Two Mutations in Thyroid Hormone Receptor Beta Gene (P453A and C36Y) in a Family with Resistance to Thyroid Hormone with Comorbid Myotonic Dystrophy.

The co-occurrence of resistance to thyroid hormone beta (RTHß) and myotonic dystrophy type 1 (DM1) was observed in a Japanese family. Two mutations, P453A and C36Y, were identified in the thyroid hormone receptor beta (THRB) gene. Whereas family members with THRBP453A exhibited RTHß, two members with THRBC36Y but without THRBP453A had normal thyroid function. Two members, one with RTHß and the other without, had a triplet expansion in the dystrophia myotonia protein kinase gene, a hallmark of DM1. The member with both RTHß and DM1 developed atrial fibrillation at the age of 16 years, suggesting a synergistic impact on the heart.

Efficacy on the risk of vertebral fracture with administration of once-weekly 17.5 mg risedronate in Japanese patients of established osteoporosis with prevalent vertebral fractures: a 156-week longitudinal observational study in daily practice.

Currently, the only available evidence for the efficacy of once-weekly 17.5 mg risedronate in preventing vertebral fractures was obtained in a 48-week study in Japan. We performed a 156-week prospective, longitudinal, observational study to determine the efficacy of the 17.5 mg risedronate in preventing vertebral fractures. We included Japanese patients with established osteoporosis who were older than 50 years and had radiographically confirmed vertebral fractures. The primary endpoint was the incidence of vertebral fractures every 24 weeks, with the final interval spanning 36 weeks. We also calculated the change in bone mineral density of the lumbar spine (L2-4 BMD) and urinary N-telopeptide of type I collagen (u-NTX), and assessed the incidence of adverse drug reactions and the drug adherence rate. Data from 241 patients were available for analysis of vertebral fracture prevention. The incidence rate of vertebral fractures decreased in a time-dependent manner (P = 0.0006; Poisson regression analysis). The risk ratio (fracture incidence per 100 person-years in the final 36 weeks versus that in the first 24 weeks) was 0.21 (95 % confidence interval 0.08-0.55). Compared to baseline values, L2-4 BMD increased by 6.41 % at 156 weeks, while u-NTX decreased by 36 % at 24 weeks and was maintained thereafter (P < 0.0001). The incidence rate of adverse drug reactions was 9.18 %. Drug adherence rates assessed every 4 weeks were over 90 %. Our results indicate that 156 weeks of treatment with once-weekly 17.5 mg risedronate effectively reduced the risk of vertebral fracture in Japanese patients with established osteoporosis older than 50 years.

[Usefulness of Polyethylene-Glycol Precipitation As a Screening Method for Macroprolactinemia].

Macroprolactin is mostly a complex of monomeric prolactin (PRL) with IgG and considered to be biological inactive. Its presence commonly leads to diagnostic confusion and misdiagnosis. Polyethylene-glycol (PEG) precipitation method is widely used for a screening of macroprolactinemia. We applied PEG precipi- tation method for 200 samples which was ordered test of PRL. The PRL recovery was 65.0±11.2% (mean ±SD). In our data, PRL recovery less than 42.5% (mean-2SD) indicates the presence of macroprolactin. The prevalence of macroprolactinemia was 4.5%(9/197) in total samples and 9.5%(2/21) in hyperprolac- tinemia. Our result indicates the need for PEG screening for macroprolactinemia to avoid misdiagnosis. [Short Communication].

Modified Cut-Off Value of the Urine Protein-To-Creatinine Ratio Is Helpful for Identifying Patients at High Risk for Chronic Kidney Disease: Validation of the Revised Japanese Guideline.

Chronic kidney disease (CKD) is a global public health issue, and strategies for its early detection and intervention are imperative. The latest Japanese CKD guideline recommends that patients without diabetes should be classified using the urine protein-to-creatinine ratio (PCR) instead of the urine albumin-to-creatinine ratio (ACR); however, no validation studies are available. This study aimed to validate the PCR-based CKD risk classification compared with the ACR-based classification and to explore more accurate classification methods. We analyzed two previously reported datasets that included diabetic and/or cardiovascular patients who were classified into early CKD stages. In total, 860 patients (131 diabetic patients and 729 cardiovascular patients, including 193 diabetic patients) were enrolled. We assessed the CKD risk classification of each patient according to the estimated glomerular filtration rate and the ACR-based or PCR-based classification. The use of the cut-off value recommended in the current guideline (PCR 0.15 g/g creatinine) resulted in risk misclassification rates of 26.0% and 16.6% for the two datasets. The misclassification was primarily caused by underestimation. Moderate to substantial agreement between each classification was achieved: Cohen's kappa, 0.56 (95% confidence interval, 0.45-0.69) and 0.72 (0.67-0.76) in each dataset, respectively. To improve the accuracy, we tested various candidate PCR cut-off values, showing that a PCR cut-off value of 0.08-0.10 g/g creatinine resulted in improvement in the misclassification rates and kappa values. Modification of the PCR cut-off value would improve its efficacy to identify high-risk populations who will benefit from early intervention.

The total urine protein-to-creatinine ratio can predict the presence of microalbuminuria.

BACKGROUND: The Kidney Disease: Improving Global Outcomes chronic kidney disease (CKD) guidelines recommend that CKD be classified based on the etiology, glomerular filtration rate (GFR) and degree of albuminuria. The present study aimed to establish a method that predicts the presence of microalbuminuria by measuring the total urine protein-to-creatinine ratio (TPCR) in patients with cardiovascular disease (CVD) risk factors. METHODS AND RESULTS: We obtained urine samples from 1,033 patients who visited the cardiovascular clinic at St. Luke's International Hospital from February 2012 to August 2012. We measured the TPCR and the urine albumin-to-creatinine ratio (ACR) from random spot urine samples. We performed correlation, receiver operating characteristic (ROC) curve, sensitivity, and subgroup analyses. There was a strong positive correlation between the TPCR and ACR (R2 = 0.861, p<0.001). A ROC curve analysis for the TPCR revealed a sensitivity of 94.4%, a specificity of 86.1%, and an area under the curve of 0.903 for detecting microalbuminuria for a TPCR cut-off value of 84 mg/g of creatinine. The subgroup analysis indicated that the cut-off value could be used for patients with CVD risk factors. CONCLUSIONS: These results suggest that the TPCR with an appropriate cut-off value could be used to screen for the presence of microalbuminuria in patients with CVD risk factors. This simple, inexpensive measurement has broader applications, leading to earlier intervention and public benefit.

[Cross-reactivity evaluation of improved estradiol (E2) assay reagent based on chemiluminescent enzyme immunoassay].

We evaluated the performance of a newly-improved estradiol(E2) assay reagent (NEW LP-E2-N), which replaces murine monoclonal antibody in the present reagent (LP-E2-N) with sheep monoclonal antibody, since we had experienced discrepant E2 assay results between LP-E2-N and other commercially available E2 assay kits. Several examinations with the new assay reagent indicated a good performance in terms of the limit of quantity, reproducibility (within-run and between-day), dilution linearity, and influence of blood components except hemoglobin. Using analogues and/or metabolites of E2, low or no cross-reactivity has been shown in NEW LP-E2-N: 0.26% with 25 ng/mL of estrone (El), 0.14% with 100 ng/mL of estradiol-3-sulfate, 0.02% with 200 ng/mL of 17α-ethynylestradiol, and less than 0.001% with 100 ng/mL of estriol(E3), estra-17-glucuronide, and estramustine, respectively. Although discrepant results between NEW LP-E2-N and LP-E2-N were observed in 12 samples, including 9 cases under oral hormone therapy, data from these samples were similar to those using 2 commercially available E2 assay kits, Architect and Eclusys, suggesting that the NEW LP E2-N shows adequate clinical efficacy. A correlation study was performed with LP E2-N, Architect, and Eclusys using 149 serum samples obtained from patients and healthy volunteers, and the correlation results were as follows: r = 0.831, y = 0.98x + 40.6 against LP-E2-N, r = 0.991, y = 1.08x + 12.4 against Architect, r = 0.995, y = 0.80x - 3.7 against Eclusys. In conclusion, the NEW LP-E2-N reagent displayed a relatively favorable kit performance except for in the elevation of assay results with hemoglobin, as well as a low cross-reactivity with E2 analogues and/or metabolites.

[A case of Burkitt lymphoma with multifocal bone invasion].

A 12-year-old boy admitted to a local hospital with fever, migratory arthralgia, and periosteal reaction on X Ray. He was transferred to our hospital because magnetic resonance imaging scan of his whole body showed multiple abnormal signals in bones. Laboratory findings on admission showed the increased erythrocyte sedimentation rate, uric acid, lactate dehydrogenase, alkaline phosphatase, C-reactive protein, immunoglobulin G, hemolytic complement activity and soluble interleukin-2 receptor. Peripheral blood and bone marrow examination did not show any abnormality. The clinical appearance of his condition suggested the diagnosis of chronic recurrent multifocal osteomyelitis (CRMO). He was treated with steroid, however his fever and bone pain continued. A bone and bone marrow biopsy was performed and the results of histopathology showed precursor-B acute leukemia/lymphoma. His bone pain relapsed after the chemotherapy for ALL. Finally, blast cells resembling L3 morphology were detected in the peripheral blood. The reevaluated bone marrow was predominantly replaced with Burkitt like lymphoblasts. He was diagnosed with Burkitt lymphoma by further specific examination.

[A case of mycoplasma hominis infection on chronic refractory lower leg ulceration caused by livedo vasculopathy].

Mycoplasma hominis is a common inhabitant of the human urogenital tract and most frequently causes diseases of the genitourinary tract. Extragenital M. hominis infections are uncommon, with almost all occurring in immunosuppressed persons or those predisposed due to surgery or trauma. We report a case of non surgical, non-traumatic wound infection caused by M. hominis. A 28-year-old immunocompetent woman with livedo vasculopathy had an open wound on dorsum of her right foot with signs and symptoms of infection. However, gram staining of the wound swab demonstrated no microorganisms, and initial bacterial cultures did not reveal any microbial growth. After 2 days of culture, minute translucent colonies were appeared and subsequently identified as M. hominis. She was successfully treated with levofloxacin(LVFX). For the patient's being immune-competent, this infection seems to need a substantial bacterial transfer from the inhabitant organ. The transfer is likely mediated by the fluid's drop, for anatomical locations of vagina and the infection site on leg. Namely, the hinder leg infection is suspected to be caused by continual and heavy bacterial exposure originated from the vaginal M. hominis. This clinical case suggests that infections may occur even in normal immunological status if the site is close to, and lacks anatomical barrier from, the M. hominis inhabitant organ. Especially in infection at chronic refractory lower leg ulceraion, M. hominis should be considered as a causative organism.

[Report of immunoassay control surveys conducted in the past 30 years by the Subcommittee for Radioisotope in vitro Test, the Medical Science and Pharmaceutical Committee, and the Japan Radioisotope Association].

Immunoassay control surveys, were conducted by the Subcommittee for Radioisotope in vitro Test, the Medical Science and Pharmaceutical Committee, and the Japan Radioisotope Association, between 1978 to 2008. A total of 40 analytes for 26 hormones, 14 tumor markers and pharmaceutical drugs were investigated in participating facilities. In the first immunoassay control survey in 1978, samples were measured using only RI kits, however, non-RI kits increased gradually during the next 30 years. In the 30th immunoassay control survey, more than 90% samples were measured using non-RI kits. Coefficient variation (CV) of intra-kits has been decreasing yearly in all analytes for hormones as well as tumor markers. However, improvement of CV in inter-kits has not been seen in the past 30 years by a lack of international standards, although there has been continuous effort over the years for the standardization of immunoassay. Growth hormone (GH) deficiency has been diagnosed using various loading tests. However, the clinical diagnosis varies according to the GH kit used. Standardization for GH measurement has been possible by using recombinant GH as the standard among commercial GH kits. The diagnosis of subclinical Cushing's syndrome also varies according to the cortisol kits being used. Candidate reference measurement procedure and low level cortisol standards have been developed by the Biomedical Standard Section, of the National Metrology Institute of Japan. Standardization of measurement is necessary for improvement of immunoassay.

Establishment of a method to detect microalbuminuria by measuring the total urinary protein-to-creatinine ratio in diabetic patients.

Diabetes and chronic kidney disease (CKD) which are risk facters of cardiovascular disease, are increasing global public health problems. Microalbuminuria is an early sign of progressive cardiovascular and renal disease in individuals with or without diabetes. Screening for microalbuminuria and early treatment are recommended for patients with increased cardiovascular and renal risk factors. However, the procedure used to measure urinary albumin is expensive. Alternatively, the measurement of total urinary protein is simple and inexpensive. Thus, we aimed to establish a method that could predict the presence of microalbuminuria by measuring the total protein-to-creatinine ratio. Spot urine samples were obtained from 150 patients with diabetes mellitus, and the total protein-to-creatinine ratio and the albumin-to-creatinine ratio (ACR) were measured. There was a significant positive correlation between the protein-to-creatinine ratio and the ACR (r = 0.95). The presence of albuminuria (both micro- and macroalbuminuria) could be predicted from the value of the protein-to-creatinine ratio in more than 90% of patients. A receiver-operating characteristic curve analysis revealed that the protein-to-creatinine ratio had a sensitivity and a specificity of 90.8% and 91.9%, respectively, for the detection of albuminuria and a cutoff value of 0.091 g/g creatinine. These results suggest that screening for microalbuminuria can be replaced by the detection of the protein-to-creatinine ratio, which may be cost-effective for patients with cardiovascular risks as well as for the general population.

[Clostridium difficile TOX A/B II TEST evaluation].

We compared the performance of two commercial toxin detection kits, C. difficile toxin A/B (C. difficile TOX A/B II test; TOX A/B II) and C. difficile toxin A (Uniquick), for (i) detection using highly purified toxin A solution; (ii) cross-reactivity using culture supernatants of toxin A-positive and B-positive C. difficile, toxin A-negative and B-positive C. difficile, and toxin A-negative and B-negative C. difficile strains and other bacteria; and (iii) sensitivity and specificity using clinical specimens. Results indicated that TOX A/B II detected toxin A at concentrations of 0.35 ng/mL and Uniquick at concentrations of 0.7 ng/mL. Uniquick performance was specific for detecting toxin A alone, while TOX A/B II detected toxin A/B specifically. Kit performance was then evaluated using 99 fecal specimens--43 specimens from patients with toxin B-positive C. difficile and 56 from those without. Sensitivity of TOX A/B II vs Uniquick was 95.3% vs 76.7%, specificity 98.2% vs 98.2%, positive predictive 97.6% vs 97.1%, and negative predictive value 96.5% vs 84.6%. Findings thus indicate that TOX A/B II is a more suitable diagnostic aid for CDAD than Uniquick because it correlates well with toxin B-positive C. difficile culture results. Stool culture for C. difficile is also required, however.

Evaluated reference intervals for serum free thyroxine and thyrotropin using the conventional outliner rejection test without regard to presence of thyroid antibodies and prevalence of thyroid dysfunction in Japanese subjects.

The determination of the reference intervals for serum free thyroxine (FT4) and thyrotropin (TSH) is usually based on central 95 percentile intervals using subjects without detectable antibodies against thyroid peroxidase (TPO) or thyroglobulin (Tg). However, some subjects with extreme data over reference intervals are generally included. The study objective was to evaluate the reference intervals for FT4 and TSH using different outlier tests. 1,007 Japanese subjects screened based on the National Academy of Clinical Biochemistry criteria in the United States participated in this study. Serum FT4, TSH, and TPOand Tg antibodies were measured in all subjects. To make appropriate reference intervals, the Smirnov-Grubbus' outlier test was taken for antibody-free subjects (Ab[-] S-G), and the conventional outlier rejection method rejecting the value out of +/-3 standard deviation was taken for antibody-free subjects (Ab[-] STD) and all subjects (ALSTD), respectively. 12.8% of all subjects had either TPOor Tg antibodies in their serum. The 2.5(th) and 97.5(th) percentiles of reference intervals of serum FT4 (ng/dL) and TSH (mU/L) were 1.03~1.66 and 0.51 approximately 5.14 in (Ab[-] S-G), 1.03 approximately 1.65 and 0.51 approximately 4.57 in (Ab[-] STD) and 1.03 approximately 1.66 and 0.51 approximately 4.67 in (ALSTD), respectively. FT4 in males were significantly and negatively correlated with age, and TSH was significantly and positively correlated with age (P<0.000001 and P<0.00001, respectively). There was a significant difference between the sexes in FT4 (P<0.00001) but not in TSH. The prevalence of hypothyroidism, subclinical hypothyroidism, sublinical hyperthyroidism and hyperthyroidism were 0.2, 3.1, 2.3 and 0.3% (Ab[-] S-G), 0.3, 4.7, 2.3 and 0.3%(Ab[-] STD), and 0.3, 4.3, 2.3 and 0.3% (AL STD), respectively. This finding indicates that the conventional outlier rejection method is both convenient and appropriate to provide reference intervals for serum FT4 and TSH levels without regard to thyroid antibodies using large samples.

Evaluation of a new rapid and fully automated electrochemiluminescence immunoassay for thyrotropin receptor autoantibodies.

BACKGROUND: Hyperthyroidism in Graves' disease is caused by autoantibodies to the TSH receptor (TSHR), and measurement of the TSHR autoantibody (TRAb) yields important information to diagnose and decide on the course of treatment of Graves' disease. We evaluated basic and clinical performance of a new, rapid, and fully automated electrochemiluminescence immunoassay Elecsys Anti-TSHR (Elecsys TRAb) for measuring serum TRAb. METHODS: For evaluation of basic performance of the assay, we carried out intra- and interassay precision studies using five serum pools and three serum pools, respectively, and the assay was compared with four commercial TRAb assays. Clinical performance of the assay was evaluated with sera from 298 patients with untreated Graves' disease, 220 patients with destructive (painless and subacute) thyroiditis, and 332 healthy volunteers. The optimal cutoff point, which was calculated by receiver operating characteristic (ROC) analysis with the above subjects, was then used to classify an independent sample set of 80 patients with untreated Graves' disease, and 152 patients with destructive thyroiditis. RESULTS: Intraassay coefficient of variation (CV) was 4.24% at 1.85 IU/L and interassay CV was 10.1% at 1.46 IU/L. All the correlation coefficient values calculated against four commercial assays were larger than 0.85. ROC analysis resulted in a specificity of 99.1% with a sensitivity of 97.0% at a decision limit of 1.86 IU/L from comparison with untreated Graves' disease and destructive thyroiditis. The cutoff point yielded a sensitivity of 87.5% and specificity of 96.7% with the independent sample set. CONCLUSION: In spite of the short measuring time of only 27 minutes, the assay showed the same or better results with the existing commercial products. The short measuring time would contribute to speedy, preconsultation diagnosis of thyroid disease, especially of Graves' disease.

[Desirable medical technologists in a community support hospital].

Recently, there have been marked advances in the technological strategies employed in medical examinations. The educational concept to nurture highly capable medical technologists is considered to be a priority issue by not only educators but also employers, even though the medical educational levels have markedly improved in every college and university. It is commonly acknowledged that the results of any examination in the clinical laboratory should be accurate and fed back to medical doctors as soon as possible. The business outline of medical technologists in our hospital is becoming more extensive because we act as a core hospital in the area, and so knowledge regarding many kinds of chemical and transfusion examinations is required in operations performed around the clock. Furthermore, medical doctors, clerical workers, nurses, and volunteers comprise a team of sophisticated workers in our hospital. To accomplish our daily work, character traits such as accuracy, honesty, perseverance, and ability to follow instruction manuals, are the most fundamental and valuable. To nurture a highly career-oriented medical technologist, we propose that the following should be focused on: self-responsibility, reduction of malpractices, economic profitability, brainstorming, education of subsequent generations, and the spirit of cooperativeness and reconciliation. Additionally, it is another basic requirement of competent medical technologists to learn to adapt to laboratory-based changes in their work throughout their career. In conclusion, how to adapt to any social demand and learn strategies in any era should be taught in college or university as well as after graduation because each hospital and institute has a different philosophy and requirements of newcomers. It is important for medical technologists and doctors to develop flexible ways of thinking, although we sometimes might accede to traditional ways.

[Anaerobiospirillum succiniciproducens septicemia].

We report the first case of septicemia caused by anaerobic spiral-shaped Gram negative bacilli, Anaerobiospirillum succiniciproducens in Japan. A 71-year-old male who had been suffered from terminal stage of liver cirrhosis and hepatocelluler carcinoma was admitted to our hospital for his symptoms of general malaise and increasing ascites on September 1, 2004. He developed diarrhea seven times a day on the eighth hospital day and had fever of 38.7 degrees C with WBC 12,600/microl and CRP 6.6 mg/dl on the next day. Blood culture grew Gram negative spiral bacilli. We initially could not identify the offending bacterium that resembled to Campyrobacter morphologically using commercially available indentification kits. However, 16SrRNA sequencing test revealed 100% compatibility with Anaerobiospirillum succiniciproducens.

[Evaluation of cardiac dysfunction after herceptin treatment in patients with metastatic breast cancer by echocardiography].

Herceptin (Trastuzumab) is a humanized recombinant monoclonal antibody that binds the extracellular domain of the human epidermal growth factor receptor 2 (HER2) and is used in the treatment of patients with HER2 overexpressing metastatic breast cancer. Treatment with Herceptin is generally well tolerated. At times, however, it exerts cardiac toxicity especially when used in combination with anthracyclines. We evaluated cardiac function before and after Herceptin treatment in nine patients with metastatic breast cancer by echocardiography, measuring ejection fraction (EF) and deceleration time (DcT). EF was significantly reduced after treatment(P<0.05). Although the present study failed to show significant changes in DcT, definite diastolic disturbance of the left ventricle did occur in a couple of patients. We conclude that cardiac dysfunction may be a common side effect of Herceptin even in early stages of treatment and that echocardiography will be a useful means of monitoring cardiac function in these patients.

[Molecular defects in plasma membrane hormone receptors].

The biological effects of hormones are mediated by plasma membrane receptors which transmit extracellular signals to the cytoplasm and nucleus. Mutations in plasma membrane receptors can affect normal signal transduction with loss-of-function mutations leading to hormone resistance and gain-of-function mutations leading to constitutive activation of signaling pathways. The loss-of-function mutations leading to familial hormone resistance disorders are germline in origin whereas the gain-of-function mutations leading to constitutively active receptors are somatic. G-protein coupled receptors (GPCR) comprise a large superfamily of proteins characterized by seven transmembrane-spanning segments and interaction with GTP-binding(G) proteins. Mutations in GPCRs have been associated with dwarfism, congenital hyperthyroidism or hypothyroidism, nephrogenic diabetes insipidus, obesity, resistance to TSH, LH, FSH and ACTH, Jansen's metaphyseal and Blomstrand's chondrodysplasia, autosomal dominant hypoparathyroidism, and neonatal severe hyperparathyroidism. Mutations in other families of receptors which are characterized into one spanning-transmembrane receptor can result in resistance to insulin, GH, leptin and AMH. This review summarizes the molecular defects in plasma membrane hormone receptors in a large number of clinical disorders.