As a result of an quality control evaluation of blood culture at our hospital, we found that the contamination rate was high. Thus, to lower the contamination rate and conduct a highly reliable test, we revised the blood culture sampling manual. The investigation period was from April 2016 to September 2017. We compared the contamination rate between the period from April to September 2016 (hereinafter referred to as before improvement) and the period from April to September 2017 (hereinafter referred to as after improvement) excluding the transition period. The disinfectant indicated in our manual before improvement was 10% povidone iodine or alcohol. However, after improvement, we started to disinfect the skin with alcohol and then with 1% chlorhexidine alcohol. Along with this change, we revised the reaction time written in the manual. Also, we revised the appropriate amount of blood from 5 to 10 mL in the manual. The contamination rate before improvement was 17.4%, and after improvement, it decreased to 4.8%. Also, the positivity rate before improvement was 22.4%, and after improvement, it decreased to 15.1%. In addition, the number of strains detected before improvement was 466, and after improvement, it decreased to 266. CNS, which is a representative of bacterial contaminants, decreased markedly in positivity rate from 44.8% to 21.8%. It is considered that altering the skin disinfection method for the blood sampling site and correctly performing the disinfection operations were effective in reducing the contamination at the time of blood collection.

Anorexia nervosa can be fatal owing to severe complications including cardiovascular dysfunction. Pericardial effusion is often observed and reportedly emerges in 22–71% of anorexia nervosa patients. Hence, it is important to examine and monitor the amount of pericardial effusion as well as cardiac function by echocardiography in these patients. Rapid weight loss, low body weight, and hypothyroidism were proposed as possible mechanisms underlying pericardial effusion in anorexia nervosa. In this study, we investigated the relationship between the amount of pericardial effusion and the biochemical and physiological examination data to elucidate the mechanism underlying pericardial effusion in anorexia nervosa patients. The levels of free T3 and T4 demonstrated a strong negative correlation with the amount of pericardial effusion. In the patients in whom the amount of pericardial effusion was reduced after the therapy against anorexia nervosa, the levels of free T3 and T4 inversely increased. These results indicate that pericardial effusion in anorexia nervosa may be associated with thyroid hormones. The evaluation of pericardial effusion in anorexia nervosa patients by echocardiography is useful for predicting the decrease of thyroid hormones and the patient’s general condition including cardiovascular function.

Diagnostic methods leading to the prevention of sarcopenia are required. We evaluated quadriceps femoris muscle contraction using electromyograms (EMGs) and ultrasound (US) images. Surface EMGs were recorded in the rectus femoris muscle, vastus lateralis and vastus medialis during knee extension with a load. We obtained three muscular discharge ratios, and they were evaluated in terms of the amount of muscular discharge in search of the repand area by integration. From the US image, we determined the circumference and cross-sectional area on the transverse image and measured the pennation angle on the sagittal image. Under isometric contraction conditions, the amount of muscular discharge increased with the strength of contraction from weak to strong. In the rectus femoris muscle, there was a significant positive correlation between the imposed weight and the muscular discharge. Since the circumference was more stable than the cross-sectional area, it was selected for evaluation. The pennation angle was larger during traction than during resting. The circumference and pennation angle tended to increase owing to voluntary contraction. However, the values did not change when the weight exceeded a certain value. We found the possibility of muscle weakness evaluation by functional and morphological analysis using EMGs and US images.

HE4 is a new ovarian tumor marker that has been clinically used in Japan since April 2017, and the level of HE4 is less elevated than that of CA125 in gynecological benign diseases, the menstrual period and pregnancy. The aim of this study was to assess the variations of the levels of the tumor markers HE4 and CA125 among pre- and postmenopausal healthy Japanese volunteers. During the first examination, we compared the measured CA125 and HE4 levels in 62 pre- and postmenopausal women. The CA125 levels exceeded the reference level in four premenopausal women. One was pregnant, and the other three women had CA125 levels that declined to below the reference level at 5 to 7 days after their menstruation. This result suggests that the CA125 level was affected by pregnancy and menstruation. In contrast, none of the women showed HE4 levels that exceeded the reference level. This suggests that the HE4 level was hardly affected by pregnancy or menstruation. There were statistically significant differences in both HE4 and CA125 levels between pre- and postmenopausal women. In the second examination, HE4 and CA125 measurements were conducted once every two to three days in a month. Among nine premenopausal women, the CV of CA125 level was 21.47% and the CV of HE4 level was 8.90%. The SD of within-subject variation of HE4 level were 2.7 pmol/L for premenopausal women, 3.2 pmol/L for postmenopausal women, and 2.6 pmol/L for men. None of the women showed HE4 levels that exceeded the reference level. These results suggest that HE4 is a more stable tumor marker than CA125, and its level is hardly affected by pregnancy or menstruation.

Currently, on the basis of the western blotting assay, we use ‘Problot HTLV-I’ for the anti-human T-cell leukemia virus type I (HTLV-I) antibody to confirm the diagnosis of HTLV-I. However, this method has a major disadvantage in terms of its high judgement pending rate. We performed basic evaluation studies of the reagent ‘INNO-LIA HTLV’ for anti-HTLV-I antibody measurement on the basis of the line blotting immunoassay. The within-run and between-day precisions of antibody titer determination by the visual evaluation of this reagent were within the range of ±1 titer step. The concordance of the positive rate for the reagent ‘INNO-LIA HTLV’ was 100.0%. However, the concordance of the negative rate was 66.7% for the pending judgment. As for the pending judgment, the amount of the reagent ‘INNO-LIA HTLV’ decreased with 12 out of 78 specimens compared with 20 out of 78 specimens using the reagent ‘Problot HTLV’. This study revealed that the reagent ‘INNO-LIA HTLV’ is suitable for routine tests.

In recent years, the sensitivity of cardiac troponin (cTn) as a marker has been increasing, and the diagnostic accuracy of this marker in the early stages of acute coronary syndrome (ACS) has improved. However, accordingly, false-positive results due to myocardial micro injury have been obtained. The heart-type fatty acid-binding protein (H-FABP) is an early, highly sensitive marker of myocardial injury. However, H-FABP is more sensitive as a marker for kidney function than cTn. To clarify the clinical usefulness of H-FABP, we compared the correlation and diagnostic accuracy between the reagents produced by two companies. In addition, the sensitivity and specificity of the two reagents, H-FABP and cTn, for ACS were compared and examined. Furthermore, in the renal dysfunction group, the correction effects of renal markers and brain natriuretic peptide (BNP) for improving the diagnostic accuracy of H-FABP were examined. Results revealed that H-FABP showed differences in diagnostic accuracy among the reagents. There were cases in which only the H-FABP reagent with high diagnostic sensitivity showed a positive result in patients with non-ST-segment elevation myocardial infarction. Furthermore, the high diagnostic sensitivity of the H-FABP reagent further increased compared with that of the cTn reagent. In cases of decreased renal function, it is suggested that using both H-FABP and BNP at a certain ratio may improve the diagnostic accuracy than using H-FABP alone.

In this study, we examined cardiac function strain in the left ventricular longitudinal axis direction before and after transcatheter aortic valve implantation (TAVI), which is one of the treatments for aortic valve stenosis, using myocardial strain. The subjects were 20 patients who underwent TAVI at our hospital. We performed echocardiography TAVI at the preoperative, postoperative acute, and postoperative chronic phases, and the indexes of the longitudinal contraction for the left ventricular myocardium global longitudinal strain (GLS) were analyzed. Results of the analysis showed that there were no significant differences in GLS between the preoperative and postoperative acute phases (p = 0.09), with GLS of −11.5% in the 20 patients with TAVI at the preoperative phase and −12.0% in those in the postoperative acute phase. On the other hand, the GLS in the postoperative chronic phase was −14.4%, which is significantly different from that in the preoperative phase (p < 0.01). On the basis of this study, it was considered that the significant improvement in GLS between the TAVI preoperative and postoperative chronic phases and the treatment of the aortic valve continuously improves myocardial function in the left ventricular longitudinal axis direction. Also, before and after TAVI, there was no significant change in the left ventricular ejection fraction (LVEF), but LVEF improved with GLS. With GLS, we were able to detect contraction abnormalities, which was not possible in the case of using LVEF, and myocardial strain was considered to be useful for the evaluation of cardiac function also in valvular disease.

The Ministry of Health, Labour and Welfare announced the implementation of free vaccination against rubella for the general public over a period of approximately three years (from 2019 to the end of fiscal year 2021), targeting males born between 1962 and 1979, who did not have the opportunity to be vaccinated for rubella. Currently, rubella is diagnosed mainly by the hemagglutination inhibition (HI) method, which requires a long assay time owing to its complicated and manual handling procedure. We performed a fundamental evaluation of “Runpia latex RUBELLA”, a latex turbidimetric immunoassay method involving anti-rubella viral antibody measurement, which can be carried out with an automated analyzer. The within-run and between-run coefficients of variation (CVs) of quality control samples are less than 7.0%, the dilution linearity is good (correlation: r ≤ 0.998), there are no effects of interfering substances, and the detection limit is 3.5 IU/mL. The correlation between the HI method and Runpia latex RUBELLA is good (Spearman’s rank correlation: r = 0.952, n = 150). A RUBELLA concentration of 2,300 IU/mL in a sample did not decrease in the measurement upper limit. Runpia latex RUBELLA can be used to replace the HI method and it showed sufficient reagent performance in a routine test using an automatic analyzer.

The rapid detection of antimicrobial drug-resistant strains, especially methicillin-resistant Staphylococcus aureus (MRSA), is important for the effective treatment and control of infectious diseases. In this study, we evaluated the applicability of the automatic analyzer RAISUS S4 system. The susceptibilities of 57 strains, including 18 MRSA strains, 21 MSSA strains, and 18 MR coagulase-negative staphylococcal strains, to antibiotics were measured using the RAISUS S4 system with the RAISUS plate RSMP, and the results were compared with those obtained using the DP panel as the reference method. The rates of agreement within ±1 dilution ranged from 86.0% to 100%, and those of category agreement ranged from 91.2% to 100%. In addition, we detected methicillin-resistant strains only 6.5 hours after the start of culture. In conclusion, the RAISUS S4 system was found to be useful for reducing the turnaround time for reporting methicillin-resistant strains and for choosing the appropriate drugs for the treatment of infectious diseases caused by staphylococcal strains.

The principle of tacrolimus measurement using the Dimension series is based on the ACMIA method, with which the pretreatment deproteinization operation is automated. We evaluated the performance of the tacrolimus reagent with modification of the method to improve tacrolimus binding to antibodies and magnetic particles, as well as improve tacrolimus reactivity with metabolites. As a result of investigating reproducibility (simultaneous, within-day difference), dilution linearity, effect of coexisting substances, limit of blank, limit of detection, limit of quantification and correlation, we found that results varied with low reproducibility (within-day difference). Moreover, Dimension showed about 10% higher correlation than ARCHITECT and Cobas8000. When the blood collected did not reach the specified amount, the measured value tended to be low owing to the increase in the concentration of EDTA-2K, but this effect was reduced by further improvement of the reagent. However, because the improvement remains incomplete, it is necessary at present to collect the specified amount of blood.

The essential requirements for a recording electrode for use in intraoperative nerve monitoring are the capacity to provide stable waveforms, rapid application, and robust against dislodgement during surgery. Here, we examined a corkscrew electrode, which satisfies these requirements and has been officially approved for both stimulation and recording, to determine if it is appropriate for the simultaneous motor evoked potential (MEP) stimulation and upper limb somatosensory evoked potential (SEP) recording. We found that the MEP and upper limb SEP waveforms changed in accordance with the timings of ischemia caused by the intraoperative interruption of blood flow and vessel recanalization by the removal of a thrombosis. Additionally, changes in these waveforms corresponded to postoperative clinical symptoms. These findings suggest that the corkscrew electrode holds great promise for application in clinical settings.

Background: In the 2015 American Thyroid Association Management Guidelines and The Bethesda System for Reporting Thyroid Cytopathology (2nd edition), a molecular biological search was indicated for certain clinical responses after cytological diagnosis. Genetic testing of thyroid tumor patients is considered to improve diagnostic accuracy and confirm the preoperative diagnosis. In this study, we examined the utility of genetic testing for the diagnosis of thyroid tumors. Methods: Thyroid tumors surgically resected from 40 patients and histopathologically diagnosed in our hospital between 2013 and 2017 were examined. The tumors were obtained from 15 patients with papillary carcinoma (conventional type), 15 patients with follicular carcinoma (excluding oxyphilic cell type), five patients with follicular adenoma (excluding oxyphilic cell type), and five patients with adenomatous goiter. By using DNA and total RNA extracted from FFPE sections, we searched for BRAF mutations, RAS mutations, RET rearrangements, and PAX8/PPARg rearrangements. Results: Genetic abnormalities (BRAF mutation V600E: 12 patients; RET/PTC1 rearrangement: 1 patient) were detected in 13 out of 15 papillary carcinoma patients (86.7%). In follicular carcinoma patients, 10 out of 15 revealed genetic abnormalities (NRAS mutation Q61R: 3 patients; Q61K: 2 patients; KRAS mutation Q61R: 2 patients; HRAS mutation Q61R: 2 patients; PAX8/PPARg rearrangement: 1 patient) (66.7%). No genetic abnormality was detected in patients with follicular adenoma and adenomatous goiter. Conclusions: In thyroid tumors, BRAF mutations, RAS mutations, RET rearrangements, and PAX8/PPARg rearrangements are highly specific to the histopathological type. The genetic testing for thyroid tumors will provide useful information for morphologic diagnosis of difficult cases and contribute to the improvement in diagnostic accuracy.

We evaluated the performance of Xpert C. difficile “Cepheid” (Beckman Coulter, Inc.) for Clostridioides difficile toxin detection. Fecal samples were obtained from 46 patients suspected of having C. difficile-associated diarrhea (CDAD) in our hospital and were analyzed from April to August 2018. The C. difficile immunochromatography (IC) test results showed that these samples were positive for glutamate dehydrogenase (GDH). As a control, the GE immunochromato-CD GDH/TOX test [Nissui] and toxigenic culture (TC) were carried out. Toxin A/B was detected in 19 TC samples and nine IC samples, whereas 19 samples were found positive for toxin B by GeneXpert. Two of them showed a negative result obtained by the Xpert method and a positive result obtained by the IC method only, and TC showed growth of Clostridium clostridioforme and negative results for toxin A/B of C. difficile. The rate of agreement between results obtained by the TC method and those obtained by the IC method was 69.6%, and that between results obtained by the TC method and those obtained using GeneXpert was 100%. Samples found positive for toxin A/B by the IC method, negative for toxin B by the Xpert method, and negative for toxin A/B by the TC method showed a different bacterial growth compared with samples found positive for toxin A/B of C. difficile by the TC method. The IC method showed a false positive result. The results of C. difficile toxin detection using the GeneXpert method were consistent with those obtained by the TC method. Therefore, the use of GeneXpert suggests the possibility of rapid diagnosis and eliminates the need for unnecessary infection prevention measures and treatment.

Unbound bilirubin (UB-Bil) level is used as a predictive index for the onset of bilirubin encephalopathy, but is prone to fluctuation owing to the effects of light. In this study, we evaluated the fluctuation of UB-Bil level under room-light exposure and attempted to design a procedure that prevents such exposure. The fluctuation of the level in a UB-Bil standard solution under room-light of 800 and 400 lx was confirmed. Moreover, the measured UB-Bil level was found to decrease with time, and a more than 30% reduction in fluctuation was observed after 1 h. Thereafter, the UB-Bil level increased with time, and after 7 h, it fluctuated by +31.2% at 800 lx and −1.6% at 400 lx compared with the baseline level. When using shielded micro blood collection tubes, no fluctuation was observed until 0.5 h, but thereafter, the measured UB-Bil level decreased with time; after 5 h, it decreased by 18.5% compared with the baseline level. The same tendency was observed in the patient samples, but the changes were more rapid than in the standard solution. UB-Bil level showed a tendency to decline with the passage of time owing to room-light exposure and exhibited a complex behavior, in which the measured level began to increase owing to longer room-light exposure. It is necessary to design an experimental procedure that enables the blocking of light from samples and quick measurements. Thus, the use of shielded micro blood collection tubes and controlling the time of collection would be useful.

Heart-type fatty acid-binding protein (H-FABP) has been reported to reach the peak faster than cardiac troponin and creatine kinase-MB (CK-MB). Given this feature, we examined the usefulness of H-FABP as a biomarker after percutaneous coronary intervention (PCI). The subjects were 58 patients requiring emergency PCI and 448 patients waiting for PCI. CK, CK-MB, and H-FABP levels were measured every four hours immediately after PCI in patients requiring emergency PCI and six hours immediately after PCI in those who waited for PCI. In the patients who waited for PCI, CK and CK-MB levels continued to increase significantly immediately after PCI, six hours later, and the following morning, and it was difficult to evaluate residual stenosis. On the other hand, the H-FABP level in the group without residual stenosis after PCI decreased significantly from six hours to the following morning, but no significant decrease was observed in the group with residual stenosis after PCI. In the emergency PCI patients, the H-FABP level peaked early. On the other hand, in the patients where the rate of increase in H-FABP level was high without peaking early, a stenosis requiring highly urgent treatment was found. H-FABP was considered to be a myocardial marker that can be used for the early detection of residual stenosis and restenosis from the rate of increase in its level and the duration of increase.

The first author had the opportunity to participate in the deep vein thrombosis (DVT) screening project conducted by the Japanese Association of Medical Technologists as part of disaster support in the aftermath of the Kumamoto Earthquake. Through this experience, we recognized not only the importance of DVT screening but also the necessity of advance preparation for any disaster support. Therefore, we compiled the “List of medical technologists who can conduct DVT screening in the Seiban area” as part of advance preparation for disaster relief support and received cooperation from various individuals in this task. In the future, we plan to compile similar lists of medical technologists across Hyogo Prefecture and collaborate with other organizations.

In our hospital, the counts of cerebrospinal fluid (CSF) white blood cells (WBCs) have been analyzed using the automated hematology analyzer Sysmex XE-5000. However, the reference values based on the manual counting method are still being used. The objective of this study was to estimate the clinical reference values for CSF WBC counts in children measured using the XE5000. This study included CSF analysis data that were analyzed using the XE5000 in Gunma Children’s Medical Center between June 1, 2009 and December 31, 2018. These data were collected from electronic medical records and were excluded sequentially if conditions known or suspected to cause CSF pleocytosis were present (e.g., meningitis and leukemia). Data for a total of 785 children were included, and they were divided into four groups according to age. The reference values were calculated using MCP-STAT Ver. 6 (Sysmex Corporation). The estimated clinical reference values were as follows according to age: 0 to 27 days after birth, 30/μL; 28 days to less than 1 year old, 13/μL; 1 to 5 years old, 8/μL; 6 to 15 years old, 3/μL. These values were higher than the reference values based on the manual counting method except for the age group 6 to 15 years. When the CSF WBC count is evaluated by automatic analysis, it is necessary to consider a reference value suitable for a hematology analyzers used.

The pneumococcal conjugate vaccine (PCV) was introduced to the routine immunization schedule in 2013, and the serotype replacement of isolated Streptococcus pneumoniae strains has attracted attention. In this study, we surveyed the capsular serotypes of strains isolated from children and compared the results with those of two previous surveys conducted in 2002 and 2008. The materials were 184 Streptococcus pneumoniae isolates from 184 patients who visited the Pediatrics Department of our hospital during the 1-year period from August 2016 to July 2017. We determined 39 capsular serotypes by the slide agglutination method using an immune serum (“SEIKEN”, Denka Seiken Co., Ltd.), and we defined isolates that did not show agglutination as nontypable (NT). All PCV13-related serotypes could be determined by this method, but subtypes could not be assessed. The serotypes were in the following order: 92 NT isolates (50.0%), 25 type-15 isolates (13.6%), 18 type-35 isolates (9.8%), 11 type-11 isolates (6.0%), 8 type-22 isolates (4.3%), and 30 isolates of other types (16.3%). PCV13-related serotypes were found in only 14 isolates (7.6%). NT isolation rates (50.0%) showed a marked increase compared with those in 2002 (3.1%) and 2008 (5.1%). The decrease in isolation rate of PCV13-related serotypes from 83.9% in 2002 and 85.5% in 2008 to 7.6% in this survey suggests that serotype replacement had occurred following the introduction of PCV13.

Stimulus-induced repetitive discharge (SIRD) is one of the abnormal responses recorded after M-waves with the exception of F-waves. There is no consensus on the clinical significance and developmental mechanism of SIRD, and it is not specific to any disease. Here, we studied the clinical significance of SIRD by accumulating cases in which abnormal responses other than F-waves (non-F-waves) were recorded after M-waves. Non-F-waves were found in 80 (28.1%) of the 284 subjects who underwent nerve conduction studies (NCSs). Among them, 30 (10.6%) had uniform waveforms. Then, we classified non-F-waves on the basis of periodicity. Uniform and periodic non F-waves were found in five diabetes patients, two amyotrophic lateral sclerosis patients, one Isaac syndrome patient, and one Parkinson’s disease patient. Uniform and periodic non-F-waves were frequently detected in the same nerve found to be abnormal in motor NCSs compared with the nonperiodic ones. On the other hand, nonuniform non-F-waves were frequently observed in diseases with involuntary movements and can be artificially elicited by voluntary muscle contraction, so caution is advised when considering it as SIRD. Uniform and periodic non-F-waves correspond to SIRD and reflect some kind of neurological dysfunction, and the use of SIRD for clinical evaluation warrants future studies. However, artifacts may be mixed in the late component of the M-waves, so it is necessary to be prudent in reading non-F-waves.

Since April 1, 2015, amendments to the law for clinical laboratory technicians have allowed these technicians to collect specimens. The sampling rate of nasal and pharyngeal specimens has increased from 17.0% in July 2017 to 30.4% after the law amendment, with an increase rate of only 13.4% in 2 years. In the present study, we aimed to establish a system for efficient and accurate influenza tests wherein an influenza specimen is collected from an outpatient by a clinical laboratory technician instead of an outpatient nurse. The introduction of this system resulted in a decrease in the burden of outpatient nurses, allowing these nurses to concentrate on their primary responsibilities. Clinical laboratory technicians could improve medical care services without extending the time required between examination requests and implementation. Compared with the nurses, the technicians accurately conducted manual creation, training, survey of manual compliance rate, and follow-up on specimen collection. As a result, the compliance rate of correct specimen collection was 100%. This time, the clinical laboratory technician could efficiently and accurately carry out influenza tests by accurately collecting influenza specimens. In the future, we plan to further improve the accuracy of this system by educating and training nurses on accurate specimen collection from ward and emergency patients.

Tosufloxacin (TFLX) is a fluoroquinolone antibiotic that was approved for use in children in Japan. In this study, we aimed to investigate the characteristics of TFLX crystals in the urine sediment of infants. Ten infants were included in this study. All of them took TFLX, and many fine brown needle-shaped crystals appeared in their urine sediments, which appeared to be sea urchins or bundles. In eight patients, urinalysis showed crystal casts, which usually showed that needle-shaped crystals penetrated into the epithelial casts. The cast matrix was generally loose with short parallel portions, which may indicate temporal renal tubular occlusion. In all the patients, the estimated glomerular filtration rates (eGFRs) were approximately normal, and the granular cast count did not increase significantly. However, cases of infant with nephropathy were reported previously, which required a careful follow-up of renal function during TFLX treatment. Previously, needle-shaped crystals in urine sediments were found in 64 infants in our hospital, and 52 (81%) of them were treated with TFLX, which suggests the relationship between needle-shaped crystals and TFLX.

The patient was a 20-year-old man who developed toxic shock syndrome (TSS) from a right knee abrasion caused by a motorcycle accident. The main symptoms were fever, vomiting, and diarrhea. TSS was suspected from the laboratory examination results, gastrointestinal symptoms, conjunctival hyperemia, and skin flushing. Staphylococcus aureus was isolated by culture of skin samples from the right knee abrasion. Staphylococcal enterotoxin A (SEA) and toxic shock syndrome toxin-1 (TSST-1), one of the superantigens, were positive. Blood culture tests were negative in two sets of samples (four bottles). In addition to an inappropriate right knee abrasion treatment, the presence of S. aureus producing the TSST-1- gene on the skin of the patient’s right knee is also considered to be the cause of the onset of TSS.

In this report, we describe a rare case of xanthine crystals found in the urine sediment of a 63-year-old man who was receiving CHOP therapy for adult T-cell leukemia with allopurinol and rasburicase treatments to prevent the onset of tumor lysis syndrome (TLS). On day 3, a reduction in urine output and deposits in the urine were recognized. A urinary examination was performed, and we found brownish yellow crystals that had a rough surface resembling phosphate crystals in the patient’s urine sediment. Also, we found that these crystals were soluble in potassium hydrate but not in acetic acid and hydrochloric acid. Later, the crystals were identified as xanthine by infrared spectrum analysis. Allopurinol treatment was stopped and forced diuresis was performed, and then the crystals disappeared. In this patient, although the levels of serum uric acid were maintained below the detection limit, xanthine crystals were found with the increased production of xanthine owing to the inhibition of xanthine oxidase. The patient was able to continue cancer treatment without developing TLS. This is the first report describing the morphological identification of xanthine crystals in urinary sediment.

Chyluria is the principal sign that suggests a fistula between the urinary tract and a lymphatic vessel. The present report is based on information obtained from the continuous urinalysis of a male patient in his 70s with a confirmed fistula between the urinary tract and a lymphatic vessel. Urinary sediments from all urine samples obtained during hospitalization contained approximately 90% lymphocytes, suggesting the long-term persistence of a fistula between the urinary tract and the lymphatic vessel. All first morning fasting urine samples had a transparent pale-yellow appearance, with chyluria appearing after meals. Thus, we confirmed that chyluria was affected by food consumption. Regarding the correlation between the protein urine/Cr ratio and the urinary lymphocyte count, the protein urine/Cr ratio was in the range of 0.41–0.82 g/gCr when the urinary lymphocyte count was ≤ 1–4 per HPF (high power field; HPF), and the ratio was in the range of 1.63–5.25 g/gCr when the urinary lymphocyte count was ≥ 5–9 per HPF. Thus, we hypothesized that the protein urine/Cr ratio was affected by the quantity of the mixture of lymphatic liquid because the ratio was linked to the increases and decreases in the urine lymphocyte count. Therefore, we infer that it is important to suspect a fistula between the urinary tract and a lymphatic vessel on the basis of an increased urine lymphocyte count and the correlation between the protein urine/Cr ratio and the urine lymphocyte count, which is not affected by the appearance of the urine.

A man in his twenties suffered from sore throat, high fever and vomiting. He came to our emergency department with a two-day history of worsening of his condition. Chest computed tomography analysis revealed bilateral infiltrative and nodular shadows with small cavities, suggesting septic pulmonary embolism. Ultrasound imaging showed thrombosis in the right interval jugular vein. Fusobacterium necrophorum was isolated from a blood culture. These findings support the diagnosis of Lemierre syndrome.

We encountered a case of blood coagulation disorder due to vitamin K deficiency in a patient who received cephem antibiotics for the prevention of postoperative infection. We started the administration of a combination of cefoperazone and sulbactam (SPZ/SBT) after surgery and on day 5, an abnormally prolonged prothrombin time (PT) and an activated partial thromboplastin time (APTT) were observed. On the basis of the results of a cross-mixing test and tests for the coagulation factors VIII and IX, we suspected vitamin K deficiency. Immediately after impaired clotting was found, we administered vitamin K and changed the antibiotics, which improved PT and APTT, and no bleeding was observed on the following day. As the causes of vitamin K deficiency, dietary vitamin K insufficiency and impaired vitamin K metabolism caused by an N-methyl tetrazole thiol group (NMTT group) in some cephem antibiotics were considered. In patients with severe symptoms, particularly those with poor ingestion, taking the possibility of blood coagulation disorder into account, regular coagulation tests and prophylactic administration of vitamin K should be considered.

Background: Inflammatory breast cancer (IBC) is a rare and aggressive breast cancer. Histiocytoid lobular carcinoma (HLC) is a rare type of invasive lobular carcinoma with morphologic characteristics resembling those of histiocytes. Herein, we report a case of an HLC patient presenting with the clinical features of IBC. Case: A 70-year-old woman presented with skin erythema of the left breast for a month. Ultrasonography of the left breast showed skin thickening, an anechoic area, and axillary lymphadenopathy. No elevated inflammatory markers were observed during laboratory examination. Fine needle aspiration cytology (FNAC) of the left breast was performed. In the cytology specimens, dyscohesive neoplastic cells showed histiocytoid features characterized by eccentrically located nuclei and abundant foamy or granular cytoplasm, consistent with HLC. Core needle biopsy specimens showed neoplastic cells with the same morphology as those in FNAC specimens. The cells were negative for E-cadherin and positive for GCDFP15, confirming the diagnosis of HLC. On the basis of clinical features and histocytological findings, the diagnosis of IBC was made. Two years later, left total mastectomy was performed. Histopathological findings showed neoplastic cells of HLC infiltrating the skin and pectoralis major muscle, and permeating dermal lymphatic vessels. Conclusion: An evaluation based on a combination of various results including clinical information and radiologic findings is necessary for the diagnosis of IBC. In the present case, cytology was important for the diagnosis of IBC and useful for estimating the histological type.

The patient was an 82-year-old woman who had been diagnosed as having IgG-κ multiple myeloma by her previous doctor in April 2015. She was referred to our hospital because she was suspected of having intraductal papillary mucinous neoplasm when she visited her previous doctor owing to stomachache in October 2017. The patient’s serum formed cryoglobulins at room temperature (22℃) as well as at 4℃. Needlelike crystals were also observed under a light microscope for serum samples stored at 4℃, and they were observable with the naked eye for samples stored at room-temperature. Cryoglobulins were resolved at 37℃, and the crystals were resolved at 42℃. The crystals were of the monoclonal IgG-κ type, as determined by various examinations. The patient does not have apparent symptoms at present; however, it is suggested that we need to pay attention to various symptoms triggered by future cold exposure.

Accurate knowledge of the “system reference” is required to record the electrical activity of the brain by digital electroencephalography. The system reference exists in only digital electroencephalography and must be used. The original data of each electrode unit are obtained by preserving the potential difference between the system reference and each electrode. By using the original data to calculate, one can draw the electroencephalogram of each montage. In addition, it is difficult to detect the failure of the differential amplifier by the monopolar reference derivation; therefore, it is necessary to record the system reference derivation in each patient.

Haemophilus influenzae causes respiratory tract infections and other invasive infections, and requires appreciable technical skill for isolation from chocolate agar (CHO). In this study, we evaluated the performance of Pourmedia^® Vi Haemophilus agar (Vi), a new screening agar for H. influenzae. Clinical respiratory specimens, such as sputum and pharyngeal mucus, were inoculated onto either CHO (conventional method) or chocolate agar with bacitracin (Baci) and Vi (Vi method), followed by incubation at 35°C for 18 to 24 h in a 5% CO₂-enriched atmosphere. After incubation, colonies suspected to be H. influenzae were isolated from each agar plate and identified using MALDI Biotyper. Counts of H. influenzae colonies detected and agreements between the two methods were compared, i.e., comparison between the usual test to detect H. influenzae (conventional method) and the new test using Vi (Vi method). From the 272 samples, 53 strains of Haemophilus spp. and Haemophilus-like organisms were isolated by the conventional method, compared with 55 strains isolated by the Vi method. Twenty-six strains (49.1%) and 31 strains (56.4%) of H. influenzae were confirmed by the conventional method and the Vi method, respectively. In this study, the Vi method was found to be more efficient than the conventional method, both in terms of the count of H. influenzae detected and agreement between the two methods. Furthermore, because the Vi method permits the examination of hemolytic properties after primary culture, the verification test is simplified, leading to enhanced utility for the isolation of H. influenzae from clinical specimens.