Objective The aim of this study was to evaluate the efficacy of combination therapy of natural human interferon-beta and ribavirin in patients infected with hepatitis C virus (HCV) genotype 1b.
Methods Inclusion criteria were HCV-genotype 1b, serum HCV RNA level of ≥100 KIU/ml before the initiation of treatment. A total of 40 patients were enrolled in this retrospective cohort study. The treatment period of combination therapy was 48 weeks. Nonparametric procedures were employed for the analysis of background features of the patients with SVR and without SVR. A p value of <0.05 was considered to indicate a significant difference.
Results Of the 40 study patients, ten had mental disorders before the initiation of combination therapy. One of the patients stopped the treatment due to exacerbation of depression and another patient stopped due to a skin rash. Three patients suspended the therapy due to an insufficient response of positive serum HCV RNA at 24 weeks after the initiation of treatment. Thus, 34 patients completed combination therapy. Fifteen had sustained virological response (SVR). The SVR rate in patients who showed negative HCV RNA 8 weeks after the initiation of combination therapy was 86.7% (13/15). On the other hand, the SVR rate in patients who showed positive HCV RNA at 8 weeks was 8% (2/25) (p<.001). Continuous period of negative serum HCV RNA was 33.1 weeks in SVR groups, and 12.5 weeks in non-SVR groups (p<.001).
Conclusion The combination therapy of IFN-beta and ribavirin is a possible therapy selection for patients with type C hepatitis of genotype 1b and high virus load.

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Objective The aim of this study was to evaluate the efficacy of combination therapy of natural human interferon-beta and ribavirin in patients infected with hepatitis C virus (HCV) genotype 2 and high virus load.
Methods Inclusion criteria were HCV-genotype 2, serum HCV RNA level of ≥100 KIU/mL before combination therapy. A total of 24 were enrolled in this retrospective cohort study. The treatment period of combination therapy was 24 weeks.
Results Of the 24 study patients, no patient stopped the treatment due to treatment-related adverse events. The dose of drugs were reduced in 8 patients. Twenty-one of 24 patients (87.5%) had sustained virological response (SVR) by the intention to treat analysis. The rate of negative HCV RNA at 8 week after the initiation of treatment was 18/21 (86%) in patients with SVR and 1/3 (33%) in patients with non-SVR. Logistic regression analysis showed that SVR occurred when serum HCV RNA at 8 week after the initiation of combination therapy was negative (hazard ratio: 40.0; 95% confidence interval=1.75-914.78; p=0.021)
Conclusion The combination therapy of IFN-beta and ribavirin offers sufficient safety and efficacy in chronic hepatitis C patients with genotype 2 and high virus load.

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Background Bullous pemphigoid (BP) is an autoimmune subepidermal blistering disorder. It is rare in the general population but the prevalence was reported to be relatively high among the elderly in nursing homes. The aim of the study was to analyze the clinical characteristics and risk factor for BP in elderly patients with a long hospital stay.
Methods This was a retrospective survey with 36 hospitalized patients, aged 64 to 101 years, staying more than 2 years from July 2005 to April 2009. We encountered 5 newly occurring BP cases during this survey period and the remaining 31 patients were non-BP cases. All of these subjects were disabled elderly patients because of cerebral stroke, etc. We assessed the clinical variables as follows: age, sex, underling disease of hospitalization, length of hospital stay, feeding method, medication, tracheal tube indwelling and frequency of death and compared these 2 groups.
Results All of the patients underwent enteral feeding by percutaneous endoscopic gastrostomy (PEG) or nasogastric (NG) tube. In the univariate analysis, PEG and tube feeding (PEG and NG) were associated with BP (p<0.05). The multivariate logistic and Cox proportional hazard regression analysis were performed with age, sex (elderly female is well known feature of BP) and PEG or tube feeding, demonstrating only PEG was significantly and independently associated with BP (p<0.05).
Conclusion We found that PEG was significant risk factor for BP. Since the sample size was small in this survey, further study is required. Greater awareness of BP is needed for physicians managing institutionalized elderly patients with PEG.

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Objective Adiposity is closely associated with the clustering of metabolic risk factors such as high blood pressure, dyslipidemia, and glucose intolerance. Waist circumference and body mass index (BMI) are the established markers of abdominal adiposity and general adiposity, respectively. However, it has not been examined whether these two markers can detect the clustering of metabolic risk factors in Japanese subjects.
Methods and Results We studied 5,796 Japanese middle-aged subjects aged 40-60 years (4,344 males and 1,452 females). Metabolic risk factors including high blood pressure, dyslipidemia, and glucose intolerance were identified according to the diagnostic criteria for metabolic syndrome in Japan. The number of metabolic risk factors was significantly associated with the BMI values in both male and female subjects. The prevalence of subjects with multiple (two or more) metabolic risk factors was 29.4% and 7.6% in males and females, respectively. According to receiver operating characteristic (ROC) analysis, the area under curve values of BMI and waist circumference did not differ in male (0.658 vs. 0.671, p=n.s.) and female (0.776 vs. 0.790, p=n.s.) subjects, indicating that the waist circumference as well as the BMI could be useful in detecting the occurrence of multiple metabolic risk factors. The appropriate cut-off values of BMI to predict the presence of multiple metabolic risk factors were 24.7 and 23.4 kg/m² in males and females, respectively. The sensitivity and specificity using these cut-off values were 58 and 65% in males and 65 and 77% in females, respectively.
Conclusion The BMI values can similarly predict the presence of multiple metabolic risk factors just as the waist circumference in Japanese middle-aged subjects.

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Objective We investigated the role of family support in glycemic control by nutritional self-care behavior of Japanese patients with type 2 diabetes.
Methods One hundred twelve Japanese out-patients with type 2 diabetes were recruited for the study at Kansai Electric Power Hospital. Interviews were conducted and HbA1c and triglyceride levels were measured.
Results HbA1c levels were significantly related to family nutritional support. Patients under 60 years old with family nutritional support showed significantly lower HbA1c than patients without family support (p<0.05). Female patients with family support showed significantly lower HbA1c than those without family support (p<0.05). In addition, male patients with family support showed significantly lower triglyceride levels than those without family support (p<0.05). In male patients, those who were supported by cooking or buying light meals showed significantly lower HbA1c than those who were supported by advice or encouragement (p<0.05). The frequency of support (every day, 2-3 days, 1 week) showed similar outcomes in glycemic control. Patients who appreciate the support and follow the advice showed lower HbA1c (6.88 ± 0.22%) than (7.43 ± 0.23%) patients who appreciate the advice but sometimes feel emotional barriers.
Conclusion Family nutritional support is useful in improving metabolic outcome of diabetic patients. Self-care practice in disease management should be carefully adjusted to the family setting of type 2 diabetic patients. Emotional barriers to family support may affect the metabolic consequences, especially in the Japanese elderly.

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A 33-year-old man presented with pain and palsy of the leg in 2008 for treatment of hepatocellular carcinoma with huge distant metastases. The patient's tumors had slowly enlarged despite several treatments. Oral administration of sorafenib at 800 mg/day with careful observation was commenced in 2009. Laboratory investigations on day 7 showed massive tumor lysis. An abdominal CT showed multiple low density areas and tumor markers decreased, indicating extended tumor necrosis. In conclusion, clinicians should bear in mind not only the published adverse effects, but also massive tumor lysis, when treating patients with large tumor burden by sorafenib.

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A 68-year-old man consulted our hospital because of back pain. A chest computed tomography (CT) demonstrated a high-density foreign body in the esophageal wall. There was no evidence of pneumomediastinum. Endoscopic examination demonstrated a large fish bone that was stuck in the esophageal wall. It was dislodged and moved into the stomach. The bone was excreted through the intestinal tract on the seventh hospital day. Unintentional ingestion of large fish bones must be considered potentially dangerous. Complications such as esophageal perforation or mediastinitis should be confirmed by CT; and then, the esophageal foreign body should be removed as soon as possible.

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Human infection with the parasite Schistosoma japonicum is rarely seen in Japan. Infection with the parasite is currently known to be endemic in China and South-east Asia, and chronic infection leads to the development of liver fibrosis, calcification and portal hypertension. We report a case of Schistosoma japonicum infection complicating infective endocarditis and liver cirrhosis. The non-invasive imaging findings and serological test were helpful to diagnose the infection with the parasite. Since Schistosoma japonicum infection is extremely rare in Japan, the diagnosis and evaluation of the patient's condition was delayed.

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A 25-year-old woman with ulcerative colitis developed heart failure due to severe aortic regurgitation. Although chest X-ray 18 months previously showed a normal cardiac shadow, thoracic aortic aneurysm progressed due to Takayasu arteritis. Aortic valve and ascending aorta replacement were performed successfully, but re-valve replacement for severe aortic regurgitation due to prosthetic valve detachment and aortic root replacement for valsalva sinus rupture were required. Human leukocyte antigen analysis showed B35 and B52, the typical haplotype in cases with coexistence of both diseases and associated sustained inflammation. Close observation and early aortic root replacement were needed in this case.

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Reversible posterior leukoencephalopathy syndrome (RPLS) is one of the important adverse events following organ transplantation, associated with calcineurin inhibitors (CNIs). We describe a case of 54-year-old woman, who was diagnosed with RPLS within weeks after transplantation. Considering the risk of causing fatal rejection by discontinuation of CNIs, the immunosuppressive regimen of the patient was switched from a cyclosporine A-based regimen to a tacrolimus-based regimen. The patient recovered rapidly from RPLS following the switch to tacrolimus. This case demonstrated that not only discontinuation but also a substitution of CNIs would be a valid treatment option for RPLS in transplant recipients.

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We demonstrated a rare case of bilateral aldosteronoma accompanied by secondary aldosteronism in a 37-year-old man with chronic renal failure on hemodialysis. He initially developed immunoglobulin A nephropathy at 11 years old, and had been treated with hemodialysis since the age of 17 years. His blood pressure was 110/68 mmHg, and no other abnormal findings were detected. Laboratory findings revealed that serum potassium was 3.9 mmol/L; plasma renin activity, 4.8 ng/ml/h and plasma aldosterone, 19,000 pg/mL. Abdominal computed tomography revealed bilateral adrenocortical tumors, measuring 34 and 40 mm in diameter in right and left tumors, respectively. ¹³¹I-Adosterol scintigram showed bilateral accumulation. Left adrenalectomy was performed under laparoscopy. The tumor was encapsulated and well-circumscribed. The majority of the tumor was composed of a dark-brown portion admixed with sporadic foci of golden-yellow portions. Hyaline degeneration was detected in its central portion. The tumor was composed of clear cortical cells in viable portions. Tumor cells demonstrated immunoreactivity for the cholesterol side-chain cleavage enzyme, 3β-hydroxysteroid dehydrogenase (3β-HSD II) and 21-hydroxylase, but not 17 α-hydroxylase. In the adjacent non-neoplastic adrenals, 3 β-HSD II was markedly present in the hyperplastic glomerulosa zone. These findings suggest that the presence of secondary aldosteronism, which is closely related to the conditions of chronic renal failure on hemodialysis, eventually promoted the development of bilateral aldosteronoma from the zona glomerulosa hyperplasia.

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Disseminated cryptococcosis infection occurs mainly in the immunocompromised host. There are only a few reports describing disseminated cryptococcosis in immunocompetent patients. Here, we describe the case of a 46-year-old healthy man who presented with primary adrenal insufficiency with hyponatremia, hyperkalemia and skin pigmentation. Contrast-enhanced adrenal computed tomography (CT) revealed bilaterally enlarged adrenal glands without enhancement. CT-guided percutaneous adrenal gland biopsy showed caseous-like necrosis and embedded cryptococcosis. The serum cryptococcal antigen titer was 1 : 512. After ten months of fluconazole treatment, the serum cryptococcal antigen titer remained elevated at 1 : 256 and contrast-enhanced adrenal magnetic resonance imaging revealed continued enlargement of bilateral adrenal glands without enhancement. The patient is currently on a therapeutic regimen of prednisolone, fludrocortisone and fluconazole and is scheduled for regular outpatient follow-up.

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Herein we report a case of a localized, massive, diffuse large B-cell splenic lymphoma diagnosed by splenectomy. A 57-year-old man complaining of weight loss and abdominal pain, was admitted to our hospital. Enhanced computed tomography scanning showed an irregularly enhanced effect in the spleen suggesting a diffuse splenic tumor. Splenectomy was done and the operation progressed without severe complications. The resected spleen weighed 3,500 g. After the operation, the patient recovered from the pancytopenia and pathology diagnosed diffuse large B-cell lymphoma. Standard CHOP plus rituximab chemotherapy was given. Complete remission has continued for 30 months.

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A 69-year-old man was admitted because of macrocytic anemia and peripheral monocytosis: hemoglobin 75 g/L and white blood cells 16.0×10⁹ /L with 22% monocytes. Five years prior, he had received CHOP regimen and radiotherapy for diffuse large B-cell lymphoma. Bone marrow was hypercellular with trilineage dysplasia and 2.4% blasts. Chromosome analysis showed 46,XY,t(1;11)(p32;q23),del(5)(q13q35),+8,inv(9)(p11q13),-15,-21,+mar1. These findings indicated a diagnosis of therapy-related myelodysplastic/myeloproliferative neoplasms (t-MDS/MPN). Fluorescence in situ hybridization revealed that the breakpoint at 11q23 was centromeric to the MLL gene. Taken together with the previously reported cases, trilineage dysplasia and del(5q) without MLL rearrangement suggests that alkylating agents may have a crucial role in the pathogenesis of t-MDS/MPN, which is a rare but recognizable entity.

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Delayed encephalopathy after carbon monoxide (CO) intoxication involves a triad of characteristic symptoms consisting of mental deterioration, urinary incontinence, and gait disturbance. Additionally, while it is not normally associated with involuntary movement, delayed encephalopathy after CO intoxication can also, in extremely rare cases, lead to chorea. We report a patient with delayed encephalopathy due to CO intoxication, suffering from chorea involving a unilateral lower limb, and subsequent cognitive impairment and other extrapyramidal symptoms.

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