Clinical practice guidelines for molecular tumor marker, 2nd edition review part 2

In recent years, rapid advancement in gene/protein analysis technology has resulted in target molecule identification that may be useful in cancer treatment. Therefore, "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" was published in Japan in September 2021. These guidelines were established to align the clinical usefulness of external diagnostic products with the evaluation criteria of the Pharmaceuticals and Medical Devices Agency. The guidelines were scoped for each tumor, and a clinical questionnaire was developed based on a serious clinical problem. This guideline was based on a careful review of the evidence obtained through a literature search, and recommendations were identified following the recommended grades of the Medical Information Network Distribution Services (Minds). Therefore, this guideline can be a tool for cancer treatment in clinical practice. We have already reported the review portion of "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" as Part 1. Here, we present the English version of each part of the Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition.

Immune and allergenic effects of the microalga Coccomyxa sp. strain KJ in healthy humans: A pilot study

BACKGROUND

The Coccomyxa sp. strain KJ (Coccomyxa KJ), a microalga found in Japan, has a potential function in controlling viral infections. Recently, its dry powder has been marketed as a health food product.

OBJECTIVES

This pilot study investigated the effects of Coccomyxa KJ powder tablet intake on allergic reactions and immune functions in healthy participants.

MATERIAL AND METHODS

Nine healthy volunteers (4 males and 5 females) who expressed interest in foods containing Coccomyxa KJ, and were willing to undergo blood tests, were recruited. Each individual was asked to take 2 Coccomyxa KJ powder tablets (0.3 g) before breakfast once a day for 4 weeks. The salivary immunoglobulin A (IgA) level and blood parameters (white blood cell (WBC) count, eosinophil and lymphocyte counts and percentages, natural killer (NK) cell activity, interleukin (IL)-6 level, and T helper (Th)1/Th2 cell ratio) were evaluated at baseline and weeks 2 and 4.

RESULTS

The 4-week intake of Coccomyxa KJ did not affect salivary IgA levels, WBC count, eosinophil and lymphocyte counts and percentages, or the Th1/Th2 ratio. There were significant differences in the NK cell activity after 4 weeks, with an average increase of 11.78 (95% confidence interval (95% CI): 6.80-16.76). None of the patients experienced adverse reactions during or after the study.

CONCLUSIONS

Long-term Coccomyxa KJ intake improved NK cell activity without causing adverse effects on the indicators of local immunity, systemic inflammation and immune response balance. This study suggests that Coccomyxa KJ powder tablets can induce beneficial immune modifications without causing any adverse effects.

Impact of the lateral skeletal stability following bilateral sagittal split ramus osteotomy for mandibular asymmetry

This study evaluated the stability of bilateral sagittal split ramus osteotomy (BSSRO) associated with positional plagiocephaly and temporal and masseter muscles using posteroanterior cephalogram analysis and three-dimensional computed tomography (3D-CT). This retrospective cohort study included 31 patients who underwent BSSRO for mandibular asymmetry. The cranial vault asymmetry index (CVAI) and the cephalic index were used as indicators of positional plagiocephaly. The distance from the vertical reference line to the menton (Me) was measured on posteroanterior cephalograms immediately and 1 year after surgery, and postoperative stability was assessed. Temporal and masseter muscles were constructed from 3D-CT data and their volumes were measured. Simple regression analysis showed a significant correlation between postoperative changes in the vertical reference line to the Me and the CVAI (R = 0.56, p = 0.001), the amount of surgical movement in the vertical reference line to the Me (R = 0.41, p = 0.023), and the variable temporal muscle volume (R = 0.27, p = 0.028). There was no significant correlation between postoperative changes in the vertical reference line to the Me and the cephalic index (R = 0.093, p = 0.62) and variable masseter muscle volume (R = 0.16, p = 0.38). According to multivariate analysis, CVAI (p = 0.003) and amount of surgical movement in the vertical reference line to the Me (p = 0.014) were significant predictors of postoperative change in the vertical reference line to the Me. Positional plagiocephaly and amount of surgical movement influence lateral skeletal stability following BSSRO for mandibular asymmetry.

Ultrasonographic Characteristics in the Fingers and Other Superficial Glomus Tumours

Glomus tumours are painful superficial tumours, and ultrasonography is an extremely useful and noninvasive diagnostic technique for superficial organs. In this study, we retrospectively examined glomus tumours using ultrasonography. Among 18 patients histopathologically diagnosed with glomus tumours via ultrasonography, we observed five different development sites: subungual areas or those surrounding the nail bed (12), other areas on the finger surface (3), abdominal wall (1), upper arm (1), and forearm (1). The ultrasonographic images revealed significant differences in tumour size, indicating that tumours on other body surfaces tended to be smaller than those on patients' fingers (p < 0.01). The depth/width ratios of tumours on the other body surfaces were significantly higher than those on the fingers (p < 0.05). The tumours showed a regular shape (72.2%) and clear border (100%). Furthermore, most tumours were low-echo tumours with a diameter of up to 15 mm, clear margins, and no lateral shadows. Abundant blood flow and vessels in and out of the tumours were also observed. In conclusion, our study describes the ultrasonographic characteristics of glomus tumours and reveals that they cannot be ruled out when diagnosing small painful subcutaneous tumours.

A pilot study of on-site evaluation as external quality assessment for ISO 15189 accreditation of laboratories performing next-generation sequencing oncology tests

BACKGROUND

As next-generation sequencing (NGS) oncology tests vary by platform, application, and target of genes, specific methods for external quality assessment (EQA) have not been universally applied. Hence, we have attempted to implement on-site evaluation as EQA in the accreditation program under ISO 15189 for laboratories that perform NGS oncology tests.

METHODS

A total of 10 laboratories that performed NGS oncology tests were enrolled. Two types of EQA samples were prepared (Acrometrix Oncology Hotspot Control DNA and OncoSpan gDNA DNA samples), and the variant allele frequency of targeted genes was assigned. The samples were subjected to NGS oncology tests in participant laboratories according to their routine protocols. Based on the result reports, auditors visited the participant laboratories to perform on-site evaluations and provided feedback regarding possible laboratory process improvement.

RESULTS

The participant laboratories identified the targeted variants in the Acrometrix Oncology Hotspot Control DNA and OncoSpan gDNA samples with a success rate of 31-100% and 9.5-100%, respectively, compared with reference information, depending on their sequencing systems, and reported a few lower-variant allele frequencies. Six of the eight evaluated laboratories failed to report at least three pathogenic variants due to errors in wet-lab and/or dry-lab processes. Based on the feedback reports and self-assessment, auditors and laboratory staff discussed potential improvements to processes during on-site evaluations for laboratory accreditations.

CONCLUSIONS

On-site evaluation as EQA for NGS oncology tests in the laboratory accreditation program under ISO 15189 was successfully implemented and proved applicable to a broad spectrum of NGS tests.

Impact of ward pharmacist-led antimicrobial stewardship in intensive care units

Various outcomes of mortality, medical costs, and antimicrobial usage result from antimicrobial stewardship (AS) programmes. Here, we clarified the effects of AS implementation by a well-trained pharmacist in an open intensive care unit (open ICU) through a retrospective, comparative study of 5123 open ICU patients of Tokai University Hospital. The 12 months before and after AS implementation were considered the control and study periods, respectively. After AS implementation, the number of AS cases increased significantly. The period until the implementation of therapeutic drug monitoring was significantly shortened, and antimicrobial drug usage increased significantly. The methicillin-resistant Staphylococcus aureus (MRSA) detection rate decreased significantly. Earlier and more frequent AS implementation could enhance treatment effects, possibly decreasing the MRSA incidence. Despite active AS implementation, antimicrobial drug usage did not necessarily decrease. ICU pharmacists with experience in AS should take on leadership roles and implement active AS strategies in open ICU settings.

Removal effect of DNA contamination by hydrogen peroxide plasma compared to ethylene-oxide gas

We examined the ability of hydrogen peroxide plasma (HPP) to remove DNA contamination, to evaluate whether it is a suitable forensic-grade treatment under ISO 18385. HPP treatment was compared to ethylene-oxide gas (EOG) treatment, which is required by ISO 18385. For the evaluation, commercial control DNA solution and cultured cells sprinkled on Petri dishes were used, and the DNA fragments (214 and 80 bp autosomal DNA fragments and 75 bp Y chromosome fragment) were quantified. HPP treatment was performed up to four times and EOG treatment was performed once. Performing HPP treatment three times was as effective as EOG treatment, with all fragments decreasing to below 1/1,000 in DNA solution. With STR and Y-STR typing, no alleles were detected for three HPP treatments of control DNA using the original amount, i.e., 1 ng. Therefore, HPP appears useful for removing DNA contamination. For cells sprinkled on Petri dishes, the DNA degradation abilities of the HPP and EOG were comparable. However, less DNA was degraded with the HPP and EOG and neither met the ISO criteria. Although the current version of ISO 18385 recommends an evaluation method using cultured cells sprinkled on Petri dishes, it needs to be revised. These findings should be considered when revising ISO 18385.

Virucidal effect of monogalactosyl diacylglyceride from a green microalga, Coccomyxa sp. KJ, against clinical isolates of SARS-CoV-2 as assessed by a plaque assay

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of coronavirus disease 2019 (COVID-19) and is capable of human-to-human transmission and rapid global spread. Thus, the establishment of high-quality viral detection and quantification methods, and the development of anti-SARS-CoV-2 agents are critical.

METHODS

Here, we present the rapid detection of infectious SARS-CoV-2 particles using a plaque assay with 0.5% agarose-ME (Medium Electroosmosis) as an overlay medium.

RESULTS

The plaques were capable of detecting the virus within 36-40 h post-infection. In addition, we showed that a monogalactosyl diacylglyceride isolated from a microalga (Coccomyxa sp. KJ) could inactivate the clinical isolates of SARS-CoV-2 in a time- and concentration-dependent manner.

CONCLUSIONS

These results would allow rapid quantification of the infectious virus titers and help develop more potent virucidal agents against SARS-CoV-2.

Nationwide external quality assessment of SARS-CoV-2 nucleic acid amplification tests in Japan

Objectives

We conducted a nationwide external quality assessment (EQA) study of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid amplification testing in Japan.

Methods

A total of 563 public health and private sector laboratories participated. The EQA samples comprised 6 RNA and full-process controls.

Results

The overall agreements were 99.3% and 97.9% for the RNA and full-process controls, respectively. A total of 530/563 (94.1%) laboratories reported correct results; public health laboratories had the highest accuracy. Thirty-three laboratories reported at least one incorrect result (26 laboratories of medical facilities, 5 commercial laboratories, 1 public health laboratory, and 1 other). Sixteen laboratories of medical facilities that used a fully automated assay system failed to detect the presence of the full-process control, due to inherent insufficiency in the limit of detection (LOD). Other causes of incorrect results included failure to ensure the LOD (n = 13), error in result judging or reporting (n = 3), and error in sample handling (n = 1).

Conclusions

Performance was mostly dependent on the laboratory category and assay evaluation, particularly the LOD. Guidance should be developed based on these results, particularly in the phase of new entry into laboratory services for SARS-CoV-2.

Evaluation of the basic assay performance of the GeneSoc® rapid PCR testing system for detection of severe acute respiratory syndrome coronavirus 2

In the ongoing coronavirus disease 2019 (COVID-19) pandemic, PCR has been widely used for screening patients displaying relevant symptoms. The rapid detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) enables prompt diagnosis and the implementation of proper precautionary and isolation measures for the patient. In the present study, we aimed to evaluate the basic assay performance of an innovative PCR system, GeneSoC^® (Kyorin Pharmaceutical Co. Ltd., Tokyo, Japan). A total of 1,445 clinical samples were submitted to the clinical laboratory, including confirmed or suspected cases of COVID-19, from February 13 to August 31. Specimen types included nasopharyngeal swabs. The sampling was performed several times for each patient every 2–7 days. Using this system, sequences specific for SARS-CoV-2 RNA could be detected in a sample within 10–15 min using the microfluidic thermal cycling technology. Analytical sensitivity studies showed that GeneSoC^® could detect the target sequence of the viral envelope and RNA-dependent RNA-polymerase (RdRp) genes at 5 and 10 copies/μL, respectively. The precision of the GeneSoC^® measurements using clinical isolates of the virus at a concentration of 10³ copies/μL was favorable for both the genes; within-run repeatability and between-run reproducibility coefficient of variation values were less than 3% and 2%, respectively; and the reproducibility of inter-detection units was less than 5%. Method comparison by LightCycler^® 480 showed the positive and negative agreement to be 100% [(174/174) and (1271/1271), respectively]. GeneSoC^® proved to be a rapid and reliable detection system for the prompt diagnosis of symptomatic COVID-19 patients and could help reduce the spread of infections and facilitate more rapid treatment of infected patients.

Reference intervals of white blood cell parameters for healthy adults in japan

INTRODUCTION

While white blood cell (WBC) parameters have been suggested to depend on ethnicity and gender, reference intervals in healthy Asian populations are limited. The present study established reference intervals of WBC parameters for healthy adults in Japan.

METHODS

A total of 750 healthy adults (447 women and 303 men; 18-67 years old, median 40 years old) at 7 Japanese centers who participated in regular medical checkups entered this study. The WBC parameters were measured using automated hematocytometers and blood film reviews by a manual microscopic examination.

RESULTS

The reference intervals of the WBC parameters according to gender in healthy adults were determined. Age-specific decreases in WBC counts of both gender groups and in neutrophil counts of women were noted. Favorable correlations between the hematocytometer and microscopic methods were found in neutrophils, lymphocytes, and eosinophils but not in monocytes or basophils.

CONCLUSION

This study suggests the need to consider gender and age in the clinical use of reference intervals of WBC parameters.

Rapid profiling of drug-resistant bacteria using DNA-binding dyes and a nanopore-based DNA sequencer

Spread of drug-resistant bacteria is a serious problem worldwide. We thus designed a new sequence-based protocol that can quickly identify bacterial compositions of clinical samples and their drug-resistance profiles simultaneously. Here we utilized propidium monoazide (PMA) that prohibits DNA amplifications from dead bacteria, and subjected the original and antibiotics-treated samples to 16S rRNA metagenome sequencing. We tested our protocol on bacterial mixtures, and observed that sequencing reads derived from drug-resistant bacteria were significantly increased compared with those from drug-sensitive bacteria when samples were treated by antibiotics. Our protocol is scalable and will be useful for quickly profiling drug-resistant bacteria.

Attempts to optimize postinduction treatment in childhood acute myeloid leukemia without core-binding factors: A report from the Japanese Pediatric Leukemia/Lymphoma Study Group (JPLSG)

We previously reported that risk-stratified therapy and intensive postremission chemotherapy (PRC) contributed to the improved survival of childhood acute myeloid leukemia (AML) in the AML99 study, which led us to consider a reduction in the number of PRC courses with more restrictive indications for stem cell transplantation (SCT) in the successor AML-05 study. We here report the outcome of AML patients without core-binding factor mutation (non-CBF AML) in the AML-05 study. Two-hundred eighty-nine children (age < 18 years old) with non-CBF AML were eligible. Patients with unfavorable cytogenetics and/or poor bone marrow response to the first induction course were candidates for SCT in the AML-05 study. After two courses of induction, a further three courses of PRC were given in AML-05, while four courses were given in the AML99 study. The 3-year event-free survival (EFS) rate in the AML-05 study (46.7%, 95% CI: 40.6-52.6%) was comparable to that of non-CBF AML in the AML99 study (51.5%, 95% CI: 42.7-59.6%) (P = .16). However, the 3-year overall survival (OS) rate in the AML-05 study (62.9%, 95% CI: 56.3-68.8%) was slightly lower than that in the AML99 study (71.6%, 95% CI: 63.2-78.5%) (P = .060), mainly due to decreased remission induction rate and increased nonrelapsed mortality. In conclusion, reductions in the number of PRC courses from four to three, together with repetitive cycles of high-dose cytarabine, were acceptable for non-CBF childhood AML.

Sonographic appearance of syphilitic induration mimicking squamous cell carcinoma in the lower lip: a case report

Background

Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum. Recently, its incidence has been increasing worldwide. We encountered a young woman who presented with induration mimicking squamous cell carcinoma in the lower lip, without major medical conditions.

Case presentation

A 25-year-old Japanese woman presented with a 1-month history of a painless induration in her lower lip. Because squamous cell carcinoma was suspected, a preoperation work up was performed, including laboratory tests, an ultrasonographic examination, and a biopsy. The ultrasonography findings showed an oval-shaped 17 × 11 × 12 mm tumor-like lesion with heterogeneous internal echo and an indistinct border. A pressure test and color Doppler sonography revealed that the lesion was soft with a very abundant blood flow. These findings suggested the possibility of underlying inflammatory causes rather than a neoplastic tumor. Serology tests for syphilis, including the anti-Treponema pallidum antibody and reactive rapid plasma reagin tests, were positive. The biopsy revealed no malignancy. Finally, she was diagnosed as having primary syphilis and treated with amoxicillin for 28 days. The rapid plasma reagin value gradually decreased and the initial induration in her lower lip disappeared.

Conclusion

This case highlights the need for prompt examinations for possible underlying infective causes, such as syphilis, when seeing a painless induration with ulcer in the lip. Ultrasonography was helpful in the differential diagnosis of a tumor-like lesion and should be included in addition to syphilis serology tests, such as anti-Treponema pallidum antibody and rapid plasma reagin tests.

Relationship between age and the impact of revascularization on mortality in patients with non-ST-elevation myocardial infarction

Background

It is known that the early coronary revascularization in patients with non-ST-elevation myocardial infarction (NSTEMI) was associated with favorable clinical outcomes. However, it is still unclear whether this efficacy is equivalent over all the ages of the patients.

Methods

Patients with NSTEMI were screened from the database of the Tokyo CCU network registry. Of those, the patients treated without revascularization (medical treatment) were matched with the patients receiving revascularization by propensity score matching. The probabilities of in-hospital death were calculated in the logistic regression model. In two subgroups stratified according to median of the age (elderly and non-elderly subgroups), the odds ratios of revascularization for in-hospital death were calculated.

Results

In the patients registered between 2013 and 2017, 4,851 patients with NSTEMI were identified. After the screening, 370 patients with medical treatment were matched with 370 patients treated with revascularization. The incidence of in-hospital death was significantly higher in the patients with medical treatment (20.3% vs 13.0%, P=0.01). The two probability curves of in-hospital death in patients with and without revascularization converged as age increased. In the elderly subgroup, the revascularization was not significantly associated with favorable outcome of mortality, whereas it had a significant impact on mortality in the non-elderly subgroup (odds ratio: 0.47 [95% CI 0.23–0.95]).

Conclusion

The impact of revascularization on short-term mortality in patients with NSTEMI tended to be reduced as age increased.

Funding Acknowledgement

Type of funding source: None

Predictors of in-hospital mortality in patients with acute myocardial infarction due to unprotected left main trunk lesion: insight from the Tokyo Cardiovascular Care Unit network multicenter registry

Background

Acute myocardial infarction (AMI) due to unprotected left main trunk (LMT) lesion remains a clinical challenge because it requires prompt and efficient revascularization in catastrophic clinical presentation. However, predictors of in-hospital prognosis in patients with LMT-AMI are still not fully understood.

Purpose

To examine the predictors of in-hospital mortality in patients with LMT-AMI.

Methods

From 20,257 AMI patients in the Tokyo Cardiovascular Care Unit network registry (comprising 72 hospitals) from 2013 to 2017, we identified 371 (1.8%) eligible LMT-AMI patients without a history of coronary artery bypass grafting (CABG) and divided them into two groups: 254 survivors and 117 non-survivors. Measured variables included patient demographics, vital signs, laboratory data on admission, and in-hospital treatment. The outcome was in-hospital mortality. We performed a multivariable logistic regression analysis for in-hospital mortality with adjustment for the following 9 potential confounders, based on previous studies: (1) age, (2) sex, (3) Killip class, (4) ST elevation, (5) wide QRS (&gt;120 msec), (6) the Thrombolysis in Myocardial Infarction (TIMI) grade on initial coronary angiography, (7) number of vessels with significant stenosis other than LMT, (8) renal dysfunction on admission, and (9) plasma glucose on admission.

Results

Overall, mean age was 70.6±11.8 years and 81.9% were male. ST-elevation myocardial infarction accounted for 61.8%. Cardiac arrest was observed in 102 (33.6%) patients. Percutaneous coronary intervention and CABG were performed in 302 (81.8%) and 63 (17.0%) patients, respectively. Intra-aortic balloon pumping and veno-arterial extracorporeal membranous oxygenation were used in 288 (77.8%) and 81 (21.9%) patients, respectively. In-hospital mortality was 31.5%. Multivariable logistic regression analysis showed that higher in-hospital mortality was significantly associated with Killip class IV (adjusted odds ratio 3.41 [95% confidence interval 1.36–8.56]; reference: Killip I), TIMI grade 0 (3.51 [1.22–10.14]; reference: TIMI grade 3), renal dysfunction (estimated glomerular filtration &lt;60 mL/min/1.73m2; 6.48 [2.53–16.57]), and high plasma glucose on admission (&gt;150 mg/dl; 3.64 [1.33–9.97]). Age, sex, ST-elevation, wide QRS, and multi-vessel disease were not significantly associated with in-hospital mortality.

Conclusions

LMT-AMI remains life-threatening in the current era of widely available revascularization. Our results showed that haemodynamic compromise, no coronary flow, renal dysfunction, and high plasma glucose on admission were strong predictors of in-hospital mortality after LMT-AMI. Given the high cardiac arrest rate, more aggressive therapeutic measures including mechanical circulatory support may be required to improve the prognosis of LMT-AMI.

Funding Acknowledgement

Type of funding source: None

The impact of low diastolic blood pressure on 30-day mortality of patients with acute myocardial infarction

Background

It is known that low diastolic blood pressure (DBP) is associated with long-term cardiovascular events after acute myocardial infarction (AMI). However, the impact of low diastolic blood pressure on short-term outcome has not yet been well investigated.

Methods and results

We included 15,208 patients who were hospitalized for AMI and registered in the Tokyo CCU network registry between 2013 and 2016. Thirty-day in-hospital mortality rate was 4.8% (728/15,208). To assess the relationship between DBP at the time of admission and 30-day mortality non-linearly, spline regression model was applied with the stratification of the cohort according to tercile of systolic blood pressure (SBP, low:≤122 mmHg, intermediate:123–148 mmHg, high:≥149 mmHg) and J-curve phenomenon was observed in the low and high SBP groups. In multivariate logistic regression analysis, adjusted odds ratio of the lowest quintile of DBP (≤64 mmHg) was 1.65 (95% CI:1.02–2.66) in low SBP group and 4.55 (95% CI:1.72–12.00) in high SBP group.

Conclusion

Low DBP was associated with increased 30-day in-hospital mortality rate after AMI even in patients with high SBP.

Funding Acknowledgement

Type of funding source: None

P889Clinical significance of four-dimensional flow magnetic resonance imaging measurement of turbulent kinetic energy for hypertrophic obstructive cardiomyopathy

Purpose

The aims of this study were to investigate the relationship between TKE value and echocardiographic findings, clinical symptoms and evaluate the usefulness of 4D flow MRI to distinguish hypertrophic obstructive cardiomyopathy (HOCM) from non-obstructive HCM (HNCM).

Methods

From April 2018 to January 2019, 18 hypertrophic obstructive cardiomyopathy (HOCM) and 14 non-obstructive HCM (HNCM) patients underwent 4D flow MRI. We investigated TKE value calculated by 4D flow MRI, echocardiographic findings; left ventricular pressure gradient (LVPG), mitral regurgitation (MR) and clinical symptom.

Results

HOCM was defined by the 30 mmHg or greater of LVPG (HOCM: 87.7±47.3 mmHg, HNCM; 5.8±7.8 mmHg, p<0.001). TKE value in HOCM patients was significantly higher than HNCM (14.2±4.7 mJ vs. 9.0±4.6 mJ, p<0.001). There was a significant positive linear relationship between TKE value and LVPG (r=0.488, p=0.046). There was no significant relationship between NYHA functional class and TKE value (p=0.47) or LVPG (p=0.11). ROC curve analysis showed that optimal cut off point of TKE value between HOCM and HNCM (sensitivity=95%, specificity=62%, AUC=0.798) was 9.270 mJ. Multiple linear regression showed that there was significant association between severity of MR and combination of TKE (p=0.015) or LVPG (p–=0.012). A representative case demonstrated the significant reduction of TKE value 1 week and 3 months after alcohol septal reduction compared with that obtained before the procedure (Figure)

Conclusion

Our findings suggest that 4D Flow MRI can effectively evaluate the energy dissipation associated with LV outflow tract obstruction and TKE value is useful for identifying HOCM. TKE value also can be the novel parameter of the severity of HOCM.

[Acute myeloid leukemia evolving from KIT D816-mutated systemic mastocytosis relapsing two months after completion of chemotherapy]

Here, we report the case of a 9-year-old girl with acute myeloid leukemia (AML) developed from systemic mastocytosis (SM). She experienced bladder and rectal disturbance due to an extramedullary nodule in the paraspinal region of the sacrum. Cytogenetic and genetic analyses of leukemic cells revealed the KIT D816Y mutation besides t (8;21) (q22:q22) /RUNX1-RUNX1T1. Despite receiving proton beam therapy after conventional chemotherapy, the patient relapsed after 2 months. As SM-AML with the KIT D816 mutation in adults exhibits a poor prognosis, hematopoietic stem cell transplantation is recommended. Owing to a few reports of SM-AML in children, the standard therapy for pediatric cases has not been established to date. Based on our experience and the related literature, the prognosis of childhood SM-AML could be as poor as in adults. Hence, further investigation, including mutational analyses of the KIT gene, is warranted to establish a risk-oriented strategy for managing childhood SM-AML.

Evaluation of high-dose cytarabine in induction therapy for children with de novo acute myeloid leukemia: a study protocol of the Japan Children's Cancer Group Multi-Center Seamless Phase II-III Randomized Trial (JPLSG AML-12)

The purpose of this study is to compare the efficacy and safety of combination therapy (HD-ECM) including high-dose cytarabine in initial induction therapy with that of combination therapy (ECM) involving the continuous administration of cytarabine for previously untreated, newly diagnosed patients with AML at <18 years of age. This is a seamless Phase II-III clinical trial, consisting of Phase II and III parts. In the Phase II part, the safety of the experimental treatment (HD-ECM) will be examined. Subsequently, the Phase III study will compare the efficacy and safety of HD-ECM with that of standard ECM. The primary endpoint of the Phase II study is the early mortality rate. The primary endpoints of the Phase III study are the 3-year event-free survival rate and the positive minimal residual disease rate by flow cytometry after initial induction therapy. This trial has been registered at the UMIN Clinical Trials Registry (UMIN000013288).

Proportion and clinical characteristics of non-asthmatic non-smokers among adults with airflow obstruction

Background and objectives

Chronic obstructive pulmonary disease (COPD) mainly develops after long-term exposure to cigarette or biomass fuel smoke, but also occurs in non-smokers with or without a history of asthma. We investigated the proportion and clinical characteristics of non-smokers among middle-aged to elderly subjects with airflow obstruction.

Methods

We retrospectively analyzed 1,892 subjects aged 40–89 years who underwent routine preoperative spirometry at a tertiary university hospital in Japan. Airflow obstruction was defined as a forced expiratory volume in 1 second (FEV₁)/forced vital capacity < 0.7 or as the lower limit of the normal.

Results

Among 323 patients presenting with FEV₁/forced vital capacity < 0.7, 43 had asthma and 280 did not. Among the non-asthmatic patients with airflow obstruction, 94 (34%) were non-smokers. A larger number of women than men with airflow obstruction had asthma (26% vs. 7.6%, p < 0.001), or were non-smokers among non-asthmatics (72% vs. 20%, p < 0.001). Non-asthmatic non-smokers, rather than non-asthmatic smokers, asthmatic non-smokers, and asthmatic smokers, exhibited better pulmonary function (median FEV₁: 79% of predicted FEV₁ vs. 73%, 69%, and 66%, respectively, p = 0.005) and less dyspnea on exertion (1% vs. 12%, 12%, and 28%, respectively, p = 0.001). Pulmonary emphysema on thoracic computed tomography was less common in non-smokers (p < 0.001). Using the lower limit of the normal to define airflow obstruction yielded similar results.

Conclusions

There are a substantial number of non-smokers with airflow obstruction compatible with COPD in Japan. In this study, airflow obstruction in non-smokers was more common in women and likelier to result in mild functional and pathological abnormalities than in smokers. Further studies are warranted to investigate the long-term prognosis and appropriate management of this population in developed countries, especially in women.

Metabolome analysis of esophageal cancer tissues using capillary electrophoresis-time-of-flight mass spectrometry

Reports of the metabolomic characteristics of esophageal cancer are limited. In the present study, we thus conducted metabolome analysis of paired tumor tissues (Ts) and non-tumor esophageal tissues (NTs) using capillary electrophoresis time-of-flight mass spectrometry (CE-TOFMS). The Ts and surrounding NTs were surgically excised pair-wise from 35 patients with esophageal cancer. Following tissue homogenization and metabolite extraction, a total of 110 compounds were absolutely quantified by CE-TOFMS. We compared the concentrations of the metabolites between Ts and NTs, between pT1 or pT2 (pT1-2) and pT3 or pT4 (pT3-4) stage, and between node-negative (pN-) and node-positive (pN+) samples. Principal component analysis and hierarchical clustering analysis revealed clear metabolomic differences between Ts and NTs. Lactate and citrate levels in Ts were significantly higher (P=0.001) and lower (P<0.001), respectively, than those in NTs, which corroborated with the Warburg effect in Ts. The concentrations of most amino acids apart from glutamine were higher in Ts than in NTs, presumably due to hyperactive glutaminolysis in Ts. The concentrations of malic acid (P=0.015) and citric acid (P=0.008) were significantly lower in pT3-4 than in pT1-2, suggesting the downregulation of tricarboxylic acid (TCA) cycle activity in pT3-4. On the whole, in this study, we demonstrate significantly different metabolomic characteristics between tumor and non-tumor tissues and identified a novel set of metabolites that were strongly associated with the degree of tumor progression. A further understanding of cancer metabolomics may enable the selection of more appropriate treatment strategies, thereby contributing to individualized medicine.

The Implementation of a Hospital-wide Practice for the Selective Use of Carbapenems Based on the Monitoring of Susceptibility of Pseudomonas aeruginosa Isolates

OBJECTIVES

To control carbapenem-resistant Pseudomonas aeruginosa, we implemented a hospital-wide policy concerning the selective use of carbapenems based on the monitoring of P. aeruginosa isolates for susceptibility to five carbapenems using a customized dry plate method. In this study, we retrospectively investigated the outcome of our measures to control carbapenem-resistant P. aeruginosa.

METHODS

To select effective carbapenems, 100 clinical isolates were collected, and the minimum inhibitory concentration (MIC) to 5 carbapenems (IPM/CS, MEPM, DRPM, BIPM and PAPM/BP) was monitored using a customized dry plate method from 2006 to 2013. Carbapenems, which were associated with a high rate of drug resistance in P. aeruginosa, were restricted from use during our intervention study. The antimicrobial use density per 100 bed-days (AUD¹⁰⁰) of carbapenems and the detection rates of carbapenem (IPM/CS and MEPM)-resistant P. aeruginosa were determined during the period of the intervention.

RESULTS

The isolates consistently showed higher rates of drug-resistant P. aeruginosa in IPM/CS and PAPM/BP. Thus, DRPM, MEPM and BIPM were adopted for hospital-wide use. The detection rates of all IPM/Cs and MEPM-resistant P. aeruginosa significantly decreased. Meanwhile, the consumption of carbapenems showed an increasing trend.

CONCLUSIONS

The outcome of the hospital-wide implementation of the selective use of carbapenems based on periodic monitoring of the susceptibility of P. aeruginosa isolates was retrospectively studied. Implementation of this measure might have contributed in part to the control of carbapenem-resistant P. aeruginosa in our hospital.

Performance Evaluation of a Newly Developed and Fully Automated Bacteriological Analyzer "RAISUS ANY" for Antimicrobial Susceptibility Testing of Fastidious Bacteria Haemophilus influenzae and Streptococcus pneumoniae

OBJECTIVE

Antimicrobial susceptibility testing for fastidious bacteria, such as Haemophilus influenzae (H. influenzae) and Streptococcus pneumoniae (S. pneumoniae) has been performed manually. We evaluated the performance of a newly developed fully automated system for rapid bacterial identification and antimicrobial susceptibility testing "RAISUS ANY" (Nissui Pharmaceutical Co., Ltd.).

METHODS

We evaluated the performance of "RAISUS ANY" for measurement of minimal inhibitory concentrations (MICs) of H. influenzae and S. pneumoniae, in comparison with the manual method (DP34, Eiken Chem. Co., Ltd.). The repeatability of MICs was studied using the reference strain of these bacteria, obtained from the American Type Culture Collection (ATCC, Manassas, VA, USA).

RESULTS

The comparison with the manual method for 35 and 36 clinical strains of H. influenzae and S. pneumonia showed 62.9-100% and 86.1-100% agreement, respectively. Five of 35 H. influenzae strains that showed a trailing effect were stably and accurately measured for MICs without a variation among the examiners.

CONCLUSION

In conclusion, the automated system "RAISUS ANY" provided a reliable MICs data for H. influenzae and S. pneumonia, suggesting its improvement in performance and reliability for routine antimicrobial susceptibility testing in clinical bacteriological laboratories.

Hypodysfibrinogenemia with a Heterozygous Mutation of γCys326Ser by the Novel Transversion of TGT to TCT in a Patient with Pulmonary Thromboembolism and Right Ventricular Thrombus

We encountered a 45-year-old Japanese man who suffered from pulmonary thromboembolism and huge right ventricular thrombus after inferior vena cava (IVC) filter implantation without apparent thrombus in either the deep veins or inside the IVC filter. The biochemical data showed a discrepancy in the level of fibrinogen between the immunological and thrombin time methods, suggesting hypodysfibrinogenemia. The sequencing of the fibrinogen γ-chain gene (FGG) revealed a novel heterozygous missense mutation in exon 8 - a TGT to TCT transversion in codon 326 - resulting in an amino acid substitution of serine for cysteine (γCys326Ser). The characterization of the protein did not show known mechanisms for thrombosis in dysfibrinogenemia, such as dimer or albumin-binding complex formation. In summary, the current case with a life-threatening thrombotic event was found to have a novel heterozygous missense mutation resulting in γCys326Ser, which was suggested as a predisposing factor of the thrombosis. Known mechanisms responsible for thrombosis in the current case were not demonstrated, suggesting other mechanisms including superimposing inherited and/or acquired risk factors. When a patient presents with unusual thrombosis such as breakthrough pulmonary embolism and huge thrombus in the right ventricle, as in the current case, the laboratory process for heritable thrombophilia should be considered.

Simultaneous and multi-point measurement of ammonia emanating from human skin surface for the estimation of whole body dermal emission rate

Ammonia is one of the members of odor gases and a possible source of odor in indoor environment. However, little has been known on the actual emission rate of ammonia from the human skin surface. Then, this study aimed to estimate the whole-body dermal emission rate of ammonia by simultaneous and multi-point measurement of emission fluxes of ammonia employing a passive flux sampler - ion chromatography system. Firstly, the emission fluxes of ammonia were non-invasively measured for ten volunteers at 13 sampling positions set in 13 anatomical regions classified by Kurazumi et al. The measured emission fluxes were then converted to partial emission rates using the surface body areas estimated by weights and heights of volunteers and partial rates of 13 body regions. Subsequent summation of the partial emission rates provided the whole body dermal emission rate of ammonia. The results ranged from 2.9 to 12mgh^-1 with an average of 5.9±3.2mgh^-1 per person for the ten healthy young volunteers. The values were much greater than those from human breath, and thus the dermal emission of ammonia was found more significant odor source than the breath exhalation in indoor environment.

Three-dimensional finite element model to predict patterns of pterygomaxillary dysjunction during Le Fort I osteotomy

The aim of this study was to determine whether non-linear three-dimensional finite element analysis (3D-FEA) can be applied to simulate pterygomaxillary dysjunction during Le Fort I osteotomy (LFI) not involving a curved osteotome (LFI-non-COSep), and to predict potential changes in the fracture pattern associated with extending the cutting line. Computed tomography (CT) image data (100 snapshots) after LFI were converted to 3D-CT images. 3D-FEA models were built using preoperative CT matrix data and used to simulate pterygomaxillary dysjunction. The pterygomaxillary dysjunction patterns predicted by the 3D-FEA models of pterygomaxillary dysjunction were classified into three categories and compared to the pterygomaxillary dysjunction patterns observed in the postoperative 3D-CT images. Extension of the cutting line was also simulated using the 3D-FEA models to predict the risk and position of pterygoid process fracture. The rate of agreement between the predicted pterygomaxillary dysjunction patterns and those observed in the postoperative 3D-CT images was 87.0% (κ coefficient 0.79). The predicted incidence of pterygoid process fracture was higher for cutting lines that extended to the pterygomaxillary junction than for conventional cutting lines (odds ratio 4.75; P<0.0001). 3D-FEA can be used to predict pterygomaxillary dysjunction patterns during LFI-non-COSep and provides useful information for selecting safer procedures during LFI-non-COSep.

[Evolution of BCR-ABL1 Testing for Chronic Myeloid Leukemia Under Tyrosine Kinase Inhibitor Treatment]

The advent and long-term use of tyrosine kinase inhibitors in molecular target therapy for chronic myeloid leukemia have resulted in a marked improvement of treatment outcomes. This has changed'the algorithm of the laboratory process for the diagnosis and therapeutic monitoring of chronic myeloid leukemia. It includes defining the molecular typing of BCR-ABL1 to establish the diagnosis, and a quantitative and/or high- sensitivity assay for minimal residual disease to evaluate the treatment response. Along with improved long-term survival outcomes, new issues have arisen regarding the best index to use for the improved clinical outcomes, such as treatment-free remission. To this end, clinical and laboratory monitoring of CML patients has been investigated. Novel methodologies and technologies have been applied to improve decision-making on patient care, tailoring the treatment to the individual characteristics of each patient, including an early index for the treatment response and deeper molecular response to realize treatment-free survival, and BCR-ABLI kinase domain mutation screening for refractory disease. In response to the advancement and applications of these emerging technologies, proper laboratory practice with the quality assurance of testing is expected. [Review].

Analysis to Estimate Genetic Variations in the Idarubicin-Resistant Derivative MOLT-3

Gene alterations are a well-established mechanism leading to drug resistance in acute leukemia cells. A full understanding of the mechanisms of drug resistance in these cells will facilitate more effective chemotherapy. In this study, we investigated the mechanism(s) of drug resistance in the human acute leukemia cell line MOLT-3 and its idarubicin-resistant derivative MOLT-3/IDR through complete mitochondrial and nuclear DNA analyses. We identified genetic differences between these two cell lines. The ND3 mutation site (p.Thr61Ile) in the mitochondrial DNA sequence was unique to MOLT-3/IDR cells. Moreover, we identified five candidate genes harboring genetic alterations, including GALNT2, via CGH array analysis. Sequencing of the GALNT2 exon revealed a G1716K mutation present within the stop codon in MOLT-3/IDR cells but absent from MOLT-3 cells. This mutation led to an additional 18 amino acids in the protein encoded by GALNT2. Using real-time PCR, we determined an expression value for this gene of 0.35. Protein structure predictions confirmed a structural change in GALNT2 in MOLT-3/IDR cells that corresponded to the site of the mutation. We speculate that this mutation may be related to idarubicin resistance.

[Accreditation of Medical Laboratory under International Standards in Clinical Trial]

In Japan, a medical laboratory accreditation program has been implemented on the basis of the international standard ISO 15189 (Medical laboratories-requirements for quality and competence), under the cooperation of the Japanese Committee for Clinical Laboratory Standards (JCCLS) and the Japan Accreditation Body (JAB). It is carried out in accordance with the specific guidance document 'Guide RM300: 2014'. The subject in the accreditation program is currently limited to common laboratory tests, which are covered by medical insur- ance, with regulatory approval. The 2012 version of ISO 15189 (ISO 15189:2012) expanded its scope, cover- ing genetic testing. In order to achieve the purpose of a clinical research core hospital that has recently been established in Japan, there is a need for an accreditation program to cover the lack of insurance coverage, such as molecular-genetic testing based on emerging technologies. To this end, the development of guid- ance documents intended for genetic testing by which medical laboratories can implement a quality system to meet ISO 15189:2012 is to be considered. In addition, it is necessary to secure human resources who are familiar with oversight and inspection regarding genome-specific matters. [Review].

[[Education and Career Development of Laboratory Personnel through Qualification System of Molecular Analysis Technologist and Specialist}]

Clinical applications of molecular-genetic testing are rapidly disseminating and expanding. A qualification system of technological professionals for molecular-genetic testing has been implemented and operating in Japan, aiming at educating and evaluating personnel who are to engage in molecular-genetic testing. It con- sists of two stages in career development with molecular analysis technologist and specialist, both of which need to be renewed every 5 years. The qualification is of significance across many fields. Human resource development of molecular-genetic testing is a cornerstone of quality assurance of measurement by medical and research laboratory personnel. In addition, expectations of the qualified personnel include the manage- ment of relevant guidelines, compliance regarding the use of personal genetic information (medical ethics) and bio-risk in the laboratories, as well as engagement in the biotechnology industry. [Review].

[Global Trends in the Use of Point-of-Care Testing Devices and Efforts toward Standardization.]

Advances in testing and information technologies have expanded the availability of Point-of-Care Testing (POCT) devices not only in healthcare but also in non-healthcare settings. POCT laboratory accreditation under ISO 22870 has been implemented in conjunction with ISO 15189 in European countries. A markedly increasing number of facilities are performing POCT in non-healthcare settings in the United States with a certificate of waiver and in European countries; concerns are being raised on the lack of oversight and re- quirements for personnel qualifications and training. Centers for Disease Control and Prevention have been making efforts to develop educational tools. In ISO Technical Committee 212 (ISO/TC212) on clinical labor- atory testing and in vitro diagnostic test systems, guidance for POCT operators is proposed, being designed as a document for operators in healthcare and non-healthcare settings who lack specific medical laboratory training. In Japan, on the basis of the international efforts on standardization and quality assurance, nation- wide efforts are necessary for increased reliability and confidence on performing POCT to promote the cost- effectiveness and quality of healthcare services.

Multianalyte Conventional Reference Material (MacRM): A Useful Tool for Nationwide Standardization of Laboratory Measurements for Medical Care—A Model Study in Japan

BACKGROUND

The Japanese Committee for Clinical Laboratory Standards (JCCLS) has developed a multianalyte conventional reference material (MacRM) for nationwide standardization of laboratory measurements.

METHODS

To prepare the MacRM, pooled sera were obtained from healthy Japanese individuals. Target values of the pooled sera for 30 analytes were assigned on the basis of the measurement results of 45 certified clinical laboratories whose calibration was verified by measuring certified reference materials (CRMs) provided by the National Institute of Standards and Technology, the Institute for Reference Materials and Measurements, and JCCLS. Commutability of MacRM was assessed by comparison with results for 150 individual inpatients at Fukuoka University Chikushi Hospital. Survey samples were prepared by essentially the same method for MacRM but without target values. The survey samples were used to assess agreement among 165 laboratories that used various assay kits and platforms calibrated with the MacRM.

RESULTS

The commutability of MacRM was confirmed for 30 analytes with sera from 150 individual patients. The imprecision (CV) of measurements of survey samples (high and low concentrations) among the 165 laboratories was 0.4%–10.0%. Twenty-six of 30 analytes were within the goals for interinstitutional allowable bias. An aliquot of MacRM stored frozen at −80 °C remained stable for ≥4 years.

CONCLUSIONS

The MacRM was successfully applied as a calibrator to achieve nationwide standardization for 30 analytes measured by 165 laboratories that used various methods from different manufacturers.

Outbreak of drug-resistant Acinetobacter baumannii ST219 caused by oral care using tap water from contaminated hand hygiene sinks as a reservoir

An outbreak of amikacin- and ciprofloxacin-resistant Acinetobacter baumannii ST219 in Tokai University hospital's emergency intensive care unit was caused by its colonization in water systems and subsequent spread through oral care using tap water. The outbreak was successfully controlled after replacement of the water system and implementation as of daily cleaning of water taps and oral care with a dry method. It is important to strictly manage the water system in critical care areas.

[Molecular-Genetic Diagnosis and Molecular-Targeted Therapy in Cancer: Challenges in the Era of Precision Medicine]

Elucidation of the molecular pathogenesis of neoplasms and application of emerging technologies for testing and therapy have resulted in a series of paradigm shifts in patient care, from conventional to personalized medicine. This has been promoted by companion diagnostics and molecular targeted therapy, tailoring the treatment to the individual characteristics of each patient. Precision oncology has been accelerated by integrating the enhanced resolution of molecular analysis, mechanism clarity, and therapeutic relevance through genomic knowledge. In its clinical implementation, there are laboratory challenges concerning accurate measurement using stored samples, differentiation between driver and passenger mutations as well as between germline and somatic mutations, bioinformatics availability, practical decision-making algorithms, and ethical issues regarding incidental findings. The medical laboratory has a new role in providing not only testing services but also an instructive approach to users to ensure the sample quality and privacy protection of personal genome information, supporting the quality of patient practice based on laboratory diagnosis.

Collaborative derivation of reference intervals for major clinical laboratory tests in Japan

Objectives

Three multicentre studies of reference intervals were conducted recently in Japan. The Committee on Common Reference Intervals of the Japan Society of Clinical Chemistry sought to establish common reference intervals for 40 laboratory tests which were measured in common in the three studies and regarded as well harmonized in Japan.

Methods

The study protocols were comparable with recruitment mostly from hospital workers with body mass index ≤28 and no medications. Age and sex distributions were made equal to obtain a final data size of 6345 individuals. Between-subgroup differences were expressed as the SD ratio (between-subgroup SD divided by SD representing the reference interval). Between-study differences were all within acceptable levels, and thus the three datasets were merged.

Results

By adopting SD ratio ≥0.50 as a guide, sex-specific reference intervals were necessary for 12 assays. Age-specific reference intervals for females partitioned at age 45 were required for five analytes. The reference intervals derived by the parametric method resulted in appreciable narrowing of the ranges by applying the latent abnormal values exclusion method in 10 items which were closely associated with prevalent disorders among healthy individuals. Sex- and age-related profiles of reference values, derived from individuals with no abnormal results in major tests, showed peculiar patterns specific to each analyte.

Conclusion

Common reference intervals for nationwide use were developed for 40 major tests, based on three multicentre studies by advanced statistical methods. Sex- and age-related profiles of reference values are of great relevance not only for interpreting test results, but for applying clinical decision limits specified in various clinical guidelines.

[Overview of Proficiency Testing and External Quality Assessment Programs of Laboratory Tests from the Standpoint of International Standardization]

In Japan, laboratory comparison, by means of proficiency testing or external quality assessment, has been conducted with separate programs on a nationwide basis, markedly contributing to quality improvement of clinical laboratory testing. However, from the standpoint of international standardization, there are issues to be addressed. Performance is evaluated once a year in each program, with time-consuming studies and different methods for data collection, analysis, and its assessment among programs, thus not leading to real-time monitoring and correction of the performance. Only the examination procedure of routine laboratory testing is focused on, while the entire process of the examination needs to be properly performed from the pre-examination down to the post-examination procedures. The development of proficiency testing for esoteric tests is needed, since both routine and esoteric ones have been provided by most medical laboratories, and a combination of them is used for decision-making in patient care. As molecular-genetic tests have been widely used, demand for the development of laboratory comparison programs has increased. In order to comprehensively evaluate the performance of laboratory, medical imaging and biophysical examination are also necessary. The overall performance of the medical laboratory must be assured along with the availability of proficiency testing or external quality assessment programs for each test to be performed, in order to contribute to optimal patient care.

[Good Practice of Clinical Physiology Examination for Patient Safety with a Team-Based Approach: Quality Practice in Ultrasonographic Examination]

For the safety of patient care, a team-based approach has been advocated as an effective measure. In clinical physiology examination, we have been making efforts to promote good practice for patient safety based on such an approach in Tokai University Hospital, as represented by quality practice in ultrasonographic examination. The entire process of ultrasonographic examination can be divided into three parts: pre-examination, examination, and post-examination processes. In each process of the examination, specific quality issues must be considered, eventually ensuring the quality and safety of patient care. A laboratory physician is responsible for not only quality assurance of examination, diagnosis, and reporting, but also patient safety. A laboratory physician can play a key role in all aspects of patient safety related to each process of the examination by taking a leadership role in the team-based approach.

[Development of Standards for Baseline Quality in Quality Management of Molecular-Diagnostic Testing]

As molecular-diagnostic testing is expanding in clinical use, the demand for its quality assurance is increasing. To this end, efforts towards quality management have been made regionally and globally. An entire testing procedure needs to be properly performed from the preanalytic, analytic, and postanalytic processes. Particularly, the preanalytic process largely affects the measurement and, thus, the result. The Japanese Committee for Clinical Laboratory and Standard developed the standard documents, such as that for the quality management of clinical specimens and best-practice guideline for quality assurance of molecular-genetic testing. These standard documents would provide not only the requirements as the best practice for testing, but also the basis of baseline quality and reliability. They can be used as the basis for assessment of the quality of practice in reimbursement coverage by payers and in certification or accreditation by a third party.