While neutrophil ratios and counts are being examined in basic laboratory tests, standards and reference ranges for morphological findings in this area have yet to be established. In October 2013, the JSLH Sub-committee for the Standardization of Blood Cell Morphology presented a new proposal (new JSLH proposal) for the differentiation of band and segmented neutrophils, combining the Japanese Association of Medical Technologists and Japanese Society for Laboratory Hematology proposals so as to be more appropriate for daily service styles. In December 2013, the JAMT and JSLH reached an agreement to cooperate to generalize the new JSLH proposal, and organized a group for this purpose, consisting of 11 members, 6 and 5 from the JAMT and JSLH, respectively, and called: the Joint Working Group for the Standardization of Blood Cell Morphology (JWG). The JWG started its activities in FY 2014 to achieve the following goals: 1) conducting basic studies on the new JSLH proposal and verifying its clinical validity; 2) developing an atlas for the new JSLH proposal based on the results of 1) to generalize it on a nationwide basis through morphology seminars held by JAMT branches; and 3) establishing the new JSLH proposal as a classification method by promoting its use for accuracy management surveys and textbooks. Having achieved the first goal with satisfactory outcomes, the JWG is currently making efforts toward the achievement of the second one.

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We examined the clinical application of the new classification criteria for neutrophil-lineage cells. Twelve facilities and 87 researchers (including individual participants) were asked to conduct cytological evaluations of 50 medical examination specimens that satisfied all the criteria in terms of biochemistry, immunology, and hematology, as well as the virtual slides prepared for CML cases. We also performed the cytological evaluation of the 60 cells used in a photosurvey and 74 clinical specimens including those from SIRS cases. The percentage of stab neutrophils (band) of the medical examination specimens ranged from 0.5 to 6.7%, which is almost the same as the national average, i.e., from 0.5 to 6.5%. The virtual slides showed characteristics such as a left-side or right-side predominance among institutions, and personal accounts themselves represented the characteristics of their institutes. The reproducibility of the new classification criteria was favorable when more than 80% of the results of the photosurvey were consistent. We also consider that the band ratio will increase in accordance with the vital signs and can be available in everyday clinical practice without causing any problem for the examination of SIRS specimens.

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The Japanese Association of Medical Technologists (JAMT) working group recommended morphological methods in hematology in 1996. After that, in 2000, the Japanese Society for Laboratory Hematology (JSLH) was established. In 2003, JSLH recommended the eye count classification of neutrophils, but this has not been widely accepted. Most facilities (about 80% in Japan) are using the JAMT classification method. The hematology blood cell standards joint working group of JSLH and JAMT was formed and has recommended a new eye count classification of neutrophils (segmented neutrophils, band neutrophils). We must consider this new eye count classification of neutrophils as part of the historical background of this review. It is very important to determine how many facilities have introduced this new classification, and we must understand this project in relation to automated hematology analyzer performance and trends of international standardization.

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Objectives: A working group (WG) for the standardization of blood cell morphology was established between the Japanese Association of Medical Technologists (JAMT) and the Japanese Society for Laboratory Hematology (JSLH). The WG established reference intervals (RIs) of observed WBC differential on the basis of the new classification criterion for the neutrophil system proposed by the Committee for the Standardization of Blood Cell Morphology of JSLH, and diffuse RIs were introduced nationwide in Japan. Methods: Exclusion criteria for reference individuals were based on the “Collaborative derivation of reference intervals of major clinical laboratory tests for nationwide use in Japan” of the Japanese Committee for Clinical Laboratory Standards (JCCLS). Reference individuals were selected from among healthy volunteers engaged in medical-care-related works or physical examination. Age and sex distributions were adjusted to obtain a final sample size of 936 individuals aged 18 to 67 years. Two hundred cells were counted under 400× magnification by an accredited hematologist or a directed laboratory technologist using the new classification criterion for the neutrophil system. Result: The distribution of the complete blood count (CBC) of the reference individuals was parallel to the RIs of JCCLS, and the validity of the reference individuals was confirmed. There were no significant differences in sex and age after observing leukocytes of peripheral blood. There were no significant RI differences between the parametric method and the nonparametric one, and the latter method was established as common RIs. Conclusion: The common RIs determined by observing leukocytes of peripheral blood are to be used nationwide. It was suggested that the networks of the JAMT should be utilized so that the RIs established in the present study become widely available.

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Rapid analyses and reliable data are desired in clinical genetic tests of various types of sample, including blood, frozen tissues, and formalin-fixed paraffin-embedded (FFPE) materials. In this article, we described the changes in genetic tests, focusing on DNA extraction methods. We compared differences in DNA amount extracted from peripheral blood among a phenol-chloroform method, a NaI method, and automated DNA extraction methods. Regarding FFPE materials, we compared various factors, including paraffin embedding processes, deparaffinization processes, and durations of formalin fixation with DNA amount. We also compared differences in DNA amount and results of DNA tests between conventional microdissection and laser microdissection of FFPE materials stained with hematoxylin and eosin (HE). In addition, we described fully automatic genetic analyzers, which will be expected to replace conventional manual procedures in the near future. Workshops conducted by the Japanese Association of Medical Technologists have been helping laboratory technologists acquire skills in the genetic testing methods described above.

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Numerous studies have shown the clinical and prognostic significance of carotid artery intima-media thickness (IMT) in atherosclerotic disease patients. However, the clinical significance of femoral artery IMT has not been fully elucidated. We examined the relationship among carotid and femoral artery IMTs and ankle brachial index (ABI) in patients with coronary artery disease. Patients (n = 213; mean age, 71 years) who were diagnosed by coronary angiography were enrolled. By ultrasonography, we evaluated the mean common carotid and femoral artery IMTs. We evaluated the diagnostic value of the carotid and femoral artery IMTs for low ABIs (< 0.9). To determine the cutoff IMT for the prediction of a low ABI, we conducted receiver operating characteristic (ROC) analysis. The median carotid IMT was 0.77 mm, and the median femoral IMT was 1.71 mm. ABIs were significantly lower in patients with large femoral IMTs (≥ 1.71 mm) than in those with small femoral IMTs (< 1.71 mm) (1.01 vs 1.08, p < 0.0001). On the other hand, there was no significant difference in ABI between patients with large carotid artery IMTs (≥ 0.77 mm) and those with small carotid artery IMTs (< 0.77 mm) (1.05 vs 1.05, p = 0.60). ROC curve analysis revealed that the optimal cutoff value for predicting an ABI of < 0.9 was 1.78 mm for femoral IMT. Femoral artery IMT, not carotid artery IMT, predicts a low ABI in patients with coronary artery disease.

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Most clinical laboratories often use enzyme immunoassay (EIA) as a rapid test for the diagnosis of Clostridium difficile infection (CDI). However, its sensitivity of detecting C. difficile toxins is insufficient for diagnosis. Therefore, toxigenic culture (TC) can play an important role in diagnosing cases of CDI. We evaluated the usefulness of TC compared with the detection of the toxin B gene by polymerase chain reaction (PCR), and then designed an algorithm that uses TC for the laboratory testing of CDI to improve the sensitivity of detecting toxins. We found that some of the media used for culture and bacterial concentration affected the results of TC. Compared with the results by PCR, the sensitivity of TC was 100% when CCMA-EX culture medium and a bacterial concentration of 4.0 McF were used. On the other hand, the sensitivity decreased to 79% when chocolate agar and a bacterial concentration of 3.0 McF were used for TC. The specificity of both groups was 100%. These experimental results indicate that it is important to determine which medium and how much concentration of bacterial suspension should be used to reduce the number of false negative results. Standardized procedures are needed for the performance of TC by laboratories.

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We report on two cases of Corynebacterium jeikeium bacteremia associated with induction chemotherapy for acute myelogenous leukemia. The patients were 55- and 37-year-old males who were undergoing chemotherapy. C. jeikeium was detected in blood cultures of both patients during chemotherapy. As the blood cultures tested positive for the bacterium and the patients were immunologically deficient, we investigated the possibility of C. jeikeium as the causative organism. The patients were started on vancomycin (VCM) therapy, after which C. jeikeium was no longer detected; thus, treatment of the primary disease was performed. Medical technological progress increases the incidence of opportunistic infections. When C. jeikeium is detected in blood cultures, it is necessary to determine whether it is the causative organism by reviewing the patients’ background and blood culture positivity time. If it is indeed the causative organism, it is necessary to consider changing VCM to the recommended antimicrobial agent.

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We encountered two cases of apocrine carcinoma of the breast; here, we report on the characteristics of apocrine carcinoma detected by ultrasonography (US). Case 1: A 60-year-old woman with a right breast tumor was initially diagnosed as having apocrine adenosis. No remarkable change was seen in the size of the mammary gland. Six years later, because of the interruption of the anterior border of the mammary gland, a fine high-echo spot, and a small amount of flow detected on her ultrasonograms, we suspected papillotubular carcinoma. Then, histopathological examination by US-guided core needle biopsy revealed apocrine carcinoma. Case 2: Screening mammography pointed out focal asymmetric density (FAD) in the right breast of a 60-year-old woman. Her lesion could be detected by magnetic resonance imaging (MRI) but it could not be observed by US. Three years later, US showed an irregular and low-echoic mass. At first, scirrhous carcinoma was suspected, and then histopathological examination revealed intraductal apocrine carcinoma. These two patients with apocrine carcinoma were diagnosed on the basis of irregular and low-echoic masses as shown in the US. Both patients were followed up as initially having benign tumor. A few years later, US findings showed that there is a possibility of malignancy. US was found to be useful for long-term follow up.

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Interdigitating dendritic cell sarcoma (IDCS) is an extremely rare neoplasm derived from a type of dendritic cells. We experienced treating a case of IDCS involving the skin and probably bone marrow. Histopathological examination of the involved skin lesion revealed a massive invasion of large atypical lymphoid cells. Immunohistochemically, the neoplastic cells were positive for S100 and CD68, and negative for CD1a, CD21, and CD23. These findings led to the diagnosis of IDCS. Although a bone marrow biopsy showed unremarkable findings, a small number of neoplastic cells were observed in a bone marrow smear. Because the skin lesions were extensive and bone marrow infiltration was suspected, the patient was administered ABVD therapy.

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The heart-type fatty acid-binding protein (H-FABP) plays a practical role as an early myocardial marker in the diagnosis of acute coronary syndrome (ACS). The basic assay performance of “Rapidchip^® H-FABP” (SEKISUI MEDICAL Co., LTD.), which is used for the quantitative determination of H-FABP, was evaluated. To verify the assay performance indicated in the package insert, precision, measurement range, interfering substances and prozone phenomena were examined. We also compared the assay with other commercially available kits and observed excellent correlation, with the exception of three samples. These discrepancies were analyzed by immunoprecipitation. In conclusion, this newly developed point-of-care testing (POCT) kit provides an accurate, precise and easy-to-use means of routine measurement of H-FABP in clinical laboratories. We hope that this kit will be a useful tool for the diagnosis and treatment of ACS in emergency situations, home medical care and during disasters.

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The basic performance of the KL-6 measurement kit “Nanopia^® KL-6 EISAI” was evaluated using LABOSPECT 008, a general-purpose automatic analyzer. The coefficients of variation (CVs) for the within-run and between-run reproducibilities ranged from 0.88% to 1.75%. The dilution linearity was maintained at about 5,000 U/mL, and the detection limit was 16.0 U/mL. No effect of interfering substances was detected. The KL-6 concentrations determined by the current and conventional methods showed a good correlation in 52 samples (r = 0.995, y = 1.03x − 40.0). Therefore, this kit, which has good basic performance using the LABOSPECT 008, is useful for testing before consultation and as an emergency test.

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We isolated atypical methicillin-resistant Staphylococcus aureus (MRSA) from two patients who were administered an antimicrobial drug for a prolonged period. These strains showed a typical colony on Colombian CNA 5% sheep blood (CNA:BD) medium for gram-positive cocci. However, these strains formed minute colonies on sheep blood agar M58 (Eiken). In addition, these strains were difficult to grow on MS-CFX agar (Nissui) as the selective medium for MRSA. Therefore, we observed the growth situation using a blood component agar and the selective MRSA medium under the conditions of aerobic culture, 5% carbon dioxide culture and anaerobic culture for five days. MRSA showed a typical colony on CNA and sheep blood agar M70 (Eiken) on the first day, but an atypical colony on the other agars. When we identified these strains using the Microbiology Systems Microscan WalkAway 96 SI (aerobic culture), they were unmeasurable owing to insufficient growth. When measurement panels cultured 5% carbon dioxide culture and anaerobiotic culture, they were miss-identified as Methicillin-sensitive Staphylococcus aureus and Staphylococcus capitis subsp. capitis. In the selective MRSA medium, no typical colony was observed. For detecting MRSA, we must be aware of the existence of atypical colonies, and it is necessary to culture MRSA in a nonselective medium in addition to the selective MRSA medium in the case of patients who were administered an antimicrobial drug for a prolonged period. When a growth difference in each agar is observed, we need to obtain the patient’s information and confirm it carefully by a method that does not use growth properties.

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Allergen-specific IgE quantitation using IMMULITE 2000 3gAllergy was evaluated. The analytical performance of this analyzer showed good precision results for within-run and between-run reproducibilities, good recovery from high and low sample dilutions, and low limit of detection from 0.048–0.061 IU_A/mL. Furthermore, serum samples were analyzed using ImmunoCAP^® and IMMULITE 2000 3gAllergy in terms of specificities for 28 allergens. The levels of specific IgE antibodies to all the allergens determined by both assays highly correlated, showing a Spearman rank-correlation coefficient of over 0.7. Overall, in comparison with ImmunoCAP^® results, specific IgE antibody levels measured using IMMULITE 2000 3gAllergy were higher for egg white, aspergillus and cat dander, and lower for wheat, peanut and dog dander.

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We compared Fuji DRI-CHEM IMMUNO AG cartridge flu AB, which utilizes silver-amplified colorless immunochromatography technology, with two other influenza diagnostic kits (kits 1 and 2). We used 131 nasal specimens from outpatients and tested them using RT-PCR. Concerning type A influenza, the positive, negative, and total agreement rates of the silver-amplified immunochromatography system, kit 1, and kit 2 were 100%/96.0%/97.7%, 83.9%/98.7%/92.4%, and 75.0%/100%/89.3%, respectively. Concerning type B influenza, those of the silver-amplified immunochromatography system, kit 1, and kit 2 were 86.7%/98.3%/96.9%, 73.3%/98.3%/95.4%, and 60.0%/99.1%/94.7%, respectively. The silver-amplified immunochromatography system had higher positive agreement rates for types A and B influenzas than the other diagnostic kits. Regarding the patients who reported having a fever of over 38°C, we investigated the relationship between the onset time and the positive agreement rate. The results showed that for the specimens taken within 24 h, the silver-amplified immunochromatography system had a higher positive agreement rate than the other diagnostic kits. The silver-amplified immunochromatography system is highly sensitive; thus, the probability of diagnosing influenza using specimens that contain small amounts of virus is high. We consider that the silver-amplified immunochromatography system is useful for the early diagnosis of influenza, which can help prevent hospital-acquired infections and the spread of influenza in the community.

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In this study, we compared the cell yield produced by the BD CytoRich™ (CR) system with that obtained by conventional methods of urine cytology. A total of 100 urine samples were processed using both the CR system and conventional methods (Bales’ method). We assessed the epithelial cell counts and cellular distribution in slides obtained by both methodologies. Urine protein and blood levels were analyzed using a dip stick and compared with the epithelial cell counts from the slides processed using the CR system and conventional method. Overall, the slides processed using the CR system showed higher epithelial cell counts than those processed using the conventional method. Similarly, in cases of proteinuria and/or hematuria, the CR system demonstrated higher epithelial cell counts than the conventional method. Taken together, we conclude that the BD CR system is superior to conventional method of urine specimen preparation.

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We evaluated the clinical usefulness of XN-550, an automated hematology analyzer (Sysmex, Japan), for the determination of cell count in cerebrospinal fluid samples. Reproducibility, linearity, sensitivity and correlation of findings with those of conventional examination using a microscope were good and reliable. Drainage samples, including deformed cells, were analyzed. However, the scattergram did not correspond to the microscopy examination results, and the number of deformed cells was classified as low among side scatter cells. XN-550 is easy to handle and provides quick results, and is therefore useful for screening examination.

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Thymus and activation regulated chemokine/chemokine (C-C motif) ligand 17 (TARC/CCL17) is a chemokine that acts as a ligand for CCR4 expressed on Th2 cells. In patients with atopic dermatitis, serum TARC levels increase in relation to the severity and acute exacerbation of the disease. The revised 2009 guidelines for the management of atopic dermatitis recommended the use of serum TARC level as a marker for the disease. In April 2014, a new serum TARC measurement method using the CLEIA method with a HISCL^®TARC kit was applied for Japanese medical insurance purposes. This method utilizes the fully automated enzyme immunoassay analyzer HISCL-2000i, which shortens the measurement time from three and a half hours to approximately 20 minutes. Patients with atopic dermatitis can obtain information on their latest serum TARC levels within a day. By this new method, we can measure high serum TARC levels in samples. A total of 51 samples including residual samples after measuring the serum TARC levels and samples obtained from volunteer staff members of our hospital were analyzed. Specifically, we evaluated the repeatability, reproducibility, dilution linearity, correlation and effect of coexisting substances. Good results were obtained, including the confirmation of dilution linearity using serum TARC levels of up to 50,000 pg/mL. In conclusion, serum TARC measurement by the CLEIA method with HISCL^®TARC kits was evaluated using routine results obtained in our hospital for Japanese medical insurance purposes. This new method may lead to early diagnosis, early treatment and adequate follow-up of patients with atopic dermatitis.

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The average life span in Ibaraki Prefecture was reported to be lower than the national average; that of males is 0.5 years and that of females is 0.6 years lower (Ibaraki Shimbun Newspaper, August 4, 2013). We analyzed the relationships among the standardized mortality ratios, the number of hospital beds per 100 thousand population, and the distances to emergency centers from the places of residence to see how these factors affected the average life span. The results are as follows: (1) As for the total area of Ibaraki Prefecture, the standardized mortality ratios of heart disease and pneumonia positively correlated with distances to emergency centers from the places of residence. (2) As for the differences in gender, the male average life span negatively correlated with the standardized mortality ratios of cerebrovascular disease, diabetes, and pneumonia, and positively correlated with the number of hospital beds per 100 thousand population, whereas the female average life span negatively correlated with the standardized mortality ratios of diabetes and heart disease. (3) As for the changes in mortality ratios owing to the changes in critical care system, there was an area where the standardized mortality ratio of heart disease did not correlate significantly with distances to emergency centers from the places of residence, supposedly owing to the development of a helicopter-aided critical care system. However, the Kashima-Namegata areas, which ranked within the bottom fifty in Japan in terms of average life span, require urgent measures.

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We evaluated MRSA-CI, CHROMagar MRSA II (CHROM), and MDRS-K media for the detection of methicillin-resistant Staphylococcus aureus (MRSA). The results obtained by the Miles & Misra method were similar among the three media. In the comparison of discrimination ability, 120 nasal cavity swab specimens were used. After 24 h of incubation, the sensitivities were 88.4% for MRSA-CI, 90.7% for CHROM, and 88.4% for MDRS-K. The specificity of the three media was 100%. Furthermore，after 48 h of incubation, the sensitivity increased in all the media. The three MRSA detection media showed equal detection capacities for MRSA. The use of MRSA detection media is a convenient method for the detection of MRSA, but it is important that we understand the characteristics of each MRSA detection medium and use each one appropriately.

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