Objective To determine the effect of Helicobacter pylori (H. pylori) eradication on blood levels of soluble CD40 ligand, leptin, oxidative stress and body composition in patients with dyspepsia infected with H. pylori.
Methods The infection of H. pylori was based on the presence of both ¹⁴C urea breath test (UBT) and histology. Patients were given triple eradication therapy for 14 days and at 3 months after the treatment, ¹⁴C UBT was reinstituted. Fasting glucose, leptin, body composition, soluble CD40 ligand, total oxidant status (TOS) were studied before and at 3 months after the treatment.
Results In 33 subjects, H. pylori infection was successfully eradicated. sCD40L, and TOS levels were significantly decreased after H. pylori eradication. The percentage of body fat and body fat mass significantly decreased whereas the fat free mass (FFM) increased after eradication. However, eradication of the organism yielded no differences in leptin levels.
Conclusion These findings suggest that H. pylori eradication reduces the sCD40L and oxidative stress, fat mass with a significant increase in fat free mass. Thus, eradication of H. pylori infection not only improves ulcer healing, but may also reduce the presumed atherosclerosis risk.

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Objective Tuberculosis (TB) in patients undergoing hemodialysis (HD) for end-stage renal disease (ESRD) is commonly thought to be associated with a very poor prognosis. Moreover, it is difficult to diagnose. This report was designed to describe this condition and to determine the mortality rate and risk factors associated with mortality. In addition, the study evaluated the usefulness of QuantiFERON TB-2G^® (QFT-2G).
Methods Retrospective study
Patients Patients with confirmed TB admitted between January 2001 and May 2009 were retrospectively identified and enrolled. The clinical, radiological, and bacteriological data at the time of admission were recorded. A multivariate analysis was performed to identify the predictive factors for mortality.
Results A total 19 TB patients (6 females; median age, 73 years) were included. TB occurred in most cases within 1.3 years from the initiation of dialysis. Most patients presented with fever (84.2%) and extrapulmonary TB (57.9%). The mortality rate within 24 weeks of the initiation of TB treatment was 36.8%. The factors associated with mortality were: a short duration of dialysis (HR 8.86, 95% CI 1.03-75.7, p=0.04), and underweight (HR 10.88, 95% CI 1.28-92.6, p=0.02). The sensitivity of QFT-2G, acid-fast smear, and polymerase chain reaction was 50, 80, and 88.2% respectively.
Conclusion These data indicate a high incidence of TB in the early stages of HD and a high mortality rate among these patients. The clinical utility of QFT-2G was found to be limited. Hypoalbuminemia might therefore be related to either indeterminate or negative results of QFT-2G.

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Background Moxifloxacin-based triple therapy has been suggested as an alternative first line therapy to clarithromycin-based triple therapy for Helicobacter pylori infection.
Aims To systematically review the efficacy and tolerance of moxifloxacin-based triple therapy, and to conduct a meta-analysis of studies comparing this regimen with clarithromycin-based triple therapy.
Methods A search of The Cochrane Library, PUBMED, EMBASE, EBM Review databases, Science Citation Index Expanded, and CMB (Chinese Biomedical Literature Database) was performed. Randomized controlled trials comparing moxifloxacin-based triple therapy to gold standard triple therapy in the first-line treatment of Helicobacter pylori infection were selected for meta-analysis. Relative risk was used as a measure of the effect of the two above-mentioned regimens with a fixed-effects model using the methods of DerSimonian and Laird.
Results Four randomized controlled trials totaling 772 patients were included. The meta-analysis showed that the mean eradication rate was 84.1 (318/378) in the moxifloxacin-based triple therapy group and 73.6 (290/394) in the clarithromycin-based triple therapy group; there was statistical significance between the two groups (RR, 1.13; 95% CI, 1.01, 1.27; P=0.04). There were no statistically significant difference in the overall side effects (RR, 0.61; 95% CI, 0.25, 1.48; P<0.28).
Conclusions Moxifloxacin-based triple therapy is more effective and does not increase the incidence of overall side effects compared to clarithromycin-based triple therapy in the treatment of H. pylori infection.

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Background During tube exchange for percutaneous endoscopic gastrostomy (PEG), a misplaced tube can cause peritonitis and death. Thus, endoscopic or radiologic observation is required at tube exchange to make sure the tube is placed correctly. However, these procedures cost extensive time and money to perform in all patients at the time of tube exchange. Therefore, we developed the "sky blue method" as a screening test to detect misplacement of the PEG tube during tube exchange.
Methods First, sky blue solution consisting of indigocarmine diluted with saline was injected into the gastric space via the old PEG tube just before the tube exchange. Next, the tube was exchanged using a standard method. Then, we checked whether the sky blue solution could be collected through the new tube or not. Finally, we confirmed correct placement of the tube by endoscopic or radiologic observation for all patients.
Results A total of 961 patients were enrolled. Each tube exchange took 1 to 3 minutes, and there were no adverse effects. Four patients experienced a misplaced tube, all of which were detectable with the sky blue method. Diagnostic parameters of the sky blue method were as follows: sensitivity, 94% (95%CI: 92-95%); specificity, 100% (95%CI: 40-100%); positive predictive value, 100% (95%CI: 100-100%); negative predictive value, 6% (95%CI: 2-16%).
Conclusion These results suggest that the number of endoscopic or radiologic observations to confirm correct replacement of the PEG tube may be reduced to one fifteenth using the sky blue method.

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Perivascular epithelioid cell (PEC) is a unique cell which expresses both myogenic and melanocytic markers, and forms PEComa. A 36-year-old woman presented with a 35 mm-diameter liver tumor. MRI showed poor fat component in the tumor. Contrast-enhanced ultrasonography using the newly developed enhancing reagent, Sonazoid, clearly demonstrated early-phase enhancement of the tumor and rapid drainage of the reagent to veins, suggesting a PEComa. Lateral segmentectomy of the liver was performed. Histologically, epithelioid tumor cells around the vessels were immunostained with both HMB-45 and α-smooth muscle actin, confirming the diagnosis of PEComa. No recurrence has been found for 18 months following the operation.

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Autoimmune pancreatitis (AIP) sometimes forms a pancreatic mass lesion, which is often difficult to distinguish from pancreatobiliary malignancy, however it generally responds to steroid therapy. A 70-year-old man was referred to our institute with the suspected diagnosis of pancreatic cancer due to a mass lesion detected at the pancreatic head. Various images demonstrated an ill-defined mass at the enlarged pancreatic head with focal narrowing of the main pancreatic duct. Serum antinuclear antibody (ANA) was negative (x40 dilution) on the onset. Forceps biopsy from the narrowed pancreaticobiliary duct and fine-needle aspiration biopsy under endoscopic ultrasonography (EUS-FNAB) ruled out pancreatobiliary malignancy. Steroid therapy was started at 40 mg per day but was not effective according to subsequent image analyses. Repeated EUS-FNA from the pancreatic mass was performed but was again negative for carcinoma. Seven months later, under steroid-off condition, still no response was recognized in the clinical image but the titer of serum ANA was increased to be positive (x80), satisfying the criteria of AIP in Japan (2006). Although very rare, this is a case meeting Japanese criteria of AIP after withdrawal of steroid without response to steroid in the clinical images, suggesting the necessity of careful follow-up.

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Diffuse liver infiltration by melanoma of unknown primary origin is rare. We encountered a unique case of diffuse liver infiltration by melanoma of unknown primary origin in our hospital. A 62-year-old woman was referred to our hospital for anorexia of 6 months duration and abdominal distension for 1 month. Ultrasonography (US), computerized tomography (CT) and magnetic resonance imaging (MRI) revealed an obvious enlarged liver without detectable nodules. She was diagnosed as liver metastasis by melanoma of unknown primary origin via percutaneous liver biopsy. The report demonstrates the difficulty of making a noninvasive diagnosis of diffuse hepatic infiltration on metastatic melanoma.

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Although chemotherapy for cholangiocellular carcinoma (CCC) is administered to those patients who are inoperable, the results are largely disappointing, especially for CCC producing parathyroid hormone-related peptide (PTHrP). We encountered a 43-year-old man with hypercalcemia due to PTHrP secretion of CCC. As the tumor was inoperable, we treated him with gemcitabine (GEM), S-1 and radiation. The tumor size was reduced 55% and the serum PTHrP level decreased markedly after the chemoradiotherapy. Although the patient died after 14 months, this case clearly suggests that the combined chemoradiotherapy of GEM, S-1 and radiation, may be useful for the treatment of CCC producing PTHrP.

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A 56-year-old man under right ventricular pacing for atrial fibrillation and bradycardia had congestive heart failure. He received a cardiac resynchronization pacemaker with a defibrillator. Four months later, follow-up transthoracic echocardiography showed a right atrial mass although he had no symptom. Transesophageal echocardiography showed a large immobile round-shaped mass on the defibrillation lead, which was attached to the free wall of the right atrium. One month after the initiation of anticoagulant therapy, the mass disappeared, suggesting that it was thrombotic. During the 5 month follow-up, he remained in good condition without the recurrence of right atrial thrombosis.

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Insulinoma is the most common cause of endogenous hyperinsulinemic hypoglycemia in adults. However, the coincidence of insulinoma and diabetes is extremely uncommon. We describe a rare, but very interesting case of diabetes mellitus which was masked by insulinoma and was overtly manifest after the removal of the insulinoma.

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A 62-year-old man presented with clinical signs of acute abdominal pain and adrenal insufficiency. Computerized tomographic scans revealed bilateral adrenal tumors and the left adrenal tumor was surgically resected. The patient was found to have retroperitoneal mesothelioma presenting as bilateral metastatic adrenal tumors, which were well controlled by systemic chemotherapy with CDDP and 5-FU. This case appears to be the first reported case in the literature of adrenal failure due to bilateral adrenal infiltration caused by retroperitoneal malignant mesothelioma.

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Hemodialysis patients are at an increased risk of bleeding due to the platelet dysfunction caused by uremia and the use of anticoagulants during dialysis. Spontaneous spinal hematoma is a rare disorder as a complication in hemodialysis patients. Also it includes the hematoma secondary to coagulopathy, vascular malformation and hemorrhagic tumors. Here, we report the case of 77-year-old woman who presented with spinal cord compression due to spontaneous spinal epidural hematoma associated with hemodialysis. When an end-stage renal disease patient suffers from back pain and neurological deficits, the clinician should be alerted for the spontaneous spinal epidural hematoma as well as cerebrovascular events.

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A 54-year-old woman was transferred to our hospital with disseminated intravascular coagulation, and was treated with heparin. On hospitalization day 13, she developed lower abdominal pain and mass followed by circulatory shock. She became oliguric and laboratory tests showed serum creatinine of 3.5 mg/dL and hemoglobin of 7.4 g/dL. Computed tomography showed hematoma in the left rectus sheath, compressing the urinary bladder exteriorly, which resulted in worsening of bilateral hydronephrosis. Conservative treatment resulted in resolution of the rectus sheath hematoma and improvement of renal function. Rectus sheath hematoma can be treated conservatively without surgical intervention even in complicated cases.

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Bilateral phrenic nerve paralysis (BPP) is a relatively rare disease manifested by slight dyspnea at rest and on exertion in the sitting and standing positions and by dyspnea in the supine position. A 67-year-old man, who was a painter presented with severe pain in both shoulder regions that had evolved into orthopnea and forced him to sleep in a sitting position at night. Dyspnea and paradoxical respiratory movement in the supine position raised suspicions of BPP. The most striking feature in this case was that the rapid onset of pain in both shoulder regions was followed by BPP. The BPP was considered to be secondary to neuralgic amyotrophy (NA).

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Patients with acquired immune deficiency syndrome (AIDS) are susceptible to secondary malignant tumors. Among those malignancies, the increased incidence of germ cell tumor (GCT) in patients with AIDS has recently been documented in Western countries, while that is still rare in Japan. Here, we report a man patient with advanced GCT (seminoma) complicated with AIDS who was continuously treated with highly active antiretroviral therapy (HAART). A partial response was obtained after resection of the primary left testis and three courses of chemotherapy. During the clinical course, he contracted unexpected gastric bleeding that made it impossible to take HAART agents and prophylactic agents for opportunistic infection. Thereafter, he suffered from a severe pulmonary infection and consequently died of severe respiratory failure. The lymphopenia related to both chemotherapy and AIDS synergistically rendered this patient immunoincompetent and thus he suffered from this fatal pulmonary infection. The recent progress in AIDS treatment has been reported to prolong the survival of tumor-bearing AIDS patients, especially GCT-bearing AIDS patients. Because of the current increase in the number of AIDS patients in Japan, it is important to report the present case which indicated that careful chemotherapy against GCT with strict management of the immunoincompetence can provide a good prognosis for GCT-bearing AIDS patients.

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We performed 3T magnetic resonance angiography (MRA) during a spontaneous migraine attack. The patient was a 42-year-old woman migraineur diagnosed by the IHS criteria. The change of the middle meningial artery (MMA) was measured on the axial brain images using MATLAB for three phases (attack-free period, during an attack, a period after medication). There were no dramatic changes of vasodilation in the MMA during the attack (2.0 mm), attack-free period (diameter 1.9 mm), or period after medication (1.7 mm), resembling extrapolations of observations in experimental animal models. This finding suggests that the dramatic vasomotion might not be associated with migraine pathophysiology.

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We present the case of a comatose patient with acute large infarction of posterior cerebral and cerebellar areas and severe hyperthermia (max. 40.4°C). Angiography demonstrated four-vessel occlusion of the main cerebral arteries, suggesting the possibility that both internal carotid and left vertebral arteries were already occluded and he became unconscious following additional occlusion of the right vertebral artery. Autopsy findings revealed bilateral ischemic damage of the hypothalamus in addition to the above infarct areas. Sudden ischemic involvement of both hypothalamic regions may have caused the extremely high fever in this case.

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Short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) is a rare primary headache syndrome. The diagnostic criteria include attacks of unilateral orbital, supraorbital or temporal stabbing pain accompanied by one of the following: conjunctival injection and/or tearing, nasal congestion and/or rhinorrhea, and eyelid edema. The duration of pain is 2 seconds to 10 minutes, and the frequency of attacks is described as once a day or more. The etiology and pathology of SUNA has yet to be documented. We report an 18-year-old man with SUNA. Lomerizine hydrochloride which is used as a preventive medicine for migraine, improved his headaches.

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We report a case of cytomegalovirus (CMV) pneumonitis that presented as a cavitary lung lesion in a patient with systemic lupus erythematosus receiving immunosuppressive treatment. The lesion was confirmed by positive polymerase chain reaction (PCR) for CMV in bronchoalveolar lavage fluid (BALF) and CMV antigenemia. PCR for CMV in BALF was demonstrated to be useful for the diagnosis of CMV pneumonitis on the basis of high sensitivity and specificity. After initiating ganciclovir, the lesion gradually regressed. A cavitary lung lesion associated with CMV is extremely rare. This presentation suggests that the differential diagnosis of cavitary lung lesion in immunocompromised individuals should include CMV.

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