Objective We investigated the risk of upper gastrointestinal (UGI) bleeding and the protective effect of concomitant anti-secretory drugs during dual antiplatelet therapy administered following implantation of drug-eluting stents (DES) for coronary heart disease. Because proton pump inhibitors (PPIs) are reported to decrease the platelet inhibitory effects of clopidogrel, we also assessed cardiovascular outcomes in patients taking thienopyridine derivatives with or without anti-secretory drug.
Methods We retrospectively analyzed 243 patients, who underwent DES implantation between January 2006 and December 2007 and were receiving dual anti-platelet therapy post-surgery. The main outcome measurement was the presence of UGI bleeding. Cardiovascular outcomes were assessed by follow-up coronary angiography (CAG) findings. Data were collected from medical records.
Results Eight cases of UGI bleeding were observed during the follow-up period, none of whom were taking anti-secretory drugs. Among the 243 cases, 108 cases were taking anti-secretory drugs: a PPI (67 cases), and an H2 receptor antagonist (41 cases). No UGI bleeding was observed among patients who were taking concomitant anti-secretory drugs. The 1- and 2-year cumulative incidences of UGI bleeding among patients who were not taking anti-secretory drugs were 4.5% and 9.2%, respectively. When CAG findings were compared between patients not taking any anti-secretory drug, taking PPI, or taking H2RA, significantly more stenotic lesions of the coronary artery were observed in the PPI-treatment group.
Conclusion Concomitant use of an anti-secretory agent was associated with a reduced risk of UGI bleeding. Use of PPI may be associated with an attenuation of the effect of dual antiplatelet therapy.

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Objectives We investigated the significance of urinary liver fatty acid-binding protein (U-L-FABP) monitoring during cardiac catheterization in patients with cardiovascular disease (CVD).
Methods The subjects included 27 consecutive patients with stable angina (SAP group) or acute coronary syndrome (ACS group) who had undergone successful percutaneous coronary intervention (PCI), and 12 patients were also enrolled as controls (C group). Urinary and serum parameters were measured immediately before and after and 1 day after PCI.
Results The ratio of U-L-FABP to U-creatinine (U-Cr) (U-L-FABP/U-Cr) in the ACS group was significantly higher than those in both the SAP and C groups before PCI. In addition, none of the patients in the SAP group showed contrast-induced nephropathy (CIN) based on the levels of serum (S)-Cr and U-L-FABP/U-Cr after PCI. Although none of the patients in the ACS group showed CIN according to S-Cr, the level of U-L-FABP/U-Cr was continuously high throughout the study period. Moreover, since there were significant differences in U-L-FABP/U-Cr, U-N-acetyl-β-D-glucosaminidase, S-uric acid and % medication with calcium channel blockers before PCI between the ACS and SAP groups, a multiple regression analysis was performed using these parameters. It showed that U-L-FABP/U-Cr was most closely associated with the classification of SAP and ACS (p<0.0001). The cut-off level for the greatest sensitivity and specificity for U-L-FABP for the diagnosis of ACS was 13.4 μg/g· Cr in all subjects (sensitivity 0.800, specificity 0.963).
Conclusions To the best of our knowledge, this is the first report incicating that the measurement of U-L-FABP can be beneficial for in the diagnosis of ACS.

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Background and Purpose We investigated which factors influence pre-hospital delay after the onset of stroke and transient ischemic attack (TIA).
Methods A total of 113 patients with ischemic stroke or TIA who were directly transported to the emergency room within 24 hours of onset were entered into the study. We analyzed factors relating to an early arrival at hospital (≤2 hours), and factors relating to an early emergency call (≤1 hour).
Results The interval between symptom onset and arrival at hospital was within 2 hours in 75 (66%) patients. The interval between symptom onset and call to emergency was significantly related to arrival within 2 hours (p<0.001), whereas time (p=0.09) and distance (p=0.32) for transportation were not. The interval between onset and emergency call was within 1 hour in 68 patients (60%). The presence of a bystander (Odds ratio 3.68) and consciousness disturbance (Odds ratio 2.49) were independently related to an early emergency call.
Conclusion An early emergency call is essential for the timely admission of stroke patients into a hospital. The presence of a bystander and consciousness disturbance are keys to an early emergency call.

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In 2008, 1,007 cases of suicide in which hydrogen sulfide was used as a suicidal agent were reported in Japan, and this has become a serious social problem. Here, we report the successful revival of a patient suffering from a severe disturbance of consciousness and respiratory failure caused by hydrogen sulfide poisoning; further, his condition was complicated by myocardial infarction. This is an important case where we examined the tendency toward improvement in myocardial damage in a patient in the acute phase of severe hydrogen sulfide poisoning who was treated for approximately 6 months.

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Good syndrome, characterized by hypogammaglobulinemia and acquired immunodeficiency, is a rare condition associated with thymoma. A 67-year-old woman, who 4 months previously had a thymoma resected, presented with generalized hypogammaglobulinemia with a severely decreased B cell population as demonstrated by flow cytometry. She was diagnosed as having bacterial mediastinitis associated with Good syndrome. For the subsequent 6 years, she suffered from repeated serious bacterial infections. As this paraneoplastic syndrome is not resolved by tumor removal, careful management with intensive infection-control using antibiotics and intravenous immunoglobulins is required for the long term. Serum immunoglobulin levels should be evaluated for patients with thymoma and suspected vulnerability to infection.

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A 53-year-old man, who had a history of angina treated by percutaneous coronary intervention without allergic reaction to contrast and coronary bypass surgery, was hospitalized due to epigastralgia and tarry stool. During an enhanced computed tomography for the evaluation of abdominal diseases, he became hypotensive and had chest pain. To diagnose acute coronary syndrome, coronary angiography (CAG) was performed after the intravenous administration of hydrocortisone. He became hypotensive again during the CAG, which revealed significant coronary artery stenosis in the right coronary artery. Despite the intensive medical treatment, he had angina even while walking in the ward. By using an intravascular ultrasound for coronary stent implantation and the second wire as a marker for the stent implantation, we performed coronary interventional procedures successfully for this patient without the use of iodinated contrast media.

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A 52-year-old man noted distal dominant slowly progressive muscle weakness at age 36 years. On muscle CT, the red muscles of the soleus, anterior tibial and paraspinal muscles, where type 1 fiber is known to predominate, were almost totally replaced by fat tissue while quadriceps femoris, gastrocnemius and upper extremity muscles were relatively spared. Quadriceps muscle biopsy revealed multi-minicores in addition to occasional larger cores, in about 70% of the type 1 fibers. A novel heterozygous nucleotide change c.5869T > A (p.S1957T) was identified in RYR1. Although pathogenicity was not confirmed, this nucleotide change was absent in 100 control DNA. We did not find a mutation in either multi-minicore disease-associated gene, SEPN1, or major distal myopathy-related genes, including GNE, ZASP, MYOT, exons 32-36 of MYH7, and the last exon of TTN. This is probably a unique form of distal myopathy characterized by the presence of multi-minicores with preferential involvement of type 1 fibers.

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This report describes the rare case of a 72-year-old woman with spinal cord infarction who presented with persistent diaphragmatic paralysis. Her neurological examination showed tetraplegia, sensory loss to pain and thermal stimulations, and paradoxical abdominal movement. Chest X-ray and diaphragmatic fluoroscopy revealed absent diaphragmatic movement. A cervical magnetic resonance image showed bilateral anterior spinal cord lesions from the level of the second to the fifth cervical vertebrae. Diaphragmatic paralysis should be recognized as a clinical sign of cervical spinal cord infarction. Particular attention must be given to paradoxical abdominal movement during respiration in this disorder.

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In September 2008, an outbreak of aseptic meningitis caused by echovirus 30 occurred in Ota City, Gunma. Among the 26 people hospitalized, 17 were members of a high school baseball club. The attack rate within the club was as high as 40%. The other 9 patients were either their families or close relatives of the baseball club members, indicating the outbreak was confined to a limited community. Although numerous outbreaks of echoviral meningitis have been reported worldwide, those with such a high attack rate within a limited community are rare. Severe physical exercise in a hot temperature could be associated with this high attack rate.

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Cardiac complications from brucellosis are unusual and usually manifest as endocarditis. The other possible complication is myocardial involvement. Brucella myocarditis and development of heart failure is a very rare complication of brucellosis. We present a patient with new onset heart failure due to brucella myocarditis treated with favorable antibiotic therapy.

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This article has been retracted due to a violation of the journal's "Information for Authors".

Editor in Chief
Internal Medicine

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