Since the 1990's, the test for serum pepsinogen as a marker for chronic atrophic gastritis has been incorporated into gastric cancer screening programs, on a trial basis, to identify people at high risk for gastric cancer. The addition of the serum test to the cancer screening program has been shown to improve the detection rate of cancer and pepsinogen testing is useful in detecting early-stage gastric cancers arising from atrophic gastric mucosa, which macroscopically tend to be elevated and histologically differentiated. Furthermore, the cost for the detection of a single cancer case is much less than that for conventional screening. Thus, with the introduction of pepsinogen testing, complimenting barium X-ray, a more efficient screening system is available.

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Background: Antibiotics have been overused for acute respiratory tract infections (ARTIs) and the recent guidelines have emphasized limiting their use.
Objective: To clarify the exact rate of antibiotic use and patient outcomes and satisfaction, under strict adherence to the guideline proposed by the American College of Physicians.
Design: Prospective cohort observational study.
Setting: Primary care clinics in Japan.
Patients: 783 patients diagnosed with ARTIs from October 2004 to April 2005, aged 15-64 and without any underlying disease.
Measurements: Scores of symptoms and patient satisfaction at the 5th, 8th and 15th day of their initial visit, when treatment had been initiated according to that strategy.
Results: In 691 non-influenza patients, comprising 554 (80%) cases of nonspecific upper respiratory tract infection (A), 11 (2%) of acute rhinosinusitis (B), 90 (13%) of acute pharyngitis (C) and 36 (5%) of acute bronchitis (D); the rates of antibiotic use were 5% [0.2%; (A), 9%; (B), 36%; (C), 3%; (D)] initially and 2% [2%; (A), 0%; (B), 1%; (C), 3%; (D)] subsequently. For the remaining 92 influenza patients, no antibiotics were prescribed, though oseltamivir was prescribed in 89 (97%). Within 7 days, more than 90% of all patients felt improved and expressed their satisfaction with the treatment. Furthermore, no patients needed emergency room visits or hospital admission.
Limitations: Only patients who gave informed consent were enrolled.
Conclusions: Adhering to the guideline, antibiotic use could be limited to only 5-7% of non-influenza ARTIs-mainly acute pharyngitis-without any problems and with a high degree of patient satisfaction.

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Pancreatic endocrine tumors are rare tumors classified into "functioning" and "nonfunctioning" tumors. A 68-year-old man was admitted to our hospital with the chief compliant of abdominal pain. Various imaging studies demonstrated a mass in the head of the pancreas with intraductal growth into the main pancreatic duct and an intraportal mass. The patient underwent a curative surgical operation. Histopathological examination revealed that it was nonfunctioning endocrine carcinoma of the pancreas. This is the first reported case of a pancreatic endocrine tumor with intraductal growth into the main pancreatic duct and tumor thrombus within the portal vein.

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In this report, we present a case of gastric antral vascular ectasia (GAVE) associated with systemic sclerosis and interstitial pneumonitis. This case showed resistance to endoscopic treatment using argon plasma coagulation (APC). After initial recognition of GAVE as the origin of persistent anemia, three sessions of APC were performed and dilated vessels on the antrum were eliminated completely. Five months after primary treatment, follow-up endoscopy revealed deformity of the gastric antrum caused by ulcer scars induced by APC, with no vascular ectasia. Ten months later, the patient showed anemia and recurrence of GAVE on endoscopy. Ablation using APC was performed again, thereby eradicating recurrent GAVE completely. At a two months' follow-up, however, recurrent GAVE was indicated. In spite of GAVE eradication by APC, a third recurrence of GAVE was observed after 32 months. During the follow-up period, systemic sclerosis and interstitial pneumonitis were controlled clinically by administration of methyl prednisolone with no aggravation.

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A 24-year-old pregnant woman was referred to our hospital for the evaluation of her cardiac function. An electrocardiogram showed Wolff-Parkinson-White syndrome. Echocardiography revealed prominent trabeculation and deep intertrabecular recesses at the left ventricular apex and mid-portion of the inferior and lateral wall, with an impaired ejection fraction. She was diagnosed as having an isolated noncompaction of the ventricular myocardium (INVM). As the pregnancy progressed, severe restrictive hemodynamics became apparent. In consideration of the fetal growth, we decided to deliver the fetus by cesarean section at 32 weeks gestation; the patient successfully delivered a female infant. Interestingly, echocardiography demonstrated INVM in both the child and mother. This report is the first description of a successful pregnancy in a patient with familial INVM.

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We describe a 65-year-old man who had repeated lung injuries after reduced-intensity allogeneic stem cell transplantation (RIST) for renal cell carcinoma. Severe pneumonitis developed twice at the time of neutrophil recovery and acute graft-versus-host disease. Both episodes were successfully treated with steroid pulse therapy. Metastases regressed after the first episode and were stable during these lung disorders, but he died of tumor progression 6 months after RIST. This case suggests that certain local inflammatory reactions may be associated with an anti-tumor effect.

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We present the case of a 56-year-old woman with anti-glomerular basement membrane (anti-GBM) antibody disease accompanied by granulomatous reaction in the kidney. Three months prior to admission to our kidney center, she had suffered from interstitial pneumonia and had a slightly elevated level of MPO-ANCA (13 EU). Her serum level of creatinine was normal (0.72 mg/dl) but proteinuria (1+) and hematuria (2+, 1-4/HF) were present. She was admitted to our hospital because of general fatigue, loss of appetite, high fever (over 38.5°C) and a rapid decline in renal function (creatinine 8.50 mg/dl). Hemodialysis therapy was started immediately after admission. The serological study was negative for MPO-ANCA and PR3-ANCA but positive for anti-GBM antibody (139 EU). Renal biopsy demonstrated necrotizing glomeruli, cellular crescents and grauloma formation with multinucleated giant cells. Immunofluorescence microscopy revealed linear staining of IgG and C3. We diagnosed graulomatous, crescentic and necrotizing glomerulonephritis, patho-logically. She was diagnosed as having anti-GBM antibody disease because alveolar hemorrhage was absent. Steroid therapy including methylprednisolone pulse therapy (500 mg/day, 3 days) and 2 courses of plasma exchange were effective in reducing the fever, anti-GBM antibody titer and C-reactive protein level. Her renal function recovered and she was able to quit hemodialysis therapy 68 days after the start of hemodialysis and she has shown no signs of pulmonary alveolar hemorrhage to date. The present case suggests that intensive therapy may restore renal function in anti-GBM disease even though renal function was sufficiently damaged and required hemodialysis therapy and active pathological changes were observed in renal biopsy specimens.

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A 76-year-old woman, who had never been seriously ill, was admitted to our hospital with fever and shaking chills. She progressively developed septic shock. We detected Streptococcus pneumoniae in a routine examination of a Giemsa-stained peripheral blood smear. Despite intensive care with antibiotic therapy, she died within several hours after admission. A peripheral blood smear occasionally shows bacteria in cases of overwhelming septicemia, thus indicating a severe impairment of splenic function. We suggest that, in cases of severe septicemia, an examination of a peripheral blood smear is therefore useful for the rapid detection of organisms in comparison to a traditional blood culture.

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We report a 47-year-old man who is considered to have sporadic encephalitis lethargica (EL). He presented with hyperpyrexia, lethargy, akinetic mutism, and posture of decorticate rigidity following coma and respiratory failure. Intravenous methylprednisolone pulse therapy improved his condition rapidly and remarkably. Electroencephalography (EEG) showed severe diffuse slow waves of bilateral frontal dominancy, and paralleled the clinical course. Our patient fulfilled the diagnostic criteria for malignant catatonia, so we diagnosed secondary malignant catatonia due to EL syndrome. The effect of corticosteroid treatment remains controversial in encephalitis; however, some EL syndrome patients exhibit an excellent response to corticosteroid treatment. Therefore, EL syndrome may be secondary to autoimmunity against deep grey matter. It is important to distinguish secondary catatonia due to general medical conditions from psychiatric catatonia and to choose a treatment suitable for the medical condition.

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We present the case of a 71-year-old woman with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS) syndrome. Overproduction of vascular endothelial growth factor (VEGF), secreted by plasmacytoma, is considered responsible for the characteristic symptoms, and therefore anti-VEGF monoclonal antibody (bevacizumab) could be a therapeutic option. The patient was treated with bevacizumab 7 years after onset. Despite a dramatic decrease in serum VEGF levels, there was no clinical improvement, possibly because aberrant angiogenesis had already developed systemically. We suggest that careful consideration should be taken for indication of bevacizumab therapy, and this agent may be used in selected patients with a short duration POEMS syndrome.

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We report two rare cases complicated by gastrointestinal mucosal disorders, including peptic ulcer and ischemic colitis. Anaphylaxis was induced by cefaclor in case 1 and by pranoprofen in case 2. These two patients developed epigastric or lower abdominal pain about 10 hours after the onset of anaphylaxis. Gastroduodenoscopy revealed severe ulcers in the stomach or duodenum, while colonoscopy detected mucosal edema, erythema, and erosions, leading to the diagnosis of ischemic colitis. It is important to keep in mind that gastrointestinal mucosal lesions can occur, albeit on rare occasions, in patients with anaphylaxis.

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A 56-year-old woman was admitted because of a high fever, right ptosis, chemosis, proptosis and ocular muscle palsy. Cranial MRI revealed a cavernous sinus thrombosis and a subarachnoid abscess. Carotid angio-gram demonstrated marked stenosis as well as aneurismal formation of the right internal carotid artery at the intracavernous portion. Chest radiograph showed bilateral multiple pulmonary nodules, some of which contained a cavity. Blood culture was positive for Streptococcus constellatus. She was diagnosed with septic cavernous sinus thrombosis complicated by narrowing of the internal carotid artery, subarachnoid abscess and multiple pulmonary septic emboli. She recovered with partial ocular sequelae as a result of seven weeks of intravenous antimicrobial therapy.

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Pleural effusion has various causes. In the setting of aortic stenosis, new onset pleural effusion is generally considered as a consequence of heart failure. Here, we describe a 50-year-old male patient who had been followed with aortic stenosis for 30 years. During his admission he presented with exertional dyspnea and pleuritic chest pain. He had no other symptoms or findings of cardiac failure. Complete blood count revealed neutrophilic leukocytosis, a normal hemoglobin level and normal platelet count. Left sided pleural effusion was noted on the posteroanterior chest X-ray. Examination of the pleural fluid revealed myeloid blasts. Bone marrow aspiration smear and flow cytometric analysis of the bone marrow and pleural fluid were consistent with acute myeloid leukemia.

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