Anti-phospholipid antibodies (aPLs) are heterogeneous autoantibodies that can be identified by enzyme-linked immunosorbent assay (ELISA), particularly anti-cardiolipin antibodies (aCL), anti-cardiolipin/β₂-glycoprotein I antibodies (aCL/β₂GPI), anti-phosphatidylserine antibodies (aPS), and anti-phosphatidylserine/prothrombin antibodies (aPS/PT). These aPLs are frequently found in the plasma of patients with systemic lupus erythematosus (SLE) and have been reported to be associated with clinical events such as arterial and venous thromboses and recurrent fetal loss. Although several aPL-ELISA techniques were established for the diagnosis of anti-phospholipid syndrome (APS), the clinical importance of these ELISA techniques has not yet been determined. In an effort to clarify the clinical significance of aPLs detected by various ELISA techniques, we examined the concentrations of aCL, aCL/β₂GPI, aPS, and aPS/PT in 184 patients with SLE (32 patients with arterial thrombosis, 39 patients with venous thrombosis, and 113 patients without thrombosis). The present study showed that aCL/β₂GPI and aPS/PT detected by specific ELISA techniques could serve as markers of arterial and venous thromboses in patients with SLE, whereas aCL and aPS are less reliable as markers of these complications. Furthermore, we found that the incidences of arterial and venous thromboses were extremely high in patients who had both aCL/β₂GPI and aPS/PT. The occurrence of recurrent thrombotic complications in SLE apparently depends on variable combinations of these types of aPLs. Therefore, it is essential to analyze the spectrum of aPLs types using ELISA in the diagnosis of APS.

The clock drawing test (CDT) is frequently used in dementia screening because it is simple and acceptable to patients. We investigated the usefulness of scoring the CDT. We enrolled 156 patients (aged 78.2 ± 8.7 years; 87 females) who were administered both the CDT and the Mini-Mental State Examination (MMSE) between October 2016 and April 2017. The scores were evaluated using the Freedman method by two clinical technologists. The CDT scores showed a significant correlation with the MMSE scores. With respect to CDT subscores, there was a tendency to perform poorly in the placement of the clock hands by Alzheimer’s patients and a tendency to perform poorly in the placement of the numbers by patients with vascular dementia and dementia with Lewy bodies. It was suggested that CDT scoring supports the diagnosis of dementia as well as helps in determining the type of dementia.

During an ultrasound examination, we sometimes depict stringlike artifacts extending from the blood vessel wall of the carotid artery and it is necessary to distinguish them from intimal flaps. Therefore, we examined the occurrence of these artifacts and report some findings. We verified whether the stringlike artifacts arose from the left or right carotid arteries in 30 healthy subjects. We investigated the blood vessel diameters of the common carotid artery (CCA) and the carotid sinus (CS), the ratio of the blood vessel diameter of the CS to that of the CCA (CA/CCA diameter ratio), the maximum blood flow velocity and diastolic blood flow velocity of the CCA, the bend angle of the CS, and the heart rate. As a result, stringlike artifacts were depicted from the blood vessel wall of the CCA into the CS in 10 out of 60 right and left carotid arteries in 9 out of the 30 subjects. In addition, the following results were obtained: the blood vessel diameter of the CCA, the CA/CCA diameter ratio, and the bend angle of the CS were significantly larger in the group in which the artifacts were observed. As for the other factors, there were no significant differences between the two groups. These findings suggest that the velocity difference in the artery is generated by the shape of the artery, which extends from the CS to the CCA, or by the enlarged angle at this junction. Therefore, we believe that the artifacts arise from the effect of this velocity difference.

Because to date, a method to culture Pneumocystis jirovecii, the causative agent of Pneumocystis pneumonia (PCP), has not yet been developed, PCP has been conventionally diagnosed on the basis of finding of nonculture methods such as smear examination, serological methods, and genetic tests. In this study, we compared with laboratory test results obtained by the loop-mediated isothermal amplification (LAMP) assay, Diff-Quik staining, and β-D glucan examination for PCP diagnosis. In the comparison of results, concordance rates were 94.6% sensitivity and 94.7% specificity for LAMP assay, 67.6% sensitivity and 96.5% specificity for Diff-Quik staining, and 89.1% sensitivity and 86.0% specificity for β-D glucan examination. When the results of these 3 laboratory tests were combined and compared for PCP diagnosis, all patients who showed positive results in 2 or more of the tests were diagnosed as having PCP. Patients diagnosed as having PCP showed positive results in at least one of these tests. Although the LAMP assay showed the highest sensitivity, it was considered inappropriate to apply this test alone for PCP diagnosis because the possibility of colonization by P. jirovecii could not be denied. By combining these tests, we hope that the PCP diagnostic accuracy will be improved, and early diagnosis and therapy of the disease will be achieved.

Analysis of the causes and effects of incidents in a laboratory is important to ensure medical safety. Of 326 incidents, 100 erroneous laboratory reports during a period of 8 years between April 2009 and March 2017 were analyzed according to frequency, department, cause, years of experience of medical technologists, and incidence. The total number of erroneous reports per 100 days was 3.4, with the physiological examination department having the largest number recorded. Erroneous reports from specimen laboratories frequently transpired during day or night duty compared with routine hours. The causes of erroneous reporting were mainly carelessness, mistake, and lack of knowledge. The length of experience of medical technologists, i.e., ≥ 30 years, was most frequently associated with erroneous reports. Some erroneous reports required reexamination, unnecessary room or hospital change, or inappropriate medication. To reduce erroneous reports, it is important to analyze the background, causes, and results, develop effective countermeasures, and share the information among medical staff members.

Urine culture is an important test for the diagnosis of urinary tract infection, and it accounts for a large proportion of culture specimens. However, many urine culture specimens show a negative result. To improve the efficiency of urine culture tests, conditions for exclusion of urine cultures were examined on the basis of a specimen’s properties and the automated urinary flow cytometer UF-1000i (Sysmex) results. We also investigated the cost-saving effects of the establishment of exclusion criteria. The conditions for exclusion of a urine culture were set as “transparent urine with leukocyte-negative and bacteria-negative by UF-1000i results”. A total of 243 urine cultures were excluded during the period from October 2016 to July 2018. The cost benefit due to the reduced amount of medium used reached 55,112 JPY. It was speculated that there were additional cost benefits from the reductions in the amounts of related materials and labor. However, the automatic exclusion of urine cultures without consideration of patient background carries a risk of overlooking clinical urinary tract infection. Therefore, a urine culture should only be excluded with a doctor’s permission. In this study, it was shown that urine culture specimens that can be excluded can be identified by considering the UF-1000i results and specimen properties. In the absence of urinary tract infection indicated by UF-1000i results, excluding urine cultures has advantages in terms of labor and cost reductions.

In recent years, gene search from pathological specimens has been indispensable for the development of molecular targeted therapeutic drugs, and the results determine the suitability of therapeutic agents. Recommendations on the type and time of specimen fixation are specified in guidelines and protocols, but detailed descriptions concerning decalcification agents are rarely seen. In this study, we examined the effect of decalcification on gene search. The DNA yield and PCR amplification were compared among FFPE specimens prepared using various decalcification agents and decalcification times. We also determined the effects of various decalcification agents on EGFR mutation. The results showed that DNA yield was low in the strong-acid-type decalcification agents K-CX and Plank-Rychlo, and no amplification by PCR was observed. Also, with the strong-acid-type decalcification and 10% formalin formic acid, the DNA yield decreased as the decalcification time increased. On the other hand, 10% EDTA yielded more DNA, and PCR amplification was good from 100 to 400 bp. Regarding decalcification time, DNA yield did not decrease even after 7 days of treatment, which was a good result. In the study of the EGFR mutation detection kit for pulmonary adenocarcinoma, detection with strong-acid-type decalcification agents and 10% formalin formic acid was impossible regardless of decalcification time, but EGFR mutation can be detected with 10% EDTA treatment for 7 days. When decalcification is required for mutation search, it is essential to use EDTA as a decalcification agent.

We performed basic evaluation studies of the reagent ‘Auto KL-6・BML’ for Krebs von den Lungen-6 (KL-6) measurement based on the latex turbidimetric immunoassay. This reagent showed within-run and between-run coefficients of variation (CVs) of less than 3.7%, a detection limit of 25.2 U/mL, and also good dilution linearity. No effects from interfering substances were detected. In addition, the correlation with ‘Nanopia KL-6 Eisai’ as the comparison product whose principle of measurement is similar to that of this reagent was good (y = 0.917x − 9.5, r = 0.949, n = 194). Moreover, the correlation with the ‘HISCL KL-6 Reagent’ as the comparison product whose principle of measurement is chemiluminescent enzyme immunoassay was also good (y = 1.010x + 20.0, r = 0.914, n = 194). ‘Auto KL-6・BML’ showed sufficient reagent performance in routine tests.

We evaluated the basic performance of chemiluminescent immunoassay-based intact PTH assay, which was newly developed as part of the AIA-CL systems. The coefficients of variation (C.V.) of within-run and between-day precisions of the assay using quality control samples or pooled plasma from patients were 1.9 to 3.7% and 3.8 to 5.1%, respectively. Good linearity was observed from 0 to 5,000 pg/mL. The LoB, LoD, and LoQ were 0.19, 0.36, and 1.92 pg/mL, respectively. No interference by endogenous substances was noted. The relationship between AIA-1800 or cobas^® 6000 and this method was good. The stability of serum in storage was poor at 4°C. Intact PTH concentrations were reduced by sample transfer to another container. This assay was only reactive against the 7–84 PTH fragment, and reactivity against the other PTH fragments (1–34, 13–34, 44–68, 39–68, 39–84, and 53–84) was below 0.1%. These results suggest that this method is useful for routine examinations, but caution is needed regarding sample stability and transfer.

We analyzed the cause of nonspecific reactions of the reagent “Determiner CL IL-2R NX” for the measurement of the soluble interleukin-2 receptor. Furthermore, the basic performance of this improved reagent and its inhibitory effect on nonspecific reactions were investigated. The improved reagent was added to suppress the causative agent. As a result of the analysis of the cause of nonspecific reactions using the improved reagent that was added to suppress alkaline phosphatase (ALP), fibrin and HAMA, it was revealed that ALP participated in nonspecific reactions. We performed a dilution analysis of a sample for nonspecific reactions. The sIL-2R value of the undiluted sample analyzed using the currently used reagent was 42,946 U/mL, but it decreased and became 1,904 U/mL after 8-fold dilution. On the other hand, the sIL-2R value obtained using the improved reagent was similar to those of the diluted and undiluted samples. We measured the sIL-2R value of nonspecific samples using the improved reagent that changed the concentration of ALP, which was a causative agent of nonspecific reactions, to examine the suppression of such reactions. As a result, the nonspecific reactions were inhibited by tenfold those of a currently used reagent. Satisfactory precision, accuracy, and linearity were obtained with the improved reagent. In summary, our results suggest that the improved reagent “Determiner CL IL-2R NX” showed sufficient performance for routine examinations and its basic performance is equal to that of the currently used reagent. Moreover, the nonspecific reactions with ALP were inhibited. However, it was considered that further examinations using different samples are necessary because we were able to analyze only one nonspecific sample in this work.

We performed basic evaluation studies of propafenone and 5-hydroxypropafenone measurements in serum using a liquid chromatograph-tandem mass spectrometer (new method). Results obtained by this method showed CVs of within-run and between-day precisions of less than 3.0%, and the accuracy was less than 13%. The dilution linearity was also good. No matrix effect was also detected. In addition, the correlation between the conventional and new methods was good (propafenone: y = 1.018x - 3.852, r = 0.996, n = 100; 5-hydroxypropafenone: y = 1.059x + 1.846, r = 0.997, n = 100). This study revealed that this new method is acceptable for use in routine tests.

[Introduction] We evaluated the analytical performance of Lumipulse L2400 (Fujirebio Co., Ltd.) in the detection of HBsAg-HQ, KL-6, and 8 tumor markers (CEA, CA19-9, AFP, CA125, CA15-3, PSA, CYFRA, and PIVKA-II). We assessed the correlation of the false positive rates of HBsAg-HQ for 5 months in routine testing and the turn-around-time (TAT) of CEA between Lumipulse L2400 and Lumipulse G1200. [Results] The within-run and between-run coefficients of variation (CVs) of all the reagents ranged from 0.0% to 6.2% in pooled serum and a control sample (n = 10). The limits of detection and quantitation (at 10% CV) were equivalent to those in the accompanying documents of reagents provided by the manufacturers, and the assay results for the serially diluted pooled serum showed excellent linearity for all the reagents. Lumipulse L2400 strongly correlated with Lumipulse G1200 within a measurement range for all the reagents (r = 0.99). For the PIVKA-II reagent, the interdevice correlation up to 100 mAU/mL (r = 0.961) was slightly lower than that with higher values (r = 0.99). There was a good reproducibility with automated 1:200 or 1:1000 dilution in a device with pooled serum or a calibrator sample (CV = 0.9–3.0%; n = 10), and the 1:1000 dilution assay showed measurements from 95.2% to 113.7% compared with manual dilution. The false positive rates of HBsAg-HQ among all HBsAg-HQ orders with Lumipulse L2400 and Lumipulse G1200 were 0.11% and 0.15%, respectively. The average TAT in Lumipulse L2400 was shortened by 7 min and the number of TATs up to 60 min was improved from 73.5% to 94.3%. [Conclusion] These results showed that Lumipulse L2400 is useful for routine measurements.

Objectives: Plasma fibrinogen levels are determined by the Clauss fibrinogen assay (CFA) using thrombin reagent in routine laboratory tests. Thrombocheck Fib (L) is a liquid, ready-to-use reagent containing human-origin thrombin for CFA. In this study, we evaluated a new Thrombocheck Fib (L) reagent, which contains bovine-origin thrombin instead of human-origin thrombin. Methods: We compared two different lots of Thrombocheck Fib (L) reagent. One contained human-origin thrombin (Lot 209) and the other contained bovine-origin thrombin (Lot 212). We evaluated these two reagents by measuring their fibrinogen levels using the control plasma Coagtrol IX/IIX and plasma samples from patients. This study was approved by the Nagoya University Hospital Ethics Committee (Identification No. 2010-1083-2). Results: The reagent containing bovine-origin thrombin showed no significant differences in within-run imprecision, between-day imprecision, dilution linearity and limit of detection compared with the reagent containing human-origin thrombin. We also found no significant inhibition by interference substances. The correlation between Lots 209 and 212 was excellent and Spearman’s r was 0.9971. Discussion and Conclusion: There are few reports on the differences between human-origin thrombin and bovine-origin thrombin for plasma fibrinogen determination. In this study, we evaluated the bovine-origin thrombin reagent in comparison with the human-origin thrombin reagent and found no significant differences between them. Future studies should be carried out to assess the reactivities of these human- and bovine-origin thrombin reagents against abnormal fibrinogen or direct oral anticoagulants.

Recently, hospitals have not only been diagnosing congenital diseases by analyzing platelets, but also evaluating the therapeutic effect of anti-platelet drugs through the platelet aggregation test. In our hospital, we evaluate the effect of anti-platelet drugs on the basis of Grade Type (G-Type) through four concentration analysis indexes installed in the semi-automated platelet aggregation analyzer PRP313M. At this time, the new analysis index of platelet aggregation (platelet aggregation level; PAL) was developed and installed in the automated blood coagulation analyzer CS-5100. We evaluated the usefulness of adenosine diphosphate (ADP)-induced PAL (APAL) and collagen-induced PAL (CPAL) by comparing them with the G-Type of each reagent. The correlation coefficients were r = 0.72 for APAL with G-Type and r = 0.71 for CPAL with G-Type. We separated the samples into two groups by our usual cutoff G-Type of −1. The distribution results of APAL and CPAL showed significant differences between groups. Moreover, an APAL of 7.1 and a CPAL of 8.0 were equivalent to a G-Type of −1 and the concordance rates of evaluation based on APAL and CPAL were 92.6% and 86.0%, respectively. From these results, we consider that we can evaluate the effect of anti-platelet drugs on the basis of PAL as well as G-Type. Furthermore, because CS-5100 is an automated blood coagulation analyzer for general coagulation tests, it enables hospitals that do not have a special analyzer for the platelet aggregation test to evaluate the effect of anti-platelet drugs.

Tosoh Corporation developed a novel reagent to be used with AIA-CL automated immunoassay analyzers to quantify adrenocorticotropic hormone (ACTH) on the basis of the principles of chemiluminescence enzyme immunoassay. The coefficients of variation (CVs) for within-run and between-run reproducibilities ranged from 1.1 to 4.4%. They showed good linearity from 0 to 1,790 pg/mL, and the limit of quantitation was 1.650 pg/mL. With its high sensitivity, the assay may be useful for detecting the presence of ACTH-producing tumors that secrete high-molecular-weight ACTH. The measurement time of this method is shorter than that of the existing method, and it is considered highly useful for routine examinations.

We previously reported that the results of improved dimension tacrolimus (TAC) assay (Siemens), which is based on the affinity column-mediated immune assay (ACMIA), are affected by EDTA used as an anticoagulant. However, EDTA was improved as a reagent to EDTA-2K in 2018. In this study, we evaluated the analytical performance of the improved TAC assay using EDTA-2K in comparison with the conventional assay. In the EDTA interference study, the TAC concentration was decreased by 16.6% with 3.8 mg/mL EDTA-2K, corresponding to a half volume in the conventional assay, and the effect was observed in a concentration-dependent manner. However, the TAC concentration was decreased by only 1.4% with 3.8 mg/mL EDTA-2K in the improved assay. The within-run precisions obtained were 4.2% at a low concentration (mean: 3.9 ng/mL), 3.7% at a medium concentration (mean: 10.9 ng/mL), and 2.8% at a high concentration (mean: 20.9 ng/mL), which were equivalent to those of the conventional assay at each concentration. In addition, the limits of quantitation of the improved and conventional assays were determined to be 0.5 and 0.3 ng/mL, respectively, confirming that the measurement accuracy of the improved assay is higher than that of the conventional assay. In conclusion, it was revealed that in the improved assay, the effect of the EDTA concentration on the blood TAC concentration measurement was reduced in comparison with that in the conventional assay. The improved assay is useful for the routine TDM of TAC.

The Clauss fibrinogen assay (CFA) has been widely used and determine functional fibrinogen levels. Although fibrinogen antigen (Ag) level determination is necessary for the diagnosis of fibrinogen abnormalities, few reagents and coagulation analyzers had been optimized for measuring fibrinogen Ag. In this study, we newly established an assay parameter to determine fibrinogen Ag level using the FactorAuto^® Fibrinogen reagent, which is based on the latex immuno-agglutination assay for the CS-5100 analyzer. We assessed within-run and between-day imprecisions using two levels of control plasma. Dilution linearity and limit of detection of the fibrinogen antigen were also investigated. The correlation between functional fibrinogen and antigenic fibrinogen was analyzed using citrated plasma from patients without dysfibrinogenemia. This study was approved by the Nagoya University Hospital Ethics Committee. Within-run imprecision and between-day imprecision were <5%, and dilution linearity was up to 720 mg/dL. The limit of detection was 4.2 mg/dL when the sample volume was increased two-fold. The correlation between fibrinogen activity (CFA) and Ag (FactorAuto^® Fibrinogen) was excellent and Spearman’s r was 0.9874. The excellent correlation between FactorAuto^® Fibrinogen and N-assay TIA Fib for the antigen was observed and Spearman’s r was 0.988. Fibrinogen Ag levels determined by FactorAuto^® Fibrinogen showed a significant difference (p < 0.005) compared with N-assay TIA Fib. These results suggest that the FactorAuto^® Fibrinogen reagent is useful for routine laboratory tests. We observed a significant difference between the FactorAuto^® Fibrinogen and the N-assay TIA Fib, and both reagents are available in CS-5100 analyzer. Taken together, automated fibrinogen antigen determination using the CS-5100 analyzer is available in clinical settings and could contribute to the diagnosis of fibrinogen abnormalities.

The receipt, storage, and transport of laboratory samples are important tasks for sample collection services in registered clinical laboratories. Among various types of sample, microbiological samples are particularly difficult to handle because they contain potentially harmful microorganisms, and specific restrictions on their handling are established. We conducted a survey by face-to-face interview on the concerns of the sample collection staff with regard to the handling of microbiological samples. The results showed that three major issues, namely, sample volume, sample confirmation, and requested test, accounted for 88% of all concerns. To resolve these issues, we prepared a microbial inspection manual and conducted workshops for the staff. We continued the workshops for five years from 2013 to 2017 and investigated the number of inquiries from the microbiology laboratory staff to the sample collection staff concerning sample confirmation and requested items. Because of this, the number of inquiries was successfully reduced by half. Furthermore, to strengthen the collaboration between the microbiology laboratory staff and the sample collection staff, a contact form was devised to share important information on both sides. In conclusion, through these efforts, understanding of the sample collection staff has been considerably improved and practical problems have significantly diminished. In addition, we would like to report also the efforts of the microbiology laboratory staff who always supports customers’ inquiries.

We investigated the usefulness of clinical decision support with the initial information of positive blood cultures provided by a microbiology laboratory. Four hundred thirty-seven positive blood cultures from April 2016 to March 2017 were determined as having bacteremia or fungemia. Immediately after detecting positive blood cultures, the laboratory reported the information of putative microorganisms on the basis of Gram staining results as “first report” to clinicians within an hour. The agreement between the first and the final reports was 92.7%. Putative microorganisms were described on medical charts in 328 cases (75.1%), and the alterations of antibiotic therapy were described in 284 cases (65.0%) in accordance with the first report from the laboratory. Clinicians altered their antibiotic therapy in 220 cases (50.3%) over the entire clinical courses, in which the antibiotic therapy in 98 cases (22.4%) was altered after the first report. The frequency of treatment changes for Gram-positive cocci microorganisms was higher after the first reports, whereas that for Gram-negative cocci microorganisms was higher after the final reports. Providing prompt and detailed information can be helpful for antibiotic selection when blood culture results are positive. In this study, we clearly demonstrated that the first reports including putative microorganisms from a microbiology laboratory can lead to a doctor’s appropriate actions such as documentation of medical charts, administration of antibiotics, and alteration of antibiotics. Thus, the prompt reporting of initial blood culture results can contribute to clinical decision-making.

The indirect immunofluorescence assay is the gold standard for the screening of antinuclear antibodies (ANAs). However, the procedure of the conventional indirect immunofluorescence assay of ANAs (FANA) is complicated, and the visual interpretation of results requires a highly skilled clinical technologist or laboratory staff. Thus, we performed a basic evaluation of ANA detection using a system for computer-aided immunofluorescence microscopy (EUROPattern Cosmic FANA System, EPA) and an automatic preprocessing device. The antibody titers of within-run and between-day precisions determined by the visual microscopic evaluation of the EPA images were within the range of +/−1 titer step. The ANA titers of healthy individuals obtained using the EPA system and the conventional method by manual operation showed no large differences. The EPA system and the conventional method showed a concordance rate of the antibody titer (within +/−1 titer step) of as high as 97.0%. The positive concordance rates of the ANA patterns, namely, homogeneous, speckled, nucleolar, and centromeric, between the EPA system and the conventional method were 79%, 84%, 88% and 88%, respectively. The EPA system should not be considered as a fully automated system for ANA evaluation. However, it is useful for routine ANA analysis.

As part of a project of the Fukuoka Association of Medical Technologists in the Chikuho region to improve the quality of tests, 13 facilities in the Chikuho region, which participated in the L-Switroll Survey, were subjected to external qualitiy control. The purpose of this study was to raise the awareness of medical technologists regarding external qualitiy control by deepening their understanding of external quality control from how to view the results and the method of evaluating the results, identifying problems in each facility, and considering the cause of each problems and countermeasures. In this paper, we reports the developments and the results of the activities for correcting the difference among facilities and the direction of continuing this study. The members analyzed were recruited in the Chikuho region, and the concentrations of 27 biochemical items were analyzed twice, and each item was evaluated with ±2SDI. CV% in 13 laboratories was within 5% for the 27 biochemical items. We visited one of the 13 laboratories, where the accuracy rate was low, and developed and implemented measures for the management of reagents and control sera, timing of calibration, and internal quality control. We visited it again to carry out Switroll I and II surveys. Calibration and remeasurement were performed for items whose concentrations were outside the manufacturer’s recommended range. The accuracy rates were 61.5% before the visit, 82.5% before the re-visit calibration, and higher than 90% after the calibration. These results suggested that improvement can be achieved by thoroughly controlling calibration frequency and the number of times. It was effective not only for medical technologists in a laboratory to evaluate each other but also for the regional associations to intervene by visiting laboratories.

Currently, urinary Mandel acid is measured using several high-performance liquid chromatography (HPLC) analytical instruments. As for precision management data, it is difficult to estimate precision values such as instrument-to-instrument precision, day-to-day precision, repeat precision, and intermediate precision by nested analysis of variance owing to missing values (operation of a part of analytical instruments). Thus, we tried the restricted maximum likelihood (REML) method, which can be used for the simultaneous estimation of multiple errors from missing values. The REML method can be used to estimate instrument-to-instrument precision, day-to-day precision, repeat precision, and room precision. The intermediate precision values of low control (0.30 g/L）and high control (0.96 g/L) were less than 2.0%. From the above experiments, the REML method was confirmed to be effective for the urinary Mandel acid assay.

Mild hemophilia is sometimes overlooked in the diagnosis even in patients with findings of a slightly prolonged APTT. Therefore, we planned to clarify the frequencies of mild hemophilia in patients with normal PT and prolonged APTT before surgery. Among the 11,465 patients who underwent surgery from 1 June 2015 to 31 May 2016 in Okayama University Hospital, 8,676 patients were administered the preoperative APTT test. All the patients who received the anticoagulant treatment were excluded. We decided that the reference APTT range was 26.9–38.1 seconds on the basis of the normal distribution of normal samples, and patients with an APTT of 38.2 seconds or longer were recruited as the subjects of this study. Among these patients, 134 (1.5%) showed APTTs beyond the upper reference range (38.2 seconds or longer). However, only 13 patients (9.7%) were subjected to further investigation; as a result, one patient was found to have von Willebrand disease (type I) and another one with mild hemophilia A. They were 0.012% each of the total 8,676 patients. These results suggest that a certain percentage of mild hemophilia patients existed in the general population and they were unaware of their bleeding disorder before surgery. Therefore, it is very important to call a physician’s attention to the possibility of mild hemophilia. Moreover, there is concern that blood coagulation disorders are not tracked because of insufficient scrutiny. A much larger study is required to clarify the actual percentage of patients with mild hemophilia in the Japanese population.

Neuron-specific enolase (NSE) has been characterized as a marker of lung small cell carcinoma or neuroblastoma. To meet clinical demands, we decided to start measuring NSE in-house instead of outsourcing the measurement. In this study, we evaluated the basic performances of the ECLusys^® reagent NSE for in-house testing. We collected serum samples from patients (n = 69) and healthy volunteers (n = 5) and analyzed them using the ECLusys^® reagent NSE in cobas^® 8000 (Roche Diagnostics). We assessed the intra-assay precision, between-day precision, dilution linearity, correlation between outsourcing and in-house measurements, inhibition by interfering substances (rheumatoid factor, bilirubin, hemoglobin, chyle) and stability after serum collection. We also investigated the impact of sample transfer between test tubes. We observed the excellent basic performance of measurement using NSE in terms of intra-assay precision, between-day precision, dilution linearity, and correlation between outsourcing and in-house measurements. The test results showed that the NSE levels were increased by the addition of hemoglobin in a dose-dependent manner. We also found that the NSE levels decreased during refrigerated storage in a time-dependent manner. These results suggest that the refrigerated storage of the serum samples for more than two days is not appropriate for NSE determination and leads to false reports owing to the pre-examination process before measurement.

HIV, tuberculosis and malaria are the three major infectious diseases in the world. In sub-Saharan Africa, the damage caused by these infectious diseases is greater. In recent years, immunochromatography using the rapid diagnostic test (RDT) has been widely used in this area. RDT is used for the initial diagnosis in Japan. In sub-Saharan Africa, it can be easily diagnosed, and this has been funded by The Global Fund. However, now, the microscopic diagnosis of tuberculosis is being carried out, and new tests for TB diagnosis are being requested. On the other hand, in Japan, patients with these infectious diseases are fewer. Thus, the diagnosis of infectious diseases by PCR leads to higher accuracy. In conclusion, reasonably identifying patients with highly prevalent infectious diseases in a country is important. It is also important to accurately diagnose low-prevalence infectious diseases in a country.

A patient made an emergency visit for chief complaints of fever, low activity, and low lactation. No increase in the cerebrospinal fluid cell count was seen by examination upon hospitalization, but the patient was hospitalized after close inspection for medical treatment purposes because an enhanced inflammation reaction was recognized by a blood test. Streptococcus agalactiae (GBS) was detected after 3 days of hospitalization by blood and cerebrospinal fluid culture, and ultralate-onset Streptococcus B group meningitis was diagnosed. After the start of therapies such as antimicrobial and γ-globulin therapies, the cell count decreased. However, a sudden increase in the cerebrospinal fluid cell count considered to be caused by aseptic meningitis was recognized after 15 days of hospitalization. However, the inflammatory reaction later attenuated and the cell count continued to decrease. The patient was discharged when her general body condition was good after 57 days of hospitalization. This is a case of ultralate-onset Streptococcus B group meningitis that developed in the patient over a period of 90 days. When the cerebrospinal fluid is first examined less than 24 hours after the onset of fever, attention should be paid to the possibility of the increase in the cerebrospinal fluid cell count.

We report the isolation of an extended-spectrum β-lactamase (ESBL)-producing Salmonella sp. from a patient who had not traveled abroad. A 53-year-old man visited the Department of Emergency of Tokyo Jikei University School of Medicine, Daisan Hospital because of watery diarrhea 20 or more times a day. An ESBL-producing Salmonella sp. (Serotype O8) was isolated from his fecal specimens. As a result of PCR analysis and DNA sequencing, the genotype of ESBL was identified to be of the CTX-M-15 type, the rate of incidence of which has been increasing recently in Japan. The detection of this ESBL-producing Salmonella sp. from this patient without a history of overseas travel suggests that the species is already prevalent in Japan. For this reason, it is necessary to consider the presence of ESBL-producing bacteria in the selection of antimicrobial agents in cases suspected of Salmonella sp. involvement.

Congenital afibrinogenemia is characterized by the complete absence of immunoreactive fibrinogen in plasma, and its prevalence is approximately 1/1,000,000. Genetic mutations within three fibrinogen genes (FGA, FGB, and FGG coding for Aα, Bβ, and γ chain, respectively) have been associated with afibrinogenemia. FGA del c.364+86_c.510+45 (FGA Δ1238 bp) in afibrinogenemia has been reported in Japan (Mie, Okayama, Fukuoka, Gifu, and Saitama prefectures) and China (Shanghai), but regional characteristics are unknown. We identified a novel case of afibrinogenemic in a girl, the second patient in Mie, with FGA Δ1238 bp. The haplotype was identified by short tandem repeat (STR)-polymerase chain reaction (PCR) and fragment analyses using seven STR loci (D4S2962, D4S2934, D4S2999, D4S3021, intron 3 of FGA (FGA-i3), D4S2631, and D4S1629) on chromosome 4. Haplotype and clinical features were compared with those of two previously affected families (Yokkaichi and Kurashiki), and six patients were reported. Each of the three families had at least three common STR loci of D4S3021-FGA-i3-D4S2631-D4S1629 (230-del-212-146 bp) and the allele with FGA Δ1238 bp. The Mie and Okayama families may be derived from the same ancestor. Afibrinogenemic patients with FGA Δ1238 bp have been identified in Western Japan, and the continuous data accumulation by haplotype and sequence analyses should provide clues to discriminate their genetic background.

Mitochondrial DNA (mtDNA) mutations and deletions are important causes of inherited mitochondrial diseases. The clinical manifestations of mtDNA disorders are extremely variable. Thus, we comprehensively determine mitochondrial diseases from the results of not only genetic tests but also image examination, histological examination, and clinical examination. In this report, we describe the case of a 1.5-year-old infant with exocrine gland disturbances and diarrhea. As blood tests showed high pyruvic acid and lactic acid levels in the plasma, mitochondrial disease was suspected. We detected no base substitution and minor deletion in the peripheral blood sample by the direct sequencing of PCR (polymerase chain reaction) products. Following long-distance PCR amplification to detect total mtDNA, a large-scale mtDNA deletion was detected in this patient. Sanger sequencing identified the breakpoints of the 5 kb deletion. Southern blot analysis confirmed that the deletion ratio of mtDNA is 33% in peripheral blood and 51% in a bone marrow sample. After molecular analysis of mtDNA and extensive clinical investigation, the patient was diagnosed as having Pearson syndrome, and we confirmed the usefulness of mitochondrial genetic tests.

Background: Primary effusion lymphoma (PEL) is a rare malignant lymphoma observed as an effusion in the body cavity without forming any tumor masses and is associated with human herpes virus type 8 (HHV-8) infection. We report a case of PEL-like lymphoma (PEL-LL) observed as a pleural effusion in the absence of HHV-8 infection. A cytology cell block of the pleural effusion was useful for diagnosis. Case: A female in her 90s complained of dyspnea. A chest X-ray examination showed a large amount of bilateral pleural effusion, and thoracic drainage was performed. Pleural effusion cytology showed a large number of atypical cells with large irregular nuclei. Immunocytochemical analysis using a cell block showed CD20, CD79a, and bcl-2 positivities. Therefore, the patient was diagnosed as having diffuse large B cell malignant lymphoma. No tumor mass or lymph node swelling was detected by enhanced computed tomography and no HHV-8 was detected. Therefore, this patient was diagnosed as having PEL-LL. Conclusion: In the present case, the use of a cytology cell block from pleural effusion drained for the first time enabled rapid immunocytochemical analysis, resulting in early diagnosis. Several previous studies have shown that PEL-LL disappeared following effusion drainage. Therefore, constructing a cytology cell block from the initial drained effusions is important for the diagnosis of PEL-LL.