Patients diagnosed as having chronic kidney disease (CKD) are known to be at a high risk not only for progression to end-stage renal disease, but also for cardiovascular disease and sudden death. Only a few studies have shown the association between CKD and electrocardiographic (ECG) parameters. We aimed to study prognostic factors based on ECG parameters in patients with CKD. Among 16,424 patients who underwent evaluation with 12-lead ECG and blood sampling between April 2009 and March 2010, 3,325 patients with an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m² were included in this study. We excluded 3,509 patients diagnosed as having atrial fibrillation and ventricular arrhythmia. Univariate and multivariate analyses were carried out to assess the association of age, sex, severity of CKD, and ECG parameters (heart rate, PR interval, QRS interval, QTc interval, and left ventricular hypertrophy) with cardiovascular/noncardiovascular death. Heart rate > 100 bpm and a QTc interval ≥ 440 were significant markers of risk of both cardiovascular and noncardiovascular death. In patients diagnosed as having CKD, a heart rate > 100 bpm and a QTc interval ≥ 440 were factors for poor long-term prognosis independent of age, sex, and severity of CKD.

To determine whether the short-term assessment of pulse rate variability (PRV) is a surrogate for that of heart rate variability (HRV) in an elderly population under resting conditions, we collected photoplethysmography (PPG) and electrocardiography (ECG) signals simultaneously, and analyzed their association and agreement with HRV and PRV components. We divided the elderly population into three groups, namely, those younger than 70 years (< 70 yrs), those older than 70 years and younger than 80 years (70–79 yrs), and those older than 80 years (≥ 80 yrs), and we found that PRV was more underestimated than HRV with increasing age, although the PRV components highly correlated with the HRV components in the three groups. Thus, PRV can be used to examine the autonomic nervous system (ANS) function in elderly populations. However, the interpretation of results should consider the effect of aging, particularly in those older than 80 years.

This study was designed to clarify the epidemiology of carbapenemase-producing Enterobacteriaceae (CPE) in Aichi Prefecture, and to evaluate the screening cut-off value of meropenem (MEPM) for the detection of CPE isolates. A total of 175 Enterobacteriaceae clinical isolates from 14 hospitals in Aichi Prefecture were tested for carbapenemase genes and MEPM susceptibility. As a result, we detected 92 CPE isolates that included 1, 1, 63, 21, 1, 2, 1, and 2 isolates with KPC-2, GES-5, IMP-1, IMP-6, NDM-1, NDM-5, and OXA-48-like genes. These CPE isolates had MEPM minimum inhibitory concentrations (MICs) that ranged from 0.25 to > 32 μg/mL. Among them, 14 (15.2%) isolates showed MEPM MICs < 2 μg/mL, and that clinical MIC breakpoints were interpreted to indicate susceptibility. Therefore, we concluded that MEPM MICs > 0.125 μg/mL (which is the cut-off value of the European Committee on Antimicrobial Susceptibility Testing Guidelines) is suitable for screening for CPE. We believe that enforcement of continuous monitoring, including surveillance of CPE based on MIC and a molecular approach, is important to prevent the future spread of CPE.

Most Corynebacterium species are gram-positive, rod- shaped bacilli. Here, we report on Corynebacterium showing a coccoid form similar to Staphylococcus detected from positive blood culture bottles. We performed several cultivation methods to study the presence or absence of possible morphological changes, identify particular species showing these changes, and evaluate the causes of the changes. In addition, we conducted further experiments on Corynebacterium strains that showed a coccoid form, when classified using MicroScan Panels. Moreover, we investigated the drug sensitivity rate of Corynebacterium species. The results showed that Corynebacterium striatum and Corynebacterium simulans presented a coccoid form when cultivated using liquid media under anaerobic conditions. Furthermore, the strains showing a coccoid form were identified as Micrococcus spp. using MicroScan Panels. Of the antibiotics tested, all strains were susceptible to vancomycin (VCM). However, many strains only showed susceptibility to VCM and were highly resistant to other antibiotics tested. Corynebacterium strains are identified as common contaminants detected from blood cultures. Despite the reports as contaminants, a high percentage of isolates showed resistance to many antibiotics. In addition, Corynebacterium strains are reported as the causes of nosocomial infections. In summary, we found that misidentification of Corynebacterium strains from blood cultures is a clinically significant problem that can lead to poor outcomes in patients, highlighting the importance of accurate clinical results.

Matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF) can identify bacteria from positive blood cultures. Commercial sample preparation kits are available. However, such commercial kits are very expensive, making it difficult to introduce them into routine clinical microbiology laboratories. We compared the in-house preparation method and a commercial kit (Sepsityper kit). In total, 100 monomicrobial cultures were prepared in this study. The total identification rate was 67% by the in-house method and 66% using the Sepsityper kit. The identification rates of gram-positive cocci were 40% by the in-house method and 45% using the Sepsityper kit. The identification rates of gram-negative rods were 92% by the in-house method and 87% using the Sepsityper kit. The processing time of our in-house method was the same as that of the Sepsityper method. Our new method does not use a special reagent and the cost is low. We demonstrated that our in-house method is superior to the Sepsityper kit.

<Objectives> The classification of cells in the CAPD drainage is important as an index for the early diagnosis of peritonitis in peritoneal dialysis patients. The automated hematology analyzer XE-5000 can be used to measure body cavity fluid samples in the body fluid cavity mode. The aim of this study is to examine the utility of XE-5000 for the classification of cells in the CAPD drainage. <Methods> From August 2014 to December 2016, we collected 87 CAPD drainage samples. We examined the correlation between XE-5000 and the manual method for classifying mononuclear cells, polymorphonuclear cells, and mesothelial cells. <Results> A significant correlation was found between XE-5000 and the manual method for mononuclear cells and polymorphonuclear cells. The correlation between XE-5000 and the manual method for mononuclear cells and polymorphonuclear cells tends to be strong because there was a high measurement cell count by XE-5000. On the other hand, no correlation was found for mesothelial cells. <Conclusions> Our data suggest that the correlation between XE-5000 and the manual method was approximately good. Although it is important to set a practical configuration to add the manual method as needed, XE-5000 seems to contribute to labor saving in the test, and results on the classification of cells in the CAPD drainage are rapidly obtained using XE-5000 as a screening test.

Lipase levels in blood are routinely measured for the diagnosis of acute pancreatitis. Such measurements are performed by colorimetric or synthetic substrate assays; however, these assays have not yet been standardized. In this study, we evaluated the performance of a new reagent for lipase measurement, “Cygnus-auto LIP”, using the synthetic substrate “DGGMR”. The coefficients of variation for within-run and between-day reproducibilities were 1.0% to 1.4% and 0.8% to 2.1%, respectively. In the accuracy test conducted using JCCLS CRM 001c, the biases from the reference values were +2.6% for Cygnus-auto LIP and −53.5% for the Nescauto VN lipase. We hypothesize that the large difference was due to the choice of the standard material. The range of the linear quantification of lipase levels is between 4.0 and 460 U/L. This range is sufficient for the diagnosis of acute pancreatitis, since usual lipase levels are approximately twice the maximum reference value. The reagent is stable within 30 days after initial use. To test the interference of various substances, the presence of sodium azide showed at least a 20% decrease in the measured lipase levels. However, this improved reagent did not change the measured lipase levels. A significant correlation was observed between Cygnus-auto LIP and Nescauto VN lipase levels, but the actual measured values were very different. The lipase levels were successfully measured using Cygnus-auto LIP under any conditions. Therefore, this reagent may be a candidate for standardized routine use.

The morbidity and mortality of colorectal cancer have been increasing yearly in Japan, and early detection and early treatment are the most important methods to reduce the mortality. In this study, we investigated the fundamental performance of HM-JACKarc^®, an automated fecal occult blood test analyzer, which is a new system for measuring the amount of hemoglobin present in stool for screening. The coefficients of variation (CV) ranges were 0.6–1.6% for the within-run reproducibility and 3.6–5.2% for the between-run reproducibility. The lower limit was 4.0 ng/mL, and the satisfactory dilution linearity was obtained at 400 ng/mL. After measuring a solution with a theoretical hemoglobin concentration of 360,000 ng/mL, the first measurement of the 0 concentration sample did not exceed the cut-off value (30 ng/mL) in a carry-over examination. Although the results could not completely deny the effect of carry-over in abnormally high concentration samples, it is considered that this problem can be entirely avoided by, for example, the proper operation and utilization of the inspection system. In the prozone test, high sensitivity was obtained up to 400 ng/mL, which is the upper limit of measurement. A linear relationship with conventional equipment was obtained. The estimated regression equation was constructed as y = 0.957 − 0.421, the correlation coefficient was 0.995, and the agreement rate was 96.6%. The equipment was estimated to be useful for the screening for colorectal cancer, because the operation method is simple, and the measurement results can be reported quickly and accurately to the clinic in routine examination.

Plasminogen activator inhibitor-1 (PAI-1), an inhibitor of fibrinolysis, is induced by inflammatory cytokines. Therefore, an increase in the concentration of PAI-1 is a significant factor for sepsis-associated disseminated intravascular coagulation. In this study, we evaluated the fundamental performance of the new reagent kit “nanopia PAI-1” for the measurement of PAI-1. The coefficient of variation (CV) of within-run precision was in the range of 1.29–3.85%. In the examination for on-board reagent stability, the concentration of PAI-1 was reduced from day 6 after the first reagent installation, whereas the CV of between-day precision in the case of installing the reagent in each measurement was stable at 2.32–5.09%. No effects of interfering substances on the measurement nor the prozone phenomenon were observed. Satisfactory results were obtained in terms of linearity and quantitation limit. The correlation with the control reagent was strong. In addition, because PAI-1 exists in platelets, we examined the effect of residual platelets on PAI-1 plasma levels. While no difference in PAI-1 was observed among the fresh samples immediately after the preparation of the platelet concentrate, the PAI-1 concentration of the freeze-thawed samples increased with platelet count and the number of freeze-thawing cycles. Therefore, the sample preparation based on the “Expert Consensus on Standardization of Sample Preparation for Clotting Time Assay” and the restriction to one freeze-thawing cycle are necessary for storing the sample for PAI-1 measurement. In conclusion, these results indicate that nanopia PAI-1 has good performance and is valuable for routine and emergency laboratory tests.

Recently, the number of patients with type I allergic disease has been increasing. The specific IgE test is one of the important tests for the diagnosis and treatment of allergic diseases. In our laboratory, we utilize two analyzers for specific IgE, namely, DiaPack3000 and MAST III. We can properly use these analyzers depending on the situation. We evaluated these analyzers and compared their performances. For specimens from pediatric departments, it is difficult to obtain specimen enough, and reducing amount of specimen is an important issue. Therefore, we also compared the standard volume method and the reducing volume method. Concerning the class correlation between MAST III and DiaPack3000, good correlation was found for Japanese cedar, Dermatophagoides farinae, and cat dander. On the other hand, for egg whites and ovomucoid, a weak positive and partial divergence was observed. However, the possibility of clinically affecting the results is unlikely. Therefore, it seems that it can cope with the transition from screening by MAST III to follow-up observation by DiaPack3000. For DiaPack3000, a good correlation was found between the standard volume method and the reducing volume method. We believe that further clinical support can be expected by increasing the number of items examined reducing volume by reducing the sample volume.

In this essay, I will report on the certificates and systems of laboratory science in Australia on the basis of my visit to an Australian laboratory in 2015. Different from a Japanese laboratory scientist, the Australian scientist is classified into two types of profession: laboratory scientist and clinical physiologist. Each type requires its own respective certificate. Although a Japanese certificate is given to these professionals, they can be identical to these different types of profession in Australia. In Australia, it is necessary to graduate from the prescribed graduate school in order to work as a laboratory scientist. I will introduce a certificate that is awarded by the Australian Institute of Medical Science (AIMS), how to apply for the examination, and what types of questions are asked. On the other hand, clinical physiologists also have to complete their medical degrees as mentioned above. However, there are various qualifications required to work in this field. Moreover, it is mentioned that the South Eastern Area Laboratory Service (SEALS) is a leading public-sector laboratory service in Australia, which is an example of an Australian laboratory.

In 2014, our hospital acquired the international standard ISO 15189:2012 that specifies the requirements for quality and competence in medical laboratories. This standard requires traceability in all processes of laboratory tests and strict management of reagents for the tests, and therefore, detailed recording is necessary. Initially, handwriting on datasheets was used in our laboratory. However, this method required a lot of work, was time-consuming, and caused entry errors. To solve these problems, we constructed a reagent management system using the GS1-128 barcode. To develop its program, we used Visual Basic for Applications in Microsoft Excel. Automatic recording using the barcode and program increased the efficiency of the recording work and prevented recording errors. In addition, electronic data reduced mistakes such as the use of expired reagents, and improved ordering efficiency. To provide accurate and safe laboratory test services, reagent ordering, inventory management, management of reagent lot numbers and expiration dates for use, and recording of the initiation and discontinuation dates of reagent use are indispensable. Our reagent management system increases the efficiency of such recording, facilitating smooth laboratory test services.

Neisseria animaloris is a gram-negative bacterium that is characterized by its ability to ferment saccharose. N. animaloris has a gram-stained image and forms colonies that resemble those of the genus Pasteurella. We encountered an interesting case of sepsis, in which both Pasteurella multocida, which is commonly detected from cat-bite-infected wounds, and N. animaloris, which is rarely detected from blood culture samples, were found. The patient was a woman in her 60s. She was diagnosed as having breast cancer a few years ago and has been treated. However, the disease has progressed and it is in the end-stage. She visited our hospital owing to severe malaise and pain of the left axilla. She kept 10 cats in her house. There was a cat bite wound, redness, and swelling in the back of her right hand. The bacterium from her cat bite wound were identified as P. multocida by MALDI Biotyper. The bacterium from her blood culture were identified as N. animaloris by 16S rRNA genetic analysis. There are only a few case reports on N. animaloris, and its clinical significance is yet to be determined. In this patient, bacteria of different genera were detected from different parts of her body. However, it is well known that N. animaloris belongs to the normal bacterial flora of cats and dogs, and there is no doubt that it is the cause of this sepsis.

Cerebrospinal fluid (CSF) is often examined for the differential diagnosis of meningitis. In the laboratory, we count the white blood cell number and differentiate between mononuclear and polymorphonuclear cells by Samson staining. The increase in the number of polymorphonuclear cells mainly suggests bacterial meningitis; however, the percent increase in the number of eosinophils in CSF is rarely investigated, which is indicative of eosinophilic meningitis. Eosinophilic meningitis is a rare disease and is usually caused by parasitic infection. Pathogenetic factors other than infection, such as intraventricular shunt malfunction, however, can also cause this disease. Here, we present 4 case reports of eosinophilic meningitis, which was suspected on the basis of cytological analysis using Samson staining in the examination of CSF. Although eosinophilic meningitis is diagnosed when the percentage of eosinophils is over 8% of the total CSF white blood cell count determined by May-Giemsa staining, the examination by Samson staining has an advantage because it is easy and fast. Therefore, the cases presented in this report suggest that the classification of polymorphonuclear cells by Samson staining is useful for the differential diagnosis of meningitis.

A 47-year-old male patient noticed a reddish brown coloration of his urine, and visited our hospital. The urinalysis revealed strongly positive occult blood and microscopically few red cells. In spite of a slightly elevated urinary myoglobin level, clinical manifestations and an increased activity of creatine kinase associated with myoglobinuria were not found. Presence of free hemoglobin in serum indicated hemoglobinuria. Increased activity of serum LD (especially of LD1), AST, and hyperbilirubinemia (indirect being dominant), a decreased haptoglobin level, and reticulocytosis indicated the presence of hemolytic anemia. However, the results of direct and indirect Coombs tests were negative. Thus, autoimmune hemolytic anemia (AIHA) was not confirmed. Paroxysmal nocturnal hemoglobinuria (PNH) that gave rise to hemoglobinuria was ruled out by absence of PNH cells shown by CD 55/59 analysis. His cold agglutinin titer was normal. He had no history of congenital hemolytic anemia. The fact that his hemolytic episode with intermittent hemoglobinuria appeared during the coldest season of the year, in addition to the low agglutinin titer and negativity for PNH cells, suggested paroxysmal cold for hemoglobinuria (PCH). The Donath–Landsteiner (DL) test was performed two weeks after the first visit. However, the results were negative. The hemolytic episode seemed to have been maximal a few weeks before the 1st visit, and it almost terminated by the 2nd visit (2 weeks later) when the DL test was carried out. Although, no conclusive diagnosis for PCH was achieved, PCH was the most likely diagnosis being considered on the basis of the hemolytic episode with intermittent hemoglobinuria in a relatively short period during the coldest season. Timely performance of the DL test would be mandatory for the diagnosis of PCH on hemolytic involvement with hemoglobinuria during the cold season.

We experienced treating a patient diagnosed as having acquired von Willebrand syndrome (AvWS). During hospitalization, he required daily blood transfusion of red blood cells owing to exacerbation of anemia due to sustained massive bleeding from advanced cancer of the esophagogastric junction and deterioration of the general condition. The patient was a male in his forties. His APTT (28.3 s), which was normal at the time of admission, was markedly prolonged on the 28th day of hospitalization (> 180.0 s). The coagulation factor VIII activity was reduced to 9%; hence, acquired hemophilia A was suspected, but the factor VIII inhibitor was not detected (0.00 BU). The cross mixing test since incubation at 37°C for 2 hours showed an upwardly convex inhibitor pattern, inhibitor type AvWS was suspected. As a result of promptly providing the above examination results to the attending physician, steroid pulse therapy was performed without waiting for the diagnosis to be confirmed. Consequently, the bleeding rapidly decreased, and the condition of the whole body improved. A confirmatory diagnosis of AvWS was obtained from the subsequent examination results. It was a case that could be treated early from the examination of clinical symptoms, which can be carried out at any institution.

We report a case of extranodal NK-/T-cell lymphoma of the nasal type (ENKTL), with bone marrow involvement in a 26-year-old female. One of the authors collected the patient’s blood sample and found lesions on the skin of her arms and knew that the skin lesions were initially purpura-like and gradually enlarged as big as a hen’s egg, and became ulcerated. Other similar skin lesions appeared in the abdomen, lumbar region and lower legs. Malignant lymphoma was suspected from these signs, and many large granular lymphocytes (LGLs) were found in her blood sample. These lines of evidence were immediately reported to a hematologist. Histologically, LGLs diffusely infiltrated in the dermis and subcutaneous tissue, as well as the bone marrow. Finally, the patient was diagnosed as having skin ENKTL.

The sensation of cold feet was examined in contrast to skin temperature and skin perfusion pressure (SPP) in hemodialysis (HD) patients with and without diabetes. The subjects comprised 204 HD patients. Their ages ranged from 25 to 91 years. Dialysis history ranged from 1 month to 34 years and 1 month. We interviewed the subjects about their foot symptoms, measured the skin temperature of their feet using an infrared skin thermometer, and measured plantar SPP. The sensation of cold feet was experienced by 31 diabetic patients and 31 nondiabetic patients. While toe and plantar temperatures were significantly lower in diabetic patients with a sensation of cold feet, there were no significant differences in toe and plantar temperatures between nondiabetic patients with the sensation of cold feet and those without the sensation. A positive correlation was observed between skin temperature and plantar SPP in diabetic and nondiabetic patients. Plantar SPP was significantly lower in diabetic patients than in nondiabetic patients. In HD patients, a correlation was found between foot skin temperature and plantar SPP, and the low skin temperature of the feet in HD patients therefore appears to be attributed to impaired blood flow in the capillaries of the feet. Furthermore, diabetic HD patients with the sensation of cold feet also showed low foot temperature and low plantar SPP, which suggested the involvement of microangiopathy and vasomotor abnormality caused by autonomic disorder, which are complications of diabetes.

We report here a case of mesenteric lymphadenitis with bacteremia caused by Salmonella Gabon and Yersinia enterocolitica. A 16-year-old male patient was admitted with fever and abdominal pain associated with mesenteric lymphadenitis. Fluid therapy with oral clarithromycin (CAM) was started. However, since his abdominal pain and fever persisted, oral administration of CAM was switched to that of levofloxacin (LVFX). Two types of Gram-negative bacilli were detected from culture of blood collected on admission. Biochemical analysis of the isolates demonstrated Salmonella sp. and Yersinia enterocolitica. Salmonella sp. was identified as Salmonella enterica subsp. enterica serovar Gabon (O7: l, w: 1, 2) by an immunoserological test. As it is difficult to detect Y. enterocolitica at 35°C, it is necessary to culture it at 25°C. In this case, it was possible to detect these bacteria by both adding a selective medium and changing the incubation temperature according to clinical information. When samples are subjected to a bacterial isolation test, it is important for both physicians and clinical microbiologists to share the information of patients and organisms causing the diseases.

The patient was a 78-year-old man. He felt bothered by the brightness of the setting sun while driving his car in the late afternoon, and experienced sudden spasms of his right hand, panicked, and collided against a guardrail. Magnetic resonance imaging of the head with a fluid-attenuated inversion recovery sequence revealed scattered high-intensity areas, and head magnetic resonance angiography showed stenosis of the right middle cerebral artery. About one second after initiating photic stimulation at 3 Hz during an electroencephalography (EEG) test, small spikes and slow waves occurred with frontal lobe dominance. Immediately after initiating photic stimulation at 12 Hz, spasms of the face and upper body occurred, and the patient did not respond when his name was called. The spasms ended after approximately 10 s, and he responded to his name being called again. This patient was clinically diagnosed as having symptomatic epilepsy on the basis of a medical interview, imaging findings, and epileptic discharge on EEG. With the arrival of the superaging society, the prevalence of epilepsy, which has been perceived as a pediatric disease, is expected to increase in the elderly as well. As epilepsy is a disease that can be treated pharmacologically, medical technologists administering EEG examinations, long-term care facility staff who work in close contact with many elderly individuals, and community care managers should be aware of elderly epilepsy.