Background/Aim Ecabet sodium has an anti-H. pylori effect. We assessed the efficacy of ecabet sodium in the rescue therapy for the eradication of H. pylori.
Methods A total of 74 patients with failed eradication of H. pylori after triple therapy with lansoprazole 30 mg bid, amoxicillin 750 mg bid and clarithromycin 200 mg bid were enrolled. They were randomly assigned to the three treatment groups as follows: LAC, lansoprazole 30 mg + amoxicillin 750 mg + clarithromycin 200 mg bid for 1 week; LAC2E, lansoprazole 30 mg bid + amoxicillin 750 mg bid + clarithromycin 200 mg bid + ecabet sodium 2 g bid for 1 week; and LA2E, lansoprazole 30 mg bid + amoxicillin 750 mg bid + ecabet sodium 2 g bid for 2 weeks. Eradication of H. pylori was assessed by the 13C-urea breath test after treatment.
Results Eradication rates in intention-to-treat and per-protocol analyses were 20.0% (95% CI: 6.8-40.7) and 20.0% (6.8-40.7) with LAC, respectively, and 16.0% (4.5-36.1) and 17.4% (5.0-38.8) with LAC2E. In contrast, respective rates with LA2E were 75% (53.3-90.2) and 85.7% (63.7-97.0), which were significantly higher than those with LAC (p<0.001 for both ITT and PP) and LAC2E (p<0.001 for both ITT and PP).
Conclusion Triple therapy with ecabet sodium, lansoprazole and amoxicillin for 2 weeks was effective as the rescue therapy after failure of the standard clarithromycin-based regimen.

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Objective The comorbid conditions questionnaire (CCQ) and the recent physical symptoms questionnaire (RPSQ) have been validated in the US for the evaluation of comorbid physical conditions in patients with irritable bowel syndrome (IBS). A lack of instruments to assess somatization in Japanese subjects with IBS warrants development of the Japanese versions of these questionnaires. The purpose of this study was to validate the Japanese versions created, the CCQ-J and RPSQ-J.
Methods and Patients Study 1 was carried out to verify the test-retest reliability and internal consistency of the CCQ-J and RPSQ-J in 49 patients with functional bowel disorder. Study 2 was performed to confirm the construct validities of these questionnaires compared to the Cornell Medical Index (CMI) in 120 patients with psychosomatic symptoms (assigned to the somatoform disorder, anxiety disorder, depressive disorder, or IBS group) and 22 healthy subjects.
Results In Study 1, high reproducibility and high intraclass correlation coefficients were demonstrated for these questionnaires. In Study 2, total score on the CMI was significantly associated with score on the CCQ-J and on the RPSQ-J in the IBS group. The proportion of patients with chronic back pain was significantly higher in the IBS group than in controls (27.3% vs. 18.5%, p<0.05).
Conclusion The CCQ-J and RPSQ-J are valid and reliable instruments for evaluating comorbid conditions in Japanese patients with IBS. Further studies are needed to confirm the direct cross-cultural comparison of the impact of somatization in IBS between different countries.

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Objective The association between carotid atherosclerosis and the metabolic syndrome (MetS) was analyzed in the general population. The usefulness of the inclusion of the serum adiponectin concentration in the MetS criteria for the detection of atherosclerosis was also examined.
Patients and Methods The 825 participants of a comprehensive health checkup who underwent carotid ultrasonography and the measurement of serum adiponectin levels were studied.
Results The carotid plaque score (PLS) was significantly higher in the MetS group than in the non-MetS group in women, but not in men. In women, a significantly higher odds ratios was obtained for MetS, in terms of the current waist circumference criterion, and a high PLS (fourth quartile) (OR=2.64, p=0.040). In men, however, a waist circumference of around 85 cm did not reflect high a PLS, and even when the waist circumference criterion was varied, the odds ratio did not increase. When the waist circumference was replaced by hypoadiponectinemia in the current MetS criteria, the odds ratio was significantly increased in men (OR=1.82, p=0.032).
Conclusion The current MetS criteria seem appropriate for women. In men, there was no significant evidence for the validity of the inclusion of the waist circumference criterion as an essential component. Incorporating hypoadiponectinemia into the current criteria would be useful for the early detection of atherosclerosis in men.

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Background The metabolic syndrome is characterized by the accumulation of several metabolic risk factors. It is important to improve physical activity and dietary habits to reduce the risk of cardiovascular disease in humans.
Methods The study participants participated in a weekly aerobic exercise program that included a session composed of a brief meeting, warm-up exercises, and primary exercises (low and high impact, stretch, muscle training, and cooling down). To evaluate the effect of this intervention we measured body fat composition, holding power, and quality of life assessment. Blood tests were also carried out before and every 3 months during the study.
Results Of the 37 participants enrolled in the exercise group, 31 (83.8%) completed the 12-week program. The control group consisted of 42 subjects, 36 (85.7%) of whom were available for follow-up at the end of the 12-week study period. In the exercise group, weight, body fat percentage, waist circumference, the World Health Organization quality of life 26 (WHO-QOL 26) score, triglyceride, total cholesterol, high density lipoprotein cholesterol and low density lipoprotein cholesterol had improved significantly at the end of three months. The high molecular weight adiponectin concentration of the participants in the exercise group increased during the 9-month period of the study, although this change did not reach statistical significance compared with pre-exercise.
Conclusion Aerobic exercise led to an improvement in body composition and lipid profiles. High molecular weight adiponectin concentrations tended to improve compared with pre-aerobic exercise levels.

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Objective Osteoporosis has been reported to increase the risk of mortality. However, these reports did not evaluate the effects of co-mobidities and the severity of osteoporosis on mortality. The aim of our study was to determine whether or not major osteoporotic fractures contribute to the increased mortality risk in Japanese women.
Method We conducted a prospective observational study. Risk factors contributing to mortality were assessed by Cox's proportional hazard model.
Subjects A total of 1,429 ambulatory postmenopausal female volunteers aged over 50 years old were enrolled in the study. Information was obtained from the subjects on baseline biochemical indices, bone mineral density (BMD), prevalent fractures, and co-morbidities. Mortality was assessed and confirmed by the certificates or hospital records. The subjects were classified into three categories in accordance with or without osteoporosis. The osteoporotic group was further categorized by the basis of the presence or absence of major osteoporotic fractures.
Results Mean age and SD of the participants were 66.5±9.3 (50-90) years old. The participants were followed for a total of 4.5±3.5 years (mean ± SD) and a total of 141 participants (9.9%) died during the observation. In addition to the traditional risks for mortality, such as age (Hazard ratio, 2.817, 95% CI, 2.237-3.560, p<0.0001), BMI (HR 0.504, 0.304-0.824, p=0.0061), prevalent malignancies (HR 2.885, 1.929-4.214, p<0.0001), dementia (HR 1.602, 1.027-2.450, p=0.038) and cardio-vascular disease (HR 1.878, 1.228-2.787, p=0.0043), the serum level of creatinine (HR 2.451, 1.107-5.284, p=0.027) and severity of osteoporosis (HR 1.390, 1.129-1.719, P=0.0018) were found to be significant independent risk factors for all-cause mortality.
Conclusion These results emphasize the importance of osteoporotic fracture in terms of survival.

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Objective The goal of this study was to determine the prevalence of type 2 diabetes among acute inpatients and evaluate its impact on the length of hospital stay in Japan.
Research Design and Methods The discharge records of 2,120,170 acute inpatients who were 30 years old or older and discharged between July and December of 2008 were obtained from the Japanese administrative case-mix system, Diagnosis Procedure Combination (DPC), and allocated for analysis. Type 2 diabetes was defined by E11 of the ICD-10 coding system on patient records. Other types of diabetes, including type 1 diabetes and diabetes in pregnancy (defined by ICD-10 codes E10 E12-14 and O24, respectively) were excluded from the analyses.
Results Type 2 diabetes was observed among 11.4% of the records, 9.9% of which were cases of diabetes as a comorbidity. Total length of hospital stay was 33,468,152 days, with diabetes patients occupying 13.9% of the total bed days. Patients with type 2 diabetes as a comorbidity had prolonged lengths of hospital stay compared to patients free from diabetes, and stratification by sex, age, surgical treatment, and disease category did not alter these results. The median length of hospital stay was 9 days among patients without diabetes and 13 days among patients with diabetes.
Conclusion Japanese acute health care is experiencing an epidemic of type 2 diabetes, with 1 out of 10 acute inpatients suffering from the disease. Complication of type 2 diabetes is associated with prolonged length of hospital stay.

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Background and Purpose Although oral antithrombotic therapy (OAT) is a risk factor of intracerebral hemorrhage (ICH), the clinical course of supratentorial ICH with prior OAT is unclear. We therefore assessed the characteristics of supratentorial ICH with OAT to determine whether OAT is independently associated with early death in supratentorial ICH.
Method We retrospectively enrolled consecutive patients with supratentorial ICH admitted to the Stroke Center of Kawasaki Medical School Hospital within 24 hours of onset, from April 2004 to March 2009. The group with OAT therapy (OA group) was compared with the group without (non-OA group).
Results A total of 389 patients with supratentorial ICH (median age 68 years, 61% males) were enrolled in the present study. OAT was used in 24% of patients. The OA group was older than the non-OA group (median 74 vs. 66 years, p<0.001). In the OA group, Glasgow Coma Scale was less (10 vs. 13, p<0.001), and hematomas were larger (22 mL vs. 14 mL, p<0.001). Early death was more frequently observed in the OA group than in the non-OA group (28% vs. 8.1%, p<0.001). Unadjusted HR of OAT for death within 14 days was 3.62 (95% CI: 2.06-6.33, p<0.001), the age- and sex-adjusted HR was 3.84 (95% CI: 2.12-6.96, p<0.001), and HR adjusted for age, sex, GCS, and hematoma volume was 2.01 (95% CI: 1.11-3.65, p=0.022). HR adjusted for age, sex, GCS, and hematoma volume at day 1 was 2.63 (p=0.34), day 3: 2.35 (p=0.03), day 7: 2.01 (p=0.04), and day 14: 1.90 (p=0.04).
Conclusion The OA group patients were older, their GCS was lower, they had larger hematoma volume, and more frequent occurrence of early death. Prior oral antithrombotic therapy is associated with early death in patients with supratentorial ICH.

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Objective The musculoskeletal system is one of the most commonly affected systems in brucellosis. The objective of this study was to determine the frequency, types, and clinical features of osteoarticular involvement among cases with brucellosis in the Central Anatolia region of Turkey and to establish the differences between patients with and without osteoarticular involvement.
Methods Included in this study were 202 patients with Brucellosis presented between June 2003 and June 2009. The diagnosis of osteoarticular system complications was established by physical examination and radiological findings obtained by diagnostic imaging tools. Magnetic resonance images of thoracic, lumbar or sacral vertebrae were acquired from patients with back pain, low back pain and sacro-iliac joint pain.
Results Osteoarticular involvement was noted in 94 patients (46.5%). The most common sources of infection are employment in farming and/or consumption of un-pasteurized milk or dairy products, especially fresh cheese in 53 (75.7%) cases. The mean age is 46.7±18 years. Sacroiliitis is the most frequent osteoarticular involvement (60.6%), 82.4% of which is bilateral. Sacroiliitis was followed by spondylodiscitis in 36 (38.3%), peripheral arthritis in 15 (16%), bursitis in 1(1.1%) case. Patients with osteoarticular involvement received medical treatment for at least three months.
Conclusion The ratio and anatomical region of osteoarticular involvement in brucellosis show variability among countries. In this study, it is demonstrated that sacroiliitis is the most common form of osteoarticular involvement in the Central Anatolia region of Turkey. In endemic countries such as Turkey, this disease should be included in the differential diagnosis for patients with symptoms of sacroiliitis, spondylodiscitis or those with articular pain.

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Neoplasms rarely arise in the intestinal lesion of Behçet's disease. We present a 77-year-old man with Behçet's disease who developed colon cancer in the ileocecal region. Ileocecal resection was performed and pathological examination of the specimen revealed advanced colon carcinoma (pT3, N1, M0). The lesion was associated with destroyed tunica muscularis and severe fibrosis suggesting a transmural ulcer scar (Ul-IVs). The p53 gene mutation analysis of the tumor showed a heterozygous deletion. This case indicates there is a possibility that cancer may develop in intestinal lesions of patients with Behçet's disease as well as in those with other inflammatory bowel diseases.

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Sclerosing cholangitis (SC) is one of the lesions frequently seen in IgG4-related systemic diseases, causing biliary stricture and mimicking bile duct carcinoma and primary sclerosing cholangitis (PSC). Although it often accompanies autoimmune pancreatitis (AIP), autoimmune-related SC without a pancreatic lesion is very rare. A 79-year-old woman was referred to our institution with suspected diagnosis of bile duct carcinoma in the previous hospital. The patient was not icteric and fever free, but with an elevated level of serum biliary enzyme, which lead us to detect this disease. Clinical images including computed tomography (CT), endoscopic retrograde cholangiopancreatography (ERCP) and intraductal ultrasonography (IDUS) demonstrated multiple strictures at the intrahepatic bile duct and enhanced wall thickness at the upper common bile duct, however her pancreas was normal. Repeated endoscopic procedures with multiple biopsies from the biliary strictures demonstrated fibrous ductal tissues with lymph-plasma cell infiltration (>10 IgG4(+) cells/HPF). By positron emission tomography using ¹⁸F-fluorodeoxyglucose (FDG-PET), the uptake of FDG was not remarkable in areas other than the biliary lesions. Additional laboratory tests showed elevated levels of serum IgG (2,571 mg/dL), and γ-globulin (29%), and positive autoantibodies, but normal IgG4 (53.2 mg/dL). Together with clinical images, laboratory and histological findings, we diagnosed this patient as sclerosing cholangitis which was thought to be associated with autoimmunity. After one year of follow-up without steroid therapy, idiopathic thrombocytopenic purpura (ITP) developed with an increased level of serological markers. We encountered a rare case of sclerosing cholangitis expected to be associated with autoimmunity, which showed biliary strictures mimicking bile duct carcinoma and needed careful diagnosis. Unlike the typical AIP, the current case demonstrated distinct serological findings and no other organ involvement. Further study is needed to clarify the characteristics of sclerosing cholangitis associated with autoimmunity with a large number of cases.

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A 39-year-old woman was referred to our hospital for treatment of a non-healing gastric ulcer. Esophagogastroduodenoscopy (EGD) revealed an erosion in the pyloric antrum and a longitudinal ulcer on the lesser curvature of the gastric body. The histopathologic examination of biopsy specimens revealed non-caseating epithelioid granulomas. Acid-fast staining did not reveal bacilli. The differential diagnosis included gastric tuberculosis, Crohn's disease, and sarcoidosis and empiric antituberculous therapy consisting of isoniazid, rifampicin, ethambutol, and pyrazinamide was initiated. Gastric lesions were subsequently resolved and non-caseating epithelioid granulomas were not demonstrated on the post-treatment examination. Recurrence was not observed during the follow-up period of 53 months.

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A 68-year-old woman presented with yellowish discharge oozing from a fistula opening in the upper epigastric area that had persisted for one month prior to her visit. The patient had undergone a left lateral segmentectomy of the liver ten years prior for treatment of intrahepatic duct (IHD) stones. An abdominal computed tomography (CT) scan showed focal stricture and proximal dilatation of remnant IHD and a 1 cm-sized rim-enhancing lesion located under the surgical bed of the abdominal wall surrounding the dilated remnant IHD. Despite conservative management including nasobiliary drainage, no further improvement was anticipated. Partial hepatectomy and fistulectomy were performed for pathologic diagnosis and treatment of the enhancing lesion. Histopathology revealed adenocarcinoma. In this case, cholangiocarcinoma might have arisen in association with IHD stones and then developed a choledocho-cutaneous fistula as a clinical manifestation.

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A 29-year-old man presented with complaints of fever and pain and itching of his left neck with atopic dermatitis and abrasion. These symptoms had persisted for two days and dullness and fever developed, but the patient did not consult a physician. On the following day, he had a fever of 40°C and redness and swelling of the left neck. He visited a local clinic and was hospitalized with suspected cellulitis. A thrombus was detected in the internal jugular vein on MRI, and he was referred to our hospital. Neck ultrasonography showed the presence of an immovable thrombus in the area from the left internal jugular vein to the left brachiocephalic peripheral vein. Blood analysis indicated a major inflammatory response and juvenile idiopathic thrombophlebitis was suspected. A filter was carefully inserted into the superior vena cava, and anticoagulant therapy and medication with antibiotics led to remission. We present this case as a rare example of a condition mimicking Lemierre syndrome that was caused by dermal infection, and we include a review of the literature.

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A 70-year-old man with a history of food-dependent exercise-induced anaphylaxis (FDEIA) since age 50 was admitted to the emergency department with chest pain and urticaria caused by FDEIA. Coronary angiography revealed total occlusion of the proximal left anterior descending coronary artery. After thrombus aspiration, a bare metal stent was placed into the culprit lesion, resulting in no residual stenosis. Urticaria disappeared on the second hospital day. This is the first reported case, to our knowledge, in which acute myocardial infarction followed FDEIA. Physicians should be aware of acute myocardial infarction as a rare but potential complication of FDEIA.

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Primary tumors of the heart are rare. Among them angiosarcoma is the most common malignant tumor of the heart and is characterized by rapid growth, local invasion, and distant metastasis. Its clinical presentation is variable. We describe a 66-year-old man who suffered from cough and hemoptysis and then experienced rapidly progressing hemorrhagic pericardial effusion. After a set of examinations he was diagnosed as right heart angiosarcoma. His outcome was poor.

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Emery-Dreifuss muscular dystrophy (EDMD) is a distinctive form of muscular dystrophy which is often associated with cardiac abnormalities. Conduction disturbances are frequently observed, and may necessitate pacemaker implantation to prevent sudden death. In this case report, we present an autopsy of a 31-year-old man with X-linked EDMD who developed only minimal skeletal muscle symptoms, and who died from ventricular arrhythmia despite undergoing a previous pacemaker implantation. Ventricular arrhythmias in X-linked EDMD patients are also discussed.

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There are few case reports regarding patients with right lung agenesis living to old age because of both severe mediastinal and cardiac displacements. We report a 61-year-old woman with right pulmonary agenesis complicated by a transient ischemic attack that was evaluated by a three-dimensional reconstruction of helical computed tomography and an echocardiography. This patient was able to survive until old age because she had no critical anomalies in other organs including the heart. A mitral valve prolapse was detected by a two-dimensional echocardiography and we treated her with anti-platelet aggregation therapy for the prevention of recurrent stroke.

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Kienböck's disease is a rare disorder that presents with wrist pain and limitation of motion and is caused by avascular necrosis of the lunate bone. Dialysis patients occasionally present with wrist pain. However, Kienböck's disease is rarely reported in dialysis patients. We report a case of 52-year-old woman with a 28-year history of hemodialysis who presented with acute wrist pain. T1-weighted magnetic resonance imaging showed diffuse low intensity of the lunate bone, consistent with the diagnosis of Kienböck's disease. Because this disease can lead to chronic debilitating wrist pain, prompt diagnosis, accurate staging, and provision of appropriate treatment is mandatory.

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A 54-year-old woman on peritoneal dialysis (PD) was hospitalized with peritonitis with a high body temperature, abdominal pain and cloudy peritoneal fluid. She progressively fell into septic-like shock within only 6 hours after onset. The causative bacteria were Streptococcus mitis (S. mitis), part of the normal flora of oral cavity, intestine, female genial tract and upper respiratory tract. S. mitis shows pathogenicity for diseases such as endocarditis, brain abscesses and sepsis in children with malignancy or transplantation. However, S. mitis rarely shows severe pathogenic responses in adults. We report herein a case of fulminant peritonitis caused by S. mitis in an adult PD patient.

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Cryptogenic organizing pneumonia (COP) generally responds well to corticosteroids with a favorable outcome. However, it can rapidly worsen and lead to respiratory failure that is refractory to corticosteroids. Adjunctive drugs have been used in refractory cases with various outcomes, but treatment experience is still lacking. We present a case of rapidly progressive COP accompanying air leak syndrome, which showed no prompt response to corticosteroids alone but gradual improvement with the addition of cyclosporine and macrolide. This case report supports the existing literature suggesting that an early therapeutic trial of this drug combination might be considered in COP patients whose condition worsens despite corticosteroid administration.

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We describe a 60-year-old Japanese patient with chronic myeloid leukemia (CML) who developed myelodysplastic syndrome (MDS) with Ph negative monosomy 7 chromosome following transient bone marrow dysplasia during imatinib treatment. Most cases that developed chromosomal abnormality in Ph negative cells during imatinib therapy were reported to have less clinical implications, while rare cases developed MDS/AML. The present case suggested that metaphase karyotype analysis and bone marrow examination should be performed for the long term follow-up under imatinib treatment in cases showing cytopenia. The results also suggested that monosomy 7 in Ph negative cells may be an indicator of a poor prognosis.

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A 26-year-old woman with a history of mild mental retardation, Charcot-Marie-Tooth disease (CMT) and idiopathic thrombocytopenic purpura developed severe thrombocytopenia with Coombs-negative hemolytic anemia. Magnetic resonance imaging revealed a fresh cerebral infarction in the left precentral gyrus. ADAMTS-13 deficiency caused by an inhibitor and anti-cardiolipin antibodies were detected in the blood. After treatment with prednisolone and fresh frozen plasma, ADAMTS-13 activity was normalized, the ADAMTS-13 inhibitor had disappeared and the thrombocytopenia with a bleeding tendency was improved. To our knowledge, this is the first case of thrombotic thrombocytopenic purpura caused by ADAMTS-13 deficiency associated with antiphospholipid antibodies and CMT.

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We report on a 60-year-old man, having angioimmunoblastic T-cell lymphoma (AITL) with aberrant expression of CD20. The initial biopsy specimen showed features of AITL with the typical CD3⁺CD20^- immunophenotype. As the disease progressed, biopsy specimens of the recurrent lesions showed unusual results for AITL with the CD20⁺ immunophenotype in both flow cytometry and immunohistochemistry analysis. Double immunostaining confirmed that the lymphoma cells were simultaneously positive for CD3 and CD20. The disease became resistant to combined chemotherapies and the patient died 3 years after the initial diagnosis. Autopsy revealed a composite of AITL and EBV-positive diffuse large B-cell lymphoma. Although it is unknown whether the instability of the CD20 antigen expression is correlated with the behaviour of AITL, the administration of rituximab should be considered as an alternative therapeutic option in such cases.

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Chronic myelogenous leukemia (CML) is a clonal hematological malignancy typically presenting with basophilia and massive proliferation of differentiating myeloid cells. We report an atypical case of CML in which mild basophilia was the sole manifestation at presentation, and the condition persisted for 27 months with no sign of progression. This case reconfirms the importance of basophilia as a clinical manifestation of CML, and BCR-ABL FISH analysis should always be applied to cases of basophilia, even when the basophilia is modest and no other features of CML are present.

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Acute transverse myelitis (ATM) has been described as an uncommon complication of vaccinations and is rarely accompanied by inflammatory peripheral neuropathy. We report a case of a 77-year-old woman who developed ATM and acute motor axonal neuropathy (AMAN) following vaccinations against seasonal and 2009 A/H1N1 influenza. She manifested ophthalmoplegia, quadriparesis and sensory impairment. MR imaging showed a longitudinally-extensive spinal cord lesion, and nerve conduction study revealed motor axonal polyneuropathy. Despite prompt treatment, her symptoms poorly recovered. While concurrent ATM and AMAN may suggest the presence of a common antigen, their scarcity indicates the importance of other factors causing immunologic disruptions.

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This report describes the case of a 71-year-old woman with a limited form of neuromyelitis optica (NMO) who had a longitudinally extensive spinal cord lesion from the fourth to the tenth thoracic vertebrae. Up to age 75, she had four subsequent recurrences of the myelitis within the same spinal cord area but with no optic neuritis. Anti-AQP4 antibody was seropositive. Recurrence within the same spinal cord area might be a characteristic clinical finding in NMO spectrum disorders. For such patients, examination for anti-AQP4 antibody might be necessary for the diagnosis and therapy of this disorder.

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Extranodal natural killer/T cell lymphoma is very rarely encountered in clinical practice. It has a high mortality rate and very short median survival. Early diagnosis of these rare tumors, especially those originating from the small intestine, is usually difficult because of its nonspecific symptoms. Herein, we describe a case of a primary small intestinal natural killer/T cell lymphoma in a 52-year-old man who presented with abdominal fullness and weight loss. The clinical symptoms, elevation of serum levels of cancer antigen-125, and presence of ascites initially led to the suspicion of tuberculous peritonitis. Abdominal computed tomography scan demonstrated a hypodense tumor in the jejunum. Finally, the tumor was surgically confirmed to be a natural killer/T-cell lymphoma. Although aggressive chemotherapy was prescribed, the patient subsequently died of disease progression. In addition, we also review the English literature on this rare disease.

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