Background/Aims Early detection and identification of bacteria in ascitic fluid could result in more timely treatment of cirrhotic patients with spontaneous bacterial peritonitis (SBP) or subclinical SBP. The aim of this study was to evaluate the usefulness of a bacterial DNA microarray for the rapid diagnosis of SBP and rapid bacterial identification in cirrhotic patients with ascites.
Methods Thirty-seven cirrhotic patients with ascites (25 men and 12 women) participated. Ascitic fluid obtained from patients was tested by the bacterial DNA microarray method and by the conventional culture method.
Results SBP and bacterascites were diagnosed in 8 (16.7%) of 48 specimens by the conventional method. The bacterial DNA microarray proved the existence of bacteria in 6 (75%) of 8 samples with SBP or bacterascites using the conventional method as a gold standard. A corresponding rate of bacterial species identification between the two methods was found in 5 of 6 samples (83.3%). It took 1.47±0.96 and 5.14±2.6 days to receive the data by the microarray and conventional method, respectively (p<0.0001). After antibiotic therapy, the cumulative survival rate of recovered cases (n=8) was higher than that of unrecovered cases (n=5) (p=0.0008).
Conclusion Although the detection rate of the bacterial DNA microarray was similar to the conventional culture method, the DNA microarray could identify pathogens about 4 times more rapidly than bacterial cultivation, thus rendering it useful for managing cirrhotic patients with ascites.

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Background and Aim This study evaluated the outcomes of antiviral therapy with nucleotide analogs for hepatitis B virus infection-related hepatocellular carcinoma.
Methods Thirty patients orally received nucleotide analogs and, as a matched control group, 20 patients who were not treated with nucleotide analogs were selected. We compared changes in liver function, HCC recurrence and survival rate between both groups.
Results In the nucleotide analog group, serum albumin, AST and ALT were significantly improved compared with baseline values. The Child-Pugh score was significantly decreased in the nucleotide analog group. Furthermore, of the 36 patients curatively treated with the initial treatment, more patients in the nucleotide analog group improved or maintained their Child-Pugh score at the time of recurrent HCC than in the control group (p=0.023). The cumulative recurrent-free survival rate of HCC did not significantly differ between the two groups; however, the cumulative survival rates of not only curative-treated patients but also all patients in the nucleotide analog group were significantly higher than those of patients in the control group (p=0.047 and p=0.02, respectively).
Conclusion The results suggest that nucleotide analog treatment increases the survival rate in patients with HCC by contributing to the improvement of remnant liver function.

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Background Exercise is recommended for the treatment and prevention of cardiac disorders. Relaxation of the sympathetic nervous system has been considered to be one of the therapeutic mechanisms. However, the means by which the level of daily physical activity affects sympathetic activity remains unclear.
Objective To evaluate the effects of daily physical activity on autonomic nervous tone.
Methods Daily physical activity was measured for 5 or more days in 26 patients with various cardiac disorders of NYHA class 1 or 2 and in 6 healthy individuals using an intelligent calorie counter. Recumbent resting ECG was recorded for 3 minutes immediately before waking up and after going to bed using a digital ECG. Low- (Lf, 0.03-0.15 Hz) and high- (Hf, 0.15-0.45 Hz) frequency components were calculated by frequency analysis of the R-R interval, and Lf/Hf ratio was calculated as an index of sympathetic tone.
Results The average values of energy expenditure and time were 145±93.6 kcal/day and 47.8±24.3 min/day, respectively. The morning Lf/Hf ratio decreased following an increased physical activity level the day before, but increased with subsequent increase in the activity level in 65.6% of subjects. A negative correlation was observed in 34.4% of subjects, which suggested that an appropriate level of physical activity led to relaxation of sympathetic tone.
Conclusion The daily level of physical activity affects sympathetic tone, and an appropriate level results in sympathetic relaxation. The results of this study provide a useful index to enable patients with cardiac disorder to perform exercise without overloading.

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Objective To investigate the correlation between lifestyle improvements, in particular increased cardio-respiratory fitness and changes in the blood lipid profile.
Methods The participants were 217 residents of Fuji and Yamato Towns, Saga City, with mildly abnormal blood pressure, serum lipids or blood glucose detected at health check-ups in 2003. Participants were randomly allocated to an Intervention (108 subjects) or Control group (109 subjects), matched for age and various conditions. The Intervention group was given exercise advice and prescription and dietary instructions. Cardio-respiratory fitness was evaluated using the work rate at double product breaking point. Changes of lipid parameters were compared before and after intervention, and examined the relationship with cardio-respiratory fitness.
Results Seventy nine subjects in each group could be followed up for 17 months without requiring pharmacotherapy. Body mass index, waist circumference, systolic blood pressure, homeostasis model assessment insulin resistance, and triglycerides were decreased in the Intervention group. Furthermore, apolipoprotein B levels were lower (p<0.05), and the ratio of LDL cholesterol to apolipoprotein B (LDL/ApoB) was higher (p<0.001). When all subjects were divided into 3 subgroups according to the degree of improvement in cardio-respiratory fitness, LDL/ApoB increased and apolipoprotein B decreased as the degree of improvement increased (p<0.05).
Conclusion Improvement was seen in atherosclerotic risk factors through lifestyle modification. In particular, improved cardiorespiratory fitness was associated with qualitative and quantitative changes in LDLs.

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Objective Obesity is currently a major public health problem and one of the potential underlying causes of obesity in a minority of patients is Cushing's syndrome (CS). Traditionally, the gold standard screening test for CS is 1 mg dexamethasone overnight suppression test. However, it is known that obese subjects have high false positive results with this test.
Design We have therefore compared the 1 mg and 2 mg overnight dexamethasone suppression tests in obese subjects. Patients whose serum cortisol after ODST was >50 nM underwent and a low-dose dexamethasone suppression test (LDDST); 24-hour urine cortisol was collected for basal urinary free cortisol (UFC). For positive results after overnight 1-mg dexamethasone suppression test we also performed the overnight 2-mg dexamethasone suppression test.
Patients We prospectively evaluated 100 patients (22 men and 78 women, ranging in age from 17 to 73 years with a body mass index (BMI) >30 kg/m² who had been referred to our hospital-affiliated endocrine clinic because of simple obesity. Suppression of serum cortisol to <50 nM (1.8 μg/dL) after dexamethasone administration was chosen as the cut-off point for normal suppression.
Measurements Thyroid function tests, lipid profiles, homocysteine, antithyroglobulin, anti-thyroid peroxidase antibody levels, vitamin B12, folate levels, insulin resistance [by homeostasis model assessment (HOMA)] and 1.0 mg postdexamethasone (postdex) suppression cortisol levels were measured.
Results We found an 8% false-positive rate in 1 mg overnight test and 2% in 2 mg overnight test (p=0.001). There was no correlation between the cortisol levels after ODST and other parameters.
Conclusions Our results indicate that the 2 mg overnight dexamethasone suppression test (ODST) is more convenient and accurate than 1-mg ODST as a screening test for excluding CS in subjects with simple obesity.

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Background Although muscle loss is thought to be a prognostic factor in chronic obstructive pulmonary disease (COPD), its determinants remain unclear.
Aim To verify the hypothesis that fat-free mass (FFM) and fat mass (FM) are associated with the extent of emphysema in COPD patients.
Patients and Methods A total of 112 stable, male current or ex-smokers with or without COPD attending a secondary care specialist COPD clinic were studied. FFM and FM were measured by bioelectrical impedance analysis. We also assessed the nutrition status, muscle strength by the handgrip test, exercise tolerance by the 6-minute walking test, airflow limitation and diffusion capacity, the extent of emphysema by high-resolution CT scan, systemic inflammation status using C-reactive protein, and a lipid-related hormone (adiponectin).
Results The FFM index (FFMI), which was defined as the FFM divided by the square of the body height, was significantly correlated with age, the total number of lymphocytes, handgrip strength, distance on 6-minute walking, airflow limitation, diffusion capacity, extent of emphysema, and C-reactive protein. On multivariate analysis, the FFMI was associated with handgrip strength and inversely correlated with the extent of emphysema. The FM index (FMI) was positively correlated with pack-years, and was inversely correlated with the extent of emphysema and concentrations of adiponectin.
Conclusion The extent of emphysema was correlated with skeletal muscle loss and also the FM.

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Objective To evaluate the clinical usefulness of piperacillin (4 g/day) therapy for community-acquired pneumonia compared to sulbactam/ampicillin (6 g/day).
Methods A randomized prospective clinical study was conducted in patients with mild to severe community-acquired bacterial pneumonia.
Results The overall clinical efficiency of piperacillin therapy (4 g/day) in these patients (41/53=77.4%) was comparable to that of sulbactam/ampicillin therapy (6 g/day: efficiency rate: 33/49=67.3%), when each therapy was administered intravenously for 3-7 days. With regards to clinical efficiency based on disease severity, bacteriological efficiency, improvement in chest X-ray findings and adverse reactions, the two therapies were comparable, even though we found more efficiency for patients who had underlying diseases and there were also cost benefits in piperacillin therapy, compared with sulbactam/ampicillin therapy
Conclusion The results suggested that piperacillin therapy has good efficiency and tolerability and that it may be highly effective, even in cases of pneumonia with underlying diseases. This regimen may thus serve as a first line treatment of community-acquired pneumonia.

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Background Recently, decrease of immunoglobulin concentrations or neutrophil counts were reported in some cases several months after administration of rituximab. We examined a number of episodes of late onset neutropenia or immunoglobulin decrease in patients with malignant lymphoma who were in complete remission following autologous transplantation with or without rituximab.
Method Patients with follicular lymphoma and diffuse large B cell lymphoma transplanted with or without rituximab in our institutes were analyzed. Immunoglobulin concentrations and neutrophil counts after transplantation, both with and without rituximab were measured serially.
Results Four weeks after transplantation, blood samples revealed lower concentrations of IgG and IgA in the rituximab group than in the non-rituximab group. Neutrophil numbers did not fall below 0.5×10⁹ /L four weeks or more after transplantation in the non-rituximab group. Neutrophil numbers dropped below 0.5×10⁹ /L in 6 of 14 cases in the rituximab group.
Conclusion Although the present study was retrospective and disease composition and pre-transplantation regimens differed between the two groups, the addition of rituximab to autologous transplantation might bring about a decrease of immunoglobulin levels and transient LON.

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The risk factors, microbial patterns, and prognosis of intramedullary abscess have varied with time. The development of an intramedullary abscess of the spinal cord (IASC) constitutes an exceptional complication of infective endocarditis (IE) in the post-antibiotic era. We present a case of cervical IASC by viridans group Streptococcus in a patient with mitral valve IE. We hypothesize that previous cervical radiotherapy for non-Hodgkin's lymphoma favoured the occurrence of this uncommon entity. This physiopathologic mechanism has not been previously reported.

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We present a case of membranous nephropathy (MN) associated with esophageal squamous cell carcinoma (ESCC) with a high serum level of squamous cell carcinoma antigen (SCC). ESCC reached complete response (CR) for radiotherapy, with a partial remission of the proteinuria and decreased serum SCC levels. Six months after radiotherapy, the ESCC recurred, and the patient was treated with endoscopic mucosal resection (EMR), achieving a pathologic CR and disappearance of proteinuria and normalized serum SCC levels. The correlation of proteinuria and the serum level of SCC indicates that SCC could be a pathogenic antigen, responsible for the pathogenesis of MN in this patient.

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We report a patient who had cerebral infarction associated with heparin-induced thrombocytopenia (HIT) during treatment of aseptic encephalitis. In patients with intracranial inflammation, such as ours, the possibility of HIT has to be considered when heparin is used, since inflammatory cerebral lesions often cause vascular damage, which is an aggravating factor for HIT-associated thrombosis.

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Pure dysarthria caused by a small cortical infarction is rare. Recent reports have revealed that a small cortical lesion can lead to pure dysarthria, furthermore some reports have revealed that a middle frontal gyrus lesion might cause pure dysarthria. We report a 64-year-old woman who presented only dysarthria and had a small limited cortical infarction located at the left middle frontal gyrus. This case indicated that an isolated middle frontal gyrus lesion can cause pure dysarthria by secondary compromising of the cortical areas related or connected to the corticobulbar tract.

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Although a cardiac papillary fibroelastoma is a benign cardiac tumor, it can cause severe embolic complications. A 51-year-old man presented with an ischemic stroke in the right middle cerebral artery territory. Transesophageal echocardiography revealed a small mobile tumor on the mitral valve as the only detectable source of emboli to the brain. On histology, the tumor was diagnosed as a papillary fibroelastoma. In this paper, the detailed characteristics of the tumor on ultrasound and histopathology are documented. In patients with cryptogenic stroke, transesophageal echocardiography should be done to rule out such an unusual emboligenic heart disease.

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