synthesis is controlled in the tumor, we measured the levels of mRNA coding for the catecholamine synthesizing enzyme, tyrosine hydroxylase (TH) and catecholamines in 6 pheochromocytomas and 2 normal adrenal glands. The TH mRNA level was overexpressed and the catecholamine contents were high in 4 out of 6 pheochromocytomas. There was a close correlation between the TH mRNA level and the catecholamines content in the tumors. We also examined the gene expression of the messengers of other catecholamine synthesizing enzymes, dopamine beta-hydroxylase (DBH) and aromatic 1-amino acid decarboxylase (AADC) in pheochromocytomas. The expression of these genes was in parallel with that of TH mRNA in the tumors. These findings indicate that catecholamine overproduction in pheochromocytomas is mediated by the overexpression of genes coding for catecholamines synthesizing enzymes, TH, DBH, and AADC.

The liver plays an important role in the metabolism of trace minerals. Hypozincemia has been well documented in cirrhotic patients and multiple mechanisms, including poor intake and depressed absorption, appear to be responsible for it. Of particular interest is a role of zinc deficiency in hepatic encephalopathy and the therapeutic potential of zinc supplementation in patients with liver cirrhosis. Although some reports indicate beneficial effects of oral zinc supplementation in cirrhotic patients with hepatic encephalopathy, not all studies have been positive. Serum selenium concentration depends on the amount of selenium ingested and the decreased levels found in cirrhotic patients should be interpreted with caution.

Hormones produced by the anterior pituitary have conventionally been measured in the serum by radioimmunoassays (RIA), whereas more sensitive immunoradiometric assays (IRMA) have now been developed and are replacing RIA. Dynamic tests (stimulatory tests and suppression tests) rather than single and random determinations are often important tools in the study of pituitary functions. Stimulatory tests (such as glucagon plus propranolol test for growth hormone and water deprivation test for arginine-vasopressin) are used to evaluate hypofunction and suppression tests (such as dexamethasone suppression test for adrenocorticotrophic hormone) are used to investigate hyperfunction. This chapter, mainly dealing with representative dynamic tests, describes test protocols and how to interpret test results.

Two patients with postoperative sternal wound infection were successfully treated by a pectral musculocutaneous flap. A single-stage procedure of debridement and immediate closure with a pectral musculocutaneous flap can eliminate irrigation, open wound management, or reoperation for closure. Therefore, this method is very safe, simple, and effective for the management of sternal wound infections.

A 79-year-old woman with a previous history of myocardial infarction, suffered acute myocardial infarction again. A coronary angiogram revealed triple vessel disease, and a left ventriculogram showed severe mitral regurgitation. The patient fell into cardiogenic shock after cardiac catheterization, and IABP was started. She underwent MAP and saphenous vein bypass grafting to the left anterior descending coronary artery and left circumflex coronary artery. Although the postoperative course was complicated by acute renal failure and respiratory dysfunction, the patient recovered from the operation and was discharged on the 137th postoperative day. Since the operative mortality of conventional valve replacement combined with CABG in ischemic mitral regurgitation has been high, we preferred MAP for this case.

We report here two cases in which patients fell into pulmonary edema due to ischemic mitral regurgitation (ischemic MR) after cardiac catheterization and underwent emergency coronary artery bypass grafting (CABG) using an intra-aortic balloon pumping. The patient were a 65-year-old man and a 80-year-old woman, and both had a chief complaint of angina after myocardiac infarction. In both cases, coronary angiography revealed triple vessel disease, and left ventriculography showed severe MR. However echocardiography, when they were hospitalized, did not show significant MR. Therefore we thought that they had gone into congestive heart failure because cardiac ischemia and volume load following cardiac catheterization provoked MR. In fact, postoperative left ventriculography and echocardiography showed decreased MR. We now think that it is important to keep in mind the cases of severe ischemic MR for which CABG alone is adequate treatment and to evaluate ischemic MR not only by left ventriculography but also by echocardiography.

Pharmacokinetics of theophylline were determined in patients with liver cirrhosis and idiopathic portal hypertension with reference to estimated hepatic blood flow assessed by indocyanine green (ICG). Decreased plasma clearance of theophylline was noted in patients with liver cirrhosis and the clearance was significantly lower in Child C group than in Child A, B groups (17.5 +/- 3.4 ml/Kg/hr vs 27.6 +/- 8.7, p less than 0.05). Theophylline has been classified as a drug with a low hepatic extraction ratio and it has been believed that changes in hepatic blood flow have little effect on its clearance. The results of present study indicate that theophylline clearance is basically not related to ICG clearance but to theophylline extraction ratio, supporting the common belief. However, it is noteworthy that the clearance was related to decreased hepatic blood flow rather than extraction ratio in a cirrhotic patient with huge extrahepatic shunt, suggesting that hepatic clearance of this drug could be affected by hepatic blood flow under some circumstances.

A 43-year-old male, who had undergone coronary artery bypass grafting 11 years ago, developed exertional chest pain. Selective coronary angiograms revealed severe stenosis and a large aneurysm in the obtuse marginal branch of the circumflex coronary artery. Previous grafts to the left anterior descending coronary artery and diagonal branch were patent. Ligation of the aneurysm and internal mammary artery grafting were performed through a left anterolateral thoracotomy. This approach made it easy to reach the aneurysm and to minimize bleeding during dissecting the adhesions. The patient had an uncomplicated postoperative course, and postoperative coronary angiograms revealed an obstructed aneurysm and a patient internal mammary artery graft. He has done well without recurrence of symptoms.

To evaluate the development of an anomalous muscle bandle of the right ventricle (RV) and results of surgical intervention, responses of the RV to atrial pacing and the isoproterenol tests were examined in both the pre- and postoperative periods. Although cardiac output did not increase in proportion to the rate of atrial pacing or the dose of isoproterenol, the pressure gradient through the RV increased abnormally from 38 mmHg to 59 mmHg (atrial pacing) and 116 mmHg (isoproterenol). On the other hand, postoperative evaluation showed normal RV responses in these tests. Since the response of the right ventricle to these tolerance tests in patients with DCRV in pre- and postoperative periods has not been well elucidated, a precise evaluation is reported in this paper.

This paper reports CABG which was successfully performed on a male patient of 70-year-old with severe chronic obstructive pulmonary disease (FEV1.0% 43%) and diabetes mellitus. The patient necessitated reintubation because of hypercapnea on 18 POD in spite of bronchodilator and physical therapies. Long respiratory care was continued after tracheotomy, and finally he could wean from the mechanical respiratory care utilizing acetazolamide (carbonic anhydrase inhibitor) on 59 POD.