A computer network system connecting the operating rooms and the blood transfusion service to control blood ordering and provision was implemented in March 2007 in an attempt to ensure the appropriate cross-checking of blood products and the registration of blood product usage. This system connected the blood control system of the blood transfusion service with the anesthetic system of the operating room and the hospital general medical system. Using this system, the patient’s wrist band is checked upon admission to the operating room, and anesthetists request the provision of blood products, order new blood products, cross-check the provided products, register their use, and record the occurrence of adverse events. On the blood transfusion service side, the blood products to be provided are cross-checked against the anesthetists’ request, the results of the cross-match test are checked, and the attachment of the appropriate matching confirmation label to the blood product is confirmed using the system. The anesthetists and the blood transfusion service staff can check the real-time list of the blood products available for the surgical patient and those already transfused. Thus, following implementation of this system, the excessive ordering of blood products by anesthetists could be avoided, the appropriate registry of the cross-checking of blood products against the patient would become available, and medical errors could be avoided. At the time of its implementation, however, incidents occurred as a result of the lack of experience of various professionals, including anesthetists, nurses, and medical technologists, who needed extensive training to be fully able to navigate this system, which works 24 h a day, including holidays. Hence, we intend to expand its function, especially to improve the prevention of medical errors.

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We surveyed the detection patterns of extended spectrum β-lactamase (ESBL)-producing enteric bacteria isolated from blood cultures between January 2006 and March 2011 in our hospital. One hundred and eighty-four strains of enteric bacteria were detected in 163 (5.8%) of 3,019 patients whose blood samples were available for culture. Among those, 16 strains (8.7%) of ESBL-producing bacteria were detected: 13 strains of Escherichia coli and 1 strain each of Klebsiella pneumoniae, Enterobacter cloacae, and Proteus mirabilis. The genotype was analyzed in 14 strains: CTX-M 1 in 3, CTX-M 2 in 1, and CTX-M 9 in 10. We conducted an epidemiological analysis of E. coli using the random amplified polymorphic DNA (RAPD) technique, which showed no transmission of the same strains and dominant plasmid transmission. Nine of eleven strains had the phylogenetic group (PG) B 2 of E. coli, with potentially high pathogenicity. A microbial sensitivity test revealed a significantly higher rate of resistance to levofloxacin or amikacin for ESBL-producing compared to non-ESBL-producing strains (p<0.05). For antimicrobial therapies, carbapenems were used in 11 of 16 patients, 8 of whom showed a favorable effect. In this survey, we identified the detection patterns of ESBL-producing enteric bacteria in blood cultures obtained over the last five years.

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Drug resistant Pseudomonas aeruginosa is responsible for severe nosocomial infections, and combination therapy is needed. We studied antibiotic combination effects by “break-point checkerboard Plate (BC plate)” and disk diffusion susceptibility test against drug resistant P. aeruginosa. Thirty-three strains of multi-drug resistant P. aeruginosa (MDRP) and metallo β lactamase (MBL) produced P. aeruginosa collected from February 2010 to June 2012 were tested using BC plate ‘eiken’ (Eiken Chemical Co. Ltd, Tokyo, Japan) to evaluate the effect with combined antibiotics. The isolates have combined effect rather than single drug effect were tested using KB disk (Eiken Chemical Co. Ltd, Tokyo, Japan). As a result, there were higher zone of inhibition against some isolates for AMK/AZT, CL/AZT, CL/RFP and RFP/AZT, and the other isolates were not strong zone (≤0.5 mm). Therefore, disk diffusion susceptibility test for MDRP and MBL produced P. aeruginosa is able to determine antibiotic combination effects when it is recognized apparent zone.

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“BACTEC” and “BacT/ALERT” are widely used for automatic blood culture analysis in Japan. We summarized the bacteria isolated in five domestic hospitals using BACTEC and BacT/ALERT and examined the factors that affected the bacterial isolation rate. Among the bacteria isolated at a high rate, the number of times blood culture was performed correlated with the isolation rate and there were no differences in the isolation rate between BACTEC and BacT/ALERT. Among the bacteria isolated at a low rate, Streptococcus pneumoniae and Campylobacter spp. were isolated at a higher rate in the BACTEC group compared with the BacT/ALERT group. Candida spp. was isolated at a higher rate in the BacT/ALERT group than in the BACTEC group. The isolation rate of some kinds of bacteria was found to differ with the equipment. These results indicate that it is essential to consider the blood culture performance status in each hospital and the characteristics of the equipment used for blood culture.

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We examined the fundamental performance of a reagent “BNP-JP Architect” and the relationship between the concentrations of brain natriuretic peptide (BNP) and the parameters of echocardiography. BNP-JP Architect had satisfactory performance, except for the effect of hemolysis. The relationship between plasma BNP level and the parameters of echocardiography was evaluated in 120 patients with sinus rhythm (mean age 69 ± 13 years old, 70 men, 50 women). Plasma BNP level correlated with left atrial dimension (LAD) (r = 0.39, p < 0.01), left ventricular end-diastolic dimension (r = 0.22, p < 0.05), ejection fraction (EF) (r = –0.40, p < 0.01), and ratio of the peak velocity of transmitral flow during early diastole to the peak myocardial velocity during early diastole at septal annulus (E/e') (r = 0.53, p < 0.01). In multivariate linear regression analysis, EF (p = 0.04) and E/e' (p < 0.01) were independent determinants of plasma BNP level. Patients with decreased renal function (estimated glomerular filtration ratio (eGFR) <60 ml/min/1.73 m²) were older (p < 0.01) and had higher LAD (p < 0.05), E/e' (p = 0.01), and plasma BNP level (p < 0.01) than patients with preserved renal function (eGFR≧60 ml/min/1.73 m²). Although renal function should be considered when interpreting plasma BNP level, the plasma BNP level measured by BNP-JP Architect can be used as a surrogate marker of left ventricular (LV) systolic function and LV filling pressure and provide useful information for the diagnosis of heart failure.

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In recent years, the automation of urinary sediment testing has been progressing and has led to increased efficiency. A quality problem arises with complete automation, however, because the material elements that appear in urine are variegated. Moreover, the measurement principles of the automated urine cell analyzers differ among makers. When we introduce equipment, it is important that we know their properties. Here, we introduce the U-SCANNER II. We describe the usefulness of classifying the sample before measuring, setting up the automatic choices, and the post-measurement element check method. For the post-measurement element check method, we devised an original method that utilizes the features of U-SCANNER II. We named this method “SPOT KYOUKEN” and we reported on its usefulness.

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We conducted nerve conduction studies (NCSs) of the ulnar nerve in 10 patients with Guyon canal syndrome. In three patients, the distal latency (DL) of compound muscle action potentials (CMAPs) recorded from the first dorsal interosseous (FDI) muscles was significantly prolonged, whereas that recorded from the abductor digiti minimi (ADM) muscles was normal. These findings indicate deep motor branch (distal to hypothenar muscles) lesions. In one patient, abnormal CMAP findings were detected in the FDI and ADM muscles. These findings indicate deep motor branch (proximal to hypothenar muscles) lesions. In three patients, the results of sensory nerve conduction studies (SCS) performed on the little finger were abnormal, as were CMAP findings in the FDI and ADM muscles. These findings indicate lesions proximal to or within the Guyon canal. In three patients, the SCS results obtained from the little finger were abnormal, whereas those of the dorsal cutaneous branch of the ulnar nerve were normal. These findings indicate superficial terminal sensory branch lesions. Evaluation of CMAPs recorded from the FDI muscle and demonstration of a normal dorsal ulnar sensory response are necessary for site of lesion diagnosis in patients with Guyon canal syndrome.

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Since there is wide interobserver variabilities in microscopic urinary sediment evaluation, quality control programs for urinary sediment test using control materials are warranted in Japan. We performed internal quality control using home-brew control materials and cross-checking of urinary sediment tests by the three technologists including two experts and one newcomer. Variabilities among the three technologists in counting red blood cell (RBC), white blood cell (WBC), and casts were found to be improved as early as five days after the start of quality control particularly in the newcomer. Half a year later, coefficients of variation of the three technologists in counting these components were all about ten percent, which were lower than those observed in the initial examination. In the cross-checking of urinary sediments, more than 93% of the results of RBC and WBC and 84% of the results casts were reported within one lank difference. The rare components including waxy cast, atypical cell, dysmorphic RBC, Trichomonas vaginalis were detected similarly by the three technologists. Thus, internal quality control of urinary sediment tests using home-brew control materials and cross-checking among medical technologists is useful for standardization of urinary sediment tests and training of a newcomer in a clinical laboratory.

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Since October 2010, the effectiveness of antimicrobial combination therapy against clinically isolated multi-drug-resistant Pseudomonas aeruginosa (MDRP) has been assessed in our hospital using the Eiken break-point checkerboard (BC) plate. These BC plates are used to screen for the appropriate antibiotic combination against the 12 strains of MDRP that were isolated over 16 months. We found combinations of amikacin (AMK) and other antimicrobial agents such as ceftazidime (CAZ) and piperacillin (PIPC) to be the most effective. After observing the results on the BC plates, the antimicrobial agent was switched in six-cases, four of which resulted in patient death within 30 days. These patients with MDRP infection experienced poor convalescence even if an agent effecticve against MDRP was used because they were in a poor state of health. Colistin (CL) is effective against MDRP alone, but it is difficult to use in Japan. The prevention of MDRP infection is important.

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The staining method using a cocktail antibody is an immunostaining method that has the strong point of being able to grasp the mutual spatial relationship of two or more antibodies on the same section. Here, regular activities were performed by the cocktail antibody produced using the commercial antibody. Prostate tissue was used as a material. AMACR, cytokeratin, and p 63, which are requested together in my hospital, were used for the antibody to mix. The strength of dyeing is the same as that of each simple stain of AMACR, p 63, and cytokeratin. A negative marker is emphasized by dyeing together and it becomes easy to recognize it by the color. Although the process of the operation for one section increases, in the cocktail antibody that was mixed and produced the commercial antibody, it is possible to produce a cocktail antibody that does not require a special method or time and was stabilized for day-to-day use.

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The management of chronic active hepatitis B is quite different from that for acute infection. We evaluated the clinical usefulness of Lumipulse HBcAb-N, which detects hepatitis B core IgG antibodies, in differentiating between acute and chronic hepatitis B as initial medical testing. Lumipulse HBcAb-N showed a remarkably high antibody titer only in patients with chronic hepatitis although Lumipulse II HBcAb, a conventional reagent, could not provide results to discriminate it from acute infection. Chronic hepatitis was also diagnosed by the trend in the antibody titer by using Lumipulse HBcAb-N; an increasing antibody titer was observed in acute hepatitis although a high titer persisted from the first examination in chronic patients. Our data suggest that Lumipulse HBcAb-N could provide more accurate and useful information for clinicians in assessing the phase of hepatitis B.

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Echinococcosis is a disease in which a cystic lesion develops mainly in the liver. It is caused by exposure to eggs of Echinococcus multilocularis and E. granulosus. Fourteen years ago, we reported a patient with unilocular hydatidosis of the liver in our hospital. This time, we report a unilocular liver cyst in his mother. Based on the familial history and magnetic resonance imaging (MRI) findings, we suspected echinococcosis, and cystectomy was conducted. In Japan, E. granulosus in very rare; therefore, our experience is limited. It is very important to cooperate with specialized laboratories who have encountered parasites from foreign countries and to examine other members of an affected patient’s family.

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Bacillus cereus is a Gram-positive spore-forming rod that is widely distributed in the environment. It is often regarded as a contaminant. This rod can occur as a systemic or local infection in immunocompromised hosts. A 73-year-old male with on implanted pacemaker was admitted to our hospital for acute brain infarction. He presented with fever and elevated inflammatory markers. Erythema at the entry site of the peripheral catheter was also observed. B. cereus was isolated from six sets of blood cultures. Echocardiography demonstrated vegetation in the right ventricle, therefore, a diagnosis of B. cereus endocarditis was made according to the Duke’s classification. Imipenem/cilastacin and minocyclin were administered, decline in the fever and inflammatory markers was subsequently observed. Repeated blood cultures and consideration of clinical information are required to determine if B. cereus is apathogen, when it is isolated from blood cultures.

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A 70-year-old woman visited our breast clinic, because a right breast mass had been noted in enhanced computed tomography (CT) before surgery for intrahepatic bile duct cancer. A tumor was located in the D region of the right breast. It was spiculated and comparatively elastic. Mammography revealed a tumor mass with coarse calcification in the middle outer quadrant of the right breast. Initially, a fibroadenoma was suspected. Ultrasonography revealed a tumor in the CD region of the right breast that was 41×41×16 mm in size, oval shaped, and smooth-surfaced, with a heterogeneous low-echoic level inside, no interruption of the border of the mammary gland, with fine or small and coarse calcification, and a small amount of flow. Magnetic resonance imaging (MRI) also led to an initial speculation that it was fibroadenoma. Core needle biopsy resulted in a diagnosis of ductal carcinoma in situ (DCIS). Right breast partial resection was performed. Pathological findings revealed an 11 mm×8 mm DCIS in the fibroadenoma, around which usual ductal hyperplasia, columnar cell lesions, flat epithelial atypia, atypical ductal hyperplasia, papillomatosis, and sclerosing adenosis were observed.

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Congenital factor V deficiency is a rare genetic disease. We report a 67 year-old man with congenital factor V deficiency who underwent trans-urethral resection of the prostate (TURP). One year after a diagnosis of congenital factor V deficiency was made for abnormal coagulation tests, the patient underwent TURP for benign prostatic hypertrophy. After the preoperative transfusion of 4 units of fresh frozen plasma (FFP), the serum level of factor V increased from 8% to 21% and the operation was uneventful. FFP was also administered postoperatively to keep the factor V activity around 20%. The patient was discharged one week after the operation with transient minor hematuria. In congenital factor V deficiency severe bleeding is infrequent. However, in major surgery, it is important to appropriately administer FFP while monitoring factor V activity.

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Fibrin degradation product (FDP) and D-dimer are useful fibrinolytic markers for diagnosis and therapeutic assessment in patients with disseminated intravascular coagulation (DIC) and deep vein thrombosis (DVT). We describe a case report in which dithiothreitol (DTT) was useful for detecting a non-specific reaction caused by IgM in a patient with marked inversion values of D-dimer and FDP. A seven-month-old female infant was referred to our hospital for evaluation of dilated cardiomyopathy. Her test results showed FDP of 3 μg/ml and D-dimer of 92.8 μg/ml. When the samples were diluted 10 to 100 times, the value of D-dimer fluctuated with the increase in the dilution ratio. Next, the value of D-dimer was 81.6 μg/ml after absorption of the sample with anti-Fbg antibody, compared with 67.2 μg/ml of the control. These suggest a false positive due to a non-specific reaction. Next, the sample was treated with DTT, and the value was 1.2 μg/ml compared with 73.6 μg/ml of the control. These findings suggest a non-specific reaction due to IgM. DTT is a cheap and easily available product that may be useful in the analysis of the non-specific IgM reaction to measure D-dimer.

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Using 71 Staphylococcus aureus isolates that are known to have a minimum inhibitory concentration (MIC) of 2 μg/ml for vancomycin (VCM), we compared the MICs obtained when the MicroScan Prompt system and manual preparation methods were used for preparing the bacterial solutions. For this analysis, the inocula were adjusted to match a 0.5 McFarland turbidity standard. We also compared the MICs seen in the case of the Pos Combo 3.1 J (PC 3.1 J) and Pos MIC 3.3J (PM 3.3 J) panels. When the Prompt system was used, 68 and 46 isolates showed a VCM MIC of 2 μg/ml with the PM 3.3 J and PC 3.1 J panels, respectively. When the manual preparation method was used, 53 isolates showed a VCM MIC of 2 μg/ml with the PM 3.3 J panel and only 22 isolates showed this MIC with the PC 3.1 J panel. The remaining isolates had an MIC of 1 μg/ml. Because a VCM MIC of 2 μg/ml or higher is clinically important in patient management, it is necessary to determine the differences between the results for the 2 panels and the 2 methods of inoculum preparation.

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The incidence of hospital-acquired infection by drug-resistant bacteria such as the extended-spectrum β-lactamases (ESBLs) producing, the metallo-β-lactamase (MBL)-producing, and the AmpC β-lactamase (AmpC)-overproducing strains is reported to have increased. Vital Media ESBL/MBL screening agar medium (ESBL/MBL medium; Kyokuto Pharmaceutical Indust. Co.) has been newly developed to selectively detect ESBLs- or MBL-producing bacteria. In this study, we compared the usefulness of ESBL/MBL medium as ChromID ESBL (Sysmex-bioMérieux Co.) or CHROMagar ESBL medium (Kanto Chemical Co.). Supporting activity for bacterial growth in the presence or absence of feces was similar between the three media. As for the selection of drug-resistant strains in the clinical samples, AmpC-overproducing strains were found to be separated most effectively when we used ESBL/MBL medium although ESBL- or MBL-producing bacteria were detected equally when we tested the three media. These results indicate that ESBL/MBL medium is superior to the other media in terms of the detection capacity of drug-resistant bacteria.

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The prothrombin time (PT) is used for detecting abnormalities in the extrinsic pathway of blood coagulation and monitoring the effects of warfarin administration. A new PT dry reagent has been developed in Japan with an International Sensitivity Index (ISI) of approximately 1.0 by the COAG 2 N System (supplied by Wako Pure Chemical Industries Ltd). In this study, we investigated the basic performance of the new reagent using the COAG 2 N System. The new reagent showed good reproducibility, especially when citrated plasma or whole blood was used as a sample, yielding interference results similar to those of bilirubin-F, bilirubin-C, hemolytic hemoglobin, and intralipid. It provided a level of performance that would satisfy the needs of users. Using specimens of patients who were prescribed a warfarin agent, good correlations were obtained in comparison to current reagents with an ISI of approximately 1.0. These findings suggest that this new PT dry reagent may be useful in testing routine coagulation and monitoring the effects of warfarin administration.

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We investigated the resistance of 846 strains of Haemophilus influenzae isolated from clinical materials in our hospital between January 2008 and December 2011. The detection rate of β-lactamase-negative ABPC-resistant H. influenzae (BLNAR) increased remarkably from 28.1% in 2009 to 53.7% in 2010. The rate of BLNAR from epipharyngeal mucus and sputum increased in all age groups. Furthermore, cefotaxime (CTX), ceftriaxone (CTRX), cefditoren pivoxil (CDTR-PI), meropenem (MEPM), and levofloxacin (LVFX) showed higher antibacterial activity.

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