Background Non-erosive reflux disease (NERD) is a more difficult to treat than reflux esophagitis (RE) due to the high prevalence of PPI resistance. Consequently, the treatment strategy for NERD is yet to be established.
Patients and Methods Subjects were 467 GERD patients (NERD 349, RE 118, 47.4 ± 16.7 years) with reflux symptoms such as heartburn. PPI was administered for 2 weeks, and total score (TS) of symptoms, seven items of reflux symptoms e.g. heartburn (reflux score: RS), and five items of dyspeptic symptoms e.g. heavy stomach (dyspeptic score: DS) were assessed using the frequency scale for the symptoms of GERD (FSSG), a GERD-specific questionnaire developed in Japan. Improvement <50% in TS was defined as non-responder. Patients' background, and pretreatment TS, RS, DS, and 12 items of FSSG were assessed. Furthermore, the effect of additional prokinetics (4 weeks) for 117 PPI non-response NERD patients was also examined.
Results Younger age, constipation, higher TS, DS, F2 (bloated stomach), 3 (heavy stomach), 5 (sick feeling after meal), 8 (satiety during meal) in FSSG were factors to be PPI non-responders in NERD. Significant improvement in TS were observed (pretreatment: 17.4 ± 7.7 vs. 2 weeks 14.6 ± 6.0 vs. 6 weeks 7.7 ± 5.2, p<0.0001) after the addition of prokinetics in PPI non-response NERD.
Conclusion Younger age, constipation, dysmotility were factors of PPI non-response in NERD. As high DS is correlated with PPI non-response, it is indicated that patients with strong dysmotility and functional dyspepsia complication might be PPI resistant. The efficacy of additional prokinetics for PPI non-response NERD was observed.

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Objective To compare body mass index (BMI), waist circumference (WC), and percent body fat (%BF) as markers for the clustering of metabolic risk factors in Japanese.
Methods Age-adjusted correlation coefficients (Rs) were calculated between the three anthropometric markers of obesity and metabolic risk factors in 2,444 men and 1,442 women among Japanese. Areas under receiver operating characteristic curves (AUCs) of BMI, WC, and %BF were calculated for diagnosing the clustering of 1 or more, 2 or more, 3 or more, and 4 risk factors among increased blood pressure, impaired fasting glucose, increased triglycerides, and decreased HDL cholesterol and for the clustering of 1 or more, 2 or more, 3 or more, 4 or more, 5 or more, and 6 risk factors among the upper four risk factors as well as increased high-sensitivity C-reactive protein and increased LDL cholesterol.
Results The Rs were not significantly different among BMI, WC, and %BF except for the difference between the R of BMI (0.217) and that of %BF (0.283) with LDL cholesterol in men (p=0.014). The AUCs of BMI, WC, and %BF for diagnosing any of the risk factor clustering patterns defined above were not significantly different in both men and women.
Conclusion The AUCs for diagnosing the clustering of metabolic risk factors were not significantly different among BMI, WC, and %BF.

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Objective Hypertensive patients have multiple risk factors such as chronic kidney disease (CKD) and hyperuricemia in addition to components of metabolic syndrome. The morbidity of cardiovascular diseases is expected to increase synergistically by clustering of them. In the present study, we assessed the clustering of cardiovascular risk factors and blood pressure (BP) control status in hypertensive patients.
Methods and Patients Subjects were 699 treated hypertensive patients (mean age: 65 ± 12 years; males 297, females 402) who had been followed at National Kyushu Medical Center, Fukuoka, Japan. We assessed the status of BP control and the presence of comorbidity including obesity, diabetes mellitus (DM), dyslipidemia, CKD and hyperuricemia.
Results Average BP level and the number of antihypertensive drugs were 133 ± 11/74 ± 10 mmHg and 2.0 ± 1.1, respectively and the average number of cardiovascular risk factors was 1.5 ± 1.1. No comorbid risk factors were found in 18.7% of the patients. On the other hand, 34.2%, 28.9% and 18.2% of the patients had one, two or more than three risk factors, respectively. There were no significant differences in BP among these groups, while patients with three or more risk factors needed a greater number of antihypertensive drugs than those with other groups. Patients with three or more risk factors group showed significantly higher body mass index, serum LDL cholesterol, triglyceride, plasma glucose and serum uric acid levels compared to those with other groups (p<0.05, respectively). They also showed significantly lower serum HDL cholesterol and estimated GFR levels compared to those in other groups (p<0.05, respectively).
Conclusion These results suggest that the majority of the treated hypertensive patients are complicated with additional cardiovascular risk factors and the patients with clustering risk factors required a greater number of antihypertensive drugs. Integrative management of BP as well as comorbid risk factors should be encouraged.

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Background Chronic obstructive pulmonary disease (COPD) is characterized by chronic airflow limitation. The prevalence of airflow limitation in Japan is 10.9% (16.4% of males and 5.0% of females). Cigarette smoking is well known as a major cause of COPD. However, few epidemiological studies have evaluated the effects of cigarette smoking on pulmonary function in healthy subjects.
Methods Subjects aged 40 years or older (n=2,917), who had participated in a community-based annual health check in Takahata, Japan, from 2004 through 2005, were enrolled in the study. The smoking histories of these subjects were investigated using a self-reported questionnaire. Forced vital capacity (FVC), forced expiratory volume in 1 second (FEV₁), and forced expiratory flow at 25-75% of FVC (FEF_25-75) were measured by standard procedures using spirometric machines.
Results There were 554 current smokers (18.6%) and 403 former smokers (13.8%). The prevalence of airflow limitation defined by FEV₁/FVC <0.7 in this population was 10.6%, and prevalence of airflow limitation defined by 5th percentile lower limit of normal was 6.4%. In smokers, percent predicted values of measured spirometric parameters (%FVC, %FEV₁ and %FEF_25-75) decreased significantly with age, except for male %FVC. Also, percent predicted values of measured spirometric parameters decreased significantly with increasing pack-years, except for female %FEF_25-75.
Conclusion Cigarette smoking increased the prevalence and severity of airflow limitation. It is concluded that cigarette smoking increases the risk of airflow limitation in a healthy Japanese population.

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Background Pulmonary complications are associated with increased mortality after liver resection. Although noninvasive ventilation (NIV) has proved to be an effective treatment for respiratory failure after abdominal surgery, including organ transplantation, its efficacy for pulmonary complications following liver resection per se has not been reported. The aim of this retrospective study was to investigate the effects of NIV in patients with postoperative pulmonary complications after liver resection.
Methods A retrospective single center study. Between April 2002 and March 2005, we used NIV in 16 patients who met the criteria for NIV after liver resection: respiratory failure and/or a massive atelectasis (NIV group). We also reviewed data on 10 patients who underwent liver resection from April 1999 to March 2002, and met the criteria for NIV after the operation and received conventional treatment (non-NIV group).
Results Respiratory-cause mortality was significantly lower in NIV group than in non-NIV group (0.0% vs. 40.0%, p=0.007), and all-cause mortality tended to be lower in NIV group (18.8% vs. 50.0%, p=0.100). After NIV treatment for 24 hours, the PaO₂/FiO₂ ratio and PaCO₂ were improved significantly but no significant improvement was noted in non-NIV group. Rate of reintubation was significantly lower in NIV group (12.5% vs. 50.0%, p=0.040). NIV was tolerated in all 16 NIV group patients, and no severe NIV-related complications were observed.
Conclusion NIV is effective in patients with respiratory failure and/or massive atelectasis after liver resection.

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Background and Objective The outcome of acute exacerbation of idiopathic pulmonary fibrosis (AE-IPF) is usually very poor, and it has been suggested that mechanical ventilation does not benefit AE-IPF patients. Noninvasive ventilation (NIV) has attracted attention as a means to avoid intubation in acute respiratory failure, including acute respiratory distress syndrome (ARDS). This study describes the outcome of patients with AE-IPF who were treated with NIV.
Methods Patients included in the study were those who fulfilled the criteria for AE-IPF during the periods between April 1998 and June 2004 at Tosei General Hospital, and in whom NIV was introduced. Clinical data were obtained retrospectively from patient records.
Results This study included 11 patients. The initial NIV settings were continuous positive airway pressure (CPAP) mode in 6 patients (mean 10.1±2.5 cmH₂O) and Spontaneous/Timed mode in 5 (mean inspiratory positive airway pressure/expiratory positive airway pressure; 15.0±3.3/10.2±2.9 cmH₂O). Five patients avoided intubation and survived more than 3 months after AE-IPF. Six patients who failed NIV died within 3 months. In these 6 patients, 4 required intubation. The other 2 patients, who refused endotrachial intubation, died without intubation. Median survival time and 3-month survivals after acute exacerbation were 30 days, and 45.5%, respectively.
Conclusion Considering extremely poor prognosis of AE-IPF, our findings suggest that NIV is a viable option for the respiratory management in AE-IPF, and should be studied in a large, well-controlled trial.

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Background It is not known whether stroke patients with intracranial stenosis often have lower extremity atherosclerosis. The aim of our study was to elucidate this issue.
Methods Consecutive stroke patients who had cerebral angiography were prospectively enrolled in this study. Cerebral artery and lower extremity artery stenoses were evaluated simultaneously using conventional angiography. To investigate sub-clinical arteriosclerosis, duplex ultrasonography was performed to assess the maximal intima media thickness (IMT) of the common carotid artery (CCA) and the femoral artery, and the ankle brachial pressure index (ABI) was determined. The patients were classified into three groups based on the cerebral angiographic findings: 1) IS group, with a ≥50% stenosis of the intracranial artery; 2) ES group, with a ≥50% of the extracranial carotid artery; 3) NS group, with no stenosis. We compared the IMT of the CCA and the femoral artery, as well as the ABI, among the three groups.
Results A total of 81 patients (mean age 63 ± 13 years old; 61 males) were enrolled. The prevalence of hypertension was greatest in the ES group. The maximal IMT of the femoral artery was highest in the ES group (ES group, 2.1 ± 1.0 mm; IS group, 1.5 ± 0.7 mm; NS group, 1.7 ± 0.9 mm; p=0.043). The ES group had the lowest ABI (ES group, 1.00 ± 0.24; IS group, 1.11 ± 0.17; NS group, 1.13 ± 0.15, p=0.031).
Conclusion The presence of sub-clinical atherosclerosis of the lower extremity arteries differed between patients with intracranial and extracranial stenosis. The mechanism of atherosclerosis may differ between intracranial and extracranial internal carotid artery.

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Objective Physicians' attire is one important factor to enhance the physician-patient relationship. However, there are few studies that examine patients' preferences for physicians' attire in Japan. We sought to assess patients' preference regarding doctors' attire and to assess the influence of doctors' attire on patients' confidence in their physician. Furthermore, we examined whether patients' preferences would change among various clinical situations.
Methods Employing a cross-sectional design, Japanese outpatients chosen over one week in October 2008 from waiting rooms in various outpatient departments at St. Luke's International Hospital, Tokyo, were given a 10-item questionnaire. A 5-point Likert scale was used to estimate patient preference for four types of attire in both male and female physicians, including semi-formal attire, white coat, surgical scrubs, and casual wear. In addition, a 4-point Likert Scale was used to measure the influence of doctors' attire on patient confidence.
Patients Japanese outpatients consecutively chosen from waiting rooms at St. Luke's International Hospital in Tokyo for one week in October 2008.
Results Of 2,272 outpatients enrolled, 1483 (67.1%) of respondents were women. Mean age of subjects was 53.8 years (SD 16.2 years). Respondents most preferred the white coat (mean rank: 4.18, SD: 0.75) and preferred casual attire the least (mean rank: 2.32, SD: 0.81). For female physicians, 1.4% of respondents ranked the white coat little/least preferred while 64.7% of respondents ranked casual wear little/least preferred. Among respondents who most preferred the white coat for physician attire, perceived hygiene (62.7%) and inspiring confidence (59.3%) were important factors for doctor's attire. Around 70% of all respondents reported that physicians' attire has an influence on their confidence in their physician.
Conclusion This study confirms that Japanese outpatients prefer a white coat. Furthermore, this study strongly suggests that wearing a white coat could favorably influence patients' confidence in the relationship with their physician in all types of practice.

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A 77-year-old man was referred to our hospital for further investigation of pancreatic masses. Imaging studies revealed hypovascular masses in the pancreatic head and body. Total pancreatectomy was performed under the diagnosis of double primary pancreatic carcinomas. Macroscopic examination revealed 3 nodules: one each in the pancreatic head, body, and tail. Microscopically, all 3 lesions showed similar carcinoma cells, which communicated with each other via the intraductal component, indicating a single large tumor. Incidentally, we also identified an adenocarcinoma of the common bile duct (CBD). The final diagnosis was synchronous double cancer involving the whole pancreas and the CBD.

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Benign schwannoma is a very rare confronted entity in the liver. Only a very few cases have been reported in the medical literature. A 56-year-old woman was admitted to our hospital with epigastric pain. In the computed tomography scan a cystic mass was observed in the liver. The mass was resected with a prediagnosis of hydatid cyst; intraoperatively a 15×10×10 cm mass filled with hemorrhagic fluid was found. The histological examination confirmed the diagnosis of a benign schwannoma, proven by verocay bodies and a positive immunoreaction with the neurogenic marker S-100 protein.

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Herbal preparations are widely available and often regarded by the public as harmless remedies for a variety of medical ailments. However, some of these products or their metabolites can cause adverse effects such as liver damage. In this case report a 53-year-old female taking Shou-Wu-Pian for 8 months presented with acute hepatitis. Histopathological assessment of liver tissue obtained by biopsy was consistent with a toxic reaction. Clinical and biochemical resolution was brought about following cessation of the drug. It is important for clinicians to consider Chinese herbal preparations as a potential cause of abnormal liver function test results.

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A 54-year-old woman presented with blepharoptosis, numbness in the lower lip, dysgeusia and pain in the extremities and back. MRI showed marked meningeal thickening and multiple bone lesions accompanying a prominent enhancing effect. CT scan of the chest and abdomen appeared to be unremarkable for primary cancer. She died 3 months after the admission, and postmortem autopsy showed a mass of about 2.5 cm in diameter in the renal medulla. Histological examination including immunohistochemistry confirmed the presence of a collecting duct carcinoma (CDC). This case is of particular interest because it emphasizes the possible fulminate clinical course of a small CDC.

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Pneumatosis cystoides intestinalis (PCI) is a rare condition in which pneumocysts develop in the submucosa or subserosa of the colon. We report herein a case of PCI induced by the alpha-glucosidase inhibitor (αGI) miglitol. There have been 9 recorded cases of PCI induced by other αGIs, but this is the first report of miglitol causing PCI. The PCI lesions in our case were smaller than those induced by voglibose or acarbose. The possibility of PCI should be considered in diabetic patients on αGI therapy who complain of gastrointestinal symptoms, and the gastrointestinal tract should be thoroughly investigated in these patients.

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Fourteen years previously, a 67-year-old man underwent percutaneous coronary intervention (PCI) for proximal left anterior descending artery lesion with a bare metal stent (BMS) for acute myocardial infarction (AMI) and attained an excellent result. Ticlopidine (200 mg) was administered for one month and 100 mg of aspirin was daily has been continued. One year after PCI, coronary angiography showed no restenosis. However, 14 years after PCI, he suffered from AMI due to stent thrombosis. Intracoronary aspiration thrombectomy and implantation of a drug-eluting stent were successful. This report demonstrates evidence of a very late case of stent thrombosis with the use of BMS.

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A 33-year-old woman with anorexia nervosa was admitted because of severe malnutrition. Acute liver injury was observed soon after the beginning of oral intake. She was prohibited from eating for 10 days and treated with parenteral nutrition until liver dysfunction was improved. One week after resuming oral intake, she presented severe hypoglycemic coma along with acute exacerbation of hepatocytic injury. Clinical laboratory data suggest that insufficient gluconeogenesis in acute liver injury was involved in severe hypoglycemia. We should be careful of severe hypoglycemia in patients with anorexia nervosa after resuming oral ingestion when signs of liver damage are detected, although hypoglycemic coma is uncommon in anorexia nervosa.

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A 30-year-old woman had a history of prolactinoma and primary hyperparathyroidism. She was diagnosed as having multiple endocrine neoplasia type 1 with gastrinoma and liver metastases. Octreotide therapy was started and the serum gastrin level decreased immediately. Octreotide continued to suppress gastrin secretion over the next 7 years. The Ki67/MIB1 proliferation index of this tumor was only 0.5 % and somatostatin receptor (SSTR) 2 expression was very strong in both 2002 and 2009. This case suggests the importance of investigating the Ki67/MIB1 index and SSTR expression in patients with metastatic gastrinoma.

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A 61-year-old man presented with central lymphocytic hypophysitis. Initial pituitary MRI imaging was normal, except for loss of the "bright spot" of the posterior lobe. A diagnosis of idiopathic diabetes insipidus was made. Two years later, pituitary gland enlargement with panhypopituitarism was detected. Eight months after commencing a replacement dose of corticosteroid, the pituitary enlargement was reduced in size. These findings resulted in a diagnosis of lymphocytic hypophysitis. In patients with idiopathic diabetes insipidus, it is important to suspect lymphocytic hypophysitis and to perform a long follow-up to repeat endocrinological examinations and pituitary imaging.

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Insulinomas are the most common hormone-producing pancreatic neuroendocrine tumors (NETs), which are usually benign, solitary and small. We describe herein a patient with a giant insulinoma (>10 cm in diameter) with concomitant thyroid tumor as detected by Somatostatin receptor scintigraphy (SRS). A 50-year-old man presented hypoglycemic symptoms 20 years after the first detection of a pancreatic tumor, which was ameliorated by administration of a somatostatin analogue, octreotide. SRS showed abnormal uptake by the insulinoma as well as by the thyroid tumor. RT-PCR and immunohistochemical study revealed abundant expression of somatostatin receptor (SSTR)-1, -2, and -5 in his insulinoma and SSTR-1 and -2 in his thyroid follicular neoplasm. This is a rare case of a slow-growing pancreatic well-differentiated neuroendocrine carcinoma over a long period of time to become a symptomatic giant insulinoma. Furthermore, SRS proves to be a useful tool for localization of insulinoma as well as concomitant thyroid neoplasm with predominant expression of SSTRs.

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Aceruloplasminemia is a rare autosomal recessive disease first reported by Miyajima et al. (Neurology 37: 761-767, 1987); it is clinically characterized by diabetes mellitus, retinal degeneration and neurological abnormalities, such as cerebellar ataxia, extrapyramidal signs and dementia. Aceruloplasminemia is caused by mutations in the ceruloplasmin gene, which results in the absence of serum ceruloplasmin and iron overload in the brain, liver, pancreas and other organ tissues. However, little is known about endocrine diseases associated with aceruloplasminemia. We report herein a case of aceruloplasminemia accompanied by central diabetes insipidus and hypothalamic hypothyroidism.

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We report a case of thrombotic thrombocytopenic purpura (TTP) secondary to antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis treated by rituximab. TTP secondary to ANCA-associated vasculitis is very rare and has a high mortality rate. We employed rituximab and successfully treated TTP secondary to ANCA-associated vasculitis, because standard therapies, such as steroid therapy, intravenous pulse cyclophosphamide, and repeated plasma exchange (PE), did not suppress her disease activity. This is the first report to suggest that rituximab can achieve complete remission of TTP secondary to ANCA-associated vasculitis.

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We report an elderly man with chronic tubulointerstitial nephritis (TIN) showing a high serum immunoglobulin G4 (IgG4) concentration. His serum creatinine (Scr) level had gradually increased from 0.9 mg/dL to 5.6 mg/dL over 18 months. Renal biopsy showed marked IgG4-positive plasma cell infiltration in the interstitium without glomerular abnormalities and IgG4-related TIN was diagnosed. Oral prednisolone reduced his Scr and IgG4 levels immediately. The present case indicates that IgG4-related TIN can not only progress rapidly but also chronically over a long period without significant urinary abnormalities, and we should consider hidden IgG4-related TIN in cases of chronic renal insufficiency.

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We report the pathological findings of the lung after acute respiratory distress syndrome (ARDS), and pulmonary function tests during five years of follow-up. A 39-year-old woman, treated for acute myelogenous leukemia, developed ARDS. She recovered from ARDS but suffered from pulmonary aspergillosis. Her aspergilloma was removed surgically. Her lung function tests and diffusing capacity of the lung for carbon monoxide (DL_CO) improved but diffusion impairment remained five years after recovery. Pathological examination of the resected material showed sclerosis in lobular septa and scattered fibrosis in alveolar ducts except for the aspergillosis. These fibrotic changes may be causally associated with her loss of DL_CO.

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We report an 86-year-old woman who presented with organizing pneumonia (OP) with a positive anti-cyclic citrullinated peptide (anti-CCP) antibodies as the first manifestation of rheumatoid arthritis (RA). She experienced dyspnea, chest X-ray showed diffuse alveolar exudates indicated OP histologically. Although she did not present with articular symptoms initially, anti-CCP antibodies measured for differentiation of RA were positive. Eight months later, she showed representative manifestations of RA. Even though OP following joint involvement is frequent in RA, in rare cases it could be the first manifestation. This is the first case showing OP with a positive result for anti-CCP antibodies as the first manifestation of RA.

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A 73-year-old woman who had been diagnosed with systemic sclerosis was admitted for further examination of bilateral hilar lymphadenopathy. Sarcoidosis was confirmed based on elevated serum levels of angiotensin-converting enzyme, a high proportion of lymphocytes and a high CD4/CD8 ratio in bronchoalveolar lavage fluid, abnormal ⁶⁷Gallium uptake in the mediastinum and noncaseating granulomas in skin biopsy specimens. In addition, high levels of antimitochondrial M2 antibodies and alkaline phosphatase indicated primary biliary cirrhosis (PBC). Here we describe a rare triplex of sarcoidosis, SSc and PBC. Although the etiology of this complex remains unknown, these three diseases might share some pathogenesis.

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Endobronchial metastasis from prostate cancer is a rare neoplasm which metastasizes to the proximal central or subsegmental bronchus, in a bronchoscopically visible range. We present a 72-year-old man with a left superior lobar bronchus mass, intrapulmonary metastases, and bone metastases, mimicking primary lung bronchogenic carcinoma. Increasing tPSA, decreasing fPSA/tPSA level, and prostatic puncture pathology proved prostate cancer. Pathomorphology and immunohistochemistry of the mucosa specimen with P504S, PSA revealed the diagnosis of pulmonary metastases from prostate cancer. The patient was treated by hormonal treatment and chemotherapy. He was in remission thirteen months after diagnosis.

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A 50-year-old man was admitted to our hospital for examination of an abnormal shadow on chest radiography. Computed tomography revealed multiple small nodular shadows in bilateral lung fields, with cavitation in a right S3 lesion that was resected by video-assisted thoracoscopic surgery. Histopathological examination revealed marked proliferation of lymphoid tissue, including many plasma cells that were polyclonal in nature. This case was considered to be pulmonary nodular lymphoid hyperplasia (PNLH). Several residual nodules spontaneously disappeared during the 6 years of follow-up. This was a rare case of PNLH with a resected cavity, followed by spontaneous regression of the remaining lesions.

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McArdle disease is a glycogenetic myopathy caused by a deficit of myophosphorylase inherited in an autosomal recessive pattern. Here, we report a case of McArdle disease in which fatigability was the only subjective complaint. Objective neurological findings were normal except for very mild muscle weakness in limbs and an elevated serum creatine kinase level. Ischemic forearm exercise test showed deficient glycogenolysis. In the muscle biopsy specimen, periodic acid Schiff (PAS) stained subsarcolemmal glycogen was increased and the muscle phosphorylase A activity was decreased. After administration of vitamin B6, fatigability was diminished and ischemic forearm exercise test showed improved glycogenolysis. Vitamin B6 may be beneficial for McArdle disease, especially for its easy fatigability.

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We present a patient of familial amyloid polyneuropathy (FAP) with predominant upper-limb involvement, the pattern of which resembled a mononeuropathy multiplex pattern. Sural nerve biopsy failed to diagnose the disorder, but lung partial resection performed later for other diagnostic purposes suggested FAP. A rare mutation in the transthyretin gene (S50R) was subsequently confirmed. Diagnostic challenges of FAP with atypical clinical presentations, including difficulties in pathological diagnosis, are discussed with a review of the literature.

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We describe two patients with small cortical infarcts, who presented with isolated proximal weakness in one of their legs. These lesions were located in the contralateral precentral gyrus, more medial than the precentral knob, but more lateral than the topmost part of the motor cortex. These clinical findings are consistent with the physiological findings of Penfield and Boldrey, and those of recent activation studies by functional MRI. It is clinically important to pay close attention to the contralateral top of the motor cortex when examining pure motor monoparesis of a proximal part of a lower extremity.

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The secreted frizzled-related proteins (SFRPs) genes are unmethylated in normal colorectal mucosa tissue but abberant methylation profiles can be detected in colorectal cancer (CRC), adenomas, and in aberrant crypt foci. The aim of the current study was to clarify whether SFRP2 methylation and K-ras structural mutation in fecal DNA can be found in stool and tumoral tissues of individuals with fistula-associated mucinous type anal adenocarcinomas (MTAA).Two man patients (68 and 56 years old) were treated for anorectal fistula in the surgical department. Patients were evaluated for clinical findings, tumoural tissue samples were examined histopathologically and DNA from fecal and tumoral tissue samples were isolated. K-ras mutation and promoter hypermethylation of SFRP2 gene in tumoral tissues were assessed by methylation-specific PCR based stripAssay hybridisation technique (Me-PCR) and compared to the healthy controls. Fecal and tumoural tissue samples from both patients were found to be fully hypermethylated profiles for SFRP2 gene and combined point mutations were detected in codon 12 and 13 of K-ras proto-oncogene. The current results showed that the combined effects of somatic mutations in K-ras and epigenetic alterations in SFRP2 genes may play an active role in the development of mucinous type anal adenocarcinoma.

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A 48-year-old HIV-positive woman presented with progressive pain and stiffness of both shoulders and hips. She was given the diagnosis of polymyalgia rheumatica (PMR) due to high erythrocyte sedimentation rate. However, a 1-week course of prednisolone failed to improve her symptoms. She later discovered a breast lump of which histopathological tissue was consistent with a diffuse large B-cell lymphoma. Whole body bone scan revealed multiple bony metastases. The presence of atypical features of PMR and lack of dramatic response to steroids should prompt physicians to raise the probability of differential diagnoses other than PMR, and in particular, malignancy.

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Paragonimiasis is the infestation of lung flukes of the trematode genus Paragonimus. Because the symptoms and radiologic findings of paragonimiasis mimic those of tuberculosis, some patients with paragonimiasis are initially treated for tuberculosis. Although Paragonimus may also reach ectopic sites such as the peritoneum or brain, infection in the skin is rare. To our knowledge, paragonimiasis has not been found in the tip of a finger. We report a case of 39-year-old woman who was belatedly diagnosed as having paragonimiasis with a parasitic migration to the tip of the left little finger after initial misdiagnosis of tubercular serositis.

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Recurrent respiratory papillomatosis (RRP) is an infrequent benign neoplasm commonly involving the upper respiratory tract with laryngeal predilection. The diagnosis and treatment of this disease are challenging due to its nonspecific clinical presentations and recurrent nature. We report here a rare juvenile case of RRP arising in the trachea without laryngeal lesions. Our experiences indicate that a high awareness of RRP and proper consideration in the right clinical context are prerequisites for early diagnosis, and a combination of multiple treatment modalities should be considered as a feasible treatment regimen.

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A 57-year old woman was admitted to our hospital with massive pericardial fluid. Culture of the pericardial fluid was negative, however, Binax NOW^® Streptococcus pneumoniae urinary antigen test was positive in pericardial fluid. 16S rDNA sequencing and PCR for lyt(A) gene of the pericardial fluid sample confirmed the microbiological diagnosis of S. pneumoniae. The patient was treated with surgical drainage and continuous intravenous infusion of penicillin G and its concentration in the serum and pericardial effusion was monitored. Incorporation of molecular methods such as antigen testing and nucleic acid sequencing would benefit the management of infectious diseases especially in culture negative cases.

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Group A streptococcal endocarditis has been described in intravenous drug misusers and as a post-varicella infection in children.
We report a 64-year-old man with no prior risk factors who presented with a persistent fever, malaise, polyuria and cola-colored urine. On examination peripheral stigmata of endocarditis without a cardiac murmur and asymptomatic pharyngeal exudates were found. Blood and urine analysis revealed renal failure from suspected glomerulonephritis. Blood cultures revealed fully sensitive Group A streptococci. Transthoracic and transesophageal echocardiographies revealed no vegetation. The Modified Duke's Criteria aided in the diagnosis of definite infective endocarditis, despite the absence of valvular vegetation.

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We report a 71-year-old man with a disseminated disease of mantle cell lymphoma (MCL). He initially noticed instability of the maxillary denture due to swelling of the hard palate. Combined positron-emission tomography and computed tomography demonstrated a marked accumulation of fluorodeoxyglucose in the palate. A biopsy of the palatine tumor disclosed diffuse infiltrates of lymphoid cells, which were positive for CD20 and cyclin D1. The peripheral blood contained lymphoma cells with the characteristic immunophenotype, and fluorescence in situ hybridization detected fusion signals indicative of t(11;14)(q13;q32). In a literature review we identified only three cases of MCL with palatine involvement to date.

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A 49-year-old female presented with diarrhea and a high fever followed by progressive dyspnea. Until this presentation, she had been healthy except for chronic dyspepsia and diarrhea. She had a smoking habit of 15 pack-years. Laboratory tests revealed lymphopenia, hypoalbuminemia and hypogammaglobulinemia. A rapid influenza test in combination with an RT-PCR assay revealed the presence of the novel influenza A (H1N1) virus. Chest computed tomography revealed centrilobular emphysema. This report suggests that regular smoking may become a risk for severe pneumonia in patients presenting with the novel influenza A (H1N1) virus, when accompanying asymptomatic emphysema is combined with other problems such as hypoalbuminemia and hypogammaglobulinemia.

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