I am very proud to follow in the footsteps of our most immediate past Presidents, Jeff Kant, Peggy Gulley, and Cheryl Willman, all of whom are continuing to work actively on behalf of AMP in various capacities. Due to their leadership, we are entering our fourth year as a society in strong shape, a 10% increase in membership over last year, and with an ambitious agenda of new goals. In addition to the contributions of our Past-Presidents, our success is in large part due to the efforts of our out-going Council members Rick Press and Carlton Garrett and our out-going Chairs of the scientific Subdivisions Bob Jenkins, Tim O'Leary, Roberta Madej and Tom Frank. And of course, the efforts of our Executive Officer Fran Pitlick and of Maricel Herrera have been indispensable. In addition to the chairs and council members, the society would not be successful without the hard work of the many volunteers who have been members of AMP’s committees.

1999 promises to be an exciting year for AMP. The Council, Chairs of Subdivisions, and committee members will be working on the following major initiatives in 1999 to promote clinical practice, basic research, and education in molecular pathology:

1. The Journal of Molecular Diagnostics. AMP, in conjunction with the American Society for Investigative Pathology (ASIP), is launching a companion journal to The American Journal of Pathology (AJP). The new journal should provide a venue for the publication of scientific articles from the rapidly growing field of molecular pathology. The two societies have agreed that the name of the journal will be The Journal of Molecular Diagnostics, American Journal of Pathology Part B. Joint committees of ASIP and AMP members are working on oversight of the new companion journal to AJP and the selection of a senior editor. We are very fortunate that AMP is represented by past Presidents Jeff Kant, Peggy Gulley, and Cheryl Willman, as well as by Dan Farkas and Wayne Grody. Our goal is to put out the first issue in time for the 1999 annual meeting, or by the beginning of 2000.

2. Opportunities for our associate members. Jeff Kant and Peggy Gulley have been working to provide more opportunities for our members-in-training to attend and participate in the Annual Meeting. We hope that you will make a contribution to the Training and Education Fund to sustain that effort.

3. Regulatory and certification issues. We have several initiatives to represent the interests of AMP members. The creation and approval of a new joint specialty of Molecular Genetics/Pathology under the auspices of the American Board of Pathology and the American Board of Medical Genetics has been a major goal of AMP. In addition, AMP continues to support certification opportunities for our members through the ABB and NCA. In addition, AMP members are active on committees of CAP, ASIP, ASCP, NCCLS, and AACC that are interfacing with national and state agencies and legislative staffs and AMP will continue to represent the interests of the molecular pathology community. For example, our new President-elect, Debra Leonard, will be working with our new Chair of Clinical Practice, Wayne Grody, to address patenting and exclusive licensing of "disease genes".

4. Communication. We have been fortunate that Jeff Kant and Tony Killeen have been respectively supervising our listserve (CHAMP) and our homepage since their inception. This year, Dan Farkas will be leading an effort to upgrade the homepage and make it more interactive. Dan is also our tireless editor of the newsletter, which helps keep the membership aware of the scientific activities of our members.

5. Annual Meeting. AMP started out as a group of molecular pathologists who regularly attended Molecular Diagnostic Workshops sponsored by UAREP in the mid-90s. We recognized the need to formalize our interactions as a result of the success of those meetings. The AMP annual meeting is thus essential to our raison d’être. We have been very fortunate that our previous meetings, under the leadership of Tony Killeen, Rita Braziel, and Carlton Garrett, have been so successful, and Karl Voelkerding is already hard at work with the Program Committee to make 1999's meeting as outstanding as the previous ones. We are committed to scientific excellence and to providing a means for the collegial networking of our members. We look forward to seeing you in St. Louis in November!

In closing, I want to encourage all our members to volunteer to work toward our common goals and to let the AMP leadership know of new initiatives that you feel would improve our discipline. We, and the AMP Executive Office, are here to meet your needs, and we will continue to work on your behalf to the fullest extent.

AMP membership dues support a variety of efforts, including production of the membership directory and the test directory, support of the CHAMP list serve, support of the annual meeting, and AMP committee activities to ensure that molecular pathologists are represented in important national and state discussions. As a new benefit, AMP, in conjunction with the American Society for Investigative Pathology (ASIP), is launching the The Journal of Molecular Diagnostics, a companion journal to The American Journal of Pathology (AJP) by the year 2000. Your subscription to the The Journal of Molecular Diagnostics will be supported by your dues.

The AMP Council has established a revised dues billing schedule to accommodate those members who join after the start of the calendar year and in anticipation of the mailing of quarterly issues of the new journal. For membership in 1999, we have established two membership start dates: January 1 and July 1. If you were a member of AMP in 1998, you will automatically (with a few exceptions-see below) be in the January 1 membership cycle. The final date for receipt of your dues this year is March 31. If your dues are not received by this date, there will not be enough time to include you in the 1999 membership directory and your other benefits (including the CHAMP listserve) will be discontinued. Exceptions to this deadline are for those members who joined late in 1998; they will be included in the July 1 membership cycle. If you are in the exception category, you will be receiving a letter from the AMP office to confirm that status by March 1.

New members who join before March 31, 1999 will be included in the January membership cycle and will receive full benefits for 1999. For new members who join after March 31, your benefits as an AMP member will begin immediately upon receipt of your dues but you will be part of the July 1 membership cycle in future years and we will be unable to provide back benefits, e.g., inclusion in the membership directory, etc.

To increase the efficiency of the AMP office, please note that in future years, dues notices will be sent out in late summer for the January membership cycle, and the final deadline for receipt of dues without discontinuation of member benefits will be Jan. 10. Notices for the July membership cycle will be sent out in the winter, with a final deadline of July 10 for receipt of dues without discontinuation of member benefits. These stricter deadlines are made necessary by the cost of mailing quarterly issues of the new journal to AMP members.

We thank you in advance for your understanding and cooperation.

The Program Committee is working to develop the 1999 AMP annual meeting to be held in St. Louis, Nov. 4-7, with Nov. 4 reserved for corporate sponsored workshops. For the Plenary Sessions, preliminary topic areas for the Genetics subdivision include phamacogenomics and the genetics of obesity. For Hemepath, presentations on chromosomal translocations in acute leukemias and apoptosis in lymphomas are anticipated. The Infectious Disease subdivision will focus on molecular epidemiology and drug resistance. Solid Tumors presentations on BRCA1 and 2 in breast and ovarian cancers and prostate cancer genetics are planned. In addition to identification & recruitment of plenary speakers, subdivision chairs and chairs-elect are defining workshops that will integrate contemporary research findings with practical issues in molecular diagnostic testing. For the Genetics workshops, problem solving in unusual Fragile X cases [ED. NOTE: especially useful in light of recent CAP proficiency survey results] and cystic fibrosis will be addressed. Advances in understanding spinal muscular atrophy (SMA) and approaches to molecular testing of SMA will be presented. Hemepath Workshops will focus on further development of sample exchanges and results of proficiency testing and methods for detecting apoptosis in hematologic malignancies. Infectious Disease workshops will address aspects of sample preparation, comparison of laboratory protocols and approaches to internal controls. For the Solid Tumor workshops, approaches for mutation detection in the RET proto-oncogene and cell cycle genes will be presented. Taken together, the ‘99 meeting promises to be both diverse and informative and we look forward to your attendance.

As the new chair of the Clinical Practice Committee, I am continually impressed by its pivotal involvement in so many matters of crucial import to all AMP members connected with laboratories delivering patient care services. In this vein, I want to start out by noting my tremendous respect for the hard work of last year’s Committee members (Rita Braziel, Andrea Ferreira-Gonzalez, Rick Nolte, Linda Wasserman) and especially the past-chair, Rick Press, for helping make the transition so seamless and offering to stay on board in an ad hoc capacity to lend his seasoned experience to the continued progress on these issues. The new and continuing members of the Clinical Practice Committee for 1998 are:

UCLA School of Medicine

By now all AMP members should have received the new 1998 edition of the AMP Test Directory. Much more comprehensive, standardized and organized than the previous version, it represents a Herculean effort by last year’s Committee and Fran Pitlick in compiling the data and putting it together in such an attractive and user-friendly format. The finished product is a unique and valuable resource to both lab directors and the general medical community, one not duplicated to my knowledge by any other professional organization. The closest thing to it in existence is the web-based HELIX directory (http://healthlinks.washington.edu/helix/) of genetic tests, but that one focuses primarily on genetic disorders, whereas ours covers the entire spectrum of molecular diagnostics. As discussed by Rick Press in previous Newsletters, the next step being addressed by the Committee and the AMP Council is to bring the Directory on-line through the AMP web site. Aspects still under discussion are the resources required to develop such a web resource, the type of restrictions and protections that would be appropriate for access to it, and whether or not it would be in our interest to link it to existing on-line directories such as HELIX. If any AMP members have strong feelings about these questions, please convey them to the Committee.

Most AMP members have been able to follow through CHAMP and at a special session of last year’s national meeting the organization’s efforts in combating overly restrictive, financially burdensome or exclusive patent licensing arrangements for particular genes and molecular tests. Much of this was sparked by the exclusive license for hereditary hemochromatosis HFE gene testing now owned by SmithKline Beecham, but in fact there are several other existing or pending examples that one could mention. The workshop on this issue put together for the Crystal City meeting by Debra Leonard was especially timely, as it gave us the chance to present these concerns to the meeting’s keynote speaker, Dr. Francis Collins, who, as director of the National Human Genome Research Institute, was able to transmit our position to other offices of NIH and the federal government. That professional input can be effective on this issue was made clear last year when a consortium of organizations, including the College of American Pathologists (CAP), the American College of Medical Genetics (ACMG), and Kaiser Permanente, was successful in reversing onerous licensing restrictions on prenatal hCG screening. The Clinical Practice Committee continues to monitor developments in this area and would like to hear from any AMP member who becomes aware of new threats in the marketplace.

As most members are aware, the FDA’s new regulations for tests utilizing analyte-specific reagents (ASRs) went into effect Nov. 23, 1998. ASRs include such products as monoclonal antibodies, DNA probes and PCR primers that are incorporated as key components in non-FDA-approved "home brew" tests. The new rule requires that the result reports of such tests include specific disclaimer language about the use of the ASR and its non-approved status. From informal conversations at the AMP meeting and many phone calls and e-mails since, it has become apparent that a great deal of confusion exists regarding how to comply with this rule. Strictly speaking, the disclaimer applies only to reagents that are explicitly labeled as ASRs by the manufacturer, a practice that has not really begun yet. The ACMG has recommended in a mailing to its members, and the Clinical Practice Committee agrees, that it would be prudent for laboratories to begin incorporating some version of the disclaimer into all their reports for home brew tests, even in the absence of specific ASR labeling by probe and primer manufacturers.

As to the specific language, under the new regulations, laboratories reporting the results of clinical diagnostic tests utilizing reagents labeled as ASRs are now required to include in their test report that "This test was developed and its performance characteristics determined by [laboratory name]. It has not been cleared or approved by the U.S. Food and Drug Administration." Although this disclaimer is now mandatory, the FDA has agreed to allow additional clarifying statements explaining (1) that ASR use does not require FDA approval, (2) that the ASR-containing test can be used for clinical purposes, (3) that the laboratory has established and verified the test’s analytical performance characteristics, and (4) that the laboratory is certified under CLIA to perform high-complexity clinical testing.

As presented in these pages before [AMP Newsletter, May 1998; go to Newsletters at http://zapruder.path.med.umich.edu/users/AMP]the new and revised set of molecular diagnostics CPT codes for test billing are now in effect, having appeared in the 1999 edition of the AMA CPT Code Manual. Laboratories are now in the process of converting their test coding structure to the new codes, though not without some confusion. The main things to remember are to use the simplest and most direct choice of codes to describe the procedural steps of each test, while recognizing that individual codes can and should be used multiple times if a test is comprised of duplicative steps such as digestion of patient DNA with several different restriction enzymes or probing with several different allele-specific oligonucleotides. Most third-party payers allow a grace period of two to four months before requiring the new codes for reimbursement.

Of even greater importance, the Health Care Financing Administration (HCFA) will soon be evaluating and setting reimbursement levels for the new codes. In support of this process, AMP has sent a cost survey to all members, similar to the one sent by ACMG to its members, soliciting a realistic cost analysis for the major molecular pathology tests. It is crucial that all member laboratories return this completed survey as soon as possible, providing a full estimate of the entirety of our costs, including indirect costs. This information will then be forwarded to HCFA. This is our one chance to achieve reasonable reimbursement levels for these complex and labor-intensive tests, in contrast to the laughably low levels that were set for the old codes. The importance of this process to the very existence of our specialty goes without saying.

The Hematopathology Plenary session and workshops at the recent Crystal City meeting were well received. Two excellent and in-depth presentations were made at the plenary session, by Cheryl Willman who spoke on the topic of minimal residual disease, and Jerry Shay who spoke on telomerase. One of the workshops, based on the sample exchange program. was attended by all participants. The other workshop was more informal, as the participants broke down into small groups to compare notes on the best methods to assess the t(9;22), t(11;14) and t(2;5).

At this time, the next Hematopathology Plenary session is planned for Friday morning, November 5, 1999. Two general areas are being considered for the session, one focusing on chromosomal translocations in acute leukemias, and the other focusing on apoptosis in malignant lymphomas. Two speakers have been identified, but have not yet been formally invited. Any comments regarding these plans are welcome (see e-mail address below).

The Workshop topics are also being worked out at this time. Preliminary ideas for two workshops include one on apoptosis, including a discussion of different methods to assess apoptosis and the potential role of apoptosis assays in clinical medicine. The second workshop is likely to be based on the ongoing sample exchange program begun a year ago. However, we are at an even earlier stage in the planning of the workshops and any suggestions from others regarding what workshop topics the hematopathology audience would like to see will be appreciated.

The sample exchange program continues and many thanks to all of those involved. In particular, thanks to Tim O’Leary and colleagues at the Armed Forces Institute of Pathology for their recent efforts. They are planning to send out unknown samples for round #2 of the immunoglobulin and T-cell receptor gene rearrangement sample exchange very shortly.

The 1998 AMP Meeting was a great success! Thank you to all of the speakers and participants in the Infectious Diseases Plenary and Workshop Sessions who contributed so much to the meeting. In the plenary session focussing on infectious agents causing cancer, Elizabeth Unger and Jan Nowak updated us on human papillomavirus and Helicobacter pylori, respectively. The first ID workshop focussed on various outcomes studies involving molecular analysis. John Ticehurst presented his work on the molecular detection of herpes and enteroviruses, and how more rapid detection might impact on management of patients with meningitis. Rob Lloyd of Visible Genetics gave us a fascinating look at the use of HIV genotyping to tailor HIV treatment combinations, using actual patient examples. Karen Kaul reviewed her studies demonstrating potentially significant savings in the cost of caring for patients admitted with a diagnosis of tuberculosis resulting from the use of molecular detection assays. The second workshop addressed development and validation of new assays, both commercial and in-house. Rick Hodinka shared his experience and approach in the development of in-house PCR assays, including enterovirus. Andrea Ferreira-Gonzalez presented an excellent summary of her validation of CMV and HCV assays. Lynette Sawyer from Chiron both educated and amazed us with the involved validation studies that laboratories should be performing prior to bringing any quantitative viral load assays on line. Additionally, the poster sessions on Friday and Saturday included 19 abstracts in the infectious disease section.

Planning is well underway for the 1999 AMP Meeting. The plenary session will have an epidemiology/public health theme, and speaker recruitment is in its final stages. At this point, the workshops are likely to be focused on 1) methods in sample preparation, and 2) "why we do what we do" in our labs. The latter workshop will revolve around the results of a questionnaire to be sent out later this year querying you all on your lab practices, and it is hoped that a lively discussion will develop!

To update you on a few other topics:

The European Concerted Action Quality Assurance group will move forward on proficiency panels for "Blood Borne Viruses" (HIV, HCV and HBV) this year. Roberta Madej has been keeping us updated on the activities of this group. A proficiency panel for enterovirus has already been distributed. Further information can be obtained from the group at qcca@man.ac.uk.

Those of you performing HIV viral load testing now have two commercial sources of controls. BioClinical Partners, Inc., is supplying a 5 specimen reference panel containing varying amounts of HIV 1 RNA. Boston Biomedica, Inc., offers a variety of single value quantitative samples, as well as a six-member graded panel. Both may be useful to labs looking for a source of quantitative standards for test validation and quality control purposes.

Several AMP members are hard at work on a draft for NCCLS guidelines on "Quantitative Molecular Methods for Infectious Diseases". The group, chaired by Roberta Madej, includes Angela Caliendo, Steve Day, Andrea Ferriera-Gonzales, Rick Nolte, and others.

As all of you who attended the Crystal City Meeting recall, this was a very dense and informative meeting (which made us forget the relative physical isolation of the convention hotel). In the Solid Tumor subdivision, we were fortunate to have an excellent plenary talk by Fred Barr on translocations in sarcomas. Sean Lee then gave us an in-depth presentation of the work that he has carried out with Dan Haber on the WT1 tumor suppressor gene. He was kind enough to substitute for Dan who had a serious scheduling conflict (his wedding!). The first solid tumor workshop was moderated by Syd Finkelstein and Ron Przygodzki, and dealt with p53 analysis. Perhaps not unexpectedly for such a huge topic, there was unfortunately insufficient time for the two speakers to finish their excellent presentations.

The second Solid Tumor Workshop was on gene amplification, and was moderated by yours truly with the help of Irene Andrulis from Mt. Sinai Hospital in Toronto. We hope that the attendees found it useful. As the new Solid Tumor Subdivision Chair, I would like to thank the outgoing Solid Tumor Chair, Tom Frank, for his outstanding efforts in organizing the 1998 meeting. As the 1998 Chair-elect, it was a learning experience for me to work with him in the program planning. This year, with the help of the new 1999 Solid Tumor Subdivision Chair-elect, Carlos Cordon-Cardo, I am preparing what I hope will be a program of broad interest in solid tumors, focusing on breast cancer, ovarian cancer, prostate cancer, as well as thyroid cancer. More details to follow.

By the way, due to our membership’s outstanding performance in hotel fire drills, the Program Committee has decided to skip this event at the St. Louis meeting in 1999.

Peutz-Jeghers syndrome (MIM 1752000) is a well-known autosomal dominant condition characterized by oral and digital melanocytic macules and gastrointestinal hamartomatous polyposis particularly in the jejunum with a predisposition to a variety of intestinal and extraintestinal cancers. Recent work has determined that LKB1 (or STK11), a ubiquitously expressed serine/threonine protein kinase on chromosome 19p13.3 is mutated in most cases. The LKB1 gene consists of 10 exons spanning 23 kb producing a 1.3 kb transcript. Mutations appear to be isolated to individual families and primarily consist of nonsense misense point mutations and some splice mutations and deletions. These result in loss of autophosphorylation. Biallelic loss of function has been demonstrated in tumors, the first example of kinase inactivation, rather than activation, leading to cancer susceptibility. However, locus heterogeneity is likely since cases in which an LKB1 mutation could not be detected, show linkage to a second site at chromosome 19p13.4.

One in one thousand infants is born with impaired hearing; the frequency increases with age. Both environmental and genetic factors contribute to deafness which can be due to conductive (outer or middle ear) or sensorineuronal (cochlea) abnormalities, and can be classified as syndromic or non-syndromic. 2% of non-syndromic deafness is X-linked (DFN, 7 loci),13% autosomal dominant (DFNA, 18 loci) and 85% autosomal recessive (DFNB, 20 loci). 47 loci have been mapped and 9 genes identified so far.

About half the individuals with recessive sensorineural deafness (and occasionally dominant, progressive hearing loss) have been found to have mutations in the connexin-26 gene (GJB2). A single mutation, 35delG, has been found to account for 85% of GJB2 mutations; one on 31 members of the general population carry 35delG.

Connexin molecules form connexons which pair with other connexons on neighboring cells to form gap junction channels that allow small molecules such as ions and small metabolites, to pass between them. The connexin nomenclature reflects the predicted molecular mass of the protein. The connexin-26 connexons are thought to be involved in the rapid potassium ion recycling required by sensory cells in the cochlea which are interconnected via gap junctions formed by connexons containing connexin-26. There are more than 11 different types of connexins, mutations in the connexin-32 (GJB1) gene can cause X-linked Charcot-Marie-Tooth disease/neuropathy, mutations in the connexin-43 gene can cause heart malformation and heterotaxia, while mutations in the connexin-50 gene can cause cataract. Very recently mutations in the connexin-31 gene (GJB3) have can result in the dominantly inherited skin abnormality, erythokeratodermia variabilis (3 mutations in the domain involved in affecting voltage gating activity) or in progressive, dominantly inherited hearing loss (2 mutations in the domain involved in regulating the specificity of the connexon-connexon interaction).

At the AMP annual meeting last November, a new session titled "Selected Technical Topics" was offered. At this session, three topics were presented: "Sample Handling, Preparation, Extraction" by Kent Williams from St. Jude Children’s Research Hospital, "PCR: Quality Control and Troubleshooting" by Barbara Griffith from Tricore Reference Laboratories (formerly University of New Mexico Health Science Center), and "DNA Probe Labeling and Hybridization for Southern Blotting" by David Olson from Fairview-University Medical Center (formerly University of Minnesota Medical Center). For each topic, there was a detailed handout that was intended to be a good source for reviewing for the NCA Molecular Biology Certification exam and an overview was discussed from the presenters experience in their own laboratories. Although it was intended to have more audience participation in the discussions, time was very limited.

This year, plans are beginning made for a similar type of session. However this time, the session will include more time for audience participation. If anyone has a topic they would like to have considered and/or are willing to participate in presenting, please rush to your nearest phone, fax, or computer and contact Cathie Leiendecker Foster at phone: 612.626.2305, fax: 612.625.6994, or e-mail: foste011@tc.umn.edu. Any ideas or help would be greatly appreciated!

Tony Killeen has been elected chair of the AACC Molecular Pathology Division (MPD). Tony has served as AMP’s Program Chair and has tirelessly overseen the AMP Homepage on the Internet. Tony is dedicated to doing what he can to promote cooperation between AMP and the AACC MPD. Taking a lead from CHAMP, he has already set up a University of Michigan-based listserve for AACC MPD members. Congratulations Tony and Good Luck!

Also related to the AACC MPD, Cathie Leiendecker Foster, an active AMP member [Cathie has two pieces in this Newsletter] has agreed to become editor of the AACC MPD Newsletter. Congratulations, Cathie!

Don't forget to encourage your residents or other trainees to submit an abstract to this year's AMP meeting in St. Louis. The abstract deadline will be at the end of July, and submission as first author will put trainees in the hunt for scholarships or travel awards - not to mention merit prizes at the meeting itself. Even trainees who do not submit an abstract still qualify for the reduced trainee pre-registration rate, so make sure the AMP meeting is on their calendar as well as your own.

The joint American Board of Pathology - American Board of Medical Genetics proposal for a special qualification exam in "Molecular Genetic Pathology" will be reconsidered and hopefully receive final endorsement this spring. When this happens, the chicken-and-egg phenomenon that has restricted the proposal or creation of formal accredited molecular pathology training programs (likely with Medicare reimbursement) will lift, so those of you training fellows keep this in mind. We'll be in contact with the Pathology Residency Review Committee (RRC) of the Accreditation Council for Graduate Medical Education (AGME) and will keep you apprised.

T & E is still looking for submissions (preferably electronic) of useful training and education resources in molecular pathology and diagnostics. Please at least put this on your side burner, as this will be a very useful archive which you may even wish to take advantage of yourself someday. If everyone submitted just one little reference, what a bright resource database this would be. So, please, sharpen those electronic pencils! The submission format again is:

1) Topic area (as broad or specific as you wish).

2) Resource title (journal article/book/chapter title if known, title of videotape, etc.)

3) Literature citation (journal or book citation if applicable, web URL, source to purchase)

4) Annotated comment (why do you like/how do you use this resource): VERY USEFUL

5) Appropriate for what level (novice, intermediate, advanced, all)

6) Other remarks

7) Person submitting

The 1999 T&E Committee welcomes suggestions or indications of interest from all members; We are:

I was pleased that Dan asked me to contribute an article to this AMP Newsletter. I’ve appreciated the questions and comments which our paper on the ASR Regulations (October, 1998 Newsletter) has generated from the AMP membership. This gives me an opportunity to share some thoughts and perhaps stimulate some interesting discussion on CHAMP or in other forums. As many of you know, I’m responsible for building a business at Promega to serve the reagent needs of "homebrew" diagnostic labs and my interests and perspectives tend to be focused in that direction.

From a commercial standpoint, progress in development of diagnostic kits for detection of mutations has lagged considerably behind those for infectious disease. Probably 80% or more of total commercial revenues are currently driven by HIV and HCV viral load, Chlamydia and GC testing. The expected introduction of HIV and HCV tests suitable for blood screening applications can be expected to tip this balance even further. At the same time, progress in the human genome project will facilitate discovery of additional clinically significant mutations. Biopharms and biotechs are developing mutation detection technologies to allow for the rapid screening protocols used in modern drug discovery. It may be expected that at least some of these technologies will evolve into formats useful for the molecular diagnostic laboratory. Many of these companies have included diagnostic applications in their mission and, more importantly, in their pitch to prospective investors.

Mutation detection for many single site changes can be addressed relatively easily by a variety of assays including RE digests of PCR fragments, cleavase analysis and various PCR primer design strategies. When there are multiple mutations spread throughout the gene at gene, especially at unknown or unpredicted sites, more advanced approaches are required.

I divide these advanced technologies into three general classes: sequencing, functional and hybridization based detection. Today, sequencing is generally considered the gold standard. Gels are giving way to capillary based systems (although at least one company is having some success in developing the gel into an attractive format). Capillaries may be expected to evolve into microcapillary "lab on a chip" based systems and possibly to mass spectroscopy based systems. All of these systems promise to generate a complete sequence which is longer, faster and less expensive. They are certainly the tools of choice for the human genome project where megabases of accurate sequence is the end goal. From a diagnostic standpoint, full sequencing may be the only approach to complex problems such as mutations in the p53 gene. For other applications, sequencing may generate information beyond the clinical knowledge base required for useful interpretation. Is a base change a "mutation" with clinical meaning or is it merely a "polymorphism?" Do you report such "changes" to the patient when you can’t properly advise them as to its meaning? Can you ethically not report such a result which might prove to be significant at some unforeseen time in the future? Is it better to avoid the issue by not generating the full sequence, but only concentrating on mutations of known importance?

The second approach are functional assays such as the protein truncation test (PTT). These assays look at the gene product to determine if there is a mutation which stops transcription or translation of the gene product. In many cases, such truncations alter the activity of the gene product and tend to be clinically significant. Of course, other equally significant mutations may simply change an amino acid, yielding an altered protein which is undetectable by this assay approach. In many ways this approach is the mirror image of full sequencing in terms of the balance between clinically relevant sensitivity and specificity. In general, tests such as the PTT are only useful where a very high proportion of the clinically significant mutations can be detected.

Hybridization detection has certainly captured the attention of the popular scientific press and the stock market. There are more versions of the hybridization than most of us can track and new ones seem to be discovered almost daily. Applications can range from Southern blots to sophisticated chips. The principle is basically the same, a hybridization probe that matches up with a sequence of interest. Detection technologies include luminescence, fluorescence, fluorescence quenching or fluorescence energy transfer coupled with a variety of different enzymes [ED. NOTE: BIOELECTRONIC DETECTION IS ANOTHER MECHANISM]. Information can be collected from one to tens or potentially hundreds of thousands of hybridization probes and assembled by informatics. Theoretically, a very large array could generate the same information obtainable by full sequencing. At least one company is talking about a chip that could simultaneously sequence all clinically relevant genes. Systems utilizing a more limited number of probes can be designed for interrogation of clinically relevant sequences. A system could be designed to be as sensitive or as specific as necessary – as long as the designer knew what to detect in advance.

It’s both fun and potentially profitable to follow the companies and technology and try to determine which will be the ultimate winners. Many of us enjoy playing "armchair quarterback" through investing in these companies and sharing in a small way in their success or failure. Those of us in industry often place a bigger bet in terms of our careers and livelihoods. Applications in diagnostics are different than basic research and place additional burdens on technology – the output needs to have the proper mix of clinical sensitivity and specificity along with absolute reliability and an affordable price.

My own feeling is that we are still early in the game and that the real winners in this area won’t shake out for at least several more years. Technology is only one factor which will separate the winners and losers. Control of patents and other intellectual property can substantially change the playing field. From a practical standpoint, the ability to address issues related to fit to laboratory workflow, quality control, quality assurance and analytical and clinical validation in the end often determines the winners in the diagnostics marketplace.

The second examination for Molecular Biology certification was offered by the National Credentialing Agency (NCA) in July of 1998. Unlike the first examination which was only offered at limited sites, this was offered at all NCA examination sites. 188 candidates sat for the examination and 75% passed. Of those taking the exam, 169 were taking it for the first time and 19 were re-taking it.

For anyone interested in becoming a Certified Laboratory Specialist in Molecular Biology, CLSp(MB), the next examination will be held in July 31,1999 at all of the NCA testing sites and the deadline for applications is April 1, 1999. It should be noted that this is the last year that the "experience only" eligibility route will exist. Beginning in the year 2000, all of the eligibility routes require either a baccalaureate degree or certification as a Clinical Laboratory Scientist (or equivalent), a Clinical Laboratory Specialist in Cytogenetics, or an Advanced Registered Technologist. Information about examination dates, how to obtain applications, etc. is posted on NCA’s Web site at http://www.applmeapro.com/nca. Alternately, NCA's address is PO Box 15945-289, Lenexa, KS 66285, 913.438.5110.

NCA is currently investigating the possibility of computerizing their examinations which will make it more convenient for examinees. More information about this will be passed on through this newsletter as it becomes available.

DNA Technology in the Clinical Laboratory, the 8^th Annual Seminar on Molecular Pathology, William Beaumont Hospital, Royal Oak, Michigan, March 25-27, 1999. This three-day symposium will include pre-meeting workshops, March 25, 1999, on: "Molecular Hematology: Clinical Applications of Genotyping" (with case studies), "Interfaces Between Flow Cytometry and Molecular Detection: Present and Potential Clinical Applications", and "Review Course for Medical Technologists’ National Certification Agency Examination in Clinical Molecular Biology"; March 26, 1999 sessions on "New Technology in Molecular Pathology" with the keynote address on "DNA Technology and the Human Genome Project" by Dr. Francis Collins, and a session on "Molecular Cardiology"; March 27, 1999 sessions on "Molecular Microbiology" and "Molecular Oncology-Hematology"; lunch roundtable presentations, vendor exhibits. CME credits available. For more information contact Domnita Crisan, M.D., Ph.D., phone: (248) 551-7261, fax: (248) 551-3694, e-mail: dcrisan@beaumont.edu or Sharon Simler, phone: 248.551.8023; fax, 248.551.3694, e-mail: ssimler@beaumont.edu or see

During the past several months, representatives from a number of professional societies have been meeting with HCFA in an attempt to draft national policies for coverage of laboratory tests. The intention was to have much of the haggling take place in this venue, leading to a draft that the involved groups would sign off on as a consensus prior to releasing the draft for public comment. Most of the work seemed to deal with non-molecular laboratory tests. However, during this process, I became aware of an apparently long-standing HCFA ruling that denies Medicare payment for non-FDA approved tests. There has been some variation in state-to-state interpretation/enforcement of this policy that may have left some of you blissfully ignorant of it as well. At any rate, working with Robin Stombler of the ASCP Washington office, there is now wording in place to let home-brew assays be reimbursable (because they fall under the ASR ruling and do not require FDA approval--an unexpectedly fortuitous consequence of the ASRs!) [ED. NOTE: for more discussion of ASRs, see Wayne Grody's piece on page 5]. Assays which will require FDA approval, including most commercial assays (HIV, HCV) that are being sold as RUO products will not be reimbursed by Medicare, though Medicaid and private insurers are at this point still paying. This was an entirely non-negotiable point during the proceedings, according to Robin. Of note, however, is the fact that some labs are doing home brews for an analyte like HIV or HCV, and using the same CPT codes as would be employed if a kit was used; the home brew is reimbursed while the kit is not. Beyond this problematic point, the draft document appears reasonable.

Secretary-Treasurer (NEWSLETTER EDITOR):