Background—The Stanford type A acute aortic dissection (AAD), whereby the dissection extends to the ascending aorta, results in high mortality. The plasma D-dimer has been used in the diagnosis of acute aortic dissection. However, its prognostic value in patients with the Stanford type A AAD has not been clarified. We investigated the prognostic value of the D-dimer in patients with Stanford type A AAD. Methods and Results—103 patients with Stanford type A AAD (mean age, 69.8 ± 13.0 years; male, 41; female, 62) were included. The level of the D-dimer was high in all the patients (34.3 ± 56.3 μg/mL). The D-dimer level in the patients of the nonsurvival group was higher than that of the survival group (36.8 μg/mL vs 8.5 μg/mL, p < 0.001). Receiver operating characteristic curve analysis showed that the cut-off level of the D-dimer was 9.71 μg/mL in nonsurviving patients with Stanford type A AAD. Kaplan–Meier curve analysis showed that a D-dimer level of more than 9.71 μg/mL indicates an increase in acute-period mortality (p < 0.001). Conclusion—It is suggested that a high plasma D-dimer level on admission is useful for the prognostic prediction for patients with Stanford type A AAD.

Plasma fibrinogen concentration is routinely measured by the automated thrombin time method, i.e., the fibrinogen functional procedure. However, the measurement of fibrinogen protein or antigenic concentration is necessary for the diagnosis of inherited fibrinogen disorders. These disorders can be divided into four types: afibrinogenemia, in which both fibrinogen functional and antigen levels are below the levels of assay sensitivity, hypofibrinogenemia, in which both fibrinogen functional and antigen levels are reduced, dysfibrinogenemia, in which the antigen level is normal but the functional level is reduced, and hypodysfibrinogenemia, in which both fibrinogen functional and antigen levels are reduced (the functional level is less than the antigen level). It is important to classify these inherited fibrinogen disorders according to the ratio of functional fibrinogen level to antigen level. In this study, we evaluated the basic performance of the Factor Auto Fibrinogen kit (antigenic fibrinogen measurement) manufactured by Q-may Laboratory Corporation (Q-method), which showed good reproducibility, linearity, and detection sensitivity. The coefficient of correlation between the Q-method and the functional method for 50 plasma samples collected from individuals without inherited fibrinogen disorders was 0.974, and the regression equation was y = 0.926x + 35.1. In addition, the coefficient of correlation between the Q-method and conventional antigen method for 19 plasma samples collected from patients with inherited fibrinogen disorders was 0.972, and the regression equation was y = 0.968x + 34.5. In conclusion, the Q-method is useful for measuring plasma fibrinogen antigen level in patients with inherited fibrinogen disorders to classify the type of disorder. It also provides useful information regarding the cause of decreased functional fibrinogen level.

Anti-Epstein-Barr virus (EBV) antibody tests are necessary for the diagnosis of EBV-related diseases such as infectious mononucleosis (IM). Antivirus capsid antigen (VCA), anti-early antigen (EA), and anti-EBV nuclear antigen (EBNA) antibodies are used as specific antibodies for EBV in clinical laboratories. Two types of VCA antibody are available: the VCA-IgM level is elevated in the first infection by EBV, whereas the VCA-IgG level increases during the period of recovery from EBV infection. We diagnose the states of EBV infection using the combination of these antibodies. BioPlex2200 (BioRad) is an auto-multiplex immunoassay system and we can measure 2 types of IgM and 3 types of IgG at the same time using the reagents for the detection of anti-EBV antibodies with this system. The results of the immunoassay are evaluated as positive or negative on the basis of the antibody index (A.I.), which is a unique unit of the immunoassay. Therefore, in this study, we assessed the utility of BioPlex2200 immunoassay by evaluating its basic performance and comparing this assay with enzyme immunoassay (EIA). The analytical performance of BioPlex2200 showed good precision for within-run validation, whereas between-day validation varies with the subset of antibodies. This BioPlex2200 immunoassay was affected by several interference materials, and thus needs to be improved. The concordance rate of this system with an EIA method was good. Our results suggest that the detection of anti-EBV antibodies with the BioPlex2200 immunoassay system is useful for the rapid diagnosis of EBV infection.

In Japan, almost all laboratories carry out HCO₃⁻ analysis based on the results obtained using blood gas system (BGS). However, at Chukyo Hospital Clinical Laboratory, HCO₃⁻ has been measured as total CO₂ using chemical analyzers for over twenty years. In this paper, we report our recent one-year findings on the differences between HCO₃⁻ measured on the basis of BGS results and HCO₃⁻ measured on the basis of total CO₂ using a chemical analyzer, and the technical factors influencing the total CO₂ measurement. In conclusion, there was a high correlation between the two methods (y = 0.977x + 0.397, r = 0.987). Moreover, the HCO₃⁻ concentration measured as total CO₂ might be influenced by the blood collection volume and the time after collection tube opening.

The BD Vacutainer^® Barricor^TM Plasma blood collection tube (Barricor) with a novel nongel mechanical separator instead of a gel separator was evaluated. Barricor improves sample quality and within-tube stability, and decreased centrifugation time to 3 min at 4,000 g at the shortest. In this study, blood samples from healthy and normal adults were used to compare the product performance between Barricor, an existing rapid-clotting blood collection tube, and an existing blood plasma collection tube with a gel separator. Overall, the differences in test results were clinically acceptable as the differences do not have a clinically meaningful impact on patient treatment and/or diagnosis. For ALP and TG, the within-tube stability differed between the serum collection tube and the blood collection tubes. For potassium and LD, Barricor demonstrated higher within-tube stability than the blood plasma collection tube with a gel separator. In daily routine analysis, fibrin deposition may cause sampling failure and reporting delay. Barricor, which improves centrifuge time and resolves the fibrin deposition problem, can be beneficial for shortening the turn-around time of daily routine work.

The latex turbidimetric immunoassay (LTIA) has been used for the measurement of matrix metalloproteinase (MMP)-3 levels. However, in the cases of healthy infants, the levels of serum MMP-3 are too low to detect by the LTIA method. In this study, we evaluated the analytical performance of a newly developed chemiluminescent enzyme immunoassay (CLEIA) kit, and compared the frequency of nonspecific reactions between the CLEIA and LTIA kits. The within-run and between-run coefficients of variation (CVs) for the newly developed CLEIA kit ranged from 1.1% to 1.6% and from 1.1% to 1.3%, respectively. The detection limit and quantitation limit (at 10% CV) of this new kit were 0.041 and 0.092 ng/mL, respectively. The assay results for the serially diluted sample of MMP-3 showed excellent linearity up to 2,575 ng/mL. The % recovery in the spiked recovery test was in the range from 99% to 107%. An interference test was performed, but no significant interference was observed. Moreover, there was a good correlation between the CLEIA kit and the two LTIA kits (r = 0.995 and r = 0.989). The serum MMP-3 levels were measured in 336 samples with various immunoserological abnormalities using the CLEIA kit and the two LTIA kits. There were 10 samples that showed value divergence among the 3 kits owing to a nonspecific reaction, but there was no sample that showed poor dilution linearity in measurements using the CLEIA kit. On the basis of these results, this newly developed CLEIA kit is useful as a measurement reagent for MMP-3.

Micropipettes are often used to dispense or dilute both patients’ and control samples. Whereas handling of micropipettes is very simple and enables one to take proper amounts of samples rapidly, it is essential to use them exactly according to the operating manual to maintain dispensing accuracy. In this study, we investigated whether the method of manipulating micropipettes affects the accuracy of divided injection by verification experiments including a questionnaire survey to determine the actual status of the manipulation method. We demonstrated that it was excellent both in terms of accuracy and reproducibility if the micropipette with the total capacity near the collection quantity is selected. Moreover, pre-wetting contributed to the improvement of the dispensing accuracy. Forward pipetting (FP) provided higher accuracy of divided injection than reverse pipetting (RP). FP provided a lower value, whereas RP provided a higher one than the theoretical value. FP showed higher reproducibility for water and RP for serum. Therefore, we should basically select FP. However, we should select RP for samples with hyperviscosity. We also found that a large difference in temperature between the tip of the micropipette and the sample affected dispensing accuracy. Various methods of divided injection were used in 91 institutions. In the future, we hope that each institution will keep the manual of the micropipettes used.

Insulin testing is widely used in the diagnosis and assessment of the stage of glucose metabolism disorders. In this study, we evaluated the performance characteristics and clinical utility of “Norudia^® Insulin”. The coefficients of variation (C.V.) for within-run and between-run precisions were 1.25–3.08% and 3.69–8.07%, respectively. Linearity was maintained up to 144.2 μU/mL, and the quantitation limit was 1.0 μU/mL. Prozone effects were observed at ≥ 202.5 μU/mL. There was significant interference by hemoglobin. Comparison with “ARCHITECT Insulin” showed good correlation with a regression equation of y = 0.96x + 1.0 and a correlation coefficient of r = 0.992 (samples from patients not receiving insulin analog formulations). In addition, the reagent was confirmed to not react with insulin analog formulations after analytical recovery testing. The results of a questionnaire survey targeting doctors at our hospital revealed that assays that can selectively measure endogenous insulin are highly desirable; in addition, they can reduced testing times and costs. As such, the assay should be a useful tool in clinical settings.

[BACKGROUND AND OBJECTIVES] A definitive diagnosis of aspergillosis requires a positive culture from a normally sterile site and histopathological evidence of infection. Also, gram staining enables the visualization of fungal elements. They appear as septate hyphae with acute-angle branching. However, their definitive detection by this method alone is difficult because filamentous fungi are difficult to observe under a microscope. The objective of this study is to evaluate “KBM” GP Fluofungi staining (modified Fluofungi staining) for the diagnosis of aspergillosis. [MATERIALS AND METHODS] We obtained 370 smear specimens of purulent sputum with filamentous fungi from 1,385 specimens prepared between July and November 2014. [RESULTS] Septate hyphae as the characteristic fungal morphology were detected in 29 specimens by Fluofungi staining. Correct detection in decreasing order of frequency was made for slides subjected to Fluofungi staining as an alternative to gram staining. Several fungal filaments under microscopy were more clearly observed by Fluofungi staining than by gram staining. However, Fluofungi staining occasionally was stained the thick smear preparation weakly. [CONCLUSIONS] Although the sensitivity of Fluofungi staining is not as good as that of the culture method, this method is rapid and useful for detecting filamentous fungi. It is necessary to develop more sensitive and specific methods for rapid diagnosis.

Autologous blood transfusion has a lower risk of adverse events than allogeneic blood transfusion, and collection of the patients’ own blood is recommended before surgery. In recent years, autologous blood transfusion has been on a downward trend. We statistically analyzed data on blood transfusion carried out in our hospital from 2007 to 2015 and examined the medical records of patients who underwent autologous blood collection in 2012–2014, including the underlying disease, operative procedure, use of allogeneic blood, percentage of wasted bags of blood, administration of erythropoiesis-stimulating agent (ESA) and iron supplementation, fluid replacement, and frequency of vasovagal reaction (VVR). In addition, we investigated the situation in each clinical department that performed autologous blood transfusion. Examined were 367 patients from whom 671 bags of blood were collected. Median age of the patients was 39 years (range, 8–91). ESA was administered to patients younger than 40 years with 2 or more blood collection events (p < 0.05). Allogeneic blood transfusion was avoided in 96.7% of patients with 236 (35.2%) bags wasted. The number of autologous blood transfusions has decreased by 46.7% since 2007, because the departments of urology and cardiovascular surgery no longer performed this type of transfusion. In patients who underwent radical prostatectomy, robot-assisted laparoscopic prostatectomy significantly reduced blood loss compared with laparoscopic radical prostatectomy (150 mL vs 1,050 mL, p < 0.001). The introduction of bloodless surgery contributed to the decrease in the number of autologous blood transfusions in the department of urology. The department of cardiovascular surgery avoided autologous blood transfusion upon termination of service for autologous blood preparation at the Red Cross blood center. In contrast, autologous blood transfusion is used preferably and tended to increase in number in the department of orthopedics, suggesting a turning point for an upward trend as a whole.

The reduction in blood product wastage (BPW) is an important issue in the hospital setting. The aim of this study was to evaluate the measures implemented to reduce BPW, BPW rate, and the causes of BPW using data from 1998–2015. The BPW rate had been reduced from 0.24% to 0.04%. Many measures to reduce BPW had been implemented, including the introduction of various systems, type & screen testing, purchase of irradiated blood products, and full-time shift of medical technologists skillful in blood transfusion. The rate of BPW by doctors or medical technologists had been decreased, whereas that of BPW due to erroneous delivery and handling as part of services had been increased. It is important to share the knowledge of blood transfusion services among hospital staffs.

To diagnose bacterial enteritis, bacteria are cultivated from fecal specimens, but in many cases, the culture needs 3 to 5 days to grow. In cooperation with the pediatrics department, we rapidly detected Escherichia coli, which causes enterohemorrhagic colitis, and Salmonella and Campylobacter, which cause enteritis, as the representative bacteria causing digestive diseases in children, by direct polymerase chain reaction (PCR) analysis of stool specimens. Stool specimens from eight cases (rapid method group) requiring hospitalizations in the pediatric department of our hospital from March 2015 to November 2016, in which bacterial enteritis was suspected, were subjected to direct PCR analysis and a culture method. Nine cases (conventional method group) from 2011 to 2015 were diagnosed only by stool culture. The diagnosis time by direct PCR analysis was within 3 to 5 hours (average 0.20 days). In contrast, the mean diagnosis times were 3.68 and 4.22 days for the cultivation of stool specimens from the rapid method group and the conventional method group, respectively. There was no significant difference in the diagnosis time between the rapid method group and the conventional method group using culture methods, but there was a significant difference between the diagnosis times using PCR versus culture (p < 0.001). Furthermore, a significant difference was observed in the hospitalization period between the rapid method group and the conventional method group (p < 0.005). The use of direct PCR analysis of fecal specimens, which gives results in hours, contributed to the shortening of the diagnosis time and the hospitalization period compared with the culture method, which requires several days to obtain a result.

A biobank is an organization that collects human biomaterials and their related clinical information for future medical research. In recent years, the number of biobanks has been increasing worldwide. Various biomaterials are collected according to the specific purpose of each institution. In September 2013, we launched the Cancer Biobank (CBB) Project and started to collect biomaterials from cancer patients who visit the Kyoto University Cancer Center. Through the hospital biobank, we collected detailed clinical data from each patient in a longitudinal manner using electronic medical charts and recorded them in our original prospective cohort database. Initially, CBB started with two departments, but now ten departments have joined CBB. In April 2015, we introduced clinical sequencing using multiplex cancer-gene assay (OncoPrime^TM) based on infrastructure of CBB. CBB is managed by six members: one coordinator who assists patients in providing informed consent and is responsible for ordering blood samples at the designated time point, two members who collect and process biomaterials and anonymize them in a linkable manner, one member who retrieves clinical information using electronic medical charts, and two members who are in charge of clinical sequencing. Here, we report the history and current status of our CBB Project.

Recently, the Japanese Committee for Clinical Laboratory Standards (JCCLS) has generalized the global standard for Reference Intervals (RIs), the so-called “Common RIs”, which play a critical role in analyzing various clinical laboratory data. It is essential to standardize RIs for data linkage among institutions. In Okayama Prefecture, some flagship hospitals began to introduce them. Our institution also started to use the Common RIs from July 2016 after having finally gained approval. We were required to confirm and improve many factors for problems related to various systems and texts owing to the conversion of the notational system in complete blood count tests. Even though the actual modification included many major revisions in the laboratory information system, electronic medical record system, related department system, related documents, analytical devices, and WEB, we were able to start using the Common RIs without serious problems by advance preparation and cooperation with other divisions. Currently, laboratory data are linked to various systems inside or outside the hospital. The laboratory institutions are responsible for maintaining the consistency or the operational management system. In the future, we expect to introduce the Common RIs across all Japanese institutions and thereby to analyze laboratory data on the basis of the same criteria used nationwide.

A hemin-requiring Pseudomonas aeruginosa small-colony variant (SCV) was isolated from the blood of a patient with double pneumonia. The isolate was capable of growing on both blood and chocolate agar plates but not on MacConkey agar plates without blood. Furthermore, the isolate failed to grow on triple-sugar iron agars. The microscopic morphology of the isolate was similar to that of Haemophilus species. When examined the auxotrophy using X-factor (hemin)- and V-factor (NAD)-impregnated discs on the Mueller-Hinton agar plate, the isolate grew only around the X-factor (hemin)-impregnated disc. However, when using the VITEK2 system, the isolate was identified as Acinetobacter lwoffii. The isolate was finally identified as P. aeruginosa by 16S rRNA gene sequencing and MALDI-TOF MS analysis. SCV phenotypes are related to persistent and recurrent infections. Moreover, it is difficult to identify SCVs because of their atypical colony morphology and altered biochemical profile. The accurate identification of SCVs is important for effective antimicrobial treatment. To the best of our knowledge, this is the first clinical isolation of a hemin-dependent P. aeruginosa SCV.

A patient wished that the Holter electrocardiogram be detached. However, with the extension of recording, we detected a paroxysmal atrioventricular block. We encountered the case of a patient that showed the importance of elucidating subjective symptoms before detaching the device. The patient was a 78-year-old female, who was conscious about two weeks previously. However, her consciousness level gradually decreased. We performed an emergency outpatient examination. Head CT showed no abnormality. An abnormality in liver function was confirmed by a blood test. A close examination of the cause of consciousness loss due to a seizure became necessary. After fitting a Holter electrocardiogram for precise examination, the patient was introduced to a gastroenterologist the following day. We visited the patient the following morning. The patient requested that the Holter electrocardiogram be removed before seeing her gastroenterologist. There were no subjective symptoms after a recording of 16 hours. After examining the patient and consulting with her gastroenterologist, it was decided that the Holter electrocardiogram be removed. A seizure occurred while she was waiting for her consultation and she became unconscious. At the time of her seizure, a paroxysmal atrioventricular block appeared. The patient showed no signs of cardiac arrest about 2 seconds or more before the Holter electrocardiogram was removed. The patient was accurately diagnosed when the Holter electrocardiographic measurement was resumed. Patients who require elucidation of their subjective symptoms should undergo recording for as long as possible until the subjective symptoms are detected.

Lithium (Li) is often used as a therapeutic agent for manic depression. Since the therapeutic dose is only slightly different from the toxic one, therapeutic drug monitoring is always necessary. Since Li is metabolized by the kidney, toxic symptoms easily develop in patients with impaired renal function. Here, we report the cases of two patients who were diagnosed as having Li toxicosis after coming to our hospital with loss of consciousness (LOC). Case 1: A thirty-year-old woman took multiple drugs at high doses including 12,800 mg of Li with suicidal intent. The concentration of Li in the blood was 13.2 mEq/L. The patient had renal dysfunction. After receiving continuous hemodialysis (CHD) for 30 hours, the Li concentration decreased to 1.2 mEq/L. Twenty-one hours after the completion of CHD, the Li concentration became 0.8 mEq/L. She was discharged from our hospital without showing signs of relapse. Case 2: In an 80-year-old woman with appetite loss, Li concentration was routinely measured. The administration of 400 mg/day Li maintained Li within the range of therapeutic concentrations. On arrival at our hospital, the concentration of Li increased to 1.8 mEq/L owing to renal dysfunction after dehydration. By fluid therapy, she recovered on the same day. We calculated the total number of patients in whom the Li concentration was measured in our laboratory over the past 17 years and confirmed that the Li concentrations in 19 (40.4%) out of 47 patients with LOS reached the toxic range. It is useful to measure the Li concentration in LOC patients taking Li.

In cases of hypergammaglobulinemia due to hematological malignancy, it has been reported that nonspecific reactions are often observed in test items that are affected by the antigen–antibody reactions. We here report on a case of angioimmunoblastic T-cell lymphoma (AITL) that exhibited false high levels of the fibrin/fibrinogen degradation product (FDP) and D-dimer (D-D). The patient was a woman in her 60s. She was diagnosed as having AITL on the basis of multiple lymphadenopathy, rash, and symptoms of liver and lung infiltration. On day 9 of hospitalization, the D-D level was found to be elevated, with the error message “prozone” displayed. As it appeared that the level exceeded the detection range of the device, dilution measurement was performed. As this resulted in a markedly lower level than the theoretical value, a nonspecific reaction was suspected and detailed tests were conducted. As immunoglobulin levels had increased when false high levels of FDP and D-D were detected, and dithiothreitol (DTT) processing decreased measurement values, we estimated that IgM was involved in causing the false high values. Western blotting results also suggested that the diluted measurement values were close to the true levels. As was shown for our patient, when false high levels of FDP and D-D are exhibited with no clinical hemorrhagic or thrombotic symptoms, dilution measurement could be a simple and effective method for determining whether a nonspecific reaction has occurred.

We encountered a case of bloodstream infection caused by Anaerobiospirillum succiniciproducens. The patient was an 80-year-old male who visited our hospital because of fever and inappetence. He had also experienced symptoms of sore throat and cough since he started to have his dog indoors. Upon observing an infiltrative shadow in the right inferior lobe of his lung by chest X-ray and chest computed tomography (CT), he was diagnosed as having pneumonia and admitted to the hospital. The blood culture obtained at the time of admission grew anaerobic spiral-shaped gram-negative bacillus cells, which were identified as A. succiniciproducens by 16S rRNA gene sequencing. He already had started treatment with sulbactam/ampicillin (SBT/ABPC) for bacterial pneumonia since the time of admission. Therefore, we did not change the antibiotics but extended the duration for the treatment of bloodstream infection based on the gram staining result of his blood culture. After the completion of the antibiotic treatment and the recovery of his general condition, he was discharged. Although there are only a few cases of bloodstream infection by A. succiniciproducens, it is still important to have collective knowledge on the process of pathogen identification and treatment outcomes.

We have launched an in-house clinical sequencing system called “CLHURC” (Clinical Sequence System in Hokkaido University Hospital for Cancer Individualized Medicine) and carried out exhaustive targeted exome sequencing for all types of cancer patients as an outpatient service since April 2016. The clinical sequencing system opens new routes for therapeutic intervention and clinical examination. DNA extracted from formalin-fixed tissues is fragmented and also contains DNA lesions that are sources of sequence artifacts. Sequence artifacts can be difficult to distinguish from true mutations, especially in the context of tumor heterogeneity, and have increasingly become an interpretive problem in this era of massively parallel sequencing. We have to maintain the quality of the clinical sequencing system, and understanding the problems and solutions is important. Thus, we are taking measures for many problems that might be encountered when using this system. In this paper, we present clinical sequencing for comprehensive genomic profiling for cancer called CLHURC.