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An 83-year-old Japanese man who underwent cholecystectomy for cholecystolithiasis 17 years ago visited our hospital owing to epigastric pain. He was initially diagnosed with choledocholithiasis and acute cholangitis following white blood cell, C-reactive protein, total bilirubin, alkaline phosphatase, and γ-glutamyltranspeptidase level elevations along with common bile duct stones on computed tomography (CT). Moreover, CT, magnetic resonance imaging, endoscopic retrograde cholangiography (ERC), and endoscopic ultrasonography (EUS) also revealed a 2-cm-diameter mass arising from the remnant cystic duct. The cytology of the bile at the time of ERC was not conclusive. However, EUS-assisted fine needle aspiration (EUS-FNA) of the mass confirmed the diagnosis of adenocarcinoma of the remnant cystic duct. The patient underwent extrahepatic bile duct resection. Cystic duct carcinoma following cholecystectomy is rare. We report a case diagnosed by EUS-FNA.

The impact of gene-editing technology has rapidly expanded into developmental engineering. Using this technology, gene targeting in mice can be performed within 2-3 months, which is a much shorter timespan than that required while using embryonic stem cell-based conventional methods, which require nearly two years. In addition, genome-editing technology omits several skillful laborious steps. This review describes the prominent merits of gene targeting using this recently established and still ongoing technology in the field of hematology. In addition, the experience of the authors is reviewed to identify and characterize genes involved in the loss of the long arm of chromosome 7 in myeloid malignancies and highlight the significance of establishing the mouse model of human diseases.

This study reports a case of a 49-year-old woman having B-cell acute lymphoblastic leukemia with glycophorin A, a representative erythroid marker, expression. According to the WHO criteria for mixed phenotype acute leukemia (MPAL), erythroid lineage is not defined, and to the best of our knowledge, only one other case with erythroid/B-cell biphenotypic acute leukemia has been reported previously. To establish the disease entity and clarify the pathophysiology of erythroid/lymphoid MPAL, additional cases need to be analyzed.

We analyzed the clinical features of 157 patients admitted to 11 institutions in the Kagawa Prefecture for volvulus of the sigmoid colon. The following were the background information of the patients:median age, 79.0 years;male-to-female ratio, 102:55;median body mass index, 20.0kg/m 2 ;and the proportion of patients with performance status ≥3, 43.9%. Abdominal bloating and pain were the chief complaints. During hospitalization, endoscopy and endoscopic detorsion were performed 157 and 100 times, respectively. An accidental complication was observed in 3 cases, all of which were intestinal perforations. Surgery, which was indicated for ischemia, was performed in 62 of the 157 cases. Endoscopy is useful in the diagnosis of ischemia, which can be treated following an early diagnosis. Of the 157 patients, 19 died, whereas the rest were discharged. The risk factors for death were age ≥80 years and creatinine kinase level ≥200IU/L.

A 67-year-old man was diagnosed with ulcerative colitis one year ago. Remission was induced via the oral administration of prednisolone and azathioprine;prednisolone was gradually reduced and discontinued. He maintained remission with azathioprine but developed fever and general malaise and visited the Kagawa Prefectural Central Hospital. Chest radiography and a urinary antigen test revealed Legionella pneumonia. His symptoms reduced immediately after the initiation of levofloxacin. Azathioprine suppresses cellular immunity and may increase the risk of Legionella pneumonia.

A 47-year-old male was admitted to our hospital because of left hypochondrium part pain and was diagnosed with splenomegaly with splenic infarctions in May 2016. His complete blood cell count was almost within normal limits, and a bone marrow biopsy revealed normal cellularity with no fibrosis. In addition, no abnormal uptake was noted on FDG PET/CT. In August 2016, he underwent splenectomy for splenomegaly. The histological examination revealed fibrotic stenosis of the blood vessels in the spleen. After splenectomy, his platelet count elevated and remained at >1,000×10 9 /l 3 months later. Finally, he was diagnosed with latent essential thrombocythemia (ET) because the JAK2V617F mutation was positive. Accordingly, oral hydroxyurea was initiated. Thrombosis could be a complication in myeloproliferative neoplasms (MPN). In our case, ET was masked, perhaps, because of hypersplenism and splenomegaly because of splenic vein thrombosis. Hence, examination of the JAK2V617F mutation in patients with splanchnic vein thrombosis is recommended because of the possibility of latent MPN.

Fifty years after its discovery, the enigma of monosomy 7 (-7) is eventually unraveling. The key to understanding -7 is "haploinsufficiency" mechanism, through which the function of myeloid tumor-suppressor genes is lost via the deletion/mutation of one allele. In this century, powerful tools such as microarray-CGH and next generation sequencing have enabled the search for tumor-suppressor genes on chromosome 7. Five genes (Samd9, Samd9-like (Samd9L), Ezh2, MLL3, and CUX1) have been identified and their myeloid tumor suppression potential has been verified using mouse models. Mice lacking one Samd9L gene developed MDS at an advanced age, whereas mice children harboring a gain-of-function mutation of Samd9 or Samd9L gene suffer from bone marrow failure, which is frequently followed by childhood MDS with -7, suggesting that these tumor-suppressor genes are the key to understanding not only MDS with -7 but also MDS in general. However, lack of Ezh2 and MLL3, which encode epigenetic regulators, contribute to the promotion of the progression of myeloid tumor cells that harbor abnormalities in the p53 or Ras pathways.

A ring-shaped ulcer was observed in the ileum of a 70-year-old male patient with capsule endoscopy of the small intestine performed for detailed investigation of black stools and iron deficiency anemia. Non-steroidal anti-inflammatory drugs (NSAIDs) use in patch form was considered as the etiology. The NSAIDs patches were discontinued, and protective therapy for small intestinal mucosa was initiated. The anemia improved;however, ileus originating from the site of the ulcer required surgical resection. The resected specimen showed no specific pathological findings. Based on the clinical findings, the patient was diagnosed with NSAIDs-induced small intestinal ulcer. The use of NSAIDs patches should be considered as a potential cause of injury to gastrointestinal mucosa.

A 61-year-old female was diagnosed with a lymphoid crisis of chronic myeloid leukemia (CML) in February 201X and started chemotherapy combined with dasatinib (DAS). After 1 month of initiating second consolidation therapy, the neutrophils decreased to 1%, bone marrow examination revealed large granular lymphocytes (LGL) at 13%, and complete cytogenetic remission was attained (CCyR). Suspecting DAS-induced agranulocytosis, DAS was discontinued. After 2 weeks, LGL disappeared and neutrophils recovered. In this case, CCyR was attained for the first time when LGL increased. We considered that the expansion of LGL correlated with the clinical efficacy, and agranulocytosis was an off-target effect of DAS.

A 74-year-old male who was receiving endocrine therapy for prostate cancer, with multiple bone and lymph node metastases (T2bN1M1 Stage D2), underwent follow-up computed tomography (CT). The CT revealed multiple liver metastases, a high serum CEA level, and an unchanged PSA level. Upper gastrointestinal endoscopy showed an elevated lesion with mucosal erosion on the lesser curvature of the middle gastric corpus, revealed to be a metastatic prostate cancer lesion following immunohistochemical confirmation. This case demonstrates the potential for gastric metastases in patients with advanced prostate cancer and high serum CEA levels.

HLA-Flow is a flow cytometry-based method using anti-HLA antibodies against mismatched HLA alleles combined with the antibodies against antigens expressed on leukemic cells. It is a sensitive assay to determine minimal residual disease (MRD) after HLA mismatched hematopoietic stem cell transplantation (HSCT). In this study, we report the results of our HLA-Flow using six-color based multicolor fluorescence-activated cell sorting for HLA-mismatched HSCT. We performed HLA-Flow monitoring after HLA mismatched HSCT from July 2013 to July 2016 in nine patients (three with acute lymphoblastic leukemia, five with acute myeloid leukemia, and one with therapy-related acute myeloid leukemia) for MRD monitoring. We detected a relapse after HSCT in three of the nine patients, two of them at MRD levels. HLA-Flow is a sensitive, fast, and inexpensive method for the detection of MRD in patients with HLA-mismatched HSCT.

A case conference of hematological malignancies based on the morphology of blood cells was held as a Joint Symposium of the Japanese Society of Laboratory Medicine and Japanese Society of Laboratory Hematology. This style of joint symposium was held four times from 2012 to 2016, whereas child cases were presented for the first time this year. The 4 cases presented in this symposium were as follows: an infant with Down syn- drome showing an atypical clinical course of transient abnormal myelopoiesis (TAM) and myeloid leukemia, a relatively older girl with juvenile myelomonocytic leukemia (JMML), one adult with acute myeloid leukemia (AML) with inv (16) (p13.1q22); CBFB-MYH11 morphologically resembling AML with t (8;21) (q22;q22.1); RUNX1-RUNX1T1, and one adult with high-grade B-cell lymphoma showing t (14;18) (q32;q21); IGH/BCL2. Each case included pathological and interesting morphological findings that were carefully examined and in- tensively discussed by two experienced commentators and participants, including pediatric hemato- pathologists. The importance of the morphological evaluation of characteristic cells such as immature leukemic blasts or lymphomatous ones was reconfirmed at this conference. In addition, immunological, cytogenetic, and molecular examinations were also essential for the final diagnosis of these cases. [Review].

Since 2013, the institutional review board (IRB) of Kyoto Prefectural University of Medicine has adopted an on-line application system for medical research protocols to shorten the term of examination. In the same year, research misconduct regarding valsartan (Diovan®) was disclosed, which prompted our institute to reorganize research ethics especially through the Center for Quality Assurance in Research and Development. Concerning the questions asked by Prof. Tohyama, the answers from the IRB of our institute were as fol- lows: 1) the evaluation of new instruments or reagents should be approved by the IRB if it may be exhibited at an academic meeting or published in a scientific journal, 2) non-invasive non-interventional data collection without prior approval would become a target of verbal warnings by the IRB, and 3) residual samples after laboratory examination could be available for research use if the protocol is explained to the patients with an opt-out guarantee. For research use of residual samples after laboratory examination, we have been able to issue a letter of consent for laboratory examination since 2008. However, unfortunately, this letter does not seem to be convenient for the majority of clinicians in our hospital. A more useful and reasonable method seems neces- sary to assist clinical research using residual samples based on Ethical Guidelines for Medical and Health Research Involving Human Subjects, which was newly published in 2015. [Review].

Microsemi LC-767CRP (LC-767, Horiba, Ltd.) is capable of simultaneous measuring of complete blood count (CBC) including 3-part differentials (3-part Diff.) of white blood cells (WBC) and C-reactive protein (CRP) in 4 minutes. Data obtained using LC-767 were intra-assay-reproducible (n = 10, CV = 0.6-4.0% for CBC, 0.6-2.5% for 3-part Diff. and 2.8-7.7% for CRP). They also showed the good linearity, no definite carry-over and the excellent correlations with routine instruments in our institution. Concerning CRP, the minimal detectable concentration revealed < 0.1 mg/dL, and prozone was observed in the sample containing > 30 mg/dL of CRP. LC-767 showed better correlation with a routine instrument in monocyte percentage than LC-667, probably due to modification of the hemolysis solution ratio and diluent temperature. In conclusion, LC-767 provided accurate CBC and CRP results, and showed improvement in CRP linearity and monocyte percentage compared with LC-667. LC-767, which is equipped with a bar-code reader with easy accessibility to electronic medical record, is suitable as the next-generation point of care testing model in the era of information and network-oriented medicine.

Industry-academia collaboration has become essential in contemporary medicine. Therefore, many institutes including university corporations have promoted the establishment of an endowed chair and/or performed collaborative research. This symposium was held to overview the present status of industry-academia collaboration in the clinical laboratory field. As a representative of the industry, Mr. Taniguchi (Sysmex) presented the development process of M2BP Glycosylation Isomer, a new marker for liver fibrosis. Mr. Saitoh (Horiba) introduced the achievements of joint collaborative research with Kyoto Prefectural University of Medicine, especially the practical realization of an automated hematology analyzer capable of simultaneously measuring C-reactive protein. Mr. Setoyama (LSI Medience) presented on the characteristic collaboration between academia and commercial laboratories such as Tsukuba Medical Laboratory of Education and Research (TMER). On the other hand, as a representative of academia, Associate Prof. Imai (Kyoto Prefectural University of Medicine) summarized the necessity of clinical laboratories spread regenerative medicine. Finally, Prof. Koshiba (Hyogo College of Medicine) presented on the industry-academia collaboration in routine laboratory work in his institute.

A 30s male was diagnosed as having the left testicular tumor in 2010. He received the anti-neoplastic chemotherapy, and could achieve the complete remission. But, he relapsed with solitary retroperitoneal lymph node swelling in 2012, and he was referred to our hospital. Laboratory examination on his admission showed the significant increase of fetal hemoglobin (HbF) up to 16.4%. But, neither anemia nor hemolysis was found at that time. Coexistence of therapy-related myeloid neoplasm or HbF production by metastatic lesion was not definite. Isoelectrofocusing of his hemolysate showed the faint HbA2 in addition to dense HbF band. Molecular analysis of his Hb gene revealed the homozygous (G)gamma-158 (C-T) together with homozygous delta-77(T-C). From these findings, he was diagnosed as having hereditary persistence of HbF (HPFH) and homozygous delta thalassemia. The precise incidence of such combined genetic variation has been unknown because the majority of such cases seem to show no significant clinical symptoms as our case. Whereas, it seems necessary to remind the possibility of such genetic variation when adult patients with various acquired diseases such as testicular tumor or hematologic malignancies show the elevated HbF level.

A 28-year-old pregnant woman presented with an abdominal mass at 12 weeks' gestation. Magnetic resonance imaging revealed a 7 cm cystic lesion arising extrinsically from the pancreatic head, which was diagnosed as a mucinous cystic neoplasm. Although we recommended surgical excision during the second trimester, the patient refused the procedure and chose to continue her pregnancy. We monitored the lesion and noted that it gradually grew to 13 cm over the course of the pregnancy. Subsequently, we enucleated it after childbirth. Histopathological examination was compatible with high-grade dysplasia and confirmed the diagnosis of mucinous cystadenoma of the pancreas.

A case conference of hematological malignancies based on the morphology of blood cells was held as a joint symposium of the Japanese Society of Laboratory Medicine and Japanese Society of Laboratory Hematology. Four cases were presented and discussed mainly from the viewpoint of cellular morphology: two cases of acute myeloid leukemia (AML) with myelodysplasia-related changes, one case of adult T-cell leukemia/lymphoma, and one case of chronic myelogenous leukemia in the blast phase. Each case included pathological and morphological findings that were carefully examined and intensively discussed by two experienced commentators and participants. The importance of the morphological evaluation of immature cells such as granular myeloblasts or promyelocytes was reconfirmed at this conference. In addition, immunological, cytogenetic, and molecular examinations were also essential for the final diagnosis of these cases.

Here we report two cases of dabigatran-induced esophageal ulcer. Case 1 was a 67-year-old man who presented with heartburn that developed a month after dabigatran administration. Case 2 was an 81-year-old woman who presented with epigastralgia that developed within a few days of dabigatran administration. Endoscopic findings were similar in both cases, including shallow esophageal ulcers covered with a thin whitish membrane. The patients were advised to consume the drug with plenty of water during meals and to remain in a sitting position for 30 min after consumption. This method successfully decreased their symptoms and ulcers, indicating that drug administration guidance is extremely effective in managing dabigatran-induced esophageal injury.

Non-steroidal anti-inflammatory drugs (NSAIDs) are roughly divided into a low-dose aspirin group used for primary and secondary prevention of cardiovascular events and non-aspirin NSAIDs used for treatment of bone and joint diseases. Both cause gastrointestinal damage directly or indirectly. In the present study, we reviewed gastrointestinal damage due to non-aspirin NSAIDs with respect to the esophagus, stomach/duodenum, small intestine and colon. Damage due to NSAIDs occurs in all digestive tracts and since the analgesic effect of NSIADs hides subjective symptoms, the symptoms are often not treated until they are advanced to a serious state. Further, patients receiving NSAIDs are mostly elderly and have complications so that the onset of the conditions is serious and prevention is important. It is necessary to investigate a method that is effective for preventing damage for all digestive tracts and the mechanisms of damage must be understood for this reason.

We collected the different volumes of venous blood(60 microL, 125 microL, 250 microL and 500 microL) into micro sample cups from respective volunteer to compare complete blood count (CBC) among 4 sample volumes, and found that 60 microL of sample volume seemed enough for CBC measurement using Microsemi LC-667 CRP (Horiba Co.). Subsequently, we measured CBC using 60 microL of peripheral blood after combining one of the 3 capillary tubes (heparin coated, EDTA coated and plain) with either EDTA coated or plain micro sample cups to examine the effect of anticoagulants contained into these commercially available maneuvers for capillary blood sampling. When we used the plain micro sample cup, platelet aggregation and false increase of white blood cell(WBC) count were observed irrespective to the combination of capillary tubes. We also tried whether commercially recommended volume (250 microL) of sample could be obtained by either fingertip or earlobe puncture from volunteers, and found that 7 of 16 fingertip and only 1 earlobe punctures could achieve sufficient volume. Whereas, at least 60 microL of sample were available more than 80% of volunteers by both methods, and CBC data obtained from these lesser samples obtained by fingertip puncture showed no statistically significant differences when compared with those of conventional venous samples (2 mL). From these findings, we concluded that at least 60 microL of capillary blood obtained from fingertip then collected into EDTA coated micro sample cup was enough to measure CBC using Microsemi LC-667 CRP.

Intense research after Hiroshima and Nagasaki atomic bomb (A-bomb) tragedy and Chernobyl nuclear plant accident revealed that ionizing radiation (IR) more than 100 mSv induces cancers that are indistinguishable from sporadic tumors. It remains controversial whether low dose IR (less than 100 mSv) is oncogenic or not. Among IR-induced malignancies, leukemia (A-bomb) and thyroid cancers (Chernobyl), in which chimeric(fusion) oncogenes formed by chromosome translocations play a critical role, develop with relatively short latency. All other cancers develop after long latency. Age-related epigenetic changes, as well as additional genetic alterations, would contribute to IR-induced carcinogenesis.

A 63-year-old man with Stage IVa pancreas tail cancer was admitted for a distal pancreatectomy and splenectomy; adjuvant chemotherapy with gemcitabine was also administered. The chemotherapy was terminated after 16 courses due to hemolytic anemia, thrombocytopenia and renal dysfunction. Plasma exchange was performed; however the patient's renal function was diminished, requiring chronic hemodialysis. Physicians should be cautious of hemolytic uremic syndrome as a possible adverse reaction to gemcitabine and be aware that tests are needed for its early detection.

We examined the basic performance of "Microsemi LC-667CRP" (LC-667, HORIBA, Ltd.) which has been newly developed as compact laboratory instrument capable of simultaneous measuring of complete blood count (CBC) including 3-part differentials of white blood cells (WBC) and C-reactive protein (CRP) using whole blood anticoagulated with ethylenediaminetetraacetic acid (EDTA). We found that CBC and CRP were intra-assay-reproducible (n = 10, CVs < 5.0%). They also showed the good linearity and no definite carry-over. Concerning the WBC differentials, percentage of monocytes (MON%) showed less intra-assay reproducibility compared with those of granulocytes (GRA%) and lymphocytes (LYM%). We also evaluated the correlation of values obtained by LC-667 and routinely used instruments in our institute. Concerning the CBC and WBC differentials, excellent correlations were found between LC-667CRP and XE-2100 (SYSMEX CORPORATION) except MON%. In addition, whole blood CRP as well as plasma and serum CRP measured by LC-667 also showed the good correlations with serum CRP measured by 7600 (Hitachi High Technologies Corporation). From these findings, LC-667 was revealed to produce the clinically reliable data using only 18 microL of sample volume in 4 minutes. Point of care testing (POCT) has been developed as the laboratory system performed at or near the site of patient to reduce the turn around time. Therefore, LC-667 seemed useful in POCT for the patients with acute inflammatory disease especially in pediatrics.

Polysomnography (PSG) has been the gold standard for the diagnosis of sleep apnea syndrome (SAS). However, PSG is not generally available since it is technically demanding, and cost and labour are necessary. Currently, there is growing demand for its diagnosis. Thus, simplified portable equipments have been increasingly utilized. Sleeprecorder SD-101 (Suzuken, Nagoya, Japan) is a pad-shaped and novel device for SAS analysis. A total of 162 sitting-sensor tips are 1.6 inch apart, embeded in the 55 x 22 inch pad, and capable of detecting load with precision of one gram. Sleeprecorder SD-101 placed beneath the chest can recognize respiratory pattern and record thoracic movement during sleep. SASLyzer (Suzuken, Nagoya, Japan), a software installed in a compatible PC, analyzes the data and indicates apnea-hypopnea index (AHI). We present a case of SAS in a 40-year-old man (181 cm, 98 kg) with peritonsillitis. We used Sleeprecorder SD-101 since he complained of severe snoring and excessive daytime sleepiness. He had severe SAS with AHI 50.7. Subsequently, conventional PSG also indicated AHI 77. In the present case with severe SAS, these two methods showed equivalent severity. Sleeprecorder SD-101 could be a useful device for screening of SAS patients.

Radiation induced acute myeloid leukemia (AML) was recognized a century ago, soon after mankind found radiation. Atomic bomb survivors developed de novo AML with relatively short latency with very high frequency. By contrast, excess occurrence of myelodysplastic syndrome (MDS) as well as solid tumors was found decades late. This difference may be due to etiology that many de novo AML patients harbor chimeric leukemogenic genes caused by chromosomal translocations, while MDS patients rarely carry chimeras. In addition, epigenetic change would play important roles. Therapy related leukemia is mainly caused by topoisomerase II inhibitors that cause de novo AML with an 11q23 translocation or by alkyrating agents that induce MDS/AML with an AML1 point mutation and monosomy 7.

With the increase in breast cancer patients in Japan, therapy for breast cancer has progressed with evidence-based medicine (EBM), and most of it has shifted to outpatient clinics (OPC) except for surgery. With the specialization of surgical techniques and pharmacological treatments, i. e. sentinel node biopsy and advanced medical treatment, many patients now visit specialized cancer clinics, and the congestion has resulted in difficulty in follow-up after surgery, and the reconsideration of how to follow-up is under way. Although the clinical guideline issued by the Japanese Breast Cancer Society recommends performing a careful history, physical examination and annual mammography, each clinic has its own follow-up program with additional modalities different approaches in EBM. Here we investigate the recommendations of the clinical guideline, how they discuss evidence, and we attempt to pinpoint the problems when used at the daily clinical level while considering the characteristics of current breast cancer practice. Then, we considered the specific characteristics of breast cancer revealed by meta-analyses, the effect of long-term adjuvant endocrine therapy after surgery, and reflecting the patient's intent in follow-up in order to conduct an ideal follow-up with a view to cooperation between cancer specialized hospitals and community clinics.

We report a 27-year-old woman who underwent off-pump coronary artery bypass grafting (OPCAB) for angina pectoris with coronary artery aneurysm due to Kawasaki disease. At the age of 3, she was diagnosed as Kawasaki disease with coronary artery aneurysms in the right coronary artery and the left anterior descending artery. She was medically followed-up since then Because an enlarged aneurysm and a stenotic lesion were recognized in the right coronary artery, operation was indicated. In operation, the right coronary artery was ligated at the inflow and the outflow of the aneurysm. OPCAB was also conducted with the right internal thoracic artery anastomosed to the right coronary artery. Postoperative course was uneventful, and she was discharged at the day 5 after operation. Revascularization using arterial grafts, especially the internal thoracic arteries, may be the choice for young patients to expect a good patency rate in the long-term.

We examined 51 patients treated with Capecitabine for metastatic breast cancer. 51 patients achieved a 30.8% response rate, 59.6% a clinical benefit rate(59.6%)and 7.2 M of time to disease progression, as previously reported. Capecitabine therapy, single agent or combination therapy, should be considered a treatment of choice for metastatic breast cancer with certain response and general tolerability.

In an attempt to assist the clinical physicians at the outpatient clinics in Kyoto Prefectural University Hospital, we opened the laboratory consultation office in January 2005. This office is staffed by one medical technologist from 9 am to 4 pm on weekdays. The technologist shows the laboratory examination result of respective patient, and then explains the significance of reference interval using the personal computer. Additional explanation such about the mechanism of abnormal result or the general interpretation of diagnostic tests is also performed according to the patients' demands. Whereas, as the major premise, the consulting technologist never comments to the patients on the clinical relevance between their laboratory results and their own disease courses. Until March 2006, 1,430 outpatients have visited the office in total, resulting in 6.1 patients/day as mean value. Almost all of the visitors (97.9%) wanted to listen to the meaning of liver function test, which was followed by renal function test (95.3%). Consulting time required for respective patient has been quite variable from 10 to 120 minutes (30 minutes/patient as mean). The questionnaire survey after consultation revealed that all of the visitors felt satisfactory for consultation, and wanted to revisit to our laboratory consultation office. We believe that the laboratory consultation office contributes as a new medical service of our hospital to outpatients.

To understand the role of the clinical laboratory in the era of mandatory postgraduate medical training, I carried out a questionnaire survey in April 2005 among both university hospitals and clinical teaching hospitals located in the Kinki area. As a result, eleven (84.6%) of the 13 responding laboratories participated in clinical laboratory medical education with an obligatory training program (5 laboratories), with an elective program (3 labs) or both (3 labs). Among the 8 laboratories with an obligatory program, educational lecture subjects included reversed clinicopathological conference (7 labs), blood transfusion (4 labs), laboratory microbiology (4 labs), and blood gas analysis (BGA) (3 labs). On the other hand, in the elective training programs among 6 laboratories, laboratory microbiology including infection control was most frequently held (4 labs) followed by blood transfusion, laboratory hematology and urinalysis (3 labs respectively). Concerning 4 areas, namely, blood transfusion, 12-lead electrocardiography at rest, BGA and ultrasonography, which have been defined as obligatory laboratory techniques for all trainees in mandatory postgraduate medical training, the majority (84.6%) of the responders in this survey replied that they were not sufficient, whereas, Gram's staining was most frequently (69.2%) recommended as an additional obligatory technique in mandatory postgraduate medical training.

A 48-year-old man was referred to our hospital because of anemia. Upper gastrointestinal endoscopy showed discolored depressive lesion like gastric cancer, 30mm in diameter, in the greater curvature of the upper gastric body. During the endoscopic examination, pulsative bleeding from the lesion was occurred and we performed clipping hemostasis. We diagnosed a gastric arteriovenous malformation by endoscopic ultrasonograph and angiography. A pylorus preserving-gastrectomy was performed and Pathohistological examination revealed arterio-venous connection in the submucosal layer of the gastric wall.

We evaluated the usefulness of fusion vaccine prepared from IL-2-gene-transduced splenic dendritic cells (DCs) and fibrosarcoma tumor cells (QRsP) in treating of lung metastasis. The IL-2 or LacZ gene was transferred into spleen-derived DCs using an adenoviral vector. Irradiated QRsP tumor cells were fused with IL-2 gene transduced DCs (fusion/IL-2) or LacZ gene transduced DCs (fusion/LacZ) by polyethyleneglycol. These fusion cells expressed major histocompatibility complex (MHC) class I and MHC class II, CD86, CD11c and CD8alpha. IFN-gamma and cytotoxic T lymphocyte (CTL) activity of splenic lymphocytes in mice vaccinated with fusion cells increased significantly as compared with those of DC or tumor cells vaccinated mice. CTL levels in fusion/IL-2-vaccinated mice were higher than that in fusion/LacZ-vaccinated mice. The number of lung metastasis in the fusion/IL-2 or fusion/LacZ-vaccineatd mice was significantly lower than that in mice vaccinated with DCs, tumor or PBS. The introduction of the IL-2 gene into fusion cells produced more potent therapeutic effects. Our results suggest that the fusion cells prepared from IL-2 gene transduced spleen derived DCs and tumor cells have the ability to induce therapeutic effect against lung metastasis.

For the prevention of perioperative nosocomial infection, 1) topical mupirocin treatment, 2) tight perioperative glycemic control and 3) immunonutrition are described. A large, prospective, randomized trial showed that the nasal application of mupirocin may effectively reduce postoperative Staphylococcus aureus nosocomial infection in the subgroup of patients who had S. aureus in their nares. Tight glycemic control after surgery, especially in the early period after operation, may also be effective in decreasing postoperative infection. In septic ICU patients, strict glycemic control even reduces ICU and hospital mortality rates. Several specific nutritional substrates such as arginine, omega-3 fatty acids, glutamine, and RNA have been shown to modulate host immune function. Some enteral formulas enriched with such immunonutrients have been commercially available in the USA and in Europe and are now available in Japan. Recent meta-analyses of randomized, controlled trials have shown that the administration of these formulas to elective surgical patients results in a significant reduction in the risk of developing infectious complications by approximately 50% and shortens the overall hospital stay.

Immunotherapy with tumor-dendritic cells (DC) fusion vaccine has been shown to induce an immune response against multiple tumor antigens including unknown tumor antigens. In this study, we examined immunological changes by tumor-DC fusion vaccine. Nine patients with advanced or recurrent gastrointestinal cancer that was unresponsive to standard surgical therapy and chemotherapy were enrolled in this study after informed consent was obtained. Monocytes were separated from the peripheral blood collected by leukapheresis, and were cultured with GM-CSF and IL-4 for 6 days. Then, TNF-alpha, IL-1beta, IL-6 and PGE2 were added for maturation of DC. Fusion of irradiated tumor cells and DC was created by polyethylene glycol and electroporation. The fusion vaccine was injected subcutaneously into the inguinal region four times every two weeks. There were no adverse effects or autoimmune responses after vaccination in any patients. The clinical response was stable in five patients, and disease progression in four patients. Delayed skin tests changed to positive in six of the nine patients after vaccination. IAP levels decreased in five patients and TGF-beta levels decreased in six patients. Th1/Th2 and Tc1/Tc2 balances improved in six of the nine patients after vaccination. In this study, it was shown that immunosuppressive factors, such as IAP and TGF-beta, and Th1 balance are useful as markers of immunomonitoring for tumor-DC fusion vaccine in patients with advanced or recurrent gastrointestinal patients.

We encountered a patient in whom TS-1/cisplatin (CDDP) combination chemotherapy was effective. The cancer became operable, and complete disappearance of liver metastasis was histopathologically confirmed. The patient was a 65-year-old man who presented with complaints of epigastric discomfort and anorexia. Based on upper GI endoscopy and abdominal CT, type 1 gastric cancer associated with liver and abdominal lymph node metastases was diagnosed. The cancer was judged to be inoperable, and chemotherapy with a combination of TS-1 and CDDP was initiated. One course of treatment consisted of administration of 120 mg/day of TS-1 for 21 days followed by 14 days of withdrawal, and administration of 100 mg/body/day of CDDP on day 8 (80 mg/body/day in the second course). After two courses of treatment, the primary lesion and the liver and lymph node metastatic lesions decreased in size (reduction ratios were 42.3%, 90.5% and 85.2%, respectively). The tumor marker values became normal. Subsequently, the cancer was judged to have become operable. After consultation with the patient, total gastrectomy, splenectomy, partial hepatectomy, and D3 dissection were performed, and curability B was achieved. The only adverse event of Grade 2 or more severity observed during drug administration was anorexia. Liver metastasis was judged from pathological findings to have disappeared. The postoperative course was uneventful and the patient was discharged from the hospital. To date, there have been no signs of recurrence. TS-1/CDDP therapy is believed to provide effective treatment against liver metastasis and lymph node metastasis of gastric cancer.

We treated seven refractory or relapsed myeloma patients resistant to conventional chemotherapy with thalidomide. We started thalidomide at 100 mg daily and the dose was increased up to 300 mg if the patient could tolerate it. The patients were evaluated at four weeks and 12 mg of dexamethasone was added for four days when the patient failed to respond to thalidomide treatment. One patient was excluded from the study because of general fatigue. Two of the six patients responded to thalidomide alone and three of the remaining four patients responded to the combination with dexamethasone. The most common adverse effect was sleepiness which was seen in three patients. Two patients showed pancytopenia (Grade 3), constipation and skin eruption. Of the six patients four needed reduction of the thalidomide dose to 200 mg because of adverse effects. Plasma levels of TNF-alpha, IL-6, bFGF and VEGF were measured before and after four weeks. High plasma bFGF levels were seen in responding patients. In conclusion, treatment with thalidomide alone or in combination with dexamethasone is feasible and effective in refractory or relapsed myeloma patients. Further study is required to clarify the role of thalidomide in the therapeutic strategy for multiple myeloma.

We report a patient with myelodysplastic syndrome (MDS) overt leukemia who developed an acute myeloid leukemia (AML) in donor cells shortly after bone marrow transplantation (BMT) from his HLA-matched sibling. Molecular analysis using microsatellite repeats by polymerase chain reaction proved the new leukemia to be of donor cell origin. The patient received chemotherapy with idarubicin and ara-C, but he died due to mucormycosis.