The aim of our study is to compare the diagnostic accuracy of salivary fine-needle aspiration cytology between the conventional method and BD CytoRich^TM liquid-based cytology (LBC). We examined 520 specimens, which included 312 specimens prepared by the conventional method and 208 specimens prepared by the BD CytoRich^TM method. The average number of slide glasses prepared in the conventional method was 3.5 slides, while that in BD CytoRich^TM was only one slide. The number of undiagnosed cases was significantly higher in the conventional method (35.3%) than in the BD CytoRich^TM (12.0%). The sensitivity (92.4%), diagnostic accuracy (91.7%), positive predictive value (76.2%), and negative predictive value (96.8%) were significantly higher in the CytoRich^TM method than in the conventional method (p < 0.001). The BD CytoRich^TM method enable the collection of all cells in the samples by the direct-to-vial route and preparation of high-quality cytological slides owing to the high rates of cell collection by centrifugation and cell adhesion to the charged glass slides. This method contributes to the decrease in the number of undiagnosed cases and the increase in the diagnostic accuracy of salivary fine-needle aspiration cytology.

During the 1-year period from January to December 2016, 318 strains of Haemophilus influenzae were isolated at our pediatric department from patients aged 29 days to 12 years and 9 months old (median age: 3 years and 0 months). Using these clinical isolates, the capsular type, β-lactamase production, and MICs of 13 antimicrobials (ABPC, PIPC, CTX, CTRX, CDTR, CFTM, AMPC/CVA, PAPM, MEPM, CAM, AZM, TFLX, and LVFX) were investigated. Then, the results were compared with those of three previous studies conducted at the same department (in 1999, 2005, and 2009). The capsular type was nontypable (NT) in 97.8%, type e in 1.9%, and type b in 0.3%. The isolation rate of NT was the highest among the 4 studies, while the isolation rate of type b was the lowest. Resistance (including intermediates) to ABPC, CTX, AMPC/CVA, MEPM, CAM, and AZM was found in 74.8%, 0.9%, 55.7%, 5.3%, 25.8%, and 1.6% of the isolates, respectively. No isolate was resistant to CTRX or LVFX. The ABPC-resistant isolates were BLNAR in 64.5%, BLPAR in 6.6%, and BLPACR in 3.8%, indicating an increase in the BLNAR isolation rate. In Japan, the Hib vaccine became part of the routine vaccination schedule in April 2013, so it is important to carefully monitor the capsular types and antimicrobial susceptibilities of H. influenzae.

We evaluated procalcitonin (PCT) measurement and the storage container used for the measurement. There is no effect of adding serum (200 μL or 1,000 μL) to a blood collection tube (p = 0.92). The PCT levels after transferring serum to A company sample cup and B company sample tube decreased by 5.6 ± 2.9% and 3.8 ± 2.0%, respectively. After transferring for the second time, the PCT levels decreased by 7.4 ± 3.5% and 11.0 ± 4.6%, respectively. There is no effect of contact time between 0 and 2 h with the sample tube (4.8 ± 2.7% vs 4.3 ± 4.6%, p = 0.61). The PCT levels in the area of contact with the sample tube (7.3 cm² and 21.1 cm²) decreased by 5.0 ± 3.7% and 9.5 ± 5.2%, respectively. The PCT levels after transferring serum to C company storage tube, D company storage tube, and E company storage tube decreased by 6.9 ± 1.9%, 6.7 ± 2.8%, and 4.2 ± 2.9%, respectively. After transferring serum for the second time, these values decreased by 13.8 ± 3.3%, 14.0 ± 4.1%, and 12.9 ± 3.2%, respectively. After the third time, they decreased by 21.6 ± 2.3%, 21.7 ± 4.8%, and 20.1 ± 3.0%, respectively. We have to pay attention to the false low level, when transferring serum from various cups and tubes more than once.

Pretesting before medical practice is becoming prevalent from the viewpoints of prompt initiation of treatment and reduction of burden on patients. To investigate the possibility of expediting the process from sample collection to result reporting, the basic performances of TSH, FT4, and FT3 were determined by chemiluminescent enzyme immunoassay on an automatic analyzer named Accuraseed, which can finish one measurement in 10 min. We also report on the comparison of rapidity between Accuraseed and the routine modular device, ARCHITECT, and Lumipulse. We evaluated the reproducibility (simultaneous, day difference), correlation, minimum detection sensitivity, linearity, and influence of coexisting substances as basic performances of these three thyroid assays. As a result, the regression equation slope (Accuraseed shows a decreasing tendency) and one diverging sample were found to correlate with the routine modular, but in all other investigations such as simultaneous reproducibility and minimum detection sensitivity, good results were obtained. For the divergent sample observed in the FT3 assay, it is considered to be influenced by heterophilic antibodies according to the observation of measured value behavior after PEG treatment. In the comparative study of rapidity, the time from applying a sample rack with five samples (three assays per sample) into the analyzer to the result output of Accuraseed and the routine modular, ARCHITECT, and Lumipulse was measured. As a result, the time until the first result output of ARCHITECT was about 5 min and that of the Accuraseed was about 7 min. The time to reporting the results of all the five samples (15 tests) is 15 min for Accuraseed, and the times to reporting for the routine modular, ARCHITECT, and Lumipulse are 27, 33, and 37 min, respectively. Our results indicate the possibility of shortening TAT using Accuraseed.

Clostridium difficile is a pathogen causing antibiotics-associated colitis. Appropriate infection control for patients with C. difficile is required to prevent nosocomial infection. Immunochromatography with C. DIFF QUIK CHEK COMPLETE (Aerial Medical) (QUIK CHEK), which detects C. difficile-specific glutamate dehydrogenase (GDH) and toxins (CD toxins), is used as the screening test for C. difficile infection. It has been reported that the sensitivity of QUIK CHEK in detecting CD toxins in stool is relatively low. Therefore, when samples test positive for GDH but negative for CD toxins using QUIK CHEK, stool samples are processed for bacterial culture. If C. difficile colonies are obtained, they are tested for CD toxins by the same assay. However, it takes about 2 days for colonies to form, thus delaying the diagnosis of C. difficile infection. To solve this problem, we conducted real-time PCR analysis to detect the CD toxin B gene using BD MAX CDIFF (Becton, Dickinson and Company). The sensitivity of BD MAX CDIFF in detecting the CD toxin B gene was shown to be higher than or equal to that of QUIK CHEK to detect GDH of C. difficile. When we tested 38 clinical samples, 24 samples tested positive for GDH but negative for CD toxin B, and the results of 22 of them tested using BD MAX CDIFF almost agreed with those obtained using QUIK CHEK. Taken together, BD MAX CDIFF is considered as a quick and useful tool for the confirmation of the presence of CD toxins in samples.

A QIAGEN method using a QIAamp DNA Mini Kit, which is conventionally used to extract DNA, is complicated and takes a long time to perform. If we select the method using a Loopamp PURE DNA Extraction Kit (PURE), which is easier and faster than the QIAGEN method to perform, we expect to improve the efficiency of our work. We compared these methods. We investigated and compared the time necessary to extract DNA using a pharyngeal swab between the QIAGEN and PURE methods. Using the DNA extracted by these methods, we measured it with the Loopamp Mycoplasma Pneumoniae Detection Reagent Kit (LAMP), and compared the positive conformity ratio, negative conformity ratio, and overall conformity ratio obtained using LAMP with those obtained using the QIAGEN and PURE methods. This investigation is based on possible cases of mycoplasma in 27 pediatric patients. The results showed that 14 patients were positive, 13 patients were negative, and the overall conformity ratio was 100%. In addition, it was more time-efficient to extract DNA by the PURE method than by the QIAGEN method. In conclusion, using the PURE method, which is a new DNA extraction method, allows us to report results to the clinical department immediately and helps in treatments by facilitating diagnosis and judgments of treatment in pediatrics.

Insulin delivery into the subcutaneous tissue depends on the use of the correct technique for insulin self-injection. Subcutaneous induration caused by an incorrect injection technique can lead to changes in insulin absorption, adversely affecting glycemic control. Subcutaneous tissue abnormalities, such as subcutaneous hemorrhage and induration, are frequently detected by inspection and palpation, whereas ultrasonography (US) is only rarely performed. In this study, we assessed by US the skin and subcutaneous tissue of patients receiving insulin therapy to identify trends in US findings and to determine whether US could be used for the assessment of insulin injection techniques. Using US, we assessed the skin and subcutaneous tissue of 35 patients receiving insulin therapy between November 2013 and December 2016. The US findings of injection sites showing palpable induration or skin discoloration were as follows. The cutaneous layer was significantly thicker at the injection sites than on the contralateral side. The cutaneous layer and subcutaneous fat layer at the injection sites were significantly hypoechoic. The border between the cutaneous layer and the subcutaneous fat layer was unclear or the structure of the subcutaneous fat layer was absent. US allows a more efficient observation of a wide area and a more objective assessment than conventional inspection and palpation because US enables the visual detection of changes in the skin and subcutaneous tissue. Furthermore, the use of US to educate patients regarding the correct injection technique and rotation of injection sites can contribute to improved glycemic control.

Clostridium difficile, a well-known nosocomial pathogen, is the major cause of antibiotic-associated diarrhea (AAD). We evaluated the usefulness of two rapid immunoassays [i.e., C. DIFF QUIK CHEK COMPLETE^® (QUIK CHEK) and GE test immunochromato-CD GDH/TOX「Nissui」(GE test)] in the detection of C. difficile toxins and glutamate dehydrogenase (GDH) in stool specimens. Compared with the results obtained from toxigenic cultures, the sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV) of toxin detection were 41.9, 100, 100, and 81.9 for QUIK CHEK and 48.8, 100, 100, and 83.7 for the GE test, respectively. The sensitivity of the GE test was approximately 6.9% higher than that of QUIK CHEK. Additionally, compared with the results obtained from toxigenic cultures, the sensitivity, specificity, PPV, and NPV of GDH detection were 90.2, 99.0, 97.9, and 95.4 for QUIK CHEK and 94.1, 95.2, 90.6, and 97.1 for the GE test, respectively. Moreover, the GE test showed a higher detection limit and a lower detection specificity of GDH in C. difficile clinical isolates than QUIK CHEK did. However, we hypothesize that cross-reactions occur during the detection of GDH in the GE test. Additionally, the GE test was more sensitive to C. difficile toxins and GDH than QUIK CHEK. Therefore, we conclude that the GE test is a useful screening kit for the diagnosis of C. difficile infections. However, we think that the GDH detection performance should be optimized.

Fibrinogen, a major plasma protein coagulation factor, is a classic positive acute-phase reactant protein and is a risk factor for DIC and hemorrhage. Therefore, fibrinogen plays a key role in hemostasis and thrombosis. The coagulation cascade reaction in the blood coagulation test occurs upon mixing of the patient’s plasma and reagents, as fibrinogen cleaved by thrombin continuously polymerizes to form a fibrin polymer, and its molecular weight increases sequentially. In light scattering, the scattered light intensity changes as the molecular weight and particle diameter increase; thus, the coagulation reaction can be measured on the basis of light scattered intensity. The final scattered light intensity of this coagulation reaction represents the fibrinogen concentration. This method is used for the measurement of the fibrinogen concentration as a PT-driven method. However, the absorbance near the end of the coagulation increases slowly, and fluctuates. Therefore, the exact intensity at the end of coagulation is difficult to measure. As the coagulation reaction profile of CP3000 can be approximated from Gompertz growth curves, we estimated fibrin concentration from the maximum of this equation using a mathematical method. Comparison of the fibrinogen concentration obtained by the Clauss method with the maximum value of each item (PT and APTT) shows that the correlation coefficient between the Clauss method and each item obtained by this method was 0.962 or more. We considered that fibrinogen concentration can be estimated by this technique.

We developed and computerized a registration system for information on class suspension caused by influenza infection. By digitizing all items in Form 1, the value of information was improved. The registration system has two main functions. One is to establish registration data for NESID and the other is to use data for GIS. The registration system features not only the data registration function for NESID but also the function to support visualization for GIS. By using ArcGIS made by ESRI, a map of the school district in a Yokohama municipal elementary school was made. By using ‘Yokohamappu’, a map of the number of reported cases per sentinel was made. By using ArcGIS, a map information for class suspension and a chart of the number of reported cases per sentinel were obtained. The visualization of a unitary epidemic state was made possible with this map. We identified the ward where the number of reported cases per sentinel is constantly small. It was found that the information on class suspension in an area does not change with other areas. Thus, the visualization of the number of reported cases per sentinel and information on class suspension provided useful information.

Neutrophil alkaline phosphatase (NAP) activity in mature neutrophils has been used as an index for the diagnosis of chronic myelocytic leukemia (CML) and paroxysmal nocturnal hemoglobinuria (PNH). Furthermore, low or high NAP activity is also found during the diagnosis of some hematological diseases. That is why the NAP score, which is used for the assessment of NAP activity, is commonly used in routine work. In the inspection procedure of the NAP score, there is a risk of scoring miscalculation due to human error. Thus, we developed a calculation system for the NAP score using Visual Basic for Applications (VBA), which is a standard function in Microsoft Excel. When we use this system, we can easily classify neutrophils on the basis of the NAP score, and there is no risk of scoring miscalculation. Furthermore, there is no development cost and thus the cost performance is perfect. This system will be very useful from the viewpoints of work efficiency and cost performance.

The screening test for human T-cell leukemia virus type 1 (HTLV-1) infection is usually performed by the detection of the HTLV-1 antibody. A new assay kit (Lumipulse HTLV-I/II FUJIREBIO) for the detection of both HTLV-1 and HTLV-2 antibodies has been developed. When we evaluated its within-precision and between-precision values, satisfactory results were obtained (the coefficient of variation was below 4%). Test results of panel sera of HTLV-1- and HTLV-2-positive samples using Lumipulse HTLV-I/II showed good agreement with the datasheet of the panel sera. Furthermore, Lumipulse HTLV-I/II showed 8- to 16-fold higher sensitivity than the current assay kit (Lumipulse HTLV-I). When 199 clinical samples from Miyazaki, Japan, an endemic area of HTLV-1, were measured using both Lumipulse HTLV-I/II and the current assay kit, two samples that tested positive with the current assay kit showed negative results with Lumipulse HTLV-I/II. These two samples tested negative by western blotting. When white blood cells from the subjects from whom these two samples were taken were tested by nested PCR, the results were negative for the HTLV-1 provirus. These results suggest that these two samples are negative for the HTLV-1 antibody. Therefore, it is considered that Lumipulse HTLV-I/II has higher sensitivity and specificity than the current assay kit.

The RAS gene mutation test is extremely important when determining whether the use of molecular target drugs in colorectal cancer treatment is appropriate and in selecting the treatment method. Here, we report on our comparison of RAS with RASKET, which is an IDV reagent, by establishing a RAS mutation measurement method using the genetic analyzer i-densy IS-5320. The subjects included 21 colorectal cancer patients at our hospital, and Mutation tests of KRAS exons 2, 3, and 4 and NRAS exons 2 and 3 were conducted using a paraffin block designated for genetic tests. The results were in agreement with those of RASKET in terms of the presence of RAS mutation as well as all mutation regions. Even in minor mutations in which the mutation frequency was low, the results showed good agreement. Efficiency and simplification of the work were realized by keeping the measurement time within 120 min using a Multitype UNIVERSAL reagent. Moreover, because this measurement method allowed us to conduct BRAF gene mutation tests at the same time, it improved the coverage rate of anti-EGFR drug resistance mutations in colorectal cancer and was suggested to provide important information on colorectal cancer treatment. Finally, the analytic validity of this measurement method was equivalent to that of the IVD method and it was sufficiently available in routine laboratory tests, leading us to believe that it is an extremely useful method.

Potassium is one of the most frequently analyzed elements in the body. It plays a clinical role in homeostasis, and hyperkalemia is a common electrolyte disorder. In the laboratory, hemolysis increases serum potassium levels and causes pseudohyperkalemia. Therefore, the determination of potassium levels using nonhemolyzed samples is recommended. However, sometimes, blood re-collection is difficult. Thus, our purpose is to develop a potassium-compensating equation to minimize the need for blood re-collection. We manufactured a hemolysis reproduction reagent from heparinized blood samples from fifty patients. We added this reagent into pooled serum and reproduced the hemolyzed samples. We determined the potassium levels and hemolysis indices of these hemolyzed samples. Using these results, we developed two compensating equations, namely, equations 4 and 5. Then, we verified the accuracies of these equations. For this verification test, serum samples from forty patients whose blood was collected twice because the first sample was hemolyzed were used. We compared the potassium levels of nonhemolyzed samples with the compensated potassium levels of hemolyzed samples. Equation 4 is not useful because the differences were large. On the other hand, equation 5 can compensate for potassium levels with differences of approximately 0.3 mmol/L. We can estimate the true potassium levels using equation 5, even when the samples are hemolyzed.

The BD SurePath^TM as a liquid-based cytology system has three types of preservative solution for cellular fixations (gyne for gynecologic materials, and red and blue for nongynecologic materials). Differences in their capability for antigenic preservation are expected in immunostaining because the three preservative solutions have different ingredients. The aim of this study was to determine the capability of each preservative solution for sequential antigenic preservation. Cellular sediments of pleural effusion from four cases of lung adenocarcinoma were stored for four different periods (1 hour, 1 week, 1 month, and 3 months). After each period, immunostaining of four markers (Ki67, p53, Cyclin A, and MCM7) was performed, and positivity rate was calculated. From the results, the following became obvious: (1) No consistent correlation was recognized in each marker with each preservative solution, although a decrease in positivity rate was recognized after each period. (2) As for the capability for antigenic preservation, no clear difference was recognized. (3) Because a decrease in positivity rate of 30% was found in a period of one-week preservation with an antibody, the possibility of incorrect decision on positivity was suggested. (4) After this, additional examination of cellular preservative methods using many types of markers that are used is necessary, and the development of an original immunostaining protocol is desired.

The direct smearing method or iodine method is commonly used in the diagnosis of Entamoeba histolytica infection. In this study, we performed Periodic acid-Schiff (PAS) staining, May-Grünwald Giemsa (MG) staining, Papanicolaou (Pap) staining, and Hematoxylin Eosin (HE) staining in three cases of E. histolytica infection. MG staining, Pap staining, and HE staining, which are excellent for nuclear staining, were useful for the observation of the nucleoli of trophozoites, chromatin granule, cysts, and chromatoid body. It was also possible to confirm erythrocytes in the endoplasm. In the puncture of liver abscess pus, trophozoites staining reddish purple after PAS staining were confirmed. These staining methods were useful for the diagnosis of E. histolytica infection.

We investigated the serotype and antimicrobial resistance of Salmonella isolates at our hospital located in Tachikawa City, Tokyo, from 2007 to 2016. Forty-two Salmonella strains were isolated. Those strains were classified into six O groups, namely, O4 (20 strains: 47.6%), O9 (15 strains: 35.7%), O7 (4 strains: 9.5%), O8 (1 strain: 2.4%), O3,10 (1 strain: 2.4%) and O21 (1 strain: 2.4%). The most prevalent serotype was Salmonella enterica subsp. enterica serovar Enteritidis (21.4%). Among the 42 strains, three showed resistance to one or more antimicrobial drugs. One showed resistance only to ABPC, one only to trimethoprim-sulfamethoxazole, and the remaining one to ABPC, third-generation cephalosporin and levofloxacin. Although the isolation rate of Salmonella has tended to decrease in recent years and our results did not show an increasing trend of the number of resistant strains in our hospital during this study period, there is a concern for the emergence of resistant Salmonella strains and multidrug-resistant strains these days. Further studies on the prevalence, antimicrobial susceptibility pattern and mechanisms of antibiotic resistance including the ability for ESBL, metallo-beta-lactamase and AmpC production by circulating strains of these species are recommended.

The role of clinical microbiological examinations in the diagnosis of infectious diseases and infection control is extremely important. The prompt reporting of blood culture results is required for patients with life-threatening infection, but accuracy is preferred over rapidity especially in an infection control situation. It is known that there are many variations in laboratory procedures and reporting methods among clinical microbiology laboratories. A questionnaire survey was conducted in order to assess the current status of clinical microbiological examinations in the clinical laboratories of both university hospitals and hospitals located in northern Japan. The results showed the present conditions of the clinical laboratories; these results will become important for pushing forward the standardization and improvement of clinical microbiological examinations.

Chronic hepatitis due to diseases such as hepatitis virus, alcoholic hepatitis, and nonalcoholic steatohepatitis causes fibrosis and may lead to liver cancer after the onset of cirrhosis in the future. The gold standard for liver fibrosis diagnosis is liver biopsy, but since it is an invasive examination, hyaluronic acid (HA), type IV collagen (collagen), which is a blood component, and physiological examination methods are used. A test using a novel liver fibrosis marker (M2BPGi) is covered by the national health insurance. Although HA is susceptible to dietary influences, the effects of the diet on M2BPGi level have not been investigated. We compared the influences of the diet on M2BPGi level as well as fluctuations in blood HA and type IV collagen levels. As a result, only the measured HA level increased significantly 1 to 2 hours after meal intake compared with before meals. M2BPGi and collagen levels were not affected by meal intake. In conclusion, M2BPGi measurement can be correctly evaluated as part of specific blood examinations.

For better efficiency of outpatient clinical service, it is important that examination results are prepared by the consultation appointment time and the consultations can be carried out as scheduled. In order to realize that, in April 2017, we established a blood collection system prioritizing patients’ clinical schedule such as consultation appointment time. As one and a half years have passed since we started the blood collection system, we analyzed the waiting time for blood collection and the required time for sampling in 7,185 patients whose blood samples were drawn in September 2017. With the introduction of the blood collection system, more than 90% of the 1,011 patients accepted from 7:30 to 7:59 before starting blood collection were those whose appointment times were early, i.e., before 10 o’clock, which led us to consider that the patients started to adjust their arrival time at the blood collection reception in accordance with their consultation appointment times. Consequently, this system made it possible to reduce the congestion of patients before blood collection starts, and enabled us to report examination results within one hour after their reception.

Acquired hemophilia A is usually indicated by the prolongation of APTT. We had an opportunity to identify patients with acquired hemophilia A by communicating with different laboratory divisions. A male aged 80, who was suspected of having miliary tuberculosis, was introduced to our hospital for detailed examinations. He was firstly subjected to echocardiography because of massive subcutaneous hemorrhage. Then, the physiology lab technician consulted with the blood examination division. The platelet count of the patient was normal, but our laboratory recommended further examination of his clotting time on the basis of his APTT finding of 100 s, which was determined using an inhibitor type of a cross-mixing test. The activity of factor VIII was lower than 1%, and the factor VIII inhibitor was positive. Finally, he was diagnosed as having acquired hemophilia A. After reviewing the lab data retrospectively, the APTT test was performed 1 month earlier, and it showed a prolonged clotting time, but nobody noticed it as a problem. To prevent overlooking abnormal data, we have started to show such data with colored characters on a viewer, which is confirmed by multiple staff members.

Clusters of squamous cells skewered on the hyphae of Candida albicans like skewered chicken meat (hereafter, “skewered clusters”) are often observed in cervical specimens from patients with candidiasis examined by liquid-based cytology (LBC). In this study, we examined whether this cytological pattern observed in the LBC specimens is a characteristic finding of Candida by comparing Candida-positive and Candida-negative specimens regarding this pattern. Moreover, we examined the Candida detection rates of the direct smear method and LBC method. The frequency of skewered clusters was significantly higher in the Candida-positive specimens than in the Candida-negative specimens. In direct smears, the frequency of appearance was lower than that of LBC specimens. The SurePath method is a density-gradient-based cell enrichment process using separation reagents. The positively charged (+) slides attract the negatively charged (−) surface of cells, which were suspended in purified water on the slides for smearing. The vertically aligned squamous cells are skewered on the hyphae of Candida to form three-dimensional clusters like skewered chicken meat. On the other hand, in the direct smear method, cells are collected by scraping the cervix with a cotton swab and smeared onto the slides directly, thus, the cells and the hyphae of Candida are spread or in a one-cell-thick layer. It was found that the appearance of skewered clusters is characteristic of LBC cervical specimens (SurePath method) from patients with candidiasis. It is important to keep in mind the possibility of candidiasis when skewered clusters are detected by optical microscopy.

Glomerular filtration rate (eGFR) estimated from creatinine (eGFRcre) and eGFR estimated from cystatine C (eGFRcys) were presented in 2008 and 2012, respectively. Even though eGFR is frequently used to estimate renal function in clinical practice, we often encounter some cases in which the eGFRcre is very different from eGFRcys. Therefore, we investigated the consistent probability between eGFRcre and eGFRcys or the features of the above cases in this study. Results showed that the correlative relationship was y = 0.92x + 2.44 and the coefficient of correlation was r = 0.868. On the other hand, the consistent probability of clinical stratification in chronic kidney disease determined on the basis of eGFRcre and eGFRcys was 55.8%. In inconsistent cases, the number of cases in which the severity determined from eGFRcre was higher than that determined from eGFRcys was the same as that of cases in which the severity determined from eGFRcre was lower than that determined from eGFRcys. Furthermore, cases diagnosed as different at two stages accounted for 3.5% (8 cases). The eGFRcys/eGFRcre ratio tended to be higher in young patients and lower in old patients than in those in their 60s (close to 1). The eGFRcys/eGFRcre ratio also tended to increase with increasing area of body surface and serum albumin level, but it is low in those with serious proteinuria. In conclusion, it is important to use the two estimation parameters while understanding their features and factors of dissociation when estimating renal function.

The patient was a 60-year-old man treated with an oral hypoglycemic agent for diabetes. He visited a local physician because of epigastralgia, which appeared 2 days earlier. Although a pain killer was prescribed, it was not effective, and he was examined during an emergency visit at our hospital. On admission, hematuria was observed. Blood chemistry showed prominent hemolysis, and anemia, disorder of blood coagulation, and elevated T-Bil, AST, and LDH levels were found. Abdominal computed tomography revealed a gas-forming liver abscess. Despite intensive treatment with infusion, blood transfusion, antibiotic therapy and surgical drainage, he died because of multiple organ failure due to rapid hemolysis 12 h after admission. Clostridium perfringens was observed in his blood and ascites culture. Prominent hemolysis may be induced followed by Clostridium perfringens septicemia. Early medical examination is indispensable because of a high mortality rate when hemolysis develops. For early treatment, the detection of large gram-positive bacilli by the gram staining of a specimen from a patient should contribute to an early treatment and the improvement of survival rate.

The patient, a woman in her forties with a family history of diabetes, was diagnosed by a previous physician as having diabetes and was admitted to our hospital for treatment. Her HbA1c level determined by the latex agglutination method as shown in her letter of introduction was 10.0%, which deviated significantly from the 5.5% obtained by the HPLC-723G8 (Tosoh) method in our hospital. The measurement principle of the G8 method is ion-exchange HPLC. Therefore, we were asked to measure HbA1c by ion-exchange HPLC precision analysis and affinity HPLC. An abnormal peak suggesting an abnormal hemoglobin level was observed in the ion-exchange HPLC precision analysis results, and the HbA1c level obtained by affinity HPLC was 8.8%. In the β-globin gene sequencing at Fukuyama Medical Laboratory, [Codon 22 GAA(Glu)→AAA(Lys)](heterozygote) HbE-Saskatoon was detected. We have to work on sharing this information with other medical staff members to understand the results of the specific analysis method.

We report a case of Evans syndrome in a 5-month-old boy, which is rare in infants. He was brought to a nearby clinic because of fever and vomiting. Severe anemia and thrombocytopenia were noted. He was admitted to our hospital and was revealed to have hemolytic anemia. His direct and indirect Coombs tests both showed positive results, and his platelet-associated IgG level was high. Although his bone marrow was hyperplastic, his myeloid cells were not dysplastic. His myeloid erythroid ratio (M/E ratio) was low and his megakaryocyte count was high. Autoimmune lymphoproliferative syndrome (ALPS) was suspected, since he was too young to have Evans syndrome and he did not have any underlying disease that causes autoimmune hemolytic anemia (AIHA) or idiopathic thrombocytopenic purpura (ITP), such as collagen or infectious diseases. However, ALPS was ruled out by flow cytometry and genetic examinations. Thus, he was diagnosed as having Evans syndrome. The patient is being treated with γ-globulins and immunosuppressive agents.

Pseudogray platelet syndrome (PGPS) is a rare in vitro phenomenon that is associated with alpha granule and dense granule secretion without aggregation on removal of extracellular Ca²⁺ in the presence of ethylenediaminetetraacetic acid (EDTA). PGPS patients usually show a normal platelet count, no bleeding tendency and no genetic abnormality. We report here a case of pseudo-thrombocytopenia associated with PGPS. An old man in his nineties was admitted for management of pneumonia. On admission, severe pseudo-thrombocytopenia was recognized. His blood films showed agranular gray platelets with large clumping only in anticoagulated blood with EDTA. On the basis of these findings, he was diagnosed as having “PGPS with platelet clumping (PGPSPC)”. We also analyzed the laboratory features of 13 previously published cases and ours. We concluded that PGPS cases can be classified into two groups, namely, PGPS and PGPSPC. About half of the reported cases were associated with platelet clumping and pseudo-thrombocytopenia in addition to platelet granule secretion. The exact mechanisms of PGPS development with or without platelet clumping remain to be elucidated.

A 70-year-old man with a history of total gastrectomy for stomach cancer underwent periodic measurements of carcinoembryonic antigen (CEA). A mild increase in CEA level led to gastrointestinal fiberscopy, colonoscopy, positron emission tomography computed tomography (PET-CT), small bowel follow-through, and thyroid and abdominal ultrasound, which showed no findings indicating metastasis. Thereafter, a further increase in CEA level was associated with the swelling of the mediastinal lymph node accompanied by increased fludeoxy glucose (FDG) uptake, as revealed by PET-CT, suggesting a metastatic disease. Because no primary lesion was found, the possibility of false high CEA levels was taken into account and scrutinized by several tests such as the dilution linearity test, acetic acid extraction treatment test by chemiluminescent immunoassay (CLIA) method, heterophil antibody absorption test, scavenger-alkaline phosphatase (ALP) treatment test, and polyethylene glycol (PEG) processing test. As a result, the increased serum CEA levels were reconfirmed. Therefore, mediastinal lymph node dissection was performed for diagnosis and treatment. Tumor cells were positive for epithelial markers and lung adenocarcinoma markers, i.e., thyroid transcription factor 1 (TTF-1) and Napsin A, as determined by immunostaining, suggesting lung cancer metastasis, although it is not conclusive. In this case, the periodic measurements of CEA led to the diagnosis of lymph node metastasis. Furthermore, a battery of tests to exclude the possibility of nonspecific reaction persuaded surgeons to undertake lymph node dissection, which contributed to clinical management.

Takotsubo cardiomyopathy (TTC) has generally good prognosis and it is characterized by transient contractility disorder of the apical part of the left ventricle (LV) with the hypercontraction of the basal LV. Clinically, TTC mimics acute coronary syndrome but there is no coronary artery disease. Recently, many atypical types involving basal, midventricle, and right ventricle (RV) have been described, and reversible LV hypertrophy during the recovery phase from TTC has also been reported. We report the case of a woman in her 80’s presenting with biventricular TTC. Transient LV apical hypertrophy was observed by serial echocardiography. Right ventricular involvement may correlate with very severe clinical conditions because of serious RV heart failure in addition to LV heart failure. Thus, the detection of RV disorder at the onset of TTC is very important and useful for its treatment. Careful observation by echocardiography is needed so as not to miss abnormal RV contraction. This case is considered to cause hyperthyroidism. Commonly, TTC is triggered by intense physical or mental stress, but its etiology is still unknown. Hyperthyroidism has been described in association with TTC. We should check thyroid function to investigate the etiology of TTC because the heart is easily affected by the thyroid hormone.

Characteristic crystals were identified in urine samples from chronic hepatitis C patients during triple-drug therapy with telaprevir, peginterferon and ribavirin. These crystals are insoluble in acid or alkaline solutions, as well as organic solvents, and they do not have any specific polarization color. In four of the five patients undergoing the triple-drug therapy, crystals appeared in urines immediately after the initiation of therapy, and their kidney function simultaneously declined. To confirm that these crystals are derived from telaprevir, we compared the infrared absorption spectra of urine and powdered telaprevir. Both wave patterns had similar peaks at approximately 1,060 nm. These results suggest that these crystals are likely from telaprevir. The detection of these crystals in urinary sediments may be useful for the prevention of renal damage caused by telaprevir administration.