Extracardiac lesions are occasionally incidentally detected on transthoracic echocardiography (TTE), but such incidental detections have seldom been comprehensively investigated. Data collection and analysis for detected cases may lead to improved diagnostic capability. We retrospectively analyzed cases in which extracardiac lesions were detected during TTE performed by clinical laboratory technicians at our hospital from 2016 to 2021. Over the 5-year period, TTE was performed on a total of 31,930 patients, and extracardiac lesions were detected in 16 (0.05%) of these patients. The detected lesions were located in the liver (n = 6), gallbladder (n = 6), pancreas (n = 1), intra-abdominal lymph node (n = 2), and mammary gland (n = 1). Ten of the patients were found to have a malignancy. Fourteen of the 16 patients (including all 10 patients with malignancies) were examined by technicians who routinely also performed diagnostic imaging of the abdomen and superficial structures. The large number of detections in the liver and gallbladder was attributed to the fact that the inferior vena cava was assessed using epigastric as well as intercostal scanning. Our study findings suggest that multidisciplinary expertise and experience contribute to higher detection rates of extracardiac lesions. Furthermore, although most TTE-detected extracardiac lesions progressed by the time of detection, a small number of patients were able to receive appropriate treatment as a result of the incidental detection.

Purpose: SARS-CoV-2 has spread in Japan since January 2020 and has mutated repeatedly, resulting in shifts in the dominant circulating strains. To clarify the usefulness of antigen testing for mutant strains, we compared qualitative and quantitative antigen tests using different SARS-CoV-2 isolates. Methods: Culture supernatants of Delta (AY.54) and Omicron (BA.2, BA.4, and BA.5.2) variants isolated in Vero E6/TMPRSS2 cells were used as samples. Dilution series were prepared from the samples using PBS (−) and performed according to the package insert of each test kit and reagent. Results: The quantitative test tended to have better detection sensitivity than the qualitative tests, although some qualitative tests had comparable detection sensitivity to the quantitative test. The detection sensitivities of the tests ranged 10⁵–10⁶ copies/40 μL. The detection sensitivities of the test did not differ among the variant strains. Conclusion: Although differences in detection sensitivity were observed among the tests, all kits could detect high viral loads. There was little difference in detection sensitivity between the different mutant strains, indicating that the antigen test method is also valid for Omicron variants.

Oxidative stress caused by the increased production of reactive oxygen species and/or decreased efficacy of the antioxidant system is known to be associated with the progression of arteriosclerosis. The purpose of this study was to establish a new biomarker “the relative oxidative stress index” to evaluate the progression of atherosclerosis. We measured both oxidation and anti-oxidation activities simultaneously in sera from 1,073 general volunteers (610 females, 463 males; aged 19–77 years; mean 44.96 years), the former by d-ROMs (reactive oxygen metabolites-derived compounds) test and the latter by BAP (biological antioxidant potential) test using a AU480 automated analyzer. To obtain a parameter representing an overall shift toward the oxidative stress, the relative oxidation stress index was devised by the following formula: OSI = C × (d-ROMs/BMP), where C denotes a coefficient for standardization to set the mean of OSI in healthy individuals at 1.0 (C = 8.85 in this study). Additionally, we measured systolic blood pressure, diastolic blood pressure, and internal carotid artery intima-media thickness (IMT) in these 1,073 subjects. The present study confirmed that the group with elevated the relative oxidation stress index had higher systolic blood pressure and significantly increased internal carotid artery thickening compared to the normal group. These results suggest that evaluating the relative oxidative stress index is useful as a biomarker test for the cardiovascular system.

In organ transplantation, recipients are known to experience serious complications from infections after transplantation from viruses brought by organ donors. Therefore, it is important for donors to confirm the presence of infection in pre-transplantation testing for infectious diseases that are contraindicated for transplantation, such as human T-cell leukemia virus type 1 (HTLV-1). However,in living donor renal transplantation, there is no contraindication to organ donation from an HTLV-1-infected donor for recipients who were infected with HTLV-1 prior to transplantation. Therefore,authors believe that quantification of HTLV-1 is necessary to assess the risk of infection. In this study, we aimed to establish a quantitative real-time polymerase chain reaction (quantitative PCR) method that can be used as a definitive method for rapid recipients and donors diagnosis, assuming cases in which the decision was withheld by the line blotting assay (LIA) method. The standard curve required for quantitative PCR was calculated as HTLV-1 DNA copies/μL from threshold cycle (Ct) values using DNA fragments generated from HTLV-1 sequences. The quantitative PCR established in this study uses artificially created DNA fragments, which should enable stable quantification of HTLV-1.

The urine collection method at our health planning center was changed from spot collection to morning collection in April 2019, and changes in positivity rates for qualitative urinary, sediment examinations, result of a measurement of the UF-1000i (Sysmex), and the microscopic examination rate. Specific gravity differences were observed between spot and morning urine samples, with spot samples showing concentration tendencies. A reduction in a few parameters for males (protein by 8.4%, occult blood by 4.1%, white blood cells (WBCs) by 1.3%) and females (protein by 5.3%, occult blood by 10.4%, WBCs by 20.1%) was observed after the switch to morning urine sample collection. Urinary sediment examinations indicated reductions in renal tubular epithelial cells (2.3%), as well as reductions in red blood cells (RBCs) (5.8%), WBCs (12.9%), squamous epithelial cells (20.6%), and bacteria (18.1%) for females. One of the factors influencing positivity changes included concentrated urine samples resulting from fluid intake restriction, which impacted protein content and specific gravity. Additionally, reduced accuracy associated with midstream urine collection during spot urine collection led to higher positivity rates for RBCs, WBCs, squamous epithelial cells, and bacteria in females due to restricted fluid intake. UF-1000i usage patterns demonstrated a reduction in microscopic examination rates from 38.6% with spot urine to 26.8% with morning urine, thereby streamlining urinary examination operations. The reduced positivity rates of protein, casts, and pathological casts detected using UF-1000i in qualitative urinary analysis led to decreased microscopic examination rates. We showed that morning urine collection improves test accuracy.

Urine sediment examination is a non-invasive and versatile clinical test that does not require special equipment. Notably, hyaline casts, components of urinary sediment, are known to reflect renal function. We investigated the potential of urinary hyaline cast count as a predictor of renal function deterioration. We targeted 250 cases with negative urinary protein qualitative tests who underwent urine sediment examination in 2015. Urinary hyaline casts were categorized into four groups: < 10, 10–29, 30–99, and ≥ 100 per whole field (WF). We observed endpoints, such as CKD severity, GFR classification, and urinary protein progression for up to 8 years. No significant trends were found when comparing patient progression among the hyaline cast count groups. Using cut-offs of 10/WF, 30/WF, and 100/WF, significant hazard ratios were observed for CKD severity and GFR progression. Comparing cumulative renal function deterioration using 10/HPF as a cut-off, cases ≥ 10/WF showed earlier renal function decline. Cases with hyaline casts ≥ 10/WF may have a higher likelihood of future renal deterioration. Our results suggest urinary hyaline cast count may be a predictor of renal function decline in cases with negative urinary protein.

[Purpose] Our objective is to determine the actual Cl concentration in the serum of a bromide (Br)-poisoned patient, which is the Cl concentration measured by the ion-selective electrode method assuming a Br selectivity factor of 1. [Method] We cryopreserved the serum of a Br-poisoned patient, whose Cl concentration could not be measured using a biochemical automatic analyzer (BAA: TBA C16000). The Cl concentration in the thawed serum was 130 mmol/L as determined using BAA in U-mode. It was diluted up to 32-fold step by step with a high-Cl-concentration (182 mmol/L) solution. The calculated initial concentration before dilution (predicted initial Cs = n × (concentration of solution (Cs) − concentration of dilution (Cd)) + Cd (Equation 1)) and the previous concentration per dilution ((previous Cs) = 2 × (Cs − Cd) + Cd (Equation 2)) were compared. [Results] The Cl concentration after dilution with Cl-free purified water was the same as expected, but the Cl concentration after dilution with the Cl-containing solution was higher than expected. The relationship between the concentration from Equation 1 minus the concentration from Equation 2 and n is y = 3.82n − 31.13 (y = −27.3 if n = 1). The actual Cl concentration was estimated to be 102.7 mmol/L. [Discussion] In BAA U-mode, the reference electrode is washed once with solution. In BAA S-mode and probably in gas analysis, it is not washed, resulting in the reduced potential difference between the calibration solution and the sample. [Conclusion] The actual Cl concentration in the serum of a Br-poisoned patient can be estimated by diluting the sample with a solution containing Cl and then measuring the Cl concentration of each diluted sample using BAA in U-mode.

Chimeric antigen receptor gene-transfected T cell (CAR-T) therapy is a treatment for relapsed/refractory CD19+ diffuse large B-cell lymphoma, acute lymphoblastic leukemia, and follicular lymphoma. In order to start CAR-T therapy, we established a centralized management system for cell collection, preparation, freezing, storage, shipping, and product receipt centered on the Blood Transfusion Department, and performed cell collection for the first case in January 2022. We have conducted 10 cases of lymphocyte collection and product receipt over a 15-month period. We performed a backward-looking analysis of our case experience to calculate collection efficiency. We found that the number of CD3+ lymphocytes in peripheral blood and the number of lymphocytes in peripheral blood were significantly correlated with the total number of CD3+ lymphocytes. A significant correlation was also observed between the total CD3+ lymphocyte count and the total number of nucleated cells. On the other hand, hemoglobin level, peripheral blood CD3+ lymphocyte count, peripheral blood lymphocyte count, platelet count, age, and collection efficiency showed no significant correlation. Through this verification, it became clear that although the number of biomedical laboratory scientist in our transfusion department is compact, with only two CAR-T therapy support stuffs among them, they are able to perform their work efficiently and safely. It was also clear that the centralized management system is an efficient system that allows physicians to concentrate on establishing a system of medical care coordination with the referring institution and on treatment. We will continue to accumulate data and aim for safer and more efficient operation.

To diagnose coronavirus disease 2019 (COVID-19), quantitative antigen test is said to be less sensitive than PCR. We examined the clinical performance of a quantitative antigen test through sensitivity of the quantitative antigen test in the SARS-CoV-2 and setting of the indeterminant. There were 165 of whom were positive in the real-time PCR (PCR) using nasopharyngeal samples and 30 of whom were negative from January 2022 to March 2023. The quantitative antigen test showed a sensitivity of 79.4%, a specificity of 100%, a positive concordance of 100%, and a negative concordance of 46.9% compared with the PCR. We found a correlation between the Ct value of PCR and the cut off index (COI) value of quantitative antigen test (r = 0.956; p < 0.01). Sensitivity of the quantitative antigen test progressively declined from 100% in Ct <30 to 69.2–94.7% in Ct 32–<34 and then to 0–27.3% in Ct 34–40. When we set the indeterminant line of quantitative antigen test up as 0.9–1.0 COI, 0.8–1.0 COI and 0.7–1.0 COI, sensitivity of the quantitative antigen test has improved as expands the range of the indeterminant compared with no setting of the indeterminant. These results suggest that the SARS-CoV-2 quantitative test is competent enough to diagnose COVID-19, and improved setting of indeterminant makes it possible to be comparable sensitivity compared with PCR.

In this study, we evaluated the basic performance of S400CF, an automated blood coagulation analyzer newly developed by Sekisui Medical Co. Repeatability and Intermediate Precision, determined using two density control reagents, yielded favorable results. On-board stability was examined using similar samples and found to be significantly superior to that of the existing analyzer, Coapresta 2000 (CP2000, Sekisui Medical Co., Ltd.). We also assessed the effects of coexisting substances (hemoglobin, chyle, free bilirubin, conjugated bilirubin, and rheumatoid factor) using Interference Check A Plus and Interference Check RF Plus (Sysmex Corporation). Up to the permissible limit concentrations specified in the package insert of each measuring reagent, no interference effects were detected for these substances. The correlation between S400CF and CP2000 was good, with correlation coefficients exceeding 0.9 and slopes ranging from 0.9 to 1.1. Dilution linearity was examined using a series of dilutions made by diluting the high-value sample for each measurement item with saline solution. The dilution linearity surpassed the upper limit of the measurement range stated on the package insert of each measurement reagent. The detection limits determined using low-value samples for each measurement item were well-below the lower limit of the measurement range stated on the package insert of each measurement reagent. The processing speed evaluated using control reagents and patient plasma was significantly improved compared with that of CP2000. In conclusion, S400CF exhibits favorable basic performance and is considered to be sufficiently useful for routine tests.

Objective: This study aims to assess the utility of stent intraluminal peak flow velocity ratios in predicting restenosis after carotid artery stent placement. Subjects and Methods: The study included 49 cases of carotid artery stent placement performed at our institution. The cases were divided into two groups: those requiring re-treatment and those with favorable postoperative outcomes. The main focus was on stent intraluminal peak systolic velocity (PSV) and the intraluminal flow ratio between the stent and the common carotid artery (referred to as stent intraluminal flow ratio). Results and Discussion: In the re-treatment group, intraluminal PSV was 219 ± 121 cm/s, intraluminal flow ratio was 3.6 ± 1.9, and plaque thickness was 1.8 ± 0.9 mm. In the favorable outcome group, PSV was 102 ± 52 cm/s, intraluminal flow ratio was 1.36 ± 0.6, and plaque thickness was 0.29 ± 0.59 mm. Statistically significant results (p < 0.05) were observed for PSV, flow ratio, and plaque thickness. A PSV > 160 cm/s had 87% sensitivity and specificity, a flow ratio of 1.96 had 87% sensitivity and 100% specificity, and a plaque thickness of 1.2 mm had 87% sensitivity and 90% specificity. Conclusion: The stent intraluminal flow ratio is a useful parameter for estimating postoperative restenosis.

Antiphospholipid syndrome (APS) is currently diagnosed on the basis of both clinical findings and laboratory evidence of persistent aPLs. At present, the detection of IgG/IgM classes of anti-cardiolipin (aCL) and anti-β₂-glycoprotein I (aβ₂GPI) antibodies measured by standardized enzyme-linked immunosorbent assay (ELISA) has been adopted as the diagnostic criterion for APS. The major problem with APS diagnosis is that even if all current commercially available ELISA techniques are performed, only about 75% of all APS cases can be diagnosed. Therefore, it is necessary to establish an ELISA technique that can detect new anti-phospholipid antibodies useful for diagnosing APS. The objective of this study was to evaluate the prevalence of autoantibodies against phosphatidylethanolamine (PE) or phosphatidylinositol (PI) in patients with APS and various autoimmune diseases. We have established a new ELISA technique with solid-phased PE or PI and examined the prevalence of anti-PE and anti-PI autoantibodies in 20 patients with primary APS (PAPS), 30 SLE patients with APS (SLE/APS), 10 SLE patients without APS, 40 other collagen disease patients (Others), and 73 healthy subjects. The present study showed that both antibody titers and positivity rates of aPI-ELISA were significantly higher in the PAPS and SLE/APS patients than in the SLE patients, Others, and healthy persons. Furthermore, aPI-ELISA showed positive results in 4 of 13 non-criteria APS patients who were negative for aCL and aβ₂GPI but had thrombotic complications peculiar to APS. These results suggest that aPI-ELISA detects autoantibodies specific to APS patients, and positive results of aPI-ELISA may be useful in diagnosing APS in addition to conventional aPLs.

There are two types of prolactin (PRL): (1) PRL, which has physiological activity, and (2) macroprolactin, which is bound by IgG and has no physiological activity. Macroprolactin in the blood may lead to false positive PRL concentrations in immunological measurements. This may result in misdiagnosis of hyperprolactinemia, leading to unnecessary tests and treatments. Therefore, it is clinically important to have an assay kit that can accurately separate PRL and macroprolactin. In this study, we compared the test performance of conventional “AIA-PACK CL Prolactin (Tosoh Co., Ltd.)” and newly developed “AIA-PACK CL Prolactin II (Tosoh Co., Ltd.)”, which was developed to reduce the reactivity with macro macroprolactin. Repeatability, reproducibility, dilution linearity, and influence of interfering substances of AIA-PACK CL Prolactin II were tested, and those results were acceptable.The correlation with the conventional AIA-PACK CL Prolactin and newly developed “AIA-PACK CL Prolactin II was as follows: regression equation: y = 1.01x + 0.12, r = 0.992, (n = 100). The results of the PEG-treatment test and gel filtration analysis of the two cases in which the measured values with AIA-PACK CL Prolactin II deviated from those with the current reagent by more than 20%, both had macroprolactin, confirming that this reagent does not measure macroprolactin compared to the current reagent. The use of AIA-PACK CL Prolactin II in clinical practice can reduce the incidence of hyperprolactinemia diagnosis even when macroprolactin is present in the blood, thereby avoiding unnecessary tests and treatments.

Clostridioides difficile (C. difficile) is a major cause of antimicrobial-associated diarrhea/enteritis. However, the sensitivity of EIA and IC methods to detect toxin has been an issue. In this study, we compared the usefulness of Quick Chaser^®CD GDH/TOX (Quick Chaser method) and Smart Gene^®CD Toxin B (SG method). The subjects were C. difficile DNA solutions of known concentrations and 52 patients with suspected CDI. C. difficile DNA solution was serially diluted to confirm the minimum detection limit. The minimum detection limit was 10 copies/μL. Compared to the toxigenic culture method (TC), ①the Quick Chaser method had a sensitivity of 94.4%, specificity of 93.8%, and agreement rate of 94.2% for detection of C. difficile-specific antigen, and 50.0% sensitivity, specificity of 95.8%, and agreement rate of 71.2% for toxin detection. ②The SG method had a sensitivity of 85.7%, specificity of 100.0%, and agreement rate of 92.3% for toxin B gene detection. Since the SG method can be performed using the remainder of the extraction solution from the Quick Chaser method, the two methods can be used together to quickly provide useful information to the clinical side, making them very useful in the treatment of CDI.

A new anti-HTLV-I/II antibody detection reagent based on the principle of Immunochromatography (IC method) has been developed by Fuji Rebio Corporation. However, as its testing performance has not been objectively evaluated sufficiently, a validation study was conducted for accuracy control. A correlation test was performed using 50 samples of anti-HTLV-I/II antibody-negative, 59 samples of anti-HTLV-I antibody-positive, and 50 samples of anti-HTLV-II antibody-positive specimens. The IC, ECLIA, CLEIA, and PA methods were applied, and the concordance rates for each test determination were calculated. The concordance rate for negative specimens and anti-HTLV-II antibody-positive specimens was 100%. In the case of anti-HTLV-I antibody-positive specimens, only one case was determined as negative in the PA method, while all other specimens were determined as positive, resulting in a concordance rate of 98.3%. The comparison of detection sensitivity involved diluting one sample each of anti-HTLV-I antibody-positive and anti-HTLV-II antibody-positive specimens at 2n dilutions using negative specimens, and measuring with IC and PA methods. Compared to the PA method, the IC method was able to detect positivity at higher dilution ratios. As a result of the study, this reagent showed comparable or even higher sensitivity performance than the conventional methods in correlation and comparison of detection sensitivity. Particularly in the comparison of detection sensitivity, nearly equivalent performance results were obtained compared to an automated analyzer, suggesting that using this reagent instead of the PA method could lead to more rapid and accurate test results.

We perform lower extremity ultrasonography on the day after surgery for patients who had surgery under general anesthesia to prevent pulmonary thromboembolism (PTE) due to deep vein thrombosis (DVT). This paper retrospectively examines the usefulness of this approach. The study included 5,232 patients who got the examination between 2014 and 2022. We investigated the following seven items: the average age of the 5,232 patients, the number of tests by clinical department, the number of DVT positive and negative, the detection site of thrombus, properties of thrombus in central DVT, the number of incidences of PTE, whether or not there is any improvement in thrombosis on lower extremity venous ultrasound for follow-up, and the period from surgery to the start of rehabilitation. DVT-positive cases were 26% (1,379/5,232 patients). Central DVTs of the DVT-positive patients were 9% (127/1,379 patients). Most clots detected were peripheral DVT, 91% (1,252/1,379 patients). Floating thrombi with a high risk of acute PTE were 53 patients among the central DVTs. Among patients with central DVT who got contrast-enhanced CT, 44 patients did not have PTE. To examine whether there is any central DVT or nothing can prevent PTE earlier or lead to safe weaning of the patient. Results indicate that confirming the presence, location, and characteristics of DVT by postoperative lower extremity venous ultrasonography is important. The author suggests that the approach of our hospital not only detects thrombi but also enables sate early mobilization and helps prevent PTE.

The prevalence of parasitic infections in Japan has decreased due to improvements in sanitation and the rigorous implementation of fecal examinations. Consequently, opportunities for learning about parasites in clinical and educational settings have diminished. However, the likelihood of completely eradicating parasitic infections within the country remains low, making it essential to sustain knowledge and skills related to parasitic testing. In this study, we developed a ‘Parasite Cards’ for use pre- and post-graduation from education and assessed its practicality. We gathered responses from 29 professionals and 137 students. Among professionals, 65.5% found it valuable for improving internal quality control in photomicrography, and 55.2% recognized the need for specialized technician training. Many students considered ‘Parasite Cards’ to be useful for exam preparation. This study suggests that, in the case of clinical laboratory professionals, this tool has the potential to enhance internal precision control. For students, it functions as an educational tool that supplements their understanding of medical parasitology and alleviates difficulties they may encounter. However, to adapt to changing educational needs, we must continue to develop and improve parasite education tools in the future.

In Japan, the Parasitic Disease Prevention Law, which was enforced until 1994, led to a substantial decrease in helminthic infections, through rigorous testing, treatment, and preventive efforts. Concurrently, the demand for parasitic testing decreased, leading to a decline in the corresponding knowledge and skills of clinical laboratory technicians. Consequently, facilities increasingly outsource the testing of parasites, and many clinical laboratory technicians have grown uncertain about performing these tests due to limited experience. To address this challenge, the Clinical General Division of the Chubu Branch of the Japan Clinical Laboratory Technologists Association conducted a questionnaire survey in 2020, regarding parasitic testing across six prefectures in the Chubu region. The survey included 163 facilities that responded, 125 of which were involved in parasitic testing. The lack of test requests resulted in the outsourcing of testing to specialized centers, unavailability of essential reagents, and the inability to maintain internal quality control. Particularly in fecal examinations, a potential for inaccuracies in testing procedures was observed. Within clinical laboratory testing strongly emphasizes precision control and standardization, highlighting the need to establish an appropriate framework for parasitic testing. Moreover, a substantial demand exists for training in parasitic testing, highlighting the necessity for regular workshops, including practical sessions, to enhance technical proficiency.

In medical training curriculums at Japanese institutions of higher learning, diverse students (“students”) participate in “clinical practice,” which is the most important curriculum in their schooling. In clinical practice, students, educational institutions, and practical training facilities have their own positions, responsibilities, and challenges. Clinical practice is discussed and implemented among these three parties. Educational institutions and practical training facilities must closely collaborate with each other to enhance the students’ understanding, share information on students’ needs, and create an appropriate learning environment. As an example of cooperation, we introduce a training seminar for medical technologists who serve as clinical supervisors. The seminar is jointly sponsored by the Japanese Association of Medical Technologists and Japanese Association of Medical Technology Education. We also discuss the results of a questionnaire survey administered to those who participated in the group-work “understanding diverse students,” which was part of the seminar. The results indicated that the participants learned the meaning of disabilities, understood the need to accommodate and care for students, and considered how to accept and relate to diverse students. The participants were also struggling to cope with practical situations. Through this article, the author points out the significance of training seminars as a means of strengthening the cooperation between educational institutions and practical training facilities as students become increasingly diversified.

The subject was a man in his 70s. In May 20XX, he visited our hospital for hyperlipidemia, hypertension, and diabetes mellitus. 6 months earlier, when he fell down at home, he hit his chest hard on a chair and complained of persistent chest pain for a while. An electrocardiogram, chest X-ray, echocardiography, and blood-centered muscle markers (cardiac troponin I, CPK, and CK-MB) were performed to be sure. Electrocardiography showed negative T waves in limb-guided I, II, III, and aV_F and positive T waves in aV_R, negative T waves in chest-guided V3 to V6, and slight ST depression in V4 and V5. Electrocardiographic findings suggested takotsubo cardiomyopathy, but echocardiography showed thickening of the left ventricular posterior wall and sigmoid septum, with no evidence of wall motion abnormality. Chest X-ray showed a cardiothoracic ratio of 56%, with no evidence of pulmonary congestion, pleural effusion, or fracture, and blood tests showed no abnormalities. An electrocardiogram 1 year and 7 months later showed no Q wave or R wave increase, a positive chest-guided T wave, and ST-segment depression had returned to normal. Since coronary angiography and other tests had not been performed, the possibility of traumatic myocardial injury could not be ruled out, but takotsubo cardiomyopathy was considered as a disease showing similar findings. Although we were unable to provide evidence to link this case to the chest contusion caused by the fall, an abnormal electrocardiogram due to takotsubo cardiomyopathy that developed asymptomatically was the most likely cause of this case.

Serous carcinoma is a highly malignant histological type of uterine cancer with a poor prognosis. We reported a case of a serous carcinoma of uterine origin in which a metastatic focus formed a multilocular cyst on the posterior aspect of the left thigh 4 years after surgery. This case involved a woman in her 80s. MRI revealed that a multilocular cystic mass had formed on the posterior aspect of the left thigh, and part of the mass was solid. PET-CT revealed FDG uptake in the solid portion, and needle aspiration cytology was performed. Cytology revealed the appearance of atypical cells, but determining the cell origin was difficult. Immunohistological staining of cell blocks was performed, and results indicated malignant cells originating from epithelial cells. An open biopsy of the left thigh was subsequently performed. The patient had previously undergone a hysterectomy due to uterine cancer, so the final histological diagnosis was serous carcinoma of uterine origin that had metastasized to the left thigh. The current case involved distant metastasis of a malignant tumor in the field of gynecology. This was a rare case, since metastasis to the soft tissue of the thigh has seldom been reported, so it has been reported here.

Currently, many facilities use the ion selective electrode (ISE) method for measuring electrolytes in serum and urine, and the ISE method for measuring sodium (Na) and potassium (K) uses a crown ether membrane. It is an electrode, has high specificity, and is less affected by interfering substances. ISE for measuring chloride (Cl) is a quaternary ammonium salt electrode or a silver-silver chloride electrode, which has lower specificity than a crown ether electrode and may give falsely high values if other halogen substances coexist. There are several reports in the past. We experienced two cases in which the serum Cl level was falsely high and was diagnosed as chronic bromine poisoning due to long-term use of commercially available analgesics. It is likely that there are other patients who exhibit pseudo-hyperchloremia due to over-the-counter analgesics as in these two cases, and clinical laboratory technicians and medical practitioners in charge of clinical tests must be careful. When measuring Cl, if the Cl value is high in the balance between the Na value and the Cl value, if an error occurs from the analyzer, or if you suspect that the Cl value is incorrect due to an interfering substance, contact the clinic. Is required. Checking the oral medications and looking at the relationship with clinical symptoms will lead to the discovery of bromine poisoning.

We experienced a case of electrocardiogram (ECG) changes with a shark fin sign pattern, accompanied by hypokalemia and Takotsubo cardiomyopathy (TTC)-like myocardial damage. Case: A woman in her 80s was brought to the emergency department after experiencing lower limb weakness and a fall. Blood tests revealed that she had metabolic alkalosis with hypokalemia. ECG after admission showed ST-segment elevation with a triangular QRS-ST-T complex in the chest leads. Transthoracic echocardiography revealed severe wall motion depression at the apex of the heart and TTC was strongly suspected. Coronary angiography was not performed because the patient was asymptomatic and considered not to be a candidate for cardiac catheterization due to the course of hospitalization, malnutrition, and age. After potassium correction, ECG changes and wall motion abnormalities improved, indicating that ECG changes accompanied by the Shark fin sign were associated with TTC. The shark-fin sign is known as a specific indicator of acute coronary syndrome and extensive myocardial ischemia, and is associated with an increased risk of ventricular fibrillation, cardiogenic shock, and high mortality. Shark fin signs are rarely observed in hypokalemia and TTC. It is extremely important to keep in mind that characteristic ECG changes such as the one that occurred this time appear in a different pathological condition than usual, and to prepare for tests and treatments as necessary.

[Case] A man in his 60s was diagnosed by renal biopsy as having segmental membranous nephritis associated with Cronkite–Canada syndrome. IgG and C3c were negative in unfixed frozen specimens as determined by the immunofluorescence method, but anti-C3d antibody immunostaining using formalin-fixed paraffin-embedded immunoperoxidase (FFPEIP)-stained specimens revealed that C3d was found in the glomerular basement membrane with a clearly recognized segmental form. C3d-positive findings in the renal tubules and interstitium, which were observed in unfixed frozen specimens by the immunofluorescence method, disappeared with FFPEIP. [Discussion] C3c observed by renal biopsy with the immunofluorescence method indicates recent complement activation and disappears over time. Therefore, the absence of C3c does not mean the absence of immune complexes. Additionally, C3c is not suitable for PEIP owing to its antigenicity, being inactivated by fixation. C3d, on the other hand, remains in place upon complement activation and is an essential component of immune complexes, making it ideal for observing them. Additionally, its antigenic deactivation due to fixation is minimal, making it suitable for PEIP. [Conclusion] C3d immunostaining using formalin-fixed paraffin-embedded specimens is a valuable tool for examining renal biopsies, particularly in membranous nephritis with negative IgG staining in frozen specimens or with focal segmental glomerular lesions, and in cases where glomeruli are not found in frozen specimens.

We experienced a woman in her 70s showing bilateral blepharoptosis with diurnal fluctuation. Positive neurological finding was right dominant bilateral blepharoptosis which worsened towards the evening. There was no weakness in the other skeletal muscles in the cranial nerve areas, limbs, and body trunk. Serum anti-acetylcholine receptor (AchR) antibody was positive. Chest X-ray computed tomography showed thymoma in the anterior mediastinum. A clinical diagnosis was ocular type myasthenia gravis (MG). We performed a lower frequency repetitive nerve stimulation test (RNS) on the right nasalis, trapezius, abductor digiti minimi, and the anconeus muscles as well. The results showed no waning phenomenon in the nasalis, trapezius, abductor digiti minimi muscles but in the anconeus muscle. The anconeus muscle is noticed as the target muscle for RNS. A waning phenomenon is reported to be less sensitive in the limb or truncal skeletal muscles in ocular type MG. The facial muscle is regarded as a better target for detecting a waning phenomenon with better sensitivity, but our case showed no waning phenomenon even in the facial muscle. Our result suggested that the anconeus muscle should be considered as a target of RNS to improve sensitivity in clinical diagnosis of ocular type MG.

Primary malignant melanoma of the brain is extremely rare, accounting for only 1% of all melanomas. We report a case of primary malignant melanoma of the brain in which the identification of atypical cells in the spinal fluid of a patient led to early diagnosis and treatment of cancerous meningitis. The patient, a 40-year-old woman, was diagnosed with primary malignant melanoma of the brain two years ago and treated with nivolumab after removal of the melanoma, but after six months, stereotactic radiotherapy was added because of recurrence. Approximately 2 weeks ago, she started feeling dizzy and nauseated, and her eyes were unable to focus, so a head MRI was performed. Meningitis was suspected from the contrast lesions along the meninges, and lumbar puncture diagnosed aseptic meningitis. The number of cells in the CSF was increased with predominance of mononuclear cells, and morphological evaluation by Samson’s stain showed atypical cells. The N/C ratio was high, the nuclei were irregularly sized, the nucleoli were markedly enlarged, and brownish-brown granules appeared sporadically in the cytoplasm. Since the granules were brown even without staining, the first possibility was that they were melanin granules. Based on the above findings, intrathecal dissemination of malignant melanoma was most suspected, and this was promptly reported to the attending physician. At the same time, cytological diagnosis was proposed, and Papanicolaou staining led to a definitive diagnosis of carcinomatous meningitis due to malignant melanoma. Although rarely encountered, cancerous meningitis is a serious disease whose prognosis depends on prompt diagnosis and treatment. It is essential to work closely with physicians and other departments including pathology on a daily basis, and to make efforts for early diagnosis and treatment.

Ammonium urate (AU) crystals in urine sediment showed various shapes that were not found in the atlas, such as sea urchin-like, needle-like, radial spherical, and dumbbell-like (iron array-like). Case 1: Female in her 30s, 6 months pregnant. Three weeks prior, she was admitted to the urology department of our hospital for bilateral hydronephrosis in another prefecture and received only intravenous drip treatment. Due to persistent dull pain, she visited the urology department of our hospital for letter of reference. Many sea urchin-like, needle-shaped, yellow-brown crystals were observed in the urine sediment. Case 2: Female in her 90s. After being admitted to our hospital’s community comprehensive care ward from another hospital, tests were conducted to assess her condition and check for fever. Yellowish brown crystals in the form of radial spheres and iron arrays were found in the urine sediment. In both cases, it was difficult to diagnose by microscopic examination, therefore crystals were collected and stone analysis was performed, which revealed acidic AU. AU crystals are spherical with spines, but this case showed that they can take a variety of shapes, including sea urchin-like, needle-like, radial spherical, and iron array-like shapes.

Fibrin casts, which are highly suggestive of local renal hypercoagulability associated with high proteinuria, can also be observed in the absence of high proteinuria. In this study, the shared background characteristics of six patients without persistent proteinuria of 2+ or higher were investigated. All six patients showed a tendency of thrombogenesis and exhibited one of three patterns: glomerular hemorrhage, disease, and adverse drug reactions. The results suggested that the detection of fibrin casts in urine sediments of patients having a tendency of thrombogenesis might aid in the prediction of diseases and other conditions. Furthermore, the appearance of fibrin casts in urine might be associated with the leakage of protein components that predispose the urine to thrombosis.

We present a case where albumin (Alb) and the α1 fraction became inseparable due to Alb tailing towards the cathode in serum protein electrophoresis. We performed immunofixation electrophoresis and immunoelectrophoresis (IEP). No paraprotein was detected, and IEP confirmed the Alb tailing. The tailing of IgG, κ, and λ toward the anode was also confirmed by IEP. These findings suggested the formation of an Alb-IgG complex. To isolate the complex, we utilized cibacron blue and protein G affinity chromatography. SDS-PAGE was performed to confirm the molecular weight of the purified fraction. Higher molecular weight bands (250 kDa) were detected in both anti-Alb and anti-IgG antibodies, indicating the formation of Alb-IgG complex in the patient’s serum. The complex disappeared when treated with a high salt solution, suggesting that ionic bonds formed the complex. When rare patterns are observed, performing more detailed testing methods, such as IEP, is essential.

We encountered three cases with structures identified in the right side of the heart. And we conducted a comparison and discussion of the clinical findings and results for each case. [Case 1] 5 years male with history of nephrotic syndrome presented with dyspnea. Echocardiography was performed to assess cardiac function. A structure with partial mobility was observed in the right ventricle. Thrombus or tumor was suspected, leading to a referral to a specialized facility. Contrast-enhanced CT at the referral center revealed findings suggestive of a thrombus. The patient was placed on medication and underwent regular ultrasound monitoring for follow up observation. [Case 2] 4 years male. The patient was referred to our hospital due to findings of ventricular septal hypertrophy. The tumor observed homogeneously hyperechoic and no mobility. No stenosis was observed due to the structure. As no abnormalities were detected on a head CT, a primary cardiac septal lipoma was suspected, leading to a referral to a specialized facility. An MRI at the referral center showed findings suggestive of a lipoma, and the patient was placed under observation until signs of progression were observed. [Case 3] 0 years male. Intracardiac masses were observed in an ultrasound screening examination performed at the time of admission, and echocardiography was requested for detailed evaluation. Multiple mobile structures were identified in the right atrium, extending into the right ventricle. These structures were present since birth, and while cardiac rhabdomyoma was suspected. The patient was placed on regular ultrasound monitoring for follow up observation. Through three cases, we re-realized the clinical usefulness of echocardiography, particularly in pediatric field, when structures are observed in right side of the heart.