Aim We investigated whether steroid therapy for Crohn's disease (CD) patients influences bone mineral density (BMD), and whether alendronate is effective for improving this loss of BMD.
Methods We recruited 16 outpatients with CD. The BMD of the whole body, the lumbar spine, and the proximal femoral neck was measured by dual-energy X-ray absorptimetry. The BMD was expressed as a T score. Some CD patients with low BMD values had been given vitamin K2 or alendronate for one year.
Results In the steroid-dependent group, the mean dose of prednisolone was 968 mg per year and 2.7 mg per day. Although the duration of the disease was not related to the T score, the amount of total steroids was negatively correlated with the T score among patients taking no preventative drugs. The T score in the vitamin K2 group after one year did was not altered in the 3 areas examined. On the other hand, the T score in the alendronate group increased by 2.8% for the whole body, 4.5% in the lumbar spine, and 3.4% in the proximal femoral neck.
Conclusion The BMD of Japanese CD patients was decreased depending on the total amount of steroid administered, and oral alendronate improved the loss of BMD.

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Objective Autoimmune pancreatitis (AIP) may be a pancreatic lesion of IgG4-related systemic disease. Lacrimal gland swelling is a rare extrapancreatic lesion of AIP. The aim of the present study was to investigate lacrimal gland function in AIP patients, and to determine changes after steroid therapy.
Patients and Methods Schirmer's test and sialochemistry were done prospectively in 11 AIP patients. These tests were also performed after steroid therapy in 7 patients.
Results Dysfunction of tear secretion was found in at least one eye in 7 (64%) patients. The average lower level in both eyes was 4.3±1.5 mm in the 7 patients with lacrimal gland dysfunction, which was significantly lower than the 8.2±2.4 mm in patients with normal lacrimal gland function (p=0.005). There were no significant differences between the two groups in age at diagnosis of AIP, sex ratio, and the presence of swelling of the lacrimal glands and the salivary glands. Although there was no significant difference, mean serum IgG4 levels and mean salivary Na+ and β2 microglobulin levels were lower in patients with normal lacrimal gland function. After steroid therapy, lacrimal gland function improved in 3 of 5 patients with impaired lacrimal gland function, though the degree of improvement was not marked compared to the improvement of salivary gland function.
Conclusion Lacrimal gland function was frequently impaired in AIP patients, even when no lacrimal gland swelling was observed clinically. Lacrimal gland function impairment appears to be similar to impairment of salivary gland function in AIP patients.

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Objective To evaluate the effects of localized irrigation with epinephrine saline after endoscopic retrograde cholangiopancreatography (ERCP).
Patients and Methods One hundred and fourteen patients who underwent ERCP in our institute were treated with or without irrigation using epinephrine diluted in saline after ERCP to prevent post-ERCP pancreatitis. The serum amylase levels, white blood cell counts, and urine amylase levels were measured at 24 and 48 hours after ERCP.
Results The treatment resulted in improvements in all items. A univariate analysis of the explanatory variables between the treatment and untreated groups revealed the treatment to be effective, but not statistically significant. Gender and cannulation of the pancreatic duct were the only variables with significant partial regression coefficients in the multiple regression model with all explanatory variables (p=0.045). When a stratified analysis was conducted using gender as a moderator variable, the treatment became a significant preventive factor (p=0.038), and cannulation of the pancreatic duct was a significant risk factor (p=0.027) in female patients.
Conclusion We suggest that irrigating with epinephrine saline into the papilla may be effective for preventing pancreatitis in female patients who received ERCP with cannulation of their pancreatic duct.

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Background High-sensitivity C-reactive protein (hs-CRP) is an independent risk factor of diabetes and cardiovascular disease and it is proposed as a component of metabolic syndrome. Blood levels of hs-CRP are reported to be much lower in Japanese than in Westerners and bimodally distributed in Japanese.
Methods Very low levels of hs-CRP were examined using medical check-up data of 1,360 Japanese men and 821 women whose plasma levels of high-sensitivity C-reactive protein (hs-CRP) were below 10 mg/L.
Results The distribution of hs-CRP levels were skewed but not bimodal in both men and women and very low levels of hs-CRP were significantly related to waist circumference, systolic blood pressure, diastolic blood pressure, fasting glucose, triglycerides, and low-density lipoprotein cholesterol in both men and women. The area under receiver operating characteristic curve of hs-CRP for diagnosing metabolic syndrome and Spearman's correlation coefficients between hs-CRP and components of metabolic syndrome were comparable to those of components of metabolic syndrome in both men and women.
Conclusion Very low levels of hs-CRP were not bimodally distributed but were significantly related to metabolic risk factors in Japanese.

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Background Human T lymphotropic virus type I (HTLV-I), the cause of human T cell leukemia, is associated with a high incidence of several other infectious diseases. However, the relationship between pulmonary infections and HTLV-I infection is still unclear.
Objective A large-scale retrospective study was conducted on hospital inpatients to evaluate the relationship between community-acquired pneumonia (CAP) and HTLV-I infection.
Methods The present study included 4,666 hospitalized patients during 1991-2007. Three hundred and thirteen of them were diagnosed as CAP. The presence of serum HTLV-I antibody was determined in all patients on admission. Prevalence of HTLV-I infection was analyzed between CAP patients and all inpatients. We also compared HTLV-I-positive CAP patients and HTLV-I-negative CAP patients for severity and manifestation of pneumonia.
Results The prevalence of HTLV-I was higher in CAP patients than in all inpatients (18.9%: 13.7%, p=0.011). The rates of renal diseases and collagen vascular disorders were higher in the HTLV-I-positive CAP patients than in the HTLV-I-negative CAP patients. Multivariate analysis revealed that HTLV-I infection, gender, COPD and collagen vascular disorders were all independent risk factors for CAP. The severity indices of CAP, the PORT score and the CURB-65 score, were higher in the HTLV-I-positive patients than in the HTLV-I-negative patients.
Conclusion This study demonstrates that HTLV-I infection might be an independent risk factor for CAP and that HTLV-I-infected patients tend to demonstrate a relatively severe form of pneumonia.

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Objective Recent studies have demonstrated gender differences in functional outcome after stroke. However, the underlying reasons for differences have been inconsistent. The present study examined whether gender differences in long-term functional outcomes exist among surviving patients with first-ever ischemic stroke and with individual subtypes of stroke.
Methods A total of 997 patients (654 men, 343 women) were followed for 5 years after discharge. Patients were assigned to 4 subtypes of ischemic stroke (atherothrombotic, lacunar, cardioembolic and unclassified infarction). Functional outcomes were expressed as locomotor activity, assessed using a questionnaire delivered by mail 1 and 5 years after stroke. Locomotor function was classified into 5 categories according to the grade of disability.
Results Women showed significantly worse locomotor function than men at both 1 and 5 years (p < 0.001 and p < 0.01, respectively). Furthermore, significant gender differences in functional outcome were observed in all subtypes of ischemic stroke at 1 and 5 years after stroke. Logistic regression analysis revealed that gender was a significant determinant for functional outcome at 1 and 5 years after stroke (p < 0.01 and p < 0.001, respectively). No significant gender difference was seen in the rate of stroke recurrence. Women also showed a worse survival ratio after stroke than men (p < 0.01).
Conclusion The present study demonstrated significantly worse functional outcomes for women than for men at 1 and 5 years after stroke. Gender differences in long-term functional outcomes by subtypes of ischemic stroke were also significant.

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Objective We have observed alterations of quantitative (q)-EEG findings occurring in interferon (IFN)-α treated chronic hepatitis C (CH-C) patients, and found patient's age to be one factor influencing such EEG alterations. In the present study we evaluated the correlation between q-EEG alterations during IFN-α treatment and the severity of hepatitis based on liver biopsies.
Methods A total of 102 CH-C patients underwent blind, prospective and serial q-EEG examinations. The IFN-α was administered under the same therapeutic regimen to all patients. Serial EEGs were obtained before, at 2 and 4 weeks, and at 2-3 days after the conclusion of treatment. The absolute powers of each frequency band in different periods were determined by q-EEG. Staging (of fibrosis) and grading (of inflammatory cell infiltration) were scaled according to Desmet's classification. We evaluated the relationship between q-EEG and scales of staging or grading.
Results Age distributions did not differ significantly among stages or grades. As the stage or grade increased, the alterations of EEG during IFN-α treatment became more pronounced, and significant (repeated-measures analysis of variances; both, p<0.0001).
Conclusion Alterations of the EEG occurring during IFN-α treatment became pronounced with more severe pathological findings for CH-C. Alterations in the EEGs during IFN-α treatment should be carefully monitored in CH-C patients with severe pathological findings.

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Objective The importance of psychiatric comorbidity in migraine has long been recognized. There is a growing body of evidence that these psychiatric comorbidities share diverse epidemiological properties, pathophysiological mechanisms, and treatment response. The prevalence of psychiatric comorbidities is high in patients with medication-overuse headache (MOH).
Methods To understand the characteristics of mood disorders in MOH in Japanese patients, we studied and evaluated the characteristics of psychiatric comorbidities in MOH.
Results The results suggested that mood disorders in MOH are similar to those in endogenous depression but different from those of secondary mood disorders associated with other diseases. Suspicion of depression and intervention are essential for providing medical care for patients with MOH.
Conclusion Affective disorders diagnosed in migraine patients might later progress to MOH. In contrast, migraine patients without MOH and healthy subjects had a similar prevalence of mood disorders.

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Objective Senile persons have reduced left ventricular (LV) relaxation and increased late diastolic filling. However, the determinant factor of the enhanced active emptying of the left atrium has not been well established.
Methods Subjects were 62 healthy individuals with a mean age of 58±19 (21-85) years. The biplane modified Simpson's rule was applied to measure left atrial (LA) volume at pre-atrial contraction (LAVpre) as an index of LA preload and LA volume change during atrial contraction (LASV) as an index of active LA emptying. These values were divided by the body surface area and represented as LAVpreI and LASVI, respectively. Postero-basal (dorsal cranial) left atrial wall velocity (LAWV) during atrial contraction as an index of LA contractility was measured in the apical three-chamber view by two-dimensional tissue Doppler echocardiography.
Results Age significantly correlated with mitral flow velocity (TMA), velocity-time integral during atrial contraction (TMAVTI) and LASVI (r= 0.63, p<0.001 and r=0.71, p<0.001, r=0.21, p=0.049, respectively). LAVpreI was significantly correlated with age (r=0.44, p<0.001), LASVI (r=0.71, p<0.001), TMA (r=0.31, p=0.008) and TMAVTI (r=0.40, p<0.001). LAWV remained unchanged with aging and had no correlation with TMA, TMAVTI or LASVI.
Conclusion The enlargement of the LA in senile persons may be a major determinant of enhanced active LA emptying and the increased LA contractility may be less contributory.

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Myocardial bridge (MB) is a congenital variation of the coronary arteries and the segment of the coronary artery through myocardium is compressed during systole. Although it is relatively asymptomatic, percutaneous coronary intervention (PCI) may be necessary to relieve symptoms. Perforation or frank rupture of coronary arteries occurs rarely in patients undergoing percutaneous coronary intervention. We report the coronary rupture in a case with myocardial bridge which occurred during percutaneous coronary intervention. We deployed a stent graft to successfully rescue the rupture of the distal segment of left anterior descending coronary artery (LAD-D) with myocardial bridge (MB).

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Whereas uterine leiomyoma is a common woman disease, intravenous leiomyomatosis with intracaval and intracardiac complications is a rare condition. The initial presentation is dependent upon the severity of the intracardiac involvement, although complete surgery is the best treatment. The case of a 39-year-old woman is described here, with an initial presentation of dyspnea and right heart failure. Leiomyomatosis originating from the uterus and extending to the inferior vena cava and right atrium was diagnosed from various preoperative studies. The patient was resuscitated because of respiratory failure and severe right heart failure. However, she was operated successfully through a two-stage approach and remained well postoperatively. This case illustrates an intriguing presentation of intravenous leiomyomatosis and a curative surgical intervention even in critical condition.

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Cardiac involvement is a rare complication with thromboangiitis obliterans (TAO). We report a 29-year-old man with TAO accompanied with non-ischemic dilated cardiomyopathy. He had no history of heart disease, but echocardiogram demonstrated diffuse hypokinesis and dilated left ventricle. Coronary angiography revealed no organic stenotic lesion. For limb salvage, he was treated with granulocyte-colony stimulating factor (G-CSF)-mobilized peripheral blood mononuclear cell (PBMNC) implantation on his right leg. Not only ischemic leg symptoms, but also plasma level of BNP and ¹²³I-metaiodobenzylguanidine scintigraphic parameters improved after 24 weeks. G-CSF-mobilized PBMNC implantation could be an effective approach to treating non-ischemic cardiomyopathy.

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We describe a case of Brugada syndrome, in which a coved type ST-segment elevation was enhanced by antihistamines and antiallergenic drugs. The patient had been treated with four kinds of antihistamines and antiallergenic drugs. The twelve-lead ECG exhibited a coved type ST-segment elevation in leads V₁ and V₂, and their enhancement was induced by pilsicainide. After discontinuing those drugs, the ST segment elevation in leads V₁ and V₂ became reduced. An ICD implantation was selected for the therapy since ventricular fibrillation was induced. Our report discusses the possible contribution of antihistamines and antiallergenic drugs to the Brugada type ST-segment changes.

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An obese 43-year-old female with a right adrenal pheochromocytoma is described. The clinical manifestations of this case included ventricular tachycardia, left ventricular thrombus, and elevation of serum myocardial enzymes. During the hospitalization, the left ventricular thrombus was detached, leading to renal infarction and embolic occlusion of the femoral arteries bilaterally.

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Macro-reentrant ventricular tachycardia (VT) developed in a 20-year-old man, 17 years after surgical repair of tetralogy of Fallot. Activation mapping of the VT revealed its counterclockwise propagation around the right ventricle, and through a critical pathway between a transannular patch and the tricuspid annulus. This critical pathway was 6 cm long and contained myocardium with a normal amplitude, while the area of low voltage was limited adjacent to the transannular patch. A linear lesion was created by radiofrequency energy delivered only to the low voltage area. After ablation, the activation wavefront through the low voltage area was blocked, and VT became non-inducible.

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To identify the location of pancreatic endocrine tumors, arterial stimulation and venous sampling (ASVS) is known to be useful for insulinoma and gastrinoma, but its usefulness for glucagonoma has not been verified to date. Here we report a case of glucagonoma that was diagnosed by ASVS with calcium loading, in which an approximately 6-fold increase of glucagon was observed in the splenic artery territory. MEN1 gene analysis verified the presence of a mutation and the glucagonoma was confirmed after operation. In conclusion, ASVS could be useful for the diagnosis of glucagonoma.

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A 69-year-old man with type 2 diabetes mellitus was admitted to our hospital because of appetite loss, nausea and vomiting. Gastroscopy revealed gastric cancer. Levels of plasma cortisol were decreased. Neither adrenocorticotropic hormone (ACTH) nor cortisol levels were adequately increased in response to a mixed intravenous administration of corticotropin-releasing hormone, growth hormone-releasing hormone, thyrotropin-releasing hormone and lutenizing hormone-releasing hormone, although other pituitary hormones were increased adequately. He was diagnosed as having isolated ACTH deficiency (IAD). Anti-pituitary antibody and anti-parietal cell antibody were positive. At least in part, these antibodies may play pathogenic roles of development of IAD and gastric cancer.

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Although recent studies recommended that insulin should be administered to patients with slowly progressive type 1 diabetes, even those with non-insulin dependent status, patients prefer oral hypoglycemic agents to insulin injections. We report a slowly progressive type 1 diabetic patient whose insulin production was preserved for 4 years (ΣC-peptide from 29.48 ng/mL to 24.58 ng/mL) using pioglitazone despite a high titer of anti-GAD antibody (GADA; 120.7 U/mL). This case suggests that pioglitazone might prevent or delay the loss of insulin secretion and insulin dependency in slowly progressive type 1 diabetic patients.

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A 43-year-old woman was admitted to hospital due to loss of consciousness. Her fasting plasma glucose and serum immunoreactive insulin levels were 14 mg/dL and 5 μU/mL, respectively. She needed continuous glucose infusion to avoid hypoglycemia. A dynamic abdominal CT scan revealed two hypervascular tumors in the pancreas. A pancreatectomy was performed and her blood glucose level was normalized. The pathological examination revealed six insulinomas but we could not find either parathyroid tumors or obvious pituitary tumor, which denied the possibility of multiple endocrine neoplasia type I. However, long-term follow-up will be necessary for monitoring the development of other tumors.

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Thyroid hemiagenesis is a rare congenital anomaly in which one of the thyroid lobes with or without isthmus fails to develop. Here we present a woman patient with thyroid hemiagenesis, Graves' disease and ophthalmopathy with nodular goiter. Fine needle aspiration biopsy of the dominant nodule was suspicious of malignancy. The patient was referred for surgery for total thyroidectomy. Histopathological examination of the surgical material revealed benign features. The present case confirms that, although rare, a number of concomitant thyroid disorders can exist in a single patient with thyroid hemiagenesis just as it is seen for a normally developed thyroid gland.

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The patient was an 84-year-old man patient diagnosed as malignant pleurisy associated with lung cancer. After drainage of the right pleural effusion, pleurodesis with distilled water was performed. Despite the enlargement of the primary lesion of the lung cancer during the follow-up period, the amount of pleural effusion did not increase for more than one year. No adverse effects associated with pleurodesis were noted. Pleurodesis with distilled water should be considered as one of the choices for treatment in the management of malignant pleurisy especially in elderly.

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A 53-year-old woman was admitted to our hospital due to a severe respiratory condition and malnutrition. Radiological and electrophysiological findings suggested the existence of inexplicable cor pulmonale. Although we commenced to determine the causes of her severe condition, she suddenly died 3 days after admission. Postmortem autopsy revealed tumor cell microemboli in the small pulmonary arteries due to gastric cancer. Such a case of cor pulmonale as the first clinical manifestation is exceptionally rare. Occult malignancy should be considered as a differential diagnosis when one encounters a patient with subacutely aggravated respiratory condition and inexplicable cor pulmonale.

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The patient was 54-year-old woman diagnosed as recurrent invasive thymoma (typeB3; WHO classification). Although partial response was obtained by systemic chemotherapy (PAC: cisplatin, doxorubicin, cyclophosphamide), the tumor started to become enlarged after cessation of chemotherapy. Combined treatment of octreotide and prednisolone was administrated because various chemotherapies, including PAC, were not effective. After seven months, the tumor size was markedly decreased. The combination of octreotide and prednisolone should be considered as one of the choices of treatment in patients with recurrent thymoma.

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A 92-year-old man who had been hospitalized for dementia developed sudden-onset bilious vomiting accompanied by a fever of 40°C. Physical examination revealed an 8 cm diameter pulsatile mass in the upper abdomen. Computed tomography of the abdomen demonstrated a huge infrarenal saccular aneurysm with a lobulated appearance. We considered this to be a mycotic abdominal aortic aneurysm compressing the third portion of the duodenum and causing proximal duodenal dilatation and superior mesenteric artery (SMA) syndrome.

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A 69-year-old man was diagnosed as having syndrome of inappropriate secretion of antidiuretic hormone (SIADH) (serum sodium: 113 mEq/L) 13 days after a right upper lobectomy due to squamous cell carcinoma of the lung (pT1N0M0, stage IA) whereas the preoperative serum sodium level was nearly normal. He had undergone pleurodesis by instillation of OK432 at 2 and 5 days after surgery for prolonged air leakage. Since other possible causes of SIADH, such as residue of lung cancer, pulmonary infections, brain disorders, or known causative drugs were ruled out, the SIADH in this patient was likely associated with pleurodesis by the use of OK-432. A review of similar cases reported suggests that it is important to be aware of the possibility of severe hyponatremia due to SIADH after chemical pleurodesis.

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A 69-year-old woman with a history of diabetes mellitus presented at our emergency room with chest pain and dyspnea. A chest computed tomography revealed a pericardial effusion. Pericardiocentesis was performed; strains of the Streptococcus milleri group were detected on culture of the fluid thus obtained. Therefore, purulent pericarditis was diagnosed. Despite treatment with panipenem/betamipron, the pericarditis worsened leading to the development of cardiac tamponade. Emergency pericardial drainage was performed, after which the condition resolved without any complications. We report an extremely rare case of purulent pericarditis caused by a strain of the Streptococcus milleri group. In addition, we review 5 previously reported cases of purulent pericarditis caused by strains.

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The standard treatment of inflammatory pseudotumor of the lung is surgical excision. However, little data is available on steroid therapy in patients with the unresectable disease. Here, we report a patient with recurrent inflammatory pseudotumor of the lung with pleural involvement who had been successfully treated with corticosteroid eleven years previously. Like the previous treatment, retreatment with corticosteroid proved to be effective for the recurred lesion. In addition, the patient had developed extramammary Paget's disease and bladder cancer after the initial onset of inflammatory pseudotumor. Steroid therapy could be an optional modality in treating unresectable inflammatory pseudotumor, although long-term follow-up is definitely necessary.

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Gabapentin (GBP) is a drug which is frequently used in diabetic neuropathy. Common adverse effects of GBP include drowsiness, dizziness, ataxia, somnolence, and fatigue. Rhabdomyolysis is an extremely rare side effect of GBP. In this report we describe a case of GBP-induced rhabdomyolysis in a 63-year-old diabetic woman. She presented with severe muscle pain in her extremities, fatigue, decreased urine output and urine discoloration within 3 weeks after starting treatment with GBP (900 mg/day) for diabetic neuropathy. Laboratory tests revealed extreme elevations of muscle enzymes, increased creatinine and potassium levels. She required hemodialysis as a result of anuria. Investigation confirmed the diagnosis of rhabdomyolysis, and discontinuation of GBP resulted in resolution of clinical and biochemical features of rhabdomyolysis.

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Azithromycin (AZM) is widely used for respiratory tract infections and otitis media because of its activity against Haemophilus influenzae and atypical pathogens, and its ease of administration. Although leukopenia is the one of the most frequent AZM-related laboratory abnormalities in children, agranulocytosis has not been reported in adults. Here, we present the case of an 81-year-old man with agranulocytosis following AZM-treatment for acute otitis media. He developed febrile neutropenia and granulocyte colony-stimulating factor and cefepim were administered. All his symptoms and absolute neutrophil counts were recovered within 7 days after admission. Physicians must be vigilant in identifying drug-induced neutropenia in AZM-treated patients because early detection can decrease the severity and prevent mortality.

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Cogan's syndrome is characterized by non syphilitic interstitial keratitis and Meniere's syndrome-like audiovestibular function disorder, as well as various systemic manifestations, including fever, arthralgia, vasculitis, and aortitis. We report the case of atypical Cogan's syndrome with aortitis; the patient's symptoms caused by active inflammation, including inflammatory ocular manifestations, audiovestibular symptoms, and aortitis, were improved by early administration of corticosteroids, however, her reduced visual acuity was not improved because of post-inflammatory change in her left eye.

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We present a case of infective endocarditis associated with community-acquired Streptococcus agalactiae in an immune competent patient. The endocarditis affected the native aortic valve with perforation of the coronary cusp and was complicated by a cerebral embolism. The use of intravenous ampicillin produced a satisfactory clinical and echocardiographic recovery despite not receiving a valve replacement. In addition to reporting an extremely rare case, this paper confirms that the opportune identification of endocarditis caused by S. agalactiae and the selection of appropriate antibiotics can prevent the necessity of cardiac surgery, usually required in such cases.

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Lopinavir, an antiretroviral drug against human immunodeficiency virus (HIV), was administered through various routes to an HIV-infected patient with duodenal malignant lymphoma. Antiretroviral drugs were first administered through a jejunal tube, and then through bypass route between the stomach and jejunum that was 20 cm distal from the ligament of Treitz after surgery. Oral administration through the bypass achieved sufficient serum concentrations of lopinavir, whereas administration through the jejunal tube did not.

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A 78-year-old woman was admitted for severe heat stroke with brain damage. She was unconscious on arrival at the emergency room. Her armpit temperature was 42.0°C and blood pressure was 76/25 mmHg. She was rapidly cooled and given intensive treatment. On magnetic resonance imaging, T1- and T2-weighted images showed no significant signals, but diffusion-weighted images demonstrated localized symmetrical injuries of the cerebellum and thalami. She gradually became conscious, but severe cerebellar ataxia persisted.

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