Background We aimed to elucidate the risk factors and preventive factors associated with chronic low-dose aspirin (L-ASA)-induced gastroduodenal mucosal injury in Japanese patients with arteriosclerotic disease.
Methods This retrospective observational study included 400 L-ASA users who underwent upper gastrointestinal endoscopy. We investigated patients' clinical characteristics, including age, peptic ulcer history, concomitant drugs [i.e. gastric agents, antiplatelet drugs, anticoagulants, non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids], abdominal symptoms, endoscopic findings, and interruption of L-ASA before endoscopy. The severity of gastroduodenal mucosal lesions was evaluated using the modified LANZA score (MLS).
Results Of 400 patients, 249 (62%) and 41 (10%) had gastroduodenal mucosal lesions (MLS ≥1) and gastroduodenal ulcers, respectively. Peptic ulcer history, abdominal symptoms, proton pump inhibitor (PPI), histamine type 2-receptor antagonists (H2RA), and the cessation of L-ASA before endoscopy were significantly associated with L-ASA-induced gastroduodenal ulcers; the odds ratio (OR) (confidence interval (CI)) was 5.49 (1.82-16.55), 4.56 (1.93-10.75), 0.12 (0.03-0.42), 0.13 (0.04-0.40) and 0.11 (0.04-0.29), respectively. Moreover, patients having two or more of five factors [i.e. advanced age (≥75), anticoagulants, antiplatelet drugs, NSAIDs and corticosteroids] had a significantly higher prevalence of L-ASA-induced gastroduodenal ulcers [OR (CI): 2.39 (1.002-5.69)].
Conclusion Peptic ulcer history, abdominal symptoms and the summation of risk factors increased the risk for L-ASA-induced gastroduodenal ulcers. H2RAs and PPIs were effective for the prevention of L-ASA-induced gastroduodenal ulcers. The cessation of L-ASA before endoscopy might lead to the underestimation of L-ASA-induced gastroduodenal injury.

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Aim of the study To study the cardiac function in patients with liver cirrhosis.
Methods Thirty patients with liver cirrhosis, referred to as group I (G 1), were selected. They were subdivided according to Child-Pugh classification into 3 groups: A, B, and C. Thirty healthy subjects, referred to as group II (G II), were selected as a control group. All persons were examined by resting ECG, abdominal ultrasound, laboratory tests, and echo-Doppler evaluation of systolic and diastolic functions of both ventricles using 2-D, M-mode, conventional Doppler, and tissue Doppler parameters.
Results Systolic and diastolic blood pressures were significantly reduced with increased resting HR and CO in G I (p<0.05). The QTc interval was prolonged in G I (0.45±0.03 ms; p<0.001) but EDV, ESV, EF%, and S´ velocity were not significantly different in both study groups for both ventricles. LAD, MPI, LVPWT, and, IVST were significantly increased in G I (p<0.05). E/A and E´/A´ ratios were reversed in G I with increased DT/E for both ventricles (p<0.001). No significant difference was found among Child A, B, C subgroups except for the LAD which was significantly increased in Child C (p<0.05). There was a significant inverse correlation between serum albumin and left ventricular MPI (r=-0.4, p<0.05).
Conclusion Many cardiovascular abnormalities occur in patients with liver cirrhosis that mandate echocardiographic evaluation especially in cases who undergo any procedure which may affect the hemodynamics.

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Objective Several epidemiological investigations have reported that green tea reduces cardiovascular and cerebral vascular risks. Green tea catechins may improve peripheral endothelial dysfunction in smokers. The purpose of this study was to elucidate the beneficial effect of green tea catechins on the repair of endothelial dysfunction in smokers.
Methods Thirty healthy male smokers divided into three groups ingested a green tea beverage containing 0 mg (control group), 80 mg (middle dose group) or 580 mg (high dose group) of green tea catechins (GTC) daily for two weeks, and endothelial-dependent vasodilatation was investigated by measuring forearm blood flow (FBF) response to reactive hyperemia (RH) by venous occlusion strain-gauge plethysmography.
Results An acute effect was that the FBF response to RH significantly increased 2 hr after GTC intake in the high dose group. However, no increase was observed in the other groups. The chronic administration of GTC for one or two weeks ameliorated the FBF responses to RH in the high dose group. On the other hand, no significant increase was observed in the FBF responses to RH in the other groups. Moreover, the plasma concentration of 8-OHdG, IL-6, TNF-alpha, and soluble Fas decreased significantly for two weeks in the high dose group, however, the level of IL-1 beta remained unchanged over this period.
Conclusion Green tea consumption over short and long periods appears to ameliorate endothelial dysfunction by scavenging free radicals with anti-inflammatory and anti-apoptotic properties in healthy male smokers.

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Objective In the hospital setting, several studies have reported proton pump inhibitor (PPI) overuse, a majority of which is continued after discharge. In addition to being expensive, PPIs are associated with an increased risk of infections, osteoporosis and serious drug interactions. We examined the trends and predictors of PPI guidelines non-compliance among academic and non- academic hospitalists in USA.
Methods and Patients Oral PPI prescriptions initiated by 2 academic and 2 non-academic hospitalist groups were reviewed. Prescription indications were recorded when explicitly stated in the chart. Otherwise, qualified physicians reviewed the chart to make such determination. Indications were then compared to the published guidelines. Several variables were tested to determine independent predictors of initiation and post discharge continuation of guideline non-compliant prescriptions.
Results Of the 400 PPI prescriptions 39% were guideline compliant. Academic hospitalists were significantly more compliant with PPI prescription guidelines (50 vs 29%). Gastrointestinal ulcer bleeding prophylaxis (GIP) for low risk patients was the most common indication for non-compliant prescriptions, while that of guideline compliant prescriptions was dyspepsia treatment. Independent predictors of the initiation of guideline non-compliant prescriptions were non-academic hospitalist group, PPI indication not documented in the chart, and GIP as part of the admission orderset. The latter was an independent predictor of those prescriptions continuation post-discharge (protective) in addition to non-academic hospitalists group.
Conclusion Hospitalists overprescribe PPI to a level comparable to that of the non-hospitalist providers in the literature. Understanding the determinants of increased compliance among academic groups is instrumental to design interventions aimed at increasing PPI prescription compliance.

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A 65-year-old woman with elevated serum levels of pancreatic enzymes was referred to our hospital for further examinations. Abdominal US and contrast-enhanced CT demonstrated swelling of the pancreas body and tail. MRCP and ERCP revealed abrupt ending of the MPD in the pancreas body. Under the suspicion of malignancy, distal pancreatectomy and splenectomy were performed. The histopathological findings showed idiopathic duct-centric pancreatitis (IDCP) with granulocytic epithelial lesions (GEL). As most cases of Japanese autoimmune pancreatitis (AIP) are lymphoplasmacytic sclerosing pancreatitis (LPSP), the present case seems to be helpful to clarify the clinical findings of IDCP in Japan.

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Herein we present a 73-year-old man with primary carcinosarcoma of the liver, a rare malignant tumor of the liver. The case was followed up due to HBV-related liver cirrhosis. Regular check-up by ultrasound demonstrated a hyperechoic tumor in the left lobe of the liver, and he was referred and admitted to our hospital. Dynamic CT studies revealed a mostly hypoenhancing hepatic mass with a peripheral ring enhancement. Surgical resection was performed, and the resected tumor was macroscopically a simple nodular type, 3 cm in diameter, with a dense fibrous capsule. Microscopically, undifferentiated cells were dominant in the tumor, while moderately differentiated hepatocellular carcinoma (HCC) were also observed. A transitional zone was noted between the undifferentiated tumor and HCC. Tumor tissue with adenocarcinoma, osteosarcoma and chondrosarcoma were also detected. Immunohistochemical studies demonstrated that tumor cells were HepPar 1 positive in hepatocellular carcinoma, and CK19 and partly CK7 positive in adenocarcinoma. Moreover, CD56, chromogranin A and c-kit were occasionally positive in undifferentiated tumor cells. The diagnosis of carcinosarcoma was made based on the concomitant presence of HCC and sarcomatous components, yet it is noteworthy that various types of tumor cells were observed.

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Marfan's syndrome (MFS) is an autosomal dominant disorder of connective tissue involving musculoskeletal, cardiovascular and ocular systems. Aortic disease is the leading cause of mortality in MFS. Among all, dilated cardiomyopathy in the absence of severe valvular dysfunction is a very rare cardiovascular feature of MFS. We report a case of biventricular heart failure in a patient with MFS, complicated by chronic type A aortic dissection and right atrial thrombus. This report clearly highlights the importance of close cardiovascular follow-up in patients with MFS.

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Polymorphic ventricular tachycardia, which occurs during the subacute phase of myocardial infarction (MI) or ischemia and is not related to ongoing ischemia, has recently been reported. It has characteristics of typical pause-dependent torsades de pointes (TdP) following excessive QT prolongation (post MI/ischemia-associated TdP). We describe a male patient with post MI/ischemia-associated TdP. The patient experienced recurrent TdP with excessive QT prolongation 2 days after transient myocardial ischemia. Genetic screening of the major LQTS-causing genes identified a KCNQ1 G643S variant. This gene variant could be a genetic predisposition to the development of TdP during the subacute phase of MI/ischemia.

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In December 2007, a woman was involved in a traffic accident. At first, her vital signs were normal, but electrocardiogram showed ST-segment elevation in the inferior leads. She was diagnosed as a blunt chest trauma-induced myocardial infarction. Her right coronary angiography showed total occlusion. She underwent an emergency coronary artery bypass surgery; 64-multi-detector-row computed tomography (64-MDCT) demonstrated an intravascular protruding lesion, which suggested subintimal hematoma. One month later, repeat coronary angiogram showed spontaneous recanalization, and 64-MDCT showed no discontinuous vessel wall. Coronary artery occlusion secondary to blunt chest trauma is rare, and it's even rarer to have spontaneous recanalization.

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Although the etiology of Graves' disease is still not clear, it is generally suggested that environmental factors such as infections contribute to the development of Graves' disease. We report here three cases of Graves' disease which presented simultaneously with infectious mononucleosis due to primary EBV infection. Acute EBV infection might play an important role in the onset of Graves' disease. These three women complained of a sore throat or neck pain, resembling subacute thyroiditis. In the case of thyrotoxicosis accompanied by sore throat or neck pain, Graves' disease must be distinguished from subacute thyroiditis.

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Bird fancier's lung (BFL) is one of the most common types of hypersensitivity pneumonitis. We report a rare case of acute-on-chronic bird fancier's lung that developed in a pigeon breeder and presented subpleural curvilinear shadow and ground glass opacity on high-resolution computed tomography (HRCT) of the chest. The results of surgical lung biopsy showed mainly intraalveolar organization and alveolitis in addition to the pattern of usual interstitial pneumonia with centrilobular fibrosis. Examination of bronchoalveolar lavage (BAL) fluid revealed an increase in lymphocytes. The results of immunoglobulin (Ig) G and IgA antibodies against pigeon dropping extracts were positive in sera and BAL fluid. Consequently, the patient was diagnosed as having BFL. Avoidance of pigeons and corticosteroid therapy led to rapid improvement.

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Sarcoidosis is an inflammatory disease of unknown cause which is characterized by the presence of noncaseating granulomas. The association of sarcoidosis with malignancy has been an issue and remains controversial. We herein report endobronchial carcinoid tumor in a patient with sarcoidosis diagnosed by nasal mucosal biopsy, excisional biopsy of cervical lymph nodes and mediastinal lymph node dissection.

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An 18-year-old Nepalese man was admitted due to general malaise and anorexia a month after coming to Japan. Laboratory tests showed elevation of transaminase and positivity for IgM anti-HEV antibody. Serum HEV RNA was detected by RT-PCR amplifications. An HEV genome phylogenetic tree, constructed using an 821-nucleotide sequence in the open reading frame 1, indicated that the genotype was 1. HEV genotype 1 is epidemic in South Asia, Africa and South America, and the incidence of acute hepatitis due to HEV genotype 1 is low in Japan. Thereafter, attention should be paid to HEV genotype 1 infection as an imported infectious disease.

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Extramedullary tumor (EMT) is a poor prognostic factor of multiple myeloma (MM). The majority of patients report poor efficacy of thalidomide in MM with EMT, and bortezomib is the preferred choice of treatment. We report two cases of MM with EMTs in which thalidomide was highly beneficial. Case 1 has been in remission for ten months with 100 mg every other day of thalidomide monotherapy, which is the lowest dose to be reported in a successfully treated case of MM with EMT. Case 2 eventually became refractory, but low dose thalidomide gave excellent disease control over a period of eleven weeks, despite the EMT being in a highly aggravated state. Some reports have speculated that EMT cases with preceding bone marrow transplantation (BMT) are an exception and have a good response to thalidomide, but the present two cases have no history of BMT. In conclusion, low dose thalidomide can be effective in MM with EMT and should be considered as a treatment option, especially in the elderly.

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A 64-year-old man was admitted to our hospital because of difficulty in walking and numbness in his lower extremities. Upon investigation, the patient was diagnosed as having predominant sensory ataxic neuronopathy associated with thymoma. Surgical resection of the thymoma followed by intravenous immunoglobulin therapy resulted in marked improvement of the patient's clinical symptoms; therefore immunological mechanisms related to the presence of the thymoma were suspected to underlie the neuropathy in this patient. We did not find any previous reports of an association of sensory ataxic neuronopathy with thymoma, even after a thorough search of the literature.

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We describe a patient with painful neuropathy associated with an abnormal anti-MAG titer in which predominant involvement of intra-epidermal nerve fiber was documented. Electrophysiological studies revealed low-borderline amplitude of sensory and compound motor action potentials registering from lower limbs and normal conduction velocity. Sural nerve biopsy disclosed only a slight loss of myelinated fiber. Skin biopsy performed at the proximal thigh and at the distal leg was consistent with a non-length-dependent small fiber neuropathy. It is likely that in this case anti-MAG antibodies played a role in the pathogenesis of small fiber neuropathy.

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We report a Japanese man who presented with multiple cranial nerve palsies with hepatitis B virus-related multiple hepatocellular carcinoma (HCC). He presented with right III, IV, VI, IX, X, and XII cranial nerve palsies. Metastases involving the clivus and the right occipital bone from HCC were diagnosed by the findings of magnetic resonance imaging of the head, cerebral angiography, and 2-deoxy-2-[¹⁸F]fluoro-D-glucose positron emission tomography/computed tomography. In this case, over one-year survival and improvement of neurological signs were achieved by radiotherapy in spite of multiple skull metastases, which are extremely rare.

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A 35-year-old woman, diagnosed as schizophrenia and treated with olanzapine for nearly 30 months, consulted our department because of severe hyperglycemia. The use of antipsychotics, switching from olanzapine to risperidone, and a one-month introduction of insulin therapy resulted in the decrease of pre-prandial blood glucose levels and the increase of insulin levels (269 to 128 mg/dL, 5.6 to 21.8 μU/mL). A higher level of insulin resistance as measured by HOMA-IR after the improvement of hyperglycemia (3.6 vs. 6.8) suggested that the long use of olanzapine reduced insulin secretion. Based on this case, impairment of pancreatic β-cells caused by olanzapine might be reversible.

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